Clinical psychology
Chapter 6
Anxiety disorders

Introduction

Anxiety: apprehension over an anticipated problem (future)
Fear: a reaction to immediate danger

Both anxiety and fear can involve arousal, or sympathetic nervous system activity.
Anxiety and fear are both adaptive.

• Fear is fundamental for fight-or-flight reactions.
• Anxiety helps us notice and plan for future threats

In some anxiety disorders, the fear system seems to misfire. A person experiences fear at a time when there is no danger in the environment.
Anxiety creates a U-shape curve with performance.

Anxiety disorders as a group are the most common type of psychiatric diagnosis.
Phobias are particularly common

Clinical descriptions of the anxiety disorder

For each anxiety disorder, several criteria must be met for a DSM-5 diagnoses to be made:

• Symptoms must interfere with important areas of functioning or cause marked stress
• Symptoms are not caused by a drug or a medical condition
• The fears and anxieties are distinct from the symptoms of another anxiety disorder

Each disorder, though, is defined by a different set of symptoms related to anxiety or fear.

Anxiety disorders:

• Specific phobia
• Social anxiety disorder
• Panic disorder
• Agoraphobia
• Generalized anxiety disorder

Specific phobias

A specific phobia: a disproportionate fear caused by a specific object or situation.
The person recognizes that the fear is excessive, but still goes to great lengths to avoid the feared object or situation.

Specific phobias tend to cluster around a small number of feared objects and situations.
The DSM categorizes specific phobias according to these sources of fear.
A person with one type of specific phobia is very likely to have another type of specific phobia as well. There is high comorbidity of specific phobias.

DSM-5 criteria:

• Marked and disproportionate fear consistently triggered by specific object or situations
• The object or situation is avoided or else endured with intense anxiety
• Symptoms persists for at least 6 months

Social anxiety disorder

Social anxiety disorder: a persistent, unrealistically intense fear of social situations that might involve being scrutinized by, or even just exposed to, unfamiliar people.
The problems caused by it tend to be much more pervasive and to interfere much more with normal activities than the problems caused by other phobias.

• People with social anxiety disorder usually try to avoid situations in which they might be evaluated, show signs of anxiety, or behave en embarrassing ways.

Social anxiety disorder generally begins during adolescence. For some, though, the symptoms first emerge during childhood.
Without treatment, social anxiety disorder tends to become chronic.

Social anxiety disorder can range in severity from a relatively few specific fears to a more generalized host of fears.
The number of fears experiences is related to more comorbidity with other disorders, and more negative effects on a person’s social and occupational activities.

DSM-5 criteria

• 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 persists for at least 6 months

Panic disorder

Panic disorder: characterized by frequent panic attacks that are unrelated to specific situations and by worry about having more panic attacks.

Panic attack: a sudden attack of intense apprehension, terror, and feelings of impending doom, accompanied by at least four other symptoms:

• Shortness of breath
• Heart palpitations
• Nausea
• Upset stomach
• Chest pain
• Feelings of choking and smothering
• Dizziness
• Lightheadedness
• Feeling faints
• Sweating
• Chills
• Heat sensations
• Numbness or tingling sensations
• Trembling
• Depersonalization: a feeling of being outside one’s body
• Derealization: a feeling of the world’s not being real
• Fears of losing control
• Fears of going crazy
• Fears of dying

The symptoms tend to come on very rapidly and reach a peak of intensity within 10 minutes.

We can think as a panic attack as a misfire of the fear system.
The person experiences a level of sympathetic nervous system arousal matching what most people might experience when faced with an immediate threat to life.
Because the symptoms are inexplicable, the person tries to make sense of the experience.
A person who beings to think that he or she is dying, losing control, or going crazy is likely to feel even more fear.

According to the DSM criteria for panic disorder, a person must experience recurrent panic attacks that are unexpected.

• Panic attacks that are triggered by specific situations, are typically related to a phobia and should bot be considered in diagnosing panic disorder.

The person must also worry about the attacks of change their behavior because of the attacks for at least 1 month.
The response to the attacks is as important as the attacks themselves in making the diagnosis.
The panic attacks must be recurrent.

Among those who develop panic disorder, the onset is typically adolescence.

DSM-5 criteria

• 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

Agoraphobia

Agoraphobia: anxiety about situations in which it would be embarrassing or difficult to escape if anxiety symptoms occurred.
Many people with agoraphobia are virtually unable to leave their house, and even those who can leave do so only with great distress.

DSM-5 criteria:

• Disproportionate and marked fear or anxiety about at least 2 situations where it would be difficult to escape or receive help in the the event of incapacitation, embarrassing symptoms, or panic-like symptoms, such as being outside of the home alone, traveling on public transportation, being in open spaces such as parking lots and marketplaces, being in enclosed spaces such as shops, theaters, or cinemas, or 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

Generalized anxiety disorder

The central feature of generalized anxiety disorder (GAD) is worry.
People with GAD are persistently worried, often about minor things.
Worry: the cognitive tendency to chew on a problem and the be unable to let go of it.

GAD is not diagnosed if a person worries only about concerns driven by another psychological disorder.
People with GAD worry about everything. And these persistent worries interfere with daily life.

GAD typically beings in adolescence, though may people who have GAD report having had a tendency to worry all their lives.
Once it develops, GAD is often chronic.

DSM-5 criteria

• Excessive anxiety and worry at least 50 percent of days about a number of events or activities.
• The person finds it hard to control the worry
• The worry is sustained for at least 6 months
• The anxiety and worry are associated with at least three (or one in children) of the following:
  • Restlessness or feeling keyed up or on edge
  • Easily fatigued
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance

Comorbidity in anxiety disorders

More than half of people with one anxiety disorder meet the criteria for another anxiety disorder during their life.
This comorbidity within the anxiety disorders is particularly pronounced for GAD, which is associated with a fourfold greater risk of developing another anxiety disorder compared to the rates in the general population.

It is very common for people with one anxiety disorder to report subthreshold symptoms of other anxiety disorders.
Subthreshold symptoms: symptoms that do not meet full diagnostic criteria.

Comorbidity within anxiety disorders arises for two primary reasons:

• The symptoms used to diagnose the various anxiety disorders overlap
• Some etiological factors, like certain neurological or personality characteristics, may increase risk for more than one anxiety disorder.

Anxiety disorder are also highly comorbid with other disorders.

Gender and sociocultural factors in anxiety disorders

Gender and culture are closely tied to the risk for anxiety disorders and to the specific types of symptoms that a person develops.

Gender

Women are at least twice as likely as men to be diagnosed with an anxiety disorder.
Women are more vulnerable to anxiety disorders than men.
Theories why:

• Women may be more likely to report their symptoms
• Psychological differences
• Social factors
• Women show more biological reactivity to stress

Culture

People in every culture seem to experience problems with anxiety disorders.
But the focus on these problems appears to vary by culture.
The objects of anxiety and fear in these syndromes relate to environmental challenges as well as to attitudes that are prevalent in the culture where the syndrome occur. Culture influences what people come to fear.

Beyond culturally-relevant syndromes, the prevalence of anxiety disorders varies across cultures.
Cultures differ with regard to factors such as:

• Attitudes toward mental illness
• Stress levels
• Nature of family relationships
• The prevalence of poverty

All of these are known to play a role in the occurrence of reporting of anxiety disorder.

Bodily symptoms can vary across cultures.

Common risk factors across the anxiety disorders

Classical conditioning of a fear response is at the heart of many anxiety disorders.
Many of the other risk factors can influence how readily a person can be conditioned to develop a new fear response.
The risk factors combine to create an increased sensitivity to threat.

Fear conditioning

Most anxiety disorders involve fears that are more frequent or intense than what most people experience.

Mowrer’s two-factor model. Two steps in the development of an anxiety disorder

• Through, classical conditioning, a person learns to fear a neutral stimulus (CS) that is paired with an intrinsically aversive stimulus (UCS)
• Through operant conditioning, a person gains relief by avoiding the CS. This avoidant response is maintained because it is reinforcing

But Mowrer’s early version of the two-factor model does not fit the evidence very well.
Once version of the model has been consider different ways in which classical conditioning could occur.

• It could occur by direct experience
• It could occur by seeing another person harmed or frightened by a stimulus
• It could occur by verbal instruction

People with anxiety disorders seem to acquire fears more readily through classical conditioning and to show a slower extinction of fears once they are acquired.

Genetic factors: are genes a diathesis for anxiety disorders?

Twin studies suggest a heritability of 20-40 percent for specific phobias, social anxiety disorder, GAD and PTSD, and about 50 percent for panic disorder.
Some genes may elevate risk for several different types of anxiety disorder, while others may elevate risk for a specific type of anxiety disorder.

Neurobiological factors: the fear circuit and the activity of neurotransmitters

Fear circuit: a set of brain structures involved when people are feeling anxious or fearful.
It appears to be related to anxiety disorders.

• One part of the fear circuit that seems particularly activated among people with anxiety is the amygdala
  Amygdala: a small, almond-shaped structure in the temporal lobe that appears to be involved in assigning emotional significance to stimuli.
  The amygdala sends signals to a range of different brain structures involved in the fear circuit.
• The medial prefrontal cortex appears to be important in helping to regulate the amygdala activity.
  It is involved in extinguishing fears as well as using emotion regulation strategies to control emotions.
  People who meet criteria for anxiety disorders display less activity in the medial prefrontal cortex.
• The pathway, linking these two regions may be deficient among those with anxiety disorders.
  It may interfere with the effective regulation and extinction of anxiety.

Many of the neurotransmitters involved in the fear circuit are involved in anxiety disorders.

• Anxiety disorders seem to be related to poor functioning of the serotonin system and higher levels of norepinephrine.
• GABA appears to be involved in inhibiting activity throughout the brain, and one of its effects is decreased anxiety.

Personality: behavioral inhibition and neuroticism

Behavioral inhibition: a tendency to become agitated and cry when faced with novel toys, people, or other stimuli.
This behavioral pattern, may be inherited and may set the stage for the later development of anxiety disorders.
Behavioral inhibition appears to be a particularly strong predictor of social anxiety disorder.

Neuroticism: a personality trait defined by the tendency to react to events with greater-than-average negative affect.

Cognitive factors

Sustained negatives beliefs about the future

People with anxiety disorders often report believing that bad thing are likely to happen.
The key issue is not who people think so negatively, but how these beliefs are sustained.

• People think and act in whats that maintain these beliefs. Safety behaviors

Perceived control

People who think that they lack control over their environment appear to be at greater risk for a broad range of anxiety disorders than people who do not have that belief.
Anxiety disorders often develop after serious life events that threaten the sense of control over one’s life.
Early and recent experiences of lack of control can influence whether a person develops anxiety disorder.

Attention to threat

People with anxiety disorders have been found to pay more attention to negative cues in their environment than do people without anxiety disorders.
The heightened attention to threatening stimuli happens automatically and very quickly.

Etiology of specific anxiety disorders

Etiology of specific phobias

The dominant model of phobias is the two-factor model of behavioral conditioning.

Behavioral factors: conditioning of specific phobias

In the behavioral model, phobias are seen as a conditioned response that develops after a threatening experience and is sustained by avoidant behavior.

The risk factors probably operate as diatheses, vulnerability factors that shape whether or not a phobia will develop in the context of a conditioning experience.

Only certain kinds of stimuli and experiences will contribute to the development of a phobia.
Researchers have suggested, that during the evolution of our species, people learned to react strongly to stimuli that could be life-threatening.
Our fear circuit may have been ‘prepared’ by evolution to learn fear of certain stimuli. → prepared learning.

Etiology of social anxiety disorder

Te trait of behavioral inhibition may also be important in the development of social anxiety disorder.

Behavioral factors: conditioning of social anxiety disorder

Two-factor conditioning model.

Cognitive factors: too much focus on negative self-evaluations

• People with social anxiety disorder appear to have unrealistically negative beliefs about the consequences of their social behaviors
• They attend more to how they are doing in social situations and their own internal sensations than other people do

Etiology of panic disorder

All perspectives focus on how people respond to somatic (bodily) changes like increased heart rate

Neurological factors

Panic attack seems to reflect a misfire of the fear circuit, with a concomitant surge in activity in the sympathetic nervous system.

Locus coeruleus: the major sources of the neurotransmitter norepinephrine in the brain.
Norepinephrine plays a major role in triggering sympathetic system activity.

Behavioral factors: classical conditioning

Panic attacks are often triggered by internal bodily sensations of arousal.
Theory suggests that panic attacks are classically conditioned responses to either the situations that trigger anxiety or the internal bodily sensations of arousal.
Interoceptive conditioning: classical conditioning of panic attacks in response to bodily sensations
A person experiences somatic signs of anxiety, which are followed by the person’s fist panic attack. Panic attacks then become a conditioned response to the somatic changes.

Cognitive factors in panic disorder

Cognitive perspectives focus on catastrophic misinterpretations of somatic changes.

• Panic attacks develop when a person interprets bodily sensations as signs of impending doom.
  Such thoughts increase the persons anxiety.

Anxiety sensitivity index: measures the extent to which people respond fearfully to their bodily sensations.

Etiology of agoraphobia

The development appears to be related to genetic vulnerability and life events.

Cognitive factors: the fear-of-fear hypotheses

Agoraphobia is driven by negative thoughts about the consequences of experiencing anxiety in public.

Etiology of generalized anxiety disorder

GAD tends to co-occur with other anxiety disorders and depression.

• Deficits in the GABA system appear to be involved in GAD.

Cognitive factors: why do people worry?

Worry is reinforcing because it distracts people from more powerful negative emotions and images.
Worrying decreases psychophysiological signs of arousal.
By worrying, people with GAD may be avoiding unpleasant emotions that would be more powerful than worry. But as consequence of this avoidance, their underlying anxiety about these images does not extinguish.

Treatment of the anxiety disorders

Only a small proportion of people with anxiety disorders seek treatment.

• The chronic nature of symptoms. People may not realize that treatment could help.

Commonalities across psychological treatments

Effective psychological treatments for anxiety disorders share a common focus:

• Exposure
  The person must face what he or she deems too terrifying to face.

Although exposure is a core aspect of many cognitive behavioral treatments (CBT), these treatments differ in their strategies

• Systematic desensitization
  • Client first taught relaxation skills. Then the client uses these skills to relax while undergoing exposure to a list of feared situations developed with the therapist. Least feared first.

The effects of CBT appear to endure when follow-up assessments are conducted 6 months after treatment.
In the years after treatment though, many people experience some return of their anxiety symptoms.
A couple of key principles appear important in protecting against relapse

• Exposure should include as many features of the feared object as possible.
• Exposure should be conduced in as many different context as possible.

The behavioral view of exposure is that it works by extinguishing the fear response.
Extinction involves learning new associations to stimuli. These newly learned associations inhibit activation of the fear
Extinction involves learning, not forgetting.

A cognitive view of exposure treatment is that exposure helps people help correcting their mistaken beliefs that they are unable to cope with the stimulus.
Exposure relieves symptoms by allowing people to realize that, contrary to their beliefs, they can tolerate aversive situations without loss of control.
Cognitive approaches of treatment of anxiety disorders typically focus on:

• Challenging a person’s belief about the likelihood of negative outcomes if he or she faces an anxiety-provoking object or situation
• Challenging the expectation that he or she will be unable to cope.

Cognitive treatments typically then invoke exposure, to help people learn that they can cope with these situations.

Psychological treatments of specific anxiety disorders

Psychological treatment of phobias

Many different types of exposure treatments have been developed for phobias.
Exposure treatments often include in vivo (real-life) exposure to feared objects.
Although systematic desensitization is effective, in vivo exposure is more effective than systematic desensitization

Psychological treatment of social anxiety disorder

Exposure also appears to be an effective treatment for social anxiety disorder.
Such treatments often begin with role playing or practicing with the therapists or in small therapy groups before undergoing exposure in some public social situations.
With prolonged exposure, anxiety typically extinguishes.

Social skill training, in which a therapist might provoke extensive modeling of behavior, can help people with social anxiety disorder who may not know what to do or say in social situations.

Safety behaviors are believed to interfere with the extinction of social anxiety.
The effects of exposure treatment seem to be enhances when people with social anxiety disorder are taught to stop using safety behaviors.

Psychological treatment of panic disorder

24 sessions focused on identifying the emotions and meanings surrounding panic attacks.
Therapist help clients gain insight into areas believed to related to panic attacks.

Cognitive behavioral treatments for panic disorder focus on exposure.
Panic control therapy (PCT). Based on the tendency of people with panic disorder to overreact to the bodily sensations.
In PCT, the therapist uses exposure techniques. Then the attacks begins, the person experiences them under safe conditions. In addition, the person practices coping tactics for dealing with somatic symptoms.
With practice and encouragement from the therapist, the person learns to stop seeing internal sensations as signals of loss of control and to see them instead as intrinsically harmless sensations than can be controlled.

In another version of cognitive treatment, the therapist helps the person identify and challenge the thoughts that make the physical sensations threatening.

Psychological treatment of agoraphobia

Focus on exposure, specifically, on the systematic exposure to feared emotions.
More effective when the partner is involved.
The partner without agoraphobia is encouraged to stop catering to the partner’s avoidance of leaving home.

Psychological treatment of generalized anxiety disorder

Almost all tested treatments for GAD include cognitive or behavioral components.
The most widely used behavioral technique involves relaxation training to promote calmness.
One form of cognitive therapy includes strategies to help people tolerate uncertainty. (more helpful than relaxation alone)

Also cognitive behavioral strategies to target worry, such as:

• Asking people to worry only during scheduled times.
• Testing whether worry ‘works’ by keeping a diary of the outcomes of worrying
• Helping people focus their thoughts on the present moment instead of worrying
• Asking people to worry only during scheduled times
• Helping people address core fears that may be avoiding through worry

Medications that reduce anxiety

Sedatives, minor tranquilizes, or anxiolytics: drugs that reduce anxiety
Two types of medications are most commonly used for the treatment of anxiety disorders:

• Benzodiazepines
• Antidepressants

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Certain drugs seem to be effective for specific anxiety disorders.

Drug choice:

• Generally, antidepressants are preferred over benzodiazepines
  People may experience severe withdrawal symptoms when they try to stop using benzodiazepines. (addictive)
• Concerns about side effects

Psychological treatments are typically considered the preferred treatment of most anxiety disorders, with the possible exception of GAD.

Combining medications with psychological treatment

In general, adding anxiolytics to exposure treatment actually leads to worse long-term outcomes.

• One possible exception: social anxiety disorder

D-cycloserine (DCS): a drug that enhances learning.
Enhances effect exposure treatment.