Judy Walters was starting up her Acura Integra when the panic struck. Suddenly terrified that her brakes would fail, she drove to a mechanic, breath short and heart racing. To her surprise, the brakes were fine. “It was me,” she says. Walters, vice-president of public relations at the Investor Relations Group in Manhattan, had developed an anxiety disorder.

She was not alone: anxiety, like depression, is one of the most common, and most underdiagnosed, mental disorders-suffered by as many as 19 million (14 percent of) Americans.

Anxiety takes a bewildering array of forms: panic disorder (recurrent panic attacks marked by overwhelming fears of imminent death or disaster); phobias (intense fear and avoidance of a specific thing or circumstance, such as animals or social situations); obsessive-compulsive disorder, or OCD (uncontrollable, repetitive behaviors or thoughts); posttraumatic stress disorder, or PTSD (recurrent, distressing dreams and memories in the wake of an accident or violent crime); and generalized anxiety disorder, or GAD (ongoing, unfounded worry about family, finances, health, etc.).These disorders also include physical symptoms-shortness of breath, heart palpitations, muscle aches, gastrointestinal upsets, fatigue and insomnia.

“Anxiety disorders can be divided into two types,” says James Potash, M.D., assistant professor of psychiatry at Johns Hopkins School of Medicine. “One type is a disease, such as panic disorder or OCD. You can be perking along, living happily, and then you start having these novel, strange panic attacks or obsessions. The other type of anxiety is more a reflection of a temperament. Some people are, in common parlance, `worriers’. The anxiety they experience is an interaction between their temperament and the major or minor events in their lives.”

He adds a third category: anxiety as a secondary symptom to depression, which is “extremely common.” The implication, scientists believe, is that both anxiety and depression reflect (among other things) imbalances in norepinephrine, serotonin and dopamine, the neurochemicals that regulate mood, thought and movement. But much remains unknown.

The patient with coexisting anxiety and depression may be whipsawed mercilessly by the symptoms. When Shannon Robshaw, executive director of the Mental Health Association of Louisiana in Baton Rouge, was first diagnosed with depression five years ago, “psychotherapy helped dramatically.” But another therapist then diagnosed a serious anxiety disorder whose symptoms included insonmia and chest pain. As Robshaw struggled with these, her depression returned. “By the time I got in to see a psychiatrist, I was desperate.” For the next two years she continued psychotherapy and also tried various medications, ending with the antidepressant Celexa. “It seems to work for both the anxiety and the depression.”

ANXIETY STAKES OUT NEW TURF A new group of people have emerged as overanxious and underdiagnosed: those over 65. Studies suggest that 20 percent of these men and women suffer some form of excessive anxiety, and that at least 10 percent have full-blown anxiety disorders.

In this age group, phobias-like that which ultimately forced Judy Walters to give up driving-are the most common anxiety disorder, says geriatric psychiatrist Gary W. Small, M.D., director of the Center on Aging at the University of California, Los Angeles. After phobias, GAD is seen most often. “Things hit you harder. The rubber band doesn’t snap back when the stressful situation goes away,” says Jenna Stiles, a motivational speaker and trainer with GAD, who also facilitates an anxiety and depression support group at the Mental Health Association of Arizona in Phoenix. She notes that anxious people are often perfectionists; a highly accomplished 70-year-old may agonize over simply forgetting a name. Real-life concerns also play a role: after her husband’s death, folk artist Betty Nathan, 73, of Savannah, Georgia, sought help for anxiety about being on her own for the first time in her life. And Judy Walters believes her fear of driving-and, later, of escalators-reflected her fears about losing control in midlife. “Feeling like I couldn’t put on the brakes was a metaphor for not being able to halt the aging process.”

WHEN TO START WORRYING When does normal, everyday worry cross the line into pathology? “People come to see me when their anxiety is interfering with their ability to work or to conduct normal relationships with family and friends,” says Dr. Potash. “The most dramatic example of serious anxiety,” he adds, “is when people become suicidal. Typically, it’s mixed depression and anxiety that leads a person to such intense despair.”

Getting an accurate diagnosis is imperative; it guides the treatment regimen. “If someone comes in with lots of depressive symptoms and also lots of anxiety symptoms,” says Dr. Potash, “one key thing is, Has she always been anxious, or did the anxiety begin at the same time as the depression? If the two clearly coincided, I would expect that by treating the depression, I’d also treat the anxiety. But if she’s always been anxious, and if her anxiety is severe, she may need psychotherapy just for that.”

Among older people, diagnosis can be especially tricky. “When a patient says, `I’m short of breath,’ the physician’s initial reaction is to work up the heart and look for physical problems,” says geriatrician Robert A. Zorowitz, M.D., medical director for senior services at DeKalb Regional Healthcare System in Decatur, Georgia. Or, regrettably, geriatric anxiety may be shrugged off: “What do you expect? He’s 82.”

Treatment Choices

Once diagnosed, anxiety disorders are highly treatable. Eliminating substances such as coffee, alcohol and cigarettes is usually the first step; the next may be medication, whether antianxiety (anxiolytic) drugs or antidepressants. (The drug-averse may also wish to investigate alternatives such as St.-John’s-wort, kava, Siberian ginseng and valerian.) Though Dr. Zorowitz estimates that three out of four of his anxious patients have been helped by medication alone, the conventional wisdom holds that drugs are most effective when coupled with psychotherapy. “Psychotherapy is helpful for every patient who has serious anxiety and/or depression,” affirms Dr. Potash, “because these disorders affect the way people think about themselves and interact with people around them.”

Anxiety sufferers may need to experiment. Betty Nathan’s insomnia was relieved by the antidepressant Paxil. Jenna Stiles uses three-times-a-week yoga and two drugs-the antidepressant Elavil and the anxiolytic Ativan-to prevent panic attacks. And Judy Walters conquered her escalator phobia through behavioral therapy (the treatment of choice for phobias), desensitizing herself through repeated exposure.

The pity is that so many people just choose to live with high anxiety. “Cut yourself some slack and get help,” urges Walters. “It’s scary to fear something you used to be able to handle, but it doesn’t make you less worthy as a human being.”

For more information, contact the National Institute of Mental Health, (888) 826-9438, www.nimh.nih.gov/anxiety; or the National Mental Health Association, (800) 969-6642.