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“All that we see or seem to see is but a dream within a dream” - Edgar Allen Poe

In recent times, we have seen a sharp increase in fear-related disorders, which has been described as an anxiety epidemic. Fear, anxiety, phobias, obsessions and compulsions are the stuff of television shows, radio columns and magazine articles. But the tide is turning and patients, who are now empowered, see themselves as consumers of health care and these consumers are demanding more.

The prevalence of anxiety disorders

It is estimated that around 273 million people, or 4.5% of the world's population, have suffered from anxiety disorders. These disorders are more common in women than men, and up to 16% of people suffer from them throughout their lives. In Western societies, this figure reaches nearly 29% of the population.

While many children suffer from normal childhood fears such as night terrors and school phobia, many diagnoses at this stage of life are incorrect and children are often misdiagnosed with problems such as physical problems or ADHD . However, anxiety levels vary from child to child and certain conditions, such as autism, can cause increased anxiety. Both adults and children can also experience traumatic events that can trigger fear and the “anxiety response.” People with anxiety disorders are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than those without anxiety disorders.

Fight or flee?

Let me first untangle some misconceptions about fear and anxiety. Like many other psychophysiological reactions (i.e. the psychological and physical response in humans), fear, when it exceeds a certain threshold, blocks the individual and prevents him from reacting appropriately to the events he faces. Fear causes humans to want to run and flee from the perceived threat, commonly referred to as the fight or flight response. In these phases of excitement, we can focus on ourselves and become hypervigilant. When we feel threatened by circumstances, fear activates the body's normal arousal system, preparing us to respond appropriately to the situation. The fight, flight, and freeze response results in dilated pupils, a rush of blood to the heart, and a cold, clammy feeling in the extremities. In this state, our hearing becomes very sensitive and we may appear paler than normal. These are normal, highly developed reactions that human beings have evolved to successfully deal with threats.

Fear and anxiety

Fear and anxiety are very closely related and both contain the idea of ​​danger or possibility of injury. In general, fear is considered a reaction to the perception of threat posed by a specific, observable danger. Anxiety, on the other hand, is considered diffuse, a kind of unfocused, objectless, future-oriented feeling. Fear is therefore a perception attached to a specific thing, thought or circumstance. For example, worries about death are more likely to take the form of nagging anxiety than true fear. Anxiety also refers to emotional states such as doubt, boredom, mental conflict, disappointment, shyness, or excitement associated with the perception of fear.

We must also understand that fear, as an emotion or psychobiological reaction, is not in itself a form of pathology or disorder; rather, it is a fundamental sensation that we use to successfully adapt to our environment. The use of fear by animals and humans has helped us survive in hostile social and physical environments. Without a good dose of fear, we would not have survived; we wouldn't care about our grades in school or the quality of our life. Not only does fear draw our attention to real dangers, but it allows us to confront these situations, having recognized them as threatening to our psychological, physical or social well-being. It is important to understand that we should never seek to suppress fear, although it would be impossible even if we wanted to, because fear is a functional, healthy, and meaningful experience that allows us to manage life effectively. Fear only becomes problematic and pathological when it fails to achieve its goal, which is to effectively manage and respond to the situation at hand. On the contrary, when it turns into anxiety, it blocks us and turns us into a trembling wreck, incapable of progress.

Pathological anxiety

Anxiety, even when intense, is rarely pathological until it becomes chronic and constantly interferes with our performance and enjoyment of life. When anxiety is excessive and disconnected from reality, it no longer serves as an accurate and reliable danger signal. As a result, you may feel anxious thinking about an important test, going to a dinner where you don't know anyone, or traveling to an unfamiliar place. These anxious thoughts are driven by "what ifs" (for example, "what if the car breaks down" or "what if I don't know anyone").

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What makes the difference between fear as a useful natural emotion and fear as a pathological reaction is that the former increases our ability to deal with reality and the events that present themselves to us. The second, on the contrary, limits us or makes us unable to react, which often leads to generalized anxiety disorders or panic attacks. It is only when our threatening perception of reality becomes incapacitating and limiting that we find ourselves faced with a difficulty that must be addressed urgently. We should not rest on our laurels regarding the effects of migrating from fear of a specific area of ​​life to an overall terror of many aspects of life's normal daily activities.

Anxiety vs. Fear

Anxiety does not necessarily require a triggering stimulus. It is the actual anticipation of a threat that stimulates the physical-psychological response to a perceived fear or threat. Anxiety can therefore become chronic and cause us to be hypervigilant in the face of any possible or potential threat, real or imagined. For example, a panic attack involves the interaction of the fear system with an inappropriate and maladaptive mode of learning (i.e., a false alarm). Panic is generally characterized by a sudden feeling of dread and imminence, as well as a number of unpleasant and distressing physical sensations, such as increased heart rate, difficulty breathing, trembling, abdominal tension and muscles, etc. The ambiguous nature of anxiety makes it difficult to overcome.

If we don't know the source of our anxiety, it is difficult to treat the problem, and this is the case with many of today's fears that people present to our clinic. It's possible to be anxious about things that will almost certainly never affect us. Anxiety can be a source of strength and can, for example, lead to better job performance. Anxious people are more likely to be goal-oriented, more organized, and more self-disciplined. They plan effectively for unforeseen events and consequences that others may overlook. They take better care of their health.

In short, anxiety is productive when it is not excessive. In fact, the goal of any good therapy is to reduce anxiety, not eliminate it.

References 

• Gibson, P. and Boardman, D. (2017) Heresies From Practice; in Simon, G., and McCarthy, I. (eds) Systemic Therapy as Transformative Practice. Everything is Connected Press.
• Gibson, P., Pietrabissa, G., Manzoni GM, et al. (2018) Brief strategic therapy for obsessive-compulsive disorder: a clinical and research protocol of a one-group observation.
• research protocol for a one-group observational study. BMJ Open 2016;6:e009118. doi:10.1136/bmjopen-2015-009118
• Gibson, P., (2019) Systemic Family Therapy Paradigm in Nardone, G., Salvini, A. (eds) The International Dictionary of Psychotherapy. Karnac Books.
• Nardone, N. and Watzlawick, P. (1990), L'Arte del Cambiamento, manuale di terapia strategica. Ipnoterapia senza trance, Ponte alle Grazie, Firenze.

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• Panic disorder and agoraphobia
• Social Phobias - Social Anxiety Disorder and Paranoia
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