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Chapter 6: Anxiety Disorders
Ch 6
Anxiety Disorders
• Anxiety refers to an unpleasant feeling of fear
and apprehension
– Neuroses is a former term that refers to a group of
disorders involving unrealistic anxiety, assumed to be
due to unconscious conflicts
• Anxiety disorders reflect the clear presence of
symptoms of anxiety
– Anxiety is not specific to anxiety disorders
– Comorbidity: A person may be diagnosed with more
than one disorder
• Distinguishing stress, fear, and anxiety
– Stress is the perception of an external demand, or
challenge
Ch 6.1
Abrupt and Aversive CNS
Response to Real Threat or
Danger
Prepares Organisms for
Immediate Action
Action Tendency “Fight” or
“Flight”
 More Diffuse Response About
Impending Real or Imagined
“Future” Threat or Danger
Real Threat
True Alarm
Adaptive
Maladaptive
False Alarm
No Threat
Etiology
“Disordered” or “Maladaptive”
Experience of
Anxiety or Fear
“Normal” or “Adaptive”
Experience of
Anxiety or Fear
Phobias
• A phobia is a fear-mediated avoidance
that is out of proportion to the object or
situation
– Phobias involve intense distress
– Phobias are disruptive
– Person recognizes that the fear is
groundless
Ch 6.2
Classes of Phobias
• Specific phobias are unwarranted fears
caused by the presence of a specific object
or situation
– Blood, injuries, or injections
– Situations (planes, elevators)
– Animals
– Natural environment (water, heights)
• Social phobia involves a persistent fear
linked to the presence of other people
Ch 6.4
 Clinical Description
 Irrational Fear of Specific Objects
or Situations
 Markedly Interferes With
Functioning
 Four Major Subtypes
 Animal Type
 Natural Environment Type
 Blood-Injection Injury Type
 Situational Type
 Other
 Blood-Injection Injury Type
 Unusual Reaction
 Vasovagal Response to Blood
 Drop in Blood Pressure
 Fainting
 Runs in Families
 Onset Early Childhood
 Situational Type
 Fears of Specific Situations
Planes, Transportation, Heights
 Response Similar to Panic
 Onset Early 20’s
 Animal Type
 Fears of Animals and Insects
 Common in Population, but
Different From Normal Revulsion
 Early Onset (About 7 yrs of Age)
 Natural Environment Type
 Fears of Natural Events
Heights, Storms, Water
 Usually More Than One Fear
 Peak Onset (About 7 yrs of Age)
 Other Type
 Fears Contracting Disease / Illness
Illness Phobia
 Fear of Choking
Avoid Swallowing Pills or Foods
 Facts and Statistics
 Occurs in 11% of Population
 Top Fears: Heights and Snakes
 Females > Males (4:1 Ratio)
 Runs a Chronic Course
 Many Do Not Seek Treatment:
WHY?
 Causes
 Direct Traumatic Conditioning
 Observational Learning
 Information and Language
 Having a Panic Attack (“False
Alarm”)
 Probably Some Evolutionary Basis
Etiology of Anxiety Disorders
• Psychoanalytic theory: phobias result from anxiety
produced by repressed id impulses
• Biological/Genetic theory: Heritability of panic
disorder, and evolutionary basis of phobias
• Behavioral theories: focus on learning as the
etiological basis of phobias
– Phobias are learned avoidance responses
– Phobias may be acquired through modeling
– We are biologically prepared to learn certain fears (e.g.
taste with nausea)
• Cognitive theory: Thought processes result in high
levels of anxiety
Ch 6.5
Treating Phobias
• Psychoanalytic therapy attempts to uncover
repressed conflicts using free association
• Behavioral approaches use systematic
desensitization and in vivo exposures to reduce
anxiety responses to phobic stimuli and
situations
– Flooding: exposure to a phobic stimulus at full
intensity (now graded exposure is used more)
• Cognitive approaches focus on altering irrational
beliefs (using socratic dialogue to disconfirm and
reconstruct automatic thoughts, images)
Ch 6.6a
Treating Phobias
• Biological approach uses drugs to eliminate
anxiety symptoms
– Anxiolytic drugs such as the benzodiazepines (Valium)
can reduce anxiety but are also addictive and give rise
to withdrawal symptoms upon termination
– MAO inhibitors such as phenelzine reduce the
degradation of norepinephrine and serotonin
• MAO inhibitors can have adverse side effects
– Selective serotonin reuptake inhibitors (SSRI’s)
(fluoxetine) increase brain serotonin
Ch 6.6b
 Exposure and More Exposure
 Structured and Consistent
 Confront Objects of Fear
 Extinguish Anxious Responding
 Disrupt Avoidance / Escape
 Blood-Injury /Injection Differs
Exercises to Offset Fainting
“ People with social phobia aren’t
necessarily shy at all. They can be
completely at ease with people most of
the time, but in particular situations,
they feel intense anxiety.”
 Clinical Description
 Marked and Persistent Fear of One
or More...
Social or Performance Situations
 Most Common Type of Social Fear?
Public Speaking
 Interferes With Life Functioning
 Facts and Statistics
 Occurs in 13.3% of Population
 Most Prevalent Disorder
 Males > Females
 Begins in Adolescence
 Presents Differently in Some
Cultures (e.g., Japan)
 Causes
 Similar to Panic and Specific Phobia
 Interaction of
Biological Vulnerability
Psychological Vulnerability
Learning Experiences
 Can be Quite Disabling
 Psychological Interventions
 Similar to Panic and Specific Phobia
 Cognitive-Behavioral Approaches
Rehearsal and Skills Training
Cognitive Restructuring
 Drug Treatments
 Antidepressants for Severe Anxiety
SSRIs (e.g., Paxil)
MAO Inhibitors
Relapse is Common
Panic Disorder
• Panic disorder involves
– an attack of labored breathing, nausea, chest pain,
dizziness and intense apprehension (terror)
– Depersonalization: the feeling of being outside of
one’s body
– Derealization: the feeling that the world is not real
• Lifetime prevalence for panic disorder is 2% for
men and 5% for women
Ch 6.7
 Panic Disorder
“ You may genuinely believe you’re having
a heart attack, losing your mind, or on the
verge of death. Attacks can occur any
time, even during nondream sleep ”
“ For me, a panic attack is a most violent experience
…I feel as though I’m losing control and going
insane. ”
 Clinical Description
 An Unexpected Panic Attack
 Develop Anxiety Over
 the Next Attack
or
 The Implications of the Attack
and Consequences
 Clinical Description
 Agoraphobia is Common
 “Fear of the Marketplace”,
avoidance of “unsafe” places
where panic attack may recur
 Consequence of Severe Unexpected
Panic Attacks
 Can Have a Life of its Own
 Facts and Statistics
 Occurs in 3.5% of Population
 75% are Women
 Onset Between (25-29 yrs)
 Initial attack often begins at puberty
 20% Attempt Suicide
 Average 37 Medical Visits / Year
 Cultural Influences
 Occurs Worldwide
 Prevalence in U.S. is Similar Across
Ethnic Groups
 Cultural variants: susto, ataques de
nervios (Latin America, Caribbean)
 Somatic symptoms emphasized in
3rd world cultures
 Nocturnal Panic
 60% Cases Panic While Asleep!
 Usually Between 1:30 - 3:30am
 Occur During Deep Sleep “Delta”
 Do Not Occur During REM Sleep
 Isolated sleep paralysis (common in
African-Americans with PD)
 Symptoms of a Panic Attack
 Palpitations / Sweating
 Trembling / Shaking
 Shortness of Breath
 Feeling of Choking, Loss of Control
 Derealization, Feeling of Dying
Etiology of Panic Disorder
• Biological theories focus on the
observations
– that panic disorder runs in families
– that panic disorder can be induced
experimentally using
• Hyperventilation may activate the autonomic
nervous system
• Infusions of lactate can induce panic attack
• Panic attack may result from an
exaggerated central response to arousal
Ch 6.8
Etiology of Panic Disorder
• The Fear-of-fear hypothesis of panic
disorder suggests that some people have
an overly aroused nervous system and a
tendency to be upset by the sensations
generated by their nervous system
– Eventually, worry about a panic attack makes
a future attack more likely (vicious circle)
– Panic attacks as “false alarm” reactions
Ch 6.9
Anxiety Sensitivity Index (ASI)
•Measures the extent to which individuals become
apprehensive in response to their bodily sensations.
•Developed by Peterson & Reiss (1987)
•High scorers on the ASI were more likely than
low scorers to experience panic attacks, especially
if they had been told they would feel relaxed
instead of aroused (Telch & Harrington, 1992) (D&N,
Table 6.3).
Panic Disorder Treatments
• Biological treatments include use of
antidepressant and anxiolytic drugs
– Require long-term use, symptoms return upon drug
cessation; risk of addiction to anxiolytics
• Psychological treatments emphasize exposure to
stimuli that accompany panic
– Barlow’s therapy includes a combination of breathing
re-training, cognitive interventions, and exposure to
the internal cues that elicit panic. Patient learns to
relax and reinterpret these sensations as nonthreatening and controllable
Ch 6.10
 The Panic Attack
 Abrupt Autonomic Surge
 Unexpected
 Uncontrollable
 Absence of Threat
 “False Alarm”
10 Minutes
 Laboratory Panic Provocation
 Lactate Infusion
 Hyperventilation
 CO2 Inhalation
 Caffeine
10 Minutes
 Causes
General Biological &
Psychological Vulnerability
STRESS
False Alarm
Bodily Cues
Learned Alarm
Involuntary physical or
cognitive anxiety cues trigger
learned alarms unpredictably
Specific Psychological Vulnerability:
Anxious apprehension focusing on future
alarms (e.g., body sensations are
dangerous)
 Biological Causes
 Runs in Families
 GABA-BZ Circuit
 Limbic System
 ANXIETY
Behavioral Inhibition System (BIS)
 FEAR / PANIC
Fight / Flight System (FF)
 Psychological Causes
Predictable
Uncontrollable
Controllable
Unpredictable
 Pharmacologic Treatments
 Block Panic
 Antidepressants (e.g., Imipramine,
Paxil, Prozac)
 20-50% Relapse
 Benzodiazapines (e.g., Xanax)
 90% Relapse
 Psychological Interventions
 Cognitive-Behavior Therapies
 Brief and Time Limited (12 Sessions)
 Graded Exposure + Coping Skills
 Panic Control Treatment (PCT)
 80-100% Panic Free After Treatment
 Combined Treatment
THE RESULT
 Multisite Study
 Imipramine Alone
 PCT Alone
 Imipramine + PCT
 Placebo Alone
 Placebo + PCT
Combined Tx
is Better in
Short
Term
PCT Alone is
Better in
Long Term
Generalized Anxiety Disorder
• Generalized Anxiety Disorder (GAD)
involves persistent anxiety and chronic
(uncontrollable) worry
• The lifetime prevalence of GAD is 5%
• Women are twice as likely to develop GAD
as are men
Ch 6.11
Generalized Anxiety Disorder:
The “Basic” Anxiety Disorder?
Figure 5.3
Clients’ answers to interviewer’s question, “Do you worry excessively
about minor things?”
Etiology of GAD
• Psychoanalytic view: generalized anxiety results
from unconscious conflicts between ego and id
impulses
• Cognitive behavioral view: anxiety results from
conditioning of anxiety to external stimuli
• Biological view: the transmitter GABA inhibits
anxiety, anxiolytic drugs enhance the release of
GABA in brain; evidence for heritability is mixed.
Ch 6.12
 Worrywart?
 Perfectionist?
 Tense and keyed up most of the time?
 Cross bridges before you get to them?
 Worry unproductive?
 Trouble Controlling Worry?
 Clinical Description
 Worry About Everything
 Worrying is Unproductive
 Cannot Stop Worrying
 Mental Agitation and Muscle Tension
 Interferes With Life Functioning
 Must Last for at Least 6 Months
 Facts and Statistics
 Occurs in 4% of Population
 Women twice as likely to develop
GAD
 Early Gradual (“insidious”) Onset
 Runs a Chronic Course
 Few Seek Treatment: WHY?
 Causes
 Unclear and Puzzling?
 Tend to show
Autonomic Restriction
Heightened Muscle Tension
High Sensitivity to Threat in General
Threat Sensitivity is Automatic
 Avoid Negative Affect Related to Threat
General Biological &
Psychological Vulnerability
STRESS
Specific Psychological Vulnerability
(Anxious Apprehension)
Worry Process
Imagery Avoidance
Intense
Cognitive Processing
Restricted
Autonomic Response
 Most Interventions are Weak
 Benzodiazepines
Frequently Prescribed
Provide Some Relief
 Cognitive-Behavioral Approaches
Process Avoided Emotional Material
Relaxation Training
Does as Well as Medication
Therapies for GAD
• Psychoanalytic therapy for GAD is similar
to that of phobia (reveal sources of conflict)
• Behavioral therapy involves a combination
of relaxation training and cognitive
intervention
• Biological therapy uses administration of
anxiolytic drugs to reduce anxiety
– Drug therapy is effective while the drugs are
taken
Ch 6.13
Obsessive-Compulsive
Disorder (OCD)
• Obsessions are intrusive and recurring
thoughts
• Compulsions are repetitive behaviors or
mental actions that are repeated over and
over in order to reduce anxiety
• The lifetime prevalence of OCD is 1-2 %
– Women are more likely than men to develop
OCD
Ch 6.14
Common Compulsions
• Pursuing cleanliness
• Avoiding particular objects (e.g. cracks in a
sidewalk)
• Performing repetitive, magical, protective
practices
• Checking (e.g. “is the gas off?”)
• Performing a particular act (e.g. chewing
slowly)
Ch 6.15
Etiology of OCD
• The psychoanalytic view is that OCD reflects
arrest of personality development at the anal
stage
• Behavioral accounts of OCD point to learned
behaviors reinforced by fear reduction
• The biological view of OCD has focused on
activation of the frontal lobes and basal ganglia
Ch 6.16
The Basal Ganglia
Ch 6.17
OCD Therapy
• Psychoanalytic procedures are not effective
• ERP: Exposure and Response Prevention
involves exposing the OCD client to
situations that elicit a compulsion and then
restraining the client from performing the
compulsion
• Biological treatment involves drugs that
increase brain serotonin activity (Prozac)
Ch 6.18
 Clinical Description
 Culmination of All Anxiety Disorders
 Obsessions: Intrusive Thoughts,
Images, or Urges That the Person
Tries to Suppress or Eliminate
 Compulsions: Thoughts or Actions to
Suppress the Obsessions and Provide
Relief
 Facts and Statistics
 Occurs in 2.6% of Population
 Most Common Obsessions
Contamination & Aggression
 Most Common Compulsions
Checking & Washing
 Almost Equal Sex Ratio (F > M)
 Onset Early Adolescence to Mid-20s
 Causes
 Anxiety Focused on Unwanted Thoughts
 Thoughts are Unacceptable
When Fighting to Control One’s
Psychology Creates More
Psychopathology
 Psychological Interventions
 Cognitive-Behavioral Treatments
 Response Prevention
Rituals are Actively Prevented
 Exposure
Systematic and Gradual Exposure to
Feared Thoughts or Situations
 May Require Hospitalization
 Drug Therapies
 Medications Show Promise
 Most Effective Medications
Inhibit Reuptake of Serotonin
 May Benefit 60% of Patients
Posttraumatic Stress Disorder
• Posttraumatic Stress Disorder (PTSD)
refers to an extreme response to an
extreme stressor
• PTSD symptoms may include:
– Increased anxiety and arousal
– Re-experiencing the traumatic event
– Avoidance of stimuli associated with the
trauma
Ch 6.19
 Clinical Description
 Exposure to Traumatic Events
War and Combat
Rape and Assault
Car Accidents
Natural Disasters
 Reexperiencing, Flashbacks, Numbing
 Sleep Disturbance, Chronic Arousal
 Subtypes
 Acute
1-3 Months After the Trauma
 Chronic
Symptoms Last > 3 Months
 Facts and Statistics
 Occurs in 7.8% of Population
 Most Common Traumas?
Combat and Assault
 Trauma is Necessary, not Sufficient
 Severity of Response Seems Important
 Runs a Chronic Course
 Causes
 Only Disorder With Clear Etiology
 Biological Vulnerability
 Experience With Events That are...
Uncontrollable and Unpredictable
 Severity of Trauma and One’s Reaction
True Alarm!
 Social Support Helps
 Psychological Interventions
 Face the Original Trauma
Imaginal Reexposure
Flooding
 Arrange for Corrective Emotional
Learning
 Problem of Secondary Gain
Disability and Compensation
New Treatment Approaches
for PTSD
• EMDR (Eye Movement Desensitization &
Reprocessing
• TFT (Thought Field Therapy)
• New Paradigms or Pseudo-Science?