The world is full of nervous, tense, apprehensive, and worried people. The stresses of contemporary society are often blamed for their plight. The poet W.H. Auden referred to his era as “the age of anxiety,” and little has changed since then. Medical historians have identified comparable periods of pervasive anxiety dating back to the time of Marcus Aurelius and Constantine, when societies were undergoing rapid and profound changes, and individuals were assailed by an overwhelming sense of insecurity, personal insignificance, and fear of the future (Rosen).
Like fatigue, nervousness, irritability, and anxiety are among the most frequent symptoms encountered in office and hospital practice. A British survey found that more than 40 percent of the population, at one time or another, experienced symptoms of severe anxiety, and approximately 5 percent suffered from lifelong anxiety states (Lader). The latter is difficult to distinguish from what is currently termed generalized anxiety disorder, a state of constant worry discussed further on. The vast amount of antianxiety medication and alcohol that is consumed in our society would tend to corroborate these figures.
Of course, any person facing a challenging or threatening task for which he may feel unprepared and inadequate experiences some degree of nervousness and anxiety. Anxiety is then not abnormal, and the alertness and attentiveness that accompany it may actually improve performance up to a point. Barratt and White found that mildly anxious medical students performed better on examinations than those lacking in anxiety. As anxiety increases, so does the standard of performance, but only to a point, after which increasing anxiety causes a rapid decline in performance (Yerkes-Dodson law).
If worry or depression stands in clear relation to serious economic reverses or loss of a loved one, the symptom is also usually accepted as normal, but no less worthy of emotional support. Only when it is excessively intense or prolonged or when accompanying visceral derangements are prominent do anxiety and depression become matters of medical concern. Admittedly, the line that separates normal emotional reactions and pathologic ones is not sharp. Chapter 48 deals with these matters more fully.
There is no unanimity as to whether symptoms of nervousness, irritability, anxiety, and fear comprise a single emotional reaction, varying only in its severity or duration, or a group of discrete reactions, each with distinctive clinical features. In some writings, anxiety is classified as a form of subacute or chronic fear but there is reason to question this assumption. Anxious patients, when frightened under experimental conditions, state that the fear reaction differs in being more overwhelming. The exceedingly frightened person is “frozen,” unable to act or to think clearly, and his responses are automatic and sometimes irrational. The fear reaction is characterized by overactivity of both the sympathetic and parasympathetic nervous systems, and the parasympathetic effects (bradycardia, sphincteric relaxation) may predominate, unlike anxiety, in which sympathetic effects are the more prominent ones. Long ago, Cicero distinguished between an acute and transient attack of fear provoked by a specific stimulus (angor) and a protracted state of fearfulness (anxietas). This distinction was elaborated by Freud, who regarded fear as an appropriate response to a sudden, unexpected external threat and anxiety as a neurotic maladjustment.
Less readily distinguishable from anxiety is the complaint of nervousness. By this vague term, the layperson usually refers to a state of restlessness, inner tension, uneasiness, apprehension, irritability, or hyperexcitability. Unfortunately, the term may have a wide range of other connotations, such as a distressing hallucination or paranoid idea, a frankly hysterical outburst, or even tics or tremulousness. Obviously, a careful inquiry as to what the patient means in complaining of nervousness is always a necessary first step in the analysis.