SAGE Books

Handbook of Counseling Women

Treatment of Anxiety Disorders

By:Dawn M. Johnson, Nicole L. Johnson, Katherine M. Fedele, Samantha Holmes & Mitzi Hutchins
Book Title: Handbook of Counseling Women
Chapter Title: "Treatment of Anxiety Disorders"
Pub. Date: 2017
Access Date: October 11, 2022
Publishing Company: SAGE Publications, Inc.
City: Thousand Oaks
Print ISBN: 9781483385310
Online ISBN: 9781506300290
DOI: https://dx.doi.org/10.4135/9781506300290.n37
Print pages: 449-469
© 2017 SAGE Publications, Inc. All Rights Reserved.
This PDF has been generated from SAGE Knowledge. Please note that the pagination of the online
version will vary from the pagination of the print book.
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Treatment of Anxiety Disorders

Chapter 35 treatment of anxiety disorders
Dawn M. Johnson Nicole L. Johnson Katherine M. Fedele Samantha Holmes Mitzi Hutchins

Recent changes to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American
Psychiatric Association, 2013) have led to changes in the classification of anxiety disorders. Specifically,
the DSM-IV-TR (American Psychiatric Association, 2000) identified the following anxiety disorders: specific
phobia, social phobia, agoraphobia, panic disorder (with or without agoraphobia), obsessive-compulsive
disorder (OCD), posttraumatic stress disorder (PTSD), and generalized anxiety disorder (GAD). While
specific phobia, social phobia, agoraphobia, panic disorder, and GAD are still classified as anxiety disorders,
OCD and PTSD have been moved to other sections of the DSM-5. OCD is now in its own separate chapter
in the DSM-5, Obsessive-Compulsive and Related Disorders (Paris, 2013). The diagnostic inclusion criteria,
however, has not changed from the DSM-IV-TR. OCD is believed to lie on a spectrum of disorders, which
include body dysmorphic disorder (BDD), hoarding disorder, trichotillomania (hair-pulling), and excoriation
(skin-picking) (Paris, 2013). OCD has significant comorbidity with the anxiety disorders, as 76% of those with
OCD have a lifetime diagnosis of an anxiety disorder (American Psychiatric Association, 2013). PTSD has
also moved from anxiety disorders into its own separate chapter, Trauma-and Stressor-Related Disorders
(American Psychiatric Association, 2013). Trauma-and stressor-related disorders are unique in that they
are the only class of disorders in which exposure to a traumatic or stressful event is explicitly listed as
a diagnostic criterion (American Psychiatric Association, 2013). Examples of DSM-5 Trauma-and Stressor-
Related Disorders, other than PTSD, include disorders specific to children (reactive attachment disorder and
disinhibited social engagement disorder), as well as acute stress disorder and adjustment disorder. Although
OCD and PTSD are no longer classified as anxiety disorders, they are discussed within this chapter as they
have been historically conceptualized as anxiety disorders. Other anxiety disorders that counselors are most
likely to see in clinical settings will also be discussed (social anxiety disorder, panic disorder, GAD).

Research consistently demonstrates the psychosocial impairment, morbidity, and cost associated with anxiety
disorders (e.g., Konnopka, Leichsenrink, Leibing, & König, 2009). Lifetime prevalence estimates indicate that
anxiety disorders are one of the most common disorders in the U.S. population, with estimates as high as
28.8% found in the National Comorbidity Survey Replication. Further, women have a significantly higher risk
than men of receiving a lifetime anxiety disorder diagnosis (Kessler, Berglund et al., 2005). This chapter
discusses the various anxiety disorders, appropriate psychological interventions, and outcome studies. Case
studies are also provided to illustrate dynamics and treatment.

Research has identified several empirically supported treatments for anxiety disorders. The majority of
research to date has focused on cognitive-behavioral techniques for the alleviation of anxiety symptoms.
Such examples include cognitive therapy, exposure treatment, stress inoculation training, exposure and
response prevention, systematic desensitization, and cognitive processing therapy (Chambless & Ollendick,
2001). More recently, mindfulness-based therapy, acceptance and commitment therapy, eye movement
desensitization and reprocessing, psychoanalytic treatment, present centered therapy, and
psychopharmacology have also demonstrated empirical support for various anxiety disorders (Chambless
& Ollendick, 2001; Hajcak, n.d.). Therefore, research suggests multiple paths to improvement from anxiety
disorders. Further information regarding empirically supported treatments separated by diagnosis is provided
within this chapter.

Although empirical support is crucial to the betterment of our field, it is also important to think beyond the
manual. Several criticisms of empirically supported treatments have been proposed including the assumption
of a “one-size-fits-all” approach to therapy. Additionally, researchers have questioned the generalizability
of the existent data due to limited diversity and comorbidity within samples (e.g., Whaley & Davis, 2007).
Therefore, it is important to consider various demographic and contextual variables when treating anxiety
disorders in women.

In 2007, the American Psychological Association (APA) published a series of guidelines for psychological
practice with girls and women that highlight the importance of going beyond the manual, to insure gender
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and culturally sensitive affirming practices. Gender and culturally sensitive practices emphasize the role of
socialization, stereotyping, bias, discrimination, and life experiences on the development and continuation
of mental disorders. They also aim to empower women through the expansion of choices and emphasis
on initiating cultural change (American Psychological Association, 2007). Therefore, when implementing the
empirically supported treatments discussed in this chapter with girls and women, it is imperative to consider
sociocultural factors and how they may impact the development and continuation of these disorders.

Social Anxiety Disorder

Social anxiety disorder, or social phobia, is marked by persistent and intense fear of social situations, such
as social interactions (e.g., having a conversation), being observed (e.g., eating), and performing in front
of others (e.g., public speaking; American Psychiatric Association, 2013). Specifically, the individuals are
worried that they will act in a way that will cause others to view them as stupid, unlikeable, crazy, weak,
anxious, or so on and consequently endure these social situations with considerable anxiety or avoid them
altogether. It is important to note that in order for a diagnosis of social anxiety disorder to be appropriate,
the experienced fear must be out of proportion to the actual threat, the anxiety or its associated avoidance
must significantly impair the individual, and the symptoms must persist for at least 6 months. Additionally,
the anxiety cannot be better explained by the effects of substances, symptoms of a medical condition, or
symptoms of another psychological disorder. When considering whether or not a woman may meet criteria for
social anxiety disorder, context is especially important. For example, if a survivor of intimate partner violence
were to exhibit anxiety in social situations involving her ex-partner, her fear response might be commensurate
to the actual threat. Similarly, if she fears all social situations after her abusive experience, even if there is not
a threat of physical danger, it is possible that this anxiety is better explained by posttraumatic stress disorder
(PTSD).

Prevalence
According to the DSM-5 (American Psychiatric Association, 2013), the 12-month prevalence rate for social
anxiety disorder in the United States is about 7%, with women meeting criteria slightly more often than men
in the general population. This effect is even larger in children and adolescents and is diminished or even
sometimes reversed in clinical populations. Additionally, some studies have found women to have higher
rates in past year prevalence but no gender differences in lifetime prevalence (e.g., McLean, Asnaani, Litz, &
Hoffman, 2011).

Evidence suggests that there are no gender differences regarding the course of social anxiety disorder (e.g.,
age of onset, persistence, and remission); however, women are more likely to have situational panic attacks
and tend to have a greater number of social fears than their male counterparts (Xu et al., 2012). Additionally,
the types of social fears experienced by women and men vary in a manner that is consistent with gender role
expectations. Specifically, women are more likely to fear speaking to authority figures, eating and drinking in
front of others, being interviewed, speaking up at a meeting, taking an important exam, being the center of
attention, and expressing disagreement or disapproval; whereas, men are more likely to fear dating situations,
urinating in a public bathroom, and returning goods to a store (Turk et al., 1998; Xu et al., 2012). While
some research suggests that men and women display similar rates of comorbidity with mood and other
anxiety disorders (Turk et al., 1998), a recent epidemiologic sample found that women are more likely to have
comorbid internalizing disorders (i.e., depression and other anxiety disorders); whereas men were more likely
to have comorbid externalizing disorders (i.e., substance disorders, conduct disorder, antisocial personality
disorder; Xu et al., 2012).

Treatment Outcomes
Cognitive behavioral therapy is the “gold standard” in treating social anxiety disorder (McGinn & Newman,
2013), however, there is conflicting evidence regarding which components are most important. One study
found that combined treatment is superior to either exposure or cognitive restructuring alone (Nortje &
Posthumus, 2012), another suggested that the combination is more effective than cognitive restructuring but

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not exposure (Otto, Hearon, & Safren, 2010), and a meta-analysis concluded that a combined approach did
not offer any gains above that of either cognitive or exposure alone (Powers, Sigmarsson, & Emmelkamp,
2008). Additionally, one study found that adding a social skills training component to an exposure treatment
resulted in improvement in some outcomes, such as “general clinical status” but not others such as remission
status, relative to exposure alone (Beidel et al., 2014).

Although cognitive and behavioral approaches have found the strongest and most prolific support in the
treatment of social anxiety, recent studies have suggested that other treatments may also be efficacious.
Specifically, some studies suggest that while cognitive behavioral therapy (CBT) may fare better than
psychodynamic therapy in the short term, no difference was found in the outcomes of the two conditions from
6 months through 2-year follow-up (Leichsenring et al., 2014). With regard to interpersonal psychotherapy,
some studies have found that while it was significantly better than a wait-list control, it did not result in as
positive outcomes as CBT (Markowitz, Lipsitz, & Milrod, 2014).

In addition to research that elucidates the relative effectiveness of specific theoretical approaches, studies
have also been conducted to assess various treatment modalities. There is evidence to suggest that cognitive
behavioral group therapy is both acceptable and feasible and that group modalities, in general, may not
differ from individual therapy with regard to outcome (McCarthy, Hevey, Brogan, & Kelly, 2013; Powers et
al., 2008). Internet-delivered approaches also have received recent attention in an attempt to provide greater
access and a more cost-effective option of treatment (McGinn & Newman, 2013). A recent pilot study reported
achieving symptom reduction and even remission in some participants with social phobia, indicating that this
format of the Internet intervention required only 20% of the time usually required of a therapist (Stott et al.,
2013). Additionally, there is considerable support for psychotropic medications, particularly selective serotonin
reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), in the treatment of
social anxiety disorder (Canton, Scott, & Glue, 2012). When compared to CBT, medications have been
found to result in quicker improvement; however, CBT was better tolerated and demonstrated more enduring
improvement. Furthermore, evidence suggests that the combination of medication and CBT may lead to
better results than either of the two alone (Canton et al., 2012).

Panic Disorder
The essential feature of panic disorder is the experience of recurrent unexpected panic attacks without an
obvious cue or trigger (American Psychiatric Association, 2013). To receive the diagnosis of panic disorder
one must also report persistent worry about additional attacks or their consequences (i.e., social concerns,
physical concerns), and/or exhibit significant maladaptive change in behavior aimed at minimizing or avoiding
attacks. Additionally, these subsequent consequences must be present for at least one month following
the onset of panic attacks. Panic attacks are characterized by four or more of the following symptoms:
accelerated heart rate, sweating, trembling, shortness of breath, choking sensation, chest pain, nausea,
dizziness, paresthesias, derealization/depersonalization, fear of losing control, or fear of dying (American
Psychiatric Association, 2013). It is imperative that these symptoms are not better accounted for by the
physiological effects of a substance, another medical condition, or another mental disorder. Additionally, panic
attacks may be present in a variety of other mental health diagnoses, thus, the mere presence of panic attacks
does not necessarily constitute a diagnosis of panic disorder.

Prevalence
The DSM-5 (American Psychiatric Association, 2013) reports a 12-month prevalence rate of 2% to 3%
in adults and adolescents. The median age of onset is 20 to 24 years, with minimal occurrence prior to
14 years of age and following 45 years of age. The course of panic disorder, if untreated, waxes and
wanes in frequency and severity. Within the United States, Native Americans have the highest prevalence of
panic disorder followed by non-Latino Whites. In research comparing non-Latino Whites to racial and ethnic
minorities, Latinos, African Americans, Caribbean Blacks, and Asian Americans report significantly lower
rates of panic disorder (American Psychiatric Association, 2013).

Women endorse significantly higher rates of panic disorder as compared to men, with an estimated ratio of
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two to one (American Psychiatric Association, 2013; Bekker & van Mens-Verhulst, 2007). Gender differences
become apparent during adolescence, as early as 14 years of age. For girls, a gradual increase in panic
disorder diagnoses is seen from puberty through adolescence (American Psychiatric Association, 2013).
Gender differences in the incidence of panic disorder appear to be sustained throughout the lifetime, however,
the clinical presentation of panic disorder is assumed to be consistent between women and men. Panic
disorder is often complicated by comorbidity of other mental health diagnoses (Kessler, Chiu, Demler, &
Walters, 2005). The most common comorbid diagnoses include additional anxiety disorders, depressive
disorders, and substance use disorders. Additionally, research has identified significant comorbidity between
panic disorder and various cardiac (5%-62%), respiratory (6.5%-47%), gastrointestinal (54%-74%), and
neurological (12.8%-33%) medical conditions (Zaubler & Katon, 1996).

Treatment Outcomes
To date, three empirically supported psychological treatments (ESTs), that is, cognitive behavioral therapy,
applied relaxation, and psychoanalytic treatment, have been identified for panic disorder (Hajcak, n.d.). CBT
is the treatment with the strongest research support. Meta-analyses and systematic reviews have been
conducted on CBT for panic disorder (e.g., Landon & Barlow, 2004; Mitte, 2005; Schmidt & Keough, 2010;
Otto & Deveney, 2005) with treatment aimed at identifying and altering panic-related thoughts and behaviors.
A primary target within CBT for panic disorder is avoidance. It is assumed that avoidance of panic-related
thoughts and triggers reinforces panic symptoms. Therefore, in vivo and interoceptive exposure to panic
related thoughts and triggers are crucial components of CBT for panic disorder (e.g., breathing into a straw to
induce the physical sensations of a panic attack; Hajcak, n.d.).

Two additional treatments for panic disorder, applied relaxation (Ost & Westling, 1995; Sanchez-Meca,
Rosa-Alcazar, Marin-Martinez, & Gomez-Conesa, 2010) and psychoanalytic treatment (Milrod et al., 2007)
have modest research support. In applied relaxation, individuals identify early cues of panic and learn
various relaxation techniques including progressive muscle relaxation. Throughout treatment, individuals are
taught to use relaxation techniques within increasingly anxiety provoking situations (Ost & Westling, 1995).
Psychoanalytic treatment aims to uncover psychological meaning for panic. The proposed mechanism of
change within psychoanalytic treatment is the reduction of unconscious conflicts resulting in symptoms of
panic (McKay, Abramowitz, Taylor, & Deacon, 2007).

In pharmacological trials, SSRI antidepressants are regarded as the first-line psychopharmacological

treatment for panic disorder (e.g., Mitte, 2005; Pohl, Wolkow, & Clary, 1998; Rivas-Vazquez, 2001). Studies
exploring additive effects of psychological treatment and psychopharmacology have demonstrated support
for reduction in panic disorder symptoms. However, a recent meta-analysis identified no difference between
CBT alone for the treatment of panic disorder and a combination of CBT and psychopharmacology (Mitte,
2005). Therefore, additional research that explores the utility of psychopharmacology for the treatment of
panic disorder is needed.

Recent research also has highlighted the importance of exploring gender differences in treatment outcomes
for panic disorder (Bekker & van Mens-Verhulst, 2007). Although research has consistently found gender
differences for panic disorder, most research and treatment remains “gender-neutral” (Bekker & van Mens-
Verhulst, 2007). The limited research exploring gender has found significant gender effects on treatment
course with men more likely to drop out of treatment following the initial intake, but those who remain in
treatment report significantly greater reduction in symptomology as compared to women (Cottone, Drucker, &
Javier, 2002). Researchers have proposed exploring the role of traditional gender roles and gender-role stress
on panic disorder. The “traditional feminine sex role discourages assertiveness and self-supportive behavior
in women and prescribes them to react to stress with dependence and helplessness” (Bekker & van Mens-
Verhulst, 2007, p. 184), thus potentially contributing to the discrepancy in the prevalence of panic disorder
between women and men.

Case Study
“Veronica” began therapy as an 18-year-old Caucasian female high school senior who reported in her first
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session, “I’ve been having these spells where I just kind of start to feel shaky like I can’t breathe, and then
I just collapse to the floor and it’s like I pass out, but not really …” Veronica is an only child and reported
living with her parents in a small rural town. Veronica reported “I never had any problems like this before.”
She stated “during these attacks, I feel like I can’t talk or move, and I’ve been to the hospital, but they say
it’s just anxiety.” Veronica reported worrying about having an attack “all the time” and stated “that just makes
it worse. I feel like all I do is worry about not panicking because it’s embarrassing, and I don’t even know
what I’m really anxious or nervous or upset about.” Veronica has maintained a 4.0 grade point average and
continues to spend time with friends and family. “This has been going on for about 4 months, and it’s just
getting worse.” Veronica reported, “It just hits me. I don’t know when it’s going to happen.” Veronica stated
“my mom just thinks I’m overreacting and she tells me to just get up, and I’ll be fine. She doesn’t understand
… I can’t control it.” Veronica reported her father “has a lot of problems with anxiety. He doesn’t even leave
the house. He never does anything but expects us to do everything for him. My mother does everything for
him. I don’t want to be like him.”

CBT helped Veronica to identify and explore the irrational thinking behind her panic attacks. Veronica had
exceptionally high expectations for herself and reported that she had come to realize the influence of that
pressure on her perception of self and fears associated not only with failure but also of becoming like her
father. Cognitive restructuring was a significant aspect of Veronica’s treatment. Disputing her irrational beliefs
and exploring her perceived “musts” fostered more realistic/accurate self-statements. Mindfulness techniques
from a more dialectical approach were also incorporated into treatment. Veronica worked on establishing a
balance between her rational mind and emotional mind to establish a wise mind to assist her in her decision-
making process. Currently, Veronica is in her freshman year of college and has maintained her 4.0 GPA. Her
panic attacks have reduced in intensity and frequency as a result of treatment, and she has not “fallen to the
floor in months.”

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) consists of excessive, uncontrollable worry about multiple life domains,
such as family members, work performance, finances, and health. (American Psychiatric Association, 2013).
The subjective worry is accompanied by symptoms such as restlessness, fatigue, difficulty concentrating,
irritability, muscle tension, and sleep difficulties. For a diagnosis of GAD to be given, the individual’s
anxiety must be disproportionate to the actual likelihood of the dreaded outcome. Consequently, context is
exceedingly important. Consider the example of a single mother living in poverty and experiencing difficulty
finding a job due to insufficient childcare and a criminal record. She may be justifiably worried about making
rent and providing adequately for her children and herself. Additionally, the effects of a substance, a medical
condition, or another mental disorder cannot better explain the symptoms and must result in significant
distress or impairment of functioning.

Prevalence
The 12-month prevalence of GAD among adults is 2.9%, with women being twice as likely as men to meet
criteria (American Psychiatric Association, 2013). There has been mixed support for the presence of other
gender differences in the presentation of GAD. For example, some studies suggest that women have an
earlier onset of the disorder whereas others suggest no gender differences (e.g., McLean et al., 2011). In
regard to burden of illness, women may have a higher level of impairment in some areas (e.g., number
of missed days of work, level of disability) and not others (e.g., physical health, overall quality of life; e.g.,
McLean et al., 2011; Vesga-Lopez et al., 2008). Relative to men, women with GAD also are less likely to have
a substance use disorder, attention deficit hyperactivity disorder (ADHD), intermittent explosive disorder, or
antisocial personality disorder but are more likely to have a comorbid depressive disorder or other anxiety
disorder. Additionally, there is some evidence to suggest that severity of symptoms may be impacted by the
menstrual cycle or postpartum state (Howell, Brawman-Mitzer-Monnier, & Yonkers, 2001).

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Treatment Outcomes
Cognitive and behavioral therapies have strong research support in treating GAD (Teachman, n.d.). One
study found that the effectiveness of combined CBT relative to its components (cognitive therapy and
self-control desensitization) changed as a factor of the duration of the illness (Newman & Fisher, 2013).
Specifically, individuals who have had GAD for a shorter period of time responded better to the full CBT
protocol, whereas those who had the diagnosis longer benefited more from the components treatments.

Recent randomized controlled trials have been conducted in an effort to assess other treatment approaches
in comparison to CBT. A short-term psychodynamic psychotherapy fared similarly to CBT with respect
to symptoms of anxiety; however, the latter resulted in greater improvement in trait anxiety, worry, and
depression (Leichsenring et al., 2009). Acceptance and commitment therapy (ACT), an approach that
emphasizes mindfulness and clients’ abilities to engage in value-congruent behaviors in an effort to increase
psychological flexibility, however, was found not only to match CBT’s effectiveness at posttreatment and
3-month follow up but also to result in a greater reduction of worrying symptoms (Avdagic, Morrissey, &
Boschen, 2014). It should be noted that pharmacological treatments, particularly SSRIs and SNRIs, also have
found support in the treatment of GAD (Baldwin, Waldman, & Allgulander, 2011).

Case Study
“Annie” is a 45-year-old Caucasian woman who sought therapy after relocating to the area following the death
of her boyfriend of 5 years. Annie stated, “I have my own place, but I’m not from around here, and I worry
about everything. I just worry about where I live and if the door is locked, and I don’t trust anyone. I can’t sleep
at night. By the time I fall asleep it’s almost morning, and I wake up for every little sound. I think I need a dog.
I would feel safer if I had a pet.” Annie reported feeling stressed out “all the time,” and stated “I know I’m just
paranoid. I shouldn’t worry this much, but I do. Is that wrong?” Annie reported having been married for 20
years prior to living with the boyfriend who recently passed away. Annie reported, “I’ve never lived alone or
been on my own. I went from living with my mom to living with my husband and then my boyfriend. I moved
here because my brother was living here, and I thought he could help me get on my feet, but he was offered
another job out of town about a month after I got here, and I didn’t want to move again. So I started planning
a life here, but I don’t know anyone.”

Annie attended 10 sessions. CBT assisted Annie in identifying and exploring her fears and how her symptoms
were potentially influenced by her irrational thoughts. Annie recently purchased a dog and has reportedly
started to implement relaxation strategies primarily in the evening as part of her bedtime ritual to improve
the quality of her sleep. Visual imagery also helped her to fall asleep faster and more consistently. Annie
continues to challenge herself to leave the house daily and accomplish tasks. “It gets easier, but I’m still afraid.
I want to live by myself and not be scared about everything all the time.”

Obsessive-Compulsive Disorder
Diagnostically, the essential feature of obsessive-compulsive disorder (OCD) is recurrent obsessions and
compulsions (American Psychiatric Association, 2013). Obsessions are defined by recurrent and persistent
thoughts, urges, or images that are experienced as intrusive and unwanted and cause anxiety and distress.
Compulsions are defined by repetitive behaviors (e.g., hand washing) or mental acts (e.g., counting) that
are performed to prevent or reduce anxiety or distress in response to obsessions or according to rigid
rules. Obsessions and compulsions are time consuming and significantly impair daily functioning (American
Psychiatric Association, 2013). Compulsions also are conceptualized to preserve obsessions (Abramowitz &
Arch, 2014). For example, after performing a ritual (e.g., checking the stove 20 times) to prevent a feared
consequence (e.g., the house burning down), the individual will attribute the house not burning down to the
compulsion of checking the stove, rather than to the low likelihood of the house burning down. Therefore,
compulsive rituals maintain obsessions and feared consequences (Abramowitz & Arch, 2014).

The content of obsessions and compulsions differs from person to person. There are common themes,
such as contamination obsessions (e.g., becoming contaminated by touching a doorknob) and cleaning
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compulsions (e.g., repeatedly washing one’s hands). Symmetry obsessions and ordering compulsions and
fears of harming oneself or others and checking compulsions also are common. Individuals with OCD often
have symptoms in more than one dimension. Many individuals experience high anxiety when in situations
that trigger their particular obsessions and compulsions. Therefore, it is common for individuals with OCD to
avoid people, places, and things that provoke their symptoms (American Psychiatric Association, 2013).

Prevalence
The DSM-5 (American Psychiatric Association, 2013) reports a 12-month prevalence rate of 1.2% and a
lifetime prevalence rate of 2.7% of OCD in the United States (American Psychiatric Association, APA, 2013;
Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012). Specifically, the lifetime prevalence rate for
women is 3.6% and is 1.8% for men (Kessler et al., 2012). Women are more commonly affected in adulthood,
whereas men are more commonly affected in childhood and more likely to have a comorbid tic disorder
(American Psychiatric Association, 2013).

Specifically, the onset or exacerbation of OCD symptoms in women has been found to be associated with
reproductive cycle events, including the premenstrual phase, menarche, pregnancy, and postpartum periods
(Guglielmi et al., 2014; Labad et al., 2005; Williams & Koran, 1997; Zambaldi et al., 2009). Specifically,
research has found an increased risk of onset during menarche, pregnancy, and postpartum (Guglielmi
et al., 2014; Williams & Koran, 1997). Additionally, the premenstrual phase has been associated with an
exacerbation of symptoms in women with OCD (Williams & Koran, 1997).

OCD is a heterogeneous disorder, and it is influenced by individual differences such as age of onset (Tukel
et al., 2005). Symmetry and religious obsessions and hoarding obsessions and compulsions were found to
be significantly more frequent in individuals with early-onset OCD (Tukel et al., 2005). Additionally, there are
gender differences in the pattern of OCD symptoms, with women more likely to have more symptoms in the
cleaning dimension, while men have more symptoms in the symmetry dimensions and forbidden thoughts
(American Psychiatric Association, 2013).

Treatment Outcomes
CBT in the form of exposure and response prevention (ERP) has been established as a highly effective
treatment for OCD (Abramowitz & Arch, 2014). There have been numerous controlled and uncontrolled
studies that have confirmed ERP to be an effective short-term and long-term treatment for OCD (see
Abramowitz & Arch, 2014; Franklin, Abramowitz, Kozak, Levitt, & Foa, 2000). Exposure-based CBT focuses
on decreasing the fear associated with obsessions and dependence on rituals and avoidance to control the
obsessions. Psycho-education, cognitive restructuring, exposure, and response prevention are used in this
approach to treating OCD (see Abramowitz & Arch, 2014). Additionally, in a meta-analysis, Ruhmland and
Margraf (2001) examined five psychological OCD treatments and determined that CBT yielded the highest
effect, with gains maintained up to 2 years.

ACT also has had modest research support. Twohig et al. (2010) compared 8 sessions of ACT and
progressive relaxation training (PRT) in a randomized control trial (RCT). ACT was found to be more effective
in decreasing OCD symptoms over PRT (Twohig et al., 2010). Future RCTs are warranted to confirm ACT as
an effective treatment for OCD.

In regard to pharmacological treatments, research has found that clomipramine (a non-selective serotonin
reuptake inhibitor) or any SSRI (e.g., fluoxetine, fluvoxamine, and sertraline), can effectively treat OCD
(Abramowitz, 1997; Romanelli, Wu, Gamba, Mojtabai, & Segal, 2014). Specifically, in a review of RCTs of
behavioral therapy and SRIs, Romanelli et al. (2014) found that among outpatients with OCD, behavioral
therapy is more effective than SRIs overall but not selective SRIs. The combination of behavioral therapy
plus an SRI is more effective than an SRI alone (Romanelli et al., 2014). In general, a combination of
pharmacotherapy and psychotherapy is recommended in cases of severe OCD or when individuals fail to
respond to psychotherapy alone (Abramowitz, 1997).

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Further research on OCD is warranted particularly in women who experience an onset or exacerbation of
symptoms during reproductive cycle events. Future research should explore specific interventions for women
who develop OCD during pregnancy and postpartum periods.

Posttraumatic Stress Disorder

The definition of PTSD is unique in that a traumatic event is conceptualized as being etiologically linked to
the disorder. The DSM-5 (2013) features the most extensive changes made to the diagnostic criteria of PTSD
since its original appearance in the DSM-III (American Psychiatric Association, 1980), including removing
the disorder from the anxiety disorders designation, changing the Criterion A definition of traumatic events,
adding three new symptoms, revising the organization to involve four symptom clusters instead of three, and
including a new diagnostic algorithm (Miller, Wolf, & Keane, 2014).

The DSM-IV-TR criteria were criticized for ambiguity regarding what was meant by the witnessing of traumatic
events (Miller et al., 2014). The DSM-5 (American Psychiatric Association, 2013) clarifies that witnessing
includes learning that a traumatic event occurred to a close family member or friend and/or “experiencing
repeated or extreme exposure to aversive details of a traumatic event.” (p. 271). The DSM-5 (American
Psychiatric Association, 2013) definition of a traumatic event also includes “exposure to actual or threatened
death, serious injury, or sexual violence” that was directly experienced and/or witnessed in person, as the
event occurred. Further, the DSM-5 specifically excludes exposure through electronic media, television,
movies, or pictures. A final change to the language of the DSM-5 is the acknowledgement that an individual
may be exposed to multiple traumatic events and that the symptoms may relate to more than one event (Miller
et al., 2014).

Given the accumulating evidence from confirmatory factor-analytic studies suggesting a four-factor model of
PTSD with effortful avoidance and numbing as separate factors (Elhai & Palmieri, 2011), the DSM-5 definition
of PTSD now includes four clusters of symptoms: intrusion symptoms (e.g., intrusive thoughts, recurrent,
distressing dreams, flashbacks), persistent avoidance of stimuli associated with the traumatic event (e.g.,
avoiding distressing memories or external reminders of traumatic event), negative alterations in cognitions
and mood associated with the traumatic event (e.g., inability to remember aspects of trauma, distorted
cognitions, detachment), and marked alterations in arousal and reactivity associated with the traumatic event
(e.g., irritability, self-destructive behavior, problems with concentration). An individual must meet a minimum of
one intrusion symptom, one persistent avoidance symptom, two negative alterations in cognitions and mood
symptoms, and two marked alterations in arousal and reactivity symptom to receive a PTSD diagnosis. As
in previous versions of the DSM, the duration of symptoms must be more than 1 month, and the symptoms
must be associated with significant psychosocial impairment. The DSM-5 (American Psychiatric Association,
2013) allows for two subtypes: with dissociative symptoms and with delayed expression.

Prevalence
The DSM-5 (American Psychiatric Association, 2013) reports a lifetime risk for PTSD of 8.7% and a 12-month
prevalence of 3.5% in the U.S. population. Across a variety of studies, research suggests that although men
are more likely to experience trauma relative to women, female victims of traumatic events are at greater
risk for PTSD relative to male victims (Breslau, 2009; Keane, Marshall, & Taft, 2006). Specifically, in the
Detroit Area Survey, Breslau and colleagues (1998) report a conditional risk of PTSD of 13% in females and
6.2% in males. This sex difference in PTSD risk was primarily due to females’ greater risk of PTSD following
assaultive violence (i.e., 35.7% in females compared to 6.0% in males), rather than female’s greater exposure
to certain types of traumatic events (e.g., sexual assault and rape; Breslau, 2009).

Why females have greater PTSD risk is unclear, although research to date can help rule out several
possibilities. As suggested above, sex differences in rates of sexual assault and rape assault are not
responsible for higher risk in females. Second, as sex differences remain when adjusting for prior trauma
experience, trauma history also does not account for sex differences in vulnerability in women. Also,
preexisting pathology such as depression or anxiety does not appear to account for male and female
differences in conditional risk. Finally, sex differences in PTSD vulnerability do not appear to be related to
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sex-related bias in reporting of symptoms (Breslau, 2009). More research is needed, and we must develop
treatments that are sensitive to the unique needs of women.

Treatment Outcomes
Psychosocial treatment of PTSD has primarily taken two different approaches. Treatment may be present-
focused, prioritizing current symptoms of PTSD or stressors and helping the client to cope or manage current
symptoms or stressors. Alternatively, treatment may be primarily past- or trauma-focused, prioritizing the
cognitive processing of prior traumatic events. The Society for Clinical Psychology’s list of research-supported
psychological treatments for PTSD includes six approaches having modest to strong support. The list includes
both present-focused (i.e., stress inoculation training (SIT), seeking safety (SS), present-centered therapy
(PCT), and past-focused approaches (i.e., cognitive processing therapy (CPT), prolonged exposure (PE),
eye movement desensitization and reprocessing (EMDR); Hajcak & Starr, n.d.). However, a variety of other
promising cognitive-behavioral treatments have been developed for specific subpopulations of women such
as victims of intimate partner violence (Johnson, Zlotnick, & Perez, 2011; Kubany et al., 2004) and women
with histories of child abuse (Cloitre et al., 2010) that have yet to achieve the rigorous research support
required by the Society for Clinical Psychology.

Present-Focused Approaches
SIT, a present-focused PTSD treatment, has modest research support (Hajcak & Starr, n.d.). SIT involves
teaching coping skills to manage trauma-related anxiety and posttrauma problems (Foa et al., 1999) and
includes training in diaphragmatic breathing, deep muscle relaxation, cue-controlled and differential
relaxation, thought stopping, cognitive restructuring, guided self-dialogue, covert modeling, and role play. SIT
also can include gradual, controlled, and repeated exposure to a stressor. One of the first approaches to be
evaluated in the treatment of PTSD, SIT has been found to significantly reduce PTSD symptoms, be superior
to supportive counseling (Foa, Rothbaum, Riggs, & Murdock, 1991), and have similar treatment effects to PE
(Foa et al., 1999) and EMDR (Lee, Gavriel, Drummond, Richards, & Greenwald, 2002). Most recently, virtual
reality has been used to enhance SIT techniques (Wiederhold & Wiederhold, 2008).

SS (Najavits, 2002), another present-focused treatment, is an integrated CBT that simultaneously addresses
PTSD and substance use disorders (SUDs; Hajcak & Starr, n.d.). SS focuses on helping clients attain safety
in their relationships and has been delivered in both individual and group formats. Multiple RCTs have found
SS to be associated with positive outcomes in multiple populations of women, including homeless women
veterans (Desai, Harpaz-Rotem, Najavits, & Rosenheck, 2008), low-income urban women (Hien, Cohen,
Miele, Litt, & Capstick, 2004), and female prisoners (Zlotnick, Johnson, & Najavits, 2009). Although the
research on SS is promising, the most recent and most rigorous randomized clinical trial suggests that SS
is associated with clinically significant reductions in PTSD symptoms but not substance use outcomes (e.g.,
Hien et al., 2009). Thus, additional treatment components might be necessary to address substance use.

PCT was originally developed as a credible alternative therapy to control for nonspecific therapeutic factors
in randomized clinical trials of PTSD (Schnurr et al., 2007). PCT focuses on current life problems that are
believed to result from PTSD and addresses general daily life difficulties. A recent meta-analysis of PCT
found large effect sizes for PCT relative to no-treatment control conditions and similar effects to existing
evidence-based treatments for PTSD (Frost, Laska, & Wampold, 2014). Further, Frost and colleagues (2014)
found lower drop-out rates for PCT relative to other evidence-based treatments, concluding that PCT is an
efficacious treatment for PTSD that provides an alternative for clients that might not be able to tolerate past-
or trauma-focused approaches.

Past-Focused Approaches
CPT (e.g., Resick et al., 2008; Resick, Williams, Suvak, Monson, & Gradus, 2012; Watts et al., 2013)
incorporates both cognitive restructuring and cognitive processing of past traumatic events and has been
found to be effective in a variety of populations, including many populations highly relevant to women such

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as female rape and sexual assault survivors (Resick et al., 2012), female adult survivors of child sexual
abuse (Chard, 2005), female survivors of interpersonal violence (Resick et al., 2008), as well as in survivors
of military sexual trauma (Surís, Link-Malcolm, Chard, Ahn, & North, 2013). A dismantling study found CPT
without the written exposure component to be as effective as the full CPT protocol (Resick et al., 2008).

PE (Foa et al., 1999; Foa et al., 2005) is based in the emotional processing theory of PTSD and combines
imaginal exposure (i.e., repeated exposure to memories of the traumatic event) and in-vivo exposure (i.e.,
gradual exposure to trauma-related stimuli that are safe but were previously avoided). PE also has been
shown to be associated with significant reductions in PTSD symptoms across a variety of populations (Foa et
al, 1999; Foa et al., 2005; Nacasch et al., 2011), including rape survivors (Resick et al., 2012), female assault
victims (Foa et al., 2005), and female veterans and active duty personnel (Schnurr et al., 2007). Both PE and
CPT are associated with long-term and lasting reductions in PTSD (Resick et al., 2012) with research to date
suggesting that cognitive therapy and exposure therapies are equally efficacious in the treatment of PTSD
(Ehlers et al., 2003; Resick et al., 2008).

EMDR (Shapiro, 1995) pairs bilateral eye movements with the cognitive processing of traumatic events.
These eye movements are proposed to facilitate information processing and integration of traumatic
memories. Although EMDR has substantial research support as a PTSD treatment (e.g., Rothbaum, Astin,
& Marsteller, 2005; van den Berg et al., 2015), EMDR is controversial (e.g., Davidson & Parker, 2001) in
that it is unclear if the bilateral eye movements are integral to the treatment. Available evidence suggests
that the mechanism of change may actually be through exposure. Several studies comparing EMDR to
exposure therapy without eye movements find both approaches to be equally efficacious, suggesting that the
eye movements do not enhance treatment (Davidson & Parker, 2001). Thus, more research is needed to
understand the proposed mechanism behind EMDR.

Sequential Treatment
Herman (1997) proposed a multistage model of recovery from trauma: (a) establishing safety, (b)
remembrance and mourning, and (c) reconnection. Survivors early in recovery benefit most from treatment
that targets trauma-related symptoms. Some argue that this need is even greater for complex and chronic
trauma populations such as survivors of intimate partner violence (Johnson et al., 2011), child abuse (Cloitre
et al., 2010), or women with PTSD and comorbid substance use (Najavits, 2013). Consistent with Herman’s
(1997) model, research also suggests that sequential treatment (i.e., an early phase stabilization and skills-
based approach followed by exposure therapy) is effective (e.g., Cloitre et al., 2010). Thus, some individuals
may benefit from this sequential approach to PTSD treatment.

Pharmocological Treatment
Research also supports pharmacologic treatment for PTSD. However, Brady and Back (2002) caution
that significant gender differences in the pharmacokinetic properties of psychotropic medications, including
differences in absorption, drug distribution bioavailability, and metabolism are likely to affect blood levels,
toxicity, side effects, and efficacy of medications used to treat PTSD. Moreover, gonadal hormones can
affect how medications are metabolized, and, therefore, efficacy and side-effect profiles may vary throughout
the month. Thus, Brady and Back emphasize that care must be taken to tailor individual pharmacological
treatment in women with PTSD. Although multiple therapeutic agents have been used in the treatment
of PTSD, a recent meta-analysis suggests that effective pharmacotherapies for PTSD include paroxetine,
sertraline, fluoxetine, risperidone, topiramate, and venlafaxine (Watts et al., 2013).

Case Study—Present-Focused
“Grace” is a 45-year-old African-American female who initiated services after seeking shelter from her long-
term reportedly verbally, physically, and emotionally abusive relationship. Grace has six biological children,
three grandchildren, and one adopted son. She endorsed fears related to her abuser finding out where she
lives, difficulty concentrating and remaining on task, feeling on edge and being easily agitated, recurring

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dreams, and intrusive thoughts. Grace reported wanting to “just not think about any of it at all. I try to avoid
that.” She identified financial concerns and wanted to feel “more stable.” Grace endorsed a history of six
abusive relationships and reported “fearing for her life” in her relationship prior to entering the shelter. She
sought support from her church and maintained relationships with her family of origin, but stated “my primary
responsibility is to my kids.”

Grace participated in a present-focused, cognitive-behavioral, and empowerment-based treatment approach,

Helping to Overcome PTSD through Empowerment (HOPE, Johnson et al., 2011). Grace completed 16
sessions that focused on establishing safety and empowerment and incorporated CBT skills training and
cognitive restructuring to help her manage PTSD symptoms (e.g., coping with triggers, self-soothing and
relaxation, safe sleep, assertiveness training). Grace was provided an “empowerment toolbox of skills” that
covered three broad areas: establishing safety and empowerment, managing symptoms, and improving
relationships. Throughout Grace’s therapy she posted quotes and handouts on her walls and found these
reminders very beneficial. Assertiveness training, facilitating Grace’s understanding of her “Healing Bill of
Rights” (a handout devoted to identifying rights that are potentially disrupted from the cycle of abuse), as
well as teaching her to “rethink,” her abuse and PTSD were cited as particularly helpful. Through treatment,
Grace understood not only the correlation between her history of abuse and her PTSD symptoms but also
the influence of her family of origin and cultural traditions. Grace stated “I never really realized how passive
and submissive I was taught to be,” and she said, “I’m not afraid anymore. I won’t be held hostage by myself
or anyone else again.” As Grace approached her final session she stated, “I’ve done a lot of work, but there’s
still more to do. I’m not ready for another relationship right now, but I am ready to start appreciating me as I
am today.” Grace reported more consistent and restful sleep; “I’ve been able to focus on me and not worry so
much about everybody else. I don’t think about him (abuser) anymore and feel more in control of my life.”

Case Study—Past-Focused
“Mary” is a 42-year-old single Caucasian woman who initially sought services because of her anxiety. Mary
reported panic attacks, nightmares, rituals related to cleaning herself prior to having sex, an aversion to the
color red (“I just freak out when I see it”), anger, and limited contact and strained relationships with her family
of origin. Mary reported, “I go out because I have to, not because I want to. I feel like people know … and it
makes me sick.” Mary suffered from back and thyroid problems and was denied disability benefits for the last
4 years.

Mary grew up in a rural area, married a man who abused her, and has lived with her boyfriend for the last
7 years. She reported being sexually and emotionally abused by her biological father “since I can remember
through age thirteen.” Mary reported a possible miscarriage around age 13 and multiple surgeries including
a full hysterectomy.” She recounted, “[M]y father would place a red pillow over my face, and I still remember
it … the way the room smelled, the way he smelled, the way the pillow smelled … it all comes back when I
talk about it.” Mary reported, “[M]y mother hates me… . She knew what he was doing to me and never did
anything about it… . I have moments where I feel better, but the panic and nightmares just never stop.” Mary
also indicated that years of therapy had not helped her.

Mary participated in CBT for approximately 1 year (45 sessions) exploring how her trauma-related thoughts
and her perceived lack of support from “the people who were supposed to protect me” were associated with
her symptoms. This exploration also increased Mary’s understanding of the impact of her family of her origin
and her anger. “Nobody ever talked about what happened or was happening to me. I always thought it was
me. I grew up thinking something had to really be wrong with me. I always thought I was just crazy.”

Exposure therapy helped Mary manage her fear symptoms. Exploring the trauma intentionally and specifically
was critical to her progress as she gradually was able to discuss the abuse through imaginal prolonged
exposure. In-vivo exposure also was used to assist Mary to habituate to the color red and reduce other
triggers. Breathing retraining was used to address the frequent panic attacks she experienced during and
outside of sessions.

Toward the close of Mary’s treatment, she reported a decrease in nightmares related to the abuse (“I still
get nervous but haven’t had an attack in a long time. I start to breathe and I manage it.”), minimal distress
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response to the color red (“I even wore it as one of the colors in my shirt once”), and decreased anger. “I’ve
let Mom go. I don’t need to be mad at her anymore,” Mary said, “I’m not keeping family secrets anymore. I
don’t feel like I have to be ashamed anymore. It still hurts, but I feel like I’m starting to heal … finally.”

Conclusion
Anxiety disorders are among the most common mental health problems and are known to be associated
with significant impairment in psychosocial functioning. As these disorders are more common in women than
men, it is integral that we develop gender sensitive treatments. The specific efficacy of treatment approaches
varies across different anxiety disorders, but research suggests that CBT and SSRIs are generally the most
effective treatments for anxiety disorders. Suggested areas for future research include exploring gender and
other group differences in the treatment of anxiety disorders, why gender differences exist, and studying the
relative and combined effects of various medications and psychotherapies.

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• anxiety disorders
• social anxiety disorder
• post-traumatic stress disorder
• Diagnostic and Statistical Manual of Mental Disorders
• disorders

http://dx.doi.org/10.4135/9781506300290.n37

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