ANXIETY DISORDERS

The Nature of Anxiety Disorders

 The term ‘Neurosis’ was coined by the Scottish doctor William Cullen in 1769.

 It is derived from the Greek word neuron (nerve) with the suffix -osis which means diseased or abnormal
condition.

 According to the psychoanalytic theory, Neurosis represents a variety of mental disorders in which
emotional distress or unconscious conflict is expressed through various physical and mental symptoms
(e.g., hysteria). The definitive symptom is anxiety.

 The American Diagnostic and Statistical Manual of Mental Disorders (DSM) has eliminated the category of
Neurosis, reflecting a decision by the editors to provide descriptions of behavior as opposed to hidden
psychological mechanisms as diagnostic criteria.

What is anxiety?

• Anxiety is an unpleasant psychological and physiological state characterized by somatic, cognitive,

emotional, and behavioral components.

• It is a diffuse, unpleasant, vague sense of apprehension, often accompanied by physiological arousal.

Difference between Anxiety and Fear?

• Fear is a biologically based alerting response to a known, definite, external threat.

• Anxiety is a future-oriented state - it warns of impending danger and enables a person to take
measures to deal with the threat.

• Everyone experiences anxiety.

• Anxiety has adaptive functions.

• Anxiety becomes a source of clinical concern when it reaches such an intense level that it interferes
with the ability to function in daily life, as a person enters a maladaptive state characterized by extreme
physical and psychological reactions.

• Anxiety Disorders affect about 28 percent of Americans on a lifetime basis (Kessler et al.,2005).

Panic Disorder and Agoraphobia

• Panic disorder is characterized by the spontaneous, unexpected occurrence of panic attacks, which
can vary from several attacks during 1 day to only few attacks during a year.

DSM-IV Diagnostic Criteria for Panic Attack

• A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms
developed abruptly and reached a peak within 10 minutes:
  Palpitations, pounding heart, or accelerated heart rate
 Sweating
 Trembling or shaking
 Sensations of shortness of breath or smothering
 Feeling of choking
 Chest pain or discomfort
 Nausea or abdominal distress
 Feeling dizzy, unsteady, lightheaded, or faint
 Derealization (feelings of unreality) or Depersonalization (being detached from oneself)
 Fear of losing control or going crazy
 Fear of dying
 Paresthesias (numbness or tingling sensations)
 Chills or hot flushes

• The DSM IV-TR emphasizes that at least some of the panic attacks must be unexpected (uncued).

• In panic attacks that are situationally bound (cued), an individual may experience a panic attack in
anticipation of confronting a particular situation or immediately following exposure to a specific
stimulus or cue in the environment.

• In cases in which the person has a tendency to have a panic attack in the situation but does not have one
every time, is referred to as a situationally predisposed panic attack.

• The clinician must rule out intoxication with stimulants or any medical conditions such as
hypoglycemia, hyperthyroidism, respiratory or cardiovascular diseases that may be causing the
symptoms.

Characteristics of Panic Disorder

 Panic disorder is diagnosed when both of the following are present:

 recurrent unexpected panic attacks

 at least one of the attacks has been followed by one (or more) of following:

(a) persistent concern about having additional attacks

(b) worry about the implications of the attack or its consequences (e.g., losing control, having a heart
attack, "going crazy")

 The peak age of onset for Panic disorder is 20, with a smaller group of cases arising among people in their
mid-thirties.

 Adolescents who experience panic attacks are at much greater risk of developing psychological disorders
than those who do not experience panic attacks.

 Panic disorder in general is a chronic condition has a variable course.

 The disorder is often associated with agoraphobia:

 Patients with agoraphobia rigidly avoid situations in which it would be difficult to obtain help.
  They prefer to be accompanied by a friend or a family member on busy streets, crowded stores,
closed-in spaces and closed-in vehicles.

 The patient might insist that they be accompanied every time they leave the house.

 People with agoraphobia may develop idiosyncratic personal styles and behaviours in order to avoid the
feared situations.

 People with agoraphobia seek out ‘safety cues’, such as a safe person, who can be trusted to help out in the
event of a panic attack.

 The lifetime prevalence of agoraphobia without panic disorder is 1.6 percent of the adult population and the
lifetime prevalence of agoraphobia with panic disorder is 1.1 percent.

 Women are twice as likely as men to suffer from it.

Theories and Treatment of Panic Disorder and Agoraphobia

Biological Perspective:

 Biological relatives of individuals with panic disorder are 8 times more likely to develop this condition.

 People who develop panic disorder before age 20 are 20 times more likely to develop this condition.

 Excess of norepinephrine in the amygdala and

 Diminished response of GABA receptors in the cortex, is thought to play a role.

 The Anxiety Sensitivity Theory suggests that people with panic disorder have a hypersensitive
‘suffocation’ mechanism.

 Thus children may inherit a predisposition in which they overreact to the threat that they may be
deprived of oxygen.

Treatment:

 The most effective antianxiety medications are benzodiazepines (diazepam).

 These medications need to be taken for at least 6 months and possible for as long as a year.

 Clinicians sometimes administer antidepressants and SSRIs (fluoxetine, setraline)

Psychological Perspective:

 Conditioned fear reactions are thought to contribute to development of panic attacks.

 David Barlow gave a cognitive-behavioural model of anxiety disorders that explains the impact of a
combination of physiological, cognitive and behavioural factors through the development of a vicious
cycle.
 Treatment:

 Relaxation training is a behavioural technique commonly used in the treatment of panic disorder
and agoraphobia.

 Breathing retraining is done to manage hyperventilation.

 Experts recommend a graduated exposure to the anxiety provoking situations in comparison to

intensive exposure.

 Panic Control Therapy (PCT) is a form of cognitive-behavioural therapy, combines cognitive

restructuring, exposing the client to the bodily sensations associated with panic attacks and
breathing retraining.

Specific Phobia

 A specific phobia is defined as an irrational and unabating fear that provokes an immediate anxiety
response, causes significant disruption in functioning and results in avoidance behavior.

 There are various types of specific phobias and are quite common - the prevalence rates are 13.2%.

Characteristics of Specific Phobias

 Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a
specific object or situation.

 Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take
the form of a situationally bound or situationally predisposed Panic Attack.

 The person recognizes that the fear is excessive or unreasonable.

 The phobic situation (s) is avoided or else is endured with intense anxiety or distress.

 The avoidance, anxious anticipation, or distress in the feared situation (s) interferes significantly with the
person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there
is marked distress about having the phobia.

 Some phobias can be avoided and cause no significant impairment in functioning.

Theories and Treatment of Specific Phobias

Biological Perspective

 Biologically programmed to fear.

 Kendler and his colleagues (2001) reported genetic contributions ranging from 25 to 37 percent in the
etiology of phobias.

 Family members share similar phobias. Individuals with blood-injury phobias or situational phobias are
likely to have biological relatives who share similar conditions.
 Psychological Perspective

 Cognitive-behavioural theorists suggest that these conditions are rooted in and maintained by faulty
cognitive styles (overestimation and overgeneralization).

 Beliefs about the stimulus - mistaken perception of an object or situation as uncontrollable,

unpredictable, dangerous or disgusting are related to vulnerability.

 CBT approaches to treatment rely on helping clients learn adaptive ways of thinking, cognitive
restructuring and thought stopping.

 Freud viewed phobia as anxiety hysteria - a result of conflicts centered on unresolved oedipal
situation.

 Behaviourists believe that phobias are conditioned fears.

 Behavioural techniques are often useful in treating phobias:

-counterconditioning

-systematic desensitization

-flooding (imaginal)

-invivo method (flooding/graduated exposure)

-new technologies: computer simulation.

Social Phobia

Most people feel anxious in performance situations but people with social phobia feel tremendous
anxiety in any situation where others may be observing them.

Characteristics of Social Phobia

 A marked and persistent fear of one or more social performance situations in which the person is exposed
to unfamiliar people or to possible scrutiny by others.

 The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or
embarrassing.

 Exposure to the social or performance situation almost invariably provokes an immediate anxiety
response. This response may take the form of a situationally bound or situationally predisposed Panic
Attack.

 The person recognizes that their fear is excessive or unreasonable.

 The social or performance situation is avoided, although it is sometimes endured with dread (intense
anxiety or distress).
 The avoidance, anxious anticipation of, or distress in, the feared social or performance situation interferes
significantly with the person's normal routine, occupational (academic) functioning, social life, or if
the person is markedly distressed about having the phobia.

 These fears vanish when the individual is alone or unobserved.

 Individuals with social phobia have low self-esteem and underestimate their actual talents and areas of
competence.

 They may become housebound in that fears about public embarrassment may prevent them from leaving the
house.

 Social phobia could be Specific or Generalized (also consider the additional diagnosis of Avoidant
Personality Disorder).

 The lifetime prevalence of social phobia is estimated at 12.6 %.

 There is a difference in the way children and adults manifest social phobia (Study on page 184).

Theories and Treatment of Social Phobia

Biological Perspective

 Genetic contributions to social phobia are suggested by findings that the parents of children with it are
more likely to be diagnosed with major depression.

 Abnormalities in the norepinephrine and serotonin systems are thought to play a role.

 Some researchers have identified left-hemispheric dysfunctions in people with social phobia.

 Medications to treat social phobia include benzodiazepines and SSRIs. Pharmacological treatment is
especially effective when combined with psychotherapy.

 Kendler and his colleagues (2001) reported genetic contributions ranging from 25 to 37 percent in the
etiology of phobias.

Psychological Perspective

 According to the cognitively oriented explanations of social phobia, people with this disorder are
unable to take the step of shifting their attention away from anticipated criticism and to their
performance.

 Due to disrupted concentration they are more likely to make mistakes thus creating a self-fulfilled
expectation.

 Dysfunctional beliefs - the fear of making mistakes also contribute.

 Avoidance of the feared social situations serves to maintain the fear (Behaviorist view)

 CBT and behavioural approaches to treatment involve helping them learn more appropriate
responses to the situations they fear.
  This is attained through cognitive restructuring, in vivo exposure, social skills training, role playing
etc.

 The goal of treatment is to make them feel confident and comfortable in their interactions.

 There are sociocultural variations in social phobia. For e.g. Taijin Kyofusho Syndrone (TKS) is a
form of social anxiety found in Japan in which individuals are concerned about offending others
through their appearance or behaviour. This suggests that concern about other’s opinion, is universal.

Generalized Anxiety Disorder

GAD is characterized by a chronic state of anxiety.

Characteristics of GAD:

 The essential feature of GAD is excessive anxiety and worry (apprehensive anticipation) about a number of
events.

 The individual finds it difficult to control the worry.

 The anxiety and worry are associated with three or more of the following:

-restlessness

-being easily fatigued

-difficulty concentrating

-irritability

-muscle tension

-sleep disturbance

 The anxiety, worry and physical symptoms cause significant distress and impairment.

 In most cases their worries seem unwarranted. For e.g., Ben (Page 185).

 When found in children, the anxieties and fears revolve around academic and athletic activities.

 GAD affects 8.3% of the population and is more common in women. Most cases begin around the age of
20; however stressful events in later life can also trigger symptoms.

Theories and treatment of GAD

 The biological perspective suggests abnormalities in the noradrenergic, GABA and serotonergic
systems as contributing to GAD.

 Individuals with a neurotic personality style tend to be genetically vulnerable.

 According to the cognitive-behavioural view, generalized anxiety stems from cognitive distortions.
  The sociocultural perspective suggests that life stresses can significantly increase the tendency to
chronic anxiety.

 Existential explanation.

Treatment

 Benzodiazepines and newer antianxiety drugs (anxiolytics) are being used. However SSRIs and mixed
reuptake inhibitors are more popular.

 Cognitive-behavioural therapy.

 Relaxation techniques.

Obsessive Compulsive Disorder

OCD is characterized by the presence of obsessions and/or compulsions.

Characteristics of OCD:

 An obsession is a persistent and intrusive idea, thought, impulse or image.

 A compulsion is a repetitive and seemingly purposeful behaviour performed in response to

uncontrollable urges or according to a ritualistic or stereotyped act of rules.

 Unlike obsessions which cause anxiety, compulsions are carried out in an effort to reduce anxiety or
distress.

 The symptoms of OCD are intrusive, time-consuming, irrational, distracting and the individual
desperately tries to resist them.

 The common types of obsessions and compulsions are:

 Contamination

 Pathological doubt

 Intrusive thoughts

 Symmetry

 Other

(Table 5.2, page 189)

 OCD is different from OCPD.

About one-third of all people with OCD also have OCPD.

 OCD has a lifetime prevalence of 1.6 percent.

Males are more likely to develop OCD between ages 6 and 15, females tend to develop OCD between ages
20 and 29.

Theories and treatment of OCD

 The biological perspective suggests abnormalities in systems involving glutamate, dopamine, serotonin
and acetylcholine affecting the functioning of the prefrontal cortex.

 The brain circuits connecting the subcortical and cortical regions (involved in inhibition) seem to
function abnormally.

 PET scans have shown heightened levels of activity in the brain motor control centers of the basal
ganglia and frontal lobes.

 Some other disorders share these neurochemical abnormalities and are thought to be related to OCD along
a continua or spectrum.

 According to the behavioural view, the symptoms of OCD become established through the process of
conditioning.

 The CBT approach suggests that maladaptive thought patterns contribute to the development and
maintenance of OCD symptoms.

Treatment

 Tricyclic antidepressants and SSRIs have been proven to be effective.

 Thought stopping.

 Exposure and response prevention. (Example on page 191.)

 Psychosurgery (Cingulotomy) or Radiosurgery is recommended sometimes.

Acute Stress Disorder and Post-Traumatic Stress Disorder

 A traumatic event is a disastrous or an extremely painful event that has severe psychological and
physiological effects.

 Traumatic events include personal tragedies or life threatening natural calamities.

Characteristics of PTSD:

 This disorder is diagnosed when:

(a) A person experiences, witnesses or confronts an event which involves actual or threatened death or
serious injury to self or others.

(b) The person’s response to the event is that of intense fear, horror or helplessness.
 The victim persistently re-experiences the event in the form of flashbacks, recurring distressing dreams,
subjective re-experiencing of the traumatic event, or intense negative psychological or physiological
response to any objective or subjective reminder of the traumatic event.

 Persistent avoidance and emotional numbing:

This involves a sufficient level of:

 avoidance of thoughts or feelings, or talking about the event;

 avoidance of behaviors, places, or people that might lead to distressing memories;
 inability to recall major parts of the trauma, or decreased involvement in significant life activities;
 decreased capacity to feel certain feelings;
 a sense of foreshortened future.

 Persistent symptoms of increased arousal not present before such as difficulty falling or staying asleep, or
problems with anger, concentration, or hypervigilance.
 Traumatic reactions may stem from early experiences of repeated exposure to neglect, abuse and parental
violence.

 The DSM V task force is considering the addition of a new diagnosis called developmental trauma
disorder, to capture symptoms experienced by children who undergo repeated trauma.

 The lifetime prevalence of PTSD is 8 %. The rates are dramatically higher for at-risk individuals.

PTSD and Combat:

 The diagnosis of PTSD was added to the DSM in 1980s when attention was drawn to the aftereffects of
combat experienced by Vietnam War veterans.

 PTSD developed in about 19-30% of Vietnam War veterans exposed to low levels of combat and 25-75% of
those exposed to high levels.

 There are reports of psychological dysfunction following exposure to combat after the Civil War and both
World wars.

 Concentration camps survivors were also reported to suffer long-term psychological effects - ‘survivor
syndrome’ of chronic depression, anxiety and difficulties in interpersonal relationships.

 Major efforts were made by the US to assess and reduce the impact of combat by developing interventions,
during the Afghanistan and Iraq wars.

 Despite this, PTSD was seen in 6.2% of the soldiers returning from Afghanistan and in 1.9% of those
returning from Iraq.

 One year after the 9/11 attacks, 11% of New Yorkers are estimated to meet criteria for PTSD.

 Similarly Tsunami led to serious psychological problems in survivors.

 Thus, relief workers trained in intervening to help cope with trauma are needed.
 Theories and treatment of PTSD

 Although there is a small association between family psychopathology and the development of PTSD, there
is no clear information on the genetic contributions to this disorder.

 Researchers have studied the role of other factors:

 Gender

 Prior experience of trauma

 Severity of the trauma

 After experience of the trauma

 Stigma of seeking treatment for combat-related psychological problems

Biological perspective

 Researchers believe that once a traumatic experience has occurred, parts of the nervous system become
hypersensitive to future threats.

 The structure of the hippocampus is thought to undergo changes due to hyperarousal of the amygdala.

 Benzodiazepines, Anticonvulsants and Antidepressants (SSRIs and MAOIs) are therapeutic.

Psychological perspective

 Psychological treatment to PTSD involves using covering and uncovering methods.

 Supportive therapy and stress management to deal with secondary problems arising from the
symptoms.

 Reliving of the trauma through imaginal flooding

 CBT approach focuses on cognitive restructuring.

Studies have shown that about 65%of PTSD patients treated through psychotherapy recover or improve
while about 50% continue to have residual symptoms.

Anxiety Disorders: The Biopsychosocial Perspective (read from the textbook)