Chapter 2

The Alarm Response

In this chapter you will learn about the alarm response to threats, identify your type of anxiety, and begin to plan your treatment.

Chronic anxiety is like having an alarm sound in your mind and body that won’t turn off. It just keeps ringing and warning you of danger. Everyone has a hardwired alarm system designed for survival. It helps you survive by mobilizing you to deal with threats. To understand how this valuable alarm response gets stuck in the “On” position, we first have to see how the mechanism works. There are four steps in the alarm response:

  1. Perception of threat—the alarm sounds.
  2. Appraisal of threat—you assess how serious the danger is and whether you have the resources to cope.
  3. Physiological and emotional responses—you experience a cascade of physical sensations preparing you to deal with danger, and the emotion of fear.
  4. Behavioral response—you do something to feel safer, such as avoiding the threat, postponing the threat until later, distracting yourself from the threat, and so on.

Perception of Threat

There are three kinds of threats we are always alert for. The first is external. You’re out in the woods and notice a bear lumbering in your direction. Or your boss frowns and says she’s concerned about your performance. Or your partner seems withdrawn and disconnected. Whether the threat is physical injury, loss of your job and livelihood, or a possible rejection, the danger is that something bad will happen to you via outside forces.

Internal threats originate with sensations in your own body. Any kind of physical pain is an example of an internal threat. A surprising, unfamiliar sensation can be threatening, as are sensations associated with danger, such as rapid heartbeat, shortness of breath, or light-headedness.

The third type of threat is a conditioned threat, or phobia. This is an object, a situation, or even an internal experience that’s not very dangerous itself, but has become associated with the expectation of harm. This process, based on classical conditioning, is how phobias are formed. Most of us experience very little sense of danger getting in a car. But if your car gets linked in your mind to a terrible accident you witnessed, or a scary near-collision you experienced, something may change. Your car changes from a neutral, non-frightening stimulus into a conditioned, threatening stimulus. You now have the same fearful response to driving your car as you had to the accident or scary near-collision.

When these learned linkages occur, almost anything can become a conditioned stimulus/threat. You’re probably aware of some of these phobias—heights, tight spaces, freeways, hypodermics, elevators, airplanes, public places, dizzy feelings, bees, feeling hot, darkness, thunder, rodents, dogs, spiders, and so on.

Appraisal of Threat

Once the alarm has gone off, your mind kicks in, trying to determine how much danger you face. First, there is an assessment of the level of threat. How big is the bear? Is it moving toward you? Does it look aggressive? In the case of conditioned threats (phobias) the evaluation of danger may be near instantaneous, and largely depends on how close you are to the feared object or situation.

Appraisal of the level of threat can run the gamut from accurate to utterly wrong. Your evaluations of conditioned threats, because they’re driven by a learned relationship between a neutral stimulus and grave danger, will usually be distorted. Inaccurate or distorted assessments of danger are called misappraisals, and two components of the treatment program in this book will help you overcome them.

In addition to appraising the immediate threat, your mind will also try to predict outcomes. What bad things might happen in five minutes, tomorrow, in a month? This fortune-telling response to threat is natural. Assessing possible catastrophic outcomes has helped us survive as a species. But when your mind locks onto threats and won’t let go, when you can’t stop preparing for all the harmful things that could happen, a normal mental process has gone awry. Instead of protecting you, this worry/rumination response can drive anxiety to overwhelming levels. This treatment program includes a component called defusion that will help you deal with ruminative thoughts.

The third appraisal in response to threat is an assessment of your ability to cope. Do you feel strong enough to face it? Do you have the resources to withstand the pain or stress this threat might bring? The appraisal of your ability to cope, if it is high, leads to self-efficacy—confidence that you can deal with difficult things. If it is low, you may experience distress intolerance—a sense that you can be quickly overwhelmed by painful events. Distress intolerance is a major contributor to chronic anxiety, and there are two components of this treatment program that target it.

Here is an outline of the typical threat appraisal process, teased apart and slowed down so that you can clearly see the three types of appraisals that determine whether your response will be a decline in anxiety or escalating anxiety and avoidance:

Perception of Threat: The alarm sounds: Danger!

Notice that the alarm bell shuts off if your appraisal of the threat or future danger is low. Likewise, the alarm diminishes or stops if you determine that you have the coping resources to face the threat. Only if the current or future danger seems high and you lack the ability to cope does the alarm continue, triggering both anxiety/fear and physiological arousal.

Avoidance behaviors typically occur only after anxiety/fear and arousal have been triggered. The decision to avoid is often automatic and unconscious, unless you have a strong reason to face the threat (for example, avoidance would trigger dire negative consequences, or there is something you value about facing this particular fear). You will learn, in this treatment program, how to consciously and deliberately make the decision to face threats and the anxiety they trigger.

Physiological and Emotional Responses

The physiological response to threat has been labeled the fight-or-flight reaction (Cannon, 1915), and more recently the fight, flight, freeze reaction (Clark, 2011). As soon as you decide there is a significant threat, your body reacts with a rapid sequence of protective responses. Your sympathetic nervous system triggers the pituitary gland to produce the stress hormone ACTH, and your adrenal gland to release the neurotransmitter epinephrine. Ultimately this results in:

All of these autonomic reactions prepare you to survive a threat in the best possible way by (1) running away, (2) fighting and defending yourself, or (3) freezing and playing dead. Your brain decides which of these to do in just a few seconds.

Meanwhile, as your body reacts, the hypothalamus and the limbic areas of your brain are beginning an emotional response—fear (a threat is right in front of you) or anxiety (a threat may occur sometime in the future). The emotion of fear/anxiety creates a painful level of arousal that makes you want to do something to stop it. While fear is adaptive, motivating you to avoid danger, false alarms trigger fear-driven avoidance that makes you run from what isn’t dangerous.

Behavioral Responses

All emotions share a single function—to organize and motivate behavior that helps you survive. Anger, for example, drives aggressive behavior to protect you from attacks. Sadness pushes you to withdraw so you can reevaluate following a loss or failure. And fear urges you to resist or avoid whatever scares you. So embedded in every emotion is an innate, hardwired urge to take action that helps to keep us alive.

The urge triggered by fear or anxiety is to seek safety. The most common safety behavior is avoidance—the flight part of the fight-or-flight reaction. Avoidance can take three forms: avoiding certain situations, avoiding certain thoughts, or avoiding certain sensations. Or instead of immediate avoidance, you might try to determine whether you are safe by checking for danger or seeking reassurance to ascertain whether the threat is as dangerous as you feared. If a threat is unavoidable, you might perform certain mental or physical rituals like invoking divine help or hand washing to feel safer. Safety behaviors can take many forms.

Example: Sheila’s Alarm Response

Several hours after getting home from a baseball game where Sheila ate two ballpark franks, she started to have sharp stomach pain. The threat led to an immediate appraisal of the level of danger.

Sheila’s mother had died of cancer several years before, and had endured a great deal of pain. As a result, Sheila had begun to recognize physical pain as something dangerous, something alarming. What would turn out to be a bad hot dog was misappraised as highly dangerous and perhaps life threatening.

Sheila began trying to predict the future. Perhaps this was cancer, and she’d need surgery and chemotherapy. Like her mother, she might not survive. How would she provide for her two teenage boys, given that her ex-husband was a lunatic and would damage her sons if he got his hands on them? How would she keep a roof over her head if she couldn’t work anymore? Sheila worried, or ruminated, about cancer until she threw up. Because she’d had a number of stomach upsets lately, she started thinking that maybe she also had irritable bowel disease.

As she struggled with the weight of catastrophic possibilities, Sheila wondered how she would cope. Her mother had “given up” at the end, and maybe she would, too. Sheila suspected that the stress would be overwhelming and that she couldn’t cope.

The misappraisal, worry/rumination, and distress intolerance were taking a toll. Sheila could feel her heart beginning to race. Her face and chest felt hot. She was light-headed. When she stood up, her legs felt shaky and weak. Now the alarm response began merging with growing anxiety. Both her body and her emotions were screaming “Danger!” Sheila noticed all this and thought, I’m in real trouble.

Half an hour later Sheila indulged in a common safety behavior—seeking reassurance. She went online to read about stomach and colon cancer as well as irritable bowel syndrome. Weeks later when a friend invited her to another ball game, Sheila turned her down, using the most common safety behavior—avoidance.

False Alarms

When you react with fear and safety behaviors like avoidance to low-danger objects or situations, that’s a false alarm. The more false alarms you experience, the more you suffer unnecessary anxiety and arousal. Frequent false alarms result in avoiding things you don’t need to avoid, constricting and diminishing your life.

False alarms have four causes:

These four factors not only create false alarms, but they also usually combine to maintain your anxiety disorder. They are literally driving and deepening your fear and your pain. Each of the treatment steps that follow in this book targets one or more of these factors. As you free yourself of their influence, your anxiety and fear, your arousal, and all the constrictions that avoidance has placed around your life will greatly diminish.

The Anxiety Disorders

In the DSM-5, the diagnostic manual followed by most therapists and used by health insurance companies to approve payment, there are six types of anxiety disorders: generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, panic disorder, specific phobia, and post-traumatic stress disorder. They are significantly different from each other, and yet there are key factors common to all. Some people’s anxiety fits neatly into one diagnosis and some people’s anxiety spans two or three categories.

Let’s look at the criteria for each and which symptoms sound familiar to you. Put a check by each disorder that might apply to you, and list the situations that you fear.

Generalized Anxiety Disorder

If you have generalized anxiety disorder (GAD), you worry about multiple things. You focus on all the bad things that might happen. Everyone worries at times about money, work, or relationships, but you worry too much and for too long. The excessive worrying prevents you from enjoying a full life. The core experience is an uncontrollable feeling of uncertainty and a fear of catastrophic outcomes. While worry is an attempt to overcome uncertainty by predicting and trying to prevent bad things that could happen, it has the effect of making you more anxious and uncertain, not less. As your anxiety rises, you then use safety behaviors to cope—things like checking, reassurance seeking, procrastinating, avoiding, overpreparing, using drugs and alcohol, distracting yourself, and other behaviors.

Generalized anxiety disorder symptoms include:

Situations I worry about:

Social Anxiety Disorder

As someone who struggles with social anxiety, you fear rejection and social shame. You worry excessively about what others may think of you. You might avoid jobs or social situations that would put you in the position of being judged by others and potentially criticized or rejected. To regulate these feelings of anxiety you may tend to isolate, leaving you feeling lonely and limiting your life and relationships.

Social anxiety disorder symptoms can include:

Situations I fear:

Obsessive-Compulsive Disorder

The core experience of obsessive-compulsive disorder (OCD) is fear plus compulsive coping behaviors. OCD is a common, chronic anxiety disorder in which a person obsessively thinks about and tries to avoid a specific fear, such as:

When a person encounters a situation that triggers the OCD fear (such as driving near a schoolyard, cutting vegetables next to a loved one, touching the latch on a toilet stall, being near someone who might have a disease, making a mistake, and so on), the person will attempt to control the fear with a safety behavior or compulsive ritual. These compulsive behaviors can include:

Situations I fear:

Panic Disorder

People with panic disorder have recurrent, unexpected panic attacks, which are sudden periods of intense fear that may include palpitations, pounding heart, accelerated heart rate, sweating, trembling or shaking, sensations of shortness of breath, the sense of being smothered or choking, or the feeling of impending doom. The core fear is of sensations in your body that are harbingers of panic, and the panic itself.

Panic disorder symptoms include:

Situations I fear:

Specific Phobia

As the name suggests, a person with specific phobia experiences intense fear in response to a particular object or situation. Fear of blood or needles, fear of enclosed places, and fear of flying are examples of specific phobia. Fear of spiders, fear of snakes, and fear of heights are some more common ones. While many people experience fear of certain situations or things, the key issue with phobia is that the individual feels (1) compelled to avoid it, and (2) the avoidance affects that person’s life in a negative way. For example, for a person who lives in New York City, a fear of snakes may not be very concerning. On the other hand, a backpacking guide with a phobia of snakes would need either treatment or a new job.

Situations I fear:

Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) can occur after you have been through a traumatic event. A traumatic event is something terrible and scary that you either witness or personally experience, such as:

During a traumatic event, you may fear that your life or others’ lives are in danger. You may feel that you have no control over what’s happening around you. Most people have some stress-related reactions after a traumatic event, but not everyone experiences PTSD. If your reactions don’t go away over time and they disrupt your life, you may have PTSD. Those with PTSD try to avoid situations or people that trigger memories of the traumatic event. They even avoid talking or thinking about the event. If you struggle with PTSD, the way you think about yourself and others may change because of the trauma. You may feel surges of anger, fear, guilt, or shame. You may also experience nightmares or unwanted flashbacks to the event.

Situations I fear:

The preceding lists of feared situations will be expanded in the next chapter. But first, the following exercise will help you plan your treatment and how you will use this book. (A downloadable version of this worksheet is available at http://www.newharbinger.com/34749.)

Comprehensive Coping Inventory

The items in this inventory are different ways of dealing with problems. As you complete this inventory, think about difficult or stressful events in your life. Do your best to rate each item in terms of how frequently you use it. There are no right or wrong answers, so choose the most accurate answer for you, not what you think is most acceptable, or what most people would say or do.

Rate each item on a scale of 1 to 5, where 1 means you don’t use that strategy at all, and 5 means you use it a great deal.

1.1 I try to stay away from things that make me anxious or uncomfortable rather than face them.

1.2 I worry about all the bad things that could happen in the future.

1.3 When I get upset by a situation, my negative thoughts often don’t turn out to be completely true.

1.4 I don’t believe I can cope with situations in which I feel anxious or fearful.

2.1 I tend to avoid situations, people, places, or things that make me feel anxious or upset.

2.2 I tend to focus on all the negative outcomes that might result from a decision.

2.3 I tend to assume things will be worse—more painful and scary—than they turn out to be.

2.4 I doubt my ability to face situations that trigger anxiety.

3.1 If I feel anxious and uncomfortable I avoid situations altogether—even though I wish I didn’t have to.

3.2 Whenever there’s a problem, I tend to dwell on the worst things that could happen.

3.3 When the situations are especially upsetting to me, I tend to have a string of thoughts about myself or others that feel true at the time, but often aren’t.

3.4 I don’t know how to cope with anxious feelings or situations in which I am fearful.

4.1 There are situations or things that make me anxious, and I try to avoid them.

4.2 I find that I tend to overthink bad scenarios that could happen.

4.3 I easily jump to conclusions when I’m upset by something—and my conclusions aren’t really accurate.

4.4 I feel distressed by fear or anxiety in a way that seems too big to cope with.

5.1 I try to avoid things I feel I must do to protect myself from feeling too anxious.

5.2 My problems trigger a lot of thinking about all the bad directions things could take.

5.3 In difficult situations I can have one negative thought after another that makes things seem worse than they really are.

5.4 I don’t feel strong enough to face fear-inducing situations.

You might feel overwhelmed by the number of items that were relevant for you. The good news is that you are bringing awareness to the coping behaviors that are reinforcing your anxiety. This is where the change starts to happen. Let’s look at what’s significant for you.

1.1, 2.1, 3.1, 4.1, and 5.1 are statements that apply to avoidance of the things that make you feel anxious. These can be people, places, situations, things, or internal sensations that you tend to avoid.

1.2, 2.2, 3.2, 4.2, and 5.2 are statements that apply to worry/rumination, extended worrying about future dangers or threats and making negative predictions about the future that get in the way of creating solutions to problems.

1.3, 2.3, 3.3, 4.3, and 5.3 are statements that apply to cognitive misappraisal, evaluating a situation, object, sensation, or person as dangerous when it isn’t.

1.4, 2.4, 3.4, 4.4, and 5.4 are statements that apply to distress intolerance, the belief that you can’t stand certain experiences and the emotions they trigger.

Your Treatment Program

Avoidance. If you scored 15 or higher on the inventory items concerning avoidance, you are in good company. You are in exactly the right spot and can confidently go on reading into the next chapter. Avoidance is the number one cause and maintainer of chronic anxiety. Most people who take this inventory score high on avoidance, and nearly half of this book is devoted to ways of solving the avoidance problem.

The number one solution to avoidance, proven in controlled study after controlled study, is exposure. Put simply, exposure is solving your anxiety problem by successfully experiencing whatever you are afraid of. The next six chapters of this book take you step by step through the process of exposure. It is a challenging but powerful and comprehensive treatment. Even if you scored relatively low in this section of the inventory, you should work diligently through the next four chapters. Mastering exposure is the key to long-term anxiety treatment.

Worry/rumination. If you scored 15 or higher on the inventory items devoted to rumination, you should supplement the next four chapters by also working through chapter 8, “Reducing Worry with Defusion.”

Cognitive misappraisal. If you scored 15 or higher on the items concerning cognitive misappraisal, you can supplement the next four chapters by including the material in chapter 7, “You Can Face Fear,” and chapter 9, “Correcting Your Anxiety Lens.”

Distress intolerance. If you scored 15 or higher on these items in the inventory, supplement the next four chapters by working on the exercises in chapter 10, “Distress Tolerance Skills.”

Finally, don’t leave this book without consulting the final chapter 11, “Relapse Prevention,” because in the long term you will need a strategy to quickly reapply your anxiety solution skills when you start to feel anxious in the future.

To summarize how to use this book, make sure you do all the work in the next four chapters and chapter 11. Depending on your particular scores on this inventory, you might also benefit from chapters 7 through 10.

Time to Begin

Anxiety takes much of the joy out of life. Every time the alarm bell goes off, you end up feeling endangered and beset with catastrophic possibilities. Your body reacts by preparing for battle or for flight, and demands that you do something to get safe. You feel aroused and overwhelmed, and all you can think about is how to escape the threat.

You must wonder: Can anything help? Could a book like this show the way to relief? The answer is yes. Anxiety isn’t a mystery. It isn’t a black box that we can’t peer into and figure out. Chronic anxiety is caused and maintained by the four factors listed above. The treatment program outlined here will help you target the four factors that turn fear and anxiety from a momentary experience into a disorder.

Help is on the way. Let’s get started.