When is it fear and when is it anxiety?

In therapy how do you deal with real fear? For instance, what about the fear of cancer, or the fear of being bullied, or the fear over whether she will ever get a job? Thanks to Jeremy for this great question!

Anna Freud offered a very useful distinction for us to keep in mind. She said that fear is our response to an objective danger. Anxiety is our response to a subjectively perceived threat, e.g., a feeling. From evolution and our understanding of the animal world and the work of Jaak Panksepp, http://www.amazon.com/Affective-Neuroscience-Foundations-Emotions-Science/dp/019517805X/ref=sr_1_2?ie=UTF8&qid=1375818755&sr=8-2&keywords=jaak+panksepp ,we know that all animals have a fear response. They perceive an objective danger (a predator wants to eat them). They have an automatic fear response which primes the body to either flee from or fight the predator if they are a mammal. If the prey is a reptile, the fear response primes the body to freeze. This fear response is pre-wired in the brain at birth as shown in the animal studies of Panksepp and some recent human studies.

Thus, if I see a bully approaching me, armed with a baseball bat, I will experience a fear response inside my body. And that fear response occurs automatically and unconsciously. It precedes my conscious awareness and thoughts about the bully.

To deal with a bully in the workplace effectively requires that we have access to our feelings that can mobilize an adaptive response. Thus, we have to help the patient face his fear toward an objective danger without using any denial. The fear will mobilize an adaptive response. In addition, we have to help the patient face his anger toward this threatening person. By facing his anger as deeply as possible, he will be able to channel it into effective action: filing a complaint with human resources, confronting the person, deactivating the person’s projections, or perhaps leaving. The access to the fear and the anger will provide him with the energy and motivation to defend himself and his interests as effectively as possible.

If the patient has cancer, his fear is not only of what the cancer will do. More fundamentally, he fears dying. This fear can motivate him to seek the best treatment possible to maximize his chances for living. However, if he uses the defense of denial, his defense may prevent him from making the right choices. Thus, we must help him face the reality of the cancer so he can make the most adaptive choices. And, sadly, the most adaptive choice in the case of stage four cancer may be to reduce pain, mourn the loss, find meaning in his life, and say goodbye to the most meaningful people in his life…to make his death illustrate the meaning of his life. In other words, there are objective threats in the world. We fear them for good reason.

The final example offered was the person who fears she will not ever find a job. This example is a bit trickier. Unemployment is a genuine threat to your survival. You will experience fear over this genuine threat in this moment. However, once you speculate about the future, you are in the realm of imagination. We cannot know what the future will bring. It is the unknown. This “fear” is not over a real danger in the present but an imaginary danger in the future. I would not regard this as a “fear” but as the result of a defense: misusing one’s imagination for the purpose of self-torture. Fantasizing about bad events in the future is a way to give a down payment of suffering in advance. It’s a way to suffer now before the future has happened. “Why wait to suffer then when I could get to work and start suffering now?”

This is why you will notice in my book, Co-Creating Change, that I point out the importance of whether a feeling is triggered by a real stimulus or an imaginary stimulus. Ask yourself, “Is my patient suffering fear of a real stimulus today or is she suffering from fear of imaginary stimuli in the future?” That assessment question will help you differentiate fear of an objective danger from the misuse of one’s imagination for the purpose of self-torment. This is what rumination usually is: a form of self-torment.

Another example: a patient is going to a meeting and feels very fearful ahead of time, convinced that people in the meeting do not respect her and that she is simply an outlier. While there she receives a great deal of respect and admiration. Now she realizes that although she previously “feared” the group, in fact she had been afraid of the projections she had placed on the group. Thus, her so-called fear was a response to an imaginary stimulus: her projection.

And, finally, there is anxiety: our unconscious bodily response to the rise of previously forbidden feelings and impulses. Here, we regulate the anxiety when necessary, and then we help the patient face the feelings which are triggering her anxiety.

Key take home points: fear is our response to an objective danger; anxiety is our response to a subjectively experienced threat: an inner impulse or feeling. To assess a patient’s “fear”, find out if it is a response to a real or imaginary stimulus. When a patient has an objective fear, help him face his fear and the stimulus without denial, and then help him feel any reactive feelings that can help him respond adaptively. When a patient’s “fear” is the result of an imaginary stimulus, restructure the defense that creates that “stimulus”: e.g., projection.






3 responses to “When is it fear and when is it anxiety?”

  1. Charles Horowitz, Ph.D. Avatar
    Charles Horowitz, Ph.D.

    Please, what about PTSD and/or paranoia? These involve currently imaginary experiences, but they seem too real and intense to the client to be called “anxiety.”

    1. istdpadmin Avatar

      When faced with complex feelings, the patient’s anxiety will rise. For some patients, this anxiety shifts into cognitive/perceptual disruption giving rise to many of the symptoms we call PTSD. When this anxiety rises so high, the patient tries to avoid the internal experience of mixed feelings by projecting those feelings onto other people. Now, rather than feel his anger, he projects it onto others and believes they are angry with him. And he believes his projections. This is the condition we refer to as paranoia. When these perceptions appear to be real to the patient, we call that a loss in reality testing: the loss of the ability to differentiate his fantasies about other people from the reality of who they are.

    2. istdpadmin Avatar

      PTSD is a condition involving excessive anxiety and a variety of primitive defenses which can overwhelm the patient. Paranoia is the irrational fear of people whom the patient equates with his projections. The paranoid person is not relating to people, but to the projections he places on people. This defense of projection is triggered by massive feelings and overwhelming anxiety. To manage unbearable anxiety, the paranoid attributes to others the feelings, impulses, and issues that he cannot tolerate yet in himself.

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