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The Development and Maintenance of Anxiety Disorders

Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C.E. Zupanick, Psy.D. and Mark Dombeck, Ph.D.

Up to this point, we have discussed anxiety in a more general sense. We now turn our attention to anxiety disorders. Biological, psychological and social forces converge to create and maintain anxiety disorders.

False alarms:

danger signWe previously discussed the fight-or-flight response. We noted fear triggers this response. It is our body's automatic response when faced with an actual threat in our present environment. Under these circumstances, the fear response represents a "true alarm." This is because there is a real and present danger and we must either escape or fight. In this case, our fear response is adaptive and appropriate.

We may also experience false alarms. During a false alarm, our bodies kick into the flight-or-fight mode. This prepares us for action, just as it would during a true alarm. However, unlike the circumstances that trigger a true alarm, there is nothing in the immediate environment that represents an actual threat. In other words, there is no clear and present danger. So, the "DANGER-DANGER" alarm is going off but for no apparent reason. When this alarm is triggered, without an immediate threat or environmental "cue," the resulting response is called an uncued panic attack. Because there is no discernable reason for the panic attack, people often describe these panic attacks as "coming out of the blue."

Although these uncued panic attacks seem to come out of the blue, their occurrence is not as random as previously thought. Research suggests that some form of underlying life stressor often triggers these unexpected or uncued panic attacks. Examples of life stressors may include: separation and loss; relationship problems; new responsibilities; a family member's illness, drug reactions; pregnancy; and/or school and work issues (Bourne, 2000). Interestingly, life stressors do not necessarily need to be "negative" in content. Indeed, "positive" stressors such as a job promotion, planning a marriage, and having children may also contribute to the level of stress that may precipitate an initial, uncued panic attack.

You will recall that during a fight-or-flight episode, our body is physically preparing for some immediate, protective action. Under the situation of a "true alarm" the chemicals released into the body to prepare for fight or flee (such as the release of adrenalin) will be discharged, or used up. As the body runs or fights, the additional fuel provided by the fight-or-flight response gets used up. This is similar to how a car burns up its fuel, particularly at high rates of speed. However, under a "false alarm" these additional chemicals are not required. The body does not need to run or fight. It merely needs to "idle." Therefore, these chemicals remain active in the body with no quick or easy way of getting rid of them. This thereby produces the unpleasant physical sensations that are associated with panic attacks. These sensations include all the physical symptoms that occur when the fight-or-flight response is activated (racing heart, accelerated respiration, perspiration, digestive upset, dizziness, etc.). Subsequently, the fight-or-flight response is not helpful at this point because there is no real threat. Instead, the person is just left feeling physically and emotionally fearful, highly uncomfortable, and ultimately exhausted.

Since there is no obvious explanation for the symptoms that occur during a "false alarm" (uncued panic attack), people understandably misinterpret them as a sign, or "cue" that something is terribly wrong. "I'm having a heart attack." "I must be going crazy." In other words, these symptoms are misinterpreted to mean, "I must be in danger." By now we know when the mind believes there is a real and present danger; it prepares the body for fight-or-flight. So, a vicious cycle gets set up. The symptoms of a panic attack are alarming and suggest danger. The body responds as it ordinarily does to a perceived threat, and the symptoms continue or worsen. As this cycle continues, exhaustion will eventually occur. Just like a car, the body does not have an unlimited supply of fuel.

People do not usually recognize the connection between a life stressor and the initial, uncued panic attack. Naturally, they will search for the cause of the attack in an effort to avoid a repeat experience. In this search for a reason, people may come to associate the place or event where the panic attack occurred as the "cause." For instance, if a woman experiences a panic attack in a grocery store, she may come to believe the grocery store "caused" the panic attack. As a result, they will avoid the grocery store at all cost. Because they believe the grocery store caused the attack, merely thinking about the need to shop for groceries may prompt another panic attack. This type of panic attack is called a cued panic attack. This is because the grocery story now serves as a cue, or signal of danger. In this respect, anxiety has been learned through a behavioral learning process called classical conditioning. Classical conditioning is discussed in the next section.