4 COGNITIVE THEORY AND RESEARCH ON ANXIETY
Although large-scale threats have their greatest impact on the psychological morbidity
of individuals directly affected by the disaster in the weeks immediately following the
traumatic event, their wider effects are evident months and years later in the heightened
concerns and worries of a significant proportion of the general population.
Fear, anxiety, and worry, however, are not the exclusive domain of disaster and
other life- threatening experiences. In the majority of cases anxiety develops within the
context of the fluctuating pressures, demands, and stresses of daily living. In fact anxi-
ety disorders represent the single largest mental health problem in the United States
(Barlow, 2002), with more than 19 million American adults having an anxiety disorder
in any given year (National Institute of Mental Health, 2001). Approximately 12–19%
of primary care patients meet diagnostic criteria for an anxiety disorder (Ansseau et al.,
2004; Olfson et al., 1997). Moreover, antidepressants and mood stabilizers are the third
most prescribed pharmacotherapy class, having 2003 global sales of $19.5 billion (IMS,
2004 ). Thus millions of people worldwide mount a daily struggle against clinical anxi-
ety and its symptoms. These disorders cause a significant economic, social and health
care burden for all countries, especially in developing countries that face frequent social
and political upheavals and high rates of natural disaster.
This chapter provides an overview of the diagnosis, clinical features, and theo-
retical perspectives on the anxiety disorders. We begin by examining definitional issues
and the distinction between fear and anxiety. The diagnosis of anxiety disorders is
then considered with particular attention to the problem of comorbidity, especially with
depression and substance abuse disorders. A brief review of the epidemiology, course,
and consequence of anxiety is presented, and contemporary biological and behavioral
explanations for anxiety are considered. The chapter concludes with arguments for the
validity of a cognitive perspective for understanding the anxiety disorders and their
treatment.
anxiety anD fearThe psychology of emotion is rich with diverse and opposing views on the nature and
function of human emotions. All emotion theorists who accept the existence of basic
emotions, however, count fear as one of them (Öhman & Wiens, 2004). As part of our
emotional nature, fear occurs as a healthy adaptive response to a perceived threat or
danger to one’s physical safety and security. It warns individuals of an imminent threat
and the need for defensive action (Beck & Greenberg, 1988; Craske, 2003). Yet fear can
be maladaptive when it occurs in a nonthreatening or neutral situation that is misinter-
preted as representing a potential danger or threat. Thus two issues are fundamental to
any theory of anxiety: how to distinguish fear and anxiety, and how to determine what
is a normal versus an abnormal reaction.
Defining Fear and Anxiety
Many different words in the English language relate to the subjective experience of anxi-
ety such as “dread,” “fright,” “panic,” “apprehension,” “nervous,” “worry,” “fear,”
“horror,” and “terror” (Barlow, 2002). This has led to considerable confusion and
inaccuracy in the common use of the term “anxious.” However, “fear” and “anxiety”