Anxiety disorders

Anxiety - a negative mood state characterized by physical tension and apprehension about the future.
Much more diffuse than fear.
Fear - an immediate alarm reaction to danger. Protects us by activating a massive response from the
autonomic nervous system (increased heart rate and blood pressure, for example), which, along with
our subjective sense of terror, motivates us to escape or, possibly, to attack. As such, this emergency
reaction is often called the flight-or-fight response.
Panic attack - an abrupt experience of intense fear or acute discomfort, accompanied by physical
symptoms that usually include heart palpitations, chest pain, shortness of breath, and, possibly,
dizziness.
 Expected (cued) panic attack – the panic attack happens in certain situations but not anywhere
else
 Unexpected (uncued) panic attack – the panic attack happens at random and you don’t have a
clue when or where the next attack will occur.
Causes of anxiety
 Biological contributions
o Inherited tendency to be tense, uptight, and anxious
o Depleted levels of GABA-benzodiazepine system
o Dysfunctional CRF
o Behavioral inhibition system (BIS) – Jeffrey Gray. activated by signals from the brain
stem of unexpected events, such as major changes in body functioning that might signal
danger. When the BIS is activated by signals that arise from the brain stem or descend
from the cortex, our tendency is to freeze, experience anxiety, and apprehensively
evaluate the situation to confirm that danger is present.
o fight/flight system (FFS) – Jeffrey Gray. When stimulated in animals, this circuit
produces an immediate alarm and-escape response that looks very much like panic in
humans
o cigarette smoking as a teenager
o overresponse limbic system, including the amygdala (abnormal bottom-up processing)
o controlling functions of the cortex that would down-regulate the hyperexcitable
amygdala are deficient (abnormal top-down processing)
 Psychological contributions
o a psychic reaction to danger surrounding the reactivation of an infantile fearful situation
(Freud)
o the product of early classical conditioning, modelling, or other forms of learning
(behaviorists)
o A general sense of uncontrollability
 parents who are overprotective and over-intrusive
o anxiety sensitivity (personality trait)
o emotional response that becomes associated with a variety of external and internal cues
that provokes a fear response and assumption of danger (even if not present); learned
or false alarm
 Social contributions
o Stressful life events
o Genetic contribution (family reaction to stress is similar)
Integrative model
  Triple vulnerability theory – David Barlow. Anxiety disorders result from the interaction of
generalized biological vulnerability, generalized psychological vulnerability, and specific
psychological vulnerability
o Generalized biological vulnerability – genetic inheritance (e.g., heritable contribution to
negative affect)
o Generalized psychological vulnerability - beliefs that make the person vulnerable to
anxiety in general (e.g., sense that events are uncontrollable/unpredictable)
o Specific psychological vulnerability - specific beliefs that make the person vulnerable to
a particular anxiety disorder (e.g., physical sensations are potentially dangerous)
Comorbidity
 Major depressive Disorder and Alcohol or drug abuse (substance use disorder)
Comorbidity with physical disorders
 Thyroid disease, respiratory disease, gastrointestinal disease, arthritis, migraine headaches,
cardiovascular disease
Suicide
 20% of patients with PD attempted suicide (Weismann et al.)
o Comparable to individuals with major depression
o The relationship between anxiety and suicide is strongest with PD and PTSD
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Generalized Anxiety Disorder – anxiety disorder characterized by intense, uncontrollable, unfocused,

chronic, and continuous worry that is distressing and unproductive, accompanied by physical symptoms
of muscle tension, irritability, and restlessness. People with GAD mostly worry about minor, everyday
life events
Clinical description
 At least 6 months of excessive anxiety and worry that is ongoing for more days than not
 Difficulty turning off or controlling the worry process
 Associated with 3 or more of the following symptoms (for children, only one physical symptom
is required):
o Restlessness or feeling keyed up or on edge (mental agitation)
o Susceptibility to fatigue
o Difficulty concentrating or mind going blank (focusing attention is hard)
o Irritability
o Muscle tension
o Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
 Causes clinically significant distress or impairment in social, occupational, or other important
areas of functioning.
 Not due to the direct physiological effects of a substance
 Not better explained by another mental disorder
Statistics
o One of the most common anxiety disorders
o 3.1% of the population meets criteria for GAD during a 1-year period and 5.7% at some point in
a person’s lifetime
o Adolescents: 1.1%
o About two-thirds are female
o Earlier and more gradual onset (median age of onset: 31) and chronic once it develops
(characterized by waxing and waning of symptoms)
 o Most common in adults (senior) over 45 years of age and least common in ages 15 to 24
Causes
o Inherited tendency, specifically in a particular trait, anxiety sensitivity: the tendency to become
distressed in response to arousal-related sensations, arising from beliefs that these anxiety-
related sensations have harmful consequences
o Compared with other anxiety disorders, GAD show less responsiveness on most physiological
measures, such as heart rate, blood pressure, skin conductance, and respiration rate
o Chronically tense (muscle tension)
o Four distinct cognitive characteristics of people with GAD (Michael Dugas and Robert Ladouceur)
o intolerance of uncertainty
o positive beliefs about worry
o poor problem orientation
o cognitive avoidance.
o Highly sensitive to threat in general
Treatment
o Benzodiazepines are most often prescribed (short-term relief)
o Risks: impairs both cognitive and motor functioning; produce dependence
o Antidepressants
o Paroxetine (paxil)
o Venlafaxine (Effexor)
o Psychological treatment (more effective long-term)
o Cognitive behavioral therapy: patients evoke the worry process during therapy sessions
and confront threatening images and thoughts head-on. The patient learns to use
cognitive therapy and other coping techniques to counteract and control the worry
process
o Meditational and mindfulness-based approaches: help teach the patient to be more
tolerant of these feelings
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Panic Disorder - which individuals experience severe unexpected panic attacks; they may think they’re
dying or otherwise losing control.
Clinical Description
o Recurrent unexpected panic attack (can occur from a calm state or an anxious state)
o Palpitations, pounding heart, or accelerated heart rate
o Sweating
o Trembling or shaking
o Sensations of shortness of breath or smothering
o Feelings of choking
o Chest pain or discomfort
o Nausea or abdominal distress
o Feeling dizzy, unsteady, light-headed, or faint
o Chills or heat sensations
o Paresthesias (numbness or tingling sensations)
o Derealization (feelings of unreality) or depersonalization (being detached from oneself)
o Fear of losing control or “going crazy”
o Fear of dying
 o At least one of the attacks has been followed by 1 month (or more) of one or both of the
following:
 Persistent concern or worry about additional panic attacks or their
consequences
 significant maladaptive change in behavior related to the attacks
o Not attributable to the physiological effects of a substance
o Not better explained by another mental disorder
Agoraphobia - fear and avoidance of situations in which a person feels unsafe or unable to escape to get
home or to a hospital in the event of developing panic symptoms or other physical symptoms, such as
loss of bladder control. People develop agoraphobia because they never know when these symptoms
might occur. In severe cases, people with agoraphobia are totally unable to leave the house, sometimes
for years on end.
Clinical Description
o Marked fear or anxiety about two or more of the following five situations:
o Using public transportation (e.g., automobiles, buses, trains, ships, planes).
o Being in open spaces (e.g., parking lots, marketplaces, bridges).
o Being in enclosed places (e.g., shops, theatres, cinemas).
o Standing in line or being in a crowd.
o Being outside of the home alone.
o The individual fears or avoids these situations because of thoughts that escape might be difficult
or help might not be available in the event of developing panic-like symptoms or other
incapacitating or embarrassing symptoms
o The agoraphobic situations almost always provoke fear or anxiety.
o The agoraphobic situations are actively avoided, require the presence of a companion, or are
endured with intense fear or anxiety.
o The fear or anxiety is out of proportion to the actual danger
o The fear, anxiety or avoidance is persistent, typically lasting for 6 months or more.
o The fear, anxiety, or avoidance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
o If another medical condition is present (e.g., inflammatory bowel disease, Parkinson’s disease) is
present, the fear, anxiety, or avoidance is clearly excessive.
o The fear, anxiety, or avoidance is not better explained by the symptoms of another mental
disorder
The development of agoraphobia
o Coined in 1871 by Karl Westphal
o In the original Greek, refers to the fear of the marketplace
o Agoraphobic avoidance behavior = complication of severe unexpected panic attacks
o anxiety is diminished for individuals with agoraphobia if they think a location or person
is safe
o independent of panic attacks: an individual who has not had a panic attack for years may still
have strong agoraphobic avoidance (one way of coping w/ unexpected panic attacks)
o other methods of coping: 1) alcohol or drugs 2) endures with intense dread
o interoceptive avoidance – avoidance of internal physical sensations; removing oneself from
situations or activities that might produce the physiological arousal that somehow resembles
the beginnings of a panic attack
Statistics
  in the US, 3.5% of the population meet the criteria for PD at some point during their life; three-
fourths are women; 5.3% meet criteria for agoraphobia
 onset: early adulthood (mid-teens through 40 years of age); mean onset: 25 to 29 years of age
 males experiencing panic attack cope in a culturally expected way: consuming large amounts of
alcohol that could lead to alcohol dependence
Cultural influence
 Asian and African counties show the lowest prevalence rate of PD
o In the US, Asian American shows the lowest while American having the highest
prevalence rate
o Rates of recover in PD are lower in African American
 Susto (Latin America)
o characterized by sweating, increased heart rate, and insomnia but not by reports of
anxiety or fear, even though a severe fright is the cause.
 Ataquis de Nervios (Carribean)
o symptoms of an ataque seem quite similar to those of panic attacks, although such
manifestations as shouting uncontrollably or bursting into tears may be associated more
frequently with an ataque than with panic
 Kayak-angst (Inuit of northern Canada and western Greenland)
o involves episodes of intense fear, worries about drowning, physical arousal sensations
(rapid heartbeat and trembling), and intense disorientation that occur when a seal
hunter or fisher is alone at sea
 can cause the hunter or fisher to avoid travel in the kayak, which can obviously
lead to significant impairments in his or her livelihood
Nocturnal panic attacks
o occur during delta wave or slow-wave sleep, which typically occurs several hours after we fall
asleep and is the deepest stage of sleep.
o people with PD often begin to panic when they start sinking into delta sleep, and then
they awaken in the midst of an attack.
o because there is no obvious reason for them to be anxious or panicky when they are
sound asleep, most of these individuals think they are dying
o Cause: change in stages of sleep to slow-wave sleep produces physical sensations of “letting go”
that are very frightening to an individual with panic disorder
o Isolated sleep paralysis - during this period the individual is unable to move and experiences a
surge of terror that resembles a panic attack; occasionally, the person also has vivid
hallucinations.
 Cause: REM sleep (stage of sleep where dream-like activity occurs; characterized
by rapid eye movement) that spills over into the waking cycle
Causes
o Generalized biological vulnerability - tendency to be generally neurobiologically overreactive to
the events of daily life
o Learned alarms: cues that become associated with several different internal and external stimuli
through a learning process (e.g., being in a movie theatre when panic first occurred would be an
external cue that might become a conditioned stimulus for future panics)
o Specific psychological vulnerability - tendency to believe that unexpected bodily sensations are
dangerous (e.g., he or she may think that the physical sensations associated with the panic
attack could mean that something terrible is about to happen, perhaps death)
 o David Clark - emphasizes the specific psychological vulnerability of people with this disorder to
interpret normal physical sensations in a catastrophic way
Treatment
o Medication (60% of patients with PD are free from panic as long as they stay on an effective
drug)
o High-potency benzodiazepine (e.g., alprazolam “Xanax”)
o Selective-serotonin reuptake inhibitors (SSRIs) (e.g., Prozac and Paxil)
o Serotonin-norepinephrine reuptake inhibitors (SNRIs) (e.g., venlafaxine)
o Psychological intervention (performed better in the long run)
o Gradual exposure exercises (sometimes combined with relaxation or breathing
retraining) -> 70% of patients show a reduction in their anxiety and panic and their
agoraphobic avoidance greatly diminished
o Panic control treatment (PCT) - concentrates on exposing patients with panic disorder
to the cluster of interoceptive sensations that remind them of their panic attacks by
attempting to create mini panic attacks
o Cognitive behavioral therapy
o Combined psychological and drug treatments
o Barlow et al., (2000) - Combined treatment was no better than individual treatments.
After six additional months of maintenance treatment the results looked much as they
did after initial treatment, except there was a slight advantage for combined treatment
o benzodiazepines taken over a long period are associated with cognitive impairment
o no advantage to combining drugs and CBT initially for panic disorder and agoraphobia.
Psychological treatment should be offered initially, followed by drug treatment for those
patients who do not respond adequately or for whom psychological treatment is not
available.
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Specific Phobia - an irrational fear of a specific object or situation that markedly interferes with
an individual’s ability to function. Was formerly called “simple phobia” in earlier versions of the
DSM to distinguish from more complex agoraphobia
Clinical Description
o Marked fear or anxiety about a specific object or situation
o The phobic object or situation almost always provokes immediate fear or anxiety
o The phobic object or situation is actively avoided or endured with intense fear or anxiety
o The fear or anxiety is out of proportion to the actual danger posed by the specific object
or situation and to the sociocultural context
o The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more
o The fear, anxiety, or avoidance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning
o The disturbance is not better explained by the symptoms of another mental disorder
Specify if:
o Animal (e.g., spiders, insects, dogs)
o Natural environment (e.g., heights, storms, water)
o Blood-injection-injury (e.g., needles, invasive medical procedures)
o Situational (e.g., airplanes, elevators, enclosed places)
o Other (e.g., situations that may lead to choking or vomiting; in children, e.g., loud
sounds or costumed characters).
 Blood-injury-injection phobia - Unreasonable fear and avoidance of exposure to blood, injury,
or the possibility of an injection. Victims experience fainting and a drop in blood pressure
 Runs in families more strongly than in other phobias; inherited a strong vasovagal
response to blood, injury, or possibility of injection
 Onset: 9 years of age
Situational phobia - Anxieties involving enclosed places (e.g., claustrophobia) or public
transportation (e.g., fear of flying)
 also runs in family similar to PD and agoraphobia
 Never experience panic attack outside the context of their phobic object or situation
compared to panic disorder
 Onset: mid-teens to mid-20s
Natural environment phobia - Extreme fear of situations or events in nature, especially heights,
storms, and water; clusters together
 Many of the situations have some danger associated with them, and therefore, the fear
which is mild to moderate can be adaptive
 Onset: 7 years of age
 have to be persistent (lasting at least six months) and to interfere substantially with the
person’s functioning, leading to avoidance of boat trips or summer vacations in the
mountains where there might be a storm.
Animal phobia - Unreasonable, enduring fear of animals or insects that usually develops early in
life.
 The fear is common but becomes phobic only if severe interference with functioning
occurs
 Onset: 7 years of age
Statistics
 Most prevalent anxiety disorder
 sex ratio is 4:1 and occurs overwhelmingly in females
 chronic course
 Pa-leng (fear of the cold) - Chinese medicine holds that there must be a balance of yin and yang
forces in the body for health to be maintained. Individuals with Pa-leng have a morbid fear of
the cold. They ruminate over loss of body heat and may wear several layers of clothing even on
a hot day
 Declines with old age
Causes
 Four ways of developing a phobia: 1) direct experience, 2) experience a false alarm (panic
attack) in a specific situation, 3) observing someone else experiencing severe fear (vicarious
experience, and 4) being told about the danger
 Information transmission – being warned repeatedly about a potential danger that leads to the
development of a phobia
Treatment
 Exposure-based exercises
o Graduated exposure-based exercise for blood-injection-injury phobia where fainty is a
possibility; Individuals must tense various muscle groups during exposure exercises to
keep their blood pressure sufficiently high to complete the practice
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Separation Anxiety Disorder - Excessive enduring fear, unrealistic and persistent worry in some children
that harm will come to them or their parents or other important people in their life, or that something
will happen to the children themselves that will separate them from their parents
 In school phobia, the fear is clearly focused on something specific to the school situation. In
sepanx, the act of separating from the parent or attachment figure provokes anxiety and fear
 4.1% of children have separation anxiety at a severe enough level to meet criteria for a disorder.
if untreated, can extend into adulthood in approximately 35% of case
 In treating separation anxiety in children, parents are often included to help structure the
exercises and also to address parental reaction to childhood anxiety
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Social Anxiety Disorder (social phobia) - Extreme, enduring, irrational fear and avoidance of social or
performance situations. In Performance anxiety, a subtype of SAD, the person usually has no difficulty
with social interaction, but when they must do something specific in front of people, anxiety takes over
and they focus on the possibility that they will embarrass themselves. The most common type of
performance anxiety, to which most people can relate, is public speaking
Clinical Description
 Marked fear or anxiety about one or more social situations in which the person is exposed to
possible scrutiny by others, with the fear that one will act in a way, or show anxiety symptoms
that will be negatively evaluated
 The social situations almost always provoke fear or anxiety, and are avoided or endured with
intense fear or anxiety
 The fear or anxiety is out of proportion to the actual threat posed by the social situation, and to
the sociocultural context.
 The fear, anxiety or avoidance is persistent, typically lasting for six months or more, and causes
clinically significant distress or impairment in social, occupational or other important areas of
functioning.
 The fear, anxiety or avoidance is not attributable to the effects of a substance or another
medical condition and is not better explained by the symptoms of another mental disorder or
condition.
Statistics
 As many as 12.1% of the general population suffer from SAD at some point in their lives
 Second only to specific phobia as the most prevalent anxiety disorder
 Sex ratio is 50:50
 Begins during adolescence, with a peak age of onset around 13 years
 Prevalent in young people (18-29 years of age), undereducated, single, and low socioeconomic
class
 A greater percentage are single
 More likely to be diagnosed among white Americans
 Cross-national data suggest t that Asian cultures show the lowest rates of SAD, whereas Russian
and U.S. samples show the highest rates
o Shinkeishitsu - a culture-bound syndrome prevalent in Japan, with symptoms that
include obsessions, perfectionism, ambivalence, social withdrawal, physical and mental
fatigue, hypersensitivity, and hypochondriasis.
 taijin kyofusho - Japanese people with this form of SAD strongly fear that some
aspect of their personal presentation (blushing, stuttering, body odor, and so
on) will appear reprehensible, causing other people to feel embarrassed. Thus,
 the focus of anxiety in this disorder is on offending or embarrassing others
rather than embarrassing oneself
Causes
 inherited tendency to fear angry faces and critical or rejecting people
 born with a temperamental profile or trait of inhibition or shyness that is evident as early as four
months of age.
 Generalized biological vulnerability - a biological tendency to be socially inhibited, or both
 Generalized psychological vulnerability - the belief that events, particularly stressful events, are
potentially uncontrollable (i.e., no alarm (but perceived poor social skills), false alarm
(associated with social-evaluative situations), and true alarm)
 Specific psychological vulnerability - The individual must also have learned growing up that
social evaluation in particular can be dangerous
Treatment
 Cognitive behavioral therapy – best treatment for this disorder
 Interpersonal psychotherapy (IPT)
 Social mishaps exposure - target the patients’ beliefs by confronting them with the actual
consequences of such mishaps (e.g., what would happen if you spilled something on yourself
while talking to somebody for the first time)
 family-based treatment
 SSRIs (i.e., Paxil, Zoloft, and Effexor)
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Selective Mutism - a rare childhood disorder characterized by a lack of speech in one or more settings in
which speaking is socially expected. Speech in selective mutism commonly occurs in some settings, such
as home, but not others, such as school, hence the term “selective.”
 the lack of speech must occur for more than one month and cannot be limited to the first
month of school.
 Treatment employs many of the same cognitive behavioral principles used successfully to treat
social anxiety in children but with a greater emphasis on speech

Reference:

Barlow, D. H., Durand, V. M., Lalumiere, M. L., & Hofmann, S. G. (2021). Abnormal
psychology: An integrative approach. Nelson Education Ltd.

Comer, R. J. (2016). Fundamentals of Abnormal Psychology. Worth Publishers.