Chapter 6: Anxiety Disorder
Anxiety: An unpleasant feeling of fear and apprehension accompanied by
increased physiological arousal. In learning theory, it is considered a drive
that mediates between a threatening situation and avoidance behaviour.
Anxiety can be assessed by self-report, by measuring physiological arousal,
and by observing overt behaviour.
Anxiety disorders are diagnosed when subjectively experienced feelings of
anxiety are clearly present. DSM-IV-TR proposed six categories: phobias,
panic disorders, generalized anxiety disorder (GAD), obsessive-compulsive
disorder (OCD), post-traumatic stress disorder (PTSD), and acute stress
Often someone with one anxiety disorder meets the diagnostic criteria for
another disorder, as well, with the possible exception of OCD. This
comorbidity among anxiety disorders arises for two reasons:
1) Symptoms of the various anxiety disorders are not entirely disorder specific.
2) The etiological factors that give rise to various anxiety disorders are
probably applicable to more than one disorder.
As a group, the anxiety disorders are the most common psychological
disorders. These disorders have early age of onset, typically during
Anxiety disorders were more common in women than in men across all age
Social anxiety disorder (SAD) was the most common anxiety disorder with a
lifetime prevalence of 8.1%
Social phobia (but not agoraphobia and specific phobia) was a powerful
predictor of the subsequent first onset of major depression. The distress disorders would include major depression dysthymic disorders,
GAD, and PTSD; the fear disorders would include panic disorder,
agoraphobia, social phobia, and specific phobia; and the bipolar disorders
would include bipolar I, bipolar II, and cyclothymia.
Master et al. recommended a “paradigm shift” toward a mixed categorical-
dimensional classification system for DSM-5 and provided an example for an
umbrella category, 300. 23Social Anxiety Disorder, that would include social
anxiety disorder avoidant personality disorder, selective mutism, separation
anxiety disorder, and school phobia. Maser et al.’s rationale for including all
of these disorder under a single, broad category is as follows:
a. All of these disorders may be treated with SSRIs and/or using common
principles of cognitive-behaviour therapy.
b. Many symptoms for each separate disorder overlap.
c. Each separate disorder has comorbidities in common with the other.
The right amygdala is implicated in PTSD
Phobias 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 suffix phobia is preceded by a Greek word for the feared object or
Some of the more familiar terms are claustrophobia, fear of closed spaces
Fear of public spaces: agoraphobia
Fear of heights: acrophobia
Fear of working: ergasiophobia
Fear of chocking: pnigophobia
Fear of being buried alive: taphephobia
Fear of contamination and dirt that plagues many people: mysophobia
Psychoanalysts focus on the content of the phobia and see the phobic object
as a symbol of an important unconscious fear. Thus, psychoanalysts believe
that the content of phobias has important symbolic value.
Specific phobias are unwarranted fears caused by the presence or
anticipation of a specific object or situation. DSM-IV-TR subdivides these
phobias according to the source of the fear: blood, injuries, and injections;
situations; animals; and the natural environment. Empirical research
suggests that fear can be grouped into one of five factors: (1) agoraphobia;
(2) fears of heights or water; (3) threat fears; (4) fears of being observed, and
(5) speaking fears. These fears reflect two higher-order categories: specific
fears and social fears. Specific phobias are high in prevalence.
The most common specific phobia subtypes in order were: (1) animal
phobia; (2) heights; (3)being in closed spaces; (4) flying; (5) being in or on
water; (6) going to the dentist; (7) seeing blood or getting an injection; and
(8) storms, thunder, or lightening.
In China, for example a person with Pa-leng (a fear of the cold) worries that
loss of body heat may be life threatening.
Another example is a Japanese syndrome called taijin kyofu-sho (TKS), fear
of other people. This is not a social phobia; rather, it is an extreme fear of
embarrassing others – for example, by blushing in their presence, glancing at
their genital areas, or making odd faces.
Social phobias are persistent, irrational fears linked generally to the presence
of other people.
SAD can be either generalized or specific, depending on the range of
situations that are feared and avoided. While generalized social phobia
involve many different interpersonal situations, specific social phobias
involve intense fear of one particular situation (e.g. public speaking). People
with the generalized type have an earlier age of onset, more comorbidity
with other disorders, such as depression and alcohol abuse, and more severe
People with a lifetime diagnosis of SAD in the National Comorbidity Survey –
Replication (NCS-R) and the CCHS and found strong support for a three-
factor model composed of (1) social interaction fears, (2) observation fears,
and (3) public speaking fears.
Social phobias have a high comorbidity rate with other disorders and often
occur in conjunction with GAD, specific phobias, panic disorders, 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 seem also to be
especially vulnerable to marijuana related problems.
Behavioural Theories: Behavioural theories focus on learning as the way in which
phobias are acquired.
Avoidance Conditioning: The main behavioural account of phobias is that such
reactions are learned avoidance responses. The avoidance-conditioning
formulation, which is based on the two-factor theory originally proposed by
Mowrer, holds that phobias develop from two related sets of learning:
1. Via classical conditioning, a person can learn to fear a neutral stimulus (the
CS) if it is paired with an intrinsically painful or frightening event (the UCS)
2. The person can learn to reduce this conditioned fear by escaping from or
avoiding the CS. This second kind of learning is assumed to be operant
conditioning; the response is maintained by its reinforcing consequences of
reducing fear. Modelling: 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
- The anxious- rearing model is based on the premise that anxiety disorders in
children are due to constant parental warning.
Prepared Learning: Another issue that the original avoidance-learning model fails to
address is that people tend to fear only certain objects and event, such as spiders,
snakes, and heights, but no others, such as lambs. The fact that certain neutral
stimuli, called prepared stimuli, are more likely than others to become classically
conditioned stimuli may account for this tendency.
Diathesis in Needed: A cognitive diathesis (predisposition)- a tendency to believe
that similar traumatic experiences will occur in the future – may be important in
developing a phobia.
Social Skills Deficits in Social Phobias: A behavioural model of social phobia
considers inappropriate behaviour or a lack of social skill as the cause of social
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 evens are more likely than
positive ones to occur in the future.
- Socially anxious people are more concerned about 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.
- Cognitive-behavioural models of social phobia link social phobia with certain
cognitive characteristics: (1) an attentional bias to focus on negative social
information, (2) perfectionistic standards for accepted social performances;
(3) a high degree of public self-consciousness.
- Rechman, Gruter-Andrew, and Shafran reported that socially anxious student
not only anticipate negative social experience, they also engage in extensive
post-event processing (PEP) of the negative social experience.
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. Lacey identified a dimension of autonomic activity that he called
stability-lability. Labile, or jumpy, individuals are those whose autonomic systems
are readily aroused by a wide range of stimuli.
- Autonomic lability: Tendency for the autonomic nervous system to be easily
aroused. Genetic Factors: Smoller et al. also identified two significant problems: (1) genetic
complexity, and (2) phenotypic complexity. Genetic complexity poses a problem
because disorders likely reflect the additive or interactive effects of multiple loci.
Phenotypic complexity is a problem because this complexity likely transcends the
DSM categories that may be useful conventions for clinicians but fail to take into
account growing evidence that genetic factors are diffuse across various anxiety
disorders and they transcend these diagnosis categories.
Psychoanalytic Theories: According to Freud, phobias are a defence against the
anxiety produced by repressed id impulses. The phobia is the ego’s way of warding
off a confrontation with the real problem, a repressed childhood conflict.
Therapies For Phobias
Systematic desensitization was the first major behavioural treatment to be
used widely in treating phobias. The individual with a phobia imagines a
series of increasingly frightening scenes while in a state of deep relaxation.
In vivo exposure: An exercise at home that requires the phobic person to be
exposed to the highly feared stimulus or situation.
Virtual reality (VR) exposure: A treatment for phobias using computer-
generated graphics and sound to construct an experience similar to one that
a client fears.
This type of exposure has been dubbed in virtuo exposure.
Blood-and-injection phobias have, in DSM-IV, been distinguished from other
kinds of serve fears and avoidances because of the distinctive reactions that
people with these phobias have to the usual behavioural approach of
relaxation paired with exposure.
By trying to relax, clients with these phobias may well contribute to the
tendency to faint, increasing their already high levels of fear and avoidance,
as well as their embarrassment.
Clients with blood-and-injection phobias are now encouraged to tense rater
than relax their muscles when confronting fearsome situation.
Some CBT therapists encourage clients to role-play interpersonal encounters
in the consulting room or in therapy groups and several studies attest to the
long-term effectiveness of this approach.
Modelling is another technique that uses exposure to feared situations. In
modelling therapy, fearful clients are exposed to filmed or live
demonstrations of other people interacting fearlessly with the phobic object.
Flooding is a therapeutic technique in which the client is exposed to the
source of the phobia at full intensity. The extreme discomfort that is
inevitable discourages therapists from using this technique, except perhaps
as a last resort when graduated exposure has not worked. Therapists who favour operant techniques ignore the fear assumed to
underlie phobias and attend instead to the overt avoidance of phobic objects
and to the approach behaviour that must replace it. They treat approach to
the feared situation as any other operant and shape it via the principles of
Many CBT therapists attend both to fear ad to avoidance, using exposure
technique to reduce fear and operant shaping to encourage approach.
A person with a phobia has often settled into an existence in which other
people cater to his or her incapacities, in a way reinforcing the person’s
phobia (psychoanalysts call this phenomenon secondary gain)
Homework or between session learning is considered to be an essential
component of CBT.
Cognitive-Behavioural Case Formulation Framework
Boschen and Oei presented a cognitive behavioural case formulation
framework (CBCFF) for anxiety disorders. In this framework, casual and
maintaining factors are outlined in a single but simple visual framework.
They argue that the elements that are common to the anxiety disorders allow
the framework to be used in a case formulation development and treatment
The following is a brief description of the flow chart components excerpted
and adapted from Boschen and Oei:
- The left-to-right chain describes a situation where an anxious person comes
into contact with a perceived danger situation and then acts in such a way to
reduce the ensuing anxiety.
- Other cognitive variables also impact on this basic chain.
- Thought bubbles and six-sided shapes represent cognition and behaviour,
respectively. Rectangular symbols represent other components.
- Approach Behaviours. Exposure-based interventions require an increase in
the frequency of approach behaviour.
- Stimulus. Feared stimuli can be drawn from external objects or situations,
interceptive stimuli, and cognitions.
- Hypervigilance to stimulus. People attend to threatening stimuli.
- 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 dimension that
predisposes people to experience negative affective states and 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