W3-M3-215-DISCUSSION
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M3-CHAPETER6.1.docxJeni: Worried about Worrying So Much Jeni is a 21-year-old college student. Although she is doing exception-ally well in school, for the past year she has worried constantly that she will fail and be thrown out. When her fellow students and professors try to reassure her, Jeni worries that they are just pretending to be nice to her because she is such a weak student. Jeni also worries about her mother becoming ill and about whether she is really liked by her friends. Although Jeni is able to acknowledge that her fears are excessive (she has supportive friends, her mother is in good health, and, based on her grades, Jeni is one of the top students in her school), she still struggles to control her worrying. Jeni has difficulty sleeping, often feels nervous and on edge, and experiences a great deal of muscle tension. When her friends suggested she take a yoga class to try and relax, Jeni even began to worry about that, fearing that she would be the worst student in the class. “I know it makes no sense,” she says, “But that’s how I am. I’ve always been a worrier. I even worry about worrying so much!”
Anxiety involves a general feeling of apprehension about possible future danger, whereas fear is an alarm reaction that occurs in response to immediate danger. The DSM has identi-fied a group of disorders—known as the anxiety disorders—that share symptoms of clinically significant anxiety or fear. Anxiety disorders affect approximately 29 percent of the U.S. population at some point in their lives and are the most common category of disorders for women and the second most common for men (Kessler, Berglund, Delmar, et al., 2005). In any 12-month period, about 18 percent of the adult population suffers from at least one anxiety disorder (Kessler, Chiu, et al., 2005). Anxiety disorders create enor-mous personal, economic, and health care problems for those affected and for society more generally. Anxiety disor-ders have the earliest age of onset of all mental disorders (Kessler, Aguilar-Gaxiola, et al., 2009) and are associated with an increased prevalence of a number of medical condi-tions including asthma, chronic pain, hypertension, arthri-tis, cardiovascular disease, and irritable bowel syndrome (Roy-Byrne et al., 2008). People with anxiety disorders also are very high users of medical services (Chavira et al., 2009). We begin by discussing the nature of fear and anxiety as emotional and cognitive states and patterns of respond-ing, each of which has an extremely important adaptive value but to which humans at times seem all too vulnerable. We will then move to a discussion of the anxiety disorders. Finally, we consider OCD and other disorders from the new obsessive-compulsive and related disorders category.
The Fear and Anxiety
Response Patterns 6.1 Distinguish between fear and anxiety. There has never been complete agreement about how dis-tinct the two emotions of fear and anxiety are from each
other. Historically, the most common way of distinguish-ing between the fear and anxiety response patterns has been to determine whether a clear and obvious source of
danger is present that would be regarded as real by most people. When the source of danger is obvious, the experi-enced emotion has been called fear (e.g., “I’m afraid of snakes”). With anxiety, however, we frequently cannot specify clearly what the danger is (e.g., “I’m anxious about my parents’ health”).
Fear In recent years, many prominent researchers have pro-posed a more fundamental distinction between the fear and anxiety response patterns (e.g., Barlow, 2002; Bouton, 2005; Sah, 2017). According to these theorists, fear is a basic emotion (shared by many animals) that involves activation of the “fight-or-flight” response of the autonomic nervous system. This is an almost instantaneous reaction to any imminent threat such as a dangerous predator or someone pointing a loaded gun. Fear’s adaptive value as a primitive alarm response to imminent danger is that it allows us to escape. When the fear response occurs in the absence of any obvious external danger, we say the person has had a spontaneous or uncued panic attack. The symptoms of a panic attack are nearly identical to those experienced during a state of fear except that panic attacks are often accompanied by a sub-jective sense of impending doom, including fears of dying, going crazy, or losing control. These latter cognitive symptoms do not generally occur during fear states. Thus, fear and panic have three components: 1. cognitive/subjective components (e.g., “I’m going to die”)
2. physiological components (e.g., increased heart rate and heavy breathing)
3. behavioral components (e.g., a strong urge to escape or flee). These components are only “loosely coupled” (Lang, 1985), which means that someone might show, for example, physiological and behavioral indications of fear or panic without much of the subjective compo-nent, or vice versa.
Anxiety
In contrast to fear and panic, the anxiety response pat-tern is a complex blend of unpleasant emotions and cog-nitions that is both more oriented to the future and much more diffuse than fear (Barlow, 2002). But like fear, it has not only cognitive/subjective components but also phys-iological and behavioral components. At the cognitive/ subjective level, anxiety involves negative mood, worry about possible future threats or danger, self-preoccupa-tion, and a sense of being unable to predict the future threat or to control it if it occurs. At a physiological level, anxiety often creates a state of tension and chronic over-arousal, which may reflect risk assessment and readiness for dealing with danger should it occur (“Something awful may happen, and I had better be ready for it if it does”). Although there is no activation of the fight-or-flight response as there is with fear, anxiety does prepare or prime a person for the fight-or-flight response should the anticipated danger occur. At a behavioral level, anxi-ety may create a strong tendency to avoid situations where danger might be encountered, but the immediate behavioral urge to flee is not present with anxiety as it is with fear (Barlow, 2002). Support for the idea that anxiety is descriptively and functionally distinct from fear or panic comes both from statistical analyses of subjective reports of panic and anxiety and from a great deal of neurobiological evidence (e.g., Bouton, 2005; Davis, 2006;
Grillon, 2008). Table 6.1 compares and contrasts the com-ponents of fear and anxiety.
The adaptive value of anxiety may be that it helps us plan and prepare for a possible threat. In mild to moderate degrees, anxiety actually enhances learning and performance. For example, a mild amount of anxiety about how you are going to do on your next exam can actually be helpful. Although anxiety is often adaptive in mild or moderate degrees, it
is maladaptive when it
becomes chronic and severe, as we see in people diagnosed with anxiety disorders. Whereas many threatening situations can occur that
For example, a girl named Angela sometimes saw
and heard her father physically abuse her mother in the evening. After this happened four or five times, Angela started to become anxious as soon as she heard her father’s car arrive in the driveway at the end of the day. In such situations a wide variety of initially neutral stim-uli may come to serve as cues that something threatening and unpleasant is about to happen—and thereby come to elicit fear or anxiety themselves. Our thoughts and images can also serve as conditioned stimuli capable of eliciting the fear or anxiety response pattern. For exam-ple, Angela came to feel anxious even when thinking about her father.
