Anxiety is part of life. Have you ever felt anxious when speaking in front of a class, peering down from a high ledge, or waiting to play in a big game? We all feel anxious at times. We may occasionally feel enough anxiety to avoid making eye contact or talking with someone—“shyness,” we call it. Fortunately for most of us, our uneasiness is not intense and persistent. Some of us, however, are especially prone to notice and remember information perceived as threatening (Mitte, 2008). When our brain’s danger-detection system becomes overly active, 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.²

The anxiety disorders are marked by distressing, persistent anxiety or by maladaptive behaviors that reduce anxiety. For example, people with social anxiety disorder become extremely anxious in social settings where others might judge them, such as parties, class presentations, or even eating in a public place. To stave off anxious thoughts and feelings (including physical symptoms such as sweating and trembling), they may avoid going out at all. Even though this behavior reduces their anxiety, it is maladaptive—it does not help them cope with their world.

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In this section we focus on three other anxiety disorders:

Generalized Anxiety Disorder

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

Tom’s unfocused, out-of-control, agitated feelings suggest 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 are women) worry continually. They are often jittery, on edge, and sleep deprived (McLean & Anderson, 2009). Their gaze becomes fixated on potential threats (Pergamin-Hight et al., 2015). Concentration is difficult as attention switches from worry to worry. Their tension may leak out through furrowed brows, twitching eyelids, trembling, sweating, or fidgeting.

The person may not be able to identify the tension’s cause, 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., 2007). Moreover, it may lead to physical problems, such as high blood pressure.

Panic Disorder

At some point in our life, many of us will experience a terrifying panic attack—a minutes-long feeling of intense fear that something horrible is about to happen. Irregular heartbeat, chest pains, shortness of breath, choking, trembling, or dizziness may accompany the fear. 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).

For the 1 person in 75 with panic disorder, panic attacks are recurrent. These anxiety tornados strike suddenly, do their damage, and disappear, but they are not forgotten. After experiencing even a few panic attacks, people may come to fear the fear itself. Those having (or observing) a panic attack often misread the symptoms as an impending heart attack or other serious physical ailment. Smokers have at least a doubled risk of a panic attack and greater symptoms when they do have an attack (Knuts et al., 2010; Zvolensky & Bernstein, 2005). Because nicotine is a stimulant, lighting up doesn’t lighten up.

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The constant fear of another attack can lead people with panic disorder to avoid situations where panic might strike. Their avoidance itself may lead to a separate and additional diagnosis of agoraphobia, the fear of again experiencing the dreaded tornado of anxiety. Fear of being unable to escape or get help during an attack may cause people with agoraphobia to avoid being outside the home, in a crowd, or at a coffee shop. Not all people with panic disorder develop agoraphobia.

Phobias

We all live with some fears. People with phobias are consumed by a persistent, irrational fear and avoidance of some object or situation. Specific phobias may focus on particular animals, insects, heights, blood, or enclosed spaces (FIGURE 13.1). Many people avoid the triggers (such as high places) that arouse their fear. Marilyn, 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 often stayed with a close relative. During a storm, she hid from windows and buried her head to avoid seeing the lightning.

As with the anxiety disorders, we can see aspects of our own behavior in obsessive-compulsive disorder (OCD). Obsessive thoughts (recall Marc’s focus on cleaning his room) are unwanted and so repetitive it may seem they will never go away. Compulsive behaviors are responses to those thoughts (cleaning and cleaning and cleaning).

On a small scale, obsessive thoughts and compulsive behaviors are part of everyday life. Have you ever felt a bit anxious about how your place will appear to others and found yourself checking and cleaning one last time before your guests arrived? Or, perhaps worried about completing an assignment, you caught yourself lining up books or devices “just so” before you began studying? Our lives are full of little rehearsals and fussy behaviors. They cross the fine line between normality and disorder when they persistently interfere with everyday life and cause us distress. Checking to see if you locked your door is normal; checking 10 times is not. Washing your hands is normal; washing so often that your skin becomes raw is not. Although people know their 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.

While serving his country in war, one soldier, Jesse, saw the killing “of children and women. It was just horrible for anyone to experience.” 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). 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., 1998b). 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, 2007; Hoge & Castro, 2006; Kessler, 2000).

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About half of us will experience at least one traumatic event in our lifetime. And most of us will display survivor resiliency—a tendency to recover after severe stress (Bonanno, 2004, 2005; Bonanno et al., 2006). Some will even experience posttraumatic growth (more on this in Chapter 14). But some 5 to 10 percent of us will develop PTSD (Bonanno et al., 2011). Why do some people develop PTSD after a traumatic event, but others don’t? One factor seems to be the amount of emotional distress that occurs during the trauma: The higher the distress, the greater the risk for posttraumatic symptoms (Ozer et al., 2003). Some examples:

What else can influence PTSD development after a trauma? Some people may have a more sensitive emotion-processing limbic system that floods their bodies with stress hormones (Kosslyn, 2005; Ozer & Weiss, 2004). Another factor is gender. After a traumatic event, women are twice as likely as men to develop PTSD symptoms (Olff et al., 2007; Ozer & Weiss, 2004).

Some psychologists believe PTSD has been overdiagnosed (Dobbs, 2009; McNally, 2003). Too often, say critics, PTSD gets stretched to include normal stress-related bad memories and dreams. In such cases, some well-intentioned procedures—such as “debriefing” people by asking them to revisit the experience and vent their emotions—may worsen stress reactions (Bonanno et al., 2010; Wakefield & Spitzer, 2002). Other research shows that reliving traumas (such as 9/11 or the Boston Marathon bombing) through media coverage sustains the stress response (Holman et al., 2014). Nevertheless, people diagnosed with PTSD can benefit from other therapies, some of which are discussed in Chapter 14.

Anxiety is both a feeling and a thought—a doubt-laden appraisal of one’s safety or social skill. How do these anxious feelings and thoughts arise? Sigmund Freud’s psychoanalytic theory (Chapter 12) proposed that, beginning in childhood, people repress certain impulses, ideas, and feelings. Freud believed that this submerged mental energy sometimes 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

Conditioning happens when we learn to associate two or more things that occur together. Through classical conditioning, our fear responses can become linked with formerly neutral objects and events. You may recall from Chapter 6 that an infant—“Little Albert”—learned to fear furry objects that researchers 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, had learned to be uneasy in their lab environment. The lab had become a cue for fear.

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Such research helps explain how anxious or traumatized people come to associate their anxiety with certain cues (Bar-Haim et al., 2007; Duits et al., 2015). In one survey, 58 percent of those with social anxiety disorder said their symptoms began after a traumatic event (Ost & Hugdahl, 1981). Anxiety or an anxiety-related disorder is more likely to develop when bad events happen unpredictably and uncontrollably (Field, 2006; Mineka & Oehlberg, 2008). Even a single painful and frightening event may trigger a full-blown phobia, thanks to two processes: classical conditioning’s stimulus generalization and operant conditioning’s 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 a driver who 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.

Reinforcement helps maintain learned fears and anxieties. Anything that enables us to avoid or escape a feared situation reduces our anxiety. This feeling of relief can reinforce maladaptive behaviors. Fearing a panic attack, a person may decide not to leave the house. Reinforced by feeling calmer, the person is likely to repeat that behavior in the future (Antony et al., 1992). Compulsive behaviors operate similarly. If washing your hands relieves your feelings of anxiety, you may wash your hands again when those feelings return.

Cognition

Learning is more than just conditioning. Cognition—our thoughts, memories, interpretations, and expectations—plays a role in many kinds of learning, including what we learn to fear. In one form of cognitive learning, we learn by observing others (Chapter 6). Consider wild monkeys’ fear of snakes. Why do 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, one researcher experimented (Mineka, 1985, 2002). Her study focused on six monkeys raised in the wild (all strongly fearful of snakes) and their lab-raised offspring (none of which feared snakes). During the study, the young monkeys repeatedly observed their parents or peers refusing to reach for food in the presence of a snake. Can you predict what happened? The young monkeys also developed a strong fear of snakes. When they 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 panic in response to a creaky sound in an old house depends on whether we interpret the sound as the wind or as a possible knife-wielding intruder. People with anxiety-related disorders tend to be hypervigilant. They attend more to threatening stimuli. They more often interpret unclear stimuli as threatening. (A pounding heart signals a heart attack. A lone spider near the bed indicates an infestation. An everyday disagreement with a partner or boss spells doom for the relationship.) And they more often 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

Learning can’t explain all aspects of anxiety disorders, OCD, and PTSD. Why do some of us develop lasting phobias or PTSD after suffering traumas, but others do not? Why do we all learn some fears more readily than others? The answers lie in part in our biology.

GENES Genes matter. 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 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). Thus, some of us are genetically predisposed to anxiety, OCD, and PTSD. 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, even at age 35, they would wade into the ocean backwards and only up to their knees. Researchers have found genes associated with OCD (Taylor, 2013) and others associated with typical anxiety disorder symptoms (Hovatta et al., 2005).

But as we have seen in so many areas, experience affects whether a gene will be expressed. Experiences such as child abuse can leave tracks in the brain, increasing the chances that a genetic vulnerability to a disorder such as PTSD will be expressed (Mehta et al., 2013; Zannas et al., 2015).

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THE BRAIN Anxiety-related disorders all involve biological events. Traumatic experiences alter our brain, paving new fear pathways, which are easy inroads for more fear experiences (Armony et al., 1998).

Generalized anxiety disorder, panic attacks, phobias, OCD, and PTSD express themselves biologically as overarousal of brain areas involved in impulse control and habitual behaviors. These disorders reflect a brain danger-detection system gone hyperactive—producing anxiety when no danger exists. In OCD, for example, when the brain detects that something is wrong, it seems to generate a mental hiccup of repeating thoughts or actions (Gehring et al., 2000). Brain scans show 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).

NATURAL SELECTION No matter how fearful or fearless we are, we humans 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.) Our Stone Age fears are easy to condition and hard to extinguish (Davey, 1995; Öhman, 1986). Even in Britain, which has only one poisonous snake species, people often fear snakes. And we have these fears at very young ages. Nine-month-old infants attend more to sounds signaling ancient threats (hisses, thunder) than they do to sounds representing modern dangers (a bomb exploding, breaking glass) (Erlich et al., 2013). Even some of our modern fears may have their roots in our evolutionary past. Fear of flying includes two ancient fears—of 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 more indifferent to planes outside their immediate neighborhood (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. Gone wild, it becomes compulsive hair pulling. So too with washing up, which becomes ritual hand washing. And checking territorial boundaries becomes checking and rechecking already locked doors (Rapoport, 1989). Although natural selection shaped our behaviors, when taken to an extreme, these behaviors can interfere with daily life.