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CHAPTER 2

ANXIETY DISORDERS

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AIMS AND OBJECTIVES

Describe the nature of fear and anxiety disorders

Discuss the range of anxiety disorders

Provide information about diagnosis, epidemiology, and treatment for each disorder

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THE NATURE OF FEAR AND ANXIETY

Flight or fight response (Cannon, 1929)

Body reacts to danger by releasing adrenaline through blood stream Related behaviours include:

Freezing – to appraise danger Flight – escape Fight – if danger is unavoidable

“True alarms” (direct danger) versus “false alarms” (no immediate threat)

False alarms are the hallmark of anxiety disorders

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THE NATURE OF FEAR AND ANXIETY

Triple vulnerability model (Barlow, 2002)

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THE NATURE OF FEAR AND ANXIETY

Fear can be acquired in several ways:

Conditioning – pairing of a conditioned stimulus with an aversive event

Informational pathway Vicarious acquisition

These all contribute to the expectation that an aversive outcome is probable

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THE NATURE OF FEAR AND ANXIETY

US (bitten by dog)

UR (fear)

CR (fear)CS (dog)

pair with

Conditioning

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SPECIFIC PHOBIA

DSM-IV-TR Diagnosis includes:

Marked fear that is excessive or unreasonable Cued by presence or anticipation of phobic object/situation Causes interference/impairment in life or marked distress Four subtypes:

Animal Natural Environment (i.e., storms, heights, water) Blood-Injection – Injury (i.e., blood, operation scenes, injections,

fainting common) Situational (i.e., planes, elevators)

Epidemiology Lifetime prevalence 4-8%, female to male ratio 2:1

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SPECIFIC PHOBIA

Aetiology

Phobias may be acquired by classical conditioning

E.g., A neutral CS (white rat) is paired with a US (loud noise) that produces fear

Problems with classical conditioning account

Many people with specific phobias do not remember an initial traumatic event (Menzies & Clark, 1993)

Preparedness: Some stimulus can be conditioned more easily (Seligman, 1971)

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SPECIFIC PHOBIA

Treatment

Exposure-based treatments are the most effective (Choy et al., 2007)

In vivo exposure – facing phobic stimulus in real life Imaginal or virtual exposure

Exposures may work through extinction Fear decreases over repeated presentations of the CS in the absence

of the US

They may also work by challenging expectations of danger, increasing self-efficacy, and increasing perception of control

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PANIC DISORDER AND AGORAPHOBIA

DSM-IV-TR Diagnosis for Panic Disorder includes:

Recurrent, unexpected panic attacks At least one attack has been followed by >1 month of:

Persistent concern about having additional attacks Worry about the implications/consequences of the attack, e.g., losing

control, dying A significant change in behavior

Agoraphobia – anxiety about being in places from which escape might be difficult or embarrassing in the event of having a panic attack

Panic disorder can occur with or without agoraphobia

Lifetime prevalence of panic disorder = 5%

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PANIC DISORDER AND AGORAPHOBIA

Aetiology

Generalised psychological vulnerability High anxiety sensitivity – fear of sensations

Specific psychological vulnerability Catastrophic misinterpretation of physical sensations

Treatment

Pharmacological – SSRIs, benzodiazepines

Psychological – Cognitive behaviour therapy Address avoidance of internal and external cues using behavioural

and cognitive techniques

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SOCIAL PHOBIA

DSM-IV-TR Diagnosis includes:

Marked, persistent fear of social situations Person recognises the fear as unreasonable Feared social situations are avoided Interference or distress

Epidemiology

Lifetime prevalence 10-16%, female to male ratio 1:1 Chronic course Delay in seeking treatment

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SOCIAL PHOBIA

Aetiology

Genetic vulnerability: 2-3x increased risk among relatives Psychosocial factors

Excessive parental criticism Cognitive dysfunctions Hypersensitivity to criticism

Treatment

Psychological– Cognitive behaviour therapy Cognitive restructuring of negative thoughts (e.g., I am boring) Exposure to feared social situations

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OBSESSIVE COMPULSIVE DISORDER (OCD) DSM-IV-TR Diagnosis includes:

Obsessions – recurrent thoughts, images or impulses experienced as inappropriate or distressing

Compulsions – repetitive behaviours that the person feels compelled to perform in response to obsession or according to rigid rules

Person recognizes that obsessions or compulsions are excessive/irrational

Marked distress/interference, time-consuming (>1 hour/day)

Several subtypes: Washing Checking Hoarding Obsessional slowness

Epidemiology Lifetime prevalence 2-3% Often chronic if untreated

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OBSESSIVE COMPULSIVE DISORDER (OCD) Aetiology

Neuropsychological model (Baxter et al., 2000) Failure of inhibitory pathways in the basal ganglia to stop

“behavioural macros” in response to internal/external stimuli

Cognitive model OCD thoughts not different from those in general population Difference is how OCD sufferers interpret the thoughts

Treatment

Psychological– Cognitive behaviour therapy Exposure and response prevention Cognitive restructuring

Pharmacological therapy

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POSTTRAUMATIC STRESS DISORDER (PTSD)

DSM-IV-TR Diagnosis includes: Exposure to a traumatic event Re-experiencing symptoms Avoidance symptoms Arousal symptoms Symptoms present for at least one month

Epidemiology Despite high frequency of exposure to traumatic stressors,

relatively few develop PTSD (4%) Research attempts to identify who is at risk for developing PTSD

after exposure to a trauma

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POSTTRAUMATIC STRESS DISORDER (PTSD) Aetiology

Cognitive models Focus on individual’s maladaptive appraisals of the event, his/her

response to the event, and the environment Learning accounts

Emphasis on classical conditioning Biological accounts

Propose that extreme sympathetic arousal at the time of trauma results in strong fear conditioning

Across accounts, avoidance of trauma reminders maintains PTSD

Treatment Pharmacological therapy Cognitive-behavioural therapy

Psychoeducation, anxiety management, cognitive restructuring, imaginal / in vivo exposure, and relapse prevention

Prevention of PTSD – applying CBT to survivors after trauma exposure

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GENERALISED ANXIETY DISORDER (GAD)

DSM-IV-TR Diagnosis includes: Excessive worry about a number of events or activities

E.g, health, finances, relationships Worries are difficult to control Present on most days for at least 6 months Associated symptoms such as irritability, fatigue, difficulty

concentrating, and muscle tension

Epidemiology Commonly experienced, lifetime prevalence of 5% Early age of onset and chronic course

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GENERALISED ANXIETY DISORDER (GAD) Aetiology

Moderate genetic predisposition Cognitive models

Information processing model – biased toward threat Metacognitive model – positive and negative meta-beliefs about worry Avoidance theory– worry to avoid imagery and underlying concerns Intolerance of uncertainty model – need to control

Treatment

Pharmacological therapy Cognitive-behavioural therapy

Cognitive restructuring, relaxation, behavioural experiments Some symptom improvement, yet only 50% of sufferers end up in

non-clinical range

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SUMMARY

Nature of Fear and Anxiety Flight or fight response Triple vulnerability model Acquisition of expectation of fear

Diagnosis, Epidemiology, Aetiology, and Treatment of:

Specific Phobia Panic Disorder and Agoraphobia Social Phobia Obsessive-Compulsive Disorder Posttraumatic Stress Disorder Generalised Anxiety Disorder