Clinical Handbook of Mindfulness (49 page)

Chapter 10 Mindfulness and Anxiety Disorders

173

Table 10.2.
Primary anxiety disorders, clinical descriptions, and lifetime

prevalence.

Diagnostic category

Clinical description

Lifetime prevalence
∗

Generalized anxiety

Persistent, pervasive worry that

5%

disorder

is difficult to control

Obsessive-compulsive

Obsessive thinking about

2.5%

Disorder

possible threats to safety and

compulsive ritualistic

behaviors to allay fear

Panic disorder

Sudden, overwhelming, intense

1.0–3.5%

fear of something going

wrong

Post-traumatic stress

Intrusive thoughts,

8%

disorder

hyperarousal, and

reexperience of past trauma

Social anxiety

Fear of negative social evaluation

Up to 13%

disorder

Specific phobia

Fear of a specific object or

7–11%

situation

∗Obtained from DSM-IV-TR,
American Psychiatric Association (2000).

heightened psychophysiological arousal, and intensely unpleasant appraisals

of one’s internal emotional experience
(Brantley, 2003).
Taken together, anxiety disorders are the most prevalent category of mental health diagnoses,

affecting an estimated 25–30 million Americans during their lifetime
(Lepine,

2002;
Narrow, Rae, Robins, & Regier, 2002).

Anxiety disorders are often conceptualized as a
fear of fear
that results in

high levels of subjective distress, somatic symptom manifestation, and disrup-

tion of daily living
(Barlow, 2002).
Worry has been described as the persistent activation of one’s cognitive representation of anxiety, including disturbing

thoughts, stories, or images about a possible danger or threat (Borkovec, Ray,

& Stober,
1998).
Despite its useful function in helping one to cope, feel safe, and prepare for what may come, persistent worry and its associated affective distress and physiological arousal can produce defensive, self-protective,

and avoidant behavior out of context, typical of psychiatric disorder
(Barlow,

2002;
Borkovec et al., 1998).

The Psychobiological Nature of Fear and Anxiety

The psychological experience of fear occurs concomitantly with a pattern of

stress-related physiological activation designed to promote survival by avoid-

ing danger through fight-flight-or-freeze behavior
(Barlow, 2002).
A startle response initiated by sensory detection of a potentially threatening stimulus,

such as a sudden loud noise, a looming shadow, or an unexpected touch,

immediately signals the subcortical structures in the brain (i.e., the limbic

system) that perceive threat and mediate an alarm reaction. This alarm reac-

tion descends from the limbic system through the brainstem, spinal cord, and

peripheral nervous system, ultimately activating a broad-spectrum physio-

logical response throughout the body. Integrated psychophysiological activa-

tion in response to a perceived threat enables one to cope through vigorous

defensive action, such as fighting or fleeing
(Schneiderman & McCabe, 1989).

These adaptive responses are generated by activation of multiple body sys-

tems, including the central and peripheral nervous systems, cardiovascular

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Jeffrey Greeson, Jeffrey Brantley

system, endocrine system, metabolic system, neuromuscular system, and

immune system
(Selye
,
1976).
Conversely, select biological systems unessential for survival in the face of an immediate threat, including the digestive

system and the reproductive system, are deactivated under conditions of fear

or stress
(Selye
,
1976).

Psychophysiological activation and accompanying energy mobilization is

certainly useful in supporting escape behavior when actual escape is possi-

ble. When a threat outweighs one’s perceived ability to escape or otherwise

cope, however, behavioral freezing and cognitive hypervigilance may occur

in an attempt to passively avoid harm
(Schneiderman & McCabe, 1989).

Under conditions of passive avoidance rather than active coping or escape,

the physiological effort and energy generated can go unused. While acute,

time-limited onset and recovery of stress-related mental and physical acti-

vation clearly provides an adaptive advantage in the face of a true threat

(i.e., when actual fighting, fleeing or freezing is needed to promote survival),

chronic or unwarranted activation of fear-related psychophysiology can be

detrimental to health. Indeed, a growing body of animal and human research

indicates that repeated, exaggerated, or prolonged activation of stress physi-

ology, as well as delayed recovery of biological responses to stress, can con-

tribute to premature breakdown of organ systems that may increase suscep-

tibility to disease
(McEwen, 1998).

Mind/Body Connections and Processes Underlying Clinical Anxiety

Anxiety disorders can be characterized by a set of dysregulated cognitive,

affective, physiological, and behavioral processes that manifest as maladap-

tive ways of responding to one’s inner experience of fear. Dysregulated cog-

nitive processes in anxiety disorders typically include the following:

• a narrow focus of attention on some disturbing aspect of internal experi-

ence, such as a distressing thought or physical sensation,

• misappraisal of threat in the absence of real danger, and

• distortion of the magnitude of a true threat or challenge through magnify-

ing, catastrophizing, or fortune telling
(Barlow, 2002).

In addition, from a cognitive standpoint, anxiety disorders can be char-

acterized by a focus of attention on future-oriented concerns about possi-

ble misfortune
(Barlow, 2002).
The narrow focus of attention on disturbing thoughts or physical sensations, coupled with a future-oriented tendency to

worry about
potential
threats of harm, can predispose an individual to a lack

of awareness of what is actually happening in the present moment
(Brantley,

2003).

When one is unaware of what is actually happening in the present

moment, one’s attentional focus is more susceptible to being hijacked by

a train of cognitive interpretations about one’s experience that may be inac-

curate and distress provoking. For instance, in the case of depression, the

“downward spiral” of automatic, negatively biased information processing,

or “depressogenic thinking,” can transform momentary emotional distress

into longer-lasting mood disturbance, which in turn, can increase suscepti-

bility to depressive relapse
(Segal, Williams, & Teasdale, 2002).
Similarly, in the case of anxiety, a cognitive style marked by a narrow focus of attention,

Chapter 10 Mindfulness and Anxiety Disorders

175

orientation to future events as opposed to present moment experience, and

a propensity to catastrophically appraise or misinterpret mental or physical

phenomena can result in the arousal of anxiety and other emotional distur-

bances such as anger, sadness, and loneliness.

While the perception of fear and anxiety occurs in the brain, the response

can be most noticeable in the body. The induction of fear and other forms

of negative affect stimulates widespread sympathetic activation, which orig-

inates from pathways in the cerebral cortex and subcortical limbic struc-

tures (e.g., amygdala, hippocampus, hypothalamus), and descends through

the brainstem, spinal cord, and peripheral sympathetic nerves to organ sys-

tems throughout the body
(Thayer & Brosschot, 2005).
Consequently, fearful cognitive interpretations and associated emotional and physiological arousal

can manifest in an array of somatic symptoms, including painful muscle ten-

sion, racing pulse, elevated blood pressure, cardiac arrhythmia, labored respi-

ration, and gastrointestinal disturbance. Moreover, given one’s anxiety-prone

cognitive style, somatic symptoms can be interpreted as evidence of harm,

which may result in even narrower attention to the symptoms, catastrophic

thinking, acute panic, emotional distress, and even a sense of impending

doom. Because these internal experiences are unpleasant and aversive, they

are typically avoided by actively attempting to distract attention away from

the inner experience when it is present and attempting to prevent recurrent

anxiety in the future by avoiding associated people, places, or things. Taken

together, it has been noted that “reactions (both cognitive and emotional) to

one’s own internal experiences (thoughts, feelings, bodily sensations) may

underlie the development and/or maintenance of anxiety disorders,” which

categorically manifest as psychological and behavioral inflexibility (Orsillo,

Roemer, & Holowka,
2005).

Overview of Current Treatments for Anxiety

Given the integrated mind/body nature of fear and experiential anxiety, it is

logical that effective treatment strategies for anxiety disorders address both

mental and physical functioning. Standard treatment approaches for clinical

anxiety include psychotherapy and medication, both of which are intended

to modulate cognitive, affective, physiological, and/or behavioral reactions to

perceived threat
(American Psychiatric Association, 2005).
Several different psychotherapies and medications are equally efficacious in the short-term

amelioration of anxiety-related symptoms (American Psychiatric Associa-

tion,
2005).
Effective psychotherapies include behavior therapy in which an individual is systematically exposed to a feared condition without being

permitted to engage in an automatic, avoidant behavioral response, and

cognitive-behavioral therapy (CBT), in which distorted beliefs, misappraisals,

contextually inappropriate emotional reactions, and inflexible behavior pat-

terns are identified and corrected using self-monitoring, cognitive restructur-

ing, and relaxation training (for detailed reviews see
Barlow, 2002).
CBT for anxiety has demonstrated to be superior to medication for long-term symptom reduction
(Otto, Smits, & Reese, 2005).
There are many “active ingredients” in psychotherapeutic approaches to anxiety disorders, and it remains

unclear to what extent specific cognitive, affective, behavioral, or psy-

choeducational components account for therapeutic change, as opposed to

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Jeffrey Greeson, Jeffrey Brantley

non-specific factors such as therapist attention, empathy and positive regard,

or perceived social support
(Barlow, 2002).
Effective medications for the treatment of clinical anxiety include benzodiazepines, tricyclic antidepressants, monoamine oxidase inhibitors, and selective serotonin reuptake

inhibitors
(Sheehan & Harnett Sheehan, 2007).
In chronic and/or treatment refractory cases, psychotherapy may be effectively combined with pharmacotherapy
(Sheehan & Harnett Sheehan, 2007).

In recent years, mindfulness- and acceptance-based approaches have

been combined with traditional change-based approaches such as CBT in

an attempt to enhance effective treatment of psychopathology, including

anxiety and depressive disorders (for reviews see
Feldman, 2007;
Hayes,

2005; Lau & McMain, 2005;
Orsillo & Roemer, 2005; Segal et al., 2002).

Because individuals who experience clinically relevant anxiety typically have

a strongly conditioned desire to avoid distressing internal experiences –

despite the tendency of experiential avoidance to prolong or even exac-

erbate distressing sensations – mindfulness practice offers a fundamentally

different orientation in which anxiety is deliberately noticed, allowed, and

responded to with openness, curiosity, and acceptance. Therefore, practic-

ing mindfulness may increase distress tolerance, interrupt habitual avoid-

ance, and ultimately promote adaptive self-regulation and healthy mind/body

functioning.

How Mindfulness May Target the Shared Roots

of Anxiety-Related Suffering

Modern-day responses to psychological stress, fear, and uncertainty are often

marked by rumination, worry, anticipatory anxiety, and stagnant delibera-

tion. These habits of thinking continue to stimulate fear reactions in the body,

which in turn, feed back to fuel worried thoughts, causing a cycle of unpleas-

ant experience
(Brosschot, Gerin, & Thayer, 2006;
Feldman, Hayes, Kumar, Greeson, & Laurenceau,
2007).
Consequently, one might say that human beings today are more likely to fight the
unpleasantness
of their own inner

experience of threat rather than fight off the threat itself. In the short term,

strategies for avoiding one’s inner experience of anxiety, such as distraction,

thought suppression, or the use of emotion-regulating substances including

cigarettes, alcohol, illicit drugs or food, may be effective in reducing dis-