We make distinctions between:

• Fear (a present-oriented alarm reaction to danger)

• Anxiety (a future-oriented reaction, usually with feelings of tension) and
• Panic (an abrupt experience of intense fear or acute discomfort, accompanied
by physical symptoms that usually include heart palpitations, chest pain,
shortness of breath and possibly dizziness). There are also 3 sub-types of
panic:
o Situationally bound – when the person knows they will have a panic
attack in that situation
o Unexpected – when the person cannot predict when they will have a
panic attack
o Situationally predisposed – when the person knows they are more
likely to have a panic attack in a situation, but they don’t know for sure
if they will have one.

Anxiety confers survival advantage, up to a point.

So, how much is too much?

Two things are needed to differentiate between an anxiety disorder and just feeling
anxious:
Over-activation of the sympathetic division of the ANS
Feelings of dread.

The different types of anxiety disorder differ in the cognitive component – intrusive
thoughts are features of PTS and OCD, but less a feature of the specific phobias and
very little in GAD.

Causes of anxiety

Multiple genes contribute to a proneness to anxiety and also probably to panic. The
main model at the moment suggests weak contributions from multiple genes.

Anxiety seems to be associated with the neurotransmitter GABA. The noradrenergic

and serotonergic systems also seem to be involved. Corticotrophic Releasing Factor
(CRF) is receiving increasing attention and that is related to levels of GABA.

It is interesting to note that different brain circuits seem to be involved in panic and in
anxiety.

The limbic system is involved as a mediator between cortex and brain stem in anxiety
but not panic. Different mid-brain structures seem to be involved in mediating panic
attacks.

Factors in the environment change the sensitivity of these circuits – smoking during
adolescence seems to be a particularly influential factor.

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Parental influence over perceptions of control seems to be important to the experience
of anxiety later in life. Overprotective and intrusive parents, who don’t let their
children experience control over the environment, produce higher anxiety in their
children.

Triple vulnerability theory.

This theory incorporates generalised biological vulnerability (a diathesis); generalised
psychological vulnerability (a viewpoint about the dangerousness of the world); and
specific psychological vulnerability (experiences of being taught that certain
situations or things are dangerous).

There are high levels of comorbidity between the various anxiety disorders and the
mood disorders. The main differences are in the focus of the anxiety and the pattern of
panic attacks. The most common extra diagnosis for all anxiety disorders is major
depression (lifetime comorbidity of 50%).

There is also comorbidity with a number of physical disorders (thyroid disease,

migraine, arthritis and allergies, for example).

Finally, in this section, there is also an elevated risk of suicide, particularly associated
with panic disorder.

Generalised Anxiety Disorder (GAD)

According to DSM-IV-TR it must last for at least 6 months and be experienced most
days.
It must also be difficult to control.
People with GAD worry about minor, everyday things.

Another distinguishing feature is sustained, high muscle tension, which often leads to
fatigue.

GAD is a chronic disorder that is more common in females and the elderly. It affects
about 4% of the general population.

There is an interesting physiological distinction between GAD and other anxiety

disorders – autonomic restriction. They show less physiological reactivity on most
physiological measures.

People with GAD are also very reactive to threats, even unconscious threats
(MacLeod & Mathews, 1991).

It looks as though these individuals have strong emotional reactions, without

conscious cognitive processes – they don’t think through or work through, the things
that evoke their anxiety. It suggests that there is a need to bring back the unconscious
into psychology.

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Treatment

Benzodiazepines, such as the early diazepam (valium), bring some relief in the short
term. Unfortunately they slow people down and create dependence so they tend to be
used just to help someone through a crisis. However, they are safer than the
previously used barbiturates, which they largely replaced.

Antidepressant medication is also sometimes used successfully.

Psychological treatments focus on deep relaxation and helping people work through
the things they find threatening, using CBT for example.

The text also cites more recent studies showing that acceptance-based mindfulness
techniques can be helpful.

Panic Disorder with or without Agoraphobia

To meet the criteria for panic disorder, a person must experience an unexpected panic
attack and develop anxiety about the possibility of another attack or the implications
of the attack.

Agoraphobia is fear and avoidance of ‘unsafe’ situations where a panic attack may
occur (it is not a specific fear of a marketplace, as the name implies). People with
panic disorder with agoraphobia (PDA) experience severe unexpected panic attacks
during which time they feel a loss of control or endangered. People may also
experience panic disorder without agoraphobia, although this is rarer and some
researchers wonder if it exists at all.

Agoraphobic avoidance appears to be one complication of severe, unexpected panic

attacks, and agoraphobic behaviour can become independent of panic attacks.
According to the DSM-IV, agoraphobia may be characterised either by avoiding
situations or enduring them with marked distress.

Approximately 60% of people with panic disorder experience nocturnal panic attacks
(i.e., panic during sleep). Nocturnal panic occurs most often between 1:30 am and
3:30 am than at any other time, and such attacks have been shown to occur during
delta wave sleep (the deepest stage of sleep, but not dream sleep). Possible causes
include physiological changes due to shifts in sleep stages and sleep apnea
(interruption of breathing during sleep).

Causes

The causes of panic disorder are numerous, and include an interaction of

psychological, biological, and social-experiential influences.

The textbook suggests that a biologically inherited vulnerability to be over-reactive to

daily events, coupled with stress, may establish a predisposition to associate the
response with internal and external cues (i.e., moving from a false alarm to a learned

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alarm response). Such factors, coupled with a psychological vulnerability to
catastrophically misinterpret such events and the development of anxiety over the
possibility of future panic attacks may, in turn, lead to panic disorder.

Interoceptive awareness, or attentiveness to internal sensations, is enhanced in people

with panic disorder.

Treatment

Medications for anxiety and panic largely affect the serotonergic, noradrenergic, and
GABA neurotransmitter systems, blocking panic attacks. As before, Benzodiazepines,
though effective in reducing panic symptoms, may cause dependence.

SSRIs (e.g., Prozac and Paxil) are currently the preferred drug for panic disorder,
though sexual dysfunction (mainly loss of libido) is a common side-effect. Relapse
rates for panic are high once the medication is discontinued.

Psychological interventions such as CBT are quite effective for panic disorder. Such
treatment typically involves gradual exposure exercises combined with anxiety-
reducing coping skills, such as relaxation and breathing retraining. About 70% of
people undergoing these treatments substantially improve, but very few achieve
complete remission of symptoms.

Panic Control Treatment (PCT) is a cognitive-behavioural treatment that arranges for

mini-exposures to panic sensations in therapy, and includes cognitive therapy to
address attitudes and misperceptions about the feared sensations and situational
triggers, relaxation, and breathing retraining.

New evidence on combined treatments (i.e., medications plus CBT) suggest that
combined treatment was no better than individual treatments in the short term;
however, in the long term persons receiving CBT alone maintained most of their
treatment gains, whereas those taking medication alone or in combination with CBT
deteriorated somewhat.

This result led to the recommendation that psychological treatment should be offered
initially, followed by drug treatment for those patients who do not respond adequately
or for whom psychological treatment is not available. New evidence suggests that
when patients are initially given CBT, non-responders may benefit from SSRI
treatment; this process of “stepped care” may help to benefit a greater percentage of
people with panic disorder.

Phobias

These involve:

 Extreme and irrational fear of a specific object or situation

 Significant impairment in functioning

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  Recognition of the fears as unreasonable
 Avoidance of the object or situation

Interestingly, among those diagnosed with antisocial personality disorder, the

incidence of agoraphobia is 0%, which gives interesting clues about causes.

Among the specific phobias, xenophobia, Islamophobia and homophobia are political
labels. They have nothing to do with the kind of dread or anxiety experienced by
people with actual phobias.

Specific fears are quite common, and the most common phobias are of snakes and
heights. With the exception of fear of heights, most persons with specific phobia are
female (4:1 ratio). Specific phobias affect about 12.5% of the population, although
people with the disorder are often not referred for treatment. Phobias tend to run a
chronic course.

There are as many phobias as there are objects and situations. The major subtypes of
specific phobia are as follows:

1. People suffering from blood-injury-injection phobia differ from all the other
phobias in that they experience drops in heart rate and blood pressure and increased
urges to faint. This vasovagal reaction occurs in response to blood, injury, or the
possibility of an injection and seems to have a strong genetic component. Mean age of
onset for this phobia is 9.

2. A situational phobia refers to a group of phobias characterised by fear of

public transport or enclosed places (e.g., planes, trains, lifts / elevators, small enclosed
spaces). Onset of this phobia is in the early to mid-20s. People with situational
phobias do not experience panic attacks outside their feared situation.

3. Natural environment phobia concerns extreme fears of situations or events

occurring in nature, such as heights, storms, or water. People may be biologically
prepared to fear some of these stimuli; so, to call such fears a phobia, requires that the
response be persistent and that it interferes with life functioning.

4. Animal phobia refers to fears of animals and insects. To be considered a

diagnosable phobia, these fears must interfere with functioning. The age of onset for
these phobias, and natural environment phobias, peaks at around 7.

5. Other phobias - a category that includes phobias that do not neatly fit into
one of the other four categories (e.g., fear of choking or vomiting). Other phobias that
are frequent and cause substantial problems include:
a. Illness phobias, or fears of contracting a disease or of settings where germs
could be found.
b. Choking phobia, or fear and avoidance of swallowing pills, food, or fluids,
which can result in significant weight loss.

Causes

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The causes of phobias are quite complex. Some, but not all, specific phobias are
caused by exposure to traumatic events. People may develop a specific phobia by
experiencing a false alarm or panic attack (e.g., during driving), observing someone
else (a parent, for example) experience severe fear (e.g., during a dental visit), or
being told of some danger (information transmission). There is a likely genetic
transmission of specific phobias, influenced also by one's cultural background and
gender roles.

Treatment

The basic treatment of a specific phobia is straightforward and involves structured and
consistent exposure-based exercises in a supervised therapeutic context. In addition,
tension and release of muscle groups may be utilised to induce relaxation.

These exposure techniques are very similar to exposure and response prevention, a
method that is often used to treat obsessive-compulsive disorder (see below).

The techniques are modified for blood-injury-injection phobia by tensing muscle

groups to keep blood pressure high enough to prevent fainting.

Social Phobia

Social phobia refers to individuals who are extremely and painfully shy in almost all
social and performance-related situations; however, social phobia is more than
shyness. People who are extremely and painfully shy in almost all social situations
meet DSM-IV-TR criteria for a subtype of social phobia - generalised type,
occasionally called social anxiety disorder. Social phobia is illustrated in the textbook
with the case of Billy.

As many as 12.1% of the general population suffer from social phobia at some point
in their lives, making social phobia second only to specific phobia as the most
prevalent anxiety disorder. Females are slightly more represented than males. Social
phobia begins during adolescence with a peak age of onset at about 13 years; most are
also single. Social phobia seems to be on the rise among young people.

Taijin kyofusho, a fear of looking people in the eye, and a corresponding fear that
some part of one's presentation will be offensive to others, is a culturally-specific
presentation of social phobia in Japan. This condition is more prevalent in males than
in females (3:2 ratio).

Hikikomori is a Japanese term to refer to the phenomenon of reclusive adolescents

and young adults (mainly young men) who have chosen to withdraw from social life -
often seeking extreme degrees of isolation and confinement due to various personal
and social factors in their lives. According to estimates by psychologist Saito Tamaki,
who first coined the word, there may be 1 million hikikomori in Japan, 20 percent of
all male adolescents in Japan, or 1 percent of the total Japanese population. Surveys
done by the Japanese Ministry of Health as well research done by health care experts
suggest a more conservative estimate of 50,000 hikikomori. As reclusive youth, by

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their very nature are difficult to poll, the true number of hikikomori most likely falls
somewhere between these two figures.

Causes

The causes of social phobia are complex. Humans may be biologically predisposed or
prepared to fear angry, critical, or rejecting people or faces. In addition, some infants
are predisposed to agitation and hyperarousal when faced with new stimuli. Such
infants may also be predisposed to increased inhibition.

Three pathways to developing social phobia include:

1. Biological vulnerability to develop anxiety or to be socially inhibited. This
vulnerability may be increased under stress or when events are perceived as
uncontrollable.
2. A person may also experience an unexpected panic attack (i.e., false alarm)
during a social situation or experience a social trauma resulting in conditioning (i.e., a
learned alarm). In these scenarios, conditioning may occur and social settings may be
avoided.
3. Modelling of socially anxious parents may also play a role in the development
of social phobia. Indeed, for a social anxiety disorder to develop, an individual with
pre-existing vulnerabilities probably also learned growing up that social evaluation
can be dangerous.

Treatment

Cognitive-behavioural treatment for social phobia includes rehearsal or role-play of

feared social situations in a group setting. In addition, intensive cognitive therapy and
social support may be employed. Evidence suggests that the exposure component is
more important in treatment than the cognitive component. Psychological treatments
are generally highly effective.

Beta-blockers may control physical symptoms such as shaking hands, but are of little
or no help with the feelings of anxiety. Tricyclic antidepressants and monoamine
oxidase inhibitors are drugs that have been found to reduce social anxiety, though
relapse is common when medications are discontinued and the side-effects mean that
people are inclined to discontinue.

A recent study indicated that adding d-cycloserine (DCS) to CBT significantly

enhances treatment outcomes. This drug is different from SSRIs in that it targets the
glutamatergic system. Glutamate is a neurotransmitter that plays a role in memory
formation and information processing. Disturbances in this system are also seen in
ADHD and possibly other disorders such as psychoses, depression, Alzheimer's
Disease and obsessive-compulsive disorder.

Posttraumatic Stress Disorder

The emotional disorder that often arises after a trauma such as war, assault, natural
disaster, or sudden death of a loved one is posttraumatic stress disorder (PTSD).

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According to the DSM-IV-TR, a person with PTSD must have been exposed to some
event during which he/she feels fear, helplessness, or horror. After the event, the
person continues to re-experience the event through memories, re-enactments,
nightmares, or flashbacks. Cues that remind the person of the event are avoided and
emotional responsiveness is numbed. Often such individuals are chronically over-
aroused, easily startled, and quick to anger. PTSD is illustrated in the textbook with
the case of the Joneses.

The DSM-IV-TR subdivides PTSD into acute and chronic types.

1. Acute PTSD may be diagnosed 1-3 months after the traumatic event, whereas
chronic PTSD is diagnosed after 3 months. PTSD cannot be diagnosed sooner than 1
month post-trauma.
2. Chronic PTSD is associated with more long-term avoidance and greater co-
morbidity than acute PTSD.
3. If a person does not show any symptoms until long after the traumatic event,
then a diagnosis of delayed onset PTSD is used.

Acute stress disorder is a new disorder in the DSM-IV, and refers to a disorder
occurring within the first month after a trauma. The different name emphasizes the
very severe reaction that some people have immediately following a traumatic event.
PTSD symptoms are accompanied by severe dissociative symptoms. This disorder
was included in the DSM-IV so that people with early severe reactions could receive
insurance coverage for immediate treatment.

Recent surveys indicate that among the population, approximately 6.8% have
experienced PTSD, and that combat and sexual assault are the most common traumas.

Many people experience a trauma but do not go on to develop PTSD. Some even
experience Post-Traumatic Growth.

Some normal reactions to trauma include:

Crisis responses

• Shock
• Disbelief
• Realisation (gradual acceptance)
• Frozen survival state (emotionally frozen and focussed on survival – this may
be mistaken for calmness)

Recovery phase

• Shock (may re-occur)

• Depression
• Mood swings
• Anger (may result in social isolation when support is most needed)
• Reflection (trying to understand what happened to try and prevent it
happening again)

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 • Laying to rest (when the traumatic event becomes an ugly memory, but not
one that interferes with the quality of life)

According to Richard Bryant of UNSW (writing in In Psych magazine, April 2009)

rates of PTSD are high in the initial months after a disaster, but subsequently decline.
For example, a survey conducted in the 5-8 weeks after the 9/11 terrorist attacks in
New York, close to the site, found 7.5% of adults had developed PTSD. Five months
after the attack, another survey in the same area found that 1.7% had PTSD. After the
2004 tsunami in Thailand, the rate of PTSD in displaced people was 12% 2 months
after the event. This dropped to 7% after 9 months. These patterns have implications
for treatment because most people get better without mental health interventions.

Two important issues for deciding on the appropriateness of interventions are:

• The extent to which the threat still exists as far as that person is concerned
• Whether the person has sufficient resources to manage the intervention. After
bushfires, for example, people will be rebuilding homes for many months and
may not be able to cope with having therapy at that stage.

The on-going stressors after many disasters can complicate the recovery process.

Causes

The intensity of the trauma has an effect.

Biological/genetic vulnerability to anxiety is also a significant factor, as are possible

neurobiological effects and changes in the locus coeruleus.

Trauma may alter brain structure and function, with studies showing damage to the
hippocampus (which plays an important role in learning and memory) in groups of
patients with combat PTSD and adult survivors of childhood sexual abuse.

Finally, social and cultural factors, particularly having strong and supportive people
around, seem to lessen the risk of developing PTSD.

Treatment

The psychological treatment of PTSD typically focuses on having the person

gradually re-experience aspects of the traumatic event within a supportive context to
develop effective coping procedures and to produce corrective emotional learning.
Because recreating the trauma is not desirable, imaginal exposure is usually
conducted, in which the therapist works with the trauma victim to develop and review
a narrative of the trauma in therapy.

Interventions immediately after a trauma may be helpful for some, but it appears that
debriefing sessions after a trauma may actually be detrimental.

Eye Movement Desensitisation and Reprocessing (EMDR) is a recent addition to the

treatments for PTSD. In 2006 it was validated by the National Institute for Health and

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Clinical Excellence (NICE) in the UK as one of the preferred treatments for PTSD. It
is a technique that can be integrated into other psychotherapeutic approaches.

The technique involves the bilateral stimulation of the brain by using either sideways
tracking movements of the eyes, tapping the client's hands or auditory cues that
alternate between left and right using headphones. This replicates the brain activity
found in REM sleep when we process information and consolidate memory. EMDR
allows people to reach an adaptive resolution to their PTS experience.

Some SSRIs (e.g., Prozac, Paxil) may be helpful for PTSD because they relieve the
severe anxiety and panic attacks that are so prominent with this disorder.

The Australian Centre for Posttraumatic Mental Health

http://www.acpmh.unimelb.edu.au/trauma/ptsd.html is a very useful resource on this
topic.

Obsessive-Compulsive Disorder (OCD)

Obsessive-compulsive disorder (OCD) is similar in many respects to the other anxiety

disorders, but the dangerous event in OCD is not external but internal (i.e., thoughts,
images, impulses). A severe and debilitating anxiety disorder, OCD is often
associated simultaneously with generalised anxiety, panic attacks, avoidance and
major depression, along with the obsessive-compulsive symptoms.

Obsessions are intrusive, usually nonsensical thoughts or urges that the individual
tries to resist or get rid of.

Compulsions are behaviours used to suppress the obsessions.

Jenike, Baer and Minichiello (1986) report the most common obsessions are:

• Contamination (55%)
• Aggressive impulses (50%)
• Sexual impulses (32%)
• Somatic concerns (35%)
• Need for symmetry (37%)

60% had multiple obsessions.

Leckman, Grice and colleagues (1997) found that checking, ordering, arranging,
washing and cleaning were the main compulsions.

Checking rituals are usually to avoid an imagined disaster or catastrophe.

Aggressive and sexual obsessions also often lead to checking rituals.
Symmetry obsessions often lead to ordering, arranging or repeating rituals.
Contamination obsessions often lead to washing rituals.

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The lifetime prevalence of OCD is 1.6%, although 10-15% of normal college students
engaged in checking behaviour substantial enough to score within the range of
patients with OCD. Most people with OCD are females and the age of onset is usually
adolescence to young adulthood.

Levels of OCD are similar in most countries although the content of the abnormal
behaviours may vary.

Causes

Freud said the origin was guilt about masturbation…

Biological contributions are not well understood. There seems to be some different
activity in the left prefrontal cortex, but it is not clear.

The causes are similar to other anxiety disorders, although some may have been
exposed to fundamentalist beliefs in which a “bad” thought is considered as bad as a
“bad” deed. They therefore try to suppress their thoughts.

Treatment

Treatment of OCD includes drug therapy to target the serotonergic neurotransmitter

system, exposure and ritual prevention, hospitalisation, and, in extreme cases,
psychosurgery (cingulotomy).

Clomipramine (a Tricyclic with the commercial name of Anafranil) and SSRIs seem
to benefit up to 60% of patients with OCD; however, the average treatment gain is
moderate, and relapse is common when medications are discontinued.

The most effective psychological treatment is exposure and ritual prevention (ERP).
Combined exposure and response prevention treatment with medication does not
work as well compared to ERP alone. The RP part of ERP raises anxiety levels, but
by a manageable amount, and then levels decline slowly.

Psychosurgery is reserved for intractable cases of OCD that fail to respond to other
less invasive forms of treatment.

A treatment for all anxiety disorders?

David Barlow presented a paper at the annual convention of the APA in 2008 that
suggests the possibility of one flexible treatment for patients with a variety of
disorders, including depression, anxiety and phobias.

According to Barlow, "The protocol takes three or four basic concepts that seem to be
present in all of our successful treatments for these emotional disorders and puts them
together as a single, unified, transdiagnostic set of principles that clinicians could
adapt to anyone sitting in front of them.”

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The protocol incorporates three strands of research:

• Changes in our understanding of how exposure therapy works. Research

now finds that it is more effective to expose people to their actual emotional
experience - which helps them better accept their emotional life and develop
more positive ways of regulating their emotions - than merely to subject them
to externally aversive conditions that may temporarily arouse those emotions
without attending to how they are processing that experience.

• New findings that demonstrate how emotional patterns and responses

affect regions of the brain. For instance, brain-imaging studies show that
cognitive reappraisal and other emotion-regulation techniques modulate the
response of both the amygdala and prefrontal cortices in ways that reduce
negative emotions, increase positive emotions, or both.

• Further research from emotion science showing that people with any of
these emotional disorders experience their emotions in similar ways. In
essence, they enter a downward spiral in which they can't accept an initial
negative emotion such as anger, depression or fear. They try to suppress or get
rid of the emotion, and they have trouble regulating and letting go of the
emotion. By contrast, healthy controls are better able to accept, let go of and
move on from their negative emotions, according to these studies.

The new treatment protocol is designed as seven modules that incorporate elements of
that research, as well as principles of change. Module topics include:

• Psychoeducation
• Motivational enhancement to aid treatment engagement
• Emotional awareness training
• Cognitive appraisal and reappraisal
• Modifying emotion-driven behaviours and emotional avoidance
• Internal somatic and situational exposure
• Relapse prevention
• Present-focused emotional awareness training.

According to Barlow, "Instead of studying treatments as some sort of fixed pattern,

practitioners will have principles they can flexibly apply to a variety of different
emotional disorders.”

The treatment plan also aims to simplify what practitioners have to learn. "Instead of
having to master, say, 12 different treatment manuals, you'd just have to master one,"
he said. "The idea is to create a protocol that's easy to disseminate and is much more
user-friendly for psychologists."

Finally, I think it is worth knowing about Anxiety Online, an initiative of the National
eTherapy Centre and housed at Swinburne University of Technology. See
http://www.anxietyonline.org.au/

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They provide information, assessment, online diagnosis and treatment across the
range of anxiety disorders.

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References

Barlow, D. H., & Durand, M. V. (2008). Abnormal Psychology: An Integrative

Approach (Fifth ed.). Belmont CA: Wadsworth Cengage Learning.
MacLeod, C., & Mathews, A. M. (1991). Cognitive-experimental approaches to the
emotional disorders. In P. R. Martin (Ed.), Handbook of behavior therapy and
psychological science: An integrative approach (pp. 116-150). Elmsford, NY:
Pergamon Press.

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