research article phobia

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• Published: 14 December 2023

Key factors behind various specific phobia subtypes

• Andras N. Zsido 1 , 2 ,
• Botond L. Kiss 1 ,
• Julia Basler 1 ,
• Bela Birkas 3 &
• Carlos M. Coelho 4  

Scientific Reports volume  13 , Article number:  22281 ( 2023 ) Cite this article

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• Risk factors

While it has been suggested that more than a quarter of the whole population is at risk of developing some form of specific phobia (SP) during their lives, we still know little about the various risk and protective factors and underlying mechanisms. Moreover, although SPs are distinct mental disorder categories, most studies do not distinguish between them, or stress their differences. Thus, our study was manifold. We examined the psychometric properties of the Specific Phobia Questionnaire (SPQ) and assessed whether it can be used for screening in the general population in a large sample (N = 685). Then, using general linear modeling on a second sample (N = 432), we tested how potential socio-demographic, cognitive emotion regulatory, and personality variables were associated with the five SP subtypes. Our results show that the SPQ is a reliable screening tool. More importantly, we identified transdiagnostic (e.g., younger age, female gender, rumination, catastrophizing, positive refocusing) as well as phobia-specific factors that may contribute to the development and maintenance of SPs. Our results support previous claims that phobias are more different than previously thought, and, consequently, should be separately studied, instead of collapsing into one category. Our findings could be pertinent for both prevention and intervention strategies.

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Introduction

Evidence shows that specific phobias (SPs) are the most common anxiety- and mental disorders with a lifetime prevalence between 7.4 and 14% among adults with a cumulative incidence of 27% that is increasing 1 , 2 , 3 . That is, over a quarter of the whole population is at risk of developing some form of SP throughout their lives. Fear and its automatic activation by the detection of an object that might signal danger 4 is an adaptive response to imminent threats insofar as it helps prepare the organism for action and reduce the risk of being harmed. However, excessive levels of fear can interfere with one’s cognitive processes and movement preparation, and, as a consequence may result in disrupted behavior 5 ; for example, a diver might ascend too fast, a pedestrian might freeze, or a policeman might freeze or shoot too early 6 . Such core negative experiences—accompanied by a panic-like fear response and a loss of control over one’s emotions and behaviors—can result in the development of SPs 7 . Even in the absence of a proportional danger, phobias then manifest as extreme fear, and can be triggered even by the thought of the feared object 8 , 9 . The possibility and likelihood of direct engagement with potential treats (e.g., spiders, snakes, storms, etc.) may affect the prevalence of 10 , 11 Thus, environmental conditions have an influence on the development of SPs. The 5th edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) distinguishes five SP subtypes: animals (e.g., snake, spider), environmental (e.g., storm, heights), situational (e.g., enclosed spaces), blood-injection-injury (BII; e.g., medical examinations), and other (e.g., choking). This categorization can also be useful in understanding fears that are not yet excessive but may foreshadow the possibility of developing a phobia (i.e., subclinical SP).

Determining the percentage of the general population that may be affected by subclinical levels of fear is vital, as SPs are often unrecognized and, consequently, often go untreated for a long time 12 . A lack of screening, diagnosis, and treatment has negative consequences both at an individual (e.g., reduced quality of life) and at a societal level (e.g., economic costs) 13 , 14 , 15 . A recent study offers a quick screening tool to assess the five subtypes of SP, the Specific Phobia Questionnaire (SPQ) 16 . The SPQ measures both fear and the extent to which fear interferes with daily life and has been proven reliable in clinical and subclinical samples as well. Assessing both fear and daily life interference is a novelty of the questionnaire and is in line with DSM-5 requirements for phobia diagnosis 8 , 17 , 18 . The tool is capable of identifying those at risk of either SP subtypes. Since SPQ has only been published in recent years, further evidence is needed about its psychometric soundness. While previous studies warn that a considerable percentage of the whole population might be affected by SPs at some point in their lives 3 , we still do not know the exact number and how it varies across countries 2 . The use of SPQ also opens the possibility of closely monitoring the percentage of the population at risk of various SPs.

While a large proportion of the population is at risk of developing SP, to date, still little is known about the particular risk factors associated with the development. The risk factors previous studies have shown can be categorized into three large groups: socio-demographic, personality, and cognitive emotion regulation (ER) strategies. A large-scale investigation in a representative sample of community-dwelling adults 19 has shown that the most prominent risk factors were female sex, a comorbid diagnosis of lifetime major depressive disorder, having experienced traumatic experiences involving significant others, the number of chronic diseases, and a comorbid diagnosis of substance use. Other studies also point to these factors, as well as higher levels of depressive mood and fewer years of education as potential risks of developing a SP 1 , 20 , 21 . Similarly, powerlessness, loss of control, and the lack of perceived control (strongly linked to one’s desire for control) and, consequently, the excessiveness of worry have long been associated with SPs 22 , 23 , 24 . It has also been shown 25 , 26 , 27 that SPs are associated with emotion dysregulation problems (e.g., using putatively maladaptive emotion regulation strategies, such as rumination). Yet, past studies have not sought to answer the question of whether these risk factors are transdiagnostic for all SPs or whether there is a specific pattern unique to each subtype.

The factors that increase the likelihood of reaching an excessive level of fear, and potentially the development of phobia, might vary across SP subtypes. There is great variability in the prevalence of SP subtypes which might indicate that besides the universal risk factors, there are subtype-specific ones as well. The key stimulus element that triggers the fear response greatly varies across SPs 28 . Consequently, there are overlaps but also unique characteristics of each SP in terms of the connected risk factors 28 . In fact, as part of the Netherlands Mental Health Survey and Incidence Study, it has been shown 17 that the likelihood of impairment, comorbidity, and personality problems also greatly vary across SP subtypes. Similarly, there is evidence that a phobia-specific pattern exists in the putatively adaptive and maladaptive cognitive ER strategies 25 . Further, neurological evidence shows that viewing various phobia-relevant objects results in a different activation pattern 23 , 29 , 30 , 31 , 32 , 33 , which also points to the direction that SP subtypes might be more different than previously thought. These results together underscore that there might be differences in the socio-demographic, cognitive emotion regulatory, and personality factors behind various SPs. Mapping the underlying transdiagnostic and unique factors for each SP can be crucial for an effective intervention therapy and may also increase the efficiency of prevention to deal with SPs.

The overarching goal of this study was twofold. First, we sought to test the SPQ in a large sample of community-dwelling adults, describe the prevalence of SP subtypes, and help establish standard scores. Second, we wanted to explore the unique and transdiagnostic risk and protective factors across SP subtypes associated with the level of fear and the interference this fear causes. We hypothesized that some factors, such as younger age, female gender, more previous traumatic life events, depressive mood, emotion dysregulation, and worry will be associated with higher rates of fear and interference. However, we also predicted that each SP subtype will have a unique pattern of associated risk factors concerning the cognitive ER strategies involved and other, perceived control-related components. To our knowledge, to this date, this is the only study to separately investigate risk and protective factors in various SP subtypes. Our results may assist counselors, social workers, and other health professionals in identifying individuals who might be at risk of developing an SP. Applications of these findings are pertinent for both prevention and intervention strategies.

Participants

We used two separate samples in this study. The first sample was used to test the psychometric properties of the SPQ and for descriptive analysis to estimate the prevalence of the five SP subtypes. For the first sample, we recruited 685 Caucasian participants (447 females), aged 18–85 years (M = 29.1, SD = 12.8). Here, we wanted to reach a large number of respondents to have a large enough sample for the descriptive analysis. For statistical purposes, we intended to increase the number of respondents by limiting the test battery to questions regarding age, gender, and the SPQ.

Then, we sought to test which sociodemographic, life history, cognitive emotion regulation, and personality-related factors play a key role in the development and maintenance of fears related to different SP subtypes. The second sample comprised 432 Caucasian participants (347 females), aged 18–67 years (M = 26.5, SD = 9.46). Here, the required sample size was determined by computing estimated statistical power with a conservative approach (f 2  = 0.10, β > 0.95, alpha = 0.05) using G*Power 3 software 34 . The analysis indicated a required minimum sample size of 373; thus, our study was adequately powered. Table 1 shows the central tendencies of the questionnaires and more details about the sample.

All participants were recruited through the Internet by posting invitations on various forums and mailing lists to obtain a non-clinical heterogeneous sample. Our goal was to obtain a heterogeneous sample representing people from a variety of demographic, socio-economic, and educational backgrounds. Table 1 shows the central tendencies of the questionnaires and more details about the samples. None of the respondents reported having been diagnosed with a specific phobia by a clinician or psychiatrist. Subjects participated voluntarily. The research was approved by the Hungarian United Ethical Review Committee for Research in Psychology and was carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki). Informed and written consent was obtained from all participants.

Questionnaires

Socio-demographic questions.

Socio-demographic questions were based on the results of a previous large-scale representative study on specific phobias 19 and included age, gender, marital status, the highest level of education, the number of personally experienced traumatic and violent life experiences, witnessed traumatic life experiences, the number of chronic diseases, smoker status, alcohol, marijuana, and other substance consumption habits, diagnosis of substance abuse disorder and major depressive disorder. These questions were selected because they emerged as significant predictors of phobias.

Specific phobia questionnaire (SPQ)

The SPQ measures the five subtypes of specific phobias with 43 items 16 . Each item is evaluated on two 5-point Likert-type scales (0—None to 4—Extreme) Fear and Interference. The Fear scales measure how fearful the respondent is of each situation, while the Interference scales measure how much the respondent’s fear interferes with their lives. The McDonald’s omegas for the Fear and Interference scales (respectively) were 0.78 and 0.84 (animals), 0.77 and 0.82 (natural environment), 0.77 and 0.78 (situational), 0.92 and 0.93 (blood-injection-injury). The Spearman–Brown coefficients for the other subscale were 0.50 and 0.65. The reason behind the lower reliability value of the other subscale is presumably due to the fact that it only consists of two items (Pearson r = 0.33 and 0.49).

All of the participants filled out the Hungarian language versions of the scales. The process of translation and adaptation of the instruments followed the recommendations of the American Psychiatric Association 8 . First, the original version of the questionnaire was given to two psychologists, both of whom were fluent in English, to translate the SPQ into Hungarian. Then, a third person, an expert in test development, was asked to compare the two versions and merge them into one to avoid any discrepancies and mistranslations. Subsequently, a person with a Master’s degree in psychology who is fluent in English translated this version back into English. Thereafter, an expert panel consisting of researchers in psychology as well as a native English speaker reviewed the back-translated version. They revised and corrected the Hungarian version to make it as close as possible in meaning to the original SPQ. We did not change any aspect of the original scale.

Cognitive emotion regulation questionnaire (CERQ)

The 18-item version of the CERQ 35 , 36 measures cognitive strategies that characterize the individual’s style of responding to stressful events. The questionnaire has 9 subscales in total, four subscales measure putatively maladaptive strategies (Self-blame, Rumination, Catastrophizing, and Other blame), and five measure putatively adaptive strategies (Acceptance, Positive refocusing, Refocus on planning, Positive reappraisal, and Putting into perspective). Items are measured on 5-point Likert scales (1—almost never to 5—almost always). Higher scores indicate that a person uses the given strategy more often. The McDonald’s omegas were 0.77 (self-blame), 0.86 (rumination), 0.81 (catastrophizing), 0.63 (other blame), 0.84 (acceptance), 0.85 (positive refocusing), 0.63 (refocus on planning), 0.74 (positive reappraisal), and 0.79 (putting into perspective).

Desirability of control

To measure the level of motivation to control the events in one's life we used the Desirability of Control questionnaire (DSC) 37 . The questionnaire is a one-scale tool comprising 20 items. Items are rated on 7-point Likert-type scales (1—doesn’t apply to me to 7—always applies to me). Higher scores indicate a stronger desirability of control. The McDonald’s omega was 0.83.

Perceived emotional control

The short, 15-item version of the Anxiety Control Questionnaire (ACQ) was used to assess three facets of perceived control: Emotion Control, Threat Control, and Stress Control 38 . Items are rated on 6-point Likert-type scales (0—strongly disagree to 5—strongly agree). Higher scores indicate a higher level of perceived control. The McDonald’s omegas were 0.79 (emotion control), 0.76 (threat control), and 0.72 (stress control).

The 6-item short version of the Beck Depression Inventory (BDI) was used to measure depressive mood 39 . Items were presented on 4-point scales, similarly to the original 21-item version. Higher scores suggest increased depressive symptomatology. The McDonald’s omega was 0.77.

The brief, 5-item version of the Penn State Worry Questionnaire (PWSQ) was used to measure the tendency, intensity, and uncontrollability of worry 40 . Items are rated on 5-point Likert-type scales (1—not at all typical of me to 5—very typical of me). Higher scores indicate a higher propensity to worry. The McDonald’s omega was 0.84.

Statistical analyses

There were no missing data because the answer was made mandatory for each question in the online surveys. We did not find any indicators of bot responses, and we did not expect to see any because participants completed all surveys voluntarily and in no instance were given any compensation. We sought for outliers who were ± 3 SDs away from the mean but we found none (which is justified by the large sample size). We also sought duplicate responses and identified four in the first sample; these were removed before the data analysis. We used Jamovi statistical software version 2.3 41 for the data analysis.

Before addressing the first objective of the study, we wanted to demonstrate that the factor structure of the SPQ suggested by the original authors is valid on an independent sample. Thus, we started by testing the five-factor model (separately for fear and interference) suggested by previous studies with confirmatory factor analysis on the first sample. We used the diagonally weighted least squares (DWLS) estimator. To assess model fit, we used the comparative fit index (CFI), the Tucker–Lewis index (TLI), the Parsimony Normed Fit Index (PNFI), the root mean square error of approximation (RMSEA), and the standardized root mean squared residual index (SRMR). The cutoffs for good model fit were CFI and TLI values of 0.95 or greater 42 , PNFI value of 0.8 or greater 43 , RMSEA and SRMR values of 0.08 or lower 44 . McDonald’s omega values were also calculated to assess the reliability of the scales.

Then moving on to the first objective of the study, using the first sample, we then examined our sample with respect to the cut-off scores suggested by the developers of SPQ 16 to report the prevalence of each SP subtype. After this, gender differences were examined using a pairwise comparison with Student’s t-test, and the possible effects of age were investigated using Pearson correlation analysis. Where normality was violated (i.e., he absolute values of Skewness and Kurtosis were greater than 2), robust alternatives (i.e., Mann–Whitney test and Spearman correlation) were used. Regarding the comparison of effect sizes between parametric and nonparametric tests the guidelines by Cohen may serve as a good basis 45 . Pearson and Spearman correlations may be interpreted along the same guidelines, i.e., an r value between 0.2 and 0.5 refers to medium effect size. For Cohen’s d (Student t test) the range of medium effect is 0.5–0.8., while for the rank biserial correlation (Mann–Whitney test) the medium effect size is 0.4–0.8. Values below can be considered small effect sizes and values above can be considered large effect sizes.

Then to address our second objective, on the second sample, we used General Linear Modelling (GLM) to explore the socio-demographic factors, cognitive emotion regulation strategies, and personality-related questionnaires that are significant predictors of SPQ subscale scores. We used the five Fear and five Interference SPQ scores as the dependent variables in separate models. For each dependent variable, we tested three models. In Model 1 we tested the effects of socio-demographic variables, therefore the independent predictors were age, gender, marital status, and the level of education, the predictors were the number of personally experienced traumatic and violent life experiences, witnessed traumatic life experiences, the number of chronic diseases, smoker status, alcohol, marijuana, and other substance consumption habits, diagnosis of substance abuse disorder and major depressive disorder. In Model 2 we tested the effects of cognitive ER strategies, thus the predictors were the nine CERQ subscales. Finally, in Model 3 we tested personality-related factors, so the predictors were the DSC, three ACQ subscales, BDI, and PWSQ scores. The assumption of normality was not violated. The absolute values of Skewness and Kurtosis were less than 2 for all SPQ Fear subscales. We used Box-Cox transformation (lambda = 0.5) on the Interference subscales to achieve normal distribution. Statistical results will be presented in tables instead of in the text to make the description of the results easier to follow and more understandable.

Ethical approval

Ethics approval was obtained from the Hungarian United Ethical Review Committee for Research in Psychology.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Factor structure and descriptive analysis

The two, five-factor structure of the SPQ showed acceptable fit for the Fear (X 2 (830) = 4366.216, p < 0.001, CFI = 0.991 TLI = 0.991, PNFI = 0.935, RMSEA = 0.062 [90% CI: 0.060–0.064], SRMR = 0.052) and the Interference subscales (X 2 (850) = 6566.073, p < 0.001, CFI = 0.994 TLI = 0.994, PNFI = 0.909, RMSEA = 0.078 [90% CI: 0.076–0.080], SRMR = 0.048). Factor loadings for the Fear scale ranged between 0.623 and 0.835 and between 0.734 and 0.906 for the Interference scale. Figure  1 shows the distribution of answers on the sample.

Percentage distribution of responses (no, mild, moderate, severe, extreme fear/interference) on the two subscales (Fear and Interference) of the Specific Phobia Questionnaire (SPQ). The left panel with the brown-yellow scale indicates the distribution of responses to the Fear subscale, where brown is no fear and yellow is extreme fear. The right panel with the blue-yellow scale indicates the distribution of responses to the Interference subscale, where blue is no fear and yellow is extreme fear. Corresponding items of the questionnaire are displayed in the middle.

The score corresponding to the 95th percentile on a given questionnaire is often considered a clinically significant limit 46 , 47 , 48 , 49 . Table 2 shows the 95th percentile scores separately for subscales and total score on the Fear and Interference scales as well as the number and percentage of participants who reached this score separately for males and females.

Further, based on the cut-off point suggested by the authors of the original questionnaire a large portion of the respondents could be considered at risk of having an SP. The prevalence values range from 12 to 60%. The exact cut-off values for the Fear and Interference subscales and the number and percentage of participants at risk of SP are shown in Table 2 .

Further analysis revealed systematic gender differences: females scored higher than males on all subscales both on the Fear scale and the Interference scale. Detailed statistical results are displayed in Table 3 . Regarding the relationship between SPQ and age, the Spearman correlation (controlled for gender differences) revealed significant but weak positive correlations for all the Interference scores (range 0.09–0.15), while we found no significant results for the Fear scale. The exact correlational values are displayed in Table 3 .

General linear models

We began by examining which socio-demographic factors, ER strategies, and personality-related questionnaires predict the five SPQ subscale scores regarding fear levels. The negative predictors may be considered protective factors because they are associated with lower levels of fear, in contrast, positive predictors can be considered risk factors as these variables are associated with higher levels of fear. Detailed statistical results, including model fit, and individual variable effects are presented in Supplementary material S1 regarding the five Fear subscales of SPQ.

For the Animals subtype , we found that age and perceived higher threat control were negative predictors, while female gender, depression diagnosis, a higher number of chronic diseases, using rumination, positive refocusing, and blaming others as ER strategies more often, and higher levels of worrying were all positive predictors.

Regarding the Environmental subtype, the significant negative predictors were more frequent alcohol consumption, using refocus on planning to regulate emotions, and perceived higher threat control; positive predictors were using rumination, positive refocusing, catastrophizing as ER strategies, higher BDI score, and worrying.

For the Situational subtype, we found that fear was negatively predicted by age and more frequent alcohol consumption, while it was positively predicted by female gender, more traumatic experiences, ruminating and using positive refocusing more often, and worrying.

For the BII subtype, the significant negative predictors were age and more frequent marijuana consumption, while positive predictors were female gender, ruminating and catastrophizing more often, and using positive refocusing to regulate emotions.

Finally, regarding the other subtype, scores were negatively associated with age, higher levels of education, more frequent alcohol and marijuana consumption, and higher levels of perceived stress control. Scores were positively associated with the female gender, ruminating and catastrophizing more often, and worrying.

In sum, it appears that some factors, such as age, gender, alcohol or marijuana consumption, a tendency to ruminate, use positive refocusing, and worry emerge as transdiagnostic factors appearing as significant predictors in nearly all subtypes. However, each subtype has a unique pattern that includes other significant predictors as well, namely depression diagnosis, chronic diseases and blaming others in animal phobias, refocus on planning and depressive mood in environmental phobias, traumatic experience in situational phobias, level of education and stress control in the other subtype.

Interference

We, then also investigated the effects of perceived interference of fears with the socio-demographic factors, ER strategies, and personality-related questionnaires as predictor variables. Again, negative predictors can be considered protective factors because they are associated with lower levels of interference; while positive predictors may be considered risk factors as they are associated with higher levels of interference. Supplementary material S2 shows the detailed statistical results, including model fit, and individual variable effects regarding the five Interference subscales of SPQ.

Regarding the Animal subtype, we found that education and using refocus on planning to regulate emotions emerged as significant negative predictors, while the female gender, using rumination, positive refocusing, and catastrophizing as ER strategies were positive predictors.

Regarding the Environmental subtype, significant negative predictors were education, more frequent alcohol consumption, using refocus on planning to regulate emotions, and higher perceived threat control. Positive predictors were using self-blame, positive refocusing, catastrophizing ER strategies, and depressive mood.

For the Situational subtype, we found that the interference was negatively predicted by education, more frequent alcohol consumption, and using acceptance to regulate emotions; while it was positively predicted by the female gender, higher number of chronic diseases, ruminating and catastrophizing more often and using putting into perspective to regulate emotions, depressive mood, and worrying.

For the BII subtype, the significant negative predictors were more frequent marijuana consumption, the use of acceptance, and refocus on planning ER strategies; while positive predictors were ruminating and catastrophizing and using refocus on planning and putting into perspective to regulate emotions.

Finally, regarding the other subtype, education, the use of acceptance to regulate emotions, and higher perceived stress control were identified as significant negative predictors, while the number of chronic diseases, catastrophizing, and worrying were positive predictors.

To sum up, we, again found some factors that emerged as transdiagnostic factors across all SP subtypes (e.g., education, a tendency to catastrophize the event); but also found several factors that seem to be subtype-specific. For instance, female gender in animal and situational phobia, self-blame and threat control in environmental phobia, marijuana consumption in BII phobia, and stress control in the other subtype.

Although SP is the most common mental disorder with a 7.4–14% lifetime prevalence and a cumulative incidence of 27% 1 , 2 , 3 , it often goes undiagnosed and untreated for a long time, possibly due to the lack of an appropriate screening tool 12 . The SPQ 16 offers a quick and reliable way to screen fears and associated interference on the five subtypes of SP; and is capable of identifying those at risk of either SP subtype. Therefore, the first goal of the present study was to examine the reliability of the SPQ in a large sample of community-dwelling adults and describe the prevalence of SP subtypes. Our results have shown that the questionnaire has sound psychometric properties and can be used in a different culture than it was developed. The results and prevalence values are similar to those of the original study. Compared to past studies 1 , 2 that used diagnostic interviews and trained personnel for data collection, the number of phobic individuals in our sample differs significantly when the cut-off points suggested by the authors are applied. In our sample, the 5 subtypes (based on fear score) varied between 12.3 and 60.3%. Here, animal phobia had a prevalence of 48.9%, compared to 3.8% in the study by Wardenaar et al. (2017). There was also a large difference regarding Situational (60.3% vs. 6.3%), BII (24.2% vs. 3.0%), and Environmental (15.3% vs. 2.3%) phobias between our and Wardenaar et al.’s study. The large differences may be partially due to the fact that the SPQ questionnaire, based on the cut-off points suggested, is not a diagnostic tool but rather a screening tool for the early identification of those at risk of SP. A higher score in this case indicates more susceptibility to these types of fears. In this way, the questionnaire can help to identify the groups most at risk of such fears, who can then be interviewed by a clinician and given appropriate help. A possible solution could be using the 95th percentile scores demonstrated in the present study as cut-offs in future research. In sum, our results provide further evidence that screening for SPs is important as it may help identify people at an early, subclinical stage where prevention can be more successful and easier than after the development of a disorder. Moreover, we have provided further evidence that SPQ is a reliable screening tool.

We sought to explore the transdiagnostic risk and protective factors across SP subtypes associated with the level of fear and the interference this fear causes as still little is known about the socio-demographic, cognitive emotion regulatory, and personality risk factors related to the development of these disorders. As expected, the factors associated with higher fear were younger age, female gender, rumination, positive refocusing, and worrying; while female gender, fewer years of education, and catastrophizing were associated with interference. Regarding gender and age, we found that females scored higher than males across all SP subtypes and had a weak negative correlation with age. These results are in line with previous studies showing a similar gender and age effect 2 , 50 , 51 , 52 as well as the fact that females compared to males are more likely to be diagnosed with SP 53 , 54 . This is also in line with the results of past studies 1 , 16 , 20 , 21 , 23 , 25 , 55 and suggests the notion that there are shared factors across SP subtypes. The fact that the prevalence and intensity of most phobias tend to decrease with age 56 and that females are at higher risk of developing an SP is well-established 57 . Similarly, emotion dysregulation is strongly associated with SPs and anxiety disorders as they can augment fears 58 , 59 , 60 . Focusing on negative emotions and failing to appropriately regulate emotions can increase worrying 61 , 62 , enhancing symptoms of anxiety 63 , therefore, augmenting everyday life interference. Our result suggests that positive refocusing, a putatively adaptive ER strategy also augments fears. Although an ER strategy may not inherently be either adaptive or maladaptive, this association may still seem contradictory. However, recent evidence 64 , 65 showed that adaptive ER strategies, if not used properly, may be associated with lower well-being and life satisfaction. Using positive refocusing means that the person thinks about positive, happy, and pleasant experiences instead of about current negative events 66 . A possible explanation behind our result is that positive refocusing might appear as an avoidance strategy in the case of phobias. Avoidance, in any form, is not an adaptive behavior insofar as it enhances fear 67 and was associated with psychopathology 65 .

We also wanted to investigate the unique pattern of risk factors associated with SPs, as there is great variability in prevalence 2 , stimulus element triggering fear 28 , the likelihood of impairment, comorbidity, and personality problems 17 , cognitive ER strategies 25 and brain activation pattern 23 , 29 , 30 of SP subtypes. As expected, our results clearly show that each SP subtype has a different pattern of associated factors; further, some factors only appear for one subtype and not for the others. Regarding animal fears, depression diagnosis, chronic diseases, blaming others, and threat control, while for the interference animal fears female gender seem to be critical phobia-specific factors. Although threat control appears for the Environmental subtype (fear) and female gender for the Situational subtype (interference). This is in line with previous studies showing gender differences in Animal phobia 47 , 51 , 52 . Further, a more restricted lifestyle and potential lack of social connections may also be associated with higher levels of fear and perceived interference 19 , 68 , which might also be the reason behind the slight overlap between Animal and environmental subtypes 69 . For the Environmental subtype, besides threat control, refocus on planning and depressive mood (fear), and self-blame were the unique factors. Environmental phobias comprise events and situations that can be foreseen and predicted and would not be possible to meet without the person approaching them. This might explain why one might blame oneself for the occurrence of an unfortunate event during a particular natural environment (e.g., water, heights) and highlights why planning and preparation can be a good coping mechanism. However, future studies are necessary to uncover the background mechanisms as Environmental phobias are understudied. We found that for Situational phobia fear was associated with traumatic experiences, while interference was associated with chronic diseases and worrying. This is in line with previous studies showing that excessive fear especially in this subtype is often evoked by one traumatic event in the past 70 , 71 . Then, the anticipation of an inevitable encounter with the object of the fear will trigger worrying, which in turn will impact the maintenance of the fear response, and increase the interference of the fear 72 . The unique predictor we found for BII phobia was marijuana consumption, and it was a protective factor. Similar to alcohol consumption we expected this to be a risk factor 19 , yet it seems that a recreational or at least subclinical form of alcohol and marijuana use may reduce fears. On the one hand, this might be a side effect, i.e., the consumption of these substances may reduce the reactivity of the individuals as shown in PTSD 73 , resulting in lesser fear and, thus, interference. On the other hand, people with these fears may be more likely to turn to these substances as self-imposed treatment, which temporarily could lower the level of fear and interference 74 . Finally, regarding the Other subtype, we found that stress control and worrying were the unique factors supporting previous studies on vomiting and choking-related fears 75 , 76 .

Limitations of the study include that we used a cross-sectional design, instead of gathering longitudinal data. Future studies are needed to test if the risk and protective factors suggested here would be predictive of the development of a SP. Further, the majority of our sample consisted mostly of females who are, according to our results and previous studies more prone to develop an SP. While this means the results are true for an endangered group of people, our results might not be universally true for other genders. Finally, although we included a large number of variables in the study, there could be more factors that can help predict the development of an SP or distinguish between subtypes. For instance, we targeted cognitive, but not behavioral or interpersonal ER strategies; we included measures of depression and anxiety but not tolerance of uncertainty or PTSD. Consequently, future studies are needed to explore all probable predictive variables.

In sum, these limitations notwithstanding, our study is among the first ones to explore phobia-specific patterns in the risk and protective factors that contribute to the development and maintenance of SPs. Our results may assist counselors, social workers, and other health professionals to identify individuals who might be at risk of developing an SP, and developing personalized treatment regimens. Younger females seem and people with a tendency to worry seem to be the most affected by such fears. Applications of our findings are also pertinent for both prevention and intervention strategies. Cognitive-behavioral-based interventions could be used to discourage the use of ER strategies—such as rumination, catastrophizing, and positive refocusing—that heighten fear levels, and instead focus on increasing the level of perceived control, and teach ER strategies—refocus on planning, in particular—that could lessen fears and its interference. These can be complemented by the inclusion of various phobia-specific factors. To further understand the socio-demographic, emotional, and personality-based mechanisms underlying the different phobia subtypes, future research should use longitudinal methods as well as experimental paradigms along with physiological measures.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Kessler, R. C. et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch. Gen. Psychiatry 62 , 593–602 (2005).

Article   PubMed   Google Scholar  

Wardenaar, K. J. et al. The cross-national epidemiology of specific phobia in the world mental health surveys. Psychol. Med. 47 , 1744–1760 (2017).

Article   CAS   PubMed   PubMed Central   Google Scholar  

Salehi, M. et al. The lifetime prevalence, risk factors, and co-morbidities of specific phobia among pediatric population: A cross-sectional national survey. Clin. Med. Insights Psychiatry 13 , 117955732110705 (2022).

Article   Google Scholar  

LeDoux, J. E. & Pine, D. S. Using neuroscience to help understand fear and anxiety: A two-system framework. Am. J. Psychiatry 173 , 1083–1093 (2016).

Zsido, A. N., Csokasi, K., Vincze, O. & Coelho, C. M. The emergency reaction questionnaire—First steps towards a new method. Int. J. Disaster Risk Reduct. 49 , 101684 (2020).

Article   PubMed   PubMed Central   Google Scholar  

Klinger, D. Into the Kill Zone: A cop’s eye view of deadly force. J. POLICE Cris. Negot. 5 , 121–124 (2005).

Google Scholar  

Vögele, C. et al. Cognitive mediation of clinical improvement after intensive exposure therapy of agoraphobia and social phobia. Depress. Anxiety 27 , 294–301 (2010).

Article   ADS   PubMed   Google Scholar  

American Psychiatric Association. Diagnostic and statistical manual of mental disorders 5th edn. (Author, 2013).

Book   Google Scholar  

Coelho, C. M. & Purkis, H. The origins of specific phobias: Influential theories and current perspectives. Rev. Gen. Psychol. 13 , 335–348 (2009).

Field, A. P. & Purkis, H. M. The role of learning in the etiology of child and adolescent fear and anxiety. in Anxiety Disorders in Children and Adolescents, Second edition 227–256 (2011). https://doi.org/10.1017/CBO9780511994920.012 .

Coelho, C. M., Polák, J., Suttiwan, P. & Zsido, A. N. Fear inoculation among snake experts. BMC Psychiatry 21 , 1–8 (2021).

Kasper, S. Anxiety disorders: Under-diagnosed and insufficiently treated. Int. J. Psychiatr. Clin. Pract. 10 , 3–9 (2006).

Konnopka, A. & König, H. Economic burden of anxiety disorders: A systematic review and meta-analysis. PharmacoEconomics 38 , 25–37 (2020).

Kessler, R. C. & Greenberg, P. The economic burden of anxiety and stress disorders. in Neuropsychopharmacology: The Fifth Generation of Progress (eds. Davis, K. L., Charney, D., Nemeroff, J. T. & Coyle, C.) 981–992 (Williams and Wilkins, Philadelphia US, 2002).

Alonso, J. et al. Disability and quality of life impact of mental disorders in Europe: Results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr. Scand. Suppl. 109 , 38–46 (2004).

Ovanessian, M. M. et al. Psychometric properties and clinical utility of the specific phobia questionnaire in an anxiety disorders sample. J. Psychopathol. Behav. Assess. 41 , 36–52 (2019).

Depla, M. F. I. A., ten Have, M. L., van Balkom, A. J. L. M. & de Graaf, R. Specific fears and phobias in the general population: Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Soc. Psychiatry Psychiatr. Epidemiol. 43 , 200–208 (2008).

Oosterink, F. M. D., de Jongh, A. & Hoogstraten, J. Prevalence of dental fear and phobia relative to other fear and phobia subtypes. Eur. J. Oral Sci. 117 , 135–143 (2009).

Coelho, C. M., Gonçalves-Bradley, D. & Zsido, A. N. Who worries about specific phobias? A population-based study of risk factors. J. Psychiatr. Res. 126 , 67–72 (2020).

Blanco, C. et al. Risk factors for anxiety disorders: Common and specific effects in a national sample. Depress. Anxiety 31 , 756–764 (2014).

Maideen, S. F. K., Sidik, S. M., Rampal, L. & Mukhtar, F. Prevalence, associated factors and predictors of anxiety: A community survey in Selangor, Malaysia. BMC Psychiatry 15 , (2015).

Armfield, J. M. & Heaton, L. J. Management of fear and anxiety in the dental clinic: A review. Aust. Dental. J. 58 , 390–407 (2013).

Article   CAS   Google Scholar  

Abado, E., Aue, T. & Okon-Singer, H. Cognitive biases in blood-injection-injury phobia: A review. Front. Psychiatry 12 , 1158 (2021).

Gallagher, M. W., Bentley, K. H. & Barlow, D. H. Perceived control and vulnerability to anxiety disorders: A meta-analytic review. Cognit. Ther. Res. 38 , 571–584 (2014).

Zsido, A. N., Lang, A., Labadi, B. & Deak, A. Phobia-specific patterns of cognitive emotion regulation strategies. Sci. Rep. (2023).

Hermann, A. et al. Emotion regulation in spider phobia: Role of the medial prefrontal cortex. Soc. Cogn. Affect. Neurosci. 4 , 257–267 (2009).

Cisler, J. M., Olatunji, B. O. & Lohr, J. M. Disgust sensitivity and emotion regulation potentiate the effect of disgust propensity on spider fear, blood-injection-injury fear, and contamination fear. J. Behav. Ther. Exp. Psychiatry 40 , 219–229 (2009).

Coelho, C. M., Araújo, A. S., Suttiwan, P. & Andras N. Zsido. An ethologically based view into human fear. Neurosci. Biobehav. Rev. 154 , 105017 (2022).

Lueken, U. et al. How specific is specific phobia? Different neural response patterns in two subtypes of specific phobia. Neuroimage 56 , 363–372 (2011).

Hilbert, K., Evens, R., Isabel Maslowski, N., Wittchen, H. U. & Lueken, U. Neurostructural correlates of two subtypes of specific phobia: A voxel-based morphometry study. Psychiatry Res. Neuroimaging 231 , 168–175 (2015).

Del Casale, A. et al. Functional neuroimaging in specific phobia. Psychiatry Res. Neuroimaging 202 , 181–197 (2012).

Caseras, X. et al. The functional neuroanatomy of blood-injection-injury phobia: A comparison with spider phobics and healthy controls. Psychol. Med. 40 , 125–134 (2010).

Article   CAS   PubMed   Google Scholar  

Caseras, X. et al. Dynamics of brain responses to phobic-related stimulation in specific phobia subtypes. Eur. J. Neurosci. 32 , 1414–1422 (2010).

Faul, F., Erdfelder, E., Lang, A.-G. & Buchner, A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav. Res. Methods 39 , 175–191 (2007).

Garnefski, N. & Kraaij, V. Cognitive emotion regulation questionnaire—development of a short 18-item version (CERQ-short). Pers. Individ. Dif. 41 , 1045–1053 (2006).

Miklósi, M., Martos, T., Kocsis-Bogár, K. & Perczel-Forintos, D. A Kognitív Érzelem-Reguláció Kérdőív magyar változatának pszichometriai jellemzői. Psychiatr. Hungarica 26 , 102–111 (2011).

Burger, J. M. & Cooper, H. M. The desirability of control. Motiv. Emot. 3 , 381–393 (1979).

Brown, T. A., White, K. S., Forsyth, J. P. & Barlow, D. H. The structure of perceived emotional control: Psychometric properties of a revised anxiety control questionnaire. Behav. Ther. 35 , 75–99 (2004).

Blom, E. H., Bech, P., Högberg, G., Larsson, J. O. & Serlachius, E. Screening for depressed mood in an adolescent psychiatric context by brief self-assessment scales—testing psychometric validity of WHO-5 and BDI-6 indices by latent trait analyses. Health Qual. Life Outcomes 10 , 1–6 (2012).

Topper, M., Emmelkamp, P. M. G., Watkins, E. & Ehring, T. Development and assessment of brief versions of the Penn State Worry Questionnaire and the Ruminative Response Scale. Br. J. Clin. Psychol. 53 , 402–421 (2014).

Jamovi Project. Jamovi. (2022).

Hu, L. & Bentler, P. M. Fit indices in covariance structure modeling: Sensitivity to underparameterized model misspecification. Psychol. Methods 3 , 424–453 (1998).

Byrne, B. M. Structural Equation Modeling with Mplus . Structural Equation Modeling with Mplus (Routledge, 2013). https://doi.org/10.4324/9780203807644 .

Browne, M. W. & Cudeck, R. Alternative ways of assessing model fit. Sociol. Methods Res. 21 , 230–258 (1992).

Cohen, J. A power primer. Psychol. Bull. 112 , 155–159 (1992).

Crawford, J. R. & Garthwaite, P. H. Percentiles please: The case for expressing neuropsychological test scores and accompanying confidence limits as percentile ranks. Clin. Neuropsychol. 23 , 193–204 (2009).

Polák, J., Sedláčková, K., Nácar, D., Landová, E. & Frynta, D. Fear the serpent: A psychometric study of snake phobia. Psychiatry Res. 242 , 163–168 (2016).

Mollema, E. D., Snoek, F. J., Pouwer, F., Heine, R. J. & Van Der Ploeg, H. M. Diabetes fear of injecting and self-testing questionnaire: A pschometric evaluation. Diabetes Care 23 , 765–769 (2000).

Clinical and Laboratory Standards Institute. C28-a3c. Defining, establishing and verifying reference intervals in the clinical laboratory; approved guideline, third edition . (2008).

Zsido, A. N. The spider and the snake—A psychometric study of two phobias and insights from the Hungarian validation. Psychiatry Res. 257 , 61–66 (2017).

Zsido, A. N., Arato, N., Inhof, O., Janszky, J. & Darnai, G. Short versions of two specific phobia measures: The snake and the spider questionnaires. J. Anxiety Disord. 54 , (2018).

Fredrikson, M., Annas, P., Fischer, H. & Wik, G. Gender and age differences in the prevalence of specific fears and phobias. Behav. Res. Ther. 34 , 33–39 (1996).

LeBeau, R. T. et al. Specific phobia: A review of DSM-IV specific phobia and preliminary recommendations for DSM-V. Depress. Anxiety 27 , 148–167 (2010).

Wittchen, H. U., Stein, M. B. & Kessler, R. C. Social fears and social phobia in a community sample of adolescents and young adults: Prevalence, risk factors and co-morbidity. Psychol. Med. 29 , 309–323 (1999).

Zsido, A. N., Coelho, C. M. & Polák, J. Nature relatedness: A protective factor for snake and spider fears and phobias. People Nat. https://doi.org/10.1002/pan3.10303 (2022).

Coelho, C. M. et al. Specific phobias in older adults: Characteristics and differential diagnosis. Int. Psychogeriatr. 22 , 702–711 (2010).

Eaton, W. W., Bienvenu, O. J. & Miloyan, B. Specific phobias. The Lancet Psychiatry 5 , 678–686 (2018).

Mennin, D. S., McLaughlin, K. A. & Flanagan, T. J. Emotion regulation deficits in generalized anxiety disorder, social anxiety disorder, and their co-occurrence. J. Anxiety Disord. 23 , 866–871 (2009).

Dryman, M. T. & Heimberg, R. G. Emotion regulation in social anxiety and depression: A systematic review of expressive suppression and cognitive reappraisal. Clin. Psychol. Rev. 65 , 17–42 (2018).

Cisler, J. M., Olatunji, B. O., Feldner, M. T. & Forsyth, J. P. Emotion regulation and the anxiety disorders: An integrative review. J. Psychopathol. Behav. Assess. 32 , 68–82 (2010).

Evans, S., Alkan, E., Bhangoo, J. K., Tenenbaum, H. & Ng-Knight, T. Effects of the COVID-19 lockdown on mental health, wellbeing, sleep, and alcohol use in a UK student sample. Psychiatry Res. 298 , 113819 (2021).

Ouellet, C., Langlois, F., Provencher, M. D. & Gosselin, P. Intolerance of uncertainty and difficulties in emotion regulation: Proposal for an integrative model of generalized anxiety disorder. Rev. Eur. Psychol. Appl. 69 , 9–18 (2019).

Jaso, B. A., Hudiburgh, S. E., Heller, A. S. & Timpano, K. R. The relationship between affect intolerance, maladaptive emotion regulation, and psychological symptoms. Int. J. Cogn. Ther. 13 , 67–82 (2020).

Elkjær, E., Mikkelsen, M. B. & O’Toole, M. S. Emotion regulation patterns: Capturing variability and flexibility in emotion regulation in an experience sampling study. Scand. J. Psychol. 63 , 297–307 (2022).

Kalokerinos, E. K., Erbas, Y., Ceulemans, E. & Kuppens, P. Differentiate to regulate: Low negative emotion differentiation is associated with ineffective use but not selection of emotion-regulation strategies. Psychol. Sci. 30 , 863–879 (2019).

Kraaij, V. & Garnefski, N. The Behavioral Emotion Regulation Questionnaire: Development, psychometric properties and relationships with emotional problems and the cognitive emotion regulation questionnaire. Pers. Individ. Dif. 137 , 56–61 (2019).

Schlund, M. W. et al. Renewal of fear and avoidance in humans to escalating threat: Implications for translational research on anxiety disorders. J. Exp. Anal. Behav. 113 , 153–171 (2020).

Patuano, A. Biophobia and urban restorativeness. Sustainability (Switzerland) 12 , 4312 (2020).

Choi, Y. H., Jang, D. P., Ku, J. H., Shin, M. B. & Kim, S. I. Short-term treatment of acrophobia with virtual reality therapy (VRT): A case report. Cyberpsychol. Behav. 4 , 349–354 (2001).

Wilhelm, F. H. & Roth, W. T. Clinical characteristics of flight phobia. J. Anxiety Disord. 11 , 241–261 (1997).

Taylor, J., Deane, F. & Podd, J. Driving-related fear: A review. Clin. Psychol. Rev. 22 , 631–645 (2002).

Clark, G. I. & Rock, A. J. Processes contributing to the maintenance of flying phobia: A narrative review. Front. Psychol. 7 , 754 (2016).

Tull, M. T., McDermott, M. J. & Gratz, K. L. Marijuana dependence moderates the effect of posttraumatic stress disorder on trauma cue reactivity in substance dependent patients. Drug Alcohol Depend. 159 , 219–226 (2016).

Flory, K., Lynam, D., Milich, R., Leukefeld, C. & Clayton, R. The relations among personality, symptoms of alcohol and marijuana abuse, and symptoms of comorbid psychopathology: Results from a community sample. Exp. Clin. Psychopharmacol. 10 , 425–434 (2002).

Simons, M. & Vloet, T. D. Emetophobia - A metacognitive therapeutic approach for an overlooked disorder. Zeitschrift fur Kinder- und Jugendpsychiatrie und Psychotherapie 46 , 57–66 (2018).

van Overveld, M., de Jong, P. J., Peters, M. L., van Hout, W. J. P. J. & Bouman, T. K. An internet-based study on the relation between disgust sensitivity and emetophobia. J. Anxiety Disord. 22 , 524–531 (2008).

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ANZS was supported by the ÚNKP-23-5, BLK and JB by the ÚNKP-23-3 New National Excellence Program of the Ministry for Innovation and Technology from the source of the National Research, Development and Innovation Fund. ANZS was also supported by OTKA PD 137588 research grant. BLK, JB, and BB also received support from OTKA K 143254 research grant. ANZS and BB was also supported by the János Bolyai Research Scholarship provided by the Hungarian Academy of Sciences. CMC was supported by the Center for Psychology at the University of Porto, Foundation for Science and Technology Portugal (FCT UIDB/00050/2020).

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Conceptualization: A.N.Z.S., C.M.C.; methodology: A.N.Z.S., C.M.C.; formal analysis: A.N.Z.S., B.L.K., J.B.; data preparation: B.L.K., J.B.; writing—original draft: A.N.Z.S., B.L.K., J.B.; visualization: B.L.K., J.B.; supervision: A.N.Z.S., B.B., C.M.C.; project administration: A.N.Z.S., B.B.; funding acquisition: A.N.Z.S., B.L.K., J.B., B.B., C.M.C.; writing—review and editing: A.N.Z.S., B.L.K., J.B., B.B., C.M.C.

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Zsido, A.N., Kiss, B.L., Basler, J. et al. Key factors behind various specific phobia subtypes. Sci Rep 13 , 22281 (2023). https://doi.org/10.1038/s41598-023-49691-0

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Research Findings on the Genetics of Phobias

Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.

Phobias are extreme fears that make it impossible to function normally. Phobias may grow out of really negative experiences, but because they are overwhelming and often irrational, they become disabling. There are many different types of phobias; some of the most common include:

• Fear of specific animals (dogs, spiders, etc.)
• Fear of open spaces, enclosed space, or high places
• Fear of natural events, such as thunderstorms

While fears are an unavoidable part of being human, most fears can be controlled and managed. Phobias, however, cause psychological and physical reactions that are difficult if not impossible to manage. As a result, people with phobias will go to great lengths to avoid the object of their fears.

What Causes Phobias?

Why does someone react to a normal, everyday event — the bark of a dog, for example — with extreme fear and anxiety? Why do other people react to the same experience with mild anxiety or calm?​

The causes of phobias are not yet widely understood. Increasingly, however, research shows that genetics may play at least some role.

Studies show that twins who are raised separately have a higher than average rate of developing similar phobias. Other studies show that some phobias run in families, with first-degree relatives of phobia sufferers more likely to develop a phobia.

In “Untangling genetic networks of panic, phobia, fear, and anxiety,” Villafuerte and Burmeister reviewed several earlier studies in an attempt to determine what, if any, genetic causes can be identified for anxiety disorders.

Family Studies Suggest a Genetic Link

If a family member has a phobia, you are at an increased risk for a phobia as well.

In general, relatives of someone with a specific anxiety disorder are most likely to develop the same disorder. In the case of agoraphobia (fear of open spaces), however, first-degree relatives are also at increased risk for panic disorder, indicating a possible genetic link between agoraphobia and panic disorder .

Researchers have found that first-degree relatives of someone suffering from a phobia are approximately three times more likely to develop a phobia.

According to the findings, twin studies showed that when one twin has agoraphobia, the second twin has a 39% chance of developing the same phobia. When one twin has a specific phobia, the second twin has a 30% chance of also developing a specific phobia. This is much higher than the 10% chance of developing an anxiety disorder found in the general population.

Gene Isolation Suggests a Link Between Phobias and Panic Disorder

Although they were unable to specifically isolate the genetic causes of phobias, Villafuerte and Burmeister reviewed several studies that appear to demonstrate genetic anomalies in both mice and humans with anxiety disorders. The early research appears to show that agoraphobia is more closely linked to panic disorder than to the other phobias, but is far from conclusive.

More research will need to be performed in order to isolate the complex genetics involved in the development of phobias and other anxiety disorders. However, this study does support the theory that genetics play a major role.

• Villafuerte, Sandra and Burmeister, Margit. Untangling genetic networks of panic, phobia, fear and anxiety . Genome Biology . July 28, 2003. 4(8):224. 

By Lisa Fritscher Lisa Fritscher is a freelance writer and editor with a deep interest in phobias and other mental health topics.

January 1, 2014

Why Do We Develop Certain Irrational Phobias?

By Andrew Watts

Katherina K. Hauner , a postdoctoral fellow at the Northwestern University Feinberg School of Medicine, answers:

Under normal circumstances, fear triggers a natural fight-or-flight response that allows animals to react quickly to threats in their environment. Irrational and excessive fear, however, is typically a maladaptive response. In humans, an unwarranted, persistent fear of a certain situation or object, known as specific phobia, can cause overwhelming distress and interfere with daily life. Specific phobia is among the more prevalent anxiety disorders, affecting an estimated 9 percent of Americans within their lifetime. Common subtypes include fear of small animals, insects, flying, enclosed spaces, blood and needles.

For fear to escalate to irrational levels, a combination of genetic and environmental factors is very likely at play. Estimates of genetic contributions to specific phobia range from roughly 25 to 65 percent, although we do not know which genes have a leading part. No specific phobia gene has been identified, and it is highly unlikely that a single gene is responsible. Rather variants in several genes may predispose an individual to developing a number of psychological symptoms and disorders, including specific phobia.

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As for the environmental component, a person may develop a phobia after a particularly frightening event, especially if he or she feels out of control. Even witnessing or hearing about a traumatic occurrence can contribute to its development. For instance, watching a devastating airplane crash on the news may trigger a fear of flying. That said, discerning the origin of the disorder can be difficult because people tend to do a poor job of identifying the source of their fears.

Our understanding of how and why phobias crop up remains limited, but we have made great strides in abating them. Exposure therapy, a form of cognitive-behavior therapy, is widely accepted as the most effective treatment for anxieties and phobias, and the vast majority of patients complete treatment within 10 sessions. During exposure therapy, a person engages with the particular fear to help diminish and ultimately overcome it over time. An individual might, for example, look at a photograph of the dreaded object or become immersed in the situation he or she loathes. Fortunately for those plagued by irrational fears, we can treat a phobia rapidly and successfully without necessarily knowing its origin.

Articles on Phobias

Displaying 1 - 20 of 26 articles.

Biophobia: search trends reveal a growing fear of nature

Ricardo Correia , University of Helsinki and Stefano Mammola , University of Helsinki

Innies, outies and omphalophobia: 7 navel-gazing questions about belly buttons answered

Sarah Leupen , University of Maryland, Baltimore County

Why are we so scared of clowns? Here’s what we’ve discovered

Sophie Scorey , University of South Wales ; James Greville , University of South Wales ; Philip Tyson , University of South Wales , and Shakiela Davies , University of South Wales

Scared of needles? Claustrophobic? One longer session of exposure therapy could help as much as several short ones

Bronwyn Graham , UNSW Sydney and Sophie H Li , UNSW Sydney

CBT? DBT? Psychodynamic? What type of therapy is right for me?

Sourav Sengupta , University at Buffalo

Pictures of COVID injections can scare the pants off people with needle phobias. Use these instead

Holly Seale , UNSW Sydney and Jessica Kaufman , Murdoch Children's Research Institute

Tokophobia is an extreme fear of childbirth. Here’s how to recognise and treat it

Julie Jomeen , Southern Cross University ; Catriona Jones , University of Hull ; Claire Marshall , University of Hull , and Colin Martin , Southern Cross University

Spider home invasion season: why the media may be to blame for your arachnophobia

Mike Jeffries , Northumbria University, Newcastle

Fear can spread from person to person faster than the coronavirus – but there are ways to slow it down

Jacek Debiec , University of Michigan

Anxiety in autistic children – why rates are so high

Keren MacLennan , University of Reading

Curious Kids: where do phobias come from?

Lara Farrell , Griffith University

Fear of the dentist: what is dental phobia and dental anxiety?

Ellie Heidari , King's College London

Get ‘inspidered’ – from fear of spiders to fascination

Gerhard J. Gries , Simon Fraser University and Andreas Fischer , Simon Fraser University

You can’t ‘erase’ bad memories, but you can learn ways to cope with them

Carol Newall , Macquarie University and Rick Richardson , UNSW Sydney

Tokophobia: what it’s like to have a phobia of pregnancy and childbirth

Catriona Jones , University of Hull ; Franziska Wadephul , University of Hull , and Julie Jomeen , University of Hull

Health Check: why are some people afraid of heights?

Bek Boynton , James Cook University and Anne Swinbourne , James Cook University

How virtual reality spiders are helping people face their arachnophobia

Why are some people afraid of cats?

Sally Shuttleworth , University of Oxford

From creepy clowns to the dancing plague – when phobias are contagious

Clare Glennan , Cardiff Metropolitan University

Fear of death underlies most of our phobias

Lisa Iverach , University of Sydney ; Rachel E. Menzies , University of Sydney , and Ross Menzies , University of Sydney

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The new evidence that explains what anxiety really is

5 April 2024

Read: The New Scientist   

The One Big Thing You Can Do for Your Kids

The research shows that you probably have less effect on your kids than you think—with one big exception: Your love will make them happy.

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W hen one of my now-adult kids was in middle school, I had a small epiphany about parenting. I had been haranguing him constantly about his homework and grades, which were indeed a problem. One night, after an especially bad day, I was taking stock of the situation, and came to a realization: I didn’t actually care very much about his grades. What I wanted was for him to grow up to become a responsible, ethical, faithful, well-adjusted man. From that day forward, I stopped talking about his grades and started talking about values. It was a relief for both of us.

But then I got to wondering: If bugging him about grades didn’t change anything, why would talking about values make a difference? Did it really matter what I said about anything ?

If you have children—or plan to have them—you probably share my concerns. According to a survey last year by the Pew Research Center , the No. 1 desire of parents for their children (which 94 percent of those surveyed say is extremely or very important) is that their kids turn out to be honest and ethical. Meanwhile, the No. 1 worry (which 76 percent of parents said was extremely-to-somewhat worrisome) is that their kids might struggle with depression or anxiety. In short, we want them above all to be good and happy people.

But just wanting these things isn’t enough. How do we achieve these goals? This question is at least as ancient as human civilization. Should we talk about these things with our children a lot, or not? Be strict with them, or lax? Or perhaps everything is genetics anyway, so maybe we should just hope and pray for the best. Fortunately, recent research has offered ways to help answer some of these difficult questions—and make us better parents.

Arthur C. Brooks: The happy art of grandparenting

A foundational question about raising children revolves around nature versus nurture: how much of a child’s development is due to their genes rather than their upbringing. When I was a child, nurture theories had the upper hand. The common belief was that kids are a blank slate, or are nearly so, and that parenting is what really matters to mold who they will become as adults. Latterly, however, this view has been turned upside down, after study upon study has shown that a huge amount of personality is biological and inherited. For example, one 1996 study involving 123 pairs of identical twins (who share 100 percent of their genes) and 127 pairs of fraternal twins (who, like any other pair of siblings, share about 50 percent) estimated that 41 percent of neuroticism may be inherited, as well as 53 percent of extroversion, 61 percent of openness to experience, 41 percent of agreeableness, and 44 percent of conscientiousness.

You might be thinking that parenting may make up the other half or so, but that’s not seemingly the case. Researchers in 2021 examined over time the correlation between the personality traits of progeny and parenting measures, and found that, in most aspects, parenting mattered about as much as birth order—which is to say, its effect was little to none.

The exceptions were in two dimensions of personality: conscientiousness and agreeableness. Children were more conscientious when parents were more involved in their lives and worked to provide cultural stimulation (such as taking them to museums); and children were more agreeable when their parents raised them with more structure and goals.

Genetics also matter a great deal for children’s happiness. One study of fraternal and identical twins found that the genetic component discernible from analyzing the subjects’ various self-reported ratings of personality traits and life satisfaction was about 31 percent . In contrast with the possibly limited influence of parenting style on most personality traits, however, parental behavior does appear to significantly affect the roughly half of children’s happiness that may not be genetically determined. Specifically, one factor—parental warmth and affection, with slightly more weight to that of fathers—has been shown to make up about a third of “psychological adjustment” differences in their children, a holistic measure that includes markers of happiness.

Parenting involves both words and actions. Even if parents like to say to their children, usually with little effect, “Do what I say,” most parents come to notice that kids pay attention to everything their parents do , rather than what they say . And research backs up the idea that actions speak louder than words. For example, a 2001 study of parental religiosity among Catholics found that the behavior of a father (even more than the mother) who acts upon faith and is practicing will most affect the likelihood of his children growing up to be religious as well. Similarly, an investigation of substance use among adolescents discovered that among those who had tried alcohol, tobacco, or other drugs, 80 percent said their parents would say they disapproved of their teenager’s behavior, but 100 percent did not say explicitly that their parents abstained from substances—suggesting that these children likely had at least one parent who used them to a lesser or greater extent.

Listen: The right choices in parenting

T his tour through the research provides a set of parenting rules to act upon—one that I could very much have used when my kids were little. Better late than never, and I can still try to follow these rules now that I am a grandfather . Try them out and see if they make parenting easier and better for you. If your goal is virtue and happiness for your kids, keep these three things in mind.

1. Even a hot mess can be a good parent. It is easy to despair at being a parent—or to give yourself a pass—if you struggle with your own happiness or with a troublesome personality. I have heard many young adults say they’re afraid to have kids because they don’t want to pass on their own problems. True, much of your personality is transmitted to your offspring without your volition. As noted above, you may not be able to do much about their degree of extroversion, which seems largely a genetic given. But when it comes to conscientiousness and agreeableness (which, again, are what we really want for our children), parenting choices to be involved in their lives, and provide structure and goals, make a significant difference. And parenting does have a huge impact on their happiness.

2. When you don’t know what to do, be warm and loving. For happiness, the parenting technique that truly matters is warmth and affection. As my wife used to say when we were at wit’s end with our son, “I guess we should just love him.” This might sound like a hippie recipe for disaster, but it isn’t. Your kids don’t need a drill sergeant, Santa Claus, or a helicopter mom; they need someone who loves them unconditionally, and shows it even when the brats deserve it the least. Especially when they’re at their most brattish. Remember: That is what they will remember and give to your grandchildren (who will never be brats) when they themselves become parents.

3. Be the person you want your kids to become. The data don’t lie, but as parents we do . Kids—who are walking BS-detectors—always notice when we say one thing and do another. Of course, deciding how to act to create the right example for them to follow isn’t always easy. A good rule of thumb is to ask yourself how you’d like your son or daughter to behave as an adult in a given situation—and then do that yourself. When you’re driving and get cut off in traffic, you would like it not to bother them—so don’t let them see it bothering you. You would prefer they don’t get drunk, so don’t drink too much yourself. You’d like them to be generous to others, so be generous too.

Arthur C. Brooks: Don’t teach your kids to fear the world

F or young and future parents reading this, one last note: You will make a lot of mistakes, but mostly they won’t matter. I can think of my selfishness and blunders as a father, and on some sleepless nights the instances roll around in my head and fill me with regret. But then I look at my son. So how did all my hectoring about grades and values work out?

He skipped college and joined the U.S. Marine Corps, in which he spent four years as a mortarman and sniper. Now 23, he is happily married and works in a job he loves as a manager at a construction company. He won’t see this column because, well, he doesn’t have time to read my stuff. But he loves me and I love him; we talk every single day; and despite all of my missteps, he turned out just fine. And most likely, so will your child.

Small protein plays big role in chronic HIV infection

UC Riverside-led study on innate immune system may lead to new treatments for patients with neuroHIV

NeuroHIV refers to the effects of HIV infection on the brain or central nervous system and, to some extent, the spinal cord and peripheral nervous system. A collection of diseases, including neuropathy and dementia, neuroHIV can cause problems with memory and thinking and compromise our ability to live a normal life. 

Using a mouse model of neuroHIV, a research team led by biomedical scientists at the University of California, Riverside, studied the effects of interferon-β (IFNβ), a small protein involved in cell signaling and integral to the body’s natural defense mechanism against viral infections. The researchers found that higher or lower than normal levels of IFNβ affect the brain in a sex-dependent fashion: some changes only occur in females, others only in males.

Marcus Kaul , a professor of biomedical sciences in the School of Medicine who led the study , explained that when infection-induced IFNβ levels become high, the brains of females and males are protected. If IFNβ production in response to infection is absent or too low, HIV can compromise brain function right away in both females and males, he said. 

“However, IFNβ also controls other cell and brain functions,” Kaul said. “If IFNβ is absent, females display reduced nerve cell connections called dendrites in the cerebral cortex, while males show diminished ‘presynaptic terminals,’ another type of nerve cell connection, in the hippocampus.” 

Dendrites are highly branched structures that increase the receptive surface of neurons. 

“Paradoxically, in the hippocampus of females and males, the damage to presynaptic terminals by HIV is diminished when IFNβ is absent but the reduction of injury is more pronounced in males,” Kaul said.

According to the researchers, the work adds to scientists’ understanding of how innate immunity affects the brain during chronic HIV infection.

“Until now, it was not known that normal levels of IFNβ are required for normal memory function and that the absence of IFNβ changes the production of nerve cell components in a sex-dependent fashion,” Kaul said. 

The findings, published in the journal Brain, Behavior, and Immunity , are noteworthy because the mouse model of neuroHIV that Kaul and his team used shares key features of brain injury and compromised function, such as impaired memory, with people living with HIV infection, or PLWH. 

Almost all cells in the body can produce IFNβ. Kaul explained IFNβ regulates the production of inflammatory factors in neuroHIV and has two major effects: (a) it changes the state of a virally infected cell from ‘normal’ to ‘anti-viral,’ making the cells uncomfortable environments for the virus, even completely shutting down virus production, and (b) IFNβ is released from infected cells as well as specialized cells that, by sensing infected cells, can alert neighboring cells and the entire body of a viral infection. 

“This is how neighboring cells adapt to become more resistant to viral infection,” Kaul said. “Some of them will also release additional anti-viral factors and a mixture of other factors that can promote or limit inflammation, such as cytokines called CCL3, CCL4 and CCL5.”   

The research was performed in Kaul’s laboratory. The team generated a new variant of an established transgenic mouse model of neuroHIV by crossbreeding this model with mice that lack IFNβ. The team then analyzed memory function and brain tissue of the transgenic mice for injury that usually occurs in neuroHIV.

“HIV and some other viruses have developed mechanisms to reduce or even prevent the production of more than normal levels of IFNβ,” said Hina Singh , an assistant project scientist in Kaul’s lab and the first author of the research paper. “We know little about the role of IFNβ in the human brain beyond that it can reduce inflammation. This is a major reason why IFNβ is used to treat multiple sclerosis, an autoimmune disease that affects more than 2.8 million people worldwide . Currently, we have almost no information about how much IFNβ is present in the brains of PLWH and what it does there.”

Singh said the study underscores the importance of having normal levels of IFNβ during no viral infection and having sufficiently high levels of IFNβ in case of neuroHIV or other viral infections. 

“The body’s many anti-viral responses observed in HIV infection are not specific to HIV but also occur with other viral infections,” she said. “But in contrast to most other viral infections, the body cannot get rid of HIV, which diminishes the effectiveness of the natural IFNβ response.”

Next, the team plans to work on confirming the findings of the neuroHIV model in PLWH. 

“For this, we will need to investigate tissues of PLWH who consented to donate them for research after death,” Kaul said. “Ultimately, we hope to develop IFNβ into a therapy for patients with neuroHIV.”

The study was funded by grants to Kaul from the National Institutes of Health. Kaul and Singh were joined in the research by scientists at UCR and The Scripps Research Institute in La Jolla, California.

The title of the research paper is “Interferon-β deficiency alters brain response to chronic HIV-1 envelope protein exposure in a transgenic model of NeuroHIV.” The paper is scheduled to appear in print in May 2024.

Second related study

Another study from the Kaul lab is scheduled to appear in print in the May 2024 issue of Brain, Behavior, and Immunity. 

“This study adds another important aspect to our understanding of how innate immunity and an inflammatory mechanism affects the brain during chronic HIV infection,” Kaul said.

The study shows that intact HIV and its viral envelope protein gp120 each cause macrophages, a type of white blood cell, to release cysteinyl leukotrienes, or CysLTs, which are pro-inflammatory mediators. The study shows for the first time that the CysLTs are critical components of macrophage neurotoxicity induced by HIV-1 , the most common of the two major types of HIV. 

“The potential translational value of our work is the demonstration that an asthma drug approved by the Food and Drug Administration, that inhibits a major receptor for CysLTs also prevents HIV-induced neurotoxicity,” Kaul said.

The research paper is titled “A critical role for Macrophage-derived Cysteinyl-Leukotrienes in HIV-1 induced neuronal injury.” Nina Yuan, a former associate specialist researcher in the Kaul lab, is the paper’s lead author. This study was supported by funds from the National Institute of Health.

Header photo shows Hina Singh (left) and Marcus Kaul. (UCR/Kaul lab)

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PERSPECTIVE article

The challenge of eco-generativity. embracing a positive mindset beyond eco-anxiety: a research agenda.

• 1 Department of Education, Languages, Intercultures, Literatures and Psychology (Psychology Section), University of Florence, Florence, Italy
• 2 THE-Tuscany Health Ecosystem NextGeneration UE-NRRP, Department of Education, Languages, Intercultures, Literatures and Psychology (Psychology Section), University of Florence, Florence, Italy

Climate change has emerged as a tough challenge affecting the world’s society and economy in the twenty-first century. Furthermore, it has been determined that global warming and climate change have detrimental effects on human health both physical and psychological. In this framework, eco-anxiety has emerged as a new construct to assess the distress in relation to climate change and its effects. In the current article, after a study of the literature regarding both eco-anxiety and generativity related to environmental issues, in the search for a healthy response to eco-anxiety, we propose the construct of eco-generativity as a sustainable development-related concept for the health of planet earth and people in the present and in the future. Accordingly, we explore the definitions of generativity in relation to the ecological environment, examining the development of the concept in accordance with the most recent research. Subsequently, according to the lens of psychology of sustainability and sustainable development, we propose key elements of eco-generativity in terms of construct and measures. Finally, a research agenda for future research and intervention on eco-generativity is provided.

Introduction

Nowadays, dealing with the global climate crisis is the most crucial issue for 21 st century societies and economies, as well as a major concern for environmental and human health (e.g., Morrison et al., 2022 ; Heeren and Asmundson, 2023 ). Climate change is shift in temperature and weather variability, including a rise in the frequency and severity of extreme environmental events ( Mariappan et al., 2022 ). Downstream implications of climate change impact the environment (e.g., forest degradation, desertification, forest fires, lack of freshwater supplies, decreasing ecosystem functionality and biodiversity) negatively impacting economic growth and human health ( Watts et al., 2021 ). The health of populations is damaged in several ways ( World Health Organization, 2021 ; Nadeau et al., 2022 ), with a widespread magnitude of negative psychological effects ( Palinkas and Wong, 2020 ). Global warming and climate change have been recognized to “deleteriously affect many aspects of planetary and human health.” ( Nadeau et al., 2022 , p. 1087). As a result, resilience to climate change is a keyword that firmly informs sustainability research (e.g., Satterthwaite et al., 2020 ).

The latest released reports by the United Nations Intergovernmental Panel on Climate Change (IPCC) have highlighted that the goal to limit global warming could be attained if climate neutrality (i.e., worldwide zero carbon emissions) was attained between 2030 and 2050 ( Intergovernmental Panel on Climate Change, 2022 ). Despite this, global temperatures will continue to rise until 2050, albeit many climate preventive actions have been planned ( Intergovernmental Panel on Climate Change, 2022 ). Thus, concerns about a sustainable future for life on earth are becoming one of the most compelling worldwide scientific, political, and informative debates ( Cianconi et al., 2023 ). In turn, a widespread emerging research line in applied psychology has examined anxiety, worry, and concerns that individual has experienced in facing the challenges of climate change (e.g., Boluda-Verdú et al., 2022 ).

Eco-anxiety

In this scenario, a growing body of literature have highlighted an emergent psychological phenomenon concerning the climate crisis, labeled “eco-anxiety” ( Boluda-Verdú et al., 2022 ). Eco-anxiety is defined as “ a chronic fear of environmental doom ” characterized by worries regarding the inadequacy of climate actions and adverse effects of warming crisis ( Clayton et al., 2017 , p. 68). Other labels used by researchers interchangeably are climate anxiety ( Boyd et al., 2023 ), climate change worry ( Stewart, 2021 ), environmental distress ( Higginbotham et al., 2006 ), ecological stress ( Helm et al., 2018 ), and ecological grief ( Cunsolo and Ellis, 2018 ). Data from a cross-national survey on adolescents revealed that 59% of them were very or extremely worried about climate change and more than 45% had impairment of everyday functioning (e.g., affecting ability to work and/or socialize) due to eco-anxiety ( Hickman et al., 2021 ). Similar results have been observed in adults ( Clayton and Karazsia, 2020 ) and observed around the globe (e.g., Gibson et al., 2020 ; Hajek and König, 2022 ; Heeren et al., 2022 ; Massazza et al., 2022 ; Tam et al., 2023 ).

Starting from this growing phenomenon, scholars have developed measurement tools to investigate eco-anxiety. In this light, the most widely used tool ( Boluda-Verdú et al., 2022 ) is the Climate Change Anxiety Scale (CCAS) ( Clayton and Karazsia, 2020 ), a 22-item scale measuring difficulties caused by the changing climate on four factors with adequate reliability: difficulties both on a cognitive level and on an emotional level, impairments on a functional level, personal experience of climate change, behavioral engagement. A brief version of the CCAS, enclosing a 13-item reliable two-factor structure, was advanced by Mouguiama-Daouda et al. (2022) . Stewart (2021) proposed the Climate Change Worry Scale (CCWS), a 10-item unidimensional scale measuring worry (persistent, repetitive, and uncontrolled thoughts) about climate change, concerns on future changes that climate may bring, and dysfunctional responses to worries, showing a one-factor solution with good psychometric properties ( Stewart, 2021 ). Other scales that can be found in the literature were all created ad hoc for research, with psychometric properties partially demonstrated and needing further study: Climate Change distress scale ( Searle and Gow, 2010 ); Habit Index of Negative Thinking adaptation ( Verplanken et al., 2020 ); Negative climate-related emotions ( Ogunbode et al., 2021 ); Eco-emotion scale ( Stanley et al., 2021 ). Even though eco-anxiety has been studied and operationalized in the most recent literature, it represents an ongoing challenge for sustainable development and sustainability research (e.g., Wang et al., 2023 ). Furthermore, researchers could embrace also different lens to study the psychological perspective of individuals that are living such adversities. For example, embracing a positive-oriented perspective, also in terms of sustainable development ( Seligman and Csikszentmihalyi, 2000 ; Di Fabio, 2017 ; Di Fabio and Rosen, 2020 ), focusing on the psychological resources that individuals have at their disposal to cope with climate change anxiety. This perspective could open new research trajectories applying positive psychological resources to promote sustainability and sustainability-related processes for the health and well-being of individual/s and the environment/s.

The psychology of sustainability and sustainable development

During the last 10 years, sustainability science has emerged as a novel academic discipline that addresses the challenges related to sustainable development through transdisciplinary lens, integrating natural, applied, and social sciences, as well as humanities ( Rosen, 2009 , 2017 ; Dincer and Rosen, 2013 ). Sustainable development is traditionally focused on strategies that could preserve the planet’s heart and human society from the ever-increasing degradation of environmental resources, promoting the protection of the environment and its ecosystem in the future ( Rosen, 2017 ). Nowadays, sustainability science ( Rosen, 2009 , 2017 ; Dincer and Rosen, 2013 ) participates directly and contributes to United Nations (UN) 17 Sustainable Development Goals (SDGs), bringing its contribution to overcome the major challenges including environmental degradation, climate change, and human well-being ( United Nations, 2022 ). More recently, a novel research area has stemmed from the sustainability science realm, namely the psychology of sustainability and sustainable development ( Di Fabio, 2017 ; Di Fabio and Rosen, 2018 , 2020 ): it proposes to integrate psychological lens in the advancement of sustainability and sustainable development. Additionally, the psychology of sustainability and sustainable development offers a psychological outlook accounting for many environments ( Di Fabio and Rosen, 2018 , 2020 ) and their interrelationships, starting from natural environment and its ecosystem including other environments such as personal/individual, social, organizational, community, digital, cross-cultural… up to global environment. Moreover, the psychology of sustainability and sustainable development is aimed at supporting the principle that sustainable processes have to be handled both by adhering to ever-decreasing supply of resources and even by regenerating resources following a positive-oriented approach ( Di Fabio, 2017 , 2022 ).

Therefore, according to this perspective, it sounds useful to switch views in studying the climate crisis concerns. This switch pertains to detecting positive variables that could regenerate psychological resources, and facilitate adaptive processes related to sustainability and sustainable development. In turn, focusing on positive psychological variables could help individuals in overcoming the limitations of focusing only on stagnation and/or negative affective states. As a result, embracing a positive-oriented approach could be not only a strategy to help individuals overcome the current environmental concerns but also to expand the field of sustainability, exploring psychological processes and resources able to open more profitable opportunities based on enhancing well-being and health of individual/s and environment/s. Eco-generativity is promising in this perspective as a viaticum to build a constructive proposal more generally, and it may be so in relation to eco-anxiety as well.

Eco-generativity

In recent years, researchers have extensively studied the construct of generativity ( Thomas and Tee, 2022 ) also outside the traditional boundaries of personality research (e.g., Doerwald et al., 2021 ; Wiktorowicz et al., 2022 ). However, despite environmental and ecological issues constitute a major global concern, only a handful of studies also investigated ecological generativity (e.g., Schoklitsch and Baumann, 2011 ; Alisat et al., 2014 ).

Eco-generativity is a concept that, on one side follows the evolution of the construct of generativity, which was first provided by Erikson in 1963; on the other side it extends the idea of generativity to the environment and the natural world and deals with passing the environment to subsequent generations, assisting the future of humankind ( Schoklitsch and Baumann, 2011 ).

Focusing on the construct of generativity in the scientific literature, also reporting relevant moments of enrichment of the perspective, the starting point to consider is the contribution of Erikson (1963 , 1968 , 1974 , 1980 , 1982 , 1986) . According to Eriksonian psychosocial stages and tasks, generativity is the seventh of eight personality development phases opposed to stagnation. Generativity is defined by Erikson as “the establishment, the guidance, and the enrichment of the living generation and the world it inherits” ( Erikson, 1974 , p. 123), and it is in relation to adults capable to define a perspective of being engaged in long-lasting affective interpersonal partnerships, and able to dedicate themselves to the next generations, nourishing and guiding them ( Erikson, 1963 , 1968 ). Furthermore, generativity deals with the capacity to provide a creation of the adult self, as a kid, a book, an idea, or a piece of knowledge that is deliberately and unselfishly shared with others and made to leave something behind, encouraging generational continuity ( Erikson, 1963 , 1968 ). Afterwards, scholars have gone beyond the notion of a “ generativity stage ,” emphasizing the presence of several facets of generativity, capable to be present in the individuals’ personality from early to late adulthood ( McAdams et al., 1993 ). McAdams et al. (1986) conceive generativity as a two-step process, containing elements of caring for subsequent generations and agentic aspects of leaving an entail of self beyond death. McAdams and de St. Aubin (1992) proposed the theory of generativity to illustrate generativity as a multidimensional personality construct composed of seven facets that could be exhibited in early, middle, or elder adulthood: (1) cultural demand; (2) inner desire; (3) concern for the next generation; (4) belief in the goodness of the human species; (5) generative commitment; (6) generative action; (7) narration of generativity ( McAdams and de St. Aubin, 1992 ). They are individually arranged, elicited by psychosocial demands (e.g., environmental, biological, psychological, social, cultural) and addressed to the goal of nourishing the following generation.

From another point of view, Kotre (1984) differentiated four distinct forms of generativity, removing any form of restrictions based on age or societal roles: biological (e.g., nursing children), parental (e.g., providing food, clothes, love, and discipline), technical (accomplished by teachers transmitting skills), and cultural (teachers who transmit not only skills but their meanings) ( Kotre, 1984 ).

Another group of scholars ( Bradley, 1997 ; Bradley and Marcia, 1998 ; Morselli, 2013 ; Morselli and Passini, 2015 ) focuses on the links between future time perspective ( Zimbardo and Boyd, 1999 ) and generativity, projecting themselves into the future being aware of future consequences nurtured by social responsibility. Following these premises, Morselli and Passini (2015) proposed the concept of social generativity describing an inclusive attitude towards society, not only a set of purposes fueled by personal and instrumental goals ( Marcia, 2010 ), but rather the responsibility for successive generations being involved in actions in the present in favor of the community’s future. Lastly, a recent systematic review of literature ( Doerwald et al., 2021 ) has underlined that generativity has a valuable role in the workplace and it was associated with a large array of work-related outcomes and well-being, suggesting including it in the area of the positive psychological resources.

Currently, an increasingly interesting space is emerging in relation to the application of generativity to environmental challenges. In the literature McAdams and de St. Aubin (1992) included environmental issues in generative concerns as motivational sources for pushing individuals towards generative actions but they did not further expand this concept. Schoklitsch and Baumann (2011) provided the first overlook on ecological generativity although considering it as the third factor of a broader measurement model together with Kotre’s (1984) four forms of generativity. Alisat et al. (2014) explored relationships between generativity and individual response to environmental issues observing that generativity was positively associated with environmental identity, environmental narratives, and strong feelings of connection with nature. However, the aforementioned authors did not further expand the concept in terms of ecological generativity. The lack of clear concepts and measures associated with ecological generativity, also without a multi-dimensional operationalization of the construct, may have limited the research and the chance to deeply explore the relationship between ecological generativity, positive psychological variables, well-being, and sustainable-related variables, highlining an open issue regarding the measure of the construct.

Measuring eco-generativity

With the present contribution, we advance new coordinates to expand the scenario in terms of eco-generativity, enriching the perspective in line with the principles of the psychology of sustainability and sustainable development ( Di Fabio, 2017 ; Di Fabio and Rosen, 2018 , 2020 ).

By reviewing the materials available in the literature to measure aspects linked to this construct, three empirically validated measures are available in relation to different aspects involved. The first one is the ecological generativity factor, included in Gen-Current (current generative concerns) and Gen-Life (lifetime generative concerns) questionnaires ( Schoklitsch and Baumann, 2011 ), two 29-item mirror measures composed of four factors: technical, cultural, social, and ecological generativity. The Ecological generativity factor covers the following concerns: (1) Use the energy wisely; (2) Leave a clean environment behind; (3) Live ecology-minded; (4) Keep waste to a minimum; (5) Purchase organic food; (6) Take care of animals; (7) Aid social institutions generativity ( Schoklitsch and Baumann, 2011 ).

Another measure linked to another facet of Eco-generativity is the Social Generativity Scale ( Morselli and Passini, 2015 ), covering aspects of eco-generativity since social generativity encloses concerns about future generations and the impact of individual behaviors on the community’s future. Social Generativity Scale showed a reliable unidimensional factor structure being composed of six items about: (1) undertaking initiatives to maintain the planet for the benefit of the next generation; (2) having sense of responsibility to support the neighborhood in which individual lives; (3) donating a portion of everyday commodities supporting the growth of future peoples; (4) being committed to ensuring the wealth of succeeding generations; (5) dedicating oneself to activities that survive even after individuals pass away; (6) assisting individuals in personal improvement ( Morselli and Passini, 2015 ).

The third measure linked to another facet of Eco-generativity is the revised Environmental Identity scale (IED-R) ( Clayton et al., 2021 ). Eco-generativity encloses features of environmental identity since it is composed of identity concerns associated with the natural world ( Alisat et al., 2014 ). Furthermore, generativity, environmental concerns, and identity are strongly associated and mutually influential ( Milfont and Sibley, 2011 ; Matsuba et al., 2012 ). The IED-R ( Clayton et al., 2021 ) is a 14-item scale assessing cognitive, behavioral, and emotional aspects of how individuals view their relationship with nature, developed from the original 24-item environmental identity scale ( Clayton, 2003 ), showing superior psychometric prosperities, cross-cultural validity, and adequate factor structure. It covers aspects associated with considering oneself a part of nature, devoting resources to protecting the context of nature, living a sustainable lifestyle, and feeling relaxed in nature ( Clayton et al., 2021 ). Thus, these three measures could constitute a starting point to promote research examining facets of eco-generativity and its relationship with psychological processes associated with sustainability and positive psychological variables.

Advancing a sustainable development-related concept of eco-generativity

As a first step, we defined the construct of eco-generativity as a specific form of generativity. This hallmark could be represented on the one hand by ecological concerns, following McAdams and de St. Aubin (1992) . On the other hand, we have to include the social dimension of generativity ( Morselli and Passini, 2015 ) since eco-generativity encapsulates a future-time perspective of care for environment and people, caring of the natural world as a fully livable and healthy environment for future generations, also including engagement in activism to preserve the environment.

These two faces of the current construct of eco-generativity appear consistent with the psychosocial lens of generativity theory, being ecological concerns activated by cultural demands and contingent aspects of the everyday life of the XXI century.

A second step in defining the eco-generativity construct requires a reflection on two concepts strictly related to eco-generativity. Environmental identity, as well as belief in the goodness of the human species to activate the passage from generativity concerns to generative commitment, actions, and narratives ( McAdams and de St. Aubin, 1992 ) seem critical elements also in terms of positive motivational aspects of confidence and of success in the future. They could be necessary for having and renovating psychological domains (cognitive, emotional, and behavioral) ( Matsuba et al., 2012 ; Alisat et al., 2014 ) in favor of eco-generativity. The environmental identity could be well reflected by the Clayton et al.’s (2021) construct assessed via the trustworthy and psychometrically sound 14 items of IED-R, as previously introduced. Regarding the belief in the goodness of the human species being a non-operationalized construct, it could be covered by the empirical construct of Hope ( Snyder et al., 1991 ). The Hope Scale ( Snyder et al., 1991 ), is a 12-item questionnaire with a reliable two-factor structure: Agency as a feeling of accomplishment in achieving objectives in the past, present, and future; Pathways as the ability to create effective strategies to achieve objectives ( Snyder et al., 1991 ).

In general, a sustainable development-related concept of eco-generativity could encompass two core features encapsulated in the constructs of ecological generativity ( Schoklitsch and Baumann, 2011 ) and social generativity ( Morselli and Passini, 2015 ), addressing the major eco-generativity concerns and two additional features represented by environmental identity ( Clayton et al., 2021 ) and hope ( Snyder et al., 1991 ).

Another important step asks for the right placement of generativity in the hierarchy levels of personality-related domains, conceptualizing it as a personality-related domain that is separated, even though associated with personality traits. In the literature, recent studies ( Navarro-Prados et al., 2018 ; Serrat et al., 2018 ; Millová et al., 2021 ) underline these relationships. Furthermore, Doerwald et al. (2021) conducted a meta-analysis where generativity emerges as a positive psychological resource positively associated with work-related outcomes. According to that, eco-generativity could be conceptualized in a positive strength-based perspective ( Di Fabio and Saklofske, 2021 ) as a positive psychological resource implementable via specific training. Nevertheless, all the advanced steps require empirical investigation to be satisfactorily explored; therefore a research agenda for eco-generativity needs to be drafted for promoting the study of its relationship with health, wellbeing, and positive psychological aspects related to the natural world, environment, and sustainability.

An eco-generativity research agenda

To cope with the challenge of the global climate crisis and several environmental issues, a new construct in the generativity framework is proposed: eco-generativity. Stemming from a generativity perspective (e.g., McAdams and de St. Aubin, 1992 ) it could be composed of four constituents: ecological generativity ( Schoklitsch and Baumann, 2011 ), social generativity ( Morselli and Passini, 2015 ), environmental identity ( Clayton et al., 2021 ) and hope ( Snyder et al., 1991 ). To be effectively introduced into the research landscape, the construct of eco-generativity should be investigated through a research agenda. It could enclose five points.

a. An in-depth study of the factor structure of the construct implementing psychometric analytic strategies.

b. An investigation on antecedents and outcomes of eco-generativity to better clarify the role of environmental identity and hope.

c. An examination of relationships among eco-generativity and relevant personality construct and/or intrinsically related, such as personality traits ( Costa and McCrae, 2008 ), emotional intelligence ( Petrides and Furnham, 2001 ), and perfectionism ( Hewitt et al., 1991 ; Feher et al., 2020 ).

d. An analysis of relationships between eco-generativity and positive psychological resources, such as empathy ( Davis, 1980 ), compassion ( Goetz et al., 2010 ), life satisfaction ( Diener et al., 1985 ), meaning in life ( Morgan and Farsides, 2009 ), flourishing ( Diener et al., 2010 ), humor ( Martin et al., 2003 ; Ruch et al., 2018 ).

e. A reflection on the value to introduce eco-generativity in the domain of positive psychological resources, positive strength-based perspective ( Di Fabio and Saklofske, 2021 ), as well as in a positive preventive perspective ( Di Fabio and Kenny, 2019 ).

Overall, the purpose of the current agenda is to promote the study of eco-generativity ( Di Fabio and Svicher, 2023a , b ) as a promising construct in the psychology of sustainability and sustainable development area, favoring its understanding and development to take a constructive perspective on coping with concerns associated with climate and environmental issues.

Global climate change and its linked impacts, such as global warming and acute and extreme weather events, are all well-documented hazards to human health and well-being ( Centers for Disease Control and Prevention, 2022 ). Moreover, these impacts are widespread and cumulative, burdening the psychological well-being of humanity ( World Health Organization, 2021 ). In such a scenario, the new concept of eco-anxiety has advanced, enclosing worry for the environment and severe individual impairments ( Clayton and Karazsia, 2020 ). Differently, eco-generativity entails caring for future environments and generations, acting from the present, as well as fostering environmental identity and hope. In this light, eco-generativity could also be a healthy response to the insecurity and stagnation arising from eco-anxiety, reinforcing the psychology of sustainability and sustainable development in helping individuals to cope positively with environmental challenges.

Through this approach, eco generativity could represent a promising candidate to enrich the study of the relationships between positive psychological resources and psychological coordinates of sustainable development (e.g., Di Fabio and Rosen, 2018 , 2020 ). Accordingly, sustainable development from a psychological point of view is also related to promoting the health and wellbeing of individual/s and their environment/s, fostering positive connections between people and the natural world to support sustainability efforts and well-being. Future research perspectives could investigate the relationship between eco-generativity, well-being, health, and eco-health variables. Thus, eco-generativity could be a new positive-oriented variable for fostering psychological strengths, assisting individuals in their well-being as well as in taking care of the sustainable development of planet earth.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Author contributions

AS wrote the first draft of the manuscript. ADF conceptualized the manuscript, supervised and tutored AS, and reviewed, edited, and wrote the final draft of the manuscript. All authors contributed to the article and approved the submitted version.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Alisat, S., Norris, J. E., Pratt, M. W., Matsuba, M. K., and McAdams, D. P. (2014). Caring for the earth: generativity as a mediator for the prediction of environmental narratives from identity among activists and nonactivists. Identity 14, 177–194. doi: 10.1080/15283488.2014.921172

Crossref Full Text | Google Scholar

Boluda-Verdú, I., Senent-Valero, M., Casas-Escolano, M., Matijasevich, A., and Pastor-Valero, M. (2022). Fear for the future: eco-anxiety and health implications, a systematic review. J. Environ. Psychol. 84:101904. doi: 10.1016/j.jenvp.2022.101904

Boyd, C., Parr, H., and Philo, C. (2023). Climate anxiety as posthuman knowledge. Wellbeing Space Soc. 4:100120. doi: 10.1016/j.wss.2022.100120

Bradley, C. L. (1997). Generativity–stagnation: development of a status model. Dev. Rev. 17, 262–290. doi: 10.1006/drev.1997.0432

Bradley, C. L., and Marcia, J. E. (1998). Generativity-stagnation: a five-category model. J. Pers. 66, 39–64. doi: 10.1111/1467-6494.00002

Centers for Disease Control and Prevention (2022). Climate effects on health. Available at: https://www.cdc.gov/climateandhealth/effects/default.htm (Accessed February 12, 2023)

Google Scholar

Cianconi, P., Hanife, B., Hirsch, D., and Janiri, L. (2023). Is climate change affecting mental health of urban populations? Curr. Opin. Psychiatry 36, 213–218. doi: 10.1097/yco.0000000000000859

PubMed Abstract | Crossref Full Text | Google Scholar

Clayton, S. (2003). “Environmental identity: a conceptual and an operational definition” in Identity and the natural environment: the psychological significance of nature . eds. S. Clayton and S. Opotow (Cambridge, MA: The MIT Press), 45–65.

Clayton, S., Czellar, S., Nartova-Bochaver, S., Skibins, J. C., Salazar, G., Tseng, Y.-C., et al. (2021). Cross-cultural validation of a revised environmental identity scale. Sustain. For. 13:2387. doi: 10.3390/su13042387

Clayton, S., and Karazsia, B. T. (2020). Development and validation of a measure of climate change anxiety. J. Environ. Psychol. 69:101434. doi: 10.1016/j.jenvp.2020.101434

Clayton, S., Manning, C. M., Krygsman, K., and Speiser, M. (2017). Mental health and our changing climate: Impacts, implications, and guidance . Washington, D.C.: American Psychological Association, and ecoAmerica.

Costa, P. T., and McCrae, R. R. (2008). The revised neo personality inventory (neo-pi-r) . Thousand Oaks, CA: Sage Publications, Inc

Cunsolo, A., and Ellis, N. R. (2018). Ecological grief as a mental health response to climate change-related loss. Nat. Clim. Chang. 8, 275–281. doi: 10.1038/s41558-018-0092-2

Davis, M. H. (1980). A multidimensional approach to individual differences in empathy. Available at: https://www.uv.es/~friasnav/Davis_1980.pdf (Accessed February 12, 2023)

Di Fabio, A. (2017). The psychology of sustainability and sustainable development for well-being in organizations. Front. Psychol. 8:01534. doi: 10.3389/fpsyg.2017.01534

Di Fabio, A. (2022). Cross-cultural perspectives on well-being and sustainability in organizations . Cham, Switzerland: Springer.

Di Fabio, A., and Kenny, M. E. (2019). Resources for enhancing employee and organizational well-being beyond personality traits: the promise of emotional intelligence and positive relational management. Pers. Individ. Differ. 151:109278. doi: 10.1016/j.paid.2019.02.022

Di Fabio, A., and Rosen, M. A. (2018). Opening the black box of psychological processes in the science of sustainable development: a new frontier. Eur. J. Sustain. Dev. Res. 2:47. doi: 10.20897/ejosdr/3933

Di Fabio, A., and Rosen, M. A. (2020). An exploratory study of a new psychological instrument for evaluating sustainability: the sustainable development goals psychological inventory. Sustain. For. 12:7617. doi: 10.3390/su12187617

Di Fabio, A., and Saklofske, D. H. (2021). The relationship of compassion and self-compassion with personality and emotional intelligence. Pers. Individ. Differ. 169:110109. doi: 10.1016/j.paid.2020.110109

Diener, E., Emmons, R. A., Larsen, R. J., and Griffin, S. (1985). The satisfaction with life scale. J. Pers. Assess. 49, 71–75. doi: 10.1207/s15327752jpa4901_13

Diener, E., Wirtz, D., Tov, W., Kim-Prieto, C., Choi, D.-W., Oishi, S., et al. (2010). New well-being measures: short scales to assess flourishing and positive and negative feelings. Soc. Indic. Res. 97, 143–156. doi: 10.1007/s11205-009-9493-y

Dincer, I., and Rosen, M. A. (2013). Exergy. Energy, environment and sustainable development 2nd. Oxford, UK: Elsevier

Di Fabio,, and Svicher, (2023a). The Eco-Generativity Scale (EGS): A New Resource to Protect the Environment and Promote Health. Int. J. Environ. Res. Public Health 20, 6474. doi: 10.3390/ijerph20156474

Di Fabio,, and Svicher, (2023b). The Eco-Generativity Scale-Short Form: A Multidimensional Item Response Theory Analysis in University Students. J. Psychoeduc. Assess. 42, 241–247. doi: 10.1177/07342829231212320

Doerwald, F., Zacher, H., Van Yperen, N. W., and Scheibe, S. (2021). Generativity at work: a meta-analysis. J. Vocat. Behav. 125:103521. doi: 10.1016/j.jvb.2020.103521

Erikson, E. H. (1963). Childhood and society (Revised ed.). New York: Norton.

Erikson, E. H. (1968). Identity: Youth and crisis . New York: Norton.

Erikson, E. H. (1974). Dimensions of a new identity . New York, NY: W. W. Norton and Company.

Erikson, E. H. (1980). Identity and the life cycle . New York: W. W. Norton and Company.

Erikson, E. H. (1982). The life cycle completed . New York: W. W. Norton and Company.

Erikson, J. M., Erikson, E. H., and Kivnick, H. (1986). Vital involvement in old age . New York: Norton and Compton.

Feher, A., Smith, M. M., Saklofske, D. H., Plouffe, R. A., Wilson, C. A., and Sherry, S. B. (2020). The big three perfectionism scale–short form (BTPS-SF): development of a brief self-report measure of multidimensional perfectionism. J. Psychoeduc. Assess. 38, 37–52. doi: 10.1177/0734282919878553

Gibson, K. E., Barnett, J., Haslam, N., and Kaplan, I. (2020). The mental health impacts of climate change: findings from a Pacific Island atoll nation. J. Anxiety Disord. 73:102237. doi: 10.1016/j.janxdis.2020.102237

Goetz, J. L., Keltner, D., and Simon-Thomas, E. (2010). Compassion: an evolutionary analysis and empirical review. Psychol. Bull. 136, 351–374. doi: 10.1037/a0018807

Hajek, A., and König, H. H. (2022). Climate anxiety in Germany. Public Health 212, 89–94. doi: 10.1016/j.puhe.2022.09.007

Heeren, A., and Asmundson, G. J. G. (2023). Understanding climate anxiety: What decision-makers, health care providers, and the mental health community need to know to promote adaptative coping. J. Anxiety Disord. 93, 102654. doi: 10.1016/j.janxdis.2022.102654

Heeren, A., Mouguiama-Daouda, C., and Contreras, A. (2022). On climate anxiety and the threat it may pose to daily life functioning and adaptation: a study among European and African French-speaking participants. Clim. Chang. 173:15. doi: 10.1007/s10584-022-03402-2

Helm, S. V., Pollitt, A., Barnett, M. A., Curran, M. A., and Craig, Z. R. (2018). Differentiating environmental concern in the context of psychological adaption to climate change. Glob. Environ. Change. 48, 158–167. doi: 10.1016/j.gloenvcha.2017.11.012

Hewitt, P. L., Flett, G. L., Turnbull-Donovan, W., and Mikail, S. F. (1991). The multidimensional perfectionism scale: reliability, validity, and psychometric properties in psychiatric samples. Psychol. Assess. 3, 464–468. doi: 10.1037/1040-3590.3.3.464

Hickman, C., Marks, E., Pihkala, P., Clayton, S., Lewandowski, R. E., Mayall, E. E., et al. (2021). Climate anxiety in children and young people and their beliefs about government responses to climate change: a global survey. Lancet Planet. Health 5, e863–e873. doi: 10.1016/S2542-5196(21)00278-3

Higginbotham, N., Connor, L., Albrecht, G., Freeman, S., and Agho, K. (2006). Validation of an environmental distress scale. EcoHealth 3, 245–254. doi: 10.1007/s10393-006-0069-x

Intergovernmental Panel on Climate Change. (2022). Climate Change 2022: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Sixth Assessment Report of the Intergovernmental Panel on Climate Change . University Press, Cambridge, UK and New York, NY, USA. doi: 10.1017/9781009325844

Kotre, J. N. (1984). Outliving the self: How we live on in future generations . New York, NY, USA: W W Norton and Co.

Marcia, J. E. (2010). “Life transitions and stress in the context of psychosocial development” in Handbook of stressful transitions across the lifespan . ed. T. W. Miller (New York: Springer), 19–34.

Mariappan, S., David Raj, A., Kumar, S., and Chatterjee, U. (2022). “Global warming impacts on the environment in the last century” in Ecological footprints of climate change: Adaptive approaches and sustainability . eds. U. Chatterjee, A. O. Akanwa, S. Kumar, S. K. Singh, and A. Dutta Roy (Cham: Springer International Publishing), 63–93.

Martin, R. A., Puhlik-Doris, P., Larsen, G., Gray, J., and Weir, K. (2003). Individual differences in uses of humor and their relation to psychological well-being: development of the humor styles questionnaire. J. Res. Pers. 37, 48–75. doi: 10.1016/S0092-6566(02)00534-2

Massazza, A., Ardino, V., and Fioravanzo, R. E. (2022). Climate change, trauma and mental health in Italy: a scoping review. Eur. J. Psychotraumatol. 13, 1–16. doi: 10.1080/20008198.2022.2046374

Matsuba, M. K., Pratt, M. W., Norris, J. E., Mohle, E., Alisat, S., and McAdams, D. P. (2012). Environmentalism as a context for expressing identity and generativity: patterns among activists and uninvolved youth and midlife adults. J. Pers. 80, 1091–1115. doi: 10.1111/j.1467-6494.2012.00765.x

McAdams, D. P., and de St Aubin, E. (1992). A theory of generativity and its assessment through self-report, behavioral acts, and narrative themes in autobiography. J. Pers. Soc. Psychol. 62, 1003–1015. doi: 10.1037/0022-3514.62.6.1003

McAdams, D. P., de St Aubin, E., and Logan, R. L. (1993). Generativity among young, midlife, and older adults. Psychol. Aging 8, 221–230. doi: 10.1037/0882-7974.8.2.221

McAdams, D. P., Ruetzel, K., and Foley, J. M. (1986). Complexity and generativity at mid-life. Relations among social motives, Ego development, and Adults' plans for the future. J. Pers. Soc. Psychol. 50, 800–807. doi: 10.1037/0022-3514.50.4.800

Milfont, T. L., and Sibley, C. G. (2011). Exploring the concept of environmental generativity. Int. J. Hisp. Psychol. 4, 21–30.

Millová, K., Malatincová, T., and Blatný, M. (2021). Intergenerational transmission of generativity and stagnation within families in a society after a macrosocial change: a two-generation study. Curr. Psychol. 42, 3061–3075. doi: 10.1007/s12144-021-01688-6

Morgan, J., and Farsides, T. (2009). Measuring meaning in life. J. Happiness Stud. 10, 197–214. doi: 10.1007/s10902-007-9075-0

Morrison, T. H., Adger, W. N., Agrawal, A., Brown, K., Hornsey, M. J., Hughes, T. P., et al. (2022). Radical interventions for climate-impacted systems. Nat. Clim. Chang. 12, 1100–1106. doi: 10.1038/s41558-022-01542-y

Morselli, D. (2013). The olive tree effect: future time perspective when the future is uncertain. Cult. Psychol. 19, 305–322. doi: 10.1177/1354067x13489319

Morselli, D., and Passini, S. (2015). Measuring prosocial attitudes for future generations: the social generativity scale. J. Adult Dev. 22, 173–182. doi: 10.1007/s10804-015-9210-9

Mouguiama-Daouda, C., Blanchard, M. A., Coussement, C., and Heeren, A. (2022). On the measurement of climate change anxiety: French validation of the climate anxiety scale. Psychol. Belg. 62, 123–135. doi: 10.5334/pb.1137

Nadeau, K. C., Agache, I., Jutel, M., Annesi Maesano, I., Akdis, M., Sampath, V., et al. (2022). Climate change: a call to action for the United Nations. Allergy 77, 1087–1090. doi: 10.1111/all.15079

Navarro-Prados, A. B., Serrate-Gonzalez, S., Muñoz-Rodríguez, J.-M., and Díaz-Orueta, U. (2018). Relationship between personality traits, generativity, and life satisfaction in individuals attending university programs for seniors. Int. J. Aging Hum. Dev. 87, 184–200. doi: 10.1177/0091415017740678

Ogunbode, C. A., Pallesen, S., Böhm, G., Doran, R., Bhullar, N., Aquino, S., et al. (2021). Negative emotions about climate change are related to insomnia symptoms and mental health: cross-sectional evidence from 25 countries. Curr. Psychol. 42, 845–854. doi: 10.1007/s12144-021-01385-4

Palinkas, L. A., and Wong, M. (2020). Global climate change and mental health. Curr. Opin. Psychol. 32, 12–16. doi: 10.1016/j.copsyc.2019.06.023

Petrides, K. V., and Furnham, A. (2001). Trait emotional intelligence: psychometric investigation with reference to established trait taxonomies. Eur. J. Personal. 15, 425–448. doi: 10.1002/per.416

Rosen, M. A. (2009). Energy sustainability: a pragmatic approach and illustrations. Sustain. For. 1, 55–80. doi: 10.3390/su1010055

Rosen, M. A. (2017). Sustainable Development: A Vital Quest Eur. J. Sustain. Dev. Res. 1:2. doi: 10.20897/ejosdr.201702

Ruch, W., Heintz, S., Platt, T., Wagner, L., and Proyer, R. T. (2018). Broadening humor: comic styles differentially tap into temperament, character, and ability. Front. Psychol. 9:6. doi: 10.3389/fpsyg.2018.00006

Satterthwaite, D., Archer, D., Colenbrander, S., Dodman, D., Hardoy, J., Mitlin, D., et al. (2020). Building Resilience to Climate Change in Informal Settlements. One Earth 2, 143–156. doi: 10.1016/j.oneear.2020.02.002

Schoklitsch, A., and Baumann, U. (2011). Measuring generativity in older adults: the development of new scales. GeroPsych: J. Gerontopsychology Geriatr. Psych. 24, 31–43. doi: 10.1024/1662-9647/a000030

Searle, K., and Gow, K. (2010). Do concerns about climate change lead to distress? Int. J. Clim. Chang. 2, 362–379. doi: 10.1108/17568691011089891

Seligman, M. E. P., and Csikszentmihalyi, M. (2000). Positive psychology: an introduction. Am. Psychol. 55, 5–14. doi: 10.1037/0003-066X.55.1.5

Serrat, R., Villar, F., Pratt, M. W., and Stukas, A. A. (2018). On the quality of adjustment to retirement: the longitudinal role of personality traits and generativity. J. Pers. 86, 435–449. doi: 10.1111/jopy.12326

Snyder, C. R., Harris, C., Anderson, J. R., Holleran, S. A., Irving, L. M., Sigmon, S. T., et al. (1991). The will and the ways: development and validation of an individual-differences measure of hope. J. Pers. Soc. Psychol. 60, 570–585. doi: 10.1037//0022-3514.60.4.570

Stanley, S. K., Hogg, T. L., Leviston, Z., and Walker, I. (2021). From anger to action: differential impacts of eco-anxiety, eco-depression, and eco-anger on climate action and wellbeing. J. Clim. Chang. Health 1:100003. doi: 10.1016/j.joclim.2021.100003

Stewart, A. E. (2021). Psychometric properties of the climate change worry scale. Int. J. Environ. Res. Public Health 18:494. doi: 10.3390/ijerph18020494

Tam, K.-P., Chan, H.-W., and Clayton, S. (2023). Climate change anxiety in China, India, Japan, and the United States. J. Environ. Psychol. 87:101991. doi: 10.1016/j.jenvp.2023.101991

Thomas, L. D. W., and Tee, R. (2022). Generativity: a systematic review and conceptual framework. Int. J. Manag. Rev. 24, 255–278. doi: 10.1111/ijmr.12277

United Nations (2022). Climate Actions. Available at: https://www.un.org/sites/un2.un.org/files/2021/08/fastfacts-health.pdf [Accessed January 16th, 2023].

Verplanken, B., Marks, E., and Dobromir, A. I. (2020). On the nature of eco-anxiety: how constructive or unconstructive is habitual worry about global warming? J. Environ. Psychol. 72:101528. doi: 10.1016/j.jenvp.2020.101528

Wang, H., Safer, D. L., Cosentino, M., Cooper, R., Van Susteren, L., Coren, E., et al. (2023). Coping with eco-anxiety: an interdisciplinary perspective for collective learning and strategic communication. J. Clim. Chang. Health 9:100211. doi: 10.1016/j.joclim.2023.100211

Watts, N., Amann, M., Arnell, N., Ayeb-Karlsson, S., Beagley, J., Belesova, K., et al. (2021). The 2020 report of the lancet countdown on health and climate change: responding to converging crises. Lancet Glob. 397, 129–170. doi: 10.1016/S0140-6736(20)32290-X

World Health Organization (2021). Climate Change. Available at: https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health#:~:text=Climate%20change%20affects%20food%20availability,700%20000%20annually%2C%20may%20rise [Accessed January 16th, 2023].

Wiktorowicz, J., Warwas, I., Turek, D., and Kuchciak, I. (2022). Does generativity matter? A meta-analysis on individual work outcomes. Eur. J. Ageing 19, 977–995. doi: 10.1007/s10433-022-00727-w

Zimbardo, P. G., and Boyd, J. N. (1999). Putting time in perspective: a valid, reliable individual-differences metric. J. Pers. Soc. Psychol. 77, 1271–1288. doi: 10.1037/0022-3514.77.6.1271

Keywords: eco-generativity, ecological generativity, hope, eco-anxiety, climate change, sustainability, sustainable development, psychology of sustainability and sustainable development

Citation: Di Fabio A and Svicher A (2024) The challenge of eco-generativity. Embracing a positive mindset beyond eco-anxiety: a research agenda. Front. Psychol . 15:1173303. doi: 10.3389/fpsyg.2024.1173303

Received: 27 February 2023; Accepted: 19 March 2024; Published: 05 April 2024.

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Copyright © 2024 Di Fabio and Svicher. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Annamaria Di Fabio, [email protected]

† ORCID: Annamaria Di Fabio, orcid.org/0000-0002-5150-1273 Andrea Svicher, orcid.org/0000-0001-5183-6113

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Treatment of anxiety disorders in clinical practice: a critical overview of recent systematic evidence

Vitor iglesias mangolini.

I Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR

II Departamento de Psiquiatria, Instituto de Psiquiatria, LIM-23, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR

Laura Helena Andrade

Francisco lotufo-neto, yuan-pang wang.

The aim of this study was to review emerging evidence of novel treatments for anxiety disorders. We searched PubMed and EMBASE for evidence-based therapeutic alternatives for anxiety disorders in adults, covering the past five years. Eligible articles were systematic reviews (with or without meta-analysis), which evaluated treatment effectiveness of either nonbiological or biological interventions for anxiety disorders. Retrieved articles were summarized as an overview. We assessed methods, quality of evidence, and risk of bias of the articles. Nineteen systematic reviews provided information on almost 88 thousand participants, distributed across 811 clinical trials. Regarding the interventions, 11 reviews investigated psychological or nonbiological treatments; 5, pharmacological or biological; and 3, more than one type of active intervention. Computer-delivered psychological interventions were helpful for treating anxiety of low-to-moderate intensity, but the therapist-oriented approaches had greater results. Recommendations for regular exercise, mindfulness, yoga, and safety behaviors were applicable to anxiety. Transcranial magnetic stimulation, medication augmentation, and new pharmacological agents (vortioxetine) presented inconclusive benefits in patients with anxiety disorders who presented partial responses or refractoriness to standard treatment. New treatment options for anxiety disorders should only be provided to the community after a thorough examination of their efficacy.

INTRODUCTION

According to the World Health Organization ( 1 ), anxiety disorders are burdensome “common mental disorders” to communities. These prevalent disorders are not communicable and affect approximately one in every five individuals of the world population ( 2 - 4 ). This figure represents the largest share of the prevalence of all mental disorders, whereas severe psychotic and bipolar disorders affect only between 1% and 2% of the population. In an upper-middle income country such as Brazil, the 12-month prevalence of anxiety disorders has been estimated as 19.9% among the dwellers of a large metropolitan area ( 5 ).

The cost of anxiety disorders to the working world is remarkable, corresponding to a total loss of 74.4 billion Euros in 2010 ( 3 ). The global burden of anxiety disorders represents 10.4% of years lived with adjusted disability (DALY) of mental disorders, reaching 26,800,000 DALYs ( 2 ). Despite the societal burden of this morbidity, only approximately one in five patients diagnosed with anxiety disorder obtain access to treatment ( 6 , 7 ).

Anxiety disorders present an early onset, even during childhood. Their enduring waxing and waning course deeply affects patients’ functionality and interpersonal relationships throughout the lifespan ( 8 ). Most pathological anxiety (specific phobias, social anxiety, generalized anxiety, separation anxiety, obsessive-compulsive, and panic disorder) is underrecognized, and patients seek treatment in outpatient settings, either in medical or specialized mental health-care contexts ( 7 ). However, anxiety disorders receive less attention from clinicians when compared with major mental disorders, such as psychotic conditions and substance use disorders that require hospitalization. Moreover, anxiety is less reported in the media than depression and suicide attempts, which reduces the help-seeking behaviors of patients suffering from anxiety. Figure 1 summarizes key uncontroversial characteristics and clinical practices regarding the treatment of anxiety disorders ( 9 - 11 ). Most experts advocate either psychotherapy and/or pharmacotherapy for alleviating or controlling symptoms of anxiety. The combination of psychological treatment with psychotropic drugs is recommended for patients with severe cases of disabling anxiety.

Traditionally, several talk therapies are subsumed as techniques of psychological treatment and have been recommended to handle different degrees of anxiety ( 11 ). Well-accepted but not always efficacious modalities of psychotherapy vary from psychoanalytic, cognitive-behavioral, interpersonal, supportive, and group therapy to brief therapy. The literature on cognitive-behavioral therapy (CBT) has established a foundation of effectiveness evidence for different anxiety disorders ( 9 , 11 ), but new therapeutic modalities should have their benefit assessed. In addition, the existing number of mental health professionals is insufficient for the number of patients who need treatment ( 6 ). Thus, a more accessible and cost-effective modality of psychotherapeutic treatment for anxiety should be offered to the community.

More than six decades ago, since the synthesis of chlordiazepoxide in 1957 ( 12 ), benzodiazepine medications have become the main class of pharmacological agents for the treatment of anxiety disorders. The introduction of these anxiolytic medicines received an immediate welcome from medical professionals and anxiety-laden patients. Nonetheless, the risk of side effects, a withdrawal syndrome and dependence on benzodiazepines have led patients in need of treatment to seek less harmful therapeutic substitutes, which do not always have proven efficacy. Accepted psychopharmacological medicines include antidepressants, buspirone, beta-blockers, and antipsychotics. Their efficacy has been demonstrated in well-designed clinical trials and abridged in comprehensive reviews ( 10 ). The combined use of psychological treatment with psychotropic drugs is more commonly recommended for cases of anxiety of greater severity and disability ( 11 ).

Many complementary and alternative treatments of mild forms of anxiety have gained popularity because of their alleged harmlessness. Examples of complementary treatment include aromatherapy, acupuncture, herbal medicine, homeopathy, massage therapy, yoga, mindfulness, exercise practice, relaxation, etc. ( 6 , 7 ). The diversity of modalities that a patient is exposed to varies in accordance with the guidance of the therapist, use of an active substance, and body manipulation. Exhaustive classification is difficult. While mental health professionals support the adjunctive addition of these modalities, for anxiety disorders in particular, the exclusive use of alternative therapies as a surrogate to well-established forms of treatment should be avoided ( 11 ). Most complementary and alternative treatments lack evidence of effectiveness. It is possible that a placebo effect and a good therapeutic relationship between the practitioner and patients underlie their positive outcomes.

There are a wealth of treatments devoted to controlling the symptoms of anxiety, but nonconventional and newer psychotherapeutic treatments and pharmacological agents are propagated without an acceptable confirmation of benefit. In the present review, we searched for recent evidence of nonbiological (psychological) and biological (pharmacological) modalities for treating anxiety disorders. The comprehensive summary of treatment advances is organized for a professional who is in training or is not a specialist in mental health to supplement existing modalities. Complementary and alternative treatments with evidence of effectiveness are explored herein under the group of nonbiological therapies. Additionally, high-quality systematic reviews (SRs) were chosen over sparse clinical trials in need of additional replication. The usefulness and public health importance of the treatment of anxiety are subsequently discussed.

Our research question was to update the evidence on recent interventions for the broad category of anxiety disorders. In the present study, the PICO components included adult Patients with a clinical diagnosis of “anxiety disorder”, who were subjected to one or more Interventions (either biological or nonbiological). The intervention must be Compared with a placebo or standard therapeutics for assessing the treatment Outcomes.

We searched for articles in the PubMed and EMBASE databases on the treatment of anxiety disorders. The key Medical Subject Heading (MeSH) terms were “anxiety disorders” AND “treatment”. The retrieved articles were displayed in the Mendeley platform and filtered in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines ( 13 ). The arguments of the search strategy can be found in Supplementary Table 1 .

Footnotes : CCDANCTR : The Cochrane Depression, Anxiety and Neurosis Review Group’s Specialized Register; CDSR : Cochrane Database of Systematic Reviews; CENTRAL : The Cochrane Central Register of Controlled Trials; CINAHL : Cumulative Index to Nursing and Allied Health Literature; Cochrane : Cochrane’s Collaboration Tool to Assess Risk of Bias; CRD : Centre for Reviews and Dissemination; DAI : Dissertation Abstracts International; ICTRP : World Health Organization’s trials portal; PBSC : Psychology and Behavioral Sciences Collection; SIGN : Scottish Intercollegiate Guidelines Network.

For inclusion, the article type must be an SR, with or without meta-analysis, of clinical trials involving adult patients diagnosed with an anxiety disorder. Rigorous randomized clinical trials (RCTs) compared with placebo or active interventions were considered the highest evidence of effectiveness. Those articles wherein participants encompassed a mixed sample of adults and children were not eligible unless separate data were comprehensively presented. Only articles published in the last 5 years, from January 2013 through September 31, 2018, were considered appropriate. There was no language restriction regarding published articles.

After hand searching, by reading the reference list of retained articles and chapters, and contact with potential authors, we identified two additional articles ( 14 , 15 ).

Regarding exclusion criteria, articles containing primary data, duplicate SR or animal models of anxiety were not eligible. Posttraumatic stress disorder was not considered in the present overview because this disorder is not covered under the MeSH term “anxiety disorders” and is no longer listed in the DSM-5 chapter of anxiety disorders ( 16 ). In contrast, while the DSM-5 describes obsessive-compulsive disorders in a separate chapter, this group of disorders is still listed under the MeSH entry of anxiety disorders. Furthermore, treatments on the cooccurrence of anxiety disorders in a specialized medical context (e.g., heart disease, endocrinological, neurological conditions, pain clinics, etc.) were eliminated. Observational studies, case reports, comments, practice guidelines and editorials on therapeutic modalities were also excluded from this overview. Two authors (V.I.M. and Y.P.W.) decided the final list of selected articles.

Study method

Often, an individual SR cannot address all proposed interventions for the same problem. Recent advances in the treatment of anxiety disorders are updated in the current study with the methodological framework of a systematic overview ( 17 ). Accordingly, this type of meta-review is a relatively new method to achieve a high level of evidence, wherein systematic evidence gathered from more than one SR or meta-analysis is examined in a single accessible work, also known as a “systematic review of systematic reviews” ( 17 ). The compilation of evidence synthesizes different interventions for the same problem or condition on different outcomes for different conditions, problems or populations. The ultimate result provides a global summary of the available evidence rather than providing data synthesis ( 17 , 18 ). Thus, an overview aims to examine the highest level of evidence and provide a global account of findings ( 19 ). This type of review has the advantage of rapidly combining relevant data to make evidence-based clinical decisions. Stakeholders, managers and health professionals can appraise multiple high-quality studies in a single general summary of a particular question.

The quality of the retained review articles was assessed in accordance with “A MeaSurement Tool to Assess systematic Reviews” (AMSTAR version 2) ( 20 ). The 16-item AMSTAR checklist ( https://amstar.ca ) represents a critical appraisal of the quality of SRs, covering different aspects related to study planning and conduct, such as the research question, review protocol, selection of study design, search strategy, explicit inclusion and exclusion criteria, risk assessment of bias, and publication bias. For the interpretation of detected weaknesses in critical and noncritical items, the AMSTAR recommends a categorization of the overall confidence in the results of the SR as follows: high, moderate, low, and critically low. The assessment of the risk of bias of an SR was supplemented with the Risk Of Bias In Systematic review (ROBIS) guidelines ( 21 ), which allows classification of the existence of bias as low, high or unclear. All rating disagreements were reconciled during discussion meetings.

Figure 2 shows the PRISMA flow diagram of the retrieved articles in this overview. From the initial 96 review articles published between 2013 and 2018, 92 nonduplicated articles were screened for title and abstract. Most studies ( k =66) were removed because the participants presented anxiety symptoms in the context of medical diseases or were nonadults. After eliminating ineligible articles that fell outside the topic of overview, 26 articles were retained for full-text reading. An additional 7 articles were excluded because 6 did not present an SR and 1 did not contain recent data. The reasons for article exclusion can be found in Supplementary Table 2 . Accordingly, 19 recent SRs were included in the final list for the qualitative synthesis. Of these studies, 3 did not estimate the pooled effect size of the outcomes through a meta-analytical quantitative synthesis ( 22 - 24 ).

NA: not applicable - no meta-analysis.

RCT/NRCT : randomized controlled trials/nonrandomized controlled trials.

Table 1 summarizes the main characteristics and methods of the 19 retained studies. From these articles, 11 referred to nonbiological treatments for anxiety (media- or internet-assisted CBT therapy, brief psychodynamic therapy, Morita therapy, effects of safety behavior, practices of exercise, mindfulness, and yoga, etc.), 5 referred to biological treatments for anxiety (repetitive transcranial magnetic stimulation and pharmacotherapy), and 3 referred to multimodal combined treatment comparisons (stepped care vs . care-as-usual and comparison of multiple treatments). All articles were published in English, and the investigators had searched for relevant articles in at least two databases. Although our search was restricted between 2013 and 2018, the majority of retained SRs covered the previous period, from the database inception date up to 2017.

Across the SRs, there were a total of 811 RCTs (range: 2–234 RCTs), with an included total of 87,773 adult participants (range: 40-37,333 patients). Three SRs ( 15 , 35 , 36 ) included over 10,000 participants, 6 SRs ( 25 - 29 , 37 ) between 9,999 and 1,000 participants, 8 SRs less than 1,000 participants ( 22 , 23 , 30 - 34 , 38 ), and 2 SRs did not report the exact number due to the mixture of adult and underage participants ( 14 , 24 ). Most SRs ( k =14) did not report or summarize the percentage of female participants. The other 5 SRs ( 25 , 28 , 30 , 33 , 38 ) indicated the proportion of women (range: 55.5%-67.7%).

Regarding the diagnosis of the participants, the majority of studies investigated the disorder either under a generic diagnostic label of anxiety disorders or common mental disorders. SRs evaluated the effects of specific interventions in social anxiety ( 14 , 15 , 23 , 24 , 35 ), panic ( 14 , 15 , 33 ), generalized anxiety ( 14 , 15 ), and obsessive-compulsive disorder ( 36 ). All articles described the exclusion of ineligible participants (e.g., posttraumatic stress or acute stress disorders, depressive disorders, comorbid physical illnesses, psychotic disorders, nonappropriate psychiatric diagnoses, underage participants, etc.) and inappropriate studies (e.g., small sample size or case studies, sampling or statistical issues, unsuitable interventions, etc.).

The Cochrane’s Collaboration Tool to Assess Risk of Bias was the most commonly used instrument ( k =14) to evaluate the risk of bias in each individual SR. Two SRs ( 14 , 15 ) used the Scottish Intercollegiate Guidelines Network (SIGN) checklist, and an additional 3 SRs ( 24 , 36 , 37 ) did not assess the risk of bias.

Evidence of treatment efficacy

Regarding the results of nonbiological or psychological treatments, 5 SRs evaluated computer-delivered psychological therapy ( 14 , 15 , 25 , 26 , 28 ). The evidence suggested that the online therapeutic approach is a feasible and beneficial treatment option. However, face-to-face therapist-guided therapy seemed to be clinically superior when compared with the computer-guided approach. Additionally, the benefit widely varied in accordance with the type and characteristics of anxiety disorder.

A meta-analysis ( 27 ) reported that short-term psychodynamic psychotherapies appear to show a reduction in anxiety symptoms in the short and medium term. The SR of Morita therapy-a specific type of self-acceptance method-showed data of limited applicability because all eligible studies were conducted in China, restricting the utility of conclusions in Western countries ( 30 ).

Three SRs ( 23 , 24 , 35 ) had specifically included patients with social anxiety. Mindfulness and acceptance-based treatment ( 23 ) was a viable option, but the level of evidence was limited due to the risk of bias. For social anxiety, limited evidence suggested that reductions in the use of safety behaviors or avoidance were related to a better CBT outcome ( 24 ). In addition, symptomatic decreases in social anxiety predicted reduced safety-behavior use over the course of treatment.

Two SRs ( 22 , 31 ) evaluated the benefit of exercise in reducing anxiety symptoms. Both studies indicated that the exercise practice was effective, regardless of the type and intensity of physical activity. However, exercise alone was less effective than standard antidepressant treatment ( 15 ). Although the effect of yoga on anxiety disorder was considered a safe intervention, the gathered evidence for its effects was inconclusive ( 32 ). Main critiques referred to the variety of diagnoses, heterogeneity of interventions, potential bias of low-quality studies, and lack of comparison to other treatments.

Regarding biological or pharmacological treatments, one meta-analysis ( 33 ) assessed transcranial magnetic stimulation in 40 participants with panic disorder. However, there was insufficient evidence to draw any solid conclusion about its efficacy because of the small sample size and significant methodological flaws. In addition to sampling issues (randomization and allocation concealment), the evidence in the 2 RCTs reviewed was of very low quality.

For pharmacological treatments, there was evidence of low-to-moderate quality for the use of selective serotonin reuptake inhibitors (SSRIs) for social anxiety ( 35 ). However, their tolerability seemed to be lower than placebo. The augmentation strategy did not appear to be beneficial in patients with treatment-resistant anxiety disorders, e.g., generalized anxiety, social anxiety, and panic disorder ( 34 ). In a comparison of the effects of second-generation antidepressants for obsessive-compulsive vs . generalized anxiety disorder, panic disorder, posttraumatic stress disorder, and social anxiety disorder (in over 15,000 participants), an SR ( 36 ) found that pharmacotherapy presented a smaller overall change score than placebo for those five categories of anxiety disorders. Finally, an SR of incipient trials of vortioxetine supported its use for anxiety ( 37 ), but more long-term placebo-controlled trials are warranted.

The SR on multimodal combined treatments reviewed 10 RCTs and compared the package of stepped care versus care-as-usual ( 38 ). The authors concluded that the stepped-care model of treatment of anxiety disorders appeared to be superior than care-as-usual in terms of efficacy and cost-effectiveness. As a consequence, stepped care can reduce the burden on service providers and increase availability. In a comprehensive SR on multiple treatment modalities with over 37 thousand participants ( 15 ), the average pre-post effect sizes of medications were more effective than psychotherapies. In general, the effects of psychotherapies did not differ from placebo pills. Surprisingly, not only psychotherapy but also medications and, to a lesser extent, placebo conditions have shown similar enduring effects in the improvement of anxiety disorders ( 14 ). Nevertheless, long-lasting treatment effects observed in the follow-up period were superimposed in patients receiving different therapeutics at the same time.

Quality of evidence

Using the AMSTAR guideline, Table 2 presents the assessment of the quality of each individual SR. The overall confidence of each study was rated after evaluating critical and noncritical items of the AMSTAR. Several SRs ( k =6) were rated as high quality ( 25 , 27 , 28 , 30 , 33 , 35 ); 3, as moderate ( 23 , 26 , 31 ); 7, as low ( 14 , 15 , 22 , 29 , 31 , 34 , 38 ); and 3, as critically low ( 24 , 36 , 37 ). All six reliable articles (AMSTAR high quality and ROBIS low risk of bias) were published in the Cochrane Database of Systematic Reviews and rigorously adhered to the guidelines of the Cochrane’s Collaboration Tool to Assess Risk of Bias.

Most of the studies clearly described the planning phase of the SR, which included explicit research questions, selection criteria, data extraction and assessment of the risk of bias. Not all studies previously registered a protocol before performing the SR. Only 3 studies reported the source of funding of the included studies ( 25 , 30 , 35 ). During the data interpretation, the most frequent problems were no clear discussion of the individual bias of selected studies ( k =9) and did not account for publication bias ( k =5). Notably, the 3 SRs that did not subject the RCTs to a meta-analytical synthesis also presented several shortcomings that critically affected the quality of the articles (e.g., omission of excluded studies, nonevidence-based discussion of results, and no prior protocol registration).

The risk of bias was rated with the aid of ROBIS ( Table 2 ), with 8 SRs having low risk ( 25 - 28 , 30 , 31 , 33 , 35 ); 8, uncertain risk ( 14 , 15 , 22 , 23 , 29 , 31 , 34 , 38 ); and 3, high risk ( 24 , 36 , 37 ). There was a rough agreement between the quality of an SR (AMSTAR) and the risk of bias (ROBIS). Unsurprisingly, while most high-to-moderate quality studies presented a low risk of bias, all three studies of critically low quality also presented a high risk of bias ( 24 , 36 , 37 ). In Supplementary Table 3 , detailed ROBIS ratings for each retained study are shown.

Supplementary Table 2

1. Alladin A. The wounded self: new approach to understanding and treating anxiety disorders. Am J Clin Hypn. 2014;56(4):368-88.

2. Bluett EJ, Homan KJ, Morrison KL, Levin ME, Twohig MP. Acceptance and commitment therapy for anxiety and OCD spectrum disorders: an empirical review. J Anxiety Disord. 2014;28(6):612-24.

3. Palm U, Leitner B, Kirsch B, Behler N, Kumpf U, Wulf L, et al. Prefrontal tDCS and sertraline in obsessive compulsive disorder: a case report and review of the literature. Neurocase. 2017;23(2):173-7.

4. Spiegel SB. Current issues in the treatment of specific phobia: recommendations for innovative applications of hypnosis. Am J Clin Hypn. 2014;56(4):389-404.

5. Reinhold JA, Rickels K. Pharmacological treatment for generalized anxiety disorder in adults: an update. Expert Opin Pharmacother. 2015;16(11):1669-81.

6. Shahar B. Emotion-focused therapy for the treatment of social anxiety: an overview of the model and a case description. Clin Psychol Psychother. 2014;21(6):536-47.

7. Gotink RA, Chu P, Busschbach JJ, Benson H, Fricchione GL, Hunink MG. Standardised mindfulness-based interventions in healthcare: an overview of systematic reviews and meta-analyses of RCTs. PLoS One. 2015;10(4):e0124344.

The current overview summarized the evidence of the efficacy of emerging treatment options in the last 5 years for adult patients with an anxiety disorder. The conclusions of 19 relevant SRs were synthesized and combined, for a total of 87,773 participants distributed in 811 RCTs. There was great cross-study heterogeneity in terms of the research question, target disorder, type of intervention, methodology, number of included RCTs, sample size of participants, and measured outcomes. Most studies investigated the benefit of different forms of psychotherapy and physical activity. In terms of biological treatments, no great evidence of effectiveness was found for transcranial magnetic stimulation and pharmacological strategies (drug augmentation or novel agents).

Newer treatments for anxiety disorders are highly relevant because the majority of cases are underdetected and undertreated within health-care systems, even in economically developed countries ( 14 ). Most anxious patients worldwide do not receive standard treatment with combined psychotherapy and pharmacological agents in terms of adherence, frequency, and adequacy ( 6 , 9 , 11 ). Consequently, untreated patients with these disorders chronically endure these symptoms, which are associated with severe impairments and restrictions in role functioning and disabilities ( 6 ). The present overview of SRs presented a resynthesis of existing data to allow better choices among emerging interventions for anxiety disorders. This rapid review of high-quality evidence can be of great clinical utility for decision-makers and public health administrators. Until more robust evidence is published, the initial enthusiasm for many proposed anti-anxiety alternatives has shrunk. Meanwhile, the evidence of many therapeutic alternatives should be watchfully disseminated to the community.

Interpretation and implications

From the present overview, there is convincing evidence that computer-delivered psychological treatment is helpful for the treatment of distressing anxiety of different intensities ( 25 ). However, the therapist-oriented CBT approach has yielded better results ( 25 , 28 ). Along similar lines, short-term psychodynamic psychotherapies have shown consistent gains, but larger studies with specific anxiety disorders are warranted ( 27 ). From a public health standpoint, computer-assisted treatment is not readily accessible in several nondeveloped countries, but this strategy can benefit those patients living in distant places or unwilling to start formal psychotherapy. Furthermore, sharing a single computer device and delivering brief psychotherapy are cost-effective for a community ( 40 ).

There is evidence of moderate-to-high quality suggesting that the online approach may be favorable and more efficacious than a wait list, informational pamphlets, or online discussion groups ( 25 ). Therefore, the self-help approach can be recommended as the first step in the treatment of mild anxiety disorders, but the short- and long-term effects of computer-delivered interventions and brief psychotherapies need to be fully established.

Although the SR of Morita therapy was of high quality and free of the risk of bias, its applicability is limited ( 30 ). All 7 RCTs of Morita therapy were conducted in Eastern countries, curbing its generalizability to Western populations ( 41 ).

Two promising high-quality SRs still required additional evidence of effectiveness with additional RCTs; pioneering transcranial magnetic stimulation ( 33 ) and the use of SSRIs in social anxiety ( 35 ) have shown insufficient evidence of efficacy. The SR of transcranial stimulation studies was conducted on 2 RCTs with 40 patients with panic disorder. Therefore, further trials with a larger sample are needed. The use of SSRIs in social anxiety has shown low-to-moderate evidence of efficacy and was less tolerable than placebo ( 35 ). These two strategies can be advised for specific anxiety disorders and those patients who presented partial response or refractoriness to standard treatment ( 35 , 42 - 45 ). In a further meta-analysis based on weekly outcome data ( 46 ), the treatment benefits of SSRIs and serotonin norepinephrine reuptake inhibitors (SNRIs) were shown for social anxiety. Higher doses of SSRIs, but not SNRIs, were associated with symptomatic improvement and treatment response. However, the potential risk of intolerance may surpass the benefit to the patients ( 46 ).

With an ever-growing list of psychotropic compounds showing apparent anxiolytic properties, current pharmacological options for treating clinical anxiety are broad and vast. Existing SRs ( 14 , 15 ) demonstrate that the magnitude of efficacy for most anxiolytic agents compared with placebo was superior. However, the likelihood of symptomatic remission after a pharmacological trial remains largely unknown. Progress in neuroscience and neurophysiology may unravel the pathways of therapeutic responsiveness.

Thus, the generalizability of emerging treatments, e.g., transcranial stimulation and newer pharmacological strategies, is limited due to sampling issues, methodological flaws, and applicability in specific anxiety disorders. These potential interventions might not be available to all consumers, and therefore, larger and more pragmatic RCTs are needed to evaluate and maximize the benefits of available interventions ( 42 - 45 ).

Behavioral recommendations of regular exercise ( 22 , 31 ), mindfulness practice ( 23 ), and yoga ( 32 ) have also been shown to be beneficial for improving anxiety symptoms. However, these SRs were of low-to-moderate quality and vulnerable to the risk of bias. The universal campaign of healthy activities might be recommended as an adjunctive treatment to standard treatment and a cost-effective strategy in regions where there is a shortage of qualified therapists. Nonetheless, these practices were less effective when compared with antidepressant pharmacotherapy ( 15 ). Even without sufficient evidence of effectiveness, these nonstandard treatments seem to be safe, inexpensive and can be easily implemented with preventive purposes to community dwellers ( 47 ).

Although methodological questions remain before its broad implementation can be supported, the personalized therapist-guided CBT approach is the most recommended nonpharmacological treatment for anxiety ( 48 ). Similarly, while the practice of physical activities is safe and helpful, traditional antidepressant treatment presents better results ( 9 , 14 ). One unanswered question refers to the potential adverse effects of the nonsupervised use of computer-assisted therapies and exercise practice. These concerns need to be refined in future RCTs.

Among those patients receiving long-term treatments with partial response or refractoriness, it is possible that novel strategies can enhance and sustain the improvements in anxiety. Hence, there is a large amount of room for amendments to treatment plans ( 34 - 38 ), at least for specific and severe anxiety disorders. Future studies should include stratification of anxiety by severity status and persistence to characterize the dose-response relationship of interventions and the combined efficacy of psychotherapy and pharmacotherapy in treating anxiety disorders, in addition to rule out potential confounding factors that affect treatment effectiveness ( 49 , 50 ).

Some SRs were untrustworthy due to their low quality and serious biases. For example, the impact of safety behaviors in social anxiety remains unknown ( 24 ), as well as the reduced response to placebo and antidepressants in obsessive-compulsive disorders ( 36 ) and the benefit of vortioxetine for the treatment of anxiety disorders ( 37 ). In general, the most common shortcomings were the lack of a published protocol, unclear study selection, inadequate search strategy, lack of explicit inclusion and exclusion criteria, nonexhaustive assessment of bias, invalid interpretation, and no report of publication bias. Consequently, these topics require urgent clarification, using a more stringent methodology and longer follow-up to answer the proposed research question.

Limitations

The heterogeneous interventions reported in these SRs with diverse outcomes preclude conducting a quantitative meta-analytical synthesis as an umbrella review ( 17 - 19 , 39 ). However, the present systematic overview has assessed the risk of bias of each individual SR, and it is secure to claim that most of the evidence reported herein was trustworthy.

The search for recent SRs on the treatment of anxiety disorders has identified main review articles, but some gray literature might have been missed. Although the studies in the Cochrane library were covered in PubMed and EMBASE, ongoing SRs must be finalized to draw solid conclusions. Along these lines, the Cochrane register and PROSPERO data were not scanned to detect other SRs. However, preliminary findings or unpublished SRs should not be integrated into the present overview. It is possibly that a selection bias of new treatment alternatives for specific anxiety disorders occurred at the time of the search. The potential omission of ongoing RCTs cannot be ruled out, but untrustworthy or partial evidence should not be taken as high-quality information.

A potential bias of overview studies is overlap in the retrieved articles or the use of the same primary study in multiple included SRs ( 51 , 52 ). In the present review, most of the treatment modalities were addressed by only one included SR, which probably reduced the probability of overlap across those studies. However, there were two interventions that were addressed by multiple studies: media-delivered psychotherapy and physical exercises. Five SRs examined media-delivered psychotherapy, with a total of 463 RCTs included in the reviews. It is possible that overlap occurred across these SRs, and subtle differences exist regarding the sample, scientific question, comparator, and inclusion of therapist. Therefore, we cannot rule out the possibility of overlapping articles, and the strength of the conclusion about media-delivered psychotherapy should be softened. In contrast, in the two existing SRs on physical exercises, we found 16.7% overlap across the included RCTs. In addition, the overall quality of the articles on physical exercise was low-to-moderate according to the AMSTAR analysis. This fact likely endorses the lower efficacy of physical exercises than standard care.

The covered period of five years may have not included all published studies before 2013. Nevertheless, these recent articles have offered updated coverage of previous studies conducted more than five years ago. Because our primary goal was to condense recent advances on the evidence-based therapeutics for anxiety, well-known modalities were outside the scope of the present review. Notwithstanding, two comprehensive meta-analyses conducted by Bandelow’s group ( 14 , 15 ) provided a broad summary of existing evidence on treatments for anxiety disorders, as well as the comparative enduring effect of psychological treatments and efficacy of treatments.

Trials with negative results might remain unpublished, and practitioners continue advising off-label use without any evidence of effectiveness or benefit. This publication bias of the file drawer effect cannot be ruled out. Small study bias and excluded participants may have affected the scientific soundness of the conclusions. For example, repetitive transcranial stimulation still requires a larger sample ( 42 - 45 ), and Morita therapy should be investigated in Western countries and regions in different stages of development ( 41 ).

CONCLUSIONS

The present overview of recent treatment trends for anxiety disorders provides an account of the evolving directions to pursue, in terms of state-of-art scientific development. Effective and older treatments should be enhanced with technological innovations such as computer-based CBT and supplemented by adjunctive physical activities. New biological or pharmacological treatment modalities for anxiety disorders still need further evidence of usefulness. Thus, all treatments for anxiety disorders with proven effectiveness should be continuously investigated to make them available to the community.

The worldwide burden of anxiety disorders is high. Therefore, obtaining access to reliable health-care services is a bonafide and essential need in a globalized world. However, direct-to-consumer universal access to emerging treatments for anxiety should be recommended only after demonstration of robust evidence of efficacy.

Supplementary Table 1 - Search Strategies

DATABASE #1

• Article types: Review
• Time period covered: Last 5 years
• Language: English, Portuguese and Spanish
• Age: Adults 19+
• Species: Humans

Search strategy:

anxiety disorders[Title/Abstract] AND treatment[Title/Abstract] AND (Review[ptyp] AND “2013/01/01”[PDAT] : “2018/12/31”[PDAT] AND “humans”[MeSH Terms] AND (English[lang] OR Portuguese[lang] OR Spanish[lang]) AND “adult”[MeSH Terms])

# of articles retrieved: 72

DATABASE #2

• Time period covered: 2013-2018
• Age: Adults

‘anxiety disorder’:ab,ti AND ‘treatment’:ab,ti AND [review]/lim AND ([english]/lim OR [portuguese]/lim OR [spanish]/lim) AND [adult]/lim AND [humans]/lim AND [2013-2018]/py

# of articles retrieved: 22

AUTHOR CONTRIBUTIONS

Mangolini VI and Wang YP contributed equally to the manuscript and were responsible for the study conception, data acquisition and extraction, and manuscript drafting. Andrade LH and Lotufo-Neto F have critically reviewed the discussion and conclusion. All of the authors approved the final version of the submitted manuscript.

Supplementary Table 3

Acknowledgments.

V.I.M. has been awarded a scholarship for graduate students from the São Paulo Research Foundation (FAPESP #2017/15060-0). The National Council for Scientific and Technological Development (CNPq) supports L.H.A.

No potential conflict of interest was reported.

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Teen Drug Use Habits Are Changing, For The Good. With Caveats.

Dr. Nora Volkow, who leads the National Institutes of Drug Abuse, would like the public to know things are getting better. Mostly.

By Matt Richtel

Historically speaking, it’s not a bad time to be the liver of a teenager. Or the lungs.

Regular use of alcohol, tobacco and drugs among high school students has been on a long downward trend.

In 2023, 46 percent of seniors said that they’d had a drink in the year before being interviewed; that is a precipitous drop from 88 percent in 1979, when the behavior peaked, according to the annual Monitoring the Future survey, a closely watched national poll of youth substance use. A similar downward trend was observed among eighth and 10th graders, and for those three age groups when it came to cigarette smoking. In 2023, just 15 percent of seniors said that they had smoked a cigarette in their life, down from a peak of 76 percent in 1977 .

Illicit drug use among teens has remained low and fairly steady for the past three decades, with some notable declines during the Covid-19 pandemic.

In 2023, 29 percent of high school seniors reported using marijuana in the previous year — down from 37 percent in 2017, and from a peak of 51 percent in 1979.

There are some sobering caveats to the good news. One is that teen overdose deaths have sharply risen, with fentanyl-involved deaths among adolescents doubling from 2019 to 2020 and remaining at that level in the subsequent years.

Dr. Nora Volkow has devoted her career to studying use of drugs and alcohol. She has been the director of the National Institute on Drug Abuse since 2003. She sat down with The New York Times to discuss changing patterns and the reasons behind shifting drug-use trends.

What’s the big picture on teens and drug use?

People don’t really realize that among young people, particularly teenagers, the rate of drug use is at the lowest risk that we have seen in decades. And that’s worth saying, too, for legal alcohol and tobacco.

What do you credit for the change?

One major factor is education and prevention campaigns. Certainly, the prevention campaign for cigarette smoking has been one of the most effective we’ve ever seen.

Some of the policies that were implemented also significantly helped, not just making the legal age for alcohol and tobacco 21 years, but enforcing those laws. Then you stop the progression from drugs that are more accessible, like tobacco and alcohol, to the illicit ones. And teenagers don’t get exposed to advertisements of legal drugs like they did in the past. All of these policies and interventions have had a downstream impact on the use of illicit drugs.

Does social media use among teens play a role?

Absolutely. Social media has shifted the opportunity of being in the physical space with other teenagers. That reduces the likelihood that they will take drugs. And this became dramatically evident when they closed schools because of Covid-19. You saw a big jump downward in the prevalence of use of many substances during the pandemic. That might be because teenagers could not be with one another.

The issue that’s interesting is that despite the fact schools are back, the prevalence of substance use has not gone up to the prepandemic period. It has remained stable or continued to go down. It was a big jump downward, a shift, and some drug use trends continue to slowly go down.

Is there any thought that the stimulation that comes from using a digital device may satisfy some of the same neurochemical experiences of drugs, or provide some of the escapism?

Yes, that’s possible. There has been a shift in the types of reinforcers available to teenagers. It’s not just social media, it’s video gaming, for example. Video gaming can be very reinforcing, and you can produce patterns of compulsive use. So, you are shifting one reinforcer, one way of escaping, with another one. That may be another factor.

Is it too simplistic to see the decline in drug use as a good news story?

If you look at it in an objective way, yes, it’s very good news. Why? Because we know that the earlier you are using these drugs, the greater the risk of becoming addicted to them. It lowers the risk these drugs will interfere with your mental health, your general health, your ability to complete an education and your future job opportunities. That is absolutely good news.

But we don’t want to become complacent.

The supply of drugs is more dangerous, leading to an increase in overdose deaths. We’re not exaggerating. I mean, taking one of these drugs can kill you.

What about vaping? It has been falling, but use is still considerably higher than for cigarettes: In 2021, about a quarter of high school seniors said that they had vaped nicotine in the preceding year . Why would teens resist cigarettes and flock to vaping?

Most of the toxicity associated with tobacco has been ascribed to the burning of the leaf. The burning of that tobacco was responsible for cancer and for most of the other adverse effects, even though nicotine is the addictive element.

What we’ve come to understand is that nicotine vaping has harms of its own, but this has not been as well understood as was the case with tobacco. The other aspect that made vaping so appealing to teenagers was that it was associated with all sorts of flavors — candy flavors. It was not until the F.D.A. made those flavors illegal that vaping became less accessible.

My argument would be there’s no reason we should be exposing teenagers to nicotine. Because nicotine is very, very addictive.

Anything else you want to add?

We also have all of this interest in cannabis and psychedelic drugs. And there’s a lot of interest in the idea that psychedelic drugs may have therapeutic benefits. To prevent these new trends in drug use among teens requires different strategies than those we’ve used for alcohol or nicotine.

For example, we can say that if you take drugs like alcohol or nicotine, that can lead to addiction. That’s supported by extensive research. But warning about addiction for drugs like cannabis and psychedelics may not be as effective.

While cannabis can also be addictive, it’s perhaps less so than nicotine or alcohol, and more research is needed in this area, especially on newer, higher-potency products. Psychedelics don’t usually lead to addiction, but they can produce adverse mental experiences that can put you at risk of psychosis.

Matt Richtel is a health and science reporter for The Times, based in Boulder, Colo. More about Matt Richtel