Is it an Anxiety Disorder or Stress?

Two Patients.

Albert never thought twice about mental health. He was a 53 year old male graphic designer in an advertising firm. His confident but calm, self-assured manner charmed his friends and co-workers. He loved his work. Married with two children, he was a happy, devoted father and husband. A friend of his from high school had experienced some "depression" and "anxiety," and occasionally Albert himself had experienced mild "nervousness" when having to speak in front of large crowds. Beyond this, he had never thought much about matters psychological. Then in December, Albert received notice that he might be named in a series of layoffs at work. Two weeks later his wife explained that the doctors were concerned about a calcified nodule in her breast. That same week, his 16 year old daughter was suspended from school for publicly using profanities towards her soccer coach. Suddenly Albert became anxious and unable to sleep. While he regularly set his alarm for 7AM, he now awoke at 5AM -- unable to fall back asleep and flooded with worrying thoughts. His insomnia led to irritability and further decreased his performance at work. Suddenly his anxiety shot up and his fears of being laid-off became a self-fulfilling prophecy.

How should we think about Albert? Does he have an "Anxiety Disorder" or is he simply responding naturally to real-life stressors? Is the string of stressors and bad news too much for anyone, however cool-headed, to bear? Was Albert vulnerable to anxiety all along, or was it purely the external environment that produced his insomnia and irritability.

Albert has a friend named Marshall who works in the same firm. Marshall is quiet and unsure of himself. When possible, he tries to "fly under the radar" and avoid unnecessary social contact in the office. He is often second-guessing himself -- worrying whether he prepared his work in the proper manner. He is often plagued by doubts about what his other co-workers think of him, this despite his consistently positive reviews. He also has a wife and two children and loves them dearly. They are healthy but worry about Marshall and whether he is happy at work. Marshall often has a hard time falling asleep at night as he "stresses" out about work. While Marshall loves his job, he often does not enjoy the hourly work it entails and the uncertainty it produces. This motivates him to always "dot his i's and cross his t's." In this way, Marshall has periodically found himself promoted through the ranks of the firm.

How should we think about Marshall? Does he have an "Anxiety Disorder?" After all, he is functional at work and seems to rise through the ranks of his firm. Yet, unlike Albert who has clear life stressors, Marshall seems to be constantly anxious over more routine things. He seems to be an anxious person at baseline.

How would we classify, diagnose and treat either Albert or Marshall? On the one hand we might posit that Marshall has an obvious Anxiety Disorder. Conversely, Albert is having a much more difficult time functioning at work, even without a natural vulnerability to anxiety.