Applied Behavior Analysis in the Treatment of Anxiety

According to the Institute of Mental Health, anxiety disorders are the most common mental illness affecting Americans. It is estimated that anxiety disorders affect 40 million adults in the US, representing a full 18 percent of the population. Although anxiety is highly treatable, only about one-third of those with anxiety disorders pursue treatment.

Anxiety disorders cost the U.S. more than $42 billion every year. Since people that experience panic attacks and other manifestations of anxiety often misinterpret what they are experiencing as heart attack or otherwise experience symptoms associated with other physical illnesses, nearly $23 billion of this cost is associated with the repeated use of healthcare services.

Anxiety disorders develop from a complex set of risk factors, including brain chemistry, personality, life events, and genetics. Thanks to an increase in the number of meta-analysis reviews and the many researchers and clinicians who have kept pace with new developments, new and exciting therapies in applied behavior analysis (ABA) for the treatment of anxiety have emerged in recent years.

Cognitive and behavioral techniques, including ABA, have become leaders in the treatment of anxiety because they are derived from scientifically supported theoretical models of anxiety problems. A clear relationship exists between the treatment techniques and the symptoms of the anxiety disorders they are used to treat.

There are several types of anxiety disorders:

Generalized Anxiety Disorder

Individuals with generalized anxiety disorder have excessive worry for months and often have a variety of symptoms, such as:

  • Constant worry
  • Restlessness or a feeling of being on edge
  • Difficulty concentrating
  • Irritability
  • Unable to fall or stay asleep, lack of satisfying sleep
  • Muscle tension

Panic Disorder

Individuals with panic disorder have unexpected and reoccurring panic attacks—periods of intense fear accompanied by one or more of the following:

  • Pounding heart
  • Sweating
  • Trembling or shaking
  • Shortness of breath
  • Feeling of choking or smothering
  • Feeling of impending doom

Those suffering panic attacks worry intensely about when the next attack will happen and often avoid places where panic attacks have occurred in the past.

Social Anxiety Disorder

Individuals with social anxiety disorder experience intense fear in specific social or performance situations. They often feel embarrassed, judged, rejected, or fearful of offending others. Some of the symptoms associated with social anxiety disorder include:

  • Feeling self-conscious in front of other people
  • Being afraid others will judge them
  • Avoiding places where there are other people
  • Having a hard time making and keeping friends
  • Blushing or trembling around other people
  • Feeling nauseous around other people
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Treating Anxiety with Applied Behavior Analysis

Unlike low-incidence disorders like autism, behavioral research on high-incidence disorders like anxiety is much less common. One of the problems is that behavior analysts in the past were reluctant to pursue research on the topic because of a lack of a strong definition of anxiety. For example, the American Psychiatric Association continues to create more symptoms and categories of symptoms for anxiety disorders. In fact, anxiety disorder is often used as an umbrella term for a range of specific and non-specific forms of anxiety.

Other behavior analysts assumed that private emotional states like anxiety are not subject to behavior analyses due to their occurrence “within the skin.” In other words, anxiety is often difficult to measure and observe.

However, many of today’s applied behavior analysts are working to address the lack of research and raise the profile of behavioral approaches to anxiety.

Anxiety disorders are often treated with psychotherapy, medication, or a combination of the two. Applied behavior analysis (ABA) treatment is directed at a person’s specific anxiety; therefore, therapy is individualized. Applied behavior analysis uses experimentally established learning principles to determine the functional relation of the behavior, create a functional analysis, and develop viable treatment options.

Using Behavioral Activation (BA) to Treat Anxiety

The primary ABA treatment for anxiety is behavioral activation (BA), which involves decreasing behaviors the individual avoids by increasing positive reinforcements.

BA incorporates strategies designed to modify approaches to behaviors and eliminate the negative reinforcement associated with avoidance behaviors. Using BA, applied behavior analysist helps individuals approach anxiety-inducing situations and learn to lessen their fears through behavioral exposure.

To implement BA, the applied behavior analyst increases the patient’s awareness of how internal and external triggers result in negative emotional responses (anxiety symptoms) and how a pattern can soon develop. Once a pattern is recognized, the goal of the applied behavior analyst is to help the patient reengage in various healthy behaviors by developing alternative coping strategies.

To further reduce avoidance behaviors, patients learn to recognize their behavior and make better informed choices regarding whether to avoid or to engage in more adaptive behaviors that may improve their mood and quality of life.

Treatment components used to facilitate BA include:

  • Rating the mastery and pleasure of activities
  • Assigning activities to increase mastery and pleasure
  • Mentally rehearsing assigned activities
  • Role-playing behavioral assignments
  • Mindfulness training or relaxation
  • Self-reinforcement
  • Periodic distraction from problems or unpleasant events
  • Skills training methods (problem-solving, assertiveness, communication, etc.)

The Extinction of Anxiety

Anxiety is most often experienced as a set of respondent behaviors that are regulated by the nervous system, including:

  • Elevated heart rate
  • Swearing
  • Shortness of Breath

Respondent behaviors are typically associated with an antecedent stimuli followed by a set of responses, or conditioned behaviors. Depending on the individual suffering with anxiety, virtually anything can serve as the antecedent, from commuting to work to being subjected to an unfamiliar social situation.

Even the most stable and well adjusted among us would agree that these situations can be stressful. But for a person suffering from anxiety disorder, the normal stress that someone would feel in these situations grows out of proportion, and can eventually have the potential to be disruptive to their social, family and work life.

This initial stimuli, followed by an anxious feeling that the individual seeks to escape from fits perfectly with the so-called ABCs of applied behavior analysis: Antecedent, behavior, and consequence.

A person with anxiety disorder may be commuting to work when they start noticing that their heart rate has become rapid. Rather than taking a few deep breaths and recognizing this as a normal response to dealing with traffic and worrying about being late for work, they may begin convincing themselves that they are having a heart attack or that they may pass out and end up in a car wreck.

The only triggering stimuli (antecedent) is the traffic and road lights that all the other motorists must negotiate, but to the individual with anxiety disorder, the fear of something as unlikely as having a heart attack while behind the wheel takes over and causes them to associate their normal morning commute with far graver concerns.

This may result in the sufferer seeking the relief that comes with escaping the situation by coming up with ways to rationalize why they shouldn’t make the morning commute, a response known as avoidance. In this example, avoidance would have a very real and destructive impact on an individual’s life as problems begin to mount as a result of consistently missing work.

Behavioral treatment in this situation might involve commuting to work with a carpool partner who could safely relieve the sufferer of their driving duties at any time. This would allow the individual with anxiety to drive under normal daily traffic conditions for longer and longer periods of time so as to ultimately come to the realization that they can deal with a situation that brings them anxiety without having to escape it. Over time, the anxiety will subsist and eventually become extinct as driving is no longer associated with feelings of anxiousness.

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The feeling of satisfaction, independence and personal victory that comes with successfully achieving the goal of driving to work without having to relinquish control to the carpool partner can effectively serve as the reward that reinforces the positive behavior.

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