ANXIETY DISORDERS
LECTURE OUTLINE
• Panic and anxiety – background and
history
• Etiology – theoretical perspectives
• Types of anxiety disorders and their
treatment
• Treatments
ANXIETY DISORDERS
Who is afraid of ?
• small insect
• animal, reptile
• speaking to a large audience
• speaking in front of a small group of
familiar people
• meeting new people
• attending social gatherings
ANXIETY DISORDERS
Background and history
• experience of anxiety – cognitive,
somatic, behavioural, emotional
• panic – discrete period of intense fear or
discomfort (brief and intense)
• palpitations, shaking, chest pain, fear of
dying, going crazy, losing control
• anxiety – negative affect, sense of
uncontrollability of future threat, selfpreoccupation
ANXIETY DISORDERS
Background and history
• panic attacks occur spontaneously
• both panic and anxiety can be “normal”
experiences
• they become maladaptive when they
become excessive, chronic, and in
absence of any real danger
ANXIETY DISORDERS
Background and history
Prevalence
• 25% of population may be expected to
have an anxiety disorder at some time in
their lives
• Ontario Health Supplement – 1-year
prevalence rates of 9% for men, 16% for
women
ANXIETY DISORDERS
Background and history
• 1800s and early 1900s – neuroses,
Freudian perspective
• 1920s – Watson, classical conditioning
model, Little Albert
• later 1900s – Eysenck – neuroticism as a
basic personality dimension – strong
emotions, moody, restless, anxious
ANXIETY DISORDERS
Etiology
Psychodynamic perspective
• realistic, neurotic, moral anxiety
• defense mechanisms
• origins in early parent-child relationships
• neurotic paradox – contradicts pleasure
principle
ANXIETY DISORDERS
Etiology
Neurotic styles – Shapiro
• inhibition of assertion/aggression
• inhibition of responsibility/independence
• inhibition of compliance/submission
• inhibition of trust/intimacy
ANXIETY DISORDERS
Etiology
Biological perspective - Genetics
• family studies show up to 25% have an
immediate family member with an anxiety
disorder
• twin studies - higher concordance rates
for MZ than DZ twins
• genetics may operate through
behavioural inhibition
ANXIETY DISORDERS
Etiology
Biological perspective - Neuroanatomy
• locus ceruleus
• amygdala
• one form of peptide (combo of amino
acids), CCK4, related to panic; CCK4 is
found in amygdala, hippocampus, cerebral
cortex, brain stem
ANXIETY DISORDERS
Etiology
Biological perspective - Neurotransmitters
• norepinephrine (NE) – concentrated in
locus ceruleus
• serotonin
• dopamine in social phobia and OCD
• interactions – serotonin affects locus
ceruleus (where NE is produced) and may
also influence GABA
ANXIETY DISORDERS
Etiology – Limitations of 2-factor theory
• cannot explain all phobias – some seem
to develop without conditioning
• difficult to create some fears in the lab
• cannot explain why some stimuli are
more likely to become feared than others
ANXIETY DISORDERS
Etiology – Rachman’s revised theory
• classical conditioning
• modelling
• informational or instructional
transmission
ANXIETY DISORDERS
Etiology – Biological preparedness theory
• Seligman – evolutionary significance of
stimuli that are easily conditioned
• Bandura – properties of stimuli
themselves (unpredictability and
uncontrollability) and the cognitive
processing that defines their threatening
nature
ANXIETY DISORDERS
Etiology – Cognitive theories
• Bandura – low perceived self-efficacy
• Beck – experiences, beliefs, appraisals
• Ellis – irrational beliefs, catastrophization
ANXIETY DISORDERS
Etiology – Biopsychosocial perspective
• emotion
• biology
• environment
• behaviour
• cognition
ANXIETY DISORDERS
Types – Specific phobia
• animal
• environmental
• blood, injury, injection
• specific situation – elevators, flying
• other
ANXIETY DISORDERS
Types – Specific phobia – Diagnostic
features
• marked and persistent fear and avoidance
of specific stimulus or situation
• must interfere significantly with person’s
life
• must be considered excessive or
unrealistic
• ANS arousal
ANXIETY DISORDERS
Types – Specific phobia
• prevalence rates from 7-11%
• often emerge during adolescence, usually
earlier than age 25
• tend to be chronic, but may fluctuate over
life course
• usually assessed with self-report
• conditioning theories
desensitization
systematic
ANXIETY DISORDERS
Systematic desensitization (SD) for
specific phobia
Wolpe (1958) – reciprocal inhibition and SD
3 components of SD
• construction of stimulus hierarchy
• progressive (deep muscle) relaxation
training
• progress through the hierarchy while
practicing relaxation response
ANXIETY DISORDERS
Panic disorder - Elements
• recurrent, unexpected panic attacks
• persistent concern, preoccupation with
having another attack
• worry about consequences of attack
• significant behaviour change in response
to attacks
ANXIETY DISORDERS
Panic disorder – Other clinical features
• often accompanied by avoidance behaviours
(agoraphobia)
• possible to have agoraphobia without panic
attacks
• onset around late adolescence, early
adulthood
• more women than men
• high rates of service utilization, poor quality
of life
ANXIETY DISORDERS
Clark’s cognitive model of panic disorder)
• catastrophic misinterpretation of arousalrelated bodily sensations
• agoraphobia (avoidance) as way of coping
ANXIETY DISORDERS
Obsessive-compulsive disorder (OCD) Elements
• recurrent obsessions, compulsion, or
both
• obsessesions – thoughts, images,
impulses, that are persistent, markedly
distressing
• compulsion – repetitive behaviours
performed in response to an obsession
ANXIETY DISORDERS
Obsessive-compulsive disorder (OCD) Elements
• common obsessions – violence, sex,
contamination, order
• common compulsions – washing,
cleaning, checking, seeking reassurance,
ordering or arranging objects
• cleaners vs. checkers – focus on harm vs.
order
ANXIETY DISORDERS
Obsessive-compulsive disorder (OCD) Background
• very rare – 2.5% lifetime prevalence rate
• little gender difference
• high overlap with depression and
Tourette’s syndrome
ANXIETY DISORDERS
Obsessive-compulsive disorder (OCD) –
Psychodynamic perspective
• anal fixation – “Does anal-retentive have
a hyphen?”
• reaction formation, undoing,
displacement
ANXIETY DISORDERS
Obsessive-compulsive disorder (OCD) –
Treatments
• Prozac - SSRIs
• Exposure and response prevention
ANXIETY DISORDERS
Post-traumatic stress disorder (PTSD) –
Description
Person has been exposed to traumatic event
3 symptom clusters
• recurrent re-experiencing of event
• avoidance of trauma-related stimuli and
numbing
• increased arousal
Persists for at least 1 month after trauma
ANXIETY DISORDERS
Post-traumatic stress disorder (PTSD) –
Etiology
Cognitive theories
• expectations and appraisals
• fear structure in long-term memory
• fear conditioning
ANXIETY DISORDERS
Generalized anxiety disorder (GAD) –
Description
• Core feature is worrying – worries are
unrealistic, difficult to control, excessive
• “Free floating” anxiety
• Verbal thoughts rather than images as in OCD
• Motor tension, vigilance, scanning
• “What if?” – background of intolerance of
uncertainty
ANXIETY DISORDERS
Generalized anxiety disorder (GAD) –
Description
3 key features
• uncontrollability
• intolerance of uncertainty
• ineffective problem-solving skills
ANXIETY DISORDERS
Treatments - Pharmacotherapy
3 main drugs
• Xanax
• Paxil
• Zoloft
SSRIs, bezodiazepines, tricyclic antidepressants, MAOs
ANXIETY DISORDERS
Treatments - Exposure
• flooding, response prevention
• confrontation with anxiety-producing
stimulus
• developing more adaptive internal
representations of the stimuli and their nonthreatening consequences
ANXIETY DISORDERS
Treatments – Cognitive restructuring
• identify maladaptive cognitions
• challenge maladaptive cognitions
• develop more adaptive cognitions
ANXIETY DISORDERS
Treatments – Relaxation training
• decreases physiological arousal through:
• deep muscle relaxation
• positive imagery
• meditation
• deep breathing
ANXIETY DISORDERS
Treatments – Problem-solving training
• What is my problem? What is my goal? What
solutions can I generate to solve the
problem? What might be the consequences of
each solution? Try a solution
• particularly relevant to GAD
• divides problems into manageable units
ANXIETY DISORDERS
SUMMARY
• both biological and psychological factors
involved in etiology of anxiety disorders –
biopsychosocial model
• shift away from Freudian perspective on
“neuroses”
• both biological and psychological
treatments for the various disorders