Anxiety Disorders

PowerPoint
Lecture Notes Presentation
Chapter 5
Anxiety Disorders
Abnormal Psychology, 11th Edition
by
Ann M. Kring, Gerald C. Davison, John M. Neale,

& Sheri L. Johnson
Anxiety vs. Fear
Anxiety
Apprehension about a future threat
Fear
Response to an immediate threat
Both involve physiological arousal

Sympathetic nervous system
Both can be adaptive

Fear triggers flight or fight
May save life
Anxiety increases preparedness

Moderate levels improve performance
Copyright 2009 John Wiley & Sons, NY
Anxiety Disorders
DSM-IV-TR
Specific and social phobias
Panic disorder and agoraphobia
Generalized anxiety disorder
Obsessive compulsive disorder
Posttraumatic stress disorder
Most common psychiatric disorders

28% report anxiety symptoms (Kessler et al., 2005)
Most common are phobias
Table 5.1 Summary of Major

Anxiety Disorders
Phobias
Disruptive fear of a particular object or

situation
Fear out of proportion to actual threat
Awareness that fear is excessive
Must be severe enough to cause distress or
interfere with job or social life
Avoidance
Two types:
Specific
Social
Specific Phobia
Unwarranted, excessive fear of specific

object or situation
Snakes, blood, flying, spiders, etc.
How likely are you to be bitten by a spider?
Most specific phobias cluster around a few

feared objects and situations (Table 5.3)
Trigger or feared object is avoided or

endured with intense anxiety
High comorbidity of specific phobias
Table 5.2Words Used to Describe Highly Unlikely Phobias
Fear
Phobia
Anything new
Neophobia
Asymmetrical things
Asymmetriphobia
Books
Bibliophobia
Children
Pedophobia
Dancing
Chorophobia
Englishness
Anglophobia
Garlic
Alliumphobia
Peanut butter sticking to the roof of the mouth
Arachibutyrophobia
Technology
Technophobia
Mice
Musophobia
Pseudoscientific terms
Hellenophobia
Source: Drawn from www.phobialist.com.
Table 5.3Types of Specific Phobias

Type of Phobia
Source of Fear
Associated Characteristics
Animal
Animals (e.g., snakes, insects)
Generally begins during childhood
Natural environment
Aspects of the natural environment
Generally begins during childhood
(e.g., storms, heights, water)
Blood, injection, injury
Blood, injury, injections, or other
Clearly runs in families
invasive medical procedures
Situational
Specific situations (e.g., public
Tends to begin either in childhood or in
transportation, tunnels, bridges,
mid-20s.
elevators, flying, driving, closed spaces)
Other
Fear of choking, fear of contracting an
illness, etc.; childrens fears of loud

sounds, clowns, etc.
Social Phobia
Persistent, intense fear of social situations

Fear of negative evaluation or scrutiny
More intense and extensive than shyness

More appropriate diagnostic label?
Social anxiety disorder
Exposure to trigger leads to anxiety about

being humiliated or embarrassed socially.
Onset often adolescence
Diagnosed as either generalized or specific
33% also diagnosed with Avoidant Personality
Disorder
Overlap in genetic vulnerability for both disorders
Figure 5.1 Spectrum Model of Social

Phobia and Avoidant Personality Disorder
10
Panic Disorder
Frequent panic attacks unrelated to specific

situations
Panic attack
Sudden, intense episode of apprehension, terror,
feelings of impending doom
Symptoms reach peak intensity within 10 minutes
Accompanied by at least 4 other symptoms:

Sweating, nausea, labored breathing, dizziness, heart
palpitations, upset stomach, lightheadedness, etc.
Other symptoms may include:

Depersonalization
Derealization
Fear of going crazy, losing control, or dying
11
Panic Disorder
Uncued attacks
Occur unexpectedly without warning
Panic disorder diagnosis requires recurrent uncued
attacks.
Cued attacks
Triggered by specific situations (e.g., tunnel)
More likely a phobia
Panic Disorder with Agoraphobia

Avoidance of situations in which escape would be
difficult or embarrassing
Panic disorder with agoraphobia tends to be more
chronic .
12
Panic Disorder
Often begins in adolescence
25% unemployed for more than 5 years
because of symptoms (Leon et al., 1995)
Prognosis worse when agoraphobia is
present
13
Generalized Anxiety
Disorder (GAD)
Involves chronic, excessive, uncontrollable

worry
Lasts at least 6 months
Interferes with daily life
Other symptoms:
Restlessness, poor concentration, irritability,

muscle tension, tires easily, sleep disturbance
Common worries:
Relationships, health, finances, daily hassles
Often begins in adolescence or earlier

Ive always been this way
14
Obsessive-Compulsive
Disorder (OCD)
Obsessions
Intrusive, persistent, and uncontrollable thoughts or

urges
Experienced as irrational
Most common:
Contamination, sexual & aggressive impulses, body
problems
Compulsions
Impulse to repeat certain behaviors or mental acts to

avoid distress
e.g., cleaning, checking, hoarding, repeating a word,
counting
Extremely difficult to resist the impulse

May involve elaborate behavioral rituals
15
Obsessive-Compulsive
Disorder (OCD)
Develops either before age 10 or during late

adolescence/early adulthood
Men
Early onset more common
Women
Cleaning compulsions and later onset more
common
OCD often chronic
16
Post Traumatic Stress

Disorder (PTSD)
Extreme response to severe stressor

Anxiety, avoidance of stimuli associated with trauma,
emotional numbing
Exposure to a traumatic event that involves actual

or threatened death or injury
e.g., war, rape, natural disaster
Trauma leads to intense fear or helplessness

Symptoms present for more than a month
Women and PTSD
Rape most common type of trauma (Creamer et al.,
2001)
17
Post Traumatic Stress

Disorder (PTSD)
Three categories of symptoms :

1.
Re-experiencing the traumatic event
2.
Nightmares, intrusive thoughts, or images
Avoidance of stimuli
e.g., Refuse to walk on street where rape occurred

Numbing
3.
Increased arousal
Decreased interest in others

Distant or estranged from others
Unable to experience positive emotions
Insomnia, irritability, hypervigilance, exaggerated startle

response
Tends to be chronic (Perkonigg et al., 2005)

18
Acute Stress Disorder

(ASD)
Symptoms similar to PTSD

Duration varies
Short term reaction
Symptoms occur between 2 days and 1 month
after trauma
As many as 90% of rape victims experience

ASD (Rothbaum et al., 1992)
More than 2/3 of those with ASD develop
PTSD within 2 years (Harvey & Bryant, 2002)
19
Comorbidity
of those with anxiety disorder meet

criteria for another disorder
60% meet criteria for major depression
al., 2001)
(Brown et
Other disorders commonly comorbid with

anxiety:
Substance abuse
Personality disorders
Avoidant
Dependent
Histrionic
Medical disorders e.g., coronary heart disease

20
Table 5.4 12-month Prevalence of

Anxiety Disorders in Germany
21
Gender &
Sociocultural Factors
Women are 2x as likely as men to have anxiety

disorder except for OCD
Possible explanations
Women may be more likely to report symptoms
Women more likely to experience childhood sexual abuse
Women show more biological stress reactivity
Sociocultural factors
Focus of anxiety varies
Taijin kyofusho
Japanese fear of offending or embarrassing others
Kayak-angst
Inuit disorder in seal hunters at sea similar to panic
Ratio of somatic to psychological symptoms

appears similar across cultures (Kirmayer, 2001)
22
Table 5.5 Factors that May Increase the

Risk for More than One Anxiety Disorder
Genetic vulnerability
Increased activity in the fear circuit of the brain
Decreased functioning of GABA and serotonin;
increased norepinephrine activity
Negative Life Events
Behavioral inhibition
Neuroticism
Cognitive factors, including attention to cues of
threat and low perception of control
23
Risk Factors
Genetic
Twin studies suggest heritability

About 20-40% for phobias, GAD,
and PTSD
About 50% for panic disorder
Relative w/phobia increases risk

for other anxiety disorders in
addition to phobia
Neurobiological
Fear circuit overactivity
Amygdala
Medial prefrontal cortex deficits
Neurotransmitters
Serotonin, GABA, Norepinephrine

24
Risk Factors: Social
Negative life events

Job loss, end of relationship, etc.
Severe stressors often precede onset
(Kendler et al., 2003)
80% with panic disorder (Barlow, 2004)

70% with any anxiety disorder (Finlay-Jones, 1989)
25
Risk Factors: Personality
Behavioral inhibition
Tendency to be agitated, distressed, and cry in
unfamilar or novel settings
Observed in infants as young as 4 months
May be inherited
Predicts anxiety in childhood and social anxiety in

adolescence
Neuroticism
React with negative affect
Linked to anxiety and depression (deGraaf et a., 2002)
Psychophysiological reactivity in firefighters predicted
development of PTSD (Guthrie & Bryant, 2005)
26
Risk Factors: Cognitive
Belief that one lacks control over environment

More vulnerable to developing anxiety disorder
Childhood trauma or punitive parenting may foster beliefs
Amount of control during trauma may influence whether
anxiety disorder will develop (Mineka & Zinbarg, 2007)
Attention to threat
Tendency to notice negative environmental cues
Selective attention to signs of threat
27
Etiology of Specific Phobias
Conditioning
Mowrers two-factor
model
Pairing of stimulus with
aversive UCS leads to
fear (Classical
Conditioning)
Avoidance maintained
though negative
reinforcement (Operant
Conditioning)
28
Etiology of Specific Phobias
Problems with two-factor model

Many people never experience aversive
interaction with phobic object (see table 5.6)
People with phobias tend to fear only
certain types of objects (prepared learning)
Snakes, insects, blood, heights, etc.
Even phobias linked to modeling influenced

by prepared learning
Monkeys acquired fear after watching another
monkey exhibit fear to snake but not flower
(Cook & Mineka, 1989)
29
Table 5.6 Percent of People Reporting

Conditioning Experiences Before the Onset
of a Phobia
30
Etiology of Social Phobia
Two factor model

Avoidance or safety behaviors
Avoid eye contact, appear aloof, stand apart from others
in social settings
Cognitive factors
Negative self evaluation
Harsh, punitive self-judgment
Fear of negative evaluation by others

Expect others to dislike them
Excessive attention to internal cues

e.g., heart rate
31
Etiology of Panic
Neurobiological
factors
Locus ceruleus
Major source of
norepinephrine
A trigger for nervous

system activity
Multiple drugs can

induce panic attacks
Typically only in those
who are overly
concerned about bodily
changes
32
Etiology of Panic
Interoceptive
conditioning
Classical conditioning
of panic in response to
bodily sensations
People with panic

disorder sustain
classically conditioned
fears longer (Michael et
al., 2007)
33
Etiology of Panic
Cognitive factors
Lack of perceived
control can trigger panic
Fear of bodily changes
Interpreted as impending
doom
I must be having a
heart attack!
Beliefs increase anxiety

and arousal
Creates vicious cycle
34
Table 5.7 Sample Items from

Anxiety Sensitivity Index
Table 5.7Sample Items from the Anxiety Sensitivity Index
Unusual body sensations scare me.

When I notice that my heart is beating rapidly, I worry that I might have a heart
attack.
It scares me when I feel faint.
It scares me when I feel shaky (trembling).
Source: Peterson & Reiss, 1987. Note: People respond to each item on a 0 (very little) to 4 (very
much) scale.
35
Etiology of Agoraphobia
Fear-of-fear hypothesis
(Goldstein &
Chambless, 1978)
Expectations about the catastrophic

consequences of having a public panic
attack.
What will people think of me?!?!
36
Etiology of GAD
GABA system deficits

Borkovecs cognitive model:
Worry reinforcing because it distracts from
negative emotions and images
Allows avoidance of more disturbing emotions
e.g., distress of previous trauma
Avoidance prevents extinction of underlying

anxiety
Individuals with GAD less able to identify their
own negative feelings (Mennin et al., 2002)
37
Etiology of OCD:
Neurobiological Factors
OCD symptoms common in certain

neurological disorders
Huntingtons chorea
Hyperactive regions of the brain:

Orbitofrontal cortex
Caudate nucleus
Anterior cingulate
Loss of neuronal function and underlying
biochemical abnormality (Ycel et al., 2007)
38
Etiology of OCD:
Behavioral & Cognitive Factors
Operant reinforcement
Compulsions negatively reinforced by the reduction
of anxiety
Cognitive factors
Lack of a satiety signal
Yadasentience
Subjective feeling of completion
Knowing that you have thought enough or cleaned enough
Individuals with OCD have a yadasentience deficit
Attempts to suppress intrusive thoughts

Trying to suppress thoughts may make matters worse
39
Etiology of PTSD
Severity and type of trauma

Neurobiological
Smaller hippocampal volume linked to PTSD

Disruption of verbal vs. nonverbal memory
Supersensitivity to cortisol
Behavioral
Two factor model
Psychological
Perception of control
Avoidance coping, dissociation, memory suppression
Intelligence and ability to grow from the

experience enhance coping
40
Common Aspects of
Psychological Treatment
Psychological treatments emphasize

Exposure
Face the situation or object that triggers
anxiety
Should include as many features of the trigger
as possible
Should be conducted in as many settings as
possible
Systematic desensitization
Relaxation plus imaginal exposure
41
Common Aspects of
Psychological Treatment
Cognitive approaches
Increase belief in ability to cope with the
anxiety trigger
Challenge expectations about negative
outcomes
42
Psychological Treatment of
Phobias
Exposure
In vivo exposure more effective than systematic

desensitization
Virtual reality as effective as in vivo
Social phobia
Exposure
Role playing or small group interaction
Social skills training
Reduce use of safety behaviors
Cognitive therapy
Enhances treatment for social but not specific phobias

Clarks (2003) cognitive therapy more effective than
medication or exposure.
43
Panic and Agoraphobia
Panic Control Therapy (PCT; Craske &

Barlow, 2001)
Exposure to somatic sensations associated
with panic attack in a safe setting
Increased heart rate, rapid breathing, dizziness
Use of coping strategies to control symptoms

Relaxation
Deep breathing
PCT benefits maintained after treatment ends.

44
Panic and Agoraphobia
Cognitive Behavioral Therapy (CBT)

Increase patients awareness of thoughts
that make physical sensations threatening
Patient learns to challenge and change
maladaptive beliefs
CBT also effective for agoraphobia

Treatment enhanced when spouse or
significant other stops catering to partners
avoidance.
45
GAD
Relaxation training
Cognitive Behavioral methods
Challenge and modify negative thoughts

Increase ability to tolerate uncertainty
Worry only during scheduled times
Focus on present moment
46
OCD
Exposure plus ritual prevention

Most widely used treatment
Cognitive therapy
Challenge beliefs about anticipated consequences
of not engaging in compulsions
Usually also involves exposure
47
PTSD
Exposure to memories and reminders of the

original trauma
Either direct (in vivo) or imaginal
Treatment may initially increase symptoms
More effective than medication or supportive therapy
Cognitive therapy
Enhance beliefs about coping abilities
Adding CT to exposure does not improve treatment
response
Treatment of ASD may prevent PTSD

Shows benefits even 5 years after the traumatic event
48
Medications
Anxiolytics
Drugs that reduce anxiety
Two common types of medications used to treat

anxiety
Benzodiazepenes
Valium, Xanax
Antidepressants
Tricyclics,Selective Serotonin Reuptake Inhibitors (SSRIs), and
Serotonin Reuptake Inhibitors (SRIs)
49
Medications
Demonstrated effectiveness as compared to

placebo
Clomipramine for OCD
Medication does not seem to help hoarding
Beta blockers commonly prescribed for social phobia
although no demonstrated effectiveness
Side effects
Withdrawal from benzodiazepenes
Weight gain, nervousness, high blood pressure from SSRIs
Relapse common after medication discontinuation
50
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PowerPoint

Lecture Notes Presentation

Ann M. Kring, Gerald C. Davison, John M. Neale,

Anxiety vs. Fear

Both involve physiological arousal

Both can be adaptive

Anxiety increases preparedness

Most common psychiatric disorders

Copyright 2009 John Wiley & Sons, NY

Table 5.1 Summary of Major

Copyright 2009 John Wiley & Sons, NY

Disruptive fear of a particular object or

Unwarranted, excessive fear of specific

Most specific phobias cluster around a few

Trigger or feared object is avoided or

Table 5.2Words Used to Describe Highly Unlikely Phobias

Peanut butter sticking to the roof of the mouth

Source: Drawn from www.phobialist.com.

Copyright 2009 John Wiley & Sons, NY

Table 5.3Types of Specific Phobias

Animals (e.g., snakes, insects)

Generally begins during childhood

Aspects of the natural environment

Generally begins during childhood

(e.g., storms, heights, water)

Blood, injection, injury

Blood, injury, injections, or other

Clearly runs in families

invasive medical procedures

Specific situations (e.g., public

Tends to begin either in childhood or in

transportation, tunnels, bridges,

elevators, flying, driving, closed spaces)

Fear of choking, fear of contracting an

illness, etc.; childrens fears of loud

Copyright 2009 John Wiley & Sons, NY

Persistent, intense fear of social situations

More intense and extensive than shyness

Exposure to trigger leads to anxiety about

Figure 5.1 Spectrum Model of Social

Copyright 2009 John Wiley & Sons, NY

Frequent panic attacks unrelated to specific

Accompanied by at least 4 other symptoms:

Other symptoms may include:

Panic Disorder with Agoraphobia

Copyright 2009 John Wiley & Sons, NY

Involves chronic, excessive, uncontrollable

Restlessness, poor concentration, irritability,

Relationships, health, finances, daily hassles

Often begins in adolescence or earlier

Copyright 2009 John Wiley & Sons, NY

Intrusive, persistent, and uncontrollable thoughts or

Impulse to repeat certain behaviors or mental acts to

Extremely difficult to resist the impulse

Copyright 2009 John Wiley & Sons, NY

Develops either before age 10 or during late

OCD often chronic

Copyright 2009 John Wiley & Sons, NY

Post Traumatic Stress

Extreme response to severe stressor

Exposure to a traumatic event that involves actual

Trauma leads to intense fear or helplessness

Post Traumatic Stress

Three categories of symptoms :