Anxiety Disorders

PowerPoint Lecture Notes Presentation Chapter 5 Anxiety DisordersAbnormal Psychology, 11th Editionby Ann M. Kring, Gerald C. Davison, John M. Neale, & Sheri L. Johnson

Copyright 2009 John Wiley & Sons, NY*Anxiety vs. FearAnxiety

Apprehension about a future threatFear

Response to an immediate threatBoth involve physiological arousal

Sympathetic nervous systemBoth can be adaptive

Fear triggers flight or fightMay save lifeAnxiety increases preparednessModerate levels improve performance

Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY*Anxiety DisordersDSM-IV-TR

Specific and social phobiasPanic disorder and agoraphobiaGeneralized anxiety disorderObsessive compulsive disorderPosttraumatic stress disorderMost common psychiatric disorders28% report anxiety symptoms (Kessler et al., 2005)Most common are phobias


Copyright 2009 John Wiley & Sons, NY*PhobiasDisruptive fear of a particular object or situation

Fear out of proportion to actual threatAwareness that fear is excessiveMust be severe enough to cause distress or interfere with job or social lifeAvoidanceTwo types:

SpecificSocial


Copyright 2009 John Wiley & Sons, NY*Specific PhobiaUnwarranted, excessive fear of specific object or situation

Snakes, blood, flying, spiders, etc. How likely are you to be bitten by a spider?Most specific phobias cluster around a few feared objects and situations (Table 5.3)Trigger or feared object is avoided or endured with intense anxietyHigh comorbidity of specific phobias


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Table 5.2Words Used to Describe Highly Unlikely PhobiasFearPhobiaAnything newNeophobiaAsymmetrical thingsAsymmetriphobiaBooksBibliophobiaChildrenPedophobiaDancingChorophobiaEnglishnessAnglophobiaGarlicAlliumphobiaPeanut butter sticking to the roof of the mouthArachibutyrophobiaTechnologyTechnophobiaMiceMusophobiaPseudoscientific termsHellenophobiaSource: Drawn from www.phobialist.com.



Table 5.3Types of Specific PhobiasType of PhobiaSource of FearAssociated CharacteristicsAnimalAnimals (e.g., snakes, insects)Generally begins during childhoodNatural environmentAspects of the natural environment (e.g., storms, heights, water)Generally begins during childhoodBlood, injection, injuryBlood, injury, injections, or other invasive medical proceduresClearly runs in familiesSituationalSpecific situations (e.g., public transportation, tunnels, bridges, elevators, flying, driving, closed spaces)Tends to begin either in childhood or in mid-20s.OtherFear of choking, fear of contracting an illness, etc.; childrens fears of loud sounds, clowns, etc.


Copyright 2009 John Wiley & Sons, NY*Social PhobiaPersistent, intense fear of social situations

Fear of negative evaluation or scrutinyMore intense and extensive than shyness

More appropriate diagnostic label?Social anxiety disorderExposure to trigger leads to anxiety about being humiliated or embarrassed socially.Onset often adolescenceDiagnosed as either generalized or specific33% also diagnosed with Avoidant Personality Disorder

Overlap in genetic vulnerability for both disorders


Copyright 2009 John Wiley & Sons, NY*Panic DisorderFrequent panic attacks unrelated to specific situationsPanic attack

Sudden, intense episode of apprehension, terror, feelings of impending doomSymptoms reach peak intensity within 10 minutesAccompanied by at least 4 other symptoms:Sweating, nausea, labored breathing, dizziness, heart palpitations, upset stomach, lightheadedness, etc. Other symptoms may include:Depersonalization Derealization Fear of going crazy, losing control, or dying


Copyright 2009 John Wiley & Sons, NY*Panic DisorderUncued attacks

Occur unexpectedly without warningPanic disorder diagnosis requires recurrent uncued attacks. Cued attacks

Triggered by specific situations (e.g., tunnel)More likely a phobiaPanic Disorder with Agoraphobia

Avoidance of situations in which escape would be difficult or embarrassingPanic disorder with agoraphobia tends to be more chronic .


Copyright 2009 John Wiley & Sons, NY*Generalized Anxiety Disorder (GAD)Involves chronic, excessive, uncontrollable worry

Lasts at least 6 monthsInterferes with daily lifeOther symptoms:

Restlessness, poor concentration, irritability, muscle tension, tires easily, sleep disturbanceCommon worries:

Relationships, health, finances, daily hasslesOften begins in adolescence or earlier

Ive always been this way


Copyright 2009 John Wiley & Sons, NY*Obsessive-Compulsive Disorder (OCD)Obsessions

Intrusive, persistent, and uncontrollable thoughts or urgesExperienced as irrationalMost common: Contamination, sexual & aggressive impulses, body problemsCompulsions

Impulse to repeat certain behaviors or mental acts to avoid distresse.g., cleaning, checking, hoarding, repeating a word, countingExtremely difficult to resist the impulseMay involve elaborate behavioral rituals


Copyright 2009 John Wiley & Sons, NY*Obsessive-Compulsive Disorder (OCD)Develops either before age 10 or during late adolescence/early adulthoodMen

Early onset more commonWomen

Cleaning compulsions and later onset more commonOCD often chronic


Copyright 2009 John Wiley & Sons, NY*Post Traumatic Stress Disorder (PTSD)Extreme response to severe stressor

Anxiety, avoidance of stimuli associated with trauma, emotional numbingExposure to a traumatic event that involves actual or threatened death or injury

e.g., war, rape, natural disasterTrauma leads to intense fear or helplessnessSymptoms present for more than a monthWomen and PTSD

Rape most common type of trauma (Creamer et al., 2001)


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Copyright 2009 John Wiley & Sons, NY*Post Traumatic Stress Disorder (PTSD)Three categories of symptoms :

Re-experiencing the traumatic eventNightmares, intrusive thoughts, or imagesAvoidance of stimulie.g., Refuse to walk on street where rape occurredNumbingDecreased interest in othersDistant or estranged from othersUnable to experience positive emotionsIncreased arousal Insomnia, irritability, hypervigilance, exaggerated startle responseTends to be chronic (Perkonigg et al., 2005)


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Copyright 2009 John Wiley & Sons, NY*Acute Stress Disorder (ASD)Symptoms similar to PTSDDuration varies

Short term reactionSymptoms occur between 2 days and 1 month after traumaAs many as 90% of rape victims experience ASD (Rothbaum et al., 1992)More than 2/3 of those with ASD develop PTSD within 2 years (Harvey & Bryant, 2002)


Copyright 2009 John Wiley & Sons, NY*Comorbidity of those with anxiety disorder meet criteria for another disorder

60% meet criteria for major depression (Brown et al., 2001)Other disorders commonly comorbid with anxiety:Substance abusePersonality disordersAvoidantDependentHistrionic Medical disorders e.g., coronary heart disease


Copyright 2009 John Wiley & Sons, NY*Gender & Sociocultural FactorsWomen are 2x as likely as men to have anxiety disorder except for OCDPossible explanations

Women may be more likely to report symptomsWomen more likely to experience childhood sexual abuseWomen show more biological stress reactivitySociocultural factors

Focus of anxiety variesTaijin kyofushoJapanese fear of offending or embarrassing othersKayak-angstInuit disorder in seal hunters at sea similar to panicRatio of somatic to psychological symptoms appears similar across cultures (Kirmayer, 2001)


Table 5.5 Factors that May Increase the Risk for More than One Anxiety DisorderGenetic vulnerabilityIncreased activity in the fear circuit of the brainDecreased functioning of GABA and serotonin; increased norepinephrine activityNegative Life EventsBehavioral inhibitionNeuroticismCognitive factors, including attention to cues of threat and low perception of control



Copyright 2009 John Wiley & Sons, NY*Risk FactorsGenetic

Twin studies suggest heritability About 20-40% for phobias, GAD, and PTSDAbout 50% for panic disorderRelative w/phobia increases risk for other anxiety disorders in addition to phobiaNeurobiological

Fear circuit overactivityAmygdala Medial prefrontal cortex deficitsNeurotransmittersSerotonin, GABA, Norepinephrine


Copyright 2009 John Wiley & Sons, NY*Risk Factors: SocialNegative life events

Job loss, end of relationship, etc.Severe stressors often precede onset (Kendler et al., 2003)80% with panic disorder (Barlow, 2004)70% with any anxiety disorder (Finlay-Jones, 1989)


Copyright 2009 John Wiley & Sons, NY*Risk Factors: PersonalityBehavioral inhibition

Tendency to be agitated, distressed, and cry in unfamilar or novel settingsObserved in infants as young as 4 monthsMay be inheritedPredicts anxiety in childhood and social anxiety in adolescenceNeuroticism

React with negative affect Linked to anxiety and depression (deGraaf et a., 2002)Psychophysiological reactivity in firefighters predicted development of PTSD (Guthrie & Bryant, 2005)


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Copyright 2009 John Wiley & Sons, NY*Risk Factors: CognitiveBelief that one lacks control over environment

More vulnerable to developing anxiety disorderChildhood trauma or punitive parenting may foster beliefsAmount of control during trauma may influence whether anxiety disorder will develop (Mineka & Zinbarg, 2007)Attention to threat

Tendency to notice negative environmental cuesSelective attention to signs of threat


Copyright 2009 John Wiley & Sons, NY*Etiology of Specific PhobiasConditioningMowrers two-factor model

Pairing of stimulus with aversive UCS leads to fear (Classical Conditioning)Avoidance maintained though negative reinforcement (Operant Conditioning)


Copyright 2009 John Wiley & Sons, NY*Etiology of Specific PhobiasProblems with two-factor model

Many people never experience aversive interaction with phobic object (see table 5.6)People with phobias tend to fear only certain types of objects (prepared learning) Snakes, insects, blood, heights, etc. Even phobias linked to modeling influenced by prepared learningMonkeys acquired fear after watching another monkey exhibit fear to snake but not flower (Cook & Mineka, 1989)


Copyright 2009 John Wiley & Sons, NY*Etiology of Social PhobiaTwo factor model

Avoidance or safety behaviorsAvoid eye contact, appear aloof, stand apart from others in social settingsCognitive factors

Negative self evaluationHarsh, punitive self-judgmentFear of negative evaluation by othersExpect others to dislike themExcessive attention to internal cues

e.g., heart rate


Copyright 2009 John Wiley & Sons, NY*Etiology of PanicNeurobiological factors

Locus ceruleusMajor source of norepinephrineA trigger for nervous system activityMultiple drugs can induce panic attacksTypically only in those who are overly concerned about bodily changes


Copyright 2009 John Wiley & Sons, NY*Etiology of PanicInteroceptive conditioning

Classical conditioning of panic in response to bodily sensationsPeople with panic disorder sustain classically conditioned fears longer (Michael et al., 2007)


Copyright 2009 John Wiley & Sons, NY*Etiology of PanicCognitive factors

Lack of perceived control can trigger panicFear of bodily changesInterpreted as impending doomI must be having a heart attack!Beliefs increase anxiety and arousalCreates vicious cycle


Copyright 2009 John Wiley & Sons, NY*Table 5.7 Sample Items from Anxiety Sensitivity Index

Table 5.7Sample Items from the Anxiety Sensitivity IndexUnusual body sensations scare me.When I notice that my heart is beating rapidly, I worry that I might have a heart attack.It scares me when I feel faint.It scares me when I feel shaky (trembling).Source: Peterson & Reiss, 1987. Note: People respond to each item on a 0 (very little) to 4 (very much) scale.


Copyright 2009 John Wiley & Sons, NY*Etiology of AgoraphobiaFear-of-fear hypothesis (Goldstein & Chambless, 1978)

Expectations about the catastrophic consequences of having a public panic attack.What will people think of me?!?!


Copyright 2009 John Wiley & Sons, NY*Etiology of GADGABA system deficitsBorkovecs cognitive model:

Worry reinforcing because it distracts from negative emotions and imagesAllows avoidance of more disturbing emotionse.g., distress of previous traumaAvoidance prevents extinction of underlying anxietyIndividuals with GAD less able to identify their own negative feelings (Mennin et al., 2002)


Copyright 2009 John Wiley & Sons, NY*Etiology of OCD: Neurobiological FactorsOCD symptoms common in certain neurological disorders

Huntingtons choreaHyperactive regions of the brain:

Orbitofrontal cortexCaudate nucleusAnterior cingulateLoss of neuronal function and underlying biochemical abnormality (Ycel et al., 2007)


Copyright 2009 John Wiley & Sons, NY*Etiology of OCD: Behavioral & Cognitive FactorsOperant reinforcement

Compulsions negatively reinforced by the reduction of anxietyCognitive factors

Lack of a satiety signalYadasentienceSubjective feeling of completionKnowing that you have thought enough or cleaned enoughIndividuals with OCD have a yadasentience deficitAttempts to suppress intrusive thoughtsTrying to suppress thoughts may make matters worse


Copyright 2009 John Wiley & Sons, NY*Etiology of PTSDSeverity and type of traumaNeurobiological

Smaller hippocampal volume linked to PTSDDisruption of verbal vs. nonverbal memorySupersensitivity to cortisolBehavioral

Two factor modelPsychological

Perception of controlAvoidance coping, dissociation, memory suppressionIntelligence and ability to grow from the experience enhance coping


Copyright 2009 John Wiley & Sons, NY*Common Aspects of Psychological Treatment Psychological treatments emphasize Exposure

Face the situation or object that triggers anxietyShould include as many features of the trigger as possibleShould be conducted in as many settings as possibleSystematic desensitization

Relaxation plus imaginal exposure


Copyright 2009 John Wiley & Sons, NY*Common Aspects of Psychological Treatment Cognitive approaches

Increase belief in ability to cope with the anxiety triggerChallenge expectations about negative outcomes


Copyright 2009 John Wiley & Sons, NY*Psychological Treatment of PhobiasExposure

In vivo exposure more effective than systematic desensitizationVirtual reality as effective as in vivoSocial phobia

ExposureRole playing or small group interactionSocial skills trainingReduce use of safety behaviorsCognitive therapy

Enhances treatment for social but not specific phobiasClarks (2003) cognitive therapy more effective than medication or exposure.


Copyright 2009 John Wiley & Sons, NY*Psychological Treatment of Panic and AgoraphobiaPanic Control Therapy (PCT; Craske & Barlow, 2001)

Exposure to somatic sensations associated with panic attack in a safe settingIncreased heart rate, rapid breathing, dizzinessUse of coping strategies to control symptomsRelaxationDeep breathingPCT benefits maintained after treatment ends.


Copyright 2009 John Wiley & Sons, NY*Psychological Treatment of Panic and AgoraphobiaCognitive Behavioral Therapy (CBT)

Increase patients awareness of thoughts that make physical sensations threateningPatient learns to challenge and change maladaptive beliefsCBT also effective for agoraphobia

Treatment enhanced when spouse or significant other stops catering to partners avoidance.


Copyright 2009 John Wiley & Sons, NY*Psychological Treatment of GADRelaxation trainingCognitive Behavioral methods

Challenge and modify negative thoughts Increase ability to tolerate uncertaintyWorry only during scheduled timesFocus on present moment


Copyright 2009 John Wiley & Sons, NY*Psychological Treatment of OCDExposure plus ritual prevention

Most widely used treatmentCognitive therapy

Challenge beliefs about anticipated consequences of not engaging in compulsionsUsually also involves exposure


Copyright 2009 John Wiley & Sons, NY*Psychological Treatment of PTSDExposure to memories and reminders of the original trauma

Either direct (in vivo) or imaginalTreatment may initially increase symptomsMore effective than medication or supportive therapyCognitive therapy

Enhance beliefs about coping abilitiesAdding CT to exposure does not improve treatment responseTreatment of ASD may prevent PTSD

Shows benefits even 5 years after the traumatic event


Copyright 2009 John Wiley & Sons, NY*MedicationsAnxiolytics

Drugs that reduce anxietyTwo common types of medications used to treat anxiety

Benzodiazepenes Valium, XanaxAntidepressants Tricyclics,Selective Serotonin Reuptake Inhibitors (SSRIs), and Serotonin Reuptake Inhibitors (SRIs)


Copyright 2009 John Wiley & Sons, NY*MedicationsDemonstrated effectiveness as compared to placebo

Clomipramine for OCDMedication does not seem to help hoardingBeta blockers commonly prescribed for social phobia although no demonstrated effectivenessSide effects

Withdrawal from benzodiazepenesWeight gain, nervousness, high blood pressure from SSRIsRelapse common after medication discontinuation


Copyright 2009 John Wiley & Sons, NY*COPYRIGHTCopyright 2005 by John Wiley & Sons, New York, NY. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission of the copyright owner.


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Anxiety Disorders

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