What are anxiety disorders? |

Introduction

The concept of anxiety is one of the most often used and loosely defined concepts in psychology. It can be used to describe a temporary state (“You seem anxious today”) or an enduring personality trait (“He is an anxious person”). It is used to assign cause (“He stumbled over the words in his speech because he was anxious”) and to describe an effect (“Having to give a speech sure makes me anxious”). It is seen as the result of discrete objects or situations such as snakes or heights or as evolving from basic existential problems such as the trauma of birth or the fear of death. All major theories in psychology in some way confront anxiety.

Because of the preeminence of anxiety in the field of psychology, there are many different theories about the nature and origin of anxiety disorders. Anxiety disorders include generalized anxiety disorder, social anxiety disorder, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and specific phobias. The two most important and influential viewpoints on anxiety are the Freudian and the behavioral viewpoints. Although these theories attempt to explain many anxiety disorders, an examination of how they apply to
phobias presents a good indication of how they work. A specific phobia can be defined as an anxiety disorder involving an intense fear of a particular thing (such as horses) or situation (such as heights).

Freudian Approach

Sigmund Freud, who said that understanding anxiety “would be bound to throw a flood of light on our whole mental existence,” had two theories of anxiety, an early one in 1917 and a later one in 1926. In the early theory, libido
(mental energy, often equated with sexual drive) builds up until it is discharged by some pleasurable activity. Sometimes the energy cannot be discharged, for example, when the sexual object is not attainable or is morally unacceptable. This undischarged energy is anxiety, and it remains even when its original, unacceptable object is repressed or eliminated from conscious awareness. This anxiety may attach itself to an otherwise harmless object, resulting in a phobia. This theory is best illustrated in one of Freud’s most famous cases, that of “Little Hans,” a five-year-old who developed a phobia of horses. Freud believed that Hans had a sexual desire for his mother and wanted his father dead so that he could have his mother to himself. This desire for his mother and hatred of his father were unacceptable impulses and so were repressed from consciousness, resulting in anxiety. This anxiety attached itself to horses, Freud thought, because the black blinders and muzzle of the horse symbolized his father’s glasses and mustache.

In Freud’s first theory, repression
causes anxiety. In psychoanalytic theory, repression is a defense mechanism that keeps unacceptable thoughts and impulses from becoming conscious. In the later theory, the relationship between them has changed: anxiety causes repression. In this theory, anxiety acts as a signal to the ego (in Freud’s theory, the rational, conscious part of the mind) that a forbidden impulse (such as Little Hans’s desire for his mother) is trying to force its way into consciousness. This signal alerts the ego to try to repress the unwanted impulse. If the ego cannot successfully repress the forbidden impulse, it may try to transfer the forbidden impulse to an irrelevant object (horses, in Little Hans’s case). This object can arouse all the emotions associated with the forbidden impulse, including the signal anxiety. In this way, it becomes a phobic object.

Two-Factor Theory

One influential behavioral approach to anxiety is O. Hobart Mowrer’s
two-factor theory. It uses the principles of Pavlovian learning—in which two stimuli are presented one after the other, and the response to the first changes because of the response automatically elicited by the second stimulus—and operant conditioning—learning in which a behavior increases or decreases depending on whether the behavior is followed by reward or punishment—to explain fear and phobic avoidance, respectively. Fear is acquired through Pavlovian conditioning when a neutral object or situation is paired with something painful or punishing. For example, having an automobile accident can result in a fear of driving. At this point, operant learning principles take over to explain phobic avoidance. In operant learning, any action that leads to a reward is likely to be repeated. The person who is anxious about driving might avoid driving. Because this avoidance is rewarded by reduced anxiety, the person is more likely to avoid driving in the future. Continued avoidance makes it harder to get back behind the wheel again.

Many problems were found with two-factor theory, and many modifications have been made to it. Two problems will be discussed here to illustrate these changes. First, the theory predicts that people will be likely to fear things that are most often associated with pain. There are very few people in modern society, however, who are phobic of electrical sockets and end tables, even though almost everyone has received a shock from the former and stubbed a toe on the latter. On the other hand, many people are afraid of snakes and spiders, even if they have never been bitten by one. This has been explained through the concept of preparedness: Evolutionary history has prepared people to learn that some things—such as reptiles, insects, heights, darkness, and closed spaces—are dangerous. These things are “easy” to learn to fear, and they account for a large proportion of phobias. On the other hand, people’s evolutionary ancestors had no experience with electric sockets or guns, so people are not prepared to become phobic of these objects even though they cause much more pain in modern society than do snakes or spiders.

Two-factor theory states that for something to cause fear, it must be paired with a painful or punishing experience. Yet people sometimes become phobic of objects or situations with which they have never had a bad experience. Indeed, many people who have never seen a live snake are afraid of snakes. Thus, there must be other ways in which fear is acquired. One of these is vicarious transmission: seeing someone act afraid of something can lead to acquiring that fear. For example, whether an infant becomes afraid of being in a high place depends on whether its mother is smiling or has an expression of fear on her face. In an ingenious set of experiments, Susan Mineka and her colleagues showed that vicarious transmission of fear is influenced by preparedness. She showed that rhesus monkeys that watched a videotape of other monkeys acting afraid of a snake became afraid of snakes themselves. Monkeys that watched other monkeys act afraid of rabbits, however, did not become afraid of rabbits because they were not evolutionarily prepared to fear rabbits. Human beings also can acquire fear by being told that something is dangerous. Children can learn to avoid running in front of oncoming cars by being told not to do this by their parents; luckily, they does not have to be hit by a car or watch someone get hit to acquire this information.

Treating Anxiety

All theories of anxiety disorders attempt to explain and organize what is known about fear and anxiety. Some of the theories, including the ones described here, also have been applied in developing treatments for anxiety disorders. As might be expected, clinical psychologists with very different ideas about the cause of anxiety will recommend very different treatments to eliminate it.

In the case of Little Hans, Freud thought that his anxiety about horses was caused by repressed sexual impulses toward his mother and hatred of his father. From this, it follows that these repressed impulses would need to be brought out into the open and resolved before his anxiety about horses would diminish. This was the basic goal of the psychoanalytic therapy Freud recommended for Hans.

On the other hand, if Little Hans’s parents had taken him to
behavioral therapy, the therapist would have assumed that the child’s fear stemmed from a fright he suffered in the presence of a horse. In fact, Freud stated that the phobia began when Hans saw a horse fall while pulling a bus. Further, the therapist would assume that now Hans was rewarded for avoiding horses by anxiety reduction and by getting extra attention from his parents. Treatment would involve having the boy gradually think about, look at, and even pet horses, and it would include being rewarded for approaching (rather than avoiding) horses.

Presented with these vastly different theories and treatments, the question arises: which is right? The theoretical issues are still debated, but it is clear that treatments based on a behavioral model of anxiety have been much more successful in reducing fear than have treatments based on the theories of Freud or his followers.

Cognitive Theories

Cognitive theories of anxiety also illustrate how theory is applied to develop a treatment. There are many different cognitive models of anxiety, but all are similar in that they assume that there is a cognitive cause of the fear state. This cognitive step is sometimes called an "irrational belief." A cognitive theorist might explain Little Hans’s fear in the following way: Hans is afraid of horses because he has some irrational belief that horses are dangerous. The specific belief might be “The horse will bite me,” or “The horse might get spooked and run into me,” or even “Horses have germs, and if I go near one, I’ll catch its germs and get sick.” The theory assumes that anxiety will stop when the irrational belief is eliminated. Thus, a cognitive therapist would first carefully question Hans to find out the specific irrational belief causing his fear. Once that is determined, the therapist would use persuasion, logical reasoning, and evidence to try to change the belief. (Little Hans was used here only to continue with the same example. A therapist probably would not try to reason with a five-year-old, and a different treatment would be used. Cognitive therapies are more commonly used with adults.)

Physiological Theories

Physiological theories of anxiety are increasing in importance. As with behavioral, psychodynamic, and cognitive theories, there are many physiological theories. They differ with respect to the brain areas, pathways, or chemicals implicated in anxiety. It is likely that many physiological theories contain an element of truth. Anxiety is a complex state, involving multiple interacting parts of the nervous system, and it will take much additional research to develop a complete model of the brain’s role in anxiety.

One physiological variable that has been integrated into many theories of anxiety is the panic attack. This is a sudden and usually short-lived attack that includes trouble with breathing, heart palpitations, dizziness, sweating, and fear of dying or going crazy. These attacks appear purely physiological at first in that they seem to come “out of the blue”; however, psychological factors determine whether they progress into a full-blown disorder. People can become anxious about having panic attacks, and this added anxiety leads to more attacks, producing panic disorder. Some people become afraid of having an attack in a place where they will be unable to cope or receive help. These people may progressively avoid more and more places. This is known as agoraphobia, which at its worst can result in people who are afraid to leave their homes.

The development of physiological theories also illustrates an important point in the relationship between theory and therapy. Thus far, it has been stressed that theories of anxiety help determine treatment. This relationship also works in reverse: success or failure of treatments adds information used in theory development. This is most clear in physiological theories. For example, the physiological mechanisms of different types of anxiety-reducing tranquilizers have been investigated to provide clues as to how the brain is involved in anxiety.

Impact on Field of Psychology

Just as most theories in psychology have a view of anxiety, anxiety is an important concept in many areas of psychology. Obviously, anxiety is very important in the fields of psychopathology and psychotherapy. It also has been very important in learning theory; experiments with conditioned fear have advanced knowledge about Pavlovian and operant conditioning. Anxiety is also an important trait in theories of personality, and it figures in theories of motivation. It might be said that anxiety is everywhere in psychology.

Theoretical developments in anxiety have been incorporated into other areas of psychology. For example, in the early 1960s, Peter Lang described fear and anxiety as being composed of three systems—that is, there are three systems in which fear is expressed: verbal (saying “I’m anxious”), behavioral (avoiding or running away from a feared object), and physiological (experiencing an increase in heart rate or sweating). An important point in understanding the three systems of fear is that the systems do not always run along parallel tracks. A person may speak of being anxious about the condition of the world environment without any physiological arousal. Alternatively, a boy’s heart might pound at the sight of a snake in the woods, but he reports no fear and does not run away in the presence of his friends. Describing fear in a three-systems framework presents an important challenge to any theory of anxiety. An adequate theory must explain why the three systems sometimes give the same information and sometimes do not. The three-systems approach not only has been very influential in anxiety theory and research, but also has been applied to many other areas of psychology, such as studying emotion, stress, and pain. This approach is an important concept in behavioral formulations of anxiety, stating that anxiety has behavioral, physiological, and verbal components and that they do not necessarily provide the same information.

Another major challenge for theories of anxiety is to begin to integrate different positions. The present theories are not all mutually exclusive. The fact that a behavioral theory of anxiety has some validity does not mean that cognitive approaches are wrong. Also, psychological theories need to be integrated with physiological theories that describe brain activity during anxiety. Although theory and research in anxiety has a long and fruitful history, there is much work to be done, and many important developments lie ahead.

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