Anxiety Disorders

Pertemuan ke-5
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Anxiety vs. Fear
Anxiety
Apprehension about a future threat
Fear
Response to an immediate threat
Both involve physiological arousal
Sympathetic nervous system
Both can be adaptive
Fear triggers flight or fight
May save life
Anxiety increases preparedness
Moderate levels improve performance
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Persamaan Cemas dan
Takut (Rahman, 1998)
Anticipation of danger or discomfort
Tense apprehensiveness
Elevated arousal
Negative affect
Uneasiness
Future oriented
Accompanied by bodily sensations
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Perbedaan Cemas dan Takut
(Rahman, 1998)
Anxiety
Source of threat is elusive
Uncertain connection between anxiety
and threat
Prolonged
Pervasive uneasiness
Can be objectless
Uncertain onset
Persistent
Uncertain offset
Without clear borders
Threat seldom imminent
Heightened vigilance
Bodily sensation of vigilance
Puzzling quality
Fear
Specific focus of threat
Understandable connection between threat and
fear
Usually episodic
Circumscribed tension
Identifiable threat
Provoked by threat cues
Declines with removal of threat
Offset is detectable
Circumscribed area of threat
Imminent threat
Quality of emergency
Bodily sensation of an emergency
Rational quality
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Anxiety Disorders
DSM-IV-TR
Specific and social phobias
Panic disorder and agoraphobia
Generalized anxiety disorder
Obsessive compulsive disorder
Posttraumatic stress disorder
Most common psychiatric disorders
28% report anxiety symptoms (Kessler et al., 2005)
Most common are phobias
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Table 5.1 Summary of Major
Anxiety Disorders
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Phobias
Disruptive fear of a particular object or
situation
Fear out of proportion to actual threat
Awareness that fear is excessive
Must be severe enough to cause distress or
interfere with job or social life
Avoidance
Two types:
Specific
Social
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Specific Phobia
Unwarranted, excessive fear of specific object or
situation
Snakes, blood, flying, spiders, etc.
How likely are you to be bitten by a spider?
Most specific phobias cluster around a few feared
objects and situations (Table 5.3)
Trigger or feared object is avoided or endured with
intense anxiety
High comorbidity of specific phobias

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Social Phobia
Persistent, intense fear of social situations
Fear of negative evaluation or scrutiny
More intense and extensive than shyness
More appropriate diagnostic label?
Social anxiety disorder
Exposure to trigger leads to anxiety about being humiliated
or embarrassed socially.
Onset often adolescence
Diagnosed as either generalized or specific
33% also diagnosed with Avoidant Personality Disorder
Overlap in genetic vulnerability for both disorders
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Panic Disorder
Frequent panic attacks unrelated to specific
situations
Panic attack
Sudden, intense episode of apprehension, terror,
feelings of impending doom
Symptoms reach peak intensity within 10 minutes
Accompanied by at least 4 other symptoms:
Sweating, nausea, labored breathing, dizziness, heart
palpitations, upset stomach, lightheadedness, etc.
Other symptoms may include:
Depersonalization
Derealization
Fear of going crazy, losing control, or dying
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Panic Disorder
Uncued attacks
Occur unexpectedly without warning
Panic disorder diagnosis requires recurrent
uncued attacks.
Cued attacks
Triggered by specific situations (e.g., tunnel): panik ketika
berada di ruangan tertutup.
More likely a phobia
Panic Disorder with Agoraphobia
Avoidance of situations in which escape would be
difficult or embarrassing
Panic disorder with agoraphobia tends to be more
chronic .
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Panic Disorder
Often begins in adolescence
25% unemployed for more than 5 years
because of symptoms (Leon et al., 1995)
Prognosis worse when agoraphobia is
present
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Generalized Anxiety Disorder (GAD)
Involves chronic, excessive, uncontrollable
worry
Lasts at least 6 months
Interferes with daily life
Other symptoms:
Restlessness, poor concentration,
irritability, muscle tension, tires easily,
sleep disturbance
Common worries:
Relationships, health, finances, daily
hassles
Often begins in adolescence or earlier
Ive always been this way
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Obsessive-Compulsive Disorder (OCD)
Obsessions
Intrusive, persistent, and uncontrollable
thoughts or urges
Experienced as irrational
Most common:
Contamination, sexual & aggressive
impulses, body problems
Compulsions
Impulse to repeat certain behaviors or mental
acts to avoid distress
e.g., cleaning, checking, hoarding, repeating
a word, counting
Extremely difficult to resist the impulse
May involve elaborate behavioral rituals
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Develops either before age 10 or during late
adolescence/early adulthood
Men
Early onset more common
Women
Cleaning compulsions and later onset more
common
OCD often chronic
Obsessive-Compulsive Disorder (OCD)
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Post Traumatic Stress Disorder (PTSD)
Extreme response to severe stressor
Anxiety, avoidance of stimuli associated with
trauma, emotional numbing
Exposure to a traumatic event that involves
actual or threatened death or injury
e.g., war, rape, natural disaster
Trauma leads to intense fear or
helplessness
Symptoms present for more than a month
Women and PTSD
Rape most common type of trauma (Creamer et
al., 2001)

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Three categories of symptoms :
1. Re-experiencing the traumatic event
Nightmares, intrusive thoughts, or images
2. Avoidance of stimuli
e.g., Refuse to walk on street where rape
occurred
Numbing
Decreased interest in others
Distant or estranged from others
Unable to experience positive emotions
3. Increased arousal
Insomnia, irritability, hypervigilance, exaggerated
startle response
Tends to be chronic (Perkonigg et al.,
2005)
Post Traumatic Stress Disorder (PTSD)
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Acute Stress Disorder (ASD)
Symptoms similar to PTSD
Duration varies
Short term reaction
Symptoms occur between 2 days and 1 month
after trauma
As many as 90
%
of rape victims experience
ASD (Rothbaum et al., 1992)
More than 2/3 of those with ASD develop
PTSD within 2 years (Harvey & Bryant, 2002)
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Comorbidity
of those with anxiety disorder meet criteria
for another disorder
60% meet criteria for major depression (Brown et
al., 2001)
Other disorders commonly comorbid with anxiety:
Substance abuse
Personality disorders
Avoidant
Dependent
Histrionic
Medical disorders e.g., coronary heart disease
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Gender & Sociocultural Factors
Women are 2x as likely as men to have anxiety
disorder except for OCD
Possible explanations
Women may be more likely to report symptoms
Women more likely to experience childhood sexual abuse
Women show more biological stress reactivity
Sociocultural factors
Focus of anxiety varies
Taijin kyofusho
Japanese fear of offending or embarrassing others
Kayak-angst
Inuit disorder in seal hunters at sea similar to panic
Ratio of somatic to psychological symptoms appears
similar across cultures (Kirmayer, 2001)
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Etiology of Specific Phobias
Conditioning
Mowrers two-factor
model
Pairing of stimulus with
aversive UCS leads to
fear (Classical
Conditioning)
Avoidance maintained
though negative
reinforcement (Operant
Conditioning)
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Etiology of Specific Phobias
Problems with two-factor model
Many people never experience aversive interaction
with phobic object (see table 5.6)
People with phobias tend to fear only certain types of
objects (prepared learning)
Snakes, insects, blood, heights, etc.
Even phobias linked to modeling influenced by
prepared learning
Monkeys acquired fear after watching another monkey
exhibit fear to snake but not flower (Cook & Mineka, 1989)

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Etiology of Social Phobia
Two factor model
Avoidance or safety behaviors
Avoid eye contact, appear aloof, stand apart from
others in social settings
Cognitive factors
Negative self evaluation
Harsh, punitive self-judgment
Fear of negative evaluation by others
Expect others to dislike them
Excessive attention to internal cues
e.g., heart rate
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Etiology of Panic
Neurobiological
factors
Locus ceruleus
Major source of
norepinephrine
A trigger for
nervous system
activity
Multiple drugs can
induce panic
attacks
Typically only in
those who are overly
concerned about
bodily changes
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Etiology of Panic
Interoceptive
conditioning
Classical conditioning of
panic in response to
bodily sensations
People with panic
disorder sustain
classically conditioned
fears longer (Michael et al.,
2007)

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Etiology of Panic
Cognitive factors
Lack of perceived control
can trigger panic
Fear of bodily changes
Interpreted as impending
doom
I must be having a
heart attack!
Beliefs increase anxiety
and arousal
Creates vicious cycle
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Etiology of Agoraphobia
Fear-of-fear hypothesis (Goldstein &
Chambless, 1978)
Expectations about the catastrophic
consequences of having a public panic
attack.
What will people think of me?!?!

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Etiology of GAD
GABA system deficits
Borkovecs cognitive model:
Worry reinforcing because it distracts from
negative emotions and images
Allows avoidance of more disturbing
emotions
e.g., distress of previous trauma
Avoidance prevents extinction of underlying
anxiety
Individuals with GAD less able to identify
their own negative feelings (Mennin et al.,
2002)

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Etiology of OCD: Neurobiological Factors
OCD symptoms common in certain neurological
disorders
Huntingtons chorea
Hyperactive regions of the brain:
Orbitofrontal cortex
Caudate nucleus
Anterior cingulate
Loss of neuronal function and underlying
biochemical abnormality (Ycel et al., 2007)
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Etiology of OCD:
Behavioral & Cognitive Factors
Operant reinforcement
Compulsions negatively reinforced by the
reduction of anxiety
Cognitive factors
Lack of a satiety signal
Yadasentience
Subjective feeling of completion
Knowing that you have thought enough or cleaned
enough
Individuals with OCD have a yadasentience
deficit
Attempts to suppress intrusive thoughts
Trying to suppress thoughts may make matters
worse


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Etiology of PTSD
Severity and type of trauma
Neurobiological
Smaller hippocampal volume linked to PTSD
Disruption of verbal vs. nonverbal memory
Supersensitivity to cortisol
Behavioral
Two factor model
Psychological
Perception of control
Avoidance coping, dissociation, memory suppression
Intelligence and ability to grow from the experience
enhance coping
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Common Aspects of
Psychological Treatment
Psychological treatments emphasize
Exposure
Face the situation or object that triggers
anxiety
Should include as many features of the trigger
as possible
Should be conducted in as many settings as
possible
Systematic desensitization
Relaxation plus imaginal exposure

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Common Aspects of
Psychological Treatment
Cognitive approaches
Increase belief in ability to cope with
the anxiety trigger
Challenge expectations about
negative outcomes

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Medications
Anxiolytics
Drugs that reduce anxiety
Two common types of medications used to
treat anxiety
Benzodiazepenes
Valium, Xanax
Antidepressants
Tricyclics,Selective Serotonin Reuptake
Inhibitors (SSRIs), and Serotonin
Reuptake Inhibitors (SRIs)
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Medications
Demonstrated effectiveness as compared to
placebo
Clomipramine for OCD
Medication does not seem to help hoarding
Beta blockers commonly prescribed for social phobia
although no demonstrated effectiveness
Side effects
Withdrawal from benzodiazepenes
Weight gain, nervousness, high blood pressure from SSRIs
Relapse common after medication discontinuation