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Chapter 8
Anxiety Disorders:
Panic Disorder, Agoraphobia,
Generalized Anxiety Disorder, Social
Anxiety Disorder and Specific Phobias
Anxiety Disorders
• Much of what we know is based on studies
using criteria the predate DSM-5
• Anxiety disorders are prevalent and quite
debilitating
• In the United States, almost one-third of
individuals will meet criteria for at least one
anxiety disorder in their lifetimes
– Prevalence rate is secondary only to substance use
disorders
Panic Attacks
• A panic attack is defined as a discrete period
of intense fear or discomfort that begins
abruptly and reaches the peak within 10
minutes (plus at least four other symptoms)
• Panic attacks may be expected (cued) or
unexpected (uncued)
• Panic attacks may occur in the nonclinical
populations and in those with a comorbid
psychiatric disorder
Panic Attack Symptoms
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath or smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded, or faint
Derealization (feelings of unreality) or depersonalization (being
detached from oneself)
Fear of losing control or going crazy
Fear of dying
Paresthesias (numbness or tingling sensations)
Chills or hot flushes
Panic Disorder: DSM-5
• The diagnosis of panic disorder requires recurrent
and unexpected (uncued) panic attacks
• Followed by one month of concern about:
— Additional attacks or implication of the attack
— Changes in behavior
• DSM-5 does not recognize subtypes of panic
disorder (respiratory, nocturnal)
Agoraphobia: DSM-5
• Agoraphobia is a fear of being in places or situations from
which escape might be difficult (or embarrassing) or in
which help may not be available if a panic attack occurred
• Patients with agoraphobia avoid (or endure with marked
distress) certain situations (large stores, crowded places;
traveling in a bus, train, or automobile) and being far away
from home
• Previously viewed as a frequent but secondary feature of
panic disorder
• Independent diagnosis in DSM-5
Generalized Anxiety Disorder (GAD):
DSM-5
• Characterized by worry, which is typically defined as repetitive thinking
about potential future threat, imagined catastrophes, uncertainties, and
risks; patients with GAD spend an excessive amount of time worrying
and feeling anxious about a variety of topics and find it difficult to
control the worry
• Associated with three (or more) of the following six symptoms:
1.
Restlessness or feeling keyed up or on edge
2.
Being easily fatigued
3.
Difficulty concentrating or mind going blank
4.
Irritability
5.
Muscle tension
6.
Sleep disturbance (difficulty falling or staying asleep, or restless
unsatisfying sleep)
Social Anxiety Disorder (SAD):
DSM-5
• Marked and persistent fear of social or performance situations
in which embarrassment may occur
• Exposure to or anticipation of the situation almost invariably
provokes anxiety, which may take the form of a situationally
bound or situationally predisposed panic attack
• Situations are avoided or endured with intense anxiety or
distress
• Clinician judgment that the fear is excessive or unreasonable
• Interferes significantly with normal functioning, or there is
marked distress about having the phobia.
Specific Phobias: DSM-5
• Marked and persistent fears of clearly discernible,
circumscribed objects or situations
• Exposure to the phobic stimulus almost invariably provokes
an immediate anxiety response, which may take the form of
a situationally bound or situationally predisposed panic
attack
• Five subtypes are recognized in DSM-5:
– Animals (snakes, spiders); natural environment (storms);
blood/injection/injury; situations (elevators, flying); and other
(choking, vomiting, falling)
• Situation is avoided or is endured with intense anxiety or
distress
Epidemiology: Panic Disorder
• Prevalence (based on panic disorder with agoraphobia)
– 1.5% to 5% lifetime; 1% to 2.7% 12-month prevalence
• Gender
– 2:1 ratio of females to males
• Age of onset
– Average of 26.5 years of age
• Comorbidity
– 59% mood or anxiety disorder
– 23% major depressive disorder
• Clinical course
– 12-month remission rate is approximately 17%, and the 5year remission rate is 39%
Epidemiology: GAD
• Prevalence
– 5.7% lifetime prevalence; 12-month prevalence is 3.1%
• Gender
– 2:1 ratio of females to males
• Age of onset
– Later than other anxiety disorder, 50% by age 31
• Comorbidity
– 26% also meet criteria for major depressive disorder
– Also highly comorbid with other anxiety disorders
• Clinical course
– Longitudinal study found that 42% who had GAD at
baseline were still symptomatic at 12-year follow-up
– Even with CBT, only 50% achieve high end-state
functioning
Epidemiology: SAD
• Prevalence
– 5.0% to 13.3% lifetime; 12-month is 2.8% to 6.8%
• Sex
– Relatively equal between genders, 1.4:1 females to males
• Age of onset
– Average age is 15; median age is 12.5 years
• Comorbidity
– 45% mood or anxiety disorder
– 28% anxiety disorder alone
– 14% major depressive disorder
• Clinical course
– The 12-month remission rate is approximately 7%, and the
5-year remission rate is approximately 27%
Epidemiology: Specific Phobia
• Prevalence
– 2% to 12.5% lifetime; 1.8% to 8.7% for 12-month
• Gender
– 4:1 ratio of females to males
• Age of onset
– Between 9 and 16 years of age
• Comorbidity
– Only 24.4% of individuals with specific phobias have a
single specific phobia
– 34% meet criteria for an additional disorder, with mood
and anxiety disorders most common
• Clinical course
– The 15-month full remission rate is estimated to be
approximately 19%
Pharmacological Treatment
• Benzodiazepines, selective serotonin reuptake inhibitors
(SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs),
monoamine oxidase inhibitors (MAOIs), and tricyclic
antidepressants
• A growing body of research suggests that SSRIs and SNRIs
should be considered the front-line pharmacological agents
for panic disorder and social anxiety disorder
• The use of pharmacological agents in the treatment of specific
phobias is limited
Cognitive-Behavioral Treatments
• Panic disorder
– CBT that incorporates psychoeducation, interoceptive and in vivo
exposures, and cognitive restructuring have been very successful
– Interoceptive exposure: Feared arousal-related sensations are
provoked to facilitate habituation and allow for disconfirmation of
feared catastrophes associated with such sensations in the absence of
maladaptive responses, such as avoidance
• Generalized anxiety disorder
– CBT shown to be effective; exposure is not used to treat worry; instead
nonadaptive patterns of awareness, physiology, behavior, and
cognition are targeted
– Less successful treatment for GAD than other anxiety disorders
Cognitive-Behavioral Treatments cont.
• Social anxiety disorder
– Psychoeducation, exposure, and cognitive restructuring
– In exposure therapy, individuals engage in feared social-evaluative
situations to allow for disconfirmation of feared catastrophes
associated with such situations
– Newer formulations incorporate manipulation of self-focused
attention, dropping of safety behaviors, reevaluation of social costs,
and change in self-perceptions
• Specific phobias
– Exposure therapy is typically used for specific phobias
– In the absence of avoidance responses, exposure leads to habituation
Assessment
• Clinical interviews
– Anxiety Disorders Interview Schedule (ADIS)
– Structured Clinical Interview (SCID)
• Clinician- and self-report measures
–
–
–
–
–
Panic Disorder Severity Scale
Generalized Anxiety Disorder Questionnaire
Agoraphobic Cognitions Questionnaire
Social Phobia and Anxiety Inventory
Fear Survey Schedule
• Behavioral tests
– Behavioral Approach Test (BAT)
– Self-monitoring
• Biological assessment
– CT and MRI for structural assessment
– SPECT fMRI and PET for functional assessment
Etiology: Behavioral Genetics
• 20% of the variance is attributable to heritable genetics
• Familial factors (i.e., environmental factors shared by twins
and siblings) account for less than 10% of the variance
• The majority of the variance (perhaps as much as 70%) is
attributed to unique environmental factors and measurement
error
• Compared to other psychological disorders, these anxiety
disorders appear to be relatively less influenced by heritable
genetics and more influenced by environment or by gene–
environment
Etiology: Biological Considerations
• Fight or flight: Designed to prevent or avoid physical danger and
harm; involves a fast and efficient response
• Amygdala  hypothalamus  releases corticotropin-releasing
factor (CRF)  triggers the pituitary to release adrenocorticotropic
hormone (ACTH)  triggers the adrenal cortex to release
hormones, including cortisol
• Hypothalamus also activates the sympathetic nervous system,
which perpetuates other changes associated with the fight-or-flight
response
• These physiological changes constitute the physical symptoms of a
panic attack
Etiology: Personality and Temperament
• Anxiety sensitivity
– Dispositional trait that is characterized by a fear of autonomic
arousal and the physical sensations associated with anxiety
states
– “Fear of fear” is often viewed as the key feature of panic
disorder
• Behavioral inhibition and shy temperament
– An enduring tendency to respond to unfamiliar events with
anxiety
– Relative stability of socially inhibited behavior from the first
years of life until adulthood is consistent with the view of social
anxiety disorder as rooted in relatively unchangeable traits
– A substantial number of children classified as BI do not go on to
develop social anxiety disorder
Etiology: Behavioral Considerations
• Classical conditioning
– Little Albert: fears can be acquired through a repeated
process of paired learning
• Operant conditioning
– Avoidance behavior that accompanies phobic fear is
maintained through a process of negative reinforcement
• Vicarious conditioning
– Observational learning or learning by modeling
• Informational acquisition
– Development of a fear as a result of receiving information,
such as from a parent or doctor
Etiology: Cognitive Considerations
• Situation-specific cognitions and related variables
– Expectancies, concerns, automatic thoughts, catastrophic thoughts,
and catastrophic misinterpretations
– Overestimations of fear and danger
– Self-efficacy
• Attentional biases
– Anxiety is associated with biases in various attentional processes,
namely orienting, engagement, and disengagement.
– Occur in all anxiety disorders
• Self-focused attention
– Tendency for socially anxious individuals to attend to internal stimuli
rather than external, social stimuli
– Important factor in the maintenance of social anxiety
Culture, Socialization,
and Social Environment
• Parental messages about the importance of interoceptive sensations;
parental reinforcement of illness behavior
• Reciprocal effects between the individual and the social environment
– Modeling; informational acquisition; selection, creation, and
interpretation of social opportunities; and the internalization of
messages that one receives about one’s social value
• Cultural variations in the disorders
– Ataque de nervios
– Taijin Kyofusho
• Life events
– Individuals with social anxiety disorder retrospectively report greater
incidence of traumatic social events than do healthy controls
– Latent inhibition