Fear and Anxiety Across the Continuum: Key Concepts and Panic Disorder

Fear vs Anxiety

Fear: immediate response to an objective threat; protective and adaptive when threat is real.
Anxiety: future-oriented apprehension; can be helpful (preparation, alertness) but may become maladaptive when excessive or persistent.
Continuum: Fear and anxiety range from typical to pathological; influenced by environment and individual factors.
Distinction: Fear is a response to present danger; anxiety is concern about potential future threats.
Diagnostic consideration: When anxiety is excessive, persistent, and impairing, it may meet criteria for an anxiety disorder.

Functional level: normal tension that helps prepare and respond.
Dysfunctional level: anxiety is more than warranted, may interfere with rest or functioning.
Likely meets criteria: anxieties are completely unrealistic or excessive, persist after threat; lead to dangerous or impairment behaviors.
Anxiety disorders involve extreme, persistent, and impairing fear/anxiety beyond the situation.
Key idea: anxiety is future-oriented; fear is about an immediate threat.

When a threat is perceived, two systems are activated by the hypothalamus:
- Autonomic nervous system (SNS, especially sympathetic division)
- Adrenal-cortical system (hormonal response)
SNS responses (direct effects):
- Liver releases glucose; metabolism increases
- Heart rate, blood pressure, and breathing rate rise; muscles tense
- Digestion inhibited; saliva and mucus dry up; air passages enlarge
- Endorphins released; surface vessels constrict; spleen releases red blood cells
Adrenal-cortical response: CRF triggers pituitary to release ACTH, which stimulates adrenal cortex to release cortisol and about 30 other hormones
Feedback: hippocampus helps turn off the cascade after threat passes; fight-or-flight is normally regulated but can be dysregulated in disorders
Visual cue (concept): ext{CRF}
ightarrow ext{ACTH}
ightarrow ext{cortisol}

Somatic (physical): tense muscles, ↑heart rate, changes in respiration, dilated pupils, increased perspiration, adrenaline release, inhibited digestion, reduced saliva, bladder relaxation
Emotional: dread, terror, restlessness, irritability
Cognitive: anticipation of harm, exaggerated danger, problems concentrating, hypervigilance, worried/ruminative thinking, fear of losing control, fear of dying, sense of unreality
Behavioral: escape, avoidance, aggression, freezing
Note: In anxiety disorders, these responses can persist even without objective threat

COVID-19 pandemic increased global anxiety and stress; coronaphobia describes pandemic-related anxiety beyond typical distress
Associated factors include: illness fears, coping strategies, religious coping, hopelessness, and suicide risk
Vulnerability factors: intolerance of uncertainty, perceived vulnerability to disease, anxiety proneness
pandemics can have multifactorial effects on mental health and coping abilities

Panic attacks: short, intense periods with symptoms such as heart palpitations, trembling, shortness of breath, dizziness, intense dread, and fear of dying
Case example (Celia): attacks can appear "out of the blue" and be terrifying, sometimes triggered by situations but often unexpected
Panic attacks can be triggered by specific situations or occur spontaneously; they are not always tied to a threat
Panic disorder (PD) diagnosis requires:
- Recurrent, unexpected panic attacks
- Worry about future attacks or significant behavioral changes related to attacks
- Attacks cause substantial distress or impairment
Prevalence and course:
- About 3 ext{ extperthousand} to 5 ext{ extperthousand} of people develop panic disorder at some time; lifetime prevalence commonly cited as 3 ext{ ext%} ext{ to } 5 ext{ ext%}
- More common in women; tends to be chronic
- Late adolescence to mid-30s typical onset; possible racial/ethnic differences in course
- Panic disorder often co-occurs with generalized anxiety, depression, and alcohol use; associated suicide risk
Attacks may occur daily for a period, then subside, with periods of fewer attacks in between
Specifiers and context can refine diagnosis (e.g., presence of agoraphobia, timing relative to life events)

Fear vs anxiety: immediate vs future-oriented; both on a continuum from normal to disorder
The fight-or-flight response: coordinated autonomic and endocrine activation; cortisol as a key stress hormone
Threat responses span somatic, emotional, cognitive, and behavioral domains
Coronaphobia illustrates how pandemics amplify anxiety and affect mental health
Panic disorder: recurrent, unexpected panic attacks with anticipatory anxiety and behavioral change; modest to moderate lifetime prevalence; chronic in many