Anxiety The diagnosis of Anxiety Disorders: Panic attacks are sudden, unexpected outbursts of severe anxiety, often characterised

d by intense physical symptoms such as breathlessness (Murray & Stein, 2008) Agoraphobia is the avoidance of situations where the individual fears a panic attack might occur and from which escape would be difficult. Individual with social anxiety disorder is keenly aware of the source of anxiety (i.e. scrutiny of others) whereas the individual with panic disorder or agoraphobia, or both experiences physically frightening symptoms for which they have no explanation (i.e. symptoms are unexpected). Social Anxiety disorder is the most common anxiety disorder (Murray & Stein, 2008). It is a risk factor for subsequent depressive illness and substance abuse. Functional neuroimaging studies point to increased activity in amygdala and insula in patients with social anxiety disorder, and genetic studies are increasingly focusing on this and other (e.g., personality trait neuroticism) core phenotypes to identify risk loci. People with anxiety disorder fear and avoid the scrutiny of others. The concern in such situations is that the individual will say or do something that will result in embarrassment or humiliation. These concerns are so pronounced that the individual shuns most interpersonal encounters (Schneier, 2006). They experience intense emotional or physical symptoms or both (e.g. fear, heart racing, sweating, trembling, trouble concentrating). They crave company of others, but shun social situations for fear of being found out as unlikable, stupid or boring. Accordingly, they avoid speaking in public speaking and expressing opinions which can lead to such individuals being mistakenly perceived as snobbish (Murray & Stein, 2008). People with social anxiety disorder are typified by low self-esteem and high selfcriticism (Cox, Fleet & Stein, 2004), and often have depressive symptoms. Social anxiety disorder has its independent burden of functional disability (including reduced workplace productivity), increased financial costs, and reduced health-related quality of life (Sareen et al, 2006). They often only reveal their problems with social anxiety upon direct questioning, rarely offering their symptoms up to their caregiver without solicitation. The reticence might be due to embarrassment about their symptoms, their belief that the practioner would not take their problem seriously, or it could be simply reflect their discomfort with authority figures (Roy-Byrne & Stein, 2005). It can, and frequently does, co-occur with major depression (Rush et al, 2005). It is a powerful risk factor for the subsequent onset of major depression (Beesdo et al, 2007). It also co-morbid with bipolar disorder (Simon et al, 2004). AETIOLOGY Cognitive theorists propose that anxiety disorders result from distorted beliefs about the dangerousness of certain situations, sensations and/or mental events (Clark, 1999). Numerous studies have shown this, where patients with anxiety disorders over-estimate the dangerousness of various stimuli and being associated with a specific type of negative belief (e.g. Harvey et al, 1993; Clark et al, 1997, Foa et al, 1999).

Most anxiety reactions are perfectly natural and they have evolved as adaptive responses that are essential for us to perform effectively in challenging circumstances. They help us anticipate and predict and is essential for activating our flight/fight response. However, people with anxiety disorders experience anxiety at an intense level in situations or to events that do not warrant such a response and is deemed as inappropriate, thus it becomes maladaptive and problematic for the individual (Lepine, 2002). Clark (1999) explains something prevents people with anxiety disorders in self-correcting their negative thinking. For example, before treatment chronic panic disorder patients have experienced numerous panic attacks where they often think they are having a heart attack they do not seem to have spotted that their repeated failure to die does not fit in with the idea that the sensations they experience in a panic attack resembles a heart attack. A similar problem arises in social phobia (social anxiety). People with social anxiety are afraid of negative evaluation from other people. They do not seem to realise people may perceive them as better than the low opinions they often associate themselves with. There are several factors that prevent patients from changing their negative thinking. Safety-seeking behaviour is defined as a behaviour which is performed in order to prevent or minimise a fear catastrophe (Salkovskis, 1991). So a patient with panic disorder might sit down and breathe slowly, erroneously believing that by doing this safety procedure they are making their anxiety go away. Salkovskiss ideas of safety behaviours influenced the Clark and Wells (1995) cognitive model of social phobia which purported internal processes were involved in maintaining social anxiety. For example, when people with social anxiety have a positive experience with people they attribute this success to something they did e.g. planning ahead their speech and memorising it. In this way, their basic fear persists. Attentional deployment refers to selective attention towards threat cues may play a role in the maintenance of anxiety disorders by enhancing the perception of threat. Lavy and van den Hout (1993) demonstrated this where subjects were presented with pictures of spider s and other non-phobic objects. Compared to non-patient controls, patients with spider phobia showed an attentional bias towards the spider pictures. People with panic disorder are obvious candidates for a possible attentional bias towards threat cues (Clark, 1999). They do not have the physical illness they are afraid of (i.e. heart attack) but they are not convinced. This could be due to their fears lead them to focus attention on their bodies and consequently they become aware of benign bodily sensations that other people do not notice. Ehlers et al (1992) support the attentional deployment hypothesis in which enhanced awareness of body cues contributes to the maintenance of panic disorders. Using a heartbeat detection paradigm, they found that panic disorder patients were more accurate at counting their heart bats than infrequent panickers, simple phobics and non-patient controls. Attention away from threat cues this is particularly applicable to social phobia/anxiety, where individuals with social anxiety tend to avoid looking at other people when in a feared social situation. This reduces some aspects of threat for a social phobic and provides a psychological escape. Chen, Ehlers, Clark and Mansell (1999) tested patients with social phobia and fund that compared to non-patient controls, patients with social phobia showed an attentional bias away from faces. Reduced processing of other people would mean that social phobics would

have less chance to observe other peoples responses in detail and thus would be unlikely to collect from other peoples reactions information that would help them see that they generally come across more positively than they think (e.g. Stopa & Clark, 1993). Reduced attention to stimuli also prevents their cognitive perception from being updated and their negative thoughts being corrected. Spontaneously occurring images Beck (1976) suggested that spontaneously occurring mental images in which patients see their fears realised are common in anxiety disorders and play an important role in enhancing perception of threat. Social phobia, again, can be applied here where social phobics are prone to experience spontaneously occurring images in which they see themselves as if viewed from outside (observer-perspective). Thy do not see what a true observe would see, but rather they see their fears visualised. Hackmann, Surawy and Clark (1989) gave patients with social phobia and non-patient controls a semi-structured interview which focused on spontaneous imagery in social anxietyprovoking situations. In contrast to 10% of non-patient controls, majority (77%) of patients with social phobia reported spontaneously occurring, negative, observer-perspective images, which they thought were at least partly distorted when they subsequently reflected on them. TREATMENT Cognitive therapy aims to modify negative beliefs and linked maintenance processes (Clark, 1999). As anxiety disorder patients beliefs are generally mistaken, and therapists can make considerable progress in correcting their negative beliefs given that patients are most likely to have encountered situations that contradicted their beliefs before coming to therapy. Images play an important role in treating symptoms of anxiety where they can be explicitly restructured in the patients eyes. For example, in most cases of treating social phobia, video feedback is often used where patients engage in a difficult social task while being videoed. They are then asked to describe in detail their image of how they appeared. Later, patients usually see the video image as more positive than their self-image. Harvey, Clark, Ehlers & Rapee (1998) found that video feedback has proved to be a powerful technique for correcting the distorted self-images of patients with social phobia, however they also noticed it could backfire as some patients continued to see the video image more negatively than an impartial observer. Questioning suggested this was because patients re-experienced feelings they had during social interactions while viewing the video which influenced their perception in a negative direction. Image modification also plays an important role in panic disorder. For example, patients who fear fainting in a supermarket might seem themselves collapsed on the floor but not getting up, recovering and going home. A useful technique in such an instance is to finish out the image by asking patients to recreate their negative image, hold it in mind until they start to feel anxious and then run it on until they seem the positive resolution. Empirical status of cognitive therapy Clark (1999) examines 7 controlled trials for cognitive therapy for panic disorder (intention-to-treat analyses) An average of 84% of the intention-to-treat sample was panic free. Immediate posttreatment response is superior to no treatment, supportive psychotherapy, applied relaxation (2 out of 3 studies) and imipramine.

Treatment gains are well-maintained at one to two year follow-up In social phobia, 15 consecutive cases were treated (Clark, 1998) and the overall improvement was substantial. For example, on the Fear of Negative Evaluation Scale (Watson & Friend, 1969), there was a mean improvement of 11 points at posttreatment and 15 points at follow-up, with pre-post effect sizes being 2.7 and 3.7 respectively.

TREATMENT for Social Anxiety A large database of RCTs shows efficacy of medications and CBT in social anxiety disorder (Fedoroff & Taylor, 2001; Stein, Ipser & Balkom, 2004), with relatively high effect sizes. In a meta-analysis, selective serotonin re-uptake inhibitors (SSRIs) had an effect size of 1.5, and exposure therapy and cognitive restructuring had an effect size of 1.8 on clinician-rated scales (Fedoroff & Taylor, 2000) Comparison of effect sizes in pharmacotherapy and psychotherapy trials is difficult because of differences in design of the relevant trials (e.g. psychotherapy trials often use a wait-list comparison) Nevertheless, seminal trials comparing drug treatment vs. CBT in social anxiety disorder suggested that drugs can have FASTER effects, but the effects of CBT might last longer (Gelernter et al, 1991; Heimberg et al, 1998). At present, no clear evidence shows that combined pharmacological and CBT is more effective than single modality treatment (Blomhoff et al, 2001; Davidson et al, 2004). The choice to begin one modality rather than another, or to use combined treatment often relies on clinical judgement about individual patients e.g. drug treatment might be advisable in a patient who was too anxious or depressed to begin psychotherapy. Early work showing that generalised social anxiety disorder responded to monoamine oxidase inhibitors had a substantial effect on the understanding and management of the disorder. Nevertheless, monoamine oxidase inhibitors were and continue to be of limited usefulness because they need strict and inconvenient dietary restrictions and can be associated with marked adverse effects. It has been thought that the addition of CBT during LT treatment of social anxiety disorder would enable the maintenance of response after stopping drug treatment, but systematic data for this idea have not been reported (Murray & Stein, 2008). CBT was effective for the treatment of social anxiety disorder in many studies (Fedoroff & Taylor, 2001). Components of this treatment can include psychoeducation, progressive muscle relaxation, social skills training, in-vivo exposure, video feedback and cognitive restructuring (Huppert, Roth & Foa, 2003). Generally, CBT entails a time-limited collaboration between clinician and patient, is focused on the present rather than the past, and aims to teach patients the behavioural and cognitive skills that will allow them to function efficiently. In social anxiety disorder, such therapy has been adapted on the basis of cognitive models that emphasise the relationship between dysfunctional belief systems and behavioural avoidance (Amir et al, 2005).

 The question of which component of CBT is the most effective remains controversial, though recent evidence suggests that including a cognitive component is crucial (Clark, Ehlers, Hackmann et al, 2006). Recent research suggests that individual therapy is more effective than group therapy (Mortberg, Clark & Sundin, 2007). As in the case of drug treatment, additional work is needed to establish the efficacy of CBT in real-world contexts (Gaston, Abbott, Rapee & Neary, 2006).