Summary of Anxiety by Rachman, 3rd edition

What is the nature of fear? Chapter 1

Fear is one of the emotions that often causes a person's daily functioning to be influenced. A large group of people suffers from disproportionate fears. This has ensured, among other things, that a lot of research into anxiety has been done and that special clinics have been set up for the treatment of people with anxiety disorders. An example of an implementation of new regulations in response to this increased interest are the NICE guidelines (National Institute for Health and Clinical Excellence) that were introduced in England in 2007. These guidelines cover the national treatment plans for people with an anxiety disorder or depression and state that the most effective treatment is cognitive behavioral therapy. This is the first treatment that is prescribed when people report anxiety symptoms. If anxiety disorders are not treated, it can lead to chronic problems. In the treatment of anxiety disorders, anxiety is often seen from a cognitive point of view, because in anxiety any cognitive processes are active. Some of these processes are vigilance, attention, perception, reasoning, and memory.

Since 1980, the DSM has a separate category for anxiety disorders. Critics state that the effect of including anxiety disorders as a separate category is that all problems related to anxiety are seen as pathological or as a mental disorder.

Definition of anxiety

A distinction is made between the term 'fear' and the term 'anxiety'. This is a substantive distinction, but it is sometimes difficult to distinguish the terms from each other. Next to this, fear and anxiety can also occur at the same time.

Fear (be afraid)

Fear is the experience of a specific emotional reaction (comparable to a reaction in an emergency situation) after seeing an identifiable object, such as a snake or a spider. It is a very intense reaction that alerts the person immediately. The fear often goes away when the danger has passed. The fear can thus be controlled and can be rational or irrational in nature. The observed source of the fear can be correct, misjudged or correctly estimated but misinterpreted. An intense, irrational fear is also called a phobia .

Anxiety (fear)

People with anxiety usually have difficulties identifying the cause of the anxiety, which makes it hard to control the emotion. The occurrence of fear is often unpredictable. It is experienced as if the fear is always in the background and can suddenly start at any moment. Anxiety is a state of constant increased vigilance and not a response to acute distress. Anxiety is also defined as a tension for an event that has yet to come. This event is experienced as threatening, but has no fixed form yet, as is the case with fear.

People with anxiety are often more difficult to deal with, because the anxiety is experienced as unpredictable and uncontrollable and has a tenacious character.

It is not easy to make the distinction between fear and anxiety, or to determine when fear turns into anxiety. Usually anxiety comes after fear, but vice versa is also possible. To make things even more difficult, terms such as social phobia and social anxiety are often used for the same psychological problem. And the term anxiety is also used to express the fear when speaking to a large audience, while the reason for the fear is indeed identifiable.

There are two assumptions about the difference between fear and anxiety. The first assumption is that anxiety can be reduced to fear. The second assumption is that fear can be treated better than anxiety. The idea is that when the cause of anxiety becomes outdated, this can be reduced to fear. Because fear is perceived as better to manage, the reduction of anxiety to fear is often seen as a progressive step in the treatment process.

An important difference between anxiety and fear is that there are also positive aspects of fear. Some people are eager to get a fear reaction, such as taking part in extreme sports, riding a roller coaster ride, or watching a very scary movie. Although this sense of heightened arousal occurs in both anxiety and fear, the shape of the arousal is different and not fully understood.

Although there are thus many differences between anxiety and fear, there are also a number of similarities between the two. These similarities are: expectation of danger, anxiety, feeling uneasy, heightened arousal, negative feelings, forward-looking and physical sensations.

The nature of fear

Some people do not have the ability or the will to recognize and admit their fears; this can be seen, for example, in soldiers during war, or in men who think their fear is not socially accepted. You don’t have to tell somebody when that person is afraid of something, but anxiety isn’t always noticed by the person him- or herself. This is because the feelings of anxiety are so vague. The person will only notice that he or she has anxiety, when someone else draws his attention to this. The same applies to the outside world: fear is often visible to others through body language and facial expressions. For outsiders, it is harder to observe anxiety.

Fear has three components that distinguish it from anxiety:

1. the subjective experience of threat,
2. physiological reactions to this threat (trembling, sweating, and palpitations),
3. certain behaviors to avoid the threatening situation or leave as quickly as possible, or to get rid of the feeling of fear.

Not everyone has to experience these components, for example, some people will have a subjective experience of fear, but they will not shake, and yet other people will not flee or avoid.

In the development of effective treatments for anxiety, there are a number of problems. For example, one problem is that there is an improvement in the behavior of the person, but that the person does not report any improvement, because the subjective experience of the fear is still present. It is also possible that the physiological reactions have disappeared, but that the person continues to complain about extreme anxiety. The most common sequence of changes in the components of anxiety is first a reduction in the physiological reactions, then an improvement in behavior and finally an improvement in the subjective experience.

Methods that can be used to measure anxiety are: self-reports, a behavioral approach test, assessments by external observers and physiological measurements. It is best not to rely on one measurement, so that errors in observations can be prevented. It is also possible to take into account factors such as exaggerating the person himself or not being honest when anxiety strikes. People often rate their fear higher in self-reports than in experiments, so only relying on self-reports is not a reliable indication of the possible problem.

A last important term in fear is the term courage. This is the ability of someone to continue despite the experienced fear and not to flee or avoid the situation.

What is the correlation between fear and avoidance behavior? Chapter 2

Mowrer is the creator of the two-stage theory of anxiety. He assumes that fear is the decisive causal factor in avoidance behavior and that fear is not only a reaction to a threatening stimulus or situation: it can also energize behavior. Mowrer uses the terms fear and anxiety interchangeably.

Mowrer's two-stage theory of anxiety claims that:

1. the reduction of anxiety is a reinforcement (because any behavior that leads to a reduction in fear is stamped in)

2. fear motivates behavior so that, in the future, the anxiety stimulus will be avoided, which in turn leads to the reduction of anxiety.

Based on this thought, a new therapy was invented: behaviour therapy.

There were a number of problems with Mowrer's theory. The first problem was that observations on laboratory animals showed that avoidance behavior continued when the unwanted stimulus was removed from the situation. According to the theory, however, you would expect that the removal of the stimulus would cause the avoidance behavior to decrease. A second problem was that the theory assumes that all fears are caused by conditioning, and that all neutral stimuli can be transformed into fear signals. To this day, it is assumed that the claim that fear is the causal factor in avoidance behavior is not correct. Avoidance behavior can also be achieved without fear. This is often oriented towards the future, whereas, according to Mowrer, fear was only driven by the past.

Based on the two-stage theory, clinicians advised patients with anxiety to refrain from avoidance behavior when confronted with anxiety stimuli. Patients were therefore encouraged to suppress their avoidance behavior. Patients were warned that their anxiety would only increase if they avoided the situations that triggered anxiety. Avoidance behavior would only be a relief for the short term, but ultimately it would only maintain fear and avoidance behavior. The golden rule was therefore: never try to avoid a situation until the fear begins to decrease. However, research has shown that there is no difference in fear and avoidance behavior between people who got the advice to avoid, and people who got the advice not to avoid. This shows that not only fear is responsible for avoidance behavioir. Other factors such as motivation, the expected level of unpleasantness and the availability of safety signals play a role in determining avoidance behavior.

The safety signals hypothesis states that safety signals are an important factor in determining avoidant behavior. A safety signal indicates a period in which no fear, pain or threat is felt. This can be because the person is around someone with whom he/she feels comfortable. In the presence of these signals, the person feels safe and can behave more freely. The expected presence of a safety signal ensures that less fear is predicted and that avoiding behavior is therefore reduced.

When the safety signal is removed, this leads to a more intense experience of the fear which is followed by more avoiding behavior.

Overestimating anxiety

Fearful people have a strong tendency to overestimate how frightened they will be when they are faced with an anxious situation. This overestimation is related to avoidance behavior. Anxious or aversive events or situations will be avoided. When people are confronted with the overestimation of their fear, they will adjust their prediction of fear and, over time, their fear of that particular object will be reduced. But, regardless of the accurary of the prediction of fear, the confrontation with what the person is afraid of will eventually lead to a reduction of fear. People can learn to predict their fear through practice. Overestimates are functional in the short term, but not in the long term. Because of the overestimation someone is inclined to avoid the stimuli and the stress that the situation entails. This avoidance behavior will have negative consequences in the long term, if the avoidance behavior is exaggerated and if it creates restrictions on the freedom of a person.

Underestimation of fear also exists, and is more annoying to experience (just like an unannounced panic attack) than an overestimation. Underestimation of fear means that the person is more afraid than he or she predicted. After repeated underestimation, the  intensity of the experienced fear will get higher.

In short: fearful people have a tendency to overestimate their fear. The prediction of the amount of anxiety to be experienced decreases after a number of overestimates, however, it increases very quickly after an underestimation. After correctly predicting the amount of fear, the predictions will remain the same. The amount of fear experienced when confronted with an object, decreases through repeated confrontation with this object, regardless of the accuracy of the prediction.

Different types of fears

Fear is a subjective emotion: what is frightening for one person is not scary at all for the other. Because it is a universal emotion, researchers have tried to design a fear rating system: mild, severe, phobia, clinical phobia. Most fears reach their peak during early adolescence (such as being scared in the dark and being afraid of certain animals). In some cases, the peak is reached during mid-adult (fear of accidents or illnesses). Research shows that as one gets older, one becomes more afraid of heights and water. Perhaps this is because the vision and physical strength is reduced in older people.

Research has shown that 5 clusters of fear can be distinguished: social fear; agoraphobic fear (fear of public places and public transport); fear of accidents or illnesses; fear of sexual or aggressive events and fear of harmless animals. Some of the most common fears such as social anxiety or fear of diseases have a rational basis, while the fear of harmless animals is irrational. This fear is disproportionate to the object that arouses the fear. The object that causes anxiety is not dangerous and even the person who experiences the fear considers the object harmless.

One of the most clear and important features of the distribution of things that people are afraid of, is that this distribution is not random. Some fears are very common and others are very rare. Another characteristic is that certain fears occur in circumstances where ethey would not be expected, for example the fact that people are afraid of snakes in places where (almost) no (dangerous) snakes occur. In this case, there may be a biological predisposition to this fear.

Some people are afraid of more than two objects / situations, for example snakes and spiders. Would there then be an underlying fear through which both are connected? Or are they separate and specific fears? Could we expect that when someone is afraid of two physically different stimuli, and the fear of one of them is taken away, that the person's response to the other fear shows the degree of connectedness between the fears? This means that when there is a connection between the fears, reducing one fear must also lead to a reduction in the other fear. When they are not connected, a reduction in one fear will not lead to a reduction in the other fear.

It seems that fears can accumulate. It does not matter whether the stimuli are shown simultaneously or sequentially. Do people with fear of multiple stimuli experience more anxiety than if they were afraid of just one stimulus? The answer appears to be "yes", but only when the fear of stimulus 2 is higher than for stimulus 1. When the person is more afraid of stimulus 1 than for stimulus 2, the fears do not accumulate, but there is a reduction in the amount of fear. The fear of both stimuli was weaker than the fear that the first object evoked. But when the first stimulus produced a weak fear and the second a strong fear, the amount of fear accumulated.

Anxiety disorders

Excessive anxiety is an important characteristic in many psychological disorders. The DSM distinguishes eight different anxiety disorders:

1. Panic disorder : these are repeated episodes of extreme anxiety or panic, some episodes of which were not expected. A combination of a panic disorder with agoraphobia is common, and is caused by extreme panic in public places, which leads to avoidance behavior.

2. Agoraphobia : the fear of public situations from which escape will not be possible or easy. The person will avoid these public situations. The avoidance can be focused on one or a few places, but it can also be that it is aimed at (almost) every place. A serious case of agoraphobia can lead to the person never going out or travelling only for small distances via a certain route, at a certain time and then only if a trusted person is involved. The term agoraphobia literally means 'fear of the marketplace'.

3. Social phobia : when the person experiences extreme anxiety in social situations and especially when the person feels that he / she is being critically examined or assessed.

4. Specific phobias: fear of a specific object or event, for example fear of animals, fear of small / enclosed spaces (claustrophobia) or fear of flying.

5. Obsessive - compulsive disorder : repetitive, intentional and stereotypic behavior, such as washing hands, or unwanted thoughts to prevent something serious from happening.

6. Generalized anxiety disorder : a persistent, exaggerated and unrealistic fear of possible accident, for example losing money or an important person, or getting a certain illness.

7. Post-traumatic stress disorder : this disorder has many symptoms, such as anxiety, problems with memory, increased arousal, avoidant behavior (of associated persons and places), unwanted memories of the trauma (dreams, hallucinations, or thoughts), and persistent fear of a certain period, after a traumatic experience such as an earthquake, an accident, or a sexual assault.

8. Health anxiety disorder : the fear about a person's current or future health. This can be either about one's own health or for someone else's.

What affects anxiety? Chapter 3

There are many different factors that play a part in the question of whether someone is experiencing fear. As mentioned above, one person may experience a situation as very threatening, while another person does not feel this at all. The experience of fear can therefore be better described as a process than as a categorical event (you have it or you do not have it).

Increased vigilance

Anxious people often have an increased vigilance (hypervigilance) when they are in a new or potentially threatening situation. This increased vigilance manifests itself in scanning the environment in search of a potential threat. When this is found, the full attention of this person is drawn to the possible threat. The information that a person receives is focused on. There are two possible conclusions that can be drawn from this: safe or dangerous. When the person concludes that it's safe, the person will continue with what he or she was doing before noticing the potential threat. When the conclusion is that something is dangerous, however, the person will become anxious and avoid the situation. In some situations people respond to signals that they do not consciously perceive.

The experience of fear is a natural reaction that people experience in unfamiliar or threatening situations and, in that way, it contributes to the survival of the individual. How is it possible that this natural process gets so out of hand with some people?

Vulnerability

There are many individual differences in detecting threats, and that is also a reason why people differ in their vulnerability to experiencing fear. It also seems that some people, besides the biological determinant of vulnerability (the temperament with which someone is born, usually introverted and neurotic), are cognitively more vulnerable. People are primed to detect threatening signs / signals through their own experiences and thoughts. Even before they are in a potentially threatening situation, they are prepared by memories of past bad luck or fear, which are combined with current beliefs about danger. The cognitive vulnerability seems to include differences in vigilance, the collection and use of information, perceptual processes, attention and judgment.

State and trait anxiety

State anxiety is a fear that arises from a perceived threat and decreases again as soon as the threat is gone. Trait anxiety, on the other hand, describes the group of people who react more quickly with anxiety. These people differ in the way they see the world and they respond differently to what they see compared with people who do not suffer from trait anxiety. The higher the trait anxiety, the more likely it is that the person will experience (more intense) anxiety in many situations. According to Spielberger, trait anxiety is a latent disposition of anxiety. Spielberger (who made the distinction between state and trait anxiety for the first time) developed a self-report assessment to measure these two forms of anxiety, the State-Trait Anxiety Inventory (STAI). Low scores indicate states of calmness and control, high scores indicate states of intense anxiety and fearfulness.

Despite the many defects of this method (especially in the psychometric field), it is often used because it is easy to use. This method is often used to measure differences in the level of anxiety during medical or surgical processes.

Anxiety Sensitivity
Anxiety sensitivity is described as the fear that arises from the misinterpretation of bodily sensations. These sensations are interpreted as harmful, for example, someone who suddenly feels his own heart beat may think that he is having a heart attack. This sensitivity to misinterpreting bodily sensations can be measured with Reiss's Anxiety Sensitivity Index (ASI). This is a self-report questionnaire, that analyzes factors such as temperament, misinterpretation and levels of arousal. Research on the ASI shows that almost all people with an anxiety disorder score high on this test. This was particularly evident in people with panic disorders.

Anxiety sensitivity is often compared to trait anxiety, although according to McNally it these are two different things. Anxiety sensitivity is the specific sensitivity to one's own bodily processes, whereas trait anxiety is a general fear of potential threats. According to Taylor, anxiety sensitivity is one of the three factors that leads to trait anxiety. Anxiety sensitivity, illness / injury sensitivity, and fear of negative evaluations all contribute to general trait anxiety.

Hypervigilance (Vigilance)

Eysenck has done a lot of research into the aforementioned vigilance, and he describes it as a response to a potential threat and as a component of cognitive vulnerability to anxiety. People who have an increased predisposition to fear express this increased vigilance in four ways:

• the frequent scanning of the environment in search of potential threats, accompanied by many rapid eye movements.

• a tendency to selectively search for threatening rather than neutral situations or stimuli.

• a widening of attention prior to the detection of a threatening stimulus.

• a narrowing of attention when a potentially threatening stimulus is processed.

Increased vigilance is a vulnerability factor for anxiety disorders and can be seen in both the clinical population and the non-clinical group that scores highly on trait anxiety. It is particularly evident during stressful situations. Selective attention is a component of hypervigilance, and has a lot to do with scanning the environment for a potential threatening stimulus. Some people are so afraid that a certain stimulus shows up, that they continuously scan the environment in search of this stimulus. They will find everything that looks similar suspicious and they will want to avoid it.

For example, someone who is very afraid of spiders will startle at every black spot on the ground or on a wall. These attention processes have a limited capacity. This means that if attention is focused on something, there is no longer any attention for other stimuli in the environment.

It may seem that people who are extremely or long-term anxious are completely focused on themselves. The narrowing of attention distracts attention from other tasks, so people often can not concentrate on their work or other things. Another disadvantage of the use of selective attention, the constant vigilance, and the attempt at constant concentration is that this can lead to fatigue. In short, the consequences of constant vigilance are the reduced attention to other people/stimuli, reduced concentration and fatigue.

Stimuli can be interpreted correctly and incorrectly. Incorrect interpretation may consist of exaggerating the possibility of a negative event or an overestimation of the seriousness of a given situation.

What is the correlation between fear and emotional processing? Chapter 4

Self-focused attention

Self-focused attention refers to the narrowing of the attention. This narrowing of attention, which occurs after detecting a potential threat, can be both internal and external. Internally, attention is focused on physical sensations, such as palpitations or sweating. Having attention for physical sensations is normal, but can become excessive. It is also thought that this excessive attention to internal (physical) signals is the basis for certain abnormal behaviors and events, such as getting a panic attack after misinterpreting a bodily sensation.

People with a chronically high level of attention for internal signals run the risk of psychological difficulties. For example, it has been found that drinking alcohol reduces this internal attention, so that people start drinking more to reduce their anxiety. These people also have less eye for the external environment, because their attention capacity is limited. This is especially common in people who suffer from anxiety, fear of their health, social anxiety and sexual anxiety.

Perceptual Factors

Perceptual disturbances take place during the experience of anxiety and decrease as soon as the fear also diminishes. This has been proven with, among other things, an experiment with people who were very afraid of snakes or spiders. They were shown a spider or snake and had to describe the behavior of the animals. These descriptions were compared with those of a control group consisting of people who had no fear of snakes or spiders. It turned out that anxious people reported that spiders jumped higher and snakes more often stuck out their tongues, compared to the reports of people in the control group. It is likely that there is a connection between these perceptual disturbances and the narrowed attention, as discussed in Part C.

Effect on Sexual Functioning

According to Barlow, disorders in the area of ​​sexual function can be caused by biological or psychological factors, or by a combination of both factors. One of the biggest factors has to do with cognitions, for example the fear of failure. Another factor has to do with attention problems which lead to problematic performance. This in turn has the effect that the person in question fails, causing fear to rise again. Barlow has done research on the similarities between sexual anxiety, social anxiety and fear of failure. He found that physical excitement in all three disorders is loosely related to a person's performance. A better predictor of a person's performance is the amount of irrelevant cognitive activity that a person shows. For example, if someone is very focused on themselves, this is related to a negative effect: it disturbs the concentration and ultimately leads to a poorer performance.

Masters and Johnson described fear as a major obstacle to normal sexual functioning. In addition, anxiety causes problems in sexual excitement. In therapy, the emphasis has shifted from reducing anxiety to reversing negative thoughts.

Bancroft did not see fear as a causal factor for sexual dysfunctioning, but rather as an effect or consequence of sexual dysfunctioning.

Sometimes fear can strengthen sexual excitement. Why and under what circumstances this is still needs further investigation. Psychological factors are not always decisive in having a sexual dysfunction. This is proven, among other things, by the fact that in men with erectile dysfunctioning psychotherapy doesn't always work, but medication like Viagra does.

Test Anxiety / Fear of failure

This is a fear that can occur in people while taking a test, or during a situation where it is known that an evaluation will take place. One explanation is that people with this fear are very focused on their inner feelings and are very afraid to fail. They approach tasks in which they will be evaluated with negative cognitions. During the test, they have more irrelevant thoughts, are more aroused and they focus their attention more on irrelevant topics, compared with people without fear of failure. It is likely that cognition and stimulation are connected to each other and influence each other. This is why therapy is now more focused on relaxation and systematic desensitization.

Anxiety and memory

It is surprising that, in people with generalized anxiety disorder, there is no explicit memory bias for events that they have experienced as threatening. This explicit memory bias does occur in people with depression. However, there are indications that anxious people have an implicit memory bias, which means that their behavior and cognitions are affected by negative memories, but that they are not aware of this. Whether there is a memory bias differs per anxiety disorder. For example, this bias is difficult to diagnose in generalized anxiety disorder, but it is a diagnostic criterion for PTSD. With OCD the memory is either very strong or very weak. People with a certain obsession can often remember in detail when their obsession started, often until years back. However, the compulsions are forgotten. This is why someone with OCD repeatedly has to check whether the door is locked: this is a compulsion, and thus the person has forgotten whether he/she has already locked the door.

While the relationship between fear and memory yields contradictory evidence, a relationship has been found between fear and mood. If a person's mood is equal to the mood he or she had during an anxious event, it is easier to remember the feelings of fear during the previous event.

Emotion processing

Naturally, people tend to remember emotional disruptive events, such as fear. Someone who does not do this has problematic emotional processing. This means that the person can not talk about the emotional event, can not listen to it or watch it and can not even think about it without experiencing stress. This is used during the treatment of anxiety (systematic desensitisation) because the anxiety reaction is changed.

When someone's emotional processing is problematic, this often manifests itself as annoying or intrusive thoughts, nightmares and persistent anxiety. Someone whose emotional processing is 'healthy', has less fear, less restless behavior and improved focus.

This is because the person learns to deal with his fears through relaxation techniques, exposure techniques and learning to recognize misinterpretations of the threat. Factors that impede healthy emotional processing are: excessive avoidance behavior, unexpected and uncontrollable repeated exposures, fatigue and persistent misinterpretations about the nature and consequences of the perceived threat.

Affect and cognition

Cognition is sometimes referred to as thoughts, and affect is referred to as feeling. In people with an anxiety disorder, affect is often stronger than cognition. This ensures that someone will show irrational behavior. There is evidence that some cognitive processes involved in emotional experiences are unconscious and function on an automatic level. Zajonc states that affective reactions (feelings) precede cognitive reactions. They are automatic, dominant, non-verbal and are triggered by stimuli which are gross, vague and global. He says that affective reactions can not be changed by changing cognitions.

Zajonc's theory has often been criticized, but it remains useful to remember that affect and cognition are relatively independent of each other. Recent ideas focus on the differences between conscious processing, which is slow and controlled, and the unconscious process, which is automatic and fast.

What are different theories about fear? Chapter 5

There are four main approaches to the development of fear.

1. Learning theories

The idea behind this theory is that fear is learned, partly through conditioning processes. The idea that fear can be learned goes back to the well-known experiments of Pavlov. The resulting flight or avoidance behaviors persist because they are at least partially successful - fleeing or avoiding reduces the fear, which confirms this successful behavior. In other words, fears are obtained through conditioning and in turn generate flight or avoidance behavior. In the original learning theories, the conclusion was drawn that, through conditioning, every neutral stimulus can be changed into an anxiety stimulus. Supporters of this learning theory have partly changed the original assumption.

Theory of Eysenck

Eysenck took the theories of Pavlov and Watson and transformed them into a learning theory, in which the conditioning processes are central. Eysenck was particularly interested in neuroses and the personality factors that give people a predisposition to these disorders. Eysenck used his two-dimensional personality model, with emotional instability (or neuroticism) at one end, and introversion / extraversion at the other end. This framework is further elaborated on page 63. He suggested that people with a high score on introversion and neuroticism have a greater chance of developing a conditioned anxiety disorder. However, people with a high score on extraversion have an increased chance of developing a behavioral disorder, personality disorder, or hysteria.

Conditioned anxiety reactions arise from a single traumatic event or a series of (sub) traumatic events in which automatic reactions of the nervous system play a role. A former neutral stimulus becomes associated with an unconditioned stimulus and thus creates a traumatic emotional reaction. When an anxiety reaction occurs, the person tries to reduce this by avoiding or fleeing the anxiety-causing situation. If this is successfully accomplished and the fear indeed diminishes, this behavior is strengthened, which leads to a continuation of the fear reaction. When conditioned reactions are not confirmed, they will disappear at a given moment. In clinical practice, this is also called spontaneous recovery (extinction).

Wolpe had the same ideas about the conditioning of anxiety, but he focused primarily on designing treatment based on this principle. The best known treatment is systematic desensitization, during which people are slowly exposed to the object of their anxiety while doing relaxation exercises.

Theory of Gray

Although Gray generally agreed with Eysenck's theory of anxiety, his theory is psycho-physiological in nature and based on psycho-pharmaceutical data and animal experiments. According to him, neuroticism is an increased sensitivity to energizing events, and introversion is the increased sensitivity to punishment signals instead of reward signals.

According to Gray, extroverts are more likely to have an anxiety reaction, but this does not apply to learning conditioned responses in general. Gray says that punishment and not getting a reward ensure that the behavioral inhibition system is activated, which leads to more arousal, more attention and inhibition of the behavior shown. This behavioral inhibition system can also be activated by new stimuli or by stimuli that are potentially threatening. Gray made a number of changes to Mowrer 's theory. According to Mowrer, stimuli followed by punishment lead to conditioned anxiety reactions. In Gray's reinterpretation of this hypothesis, he describes safety signals. These are signals that function as reward and cause behavior. They also indicate a time and place in which the person does not have to be afraid to be punished. When experiencing a safety signal, a conditioned stimulus will not lead to an anxiety reaction. At the same time, the fear is not completely taken away and will therefore continue to live on in the person.

Gray argues that phobias only occur with objects or situations that endanger the survival of the organism, or with potential hunters or unfamiliar situations. Such fears are normal because we are all biologically prepared for such a situation. This is a very different view from what the conditioning theory is based on.

2. Cognitive Theories

Within these theories there is a great emphasis on the connection between a person's cognitions and the behavior that someone exhibits. Beck 's work has been important for these theories. He suggested that new situations, with the probability of potential threat, are perceived as dangerous and that people increase the likelihood and intensity of any threatening situation.

Salvolski has elaborated Beck's theory a bit further. He states that emotions are experienced as a result of the way in which events are interpreted. It is the meaning given to the event that determines the emotions rather than the event itself. The way an event is interpreted depends on a number of things:

• the context in which the event takes place

• the mood of the person at the time of the event

• the experiences that the person already has at the time of the occurrence of the event

This means that the same event can elicit a different emotion from different people or even a different emotion from the same person at another time. Clark argued that panic is caused by misinterpretations of body processes. His theory was strongly influenced by Beck's theory, although his theory shows more understanding of abnormal functioning and does not immediately see it as a pathological problem.

Cognitive models place a lot of emphasis on the personal interpretations of the event, but learning processes (such as conditioning) are also important. Furthermore, it is found that an anxiety reaction is maintained by maladaptive cognitions, which must be changed to get rid of this fear. The most important element to treat someone with anxiety is to change the behavior of the patient. This is because it is not always the cognitions that cause fear, sometimes the deformed cognitions are maintained by problematic behaviors (such as avoidance, physical or mental flight).

3. Psychoanalytic Theories

Freud was one of the first researchers to pay attention to fear. According to Freud, fear was a persistent and important component in neuroses. He distinguished between different types of fear:

• Objective anxiety : fear reactions in response to an external danger, or something that has yet to come. Usually this fear is rational and goal-oriented, but in some cases this can turn into inappropriate and excessive emotions with a tendency toward neurotic anxiety.

• Neurotic anxiety : this fear is not goal-oriented, it is excessive and leads to crippling reactions and possibly even to flight behavior. These people are always prepared for the worst, are pessimistic, and continuously afraid. It is seen as a personality trait.

A third category of fear, which we now know under the name of 'phobias', covers feelings that are not completely irrational in nature, but exaggerated and inappropriate. According to Freud, people are predisposed to a number of phobias. With this, Freud acknowledged the prepared fears that Hall was talking about. These are built-in fears to protect us from danger.

Newer psychoanalytic theories are based on Freud's thoughts, namely that fear arises from unacceptable sexual impulses that are suppressed in the subconscious. These suppressed impulses are then expressed in symbolic representations, expressed in dreams, neurotic symptoms, etc. In other words, the fear comes from reactions of the ego to the threat of the libido by which an internal threat is transformed into an external threat. Inappropriate sexual desires or impulses are transformed into, for example, fear, because this is more socially accepted. According to Freud, someone can not have a phobia if he or she had experienced normal sexual development and had a satisfying sex life.

Although psychoanalysis has been subject to much criticism, there are useful elements in this theory. For example, it appears that some fears are symbolic and that unconscious processes maintain fear. However, psychoanalysis does not play a role within the DSM.

4. Biological Theories

Biological theories are more focused on explaining certain disorders than on explaining fear in general. Psychological and biological theories have a lot in common, but they can also collide with each other. For example, the biological theory of anxiety states that when a psychological suffocation alarm system comes into effect, a panic feeling follows.

The psychological theory states that panic is caused by misinterpreting certain bodily processes. The psychological theory leads to (cognitive) treatment, while the biological theory states that medication is a better treatment. The effect of medication supports the biological theories. This therefore breaks down the existence of pure psychological theories.

What is covered by phobias and conditioned anxiety? Chapter 6

The conditioning theory of fear

According to the conditioning theory, fears are not innate, but are obtained through conditioning. Neutral stimuli can, under certain circumstances, become conditioned anxiety stimuli. The intensity of the anxiety is determined by how often the association between a stimulus and a fear-stopping object occurs and the intensity of the fear or pain experienced. Stimuli that resemble the conditioned stimulus can also be perceived as scary. These are called secondary conditioned stimuli. An object or situation that arouses fear will at the same time also motivate behavior to reduce anxiety, such as flight or avoidance behavior.

Wolpe's contribution to anxiety conditioning did not take into account individual differences of vulnerability, but Eysenck's theory did. According to Eysenck, neurotic introverts are easier to condition and therefore they will develop excessive fears.

The role of anxiety conditioning was supported by six sources:

1. Animal research

2. Anxiety disorders in soldiers, such as PTSD

3. Experiments with children

4. Clinical observations: most people with phobia can remember the moment (traumatic experience) when their phobia started to develop

5. Observations of aversion therapy: people with an alcohol problem receive a drug that, when they drink alcohol, evokes nausea. This creates an association between alcohol and nausea, and as a result people will drink alcohol less quickly

6. Effects of traumatic stimulation, such as administering injections that make breathing more difficult

However, it has also been shown that some fears develop in the absence of a conditioning process, such as the fear of snakes that people have who live in an area where there are no snakes. There are a number of critiques on the conditioning theory. The most important eight are mentioned below:

1. During the Second World War it was expected that there would be a major panic during an air raid among the population. In practice, however, it turned out to be not too bad, exposure to repeated air attacks did not result in an increase in psychological disorders. Short fear reactions were frequently observed, but only a few people developed a phobia. So, contrary to what the conditioning theory states, there is not always a direct connection between a traumatic event and conditioned anxiety, because not everyone experiences a prolonged fear response after a traumatic event.

2. It is difficult to generate stable conditioned anxiety reactions in humans, even under experimental conditions.

3. Based on the theory, you would expect all stimuli to have an equal chance of causing anxiety, but some stimuli induce more anxiety in some people than in others.

4. For example, more people suffer from fear of flying rather than fear of getting on the bike. Not all stimuli are equally suited to being conditioned.

5. The distribution of fears in the population is not the same. On the basis of the conditioning theory, however, you would expect everyone to have an equal chance of obtaining a fear.

6. Some people with phobia have not obtained this phobia due to a traumatic event, so fear is not conditioned. According to an analysis carried out by Ost in 1985, only 65% ​​of the phobias were obtained through conditioning.

7. Fears can also be learned through observations by children. In one experiment, infants were exposed to plastic spiders and snakes that were combined with a certain facial expression of the mother (positive, negative or neutral). This experiment showed that there is a strong connection between the facial expression of the mother and the fear that the children develop for the plastic spiders and snakes.

8. Fears can be obtained through verbal information from others.

9. Fear can arise later, if nothing happens after the stimuli. An example is eating bad food: at first you notice nothing, but you will get sick later.

After all criticism, some scientists believe that people are predisposed to obtain some fears. They therefore assume that some fears are inborn and are not obtained by means of conditioning, for example. This is supported by the fact that some fears are much more common than others, such as fear of snakes, even among people living in an area where there are no snakes. It is thought that these fears are predisposed because they are important to survive.

With this view too, it remains difficult to explain that the distribution of fears within the population is not normal. This theory offers two explanations. The first is that predisposition is genetically determined and that is why some people are predisposed and others are not. Another explanation is that the predispositions are adjusted by life experiences.

Neo-conditioning

The traditional approach that there must be a direct follow-up in time between a conditioned stimulus (CS) and an unconditioned stimulus (US) for the conditioning process to take place, is not correct. Conditioned responses can occur even when the CS and US are separated in time. One event is enough to induce a prolonged conditioned dislike, even if this negative stimulus occurs minutes or hours after the first stimulus, for example: a dog gets to eat, and hours later the dog becomes ill, the dog will not want to eat the food again. This is also called non-contiguous conditioning . The realization that conditioned processes do not always have to take place has been discovered through research on blocking effects and the consequences of random control. A stimulus will not be conditioned (CS) even if it is repeatedly shown to the person for the unconditioned stimulus (US), if the person does not think it is relevant.

If the US event is already predicted by another stimulus, no conditioning will take place. The CS blocks the possibility of developing a second CS. For example: if the shock is predicted by a tone (CS) after which a visual stimulus (CS) occurs, the visual stimulus will have no predictive value, and will therefore not show a conditioned response. The first CS is sufficient to allow conditioning to occur. Unless the second stimulus is a better predictor than the first.

Random delivery of a stimulus will also not cause conditioning. For example, if a shock is sometimes delivered after hearing a bell and sometimes without hearing the bell, no conditioning will occur.

Another change compared to conventional conditioning is that it is assumed that not every stimulus has an equal chance of being conditioned. Some stimuli are therefore easier to convert into a conditioned signal than others. For example, no man will be afraid of dog leashes, although almost every dog ​​carries one. The experience with a particular stimulus also influences the ease with which a stimulus can be conditioned. For example, if there have already been hundreds of positive experiences with dogs, a negative experience will probably not condition a fear of dogs. Furthermore, it has been shown that animals can not only develop anxiety for a stimulus, but also for connections between different stimuli. Conditioning can occur if the stimuli follow each other over time, as well as for abstract stimuli.

The conditioning theories can partly explain how anxiety is caused, yet this theory does not yet explain why fear can exist for stimuli that have never been encountered.

Specific phobias

Specific phobias can be divided into three groups:

1. Social phobias

2. Phobias for animals

3. Injury / Disease phobias (including fear of suffocation).

A fear can only be seen as a phobia if it is very serious, permanent, and maladaptive. Although the dividing line between serious fears and phobias is not very clear. Few people with phobia seek help. In the last 30 years, efficient methods have been developed to help these people. One of the first techniques, desensitization, was developed by Wolpe. During desensitization, the patient is repeatedly confronted with the frightening stimulus in a controlled manner, while the patient is kept calm. These confrontations can be in real life, this is called in vivo, or with imagined representations of the stimulus. In imitation of in vivo, there is now also a technique in which situations from daily life are imitated as well as possible by computers, among other things. This helps with fears such as fear of flying and fear of heights.

Therapeutic modeling , in which the patient is encouraged to imitate the approach behavior of the therapist, is also a popular method. According to the latest statistics, only six sessions are needed to get rid of a phobia. In some cases, cognitive methods are also useful, especially in the treatment of claustrophobia. Medication does not seem to help in the treatment of phobias. Explanations for the positive outcomes of the treatment methods are inhibition, habituation and extinction.

What is the difference between panic and fear? Chapter 7

What is a Panic Disorder?

Panic is a temporary experience of intense fear that suddenly starts. This fear is usually accompanied by unpleasant bodily reactions, difficulties in reasoning, and the feeling that something terrible is going on. There is a close link between panic and anxiety: fear increases the likelihood of panic, and panic is usually followed by a persistent fear. As a result of a panic reaction, people often develop expectation anxiety: fear of a new panic reaction. Panic reactions occur in almost all anxiety disorders.

A panic attack is fairly common, about 22.7% of the population gets one or more panic attacks. When the panic attacks keep coming back, some of them have arisen spontaneously and these attacks cause stress, chances are that this person will be diagnosed with panic disorder. Panic and agoraphobia often occur together; in fact, agoraphobia rarely occurs without panic.

In some cases it seems as if a panic attack is suddenly coming, but usually it is caused by something tangible / identifiable, so that people can anticipate it. People who have a panic attack often feel that they are dying, that they lose control, go crazy or lose consciousness. In general, an unpredicted panic attack is stressful and very scary, and lasts about 5 to 20 minutes, but for the person who's experiencing it, it seems to last forever. In the case of panic attacks that occur suddenly, there is usually a misinterpretation of physical reactions. This is so strong that people, for example, feel that they are having a heart attack. After a panic attack, someone often feels anxious, shaky and tired. This can continue for a few hours after the panic attack.

The DSM has listed a number of criteria that a person must meet to get diagnosed with a panic disorder. Repeated panic episodes, some of which seem to come from nowhere, and of which at least one was followed by persistent worries (for about 1 month or longer) about getting a next panic episode. During such an episode at least 4 of the following symptoms must be present:

• difficulty breathing / shortness of breath

• dizziness or fainting

• increased heart rate

• trembling or shaking

• choking

• sweating

• stomach pain or nausea

• feeling that the person himself or the surrounding environment is not real

• feeling of paralysis

• suddenly getting very cold or hot

• pain or annoying feeling in the chest

• fear of dying / losing control / going crazy

These symptoms can occur every day, or return several days a week. After the first episode, reassurance by a doctor is enough to make the person realize that nothing is wrong (medically). This will become more difficult after repeated episodes, when someone has a fear of a new, unpredicatable panic attack. The feeling that the attack can occur at any moment creates a permanent feeling of fear. The patient will start to avoid certain places / situations and have no sense of security. A panic episode is accompanied by the feeling that there is no way back, and the person feels trapped and everything but safe. This can lead to risky behaviors, such as speeding or just running somewhere.In the most extreme cases there is nothing left for the person but to stay at home, which in addition to a diagnosis for panic disorder also leads to a diagnosis for agoraphobia. Klein argued that after experiencing multiple panic attacks, people start developing symptoms of agoraphobia.

The numbers on the occurrence of panic disorders and other psychological problems are mainly based on Klerman's ECA (Epidemiologic Catchment Area) study. This study showed that about 20% of the American population has to deal with a mental disorder at some point in their lives and that anxiety disorders are the most common. Women develop panic disorder more often (2.1%) than men (1.0%). It is most common in mid-adult and almost doesn't occur in people over 65 years of age; in these people anxiety mainly starts after a major illness or after injury. About 1/3 of the initial panic attacks take place in public places, ¼ in the car and 1/3 at home.  The first panic attack usually takes place after a period of stress.

Theory of Small (1)

According to Klein , a panic disorder can be distinguished from other anxiety disorders and is biological in nature. This vision gave rise to a debate about the nature of panic in which followers of the biological and psychological view were opposed. The biological model assumes that panic is a disorder of the body, that people have a genetic vulnerability for this and that it can be treated with medication. The cognitive-behavioral model, however, assumes that panic is a disorder of the psyche, because panic arises after wrong cognitive interpretations, and therefore must be treated with psychotherapy.

Klein based his view on two principles, which state that patients with a history of panic disorders respond well to antidepressants (Imipramine) and not to other medications prescribed for anxiety disorders, and that the administration of lactate can lead to a panic attack in by people with a history of panic attacks. Because patients with a panic attack responded to specific medication and because the panic attack could be provoked, while other people were insensitive to this, evidence would be that a panic disorder is a separate category.

Klein claimed that spontaneous panic attacks are caused by an incorrect activated suffocation alarm system. More evidence has been found for this than for his other assumption, which states that panic attacks can be provoked by the patient, with a history of panic attacks, by injecting lactate. Many chemicals have been found that can elicit such an emotion, and not only in people with a history of panic disorders.

Klein's idea that agoraphobia is caused by repeated panic episodes is adopted by almost everyone. Many studies have shown that between 80% and 100% of people with panic disorder also experience agoraphobia.

The biological theory is not entirely sustainable after it has been shown that panic attacks can also be caused by psychological processes. There is evidence that cognitive behavioral therapy is a good treatment method for patients with panic disorder. It also turned out that the two assumptions of Klein could not be supported by evidence. For example, the assumption about provoking a panic attack by the injection of lactate was not supported because there were a lot of shortcomings in the investigation into this phenomenon. Next to this, the claim that Imipramine works well for treating unpredictable panic attacks does not seem to be supported by enough different evidence. Furthermore, the claim that panic disorders are strongly distinguishable from other anxiety disorders is also undermined.It appears that panic attacks occur in a lot of anxiety disorders and that it is actually not so strongly distinguishable. The biological model can not explain why women are so much more vulnerable and why panic attacks are most common in early adulthood.

Theory of Small (2)

Klein suggested that the suffocation alarm system is biological in nature, with physical mechanisms for detecting elevated levels of carbon dioxide and lactate in the brain. After an elevated level has been established, the person is confronted with breathing difficulties, resulting in hyperventilation followed by panic and flight behavior. This system is important for survival, because when we can not (properly) breathe, nothing else is more important. In short, Klein stated that panic is the result of a false alarm, because the system is triggered without there being an actual threat to the availability of air to breathe. People would thus more often get a panic attack in, for example, small spaces in which many people are present.

Klein suggests that this alarm system can also be activated by psychological factors, as a result of which the suffocation alarm system can give a false alarm. This happens especially in people with a sensitive suffocation alarm system. Unpredictable panic attacks are caused by such a false alarm from the suffocation alarm system. Because of these changes to Klein's theory, it has become a psycho-biological theory, instead of just biological. Klein referred to the congenital hypoventilation syndrome, which is totally the opposite of what happens when you are hypersensitive to carbon dioxide. This syndrome is also called 'Ondine's curse'. These people have problems with breathing during their sleep, are not sensitive to carbon monoxide, and their suffocation alarm does not work. According to Klein, this was evidence of the existence of a suffocating detector: most people have it, but people with the syndrome do not.

Despite the successes that this theory of Klein has had, it was also criticized. It is said that the theory is not detailed enough, so that the theory can not be investigated thoroughly enough. It also does not make it clear why the suffocation alarm system fails for some people, causing them to die. Klein gave as a rebuttal that certain chemicals can cause the suffocation alarm system to fail.

Although this theory has thus been criticized and not all assumptions can be proven, it has nevertheless been of value for explaining the development of a panic disorder. It laid the foundation for pharmacological treatments and established a link between agoraphobia and panic disorders. The two principles on which Klein based his theory are seen as a sort of scaffold that further work has built on.

Cognitive theories about panic disorders

Cognitive theorists (including Clark and Barlow) state that panic is caused by catastrophic misinterpretations of certain bodily reactions. An accelerated heartbeat or dizziness can be interpreted as dangerous. For example, an accelerated heartbeat is interpreted as a heart condition, or dizziness is interpreted as losing control of yourself. There are many stimuli that can cause panic, both internal stimuli and external stimuli, but usually the internal stimuli are the cause. Clark stated that changes in physical sensations often precede panic episodes. People with panic disorders interpret bodily reactions much more frequently and faster in a catastrophic way than people without a panic disorder. When someone makes a catastrophic misinterpretation, the chance of experiencing panic is also increased. Although some evidence has been found for the causal relationship between cognition and panic, these are not yet sufficient to assume that there really is a causal relationship between cognition and panic or that panic may cause 'wrong' cognitions.

A person is more likely to interpret physical changes as dangerous when there have been negative / aversive life events, when there is alarming information and when the person has a negative attribution style. The exciting events are a threatening situation and the absence of safety signals. The vulnerability to panic episodes can be reduced by making sure that the actions that cause physical changes, such as drinking caffeinated drinks, are avoided or by developing safety signals, but best of course by correctly interpreting the bodily changes. It has been shown that if people feel that they are in control of themselves, the chance of a panic attack decreases.

The cognitive approach to panic disorders has multiple strengths. Thus it has therapeutic implications and integrates much of the previous information obtained in the field of panic disorders, for example of biological theory. Cognitive therapy is aimed at reversing the misinterpretations to reassuring thoughts, such as a rational explanation of the change of bodily sensations. This form of therapy appears to be very effective and is therefore considered as preferential treatment for NICE among others (see chapter 1).

Vulnerability

According to Clark, some people are more vulnerable than others to develop panic disorder because they tend to misinterpret physical sensations.

There are three types of vulnerability:

1. the person has a predisposition for the intense or regular experience of bodily sensations

2. the person has a predisposition to make catastrophic misinterpretations. This possibility has received the most attention, because almost everyone experiences ever-changing body sensations, but this only leads to a panic attack under certain circumstances and with certain people.

3. the person has both

Research has shown that people with (a history of) panic episodes tend to have an increased sensitivity to physical sensations. Treatment of panic also leads to people being less inclined to make these catastrophic misinterpretations.

Criticism of cognitive theory has come mainly from supporters of the conditioning theory and the biological theory. They state that Clark's theory contains too few details and is sometimes inconsistent with evidence. They also state that the effect of medication is contradictory to theory and that panic episodes can not occur when a person is calm. It is also said that the cognitive approach can not explain the positive effect of non-cognitive treatments, such as exposure.

Therapy

A panic disorder can be treated by medication, psychological techniques, or by a combination of both. Until the Cognitive Behavioral Therapy (CBT) was invented, patients with panic disorder were treated by means of in vivo exposure. This technique proved to be reasonably effective and was often supplemented with, for example, training in relaxation.

CBT consists of two components:

1. Identification of the misinterpretations and replacement by correct interpretations.

2. Techniques to make these cognitive changes happen easily.

This treatment is effective in about 80-90% of people with panic disorder. Although this cognitive treatment turns out to be very effective, many patients still receive medication to get rid of the panic disorder. Imipramine is a very effective medication that is given to patients with a panic disorder. The disadvantage is that there may be unpleasant side effects and that there may be a relapse when these drugs are stopped. The relapse was also high when treated with Benzodiazepines (medicines for anxiety disorders), with 50% or more of the cases involved.

Although it would be logical that a combination of psychological and biological treatment methods would work best, the opposite is proven. Studies have shown that only psychological or only biological treatments work just as well as a combination of these two. The effect of the psychological treatment was long-term, while in medication 40-50% of the cases there was a relapse. This should make the psychological treatment the favorite treatment. There are indications that medicines in some cases hamper psychological treatment. Nevertheless, the combination of both treatments is still the most applied.

What is agoraphobia? Chapter 8

The original definition of agoraphobia is the fear and avoidance of public places, but over the years, this definition has become more and more connected to panic disorder. In the past, agoraphobia was mainly seen as a neurosis.

The main symptoms of agoraphobia are:

• fear and avoidance of public places

• fear and avoidance of travel (especially with public transport)

In addition to these symptoms, people with agoraphobia also suffer from:

• fear of being alone, even in their own home

• fear of fainting, getting a heart attack, being trapped, losing control, or experiencing another form of stress

• unpleasant physical sensations during trips out of the safe environment (usually their home) and even when anticipating these trips.

All these symptoms are crucial for the onset of a panic attack.

In severe cases, the patient will not want to go anywhere without the guidance of a trusted person. The disorder is most common during early adulthood. Rates in women are two times higher than rates in men. Comorbidity often exists with other disorders such as panic disorders, claustrophobia, or depression. Patients with agoraphobia who do not suffer from panic attacks are rare. This has led to the fact that in the current view on agoraphobia, agoraphobia occurs secondary to the development of panic disorder. Agoraphobia is often linked to other mental disorders, not only to panic attacks, but also to depression.

People with agoraphobia usually have a higher level of general anxiety than people without agoraphobia. The fear can persist for years, but the intensity can vary daily or weekly.

In the 1950s, followers of learning theory, including Eysenck and Wolpe, thought that conditioned anxiety was the central component in agoraphobia. The conditioned fear consisted of public places and public transport. The conditioned fear then caused avoidance behavior, because people teach themselves to avoid places where they have experienced anxiety. With the emergence of explanations for abnormal behavior from the cognitive point of view, the question arose whether people with agoraphobia were actually afraid of public places or not. Instead, people would be afraid of what could happen to themselves in these public places, and this thought was more frightening than the public place itself. In 1987, Klein introduced the idea that agoraphobia is not so much an isolated disorder, but a by-product of a panic disorder. According to Klein, people developed avoidance patterns because they had experienced a panic attack or panic. This is still the contemporary vision. Public places and public transport are now seen as the context in which panic-related fears are expressed. This shifted attention to the causes and consequences of panic, and not to the causes and consequences of agoraphobia.

The fact that agoraphobia can also occur after the death of a loved one poses a problem in both learning theory and Klein's theory. In a study of 900 people with agoraphobia, done in 1983, Thorpe and Burns found that 23% of them had developed agoraphobia after the loss of a family member or friend. In 13%, agoraphobia had developed after a disease. It is thought that losing someone or going through a disease process must undermine someone's sense of security, especially in people who have a fearful tendency. By increasing someone's sense of security, the fear will diminish. This can be learned through self-help procedures, addressing cognitive processes and learning good coping strategies. The sense of security is strengthened by dependence and predictability.

Therapy

In the past, people treated agoraphobia with trips to the places for which the person was afraid. Although this in vivo exposure method seemed to help to reduce the symptoms, one now treats the panic disorder that underlies agoraphobia.

What is an obsessive-compulsive disorder (OCD)? Chapter 9

In the DSM, obsessive compulsive disorders are categorized as anxiety disorders. OCD is one of the most complex forms of anxiety and causes a lot of stress for those who suffer from it, but also for the environment. Most people with OCD suffer from both obsessions and compulsions, but one of the two is usually more dominant. OCDs often occur together with depression, and when these are not treated, the disorder can have a chronic course. Most people with OCD suffer from compulsions, which is the performance of a compulsory, irrelevant and repetitive action, such as washing their hands. These are actually stereotypical actions that repeat themselves. Most people know that their actions are irrational, but still they can not control the actions. This often causes frustration and stress. Actions are described as compulsive when the urge to act is very strong and when the person forces himself to perform the action, not the environment. In addition, the actions serve a purpose and are carried out with full awareness, in contrast to people who, for example, suffer from tics.

Obsessions are recurring, unwanted and penetrating thoughts that usually have a repulsive character, which the person tries to resist. The most common themes are: unacceptable religious thoughts / images; unacceptable sexual thoughts / images; and unacceptable thoughts about injuring other people. These thoughts cause a conflict with one's morality, but are difficult to suppress. People who have such thoughts do recognize that these are their own thoughts, and they know that the thoughts have not been implemented in their heads from the outside.

Prevalence

OCD is not a disorder that occurs very often. Research done in America showed that 2-3% of the population will be confronted with OCD. Many people suffer from an innocent form of OCD, this form does not cause stress nor makes it too hard to live their daily life. People who suffer from clinical OCD often don't seek professional help, for fear of criticism or shame. However, they try everything to hide their OCD.

OCD occurs equally among men and women. The only difference lies in the appearance of OCD. For example, women often have cleaning compilations. The disorder usually manifests itself around adolescence, often before the 25th year of life. In most cases the problem develops gradually, but it can also occur suddenly. In the event of a sudden onset, people often suffer from compulsive cleaning, and less from compulsive check-ups, such as constantly checking whether the door is locked or if the gas is turned off.

Types of compulsive behavior

There are roughly two types of compulsive actions:

1. Compulsive check

These repetitive behaviors are meant to prevent something from happening to the person who is suffering from OCD or to friends and family. This is almost always future-oriented, and is sometimes seen as a form of preventive behavior. These actions give the person much doubt and indecision, so the behavior takes a long time and is often carried out slowly. Patients often state that their memory is not working properly, so they have forgotten whether they have turned off the gas, for example. The view, however, is that these people do not trust their memory enough because these people can remember other events that have nothing to do with the compulsion in detail. This is also referred to as a precise and liberating memory.

2. Compulsive cleaning

The underlying cause of compulsive cleaning is the fear of contamination. It is most evident in washing hands, some people do this dozens of times a day. These actions are the same as those in compulsive checking, but this is often passive avoidance. This means that someone is taking steps to avoid situations that require the urge to clean up and stimuli that may be contaminated. After compulsive checking, compulsive cleaning is most common in people with OCD. Patients assume that any contamination can cause damage to their physical and mental health and social life. Compulsive cleaning is the way to prevent a threat of contamination.The fear of contamination can also arise without anyone actually having been in contact with someone or something that could be contaminated. Infections fall into four categories: possible contaminated objects (blood), dirt, harmful substances and mental infections. A mental infection is the feeling of internal filth, which can occur after a period of emotional or physical abuse. It can also come from someone's own thoughts, imaginations or memories. This is also referred to as self-infection. The fear of mental infections does not diminish by cleaning. Cognitive therapy often produces improvement.

Most people have elements from both forms of compulsive actions, but one of the two is usually dominant.

One of the most incomprehensible points of OCD is perseverance. Why would people participate in irrational, tiring, shameful and self-damaging behaviors? An answer to this question is that compulsive behaviors reduce the feeling of anxiety. Mowrer's two-stage theory of fear and avoidance states that successful avoidance maintains the anxiety. This theory was also used to understand OCD. Experiments have shown that when people with OCD are stimulated to touch the dreaded object (e.g. mud), they report a large increase in anxiety and the tendency to perform compulsive behavior. When they are allowed to perform their compulsive behavior (washing) afterwards, the fear quickly declines. This corresponds with the theory of Mowrer, the compulsive behavior here is the avoidance behavior. When there was a bit of time between touching the dreaded object and the performance of the compulsive behavior, the anxiety first remained present but then it reduced very slowly. Most participants reported no fear after three hours. This spontaneous decrease in fear, without performing a compulsive act, is contrary to Mowrer's theory.

The above experiments applied to almost all persons in whom compulsive cleaning was dominant. However, exceptions were found in people in whom compulsive checking was dominant, these actions did not alleviate anxiety in everyone, and in some cases even increased anxiety. As discussed earlier, people who obsessively check things, think that because of their actions, they can prevent something bad from happening in the future. This ensures that it is never enough, future threats can never be completely excluded. Someone therefore does not have a complete sense of security, nor does it obtain this by compulsive checking. In addition, people no longer rely on their own memory when they think about whether they have already carried out a certain action. These people also have a cognitive bias, they assume that once they are responsible for something, the likelihood of something going wrong increases when, for example, someone else would be responsible. This often depends on the bias that someone's sense of responsibility increases after they have performed a compulsive check. These four elements (not being able to exclude all threats, not relying on their own memory and the cognitive biases) provide a mechanism that maintains the OCD.

Obsessions

Most people sometimes suffer from unwanted and intrusive thoughts that resemble obsessions, but they are different from those of OCD patients in terms of duration and intensity. Some of these people think that when they have such a thought it will increase the chance of the bad event taking place, which in turn leads to an increased sense of responsibility and an increase in fear. This phenomenon is called thought-action-fusio. This is the difference between patients with OCD and 'normal' people.

Obsessive thoughts can be recurring or prolonged and they can involve a lot of stress. They often lead to flight or avoidance behavior, both the clear forms of this and the less clear forms such as neutralizing thoughts and constantly asking for reassurance. The person is not really looking for information, because he / she already knows the answer, but they do this in an attempt to cope with their fear. As is the case with several anxiety disorders, this reassurance does not last long either. Most people use overt compulsions to deal with the recurring obsessions. Most obsessions are generated internally, but they can also be promptly and easily triggered by an external stimulus. For example, seeing a knife or other sharp object near a mother may suggest that she would hurt her children with a sharp object, so she does not want to be left alone in the vicinity of knives and other sharp objects.

It is thought that there is a connection between the intrusive unwanted thoughts in daily life and certain aspects of clinical obsessions. Obsessions are common to everyone and the form or content that is reported by the non-clinical population and the clinical population is very similar. The difference is that the clinical population has these thoughts more often, more intensively and for longer periods. They also cause more fear and are more difficult to resist and reject. The anxiety-causing and stress-inducing obsessions are the most difficult to control.

The normal obsessions, which are reported by the non-clinical population, can easily be rejected, blocked or diverted. Common obsessions are: the idea of ​​causing damage to children or the elderly, thoughts about the violence to animals and disturbing thoughts, for example thoughts about shouting during the prayer in church.

Followers of the cognitive theory are of the opinion that obsessions are caused by the catastrophic misinterpretation of the personal importance of intrusive thoughts. When the person interprets the unacceptable thoughts as personal interest or believes that these thoughts can be revealed, this can cause stress. The person then thinks that the thoughts reveal that he / she is crazy, bad or dangerous. When the person tries to suppress the thoughts, it often results in a rise in the frequency of these thoughts. Other ways in which the person tries to control the thoughts, such as compulsions, are useless. Obsessions could therefore best be dealt with by changing the importance attached to the thoughts.

Hoarding

Compulsive hoarding can be distinguished from the aforementioned compulsions. Hoarding is often associated with OCD, but it also occurs in people with a mental illness or dementia. There is also a large group of hoarders that has no other disorder. Excessive hoarding is characterized by five elements:

1. The excessive acquisition of large numbers of unnecessary or worthless objects

2. Irrational and emotional attachment to these objects

3. Strong tendency to protect the collected objects

4. Using the environment as a storage location

5. Emotional and behavioral revolt against the removal of these objects

Hoarding is seen as excessive when it interferes with daily life. People can also get problems in their social life if their environment increases the pressure to throw objects away. People who hoard often see that their collecting enthusiasm is excessive, but justify this and therefore rarely seek psychological help.

Hoarding is five times more common than OCD, and about 1 / 3rd of people with OCD also exhibit hamster behavior. The similarities between hoarding and OCD are that they have to perform certain actions and can not resist this feeling. In addition, in both cases it is repetitive behavior. Unlike people with OCD, people who hoard do not have the insight that their behavior is abnormal, they justify their behavior towards themselves and the outside world. Usually there is a positive feeling tied to the acquisition of new objects, while people with OCD often have a negative attitude toward this. The negative feeling that people who hoard have, is often caused by social pressure. Next to this, hamstering is not a stereotype action: although the result is always the same, the action is always different.

OCD in relation to Anxiety

There is a link between most forms of OCD and anxiety. This relationship is strongest between anxiety and compulsive cleaning. The psychophysiological reactions of people with obsessions and people with phobic tendencies have a lot in common. In both cases the resulting behaviors lead to autonomic behaviors, which decrease after successful treatment. For both disorders, the patient also shows avoidance behavior, which decreases after successful treatment.

Therapy

The psychological techniques used to reduce other anxiety disorders can also be applied to OCD. For people who are afraid of infection risk due to physical contact, exposure and response prevention treatment is preferred. During this treatment, patients are monitored and exposed slowly to stimuli that can trigger anxiety, followed by an inhibition of compulsive behavior. Fear of mental infections can best be treated with cognitive behavioral therapy. Cognitive therapy is also used for people who suffer from obsessions, to reduce the personal importance of unwanted thoughts. Because OCD often occurs with depression, it can help to prescribe a pharmacological treatment first to deal with the depression.

How to deal with anxiety about health and other disorders? Chapter 10

Health Anxiety Disorder (HAD) is an anxiety disorder in which a person experiences intense and persistent anxiety about his or her current and / or future health. According to Salkovskis and Warwick HAD arises after the catastrophic misinterpretation of bodily sensations and symptoms, such as pain, fatigue and dizziness. This is a cognitive view of HAD. The idea that an anxiety disorder occurs because physical symptoms are misinterpreted is also seen in other anxiety disorders, such as in panic disorder, and is not unique to HAD. Consistent to this, people with HAD think that the signals they feel say much more than they actually do. They overestimate their chances of becoming ill and the impact that the disease will have. The cognitive model of HAD is derived from the model for panic attacks. However, this model did not take into account the fear of future events and the future threat to a person's health. For example, someone may be afraid of developing cancer later in life. The model has therefore been adapted for HAD.

HAD is, like more psychological disorders, a continuum. On the one hand, people seriously overestimate the likelihood of having a serious illness. On the other hand, however, there is a group that is likely to develop a disease and underestimate its seriousness. This is also referred to as unrealistic optimism.

Hypochondria

A form of anxiety about health is also referred to as hypochondria. Hypochondria is described as the fear that someone is suffering from a serious illness. A disturbed belief that someone is ill is necessary for diagnosis, even if someone is repeatedly reassured by, for example, a doctor. Someone with hypochondria is convinced that he or she is ill and that the doctors overlook this. In contrast to HAD, hypochondria is not focused on the future: people are convinced that something is going on right now.

People with hypochondria report that they regularly suffer from imaginary thoughts about the threat of their own health, which caused stress. This shows that if someone has an idea of ​​what will happen in the future, someone's perception that this event will actually take place increases.

Cognitions about health

As mentioned above, people with HAD are very much occupied with their own health and they overestimate the probability that they have a serious illness or that they are at risk of developing a serious illness. Often, they even think that the disease will be fatal. Changes in bodily sensations or functions and unwanted distorted thoughts are interpreted as a possible illness. People with HAD also think that they are extremely vulnerable to contracting diseases. This can have a general course, but it can also be focused on a specific disease, such as diabetes or cancer. In these people, there has often been someone in the area who has had the specific disease. Meanwhile, the fear of developing a mental disorder is also seen as part of HAD.People are afraid to lose control and eventually have to be admitted to a psychiatric hospital.

In addition to personal cognitions about their health, people with HAD often also have anxiety-provoking general cognitions about health and illness, such as the belief that all little pains that they feel should be explained and that disease is much more common than people think. However, it is the personal cognitions that are most important for the development of HAD.

Ways that lead to fear

There are three ways that lead to anxiety:

1. Obtained through the experience of disturbing or harmful events such as pain, swelling and changes in physical function.

2. Substitute acquisition (sickness of a close relative or close friend).

3. Obtained through threatening information, such as information about epidemics or the risk of contamination of certain diseases such as AIDS. People who are sensitive to this type of information are especially vulnerable to generalized fears about health and not so much about specific diseases.

Pain

Pain is an alarming symptom and often a reason to seek medical attention. In people with chronic pain, high levels of anxiety about health are often found. These patients exhibit more frequent safety behaviors than patients who have chronic pain in combination with a low level of anxiety about health. For example, safety behavior means following a strict diet or avoiding contact with sick people.

The question that scientists are currently focusing on is why only a few people suffer from HAD, while physical and mental complaints often occur. Everyone has a headache or abdominal pain, but this leads to the development of HAD only in a small number of people.

Cognitive biases

Different cognitive biases are at the base of HAD. The ex-consequentia reasoning is a bias that states that, if someone is afraid, it means that there is actual danger. If this anxiety is caused by someone suffering from headaches, for example, this would mean that a significant danger lurks. A confirmatory bias reinforces anxiety and ensures that patients with HAD selectively record information and can remember things that contains negative information about their health.

The thought-action-fusion bias states that patients assume that the thoughts they have about a future negative event increase their chance that this event will actually occur.

Safety behavior

Safety behavior is an important element in HAD. People with HAD try to deal with their fears by conducting behavior that is safe for them. There are four forms of safety behavior:

1. Avoidance

2. Checking

3. Searching for information

4. Asking for reassurance

People who participate in avoidance behavior scan the environment for possible health-threatening factors (such as a sick person) and then try to avoid these factors as much as possible. Because people want to be reassured with HAD, they often seek medical advice. Because medical advice is usually exclusive and it only excludes a few things, it is never satisfactory: there are still a lot of other possibilities that could explain the pain.

There are a number of aspects that maintain fear about health, namely: selective attention to information that could pose a threat to health, the sum of threatening memories, distorted images, cognitive biases, changes in bodily functions, pain and the use of safety behaviors.

Fear of health and other disorders

HAD has a number of links with panic attacks. In both cases it is about misinterpreting bodily sensations. These interpretations evoke fear. In HAD the possible threatening sensations are broader than with panic attacks. Panic attacks last only 5-20 minutes, while HAD experiences a heightened sense of anxiety for a longer period of time. So, both disorders have in common that a large cognitive component plays a role.

The repetitive and sometimes compulsive search for reassurance is comparable to OCD. People with OCD, however, know that their behavior and thoughts are not rational. People are ashamed of it and do their best to conceal their OCD. People with HAD, however, find their fears rational and are open about it. In both disorders, those who suffer from it overestimate the likelihood that something will happen to their health. This causes stress and it increases the levels of excitement, safety behavior and control. Both disorders are also often linked to depression.

Therapy

HAD is usually treated with cognitive behavioral therapy. It is important to take the belief that someone is ill at that moment seriously. Experiments have shown that cognitive behavioral therapy leads to good results: there was a significant reduction in both anxiety about health and the belief that someone was ill at that time. However, there is still too little research done to be able to state that cognitive behavioral therapy is always successful. Cognitive behavioral therapy is derived directly from the previously discussed cognitive model. The fact that the therapy seems successful to date means that the cognitive model has become plausible.

What is social anxiety? Chapter 11

Definition

In short, people with social anxiety experience intense anxiety before a social occasion. Social anxiety develops in adolescence or young adulthood, has a chronic course and is often associated with other mental disorders, especially depression. In literature, the terms social anxiety and social phobia are often used interchangeably. Social phobia is sometimes used to indicate an extreme form of social anxiety, with an intense and persistent fear of social occasions and / or occasions when someone has to perform. The diagnosis is only made when this anxiety is so intense that it causes severe stress or hinders someone's life.People with social anxiety are afraid that they will be embarrassed and behave in a socially unacceptable way. The symptoms of social anxiety are sweating, flushing, inability to write, eat or speak in public and stage fright.

Some people experience anxiety in a broad spectrum of social situations (generalized social anxiety), others have a specific situation (specific social anxiety) in which they experience anxiety. Generalized social anxiety often occurs together with other psychological disorders. Specific social anxiety often develops after a trauma. It is sometimes difficult to distinguish between people with social anxiety and people with an avoidant personality disorder. People with social anxiety recognize that their fear is a problem and want to get rid of it. Someone with an avoiding personality disorder lives consciously and voluntarily in isolation.

Most people with social anxiety try to avoid social interactions, but this is of course not always possible in daily life. Social anxiety therefore also consists of situational anxiety, but also of anticipatory anxiety. This means that the prospect of a certain situation already creates anxiety. Social anxiety has the most chronic nature of all anxiety disorders and has a prevalence of 7.8%. Specific social anxiety, such as the fear of public speaking, is much more frequent, with up to 70% of the population being affected.

People with social anxiety often assess their own social skills as less than average. There is consensus that people with intense social anxiety indeed have disturbed social skills, but how this plays a role in the expression of social anxiety is not yet clear.

There is a link between social anxiety and alcohol consumption. Alcohol usually reduces anxiety, but this depends on various factors, such as the situation in which people drink and someone's personal history with alcohol. Under certain circumstances, drinking alcohol can actually increase anxiety, for example because someone misinterprets the changing physical sensations that occur after alcohol consumption.

Cognitive theory about social anxiety

The cognitive theory about the explanation of panic disorders, originally developed by Clark, is also widely used as a springboard for a theory of social phobia. According to Clark and Wells (1995) people with social anxiety would very much like to leave a good impression on other people, but feel insecure about their own ability to do this. They believe that when they enter a social situation they are in danger of behaving in a shameful manner and that these behaviors lead to loss of status and exclusion by the group. Clark and Wells believe that the cognitive biases in different anxiety disorders are the same: people with social anxiety also overestimate the likelihood and severity of the occurrence of negative social events. People with a social phobia tend to view social situations as threatening. This is because they make a number of distorted assumptions about themselves and the behavior they have to show in social situations. Clark and Wells distinguish three categories of these dysfunctional thoughts:

• unconditional views about the self (such as: I'm stupid / I'm boring)

• conditional beliefs about social evaluation (such as: if people knew the true me, they would not accept me)

• extremely high standards for social performance (such as: I must always look intelligent / I have to hide that I am afraid)

Also, socially anxious people have dysfunctional beliefs about other people, namely:

• the belief that other people only pay attention to the appearance or behavior of the person

• the belief that other people can 'read' the phobic emotions of the person

• the convictions that people will reject the person immediately when they behave ridiculously

When social phobic people approach a new, demanding or important social situation, their anxiety programs are activated: the person automatically starts to sweat, to blush, to shake, or becomes nervous. These bodily sensations impede the person's ability to process normal information that occurs from the social situation, provoking the negative thoughts about the self. The person takes the physical sensations as proof of his / her inadequacy and strangeness. When these people become anxious, they will no longer be able to behave in a friendly manner, which provokes the behavior of the other person, thus reinforcing the fear of the person.

During such a situation, three processes are activated:

1. increased attention to the individual.

2. activation of safety behavior

3. the occurrence of problems in the behavior provoked by fear

Because socially phobic people have a negative self-image, they think that others should see them that way. They place more value on the internally generated information than on information that is given by people they are with. They focus more on processing their own physical processes than on the person who they're talking with, and this increases the anxious feelings even more.

Research shows that socially anxious people overestimate the extent to which their fear is visible to others. Because of the cognitive bias that these people have, they will perceive things that are being said by the person they're talking with in a negative way or see it as a critique of themselves. Because people want to reduce the chances of getting a negative evaluation, they will try to create a sense of security. Unfortunately, these actions to ensure safety can ensure that the negative thoughts that people have about themselves can not be disproved, so that these thoughts persist.

Post event processing is the tendency of socially anxious people to reconsider past social experiences, with a lot of attention for failures in this social experience. They go over this experience again and again and this will reinforce the negative thoughts they have. A number of studies have shown that if a person inhibits this process, then it will have beneficial consequences for him / her.

There is not enough evidence for cognitive theory yet, but this theory offers a direction for research into social anxiety disorders. There is evidence that socially anxious people have more negative thoughts about themselves than people without a social anxiety disorder. There is also evidence that these socially anxious people perceive social situations as more threatening, and that they underestimate their own social competence. It was found that these people rejected praise about their performance and that they would accept criticism more easily.

The cognitive theory of anxiety shows many similarities with the general cognitive theory of anxiety. The cognitive vulnerability spoken of in the general cognitive theory of anxiety is specific for social phobias. This makes a socially anxious person more alert when he enters a social situation and a process of scanning is started. When a potential threat is found the attention will narrow and will then be focused on the inner physical sensations.

Therapy

Because social anxiety occurs among many people, much research has been done into the best treatment method. The first psychological methods used were mainly aimed at behavior: they were behavioral exercises that had to reduce one's fear and avoidance. These exercises were repeated and there was an average decrease in feelings of anxiety in situations that first raised a high level of anxiety.

Cognitive behavioral therapy also works with behavioral exercises, but it focuses on the cognitions of the patient as well. Cognitive behavioral therapy proved to be more effective than interpersonal therapy and relaxation exercises.

Different types of medicines have been tried in treating social phobia, but not one drug was really effective. Given that many people with social anxiety also suffer from depression, antidepressants are sometimes prescribed in the treatment of social anxiety. The disadvantage is that antidepressants often have unpleasant side effects. Because of the risks that drugs entail and the small effect they produce, they are usually seen as a back-up plan.

What is a Generalized Anxiety Disorder (GAD)? Chapter 12

GAD is an anxiety disorder in which the person feels more or less anxious for a period of at least 6 months. People usually worry about work, finances, health, relationships and family. This fear is excessive, it is not realistic compared to the possible chance of a negative event. The main characteristic of GAD is a penetrating, persistent and uncontrollable fear or worry. The worrying thoughts are accompanied by a number of physical symptoms such as: increased arousal, dizziness, increased muscle tone, abdominal cramps, increased frequency of urination and difficulty in swallowing. People with GAD also complain about restlessness, difficulties with concentration and stress. The fear often turns into attempts to prevent a certain event.

The many symptoms of GAD are also present in the other anxiety and mood disorders. The symptoms often start during childhood or adolescence, but it is also regularly reported that it started after the 20th year of life. The prevalence is about 5.7%. Of the people who have registered themselves for treatment, 12% has GAD.

There are many similarities between GAD and other mental disorders, especially depression, fear of health and social phobias. This raises the question to what extent GAD is a separate disorder. In fact, none of the diagnostic criteria for GAD is specific to GAD, and they all occur in other mental disorders as well. Some critics therefore call GAD the residue category. According to Barlow, GAD is a separate disorder, because the person is 'chronically' worried and these concerns are very broad. In addition, people with GAD have a greater sense of responsibility: they feel responsible not only for themselves, but also for the people around them. Barlow also states that GAD often persists after the treatment of another disorder, which shows that it is a separate disorder.

A number of researchers state that GAD can also be distinguished from other anxiety disorders because of the intolerance of uncertainty that is remarkably prevalent among people with GAD. According to them, this could be the main characteristic of GAD. The intolerance of uncertainty can be linked to the pursuit of safety that can often be seen in people with an anxiety disorder. Uncertainty is linked to feelings of insecurity. Constant high levels of vigilance are also an important characteristic of GAD. People with GAD continuously scan the environment for signs of possible danger, and have a bias for stimuli that emit threats or danger. According to Barlow, people with GAD exhibit both active and passive avoidance behavior. The active avoidance behavior consists of taking excessive safety measures and always asking for confirmation.

GAD can be seen as an interaction between threat signals and safety signals. When someone can not find safety, the threat continues. People with GAD are almost obsessively looking for safety signals to prevent something from happening. According to Woody and Rachman, GAD can therefore be seen as the result of an unsatisfactory search for safety. People with GAD do everything they can to create a safe environment, but they rarely succeed completely, keeping them in a high state of alertness.

According to Gray, safety signals have an important influence on reducing avoidance behavior. The underlying idea is that fear evokes flight and avoidance behavior, but it also evokes the search for safety. Signals that provide safety reduce the avoidance behavior. The importance of safety signals can already be seen in childhood, where children often play quietly as long as the mother is around, but panic as soon as the mother disappears from view.

Therapy

As with most disorders, GAD can be treated using only psychological treatment methods, medication alone, or a combination of both. Of all psychological treatment methods, cognitive behavioral therapy is preferred. GAD can be successfully treated, but treatment must include the different components of GAD, such as adjusting cognitions and other coping strategies. Medication can be helpful in treating anxiety disorders, but there is no specific medication available for GAD.

What is Post-Traumatic Stress Disorder (PTSD)? Chapter 13

People who suffer from PTSD feel that they are under constant threat. In addition, they suffer from re-experiencing trauma, they have problems with memory and they suffer from excessively high arousal.

It has been known for a long time that people who experience trauma often experience psychological consequences. These consequences can cause stress and last for a long time. The current PTSD arose after observing soldiers and their reaction to stimuli related to war and / or fighting. These soldiers were mainly veterans of the Vietnam War. PTSD is included as an anxiety disorder because the two main components, anxiety and avoidance, are prominently present in PTSD. However, it also has a number of distinctive features, such as: problems with memory and reliving the trauma. How PTSD manifests itself can differ per person, this makes the disorder very broad and complex.

For PTSD, it is important to keep in mind that not everyone who has experienced a traumatic event develops PTSD. According to Gilbert, everyone possesses a psychological immune system, and PTSD arises only if this system is suppressed or works badly.

Why do some people develop PTSD? According to Ehlers and Clark, this is because these people feel like they're under a constant threat.

The symptoms of PTSD fall into three major categories:

1. Re-experience of the trauma: during a re-experience people have the idea that the traumatic event did not occur in the past, but that it takes place in the present. This creates the above mentioned feeling of being under constant threat. People with PTSD often have holes in their memory, they can hardly remember crucial elements of the event. This is something unique for PTSD and does not occur in other anxiety disorders.

2. Fear and avoidance: people with PTSD avoid places or people who are associated with the trauma. They also avoid thinking about or talking about the trauma and associations with the trauma.

3. Constantly elevated arousal: people with PTSD experience increased levels of arousal. This manifests itself, among other things, in disturbed sleep, nightmares, irritability and anger, fright reactions and increased vigilance.

DSM 5 is likely to change the diagnostic criteria for PTSD. Currently, the DSM states that someone must have experienced a life-threatening trauma before someone is eligible for the PTSD diagnosis. DSM 5 wants to broaden the criterion into negative life-changing events, such as the death of a partner and sexual violence. If these events are followed by a sense of threat, fear and avoidance, an increased arousal and problems with memory, someone can also qualify for the diagnosis.

The characteristics of PTSD do not have to occur immediately after the trauma: there can be years between the trauma and the first characteristics of PTSD. In these cases PTSD is often triggered by a new experience that can be experienced as traumatic. It is clear that an event precedes PTSD. This event is clear for both the victim and the environment. There is a clear connection between the trauma and the subsequent fear, and this fits well within the conditioning theory.

Statements for PTSD

Because of the wide variety of causes for PTSD and the many ways in which PTSD can be expressed, it is difficult to give a single explanation for the development. The conditioning theory has been the most influential theory for a long time. Since it has been discovered that anxiety can also arise without any learning experiences, but for example because of the negative information transfer from another person, this theory is less influential on PTSD. However, elements of this have been incorporated in the emotional processing theory.

There are currently three prominent explanations for PTSD:

1) Emotional processing of traumatic events

This statement is based on the ideas of Freud. Freud saw the symptoms as remnants and memories of symbols of certain traumatic events. A widely used example is Anna O. The idea that emotional experiences can linger for a long time and that it can disrupt behavior, is now generally accepted. In fact, PTSD can be seen as a long period of re-experience. Even if people process their emotions in a good way, memories and flashbacks can let them return to a certain event, often to the surprise of the person himself.

Emotional processing is a process in which emotional disturbances are absorbed and reduced to such an extent that other experiences and the behavior of the person are not disturbed. When emotions are not (sufficiently) absorbed, a number of symptoms can become visible. These are usually visible at intervals and can be directly and clearly visible, but also indirectly and subtly. The direct and visible characteristics of inadequate emotional processing are the persistence or return of signs of emotional activity, such as: obsessions, flashbacks, nightmares, talking under pressure, expressing or experiencing emotions that do not fit in the context or are out of proportion and maladaptive avoidance. The indirect and / or subtle characteristics of insufficient emotional processing are: difficulties in concentrating,restlessness, irritability and other signs of increased arousal.

When there is good emotional processing, it can be checked whether someone can talk about the event and can be reminded of the event without experiencing stress or disruptions.

In this model all the above characteristics of PTSD are processed. A major shortcoming in this model is that it does take cognitions into account at all. Too little attention is paid to problems with memory that can be seen in people with PTSD. The treatment implications of this model further state that the stimuli or memories that evoke emotions must be transformed or neutralized. To achieve this, the patient had to be confronted with his or her fear, in order to activate the fear structures in the brain and then be able to tackle them. However, research has shown that to reduce anxiety these structures do not necessarily have to be activated, but that there are other ways to reduce anxiety, such as giving information and cognitive therapy.

2) Dual representation theory

In the dual representation theory, from Brewin, memory and its vicissitude are the centrepiece, in contrast to the emotion processing theory mentioned above. According to Brewin, the characteristics of PTSD arise when the memories of trauma become dissociated from the 'ordinary' memory. PSTD is not transferred until these memories are transformed into ordinary memories. According to Brewin there are at least two systems of memory, and information about the trauma is represented in one of these two systems. Normal memories are stored in the verbally accessible memory (VAM) and memories of a trauma are stored in the situationally accessible memory (SAM). The two systems react differently to extremely elevated levels of stress. The SAM is involuntarily activated by clues associated with the trauma and causes flashbacks. These memories are also more emotional and vivid than ordinary memories, but are usually not easily accessible. They are poorly integrated into our biographical knowledge and difficult for the person to describe. It is stated that the emotions associated with the memories in the SAM are limited to the primary emotions that were experienced during the trauma. The normal memory system (VAM) consists of spoken or written stories and is easily and voluntarily accessible to the person. It is also well integrated in our biographical knowledge. According to Brewin, flashbacks, re-experiences and other related phenomena lead to a shift of memories from the SAM to the VAM. A complete cognitive treatment would not help because the memories in the SAM are not accessible. Aspects of Brewin's theory are, however, used within cognitive theory.

3) Cognitive theory

This theory was devised by Ehlers and Clark. The theory answers the central question why post-traumatic symptoms persist and are not well enough processed. The theory states that when there is insufficient emotional processing, the person lags behind with a feeling that he / she is under a current threat. This can be either an external threat or an internal threat to themselves or their future. There are two mechanisms that lead to this feeling of threat, namely the negative assessment of the event and the consequences and the nature of the memory of the trauma itself. The feeling that someone is under current threat is accompanied by images, thoughts or memories, the reliving of the trauma and heightened arousal and fear. Negative assessment of these symptoms may increase the feeling that someone is under current threat. They can start thinking: 'I will never get over it', 'My brain is permanently damaged' or 'I am in danger, I don't feel safe anywhere'. These thoughts are so stressful that the person tries to block or avoid them, allowing the disorder to continue.

Ehlers and Clark argue that the difficulty in remembering details of the trauma lies in the fact that the memory of the trauma is fragmented and poorly organized. Involuntary intrusive memories are so badly processed that they are not properly integrated into normal autobiographical memory. These fragmented, involuntary memories tend to be very lively, intrusive and  emotional. Experiencing these memories will make the negative appraisals about the traumatic event even stronger.

The treatment resulting from this vision consists of three elements. First, the memories have to be elaborated and integrated. Second, the negative and maladaptive appraisals of the trauma and its consequences must be analyzed and changed. Third, the non-adaptive methods that a person uses to avoid or reduce stress must be identified and prevented. These methods include avoiding certain situations or persons, attempting not to think about the trauma and not talking about the trauma and its consequences. Not being able / willing to talk about the trauma and the consequences makes it difficult for many people with PTSD to go to therapy.

Initial studies have shown that this treatment is effective. This is because it is a derivation of the cognitive theory. This theory is also good because it overlaps a bit with the previous two theories, the emotional processing theory and the dual-processing theory. The addition that people feel that they are under current threat and that this threat is not a thing of the past, contributes to explaining the persistent character of PTSD. The cognitive theory is able to explain most of PTSD.

EMDR

EMDR stands for ' eye-movement desensitization and reprocessing' and is a technique that was invented by Shapiro. People are asked to evoke an image related to the traumatic experience and then had to move their eyes from left to right. This results in a decrease of anxiety when thinking about the traumatic image. The introduction of EMDR has evoked a lot of criticism and skepticism. It had no theoretical basis and although according to Shapiro the repetitive eye movements were of great importance, research showed that other repetitive movements caused the same effect. Nevertheless, EMDR has gained some ground and is now recommended by NICE as the preferred treatment for people with PTSD. EMDR is thought to work because it affects the working memory: the liveliness and emotionality that the images of the traumatic event first called up, eventually fade.