Anxiety, worry, unease, distress, and apprehension are often used interchangeably. Anxiety is a feeling similar to fear. A person perceives it as a feeling of unease, sometimes as a sense of worry with no apparent cause, as if something bad is about to happen. It can be experienced with varying intensity, from mild unease and tension to panic. In anxious states, heart rate, breathing, and muscle tension increase; sweating and dry mouth may occur; blood pressure rises; and frequent urination may be common. All these changes indicate that the organism's "fight or flight" response to sudden danger is activated. In this sense, anxiety can be considered a natural response that the organism activates as a result of perceiving a perceived danger. Anxiety is a feeling experienced by everyone, but it only becomes an abnormal condition, an anxiety disorder, when it impairs an individual's functionality in their work, social, and personal life.
Anxiety is related to the perception of a physical or psychological threat or danger. When an individual perceives a situation or sensation as dangerous, an "anxiety program" is activated. The anxiety program has a complex structure involving bodily, cognitive, and behavioral changes. This structure stems from the developmental characteristics of the human species and is actually a program that protects humans from primitive and truly dangerous environmental factors. However, in anxiety disorders, the danger is more mental than real, and the reaction to the anxiety-provoking stimulus is exaggerated. In this context, instead of serving a useful purpose, the anxiety program creates various vicious cycles, causing the exacerbation and chronicity of anxiety disorders. There are two main types of vicious cycles in anxiety disorders. The first cycle is where the bodily and cognitive symptoms of anxiety increase the perception of threat and danger. In other words, various bodily and cognitive symptoms are perceived as additional resources that increase the perception of threat. For example, when a bodily symptom such as blushing is perceived by the person as falling into an embarrassing situation, the feeling of shame will increase even more, thus causing the person to blush even more. When heart palpitations are perceived as evidence of a heart attack, anxiety will increase, and the palpitations will become more pronounced. Increased palpitations, in turn, will reinforce the belief that the person is having a heart attack. The second vicious cycle stems from the dysfunctional cognitive and behavioral strategies that anxiety sufferers use to avoid feared outcomes. Because the source of the fear is unrealistic, the strategies used eliminate the patient's chance to see that their thoughts and beliefs are inappropriate. For example, a patient experiencing palpitations and intense distress might leave the environment during a panic attack or try to distract themselves by talking to someone nearby; this same patient later believes that they escaped going insane or dying thanks to using these strategies. Thus, they are prevented from realizing that they would not have died or gone insane even if they hadn't used these avoidance strategies. These two vicious cycles summarize the basis of anxiety disorders.
Cognitive models used to understand/explain different anxiety disorders share a number of common characteristics:
A) In anxiety disorders, individuals who respond to certain stimuli with an anxiety response perceive these stimuli as more dangerous/threatening than they actually are (such as the perception of harmless bodily sensations as dangerous in panic disorder).
B) Anxiety patients also perceive the probability of the negative outcomes they fear occurring as more exaggerated than reality (for example, social phobic patients may firmly believe that their hands will tremble, their faces will blush, and they will sweat in a social situation).
C) Anxiety patients, when their feared outcome occurs, believe it will be a catastrophe (catastrophizing) (for example, social phobic patients may think their hands tremble or their faces blush, leading to embarrassment and being unwanted by those around them, or patients diagnosed with panic disorder may believe they will go crazy if they have a panic attack).12
D) Anxiety sufferers use a range of cognitive and behavioral strategies (such as fleeing, avoidance, distraction, trying not to think about it, carrying medication, not going alone to places they perceive as dangerous, sitting near the exit in crowded places like cinemas and theaters so they can leave immediately if they feel distressed) to prevent the outcome they fear from occurring (to prevent the catastrophe). 12
The aim of these strategies is to provide reassurance in feared situations, thereby preventing the feared outcome from occurring. The patient associates the occurrence of the feared outcome with the use of these strategies, and these reassurance-oriented behaviors prevent the patient from realizing that the feared outcome will not happen, leading to the persistence of the fear without change.
For example, a patient who has experienced multiple panic attacks and has seen that they haven't died or gone insane might attribute the absence of the feared outcome to having a trusted person with them during the attack or to the medication they took. Thus, they lose the chance to see that they wouldn't die or go insane even without medication or a trusted person, and their dysfunctional thoughts and beliefs ("panic attacks are dangerous and can be fatal," for example) remain unchanged.
E) In many anxiety disorders, the physical symptoms of anxiety are perceived as further evidence that the perceived danger/threat is real. As anxiety increases, physical symptoms increase, and as physical symptoms increase, the perception of danger/threat (anxiety) increases, thus creating a vicious cycle that perpetuates anxiety.
All anxiety disorders involve a perception of threat and danger. Phobic patients perceive danger in relation to a specific situation, object, or function, while panic disorder patients perceive bodily sensations as dangerous. Hypochondriac (health anxiety) patients worry about developing a serious illness, social phobics fear forming negative social judgments in social situations, and obsessive-compulsive patients fear causing harm. Patients with generalized anxiety disorder perceive uncertainty as a threat.