Anxiety is part of life. Speaking in front of a class, peering down from a ladder, or waiting to play in a big game might make any one of us feel nervous. Anxiety may even cause us to avoid talking or making eye contact—“shyness,” we call it. Fortunately for most of us, our uneasiness is not intense and persistent. Some of us, however, are more prone to notice and remember information perceived as threatening (Mitte, 2008). When the brain’s danger-detection system becomes hyperactive, we are at greater risk for an anxiety disorder, or for two other disorders that involve anxiety: obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD).¹

14-7 How do generalized anxiety disorder, panic disorder, and phobias differ?

The anxiety disorders are marked by distressing, persistent anxiety and often dysfunctional anxiety-reducing behaviors. These include:

Generalized Anxiety Disorder

Tom was a 27-year-old electrician. For two years, he had been bothered by dizziness, sweating palms, and irregular heartbeat. He felt on edge and sometimes found himself shaking. Tom had been reasonably successful in hiding his symptoms from his family and co-workers, but occasionally he had to leave work. He allowed himself few other social contacts. Neither his family doctor nor a neurologist had been able to find any physical problem.

Tom’s unfocused, out-of-control, agitated feelings suggest a generalized anxiety disorder. The symptoms of this disorder are commonplace; their persistence, for six months or more, is not. People with this condition (two-thirds women) worry continually, and they are often jittery, on edge, and sleep deprived (McLean & Anderson, 2009). Concentration is difficult as attention switches from worry to worry. Their tension and apprehension may leak out through furrowed brows, twitching eyelids, trembling, perspiration, or fidgeting from autonomic nervous system arousal.

People may not be able to identify the cause of their anxiety, and therefore cannot relieve or avoid it. To use Sigmund Freud’s term, the anxiety is free-floating (not linked to a specific stressor or threat). Generalized anxiety disorder and depression often go hand in hand, but even without depression, this disorder tends to be disabling (Hunt et al., 2004; Moffitt et al., 2007b). Moreover, it may lead to physical problems, such as high blood pressure.

Panic Disorder

For the 1 person in 75 with panic disorder, anxiety suddenly escalates into a terrifying panic attack—a minutes-long episode of intense fear that something horrible is about to happen. Physical symptoms, such as irregular heartbeat, chest pains, shortness of breath, choking, trembling, or dizziness may accompany the panic. One woman recalled suddenly feeling

hot and as though I couldn’t breathe. My heart was racing and I started to sweat and tremble and I was sure I was going to faint. Then my fingers started to feel numb and tingly and things seemed unreal. It was so bad I wondered if I was dying and asked my husband to take me to the emergency room. By the time we got there (about 10 minutes) the worst of the attack was over and I just felt washed out (Greist et al., 1986).

These anxiety tornados strike suddenly, wreak havoc, and disappear, but they are not forgotten. Ironically, worries about anxiety—perhaps fearing another panic attack, or fearing anxiety-related symptoms in public—can amplify anxiety symptoms (Olatunji & Wolitzky-Taylor, 2009). After several panic attacks, people may come to fear the fear itself. This may trigger agoraphobia—fear or avoidance of public situations from which escape might be difficult. People with agoraphobia may avoid being outside the home, in a crowd, on a bus, or in an elevator.

Charles Darwin began suffering from panic disorder at age 28, after spending five years sailing the world. As a result, he moved to the country, avoided social gatherings, and traveled only in his wife’s company. But the relative seclusion did free him to develop his evolutionary theory. “Even ill health,” he reflected, “has saved me from the distraction of society and its amusements” (quoted in Ma, 1997).

Smokers have at least a doubled risk of panic disorder (Zvolensky & Bernstein, 2005). They also show greater panic symptoms in situations that often produce panic attacks (Knuts et al., 2010). Because nicotine is a stimulant, lighting up doesn’t help us lighten up.

Phobias

We all live with some fears. But people with phobias are consumed by a persistent, irrational fear and avoidance of some object, activity, or situation. Specific phobias may focus on particular animals, insects, heights, blood, or closed spaces (FIGURE 14.3). Many people avoid the triggers, such as high places, that arouse their fear. Marilyn², an otherwise healthy and happy 28-year-old, so feared thunderstorms that she felt anxious as soon as a weather forecaster mentioned possible storms later in the week. If her husband was away and a storm was forecast, she would often stay with a close relative. During a storm, she hid from windows and buried her head to avoid seeing the lightning.

Not all phobias are so specific. Social anxiety disorder (formerly called “social phobia”) is shyness taken to an extreme. People with this disorder have an intense fear of other people’s negative judgments. They may avoid social situations, such as speaking up in a group, eating out, or going to parties. Finding themselves in such a situation, they may experience symptoms of their anxiety, such as sweating or trembling.

14-8 What is OCD?

As with the anxiety disorders, we can see aspects of our own behavior in obsessive-compulsive disorder (OCD). Obsessive thoughts are unwanted and so repetitive it may seem they will never end. Compulsive behaviors are responses to those thoughts.

We all are at times obsessed with thoughts that will not go away, and we all at times behave compulsively. Anxious about how your place will appear to others, you may catch yourself compulsively cleaning before guests arrive. Concerned that you may not make the grade on your final, you may find yourself lining up books and pencils “just so” before studying. On a small scale, obsessive thoughts and compulsive behaviors are a part of everyday life. They cross the fine line between normality and disorder when they persistently interfere with everyday life and cause us distress. Checking to see that you locked the door is normal; checking 10 times is not. Washing your hands is normal; washing so often that your skin becomes raw is not. (TABLE 14.4 offers more examples.) At some time during their lives, often during their late teens or twenties, some 2 percent of people cross that line from normal preoccupations and fussy behaviors to debilitating disorder (Kessler et al., 2012). Twin studies reveal that OCD has a strong genetic basis (Taylor, 2011). Although the person knows the anxiety-fueled obsessive thoughts are irrational, these thoughts can become so haunting, and the compulsive rituals so senselessly time consuming, that effective functioning becomes impossible.

Data from: Rapoport, 1989.

OCD is more common among teens and young adults than among older people (Samuels & Nestadt, 1997). A 40-year follow-up study of 144 Swedish people diagnosed with the disorder found that, for most, the obsessions and compulsions had gradually lessened, though only 1 in 5 had completely recovered (Skoog & Skoog, 1999).

14-9 What is PTSD?

While serving his country in war, one soldier, Jesse, observed the killing “of children and women. It was just horrible for anyone to experience.” After calling in a helicopter strike on one house where he had seen ammunition crates carried in, he heard the screams of children from within. “I didn’t know there were kids there,” he recalled. Back home, he suffered “real bad flashbacks” (Welch, 2005).

Jesse is not alone. In one study of 103,788 veterans returning from Iraq and Afghanistan, 25 percent were diagnosed with a psychological disorder (Seal et al., 2007). Some had traumatic brain injuries (TBI), but the most frequent diagnosis was posttraumatic stress disorder (PTSD). Typical symptoms include recurring haunting memories and nightmares, a numb feeling of social withdrawal, jumpy anxiety, and trouble sleeping (Germain, 2013; Hoge et al., 2004, 2006, 2007; Kessler, 2000). Survivors of accidents, disasters, and violent and sexual assaults (including an estimated two-thirds of prostitutes) have also experienced PTSD symptoms (Brewin et al., 1999; Farley et al., 1998; Taylor et al., 1998). Reliving traumas such as 9/11 or the Boston Marathon bombing—by being glued to television replays, for example—sustains the stress response (Holman et al., 2014).

The greater one’s emotional distress during a trauma, the higher the risk for posttraumatic symptoms (Ozer et al., 2003). Among American military personnel in Afghanistan, 7.6 percent of combatants and 1.4 percent of noncombatants developed PTSD (McNally, 2012). Among New Yorkers who witnessed or responded to the 9/11 terrorist attacks, most did not experience PTSD (Neria et al., 2011). PTSD diagnoses among survivors who had been inside the World Trade Center during the attack were, however, double the rates found among those who were outside (Bonanno et al., 2006).

About half of us will experience at least one traumatic event in our lifetime. Why do some 5 to 10 percent of people develop PTSD after a traumatic event, but others don’t (Bonanno et al., 2011)? Some people may have a more sensitive emotion-processing limbic system that floods their bodies with stress hormones (Kosslyn, 2005; Ozer & Weiss, 2004). The odds of getting this disorder after a traumatic event are higher for women (about 1 in 10) than for men (1 in 20) (Olff et al., 2007; Ozer & Weiss, 2004).

Some psychologists believe that PTSD has been overdiagnosed (Dobbs, 2009; McNally, 2003). Too often, say critics, PTSD gets stretched to include normal stress-related bad memories and dreams. And “debriefing” people, by having them relive a trauma soon after, may actually worsen normal stress reactions (Bonanno et al., 2010; Wakefield & Spitzer, 2002).

Most people, male and female, display an impressive survivor resiliency, or ability to recover after severe stress (Bonanno et al., 2010). For more on human resilience and on the posttraumatic growth that some experience, see Chapter 15.

14-10 How do conditioning, cognition, and biology contribute to the feelings and thoughts that mark anxiety disorders, OCD, and PTSD?

Anxiety is both a feeling and a cognition—a doubt-laden appraisal of one’s safety or social skill. How do these anxious feelings and cognitions arise? Sigmund Freud’s psychoanalytic theory proposed that, beginning in childhood, people repress intolerable impulses, ideas, and feelings. This submerged mental energy sometimes, he thought, leaks out in odd symptoms, such as anxious hand washing. Few of today’s psychologists interpret anxiety this way. Most believe that three modern perspectives—conditioning, cognition, and biology—are more helpful.

Conditioning

Some bad events come with a warning. You’re running late and might miss the bus. But when bad events happen unpredictably and uncontrollably, anxiety or other disorders often develop (Field, 2006; Mineka & Oehlberg, 2008). In a classic experiment, infant “Little Albert” learned to fear furry objects that were paired with loud noises. In other experiments, researchers have created anxious animals by giving rats unpredictable electric shocks (Schwartz, 1984). The rats, like assault victims who report feeling anxious when returning to the scene of the crime, learn to become uneasy in their lab environment. The lab had become a cue for fear.

Such research helps explain how panic-prone people learn to associate anxiety with certain cues, and why anxious people are hyperattentive to possible threats (Bar-Haim et al., 2007; Duits et al., 2015). In one survey, 58 percent of those with social anxiety disorder said their disorder began after a traumatic event (Ost & Hugdahl, 1981).

How might learning magnify a single painful and frightening event into a full-blown phobia? The answer lies in part in two conditioning processes: stimulus generalization and reinforcement.

Stimulus generalization occurs when a person experiences a fearful event and later develops a fear of similar events. My [DM’s] car was once struck by another whose driver missed a stop sign. For months afterward, I felt a twinge of unease when any car approached from a side street. Likewise, I [ND] was watching a terrifying movie about spiders, Arachnophobia, when a severe thunderstorm struck and the theater lost power. For months, I experienced anxiety at the sight of spiders or cobwebs. Those fears eventually disappeared, but sometimes fears linger and grow. Marilyn’s thunderstorm phobia may have similarly generalized after a terrifying or painful experience during a thunderstorm.

Once fears and anxieties are learned, reinforcement helps maintain them. Anything that helps us avoid or escape the feared situation reduces anxiety. This feeling of relief can reinforce phobic behaviors. Fearing a panic attack, we may decide not to leave the house. Reinforced by feeling calmer, we are likely to repeat that maladaptive behavior in the future (Antony et al., 1992). So, too, with compulsive behaviors. If washing our hands relieves our feelings of anxiety, we may wash our hands again when those feelings return.

Cognition

Conditioning influences our feelings of anxiety, but so does cognition—our thoughts, memories, interpretations, and expectations. We learn some fears by observing others. Nearly all monkeys raised in the wild fear snakes, yet lab-raised monkeys do not. Surely, most wild monkeys do not actually suffer snake bites. Do they learn their fear through observation? To find out, Susan Mineka (1985, 2002) experimented with six monkeys raised in the wild (all strongly fearful of snakes) and their lab-raised offspring (virtually none of which feared snakes). After repeatedly observing their parents or peers refusing to reach for food in the presence of a snake, the younger monkeys developed a similar strong fear of snakes. When the monkeys were retested three months later, their learned fear persisted. We humans learn many of our own fears by observing others (Helsen et al., 2011; Olsson et al., 2007).

Our interpretations and expectations also shape our reactions. Whether we interpret the creaky sound in the old house simply as the wind or as a possible knife-wielding intruder determines whether we panic. People with anxiety disorders tend to be hypervigilant. They attend more to threatening stimuli. They more often interpret ambiguous stimuli as threatening: a pounding heart signals a heart attack, a lone spider near the bed indicates an infestation, and an everyday disagreement with a friend or a boss spells doom for the relationship. And they more readily remember threatening events (Van Bockstaele et al., 2014). Anxiety is especially common when people cannot switch off such intrusive thoughts and perceive a loss of control and a sense of helplessness (Franklin & Foa, 2011).

Biology

Some aspects of anxiety disorders, OCD, and PTSD are not easily understandable in terms of conditioning and cognitive processes alone. Why do some of us develop lasting phobias after suffering traumas, but others do not? Why do we all learn some fears more readily? Our biology also plays a role.

GENES Among monkeys, fearfulness runs in families. A monkey reacts more strongly to stress if its close biological relatives have sensitive, high-strung temperaments (Suomi, 1986). So, too, with people. Some of us are predisposed to anxiety. If one identical twin has an anxiety disorder, the other is likewise at risk (Hettema et al., 2001; Kendler et al., 2002a,b; Van Houtem et al., 2013). Even when raised separately, identical twins may develop similar phobias (Carey, 1990; Eckert et al., 1981). One pair of separated identical twins independently became so afraid of water that, at age 35, they would wade into the ocean backward and only up to their knees.

Given the genetic contribution to anxiety disorders, researchers are now sleuthing the culprit genes. Among their findings are 17 gene variations associated with typical anxiety disorder symptoms (Hovatta et al., 2005), and others that are associated specifically with OCD (Taylor, 2013).

Some genes influence anxiety disorders by regulating brain levels of neurotransmitters. These include serotonin, which influences sleep, mood, and attending to threat (Canli, 2008; Pergamin-Hight et al., 2012), and glutamate, which heightens activity in the brain’s alarm centers (Lafleur et al., 2006; Welch et al., 2007).

So genes matter. Some of us have genes that make us like orchids—fragile, yet capable of beauty under favorable circumstances. Others of us are like dandelions—hardy, and able to thrive in varied circumstances (Ellis & Boyce, 2008; Pluess & Belsky, 2013).

But experience affects gene expression. Among PTSD patients, a history of child abuse leaves long-term epigenetic marks, which are often organic molecules. These molecular tags attach to our chromosomes and turn certain genes on or off. Thus, experiences such as abuse can increase the likelihood that a genetic vulnerability to a disorder will be expressed (Mehta et al., 2013). Suicide victims show a similar epigenetic effect (McGowan et al., 2009).

THE BRAIN Our experiences change our brain, paving new pathways. Traumatic fear-learning experiences can leave tracks in the brain, creating fear circuits within the amygdala (Etkin & Wager, 2007; Herringa et al., 2013; Kolassa & Elbert, 2007). These fear pathways create easy inroads for more fear experiences (Armony et al., 1998). Some antidepressant drugs dampen this fear-circuit activity and associated obsessive-compulsive behaviors.

Anxiety-related disorders all involve biological events. Brain scans of people with PTSD show higher-than-normal activity in the amygdala when they view traumatic images (Nutt & Malizia, 2004). When the disordered brain of an OCD patient detects that something is amiss, it generates a mental hiccup of repeating thoughts (obsessions) or actions (compulsions) (Gehring et al., 2000). Brain scans reveal elevated activity in specific brain areas during behaviors such as compulsive hand washing, checking, ordering, or hoarding (Insel, 2010; Mataix-Cols et al., 2004, 2005). As FIGURE 14.4 shows, the anterior cingulate cortex, a brain region that monitors our actions and checks for errors, seems especially likely to be hyperactive (Maltby et al., 2005).

NATURAL SELECTION We seem biologically prepared to fear the threats our ancestors faced—spiders and snakes, enclosed spaces and heights, storms and darkness. (In the distant past, those who did not fear these threats were less likely to survive and leave descendants.) Thus, in Britain, which has only one poisonous snake species, people often fear snakes. Even 9-month-olds attend less to modern danger sounds than to sounds signaling ancient threats—hisses, thunder, angry voices (Erlich et al., 2013). Our Stone Age fears are easy to condition and hard to extinguish (Coelho & Purkis, 2009; Davey, 1995; Öhman, 2009). Some of our modern fears may also have an evolutionary explanation. A fear of flying may be rooted in our biological predisposition to fear confinement and heights.

Compare our easily conditioned fears to what we do not easily learn to fear. World War II air raids, for example, produced remarkably few lasting phobias. As the air strikes continued, the British, Japanese, and German populations did not become more and more panicked. Rather, they grew increasingly indifferent to planes outside their immediate neighborhoods (Mineka & Zinbarg, 1996). Evolution has not prepared us to fear bombs dropping from the sky.

Our phobias focus on dangers our ancestors faced. Our compulsive acts typically exaggerate behaviors that helped them survive. Grooming had survival value; it detected insects and infections. Gone wild, it becomes compulsive hair pulling. Washing up helped people stay healthy. Out of control, it becomes ritual hand washing. Checking territorial boundaries helped ward off enemies. In OCD, it becomes checking and rechecking an already locked door (Rapoport, 1989).

Learning Objectives

Test Yourself by taking a moment to answer each of these Learning Objective Questions (repeated here from within the chapter). Research suggests that trying to answer these questions on your own will improve your long-term memory of the concepts (McDaniel et al., 2009).

Question

Question

Question

Question

Terms and Concepts to Remember

Test yourself on these terms.

Question

Experience the Testing Effect

Test yourself repeatedly throughout your studies. This will not only help you figure out what you know and don’t know; the testing itself will help you learn and remember the information more effectively thanks to the testing effect.

Question 14.9

Question 14.10

Question 14.11

Question 14.12

Use to create your personalized study plan, which will direct you to the resources that will help you most in .