The Emotions of Anxiety
Anxiety for most of us is an inevitable part of life. We all encounter everyday, real-life situations to which anxiety is a reasonable response. These situations can be as major as a death, divorce, or job loss, or as seemingly minor as going to the doctor or meeting new people at a social event.

Although anxiety is a very common emotional response, its expression can take different forms. It varies in intensity from being an appropriate response to stressful or difficult situations to being an actual psychiatric disorder. Disorders can occur when symptoms persist or are severe in nature. Some women have anxiety symptoms so intense that the symptoms interfere with their ability to function on a day-to-day basis.

The Physiology of Anxiety
While most women experience anxiety emotionally as upset and distress, we also react to these upsetting feelings on a physical level. What actually happens to our body when we are feeling anxious, nervous, or even panicky? Anxiety feelings normally set off an alarm reaction in our body called the "fight-or-flight" response. This response occurs to any perceived threat, whether it is physically real, psychologically upsetting, or even imaginary. Our thoughts and feelings can trigger this response; it can even occur simply when we're excited. The fight-or-flight response is a powerful protective mechanism that allows our body to mobilize energy quickly and either escape from or confront any type of danger.

The fight-or-flight response begins in our nervous system. The nervous system consists of the brain, the spinal cord, and the peripheral nerves. It is divided by function into two parts: the voluntary nervous system and the involuntary (or autonomic) nervous system.

The voluntary nervous system manages activity in the con-scious domain. For example, if you place your hand on a hot stove, pain fibers will trigger a response that is sent to the brain. The brain sends back an immediate response telling you to move your hand before you burn yourself. You then pull your hand away, fast.

The autonomic nervous system regulates functions of which the average person is usually unaware, such as muscle tension, pulse rate, respiration, glandular function, and the circulation of the blood. The autonomic nervous system is also divided into two parts that oppose and complement each other: the sympathetic and parasympathetic nervous systems. These control the upper and lower limits of your physiology, respectively. For example, if excitement speeds up the heart rate too much, the parasympa-thetic nervous system's job is to act as a control circuit and slow it down. If the heart slows down too much, then the sympathetic nervous system's job is to speed it up.

A fight-or-flight response stimulates the sympathetic nervous system, triggering several different physical responses. Our adrenal glands increase their output of adrenaline and cortisone as body chemistry adjusts to meet the crisis. The outpouring of these hormones causes the heart and pulse rate to speed up, the breath-ing to become shallow and rapid, and the hands and feet to become icy cold. In addition, muscles tighten up and become tense and contracted. The sympathetic nervous system also trig-gers the release of stored sugar in the liver, an increase in the metabolic rate of the body, inhibition of digestion, and an excess secretion of acid in the stomach-all in response to feelings of anxiety and stress.

Though the physiological response to anxiety or stress is the same no matter what the initial stressor is (physical danger, psychological distress, or imaginary threat), the chemical trigger for anxiety can vary greatly. For example, the chemical imbalance that triggers PMS-related anxiety is often quite different from the chemical or hormonal imbalances seen in hyperthyroidism or menopause-related anxiety. I will discuss the chemical triggers as I explore the common causes of anxiety.

In women with anxiety or panic episodes, the sympathetic nervous system is actually too sensitive or too easily triggered. Their systems are too often in a state of readiness to react to a crisis. This puts them in a constant state of tension-fight-or-flight.

The Common Causes of Anxiety
When a woman identifies anxiety as a serious complaint, any of four body systems may be compromised:

• · The nervous system, which comprises the fibers that connect the brain, organs, and muscles by transmitting impulses that allow normal bodily sensation and movement, as well as the experi-ence and expression of moods and feelings.

• The endocrine or glandular system, which regulates repro-ductive and metabolic functions, such as menstruation and the efficient burning of food for energy. The endocrine glands com-municate with one another by secreting into the bloodstream chemicals called hormones that carry chemical messages from one gland to another. The immune system, which fights foreign invaders in the body, such as bacteria, viruses, and cancer cells.

• The cardiovascular system, which consists of the heart and all the blood vessels in the body.

The remainder of this chapter discusses the most common physical and psychological problems in these systems that I have encountered over the years in my medical practice. Many (but not all) of them are problems often seen by any physician practicing primary care medicine. Most likely your symptoms of anxiety are related to one or more of these health problems.

Types of Anxiety Disorders
Three major types of psychologically-based anxiety disorders are most pertinent to women: generalized anxiety disorder, panic disorder, and phobias. Research in brain chemistry has shown that these anxiety disorders may also be linked to specific chemical changes in the brain, thus suggesting a strong mind-body link. The field of psychiatry recognizes other types of anxiety disorders, such as obsessive-compulsive disorder and post-traumatic stress syndrome, which I will not cover in this book; although they are important problems, they have less relevance for most women. While there tends to be some overlap in the symptoms experi-enced by women with the various types of anxiety disorders, there are still significant differences among the specific types.

Generalized Anxiety
Generalized anxiety disorder is characterized by chronic anxiety that tends to focus on real-life issues, such as problems with work, finances, relationships, or health, which feel dangerous or threat-ening to a woman's security and well-being. The emotional and physical symptoms of anxiety that these situations elicit must persist for at least six months to establish this diagnosis. Often, the real-life issues in turn elicit deeper emotional concerns, such as fear of abandonment, rejection, or not being loved. These deep fears may underlie the anxiety around troubled personal relation-ships, fear of failure, inability to cope effectively with stressful situations, and even fear of death when there are health concerns. Since the symptoms are experienced frequently, they can interfere with a woman's quality of life and her ability to function optimally on a daily basis.

Common symptoms include frequent upset, worry, and nervous tension, as well as insomnia, irritability, difficulty concen-trating, and startling easily. Physical symptoms include the typical fight-or-flight response of rapid heartbeat, cold hands and feet, shortness of breath, muscle tension, shakiness, depression, and chronic fatigue. The symptoms, however, are not so severe as to be complicated by panic attacks and phobias. Generalized anxiety disorder can date back as early as childhood, but a majority of patients are initially diagnosed in their twenties or thirties. The disorder seems to occur with equal frequency among both men and women. Consult a physician if you suffer from an apparent general-ized anxiety disorder to rule out any possible medical disorders that could be causing these symptoms. For example, hyper-thyroidism, food allergies, or PMS are often mistaken for an anxiety disorder. In addition, since anxiety and depression can coexist, it is important to know which is the primary component, as treatment can differ depending on which is primary and which is secondary.

Panic Disorder
The experience of panic is characterized by the sudden onset of intense fear or apprehension that occurs unexpectedly for no apparent reason. Usually the panic symptoms appear without prior warning, catching a person unaware; a woman is often in the middle of a panic episode before she even has time to register what is happening. Luckily, the acute phase of the panic attack tends to be short-lived, lasting only a few minutes. However, the symptoms may persist beyond the initial attack, though at a level of lesser intensity. To have the diagnosis of panic disorder, a woman must have experienced at least four panic attacks in a one-month period, or have experienced significant apprehension and worry throughout an entire month following a single panic attack. As in generalized anxiety disorder, the symptoms are typical of the fight-or-flight reaction, although panic attacks tend to be much more intense and disabling.

Since panic attacks are acute and short-lived, they also differ in duration from generalized anxiety disorder, where the symptoms are persistent and chronic. Typical symptoms include at least four of the following: rapid heartbeat or heart palpitations, chest pain, shakiness, dizziness, faintness, shortness of breath, cold hands and feet, numbness and tingling in the hands and feet, intestinal distress, sweating, feelings of losing control, and feelings of unreality. Between panic episodes, women can suffer much fear and apprehension, worrying about their recurrence. Panic disorder tends to coexist with agoraphobia (fear of open spaces or public places), which is also discussed in this chapter. In fact, panic attacks in combination with agoraphobia affect 5 percent of the population in this country, while only 1 percent suffer from panic disorder alone. Panic disorder tends to develop during the twenties in susceptible women.

It is important to differentiate panic disorder from medical problems such as mitral valve prolapse (which can coexist with panic disorder and produce similar symptoms) and hypogly-cemia,or even chemical imbalances like drug withdrawal or excessive caffeine intake. A careful diagnostic evaluation should be done by a physician to make sure that a medical problem necessitating specific, nonpsychiatric therapies has not been over-looked or misdiagnosed.

Phobias
Phobias are characterized by an excessive, persistent, and often irrational fear of a person, object, place, or situation. In severe cases, the person suffering from a particular phobia will try to avoid the inciting trigger. At the very least, a phobia can create severe emotional distress and can cause a person to postpone facing situations that trigger the phobia. Day-to-day functioning or even one's health and well-being can be compromised, particu-larly when the phobia centers on being in public places, going to social gatherings, giving public speeches, or even seeing a doctor or dentist.

As mentioned earlier, agoraphobia (fear of open or public spaces) is fairly prevalent in our society, affecting 5 percent of the population to some degree. In fact, it is the most common of all the anxiety disorders. Approximately three-quarters of all agora-phobics are women. Women with agoraphobia may develop a panic attack when placed in such common situations as using public transportation (buses, airplanes, trains), being in public places like department stores, shopping malls, and crowded restaurants, or being in confined spaces such as tunnels. In all these cases, an overriding concern is the fear of being trapped in a place where escape is difficult and being overcome by a panic attack. Many women are also concerned about the reactions people around them may have if a panic attack occurs.