1. CHAPTER 2 ANXIETY DISORDERS

2. AIMS AND OBJECTIVES Describe the nature of fear and anxiety disorders
Discuss the range of anxiety disorders
Provide information about diagnosis, epidemiology, and treatment for each disorder

3. THE NATURE OF FEAR AND ANXIETY
Flight or fight response (Cannon, 1929)
Body reacts to danger by releasing adrenaline through blood stream Related behaviours include:
Freezing – to appraise danger
Flight – escape
Fight – if danger is unavoidable
“True alarms” (direct danger) versus “false alarms” (no immediate threat)
False alarms are the hallmark of anxiety disorders

4. THE NATURE OF FEAR AND ANXIETY
Triple vulnerability model (Barlow, 2002)

5. THE NATURE OF FEAR AND ANXIETY
Fear can be acquired in several ways:
Conditioning – pairing of a conditioned stimulus with an aversive event
Informational pathway
Vicarious acquisition
These all contribute to the expectation that an aversive outcome is probable

6. THE NATURE OF FEAR AND ANXIETY
Conditioning
US (bitten by dog)
UR (fear)
CS (dog)
pair with
CR (fear)

7. SPECIFIC PHOBIA DSM-IV-TR Diagnosis includes: Epidemiology
Marked fear that is excessive or unreasonable
Cued by presence or anticipation of phobic object/situation
Causes interference/impairment in life or marked distress
Four subtypes:
Animal
Natural Environment (i.e., storms, heights, water)
Blood-Injection – Injury (i.e., blood, operation scenes, injections, fainting common)
Situational (i.e., planes, elevators)
Epidemiology
Lifetime prevalence 4-8%, female to male ratio 2:1

8. SPECIFIC PHOBIA Aetiology
Phobias may be acquired by classical conditioning
E.g., A neutral CS (white rat) is paired with a US (loud noise) that produces fear
Problems with classical conditioning account
Many people with specific phobias do not remember an initial traumatic event (Menzies & Clark, 1993)
Preparedness: Some stimulus can be conditioned more easily (Seligman, 1971)

9. SPECIFIC PHOBIA Treatment
Exposure-based treatments are the most effective (Choy et al., 2007)
In vivo exposure – facing phobic stimulus in real life
Imaginal or virtual exposure
Exposures may work through extinction
Fear decreases over repeated presentations of the CS in the absence of the US
They may also work by challenging expectations of danger, increasing self-efficacy, and increasing perception of control

10. PANIC DISORDER AND AGORAPHOBIA
DSM-IV-TR Diagnosis for Panic Disorder includes:
Recurrent, unexpected panic attacks
At least one attack has been followed by >1 month of:
Persistent concern about having additional attacks
Worry about the implications/consequences of the attack, e.g., losing control, dying
A significant change in behavior
Agoraphobia – anxiety about being in places from which escape might be difficult or embarrassing in the event of having a panic attack
Panic disorder can occur with or without agoraphobia
Lifetime prevalence of panic disorder = 5%

11. PANIC DISORDER AND AGORAPHOBIA
Aetiology
Generalised psychological vulnerability
High anxiety sensitivity – fear of sensations
Specific psychological vulnerability
Catastrophic misinterpretation of physical sensations
Treatment
Pharmacological – SSRIs, benzodiazepines
Psychological – Cognitive behaviour therapy
Address avoidance of internal and external cues using behavioural and cognitive techniques

12. SOCIAL PHOBIA DSM-IV-TR Diagnosis includes: Epidemiology
Marked, persistent fear of social situations
Person recognises the fear as unreasonable
Feared social situations are avoided
Interference or distress
Epidemiology
Lifetime prevalence 10-16%, female to male ratio 1:1
Chronic course
Delay in seeking treatment

13. SOCIAL PHOBIA Aetiology Treatment
Genetic vulnerability: 2-3x increased risk among relatives
Psychosocial factors
Excessive parental criticism
Cognitive dysfunctions
Hypersensitivity to criticism
Treatment
Psychological– Cognitive behaviour therapy
Cognitive restructuring of negative thoughts (e.g., I am boring)
Exposure to feared social situations

14. OBSESSIVE COMPULSIVE DISORDER (OCD)
DSM-IV-TR Diagnosis includes:
Obsessions – recurrent thoughts, images or impulses experienced as inappropriate or distressing
Compulsions – repetitive behaviours that the person feels compelled to perform in response to obsession or according to rigid rules
Person recognizes that obsessions or compulsions are excessive/irrational
Marked distress/interference, time-consuming (>1 hour/day)
Several subtypes:
Washing
Checking
Hoarding
Obsessional slowness
Epidemiology
Lifetime prevalence 2-3%
Often chronic if untreated

15. OBSESSIVE COMPULSIVE DISORDER (OCD)
Aetiology
Neuropsychological model (Baxter et al., 2000)
Failure of inhibitory pathways in the basal ganglia to stop “behavioural macros” in response to internal/external stimuli
Cognitive model
OCD thoughts not different from those in general population
Difference is how OCD sufferers interpret the thoughts
Treatment
Psychological– Cognitive behaviour therapy
Exposure and response prevention
Cognitive restructuring
Pharmacological therapy

16. POSTTRAUMATIC STRESS DISORDER (PTSD)
DSM-IV-TR Diagnosis includes:
Exposure to a traumatic event
Re-experiencing symptoms
Avoidance symptoms
Arousal symptoms
Symptoms present for at least one month
Epidemiology
Despite high frequency of exposure to traumatic stressors, relatively few develop PTSD (4%)
Research attempts to identify who is at risk for developing PTSD after exposure to a trauma

17. POSTTRAUMATIC STRESS DISORDER (PTSD)
Aetiology
Cognitive models
Focus on individual’s maladaptive appraisals of the event, his/her response to the event, and the environment
Learning accounts
Emphasis on classical conditioning
Biological accounts
Propose that extreme sympathetic arousal at the time of trauma results in strong fear conditioning
Across accounts, avoidance of trauma reminders maintains PTSD
Treatment
Pharmacological therapy
Cognitive-behavioural therapy
Psychoeducation, anxiety management, cognitive restructuring, imaginal / in vivo exposure, and relapse prevention
Prevention of PTSD – applying CBT to survivors after trauma exposure

18. GENERALISED ANXIETY DISORDER (GAD)
DSM-IV-TR Diagnosis includes:
Excessive worry about a number of events or activities
E.g, health, finances, relationships
Worries are difficult to control
Present on most days for at least 6 months
Associated symptoms such as irritability, fatigue, difficulty concentrating, and muscle tension
Epidemiology
Commonly experienced, lifetime prevalence of 5%
Early age of onset and chronic course

19. GENERALISED ANXIETY DISORDER (GAD)
Aetiology
Moderate genetic predisposition
Cognitive models
Information processing model – biased toward threat
Metacognitive model – positive and negative meta-beliefs about worry
Avoidance theory– worry to avoid imagery and underlying concerns
Intolerance of uncertainty model – need to control
Treatment
Pharmacological therapy
Cognitive-behavioural therapy
Cognitive restructuring, relaxation, behavioural experiments
Some symptom improvement, yet only 50% of sufferers end up in non-clinical range

20. SUMMARY Nature of Fear and Anxiety
Flight or fight response
Triple vulnerability model
Acquisition of expectation of fear
Diagnosis, Epidemiology, Aetiology, and Treatment of:
Specific Phobia
Panic Disorder and Agoraphobia
Social Phobia
Obsessive-Compulsive Disorder
Posttraumatic Stress Disorder
Generalised Anxiety Disorder