____________________________________________________________________________ Anxiety Disorders
Another coping mechanism observed in persons with anxiety disorder is safety signals, defined as the people or objects used to diminish distress in situations that elicit anxiety. Safety sig- nals are also potentially counterproductive; they offer immedi- ate relief but facilitate persistence of the anxiety disorder over time by preventing direct confrontation of feared stimuli in the absence of “safe” objects/people and by maintaining percep- tions of risk/harm and coping inability. A patient’s continued use of safety signals impedes therapeutic progress, in particular the response to exposure therapy. However, safety behaviors may be helpful early in treatment by making exposure therapy more tolerable and less threatening [1]. PRIMARY FEATURES OF ANXIETY AND RELATED DISORDERS The distinguishing features of specific anxiety disorders are summarized in the following section. Related conditions of post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD) are included because, although no longer classed as anxiety disorders by the 2013 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), they are often included in research that pre-dates 2013 and can co-occur with anxiety disorders [2]. Situations or objects that evoke intense anxiety in patients with agoraphobia, social anxiety disorder, or specific phobia are either avoided or endured with significant personal distress. Generalized Anxiety Disorder Generalized anxiety disorder (GAD) is characterized by repeti- tive thinking and intrusive worrying about potentially harmful future events that is persistent (lasting more than a few months) and not restricted to circumstances [3]. While recognizing that some degree of worry may be helpful, patients with GAD report experiencing excessive, uncontrollable worry causing distress or impairment. These patients have physical anxiety symptoms and key psychologic symptoms (i.e., restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and disturbed sleep). GAD is often comorbid with major depression, panic disorder, phobic anxiety disorders, health anxiety, and OCD [3]. Panic Disorder Panic disorder is characterized by recurrent unexpected surges of severe anxiety (“panic attacks”), with varying degrees of anticipatory anxiety between attacks [3]. Panic attacks are characterized by sudden onset of intense fear (terror) accompa- nied by such symptoms as uncontrollable trembling, sweating, palpitations, dizziness, shortness of breath, numbness and tingling, and chest pain. These attacks are often incapacitat- ing, typically peak within 10 minutes and last around 30 to 45 minutes. Most patients also develop a fear of having future panic attacks, which is considered a key element in classifying such episodes as panic disorder [3].
INTRODUCTION Anxiety is an extreme form of worry, life’s adaptative response to perceived impending physical and emotional threats both large and small; as such, anxiety focuses attention and, if necessary, prompts one to prepare for “fight or flight.” Small moments of anxiety are useful and expected in the course everyday life; such experiences are transient, having no sig- nificant impact on social and occupational activities. Anxiety disorders are maladaptive forms of excessive apprehension and fearfulness—taxing, counter-productive, robbing life of its productivity and joy. Anxiety disorders are characterized by several distinct clinical patterns that share a common refrain: acute exacerbation and chronic states of excessive worry and apprehension around otherwise normal circumstance and everyday situations. Anxiety syndromes include fearfulness in response to social and performance expectations, situational and triggered panic attacks, general (anticipatory) anxiety states, and avoidance (safety) behaviors. The diagnosis of anxiety disorder requires that the patient has experienced a certain number of symptoms or symptomatic episodes for more than a minimum specified period, causing significant personal distress and impairing everyday function [3; 350]. Anxiety disorders are thought to develop from the interaction of genetic predisposition in the face of perceived overwhelming challenges to self—biopsychosocial stress or trauma that leads to clinically significant syndromes. The influence of hereditary factors and adverse psychosocial experiences on pathogenesis and pathophysiology is complex, but neuroscience advances have greatly improved the understanding of the underlying fac- tors in the development and maintenance of anxiety disorders.
BACKGROUND
SAFETY BEHAVIORS AND SIGNALS Safety behaviors are coping tactics used by persons with anxiety disorders to prevent, escape from, or diminish the severity of a perceived threat. Safety behaviors are particularly common in persons with panic disorder, agoraphobia, and social anxiety disorder. These behaviors emerge in response to external (e.g., situations, persons, activities) and/or internal (e.g., thoughts, emotions, memories) foci of perceived threat and are either anticipatory (avoidant) or consequential (escape) [1]. While safety behaviors may provide some measure of immediate relief, they have no impact on the individual’s propensity for anxiety, nor do they diminish the frequency and severity of future symptomatic events. However, assessment of safety behavior provides guidance for implementing targeted interventions, and accurate assessment and elimination of safety behaviors is often necessary to maximize treatment of clinical anxiety [351].
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