Anxiety Disorders

Abnormal Psychology

Anxiety, which can also refer to a syndrome, is a mood response to an internal threat that could be the expectation of an external threat. It is an emotional response that is out of proportion with any genuine threat found in the environment. Furthermore, instead of being directed towards a current stimulus, anxiety is associated with the anticipation of a future problem. Anxiety differs from fear in that fea r is a response to an immediate external, genuine threat. Physiologically, the symptoms of anxiety accord to those for fear, including nausea, light-headedness, shortness of breath, and increased heart rate--the typical fight-or-flight response; yet when there is no genuine danger in the environment, these symptoms can be extremely aversive and stressful for the individual. Although personal distress can lead to functional impairment, the diagnostic criteria for the syndrome of anxiety disorders only requires that the individual experience grave personal distress. There are several diagnostic categories for anxiety disorders: panic disorder with or without agoraphobia, agoraphobia with panic disorder, obsessive-compulsive disorder ( OCD), specific phobia, social phobia, posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and generalized anxiety disorder.

Anxiety disorders, with a prevalence rate of 17 percent, represent the most common type of disorders. Regarding this prevalence rate, however, it must be noted that only about 25 percent of individuals suffering from a possible anxiety disorder seek treatment.

Specific and social phobias are the most common types of anxiety disorders, and generalized anxiety disorder and agoraphobia without panic disorder both have a prevalence rate of 3 percent. OCD has a prevalence rate of 2 percent and panic disorder has a point prevalence rate of 2 percent. Anxiety disorders are highly comorbid with each other and with mood disorders. All types of anxiety disorders except OCD are more likely to be found among women than men, and among the young than the elderly. Cross-cultural differences seem to affect the focus or content of typical anxiety complaints. From a historical perspective, individuals with anxiety disorders have not recei ved much attention from the medical community, since anxiety disorders seldom require institutionalization. Sigmund Freud and proponents of his theories, which focus on mental conflicts and innate biological impulses, were among the first to describe and classify anxiety disorders. According to Freud, anxiety has a very adaptive purpose of signaling to an individual that he or she is about to engage in an act previously associated with punishment and disapproval. This signal anxiety leads to ego defense mechanisms such as repression, which prevents the individual from recognizing consciously the forbidden impulse and from acting on the impulse, thus resulting in conformity to societa l rules and a decrease in anxiety. Nevertheless, if the level of pathological anxiety is too intense, extreme, or overwhelming, this could result in additional defense mechanisms that result in such disorders as compulsions and phobias. Regardless of the specific defense mechanism used, according to Freud, the underlying process remains the same for all types of anxiety disorders.

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Terms

Acute Stress Disorder (ASD) - A category of mental disorders defined by the DSM- IV as a reaction occurring within four weeks following a traumatic event and which is characterized by dissociative symptoms, avoidance, reexperiencing, and marked anxiety or arousal.

Agoraphobia -An irrational or abnormal fear of being in a situation where escape might be difficult. Literally meaning "fear of the marketplace," this disorder is sometimes described as fear of open or public places.

Anxiety -An emotional response that is out of proportion with any genuine threat in the environment. In addition, anxiety, instead of being directed towards a current stimulus, is usually associated with the anticipation of a future problem.

Anxiety Disorders -The class of mental disorders, including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, phobias, acute stress disorder, and posttraumatic stress disorder, in which fear or anxiety is the most prominent symptom.

Anxious Apprehension -A term coined by the psychologist David Barlow which is used to describe a maladaptive type of anxiety that consists of a focus on negative emotions, perceptions of lack of control, and a constant state of self-preoccupation.

Attention -A process wherein mental activity is focused along a specific track, regardless of whether this track consists of inner memories and knowledge or is centered around an external stimulus.

Avoidance -An important component of the definition of a phobia, avoidance is characterized by evasion of the anxiety-inducing or feared stimuli, even if it entails utilizing extreme or irrational methods.

Benzodiazepines (Antianxiety Drugs) -A group of drugs, such as diazepam (Valium) and alprazolam (Xanax), which show an affinity for receptor sites normally associated with the neurotransmitter gamma-aminobutyric acid (GABA). Minor tranquilizers, or benzodiazepines, which have a potent hypnotic, sedative, and anxiolytic (anxiety relieving) action, inhibit the activity of the GABA neurons. Side effects of these drugs (which are subdivided into two categories based on their rate of absorption and elimination from the body) include sedation, followed by mild cognitive and psychomotor impairments, and more seriously, the possibility of addiction.

Cingulum -A marked fiber bundle passing longitudinally in the white matter in the cingulate gyrus (a structure found on the medial surface of the cerebral hemispheres) and extending from the region of the anterior perforated substance back over the dorsal surface of the corpus callosum (the bridge of nervous tissue that connects the right and left hemispheres of the brain). More importantly, it contains association fibers connecting various gyri with the frontal cortex, and the various subdivisions within the gyri.

Clark's Cognitive Model of Panic Disorder-A theory proposed by David Clark that hypothesizes a possible psychological basis of panic disorders. According to Clark, panic disorders result from a gross misinterpretation of bodily sensations. Regardless of whether or not the trigger stimulus is an external or internal stimulus, the panic attack is associated with a cognitive misinterpretation of a biological reaction.

Compulsion - Repetitive, ritualistic behavior or mental acts that a person, although he/she realizes that the act is senseless or irrational, feels driven to perform either because it reduces stress or prevents some dreaded outcome.

Control Group -In an experimental design, the group of participants who are not manipulated. This means that the control group, unlike the experimental group, which receives an active treatment, does not receive any form of treatment or may be given a placebo treatment.

Displacement -A type of defense mechanism wherein unconscious and unacceptable feelings, wishes, or actions are transferred from one person or object to another that is less threatening, and therefore more acceptable.

Evolutionary Preparedness -A theory proposing that certain mechanisms and experiences of learning are based on, and in fact may depend on, the existence of "prepared," or biologically predetermined, associations between stimuli.

Exposure Habituation -A type of non-pharmacological treatment of anxiety disorders wherein individuals are exposed to the anxiety inducing stimuli, but then they allow the anxiety to pass and to let the body return to a normal, calmer state without engaging in any anxiety-reducing acts. In this type of intervention, the procedure is attempting to break the negative reinforcement paradigm, by allowing the fight/flight response to simply pass.

Fear -An unpleasant emotional reaction experienced in the face of real, immediate danger. Fear usually builds quickly in intensity and helps to organize the body's responses to possible external threats.

Fight-or-Flight Response -A series of psychophysiological reactions, such as increased heart rate and shortness of breath, that prepare the body to take action against possible threats or dangers in the environment.

Generalized Anxiety Disorder -One of the anxiety disorders characterized by severe, excessive, prolonged, and uncontrollable worry about a number of events or activities, but is not consistently associated in the individual's mind with any particular object or event in the environment or any specific life experience. Symptoms of arousal are also associated with this disorder.

Insecure Attachment - In the field of developmental psychology, a term used to describe infants who display either avoidant or anxious behavior towards their caregiver (too attached or not attached enough).

Isolation -A defense mechanism, a process wherein a memory or an idea is separated from its emotional component.

Modeling Coping -A social learning technique similar to modeling mastery, wherein an approach to anxiety-inducing stimuli is presented without the expression of anxious symptoms. In this exposure-by-proxy procedure, however, the dimension of coping mechanisms, such as deep-breathing exercises and relaxation techniques, is also introduced.

Modeling Mastery -A social learning technique wherein an approach to anxiety-inducing stimuli, without the expression of anxious symptoms, is presented. This exposure-by- proxy procedure, therefore, breaks the pattern of negative reinforcement by showing that nothing bad is prevented by anxiety responses.

Negative Reinforcement -In operant conditioning, the process which occurs when the cessation or decrease of a stimulus, such as anxiety, increases the likelihood of that behavior being repeated (a compulsive act, for instance). In other words, negative reinforcement is the condition in which a particular response results in the removal of a negative reinforcer.

Obsession -Recurrent, persistent thoughts, images, or impulses that are experienced as intrusive and which the individual cannot stop from occurring. The individual realizes that these unwanted and generally unpleasant cognitive events, which usually lead to an increase in subjective anxiety, are a product of their own mind.

Obsessive-Compulsive Disorder (OCD) -A disorder characterized by a repeated, disturbing, irrational mental act that increases levels of anxiety and can then only be alleviated (temporarily) by performing some repetitive action or ritualistic behavior.

Panic Attack -A major characteristic of panic disorders, panic attacks are a sudden, overwhelming experience of terror or fright, which is much more focused than anxiety.

Panic Disorder -A psychosomatic disorder characterized by a preoccupation with pain, but differentiated from somatoform disorders in that panic disorder consists of an inherent psychological component. Panic disorder is characterized by the presence of attacks that seemingly come out of nowhere and are not precipitated by the threat of some external stimulus. For one month following the attack, one of these symptoms must be experienced for the individual to meet the diagnostic criteria of panic disorder: there must be implications of the panic attack; persistent concern of having another attack; and a significant change in behavior in response to the attack.

Perception of Control -A social theory proposing that individuals who believe that they have power and control over the events that occur in their lives and in the environment are generally less vulnerable to developing certain types of disorders, such as anxiety disorders.

Phobia -A persistent or irrational fear that is associated with the presence or anticipation of a specific object or situation.

Positron Emission Tomography (PET) -A visual display of brain activity that is based upon the uptake and distribution of a radioactive form of oxygen into active areas of the brain.

Posttraumatic Stress Disorder (PTSD) -A psychological disorder that is directly and explicitly associated with the experience of a particular traumatic incident or set of incidents and that is characterized by recurring symptoms of numbing, reexperiencing, and hyperarousal following exposure to some traumatic stressor. In addition, in contrast to ASD, PTSD usually lasts longer and has a delayed onset.

Psychosomatic -Pertaining to the influence of the mind or of higher cognitive functions of the brain, such as emotions, fears, and desires, upon the functions of the body, especially in relation to diseases or bodily disorders. The term "psychosomatic disorder," therefore, describes a physical disease that is a product both of the psyche and of the body.

Reaction Formation -A type of defense mechanism wherein the mind turns a painful, unacceptable, or frightening thought or wish into its safer opposite.

Repression -A type of defense mechanism wherein the mind prevents anxiety-provoking or threatening thoughts from becoming conscious.

Retrospective Studies - A study based on the individual's recollections about past experiences. These types of studies are often criticized for their lack of reliability and validity.

Self-Fulfilling Prophecy - A process by which the expectation or belief of a certain outcome, whether initially true or false, may conform or affect behavior and performance in such a manner that it creates the reality. (Also called the Pygmalion Effect.)

Social Phobia -Any type of phobia, such as fear of public speaking, wherein the basic fear is of being placed in a social situation that would require scrutiny or evaluation by other people.

Specific Phobia -Any phobia characterized by fear of a well-defined category of objects, such as snakes or environmental situations (excluding other people).

Tourette's Syndrome -A rare disorder characterized by repeated motor and verbal tics.

Trichotillomania -A compulsion to pull out one's own hair.

Undoing -A defense mechanism through which an individual reacts to an psychologically unacceptable event by unconsciously attempting to reverse the act by doing its opposite, usually repetitiously, to relieve anxiety.

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Social-Cultural Etiology of Anxiety Disorders

Studies have shown that like depression, stressful life events can serve as a precursor to the onset of anxiety disorders. Unlike depression, however, where the nature of the stressor is centered on loss, anxiety disorders seem to be associated with environmental circumstances concerning danger or insecurity.

For example, serious interpersonal conflicts seem to be associated with the presence of agoraphobia. Similarly, individuals suffering from panic disorder report higher instances of childhood adversity, such as abuse and parental indifference, while individuals with agoraphobia and specific phobias were indistinguishable from the control group on the scale of childhood adversity. Attachment difficulties in childhood with one's caretaker have also been implicated as an influence, or risk, of developing anxiety disorders in adulthood, especially agoraphobia. A relationship of insecure attachment with their caretakers has been reported by many individuals suffering from anxiety disorders. Yet, as with all retrospective studies (which are usually subjective and lacking in accuracy and reliability), one must be hesitant to attribute a causal relationship between childhood attachment and adult anxiety disorders until longitudinal studies can be conducted to test these hypotheses. (However, interestingly, one such study found that whereas a strict and moral or religious upbringing was more likely to decrease the risk of an individual committing suicide, this same environment increased the likelihood that such individuals would develop OCD.)

Culture is also a factor, tending to shape the content of individuals' obsessions in particular disorders (such as OCD).

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Psychological Etiology of Anxiety Disorders

One of the most important cognitive factors that may influence the development of anxiety disorders is the concept of perception of control. Empirical evidence supports the assertion that people who feel they are more able to control events in their environments are less likely to develop some type of anxiety disorder. One experiment involving people with panic disorder, in particular, performed by Sanderson, Rapee, and Barlow, found that the individual's illusion of control served as a good predictor of whether or not the person would experience a panic attack. Another important psychological paradigm that has been proposed to explain the causes of panic disorders was proposed by David Clark. According to Clark, panic disorders result from a gross misinterpretation of bodily sensations. Regardless of whether or not the trigger stimulus is an external or internal stimulus, the panic attack is associated with a cognitive misinterpretation of a biological reaction. Support for Clark's cognitive model of panic disorder comes from laboratory studies wherein attacks are induced in individuals with panic disorder by increasing the amount of carbon dioxide in the room or injecting chemical lactate into the patient, both of which are known to produce such physiological reactions as lightheadedness and increased heart palpitations. People without panic disorder, therefore, experience the same autonomic responses as individuals with the disorder, but do not attribute the same cognitive reasoning. In a type of self-fulfilling prophecy, then, the thought of the perceived threat becomes the problem and leads to the onset of the attack.

Attention has also been shown to play a role in the etiology and maintenance of some anxiety disorders, such as social phobias. Basically, individuals who are prone to worrying develop complicated cognitive strategies to cope with and avoid signals of future or anticipated threats. They become overly sensitive to cues that signal a potential threat and, therefore, although maladaptive, exist in a state of anxious apprehension that temporarily relieves psychological discomfort associated with the physiological symptoms. The problem, however, with attentional processes, is that the individual learns to focus on the negative associations between the thought and their emotional response and attempts to suppress the thought instead of relying on productive coping mechanisms and focusing on the external aspects of the problem. Obsessive-compulsive disorder, then, for example, could be seen as the result of a maladaptive process to control, or suppress, unwanted or threatening thoughts. Individuals prone to OCD, like other normal people, occasionally have bizarre or abnormal thoughts, but they differ in that they then tend to overreact. Distressed by their exaggerated reaction, a vicious cycle begins wherein the OCD individual will attempt to suppress the thought, but, in a type of rebound effect, their attempt to avoid such thoughts leads to an obsession with that specific thought. Evidence suggests that a type of classical conditioning occurs, wherein the emotional state and the thought the individual is trying to suppress, anxiety and the forbidden thought, become linked. Operant conditioning may also be at work in OCD because when the individual performs the act, their anxiety goes down and they are therefore more likely to repeat the behavior; a type of negative reinforcement.

Psychoanalytic theory also provides a possible explanation of OCD. Psychologists within this group believe that the potential for developing OCD becomes fixed during the anal stage of development. Around the age of two years old, when the id impulse is very destructive and gains pleasure from destroying things, and especially if parents are too strict with toilet training, the child develops, at an unconscious level, rage against the parents and a desire to kill them. This thought is very frightening and untenable to a person of any age; in order to deal with the conflict between the id and the ego, the individual may develop four defense mechanisms: isolation, displacement, reaction formation, and undoing, which express themselves in the form of the OCD paradigm. Individuals who suffer from OCD are therefore trapped in this stage of development.

Finally, some phobias may be learned by observing and imitating the behavior of other individuals. Vicarious learning and direct experience have both been shown to increase the potential for developing negative associations between stimuli. One experiment, conducted by Mineka and Cook, demonstrated that rhesus monkeys learn to selectively fear certain stimuli such as snakes by observing the behavior and reaction of wild monkeys. Yet, this study also demonstrated that the learning was selective, in that there had to be a possible evolutionary prepared association of the snake, or crocodile, as relevant to fear: the behavior was not reproduced for fear-irrelevant stimuli, such as kittens, which points to a biological basis of modeling.

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Biological Etiology of Anxiety Disorders

Family studies not only indicate a strong genetic influence in the development of anxiety disorders, but also support the current classification system used by the DSM-IV. There is a high rate of panic disorder and depression among the families of individuals with panic disorder, leading to the conclusions that some individuals inherit a genetic predisposition to panic disorder, and that panic disorder and depression share some etiological considerations. Furthermore, family studies indicate that there is an increased risk that specific types of anxiety disorders will be genetically transmitted. This means that if there is a history of generalized social phobia in a family, an individual has a greater chance of inheriting social phobia (but not any other type of anxiety disorder). OCD is the only form of anxiety disorder where there is a predisposition to inherit an anxiety disorder and not OCD specifically. Twin studies indicate that anxiety disorders are moderately heritable. Although the concordance rates of monozygotic twins were higher than that of dizygotics, the numbers were relatively low, except for agoraphobia. The evidence from twin studies point to several interesting conclusions concerning the genetic risk for anxiety disorders. The genetic risk factors for these disorders are neither highly specific nor non-specific; one genetic factor was found which associated generalized anxiety disorder with depression, and another associated panic disorder with social phobias.

Finally, not only do unique environmental factors play a role in the etiology of these disorders, but also some environmental risk factors were specific to certain disorders. Neurological studies have found that there is increased activity in the anterior portion of the temporal lobe, an area associated with fear and emotions, in individuals suffering from panic disorder. Similar studies have also found that some patients with panic disorder also exhibit dysfunctions in the regulation of their norepinephrine system--but these results are mixed. Hormonal shifts, such as in the production of estrogen and progesterone, seem to play a role in the strength of the expression of OCD. There may also be a genetic link between Tourette's syndrome and OCD, and OCD and trichotillomania. Lastly, PET scan studies have discovered an over-activity of cingulum bundles, associated with the severity of the disorder, in the orbital prefrontal cortex. Support for this comes from the fact that symptoms can be alleviated through a surgical procedure known as cingulotomy, which destroys the axons connecting the prefrontal and cingulate cortex with the limbic cortex of the temporal lobe.

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Panic Disorder

Panic disorder is a psychosomatic disorder characterized by a preoccupation with pain, but can be differentiated from the somatoform disorder in that panic disorder consists of an inherent psychological component. The attacks must come out of nowhere and cannot be precipitated by the threat of some external stimulus. For one month following the attack, one of these symptoms must be experienced: there must be implications of the attack, persistent concern of having another attack, and a significant change in behavior in response to the attack. Behavioral psychologists would say that this is a type of conditioning response, wherein associations develop between the attack and certain environmental circumstances, such as the place where the attack occurred. The symptoms of a panic attack consist of heart palpitations, dizziness, nausea, trembling/shaking, shortness of breath/smothering, fear of dying, numb tingly sensations, chills/hot flashes, fear of losing control/going crazy, derealization/depersonalization, sweating, chest pains/discomfort, and choking. The individual must experience at least four of these symptoms to meet diagnostic criteria for panic disorder.

"Panic disorder with agoraphobia" describes the anxiety of being in a place or situation where escape will be unlikely. Those situations or places are avoided or endured with intense anxiety. Avoidance and distress are essential elements of the definition, and an individual may go to great lengths to avoid the situation or insist on the presence of another individual who can provide comfort and security. If a person meets the criteria for agoraphobia and not the criteria for panic disorder, then the individual is diagnosed as having agoraphobia without a history of panic disorders. The prevalence of panic disorders ranges from 1.5 to 3.5 percent of the population. One third of the individuals with panic disorder have agoraphobia. Women are twice as likely as men to have panic disorder without agoraphobia and three times as likely as men to have panic disorder with agoraphobia. These gender differences may be accounted for by the fact that it is easier to explain, and viewed as more acceptable socially, for women to be housebound. Furthermore, 95 percent of individuals who have agoraphobia also suffer from panic disorders, and the other five percent probably have some other form of anxiety disorders. The age of onset for panic disorder ranges from adolescence to mid-thirties.

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Obsessive-Compulsive Disorder

The core features of OCD are the presence of either obsessions or compulsions, but not necessarily both. There might be patterns of anxiety with compulsions, but not necessarily obsessions. Obsessions can be characterized as recurrent, persistent thoughts, images, or impulses that are experienced as intrusive. The individual is unable to get rid of them. Furthermore, the person must recognize that they are unreasonable and that these thoughts are a product of their own mind (an essential element that distinguishes obsessions from delusions). The two most frequent types of obsessions are the fear of contamination, of being infected by dirt or germs, and the fear of causing harm or injury to others.

Compulsions are repetitive behaviors or mental acts that the person feels driven to perform either because it reduces his or her distress or because it prevents some dreaded outcome. There does not have to be a realistic or logical connection between the compulsive behavior or act performed and the outcome intended to be avoided. It is, instead, a divorcing from rational thought and emotional experience. The most popular compulsions are washing, checking, counting, and praying. Many times, the behavior does not necessarily increase risk of death, but it can cause extreme personal distress and functional impairment. If an individual spends more than an hour a day on the compulsion or obsession, and is therefore incurring great costs to their opportunity and livelihood, he or she meets the DSM-IV criteria for the disorder. The prevalence rate for OCD is about 2.5 percent of the population, and there are no gender differences in the risk for developing OCD. There are, however, gender differences in age of onset of the disorder, however, with the age of onset for men typically falling between six years of age and fifteen, while it ranges from twenty to twenty-nine years of age for women.

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Phobias

A phobia can be described as a persistent and irrational fear that is associated with the presence or anticipation of a specific object or situation. Avoidance, as in agoraphobia, is an important component of the definition of a phobia. AS in the case of OCD, the individual must realize that the fear is uncommon in order to meet diagnostic criteria. Yet, unlike OCD, both personal distress and functional impairment must be present. Social phobias are centered on the persistent fear of social situations that might expose the individual to scrutiny and evaluation by others, such as a fear of public speaking. There are four types of specific phobias: animal, natural/environmental, blood injection-injury type, and situational type. The difference between environmental and natural centers on whether or not the situation is simply encountered as part of nature or whether it is man-made. The age of onset for developing phobias ranges from very young to childhood. The likelihood of women developing phobias is about 75 to 90 percent higher than males in all except for the blood injection-injury type. These gender differences may be accounted for by the sociological consideration that it is more acceptable for women to have phobias than men. To explain the exception in the case of blood injection-injury type phobias, women are usually more often exposed to blood (such as during monthly periods of menstruation) than men, and are therefore less likely to develop a fear of blood. About 10 percent of the population suffers from some type of social or specific phobia.

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Treatment of Anxiety Disorders

Medication is currently the most effective and most common form of treatment of anxiety disorders. Minor tranquilizers known as benzodiazepines, such as diazepam (Valium) and alprazolam (Xanax), are the most common forms of biological intervention used in conjunction with psychological intervention. Benzodiazepines show an affinity for receptor sites normally associated with the neurotransmitter gamma-aminobutyric acid (GABA). The benzodiazepines, which are subdivided into two types based on their rate of absorption and elimination from the body, inhibit the activity of the GABA neurons. Side effects of benzodiazepines include sedation, followed by mild cognitive and psychomotor impairments. The most serious side effect of this class of drugs is the threat of addiction. Tricyclic antidepressants, such as imipramine (Trofanil) and Clomipramine (Anafranil), are another class of drugs that have proven effective in treating anxiety disorders, especially OCD. These anti-depressants have severely aversive side effects such as dry mouth, weight gain, and, ironically, symptoms resembling those of a panic attack, such as heart palpitations, which leads some individuals to stop using them. Yet the chances of the individual becoming dependent on them are lower those associated with becoming addicted to benzodiazepines. And again, similar to depression, SSRI's, such as fluvoxamine (LuVox) and fluoxetine (Prozac) have been shown to be effective in treating anxiety disorders. With all of these drugs, relapse rates significantly increase if their use is discontinued. The most effective drugs for treating panic disorder are imipramine (Trofranil) and alprazolam (Xanax). The most effective treatment for agoraphobia is imipramine (Trofanil) and individuals with generalized anxiety disorder respond best to alprazolam (Xanax) or diazepam (Valium). Propranolol (Inderal) is used to treat social phobias, whilst clomipramine (Anafranil) and fluoxetine (Prozac) are effective forms of treatment for OCD.

There are six main types of non-pharmacological interventions in the treatment of anxiety disorders. Firstly, exposure- response prevention consists of exposure to the anxiety-causing object or circumstance without allowing an avoidant or compulsive response. This helps to break the pattern of negative reinforcement of anxiety responses. Exposure habituation procedures are intended not only to break the negative reinforcement paradigm, but they also allow the fight/flight response to pass. In this type of intervention, individuals are exposed to the anxiety-inducing stimuli, but then they allow the anxiety to pass and to let the body return to a normal, calmer state. In systematic desensitization, an inconsistent response, such as muscle relaxation, is paired with exposure to the feared stimuli in progressively challenging steps. This also breaks the negative reinforcement pattern and decreases the fight/flight response. Instead of being progressively introduced to more frightening stimuli, some individuals undergo a technique known as flooding, which involves beginning with exposure to the most feared stimuli. Cognitive therapy, which involves cognitive restructuring, focuses on making the individual aware of the maladaptive associations between behavior and thought. It teaches patients to reinterpret the anxiety symptoms as non-catastrophic. Since it decreases the misinterpretation of the bodily reactions, this form of therapy also decreases the physical levels of arousal. Modeling mastery is a technique wherein an approach to the anxiety-inducing stimuli without anxiety is presented. For instance, if a therapist were dealing with a patient who is afraid of spiders, the therapist would put a spider on his or her arm to show the patient that it is no big deal. This is considered a form of exposure-by-proxy that breaks the negative reinforcement of anxiety responses by showing that nothing bad is prevented by anxiety responses.

Finally, modeling coping is a procedure similar to modeling mastery, except with the added dimension of coping mechanisms. This is a much more realistic and effective form of treatment than modeling mastery since it acquiesces that although the individual may experience some difficulties, he or she does have the ability to perform the act. Cognitive therapy is the most effective non- pharmacological treatment for panic disorder and agoraphobia. Individuals with agoraphobia, like people suffering from specific phobias, also benefit from exposure-in-vivo techniques, such as flooding. Generalized anxiety disorder responds best to cognitive therapy and applied relaxation techniques, while social phobias are best treated by a combination of cognitive therapy and social skills training. Lastly, exposure plus response prevention has been the most effective non-pharmacological treatment for OCD. Again, all of these forms of therapy work best in conjunction with medication.