Anxiety

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Definition

Anxiety is a multisystem response to a perceived threat or danger. It reflects a combination of biochemical changes in the body, the patient's personal history and memory, and the social situation. As far as we know, anxiety is a uniquely human experience. Other animals clearly know fear, but human anxiety involves an ability, to use memory and imagination to move backward and forward in time, that animals do not appear to have. The anxiety that occurs in post-traumatic syndromes indicates that human memory is a much more complicated mental function than animal memory. Moreover, a large portion of human anxiety is produced by anticipation of future events. Without a sense of personal continuity over time, people would not have the "raw materials" of anxiety.

It is important to distinguish between anxiety as a feeling or experience, and an anxiety disorder as a psychiatric diagnosis. A person may feel anxious without having an anxiety disorder. Also a person facing a clear and present danger or a realistic fear is not usually considered to be in a state of anxiety. In addition, anxiety frequently occurs as a symptom in other categories of psychiatric disturbance.

Description

Although anxiety is a commonplace experience that everyone has from time to time, it is difficult to describe concretely because it has so many different potential causes and degrees of intensity. Doctors sometimes categorize anxiety as an emotion or an affect depending on whether it is being described by the person having it (emotion) or by an outside observer (affect). The word emotion is generally used for the biochemical changes and feeling state that underlie a person's internal sense of anxiety. Affect is used to describe the person's emotional state from an observer's perspective. If a doctor says that a patient has an anxious affect, he or she means that the patient appears nervous or anxious, or responds to others in an anxious way (for example, the individual is shaky, tremulous, etc.).

Although anxiety is related to fear, it is not the same thing. Fear is a direct, focused response to a specific event or object, and the person is consciously aware of it. Most people will feel fear if someone points a loaded gun at them or if they see a tornado forming on the horizon. They also will recognize that they are afraid. Anxiety, on the other hand, is often unfocused, vague, and hard to pin down to a specific cause. In this form it is called free-floating anxiety. Sometimes anxiety being experienced in the present may stem from an event or person that produced pain and fear in the past, but the anxious individual is not consciously aware of the original source of the feeling. It is anxiety's aspect of remoteness that makes it hard for people to compare their experiences of it. Whereas most people will be fearful in physically dangerous situations, and can agree that fear is an appropriate response in the presence of danger, anxiety is often triggered by objects or events that are unique and specific to an individual. An individual might be anxious because of a unique meaning or memory being stimulated by present circumstances, not because of some immediate danger. Another individual looking at the anxious person from the outside may be truly puzzled as to the reason for the person's anxiety.

— Rebecca J. Frey

Dictionary: anx·i·e·ty  (ăng-zī'ĭ-tē)

1. 1. A state of uneasiness and apprehension, as about future uncertainties.
   2. A cause of anxiety: For some people, air travel is a real anxiety.
2. Psychiatry. A state of apprehension, uncertainty, and fear resulting from the anticipation of a realistic or fantasized threatening event or situation, often impairing physical and psychological functioning.
3. Eager, often agitated desire: my anxiety to make a good impression.

[Latin ānxietās, from ānxius, anxious. See anxious.]

SYNONYMS  anxiety, worry, care, concern, solicitude. These nouns refer to troubled states of mind. Anxiety suggests feelings of fear and apprehension: “Feelings of resentment and rage over this devious form of manipulation cannot surface in the child.... At the most, he will experience feelings of anxiety, shame, insecurity, and helplessness” (Alice Miller). Worry implies persistent doubt or fear: “Having come to a decision the lad felt a sense of relief from the worry that had haunted him for many sleepless nights” (Edgar Rice Burroughs). Care denotes a state of mind burdened by heavy responsibilities: The old man's face was worn with care. Concern stresses serious thought combined with emotion: “Concern for man himself and his fate must always form the chief interest of all technical endeavors” (Albert Einstein). Solicitude is active and sometimes excessive concern for another's well-being: “Animosity had given way … to worried solicitude for Lindbergh's safety” (Warren Trabant).

Anxiety is an emotional state, represented by a feeling of dread, apprehension, or fear. In humans, this can be defined by description using language; in animals, it must be inferred from behavioural observations. Tests of anxiety in man are thus based on self report, and these may be divided into features that characterize the person's temperament (‘trait’ anxiety) or that describe a current emotional state (‘state’ anxiety). In animals, it is inferred by the animal's response to an anxiety-provoking situation such as a threatening environment. Distinctions between anxiety and other emotional states, such as fear or even ‘arousal’, are not always clear. Also, there are close associations between cognition and emotion: man has the capacity not only to know, but also to respond emotionally to what he knows.

However, anxiety is not only a behavioural phenomenon. Characteristic autonomic changes take place, typically including increased heart rate and/or blood pressure. There is also marked endocrine activation, particularly increased secretion of the adrenal hormones adrenaline (and noradrenaline) and cortisol (the ‘stress’ hormone). There has been much discussion of how far these ‘peripheral’ events can actually induce emotional states such as anxiety, or are part of the body's response to those states. Current opinion puts most emphasis on ‘central’ instigation (by neural mechanisms), though it may be true that accentuated autonomic activity can elicit emotional states, especially when there is a perceived rationale for such activity — ‘cognitive labelling’. Persistent changes in certain hormones (for example, cortisol) may alter the ability of an individual to respond anxiously to provoking stimuli.

Biologically, anxiety has a prime function in adapting to, or avoiding, threatening situations. In animals, one of many ways of inducing such a presumed response would be by pairing a neutral stimulus (say, a light) with a consequent aversive stimulus (such as a footshock). After several such pairings, presentation of the light alone will result in the behavioural and physiological features of anxiety. Similar features can be elicited by exposing animals to situations that they find naturally threatening, such as strange surroundings, or physical peril. This implies that a state of high anxiety is aversive — borne out in humans by the demand for drugs that reduce it, and in animals by showing that they will work to reduce their anxiety levels. Because animals and people find anxiety aversive, they will avoid those circumstances that give rise to it, and hence the threat itself. ‘Fear’ can be substituted for ‘anxiety’ in many of these contexts.

Anxiety can, therefore, be the result of stimuli which are naturally threatening (for example the response of a rat to the presence of a cat), those that have been associated with previous danger (the surroundings where the cat is found), or stimuli that are not in themselves threatening, but have become so because of a learned association between them and subsequent discomfort or threat.

Clinically, if significant or disabling levels of anxiety occur without there being sufficient apparent cause, either current or past, then the patient is said to suffer from an anxiety disorder. These disorders can be ‘global’, or generalized, in those people who have high levels of anxiety without evident provoking events; or they can be ‘specific’, where high anxiety is induced by circumstances which, for most people, would not be considered anxiogenic (such as open spaces, spiders, meeting people) — these are sometimes termed ‘phobias’. In some cases, anxiety occurs in sudden waves (‘panic attacks’). Anxiety may also occur as part of another medical condition, or as one result of a drug of abuse or a medication. Post-traumatic stress disorder is a particular form of anxious attack provoked by involuntary recall of a previously life-threatening episode (usually triggered by some salient stimulus; for example the sound of a helicopter in those traumatized by war). Psychoanalytical theory has been much concerned with the causes and meaning of individual differences in anxiety.

Attempts have been made to define particular parts of the brain that may be responsible both for physiological or pathological anxiety. There is general agreement that damage to the amygdala can reduce anxiety, both that which is a response to ‘natural’ stimuli and that generated by learned associations. The amygdala (or amygdaloid complex, or nucleus) is a collection of grey matter that is part of the limbic system, situated in each temporal lobe of the brain, between the cerebral cortex and the hypothalamus. It consists of a number of sub-components (nuclei), and some evidence is emerging that different nuclei in the amygdala may play defined roles in certain forms of anxiety. Electrical or chemical stimulation of the amygdala may induce anxiety-like states. There are those who think that the principal or only role of the amygdala is to generate fear or anxiety-like states, but it is more likely that this is one special case of a more general role for this part of the brain. Humans with congenital damage to the amygdala may also have difficulty, for example, in recognizing emotionality, such as fear, in others, or the emotional content of stories.

Scans of the brain by magnetic resonance imaging (MRI) show that the amygdala is activated by stimuli that induce or represent emotional states, including fear or anxiety. However, MRI and other imaging techniques have also shown many other parts of the brain to be activated in anxiety states, depending on the condition being studied, or the way in which anxiety is generated; these include parts of the cortex of the frontal lobes, known to be involved in emotional responses, and closely associated cortical areas. There are many connections between the amygdala and these areas of cortex. There is some evidence in the human brain for asymmetry in the role of the frontal cortex: the right side may be particularly important in aversive emotional states such as anxiety.

A number of chemical systems in the brain have been implicated in anxiety. The discovery that the benzodiazepine drugs (e.g. librium, valium) had major and quite specific anxiety-reducing (anxiolytic) effects on both humans and experimental animals prompted the search for chemicals in the brain that might regulate anxiety levels. Benzodiazepines act by antagonizing the neurotransmitter GABA (γ-amino-butyric acid), a compound widely used by nerve cells in the brain to inhibit the activity of other nerve cells. Why this should result in a specific effect on anxiety remains an enigma. At one time, many millions of prescriptions for benzodiazepines were written each year, but it has now become apparent that persistent use may have undesirable side effects, including rebound anxiety once they are discontinued. They nevertheless remain a staple treatment for anxiety disorders. Drugs acting on other systems also have clinically useful anxiolytic effects; these include drugs that modify the action in the brain of serotonin or of noradrenaline. Both serotonin and noradrenaline are activated in the brain by anxiety-inducing circumstances.

More recently, certain peptides in the brain have been shown to be involved in anxiety. One is corticotrophin-releasing factor (CRF). This peptide, when infused into the brain of an experimental animal, results in anxiety-like behaviour, as well as the other physiological signs of anxiety. CRF acts on specific receptors on neuronal cell membranes in the brain. These have been shown to be responsible for its anxiogenic actions, because drugs that block CRF1 receptors, or animals that are bred without these receptors (CRF1R-deficient transgenic mice), show reduced anxiety. CRF antagonists may, therefore, be the precursors of a new generation of anti-anxiety drugs. However, CRF has other behavioural effects, including actions on food intake and sexual behaviour, and it remains to be established whether other categories of receptors are responsible for these various roles. It is also not clear whether anxiety disorders can be related to inappropriate amounts of these normal neuropeptides, or to the presence of abnormal molecules.

— J. Herbert

Bibliography

• Davis, M. (1992). The role of the amygdala in fear and anxiety. Annual Review of Neuroscience, 15, 353-75.
• Le Doux, J. E. (1995). Emotion: clues from the brain. Annual Review of Psychology, 46, 209-35.
• LeDoux, J. E. (1998). The emotional brain. Weidenfeld and Nicolson, London

See also conditioning; peptides; membrane receptors; stress.

Anxiety produces feelings of apprehension and tension. Two components have been recognized: cognitive anxiety, characterized by distressing thought processes, and somatic anxiety expressed in physical reactions, such as butterflies and sweating. Anxiety may be an enduring personality trait (known as A-trait) or a temporary state (known as A-state). The term is often used synonymously with arousal, but anxiety corresponds only to high arousal states that produce feelings of discomfort. It is also closely associated with the concept of fear, but anxiety is more a feeling of what might happen rather than a response to an immediate fear-provoking situation.

Regular aerobic exercise may reduce general anxiety levels. Habitual exercisers often state that they feel better as a result of engaging in vigorous activity. This may be because exercise stimulates the brain to secrete endorphins, natural chemicals which have characteristics similar to morphine. Relaxation exercises may also reduce anxiety (see relaxation).

High levels of anxiety can adversely affect sporting performance. This can cause an athlete to enter an anxiety-stress spiral: the poor performance induced by anxiety results in even more anxiety and another poor performance. Anxious performers usually find it more difficult to focus attention, consequently they waste time and energy doing irrelevant tasks. See also catastrophe theory.

noun

A troubled or anxious state of mind: angst, anxiousness, care, concern, disquiet, disquietude, distress, nervousness, solicitude, unease, uneasiness, worry. See feelings.

Definition: worry, tension
Antonyms: assurance, calmness, composure, contentment, ease, happiness, nonchalance, peace, tranquility

A condition of heightened and often disruptive tension accompanied by an ill-defined and distressing aura of impending harm or injury. Anxiety can disrupt physiologic functions through its effect on the autonomic nervous system. The patient may assume a tense posture, show excessive vigilance, move the hands and feet restlessly, and speak with a strained, uneven voice. The pupils may be widely dilated, giving the appearance of unrestrained fright, and the hands and face may perspire excessively. In extremely acute forms the patient may have generalized visceral reactions of respiratory, cardiac, vascular, and gastrointestinal dysfunction. The dentist must recognize the existence of anxiety, seek its etiology and relation to dental treatment, and determine ways that the patient’s defenses against anxiety can be used to facilitate rather than inhibit treatment.

Definition

Anxiety is a bodily response to a perceived threat or danger. It is triggered by a combination of biochemical changes in the body, the patient's personal history and memory, and the social situation.

It is important to distinguish between anxiety as a feeling or experience and an anxiety disorder as a psychiatric diagnosis. A person may feel anxious without having an anxiety disorder. Also, a person facing a clear and present danger or a realistic fear is not usually considered to be in a state of anxiety. In addition, anxiety frequently occurs as a symptom in other categories of psychiatric disturbance.

Description

Anxiety is related to fear, but it is not the same thing. Fear is a direct, focused response to a specific event or object of which an individual is consciously aware. Most people will feel fear if someone points a loaded gun at them or if they see a tornado forming on the horizon. They also will recognize that they are afraid. Anxiety, on the other hand, is often unfocused, vague, and hard to pin down to a specific cause.

Sometimes anxiety experienced in the present may stem from an event or person that produced pain and fear in the past. In this experience, the anxious individual may not be consciously aware of the original source of the feeling. Anxiety has an aspect of remoteness that makes it hard for people to compare their experiences. Whereas most people will be fearful in physically dangerous situations, and can agree that fear is an appropriate response in the presence of danger, anxiety is often triggered by objects or events that are unique and specific to an individual. An individual might be anxious because of a unique meaning or memory being stimulated by present circumstances, not because of some immediate danger.

Causes & Symptoms

Anxiety is characterized by the following symptoms:

• Somatic. These physical symptoms include headaches, dizziness or lightheadedness, nausea and/or vomiting, diarrhea, tingling, pale complexion, sweating, numbness, difficulty in breathing, and sensations of tightness in the chest, neck, shoulders, or hands. These symptoms are produced by the hormonal, muscular, and cardiovascular reactions involved in the fight-or-flight reaction.
• Behavioral. Behavioral symptoms of anxiety include pacing, trembling, general restlessness, hyperventilation, pressured speech, hand wringing, and finger tapping.
• Cognitive. Cognitive symptoms of anxiety include recurrent or obsessive thoughts, feelings of doom, morbid or fear-inducing thoughts or ideas, and confusion or inability to concentrate.
• Emotional. Emotional symptoms include feelings of tension or nervousness, feeling "hyper" or "keyed up," and feelings of unreality, panic, or terror.

Anxiety can have a number of different causes. It is a multidimensional response to stimuli in the person's environment, or a response to an internal stimulus (for example, a hypochondriac's reaction to a stomach rumbling) resulting from a combination of general biological and individual psychological processes.

Physical Triggers

In some cases, anxiety is produced by physical responses to stress or by certain disease processes or medications.

THE AUTONOMIC NERVOUS SYSTEM (ANS). The nervous system of human beings is hard-wired to respond to dangers or threats. These responses are not subject to conscious control and are the same in humans as in lower animals. They represent an evolutionary adaptation to animal predators and other dangers that all animals—including primitive humans—had to cope with.

The most familiar reaction of this type is the fight-or-flight reaction to a life-threatening situation. When people have fight-or-flight reactions, the level of stress hormones in their blood rises. They become more alert and attentive, their eyes dilate, their heartbeats increase, their breathing rates increase, and their digestion slows down, making more energy available to the muscles.

This emergency reaction is regulated by a part of the nervous system called the autonomic nervous system, or ANS. The ANS is controlled by the hypothalamus, a specialized part of the brainstem that is among a group of structures called the limbic system. The limbic system controls human emotions through its connections to glands and muscles; it also connects to the ANS and higher brain centers, such as parts of the cerebral cortex.

One problem with this arrangement is that the limbic system cannot tell the difference between a real physical threat and an anxiety-producing thought or idea. The hypothalamus may trigger the release of stress hormones from the pituitary gland even when there is no external danger.

A second problem is caused by the biochemical side effects of too many false alarms in the ANS. When a person responds to a real danger, his or her body relieves itself of the stress hormones by facing up to the danger or fleeing from it. In modern life, however, people often have fight-or-flight reactions in situations where they can neither run away nor lash out physically. As a result, their bodies have to absorb all the biochemical changes of hyperarousal rather than release them. These biochemical changes can produce anxious feelings as well as muscle tension and other physical symptoms of anxiety.

DISEASES AND DISORDERS. Anxiety can be a symptom of certain medical conditions. For example, anxiety is a symptom of certain endocrine disorders that are characterized by over activity or under activity of the thyroid gland. Cushing's syndrome, in which the adrenal cortex overproduces cortisol, is one such disorder. Other medical conditions that can produce anxiety include respiratory distress syndrome, mitral valve prolapse, porphyria, and chest pain caused by inadequate blood supply to the heart (angina pectoris).

MEDICATIONS AND SUBSTANCE USE. Numerous medications may cause anxiety-like symptoms as a side effect. They include birth control pills, some thyroid or asthma drugs, some psychotropic agents, corticosteroids, antihypertensive drugs, nonsteroidal anti-inflammatory drugs (such as flurbiprofen and ibuprofen), and local anesthetics. Caffeine can also cause anxiety-like symptoms when consumed in sufficient quantity.

Withdrawal from certain prescription drugs—primarily beta-blockers and corticosteroids—can cause anxiety. Withdrawal from drugs of abuse, including LSD, cocaine, alcohol, and opiates, can also cause anxiety.

Childhood Development and Anxiety

Researchers in early childhood development regard anxiety in adult life as a residue of childhood memories of dependency. Humans learn during the first year of life that they are not self-sufficient and that their basic survival depends on others. It is thought that this early experience of helplessness underlies the most common anxieties of adult life, including fear of powerlessness and fear of not being loved. Thus, adults can be made anxious by symbolic threats to their sense of competence or significant relationships, even though they are no longer helpless children.

Symbolization

The psychoanalytic model gives a lot of weight to the symbolic aspect of human anxiety; examples include phobic disorders, obsessions, compulsions, and other forms of anxiety that are highly individualized. Because humans mature slowly, children and adolescents have many opportunities to connect their negative experiences to specific objects or events that can trigger anxious feelings in later life. For example, a person who was frightened as a child by a tall man wearing glasses may feel panicky years later, without consciously knowing why, by something that reminds him of that person or experience.

Freud thought that anxiety results from a person's internal conflicts. According to his theory, people feel anxious when they feel torn between moral restrictions and desires or urges toward certain actions. In some cases, the person's anxiety may attach itself to an object that represents the inner conflict. For example, someone who feels anxious around money may be pulled between a desire to steal and the belief that stealing is wrong. Money becomes a symbol for the inner conflict between doing what is considered right and doing what one wants.

Phobias

Phobias are a special type of anxiety reaction in which the person concentrates his or her anxiety on a specific object or situation and then tries to avoid. In most cases, the person's fear is out of proportion to its "cause." It is estimated that 10–11% of the population will develop a phobia in their lifetime. Some phobias—agoraphobia (fear of open spaces), claustrophobia (fear of small or confined spaces), and social phobia, for example—are shared by large numbers of people. Others are less common or are unique to the patient.

Social and Environmental Stressors

Because humans are social creatures, anxiety often has a social dimension. People frequently report feelings of high anxiety when they anticipate or fear the loss of social approval or love. Social phobia is a specific anxiety disorder that is marked by high levels of anxiety or fear of embarrassment in social situations.

Another social stressor is prejudice. People who belong to groups that are targets of bias have a higher risk of developing anxiety disorders. Some experts think, for example, that the higher rates of phobias and panic disorder among women reflects their greater social and economic vulnerability.

Several controversial studies indicate that the increase in violent or upsetting pictures and stories in news reports and entertainment may raise people's anxiety levels. Stress and anxiety management programs often recommend that patients cut down their exposure to upsetting stimuli.

Environmental or occupational factors can also cause anxiety. People who must live or work around sudden or loud noises, bright or flashing lights, chemical vapors, or similar nuisances that they cannot avoid or control may develop heightened anxiety levels.

Diagnosis

Diagnosing anxiety is difficult and complex because of the variety of possible causes and because each person's symptoms arise from highly personalized and individualized experiences. When a doctor examines an anxious patient, he or she will first rule out physical conditions and diseases that have anxiety as a symptom. The doctor will then take the patient's history to see if prescription drugs, alcohol or drug abuse, caffeine, work environment, or other external stressors could be triggering the anxiety. In most cases, the most important source of diagnostic information is the patient's psychological and social history. The doctor may administer several brief psychological tests, including the Hamilton Anxiety Scale and the Anxiety Disorders Interview Schedule (ADIS).

Treatment

Meditation and mindfulness training can benefit patients with phobias and panic disorder. Hydrotherapy, massage therapy, and aromatherapy are useful to some anxious patients because they can promote general relaxation of the nervous system. Essential oils of lavender, chamomile, neroli, sweet marjoram, and ylang-ylang are commonly recommended by aromatherapists for stress relief and anxiety reduction.

Relaxation training, which is sometimes called anxiety management training, includes breathing exercises and similar techniques intended to help the patient prevent hyperventilation and relieve the muscle tension associated with the fight-or-flight reaction. Yoga, aikido, tai chi, and dance therapy help patients work with the physical, as well as the emotional, tensions that either promote anxiety or are created by the anxiety.

Homeopathy and traditional Chinese medicine (TCM) approach anxiety as a symptom of a holistic imbalance. Homeopathic practitioners select a remedy based on other associated symptoms and the patient's general constitution. Homeopathic remedies for anxiety include ignatia, gelsemium, aconite, pulsatilla, arsenicum album, and coffea cruda. These remedies should be prescribed by a homeopathic healthcare professional.

Chinese medicine regards anxiety as a disruption of qi, or energy flow, inside the patient's body. Acupuncture and/or herbal therapy are standard remedies for rebalancing the entire system. Reishi (Ganoderma lucidum or Ling-Zhi) is a medicinal mushroom prescribed in TCM to reduce anxiety and insomnia. However, because reishi can interact with other prescription drugs and is not recommended for patients with certain medical conditions, individuals should consult their healthcare practitioner before taking the remedy. Other TCM herbal remedies for anxiety include the cordyceps mushroom (also known as catepillar fungus) and Chinese green tea. In addition, there are numerous TCM formulas that combine multiple herbs for use as an anxiety treatment, depending on the individual problem.

Herbs known as adaptogens may also be prescribed by herbalists or holistic healthcare providers to treat anxiety. These herbs are thought to promote adaptability to stress, and include Siberian ginseng (Eleutherococcus senticosus), ginseng (Panax ginseng), wild yam (Dioscorea villosa), borage (Borago officinalis), licorice (Glycyrrhiza glabra), chamomile (Chamaemelum nobile), milk thistle (Silybum marianum), and nettles (Urtica dioica). Tonics of skullcap (Scutellaria lateriafolia), and oats (Avena sativa), may also be recommended to ease anxiety.

A 2002 preliminary study found that St. John's wort could be an effective treatment for generalized anxiety. Patients taking 900 mg a day and higher doses responded well in early trials. However, further research was needed, particularly at doses higher than 900 mg per day. The Ayurvedic herb gotu kola, long used by practitioners of India's holistic medical system to enhance memory and relieve varicose veins, may also help patients with anxiety by working against the startle response.

Allopathic Treatment

Because anxiety often has more than one cause and is experienced in highly individual ways, its treatment often requires more than one type of therapy. In some cases, several types of treatment may need to be tried before the best combination is discovered. It usually takes about six to eight weeks to evaluate the effectiveness of a treatment regimen.

Medications

Medications are often prescribed to relieve the physical and psychological symptoms of anxiety. Most medications work by counteracting the biochemical and muscular changes involved in the fight-or-flight reaction. Some work directly on the brain chemicals that are thought to underlie the anxiety.

ANXIOLYTICS. Anxiolytics are sometimes called tranquilizers. Most anxiolytic drugs are either benzodiazepines or barbiturates. However, barbiturates, once commonly used, are now rarely used in clinical practice. Benzodiazepines work by relaxing the skeletal muscles and calming the limbic system. They include such drugs as chlordiazepoxide (Librium) and diazepam (Valium). Both barbiturates and benzodiazepines are potentially habit-forming and may cause withdrawal symptoms, but benzodiazepines are far less likely than barbiturates to cause physical dependency.

Two other types of anxiolytic medications include meprobamate (Equanil), which is now rarely used, and buspirone (BuSpar), a new type of anxiolytic that appears to work by increasing the efficiency of the body's own emotion-regulating brain chemicals. Unlike barbiturates and benzodiazepines, buspirone does not cause dependence problems, does not interact with alcohol, and does not affect the patient's ability to drive or operate machinery. However, buspirone is not effective against certain types of anxiety, such as panic disorder.

ANTIDEPRESSANTS AND BETA-BLOCKERS. The treatment of choice for obsessive-compulsive disorder, panic type anxiety, and other anxiety disorders is a group of antidepressants known as selective serotonin reuptake inhibitors (SSRIs), such as Prozac and Paxil. When anxiety occurs in tandem with depressive symptoms, tricyclic antidepressants such as imipramine (Tofranil) or monoamine oxidase inhibitors (MAO inhibitors) such as phenelzine (Nardil) are sometimes prescribed.

Beta-blockers are medications that work by blocking the body's reaction to the stress hormones that are released during the fight-or-flight reaction. They include drugs like propranolol (Inderal) or atenolol (Tenormin). Beta-blockers are sometimes given to patients with post-traumatic anxiety symptoms or social phobic anxiety.

Psychotherapy

Most patients with anxiety will be given some form of psychotherapy along with medication. Many patients benefit from insight-oriented therapies, which are designed to help them uncover unconscious conflicts and defense mechanisms in order to understand how their symptoms developed.

Cognitive-behavioral therapy (CBT) also works well with anxious patients. In CBT, the patient is taught to identify thoughts and situations that stimulate his or her anxiety, and to view them more realistically. In the behavioral part of the program, the patient is exposed to the anxiety-provoking object, situation, or internal stimulus (like a rapid heart beat) in gradual stages until he or she is desensitized to it.

Expected Results

Unfortunately, a 2002 report stated that about half of the patients with an anxiety disorder who see their primary care physician go untreated. The prognosis for resolving anxiety depends on the specific disorder and a wide variety of factors, including the patient's age, general health, living situation, belief system, social support network, and responses to different medications and forms of therapy.

Resources

Books

"Anxiety Disorders." In Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: The American Psychiatric Association, 1994.

Bloomfield, Harold H. Healing Anxiety with Herbs. New York: HarperCollins, 1998.

Corbman, Gene R. "Anxiety Disorders." In Current Diagnosis 9, edited by Rex B. Conn, et al. Philadelphia: W. B. Saunders, 1997.

Periodicals

Gaby, Alan R. "Consider St. John's Wort as Alternative to Kava. (Literature Review & Commentary)." Townsend Letter for Doctors and Patients (May 2002):34.

Mandile, Maria Noel. "Gotu Kola: This Ayurvedic Herb May Reduce Your Anxiety Without the Side Effects of Drugs." Natural Health (May–June 2002):34.

Zoler, Michael L. "Anxiety Disorder Often Goes Untreated in Primary Care. (504 Patients in 15 Practices Studied)." Family Practice News (April 1, 2002):14 –21.

Organization

The American Botanical Council. P.O. Box 144345, Austin, Texas 78714-4345. (512) 926-4900. Fax: (512) 926-2345. http://www.herbalgram.org.

[Article by: Paula Ford-Martin; Teresa G. Odle]

Definition

Anxiety is a condition of persistent and uncontrollable nervousness, stress, and worry that is triggered by anticipation of future events, memories of past events, or ruminations over day-to-day events, both trivial and major, with disproportionate fears of catastrophic consequences.

Description

Stimulated by real or imagined dangers, anxiety affects people of all ages and social backgrounds. When it occurs in unrealistic situations or with unusual intensity, it can disrupt everyday life. Some researchers believe anxiety is synonymous with fear, occurring in varying degrees and in situations in which people feel threatened by some danger. Others describe anxiety as an unpleasant emotion caused by unidentifiable dangers or dangers that, in reality, pose no threat. Unlike fear, which is caused by realistic, known dangers, anxiety can be more difficult to identify and alleviate.

A small amount of anxiety is normal in the developing child, especially among adolescents and teens. Anxiety is often a realistic response to new roles and responsibilities, as well as to sexual and identity development. When symptoms become extreme, disabling, and/or when children or adolescents experience several symptoms over a period of a month or more, these symptoms may be a sign of an anxiety disorder, and professional intervention may be necessary. Two common forms of childhood anxiety are general anxiety disorder (GAD) and separation anxiety disorder (SAD), although many physicians and psychologists also include panic disorder and obsessive-compulsive disorder, which tend to occur more frequently in adults. Anxiety that is the result of experiencing a violent event, disaster, or physical abuse is identified as post-traumatic stress disorder (PTSD). Most adult anxiety disorders begin in adolescence or young adulthood and are more common among women than men.

Demographics

According to the U.S. surgeon general, 13 percent, or over 6 million children, suffer from anxiety, making it the most common emotional problem in children. Among adolescents, more girls than boys are affected. About half of the children and adolescents with anxiety disorders also have a second anxiety disorder or other mental or behavioral disorder, such as depression.

Causes and Symptoms

A child's genetics, biochemistry, environment, history, and psychological profile all seem to contribute to the development of anxiety disorders. Most children with these disorders seem to have a biological vulnerability to stress, making them more susceptible to environmental stimuli than the rest of the population.

Emotional and behavioral symptoms of anxiety disorders include tension; self-consciousness; new or recurring fears (such as fear of the dark, fear of being alone, or fear of strangers); self-doubt and questioning; crying and whining; worries; constant need for reassurance (clinging to parent and unwilling to let the parent out of sight); distractibility; decreased appetite or other changes in eating habits; inability to control emotions; feeling as if one is about to have a heart attack, die, or go insane; nightmares; irritability, stubbornness, and anger; regression to behaviors that are typical of an earlier developmental stage; and unwillingness to participate in family and school activities. Physical symptoms include rapid heartbeat; sweating; trembling; muscle aches (from tension); dry mouth; headache; stomach distress; diarrhea; constipation; frequent urination; new or recurrent bedwetting; stuttering; hot flashes or chills; throat constriction (lump in the throat); sleep disturbances; and fatigue. Many of these anxiety symptoms are very similar to those of depression, and as many as 50 percent of children with anxiety also suffer from depression. Generally, physiological hyperarousal (excitedness, shortness of breath, the fight or flight response) characterizes anxiety disorders, whereas underarousal (lack of pleasure and feelings of guilt) characterizes depression. Other signs of anxiety problems are poor school performance, loss of interest in previously enjoyed activities, obsession about appearance or weight, social phobias (e.g., fear of walking into a room full of people), and the persistence of imaginary fears after ages six to eight. Children with anxiety disorders are often perfectionists and are concerned about "getting everything right," but rarely feel that their work is satisfactory.

Shyness does not necessarily indicate a disorder, unless it interferes with normal activities and occurs with other symptoms. A small proportion of children do experience social anxiety, incapacitating shyness that persists for months or more, which should be treated. Similarly, performance anxiety experienced before athletic, academic, or theatrical events does not indicate a disorder, unless it significantly interferes with the activity.

Separation anxiety disorder (SAD) is the most common anxiety disorder among children, affecting 2 to 3 percent of school-aged children. SAD involves extreme and disproportionate distress over day-to-day separation from parents or home and unrealistic fears of harm to self or loved ones. Approximately 75 to 85 percent of children who refuse to go to school have separation anxiety. Normal separation fears are outgrown by children by the ages of five or six, but SAD usually starts between the ages of seven and 11.

When to Call the Doctor

A qualified mental health professional should be consulted if a child's anxiety begins to affect his or her ability to perform the three main responsibilities of childhood: to learn, to make friends, and to have fun. Often fears and anxieties come and go with time and age. However, in some children, anxiety becomes severe, excessive, unreasonable, and long-lasting (usually considered as long-lasting if the child experiences the elevated level of anxiety for a month or more), interferes with the child's ability to function normally, and causes the child to be distraught and easily upset, thus necessitating professional intervention.

Diagnosis

Diagnosing children with an anxiety disorder can be very difficult, since anxiety often results in disruptive behaviors that overlap with other disorders such as attention-deficit hyperactivity. Children showing signs of an anxiety disorder should first get a physical exam to rule out any possible illness or physical problem. Diagnosis of normal versus abnormal anxiety depends largely upon the degree of distress and its effect on a child's functioning. The degree of abnormality must be gauged within the context of the child's age and developmental level. The specific anxiety disorder is diagnosed by the pattern and intensity of symptoms using various psychological diagnostic tools.

Treatment

Depending on the severity of the problem, treatments for anxiety include school counseling, family therapy, and cognitive-behavioral or dynamic psychotherapy, sometimes combined with antianxiety drugs. Therapies generally aim for support by providing a positive, entirely accepting, pressure-free environment in which to explore problems; by providing insight through discovering and working with the child or adolescent's underlying thoughts and beliefs; and by exposure through gradually reintroducing the anxiety-producing thoughts, people, situations, or events in a manner so as to confront them calmly. Relaxation techniques, including meditation, may be employed in order to control the symptoms of physiological arousal and provide a tool the child can use to control his or her response.

Creative visualization, sometimes called rehearsal imagery by actors and athletes, may also be used. In this technique, the child writes down (or draws pictures of) each detail of the anxiety-producing event or situation and imagines his or her movements in performing the activity. The child also learns to perform these techniques in new, unanticipated situations.

In severe cases of diagnosed anxiety disorders, anti-anxiety and/or antidepressant drugs may be prescribed in order to enable therapy and normal daily activities to continue. Previously, narcotics and other sedatives, drugs that are highly addictive and interfere with cognitive capacity, were prescribed. With pharmacological advances and the development of synthetic drugs, which act in specific ways on brain chemicals, a more refined set of antianxiety drugs became available. Studies have found that generalized anxiety responds well to these drugs (benxodiazepines are the most common), which serve to quell the physiological symptoms of anxiety. Other forms of anxiety such as panic attacks, in which the symptoms occur in isolated episodes and are predominantly physical (and the object of fear is vague, fantastic, or unknown), respond best to the antidepressant drugs. Childhood separation anxiety is thought to be included in this category. Psychoactive drugs should only be considered as a last treatment alternative, and extra caution should be used when they are prescribed for children.

Prognosis

Studies consistently report that anxiety disorders can be debilitating and impinge seriously on a person's quality of life. Despite their common occurrence, little is underbstood about the natural course of anxiety disorder. Adults experiencing anxiety disorders often report that they have felt anxious all of their lives, with one half of adults with general anxiety disorder reporting that the onset of the condition occurred during childhood or adolescence. Anxiety disorders can be chronic, and the severity of symptoms can fluctuate significantly, with symptoms being more severe when stressors are present. Without treatment, extended periods of remission are not likely.

Prevention

Parents can help their child respond to stress by taking the following steps:

• providing a safe, secure, familiar, and consistent home life
• being selective in the types of television programs that children watch (including news shows), which can produce fears and anxieties
• spending calm and relaxed time with their child
• encouraging questions and expressions of fears, worries, or concerns
• listening to the child with encouragement and affection and without being critical
• rewarding (and not punishing) the child for effort rather than success
• providing the child with opportunities to make choices; with more control over situations, the child has a better response to stress
• involving the child in activities in which he or she can succeed and limiting events and situations that are stressful for the child
• developing an awareness of the situations and activities that are stressful for the child and recognizing signs of stress in the child
• keeping the child informed of necessary and anticipated changes (e.g., moving, change of school) that may cause the child to be stressed
• seeking professional help or advice when the symptoms of stress do not decrease or disappear

The child should also be encouraged to use various techniques to reduce stress, including the following strategies:

• talking about problems to parents or others whom the child trusts
• relaxing by listening to music, taking a warm bath, meditating, practicing breathing exercises, or participating in a favorite hobby or activity
• exercising
• respecting themselves and others
• avoiding the use of drugs and alcohol
• feeling free to ask for help if he or she is having difficulties with stress management

Parental Concerns

Parenting an anxious child is difficult and can create stress within the entire family. Parents need to help the child learn and apply techniques to manage his or her anxiety. The use of support groups and professional assistance is recommended.

Parents of children with anxiety disorders may exhibit anxiety symptoms themselves and should also seek professional assistance.

See also Fear; Separation anxiety.

Resources

Books

Chansky, Tamar E. Freeing Your Child from Anxiety: Powerful, Practical Solutions to Overcome Your Child's Fears, Worries, and Phobias. New York: Broadway Books, 2004.

Dacey, John S., and Lisa B. Fiore. Your Anxious Child: How Parents and Teachers Can Relieve Anxiety in Children. New York: John Wiley & Sons, 2001.

Fox, Paul. The Worried Child: Recognizing Anxiety in Children and Helping Them Heal. Alameda, CA: Hunter House Publishers, 2004.

Rapee, Ron, Sue Spence, and Ann Wignall. Helping Your Anxious Child. Oakland, CA: New Harbinger Publications, 2000.

Spencer, Elizabeth, Robert L. Dupont, and Caroline M. Dupont. The Anxiety Cure for Kids: A Guide for Parents. New York: John Wiley & Sons Inc., 2003.

Wagner, Aureen Pinto Worried No More: Help and Hope for Anxious Children. Rochester, NY: Lighthouse Press Inc., 2002.

Organizations

Anxiety Disorders Association of America. 8730 Georgia Avenue, Suite 600, Silver Spring, MD 20910. Web site: www.adaa.org.

National Institute of Mental Health (NIMH), Office of Communications. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. Web site: www.nimh.nih.gov/.

Web Sites

The Child Anxiety Network. www.childanxiety.net/ (accessed October 11, 2004).

[Article by: Judith Sims]

For more information on anxiety, visit Britannica.com.

A general, and sometimes neurotic, state of fear or dread. See Angst.

A subjective feeling of apprehension and heightened physiological tension. The term is often used synonymously with arousal, but anxiety is usually restricted to high arousal states, which produce feelings of discomfort. The condition is closely associated with the concept of fear, but is more a feeling of what might happen, rather than a response to an obvious fear-provoking situation. Anxiety can be viewed as an enduring personality trait (see trait anxiety) and also as a temporary state (see state anxiety). Anxiety in sport may be affected by the objective competitive situation and the subjective competitive situation. Generally, a high level of pre-competitive anxiety depresses the level of performance by its effects on selectivity and/or intensity of attention. The detrimental effect may be due to cognitive state anxiety (also known as task irrelevant cognitive anxiety or tica) impairing a person's ability to discriminate between relevant and irrelevant information, resulting in the person wasting time doing irrelevant tasks. Regular exercise may reduce anxiety levels.

Anxiety is an unpleasurable affect in which the individual experiences a feeling of danger whose cause is unconscious. Freud had already begun considering the problem of anxiety in his correspondence with Wilhelm Fliess at the very start of his psychoanalytic work (1950a [1887-1902]). His subsequent efforts were more and more systematic as he developed two successive theories of anxiety.

In both of Freud's theories of anxiety a fundamental role is played by an absence of discharge, and hence of instinctual satisfaction. In his first account, the sexual instinct, undischarged, was described as being transformed explicitly into anxiety by a seemingly biological mechanism (1895b [1894]). Somatic sexual excitation with the help of sexual ideas thus could not develop into psychic libido. However, sexual representations could be repressed, and their attendant excitation either diverted toward somatic outlets, so giving rise to hysterical conversion symptoms or, alternatively, redirected into the substitute representations typical of anxiety hysteria or phobic neurosis.

In Freud's second theory of anxiety, set forth in Inhibitions, Symptoms, and Anxiety (1926d [1925]), unsatisfied instincts were not explicitly evoked. In this account, anxiety as a signal is developed by the ego as a defensive measure against automatic anxiety. The infant's biological and mental immaturity does not enable it to confront the increase in tension arising from the enormous amounts of instinctual excitation that it cannot discharge and satisfy. This generates a state of distress that is traumatic for the newborn, triggering automatic anxiety. The infant gradually comes to understand that the maternal object can put an end to this state of affairs. It is then that the loss of the mother is experienced as a danger, and this experience constitutes anxiety as a signal.

When the newborn begins to perceive its mother, it is unable to distinguish temporary absence from enduring loss; thus from the moment the mother is lost sight of, the baby behaves as if it is never going to see her again. Repeated experiences of satisfaction have created this object, the mother, which, as need arises, is intensely cathected in a way that might be described as nostalgic. From this moment on, in Freud's view, object-loss provokes psychic pain, while anxiety is the reaction to the danger associated with that loss. Sadness arises whenever reality-testing forces an acknowledgment that the object has been lost. In its various forms, object-loss becomes the prototype of later anxieties, which Freud lists as: anxiety at the loss of the love of the object, castration anxiety, and anxiety at the loss of the love of the superego.

The novelty of this theorization derives, on the one hand, from the genetic notion according to which anxiety is tied to the fear of re-experiencing very early human states of distress, and on the other hand, from the fact that these states are associated during early infancy with various fantasies about the maternal object, and later with fantasies concerning other objects, including the father (castration anxiety or anxiety at the loss of the love of the superego). The close connection thus posited between anxiety and ideation is radically at odds with Freud's first theory of anxiety.

Anxiety always occupied a central place in the work of Melanie Klein, first of all with respect to technique, and secondly in terms of theory. She stated repeatedly that her chief technical principle was that interpretation must focus on the point of maximum anxiety. Equilibrium between the life instincts and the death instincts was fundamental to Klein's understanding of the different forms of anxiety and the fantasies that expressed them. In her earliest writings, she associated anxiety and its related inhibitions with sexual conflicts of childhood bound up with the Oedipus complex. At the same time, however, she was struck by the scope of aggressive fantasies in young children, especially during what she called the phase of maximal sadism. She gradually came to view the child's aggressiveness towards the mother's body and its fantasy contents (penis, baby, feces, etc.) as responsible for an anxiety based on the fear of the reciprocal aggression it could provoke. The danger intrinsic to anxiety was thus seen as the result of the subject's excessive aggressiveness.

Although to begin with Klein's theory leaned heavily on Freud's Inhibitions, Symptoms, and Anxiety, from 1935 on, and especially after 1940, with the gradual working out of the concept of the "depressive position," she assigned object-loss a central role. This implied a change in the conceptualization of anxiety, which acquired a depressive character: anxiety was now seen as expressing "pain," which for Klein included both suffering and sadness in Freud's sense. Anxiety states were engendered by lived experiences of object-loss that were more or less definitive and irreversible.

Since experiences of loss were closely associated with the damage wreaked in fantasy by aggressive impulses, painful feelings were accompanied by feelings of conscious or unconscious guilt. This guilt generally tended to remain unconscious because of the great importance it assumed for the subject, who attributed an all-powerful destructiveness to his own aggression. The ego would then turn to radical (psychotic, manic, or depressive) defenses, which also made it difficult for painful feelings to gain access to consciousness. On the other hand, the more real the guilt, the more vigorously it would be supported by the ego, clearing a path to consciousness by way of feelings of sadness. A basic exception to this rule were the strong guilt feelings manifested by melancholics, whose self-reproach masked an attempt by the ego to overwhelm the introjected and attacked object with guilt.

After introducing the "paranoid-schizoid position" (1946), which she contrasted with the depressive position as a type of psychic functioning, Melanie Klein was able to develop a systematic theory of anxiety and guilt (1948). The theory relied primarily on Freud's concept of the death instinct, which Klein had adopted. In this view, anxiety was provoked by the danger with which the death instinct threatened the organism. Klein spoke of anxiety about "annihilation" and "fragmentation" with reference to very primitive terrors triggered by the inner working of the death instinct and with reference to the paranoid anxiety generated by persecutory objects or by the primitive superego. In this sense fragmentation anxiety may be considered a very archaic precursor of castration anxiety.

In the face of maternal frustration, Klein contended, the sense of an internal threat created by the death instinct reinforces the projection of destructive impulses by the primitive ego of the paranoid-schizoid position. As a consequence the breast as "bad" part-object becomes the source of "paranoid" or persecutory anxiety. Another portion of the death instinct is used by the ego in the form of aggression to attack the persecutory object. Introjection of both the persecutory breast and the persecutory penis is the foundation of the primitive superego, which is at first difficult to distinguish from internal persecutory objects since it provokes very intense persecutory anxiety (fear of fragmentation). This very early superego, in spite of its aggressiveness, strives to protect the libidinal bonds that the ego is meanwhile forming with good or idealized objects, which are experienced as the source of life.

As progress is made, with the help of libidinal instincts, toward the successful integration of aggression, fantasies arise, characteristic of the early stages of the Oedipus complex, involving part-objects in the process of being made whole: the mother's stomach and its fantasized contents (penis, baby, feces, etc.). If such objects provoke psychotic persecutory anxieties, these will manifest themselves clinically as the outcome of a defensive transformation of intolerable depressive anxieties produced under pressure from an overly aggressive primitive superego. In fact, as Klein indicated in her last writings, the paranoid-schizoid and depressive positions act simultaneously, whether in the service of defense or of integration. In clinical work, this is reflected in the coexistence of paranoid and depressive anxieties; one or the other will prevail, depending on which position is predominant in the patient.

During the various steps in the integration of the depressive position, a whole range of depressive anxieties is encountered, as distinguished by the particular fantasies that attend the loss of the libidinally cathected object in each type of case (Palacio Espasa, 1993). Thus whenever fantasies of catastrophic destruction come to the fore and the damage is experienced by the subject as irreparable because of the great force of his aggression, as he perceives it, the intensity of the ensuing guilt makes the pain and sadness hard to bear. The ego can only resort to psychotic defenses that transform these disastrous depressive anxieties into persecutory anxieties.

Where fantasies of destruction are less significant, and the subject's aggressiveness is experienced as less destructive, fantasies of the death of libidinally cathected objects may be prevalent. The ego can then use its store of libido, which it experiences as limited, as a massive barrier to any manifestation of aggression. This arouses intense feelings of guilt, and hence of responsibility for fears of death or of object-loss. The ego tends to defend itself against such painful depressive affects either in manic fashion, through identification with idealized and intact objects, or else by melancholic means, such as identification with the dead or destroyed aspects of objects.

When fantasies of loss of the object's love predominate, they center on rejection or abandonment by the object. Death fantasies are less intense and are experienced as more easily reversible because of the greater libidinal capacity available to the ego of subjects in this category. Under these circumstances the ego has a whole panoply of neurotic defenses at its disposal. These include the retroactive denial of the ill consequences of the subject's aggression and reaction-formations against aggression of a typically obsessive-neurotic kind. By means of phobic displacement and symbolization, a predominance of libidinal impulses facilitates the transformation of the conflict provoked by the loss of the object's love into a triangular conflict in which fantasies of exclusion become more prominent. Given well-integrated instinctual relationships with two highly cathected parental imagos, the experienced object-loss may be reduced to that of the loss of the incestuous object's exclusive love. On the other hand, the dangerous aggressiveness deemed responsible for the loss of the object's love may be projected onto the other parent, who then becomes a rival. An oedipal situation is thus created, along with the various conflicts, directly or indirectly expressed, that characterize the Oedipus complex.

In short, as the intensity of depressive anxieties decreases, the Oedipus complex comes to the fore thanks to the transformation of depressive conflict into a variety of neurotic conflicts that generate castration anxiety. In neurosis, however, along with castration anxiety intense depressive anxieties (especially guilt) may continue to exist with respect to the oedipal parents—more complete objects, often neglected in the literature on neurosis. Such anxieties may indeed occasion significant regression back toward depressive conflict.

In psychoanalytic theory castration anxiety is closely bound up with the Oedipus complex. For Freud castration is one of the primal fantasies. In his view of childhood sexuality, the Oedipus complex makes its appearance during the stage of phallic primacy, which means that castration anxiety is rather similar in the two sexes. Because of the overvaluation of the phallus, the child does not recognize the female sex as such and considers it to be the result of castration. In Inhibitions, Symptoms, and Anxiety Freud sees castration as one loss, on the level of genital sexuality, in a series of object-losses: the loss of the mother's breast, the loss of the contents of the intestines, and so on.

For Melanie Klein castration anxiety develops as a fear of reprisal for the child's oedipal rivalry with the parent of the same sex. In boys this becomes an anxiety about the loss of the penis at the hands of a vengeful father; in girls it becomes an anxiety about attacks against her own belly by the persecuting maternal object. From this theoretical standpoint, castration anxiety appears as a form of punishment for the manic and narcissistic fantasies constructed by the young child as protection against its feelings of exclusion from the sexual and genital relations of the parents, to which it does not have access because of its biological immaturity. The infant then takes possession in fantasy of the idealized sexual attributes of the parent of the same sex, who thus becomes a rival, and imagines it is the exclusive recipient of the love of the parent of the opposite sex. Such a fantasy position can only generate castration anxiety, if for no other reason than that it derives from the infant's apprehension of its own biological immaturity as a mutilation.

Separation anxiety appears when the subject experiences separation as a more or less irreversible object-loss. In the descriptions given by Margaret Mahler, the very young infant manifests separation anxieties after the fifth or sixth month, and they become especially significant between 15 and 18 months of age, during the rapprochement subphase of the separation-individuation (Mahler et al.). During this time the baby experiences real despair, feelings close to the nascent melancholy that Klein describes as occurring at the height of the depressive position. The presence of the external mother is essential, for her internal image is experienced as very much under threat from the child's aggressive fantasies, perceived by the child as massive and highly destructive. Only after the age of two or three, during the phase of object constancy, does the child become able little by little to overcome separation anxiety; by then it can retain an inner mental representation of the mother that is cathected for the most part by libidinal impulses.

Anxiety in the presence of actual danger, or "realistic anxiety," is a somewhat paradoxical concept employed by Freud in Inhibitions, Symptoms, and Anxiety, where (as we have seen) he views anxiety as arising from a felt danger from within occasioned by object-loss. Freud himself resolves the ambiguity when he asserts, in discussing apparently external dangers such as the loss of the object's love, or castration anxiety, that "the loved person would not care to love us nor should we be threatened with castration if we did not entertain certain feelings and intentions within us. Thus such instinctual impulses are determinants of external dangers and so become dangerous in themselves" (p. 145). In other words, all realistic anxiety is also anxiety tout court, and not simply fear of an external danger, for it always arouses an internal threat. This idea is crucial, of course, to the Kleinian concept of the depressive position, where every outside loss is accompanied by an experience of the loss of internal objects. Primitive experiences of loss are reactivated by the real loss, so that the working-through of such early internal losses is a prerequisite if objects lost in the outside world are to be successfully mourned.

Bibliography

Freud, Sigmund. (1895b [1894]). On the grounds for detaching a particular syndrome from neurasthenia under the description "anxiety neurosis." SE, 3: 87-115.

——. (1926d [1925]). Inhibitions, symptoms and anxiety. SE, 20: 87-172.

——. (1950a [1887-1902]). Extract from the Fliess papers. SE, 1: 173-280.

Klein, Melanie. (1946). Notes on some schizoid mechanisms. International Journal of Psycho-Analysis, 27, 99-110.

——. (1948). On the theory of anxiety and guilt. International Journal of Psycho-Analysis, 29, 113-123.

Mahler, Margaret S., Pine, Fred, and Bergman, Anni. (1975). The psychological birth of the human infant. New York: Basic Books.

Palacio Espasa, Francisco. (1993). La pratique psychothérapique avec l'enfant. Paris: Bayard.

Further Reading

Hurvich, Marvin. (1997). "The ego in anxiety" & "Addendum to Freud's theory of anxiety". Psychoanalytic Review, 84, 483-504.

——. (2000). Fear of being overwhelmed and psychoanalytic theories of anxiety. Psychoanalytic Review, 87, 615-650.

Roose, Stephen P. , and Glick, Robert. A. (Eds). (1995). Anxiety as symptom and signal. Hillsdale, NJ: Analytic Press.

—FRANCISCO PALACIO ESPASA

Emotional distress, especially that brought on by fear of failure. (See also angst.)