Nature of Anxiety and Fear
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Differences between Anxiety and
Fear
Normal Emotional States?
• Roller Coaster Ride
• Driving on the freeway
• Taking a test
Performance
Yerkes-Dodson Law
Arousal
Characteristics of
Anxiety Disorders
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Pervasive and persistent symptoms
of anxiety and fear
Excessive avoidance and escape
tendencies
Clinically significant distress and
impairment
Are the most common forms of
psychopathology
Biological Aspects of Anxiety
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Genetic vulnerability
Anxiety and brain circuits
• Depleted levels of GABA
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Corticotropin releasing factor (CRF) and
HYPAC axis
Limbic System (and subsystems)
Behavioral inhibition (BIS)
Fight/flight (FF) systems
Psychological Factors of Anxiety

Began with Freud
• Anxiety is a psychic reaction to fear
• Anxiety involves reactivation of an infantile fear situation
• Repression
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Behavioral and Cognitive Aspects
• Invokes conditioning and cognitive explanations
• Anxiety and fear are learned responses
• Catastrophic thinking and appraisals play a role
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Early Childhood Contributions
• Experiences with uncontrollability and unpredictability
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Social Contributions
• Stressful life events trigger vulnerabilities
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Cultural Expectations
Triple Vulnerability Model
Comorbidity
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Comorbidity is common across the anxiety
disorders
Major depression is the most common
secondary diagnosis
About half of patients have two or more
secondary diagnoses
Comorbidity suggests
• Common factors
• A relation between anxiety and depression
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Substance Abuse Disorders
Anxiety Disorders Categories
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Generalized Anxiety Disorder
Panic Disorder with and without
Agoraphobia
Specific Phobias
Social Phobia
Posttraumatic Stress Disorder
Obsessive-Compulsive Disorder
Generalized Anxiety
Disorder

Worry
• About Everything
• Worrying is Unproductive
(Interferes with Functioning)
• Strong, Persistent
• Uncontrollable
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Somatic symptoms
• Differ from panic (e.g., muscle
tension, fatigue, irritability)
“Do you worry excessively about minor things?”
Treatment of GAD
Generally Weak
 Benzodiazepines
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•Most often prescribed
•Offers some relief
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Psychological interventions
•Cognitive-Behavioral Therapy
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Including “exposure” to worries
Panic
“You may genuinely believe you’re
having a heart attack, losing your
mind, or on the verge of death.
Attacks can occur any time, even
during sleep.”
“For me, a panic attack is a most
violent experience …
I feel as though I’m losing control and
going insane.”
Symptoms of
Panic Attacks
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Palpitations / Sweating
Trembling / Shaking
Shortness of Breath
Feeling of Choking
Feeling of Dying
Loss of Control
Derealization
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Connection to?
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Panic Attack
Abrupt Autonomic Surge
 Intense Fear or Discomfort
 Unexpected and
Uncontrollable
 Absence of Actual Threat
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•“False Alarm”
Panic Disorder
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An Unexpected Panic Attack
Develop Anxiety Over:
• The Next Attack or
• The Implications of the Attack and
Consequences

Agoraphobia is Common
• “Fear of the Marketplace”
• Consequence of Unexpected Panic
Attacks
• Can be a separate disorder
Panic Disorder Treatment
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Medication Treatment of Panic Disorder
• Benzodiazepines
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Relapse and avoidance
• SSRIs
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Preferred drugs
• Relapse rates are high following medication
discontinuation
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Psychological and Combined Treatments
• Cognitive-behavior therapies seem highly
effective
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Panic Control Treatment
Graded Exposure plus Coping Skills
• Combined treatments do well in the short term
• Some indication that CBT alone is most
effective
Specific Phobias
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Rather common
Any examples?
 HUGE list!
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Diagnosable?
Types of Specific Phobia
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Natural Environment
• Water, spaces, storms, etc.
• Often more than one
• Peak onset about 7 years old
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Animals
• Snakes, spiders, dogs, etc.
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Blood-Injection Injury
Situational
• Planes, heights, etc.
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Separation anxiety/school phobia
Others, including…
Specific Phobia Diagnosis
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Extreme and irrational fear of a
specific object or situation
Go to great lengths to avoid
phobic objects
Often recognize fears are
unreasonable
Markedly interferes with one's
ability to function
Treatment of
Specific Phobias
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Psychological Treatments
• Cognitive-behavior therapies are highly
effective
• Graduated exposure-based exercises
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Structured and consistent
Systematic Desensitization
Prevent Avoidance/Escape
• Blood/Injection Phobia Different
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Actually Increase Tension to Prevent
Fainting
Social Phobia Diagnosis
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Marked and Persistent Fear of
• Social or Performance Situations
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Often avoid social situations or endure
them with great distress
Most Common Type of Social Fear?
• Public Speaking
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Interferes with Life Functioning
Treatment for
Social Phobia
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Medication Treatment of Social Phobia
• Antidepressants
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Tricyclics and MAO Inhibitors
SSRIs
• Paxil, Zoloft, Effexor FDA approved
• High relapse rates following discontinuation
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Psychological Treatment
• Cognitive-behavioral treatment
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Exposure, rehearsal, role-play in a group setting
Highly effective
Posttraumatic Stress
Disorder (PTSD)
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Exposure to a traumatic event
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War and Combat
Rape and Assault
Car Accidents
Natural Disasters
Re-experience the event (e.g., memories,
nightmares, flashbacks)
Avoidance of cues that remind person of event
Emotional numbing, sleep disturbance,
hyperarousal, and interpersonal problems are
common
Markedly interferes with one's ability to function
Subtypes of Post
Traumatic Stress
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Acute Stress Disorder
• Immediately post-trauma
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Acute PTSD
• 1-3 months post trauma
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Chronic PTSD
• 3+ months post trauma
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Delayed Onset PTSD
• Onset of symptoms 6 months or more post
trauma
Fig. 4-10, p. 153
PTSD Treatment
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Psychological Treatment of PTSD
• Face the Original Trauma—under positive
conditions
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Imaginal Reexposure
Corrective Emotional Learning and Catharsis
Virtual Reality
• Increase positive coping skills and social
support
• Cognitive-behavior therapies are highly
effective
• Eye Movement Desensitization and Retraining
(EMDR)
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Controversial, but has research support
Obsessive-Compulsive
Disorder
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Culmination of All Anxiety Disorders
Obsessions
• Intrusive Thoughts, Images, or Urges
• Attempts to Suppress or Eliminate
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Compulsions
• Thoughts or Actions
• Attempts to Suppress the Obsessions
• Attempts to Obtain Relief
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Most people with OCD display multiple obsessions
Most Common Problem?
• Cleaning and washing or checking rituals
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NOT the same as Obsessive-Compulsive
Personality Disorder
Fig. 4-11, p. 157
Treatment for OCD
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Biological Interventions
• SSRIs seem to benefit up to 60% of patients
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Limited extent of help
• Relapse is common with medication
discontinuation
• Psychosurgery (cingulotomy) is used in
extreme cases
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Psychological Treatment
• Cognitive-behavioral therapy is most effective
with OCD
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Exposure and response prevention
• Combining medication with CBT may be no
better than CBT alone
Factors in Treating Anxiety
Disorders
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Biological Interventions
Cognitive-Behavioral Interventions
What about:
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Psychoanalytic Interventions
Existential Interventions
Humanistic Interventions
Constructivist Interventions
And, then again, what about:
• Social Interventions
• Cultural Interventions
Integrative View of Anxiety-Related Disorders
pp. 162-163