Chapter 6: Anxiety Disorders
Anxiety: unpleasant feeling of fear and apprehension
Anxiety disorders are diagnosed when one subjectively experienced feelings
of anxiety are clearly presented. The DSM proposes six categories: phobias,
panic disorder, generalized anxiety disorder, obsessive-compulsive disorder,
posttraumatic stress disorder, and acute stress disorder.
Comorbidity among anxiety disorders arises for two reasons (except OCD):
1. Symptoms of the various anxiety disorders are not entirely disorder
2. The etiological factors that give rise to various anxiety disorders are
probably applicable to more than one disorder.
All comorbidity could reflect the operation of common mechanisms.
The theories of anxiety disorders and to focus exclusively on a single
Anxiety disorders are the most common psychological disorders.
Women have higher prevalence rates of anxiety disorders than men.
Anxiety disorders are quite common among university students.
Social anxiety disorder was the most common anxiety disorder.
Those with an anxiety disorder were less likely to seek help from any mental
health services, relative to those with a mood disorder.
Social phobia was a powerful predictor of the subsequence first onset of
The tripartite model posits that anxiety and depression share a common
component of negative affect; however, they can be differentiated by higher
physiological hyperarousal associated with anxiety and viable positive effect
associated with depression.
Some experts have recommended paradigm shift toward a mixed categorical
– dimensional classification system for the DSM five. These experts wants to
categorize a number of disorders under one umbrella because:
o they may be treated with SSRIs and using common principles of
cognitive behavior therapy
o many symptoms for each separate disorder overlap
o each separate disorder has comorbidities in common with the other
The right amygdala is related to PTSD.
Phobia is a disrupting, fear mediated avoidance that is out of proportion to
the danger actually posed and is recognized by the sufferer as groundless.
The term phobia usually implies that the person suffers intense distress and
social or occupational impairment because of the anxiety.
Psychologists tend to focus on different aspects of phobias according to the
paradigm they have adopted.
Specific phobias are unwarranted fears caused by the presence or
anticipation of a specific object or situation. The DSM-IV – TR subdivides these phobias according to the source of the
fear: blood, injuries, and injections; situations; animals; the natural
Empirical research suggests that fears can be grouped into one of the five
2. Fear of heights or water
3. Threat fears (blood, needles, storms, thunder)
4. Fears of being observed
5. Speaking fears
These fears reflect to higher – order categories: specific fears and social fears
Specific phobias are high in prevalence. The mean onset was around 10 years
old. The mean duration was 20 years and only 8% with a specific phobia
receive treatment for their specific phobia or phobias.
The most common specific phobia subtypes in order were:
1. Animal phobias
3. Being in closed spaces
5. Being in or on water
6. Going to the dentist
7. Seeing blood or getting an injection
8. Storms, thunder, or lightning
Social phobias are persistent, irrational fears linked generally to the presence
of other people. Individuals with a social phobia try to avoid particular
situations in which they might be evaluated, fearing that they will reveal
signs of anxiousness or behave embarrassingly.
Social anxiety disorder can be either generalized or specific, depending on
the range of situations that are feared and avoided. Generalized social
phobias involve many different interpersonal situations; specific social
phobias involve intense fear of one particular situation.
People with the generalized type have an earlier age of onset, or comorbidity
with other disorders, such as depression and alcohol abuse, and more severe
The three factor model reveals the structure of feared situation on most
people with a lifetime diagnosis of social anxiety disorder:
1. Social interaction fears
2. Observation fears
3. Public speaking fears
Individuals with generalized SAD are most likely to report social interaction
and observation fears.
Social phobias have high comorbidity rate with other disorders and often
occur in conjunction with generalized anxiety disorder, specific phobias,
panic disorder, avoidant personality disorder and mood disorders. Social phobia also has high levels of comorbidity with heavy drinking and
alcohol dependence, perhaps due to self-medication with alcohol.
People diagnosed with SAD also tend to be especially vulnerable to
marijuana related problems.
Onset generally takes place during adolescence, when social awareness and
interaction with others become much more important in a person's life. The
average age of onset was 13 years and average duration of symptoms was 20
The prevalence of social phobia was higher among people who never
married or divorced, not completed secondary education, had lower income
or were unemployed, reported lacking adequate social support, reported low
quality of life and had a chronic physical condition.
Students with social phobias have lower self-esteem and a distorted body
image relative to students who were not phobic.
Prevalence increased and the gender ratio shifted to primarily females as age
increased. Social phobia was associated with educational, impairment,
depression and anxiety and parents and peer victimization.
Predictors of recovery included being employed, no lifetime depression,
fewer than three lifetime psychiatric disorders, and fewer daily hassles.
Etiology of Phobias: Behavioral Theories
Behavioral theories focus on learning the way in which phobias are acquired.
Avoidance conditioning: the main behavioral accounts of phobias are that
such reactions are learned avoidance responses. The avoidance –
conditioning formulation, which is based on the two factor theory holds that
phobias develop from two related sets of learning:
o Via classical conditioning, a person can learn to fear the neutral
stimulus if it is paired with an intrinsically painful or frightening event
o The person can learn to reduce this conditioned fear by escaping from
for avoiding neutral stimulus. The second kind of learning is assumed
to be operant conditioning; the responses maintained by its
reinforcing consequence of reducing fear
Observing another person's fear response and not having an explicit,
conscious awareness of this conditioned stimulus can still contribute to the
apparent learning of a fear response.
Fear is extinguished rather quickly when the neutral stimulus is presented a
few times without the reinforcement of moderate levels of shock.
Modeling: a person can also learn fears through imitating the reactions of
others. The learning of fear by observing others is generally referred to as
Vicarious learning may be accomplished through verbal instructions.
The anxious–rearing model is based on the premise that anxiety disorders in
children are due to constant parental warnings that increase anxiety in a
Prepared Learning: people tend to fear only certain objects and events. The
fact that certain neutral stimuli, called prepared stimuli for, are more likely than others to become classically conditioned stimuli may account for this
A Diathesis is Needed: a predisposition (cognitive diathesis)-tendency to
believe that similar dramatic experiences will occur in the future-may be
important in developing a phobia. Another possible psychological diathesis is
a history of not being able to control the environment.
Social Skills Deficits in Social Phobias
A behavioral model of social phobia considers inappropriate behavior or lack
of social skills is the cause of social anxiety.
The individual has not learned how to behave so that he or she feels
comfortable with others, or the person repeatedly commits faux pas, is
awkward and socially inept and is often criticized by social companions.
Etiology of Phobias: Cognitive Theories
Cognitive views focus on how people's thought processes can serve as a
diathesis and on how thoughts can maintain a phobia or anxiety.
Anxiety is related to being more likely to attend to negative stimuli, to
interpret ambiguous information as threatening, and to believe that negative
events are more likely than positive ones to occur in the future.
Socially anxious people are more concerned about the evaluation than are
people who are not socially anxious, are more aware of the image they
present to others, and are preoccupied with hiding imperfections and not
making mistakes in front of other people. They are less certain about their
positive self-views. Socially anxious people tend to have a cognitive bias
toward being more attentive visually to negative faces than to positive faces.
Cognitive behavioral models of social phobia of his social phobia link social
phobia with certain cognitive characteristics:
1. an attentional bias to focus on negative social information and interpret
ambiguous situations as negative
2. perfectionistic standards for accepted social performances
3. a high degree of public self-consciousness
Excessive self-consciousness and self-focus tend to increase social anxiety.
People with social phobia have a memory bias owing to a negative
interpretation bias. People with social phobia tend to falsely recall events
that interpreted as having emotionally negative features.
The fundamental core fear in social phobia is that the self is deficient. The
key situational triggers are those situations and circumstances that will
publicly reveal the self as inadequate.
Social phobia is linked with excessive self-criticism.
Researchers have begun to focus and interventions designed to boost self-
efficacy, especially in the terms of self-efficacy for changing social anxiety.
Socially anxious students also engage in extensive post-event processing
(PEP) of the negative social experiences, sometimes experiencing intrusive
thoughts and images associated typically with OCD.
Predisposing Biological Factors
Autonomic Nervous System One way people differ in their reaction to certain environmental situations is
the ease with which their autonomic nervous systems become aroused.
Individuals who are jumpy or labile are those whose autonomic systems are
readily aroused by a wide range of stimuli.
Blood-and-injection phobia is strongly familial.
Two significant problems have been identified:
o Genetic complexity: disorders likely reflect the additive or interactive
effect of multiple loci
o Phenotypic complexity: this complexity likely transcends the DSM
categories that may be useful conventions for clinicians but failed to
take into account growing evidence that genetic factors are diffuse
across various inside the disorders and they transcend these
According to Freud, phobias are a defense against the anxiety produced by
repressed id impulses. This anxiety is displaced from the feared id impulse
and moved to an object or situation that has some symbolic connection to it.
By avoiding the objects or situations that person fears, the person is able to
avoid dealing with repressed conflicts.
The phobia is the ego's way of warding off a confrontation with the real
problem, a repressed childhood conflict.
Therapies for Phobia
Systematic desensitization was the first major behavioral treatment to be
used widely in treating phobias.
Many behavior therapists, however, came to recognize the critical
importance of exposure to real life phobic situations, sometimes during the
period in which a client is being desensitized in imagination and sometimes
instead of imagery-based procedure.
Historically, clinical researchers have regarded in vivo exposure superior to
techniques using imagination, not surprising finding given that imaginary
stimuli are by definition not the real thing.
In a meta-analytic review of 33 randomized controlled trials of the treatment
of specific phobias, concluded that exposure-based treatment produced large
effect sizes relative to no treatment and outperformed both placebo
conditions and other psychotherapeutic approaches.
While most phobias do respond well two in vivo exposures, it is associated
with a high dropout rate and low treatment acceptance.
Some research comparing in vivo exposure with virtual reality (VR) exposure
treatments is found VR exposure to be just as effective as in vivo exposure
and just as effective as group CBT.
Virtual reality involves exposure to stimuli that come into form of computer-
generated graphics. Clients with blood and injection phobias are encouraged to tense rather than
relax their muscles when confronting fearsome situations.
Modeling is a technique that is also used in exposure-feared situations. In
modeling therapy, fearful clients are exposed to film or live demonstrations
of other people interacting fearlessly with phobic object.
Flooding is a therapeutic technique in which the clients are exposed to the
source of the phobia at full intensity.
Flooding is used for OCD and PTSD.
Real life exposures to the phobic object are gradually achieve and the client is
rewarded for even minimal successes in moving closer to it. Exposure is in
inevitable aspect of any operant shaping of approach behaviors.
In the initial stages of treatment, when fear and avoidance is are both very
great, the therapist concentrates on reducing the fear through relaxation
training and graded exposures to the phobic situation. As therapy progresses,
fear becomes less of an issue and avoidance more.
Cognitive treatments for specific phobias have been viewed with skepticism
because of the central defining characteristic of phobias: the phobic fears
recognized by the individual as excessive or unreasonable.
Social phobias, and the other hand, such cognitive methods – sometimes
combined with social skills training – are more promising.
In a cognitive approach, patients may be persuaded by the therapist tovmore
accurately appraise people's reactions to them, but also to rely less and
approval of others for a sense of self-worth.
CBT interventions also been used to treat other anxiety disorders and meta-
analysis support their usefulness.
CBT interventions are generally more successful than drug treatments
because they create lasting change, while the benefits of drug treatments are
less permanent and appeared to be largely palliative in nature.
All the behavioral and cognitive therapies for phobias have a recurring theme
– the need for the client to begin exposing him or herself to what has been
deemed to terrifying to face. Homework or between session learning is
considered to be an essential component of CBT.
A Cognitive-Behavioral Case Formulation
Approach behaviors. Contact with anxiety eliciting stimuli often occurs as a
consequence of the person's behavior.
Stimulus. Feared stimuli can be drawn from external objects or situations,
interoreceptive stimuli, and cognitions. Stimulis are not directly targeted by
any particular CBT intervention.
Hypervigilance to stimulus. People attend to threatening stimuli.
Interventions address hypervigilance to threat cues.
Perception of danger. The perception of threat or danger elicits anxiety.
Cognitive restructuring is the primary vehicle by which perceptions of
danger are addressed. Neuroticism. Neuroticism is a stable, pervasive personality they mentioned
that predisposes people to experience negative affective states that influence
both cognition and anxiety symptoms.
Information or experience. Stimuli can come to be appraised as threatening
through direct experience, observation, and verbal acquisition. CBT
treatments usually begin with psychoeducation – corrective information
provided to the client about anxiety and client specific disorder. Verbal
information acquired during therapy sessions is consolidated through
Increased anxiety. Excessive, unreasonable anxiety is experienced through a
constellation of emotional, physiological, cognitive, and behavioral
symptoms. Methods of managing anxiety include relaxation training and
breathing control training.
Reduced self-efficacy. Perceptions of ability to cope with anxiety provoking
stimuli and consequent symptoms have been implicated in the anxiety
Anxiety reducing behavior. The choice of anxiety reducing behavior use is
influenced by the nature of the anxiety provoking stimuli. As part of the
treatment, the person needs to refrain from the behaviors usually used to
relieve anxiety, circumventing negative reinforcement and strengthening
perception of coping ability.
Safety signals. Many anxiety reducing behaviors are aimed at obtaining a
sense of safety through degeneration of safety signals – stimuli that indicate
an aversive event outcome is less likely. During exposure the person
surrenders previously used safety signals, thereby enhancing self-efficacy
reduced anxiety and reinforcement of inciting reducing behaviors. Anxiety
reducing behavior and use of safety signals produce a decrease in anxiety
symptoms, which reinforces their use. During treatment the client inhibits
usual anxiety reducing behavior and overtime it extinguishes.
Punishment of approach behaviors. Arousal symptoms that accompany
danger perception are an aversive, punishing experience. During exposure
habituation occurs and the punishing effects of anxiety are diminished.
Drugs that reduce anxiety are referred to as sedatives, tranquilizers or
Barbiturates were the first major category of drugs to treat anxiety disorders,
but because they are highly addictive and present great risk of legal
overdose, they were supplanted in the 1950s by two other classes of drugs:
propanediols (Miltown) and benzodiazepines (Valium and Xanax).
Valium and Xanax are still used today, although they have been largely
supplanted by newer benzodiazepines, such as Ativan and Clonapam.
These drugs are of demonstrated benefit with some anxiety disorders;
however they are not used extensively with the specific phobias.
Although the risk of lethal dose is not as great as barbiturates,
benzodiazepines and can produce a severe withdrawal syndrome. Drugs originally developed to treat depression have become popular in
treating many anxiety disorders, phobias included.
One class of these drugs, the monoamine oxidase (MAO) inhibitors, fared
better in treating social phobias than benzodiazepine and in another study
was as effective as CBT at a 12-week follow-up.
MOA inhibitors such as phenelzine (Nardil), can lead to weight gain,
insomnia, sexual dysfunction, and hypertension. The selective serotonin
reuptake inhibitors, such as fluoxetine (Prozac), for also originally developed
to treat depression. They show some promise in reducing social phobia in
double blind Canadian studies, and the meta-analysis of past studies confirm
Classical psychoanalytic treatments of phobias attempted to uncover the
repressed conflicts believed to underlie the extreme fear and avoidance
characteristics of these disorders.
Panic disorder, a person suffers a sudden and often inexplicable attack of a
host of jarring and symptoms: labored breathing, heart palpitations, nausea
and chest pain; feelings of choking and smothering; dizziness, sweating, and
trembling; and intense apprehension, terror, and feelings of impending
Depersonalization, a feeling of being outside one's body and derealization, a
feeling of the world's not being a real, as well as fears of losing control, of
going crazy, or even the dying may beset and overwhelm the person.
Panic attacks may occur frequently, perhaps once a week or more often; they
usually last for minutes, fairly for hours; and are sometimes linked to specific
situations, such as driving car.
They are referred to as cued panic attacks when they are associated strongly
with situational triggers.
When their relationship with stimuli is present but not as strong, they are
referred to as situationally predisposed attacks.
Panic attacks can also occur in seemingly benign states, such as relaxation,
sleep and in unexpected situations; in these cases there referred to as uncued
Panic attacks are related to numerous psychological and physical function
variables, including poor overall functioning, suicidal ideation, psychological
distress, activity restriction, chronic physical conditions, and self rated
physical and mental health.
Agoraphobia is a cluster of fears centering on public places and being unable
to escape or find help should one become incapacitated.
People with panic disorder typically avoid the situations in which a panic
attack could be dangerous or embarrassing.
Panic disorder has been linked with a wide range of conditions, including
depression, GAD, alcohol and drug use, and personality disorders. Panic
disorders also include physical conditions such as asthma, and in people suffering from both, it is believed that the panic exacerbates the asthma and