Disordered Fear And Anxiety

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Fear and anxiety can become disordered in a variety of ways. We can experience excessive fear to relatively harmless objects or we can develop beliefs that certain things are threatening or harmful when they are not. In other situations fear or anxiety can seem appropriate but overgeneralised such as in post-traumatic reactions or chronic worry. The challenge for any theory that seeks to explain both fear order and fear disorder is to account for the varieties of abnormal fear without making them seem like discrete pathological entities. Balancing this challenge is the need to integrate new ideas with the existing literature on disordered fear that is centred around the so-called anxiety disorders. In this second half of the chapter we have elected to use the anxiety disorder categories to organise our discussion of fear disorder. We must emphasise, however, that the use of such categories by no means reflects a belief on our part that anxiety disorders are qualitatively different from normal fear reactions (see also Rosen & Schulkin, 1998).

Within psychiatric classification systems such as DSM-IV (APA, 1994), disorders of fear are categorised as: phobias, post-traumatic stress disorder, panic disorder and generalised anxiety disorder (see Table 6.1).

So, if individuals experience frequent, recurrent, unexpected panic attacks combined with concern about such attacks and worry about the implications of such attacks, then they are considered to be suffering from a panic disorder. Phobias, in contrast to panic attacks where the nosological focus is on the symptoms of fear or anxiety, are defined with respect to the avoided situations. So, social phobic people exhibit excessive and inappropriate fear of situations involving putative scrutiny by others or situations in which there is a perceived risk of embarrassment or humiliation. Specific phobias involve fear that is focused on specific, discrete stimuli such as small animals, heights, blood, receiving an injection, etc. The individual with the specific phobia recognises that the fear is excessive or unreasonable and avoids the fear-provoking stimulus. There is a considerable degree of lifetime co-morbidity between the anxiety disorders such that sufferers are likely to experience more than one category across a lifetime; a recent large twin study analysis by Hettema et al. (2005) suggests one genetic vulnerability factor for GAD (generalised anxiety disorder), panic, and agoraphobia, and a second for specific phobias, with social phobias spanning the two, although the contribution of environmental factors (e.g., life events) is far greater than genetic factors for anxiety disorders.

When the fear reaction is a result of exposure to a traumatic, possibly life-threatening event, then the individual may be thought of as suffering from post-traumatic stress disorder (PTSD) in which: the traumatic event is persistently "re-experienced" (for example, in the form of nightmares); stimuli or events associated with the trauma are persistently avoided (for example, via emotional numbing); and the individual experiences symptoms of hyperarousal (for example, irritability).

In manifestations of disordered fear in which the emotional response is not a discrete episode as in panic disorder, or is not instigated by a specific event or situation, as in phobias or PTSD, then disordered fear can take the form of generalised anxiety disorder (GAD). In GAD, the individual is bothered by excessive anxiety and worry about life circumstances such as financial problems, health, relationships, and so on. Such worry is accompanied by symptoms of fear.

The final so-called anxiety disorder within psychiatric classification systems is obsessive compulsive disorder (OCD). However, no fear symptoms are usually listed for this disorder and a detailed consideration of OCD is, therefore, outside the scope of our ambitions for this chapter. Instead, we present a brief analysis of those obsessions we believe to be fear-based and offer further discussion in Chapter 9 in

Table 6.1 Symptoms of anxiety in the so-called anxiety disorders

Panic disorder Phobias Post-traumatic stress disorder Generalised anxiety disorder

Table 6.1 Symptoms of anxiety in the so-called anxiety disorders

Panic disorder Phobias Post-traumatic stress disorder Generalised anxiety disorder

Shortness of breath

Feeling

Difficulty falling or staying asleep

Trembling, twitching or feeling shaky

Dizziness, unsteady feeling or

panicky

Irritability or outbursts of anger

Muscle tension, aches or soreness

faintness

Sweating

Difficulty concentrating

Restlessness

Palpitations or tachycardia

Tachycardia

Hypervigilance

Easy fatigability

Trembling and shaking

Difficulty

Exaggerated startle

Shortness of breath

Sweating

breathing

Enhanced physiological reactivity to

Palpitations or tachycardia

Choking

relevant stimuli

Sweating or cold, clammy hands

Nausea or abdominal distress

Dry mouth

Depersonalisation or derealisation

Dizziness or lightheadedness

Numbness or tingling sensation

Nausea or abdominal distress

Flushes (hot flashes) or chills

Flushes or chills

Chest pain or discomfort

Frequent urination

Fear of dying

Trouble swallowing ("lump in throat')

Fear of going crazy or doing

Feeling keyed up or on edge

something uncontrolled

Exaggerated startle response Difficulty concentrating or blank mind Trouble falling or staying asleep Irritability.

Based on Ohman, 1993.

Based on Ohman, 1993.

-o which we suggest that some types of OCD can be considered to be primarily based on disgust, rather than being derived from fear alone.

When the symptoms of fear/anxiety characteristic of each of the different so-called anxiety disorders are listed side by side as in Table 6.1, as Ohman notes:

there is a striking overlap among them. It is clear that these clinical symptoms can easily be subsumed under the headings of "Somatic Overactivity" versus "Cognitive/Psychic Activity" . . . The somatic symptoms seem to be dominant in panic and in phobic responses, whereas cognitive symptoms are more prevalent in PTSD and particularly in Generalised Anxiety Disorder. (1993, p. 514)

We broadly concur with Ohman's analysis; however, we shall argue in this chapter that different anxiety disorders represent disordered processing involving either the interpretation, the appraisal, or the physiological activity components within the SPAARS framework, with the disorder focusing on either the direct access associative generation of fear or on the appraisal-based, schematic model route. In illustration, we consider in some detail panic disorder, generalised anxiety disorder, and post-traumatic stress disorder, offering first a description of the characteristics of the disorder, then a review of extant cognitive theories and research, and finally, in the case of panic disorder, a brief re-analysis in terms of the two routes to emotion in SPAARS; and, in the case of PTSD, a much more detailed analysis of the disorder within the SPAARS framework. The remaining so-called anxiety disorders (specific phobias, social phobia, and some types of OCD) are considered only briefly here and are revisited in the chapter on disgust.

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