Anxiety Responses and Anxiety Disorders

Anxiety Responses and Anxiety Disorders

Gail W. Stuart

Anxiety is a part of everyday life. It has always existed and belongs to no particular era or culture. Anxiety involves one’s body, perceptions of self, and relationships with others, making it a basic concept in the study of psychiatric nursing and human behavior.

Anxiety disorders are the most common psychiatric disorders in the United States, affecting between 15% and 25% of the population. Those with an anxiety disorder have significant impairment in quality of life and functioning.

It has been estimated that only about one fourth of those with anxiety disorders receive treatment (Giacobbe et al, 2008). However, these people are high users of health care services because they seek treatment for the various symptoms caused by anxiety, such as chest pain, palpitations, dizziness, and shortness of breath.

Continuum of Anxiety Responses

Anxiety is a vague sense of apprehension that is accompanied by feelings of uncertainty, helplessness, isolation, and insecurity. The person senses that the core of his personality is being threatened. Experiences provoking anxiety begin in infancy and continue throughout life. They end with the fear of the greatest unknown, death.

Defining Characteristics

Anxiety is an emotion and a subjective individual experience. It is energy and cannot be observed directly. A nurse infers that a patient is anxious based on certain behaviors. The nurse needs to validate this inference with the patient.

Anxiety is an emotion without a specific object. It is provoked by the unknown and accompanies all new experiences,


This case can help you understand some of the issues you will be reading about. Read the case background and then, as you read the chapter, think about your answers to the Case Critical Reasoning Questions. Case outcomes are presented at the end of the chapter.

Case Background

It was all so hard to explain. He said it took months, but yet it had happened so suddenly that it is difficult to say where to start. He had been a very successful contractor, more successful than he had ever expected. Then he underbid a project and lost money; his foreman quit and became a competitor; and slowly he began to doubt himself. Finally it happened. One morning before leaving the house, his heart started pounding; he began to tremble and felt numb. He felt strange, like he was in a movie, so unreal. He started gasping for breath. He thought he was having a heart attack or was about to die. He was terrified. Nothing like this had ever happened to him before.

His wife took him to an urgent care center in town where they did an EKG and told him his heart was fine; he was just stressed. He took the day off. Before he knew it, he couldn’t leave his house and he would shake whenever he tried to get in his truck. Quickly his crew went to work for his competitor, and he could no longer bid on jobs. His business started failing. He started drinking and soon was drinking a 12-pack of beer a day just to get by. His wife said if he didn’t do something, she was leaving him. Now he was really scared but didn’t know what to do.

When he arrived in the primary care office his appearance was flushed; he was sweating; his hands were shaking; he was breathing rapidly; and he was very tense. He said he hated what his life had become.

such as entering school, starting a new job, or giving birth to a child. This characteristic of anxiety differentiates it from fear.

Fear has a specific source or object that the person can identify and describe. Fear involves the cognitive appraisal of a threatening stimulus; anxiety is the emotional response to that appraisal. Fear is caused by physical or psychological exposure to a threatening situation. Fear produces anxiety. Fear and anxiety are different, and this is reflected in our speech: We speak of having a fear but of being anxious.

Anxiety is communicated interpersonally. If a nurse is talking with a patient who is anxious, within a short time the nurse also will experience feelings of anxiety. Similarly, if a nurse is anxious in a particular situation, this anxiety will be communicated to the patient. The “contagious” nature of anxiety can have positive and negative effects on the therapeutic relationship. The nurse must carefully monitor these effects.

Anxiety is about self-preservation. It occurs as a result of a threat to a person’s selfhood, self-esteem, or identity. It results from a threat to something that is central to one’s personality and essential to one’s existence and security. It may be connected with fear of punishment, disapproval, withdrawal of love, disruption of a relationship, isolation, or loss of body functioning. Culture is related to anxiety, because culture can influence the values one considers most important (Gwynn et al, 2008; Westermeyer et al, 2010).

It is important to remember that anxiety is part of everyday life. It is basic to the human condition and provides a valuable warning. In fact, the capacity to be anxious is necessary for survival. In addition, one can grow from it if one successfully confronts, deals with, and learns from anxiety-creating experiences.

Levels of Anxiety

Peplau (1963) identified four levels of anxiety and described their effects:

1. Mild anxiety occurs with the tension of day-to-day living. During this stage the person is alert and the perceptual field is increased. The person sees, hears, and grasps more than before. This kind of anxiety can motivate learning and produce growth and creativity.

2. Moderate anxiety, in which the person focuses only on immediate concerns, involves narrowing of the perceptual field. The person sees, hears, and grasps less. The person blocks selected areas but can attend to more if directed to do so.

3. Severe anxiety is marked by a significant reduction in the perceptual field. The person tends to focus on a specific detail and not think about anything else. All behavior is aimed at relieving anxiety, and much direction is needed to focus on another area.

4. Panic is associated with dread and terror, as the person experiencing panic is unable to do things even with direction. Increased motor activity, decreased ability to relate to others, distorted perceptions, and loss of rational thought are all symptoms of panic. The panicked person is unable to communicate or function effectively. This level of anxiety cannot persist indefinitely, because it is incompatible with life. A prolonged period of panic would result in exhaustion and death. But panic can be treated safely and effectively.

The nurse needs to be able to identify which level of anxiety a patient is experiencing by the behaviors observed. Figure 15-1 shows the range of anxiety responses from the most adaptive response of anticipation to the most maladaptive response of panic. The patient’s level of anxiety and its position on the continuum of coping responses are relevant to the nursing diagnosis and influence the type of intervention the nurse implements.



Anxiety can be expressed directly through physiological and behavioral changes or indirectly through cognitive and affective responses, including the formation of symptoms or coping mechanisms developed as a defense against anxiety. The nature of the responses displayed depends on the level of anxiety. The intensity of the response increases with increasing anxiety.

In describing the effects of anxiety on physiological responses, mild and moderate anxiety levels heighten a person’s capacities. In contrast, severe anxiety and panic paralyze or overwork capacities. The physiological responses associated with anxiety are modulated primarily by the brain through the autonomic nervous system (Figure 15-2). The body adjusts internally without a conscious or voluntary effort.

There are two types of autonomic responses:

The sympathetic reaction occurs most often in anxiety responses. This reaction prepares the body to deal with an emergency situation by a fight-or-flight reaction. It also can trigger the general adaptation syndrome (Chapter 16). When the cortex of the brain perceives a threat, it sends a stimulus down the sympathetic branch of the autonomic nervous system to the adrenal glands. Because of a release of epinephrine, respiration deepens, the heart beats more rapidly, and arterial pressure rises. Blood is shifted away from the stomach and intestines to the heart, central nervous system, and muscles. Glycogenolysis is accelerated, and the blood glucose level rises.

For a few people the parasympathetic reaction may coexist or dominate and produce opposite effects. Other physiological reactions also may be evident. The variety of physiological responses to anxiety that the nurse may observe in patients is summarized in Box 15-1.



Parasympathetic response.

Behavioral responses of the anxious patient have both personal and interpersonal aspects. High levels of anxiety affect coordination, involuntary movements, and responsiveness and also can disrupt human relationships. The anxious patient typically withdraws and decreases interpersonal involvement. The possible behavioral responses the nurse might observe are presented in Box 15-1.

Mental or intellectual functioning also is affected by anxiety, resulting in problems concentrating, confusion, and poor problem solving. Cognitive responses the patient might display when experiencing anxiety are described in Box 15-1.

Finally, the nurse can assess a patient’s emotional reactions, or affective responses, to anxiety by the subjective description of the patient’s personal experience. Often, patients describe themselves as tense, jittery, on edge, jumpy, worried, or restless. One patient described feelings in the following way: “I’m expecting something terribly bad to happen, but I don’t know what. I’m afraid, but I don’t know why. I guess you can call it a generalized bad feeling.” All these phrases are expressions of apprehension and overalertness. It seems clear that the person interprets anxiety as a kind of warning sign. Additional affective responses are listed in Box 15-1.

Anxiety is an unpleasant and uncomfortable experience that most people try to avoid. They often try to replace anxiety with a more tolerable feeling. Pure anxiety is rarely seen. Anxiety is usually observed in combination with other emotions.

Patients might describe feelings of anger, boredom, contempt, depression, irritation, worthlessness, jealousy, self-depreciation, suspicion, sadness, or helplessness. This combination of emotions makes it difficult for the nurse to discriminate between anxiety and depression, for instance, because the patient’s descriptions may be similar.

Close ties exist among anxiety, depression, guilt, and hostility. One feeling can act to generate and reinforce the others. The relationship between anxiety and hostility is particularly close. The pain experienced with anxiety often causes anger and resentment toward those thought to be responsible. These feelings of hostility in turn increase anxiety.

This cycle was seen in the case of a highly anxious, dependent, and insecure wife who was very attached to her husband. In exploring her feelings she also expressed great hostility toward her husband and their relationship. Verbalizing these angry feelings further increased her anxiety and unresolved conflict. Anxiety is often expressed through anger, and a tense and anxious person is more likely to become angry.

Predisposing Factors


The majority of studies point to a dysfunction in multiple systems rather than implicating one particular neurotransmitter in the development of an anxiety disorder. These systems include the following:

• GABA system. The regulation of anxiety is related to the activity of the neurotransmitter gamma-aminobutyric acid (GABA), which controls the activity, or firing rates, of neurons in the parts of the brain responsible for producing anxiety. GABA is the most common inhibitory neurotransmitter in the brain.

• When it crosses the synapse and attaches or binds to the GABA receptor on the postsynaptic membrane, the receptor channel opens, allowing for the exchange of ions. This exchange results in an inhibition or reduction of cell excitability and thus a slowing of cell activity. The theory is that people who have an excess of anxiety have a problem with the efficiency of this neurotransmission process.

• When a person with anxiety takes a benzodiazepine (BZ) medication, which is from the antianxiety class of drugs, it binds to a place on the GABA receptor next to GABA. This makes the postsynaptic receptor more sensitive to the effects of GABA, enhancing neurotransmission and causing even more inhibition of cell activity (Figure 15-3).

• The effect of GABA and BZ at the GABA receptor in various parts of the brain is a reduced firing rate of cells in areas implicated in anxiety disorders. The clinical result is that the person becomes less anxious.

• The areas of the brain where GABA receptors are coupled to BZ receptors include the amygdala and hippocampus, both structures of the limbic system, which functions as the center of emotions (e.g., rage, arousal, fear) and memory. Patients with anxiety disorders may have a decreased antianxiety capacity of the GABA receptors in areas of the limbic system, making them more sensitive to anxiety and panic.

• Norepinephrine system. The norepinephrine (NE) system is thought to mediate the fight-or-flight response. The part of the brain that manufactures NE is the locus ceruleus. It is connected by neurotransmitter pathways to other structures of the brain associated with anxiety, such as the amygdala, the hippocampus, and the cerebral cortex (the thinking, interpreting, and planning part of the brain).

• Serotonin system. A dysregulation of serotonin (5-HT) neurotransmission may play a role in the etiology of anxiety, because patients experiencing these disorders may have hypersensitive 5-HT receptors.

Traumatic experiences may change the brain and the ways in which it responds to subsequent stressors. The effects of trauma involve alterations in many regions of the brain, particularly the limbic system. The hypothalamic-pituitary-adrenal (HPA) axis, a major response system, appears to be modified by trauma, as do the neurotransmitters discussed earlier.

Studies also suggest an excess of inflammatory actions of the immune system in individuals with chronic posttraumatic stress disorder (PTSD). High levels of inflammatory cytokines have been linked to PTSD vulnerability in traumatized individuals. The excessive inflammation may result from insufficient regulation by cortisol (Gill et al, 2009).

A person’s general health has a great effect on predisposition to anxiety. Anxiety may accompany some physical disorders, such as those listed in Box 15-2. Coping mechanisms also may be impaired by toxic influences, dietary deficiencies, reduced blood supply, hormonal changes, and other physical causes (Strine et al, 2008). In addition, symptoms from some physical disorders may mimic or exacerbate anxiety.

Similarly, fatigue increases irritability and feelings of anxiety. It appears that fatigue caused by nervous factors predisposes the person to a greater degree of anxiety than does fatigue caused by purely physical causes. Thus fatigue may actually be an early symptom of anxiety. Patients with nervous fatigue and sleep problems may already be experiencing moderate anxiety and be more susceptible to future stress situations.


Learning theorists believe that people who have been exposed in early life to intense fears are more likely to be anxious in later life, so parental influences are important. Children who see their parents respond with anxiety to every minor stress soon develop a similar pattern. In contrast, if parents are completely unmoved by potentially stressful situations, children feel alone and lack emotional support from their families. The appropriate emotional response of parents gives children security and helps them learn constructive coping methods.

A person’s level of self-esteem is an important factor related to anxiety. A person who is easily threatened or has a low level of self-esteem is more susceptible to anxiety. This is seen in students who have test anxiety. Anxiety is high because they doubt they can succeed. This anxiety may have nothing to do with their actual abilities or how much they studied. The anxiety is caused only by their perception of their ability, which reflects their self-concept. They may be well prepared for the examination, but their severe level of anxiety reduces their perceptual field significantly. They may omit, misinterpret, or distort the meaning of the test items. They may even block out all their previous studying. The result will be a poor grade, which reinforces their poor perception of self.

Perhaps the most important psychological trait is resilience to stress. Resilience is the ability to maintain normal functioning despite adversity. Resilience is associated with a number of protective psychosocial factors, including active coping style, positive outlook, interpersonal relatedness, moral compass, social support, role models, and cognitive flexibility. Resilience is discussed in Chapter 12.

Having purpose in life and undertaking and mastering difficult tasks are effective ways to increase one’s resilience to stress (Alim et al, 2008). For example, men and women who successfully managed stressful situations in childhood, such as death or illness of a parent or sibling, family relocation, or loss of friendship, are more resistant to adult stressors, such as divorce, death, major illness, or job loss. However individuals who experienced extreme childhood stress that they could not control or master, such as physical or sexual abuse, may be more vulnerable to future stressors.


Anxiety can be a product of frustration caused by anything that interferes with attaining a desired goal. An example of an external frustration might be the loss of a job. Many goals may thus be blocked, such as financial security, pride in work, and perception of self as family provider. An internal frustration is seen when young college graduates set unrealistically high career goals and are frustrated by entry-level job offers. Their view of self is threatened by their unrealistic goals and they are likely to experience feelings of failure, insignificance, and mounting anxiety.

Anxiety also may arise through conflict that occurs when a person experiences two competing drives and must choose between them. A reciprocal relationship exists between conflict and anxiety. Conflict produces anxiety, and anxiety increases the perception of conflict by producing feelings of helplessness.

In this view conflict is a result of two desires: approach and avoidance. Approach is the desire to do something or move toward something. Avoidance is the opposite desire: not to do something or not to move toward something. There are four kinds of conflict:

1. Approach-approach, in which the person wants to pursue two equally desirable but incompatible goals. An example is having two very attractive job offers. This type of conflict seldom produces anxiety.

2. Approach-avoidance, in which the person wishes to both pursue and avoid the same goal. The patient who wants to express anger but feels great anxiety and fear in doing so experiences this type of conflict. Another example is the ambitious business executive who must compromise values of honesty and loyalty to be promoted.

3. Avoidance-avoidance, in which the person must choose between two undesirable goals. Because neither alternative seems beneficial, this is a difficult choice that is usually accompanied by much anxiety. An example is when a person observes a friend cheating and feels the need to report the act but worries about the loss of friends that might result from reporting the violation.

4. Double approach-avoidance, in which the person can see both desirable and undesirable aspects of both alternatives. An example is the conflict experienced by a person living with the pain of an unsatisfying social and emotional life. The alternative is to seek psychiatric help and expose oneself to the threat and potential pain of the therapy process. Double approach-avoidance conflict feelings often are described as ambivalence.

Precipitating Stressors

Experiencing or witnessing trauma has been associated with a variety of anxiety disorders, particularly posttraumatic stress disorder (PTSD). Most traumatized individuals experience more than one trauma in their lifetime, and the risk of PTSD increases with each event (Nayback, 2009; Doctor et al, 2011).

The majority of individuals involved in traumatic events will not develop a psychological disorder. Only 5% to 10% of those who experience trauma develop PTSD (Snyder, 2008). The so-called “normal” response is highly variable. Some people develop a marked initial reaction that resolves over a few weeks. Others have little or no initial reaction and do not develop any difficulties. However, a minority develop mental health problems that require intervention.

With the return of soldiers serving in wars and the increasing violence in society, PTSD is becoming a more prevalent and impairing condition (Ray, 2008). Specifically, the negative effects of combat are deep and enduring, and veterans with combat stress reaction may be six times more likely to develop PTSD. PTSD in veterans is discussed in Chapter 39.

An individual at risk for PTSD should be screened using the primary care tool presented in Box 15-3. It focuses on the core PTSD symptom clusters. Anyone answering “yes” to three of the four items should have a more formal assessment.

Maturational and situational crises, as described in Chapter 13, also can precipitate a maladaptive anxiety response (Ameratunga et al, 2009). In total, precipitating stressors can be grouped into two categories: threats to physical integrity and threats to self-system.

Threats to Self-System

Threats to one’s self-system involve harm to a person’s identity, self-esteem, and integrated social functioning. Both external and internal sources can threaten self-esteem.

External sources include the loss of a valued person through death, divorce, or relocation; a change in job status; an ethical dilemma; social or cultural group pressures; and work stress. Internal sources include interpersonal problems at home or at work or when assuming a new role, such as parent, student, or employee. In addition, many threats to physical integrity also threaten self-esteem, because the mind-body relationship is an overlapping one.

It is important to remember, however, that this distinction of categories is only theoretical. The person responds to all stressors, whatever their nature and origin, as an integrated whole. No specific event is equally stressful to all people or even to the same person at different times.

Coping Mechanisms

As anxiety increases to the severe and panic levels, the behaviors displayed by a person become more intense and potentially injurious, and quality of life decreases. People seek to avoid anxiety and the circumstances that produce it. When experiencing anxiety, people use various coping mechanisms to try to relieve it (Box 15-4). The inability to cope with anxiety constructively is a primary cause of psychological problems.

The nurse needs to be familiar with the coping mechanisms people use when experiencing the various levels of anxiety. For mild anxiety, caused by the tensions of day-to-day living, several coping mechanisms commonly used include

crying, sleeping, eating, yawning, laughing, cursing, physical exercise, and daydreaming. Oral behavior, such as smoking and drinking, is another way of coping with mild anxiety.

When dealing with other people, the individual copes with low levels of anxiety through superficiality, lack of eye contact, use of clichés, and limited self-disclosure. People also can protect themselves from anxiety by assuming comfortable roles and limiting close relationships to those with values similar to their own.

Moderate, severe, and panic levels of anxiety pose greater threats to the ego. They require more energy to cope with the threat. These coping mechanisms can be categorized as problem or task focused and as emotion or ego focused.

Problem- or Task-Focused Coping

Problem- or task-focused coping mechanisms are thoughtful, deliberate attempts to solve problems, resolve conflicts, and gratify needs. These reactions can include attack, withdrawal, and compromise. They are aimed at realistically meeting the demands of a stress situation that has been objectively appraised. They are consciously directed and action oriented.

In attack behavior a person attempts to remove or overcome obstacles to satisfy a need. There are many possible ways of attacking problems, and this type of reaction can be destructive or constructive. Destructive patterns are usually accompanied by great feelings of anger and hostility. These feelings may be expressed by negative or aggressive behavior that violates the rights, property, and well-being of others. Constructive patterns reflect a problem-solving approach. They are evident in self-assertive behaviors that respect the rights of others.

Withdrawal behavior may be expressed physically or psychologically. Physically, withdrawal involves removing oneself from the source of the threat. This reaction can apply to biological stressors, such as smoke-filled rooms, exposure to radiation, or contact with contagious diseases.

A person also can withdraw in various psychological ways, such as by admitting defeat, becoming apathetic, or lowering aspirations. As with attack, this type of reaction can be constructive or destructive. When it isolates the person from others and interferes with the ability to work, the reaction creates additional problems.

Compromise involves changing one’s usual way of thinking about things, substituting goals, or sacrificing aspects of personal needs. It is necessary in situations that cannot be resolved through attack or withdrawal. Compromise reactions are usually constructive and are often used in approach-approach and avoidance-avoidance situations. Occasionally, however, the person realizes over time that the compromise is not acceptable; a solution must then be renegotiated or a different coping mechanism adopted.

The likelihood of effective problem solving is influenced by the person’s expectation of at least partial success. This depends on remembering past successes in similar situations, which allows the person to go forward and deal with the current stressful situation.

Emotion- or Ego-Focused Coping

Emotion- or ego-focused coping mechanisms, known as defense mechanisms, protect the person from feelings of inadequacy and worthlessness and prevent awareness of anxiety. Everyone uses them, and they often help people cope successfully with mild and moderate levels of anxiety. However, they can be used to such an extreme degree that they distort reality, interfere with interpersonal relationships, and limit the ability to work productively.

As coping mechanisms, they have certain drawbacks. First, ego defense mechanisms operate on unconscious levels. The person has little awareness of what is happening and little control over events. Secondly, they involve a degree of self-deception and reality distortion. Therefore they usually do not help the person cope with the problem realistically. Table 15-1 lists some of the more common ego defense mechanisms and examples of each.

TABLE 15-1


Compensation: Process by which people make up for a perceived weakness by strongly emphasizing a feature that they consider more desirable. A businessman perceives his small physical stature negatively. He tries to overcome this by being aggressive, forceful, and controlling in business dealings.
Denial: Avoidance of disagreeable realities by ignoring or refusing to recognize them; the simplest and most primitive of all defense mechanisms. Ms. P has just been told that her breast biopsy indicates a malignancy. When her husband visits her that evening, she tells him that no one has discussed the laboratory results with her.
Displacement: Shift of emotion from a person or object to another, usually neutral or less dangerous, person or object. A 4-year-old boy is angry because he has just been punished by his mother for drawing on his bedroom walls. He begins to play war with his soldier toys and has them fight with each other.
Dissociation: The separation of a group of mental or behavioral processes from the rest of the person’s consciousness or identity. A man is brought to the emergency room by the police and is unable to explain who he is and where he lives or works.
Identification: Process by which people try to become like someone they admire by taking on thoughts, mannerisms, or tastes of that person. Sally, 15 years old, has her hair styled like that of her young English teacher, whom she admires.
Intellectualization: Excessive reasoning or logic is used to avoid experiencing disturbing feelings. A woman avoids dealing with her anxiety in shopping malls by explaining that shopping is a frivolous waste of time and money.
Introjection: Intense identification in which people incorporate qualities or values of another person or group into their own ego structure. It is one of the earliest mechanisms of the child, important in formation of conscience. Eight-year-old Jimmy tells his 3-year-old sister, “Don’t scribble in your book of nursery rhymes. Just look at the pretty pictures,” thus expressing his parents’ values.
Isolation: Splitting off of emotional components of a thought, which may be temporary or long term. A medical student dissects a cadaver for her anatomy course without being disturbed by thoughts of death.
Projection: Attributing one’s thoughts or impulses to another person. Through this process one can attribute intolerable wishes, emotional feelings, or motivation to another person. A young woman who denies she has sexual feelings about a co-worker accuses him without basis of trying to seduce her.
Rationalization: Offering a socially acceptable or apparently logical explanation to justify or make acceptable otherwise unacceptable impulses, feelings, behaviors, and motives. John fails an examination and complains that the lectures were not well organized or clearly presented.
Reaction formation: Development of conscious attitudes and behavior patterns that are opposite to what one really feels or would like to do. A married woman who feels attracted to one of her husband’s friends treats him rudely.
Regression: Retreat to behavior characteristic of an earlier level of development. Four-year-old Nicole, who has been toilet trained for more than 1 year, begins to wet her pants again when her new baby brother is brought home from the hospital.
Repression: Involuntary exclusion of a painful or conflicted thought, impulse, or memory from awareness. It is the primary ego defense, and other mechanisms tend to reinforce it. Mr. R does not recall hitting his wife when she was pregnant.
Splitting: Viewing people and situations as either all good or all bad; failure to integrate the positive and negative qualities of oneself. A friend tells you that you are the most wonderful person in the world one day and how much she hates you the next day.
Sublimation: Acceptance of a socially approved substitute goal for a drive whose normal channel of expression is blocked. Ed has an impulsive and physically aggressive nature. He tries out for the football team and becomes a star tackle.
Suppression: A process often listed as a defense mechanism, but really it is a conscious counterpart of repression. It is intentional exclusion of material from consciousness. At times, it may lead to repression. A young man at work finds he is thinking so much about his date that evening that it is interfering with his work. He decides to put it out of his mind until he leaves the office for the day.
Undoing: Act or communication that partially negates a previous one; a primitive defense mechanism. Larry makes a passionate declaration of love to Sue on a date. At their next meeting he treats her formally and distantly.

Feb 25, 2017 | Posted by in NURSING | Comments Off on Anxiety Responses and Anxiety Disorders
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