Starting from the concept of anxiety, we proceeded to separate the “physiological” form from the “pathological” forms, distinguishing between fear, anguish, panic, phobia, fear, terror and stress, all terms often confused and overlapped in the common jargon. Distinguishing the individual psychopathologies contained in DSM-V anxiety disorders, with a focus on the psychodynamic profile, the analysis focused on the neural correlates involved in anxiety disorders and on the best pharmacological and psychotherapeutic approaches chosen to treat the morbid condition, paying particular attention to the strategic model and the most important clinical techniques.
The definition of anxiety is not unequivocal in the literature  although the descriptive characteristics are well circumscribed and easily identifiable. The American Psychiatric Association, on the definition of anxiety, describes anxi- ety as the anticipated anticipation of a future danger or negative event, accompanied by feelings of dysphoria or physical symptoms of tension. The elements exposed to risk may belong both to the internal world and to the external world  Similarly, in the Italian Treaty of Psychiatry, precisely in reference to the definition of anxiety, it is referred to as emotional state with an unpleasant content, associated with a condition of alarm and fear that arises in the absence of danger real and which, however, is disproportionate to any triggering stimuli .
However, the idea that it consists of a psychophysical state characterized by a feeling of apprehension, uncertainty, fear and alarm towards events towards which the subject feels helpless and/or is univocal helpless. It involves a psychic and somatic involvement, associating itself with biological modifications, and involving different systems, among which: neuro-transmittitorial, immune, neuroendocrine .
It represents an essential emotion for the correct functioning of our organism in response to external or internal stimuli, allowing a functional adaptation to environmental demands. The related manifestations of anxiety have prevalence,in the general population, of 2-4%, a value that rises to 20% in the non-psychotic psychiatric population. The feeling of anxiety, as well as, in an extremely polymorphous way, is felt by every human being, is characterized by a vague, widespread and unpleasant sense of apprehension, often accompanied by somatic symptoms autonomous species (palpitations, tachycardia, tremors, hyperhidrosis, etc.), but also from psychic symptoms and behavioral manifestations. Therefore, anxiety is necessary for the development of one’s existence; it becomes the source of a morbid condi- tion if the management of it becomes uncontrollable, to the point of undergoing a negative change in one’s lifestyle.
Anxiety is innate and is part of human nature. It is the normal response of our body that prepares to face what it perceives as a danger. We have the feeling of being vulner- able, even if sometimes we do not understand for sure why. When our ancestors faced the threat of ferocious animals or hostile peoples, the changes that took place in their bodies prepared them for struggle or flight. Nowadays the dangers are of a completely different nature, but faced with a situ- ation that frightens us, or that we perceive as threatening, the same changes occur in us at the time. When anxiety is moderate it can be useful, because it puts us on the alert in the face of a difficult situation allowing us to react quickly. It can become a real problem when it is excessive compared to the situation we are facing or lasts too long, to the point that doing the simplest thing can become a huge effort .
Another study then focused on the identification of the main constructs that cognitive theory associates with anxiety. In detail: the psychopathological constructs of anxiety are:
The “pathological” anxiety  therefore, can manifest itself in many ways:
In summary, when physiological anxiety becomes an abnormal reaction to a normal alarm situation, it then takes on the pathological appearance of one of the anxiety disorders described in the DSM-V and which we will see in the next section. To be straightforward, physiological anx- iety is the sensation of not being able to pass a university exam; the pathological version consists in the choice not to present ourselves at the exam session, despite the fact that there is an intense study of several months behind.
“Healthy” anxiety, however, must also be distinguished from other feelings, often confused in the common jargon in terms of terminology. We are talking about fear, anguish, phobia, panic, fear, terror and stress.
Let’s start with fear: anxiety is distinguished from fear because of the lack of a specific and recognizable stim- ulus that evokes the answer. This difference is underlined by several authors, including Nisita and Petracca, who de- scribe anxiety as an emotion that anticipates the danger in the absence of a clearly identified object”  defines anxiety in a timely manner as an objectless fear, and Rachman 2004, differentiates anxiety from fear, describing the former as a state of increased vigilance and the latter as a consequent emergency reaction to trigger factors. Fear can therefore be defined as that primordial feeling, present in every mam- mal, which allows automatic evaluation of a potential threat or danger so perceived, while anxiety is, instead, a more complex response system involving cognitive and emotional factors. ,behavioral and physiological. On this basis, it seems correct to state that anxiety and fear are physiological and normal responses in all individuals. Not surprisingly, sev- eral studies of cognitive neuroscience  have shown be- yond any doubt that anxiety states arise from an abnormal control of fear; in particular, starting from the assumption that anxiety is an adaptive state, anxiety disorders have a genetic component and that the anxious disorders are dif- ferent in intensity, time course and specific symptomatolo- gy, the researchers have concluded, also thanks to the use of images of neurovisualization (fMRI), which in the states of fear and anxiety, are called into question the neural circuits that originate in the amygdala; indeed, the activation of the amygdala was recorded in response to the presentation of a stimulus that induces fear, not consciously perceived.
Anguish is the extreme opposite of peace, the fifth extreme essence of dysfunctional anxiety, where the inva- siveness, the restlessness and the sense of catastrophe seen and perceived, from a psychodynamic point of view, from the Ego, such as to undermine the ego’s ability to control and manage the pressures of the Super-ego and the id, consisting of a painful emotional state in which there were processes of discharge, capable of creating symptoms . From this description we derive the general definition, which embodies it in the sense of frustration and psychophysical malaise, a prelude to various pathologies, precisely because this condition remains for a long time, in a subtle and constant way. In the clinic, we tend to distinguish the “situational or transitory” form (due to a specific circum- stance) from the “existential or chronic” form (due to the lack of processing and maturation of the triggering condi- tion).
The phobia is the pathological condition that is gen- erated as a result of specific fear and is determined by a sit- uation that is not really dangerous (or at least less danger- ous than the subject feels); this because the phobia, unlike fear, is not proportional to the risk to which one is aware of being exposed or believed to be exposed. In essence, fear degenerates deeply, thus provoking unjustified anxiety. The phobic object that triggers the episode can be of any kind  among the best known and widespread :
Panic is an abnormal and uncontrolled reaction to an initially neutral or mildly stressful situation. If, therefore, pathological anxiety, in most cases, is due to the limits that we impose ourselves for some form of fear, and the anguish is the result of a false Self, of an identity that does not belong to us but that we consider ours and that we do not recognize as false, the panic attack is the clinical manifestation of the result of a long-standing anxiety, to which we have never left space for the elaboration and that, in a moment often of apparent banality or serenity, while the ego’s defenses are at a minimum, it hits the victim by paralyzing her. It is not by chance that the main symptoms of a panic attack,according to the DSM-5 are: palpitations, cardio palmos, or tachycardia, sweating, fine tremors or great tremors, dyspnoea or suffocation, feeling of asphyxiation (lack of air), chest pain or discomfort, abdominal discomfort, discomfort, instability, lightheaded or fainting, derealisation (feeling of unreality) or depersonalization (being detached from oneself), fear of losing control or going crazy, fear of dying, paresthesia (sensations of numbness or tingling), chills or hot flashes. From the panic attack, which single episode, however, should be distinguished the real panic disorder, or the simultaneous presence of multiple, unexpected and recurrent panic attacks and at least one of the attacks must have been preceded by the persistent worry of having other attacks or concerns about the implications of the attack or its consequences (eg, losing control, having a heart attack, “going crazy”) or significant alteration of the behavior related to the attacks. The presence or absence of agoraphobia then represents a specification.
The fear is simply: the state of mind of those who fear can occur a harmful, painful or unpleasant event. It arises when a situation that suggests a pleasant effect, joins the possibility of suffering. One is afraid when the hypothesis that the expected pleasure may not occur is considered, however the hope is still present that pleasure comes and covers the thoughts of different and painful hypotheses. It’s the case of a person who waits for the beloved/or an appointment. A minimum delay ignites the fear that the pleasure (loved one) may not arrive, together with the frustration and sorrow (pain) that will ensue. When the person arrives, a smile of contentment covers the previous fear 
Terror, by contrast: is even more serious than panic. In terror, the muscles are paralyzed; the fight/flight reaction is entirely inhibited. It arises in extreme danger or pain situations. It is said: “frozen/petrified” by terror. The body deactivates any sensation coming from the periphery to limit the body’s sensitivity in the agony that precedes death. It is a withdrawal inward, as in a state of shock. The breath remains paralyzed in the exhalation phase. Terror can precede fainting; in this case life is maintained by the neuro-vegetative system through unconscious processes. If the terror persists for a long period of time, the depersonalization, dissociation of the ego perceived by the bodily processes It can occur both on a conscious level and during the night hours (eg night terror).  And finally the stress. A term widely used in popular jargon to indicate a state of nervousness and low-level anxiety, often connected to the family or work environment. In the literature, stress is universally regarded as the nonspecific psychophysical response of the organism to every request made on it [15, 16]
Based on the duration of the stressful event it is possible to distinguish two categories of stress: if the stimulus occurs only once and has a limited duration, it is called “acute stress”; if instead the source of stress persists over time, the expression “chronic stress” is used. Furthermore, according to the nature, the stressor (stressful events) is distinguished in distress, as an event that lowers the immune defenses (correlating it to frustration and anxiety), and eustress, which is an event that fosters greater vitality.
The generally perceived symptoms depend on the triggering event but can be summarized in physical-somatic (headache, abdominal pain, muscle pain, sensory disturbances, sexual disorders), emotional (tension, anxiety, unhappiness, restlessness), behavioral (feeding impaired sleep disorders, anger, substance abuse) and cognitive impairment (memory and attention deficit, difficulty in problem solving and agitation).
Anxiety disorders. Classifications according to the DSM-V and the psychodynamic model
Anxiety can become a symptom present in numerous psychopathological disorders. In other cases, it itself becomes the predominant framework of the clinical context (eg anxiety disorders). Anxiety disorders include all those disorders that share excessive fear and anxiety character- istics; fear as an emotional response to an imminent threat, not necessarily real, while anxiety as the anticipation of an imminent or future threat. Anxiety disorders are different from each other by type, nature and symptomatology; the DSM-V lists the following specific disorders in the category under consideration:
by the thoughts of imminence of the attack itself. It is severely disabling and often forces the subject to limit himself. It can be in comorbidity with the agoraphobic disorder that is the feeling of fear or serious discomfort that a subject feels when he finds himself in unfamiliar surroundings or in large open spaces, fearing he can- not control the situation, leading him to the need to find an immediate escape route to a place that he considers safer.
Generalized anxiety disorder is characterized by symptoms of persistent, pervasive, uncontrollable and generalist anxiety, induced by the excessive preoccupation with respect to the feared event. Individuals suffering from this disorder report feelings of anxiety and apprehension that are reflected in a general inability to relax or in more specific symptoms such as muscle weakness, rumination and irritability.
From a strictly psychodynamic point of view, in the Freudian model, anxiety corresponds to an ego affection, which controls access to consciousness, leading to censorship and the removal of the impulse of gratification if not accepted by external reality. An instinctual desire or a removed impulse can however be expressed in the form of a symptom; then, depending on the defense mechanisms involved, the hysterical rather than the phobic symptom will be witnessed, with the compulsive symptom rather than the avoidant symptom. At a more mature (and therefore conscious) level, the anxiety that comes from the superego can be understood in terms of torments of consciousness and feelings of guilt, deriving precisely from the gap between social expectation and actual moral manifestation [17-23]
The neural correlates in anxiety disorders
The brain systems that regulate the anxious re- sponse are quite complex; among the regions that play a primary role we find the amygdala, the hippocampus and the prefrontal cortex. The amygdala is the central nucleus of the circuits of fear, as a very complex structure able to respond promptly to the danger (be it potential or real), ac- tivating a whole series of somatic responses (such as the increase in heart rate and blood pressure, up to hyperventi- lation) and emotional and behavioral reflexes (such as reaction and flight).
The circuit in question takes into account anxiety, as a physiological and functional measuring mechanism for survival and evolution; however, if the critical threshold is exceeded, anxiety turns from adaptive to maladaptive (and therefore dysfunctional), leading to a worsening of performance and reactions.
Figure 1: The relationship between anxiety level and performance.
From a neuronal point of view, the anxiety-fear circuit involves the activation of two different ways: a “short” path (short loop) and a “long” path (long loop). In the first, the sensory thalamus, which collects all the sensory perceptions of our body, transmits the stimuli to the lateral amygdaloid nucleus, which in turn transmits them back to the central nucleus. From this last part stimulation of further structures determining: the increase of the respiratory frequency (due to the stimulation of the parabrachial nucleus), the increase of the arterial pressure and of the heart rate (due to an increase in the noradrenaline release induced by stimulation of the locus ceruleus). Moreover, the activation of the gray substance and of the paraventricular nucleus of the hypothalamus will determine, respectively, the manifestation of a defensive response of “block” and the activation of the hypothalamic-pituitary-adrenal (HPA) axis with a consequent increase in the adreno-corticoid. In the “long” way, the sensory cortex, the insula and the prefrontal cortex send the signal to the lateral amygdaloid nucleus. From here the signal is sent to the brainstem and hypothalamus. Central, in this way, unlike the short one, is the activation of the prefrontal cortex whose function is to modulate anxiety [4, 23]
The thalamus performs a function of primary link between the sensory systems exteroceptive (auditory, visual, somatosensory), main afferents of the neuronal circuits that determine anxiety and fear, and the primary sensory areas of the cerebral cortex, which project the sensory input to adjacent associative areas, for integrated stimulus processing. The cortical associative areas then send projections to various brain structures, such as amygdala, entorhinal cortex, orbital-frontal cortex, and the cingulum gyrus. The visceral afferences do not converge on the thalamus and activate the locus coeruleus and the amygdala, either through direct connections, or through pathways mediated by the paragigantocellular nucleus and by the nucleus of the solitary tract.
The fear response is particularly related to three of the 13 nuclei of the amygdala: the central nucleus (CA), the lateral amygdaloid nucleus (LA) and the basal nucleus (BA). Two circuits are known: the short one (short loop) that receives the stimuli from the sensory thalamus and transmits them to the LA which, in turn, transmits them to the CA. The long circuit (long loop) instead sends signals to the LA, by the SC, insula (INS) and the prefrontal cortex. From these areas signals are sent to the brainstem (BS) and to the hypothalamus (HYP), to which the autonomic and behavioral response of fear follows. The amygdala also receives unprocessed information from the thalamus; it represents the epicenter of the events involved in the modulation of anxiety states, both in animals and in humans, with a wide spectrum of reciprocal connections with the cortical and limbic structures, implicated in the emotional, cognitive, autonomic and endocrine response to stress. The neuronal interactions between the amygdala and the other cortical and subcortical regions allow the implementation of risk reaction behaviors, dependent on multiple variables such as the individual’s biological characteristics, his temperament, previous experiences, the contingent emotional situation, etc. In this sense, the importance of the stressful load of an event is more related to the subjective evaluation of an individual than to the objective reality of the event itself [10, 24]
Furthermore: the efferent pathways of the anxiety-fear circuit trigger an autonomic response, which involves the sympathetic and parasympathetic system. The sympathetic activation, mediated by the stimulation of the hypothalamus by amygdala and locus coeruleus, determines an increase in blood pressure and heart rate, sweating, piloerection and pupillary dilatation. Para-sympathetic activation, whose main projections are represented by the vague and splanchnic nerves, mediated by the hypothalamus, the paraventricular nucleus, the amygdala and the locus coeruleus, may be linked to visceral symptoms associated with anxiety, such as disorders gastrointestinal and genito-urinary. Finally, the CNS directly and indirectly influences the immune system through complex neuroendocrine and neuro-trans-territorial interactions: the modulation of the immuno surveillance can, then, under certain conditions of intense and protracted stress exposure, determine an organ or system meiopragy, until the appearance of an organic disease 
Several recent researches have also shown that:
Pharmacological and psychotherapeutic therapy for the resolution of anxiety disorders.Focus on the strategic approach
Anxious forms, in the first instance, are treated with psychotherapy. The most used approach is undoubtedly the cognitive-behavioral one, even if the protocol foreseen for the specific case is not always perfectly adapted to the patient, thus risking an incomplete resolution of the problems described in the anamnesis or worse a slippage of the object towards another object, as it often happens for the treatment of specific phobias. The list is therefore subject to continuous variations. However, it has been noted, in various researches [10,28] that psychotherapeutic treatment, if associated with pharmacological therapy, increases the chances of maintaining the desired result longer and faster, practicing distinct distinctions; in fact:
Cognitive behavioral therapy (TCC) is based on the assumption that our thoughts (and not external events) influence the way we feel; therefore, they determine our emotions not the situations but as we interpret and perceive the same. All modern cognitive theories assume that human experience is internalized and stored in memory in an organized manner. According to this perspective, anxious people have internalized certain cognitive patterns concerning the potential danger of certain situations with respect to their coping skills. The goal of TCC in the treatment of anxiety disorders is to identify and correct dysfunctional thoughts and beliefs, changing the behavior that causes the discomfort, also taking into account the factors of maintenance of these disorders, namely: avoidance of the feared object or situation; b) the continuation of the underlying problem; c) the automatic shift of attention to one’s anxious state (the reflection on ...), which produces a second-order anxiety. The TCC, however, provides several tasks, including: a) learn to recognize when you feel anxiety and how it manifests at the body level; b) to learn coping skills and relaxation techniques to deal with anxiety and panic; c) to face the feared situations (in imagination and in reality). Among the various techniques we mention: a) the “exposure”, implying precisely the gradual or drastic exposure of the person to feared situations and objects, allowing the person to feel more and more in charge of the situation through the ability to manage and lower anxiety levels; b) “systematic desensitization”, with which the situations considered as anxiety are progressively faced, according to a model constructed in three phases (learning of relaxation techniques, creation of a hierarchy of disturbing situations, active intervention).
A related model is the social learning of Bandura’s anxiety, according to which the basic mechanism that produces anxiety is the lack of self-efficacy beliefs in the individual. The cognitive model then expands the conditioning paradigm by suggesting that the initial automatic association between traumatic experiences and the specific object or situation results in the formation of patterns related to the danger. These then influence the anticipations of catastrophic ruin every time the individual confronts the feared object or situation. While the first versions of the cognitive and cognitive-behavioral model focused on conscious cognitions, now the most recent hypotheses focused on unconscious cognitive patterns, thus approaching the psychoanalytic, especially the more recent, which has shifted the focus away from the conflict to the unconscious representations of the Self, and of the Self in relation to the other, as the main determinants of conscious thought and behavior 
Also other approaches can then help for the resolution of anxiety disorders.
The experiential approach focuses on the emotions and the Greenberg model, linked to the concept of emotional patterns: An analysis of the content of such catastrophic conflicts shows that they reflect more broadly existential crises: the inevitability the loss, the experience of a separate consciousness that is often associated with the fear of being alone, the weight of individual responsibility, awareness and acceptance of one’s death, the need to balance our actions and expressiveness than the socio-cultural demands, the need to go through the painful process of deciding how much freedom, autonomy and novelty we need in our experience of comfort, security and protection. Each of these problems is involved in the struggle for self-esteem, and this battle necessarily involves the experience of demeaning emotions, such as humiliation, guilt, shame, anger. Depression is lurking. The experiential perspective is the one that most has to say about the role of emotions in the development and maintenance of disorders. This view differs from all others in the assumption that emotions are sources of biologically adaptive information that individuals ignore at their own risk. The problems derive from the learning of erroneous cognitions regarding emotional expression, which, as felt as dangerous or useless, is not followed .
The approach of the Self, according to Wolfe’s approach. In an anxious individual anxiety is felt as a basic threat to deep beliefs about the Self. This experience of self-impairment is characterized by a variety of states, which include a sense of loss of control, lack of security and impotence, and which push the individual to believe that he is unable to avoid a traumatic experience, or extremely painful, or humiliating. When people are in the middle of this experience they automatically shift their attention from the direct experience of anxiety to the thought of being anxious and this inevitably increases the level of anxiety. When, as happens in therapy, people manage to stay in touch with their immediate anxious experience, they understand that the experience of self-impairment represents a feared confrontation with a terribly painful self-perception. And it is only through this exploration of the implicit meaning of anxiety that lasting healing can take place. Wolfe indicates five types of wounds of the Self, corresponding to five types of strongly anxious painful perceptions of self: a) the biologically vulnerable Self (fear of extreme vulnerability to diseases or physical impediments); b) the inadequate or incapable Self (fear of situations reminiscent of past failures of a performance); c) the shameful, imperfect, humbled self; d) the dissatisfied or isolated Self; e) the Conflict or confused Self (often a difficulty in recognizing one’s needs or a conflict between the basic needs of the individual and his values). There are many sources of wounds of the Self, most of which are interconnected: traumatic experiences, ideas of shame or humiliation, betrayals by other significant, emotional diseducation, ineffective responses to life’s existential data. Anxiety disorders are maintained by numerous factors, most of which have to do with protecting oneself from the atrociously painful perception of the self. Instead of confronting openly with the wounds of the Self, anxious people generally implement these three strategies to keep them hidden: reflection on the state of anxiety and on potential catastrophes, avoidance of anxiogenic situations, negative circles of interpersonal behavior (those who see themselves negatively involve so that others reinforce this idea). These strategies result in a temporary reduction in anxiety but at the high price of reinforcing the maladaptive beliefs of one’s inability to manage the feared situations. The three fundamental elements of anxiety disorders are therefore: 1) immediate experience of anxiety; 2) the automatic shift of attention to one’s anxious state (to reflect on), which produces second-order anxiety; 3) a tacit perception of self, but painful 
The emotional approach, linked to Bowlby’s thinking, is based on the concept of attachment. The child preserves and classifies the facts and emotions he feels on the basis of the decoding, or interpretation, of which the parent provides them. When parents give him a distorted codification of facts and emotions that is, not corresponding to the actual emotion that the child feels, it follows for him the impossibility to accept all the experiences that on the conscious level When we cannot use our emotions, there is a risk of psychopathological implications. The memories of the responses coming from the attachment figures are incorporated into cognitive structures that will constitute the convictions and expectations of the child and then of the adult each time they are in difficult conditions [32, 33].
But without doubt, the most complete is the short strategic approach. The strategic therapist has the task of developing a series of intervention strategies capable of producing effective, rapid and resolutive changes to theproblem that afflicts the patient. From the focus of the strategic, suggestive and persuasive Chinese art to modern times, with Bateson, Watzlawick and other researchers from the Mental Research Institute (known as the “Palo Alto School”) and in Italy, with Nardone and Petruccelli, the approach strategic has found its space ever more dominant in the psychological landscape. Assuming that the individual should not be considered, but all the context and relationships that bind the patient to all the components of his mental and social universe, there is no objective reality and pathologies are the manifestation of discomfort, the result of attempted solutions rigidly applied. An attempted solution that does not work, if repeated, does not solve the problem but complicates it, eg avoidance of the anxiogenic situation in phobic disorder. It is therefore necessary to block the attempted ineffective and pathological solutions and to stimulate the experiences that change the perception of the problem. The intervention that leads to change is the provoking of concrete perceptive experiences that put the person in a position to try something different in relation to the reality to be changed. Strategic therapy is not a superficial and symptomatic therapy but a radical intervention, as it aims at restructuring the ways through which each one organizes the reality that then undergoes. Therapeutic attention is focused on: a) how the person, and the people around her, have tried unsuccessfully to solve the problem, or the attempted solutions that feed the problem; b) to ask oneself not the why but how it is maintained and how to change the negative experience in positive. In the hypothesis of anxiety disorders, the suggested therapeutic strategies concern: a) give a task that distracts, exposing however to the situation avoided The strategic approach then proceeds by agreed objectives, pursues results and solutions and adapts perfectly to the patient, without fixed or rigid schemes, elevating the word spearhead of the therapist’s tools, also thanks to the choice of the use of the criteria strategic operations, i.e. the logic of paradox, contradiction and belief. The approach in question, using these logics, allows you to quickly interrupt the vicious circles by offering the patient the most effective maneuver (with respect to the result) and more efficient (with respect to time and cost/ benefit). On the other hand, given the results, the advantages of this approach cannot be questioned: the safety of the results; the effectiveness obtained in a short time; the use of tools, guidelines and protocols already successfully tested; the positive modification of the patient’s way of feeling the world; the stability of positive results over time. 
The most decisive treatment for anxiety disorders is identified in the combination between the profiles linked to the psychotherapeutic approach and to the pharmacological one. Compared to the first element, the short-term strategic approach seems to be the best in terms of healing, as it provides the tools necessary for its resolution, drawing on the cognitive-behavioral protocols extended with the strategic techniques of the Palo Alto school and the systemic-relational school. Compared to the second element, on the other hand, it certainly appears useful in two precise hypotheses: 1) when the symptomatology is so invalidating as to prevent the patient from orienting himself favorably towards psychotherapeutic therapy; 2) when the word approach alone is not sufficient to teach the patient the best management of his disorder, perhaps in the presence of a biological or family vulnerability.