Anxiety Disorders
Symptoms
Diagnosis
Frequency
Causes
Treatment
FEAR
Experienced in the face
of real, immediate
danger
Builds quickly in
intensity
Helps organize the
person’s behavioral
responses to threats
Fight/Flight response
sympathetic n.s.
ANXIETY
Anticipation of future
problems
Prepares us to take
action
Involves more general
or diffuse emotional
reactions

At the same time, we can also worry too
much, feel anxious too often or be afraid at
inappropriate times.

The questions is: how maladaptive are these
behaviors and to what extent do they
interfere in one’s ability to function normally?


Most common type of abnormal behavior
Share similarities with mood disorders:
 Both defined in terms of negative emotional
responses (Case of Johanna, inter and/or
intrapersonal?)
 Close relationship between symptoms of anxiety
and depression (e.g., guilt, worry, anger).
 May share similar causal features:
▪ stress, cognitive factors, biological.


People with anxiety disorders share a
preoccupation with, or persistent
avoidance of, thoughts or situations that
provoke fear or anxiety.
The diagnosis of anxiety disorders
depends on several types of symptoms.




David Barlow’s anxious apprehension:
1) High levels of diffuse negative emotion
2) Sense of uncontrollability
3) Shift in attention to a primary self focus or
state of self preoccupation
The emotional experience
is out of proportion
to the threat

Excessive Worry
 Cognitive activity associated with anxiety.
 A relatively uncontrollable sequence of
negative, emotional thoughts that are
concerned with possible future threats or
danger.
?
?

Excessive Worry
 Worriers are preoccupied with “self-talk” Worry
 Distinctions hinges on quantity and quality of
worrisome thoughts and the negativity of
content.

Panic Attacks
 Discrete episode of acute terror in the absence
of real danger
 A sudden, intense, overwhelming experience of
terror or fright
 Emotional response more focused
A discrete period of intense fear or discomfort, in which four (or more)
of the following symptoms developed abruptly and reached a peak
within 10 minutes:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath or smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded, or faint
Derealization (feelings of unreality) or depersonalization (being
detached from oneself)
Fear of losing control or going crazy
Fear of dying
Paresthesias (numbness or tingling sensations)
Chills or hot flushes
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,Text Revision.

Panic Attacks (continued)
 Misinterpretations of bodily sensations lies at
the core of panic disorder
▪ Heart palpitations
▪ Racing thoughts
heart attacks
lose their mind

Panic Attacks (continued)
 Described in situations in which they occur:
▪ Cued: if expected, or if it occurs only in the
presence of a particular stimulus
▪ Unexpected: panic attacks appears without
warning or expectation, as if “out of the
blue.”
OBSESSIONS
COMPULSIONS
Unwanted, anxietyprovoking
thoughts/images
 “out of the blue”
 May seem silly or
crazy, socially
inappropriate or
horrific


Compulsions cannot
be resisted without
distress
 Reduce (neutralize)
anxiety, but do not
produce pleasure
 Irrational rituals
stress disorder
▪ Recurrent, unexpected panic attacks
▪ At least one of the attacks must be followed
by a period of 1 month or more with
persistent concerns about having
additional attacks.
▪ Divided into two subtypes: presence of
absence of agoraphobia
 Defined as intense, persistent, irrational, fear
and avoidance of a specific object or situation
 Reactions are unreasonable.
 Agoraphobia
▪ Fear of public places in which individual
fears that s/he cannot escape.
▪ Typical situations
▪ Crowded streets, shops
▪ Public transportation
▪ Wide open areas
Fears are focused on social situations
where there is a possibility of being
judged/observed/humiliated/embarrassed
 Two broad headings:
 Performance Anxiety
 Interpersonal interaction

▪ A “marked and persistent fear that is
excessive or unreasonable, cued by the
presence or anticipation of a specific object
or situation.”
▪ Exposure to phobic stimulus must be
followed by an immediate fear response.
▪ “Catchall” category
1) Animals
2) Natural Environmental
3) Blood/Injury/Injection
4) Situational
▪
▪
▪
▪
Chronic (>6 mos),debilitating, excessive anxiety and worry
Trouble controlling the worries
Worries lead to significant distress
Pervasive: worries must be about different events or
activities
▪ Includes three or more of the following:
Restlessness
Sleep disturbance
Fatigue
Irritability
Muscle Tension
Difficulty concentrating
▪ Recognition that the obsessions or
compulsions are excessive or unreasonable.
▪ Attempts to ignore, suppress, or neutralize
the unwanted thoughts or impulses.
 ♀ > ♂ 2-3 times
 Relapse rates: higher for ♀
 OCD: no significant gender differences
 Specific phobia: ♀ are three times more likely
 Panic disorder, agoraphobia (without panic
disorder): ♀ about twice as likely
 Social phobia: more common among ♀
 Evolutionary perspective focuses on
significance of anxiety and fear. Fear/Anxiety
may mobilize. Help the person survive in the
face of both immediate danger and long-range
threats

Adaptive and Maladaptive Fears
▪ Preparedness Model (preconditioning theory)
▪ Research results appear to support that
conditioned responses to fear-relevant stimuli
(e.g., spiders, snakes) are more resistant to
extinction that those to fear-irrelevant stimuli
(e.g., flowers).
 Causal patterns are complex. Multicausal.
 Stressful life events, particularly involving
danger and interpersonal conflict, can trigger
the onset of certain kinds of anxiety disorders
and depression.

Nature of the event: important factor

Anxiety: danger

Depression: severe loss (lack of hope)
Maternal prenatal
stress (higher cortisol
levels at birth)
 Multiple maternal
partner changes
 Parental indifference
(neglect)
 Physical abuse.

more likely to
develop anxiety
disorders
 Anxiety is an innate response to separation, or
threat of separation.
 People with anxiety disorders more likely to
have had attachment problems as children.
 Specific fears might be learned through
classical conditioning.

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Watson and Rayner (1920) “Little Albert”
study
Conditioned fears “persist and modify
personality throughout life”
Mary Cover Jones (1924) later used
classical conditioning to remove fears in
another boy

White rat
no reaction
(NS)


Loud Noise
(UCS)
White Rat + Loud Noise
(NS)

White rat
(CS)
(UCS)
Fear
(UCR)
Fear
(UCR)
Fear
(CR)

Perceptions, memory, and attention all influence
reaction to events.
▪ Four aspects:
▪ Perception of controllability
▪ Catastrophic misinterpretation
▪ Attentional biases
▪ Thought suppression

Control events in their environments: less
likely to show anxiety than people who
believe they are helpless.

Feelings of lack of control = onset of panic
attacks
Anxiety
Control
 Catastrophic Misinterpretation
▪ Panic attacks can be precipitated by internal
stimuli, such as bodily sensations, thoughts,
or images.
▪ Misinterpret bodily sensations = catastrophic
event.
▪ Automatic, negative thoughts lead to
behaviors that are expected to increase
safety, when they are in fact
counterproductive.

Attention to Threat and Biased Information
Processing
▪ Unusually sensitive to cues that signal the
existence of future threats.
▪ Recognition of danger triggers maladaptive,
self-perpetuating cycles that quickly spin out of
control.

Trying to rid one’s mind of a distressing or
unwanted thought can have the unintended
effect of making the thought more intrusive
(especially for OCD).

Thalamus
Amygdala
Flight or Fight
(behavioral responses coordinated through
the hypothalamus)
Endocrine glands
& Autonomic Nervous System (FIGURE 6-3)
Thalamus
Visual Cortex
Amygdala
(triggers an organized response to threat).
 Psychoanalytic psychotherapy
▪ Fosters insight regarding the unconscious
motives that presumably lie at the heart of
the patient’s symptoms.
 Relaxation Skills Training
▪ Teaching alternately to tense and relax specific
muscle groups while breathing slowly and deeply.
 Breathing Retraining
▪ Education about the physiological effects of
hyperventilation and practice in slow breathing.
▪ Learn to control breathing through repeated practice
using muscles of the diaphragm, rather than the
chest.
 Systematic Desensitization
▪ Systematic maintained exposure to the
feared stimuli.
▪ Progressive relaxation
▪ A hierarchy of feared stimuli
 Exposure Treatments
▪ Situational Exposure: used to treat
agoraphobic avoidance
▪ Involves repeatedly confronting the
situations that have been previously
avoided.
▪ Interoceptive Exposure: aimed at reducing
the person’s fear of internal, bodily
sensations frequently associated with panic
 Cognitive Therapy
▪ Identify thoughts that are relevant to their
problems.
▪ Recognize the relation between these
thoughts and maladaptive emotional
responses.
▪ Examine evidence that supports or
contradicts these beliefs.
▪ Teach more useful ways of
interpreting events.
 Antianxiety Medications—Anxiolytics
 Work on GABA
▪ Most frequently used types of minor
tranquilizers -- benzodiazepines.
▪ Valium and Xanax
▪ Reduce many symptoms of anxiety, especially
vigilance and somatic sensations.
▪ Have less effect on worry and rumination.
 Benzodiazepines
▪ Shown to be effective in the treatment of GAD
and social phobias
▪ Not typically beneficial for specific phobias or
OCD
▪ Many with panic disorder and agoraphobia
relapse if they discontinue taking medication.
Side Effects
▪ Sedation accompanied by mild
psychomotor and cognitive impairments
▪ Problems in attention and memory,
especially among elderly
▪ Potential for addiction
 Antidepressant Medications
▪ Selective Serotonin Reuptake Inhibitors
(SSRIs)
▪ Zoloft
▪ Paxil
▪ Prozac
▪ Luvox
 SSRIs
▪ Reduce symptoms of various anxiety disorders.
▪ Fewer unpleasant side effects and are safer to
use.
▪ Withdrawal reactions are less prominent
▪ First-line medication for treating panic disorder,
social phobias, and OCD
 Antidepressant Medications: Tricylics
(norepinephrine)
 Used less frequently than the SSRIs because
they produce several unpleasant side effects
▪ Anafranil: OCD
▪ Improvement in see in 50% receiving
clomipramine, but relapse is common if
medication is discontinued.
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Buspar—drug mechanisms are unknown.
May work on serotonin or dopamine systems
Less potent, but less addictive with less side
effects.
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Often treated with a combination of
psychological and biological procedures.
Selection of specific treatment
components depends on presenting
symptoms.