Understanding and Treating Anxiety Disorders

Anxiety disorders are the most commonly experienced psychological disorder in the world. In the United States, for example, approximately 18% of adults between the ages of 18 and 54 – approximately 40 million people – experience an anxiety disorder in a given year. Many of these individuals take medication (often times an antidepressant medication) to help with their condition.

Anxiety disorders generally involve a pattern in which an individual possesses a fear that either significantly interferes with their daily life or is endured in their daily life with significant distress. The mental health profession formally considers generalized anxiety disorder, phobias of various kinds (including agoraphobia and social phobia), obsessive-compulsive disorder, panic disorder, acute stress disorder, and post-traumatic stress disorder to be anxiety disorders. Other mental illnesses often involve the experience of significant anxiety as well, including hypochondriasis, eating disorders, depression, substance use disorders, and several personality disorders such as avoidant personality disorder, obsessive-compulsive personality disorder, and borderline personality disorder.

One of the best ways to conceptualize the psychology of anxiety disorders is through an understanding of classical conditioning principles. In general, in the acquisition phase of classical conditioning, an individual learns to associate a response (conditioned response) to a previously neutral stimulus (conditioned stimulus). This learning occurs because that previously neutral stimulus was associated with a stimulus (unconditioned stimulus) that automatically triggered a response (unconditioned response). Often times, this process may be very adaptive, as it helps to prepare individuals for potentially harmful stimuli. Many individuals with anxiety disorders, however, have generalized a conditioned response to a conditioned stimulus to the point where it impairs their functioning in daily life.

For example, when I used to work at the Veteran’s Hospital in Minneapolis, I worked with veterans diagnosed with post-traumatic stress disorder. Often times, they reported being in combat situations (unconditioned stimulus) that naturally elicited fear (unconditioned response). Certain stimuli often were associated with these situations, including loud noises or particular smells (conditioned stimuli) which, by themselves, became able to elicit fear as well (unconditioned responses). Although this might be helpful during times of war to help soldiers prepare for threat, many people generalize the process well beyond combat situations, often times years afterward. Many of my patients, for instance, would experience flashbacks if they encountered loud noises or smelled gunpowder. Many became hypersensitive to threatening situations. Naturally, this also led many to avoid situations that had the potential to evoke these kinds of fear responses. These symptoms often times significantly impaired their daily lives.

Thankfully, much of what can be learned can be unlearned as well. In classical conditioning, the extinction phase refers to a process in which individuals learn to distinguish between the conditioned stimulus and unconditioned stimulus. This is possible because the conditioned stimulus may be presented repeatedly without the unconditioned stimulus. For instance, if a soldier showed a post-traumatic response to the smell of gunpowder, they might be encouraged to smell gunpowder repeatedly outside of a combat situation. The individual would be expected to show a strong fear response initially, but eventually, they likely would learn that the gunpowder is not associated any more with danger, leading their fear to gunpowder to decrease.

For many people who struggle with anxiety, what they most fear is the experience of fear itself. I have had times in my life where this has been true for me and, though different from a classically conditioned response, I find behavioral exposure helpful for this as well. During times where I become sensitized to being anxious, I slow myself down and focus on the sensations of anxiety. For instance, I allow myself to experience a feeling of tenseness in my stomach or chest, quickened breathing, or a jumpy heart. When I do this, the experience of anxiety tends to fade, often after I realize that, though I don’t really prefer the sensation, it’s actually not that bad.

Clinical trials have shown that these applications of behavioral exposure very effectively treat various kinds of anxiety disorders. For instance, exposure is more effective than medication or other forms of psychotherapy. Furthermore, behavioral exposure seems to be an effective treatment even when the cause of an anxiety problem cannot be traced to the acquisition phase of classical conditioning.

One of the primary reasons why behavioral exposure works so effectively with anxiety disorders is that it counteracts the natural tendency people have to avoid what they fear. This kind of treatment conveys to people that they are capable of confronting their fear and, typically, provides an experience that supports this new, empowering belief.

Like all human behavior, anxiety responses cannot be understood through a single process; they are complex and multi-faceted. For example, some people who go through traumatic experiences will not develop post-traumatic stress disorder, perhaps because they are not as biologically predisposed to negative emotion, because of coping and social resources they possess that make them more resilient, because of lifestyle factors that minimize the effects of stress, or because of a “what if” negative thinking pattern. Some people who go through exposure therapy may not improve as much as others for these reasons as well. Yet, classical conditioning provides a framework for conceptualizing anxiety disorders that provides a significant contribution to understanding and treatment. Effectively applied, it might mean that many people who suffer from anxiety disorders, or who take medication to help them to cope, may be able to overcome their difficulties through natural processes.

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