Anxiety 101

Specific phobia

What is specific phobia?

Almost everyone has a fear – mice, needles, flying on a plane, etc. We may feel uneasy, frightened or even try to avoid our fears, but people with specific phobia express a persistent and irrational fear that is excessive and driven by the presence or anticipation of a specific object or situation (APA, 2013). Although individuals with specific phobia may recognize their fear as unreasonable or extreme, exposure to or anticipation of to the phobic stimulus/situation prompts an anxiety response (e.g., symptoms of heart racing, nausea, diarrhea, sweating, trembling, numbness, problems with breathing, feeling dizzy), or the phobic situation/object is completely avoided. Importantly, the distress, avoidance, or anxious anticipation of the feared situation/object must interfere significantly with the person’s daily routine, occupational (or academic) functioning, social activities, or relationships for at least six months, to meet diagnostic criteria of specific phobia.

For example:

“Normal” fearPhobia
Feeling nervous when you see a pit bull at a park.Missing a picnic with your friends because you are afraid that you may see a dog at the park.
Experiencing heart palpitations when peering down from the 20th floor of a building.Turning down an amazing job offer because it’s on the 20th floor of an office building.
Feeling nauseous when getting a shot at a doctor’s office.Avoiding necessary medical treatments or doctor’s checkups because you’re terrified of needles.

Types of specific phobias

There are four general types of phobias and fears:

  • Animal type: fear relating to animals or insects
  • Natural environment type: fear associated with the natural environment (e.g. fear of thunder or heights).
  • Situational type: fear of specific situations (e.g. elevators, bridges, or driving)
  • Blood/injection/injury type: fear of medical procedures, blood, or getting injured
  • Other: any other specific phobias (e.g. fear of choking, contracting an illness, costumed characters)
Panic disorder and Agoraphobia

Panic disorder is characterized by unexpected and recurring panic attacks, which contribute to worry about the occurrence or consequences of such attacks (APA, 2013). Panic attacks can best be described as a sudden feeling of intense fear or discomfort that lasts several minutes (APA, 2013). During panic attacks, an individual might start to sweat, have heart palpitations, start shaking, feel dizzy, fear that they might die, as well as many other distressing symptoms. People who are anxious about experiencing panic attacks may also show fear towards two or more of the following: public transportation, open spaces, enclosed spaces, being in a crowd, or being alone and away from their home. When people actively avoid these situations because of thoughts that escape may be difficult or impossible if they were to develop panic-like or embarrassing symptoms, they are diagnosed with Agoraphobia.

Clark’s (1986) cognitive model proposes that panic attacks are a result of catastrophically misinterpreting our bodily sensations, mainly, our sensations related to normal anxiety responses. Commonly misinterpreted sensations include - but are not limited to - breathlessness, dizziness, and palpitations (Clark, 1986). These sensations are often perceived as more dangerous than they actually are. For example, people with panic disorder often misinterpret normal changes in heart rate as an indication that they are having a panic attack. They may then do things to reduce their anxiety, like sit down or go to the emergency room, which tends to make their anxiety worse in the long term by reinforcing their beliefs that they are unable to tolerate changes in bodily symptoms, or that they should never go into hot rooms because they may trigger a heart attack.

Social anxiety disorder

Social anxiety has been defined as the fear of social or performance situations in which others may scrutinize the individual (APA, 2013). This fear can be specific to one or two situations (e.g., public speaking) or can generalize across many situations (e.g., speaking on the phone, being assertive, eating in front of others, going to parties). Whereas some anxiety about being liked by others is adaptive, excessive anxiety can lead to avoidance of social situations, which can severely impact quality of life. Sometimes people attend social situations even though they are anxious, but use safety behaviours, such as staying silent, interacting only with a trusted other, drinking alcohol, or bringing their phone so they can appear busy whenever they need to. Both avoidance and safety behaviour reduce anxiety in the short-term, but increase social anxiety in the long term, by confirming maladaptive beliefs such as “I never have anything to say to others”, “It would be terrible if somebody rejected me”, and “I can’t tolerate feeling anxious in front of others.

In addition to these explicit beliefs, implicit or automatic associations in memory between these situations and concepts such as scrutiny and evaluation can characterize this fear. Thus, implicit associations—automatic mental associations between concepts in memory—are correlated with social anxiety severity and they may also be modified to reduce social anxiety (Clerkin & Teachman, 2010). Moreover, automatic associations may also contribute to cognitive biases towards threat-related stimuli (Ouimet, Gawronski, & Dozois, 2009). For example, a person with speech-related social anxiety that is giving a speech may concentrate their attention on the one person that is yawning (attentional bias) and interpret this as “I must be boring” (interpretational bias).

Generalized anxiety disorder

Generalized anxiety disorder (GAD) is characterized by exaggerated, uncontrollable, and unrealistic worry about many aspects of life, such as money, work, relationships, health, etc. GAD symptoms often include obsessive worrying, difficulty concentrating, restlessness, indecisiveness, and a variety of physical manifestations of anxiety (e.g., headaches, trouble sleeping, etc.). One model of GAD suggests that the main driving force of the worry is intolerance of uncertainty (e.g., Dugas, Gosselin, & Ladouceur, 2001). When people have difficulty tolerating uncertainty (e.g., what if the bus is late and I miss my appointment?), they may do things to try to reduce their anxiety, such as always leaving 30 minutes early for an appointment. This behaviour can make their anxiety worse in the long-term by reinforcing beliefs such as “I must always plan for any possible problem” and increasing worry.

Obsessive compulsive disorder

An individual with obsessive-compulsive disorder (OCD) has obsessions, compulsions, or both (APA, 2013). An obsession is defined as recurring and persisting thoughts, images, or urges that are unwanted or intrusive, which cause anxiety or distress to the individual. People may try to ignore or suppress these thoughts with other thoughts or actions to reduce their anxiety. They may also engage in compulsions, which are repetitive behaviours used to reduce the anxiety and distress that result from these thoughts.

Researchers suggest that people with OCD catastrophically misinterpret the meaning of their intrusive thoughts as indicating that they are immoral, dangerous, or crazy (Rachman 1997, 1998). Although the things they do to cope with this interpretation reduce their anxiety in the short-term (e.g., checking to make sure the stove is off shows that I’m a good person), it likely increases anxiety in the long-term by reinforcing maladaptive beliefs (If I don’t check the stove, I’m a bad person).

Health / Illness anxiety

Health/Illness Anxiety is an anxiety disorder characterized by excessive worrying about one’s current and/or future health status. This obsessive preoccupation of having or eventually developing a serious medical condition is often the result of an individual’s catastrophic misinterpretation of harmless physical symptoms, and persists despite reassurance by healthcare providers that the individual does not suffer from feared diseases/illnesses (APA, 2013). Interestingly, cognitive models suggest that symptoms may actually persist because of reassurance by healthcare providers, or other things people do to reduce their anxiety (Furer & Walker, 2008; Warwick & Salkovskis, 1990). For example, somebody who is worried that a beauty mark is a sign of cancer, may repeatedly touch, poke, and check the beauty mark to make sure that it hasn’t changed. As a result, the skin around the beauty mark may actually become red or swollen, providing “evidence” to the person that they have skin cancer (when in fact, the beauty mark is benign).

CBT for anxiety disorders

Cognitive behavioural therapy (CBT) is the most supported therapy for anxiety disorders (Norton, 2007). CBT involves two main components, although these likely both impact thoughts and behaviour:

  • Cognitive therapy: explores how negative thoughts or cognitions contribute to anxiety
  • Behaviour therapy: examines behaviours and reactions in situations that trigger anxiety.

The theoretical models behind CBT posit that our thoughts about a situation influence how we feel emotionally and physically, and subsequently affect how we behave in that situation. These behaviours, in turn, are believed to reinforce the original maladaptive thoughts. The target of CBT for anxiety is to recognize and modify the negative thoughts and beliefs, in order to reduce anxiety symptomology and maladaptive behaviours triggered by anxiety.

CBT for anxiety disorders may include:

  • Learning to identify and describe physiological symptoms when one is experiencing anxiety
  • Testing beliefs about different situations to see whether there is any evidence that they are true
  • Confronting fears – either imaginative or in real life

An important treatment technique used in CBT is cognitive restructuring, the process whereby one tests the negative thinking that contributes to his/her anxiety, and hopefully develops more helpful thoughts.

Example:

Situation: Maria has a job interview to attend but she wants to cancel it because she is feeling very anxious, believes that she will fumble her words, and the interviewer will see her sweating profusely.

Negative thought: What if my mind goes blank on a question? They will think I am unqualified and a waste of their time.

Testing the thought: Will I actually be refused a job if I stutter on a couple of words? I have seen lots of people stutter, and not rejected them. Also, I’ve gotten most jobs I’ve interviewed for in the past.

Finding more helpful thoughts: It is common for interviewees to feel and look nervous while giving an interview. If I fumble my words, I can take a deep breath, and slow down my talking.

Other important treatment techniques used in CBT include behavioural experiments and exposure, both of which involve testing out the effects of a specific behaviour to see whether a prediction is accurate.

Example:

Situation: Maria has a job interview to attend but she wants to cancel it because she is feeling very anxious, believes that she will fumble her words, and the interviewer will see her sweating profusely.

Negative prediction: What if my mind goes blank on a question? They will think I am unqualified and a waste of their time.

Testing the thought: Maria and her therapist go together to talk to different people in the building. The therapist intentionally stutters words and makes a few mistakes. Maria observes the other person in the conversation looking for specific signs of rejection or negative evaluation. 

Outcome: Maria notices that people do not tend to react negatively to the therapist jumbling his/her words, and gathers some evidence that people often make small mistakes in conversation that are not catastrophic.

CADRe Lab

The CADRe lab is interested in explaining how anxiety disorders develop and are maintained. To achieve this, we use a variety of techniques including cognitive and behavioural tasks, self-report questionnaires, and psychophysiological measures. Our goal is to use this information to help improve the efficacy and effectiveness of cognitive behavioural therapy (CBT).

Resources

You can find out more information about anxiety and other mental health problems at the following websites:

If you would like to receive support or help for psychological problems in the Ottawa area, the following resources may be of use:

If you are interested in seeking self-help resources, the Association of Behavioural and Cognitive Therapies maintains a searchable database of recommended books for a series of concerns, which can be found online: http://www.abct.org/SHBooks/

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Arlington, VA: American Psychiatric Publishing, Inc.

Clark, D.A., & Beck, A.T. (2010). Cognitive therapy of anxiety disorders. New York: Guilford Press

Clark, D. M.(1986). A cognitive model of panic. Behaviour Research and Therapy, 24(4), 461–470.

Clerkin, E. M., & Teachman, B. A. (2010). Training implicit social anxiety associations: An experimental intervention. Journal of Anxiety Disorders, 24(3), 300–308.

Dugas, M. J., Gosselin, P., & Ladouceur, R. (2001). Intolerance of uncertainty and worry: Investigating specificity in a nonclinical sample. Cognitive Therapy and Research, 25(5), 551–558.

Furer, P., & Walker, J. R. (2008). Death Anxiety: A Cognitive-Behavioral Approach. Journal of Cognitive Psychotherapy, 22(2), 167–182. http://doi.org/10.1891/0889-8391.22.2.167

Ouimet, A. J., Gawronski, B., & Dozois, D. J. A. (2009). Cognitive vulnerability to anxiety: A review and an integrative model. Clinical Psychology Review, 29(6), 459–470.

Rachman, S. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35(9), 793–802.

Rachman, S. (1998). A cognitive theory of obsessions: Elaborations. Behaviour Research and Therapy, 36(4), 385–401.

Warwick, H., & Salkovskis, P. M. (1990). Hypochondriasis. Behaviour Research and Therapy, 28(2), 105–117.

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