Anxiety and Fear
• Anxiety – a negative mood state with
Chapter 4a
Anxiety Disorders
Anxiety and Fear
• Both can be adaptive
– Performance enhanced by a little anxiety
– Fear prepares us for life-saving action
• “fight or flight”
• Problem is that excessive anxiety, false
alarms can disrupt normal functioning
Anxiety Disorders
• Symptoms of anxiety disorders involve:
– Cognitions: apprehension about the future
– Bodily responses: muscle tension and
sympathetic reactivity
– Behavior: avoidance of anxiety- evoking
stimuli or performing rituals
– Insight: understanding that symptoms are
irrational
– Impairment: lowered functioning
somatic symptoms and apprehension
due to unpredictability and lack of
control over future events
• Fear – alarm reaction to danger with
strong escapist tendencies due to
present danger or life-threatening
emergencies
Types of Anxiety Disorders
• Panic Disorder
• Panic Disorder with Agoraphobia (PDA)
• Generalized Anxiety Disorder (GAD)
• Specific Phobia
• Social Phobia
• Posttraumatic Stress Disorder (PTSD)
• Obsessive- Compulsive Disorder (OCD)
Statistics and Demographics
• Yearly Incidence is 18.1% of American
adults
• 29% of people develop it at some point
– But, only 20% of sufferers seek treatment
• People with anxiety disorders
– 81% have more than one type of anxiety
– 90% have more than one psychological
disorder
 Statistics and Demographics
• All, except OCD, are more common in
women
• Childhood and adolescent onsets are
likely, except in Panic Disorder
• Costs society about $42 billion/year in
health care costs, lost wages, and
productivity
Causes of Anxiety Disorders
• General psychological vulnerability
– Lack of self-esteem and inability to cope
– External locus of control
– Dangerous or life threatening living
environments
• 9-11
• Race / Poverty
• Aging
Panic Disorder
• DSM Checklist
– Recurrent unexpected Panic Attacks
– A month or more of one (1) of the
following
• Persistent concern about having additional
attacks
• Worry about the implications/consequences
of an attack
• Significant change in behavior related to the
attacks
Causes of Anxiety Disorders
• General biological vulnerability
– Behavioral inhibition system
• limbic system misinterprets threat signals
– GABA depletion
– Genetic influences
– Personality factors
• Pessimistic, irritable, driven
– Evolutionary preparedness
• Fear snakes, spiders, angry rejecting people
Causes of Anxiety Disorders
• Specific psychological vulnerability
– We are taught what to situations to fear by
our parents
– Sometimes phobic behavior linked to
specific experiences:
• Attacked by dog
• Bad public speaking experience
– Learned alarms associate true cues for
danger with innocuous cues
Panic Attack
• Panic Attack- periodic short bouts of
panic that occur suddenly, reach a peak
within 10 minutes, and gradually pass
• Edward Munch’s
“The Scream” immortalizes
his own panic attack on a
bridge at sunset
 Panic Attacks Panic Disorder

• Three basic types: • Agoraphobia sometimes develops as a

– Situationally bound (cued) only occurs in
the stimulus environment
• Specific or Social phobia
– Unexpected (uncued) occurs without a
stimulus
– Situationally predisposed an increased
likelihood of occurrence in stimulus
environment
• Panic Disorder
consequence of extreme phobic
avoidance of panic attacks
• Though initially tied to panic, it can
become relatively independent of it
• Also related to introceptive avoidance
– Avoiding activities that might trigger
somatic sensations of panic

Agoraphobia Cognitive Theory

Trigger
• “Fear of the marketplace” or fear of Stimulus
public areas (i.e. cue)
Apprehension
• Anxiety about being in situation where Precieved Threat
or Worry
escape difficult or embarrassing or
where help not available in case of panic
attack
• Sample situations: outside home alone,
in crowd, bridges, freeways, tunnels, on Catastrophic
Body Sensations
Interpretation
a bus, etc. Trigger
Stimulus
(i.e.caffeine)

Panic Disorder Biological Theory

• Physiological Findings • The circuit of the brain that produces

– Higher rates of: panic reactions
• Mitral valve prolapse – Amygdala, Ventromedial nucleus, central
– Awareness of heart pounding gray matter, and locus ceruleus
• Hypothyroidism • Indicates that norepinephrine activity is
• Hypoglycemia irregular
• Vestibular function (motion sickness due to • Different from people with Anxiety which is
inner ear) due to GABA inactivity
– Induce panic attacks by CO2 inhalation, • The system only shares the amygdala
hyperventilation, and caffeine ingestion (responsible for fear and other emotions)
 Statistics and Demographics

• 2.3 % of the U.S. population suffer from

Panic Disorder (Weissman et al., 1997) a
worldwide incidence rates are similar Chapter 4b
– Susto, ataques de nervios, and Kyol goeu
• > 75% of PDA sufferers are women
Anxiety Disorders
– Culturally accepted for women to express
fear and panic
• 60% have nocturnal panic occuring
during Delta wave (deep sleep)

Generalized Anxiety Disorder Generalized Anxiety Disorder

• DSM Checklist • Sometimes called “free floating” anxiety

– Excessive or ongoing anxiety and worry for or the “what if?” disorder
at least six months, about numerous events
or activities • Diagnosed after ruling out all other Axis
– Difficulty controlling the worry I disorders as source of anxiety
– At least three (3) of the following • Often chronic and worsens with stress
• Restlessness •Muscle tension • Probably the least studied anxiety
• Fatigue
• Irritability
•Sleep disturbance disorders
– SDI

Statistics and Demographics of

GAD
• Yearly incidence is about 4%, it is the
most common anxiety disorder
• Occurs more commonly in Western
cultures but in 3- 4% of worldwide
population (3.5% W, 6% AA)
• Usually first appears in childhood but
can occur at any age due to a stressor
and may get worse in the elderly
• Sex ratio more likely in women, 2:1
GAD Theories
• Sociocultural
– Societal dangers and economic stress
• Psychodynamic
– Excessive anxiety and poor defenses
• Humanistic
– Failure to receive unconditional positive
regard and are overcritical of themselves
 Cognitive Theories
• Maladaptive assumptions and beliefs
“life is dangerous unless proven safe”
• Power and value of worrying
– Worry about worrying (negative view of
worry)
– Worry about unknown
– Worry reduces arousal
Specific Phobia
• DSM Checklist
– At least six months of marked and
persistent fear of a specific object or
situation
– Immediate anxiety from exposure
– Recognition that the fear is excessive or
unreasonable
– Avoidance of the object
– SDI
Specific Phobia
• Named after their Greek word origins
– Some interesting phobias
• Ailurophobia (animals)
• Astraphobia (natural)
• Haptephobia (bii)
• Gephyrophobia (situational)
• Coulrophobia (other)
• Hexakosioihexekontahexaphobia (other)
• Anatidaephobia (other)
Biological Theory
• Hashimoto’s thyroiditis
(Hypothyroidism)
– Levels of hormone waiver to try and avoid
the condition
• Hypothalamic-pituitary-axis
– Associated with an abnormal response to
stress
– Increased sensitivity of neurons to firing
Subtypes of Specific Phobia
• Animal (onset ~7 years)
– Fear of animals or insects that usually develop in childhood
• Natural (onset ~7 years)
– Fear of situations or events in nature (i.e. storms, heights,
water, etc.); tend to cluster together
• Blood injection-injury (onset ~9 years)
– Fear of blood, injury, or possibility of an injection, unlike
other phobias usually results in a lowering in BP
• Situational (onset early to mid 20s)
– Fear of enclosed spaces (i.e. claustrophobia) or public
transportation (i.e. flying, trains) which is atypical
• Other
– Fear of choking, vomiting, contracting an illness, loud
sounds, or costumed characters
Statistics and Demographics
• Phobias affect up to 9% of population
• Approximately 11% of people will have severe
enough specific fears at some point in life to
classify as phobia
• Females > Males (4:1 worldwide prevalence),
except for some exceptions (i.e. heights,
dentists)
• More frequent with Hispanics than Whites
• Onset: childhood (may remit adolescence or
decline in old age) but tends to run a chronic
course (lasts a lifetime)
 Etiology Specific Phobia
General Biological Vulnerability

• Direct Experience - only 50% Direct Experience Vicarious Experience

STRESS
• False alarm - panic attack with situation
• Observational learning - learning fears False Alarm True Alarm
vicariously
• Informational transmission - repeated Learned Alarm
warnings and cautions
• General Biological Vulnerability (Seligman’s Specific Psychological
evolutionary “preparedness” model) Vulnerability
– Distribution of phobias does not correspond with
distribution of traumatic learning experiences but General Psychological
SPECIFIC PHOBIA
rather evolutionary dangers Vulnerability

Separation Anxiety Disorder Social Phobia

• A related anxiety disorder that is unique • DSM Checklist

to children:
– Excessive, enduring fear that separation
from parent or guardian will result in harm
to themselves or their parents (i.e. lost,
kidnapped, killed, etc.)
– Manifests as distress and anxiety which
results in a refusal to go school, leave home,
or even sleep alone
– At least six months of marked and
persistent fear of social or performance
situations involving exposure to unfamiliar
people/scrutiny. Concerned about
embarrassment
– Anxiety produced by exposure
– Recognition that the fear is excessive or
unreasonable
– Avoidance of situation and SDI

Social Phobia Statistics and Demographics

• Subtype: • Social phobia affects up to 8% of population;

– Generalized: fear most social situations,
which is often confused with panic disorder
with agoraphobia; Often emerges out of
childhood
– Fear of doing something in public (i.e.
eating, writing, speaking)
– Fear public places (restrooms, restaurants)
– Fear of social interactions (speaking to
strangers, dating)
up to 13% will experience this problem at some
point
– Most common psychological disorder affecting ~35
million people in the U.S.
– Most prevalent in adults age 18-29, low SES,
single, and undereducated; decreases with elderly
• Sex ratio slightly favors women; 1.4:1.0
– Females > Males in community samples; but
roughly equal in clinical samples
• Begins in late childhood / adolescence ~15
years
 Etiology PTSD
General Psychological General Biological
Vulnerability Vulnerability

STRESSORS
• DSM Checklist
1st 3rd – Exposure to actual or threatened
2nd
No Alarm False Alarm True Alarm death/injury (to self or others)
– At least 1 month of Core Symptoms (3
Learned Alarm Major Categories):
• Psychological re-experiencing
– Recurrent recollections of the event, dreams,
Anxious Apprehension flashbacks
– Triggered by seemingly innocuous event
Specific Psychological
Vulnerability SOCIAL PHOBIA

PTSD Types of PTSD

• Avoidance (“psychic numbing” or emotional • Delayed Subtype

anesthesia)
– Avoidance of reminders of event (avoid news, – symptoms occur 6 months after a traumatic
reading) event
• Increased Arousal • Acute Stress Disorder
– Pronounced startle reflex; hypervigilance
– Symptoms occur < 1 month
– Some Associated Symptoms
• Survivor guilt
• Sense of foreshortened future (impending
catastrophe)
• “Omen formation” (sense can predict omen;
most common in kids)

Statistics and Demographics Etiology

General Psychological General Biological
Vulnerability Vulnerability
• PTSD Risk factors:
TRAUMA
– Duration, proximity, and severity of traumatic
event
True Alarm
– Alcoholism
– Other anxiety disorders
Learned Alarm
– Child abuse
– Low social support Avoidance or numbing of
Anxious Apprehension
• Onset: usually within 3 months of the stressor; emotional response

delayed subtype (at least 6 months after Moderated by social support

And ability to cope
stressor; highly controversial) PTSD
• Can be exacerbated or reactivated years later
Obsessive- Compulsive Disorder
• DSM Checklist
– Recurrent obsessions or compulsions
– Past or present recognition that the
obsessions or compulsions are excessive or
unreasonable
– Significant distress and impairment in
functioning and relationships, or disruption
by symptoms for more than one hour a day
Common Themes in OCD
• Obsessive thoughts, wishes, impulses, images
or ideas about:
– Dirt and Germs (Louis Pasteur)
– Aggression and violence
– Orderliness
– Religion
– Sex
• Compulsive or ritualistic behavior or thoughts
that reduce anxiety such as:
– Hand washing or cleaning (Beethoven)
– Checking, order, and balance (stacking)
– Touching
– Verbal rituals and counting
Statistics and Demographics
• As many as 2- 3 % have OCD in U.S. and
other countries in a given year (~ 5 million
people in the U.S.)
• Equally common in men and women and
races/ethnic groups (slightly more common in
adult females; in childhood sex ratio is
reversed)
• Usually begins in young adulthood (mid-20’s)
and persists over time but intensity may
fluctuate
– Peaks earlier in males (13-15) than females (20-24)
OCD
• Obsessions are intrusive and mostly
nonsensical thoughts, images, or urges
that the individual resists or attempts to
eliminate
• Compulsions are thoughts or actions
used to suppress the obsessions and
provide relief. Can be behavioral or
mental
Comorbidity
• In conjunction with obsessions and
compulsions, a person with OCD may
experience:
– Generalized anxiety
– Panic attacks
– Debilitating avoidance
– Major depression
OCD Theories
• Rituals are a way to neutralize any
negative effect caused by thinking or to
suppress the thinking itself so that
anxiety is temporarily relieved
• Thought-action fusion
– Thoughts are equated with the specific
action or activity represented
– Caused by attitudes of excessive
responsibility
 OCD Theories Etiology
General Psychological General Biological
Vulnerability Vulnerability
• Psychodynamic
STRESS
– Battle of Id impulses (obsessions) and ego defenses
(counterthoughts/rituals) Intrusive thoughts, images, or impulses
• Cognitive Behaviorists
– Obsessions grow from normal human tendency to Specific Psychological
have unwanted and unpleasant thoughts Vulnerability

• Biological Theory Anxious Apprehension False Alarms

– Low serotonin and abnormal functioning
Cognitive or Behavioral
– Abnormal orbitofrontal cortex and caudate nuclei Learned Alarm
Rituals to neutralize or
• Converts sensory information into action suppress thoughts
OCD

Treatments Treatments

• Behavioral Therapy • Behavioral Treatments

– Ideas are derived from basic learning
principles of classical and operant
conditioning
– Involves cognitive restructuring
• Chest pain is interpreted as “I’m having a heart
attack” restructured to “This is uncomfortable
but not dangerous”
– Found to be as effective as drug treatments
but less invasive, so it is the first choice
– Flooding
• Exposure (prolonged contact with feared
stimulus); must be sure anxiety is fully
extinguished/habituated before removal,
otherwise symptoms will worsen
• Response Prevention (preventing response that
minimizes anxiety)
– Prevent execution of ritual, thought stopping
– EMDR facilitates exposure (does not work better
than other exposure treatments)
– Effective for phobias, OCD and perhaps PTSD

Treatments Treatments

• Behavioral Treatments • Biological Treatments

– Tricyclic and SSRI Antidepressants (Imipramine,
– Modeling Prozac, Lexapro)
• Handle feared object in front of person • Especially effective with panic disorder and OCD
(Lexapro)
– Systematic desensitization • Not effective for social phobias
– Benzodiazapines (Xanax, Valium. Librium)
• Relaxation and anxiety are incompatible
• Effective for GAD (short-term)
– Deep muscle relaxation (physiological state that is • Addictive
incompatible with anxiety)
– Chlomipramine
– Anxiety hierarchy of stimuli (least to most • OCD
threatening)
– Buspirone
– In vivo or imaginally (effective in ~90% of phobias) • GAD
– Works via reciprocal inhibition
 Review Review

• Anxiety and Fear are adaptive, but in excess
and in the absence of true danger are
considered disorders
• Anxiety disorders
– Panic Disorder
• Panic Attack Features and Subtypes
– Panic Disorder with Agoraphobia (PDA)
• Panic attacks with a strong phobic avoidance of future
attacks, consequences of attacks, significant change of
behavior to avoid attacks
– Generalized Anxiety Disorder (GAD)
• “Free floating” anxiety
• Symptoms of anxiety disorders involve:
– Cognitions, Bodily responses, Behavior, Insight,
and Impairment
• Etiology
– General Biological Vulnerability
– General Psychological Vulnerability
– Specific Psychological Vulnerability
• Shared vulnerabilities often results in
comorbidities
– An Additional Anxiety Disorder, Major
Depression, Alcoholism or Substance Abuse
Disorders, and Panic Attacks

Types of Anxiety Disorders

• Panic Disorder
• Panic Disorder with Agoraphobia (PDA)
• Generalized Anxiety Disorder (GAD)
• Specific Phobia
• Social Phobia
• Posttraumatic Stress Disorder (PTSD)
• Obsessive- Compulsive Disorder (OCD)