PowerPoint  Lecture Notes Presentation

Anxiety Disorders

Abnormal Psychology
MEGA MINDS PSYCHOLOGY REVIEW CENTER
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 Chapter Outline
 Anxiety Disorders

I. Clinical Descriptions of Anxiety Disorders

II. Common Risk Factors Across the Anxiety Disorders
III. Etiology of Specific Anxiety Disorders
IV. Treatments of Anxiety Disorders

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 Anxiety vs. Fear
 Anxiety
– Apprehension about a future threat
 Fear
– Response to an immediate threat
 Both involve physiological arousal
– Sympathetic nervous system
 Both can be adaptive
– Fear triggers “fight or flight”
 May save life
– Anxiety increases preparedness
 “U-shaped” curve (Yerkes & Dodson, 1908)
 Absence of anxiety interferes with performance
 Moderate levels of anxiety improve performance
 High levels of anxiety are detrimental to performance
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 Anxiety Disorders
 DSM-5 Anxiety Disorders
– Specific phobias
– Social anxiety disorder
– Panic disorder
– Agoraphobia
– Generalized anxiety disorder
 Most common psychiatric disorders
 28% report anxiety symptoms
 Most common are phobias

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 Criteria for Anxiety Disorders
• DSM-5 criteria for each disorder:
– Symptoms interfere with important areas of functioning
or cause marked distress
– Symptoms are not caused by a drug or a medical
condition
– Symptoms persist for at least 6 months or at least 1
month for panic disorder
– The fears and anxieties are distinct from the symptoms of
another anxiety disorder

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 Phobias
 Disruptive fear of a particular object or situation
– Fear out of proportion to actual threat
– Awareness that fear is excessive
– Must be severe enough to cause distress or interfere with job or
social life
 Avoidance

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 Specific Phobia
 Disproportionate fear of a particular object or situation
– Common examples: fear of flying, snakes, heights, etc.
– Fear out of proportion to actual threat
– Awareness that fear is excessive
– Most specific phobias cluster around a few feared objects and
situations
– High comorbidity of specific phobias

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 DSM-5 Criteria for Specific Phobia

 Marked and disproportionate fear consistently triggered by

specific objects or situations
 The object or situation is avoided or else endured with
intense anxiety
 Symptoms persist for at least 6 months

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Table 6.2: Types of Specific Phobias

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 Social Anxiety Disorder
 Previously called Social Phobia
– Causes more life disruption than other phobias
 More intense and extensive than shyness
– Persistent, intense fear and avoidance of social
situations
– Fear of negative evaluation or scrutiny
– Exposure to trigger leads to anxiety about being
humiliated or embarrassed socially
– Onset often adolescence
 33% also diagnosed with Avoidant Personality
Disorder
– Overlap in genetic vulnerability for both disorders

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 DSM-5 Criteria for Social Anxiety Disorder

 Marked and disproportionate fear consistently triggered by exposure to

potential social scrutiny
 Exposure to the trigger leads to intense anxiety about being evaluated
negatively
 Trigger situations are avoided or else endured with intense anxiety
 Symptoms persist for at least 6 months

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 Panic Disorder
 Frequent panic attacks unrelated to specific situations
 Panic attack
– Sudden, intense episode of apprehension, terror, feelings of impending doom
 Intense urge to flee
 Symptoms reach peak intensity within 10 minutes
– Physical symptoms can include:
 Labored breathing, heart palpitations, nausea, upset stomach, chest pain, feelings of
choking and smothering, dizziness, sweating, lightheadedness, chills, heat sensations, and
trembling
– Other symptoms may include:
 Depersonalization
 Derealization
 Fears of going crazy, losing control, or dying
 25% of people will experience a single panic attack (not the
same as panic disorder)
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 Panic Disorder
 Uncued panic attacks
– Occur unexpectedly without warning
– Panic disorder diagnosis requires
recurrent uncued attacks
– Causes worry about future attacks
 Cued panic attacks
– Triggered by specific situations (e.g.,
seeing a snake)
 More likely a specific phobia

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 DSM-5 Criteria for Panic Disorder

 Recurrent unexpected panic attacks

 At least 1 month of concern about the possibility of
more attacks, worry about the consequences of an
attack, or maladaptive behavioral changes because
of the attacks

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 Agoraphobia
 From the Greek word “agora” or
marketplace
 Anxiety about inability to flee anxiety-
provoking situations
– E.g., crowds, stores, malls, churches,
trains, bridges, tunnels, etc.
– Causes significant impairment
 In DSM-IV-TR, was a subtype of Panic
Disorder
– At least half of agoraphobics do not suffer
panic attacks
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 DSM-5 Criteria for Agoraphobia
 Disproportionate and marked fear or anxiety about at least 2
situations where it would be difficult to escape or receive help
in the event of incapacitation or panic-like symptoms, such as:
– being outside of the home alone; traveling on public transportation;
open spaces such as parking lots and marketplaces; being in shops,
theaters, or cinemas; standing in line or being in a crowd
 These situations consistently provoke fear or anxiety
 These situations are avoided, require the presence of a
companion, or are endured with intense fear or anxiety
 Symptoms last at least 6 months

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 Generalized Anxiety
Disorder (GAD)
 Involves chronic, excessive, generalized,
uncontrollable worry
– Lasts at least 6 months
– Interferes with daily life
 Often cannot decide on a solution or course of
action
 Other symptoms:
– Restlessness, poor concentration, tiring
easily, restlessness, irritability, muscle tension
 Common worries:
– Relationships, health, finances, daily hassles
 Often begins in adolescence or earlier
– I’ve always been this way
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 DSM-5 Criteria for
Generalized Anxiety Disorder
 Excessive anxiety and worry at least 50 percent of days about at least two life domains
(e.g., family, health, finances, work, and school)
 The person finds it hard to control the worry
 The worry is sustained for at least 3 months
 The anxiety and worry are associated with at least three (or one in children) of the
following:
– 1. restlessness or feeling keyed up or on edge
– 2. being easily fatigued
– 3. difficulty concentrating or mind going blank
– 4. irritability
– 5. muscle tension
– 6. sleep disturbance
 The anxiety and worry are associated with marked avoidance of situations in which
negative outcomes could occur, marked time and effort preparing for situations that might
have a negative outcome, marked procrastination, difficulty making decisions due to
worries, or repeatedly seeking reassurance due to worries
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 Comorbidity
 50% of those with anxiety disorder meet criteria for
another anxiety disorder
 75% of those with anxiety disorder meet criteria for
another psychological disorder
– Disorders commonly comorbid with anxiety:
 60% with anxiety also have depression
 Substance abuse
 Personality disorders
 Medical disorders, e.g. coronary heart disease

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 Gender and
Sociocultural Factors
 Women are twice as likely as men to have anxiety disorder
– Possible explanations
 Women may be more likely to report symptoms
 Men more likely to be encouraged to face fears
 Women more likely to experience childhood sexual abuse
 Women show more biological stress reactivity

 Cultural factors
– Culture can shape anxieties and fears
– Culturally specific syndromes
 Taijin kyofusho
 Japanese fear of offending or embarrassing others
 Kayak-angst
 Inuit disorder in seal hunters at sea similar to panic

– Rate of anxiety disorders varies by culture, but ratio of somatic to psychological

symptoms appears similar (Kirmayer, 2001)

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 Factors that May Increase the Risk for More than One Anxiety
Disorder
 Behavioral conditioning (classical and operant
conditioning)
 Genetic vulnerability
 Increased activity in the fear circuit of the brain
 Decreased functioning of GABA and serotonin; increased
norepinephrine activity
 Behavioral inhibition
 Neuroticism
 Cognitive factors, including sustained negative beliefs,
perceived lack of control, and attention to cues of threat
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 Etiology of Specific Phobias
 Conditioning
 Mowrer’s two-factor
model
– Pairing of stimulus with
aversive UCS leads to fear
(Classical Conditioning)
– Avoidance maintained
though negative
reinforcement (Operant
Conditioning)

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 Etiology of Specific Phobias
 Extensions of the two-factor model
– Modeling
 Seeing another person harmed by the stimulus
– Verbal instruction
 Parent warning a child about a danger
– Those with anxiety tend to acquire fear more readily
 And to be more resistant to extinction

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 Risk Factors
 Genetic
– Twin studies suggest heritability
 About 20-40% for phobias, GAD, and PTSD
 About 50% for panic disorder
– Relative with phobia increases risk for
other anxiety disorders in addition to
phobia
 Neurobiological
– Fear circuit overactivity
 Amygdala
 Medial prefrontal cortex deficits
– Neurotransmitters
 Poor functioning of serotonin and GABA
 Higher levels of norepinephrine
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 Risk Factors: Personality
 Behavioral inhibition
– Tendency to be agitated, distressed, and cry in unfamiliar or novel
settings
 Observed in infants as young as 4 months
 May be inherited
– Predicts anxiety in childhood and social anxiety in adolescence
 Neuroticism
– Tendency to react with frequent negative affect
– Linked to anxiety and depression
– Higher levels linked to double the likelihood of developing anxiety
disorders

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 Risk Factors: Cognitive
 Sustained negative beliefs about future
– Bad things will happen
– Engage in safety behaviors
 Belief that one lacks control over environment
– More vulnerable to developing anxiety disorder
 Childhood trauma or punitive parenting may foster beliefs
 Serious life events can threaten sense of control
 Attention to threat
– Tendency to notice negative environmental cues
 Selective attention to signs of threat
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 Etiology of Specific Phobias

 Two-factor model of behavioral conditioning

– Conditioned responses to threat
– Sustained by avoidance or safety behaviors
 Avoid eye contact, appear aloof, stand apart from others in social
settings
 Risk factors act as diatheses
– Vulnerabilities influence development of phobias
 Prepared learning
– Evolutionary preparation to fear certain stimuli
 Potentially life-threatening (heights, snakes, etc.)
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 Etiology of Social Anxiety Disorder

 Behavioral factors
– Factors similar to specific phobia (i.e., classical and operant
conditioning)
 Cognitive factors
– Unrealistic negative beliefs about consequences of behaviors
– Excessive attention to internal cues
– Fear of negative evaluation by others
 Expect others to dislike them
– Negative self-evaluation
 Harsh, punitive self-judgment

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 Etiology of Panic Disorder
 Neurobiological factors
– Locus coeruleus
 Major source of norepinephrine
 A trigger for nervous system activity
 People with panic disorder more
sensitive to drugs that trigger the
release of norepinephrine

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 Etiology of Panic Disorder
 Behavioral factors:
– Interoceptive conditioning
 Classical conditioning of panic in
response to internal bodily sensations

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 Etiology of Panic Disorder
 Cognitive factors
– Catastrophic misinterpretations of
somatic changes
 Interpreted as impending doom
 I must be having a heart attack!
 Beliefs increase anxiety and arousal
 Creates vicious cycle
 Anxiety Sensitivity Index
– High scores predict development of panic
 “Unusual body sensations scare me.”
 “When I notice that my heart is beating rapidly, I worry that I
might have a heart attack.”

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 Etiology of Panic Disorder
 Genetic risk
– Polymorphism in a gene guiding neuropeptide S function,
the NPSR1 gene, has been tied to an increased risk of panic
disorder and is associated with:
 Amygdala response to threat
 Cortisol response
 Higher anxiety sensitivity scores
– Genetic risk shapes stress responses and hypersensitivity
to somatic changes, and this may then increase the risk for
panic disorder.
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 Etiology of Agoraphobia
 Fear-of-fear hypothesis (Goldstein & Chambless, 1978)
– Expectations about the catastrophic consequences of
having a public panic attack
 What will people think of me?!?!

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 Etiology of GAD
 GABA system deficits
 Borkovec’s cognitive model:
– Worry: reinforcing because it distracts from negative
emotions and images
– Allows avoidance of more disturbing emotions
 e.g., distress of previous trauma
– Worrying decreases psychophysiological arousal
– Avoidance prevents extinction of underlying anxiety

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Figure 6.8: The Excessive Worry of GAD May Be an
Attempt to Avoid Intense Emotions

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 EXPLORING ANXIETY DISORDERS
(Barlow and Durand, 2015)
Biological Influences
• Inherited vulnerability to experience anxiety and/or
panic attacks
• Activation of specific brain circuits,
neurotransmitters, and neurochemical systems

Social Influences
• Social support reduces Behavioral Influences
intensity of physical and • Marked avoidance of
emotional reactions to situations and/or people
triggers or stress ANXIETY DISORDERS associated with fear,
• Lack of support intensifies anxiety, or panic attacks
symptoms

Emotional and Cognitive Influences

• Heightened sensitivity to situations or people
perceived as threats
• Unconscious feeling that physical symptoms of
panic are catastrophic (intensifies physical
reactions)
 Treatment of the Anxiety Disorders

 Psychological treatments emphasize

Exposure
– Face the situation or object that triggers anxiety
 Should include as many features of the trigger as possible
 Should be conducted in as many settings as possible
 70-90% effective
 Systematic desensitization
– Relaxation plus imaginal exposure
 Cognitive approaches
– Increase belief in ability to cope with the anxiety trigger
– Challenge expectations about negative outcomes
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 Psychological Treatment of Phobias
 Phobias
– Exposure
 In vivo (real-life) exposure more effective than systematic desensitization
 Social Anxiety Disorder
– Exposure
 Role playing or small group interaction
– Social skills training
 Reduce use of safety behaviors
– Cognitive therapy
 Clark’s (2003) cognitive therapy more effective than medication or exposure

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 Psychological Treatment of Panic

 Panic Control Therapy (PCT; Craske & Barlow, 2001)

– Exposure to somatic sensations associated with panic
attack in a safe setting
 Increased heart rate, rapid breathing, dizziness
– Use of coping strategies to control symptoms
 Relaxation
 Deep breathing
– PCT benefits maintained after treatment ends

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 Psychological Treatment of Agoraphobia

 Cognitive Behavioral Therapy (CBT)

– Systematic exposure to feared situations
– Self-guided treatment effective

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 Psychological Treatment of GAD
 Relaxation training
 Cognitive behavioral methods
– Challenge and modify negative thoughts
– Increase ability to tolerate uncertainty
– Worry only during “scheduled” times
– Focus on present moment

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 Medications
 Anxiolytics: drugs that reduce
anxiety
– Benzodiazepenes
 Valium
 Xanax
– Antidepressants
 Tricyclics
 Selective Serotonin Reuptake Inhibitors (SSRIs)
 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
– Side effects can be problematic with
continuing medication
 D-cycloserine (DCS)
 Enhances learning and can bolstered treatment effectiveness

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