What Is Anxiety?

The word anxiety means “a state of being uneasy, apprehensive, or worried about what may happen.” It is also described as a “feeling of being powerless and unable to cope with threatening events . . . [characterized] by physical tension.” Though this is a dictionary definition, it certainly fits the way that many women feel about their lives today. The frequency with which women feel anxiety is reflected in my medical practice: My patients complain about anxiety and other emotional symptoms more than anything else. This is true whether they are seeking help for primarily psychological or physical ailments.


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.


As the phobia becomes worse, even thinking about being in a situation to which one has a phobic reaction can engender panic. As a result, women with agoraphobia often begin to restrict their range of activities and locations. In extreme cases, they may only venture out when accompanied by a trusted friend or relative. Some agoraphobias are even afraid to be alone in their own homes unless a companion remains with them. Luckily, agoraphobia is an easily treated condition if the appropriate therapy is under-taken. A combination of medication, counseling, and stress management training will produce good results in as many as 90 percent of all people suffering from this condition.


Another common type of phobia is social phobia. This occurs when there is fear of performing in front of other people or being scrutinized by other people. The most common social phobia involves public speaking. This is a major issue for many people, including students giving speeches in class, women who must give a formal presentation at work or at social or charitable func-tions, and even professional actors and other performers. Other common social phobias include fear of eating in public, fear of being watched or looked at while at social gatherings, fear of signing documents in front of other people, fear of being photo-graphed in a crowded room, or even fear of blushing in public. These phobias may begin in childhood and can persist throughout adult life (although in many women, social phobias decrease in severity with age). They often develop in children who are more shy and self-conscious.


Many people employ a variety of self help techniques to deal with social phobias, some of which are remarkably effective. For example, professional and amateur speaking groups and organi-zations give people the chance to speak in front of a supportive peer group; this often helps decrease anxiety related to public speaking. Classes on self-image and self-esteem utilize a variety of imaging and assertiveness techniques; these classes tend to be very popular and well-attended. Some women find that they can effectively dispel social phobias when engaged in one-on-one counseling.


A third type of phobia, called simple phobia, involves fear of a particular situation or object. Common examples of simple phobias include fear of animals like dogs or snakes, airplanes (for fear the airplane will crash), heights, or even having blood drawn for a medical test. Many simple phobias originate in childhood and persist into adult life (even though the adult may recognize that they are irrational). They may also originate in a traumatic event, such as being stuck in an elevator or experiencing a near accident during plane travel. A traumatic event may condition a person to fear repeated exposure to a similar situation (e.g., plane travel or using an elevator). Simple phobias are easiest to treat, because the fear response can usually be handled by gradual exposure to the phobia-inducing situation or object as well as the practice of a variety of stress-reducing techniques such as visual-izations and affirmations. These are discussed in the self help section of this book.


Risk Factors for Anxiety Disorders


A variety of factors can predispose a woman to develop anxiety disorders. These include physiological imbalances, genetic factors (familial predisposition), family programming, major long- and short-term life stresses, and personal belief systems.


Physiological Imbalances


Research suggests that women with generalized anxiety disorder may have an imbalance of gamma amino butyric acid (GABA) in their brain. GABA is a neurotransmitter, a substance that transmits messages from one part of the brain to another. When people are given GABA or placed on drugs that increase the activity of GABA, their anxiety is diminished. While the exact mechanism triggering generalized anxiety is not known, it is possible that a GABA deficiency or extreme sensitivity on the part of the body to the available GABA levels may play a role in its etiology. Similarly, panic disorders have been identified as occurring in animals when there is a dysfunction in a specific system in the brain called the noradrenergic system. This system is very sensitive to another neurotransmitter called norepinephrine. When there is a dysfun. tion in the way the noradrenergic system functions, panic attack are triggered.


Genetic Factors (Familial Predisposition)


Genetic factors seem to have some relevance as risk factors for developing anxiety disorders. For example, in studies of identical twins, the likelihood of both twins having an anxiety disorder if one is afflicted is statistically significant (greater than 30 percent) Fraternal twins, who do not have the same genetic makeup, are also at higher risk of developing an anxiety disorder if their sibling is affected, although they do not have nearly the risk of identical twins. Agoraphobia, the most common anxiety disorder also seems to show a familial predisposition. While 5 percent of the entire population suffers from this condition, the rate of agoraphobia in people with one parent who had this diagnosis if 15 to 25 percent.


Family Programming


Certain types of family environments seem to predispose children to develop anxiety disorders, producing insecurity, fear, and dependency in susceptible children. One such setting is created ~ parents who are critical perfectionists, constantly demanding that a child perform at peak levels. In this family, any departure from peak performance is punished or criticized. A child in this situa-tion may grow up with a poor sense of self-esteem, anxious and afraid to take risks for fear of failing.


Parents who themselves have phobias or are overly anxious may also raise children who suffer from anxiety. These parents tend to teach their children that the world is a fearful place, full c danger and risks. This type of family may raise a child who is timid and anxious about meeting new life challenges.


Parents who are overly controlling and suppress a child’s self-assertiveness by punishment may engender anxiety in their children. In this environment, children are punished for speaking out and expressing their feelings. Such children may grow up afraid to take initiative or show their true convictions.


Not all children raised in stressful family environments develop anxiety disorders. Many children grow up in very difficult family environments without ever suffering excessive anxiety. The likeli-hood of developing an anxiety disorder when raised in a high-stress family is probably greater in children born with more sensitive and reactive personalities. These are children whose fight-or-flight response is easily triggered by upsetting circumstances.


Major Life Stresses


Women who have suffered from major life stresses over a long period of time, such as marriage to an abusive husband, death, chronic illness in several family members, or constant financial worries, may find their ability to handle stress with equanimity and calm hampered. Unremitting major life stresses are likely to cause wear and tear on the nervous system and, over time, cause a woman to be excessively anxious or tense.


In addition, a major stress occurring in a short period of time can also engender anxiety. This is particularly true when the stres-sor-such as death of a spouse or loss of a long-term job-causes significant life change or dislocation. Even positive experiences such as getting married or having a baby cause anxiety, because they throw people into entirely new situations for which they may have no preparation.


Personal Belief Systems


Many women have belief systems that reinforce the anxiety disor-ders and engender behavior that maintains the anxiety state. These include poor self-image and a low estimate of one’s abili-ties. Many women with anxiety disorders are very insecure and feel ill-equipped to make the life changes necessary to confront and change anxiety-related issues.


Women with anxiety disorders often hold a negative view of the world. They see life situations and places as dangerous and threatening, whereas women without anxiety disorders may see the same circumstances as harmless and benign. These negative belief systems about the outside world, if too ingrained, may make it difficult to change.


In addition, women with anxiety disorders often reinforce their own upset through their internal dialogue. A woman who engages in constant fearful and anxious self-talk may anticipate certain sit-uations and people as threatening and dangerous, thus reinforcing her feelings of anxiety. Because we are all constantly dialoguing with ourselves throughout much of the day, negative self-talk can be a big factor in perpetuating anxiety disorders.


In summary, anxiety disorders can take a variety of forms, including generalized anxiety disorder, panic disorder, and pho-bias. Many circumstances can increase the risk of developing an anxiety disorder, such as physiological imbalances, genetic factors, family upbringing, major long- and short-term life stress, and the person’s own personal beliefs and negative self-talk, which can keep an anxiety disorder going once it has become an established process. Anxiety disorders can be treated through counseling, stress management techniques and breathing exercises, nutritional therapies, and regular exercise. These are discussed in depth in the self help chapters of this book.


Anxiety Due to Endocrine Imbalances


Many endocrine-related health problems have anxiety and mood swings as major symptoms. These health conditions are discussed in this section.


Premenstrual Syndrome


Anxiety and mood swings are the hallmark of premenstrual syndrome (PMS), one of the most common problems affecting women during their reproductive years (from the teens to the early fifties). In my practice, more than 90 percent of women with PMS complain of heightened anxiety and irritability that increases in intensity the week or two prior to menstruation. Many PMS patients describe severe personality changes-much like Dr. Jekyll and Mr. Hyde. They say they are irritable, witchy, and mean, that they yell at their children, pick fights with their spouses, and snap at friends and co-workers. Some spend the rest of the month repairing the emotional damage done to their relationships during this time.


Because PMS affects one-third to one-half of American women between the ages of 20 and 50 (as many as 10 to 14 million women), it is a common cause of anxiety as well as of other emotional symptoms like depression and fatigue.


In addition to the emotional symptoms, PMS has numerous physical symptoms involving almost every system in the body. More than 150 symptoms have been documented, including headaches, bloating, breast tenderness, weight gain, sugar crav-ing, and acne. However, for many women, the emotional symp-toms and fatigue are the most severe, adversely affecting their family relationships and their ability to work. In addition, it is not unusual for women to have as many as 10 or 12 of the symptoms.


There is no single cause of PMS; medical researchers now believe that various hormonal and chemical imbalances can trigger PMS symptoms. Though it is not entirely known what causes the anxiety symptoms, research suggests that several types of imbalances are likely culprits. One possible cause is an imbalance in the body’s estrogen and progesterone levels. Both estrogen and progesterone increase during the second half of the menstrual cycle. Their chemical actions affect the function of almost every organ system in the body. When properly balanced, estrogen and progesterone promote healthy and balanced emo-tions. However, PMS mood symptoms may occur if the balance between these hormones is abnormal, because they have an opposing effect on the chemistry of the brain. Estrogen acts as a stimulant and progesterone has a sedative effect on the nervous system, so if estrogen predominates, women tend to feel anxious and if progesterone predominates, women tend to feel depresses Other examples of the opposing effects of estrogen and proges-terone include the following: estrogen lowers blood sugar, proge sterone elevates it; estrogen promotes synthesis of fats in the tissues, progesterone breaks them down. Thus, when estrogen al progesterone are appropriately balanced, women are more likely to have normal mood and behavioral patterns.


The balance between these hormones depends on two things: how much hormone the body produces, and how efficiently the body breaks it down and disposes of it. The ovaries are the primary source of estrogen and progesterone in premenopausal women (with estrogen also being synthesized by intestinal bacte ria and by conversion of adrenal hormones to estrogen by the fat tissues); the liver has the major responsibility for inactivating estrogen. The liver tries to make sure the levels of estrogen circulating through the body in a chemically active form don’t become too high.


Breakdown in the liver’s ability to perform this function affect the levels of estrogen in the body. Both emotional stress and you nutritional habits play significant roles in how efficiently this sys tem will run. For example, excessive intake of fats, alcohol, and sugar stresses the liver, which must process these foods as well as the hormone. With vitamin B deficiency, which can be caused by poor nutrition or by emotional stress, the liver lacks the raw material to carry out its metabolic tasks. In either case, the liver cannot break down the hormones efficiently, so higher levels of hormone continue to circulate in the blood without proper disposal, tipping the balance toward excessive anxiety-producing estrogen.


Other research studies link the emotional symptoms of PMS to chemical imbalances in the central nervous system. Some researchers suggest that the symptoms of anxiety and mood swings are due to a heightened sensitivity in some women to fluc tuations in the body’s level of beta endorphins. These substances are the body’s natural opiates, producing a sense of well-being and even elation when present in large amounts. (Beta endorphins are responsible for the “runner’s high” that many people experi-ence after prolonged aerobic exercise, because exercise increases beta endorphin production.) Beta endorphin levels increase soon after ovulation at mid-cycle and may decline with the approach of menstruation. A fall in beta endorphin levels in women who are very sensitive to the effects of these chemicals or who produce large amounts of beta endorphin could, like opiate withdrawal, cause symptoms such as anxiety and irritability.


Another possible cause of PMS anxiety symptoms may be the lack of sufficient serotonin in the brain. Serotonin is a neurotrans-mitter that regulates rapid eye movement (REM) sleep and appetite. Inadequate levels of serotonin could explain the poor sleep quality with the resultant fatigue, anxiety, and irritability from which some women with PMS suffer. It could also explain, at least in part, why some women with PMS feel that they have such a difficult time controlling their eating habits and managing their food cravings during the premenstrual time. Serotonin is produced in the body from an amino acid called tryptophan. Tryptophan is an essential amino acid that must be replaced daily through adequate dietary intake since our body cannot manufac-ture it from other sources. Good sources of tryptophan include almonds, pumpkin seeds, and sesame seeds.


Many factors increase the risk of PMS in susceptible women. PMS occurs most frequently in women over 30; the most severe symptoms occur in women in their thirties and forties. Women are at high risk when they are under significant emotional stress or if they have poor nutritional habits and don’t exercise. Women who are unable to tolerate birth control pills seem to be more likely to suffer PMS, as are women who have had a pregnancy complicated by toxemia. Also, the more children a woman has, the more severe her PMS symptoms.


PMS rarely goes away spontaneously without treatment. My experience is that it gets worse with age. Some of my most uncomfortable patients are women in their middle to late forties who are also approaching menopause. These women often feel they have the worst of both life phases as they pass from their repro-ductive years into menopause. Often, PMS symptoms coexist with bleeding irregularities and hot flashes. Once the PMS is treated, the accompanying fatigue and mood symptoms clear up. Therapies for PMS are discussed in the self help section of this book.


As mentioned earlier, no single hormonal or chemical imbalance has been linked to PMS. Instead, nearly two dozen hormonal, chemical, and nutritional imbalances may contribute to causing the symptoms. Even more confusing for patients and physicians alike is that the underlying causes may differ from one woman to another. As a result, no single wonder drug cures PMS, although many drugs have been tested, including hormones, tranquilizers, antidepressants, and diuretics. Luckily, the anxiety and mood swing symptoms of PMS as well as the physical symptoms respond very well to healthful lifestyle changes. In my practice, I have found PMS to be a very treatable problem. Achieving results does, however, require that women participate actively in their own program, adopt good nutritional habits, and deal with stress more effectively.


Menopause


Menopause, the end of all menstrual bleeding, occurs for most women between the ages of 48 and 52. However, some women cease menstruating as young as their late thirties or early forties, while others continue to menstruate into their mid-fifties. Anxiety, mood swings, and fatigue often accompany this process as women go through the hormonal changes that lead to the cessation of menstruation.


For most women, the transition to menopause occurs gradually, triggered by a slowdown in the function of their ovaries. The process begins four to six years before the last menstrual period and continues for several years after. During this period of
transition, estrogen production from the ovaries decreases, even-tually dropping to such low levels that menstruation becomes irregular and finally ceases entirely. For some women this transi-tion to a new, lower level of hormonal equilibrium is easy and uneventful. For many women, however, the transition is difficult, fraught with many uncomfortable symptoms, such as irregular bleeding, hot flashes, anxiety, mood swings, and fatigue. As many as 80 percent of women going through menopause experience some of these symptoms.


In my medical practice, I have seen many women who experi-enced marked emotional symptoms while going through meno-pause. In fact, many of my patients have described symptoms similar to those of PMS. The psychological symptoms of meno-pause include insomnia (often associated with hot flashes), irritability, anxiety, depression, and fatigue. As mentioned in the section on PMS, both estrogen and progesterone have been studied for their effects on mood: If estrogen predominates, women tend to feel anxious; if progesterone predominates, women may feel depressed and tired. As women go through menopause, there is first an imbalance in these hormones and finally a deficiency in both as their ovarian production drops to very low levels or ceases entirely. The severity of the symptoms probably depends on the individual woman’s biochemistry and on psychosocial factors. Women have worse symptoms if they are under severe emotional stress or have aggravating dietary habits, such as excessive caffeine, sugar, or alcohol intake.


The emotional symptoms of menopause can also be aggravated by lifestyle issues. For some women, the social and cultural factors occurring before, during, and after menopause may be quite stressful. Menopause can be a time when children leave home and move away, major career changes are made, and marriage ends in divorce or starts anew. Of course, these major life changes can occur at other times besides the “mid-life crisis,” but the combina-tion of hormonal and biochemical changes plus lifestyle changes can be quite difficult to handle.


There are many effective treatments to reduce the emotional and physical symptoms of menopause. These include hormonal replacement therapy and, in more severe cases, the use of mood-altering drugs. Vitamin, herbal, and mineral supplements help support menopausal women’s reproductive and glandular systems. Stress-management techniques and regular exercise may also help restore energy and vitality and stabilize mood. These are discussed in the self help section of this book.


Hyperthyroidism


When the thyroid gland excretes an excessive amount of thyroid hormone, hyperthyroidism occurs. This is a potentially serious and dangerous problem if not diagnosed right away. Symptoms of hyperthyroidism can mimic those of anxiety attacks, and include generalized anxiety, insomnia, easy fatigability, rapid heartbeat, sweating, heat intolerance, and loose bowel movements. In fact, the correct diagnosis may often be missed initially, especially with women who are in menopause, if the symptoms are thought to be due simply to stress or the change of life.


Hyperthyroidism does, however, present with other symptoms that should tip off both the woman and her physician that there is a physiological imbalance present. These symptoms include weight loss despite a ravenous appetite, quick movements, trem-bling of the hands, and difficulty focusing the eyes. On a medical examination, many signs of hyperthyroidism may also be present. The skin of a woman with this problem is usually warm and moist. A goiter (enlargement of the thyroid) may be felt by the physician. The skin and hair are usually thin and silky in texture. The eyes usually tend to stare, and in more advanced cases, even bulge from the eye sockets. In advanced cases, there is also muscle wast-ing and bone loss (osteoporosis) as well as heart abnormalities. As you can see, hyperthyroidism causes severe and potentially dan-gerous changes in the body and should be considered when trying to diagnose the cause of anxiety episodes.


A diagnosis of hyperthyroidism can be made early by blood tests that show excessive secretion of thyroid hormones, as well as other changes in the blood. If heart and bone abnormalities are present also, they may show on an electrocardiograph and on x-rays. Once diagnosed, hyperthyroidism should be treated immediately to reduce the hormonal output. Treatments include the use of drugs that suppress and even inactivate the thyroid gland, as well as surgical removal of the thyroid. This is discussed in detail in Chapter 11 of this book.


Women with thyroid dysfunction often have exhaustion in other endocrine glands. The adrenal glands are particularly affected by poor thyroid function, as well as any other physical and emotional stress. The adrenals are two almond-sized glands that secrete several dozen hormones. One of these is cortisol, an important hormone that helps regulate our response to stress. Stress can be a response to strong emotional feelings, such as anxiety or depres-sion, or to physical triggers, such as an allergic reaction, infectious disease, burns, surgery, or an accident. Whatever the source of stress, cortisol lessens its injurious effects on the body, reducing pain, swelling, and fever.


When stress has been recurrent and of long duration, the adrenal glands can become exhausted, mustering less and less ability to buffer the negative effects of physical and emotional stress. As a result of adrenal exhaustion, the individual may experience an increase in fatigue and tiredness. Much rest, stress management, and nutritional support are required to restore the adrenals and rebuild the physiological “cushion” to deal with stress. There are many helpful techniques listed in the self help section of this book to help restore the glandular system.


Hypoglycemia


This condition occurs when the blood sugar levels in the body fall too low. With this condition, people experience many symptoms similar to those of anxiety attacks, including anxiety, irritability, trembling, disorientation, lightheadedness, spaciness, and even palpitations. The dietary trigger for hypoglycemia episodes is excessive intake of simple sugars such as white sugar, honey, fruit juice, white flour products, and sugar-laden desserts such as cook-ies, doughnuts, and candies.


Glucose, or sugar, is critical for survival because it is the major fuel our bodies run on (the brain alone uses up to 20 percent of the glucose available in the body to fuel its normal level of function-ing). However, simple sugars require little processing in the digestive tract and are absorbed rapidly into the blood circulation, overloading the body with fuel. To move this abundance of sugar into the cells where it can be processed and utilized for the cells’ energy needs, the hormone insulin is released from the pancreas. Without adequate insulin, sugar cannot be moved into the cells. Unfortunately, when too much sugar is dumped into the blood circulation, usually the reverse situation occurs and too much insulin is secreted. This can actually drop the blood sugar too low (below 50-60 milligrams per milliliter) to levels where the typical anxiety-like symptoms of hypoglycemia occur. Interestingly, drops in the blood sugar level can also occur simply in response to heightened levels of stress, because the body utilizes extra glucose or fuel during this time.


When the blood sugar level falls too low, the brain is rapidly deprived of energy. A correction must occur in order to bring the glucose levels back to normal, so the adrenal glands release the hormones cortisol and adrenaline which cause the liver to release stored sugar. Though the stored sugar from the liver does restore the blood sugar balance, the rise in adrenal hormonal output also increases emotional arousal and anxiety. Thus, the hypoglycemia cycle can perpetuate the physical and psychological symptoms of anxiety. Women who continue to eat a diet high in simple sugar often feel as though they are on an emotional roller coaster, tossed from highs to lows of anxiety and irritability on the one hand and fatigue and depression on the other, as their blood sugar levels fluctuate.


Most women can easily solve this problem by switching to a diet high in complex carbohydrate foods. These include whole grains, starches, whole fruits, and vegetables. When eaten by themselves or when combined with high-quality proteins such as nuts, seeds, and fish, the complex carbohydrates are broken down to glucose and slowly absorbed into the blood circulation, thus not triggering excessive insulin output. As a result, both the blood sugar level and the emotions stay healthy and balanced. In addi-tion, consuming proper vitamins and minerals supports glucose metabolism and pancreatic function, thereby preventing symp-toms in women prone to hypoglycemia-related anxiety attacks. Both the optimal diet and nutritional supplements for hypogly-cemia are discussed in the self help chapters of this book.


Anxiety Due to Immune System Imbalances


Immune system disorders can cause a variety of psychological as well as physical symptoms. These imbalances are discussed in detail in this section.


Allergies, Including Food Allergies


Many women are unaware that allergic reactions can cause mood changes such as anxiety. Allergies occur when the body’s immune system overreacts to harmless substances. Normally, the immune system is on the alert for invaders such as viruses, bacteria, and other organisms that cause disease. The immune system’s job is to identify these invaders and to produce antibodies which destroy them before they cause illness. In allergic people, this system begins to react to other substances-typically pollens, molds, or foods. Common food allergens include wheat, milk (and milk products), alcohol, chocolate, eggs, yeast, peanuts, citrus fruits, tomatoes, corn, and shellfish.


Sometimes allergic reactions are easily diagnosed, because the symptoms occur immediately after the encounter with the allergen.


Immediate allergic symptoms include wheezing, itching and tear-ing of the eyes, nasal congestion, and hives. Some allergic reactions are delayed; they may occur hours or days after exposure to the allergen. Delayed symptoms include anxiety, depression, fatigue, dizziness, spaciness, headaches, joint and muscle aches and pains, and eczema. Food allergies can also affect digestive function, caus-ing inflammation of the intestinal lining and pain in the abdominal area. Damage to the intestinal lining causes it to become more porous and permeable. When large particles of poorly digested food, to which the person is allergic, are absorbed into the body, the body’s defense system is activated, precipitating damage to many organs and tissues by autoantibodies. (These are the immune complexes that attack your own tissues as if they were foreign sub-stances.) The person affected may be unaware that an allergy is causing her emotional and physical symptoms. This often occurs with food allergies, as well as with a variety of chemical triggers.


Food allergies commonly trigger anxiety episodes in suscep-tible women. Often, you crave the foods to which you are allergic. Thus, food addiction may actually be a sign of food allergy. Women commonly crave foods such as chocolate, chips, pasta, bread, and milk products. Often they find that once they start eat-ing these foods, they have a difficult time stopping. A woman who has the desire to have one chocolate can end up eating a whole box. The decision to eat one cookie can turn into a binge of ten or fifteen at one session, or a small dish of ice cream becomes a pint. Though hinging tendencies can be seen throughout the month in women with food allergies, they tend to be worse during the pre-menstrual period (which may commence as early as two weeks prior to the onset of menstruation). Alterations in mood as well as physical symptoms typical of anxiety, such as increased heart rate and respiration, often coexist with the food craving symptom.


Some holistic physicians test for food allergies by doing sublin-gual provocative tests. In this test, a food extract is placed under the tongue to see whether it elicits a reaction. Neutralizing anti-dotes are then administered to the patient to reduce or eliminate symptoms. This test is not used by traditional allergists, who con-sider it to be ineffective. Another way to test for food sensitivities is simply to eliminate suspected food allergens. First, the patient fasts, taking only distilled water for several days. Then she rein-troduces foods one at a time. If the patient is allergic to a specific food, a reaction will occur after she adds that food to her diet. Another method is to maintain a low-stress diet and to eliminate only the particular food to which you suspect you may be allergic, again reintroducing these foods sequentially to see how your body reacts. You may actually feel worse initially after eliminating high-stress foods, due to the withdrawal symptoms that occur after stopping anything to which you are addicted. (This can also hap-pen when stopping drugs and cigarettes.) During the period when you are determining your food allergies, keep a diary in which you record your emotional and physical symptoms, both on and off the offending foods. This will help you evaluate the severity of your reactions. Finally, there is a blood test now available called the RAST test; while quite expensive, it gives the physician a com-plete profile of allergens, including foods, pollens, flowers, grasses, and so forth.


Treatment for food and other allergies usually includes avoid-ing the offending substance, if possible, or using over-the-counter and prescription medication and desensitization shots. Managing stress and following a low-stress elimination diet may also help treat and prevent allergies. It is important to rotate foods and choose from a wide variety of high-nutrient foods. Certain nutri-tional supplements also help to support and strengthen the immune system. These topics are discussed in the self help section of this book.


Anxiety Due to Cardiovascular System Disorders


While cardiovascular problems primarily cause physical symptoms, mitral valve prolapse can cause psychological symptoms as well.


Mitral Valve Prolapse


Mitral valve prolapse is a heart condition that can cause anxiety–like episodes of palpitations, chest pain, shortness of breath, and fatigue. It does appear to be present more frequently in people with anxiety and panic episodes than in the general population. It is caused by a mild defect in the mitral valve, which is located between the upper and lower chamber on the left side of the heart. Normally, blood flows unimpeded between the two chambers. However, with mitral valve prolapse, the valve doesn’t close completely. As a result, the heart is put under stress and can beat either too fast or erratically.


In more severe cases, the heartbeat can be slowed through the use of beta blockers, drugs that decrease heart rate and heart con-tractility by decreasing oxygen consumption. (This is discussed in detail in Chapter 11 of this book.) In addition, undue stress and stimulants such as caffeine-containing beverages like coffee, tea, and cola drinks should be eliminated in order to avoid triggering episodes of rapid heartbeat. Deficiencies of calcium, magnesium, and potassium should be avoided since these essential minerals help to regulate and reduce cardiac irritability. To ensure adequate daily intake, it is important to maintain a diet with sufficient amounts of these nutrients or to use supplements.


Common Causes of Anxiety



Types of anxiety disorders

Generalized anxiety disorder

Panic disorder

Phobias

















Physical conditions associated with anxiety
Premenstrual syndrome Hypoglycemia
Menopause Food allergies
Hyperthyroidism Mitral valve prolapse

Avatar Written by Susan M. Lark MD

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