Anxiety

S Rachman, Stanley J. Rachman

• Publisher: Psychology Press
• Year: 2020
• ISBN:
  9780429859267
• Edition: 4
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Anxiety is a complex phenomenon and a central feature of many psychological problems. This new edition of Anxiety, part of the popular Clinical Psychology: A Modular Course Series, updates the remarkable developments that have occurred in the understanding of anxiety and the astonishing dissemination of effective methods of treatment.

This book details the growth of positive psychology, with its emphasis on learned optimism and resilience, influencing clinical psychology and psychological therapy, and explains the new concept of prospection, a key element in positive psychology based on the human ability to imagine thoughts and images about the future. It is said that we are influenced by the past but drawn into the future, and this notion has significant implications for anxiety. The recent infusion of positivity into theorising about anxiety has introduced a welcome balance into our understanding of this phenomenon.

This informative book covers the latest developments in research, therapy and theorising, containing numerous case-history illustrations about anxiety. It should appeal to practising and trainee psychologists and practitioners in related fields.

1

The nature of anxiety

Over the past 50 years research on anxiety has accelerated and the publication of books and journal articles on the subject continues to increase. All of this growth is justified because anxiety is one of the most troubling and pervasive emotions and large numbers of people are distressed by inappropriate or excessive anxiety. In part, the steep increase in interest was prompted by the decision of the American Psychiatric Association committee to prepare a new diagnostic system – the DSM (Diagnostic and Statistical Manual of Mental Disorders). A separate category for Anxiety Disorders introduced definitions and criteria for diagnosing these disorders (Barlow 2002; Norton et al. 1995). The statistical information is meagre. Over the years the number of mental disorders included in the Manual has inflated and now exceeds 300.

The introduction of the DSM classification system was a major advance on the chaos that prevailed before 1980, but the scheme has its shortcomings. It encouraged the unfortunate idea that all problems with anxiety are pathological, as indeed are mental disorders.

The present book is a description and psychological analysis of the phenomena of anxiety. The therapeutic implications of current knowledge are considered because anxiety is a central feature of many psychological problems, including those that were formerly called ‘neuroses’.

Anxiety disorders are distressing, often disabling and costly. Large-scale surveys carried out in the USA led to the conclusion that ‘anxiety disorders represent the single largest mental health problem in the country’ (Barlow 2002: 22). If they are left untreated, anxiety disorders can become chronic. Affected people require and use many specialised services, and affected men are four times as likely as non-sufferers to be chronically unemployed (Leon et al. 1995). The rates of alcoholism and drug abuse are elevated among sufferers.

Specialised clinics for dealing with anxiety disorders have been introduced and self-help groups established in many parts of the world. In England a momentous expansion of psychotherapy services for people suffering from anxiety disorders and related psychological problems (mainly depression) was introduced in 2007. In the first year, 2008–9, 40,000 people were seen and 10,000 treated. By the fifth year 720,000 people were seen and 395,000 were treated (Layard and Clark 2014: 201–202). Two-thirds showed systematic improvement and the recovery rate was 46% and rising (over 50% in 2018).

The study of anxiety was stimulated by the infusion of cognitive concepts and analyses. One of the earliest and most influential contributions was made by A.T. Beck (Beck 1976, 2005; Beck and Emery 1985; D.A. Clark and Beck 2010) whose writings on depression in the 1970s were timely and very important. Paradoxically, the extension of cognitive ideas into the study of anxiety and its disorders has been even more successful and more quickly successful than the original work on depression. The introduction of the cognitive theory of panic by D.M. Clark (1986) and the cognitive analysis of obsessive–compulsive disorders spawned a profusion of new ideas and applications (Salkovskis 1985). Virtually all contemporary discussions of anxiety incorporate the cognitive view.

Anxiety is an intriguing and complex phenomenon that lends itself to cognitive analyses because it involves the interplay of vigilance, attention, perception, reasoning and memory, the very meat of cognitive processing. Moreover, many of these operations take place at a non-conscious level.

Psychologists have an excellent reason for pursuing their interest in anxiety because it turns out that they are ‘good at it’ and have developed demonstrably effective techniques for reducing unadaptive, distressing anxiety. It is one of the major achievements of modern clinical psychology.

Advances in understanding anxiety have led to important changes in the larger subject of psychopathology and led to the development of effective methods of treatment. In all of this, the mighty debate about the relative importance of biological and psychological influences on anxiety rumbles on.

Clinical features and relevant aspects

Anxiety is a tense unsettling anticipation of a threatening but formless event, a feeling of uneasy suspense. It is a negative affect so closely related to fear that in many circumstances the two terms are used interchangeably. Fear is also a combination of tension and unpleasant anticipation, but distinctions can be made of the causes, duration, and maintenance of fear and of anxiety. Strictly, the term fear is used to describe an emotional reaction to a perceived danger, to a threat that is identifiable, such as a poisonous snake. Most fear reactions are intense and have the quality of an emergency. The person’s level of arousal is sharply elevated. However, feelings of anxiety persist for lengthy periods and can nag away ‘at the back of one’s mind’ for days, weeks or months.

Fear has a specific focus. Typically, it is episodic and recedes or ceases when the danger is removed from the person, or the person from the danger. It is determined by perceivable events or stimuli. The perceived source of the danger may be accurately or inaccurately identified, or correctly identified but wrongly evaluated. The fear may be rational or irrational. Intense but irrational fears are termed phobias, as in claustrophobia (intense fear of enclosed spaces), dog-phobia, and so on.

When feeling anxious the person has difficulty in identifying the cause of the uneasy tension or the nature of the anticipated event or disaster. The emotion can be puzzling for the person experiencing it. In its purest form anxiety is diffuse, objectless, unpleasant and persistent. Usually it is uncontrollable and unpredictable. The rise and decline of fear tends to be limited in time and space, whereas anxiety tends to be pervasive and persistent, with uncertain points of onset and offset. It seems to be present, as if in the background, almost all of the time. ‘I constantly feel as if something dreadful is going to happen.’ Anxiety is a state of heightened vigilance rather than an emergency reaction. Fear and anxiety are marked by elevated arousal, subjective and/or physiological arousal. Fear is more likely to be intense and brief, is provoked by triggers and is circumscribed. Anxiety tends to be shapeless, grating along at a lower level of intensity, its onset and offset are difficult to time, and it lacks clear borders. Anxiety is not a lesser and pale form of fear and in many instances it is more difficult to tolerate than fear. It is unpleasant, unsettling, persistent, pervasive and draining. Intense and prolonged anxiety can be disabling and even destructive.

It is illustrated by two examples of people suffering from anxiety and one of a person suffering from an intense circumscribed fear, a phobia.

Anne complained of being tense, edgy and apprehensive. Every morning she woke up with a feeling that something awful but elusive was about to happen. This feeling of dread usually persisted into the late morning, accompanied by uncomfortable sensations such as nausea, fast pulse and shallow breathing. It was unsettling and tiring. In the first weeks of her experience of this anxiety, she spent a lot of time and energy trying to understand why she was feeling so poorly, struggling to identify what was troubling her. The elusive and puzzling quality of her dread was an added source of discomfort.

Anne made a clear distinction between this daily anxiety and the fear she had experienced when encountering a snake in the countryside. Her reaction to the snake was sharp, intense and focused, but quickly subsided when the snake scurried away into the undergrowth. She experienced strong bodily sensations, especially a rapidly racing heart, but recognised the threat and was not puzzled.

Brian worried incessantly about his health, constantly scanning his body for external or internal signs of trouble, and frequently sought medical advice. He dreaded the possibility of illness or injury, and often felt that ‘something’ was seriously wrong. Brian was careful to avoid sources of real or imagined infection, restricted his diet, and lifted or carried objects with deliberate care. He recognised that he has an excellent health record and was puzzled by the intrusive and disturbing anxiety about his wellbeing. Brian was unable to dampen or stifle the continuing feelings of dread. He described episodes of fear, such as his intense but circumscribed and brief reactions to near-accidents on the road, and made a clear distinction between these fearful events and his pervasive anxiety about his health.

A young horticulturalist sought help because her intense, circumscribed fear of spiders was interfering with her work. She was so frightened of encountering spiders that she was unable to work alone in the gardens. The fear was so intense and disabling that it qualified for the term phobia. She had no other fears, anxiety or psychological problems. The fear had a specific identifiable focus and was episodically evoked by contact with the threatening stimulus.

It is easier to distinguish between fear and anxiety in theory than in practice. Distinctions between fear and anxiety based on the focus of threat can be blurred in clinical conditions. For example, episodes of acute fear, such as panic, tend to be followed by a mixture of the fear and prolonged anxiety. Episodes of panic leave a residue of anxiety.

There is no distinct transition from fear to anxiety and at times it is not possible to distinguish between the two. Although panic is one of the purest expressions of fear, the triggers of episodes of panic are not always immediately discernible. The relationships between fear and anxiety can be complex. Anxiety often follows fear (as in the anxiety that one might panic again and lose control) but repeated experiences of anxiety can in turn generate fears.

Clinicians and patients devote considerable time and effort to unravelling the cause or causes of the person’s anxiety, precisely because of the uncertainty or indeterminacy of the sources of the threat. It is assumed by both patient and therapist that there are identifiable causes of anxiety. Insofar as they are successful in identifying the cause of the patient’s apprehensiveness, the definition should change from anxiety to fear, from an unknown source to a focused trigger.

Matters are complicated by the fact that fear/anxiety can be caused by external cues of danger or by internal threats, which tend to be elusive. Furthermore, qualifiers are often introduced when describing different types of anxiety, such as generalised anxiety, free-floating anxiety, and so forth. Earlier hopes that fear and anxiety could be teased apart by physiological analyses of the two states were not fulfilled and even the types of behaviour associated with fear and with anxiety (especially avoidance) are not easily distinguishable. Fear and anxiety are both accompanied by bodily sensations, notably muscle tightness, pounding heart, but there are some differences in the sensations and discomfort experienced in the two states. The bodily sensations most frequently reported in dangerously frightening military contexts are pounding heart, sweating, dry mouth and trembling. The sensations frequently reported by patients with anxiety disorders are faintness, dizziness and chest pain (McMillan and Rachman 1988).

The differences between fear and anxiety are most evident in extreme instances. Sharp and brief fearful reactions to a poisonous snake are different from the pervasive and persistent uneasiness experienced as a result of a disturbed personal relationship. Leaving aside extreme illustrations, however, fear and anxiety often blend in everyday language as in clinical practice. For example, the terms social anxiety and social phobia are used interchangeably to refer to the same psychological problem – intense discomfort when under social scrutiny and the subsequent avoidance of social gatherings. The term anxiety is also used to describe problems such as public speaking anxiety, and sexual anxiety, even though the focus of the concern is identifiable. The use of the terms ‘fear’ and ‘anxiety’ is not always consistent with the definitional distinction made between fear, which has a specific focus, and anxiety, in which there is no such focus.

A number of common assumptions made about the distinctions between fear and anxiety repay consideration. Although psychoanalytical and academic writers differ on almost all important aspects of emotion, many of them share the view that useful distinctions can be made between fear and anxiety. An assumption common to many different points of view, but not necessarily correct, is the idea that anxiety is potentially reducible to fear. If the cause of the anxiety is potentially knowable and the focus is identifiable, then by diligent work, therapeutic or not, it should be possible to convert puzzling anxiety into clear-cut fear. Associated with this assumption is the idea that fear is more manageable than anxiety. Hence it is often assumed that reducing a state of anxiety to a state of fear is a progressive step. Also associated with the idea that anxiety is theoretically reducible to fear is the notion that anxiety is ‘not-fear’ simply by reason of default, that is, we have anxiety when the focus of fear is elusive.

There is no universally accepted definition of ‘anxiety’ (Barlow 2002) and some dissatisfaction with the way in which the term is used. In addition to the several meanings of anxiety in technical language, the word also has several meanings in common language, ranging from dread to endeavour or eagerness. For example, ‘I am anxious to go to the new production of the opera’.

At least two of the commonly recognised features of fear/anxiety, a state of elevated arousal and negative affect, require comment. In most circumstances these features are indisputably part of a fear reaction, but fear can also have a positive and desirable quality in exceptional instances. People even seek it out, try to provoke it, as they do in dangerous sports, attending frightening movies, riding on roller coasters and other curious diversions. These exceptions should be noted but need not obscure the major and common features of fear. Elevated arousal is one such common feature but some findings suggest that, although elevated arousal is typical of fear, it is less evident in anxiety (Brewin 1996; Rapee 1995).

There is a long-standing debate about the precise meaning of the term angst, a concept of particular importance in psychoanalysis. This German term is often taken to mean anxiety, but Lewis (1980) argued that this can be misleading. The disagreement about this term among German writers has been compounded by problems of translation, and in the English literature the term ‘anxiety’ cannot be taken to mean angst.

The term ‘anxiety’ appears to have been derived from the Greek root angh, a tightness or constriction. Related words such as anguish and anger come from the same root but are rarely confused with anxiety, even though they are often used to describe related psychological states or reactions (Barlow 2002).

To avoid confusion, for the remainder of this book, the terms used by the original writers, clinicians and research workers will be retained except in those instances when to do so would introduce confusion.

The nature of fear

Admissions of fear are discouraged in war, and in population surveys tend to be under-reported because admitting to certain fears is considered to be socially undesirable. People rarely have to be told that they are feeling frightened, but feelings of anxiety can be so diffuse and vague that the person may fail to recognise the anxiety until someone else draws attention to it.

The social influences that obscure accurate expressions of fear complicate the difficulty of recognising and describing our feelings and experiences with accuracy. Many people who say that they are fearful of a particular situation are later seen to display fearless behaviour when they encounter it. Assessments of the intensity of the fear are limited by the difficulty involved in translating such expressions as ‘extremely frightened’, ‘terrified’ and ‘slightly anxious’ into a quantitative scale with stable properties. For these reasons, among others, psychologists have extended the study of fear beyond an exclusive reliance on subjective reports by including indices of physiological change and measures of observable behaviour.

It is helpful to think of fear as comprising three main components: the subjective experience of dread, associated physiological changes, and behavioural attempts to avoid or escape from the threatening situation. The three components of fear do not always correspond (Lang et al. 1983). Some people experience subjective fear but remain outwardly calm and show none of the expected physiological correlates of fear, such as trembling, palpitations or perspiring; others report subjective fear but make no attempt to escape from or avoid the threatening situation. The existence of these three components of fear, and the fact that they do not always correspond, make it helpful to specify which component of the fear one is describing.

In everyday exchanges we rely on people telling us of their fears and supplement this information with clues provided by their facial and other bodily expressions. Unfortunately, when our assessments are made in the absence of supporting cues from the context in which the observation is made, the interpretations can be misleading. Moreover, the value of observations of facial and other expressions is limited to certain categories of fear, especially the acute fears. The chronic and diffuse fears are less visible, as is also true for most forms of anxiety. For example, we may without difficulty observe signs of fear in passengers during the descent of an aircraft, but fail to recognise fear in a person who is extremely apprehensive about meeting new people. The signs of anxiety are especially difficult to detect because anxiety tends to be relatively formless, pervasive and puzzling even to the person experiencing this emotion.

In the course of developing effective techniques for reducing fear, some unexpected and complex findings emerged. Perplexing results also emerged in the clinical application of these techniques. Despite the appearance of marked improv...