Oscar Pistorius faces psychiatric tests – what are anxiety disorders?

The judge in Oscar Pistorius’ trial has asked for his mental health to be assessed. EPA/Gianluigi Guercia

Oscar Pistorius’ trial took another dramatic turn earlier this week when the judge in the case agreed to a prosecution request to have his mental health assessed. After a psychiatrist called by the defence said Pistorius had an anxiety disorder, prosecutor Gerrie Nel expressed concern that mental health issues may be used to try to reduce his sentence.

Judge Thokozile Masipa said the court wasn’t equipped to decide whether the diagnosis of generalised anxiety disorder would have affected Pistorius’ action on the night he shot dead his girlfriend Reeva Steenkamp in their home. She will provide detailed instructions for a psychiatric evaluation on Tuesday.

Whether an anxiety disorder can be argued to mitigate responsibility in a case like this is a tricky issue. Some background about the nature and characteristics of these disorders will illustrate some of the complications.

A common disorder

Anxiety disorders are the most common form of mental disorder and affect approximately 10% to 15% of the population in any given year. Their range includes panic disorder, social anxiety disorder, and generalised anxiety disorder.

People suffering anxiety disorders report fears and worries that often cover many areas and affect their lives in a variety of ways.

One of the key features of anxiety is avoidance – anxious people typically avoid situations they fear. This is usually a central component of the life interference that distinguishes a disorder from sub-clinical levels of anxiety. Everyone experiences some anxiety occasionally, but it’s only considered to be a “clinical disorder” when it causes significant distress or markedly affects someone’s life.

People with social anxiety disorder, for instance, fear and avoid a range of social activities and interactions, such as going on dates, meeting new people, talking to authority figures, or giving talks. This avoidance restricts their opportunities, impacting on relationships, career, and self concept.

Generalised anxiety disorder

In this case, the defence psychiatrist said she had diagnosed Pistorius with generalised anxiety disorder. Generalised anxiety disorder is one of the more common forms of mental disorder and affects around 3% to 8% of Western populations in a 12-month period. It’s more common among women than men.

Generalised anxiety disorder is characterised by worry about such matters as health, family, relationships, or finances. When they worry, people with the disorder will often report a range of physical symptoms such as headaches, diarrhoea, or muscle tension. But its main feature is ongoing and persistent worry.

In many ways, generalised anxiety disorder is like a personality aspect of the individual. It usually begins very early in life and sufferers often report being “worriers” for as long as they can remember.

People with the disorder also commonly show many other characteristics that follow from this tendency to worry. They may have difficulties sleeping, for instance, are often perfectionistic and may procrastinate on projects, or they may be eternal pessimists.

It’s very common for people with a generalised anxiety disorder to misinterpret ambiguous information and assume the worst. DG Jones, CC BY-NC

A precarious existence

One of the underlying aspects of generalised anxiety disorder (and, in fact, many anxiety disorders) is a tendency to focus on and exaggerate dangers in the world. Someone with generalised anxiety disorder might believe they’re very likely to make mistakes, for instance, and that making a mistake would be catastrophic.

This might lead them to regularly check locks and doors or to be very slow in completing tasks and they may be very unwilling to take on new or complicated activities. So, on the one hand, we might expect a person with generalised anxiety disorder to be very careful and structured about routines – they think carefully before acting, and are hesitant and inconclusive rather than taking decisive action.

But, on the other hand, it’s very common for people with the disorder to misinterpret ambiguous information and assume the worst. So we shouldn’t be surprised if a sufferer believes that every noise outside is a burglar or that every burglar is there to hurt them.

In fact, research has shown generalised anxiety disorder sufferers are much more likely than the average person to interpret ambiguous information as dangerous and to overestimate the amount of danger. It’s also common for these people to engage in frequent safety behaviours to try to convince themselves they are safe.

They may frustrate their loved ones with constant reassurance-seeking, for instance, or may hate to be alone, or have detailed routines around checking and safety. In addition, people with generalised anxiety will focus all of their attention onto a perceived threat, often leading them to ignore other information around them.

Diagnosing anxiety disorders

Diagnosing a mental disorder such as generalised anxiety disorder is not an exact science. There’s no physical test for it, and the only way to diagnose it is for a mental health professional to interview the patient (and perhaps people who know them well) to build up a clear and consistent picture of their thoughts, feelings, and behaviours.

Technically, a diagnosis is made following a set of guidelines described in official diagnosis manuals – the most famous being the Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition (DSM-5).

According to the DSM-5, a diagnosis of generalised anxiety disorder requires excessive worry about a number of events or activities, most of the time, over at least six months. The person must also feel as though he cannot easily control worrying, must report at least three general symptoms, and the worry must interfere with his life.

Other information, including a history of related problems (such as depression), a family history, or broader behavioural patterns may be used to support the diagnosis.

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