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Chapter 5
Anxiety Disorders
Abnormal Psychology, 11th Edition
by
Ann M. Kring, Gerald C. Davison, John M. Neale,
& Sheri L. Johnson
Anxiety vs. Fear

Anxiety
» Apprehension about a future threat

Fear
» Response to an immediate threat

Both involve physiological arousal
» Sympathetic nervous system

Both can be adaptive
» Fear triggers “flight or fight”
– May save life
» Anxiety increases preparedness
– Moderate levels improve performance
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Anxiety Disorders

DSM-IV-TR
» Specific and social phobias
» Panic disorder and agoraphobia
» Generalized anxiety disorder
» Obsessive compulsive disorder
» Posttraumatic stress disorder
Most common psychiatric disorders
 28% report anxiety symptoms (Kessler et al., 2005)
 Most common are phobias

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Table 5.1 Summary of Major
Anxiety Disorders
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Phobias

Disruptive fear of a particular object or
situation
» Fear out of proportion to actual threat
» Awareness that fear is excessive
» Must be severe enough to cause distress or
interfere with job or social life
– Avoidance

Two types:
» Specific
» Social
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Specific Phobia

Unwarranted, excessive fear of specific
object or situation
» Snakes, blood, flying, spiders, etc.
– How likely are you to be bitten by a spider?
» Most specific phobias cluster around a few
feared objects and situations (Table 5.3)


Trigger or feared object is avoided or
endured with intense anxiety
High comorbidity of specific phobias
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Table 5.2 Words Used to Describe Highly Unlikely Phobias
Fear
Phobia
Anything new
Neophobia
Asymmetrical things
Asymmetriphobia
Books
Bibliophobia
Children
Pedophobia
Dancing
Chorophobia
Englishness
Anglophobia
Garlic
Alliumphobia
Peanut butter sticking to the roof of the mouth
Arachibutyrophobia
Technology
Technophobia
Mice
Musophobia
Pseudoscientific terms
Hellenophobia
Source: Drawn from www.phobialist.com.
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Table 5.3 Types of Specific Phobias
Type of Phobia
Source of Fear
Associated Characteristics
Animal
Animals (e.g., snakes, insects)
Generally begins during childhood
Natural environment
Aspects of the natural environment
Generally begins during childhood
(e.g., storms, heights, water)
Blood, injection, injury
Blood, injury, injections, or other
Clearly runs in families
invasive medical procedures
Situational
Specific situations (e.g., public
Tends to begin either in childhood or in
transportation, tunnels, bridges,
mid-20s.
elevators, flying, driving, closed spaces)
Other
Fear of choking, fear of contracting an
—
illness, etc.; children’s fears of loud
sounds, clowns, etc.
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Social Phobia

Persistent, intense fear of social situations
» Fear of negative evaluation or scrutiny

More intense and extensive than shyness
» More appropriate diagnostic label?
– Social anxiety disorder

» Exposure to trigger leads to anxiety about
being humiliated or embarrassed socially.
» Onset often adolescence
» Diagnosed as either generalized or specific
33% also diagnosed with Avoidant Personality
Disorder
» Overlap in genetic vulnerability for both disorders
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Figure 5.1 Spectrum Model of Social Phobia and
Avoidant Personality Disorder
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Panic Disorder


Frequent panic attacks unrelated to specific
situations
Panic attack
» Sudden, intense episode of apprehension, terror,
feelings of impending doom
– Symptoms reach peak intensity within 10 minutes
» Accompanied by at least 4 other symptoms:
– Sweating, nausea, labored breathing, dizziness, heart
palpitations, upset stomach, lightheadedness, etc.
» Other symptoms may include:
– Depersonalization
– Derealization
– Fear of going crazy, losing control, or dying
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Panic Disorder

Uncued attacks
» Occur unexpectedly without warning
» Panic disorder diagnosis requires recurrent uncued
attacks.

Cued attacks
– Triggered by specific situations (e.g., tunnel)
– More likely a phobia

Panic Disorder with Agoraphobia
» Avoidance of situations in which escape would be
difficult or embarrassing
» Panic disorder with agoraphobia tends to be more
chronic .
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Panic Disorder
Often begins in adolescence
 25% unemployed for more than 5 years
because of symptoms (Leon et al., 1995)
 Prognosis worse when agoraphobia is
present

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Generalized Anxiety
Disorder (GAD)

Involves chronic, excessive, uncontrollable
worry
» Lasts at least 6 months
» Interferes with daily life

Other symptoms:
» Restlessness, poor concentration, irritability,
muscle tension, tires easily, sleep disturbance

Common worries:
» Relationships, health, finances, daily hassles

Often begins in adolescence or earlier
» I’ve always been this way
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Obsessive-Compulsive Disorder
(OCD)

Obsessions
» Intrusive, persistent, and uncontrollable thoughts or
urges
» Experienced as irrational
» Most common:
– Contamination, sexual & aggressive impulses, body
problems

Compulsions
» Impulse to repeat certain behaviors or mental acts to
avoid distress
– e.g., cleaning, checking, hoarding, repeating a word,
counting
» Extremely difficult to resist the impulse
» May involve elaborate behavioral rituals
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Obsessive-Compulsive Disorder
(OCD)


Develops either before age 10 or during late
adolescence/early adulthood
Men
» Early onset more common

Women
» Cleaning compulsions and later onset more
common

OCD often chronic
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Post Traumatic Stress Disorder
(PTSD)

Extreme response to severe stressor
» Anxiety, avoidance of stimuli associated with trauma,
emotional numbing

Exposure to a traumatic event that involves actual
or threatened death or injury
» e.g., war, rape, natural disaster



Trauma leads to intense fear or helplessness
Symptoms present for more than a month
Women and PTSD
» Rape most common type of trauma (Creamer et al.,
2001)
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Post Traumatic Stress Disorder
(PTSD)

Three categories of symptoms :
1.
Re-experiencing the traumatic event
»
2.
Nightmares, intrusive thoughts, or images
Avoidance of stimuli
»
»
e.g., Refuse to walk on street where rape occurred
Numbing
»
»
»
3.
Increased arousal
»

Decreased interest in others
Distant or estranged from others
Unable to experience positive emotions
Insomnia, irritability, hypervigilance, exaggerated startle
response
Tends to be chronic (Perkonigg et al., 2005)
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Acute Stress Disorder (ASD)


Symptoms similar to PTSD
Duration varies
» Short term reaction
» Symptoms occur between 2 days and 1 month
after trauma


As many as 90% of rape victims experience
ASD (Rothbaum et al., 1992)
More than 2/3 of those with ASD develop
PTSD within 2 years (Harvey & Bryant, 2002)
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Comorbidity

¾ of those with anxiety disorder meet
criteria for another disorder
» 60% meet criteria for major depression (Brown et
al., 2001)
» Other disorders commonly comorbid with
anxiety:
– Substance abuse
– Personality disorders



Avoidant
Dependent
Histrionic
– Medical disorders e.g., coronary heart disease
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Table 5.4 12-month Prevalence of Anxiety
Disorders in Germany
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Gender &
Sociocultural Factors

Women are 2x as likely as men to have anxiety
disorder except for OCD

Possible explanations
» Women may be more likely to report symptoms
» Women more likely to experience childhood sexual abuse
» Women show more biological stress reactivity

Sociocultural factors
» Focus of anxiety varies
– Taijin kyofusho

Japanese fear of offending or embarrassing others
– Kayak-angst

Inuit disorder in seal hunters at sea similar to panic
» Ratio of somatic to psychological symptoms
appears similar across cultures (Kirmayer, 2001)
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Table 5.5 Factors that May Increase the Risk for
More than One Anxiety Disorder







Genetic vulnerability
Increased activity in the fear circuit of the brain
Decreased functioning of GABA and serotonin;
increased norepinephrine activity
Negative Life Events
Behavioral inhibition
Neuroticism
Cognitive factors, including attention to cues of
threat and low perception of control
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Risk Factors

Genetic
» Twin studies suggest heritability
– About 20-40% for phobias, GAD,
and PTSD
– About 50% for panic disorder
» Relative w/phobia increases risk
for other anxiety disorders in
addition to phobia

Neurobiological
» Fear circuit overactivity
– Amygdala
– Medial prefrontal cortex deficits
» Neurotransmitters
– Serotonin, GABA, Norepinephrine
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Risk Factors: Social

Negative life events
» Job loss, end of relationship, etc.
» Severe stressors often precede onset
(Kendler et al., 2003)
– 80% with panic disorder (Barlow, 2004)
– 70% with any anxiety disorder (Finlay-Jones, 1989)
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Risk Factors: Personality

Behavioral inhibition
» Tendency to be agitated, distressed, and cry in
unfamilar or novel settings
– Observed in infants as young as 4 months
– May be inherited
» Predicts anxiety in childhood and social anxiety in
adolescence

Neuroticism
» React with negative affect
» Linked to anxiety and depression (deGraaf et a., 2002)
» Psychophysiological reactivity in firefighters predicted
development of PTSD (Guthrie & Bryant, 2005)
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Risk Factors: Cognitive

Belief that one lacks control over environment
» More vulnerable to developing anxiety disorder
– Childhood trauma or punitive parenting may foster beliefs
– Amount of control during trauma may influence whether
anxiety disorder will develop (Mineka & Zinbarg, 2007)

Attention to threat
» Tendency to notice negative environmental cues
– Selective attention to signs of threat
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Etiology of Specific Phobias


Conditioning
Mowrer’s two-factor
model
» Pairing of stimulus with
aversive UCS leads to
fear (Classical
Conditioning)
» Avoidance maintained
though negative
reinforcement (Operant
Conditioning)
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Etiology of Specific Phobias

Problems with two-factor model
» Many people never experience aversive
interaction with phobic object (see table 5.6)
» People with phobias tend to fear only
certain types of objects (prepared learning)
– Snakes, insects, blood, heights, etc.
» Even phobias linked to modeling influenced
by prepared learning
– Monkeys acquired fear after watching another
monkey exhibit fear to snake but not flower
(Cook & Mineka, 1989)
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Table 5.6 Percent of People Reporting
Conditioning Experiences Before the Onset of a
Phobia
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Etiology of Social Phobia

Two factor model
» Avoidance or safety behaviors
– Avoid eye contact, appear aloof, stand apart from others
in social settings

Cognitive factors
» Negative self evaluation
– Harsh, punitive self-judgment
» Fear of negative evaluation by others
– Expect others to dislike them

Excessive attention to internal cues
» e.g., heart rate
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Etiology of Panic

Neurobiological
factors
» Locus ceruleus
– Major source of
norepinephrine

A trigger for nervous
system activity
» Multiple drugs can
induce panic attacks
– Typically only in those
who are overly
concerned about bodily
changes
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Etiology of Panic

Interoceptive
conditioning
» Classical conditioning
of panic in response to
bodily sensations

People with panic
disorder sustain
classically conditioned
fears longer (Michael et
al., 2007)
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Etiology of Panic

Cognitive factors
» Lack of perceived
control can trigger panic
» Fear of bodily changes
– Interpreted as impending
doom

I must be having a
heart attack!
– Beliefs increase anxiety
and arousal
– Creates vicious cycle
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Table 5.7 Sample Items from
Anxiety Sensitivity Index
Table 5.7 Sample Items from the Anxiety Sensitivity Index
Unusual body sensations scare me.
When I notice that my heart is beating rapidly, I worry that I might have a heart
attack.
It scares me when I feel faint.
It scares me when I feel “shaky” (trembling).
Source: Peterson & Reiss, 1987. Note: People respond to each item on a 0 (very little) to 4 (very
much) scale.
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Etiology of Agoraphobia

Fear-of-fear hypothesis (Goldstein &
Chambless, 1978)
» Expectations about the catastrophic
consequences of having a public panic
attack.
– What will people think of me?!?!
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Etiology of GAD


GABA system deficits
Borkovec’s cognitive model:
» Worry reinforcing because it distracts from
negative emotions and images
» Allows avoidance of more disturbing emotions
– e.g., distress of previous trauma
» Avoidance prevents extinction of underlying
anxiety
» Individuals with GAD less able to identify their
own negative feelings (Mennin et al., 2002)
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Etiology of OCD: Neurobiological
Factors

OCD symptoms common in certain
neurological disorders
» Huntington’s chorea

Hyperactive regions of the brain:
» Orbitofrontal cortex
» Caudate nucleus
» Anterior cingulate
– Loss of neuronal function and underlying
biochemical abnormality (Yücel et al., 2007)
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Etiology of OCD:
Behavioral & Cognitive Factors

Operant reinforcement
» Compulsions negatively reinforced by the reduction
of anxiety

Cognitive factors
» Lack of a satiety signal
» Yadasentience
– Subjective feeling of completion

Knowing that you have thought enough or cleaned enough
– Individuals with OCD have a yadasentience deficit
» Attempts to suppress intrusive thoughts
– Trying to suppress thoughts may make matters worse
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Etiology of PTSD


Severity and type of trauma
Neurobiological
» Smaller hippocampal volume linked to PTSD
– Disruption of verbal vs. nonverbal memory
» Supersensitivity to cortisol

Behavioral
» Two factor model

Psychological
» Perception of control
» Avoidance coping, dissociation, memory suppression

Intelligence and ability to grow from the
experience enhance coping
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Common Aspects of
Psychological Treatment

Psychological treatments emphasize
Exposure
» Face the situation or object that triggers
anxiety
– Should include as many features of the trigger
as possible
– Should be conducted in as many settings as
possible

Systematic desensitization
» Relaxation plus imaginal exposure
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Common Aspects of
Psychological Treatment

Cognitive approaches
» Increase belief in ability to cope with the
anxiety trigger
» Challenge expectations about negative
outcomes
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Psychological Treatment of
Phobias

Exposure
» In vivo exposure more effective than systematic
desensitization
– Virtual reality as effective as in vivo

Social phobia
» Exposure
– Role playing or small group interaction
» Social skills training
– Reduce use of safety behaviors

Cognitive therapy
» Enhances treatment for social but not specific phobias
» Clark’s (2003) cognitive therapy more effective than
medication or exposure.
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Psychological Treatment of Panic
and Agoraphobia

Panic Control Therapy (PCT; Craske &
Barlow, 2001)
» Exposure to somatic sensations associated
with panic attack in a safe setting
– Increased heart rate, rapid breathing, dizziness
» Use of coping strategies to control symptoms
– Relaxation
– Deep breathing
» PCT benefits maintained after treatment ends.
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Psychological Treatment of Panic
and Agoraphobia

Cognitive Behavioral Therapy (CBT)
» Increase patient’s awareness of thoughts
that make physical sensations threatening
» Patient learns to challenge and change
maladaptive beliefs

CBT also effective for agoraphobia
» Treatment enhanced when spouse or
significant other stops catering to partner’s
avoidance.
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Psychological Treatment of
GAD


Relaxation training
Cognitive Behavioral methods
»
»
»
»
Challenge and modify negative thoughts
Increase ability to tolerate uncertainty
Worry only during “scheduled” times
Focus on present moment
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Psychological Treatment of
OCD

Exposure plus ritual prevention
» Most widely used treatment

Cognitive therapy
» Challenge beliefs about anticipated consequences
of not engaging in compulsions
– Usually also involves exposure
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Psychological Treatment of
PTSD

Exposure to memories and reminders of the
original trauma
» Either direct (in vivo) or imaginal
» Treatment may initially increase symptoms
» More effective than medication or supportive therapy

Cognitive therapy
» Enhance beliefs about coping abilities
» Adding CT to exposure does not improve treatment
response

Treatment of ASD may prevent PTSD
» Shows benefits even 5 years after the traumatic event
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Medications

Anxiolytics
» Drugs that reduce anxiety

Two common types of medications used to treat
anxiety
» Benzodiazepenes
– Valium, Xanax
» Antidepressants
– Tricyclics,Selective Serotonin Reuptake Inhibitors (SSRIs), and
Serotonin Reuptake Inhibitors (SRIs)
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Medications

Demonstrated effectiveness as compared to
placebo
» Clomipramine for OCD
» Medication does not seem to help hoarding
» Beta blockers commonly prescribed for social phobia
although no demonstrated effectiveness

Side effects
» Withdrawal from benzodiazepenes
» Weight gain, nervousness, high blood pressure from SSRIs

Relapse common after medication discontinuation
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COPYRIGHT
Copyright 2005 by John Wiley & Sons, New
York, NY. All rights reserved. No part of the
material protected by this copyright may be
reproduced or utilized in any form or by any
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photocopying, recording or by any information
storage and retrieval system, without written
permission of the copyright owner.
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