Abnormal Psychology
Fifth Edition
Oltmanns and Emery
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Chapter Six
Anxiety Disorders
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Chapter Outline
• Symptoms
• Diagnosis
• Frequency
• Causes
• Treatment
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Overview
• Taken together, the various forms of anxiety
disorders—including phobias, obsessions,
compulsions, and extreme worry—represent
the most common type of abnormal behavior.
• Anxiety disorders share several important
similarities with mood disorders.
• From a descriptive point of view, both
categories are defined in terms of negative
emotional responses.
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Overview
• Stressful life events seem to play a role in
the onset of both depression and anxiety.
• Cognitive factors are also important in both
types of problems.
• From a biological point of view, certain
brain regions and a number of
neurotransmitters are involved in the
etiology of anxiety disorders as well as
mood disorders.
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Symptoms
• People with anxiety disorders share a
preoccupation with, or persistent avoidance
of, thoughts or situations that provoke fear
or anxiety.
• Anxiety disorders frequently have a
negative impact on various aspects of a
person’s life.
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Symptoms
Anxiety
• Anxious mood is often defined in contrast to
the specific emotion of fear, which is more
easily understood.
• Fear is experienced in the face of real,
immediate danger.
• In contrast to fear, anxiety involves a more
general or diffuse emotional reaction—beyond
simple fear—that is out of proportion to threats
from the environment.
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Symptoms
Anxiety (continued)
• Rather than being directed toward the
person’s present circumstances, anxiety is
associated with the anticipation of future
problems.
• Anxiety can be adaptive at low levels,
because it serves as a signal that the person
must prepare for an upcoming event.
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Symptoms
Anxiety (continued)
• A pervasively anxious mood is often
associated with pessimistic thoughts and
feelings.
• The person’s attention turns inward,
focusing on negative emotions and selfevaluation rather than on the organization or
rehearsal of adaptive responses that might
be useful in coping with negative events.
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Symptoms
Excessive Worry
• Worrying is a cognitive activity that is
associated with anxiety.
• Worry can be defined as a relatively
uncontrollable sequence of negative,
emotional thoughts that are concerned with
possible future threats or danger.
• Worriers are preoccupied with “self-talk”
rather than unpleasant visual images.
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Symptoms
Excessive Worry (continued)
• The distinction between pathological and normal
worry hinges on quantity—how often the person
worries and about how many different topics the
person worries.
• It also depends on the quality of worrisome
thought.
• Excessive worriers are more likely than other
people to report that the content of their thoughts
is negative, that they have less control over the
content and direction of their thoughts, and that in
comparison to other adults, their worries are less
realistic.
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Symptoms
Panic Attacks
• A panic attack is a sudden, overwhelming
experience of terror or fright.
• Whereas anxiety involves a blend of several
negative emotions, panic is more focused.
• Some clinicians think of panic as a normal
fear response that is triggered at an
inappropriate time.
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Symptoms
Panic Attacks (continued)
• Descriptively, panic can be distinguished
from anxiety in two other respects: It is
more intense, and it has a sudden onset.
• Panic attacks are defined largely in terms of
a list of somatic or physical sensations,
ranging from heart palpitations, sweating,
and trembling to nausea, dizziness, and
chills.
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Symptoms
Panic Attacks (continued)
• People undergoing a panic attack also report
a number of cognitive symptoms.
• They may feel as though they are about to
die, lose control, or go crazy.
• Some clinicians believe that the
misinterpretation of bodily sensations lies at
the core of panic disorder.
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Symptoms
Panic Attacks (continued)
• Panic attacks are further described in terms
of the situations in which they occur, as well
as the person’s expectations about their
occurrence.
• An attack is said to be expected, or cued, if
it occurs only in the presence of a particular
stimulus.
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Symptoms
Phobias
• Phobias are persistent, irrational, narrowly
defined fears that are associated with a
specific object or situation.
• A fear is not considered phobic unless the
person avoids contact with the source of the
fear or experiences intense anxiety in the
presence of the stimulus.
• Phobias are also irrational or unreasonable.
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Symptoms
Phobias (continued)
• The most straightforward type of phobia
involves fear of specific objects or situations.
• Some people experience marked fear when
they are forced to engage in certain activities,
such as public speaking, initiating a
conversation, eating in restaurants, or using
public rest rooms, which might involve being
observed or evaluated by other people.
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Symptoms
Phobias (continued)
• The most complex and incapacitating form of
phobic disorder is agoraphobia, which
literally means “fear of the marketplace (or
places of assembly)” and is usually described
as fear of public spaces.
• People with agoraphobia are frequently afraid
that they will experience an “attack” of
symptoms that will be either incapacitating or
embarrassing, and that help will not be
available to them.
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Symptoms
Obsessions and Compulsions
• Obsessions are repetitive, unwanted,
intrusive cognitive events that may take the
form of thoughts or images or impulses.
• They intrude suddenly into consciousness
and lead to an increase in subjective
anxiety.
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Symptoms
Obsessions and Compulsions (continued)
•
Obsessive thinking can be distinguished from worry
in two primary ways:
1) Obsessions are usually experienced as coming
from “out of the blue,” whereas worries are often
triggered by problems in everyday living; and
2) the content of obsessions most often involves
themes that are perceived as being socially
unacceptable or horrific, such as sex, violence,
and disease/contamination, whereas the content of
worries tends to center around more acceptable,
commonplace concerns, such as money and work.
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Symptoms
Obsessions and Compulsions (continued)
• Compulsions are repetitive behaviors or
mental acts that are used to reduce anxiety.
• In contrast to the obsessions described by
people who are not in treatment, those
experienced by clinical patients occur more
frequently, last longer, and are associated
with higher levels of discomfort than
normal obsessions.
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Symptoms
Obsessions and Compulsions (continued)
• Compulsions reduce anxiety, but they do
not produce pleasure.
• Thus some behaviors, such as gambling and
drug use, that people describe as being
“compulsive” are not considered true
compulsions according to this definition.
• The two most common forms of compulsive
behavior are cleaning and checking.
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Diagnosis
Brief Historical Perspective
• Anxiety and abnormal fears did not play a
prominent role in the psychiatric classification
systems that began to emerge in Europe during the
second half of the nineteenth century.
• People with anxiety problems seldom came to the
attention of psychiatrists during the nineteenth
century because very few cases of anxiety disorder
require institutionalization.
• Freud and his followers were responsible for some
of the first extensive clinical descriptions of
pathological anxiety states.
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Diagnosis
Brief Historical Perspective (continued)
• Freud focused primarily on the importance of mental
conflicts and innate biological impulses in the etiology
of anxiety.
• This perspective played a central role in the way that
anxiety disorders were classified in early versions of
the DSM.
• They were grouped with several other types of
problems under the general heading of neurosis, a
term used to describe persistent emotional
disturbances, such as anxiety and depression, in which
the person is aware of the nature of the problem.
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Diagnosis
Brief Historical Perspective (continued)
• The basic outline of Freud’s theory of anxiety
hinges on the notion that the person’s ego can
experience a small amount of anxiety as a signal
indicating that an instinctual impulse that has
previously been associated with punishment and
disapproval is about to be acted on.
• This usually means that the person is going to do
something aggressive or sexual that is considered
inappropriate.
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Diagnosis
Brief Historical Perspective (continued)
• Signal anxiety triggers the use of ego defenses—
primarily repression—that prevent conscious
recognition of the forbidden impulse, inhibit its
expression, and thereby reduce the person’s
anxiety.
• When the system works as it should, anxiety is
adaptive, and the person’s behavior is regulated to
conform with social expectations.
• Unfortunately, people can still experience
pathological levels of anxiety if the system is
overwhelmed.
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Diagnosis
Contemporary Diagnostic Systems (DSM-IV-TR)
• The DSM-IV-TR approach to classifying anxiety
disorders is based primarily on descriptive
features, rather than etiological hypotheses, and
recognizes several specific subtypes.
• They include panic disorder, three types of phobic
disorders, obsessive–compulsive disorder, and
generalized anxiety disorder, as well as
posttraumatic stress disorder (PTSD) and acute
stress disorder.
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Diagnosis
Contemporary Diagnostic Systems
(DSM-IV-TR) (continued)
• To meet the diagnostic criteria for
panic disorder, a person must
experience recurrent, unexpected panic
attacks.
• Panic disorder is divided into two
subtypes, depending on the presence or
absence of agoraphobia.
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Diagnosis
Contemporary Diagnostic Systems (DSMIV-TR) (continued)
• DSM-IV-TR defines agoraphobia in terms
of anxiety about being in situations from
which escape might be either difficult or
embarrassing.
• This approach is based on the view that
agoraphobia is typically a complication that
follows upon the experience of panic
attacks.
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Diagnosis
Contemporary Diagnostic Systems (DSM-IV-TR)
(continued)
• A specific phobia is defined in DSMIV-TR as “a
marked and persistent fear that is excessive or
unreasonable, cued by the presence or anticipation
of a specific object or situation.”
• Frequently observed types of specific phobia
include fear of heights, small animals, tunnels or
bridges, storms, illness and injury, being in a
closed place, and being on certain kinds of public
transportation.
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Diagnosis
Contemporary Diagnostic Systems (DSM-IV-TR)
(continued)
• The DSM-IV-TR definition of social phobia is
almost identical to that for specific phobia, but it
includes the additional element of performance.
• A person with a social phobia is afraid of (and
avoids) social situations.
• These situations fall into two broad headings: doing
something in front of unfamiliar people
(performance anxiety) and interpersonal interactions
(such as dating and parties).
• Fear of being humiliated or embarrassed presumably
lies at the heart of the person’s discomfort.
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Diagnosis
Contemporary Diagnostic Systems (DSM-IV-TR)
(continued)
• Excessive anxiety and worry are the primary
symptoms of generalized anxiety disorder
(GAD).
• The person must have trouble controlling these
worries, and the worries must lead to significant
distress or impairment in occupational or social
functioning.
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Diagnosis
Contemporary Diagnostic Systems (DSMIV-TR) (continued)
• In order to distinguish GAD from other
forms of anxiety disorder, DSM-IV-TR
notes that the person’s worries should not be
focused on having a panic attack (as in
panic disorder), being embarrassed in public
(as in social phobia), or being contaminated
(as in obsessive–compulsive disorder).
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Diagnosis
Contemporary Diagnostic Systems (DSM-IV-TR)
(continued)
•
The person’s worries and free-floating anxiety must
be accompanied by at least three of the following
symptoms:
1) restlessness or feeling keyed up or on edge,
2) being easily fatigued,
3) difficulty concentrating or mind going blank,
4) irritability,
5) muscle tension, and
6) sleep disturbance.
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Diagnosis
Contemporary Diagnostic Systems (DSM-IV-TR)
(continued)
• DSM-IV-TR defines obsessive–compulsive
disorder (OCD) in terms of the presence of either
obsessions or compulsions.
• Most people who meet the criteria for this disorder
actually exhibit both of these symptoms.
• The DSM-IV-TR definition requires that the
person must attempt to ignore, suppress, or
neutralize the unwanted thoughts or impulses.
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Diagnosis
“Lumpers” and “Splitters”
• Experts who classify mental disorders can be
described informally as belonging to one of two
groups, “lumpers” and “splitters.”
• Lumpers argue that anxiety is a generalized
condition or set of symptoms without any special
subdivisions.
• Splitters distinguish among a number of
conditions, each of which is presumed to have its
own etiology.
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Diagnosis
Course and Outcome
• Long-term follow-up studies focused on
clinical populations indicate that many
people continue to experience symptoms of
anxiety and associated social and
occupational impairment many years after
their problems are initially recognized.
• On the other hand, some people do recover
completely.
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Frequency
Prevalence
• The National Comorbidity Survey (NCS), which
included approximately 8,000 people aged 15 to
54 throughout the United States, found that
anxiety disorders are more common than any other
form of mental disorder.
• The same conclusion had been reached previously
in the ECA study.
• Specific phobias are the most common type of
anxiety disorder, with a 1-year prevalence of about
9 percent of the adult population (men and women
combined).
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Frequency
Comorbidity
• One study found that 50 percent of people
who met the criteria for one anxiety
disorder also met the criteria for at least one
other form of anxiety disorder or mood
disorder.
• Both anxiety and depression are based on
emotional distress, so it is not surprising
that considerable overlap also exists
between anxiety disorders and mood
disorders.
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Frequency
Comorbidity (continued)
• Approximately 60 percent of people who
receive a primary diagnosis of major
depression also qualify for a secondary
diagnosis of some type of anxiety disorder.
• People who have an anxiety disorder are
about three times more likely to have an
alcohol use disorder than are people without
an anxiety disorder.
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Frequency
Gender Differences
• Women are three times as likely as men to
experience specific phobias.
• Women are about twice as likely as men to
experience panic disorder, agoraphobia (without
panic disorder), and generalized anxiety disorder.
• Social phobia is also more common among
women than among men, but the difference is not
as striking as it is for other types of phobia.
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Frequency
Gender Differences (continued)
• The only type of anxiety disorder for which
there does not appear to be a significant
gender difference is OCD.
• Among people who have anxiety disorder,
relapse rates are also much higher for
women than for men.
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Frequency
Anxiety Across the Life Span
• Data from the ECA study indicate that the
prevalence of anxiety disorders is lower
among elderly men and women than it is
among people in other age groups.
• Most elderly people with an anxiety
disorder have had the symptoms for many
years.
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Frequency
Anxiety Across the Life Span (continued)
• It is relatively unusual for a person to develop a
new case of panic disorder, specific phobia, social
phobia, or obsessive–compulsive disorder at an
advanced age.
• The only type of anxiety disorder that begins with
any noticeable frequency in late life is
agoraphobia.
• The diagnosis of anxiety disorders among elderly
people is complicated by the need to consider
factors such as medical illnesses and other
physical impairments and limitations.
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Frequency
Cross-Cultural Comparisons
• People in Western societies often experience
anxiety in relation to their work performance,
whereas in other societies people may be more
concerned with family issues or religious
experiences.
• Anxiety disorders have been observed in
preliterate as well as Westernized cultures.
• Of course, the same descriptive and diagnostic
terms are not used in every culture, but the basic
psychological phenomena appear to be similar.
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Causes
Adaptive and Maladaptive Fears
• Current theories regarding the causes of anxiety
disorders often focus on the evolutionary
significance of anxiety and fear.
• These emotional response systems are clearly
adaptive in many situations.
• They mobilize responses that help the person
survive in the face of both immediate dangers and
long-range threats.
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Causes
Adaptive and Maladaptive Fears (continued)
• An evolutionary perspective helps to explain
why human beings are vulnerable to anxiety
disorders, which can be viewed as problems
that arise in the regulation of these necessary
response systems.
• The important question is not why we
experience anxiety, but why it occasionally
becomes maladaptive.
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Causes
Adaptive and Maladaptive Fears (continued)
• Isaac Marks and Randolph Nesse suggest that
generalized forms of anxiety probably evolved to
help the person prepare for threats that could not
be identified clearly.
• More specific forms of anxiety and fear probably
evolved to provide more effective responses to
certain types of danger.
• Each type of anxiety disorder can be viewed as the
dysregulation of a mechanism that evolved to deal
with a particular kind of danger.
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Causes
Social Factors
• Several investigations suggest that stressful
life events can influence the onset of
anxiety disorders as well as depression.
• Patients with anxiety disorders are more
likely than other people to report having
experienced a negative event in the months
preceding the initial development of their
symptoms.
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Causes
Social Factors (continued)
• Why do some negative life events lead to
depression while others lead to anxiety?
• The nature of the event may be an important factor
in determining the type of mental disorder that
appears.
• People who develop an anxiety disorder are much
more likely to have experienced an event
involving danger (lack of security), whereas
people who are depressed are more likely to have
experienced a severe loss (lack of hope).
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Causes
Social Factors (continued)
• People who report parental neglect, abuse,
and violence are more vulnerable to the
development of both mood disorders and
anxiety disorders.
• Causal pathways are complex.
• There does not seem to be a direct
connection between particular forms of
adverse environmental events and specific
types of mental disorder.
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Causes
Social Factors (continued)
• Several studies have found that people with panic
disorder and agoraphobia are more likely to report
that they had problems associated with insecure
attachment as children.
• Attachment difficulties are not restricted to
agoraphobia.
• Studies indicate that they also set the stage for
other types of anxiety in adults, including
generalized anxiety disorder, and social phobia.
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Causes
Psychological Factors
• Since the 1920s, experimental psychologists
working in laboratory settings have been
interested in the possibility that specific
fears might be learned through classical (or
Pavlovian) conditioning.
• Many intense, persistent, irrational fears
seem to develop after the person has
experienced a traumatic event.
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Causes
Psychological Factors (continued)
• Current views on the process by which fears
are learned suggest that the process is
guided by a module, or specialized circuit in
the brain, that has been shaped by
evolutionary pressures.
• These modules are designed to operate at
maximal speed, are activated automatically,
and perform without conscious awareness.
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Causes
Psychological Factors (continued)
• Human beings seem to be prepared to
develop intense, persistent fears only to a
select set of objects or situations.
• Many investigations have been conducted to
test various facets of this preparedness
model.
• The results of these studies support many
features of the theory.
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Causes
Psychological Factors (continued)
• Observational learning may also affect the
development of intense fear, because some
phobias develop in the absence of any direct
experience with the feared object.
• Learning experiences are clearly important in the
origins of phobias, but their impact often depends
on the existence of prepared associations between
stimuli.
• Furthermore, vicarious learning is often as
important as direct experience.
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Causes
Psychological Factors (continued)
• Cognitive events play an important role as
mediators between experience and response.
• Perceptions, memory, and attention all
influence the ways that we react to events in
our environments.
• It is now widely accepted that these cognitive
factors play a crucial role in the development
and maintenance of various types of anxiety
disorders.
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Causes
Psychological Factors (continued)
• There is an important relationship between anxiety
and the perception of control.
• People who believe that they are able to control
events in their environment are less likely to show
symptoms of anxiety than are people who believe
that they are helpless.
• An extensive body of evidence supports the
conclusion that people who believe that they are
less able to control events in their environment are
more likely to develop global forms of anxiety, as
well as various specific types of anxiety disorder.
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Causes
Psychological Factors (continued)
• According to David Clark, panic disorder may
be caused by the catastrophic
misinterpretation of bodily sensations or
perceived threat.
• Anxious mood is accompanied by a narrowing
of the person’s attentional focus and an
increased awareness of bodily sensations.
• The crucial stage comes next, when the person
misinterprets the bodily sensation as a
catastrophic event.
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Causes
Psychological Factors (continued)
• In recent years, several lines of research
have converged to clarify the basic
cognitive mechanisms involved in worry.
• Experts now believe that attention plays a
crucial role in the onset of this process.
• People who are prone to excessive worrying
are unusually sensitive to cues that signal
the existence of future threats.
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Causes
Psychological Factors (continued)
• Once attention has been drawn to threatening
cues, the performance of adaptive, problemsolving behaviors is disrupted, and the
worrying cycle launches into a repetitive
sequence in which the person rehearses
anticipated events and searches for ways to
avoid them.
• Attentional mechanisms also seem to be
involved in the etiology and maintenance of
social phobias.
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Causes
Psychological Factors (continued)
• Worrying is unproductive and self-defeating in
large part because it is associated with a focus on
self-evaluation (fear of failure) and negative
emotional responses rather than on external
aspects of the problem and active coping
behaviors.
• We may be consciously aware of these processes
and simultaneously be unable to inhibit them.
• The struggle to control our thoughts often leads to
a process known as thought suppression, an
active attempt to stop thinking about something.
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Causes
Psychological Factors (continued)
• Recent evidence suggests that trying to rid one’s
mind of a distressing or unwanted thought can
have the unintended effect of making the thought
more intrusive.
• Thought suppression might actually increase,
rather then decrease, the strong emotions
associated with those thoughts.
• Obsessive–compulsive disorder may be related, in
part, to the maladaptive consequences of attempts
to suppress unwanted or threatening thoughts that
the person has learned to see as being dangerous
or forbidden.
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Causes
Biological Factors
• Several pieces of evidence indicate that
biological events play an important role in
the development and maintenance of
anxiety disorders.
• Family studies indicate that the relatives of
people with panic disorder show an elevated
risk of panic disorder themselves but not an
elevated risk of generalized anxiety
disorder.
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Causes
Biological Factors (continued)
• The same pattern holds for the relatives of people
with generalized anxiety disorder: The relatives
exhibit a high rate of GAD but not a high rate of
panic disorder.
• This evidence is consistent with the proposition that
panic disorder and GAD are, indeed, etiologically
separate disorders.
• A family study of social phobia has demonstrated
that the generalized form of this disorder (where the
person is fearful in most types of social situations) is
also familial in nature and etiologically distinct from
other types of anxiety disorder.
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Causes
Biological Factors (continued)
• Research results suggest that the nongeneralized
form of social phobia is not influenced by genetic
factors.
• Data regarding obsessive–compulsive disorder
suggest that a more general vulnerability to anxiety
disorders is genetically transmitted through the
family.
• The results of the family studies all point toward the
potential influence of genetic factors in anxiety
disorders.
• Most of the evidence also supports the validity of
the DSM-IV-TR subtypes.
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Causes
Biological Factors (continued)
• Family studies do not prove the involvement of
genes, because family members also share
environmental factors (diet, culture, and so on).
• Twin studies provide a more stringent test of the
genetic hypothesis.
• Kenneth Kendler, a psychiatrist at the Medical
College of Virginia, and his colleagues have
studied anxiety disorders in very large samples of
male–male and female–female twin pairs.
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Causes
Biological Factors (continued)
•
Their analyses have led them to several important
conclusions:
1. Genetic risk factors for these disorders are neither
highly specific (a different set of genes being
associated with each disorder) nor highly
nonspecific (one common set of genes causing
vulnerability for all disorders).
2. Two genetic factors have been identified: one
associated with GAD, panic disorder, and
agoraphobia, and the other with specific phobias.
3. Environmental risk factors that would be unique to
individuals also play an important role in the
etiology of all anxiety disorders.
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Causes
Biological Factors (continued)
• Laboratory studies of fear conditioning in
animals have identified specific pathways in
the brain that are responsible for detecting
and organizing a response to danger.
• The amygdala plays a central role in these
circuits, which represent the biological
underpinnings of the evolved fear module
that we discussed earlier in connection with
classical conditioning of phobias.
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Causes
Biological Factors (continued)
• Studies with animals have shown that artificial
stimulation of the amygdala can produce different
effects, depending in large part on the
environmental context in which the animal is
stimulated.
• Anger, disgust, and sexual arousal are all
emotional states that are associated with activity in
pathways connecting the thalamus, the amygdala,
and their projections to other brain areas.
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Causes
Biological Factors (continued)
• The brain regions that have been identified
in studies of fear conditioning seem to play
an important role in both phobic disorders
and panic disorder.
• The locus ceruleus, a small area located in
the brain stem, has also been the focus of
considerable emphasis in research on panic
disorder.
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Causes
Biological Factors (continued)
• Research with monkeys has demonstrated
that the firing rate of neurons in the locus
ceruleus increases dramatically when a
monkey is frightened.
• Furthermore, electrical stimulation of the
locus ceruleus triggers a strong fear
response that resembles a panic attack.
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Causes
Biological Factors (continued)
• The results of studies using brain imaging
procedures with OCD patients do not overlap a
great deal with findings for other types of anxiety
disorder.
• Obsessions and compulsions are associated with
multiple brain regions, including the basal ganglia
(a system that includes the caudate nucleus and the
putamen), the orbital prefrontal cortex, and the
anterior cingulate cortex.
• These circuits are overly active in people with
OCD, especially when the person is confronted
with stimuli that provoke his or her obsessions.
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Causes
Biological Factors (continued)
• Pharmacological challenge procedures have
played an important role in exploring the
neurochemistry of panic disorder.
• The logic behind this method is simple: If a
particular brain mechanism is “challenged,” or
stressed, by the artificial administration of
chemicals, and if that procedure leads to the onset
of a panic attack, then the neurochemical process
that mediates that effect may also be responsible
for panic attacks that take place outside the
laboratory.
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Causes
Biological Factors (continued)
• Pharmacological challenge procedures were
inspired by a few clinical studies, reported in the
1940s and 1950s, which noted that patients with
“anxiety neurosis” sometimes experienced an
increase in subjective anxiety following vigorous
physical exercise.
• This change in subjective symptoms appeared to
be associated with an extremely rapid and
excessive increase in lactic acid in the blood.
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Causes
Biological Factors (continued)
• A large number of studies have
demonstrated that lactate infusions can
provoke panic attacks in anywhere from 50
to 90 percent of patients with anxiety or
panic disorders, as compared to only 0 to 25
percent of normal control subjects.
• Many other procedures have been found to
induce panic in the laboratory.
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Causes
Biological Factors (continued)
• These include the infusion of different chemicals,
such as caffeine, as well as the inhalation of air
enriched with carbon dioxide.
• Various pharmacological challenge studies have
suggested the influence of serotonin,
norepinephrine, GABA, and dopamine in the
production of panic attacks.
• The general finding appears to be that several
neurotransmitter systems are involved in the
etiology of panic disorder.
• This conclusion also applies to other forms of
anxiety disorder, such as GAD and social phobia.
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Treatment
Psychological Interventions
• Like psychoanalysis, behavior therapy was
initially developed for the purpose of treating
anxiety disorders, especially specific phobias.
• The first widely adopted procedure was systematic
desensitization.
• In the years since systematic desensitization was
originally proposed, many different variations on
this procedure have been employed.
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Treatment
Psychological Interventions (continued)
• The crucial feature of the treatment involves
systematic maintained exposure to the feared
stimulus.
• Positive outcomes have been reported, regardless
of the specific manner in which exposure is
accomplished.
• The treatment of panic disorder often includes two
specific forms of exposure.
• One, situational exposure, is used to treat
agoraphobic avoidance.
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Treatment
Psychological Interventions (continued)
• In this procedure, the person repeatedly confronts
the situations that have previously been avoided.
• Interoceptive exposure, the other form of
exposure, is aimed at reducing the person’s fear of
internal, bodily sensations that are frequently
associated with the onset of a panic attack, such as
increased heart and respiration rate and dizziness.
• The process is accomplished by having the person
engage in standardized exercises that are known to
produce such physical sensations.
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Treatment
Psychological Interventions (continued)
• The most effective form of psychological
treatment for obsessive–compulsive
disorder combines prolonged exposure to
the situation that increases the person’s
anxiety with prevention of the person’s
typical compulsive response.
• Behavior therapists have used relaxation
procedures for many years.
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Treatment
Psychological Interventions (continued)
• Relaxation training usually involves
teaching the client alternately to tense and
relax specific muscle groups while
breathing slowly and deeply.
• Outcome studies indicate that relaxation is a
useful form of treatment for generalized
anxiety disorder.
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Treatment
Psychological Interventions (continued)
• Breathing retraining is a procedure that involves
education about the physiological effects of
hyperventilation and practice in slow breathing
techniques.
• It is often incorporated in treatments used for
panic disorder.
• Some clinicians believe that the process works by
enhancing relaxation or increasing the person’s
perception of control.
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Treatment
Psychological Interventions (continued)
• Cognitive therapy is used extensively in the
treatment of anxiety disorders.
• Therapists help clients identify cognitions that are
relevant to their problem; recognize the relation
between these thoughts and maladaptive emotional
responses (such as prolonged anxiety); examine
the evidence that supports or contradicts these
beliefs; and teach clients more useful ways of
interpreting events in their environment.
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Treatment
Psychological Interventions (continued)
• In the case of anxiety disorders, cognitive therapy
is usually accompanied by additional behavior
therapy procedures.
• Several controlled outcome studies attest to the
efficacy of cognitive therapy in the treatment of
various types of anxiety disorder, including panic
disorder, agoraphobia, social phobia, generalized
anxiety disorder, and obsessive–compulsive
disorder.
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Treatment
Biological Interventions
• Medication is the most effective and most commonly
used biological approach to the treatment of anxiety
disorders.
• The most frequently used types of minor tranquilizers
are from the class of drugs known as benzodiazepines.
• These drugs reduce many symptoms of anxiety,
especially vigilance and subjective somatic sensations,
such as increased muscle tension, palpitations,
increased perspiration, and gastrointestinal distress.
• They have relatively less effect on a person’s tendency
toward worry and rumination.
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Treatment
Biological Interventions (continued)
• Benzodiazepines have been shown to be effective
in the treatment of generalized anxiety disorders
and social phobias.
• Many patients with panic disorder and
agoraphobia relapse if they discontinue taking
medication.
• Common side effects of benzodiazepines include
sedation accompanied by mild psychomotor and
cognitive impairments.
• The most serious adverse effect of
benzodiazepines is their potential for addiction.
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Treatment
Biological Interventions (continued)
• Another class of anti-anxiety medication, known as
the azapirones, includes drugs that work on entirely
different neural pathways than the benzodiazepines.
• The only azapirone in clinical use is known as
buspirone (BuSpar).
• Some clinicians believe that buspirone is preferable to
the benzodiazepines because it does not cause
drowsiness and does not interact with the effects of
alcohol.
• The disadvantage is that patients do not experience
relief from severe anxiety symptoms as quickly with
buspirone as they do with benzodiazepines.
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Treatment
Biological Interventions (continued)
• The selective serotonin reuptake inhibitors
(SSRIs) have become the preferred form of
medication for treating almost all forms of anxiety
disorder.
• Reviews of controlled outcome studies indicate
that they are at least as effective as other, more
traditional forms of antidepressants in reducing
symptoms of various anxiety disorders.
• They also have fewer unpleasant side effects, they
are safer to use, and withdrawal reactions are less
prominent when they are discontinued.
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Treatment
Biological Interventions (continued)
• Imipramine (Tofranil), a tricyclic antidepressant
medication, has been used for more than 40 years in
the treatment of patients with panic disorder.
• Psychiatrists often prefer imipramine to anti-anxiety
drugs for the treatment of panic disorder because
patients are less likely to become dependent on the
drug than they are to high-potency benzodiazepines
like alprazolam.
• The tricyclic antidepressants are used less frequently
than the SSRIs because they produce several
unpleasant side effects, including weight gain, dry
mouth, and over-stimulation (sometimes referred to as
an “amphetamine-like” response).
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Treatment
Biological Interventions (continued)
• Clomipramine (Anafranil), another tricyclic
antidepressant, has been used extensively in
treating obsessive–compulsive disorder.
• Patients who continue to take the drug
maintain the improvement, but relapse is
common if medication is discontinued.
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Treatment
Biological Interventions (continued)
• In actual practice, anxiety disorders are often
treated with a combination of psychological and
biological procedures.
• Current evidence suggests that patients who
receive both medication and psychotherapy may
do better in the short run, but patients who receive
only cognitive behavior therapy may do better in
the long run because of difficulties that can be
encountered when medication is discontinued.
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