Oxford handbook of anxiety and related disorders
Hudson, J. L., & Rapee, R. M. (2009)
Familial and social environments in the etiology and maintenance of anxiety disorders.

Introduction  

Factors in the individual’s environment are likely to provide understanding of why one vulnerable individual may develop anxiety disorder and another may not. It is an individual’s specific environment (non-shared) that accounts for the most environmental influence.

Individuals with specific genetic vulnerabilities may elicit particular environments. Individuals at genetic risk who are exposed to a relevant environmental factor may show an increased morbidity.

The role of the family in anxiety disorders

Parenting

There is a link between avoidance of threatening stimuli and the maintenance of anxiety disorders. Parenting behaviours that serve to accommodate or enhance avoidant strategies are likely to impact on the maintenance of anxiety disorders. They may also contribute to the development of anxiety disorders in individuals with an existing anxious vulnerability.

There is a positive relationship between the anxiety disorders and parenting that is controlling, overprotective, or lacking in autonomy granting. The ultimate consequence of overprotective parenting is that the child avoids potentially threatening situations and is prevented from potentially learning the situation is not as dangerous as predicted or she or he is able to exert some control in the situation.

There is some evidence that parenting high in negativity and rejection and low in warmth is also associated with anxiety disorders.

Temperamental factors interact with parent behaviour and play a role in eliciting overprotective parenting. An anxious child may elicit increased involvement and help from their environment. This increased help will serve to decrease the child’s autonomy and increase avoidance of novel anxiety-provoking situations and ultimately maintain the child’s vulnerability to anxiety.

Overprotection/control and rejection/negativity may reduce the child’s opportunity to approach novel situations and to experience confidence and independence.

Parents of anxious children are more likely to support avoidant responding to ambiguously threatening stimuli.

Summary

The key parenting variables that have been associated with anxiety disorders are parenting that is: overprotective/controlling and lacking autonomy granting, negative and lacking warmth and parenting that enhances the child’s avoidance of ambiguously threatening situations. These parenting variables are of most importance in the context of a temperamentally vulnerable child.

Family environment

There are a number of more general facets of the family environment that may be of interest in the development of anxiety disorders. These are cohesion, inter-parental conflict and stressful and negative family environments

There is a causal link between inter-parental conflict and increased anxiety symptoms. There is an important role for the child’s perceptions of self-blame and threat, as well as the child’s coping response and emotional security, in determining the child’s response to parental conflict.

Parent-child attachment

The absence of a secure attachment has been linked to increased anxiety symptoms. Infant attachment predicts later anxiety in a greater degree than maternal anxiety and temperament.

Parental modelling and transmission of threat information

Part of the development of fears and phobias comes from observation and verbal information about potential dangers from external sources.

There is growing evidence that children’s fears can be learned at a very young age via observation of fear in their mother.

Modelling of anxious behaviour and verbal instruction of threat information can be associated with increased anxiety in the offspring. Individuals with anxious parents are at greater risk of exposure to parental anxious modelling and verbal instruction. Presence of parental anxiety places an individual at increased risk of anxiety symptoms.

Partner and sibling relationships

Siblings and spouse who display over-involvement, lack of warmth or anxious modelling may have a significant impact on the development of anxiety disorder.

Social relationships and anxiety disorders

Social rejection and neglect

Anxious individuals engage in fewer social interactions. People with anxiety disorders have fewer friends.

By adulthood people with social phobia have the requisite skills for social interaction, but fail to use the under all circumstances.

Shy individuals tend to be perceived as less likable and others are less likely to want further interaction with them than with others.

It is likely that socially withdrawn and inhibited behaviour may lead to reduced social interaction skills, and that these restricted displays lead to peer rejection. It is possible that peer rejection and lack of peer interactions lead to increased anxiety.

Peer victimization

Victimization can be viewed as the extreme example of peer rejection. Peer victimization may be associated relatively specifically with more social forms of anxiety.

It is likely that there is a bidirectional relationship whereby higher levels of anxiety and negative affect lead to victimization, which in turn increases levels of anxiety and/or depression.

Peers and social learning

The impact of anxious modelling is not likely specific to the parent-child relationship. An individual’s peers and non-familial social environment are likely to provide important models that shape an individual toward or away from anxiety disorders.

There is an important influence of maternal modelling in shaping the impact of other non-familial modelling experiences.

Partner support of inhibition

Friendships may play a maintaining role in disorder through the information they impart. Anxious children may associate with other anxious children and this may help maintain or even exacerbate their anxiety through shared goals, attitudes, and support of avoidant behaviours. Later, these functions may be passed on to the spouse.

Cultural influences

There is a common belief that Eastern cultures display higher levels of social reticence and anxiety than do Western cultures. More collectivistic cultures may have a more positive appraisal of socially withdrawn behaviours, and as a result, these behaviours may not produce the life interference in these countries than they do in more individualistic cultures.

One of the principal influences of culture is to affect the diagnostic threshold of a disorder. Cultural norms may influence psychopathology by determining the level at which symptoms are perceived as problematic in the individual’s life.

The form of anxious expression may vary across cultures.

Relationships and treatment outcome

Do relationships affect treatment outcome?

Expressed emotion is criticism, hostility, and emotional over-involvement.

Individuals from families with high levels of perceived criticism and negative family environments show poorer treatment outcome. Higher perceived family criticism and hostility predicts poorer treatment outcome.

Greater family dysfunction at pre-treatment is associated with less treatment change.

Marital satisfaction may be a more robust predictor of long-term outcome as opposed to post-treatment outcome.

Parental psychopathology is a predictor of outcome in the treatment of childhood anxiety disorders.

Does treatment affect relationships?

Treatment for anxiety disorders has positive effects on the individual’s family and social interactions.

Involving the family in treatment

Involving family members in treatment may lead to enhanced outcomes. When family members are involved, behaviours that may have assisted in developing or maintaining anxiety can be addressed. On the other hand, involving family members may merely hinder the anxious individual from gaining independence and autonomy.