Anxiety based disorders

Module 3
While everyone may experience some level of anxiety at one time
or another, those with anxiety disorders experience it consistently
and so intensely that it has a significantly negative impact on their
quality of life. (Photo: Zetson)
Which of the following characterizes the mood-state known as anxiety?
Anxiety is closely related to which of the following psychological disorders?
People tend to have their best performance on tasks when they are ___________.
When people experience severe anxiety, they
Out of the blue, my heart started racing. I felt my chest. Then I broke into a cold sweat, began
hyperventilating, and became convinced I was having a heart attack. The people in the car next to mine
seemed totally unaware that anything was wrong. My heart just kept racing. I couldn’t stop it. I was going
to die. How could I stop it? It was getting worse. I was dying! The driver behind me started blowing his
horn. The light had turned green. I needed help. I couldn’t get out of the car. “God help me!” I prayed. Then
it stopped—just like that, my heart stopped racing. I put my hand to my heart again. It felt normal. My
hands and arms were covered with a cold clammy sweat. I wiped the perspiration from my face and
looked at myself in the rearview mirror. For the first time in my life, I caught sight of a frightened Earl
Campbell and I didn’t like it . . .

(Campbell & Ruane, 1999, pp. 83–84)

Anxiety
• Anxiety : general feeling of apprehension about possible danger.
• Anxiety disorders include disorders that share features of excessive
fear and anxiety and related behavioral disturbances.
• The anxiety disorders differ from one another in the types of objects
or situations that induce fear, anxiety, or avoidance behavior, and
the associated cognitive ideation.
The fear & anxiety response patterns
•Anxiety is defined as apprehension over an
anticipated problem, fear is defined as a reaction to
immediate danger.
•Fear tends to be about a threat that’s happening
now, whereas anxiety tends to be about a future
threat.
•Thus, a person facing a bear experiences fear,
whereas a college student concerned about the
possibility of unemployment after graduation
experiences anxiety.
The fear & anxiety response patterns

●When the source of danger is obvious, the

experienced emotions is called fear.
●Anxiety is experienced as an unpleasant
inner state in which we anticipate some
dreadful thing happening that is not
entirely predictable from our actual
circumstances.
Fear components
● Cognitive/subjective component(eg., I feel
afraid)
● Physiological component(eg., increased heart
rate)
● Behavioral component(eg., a strong urge to
escape)
● At the cognitive/subjective, level anxiety involves
negative mood , worry about possible threat , self
reoccupation & a sense of being unable to
predict the future threat or to control it if it
occurs.
Anxiety

▣ At a physiological level , anxiety involves a state of chronic over

arousal which may reflect the state of readiness for dealing with
danger should it occur(preparations for the flight/fight response).
▣ At a behavioral level anxiety involves a state of strong tendency
to avoid situations where the threat might be encountered.
▣ An anxiety disorder has an unrealistic, irrational fear or anxiety of
disabling intensity at its core & also as its principal & most
obvious manifestation.
Adaptive value of anxiety

• Anxiety is adaptive in helping us notice and plan for future

threats, to increase our preparedness, to help people avoid
potentially dangerous situations, and to think through
potential problems before they happen.
• Anxiety provides a classic example of a U-shaped curve with
performance—an absence of anxiety is a problem, a little
anxiety is adaptive, and a lot of anxiety is detrimental.
types
• 5 types of anxiety disorders (DSM-V):
• Phobic disorders of the specific type, social type, panic disorder with
agoraphobia, without agoraphobia, Generalized anxiety disorder.
DSM-IV-TR Diagnoses Anxiety Disorders DSM-5 Diagnoses Anxiety Disorders

Specific phobia Specific phobia

Social phobia Social anxiety disorder
Panic disorder Panic disorder
(with or without agoraphobia)
Agoraphobia
Generalized anxiety disorder Generalized anxiety disorder
Obsessive–Compulsive and Related Disorders
OCD OCD
Trauma– and Stressor–Related Disorders
Acute stress disorder
PTSD
• Mr. S was a successful lawyer who presented for treatment to which he
had previously been able to walk from home, moved to a new location
that he could only reach by driving. Mr. S reported that he was
“terrified” of driving, particularly on highways.
• Even the thought of getting into a car led him to worry that he would die
in a fiery crash. His thoughts were associated with intense fear and
numerous somatic symptoms, including a racing heart, nausea, and
sweating. Although the thought of driving was terrifying in and of itself,
Mr. S became nearly incapacitated when he drove on busy roads, often
having to pull over to vomit.(Courtesy of Erin B. McClure-Tone, Ph.D.,
and Daniel S. Pine, M.D.)
From DSM IV TR to DSM 5
Disorder Description Key changes in DSM 5

Specific phobia Fear of objects or situations that Duration criteria specified for
is out of proportion to any real adults
danger Person need not perceive fear as
unrealistic

Social anxiety disorder Fear of unfamiliar people or Name changed from social
social scrutiny phobia
Duration criteria specified for
adults
Panic disorder Anxiety about recurrent
panic attacks
From DSM IV TR to DSM 5
Disorder Description Key changes in DSM 5

Agoraphobia Anxiety about being in places New disorder (formerly a subtype

where escaping or getting help of
panic disorder)
would be difficult if anxiety
symptoms occurred

Generalized anxiety disorder Uncontrollable worry for at least More speific criteria for children
6 months
Phobic Disorder

• The term phobia refers to an excessive fear of a specific object,

circumstance, or situation.
• A specific phobia is a strong, persisting fear of an object or situation.
• The diagnosis of specific phobia requires the development of intense
anxiety when exposed to the feared object.
Types
•Acrophobia •Fear of heights
•Agoraphobia •Fear of open places
•Ailurophobia •Fear of cats
•Hydrophobia •Fear of water
•Claustrophobia •Fear of closed places
•Cynophobia •Fear of dogs
•Mysophobia •Fear of dirt/germs
•Pyrophobia •Fear of fire
•Xenophobia •Fear of strangers
•Zophobia •Fear of animals
Names of highly unlikely phobias
Fear Phobia
•Anything new •Neophobia
•Asymmetrical things •Asymmetriphobia
•Books •Bibliophobia
•Children •Pedophobia
•Dancing •Chorophobia
• Englishness •Anglophobia
•Garlic •Alliumphobia
Names of highly unlikely phobias

Fear Phobia
•Peanut butter sticking to the roof Arachibutyrophobia
of the mouth
•Technology Technophobia
•Mice Musophobia

•Pseudoscientific terms Hellenophobia

 Types of Specific Phobias
Type of Phobia Examples of the Feared Associated Characteristics
Object
Animal Snakes, insects Generally begins during
childhood

Natural environment Storms, heights, water Generally begins during

childhood

Blood, injection, injury Blood, injury, injections, or Clearly runs in families;

(LeBeau et al., 2010) other invasive medical profile of heart rate slowing
procedures and possible fainting when
facing feared stimulus
Type of Phobia Examples of the Feared Associated
Object Characteristics

Situational Public transportation, Tends to begin either in

tunnels, bridges, childhood or in mid-20s.
elevators, flying, driving,
closed spaces

Other Fear of choking, fear of

contracting an illness,
etc.;
children’s fears of loud
sounds, clowns, etc.
Criteria for specific phobia
A. Marked fear or anxiety about a specific object or situation (e.g.,
flying, heights, animals, receiving an injection, seeing blood).
B. The phobic object or situation almost always provokes immediate
fear or anxiety.
C. The phobic object or situation is actively avoided or endured with
intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger
posed by the specific object or situation and to the sociocultural
context.
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6
months or more.
Criteria for specific phobia

F. The fear, anxiety, or avoidance causes clinically significant distress or

impairment in social, occupational, or other important areas of
functioning.
G. The disturbance is not better explained by the symptoms of another
mental disorder, including fear, anxiety, and avoidance of situations
associated with panic-like symptoms or other incapacitating symptoms (as
in agoraphobia): objects or situations related to obsessions (as in
obsessive-compulsive disorder); reminders of traumatic events (as in
posttraumatic stress disorder); separation from home or attachment
figures (as in separation anxiety disorder); or social situations (as in social
anxiety disorder).
specific phobia

• Phobic behavior tends to be reinforced by the reduction in anxiety

that occurs each time a feared situation is avoided.
• Phobias may be maintained by secondary gains (benefits derived
from being disabled) such as increased attention, sympathy and
some control over the behavior of others; Blood- injection-injury
phobia- The afflicted person shows a unique physiological response
at the slight of blood or injury.
specific phobia

• These people show an initial acceleration in heart rate and blood

pleasure followed by a dramatic drop.
• This is accompanied by nausea, dizziness, and fainting.
 Blood–Injury–Injection Phobia

● Those with blood–injury–injection phobias almost always

differ in their physiological reaction from people with other
types of phobia (Craske, Anthony, & Barlow, 2006).
● It runs in families more strongly than any other phobic
disorder.
● Because people with this phobia inherit a strong vasovagal
response to blood, injury, or the possibility of an injection,
all of which cause a drop in blood pressure and a tendency
to faint. The phobia develops over the possibility of having
this response.
 Situational phobia

● Phobias characterized by fear of public transportation or

enclosed Places. Eg., Claustrophobia, a fear of small,
enclosed places
● People with situational phobia never experience panic
attacks outside the context of their phobic object or
situation.
● Therefore, they can relax when they don’t have to confront
their phobic situation.
● People with panic disorder, in contrast, might experience
unexpected, uncued panic attacks at any time
Natural
environment
phobia
Fears of situations
or events occurring
in nature,
example:heights,
storms, and water.
These fears also
seem to cluster
together (Antony &
Barlow, 2002):
 Animal phobia

● Fears of animals and insects

● People with snake or mice phobias are unable to
read magazines for fear of unexpectedly coming
across a picture of one of these animals.
● There are many places that these people are unable
to go, even if they want to very much.
● The fear experienced by people with animal phobias
is different from an ordinary mild revulsion.
Phobias

• Marianne: Seeing a spider makes me rigid with fear, hot,

trembling and dizzy. I have occasionally vomited and once
fainted in order to escape from the situation. These
symptoms last three or four days after seeing a spider.
Realistic pictures can cause the same effect, especially if I
inadvertently place my hand on one.(Melville, 1978, p. 44)
Phobias

•Trisha: At the end of March each year, I start getting

agitated because summer is coming and that means
thunderstorms. I have been afraid since my early twenties,
but the last three years have been the worst. I have such a
heartbeat that for hours after a storm my whole left side is
painful. . . . I say I will stay in the room, but when it comes I
am a jelly, reduced to nothing. I have a little cupboard and I
go there, I press my eyes so hard I can’t see for about an
hour, and if I sit in the cupboard over an hour my husband
has to straighten me up. (Melville, 1978, p. 104)
Phobias

•We got on board, and then there was the take-off. There it
was again, that horrible feeling as we gathered speed. It was
creeping over me again, that old feeling of panic. I kept
seeing everyone as puppets, all strapped to their seats with
no control over their destinies, me included. Every time the
plane did a variation of speed or route, my heart would leap
and I would hurriedly ask what was happening. When the
plane started to lose height, I was terrified that we were
about to crash.(Melville, 1978, p. 59)
Causal factors

• Genetic Factors. Specific phobia tends to run in

families.
• The blood-injection-injury type has a particularly
high familial tendency.
 Psychosocial causal factors
• Psychodynamic: phobias represent a defense against
anxiety, that stems from repressed impulses from the id.
• Because it is dangerous to know the repressed id impulse,
the anxiety is displaced onto some external object or
situation that has some symbolic relationship to the real
object of the anxiety.
•
Causes

o Phobias as learned behavior: classical conditioning

accounts for the acquisition of irrational fears &
phobias.
o Once acquired, phobic fears would generalize to other
similar objects or situations.
⦿ Fears can be transmitted from one person to another
through a process of vicarious or observational learning.
⦿ Merely observing the fear of another one in a given situation
may cause the observer to acquire a fear.
Causes

• The fear response can be conditioned to previously

neutral stimuli when they are paired with traumatic
events.
• Watching a non fearful person undergoing a frightening
experience can also lead to vicarious conditioning.
 Causes

• Individual differences in learning: Some life experiences may

serve as risk factors and make certain people more vulnerable
to phobias than others where as others experiences may
serve as protective factors for the development of phobias.
• Experiencing an inescapable & uncontrollable event such as
having a traumatic experience that one can’t escape condition
fear much more painfully than experiencing the same
intensity of trauma that one can escape from or to some
external control.
Causes

• Genetic & temperamental causal factors: A moderate

genetic contribution exist.
• Personality or temperamental variables are known to
affect the speed & strength of conditioning of fear.
• Children defined as behaviorally inhibited
(excessively timid, shy) at 21 months of age were at
higher risk for the development of multiple specific
phobias at 7 to 8 years of age.
 Causes

• Preparedness & the non random distribution Primates & humans

may be prepared biologically to rapidly associate certain kinds of
objects-such as snakes, spiders, water & enclosed places- with
aversive events.
• Fear was conditioned more effectively to fear relevant stimuli(
snakes & spiders) than to fear irrelevant stimuli ( flowers &
mushrooms).
• Monkeys easily acquire fears of fear relevant stimuli such as toy
snakes but not of fear irrelevant stimuli such as toy rabbit.
• Evolutionary factors may be responsible for this association.
Causes

● Cognitive risk factors: Negative thought patterns, or

cognitive distortions.
● People with anxiety disorders often have ongoing thoughts
about potential or actual threat from external events
● Common cognitive distortions in people with anxiety
disorders include jumping to conclusions, catastrophizing,
and emotional reasoning
 Cognitive distortions
● Someone who jumps to
conclusions assumes something
bad will happen or has happened
despite lack of evidence to
support this assumption.
● Someone may assume terrible
but incorrect consequences will
result from an event—this is
catastrophizing.
● A person may also assume her
physical feelings reflect how
things truly are—this is emotional
reasoning.
● A person may wrongly assume
that speaking before a small
group will result in a poor
performance.
● A person who makes mistakes in
a speech may thus wrongly
assume he will lose his job
● People who are nervous
speaking before others, and who
have strong physical feelings of
anxiety, may wrongly assume
everyone can tell how nervous
they are.
treatment
• Exposure therapy- controlled exposure to the stimuli or situations
that elicit phobic fear
• Participant modeling-therapist calmly models ways of interacting
with the phobic stimulus or situation
• Virtual reality environments stimulate certain kinds of phobic
situations, such as heights as places to conduct exposure treatment.
• Ms. B was a 29-year-old computer programmer who presented for
treatment after she was offered promotion to a managerial
position. Although she wanted the raise and the increased
responsibility that would come with the new job, which she had
agreed to try on a probationary basis, Ms. B reported that she was
reluctant to accept the position because it required frequent
interactions with employees from other divisions of the company,
as well as occasional public speaking. She stated that she had
always felt nervous around new people, whom she worried would
ridicule her for “saying stupid things” or committing social faux
pas. She also reported feeling “terrified” to speak before groups.
These fears had not previously interfered with her social life and
job performance. However, since starting her probationary job,
Ms. B reported that they had become problematic.
• She noted that when she had to interact with others,
her heart started racing, her mouth became dry, and
she felt sweaty. At meetings, she had sudden
thoughts that she would say something very foolish
or commit a terrible social gaffe that would cause
people to laugh. As a consequence, she had skipped
several important meetings and left others early.
(Courtesy of Erin B. McClure-Tone, Ph.D., and Daniel
S. Pine, M.D.)
 Social anxiety disorder (Social phobia)
• Persistent, unrealistically intense fear of social situations that might involve
being scrutinized by, or even just exposed to, unfamiliar people.
• Persons with social anxiety disorder are fearful of embarrassing themselves
in social situations (i.e., social gatherings, oral presentations, meeting new
people).
• They may have specific fears about performing specific activities such as
eating or speaking in front of others,or they may experience a vague,
nonspecific fear of “embarrassing oneself.
• ”Fear of negative evaluation by others is the hallmark.
⚫ Two subtypes of social phobia- specific & generalized.
Criteria
A. Marked fear or anxiety about one or more social situations in
which the individual is exposed to possible scrutiny by others.
Examples include social interactions (e.g., having a conversation,
meeting unfamiliar people), being observed (e.g., eating or
drinking), and performing in front of others (e.g., giving a speech).
B. The individual fears that he or she will act in a way or show
anxiety symptoms that will be negatively evaluated (i.e., will be
humiliating or embarrassing: will lead to rejection or offend others).
C. The social situations almost always provoke fear or anxiety.
Diagnostic criteria
D. The social situations are avoided or endured with intense fear or
anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by
the social situation and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6
months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress
or impairment in social, occupational, or other important areas of
functioning.
Diagnostic criteria
H. The fear, anxiety, or avoidance is not attributable to the
physiological effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by
the symptoms of another mental disorder, such as panic
disorder, body dysmorphic disorder, or autism spectrum
disorder.
J. If another medical condition (e.g., Parkinson’s disease,
obesity, disfigurement from bums or injury) is present, the
fear, anxiety, or avoidance is clearly unrelated or is excessive
• Because of their fears they avoid situations.
• Individuals with generalized social phobia have significant fears of
most social situations(both public performance situations &
situations requiring social interactions)
• They often share a diagnosis of avoidant personality disorders.
In 2004, Austrian author Elfriede Jelinek, the Nobel prize winner in literature,
had to accept this prestigious honor and present her Nobel lecture by video
transmission because her social phobia prevented her from attending the
festivities in Stockholm in person. She was the first literature winner in 40
years not to attend the prize ceremony.
Rachel was a twenty-six-year-old woman who worked as an assistant manager of a small bookstore. [She
sought treatment] for her intense anxiety about her upcoming wedding. Rachel wasn’t afraid of being married
(i.e., the commitment, living with her spouse, etc.); she was terrified of the wedding itself. The idea of being on
display in front of such a large audience was almost unthinkable. In fact, she had postponed her wedding on
two previous occasions because of her performance fears. . . .

She reported being shy from the time she was very young. When she was in high school, her anxiety around
people had become increasingly intense and had affected her school life. She was convinced that her
classmates would fi nd her dull or boring or that they would notice her anxiety and assume that she was
incompetent. Typically, she avoided doing oral reports at school and didn’t take any classes where she felt her
performance might be observed or judged by her classmates (e.g., gym). On a few occasions, she even went
out of her way to obtain special permission to hand in a written essay instead of doing an oral report. Despite
being an excellent student, she generally tended to be very quiet in class and rarely asked questions or
participated in class discussions.

Throughout college, Rachel had difficulty making new friends. Although people liked her company and often
invited her to parties and other social events, she rarely accepted. She had a long list of excuses to get out of
socializing with other people. She was comfortable only with her family and several longtime friends but aside
from those, she tended to avoid signifi cant contact with other people.
 Psychosocial causal factors
• Social phobias as learned behavior: It originates out of vicarious or direct
classical conditioning eg. experiencing or witnessing a social defeat or
humiliation or witnessing the target of anger or criticism.
• A social situation (the conditioned stimulus) becomes paired with a negative
social experience (such as public humiliation) to produce a conditioned
emotional response.The conditioned response (fear or anxiety) may
generalize to other, or even all, types of social situations.
• Operant conditioning: a person with social phobia might avoid social
situations in order to decrease the probability of an uncomfortable
experience. The avoidant behavior does decrease anxiety and is thus
reinforced
Psychosocial causal factors

• Social phobias as learned behavior: Generalized social phobia

occur due to parents who were socially isolated & who
devalued sociability &there by providing ample opportunity for
vicarious learning .
• Extreme overprotection by parents is associated with
childhood anxiety and such overprotection may lead children
to cope with their anxiety through avoidance
Culture

Culture can influence the nature of

the symptoms of social phobia.

In Korea, for example, social fears

called taijin kyofusho involve the
possibility of offending others,
perhaps through body odor or
blushing.
 Social phobias in an evolutionary context
• Social phobias are a byproduct of dominance hierarchies among
animals like primates.
• Dominance hierarchies are established through accretive
encounters between members of a group & a defeated
individual typically displays fear & submissive behaviour but
only rarely attempts to escape the situation.
• So social phobias can be understood in an evolutionary context.
 Genetic and temperamental factors

• There is a moderate genetic contribution to social

phobia.
• Behaviorally inhibited infants who are shy & avoidant are
more likely to become fearful during childhood, & by
adolescence ,show increased risk of developing social
phobia.
Perceptions of uncontrollability &
unpredictability
• Perceptions of uncontrollability lead to submissive &
unassertive behavior such as that characteristics of
socially anxious or phobic persons.
• Social phobics have a diminished sense of personal control
over events in their lives.
• It may develop at least in part as a function of having been
raised in families with over protective(sometimes
rejecting)parents.
 Cognitive variables
⦿ People with social phobia have particular biases in attention and memory.
⦿ They seem to pay more attention to—and hence better remember— faces that
they perceive as critical, which in turn feeds into their fears about being evaluated.
⦿ They tend to expect that other people will reject or negatively evaluate
them(Beck).
⦿ This leads to a sense of vulnerability when they are around people who pose a
threat.
⦿ These danger schemas lead them to expect that they will behave in an awkward &
unacceptable fashion resulting in rejection & loss of status.
⦿ Social phobics’ awkward behavior may lead others to react to them in a less
friendly fashion, confirming their expectations.
⦿ They use distorted emotional reasoning as proof that they will be judged
negatively
treatment
• BT & CBT are effective
• Clients are helped to identify their negative
automatic thoughts & directed to change inner
thoughts & beliefs through logical reanalysis
• Antidepressants are also used
• I was inside a very busy shopping precinct and all of a sudden it
happened: in a matter of seconds I was like a mad woman. It was like a
nightmare, only I was awake; everything went black and sweat poured
out of me—my body, my hands and even my hair got wet through. All
the blood seemed to drain out of me; I went as white as a ghost. I felt
as if I were going to collapse; it was as if I had no control over my
limbs; my back and legs were very weak and I felt as though it were
impossible to move. It was as if I had been taken over by some
stronger force. I saw all the people looking at me—just faces, no
bodies, all merged into one. My heart started pounding in my head and
in my ears; I thought my heart was going to stop. I could see black and
yellow lights. I could hear the voices of the people but from a long way
off. I could not think of anything except the way I was feeling and that
now I had to get out and run quickly or I would die. I must escape and
get into the fresh air.(Hawkrigg, 1975)
Panic disorder

● It is characterized by frequent, unexpected panic attacks,

along with fear of further attacks and possible restrictions
of behavior in order to prevent such attacks.
● Women are two to three times more likely than men to be
diagnosed with panic disorder.
● The frequency of panic attacks varies from person to
person:
° Some people get panic attacks once a week for months,
° Others have attacks every day for a week.
 Panic disorder: Diagnostic criteria
• Recurrent unexpected panic attacks. A panic attack is an abrupt surge of
intense fear or intense discomfort that reaches a peak within minutes, and
during which time four (or more) of the following symptoms occur;
• Note: The abrupt surge can occur from a calm state or an anxious state.
• 1. Palpitations, pounding heart, or accelerated heart rate. 2. Sweating
3. Trembling or shaking. 4. Sensations of shortness of breath or smothering. 5.
Feelings of choking. 6. Chest pain or discomfort. 7. Nausea or abdominal
distress. 8. Feeling dizzy, unsteady, light-headed, or faint. 9. Chills or heat
sensations. 10. Paresthesias (numbness or tingling sensations). 11.
Derealization (feelings of unreality) or depersonalization (being detached from
oneself). 12. Fear of losing control or “going crazy.” 13. Fear of dying.
• Panic attacks are unexpected
 Diagnostic criteria
B. At least one of the attacks has been followed by 1 month (or
more) of one or both of the following:
1. Persistent concern or worry about additional panic attacks or
their consequences (e.g., losing control, having a heart attack,
“going crazy”).
2. A significant maladaptive change in behavior related to the
attacks (e.g., behaviors designed to avoid having panic attacks,
such as avoidance of exercise or unfamiliar situations).
 Diagnostic criteria
C. The disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition (e.g., hyperthyroidism, cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder
(e.g., the panic attacks do not occur only in response to feared social
situations, as in social anxiety disorder: in response to circumscribed
phobic objects or situations, as in specific phobia: in response to
obsessions, as in obsessive-compulsive disorder: in response to reminders
of traumatic events, as in posttraumatic stress disorder: or in response to
separation from attachment figures, as in separation anxiety disorder).
 Panic disorder

● In some cases, panic attacks are cued—they are associated with particular
objects, situations, or sensations
● In other cases, panic attacks are uncued—they are spontaneous—they feel as
though they come out of the blue, and are not associated with a particular object
or situation.
● Panic attacks can occur at any time, even while sleeping (referred to as nocturnal
panic attacks)
● The symptoms of a panic attack are so unpleasant that people who suffer from
this disorder may try to prevent another attack by avoiding environments and
activities that increase their heart rates (hot places, crowded rooms, elevators,
exercise, sex, mass transportation, or sporting events).
● They might even avoid leaving home
There isn’t much I can say about how I became agoraphobic. I just slipped a little day by
day. . . . My daughter Nadeen was always by my side on those rare occasions when I ventured
outside, forced to leave my home when I needed medical attention. In the past my fear kept
me at home with all sorts of physical pains and ailments, as horrifi c as the pain was, the pain
of facing the outside world was greater. When I had two abscessed teeth and my jaw was
swollen to twice its normal size I was in such excruciating pain that I had to go to the dentist.
So with my legs wobbling, my heart pounding, my hands sweating, and my throat choking,
to the dentist I went. After examining my x-rays, the dentist said he wouldn’t be able to do
anything with my teeth because they were so infected, he prescribed medication for the pain
and infection and said that I must return in ten days, not in two years. I felt as though those
ten days were a countdown to my own execution. Each day passed at lightning speed—like a
clock ticking away. The fear grew stronger and stronger. I had to walk around with my hand
on my heart to keep it from jumping so hard, as if I were pledging allegiance, which I was—to
my fears and phobia. I asked God to please give me strength to go back to the dentist. When
the day came, I knew that my preparations would take me a little over four hours. I had to
leave time, not just to bathe and dress, but to debate with myself about going.
Source: Anxiety Disorders Association of America.
 Agoraphobia- diagnostic criteria
• A. Marked fear or anxiety about two (or more) of the following
five situations:
• 1. Using public transportation (e.g., automobiles, buses, trains,
ships, planes).
• 2. Being in open spaces (e.g., parking lots, marketplaces,
bridges).
• 3. Being in enclosed places (e.g., shops, theaters, cinemas).
• 4. Standing in line or being in a crowd.
• 5. Being outside of the home alone.
Agoraphobia
• B. The individual fears or avoids these situations because of thoughts
that escape might be difficult or help might not be available in the
event of developing panic-like symptoms or other incapacitating or
embarrassing symptoms (e.g., fear of falling in the elderly; fear of
incontinence).
• C. The agoraphobic situations almost always provoke fear or anxiety.
• D. The agoraphobic situations are actively avoided, require the
presence of a companion, or are endured with intense fear or
anxiety.
• E. The fear or anxiety is out of proportion to the actual danger posed
by the agoraphobic situations and to the sociocultural context.
 Agoraphobia
• F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or
more.
• G. The fear, anxiety, or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
• H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s
disease) is present, the fear, anxiety, or avoidance is clearly excessive.
• I. The fear, anxiety, or avoidance is not better explained by the symptoms of
another mental disorder—for example, the symptoms are not confined to specific
phobia, situational type; do not involve only social situations (as in social anxiety
disorder): and are not related exclusively to obsessions (as in
obsessive-compulsive disorder), perceived defects or flaws in physical appearance
(as in body dysmorphic disorder), reminders of traumatic events (as in
posttraumatic stress disorder), or fear of separation (as in separation anxiety
disorder).
Agoraphobia without panic

● Agoraphobia is most commonly associated with panic disorder; usually, the

sufferer will have a history of anxiety attacks, with symptoms of agoraphobia
developing later.
● However, the condition can also be diagnosed without some of the symptoms
of panic - this is called agoraphobia without panic disorder.
● This condition differs from more general agoraphobia because the individual
does not have a history of panic attacks, although the symptoms are usually
similar to those of agoraphobia.
● Agoraphobia without panic disorder can be triggered by various phobias, such
as: Fear of becoming a victim of crime or a terrorist attack, Concerns that being
out in public could result in the contraction of a contagious disease, Worries
about being humiliated or doing something embarrassing in public
Biological causal factors
• Genetic factors : panic disorder has a moderate heritable
component.
Biochemical abnormalities.
• People with panic disorder are more likely to experience
panic attacks when they are exposed to various biological
challenge procedures than are normal people e.g.; infusions
of sodium lactate, inhaling co2 & ingesting caffeine produce
panic attacks in them. These are called panic provocation
agents.
Biological causal factors

• 2 neurotransmitters systems are implicated in panic attacks: the

noradrenergic & serotonergic systems.
• Noradrenergic activity in certain brain areas can stimulate
cardiovascular symptoms associated with panic.
• Increased serotonergic activity also decreases noradrenergic activity.
• Panic & the brain: abnormal norepinephrine activity in the locus
coeruleus in the brain stem may play a crucial causal role in panic
attack
Biological causal factors

• It has increased activity in the amygdala.

• Panic is likely to develop in people who have abnormally sensitive
fear networks that get activated too readily to be adaptive.
• The anticipatory anxiety that people develop about having another
panic attack is thought to arise from activity in the hippocampus
which is involved in the learning of emotional responses.
• Phobic avoidance, a learned response, may involve activity of the
hippocampus.
 Behavioral & causal factors
• Panic attacks occur through a process of interoceptive conditioning .
• Initially, a person may have had a first panic attack in response to a stressful or
dangerous life event (a true alarm).
• This experience produces conditioning, whereby the initial bodily sensations of
panic (such as increased heart rate or sweaty palms) become false alarms
associated with panic attacks.
• Thus, the individual comes to fear those interoceptive cues (that is, cues
received from the interior of the body) or the external environment in which
they had the panic attack.
• As these normal sensations that are part of the fight-or-flight response come to
be associated with subsequent panic attacks, the bodily sensations of arousal
themselves come to elicit panic attacks (learned alarms). The person then
develops a fear of fear—a fear that the arousal symptoms of fear will lead to a
panic attack
 Cognitive factors
⦿ Beck & Emery proposed a cognitive model of panic. Any kind
of perceived threat may lead to apprehension or worry which
is accompanied by various bodily sensations.
⦿ If a person then catastrophizes about the meaning of his
bodily sensations, this will raise the level of perceived threat,
thus creating more apprehension & worry, as well as more
physical symptoms, which fuel further catastrophic thoughts.
⦿ This vicious circle can result in a panic attack.
 Comparing learning and cognitive views
⦿ The initial physical sensations need not arise from the perceived
threat , but may come from other sources (exercise, anger ,
psychoactive drugs, etc)
⦿ Learning theory of panic is different from cognitive theory
because according to it, it would be only those with panic
disorder for whom the cues might serve as interoceptive
conditioning, that can trigger anxiety & panic because of their
associations with panic.
⦿ The cognitive model places importance on the meaning that
people attach to their bodily sensations, they will experience
panic only if they make catastrophic interpretations of certain
bodily sensations.
 Anxiety sensitivity & perceived control
• A tendency toward catastrophic thinking is related to anxiety sensitivity,
which is a tendency to fear bodily sensations that are related to anxiety,
along with the belief that such sensations indicate that harmful
consequences will follow
• People who have high levels of anxiety sensitivity are more prone to
developing panic attacks & panic disorder.
• for instance, that exercise caused a faster heart rate—but they become
afraid anyway, believing that danger is indicated, even if it is not an
immediate danger
• Having a sense of perceived control. e.g.; over the amount of co2 altered air
that is inhaled(a panic provocation procedure)- reduces anxiety & even
blocks panic.
 Safety behaviors & the persistence of panic
⦿ People with panic disorder frequently engage in safety
behaviors(such as breathing slowly) before or during an attack.
They then mistakenly tend to attribute the lack of catastrophe to
their having engaged in this safety behavior rather than to the idea
that panic attacks do not lead to heart attacks.
⦿ Cognitive biases & the maintenance of panic: People with panic
disorder are biased in the way they process threatening
information.
⦿ They not only interpret ambiguous bodily sensations as
threatening , but also interpret other ambiguous bodily sensations
as threatening.
Cognitive bias
•These people’s attention automatically drawn to
threatening information in their environment such as
words that represent things they fear.
•These biases are certainly likely to help
Treatment

•Antianxiety drugs & antidepressants are helpful

•Exposure based treatments are also effective
•Interoceptive exposure- deliberate exposure to feared
internal sensations
•Clients are asked to do exercises that bring on the physical
sensations they fear.
• Francis presents with extraordinary concern about the safety of his wife and
young daughter. He rarely leaves them alone when away (e.g., at work) he
telephones home every hour. He has lost one job because of this, and his wife
has threatened to leave him if he does not seek psychiatric help. Six months
ago, the symptoms, which have been present for years, became worse after his
wife had a serious automobile accident. Francis describes recurrent, unbidden
thoughts in which dangerous events befall his family and he is not there to
save them. He knows the thoughts are “silly” and they come from his own
mind rather than any real danger, but he cannot resist contacting his wife or
daughter in some way to be certain they are safe. His wife has arranged to lift
the telephone receiver briefly, then hang up, which is usually sufficient to allay
his fears for an hour or so. There is no history of significant medical illness or
Substance Abuse. The client completed 2 years of college and has a responsible
job. He performs well, and is not particularly perfectionistic, overly
conscientious (except with regard to his family’s safety), rigid, or preoccupied
with details.
GAD
•It involves anxiety & worry about many different
aspects of life(including minor events) & it becomes
chronic, excessive & unreasonable.
Diagnostic criteria
• A. Excessive anxiety and worry (apprehensive expectation), occurring
more days than not for at least 6 months, about a number of events
or activities (such as work or school performance).
• B. The individual finds it difficult to control the worry.
• C. The anxiety and worry are associated with three (or more) of the
following six symptoms (with at least some symptoms having been
present for more days than not for the past 6 months);
Diagnostic criteria

C. Anxiety & worry associated with 3 or more of the

following 6 symptoms for more days than not:
1. Restlessness or feeling keyed up.
2. Being easily fatigued.
3. Difficulty concentrating.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance.
Diagnostic criteria

• The anxiety, worry, or physical symptoms cause clinically significant distress or

impairment in social, occupational, or other important areas of functioning.
• E. The disturbance is not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication) or another medical condition (e.g.,
hyperthyroidism).
• F. The disturbance is not better explained by another mental disorder (e.g.,
anxiety or worry about having panic attacks in panic disorder, negative
evaluation in social anxiety disorder [social phobia], contamination or other
obsessions in obsessive-compulsive disorder, separation from attachment
figures in separation anxiety disorder, reminders of traumatic events in
posttraumatic stress disorder, gaining weight in anorexia nervosa, physical
complaints in somatic symptom disorder, perceived appearance flaws in body
dysmorphic disorder, having a serious illness in illness anxiety disorder, or the
content of delusional beliefs in schizophrenia or delusional disorder).
General characteristics
•People with GAD live in a relatively future-oriented mood
state of anxious apprehension, chronic tension, worry &
diffuse uneasiness.
•They show marked vigilance for possible signs of threat in
the environment and frequently engage in subtle avoidance
activities such as procrastination, checking, or calling a loved
one frequently to see if he or she is safe.
•Their anxious apprehension make them ready to deal with
upcoming negative events.
General characteristics
• They have difficulty making decisions, but if they have managed to
make a decision, they worry endlessly over possible errors.
• They are continuously upset, uneasy & discouraged.
• They fail to escape the illusory world created in their thoughts and
images and rarely experience the present moment that possess the
potential to bring them joy (Behar & Borkovec, 2006).
Psychosocial causal factors
⦿ The psychoanalytic viewpoint: GAD results from an unconscious
conflict between the id & impulse that is not adequately dealt with
because the person’s defense mechanisms have either broken down
or have never developed.
⦿ It was primarily sexual & aggressive impulses that had been either
blocked from expression.
On a day when life seems absolutely wonderful—say, a beautiful fall
Saturday or Sunday when I’m watching one of my boys play
football—I’ll often be overcome by the fear that it will all come to an
end somehow. It’s just too good. Something bad is going to ruin it
for me. This past year was the most difficult one I’ve had . . . Tyler
[his son] was in the fifth grade, and I worried the entire year. I was in
the fifth grade when my father died, and I thought my fate was
sealed. I was scared I would die and my boys would have to go
through life without a father, the way I did.
(Campbell & Ruane, 1999, p. 204)
Psychosocial causal factors
• The role of unpredictable & uncontrollable events: people with GAD
may have a history of experiencing many important events in their
lives as unpredictable & uncomfortable.
• E.g.; having a boss who has unpredictable bad moods.
Psychosocial causal factors
• The high sensitivity may have arisen in early stressful experiences
where they learned that the world is dangerous and out of control,
and they might not be able to cope (generalized psychological
vulnerability).
Furthermore, this acute awareness of potential threat, particularly if
it is personal, seems to be entirely automatic or unconscious.
• Their intolerance for uncertainty as well as their tension & hyper
vigilance stems from their lacking safety signals in their environment.
• Without such safety signals such as knowing when their boss will or
will not be angry with them, they may never be able to relax & feel
safe.
Psychosocial causal factors
• A sense of mastery, the possibility of immunizing against anxiety: early
experiences with control & mastery immunize the individual against the
harmful effects of exposure to stressful situations & against the
development of GAD.
• Parent’s responsiveness to their children’s needs directly influences their
children’s developing sense of mastery.
• Parents of anxious children have an intrusive, over controlling parental
style, which promotes children’s anxious behavior by making them think
that world is an unsafe place and they require protection and have little
control themselves
The reinforcing properties of worry
• The 5 benefits that people with GAD most commonly think
deriving from worry are:
• Superstitious avoidance of catastrophe (worrying makes it less
likely that the feared event will occur).
• Avoidance of deeper emotional topics (worrying about most of
the things I worry about is a way to distract myself from
worrying about even more emotional things, things that I do
not want to think about)
The reinforcing properties of worry

• Coping & preparation(worrying about a predicted

negative event helps me to prepare for its occurrence)
• When they worry, the emotional & physiological
responding are suppressed, & this serve to reinforce the
process of worry.
etiology
• The negative consequences of worry: worry can lead to a
greater sense of danger & anxiety because of all the possible
catastrophic outcomes that the person envisions.
• People who worry tend to have more negative intrusive
thoughts.
• Attempts to control thoughts and worry paradoxically lead to
increased experience of intrusive thoughts and enhanced
perception of being unable to control them.
etiology
• Cognitive biases for threatening information: they
process threatening information in a biased way.
• Attentional bias play a causal role in anxiety.
⦿ Anxious people think that bad things are likely to
happen in the future, & they have a tendency to
interpret ambiguous information in a threatening way.
etiology
⦿ Biological causal factors: there is a modest heritability in GAD
⦿ Functional deficiency of GABA: Highly anxious people have a kind of
functional deficiency in GABA, gamma amino butyric acid, a
neurotransmitter which plays an important role in the way brain
inhibits anxiety in stressful situations.
•Another neurotransmitter- serotonin is also
involved in modulating generalized anxiety.
•The corticotrophin-releasing hormone
system & anxiety: An anxiety producing
hormone called CRH has been strongly
implicated as playing an important role in
GAD.
• The brain areas & neurotransmitters that is strongly implicated in
panic are amygdala, nor epinephrine & serotonin, but in anxiety, it is
limbic system, GABA & CRH.
• Neurological differences between anxiety & panic: Fear & panic
involve activation of the flight or fight response where as GAD or
anxious apprehension is a more diffuse emotional state involving
arousal & a preparation for possible impending threat.
treatment
• Antianxiety& antidepressant drugs are useful
• CBT- applied muscle relaxation & cognitive restructuring techniques