Chapter 4: Anxiety Disorders
Chapter Overview
In Chapter 4, we will discuss matters related to anxiety disorders including their clinical presentation, epidemiology, comorbidity, treatment options, and etiology. Our discussion will include Panic Disorder, Generalized Anxiety Disorder, Specific Phobias, Social Anxiety Disorder, and Agoraphobia. Be sure you refer to Chapters 1-3 for explanations of key terms (Chapter 1), an overview of the various models to explain psychopathology (Chapter 2), and descriptions of the various therapies (Chapter 3).
Chapter Outline
4.1. Panic Disorder
4.2. Generalized Anxiety Disorder
4.3. Specific Phobia
4.4. Social Anxiety Disorder
4.5. Agoraphobia
4.6 EtiologyChapter Learning Outcomes
Describe the various anxiety disorders and their symptoms.
Describe the epidemiology of anxiety disorders.
Describe comorbidity in relation to anxiety disorders.
Describe treatment options for anxiety disorders.
Describe the etiology of anxiety disorders.
4.1 Panic Disorder
Section Learning Objectives
Describe how panic disorder presents itself.
Describe the epidemiology of panic disorder.
Indicate which disorders are commonly comorbid with panic disorder.
Describe the treatment options for panic disorder.
4.1.1 Clinical Description
Panic disorder consists of a series of recurrent, unexpected panic attacks coupled with the fear of future panic attacks. A panic attack is defined as a sudden or abrupt surge or fear or impending doom along with at least four physical or cognitive symptoms (listed below). The symptoms generally peak within a few minutes, although it seems much longer for the individual experiencing the panic attack.
There are two key components to panic disorder—the attacks are unexpected meaning there is nothing that triggers them, and they are recurrent meaning they occur multiple times. Because these panic attacks occur frequently and essentially “out of the blue,” they cause significant worry or anxiety in the individual as they are unsure of when the next attack will occur. In some individuals, significant behavioral changes such as fear of leaving their home or attending large events occur as the individual is fearful an attack will happen in one of these situations, causing embarrassment. Additionally, individuals report worry that other’s will think they are “going crazy” or losing control if they were to observe an individual experiencing a panic attack. Occasionally, an additional diagnosis of agoraphobia is given to an individual with panic disorder if their behaviors meet diagnostic criteria for this disorder as well (see more below).
The frequency and intensity of these panic attacks vary widely among individuals. Some people report panic attacks occurring once a week for months on end, others report more frequent attacks multiple times a day, but then experience weeks or months without any attacks. The intensity of symptoms also varies among individuals, with some individuals reporting experiencing nearly all 14 symptoms and others only reporting the minimum 4 required for the diagnosis. Furthermore, individuals report variability within their own panic attack symptoms, with some panic attacks presenting with more symptoms than others. It should be noted that at this time, there is no identifying information (i.e. demographic information) to suggest why some individuals experience panic attacks more frequently or more severe than others.
4.1.2 Epidemiology
Prevalence rates for panic disorder are estimated at around 2-3% in adults and adolescents. Higher rates of panic disorder are found in American Indians and non-Latino whites. Females are more commonly diagnosed than males with a 2:1 diagnosis rate—this gender discrepancy is seen throughout the lifespan. Although panic disorder can occur in young children, it is generally not observed in individuals younger than 14 years of age.
4.1.3 Comorbidity
Panic disorder rarely occurs in isolation, as many individuals also report symptoms of other anxiety disorders, major depression, and substance abuse. There is mixed evidence as to whether panic disorder precedes other comorbid psychological disorders—estimates suggest that 1/3 of individuals with panic disorder will experience depressive symptoms prior to panic symptoms whereas the remaining 2/3 will experience depressive symptoms concurrently or after the onset of panic disorder (APA, 2013).
Unlike some of the other anxiety disorders, there is a high comorbid diagnosis with general medical symptoms. More specifically, individuals with panic disorder are more likely to report somatic symptoms such as dizziness, cardiac arrhythmias, asthma, irritable bowel syndrome, and hyperthyroidism (APA, 2013). The relationship between panic symptoms and somatic symptoms is unclear; however, there does not appear to be a direct medical cause between the two.
.1.4 Treatment
4.1.4.1 Cognitive Behavioral Therapy (CBT)
CBT is the most effective treatment option for individuals with panic disorder as the focus is on correcting misinterpretations of bodily sensations (Craske & Barlow, 2014). Nearly 80 percent of people with panic disorder report complete remission of symptoms after mastering the following five components of CBT for panic disorder (Craske & Barlow, 2014).
Psychoeducation. Treatment begins by educating the client on the nature of panic disorder, the underlying causes of panic disorder, as well as the mechanisms that maintain the disorder such as the physical, cognitive, and behavioral response systems (Craske & Barlow, 2014). This part of treatment is fundamental in correcting any myths or misconceptions about panic symptoms, as they often contribute to the exacerbation of panic symptoms.
Self-monitoring. Self-monitoring, or the awareness of self-observation, is essential to the CBT treatment process for panic disorder. In this part of treatment, the individual is taught to identify the physiological cues immediately leading up to and during a panic attack. The client is then encouraged to identify and document/record the thoughts and behaviors associated with these physiological symptoms. By bringing awareness to the symptoms, as well as the relationship between physical arousal and cognitive/behavioral responses, the client is learning the fundamental processes in which they can manage their panic symptoms (Craske & Barlow, 2014).
Relaxation training. Prior to engaging in exposure training, the individual must learn a relaxation technique to apply during the onset of panic attacks. While breathing training was once included as the relaxation training technique of choice for panic disorder, due to the high report of hyperventilation during panic attacks more recent research has failed to support this technique as effective in the use of panic disorder (Schmidt et al., 2000). Findings suggest that breathing retraining is more commonly misused as a means for avoiding physical symptoms as opposed to an effective physiological response to stress (Craske & Barlow, 2014). To replace the breathing retraining, Craske & Barlow (2014) suggest progressive muscle relaxation (PMR). In PMR, the client learns to tense and relax various large muscle groups throughout the body. Generally speaking, the client is encouraged to start at either the head or the feet, and gradually work their way up through the entire body, holding the tension for roughly 10 seconds before relaxing. The theory behind PMR is that in tensing the muscles for a prolonged period of time, the individual exhausts those muscles, forcing them (and eventually) the entire body to engage in relaxation (McCallie, Blum, & Hood, 2006).
Cognitive restructuring. Cognitive restructuring, or the ability to recognize cognitive errors and replace them with alternate, more appropriate thoughts, is likely the most powerful part of CBT treatment for panic disorder, aside from the exposure part. Cognitive restructuring involves identifying the role of thoughts in generating and maintaining emotions. The clinician encourages the individual to view these thoughts as “hypotheses” as opposed to facts, which allows the thoughts to be questioned and challenged. This is where the detailed recordings in the self-monitoring section of treatment are helpful. By discussing specifically what the client has recorded for the relationship between physiological arousal and thoughts/behaviors, the clinician is able to help the individual restructure the maladaptive thought processes to more positive thought processes which in return, helps to reduce fear and anxiety.
Exposure. Next, the client is encouraged to engage in a variety of exposure techniques such as in vivo exposure and interoceptive exposure, while also incorporating the cognitive restructuring and relaxation techniques previously learned in efforts to reduce and eliminate ongoing distress. Interoceptive exposure involves inducing panic specific symptoms to the individual repeatedly, for a prolonged time period, so that maladaptive thoughts about the sensations can be disconfirmed and conditional anxiety responses are extinguished (Craske & Barlow, 2014). Some examples of these exposure techniques are spinning a client repeatedly in a chair to induce dizziness and breathing in a paper bag to induce hyperventilation. These treatment approaches can be presented in a gradual manner; however, the client must endure the physiological sensations for at least 30 seconds to 1 minute to ensure adequate time for applying cognitive strategies to misappraisal of cognitive symptoms (Craske & Barlow, 2014). Interoceptive exposure is continued both in and outside of treatment until panic symptoms remit. Over time, the habituation of fear within an exposure session will ultimately lead to habituation across treatment, which leads to long-term remission of panic symptoms (Foa & McNally, 1996). Occasionally, panic symptoms will return in individuals who report complete remission of panic disorder. Follow-up booster sessions reviewing the steps above is generally effective in eliminating symptoms again.
4.1.4.2 Pharmacological Interventions
According to Craske & Barlow (2014), nearly half of people with panic disorder present to psychotherapy already on medication, likely prescribed by their primary care physician. Some researchers argue that anti-anxiety medications impede the progress of CBT treatment as the individual is not able to fully experience the physiological sensations during exposure sessions, thus limiting their ability to modify maladaptive thoughts maintaining the panic symptoms. Results from large clinical trials suggest no advantage during or immediately after treatment of combining CBT and medication (Craske & Barlow, 2014). Additionally, when medications were discontinued post-treatment, the CBT+ medication groups fared worse than the CBT treatment alone groups, thus supporting the theory that immersion in interoceptive exposure is limited by the use of medication. Therefore, it is suggested that medications are reserved for those who do not respond to CBT therapy alone (Kampman, Keijers, Hoogduin & Hendriks, 2002).
4.2 Generalized Anxiety Disorder
Section Learning Objectives
Describe how generalized anxiety disorder presents itself.
Describe the epidemiology of generalized anxiety disorder.
Indicate which disorders are commonly comorbid with generalized anxiety disorder.
Describe the treatment options for generalized anxiety disorder.
4.2.1 Clinical Description
Generalized anxiety disorder, commonly referred to as GAD, is a disorder characterized by an underlying excessive worry related to a wide range of events or activities. While many individuals experience some levels of worry throughout the day, individuals with GAD experience worry of a greater intensity and for longer periods of times than the average person. Additionally, they are often unable to control their worry through various coping strategies, which directly interferes with their ability to engage in daily social and occupational tasks. There are six characteristic symptoms of generalized anxiety disorder and in order to be diagnosed with the disorder, individuals must experience at least three of them. These symptoms are: feeling restless, being easily fatigued, having difficulty concentrating, feeling irritable, having muscle tension, experiencing problems with sleep.
4.2.2 Epidemiology
The prevalence rate for generalized anxiety disorder is estimated to be 3% of the general population, with nearly 6% of individuals experiencing GAD sometime during their lives. While it can present at any age, it generally appears first in childhood or adolescence. Similar to most anxiety-related disorders, females are twice as likely to be diagnosed with GAD as males (APA, 2013).
4.2.3 Comorbidity
There is a high comorbidity between generalized anxiety disorder and the other anxiety-related disorders, as well as major depressive disorder, suggesting they all share common vulnerabilities, both biological and psychological.
4.2.4 Treatment
4.2.4.1 Psychopharmacology
Benzodiazepines, a class of sedative-hypnotic drugs, originally replaced barbiturates as the leading anti-anxiety medication due to their less addictive nature, yet equally effective ability to calm individuals at low dosages. Unfortunately, as more research was conducted on benzodiazepines, serious side effects, as well as physical dependence have routinely been documented (NIMH, 2013). Due to these negative effects, selective serotonin-reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are generally considered to be first-line medication options for those with GAD. Findings indicate a 30-50% positive response rate to these psychopharmacological interventions (Reinhold & Rickels, 2015). Unfortunately, none of these medications continue to provide any benefit once they are stopped; therefore, other more effective treatment options such as CBT, relaxation training, and biofeedback are often encouraged before the use of pharmacological interventions.
4.2.4.2 Rational-Emotive Therapy
Rational emotive therapy was developed by Albert Ellis in the mid-1950s as one of the first forms of cognitive-behavioral therapy. Ellis proposed that individuals were not aware of the effect their negative thoughts had on their behaviors and various relationships and thus, identified a treatment aimed to address these thoughts in an effort to provide relief to those experiencing anxiety and depression. The goal of rational emotive therapy is to identify irrational, self-defeating assumptions, challenge the rationality of those assumptions, and to replace them with new more productive thoughts and feelings. It is proposed that through identifying and replacing these assumptions that one will experience relief of GAD symptoms (Ellis, 2014).
4.2.4.3 Cognitive Behavioral Therapy (CBT)
CBT is among the most effective treatment options for a variety of anxiety disorders, including GAD. In fact, findings suggest 60% of individuals report a significant reduction/elimination in anxious thoughts one-year post-treatment (Hanrahan, Field, Jones, & Davy, 2013). The fundamental goal of CBT is a combination of cognitive and behavioral strategies aimed to identify and restructure maladaptive thoughts while also providing opportunities to utilize these more effective thought patterns through exposure based experiences. Through repetition, the individual will be able to identify and replace anxious thoughts outside of therapy sessions, ultimately reducing their overall anxiety levels (Borkovec, & Ruscio, 2001).
4.2.4.4 Biofeedback
Biofeedback provides a visual representation of a clients’s physiological arousal. To achieve this feedback, a client is connected to a computer that provides continuous information on their physiological states. There are several ways a client can be connected to the computer. Among the most common is electromyography (EMG). EMG measures the amount of muscle activity currently experienced by the individual. An electrode is placed on a individuals’s skin just above a major muscle group- commonly the forearm or the forehead. Other common types of measurement are electroencephalography (EEG) which measures the neurofeedback or brain activity; heart rate variability (HRV) which measures autonomic activity such as heart rate or blood pressure; and galvanic skin response (GSR) which measures sweat.
Once the client is connected to the biofeedback machine, the clinician is able to walk the client through a series of relaxation scripts or techniques as the computer simultaneously measures the changes in muscle tension. The theory behind biofeedback is that in providing a client with a visual representation of changes in their physiological state, they become more skilled at voluntarily reducing their physiological arousal, and thus, their overall sense of anxiety or stress. While research has identified only a modest effect of biofeedback on anxiety levels, clients do report a positive experience with the treatment due to the visual feedback of their physiological arousal (Brambrink, 2004).
4.3 Specific Phobia
Section Learning Objectives
Describe how specific phobia presents itself.
Describe the epidemiology of specific phobia.
Indicate which disorders are commonly comorbid with specific phobia.
Describe the treatment options for specific phobia.
4.3.1 Clinical Description
Specific phobia is distinguished by an individual’s fear or anxiety specific to an object or a situation. While the amount of fear or anxiety related to the specific object or situation varies among individuals, it also varies related to the proximity of the object/situation. When individuals are face-to-face with their specific phobia, immediate fear is present. It should also be noted that these fears are more excessive and more persistent than a “normal” fear, often severely impacting one’s daily functioning (APA, 2013).
Individuals can experience multiple specific phobias at one time. In fact, nearly 75% of individuals with a specific phobia report fear in more than one object (APA, 2013). When making a diagnosis of specific phobia, it is important to identify the specific phobic stimulus. Among the most commonly diagnosed specific phobias are animals, natural environments (height, storms, water), blood-injection-injury (needles, invasive medical procedures), or situational (airplanes, elevators, enclosed places; APA, 2013). Given the high percentage of individuals who experience more than one specific phobia, all specific phobias should be listed as a diagnosis in efforts to identify an appropriate treatment plan.
4.3.2 Epidemiology
The prevalence rate for specific phobias is 7-9% within the united states. While young children have a prevalence rate of approximately 5%, teens have nearly a double prevalence rate than that of the general public at 16%. There is a 2:1 ratio of females to males diagnosed with specific phobia; however, this rate changes depending on the different phobic stimuli. More specifically, animal, natural environment, and situational specific phobias are more commonly diagnosed in females, whereas blood-injection-injury phobia is reportedly diagnosed equally between genders.
4.3.3. Comorbidity
Seeing as the onset of specific phobias occurs at a younger age than most other anxiety disorders, it is generally the primary diagnosis with generalized anxiety disorder as an occasional comorbid diagnosis. It should be noted that children/teens diagnosed with a specific phobia are at an increased risk for additional psychopathology later in life. More specifically, other anxiety disorders, depressive disorders, substance-related disorders and somatic symptom disorders.
4.3.4 Treatment
4.3.4.1 Exposure Treatments
While there are many treatment options for specific phobias, research routinely supports the behavioral techniques as the most effective treatment strategies. Seeing as the behavioral theory suggests phobias are developed via classical conditioning, the treatment approach revolves around breaking the maladaptive association developed between the object and fear. This is generally accomplished through exposure treatments. As the name implies, the individual is exposed to their feared stimuli. This can be done using several different approaches: systematic desensitization, flooding, and modeling.
Systematic desensitization is an exposure technique that utilizes relaxation strategies to help calm the individual as they are presented with the fearful object. The notion behind this technique is that both fear and relaxation cannot exist at the same time; therefore, the individual is taught how to replace their fearful reaction with a calm, relaxing reaction. To begin, the client, with assistance from the clinician, will identify a fear hierarchy, or a list of feared objects/situations ordered from least fearful to most fearful. After learning intensive relaxation techniques, the clinician will present items from the fear hierarchy- starting from the least fearful object/subject- while the patient practices using the learned relaxation techniques. The presentation of the feared object/situation can be in person (in vivo exposure) or it can be imagined (imaginal exposure). Imaginal exposure tends to be less intensive than in vivo exposure; however, it is less effective than in vivo exposure in eliminating the phobia. Depending on the phobia, in vivo exposure may not be an option, such as with a fear of a tornado. Once the patient is able to effectively employ relaxation techniques to reduce their fear/anxiety to a manageable level, the clinician will slowly move up the fear hierarchy until the individual does not experience excessive fear of any objects on the list.
Another exposure technique is flooding. In flooding, the clinician does not utilize a fear hierarchy, but rather repeatedly exposes the individual to their most feared object/subject. Similar to systematic desensitization, flooding can be done in either in vivo or imaginal exposure. Clearly, this technique is more intensive than the systematic or gradual exposure to feared objects. Because of this, patients are at a greater likelihood of dropping out of treatment, thus not successfully overcoming their phobias.
Finally, modeling is a common technique that is used to treat specific phobias (Kelly, Barker, Field, Wilson, & Reynolds, 2010). In this technique, the clinician approaches the feared object/subject while the patient observes. Like the name implies, the clinician models appropriate behaviors when exposed to the feared stimulus, implying that the phobia is irrational. After modeling several times, the clinician encourages the patient to confront the feared stimulus with the clinician, and then ultimately, without the clinician.
4.4 Social Anxiety Disorder
Section Learning Objectives
Describe how social anxiety disorder presents itself.
Describe the epidemiology of social anxiety disorder.
Indicate which disorders are commonly comorbid with social anxiety disorder.
Describe the treatment options for social anxiety disorder.
4.4.1 Clinical Description
For social anxiety disorder (formerly known as social phobia), the anxiety is directed toward the fear of social situations, particularly those in which an individual can be evaluated by others. More specifically, the individual is worried that they will be judged negatively and viewed as stupid, anxious, crazy, boring, unlikeable, or boring to name a few. Some individuals report feeling concerned that their anxiety symptoms will be obvious to others via blushing, stuttering, sweating, trembling, etc. These fears severely limit an individual’s behavior in social settings. For example, an individual may avoid holding drinks or plates if they know they will tremble in fear of dropping or spilling food/water. Additionally, if one is known to sweat a lot in social situations, they may limit physical contact with others, refusing to shake hands.
Unfortunately, for those with social anxiety disorder, all or nearly all social situations provoke this intense fear. Some individuals even report significant anticipatory fear days or weeks before a social event is to occur. This anticipatory fear often leads to avoidance of social events in some individuals; others will attend social events with a marked fear of possible threats. Because of these fears, there is a significant impact on one’s social and occupational functioning.
It is important to note that the cognitive interpretation of these social events is often excessive and out of proportion to the actual risk of being negatively evaluated. There are instances where one may experience anxiety toward a real threat such as bullying or ostracizing. In this instance, social anxiety disorder would not be diagnosed as the negative evaluation and threat are real.
4.4.2 Epidemiology
The overall prevalence rate of social anxiety disorder is significantly higher in the United States than in other countries worldwide, with an estimated 7% of the US population diagnosed with social anxiety disorder. Within the US, the prevalence rate remains the same among children through adults; however, there appears to a significant decrease in the diagnosis of social anxiety disorder among older individuals. With regards to gender, there is a higher diagnosis rate in females than males. This gender discrepancy appears to be larger in children/adolescents than adults.
4.4.3 Comorbidity
Among the most common comorbid diagnoses with social anxiety disorder are other anxiety-related disorders, major depressive disorder, and substance-related disorders. Generally speaking, social anxiety disorders will precede that of other mental health disorders, with the exception of separation anxiety disorder and specific phobia, seeing as these two disorders are more commonly diagnosed in childhood (APA, 2013). The high comorbidity rate among anxiety-related disorders and substance-related disorders is likely related to the efforts of self-medicating. For example, an individual with social anxiety disorder may consume larger amounts of alcohol in social settings in efforts to alleviate the anxiety of the social situation.
4.4.4 Treatment
4.4.4.1 Exposure
A hallmark treatment approach for all anxiety disorders is exposure. Specific to social anxiety disorder, the individual is encouraged to engage in social situations where they are likely to experience increased anxiety. Initially, the clinician will engage in role-playing of various social situations with the client so that he/she can practice social interactions in a safe, controlled environment (Rodebaugh, Holaway, & Heimberg, 2004). As the client becomes habituated to the interaction with the clinician, the clinician and client may venture outside of the treatment room and engage in social settings with random strangers at various locations such as fast food restaurants, local stores, libraries, etc. The client is encouraged to continue with these exposure based social interactions outside of treatment to help reduce anxiety related to social situations.
4.4.4.2 Social Skills Training
This treatment is specific to social anxiety disorder as it focuses on skill deficits or inadequate social interactions displayed by the client that contributes to the negative social experiences and anxiety. The clinician may use a combination of skills such as modeling, corrective feedback, and positive reinforcement to provide feedback and encouragement to the client regarding his/her behavioral interactions (Rodebaugh, Holaway, & Heimberg, 2004). By incorporating the clinician’s feedback into their social repertoire, the client can engage in positive social behaviors outside of the treatment room in hopes to improve overall social interactions and reduce ongoing social anxiety.
4.4.4.3 Cognitive Restructuring
While exposure and social skills training are helpful treatment options, research routinely supports the need to incorporate cognitive restructuring as an additive component in treatment to provide substantial symptom reduction. Here the client will work with the therapist to identify negative, automatic thoughts that contribute to the distress in social situations. The clinician can then help the client establish new, positive thoughts to replace these negative thoughts. Research indicates that implementing cognitive restructuring techniques before, during, and after exposure sessions enhances the overall effects of treatment of social anxiety disorder (Heimberg & Becker, 2002).
4.5 Agoraphobia
Section Learning Objectives
Describe how agoraphobia presents itself.
Describe the epidemiology of agoraphobia.
Indicate which disorders are commonly comorbid with agoraphobia.
Describe the treatment options for agoraphobia.
4.5.1 Clinical Description
Similar to GAD, agoraphobia is defined as an intense fear triggered by a wide range of situations; however, unlike GAD, agoraphobia’s fears are related to situations in which the individual is in public situations where escape may be difficult. In order to receive a diagnosis of agoraphobia, there must be a presence of fear in at least two of the following situations: using public transportation such as planes, trains, ships, buses; being in large, open spaces such as parking lots or on bridges; being in enclosed spaces like stores or movie theaters; being in a large crowd similar to those at a concert; or being outside of the home in general (APA, 2013). When an individual is in one (or more) of these situations, they experience significant fear, often reporting panic-like symptoms (see Panic Disorder). It should be noted that fear and anxiety related symptoms are present every time the individual is presented with these situations. Should symptoms only occur occasionally, a diagnosis of agoraphobia is not warranted.
Due to the intense fear and somatic symptoms, individuals will go to great lengths to avoid these situations, often preferring to remain within their home where they feel safe, thus causing significant impairment in one’s daily functioning. They may also engage in active avoidance, where the individual will intentionally avoid agoraphobic situations. These avoidance behaviors may be behavioral, including having food delivery to avoid going to grocery store or only taking a job that does not require the use of public transportation, or cognitive, by using distraction and various other cognitive techniques to successfully get through the agoraphobic situation.
4.5.2 Epidemiology
The yearly prevalence rate for agoraphobia across the lifespan is roughly 1.7%. Females are twice as likely as males to be diagnosed with agoraphobia (notice the trend…). While it can occur in childhood, agoraphobia typically does not develop until late adolescence/early adulthood and typically tapers off in later adulthood.
4.5.3 Comorbidity
Similar to the other anxiety disorders, comorbid diagnoses include other anxiety disorders, depr
