Abnormal Psychology, Thirteenth
Edition, DSM-5 Update
by
Ann M. Kring,
Sheri L. Johnson,
Gerald C. Davison,
& John M. Neale
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Chapter
I.
II.
III.
IV.
6: Anxiety Disorders
Clinical Descriptions of Anxiety Disorders
Common Risk Factors Across the Anxiety
Disorders
Etiology of Specific Anxiety Disorders
Treatments of Anxiety Disorders
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Anxiety
• Apprehension about a future threat
 Fear
• Response to an immediate threat
 Both
involve physiological arousal
 Both
can be adaptive
• Sympathetic nervous system
• Fear triggers “fight or flight”
 May save life
• Anxiety increases preparedness
 “U-shaped” curve (Yerkes & Dodson, 1908)
 Absence of anxiety interferes with performance
 Moderate levels of anxiety improve performance
 High levels of anxiety are detrimental to performance
© 2015 John Wiley & Sons, Inc. All rights reserved.
 DSM-5 Anxiety Disorders
• Specific phobias
• Social anxiety disorder
• Panic disorder
• Agoraphobia
• Generalized anxiety disorder
 Most common psychiatric
disorders
 28% report anxiety symptoms
 Most common are phobias
© 2015 John Wiley & Sons, Inc. All rights reserved.
 DSM-5
criteria for each disorder:
• Symptoms interfere with important areas of
functioning or cause marked distress
• Symptoms are not caused by a drug or a medical
condition
• Symptoms persist for at least 6 months or at least 1
month for panic disorder
• The fears and anxieties are distinct from the
symptoms of another anxiety disorder
© 2015 John Wiley & Sons, Inc. All rights reserved.
 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
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Disproportionate
fear of a particular object or
situation
• Common examples: fear of flying, snakes, heights, etc.
• Fear out of proportion to actual threat
• Awareness that fear is excessive
• Most specific phobias cluster around a few feared objects
and situations
• High comorbidity of specific phobias
© 2015 John Wiley & Sons, Inc. All rights reserved.
Marked and disproportionate fear consistently
triggered by specific objects or situations
 The object or situation is avoided or else endured
with intense anxiety
 Symptoms persist for at least 6 months

© 2015 John Wiley & Sons, Inc. All rights reserved.
© 2015 John Wiley & Sons, Inc. All rights reserved.

Previously called Social Phobia
• Causes more life disruption than other phobias

More intense and extensive than shyness
• Persistent, intense fear and avoidance of social situations
• Fear of negative evaluation or scrutiny
• Exposure to trigger leads to anxiety about being
humiliated or embarrassed socially
• Onset often adolescence

33% also diagnosed with Avoidant Personality Disorder
• Overlap in genetic vulnerability for both disorders
© 2015 John Wiley & Sons, Inc. All rights reserved.




Marked and disproportionate fear consistently triggered by
exposure to potential social scrutiny
Exposure to the trigger leads to intense anxiety about being
evaluated negatively
Trigger situations are avoided or else endured with intense
anxiety
Symptoms persist for at least 6 months
© 2015 John Wiley & Sons, Inc. All rights reserved.
Frequent panic attacks unrelated to specific
situations
 Panic attack

• Sudden, intense episode of apprehension, terror, feelings of
impending doom
 Intense urge to flee
 Symptoms reach peak intensity within 10 minutes
• Physical symptoms can include:
 Labored breathing, heart palpitations, nausea, upset stomach, chest
pain, feelings of choking and smothering, dizziness, sweating,
lightheadedness, chills, heat sensations, and trembling
• Other symptoms may include:
 Depersonalization
 Derealization
 Fears of going crazy, losing control, or dying
 25%
of people will experience a single panic
attack (not the same as panic disorder)
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Uncued
panic attacks
• Occur unexpectedly without warning
• Panic disorder diagnosis requires recurrent uncued
attacks
• Causes worry about future attacks
 Cued
panic attacks
• Triggered by specific situations (e.g., seeing a
snake)
 More likely a specific phobia
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Recurrent
unexpected panic attacks
 At least 1 month of concern about the
possibility of more attacks, worry about the
consequences of an attack, or maladaptive
behavioral changes because of the attacks
© 2015 John Wiley & Sons, Inc. All rights reserved.
 From
the Greek word “agora” or marketplace
 Anxiety about inability to flee anxietyprovoking situations
• E.g., crowds, stores, malls, churches, trains, bridges,
tunnels, etc.
• Causes significant impairment
 In
DSM-IV-TR, was a subtype of Panic
Disorder
• At least half of agoraphobics do not suffer panic attacks
© 2015 John Wiley & Sons, Inc. All rights reserved.

Disproportionate and marked fear or anxiety about
at least 2 situations where it would be difficult to
escape or receive help in the event of incapacitation
or panic-like symptoms, such as:
• being outside of the home alone; traveling on public
transportation; open spaces such as parking lots and
marketplaces; being in shops, theaters, or cinemas; standing
in line or being in a crowd
These situations consistently provoke fear or
anxiety
 These situations are avoided, require the presence
of a companion, or are endured with intense fear or
anxiety
 Symptoms last at least 6 months

© 2015 John Wiley & Sons, Inc. All rights reserved.
 Involves
chronic, excessive, generalized,
uncontrollable worry
• Lasts at least 6 months
• Interferes with daily life
 Often cannot decide on a solution or course of action
 Other symptoms:
• Restlessness, poor concentration, tiring easily,
restlessness, irritability, muscle tension
 Common worries:
• Relationships, health, finances, daily hassles
 Often begins in adolescence or earlier
• I’ve always been this way
© 2015 John Wiley & Sons, Inc. All rights reserved.




Excessive anxiety and worry at least 50 percent of days about at
least two life domains (e.g., family, health, finances, work, and
school)
The person finds it hard to control the worry
The worry is sustained for at least 3 months
The anxiety and worry are associated with at least three (or one in
children) of the following:
•
•
•
•
•
•

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
6. sleep disturbance
The anxiety and worry are associated with marked avoidance of
situations in which negative outcomes could occur, marked time
and effort preparing for situations that might have a negative
outcome, marked procrastination, difficulty making decisions due
to worries, or repeatedly seeking reassurance due to worries
© 2015 John Wiley & Sons, Inc. All rights reserved.
 50%
of those with anxiety disorder meet
criteria for another anxiety disorder
 75% of those with anxiety disorder meet
criteria for another psychological disorder
• Disorders commonly comorbid with anxiety:
 60% with anxiety also have depression
 Substance abuse
 Personality disorders
 Medical disorders, e.g. coronary heart disease
© 2015 John Wiley & Sons, Inc. All rights reserved.

Women are twice as likely as men to have anxiety
disorder
• Possible explanations





Women may be more likely to report symptoms
Men more likely to be encouraged to face fears
Women more likely to experience childhood sexual abuse
Women show more biological stress reactivity
Cultural factors
• Culture can shape anxieties and fears
• Culturally specific syndromes
 Taijin kyofusho
 Japanese fear of offending or embarrassing others
 Kayak-angst
 Inuit disorder in seal hunters at sea similar to panic
• Rate of anxiety disorders varies by culture, but ratio of somatic to
psychological symptoms appears similar (Kirmayer, 2001)
© 2015 John Wiley & Sons, Inc. All rights reserved.
© 2015 John Wiley & Sons, Inc. All rights reserved.
Behavioral conditioning (classical and operant
conditioning)
 Genetic vulnerability
 Increased activity in the fear circuit of the
brain
 Decreased functioning of GABA and serotonin;
increased norepinephrine activity
 Behavioral inhibition
 Neuroticism
 Cognitive factors, including sustained negative
beliefs, perceived lack of control, and attention
to cues of threat

© 2015 John Wiley & Sons, Inc. All rights reserved.


Conditioning
Mowrer’s two-factor
model
• Pairing of stimulus
with aversive UCS
leads to fear (Classical
Conditioning)
• Avoidance maintained
though negative
reinforcement
(Operant Conditioning)
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Extensions
of the two-factor model
• Modeling
 Seeing another person harmed by the stimulus
• Verbal instruction
 Parent warning a child about a danger
• Those with anxiety tend to acquire fear more
readily
 And to be more resistant to extinction
© 2015 John Wiley & Sons, Inc. All rights reserved.

Genetic
• Twin studies suggest heritability
 About 20-40% for phobias, GAD, and
PTSD
 About 50% for panic disorder
• Relative with phobia increases
risk for other anxiety disorders in
addition to phobia

Neurobiological
• Fear circuit overactivity
 Amygdala
 Medial prefrontal cortex deficits
• Neurotransmitters
 Poor functioning of serotonin and
GABA
 Higher levels of norepinephrine
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Behavioral
inhibition
• Tendency to be agitated, distressed, and cry in
unfamiliar or novel settings
 Observed in infants as young as 4 months
 May be inherited
• Predicts anxiety in childhood and social anxiety in
adolescence
 Neuroticism
• Tendency to react with frequent negative affect
• Linked to anxiety and depression
• Higher levels linked to double the likelihood of
developing anxiety disorders
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Sustained negative beliefs about future
• Bad things will happen
• Engage in safety behaviors
 Belief that one lacks control over
environment
• More vulnerable to developing anxiety disorder
 Childhood trauma or punitive parenting may foster beliefs
 Serious life events can threaten sense of control
 Attention to threat
• Tendency to notice negative environmental cues
 Selective attention to signs of threat
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Two-factor
model of behavioral
conditioning
• Conditioned responses to threat
• Sustained by avoidance or safety behaviors
 Avoid eye contact, appear aloof, stand apart from others
in social settings
 Risk factors act as diatheses
• Vulnerabilities influence development of phobias
 Prepared learning
• Evolutionary preparation to fear certain stimuli
 Potentially life-threatening (heights, snakes, etc.)
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Behavioral factors
• Factors similar to specific phobia (i.e., classical
and operant conditioning)
 Cognitive factors
• Unrealistic negative beliefs about consequences of
behaviors
• Excessive attention to internal cues
• Fear of negative evaluation by others
 Expect others to dislike them
• Negative self-evaluation
 Harsh, punitive self-judgment
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Neurobiological
factors
• Locus coeruleus
 Major source of
norepinephrine
 A trigger for nervous system
activity
 People with panic disorder
more sensitive to drugs that
trigger the release of
norepinephrine
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Behavioral
factors:
• Interoceptive conditioning
 Classical conditioning of panic
in response to internal bodily
sensations
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Cognitive
factors
• Catastrophic
misinterpretations of somatic
changes
 Interpreted as impending doom
 I must be having a heart attack!
 Beliefs increase anxiety and
arousal
 Creates vicious cycle
 Anxiety
Sensitivity Index
• High scores predict development of
panic
 “Unusual body sensations scare me.”
 “When I notice that my heart is beating rapidly, I
worry that I might have a heart attack.”
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Genetic risk
• Polymorphism in a gene guiding neuropeptide S
function, the NPSR1 gene, has been tied to an
increased risk of panic disorder and is associated
with:
 Amygdala response to threat
 Cortisol response
 Higher anxiety sensitivity scores
• Genetic risk shapes stress responses and
hypersensitivity to somatic changes, and this may
then increase the risk for panic disorder.
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Fear-of-fear
hypothesis (Goldstein & Chambless,
1978)
• Expectations about the catastrophic consequences
of having a public panic attack
 What will people think of me?!?!
© 2015 John Wiley & Sons, Inc. All rights reserved.
 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
• Worrying decreases psychophysiological arousal
• Avoidance prevents extinction of underlying anxiety
© 2015 John Wiley & Sons, Inc. All rights reserved.
© 2015 John Wiley & Sons, Inc. All rights reserved.
 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
 70-90% effective
 Systematic desensitization
• Relaxation plus imaginal exposure
 Cognitive
approaches
• Increase belief in ability to cope with the anxiety trigger
• Challenge expectations about negative outcomes
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Phobias
• Exposure
 In vivo (real-life) exposure more effective than systematic
desensitization
 Social Anxiety
• Exposure
Disorder
 Role playing or small group interaction
• Social skills training
 Reduce use of safety behaviors
• Cognitive therapy
 Clark’s (2003) cognitive therapy more effective than
medication or exposure
© 2015 John Wiley & Sons, Inc. All rights reserved.
 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
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Cognitive Behavioral Therapy (CBT)
• Systematic exposure to feared situations
• Self-guided treatment effective
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Relaxation
training
 Cognitive behavioral methods
• Challenge and modify negative thoughts
• Increase ability to tolerate uncertainty
• Worry only during “scheduled” times
• Focus on present moment
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Anxiolytics: drugs
• Benzodiazepenes
that reduce anxiety
 Valium
 Xanax
• Antidepressants
 Tricyclics
 Selective Serotonin Reuptake Inhibitors (SSRIs)
 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
• Side effects can be problematic with continuing
medication
 D-cycloserine (DCS)
 Enhances learning and can bolstered treatment effectiveness
© 2015 John Wiley & Sons, Inc. All rights reserved.
Copyright 2015 by John Wiley & Sons, Inc. All
rights reserved. No part of the material protected
by this copyright may be reproduced or utilized in
any form or by any means, electronic or
mechanical, including photocopying, recording
or by any information storage and retrieval
system, without written permission of the
copyright owner.
© 2015 John Wiley & Sons, Inc. All rights reserved.