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Anxiety Disorders
Chapter 6
Anxiety Disorders: Defining Fear
• Fear functions to protect us from danger
• Anxiety
– Future-oriented response to perception of
anticipated threat
• Fear
– Response to immediate threat
• Worry
– Mental strategy used to avoid future danger
• Examples of normal fear responses
Anxiety consequences
• Physiological arousal
– Sympathetic nervous system – “fight or flight”
• Emotional symptoms
• Cognitive
– Worry, attentional shifts
• Behavioral responses
– Fight
– Flee (Escape/avoidance)
Adaptive
• Fear triggers “fight or flight”
– May save life
• Anxiety increases preparedness
– “U-shaped” curve (Yerkes & Dodson, 1908)
when normal anxiety goes awry
• Most experience excessive anxiety
• Excessive Worry
– Feels uncontrollable, can be less realistic concerns
• Phobias
– Irrational/unreasonable fear of specific
objects/situations
– Avoidance and/or extreme distress
• Panic Attacks
The Anxiety Disorders and Their
Commonalities
• Anxiety disorders have unrealistic, irrational
fears or anxieties of disabling intensity as their
most obvious manifestation
6
The Anxiety Disorders and Their
Commonalities
• The DSM-5 recognizes five primary types of
anxiety disorders
Specific phobias
Social anxiety disorder
Panic disorder
Agoraphobia
Generalized anxiety disorder
7
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 Traumaand Stressor-Related
Disorders. Agoraphobia
has been changed from a
subtype of panic
disorder to a diagnosis in
its own right.
Table 6. 1: DSM-IV-TR and DSM-5 Diagnoses of
Anxiety Disorders
More specific criteria for
children
Body’s response to fear
• The hypothalamus (in the brain) triggers a
series of reactions in response to arousal and
fear
• Two systems are activated
– Autonomic nervous system
• Sympathetic-adrenomedullary (SAM)
– Endocrine system
• Hypothalamic-pituitary adrenocortical (HPA)
ANS
• Autonomic nervous system
– Network of nerve fibers that connects the CNS to the
organs of the body
– Regulates involuntary actions
•
•
•
•
Heartbeat
Breathing
Blood pressure
Perspiration
– Two pathways:
• Sympathetic nervous system
• Parasympathetic nervous system
Sympathetic nervous system
• “Flight or fight” response
– Discharge of adrenaline
– Heart rate increased
– Pupils dilated
– Skin constricts
– Blood sugar increases
• Neurotransmitters involved
– Norepinephrine, serotonin, and dopamine
HPA axis
1. Stressors
2. Hypothalamus signals
the pituitary gland to
secrete ACTH
3. Adrenal glands are
stimulated, triggering
release of
corticosteroids
4. Long-term impact
DSM Panic Attacks:
Defined by 4 or more of the following 13 symptoms
11 Somatic Symptoms
• Increased heart rate
• Shortness of breath
• Chest pain
• Choking sensation
• Trembling
• Sweating
• Nausea
• Dizziness
• Numbness/Tingling
• Hot flashes or chills
• Depersonalization
2 Cognitive Symptoms
• Fear of dying
• Fear of losing control
Types of Panic Attacks
• Unexpected (uncued)
– Not associated with situational trigger
• Situationally bound (cued)
– Exposure to, or in anticipation of, a trigger
• Situationally pre-disposed
– More likely to occur on exposure to trigger, but
not invariably associated; do not necessarily occur
immediately
Panic Disorder
• Recurrent unexpected panic attacks
Criterion B
• Worry about future attacks
• Worry about the consequences of the attack
(i.e., having a heart attack)
• Substantial behavioral changes in response to
the attacks
Panic Disorder
• The two features of
panic attacks that
distinguish them from
other types of anxiety
are
Their characteristic
brevity
Their intensity
• Associated symptoms:
– General anxiety
– Hypersensitive to
physical cues
– Demoralization
– Major depressive
disorder
– Substance related
disorders
– High comorbidity
– Visits to ER
Panic Disorder
• 3.5 percent of the adult population have had
panic disorder at some time in their lives
• It’s twice as prevalent in women as men
• 50 percent of people with panic disorder have
additional diagnoses
• DSM-5 – 2-3% 12 month prevalence
• NCS – 1.5-4.7%
19
Panic Disorder
• Age of onset
• Course
• Differential diagnosis
Case example
• Abby, a 29 year old female, reports unexpected panic
attacks and describes increased heart rate,
lightheadedness, shortness of breath, and tingling
sensations in her arms. When she experiences these
episodes, she believes that she is going to faint; she
describes fainting as both embarrassing and
dangerous. She worries about having these episodes
when in public places and places where getting help
would be difficult. Because of her fear, she avoids
going to public places alone and always carries her
cell phone in case she needs to call for help.
Biological Causal Factors
• Panic disorder has a moderate heritable
component
• There is a broad range of biochemical panic
provocation agents
• There are also several areas of the brain
implicated in panic attacks
22
Panic and the Brain
The anticipatory anxiety about future
panic attacks is thought to arise from
activity in the limbic system
Phobic avoidance may
involve activity of the
hippocampus
Panic attacks may arise
from abnormal activity in
the amygdala
23
Panic Disorder- Cognitive-Behavioral
Model
• Attuned to cues
• Interoceptive fears
– Interoceptive conditioning
• Cognitive component
• Leads to cycle
24
Core Patterns in Panic Disorder
• Fears of symptoms of anxiety (anxiety
sensitivity)
– Risk for onset of panic attacks
– Risk for biological provocation of panic
– Risk for panic disorder relapse
(McNally , 2002)
Common Catastrophic Thoughts
in Panic Disorder
• Fears of death or disability
– Am I having a heart attack?
– I am having a stroke!
– I am going to suffocate!
• Fears of losing control/insanity
– I am going to lose control and scream
– I am having a nervous breakdown
– If I don’t escape, I will go crazy
• Fears of humiliation or embarrassment
– People will think something is wrong with me
– They will think I am a lunatic
– I will faint and be embarrassed
Cognitive-Behavioral Model of
Panic Disorder
Stress
Biological Diathesis
Alarm Reaction
Rapid heart rate, heart palpitations
Shortness of breath, smothering sensations
Chest pain or discomfort, numbness or tingling
Increased anxiety and fear
Conditioned
Fear of
Somatic Sensations
Catastrophic misinterpretations
of symptoms
Hypervigilance to symptoms
Anticipatory anxiety
Memory of past attacks
Integrated Model
Biological
Vulnerability to
hypersensitive
fight or flight
response
Tendency to
engage in
catastrophic
cognitions about
physiological
symptoms
Panic
attacks and
hypervigiliance for
signs of
panic
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 paniclike 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
Agoraphobia
• 1.7% 12 month prevalence
• 75-80% of people with severe agoraphobia are
female.
• Elderly – usually traced to an illness or injury
• Usually develops within one year of panic
attacks when associated with panic disorder.
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?!?!
© 2012 John Wiley & Sons, Inc. All
rights reserved.
Treating Panic Disorder and
Agoraphobia
• Medications
– Benzodiazepine
– Antidepressants- SSRIs
• Behavioral and cognitive-behavioral
treatments
– Information
– Cognitive interventions
– Interoceptive exposure
– In vivo exposure
32
Information Interventions
• May include handouts or patient manuals
• Distinguishes between symptoms, thoughts, and
behaviors – and introduces the cascade between these
elements
• Introduces the notion and consequences of
catastrophic thoughts
• Addresses the role of escape and avoidance in
maintaining fear
• Helps the patient adopt an informed and active role in
treatment
Cognitive Restructuring - General
• Identify the nature of thoughts: they don’t
have to be true to affect emotions
• Learn about common biases in thoughts
• Treat thoughts as “guesses” or “hypotheses”
about the world
Cognitive Restructuring - Specific
• Increase awareness of thinking patterns
– Over-estimating the probability of negative outcomes
– Assuming the consequence will be unmanageable
• Monitor relationship between thinking and panic
episodes
• Challenge thinking
– Evaluating evidence for the thought
– Evaluating the cost of the feared outcome
• Establish adaptive thinking patterns
– Reality based thinking and not just positive thinking
Exposure!
• Provide clients with a way to unlearn their
fears
• Learn to master situations that cause anxiety
• Habituation to anxiety at each step
– Biggest trap is to flee a step at height of fear
– Reinforces association between situation and fear
– Confront fear regularly and frequently
Exposure Interventions
• Provide rationale for confronting feared
situations
• Establish a hierarchy of feared situations
• Provide accurate expectations
• Repeat exposure until fear diminishes
• Attend to the disconfirmation of fears (“What
was learned from the exposure?”)
Common Interoceptive Exposure Procedures
• Headrolling – 30 seconds - dizziness, disorientation
• Hyperventilation – 1 minute - produces dizziness
lightheadedness, numbness, tingling, hot flushes, visual
distortion
• Stair running – a few flights – produces breathlessness, a
pounding heart, heavy legs, trembling
• Full body tension – 1 minute – produces trembling,
heavy muscles, numbness
• Chair spinning – several times around – produces strong
dizziness, disorientation
• Mirror (or hand) staring – 1 minute – produces
derealization
Relative Comfort
Panic Cycle
Uh oh!
What if:
•Notice the sensation
•This gets worse?
•I lose control?
•This is a stroke?
I have to control this!
•Do nothing to control it.
•Relax WITH the sensation
Learning Safety in Panic
Interoceptive exposure
• Feared sensations become safe sensations
– in the office with the therapist
– at home
– independent of the treatment context
Situational Exposures
• Rationale:
– Providing a new learning opportunity to examine
negative predictions about feared outcomes
– Increasing tolerance to internal sensations in
feared situations
Situational Exposure Guidelines
• Prior to completing in-vivo exposures, create a fear
hierarchy identifying feared and avoided situations
• Identify safety behaviors- actions taken to avoid,
prevent, or manage a potential threat
– Avoidance
– Checking (pulse, exits, hospitals)
– Carrying aids (rescue medications, cellular phones)
Example hierarchy
•
•
•
•
•
•
•
Traveling one stop, quiet time of day
Traveling two stops, quiet time
Traveling two stops, rush hour
Traveling five stops, quiet time
Traveling five stops, rush hour
Traveling all of the way, quiet time
Traveling all of the way, rush hour
Exposure
• Common situations include bridges, malls,
theaters
Phobic Disorders
• A phobia is a persistent and disproportionate
fear of some specific object or situation that
presents little or no actual danger
• Severity
• The DSM-5:
– Specific phobia
– Social anxiety disorder
46
Specific Phobia
• Marked and persistent fear of a specific object or
situation
– Other than those associated with agoraphobia or
social anxiety disorder
• Anticipated harm
• Fear of losing control, panicking, or fainting
• Exposure to feared stimulus produces a panic attack
or anxiety response
– avoidance
Specific Phobia
•
•
•
•
Insight in adults
Must interfere or caused marked distress
Onset
Rates
Table 6.3: Types of Specific Phobias
Specific Phobias- Behavioral
Explanations
• Direct conditioning
• Vicarious learning
• Mowrer’s 2 factor theory
– Classical conditioning
– Avoidance conditioning
50
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)
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
© 2012 John Wiley & Sons, Inc. All
rights reserved.
Specific Phobias- etiology
• Cognitive variables
• Genetic
• Biological preparedness
– We may be biologically prepared to rapidly
associate some objects with aversive
consequences
Treating Specific Phobias
• Exposure therapy is the most commonly used
treatment for specific phobias
• Other therapies include
– Participant modeling
– Virtual reality therapies
– Combining cognitive techniques with exposurebased therapies
54
Social Anxiety Disorder
• Involves disabling fears of one or more
discrete social situations in which a person
fears that she or he may be exposed to the
scrutiny and potential negative evaluation of
others
55
Common fears
•
•
•
•
Public speaking
Attending parties
Speaking to authority figures
Writing/eating in public
Social Anxiety Disorder:
Associated features
•
•
•
•
•
•
Self-medication
Depression
Hypersensitivity to criticism
Problems being assertive
Social skills
underachievement
Social Anxiety Disorder
• Social phobias generally involve learned behaviors
– Such learning is most likely to occur in people who are
genetically or temperamentally at risk
• 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
58
Social Anxiety Disorder
• Treatments for social phobias include
– Behavior therapy
– Cognitive-behavioral therapy
– Medications
• Beta blockers
• SSRIs
• Anxiolytics
– Benzodiazepine
– Others- BuSpar
59
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.
60
GAD
• Each year 3% of the population experiences
GAD
• It is twice as common in women as in men
• It often co-occurs with other AXIS I disorders
Generalized Anxiety Disorder:
Psychosocial Causal Factors
• It may occur in people who have had
extensive experience with uncontrollable
events
• 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
62
Figure 6.8: The Excessive Worry of GAD May be
an Attempt to Avoid Intense Emotions
Generalized Anxiety Disorder:
Biological Causal Factors
• It is modestly heritable
• The neurotransmitters GABA,
serotonin, and perhaps
norepinephrine all play a roll in
anxiety
• CRH also plays a role
• Neurobiological factors
implicated in panic disorders
and GAD are not the same
64
Treating Generalized Anxiety Disorder
• Drugs such as Valium are
often misused
• Buspirone seems effective
and nonaddictive
• Cognitive-behavioral
therapy has become
increasingly effective
65
Table 6.4: Percent of People Who Meet Diagnostic Criteria for
Anxiety Disorders in the Past Year and in Their Lifetime
© 2012 John Wiley & Sons, Inc. All
rights reserved.
Epidemiology
• NCSR – Median age of onset
Specific Phobia: 7
SAD: 13
OCD: 19
Agoraphobia w/o panic: 20
Panic Disorder: 24
GAD
31
Any anxiety disorder: 11
16
14
18-29
30-44
45-59
60+
12
10
8
6
4
2
0
Panic disorder
Specific phobia
Social phobia
GAD
OCD
Epidemiology
• Gender
– Women more likely to experience all anxiety
disorders
– Women more likely to relapse
– Women may be more vulnerable to substance
misuse
– Why?
•
•
•
•
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
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
Diagnostic Considerations
• High rates of comorbidity among the anxiety
disorders
– Are they truly unique disorders?
• High rates of comorbidity with depression
– Are anxiety d/o separate from mood d/o?
– Both are characterized by high levels of negative
emotion, but depression is also characterized by
low positive emotion whereas anxiety is not.
The Anxiety Disorders and Their
Commonalities
• There are some important similarities among
– The basic biological causes of these disorders
– The basic psychological causes of these disorders
– The effective treatments for these disorders
71
Etiology in general
• Biological factors
• Social factors
• Psychological factors
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
Etiology – Biological factors
Genes
• Family studies
Proband Diagnosis
Panic Disorder
GAD
SAD
OCD
1st degree relatives with
Disorder
15%
19%
16%
2%
NCSR Lifetime
Prevalence
4.7%
5.7%
12.1%
1.6%
• Twin studies
– Concordance rates significantly higher in MZ vs DZ twins
(Kendler et al., 1992)
Etiology – Biological factors
Nervous system
• Fear circuit overactivity
• Amygdala
• Medial prefrontal cortex deficits
• Neurotransmitters are thought to play a role
• Poor functioning of serotonin and GABA
• Higher levels of norepinephrine
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
Etiology – Social Factors
• Stressful life events
– Prospective data indicate may increase anxiety d/o
vulnerability
– How differ from depression?
• Dangerous event -> anxiety
• Severe loss -> depression
Table 6.6: Percent of People Reporting Conditioning
Experiences Before the Onset of a Phobia
Etiology – Psychological Factors
Learning
• Observational Learning
• Preparedness model (Mineka & Ohman, 2002)
– It is easier for us to learn and maintain CR to
dangerous stimuli (e.g., snake) than nondangerous ones (e.g., flower)
Etiology – Psychological Factors
Cognitions
• Sustained negative beliefs about future
– Bad things will happen
– Engage in safety behaviors
• Perceived lack of control
– More vulnerable to developing anxiety disorder
• Childhood trauma or punitive parenting may foster
beliefs
• Serious life events can threaten sense of control
• Attentional biases to threat
• Maladaptive attempts at thought suppression
Medications, continued
• Antidepressant medications
– Selective serotonin reuptake inhibitors (SSRI) –
preferred medication treatment for most anxiety
disorders.
– Tricyclics (e.g., imipramine) – also effective but
more side effects
Treatment - Behavioral
Exposure
• Types
– Prolonged
• In vivo
• Imaginal
– Flooding
– Interoceptive exposure – treatment for panic disorder,
exposure to anxious provoking physiological symptoms
(e.g., sweating, dizziness).
Treatment – Cognitive
• Usually combined with behavioral techniques
• Addresses present cognitive distortions
– Catastrophizing
– Fortune telling
• What if?
– Overestimation of negative probabilities
Treatment – what works for what
• Some Meta-analytical findings (Butler et al., 2006; Butler
et al., 2004; Mitte, 2005; Eddy et al., 2004)
Panic (treatment vs. placebo condition)
Effect Size
Antidepressants
Benzodiazapines
Behavior therapy
Cognitive therapy
.82
.29
1.36
.75
Generalized Anxiety disorder
CBT vs. no treatment
CBT vs. placebo
CBT vs. medications
.82
.57
.33
Treatment – Cognitive-Behavioral
• Some evidence that combining meds and
psychosocial treatments less effective than
singular treatments for some anxiety disorders