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 selfreport, by measuring physiological arousal, and by observing
• Stress, worry, inability to relax, fear of worst happening
• Will go to a medical doctor, complain about the symptoms
• Not one single symptom that will allow you to diagnose anxiety disorder
not disordered specific
• Anxiety disorders are diagnosed when subjectively experienced feelings of
anxiety are clearly present. DSMIVTR proposed six categories: phobias, panic
disorders, generalized anxiety disorder (GAD), obsessivecompulsive disorder
(OCD), posttraumatic stress disorder (PTSD), and acute stress disorder.
• 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 childhood.
• 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 DSM5 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 cognitivebehaviour 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, fearmediated 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 situation.
• Whatever the object is will cause a disruption in their social occupational
• They hide from whatever remembers them of their phobia
• Destructs your everyday living
• They have insight into how they feel and react to these
• 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 • Specific phobias are unwarranted fears caused by the presence or anticipation of a
specific object or situation. DSMIVTR 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.
• Levels of fear change
• Even thinking about coming across your phobia will cause symptoms
• 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
• In China, for example a person with Paleng (a fear of the cold) worries that loss
of body heat may be life threatening.
• Another example is a Japanese syndrome called taijin kyofusho (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
• Won’t even leave their home
• Avoid all situations; fear everyone will look at them negatively
• 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 impairment.
• People with a lifetime diagnosis of SAD in the National Comorbidity Survey –
Replication (NCSR) and the CCHS and found strong support for a threefactor
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 selfmedication 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 avoidanceconditioning formulation, which is based
on the twofactor 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 learning.
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 avoidancelearning 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
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 anxiety.
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
Cognitivebehavioural 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 selfconsciousness.
Rechman, GruterAndrew, 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
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 computergenerated
graphics and sound to construct an experience similar to one that a client fears.
(e.g., social phobic)
• This type of exposure has been dubbed in virtuo exposure.
• Bloodandinjection phobias have, in DSMIV, 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
• Clients with bloodandinjection phobias are now encouraged to tense rater than
relax their muscles when confronting fearsome situation.
• Some CBT therapists encourage clients to roleplay 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.
• Throwing the person in their fear situation
• E.g., if someone was scared of heights, a clinician would make them sky dive
• 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 successive
• 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.
CognitiveBehavioural 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 planning.
• The following is a brief description of the flow chart components excerpted and
adapted from Boschen and Oei:
The lefttoright 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 sixsided shapes represent cognition and behaviour,
respectively. Rectangular symbols represent other components.
Approach Behaviours. Exposurebased 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 – corrective information provided to the
client about anxiety and the client’s