Chapter 6
Anxiety Disorders
Outline of Chapter 6
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Fear, Anxiety, and Panic Attacks
Panic Disorder with & without Agoraphobia
Generalized Anxiety Disorder
Specific Phobia
Social Phobia
Obsessive-Compulsive Disorder
What do anxiety disorders
have in common?

People with anxiety disorders share
a preoccupation with or persistent
avoidance of thoughts and
situations that provoke fear or
anxiety.
Epidemiology of Anxiety
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Prevalence: Anxiety disorders are more
common than any other form of mental
disorders.
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Comorbidity: High comorbidity among
different anxiety disorders. High level of
comorbidity between anxiety and
depression.
Why the comorbidity?
Anxiety and depression:

both defined in terms of negative
emotional experience

both triggered by stressful experiences
Clark and Watson model
2 dimensions of experience: positive
affect and negative affect
 Both anxiety and depression have
high negative affect
 Anxiety has high positive affect
 Depression has low positive affect

High negative affect
Depression
Anxiety
Low arousal/positive affect
High arousal/positive affect
Low negative affect
Anxiety versus fear
ANXIETY
-anxious apprehension
and worry that is a more
general reaction that is
out of proportion to
threats in environment
-future oriented
-can be adaptive if not
excessive

FEAR
-Experienced when a
person is faced with
real and immediate
danger.
-Present-oriented
-Can be adaptive
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A new model of anxiety
ANXIETY
ANXIOUS
APPREHENSION
ANXIOUS
AROUSAL
Anxiety: a new model
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-
-
-
Anxious apprehension
characterized by
concern for the future
and verbal rumination
about negative
expectancies or fears
often accompanied by
muscle tension,
restlessness and
fatigue
Important variable in
GAD
Anxious arousal
-characterized by a set of
somatic symptoms
including shortness of
breath, pounding heart,
dizziness, sweating and
feelings of choking
-important variable in
panic attacks
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Panic Attack
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Panic attack: abrupt experience of
intense fear or acute discomfort ,
accompanied by physical symptoms
(e.g., heart palpitations, chest pain,
shortness of breath, dizziness).
Symptoms develop suddenly and reach
a peak within 10 minutes
Criteria for panic attack
1)
2)
3)
4)
5)
6)
Palpitations, pounding heart, or
accelerated heart rate
Sweating
Trembling and shaking
Sensations of shortness of breath or
smothering
Feeling of choking
Chest pain or discomfort
Criteria for panic attack
(contd.)
7) Nausea or abdominal distress
8) Feeling dizzy, unsteady or faint
9) Derealization (feelings of unreality) or
depersonalization (being detached from
oneself)
10) Fear of losing control or going crazy
11) Fear of dying
12) Paresthesias (numbness or tingling
sensations)
13) Chills or hot flushes
Panic Attacks
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Three types of Panic Attacks
 Situationally bound (cued): panic only when see a
spider
 Unexpected (uncued): unexpected, out of the blue
 Situationally predisposed: you are more likely to
have a panic attack where you have had one
before (crowded restaurant), but it isn’t inevitable-you don’t know if it will happen today
Agoraphobia
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a)
b)
The essential feature of agoraphobia
is anxious apprehension about being
in places or situations from which:
escape might be difficult or
embarrassing
help may not be available if one has a
panic attack.
Panic Disorder

a)
b)
c)
d)
Panic disorder is the presence of:
recurrent, unexpected panic attacks followed
by at least 1 month of persistent concern
about having another attack
worry about the possible implications of the
panic attacks
significant behavioral change related to the
attacks.
Panic disorder can be present with or
without agoraphobia.
Panic attacks: etiological
factors
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What is Catastrophic misinterpretation?
Step 1: A person misinterprets bodily
sensations such as rapid heart rate
associated with anxiety as serious
Step 2:this leads to increased awareness
of biological reactions
Step 3: misinterprets these sensations
as catastrophic events (I’m going crazy,
I’m going to die)
Panic attacks: etiological
factors
Neurochemistry:
- Another biological vulnerability to anxiety
disorders may involve neurochemicals.
-One theory suggests that several
neurotransmitter systems may be
“hyperactive” in people with panic disorder.
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A systems model for panic
attacks
Klein’s False Suffocation Alarms Model
incorporates biological and psychological
factors to explain panic attacks and
agoraphobia.
-the brain may have a suffocation monitoring
system but people prone to panic attacks are
hypersensitive and may have false alarms
-the threshold for a person’s suffocation alarm
can be influenced by biological, social and
psychological factors such as stressful life
events.
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Obsessive-Compulsive
Disorder
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Obsessions -- intrusive & nonsensical
thoughts, images, urges that one tries to
resist or eliminate
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Compulsions -- thoughts or actions
designed to suppress the thoughts &
provide relief from anxiety from obsessions
Obsessive-Compulsive
Disorder
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Typical obsessions include contamination,
aggressive impulses, sexual content, somatic
concerns, symmetry
Obsessions are often about normal concerns,
but differ in intensity level compared to people
without OCD
Onset: early adolescence to young adulthood
Course: typically chronic
Obsessive-Compulsive
Disorder
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The vast majority of people with OCD exhibit
both obsessions and compulsions
However, according to the DSM, compulsions
cannot exist without obsessions but
obsessions can exist without compulsions
Some individuals with OCD do recognize that
their obsessions and compulsions are
unreasonable
OCD: etiology
Cognition:
-Thought suppression. People who worry
excessively try to control their thoughts.
However, trying to control thoughts may
make the thought more intrusive and
increase the emotions associated with
the thoughts
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OCD: Treatment
Exposure and response prevention
Step 1: Information gathering about rituals
to enable the client to monitor them
effectively
Step 2: repeated, prolonged exposure to
situations that provoke anxiety and
instructions to refrain from ritual
behaviors
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OCD: Treatment
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Step 3:patients must keep an accurate
record of ritualistic behavior during
treatment
Step 4: homework assignments to
expose oneself to anxiety-provoking
stimuli
OCD: Treatment
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Step 5: support person must be
encouraging and remind the patient of
rationale of response prevention
Mental rituals must be prevented as
much as overt rituals, even though they
are much harder to address
Specific Phobia
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Excessive or unreasonable fear related
to a specific object/situation
Most common are snakes & heights
Some anxiety is maladaptive, high
levels are maladaptive
often have associated panic attacks
Specific Phobia
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FRED HATES SNAKES
How do we know if this is a phobia or not?
Fred would be very upset/fearful if
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he were thrown into a pit of cobras
someone put a large snake around his neck
he had to walk by a snake in a cage
he had to watch Raiders of the Lost Ark
Specific Phobia: Treatment
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Exposure therapy (in vivo) components:
1) phobic learning history – create new learning
history
2) Stimulus exposure > anxiety >relaxation >
decreased anxiety
3) Fear & Avoidance Hierarchy (FAH)
4) Subjective Units of Distress Scale (SUDS)
Generalized Anxiety Disorder
anxiety focuses on everyday events (worry +
physical symptoms)
 DSM criteria for GAD include:
--Excessive worry occurring more days than not
--person finds it difficult to control the worry
--restlessness, easy fatigue, muscle tension,
sleep disturbance
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Generalized Anxiety Disorder

a)
b)
c)
Characterized by anxious apprehension, a
state of
high negative affect and chronic
overarousal
sense of uncontrollability
focus on threat-related stimuli that may
indicate future negative events
Generalized Anxiety Disorder
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Etiology -- variety of contributing factors
 Anxiety as trait does seem to run in
families but GAD results less conclusive
 The course of GAD has also been related
to the presence or absence of life
stressors.
 There is a high level of comorbidity with
other anxiety and mood disorders.
Treatment of GAD
Targets of treatment:
 Cognitive symptoms (e.g. ,excessive
worry) have been addressed by
cognitive therapy
 Somatic symptoms (e.g., muscle
tension) have been addressed by
relaxation treatments
Treatment of GAD
Example of cognitive therapy:
Step 1: provide client with overview of
how his/her cognitions work, including:
1)
their automatic anxious thoughts
2)
situation-specific nature of anxious
predictions about the future
3)
how cognitions responsible for anxiety
are not challenged by client
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Treatment of GAD
Step 2: make client understand the nature
of inappropriate anxiety and the role of
his/her interpretation of situations that
create negative affect.
Treatment of GAD: cognitive
Step 3
Identify the specific interpretations/
negative predictions that your client is
making and challenge them. Two
types are particularly important:
a)
Probability overestimation
b)
Catastrophic thinking
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Treatment of GAD: cognitive
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a)
b)
c)
The three main facets of such an approach
are:
Considering thoughts as hypotheses rather
than facts that can be supported (or not) by
evidence
Utilizing past and present evidence to
examine the validity of the belief
Exploring and generating all possible
predictions or interpretations of an event.
Treatment of GAD: Relaxation
Step 1:
Using the 16 muscle groups, clients are
taught to discriminate and detect early
signs of muscle tension
 Step 2:
Relaxation deepening techniques are
employed including diaphragmatic
breathing
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Treatment of GAD: Relaxation
Step 3
Clients rationalize that relaxation is aimed at
alleviating the physiological components of
anxiety by interrupting the learned
association between overarousal and worry
 Step 4
Clients model relaxation in the session and then
practice it at home with tapes of the session
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Social Phobia: criteria
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Marked and persistent fear of one or more
social or performance situations in which a
person is exposed to unfamiliar people or
possible scrutiny by others
Exposed to the feared social situation
invariably provokes anxiety
The person realizes that the fear is excessive
or unreasonable
The feared situation is avoided or endured
with great distress
Social phobia
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Characterized by fear of humiliation by
either performing badly or by displaying
visible symptoms of anxiety.
More than shyness
If the fears include most social
situations, it is considered generalized
social phobia
Social Phobia: etiology
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1)
2)
3)
Cognitive biases that impact social phobia
Attentional bias: what people attend to
Memory bias: what people remember
Judgment bias: how people judge things
(e.g., how likely certain outcomes are) and
their judgments of what the costs and
benefits would be of various outcomes
Social Phobia: judgment bias
2 kinds of judgment biases in individuals
with anxiety disorders
1)
Exaggerated estimates of the
occurrence of negative events
2)
Exaggerated estimates of the cost
(valence) of negative events
•
Social phobia is more distinguished by
exaggerated cost.
Social phobia: etiology
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There is also evidence that social
phobia runs in families
Modeling of socially anxious parents
has an effect on children
In particular, overprotective and
rejecting behavior increase the odds of
developing social phobia
Treatment: Cognitive and
exposure
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Step 1: simulated exposure to feared
situations in the session
Step 2: cognitive rethinking about the
social cost of behavior
Step 3: homework assignments for in
vivo exposure that is developed in the
session and is relevant to the person’s
life
Special topic
Cross-cultural differences in
social phobia
Culture and social phobia
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Researchers have consistently found that
Asian Americans score higher on measures
of social anxiety than White Americans
This has been found in both college (e.g.,
Okazaki, 1997) and community samples (e.g.,
Ying, 1988)
In fact, Asian Americans have been found to
have the highest rates of social anxiety of any
racial group
Sue et al, 1990 study
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The students were asked to role-play a series
of 13 situations requiring assertion with either
an Asian experimenter or a White
experimenter.
The Chinese-American students were as
assertive as the White Americans on all
behavioral measures.
However, one self-report measure revealed a
significant difference between the two groups,
suggesting that Chinese Americans were
more apprehensive than White Americans in
social situations.
Why these differences?
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Hypothesis 1: a higher level of generalized
distress among Asian Americans
This could be due to political experiences that
Asian Americans face (e.g., racism) (Kuo,
1984)
Acculturative stress of being recent
immigrants, including financial difficulties
associated with moving to a new country and
finding new employment, and learning a new
language for personal and professional
communication
Why these differences?
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Hypothesis 2 :
Cultural values and norms for
functioning and distress.
Identify differences in cultural norms
and how they predict emotional distress
for Asian Americans and White
Americans.
Cultural norms about the self
The role of self-construal:
People socialized by values from Asian
societies are more likely to have an
interdependent self-construal.
 definition includes attending to others,
fitting in and harmonious
interdependence with others (Markus &
Kitayama, 1991)
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Cultural norms about the self
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Independent self-construal is valued by
mainstream American society
Includes viewing oneself as an
independent person and making one’s
own decisions for personal benefit
Okazaki study (1997)
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subjects who held less independent selfconstrual were found to be more socially
anxious
also found that Asian Americans’ high reports
of distress persisted on a measure of social
anxiety but not on depression, after taking
into account the comorbidity between social
anxiety and depression.
Results
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Social anxiety appeared to be a
particularly salient form of distress for
Asian Americans.
This would make sense given the value
placed on interpersonal sensitivity in
Asian cultures.
Cultural norms about
functioning
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Depending on cultural norms about
social anxiety, a person may feel less or
more distressed by his/her experience
of it
Cultural norms about
functioning
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Okazaki (2002) examined cultural
norms in functioning would contribute to
reports of psychological distress
Asian Americans found reports of social
anxiety less distressing
Cultural norms significantly predicted
how socially anxious they were,
compared to White Americans.
Conclusions
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raises questions about the cultural
validity of commonly used assessment
tools with different groups
Understanding cultural norms and
standards in behavior may further our
understanding of distress in different
groups.
Prevalence rates for anxiety
disorders (lifetime)
Disorder
Panic
GAD
Social phobia
OCD
All
Males
2
4
11
1.9
19
Females
5
7
16
2
31
Prevalence rates for anxiety
disorders (12 month)
Disorder
Panic
GAD
Social phobia
OCD
All
Males
1.3
2
7
1.9
12
Females
3.2
4
9
1.4
23