Social phobia generally develops in childhood or adolescence and affects women and men equally (Bourdon et al. 1988). Many people with social phobia self-medicate by using alcohol or drugs prior to a social engagement in order to “calm down,” which can lead to substance dependence or abuse.
Specific Phobias
John is a twenty-six-year-old national sales executive for a financial firm. He works ten- to twelve-hour days, spending a lot of time on the phone and driving to meet with clients in an effort to close deals. He tells himself and others that he enjoys the pace, and actually does feel that he thrives on the challenges the job offers. But when he has to fly to a meeting across the country, he experiences sweaty palms, a rapid heartbeat, racing thoughts, and a feeling that he’s losing it. As a result, he has started avoiding taking on clients in locations that might require travel by plane. In addition, his partner, Matt, loves to travel, but John has made excuse after excuse about why they can’t take a trip together, which is both disappointing and frustrating to Matt.
John is experiencing a specific phobia. Specific phobias are intense, irrational fears of something that doesn’t actually pose a threat. People who have specific phobias are usually aware that their fears are irrational, but they’re unable to talk themselves out of their reaction to the triggering situation. For some, just thinking about the feared object or situation is enough to bring on severe anxiety.
Common specific phobias involve flying, heights, elevators, enclosed places, animals or insects, blood or needles, water, bridges, and storms. Something interesting about specific phobias is how very specific they can be. For example, someone may be able to hike up a mountain and look over the landscape below with no problem but be terrified of going above the third floor of an office building.
Specific phobias can cause problems by restricting people’s lives in a variety of ways. Someone who has a fear of driving over bridges, for example, probably won’t take a job that involves a commute over a bridge. A person with a fear of blood may avoid needed medical or dental procedures. Someone with a fear of dogs may panic if a dog approaches and run into traffic while trying to escape.
Phobias often develop in childhood, but they can appear at any time. Unless the person receives treatment, the phobia tends to persist. Specific phobias are twice as common in women as men (Bourdon et al. 1988). While it’s unclear exactly what causes specific phobias to develop, they generally respond well to targeted exposure therapy, which I’ll discuss in detail in chapter 6.
Anxiety in Women vs. Men
As you probably noticed when reading the sections about the different anxiety disorders, women are diagnosed with many of them more frequently than men are. To review, women are twice as likely as men to have GAD, panic disorder, PTSD, or specific phobias and are equally as likely to be diagnosed with OCD or social phobia. In addition, anxiety disorders are more common among women who didn’t complete high school or college than among men with the same level of education (Kessler et al. 1995).
Despite these startling numbers, little is known about why women are more likely to develop anxiety disorders. There are, however, several hypotheses, including causes such as genetic influences, early exposure to physical or sexual abuse (which is more typical for girls than boys), early exposure to stressful events, and the effects of women’s menstrual cycles (Shear et al. 2005). What does all of this mean if your partner is female? Here are some of the findings:
Your partner is not only more likely to have an anxiety disorder, but also more likely to have a comorbid disorder, such as depression or alcohol or drug abuse (Kessler et al. 2002).
Panic disorder is often more severe in women than in men. Among women, panic disorder is also associated with higher levels of comorbid psychiatric illnesses, such as agoraphobia and GAD (Pigott 1999; Turgeon, Marchand, and Dupuis 1998).
Women who have been assaulted are nearly three times more likely to develop PTSD than men who have had a similar experience. Women with PTSD often have symptoms of avoidance and numbing, whereas men report difficulties with impulse control and irritability (Breslau 2002).
Women with social anxiety disorder may be at greater risk for agoraphobia than men (Pigott 1999).
Women with OCD are more likely to have obsessions and compulsions related to cleaning, contamination, or checking, or to have co-occurring depression or eating disorders, but also symptoms that are, overall, less severe than those of men (Pigott 1999).
There is evidence that anxiety improves during pregnancy, particularly during the third trimester. However, small studies have indicated that, once the baby is born, panic disorder and OCD are exacerbated, which can lead to an increase of OCD behaviors, as well as depression (Cohen et al. 1994).
Conversely, men are diagnosed with anxiety disorders less frequently than women, and there are several theories about why this discrepancy exists. One is that men are often misdiagnosed when they go to their doctors with symptoms of anxiety disorders. Other theories are that men are more likely to self-medicate with drugs or alcohol, or that men tend to avoid seeking treatment because of cultural biases that anxiety is unacceptable for men. Nevertheless, it also appears that men genuinely are not as prone to anxiety as women are—and, again, the reasons for this remain unknown. However, a recent study at Florida State University indicated that men’s higher levels of testosterone might play a role in reducing anxiety levels (Hartung 2010).
Treatments for Anxiety Disorders
While it’s helpful to understand anxiety, the distinctions between different anxiety disorders, and gender differences in the prevalence of anxiety, you probably have a more pressing question: How is anxiety treated? There are many approaches, and later chapters in this book will introduce you and your partner to a variety of techniques for reducing or eliminating anxiety that don’t involve medication or psychotherapy. But sometimes professional treatment for anxiety is the most effective approach, so let’s take a look at what that might mean for your partner. The good news is that anxiety usually responds quickly to effective treatment.
In general, when people seek help from mental health professionals for anxiety disorders, they receive recommendations for specific types of talk therapy and/or psychiatric medications. The type of treatment that’s appropriate is specific to the person; what may work for one person may not be effective for another. The diagnosing professional must take a careful history to determine the origins of the anxiety and particularly whether it’s a psychological or physical problem, as some physical illnesses can cause symptoms similar to those of anxiety but the symptoms will resolve when the physical illness is treated. If professionals determine that an anxiety disorder is present, they also look for comorbid disorders, such as depression, drug and/or alcohol abuse, or another anxiety disorder.
In the rest of this chapter, I’ll discuss the most common medications and types of therapy recommended for anxiety. In addition, you and your partner may consider complementary and alternative medicine (CAM) therapies. Unfortunately, studies looking at the effectiveness of psychiatric medications and psychological therapies for treating anxiety vastly outnumber those examining the effectiveness of CAM approaches (Antonacci et al. 2010), so these treatments are generally only recommended either in conjunction with standard therapies or if standard therapies haven’t worked well. CAM options include exercise, acupuncture, herbal supplements, and relaxation techniques, and I’ll cover some of these approaches in chapters 5, 6, and 7. Should your partner decide to try CAM options, it’s a good idea to inform his doctor about everything he’s trying to ensure all of the treatments are compatible. For example, some supplements can have problematic interactions with prescription medications. Keeping his doctor informed is also important in the event that your partner develops a medical problem.
Medications for Anxiety Disorders
Common types of medication prescribed for anxiety disorders include antianxiety drugs, antidepressants, and beta-blockers. These medications can h
elp control symptoms, but they don’t eradicate the anxiety disorder in the same way that an antibiotic would get rid of an infection. That’s why psychotherapy is often recommended in conjunction with medication: People need to learn techniques for working with anxiety-related thoughts and practice coping skills that can help relieve anxiety symptoms.
If your partner is considering medications to relieve his anxiety, it’s imperative that his doctor be aware of all other medicines he’s taking, prescription or over-the-counter, as well as any vitamins, herbs, or other supplements. In addition, it’s important to be honest about using illicit drugs or alcohol because of potentially fatal interactions.
Antianxiety Medications
Benzodiazepines are effective in managing anxiety symptoms. Commonly prescribed benzodiazepines include clonazepam (Klonopin) for social phobia and GAD, lorazepam (Ativan) for panic disorder, and alprazolam (Xanax) for panic disorder and GAD. In addition, a newer antianxiety medication, buspirone (Buspar), which is an azapirone, is used to treat GAD (NIMH 2009).
Benzodiazepines work quickly to relieve anxiety symptoms but can also result in dependence, meaning people need to take increasingly higher dosages to get the same results. Therefore, doctors generally only prescribe benzodiazepines for a short amount of time in order to prevent dependence. Buspirone, on the other hand, doesn’t cause dependence, but it must be taken for approximately two weeks before the person will feel any effects.
Antidepressants
Despite their name, some antidepressants have been shown to be effective in treating anxiety disorders, in addition to depression. Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed antidepressants today. They work by altering the levels of neurotransmitters in the brain, which affects communication among brain cells. According to the National Institute of Mental Health, “Fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa) are some of the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. Venlafaxine (Effexor), a drug closely related to the SSRIs, is used to treat GAD. These medications are started at low doses and gradually increased until they have a beneficial effect” (NIMH 2009, 15).
Monoamine oxidase inhibitors (MAOIs) are the oldest type of antidepressants. MAOIs commonly prescribed for anxiety include phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan). These drugs have been shown to be effective in treating panic disorder and social phobia (NIMH 2009). However, MAOIs are not prescribed very frequently because taking them requires many dietary restrictions, and because they can cause dangerous side effects when combined with other medicines, such as pain relievers, birth control pills, herbal supplements, cold and allergy medications, and other antidepressants.
A third type of antidepressant, tricyclics, can also be helpful in treating anxiety disorders. Imipramine (Tofranil) is useful for treating panic disorder and GAD, and clomipramine (Anafranil) is helpful for OCD (NIMH 2009).
Beta-Blockers
Beta-blockers were originally developed to treat heart conditions. However, they were subsequently found to be effective for some people in preventing the physical symptoms of anxiety, such as rapid heart rate and tremors. They are especially effective for symptoms of social phobia. A key benefit of taking a beta-blocker is that it helps assure people that their symptoms won’t escalate, and this reduces the fear of something “disastrous” happening.
Psychotherapy for Anxiety
Psychotherapy is often recommended for treating anxiety disorders, sometimes in conjunction with medication and sometimes on its own. Psychotherapy is conducted by trained mental health professionals, including psychiatrists, psychologists, counselors, and social workers. The purpose of psychotherapy for anxiety disorders is to discover how the anxiety began and what triggers it and to help the person learn techniques to reduce, limit, or prevent anxiety.
Cognitive behavioral therapy (CBT) is especially helpful for anxiety. It’s considered an evidence-based treatment, meaning extensive research has proven its effectiveness. The National Association of Cognitive-Behavioral Therapists defines CBT as “therapy that is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel/act better even if the situation does not change” (2011).
The cognitive part of CBT focuses on changing people’s thoughts and feelings regarding their anxiety. That means the therapist and your partner will identify what those thoughts and feelings are, examine how they are affecting him, and then work to transform the thoughts and feelings so they no longer interfere with your partner’s functioning and quality of life. The behavioral part of CBT looks at changing people’s behaviors in response to their anxiety. Many CBT therapists also teach relaxation techniques and other coping skills to help manage anxiety symptoms. I’ll explain several of these techniques in chapters 5, 6, and 7 so you and your partner can try them at home.
Treatment Failure
People often feel treatments for anxiety have failed when the actual problem is that the treatment hasn’t been given enough time to work or the treatment is inappropriate for the problem. If your partner has previously tried treatment for his anxiety and it was unsuccessful, you may encounter some resistance about seeking professional help again. It is essential that he be honest with a new practitioner about previous attempts at treatment. This information can guide the practitioner in choosing a new and hopefully more effective treatment approach. Your partner also needs to advocate for himself and be honest about how he’s responding to treatment. There are many options for treating anxiety, and it’s usually possible to make adjustments until the person feels relief. If your partner is working with a treatment provider who’s unwilling to listen to feedback about the treatment approach and make changes, he should seek out a new treatment provider.
In addition, you both need to have realistic expectations about what treatment can do. Psychoeducation about anxiety can help both of you learn about what to expect, what is “normal,” and what has been proven to help. To achieve maximum benefits, it’s imperative that your partner be active in his treatment. This includes following all instructions about when and how to take any prescribed medications, keeping appointments, and participating in psychotherapy, both in session and with homework assignments. Recovering from an anxiety disorder takes a lot of hard work, and having a supportive, understanding, and educated partner is extremely beneficial during that process.
What’s Next?
After reading the descriptions of the six anxiety disorders in this chapter, you may have recognized your partner’s symptoms as typical of one of the disorders. On the other hand, you may be thinking Well, he doesn’t quite fit any of the categories, but I know he has anxiety. The truth is, it doesn’t really matter whether your partner’s anxiety is “diagnosable.” If it’s impairing your relationship or diminishing your partner’s quality of life or your own quality of life, it will be worthwhile to make some changes. The rest of this book will give you tools and strategies to help your partner manage his anxiety and help both of you limit its impacts on your lives and relationship. Some of these techniques include writing exercises, so it would be helpful for you to have a journal handy as you read on.
Worry or Rumination?
Both worry and rumination are persistent forms of negative thinking. Worry thoughts are fixated on the what-ifs of the future, while rumination involves being consumed with unpleasant thoughts about past events. Another difference between the two is that worry is usually focused on danger, whereas rumination is entangled with hopelessness, failure, and loss. People who ruminate have a higher risk of depression.
Panic Attack or “Crazy Worry”?
Your partner may be describing his experience of intense anxiety as pan
ic attacks when, in reality, a better name for what he’s experiencing would be “crazy worry.” Here are some key differences between a true panic attack and “crazy worry”:
Panic attacks are usually short in duration, peaking in ten minutes or so and then subsiding. “Crazy worry” can go on for hours, days, or even weeks or months.
Panic attack symptoms, while similar to “crazy worry” symptoms, tend to be more intense. During a panic attack, people may feel as if they are having a heart attack, going crazy, or dying. “Crazy worry” symptoms are generally tolerable even though they’re really uncomfortable. People call ambulances for panic attacks; it’s less likely that would happen for someone experiencing “crazy worry.”
“Crazy worry” usually occurs in response to a stressor. Panic attacks come out of the blue and may not be associated with anything in particular.
Chapter 2
How Anxiety Affects Relationships
Anxiety affects nearly every aspect of a relationship. When you decided to enter into the relationship, you probably expected that your partner would be just that: a partner—someone who could communicate with you openly, who would accompany you to parties and events and on vacations, who would be your willing sexual partner, who would contribute financially to the relationship by having a job, and perhaps with whom you would have and raise children. Even if you were aware of your partner’s anxiety at the outset, it might not have occurred to you that it could interfere with these dreams and expectations.
Loving Someone with Anxiety Page 3