Anxiety is part of life. Speaking in front of a class, peering down from a ladder, or waiting to play in a big game, any one of us might feel anxious. 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 threats (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) or posttraumatic stress disorder (PTSD).¹

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15-7 How do generalized anxiety disorder, panic disorder, and phobias differ?

The anxiety disorders are marked by distressing, persistent anxiety or dysfunctional anxiety-reducing behaviors. Let’s take a closer look at three of them:

For the past two years, Tom, a 27-year-old electrician, has been bothered by dizziness, sweating palms, heart palpitations, and ringing in his ears. He feels on edge and sometimes finds himself shaking. With reasonable success, he hides his symptoms from his family and co-workers. But he allows himself few other social contacts, and occasionally he has to leave work. His family doctor and a neurologist can find no physical problem.

Tom’s unfocused, out-of-control, agitated feelings suggest a generalized anxiety disorder, which is marked by excessive and uncontrollable worry. The symptoms of this disorder are commonplace; their persistence, for six months or more, is not. People with this condition worry continually, and they are often jittery, agitated, and sleep-deprived. 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.

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

Women are twice as likely as men to experience generalized anxiety disorder (McLean & Anderson, 2009). This anxiety gender difference was reflected in a Gallup poll taken eight months after 9/11, when more U.S. women (34 percent) than men (19 percent) said they were still less willing than before 9/11 to go into skyscrapers or fly on planes. And in early 2003, more women (57 percent) than men (36 percent) said they were “somewhat worried” about becoming a terrorist victim (Jones, 2003).

Some people with generalized anxiety disorder were maltreated and inhibited as children (Moffitt et al., 2007a). As time passes, however, emotions tend to mellow, and by age 50, generalized anxiety disorder becomes fairly rare (Rubio & López-Ibor, 2007).

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).

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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-caused sweating in public—can amplify anxiety symptoms (Olatunji & Wolitzky-Taylor, 2009). After several panic attacks, people may avoid situations where the previous panic attacks have struck. If their fear is intense enough, people may develop agoraphobia, fear or avoidance of situations in which escape might be difficult when panic strikes. Given such fear, people may avoid being outside the home, in a crowd, on a bus, or in an elevator.

Charles Darwin began suffering panic disorder at age 28, after spending five years sailing the world. Because of the attacks, he moved to the country, avoided social gatherings, and traveled only in his wife’s company. But the relative seclusion did free him to focus on developing 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, such as when they hyperventilate (Knuts et al., 2010). Because nicotine is a stimulant, lighting up doesn’t lighten up.

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 animals, insects, heights, blood, or close spaces (FIGURE 15.3 below). Many people avoid the triggers, such as high places, that arouse their fear, and they manage to live with their phobia. Others are incapacitated by their efforts to avoid the feared situation. Marilyn, an otherwise healthy and happy 28-year-old, fears thunderstorms so intensely that she feels anxious as soon as a weather forecaster mentions possible storms later in the week. If her husband is away and a storm is forecast, she may stay with a close relative. During a storm, she hides from windows and buries her head to avoid seeing the lightning.

Not all phobias have specific triggers. 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 potentially embarrassing social situations—such as speaking up, eating out, or going to parties—or they may sweat or tremble when doing so.

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15-8 What is OCD?

As with the anxiety disorders, we can see aspects of obsessive-compulsive disorder (OCD) in our everyday behavior. We all may at times be obsessed with senseless or offensive thoughts that will not go away. Or we may engage in compulsive behaviors, perhaps lining up books and pencils “just so” before studying.

Obsessive thoughts and compulsive behaviors cross the fine line between normality and disorder when they persistently interfere with everyday living and cause distress. Checking to see 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 15.4 offers more examples.) At some time during their lives, often during their late teens or twenties, 1 to nearly 3 percent of people cross that line from normal preoccupations and fussiness to debilitating disorder (Kessler et al., 2012). An analysis of 14 twin studies showed that OCD has a strong genetic basis (Taylor, 2011). Although the person knows them to be irrational, the anxiety-fueled obsessive thoughts become so haunting, the compulsive rituals so senselessly time-consuming, that effective functioning becomes impossible.

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Former professional basketball player Royce White, who is open about his obsessive-compulsive disorder, said that his wealth allowed him to purchase a large house. What was the most difficult part of his transition to mansion living? “The toughest thing is going around and seeing that dust has collected in a room [I] don’t use often. And then I’ve got to spend 30 minutes dusting that thing” (Wrenn, 2012).

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).

15-9 What is PTSD?

As an Iraq war soldier, Jesse “saw the murder 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 in Texas, 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). Although many battle-scarred veterans have been diagnosed with PTSD, others also suffer from this disorder. Survivors of accidents, disasters, and violent and sexual assaults (including an estimated two-thirds of prostitutes) have experienced PTSD symptoms (Brewin et al., 1999; Farley et al., 1998; Taylor et al., 1998).

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). After experiencing a traumatic life event, about 5 to 10 percent of people develop PTSD (Bonanno 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 people develop PTSD after a traumatic event, but others don’t? Some people may have more sensitive emotion-processing limbic systems that flood their bodies with stress hormones (Kosslyn, 2005; Ozer & Weiss, 2004). PTSD patients have smaller amygdala—that acorn-shaped brain region that governs fear (Morey et al., 2012). Genes and gender also matter. Twins, compared with nontwins, more commonly share PTSD cognitive risk factors (Gilbertson et al., 2006). And the odds of getting this disorder after a traumatic event are about two times higher for women than for men (Olff et al., 2007; Ozer & Weiss, 2004).

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Some psychologists believe that PTSD has been overdiagnosed, due partly to a broadening definition of trauma (Dobbs, 2009; McNally, 2003). Too often, say some critics, PTSD gets stretched to include normal bad memories and dreams after a bad experience. In such cases, well-intentioned attempts to have people relive the trauma may amplify their emotions and pathologize normal stress reactions (Wakefield & Spitzer, 2002). For example, survivors may be “debriefed” right after a trauma and asked to revisit the experience and vent emotions. This tactic has been generally ineffective and sometimes harmful (Bonanno et al., 2010).

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 16.

15-10 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 handwashing. Few of today’s psychologists share Freud’s interpretation of anxiety. Most believe that three modern perspectives—conditioning, cognition, and biology—are more helpful.

Some bad events come with a warning. Your underdog team might lose the big game. You aren’t prepared and you may fail your quiz. You’re running late and might miss the bus. But when bad events happen unpredictably and uncontrollably, anxiety and other disorders often develop (Field, 2006; Mineka & Oehlberg, 2008). In a classic experiment, an infant called “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, became uneasy in their lab environment. The lab had become a cue for fear.

Such research helps explain why anxious people are hyperattentive to possible threats, and how panic-prone people come to associate anxiety with certain cues (Bar-Haim et al., 2007; Bouton et al., 2001). In one survey, 58 percent of those with social anxiety disorder experienced their disorder after a traumatic event (Ost & Hugdahl, 1981).

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Through conditioning, the short list of naturally painful and frightening events can multiply into a long list of human fears. Can you recall a frightening event that left you fearful for a while? We can. I [DM] was headed home when my car was struck by another when its driver missed a stop sign. For months afterward, I felt a twinge of unease as a car approached from a side street. Likewise, I [ND] remember 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 harmless cobwebs.

How might conditioning 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. Each of us [DM and ND] generalized our fears: One of us feared cars approaching from side streets and the other feared spiders. Those fears eventually disappeared, but sometimes fears can linger and grow. Marilyn’s thunderstorm phobia may have similarly generalized after a terrifying or painful experience during a thunderstorm.

Once fears and anxieties arise, reinforcement helps maintain them. Anything that helps us avoid or escape the feared situation can be reinforcing because it reduces anxiety and gives us a feeling of relief. 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.

Conditioning influences our feelings of anxiety, but so does cognition—our thoughts, memories, interpretations, and expectations. By observing others, we can learn to fear what they fear. 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 past experiences shape our expectations and influence our interpretations and 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. A pounding heart signals a heart attack. A lone spider near the bed becomes a likely infestation. An everyday disagreement with a friend or boss spells possible doom for the relationship. 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).

There is, however, more to anxiety disorders, OCD, and PTSD than conditioning and cognitive processes alone. Why will some of us develop lasting phobias or PTSD after suffering traumas? Why do we all learn some fears so readily? Why are some of us more vulnerable? The biological perspective offers insight.

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Genes Genes matter. Pair a traumatic event with a sensitive, high-strung temperament and the result may be a new phobia (Belsky & Pluess, 2009). 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).

Among monkeys, fearfulness runs in families. A monkey reacts more strongly to stress if its close biological relatives are anxiously reactive (Suomi, 1986). So, too, with people. 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 35-year-old female identical twins independently became so afraid of water that each would wade in the ocean backward and only up to the knees.

Given the genetic contribution to anxiety disorders, researchers are now sleuthing the culprit genes. One research team identified 17 gene variations associated with typical anxiety disorder symptoms (Hovatta et al., 2005). Other teams have found genes associated specifically with OCD (Taylor, 2013).

Genes can influence disorders by regulating neurotransmitters. Some studies point to an “anxiety gene” that affects brain levels of serotonin, a neurotransmitter that influences sleep, mood, and attention to negative images (Canli, 2008; Pergamin-Hight et al., 2012). Other studies implicate genes that regulate the neurotransmitter glutamate (Lafleur et al., 2006; Welch et al., 2007). With too much glutamate, the brain’s alarm centers become overactive.

Among PTSD patients, a history of child abuse leaves long-term epigenetic marks, increasing the likelihood that a genetic vulnerability to the 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; Kolassa & Elbert, 2007; Herringa et al., 2013). These fear pathways create easy inroads for more fear experiences (Armony et al., 1998).

Anxiety-related disorders differ from one another, but they all involve biological events. In OCD, for example, when the disordered brain detects that something is amiss, it generates a mental hiccup of repeating thoughts (obsessions) or actions (compulsions) (Gehring et al., 2000). Brain scans of people with PTSD show higher-than-normal activity in the amygdala when they view traumatic images (Nutt & Malizia, 2004). Brain scans of people with OCD 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). These brain areas are not only more active among people with OCD, they are also enlarged (Rotge et al., 2010). As FIGURE 15.4 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). When deciding to get rid of one’s personal possessions, those with hoarding disorder also show elevated activity in the anterior cingulate cortex (Tolin et al., 2012).

Some antidepressant drugs dampen this fear-circuit activity and its associated obsessive-compulsive behavior. Fears can also be blunted by giving people drugs as they recall and then rerecord (“reconsolidate”) a traumatic experience (Kindt et al., 2009; Norberg, et al., 2008). Although they don’t forget the experience, the associated emotion is largely erased.

Natural Selection We seem biologically prepared to fear threats faced by our ancestors. Our phobias focus on such specific fears: spiders, snakes, and other animals; enclosed spaces and heights; storms and darkness. (Those fearless about these occasional threats were less likely to survive and leave descendants.) Thus, even in Britain, with only one poisonous snake species, people often fear snakes. It is easy to condition and hard to extinguish fears of such “evolutionarily relevant” stimuli (Coelho & Purkis, 2009; Davey, 1995; Öhman, 2009). Some of our modern fears can also have an evolutionary explanation. A fear of flying may be rooted in our biological predisposition to fear confinement and heights.

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Compare our easily conditional 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 blitzes continued, the British, Japanese, and German populations did not become more and more panicked. Rather, they grew more indifferent to planes outside their immediate neighborhoods (Mineka & Zinbarg, 1996). Evolution has not prepared us to fear bombs dropping from the sky.

Just as our phobias focus on dangers faced by our ancestors, our compulsive acts typically exaggerate behaviors that contributed to our species’ survival. Grooming gone wild becomes hair pulling. Washing up becomes ritual hand washing. Checking territorial boundaries becomes rechecking an already locked door (Rapoport, 1989).

LEARNING OBJECTIVES

RETRIEVAL PRACTICE Take a moment to answer each of these Learning Objective Questions (repeated here from within this section). Then click the 'show answer' button to check your answers. Research suggests that trying to answer these questions on your own will improve your long-term retention (McDaniel et al., 2009).

15-7 How do generalized anxiety disorder, panic disorder, and phobias differ?

15-8 What is OCD?

15-9 What is PTSD?

15-10 How do conditioning, cognition, and biology contribute to the feelings and thoughts that mark anxiety disorders, OCD, and PTSD?

TERMS AND CONCEPTS TO REMEMBER

RETRIEVAL PRACTICE Match each of the terms on the left with its definition on the right. Click on the term first and then click on the matching definition. As you match them correctly they will move to the bottom of the activity.

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