10/16/25-10/21/25 Anxiety disorders

What is anxiety?

Emotional state marked by the anticipation of danger of misfortune, intense distress, bodily tension, and nervousness

• Accompanied by physical sensations

Why are people anxious?

It is a functional response- lack of anxiety is problematic, since it emerges in response to perceived threat

• Throughout human history, anxiety played a pivotal role in the survival of our species

• Creates physical change (aka fight or flight response) that mobilizes us to guard against or escape from danger successfully

What is the effect of anxiety being part of our evolutionary heritage?

We will all always experience it

What do anxiety disorders entail?

Levels of anxiety that are frequent, debilitating, and disproportionate to the circumstances

General prevalence of anxiety disorders

Among the most prevalent psychological disorders, ~1/3 of people will experience an anxiety disorder at some point

When does an anxiety disorder commonly start?

In childhood

What is one explanation for the high prevalence of anxiety disorders?

Humans who are alive today are the ones whose ancestors developed the keenest reactions to threats

How does evolution explain the early onset of anxiety?

Even a very young child needs to be prepared for fight or flight

What are physical signs of anxiety derived from?

Derived from fight-or-flight response, it prioritizes directing energy to the most essential functions for survival

Does anxiety bring on the same or different symptoms depending on the circumstances?

The same symptoms manifest in you, regardless of the circumstances that bring them on, reflecting how fight-or-flight is effective against many types of threat

Examples of physical reactions / purpose for fight or flight / other associated feelings

2 main cognitive symptoms of anxiety

1. Perception of threat or danger- when we are anxious, we perceive ourselves as in danger even though we are physically safe

2. Worry- repetitive negative thoughts about the possibility of future danger, misfortune, or hardship

Are worry and perception of threat short-term or long-term?

Both worry and the perception of threat are often illusory

How are fear and worry different?

Fear and worry are related, but fear tends to be present-oriented (right now) whereas worry tends to be future oriented (anticipation)

• “I’ve had a lot of worries in my life — most of which have never happened.” -Mark Twain

7 anxiety disorders in the DSM-5

Comorbidity and anxiety disorders

Anxiety disorders are highly comorbid with each other.

People may often have predisposition towards anxiety, but will have different anxiety disorders at different points in their lives

Specific Phobia criteria

• Marked fear or anxiety about a specific object or situation (e.g. flying, heights, animals, needles, blood, etc.)

• Phobic object or situation almost always provokes immediate fear or anxiety. It is actively avoided or endured with intense fear or anxiety. 

• The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.

• The fear, anxiety, or avoidance is persistent, typically lasting 6+ months.

• The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational or other important areas of functioning

  • Failure to meet the functioning criteria is why most of our normal fears are not considered phobias

Specific Phobia: main phobia categories

• Blood, injection, injury

• Situations (e.g. enclosed spaces, airplanes, elevators, bridges)

• Natural environment (e.g. storms, heights)

• Animals

In terms of evolutionary psychology, what is a theory about the main phobia categories?

These stimuli are things that posed a consistent threat to human survival throughout history, such as poisonous animals, dangerous environmental situations, and events that could cause injury or infection, like bleeding

Specific Phobia: if a phobic stimulus is encountered, what will happen?

The person will experience immediate fear/horror

What is the main behavioral symptom of anxiety?

Avoidance, because people do not want to feel that level of fear/distress

How is avoidance a paradox?

It reduces anxiety short-term, but will increase anxiety long-term, because it solidifies beliefs around phobic stimulus.

It also limits the opportunity to learn that seemingly threatening circumstances are not dangerous, so there is no formation of new beliefs or experiences.

Avoidant behavior provides negative reinforcement

Each time you engage in avoidant behavior, you eliminate aversive feelings of anxiety, making it more likely that you will engage in that behavior again/repeat it in the future

Treating phobias

The core of treatment is to eliminate reinforcement associated with avoidance.

If we consciously modify an avoidant behavior, we can change the beliefs that maintain anxiety and anxious feelings themselves

How can we eliminate the reinforcement associated with avoidance?

Through exposure therapy

Exposures (aka CBT for Specific Phobia)

The most effective treatments for phobias all involve exposure to a fear-provoking stimulus, but limiting the anxiety-reducing response (avoidance)

With prolonged exposure, people habituate (body acclimates to the feeling of anxiety), affirming that they can deal with a situation like this

Exposures help people form new beliefs about the feared situation and their ability to cope with it

What happens when confronting the phobic stimulus without avoidance?

Anxiety will be experienced → through this, exposure therapy is essentially making people more anxious right now, so that they will become less anxious in general

Fear and Avoidance Hierarchy

Part of exposure therapy

• Developed collaboratively with therapist

• Ordered list of situations in which a client experiences fear of phobic stimulus

• Used as a guide for exposures in therapy, clients will work from least feared to most feared stimulus

• Each situation gets rated in terms of how much fear it generates and the lengths to which a client will go to avoid that situation

How are Fear and Avoidance Hierarchies individualized?

Every hierarchy is individualized to the client’s specific fears

Steps for effective exposure

1. Identify thoughts about situation before exposure occurs

2. Rate level of distress before exposure begins

3. During exposure, continue to rate distress every 5 minutes

4. During exposure, stay focused, do not try to distract self (avoidant behavior)

5. During exposure, maintain objective awareness of physical symptoms and thoughts

6. Continue exposure until anxiety goes down, 3 or 4 on a scale of 10 is optimal aka manageable feelings

7. After exposure, rate level of distress and evaluate thoughts again

Most important rule of anxiety treatment in general

Never stop an exposure before habituation occurs.

Otherwise, all that is reinforced is the sense that the anxiety producing stimulus is something that should be feared.

What are the 3 ways that exposures be conducted?

1. In session

2. In vivo (in life) - return to the place where the stimulus occurred

3. Imaginal

Goal for anxiety treatment

Realization that even though anxiety is uncomfortable, the risks of anxiety are minimal.

The goal is not to “get rid of anxiety”