Anxiety disorders inflict enormous suffering on large numbers of people and, once acquired, tend to be chronic. But what is the nature of anxiety? And how do we acquire anxiety and its disorders? In this article I explore the process of anxiety, concluding that an emotionally based sense that important events are careening out of one's control is at the heart of anxiety. This sense of uncontrollability is accompanied by a variety of cognitive, affective, and neurobiological processes about which we have learned a great deal. The article concludes with a description of a relatively new theory describing triple vulnerabilities that may interact to cause anxiety disorders. These include a genetic or heritable component, a generalized psychological vulnerability based on early experience, and a more specific psychological vulnerability in which we learn to focus anxiety on certain objects or situations. Some of these ideas are based on work over the past two decades in our sexual dysfunction laboratory, which is reviewed.
Anxiety disorders are common, chronic, and crippling. Best estimates of one-year prevalence of anxiety disorders combining information from the Epidemiological Catchment Area study and the National Comorbidity Survey (NCS) put the prevalence at 16.4% (Kessler et al., 1994). This makes anxiety disorders the most prevalent class of mental disorders in the population (Barlow, 2002). The prevalence of anxiety that may not meet definitional thresholds for DSM-IV diagnoses in primary care practice settings (subthreshold conditions) is even higher. One recent study documented that over 50% of the estimated $1,500+ cost per individual suffering from anxiety in the United States was attributed to the utilization of primary care services ( Greenberg et al., 1999; Mostofsky & Barlow, 2000). Data from the NCS suggest that the higher ratio of 12-month to lifetime anxiety disorder prevalence indicates that these disorders are more chronic than either mood disorders or substance abuse disorders (Kessler et al., 1994).
With these data on prevalence and chronicity, one would expect that anxiety disorders would be associated with substantial costs to individuals and to our health care system. The actual expenses, however, dwarf even the most pessimistic estimates (Greenberg et al., 1999; Hofmann & Barlow, 1999). For example, in recent years anxiety disorders accounted for approximately 30% of total costs of mental health care, compared to 22% for mood disorders and 20% for schizophrenia (Rice & Miller, 1993). DuPont et al. (1996) estimated these costs in 1990 at $46.6 billion out of a total expenditure on mental illness of $ 147.8 billion that year, or 31.5% of the total. These costs included not only the direct cost of services, but also indirect costs of lost productivity. Understanding the causes of anxiety and related disorders is a top priority.
In this article I review the nature of anxiety with particular emphasis on the centrality of a sense of control to the experiences of anxiety. Research from our laboratory of psychogenic sexual dysfunction illustrates many of these functions. I conclude with a description of the theory of triple vulnerabilities in the etiology of anxiety and its disorders.
The Nature of Anxious Apprehension
Beginning in 1988, and subsequently (Barlow, 1988, 2000, 2002), I have described anxiety as a unique, coherent cognitive-affective construct within a defensive motivational system. At the heart of this construct is a sense of uncontrollability focused largely on possible future threat, danger, or other challenges that may have a negative outcome. Thus, this state could be characterized, roughly, as a state of helplessness because of a perceived inability to predict, control, or obtain desired results or outcomes in certain upcoming situations or contexts. Accompanying this negative affective state is a strong physiological or somatic component that may reflect activation of distinct brain circuits associated with engagement of the corticotrophin releasing factor ( CRF) system and/or Gray's behavioral inhibition system (Chorpita & Barlow, 1998; Gray & McNaughton, 1996; Sullivan, Kent, & Coplan, 2000). This somatic state may be the physiological substrate of readiness, often described as vigilance or hypervigilance, which may underlie a state of preparation to counteract helplessness. If one were to put anxiety into words, one might say, "That terrible event could happen again, and I might not be able to deal with it, but I've got to be ready to try." For these reasons we have suggested that a better and more precise term for anxiety might be anxious apprehension. This conveys the notion that anxiety is a future-oriented mood state in which one is ready or prepared to attempt to cope with upcoming negative events. Another term often paired with anxiety is anticipatory. But in the present definition, all anxiety is anticipatory.
Anxiety is also clearly discriminable from panic or fear--terms that have often been categorized under the general rubric of anxiety in the past. This is because fear is a different emotion, occupying different brain circuits, that is best known as our emergency or flight-fight reaction. If anxiety is future danger, fear is present danger, requiring immediate action. If this reaction occurs when there is nothing to be afraid of (there is no danger), it is called panic. Returning to anxiety, the process of anxiety as described above is presented in Figure 1.
A variety of triggers, cues, or propositions, to use Lang's term (1985, 1994a, 1994b), would be sufficient to evoke anxious apprehension. It is important to note that this process could occur without the necessity of a conscious, rational appraisal. For example, one might experience anxiety without awareness of the specific trigger or cue, such as an object or situation that "represents" an earlier trauma, or an internal somatic sensation. These cues may be broad based or very narrow. An example of a narrow set of cues would be the case of test anxiety or sexual dysfunction (described further below), in which cues signaling the necessity of imminent performance would evoke a state of anxious apprehension, with associated increased tension and arousal. This state, in turn, is associated with a shift in attention to a self-evaluative focus, or a rapidly shifting focus of attention from an external, potentially threatening context to internal self-evaluative content in which evaluation of one's (inadequate) capabilities to deal with the threat is prominent. Evidence suggests that this shift to a self-focused attentional state further increases arousal and negative affect, thus forming its own small positive feedback loop. This subsystem is also represented in Figure 1.
Continuing on in the larger system, a variety of cognitive changes become apparent. Attention narrows to sources of threat or danger, setting the stage for additional distortions in the processing of information, either through attentional or interpretive biases, reflecting preexisting hypervalent cognitive schemata. How one initially develops these cognitive sets will be taken up below. In any case, one becomes hypervigilant for cues or stimuli associated with sources of anxious apprehension. At sufficient intensity, this process results in disruption of concentration and performance.
The process of anxiety is seldom pathological, even when intense, until it becomes chronic. When this happens, one or both of two prominent consequences of the process of anxiety develop as attempts to cope with negative affect and its triggers. First, a tendency to avoid entering a state of anxious apprehension is always present. This tendency becomes more pronounced and observable, depending on the severity or intensity of the state, and the specificity of the contextual cues that set the occasion for anxious apprehension. Thus, test-anxious individuals will avoid tests to the extent that this is possible, and sexually dysfunctional individuals will eventually avoid sex. But this rather maladaptive coping skill may not be available to individuals whose anxious apprehension has diffused to many different situational contexts (or, more accurately in Langian terms, across many different " networks in memory"). In these individuals, subtle avoidance behaviors, rituals, or "superstitious" behavior may become established in an attempt to reduce anxiety. Second, worry driven by the process of anxiety, which (at intense levels) is very difficult to control (Brown, Dowdall, CÃ´tÃ©, & Barlow, 1994), seems best construed as an additional, most often futile, attempt to cope with chronic anxiety. In DSM-IV, lack of control over the worry process is a defining feature of generalized anxiety disorder ( Brown, Barlow, & Liebowitz, 1994). Worry, or concern over future events, is, of course, not problematic and may even be adaptive under some circumstances. Most people worry every day as one way of planning for future challenges. But, when worry is so driven by anxiety it becomes intense and uncontrollable, then worry can become chronic and maladaptive.
Illusions of Control and Psychological Vulnerabilities
The model of the process of anxiety presented in Figure 1 suggests that perceptions of lack of control over potentially challenging or threatening events is at the core of anxiety. We have examined this premise in our sexual dysfunction research laboratory over the past two decades. Our model of sexual functioning (Barlow, 1986), which formed the basis for the development of the model of anxiety described above, proposes that functional and dysfunctional individuals enter a sexual situation with, among other things, differential expectancies for their performance. Dysfunctional individuals expect to perform poorly, and functional individuals expect to perform well. Interestingly, results from several experiments in our laboratory seem to indicate that sexually functional participants have a resistance to the formation of negative expectancies evident in functional individuals (Cranston-Cuebas, 1995; Cranston-Cuebas & Barlow, 1990; Cranston-Cuebas, Barlow, Mitchell, & Athanasiou, 1993; see Barlow, 2002; Barlow, Chorpita, & Turovsky, 1996).
Before proceeding, it is necessary to say a word about our methods. In the laboratory we have the capacity to measure sexual arousal in response to erotic stimuli not only by self-report, but also physiologically by measuring vaginal blood flow changes in women and penile circumference changes in males. In many cases participants are unsure of these changes, producing discrepancies or "splits" between subjective and more objective measures of arousal. For example, early studies in our laboratory with males found that sexually functional participants overlooked small decrements in their performance, and failed to report decreases in their physiological arousal (Abrahamson, Barlow, Sakheim, Beck, & Athanasiou, 1985). This finding suggested that sexually functional men may ignore evidence that might lead to or support the notion that they might have difficulty performing ( negative expectancies of performance). In contrast, because sexually dysfunctional men tend to under-report their physiological arousal (Sakheim, Barlow, Abrahamson, & Beck, 1987), we might conclude that these patients feel they have little control over their arousal, think the worst, and maintain negative expectancies of performance.
Findings from another pilot study (Weisberg, Sbrocco, & Barlow, 1994) also support the possibility that functionals retain an illusion of control regarding sexual performance. Fantasy use, or the ability to form vivid, mental representations, has repeatedly been found to be important for the voluntary control of sexual arousal (e.g., Stock & Geer, 1982 ). Patients with dysfunction in our laboratory report feeling they have less control over their arousal (Mitchell, Marten, Williams, & Barlow, 1990) and also report less use of fantasy in sexual situations (Marten & Barlow, 1991; Weisberg et al., 1994). Thus we explored the relationship between imagery ability, fantasy content, and voluntary arousal (Weisberg et al., 1994). Sexually functional males were asked to engage in either a fantasy in which they would not be able to attain and maintain an erection, or a fantasy in which their performance was satisfactory. Surprisingly, there were no differences in arousal between fantasy groups. Sexually functional men who were asked to create a fantasy in which they experienced sexual difficulties evidenced penile tumescence and subjective arousal equal to those asked to engage in a fantasy in which no problems occurred. Examination of the written fantasies of participants in the "negative" fantasy condition revealed that their fantasies included accounts of sexual problems, as per the instructions, but that these problems were not the focus of the fantasies. In other words, these individuals created arousing fantasies in which problems occurred (such as detumescence), but were not dwelled upon, or they were fantasized as being only temporary.
In a related experiment (Bach, Brown, & Barlow, 1999), we examined the effects of low efficacy expectancies for obtaining adequate erectile responses on subsequent sexual arousal in sexually functionally men. Twenty-six males were randomly assigned to either a false negative-feedback group or a no-feedback group. After viewing several erotic films, the participants in the false-feedback group were told that their responses were less than the average participant in our laboratory. The control group received no such feedback. The instructions were credible to the participants because efficacy expectations were considerably lower when the feedback group viewed a third erotic film, as was physiological response measured by the penile strain gauge. Despite these effects on physiological arousal, and counter to predictions, the false feedback did not lead to a decline in either reports of subjective arousal or an increase in negative affect. Thus, a self-focus on potential inadequate responding did lower physiological sexual arousal. But the fact that this false-feedback condition was not associated with changes in subjective arousal, self-estimates of arousal, or negative affect, once again suggests that sexually functional males may have an "illusion of control" mentality. That is, by ignoring or discounting occasional decrements in erectile response, functional males may retain an illusion of control over their responding, and thus protect themselves from subsequent difficulties.
These findings have parallels in social psychological research, where findings from a variety of studies suggest that individuals frequently avoid accurate knowledge about themselves, and will often sustain inaccurate knowledge if the truth is threatening in some way (Gibbons, 1991; Thompson, 1999; Thompson, Armstrong, & Thomas, 1998). In an early study, Sackeim and Gur (1979) reported that answering "no" to questions that should be universally true, such as "Have you ever doubted your sexual adequacy?" or "Have you ever thought your parents hated you?" was negatively correlated with depression and neuroticism. In other words, this "self-deception" might be a characteristic of mental health. In a classic experiment, Alloy and Abramson (1979) found that individuals with depressed mood, even if this mood was induced experimentally in the laboratory, demonstrated a more realistic assessment of their ability to control an outcome than individuals with normal mood who evidenced an illusion of control. In a study with results resembling the Weisberg et al. (1994) and Bach et al. (1999) studies described above, Alloy and Clements (1992) found that participants who displayed greater illusion of control in a laboratory task experienced less negative mood after a failure on the task, but also were less likely to get depressed months later after experiencing negative life events than participants with less illusion of control. Taylor and Brown (1988, 1994) and Taylor, Kemeny, Reed, Bower, and Gruenewald (2000) documented the large number of findings from social psychological experimentation supporting the adaptive function of retaining an illusion of control on both mental and physical health.
Because it seems likely that our sexually functional participants, without problems, maintain an illusion of control when confronted with occasional difficulties and failures, which serves a protective function, it is tempting to conclude that our clinical patients with sexual dysfunction and other anxiety disorders are somehow lacking this illusion of control, and that this deficit predates the onset of any difficulties. This formulation would, of course, be consistent with a diathesis - stress model of etiology. In fact, a developing web of evidence points to the existence of psychological vulnerability that predates the beginnings of a specific clinically significant problem. Some tantalizing evidence in support of this suggestion has now emerged from our laboratory.
In a study that extended the findings of Bach et al. (1999) utilizing a similar paradigm, attributions for perceived erectile failure were manipulated following a similar bogus-feedback condition (Weisberg, Brown, Wincze, & Barlow, 2001). Specifically, 52 young men with normal sexual functioning viewed similar sexually explicit films while wearing a penile strain gauge. Once again, all men were told that they did not become as aroused as the typical study participant, but were then given either an external fluctuating attribution (i.e., the films must have been very poor quality) or an internal constant attribution (i.e., it seems from questionnaires you filled out that you may have a type of belief about sex that sometimes makes it difficult to get aroused here in our lab) as the cause of their poor erectile performance. All participants then viewed a third film to examine responsivity under the differing attributions.
The results indicated that participants in the external fluctuating attribution group showed greater physiological and subjective sexual arousal during a third film than did participants with the internal causal attribution. In addition, preexisting negative affect and perceptions of erectile control negatively influenced sexual arousal during the third film. These results would suggest that, after an occasion of erectile difficulty, the cause to which the difficulty is attributed, the degree of negative affect experienced, and the degree of perceived erectile control all seem to influence future sexual functioning. Thus, the results suggest that, in the context of negative affect and somewhat lower perceived control, direct manipulation of attributions may temporarily diminish to a certain degree the illusion of control that exists in otherwise functional individuals, because both objective and subjective sexual arousal were somewhat lower under these conditions. The implication of these and other experiments is that perceived lack of control and resulting negative internal attributions may be a psychological vulnerability. This vulnerability makes it likely that one may develop sexual dysfunction or some other anxiety disorder after experiencing failure or a stressful negative event.
In 1988, I first speculated on an interacting set of three vulnerabilities or diatheses relevant to the development of anxiety, anxiety disorders (including sexual dysfunctions), and related emotional disorders (Barlow, 1988, 2000, 2002 ). Genetic contributions to the development of anxiety and negative affect constitute a generalized heritable vulnerability. In addition, evidence is available, some of it reviewed above, supporting the existence of a psychological vulnerability to experience anxiety and related negative affective states generally, best characterized as a diminished sense of control that arises out of early life experiences (Barlow, 2002; Barlow et al., 1996; Chorpita & Barlow, 1998). The unfortunate co-occurrence of generalized biological and psychological vulnerabilities may be sufficient to produce anxiety and related states, particularly generalized anxiety disorder and depression when triggered by stress. But, a third set of vulnerabilities seems necessary to account for the development of at least some specific anxiety disorders, including sexual dysfunction. Specifically, a web of evidence based only on retrospective reports at the current time, suggests that early learning experiences seem to focus anxiety on certain life circumstances. That is, certain circumstances or events, such as the occurrence of unexplained somatic sensations or social evaluation, become imbued with a heightened sense of threat and danger. It is this specific psychological vulnerability that, when coordinated with generalized biological and psychological vulnerabilities mentioned above, seems to contribute to the development of specific disorders such as social anxiety disorder, anxiety-related psychogenic sexual dysfunctions, obsessive-compulsive disorder, panic disorder, and specific phobias. A summary of this theory is presented in Barlow (2000) and is more fully developed in Barlow ( 2002). What follows is a brief outline.
Generalized Biological Vulnerability: Genetic Contributions
Elsewhere (Barlow, 2000, 2002), I elaborate on the notion that the relationships among the closely related traits or temperaments of neuroticism, negative affect, behavioral inhibition, and so forth have yet to be fully worked out, but it is likely that each represents variations on a theme underlying a heritable vulnerability to develop emotional disorders generally. Genetic contributions to the expression of these generalized traits are most usually estimated to run in the range of 30-50% of the variance, although the intimate dance of environmental and genetic influences makes these estimates imprecise and misleading. Moreover, it has now been established that traits of neuroticism or negative affectivity are positively related to anxiety and anxiety disorders (Brown, Chorpita, & Barlow, 1998; Clark, Watson, & Mineka, 1994; Trull & Sher, 1994; Zinbarg & Barlow, 1996). Only recently have prospective studies begun to appear detailing the relationship between neurotic temperaments and the later development of anxiety. For example, Gershuny and Sher (1998) found that an interaction of (high) neuroticism and (low) extroversion indiscriminately predicted both global anxiety and depression three years after initial assessment. While conclusions of this study were limited by a narrowly defined sample of undergraduates who were part of an ongoing longitudinal study of risk factors for alcohol-related problems, and a very limited web of indicators in the structural models, the study represents an important beginning in the prospective examination of vulnerabilities to the later development of anxiety and related disorders.
Generalized Psychological Vulnerabilities
In Figure 1, I refer to a sense of unpredictability and uncontrollability as the core of anxiety, and describe some experiments above that illustrate this phenomenon in the context of sexual dysfunction. Robust animal models of the etiology on anxiety suggest that early experiences that foster a sense that important events in the environment occur unpredictably and uncontrollably result in relatively permanent alterations in brain function, particularly in CRF-containing neurons and receptors. We have hypothesized elsewhere (see Figure 2 of Chorpita & Barlow, 1998) that these early experiences initially mediate the emergence of anxiety and depression early in development. This experience may then help to foster a (cognitive) template that may then begin to operate as an amplifier for stressful life events in the context of a more moderational model.
There is also some evidence that these experiences differentially affect young girls compared to boys, accounting for the later preponderance of women among those with anxiety or mood disorders (Barlow, 1988, 1991; Mineka, 1985; Nolen-Hoeksema, 1987, 1990; Nolen-Hoeksema & Girgus, 1994). What seems to happen is that girls may learn early on that their behavior has less impact on their environment than the behavior of boys. Girls may also be subjected to a larger number of negative life events during childhood and adolescence. It is these factors that are thought to contribute to a sense of uncontrollability in girls and foster the development of pessimistic attributional styles. The resulting cognitive template seems to place girls at higher risk for later emotional disorders. Thus, we have hypothesized (Barlow, 2002) that gender differences and the prevalence of anxiety and mood disorders may well be traced to a heightened generalized psychological disposition to experience salient events as unpredictable and uncontrollable. Based on cross-fostering studies demonstrating the necessity of heritable contributions to negative affect to be incubated in the fertile ground of early experience (Barlow, 2002; Suomi, 1999, 2000), it is likely that the development of emotional disorders later in life represent an interaction of generalized biological and generalized psychological vulnerabilities as suggested in Chorpita, Brown, and Barlow's (1998) study with children. This rather complex set of findings and speculations is laid out in great detail in Chorpita and Barlow (1998) and Barlow (2002).
Specific Psychological Vulnerabilities: Learning What is Dangerous
I also suggested the existence of a second set of psychological vulnerabilities that predisposes the individual to focus anxiety on some specific object or event (Barlow, 1988, 2002; Bouton, Mineka, & Barlow, 2001). For example, evidence exists in panic disorder (based on retrospective analysis) that caregivers, through modeling or information transmission, convey the information that unexplained somatic sensations are dangerous and could signal possible illness or death. In specific phobia, this set of vulnerabilities contributes substantially to determining the particular object or situation that becomes the focus of fear ( Antony & Barlow, 2002). In social anxiety disorder there is evidence that individuals have been differentially subjected to early experiences in which the potential danger of social evaluation was clearly communicated by parents or other important caregivers or friends (e.g., Barrett, Rapee, Dadds, & Ryan, 1996; Rapee, 1997). In obsessive-compulsive disorder, in which obsessional thoughts, images, or urges themselves become the focus of anxiety, there is evidence that at least some of these individuals had previously learned to equate dangerous thoughts with dangerous actions (i.e., thought-action fusion; Steketee & Barlow, 2002).
For sexual dysfunction, the concept of erotophobia (Byrne & Schulte, 1990) seems to reflect a specific psychological vulnerability to respond to sexual cues with negative affect and evaluation. As Byrne (1983) points out, erotophobia is presumably learned in childhood and adolescence through experiences associating sexual cues with negative emotional states. In a variety of studies, individuals scoring in the erotophobic range of the Sexual Opinion Survey (SOS; Fisher, Byrne, White, & Kelley, 1988) report more parental strictness about sexual matters and greater religiosity. Thus, much as children seem to be taught to focus anxiety on unexplained somatic sensations or social evaluation, it seems that children can also learn to focus anxiety on sexual activity (Byrne & Schulte, 1990). Scores on this SOS consistently differentiate sexually functional and dysfunctional participants in our laboratory.
The synergism of these triple vulnerabilities is detailed in Figure 2. This theory has been in existence for over a decade with refinements in the last several years (Barlow, 2002; Bouton et al., 2001). There is increasing retrospective evidence supporting the notion that generalized vulnerabilities lead to anxiety (and mood) disorders, and that one learns to focus anxiety on specific events or circumstances. Nevertheless, the theory requires in-depth prospective confirmation, a task we are beginning to undertake.
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