Is Anxiety Adaptive?

Anxiety and fear both are alerting signals and act as a warning of an internal and external threat. Anxiety can be conceptualized as a normal and adaptive response that has lifesaving qualities, and warns of threats of bodily damage, pain, helplessness, possible punishment, or the frustration of social or bodily needs; of separation from loved ones; of a menace to one's success or status; and ultimately of threats to unity or wholeness. It prompts a person to take the necessary steps to prevent the threat or to lessen its consequences. This preparation is accompanied by increased somatic and autonomic activity controlled by the interaction of the sympathetic and parasympathetic nervous systems. Examples of a person warding off threats in daily life include getting down to the hard work of preparing for an examination, dodging a ball thrown at the head, sneaking into the dormitory after curfew to prevent punishment, and running to catch the last commuter train. Thus, anxiety prevents damage by alerting the person to carry out certain acts that forestall the danger. Stress and Anxiety Whether an event is perceived as stressful depends on the nature of the event and on the person's resources, psychological defenses, and coping mechanisms. All involve the ego, a collective abstraction for the process by which a person perceives, thinks, and acts on external events or internal drives. A person whose ego is functioning properly is in adaptive balance with both external and internal worlds; if the ego is not functioning properly and the resulting imbalance continues sufficiently long, the person experiences chronic anxiety. Whether the imbalance is external, between the pressures of the outside world and the person's ego, or internal, between the person's impulses (e.g., aggressive, sexual, and dependent impulses) and conscience, the imbalance produces a conflict. Externally caused conflicts are usually interpersonal, whereas those that are internally caused are intrapsychic or intrapersonal. A combination of the two is possible, as in the case of employees whose excessively demanding and critical boss provokes impulses that they must control for fear of losing their jobs. Interpersonal and intrapsychic conflicts, in fact, are usually intertwined. Because human beings are social, their main conflicts are usually with other persons. Symptoms of Anxiety The experience of anxiety has two components: the awareness of the physiological sensations (e.g., palpitations and sweating) and the awareness of being nervous or frightened. A feeling of shame may increase anxietyOthers will recognize that I am frightened. Many persons are astonished to find out that others are not aware of their anxiety or, if they are, do not appreciate its intensity. In addition to motor and visceral effects (Table 16.1-2), anxiety affects thinking, perception, and learning. It tends to produce confusion and distortions of perception, not only of time and space but also of persons and the meanings of events. These distortions can interfere with learning by lowering concentration, reducing recall, and impairing the ability to relate one item to anotherthat is, to make associations. An important aspect of emotions is their effect on the selectivity of attention. Anxious persons likely select certain things in their environment and overlook others in their effort to prove that they are justified in considering the situation frightening. If they falsely justify their fear, they augment their anxieties by the selective response and set up a vicious circle of anxiety, distorted perception, and increased anxiety. If, alternatively, they falsely reassure themselves by selective thinking, appropriate anxiety may be reduced, and they may fail to take necessary precautions.

Epidemiology The anxiety disorders make up one of the most common groups of psychiatric disorders. The National Comorbidity Study reported that one of four persons met the diagnostic criteria for at least one anxiety disorder and that there is a 12-month prevalence rate of 17.7 percent. Women (30.5 percent lifetime prevalence) are more likely to have an anxiety disorder than are men (19.2 percent lifetime prevalence). The prevalence of anxiety disorders decreases with higher socioeconomic status. 14.1 Anxiety Disorders: Introduction and Overview Daniel S. Pine M.D. Introduction Anxiety represents a core phenomenon around which considerable psychiatric theory has been organized. Thus, the term anxiety has played a central role in psychodynamic theory, Epidemiology The anxiety disorders make up one of the most common groups of psychiatric disorders. The National Comorbidity Study reported that one of four persons met the diagnostic criteria for at least one anxiety disorder and that there is a 12-month prevalence rate of 17.7 percent. Women (30.5 percent lifetime prevalence) are more likely to have an anxiety disorder than are men (19.2 percent lifetime prevalence). The prevalence of anxiety disorders decreases with higher socioeconomic status. as well as in neuroscience-focused research and various schools of thought heavily influenced by cognitivebehavioral principles. Indeed, inspection of many chapters throughout this textbook reveals varied contexts in which theories about anxiety have emerged. These varied contexts, in turn, are associated with differing definitions of anxiety and distinct focuses of research or clinical application. Clearly, each view of anxiety, across the varied chapters, shares a lineage in terms of conceptualizations that each recognizes anxiety to be one of a handful of core, negative affective states. Moreover, in each chapter, the close relationship between anxiety and perception of danger appears tantamount. Nevertheless, despite these shared approaches, anxiety also has been conceptualized somewhat differently across the varied theoretical schools. This introduction summarizes the manner in which anxiety is conceptualized across the sections comprising this chapter. Thus, the introduction begins with a series of definitions for key constructs related to anxiety. The definitions used here also are briefly contrasted with those used in other writings focused on anxiety. Next, core principles that provide a backbone for each section in this chapter are summarized. These principles represent areas of mutually agreed-on focus for all the sections contained herein, and, again, the focus here distinguishes the view of anxiety in this chapter from that held in other chapters. Finally, the content within each of the eight sections appearing within the current chapter is briefly reviewed. This review includes a summary of material appearing in each section, as well as a delineation of key questions emerging from the material contained within each section. Definitions Fear and anxiety can be conceptualized as two key core negative emotions. As such, definitions of fear and of anxiety must be based in broader definitions for emotions in general. For the current set of sections, the term emotion refers to the brain state associated with the perception of a motivationally salient stimulus, a stimulus that creates a need for the organism to act. Motivational stimuli can in turn be divided into rewards and

punishments, where a reward refers to a stimulus for which an organism will expend effort to approach, and a punishment refers to a stimulus for which an organism will expend effort to avoid. Fear refers to the specific set of emotions or brain states that are elicited in an organism when it confronts danger. Many current approaches refer to fears in the plural because fears are viewed as a collection of closely related but distinguishable brain states, as opposed to one, single state. This view reflects the fact that different forms of danger elicit different neural responses and associated differences in information processing and behavior: The response to a conspecific or some other form of innately dangerous stimulus can be distinguished, and both of these can in turn be distinguished from the response to objects that are viewed as dangerous through the effects of learning from experience. The term danger, in turn, refers to any stimulus or situation that is capable of producing harm to the organisms. The act of encountering a specifically dangerous object, such as a predator, can also be conceptualized as a threat. Moreover, because organisms tend to exert effort to avoid virtually all threats or dangerous scenarios, threats and dangerous scenarios can also be conceptualized as punishments. A few notable aspects of these definitions call attention to an emphasis in material throughout this chapter. First, the present section views anxiety as a phenomenon that begins in the brainno definition of the term is relevant unless it is grounded in neuroscience. Second, in a related fashion, given this emphasis on neural responses, the definitions employed here can be used with similar ease to quantify emotions, fear, and anxiety in a range of mammalian species, including humans. This allows the conceptualizations used throughout this chapter to facilitate an emphasis on cross-species comparisons. Despite this focus on brain states and cross-species comparisons, this chapter also clearly focuses on the unique manner in which humans are capable of expressing emotions. Thus, humans possess the unique ability to provide richly textured self-reports of feeling states, phenomena sometimes referred to as qualia. Indeed, throughout this chapter much of the research focuses on the self-report of anxiety as manifest in studies of diagnosis, neurobiology, genetics, or treatment. However, despite the importance of self-reported feeling states in research on human emotion in general and anxiety in particular, self-reported feeling states must not be confused with emotions per se. The term emotion does not refer to a self-report but rather to a stimulus-evoked brain state; the self-report represents one manifestation of the elicited brain state, along with changes in behavior or physiology. Indeed, one of the great mysteries of emotional states in humans reflects the fact that the brain can evoke varied and relatively weakly correlated changes in physiology, behavior, and self-report following the processing of one, single stimulus. As such, although an emphasis on self-report is a key for understanding clinical manifestations P.1840 of anxiety as expressed by humans, this emphasis must grapple with the fact that self-report represents a relatively distal, downstream manifestation of any emotion. The term fear can be distinguished from the term anxiety in a few respects. Fear is typically taken to refer to brain states associated with presentations of overtly dangerous stimuli. For example, fear is the emotion aroused when an organism immediately confronts a predator or a dangerous conspecific appearing in close proximity directly in front of the organism. As such, fear represents an acute, immediate reaction, manifest on abrupt encounters with highly salient threats. In research with rodents, this definition has at times been used to model normal responses in humans to dangers. For example, this type of fear response in the rodent is often modeled with the classic conditioning paradigm in which a rodent is placed in a cage and exposed to a cue, such as a tone or a light, that predicts

the immediate occurrence of an unconditioned aversive stimulus, such as a shock (UCS). In this fear conditioning paradigm the cue is conceptualized as a conditioned stimulus (CS+), and the organism's response to the cue can be viewed as an analogue of fear. Unlike fear, from this perspective anxiety refers to brain states elicited by signals that predict impending but not immediately present danger. Thus, unlike fear, anxiety involves a more sustained change in the brain, manifest when a threat is still relatively removed from the organism in a spatial or temporal context. For example, anxiety might be conceptualized as the emotion aroused when an organism enters a deserted, isolated context where encounter with a predator appears likely, despite the isolated nature of the context and the absence of any overt cues indicating that the predator is lurking. In the fear conditioning experiment, anxiety is considered an analogue of pathological reactions to danger in humans, as occurs in the anxiety disorders. This view reflects the relatively pervasive, chronic state of negative affect in clinical syndromes. In rodent experimental studies using fear conditioning, anxiety can be contrasted with fear, which manifests on immediate confrontation of the CS+; anxiety typically is considered as manifesting to the general context of the fear-conditioning experiment. Thus, anxiety might be elicited when the organism is placed in the cage where the fear-conditioning experiment was previously conducted. Thus, fear and anxiety have been distinguished on both temporal and spatial grounds. From the temporal perspective, fear refers to the acute, immediate response to suddenly appearing, imminent danger, whereas anxiety refers to the sustained, insidious response to danger, as might manifest when the degree to which a threat is present remains ambiguous. From the spatial perspective, fear refers to the acute response to proximal threats, whereas anxiety refers to the response to distal threats. As such, fear in rodents can be considered an analogue of normal human emotions elicited by thoughts about danger. Anxiety can be considered an analogue of abnormal human emotions in similar scenarios. Parenthetically, when an acute, proximal threat is particularly dangerous, however, the emotional state elicited in the organism might better be characterized as panic as opposed to fear. Normal and Abnormal Conceptualizations of normal and abnormal fears and anxieties emerging from research directly among humans differ somewhat from conceptualizations in rodent-based or other basic research. As reviewed by Erin B. McClure-Tone and the author in the first section within this chapter, definitions in humans rest heavily on the presence of impairment, a disruption in normal functioning, or the presence of clinically significant distress. Basing definitions of abnormal anxiety on impairment or clinical judgments about distress does create some problems for attempts to conduct cross-species and neuroscience-focused research. The degree to which impairment or distress might manifest can be heavily influenced by the environmental circumstances to which the individual is exposed. Thus, two individuals manifesting identical neural responses to a dangerous stimulus might be classified differently in terms of the degree to which their associated anxiety can be considered normal. If one individual faces hurdles not encountered by the other due to the nature of their environment and associated resources, these two individuals, who function identically from a neuroscience perspective, will be classified differently from a clinical perspective. This discrepancy between clinical and basic perspectives is necessary due to the limited knowledge base on human brain function. Obviously, clinicians, who must make decisions about when and for whom to provide treatment, cannot wait for knowledge to accumulate so that they can base these decisions on neuroscience. In this context, the current clinical approach of relying on judgments about distress and impairment seems sensible.

Nevertheless, much as in cardiology, where asymptomatic individuals can be treated quite differently based on physiological measures of heart function, one day in the future, for the mental health clinician, distinct groups of asymptomatic individuals also may be treated differently based on patterns of brain function in the distinct groups. However, until that time is reached, definitions of clinically significant anxiety will remain removed from neuroscience, and clinical decision making will rest heavily on clinical judgments about impairment and distress. Thus, as delineated in the present chapter, specifically in the sections on neurophysiology, neurochemistry, and brain circuitry, great excitement has emerged in the study of anxiety; the field is entering a period in which ongoing research in basic brain function will lay the foundations for a future clinical approach that rests on understandings of pathophysiology. Nevertheless, this excitement is also tempered by the current reality, as described in the sections on diagnosis and treatment. Here, despite considerable progress in research on pathophysiology, clinical decision making and the associated standards of care must remain relatively removed for the time-being from current understandings of pathophysiology. Thus, research reviewed throughout this chapter generates as much or more enthusiasm for potential future approaches to the assessment and treatment of anxiety as it does for justifying the approaches that are currently standard in the field.
In Section 14.3, Kathleen Ries Merikangas and Amanda E. Kalaydjan review data from epidemiological investigations. A few key observations emerge from this section. First, in both the clinical and the community setting, the prevalence of anxiety disorders is truly staggering; these are among the most common of all mental disorders. Second, anxiety disorders exhibit a varying course and changing manifestations over time. Thus, comorbidity is the rule rather than the exception in epidemiological studies, such that most anxiety disorders are associated with another anxiety disorder, either concurrently or at later points in time. Comorbidity with mood disorders is also substantial, raising questions about the degree to which mood and anxiety disorders emerge from a shared substrate. Moreover, whereas some anxiety disorders represent chronic conditions, many individuals experience a relatively benign course. Epidemiological data do generate some initial hypotheses concerning how best to characterize one or another specific group of anxiety disorder patients. However, questions in this area emerge as the major issue to be addressed in future epidemiology research. Thus, how exactly do we understand why one individual manifests only transient anxiety, whereas another individual exhibits persistent anxiety with a relatively unchanging presentation, and yet a third individual manifests an ever-changing panoply of mood and anxiety disorders? Epidemiology clearly demonstrates the occurrence of all three patterns but has yet to clarify factors that predict which individuals will follow which specific pattern

14.4 Anxiety Disorders: Psychophysiological Aspects Christian Grillon Ph.D. Brian R. Cornwell Ph.D. Introduction A prominent concomitant of anxiety, like all emotions, is physiological arousal. Fear and anxiety lead to an increase in sympathetic activity that affects cardiovascular activity (cardiac activity and blood pressure) and the electrodermal system (perspiration). Anxiety increases reflexes and enhances muscle tension, including facial muscles involved in emotional expression (corrugator muscles). Anxiety is also accompanied by subjective feelings, including feelings of increased muscle tension, heart racing, perspiration, shortness of breath, and palpitations. In cases of extreme fear the organism prepares to escape or fight. These three aspects of anxietyphysiological activity, subjective reports, and overt behaviorsdo

not constitute distinct indicators of a homogeneous aversive state but dissociable components of a loosely coupled emotional response. Because no single set of measures provides a clear picture, evaluation of anxiety and anxiety disorders requires measurement of each component. Yet, psychophysiology, the science dedicated to the quantification of physiological activity and reactivity and to the understanding of the biological bases of human behaviors and mental processes, has not been integrated into the clinic. Clinicians continue to rely exclusively on face-to-face interviews and self-report. This is a paradoxical situation, given that somatic symptoms play a prominent role in the diagnosis of anxiety disorders (fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders [DSM-IV]) (Table 14.4-1). For example, 10 of 13 symptoms of panic attacks are somatic symptoms, and physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event and persistent symptoms of increased arousal, including exaggerated startle, are criteria for posttraumatic stress disorder (PTSD). Compounding this problem, it is well-established that an individual's perception of his or her bodily symptoms is poor. Such perception may be further distorted in distressed states and can be affected by the mood of the patient. A hallmark of panic disorder, for instance, is the experience of panic attacks. Although panic attacks are experienced as a patient-reported surge in physiological arousal, ambulatory monitoring has shown that panic attacks sometimes occur without actual changes in physiology. With advances in computer technology, psychophysiology has become inexpensive and easy to integrate into a clinical program. It would therefore seem that psychophysiology, by contributing a more objective assessment of patients' physiological state, would be a welcome addition to self-report for the diagnosis and assessment of treatment efficacy. Yet, psychophysiology remains essentially a research tool when it comes to psychopathology. Evidence points to the potential clinical utility of psychophysiology as an adjunct to selfreport to better characterize the various somatic manifestations of anxiety disorders. Psychophysiology could also assist in identifying psychological and neurobiological dysfunctions. This includes identifying endophenotypes not observable by diagnostic interviews. Markers of physiological vulnerability are crucial for the identification of highrisk individuals in genetic linkage studies. P.1865

Historically, psychophysiology has relied on bioelectrical signals recorded via electrodes placed on the skin (scalp, hands, face). Examples of psychophysiological measures include palmar sweating (skin conductance), electromyographic and electrocortical activity, respiration, peripheral vasoconstriction, heart rate, blood pressure, and somatic reflexes. The field of psychophysiology now encompasses neuroendocrinology and brain imaging (e.g., positron emission tomography [PET]). Psychophysiology of Fear and Anxiety Fear and anxiety can be conceptualized as a normal and adaptive response that prepares the organism threatened by danger. Responses to threat must be thought of in terms of model systems depending on functionally different neural structures activating distinct sets of behaviors controlling adaptive responses. The various editions of the DSM recognize that anxiety states are not homogeneous. A recognized differentiation is that between fear and anxiety. Fear is associated with a clearly identifiable and imminent danger that requires immediate actionfight or escape when possibleor other actions aimed at reducing the impact of the threat, for example, by decreasing pain sensitivity when action is thwarted. Fear

is a sympathetically dominated, phasic alarm reaction that generates an immediate surge of physiological arousal lasting as long as threat is imminent. In contrast, anxiety is a more persistent state of chronic apprehension and vigilance in response to more distal or unpredictable threats. It is characterized by tension, worry, negative affect, and a feeling of insecurity. These two types of responses are associated with different psychophysiological profiles. Both fear and anxiety can become abnormal when excessive or inappropriate with regard to the threat. Although specific phobias are the prototype of fear disorders, generalized anxiety disorder is the archetype of anxiety disorder. However, symptoms of both fear and anxiety can be found in panic disorder and PTSD. Pathological fear and anxiety result in strong subjective feelings accompanied by similar physiological activation as normal anxiety, including muscle tension, shortness of breath, hyperventilation, heart palpitation or heart pounding, increased perspiration or cold sweat, and exaggerated startle. Some of these physiological changes, such as skin conductance (sweat), heart rate, muscle tension, and reflex potentiation, can be recorded easily and inexpensively. Other response systems, such as respiration volume and cardiac output, are more costly and cumbersome to record. Anxiety disorders are associated not only with heightened fear and anxiety, but also with impaired emotion regulationthe ability to reduce emotional reactivity. Recent evidence suggests that the ability to respond adaptively and organize physiological resources in the face of external challenges can be indexed by tonic heart rate variability, an index of sympathetic and parasympathetic influences on the heart. Electrodermal Activity The electrodermal system has a long history in psychophysiology. The electrodermal system has been very popular in psychophysiology since the discovery in 1888 by the French neurologist Charles Fr that various emotional and physical stimuli induced changes in electrical activity of the skin. Unlike the heart rate and most other autonomic functions, which are under sympathetic and parasympathetic influences, the electrodermal system is controlled by the sympathetic branch of the autonomic nervous system (ANS). Widespread focus on the role of sympathetic activity in response to novel or threatening stimuli has given center stage to electrodermal activity in anxiety research. Intense emotions, including fear and anxiety, are often accompanied by the activation of sweat glands (e.g., moist hands), which can be easily quantified with recording devices. Electrodermal activity is recorded as a change in electrical resistance following passage of a small painless current across the skin. The recording of electrodermal activity is usually made from two electrodes placed either on the inside of the hand or on the second phalanx of the second and third fingers of one hand. Various measures of electrodermal activity can be implemented to assess tonic or phasic activity to quantify responses to sensory and psychological stimuli. Tonic activity is referred to as skin conductance level. Tonic activity has been linked to vigilance, sustained attention, and arousal, but it is also increased in anxious states. In contrast, depression is characterized by low skin conductance. Phasic changes can be time-locked to a specific stimulus and give rise to skin conductance responses (SCRs), or they can occur in the absence of a stimulus and are labeled spontaneous fluctuations. The SCR is the traditional measure in Pavlovian aversive conditioning studies. It should be considered a measure of an attentional process (e.g., orienting response) rather than a measure of an emotional response (e.g., fear). The number of spontaneous fluctuations has been related to arousal and anxiety.