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Chapter 4
Anxiety Disorders
Cause clinically significant distress and impairment
The Complexity of Anxiety Disorders
• Anxiety – future-oriented mood state
– Apprehension about future danger or
misfortune; especially inability to control
– Somatic and behavior symptoms of tension
– Characterized by negative affect
• Anxiety and fear are normal emotional states
The Complexity of Anxiety Disorders
• Fear – the present-oriented mood state
– Immediate fight or flight response to danger or
threat
– Involves sympathetic nervous system
– Strong avoidance/escapist tendencies
– Marked negative affect
Biological Contributions to Anxiety and
Panic
• Genetic vulnerability
• Anxiety and brain circuits
– Depleted levels of GABA
Biological Contributions to Anxiety and
Panic (continued)
• Limbic (amygdala)
• septal-hippocampal systems to frontal cortex
called the Behavioral inhibition system (BIS)
– Anxiety
• Fight/flight system (FF)
– panic
Psychological Contributions to Anxiety
• Integrated model
– Early childhood - Experiences with
uncontrollability and unpredictability
– Especially how parents respond to child’s needs
– “secure base” vs. overprotective parents
Psychological Contributions to Fear
• Behavioral and cognitive views
– Invokes conditioning and cognitive explanations
– Anxiety and fear are learned responses
– Catastrophic thinking and appraisals play a role
• Social contributions
– Stressful life events trigger vulnerabilities
An Integrated Model
– Comorbidity is common across the anxiety
disorders (about 50%)
– Major depression is the most common
secondary diagnosis
The Anxiety Disorders:
An Overview
• Generalized anxiety disorder (GAD)
• Panic disorder with and without agoraphobia
(PDA)
• Specific phobias
• Social phobia (SAD)
• Posttraumatic stress disorder (PTSD)
• Obsessive-compulsive disorder (OCD)
Generalized Anxiety Disorder: The
“Basic” Anxiety Disorder
– Excessive uncontrollable, unfocused, anxious
apprehension and worry, persistent anxiety
– Difficulties in controlling the worry
– Persists for six months or more
– Somatic symptoms differ from panic
(e.g., muscle tension)
Generalized Anxiety Disorder: The
“Basic” Anxiety Disorder
• Statistics
– about 3.1% of the general population
– Females outnumber males approximately 2:1
– Onset is often insidious, beginning in early
adulthood (median age is 31)
– Very prevalent among the elderly
– Tends to run in families
Generalized Anxiety Disorder:
Associated Features and Treatment
• Associated features
– Persons with GAD have been called “autonomic
restrictors”
– Fail to process emotional component of thoughts
and images
• Causes – factors influencing
– Genetics
– Muscle tension
– Personal threat
– Automatic restrictors
Generalized Anxiety Disorder:
Associated Features and Treatment
• Treatment of GAD: Generally weak
– Benzodiazapines – often prescribed
– Antidepressents (may be more effective than benzos)
– Psychological interventions –
cognitive-behavioral therapy
– Meditation therapy
The Phenomenology of Panic Attacks
• What is a panic attack?
– Abrupt experience of intense fear or discomfort
– Several physical symptoms
(e.g., breathlessness, chest pain)
– Fear as an alarm response
DSM-IV for Panic Attack
• Intense fear or discomfort, in which four (or more) symptoms
developed abruptly and reached a peak within 10 minutes:
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1) palpitations, pounding heart, or accelerated heart rate
2) sweating
3) trembling or shaking
4) sensations of shortness of breath or smothering
5) feeling of choking
6) chest pain or discomfort
7) nausea or abdominal distress
8) feeling dizzy, unsteady, lightheaded, or faint
9) derealization (feelings of unreality) or depersonalization (being detached
from oneself)
10) fear of losing control or going crazy
11) fear of dying
12) paresthesias (numbness or tingling sensations)
13) chills or hot flushes
The Phenomenology of
Panic Attacks
• DSM-IV-TR subtypes of panic attacks
– Situationally bound (cued)
– Unexpected (uncued)
– Situationally predisposed
• Cultural influences on anxiety
Panic Disorder With and Without
Agoraphobia
• Overview and defining features
– Experience of unexpected panic attack (i.e., a false
alarm)
– Develop anxiety, worry, or fear about another
attack
– Many develop agoraphobia
Panic Disorder With and Without
Agoraphobia
• Facts and statistics
– Affects about 2.7% of the general population
– Onset is often acute, mean onset between 20 and
24 years of age
– 66% female
• Cultural influences
• Associated features
– Nocturnal panic attacks – 60% panic during deep
non-REM sleep
– Interoceptive/exteroceptive cues avoidance
Panic Disorder: Associated Features and
Treatment
• Causes
– Biological, psychological and social (triad)
– 8% to 12% of people have occasional panic attacks
• Medication treatment
- Effective in 60%
– Target serotonergic, noradrenergic, and GABA systems
– SSRIs (e.g., Prozac and Paxil) are preferred drugs
– Relapse rates (90%)
Panic Disorder: Associated Features and
Treatment
• Psychological and combined treatments
– Cognitive-behavioral therapies highly effective – 70%
– No evidence that combined treatment produces
better outcome
– Best long-term outcome is with cognitive-behavioral
therapy alone (6 months after tx terminated)
Panic Disorder: Associated Features and
Treatment
• Panic control treatment (PCT)
• Innovative approaches
– Psychological (CBT) treatment followed by drug
treatments
– D-cycloserine (DCS)
Specific Phobias: An Overview
• Overview and defining
features
– Extreme irrational fear of a
specific object or situation
– Persons will go to great lengths
to avoid phobic objects
– Most recognize that the fear and
avoidance are unreasonable
– Markedly interferes with one’s
ability to function
Some phobias (from phobialist.com)
Iatrophobia- Fear of going to the doctor or of doctors.
Ichthyophobia- Fear of fish.
Ideophobia- Fear of ideas.
Illyngophobia- Fear of vertigo or feeling dizzy when looking down.
Iophobia- Fear of poison.
Insectophobia - Fear of insects.
Isolophobia- Fear of solitude, being alone.
Isopterophobia- Fear of termites, insects that eat wood.
Ithyphallophobia- Fear of seeing, thinking about or having an erect penis.
Japanophobia- Fear of Japanese.
Judeophobia- Fear of Jews.
Radiophobia- Fear of radiation, x-rays.
Ranidaphobia- Fear of frogs.
Rectophobia- Fear of rectum or rectal diseases.
Rhabdophobia- Fear of being severely punished or beaten by a rod, or of being severely criticized.
Also fear of magic.(wand)
Rhypophobia- Fear of defecation.
Rhytiphobia- Fear of getting wrinkles.
Rupophobia- Fear of dirt.
Russophobia- Fear of Russians.
Specific Phobias: Associated Features
and Treatment
• Subtypes of specific phobia
1) Blood-injury-injection phobia – unusual
vasovagal response
2) Situational phobia – trains, planes,
automobiles, closed spaces
3) Natural environment phobia – natural
events (e.g., heights, storms)
4) Animal phobia – animals and insects
– Other
– Separation anxiety – seen in children
Specific Phobias: An Overview
• Facts and statistics
– Females are again over-represented (4:1)
– Affects about 12.5% of the general population
– Phobias tend to last a lifetime
Specific Phobias: Associated Features
and Treatment
• Causes of phobias
– Direct experience or traumatic conditioning,
prepared tendency, event will happen again
• Psychological treatments of specific phobias
– Cognitive-behavior therapies are highly effective –
exposure therapy
Social Phobia: An Overview
– Extreme and irrational fear in social/performance
situations
– Markedly interferes with one’s ability to function
– Often avoid social situations or endure them with
great distress
– Generalized subtype – affects many social situations
Social Phobia: An Overview
• Facts and statistics
– Affects about 12.1% of the general population
– Prevalence is slightly greater in females than
males
– Second only to specific phobia in the anxiety
disorders
– Peak age of onset at about 13 years
Social Phobia: Associated Features and
Treatment
• Causes
– Biological and evolutionary vulnerability
– Similar learning pathways as specific phobias
• Psychological treatment
– CBT highly effective
– Cognitive-behavioral group treatment (CBGT)
Social Phobia: Associated Features and
Treatment
• Medication treatment
– Tricyclic antidepressants and monoamine oxidase
inhibitors
– SSRIs - Paxil, Zoloft, or Effexor (SNRI)
– Relapse rates high following medication
discontinuation
Posttraumatic Stress Disorder (PTSD):
An Overview
• Overview and defining features
– Main etiologic characteristics – trauma exposure
and response
– Reexperiencing (e.g., memories, nightmares,
flashbacks)
– Avoidance
– Emotional numbing and interpersonal problems
– Markedly interferes with one's ability to function
– PTSD diagnosis – only after one month posttrauma
Posttraumatic Stress Disorder (PTSD):
An Overview
• Statistics
– Combat and sexual assault are the most common
traumas
– Lower than expected prevalence rates in trauma
victims
PTSD: Causes and Associated Features
• Subtypes and associated features of PTSD
– Acute – may be diagnosed one-three months post
trauma
– Chronic – diagnosed after three months post
trauma
– Delayed onset – onset six months or more post
trauma
– Acute stress disorder – PTSD immediately posttrauma
PTSD: Causes and Associated Features
• Causes of PTSD
– Intensity of the trauma and one's reaction to it
(i.e., true alarm)
– Learn alarms – direct conditioning and
observational learning
– Biological vulnerability
– Uncontrollability and unpredictability
– Extent of social support, or lack thereof, posttrauma
PTSD: Treatment
• Psychological treatments
– Cognitive-behavioral therapies (CBT) are highly
effective
– CBT may include graduated or massed (e.g.,
flooding) imaginal exposure
– SSRIs
Obsessive-Compulsive Disorder (OCD):
An Overview
• Overview and defining features
– Obsessions – intrusive and
nonsensical thoughts, images, or
urges
• Symmetry 26.7%, forbidden thoughts
21%, cleaning and contamination
15.9% and hording 15.4%
– Compulsions – thoughts or actions
to neutralize thoughts
– Cleaning and washing or checking
rituals are common
Obsessive-Compulsive Disorder (OCD):
An Overview
• Overview and defining features
– Tic disorder and OCD
– Hoarding
OCD: Causes and Associated Features
• Statistics
– Affects about 1.6% of the general population
– Most with OCD are female
– Onset usually in early adolescence or young
adulthood
– chronic
OCD: Causes and Associated Features
• Causes of OCD
– Parallels the other anxiety disorders
– Early life experiences
– Learning that some thoughts are
dangerous/unacceptable
– Thought-action fusion – the thought is similar to
the action
OCD: Treatment
• Medication treatment
– Clomipramine and other SSRIs – benefit up to 60%
of patients
– Relapse is common with medication
discontinuation
– Psychosurgery (cingulotomy) is used in extreme
cases
OCD: Treatment
• Psychological treatment
– Cognitive-behavioral therapy is
most effective
– CBT involves exposure and
response prevention (ERP)
– Combining CBT with medication
– no better than CBT alone
– ERP more effective than drugs
Summary of the Anxiety Disorders
• Most common forms of psychopathology
• From a normal to a disordered experience of
anxiety and fear
– Triple vulnerabilities – bio-psycho-social
– Fear and anxiety – non-dangerous bodily or
environmental cues
– Symptoms and avoidance – significant distress and
impairment
Summary of the Anxiety Disorders
• Psychological treatments are generally
superior in the long-term
– Similar treatments for different anxiety disorders
– Suggests that anxiety-related disorders share
common processes
DSM-5 Proposed Changes
• http://www.dsm5.org/ProposedRevisions/Pag
es/AnxietyDisorders.aspx