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Subject PSYCHOLOGY

Paper No and Title Paper No 15: Clinical Psychology

Module No and Title Module No 12: Major Adulthood Disorders Anxiety

Disorders
Module Tag PSY_P15_M12

TABLE OF CONTENTS
1. Learning Outcomes
2. Introduction
3. Generalized Anxiety Disorder
4. Obsessive Compulsive Disorder
5. Phobias
5.1 Specific Phobias
5.2 Social Phobias
6. Panic Disorder
7. Summary

PSYCHOLOGY Paper No 15: Clinical Psychology

Module No 12: Major Adulthood Disorders Anxiety Disorders
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1. Learning Outcomes
After studying this module, you shall be able to

 What are types of anxieties

 Learn about the various anxiety disorders
 Identify the causes of these disorders
 Know about their treatment

2. Introduction

Anxiety is an uncomfortable and highly unbearable condition wherein the person

suffering, feels uneasy. Anxiety can be triggered by a particular situation, person, object
or thought. This feeling of uneasiness can be experienced by people of any age, adult or
child. For example, a child may feel anxious before writing his examination. Similarly,
an adult might feel anxious when he is about to give a presentation. Anxiety to some
people must be like an emotion that is regular or harmless. But there are some people
who think of it as threatening and dangerous.

‘Anxiety’ the term can be used in two varying ways as mentioned by Spielberger et al,
1970. One way of using the term anxiety is to describe a person’s relatively enduring
characteristic. This characteristic may remain fixed or constant in any and every situation,
may it be a happy or a disturbing situation. This type of anxiety which remains constant
throughout is called the trait anxiety.

Another way in which the term anxiety is used is in specific situations. A person may
only experience anxiety when he or she comes across a particular specific situation. This
type of anxiety is called the state anxiety. These two types of anxieties help us distinguish
between the various anxiety disorders that are diagnosed. Some disorders show trait
where as some disorders reflect state anxiety.

The major adulthood anxiety disorders are:

 Generalized Anxiety Disorder

 Obsessive Compulsive Disorder
 Phobias- Specific phobias and Social phobias
 Panic Disorder

PSYCHOLOGY Paper No 15: Clinical Psychology

Module No 12: Major Adulthood Disorders Anxiety Disorders
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2. Generalized Anxiety Disorder

Generalized Anxiety Disorder, as the name suggests is the most basic and general form of
anxiety disorders. The main focus of this disorder is upon the concept of worry. It
presents the highest degree of trait anxiety as mentioned above. This means that the
person suffering from generalized anxiety disorder is suffering from a very high degree
of anxiety which is not specifically related to any situation or object or person. The
person worries throughout the day without any threatening stimulus being present. This
type of anxiety is also known as the ‘free floating anxiety’. It is difficult to diagnose this
disorder, but it can easily be differentiated from a phobia once it is diagnosed. Phobia is a
fear of a specific situation, object or person, whereas generalized anxiety disorder lacks a
specific stimulus.

DSM-IV provides a criteria which helps in diagnosing GAD. The criteria states that the
patient must report extreme worry over several of activities. The patient must also report
that this worry has been present for not less than 6 months and for the most days in these
six months. There is also a list of symptoms that has been listed by DSM-IV, out of
which the patient must report at least three symptoms.

 Controlling the worry is difficult.

 The worry and anxiety is related to three or more of the following:
1. Feeling of being on the edge and restlessness
2. Getting tired fast
3. Low concentration level or blank mind
4. Mood mostly being irritated
5. Disturbed sleep
6. Muscle tension
 Distress and impairment being caused in daily life due to the worry and anxiety

Epidemiology for Generalized Anxiety Disorder is as follows:

Generalized anxiety disorder if compared with other anxiety disorders, is more

commonly found in women than men. Studies have been conducted and it has been found
that the onset of this disorder is generally early 20s or the mid teens. The patients
suffering from generalized anxiety disorder describe the onset of this disorder as gradual
and insidious. Finally, studies also show that the prevalence of GAD is 3% in a time span
of 12 months and a prevalence of 5% in a whole lifetime.

PSYCHOLOGY Paper No 15: Clinical Psychology

Module No 12: Major Adulthood Disorders Anxiety Disorders
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The Etiology of Generalized Anxiety Disorder provides

explanation with the help of various perspectives.

 Psychoanalytic factors: according to Freud, there were two main reasons for a
person to be diagnosed with this disorder. One cause was overprotective parents
and the other was excessive punishment. If a child is punished for the smallest
mistake and is forced to suppress his id impulses, he will develop a feeling of fear
and anxiety. This anxiety keeps building up until the child has grown into an
adult, and this anxiety comes out as free floating or trait anxiety.
Also, when the child has over protective parents who protect the child from the
smallest threat, he is unable to develop any defense mechanisms. Thus, after
growing up when he faces the smallest threat or fear, it leads to very high levels
of anxiety.
 Cognitive-behavioral factors: it is believed that people with anxiety disorders
have a tendency to focus their attention more towards the negative or threatful
information rather than positive information. This leads to a feeling of fear and
anxiety throughout the day.
 Humanistic explanation: humanists suggested that people suffer from GAD
because they are unable to accept themselves for who they are. This happens due
to extremely strict parenting which leads to criticism and punishment. As a result,
the child grows up to think that he is worth nothing and with low self-confidence
and low self-esteem which causes anxiety in the person when he faces even a
slightly threatful situation.
 Socio cultural factors: it is believed that the socio economic status of an
individual may affect him on a mental level. It has been seen that people
belonging to the ethnic minority groups or the lower socio economic groups are
the ones under extreme pressure of the society. Thus, these people experience
high levels of GAD. Child sexual abuse in women also has led to high levels of
GAD.
 Genetic factors: a meta-analysis study done by Hettema et al. (2001a) showed that
the coefficient of heritability in cases with GAD is about 0.32. This means that the
possibility of genetically acquiring GAD is only 0.32 coefficients. Also, studies
have shown that there is very low concordance rate between twin pairs. And no
difference in concordance rate was found between dizygotic and monozygotic
twins.
 Biological factors: over activation of the system of the brain which involves the
Papez circuit and the septohippocampal system are responsible for high levels of
anxiety. This system is also called the behavioral inhibition system (BIS) as
mentioned by Gray in 1983. GABA receptors also play a role. These receptors
are responsible for controlling the activity taking place within the hypothalamus
and sympathetic nervous system.

Treatment:
 Cognitive behavioral treatment: treatment for GAD involves the exposing the
patient to the stimulus he fears and then applying various techniques by which he
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may prevent the response to such feared stimuli.

There are three main key techniques which have
been found to be effective in treatment of GAD. These techniques are: relaxation
training, worry exposure assignments and cognitive restructuring of anxiety-
provoking thoughts.
 Psychoanalytic therapy: the aim of this type of therapy is to explore the subject’s
problems by understanding the patient’s relationship with people around him,
development throughout their childhood and by also noting the use of resistance
and transference during the sessions.
 Pharmacological therapy: Benzodiazepines is one medicine that has been used for
the cases of GAD and has been found affective to some extent. But
Benzodiazepines has several limitations if used for a long term.

3. Obsessive Compulsive Disorder

The obsessive compulsive disorder is considered to be one of the most severe and chronic
of the anxiety disorders as stated by American Psychiatric Association (APA). This
disorder consists of obsessions and compulsions.

Obsessions are repeatedly occurring intrusive thoughts or visual images with an urge that
is difficult to control. Obsessions are of different types including: feeling of
contamination, fear of acquiring a disease in case of contact with others, tidiness or
orderliness, bodily concerns etc. Obsessions arise because the patient is unable to realize
the fact that the suppressed thoughts and images are increasing the strength of these
obsessions.

Compulsions, on the other hand, are repetitive behaviors (overt or covert) which are
purposefully done to reduce or completely get rid of the anxiety which arises due to the
repeatedly occurring thoughts or images known as obsessions. Compulsions are
performed in a ritualistic manner, with a particular procedure and number of times that
they must be repeated. The most commonly seen and reported compulsions include, hand
washing, cleaning, tidying or orderliness, counting, checking of locks etc.

Epidemiology for Obsessive Compulsive Disorder is as follows:

Obsessive compulsive disorder is slightly more commonly found in women than in men.
The onset of OCD is found to lie between late adolescence and early adulthood. Another
important point is that this disorder is that the age of onset is earlier in men than women.
The course of OCD is chronic.

The Etiology of Obsessive Compulsive Disorder provides explanation with the help of
various perspectives.

 Psychoanalytic factors: the founder of psychoanalysis, Freud said that obsessive

thoughts are a result of the suppressed id impulses and the compulsions arise as a
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result of the ego defenses. Freud also believed that

obsessions might arise due to the child being
fixated on the anal stage. When the parents apply strict and rigid rules over the
child’s toilet training, the child tends to develop a rigid and obsessive personality
while growing up.
 Behavioral factors: just like GAD, behaviorists believe that OCD can result from
a fear of a stimulus which is acquired by classical conditioning and the fear is
maintained by operant conditioning.
 Cognitive factors: cognitive psychologists believe that the obsessive thoughts are
intrusive and the person fears that he might hurt someone, thus the anxiety builds
up. To reduce this anxiety, compulsions arise in the form of overt or covert
behaviors.
 Genetic factors: genetic studies have been providing mixed responses. That is,
some researchers say that people suffering from OCD might have some genetic
evidence but some might not.
 Biological factors: biologists have found out two causes that may result on OCD.
The first brain system is the loop connecting the orbito- frontal area to the
thalamic region. And the second brain system is the loop that connects the orbito-
frontal region to the thalamic region, but via the corpus striatus.

Treatment:
 Behavioral intervention: like phobias, the patients are exposed to the feared
stimulus and then they are helped how to prevent the reaction of the feared
stimulus. This procedure helps the patient to see that there is no association
between the stimulus and the patient’s reactions. Relaxation is also used in order
to help reduce anxiety and avoid the compulsions from happening.
 Cognitive behavioral treatment: mind experiments, behavioral hypothesis testing,
challenging inappropriate thoughts, thought stopping. These are some of the
techniques that are used for treatment using cognitive behavioral interventions.
 Pharmacological intervention: Clomipramine and SSRIs are effective drugs that
help in treatment of OCD, but have several side effects also.
 Surgical approaches: surgery in people with OCD is only done when it is at the
severe level and the person has not been responding to the treatment of any sort. It
is not very clear how exactly surgery affects OCD patients. But it has been
hypothesized that it severs the connections between the orbito-frontal and
thalamic areas which dampens down the activity within this circuit and hence the
obsessive-compulsive disorder symptoms.

4. Phobias
Phobias are fears that are irrational and persistence of certain objects, situations or
animals. Phobias can be of two types: specific phobias and social phobias.

PSYCHOLOGY Paper No 15: Clinical Psychology

Module No 12: Major Adulthood Disorders Anxiety Disorders
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4.1 Specific Phobias

These phobias are irrational and persistent fears of specific or particular objects and
animals. DSM-IV presents a number of features of the specific phobias.

 Fear in specific phobia is directed or indicated towards a specific object.

 When the person comes across these specific objects or situations, they
experience intense fear and anxiety followed by avoidance of that object.
 The fear and anxiety rise to such a level that they interfere with the patient’s daily
functioning.

DSM-IV tries to categorize between 4 types of commonly seen specific phobias: Animal
type (lizards, snake, spiders etc.), natural environment type (dark places and heights),
blood-injection-injury type (dentists) and situational type (elevators or closed places).

Epidemiology of specific phobias is as follows:

Phobias are one of the most commonly found mental disorders. It was found that
situational type phobias were more commonly seen than animal type blood-injection-
injury phobias. Specific phobias are more commonly diagnosed and acquired in women
than men. Usually phobias start to set in at childhood.

Etiology
 Behavioral factors: behaviorists believe that a person acquires a specific phobia
when he has experienced a traumatic accident or incident. There are three basic
principles of behaviorism which can explain the fear of a person from specific
objects. These three principles are: operant-conditioning principle, vicarious-
conditioning principle and respondent-conditioning principle.
 Evolutionary factors: ever since we have been evolving, we have learnt from our
ancestors that some objects or animals are to be feared of or to be stayed away
from. For example spiders or snakes etc.
 Biological factors: there is a great possibility of heritability of specific phobias.
Genetic basis also play an important role here. Researchers have proved that there
is a greater concordance rate within monozygotic twins than the dizygotic twins.
 A diathesis-stress viewpoint: this model states that specific phobias are acquires
due to high exposure to psychosocial factors such as direct or indirect
conditioning and biologically influenced propensity to experience fear and
anxiety.

4.2 Social Phobias (Social Anxiety Disorder)

We all experience some sort of social fears in our day to day lives such as meeting new
people or presenting in front of our superiors etc. but people who suffer from social
phobias are on a completely extreme side. People with social phobias have persistent and
extreme fear of multiple types of situations. Social phobia was never considered to be a

PSYCHOLOGY Paper No 15: Clinical Psychology

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psychological problem for many years. But in 1994 an

alternate term ‘social anxiety disorder’ was given to this
problem which was given by DSM-IV.

Clinically, a person suffering from a social phobia is one who experiences fear and
anxiety in going to new places, meeting new people and being in new situations
altogether. The person feels that he might do some inappropriate behavior and he might
embarrass or humiliate the other people around him and sometimes himself. Therefore,
the patient avoids going to social gatherings or to new places and meeting new people.

When a person suffering from social phobias is exposed to situations he fears, he

experiences some physical symptoms such as blushing, fastening of heart beat, drying of
mouth sweating etc.

Epidemiology of social phobias is as follows:

Social phobias are commonly seen to begin in the late adolescence that is from the age of
13 to 20 years. Its course is found to be chronic and unremitting. Most studies show that
social phobias are more commonly diagnosed in women but some studies say that there is
an equal distribution across both genders.

Etiology:
 Biological factors: family studies show that there are higher possibilities of
acquiring social phobias if a relative already has it. This prevalence rate is highest
for social phobias.
 Behavioral factors: conditioning plays a vital role in the development of this
disorder. Public speaking and blushing in public strengthens the effect. Socially
phobic individuals differ from healthy people because when excursuses are done
in order to reduce fear and talk in front of people, healthy people take it in a
positive manner, whereas for socially phobic people it goes into a complete
negative and opposite direction.
 Cognitive factors: people with social phobias have certain negative beliefs such as
‘whenever I talk, I sound stupid’ or ‘I hope I don’t stare too much at anybody’.
These people always feel and believe that they will say something wrong, this
leads them t feel anxious and fearful. Also, socially phobic people tend to
selectively pay attention to threatful or negative situations.

Treatment:
 Behavioral treatment: systematic desensitization is the first very commonly used
technique. In this technique the person is exposed to the stimulus he fears in a
systematic or hierarchical manner, and is then is taught how to reduce the anxiety.
On the other hand, flooding is another technique which uses the same procedure,
but the exposure of the feared stimulus in this technique is sudden and at once.
 Pharmacological treatments: many researchers have suggested that in case of
phobias, medication is hardly required or even used. Thus, behavioral treatment is
PSYCHOLOGY Paper No 15: Clinical Psychology
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the best treatment theta should and can be

provided to people suffering from any kind of
phobias.

5. Panic Disorder
Panic attacks have been a topic of research and concern for many years. According to
DSM-III panic disorder was defined as a part of anxiety disorders but differed from other
anxiety disorders in only one way that is, the presence of panic attacks.

Panic attacks are referred to as sudden attacks or episodes of anxiety in full force
accompanied by fear of losing owns mind, going crazy or dying. The person suffering
from a panic attack experiences physical symptoms including palpitation, high blood
pressure, choking, shortness of breath, sweating, dizziness and sometimes nausea. The
panic attacks are experienced at different levels by different people that is, some people
might experience 5 of the physical symptoms mentioned above whereas some might
experience only 2 symptoms, but both may be experiencing panic attacks.

Many years later DSM-IV categorized three different types of panic attacks: Situationally
bound attacks (panic attacks which take place in the presence of a particular object or
situation), situationally predisposed attacks (panic attacks which take place only in the
presence of some situations not all) and unexpected or spontaneous attacks (panic attacks
in these cases occur at any point randomly or out of the blue).

Another characteristic of panic attacks is that they occur or take place in all anxiety
disorders and are not only bound to occur in panic disorder.

Epidemiology of panic attacks is as follows:

Panic disorder attacks are a prevalent and chronic condition. The lifetime prevalence is
estimated to be 1–4% (APA, 2000). Researchers have found that women have twice the
chance to acquire this disorder than men. A median of 24 years has been found to be the
approximate age for this disorder to be acquired.

Etiology:
 Biological factors: researchers say that there is a there is genetic component in
acquiring this disorder. Patients who suffer from this disorder have higher chances
of experiencing a panic attack on inhaling carbon dioxide than patients who have
other anxiety disorders.
 Behavioral factors: behaviorists believe that like all other anxiety disorders, even
panic attack can be a result of classical conditioning and an association of
unconditional and conditional stimuli.

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 Cognitive factors: some cognitive factors that

contribute to panic attacks are predictability, controllability, and expectancies.

Treatment:
 Cognitive behavioral interventions: the three steps taken from Clark’s model are
used for the treatment of panic attacks. Relaxation (breathing and body
relaxation), cognitive procedures (instructing oneself to relax in threatful
situations) and behavioral procedures (here the person is made to realize that if
the person does not react, the situation will pass and not harm him or not occur
also).
 Pharmacological treatment: panic disorders have been treated effectively with the
help of Benzodiazepines and SSRIs.
 Combination intervention: researchers have also found that combining short term
dosage of benzodiazepines and long term sessions of cognitive behavioral
interventions have been very effective in improving the condition of patients
suffering with panic disorders.

7. Summary

 Anxiety as we all know is a feeling of distress and uneasiness experienced when

one comes across a threatful situation or a feared stimulus.
 Anxiety can be of two types: trait anxiety and state anxiety.
 There are several anxiety disorders: Generalized disorder, obsessive compulsive
disorder, specific phobias, social phobias, panic attacks or disorder.
 GAD is an anxiety disorder where the person experiences free floating anxiety
without any specific stimulus. The person keeps worrying all the time.
 Phobias are of two types: specific and social phobias. They differ based on the
type of stimuli the person fears.
 OCD is another commonly found disorder. This involves obsessions which elicit
anxiety, and to avoid the anxiety or feeling of fear and guilt sometimes, the
compulsions are performed (overt or covert).
 Panic disorder or attacks is another anxiety disorder where the person panics
either on seeing or remembering something and sometimes just out of the blue.
 The disorders mentioned above have several causes and the treatment for each
disorder have also been mentioned above.
 The commonly used treatments are pharmacological treatments, cognitive
behavioral and cognitive interventions, and sometimes even psychoanalytic
therapy.

PSYCHOLOGY Paper No 15: Clinical Psychology

Module No 12: Major Adulthood Disorders Anxiety Disorders
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PSYCHOLOGY Paper No 15: Clinical Psychology

Module No 12: Major Adulthood Disorders Anxiety Disorders