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PSY 301
INTRODUCTION to PSYCHOPATHOLOGY
Dr. İlkiz Altınoğlu Dikmeer
Fall 2014
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PowerPoint  Lecture Notes Presentation
Chapter 6 (ch 5 in 11th ed)
Abnormal Psychology,
Twelfth Edition
Anxiety Disorders
by
Ann M. Kring,
Sheri L. Johnson,
Gerald C. Davison,
& John M. Neale
Copyright © 2012 John Wiley & Sons, Inc. All rights reserved.
Chapter Outline
• Chapter 6: Anxiety Disorders
I. Clinical Descriptions of Anxiety Disorders
II. Common Risk Factors Across the Anxiety
Disorders
III. Treatment of Anxiety Disorders
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Anxiety vs. Fear
• Anxiety
– Apprehension about a future threat
• Fear
– Response to an immediate threat
• Both involve physiological arousal
– Sympathetic nervous system
• Both can be adaptive
– Fear triggers “fight or flight ”
• May save life
– Anxiety increases preparedness
• “U-shaped” curve (Yerkes & Dodson, 1908)
– Absence of anxiety interferes with performance
– Moderate levels of anxiety improve performance
– High levels of anxiety are detrimental to performance
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Anxiety Disorders
• Most common psychiatric disorders
• 28% report anxiety symptoms
• Most common are phobias
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Anxiety Disorders
• DSM-IV-TR
• DSM-5
– Specific and social phobias
– Panic disorder and
agoraphobia
– Generalized anxiety disorder
– Obsessive compulsive
disorder
– Posttraumatic stress disorder
–
–
–
–
–
Specific phobias
Social anxiety disorder
Panic disorder
Agoraphobia
Generalized anxiety disorder
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Figure 6.1: Diagnoses of Anxiety Disorders
The DSM-IV-TR Anxiety Disorders
have been divided into three
chapters in the proposed DSM-5:
Anxiety Disorders, ObsessiveCompulsive and Related
Disorders, and Trauma- and
Stressor-Related Disorders.
Agoraphobia has been changed
from a subtype of panic disorder
to a diagnosis in its own right.
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Table 6. 1: DSM-IV-TR and Proposed DSM-5 Diagnoses
of Anxiety Disorders
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Phobias
• Disruptive fear of a particular object or situation
– Fear out of proportion to actual threat
– Awareness that fear is excessive
– Must be severe enough to cause distress or interfere with job or
social life
• Avoidance
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Specific Phobia
• Disproportionate fear of a particular object or situation
–
–
–
–
Common examples: fear of flying, snakes, heights, etc.
Fear out of proportion to actual threat
Awareness that fear is excessive
Most specific phobias cluster around a few feared objects and
situations
– High comorbidity of specific phobias
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Proposed DSM-5 Criteria for Specific Phobia
• Marked and disproportionate fear consistently triggered by
specific objects or situations
• The object or situation is avoided or else endured with
intense anxiety
• Symptoms persist for at least 6 months
– Note: The DSM-IV-TR criterion that the person recognizes that the
fear is unrealistic is not included in DSM-5.
– DSM-IV-TR includes the duration criterion only for those under age
18
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Table 6.2:
Words Used to Describe Highly Unlikely Phobias
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Table 6.3: Types of Specific Phobias
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Social Anxiety Disorder
• Called Social Phobia in DSM-IV-TR
– Causes more life disruption than other phobias
• More intense and extensive than shyness
– Persistent, intense fear and avoidance of social situations
– Fear of negative evaluation or scrutiny
– Exposure to trigger leads to anxiety about being humiliated or
embarrassed socially
– Onset often adolescence
• 33% also diagnosed with Avoidant Personality Disorder
– Overlap in genetic vulnerability for both disorders
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Proposed DSM-5 Criteria for Social Anxiety Disorder
• Marked and disproportionate fear consistently triggered by
exposure to potential social scrutiny
• Exposure to the trigger leads to intense anxiety about being
evaluated negatively
• Trigger situations are avoided or else endured with intense
anxiety
• Symptoms persist for at least 6 months.
– Note: DSM-IV-TR labels this disorder as social phobia
– The DSM-IV-TR, but not the DSM-5, specifies that the person recognizes the fear is
unrealistic
– DSM-IV-TR includes the duration criterion only for those under age 18
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Panic Disorder
• Frequent panic attacks unrelated to specific situations
• Panic attack
– Sudden, intense episode of apprehension, terror, feelings of
impending doom
• Intense urge to flee
• Symptoms reach peak intensity within 10 minutes
– Physical symptoms can include:
• Labored breathing, heart palpitations, nausea, upset stomach, chest pain,
feelings of choking and smothering, dizziness, sweating, lightheadedness,
chills, heat sensations, and trembling
– Other symptoms may include:
• Depersonalization
• Derealization
• Fears of going crazy, losing control, or dying
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Panic Disorder
• Uncued attacks
– Occur unexpectedly without warning
– Panic disorder diagnosis requires recurrent uncued
attacks
– Causes worry about future attacks
• Cued attacks
– Triggered by specific situations (e.g., seeing a snake)
• More likely a phobia
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Proposed DSM-5 Criteria for Panic Disorder
• Recurrent uncued panic attacks
• At least 1 month of concern about the possibility of
more attacks, worry about the consequences of an
attack, or behavioral changes because of the attacks
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Agoraphobia
• From the Greek word “agora” or marketplace
• Anxiety about inability to flee anxiety- provoking
situations
– E.g., crowds, stores, malls, churches, trains, bridges, tunnels,
etc.
– Causes significant impairment
• In DSM-IV-TR, was a subtype of Panic Disorder
– Al least half of agoraphobics do not suffer panic attacks
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Proposed DSM-5 Criteria for Agoraphobia
• Disproportionate and marked fear or anxiety about at least 2
situations where it would be difficult to escape or receive help
in the event of incapacitation or panic-like symptoms, such as:
– being outside of the home alone; traveling on public
transportation; open spaces such as parking lots and marketplaces;
being in shops, theaters, or cinemas; standing in line or being in a
crowd
• These situations consistently provoke fear or anxiety
• These situations are avoided, require the presence of a
companion, or are endured with intense fear or anxiety
• Symptoms last at least 6 months
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Generalized Anxiety
Disorder (GAD)
• Involves chronic, excessive, uncontrollable worry
– Lasts at least 6 months
– Interferes with daily life
• Often cannot decide on a solution or course of action
• Other symptoms:
– Restlessness, poor concentration, tiring easily, restlessness,
irritability, muscle tension
• Common worries:
– Relationships, health, finances, daily hassles
• Often begins in adolescence or earlier
– I’ve always been this way
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Proposed DSM-5 Criteria for
Generalized Anxiety Disorder
•
•
•
Excessive anxiety and worry at least 50 percent of days about at least two life domains (e.g.,
family, health, finances, work, and school)
The worry is sustained for at least 3 months
The anxiety and worry are associated with at least three of the following:
–
–
–
–
–
–
•
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
The anxiety and worry are associated with marked avoidance of situations in which negative
outcomes could occur, marked time and effort preparing for situations that might have a negative
outcome, marked procrastination, difficulty making decisions due to worries, or repeatedly seeking
reassurance due to worries
–
–
–
–
Note: Italics reflect changes introduced in DSM-5.
The DSM-IV-TR criterion that the person finds it hard to control the worry is not included in DSM-5.
The DSM-IV-TR criteria specify duration of 6 months rather than 3 months.
DSM-IV-TR criteria specified that the anxiety was about a number of events or activities.
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Comorbidity
• 80% of those with anxiety disorder meet criteria for
another anxiety disorder
– Subthreshold symptoms (do not meet full DSM) very common
– Causes of comorbidity
• Symptoms used to diagnose the various anxiety disorders overlap:
– Social anxiety and agoraphobia might both involve a fear of crowds
• Etiological factors may increase risk for more than one anxiety disorder
• 75% of those with anxiety disorder meet criteria for
another psychological disorder
– Disorders commonly comorbid with anxiety:
•
•
•
•
60% with anxiety also have depression
Substance abuse
Personality disorders
Medical disorders, e.g. coronary heart disease
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Gender and
Sociocultural Factors
• Women are twice as likely as men to have anxiety disorder
– Possible explanations
•
•
•
•
Women may be more likely to report symptoms
Men more likely to be encouraged to face fears
Women more likely to experience childhood sexual abuse
Women show more biological stress reactivity
• Cultural factors
– Culturally specific syndromes
• Taijin kyofusho
– Japanese fear of offending or embarrassing others
• Kayak-angst
– Inuit disorder in seal hunters at sea similar to panic
– Ratio of somatic to psychological symptoms appears similar
across cultures (Kirmayer, 2001)
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Table 6.4: Percent of People Who Meet Diagnostic Criteria for Anxiety
Disorders in the Past Year and in Their Lifetime
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Table 6.5: Factors that May Increase the Risk for More than
One Anxiety Disorder
•
•
•
•
Behavioral conditioning
Genetic vulnerability
Increased activity in the fear circuit of the brain
Decreased functioning of GABA and serotonin; increased
norepinephrine activity
• Behavioral inhibition
• Neuroticism
• Cognitive factors, including sustained negative beliefs,
perceived lack of control, and attention to cues of threat
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Etiology of Specific Phobias
• Conditioning
• Mowrer’s two-factor
model
– Pairing of stimulus with
aversive UCS leads to fear
(Classical Conditioning)
– Avoidance maintained
though negative
reinforcement (Operant
Conditioning)
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Etiology of Specific Phobias
• Extensions of the two-factor model
– Modeling
• Seeing another person harmed by the stimulus
– Verbal instruction
• Parent warning a child about a danger
– Those with anxiety tend to acquire fear more readily
• And to be more resistant to extinction
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Risk Factors
• Genetic
– Twin studies suggest heritability
• About 20-40% for phobias, GAD, and PTSD
• About 50% for panic disorder
– Relative with phobia increases risk for
other anxiety disorders in addition to
phobia
• Neurobiological
– Fear circuit overactivity
• Amygdala
• Medial prefrontal cortex deficits
– Neurotransmitters
• Poor functioning of serotonin and GABA
• Higher levels of norepinephrine
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Risk Factors: Personality
• Behavioral inhibition
– Tendency to be agitated, distressed, and cry in unfamiliar or novel
settings
• Observed in infants as young as 4 months
• May be inherited
– Predicts anxiety in childhood and social anxiety in adolescence
• Neuroticism
– React with negative affect
– Linked to anxiety and depression
– Higher levels linked to double the likelihood of developing anxiety
disorders
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Risk Factors: Cognitive
• Sustained negative beliefs about future
– Bad things will happen
– Engage in safety behaviors
• Belief that one lacks control over environment
– More vulnerable to developing anxiety disorder
• Childhood trauma or punitive parenting may foster beliefs
• Serious life events can threaten sense of control
• Attention to threat
– Tendency to notice negative environmental cues
• Selective attention to signs of threat
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Table 6.6: Percent of People Reporting Conditioning
Experiences Before the Onset of a Phobia
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Etiology of Specific Phobias
• Two-factor model of behavioral conditioning
– Conditioned responses to threat
– Sustained by avoidance or safety behaviors
• Avoid eye contact, appear aloof, stand apart from others in social
settings
• Risk factors act as diatheses
– Vulnerabilities influence development of phobias
• Prepared learning
– Evolutionary preparation to fear certain stimuli
• Potentially life-threatening (heights, snakes, etc.)
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Etiology of Social Anxiety Disorder
• Cognitive factors
– Unrealistic negative beliefs about consequences of
behaviors
– Excessive attention to internal cues
– Fear of negative evaluation by others
• Expect others to dislike them
– Negative self evaluation
• Harsh, punitive self-judgment
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Etiology of Panic
• Neurobiological factors
– Locus ceruleus
• Major source of norepinephrine
– A trigger for nervous system
activity
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Etiology of Panic
• Interoceptive conditioning
– Classical conditioning of panic in
response to internal bodily
sensations
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Etiology of Panic
• Cognitive factors
– Catastrophic misinterpretations of
somatic changes
• Interpreted as impending doom
– I must be having a heart attack!
• Beliefs increase anxiety and arousal
• Creates vicious cycle
• Anxiety Sensitivity Index
– High scores predict development of panic
• “Unusual body sensations scare me.”
• “When I notice that my heart is beating rapidly, I worry
that I might have a heart attack.”
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Etiology of Agoraphobia
• Fear-of-fear hypothesis (Goldstein & Chambless, 1978)
– Expectations about the catastrophic consequences of
having a public panic attack
• What will people think of me?!?!
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Etiology of GAD
• GABA system deficits
• Borkovec’s cognitive model:
– Worry reinforcing because it distracts from negative
emotions and images
– Allows avoidance of more disturbing emotions
• e.g., distress of previous trauma
– Worrying decreases psychophysiological arousal
– Avoidance prevents extinction of underlying anxiety
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Figure 6.8: The Excessive Worry of GAD May be an
Attempt to Avoid Intense Emotions
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Treatment of the Anxiety Disorders
• Psychological treatments emphasize
Exposure
– Face the situation or object that triggers anxiety
• Should include as many features of the trigger as possible
• Should be conducted in as many settings as possible
• 70-90% effective
• Systematic desensitization
– Relaxation plus imaginal exposure
• Cognitive approaches
– Increase belief in ability to cope with the anxiety trigger
– Challenge expectations about negative outcomes
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Psychological Treatment of Phobias
• Phobias
– Exposure
• In vivo (real-life) exposure more effective than systematic desensitization
• Social Anxiety Disorder
– Exposure
• Role playing or small group interaction
– Social skills training
• Reduce use of safety behaviors
– Cognitive therapy
• Clark’s (2003) cognitive therapy more effective than medication or
exposure
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Psychological Treatment of Panic
• Panic Control Therapy (PCT; Craske & Barlow, 2001)
– Exposure to somatic sensations associated with panic
attack in a safe setting
• Increased heart rate, rapid breathing, dizziness
– Use of coping strategies to control symptoms
• Relaxation
• Deep breathing
– PCT benefits maintained after treatment ends
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Psychological Treatment of Agoraphobia
• Cognitive Behavioral Therapy (CBT)
– Systematic exposure to feared situations
– Self-guided treatment effective
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Psychological Treatment of GAD
• Relaxation training
• Cognitive Behavioral methods
–
–
–
–
Challenge and modify negative thoughts
Increase ability to tolerate uncertainty
Worry only during “scheduled” times
Focus on present moment
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Medications
• Anxiolytics: drugs that reduce anxiety
– Benzodiazepenes
• Valium
• Xanax
– Antidepressants
• Tricyclics
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
– D-cycloserine (DCS)
• Enhances learning during exposure treatment
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