Acceptance & Commitment Therapy for Anxiety Disorders

Chapter 2

Overview of Anxiety Disorders

When you change the way you look at things, the things you look at change.

—Wayne Dyer

In this book we focus on the features and processes that all anxiety disorders share rather than on the differences between them. Nonetheless, at the beginning of this book it may be useful to review the features that have come to define the most common anxiety disorders, including the latest data on the prevalence and demographics of such problems. We also present some commonalities and differences between disorders in terms of both symptom presentation and the core processes underlying disordered anxiety.

Anxiety and Efforts to Control It Are Ubiquitous

Despite some nuances, anxiety disorders are ubiquitous and can be found in all ethnic groups, countries, and cultures. In fact, anxiety disorders are among the most prevalent psychological disorders, affecting up to 25 percent of the general population at some point in their lifetime (Kessler et al., 1994). The core processes that contribute to such disorders—avoidance, escape, and other control tendencies to manage unpleasant emotions—are particularly common in Westernized countries. For instance, most of us learned early on to avoid touching a red-hot stove because it hurts. Some of us learned this the hard way, and others by listening to our parents or caregivers warn us about the consequences. We also learn how to manage physical pain when it comes and are socialized to use physical and psychological pain and suffering as reasonable reasons for our behavior and that of others. For instance, it is acceptable to miss a day at work or school for feeling ill, but it is not acceptable to miss a day of work or school for feeling full of life.

Through multiple examples such as this, we also learn to apply the very same control strategies to our thoughts, memories, and emotions—particularly to those that are unpleasant or painful. Anxiety and fear become much like the hot stove, and our behavior with respect to them must be managed somehow. Yet, the sensible strategy of dealing with potential sources of real pain and harm rarely works in the same way when applied to our thoughts and emotions. We can’t turn them on or off in the same way we can move our hand on or off the hot stove. Our thoughts and feelings are with us wherever we go. We cannot escape or avoid them. They are part of us.

Anxiety Disorders Are Expensive

Barlow (2002) summarized the human costs of anxiety disorders as follows:

In our society, individuals spend millions of dollars yearly to rid themselves of anxiety. The costs of visits to primary care physicians, and the utilization of health care services in general by individuals with anxiety disorders, are double what they are for those without anxiety disorders, even if the latter are physically ill. (p. 1)

People with panic disorder are indeed more likely to seek help for their problem than those with any other psychiatric diagnoses (including schizophrenia). Moreover, compared to people with other emotional problems, individuals with anxiety disorders are the highest users of emergency room services (Eifert, Zvolensky, & Lejuez, 2000; Eifert & Zvolensky, 2004). In addition, most anxiety disorders tend not to go away by themselves if left untreated. Instead, they tend to stay the same or get worse over time until people reach their fifties, with an increasing negative impact on quality of life for affected individuals and their families.

With high prevalence and chronicity, it is no surprise that anxiety disorders are associated with enormous personal and social costs as well as substantial economic costs. In fact, as Barlow (2002) aptly noted, “the actual expenses dwarf even the most pessimistic estimates … In recent years, anxiety disorders accounted for 31 percent of total costs of mental health care, compared to 22 percent for mood disorders and 20 percent for schizophrenia” (p. 26). Counting both the direct costs of services and lost productivity, the total annual costs of anxiety disorders in the United States are estimated at approximately $45 billion, with only 30 percent of that amount stemming from psychological and psychiatric treatment. In fact, over 50 percent of the costs come from excess (mostly unnecessary) utilization of primary health-care services. A number of studies have reported that the cost savings of effectively treating anxiety disorders far outweigh treatment costs. Not treating an anxiety disorder is ultimately more expensive than providing appropriate treatment (for a more detailed discussion, see Barlow, 2002).

Nature and Function of Fear and Anxiety

The nature and function of fear and anxiety teach us much about the core processes involved in “abnormal” or disordered anxiety. When we seek to understand the predicament of individuals with anxiety disorders, it is particularly important to consider the strong and mostly adaptive urge to escape from situations that elicit fear.

Fear—The Present-Oriented Basic Emotion

Fear is a present-oriented state that occurs in response to real or imagined danger or threat. Some of these threats are present in the here and now (e.g., a situation that is dangerous or distressing), others are in response to what is going on inside the client (e.g., a disturbing physical sensation, a thought, or a memory of the past), and some are a combination of these. Fear is typically characterized by an abrupt and acute surge of the sympathetic branch of the autonomic nervous system, accompanied by intense physiological changes (e.g., increased perspiration, rapid heartbeat, breathlessness, increased blood pressure) and a powerful action tendency to fight or flee from signs of threat or danger. Fear is also associated with greater vigilance and a narrowing of attention so that the individual’s attention stays focused on the event that elicits the fear (Barlow, 2002). Under most circumstances, fear is perfectly adaptive because it serves an important function: it motivates and mobilizes the individual to take defensive action. Both the physiological and psychological changes that are associated with fear are designed to maximize the behavioral effectiveness of the individual to avert the threatening event.

Anxiety and Worry—The Future-Oriented Emotions

Anxiety, by contrast, is a future-oriented mood state that is accompanied by anxious apprehension, worry, increased muscle tension, restricted peripheral autonomic arousal, and marked increases in EEG beta activity reflecting intense cognitive processing in the frontal lobes (Borkovec, Alcaine, & Behar, 2004; Craske, 1999). Several studies have shown that people who are chronic anxious worriers show less physiological responsivity than people with phobic disorders (Roemer & Orsillo, 2002). Indeed, autonomic physiological changes associated with anxiety are much less pronounced and dramatic compared with fear. This may be due, in part, to the future-oriented and largely verbal-symbolic nature of anxiety. That is, people are typically anxious about something that may happen in the future, whereas people experiencing fear are afraid of what is happening right now. As an example, anxiety would be a more typical response to the thought of the possibility of living through an earthquake and its aftermath, whereas fear would be the more typical response when the earth is actually shaking. Behaviors that are most closely associated with anxiety are largely verbal or cognitive (e.g., worrying and making plans), whereas behaviors most closely associated with fear involve overt behavioral actions such as escaping, fighting, or freezing.

The Function of Normal Fear and Anxiety

Fear is an alarm response that makes us take some type of protective action when our safety or health appears to be threatened. These types of actions are in some cases reflexive and occur on an unconditioned (unlearned) basis, as when we close our eyes and turn our heads sideways in response to an object that flies toward us. In other cases, these actions occur on a learned (conditioned) basis, often with the help of language. Thus, when we take evasive action and jump to our left because someone shouts “danger on your right,” we are doing so, in part, because of language learning. Even anxiety and worry about some future event that could threaten our livelihood can be useful and adaptive. For example, a bout of worrying can help us put together an action plan so as to more effectively respond to potential threats to our health, employment, safety, or the welfare of our family. In some instances, such plans need to be quite elaborate so that we can respond effectively when we are faced with an actual threat. A good example of such plans would be a family coming up with a plan in the event of a house fire.

Avoidance Makes Anxiety Problematic or “Disordered”

Thus, experiencing fear and anxiety is in many instances healthy and adaptive. Both emotions serve a purpose, namely, to keep us out of trouble and alive. This, by the way, is also an important fact to convey to clients in the beginning of a treatment program. Physical sensations, thoughts, and actions that accompany fear and anxiety are not abnormal or disordered per se. This is true even when fear and anxiety occur with great intensity. It is true even when fear and anxiety occur on a learned basis in response to a trauma. Consider, for instance, a client who has been bitten by a pit bull and subsequently experiences a strong fear response when encountering the same or similar dogs. Here, the tendency would be to describe the client’s problems as a specific phobia—animal type. Yet, avoiding such dogs is not disordered or abnormal—it is a sensible response that is designed to avert another attack or injury and protect the client’s physical health. Likewise, it is normal and adaptive for a woman who has been sexually assaulted to experience a fear response when encountering her assailant at a later time. If she were to encounter the man again, such fear could lead to a swift escape or other defensive responses to protect herself. Also, thinking about that man and worrying what might happen if she met him again can be adaptive and useful for her safety. It might help her devise an action plan of what she needs to do to protect herself and how she can best avoid being victimized in future. These learned alarm responses are normal and quite adaptive.

On the other hand, too much fear or anxiety can impede one’s ability to take productive and effective action. Even animals don’t do well under extreme fear. They freeze, shake uncontrollably, try to escape, or struggle to get away from the source of fear. Humans are the same as other animals in this respect. For example, false alarms, such as panic attacks, seem to occur for no good reason—out of the blue—in inappropriate or inconvenient situations (e.g., while getting ready to give a speech). They are quite often disruptive and challenging. Over time, some individuals seem to learn how to be with and experience such attacks, whereas others do not. This variation in responses is a critical point.

In many cases false alarms are not clinical problems that warrant clinical attention. What might help us understand how fear and anxiety can become disordered is to examine the much larger number of people in the general population who have panic attacks and no panic disorder. Epidemiological studies consistently place the prevalence of panic disorder in the general population at around 3 to 5 percent (Salkovskis, 1998). Several studies (for details, see Barlow, 2002) have shown that about 35 percent of presumably normal young adults had one or more panic attacks in a given year. The difference between such “normal panickers” and people with panic disorder is not primarily the intensity or frequency of panic attacks. Instead, it seems that people in these two groups react differently to their experience of panic attacks.

Most people who experience an occasional panic attack learn to wait it out and hang in there until it subsides. They do not attempt to escape from their fear. Rather, “nonclinical” panickers pick up from where they were before the attack and continue to live their lives without spending too much time worrying about future panic attacks—and, most importantly, without doing things to avoid the experience of panic and the places where they had panic attacks. We believe that this posture of acceptance and nonavoidance is one of the key preventive mechanisms that protects many of these nonclinical panickers from developing panic disorder or social phobia. It is only when people desperately and rigidly try to avoid the experience of panic attacks, and devote increasingly larger portions of their life energy and space to that task, that they are at high risk of developing actual panic disorder.

Both the DSM and anxiety researchers (e.g., Craske, 1999) have long emphasized that what turns nonclinical panic into clinical panic is fear of, and worry about, future attacks and associated behavioral changes (e.g., restriction of activities, avoidance behavior) to reduce the likelihood of having another attack. Nonhuman animals do some of this preparatory planning too. For instance, when an animal that is always shocked following a tone hears that tone again, the animal will interrupt its behavior and move its head and attention toward the tone. We could say that this animal is concerned with a real threat (i.e., the possibility of being shocked again) in the immediate future. Humans, by contrast, can go much farther in terms of both time frame and what might happen to them. This is possible, in part, because humans, unlike other animals, have the ability to think, imagine, and speak. These otherwise functional abilities also make it possible for humans to get caught up in a struggle with their own emotions in an effort not to have them. This struggle, in turn, can feed on itself in a self-perpetuating cycle, paradoxically creating more of the very emotions that are undesirable. More importantly, the struggle itself takes effort. Such effort directed at struggling to minimize or prevent anxiety and fear is energy and time no longer available to pursue other valued life activities. More fundamentally, this struggle for control is really a battle with one’s own experiences. It is a battle that, somewhat paradoxically, cannot be won. We provide a detailed discussion of this struggle in chapter 4 because it is central to a deeper understanding of anxiety disorders and the ACT approach to treatment.

Overview of Anxiety Disorders

This section is designed to give the reader a brief overview of the central features of the major anxiety disorders as currently defined by the DSM.

Panic Attacks

Barlow (2002) noted that clinical manifestation of the basic emotion of fear is most evident in panic attacks. In addition to a strong autonomic surge that typically reaches its peak within ten minutes, and sometimes in as little as two minutes, individuals experiencing a panic attack report extreme fear and terror, thoughts of dying and losing control, and an overwhelming behavioral urge to escape and get away from wherever they are. Such fear responses are emergency or alarm reactions. They function to prepare humans and other mammals for action. Typically, such actions aim to ward off the potential impact of a threatening environmental stimulus or event. Thus, at its most basic level, the core of that response is a fight-or-flight action tendency. Classifying panic as an intense fear response and as an action tendency means that it is an e-motional alarm response: it serves to elicit motion. It is that strong urge to escape that leads people to avoid places where escape could be difficult (e.g., movie theaters, large shopping malls, formal social gatherings). If the action tendency is actually blocked, the intensity of fear increases.

Panic Disorder and Agoraphobia

Panic Disorder (PD) is characterized by recurrent panic attacks, fear of bodily sensations associated with autonomic arousal, and anxiety concerning the possibility of future panic attacks. Current diagnostic criteria for a diagnosis of PD require that an individual experiences recurrent and unexpected attacks. At least one of the attacks must be followed by at least one month of persistent worry about future attacks, worry about the consequences of the attacks, or a behavioral change because of the attacks (e.g., some type of avoidance). At the core, panic disorder is a fear of experiencing fear, where people are literally afraid of panic attacks and the potential consequences of such attacks. Agoraphobic avoidance occurs when people avoid places (e.g., malls, movie theaters, grocery stores) where they might have had a panic attack, and where escape may be difficult, in case they have another attack. Recall that agoraphobia is essentially a fear of having a panic attack in particular places, not a fear of those places as was previously thought. Accordingly, agoraphobia may best be viewed as a complication of panic disorder, where people attempt to avoid future panic attacks by staying in “safe” areas and avoiding stimuli and places that have previously been associated with panic. Nearly all persons who develop agoraphobia do so after first experiencing panic attacks; in fact, only 1 percent of people with agoraphobia do not experience panic attacks.

The onset of PD is typically in the mid to late twenties. Stressful life events frequently precede the onset of the disorder. Yet, absolute frequency of negative life events does not reliably differentiate persons with PD from persons with or without other anxiety disorders. Persons with PD do, however, report experiencing negative life events as more distressing compared to other people. Persons with PD also report a high degree of concern about their health status, particularly in regard to changes associated with bodily states. Without professional intervention, the course of PD is often chronic, with an increase in the number and intensity of attacks occurring during periods of stress. PD is twice as common in women as in men. This gender difference is consistently found in studies around the world and is largely due to sociocultural factors that moderate the experience and expression of emotion differently in males and females (Craske, 2003). For example, it is more socially acceptable for women to respond to fear by engaging in agoraphobic avoidance behavior, whereas men may attempt to endure fear and anxiety with the help of alcohol and other substances (“self-medication”).

Specific Phobias

A specific phobia is a marked, persistent, and excessive or unreasonable fear of a specific object or situation. Exposure to the feared object usually produces an immediate and intense fear reaction (i.e., a panic attack). This alarm response is accompanied by a strong urge to flee from the object or situation and may be accompanied by significant impairment and distress about the fear. Persons suffering from specific phobias often act to avoid future encounters with the feared object as much as they can and will make great efforts to do so. Nonetheless, they typically recognize that their fear is excessive or unreasonable. This knowledge, however, has no impact on the urge to escape and avoid feared objects or the ability to control physiological and subjective responses that follow.

Specific phobias, along with other anxiety disorders, are typically defined as involving changes in three loosely connected “response systems” (Eifert & Wilson, 1991): motor behavior (e.g., avoidance or escape); elevated physiological activity (e.g., increased heart rate, perspiration, respiration, and muscle tension); and verbal-cognitive activity such as reports of distress and apprehension that precede, accompany, or follow the occurrence of anxiety.

Some specific phobias are situational (e.g., closed spaces, heights, or airplanes), whereas others focus on the natural environment (e.g., heights, storms, lightning, or water), animals (e.g., snakes, rats, or spiders), or bodily harm (e.g., diseases, injuries, or the sight of blood). Specific phobias are quite common in the general population, with large surveys showing a lifetime prevalence of 11 percent (Kessler et al., 1994). The most common phobias are (in descending order) fear of animals, heights, closed spaces, blood and injuries, storms and lightning, and flying.

In spite of this high prevalence, most people with specific phobias never seek treatment. Antony and Barlow (2002) report that in their anxiety clinics only 5 to 6 percent of patients present with a specific phobia as their major complaint. Yet, 26 percent of people presenting for other anxiety disorders also suffer from a specific phobia as a secondary problem. Most people with a specific phobia do not seek treatment for their fears, in part because they are quite adept at avoiding the objects of their fear and/or because contact with feared objects is not an issue in their daily lives (e.g., seeing a snake in midtown Manhattan). Such avoidance is possible because the fear-eliciting stimulus is clearly known and discernible. Yet even this “successful” avoidance occasionally comes at a high personal or social price. For instance, the family of one of Georg’s clients in Australia could not take trips to a beautiful island just three miles offshore (a favorite weekend getaway destination for many people in the city) because she had a shark phobia and couldn’t stand the thought of sharks swimming underneath the ferryboat during the crossing.

A number of specific fears may serve an evolutionary function. Researchers have observed that the most prevalent fears tend to involve stimuli that are associated with harm and have thus threatened survival (e.g., snakes, spiders, thunderstorms, heights). Over time, we have become “biologically prepared” to react in a hypervigilant, fearful manner to such stimuli to secure our survival (Seligman, 1971). Many studies, including several in our own lab (e.g., Forsyth & Eifert, 1998b), have demonstrated that fears of evolutionarily prepared objects are indeed more easily acquired than fears of other equally dangerous objects of more recent origin (e.g., electrical outlets, guns).

Social Phobia

Social phobia is characterized by an excessive and persistent fear and avoidance of situations that involve social interaction and evaluation by others. Persons with such problems tend to be particularly concerned about being negatively evaluated by others, show heightened personal awareness of autonomic activity in social situations, and experience real or perceived social inadequacy. They also worry that others might detect their social discomfort. These fears are often experienced as unreasonable and as causes of life distress.

Not surprisingly, people with social phobia typically avoid and escape from social situations as much as they can. Such situations include, but are not limited to, public speaking, interpersonal communication with persons of the opposite sex, group meetings, telephone-based communication, social gatherings, and at times quasi-social activities such as using public restrooms or public transportation. More than 90 percent of all persons diagnosed with social phobia fear and avoid more than one social activity. Researchers often differentiate a fear of specific or discrete social situations (e.g., public speaking) from generalized social phobia. The latter of these is characterized by fears and avoidance of most social situations. The generalized type also is associated with a greater degree of psychological suffering compared to specific social phobia (see Hofmann & Barlow, 2002, for a full discussion).

The problems experienced by individuals with social phobia typically go well beyond a fear of the actual social situation. Recall that individuals with agoraphobia, panic disorder, and specific phobias are not primarily afraid of public places, situations associated with panic attacks, or specific objects per se. They are afraid of experiencing unwanted psychological and emotional events in those contexts. The same is true of individuals with social phobia, where the fear is often focused on having a panic attack, somehow failing in front of others, or being humiliated or embarrassed while in a social situation. Thus, as with the other anxiety disorders, the core issue for individuals with social phobia appears to revolve around avoiding the experience of negative affect.

We know that the prevalence of social phobias is much more common than previously thought, with recent data (for a summary, see Hofmann & Barlow, 2002) showing a lifetime prevalence of 13.3 percent. This makes social phobia the most common anxiety disorder and the third-most-common psychological disorder after major depression (17 percent) and alcohol dependence (14 percent). Studies consistently show that about 70 percent of individuals with social phobias are female (Juster & Heimberg, 1998) and that social phobia tends to develop gradually over time. Few persons report a traumatic experience precipitating the disorder. In fact, many socially anxious persons report that they “have always had the problem.” This is supported by other epidemiological data showing that the median age of onset occurs on or about puberty (i.e., twelve years of age), with more than 90 percent of individuals developing the disorder prior to age twenty-five (Juster & Heimberg, 1998).

Post-Traumatic Stress Disorder

The major clinical features of Post-Traumatic Stress Disorder (PTSD) fall into three broad clusters: reexperiencing of the traumatic event, avoidance of trauma-related stimuli, and chronically elevated bodily arousal. Great concerns regarding threats to personal safety (e.g., death) are central to the disorder.

The first cluster is also the most personally distressing feature of PTSD and involves reexperiencing aspects of the traumatic events by means of flashbacks, nightmares, intrusive thoughts, and emotional distress in response to internal or external cues that serve as reminders of the trauma (Jaycox & Foa, 1998). Trauma-related stimuli often trigger a reexperience of the trauma, heightened somatic activity, and behavioral manifestations of extreme terror, such as immobility. During flashbacks and nightmares, people with PTSD can relive traumatic experiences vividly and in a way that seems very realistic to them.

The second cluster involves avoidance behavior. For instance, persons with PTSD typically go to great lengths to avoid thinking about the traumatic event or any cues or situations that may serve as reminders of the event. The central function of such avoidance is to prevent reexperiencing the negative affect and psychological pain associated with the trauma. As with other anxiety disorders, avoidance behavior can vary from highly limited and circumscribed to highly generalized and extensive. As avoidance becomes extensive, it tends to restrict life functioning to such a degree that PTSD sufferers no longer engage in routine activities. For instance, some PTSD rape victims decrease contact only with certain types of males (e.g., males of the same race as the perpetrator), whereas other victims cease contact with all males. Another common form of emotional avoidance in PTSD is numbing, which refers to detachment from others and restricted range of affect. For instance, some rape victims with PTSD report a decreased level of enjoyment in sexual activity compared to other females despite achieving an equivalent number of orgasms. Many others simply report an inability to experience pleasure in life and an inability to trust and become close to others.

Lastly, the third PTSD cluster consists of experiences associated with elevated bodily arousal or the alarm response. Clinical features associated with arousal include sleep disturbances, elevated startle responses, irritability, anger outbursts, and hypervigilance. For instance, some rape victims constantly scan their environment for stimuli that are associated with the perpetrator and traumatic event. It is quite common for this elevated bodily arousal to spiral up into a full-blown panic attack.

PTSD is the only psychological problem with a clear etiological marker, namely one or more traumatic events. Although problem responses may manifest in a relatively short time after the trauma (e.g., within three to six months), they also can arise years after a traumatic event. Jaycox and Foa (1998) rightly called the prevalence of traumatic experiences and clinical PTSD alarming. Approximately 39 percent of the U.S. population will experience at least one traumatic event in their lifetime. Yet, of those people, only 24 percent will go on to develop PTSD, accounting for a 9 percent lifetime prevalence of PTSD in the general population. These numbers are certainly high, particularly when considering that up to 15 percent of the population suffers from subclinical PTSD. Nonetheless, we know from such studies that about two-thirds of trauma victims do not develop PTSD. Again, we must ask, why do most people emerge from traumatic experiences psychologically relatively unscathed? Why do some people only experience acute problems following trauma that dissipate on their own after a few months? And, why, in other cases, do problem responses persist and develop into the disorder we call PTSD? As we discuss in chapters 3 and 4, this is probably not a question of differences in traumatic conditioning, luck, or fate. Examining the core dimension of rigid avoidance of negative affect may hold the key to answering these and other crucial questions.

Generalized Anxiety Disorder

The clinical features of generalized anxiety disorder (GAD) are excessive worry about a number of events and activities occurring more days than not for at least six months, causing clinically significant distress or impaired functioning; unsuccessful attempts to stop or control worrying and to reduce anxiety by means of worrying; and a number of central nervous system problems such as muscle tension, restlessness, fatigue, difficulty concentrating, irritability, and sleep disturbance.

Approximately 5 percent of the general population will suffer from GAD at some point in their lives. Of these, about 60 percent of all cases are female. The onset of GAD is typically insidious, often beginning at an earlier age compared with other anxiety disorders. However, we should add that GAD onset late in life is common, too (Roemer & Orsillo, 2002). Worry and anxiety-related responses are likely to be particularly intense during periods of life stress and tend to decrease during periods of low stress. As with social phobia, the onset of GAD is not typically associated with negative life events. Rather, individuals commonly report that they are “stressed” and frequently overwhelmed by everyday life experiences (“daily hassles”). These observations further support the view that it is the frequent experiencing of negative uncontrollable life events in general, rather than a specific traumatic experience, that determines individual susceptibility to GAD. As a result, persons with GAD learn that they can do little to predict and control such events and end up worrying about them and avoiding them as much as possible.

Obsessive-Compulsive Disorder

Obsessions are recurring persistent thoughts, impulses, or images that are associated with significant anxiety and are experienced as intrusive, unreasonable, and distressing. Compulsions, by contrast, are repeated behaviors (e.g., checking, hand washing) and mental acts (e.g., counting, praying) that people engage in rigidly and excessively to relieve anxiety provoked by the obsessions (Steketee & Frost, 1998). The goal of ritualistic thoughts or actions is to suppress, neutralize, or otherwise control disturbing obsessional content. The behavioral or mental acts serve to restore safety, reduce anxiety, and prevent the dreaded event from happening. Obsessions and compulsive rituals cause marked distress and interfere with daily routines and social functioning more significantly than any of the other major anxiety disorders. In fact, when individuals are hospitalized because of anxiety, it is typically because they suffer from obsessive-compulsive disorder (OCD) (Steketee & Barlow, 2002). Hospitalization often represents the culmination of the downward vicious cycle of compulsions and obsessive rituals. Both tend to put so many constraints on people’s lives, while consuming so much time every day, that some individuals literally run out of time to do what they really need to do. Hospitalization in such cases is typically a last resort to break this cycle.

Unlike cognitions associated with GAD, the intrusive thoughts and worries experienced by persons with OCD are not simply excessive worries about real, everyday life problems. Instead, OCD is characterized by unrealistic, unreasonable, and often bizarre concerns. Most human beings have had such intrusive and bizarre concerns at some point. Yet, intrusive thoughts and images tend to elicit more anxiety and are more difficult to dismiss in OCD sufferers compared with other people (Steketee & Frost, 1998). Such thoughts, in turn, also often culminate in a paniclike reaction and are typically avoided and resisted. This is why Steketee and Barlow (2002) describe the response of individuals with OCD as another type of phobic reaction. This reaction is similar to that seen in panic disorder, except that the phobic objects in OCD are cognitions, not bodily sensations.

Most people with OCD realize that their rituals are excessive and unreasonable. Yet they continue to engage in behaviors that are designed to control or reduce unwanted thoughts. It is certainly possible that OCD sufferers engage in such control behavior because obsessive intrusions provoke more anxiety in them than in other people. Yet, it is also possible that the very tendency to neutralize and control intrusions inadvertently contributes to elevated anxiety. There is indeed mounting empirical support for the negative and backfiring effects of attempts to suppress or control unwanted thoughts and images (Hayes et al., 1996; Wegner, 1994). We will have more to say about this line of research in subsequent chapters.

Although the age of onset for OCD is typically mid to late adolescence, problems can start in children as young as five to six years of age. In childhood and adolescence, there are more males than females suffering from OCD (sex ratio 2:1), but by adulthood the gender distribution is approximately equal. OCD rarely begins after age fifty (Steketee & Barlow, 2002). If untreated, the prognosis of OCD is poor.

Anxiety Disorders Have Much in Common

In the past, researchers and therapists have focused on the differences between anxiety disorders. At the phenomenological level such differences are obvious, particularly if one focuses on events that elicit fear and anxiety across the anxiety disorders. In specific phobias, for instance, we have focused on a specific object, event, or situation. In social phobia, we have focused on social situations. In panic disorder, we have focused on discrete episodes of intense fear elicited by bodily sensations. In PTSD, we have focused on past traumatic events and associated memories. We also differentiate cued or expected fear responses, where we know the fear-eliciting stimuli (e.g., in specific and social phobias and PTSD), from uncued or unexpected types of fear responses that appear to occur out of the blue (e.g., in panic disorder), where we often have no clear understanding of the eliciting stimuli. We have also focused on differences in the duration and intensity of responses. For instance, fear and the associated physical changes in panic disorder are intense but relatively short-lived, whereas anxiety and physiological responses in GAD are less intense and occur over much longer periods of time.

Phenomenological Overlap

Despite these differences amongst the various anxiety disorders, there are some striking commonalities that have been studied extensively. For instance, although panic attacks most frequently occur in persons with PD, they also can and do occur in persons with all other anxiety disorders. For instance, at least 50 percent of people with social phobia and at least 30 percent of people with GAD and OCD experience occasional or frequent panic attacks.

Additionally, we have known for some time that there is little difference between a panic attack that occurs within the context of panic disorder and cued (situationally bound) panic attacks that occur in the presence of specific stimuli (e.g., in specific and social phobias, PTSD; cf. Craske, 1991). Most importantly, the tendency to avoid and escape from fear and anxiety is characteristic of just about every individual diagnosed with an anxiety-related disorder. The specific types of escape and avoidance behavior may differ at a phenomenological level. Yet, the basic function of those behaviors is the same: they serve to make the fear and anxiety go away and get the person out of the situation where they experience fear and anxiety. There is also much overlap between anxiety disorders and major mood disorders such as major depression and dysthymia. Barlow and colleagues (2004) report that 55 percent of patients with a principal anxiety or mood disorder had at least one other additional anxiety or depressive disorder at the time of assessment. This rate increased to 76 percent when additional lifetime diagnoses were considered.

Panic attacks are indeed common occurrences in persons with major emotional disorders. For instance, as many as 25 to 50 percent of persons suffering from major depression, and 35 to 60 percent of those with somatization disorder or hypochondriasis, experience panic attacks (Salkovskis, 1998). Brown and Barlow (2002) discuss several large-scale studies that all show that major depression is by far the most common additional lifetime diagnosis in patients with a principal anxiety disorder. A surprising finding was that the overwhelming majority of patients with mood disorders also presented with a current or past anxiety disorder. In fact, only 5 percent of 670 patients who had lifetime major depression or dysthymia did not have a current or past anxiety disorder. In the majority of cases of coexisting anxiety and depression, anxiety disorders preceded rather than followed the onset of mood disorders.

We therefore agree with Barlow and colleagues (2004) that there is a remarkable degree of functional overlap across the anxiety disorders. We also agree that all the emerging evidence points to the overriding importance of common factors in the genesis and presentation of emotional disorders. The observable overlapping features of the various anxiety disorders, as well as the large co-occurrence of anxiety and mood disorders, point to a more basic fundamental overlap at the process level:

Deepening understanding of the nature of emotional disorders reveals that commonalities in etiology and latent structure among these disorders supercede differences [p. 205] … There is wide agreement that the DSM-IVrepresents the zenith of a splitting approach to nosology, with the obtained advantage of high rates of diagnostic reliability. But there is growing suspicion that this achievement has come at the expense of diagnostic validity, and that the current system … may be erroneously distinguishing categories that are minor variations of broader underlying syndromes. (Barlow et al., 2004, p. 211)

Common Core Pathological Processes

We believe that a better understanding of the common core processes by which normal anxiety and other emotions become disordered is essential to a successful approach to treating people with anxiety and other emotional disorders. There is increasing empirical support for the notion that the powerful and self-defeating impact of avoiding negative affect is the core pathological process that fuels all anxiety disorders. In our view, the way people with GAD use worry to avoid and reduce the stress associated with anxiety can teach us a lot about the core problem behavior that is at the heart of all anxiety disorders: rigid and excessive attempts to avoid experiencing anxiety.


GAD used to be a catchall diagnosis for persons who presented with an anxiety problem that did not neatly fit into one or more of the other, more specific anxiety categories. In recent years, the shift in GAD diagnostic criteria from specific motor and autonomic symptoms to the core processes of worry and anxious apprehension has led to the notion that GAD may in fact be the “basic” anxiety disorder. Indeed, Barlow (2002) views anxious apprehension as a core process that can serve as a platform for the genesis and maintenance of all anxiety disorders. He defines anxious apprehension as a future-oriented mood state in which an individual becomes ready for, or prepares to cope with, upcoming negative events. This state is associated with heightened negative affect, chronic overarousal, a sense of unpredictability and uncontrollability, and an attentional focus on threat-related stimuli. Barlow points out that the process of anxious apprehension is present in all anxiety disorders, but the specific content of that apprehension varies from disorder to disorder.

Our much improved understanding of GAD gives us important clues as to what can make anxiety disordered and what behaviors we need to address in treatment. Worry functions as a cognitive avoidance response to threatening material. Borkovec and associates (2004), for instance, have gathered convincing empirical evidence that the function of worry is to avoid imagery and physiological arousal associated with anxiety and negative affect. When people worry, they are mostly talking to themselves. That is, worry involves more abstract verbal thinking than imagery (Borkovec & Newman, 1998). Hence, worry allows people to approach emotional topics from an abstract conceptual perspective and thereby avoid aversive images and intense negative emotions in the short run. In the long run, however, this strategy is ineffective. In fact, individuals tend to experience even more intense anxiety over the long haul, which is usually followed by efforts to reduce anxiety by engaging in more worrying (Mennin, Heimberg, Turk, & Fresco, 2002).

[People with GAD] are thinking so hard about upcoming problems that they do not have the attentional capacity left for the important process of creating images of the potential threat, images that would elicit more negative affect and autonomic activity. In other words, they avoid all the negative affect associated with the threat … [As a result] they may avoid much of the unpleasantness associated with the negative affect and imagery, but they are never able to work through their problems and arrive at solutions. Therefore they become chronic worriers, with accompanying autonomic inflexibility and quite severe muscle tension. Thus, intense worrying for an individual with GAD may serve the same maladaptive purpose as avoidance does for people with phobias. It prevents the person from facing the feared situation, and so adaptation and real problem-solving can never occur. (Barlow & Durand, 2004, p. 130)

It has proven difficult to explain why worry helps GAD sufferers avoid distressing emotional experiences and why these experiences are so aversive that such individuals feel they need to avoid them in the first place. Still, Mennin and colleagues (2002) have provided an explanation that we believe is quite compelling. These authors found that individuals with GAD have emotional reactions that occur more easily, quickly, and intensely than for most other people. At the same time, they also appear to have a poorer understanding of emotions, respond to their emotions in a negative way, and use maladaptive strategies to control and constrain their emotional experience to decrease this aversive state. Thus, GAD tends to be associated with indiscriminate avoidance of negative affect that is, in some sense, on autopilot.

Avoiding Fear and Anxiety at All Costs

There is increasing evidence that the key problem of most people with anxiety disorders is not their intense fear or pervasive anxiety. The problem is that such persons tend to be overwhelmed by the action tendency to avoid experiencing fear and anxiety. They quite literally live a life focused on trying not to have anxiety and fear, unwanted thoughts, past memories, worries, and the like. Such a life lived in the service of anxiety and fear can take several forms, such as avoiding people, places, activities, and situations that might lead to anxious and fearful feelings, using substances to minimize the occurrence of such feelings, and escaping from situations during unpleasant emotional states. A life lived in the service of not having anxiety and fear, particularly when rigidly and inflexibly applied, is quite limiting and likely has come to define how clients are living their lives by the time they enter therapy. It is when this strategy of avoidance and escape is applied rigidly and inflexibly to anxiety and fear, including the circumstances that occasion such responses, that we begin to talk about the shift from normal anxiety and fear to disordered experiences of anxiety and fear. Most of this activity is verbally constructed and evaluative, and hence the reason why ACT considers language at the heart of this experiential avoidance problem. Indeed, from an ACT perspective, anxiety and fear become problematic when persons:

§    are unwilling to have anxiety and fear;

§    routinely act to avoid, suppress, and escape from such emotions, associated thoughts, physical sensations, and the circumstances that may occasion them; and

§    devote enormous effort and time to this struggle with anxiety and fear at the expense of other valued and important life activities and goals.

As we show in part 3, ACT aims to break up this cycle by undermining this natural tendency to avoid and escape and increasing flexibility and willingness to experience anxiety and fear for what it is. At the same time, ACT helps clients focus attention on important and valued life domains that are being sidelined during this struggle.