Anxiety vs Fear

• Anxiety - apprehension over an anticipated problem

o About a future threat
• Fear - reaction to immediate danger
o About a threat that is happening now
• Both anxiety and fear involve arousal (sympathetic nervous system activity)
o Anxiety - moderate arousal (restless energy and physiological tension)
o Fear - higher arousal (sweating profusely, breathing rapidly, overpowering urge to run)
• Both are adaptive
o Fear - fundamental for fight-or-flight reactions (rapid changes in sympathetic nervous system)
▪ In the right circumstances -- fear can save lives
o Anxiety helps us notice and plan for future threats
▪ U shaped curve with performance
▪ Absence of anxiety is a problem
▪ Little anxiety is adaptive
▪ Too much anxiety is detrimental
▪ Anxiety to increase preparedness, to avoid potentially dangerous situations
ANXIETY DISORDERS

• Most common type of psychiatric diagnosis

o Approx 28% people report having symptoms that qualify for diagnosis of an anxiety disorder
• Phobias are common

• A lot of overlap in definition of anxiety disorders

o Need to have several criteria to be met for DSM-5 diagnosis:
▪ Symptoms must interfere with important areas of functioning or cause marked distress
▪ Symptoms are not caused by a drug or a medical condition
▪ The fears and anxieties are distinct from the symptoms of anxiety disorder

• Specific Phobias
o Symptoms:
▪ Disproportionate fear caused by a specific object or situation
▪ Person recognizes that fear is excessive but still goes to great lengths to avoid the feared
object or situation
▪ Must persist for at least 6 months
o Naming a phobia
▪ Greek word for feared object/situation + suffix phobia (Greek god phobos who frightened
enemies)
o Common phobias
▪ Claustrophobia (fear of closed spaces)
▪ Acrophobia (fear of heights)
▪ Specific phobias tend to cluster around a small number of feared objects and situations
o A person with one type of specific phobia is likely to have another type of phobia as well
• Social Anxiety Disorder
o A persistent, unrealistically intense fear of social situations that might involve being scrutinized
by, exposed to, unfamiliar people
o In DSM-IV-TR, this is labeled as social phobia
▪ But DSM-5 considered it as a disorder
▪ Because problems it caused are more pervasive and interfere much more with normal
activities than problems caused by other phobias
o Most common fears involve
▪ Public speaking, speaking up in meetings or classes, meeting new people, talking to people
in authority
o NOT SHYNESS
▪ People with social anxiety disorder AVOID MORE social situations, feel more discomfort
socially, and experience symptoms for longer periods
▪ People with the disorder would rather work in an unrewarding job with little social
demand
o 1/3 of people with social anxiety disorder meet criteria for DSM-IV-TR criteria for avoidant
personality disorder
▪ Symptoms tend to overlap
▪ Overlap in genetic vulnerability of the conditions
o Social anxiety disorder generally begins in adolescence (social interactions are important during
this stage)
• Panic Disorder
o Characterized by frequent panic attacks that are unrelated to specific situations and by worry
about having more panic attacks
o Panic attack - sudden attack of intense apprehension, terror, and feelings of impending doom,
accompanied by at least four other symptoms:
▪ Physical symptoms - shortness of breath, heart palpitations, nausea, upset stomach, chest
pain, feelings of choking and smothering, dizziness, lightheadedness, feeling faint,
sweating, chills, etc,
▪ Other symptoms:
▪ Depersonalization - feeling of being outside one's body
▪ Derealization - a feeling of the world's not being real
▪ Fears of losing control, of going crazy, of dying
▪ Symptoms are rapid and reach peak intensity within 10 minutes
o Panic attack as misfire of the fear system
▪ You normally experience physiologically what a normal person would experience when
faced with an immediate threat
o Criteria for panic disorder
▪ Person must experience recurrent panic attacks that are unexpected
▪ Panic attack that is triggered by specific situations (such as related to phobia)
SHOULD NOT be considered in diagnosing panic disorder
▪ For at least one month, person must worry about the attacks --- response to panic attacks
are as important as the attacks themselves

• Agoraphobia
o Greek agora meaning "marketplace"
o Anxiety about situations in which it would be embarrassing or difficult to escape if anxiety
symptoms occurred
▪ Situations such as crowds, crowded places like grocery stores, malls and churches
▪ Virtually unable to leave their house --- and when they do so, leave houses with great
distress
o In DSM-IV-TR agoraphobia is coded as subtype of panic disorder
▪ BUT in DSM-5 considered as separate diagnosis
▪ In accordance with International Classification of Diseases (ICD)
• Generalized Anxiety Disorder
o "worry" as central feature
▪ The cognitive tendency to chew on a problem and to be unable to let go of it
▪ Worry continues because cannot settle on a solution to the problem
▪ Worries of GAD are excessive, uncontrollable, and long-lasting
▪ Worries of GAD are similar in focus to those of most people (relationships, health,
finances, daily hassles) --- BUT THEY WORRY MORE
o Other symptoms of GAD:
▪ Difficulty concentrating, tiring easily, restlessness, irritability and muscle tension
▪ Symptoms must be present at least 6 months to qualify for a diagnosis of GAD
• Comorbidity in Anxiety Disorders
o More than 1/2 people with one anxiety disorder meet criteria for another anxiety disorder
o Comorbidity is particularly pronounced for people with GAD
▪ Fourfold risk of developing another anxiety disorder
▪ More than 80% of people with GAD will meet criteria for another anxiety disorder
o Very common for people with one anxiety disorder to report subthreshold symptoms
▪ Subthreshold symptoms - symptoms that do not meet full diagnostic criteria
o Reasons for comorbidity:
▪ Symptoms used to diagnose various anxiety disorders overlap
▪ I.e. social anxiety and agoraphobia involve both fear of crowds
▪ Etiological factors increase risk for more than one anxiety disorder
o 60% people in treatment for anxiety disorders meet criteria for major depression
▪ Other disorders comorbid include:
 ▪ Substance abuse
▪ Personality disorders

GENDER AND SOCIOCULTURAL FACTORS IN ANXIETY DISORDERS

• Gender
o Women are twice as likely to be diagnosed with an anxiety disorder
o Probable reasons WHY?
▪ Women may be more likely to report their symptoms
▪ Psychological differences such as that men may be raised to believe more in their personal
control over situations
▪ Social factors like gender roles
▪ Women experience different life circumstances than do men:
▪ They are likely than men to be sexually assaulted in childhood/adulthood

• Culturally specific syndromes which shows how culture and environment may shape the focus of an
anxiety disorder
o Taijin kyofusho (Japan)
▪ Involves fear of displeasing or embarrassing others
▪ People fear making eye contact, blushing, having body odor, etc.
▪ Focus on others' feeling makes it distinct from social anxiety disorder
▪ Maybe related to characteristic of traditional Japanese culture that encourage
extreme concern for the feelings of others and discourage the direct communication
of one's own feelings
o Kayak-angst (Inuit people of western Greenland)
▪ Similar to panic disorder
▪ Seal hunters who are alone at sea may experience intense fear, disorientation, and
concerns about drowning
o Koro (southern and eastern Asia)
▪ Sudden fear that one's genitals will recede into the body
o Shenkui (China)
▪ Intense anxiety and somatic symptoms attributed to the loss of semen through
masturbation or excessive sexual activity
o Susto (Latin America and Latinos in the US)
▪ Fright-illness - the belief that a severe fright has caused the soul to leave the body
o Culture influences what people come to fear

• Prevalence of anxiety disorders across cultures differ

o In Taiwan and Japan, prevalence of anxiety disorders seems to be quite low
▪ This may reflect however a strong stigma associated with having mental problems
▪ Leading to underreporting
o In Cambodia and among Cambodian refugees
▪ Elevated rates of panic disorder -- traditionally diagnosed as kyol goeu or "wind overload"
▪ Maybe because of extreme stress experienced by Cambodians

• Do people from specific cultures express symptoms of the same disorder differently?
o Many researchers believed that somatic (physical) expressions of distress were more common
in "collectivistic" cultures (as opposed to individualistic Western cultures)
o BUT this conclusion might be a result of sampling problems
o Person seeing a medical doctor is likely to emphasize somatic concerns
 o WHEN interviewed people in similar settings (as those in Western) and ask specifically about
psychological concerns, ratio of somatic to psychological symptoms were more similar across
cultures

COMMON RISK FACTORS ACROSS ANXIETY DISORDERS

• Fear conditioning
o Mowrer's two-factor model (1947) suggest 2 steps in development of anxiety disorder:

1. Classical conditioning: person learns to fear neutral stimulus (CS) that is paired with an
intrinsically aversive stimulus (the UCS)
2. Operant conditioning: person gains relief by avoiding the CS --- this avoidant response is
maintained because it is reinforcing (reduces fear)
o Explains why the phobia is not extinguished

• Extension of Mowrer's model which considers different ways in which classical conditioning
could occur:
o Occur by direct experience
o Occur by seeing another person harmed or frightened by a stimulus -- learning called
"modeling"
o Occur by verbal instruction
• People with anxiety disorders seem to acquire fears more readily through classical conditioning
AND a slower extinction of fears once acquired

• Genetic Factors
o Twin studies suggest heritability of 20-40 percent for specific phobias, social anxiety disorder,
GAD and PTSD
o 50 percent heritability for panic disorder

• Neurobiological Factors
o Fear circuit - set of brain structures involved when people are feeling anxious or fearful
▪ Related to anxiety disorders
o Amygdala (part of fear circuit) is activated among people with anxiety disorders
▪ Small almond shaped structure in the temporal lobe
 ▪ Involved in assigning emotional significance to stimuli
o Medial prefrontal cortex important in helping to regulate amygdala activity
▪ Involved in extinguishing fears and using emotion regulation strategies
▪ LESS ACTIVITY in the medial prefrontal cortex in people who meet criteria for anxiety
disorders
▪ Evidence suggests that PATHWAY linking medial prefrontal cortex AND amygdala may be
deficient among those with anxiety disorders
▪ Deficits in connectivity may interfere with effective regulation and extinction of
anxiety
o Neurotransmitters
▪ Poor functioning of serotonin and higher than normal levels of norepinephrine related to
anxiety disorders
▪ Poor GABA function (which inhibits activity throughout the brain) may contribute to
anxiety

• Personality
o Behavioral inhibition - tendency to become agitated and cry when faced with novel toys,
people, or other stimuli
▪ Described in infant as young as 4 months old
▪ May be inherited and SET the stage for later development of anxiety disorders
▪ Behavioral inhibition is strong predictor of social anxiety disorder
▪ 30% infants showing elevated behavioral inhibition developed social anxiety disorder
by adolescence
o Neuroticism - tendency to react to events with greater-than-average negative affect
▪ Neuroticism predicted the onset of both anxiety disorders and depression
▪ High level of neuroticism more than twice likely to develop anxiety disorder than those
with low levels

• Cognitive Factors

• Sustained Negative Beliefs about the Future

o People with anxiety disorders report believing that bad things are likely to happen
o David Clark and colleagues: Key issue is NOT why people think negatively BUT how these
beliefs are sustained
o BUT HOW?
▪ People may think and act in ways that maintain these beliefs
▪ They engage in safety behaviors (to protect against feared consequences)
▪ They will come to believe that only their safety behaviors have kept them alive
• Perceived Control
o People with anxiety disorders report experiencing little sense of control over their
surroundings
o Childhood events such as traumatic events, punitive and restrictive parenting or abuse
▪ May promote view that life is not controllable
o More than 70% people report severe life event before the onset of an anxiety disorder
• Attention to Threat
o People with anxiety disorders found to pay more attention to negative cues in their
environment than do people w/o anxiety disorders
o The dot probe task
▪ Each specific anxiety disorder associated with heightened attention to threatening
stimuli on the dot probe task
o Research examined whether attention to anxiety-related information can be created
▪ Findings suggest that the way we focus our attention can foster an anxious mood
 ▪ We can also train positive bias -- parallel benefits of attention training have been
shown among people with social anxiety

ETIOLOGY OF SPECIFIC ANXIETY DISORDERS

• Etiology of Specific Phobias

o Two-factor Model of behavioral conditioning (see Mowrer's two-factor model)
▪ In behavioral model, phobias are seen as conditioned response that develops after a
threatening experience and is sustained by avoidant behavior
▪ Behavioral theory suggests that phobias COULD be conditioned by direct trauma,
modeling, or verbal instruction
▪ John Watson and Rosalie Rayner's Little Albert
▪ Created intense fear of a rat in Little Albert using classical conditioning
o Prepared Learning
▪ Fear circuit may have been "prepared" by evolution to learn fear of certain stimuli
▪ Prepared learning is also relevant to modeling
▪ Easier to condition fear of potentially life-threatening stimuli than of neutral stimuli
▪ Monkeys only acquired fear of toy snake/crocodile and NOT fear of flowers/toy
rabbit

• Etiology of Social Anxiety Disorder

o Behavioral factors
▪ Similar to those on specific phobias (based on two-factor conditioning model)
▪ Person could have negative social experience (direct, modeling or verbal instruction) and
become classically conditioned to fear similar situations
▪ Few opportunities to extinguish fear
▪ Even when person interacts with others, he/she may show avoidant behavior (that
have been labeled as safety behaviors)
▪ Safety behaviors: avoiding eye contact, disengaging from conversation, and standing
apart from others
▪ Although they are used to avoid negative feedback -- they actually create more
problems

• Cognitive factors
o People with social anxiety disorders appear to have unrealistically negative beliefs about the
consequences of their social behaviors
o They attend more to how they are doing in social situations and their own internal
sensations than other people do
▪ Instead of paying attention to the other in a conversation, they think about how
others might perceive them
▪ They form powerful negative visual images of how others will react to them
▪ May foster social awkwardness
o Social anxiety disorder is related to attention to internal cues rather than external (social)
cues
▪ People diagnosed with social anxiety disorder attended more closely to their own
heart rate than did people who were not diagnosed with social anxiety disorder
▪ They are busy monitoring their own anxiety levels

• Etiology of Panic Disorder

o Neurobiological factor: Locus coeruleus
▪ Part of the fear circuit that is especially important in panic disorder
 ▪ The major source of norepinephrine in the brain
▪ Norepinephrine - plays major role in triggering sympathetic nervous system activity
▪ Drugs that increase activity in the locus coeruleus can trigger panic attacks
▪ Drugs that decrease activity in locus coeruleus (clonidine and antidepressants) decrease
the risk of panic attacks
o Behavioral factor: classical conditioning
▪ Panic attacks are often triggered by internal bodily sensations of arousal
▪ Theory suggests that panic attacks are classically conditioned responses to either the
situations that trigger anxiety or the internal bodily sensations of arousal
▪ Interoceptive conditioning - person experiences somatic signs of anxiety which are
followed by person's first panic attack --->> panic attacks then become conditioned
response to somatic changes

• Cognitive factors
o Catastrophic misinterpretations of somatic changes (D. M. Clark)
▪ Panic attacks develop when a person interprets bodily sensations as signs of
impending doom
o Researchers manipulated carbon dioxide levels
▪ Those who had received a full explanation about the physical sensations were likely
to experience fewer catastrophic interpretations of their bodily sensations
▪ And were much less likely to have a panic attack
o Anxiety Sensitivity Index
▪ Measures the extent to which people respond fearfully to their bodily sensations
▪ A study:
▪ People were divided into high/low scorers based on the Anxiety Sensitivity
Index
▪ Unexplained physiological arousal in someone who is fearful of such sensations
leads to panic attacks
▪ Shown to predict the onset of panic attacks in longer-term studies
• Etiology of Agoraphobia
o Less is known about its etiology
▪ Only recognized as a distinct disorder in DSM-5
▪ Development of agoraphobia appears related to genetic vulnerability and life events
o Cognitive factor: Fear-of-Fear hypothesis
▪ Suggests that agoraphobia is driven by negative thoughts about the consequences of
experiencing anxiety in public

• Etiology of Generalized Anxiety Disorder

o GAD tends to co-occur with other anxiety disorders and with depression
▪ Factors involved in anxiety disorders in general are important in understanding GAD
▪ Example: deficits in functioning of GABA system, important for many anxiety disorders,
appear to be involved in GAD
o Cognitive factors: Why do people worry?
▪ Borkovec and colleagues: Worry is actually REINFORCING because it distracts people from
more powerful negative emotions and images
▪ UNDERSTAND that worry does not involve powerful visual images and does not
produce physiological changes that usually accompany emotion
▪ By worrying, people with GAD may be avoiding unpleasant emotions
▪ As a consequence, underlying anxiety about these images does not extinguish
▪ Many people with GAD report past traumas involving death, injury, or illness
▪ Worry distracts people with GAD from the distress of remembering these past
traumas
 ▪ People with GAD may be avoiding emotions
▪ Harder to understand and label their feelings
▪ People who have a hard time accepting ambiguity -- more likely to worry and to develop
GAD

TREATMENTS OF ANXIETY DISORDERS

Only small proportion of people with anxiety disorders seek treatment

One reason for lack of treatment seeking may be the chronic nature of symptoms

• Commonalities across psychological treatments

o Common focus: exposure - person must face what he/she deems too terrifying to face
▪ Chinese proverb: Go straight to the heart of danger, for there you will find safety.
▪ Although exposure is a core aspect of many cognitive behavioral treatments (CBT), these
treatments differ in their strategies
o Systematic desensitization
▪ First widely used exposure treatment
▪ Client is taught relaxation skills and uses these skills to relax while undergoing exposure to
list of feared situations
▪ Researchers documented that exposure treatment works even if relaxation component is
not included
o Principles in protecting against relapse
▪ Exposure should include as many features of the feared object as possible
▪ Exposure should be conducted in as many different contexts as possible

• Behavioral view of exposure

o Exposure works by extinguishing fear response
o Extinction does not work like an eraser
▪ extinction wont erase fear of object altogether
▪ Conditioned fear still resides in the brain
▪ Extinction involves learning new associations to stimuli -- these inhibit activation of
the fear
▪ Extinction involves LEARNING, NOT FORGETTING

• Cognitive view of exposure

o Exposure helps people correct their mistaken beliefs that they are unable to cope with the
stimulus
o Exposure relieves symptoms by allowing people to realize that they can tolerate aversive
situations without loss of control
o Focus of cognitive treatments
▪ Challenging person's beliefs about the likelihood of negative outcomes if he/she
fears anxiety-provoking object or situation
▪ Challenging expectation that he/she will be unable to cope
o Most studies suggest that adding cognitive therapy component to exposure therapy for
anxiety disorders does not bolster results

• Virtual reality - used to simulate feared situations

o Exposure to these simulated situations appear to be as effective as in vivo (real life)
exposure
• Series of computerized programs have been developed to guide clients in CBT
o SEEMS to work best when at least some human contact is provided
 o Example: therapists might conduct the initial screening
o These kind of programs substantially reduce the amount of professional contact time
required to complete exposure treatment

• Psychological Treatments of Specific Anxiety Disorders

• Phobias
o Exposure treatments include in vivo exposure to feared objects
o In vivo exposure is more effective than systematic desensitization

• Social Anxiety Disorder

o Exposure treatments begin with role playing or practicing with the therapist in small groups
before undergoing exposure in MORE public situations
o Social skills training
▪ Therapist provides extensive modeling of behavior
▪ Helps people what to do or say in social situations
o Effect of exposure treatment enhanced when people are taught to STOP using safety
behaviors
▪ They are asked to make direct eye contact
▪ To engage in conversation, and to be fully present
o David Clark
▪ Developed version of cognitive therapy for people with social anxiety disorder
▪ Therapist helps people learn not to focus their attention internally
▪ Helps them combat their very negative images of how others will react to them
▪ This therapy is MORE effective than fluoxetine or exposure treatment plus relaxation

• Panic Disorder
o Psychodynamic treatment
▪ 24 sessions focused on identifying the emotions and meanings surrounded in panic
attacks
▪ Therapists help client gain insights believed to related to the panic attacks
▪ Related to diminished rates of relapse WHEN added as supplement to
antidepressant treatment
o Panic control therapy (PCT)
▪ A cognitive behavioral treatment approach
▪ Based on the tendency of people with panic disorder to overreact to the bodily
sensations
▪ Therapist uses exposure techniques -- persuade the client to deliberately elicit bodily
sensations associated with the panic
▪ When sensations and other signs of panic begin, person experiences them
under safe conditions --- and practices coping tactics for dealing with somatic
symptoms
▪ Person learns to stop seeing internal sensations as signals of loss of control
o Another version of cognitive treatment
▪ Therapist helps the person identify and challenge the thoughts that make the
physical sensations threatening

• Agoraphobia
o Systematic exposure to feared situations
o Exposure treatment is more effective when the partner is involved
o May conduct own step-by-step exposure treatment through a manual
 • Generalized Anxiety Disorder
o All treatments of GAD include several cognitive or behavioral components
o Relaxation training
▪ Most widely used behavioral technique to promote calmness
▪ Involve relaxing muscle groups one-by-one OR generating calming mental images
▪ Studies suggest that relaxation training is more effective than nondirective treatment
or no treatment
o Cognitive therapy including strategies to help people tolerate uncertainty
▪ More helpful than relaxation therapy alone
o Borkovec and colleagues designed cognitive behavioral strategies to target worry
▪ Such as asking people to worry only during scheduled times

• Medications that reduce anxiety

o Anxiolytics
▪ Drugs that reduce anxiety
▪ Also called sedatives or minor tranquilizers
o Types:
▪ Benzodiazepines (e.g. Valium and Xanax)
▪ Antidepressants
▪ Tricyclic antidepressants
▪ Selective serotonin reuptake inhibitors (SSRIs)
▪ Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Studies confirm that benzodiazepines and antidepressants provide more benefit than do
placebos for anxiety disorders
Certain drugs seem effective for specific anxiety disorders (e.g. buspirone or BuSpar for
GAD)

• How does one decide which to use?

o Generally antidepressants are preferred over benzodiazepines
▪ People may experience withdrawal symptoms when they try to stop
benzodiazepines (can be addictive)
o Concern about side effects - all anxiolytics have side effects
▪ Benzodiazepine - significant cognitive and motor side effects (memory lapses and
difficulty driving)
▪ Antidepressants - fewer side effects than benzodiazepines
▪ Jitteriness, weight gain, elevated heart rate, and high blood pressure
▪ SSRIs have fewer side effects when compared to tricyclic antidepressants --
SSRI being first line medications for treatment of most anxiety disorders
▪ Side effects of SSRIs (restlessness, insomnia, headache, and diminished
sexual functioning)
o Most people relapse once they stop taking medications
▪ Psychological treatments are typically considered the preferred treatment of most
anxiety disorders with the possible exception of GAD

• Combining medications with psychological treatment

o Adding anxiolytics to treatment actually leads to WORSE long-term outcomes than exposure
treatment without anxiolytics
▪ EXCEPTION: Treatment of Social Anxiety Disorder
▪ Suggested that combination treatment of anxiolytics and cognitive-behavioral exposure
achieved stronger results than either anxiolytics OR cognitive-behavioral treatment alone
o D-cycloserine (DCS)
▪ Drug that enhances learning
▪ DCS was found to enhance the effects of exposure treatment for social anxiety disorder
and for panic disorder
▪ DCS appears to bolster effects of psychotherapy based on conditioning principles