PowerPoint  Lecture Notes Presentation

Chapter 6
Anxiety Disorders
Abnormal Psychology, Thirteenth Edition,
DSM-5 Update
by
Ann M. Kring,
Sheri L. Johnson,
Gerald C. Davison,
& John M. Neale
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Chapter Outline
 Chapter 6: 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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)
© 2015 John Wiley & Sons, Inc. All rights reserved.
 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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
© 2015 John Wiley & Sons, Inc. All rights reserved.
 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
© 2015 John Wiley & Sons, Inc. All rights reserved.
 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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)

© 2015 John Wiley & Sons, Inc. All rights reserved.

Table 6.3: Percent of People Who Meet Diagnostic Criteria for
Anxiety Disorders in the Past Year and in Their Lifetime

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 Table 6.5: 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
© 2015 John Wiley & Sons, Inc. All rights reserved.
 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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
© 2015 John Wiley & Sons, Inc. All rights reserved.
 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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.)

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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.”

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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.

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

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

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 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 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

© 2015 John Wiley & Sons, Inc. All rights reserved.

 COPYRIGHT
Copyright 2015 by John Wiley & Sons, Inc. All rights
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