1. Chapter 4 Anxiety Disorders
Chapter 4 Anxiety Disorders

2. Nature of Anxiety and Fear
Fear – The Present-Oriented Mood State
Immediate fight or flight response to danger or threat
Involves abrupt activation of the sympathetic nervous system
Strong avoidance/escapist tendencies
Marked negative affect

3. Nature of Anxiety and Fear
Anxiety – The Future-Oriented Mood State
Apprehension about future danger or misfortune
Somatic symptoms of tension
Characterized by marked negative affect
Anxiety and Fear are Normal Emotional States

4. From Normal to Disordered Anxiety and Fear
Characteristics of Anxiety Disorders
Pervasive and persistent symptoms of anxiety and fear
Involve excessive avoidance and escape
Cause clinically significant distress and impairment

5. The Phenomenology of Panic Attacks
What is a Panic Attack?
Abrupt experience of intense fear or discomfort
Several physical symptoms (e.g., breathlessness, chest pain)
Fear as an alarm response

6. The Phenomenology of Panic Attacks (continued)
DSM-IV-TR Subtypes of Panic Attacks
Situationally bound (cued)
Unexpected (uncued)
Situationally predisposed

7. Figure 4.1 The relationships among anxiety, fear, and panic attack
Fig. 4.1, p. 126

8. Biological Contributions to Anxiety and Panic
Genetic Vulnerability
Anxiety and brain circuits
Depleted levels of GABA
Corticotropin releasing factor (CRF) and HYPAC axis

9. Biological Contributions to Anxiety and Panic (continued)
Limbic (amygdala) and the septal- hippocampal systems
Behavioral inhibition (BIS)
Anxiety
Fight/flight (FF) systems
Fear

10. Psychological Contributions to Anxiety and Fear
Began with Freud
Anxiety is a psychic reaction to fear
Anxiety involves reactivation of an infantile fear situation

11. Psychological Contributions to Anxiety and Fear (continued)
Behavioral and Cognitive Views
Invokes conditioning and cognitive explanations
Anxiety and fear are learned responses
Catastrophic thinking and appraisals play a role

12. Psychological Contributions to Anxiety and Fear (continued)
Early Childhood Contributions
Experiences with uncontrollability and unpredictability
Social Contributions
Stressful life events trigger vulnerabilities

13. An Integrated Model
Integrative View – Triple Vulnerability Model
Generalized biological vulnerability
Generalized psychological vulnerability
Specific psychological vulnerability

14. An Integrated Model (continued)
Common Processes: The Problem of Comorbidity
Comorbidity is common across the anxiety disorders
Major depression is the most common secondary diagnoses

15. An Integrated Model (continued)
About half of patients have two or more secondary diagnoses
Comorbidity Suggests
Common factors
A relation between anxiety and depression

16. The Anxiety Disorders: An Overview
Generalized Anxiety Disorder
Panic Disorder with and without Agoraphobia
Specific Phobias
Social Phobia
Posttraumatic Stress Disorder
Obsessive-Compulsive Disorder

17. “Do you worry excessively about minor things?”
Figure 4.3 Clients’ answers to interviewer’s question, “Do you worry excessively about minor things?” (From “A Description of Patients Diagnosed with DSM-III-R Generalized Anxiety Disorder,” by W.C. Sanderson and D.H. Barlow, 1990, Journal of Nervous and Mental Disease, 178, p.590. Copyright© 1990 by Lippincott, Williams & Wilkins)
Fig. 4.3, p. 132

18. Generalized Anxiety Disorder: The “Basic” Anxiety Disorder
Overview and Defining Features
Excessive uncontrollable anxious apprehension and worry
Coupled with strong, persistent anxiety
Persists for 6 months or more
Somatic symptoms differ from panic (e.g., muscle tension)

19. Generalized Anxiety Disorder: The “Basic” Anxiety Disorder (continued)
Statistics
Affects about 4% of the general population
Females outnumber males approximately 2:1
Onset is often insidious, beginning in early adulthood
Very prevalent among the elderly
Tends to run in families

20. Generalized Anxiety Disorder: Associated Features and Treatment
Persons with GAD have been called “autonomic restrictors”
Fail to process emotional component of thoughts and images
Treatment of GAD: Generally Weak
Benzodiazapines – Often Prescribed
Psychological interventions – Cognitive- Behavioral Therapy
Combined treatments – Acute vs. Long- Term Outcomes

21. Figure 5.4 An integrative model of generalized anxiety disorder
Fig. 4.4, p. 134

22. Panic Disorder With and Without Agoraphobia
Overview and Defining Features
Experience of unexpected panic attack (i.e., a false alarm)
Develop anxiety, worry, or fear about another attack
Many develop agoraphobia

23. Panic Disorder With and Without Agoraphobia (continued)
Facts and Statistics
Affects about 3.5% of the general population
Onset is often acute, beginning between 25 and 29 years of age
75% of individuals with agoraphobia are female

24. Panic Disorder: Associated Features and Treatment
Nocturnal panic attacks – 60% panic during deep non-REM sleep
Interoceptive/exteroceptive avoidance
Medication Treatment
Target serotonergic, noraadrenergic, and GABA systems
SSRIs (e.g., Prozac and Paxil) are preferred drugs
Relapse rates are high following medication discontinuation

25. Panic Disorder: Associated Features and Treatment (continued)
Psychological and Combined Treatments
Cognitive-behavior therapies are highly effective
No evidence that combined treatment produces better outcome
Best long-term outcome is with cognitive- behavior therapy alone

26. Specific Phobias: An Overview
Overview and Defining Features
Extreme irrational fear of a specific object or situation
Persons will go to great lengths to avoid phobic objects
Most recognize that the fear and avoidance are unreasonable
Markedly interferes with one’s ability to function

27. Specific Phobias: An Overview (continued)
Facts and Statistics
Females are again over-represented
Affects about 11% of the general population
Phobias tend to run a chronic course

28. Specific Phobias: Associated Features and Treatment
Associated Features and Subtypes of Specific Phobia
Blood-injury-injection phobia – Unusual vasovagal response
Situational phobia – Trains, planes, automobiles, closed spaces
Natural Environment phobia – Natural events (e.g., heights, storms)
Animal phobia – Animals and insects
Separation Anxiety – Seen in children

29. Specific Phobias: Associated Features and Treatment (continued)
Causes of Phobias
Biological and evolutionary vulnerability
Three pathways -- Conditioning, observational learning, information
Psychological Treatments of Specific Phobias
Cognitive-behavior therapies are highly effective – Exposure

30. Figure 4.8 A model of the various ways a specific phobia may develop (From Barlow, 2002)
Fig. 4.8, p. 150

31. Social Phobia: An Overview
Overview and Defining Features
Extreme and irrational fear in social/performance situations
Markedly interferes with one’s ability to function
Often avoid social situations or endure them with great distress
Generalized subtype – Affects many social situations

32. Social Phobia: An Overview (continued)
Facts and Statistics
Affects about 13% of the general population
Prevalence is slightly greater in females than males
Onset is usually during adolescence
Peak age of onset at about 15 years

33. Social Phobia: Associated Features and Treatment
Causes
Biological and evolutionary vulnerability
Similar learning pathways as specific phobias
Psychological Treatment
Cognitive-behavioral treatment
Cognitive-behavior therapies are highly effective

34. Social Phobia: Associated Features and Treatment (continued)
Medication Treatment
Tricyclic antidepressants and monoamine oxidase inhibitors
SSRIs Paxil, Zoloft, and Effexer – Are FDA approved
Relapse rates are high following medication discontinuation

35. Posttraumatic Stress Disorder (PTSD): An Overview
Overview and Defining Features
Main etiologic characteristics – Trauma exposure and response
Reexperiencing (e.g., memories, nightmares, flashbacks)
Avoidance

36. Posttraumatic Stress Disorder (PTSD): An Overview (continued)
Emotional numbing and interpersonal problems
Markedly interferes with one's ability to function
PTSD diagnosis – Only after 1 month post- trauma

37. Posttraumatic Stress Disorder (PTSD): An Overview (continued)
Statistics
Combat and sexual assault are the most common traumas
About 7.8% of the general population meet criteria for PTSD

38. Posttraumatic Stress Disorder (PTSD): Causes and Associated Features
Subtypes and Associated Features of PTSD
Acute – May be diagnosed 1-3 months post trauma
Chronic – Diagnosed after 3 months post trauma
Delayed onset – Onset 6 months or more post trauma
Acute stress disorder – PTSD immediately post-trauma

39. Posttraumatic Stress Disorder (PTSD): Causes and Associated Features (continued)
Causes of PTSD
Intensity of the trauma and one's reaction to it (i.e., true alarm)
Learn alarms -- Direct conditioning and observational learning
Biological vulnerability
Uncontrollability and unpredictability
Extent of social support, or lack thereof post-trauma

40. Posttraumatic Stress Disorder (PTSD): Treatment
Psychological Treatments
Cognitive-behavior therapies (CBT) are highly effective
CBT may include graduated or massed (e.g., flooding) imaginal exposure
Aim of CBT for PTSD

41. Obsessive-Compulsive Disorder (OCD): An Overview
Overview and Defining Features
Obsessions - Intrusive and nonsensical thoughts, images, or urges
Compulsions - Thoughts or actions to neutralize thoughts
Vicious cycle of obsessions and compulsions
Cleaning and washing or checking rituals are common

42. Obsessive-Compulsive Disorder (OCD): Causes and Associated Features
Statistics
Affects about 2.6% of the general population
Most with OCD are female
Onset is typically in early adolescence or young adulthood
OCD tends to be chronic

43. Obsessive-Compulsive Disorder (OCD): Causes and Associated Features (continued)
Causes of OCD
Parallels the other anxiety disorders
Early life experiences
Learning that some thoughts are dangerous/unacceptable
Thought-action fusion -- The thought is similar to the action

44. Obsessive-Compulsive Disorder (OCD): Treatment
Medication Treatment
Clomipramine and other SSRIs – Benefit up to 60% of patients
Relapse is common with medication discontinuation
Psychosurgery (cingulotomy) is used in extreme cases

45. Obsessive-Compulsive Disorder (OCD): Treatment (continued)
Psychological Treatment
Cognitive-behavioral therapy is most effective
CBT involves exposure and response prevention
Combining CBT with medication -- No better than CBT alone

46. Summary of the Anxiety Disorders
Most Common Forms of Psychopathology
From a Normal to a Disordered Experience of Anxiety and Fear
Triple Vulnerabilities – Bio-psycho-social
Fear and anxiety – Non-dangerous bodily or environmental cues
Symptoms and avoidance – Significant distress and impairment

47. Summary of the Anxiety Disorders (continued)
Psychological Treatments are Generally Superior in the Long-Term
Similar treatments for different anxiety disorders
Suggests that anxiety-related disorders share common processes