s we noted in Chapter 5, even stable, well-adjusted people may break down ifforced to face extensive combat stress,torture, or devastating natural disaster. Butfor some people, simply performing everyday activities can be stressful.Faced withthe normal demands of life-socializing with friends, waiting in line for a bus, beingon an airplane, touching a doorknob-they become seriously fearful or anxious. Inthe most severe cases, people with anxiety problems may be unable even to leavetheir homes for fear of having a panic attack, or may spend much of their time inmaladaptive behavior such as constanthand washing.
general feeling of apprehension about possible danger-was, inFreud's formulation, a sign of an inner battle or conflict between some primitivedesire (from the id) and prohibitions against its expression (from the ego and super-ego). Today the DSM has identified a group of disorders that share obvious symp-toms and features of fear and anxiety. These
as they are known,affect approximately 25 to 29 percent of the U.s. population at some point in theirlives (over 23 million Americans) and are the most common category of disorders forwomen and the second most common for men (Kessler et aI., 1994; Kessler, Berglund,
et aI., 2005b). In any 12-month period, about 23 percent of women and 12 percent ofmen suffer from at least one anxiety disorder (Kessler et aI., 1994). Anxiety disorderscreate enormous personal, economic,and health care problems for those affected.
For example, in 1990 anxiety disorders cost the United States $42.3 billion in directand indirect costs, with 90 percent of these being direct costs (about 30 percent ofthe nation's total mental health bill of $148 billion in 1990; Greenberg et aI., 1999).
Consider the following case of an anxious electrician:
A 27-year-old married electrician complains of dizziness,
sweating palms, heart palpitations, and ringingofthe earsofmore than
months' duration.Hehas also experienced
dry mouth and throat, periods of extreme muscle tension,and a constant "edgy" and watchful feeling that has ofteninterfered with his ability to concentrate. These feelingshave been presentmost ofthe time during the previous 2years ...Because ofthese symptoms the patient has seena familypractitioner, a neurologist, a neurosurgeon, a chi-ropractor,and an ear-nose-throat specialist....Healso has
many worries.He constantly worries about the health of his parents ... Healso worries about whether he isa "goodfather," whether his wife will ever leave him (there is noindication that she is dissatisfied with the marriage), andwhether he is liked by co-workers on the job. Although herecognizes that his worries are often unfounded, he can'tstop worrying.Forthe past 2years the patient has had fewsocial contacts because of his nervous symptoms...he
sometimes has to leaveworkwhen the symptoms becomeintolerable. (Adapted fromSpitzer et aI.,2002.)
Adaptedwith permission from the
DSM-/V - TR Casebook
American Psychiatric Publishing,Inc.)
Thephysicians thismanconsulted couldnot determine
the cause of hisphysicalsymptoms, andone of them
finally ref erred him for treatmentatamental healthclinic,
wherehewas diagnosed ashaving
generalized anxietyd is-
or d er -one
of seven primary anxiety disorders.
Historically, cases likethis andother cases of anxiety
disorders were considered to beclassic examples of
neurotic behavior.Although neuroticbehavior is mal-
adaptive andself-def eating, aneurotic personis notoutof
touchwithreality,incoherent,or dangerous. To Freud,
neuroseswerepsychological disordersthat resulted when
intrapsychic conflict producedsignif icantanxiety.Some-
times this anxiety was overtly expressed(as inthosedis-
orders knowntoday asthe anxietydisorders). In certain
other neurotic disorders, however, hebelieved that the
beobvious, either to theperson involved
or to others,if psychological def ense mechanisms were
able todeflect or mask it.In1980 the DSM -III dropped the
andreclassif ied mostof these disorders that
didnot involve obvious anxiety symptoms as eitherdisso-
ciative or somatoform disorders(see Chapter 8).DSM-III
made this change in order to group together smaller sets of
disordersthatsharemore obvious symptoms and features.
Webegin bydiscussing thenature of fear and anxiety
as emotionalstates, both of whichhaveanextremely
importantadaptive value butto which humans attimes
seem alltoo vulnerable. We willthen moveto a discussion
of the anxietydisorders.