CHAPTER SIX
Anxiety Disorders
SymptomsDiagnosisFrequency
CausesTreatment
Anxiety and Fear ARE normal!!
Serves important roles: Adaptation, initiation, motivation
Anxiety prepares us to take actionand is normal is moderate amounts
SYMPTOMS: THE NATURE OF ANXIETY VS FEARFEAR
Experienced in the face of real, immediate danger
Builds quickly in intensity
Helps organize the person’s behavioral responses to threats
Fight/Flight response sympathetic n.s.
ANXIETYAnticipation of future
problemsPrepares us to take
actionInvolves more general
or diffuse emotional reactions
At the same time, we can also worry too much, feel anxious too often or be afraid at inappropriate times.
The questions is: how maladaptive are these behaviors and to what extent do they interfere in one’s ability to function normally?
Most common type of abnormal behavior Share similarities with mood disorders:
Both defined in terms of negative emotional responses (Case of Johanna, inter and/or intrapersonal?)
Close relationship between symptoms of anxiety and depression (e.g., guilt, worry, anger).
May share similar causal features:▪ stress, cognitive factors, biological.
OVERVIEW OF ANXIETY DISORDERS
People with anxiety disorders share a preoccupation with, or persistent avoidance of, thoughts or situations that provoke fear or anxiety.
The diagnosis of anxiety disorders depends on several types of symptoms.
SYMPTOMS
David Barlow’s anxious apprehension:
1) High levels of diffuse negative emotion
2) Sense of uncontrollability3) Shift in attention to a primary self
focus or state of self preoccupation
The emotional experience
is out of proportionto the threat
SYMPTOMS
Excessive Worry Cognitive activity associated with anxiety. A relatively uncontrollable sequence of
negative, emotional thoughts that are concerned with possible future threats or danger.
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SYMPTOMS
Excessive Worry Worriers are preoccupied with “self-talk” Worry Distinctions hinges on quantity and quality of
worrisome thoughts and the negativity of content.
SYMPTOMS
Panic Attacks Discrete episode of acute terror in the absence
of real danger A sudden, intense, overwhelming experience of
terror or fright Emotional response more focused
SYMPTOMS
TABLE 6–1 Diagnostic Criteria for Panic Attack in DSM-IV-TR (page 142)
A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:
1. Palpitations, pounding heart, or accelerated heart rate2. Sweating3. Trembling or shaking4. Sensations of shortness of breath or smothering5. Feeling of choking6. Chest pain or discomfort7. Nausea or abdominal distress8. Feeling dizzy, unsteady, lightheaded, or faint9. Derealization (feelings of unreality) or depersonalization (being
detached from oneself)10. Fear of losing control or going crazy11. Fear of dying12. Paresthesias (numbness or tingling sensations)13. Chills or hot flushesSource: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,Text Revision.
Panic Attacks (continued) Misinterpretations of bodily sensations lies at
the core of panic disorder▪ Heart palpitations heart attacks▪ Racing thoughts lose their mind
SYMPTOMS
Panic attack cycle
Panic Attacks (continued) Described in situations in which they occur:
▪ Cued: if expected, or if it occurs only in the presence of a particular stimulus
▪ Unexpected: panic attacks appears without warning or expectation, as if “out of the blue.”
SYMPTOMS
SYMPTOMS
OBSESSIONS Unwanted, anxiety-
provoking thoughts/images
“out of the blue” May seem silly or
crazy, socially inappropriate or horrific
COMPULSIONS Compulsions cannot
be resisted without distress
Reduce (neutralize) anxiety, but do not produce pleasure
Irrational rituals
Anxiety Disorder Subtypes
stress disorder
Panic Disorder
▪ Recurrent, unexpected panic attacks▪ At least one of the attacks must be followed
by a period of 1 month or more with persistent concerns about having additional attacks.
▪ Divided into two subtypes: presence of absence of agoraphobia
Criteria for Panic Disorder
Defined as intense, persistent, irrational, fear and avoidance of a specific object or situation
Reactions are unreasonable.
PHOBIAS
Criteria for Phobias
Agoraphobia ▪ Fear of public places in which individual
fears that s/he cannot escape. ▪ Typical situations
▪ Crowded streets, shops▪ Public transportation▪ Wide open areas
Subtypes of Phobias
Social Phobia
Fears are focused on social situations where there is a possibility of being judged/observed/humiliated/embarrassed
Two broad headings: Performance Anxiety Interpersonal interaction
SPECIFIC PHOBIA
▪ A “marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation.”
▪ Exposure to phobic stimulus must be followed by an immediate fear response.
▪ “Catchall” category
SPECIFIC PHOBIA--subtypes
1) Animals
2) Natural Environmental
3) Blood/Injury/Injection
4) Situational
Generalized Anxiety Disorder (GAD)
▪ Chronic (>6 mos),debilitating, excessive anxiety and worry▪ Trouble controlling the worries▪ Worries lead to significant distress▪ Pervasive: worries must be about different events or
activities▪ Includes three or more of the following: Restlessness
Sleep disturbance Fatigue Irritability Muscle Tension
Difficulty concentrating
Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder
▪ Recognition that the obsessions or compulsions are excessive or unreasonable.
▪ Attempts to ignore, suppress, or neutralize the unwanted thoughts or impulses.
Comorbidity
Gender Differences
♀ > ♂ 2-3 times Relapse rates: higher for ♀ OCD: no significant gender differences Specific phobia: ♀ are three times more likely Panic disorder, agoraphobia (without panic
disorder): ♀ about twice as likely Social phobia: more common among ♀
CAUSES--Adaptive vs. Maladaptive Fears
Evolutionary perspective focuses on significance of anxiety and fear. Fear/Anxiety may mobilize. Help the person survive in the face of both immediate danger and long-range threats
CAUSES
Adaptive and Maladaptive Fears▪ Preparedness Model (preconditioning theory)
▪ Research results appear to support that conditioned responses to fear-relevant stimuli (e.g., spiders, snakes) are more resistant to extinction that those to fear-irrelevant stimuli (e.g., flowers).
CAUSES--Social Factors
Causal patterns are complex. Multicausal. Stressful life events, particularly involving
danger and interpersonal conflict, can trigger the onset of certain kinds of anxiety disorders and depression.
Why do some negative life events lead to depression while other lead to anxiety?
Nature of the event: important factor
Anxiety: danger
Depression: severe loss (lack of hope)
Causes—Childhood Adversity Maternal prenatal
stress (higher cortisol levels at birth)
Multiple maternal partner changes
Parental indifference (neglect)
Physical abuse.
more likely to develop anxiety disorders
Causes--Attachment Relationships and Separation Anxiety
Anxiety is an innate response to separation, or threat of separation.
People with anxiety disorders more likely to have had attachment problems as children.
CAUSES-- Psychological FactorsLearning Processes
Specific fears might be learned through classical conditioning.
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Watson and Rayner (1920) “Little Albert” studyConditioned fears “persist and modify personality throughout life”Mary Cover Jones (1924) later used classical conditioning to remove fears in another boy
Classical Conditioning
White rat no reaction (NS)
Loud Noise Fear (UCS)
(UCR)White Rat + Loud Noise
Fear (NS) (UCS) (UCR)
White rat Fear (CS) (CR)
CAUSES--Cognitive Factors
Perceptions, memory, and attention all influence reaction to events.
▪ Four aspects:▪ Perception of controllability▪ Catastrophic misinterpretation▪ Attentional biases▪ Thought suppression
CAUSES
Control events in their environments: less likely to show anxiety than people who believe they are helpless.
Feelings of lack of control = onset of panic attacks
Anxiety Control
Causes
Catastrophic Misinterpretation▪ Panic attacks can be precipitated by internal
stimuli, such as bodily sensations, thoughts, or images.
▪ Misinterpret bodily sensations = catastrophic event.
▪ Automatic, negative thoughts lead to behaviors that are expected to increase safety, when they are in fact counterproductive.
Causes
Attention to Threat and Biased Information Processing
▪ Unusually sensitive to cues that signal the existence of future threats.
▪ Recognition of danger triggers maladaptive, self-perpetuating cycles that quickly spin out of control.
Is it useful to struggle actively against unwanted thoughts?
Trying to rid one’s mind of a distressing or unwanted thought can have the unintended effect of making the thought more intrusive (especially for OCD).
CAUSES--Biological
Thalamus Amygdala Flight or Fight (behavioral responses coordinated through the hypothalamus) Endocrine glands & Autonomic Nervous System (FIGURE 6-3)
CAUSES
Thalamus Visual Cortex Amygdala
(triggers an organized response to threat).
PSYCHOLOGICAL TREATMENT Psychoanalytic psychotherapy
▪ Fosters insight regarding the unconscious motives that presumably lie at the heart of the patient’s symptoms.
PSYCHOLOGICAL TREATMENT
Relaxation Skills Training▪ Teaching alternately to tense and relax specific
muscle groups while breathing slowly and deeply. Breathing Retraining
▪ Education about the physiological effects of hyperventilation and practice in slow breathing.
▪ Learn to control breathing through repeated practice using muscles of the diaphragm, rather than the chest.
PSYCHOLOGICAL TREATMENT
Systematic Desensitization▪ Systematic maintained exposure to the
feared stimuli.▪ Progressive relaxation ▪ A hierarchy of feared stimuli
PSYCHOLOGICAL TREATMENT
Exposure Treatments▪ Situational Exposure: used to treat
agoraphobic avoidance▪ Involves repeatedly confronting the situations
that have been previously avoided.▪ Interoceptive Exposure: aimed at reducing
the person’s fear of internal, bodily sensations frequently associated with panic
PSYCHOLOGICAL TREATMENT
Cognitive Therapy▪ Identify thoughts that are relevant to their
problems.▪ Recognize the relation between these
thoughts and maladaptive emotional responses.
▪ Examine evidence that supports or contradicts these beliefs.
▪ Teach more useful ways of interpreting events.
BIOLOGICAL TREATMENT Antianxiety Medications—Anxiolytics Work on GABA
▪ Most frequently used types of minor tranquilizers -- benzodiazepines.▪ Valium and Xanax
▪ Reduce many symptoms of anxiety, especially vigilance and somatic sensations.
▪ Have less effect on worry and rumination.
BIOLOGICAL TREATMENT
Benzodiazepines▪ Shown to be effective in the treatment of
GAD and social phobias▪ Not typically beneficial for specific phobias or
OCD▪ Many with panic disorder and agoraphobia
relapse if they discontinue taking medication.
BIOLOGICAL TREATMENT
Side Effects▪ Sedation accompanied by mild psychomotor and cognitive impairments
▪ Problems in attention and memory, especially among elderly
▪ Potential for addiction
BIOLOGICAL TREATMENT
Antidepressant Medications
▪ Selective Serotonin Reuptake Inhibitors (SSRIs)
▪Zoloft
▪Paxil
▪Prozac
▪Luvox
BIOLOGICAL TREATMENT SSRIs
▪ Reduce symptoms of various anxiety disorders.
▪ Fewer unpleasant side effects and are safer to use.
▪ Withdrawal reactions are less prominent
▪ First-line medication for treating panic disorder, social phobias, and OCD
BIOLOGICAL TREATMENT
Antidepressant Medications: Tricylics (norepinephrine)
Used less frequently than the SSRIs because they produce several unpleasant side effects
▪ Anafranil: OCD▪ Improvement in see in 50% receiving clomipramine,
but relapse is common if medication is discontinued.
BIOLOGICAL TREATMENT
Buspar—drug mechanisms are unknown.
May work on serotonin or dopamine systems
Less potent, but less addictive with less side effects.
Do psychological treatments have any advantages over medication for treatment of anxiety? Often treated with a combination of
psychological and biological procedures. Selection of specific treatment
components depends on presenting symptoms.
