Introduction: What is Anxiety?
Anxiety, in its simplest terms, a response to perceived threat. This response contains different components including changes to thoughts, bodily reactions and behavioural responses. Anxiety is experienced by all living animals and is a normal and useful part of their mental activity. Throughout all of human history anxiety has been useful- if our early ancestors did not fear dangerous predators, they would not have survived.
Feeling fear in response to genuine threats is an essential part of human experience- fear motivates us to avoid or escape from threat and prepares your body for action. However, fear becomes a problem when it is experienced excessively, recurrently or in a way that is disproportionate to the true level of danger you are in. These “false alarms” in our response to danger, or clinical anxiety as they would be officially termed, can become highly distressing and debilitating to those who experience them.
Clinical anxiety has many forms including generalized anxiety disorder, panic disorder, agoraphobia, social anxiety disorder, specific phobia, obsessive-compulsive disorder (OCD), body dysmorphic disorder, posttraumatic stress disorder, and illness anxiety disorder. Anxiety disorders such as these are the most common form of mental health disorder in the world today. (Kessler, Chiu, Demler, & Walters, 2005)
Treatment of anxiety disorders has historically been undertaken using a disorder focused approach (Deacon, 2013) in which conditions are diagnosed using a list of symptoms in a standard classification manual such as the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) and the International Classification of Diseases, 11th edition (ICD 11). Research is focused on how these disorders form and maintain themselves and on developing more effective treatments. Treatment usually proceeds systematically- clinicians assess a patient’s symptoms, and then develop a treatment plan to alleviate each symptom and disorder in turn.
Anxiety disorders may have very different symptoms and may lead to experiencing anxiety in response to very different triggers, but the essential building blocks that form and maintain these disorders are remarkably similar. Mental processes such as the overestimation of threat, and patterns of acting in response to this threat are often very similar across different conditions.
Anxiety disorders should not be considered “defects”. Rather, they exist on the same continuum as normal, healthy anxiety, and are made up of the same biases in thinking and patterns of acting that can be observed in people who are not diagnosed with any kind of disorder. It is only the frequency, intensity or duration of these individual factors which varies from diagnosed to non-diagnosed individuals.
Relying fully on diagnosis using classification tools can be unhelpful in treating anxiety. Many people who experience severe, life-impacting anxiety do not meet the criteria for any diagnosis. Furthermore, an individual may be experiencing a very specific set of anxiety symptoms and yet meet the criteria for multiple different disorders. Due to the closely related nature of many anxiety disorders, pinning down a single “correct” diagnosis can be tricky. For example, imagine a woman with recurring, debilitating fears that she has contracted colon cancer, who continually monitors her body for the signs and symptoms of this illness, and who experiences panic attacks whenever she thinks she has spotted a sign. Should she be diagnosed with obsessive compulsive disorder, illness anxiety disorder, or panic disorder? Or consider a man who experiences crippling anxiety in large crowds and is terrified that he will have a panic attack in a public place as this will cause him to lose control and make a fool of himself. Would a clinician diagnose this man with panic disorder, agoraphobia, or social anxiety, or some combination of all three?
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Chapter 1: Overestimation of Threat
Jenny is an administrator in a law firm with an intense fear of public speaking. Her work does not often require her to speak in front of large groups, but every few weeks her boss asks her to present reports and updates at meetings, which requires her to report on complex, technical issues in front of a large room of work colleagues. While her colleagues and superiors often report that Jenny handles these presentations well, she herself experiences intense dread in the run up to each one. She frequently anticipates making a fool of herself in front of all the people she works with, and her mind is constantly filled with worst-case scenario predictions such as “I’ll mis-pronounce a client’s name and everyone will laugh” or “I’ll be sweating and shaking so much that everyone will notice and it’ll be so embarrassing.”
Before each presentation Jenny became convinced that if she made any errors she would be fired on the spot and her career would be over. To combat these fears, Jenny prepared excessively for each presentation, staying up for hours and hours the night before until she had each figure checked and every sentence memorised word for word. She would also put on dark clothing and wear makeup to make sure any sweating or blushing wouldn’t be noticeable to her colleagues.
Fear of public speaking, like that which Jenny experiences, is very common. A key component of this anxiety is overestimating the threat that public speaking represents. In Jenny’s case, she has been proven on multiple occasions to be a competent public speaker, and her fears about losing her job and making a fool of herself are clearly unreasonable. And yet the fear persists.
Overestimation of threat is a common component of many anxiety disorders. There are two main types of threat overestimation: overestimating the severity or cost of the feared events (e.g. “if I mess up this presentation I’ll lose my job”) and overestimating the likelihood of the feared event (e.g. “I’m going to get the figures wrong if I don’t practice all night”).
Likelihood overestimation occurs when the feared outcomes are judged to be much more likely than they really are. Fear of flying is a common example- the odds of a plane crashing are extremely low and yet people with this phobia will often avoid flying altogether due to the fear of a crash.
Severity overestimation, also called catastrophising, occurs when the feared outcome is seen as far more unbearable than most people would consider reasonable. Examples may include believing that a bee sting would be unbearably painful and dangerous, or believing that performing poorly in an exam will “ruin your career prospects forever”.
A Model of Threat Overestimation
A cognitive-behavioural model can help us understand threat overestimation and its role in anxiety. Cognitive Behavioural theory states that thoughts play a key role in the experience of emotions. In this view emotions are not caused directly by situations or events around us, but by our interpretation of them (Beck, 1976). Particular interpretations will often lead to specific emotions, for example interpretation of events based around loss will produce feelings of sadness, while interpreting events as a direct attack on you personally may lead to feelings of anger. Similarly, interpreting a situation or stimulus as dangerous in a way that exaggerates or overestimates the level of threat present will naturally lead to feelings of anxiety. (e.g., Amir, Foa, & Coles, 1998; Beck, Emery, & Greenberg, 2005).
Think back to Jenny’s case. The presentations she gives are not threatening or dangerous in and of themselves. Rather, it is her interpretation of her situation and the possible consequences that leads to her distress. By overestimating both the likelihood of something going wrong, and the severity of the consequences, Jenny is inadvertently turning a harmless situation into a tremendous source of worry.
Since it is the interpretation and not the situation itself that is the real issue, challenging and correcting the overestimation of threat is often a key part of overcoming any anxiety disorder. Often this process occurs naturally- people overestimate the threat a situation poses, and then experience proves them wrong. But for others, especially those diagnosed with clinical anxiety, this self-correction does not occur. Jenny has given many presentations and received positive feedback on each occasion- why hasn’t she come to the conclusion that she is a good public speaker? Why does she still view these routine presentations as such a threat in the face of such contrary evidence?
One reason threat overestimation persists in the face of contrary evidence is the presence of safety behaviours- actions taken in order to detect or avoid the feared situation. Safety behaviours are undertaken in order to reduce anxiety but often they serve to maintain it by leading individuals to think that they are dependent on them to avoid feeling anxious (Salkovskis, 1991).
Jenny’s response to feeling nervous the night before giving a presentation was to rehearse over and over for hours. When she performs well in her presentations, she concludes that it must be because she spent so long rehearsing. Rather than seeing that she is actually a competent public speaker and that her regular presentations pose no threat, her over preparation serves to cement the fear in her mind. As long as she continues to perform the safety behaviour of excessive rehearsal, Jenny never gets to see that she can function fine without it, and her overestimation of the threat posed by public speaking remains unchallenged (e.g., Salkovskis, Clark, Hackmann, Wells, & Gelder, 1999).
Information Processing Bias
When feeling fear, all humans have a tendency to filter the information around them in a way that confirms their threat overestimation. This bias, like other aspects of fear, has useful origins in normal human behaviour. When danger is present, being vigilant for any potential source of harm is an essential part of survival. But when we are not in any danger, being predisposed to see threats can keep us overestimating the danger we are in.
Once specific way our brains inadvertently keep us overestimating the threat of non-dangerous situations is through a process called selective attention. This effect simply means that whenever we perceive a potential threat in our surroundings, our attention automatically shifts to fully focus on the source of danger. This, as you can probably imagine, is a very useful trait when confronted with genuine sources of danger- fully focusing on the threat and disregarding all else can give a huge survival advantage. But this effect can also serve to provide “evidence” that a situation is dangerous when in fact it is not.
Going back to Jenny’s fear of presentations, her belief that standing up in front of a large group is a threatening and dangerous situation causes her mind to focus in on any possible source of “danger” around her. As such she instantly picks up on every whisper or disapproving look in the crowd and interprets them as being a sign that she has made an error and people are talking about her. This only serves to reinforce her notion of public speaking being an unsafe situation. Someone who did not hold this fear may well not pick up on the whispering from the crowd, and so continue to have no reason to feel under threat.
A similar mechanism known as confirmation bias also comes into play in keeping threat overestimation firmly in place. When it comes to survival, it is often better to assume you are under threat and be proven wrong that to assume safety and be caught out. As such, when we think we may be in danger, out brains automatically seek out information to confirm our suspicions. If our perceptions of danger are inaccurate or overestimated, as they are in clinical anxiety, our brains will still collect information to support the sense of danger, drawing on whatever they can find to confirm our fears. This leads to the interpretation of perfectly harmless events and stimuli as being evidence of danger, and at the same time causes us to disregard any evidence to the contrary.
For example, as Jenny looks around the room while giving her presentation, she may interpret the faces of her colleagues as being critical or disapproving when a more objective viewer may see them as being neutral. She would also be more likely to disregard or explain away any positive or encouraging faces she sees in the crowd, perhaps thinking they are smiling out of pity. Since our brains are wired to assume threat rather than assuming safety, once we feel under threat all evidence tends to point in the same direction.
Ours minds do not just draw attention to threats and make us predisposed to interpret ambiguous information as being threatening- they can also affect how we recall information. Memory bias causes us to recall fear-related information more easily than non-frightening memories. Memory bias serves to maintain our threat overestimation by ensuring that any distressing memories relating to our object of fear stay fresh in our minds. Jenny may be unable to recall in great detail the many occasions she handled public speaking well, but the one occasion she feels that she made a mistake will be firmly lodged in her memory.
A final bias that contributes to threat overestimation is known as emotional reasoning. The very experience of feeling afraid can give rise to an increased sense of danger- we notice that we are feeling afraid, conclude that there must be a reason, and so interpret our situation as being threatening (Arntz, Rauner,& van den Hout, 1995). This can form a vicious cycle in which a situation produces feelings of anxiety, and these feelings contribute to higher interpretation of the threat level, leading to further anxiety.
Identifying Threat Overestimation
You can ask yourself the following questions to identify whether threat overestimation is at play when feeling anxious:
- What goes through your mind when you’re feeling anxious?
- What, specifically, do you think will happen in this situation?
- What is it that motivates you to avoid this situation?
What do you think is the worst thing that could happen to you in this situation?
Common Examples of Threat Overestimation
Here are some common examples of threat overestimations relating to different kinds of feared situations and stimuli.
|Likelihood Overestimation||Severity Overestimation|
|If I go near a snake it will definitely bite me||If I get bit I could die|
|The bee will definitely sting me||The pain from a sting would be unbearable|
|Everyone will think I’m awkward and boring||No one will ever want to be friends with me|
|Everyone will notice my spots||I’ll never find anyone who wants to marry me because I’m so ugly|
|Eating food on the “best before” date will cause me to get sick||Getting sick will mean I have to go to hospital|
|Using a public toilet is unsafe and could cause me to get infected||I could get HIV from a toilet and die|
|If I’m ever alone with a man he might assault me||If I’m assaulted I could be killed|
|If my son hasn’t texted me it means his plane crashed||My son could be dying or dead right now|
Implications for Different Fears
Natural Environment and Disasters
Threat overestimation plays a part in fear of many potentially catastrophic situations such as being in a car crash, standing on a high ledge, being in a confined space, flying, and being in a storm. Clearly the consequences of crashing your car, or falling from a high place, or being in a severe lightning storm would be disastrous, but all of these things are extremely unlikely. Likelihood overestimation is clearly playing a part here, leading one to believe these occurrences are likely (or even certain) to happen despite the low objective risk. Severity overestimation can also be a factor, for example in causing you to believe that if lighting hits your house it will catch fire and lead to a fatal explosion.
Many people who fear these situations can also come to fear experiencing symptoms of anxiety while in them. A man who is highly anxious about car crashed may believe that if he becomes very anxious his hands may start to shake on the steering wheel, causing him to lose control of the car. Equally, someone who is afraid of being in enclosed spaces such as elevators may interpret their anxiety-related shortness of breath as a sign that they are running out of air and likely to suffocate (e.g., Radomsky, Rachman, Thordarson, McIsaac, & Teachman, 2001). Severity overestimation can also focus on the imagined embarrassment that would occur as a result of feeling anxious- for example panicking in public and making a fool of yourself.
Threat overestimation plays a key part in fear of social situations, as we saw with the example of Jenny. Overestimations often concern the probably and significance of being observed, judged or criticised by others or being seen as foolish. People with this fear overestimate the likelihood that onlookers will notice their shortcomings, while also overestimating the severity of such observance- believing that appearing foolish to others would be catastrophic to the same extent as severe injury or death.
These kinds of threat overestimations of threat lead people to avoid social situations and go to great lengths toa void being noticed or seen as foolish. Avoiding feared social situations serves to keep the threat overestimation in place, since doing so prevents you from seeing that other people are far less observant of your shortcomings than you might think.
Fear of the Importance of Meaning of Thoughts
Everyone experiences unwanted thoughts from time to time. However, some people come to fear the significance of these thoughts and begin to view them as a threat. Obsessions, a central aspect of obsessive compulsive disorder (OCD), are overestimations of the cost of experiencing unwanted thoughts on topics such as contamination, sex, violence or physical safety. People with OCD often misinterpret these intrusive thoughts as having some significant and disastrous meaning to them personally. They may worry that they will inadvertently act on intrusive violent or sexual thoughts or may fear that their thoughts indicate that deep down they are bad people.
People who regularly experience distressing intrusive thoughts may take steps to try and avoid them, such as staying clear of situations that trigger such thoughts, or performing mental rituals to “counter” the unwanted thoughts with more acceptable ones. As with all safety behaviours, these rituals and avoidance strategies prevent people from seeing that intrusive thoughts are, in fact, totally harmless.
Fear of Somatic Cues
Fears regarding changes and sensations within your own body are common in many anxiety disorders. These fears of somatic cues come in three main types: fears around immediate versus long-term health issues, fears regarding anxiety or arousal related sensations, and fears that internal sensations will cause external negative outcomes. These fears of internal somatic cues are often experienced across different anxiety disorders- any they may also be experienced by individuals who do not meet the criteria for any specific disorder. It’s therefore important to think about the similarities between the symptoms present in different disorders and take a trans-diagnostic approach when thinking about somatic cues.
One common form of fear around somatic cues is the belief that harmless internal sensations will lead to some form of negative outcome. Individuals with panic disorder may interpret a raised heartbeat as a warning sign of an imminent panic attack, someone with social anxiety may fear trembling or blushing due to the possibility of them being noticed by others, and someone with illness anxiety may interpret harmless muscle tension or a mild headache as something far more serious. Individuals who fear somatic cues spend a lot of time monitoring their bodies for these “warning signs” and become hyper-sensitive to any changes in their body.
Fear of Contamination
Fear of being contaminated is a key feature of both OCD and illness anxiety disorder. Individuals with this fear are often anxious about situations or stimuli they perceive to be unclean, such as public restrooms, people who are sick, or hospitals. While fears around physical contamination are the most common example, fears of mental contamination are also possible; some people may fear “unclean” thoughts of a sexual, immoral or unclean nature (Rachman, 2006).
Fears around contamination often lead individuals to avoid any sources of contamination and to engage in frequent cleaning, hand washing and similar activities. These excessive cleaning and cleansing activities prevent people with contamination fears from ever seeing that their feared situations or stimuli pose no real threat. Someone who washes their hands dozens of times per day, for example, never gets to see that not doing so has no negative outcome, and so their fears remain unchallenged.
Fear of Traumatic Events (and Post Traumatic Sequelae)
Most people who witness or experience traumatic events first-hand recover and suffer no long-term psychological consequences. However, some who experiences traumas such as severe accidents, disasters, sexual assaults and other criminal events develop symptoms of post-traumatic stress disorder (PTSD) in the wake of these events (e.g., Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992). Symptoms such as nightmares, flashbacks and feeling constantly on edge are common after any traumatic event, and in most people they subside naturally. In those with PTSD, these symptoms remain and can cause significant psychological distress.
PTSD symptoms are grouped into four main categories: intrusion, avoidance, negative changes to thoughts and mood, and alternations to mental arousal and reactivity. A common trait among trauma survivors is that they tend to hold unrealistic beliefs about the danger of the world, or other people, or even themselves (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999). Threat overestimation beliefs such as “the world is a dangerous place” or “people cannot be trusted” are common.
One common threat overestimation is a fear of being re-traumatised. Individuals who have been through traumatic events may now view the world as being unsafe, and so fear having the same experience again. They may start to feel especially vulnerable in situations similar to their traumatic experience. This could be seen as an overestimation of the likelihood of the traumatic events reoccurring- just because a person was assaulted or involved in a crash once, there is no reason it is likely to occur again. Overestimation of the severity of being re-traumatised are also a common factor- individuals may believe that if something happened to them again, they would never be able to recover.
Another possible form of threat overestimation is fear surrounding the interpretations of trauma symptoms. Individuals may believe that the symptoms themselves pose them some form of threat, such as fearing that nightmares and high anxiety levels are a sign hey are losing their mind. These fears about experiencing trauma symptoms often cause individuals to avoid any situations similar to their original trauma, and may incline them to engage in unhelpful coping strategies such as self-medication with alcohol or drugs. Both avoidance and unhelpful coping only serve to exacerbate the individual’s distress by reinforcing the notion that their symptoms are harmful.
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Chapter 2: Safety Behaviours
As mentioned in chapter 1, safety behaviours are actions an anxious person takes in order to reduce the anxiety they feel. On the surface this seems like a normal and useful way to act. However, safety behaviours reinforce the link between the stimulus/situation and a need to escape or avoid, thereby keeping exaggerated perceptions of danger or threat in place. For many people, experiencing their feared stimulus directly, without any safety behaviours, would be enough to convince them that it is not as dangerous as they had believed. So long as they continue to rely on safety behaviours this is not possible. Safety behaviours are sometimes referred to as unnecessary protective behaviours, since they are aimed at providing some kind of protection against a perceived threat that offers no real danger.
Recent research into safety behaviours has looked into the role they play in developing and exacerbating symptoms of fear, and the effect they have on attempts to reduce anxiety through exposure to the feared stimulus.
Safety behaviours are normally linked to the type of threat a person anticipates. A patient with anxiety around having a heart attack may repeatedly monitor their pulse or heart rate to try and reassure themselves and avoid any activities that raise their heart rate (Salkovskis, 1991). A person who fears spiders may feel the need to scan the floor for any movement before entering a room, and so on. See the table below for examples of safety behaviours relating to different anxiety disorders.
|Disorder||Perceived Threat||Safety Behaviour|
|Panic Disorder||Fear of cardiac arrest during a panic attack||Stop drinking caffeine as it raises heart rate|
|Agoraphobia||Fear of making a fool of oneself when panicking in public||
Avoid crowded places
Only leave the house with a trusted companion
|Social anxiety disorder||Fear that others at a social gathering will notice your discomfort and anxiety||
Wearing dark clothes so that no sweat patches are visible
Mentally replaying conversations in case you said something embarrassing
|Generalised anxiety disorder||Fear that you will get fired||
Frequently asking your boss for reassurance about your position
Researching other jobs just in case
|Phobia (dogs)||Fear of unprovoked attack from vicious dogs||Avoiding streets with dogs in the gardens|
|Obsessive compulsive disorder||Fear of becoming contaminated and seriously ill when going to public places||
Opening doors with a paper towel over your hand
Frequently cleaning your hands with sanitizer
|Posttraumatic stress disorder||Fear of being attacked in public places||
Never leaving the house alone
Carrying pepper spray in case of an attack
|Illness anxiety disorder||Fear of being diagnosed with skin cancer||
Extensively researching signs and symptoms
Checking moles for any changes daily
Different Kinds of Safety Behaviour
The two main forms of safety behaviour seen in people with anxiety disorders are preventative and restorative safety behaviours. Preventative safety behaviours are those which aim to reduce the threat of the feared situation- examples include checking a room for spiders or not directly touching the handle when opening a door. Restorative safety behaviours are aimed at bringing the situation back to a desired state after contact with the threat- examples include washing hands after contact with the door.
Awareness of safety behaviours differs greatly between different people with anxiety. Some may be aware of the actions they are taking, and why, while for others the action may be so automatic that they do not realise they are performing the action to keep themselves safe.
Misattribution of Safety
The primary reason safety behaviours are problematic is that the anxious person believes their safety to a result of the safety behaviour- rather than the fact that the situation is not dangerous (Salkovskis 1991). Rather than being able to see that flying, or contamination, or whatever the feared situation is poses no real threat, the anxious individual misattributes their safety to the actions they have taken and continues to think that the situation would have been dangerous had they not acted in this way.
As an example, imagine a man who fears having a heart attack if he ever starts panicking in public. His safety behaviour is to find a public bench somewhere quiet and sit until he has calmed down every time he feels his heart rate increase. After a few minutes of sitting he starts to calm down and thinks “thank goodness I took the time to sit down- I could have had a heart attack and died otherwise!” This is totally inaccurate- it’s not possible to have a heart attack as a result of panicking- but this man firmly believes that his actions are the only reason he is safe.
Salkovskis, P. M. (1991). The importance of behaviour in the maintenance of anxiety and panic: A cognitive account. Behavioural and Cognitive Psychotherapy, 19(1), 6–19. http://dx.doi.org/10.1017/S0141347300011472
Chapter 3: Intolerance of Uncertainty
Ever since he watched a documentary about healthy eating and organic farming in school, Simon became increasingly worried about getting ill from eating food contaminated with chemicals and pesticides. As he grew older he became very preoccupied with the idea of getting a serious illness as a result of exposure to deadly chemicals from his food. He began to cut all nonorganic food from his diet and went to great lengths to make sure his fruit and veg came from farms that didn’t use any pesticides or chemicals. He stopped eating at restaurants which couldn’t prove where their food had come from, and even food made by his fiancé was subject to close scrutiny before being eaten.
Despite all his precautions, Simon still feared he would somehow get ill. Every time he thought he felt any symptoms of illness he would check them online to see if they were sings of something serious, and went to the doctor regularly to get himself checked. And yet even with his obsessive checking of his food and health, Simon felt he could never truly be sure he wasn’t getting seriously ill, and so was constantly worried and distressed by the possibility.
Simon’s fears and hardships stem from his inability to tolerate uncertainty. To him, not being able to know with certainty what state of health he is in is unacceptable and causes him great discomfort. This discomfort causes him to go to ever greater lengths to assess his health and ensure his diet is risk-free on a doomed quest to eliminate any uncertainty from his mind.
All of life involves some level of risk and uncertainty. Each time we switch on an oven or get in a car, we have to accept some small level of risk. For most people, this is something they simply acknowledge and accept- the risk level is small and unavoidable. By contrast, individuals such as Simon display a trait known as intolerance of uncertainty (IU), a trait common to people experiencing many forms of anxiety disorder. People with high IU find any level of risk or unpredictability intolerable and believe it is necessary to have absolute guarantees of their safety before they feel safe. Where most people are happy to be “pretty sure”, people with IU have to be 100% sure before they feel safe.
IU can be split into two main components (McEvoy & Mahoney, 2012). Prospective IU refers to information-seeking behaviours and the desire to know for sure what the future holds. In Simon’s case this was in relation to his health, and his efforts to gather information about his diet and any possible illnesses so as to eliminate any chance of ill health. Inhibitory IU is the aspect of IU characterised by avoiding situations that provoke uncertainty in any way- such as Simon’s refusal to eat in situations where he didn’t have complete certainty about the meal’s source.