Abnormal Psychology, Thirteenth

Edition, DSM-5 Update

by
Ann M. Kring,
Sheri L. Johnson,
Gerald C. Davison,
& John M. Neale
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Chapter 6: Anxiety Disorders

I. Clinical Descriptions of Anxiety Disorders

II. Common Risk Factors Across the Anxiety
Disorders
III. Etiology of Specific Anxiety Disorders
IV. Treatments of Anxiety Disorders

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 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 “fight or flight”
 May save life
• Anxiety increases preparedness
 “U-shaped” curve (Yerkes & Dodson, 1908)
 Absence of anxiety interferes with performance
 Moderate levels of anxiety improve performance
 High levels of anxiety are detrimental to performance

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 DSM-5 Anxiety Disorders
• Specific phobias
• Social anxiety disorder
• Panic disorder
• Agoraphobia
• Generalized anxiety disorder
 Most common psychiatric disorders
 28% report anxiety symptoms
 Most common are phobias

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 DSM-5 criteria for each disorder:
• Symptoms interfere with important areas of
functioning or cause marked distress
• Symptoms are not caused by a drug or a medical
condition
• Symptoms persist for at least 6 months or at least 1
month for panic disorder
• The fears and anxieties are distinct from the
symptoms of another anxiety disorder

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 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

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 Disproportionate fear of a particular object or
situation
• Common examples: fear of flying, snakes, heights, etc.
• Fear out of proportion to actual threat
• Awareness that fear is excessive
• Most specific phobias cluster around a few feared objects
and situations
• High comorbidity of specific phobias

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Marked and disproportionate fear consistently
triggered by specific objects or situations
 The object or situation is avoided or else endured
with intense anxiety
 Symptoms persist for at least 6 months

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© 2015 John Wiley & Sons, Inc. All rights reserved.
 Previously called Social Phobia
• Causes more life disruption than other phobias
 More intense and extensive than shyness
• Persistent, intense fear and avoidance of social situations
• Fear of negative evaluation or scrutiny
• Exposure to trigger leads to anxiety about being
humiliated or embarrassed socially
• Onset often adolescence
 33% also diagnosed with Avoidant Personality Disorder
• Overlap in genetic vulnerability for both disorders

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 Marked and disproportionate fear consistently triggered by
exposure to potential social scrutiny
 Exposure to the trigger leads to intense anxiety about being
evaluated negatively
 Trigger situations are avoided or else endured with intense
anxiety
 Symptoms persist for at least 6 months

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 Frequent panic attacks unrelated to specific
situations
 Panic attack
• Sudden, intense episode of apprehension, terror, feelings of
impending doom
 Intense urge to flee
 Symptoms reach peak intensity within 10 minutes
• Physical symptoms can include:
 Labored breathing, heart palpitations, nausea, upset stomach, chest
pain, feelings of choking and smothering, dizziness, sweating,
lightheadedness, chills, heat sensations, and trembling
• Other symptoms may include:
 Depersonalization
 Derealization
 Fears of going crazy, losing control, or dying
 25% of people will experience a single panic
attack (not the same as panic disorder)

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Uncued panic attacks
• Occur unexpectedly without warning
• Panic disorder diagnosis requires recurrent uncued
attacks
• Causes worry about future attacks
 Cued panic attacks
• Triggered by specific situations (e.g., seeing a
snake)
 More likely a specific phobia

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Recurrent unexpected panic attacks
 At least 1 month of concern about the
possibility of more attacks, worry about the
consequences of an attack, or maladaptive
behavioral changes because of the attacks

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 From the Greek word “agora” or marketplace
 Anxiety about inability to flee anxiety-
provoking situations
• E.g., crowds, stores, malls, churches, trains, bridges,
tunnels, etc.
• Causes significant impairment
 In
DSM-IV-TR, was a subtype of Panic
Disorder
• At least half of agoraphobics do not suffer panic attacks

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 Disproportionate and marked fear or anxiety about
at least 2 situations where it would be difficult to
escape or receive help in the event of incapacitation
or panic-like symptoms, such as:
• being outside of the home alone; traveling on public
transportation; open spaces such as parking lots and
marketplaces; being in shops, theaters, or cinemas; standing
in line or being in a crowd
 These situations consistently provoke fear or
anxiety
 These situations are avoided, require the presence
of a companion, or are endured with intense fear or
anxiety
 Symptoms last at least 6 months

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 Involves
chronic, excessive, generalized,
uncontrollable worry
• Lasts at least 6 months
• Interferes with daily life
 Often cannot decide on a solution or course of action
 Other symptoms:
• Restlessness, poor concentration, tiring easily,
restlessness, irritability, muscle tension
 Common worries:
• Relationships, health, finances, daily hassles
 Often begins in adolescence or earlier
• I’ve always been this way

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 Excessive anxiety and worry at least 50 percent of days about at
least two life domains (e.g., family, health, finances, work, and
school)
 The person finds it hard to control the worry
 The worry is sustained for at least 3 months
 The anxiety and worry are associated with at least three (or one in
children) of the following:
• 1. restlessness or feeling keyed up or on edge
• 2. being easily fatigued
• 3. difficulty concentrating or mind going blank
• 4. irritability
• 5. muscle tension
• 6. sleep disturbance
 The anxiety and worry are associated with marked avoidance of
situations in which negative outcomes could occur, marked time
and effort preparing for situations that might have a negative
outcome, marked procrastination, difficulty making decisions due
to worries, or repeatedly seeking reassurance due to worries
© 2015 John Wiley & Sons, Inc. All rights reserved.
 50% of those with anxiety disorder meet
criteria for another anxiety disorder
 75% of those with anxiety disorder meet
criteria for another psychological disorder
• Disorders commonly comorbid with anxiety:
 60% with anxiety also have depression
 Substance abuse
 Personality disorders
 Medical disorders, e.g. coronary heart disease

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Women are twice as likely as men to have anxiety
disorder
• Possible explanations
 Women may be more likely to report symptoms
 Men more likely to be encouraged to face fears
 Women more likely to experience childhood sexual abuse
 Women show more biological stress reactivity

 Cultural factors
• Culture can shape anxieties and fears
• Culturally specific syndromes
 Taijin kyofusho
 Japanese fear of offending or embarrassing others
 Kayak-angst
 Inuit disorder in seal hunters at sea similar to panic
• Rate of anxiety disorders varies by culture, but ratio of somatic to
psychological symptoms appears similar (Kirmayer, 2001)

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.
 Behavioral conditioning (classical and operant
conditioning)
 Genetic vulnerability
 Increased activity in the fear circuit of the
brain
 Decreased functioning of GABA and serotonin;
increased norepinephrine activity
 Behavioral inhibition
 Neuroticism
 Cognitive factors, including sustained negative
beliefs, perceived lack of control, and attention
to cues of threat
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Conditioning
 Mowrer’s two-factor
model
• Pairing of stimulus
with aversive UCS
leads to fear (Classical
Conditioning)
• Avoidance maintained
though negative
reinforcement
(Operant Conditioning)

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 Extensions of the two-factor model
• Modeling
 Seeing another person harmed by the stimulus
• Verbal instruction
 Parent warning a child about a danger
• Those with anxiety tend to acquire fear more
readily
 And to be more resistant to extinction

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 Genetic
• Twin studies suggest heritability
 About 20-40% for phobias, GAD, and
PTSD
 About 50% for panic disorder
• Relative with phobia increases
risk for other anxiety disorders in
addition to phobia
 Neurobiological
• Fear circuit overactivity
 Amygdala
 Medial prefrontal cortex deficits
• Neurotransmitters
 Poor functioning of serotonin and
GABA
 Higher levels of norepinephrine

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 Behavioral inhibition
• Tendency to be agitated, distressed, and cry in
unfamiliar or novel settings
 Observed in infants as young as 4 months
 May be inherited
• Predicts anxiety in childhood and social anxiety in
adolescence
 Neuroticism
• Tendency to react with frequent negative affect
• Linked to anxiety and depression
• Higher levels linked to double the likelihood of
developing anxiety disorders

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 Sustained negative beliefs about future
• Bad things will happen
• Engage in safety behaviors
 Belief that one lacks control over
environment
• More vulnerable to developing anxiety disorder
 Childhood trauma or punitive parenting may foster beliefs
 Serious life events can threaten sense of control
 Attention to threat
• Tendency to notice negative environmental cues
 Selective attention to signs of threat

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Two-factormodel of behavioral
conditioning
• Conditioned responses to threat
• Sustained by avoidance or safety behaviors
 Avoid eye contact, appear aloof, stand apart from others
in social settings
 Risk factors act as diatheses
• Vulnerabilities influence development of phobias
 Prepared learning
• Evolutionary preparation to fear certain stimuli
 Potentially life-threatening (heights, snakes, etc.)
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Behavioral factors
• Factors similar to specific phobia (i.e., classical
and operant conditioning)
 Cognitive factors
• Unrealistic negative beliefs about consequences of
behaviors
• Excessive attention to internal cues
• Fear of negative evaluation by others
 Expect others to dislike them
• Negative self-evaluation
 Harsh, punitive self-judgment

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Neurobiological factors
• Locus coeruleus
 Major source of
norepinephrine
 A trigger for nervous system
activity
 People with panic disorder
more sensitive to drugs that
trigger the release of
norepinephrine

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Behavioral factors:
• Interoceptive conditioning
 Classical conditioning of panic
in response to internal bodily
sensations

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 Cognitive factors
• Catastrophic
misinterpretations of somatic
changes
 Interpreted as impending doom
 I must be having a heart attack!
 Beliefs increase anxiety and
arousal
 Creates vicious cycle
 Anxiety Sensitivity Index
• High scores predict development of
panic
 “Unusual body sensations scare me.”
 “When I notice that my heart is beating rapidly, I
worry that I might have a heart attack.”

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Genetic risk
• Polymorphism in a gene guiding neuropeptide S
function, the NPSR1 gene, has been tied to an
increased risk of panic disorder and is associated
with:
 Amygdala response to threat
 Cortisol response
 Higher anxiety sensitivity scores
• Genetic risk shapes stress responses and
hypersensitivity to somatic changes, and this may
then increase the risk for panic disorder.

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Fear-of-fear hypothesis (Goldstein & Chambless,
1978)
• Expectations about the catastrophic consequences
of having a public panic attack
 What will people think of me?!?!

© 2015 John Wiley & Sons, Inc. All rights reserved.

 GABA system deficits
 Borkovec’s cognitive model:
• Worry reinforcing because it distracts from
negative emotions and images
• Allows avoidance of more disturbing emotions
 e.g., distress of previous trauma
• Worrying decreases psychophysiological arousal
• Avoidance prevents extinction of underlying anxiety

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.
 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
 70-90% effective
 Systematic desensitization
• Relaxation plus imaginal exposure
 Cognitive approaches
• Increase belief in ability to cope with the anxiety trigger
• Challenge expectations about negative outcomes
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Phobias
• Exposure
 In vivo (real-life) exposure more effective than systematic
desensitization
 Social Anxiety Disorder
• Exposure
 Role playing or small group interaction
• Social skills training
 Reduce use of safety behaviors
• Cognitive therapy
 Clark’s (2003) cognitive therapy more effective than
medication or exposure

© 2015 John Wiley & Sons, Inc. All rights reserved.

 PanicControl 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

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 Cognitive Behavioral Therapy (CBT)
• Systematic exposure to feared situations
• Self-guided treatment effective

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 Relaxation training
 Cognitive behavioral methods
• Challenge and modify negative thoughts
• Increase ability to tolerate uncertainty
• Worry only during “scheduled” times
• Focus on present moment

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Anxiolytics: drugs that reduce anxiety
• Benzodiazepenes
 Valium
 Xanax
• Antidepressants
 Tricyclics
 Selective Serotonin Reuptake Inhibitors (SSRIs)
 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
• Side effects can be problematic with continuing
medication
 D-cycloserine (DCS)
 Enhances learning and can bolstered treatment effectiveness

© 2015 John Wiley & Sons, Inc. All rights reserved.

Copyright 2015 by John Wiley & Sons, Inc. All
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