"I've frozen, mortifyingly, on stage at public lectures and presentations, and on several occasions I have been compelled to run offstage. I've abandoned dates, walked out of exams, and had breakdowns during job interviews, on plane flights, train trips, and car rides, and simply walking down the street. On ordinary days, doing ordinary things - reading a book, lying in bed, talking on the phone, sitting in a meeting, playing tennis - I have thousands of times been stricken by a pervasive sense of existential dread and been beset by nausea, vertigo, shaking, and a panoply of other physical symptoms. In these instances, I have sometimes been convinced that death, or something somehow worse, was imminent.
"Even when not actively afflicted by such acute episodes, I am buffeted by worry: about my health and my family members' health; about finances; about work; about the rattle in my car and the dripping in my basement; about the encroachment of old age and the inevitability of death; about everything and nothing. Sometimes this worry gets transmuted into low-grade physical discomfort - stomachaches, headaches, dizziness, pains in my arms and legs - or a general malaise, as though I have mononucleosis or the flu. At various times, I have developed anxiety-induced difficulties, breathing, swallowing, even walking; these difficulties then become obsessions, consuming all of my thinking...."
This is how journalist Scott Stossel, who wrote the bestseller 'My Age of Anxiety: Fear, Hope, Dread and the Search for Peace of Mind', describes his life as the result of a disorder that he began to suffer at the age of ten and has still not overcome now in his mid-forties. It will ring a bell with many people, because during the past 12 months about six per cent of the population of Spain has been affected by anxiety.
Actually, anxiety as such is not a bad thing, believe it or not. It is just an emotion that prepares us to adapt to, or face up to, certain circumstances. "It's a warning sign about a stimulus that could threaten our interests," says Dr Antonio Cano Vindel, president of the Spanish Society for the Study of Anxiety and Stress (SEAS).
Obviously, some situations are more worrying than others: "These are the ones that involve a major stress component, where there is a lot of uncertainty. They make the patient feel defenceless because they don't know how to get out of the situation and they see it as a threat.
"It's very similar to fear, but we know what is causing us to feel afraid. With anxiety we don't know why we're feelng like that, so we don't know what to do about it," explains Dr José García, psychiatric advisor of the Spanish Confederation of Associations for Families and People with Mental Illness (FEAFES).
It's quite logical for us to function with a certain amount of anxiety, because it 'activates' us in situations where this is necessary, such as when we are sitting an exam, for example, and it 'deactivates' us afterwards, when we need to rest.
"It is important to bear that in mind, because anxiety is not a problem until it intensifies, becomes chronic or takes the form of attacks and crises which mean the person loses control, and it turns into a series of symptoms that are classified as a mental health problem," says Dr García.
So when people suffer permanent or chronic anxious reactions, more intensive symptoms occur and, over time, it becomes a type of illness. "At first anxiety helps us to perform better, but if it doesn't allow us to rest then it wears us out," says Dr Cano.
Stossel's testimony shows that anxiety produces numerous symptoms, including shaking, stomach pains, palpitations and hypertension, and these can sometimes be confused with physical illness. It can also occur the other way round, when what appears to be a symptom of anxiety is actually something else. "It is important to identify the difference," stresses Dr García.
What are these symptoms, though? The president of SEAS says they have to be considered on different levels: cognitive-subjective, physiological and motor.
At a cognitive-subjective level they can include feeling unwell, worry, hypervigilance, tension, fear, insecurity, a feeling of losing control, negative thoughts about oneself or the way one acts in front of others, difficulty in thinking or concentrating, and perceiving major physiological changes (cardiac, respiratory etc.).
At a physiological level different systems are activated, principally to do with the nervous, endocrine and immune systems. Many changes can occur, but the individual may only notice some of them such as heart rate, breathing, sweating, muscular tension, gastric sensations, dry mouth, nausea, dizziness etc. There can also be transitory psycho-physiological disorders such as headaches, insomnia, erectile dysfunction, muscle cramps, gastric disorders etc.
At a motor level symptoms may include restlessness, hyperactivity, repetitive movements, difficulties in communication (stammering), avoiding fearful situations, consuming substances (food, drink, tobacco...), crying, tense facial expression etc.
Excessive anxiety, with its constant nervousness and activity, can cause an anxiety disorder. When it reaches this point, each person will have specific reactions and those will determine the type of disorder from which they are suffering.
When people who have an anxiety disorder are asked how much time they spend thinking about their problem, they normally say about 80 per cent of their free time. People who suffer from panic magnify their physical sensations of anxiety and pay them a lot of attention, while those with social anxiety are concerned about their conduct in social situations, which they consider inappropriate, so they focus their attention and spend a lot of time thinking about that.
Let's take a look at the different reactions and disorders:
Panic attacks (crises of anxiety or anguish). This involves an intense anxious reaction which you feel you are unable to control (especially the physical signs) and a conviction that you could die at any moment. Those feelings (such as imminent death, heart attack etc.) are caused by extremely worrying thoughts and you often hyperventilate, causing a very rapid increase in generalised physiological activation.
Agoraphobia. This is caused by anticipating and avoiding situations which could lead to an anxious reaction or panic attack which other people could not fail to notice. If it is not possible to avoid some of these situations, this can trigger the expected anxious reaction. Examples include crowded rooms and flying.
Specific phobia. Anxiety is produced in specific situations so people avoid them, such as being afraid of enclosed spaces.
Social phobias. Very intense anxious reactions occur when the individual is in a social environment, so they often try to avoid such situations, such as public speaking.
Obsessive-Compulsive Disorder. The obsessions can take the form of persistent ideas, thoughts, impulses or images which the individual considers intrusive and inappropriate and which cause them considerable anxiety or discomfort. These are not just simple concerns about everyday life. The person tries to control or neutralise obsessive thoughts (dirt, untidiness, illness, the gas valve, damaging others...) through other thoughts or actions (compulsions). The most common compulsions are checking something several times, counting, washing, avoiding being alone with somebody... in the end the sufferer wastes a great deal of time, which interferes in their life and causes them considerable discomfort and high levels of anxiety.
Post-traumatic stress disorder. This occurs after having suffered or observed a very traumatic event (an attack, rape, assault, accident...) in which people's lives were in danger. The images of the traumatic situation keep returning over and over again (flashbacks), against the person's will, in full detail, and they lead to intense reactions of anxiety (worry, fear, lack of control, high physiological activation, avoidance of related situtions...)
Acute stress disorder. Similar to post-traumatic stress disorder, it appears immediately after the traumatic event.
Generalised anxiety disorder. This is suffered by people who have intense anxiety reactions (worry, high physiological activation etc.) for more than six months, in very common situations, which are not classified as phobia, obsession, panic or post-traumatic disorders. People who suffer from this disorder show signs of worry and anxiety nearly all the time. The anxiety is caused by mistaken interpretations or anticipatory thoughts about everyday problems.
Anxiety disorder due to medical illness. Many anxiety symptoms are considered side effects of a medical illness such as hypothyroidism.
Substance-induced anxiety. The symptoms are associated with the consumption, abuse of or dependence upon a drug . Habitual consumers show higher levels of anxiety than non-consumers, even after they have stopped consuming the substance, and they are more likely to develop panic attacks.
Non-specific anxiety disorder. This is a classification which is used when there are strong signs of anxiety or phobic avoidance but they do not meet the criteria to be diagnosed in any other category of anxiety disorder.
Reducing the amount of time that sufferers spend thinking about their problem and disarming those thoughts are part of the treatment to 'deactivate' anxiety. They also need to face up to the situations which cause them stress without giving them the normal ritual importance, such as people who wash their hands over and over again because they think there may be microbes on them, for example.
"They have to force themselves not to keep washing, not to keep checking that they have locked the door... and when nothing bad happens they begin to realise that what they thought was so important actually isn't importantat all,"says Dr Cano.
"There are also associated conditionings, such as if someone is attacked once when they are drawing cash at an ATM, they daren't go to a machine again because they are convinced the same thing will happen if they do. That affects their normal life. They have to relearn, and gradually the symptoms which caused them so much anxiety will start to disappear." In this way, people gradually learn how to use relaxation methods and control the anxiety caused by these problems.
This cognitive-behavioural treatment, which experts say is better than drugs, is now being carried out by some GPs. "It is being used in 14 health centres in Madrid, Castilla La Mancha, the Balearics, the Basque Country and Valencia to treat anxiety disorder. We give the patients information and teach them relaxation and cognitive skills so they don't magnify the situation, they don't see it as a threat and so they don't have to avoid situations which cause them anxiety," says Dr García.
When it comes to using medication, doctors need to be very rigorous because there has been a considerable increase in the use of hypnotics, antidepressants and anxiolytics in recent years and Spain is one of the countries with the highest consumption of anxiolytic drugs.
"Sometimes they solve the problem but they can also have a downside; they can have side effects which stop the patient learning self-control," explains Dr García.