Emotional Resilience Blog from The Fear Course

The latest research, realisations and thinking in the world of emotional resilience, anxiety and fear reduction from around the world.

Why the Fear of the Fear is More Damaging than the Original Fear

Why the Fear of the Fear is More Damaging than the Original Fear

When someone gets anxious or has a fear the feelings, thoughts, memories, physical sensations and other internal experiences the the fear or anxiety bring about are frequently so unpleasant that the individual will do just about anything to avoid them. This fear of the fear, or more correctly the fear of the effects of the fear is so distressing for many people that even talking about the issue is a problem. The distress is often heightened when there is no apparent direct cause or fear as occurs with GAD or General Anxiety Disorder or SAD Social Anxiety Disorder. There is a fear that these feelings could strike at any time.

It is not surprising then that people with fear and anxiety often end up not just avoiding the object of the anxiety, if there is one, but also of the resultant feelings, thoughts, memories, physical sensations and other internal experiences. This second type of avoidance is known as Experiential Avoidance.

Recent research has shown that how one reacts to the emotions and feelings that result from the anxiety makes a huge difference as to whether the individual is likely to get worse or not.

A swath of research is showing that people who are unwilling to experience the feelings, thoughts, memories, physical sensations and other internal experiences associated with the anxiety are much more likely to find the symptoms escalating and deeper problems arising.

Part of the problem is avoidance can only ever be a temporary relief and will never 'fix or solve' the problem. It merely side-steps the issue, which means that it is left still to face later. This is one reason why people who engage in avoidance as an emotion regulation strategy keep having the same and often escalating problem.

Another issue is that avoidance of anything psychologically reinforces the idea that the thing, in this case the feelings and thoughts, being avoided are bad or even dangerous in some way.

In order to avoid something requires that you end up focussing on and in many cases often obsessing about the very thing you are trying to avoid. This then means that the individual is focussing and obsessing about a negative. This takes time and effort and in effect crowds out all the other experiences of being a human, many of which are positive and joyful. As the individual focusses more and more on avoiding the horrible feelings and experiences, less and less concentration is placed on the positive things in life. In effect it becomes a negative vortex, dragging the individual down, often resulting eventually in depression, OCD, resorting to drugs and alcohol, self-harming, restricting food intake and even suicide.
We are finding that all of these problems frequently stem from Experiential Avoidance.

This is one of the reasons I deal with the avoidance as a matter of importance whilst treating the presenting anxiety and help the individual develop better and more effective emotion regulation strategies.





Chawla, Neharika; Ostafin, Brian (2007). "Experiential avoidance as a functional dimensional approach to psychopathology: An empirical review". Journal of Clinical Psychology 63 (9): 871–90. doi:10.1002/jclp.20400.PMID 17674402.

Gámez, Wakiza; et al (2011). "Development of a measure of experiential avoidance: The Multidimensional Experiential Avoidance Questionnaire". Psychological Assessment23 (3): 692–713. doi:10.1037/a0023242. PMID 21534697.

Hayes, Steven C.et al (1999). Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York: Guilford Press. ISBN 1-57230-481-2.

Hayes, Steven C. Et Al (1996). "Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment". Journal of Consulting and Clinical Psychology 64 (6): 1152–68. doi:10.1037/0022-006X.64.6.1152. PMID 8991302.

Losada, A. etal (2014) Development and validation of the experiential avoidance in caregiving questionnaire (EACQ). Aging & Mental Health. Volume 18, Issue 7, 2014


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The Cost of Anxiety

The Cost of Anxiety

It is widely known in the medical research community that anxiety disorders are the most common disorders there is, bar none. Not only are anxiety disorders the most frequently suffered disorder there is, a research paper published in journal Neuropsychopharmacology worked out that in the US alone in 2002 anxiety cost about 100 Billion dollars or £58,326,044,000 per year, which is the last reliable estimate of the general cost of anxiety. Given that this was firstly back in 2002 and secondly just in the US, which only accounts for about 4,44% of the worlds population you can start to get some idea of the size of the problem.

The cost obviously goes way beyond the financial burden, in terms of the incalculable effects it has on people's lives on a daily basis. Especially when you take into account the reduction in opportunities anxiety causes. Right now as I write this I have personal clients who:

  • couldn't go out,
  • wouldn't fly,
  • found it hard to speak at meetings,
  • got flustered and avoided social events, meetings, dating and a whole host of other social situations,
  • couldn't go shopping,
  • wouldn't drive,
  • wouldn't be a passenger in a car being driven by someone else,
  • couldn't go for job interviews,
  • wouldn't take a promotion,
  • avoided public places,
  • avoided intimate relationships,
  • were putting off an operation,

and that is just the start. The cost to these people in terms of the reduced opportunities and social functioning cannot be put into monetary terms. Not only that the emotional cost is almost impossible to articulate. Until you have had a panic or anxiety attack, or found yourself avoiding things or had depression, it is very difficult to understand what this does inside to a person.

The cost does not end there. There is now a growing body of evidence about the direct and indirect health costs of anxiety disorders. For example people with an anxiety disorder are 3 to 4 times more likely to develop cardiovascular disease, and twice as likely to die from some form of heart problem or a heart attack as the people without anxiety. Additionally as I reported in 'People with anxiety are more likely to develop depression' people with anxiety are 50-70% more likely to develop depression than the general population. Further there are a whole host of other health problems associated with anxiety which greatly effect the quality of life like cancer and cost the individual in mental and emotional ways beyond just financial costs.

And yet if you go to the doctors with any anxiety disorder the frequent response is to be put on a waiting list for online CBT or anti-depressants. Whilst I understand the primacy physical illnesses like coronary and cancer ( See 'Links between anxiety and cancer' ) care has, it is about time anxiety disorders also got the attention and priority other illnesses have form the medical professions. Anxiety which often either underlies, predicts or complicates the physical illness or as reported here '(The effects of pre-operation anxiety on the recovery of heart surgery patients') actually exacerbates or worsens the prognosis of the patient.

Anxiety treatment and prevention needs to become a priority for all of the health services. It's not like there is a lack of evidence.




Bardeen, J.R. etal (2014) Exploring the relationship between positive and negative emotional avoidance and anxiety symptom severity: The moderating role of attentional control. Journal of Behavior Therapy and Experimental Psychiatry. Volume 45, Issue 3, September 2014, Pages 415–420

Chalmers J, Quintana DS, Abbott MJ and Kemp AH (2014). Anxiety disorders are associated with reduced heart rate variability: A meta-analysis. Front. Psychiatry 5:80. doi: 10.3389/fpsyt.2014.00080

Fagundes, C.P. etal (2014) Attachment Anxiety is Related to Epstein-Barr Virus Latency. Brain, Behavior, and Immunity (2014), doi: http:// dx.doi.org/10.1016/j.bbi.2014.04.002

Jacobson N.C. & Newman, M.G. (2014) Avoidance mediates the relationship between anxiety and depression over a decade later. Journal of Anxiety Disorders. 28 (2014) 437-445.

Kessler, R. C., & Greenberg, P. E. (2002). The economic burden of anxiety and stress disorders. Neuropsychopharmacology: The fifth generation of progress, 67, 982-992.

Kravitz HM, Schott LL, Joffe H, Cyranowski JM, Bromberger JT (2014) Do anxiety symptoms predict major depressive disorder in midlife women? The Study of Women's Health Across the Nation (SWAN) Mental Health Study (MHS). Psychological Medicine [2014:1-10] DOI: 10.1017/S0033291714000075

Mohanty, S. et al (2014) Baseline anxiety impacts improvement in quality of life in atrial fibrillation undergoing catheter albtion. J Am Coll Cardiol. 2014;63(12_S):. doi:10.1016/S0735-1097(14)60395-8

Rubertsson, C et al. (2014) Anxiety in early pregnancy: prevalence and contributing factors. Archives of Women's Mental Health June 2014, Volume 17, Issue 3, pp 221-228

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Run Away!: Why Avoiding What Makes You Anxious is Probably Making Things Worse

Run Away!: Why Avoiding What Makes You Anxious is Probably Making Things Worse

Did you know anxiety disorders are the number one most commonly suffered mental health issues. Almost 20% of the population, or 1 in 5 of us will suffer from some form of non-minor anxiety in any year. As well as the distress caused, anxiety results in a range of other secondary issues like social avoidance, problems associated with jobs and employment, achievement, functioning as a family member as well as decreased health and lower levels of quality of life compared to people without anxiety. The economic cost is estimated to over $42 billion a year in the US alone.

Recent research attention has been focussing on a number of issues and in particular the effect avoidance (see my last blog) has on individuals with anxiety. As I mentioned previously there are broadly three tiers or levels of problem caused by anxiety based avoidance.

1. The individual avoids the stimulus of the anxiety: flying, meetings or public speaking for example, which means they won't realise the positive effects of that activity
2. Avoidance, once used as a coping strategy, tends then to become the first method of dealing with any difficult emotion, thereby habituating it.
3. The individuals tend to avoid any associated activities connected to the anxiety, including treatment.

A study just published by researchers from the University of Mississippi Medical Center in Jackson, and Northern Illinois University in DeKalb in the United States looked in more detail at the effects of anxiety avoidance.

They discovered a number of important things:
1. Firstly they found that people who turned to avoidance or flight as a coping strategy not only tended to avoid all negative emotions in this way, but also positive emotions. In effect people who use avoidance as a coping strategy down regulate positive emotions as well. This obviously exacerbates things and has a powerful negative effect on their quality of life.
2. People who tend to avoid negative emotions also tend to suffer from heightened levels of anxiety.
3. People who have lower levels of ability to take and maintain control over what they pay attention to, also had lower emotion regulation capability. What this means in effect is that it is very likely that the basis of many emotion regulation (and therefore emotional resilience) techniques is the ability to shift our focus away from internal emotions, and in particular negative emotions, to more productive activities and focus.

In short, avoiding anxiety and the causes of anxiety tends also to avoid positive emotions. They are also more likely to suffer from greater levels of anxiety, and are less likely to have the skills (these can be learnt) needed to deal effectively with other negative and positive emotions overall.





Bardeen, J.R. et al., (2014) Exploring the relationship between positive and negative emotional avoidance and anxiety symptom severity: The moderating role of attentional control. Journal of Behavior Therapy and Experimental Psychiatry. Volume 45, Issue 3, September 2014, Pages 415–420



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The Perfect Catch 22: Anxiety

The Perfect Catch 22: Anxiety

In Joseph Hellers famous book 'Catch 22', the servicemen found themselves in a perfect double bind. In order to escape conscription you had to prove you were mad. The problem was that if you tried to get discharged by showing you are mad the authorities assumed you are sane as you wanted to be discharged. As only mad people would want to fight, they wouldn't want to be discharged and therefore wouldn't try to show they were mad. Therefore the only people trying to get discharged due to madness must be sane and as a result weren't eligible to be discharged and as the mad people wanted to fight and not apply for discharge the military couldn't discharge them either as they weren't trying to prove they were mad!

In many ways anxiety is the perfect double bind or catch 22.

One of the defining symptoms of anxiety is avoidance. People with anxiety tend to have a heightened threat assessment which means they tend to perceive things as being a risk that other people might not. For example, talking at a meeting, going on a date or to a party for example. Many people don't have an emotional problem with these activities. They just do them and reap the benefits. However a person with an anxiety about talking at meetings for example will focus on the risk of embarrassment, saying the wrong thing, being seen to be stupid, or just the fear of general rejection.

This then results in flight or avoidance behaviour.

The issue of avoidance now becomes a three tiered problem. Firstly the individual is likely to go to increasing lengths to not go to meeting where they might have to talk. The effect of this is that firstly, the individual will never realise any of the benefits of talking at meetings such as increased self-worth, confidence, greater credibility, closer social relationships etc. Secondly, once the individual starts to engage in flight behaviour as a coping strategy, the avoidance tends to become the first strategy to use for any difficult emotion. This then very quickly becomes a habit or habituated response, making it much more likely to be the response in future experiences which give rise to anxiety, thus accelerating other anxieties.

The third level of problem avoidance brings about, is that not only will the individual avoid the problematic experience, dating, parties, flying etc. but in many cases they are also likely to avoid any contact with anything associated with the anxiety. This includes facing up to the emotions and dealing with them.

People with anxiety are much less likely to get the anxiety treated than people with other conditions. Herein lies the perfect double bind. Anxiety leads to avoidance. Avoidance makes the anxiety worse. Heightened levels of anxiety leads to greater levels of avoidance, to the exert that the individual won't seek treatment as they don't want to approach the anxiety. This avoidance then leads to even greater levels of avoidance.

Avoidance is a coping strategy, not a treatment.




Bardeen, J.R. etal (2014) Exploring the relationship between positive and negative emotional avoidance and anxiety symptom severity: The moderating role of attentional control. Journal of Behavior Therapy and Experimental Psychiatry. Volume 45, Issue 3, September 2014, Pages 415–420

Hayes et al., (1996) Experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64 (1996), pp. 1152–1168

N. Eisenberg, R.A. Fabes, I.K. Guthrie, M. Reiser (2000) Dispositional emotionality and regulation: their role in predicting quality of social functioning Journal of Personality and Social Psychology, 78 (2000), pp. 136–157

Maner, J.K. & Schmidt, N.B. (2006) The Role of Risk Avoidance in Anxiety. Behavior Therapy. Volume 37, Issue 2, June 2006, Pages 181–189

Maner. J.K. et al (2007) Dispositional anxiety and risk-avoidant decision-making. Personality and Individual Differences 42 (2007) 665–675

Salters-Pedneault et al., (2004) The role of avoidance of emotional material in the anxiety disorders. Applied and Preventive Psychology, 11 (2004), pp. 95–114

Williams et al., (1997) Are emotions frightening? an extension of the fear of fear concept. Behaviour Research and Therapy, 35 (1997), pp. 239–248

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Different types of control predicts depression

Different types of control predicts depression

Following on from the research articles reported in last week's blogs (here and here) about the links between anxiety and depression and the finding that people who avoid the object that is causing their anxiety are much more likely to have their anxiety turn to depression if the anxiety continues for some time, a third article just published sheds more light on the situation..

Largely there are three types of control that people use to cope with negative emotions: primary, secondary and disengagement control.
Primary control coping is based on changing and influencing our environment in order to cope. Choosing which friends to go out with based on who makes us feel good, problem solving to deal with the situation and engaging in emotion regulation techniques.
Secondary control is coping by adjusting ourselves to the environment, for example accepting the situation.
The third form of coping people engage in is to disengage completely or avoid the object or situation that is causing the negative emotion.

A study just published in Anxiety, Stress & Coping looked at the coping mechanisms of people who had previously been depressed and compared them with the coping mechanisms of people who have never been depressed
They found that people who had never had depression and who tend to use fewer primary coping skills in preference for avoidance coping strategies are significantly more likely to develop depression.
People, whether they had previously had depression or not, who develop secondary coping strategies, accepting the situation and their emotions (which is different to resignation), tend to see a decrease in their depressive symptoms.
They also discovered that people with greater levels of mental flexibility also tended to suffer from less depressive symptoms and recover more quickly from depression than people with less cognitive flexibility.

The researchers recommend that people at risk of depression should either be helped to develop emotion regulation strategies (primary control coping) or acceptance strategies (secondary control coping). Obviously learning both would be better, significantly reducing the risk of depression regardless of whether you have had it or not before.



Morris, M.C. et al (2014) Executive function moderates the relation between coping and depressive symptoms. Anxiety, Stress & Coping: An International Journal. 2014 June DOI: 10.1080/10615806.2014.925545

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One of the reasons anxiety turns into depression - new study

One of the reasons anxiety turns into depression - new study

As reported in Thursdays blog, more and more evidence is being found that long term untreated anxiety is likely to turn into depression. The study quoted on thursday found that this was likely to happen to about 50% of the population of anxiety sufferers. Another study also published recently suggests that untreated long term anxiety is likely to turn into depression in up to 77% of cases.
It has also been found that those that develop depression following long term anxiety, tend to get more severe forms of depression compared to those who develop depression without first suffering bouts of anxiety.

These are sobering findings and really highlight the importance of dealing with anxiety in its early forms and of learning the tools and techniques of proper emotion regulation.

However a question arises as to what is causing the anxiety to turn into depression. Surprisingly only three studies have looked look at the potential causes of this phenomenon. The first research study from 1999 looked at whether specific negative life events or reassurance seeking behaviours could be what transforms anxiety into depression, however the researchers could not find the expected connections. The second study from 2009 looked at the hypothesis that a lack of problem solving skills or individuals with anxiety who perceive that they have little or no control over the things that happen to and around them might cause, in part at least, the anxiety to turn to depression. Like the 1999 study, this study was unable to find such a causal effect.

However a study published a few weeks ago does finally shed light on this transformation. The study by researchers at The Pennsylvania State University in the United States used a large scale sample between 1994 and 2008 in four waves of observation with between 6504 and 4834 people to try to find what might be one of the causes for depression with people suffering from anxiety.

A prominent feature of anxiety is avoidance or flight. If an individual is anxious about something, say meetings, or public speaking or flying for example, they will tend to avoid engaging in that activity as a method trying to regulate the anxiety. As members of the free course will know this is one of three primary responses to what is known as the 'fear of the fear' phenomenon.

The researchers tested the hypothesis that avoiding the anxiety inducing subject, e.g. flying, public speaking etc. was a factor in the onset of depression. If this hypothesis were to prove to be correct one would expect that the greater the level of avoidance the greater the chance the individual has of becoming depressed. Indeed this is exactly what the researchers found.
The more someone avoids the anxiety promoting stimulus the greater their chances of becoming depressed.

There is now a hunt ongoing to find why this might be the case.


N.C. Jacobson & M.G. Newman (2014) Avoidance mediates the relationship between anxiety and depression over a decade later. Journal of Anxiety Disorders. 28 (2014) 437-445.

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If you are avoiding doing something does setting a goal really help?

If you are avoiding doing something does setting a goal really help?

Are you avoiding doing something? Do you have a goal that you are not really moving on? Anxiety is more than likely the main reason why you are not achieving your goals, but does goal setting actually help?

One of the main criteria for the diagnosis of anxiety and anxiety related disorders is avoidance. Not only does anxiety and fear create the conditions where we avoid the thing we are anxious about but that avoidance is also part of the process of worsening the anxiety and keeping it at the heightened sensitivity levels that it tends to reach.

One of the problems with anxiety based avoidance, like a fear of failure for example, is that the individual often creates a psudo-logical rationale to explain and maintain the avoidance often whilst at the same time understanding that the fear is irrational.

What this means is that we can have (at least) two opposing rationales working at the same time. The psudo-rationale which explains why the fear exists and in effect validates the fear and the cognitive logical rationale which understands that the anxiety is irrational. At the same time we have a couple of systems, both the cognitive (thinking) and the emotional (pathological) which are driving the avoidance feelings and behaviour.

So what has this got to do with setting goals? Well we can set quite logical and rationale goals and even feel motivated to achieve them, however these intentions can be undermined by both conscious and unconscious anxiety based avoidance behaviour.

A number of recent studies in this area have focussed on the role of reward (and loss) in the achievement of goals, particularly in an environment where anxiety based avoidance is prevalent.

In effect the decision to actually pursue a goal involves a series of factors including:

  • the value or the importance of the goal relative to other goals and activities currently in action,
  • the level of anxiety based avoidance being experienced, either consciously or unconsciously, and
  • the worth to the individual of the reward likely to be obtained from achievement of the goal, and
  • the likelihood or probability of that reward being realised.

Now when you think about it, this whole scenario is about decision making. Do I decide to pursue this line of action or that? For example, do I write that report I keep meaning to write or just check Facebook first? They are all decisions. Unfortunately anxiety can significantly sway our decisions.

A study published this month looks at the issue of anxiety based avoidance versus reward in goal setting. What they found was that not only was anxiety based avoidance a strong and persistent factor in failure to achieve goals, people with such anxiety based avoidance made decisions that limited their success and gave them less advantageous outcomes in the long run, especially when compared to people without anxiety. What they found was that people who suffer from anxiety based avoidance tend to also to suffer from greater long-term costs and lower rewards than those without anxiety.

However there is some good news. The study found that repeated exposure to the decision making process inherent in focussing on a goal did slowly improve matters.

So if you want to write a book, for example and you keep putting it off, keeping the goal in mind and regularly and frequently facing that goal and most importantly having to keep making the decision to take action or not, should (eventually) help to break down the barriers to action.

The moral of this is keep your goals alive, keep facing them and eventually you will make more advantageous decisions. Either that or visit the Fear Course - it's much quicker!

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Alpers, G.W. (2010) Avoiding treatment failures in specific phobias in M.W. Otto, S.G. Hofmann (Eds.), Avoiding Treatment Failures in the Anxiety Disorders, Springer, New York, NY (2010), pp. 209–227

Craske et al., (2009) What is an anxiety disorder Depression and Anxiety, 26 (2009), pp. 1066–1085 http://dx.doi.org/10.1002/da.20633

Kashdan et al., (2008) Social anxiety and disinhibition: an analysis of curiosity and social rank appraisals, approach-avoidance conflicts, and disruptive risk-taking behaviour Journal of Anxiety Disorders, 22 (2008), pp. 925–939 http://dx.doi.org/10.1016/j.janxdis.2007.09.009

Pittig, A. et al (2014) The cost of fear: Avoidant decision making in a spider gambling task. Journal of Anxiety Disorders. March 2014, Vol. 28. Pp 326-334


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