The most prominent form, and one might argue, the most prevalent form, of psychiatric illness, is anxiety, yet we to date have poor and incoomplete definitions of what anxiety is.

We need to address, then cetrain core questions:

(1) Is there something new about anxiety ?

(2) Is anxiety the same thing as fear ?

(3) Is the term "anxiety" used accurately or usefully ?

(4) What is the relationship of anxiety and other psychiatric syndromes ?

To address the first point: this time we live in has been called the "Age of Anxiety". Of special interest, psychiatry in its most current form (separate from the casuistry of the current academic assertions), is based upon the study of anxiety. Does that mean that it is a new phenomena ? Some aspects of anxiety are truly new.

The second question, the distinction between anxiety and fear, is troubling. The term "phobia", which describes so many different psychiatric events, is literally fear in Greek (Phobia (in Wikipedia))

Given that in the past, psychiatry as a medical science has stumbled repeatedly in attempting to provide this definition (or disntinction), we should be able to assert that there is a real distinction.

Fear is the present concern, based on reality, that one is facing loss of life and limb. For instance, in the stereotypical movie scene where the heroine is facing a stalking but unidentified killer, we call the repsonse of the heroine "fear."

In the case, however, of anxiety, we are looking not at a conscious awareness of peril of life and limb, but at something quite different.

The stereotypical case of fear, in the real world, might be described in the following way. One is in a car that one cannot escape from, and a speeding train is visible in the distance, and the car is on the train track. One feels fear, based on a real awareness of danger.

What we do not typically deny is fear, and yet does not have an explicit and aware feature to it, is the sense of danger that has no conscious component.

Examples of this might include a peripheral awareness of sounds or shapes moving in the dusk or early evening.

In such a case, rather than calling the response anxiety, we might more accurately describe it as primal fear.

Primal fear, then, is quite distinct from a direct awareness fear. For instance, consider a patient who has an apparent anxiety when at dusk, in the tropics, passing a short stand of mangrove trees, becomes acutely and suddenly distressed. Then, within a few seconds a dog passes from behind the mangrove trees. It is much more likely this is primal fear, vs. an anxiety about dogs, (unless we have a history otherwise), and is a primal fear of predation.

The fear of predation must, at some level, be present in all humans.

We can find specific examples in human responses to a wide range of animals, and a wide range of environmental scenarios.

For instance, take the example of a swimmer, passing over the surface of the deep ocean. There is no known threat. Nothing can be observed below but the dark green of the ocean depths. And yet, the swimmer has a knawing sense of unease, not completely at ease with his transit over the surface. That is indeed an example of primal fear.

And yet, primal fear is not simply a reflection of our CNS responding to the stimuli that are lying in the mind, based on predation.

Instead, consider the baby, the infant, and even the child, who, once out of hearing range of its mother's voice, becomes fussy, then desparate, then tearful, and eventually, in a full rage and tantrum. We might argue that the child is simply responding to a loss of comfort, but instead, we can think of the absence of the mother as producing a primal fear of loss of the mother. There may indeed be a basic instinct to demand the return of the mother and to warn the mother of the danger of her absence, but this can be argued to be accompanied by a primal fear of permanent loss of the mother.

Let use turn, then, to a quite different scenario.

Consider anxiety as a product of physical illness. For instance, a classic anxiety event producing physical illness include the following scenarios.

(1) Cardiac failure

(2) Myocardial infarcts

(3) Acute emphysema.

In each case we would see the following series of events: pain, shortness of breath, a sense of impending doom, a wish to have increased breath, rapid heart rate, sweating, confusion, and a rush of adrenaline.

The patient is attempting to find a means to alleviate the physical condition, but cannot, and in addition, and what is most distnct from fear, is unable to determine the source of the distress.

Thus it is that anything that produces similar physiologic responses, will produce anxiety, and that anxiety is simply the aware mind's confusion as to what the source of the physiologic effect is.

Many of the classic anxiety events -- panic is an example -- are occuring in a learned way. Learning and memory, then, can bring about anxiety, even when no actual primary physical illness is occuring, and such learning and memory can induce physiologic response and subjective anxiety that, in turn, can itself produce a secondary illness that itslef is simply a product of underlying risk factors.

Thus, a patient with anxiety produded by panic or a phobia, then finds a need to smoke a cigarette, and subsequent angina produces an autonomic response that amplifies the original autonomic response that is co - morbid to phobia or to panic.

Anxiety is best described, like depression, or delirium, or dementia, as a syndrome.

The general approach to anxiety is that it is triggered by something -- that it is focal.

When the anxiety occurs, and there is no evident focal source, the proper task of the psychiatrist is to seek out a mechanism by which the anxiety comes into play.

Freud's primary contribution was to describe the anxiety neurosis, which is the appearance of anxiety in the presence of an stimuli that is not obvious except with psychiatric examination.

We can also interpret Freud as providing clinical descriptions that are consistent with anxiety not being evident either to the examiner or to the patient until at least one examination has been completed.

In other words, the presence of the anxiety itself, remains hidden as the patient brings a complaint that does not appear to be anxiety - related, at first.

We then have at least three different scenarios for anxiety.

(1) Accompanying primary non - psychiatric illness

(2) Learned

(3) Neurotic

However, the simplest definition is one that will allow the coincidence of multiple factors.

In other words, a given episode of anxiety can include contributions from neurosis (or other syndromes described by Freud, such as obsessions and compulsions), learned anxiety, and contributions from underlying illness.

However, this does not exhaust the sources of anxiety. Any psychiatric illness, including major depression, schizophrenia, bipolar disease, schizoaffective disease, and a range of illnesses of cogntiion, can lead to anxiety.

In such cases, it helps to determine what is the primary agent in the illness process.

For instance, in many forms of developmental disability, the outcome of the struggle to cope with illness leads to anxiety. It does little good to any patient to treat anxiety, as a syndrome, without determining and treating its orgigin. To do so is to provide an incomplete diagnosis, just as Freud pointed out, to ignore the possibility of non - obvious anxiety in a matter where its presence should be suspected at least, is also an incomplete diagnosis.

More over, untreated anxiety (and thus its untreated antecedents) can lead to events that in and of themselves, if only seen in isolation, can lead to an erroneous conclusion about the illness.

A quite different source of anxiety is often ignored. Of interest, Freud also ignored the presence of it -- that is to say, when a patient has something that they urgently need to do -- or wish to do -- either may be true, then anxiety appears. We may call it urgency anxiety.

The two types of urgency anxiety are the following:

(1) Physiologic (examples include urgency to consume a substance one is dependent one, such as tobacco, or urgency of micturation or defecation)

(2)(a) Anxiety to complete a compulsion. This latter is not identified as a specific anxiety, but rather is to be found implicitly in Freud's wiritngs.

(2) (b) The compulsion may be a normal compulsion, but not physiologic. An example of the latter is the wish to complete a task in order to fullfill a social obligation or to complete a social gain. For instance, one may wish to go to the shortest line in the check out portion of a grocery store. This is due to not only the learned expectation that if one does not do so, other tasks accumulate (a learned anxiety) but also social in nature (the potential social reward of returning to work on time is present).

Both types of anxiety -- response to physiologic necessity, and response to compulsion, tend to be ignored in the psychiatric diagnostic process and in typical psychiatric illness taxonomies found in current texts.

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