Anxiety is a complex blend of emotions and cognitions oriented to the future. The evolutionary advantage of anxiety lies in its ability to heighten our awareness and readiness for potential dangers or challenges in the future. Anxiety enhances learning and performance when it is in mild and moderate levels, otherwise, people are diagnosed with anxiety disorders when anxiety is severe and maladaptive. In DSM-5, anxiety disorders are characterized by irrational fears that cause impairments in the affected person’s social, occupational and personal lives.
1. Specific Phobia
Strong and persistent fear is triggered by the presence of a specific object or situation known as a phobic object or situation. The object or the situation is either avoided or endured by the individuals. The fear or anxiety is disproportionate to the actual threat posed by the phobic entity, and it persists for more than 6 months. The prevalence of specific phobias is 12% and is more common in females than males. Phobias related to animals and blood-injection-injury commences during childhood whereas, phobias are related to various situations like driving and closed spaces. It has several subtypes like:
- Others: choking, vomiting etc.
- Animals: snakes, spiders, insects
- Natural environment: storms, heights, water
- Situational: public transport, tunnels, bridges, flying, driving
- Blood-injection-injury: seeing blood, injury, seeing someone in a wheelchair
Psychological causal factors
- Risk factors predispose certain individuals to contract phobias rather than others who might have protective factors that prevent them from becoming vulnerable to phobias.
- According to the psychoanalytical viewpoint, phobias represent defences against anxiety which stems from repressed impulses from the id and is further displaced into an object or situation.
- Phobias can evolve as a learned behaviour as well. Fear responses can be conditioned to neutral stimuli once they are paired with a traumatic event. Similarly, a specific phobia can develop through vicarious conditioning – viewing a person behaving fearfully with their phobic situation or object can be distressing to the observer and hence phobia gets transmitted to them.
- Phobias can be acquired through prepared learning where objects or situations that posed a real threat to our ancestors or primates, are associated as unpleasant entities, thus capable of being a phobic object or situation. Moreover, fear is conditioned more effectively to fear-relevant stimuli (such as snakes and spiders) than to fear-irrelevant stimuli (like flowers or mushrooms).
Biological factors
- Genetic and temperamental factors influence both the intensity and the rate at which fear is conditioned.
- Individuals who carry one of the two variants of the serotonin-transporter gene show superior fear conditioning than those without the variant.
- Individuals who carry one of the variants of the COMT met gene do not show superior fear conditioning but show enhanced resistance to fear extinction.
- Behaviorally inhibited toddlers who are characterized as shy, timid and easily distressed are more likely to acquire multiple specific phobias by 7-8 years of age than behaviorally uninhibited toddlers.
Treatment
- Virtual reality: This has proved effective with individuals having a fear of heights
- Participant modelling: The therapist models the way of interacting with the phobic objects or situations
- Exposure therapy: It involves a method of controlled exposure to objects or situations that elicits phobic fear or anxiety in individuals.
- Cognitive restructuring: This method involves challenging irrational thoughts and understanding that the perceived threat is out of proportion to the actual threat posed by the phobic object or situation employing logical reanalysis.
- D-cycloserine promotes the extinction of conditioned fear responses in animals and helps them unlearn the same acquired fears. However, research studies portray that anti-anxiety medications may cause hindrance and interfere with the progress and beneficial effects of exposure therapy.
2. Social Phobia/ Social Anxiety Disorder
Disabling fears of one or more social situations. Its prevalence is 12% with women (60%) greatly affected than men (40%). Additionally, its onset begins around early adulthood or adolescence. According to the DSM-5, social phobia is characterized by fear or anxiety regarding social situations in which an individual may be subject to the scrutiny of others. The individual fears that they will act in a way or show symptoms that will be negatively evaluated – humiliation, rejection or embarrassment. Moreover, the symptoms prevail for 6 months. Its subtypes include performance situations like public speaking or non-performance situations like eating in public scenarios.
Psychosocial factors
- Exposure to unpredictable and uncontrollable stressful events can lead to the development of social phobia.
- It can be acquired through learned behaviour, classical conditioning, or by observing others’ experiences, known as vicarious conditioning.
- Social phobias evolved as a by-product of dominance hierarchies – where defeated individuals typically exhibit submissive behaviour or fear after aggressive encounters by the members of a social group. Moreover, they rarely flee or escape the situation and endure it mostly.
- Cognitive factors play a crucial role in developing social phobias as socially phobic individuals usually think about being negatively evaluated or rejected by others. They fear that they will behave awkwardly or unacceptably. Moreover, they tend to interpret ambiguous social information in a negative rather than benign manner. For example, if someone smiles at them they think people are evaluating them as foolish.
Biological causal factors
- Neuroticism and introversion traits are high in individuals having social anxiety disorder.
- Behaviorally inhibited toddlers who are characterized as shy, timid and easily distressed are more likely to acquire social phobia than behaviorally uninhibited toddlers.
Treatment
- Exposure therapy: It involves a method of controlled exposure to social situations that elicit fear or anxiety in individuals
- Cognitive behavioural therapy: Cognitive restructuring is used to change the maladaptive inner thoughts by logical analysis
- Research studies show that d-cycloserine and exposure therapy prove to be the most effective treatment plan for this disorder.
- Antidepressants such as monoamine oxidase inhibitors and SSRIs (selective serotonin reuptake inhibitors) are used for the treatment.
3. Agoraphobia
‘Agora’ is a Greek term for an open gathering place. The most commonly avoided and feared situations include streets and crowded places such as malls, theatres, and stores. Individuals affected with this disorder are concerned that they might have a panic attack or get sick and escape from places or situations that will be difficult or embarrassing or where immediate help would be unavailable if adverse events arise. These situations are avoided, require the presence of a companion or endure intense anxiety or fear. Symptoms of agoraphobia should not last more than 6 months and the marked fear or anxiety should prevail in two of the below five situations:
- Using public transportation – automobiles, buses
- Being in open spaces – parking lot, market
- Being in enclosed places – cinema theatres, stores
- Standing in line/being in a crowd
- Being outside of home alone
4. Panic Disorders
A panic attack is an abrupt surge of intense fear or discomfort that reaches a peak within minutes. It is marked by recurrent, unexpected attacks, accompanied by ongoing concern about the possibility of experiencing another attack or worrying about the implications of having one, lasting for at least a month. Four or more symptoms out of the thirteen symptoms should occur in an individual to be diagnosed with a panic disorder.
Three of the thirteen symptoms are cognitive: derealization or depersonalization, fear of losing control or going crazy, and fear of dying. The remaining ten symptoms are physical and include palpitations, excessive sweating, trembling, feelings of choking, chest pain, dizziness, nausea, paresthesias (numbness or tingling sensations), and sensations of chills or heat. Its prevalence is 4.7% globally with or without agoraphobia and its onset is in early adulthood or late teen years. 80-90% of the individuals affected are females.
Biological causal factors
Genetic vulnerability is manifested at the psychological level by a trait called neuroticism which in turn is related to the temperamental construct of behavioral inhibition. Thus, certain individuals are predisposed to this disorder. Locus coeruleus in the brain stem and norepinephrine are responsible for the neurobiological cause of panic attacks.
Although, the role of amygdala plays a more crucial role in the pathology of panic attacks as it is involved in the emotion of fear. Stimulation of the central nucleus of the amygdala is known to stimulate the locus coeruleus as well as other autonomic, neuroendocrine responses that occur during panic attacks. Additionally, research studies portray the role of the amygdala as a central area involved in the fear networks, thus, according to this view, individuals who have abnormally weak or sensitive fear networks tend to have panic attacks.
Panic attacks are alarm reactions caused by biochemical dysfunctions. The noradrenergic system’s activity in certain brain areas stimulates cardiovascular symptoms associated with panic attacks. Thus, SSRIs (selective serotonin reuptake inhibitors) are used for the treatment of panic attacks, as increased levels of serotonergic activity in the brain, decrease the noradrenergic activity thereby causing a decrease in cardiovascular symptoms. GABA (gamma-aminobutyric acid) levels are observed to be low in the cortex of individuals experiencing panic attacks.
Psychological factors
- Cognitive theory of panic: The panic circle commences with the trigger stimulus – either internal (people having panic attacks are hypersensitive and vigilant to their bodily sensations) or external (environmental threats) which creates the apprehension or worry about having another attack. This further increases the bodily sensations and the individuals interpret these sensations as catastrophic and the vicious cycle continues to run.
- Anxiety sensitivity: Individuals often misinterpret the cues of heart palpitations or heavy breathing with that of having a heart attack.
- Safety behaviours and panic attacks: Individuals having panic attacks engage in safety behaviours like taking medicines and breathing slowly, which is attributed to the lack of panic attacks. Thus, they use these safety measures instead of understanding that the panic attack was never that catastrophic.
- Individuals interpret ambiguous bodily sensations as threatening. Moreover, they have their attention automatically drawn to the threatening information in the environment and thus have hypervigilance.
Treatment
- Prolonged exposure therapy: generally useful with clients having agoraphobia
- Cognitive Behavioral Therapy: Cognitive restructuring is used to change the maladaptive inner thoughts by logical analysis.
- Interoceptive exposure: Individuals are asked to engage in exercises to get familiar with various bodily sensations, thus the individual gets habituated to the trigger of panic attacks – the fear of these internal cues.
- Panic Control Treatment (PCT): This involves getting educated about panic and anxiety, controlled breathing, logical errors that these individuals are prone to make and control their automatic thought processes through logical reanalysis. Moreover, they are even exposed to feared situations to build their tolerance.
- Medicines: Anxiolytics (anti-anxiety pills) – Xanax or Klonopin which act within 30-60 minutes of drug administration thereby reducing acute anxiety or panic. Antidepressants – SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors) take four weeks for effective results.
5. Generalized Anxiety Disorder
This disorder is characterized by incessant worrying about many aspects of life which becomes chronic, unreasonable and excessive for at least six months. Three out of the six symptoms should occur in the individuals to be diagnosed as generalized anxiety disorder – restlessness, being fatigued easily, difficulty in concentrating, irritability, muscle tension and sleep disturbances. It affects 3% of the global population and is observed to be twice as prevalent in women compared to men. Moreover, the age of onset is difficult to determine since they have been anxious all their life.
Psychological factors
- Uncontrollability and unpredictability: Uncertain events lead to much more anxiety than predictable events.
- Cognitive biases: Anxious individuals tend to interpret ambiguous stimuli as threats. Moreover, they constantly search for threats in their environment and are vigilant.
- Generalized or free-floating anxiety results from conflict between ego and id impulses and was not dealt with properly via defence mechanisms which either were never developed or were broken down.
- Reinforces of worry: Superstitious beliefs – if one worries, it is less likely to happen. Moreover, worrying or anxiety helps in avoiding emotional circumstances that one does not desire to think about. Additionally, worrying makes one better prepared for future possible threats.
- Sense of mastery: An individual’s history of control over important aspects of their environment is a significant experiential variable strongly affecting reactions to anxiety-provoking situations. For example, over-controlling parenting styles tend to make children anxious and a belief develops within them that the world is unsafe, where they constantly require protection and have very little control of themselves.
Biological factors
- Genetic factors: Generalized anxiety disorder has very little evidence concerning heritability because of the evolving nature of its diagnostic criteria.
- Decreased levels of GABA (gamma-aminobutyric acid) are found in the limbic system of the affected individual’s brain. Thus, the benzodiazepine category of medicines is given to individuals for the treatment to reduce anxiety by elevating the levels of GABA.
- Increased cortisol production leads to generalized anxiety disorder.
Treatment
- Relaxation techniques: Muscle relaxation, yoga (Sudarshan Kriya Yoga) and meditation help alleviate anxiety
- Medicines: Anxiolytics (anti-anxiety pills’-: Xanax or Klonopin which act within 30-60 minutes of drug administration.
- Cognitive Behavioral Therapy: Cognitive restructuring is used to change the maladaptive inner thoughts by logical analysis
Anxiety is characterized by a feeling of apprehension about a possible future danger whereas fear is an alarm reaction that occurs in response to immediate danger. Obsessive-compulsive and related disorders were considered in the previous editions of the DSM under anxiety disorders but have a separate category of diagnosis in DSM-5.
Historically, anxiety disorders were viewed as classic neurotic disorders characterized by maladaptive and self-defeating behaviours. This perspective suggested that individuals with anxiety exhibited patterns of thought and behaviour that hindered their ability to cope effectively with stressors and challenges. However, the term neurosis was dropped from the DSM in 1980.
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