Abstract

Anxiety is a leading mental health issue both in Australia and globally. It is important to distinguish between anxiety which serves a protective function and anxiety that may become an unproductive and sometimes debilitating issue. While our clients may not always fit diagnostic or other criteria for anxiety disorders, their health and wellbeing may be compromised by their various forms of anxiety. As counsellors, we need to be aware of the various factors, biological, psychological, social, developmental, and contextual, that may impact anxiety in our clients. Finally, when considering interventions, counsellors need to be aware of the different approaches and modalities available and how they may best fit with the client’s circumstances.

Introduction

What is anxiety? What are its nature, types, degree, causes, effects, and responses? Anxiety may be seen as a natural response to stressful situations and be accompanied by feelings of worry, nervousness, and/or apprehension (Australian Psychological Society, 2022). When these feelings do not resolve after the stressful situation has passed, become excessive, or compromise the health and wellbeing of a client, there may be an anxiety issue needing intervention. These feelings of excessive worry may lead to avoidance of situations felt to be associated with the anxiety (Beck & Hindman, 2021). The risk is that this avoidance of internal and external stimuli decreases the healthy interaction a person has with their world and the people within it (Australian Bureau of Statistics, 2022a). In this way, the ‘safety behaviours’ actually increase rather than decrease anxiety (Centre for Clinical Interventions, 2021). Ultimately, clients experience anxiety within many situations they face. What is important for counsellors to identify are the potential factors that can lead to an increase in anxiety and interventions that have been found to decrease the impact of anxiety. Both are discussed later in this chapter. The interventions are explored through Reavley et al.’s (2019) analysis of evidence-based approaches.

It is important to distinguish between productive and unproductive anxiety. Not all anxiety is “irrational, abnormal and neurotic … the capacity to be anxious is a biological function necessary for survival” (Rycroft, 1988, p. xii). Our evolutionary history required the quick assessment of potential threats. Anxiety formed the basis of ‘life or death’ decisions (Arden & Linford, 2009). When walking into traffic we unconsciously respond using our evolved ‘predatory defense’ (LeDoux & Pine, 2016), treating the traffic as if a predator threatening our survival. We instantly stop our forward motion and return to safety. In contrast to the obvious external threat of traffic, we may also experience anxiety when internal signals indicate conditions such as low energy supplies, fluid imbalance, or hypothermia (LeDoux & Pine, 2016). Crocq (2015) argued, not only is anxiety “a normal emotion” but it is “adaptive since it promotes survival by inciting persons to steer clear of perilous places” (p. 319). It is also described as an inborn and adaptive emotion (Glick & Roose, 2010; Mulhare et al., 2010; Ray et al., 2017).

Clients usually only seek assistance for their anxiety when it moves beyond a short-term response to events they face. This persistence impacts the client in a variety of ways, including reducing their engagement in their world (Craske & Stein, 2016) and may “eclipse critical priorities” (Westra, 2012, p. 3) including education, career, relationships, leisure activities, and feelings of contentment. Whilst anxiety might be seen as common, the distress, impairment, and reduced quality of life require attention and interventions to reduce its impact (Westra, 2012).

Fear appears to be at the centre of all anxiety issues (Arden & Linford, 2009; Craske et al., 2009; Duits et al., 2015; Dunsmoor & Paz, 2015; Milad et al., 2014; Stein et al., 2007). So the words ‘fear’ and ‘anxiety’ are often used interchangeably. Further, in the literature no distinction is made between the subjective states of fear and anxiety, or the different systems involved in each (LeDoux & Pine, 2016). It is perhaps more accurate, according to LeDoux and Pine (2016), to consider both fear and anxiety as both mental states and subjective feelings. These states and feelings are underpinned by different behavioural and physiological responses. This distinction highlights the differences between feelings of fear, which arise when a threat “is either immediate or imminent” to the client and specific in nature, and anxiety, which arises when the threat “is uncertain or is distal in space or time” or further away from the client (LeDoux & Pine, 2016, p. 1084). Additionally, anxiety is not circumstance or context-specific, rather it is non-specific in nature (Craske & Stein, 2016; LeDoux & Pine, 2016). A further distinction is between anxietus or trait anxiety (i.e., being prone to anxiety due to a tendency to respond to various situations with concerns and worry, e.g., generalised anxiety) and angor or state anxiety (i.e., current anxiety that tends to be transitory after the situation passes, e.g., dental anxiety) (Crocq, 2015; Saviola et al., 2020).

Anxiety is also used as a clinical term to suggest a particular type of mental disorder category, as described in the ICD-11 (World Health Organization, 2022a), or DSM-5-TR (American Psychiatric Association, 2022). Different forms of anxiety are categorised according to their intensity, usually expressed as mild, moderate, or severe. Distinctions are also made based on the characteristics of each presentation of anxiety. Depending on the presentation, anxiety may be categorised into:

•  generalised—a free-floating form that something is just not right
• phobic—associated with situations such as giving a speech, sensations such as fear of falling, or fear of animals or insects such as cats or spiders
• as part of post-traumatic stress disorder (PTSD)—episodic, acute, associated with flashbacks, and can be triggered to the level of the panic attack by stimulus like a car backfiring
• complex PTSD (C-PTSD)—the consequence of repeated or chronic traumatisation and repeated losses leading to the person organising their life around survival (Schwartz, 2021)
• obsessive compulsive disorder (OCD)—fear that a catastrophe is waiting to happen and can be forestalled by the use of rituals such as putting things in a particular order or scrubbing the hands alongside or part of a medical issue (Arden & Linford, 2009).

The general diagnostic criteria for anxiety include:

• feeling very worried or anxious most of the time
• finding it difficult to calm down
• feeling overwhelmed or frightened by sudden feelings of intense panic/anxiety
• experiencing recurring thoughts that cause anxiety, but may seem silly to others
• avoiding situations or things which cause anxiety (e.g., social events or crowded places)
• experiencing ongoing difficulties (e.g., nightmares/flashbacks) after a traumatic event (Reavley et al., 2019, p. 6).

The Australian Psychological Society (2022) adds characteristics of difficulty concentrating, restlessness, rapid heartbeat, trembling or shaking, feeling lightheaded or faint, numbness or nausea, and/or sweating. Clients may also experience nausea, stomach pains, tension in neck and shoulders, sleep issues, and irritability as anxiety builds (Australian Government, Department of Health and Aged Care, 2019).

Rather than focusing on specific anxiety disorders as per DSM-5-TR (APA, 2022) and ICD11 (WHO, 2022), this chapter takes a broader approach to include aspects of anxiety which involve biological, psychological, social, developmental, and contextual elements as well as their interplay. This aligns with Eifert and Forsyth’s (2005) suggestion that looking at common processes involved in the establishment and maintenance of anxiety-related issues can lead to more effective and impactful interventions.

Prevalence

Anxiety is considered a common mental health issue both in Australia and globally. In its 2022 World mental health report, the World Health Organization (WHO, 2022b) noted both the commonality of anxiety and its increase by 25% during the first year of the pandemic. The Australian Bureau of Statistics (ABS) reported 16.8% or 3.3 million people in Australia reported anxiety in the 12 months of 2020–2021 (2022a). The ABS figures were further broken down into panic disorder (3.7%), agoraphobia (4.6%), social phobia (7.0%), generalised anxiety disorder (3.8%), obsessive compulsive disorder (3.1%), and post traumatic stress disorder (5.7%). These figures represent people who have been diagnosed; however, they do not represent people who may have diagnosable anxiety yet remain undiagnosed or those whose anxiety is not at the level required for diagnosis.

Risk Factors

The World Health Organization (WHO, 2022b) identified a diverse set of individual, family, community, and structural circumstances that all contribute to mental health. Additionally, the combination of life experiences and genetic predisposition may increase anxiety into a more intense form of anxiety (Hofer, 2010). These diverse factors are included when assessing anxiety from a biopsychosocial perspective (Engel, 1977). Anxiety, from this perspective, is seen as a combination of the biological factors of the person, the psychological factors of the person, and their reciprocal interactions with the social aspects of the person (Engel, 1977). This can be complemented by developmental theories from Bronfenbrenner (ecological model) and Samorof (transactional model). These models emphasise the importance of seeing the biopsychosocial factors within the broader context and culture of a person’s life. These factors interact and develop over the lifetime of the person and are unique to the historical time of that person (Lehman et al., 2017).

While any person can develop anxiety, there are some additional risks based on specific characteristics. It is beyond the scope of this chapter to discuss all the potential risk groups and factors. However, some are discussed next.

Gender

The ABS (2022) reported that gender comparisons show females are more likely than males to develop anxiety (21% compared to 12.4%). Drilling further down into the statistics, females were more likely than males to have social anxiety (9.8% compared with 5.7%) and post-traumatic stress disorder (7.6% and 3.6%) (ABS, 2022). This is a consistent finding in the research on anxiety (Cabral & Patel, 2020). These differences may be due to biological differences in brain structure which are impacted by genes, hormones, and environment. Gender-role expectations, power dynamics, vulnerability to impacts of domestic violence and sexual assault, and other risk factors may also impact. These factors may be combined with misogyny, discrimination, being seen as inferior to males, and lower rates of pay that affect females (Rodgers et al., 2020). Gender is a complex and not yet clearly understood dynamic of anxiety.

Age

In the 16–24 year old age group in Australia, almost a third (31.5%) were identified as having anxiety, including 41.3% of females (ABS, 2022). Anxiety may be compounded by sleep issues. This is particularly relevant to this age group due to the brain development at this time. Issues with sleep can be exacerbated by social media and other technologies, and potentially associated cyberbullying (Cabral & Patel, 2020). Bandelow and Michaelis (2015) reported that anxiety issues start in childhood and adolescence or early adulthood, peak in middle age, then tend to decrease with older age. This pattern was identified in epidemiological studies and supported by Craske and Stein (2016), who further argued that it is important to identify people at risk and commence interventions as early as possible. Longitudinal studies, according to Pine and Fox (2015), typically suggest that adults who exhibit chronic anxiety had experienced it from childhood. It is, therefore, not surprising to find the age group of 16–24 year old has a high rate for anxiety. It is also important to consider that anxiety may arise in later periods due to exposure to accidents, illness, and other issues. So anxiety, whilst most prevalent in earlier stages of life, can continue or arise in later stages.

Additional areas of concern for youth include separation anxiety, selective mutism, social anxiety, and generalized anxiety (Palitz & Kendall, 2020). Excessive and developmentally inappropriate anxiety from actual or imagined separation from caregivers in youth over six years old is seen as separation anxiety. As Palitz and Kendall (2020) noted, similar separation anxiety before six years old is considered developmentally appropriate. Social anxiety may arise in youth as avoidance of social situations, avoiding asking questions in class, difficulties with starting or joining conversations, and is present both with adults and peers. Selective mutism is a failure to speak in certain situations despite being able to speak in others. It is important to note that when youth have one form of anxiety, they have a roughly 80% chance of a co-existing anxiety issue of another form (Palitz & Kendall, 2020).

Of additional concern in the youth age group is the increased risk of self-harm and suicide. While the median age of suicide is 44.8 years, there is a higher rate of suicide in youth (Suicide Prevention Australia, 2022). This is something to be mindful of at any age but is particularly important as the brains of youth develop, impulse control and risk analysis may be low, and feelings of anxiety and isolation can be overwhelming.

Identification

The ABS (2022) reported that 44.7% of people who identify as gay, lesbian, bisexual, asexual, pansexual, or queer reported anxiety. People in these groups may encounter stigma, prejudice, and discrimination leading to a social environment that can be both stressful and hostile (Hill et al., 2020). These phenomena may present in medical treatment that is culturally insensitive or misinformed, violence and harassment, lack of family support, and workplace mistreatment (Rodgers et al., 2020).

Social Circumstances

There are a range of social circumstances that potentially affect the prevalence of anxiety. People living in one parent family households with dependent children (28.7%) reported anxiety (ABS, 2022). Low socioeconomic status contributes to higher rates of anxiety (Moreno-Peral et al., 2014). Existential concerns can trigger anxiety. These concerns may include not leading a meaningful life or the eventuality of death (LeDoux & Pine, 2016). Stressful events which are ongoing and/or uncertain may also trigger anxiety, for example, being a new parent, work changes, relationship issues, and the death of loved ones (Reavley et al., 2019).

Family factors

Based on epidemiological studies, heritability of anxiety issues is estimated to be between 30–50% (Shimada-Sugimoto et al., 2015). Factors increasing anxiety risk for children include parental anxiety issues (Beesdo-Baum & Knappe, 2012; Strawn et al., 2020) and certain parental personality disorders (cluster A and cluster C) (Kaplowitz & Markowitz, 2010; Strawn et al., 2020). Children are also at an increased risk of a variety of mental health issues, including anxiety, through: childhood maltreatment and neglect (Chu et al., 2013; Vachon et al., 2015); physical punishment in childhood (Clauss & Blackford, 2012);. and over-protective or overly harsh parenting style (Beesdo-Baum & Knappe, 2012). Attachment research has highlighted the increased risk of anxiety issues in children with an anxious attachment style (Bowlby, 1973). This includes all forms of insecure attachment as these styles raise anxiety sensitivity and contribute to viewing others as undependable, result in chronic anxiety, increase difficulty in emotional regulation, and cause cognitive errors about threats (Mulhare et al., 2010). Similarly, separation anxiety (from major attachment figures) has been studied by researchers as a form of persistent, developmentally inappropriate anxiety (Bögels et al., 2013; Comer & Olfson, 2010). The authors report that one third of childhood separation anxiety persists into adulthood (Comer & Olfson, 2010) while Silove et al. (2015) reported over 43% of lifetime separation anxiety had an onset after 18 years of age. Separation anxiety can also reform into other forms of anxiety and depression.

Aboriginal and Torres Strait Islander peoples

Reavley et al. (2019) reported high levels of psychological distress, including feelings of anxiety, in Aboriginal and Torres Strait Islander peoples. The identified causes of anxiety in this group of peoples needs to be understood through the existence of intergenerational trauma, and social, historical, cultural, and spiritual factors. These causes include racism and discrimination, loss of cultural identity, being away from country, and not being able to have ceremony. Further information on this issue can be found in the Intergenerational Trauma Animation below [4:02].

Culturally and linguistically diverse (CALD)

People from culturally and linguistically diverse (CALD) backgrounds represent a significant group within Australia. The ABS (2021) reported just over 7 million (27.6%) of the population (almost 26 million) were born overseas (ABS, 2022). A range of issues may arise from being in the CALD group and may contribute to anxiety or other mental health issues. These include increased stigma in their native cultures around mental health issues as well as concerns about trust and confidentiality when interacting with providers of health services (Baker et al., 2016). This lack of trust is particularly understandable for those who have experienced human rights violations and persecution leading to their relocation (Phillips, 2015). Trauma, and its associated anxiety, may arise from a variety of causes in their homelands—such as poverty, political unrest, gang violence, and natural disasters (Amnesty International, 2022). Appreciating such potential for trauma may be contributing to presenting anxiety is an important aspect of working with people from CALD.

Individual attributes

Many individual attributes contribute to anxiety risk. For example, Clauss and Blackford‘s (2012) meta-analysis found behavioural inhibition, such as clinging to familiar others in the presence of strangers, was specifically predictive of social anxiety. Tendencies towards perfectionism, being easily flustered, timid, inhibited, having low self-esteem, and/or wanting to control everything can contribute to anxiety in childhood, adolescence, and adulthood (Beyond Blue, 2022). So too can certain thinking styles including anticipating the worst, and persistent negative self-talk. These can occur alongside difficulty accepting uncertainty, low self-esteem, sensitivity to internal physical responses, such as increased heart rate, and misinterpreting these physical symptoms as indicating something catastrophic (APA, 2022).

A tendency to misinterpret ambiguous situations contributes to a range of emotional issues including anxiety in both social and generalised forms. This tendency for misinterpretation also contributes to specific issues such as body dysmorphia (Dietel et al., 2021). Body dysmorphia is related to physical appearance interpretation bias (reduced positive and increased negative). This interpretation bias promotes social anxiety which also has a higher fear of negative evaluation (Fang & Hoffman, 2010).

Coping mechanisms

Some coping mechanisms work well to reduce the development and impact of anxiety. These are often referred to as adaptive coping mechanisms. They sit alongside protective factors to reduce the risk of developing ongoing anxiety. However, clients will often be drawn to coping mechanisms that may negatively impact their anxiety.

Some coping mechanisms that place a client at greater risk of anxiety include the use of substances such as alcohol, cannabis, amphetamines, sedatives, emotional eating, gambling, and so forth. These can reduce effects of anxiety initially but increase the anxiety when the effects of the coping mechanism begin wearing off (Reavley et al., 2019). A common coping mechanism is avoidance. Avoidance is mentioned by researchers such as Dietel et al. (2021) and features in the diagnostic criteria for anxiety disorders (APA, 2022; WHO, 2022a). The tendency to avoid situations that trigger anxiety, rather than facing such situations, can result in an increase of anxious indicators (APS, 2022a; Westra, 2012).

Life events

While many life events may involve or contribute to anxiety, this chapter focuses here on four examples of life events where anxiety can arise. The first two relate to common developmental issues—having a baby, and ageing. These show that specific life events that are developmentally common can give rise to anxiety containing both general and specific aspects. The second two relate to specific issues that give rise to both general and specific forms of anxiety—athletic competition, and test anxiety.

Having a baby

The impact of having a baby is far-reaching. One impact can be maternal anxiety which may arise or increase in the post-natal period (Seymour et al., 2015). Seymour et al.’s 2015 study of 224 Australian mothers of infants (aged 0–12 months) identified that 18% had mild to extremely severe symptoms of anxiety. The flow on effects of this anxiety included fewer close, warm and affectionate interactions with their infants alongside less involvement in their infant’s learning activities such as playing indoors and reading stories. When co-existing depression was evident, there was also a sense of lower efficacy and satisfaction as a parent, and high parental hostility. Factors that contributed to maternal anxiety included lower educational attainment, perceived need for social support, poor couple relationship, difficult child behaviour, and poor quality of sleep.

Ageing

Older people often experience anxiety alongside other issues related to both physical and mental health. Of import, according to Andreescu and Lee (2020), late-life generalised anxiety disorder, for example, has a more severe course and impact. Additionally, bidirectionality exists in the causal relationship between late-life anxiety and cognitive impairment. Impaired cognitive performance increases anxiety on one hand and chronic anxiety states may increase the risk for central nervous system damage due to the impact of chronically elevated cortisol, blood pressure, or excessive benzodiazepine prescriptions.

An earlier study by Andreescu et al. (2008) showed prevalence rates of generalised anxiety disorder for those in residential community care to be similar to the general population. In older people, however, they identified additional anxieties connected to impairments in the quality of life, cognitive impairment, increased health care utilisation, and poorer functional recovery after disabling medical events such as stroke. What is also important to note is that those people in the 60+ age group have a different profile to those under 60 years old including higher rates of uncontrolled worry and different worry content.

Athletic competition

Given Australia is such a sporting nation, it seems relevant to include something on the anxiety associated with athletic competition. Athletes experience anxiety from factors faced by the general population as well as athlete-specific factors, such as pressure to perform, public scrutiny, career uncertainty or dissatisfaction, and injury (Vu & Conant-Norville, 2021). Specific forms of anxiety that may be experienced by athletes include: injury-associated anxiety (related to the injury itself or not being able to compete); somatic state anxiety (where a fear of failure or internalizing worries is expressed physically); cognitive state anxiety (where hope for success is reduced due to the memorable expression of anxiety); and competitive anxiety (which tends to increase before and during competitions and when those contests are away from home). Vu and Conant-Norville (2021) stress the importance of responding to both the general and specific contributors to anxiety in athletes. This principle seems more widely applicable to clients who have anxiety so they are not responded to with generic interventions but ones which are tailored to their specific needs.

Test anxiety

Test anxiety has been selected as an example as some readers of this chapter may be students affected by this form of anxiety. This specific form of anxiety is an important one to consider as it impacts on the capacity of a person to engage successfully with studies. Lotz and Sparfeldt (2017) argued that test anxiety is a transitory or state anxiety related to possible negative consequences of failure on an exam as opposed to the more stable trait test anxiety in which the predisposition is to interpret test situations as overly threatening. Understandably, high-stake assessments, such as end of semester exams or other summative tests and assessments, especially those described as capstone assessments, elicit more test anxiety than low-stake assessments. Interestingly, Lotz and Sparfeldt (2017) identified anticipatory test anxiety actually commenced at the beginning of the semester and then modestly increases as the tests approached. A useful set of study tips from Therapist Aid can assist in managing text anxiety.

Co-existence with other issues

While we may see the statistics reported so far as indicative of anxiety alone, anxiety often co-exists with other issues in both biological and psychosocial domains (WHO, 2022b). This interplay supports a thorough approach to understanding the individual circumstances of each client. It also counters the notion that anxiety is an intrapsychic issue alone. This discussion identifies three separate forms of potential co-existence: 1. with a variety of medical issues that can contribute to, or exacerbate, anxiety; 2. as complex anxiety, i.e., one form of anxiety co-existing with other forms of anxiety (Bandelow & Michaelis, 2015); 3. with other mental health issues.

Medical issues

Medical issues can be anxiety-provoking, depending on what they are and their impact. As an example, research into rheumatoid arthritis (Covic et al., 2012) used two scales to assess the level of anxiety: Depression, Anxiety, Stress Scale (DASS) and Hospital Anxiety and Depression Scale (HADS). In the sample of 169 people in both the United Kingdom and Australia, 7.8% showed severe or extremely severe anxiety on DASS while 19.5% showed mild to moderate anxiety. This represents about a 50% increase over general population figures for anxiety. On the HADS, 13.5% showed anxiety only while 21.8% showed possible and/or probable anxiety and depression.

Equally, cardiac issues can be anxiety-provoking. For example, Schluep et al. (2022) followed up in-hospital cardiac arrest patients at 3 and 12 months post-release from hospital. In the follow up of 3 months, 15 of the 125 people (12%) had moderate-major problems on the anxiety scale and 16 of the 108 people (14.8%) followed up at 12 months. These anxiety rates were higher than the moderate-major depression rates of 5.6% at 3 months and 11.3% at 12 months.

Other specific examples of medical issues that have shown a connection with anxiety are hypothyroidism or underactive thyroid (Craske & Stein 2016), diabetes, asthma, heart disease (Reavley et al., 2019), paediatric cardiac diagnoses including anxiety and PTSD (Patel et al., 2017), childhood absence epilepsy (i.e., epilepsy without the seizures) (Vega et al., 2011), fibromyalgia, epilepsy, and cerebral palsy (Meuret et al., 2020).

A specific and broader form of anxiety related to medical issues is health anxiety. This arises when a client has persistent and excessive fear of being seriously ill (Hedman-Lagerlöf et al., 2019). This may involve seeking more tests and examinations, using more health services and resources, and may exist with or without medical disease or diagnosis. Indicators of health anxiety include:

• worry about health that quickly and repeatedly resurfaces after reassurance
• frequent attendance
• spending excessive time online searching for health-related information (cyberchondria)
• health worries that lead to substantial functional impairment (Hedman-Lagerlöf et al., 2019, p. 1).

More recently, in light of the pandemic, a different form of anxiety has been identified which relates to health and medical conditions—coronaphobia (Asmundson & Taylor, 2020) which is fear and anxiety about COVID-19 (Lee et al., 2020). A brief screen for this form of anxiety was developed by Lee (2020).

A final form of anxiety discussed here is dental anxiety (Svensson et al., 2020). This form of anxiety is specifically mentioned as it affects between 4–20% of the populations in a number of countries and cultures. It has significant impacts on the dental health specifically but more generally the medical, psychological, and social consequences can be significant (Svensson et al., 2020).

Different forms of anxiety

Co-existence of one form of anxiety with other forms of anxiety is prevalent and may be referred to as complex anxiety (Bandelow & Michaelis, 2015). For example, health anxiety often co-exists with generalized anxiety, obsessive-compulsive, panic, and medically unexplained symptoms (Hedman-Lagerlöf et al., 2019). Health anxiety may include OCD, be a specific disease phobia, or when concerns extend beyond health alone (e.g., financial, interpersonal, occupational) it may be generalised anxiety, and may involve panic attacks (Harding et al., 2010).

Obsessive compulsive checking or obsessive behaviour are features of eco-anxiety, i.e., a chronic fear of environmental degradation due to the sense that ecological foundations of existence are collapsing (Panu, 2020). This co-existence of obsessive compulsive behaviours also exists with PTSD and CPTSD. Møller et al. (2021) found in their sample of 106 Danish outpatients:

• 42% diagnosed with PTSD or complex PTSD also had panic disorder
• 25% diagnosed with PTSD and 22% diagnosed with complex PTSD also had agoraphobia
• 4% diagnosed with PTSD and 15% diagnosed with complex PTSD had social anxiety disorder
• 21% diagnosed with PTSD and 13% diagnosed with complex PTSD had OCD.

Other mental health issues

Anxiety co-exists with a range of other mental health issues. The co-existence of anxiety and body dysmorphia has been discussed. This is a more obscure co-existence due to the low prevalence of body dysmorphia—estimated to be 2% (Swinburne University of Technology, 2022). However, other forms of mental health issues have a higher prevalence rate. For example, Reavley et al. (2019) estimated that over half of those experiencing depression also experience anxiety. They also stressed that in some cases, the presence of one can lead to the onset of the other. Choi et al. (2020) add that 45%–67% of those meeting the criteria for depression will meet the criteria for at least one anxiety issue.

Wagner (2006) found co-existence of bipolar in children and adolescents with various forms of anxiety, including OCD, GAD, social phobia, panic disorder, and PTSD. Additionally, ADHD, conduct disorder, and oppositional defiant disorder were found to co-exist with anxiety (Wagner, 2006). Autism and ADHD were also associated with higher rates of anxiety than in the general population (Avni et al., 2018).

Research suggests that anxiety forms part of many eating disorders, such as anorexia nervosa and bulimia nervosa. Anxiety has been reported in 50% of cases reviewed by Keski-Rahkonen and Mustelin (2016). Anxiety often precedes the development of an eating disorder and may, therefore, predispose a person to an eating disorder (Grave et al., 2021). Anxiety may also arise as part of the eating disorder itself. For example, avoidance of socialising may arise not due to social anxiety but because of the difficulties eating in front of others and/or exposing their body shape. Avoidance of social eating and low self-esteem were offered as potential links between from eating disorders and trait anxiety (Forrest et al., 2019). It is important to note that anxiety may resolve itself when the eating disorder is successfully treated (Grave et al., 2021).

Conceptualising anxiety

As seen in the introduction, conceptions of anxiety are affected by the lenses through which we view it. In this section several key counselling theories are offered first. Corey (2016) is the main source for this comparison due to his extensive writing in the field of counselling theories and practice. The main theories covered are psychoanalytic, behavioural, cognitive behavioural, acceptance commitment, gestalt, humanistic, existential, and systems theories. The section then explores the biological aspects of anxiety through the polyvagal theory.

Psychoanalytic theory identifies anxiety as a feeling of dread resulting from repressed feelings, memories, desires, and experiences that emerged in the surface of awareness. At the core of anxiety is a conflict between the id, ego, and superego for control of the psychic energy. Two forms of anxiety are reality anxiety and neurotic anxiety. Reality anxiety is proportionate to the degree of real threat from dangers in the external world. In contrast, neurotic anxiety arises when instincts (id) may get out of hand and create a scenario in which a person will be punished. Of import is the defense mechanisms a person uses to reduce anxiety (Corey, 2016). Countering defense mechanisms and strengthening the ego are central to managing neurotic anxiety.

Behavioural theory rests on conditioning: operant or classical. Operant conditioning involves learning through consequences whilst classical conditioning involves automatic associations between a conditioned stimulus and a conditioned response, e.g., Pavlov’s dog. To include social factors which affect people and their conditioning, the social learning theory was developed. Anxiety is seen as a conditioned response and to counter it, new conditioning needs to take place (Corey, 2016).

Cognitive behavioural theory incorporates feelings and thoughts in addition to the behavioural aspects of conditioning (Corey, 2016). Kaczkurkin and Foa (2015) explain that anxiety results from maladaptive thinking, feelings, or behaving. This includes a tendency to overestimate the possibility of negative outcomes. These automatic thoughts are often distorted and thus challenging the thoughts, feelings, and behaving are central to this approach.

Acceptance and commitment theory takes a different approach to traditional cognitive behavioural theory. Anxiety is seen as a movement away from the present into the future. Controlling anxiety is seen as problematic so instead of focusing on the anxiety itself, acceptance and commitment theory engages the client in accepting thoughts and feelings without judgement and with curiosity, choosing directions for their life based on their values, and promoting action for change (Eifert & Forsyth, 2005). Mindfulness techniques and being present in the here and now are promoted (Corey, 2016). In this way, acceptance commitment theory aligns with gestalt theory which also focuses on the here and now.

Gestalt theory sees anxiety as resulting from the present and future being non-differentiated (Corey, 2016). In this way, something that may or may not occur in the future becomes present as anxiety. Gestalt theory focuses on the present moment including immediate thoughts, feelings, and behaviours that lead to the anxiety (Corey, 2016).

Humanistic theory suggests anxiety is a part of living. However, it can negatively impact a person when they are judgemental and apply conditional positive regard to themselves. This conditional state leads them to not accept the person they have become. It thwarts the actualising tendency of the person and creates issues such as anxiety (Corey, 2016). Self-acceptance, as well as unconditional positive regard for oneself, form the basis of countering anxiety as congruence results.

Existential theory also proposes that anxiety is a condition of living. Anxiety results from confronting the ‘givens of existence’—death, freedom, choice, isolation, and meaninglessness. These givens can result in anxiety as a person realises their mortality, confronts their pain and suffering, struggles for survival, or recognises their fallibility. As with other theories, existential theory differentiates normal from neurotic anxiety. Normal anxiety is an appropriate response to the event being faced whilst neurotic anxiety is out of proportion to the event. Neurotic anxiety is seen as not being within the awareness of the person and immobilising (Corey, 2016). In relation to anxiety, existential theory suggests we reduce the neurotic anxiety whilst embracing the normal anxiety as part of life.

Systems theories are mentioned here as family systems tend to create modelling from parent/s to children, often contain patterns of behaving aimed at reducing anxiety, and feedback loops that reinforce behaviours. The impact of families was discussed in the prevalence section but here it is important to note that most systems approaches aim to destabilise the current dynamics in order to promote more functional dynamics within the family, in order to reduce anxiety (Corey, 2016).

Neuroscience has added much understanding of anxiety and other mental health issues. This is a wide-reaching set of theories and beyond the scope of this chapter to explore in depth. However, one neuroscientific theory, the polyvagal theory (Porges, 2022), is offered here as it is central to working with clients. This theory also builds on the biological aspects discussed in this chapter, e.g., genetics, temperament etc. At the heart of polyvagal theory is the notion that safety is a core determinant of human functioning. When humans feel safe, their nervous system is downregulated or calm. This allows the homeostatic balance of the person to be supported for health, growth, and restoration. Additionally, due to safety being experienced, the person can be more fully engaged with others and their world. The opposite occurs when people perceive they are not safe. An additional feature of the polyvagal theory is the connection between calm resulting from safety and higher order thinking capacity. When in an unsafe or anxious state, the amygdala dominates processing and reacting. The amygdala also reduces or disconnects from the higher order thinking parts of the brain, leaving the person vulnerable to reactive states of being. Creating safety through connection to another person promotes downregulation of the other’s physiological state and promotes trust. The higher order thinking is more likely to come back online and engage in problem solving, creativity, sociability, and optimisation of health and wellbeing.

Assessment

As discussed earlier in this chapter, WHO (2022b) suggests a biopsychosocial approach for mental health. This approach is relevant for both assessment and interventions for clients, alongside both developmental and contextual issues. These will now be discussed and applied to the case study of Jess.

Initial assessment of anxiety and its impact on the client’s life can be completed through observation by a counsellor (the counsellor observes indicators of anxiety such as rapid breathing, racing thoughts, and so forth) together with client self-report (the client describes their experiences of anxiety, including history, frequency, intensity, and impact). While the client provides this self-report, the counsellor may engage in specific questions based on their understanding of the impact and type of anxiety the client may be experiencing. These questions might be based on some of the formal inventories that can be used to assess anxiety. At this stage of assessment, as the therapeutic relationship is being developed, inventories may be less helpful as they may interfere with developing the relationship. They may also feel intrusive and robotic to clients in the early stages of working together.

Subsequent assessment can involve ongoing observation and client self-report supplemented with formal inventories. The Depression, Anxiety, Stress Scales (DASS 42) is a 42 item inventory. In this full version, the anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. High scorers in the anxiety scale tend to show these characteristics:

• being apprehensive, panicky, trembly, shaky
• showing awareness of dryness of the mouth, breathing difficulties, pounding of the heart, sweatiness of the palms
•  being worried about performance and possible loss of control (Psychology Foundation of Australia, 2022).

The Depression, Anxiety, Stress Scales 21 (DASS 21) is a shortened version of the full 42 item Depression, Anxiety, Stress Scales (DASS) and is more commonly used. The self-rating asks clients to assign a rating (0 = never, 1 = sometimes, 2 = often, 3 = almost always) to each statement, e.g., I find it hard to wind down, I tend to over-react to situations, I feel that I was using a lot of nervous energy. The outcomes of the scores on the DASS 21 can be normal anxiety (0–3), mild anxiety (4–5), moderate anxiety (6–7), severe anxiety (8–9), extremely severe (10+). This is a direct link to the DASS 21. It is useful to be familiar with the DASS 21 items when working with clients.

Additional inventories that can be applied in counselling include:

•  Generalized Anxiety Disorder 7-Item Scale (GAD-7) – 7 item self-report related to the frequency of anxiety behaviours
• Generalized Anxiety Disorder Severity Scale (GADSS) – 6 item self-report measuring both frequency and intensity of anxiety indicators
• Beck Anxiety Inventory (BAI) – 32 item self-report measuring severity of anxiety indicators
• Hamilton Anxiety Rating Scale (HARS) – 14 item self-report measuring global anxiety in adolescents and adults
•  Leibowitz Social Anxiety Scale (LSAS) – 24 item self-report measuring social anxiety or social phobia
• Overall Anxiety Severity and Impairment Scale (OASIS) – 5 item self-report measuring indicators of a broad range of anxiety issues
• Spence Children’s Anxiety Scale – a 44 item self-report measure used in combination with the parent version for comparison purposes (Spence, 1998)
• Generalized Anxiety Disorder Questionnaire for Adults (GADSS) – 6 item scale to assess the severity of generalized anxiety disorder symptoms on a 5 point severity scale (0=none to 4= very severe). The 6 items are frequency of worry, distress due to worry, frequency of associated symptoms, severity and distress of associated symptoms, impairment in work, and impairment in social function.

Wagner (2006) argued that due to the potential co-existence of bi-polar (I and II) and anxiety issues, it is important to screen for both. Whilst bipolar disorder may be indicated by severe irritability or rapidly fluctuating mood, these indicators may mask underlying obsessive thoughts, worries, compulsions, and/or somatic symptoms that indicate anxiety issues.

The overall aim of assessment is to identify the forms of anxiety being faced by the client, their developmental issues (such as age, onset, trauma, etc), and which evidence and clinical based interventions may assist. It is also important to move beyond the anxiety itself and see what contextual events may be contributing and how to respond to these impactors.

Interventions

While we may consider the existence of anxiety to be a modern condition, its roots go back to the Ancient Greek and Latin authors who reported “pathological anxiety…as medical disorders” (Crocq, 2015). Since then, different theories have arisen based on different schools of thought within counselling. Each school of thought, as previously discussed, conceptualises anxiety in its own manner. This conceptualisation is based on the core tenants of the specific school of thought. Putting aside the different conceptions, we now turn to the most effective approaches. These approaches are evidence-based and shown to have efficacy (Reavley et al., 2019).

Top down and bottom up strategies

Depending on the client and their anxiety, as well as other issues, we need to consider whether top down or bottom up strategies or a combination are the most useful. As noted in the neuroscience conception of anxiety, not all anxiety can be reached through the ‘thinking’ mind and instead comes from neuroception which needs to be dealt with indirectly (Porges, 2022). Neuroception can create anxiety sensitivity as discussed earlier. Sussman et al. (2016) and Capron et al. (2017) argue for awareness of both top down and bottom-up strategies for anxiety. This responds to the:

• bottom up, sensory driven mechanism that selects stimuli based on their physical salience
• mechanism with variable selection criteria, which selects stimuli based on expectations, knowledge, and goals.

While top-down approaches, including psychoeducation and various forms of CBT, may assist in general awareness and understanding of anxiety, the challenge is that bottom up mechanisms tend to bypass these thinking processes and automatically shift resources and focus to the stimuli which is perceived as a potential threat (Porges, 2022; Sussman et al., 2016). In the counselling context, this difference may be fed back by clients when they state that they ‘know’ about anxiety and ‘still’ cannot manage it. These quick response systems (e.g., the amygdala in the brain) have evolved to activate quickly to protect the person from threats, and the default of this process is to override conscious control (Porges, 2022). As you will see in the case study, a combination of top-down and bottom-up approaches can be helpful.

As with all mental health issues our clients face, there is potential ambivalence about change. As Westra (2012, p. 3) argued this ambivalence may arise when the negative effects of anxiety are countered by the “familiar patterns [that] have a seductive quality”. In response to this ambivalence, we can use motivational interviewing and an appreciation of the stages of change as underpinning models (Westra, 2012). Further information on motivational interviewing can be found in this video while stages of change can be found in this video.

Increasing protective factors applies to anxiety interventions as well as in general counselling. Cabral and Patel (2020) identify protective factors in three areas: individual, family, and community. All combine to assist the client. As you read the lists offered by Cabral and Patel (2020), you will see that some target specific indicators of anxiety whilst others focus on broader issues:

• individual—ability to overcome adversity, adaptability, adequate sleep, conflict management skills, self-esteem, self-sufficiency, stress coping skills present
• family—affirmative parent-child relationship, cohesive family unit, higher parental education, parental employment and higher socioeconomic status, parental security, positive parenting, support from family
• community—community networks, empowered social relationships, integrated ethnic minority groups, positive environment and the school system, social awareness and involvement, social responsibility, support from friends and the community (p. 556).

Technology-enhanced interventions

We have many technology-enhanced interventions available for assisting with anxiety. These may be particularly appealing for younger clients who may be tech-savvy and they are also useful for clients who wish to develop autonomy. Many of these interventions are free or low cost and can be used within counselling sessions and/or by the client as self-help tools. They can also be combined with counselling interventions (Apolinário-Hagen et al., 2020). For example, anxiety sensitivity is an aspect of anxiety that can be worked on in counselling sessions using technology. Anxiety sensitivity involves fear related to the sensations and behaviours associated with anxiety or, as Capron et al. (2017) define it, fear of anxiety-related sensations. Anxiety sensitivity is a risk factor for anxiety issues (Capron et al., 2017). The difficulty in countering anxiety sensitivity is that it tends to be automatic cognitive processing which is unconscious, efficient, unintentional, and uncontrollable and focuses attention on threat-relevant information (Teachman et al., 2012).

To reduce anxiety sensitivity, the cognitive anxiety sensitivity treatment (CAST) focuses on the interoceptive conditioning that is a risk factor of panic disorders and separation anxieties (Schiele et al., 2021). This incorporates elements from two computer assisted programs:

1. anxiety sensitivity amelioration training (ASAT) which provides information on the nature of stress, effects of stress on the body, teaches participants about interoceptive conditioning along with instructions on exposure exercises, delivered via audiovisual computer presentations
2. 2. anxiety sensitivity education and reduction of training (ASERT) which includes psycho educative elements, stress reduction training, interoceptive exposure exercises focusing on respiratory distress (hyperventilation, breathing through a straw).

CAST incorporates the elements from both ASAT and ASERT in a more sophisticated computer presentation, video instructions of repeated interoceptive hyperventilation and straw breathing exercises, and quizzes testing comprehension of important material. The psychoeducation aspect of this approach is focused on the nature of stress, its effect on the body, and dispelling the myths regarding the immediate dangers of stress. It highlights that anxiety may be a conditioned fear. This fear response elevates the anxiety sensitivity.

Other possibilities for effective programs and apps include:

• Made-4-Me program
• e-couch Social Anxiety program
• Mindspot Wellbeing course
• e-couch Anxiety and Worry program
• myCompass
• PANIC STOP!
• WorryTime app
• GAD Online program
• SAD Online program
• BeyondBlue Anxiety forum (Australian Government, Department of Health and Aged Care, 2019).

General principles underpinning specific interventions

One of the important aims of this book and this chapter is to offer an integrative approach in tailoring interventions to the client. On this basis, we now turn to a number of general principles that can assist counsellors when working with clients with anxiety.

1. Establish and maintain a safe and regulated therapeutic relationship with the client. Therapeutic relationships are particularly important for clients who have anxiety as they provide safety (Porges, 2022). They can also provide a secure attachment for the client.
2. Obtain a comprehensive history from the client as this allows identification of biopsychosocial factors, developmental and contextual factors, their interrelationships, and their impact (WHO, 2022b).
3. Provide a referral to the client’s GP for medical evaluation, in case specialised interventions are required.
4. Reassure the client that anxiety is an important survival response (reframing and psychoeducation can assist the client to rethink anxiety and its usefulness). A useful addition is externalising the anxiety from narrative therapy (Madigan, 2019). Externalising allows the client to gain some agency over the anxiety and appreciate its purpose in their lives.
5. Provide strategies for the client to be in the present moment rather than caught in their anxiety which is future-based. ACT and other approaches incorporating mindfulness emphasise the importance of this strategy.
6. Provide bottom-up strategies to assist the client when their anxiety is too high for top-down strategies (including grounding, breathing, relaxation, centring, expulsive such as skipping, singing, or similar) (Sussman et al., 2016). These strategies can assist the client to break the cycle of avoidance and escalation of anxiety.
7. Assist the client to identify the sources of anxiety and how to manage them more directly. An anxiety or exposure hierarchy is useful to identify the sources along with an extra column for specific strategies to assist the client. Having this in written form means the client can consult this when higher levels of anxiety exist which compromise the top-down strategies. Worry coping cards are an electronic version that can be integrated into the last column.
8. Assist clients to assess evidence for anxious thoughts and beliefs can be beneficial (CBT is the best source for this strategy). By focusing on the evidence, there is a redirection away from the anxiety and an awareness that the anxious thoughts may have no foundation.
9. Provide expanded physical awareness activities so the client moves beyond their own tendency to anxiety sensitivity (focus on areas of the body where there is no anxiety).
10. Ask the client to imagine this issue in 3 months then 6 months time and whether this aligns with what the client wants in their life. This is motivational interviewing and works to reduce the impact of the anxiety and offers the option that this can be managed. It also builds a commitment to change.
11. Refocus the client on what sort of life they wish to have (using ACT strategies of focusing on values). Focusing on strengthening protective factors can also assist.
12. Establish a broader and more nuanced vocabulary for affective states (often clients with anxiety have limited and high-intensity descriptions of their feelings, such as awful, terrible, intense) (Pine & Fox, 2015).
13. Increase emotional management strategies to intervene as low as possible when anxiety is building (dialectical behaviour therapy is useful here).

Medications

The primary psychotropic medications that are used to assist in anxiety management include SSRIs (Bandelow, 2020; Choi et al., 2020; LeDoux & Pine, 2016; Strawn et al., 2020), benzodiazepines which can assist in reduction of anxiety in some clients (Balon & Starcevic, 2020; Bandelow, 2020; Choi et al., 2020; Leoux & Pine, 2016), SNRIs (Bandelow, 2020; Choi et al., 2020; Craske & Stein, 2016; Strawn et al., 2020), and tricyclic antidepressants (Bandelow, 2020). However, we need to be clear that some medications are contra-indicated for certain forms of anxiety. As an example, Reavley et al. (2019) created a table showing the different forms of medication and the specific forms of anxiety they address. As with most medication, its efficacy alone is lower than when it is combined with counselling (Crakse & Stein, 2016). Capron et al. (2017) also highlight that medication requires careful consideration as once it is stopped, most gains from the medication are lost and may also remove the gains from counselling.

Conclusion

This chapter introduced the different forms of anxiety and highlighted that not all anxiety is neurotic or unhelpful. The chapter discussed the complexities of anxiety, including its co-existence with a variety of medical issues, other mental health issues, and between the different forms of anxiety. The impacts of anxiety in its various forms may impact all aspects of a client’s life. It is therefore crucial for counsellors to understand the circumstances in which the client finds themselves. Equally important are the client’s thinking, behaving, affect, and coping responses. There are multiple interventions available to clients both within a counselling context and in other healing orientations. Our role as counsellors is to appraise best fit for our client, in a collaborative and client-focused approach.

Recommended resources

This section highlights some of the resources available to you when working with anxiety issues. It is recommended that you also see the list of references for this chapter as it offers many resources for your use.

Resources

• Creating a story of safety: A polyvagal guide to managing anxiety. [Video].
• Arden, J., & Lindford, L. (2009). The heal your anxiety workbook: New techniques for moving from panic to inner peace. Quarto Publishing Group USA. This is a useful workbook for clients as part of counselling processes. According to my own reading and that of many clients I have referred to this book, it is readable and informative.
• Coping with anxiety [PDF]: A useful resource for both counsellor and client use.
• Beyond Blue: As there is often a co-existence of anxiety and depression, Beyond Blue has developed resources for both.
• Black Dog Institute offers information on anxiety and also other mental health issues. This includes a mental health assessment tool.
• Centre for Clinical Interventions. clinician resources demonstration videos for counsellors.
• by Headspace
• Head to Health website which provides valuable information on technology and applications that can assist both counsellors and clients.
• Kim, Y.-K. (Ed.) (2020). Anxiety disorders: Rethinking and understanding recent discoveries. Springer. https://doi.org/10.1007/978-981-32-9705-0_28
• Queensland Government, Department of Health. (2022). Anxiety disorders. https://www.headtohealth.gov.au/mental-health-difficulties/mental-health-conditions/anxiety-disorders
• SANE. SANE is an organisation that works for people with complex mental health issues. This is a useful site for many clients and provides resources and communities with whom they can connect.
• The Dulwich Centre. Various videos on the application of narrative therapy to issues. Whilst narrative therapy is not mentioned in the Reavley et al. (2019) analysis offered in this chapter, it has been found effective in many domains of counselling practice. Of particular note is their work on creating cultural resonance with Aboriginal and Torres Strait Islander peoples.
• Therapist Aid is an excellent website that offers many worksheets for use in counselling. This link takes you directly to the dialectical behaviour therapy worksheets.

Glossary of terms

Forms of anxiety:

anxiety—a response to stressful situations accompanied by feelings of worry, nervousness, and/or apprehension

coronaphobia—fear and anxiety about COVID-19

eco-anxiety—a chronic fear of environmental degradation due to the sense that ecological foundations of existence are collapsing

generalised anxiety—a free-floating form of anxiety that something is just not right

phobic anxiety—anxiety associated with situations such as giving a speech, sensations such as fear of falling, or fear of animals or insects such as cats or spiders

complex post-traumatic stress disorder (CPTSD) and post-traumatic stress disorder (PTSD)—episodic and acute anxiety, associated with flashbacks, and can be triggered to the level of the panic attack by stimulus like a car backfiring

health anxiety—persistent and excessive fear of being seriously ill

obsessive compulsive disorder (OCD)—fear that a catastrophe is waiting to happen and can be forestalled by the use of rituals, such as putting things in a particular order or scrubbing the hands

psychotropic medication—any medication that affects behaviour, mood, thoughts, or perception, including anti-depressants, anti-psychotics, and mood stabilisers

separation anxiety—anxiety arising when separation from major attachment figures occurs

test anxiety—a transitory state anxiety related to possible negative consequences of failure on an exam

Diagnostic tools:

DSM—the DSM is the abbreviation for the Diagnostic and Statistical Manual of Mental Disorders. This text is a classification guide for psychiatric disorders and is used within clinical psychology, psychiatry, and research. The current manual is in its 5-TR edition.

ICD—the ICD is the abbreviation for the International Classification of Diseases. It is now in its 11th edition.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: Text revised version (5th ed.). https://doi.org/10.1176/appi.books.9780890425787

Amnesty International. (2022). Refugees, asylum seekers, and migrants. https://www.amnesty.org/en/what-we-do/refugees-asylum-seekers-and-migrants/

Andreescu, C., Belnap, B. H., Rollman, B. L., Houck, P., Ciliberti, C., Mazumdar, S., Shear, M. K., & Lenze, E. J. (2008). Generalized anxiety disorder severity scale validation in older adults. The American Journal of Geriatric Psychiatry, 16(10), 813–818. https://doi.org/10.1097/jgp.0b013e31817c6aab

Andreescu, C., & Lee, S. (2020). Anxiety disorders in the elderly. In Y.-K. Kim (Ed.), Anxiety disorders: Rethinking and understanding recent discoveries (pp. 561–576). Springer. https://doi.org/10.1007/978-981-32-9705-0_28

Apolinário-Hagen, J., Drüge, M., & Fritsche, L. (2020). Cognitive behavioral therapy, mindfulness-based cognitive therapy and acceptance commitment therapy for anxiety disorders: Integrating traditional with digital treatment approaches. In Y.-K. Kim (Ed.), Anxiety disorders: Rethinking and understanding recent discoveries (pp. 291–330). Springer. https://doi.org/10.1007/978-981-32-9705-0_17

Arden, J. B., & Linford, L. (2009). Brain-based therapy with adults. John Wiley & Sons.

Asmundson, G. J. G., & Taylor, S. (2020). Coronaphobia: Fear and the 2019-nCoV outbreak. Journal of Anxiety Disorders, 70. https://doi.org/10.1016/j.janxdis.2020.102196

Australian Bureau of Statistics. (ABS). (2022a, July 22). National study of mental health and wellbeing, 2020–21. https://www.abs.gov.au/statistics/health/mental-health/national-study-mental-health-and-wellbeing/latest-release#prevalence-of-mental-disorders

Australian Bureau of Statistics. (2022b). Cultural diversity of Australia. https://www.abs.gov.au/articles/cultural-diversity-australia

Australian Government, Department of Health and Aged Care. (2019). Anxiety disorders. https://www.headtohealth.gov.au/mental-health-difficulties/mental-health-conditions/anxiety-disorders

Australian Psychological Society. (2022). Anxiety disorders. https://psychology.org.au/for-the-public/psychology-topics/anxiety

Avni, E., Ben-Itzchak, E., & Zachor, D. A. (2018). The presence of comorbid ADHD and anxiety symptoms in autism spectrum disorder: Clinical presentation and predictors. Frontiers in Psychiatry, 9. https://doi.org/10.3389/fpsyt.2018.00717

Baker, A. E. Z., Proctor, N. G., & Ferguson, M. S. (2016). Engaging with culturally and linguistically diverse communities to reduce the impact of depression and anxiety: A narrative review. Health & Social Care Community Actions, 24(4), 386–98. https://doi.org/10.1111/hsc.12241

Balon, R., & Starcevic, V. (2020). Role of benzodiazepines in anxiety disorders. In Y.-K. Kim (Ed.), Anxiety disorders: Rethinking and understanding recent discoveries (pp. 367–388). Springer. https://doi.org/10.1007/978-981-32-9705-0_20

Bandelow, B. (2020). Current and novel psychopharmacological drugs for anxiety disorders. In Y.-K. Kim (Ed.), Anxiety disorders: Rethinking and understanding recent discoveries (pp. 347–366). Springer. https://doi.org/10.1007/978-981-32-9705-0_19

Bandelow, B., & Michaelis, S. (2015). Epidemiology of anxiety disorders in the 21st century. Dialogues in Clinical Neuroscience, 17(3), 327–335. https://doi.org/10.31887/dcns.2015.17.3/bbandelow

Beck, J., & Hindman, R. (2021). Coping with anxiety. https://beckinstitute.org/wp-content/uploads/2021/08/Coping-with-Anxiety.pdf

Beesdo-Baum, K., & Knappe, S. (2012). Developmental epidemiology of anxiety disorders. Child and Adolescent Psychiatric Clinics of North America, 21(3), 457–478. https://doi.org/10.1016/j.chc.2012.05.001

Beyond Blue. (2022). Anxiety [Factsheet]. https://www.beyondblue.org.au/the-facts/anxiety/what-causes-anxiety

Bögels, S. M., Knappe, S., & Clark, L. A. (2013). Adult separation anxiety disorder in DSM-5. Clinical Psychology Review, 33(5), 663–674. https://doi.org/10.1016/j.cpr.2013.03.006

Bowlby, J. (1973). Attachment and Loss: Vol. 2: Separation. Basic Books.

Cabral, M. D., & Patel, D. R. (2020). Risk factors and prevention strategies for anxiety disorders in childhood and adolescence. In Y.-K. Kim (Ed.), Anxiety disorders: Rethinking and understanding recent discoveries (pp. 543–559). Springer. https://doi.org/10.1007/978-981-32-9705-0_27

Capron, D. W., Norr, A. M., Allan, N. P., & Schmidt, N. B. (2017). Combined “top-down” and “bottom-up” intervention for anxiety sensitivity: Pilot randomized trial testing the additive effect of interpretation bias modification. Journal of Psychiatric Research, 85, 75–82. https://doi.org/10.1016/j.jpsychires.2016.11.003

Centre for Clinical Interventions. (2021). What are safety behaviours? CCI. https://www.cci.health.wa.gov.au/~/media/CCI/Mental-Health-Professionals/Anxiety/Anxiety—Information-Sheets/Anxiety-Information-Sheet—07-What-are-Safety-Behaviours.pdf

Choi, K. W., Kim, Y.-K., & Jeon, H. J. (2020). Comorbid anxiety and depression: Clinical and conceptual consideration and transdiagnostic treatment. In Y.-K. Kim (Ed.), Anxiety disorders: Rethinking and understanding recent discoveries (pp. 219–236). Springer. https://doi.org/10.1007/978-981-32-9705-0_14

Chu, D. A., Williams, L. M., Harris, A. W. F., Bryant, R. A., & Gatt, J. M. (2013). Early life trauma predicts self-reported levels of depressive and anxiety symptoms in nonclinical community adults: Relative contributions of early life stressor types and adult trauma exposure. Journal of Psychiatric Research, 47(1), 23–32. https://doi.org/10.1016/j.jpsychires.2012.08.006

Clauss, J. A., & Blackford, J. U. (2012). Behavioral inhibition and risk for developing social anxiety disorder: A meta-analytic study. Journal of the American Academy of Child & Adolescent Psychiatry, 51(10), 1066–1075. https://doi.org/10.1016/j.jaac.2012.08.002

Comer, J. S., & Olfson, M. (2010). The epidemiology of anxiety disorders. In H. B. Simpson, Y. Neria, R. Lewis-Fernández, & F. Schneier (Eds.), Anxiety disorders: Theory, research, and clinical perspectives (pp. 6–19). Cambridge University Press. https://doi.org/10.1017/cbo9780511777578

Corey, G. (2016). Theory and practice of counseling and psychotherapy (10th ed.). Books/Cole, Cengage.

Covic, T., Cumming, S. R., Pallant, J. F., Manolios, N., Emery, P., Conaghan, P. G., & Tennant, A. (2012). Depression and anxiety in patients with rheumatoid arthritis: prevalence rates based on a comparison of the depression, anxiety and stress scale (DASS) and the hospital, anxiety and depression scale (HADS). BMC Psychiatry, 12(6). https://doi.org/10.1186/1471-244x-12-6

Craske, M. G., Rauch, S. L., Ursano, R., Prenoveau, J., Pine, D. S., & Zinbarg, R. E. (2009). What is an anxiety disorder? Depression and Anxiety, 26(12), 1066–1085. https://doi.org/10.1002/da.20633

Craske, M. G., & Stein, M. B. (2016). Anxiety. The Lancet, 388(10063), 3048–3059. https://doi.org/10.1016/s0140-6736(16)30381-6

Crocq, M.-A. (2015). A history of anxiety: From Hippocrates to DSM. Dialogues in Clinical Neuroscience, 17(3), 319–325. https://doi.org/10.31887/dcns.2015.17.3/macrocq

Dietel, F. A., Möllmann, A., Bürkner, P.-C., Wilhelm, S., & Buhlmann, U. (2021). Interpretation bias across body dysmorphic, social anxiety and generalized anxiety disorder—A multilevel, diffusion model account. Cognitive Therapy and Research, 45, 715–729. https://doi.org/10.1007/s10608-020-10180-7

Duits, P., Cath, D. C., Lissek, S., Hox, J. J., Hamm, A. O., Engelhard, I. M., van den Hout, M. A., & Baas, J. M. P. (2015). Updated meta-analysis of classical fear conditioning in the anxiety disorders. Depression and Anxiety, 32(4), 239–253. https://doi.org/10.1002/da.22353

Dunsmoor, J. E., & Paz, R. (2015). Fear generalization and anxiety: Behavioral and neural mechanisms. Biological Psychiatry, 78(5), 336–343. https://doi.org/10.1016/j.biopsych.2015.04.010

Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and commitment therapy for anxiety disorders. New Harbinger Publications.

Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129-136. https://doi.org/10.1126/science.847460

Fang, A., & Hoffmann, S. G. (2010). Relationship between social anxiety disorder and body dysmorphic disorder. Clinical Psychology Review, 30(8), 1040–1048. https://doi.org/10.1016/j.cpr.2010.08.001

Forrest, L. N., Sarfan, L. D., Ortiz, S. N., Brown, T. A., & Smith, A. R. (2019). Bridging eating disorder symptoms and trait anxiety in patients with eating disorders: A network approach. Journal of Eating Disorders, 52, 701–711. https://doi.org/10.1002/eat.23070

Glick, R. A., & Roose, S. P. (2010). Anxiety as a signal, symptom, and syndrome. In H. B. Simpson, Y. Neria, R. Lewis-Fernández, & F. Schneier (Eds.), Anxiety disorders: Theory, research, and clinical perspectives (pp. 51–58). Cambridge University Press. https://doi.org/10.1017/cbo9780511777578

Grave, R. D., Sartirana, M., & Calugi, S. (2021). Complex cases and comorbidity in eating disorders. Assessment and management. Springer. https://doi.org/10.1007/978-3-030-69341-1

Harding, K. J. K., Skritskaya, N., Doherty, E. R., & Fallon, B. A. (2010). Understanding health anxiety. In H. B. Simpson, Y. Neria, R. Lewis-Fernández, & F. Schneier (Eds.), Anxiety disorders: Theory, research, and clinical perspectives (pp. 103–115). Cambridge University Press. https://doi.org/10.1017/cbo9780511777578

Hedman-Lagerlöf, E., Tyrer, P., Hague, J., & Tyrer, H. (2019). Health anxiety. BMJ, 364, l774. https://doi.org/10.1136/bmj.l774

Hill, A. O., Bourne, A., McNair, R., Carman, M. & Lyons, A. (2020). Private Lives 3: The health and wellbeing of LGBTIQ people in Australia. ARCSHS Monograph Series No. 122. Australian Research Centre in Sex, Health and Society, La Trobe University.

Hofer, M. A. (2010). New concepts in the evolution and development of anxiety. In H. B. Simpson, Y. Neria, R. Lewis-Fernández, & F. Schneier (Eds.), Anxiety disorders: Theory, research, and clinical perspectives (pp. 59–68). Cambridge University Press. https://doi.org/10.1017/cbo9780511777578

Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy for anxiety disorders: An update in the empirical evidence. Dialogues in Clinical Neuroscience, 17(3), 337–346. https://doi.org/10.31887/DCNS.2015.17.3/akaczkurkin

Kaplowitz, M. J., & Markowitz, J. C. (2010). Axis II and anxiety disorders. In H. B. Simpson, Y. Neria, R. Lewis-Fernández, & F. Schneier (Eds.). Anxiety disorders: Theory, research, and clinical perspectives (pp. 116–126). Cambridge University Press.

Keski-Rahkonen A., & Mustelin, L. (2016). Epidemiology of eating disorders in Europe: prevalence, incidence, comorbidity, course, consequences, and risk factors. Current Opinion in Psychiatry, 29(6), 340–5. https://doi.org/10.1097/yco.0000000000000278

LeDoux, J. E., & Pine, D. S. (2016). Using neuroscience to help understand fear and anxiety: A two-system framework. American Journal of Psychiatry, 173(11), 1083–1093. https://doi.org/10.1176/appi.ajp.2016.16030353

Lee, S. A. (2020). Coronavirus anxiety scale: A brief mental health screener for COVID-19 related anxiety. Death Studies, 44(7), 393–401. https://doi.org/10.1080/07481187.2020.1748481

Lee, S. A., Jobe, M. C., Mathis, A. A., & Gibbons, J. A. (2020). Incremental validity of coronaphobia: Coronavirus anxiety explains depression, generalized anxiety, and death anxiety. Journal of Anxiety Disorders, 74, 102268. https://doi.org/10.1016/j.janxdis.2020.102268

Lehman, B. J., David, D. M., & Gruber, J. A. (2017). Rethinking the biopsychosocial model of health: Understanding health as a dynamic system. Social and Personality Psychology Compass, 11(e12328). https://doi.org/10.1111/spc3.12328

Lotz, C., & Sparfeldt, J. R. (2017). Does test anxiety increase as the exam draws near? – Students’ state test anxiety recorded over the course of one semester. Personality and Individual Differences, 104, 397–400. https://doi.org/10.1016/j.paid.2016.08.032

Madigan, S. (2019). Narrative therapy (2nd ed.). American Psychological Association.

Meuret, A. E., Tunnell, N., & Roque, A. (2020). Anxiety disorders and medical comorbidity: Treatment implications. In Y.-K. Kim (Ed.), Anxiety disorders: Rethinking and understanding recent discoveries (pp. 237–261). Springer. https://doi.org/10.1007/978-981-32-9705-0_15

Milad, M. R., Rosenbaum, B. L., & Simon, N. M. (2014). Neuroscience of fear extinction: Implications for assessment and treatment of fear-based and anxiety related disorders. Behaviour Research and Therapy, 62, 17–23. https://doi.org/10.1016/j.brat.2014.08.006

Møller, L., Søgaard, U., Elklit, A., & Simonsen, E. (2021). Differences between ICD-11 PTSD and complex PTSD on DSM-5 section III personality traits. European Journal of Psychotraumatology, 12(1), 1894805. https://doi.org/10.1080/20008198.2021.1894805

Moreno-Peral, P., Conejo-Cerón, S., Motrico, E., Rodríguez-Morejón, A., Fernández, A., García-Campayo, J., Roca, M., Serrano-Blanco, A., Rubio-Valera, M., & Ángel Bellón, J. (2014). Risk factors for the onset of panic and generalised anxiety disorders in the general adult population: A systematic review of cohort studies. Journal of Affective Disorders, 168, 337–348. https://doi.org/10.1016/j.jad.2014.06.021

Mulhare, E. S., Ghesquiere, A., & Shear, M. K. (2010). Attachment, separation, and anxiety disorders. In H. B. Simpson, Y. Neria, R. Lewis-Fernández, & F. Schneier (Eds.). Anxiety disorders: Theory, research, and clinical perspectives (pp. 227–238). Cambridge University Press.

NSW Department of Health. (2022). How can I support a culturally and linguistically diverse person with a mental health condition? https://www.health.nsw.gov.au/mentalhealth/psychosocial/strategies/Pages/diversity-cultural.aspx

Palitz, S. A., & Kendall, P. C. (2020). Anxiety disorders in children. In E. Bui, M. E. Charney, & A. W. Baker (Eds.), Clinical handbook of anxiety disorders: From theory to practice (pp. 141–156). Humana Press/Springer Nature. https://doi.org/10.1007/978-3-030-30687-8_7

Panu, P. (2020). Anxiety and the ecological crisis: An analysis of eco-anxiety and climate anxiety. Sustainability, 12(19), 7836. https://doi.org/10.3390/su12197836

Patel, B. J., Lai, L., Goldfield, G., Sananes, R., & Longmuir, P. E. (2017). Psychosocial health and quality of life among children with cardiac diagnoses: Agreement and discrepancies between parent and child reports. Cardiology in the Young, 27(4), 713–721. https://doi.org/10.1017/s1047951116001141

Phillips, J. (2015). Asylum seekers and refugees: What are the facts? https://www.aph.gov.au/about_parliament/parliamentary_departments/parliamentary_library/pubs/rp/rp1415/asylumfacts

Pine, D. S., & Fox, N. A. (2015). Childhood antecedents and risk for adult mental disorders. Annual Review of Psychology, 66(1), 459–485. https://doi.org/10.1146/annurev-psych-010814-015038

Porges, S. W. (2022). Polyvagal theory: A science of safety. Frontiers in Integrative Neuroscience, 16.
https://doi.org/10.3389/fnint.2022.871227

Psychology Foundation of Australia. (2022). Depression anxiety stress scales (DASS). http://www2.psy.unsw.edu.au/DASS/

Psychotherapy and Counselling Federation of Australia (PACFA). (2021). PACFA Indigenous Healing Practice Training Standards. https://www.pacfa.org.au/common/Uploaded%20files/PCFA/PACFA_CATSIHP_IndigenousHealingPracticeTrainingStandards_2021.pdf

Ray, A., Gulati, K., & Rai, N. (2017). Stress, anxiety, and immunomodulation: A pharmacological analysis. In G. Litwack (Ed.), Anxiety (pp. 1–25). Elsevier.

Reavley, N., Morgan, A., Jorm, A., Wright, J., Bassilios, B., Hopwood, M., Allen, N., & Purcell, R. (2019). A guide to what works for anxiety: An evidence-based review. https://www.beyondblue.org.au/docs/default-source/resources/484150_0220_bl0762_acc.pdf

Rodgers, R. F., Berry, R., & Fischer, L. E. (2020). Anxiety disorders: A feminist ecological approach. In E. Bui, M. E., Charney, & A. W. Baker (Eds.), Clinical handbook of anxiety disorders. From theory to practice (pp. 43–58). Humana Press. https://doi.org/10.1007/978-3-030-30687-8

Rycroft, C. (1988). Anxiety and neurosis. Taylor & Francis Group.

Saviola, F., Pappaianni, E., Monti, A., Grecucci, A., Jovicich, J., & De Pisapia, N. (2020). Trait and state anxiety are mapped differently in the human brain. Scientific Reports, 10(11112). https://doi.org/10.1038/s41598-020-68008-z

Schiele, M. A., Vietz, M., Gajewska, A., Unterecker, S., Gottschalk, M. G., Deckert, J., Neufang, S., Schmidt, N. B., & Domschke, K. (2021). The cognitive anxiety sensitivity treatment (CAST) in anxiety prevention – Focus on separation anxiety and interoception. European Neuropsychopharmacology, 53, 104–113. https://doi.org/10.1016/j.euroneuro.2021.08.265

Schluep, M., Endeman, H., Gravesteijn, B. Y., Kuijs, C., Blans, M. J., van den Bogaard, B., Van Gemert, A. W. M. M. K., Hukshorn, C. J., van der Meer, B. J. M., Knook, A. H. M., van Melsen, T., Peters, R., Simons, K. S., Spijkers, G., Vermeijden, J. W., Wils, E.-J. ., Stolker, R. J., & Hoeks, S. E. (2022). In-depth assessment of health-related quality of life after in-hospital cardiac arrest. Journal of Critical Care, 68, 22–30. https://doi.org/10.1016/j.jcrc.2021.11.008

Schwartz, A. (2021). The complex PTSD treatment manual: An integrative, mind-body approach to trauma recovery. PESI.

Seymour, M., Giallo, R., Cooklin, A., & Dunning, M. (2015). Maternal anxiety, risk factors and parenting in the first post-natal year. Child: Care, health and development, 41(2). 314–323. https://doi.org/10.1111/cch.12178

Shimada-Sugimoto, M., Otowa, T., & Hettema, J. M. (2015). Genetics of anxiety disorders: Genetic epidemiological and molecular studies in humans. Psychiatry and Clinical Neurosciences, 69(7), 388–401. https://doi.org/10.1111/pcn.12291

Silove, D., Alonso, J., Bromet, E., Gruber, M., Sampson, N., Scott, K., Andrade, L., Benjet, C., Caldas de Almeida, J. M., De Girolamo, G., de Jonge, P., Demyttenaere, K., Fiestas, F., Florescu, S., Gureje, O., He, Y., Karam, E., Lepine, J.-P., Murphy, S., & Villa-Posada, J. (2015). Pediatric-onset and adult-onset separation anxiety disorder across countries in the world mental health survey. American Journal of Psychiatry, 172(7), 647–656. https://doi.org/10.1176/appi.ajp.2015.14091185

Spence, S. H. (1998). A measure of anxiety symptoms among children. Behaviour Research and Therapy, 36(5), 545–566. https://doi.org/10.1016/s0005-7967(98)00034-5

Stein, M. B., Simmons, A. N., Feinstein, J. S., & Paulus, M. P. (2007). Increased amygdala and insula activation during emotion processing in anxiety-prone subjects. American Journal of Psychiatry, 164(2), 318–327. https://doi.org/10.1176/ajp.2007.164.2.318

Strawn, J. R., Lu, L., Peris, T. S., Levine, A., & Walkup, J. T. (2020). Research review: Pediatric anxiety disorders – what have we learnt in the last 10 years? Journal of Child Psychology and Psychiatry, 62(2), 114–139. https://doi.org/10.1111/jcpp.13262

Suicide Prevention Australia. (2022). ABS 2021 Causes of Death Data. https://www.suicidepreventionaust.org/news/statsandfacts#1666152045318-6fe592ec-5607

Sussman, T. J., Jin, J., & Mohanty, A. (2016). Top-down and bottom-up factors in threat-related perception and attention in anxiety. Biological Psychology, 121, 160–172. https://doi.org/10.1016/j.biopsycho.2016.08.006

Svensson, L., Hakeberg, M., & Wide, U. (2020). Evaluating the validity of the index of dental anxiety and fear (IDAF‐4C+) in adults with severe dental anxiety. European Journal of Oral Sciences, 128(5), 423–428. https://doi.org/10.1111/eos.12731

Swinburne University of Technology. (2022). Body dysmorphic disorder. https://www.swinburne.edu.au/research/centres-groups-clinics/centre-for-mental-health/our-research/body-dysmorphic-disorder/

Teachman, B. A., Joormann, J., Steinman, S. A., & Gotlib, I. H. (2012). Automaticity in anxiety disorders and major depressive disorder. Clinical Psychology Review, 32(6), 575–603. https://doi.org/10.1016/j.cpr.2012.06.004

Vachon, D. D., Krueger, R. F., Rogosch, F. A., & Cicchetti, D. (2015). Assessment of the harmful psychiatric and behavioral effects of different forms of child maltreatment. JAMA Psychiatry, 72(11), 1135–1142. https://doi.org/10.1001/jamapsychiatry.2015.1792

Vega, C., Guo, J., Killory, B., Danielson, N., Vestal, M., Berman, R., Martin, L., Gonzalez, J. L., Blumenfeld, H., & Spann, M. N. (2011). Symptoms of anxiety and depression in childhood absence epilepsy. Epilepsia, 52(8), e70–e74. https://doi.org/10.1111/j.1528-1167.2011.03119.x

Vu, V., & Conant-Norville, D. (2021). Anxiety: Recognition and treatment options. Psychiatric Clinics of North America, 44(3), 373–380. https://doi.org/10.1016/j.psc.2021.04.005

Wagner, K. D. (2006). Bipolar disorder and co-morbid anxiety disorders in children and adolescents. Journal of Clinical Psychiatry, 67(Suppl. 1), 16–20.

Westra, H. A. (2012). Motivational interviewing in the treatment of anxiety. Guildford Publications, Inc.

World Health Organization. (2022a). The ICD-11 classification of mental and behavioural disorders: Diagnostic criteria for research. World Health Organization.

World Health Organization. (2022b). World mental health report: Transforming mental health for all. Executive summary. https://www.who.int/publications/i/item/9789240049338

Author Information

Dr Christine Chinchen has been engaged as an educator, academic researcher, and writer for over three decades. Her background in adult education featured in her 2020 PhD on learning in tertiary education and is applied in learning processes in counselling education. During her career, Christine has been an educator in both VET and Higher Education, teaching from Diploma to Masters levels, in both independent higher education providers and universities. She worked for agencies and non-government organisations for over a decade before setting up private practice on the Northern Beaches of Sydney. Clinical supervision of organisations and individual counsellors and psychologists has been part of her practice for over fifteen years.

As an experienced counsellor, Christine specialised in issues such as trauma, crisis, complex family issues including domestic violence, loss and grief, and suicide prevention.

SFHEA; PhD; MEd (Adult); Grad Cert Higher Education Academic Practice; Grad Cert Higher Education (Learning and teaching); Grad Cert Helping Skills; BEd (Adult; App. Psych sub-major); Dip. Ind, Couple & Family Therapy; Assoc Dip Ad Ed (Community); Adv Cert in Trg & Dev; Cert Pers. Mmt.