ANXIETY DISORDERS - 1
I. Anxiety and its Causes
A. Anxiety, fear, and panic
1. Anxiety - mood state characterized by tension,
apprehension of future danger or misfortune. In humans,
anxiety may be expressed as subjective unease, worried
behaviors, and/or physiological responses.
a. Normal emotion that is adaptive when experienced in
moderate amounts. Helps performance.
b. Becomes problematic (psychologically speaking) when
excessive and interferences with functioning.
2. Fear - immediate alarm reaction to dangerous or life
threatening situations (fight or flight response; emergency or
defensive reaction). A present-oriented mood state
characterized by strong avoidance and activation of SNS.
a. Normal emotional response that is adaptive when
experienced in response to real danger or threat.
b. Becomes problematic (psychologically speaking) when it
excessive, in the absence of real threat or danger, and
interferes with important areas of life functioning.
c. Textbook case of Gretchen illustrates excessive fear in
the absence of real threat or danger.
3. Panic attack - abrupt experience of intense fear or
discomfort accompanied by physical symptoms such as
heart palpitations, chest pain, shortness of breath, and
Three types of panic attacks are described in the DSM-IV:
a. Situationally bound (cued) panic attack is one that
is expected in a given situation and is bound to some
situations and not others. This type of panic attack is
common in persons suffering from specific phobias and
b. Unexpected (uncued) panic attack is completely
unanticipated in nature, and often occurs without
warning. This form of panic attack is common in persons
suffering from panic disorder.
c. Situationally predisposed panic attack falls between
situationally bound and unexpected panic, and is
characterized by panic that may be more likely in a
certain setting, but not inevitable. This form of panic
attack is also common in persons suffering from panic
disorder. ANXIETY DISORDERS - 2
B. Causes of anxiety
1. Biological contributions - people inherit the tendency to be
anxious or highly emotional. Seems to run in families. Anxiety
is associated with specific brain circuits and neurotransmitter
2. Psychological contributions - anxiety results from classical
conditioning or modeling. Some studies suggest that a sense
of not being able to control things in the environment
predisposes a child to anxiety later in life.
3. Social contributions - stressful life events as triggers for
biological and psychological vulnerabilities for anxiety and
panic. Interpersonal stressors (e.g., marriage, divorce, work
problems, death of a loved one, including social pressures
related to school, peers).
4. Integrated model - etiological risk factors considers the
complex interaction among biological, psychological,
experiential, and social variables. One may be born with a
biological vulnerability to be anxious, [but this vulnerability
then interacts with socialized beliefs that the world is
dangerous and that events are uncontrollable]. Such factors,
coupled with experience of life stressors and learning
experiences, may then activate the diathesis for anxiety and
begin a positive spiral that may lead to an anxiety disorder.
C. Anxiety disorders often co-occur, and rates of comorbidity among
anxiety disorders are high (e.g., a recent study showed that 55% of
patients who received a principal diagnosis of an anxiety or depressive
disorder had at least one additional anxiety or depressive disorder at
the time of assessment).
1. PTSD and GAD have the highest comorbidity rates.
2. Major depression is often the most common secondary
diagnosis in persons suffering from anxiety disorders. This fact
emphasizes that anxiety disorders (and depression) share
common features, including similar vulnerabilities. Anxiety
disorders differ with respect to their foci and pattern. ANXIETY DISORDERS - 3
II. Generalized Anxiety Disorder
A. Generalized anxiety disorder (GAD) is often considered the "basic"
anxiety disorder because it is characterized by intense, unfocused
anxiety. Persons with GAD typically worry about minor daily life
events, whereas children with GAD worry about academic, athletic, or
social competence and physical injury. The elderly tend to focus on
health and often report difficulty sleeping. The textbook illustrates the
features of GAD with the case of Irene.
1. The DSM-IV criteria specify that excessive anxiety and worry
(apprehensive expectation) must be ongoing more days than
not for a period of a least 6 months. It must also be difficult to
turn off or control the worry process; a feature that
distinguishes pathological worry from normal worry.
2. The physical symptoms of GAD differ from panic, and include
muscle tension, mental agitation, susceptibility to fatigue,
irritability, and difficulty sleeping. Focusing attention is often
B. Approximately 4% of the general population meet criteria for GAD
(during a given 6-month period).
Quite common in the elderly (perhaps as high as 7%).
Few seek treatment compared to those with panic disorder.
Male to female ratio for GAD is about 1:2.
Onset is usually in early adulthood, usually in response to some life
stressor, often more gradual than with other anxiety disorders.
C. GAD may be caused by several factors, including a genetic contribution
as indicated by twin studies. Probably what is inherited is a tendency
to be anxious, not GAD itself.
D. Individuals with GAD are less physiologically responsive than persons
with anxiety disorders where panic is prominent. Muscle tension is the
only autonomic measure that consistently distinguishes persons with
GAD from other nonanxious persons. It is believed that autonomic
restriction is the result of automatic bias for threat (highly
sensitive to threat—allocate attention more readily than nonanxious
do), coupled with a limited processing of the associated imagery
(intense EEG activity in the left frontal lobe) and the emotional
components of that imagery that would normally elicit strong
autonomic responses. Perhaps worrying helps them avoid the fear
reaction, but also means they never resolve the problem. ANXIETY DISORDERS - 4
E. Treatment of GAD are relatively weak and not well developed.
Benzodiazepine drug treatment, although most studies don’t go
beyond 8 weeks. Even if for 6 months, relatively modest
improvement. Impair cognitive and motor functioning (less alert).
Falls for the elderly. (See handout.) Perhaps anti-depressants may be
Psychological treatments focus on the worry process and avoidance
of feelings of anxiety and negative affect and seem to work about as
well as drugs, perhaps better in the long run (1-year follow-up).
Exposure to worrisome thoughts and anxious images is utilized with
coping skills training. CBT.
III. Panic Disorder
A. To meet criteria for panic disorder, a person must experience an
unexpected panic attack and develop anxiety about the possibility of
another attack or the implications of the attack. Agoraphobia is fear
and avoidance of "unsafe" situations where a panic attack may occur.
Persons with panic disorder with agoraphobia (PDA) experience
severe unexpected panic attacks during which time they feel a loss of
control or endangered. Persons may also experience panic disorder
without agoraphobia. (The textbook illustrates panic disorder with
extreme agoraphobia in the case of Mrs. M.)
B. Many persons with panic disorder develop agoraphobia (i.e., fear of
the marketplace). Agoraphobic avoidance appears to be one
complication of severe unexpected panic attacks. Agoraphobic
behavior can become independent of panic attacks (according to fear
of the attack, rather than actual number or intensity). According to the
DSM-IV, agoraphobia may be characterized either by avoiding
situations or enduring them with marked distress. Some forms of
agoraphobia involve interoceptive avoidance, particularly of
activities that may increase physical symptoms of arousal. (See page
C. Lifetime prevalence of 3.5% in the general population.
Two-thirds are women.
Mean age of onset between 25 - 29.
Most initial unexpected panic attacks begin after puberty.
Panic disorder is generally less pervasive among the elderly; though
agoraphobia is quite common. ANXIETY DISORDERS - 5
D. Panic disorder exists worldwide, though how it is expressed varies
widely across cultures (sometimes focusing more on somatic
symptoms than cognitive, sometimes w/shouting and crying). Rates of
PD are similar across different ethnic groups in the US.
E. Approximately 60% of people with panic disorder experience
nocturnal panic attacks (i.e., panic during sleep). Nocturnal panic
occurs most often between 1:30 am and 3:30 am than at any other
time, and such attacks have been shown to occur during delta wave
sleep (the deepest stage of sleep, but not dream sleep).
F. The causes of panic disorder are numerous, and include an
interaction of psychological, biological, and social-experiential
influences. The textbook suggests that a biologically inherited
vulnerability to be overreactive to daily events, coupled with stress,
may establish a predisposition to associate the response with internal
and external cues (i.e., moving from a false to a learned alarm
response). Such factors, coupled with a psychological vulnerability to
catastrophically misinterpret such events and the development of
anxiety over the possibility of future panic attacks may, in turn, lead to
panic disorder. (8-12% of people experience a panic attack, usually
under intense stress; only 3% develop panic disorder.) ANXIETY DISORDERS - 1
G. Treatment of Panic Disorders
1. Medications for anxiety and panic largely affect the
serotonergic, noradrenergic, and benzodiazepine GABA
neurotransmitter systems, such as imipramine (tricyclic
antidepressant), tend to block panic attacks. SSRIs (Selective
Serotonin Reuptake Inhibitors e.g., Prozac and Paxil) are currently
the preferred drug for panic disorder; though sexual
dysfunction is a common side effect. Relapse rates for panic are
high once the medication is discontinued.
2. Psychological interventions, and particularly cognitive-
behavior therapies, are quite effective for panic disorder, with
as many as 80% to 100% of patients free of panic after about
12 weekly sessions. Treatment typically involves gradual
exposure exercises combined with anxiety-reducing coping
skills, such as relaxation and breathing retraining. As many as
70% of patients undergoing these treatments substantially
improve, but very few are cured. Panic Control Treatment
(PCT) is a cognitive-behavioral treatment that arranges for
mini-exposures to panic sensations in therapy, and includes
cognitive therapy to address attitudes and misperceptions
about the feared sensations and situational triggers and
relaxation and breathing retraining.
3. Evidence from combined treatments (i.e., medications plus
cognitive-behavior therapy) suggest that combined treatment
was no better than individual treatments in the short term,
however in the long term persons receiving CBT alone
maintained most of their treatment gains, whereas those taking
medication alone or in combination with CBT deteriorated
somewhat. This result led to the recommendation that
psychological treatment should be offered initially, followed by
drug treatment for those patients who do not respond
adequately or for whom psychological treatment is not
4. Nutritional Treatment – nutrients play a role. Blood sugar,
magnesium, etc. ANXIETY DISORDERS - 2
A. Specific phobia
1. A specific phobia is an extreme and irrational fear of a specific
object or situation that markedly interferes with one's ability to
function. Most persons with specific phobias recognize that their
fears are unreasonable. Many go to great lengths to avoid the
objects of their fear. There are as many phobias as there are
objects and situations. The four major subtypes of specific
phobia are as follows:
a. Persons suffering from blood-injury-injection phobia
differ from all the other phobias in that they experience
drops in heart rate and blood pressure and increased
urges to faint. This vasovagal reaction occurs in
response to blood, injury, or the possibility of an
injection and has a strong genetic component. The
phobia develops over t