 Fear as a basic characteristic of anxiety:

 Functional or normal fear:

◦ Fear is in response to objectively threatening
events.
◦ Fear is of appropriate severity given the threat.
◦ Fear subsides when threat has passed.
◦ Fear leads to adaptive behavior.
 Fear is slightly maladaptive when:
◦ Fear is somewhat unrealistic
◦ Fear persists after the threat has passed.
◦ Fear may lead to behavior that may be somewhat
inappropriate.
 Fear potentially meets criteria for an anxiety
disorder:
◦ Fear is moderately unrealistic.
◦ Fear is definitely more than is warranted given the
severity of the threat.
◦ Fear persists for quite awhile after the threat has
passed.
◦ Fear leads to behaviors that are potentially
dangerous or impairing.
 Fear likely meets diagnostic criteria for an
anxiety disorder:
◦ Fears are completely unrealistic.
◦ Fears are excessive given the objective threat.
◦ Fears persist long after the threat has passed and
chronic anticipatory anxiety exists.
◦ Fear leads to dangerous behavior or impairment.
 The hypothalamus activates the adrenal-
cortical system by releasing corticotropin-release
factor (CRF), which signals the pituitary gland to
secrete ACTH, the body’s major stress hormone.
ACTH stimulates the outer layer of the adrenal
glands , releasing group of hormones such as
cortisol. The amount of cortisol in the blood or urine
is often used as a measure of stress. ACTH also
signals the adrenal glands to release about 30 other
hormones, each plays a major role in the body’s
adjustment to emergency situations.
 Eventually, when the threatening stimulus
had passed, the hippocampus, a part of the
brain that helps regulate emotions turns off
this physiological cascade.
 Freud’s theory:
◦ Accumulation of the undischarged libido is
transformed into anxiety
◦ Libido could either result from external obstacles
to its appropriate discharge or form internal
inhibitions related to unconscious conflicts about
sexual gratification
◦ Freud referred to this anxiety as actual neurosis. It
is associated with pathological and overwhelming
fear. It is usually associated with a number of
physiological symptoms and an overwhelming
sense of panic and terror.
 ◦ Anxiety has a biological or genetic basis.
◦ Traumatic situations are central to the development
of anxiety
◦ As children developed, they learn to anticipate
dangerous situation before it happens and react to
it with anxiety. He called this signal anxiety.
 Anxiety is both symptomatic manifestation of
neurotic conflict and an adaptive signal to avoid
awareness of neurotic conflict. Signal anxiety is a
way of attenuating a more profound and terrifying
anxiety.
• Repression is a defense mechanism that keeps
undesirable id impulses from coming into
consciousness. Reaction formation may also be
another defense from an underlying wish related to
drive pressures.
 Melanie Klein expanded on Freud's view by
developing a theory of internal object relations
linked to drives. She regarded fear of annihilation
as the most fundamental anxiety and related it to
Freud's death instinct.
 In her view, the ego engaged in a splitting
process to deal with that fear of annihilation. All
the derivatives of the death instinct, such as
sadism, hatred, aggression, and any form of
“badness,” were evacuated from the infant and
projected into the mother.
 As the infant moved from the paranoid-
schizoid position to the depressive position,
splitting of the ego was overcome by an
integrative effort that was designed to link
good and bad aspects of the self and of
objects. Instead of viewing the mother as “all
bad,” the child is now able to see that mother
has both good and bad qualities.
 When the child becomes aware that the loving
and nurturing mother is basically the same
person as the hateful, rejecting mother, an
important developmental moment has been
achieved.
• Hence depressive anxiety can be summarized as a
concern about the loss of the love object through
one's own destructiveness. The child learns to deal
with these guilt feelings through a process of
reparation, in which the child attempts to repair the
perceived damage through loving behavior toward the
ambivalently regarded object. ( Kaplan & Saddock,
2000 p.3010)
◦ His emphasis is on infantile needs rather than repressed
wishes or drives.
◦ He believes that the need to maintain self-esteem and
well-being is as powerful as sexuality and aggression in
molding a human person.
◦ The child has powerful to idealize a parent; to receive
affirmation, validation and empathy from that parent
and to maintain a sense of wholeness of the self.
◦ Disintegration anxiety is the most fundamental concern
of the individual. This anxiety is generated by the child’s
concern that the failure of adequate self object
responses in the environment will lead to fragmentation
of self.
◦ Biological mechanisms are linked to the generation
of anxiety.
◦ Acute panic attacks appear to arise in the brainstem
and represent spontaneous hyperactivity of
noradrenergic nuclei in conjunction with lowered
firing thresholds in medullary respiratory
chemoreceptors. By contrast, anticipatory anxiety
seems to represent the effect of a kindling in the
limbic lobe. Phobic avoidance appears to be
cortical in origin.
 Developmental Hierarchy of Anxiety:
◦ Superego anxiety
◦ Castration anxiety
◦ Fear of loss of love
◦ Separation anxiety – fear of loss of the object (
Kleneian depressive anxiety)
◦ Persecutory anxiety
◦ Disintegration anxiety
 Biochemical findings:
◦ High levels of cortisol indicate an elevated stress
response.
◦ Resting levels of cortisol among people with PTSD (
when not exposed to trauma reminders) tend to be
lower than among people without PTSD.
◦ Cortisol acts to reduce sympathetic nervous system
activity after stress, so lower levels may result in
prolonged activity of the sympathetic nervous
system.
 Neuroimaging findings:
◦ Differences between brain activity of those with
PTSD from those without PTSD can be seen in areas
that regulate flight-or-fight response and memory
including amygdala, hippocampus and prefrontal
cortex.
◦ Amygdala responds more actively to emotional
stimuli to those with PTSD.
◦ Prefrontal is less active
◦ Damage to the hippocampus my interfere with
returning to normal level after the threat has
passed.
 Psychodynamics:
◦ Difficulty tolerating anger
◦ Physical or emotional separation from significant
persons both in childhood and adult life
◦ May be triggered by situation of increased work
responsibilities.
◦ Perception of parents as controlling, frightening,
critical and demanding.
◦ Internal representations of relationships involving
sexual or physical abuse.
 A chronic sense of feeling trapped
 Psychodynamics:
◦ Difficulty tolerating anger
◦ Physical or emotional separation from significant
persons both in childhood and adult life
◦ May be triggered by situation of increased work
responsibilities.
◦ Perception of parents as controlling, frightening,
critical and demanding.
 Internal representations of relationships
involving sexual or physical abuse.
◦ A chronic sense of feeling trapped.
◦ A vicious cycle of anger at parental-rejecting
behavior followed by anxiety that the fantasy will
destroy the tie with the parent.
◦ Failure of signal anxiety function in ego-related
disorder to self-fragmentation and sle-other
boundary confusion.
◦ Typical defense mechanisms: reaction formation;
undoing; somatization and externalization.
 Panic disorder runs in families.
 Poor regulation of several neurotransmitters
including norepinephrine, serotonin, GABA
and cholecystokinin
 Brain mechanisms:
◦ Amygdala
◦ Hypothalamus
◦ Hippocampus
◦ Periaqueductal gray
◦ Locus ceruleus – dysregulation of norepinephrine
systems
 Poor regulation in the locus ceruleus may
cause panic attacks which then stimulates the
limbic system, lowering the threshold for the
activation of diffuse and chronic anxiety.
 The hormone progesterone can affect the
activity of both serotonin and GABA
neurotransmitter system.
 Cognitive factors:
◦ People prone to panic attacks tend to:
 Pay very close attention to their bodily sensations.
 Misinterpret these sensations in a negative way.
 Engage in snowballing catastrophic thinking,
exaggerating symptoms and their consequences
 ◦ Defense mechanisms include: displacement,
projection and avoidance
◦ Environmental stressors including humiliation and
criticisms from an older sibling, parental fights, or
loss and separation from parents interact with
genetic –constitutional diathesis.
 A characteristic pattern of internal object
relations is externalized in social situations in
the case of social phobia
 ◦ Defense mechanisms include: displacement,
projection and avoidance
 Environmental stressors including humiliation
and criticisms from an older sibling, parental
fights, or loss and separation from parents
interact with genetic –constitutional diathesis
 ◦ Defense mechanisms include: displacement,
projection and avoidance.

 Environmental stressors including humiliation

and criticisms from an older sibling, parental
fights, or loss and separation from parents
interact with genetic –constitutional diathesis
 Psychodynamics:
◦ Worrying serves as a defensive function to avoid thinking
about more disturbing issues.
◦ Increased prevalence of past traumas is highly
characteristic.
◦ Link with an insecure/conflicted attachment in
childhood.
◦ The underlying conflict that creates the anxiety can be
related to any number of developmental themes.
◦ The unconscious conflict continues to be alive in self-
defeating patterns in relationships.
◦ Resistance is common in moving below the level of
symptoms to underlying symptoms of conflict.
 A 35-year-old woman who had witnessed her son's death
in an auto accident felt she could never get over what
happened. Much of her psychotherapy focused on her
repeated reexperiencing of the event, including vivid
nightmares that caused her to wake up crying. The
therapist repeatedly tried to get the patient to mourn the
loss of her child, but the patient steadfastly refused,
saying she did not know how to grieve and she did not
think she could ever get over it. The therapist interpreted
her wish to hang on the images of the son as a way of
avoiding the mourning. The interpretations fell on deaf
ears, and the patient continued to talk about the accident
and her feelings of guilt in connection with it. After
months of this repetitive interaction in the therapy, the
therapist began to feel angry and irritated at the patient
for thwarting all his attempts.
 He became more and more forceful in his efforts to
provide her with insight about how she was holding on to
the past. Finally, the patient experienced him as intrusive
and unsympathetic, and she shouted at him: “Would you
stop trying tomake me do what you want me to do and
just leave me alone?!” As the therapist reflected on this
outburst, he recognized that he had felt so helpless and
inadequate that he had had re-created an abusive
situation in the therapeutic relationship. The patient was
again feeling victimized, not only by the cruel hand of fate
in the death of her son and by the drunken driver who
killed him but also by the therapist himself. As this
fragment of a psychotherapy process reveals, many
patients with posttraumatic stress disorder present
formidable challenges to the psychotherapist:
 A 26-year-old single man was admitted to a psychiatric hospital with
obsessive-compulsive disorder because he had refused to cooperate
with pharmacotherapy and behavior therapy approaches. He was
obsessed with the concern that his father and mother might bring the
“AIDS virus” into the home, so he asked that everything be sprayed with
disinfectants. He also insisted that his parents wear gloves around the
house and specifically when handling his personal items or touching the
doorknob of his room. His parents had reluctantly complied with these
instructions because they feared his wrath when they did not go along
with him. When he arrived in the hospital, the young man became
concerned that the previous occupant of his room might have
masturbated and left semen stains in his room that could transmit HIV
infection to him. Even though the hospital staff tried to engage him in
discussions of other issues, he repeatedly wanted to get everyone to
discuss the possibility of human immunodeficiency virus (HIV)
contamination in the room.
 One nurse who was assigned to him was told each day not to
touch anything in his room unless he was wearing gloves.
Eventually, the nurse capitulated and began wearing gloves when
entering the patient's room. The nurse felt embarrassed about
this capitulation and tried to keep it secret from the other
hospital staff, but he was eventually discovered wearing gloves
when he emerged from the patient's room. The behavior led to a
useful discussion of counter transference in treating such
patients. It also led to a productive exploration of the patient's
entitlement. He was indignant when people did not comply with
his expectations. In this regard his hospital psychiatrist
confronted him with the observation that he tended to deny the
autonomy and subjectivity of anyone else in his life. All family
members and all treated were supposed to respond primarily to
his needs rather than their own needs. These confrontations
eventually helped the patient to recognize his omnipotent
control of others, and he began to withdraw his demandingness.
Discussion : This case example reflects how patterns of
relationships become internalized because of the specific
needs of the patient with obsessive-compulsive disorder. His
needs to avoid contamination became paramount over every
other concern in his environment. This pattern of omnipotent
control was internalized as his characteristic mode of object
relatedness. His admission into the hospital and the
recapitulation of that pattern of relatedness is an example of
the time-honored principle of psychodynamic hospital
treatment—namely, that the patient attempts to re-create his
family situation in the milieu of the hospital with various staff
members.
 This case also illustrates the extent to which significant
characterological issues may operate in concert with the
symptoms of obsessive-compulsive disorder. To some degree
the patient had everyone in his family waiting on him hand
and foot and doing exactly what he wanted them to do. He
was thus reluctant to enter into any treatment program that
might change his behaviors and loosen the hold he had on
his family. Studies have suggested that patients with
comorbid personality disorders in association with obsessive-
compulsive disorder are much more likely to terminate
behavior therapy and be classified as treatment resistant.