Today we start our Mental Health Month series. As a short recap: every Thursday, Friday, and Saturday this month we will be covering different DSM-5 diagnoses, recent research, and featuring personal stories from YOU. This week we’re covering Anxiety disorders, OCD and Related Disorders, and Trauma and Stressor Related Disorders. If you want the FULL LINE UP, click HERE. If you want to submit your story, CONTACT ME, or find my social media handles below.
Now that that’s over, let’s get into today’s topic: ANXIETY DISORDERS.
We all know feeling anxious isn’t uncommon. It’s simply our body’s natural response to stress. If you look at the state of the world right now, it’s not surprising pharmacies were running out of anxiety medications.
So far, we believe this stress response prompts waves of catecholamines (neurotransmitters like dopamine and epinephrine) which give rise to our flight-or-fight response. From an evolutionary standpoint, this may come in handy if you’re scrounging for food in tiger territory. From a modern standpoint, our sympathetic nervous system is constantly bombarded with new information and new things to worry about. From an epigenetic standpoint, your resulting anxiety from this overstimulation influences the on-off switch in the genes of your child, creating a world of ever-more-anxious, alert, frightened children.
There’s no definitive proof for any of these hypotheses. There is evidence suggesting all sides, and more, but studying humans is hard and concluding one idea over the other might not be practical. Please do not take this ambiguity lightly. Most people want to agree with one of the three hypotheses listed above because it just makes sense to them. This is a trap of confirmation bias.
I find that anxiety becomes a fear of the future, a fear that the present could not possibly (or will exactly) lead to the future, and a fear that the past has ruined the future; anxiety, today, is a summation of fears.
Let’s talk about what happens when this becomes debilitating.
Let’s first consult the DSM-5:
It states, “Anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioral disturbances.”
Not vague at all, right? You’ll learn much of the DSM is vague and simple in a convoluted way that makes diagnosis tricky: much of it is based on the subjective interpretation of the clinician.
There are 11 total anxiety diagnoses in the DSM-5:
1. Separation Anxiety Disorder
2. Selective Mutism
3. Specific Phobia
4. Social Anxiety Disorder
5. Panic Disorder (with panic attack specifier)
7. Generalized Anxiety Disorder
8. Substance/medication-induced anxiety disorder
9. Anxiety disorder due to another medical condition.
10. Other specified anxiety disorder
11. Unspecified Anxiety disorder
For the sake of the attention span of the average person (including me), we’re going to list the criteria of two of these diagnoses in depth so that you may see how they are broken down.
Let’s run through criteria, and then we’ll talk “causes” and treatment.
For this diagnosis, you must have the following (criteria summarized for all of our sake):
A) Consistent failure to speak in situations where there is expectation to do so, like at school.
B) Interferes with education, occupational, social achievement and communication
C) Lasts at least one month.
D) Not attributed to a lack of knowledge or comfort with the spoken language.
E) Not better explained by a communication disorder and does not occur during the course of autism, Schizophrenia, or another psychotic disorder.
These kids will speak in their homes with their immediate family but not with close friends or second-degree relatives—like grandparents. They “refuse” to speak at school, so says the DSM, although I’d argue it’s much more like an anxious reflex, this coming from someone who had this diagnosis; the anxiety is so severe the only option is for the child to shut down.
This also can include “excessive shyness, fear of social embarrassment, social isolation, and withdrawal, clinging, compulsive traits, negativism, temper tantrums, or mild oppositional behavior.” It is a “relatively rare disorder”, usually appears before 5 years old, but it may not be obvious until the child enters school. The long-term of this disorder is unknown, and “clinical reports suggest that individuals may ‘outgrow’ selective mutism.”
This next line is what happened to me: “In some cases, particularly in individuals with social anxiety disorder, selective mutism may disappear, but symptoms of social anxiety disorder remain.”
Temperamental factors are not well identified. Environmental factors, such as parents modeling social reticence, can contribute to the development of selective mutism. This may include controlling parents or overprotective parents.
Genetic factors: nothing identified.
For this diagnosis, it’s exactly what you think and some of what you may not have thought of. These criteria have a longer list, so I will summarize in a paragraph:
There must be obvious anxiety about social situations when the person is exposed to possible scrutiny of others, like meeting with unfamiliar people. In children this must be observed with peers and not just adults. The person fears showing anxiety symptoms which could be judged negatively. Social situations always provoke fear. In children, this maybe seen as crying, freezing, tantrums. These situations are avoided or endured terribly—very terribly.
Of course the fear must be deemed out of proportion to the actual threat of the social situation. This lasts for six months or more (like my entire life) and influences impairment in social, occupational, and other areas of life. It’s not attributed to substance use or other medical conditions, and can’t be explained with another disorder.
Apparently, “the duration of the disturbance is typically 6 months” and so I would like a refund please—24 years and counting.
It’s seen that individuals with this disorder might be poorly assertive or excessively submissive or even highly controlling of the conversation. They might not use a lot of eye contact—so parents, don’t worry, your anxious child probably does NOT have autism. They may be withdrawn, and disclose very little about themselves, or speak with an overly soft voice.
They may live at home longer.
Self-medication is common.
The median age of onset is 13 years old. If that average were taken with kids also diagnosed with Selective Mutism, the median age, I’m speculating, would be much lower.
Temperament: The trait of behavioral inhibition (shrinking away from unfamiliar situations) has been linked to the development of this disorder.
Environmental: No increased rates of childhood maltreatment in the development of this disorder, BUT maltreatment is a risk factor.
Genetic: Traits, like behavioral inhibition, are genetically influenced. Social anxiety is heritable (NOT inherited). No specific genetic factors have been identified.
What’s the first thing that comes to your mind? Trauma? For those of us who have been ingrained in the mental health system for a while, you might think “chemical imbalance”. Not even the DSM endorses that as absolute. You will find that genetic factors are no where near being identified, much less a chemical imbalance.
When tackling this, we must remember that your genes, your body, your cells, your thoughts, are incredibly malleable. When we talk about “predisposition” in relation to genes, we’re talking about the propensity for them to switch on and off. For example, it seems that some genes are more likely to, in response to a traumatic event, turn on.
Every cell in your body is influenced by your environment. This makes it extremely difficult to confirm what is solid at birth—were you doomed to live with anxiety?—and what is developed after birth. In fact, we may never know.
If you Google “what causes anxiety”, you will be lead to proper links citing similar things as the DSM: personality traits with an unknown genetic basis has a large influence.
If you Google “what causes anxiety disorders”, you will be fed a mix of “chemical imbalance like diabetes” and “stress”.
If Anxiety, or any mental health condition, was a chemical imbalance like diabetes, we’d have a psychotropic equivalent to insulin.
If you search for a similar phrase in psychology databases, you won’t find what you’re looking for.
I managed to find an article entitled “Biological markers for anxiety disorders, OCD, and PTSD: a consensus statement. Part 2: Neurochemistry, Neurophysiolgy,, and neurocognition”. If you are interested in it, I only have access through a database, so I can email you the full text.
This paper from the World Journal of Biological Psychiatry summarizes all the current biomarkers (as of 2017) for anxiety disorders, OCD, and PTSD. They state “none of the putative biomarkers is sufficient and specific as a diagnostic tool, [but] an abundance of high quality research has accumulated that should improve our understanding of the neurobiological causes of anxiety disorders, OCD, and PTSD.” It cites Serotonin precursors, GABA, Dopamine, Neuropeptides, and even Oxytocin the love neurotransmitter.
My criticism for this starts with their PTSD makers. It states: “Compared with control subjects, PTSD patients showed significantly elevated platelet-poor plasma NE (norepinephrine) levels and significantly higher mean 24 hour urinary excretion of all three catecholamines (NE, Dopamine, HVA).” It cites another study as the source for this, which I can’t find yet. What could other factors be for this rise in stress neurotransmitters? My point: you couldn’t possibly pinpoint this particular rise in catecholamines to PTSD alone because we can’t isolate the PTSD from the rest of the body/brain. Take everything with a grain of salt.
Biomarkers are real. We ARE biological beings, and to ignore that would be, well, ignorant. However, the lack of understanding for how our biology transforms through life means attributing brain states to only chemical differences without connecting the body’s experience of physical life is just as ignorant.
So, we ask, are anxiety disorders a chemical imbalance? The answers is: we don’t know. And we may never know.
Medication has been a go-to for years. Benzodiazepines, dangerously addictive and physiologically dependent in a short amount of time (2-4 weeks) do well at cutting panic attacks down for size. Valium, Ativan, and Klonopin have saved me more than once. SSRI’s and SNRI’s, researched for depression and sold for everything else without care, can sometimes help calm anxiety. Lexapro, Effexor, Zoloft, and Trintellix—honestly I couldn’t tell if they did anything at all to my anxiety. But for some people, they work.
Some antipsychotics like Abilify (some, again, sold against the label) are added on to antidepressants with the purpose of easing depression, but can also inadvertently help anxiety and there’s no rhyme or reason for it. It can probably be dedicated to the sedating effect.
Certain therapies, however, have been proven time and time again to be more potent than medication for SOME disorders, and many experiments show a combination of therapy and medication is better than mediation alone or therapy alone. These studies must be scrutinized with care however: some of them have no control group or comparison treatment.
For example, Cognitive Behavioral Therapy has been shown to significantly reduce distress in Panic Disorder and PTSD when compared to medication and no treatment. What will work depends on your willingness to throw yourself into the process. I’ve done much CBT and found that it only started working after I stopped putting off the homework. There are also personalities and onset of the condition that affect this, which you can read about here.
Other treatments are being studied too. We talked about Freespira here, the medication free treatment that is entirely invalid.
There is study going into Chamomile treatment for Generalized Anxiety Disorder. This study concludes there was non-significant reduction in GAD relapse but significantly better GAD symptoms and improved psychological well-being. Part of their funding came from the Nations institutes of health and a cancer center, and the authors have no conflicts of interest. It was a randomized clinical trial. Read it here.
Naturopathic care, including certain vitamins, need more research, but has some success in this article. My criticism is that if the participants were aware that anxiety was being studied, the placebo effect could be huge. I didn’t read through the entire study, admittedly, but if YOU find whether participants were aware or if they were deceived as they should have been, let us know.
If you feel you are struggling with anxiety, please reach out. If you don’t have close friends or family, message me.
If you want to speak with someone anonymously, I recommend Peer Support warmlines. These are not hotlines for crisis, but for meaningful conversation with someone who has been there. There is a list at this link. Those are for California, but anyone can call from anywhere. I’ve spoken to people from England before. You can search for some in your own state or region as well.
If you don’t trust any of those, give us a call at 831-688-0967. We are also a peer warm line service where I work, and have gotten calls from people throughout the country. We are open right now, 24/7. We try and keep conversations to twenty minutes, but I’ve been known to stay on longer if nothing else is going on in the house and the person is really needing support. *I will say I won’t necessarily be the person to pick up. We have other staff members.* If something comes up in the house, our current guests are a priority and we may need to get off the phone.
If you choose Therapy, online or otherwise, is another option. I recommend Psychology Today to find a therapist near you, or your health insurance website.
Your general practitioner may also have suggestions. If you choose the medication route, I suggest researching a good psychiatrist, reading your OWN research, and not allowing your general practitioner to run your psychotropic medication case. They are not trained for that.
Our Mental Health Month Featured story is at THIS LINK: Read about Caz and her journey through anxiety and into a mental health nurse career.
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