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In Transition

Generalized Anxiety Disorder and Social Phobia


Dr. Peter Melgaard Thompson

We left off the last column writing about Obsessive Compulsive Disorder and anxiety in general. Right now, I am anxious that you understood what I was writing about. Since I am on an airplane flying several miles above the ground, I am also a little afraid of a plane crash. Now you could say I am an anxious fellow, and you would probably be right.

But do I have the psychiatric disorder called Generalized Anxiety disorder (GAD) or Social Phobia or am I just phobic of airplanes? Now having written this about myself, I will proceed from the specific to the general. Consequently, I will not be discussing my anxieties, but rather when anxiety and anxious worry is an illness and how to medically treat people with phobias.

General Anxiety Disorder

General Anxiety disorder or GAD for short (GAD) is excessive anxiety or worry that occurs most of the time. GAD occurs in about 5% of the population. Most people will first seek treatment in their early 20s, though most people with GAD say they started being excessively anxious as children. This is a life long or chronic illness. But there are always exceptions. As with most chronic diseases, sufferers have good and bad times.

Doctors diagnose GAD when a person has excessive anxiety that is out of proportion to the stress of one's life and that has lasted for at least 6 months. Now having written this, what is meant by it? First, what is excessive anxiety? I am not sure that I know but I have a pretty good idea of what is normal fear. A good example of a normal anxiety is fearing poverty when your are unemployed. When your child is sick, it is normal to worry about his/her health. However when you are employed and your job is in good shape and you still spend all day worrying about the job -- that is excessive. If your child is not ill but your cannot stop thinking about what if he/she were ill, that is also excessive.

In addition to the worry part of GAD there are physical symptoms including restlessness, excessive fatigue muscle tension and the like.

Social Phobia and Specific Phobias

Less is know about Social and Specific (simple) Phobias, but the symptoms usually first occur when patients are in their late teens. About 10% of the population suffer from this disease. This is another chronic disease with most patients showing symptoms all their lives. These patients are sometimes less fearful than at other times.

In social phobia, individuals also excessively worry, but the worry is a specific sense of embarrassment when under the public's eye. One example is worrying so much about the speech you will have to give if you promoted that you turn down the promotion. Other types of social phobia include fear of using a public bathroom or fear of writing or eating in front of other people. Another kind of phobia is called specific phobia which is the fear of a particular (specific) thing. For example the fear of heights, certain animals, insects, snakes and closed spaces are all specific phobias.

These fears are not diseases unless they seriously impair the sufferer. Again we must define our terms - what is impairment? A mental impairment occurs when an individual is stopped from doing something important that they would otherwise do. If a person has a social phobia of public speaking and has found a meaningful life requiring no public speaking, then the person would not have a social phobia. But the same person could manifest the disease of social phobia simply getting by a new job requiring public speaking. If tortuous agony would result, this new circumstance would realize the latent disease of social phobia. Impairment may also happen to people with specific phobias. For example a roofer who develops a fear of heights and then becomes unable to perform his/her job, is impaired.

So what? Well the so what is that there are effective treatments, if the correct diagnosis is made!


First, if the anxiety is caused by a medical non-brain condition, such as hyperthyroid disease, chronic lung disease or cancer, then the treatments discussed below will not work unless the underlying illness is treated. Consequently if you think this applies to you then you are best advised to first consult your physician.

Another kind of anxiety or phobia treated differently is the anxiety caused by the use of excessive alcohol or street drugs.

Since we have extensive research on the treatment of anxiety we have a pretty good idea of what will work to make people feel better. Treatments basically fall into 3 categories; medication treatment (drugs), psychotherapy and quackery. I am only going to write about the first two; you have no doubt already been exposed to the third.

If you have a mild case of any type of anxiety, the best treatment is psychotherapy or counseling. The types of psychotherapies that have been demonstrated to be helpful include, behavioral, cognitive, inter-personal and psychodynamic. Which one you use is best decided by you and your doctor. For people with more severe symptoms the optimum treatment is a combination of drugs and psychotherapy. Drugs treatment is most effective in reducing the symptoms of GAD. They have some effect against social phobias but are ineffective in treating specific phobias. For people with these diseases who can't take medication, psychotherapy is the only treatment.

The reverse is also the case in that some people do not benefit by psychotherapy. In that case drug treatment is the only alternative.

For those who can and will take medications then there are many that are effective. Social phobias like public speaking phobia can be treated with the beta-blockers like propanolol for moderate cases and monoamine oxidases inhibitors like Nardil for severe ones. The beta-blockers block sensors (nerves) in your body from sending signals that the brain over reacts to. They also slow heart rate and decrease sweating. The monoamine oxidases inhibitors alter signals within the brain itself. A note of caution: all medications have the potential for side effects and should only be used under a doctor's supervision.

There are quite a few medications that are effective treating GAD. The most well known class of medications are the benzodiazepines. This class of medications includes Valium, Librium, Ativan, and Serax. These drugs are addictive and if misused are very dangerous. There is a public debate raging over the use of these drugs. People addicted to alcohol or street drugs should not use them. But given that caveat, this class of medications, if used correctly with proper medical supervision, is safe and effective. As it turns out all of the antidepressants are also effective. These include the selective serotonin re-uptake inhibitors (fluoxetine, sertraline and paroxetine) and the tricyclics (amitriptyline, nortriptyline and desipramine).

A final reminder is that anxiety disorders usually are chronic, lifelong and the severity of the symptoms will fluctuate. If you are just starting medication treatment and its helps, you should try staying on the medicine for about 6-12 months. Then you can slowly reduce the dosage. If the anxiety returns you will have to increase the dosage of your medication. If on the other hand your anxiety does not resurface even after you have stopped taking any medication, then there is no need to continue the medical treatment unless your symptoms recur. But just remember the point of all of this is to make you feel better. If the drugs work, use them. If they don't help, try something else but don't fool around with quacks.

© 1997 Peter Melgaard Thompson

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