by guest blogger Margo C. Watt, Ph.D.

Like death and taxes, everyone is familiar with fear and anxiety. Speaking in public, watching a scary movie, or meeting a bear in the woods; all can elicit physical sensations that accompany feelings of fear and anxiety – racing heartbeat, shortness of breath, sweating, and dizziness. Although we often use the words "fear" and "anxiety" interchangeably, they are not exactly the same thing. Fear, for example, is the emotion we feel when we encounter a clear and present danger such as meeting a bear in the woods. Anxiety, on the other hand, is what we feel when we anticipate a fearful situation or event in the future (anticipating the bear in the woods).

Anxiety is a normal part of being human. In some situations, being anxious may be appropriate or even desirable. For example, if you are preparing for a job interview or a tennis match, having some anxiety will actually enhance your performance. If you get too anxious before these events, however, your performance might suffer or you might avoid participating at all. Someone who is prone to panic anxiety might even experience a panic attack if they become too anxious. Panic attacks are abrupt episodes of intense fear or discomfort. Some people are more inclined to experience panic attacks than others. People with high levels of anxiety sensitivity (AS), for example, are at higher risk for panic attacks than people with low levels of anxiety sensitivity.

Anxiety sensitivity (AS) refers to the fear of bodily sensations associated with anxiety. This fear arises from the belief that these sensations have harmful physical, psychological, and/or social consequences. For example, a person with high AS might fear that a racing heart signifies an impending heart attack, might fear that dizziness means they are going crazy, or might fear social embarrassment if others should notice that their hands are shaking. AS is basically an anxiety amplifier. High AS has been associated with the development and maintenance of anxiety disorders including panic disorder, social phobia, and post-traumatic stress disorder. High AS also has been linked to anxiety-related disorders including hypochondriasis, depression, substance abuse, and chronic pain.

Research indicates that AS may arise from either genetic factors and/or learning experiences. Watt, Stewart, and Cox (1998), for example, found that levels of AS in a sample of young adults were related to learning experiences in their childhood. People who reported being reinforced for sick role behavior related to anxiety as children, such as being allowed to stay home from school or miss gym class when they experienced anxiety-related sensations, were more apt to fear these sensations in adulthood. People who reported witnessing their parents being frightened by anxiety-related sensations also reported higher levels of anxiety sensitivity. Indeed, certain learning experiences in childhood, such as exposure to parental uncontrolled behavior due to drunkenness and/or anger, have been linked to elevated AS levels in early adulthood.

Efforts to help people reduce their levels of AS have been impelled by the notion that lower levels mean lower risk for developing anxiety and related disorders. Following from the initiative of other researchers, such as Drs. David Barlow at Boston University and Michelle Craske at the University of California, Los Angeles, as well as Dr. Patricia Conrod at the Institute of Psychiatry in London, UK, Drs. Margo Watt and Sherry Stewart have designed a brief group-based cognitive-behavioral treatment (CBT) to specifically target elevated levels of AS in young adults at risk for anxiety disorders. Randomized controlled trials have been conducted in order to evaluate the efficacy of this intervention with female undergraduate students. To date, only female participants have been recruited for the intervention, so as to control for the effects of gender. Moreover, studies show that women tend to report higher levels of AS, as well as a greater risk for many anxiety disorders. The trial of the intervention involved participants being randomly assigned to either the brief CBT or control condition.

All participants attend three one-hour sessions which include three components. The psycho-education component of the brief CBT condition consists of informing participants about the anxiety cycle and how exposure to anxiety-related sensations (stressful situations) can trigger negative ways of thinking which in turn can trigger behaviors (e.g., such as avoidance) which maintain anxiety in he longer-term. Participants learn about two types of thinking errors that can occur in processing information related to anxiety: (1) catastrophizing (i.e., thinking the worst) and overestimating the probability that something bad will happen. Participants learn how to identify and challenge these dysfunctional automatic thoughts by examining the evidence [“what are the chances” that a harmful consequence (e.g., fainting) will ensue?], decatastrophizing (“what if” you did faint?), and substituting anxiety-provoking cognitions with more reasonable thoughts (“what else” could you think? - what is another way of looking at it?). In the third session, participants take part in running which acts as an interoceptive exposure activity. Interoceptive exposure involves the repeated, intentional elicitation of physical sensations that produce anxiety (e.g., via running) with the goal of breaking the connection between physical sensations and fear. This occurs by providing the individual with concrete experiences indicating that the physical sensations do not lead to the feared consequences, and by permitting habituation to occur (Carter & Barlow, 1993). The rationale for using running as an interoceptive exposure technique within the brief CBT was that research has found that high AS individuals tend to avoid activities, such as sex and physical exercise, which can induce the feared anxiety-related bodily sensations (McWilliams & Asmundson, 2001). Reduced physical activity, of course, can lead to other problems such as elevating one’s risk for both mental disorders (anxiety, depression) and physical disorders (obesity, type II diabetes).

To date, research with the brief CBT has produced a number of positive results. In addition to significantly reducing AS levels among participants with high (vs. low) AS who were assigned to the CBT (vs. control) condition (Watt, Stewart, Lefaivre, & Uman, 2006), other positive findings include a significant reduction in depressed mood (versus depressed symptoms), again specific to high AS (vs. low AS) individuals in CBT (vs. control) condition (Watt, Stewart, & Bernier, 2005). The brief CBT has been found to reduce the proportion of “high consequence” drinkers (i.e., those scoring above a clinical cut-off point) from pre-intervention to follow-up for high AS participants in the CBT condition only, as well as a reduction in relief alcohol outcome expectancies (i.e., strong endorsement of items such as “Drinking would make me feel less jittery”), and in conformity motives for drinking alcohol (i.e., drinking to fit in with a desired peer group) (Watt, Stewart, Birch, & Bernier, 2008).

Another exciting finding has been that the brief CBT intervention produced a moderate reduction in pain-related anxiety. High AS individuals who were randomly assigned to participate in the CBT program showed a significant reduction in overall pain anxiety scores as compared to high AS individuals in the control (NST) condition or low AS individuals in either treatment condition. Studies have found that regardless of pain severity, AS levels in chronic pain patients correlate positively with cognitive anxiety related to pain, escape/avoidance tendencies, and fear of the negative consequences that may accompany pain (see Asmundson & Norton, 1995). Thus, targeting cognitions that can exacerbate fear of fear (e.g., catastrophizing about the consequences of arousal-related sensations) could work to prevent the development of chronic and persistent pain. Moreover, reducing AS levels may yield positive benefits in terms of the use of analgesics given the findings of Asmundson and Norton (1995) that chronic pain patients with high AS report more continued use of pain-relieving medications as compared to chronic pain patients with moderate and low levels of AS. Given that chronic pain is a complex problem with both clinical and psychological implications, interventions, such as this brief CBT program designed to target a risk factor associated with chronic pain, could represent an important step toward developing a time- and cost-efficient approach to the prevention and treatment of chronic pain. This empirically supported approach to reducing AS is soon to be published as a self-help manual which high AS individuals may wish to use on their own, or more preferably with the advice and guidance of a trained mental health practitioner.

Margo C. Watt, Ph.D. is the co-author (along with Sherry H. Stewart, Ph.D.) of Overcoming The Fear of Fear: How to Reduce Anxiety Sensitivity.