Chapter 4

Anxiety Disorders

Fear

• Fear – the present-oriented mood state– Immediate fight or flight response to danger or

threat– Involves abrupt activation of the sympathetic

nervous system– Strong avoidance/escapist tendencies– Marked negative affect

Anxiety

• Anxiety – the future-oriented mood state– Apprehension about future danger or misfortune– Somatic symptoms of tension– Characterized by marked negative affect

• Anxiety and fear are normal emotional states

From Normal to Disordered Fear and Anxiety

• Characteristics of anxiety disorders– Pervasive and persistent symptoms of anxiety and

fear– Involve excessive avoidance and escape– Cause clinically significant distress and impairment

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

The Phenomenology of Panic Attacks

• DSM-IV-TR subtypes of panic attacks– Situationally bound (cued) – Unexpected (uncued) – Situationally predisposed

• Cultural influences on anxiety

The Complexity of Anxiety Disorders

Biological Contributions to Anxiety and Panic

• Genetic vulnerability• Anxiety and brain circuits – Depleted levels of GABA

• Behavioral inhibition system (BIS) – Limbic system – responds to threat signals by

inhibiting activity and causing anxiety

• Fight/flight system (FF) – Fear

Psychological Contributions to Anxiety and Fear

• Early childhood Experiences– Uncontrollability and unpredictability– Observational learning/modeling

• 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

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An Integrated Model

• Integrative view – triple vulnerability model– Generalized biological vulnerability – Generalized psychological vulnerability– Specific psychological vulnerability

An Integrated Model

An Integrated Model – Comorbidity

• Common processes: the problem of comorbidity – Comorbidity is common across the anxiety

disorders– Major depression is the most common secondary

diagnosis– About half of patients have two or more

secondary diagnoses– Comorbidity suggests• Common factors• A relation between anxiety and depression

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

• Overview and defining features– Excessive uncontrollable anxious apprehension

and worry– Coupled with strong, persistent anxiety– Persists for six months or more– Somatic symptoms differ from panic

(e.g., muscle tension)

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Difficulty concentrating

Generalized Anxiety Disorder: The “Basic” Anxiety Disorder

Generalized Anxiety Disorder: The “Basic” Anxiety Disorder

• Statistics– Affects about 3.1% of the general population– Females outnumber males approximately 2:1– Onset is often insidious, beginning in early

adulthood– Very prevalent among the elderly– Tends to run in families

Generalized Anxiety Disorder: Associated Features and Treatment

• Associated features– Genetics – not GAD, but the tendency to become

anxious– Chronically tense – high muscle tension– Highly sensitive to personal threat– “Automatic restrictors”• Individuals with GAD show less responsiveness on most

physiological measures (e.g., heart rate, blood pressures) than individuals with other anxiety disorders• Intense “cognitive processing” in frontal lobes

– Results in constant worrying = fail to process emotional component of thoughts and images (i.e., mental avoidance)

Generalized Anxiety Disorder: Associated Features and Treatment

• Treatment of GAD: Generally weak– Benzodiazepines – often prescribed– Antidepressants – SSRIs; may be treatment of choice– Psychological interventions –

cognitive-behavioral therapy– Meditation therapy– Psychological treatments are typically more effective

in the long-term

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 • Fear of being in places where escape might be difficult,

or where help might not be available• Typically results in being “housebound” or only being

able to leave your house within a certain radius

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Panic Disorder With and Without 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% of individuals with agoraphobia are female

• Causes– Triad – biological, psychological, social• Theme for most disorders…

– Vulnerability to stress = strong “alarm” system• Interpret normal physical sensations in catastrophic

way; then get more anxious… “vicious cycle”

Panic Disorder With and Without Agoraphobia

Panic Disorder: Associated Features and Treatment

• Associated features– Nocturnal panic attacks – 60% panic during deep non-

REM sleep– Interoceptive/exteroceptive avoidance• Avoid situations/activities that may elicit certain

physiological arousal

• Medication treatment– Target serotonergic, noradrenergic, and GABA systems– SSRIs (e.g., Prozac and Paxil) are preferred drugs– Relapse rates are high following medication

discontinuation

Panic Disorder: Associated Features and Treatment

• Psychological and combined treatments– Cognitive-behavioral therapies are highly effective– No evidence that combined treatment produces

better outcome– Best long-term outcome is with cognitive-

behavioral therapy alone

Specific Phobias

• 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

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Specific Phobias

Specific Phobias

• Facts and statistics– Females are again over-represented (varies by

phobia)– Affects about 12.5% of the general population• One of the most common psychological disorders in

the U.S. and around the world

– Phobias tend to run a chronic course• Only the most severe cases seek treatment

– Mildly affected people tend to work around their phobias

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Specific Phobias: Associated Features and Treatment

• Subtypes of specific phobia– Blood-injury-injection – seeing blood or receiving

an injection– Situational – e.g., bridges, elevators, flying,

driving, enclosed places– Natural environment – e.g., storms, heights, water– Animal phobia – animals and insects– Other – e.g., fear of chocking, vomiting,

contracting an illness– *[Separation anxiety – seen in children]

Specific Phobias: Associated Features and Treatment

• Causes of phobias– Traumatic conditioning

• Direct experience – real danger or pain results in a true alarm response• Vicarious – observational learning• Information transmission – receive information/warned

– Prepared tendency• Biological and evolutionary vulnerability

– Thoughts/worry that the event will happen again

• Psychological treatments of specific phobias– Cognitive-behavior therapies are highly effective – exposure-

based

Social Phobia

• Overview and defining features– 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

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Social Phobia

Social Phobia

• 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– Onset is usually during adolescence– Peak age of onset at about 13 years

Social Phobia: Associated Features and Treatment

• Medication treatment – Tricyclic antidepressants and monoamine oxidase

inhibitors – SSRIs Paxil, Zoloft, and Effexer – are FDA approved – Relapse rates are high following medication

discontinuation

Social Phobia: Associated Features and Treatment

• Causes– Biological and evolutionary vulnerability– Similar learning pathways as specific phobias

• Psychological treatment– Cognitive-behavioral treatment (CBT)– Cognitive-behavioral group treatment (CBGT)– Cognitive-behavioral therapies are highly effective

Posttraumatic Stress Disorder (PTSD)

• 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 post-trauma• Acute Stress Disorder – symptoms begin within four weeks

of event and last for less than one month

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Posttraumatic Stress Disorder (PTSD)

Posttraumatic Stress Disorder (PTSD):

• Statistics– Many individuals who experience trauma do not

go on to develop PTSD• i.e., lower than expected rates in trauma victims

– Affects about 6.8% of the general population– Combat and sexual assault are the most common

traumas

PTSD: Associated Features and Treatment

• 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 post-

trauma

PTSD: Associated Features and Treatment

• Causes of PTSD– Intensity of the trauma and one's reaction to it

(i.e., true alarm)– Learned alarms – direct conditioning and

observational learning – Biological vulnerability– Uncontrollability and unpredictability– Extent of social support, or lack thereof, post-

trauma

PTSD: Associated Features and Treatment

PTSD: Associated Features and Treatment

• Psychological treatments– Cognitive-behavioral therapies (CBT) are highly

effective– CBT may include graduated or massed (e.g.,

flooding) imaginal exposure• Specific approach: Trauma-Focused CBT

– Aim of CBT for PTSD– SSRIs

Obsessive-Compulsive Disorder (OCD)

• Overview and defining features– Obsessions – intrusive and nonsensical thoughts,

images, or urges• Symmetry, forbidden thoughts, cleaning and

contamination, safety-memory, [hording 15.4%]

– Compulsions – thoughts or actions to neutralize thoughts (i.e., reduces anxiety for a short period)• Cleaning; checking; order/balance; touching, verbal,

and/or counting

– Vicious cycle of obsessions and compulsions– Cleaning and washing or checking rituals are

common

Obsessive-Compulsive Disorder (OCD)

• Overview and defining features– Tic disorder (involuntary movement) is common

to co-occur with OCD, especially children– [Involuntary vocalizations is referred to as

Tourette’s Disorder]– Hoarding• Often experience great pleasure (sometimes euphoria)

from shopping/collecting various items– Often in response to depressive feelings – “retail therapy”

• Great anxiety and distress to throw anthing away (because it might be something important)• Greatly impairs daily/social functioning

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Obsessive-Compulsive Disorder (OCD)

OCD: Associated Features and Treatment

• Statistics – Affects about 1.6% of the general population– Most with OCD are female– Onset is typically in early adolescence or young

adulthood– OCD tends to be chronic

OCD: Associated Features and Treatment

• 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: Associated Features and Treatment

• Medication treatment– Clomipramine and other SSRIs – benefit up to 60%

of patients– Relapse is common with medication

discontinuation– Psychosurgery (cingulotomy – lesion of the

cingulate bundle) is used in extreme cases

OCD: Associated Features and Treatment

• Psychological treatment– Cognitive-behavioral therapy is most effective– CBT involves exposure and response prevention– Combining CBT with medication – no better than

CBT alone– Exposure and ritual prevention (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• CBT is generally the most effective form of treatment

across all anxiety disorders

– Suggests that anxiety-related disorders share common processes

DSM-5 Proposed Changes

• http://www.dsm5.org/ProposedRevisions/Pages/AnxietyDisorders.aspx