“Okay, time for a pop quiz that will be half your grade for this class.” If your instructor had actually said that, you would probably have experienced a wave of anxiety and dread. Your reaction would not be a sign that you have a mental disorder. In fact, situation-related anxiety is normal and adaptive: in this case, perhaps by reminding you to keep up with your textbook assignments so you are prepared for pop quizzes. But when anxiety arises that is out of proportion to real threats and challenges, it is maladaptive: It can take hold of people’s lives, stealing their peace of mind and undermining their ability to function normally. Pathological anxiety is expressed as an anxiety disorder, the class of mental disorder in which anxiety is the predominant feature. Among the anxiety disorders recognized in the DSM–5 are phobic disorders, panic disorder, and generalized anxiety disorder.

Mary, a 47-year-old mother of three, sought treatment for claustrophobia—an intense fear of enclosed spaces. She traced her fear to childhood, when her older siblings would scare her by locking her in closets and confining her under blankets. She wanted to find a job but could not do so because of a terror of elevators and other confined places that, she felt, shackled her to her home (Carson, Butcher, & Mineka, 2000). Many people feel a little anxious in enclosed spaces, but Mary’s fears were abnormal and dysfunctional because they were disproportionate to any actual risk and impaired her ability to carry out a normal life. The DSM–5 describes phobic disorders as disorders characterized by marked, persistent, and excessive fear and avoidance of specific objects, activities, or situations. An individual with a phobic disorder recognizes that the fear is irrational but cannot prevent it from interfering with everyday functioning.

A specific phobia is a disorder that involves an irrational fear of a particular object or situation that markedly interferes with an individual’s ability to function. Specific phobias fall into five categories: (1) animals (e.g., dogs, cats, rats, snakes, spiders); (2) natural environments (e.g., heights, darkness, water, storms); (3) situations (e.g., bridges, elevators, tunnels, enclosed places); (4) blood, injections, and injury; and (5) other phobias, including choking or vomiting; and in children, loud noises or costumed characters. Approximately 12% of people in the United States will develop a specific phobia during their lives (Kessler, Berglund, et al., 2005), with rates slightly higher among women than men (Kessler et al., 2012).

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Social phobia is a disorder that involves an irrational fear of being publicly humiliated or embarrassed. Social phobia can be restricted to situations such as public speaking, eating in public, or urinating in a public bathroom or generalized to a variety of social situations that involve being observed or interacting with unfamiliar people. Individuals with social phobia try to avoid situations in which unfamiliar people might evaluate them, and such individuals experience intense anxiety and distress when public exposure is unavoidable. Social phobia can develop in childhood, but it typically emerges between early adolescence and early adulthood (Kessler, Berglund, et al., 2005). About 12% of men and 14% of women qualify for a diagnosis of social phobia at some time in their lives (Kessler et al., 2012).

Why are phobias so common? The high rates of both specific and social phobias suggest a predisposition to be fearful of certain objects and situations. Indeed, most of the situations and objects of people’s phobias could pose a real threat—for example, falling from a high place or being attacked by a vicious dog or poisonous snake or spider. Social situations have their own dangers. A roomful of strangers could form impressions that affect your prospects for friends, jobs, or marriage. And of course, in some very rare cases, they could attack or bite.

Observations such as these are the basis for the preparedness theory of phobias, which is the idea that people are instinctively predisposed toward certain fears (Seligman, 1971). The preparedness theory is supported by research showing that both humans and monkeys can quickly be conditioned to have a fear response for stimuli such as snakes and spiders, but not for neutral stimuli such as flowers or toy rabbits (Cook & Mineka, 1989; Öhman, Dimberg, & Öst, 1985). Similarly, research on facial expressions has shown that people are more easily conditioned to fear angry facial expressions than other types of expressions (Öhman, 1996; Woody & Nosen, 2008). Phobias are particularly likely to form for objects that evolution has predisposed us to avoid.

Neurobiological factors may also play a role. Abnormalities in the neurotransmitters serotonin and dopamine are more common in individuals who report phobias than among people who don’t (Stein, 1998). In addition, individuals with phobias sometimes show abnormally high levels of activity in the amygdala, an area of the brain linked with the development of emotional associations (discussed in the chapter on Emotion and Motivation and in Stein, Chavira, & Jang, 2001). Interestingly, although people with social phobia report feeling much more distressed than those without social phobia during tasks involving social evaluation (such as giving a speech), they are actually no more physiologically aroused than others (Jamieson, Nock, & Mendes, 2013). This suggests that social phobia may be due to a person’s subjective experience of the situation rather than an abnormal physiological stress response to such situations.

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This evidence does not rule out the influence of environments and upbringing on the development of phobic overreactions. As learning theorist John Watson (1924) demonstrated many years ago, phobias can be classically conditioned (see the discussion of Little Albert and the white rat in the Learning chapter). Similarly, the discomfort of a dog bite could create a conditioned association between dogs and pain, resulting in an irrational fear of all dogs. The idea that phobias are learned from emotional experiences with feared objects, however, is not a complete explanation for the occurrence of phobias. Most studies find that people with phobias are no more likely than people without phobias to recall personal experiences with the feared object that could have provided the basis for classical conditioning (Craske, 1999; McNally & Steketee, 1985). Moreover, many people are bitten by dogs, but few develop phobias. Despite its shortcomings, however, the idea that this is a matter of learning provides a useful model for therapy (see the Treatment chapter).

Wesley, a 20-year-old college student, began having panic attacks with increasing frequency, often two or three times a day. The attacks began with a sudden wave of “intense, terrifying fear” that seemed to come out of nowhere, often accompanied by dizziness, a tightening of the chest, and the thought that he was going to pass out or possibly die. Wesley finally decided to come in for treatment because he had begun to avoid buses, trains, and public places for fear that he would have an attack like this and not be able to escape.

Wesley’s condition, called panic disorder, is a disorder characterized by the sudden occurrence of multiple psychological and physiological symptoms that contribute to a feeling of stark terror. The acute symptoms of a panic attack typically last only a few minutes and include shortness of breath, heart palpitations, sweating, dizziness, depersonalization (a feeling of being detached from one’s body) or derealization (a feeling that the external world is strange or unreal), and a fear that one is going crazy or about to die. Not surprisingly, panic attacks often send people rushing to emergency rooms or their physicians’ offices for what they believe are heart attacks. Unfortunately, because many of the symptoms mimic various medical disorders, a correct diagnosis may take years in spite of costly medical tests that produce normal results (Katon, 1994). According to the DSM–5 diagnostic criteria, people should be diagnosed with panic disorder only if they experience recurrent unexpected attacks and report significant anxiety about having another attack.

A common complication of panic disorder is agoraphobia, a specific phobia involving a fear of public places. Many people with agoraphobia, including Wesley, are not frightened of public places in themselves; instead, such individuals are afraid of having a panic attack in a public place. In severe cases, people who have panic disorder with agoraphobia are unable to leave home, sometimes for years.

Approximately 22% of the U.S. population reports having had at least one panic attack (Kessler, Chiu, et al., 2006), typically during a period of intense stress (Telch, Lucas, & Nelson, 1989). An occasional episode is not sufficient for a diagnosis of panic disorder: The individual also has to experience significant dread and anxiety about having another attack. When this criterion is applied, approximately 5% of people will have diagnosable panic disorder sometime in their lives (Kessler, Berglund, et al., 2005). Panic disorder is more prevalent among women (7%) than men (3%; Kessler et al., 2012).

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People who experience panic attacks may be hypersensitive to physiological signs of anxiety, which they interpret as having disastrous consequences for their well-being. Supporting this cognitive explanation is research showing that people who are high in anxiety sensitivity (i.e., they believe that bodily arousal and other symptoms of anxiety can have dire consequences) have an elevated risk for experiencing panic attacks (Olatunji & Wolitzky-Taylor, 2009). Thus, panic attacks may be conceptualized as a “fear of fear” itself.

Gina, a 24-year-old woman, began to experience debilitating anxiety during her first year of graduate school for clinical psychology. At first, she worried about whether she was sufficiently completing all of her assignments, then she worried about whether her clients were improving or if she was actually making them worse. Soon her concerns spread to focus on her health (did she have an undiagnosed medical problem?) as well as that of her boyfriend (he smokes cigarettes … is he giving himself cancer?). She worried incessantly for a year and ultimately took time off from school to get treatment for her worries, extreme agitation, fatigue, and feelings of sadness and depression.

Gina’s symptoms are typical of generalized anxiety disorder (GAD)—called generalized because the unrelenting worries are not focused on any particular threat. GAD is a disorder characterized by chronic excessive worry accompanied by three or more of the following symptoms: restlessness, fatigue, concentration problems, irritability, muscle tension, and sleep disturbance. In people suffering from GAD, the uncontrollable worrying produces a sense of loss of control that can so erode self-confidence that simple decisions seem fraught with dire consequences. For example, Gina struggled to make everyday decisions as basic as which vegetables to buy at the market and how to prepare her dinner.

Approximately 6% of people in the United States suffer from GAD at some time in their lives (Kessler, Berglund, et al., 2005), with women experiencing GAD at higher rates (8%) than men (5%; Kessler et al., 2012). Biological explanations of GAD suggest that neurotransmitter imbalances may play a role in the disorder. Although the precise nature of this imbalance is not clear, benzodiazepines (a class of sedative drugs discussed in the Treatment chapter) that appear to stimulate the neurotransmitter gamma-aminobutyric acid (GABA) can sometimes reduce the symptoms of GAD, suggesting a potential role for this neurotransmitter in the occurrence of GAD. Psychological explanations focus on anxiety-provoking situations that produce high levels of GAD. The condition is especially prevalent among people who have low incomes, are living in large cities, and/or are in environments rendered unpredictable by political and economic strife. Research shows that unpredictable traumatic experiences in childhood increase the risk of developing GAD (Torgensen, 1986). Risk of GAD also increases following the experience of a loss, such as the loss of a home due to foreclosure (McLaughlin et al., 2012). Still, many people who might be expected to develop GAD don’t, supporting the diathesis–stress notion that personal vulnerability must also be a key factor in this disorder.

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