Introduction to Anxiety Disorders; Prevalence Panic Disorder and Generalized Anxiety

Disorder
Anxiety is characterized of unpleasant emotions and cognitions that are future-oriented
and is much more complexresponse pattern when compared to fear (Barlow, 1988, 2002). While
fear is merely a reaction to immediate danger, anxiety is a blend of physiological, cognitive as
well as behavioural components; at a physiological level, anxiety is often a chronic state of
tension and arousal where the sympathetic nervous system activity.The cognitive components
contribute in inducing negative mood, worry about possible threats or danger in the future, and a
sense uncertainty about the future, which are often followed by risk assessment behaviours of
readiness and constant alertness to deal with anticipated dangers. Though the physiological
responses in both anxiety and fear involve the sympathetic nervous system, in anxiety there is
fear of the anticipated whereas in the response to fear is more immediate and induces a series of
“fight or flight” reactions. However, anxiety can be adaptive and help individuals to notice and
plan for the potential threats that one might face in the future— aiding the individual to increase
his/her preparedness about a particular event, help them avoid potentially dangerous situations,
and to think through potential problems before facing them.

DSM-V
ANXIETY DISORDERS

Social
Specific Anxiety Panic
Selective Phobia Disorder Disorder Agoraphobia
Separation Mutism Generalized
Anxiety Disorder Anxiety Disorder

Fig. 1.1 An overview of Anxiety Disorders according to the DSM-V Classification

 Panic Disorder and Generalized Anxiety Disorder are categorized under “Anxiety
Disorders”bytheDiagnostic and Statistical Manual of Mental Disorders- V (DSM-V).
TheInternational Classification of Diseases-10 (ICD-10) lists Generalized Anxiety Disorder as
a disorder sub-categorized under anxiety disorders andbroadlycategorized under “Neurotic,
stress-related and somatoform disorders” (F40-F48). However, ICD-10 lists Panic Disorder
with “Agoraphobia” as a specification— “Panic Disorder with Agoraphobia” and “Panic
Disorder without Agoraphobia”, under the sub-section of “Phobic Anxiety Disorder”. This is
because panic attacks may be expected, such as in response to a typically feared object or
situation, or unexpected, meaning that the panic attack occurs for no apparent reason. Thus panic
attack may therefore be used as a descriptive specifier for any anxiety disorder as well as other
mental disorders. Throughout this unit we will be intermittently considering the diagnostic
criteria and the clinical description provided by both DSM-V as well as ICD-10.
Panic disorder on the other hand is characterized by recurrent individual and unexpected
experiences of panic attacks. Individuals having panic disorder are persistently concerned or
worried about having more panic attacks. Panic attacks are abrupt surges of intense fear or
intense discomfort that reach a peak within minutes, accompanied by physical and/or cognitive
symptoms (APA, 2013).
Generalized anxiety disorder (formerly known as free-floating anxiety) is characterized
by an excessive and inappropriate worrying that is persistent and not restricted to particular
circumstances. Individuals with generalized anxiety disorder have physical anxiety symptoms
(such as tachycardia and tremor) and key psychological symptoms, including restlessness,
fatigue, difficulty in concentrating, irritability, muscle tension and disturbed sleep (APA, 2013).
Anxiety disorders are the sixth leading cause of disability worldwide. The global
statistics of the prevalence of anxiety disorders is roughly 273 million (WHO, 2017). Anxiety
disorders particularly panic and generalized anxiety disordersare more commonly reported in the
western societies than in non-western societies (Source: https://www.futurity.org/globally-1-in-
13-suffers-from-anxiety/). When compared to the other anxiety disorders, panic disorder does
not record to have a high prevalence; however, GAD is reported to affects 4.3% of the world’s
population (Bandelow, &Michaelis, 2015). It should be noted that factors associated with panic
disorder andGAD overlap more strongly with those specific to anxiety disorders than those
specific to other mental disorders such as depression, etc(Beesdo, Pine, Lieb, &Wittchen, 2010).
 The extensive study on the prevalence and incidence of anxiety disorders in the country,
the National Mental Health Survey of India reported the prevalence of panic disorder and
generalized anxiety disorder as 0.5% and 0.6% respectively. The study also reported that
generalized anxiety disorder is highly prevalent among females than males (Murthy, 2017),
which remains the same even in the global scenario.However, it should be noted that these
numbers reflect those individuals who have been diagnosed and reported mental illness. It should
not be forgotten that large numbers of the country’s population stay in the dark and seldom
approach professional assistance for symptoms of many mental disorders. In a highly populated
country like ours with limited mental healthcare professionals it is the need of the hour to carry
out mental health awareness camps and programs in manifold ways to reach the large numbers
and ensure their mental well-being.

Panic Disorder: Clinical Picture (diagnostic criteria), Etiology and Treatment Procedures.

PANIC DISORDER
Case Study for Panic Disorder:
Katie Smith, a 27-year old female, enters the emergency room after experiencing an episode of
extreme chest pain, difficulty breathing, and numbness in her arms. She states the following to
the admitting physician:
“I was walking my dog earlier when I started
sweating. Since it isn’t hot outside, then I started
having trouble breathing and really got scared. My
heart was pounding so hard I thought it might
explode out of my chest. My knees felt weak – it
seemed like my whole body was shaking, then my
arms went numb. Apparently the whole thing only lasted a few minutes, but it felt like each
second was an hour. Did I have a heart attack? Am I going crazy? I felt like I was going to die.”
Katie is given an EKG, but the test comes back in normal range, indicating that she did
not have a heart attack. Her physician believes she may have had a panic attack and refers her to
a clinical psychologist.Four weeks later, Katie sees the psychologist and reports that she has
experienced over two-dozen panic attacks with similar symptoms since her time in the
emergency room. At this point, her day-to-day functioning is significantly impaired; she avoids
work, time with family and friends, and walking her dog because she thinks it might trigger
another attack. There is no concrete source of anxiety or fear in Katie’s life other than fear of the
attacks themselves. Her psychologist diagnoses her with panic disorder and uses a variety of
different exercises to improve her functioning.
(Source: https://www.khanacademy.org/test-prep/mcat/social-sciences-practice/social-science-
practice-tut/e/case-study-of-panic-disorder-in-an-adult-female)

Clinical Picture: Panic Disorder

As described earlier, individuals with panic disorder experience what we call as a “panic
attack” and the constant anticipation of having these attacks more often. Panic attacks are sudden
attacks of intense apprehension, terror, and feelings of impending doom. These intense fears are
usually accompanied by at least four of the following symptoms, i.e. physical symptoms of heart
palpitations, profuse sweating, trembling, shortness of breath, feelings nauseous, feeling choking,
abdominal discomfort,feelinglightheaded, and chills or heat sensations. Other symptom such as
paresthesias (numbness or tingling sensations),de-realization (feelings of unreality) or
depersonalization (being detached from oneself), fear of losing control over one’s being and the
fear of dying are also commonly experienced during panic attacks. These symptoms can surge up
from a sudden anxious state or have a gradual onset from a calm state, to escalate and reach their
peak of uncontrollable physical and psychological symptoms in the matter of minutes.Although
these attacks can occur in situations least expected (referred to as uncuedattacks) by the
individual (for e.g. panic attacks during sleep- known as nocturnal panic), they can also
spontaneously occur in particular situations which the individual has been predisposed to. For an
individual to be diagnosed with panic disorder he/she must experience recurrentuncued panic
attacks, which often alter their behaviours, forcing them to avoid certain situations, being tensed
about particular events and planning their activities to avoid encounters which they believe can
trigger the attacks.

Diagnostic Criteria for Panic Disorder

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that
reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate; 2. Sweating; 3. Trembling or shaking; 4. Sensations of
shortness of breath or smothering; 5. Feelings of choking; 6. Chest pain or discomfort; 7. Nausea or abdominal
distress; 8. Feeling dizzy, unsteady, light-headed, or faint; 9. Chills or heat sensations; 10. Paresthesias (numbness or
tingling sensations); 11. De-realization (feelings of unreality) or depersonalization (being detached from oneself);
12. Fear of losing control; 13. Fear of dying;
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a
heart attack, “going crazy”); 2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors
designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication)
or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in
response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or
situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to
reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment
figures, as in separation anxiety disorder).
Source: Diagnostic and Statistical Manuel of Mental Disorders, Fifth Edition, American Psychiatric Association, (2013).

Etiology: Panic Disorder

The various biological and psychological causal factors of panic disorder are elucidated below:

Biological Causal Factors

Genetics: The heritability component of panic disorder, as reported by many family as
well as twin studies has been moderate (Kendler et al., 1992b, 1992c; Kendler et al., 2001;
Norrholm&Ressler, 2009). Recent research has identified the specific “genetic polymorphisms”
that can cause panic attacks, solely or when in interaction with certain stressful events faced by
an individual in his/her lifetime (Strug et al., 2010).Such studies must be replicated to draw any
further generalizations from the findings. Nevertheless, a genetic vulnerability for developing
panic disorder can be manifested at a psychological level through the trait of neuroticism. Those
individuals who have a history of phobias (social or specific) are at a greater risk of developing
panic disorder (Biederman et al., 2006). However, we cannot draw conclusions as there is a
dearth for further research to strengthen these findings.
 Brain& Panic Disorder: Functional Abnormalities: Research suggests that increased
activity in the amygdala plays a central role in panic attacks.The amygdala is a part of the brain
which is considered the centre for emotions. It is critically involved in the emotion of fear. The
amygdale is a collection of nuclei (a collection specific structures in the brain is referred to as
nuclei) located in front of the hippocampus in the limbic system of the brain. Stimulating the
central nucleus of the amygdale, stimulates the locus coeruleus(a structure in the brain stem
where the neurotransmitter—norepinephrine—plays a central role in the brain activity in this
area) which in turn stimulate the autonomic, neuro-endocrine, as well as the behavioral responses
that occur during a panic attacks (Gorman et al., 2000; LeDoux, 2000). Other researchers suggest
that the along with its connections with the lower areas in the brain, amygdaleis also connected
to the higher brain areas such as the prefrontal cortex (Gorman et al., 2000). Thus, the amygdale
plays a central role in the “fear network” of the brain, which can be activated either by cortical
inputs or by inputs from lower brain areas during a panic attack. According to this theory, panic
disorders are most likely to occur in individuals who have an abnormally and highly sensitive
fear network ––– individuals who show heightened startle responses to loud noise stimuli and
slower habituation to such responses (Ludewig et al., 2005; Shin &Liberzon, 2010). These
abnormally sensitive fear networks may be partially heritable but may also develop as a result of
repeated stressful life experiences, particularly those which are encountered early in an
individual’s life (Gorman et al., 2000; Ladd et al., 2000).
Biochemical Abnormalities have suggested that thethese abnormalities put a lot of stress
oncertain neurobiological systems, which in turn produce intensephysical symptoms of arousal
(such as increased heart rate, respiration,and blood pressure). The two primary neurotransmitter
systems that are mostimplicated in panic attacks—are the noradrenergic and the
serotonergicsystems (Gorman et al., 2000; Graeff& Del-Ben, 2008). Noradrenergic activity in
certain brainareas can stimulate cardiovascular symptoms associated withpanicandincreased
serotonergic activity alsodecreases noradrenergic activity. Abnormalities in the release of these
two systems in the brain lead to the symptoms of panic disorder(Gorman et al., 2000).
The theory of the inhibitory neurotransmitter GABA in the brain which isknown to inhibit
anxiety has been shown to be abnormallylow in certain parts of the cortex in people with panic
disorder(Goddard, Mason, et al., 2001, 2004).
Psychological Causal Factors
Cognitive theorists: Being panic-prone can be a major psychological contributor to panic
disorder. As people who are panic-prone may be very sensitive to certain bodily sensations;
when experiencing any such sensations, they often misinterpret them as signs of a medical
catastrophe (Gloster et al., 2014).Thus misinterpreting and over emphasizing on every detail due
to their day to day lives, many situations and sensations are viewed as increasingly upsetting and
losing control, fearing the worst, and rapidly plunge into panic. They are also convinced and
belief that thesesensationswill return at any time or in particular events and so set themselves up
for future panic attacks.
A learning theory of panic disorder that accounts for most of the known findings about
panic disorder says thattheinternal bodily sensations of anxiety or arousal (such as heart
palpitations) effectively become interoceptive conditioned stimuli associated with higher levels
of anxiety or arousal (Goldstein &Chambless, 1978). According to this theory, initial panic
attacks become associated with initially neutral internal (interoceptive) and external
(exteroceptive) cues through an interoceptive conditioning (or exteroceptive conditioning)
process (e.g., Acheson et al., 2007; Forsyth &Eifert, 1998). One primary effect of this
conditioning is that anxiety becomes conditioned to these Conditioned Stimuli, and the more
intense the panic attack, the more robust the conditioning that will occur (Forsyth et al., 2000).
Thus this conditioning of anxiety to the internal or external cues associated with panic thus leads
to the other components of the anticipatory anxiety. Moreover, a recent study demonstrated that
once an individual has developed panic disorder they show greater generalization of conditioned
responding to other similar cues than do the participants in the control group without panic
disorder (Lissek et al., 2010).

Treatment: Panic Disorder

Pharmacotherapy: Anti-anxiety medication such as anxiolytics are prescribed for people
with panic disorder, and other medication from the benzodiazepine category such as
alprazolam(Xanax) or clonazepam (Klonopin) can also be prescribed. There is symptom relief
from these medications to an extent, and people suffering with this disease can function more
effectively after the use of medication. These drugs act very quickly (30–60 minutes) and are
useful in acute situations of intense panic or anxiety. However, these anxiolytic medications can
also pose certain side effects such as drowsiness and sedation, which can lead to impaired
cognitive and motor performance. Also, prolonged use of moderate to high doses develop
physiological dependence on the drug, which results in withdrawal symptoms when the drug is
discontinued (e.g., nervousness, sleep disturbance, dizziness, and further panic attacks) (Pollack
& Simon, 2009),thus making these medications unpopular and seldom used for the purpose of
treatment in panic disorder.
The other category of medication that is useful in the treatment of panic disorder are the
antidepressants(including primarily the tricyclics, the SSRIs, and most recently the serotonin-
norepinephrine reuptake inhibitors—SNRIs). When compared to benzodiazepines, these do not
create a physiological dependence and they also aid in alleviating any co-morbid depressive
symptoms or disorders (Pollack & Simon, 2009; Roy-Byrne & Cowley,2007).
Few side effects posed by these medications are dry mouth, constipation, and blurred vision with
the tricyclics, and interference with sexual arousal.

Psychological Treatments: One of the most widely used techniques involves the variant
on exposure known as interoceptive exposure, i.e. deliberately exposing an individual suffering
with panic disorder to feared internal sensations. This was adopted considering that the fear of
these internal sensations should be treated in the same way that fear of external agoraphobic
situations is treated—namely, through prolonged exposure to those internal sensations so that the
fear may extinguish.
The second set of techniques are often called the cognitive restructuring techniques,
which state that catastrophic automatic thoughts may help maintain and make panic attacks
recur.
One of these techniques which are effective in treating panic disorder is the panic
control treatment (PCT).In PCT, initially the clients (persons suffering with panic attacks) are
educated about the nature of anxiety and panic and how the capacity to experience both is
adaptive. Secondly, the treatment involves teaching the clients with panic disorder to control
their breathing. As the third step, clients are taught about the logical errors that people with panic
disorders are prone to make and are taught to subject their own automatic non-rational thoughts
to a logical reanalysis. Finally, they are exposed to feared situations and feared bodily sensations
to build up a tolerance to the discomfort.
 Generally, the magnitude of improvement is often greater with these cognitive and
behavioral treatments than with medications (Arch & Craske, 2009; Barlow et al., 2002).
Moreover, these treatments have been extended and shown to be very useful in treating people
who also have nocturnal panic (Arch & Craske, 2008). However, combined treatment, i.e.
combining cognitive-behavioural therapies with pharmacotherapy can usually prove to produces
a slightly superior result compared to either type of treatment alone (Barlow et al., 2007).
Generalized Anxiety Disorder: Clinical Picture (diagnostic criteria), Etiology and
Treatment Procedures.
GENERALIZED ANXIETY DISORDER
A Case Study
Mary is aged 42 years old female who is divorced and
has two children. She is a part time employee and cares
for her mother who has Alzheimer’s disease. Mary has
no significant past medical history, although she
frequently makes appointments with her GP and
practice nurse about problems experienced by her and
her children. She was moderately depressed following
her divorce 5 years ago and was offered antidepressants
but declined them. She was referred for six sessions of
counselling, which led to some improvement in her symptoms. On examination Mary complains
of feeling ‘stressed’ all the time and constantly worries about ‘anything and everything’. She
describes herself as always having been a ‘worrier’ but her anxiety has become much worse in
the past 12 months since her mother became unwell, and she no longer feels that she can control
these thoughts. When worried, Mary feels tension in her shoulders, stomach and legs, her heart
races and sometimes she finds it difficult to breathe. Her sleep is poor with difficulty getting off
to sleep due to worrying and frequent wakening. She feels tired and irritable. She does not drink
any alcohol. (Source: https://www.nice.org.uk)

Clinical Picture: Generalized Anxiety

Disorder
 People with generalized anxiety disorder experience excessive anxiety under most
circumstances and worry about practically anything. Individuals with GAD typically feel
restless, keyed up, or on edge; tire easily; have difficulty concentrating; suffer from muscle
tension; and have sleep problems. The symptoms last at least 6 months (APA, 2013).
Nevertheless, most people with the disorder are able, although with some difficulty, to carry on
social relationships and job activities.

Diagnostic Criteria for Generalized Anxiety Disorder

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months,
about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some
symptoms having been present for more days than not for the past 6 months):
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
Note:Only one item is required in children.
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
E. The disturbance should not be attributable to the physiological effects of a substance or another medical
condition.
F. The disturbance is not better accounted for by another mental disorder.
Source: Diagnostic and Statistical Manuel of Mental Disorders, Fifth Edition, American Psychiatric Association, (2013).

Etiology: Generalized Anxiety Disorder

Psychological Causal Factors: Psychoanalytic View point: The psychoanalytical
viewpoint owes up the developing of the symptoms of generalized anxiety disorder to the
unconscious conflict between ego and id impulses which is not adequately dealt with because the
person’s defense mechanisms have either broken down or have never developed.
Freud believed that it was primarily sexual and aggressive impulses that had been either
blocked from expression or punished upon expression that led this generalized anxiety. Defense
mechanisms may become overwhelmed when a person experiences frequent and extreme levels
of anxiety, as might happen if id impulses are frequently blocked from expression(e.g., under
periods of prolonged deprivation from meeting the basic needs of the id). According to this view,
the primary difference between specific phobias and generalized anxiety is that in phobias, the
defense mechanisms of repression and displacement of an external object or situation actually
work, whereas in generalized anxiety these defense mechanisms do not work, leaving the person
anxious most of the time. However, as most psychoanalytical viewpoints, this too has not been
testable and has therefore remains usually abandoned among researchers.
Uncontrollable and unpredictable aversive events are much more stressful than
controllable and predictable aversive events. People with GAD may have a history of
experiencing many important events in their lives as unpredictable or uncontrollable, may be
more likely to have had a history of trauma in childhood than individuals with several other
anxiety disorders (Borkovec et al., 2004). People with GAD clearly have far less tolerance for
uncertainty than non anxious controls and than people with panic disorder (Dugas et al., 2004,
2005; Koerner & Dugas, 2008). This low tolerance for uncertainty in people with GAD suggests
that they are especially disturbed by not being able to predict the future (Roemer et al., 2002). A
person’s history of control over important aspects of his or her environment is another important
experiential variable strongly affecting reactions to anxiety-provoking situations. As the process
of worry is considered the central feature of GAD investigated both what people with GAD think
the benefits of worrying are and what actual functions worry serves.
Several of the benefits that people with GAD most commonly think derive from worrying
are: Superstitious avoidance of catastrophe (“Worrying makes it less likely that the feared event
will occur”). Avoidance of deeper emotional topics (“Worrying about most of the things I worry
about is a way to distract myself from worrying about even more emotional things, things that I
don’t want to think about”). Coping and preparation (“Worrying about a predicted negative event
helps me to prepare for its occurrence” (Borkovec and colleagues, 1994, 2004, 2006).

Biological Causal Factors: Genetic evidence is increasingly regarding GAD and major
depressive disorder has a strong common underlying genetic predisposition(Kendler et al.,
2007).The factor that determines whether individuals with a genetic risk for GADand/or major
depression develop one or the other disorder seemsto be the specific non-shared environmental
experiences faced by the individual.
A functional deficiency in the release of GABA has been found to reduceanxiety.It
appears that highly anxious people havea kind of functional deficiency in GABA, which
ordinarily plays an important role in the way our brain inhibits anxiety in stressful situations.
However, whether the functional deficiency in GABA in anxious people causes their anxiety or
occurs as a consequence of it is not yet known, but it does appear that this functional deficiency
promotes the maintenance of anxiety.
More recently, researchers have discovered that another neurotransmitter—serotonin—is
also involved in modulating generalized anxiety (Goodman, 2004; Nutt et al., 2006). Research
suggest that GABA, serotonin, and perhaps norepinephrine all play a role in anxiety.

Treatments: Generalized Anxiety Disorder

Pharmacotherapy: Persons with generalized anxiety disorder consult family physicians,
seeking relief from their anxieties often attributing it to their various functional physical
problems. Medications from the benzodiazepine(anxiolytic) category such as Xanax or Klonopin
are usually used for tension relief, reduction of other somatic symptoms, and relaxation.
However, their effects on worry and other psychological symptoms related to GAD are not up to
the mark. Moreover, they can create physiological and psychological dependence and
withdrawal symptoms too can occur.
However, a new medication known as the buspirone is also effective, and it neither has
sedating nor leads to physiological dependence. It also has greater effects on psychic anxiety
than do the benzodiazepines. Also, various categories of antidepressant medications like those
used in the treatment of panic disorder are also useful in the treatment of GAD, and they also
seem to have a greater effect onthe psychological symptoms of GAD when compared to the
benzodiazepines (Roy-Byrne & Cowley, 2002, 2007). However, improvement in the symptoms
due to the use of these medications is gradual.

Psychological therapy: Cognitive behavioural therapy has become increasingly effective

n the face of GAD. The therapy usually involves a combination of behavioral techniques, such as
training in applied muscle relaxation, and cognitive restructuring techniques aimed at reducing
distorted cognitions and information-processing biases associated with GAD as well as reducing
catastrophizing about minor events (Barlow, Allen, & Basden, 2007; Borkovec, 2006; Borkovec
et al., 2002).
Yet another nonchemical biological technique commonly used to treat generalized
anxiety disorder other than CBT is relaxation training. The idea behind relaxation training, is that
the relaxation of the physical body will lead to a state of psychological relaxation. Psychologists
or therapists teach their clients to identify individual muscle groups, and consciously tense these
muscle groups and release the tension, which ultimately relaxes the whole body. On practice,
clients can bring on a state of deep muscle relaxation and reduce their state of anxiety.
Research indicates that relaxation training is more effective than no treatment or placebo
treatment in cases of generalized anxiety disorder (Hayes-Skelton et al., 2013). Also the other
techniques that are known to relax people, such as basic meditation, often seem to be equally
effective (Bourneet al., 2004).
Biofeedback is another technique where the therapist uses electrical signals from the
body to train people to control physiological processes such as heart rate or muscle tension. In
this clients are connected to a monitor that gives them continuous information about their bodily
activities. The device then converts the electric energy coming from the muscles into an image,
such as lines ona screen, or into a tone whose pitch changes along with changes in muscle
tension. Thus clients “see” or “hear” when their muscles are becoming more or less tense. The
clients attend to the signals from the monitor and they gradually may learn to control even the
involuntary physiological processes. Through repeated trial and error, the individuals become
skilled at voluntarily reducing muscle tension and, theoretically, at reducing tension and anxiety
in everyday stressful situations.