LO 4 Define anxiety disorders and demonstrate an understanding of their causes.

Think about the objects or situations that cause you to feel afraid or uneasy. Maybe you fear creepy crawly insects, slithery snakes, or crowded public spaces. A mild fear of spiders or overcrowded subways is normal, but if you become highly disturbed by the mere thought of them, or if the fear interferes with your everyday functioning, then a problem may exist. People who suffer from anxiety disorders have extreme anxiety and/or irrational fears that are debilitating (Table 12.3).

How do we differentiate between normal anxiety and an anxiety disorder? We look at the degree of dysfunction the anxiety causes, how much distress it creates, and whether it gets in the way of everyday behavior (interfering with relationships, work, and time management, for example). Let’s take a look at some of the anxiety disorders identified in the DSM–5: panic disorder, specific phobia, agoraphobia, social anxiety disorder, and generalized anxiety disorder.

What should you do if you see somebody trembling and sweating, gasping for breath, or complaining of heart palpitations? If you are concerned it’s a heart attack, you may be correct; call 911 immediately if you are not sure. However, a person experiencing a panic attack may behave very similarly to someone having a heart attack. A panic attack is a sudden, extreme fear or discomfort that escalates quickly, often with no evident cause, and includes symptoms such as increased heart rate, sweating, shortness of breath, chest pain, nausea, lightheadedness, and fear of dying. A diagnosis of panic disorder requires such attacks to recur unexpectedly and have no obvious trigger. In addition, the person worries about having more panic attacks, or she feels she may be losing control. People with panic disorder often make decisions that are maladaptive, like purposefully avoiding exercise or places that are unfamiliar.

THE BIOLOGY OF PANIC DISORDER Panic disorder does appear to have a biological cause (American Psychiatric Association, 2013). Researchers have identified specific parts of the brain thought to be responsible for panic attacks, including regions of the hypothalamus, which is involved in the fight-or-flight response (Johnson et al., 2010). There is also evidence suggesting that people diagnosed with panic disorder have a smaller amygdala. The amygdala is involved in fear and aggression, as well as the memories associated with those emotions. A smaller amygdala could lead to dysfunction in the autonomic nervous system (which directs the fight-or-flight response), resulting in behavioral and physical symptoms of panic attacks (Hayano et al., 2009).

GENETICS, GENDER, AND PANIC DISORDER Panic disorder affects about 2–3% of the population (American Psychiatric Association, 2013). Research indicates that panic disorder runs in families, with heritability estimates around 40–48% (Maron, Hettema, & Shlik, 2010; Weber et al., 2012). This means that over 40% of the variation of the disorder in the population can be attributed to genetic factors and the remaining 60% is due to environmental factors. In other words, the frequency and distribution of panic disorder across people result from a combination of factors, 40% of which are genetic, and 60% nongenetic. People often assume heritability refers to an individual’s risk for a disorder (“Her panic disorder is 40% the result of her genes, and 60% due to her environment”). This is incorrect. Remember, heritability explains the variation and risk among individuals in a population.

Women are twice as likely as men to be diagnosed with panic disorder, and this disparity is already apparent by the age of 14 (American Psychiatric Association, 2013; Craske et al., 2010; Weber et al., 2012). Such gender differences may have a biological basis, but we must also consider psychological and social factors.

LEARNING AND PANIC DISORDER Some researchers propose that learning—particularly classical conditioning—can play a role in the development of panic disorder (Bouton, Mineka, & Barlow, 2001). In a panic disorder scenario, the neutral stimulus might be something like a location (a shopping mall), the unconditioned stimulus an unexpected panic attack, and the unconditioned response the fear resulting from the panic attack. The panic attack location (the shopping mall) would become the conditioned stimulus, such that every time the person thinks of the shopping mall, she responds with fear (now the conditioned response).

COGNITION AND PANIC DISORDER Other researchers suggest there is a cognitive component of panic disorder, with some individuals misinterpreting physical sensations as signs of major physical or psychological problems (Clark et al., 1997; Teachman, Marker, & Clerkin, 2010). For example, many people have a strange sensation when their hearts skip a beat (technically known as arrhythmia), but they realize it is probably not serious, perhaps just the result of too much coffee. A person with panic disorder might interpret that sensation as an indication of an imminent heart attack.

Panic attacks can occur without apparent triggers. This is not the case with a specific phobia, which centers on a particular object or situation, such as rats or airplane travel. Most people who have a phobia do their best to avoid the feared object or situation. If avoidance is not possible, they withstand it, but only with extreme fear and anxiousness. Take a look at Table 12.4 for a list of some specific phobias.

LEARNING AND SPECIFIC PHOBIAS As with panic disorder, phobias can be explained using the principles of learning (LeBeau et al., 2010). Classical conditioning may lead to the acquisition of a fear, through the pairing of stimuli. Operant conditioning could maintain the phobia, through negative reinforcement; if anxiety (the unpleasant stimulus) is reduced by avoiding a feared object or situation, the avoidance behavior is negatively reinforced and thus more likely to recur. Observational learning can also help explain the development of a phobia. Simply watching someone else experience a phobia could create fear in an observer. Some research demonstrates that even rhesus monkeys become afraid of snakes if they observe other monkeys reacting fearfully to real or toy snakes (Heyes, 2012; Mineka, Davidson, Cook, & Keir, 1984).

BIOLOGY, CULTURE, AND SPECIFIC PHOBIAS Phobias can also be understood through the lens of evolutionary psychology. Humans seem to be biologically predisposed to fear certain threats such as spiders, snakes, foul smells, and bitter foods. Spiders, in particular, may inspire fear or disgust because they can be dangerous, but such reactions can also be influenced by culture (Gerdes, Uhl, & Alpers, 2009). From an evolutionary standpoint, these types of fears would tend to protect us from true danger. But the link between anxiety and evolution is not always so apparent. It’s hard to imagine how an intense fear of being in public, for example, would promote survival.

AGORAPHOBIA Do you ever feel a little anxious when you are out in public, in a new city, or at a crowded amusement park? A person with agoraphobia (a-gə-rə-'fō-bē-ə) feels extremely anxious in these types of settings. This disorder is characterized by a distinct fear or anxiety related to public transportation, open spaces, retail stores, crowds, or being alone and away from home in general. Agoraphobia may also result in “panic-like symptoms,” which can be difficult to handle. Typically, people with agoraphobia need another person to accompany them on outings, because they feel they may not be able to cope on their own. They may avoid situations that frighten them, or be overwhelmed with fear when avoidance or escape is not possible. As with other anxiety disorders, the fear felt by someone with agoraphobia is beyond what is commonly expected in a particular cultural context (American Psychiatric Association, 2013).

According to the DSM–5, a person with social anxiety disorder (social phobia) has a distinct fear of social situations and scrutiny by others. This fear could arise during a speech or presentation, while eating a meal, or simply in an intimate conversation. Social anxiety often stems from a preoccupation with offending someone or behaving in a way that reveals one’s anxiety. This extreme fear is not warranted, however. Being evaluated or even mocked by others is not necessarily a dangerous situation and should not cause debilitating stress. This type of social anxiety, where one fears the judgment and scrutiny of others, is what psychologists often observe in Western societies. In other parts of the world, social anxiety may take a different form.

across the WORLD

Thus far we have discussed anxiety disorders that center on specific objects or scenarios, but what about anxiety that is pervasive, or widespread? Someone with generalized anxiety disorder experiences an excessive amount of worry and anxiety about many activities relating to family, health, school, and other aspects of daily life (American Psychiatric Association, 2013). The psychological distress is accompanied by physical symptoms such as muscle tension and restlessness. Individuals with generalized anxiety disorder may avoid activities they believe will not go smoothly, spend a great deal of time getting ready for such events, or wait until the very last minute to engage in the anxiety-producing activity. Like other disorders, the anxiety must cause substantial distress in social settings or work environments to merit a diagnosis.

Twin studies suggest there is a hereditary component to generalized anxiety disorder. This genetic factor appears to be associated with irregularities in parts of the brain associated with fear, such as the amygdala and hippocampus (Hettema et al., 2012; Hettema, Neale, & Kendler, 2001). Environmental factors such as adversity in childhood and overprotective parents also appear to be associated with the development of generalized anxiety disorder (American Psychiatric Association, 2013).

LO 5 Summarize the symptoms and causes of obsessive-compulsive disorder.

At age 12, Melissa was diagnosed with obsessive-compulsive disorder (OCD), a psychological disorder characterized by unwanted thoughts, or obsessions, and repetitive, ritualistic behaviors known as compulsions. An obsession is a thought, urge, or image that recurs repeatedly, is intrusive and unwelcome, and often causes feelings of intense anxiety and distress. Melissa’s recurrent, all-consuming thoughts of disaster and death are examples of obsessions. People with OCD attempt to stop, or at least ignore, their obsessions by engaging in a replacement thought or activity. This isn’t always helpful, though, because the replacement can become a compulsion, which is a behavior or “mental act” repeated over and over.

Those who suffer from OCD experience various types of obsessions and compulsions. In many cases, obsessions focus on fears of contamination with germs or dirt, and compulsions revolve around cleaning and sterilizing (Cisler, Brady, Olatunji, & Lohr, 2010). One such OCD sufferer reported washing her hands until her knuckles bled, living in fear that she would kill someone with her germs (Turk, Marks, & Horder, 1990). Other common compulsions include repetitive rituals and checking behaviors. Melissa, for example, developed a compulsion about locking her car. Unlike most people, who lock their cars once and walk away, Melissa felt compelled to lock it twice. Then she would begin to wonder whether the car was really locked, so she would lock it a third time—just in case. But 3 is an odd number, and odd numbers don’t sit well with Melissa, so she would lock it a fourth time. By the time Melissa finally felt comfortable enough to walk away, she had locked her car eight times. And sometimes that was still not enough.

THE OCD DIAGNOSIS How do you explain this type of behavior? OCD compulsions often aim to thwart unwanted situations, and thereby reduce anxiety and distress. Melissa was tormented by multiple obsessions ranging from catastrophic (the death of her mother) to minor (someone stealing her iPod). But the compulsive behaviors of OCD are either “clearly excessive” or not logically related to the event or situation the person is trying to prevent (American Psychiatric Association, 2013).

Where do we draw the line between obsessive or compulsive behavior and the diagnosis of a disorder? Remember, behaviors or symptoms must be significantly distressing or disabling in order to be considered abnormal and qualify as a disorder. This is certainly the case with OCD, in which obsessions and/or compulsions are very time-consuming (taking more than 1 hour a day) and cause a great deal of distress and disruption in daily life. Everyone has odd thoughts and quirky routines, but they don’t eat up multiple hours of the day and interfere with school, work, and relationships. That’s the key distinction between normal preoccupations and OCD (American Psychiatric Association, 2013).

THE BIOLOGY OF OCD Evidence suggests that the symptoms of OCD are related to abnormal activity of neurotransmitters. Reduced activity of serotonin is thought to play a role, though other neurotransmitters are also being studied (Bloch, McGuire, Landeros-Weisenberger, Leckman, & Pittenger, 2010). Certain areas of the brain have been implicated, including locations in the basal ganglia, cingulate gyri, and orbital frontal cortex (American Psychiatric Association, 2013; Radua & Mataix-Cols, 2009). These regions play a role in planning and regulating movement (Rotge et al., 2009).

Why do these biological differences arise? There appears to be a genetic basis for OCD. If a first-degree relative (parent, sibling, or offspring who shares about 50% of one’s DNA) has an OCD diagnosis, the risk of developing OCD is twice as high as someone whose first-degree relatives do not have the disorder (American Psychiatric Association, 2013).

THE ROLE OF REINFORCEMENT To ease her anxiety, Melissa turned to compulsions—repetitive, ritualistic behaviors aimed at relieving or offsetting her obsessions. Because her greatest fears never came to pass, Melissa assumed that her actions had prevented them. I didn’t die because I touched all the things in my room just the right way, she would think to herself. The more she followed through on her compulsions and saw that her fears never played out, the more convinced she became that her behaviors prevented them. As Melissa put it, “When you feed it, feed it, feed it, it gets stronger.”

Here, we see how learning can play a role in OCD. Melissa’s compulsions were negatively reinforced by the reduction in her fear. The negative reinforcement led to more compulsive behaviors, those compulsions were negatively reinforced, and so on. This learning process is ongoing and potentially very powerful. In one study, researchers monitored 144 people with OCD diagnoses for more than 40 years. The participants’ OCD symptoms improved, but almost half continued to show “clinically relevant” symptoms after four decades (Skoog & Skoog, 1999).

Question 1

Question 2

Question 3

1. obsessions.

2. classical conditioning.

3. panic attacks.

4. compulsions.

Question 4