Category: Anxiety

According to a survey, constructed by the National Survey of Mental Health and Wellbeing in 2007, nearly half of adult population (aged 16-85) experienced a mental health disorder within 12-month or lifetime period, while the most common diagnoses among mental illnesses are depression and anxiety (Tiller, 2013). Other research estimated that 39% of consumers with Anxiety Disorder had symptoms of depression (Hunt, Issakidis, & Andrews, 2002). On the other hand, music therapy intervention was found to effectively improve depression and anxiety symptoms along with standard care in psychiatric hospitals (Erkkila, et al., 2011).

As my experience, it is common that consumers with principle diagnoses, for instance, Dementia or Anorexia nervosa, also showed symptoms of depression or anxiety. On the other hand, according to current researches, several music-intervention approaches in psychiatry involve verbal reflection which requires therapists’ counselling skills. To understand the basis and the application of music therapy in the mental health area and how to integrate it with other psychological therapies to reduce depression and/or anxiety symptoms, this literature review will mainly focus on group music therapy intervention with psychiatric patients. The following paragraphs will define the diagnosis and clinical needs of Depression and Anxiety disorder, describe the basis and the benefit of Group Music Therapy(GMT) and explain the approaches and relevant theories. Finally, synthesising results and giving suggestions for future research.

Method

Initially, literature was derived from several databases including Cochrane library, Western Sydney University library and EBSCO Open Dissertations, while search terms were music therapy, depression and anxiety. To keep the information up to date, only scholarly literature published within twenty years were selected. However, treatment for reducing depression and anxiety symptoms were broadly used with various populations, including prisoners or cancer patients, therefore, the research was narrowed to music therapy with psychiatric patients. On the other hand, based on the current research, cognitive behaviour therapy was commonly combined with group music therapy in psychiatry, therefore, instead of describing the combination with several psychological treatments, this research will mainly explain the integration of cognitive behavioural therapy and music therapy.

Clinical Diagnosis

Depression is a common reaction for people experiencing loss or trauma, however, when the state of depression persisted and the individual was incapable to anticipate pleasure, it was considered as a mental illness (Jackson, 2012). According to the American Psychiatric Association (APA, 2013), the criteria of Major Depressive Disorder included a significant change in daily functioning at least two weeks in either depressed mood or loss of interest or pleasure, along with four other symptoms, such as significant weight change, psychomotor agitation or retardation, loss of energy, feelings of worthlessness or suicidal ideation. The general symptoms written above may vary from individual to individual and the symptoms could overlap one another (Jackson, 2012). For instance, weight loss may result from a decrease in appetite, while the sense of worthlessness may be associated with unrealistic negative thoughts.

On the other hand, symptoms of Anxiety Disorder are commonly experienced by patients with depressive disorder (Fava, Rush, & Alpert, 2008). The types of anxiety disorder differ from the examinations of the anxiety-producing situation. For instance, avoidance of social situation might be defined as Social Anxiety Disorder. In contrast, generalized anxiety disorder is defined as excessive anxiety and worry, lasting over six months, regarding numerous events happening in multiple aspects of an individual’s life(APA, 2013). Anxiety Disorder may negatively impact on physical and emotional aspects, such as sleep disturbance or irritability. To avoid perceiving anxiety-producing activities, patients with Anxiety Disorder may tend to withdraw their feelings or contrarily experience a certain amount of distress which significantly affecting their functioning in a variety of areas (Jackson, 2012).

Clinical Needs and Common Goals

Instead of eliminating symptoms, researches mostly aim to reduce depression and anxiety and focus on reality orientation (Carr, Odell-Miller, & Priebe, 2013). In other words, facilitating consumers to utilize their strengths and resources to improve their current situation. From psychological aspects, the most common goals mentioned in researches are emotion regulation and socialization (Thoreau, 2016; McEntire, 2016; Tiller, 2013; Gold, 2011), however, some articles also emphasized the positive impact of physical relaxation for recovery (Zhou, et al., 2015; Tiller, 2013).

To further explain, physically, consumers with depression and/or anxiety mostly present with low energy resulting from their negative emotional state. While consumers with anxiety might have agitated behaviour, high-level energy usually useless in their daily functioning (Jackson, 2012). On the other hand, Consumers’ emotional reactions tended to be triggered easily and intensively partially resulting from their difficulties to recognize emotions and further modulate its (Mennin, Heimberg, Turk, & Fresco, 2002). To illustrate, since consumers possibly unable to identify and respond to negative emotions and thoughts, they often hardly develop a positive solution, such as coping skills, to improve their current emotion status, which might arise suicidal ideations along with the feelings of helplessness. Jackson (2012) stated that the inability to express their inner emotional experiences properly lead to the difficulty to interact with others.

Group Music Therapy in Psychiatry

Based on the selected articles, most of the researchers focused on short-term interventions, therefore, the immediate effect of a single session and short-term goals are prominent for consumers (Carr, Odell-Miller, & Priebe, 2013). The average length of interventions varied from 13 weeks (Crocke, et al., 2014) to 20 weeks (Erkkila, et al., 2011), while the interventions usually were conducted once (Gutiérrez & Camarena, 2015; Aalbers, et al., 2019) or twice (Silverman & Marcionetti, 2004; Gold, 2011) per week.

Music therapy is an evident-based and non-invasive intervention that can be understood from neurobiological and psychological perspectives. From neurobiological aspects, Koelsch(2009) stated music therapy can stimulate various parts of the human brain, for instance, the activation of limbic structures is related to emotional modulation. A randomized control trial also demonstrated that music intervention can increase frontal theta power, which has a positive impact on improving anxiety symptoms (Fachner, Gold, & Erkkilä, 2013). On the other hand, several articles indicated that music therapy can improve consumers’ emotional states (Legge, 2015; Carr, et al., 2012; Gutiérrez & Camarena, 2015). For instance, Juslin and Sloboda (2010) stated that music interventions not only facilitated people to explore and process emotions in different ways but also build positive relationships, which was essential for mental health improvement, among therapists, music and consumers. Besides, the lake of pleasure and meaning in life was recognised as a symptom of depression and anxiety (Maratos, Crawford, & Procter, 2011). McEntire(2016) indicated that receptive approaches, such as listening, can facilitate consumers to recognize positive experience in their life while socially meaningful experiences can be created via active music interventions, such as song-writing activity.

As for group music therapy, improvement of social isolation and communication skills were frequently mentioned in researches since group-based sessions provide more social opportunities. Furthermore, when consumers realised their peers experienced similar problems regardless of different psychiatric diagnoses, they mostly become more concentrated in the session to understand and learn from each other (Silverman, Therapeutic mechanisms in psychiatric music, 2015).

Integration with Cognitive Behaviour Therapy

Music therapy interventions for mental illnesses are commonly combined with other treatment, such as medications and psychiatric counselling (Jackson, 2012), while the integration with Cognitive Behaviour Therapy (CBT) is frequently referred in several articles. The concept of CBT believes that developments of psychological disorders result from maladaptive thoughts, feelings and behaviour, hence, the symptoms can be reduced by developing consumers’ coping skills and altering interpretations of information (Tiller, 2013). In other words, CBT focuses on facilitating consumers to recognise, challenge and change their negative thoughts and further utilised their resources, such as coping skills or personal strength, to improve their mental disorders. Besides, the altering of interpretations was considered to be an effective way to improve emotion regulation, which was one of the dominant goals for consumers with depression or anxiety disorders (Aalbers, et al., 2019). This approach was commonly adapted with GMT due to the optimization of personal resources and immediate effectiveness (Gutiérrez & Camarena, 2015). The combination of MT and CBT usually applied in activities relying on verbal reflection, for instance, songwriting activity. In Stige’s study (Solli, Rolvsjord, & Borg, 2013), verbal reflection after listening to the music can stimulate consumers’ awareness of emotions, while therapeutic counselling skills can facilitate patients to express their feelings. Besides, those reflection evoked by musical experience can be correlated to emotion regulation and depression symptoms in daily life (Aalbers, et al., 2019).

However, verbal psychotherapy might be insufficient since some individuals may find it distressing or intrusive (Slootsky, et al., 2016). Therefore, researchers also emphasized the non-verbal component of music therapy, for instance, playing musical instruments as an alternative way to express feelings. On the other hand, the musical elements, pulse, phrases or dynamics, were related to emotions and could be used to communicate with consumers. For example, therapists might reinforce an implied direction to attune consumers’ melodic fragment or playing a counter melody as responses to consumers’ improvised thoughts (Maratos, Crawford, & Procter, 2011).

Hence, the integrative treatment of CBT and MT in mental health may focus on assisting consumers to utilize their resources to overcome current mental illness via verbal or non-verbal approaches.

Approaches

Music therapy can be conducted in various form depending on consumers’ individual need. To establish a comprehensive framework, this paragraph will examine the outcomes of four major approaches, receptive, re-creative, improvisational and compositional, being used in psychiatry.

Receptive Music listening

This form of intervention involves listening to pre-recording or live-performing music by the therapist and verbal reflection with participants after listening activity. A study with adults on a hospital neuroscience unit found that consumers were more likely to select receptive music listening rather than active music therapy, either singing or improvisation, due to not feeling comfortable playing the instrument (Rebecca & Michael, 2020). However, fewer researches adapted receptive music listening as domestic intervention. From neurological aspects, Legge (2015) suggested that music listening can induce emotions and allow consumers to explore different feelings. According to his research, autobiographically relevant music can activate left-hemispheric sites of the human brain which were related to long-term memories, while different musical stimuli may evoke various emotion responses, for instance, dissonant sounds may result in activation of the amygdala, a part of brain region used to process fear. Another study at a psychiatric hospital demonstrated that consumers with schizophrenia showed a significant improvement of depression symptoms after receiving musical interventions, involving listening to familiar music and group reflection, compared to the controls (Lu, et al., 2013). However, the study also indicated that the improvement of the intervention group was declaimed after three months.

Re-Creative activity

This form of intervention involves vocal or instrumental ensembles using pre-composed music and often along with verbal reflection regarding lyrics or melody. Although withdrawal and isolation from others are frequently experienced by clients with depression or anxiety, self-disclosure or self-exploration at the early treatment stage might be too exposed for consumers (Jackson, 2012). Whereas engaging in music ensembles allow consumers to connect with others in a non-threatening environment. On the other hand, playing musical instruments involve physical movement which correlates highly with the alleviation of depression (Maratos, Crawford, & Procter, 2011).

The choice of the song was usually advised by participants. A study conducted by Silverman suggested that the meaning behind song choice may have potential to achieve multiple goals (Silverman & Marcionetti, Immediate effects of a single music therapy intervention with persons who are severely mentally ill, 2004). For instance, consumers may select a song related to a positive experience which might be their resources to cope with difficult feelings. Through the discussion after playing the song, the result possibly facilitates consumers to build their insight and further understanding of their mental illness.

Improvisation

Improvisation could be implemented with vocal or either tuned or untuned instrument. Jackson (2012) stated that consumers with symptoms of depression or anxiety often claimed they stuck in a certain mood state. To address the needs, therapeutical improvisation is used to mobilize affect by creating music to stimulate a variety of emotional expression. Another study demonstrated the use of verbal reflection during and after improvisations can facilitate clients to build insight of emotional patterns (Aalbers, et al., 2019). On the other hand, some literature stated the benefits provided by the non-verbal component of improvisation (Aalbers, et al., 2019; Erkkila, et al., 2011; Jackson, 2012). For instance, the musical elements, pause, phrases or counter melody, can form a conversation between therapist and clients and possibly build a positive relationship among participants. Furthermore, it allowed consumers, who tend to avoid verbal communication, to express their feelings in an unthreatening way.

Composition

The creation of original music and lyrics can support consumers to explore their experience and emotions, while the final composition can be recorded or performed repeatedly by participants (Windle, Hickling, Jayacodi, & Carr, 2020). Furthermore, discussion with peers can inspire other coping skills to overcome difficulties in their lives. In other words, the process of songwriting involves self-expression, social skills, building resources and problem-solving, besides, the topics of the song are highly adaptable to consumers’ need.

A result of short-term group intervention in psychiatry demonstrated a significant improvement regarding symptoms of depression and anxiety after songwriting intervention (Windle, Hickling, Jayacodi, & Carr, 2020). According to the same research, consumers described their enjoyment to express themselves in a safe environment and the process of songwriting rebuilt their connections with others. However, consumers also revealed feeling lost which might result from the high intensity of the short-term intervention, when the group was terminated.

On the other hand, there were fewer researches focused on compositional intervention in a group setting. Songwriting activity often required a longer period for participants to discuss and integrate ideas whereas group members in psychiatry can be highly floating due to different length of stay or other medical situations.

Results and Suggestions

To conclude, instead of eliminating symptoms, music therapy for consumers with depression or anxiety mainly targeted at emotional aspect, such as emotion regulation or coping with difficult feelings. Additionally, music intervention implemented in group setting can facilitate to rebuild positive relationship with others. The benefit of group music intervention may vary depending on the level of group cohesion. However, due to the high mobility of group members in psychiatry, research on maintaining group cohesion for each session in this environment is needed.

On the other hand, since the result of this literature review demonstrated that music intervention in psychiatry often contains a great amount of verbal reflection, the intergration with cognitive behaviour therapy can facilitate consumers to alter maladaptive thoughts and further finding different ways to cope with different feelings. Besides, the non-verbal components of music therapy allow consumers to express themselves in different ways if they refused to express verbally.

Finally, in terms of the form of interventions, although Rebecca and Michael (2020) reported consumers preferred to choose receptive music listening rather than active music making, most literature focused on the outcome of active music approaches including songwriting, vocal and instrumental ensembles. However, one of the study also indicated that the improvement of symptoms decreased after the termination of receptive music intervention (Lu, et al., 2013). Overall, the result shows that the collaboration of different forms of intervention to address individuals’ needs and maintain the efficiency is necessary.

1 in 14 teenagers aged 13– 17 experience an anxiety disorder of some sort. That’s 278 000 young people! This means the rate of anxiety levels within teenagers has risen by 53% since 2004. Have you ever stressed over a test or worried about going out with friends? These are little factors that can relate to the issue of anxiety. Anxiety is a mental health disorder characterised by feelings of worry, anxiety or fear that are strong enough to interfere with your daily activities. Most teenagers go through some sort of anxiety in their day to day life, although sometimes it can proceed to get worse and can make you overthink simple thoughts. Anxiety has made a big impact on some teenager’s academic life, social life and family life. Overall, the big picture is that anxiety is causing unneeded stress for teenagers, making their life harder than it already is, and the statistics are growing rapidly. Something needs to change.

Anxiety can have a negative impact on all teenager’s education. It has been proven that students with anxiety frequently show lower academic achievements, self-efficacy, and self-concept. 61% of students are stressed in school over their grades and report cards, and the school department isn’t doing anything to help them. Sure, they have psychologists, but teens can be scared to go to them in school when everyone would be asking where were you in class. Look at a photo of a phone from the 1950’s, now look at one now. What about if we look at a classroom from years ago, and one from todays era. No difference. Schools haven’t changed in over 50 years, and as we know from statistics the number of teenagers that have anxiety are going up mainly from school, and the system isn’t changing to benefit them as what they say “the kids of the future”. To lower these anxiety rates, something at school needs to change as it is affecting teenager’s growth and ability to learn.

An anxiety disorder can affect a teenager’s relationship with their friends in multiple ways. Teens with anxiety disorders often go through what’s called ‘social isolation’, meaning they usually avoid interacting with others because of the fear of embarrassing themselves. Anxiety can make teens want to be alone more and not want to engage in any events or activities outside of the house with friends, making them distant from everyone around them and not confronting stressful situations or public areas. This avoidance can much interfere with teenagers’ simple daily activities they once did and reducing the number of interactions with friends. Others can often start to see differences in their friends choices, and to help, they can keep checking up on them and try to get them out of the house. It is proven that friends can have a big impact on their friends opinions and lifestyle, so they can help in many different ways.

Anxiety frequently has a ‘ripple effect’ on families, developing tension, uncertainty, troubled feelings and great changes in how teens live their lives. Each family member is usually affected in different ways from their daughter or sons behaviour. Often parents don’t know how to respond to their child’s behaviours, as most describe their experience as “walking on eggshells” around their child with anxiety. Tension between the child and their parents can cause problems bonding and communicating, which can have a big impact on the families trust and connection with each other. Although teenagers usually don’t want to talk to their parents about what’s going on in their life, and as parents don’t realise this they try to push it by wanting to know everything. Parents can have a major part in helping their child cope with anxiety by just letting them be and grow and can help by slowly trying to talk to them about it, when there child is ready.

Mental health is a frequent thing that happens in nearly all teenagers, anxiety being one of the most common, whether its irregular or regular feelings everyone can experience it. It’s affecting teenagers life in school and with their family and friends, and as the statistics are growing, something needs to change!

What is anxiety?

Anxiety is like stress. It is a fear of something that is coming in the near future. Anxiety is a totally normal thing to have, it is a natural thing that your body does, but when your anxiety last for long amounts of time and starts to affect your day to day life, then you have an anxiety disorder.

What are some of the signs that someone has anxiety? (Emotionally)

Some of the signs include being unnecessarily stressed over simple things and finding simple problems overwhelming. Always worrying about something that’s coming up in the near future (the inability to subside worries and restlessness.) A lack of concentration is a common sign of anxiety because your mind is constantly worrying and stressing about other things. Having a small feeling of impending doom and that nothing is ever going to go right. These are some of the emotional signs that you have anxiety.

What are some of the signs that someone has anxiety? (Physically)

All this stress and worrying affects your physical health as well as your mental health. Some of the thing anxiety do to your body are insomnia, nausea, palpitation, shortness of breath and sweating. Insomnia is a disorder that means you find it hard to sleep, you find it hard to get to sleep and you wake up a lot at night. Lack of sleep causes headaches and fatigue which are also physical symptoms of anxiety. Nausea is an uncomfortable feeling that makes you dizzy and it also makes you feel like vomiting. Palpitation is an increase of the pace or strength of your heart rate, palpitation only occurs if you haven’t been doing physical exercise. Like palpitation, shortness of breath and sweating are normal things that happens to the body when you are doing exercise (for sweating this include heat as well) but when this happens when you are stressing then it is a sign of anxiety.

What types of Anxiety orders are there?

Generalised anxiety order

This is the most common type of anxiety disorder is the generalised anxiety order (also known as GAD). Anyone at any age can get this type of anxiety disorder, the effects of it are the exact same to the ones that were listed previously. Treatment can be given by a therapist or antidepressant drugs.

This case report is about a 45 year old man called Joe. He spent 20 years in the army but he doesn’t not suffer from post dramatic stress. He described himself as a ‘worrier.’ Ever since he was a kid he always used to worry about everything. Once he went to the army his anxiety died down but once he left the army it came back stronger than ever. His wife pushed him to seek professional help and once he started seeing a psychologist she diagnosed him with GAD. He practiced different exercises to reduce his stress and it really helped with his GAD. Now days Joe is cured of his GAD with no antidepressant and just by seeing a psychologist.

Social anxiety

Social anxiety is a type of anxiety that you get from social situations. It makes you feel like you are being watched and judged by other people. You get embarrassed easily and you are always self-conscious.

Chloe has self-diagnosed herself to have Social anxiety. Whenever she is in public places she wants to get out of there. She feels uncomfortable when she’s in those types of those situations. All she wants to do is be alone in her room. She has not looked professional help and if she still has Social anxiety is unknown.

Panic disorder

Panic disorder is a disorder that means that you have recurring, unexpected and unnecessary panic attacks throughout your day to day life.

This is a story about a person called Katie. Katie suffered from a panic disorder. It wasn’t always so bad but it slowly got worse to a point where she really needed help. She got help and it helped a bit but it wasn’t enough. She decided to take up drinking, things were starting to get really bad but her mum and dad came to her aid. They helped her to see good in her life and now she’s a lot better.

Obsessive compulsive disorder

Obsessive compulsive disorder also known as OCD, is a disorder that causes you to have rather crazy, compulsive, obsessions. These can include the arrangement of objects and having germaphobia.

This case report is about a person called Daince. It started one day while she was at church and all of a sudden she felt like when she looked at someone it was wrong. After ten years she decided that she needed a new psychiatrist. This one specialized in anxiety disorders and then over the next five years she made a remarkable improvement. Her fellow siblings looked after her very well and not long after that she was for the most part better.

Post dramatic stress disorder

Post-traumatic stress disorder (also known as PTSD) is a special type of anxiety which people get from a memory of something. This occurs a lot in soldiers coming back from a war.

This is a story about P.K. Phillps. He was physically, mentally and sexually abused at a young age. He was also stabbed and left to die, but he didn’t. After the police stepped in they offered him a rape councilor but he denied help. For the next couple of years he had trouble with sleeping, he couldn’t get to sleep without seeing his attacker. After he turned 17 his visons died down to very few a year but once he had a daughter they started happening again but with his daughter. Only this time he got help, he was diagnosed with PTSD. Now days they have reduced to a minimal amount again and he is continuing his life as normal again.

What can people do about anxiety?

The most important thing you need to do if you have anxiety is talk about it to someone, start of with someone you know and trust. If it still seems to get worse talk to a professional. You are not ‘weak’ to talk about this with someone. In fact, people who don’t talk to anyone a weaker and they won’t get any better.

From English Oxford dictionary(Stevenson, 2015) anxiety is defined as a feeling of worry, nervousness, or unease about something with an uncertain outcome. The American Psychology Association defines anxiety based on Encyclopaedia of Psychology (Kazdin, 2019) as an emotion characterized by feelings of tension, worried thoughts and physical changes. Anxiety can be a normal and expected feeling in life. However, when it causes the disproportions and interferences to the daily activities, job performance and relationship of the individual, it is called as Anxiety Disorder. According to the latest DSM-5 (Grohol, 2013) criteria for Anxiety Disorder, it is divided into seven categories such as Separation Anxiety Disorder, Selective Mutism, Specific Phobia, Social Anxiety Disorder (Social Phobia), Panic Disorder, Panic Attack (Specifier), Agoraphobia and Generalized Anxiety Disorder. Generally, an anxiety reaction may be developed due to an acute pain (Woo, 2010). The example of acute pain that is going to be explored in relation to anxiety in this study will be venipuncture.

Venipuncture is one of the commonest medical procedure whereby the vein is punctured with the needle to withdraw the blood or for intravenous medication purposes. Despite of it common, there is approximately 10% of individuals in medical settings report an excessive fear of the needle which subsequently may lead to significant avoidance, distress and problems in managing and treating the patients (Buowari, 2013; Hamilton, 1995). There are number of studies that investigated the anxiety and pain on venipuncture and cannulations procedures in the recent years. However, the studies focused on the children and young adult populations (Humphrey, Boon, van Linden van den Heuvell, & van de Wiel, 1992; Inan & Inal, 2019; McLenon & Rogers, 2019; Shave, Ali, Scott, & Hartling, 2018). Mc Lenon et. al. (2019) found the prevalence for needle fear ranged from 20-50% in adolescents and 20-30% in young adults. Another study done by Humphrey et al. (1992) also found that high level of distress for venipuncture is common and the prevalence of young adults aged 12 years old and above experienced it was 28%. Nevertheless, very limited source of studies and available data that looked into the fear and anxiety of venipuncture among the adult populations (Deacon & Abramowitz, 2006; Kivrak, Kose-Ozlece, Ustundag, & Asoglu, 2016).

There are several factors that may be associated with anxiety among patients with an invasive procedure particularly venipuncture. A study done by Bisogoni et al (2014) looking at the association in children who are repeatedly exposed to the painful procedures especially those with the chronic diseases with their level of perception to pain. He compared with those who has no previous health problem nor experience with venipuncture. Initially it was thought that chronic disease children patient will have higher threshold to pain and therefore lesser anxiousness. Oppositely, the findings has contradict to the common belief. Besides, there were other studies looking at the association between age and gender versus pain and distress level where it demonstrated the inverse correlation between the variables during an invasive procedure (Fowler-Kerry & Lander, 1991; Goodenough, Champion, Laubreaux, Tabah, & Kampel, 1998). However, Bisogoni et. al (2014) found in his study that there was no statistical significance that can support the older children will have lower pain and distress level (p>0.05).

Other factor that may be associated with the level of anxiety of patient with venipuncture procedure is the presence of accompany together with the patient during the procedure. Alireza et.al(2019) was comparing the effect of the trained versus untrained family presence on their anxiety during invasive procedures in emergency department using Spielberger State-Trait Anxiety Inventory (STAI). She found that the presence of untrained family members during the invasive procedures has reduce the level of anxiety significantly compared to the presence of trained family with p=0.011.

Celikol et. al(2019) studied on the effect of different means of games used during pediatric blood flow on the levels of procedure-induced fear and anxiety. The study found that music or watch a video during venipuncture has decreased the level of anxiety significantly with reported p-value of

Apart from concerning on the level of anxiety of the patients who are waiting for the venipuncture procedure, there are other aspect that we shall look through which affect the venipuncture services itself as well as patient’s satisfaction. Several studies found in relation to healthcare services provided in venipuncture. (Kantartjis et al., 2017; Mijailovic et al., 2014; Oatey & Stiller, 2009; Saunsbury & Howarth, 2016; Yip, Pang, Chan, Chan, & Lee, 2016). However, no similar study found from Malaysian setting. Most of the factor that to be associated with the venipuncture services provided were patient waiting time, difficulties of venipuncture procedures per patient, interpersonal skills of phlebotomist and excellent venipuncture skills in first pass. (Oatey & Stiller, 2009; Piredda et al., 2017)

From the literatures, we can see that the pattern of previous studies on anxiety versus venipuncture or other invasive procedures were mainly conducted in children and young population. The topic of venipuncture services in our local also yet still under study. Since there are very limited studies done on this area especially among the adult population in Malaysian setting, it opens an area for the researcher to explore further the level of anxiety and factors that may be associated with among our patients with venipuncture.

I would like to explore the experience of the adult patients dealing with blood taking procedures in (UiTMSCSB) and to determine factors that may associate with their level of anxiety while waiting for the procedure. In addition, I would like to access the perception of the venipuncture services from patient perspective in UiTMSCSB. The findings from the study will give some ideas and insight to the medical professional personnel especially to the phlebotomist and clinician into this problem. Hence, a specific measure can be introduced and applied in the future especially to this group of patients who are having anxiety to venipuncture

Anxiety disorders affect about 40 million Americans, but for many, it is a shameful secret. Numerous individuals suffering from anxiety disorders will not let anyone know they are in distress. Attempting to hide these disorders is no easy task, though, many have no choice. Anxiety Disorders hold a very strong stigma in society, they are often seen as dramatic reactions to common activities. For a person struggling to deal with an anxiety disorder, simple daily actions can be debilitating. The stigmatization and degradation of people suffering from anxiety disorders is problematic because it causes people with anxiety to feel like a burden in the workplace which makes them less likely to contribute, creates fear to reach out and get help in distress that they will be judged by others, it degrades these sufferers and lessens their self-esteem ultimately leading to isolation and depression, and it increases and normalizes negative feelings toward people with anxiety disorders in society.

Formerly, in the 1950s anxiety was thoroughly examined by many physicians and psychiatrists. Anxiety left many medical professionals scratching their heads, nobody knew exactly what anxiety was. Anxiety was often thought of as nerves or stress rather than mental illness. Dr. Allan V. Horowitz holds a Ph.D. in Sociology from Yale University and is currently a Board of Governors Professor in the Department of Sociology at Rutgers University. In a journal written by Dr. Horowitz he states that “During this period, the cultural conception of anxiety was not so much as a particular type of psychiatric illness as a general psychic consequence of the demands and pace of modern conditions of life.” In the past, anxiety was not seen as a very big deal, it was often seen as an overreaction. It was overlooked as a serious condition so when the reactions to panic attacks were severe people were looked at as if they were psychotic. Today, the stigmatization behind people with anxiety disorders persists. With modern medicine, it is common knowledge, or at least it should be, that these disorders are real and not just a case of nerves. So, it is odd that people who suffer from these disorders are still looked at with repulsion. Common anxiety disorders that affect many Americans today include general anxiety disorder, obsessive-compulsive disorder, and social anxiety disorder. The stigmatization behind these disorders can be detrimental. These illnesses are often seen as an overreaction, some think individuals who are inflicted are just feeble-minded. One of the most common assumptions about people with anxiety is that they are crazy. Mental illness in any sense is out of the control of the person who is dealing with it. Similar to illness and disease, it is not something that one can just get over. It is an infliction that must be dealt with. Sure, having a positive outlook can help, but it will not cure.

First off, the stigmatization of individuals with anxiety disorders makes them feel as if they are a burden in the workplace. They are often made to feel as if they are not capable individuals due to their disorders. When made to feel as if they are incompetent workers, they are less likely to contribute to the workforce. It is already difficult to find and keep a job after a disorder is disclosed. The pressure to hide these disorders is strong and allowing others to know of their issues becomes problematic to their careers. Elaine Brohan, a Ph.D. of Psychology holder and current health psychologist states that “Stigma and discrimination present an important barrier to finding and keeping work for individuals with a mental health problem.” Brohan also states that “Mental health services users face difficulties in deciding whether to disclose a mental health problem in the employment context”. It is difficult for someone with an anxiety disorder to know when it is ok to tell their employer of illness. Before it is mentioned, there is just no telling what the reaction may be. Many fear of being demoted or even losing their jobs. For many people suffering from these disorders, it seems easier to work from home or not work at all. There is just not much support in the workplace for mental illness.

Furthermore, the stigmatization of anxiety disorders not only keeps these individuals from making a living, but it also keeps them from getting help. Some of these anxiety disorders can be so debilitating that they require medical assistance and therapy. Anxiety can make it difficult to do even simple everyday tasks. Many are afraid to seek out help because they don’t want anyone to know they are suffering from mental illness. The stigma surrounding these illnesses play a huge role in the number of people willing to seek out therapy. Dr. Norhayati Ibrahim is a senior lecturer of Healthcare Sciences at the National University of Malaysia, she has done much research on mental illness and its effects on health. According to Dr. Ibrahim “Seeking help for mental health issues is the first step toward assessing the mental state, getting the proper diagnosis and subsequently undergoing the intervention and management of mental health by professionals”. Seeking out help is crucial on the journey to being able to live with mental illness. Many can’t get through it alone and are unable to function in certain situations. A huge part of being able to deal with the illness is knowing that they are not alone and there is help. Dr. Ibrahim also states that “Studies showed that stigma is one of the deterring factors for seeking mental help in various populations, such as among university students [15, 16], faith communities [17], veterans and military personnel [18, 19] and healthcare students and professionals”. There is a wide array of people affected by these disorders, but a similar factor that keeps many from seeking out help is the stigma held over their heads. If they seek out help they are proving the stigma, they are accepting that the things people are saying are true. Seeking out help makes these individuals feel weak, but in reality, it is very brave to get help. These individuals are putting themselves at risk for being stigmatized even further when they pursue assistance, but ultimately it is very beneficial.

Moreover, the stigmatization of these individuals breaks down their self-esteem and value. When constantly being degraded and judged for circumstances out of their control it takes a toll on their self-worth. These individuals have issues that are greatly debilitating and on top of it, they are scrutinized for it severely. This combination is enough to break anyone down. Stigmatization and degradation put them at risk for further mental instability. Many who are pushed to their limits become depressed and isolate themselves from others. Teresa Hall is a current Ph.D. candidate at the University of Melbourne’s centre for international mental health. In Hall’s article about social inclusion and exclusion of people with mental illness, she states “Stigma, discrimination and social exclusion have deleterious effects on people with mental illness. Stigmatising attitudes towards people with mental illness are linked to poor well-being and self-esteem [17]. Mental illness and social isolation are both linked with early death through the direct and indirect pathways of chronic disease and lifestyle factors”. Stigmatization of people with mental illness creates detrimental feelings toward themselves. These factors lead to depression and a lack of self-care. When stigmatizing these individuals it leads them to be excluded from social groupings and isolates them from society. It is crucial for all people to feel accepted in society, people suffering from mental illness especially need acceptance. They are dealing with the effects of their anxiety constantly and need to know they are not alone. It is not healthy for these individuals to deal with their illness alone.

In addition to all of the issues stigmatization brings into the lives of people dealing with anxiety disorders, it also normalizes the negative feelings toward these individuals in society. Unfortunately, it is not only the general population that feels negatively toward anxiety and other mental disorders, but healthcare professionals in some areas also harbor stigmatization. The feelings society carries regarding these disorders relies heavily on the feelings of the healthcare professionals in the area. These ideas normalize the mistreatment and negative attitudes toward people with disorders. Dr. Elina A. Stefanovics is a Ph.D. holder of psychiatry and board member of the human investigation committee at Yale University. According to Dr. Stefanovics “in some studies, providers have demonstrated more negative attitudes than the general population [21, 24–26]—an issue of special concern, since they are responsible for both providing care and for educating the larger society about mental illness”. These attitudes make it more difficult for people with disorders to break through the barriers set by stigmatization. When the healthcare providers carry these attitudes there is nowhere left for them to turn. Dr. Stefanovics states that “Mental health providers and the general public within a given culture or nation may share similar stigmatized or positive attitudes toward people with mental illness” When the consensus within a population falls into a certain category it becomes the norm. This is highly problematic as it creates a more toxic environment for people suffering from anxiety disorders and can even make anxiety worsen.

Therefore, the stigmatization of individuals with anxiety disorders must be resolved to protect their dignity and worth. To solve the stigmatization and degradation of those affected by anxiety disorders there needs to be serious changes within society through education to combat ignorance. A solution to the issue at hand is to implement anxiety disorder awareness programs in higher education and the workplace. These programs will aim to educate and bring awareness of how detrimental stigma and negativity toward individuals with anxiety disorders can be. These programs will include physicians and activist speakers who are well educated in anxiety disorders. The presentation of the information will include how to find help, how to know when an anxiety disorder is present, how to avoid stigmatization in conversation and a special hotline for individuals to anonymously call when experiencing a panic attack or need advice on how to deal with their anxiety. The hotline will be run by volunteer therapists and individuals who have similar disorders and want to help others through hard times. Ultimately, these programs will help individuals with anxiety disorders feel like they have somewhere to turn when they feel alone, it will also educate others in the workplace and in the school environment just how real and damaging these disorders can be. These programs will be paid for through charitable donations of individuals who want to bring awareness to the reality of anxiety disorders in society. With the implementation of these programs, the stigma behind anxiety disorders can be greatly decreased within society.

Although, a viable solution may be present there is not always a widespread acceptance. Regarding the remedy of stigmatization of anxiety disorders, there is a cloud of controversy around the safety of being around these individuals at all. Many stigmatize these individuals since their mental stability is in question. It is a popular belief that one should be cautious when around an individual with anxiety disorders or any other mental illness. This is a common reason this stigmatization exists. The belief is that without proper treatment or medication these individuals are dangerous to those around them. Donald Stone is a professor of Law at the University of Baltimore with expertise in mental health law, according to Stone “There is growing pressure from various comers of society to address the presence of people with mental illness who are perceived as dangerous in the community. Certain segments of the public want to identify and remove such persons from neighborhoods before they do harm.” This idea highlights the point that the stigmatization of these individuals is reflected through a lack of understanding. The criteria around the level of mental illness that requires medical attention bring individuals to believe that all people with disorders are a danger to the public. This may become an issue in the open-mindedness of individuals to inherit a new perspective regarding people with anxiety disorders. Anxiety disorders differ from other mental disorders that cause adverse psychiatric issues. Yet, many are unable to see a difference due to common beliefs among communities. In the same article, Stone states “Others in the mental health advocacy field worry that this knee-jerk reaction is based on the myth that people who are mentally ill pose a greater danger to the public than those persons without such a diagnosis. Complicating the picture is the lack of precise science on how to predict future dangerous behavior”. These conceptions are based upon common ideas within a community. This is a myth and is believed as an automatic response to mental health issues. Again, a solution to the issue is a debunking of such ideas. The education of individuals who stigmatize people with anxiety disorders and group them up with individuals with severe psychiatric illnesses is key. These ideas are based upon a common stereotype and stigma, this is not the case for all mental disorders. Furthermore, with proper medical attention, these disorders can be controlled and managed. The stigma surrounding these disorders is what keeps these individuals from getting the help they need. It is a domino effect, the stigma keeps them from getting help, but not getting help is what is causing the stigma. One is caused by the other. Stigmatization needs to be reduced for these individuals to feel safe to get proper medical help. The key to solving the stigma is educating the public about the truth behind anxiety disorders.

Moreover, the education required to combat stigma needs to be paid for. A way to pay for such education is through charitable donations. Charity is a great way for individuals to help out with causes they stand behind even if they are not “hands-on” in the solution. Though, not all charities are using the money as they say they are. Carolyn J. Cordery is a professor in charity accounting and accountability at the Aston business school in Birmingham United Kingdom, Cordery states that “sustained charity fraud is supported when organisations do not develop strong accountability links to salient stakeholders”. When organizations do not give necessary information to donors it becomes easier for these charities to commit fraud. When all parties involved in the charity are not disclosed it is difficult to determine where the money is going. Not all stakeholders have the same goals, and many are in it for the profit. For a charity to be trustworthy, their hearts have to be in the right place. There are many scam charities out there, but with the proper research, it is possible to figure out which ones are giving back to their organizations. Deciding which charities to give to can be tough, many do not know how to choose a reliable organization to donate to. There are resources that aid in helping identify which charities are trustworthy and which are not. Mallie Jane Kim is a journalist and reporter for US News & World Report, according to Kim, “Charity Navigator rates nonprofits based on their financial viability and efficiency (how much of every dollar goes to run programs and how much toward administrative and fundraising costs), and the Better Business Bureau rates them based on 20 standards of accountability, including the structure of the board of directors and the transparency of financial data”. These references are there to help individuals in choosing a proper organization to donate to. They should be utilized before choosing to donate. Kim also states that “Any charity that meets all 20 standards is classified as a BBB Accredited Charity. A quick search on sites like these is a great way to find out if an organization actually exists and to avoid giving to sound-alike charities”. Honest charities can be hard to spot at times, but they are out there, and many sites list trustworthy organizations. With a quick google search choosing a noble cause can be easy. Organizations that steal from individuals that just want to help are immoral. Individuals who decide to donate to any charities should take the proper precautions before sending money. References and all numerical data will be available online for the public to see. There will be no hiding the facts of this organization from the public. All donations will go toward the establishment of these programs and call centers as this will be a non-profit organization dedicated to the education of anxiety disorders.

Likewise, there can be issues that arise with hotline services and the availability of volunteers to run said hotlines. There may be issues with the availability of volunteers to be ready to counsel individuals in need. This may cause a conflict if there are individuals in need of assistance in a time when volunteers may be temporarily unavailable. Prudi Koeninger is a founder and director of the Wildlife Coalition, in Dallas Texas which operates a community supported wildlife conflict solution hotline. Koeninger speaks on issues with running a volunteer-based hotline. In his article, he states that “Our greatest challenge was determining how to handle vacant shifts, such as when a volunteer calls out sick, has a family emergency, or goes on vacation. During an hour-long shift, a volunteer may handle up to 20 calls”. This may become an issue as many calls come in daily, but there may not always be a volunteer ready to take a call. As with most volunteer-run hotlines, people who volunteer to take calls have other obligations outside of their volunteer work that may cause them to be unavailable at times. As a solution to the issues, Koeninger explains how they are handled in his organization, “Our hosted PBX phone system option for “parking” calls during a vacant shift has proven helpful in this regard. When the system is in ‘park’ mode, the public cannot leave a voicemail but they are given instructions; in this case, we created a message directing callers to our website for answers”. There are solutions to the issue of unavailability. In the event of unavailable helpers, there will be resources that can be found online to help callers. There will also be a given time in the recording when there will be available helpers to take calls, so individuals know when to call back. All resources regarding finding help and information on how to deal with panic attacks and episodes will be found on the website. Even in the case of the hotline being down the resources and help will still be available to the public online. There will be help articles written by professionals as well as chat and email services available where questions can be answered even if a physical phone call is not available. This may also help with individuals who are anxious to speak on the phone and would rather type their questions.

Mental illnesses, as a whole, in today’s society have a reputation for making a person seem weak or seeking attention from others. It is surrounded by a negative stigma, and so often goes untreated. Of the mental illnesses, anxiety is one of the least recognized and least treated. There are an estimated 30 million Americans that suffer from some form of anxiety disorder such as generalized anxiety disorder, panic disorder, and post-traumatic stress disorder. Of these 30 million Americans suffering from the different types of anxiety disorders, only around 15-36% of these Americans are receiving treatment (Kroenke, Spitzer, Williams, Monahan, & Lowe, 2007). In a dissertation written by Brandon Guin in 2014, he discussed the relationship between trauma and anxiety. One of his main points was that trauma is experienced by 6.8% of Americans, and then diagnosed with post traumatic stress disorder. He went on to explain how disabling this anxiety disorder can be depending on the severity of the traumatic event. The awareness of anxiety is increasing slowly, but surely. Treatments for the different anxiety disorders are becoming more available, but with fewer people coming forward and looking for treatment, the percentage of people that are diagnosed and treated is much less than the patients that are receiving treatment. According to Freeman and Fowler in 2009, traumatic experiences are often closely related to the cause of psychotic breaks, hallucinations, and anxiety. These traumas can be defined by events such as sexual assault, substance abuse, and even non-victimization events.

Anxiety in Fourteen-Year-Old Girls

It is automatically assumed that an anxiety disorder is acquired because of stressful life events. It has been researched frequently in twins to see if anxiety is present in a person due to genetics or life events. Silberg, Rutter, Neale, and Eaves conducted a longitudinal study on adolescent girls in 2001. It revealed that anxiety was developed due to different traumatic events throughout the teen’s lives. Some of the different traumatic events included a sibling leaving home, indicating separation anxiety, a new sibling being introduced into the family due to a parent getting married, or the family income decreasing because of a parent losing a job. The researchers used a group of 184 fourteen-year-old girls, and began with an interview. The interview incorporated the Child and Adolescent Psychiatric Assessment that aided the researchers in diagnosing the defects in the girl’s mental status before the study began. This gave them a baseline to collect the remaining data. They were observed over the next three months. This age was believed to be the age where the girls were mature enough to process the different events occurring in their lives and it affect their mental health. After observing the girls over the three months, the study revealed a .06 correlation between the traumatic events listed above and their anxiety levels.

Substance Abuse Induced Anxiety

Developing a substance abuse disorder is another factor that is believed to affect mental health. Excessive substance abuse is known to be a way to cope with different mental issues as a way to self medicate. A correlational study was conducted along the Mexican border to observe the relationship between substance abuse among people from different communities around the border and their feelings of anxiety and hopelessness. The study gathered 100 Mexican Americans that were classified as heavy drinkers by a CAGE questionnaire. The participants were then interviewed using the Structured Clinical Interview for DSM-IV Axis I disorders to analyze the type of anxiety disorders and substance abuse present in each participant. The results of the study revealed that the Mexican Americans self-medicated with alcohol to cope with the anxiety that came from acculturation (Blume, Resor, Villanueva, & Braddy, 2009). It would make sense that people would use substances to cope with anxiety because they are trying to conform to a new society that is foreign to what the citizen is accustomed to. This study helped prove the fact that a culture change and assimilation can have a huge impact on a person’s life resulting in different anxiety disorders.

Anxiety presented through nightmares. A big indicator of trauma and anxiety disorders in children is the presence of nightmares. Even though it is common for children to have nightmares every once in a while, an extreme amount of them, or some that are severe enough to be classified as night terrors, can reveal the presence of anxiety in a child. After a traumatic event in a child’s life, the child typically starts to have higher rates of sleep interruptions accompanied by nightmares. This is what clinicians will look for when attempting to diagnose a child with an anxiety disorder. The clinicians can typically analyze the child’s dreams and determine the trauma that occurred because children’s dreams typically reflect their life events. The studies discussed in this dissertation written by Marie Ardill in 2017, describe the different effects that anxiety has on children. It is mainly all about the nightmares that children experience. It also discusses the different causes of anxiety in children such as parental styles that can instill feelings of anxiety in children. How a child is raised and treated early on has a huge impact on the mental health of the child, since their mind is developing so rapidly. Any type of trauma occurring can send a child into critical anxious states that are reflected by their nightmares.

Indirect anxiety from parenting. Some anxiety isn’t due to direct trauma, but instead due to worrying about possible trauma in the future. An example of this would be a pregnant mother that is anxious about the birth of her child. A quantitative study was done on 150 pregnant women. The study was made quantitative by using a twenty-eight question survey and a State Trait Anxiety Inventory, that rated the psychological status of the pregnant woman on a scale of 1-4. The results of these two tests revealed that 104 of them displayed traits of anxiety. The main complications that the women were anxious about were possible health issues for their newborn. Other causes of anxiety in the pregnant women were the different changes that were occurring in their bodies, such as the hormonal imbalances and weight gain, and then feelings of loneliness and anxiety about how to raise the child if the father was not present in the child/mother’s life anymore (Deklava, Lubina, Circenis, Sudraba, & Millere, 2015). According to a study conducted by Turner, Beidel, Roberson-Nay, and Tervo in 2003, anxious parenting continues on past birth and pregnancy. These researchers observed a group of parents that were constantly worried about the activities that their children participated in. It revealed that the stress levels for the children were much higher because of the parent’s anxiety than the children that had parents without anxiety disorders. Having a household that is run by anxiety would put more stress on everyone in the house because the family members would constantly worry about trying to make everything perfect. This would then transfer into the children’s children and create a cycle.

Another form of indirect anxiety comes from being raised around constant anxiety. Researchers studied the children of parents that were victims of the Holocaust with PTSD, and children that had parents without Holocaust experience without PTSD. They were given several different tests to analyze their mental status and health and then observed. The results of this study revealed that the children of parents that were victims of the Holocaust and suffered from PTSD also suffered from an anxiety disorder (Yehuda, Halligan, & Bierer, 2001). This study shows that when children are raised around chronically anxious parents, the children watch and learn those same behaviors. Nurture has a big effect on the way that children grow up when it comes to their personality, the way they live, and the way they act. Being raised with lots of anxious influence, it is no surprise that those children suffer from an anxiety disorder too. Even though the trauma did not specifically happen to the children, it still affected them because they experienced the trauma second handedly from their parents.

Post-traumatic stress disorder is extremely common in rape victims. A descriptive study compared the anxiety levels of rape victims when they were asked to discuss their feelings and thoughts about their assault. They were separated into two groups: those diagnosed with PTSD and those without PTSD. Thirty-six women were used in the study, seventeen of them had been diagnosed with PTSD and the other nineteen women had not. They were given nine minutes to write out thoughts about their assault and then were given a period of time to reflect. After this time of reflection, they were given nine more minutes to write out thoughts and feelings after being instructed to not think about the assault. The victims with PTSD had a much harder time controlling their thoughts and remaining calm. It was clear that the victims with PTSD were consumed with anxiety because of the trauma that was inflicted on them (Shipherd & Beck 1999).

The studies conducted and other research finds a strong correlation between past trauma and people suffering from all types of anxiety disorders. It is clear how debilitating these anxiety disorders can be, and how important it is for people suffering from these disorders is to be treated. As a researcher, more studies should be conducted to research the types of traumas that affect the elderly. Since the elderly have lived much longer and experienced a lot of life, it would be interesting to see exactly what causes their anxiety or see if anxiety decreases as age increases. My prediction would be that the elderly have the lowest amount of anxiety since they have lived the longest and have the most life experience. With more life experience comes the ability to learn how to cope in healthier ways, and realize that bad experiences happen to everyone. The elderly would be wise enough to see that people should enjoy life while they can since they are becoming aware of the fact that their days are numbered and life does not last forever.

INDRODUCTION

Yoga refer to a scientific scheme of physiological or intellectual practices that arised in India approximately 3000 years ago. The aims of yoga are , development of the following via strong and flexible body free of pain, a balanced autonomic neural system with all physiological systems like digestion, endocrine, functioning optimally and a calm and clear mind. Studies have indicated that anxiety, depression, anger, fatigue -patients improved following at least one yoga session. Research has demonstrated that long-term yoga practitioners have lower intellectual disturbances ,anxiety, fatigue scores in comparison to non-experienced participants.

Anxiety chaos are among the most prevalent mental health problems found in the community in the United Kingdom according to the survey carried out by the Office for National Statistics (ONS) in the year 2000.Conditions such as mixed anxiety and depressive disorder, generalised anxiety disorder, phobias, obsessive compulsive disorder, along with stress disorder make up over 86% of neurotic disorders found.Excessive concern is a key component or symptom in all of these conditions.

Studies have revealed effect of yoga for different conditions like multiple sclerosis ,asthma ,lymphoma ,hypertension ,drug addiction, osteoarthritis, and mental health problems ,elevated stress, depression as well as anxiety are the features of modern lifestyle. Due to the unfavorable effects of drugs in the handling of anxiety and in some instance their lack of effectiveness, researchers try to find nonpharmacological and noninvasive treatment for these disorders.Yoga exercises was boosted the elements of self-description, psychological state, as well as the quality of life. Researchers suggest that yoga as an intellectual and mental exercise, improves fine fettle feeling.Moreover,yoga can improve the psychological states, negative emotions, elavates positive emotions, also help mental balance. In a three month trial organized with medical students, Malathi and Damodaran developed a crucial deduction in concern following handling for the yoga group one month before examinations and on the actual day of assessment.On the day of the examination, the mean state-trait anxiety inventory score for the yoga group fell by 34.0% from the moderate concern range prior to treatment to the low anxiety range after treatment, go to bat for a clinically significant change.

METHODOLOGY

Some questions were included while conducting this research. Which are:

1. How does this method work? To find out in what way yoga deals with anxiety issues .
2. Which one is better Yoga or medication? To find out whether yoga is better than medication or vice versa

INCLUSION CRITERIA

In order to ensure that research is focused on selected participants who have experienced post traumatic stress, violence and to find out comparison between yoga and medications, valid data are analyzed as two groups. Some data are supporting only yoga, but the other supports only medication for anxiety disease and all the other data that show effectiveness in both groups are included.

FINDINGS

There is increasing interest in the use of yoga as way to manage or treat depression plus anxiety. Yoga is afford- able, appealing, and accessible for many people, and there are plausible cognitive/affective and biologic mechanisms by which yoga could have a positive impact on depression as well as anxiety. There is indeed preliminary evidence that yoga perhaps helpful for these problems, together with there are several ongoing larger-scale randomized clinical series. The current proof base is strongest for yoga as efficacious in reducing signs of unipolar depression.However,there may be risks to engaging in yoga as well. Healthcare providers can help patients evaluate whether a particular community-based yoga class is helpful and safe for them.

Though Yoga is an attractive therapeutic option because of its popularity recently demonstrated in the United states of America and like exercise, may be of particular use where clients reject psychological diagnoses and treatments. The National Institute for Clinical Excellence (NICE) commend that patients with tension disorder as well as anxiety disorder are informed about workout as part of good general well-being If proved efficacious, yoga would be an attractive option because it is non-pharmacological, has minimal adverse effects if practised as recommended and enjoys international acceptance. Stress, fear, anxiety – if we start counting all those instances in life when we experienced these emotions, we may just lose count! Anxiety about an exam result or the reaction of our parents to the report card; nervousness about a job interview – we all would have lived through these moments. A little bit of fear is normal;in fact, just like salt in the food, it is needed so that we remain disciplined and focused. now only a yoga technique away!

Currently, researchers are studying the efficacy and productiveness of mind-body interventions like yoga as an alternative and complementary managment for depression. Yoga, with its origin in ancient India, is recognized as an alternative medicine. The philosophy of yoga is based on 8 limbs that are better described just as ethical principles for meaningful and purposeful living.While there is no specific definition, yoga has been interpreted as a process of uniting the body via mind and enthusiasm to promote physical and mental wellness. Although much research has already been done on the health effects of yoga, multiple of studies have included only small numbers of people and have not been of high quality.So in most instances, we can only say that yoga has shown promise in helping to manage a particular health state , not that it has been proven effective. Yoga is commonly safe for healthy people when performed properly and in right way; individuals with health state should discuss their needs with their health care providers and the yoga instructor also.People with health states, older adults, and pregnant women may need to avoid or modify some yoga poses and practices and should discuss their individual needs with their health care providers and the yoga instructor. Different situations call for different restrictions. For example, people with conditions that weaken their bones should avoid forceful forms of yoga, and people with glaucoma should avoid upside-down positions.

The yogic practices or breathing techniques which is known as pranayama, remarkably increases vagal tone.“Resistance breathing,” such as Ujjayi this means ocean-sounding breath, increase parasympathetic activity and heart rate variability.

CONCLUSION

Yoga has an potent role in deducing stress, anxiety, and depression that can be reflected as harmonious medicine and reduce the medical cost per treatment by reducing the use of drugs .Yoga has been with us since ancient times and has been used by mankind to alleviate various problems. Yoga is supported by research evidence as a safe , and convincing method that the patient can follow at home to reduce symptom of concern. Anxiety is a symptom that is often psychological in nature and has its determinants in the patient’s environment. Therefore at times biological treatment and drug handling may not be able to deduct the patient’s symptoms. Yoga may serve as an effective substitute or accompaniment to biological treatments in anxiety. Further use of various yogic postures and workouts in specific populations with specific anxiety disorders needs to be researched. This could add to the number of treatments available for the management of anxiety disorders.

REFERENCES

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The high prevalence rates of anxiety disorders emphasize the need to understand the underlying mechanisms. Panic disorder (PD) is an anxiety disorder that is particularly debilitating, as the panic attacks are unexpected and peak quickly (American Psychiatric Association, 2013). The diagnostic criteria require at least four of the following symptoms: palpitations, sweating, trembling, shortness of breath or smothering, feelings of choking, chest pain, nausea, dizziness, chills or heat sensations, paresthesia, derealisation or depersonalization, fear of losing control and fear of dying (American Psychiatric Association, 2013). This paper will examine the epigenetics perspective and catastrophic misinterpretations model to help explain the symptoms of PD, as well as consider its limitations. The epigenetics perspective and catastrophic misinterpretations model are reciprocal in explaining the symptoms of PD.

The epigenetics perspective is useful for understanding PD symptoms. Epigenetics are changes in gene expression (instead of DNA) due to interactions with the environment (Nieto, Patriquin, Nielsen & Kosten, 2016). Corticotropin releasing hormone receptor 1 (CRHR1) plays a critical role in the hypothalamic-pituitary-adrenal (HPA) axis during stressful situations; CRHR1 triggers a chain reaction in the HPA axis, which releases cortisol and triggers the stress response (Schartner et al., 2017). Schartner et al. (2017) found that CRHR1 methylation (adding methyl group to DNA which changes gene expression) in PD patients was significantly decreased as compared to controls. Findings suggest CRHR1 hypomethylation causes increased CRHR1 expression, indicating a link between the stress response and PD (Shartner et al., 2017).

Shimada-Sugimoto et al. (2017) conducted an epigenome-wide association study (EWAS) to consider whether different levels of DNA methylation is associated with PD. The results revealed that DNA methylation levels in 40 CpG sites were significantly different between PD and control subjects (Shimada-Sugimoto et al., 2017). Furthermore, Lurato et al. (2017) conducted a replication of the previous EWAS, stratified by gender. Although no association was found for male participants, methylation differences were found in female participants and the HECA gene was hypermethylated for female PD patients (Lurato et al., 2017). Also, DNA methylation of monoamine oxidase A (MAOA) and glucocorticoid receptor genes are significantly altered in PD patients (Domschke et al., 2017; Nieto et al., 2016). The studies show DNA methylation in PD patients is evidently altered, increasing the stress response.

Catastrophic misinterpretations model explains symptoms of PD. This model proposes that physiological sensations (e.g. palpitations) cause distress due to biased appraisals (Bailey & Wells, 2015). PD patients perceive relatively harmless symptoms as serious and life-threatening, resulting in panic attacks and avoidance behaviour (Bailey & Wells, 2015). Ohst & Tuschen-Caffier (2018) conducted a meta-analysis of studies comparing the strength of catastrophic misinterpretations of bodily sensations and external events among PD patients, patients with other anxiety disorders and healthy controls. The findings revealed that PD patients have significantly more catastrophic misinterpretations of bodily sensations than other groups (Ohst & Tuschen-Caffier, 2018). Regarding external events, PD patients had similar effects with patients with other anxiety disorders; the similar effects may be due to systematic influences (Ohst & Tuschen-Caffier, 2018). Furthermore, Bailey & Wells (2015) found that catastrophic misinterpretations in anxiety-provoking situations are dependent on metacognitive beliefs (beliefs about thinking). Bailey & Wells (2015) claim that negative metacognitive beliefs (e.g. “I need to stop worrying”) are more harmful than positive metacognitive beliefs (e.g. “worrying is useful”), as it escalates feeling of distress. This finding supports the catastrophic misinterpretations model and demonstrates the impact maladaptive cognitions has on PD.

The epigenetics perspective and catastrophic misinterpretations model are reciprocally related to the symptoms of PD. Individuals with PD have a hyperactive HPA axis and experience epigenetic changes during stressful events, causing physiological sensations. As a result, PD patients develop catastrophic misinterpretations of these bodily sensations, which worsens the symptoms and causes panic attacks. Furthermore, epigenetic changes in the DNA methylation and hyperactivity of the HPA axis causes heightened “fight or flight” bodily sensations, such as palpitations, sweating, trembling and shortness of breath, as seen in PD patients. Other bodily sensations of PD patients are likely due to related epigenetic changes. Also, catastrophic misinterpretations model explains the following symptoms of PD: derealisation, depersonalization, fear of losing control and dying. PD patients misattribute their physiological sensations as abnormal and develop maladaptive cognitions which exacerbate their symptoms. Both perspectives are integral for a comprehensive understanding of the symptoms.

Although the epigenetic perspective and catastrophic misinterpretation model provides insight to PD, there are several limitations. The epigenetic studies were fewer in number (only two EWAS), had small sample sizes and lacked replication studies. The meta-analysis study of catastrophic misinterpretations had relatively few studies that meet all criteria (Ohst & Tuschen-Caffier, 2018). Also, the meta-analysis had systematic influence: the measurement of anxiety was not exhaustive and there was inconsistency in instruments (Ohst & Tuschen-Caffier, 2018).

Overall, the epigenetic perspective and catastrophic interpretation model helps explain the symptoms of PD. Epigenetically driven changes in the HPA axis and DNA methylation increases physiological sensations that are seen in PD patients. These symptoms are then misinterpreted as life-threatening and cause distress in PD patients. Future studies are required to extend the knowledge on PD and replication studies are recommended.

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
2. Bailey, R., & Wells, A. (2015). Metacognitive beliefs moderate the relationship between catastrophic misinterpretation and health anxiety. Journal of Anxiety Disorders, 34, 8–14. http://dx.doi.org/10.1016/j.janxdis.2015.05.005
3. Domschke, K., Ziegler, C., Richter, J., Mahr, M., Gajewska, A., Lang, T., Pauli, P., Rief, W., Kircher, T., Arolt, V., Hamm, A. O., Deckert, J. (2017). From candidate gene to (epi)genome-wide analysis of therapy response in adult anxiety disorders. European Neuropsychopharmacology, 27(4), 534-535. doi: 10.1016/S0924-977X(17)31015-5
4. Lurato, S., Carillo-Roa, T., Arloth, J., Czamara, D., Diener-Hölzl, L., Lange, J., Müller-Myhsok, B., Binder, E. B., Erhardt, A. (2017). DNA methylation signatures in panic disorder. Translational Psychiatry, 7, 1-10. doi: 10.1038/s41398-017-0026-1
5. Nieto, S. J., Patriquin, M. A., Nielsen, D. A., & Kosten, T. A. (2016). Don’t worry; be informed about the epigenetics of anxiety. Pharmacology, Biochemistry and Behavior, 146–147, 60– 72. doi: 10.1016/j.pbb.2016.05.006
6. Ohst, B. & Tuschen-Caffier, B. (2018). Catastrophic misinterpretation of bodily sensations and external events in panic disorder, and other anxiety disorders, and healthy subjects: A systematic review and meta-analysis. PLoS ONE, 13(3), 1-11. doi: 10.1371/journal.pone.0194493
7. Schartner, C., Ziegler, C., Schiele, M. A., Kollert, L., Weber, H., Zwanzger, P., Arolt, V., Pauli, P., Dechkert, J., Reif, A., Domschke, K. (2017). CRHR1 promoter hypomethylation: An epigenetic readout of panic disorder? European Neuropsychopharmacology, 27(4), 360- 371. http://dx.doi.org/10.1016/j.euroneuro.2017.01.005
8. Shimada-Sugimoto, M., Otowa, T., Miyagawa, T., Umekage, T., Kawamura, Y., Bundo, M., Kazuya, L., Tochigi, M., Kasai, K., Tanii, H., Okazaki, Y., Tokunaga, K., Sasaki, T. (2017). Epigenome-wide association study of DNA methylation in panic disorder. Clinical Epigenetics, 9(6), 1-11. doi: 10.1186/s13148-016-0307-1

Introduction

Humans are cognizant of others’ actions and opinions and are therefore susceptible to others’ evaluations. The urge to appear publicly acceptable and conform to societal norms has likely caused lower self-esteem in this generation. Leary (1999) states that sociometer theory suggests that self-esteem is a method of monitoring social acceptance and avoiding public rejection; therefore, self-esteem acts as a protective measure that warns of potential social devaluation so corrective actions can be taken to mediate the problem. Considering positive social interactions are linked to emotional well-being, consistent negative interactions with others or oneself can lead to an overwhelming number of psychological issues. Self-esteem is lowered by failure, criticism, rejection and other outcomes that could lead to further devaluation of self-worth. Fox (1997) found that low self-esteem is known to cause a wide array of psychological issues such as social avoidance while high self-esteem increases coping skills. Self-esteem likely acts as a feedback loop, where positive social interactions lead to and maintain self-esteem while negative social interactions stop or hinder it.

The transition from secondary school to university is overwhelming and requires the evaluation and acceptance of one’s competence and abilities. If the student believes he/she is the right fit for the school, he/she may feel nervous, worried, or uneasy. Furthermore, it is likely that anxiety while choosing a suitable university and major can also lead to self-esteem problems. For example, consider a student who believes he/she should not belong at X university or Y major. He/she is likely to have problems finding positive social interactions among other students and can also lead to a drop in academic performance. Continuous lack of interaction and personal academic failure can further perpetuate low self-esteem.

According to Seleh et al. (2017) anxiety is characterized by the feeling of unease and nervousness for an uncertain outcome. This can affect academic performance and persistence and are more likely to higher dropout rates. Seleh et al. (2017) also found that students with higher levels of anxiety were more likely to have mental health symptoms and low self-esteem. Anxiety is likely prevalent for students who rest their self-worth on the opinions of others. Because college students are transitioning from adolescence into adulthood, they might be more emotionally prone to the thoughts of others. If a student does not believe in his/her abilities, then it could lower self-esteem and his/her overall ability to maintain his/her current self-esteem. McClain (2016) states that those in minority groups who are successful in college might feel anxiety from expected judgment from other groups. Therefore, it is likely that increased anxiety levels due to a variety of factors in college age students increases stress levels in these students. Furthermore, it is likely that increased stress levels further perpetuate increased levels of anxiety.

This study utilizes the Perceived Fraudulence Scale (PFS) and self-report measures (Kolligian & Sternberg, 1991). The PFS is used to determine anxiety and other factors that could affect self-esteem. Another self-report survey is given that asks a question about behaviors that may affect anxiety. The survey has a 5-point scale that ranges from strongly agree to strongly disagree. The self-report survey is discrete with an interval level of measurement. Self-esteem is measured through the Rosenberg Self-Esteem Scale (Sinclair et al., 2010). The Rosenberg Self-Esteem Scale is discrete with an interval level of measurement.

This study utilizes a correlation research design. To experimentally manipulate the independent variable, the research must alter the amount of nail-biting a person does, amount of sleep, and the number of social events participants miss. Due to constraints to manipulate the independent variable, for ethical reasons, a correlational research design is the best fit for determining a relationship between the two constructs. Furthermore, it’s unlikely that anxiety is the sole factor that can cause self-esteem levels, so instead of looking for a cause-effect relationship, a strong or weak level of correlation should be determined first. Therefore, the Anxiety survey consisted of one question pertaining to anxiety only.

If self-perceived levels of anxiety are highly associated with the environment in specific universities and majors, then those who exhibit high levels of symptoms in those groups score lower on the Rosenberg Self Esteem Scale.

Possible threats to internal validity are other factors that are associated with anxiety. For example, the type of major may significantly affect how much workload a person has and has the possibility of increased anxiety because of it. To mitigate this error, the study can separate students based on specific demographics such as majors and universities. Furthermore, students who are depressed in college could inadvertently affect the results as they may feel stress from being depressed. Each participant can take a depression test to determine if it influences data. Otherwise, the extra testing may induce anxiety in the participant. Anxiety can be operationalized in multiple fashions and the factors that aren’t considered may affect the results. For example, those with anxiety may bite their nails and feel itchy but there could be symptoms that aren’t known for some anxious participants; the resources to mitigate the problem outweigh the possible benefits. Problems could arise in the survey portion where participants may not answer accurately because of social pressures to feel normal.

High external validity is not feasible because of the conditions of the study to increase internal validity. Separating the participants into different demographics to account for workload decreases the overall external validity as a single group cannot be used to generalize everyone in all universities. To separate depressed participants from non-depressed participants, we cannot generalize the results for everyone as there could be moderately depressed students. By not accounting for every operationalizable variable that could characterize anxiety, external validity increases. However, to improve external validity, random sampling and selection is utilized to increase generalizability of the population. Furthermore, by utilizing multiple university’s and increasing diversity of the study, the more likely that this data can be generalized to multiple other universities.

The population is composed of college students attending four-year universities on the eastern coast of the Americas. Because of the high social demand and emotional transition from adolescence to adulthood, college and college-bound students are likely to feel anxiety from leaving home for long periods. Four-year universities are the most common types of schools and eliminating other types of schools increases the internal validity of the study. Furthermore, the eastern coast of the United States is chosen for convenience and reduces the chances that other regions may have drastically different school curriculum that could affect anxiety levels.

Stratified sampling is utilized in this study to assure the proper number of participants fit each demographic equally. This is to reduce sampling error and decrease variability in the study. The groups consist of majors such as Computer Science, Psychology, Economics, Business, Biology, Math, Physics, and English. In these groups, there are also subgroups consisting of Universities, such as the University of Maryland, Cornell, Penn State, Boston University, Boston College, and Towson. A total of N = 1000 participants is sampled from ten universities and ten majors. Each group contains g =100 participants and each subgroup contains sg =10 participants. Booths are placed at each university to advertise the study and each prospective participant is asked to provide demographic information. A subgroup for a group may contain more participants than needed; therefore, an online random number generator is used to randomly select participants from the overflowed subgroup.

To assure participant public safety, the data received is encrypted and uploaded to a remote database. Because anxiety is a personal issue, each participant can skip parts of questions or withhold information. Furthermore, to maintain anonymity, participants are encouraged not to provide their names for each survey and can take the surveys at home.

Methods

Participants

A total of 1654 applied and 667 were disqualified from the study due to their specific major or University. Those who did not fit into one of the predefined majors and Universities for this study were disqualified. 987 undergraduate students from College Park, Cornell, Penn State, Boston University, Boston College, Towson, Harvard, Yale, Georgetown, American University participated in the study. Of those 987 undergraduate students, they were separated into their corresponding majors: Computer Science, Psychology, Economics, Business, Biology, Math, Physics, English, Public Policy, and Chemistry. 832 of them reported their gender: 453 males and 379 females. 543 reported their race: 40% white, 20% black, 20% Asian, and 20% Hispanic. Participants were recruited through online advertisements or booths placed at each University. Subjects were compensated $20 for their time.

Measures

Informed consent forms briefed participants of the study’s purpose (to measure the effects of anxiety on self-esteem) and explained the nuances of participating in the study: participation was voluntary, and all responses remained confidential. Two surveys were utilized in the study and were online and followed similar formatting provided by the University of Maryland Qualtrics survey builder. Each survey prompted the reader to read the questions and respond accordingly to how they felt during the week when the survey was taken.

The Rosenberg Self Esteem Survey contains 10 questions that asked the participant how he/she feels about him/herself. The questions follow a Likert Scale which has evenly balanced answer choices: there is an equal amount of negative and positive choices. The Rosenberg Self Esteem Survey contains 5 different choices: Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree. Different question responses were summed to create a score for a construct and each response is equally spaced from each other. The Anxiety Survey contains 1 question that asked the participants about how he/she feels about future events. A scale from 1-10 is used and participants can use their mouse to move the score up and down the scale. Participants were able to skip this part if they were uncomfortable. However, their data were excluded from the study.

All participants were plotted on a self-esteem to anxiety chart, and a regression for the data was determined. The correlation coefficient was used to determine if a relationship existed between anxiety and stress. For each major, all the participants were plotted on a self-esteem to anxiety chart and a regression for the data was determined. The correlation coefficient from the regression was used as a method of comparing other majors’ correlation coefficient. For each University, all the participants from every major were plotted on a self-esteem to anxiety chart and a regression for the data was determined. The correlation coefficient from the regression was used as a method of comparing to other Universities’ correlation coefficient.

Procedures

Each participant was able to take the electronic survey wherever they wanted. However, the suggested time was during the afternoon; this was to removed confounding factors. Furthermore, participants were told to take the surveys on a laptop or desktop to make the surveys easier to read and answer. At the beginning of each survey, subjects were prompted with an informed consent form to be read and electronically signed. Participants were then given the surveys to complete and upon completion, via hitting the submit button, results were confidentially recorded on the study’s database. The data was examined a couple of months after the surveys were issued to the participants.

Design

The study utilized a correlation research design via surveys that assessed participant self-esteem and anxiety levels. The Rosenberg Self Esteem Survey (Appendix B) asks questions about how the participant feels about his/her self-esteem and the Anxiety Survey (Appendix A) asks one question on how the participant felt about their anxiety levels. The surveys were graded with a Likert scale. The participants’ anxiety is the independent variable and the quasi-independent variables are the major and university that the participants chose and attended, respectively. Each major and University had their self-esteem to anxiety correlation chart. The score on the Anxiety Survey was correlated with the score on the Rosenberg Self Esteem Survey. A p-value of p > 0.10 is considered statistically significant. To reiterate, is it possible that mounting anxiety from students decreases self-perceived self-esteem?

References

1. Fox, K. R. (1997). The physical self and processes in self-esteem development.
2. Kolligian Jr, J., & Sternberg, R. J. (1991). Perceived Fraudulence in Young Adults: Is There an’Imposter Syndrome’?. Journal of personality assessment, 56(2), 308-326.
3. Leary, M. R. (1999). Making sense of self-esteem. Current directions in psychological science, 8(1), 32-35.
4. Lige, Q. M., Peteet, B. J., & Brown, C. M. (2017). Racial identity, self-esteem, and the impostor phenomenon among African American college students. Journal of Black Psychology, 43(4), 345-357.
5. Nordstrom, A. H., Goguen, L. M. S., & Hiester, M. (2014). The effect of social anxiety and self‐esteem on college adjustment, academics, and retention. Journal of College Counseling, 17(1), 48-63.
6. Saleh, D., Camart, N., & Romo, L. (2017). Predictors of stress in college students. Frontiers in psychology, 8, 19.
7. Sinclair, S. J., Blais, M. A., Gansler, D. A., Sandberg, E., Bistis, K., & LoCicero, A. (2010). Psychometric Properties of the Rosenberg Self-Esteem Scale: Overall and Across Demographic Groups Living Within the United States. Evaluation & the Health Professions, 33(1), 56–80. https://doi.org/10.1177/0163278709356187

Summary

The fundamental skill of being able to process facial expressions is crucial in being able to socialise within everyday life. One clinical disorder which is often linked with atypical facial processing is social anxiety disorder (SAD). The majority of previous research investigates a link between SAD and a hypersensitivity to negative expressions. However, there is a lack of research exclusively looking at the way individuals with SAD process positive expressions. It could be hypothesised that individuals with SAD process positive expressions in a negative way, leading to an impairment in positive facial processing. Funding this experiment would help add additional evidence to the existing literature about how the atypical processing in SAD may not be solely linked with negative stimuli. Evidence from the funding would help develop further knowledge about the disorder, while also being able to expand treatment programmes, such as cognitive behavioural therapy (CBT).

This study aims to investigate the way individuals with SAD process positive facial stimuli. Each participant will complete the Social Interaction Anxiety Scale (SIAS) (Mattick & Clarke, 1998) and then take part in a functional magnetic resonance imaging (MRI) scan. While undergoing an fMRI scan, they will perform a facial expression task. This task will only focus on the responses to positive faces. Results will show whether there are any differences in brain activity between SAD processing and a control group.

Scientific summary

Even though there is a lot of research giving priority to negative association to negative facial expressions within SAD, there is a lack of research specifically focusing on the way individuals with SAD process positive expressions. Previous research has shown that when individuals with anxiety focus on negative expressions there is an increased activation in the amygdala and insula, as well as the prefrontal cortex. The current study aims to determine whether there is a difference in activated regions, when processing positive facial expressions, compared to negative expressions. Participants will complete the SIAS on a 5-point scale before undergoing an MRI scan while taking part in a facial processing task. The fMRI will detect any increases in blood oxygen levels while the participant carries out the facial processing task.

Results of the fMRI will show the blood oxygen level dependent response (BOLD) which will display the neural activity while the participant was carrying out the cognitive task. Each participant’s BOLD response will then be compared to see if there are any significant similarities within neural activity and their SIAS rating. Funding this research will show if there is any atypical processing in the way an individual with anxiety processes positive facial expressions. Funding of this kind would be beneficial to clinical settings to aid therapy practices. Supporting such research is vital to improving the well-being of SAD individuals, but it is also valuable for the individual’s family, friends, relationships and even wider connections such as their working community.

Case for Support

The importance of emotional facial processing has been researched widely. Emotional facial expressions are demonstrated to be a vital source of valuable information for individuals. This emphasis on the importance of emotional facial expressions dates all the way back to Darwin. He posed that facial expressions are an innate and widespread element of non-verbal communication (Darwin, 1872). This has been evident in the amount of research that has been done on facial expressions, suggesting they provide information about thoughts, emotions and intentions of others. These in turn can influence the viewers perception of them, as well as their preceding intentions and actions (Seidel, Habel, Kirschner, Gur, & Derntl, 2010). Individuals who have an impairment within emotional facial processing often have difficulties in social interactions.

One model of psychiatric disorder argues that an impairment in facial processing may in fact be one of the factors that initiates and maintains the disorder instead of it being a symptom (Harmer, Goodwin, & Cowen, 2009). This means that a deficit in facial processing might be a core element within psychiatric disorders, instead of just being a casual symptom within the disorder. The model by Harmer, Goodwin & Cowen (2009) suggests that atypical emotional facial processing can result in distorted negative behaviours. They argue that this distorted view of facial processing subsequently leads to a sequence of negative social behaviour. Thus, allowing them to stress the importance of understanding the neural processes of such individuals in order to determine the aetiology of any psychiatric disorder. As well as, being crucial basis for developing strategic treatment plans.

Atypical emotional facial processing is thought to be a key feature of some clinical and neuropsychological disorders. For example, some individuals with prosopagnosia which is a deficit in face recognition, demonstrate that their deficit results in a constant source of social stress. Another psychiatric disorder believed to be affected by an impairment in emotional facial processing is SAD. A common hypothesis of SAD is that an individual with social anxiety will process a facial expression in a biased way to make it appear more threatening. Lots of present research has put emphasis on the way individuals process negative facial expressions and posing a hypersensitivity within negative processing. However, The American Psychiatric Association (APA) define social anxiety disorder as “a persistent fear of one or more social situations where embarrassment may occur and the fear of anxiety is out of proportion to the actual threat posed by the social situation as determined by the persons cultural norms” (APA, 2000). Despite the APA definition of SAD having no exclusive emphasis on SAD being associated with negative expressions, the majority of present research does. Much of the current literature emphasises this association, it leads to an disregarded concern about how SAD individuals interpret and process positive facial stimuli.

Anxiety disorders are highly common within the general population and are often related to stress, which can overall have an impact on an individual’s quality of life (Barrera & Norton, 2009). A common aspect of individuals with SAD is the inability to trust others (Cooper, et al., 2014), which could be down to the way they process facial expressions. In other words, an individual with SAD may take someone’s facial expression of warmth and kindness, as being negative and dishonest. It has been expressed that as a self-protection mechanism socially, anxious individuals often create a biased means of unambiguous facial expressions as untrustworthy and negative (Heimberg, Brozovich, & Rapee, 2014). This is often as a result of a deficit in the ability of processing emotional expressions.

Within cognitive neuroscience, it has been evident that symptoms of anxiety disorders are thought to be as a result of an imbalance of activity within the emotional regions of the brain. In a study by Evans et al. (2008), they found that perception of negative faces (including angry and harsh faces) by individuals with social anxiety led to a greater activation in the amygdala, insula and dorsal anterior cingulate cortex (ACC). For funding this type of research an MRI scan is pivotal, as it can address the associations between the neural activity and the cognitive task. It involves putting together an overall image of the different, most activated parts of the brain, while carrying out the facial expression task. This is important as it allows us to see the transformation from the baseline periods of the brain, where it is in a relative normal state, all the way to when it is performing the task.

Plan for investigation

A total of twenty participants will be recruited for the experiment, who have good to excellent vision. Ten of those recruited will have SAD, while the other ten participants will act as a control group. Once participants have given their consent, all participants will complete the SIAS, and be briefed about the MRI procedure. The whole experiment should last about 60-100 minutes. After this they will all receive the task instructions. This will entail how they will receive a face of a positive expression on a screen within the MRI scanner. The images will be presented individually and centrally on the screen in a randomised order to reduce any order effects. By the means of a key press, participants’ task is to quickly and accurately identify if a positive emotion is being presented. Each image remains on the screen until a response was detected or a 4 second elapse. Experimental trials were preceded by two practice trials. An eye tracker will also be in place during the experiment to make sure participants are not distracted and are concentrating on the task. The MRI scan will show which parts of the brain are needing more oxygen for their activity by their BOLD response which is measured by an fMRI. The findings from the MRI will be displayed on a probability map whereby the brain is divided into a number of voxels. Then an fMRI software will be used to determine the BOLD response for each voxel.

Ethical considerations

As the participants are taking part in an MRI scan, they will need to be free of any MRI contradictions. This includes anyone whom may be pregnant or is pregnant, as specialists are unsure of the implications of an MRI scan on the foetus. Also, individuals with tattoos need to be excluded as some tattoos include small fragments of metal for pigmentation. There are also other cautions with wigs, insulin pump, pacemakers, epilepsy etc. To make sure participants are free of any contradictions they will be asked about them before taking part. All healthy controls will have no medical, neurological, or psychiatric disorder history. This will help reduce any inconsistencies in brain activity between the control and experimental group. In addition, all participants will be free of any head injuries, frequent drug, cigarette or alcohol use, to help attain accurate brain activity results.

Another ethical consideration is that many claustrophobic individuals cannot stand the confined space of the MRI bore. This may be a key problem for SAD participants as it may bring on a panic attack. To help minimise participants anxiety while in the bore, they will be told to raise their hand at any time they wish to terminate or pause the experiment. There will also be a neck brace in place to help ensure participants feel secure and at ease. The brace will also help reduce peripheral muscle or nerve stimulation which may feel like a twitching sensation caused by the noise of the magnetic field within the MRI. In addition to the neck brace, participants will be given adequate ear protection to protect them from the loud noises that the magnetic fields produce. A quick questionnaire about how participants are feeling before and after the scan will be conducted to help prevent and measure any psychological stress, so the right help can be provided if required.

As any procedure, an MRI scan may have side effects to the participant. The information sheet and the debrief, will advise participants to seek help from their general practitioner if believed to be having side effects. Carrying out such precautions like these should help provide a reliable and valid study. Funding this study will therefore provide results which can be utilised and be benefited by the wider society.

Expected outcomes and impact

As stated previously, findings from the fMRI software will determine the BOLD response for each voxel, following each radio pulse. An increased signal would result in more oxygen being present in that region. Thus, highlighting an increase in neural activity within that area of the brain. Such findings will help demonstrate any increased activation in areas of the brain which may be alternative to the control group. In addition to this, the different scores on the SIAS and activated brain regions could be compared to determine any differences and correlations. Once results have been obtained, further work can be done to compare the current findings to previous findings such as Evans et al. (2008). This will reveal if there are any differences in the way SAD individuals process negative and positive expressions in respect to their neural activity.

However, further work would be needed to interpret results accurately. One expected outcome will be that SAD individuals have atypical processing of positive facial stimuli, which will be demonstrated through irregular neural activity. From funding this research, findings would therefore help explain how individuals with anxiety often interpret positive as well as negative facial expressions in an atypical way. Such results may allow clinical settings to tailor their therapy in a way to help the individual change their processing pathway of positive expressions. This in turn may help reduce such symptoms of anxiety or their power over the individual. Finally resulting in coercive treatment plans for anxiety sufferers being available.

The impact of such funding doesn’t only help individuals with SAD, but also helps society as a whole. While, obviously improving the well-being of SAD individuals, it may also elp them become more socially active. This may encourage them to apply for jobs which would help reduce rates of unemployment. Thus, becoming beneficial to the economy. Aiding their well-being also involves improving individual’s mental health who suffer from SAD. From this, the rate of suicide, self-harm and other self-reduction methods may be reduced, making the individual a more positive person.

References

1. Barrera, T. L., & Norton, P. J. (2009). Quality of life impairment in generalised anxiety disorder, social phobia, and panic disorder. Journal of Anxiety Disorders, 23, 1086-1090.
2. Cooper, R., Doehrmann, O., Fang, A., Gerlack, A. L., Hoijtink, H. J., & Hofmann, S. G. (2014). Relationship between social anxiety and percieved trustworthiness. Jornal of Anxiety, Stress and Coping, 27, 190-201.
3. Darwin, C. (1872). The expression of the emotions in man and the animals. London: John Murray.
4. Evans, K. C., Wright, C. L., Wedig, M. M., Gold, A. L., Pollack, M. H., & Rauch, S. L. (2008). A functional MRI study of amygdala responses to angry schematic faces in social anxiety disorder. Depression and Anxiety, 25, 496-505.
5. Harmer, C. J., Goodwin, G. M., & Cowen, P. J. (2009). Why do antidepressants take so long to work? A cognitive neuropsychological model of antidepressants drug action. British Journal of Psychiatry(195), 102-108.
6. Heimberg, R. C., Brozovich, F. A., & Rapee, R. M. (2014). A cognitive-behavioural model of social anxiety disorder. Social anxiety: Clinical, developmental and social perspectives, 3, 705-728.
7. Mattick, R. P., & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Journal of Behaviour Research and Therapy, 36, 455-470.
8. Seidel, E. M., Habel, U., Kirschner, M., Gur, R. C., & Derntl, B. (2010). The impact of facial emotional expressions on behavioural tendencies in women and men. Journal of Experimental Psychology on Human Perception and Performance, 36, 500-507.