Anxiety: A Common Human Emotion

Ask anyone to define anxiety and you will quickly realize there is no shortage of examples that people can provide. Although anxiety is a very common human experience, the descriptions that people provide are quite varied.

Anxiety is a human emotion. Everyone experiences it. Yet, each person experiences this emotion in unique ways. The following case examples illustrate these various experiences of anxiety.

Examples of Anxiety

• 
  Sally is a 24-year-old sales associate in a highly prestigious pharmaceutical firm. She constantly works under a great deal of pressure. She says it’s “no big deal.” She even believes she thrives off this stress. However, she recently walked into her local grocery store and began to sweat. Her heart began to race. She felt like she was losing control. This happened on several occasions. She became so distressed she decided to order her groceries online to avoid another repeat episode.
• 
  Bill is a 47-year-old hardware store owner. Bill is constantly “worrying” about (what seems to him) just about everything. Whether he is concerned about his business not doing well…or, what if that mole on his back is not just a beauty mark?…or, how on earth is he ever going to drive to Michigan all by himself to see his son (even with the brand new navigation system)?…Bill just cannot seem to “control” his worry.
• 
  Kim is a 36-year-old, part-time, freelance web-designer. She is ordinarily calm and low-key. This is true until she has to go over a bridge, or travel in an airplane. For Kim, she hates places where she feels she cannot escape. She finds that she will often worry for days or even months in advance of these situations. As a result, she makes it a habit to avoid these situations at all costs; or, she “barely gets through them.”
• 
  Lastly, we have Pete. He is a 32-year-old law student. Pete cannot quite explain why he is anxious; however, he wakes up every morning feeling a sense of “dread.” His anxiety usually lingers until about mid-day. At that point, he finally gets into the swing of his normal, daily routine.

So who is right? Are they all describing the same thing? Simply stated, yes they are. The reason behind this paradox is that anxiety is best considered a complex, subjective experience. Anxiety is produced by multiple causes. It is expressed by a diverse set of symptoms. These symptoms include physical, emotional, behavioral, and cognitive components. This is why we can ask many different people about a very common experience; yet, get totally different definitions of what it means to be anxious.

Different Levels and Degrees of Impairment

People also differ in how often, and how intensely, they experience anxiety. For most people, anxiety is a normal and even adaptive occurrence. A normal degree of anxiety is part of the everyday humanexperience. Unfortunately, other people may experience anxiety to such a heightened degree that it causes them great distress. Sadly, this level of anxiety can interfere with people’s ability to function well. It may affect many important areas of their lives such as work, school, and relationships. When anxiety reaches this level of distress, and results in impaired functioning, we begin to speak of an anxiety disorder. Luckily, experts in the field have come a long way in understanding and treating anxiety problems.

Research provides strong evidence for an inherited predisposition (tendency) toward developing an eating disorder. In other words, eating disorders are often biologically inherited and tend to run in families. Recent research suggests that inherited biological and genetic factors contribute approximately 56% of the risk for developing an eating disorder. Individuals who have a mother or a sister with anorexia nervosa are approximately twelve times more likely to develop anorexia and four times more likely to develop bulimia than other individuals without a family history of these disorders. Studies of twins have shown a higher rate of eating disorders when they are identical (compared to fraternal twins or other siblings). Samples of DNA, the substance inside cells that carries genetic information, from pairs of siblings with eating disorders are now being analyzed to determine if they share genetic characteristics that are different from pairs of siblings without these disorders.

Research has also focused on abnormalities in the structure or activity of the hypothalamus, a brain structure responsible for regulating eating behaviors. Studies suggest that the hypothalamus of bulimics may not trigger a normal satiation (feeling full or finished) response. So, even after a meal, these individuals do not feel full. A wealth of research suggests that several different neurotransmitters are involved in eating disorders. Before discussing the contributions of specific neurotransmitters to different disorders, it is important to provide a bit of background about the functioning of these chemicals.

Neurotransmitters carry messages from cell to cell throughout the brain and nervous system. Neurotransmitters released from one cell travel across a cellular space (called a synapse) and attach to another cell’s receptors. These receptors are specifically designed to receive certain neurotransmitters. In our brain and nervous system, multiple neurotransmitters are working simultaneously to control all sorts of functions such as mood, appetite, energy level, memory, etc. The effect of the neurotransmitter depends on the type of receptor being stimulated (i.e., whether it slows down or speeds up the receiving cell) as well as the part of the brain or nervous system that receives it. For example, serotonin (discussed below) can affect sleep, eating, temperature regulation, muscle movement, memory, and host of other behaviors depending on the specific receptors stimulated, and where in the body or brain those receptors are located.

The neurotransmitter serotonin affects binging behavior in bulimics. These individuals often crave (and gorge) on foods rich in carbohydrates. The body converts sugars from carbohydrates, through a multi-step process, into tryptophan. Tryptophan is then used to create serotonin, which is partially responsible for the regulation of appetite, creating a sense of satiation, and regulating emotions and judgment. Thus, the binge behavior of bulimics may also be a response to low serotonin levels in the brain. A research team at the University of Pittsburgh found that individuals successfully treated for bulimia still had abnormally low serotonin levels, although other brain chemicals, such as dopamine and norephinephrine, were normal in comparison to individuals with no history of eating disorders. The successful treatment of bulimia with Prozac (a medication typically used for depression), which acts to increase the amount of serotonin in the brain, is additional evidence of the importance of this brain chemical.

There are three primary eating disorders: Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder. Each disorder is characterized by a distinctive pattern of disordered and harmful eating behavior. Anorexia generally involves the severe and extreme restriction of eating in an effort to lose weight. Because of this restriction, anorexics are typically underweight (defined as weighing only 85% or less of the expected weight for their height and gender). Bulimia is characterized by the presence of binges, which are episodes of consuming abnormally large amounts of food in a short period of time. Bulimic binges are often followed by compensatory purge behaviors that are an attempt to get rid of the consumed calories. Inducing vomiting, taking laxatives and excessive exercising are examples of purging behavior characteristic of bulimia, all performed in an effort to prevent weight gain.

Binge and purge behavior may occur during anorexia as well as in bulimia. However, extreme eating restriction is always present in anorexics and rarely in bulimics. Binge Eating Disorder is similar to Bulimia because both conditions share binge-eating behavior. However, individuals with Binge Eating Disorder do not purge or get rid of what they have consumed, unlike those with Bulimia.

Harmful eating behavior may start as isolated experiments with food restriction or binge/purge behaviors that gradually progress to become both chronic and cyclic in nature. In other words, disordered eating becomes an ongoing problem, one that often waxes and wanes in intensity over time. Eating disordered individuals who successfully manage to restrict and control what they eat may feel a short-term sense of empowerment and accomplishment. Such positive feelings do not tend to last very long, however. A bad day at school or work, a conflict with another person, or simply reading a fashion magazine or watching television may trigger renewed feelings of self-hatred and disgust, and lead to consumption of “banned” foods. This breakdown in willpower leads to self-perceptions of weakness and unacceptability, which in turn motivate further food restriction. Endless cycling of dysfunctional eating behaviors create ripe conditions for a disorder.

Things all eating disorders have in common:

As mentioned previously, all three eating disorders are serious mental and physical conditions with potentially life-threatening repercussions. These disorders can impair daily functioning and destroy general health. Individuals typically experience painful emotions before, during and after the maladaptive eating behaviors. In addition, people with eating disorders are generally fixated on their weight. They often fear gaining any weight, and their self-esteem is highly influenced by their body weight. This fixation can develop into a distorted body image. Body image has to do with how people interpret images of their bodies, including literal images (such as occur when looking in a mirror), and remembered images (such as occur when thinking about what you look like). Most of those suffering from eating disorders feel badly about their body image, and furthermore, are not able to accurately see themselves as others perceive them. Even when friends, family and coworkers worry about an individual’s weight loss and painfully thin appearance, these individuals still consider themselves fat, and discount the value and worth of other’s opinions. Rejecting other people’s perceptions enables eating disordered individuals to maintain their negative opinion of themselves, as well as their distorted sense of body image.

People diagnosed with eating disorders tend to be anxious about and sensitive to social acceptance. They tend to measure their success against unrealistically high standards or social ideals that are virtually unattainable. They are often acutely aware of their failure to reach these self-imposed standards, and believe that they have let down their community and themselves as a consequence. Frequently, this sense of failure drives them to work harder toward reducing the discrepancy between their current weight and their idealized weight. This drive can be so strong that some people abuse their bodies to the point of serious illness and even death.

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We live in an image conscious culture, which urges all of us (especially women) to improve our appearance. The messages sent by magazines, t.v., and other media include “buy certain clothes and products; straighten and whiten your teeth; get rid of your wrinkles; and most commonly, LOSE WEIGHT and you will be happy, admired, and loved.” The recent and recurrent debate concerning the unhealthy, stick thin models used in the fashion industry is a perfect example of how strongly entrenched our notion of “thinness equals happiness” has become.

Although many of us would benefit from eating a bit less and exercising more in order improve our health and fitness, simply watching what you eat is NOT an eating disorder. Eating Disorders are potentially life-threatening illnesses which are simultaneously psychological and physical in nature. They are characterized by a range of abnormal and harmful eating behaviors which are accompanied and motivated by unhealthy beliefs, perceptions and expectations concerning eating, weight, and body shape. As a general characterization, individuals with eating disorders tend to have difficulty accepting and feeling good about themselves. They tend to think of themselves as “fat” and “ugly” because of their body size and shape, even when this self-judgment is objectively inaccurate and false. Identifying and defining themselves according to their perceived “fatness”, eating disordered people tend to conclude that they are unacceptable and undesirable, and as a result, feel quite insecure and inadequate, especially about their bodies. For them, controlling their eating behaviors is the logical pathway in their quest for thinness.

The current article is designed to provide you with more information about the nature of eating disorders, their causes, potential treatments, and strategies for prevention. This information can be helpful in determining whether you or someone you love has an eating disorder. Before we begin, though, we want to stress two important points:

First, if you (or someone you love) have an eating disorder, YOU ARE NOT ALONE! Between 5 and 10 million Americans have anorexia or bulimia and another 25 million suffer with binge eating disorder. Hopefully, knowing that other people have experienced what you are going through, and have gotten better with treatment, will provide you with some sense of hope.

Second, don’t rely on your “willpower” to get over this condition. As mentioned previously, an eating disorder is a serious, potentially life-threatening disease. Between 6% and 20% of eating disordered individuals will literally die as a result of their disease. Seek PROFESSIONAL help for yourself or someone you love as soon as possible if you suspect there is a problem.

As the name implies, the obsessive-compulsive disorder (OCD) is the kingpin of the entire category of disorders called obsessive-compulsive and related disorders. Obsessions are repetitive and distressing thoughts, urges, or imagery that are experienced as uncontrollable. Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to obsessions. These obsessions and compulsions are at times consuming (an hour or more per day). They create significant distress and/or interfere with a person’s functioning.

Ordinarily, obsessional thoughts, images, or impulses are not about typical, everyday things. Common obsessional themes are:

• extreme and unrealistic concerns about contamination, and/or need for cleanliness;
• repeated and excessive doubts, such as wondering if a door was left unlocked, or if a coffee pot was turned off;
• the need to have things in a precise and particular order or arrangement (with intense distress or distractions if this order or arrangement is disturbed);
• aggressive or horrific impulses, such as a desire to harm one’s child; and
• disturbing sexual imagery, such as intrusive pornographic imagery.

These are the most common types of obsessions. However, any distressing, repetitive, uncontrollable, and unwanted thought can form an obsession.

Obsessions are not the same as hallucinations, which are a hallmark symptom of several other, rather severe, mental disorders (psychotic disorders). When someone is experiencing a hallucination, they are unaware that what they are experiencing is not real and a creation of their own mind. In contrast, people who experience obsessions recognize that the obsessions are generated by their own mind. This is true, even for people with limited insight.

People with OCD try to ignore or neutralize these intrusive thoughts, images, or impulses. In other words, they attempt to counteract or block these distressing and repetitive thoughts. One way people try to block or neutralize obsessions is with compulsions. Compulsions are recurring behaviors (such as repeatedly checking appliances or repeatedly washing hands) or repetitive mental acts (such as counting or praying) that an individual feels they must do in response to an obsession.

Compulsions serve to avoid or reduce distress. In some cases, a person may believe they must perform compulsive acts in order to prevent something terrible from happening. For example, a person may touch things only after they have all been bleached. They believe they must perform this act in order to prevent disease.

Children’s OCD symptoms are similar to adults. However, children may not ask for help. Therefore, it becomes their caregivers’ responsibility to identify these symptoms and seek treatment. While an adult may be able to tell you their rationale for the compulsive act (“I’m washing my hands so I don’t contract HIV”), a child may not be able to articulate this. Even though children may be unable explain the reason for their compulsive behavior, they may still try to minimize their compulsions in front of others.

The diagnosis of OCD includes an insight specifier to further refine the diagnosis. While it is true that obsessions and compulsions are based on inaccurate or irrational beliefs, people differ in terms of whether they recognize this fact. In other words, some people readily recognize and accept that obsessions and are not sensible. Nonetheless, this insight is insufficient to prevent the obsessions and compulsions. Other people lack this insight. They firmly cling to their distorted beliefs, despite evidence that refutes the validity of such beliefs. This lack of insight is important with respect to treatment. In general, people with poor or absent insight have a poorer prognosis for a full and complete recovery. However, the degree of insight can be quite variable. In one moment, a person may be well aware their beliefs are irrational. Later, when directly faced with a fearful situation, this insight may vanish completely.

There are three insight specifiers: 1) good/fair, 2) poor, or 3) absent/delusional. An insight specifier rates a person’s degree of insight about their disorder-related beliefs. For instance, some people realize that checking the locks, dozens of times throughout the day, is unlikely to affect whether or not a burglary occurs. This indicates good/fair insight. Someone else may believe that without this degree of vigilance a burglary is nearly certain to occur. This indicates poor insight. A small minority of people are absolutely convinced a burglary is certain to occur without rigorous checking of locks. These people demonstrate absent/delusional insight.

The presence of absent/delusional insight requires very careful diagnostic evaluation. Delusional thoughts are also a symptom of another category of rather severe disorders, called psychotic disorders. Therefore, is very important that the absent/delusional insight in an OCRD is not misdiagnosed as psychotic disorder merely because of delusional beliefs. Proper diagnosis is essential to receiving the right treatment. For example, the medications used to treat psychotic disorders are very different than for OCRDs. If the symptoms of OCRDs are misdiagnosed as a psychotic disorder, a person might receive the wrong kind of medication.

About 30% of people with OCD will also have a tic disorder at some point in their lives. For this reason, OCD has a tic specifier. This diagnostic distinction is made because people with tic disorder have different presentations of OCD than those who never had a tic disorder. Tic disorder is more common in males with childhood onset OCD (APA, 2013).

Obsessive-compulsive disorders are a group of psychiatric disorders characterized by some combination of repetitive thoughts, distressing emotions, and compulsive behaviors. The specific types of thoughts, emotions, and behaviors vary according to each disorder within this group.

The idea of a spectrum of disorders with obsessive-compulsive features is nothing new. Indeed, evidence spanning over a 20-year period has continued to accumulate. This research supports the theoretical and clinical utility of grouping these disorders together. As research continues, the types of disorders included in this group may change. Moreover, our understanding of this obsessive-compulsive spectrum will continue to be refined.

The Diagnostic and Statistical Manual of Mental Disorders- Edition 5 (DSM-5; APA, 2013) places these disorders into a category called obsessive-compulsive and related disorders (OCRDs). The DSM-5 is a manual used by mental health professionals to diagnosis mental disorders. The primary purpose of theDSM-5 is to help clinicians reliably identify and diagnose various mental disorders.

Each disorder in the DSM-5 includes a list of symptoms associated with that disorder. The manual also includes additional features of the disorder (e.g., age of onset, family history, etc.). It further provides criteria for distinguishing the disorders from each other. This is particularly important as many mental disorders share similar symptoms. Accurate diagnosis aids clinicians to identify which people may benefit from treatment. Perhaps more importantly, it helps clinicians select the most effective treatment approach. Just as there are many cancers with different methods of effective treatments, so too are there many mental disorders with different forms of effective treatments.

The following disorders are included in the DSM-5 category called obsessive-compulsive and related disorders category (OCRDs):

• obsessive compulsive disorder (OCD);
• body dysmorphic disorder (BDD);
• hoarding disorder;
• trichotillomania (hair pulling); and,
• excoriation (skin picking) disorder.

In addition, several other “lower order” disorders are included in this category:

• substance/medication-induced obsessive-compulsive related disorder;
• obsessive-compulsive and related disorder due to another medical condition;
• other specified obsessive and compulsive and related disorders; and,
• unspecified obsessive-compulsive and related disorders (such as body-focused repetitive behavior disorder and obsessional jealousy).

Decisions about which disorders are grouped together in the DSM-5 are based on whether there is some underlying relationship between two or more disorders. In other words, do these disorders have something in common with each other? With respect to mental disorders, there are several things that suggest a similarity between disorders. Some examples are: symptom similarity; frequency of co-occurrence (called comorbidity); the onset and usual pattern of the disorder; genetic risk factors; environmental risk factors; neural substrates, biological markers; and treatment response. To date, the strongest evidence for similarities among the OCRDs comes from symptom similarity, as well as the high degree of co-occurrence (comorbidity) among the disorders.

It is interesting to note the rationale used to organize the entire DSM-5 manual is similar to the rationale used for grouping the obsessive-compulsive and related disorders (OCRDs) together. For example, the chapter on anxiety disorders precedes the chapter on OCRDS. The purpose behind this placement is to inform clinicians there is a similarity between anxiety disorders and OCRDs. While anxiety is a key feature in OCRDs, there are enough unique differences between anxiety disorders (e.g., panic disorder, social phobia) and OCRDs to justify a separate category.

To recap, the hallmark features of OCRDs are repetitive thoughts, distressing emotions, and compulsive behaviors. Although there is symptom similarity and overlap, each disorder has its own unique features. These differences affect treatment decisions in several ways: 1) the choice of treatment type; 2) the ordering, and pacing of therapeutic interventions; and, 3) setting realistic goals and expectations for clinicians, patients, and family members about treatment progress. These differences are discussed in the treatment section.

What is an Obsessive-Compulsive Disorder?

Obsessive-compulsive spectrum disorders are a group of similar psychiatric disorders characterized by repetitive thoughts, distressing emotions, and compulsive behaviors. The specific types of thoughts, emotions, and behaviors vary according to each disorder.

Some examples of these disorders include:

1. Obsessive-compulsive disorder (OCD).
2. Body dysmorphic disorder (BDD).
3. Hoarding disorder.
4. Hair-pulling disorder (trichotillomania).
5. Skin-picking disorder (excoriation).