6.8 SUMMING UP

Common Features of Anxiety Disorders

• The key symptoms of anxiety disorders are fear, extreme anxiety, intense arousal, and attempts to avoid stimuli that lead to fear and anxiety.
• The fight-or-flight response (also called the stress response) arises when people perceive a threat; when the arousal feels out of control—either because the person has an overactive stress response or because he or she misinterprets the arousal—the person may experience panic. In response to the panic, some people develop a phobia of stimuli related to their panic and anxiety symptoms.
• Anxiety disorders frequently co-occur with other psychological disorders, such as depression or substance-use disorders. Mental health clinicians must determine whether the anxiety symptoms are the primary cause of the problem or are the by-product of another type of disorder.
• The high comorbidity of depression and anxiety disorders suggests that the two disorders share some of the same features, specifically high levels of negative emotions and distress—which can lead to concentration and sleep problems and irritability.

Generalized Anxiety Disorder

• Generalized anxiety disorder is marked by persistent and excessive worry about a number of events or activities that are not solely the focus of another disorder. Most people with GAD also have comorbid depression.
• Neurological factors associated with GAD include:
  • decreased arousal because the parasympathetic nervous system is extremely responsive (this is unlike most other anxiety disorders).
  • abnormal activity of serotonin, dopamine, and other neurotransmitters, which in turn influences motivation, response to reward, and attention.
  • a genetic predisposition to become anxious and/or depressed. This predisposition, however, is not specific to GAD.
• Psychological factors that contribute to GAD include being hypervigilant for possible threats, a sense that the worrying is out of control, and the reinforcing experience that worrying prevents panic.
• Social factors that contribute to GAD include stressful life events, which can trigger the disorder.
• Treatments for GAD include:
  • medication (which targets neurological factors), such as buspirone or an SNRI or SSRI when depression is present as a comorbid disorder.
  • CBT (which targets psychological factors), which may include breathing retraining, muscle relaxation training, worry exposure, cognitive restructuring, self-monitoring, problem solving, psychoeducation, and/or meditation.

Panic Disorder and Agoraphobia

• The hallmark of panic disorder is recurrent panic attacks—periods of fear and discomfort along with physical arousal symptoms or cognitive symptoms. Panic attacks may be cued by particular stimuli (usually internal sensations), or they may arise without any clear cue. Panic disorder also involves fear of further attacks and, in some cases, restricted behavior in an effort to prevent further attacks.
• People in different cultures may have similar—but not identical—constellations of panic symptoms, such as ataque de nervios and wind-and-blood pressure.
• About half of people with panic disorder also develop agoraphobia—avoiding situations that might trigger a panic attack or from which escape would be difficult, such as crowded locations or tunnels.
• Neurological factors that contribute to panic disorder and agoraphobia include:
  • A heightened sensitivity to breathing changes, which in turn leads to hyperventilation, panic, and a sense of needing to escape.
  • Too much norepinephrine (produced by an over-reactive locus coeruleus), which increases heart and respiration rates and other aspects of the fight-or-flight response.
  • A genetic predisposition to anxiety disorders, which makes some people vulnerable to panic disorder and agoraphobia.
• Psychological factors that contribute to panic disorder and agoraphobia include:
  • Conditioning of the initial bodily sensations of panic (interoceptive cues) or of external cues related to panic attacks, which leads them to become learned alarms and elicit panic symptoms. Some people then develop a fear of fear and avoid panic-related cues.
  • Heightened anxiety sensitivity and misinterpretation of bodily symptoms of arousal as symptoms of a more serious problem, such as a heart attack, which can, in turn, lead to hypervigilance for—and fear of—further sensations and cause increased arousal, creating a vicious cycle.
• Social factors related to panic disorder and agoraphobia include:
  • greater-than-average number of social stressors during childhood and adolescence.
  • cultural factors, which can influence whether people develop panic disorder.
  • the presence of a safe person, which can decrease catastrophic thinking and panic.
• The treatment that targets neurological factors is medication, specifically benzodiazepines for short-term relief and antidepressants for long-term use.
• CBT is the first-line treatment for panic disorder and targets psychological factors. Behavioral methods focus on the bodily signals of arousal, panic, and agoraphobic avoidance. Cognitive methods (psychoeducation and cognitive restructuring) focus on the misappraisal of bodily sensations and on mistaken inferences about them.
• Treatments that target social factors include group therapy focused on panic disorder, and couples or family therapy, particularly when a family member is a safe person.

Social Anxiety Disorder (Social Phobia)

• Social anxiety disorder is an intense fear of or anxiety about being in any of three types of social situations: social interactions (such as a conversation); being observed (such as when eating or using public restrooms); and performing (such as giving a speech). When such social situations cannot be avoided, they trigger panic or anxiety.
• The anxiety about performing poorly and being evaluated by others can, in turn, impair a person’s performance, creating a vicious cycle. The symptoms of social anxiety disorder may lead people with this disorder to be less successful than they could otherwise be because they avoid job-related social interactions that are required for advancement.
• Neurological factors that give rise to social anxiety disorder include an amygdala that is more easily activated in response to social stimuli, too little dopamine and serotonin, and a genetic predisposition toward a shy temperament (behavioral inhibition).
• Psychological factors that give rise to social anxiety disorder include cognitive distortions and hypervigilance for social threats—particularly about being negatively evaluated. Classical conditioning of a fear response in social situations may contribute to social anxiety disorder; avoiding feared social situations is then negatively reinforced (operant conditioning).
• Social factors that give rise to social anxiety disorder include parents’ encouraging a child to avoid anxiety-inducing social interactions. Moreover, people in different cultures may express their social fears somewhat differently (e.g., taijin kyofusho). The rate of social anxiety disorder appears to be increasing in more recent birth cohorts.
• Medication is the treatment that targets neurological factors, specifically beta-blockers for periodic performance anxiety and SSRIs or SNRIs for more generalized social anxiety disorder. CBT is the treatment that targets psychological factors, specifically exposure and cognitive restructuring. Group CBT and exposure to feared social stimuli are the treatments that target social factors.

Specific Phobia

• Specific phobia involves (a) marked anxiety or fear related to a specific stimulus that (b) is disproportional to the actual danger posed, and (c) leads to attempts to avoid that feared stimulus. DSM-5 specifies five types of specific phobia: animal, natural environment, blood-injection-injury, situational, and other.
• People are biologically prepared to develop specific phobia to certain stimuli as well as to resist developing phobias to certain other stimuli.
• Neurological factors, such as an overly reactive amygdala, appear to contribute to specific phobia. GABA is one neurotransmitter that is involved in specific phobia. Research also suggests that some genes are associated with specific phobia generally, whereas other genes are associated with particular types of specific phobia.
• Psychological factors that give rise to specific phobia may include classical conditioning (but rarely), operant conditioning (negative reinforcement of avoiding the feared stimulus), and cognitive biases related to the stimulus (such as overestimating the probability that a negative event will occur following contact with the feared stimulus).
• Observational learning—a social factor—can influence what particular stimulus a person comes to fear.
• Treatment for specific phobia can include medication (targeting neurological factors), specifically a benzodiazepine. However, medication is usually not necessary because CBT—the treatment of choice for specific phobia—is extremely effective (targeting psychological factors). CBT—particularly when exposure is part of the treatment—can be effective after just one session.

Separation Anxiety Disorder

• Separation anxiety disorder is characterized by excessive anxiety about separation from home or from someone to whom the person is strongly attached.
• Separation anxiety disorder is most common in children but also can occur in adults.
• Separation anxiety disorder is moderately heritable; overprotective family members may inadvertently reinforce behaviors associated with separation anxiety and punish behaviors associated with appropriate separation.
• Separation anxiety disorder is treated with methods used to treat other anxiety disorders: CBT that includes exposure and cognitive restructuring, along with family therapy.