Fear, Anxiety

Question 1

Fear

Answer 1

• -> Unpleasant emotion caused by “real” threat.
• ->It has a survival value and it prepares the organism for the fight and flight response.
• -> Physical changes : Increased heart rate, shortness of breath, dizziness etc. (we all know how fear feels like)
• -> It is different from the stress and anxiety. (Stress = reaction itself, not an emotion, Anxiety = caused by anticipatory threat )
• Fear is a great emotion, it helps you to avoid and deal with the danger

Question 2

Differences between Anxiety and Fear (Fear Card)

Answer 2

Fear :
1- Caused by an observable threat
2-Threat “Here and Now”
3-It has an objective reason (Like a dangerous animal approaching you)
4- Fight/Flight response triggered
5-It NARROWS your attention (You only focus on the object of the threat)
6- Feeling is gone when the threat is disappeared.

Question 3

Differences between Anxiety and Fear (Anxiety Card)

Answer 3

1- Caused by the anticipation of a potential threat
2- Object of the anxiety is in the potential future (Not here and now)
3- Source of the anxiety is subjective.
4-Fight/Flight response is triggered (Same as Fear)
5- BROADENING of attention (you try to be ready for any kind of problem that may affect you in future, you look for them carefully)
6- Anxiety (since it is not caused by real threat) can be chronic and very harmful to your health.

Question 4

Responses to Danger

Answer 4

Fight
Flight
Freeze (can be experienced as black-out)
Avoidance

Question 5

Reticular Activating System (RAS)

Answer 5

A part of reticular formation, thought to be particularly involved in the regulation of arousal, alertness and sleep-wake cycles.

Question 6

Arousal

Answer 6

1- State of physical activation or cortical responsiveness / A state of excitement or energy expenditure
2- Associated with sensory stimulation and activation of fibers from the “Reticular Activating System”
3- Highly Related to : Person’s appraisal of the situation (this is the cognitive part of arousal) & Physical intensity of the stimulus
4- Arousal can facilitate or debilitate the performance

Question 7

Physiology of Arousal (2 Pathways)

Answer 7

1- Sympathetic-Adrenal-Medullary Axis ( “SA Axis”)
2- Hypothalamic-Pituitary-Adrenal Axis (“HPA Axis”)

BOTH AXIS START FROM THE HYPOTHALAMUS

Question 8

Sympathetic-Adrenal Medullary Axis

Answer 8

+ Neuroendocrine stress-response system.
+ Activated immediately during a stressful situation.
1- Stressor perceived via sympathetic nervous system.
2- Sympathetic nervous system triggers production and release of the “epinephrine and norepinephrine” hormones by the adrenal gland. ( specifically medulla)
*SA axis chemically interacts with HPA axis. ( Norepinephrine stimulates release of CRH and activates HPA axis)

Hypothalamus –> Sympathetic Nervous System –> Adrenal Medulla –> Release of Adrenalin + Noradrenalin

• Adrenal medulla and medulla oblongata are different things!! Second one is in the brain and Adrenal Medulla placed in your kidneys.

Question 9

Hypothalamic Pituitary Adrenal Axis (HPA)

Answer 9

+ Maintains body homeostasis by regulating neuroendocrine and sympathetic nervous system
+ Modulates immune response.
+ Core of the physical response to stress (But it also plays an important role in the food consumption, digestion, reproduction, cardiovascular functioning memory, emotion etc.)

Hypothalamus (Corticotropin Releasing Hormone [CRH]) –> Pituitary Gland (Adrenocorticotropic Hormone [ACTH]) –> Adrenal Glands –> Cortisol

*Difference between SA and HPA is that, HPA axis more related to long-term and consistent exposure to stressors.

Question 10

Negative Feedback Loop and HPA axis

Answer 10

–> Under the normal conditions, certain level of cortisol in the blood exerts a negative feedback to the hypothalamic release of CRH and pituitary gland release of ACTH. So, it inhibits the release of CRH and ACTH which directly inhibits the release of more cortisol into the blood. This system is called Negative Feedback Loop.

–> Dysfunction of HPA axis may cause different disorders such as mood disorders or anxiety disorders.

Question 11

Pathological Anxiety

Answer 11

• Hypersensitive Arousal System : Even a minor thing is enough to activate the stress response
• No real danger but you are freaking out ! (extreme anxiety)
• High intensity, long duration and high frequency anxiety experience
• Chronic, Disruptive
• Negative effect on person’s functionality and well-being.

Question 12

Agoraphobia (Can’t go out ! I am not safe)

Answer 12

+Most people develop this disorder after experiencing at least one panic attack

+People with Agoraphobia experience extreme level of anxiety when they are in places where it is difficult to escape (crowded public transport) or find help when they need [ basically it can be anywhere ,both enclosed and open spaces and they may consider their home as the only safe place]

+ They show avoidance behavior (Not going out at all or not going crowded places- depends on the severity of the disorder)

+They may heavily rely on a person (Going everywhere with accompanying people )

+Can be seen with/without panic disorder
(with panic disorders: panic attacks accompany to Agoraphobia)

Question 13

Panic Disorder (I can’t breath, my heart is beating so fast and I think I am dying! )

Answer 13

+ Recurrent and unexpected panic attacks !
+Sudden onset of anxiety and it escalates very quickly
+ It feels like your body is giving a fight/flight response out of nowhere [Autonomic Nervous System is activated]
+Shortness of breath, palpitations, tremor, dizziness etc.

+“Fear of dying”, fear of losing control, fear of going crazy may seen with panic attacks
(most of the time people think they are having a heart attack and they run to the hospitals or call an ambulance)

Question 14

Anticipatory Anxiety (Fear of fear)

Answer 14

+ People who feel extreme anxiety while they are thinking about future possible (or maybe not possible in reality) events or situations.

+ These people anticipate the worst from the future and mostly show catastrophizing thinking style
(Being extremely anxious about a future “possibility” of what happens if you lose your passport while going to airport and person who finds it ended up being a criminal and left your passport in a crime scene! )

+ Not a disorder by itself but generally comorbid with other anxiety disorders (Such as generalized anxiety or panic disorder)

+For diagnosis : Impairment in functioning and behavioral change at least for one month.

Question 15

Social Phobia (Oops ! There are people here)

Answer 15

+ Fear of scrutiny by people in social situations
(Can’t talk, can’t eat, can’t relax … Because people are judging you all the time)

+ Fear of embarrass yourself especially by the presence of the anxiety symptoms. Because your face is getting red, you are sweating etc.

+Because of the social anxiety people avoid social situations or apply specific tactics (Such as talking too fast)

Question 16

Specific Phobia

Answer 16

+ Exaggerated fear RESTRICTED TO specific situations or objects .

+ It can be anything (insects, clowns, elevators, weird stuff… There is even a phobia called “fear of money” (Plutophobia ) and I am happy to help those people :)

+Injection phobia is interesting because normally, our body gives fight or flight response (Sympathetic Nervous System) or maybe freeze response when we encounter the object of our phobia. In real life people don’t faint when they see a dog. But in blood and injection phobia people actually faint due to low blood pressure !

• Fun fact (maybe not fun for you) : Arachnophobia (fear of spiders) and Ophidiophobia (fear of snakes) are the most common 2 phobias in worldwide. Maybe our ancestors suffered from these two and these phobias are carried along through the genes)

Question 17

Generalized Anxiety Disorder (Everything makes me anxious ! )

Answer 17

+ Free-floating anxiety

+Exaggerated anxiety and worries that are generalized to many topics in everyday life

+ These people can’t stop worrying about everything and can’t control their anxiety

+Multiple physiological complaints and concentration problems, irritability, insomnia are experienced by the patients.

Diagnosis: This worrying about everything situation should be present at least for 6 months and should be seen at least 50% of the day.

Question 18

Experience of Fear : “Fearless” Patient SM

Answer 18

Fear experience is directly related to : Amygdala

Patient SM has “Bilateral Amygdala damage” and she can’t experience fear also she cannot give fear response

Her problem is only about “fear”. She can experience other emotions such as happiness.

How they tested it : In the case study she pets snakes, goes to horror house and has fun and finally watches horror movies and enjoys herself. When they asked her whether she felt any fear she answers them as “No ! I had fun”
Their conclusion : Wow ! This woman is fearless…

Question 19

Anxiety Makes your Hippocampus Smaller !!

Answer 19

On-going HPA axis stress response (chronic stress) is toxic to the Hippocampus and makes it shrink !

Question 20

Role of Hippocampus in Fear Experience

Answer 20

+ Processes contextual information
+ Has a role in the acquisition and expression of fear memories
+Context conditioning and context specificity of fear extinction : You experienced fear but in which context and where

• They generally give shock to mice in different mazes and observe whether they can differentiate dangerous maze and safe maze. Hippocampus works together with Amygdala to encode the “specific context of the fear”.

Question 21

Anxiety Drugs

Answer 21

● Serotonin Reuptake Inhibitors (SSRI)
● Serotonin- Norepinephrine Reuptake Inhibitors
● Benzodiazepines (sedated you)
● Monoamine oxidase inhibitors
● Tricyclic Antidepressant Drugs

*Both increasing and decreasing norepinephrine in the blood decreases anxiety. So we really don’t know how these drugs work…

Question 22

Psychotherapy : Cognitive Behavioral Therapy

Answer 22

+ Whether you feel anxiety about a certain situation is highly subjective and open to discussion.

+Therapist challenges your beliefs that trigger anxiety (I am not safe, People are always judging me etc.) and teaches you better coping mechanisms to deal with your anxiety.

“Change how you think –> Change how you feel”

Question 23

Psychotherapy: Exposure Therapy

Answer 23

• -> Great with specific phobias !
• -> Face your fears in a safe environment.

It can be “in vivo” or “gradual” exposure

Gradual: Starts from “imagining” the object of your phobia, step by step getting closer to actually facing with it.

Example : You have dog phobia. First you imagine it, second you imagine yourself while petting the dog… seeing dog 1 km away, being with a dog in the same room and finally touching the dog in real life.

In Vivo : You have a dog phobia. You tell this to your therapist. Your therapist puts you and the dog in the same room and leaves the room. You either die or overcome your phobia :)

Question 24

Psychotherapy : Relaxation Techniques

Answer 24

Progressive muscle relaxation is a very common technique that helps you relax and control your anxiety. It is used together with other psychotherapy techniques.

Imagery can also be used as a relaxation technique. Basically you imagine relaxing places (forest, sea etc.) and mentally send yourself to that place.

If you need to relax:
https://www.youtube.com/watch?v=86HUcX8ZtAk