ANXIETY DISORDER

 The DSM has identified a group of disorders—known as anxiety disorders—that share

symptoms of clinically significant anxiety or fear.
 Anxiety disorders affect approximately 29 percent of the U.S. population at some point in their
lives and are the most common category of disorders for women and the second most
common for men. In any 12 months, about 18 percent of the adult population suffers from at
least one anxiety disorder.
 Anxiety disorders create enormous personal, economic, and health care problems for those
affected and for society more generally. Historically, anxiety disorders were considered to be
classic neurotic disorders.
 Although individuals with neurotic disorders show maladaptive and self-defeating behaviors,
they are not incoherent, dangerous, or out of touch with reality. To Freud, these neurotic
disorders developed when intrapsychic conflict produced significant anxiety. Anxiety was, in
Freud’s formulation, a sign of an inner battle or conflict between some primitive desire (from
the id) and prohibitions against its expression (from the ego and superego). Sometimes this
anxiety was overtly expressed (as in those disorders known today as the anxiety disorders). In
certain other neurotic disorders, however, he believed that the anxiety might not be obvious,
either to the person involved or to others, if psychological defense mechanisms were able to
deflect or mask it.
 The term neurosis was dropped from the DSM in 1980. In addition, in DSM-III, some disorders
that did not involve obvious anxiety symptoms were reclassified as either dissociative or
somatoform disorders.
 Obsessive-compulsive disorder (OCD) is no longer classified as an anxiety disorder. Instead, it is
now listed in its category of obsessive-compulsive and related disorders.
 The adaptive value of anxiety may be that it helps us plan and prepare for a possible threat. In
mild to moderate degrees, anxiety actually enhances learning and performance. For example,
a mild amount of anxiety about how you are going to do on your next exam, or in your next
tennis match, can actually be helpful. But, although anxiety is often adaptive in mild or
moderate degrees, it is maladaptive when it becomes chronic and severe, as we see in people
diagnosed with anxiety disorders.
 Overview of Anxiety Disorders:
Anxiety is characterized by a wide range of symptoms that cut across physical, behavioral, and
cognitive domains:
a) Physical features may include jumpiness, jitteriness, trembling or shaking, tightness in the pit
of the stomach or chest, heavy perspiration, sweaty palms, lightheadedness or faintness,
dryness in the mouth or throat, shortness of breath, heart pounding or racing, cold fingers or
limbs, and upset stomach or nausea, among other physical symptoms.
 b) Behavioral features may include avoidance behavior, clinging or dependent behavior, and
agitated behavior.
c) Cognitive features may include worrying, a nagging sense of dread or apprehension about
the future, preoccupation with or keen awareness of bodily sensations, fear of losing control,
thinking the same disturbing thoughts over and over, jumbled or confused thoughts, difficulty
concentrating or focusing one’s thoughts, and thinking that things are getting out of hand.

 Difference between fear and anxiety: There has never been complete agreement about how
distinct the two emotions of fear and anxiety are from each other. Historically, the most
common way of distinguishing between the fear and anxiety response patterns has been to
determine whether a clear source of danger is present that would be regarded as real by most
people. When the source of danger is obvious, the experienced emotion has been called fear
(e.g., “I’m afraid of snakes”). With anxiety, however, we frequently cannot specify clearly what
the danger is (e.g., “I’m anxious about my parents’ health”).
 FEAR: fear is a basic emotion (shared by many animals) that involves activation of the
“fight-or-flight” response of the autonomic nervous system. This is an almost instantaneous
reaction to any imminent threat such as a dangerous predator or someone pointing a
loaded gun. Its adaptive value as a primitive alarm response to imminent danger is that it
allows us to escape. When the fear response occurs in the absence of any obvious external
danger, we say the person has had a spontaneous or uncued panic attack. The symptoms
of a panic attack are nearly identical to those experienced during a state of fear except that
panic attacks are often accompanied by a subjective sense of impending doom, including
fears of dying, going crazy, or losing control. These latter cognitive symptoms do not
generally occur during fear states. Thus, fear and panic have three components:
1. cognitive/subjective components (e.g., “I’m going to die”)
2. physiological components (e.g., increased heart rate and heavy breathing)
3. behavioral components (e.g., a strong urge to escape or flee).
 Anxiety disorders are characterized by unrealistic, irrational fears or anxieties that cause
significant distress and/or impairments in functioning. Among the disorders recognized in
DSM-5 are:
1. specific phobia
2. social anxiety disorder (social phobia)
3. panic disorder
4. agoraphobia
5. generalized anxiety disorder.
  It is also important to note that many people with one anxiety disorder will experience
at least one more anxiety disorder and/or depression either concurrently or at a different
point in their lives

1. SPECIFIC PHOBIA:

 We all have things that we are afraid of: scary movies, tigers, clowns, scary movies
about tiger-riding clowns. Having such fears is normal. However, a specific phobia is said to
be present if a person shows strong and persistent fear that is triggered by the presence of a
specific object or situation and leads to significant distress and/or impairment in a person’s
ability to function.
 Indeed, they often even avoid seemingly harmless representations of it such as
photographs or television images. For example, claustrophobic persons may go to great
lengths to avoid entering a closet or an elevator, even if this means climbing many flights of
stairs or turning down jobs that might require them to take an elevator. Generally, people
with specific phobias recognize that their fear is somewhat excessive or unreasonable
although occasionally they may not have this insight.
Diagnostic Criteria:
A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals,
receiving an injection, seeing blood). Note: In children, the fear or anxiety may be expressed by
crying, tantrums, freezing, or clinging.
B. The phobic object or situation almost always provokes immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or
situation and to the socio-cultural context.
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
G. The disturbance is not better explained by the symptoms of another mental disorder,
including fear, anxiety, and avoidance of situations associated with panic-like symptoms or
other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions
(as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress
disorder); separation from home or attachment figures (as in separation anxiety disorder); or
social situations (as in social anxiety disorder).
 One category of specific phobias that has several interesting and unique characteristics
is blood-injection injury phobia. It occurs in approximately 3 to 4 percent of the population
(Ayala et al., 2009). People afflicted with this phobia typically experience at least as much (if
not more) disgust as fear. They also show a unique physiological response when confronted
with the sight of blood or injury. Rather than showing the simple increase in heart rate and
blood pressure is seen when most people with phobias encounter their phobic object, these
people show an initial acceleration, followed by a dramatic drop in both heart rate and blood
pressure. This is very frequently accompanied by nausea, dizziness, or fainting, which does not
occur with other specific phobias From an evolutionary and functional standpoint, this unique
physiological response pattern may have evolved for a specific purpose: By fainting, the person
being attacked might inhibit further attack, and if an attack did occur, the drop in blood
pressure would minimize blood loss. This type of phobia appears to be highly heritable

Etiology:
PSYCHOANALYTIC VIEWPOINT According to the psychoanalytic view, phobias represent a
defense against anxiety stemming from the id's repressed impulses. Because it is too dangerous
to “know” the repressed id impulse, the anxiety is displaced onto some external object or
situation that has some symbolic relationship to the real object of the anxiety (Freud, 1909).
However, this prototypical psychodynamic account of how phobias are acquired was long
criticized as being far too speculative. From the psychodynamic perspective, anxiety is a
dangerous signal that threatening impulses of a sexual or aggressive (murderous or suicidal)
nature are nearing the level of awareness. To fend off these threatening impulses, the ego
mobilizes its defense mechanisms. In phobias, the Freudian defense mechanism of projection
comes into play. A phobic reaction is a projection of the person’s own threatening impulses
onto the phobic object. For instance, a fear of knives or other sharp instruments may represent
the projection of one’s own destructive impulses onto the phobic object. The phobia serves a
useful function. Avoiding contact with sharp instruments prevents these destructive wishes
toward the self or others from becoming consciously realized or acted on. The threatening
impulses remain safely repressed. Similarly, people with acrophobia may harbor unconscious
wishes to jump that are controlled by avoiding heights. The phobic object or situation
symbolizes or represents these unconscious wishes or desires. The person is aware of the
phobia, but not of the unconscious impulses it symbolizes.

PHOBIAS AS LEARNED BEHAVIOR Wolpe and Rachman (1960) developed an account based on
learning theory, Vicarious Conditioning Direct traumatic conditioning in which a person has a
terrifying experience in the presence of a neutral object or situation is not the only way that
people can learn irrational, phobic fears. Simply watching a phobic person behaving fearfully
with his or her phobic object can be distressing to the observer and can result in fear being
transmitted from one person to another through vicarious or observational classical
conditioning. In addition, watching a non-fearful person undergo a frightening experience can
also lead to vicarious conditioning. For example, one man, as a boy, had witnessed his
grandfather vomit while dying. Shortly after this traumatic event (his grandfather’s distress
while dying), the boy had developed a strong and persistent vomiting phobia.

BIOLOGICAL CAUSAL FACTORS Genetic and temperamental variables also affect the speed and
strength of conditioning of fear. For example, Lonsdorf and colleagues (2009) found that
individuals who are carriers of one of the two variants of the serotonin transporter gene (the s
allele, which has been linked to heightened neuroticism) show superior fear conditioning than
those without the s allele. However, those with one of two variants of a different gene (the
COMT met/met genotype) did not show superior conditioning but did show enhanced
resistance to extinction.

2. SOCIAL PHOBIA
 Social phobia (or social anxiety disorder) is characterized by disabling fears of one or
more specific social situations (such as public speaking, urinating in a public bathroom, or
eating or writing in public).
 In these situations, a person fears that she or he may be exposed to the scrutiny and
potential negative evaluation of others or that she or he may act in an embarrassing or
humiliating manner. Because of their fears, people with social phobia either avoid these
situations or endure them with great distress.
 DSM-5 also identifies two subtypes of social phobia, one of which centers on
performance situations such as public speaking and one of which is more general and
includes nonperformance situations (such as eating in public). People with the more general
subtype of social phobia often have significant fears of most social situations (rather than
simply a few) and often also have a diagnosis of avoidant personality disorder.

Diagnostic criteria:

A. Marked fear or anxiety about one or more social situations in which the individual is
exposed to possible scrutiny by others. Examples include social interactions (e.g., having a
conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and
performing in front of others (e.g., giving a speech). Note: In children, the anxiety must
occur in peer settings and not just during interactions with adults.
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be
negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or
offend others).
C. social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety
may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in
social situations.
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and
to the socio-cultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physio logical effects of a
substance (e.g., a drug of abuse, a medication) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental
disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or
injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
Etiology:
SOCIAL PHOBIA AS LEARNED BEHAVIOR As with specific phobias, social phobia often seems to
originate from simple instances of direct or vicarious classical conditioning such as experiencing
or witnessing a perceived social defeat or humiliation, or being or witnessing the target of
anger or criticism. It is important to keep in mind that, as with specific phobias, not everyone
who experiences direct or vicarious conditioning in social situations develops social phobia.
Individual differences in experiences play an important role in who develops social phobia, as is
the case with specific phobias.
PERCEPTIONS OF UNCONTROLLABILITY AND UNPREDICTABILITY Being exposed to
uncontrollable and unpredictable stressful events (such as parental separation and divorce,
family conflict, or sexual abuse) may play an important role in the development of a social
phobia. Consistent with this, people with social phobia have a diminished sense of personal
control over events in their lives. This diminished expectation of personal control may develop,
at least in part, as a function of having been raised in families with somewhat overprotective
(and sometimes rejecting) parents.
COGNITIVE BIASES Cognitive factors also play a role in the onset and maintenance of social
phobia. Beck and colleagues (1985) suggested that people with social phobia tend to expect
that other people will reject or negatively evaluate them. They argued that this leads to a sense
of vulnerability when they are around people who might pose a threat. Clark and Wells later
further proposed that these dangerous schemas of socially anxious people lead them to expect
that they will behave awkwardly and unacceptably, resulting in rejection and loss of status.
Such negative expectations lead to their being preoccupied with bodily responses and with
stereotyped, negative self-images in social situations; to their overestimating how easily others
will detect their anxiety; and to their misunderstanding how well they come across to others.
Such intense self-preoccupation during social situations, even to the point of attending to their
heart rate, interferes with their ability to interact skillfully. A vicious cycle may evolve: The
inward attention and potentially awkward interactions of someone with social phobia may lead
others to react to them in a less friendly fashion, confirming their expectations. Another
cognitive bias seen in social phobia is a tendency to interpret ambiguous social information in a
negative rather than a benign manner (e.g., when someone smiles at you, does it mean they
like you or that they think you’re foolish?). Moreover, it is the negatively biased interpretations
that socially anxious people make that are remembered. It has also been suggested that these
biased cognitive processes combine to maintain social phobia and possibly even contribute to
its development (Hirsch et al., 2006). Biological Causal Factors The most important
temperamental variable is behavioral inhibition, which shares characteristics with both
neuroticism and introversion (Bienvenu et al., 2007). Behaviorally inhibited infants who are
easily distressed by unfamiliar stimuli and who are shy and avoidant are more likely to become
fearful during childhood and, by adolescence, to show an increased risk of developing social
phobia.
Oversensitivity to threatening cues: People with phobias tend to perceive danger in situations
most people consider safe, such as riding on elevators or driving over bridges. Similarly, people
with social anxiety tend to be overly sensitive to social cues of rejection or negative evaluation
from others (Schmidt et al., 2009).
Overprediction of danger: Phobic individuals tend to overpredict how much fear or anxiety they
will experience in the fearful situation. A person with a snake phobia, for example, may expect
to tremble when he or she encounters a snake in a cage. People with dental phobia may have
exaggerated expectations of the pain they will experience during dental visits. Typically
speaking, the actual fear or pain experienced during exposure to the phobic stimulus is a good
deal less than what people expect. Yet the tendency to expect the worst encourages the
avoidance of feared situations, which in turn prevents the individual from learning to manage
and overcome anxiety.
Self-defeating thoughts and irrational beliefs: Self-defeating thoughts can heighten and
perpetuate anxiety and phobic disorders. When faced with fear-evoking stimuli, the person
may think, “I’ve got to get out of here,” or “My heart is going to leap out of my chest.”
Thoughts like these intensify autonomic arousal, disrupt planning, magnify the aversiveness of
stimuli, prompt avoidance behavior, and decrease self-efficacy expectancies concerning a
person’s ability to control the situation. Similarly, people with social anxiety may think, “I’ll
sound stupid,” whenever they have an opportunity to speak in front of a group of people
(Hoffmann et al., 2004). Such self-defeating thoughts may stifle social participation.

PANIC DISORDER:

 Panic disorder is defined and characterized by the occurrence of panic attacks that often
seem to come “out of the blue.”
 According to the DSM-5 criteria for panic disorder, the person must have experienced
recurrent, unexpected attacks and must have been persistently concerned about having
another attack or worried about the consequences of having an attack for at least a month
(often referred to as anticipatory anxiety).
 For such an event to qualify as a full-blown panic attack, there must be an abrupt onset of
at least 4 of 13 symptoms. Most of these symptoms are physical, although three are
cognitive.
 Panic attacks are fairly brief but intense, with symptoms developing abruptly and usually
reaching peak intensity within 10 minutes; the attacks often subside in 20 to 30 minutes and
rarely last more than an hour.
 Periods of anxiety, by contrast, do not typically have such an abrupt onset and are more
long-lasting. Panic attacks often are “unexpected” or “uncued” in the sense that they do not
appear to be provoked by identifiable aspects of the immediate situation. Indeed, they
sometimes occur in situations in which they might be least expected, such as during
relaxation or sleep (known as nocturnal panic).
 In other cases, however, panic attacks are said to be situationally predisposed, occurring
only sometimes while the person is in a particular situation such as while driving a car or
being in a crowd.
 Because most symptoms of a panic attack are physical, it is not surprising that as many as
85 percent of people having a panic attack may show up repeatedly at emergency
departments or physicians’ offices for what they are convinced is a medical problem—
usually cardiac, respiratory, or neurological.
 Unfortunately, a correct diagnosis is often not made for years due to the normal results of
numerous costly medical tests. Further complications arise because patients with cardiac
problems are at a nearly twofold elevated risk for developing panic disorder.
 Prompt diagnosis and treatment are also important because panic disorder causes
approximately as much impairment in social and occupational functioning as that caused by
a major depressive disorder and because the panic disorder can contribute to the
development or worsening of a variety of medical problems.
Diagnostic Criteria:
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or
intense discomfort that reaches a peak within minutes, and during which time four (or
more) of the following symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
 6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying. Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache,
uncontrollable screaming, or crying) may be seen. Such symptoms should not count as one
of the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the
following:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g.,
losing control, having a heart attack, “going crazy”).
2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors
designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar
situations).
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary
disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks
do not occur only in response to feared social situations, as in social anxiety disorder; in
response to circumscribed phobic objects or situations, as in specific phobia; in response to
obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic
events, as in posttraumatic stress disorder; or in response to separation from attachment
figures, as in separation anxiety disorder).

AGORAPHOBIA:

 Historically, agoraphobia was thought to involve a fear of the agora—the Greek word for
“open gathering place.” In agoraphobia the most commonly feared and avoided situations
include streets and crowded places such as shopping malls, movie theatres, and stores.
Standing in line can be particularly difficult. Sometimes, agoraphobia develops as a
complication of having panic attacks in one or more such situations.
 Concerned that they may have a panic attack or get sick, people with agoraphobia are
anxious about being in places or situations from which escape would be difficult or
embarrassing, or in which immediate help would be unavailable if something bad
happened.
 Typically, people with agoraphobia are also frightened by their bodily sensations, so they
also avoid activities that will create arousal such as exercising, watching scary movies,
drinking caffeine, and even engaging in sexual activity.
Diagnostic Criteria:
A. Marked fear or anxiety about two (or more) of the following five situations:
1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).
2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
3. Being in enclosed places (e.g., shops, theatres, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.
B. The individual fears or avoids these situations because of thoughts that escape might be
difficult or help might not be available in the event of developing panic-like symptoms or
other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear
of incontinence).
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence of a companion,
or are endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic
situations and to the socio-cultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is
present, the fear, anxiety, or avoidance is clearly excessive.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another
mental disorder—for example, the symptoms are not confined to specific phobia,
situational type; do not involve only social situations (as in social anxiety disorder), and
are not related exclusively to obsessions (as in obsessive-compulsive disorder),
perceived defects or flaws in physical appearance (as in body dysmorphic disorder),
reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation
(as in separation anxiety disorder). Note: Agoraphobia is diagnosed irrespective of the
presence of panic disorder. If an individual’s presentation meets the criteria for panic
disorder and agoraphobia, both diagnoses should be assigned.
Comorbidity with other disorders:
The vast majority of people with panic disorder (83 percent) have at least one comorbid
disorder, most often generalized anxiety disorder, social phobia, specific phobia, PTSD,
depression, and substance use disorders. Depression is especially common among those with
panic disorder, with approximately 50 to 70 per cent of people with panic disorder experiencing
serious depression at some point in their lives. Perhaps related to the fear of having a panic
attack, they may also meet the criteria for dependent or avoidant personality disorder.
Timing of first panic attack:
Although panic attacks themselves appear to come “out of the blue,” the first one frequently
occurs following feelings of distress or some highly stressful life circumstance such as loss of a
loved one, loss of an important relationship, loss of a job, or criminal victimization. Although
not all studies have found this, some have estimated that approximately 80 to 90 percent of
people report that their first panic attack occurred after one or more negative life events.
Etiology of panic disorder and agoraphobia:
GENETIC FACTORS According to family and twin studies, panic disorder has a moderately
heritable component. As noted earlier, this genetic vulnerability is manifested at a
psychological level at least in part by the important personality trait called neuroticism (which is
in turn related to the temperamental construct of behavioral inhibition). Some studies have
suggested that this heritability is at least partly specific for panic disorder (rather than for all
anxiety disorders), but twin studies suggest that there is overlap in the genetic vulnerability
factors for panic disorder and both phobias and separation anxiety However, another study
suggests overlap in the genetic vulnerability for panic disorder, generalized anxiety disorder,
and agoraphobia. Only further research can resolve these inconsistencies in findings.
PANIC AND THE BRAIN: The amygdala is a collection of nuclei in front of the hippocampus in the
limbic system of the brain that is critically involved in the emotion of fear. Stimulation of the
central nucleus of the amygdala is known to stimulate the locus coeruleus as well as the other
autonomic, neuroendocrine, and behavioral responses that occur during panic attacks. Finally,
the cognitive symptoms that occur during panic attacks (fears of dying or of losing control) and
overreactions to the danger posed by possibly threatening bodily sensations are likely to be
mediated by higher cortical centers.
BIOCHEMICAL ABNORMALITIES: The inhibitory neurotransmitter GABA has also been implicated
in the anticipatory anxiety that many people with panic disorder have about experiencing
another attack. GABA is known to inhibit anxiety and is abnormally low in certain parts of the
cortex in people with panic disorder
COGNITIVE THEORY OF PANIC The cognitive theory of panic disorder proposes that people with
panic disorder are hypersensitive to their bodily sensations and are very prone to giving them
the direst interpretation possible. Any kind of perceived threat may lead to apprehension or
worry, which is accompanied by various bodily sensations. According to the cognitive model of
panic, if a person then catastrophizes about the meaning of his or her bodily sensations, this
will raise the level of perceived threat, thus creating more apprehension and worry as well as
more physical symptoms, which fuel further catastrophic thoughts. This vicious circle can
culminate in a panic attack. The initial physical sensations need not arise from the perceived
threat (as shown at the top of the circle) but may come from other sources (exercise, anger,
psychoactive drugs, etc., as shown at the bottom of the circle). The person is not necessarily
aware of making these catastrophic interpretations; rather, the thoughts are often just barely
out of the realm of awareness. Although it is not yet clear how the tendency to catastrophize
develops, the cognitive model proposes that only people with this tendency to catastrophize go
on to develop panic disorder. The model also predicts that changing their cognitions about their
bodily symptoms should reduce or prevent panic. Evidence that cognitive therapy for panic
works is consistent with this prediction. In addition, a brief explanation of what to expect in a
panic provocation study can prevent or reduce panic symptoms.

SUFFOCATION FALSE ALARM THEORY The biological underpinnings of panic attacks may involve
an unusually sensitive internal alarm system involving parts of the brain, especially the limbic
system and frontal lobes, that normally become involved in responding to cues of threat or
danger. Psychiatrist Donald Klein (1994) proposed a variation of the alarm model called the
suffocation false alarm theory. He postulated that a defect in the brain’s respiratory alarm
system triggers a false alarm in response to minor cues of suffocation. In Klein’s model, small
changes in the level of carbon dioxide in the blood, perhaps resulting from hyperventilation,
produce sensations of suffocation. These respiratory sensations trigger the respiratory alarm,
leading to a cascade of physical symptoms associated with the classic panic attack: shortness of
breath, smothering sensations, dizziness, faintness, increased heart rate or palpitations,
trembling, sensations of hot or cold flashes, and feelings of nausea.
COMPREHENSIVE LEARNING THEORY OF PANIC DISORDER A comprehensive learning theory of
panic disorder developed during the past few decades suggests that initial panic attacks
become associated with initially neutral internal (interoceptive) and external (exteroceptive)
cues through an interoceptive conditioning (or exteroceptive conditioning) process, which leads
anxiety to become conditioned to these CSs, and the more intense the panic attack, the more
robust the conditioning that will occur. This conditioning of anxiety to the internal or external
cues associated with panic thus sets the stage for the development of two of the three
components of panic disorder: anticipatory anxiety and, sometimes, agoraphobic fears.
Specifically, when people experience their initial panic attacks (which are terrifying emotional
events replete with strong internal bodily sensations), interoceptive and exteroceptive
conditioning can occur to different kinds of cues, ranging from heart palpitations and dizziness
to shopping malls. Because anxiety becomes conditioned to these CSs, anxious apprehension
about having another attack, particularly in certain contexts, may develop, as may agoraphobic
avoidance of contexts in which panic attacks might occur in a subset of individuals. In
individuals who have panic disorder, extinction of conditioned anxiety responses occurs more
slowly than in normal controls (Michael et al., 2007). Because extinction involves inhibitory
learning, which seems to be impaired in panic disorder, it is not surprising that individuals with
panic disorder also show impaired discriminative conditioning because of their deficits in
learning that a CS is a safety cue.
COGNITIVE BIASES AND THE MAINTENANCE OF PANIC Finally, many studies have shown that
people with panic disorder are biased in the way they process threatening information. Such
people not only interpret ambiguous bodily sensations as threatening, but they also interpret
other ambiguous situations as more threatening than do controls. People with panic disorder
also seem to have their attention automatically drawn to threatening information in their
environments such as words that represent things they fear, such as palpitations, numbness, or
faintness.
GAMMA AMINO BUTYRIC ACID (GABA): GABA is an inhibitory neurotransmitter, which means
that it tones down excess activity in the central nervous system and helps quell the body’s
response to stress. When the action of GABA is inadequate, neurons may fire excessively,
possibly bringing about seizures. In less dramatic cases, inadequate action of GABA may
heighten states of anxiety or nervous tension. People with panic disorder tend to have low
levels of GABA in some parts of the brain (Goddard et al., 2001). Other neurotransmitters,
especially serotonin, help regulate emotional states. Serotonin’s role is supported by evidence,
that antidepressant drugs that specifically target serotonin activity in the brain have beneficial
effects on some forms of anxiety as well as depression.

GENERALIZED ANXIETY DISORDER:

 People suffering from GAD live in a relatively constant, future-oriented mood state of
anxious apprehension, chronic tension, worry, and diffuse uneasiness that they cannot
control.
 They also show marked vigilance for possible signs of threat in the environment and
frequently engage in subtle avoidance activities such as procrastination, checking, or calling
a loved one frequently to see if he or she is safe.
 The nearly constant worries of people with generalized anxiety disorder leave them
continually upset and discouraged.
 Not only do those with GAD have difficulty making decisions, but after they have managed
to make a decision they worry endlessly, even after going to bed, over possible errors and
unforeseen circumstances that may prove the decision wrong and lead to disaster.
 They have no appreciation of the logic by which most of us conclude that it is pointless to
torment ourselves about possible outcomes over which we have no control.
Diagnostic criteria:
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not
for at least 6 months, about several events or activities (such as work or school
performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six
symptoms (with at least some symptoms having been present for more days than not
for the past 6 months): Note: Only one item is required in children.
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 (difficulty falling or staying asleep, or restless, unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
F. The disturbance is not better explained by another mental disorder (e.g., anxiety or
worry about having panic attacks in panic disorder, negative evaluation in social anxiety
disorder [social phobia], contamination or other obsessions in obsessive-compulsive
disorder, separation from attachment figures in separation anxiety disorder, reminders
of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa,
physical complaints in somatic symptom disorder, perceived appearance flaws in body
dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of
delusional beliefs in schizophrenia or delusional disorder).
Etiology:
THE PSYCHOANALYTIC VIEWPOINT According to this viewpoint, generalized or free-floating
anxiety results from an unconscious conflict between ego and id impulses that is not
adequately dealt with because of the person’s defense mechanisms have either broken
down or have never developed. Freud believed that it was primarily sexual and aggressive
impulses that had been either blocked from expression or punished upon expression that
led to free-floating anxiety. Defense mechanisms may become overwhelmed when a person
experiences frequent and extreme levels of anxiety, as might happen if id impulses are
frequently blocked from expression (e.g., under periods of prolonged sexual deprivation).
According to this view, the primary difference between specific phobias and free-floating
anxiety is that in phobias, the defense mechanisms of repression and displacement of an
external object or situation actually work, whereas in free-floating anxiety these defense
mechanisms do not work, leaving the person anxious nearly all the time. Unfortunately, this
viewpoint is not testable and therefore has been largely abandoned among clinical
researchers.
PERCEPTIONS OF UNCONTROLLABILITY AND UNPREDICTABILITY Uncontrollable and
unpredictable aversive events are much more stressful than controllable and predictable
aversive events, so it is perhaps not surprising that the former creates more fear and
anxiety, as we discussed with specific and social phobias. This has led researchers to
hypothesize that people with GAD may have a history of experiencing many important
events in their lives as unpredictable or uncontrollable. For example, having a boss or
spouse who has unpredictable bad moods or outbursts of temper for seemingly trivial
reasons might keep a person in a chronic state of anxiety. some evidence indicates that
people with GAD may be more likely to have had a history of trauma in childhood than
individuals with several other anxiety disorders. Moreover, people with GAD have far less
tolerance for uncertainty than non-anxious controls and even people with panic disorder.
This low tolerance for uncertainty in people with GAD suggests that they are especially
disturbed by not being able to predict the future.
GENETIC FACTORS Evidence for genetic factors in GAD is mixed, but there does seem to be a
modest heritability, although perhaps smaller than that for most other anxiety disorders
except phobias. The evidence is increasingly strong that GAD and major depressive disorder
have a common underlying genetic predisposition.
NEUROTRANSMITTER AND NEUROHORMONAL ABNORMALITIES It appears that highly
anxious people have a kind of functional deficiency in GABA, which ordinarily plays an
important role in the way our brain inhibits anxiety in stressful situations. The
benzodiazepine drugs appear to reduce anxiety by increasing GABA activity in certain parts
of the brain implicated in anxiety, such as the limbic system, and by suppressing the stress
hormone cortisol. At present, it seems that GABA, serotonin, and perhaps norepinephrine
all play a role in anxiety, but how they interact remains largely unknown.
THE COGNITIVE PERSPECTIVE The cognitive perspective on GAD emphasizes the role of
exaggerated or distorted thoughts and beliefs, especially beliefs that underlie worry. People
with GAD tend to worry just about everything. They also tend to be overly attentive to
threatening cues in the environment (Amir et al., 2009), perceiving danger and calamitous
consequences at every turn. Consequently, they feel continually on edge, as their nervous
systems respond to the perception of threat or danger with activation of the sympathetic
nervous system, leading to increased states of bodily arousal and the accompanying feelings
of anxiety.
THE BIOLOGICAL PERSPECTIVE The cognitive and biological perspectives converge in
evidence showing irregularities in the functioning of the amygdala in GAD patients and its
connections to the brain’s thinking center, the prefrontal cortex (PFC). It appears that in
people with GAD, the PFC may rely on worrying as a cognitive strategy for dealing with the
fear generated by an overactive amygdala. We also suspect irregularities in
neurotransmitter activity in GAD. Antianxiety drugs such as the benzodiazepines diazepam
(Valium) and alprazolam (Xanax) increase the effects of GABA, an inhibitory
neurotransmitter that tones down central nervous system arousal. Similarly, irregularities of
the neurotransmitter serotonin are implicated in GAD based on evidence that GAD
responds favorably to the antidepressant drug paroxetine (Paxil), which specifically targets
serotonin (Sheehan & Mao, 2003). Neurotransmitters work on brain structures that regulate
emotional states such as anxiety, so it is possible that an over-reactivity of these brain
structures (the amygdala, for example) is involved.