Panic, Anxiety, andTheir Disorders

THE FEAR AND ANXIETY RESPONSE PATTERNS

OVERVIEW OF THE ANXIETY DISORDERS ANDTHEIR COMMONALITIES

SPECIFIC PHOBIASBlood- Injection- Injury PhobiaAge of Onset and Gender Differences in

Specific PhobiasPsychosocial Causal FactorsGenetic and Temperamental Causal FactorsTreating Specific Phobias

SOCIAL PHOBIASInteraction of Psychosocial and Biological

Causal FactorsTreating Social Phobias

PANIC DISORDER WITH AND WITHOUTAGORAPHOBIAPanic DisorderAgoraphobiaPrevalence, Gender, and Age of Onset of Panic

Disorder with and without AgoraphobiaComorbidity with Other Disorders

The Timing of a First Panic AttackBiological Causal FactorsBehavioral and Cognitive Causal FactorsTreating Panic Disorder and Agoraphobia

GENERALIZED ANXIETY DISORDERGeneral CharacteristicsPrevalence and Age of OnsetComorbidity with Other DisordersPsychosocial Causal FactorsBiological Causal FactorsTreating Generalized Anxiety Disorder

OBSESSIVE-COMPULSIVE DISORDERPrevalence, Age of Onset, and ComorbidityCharacteristics of OCDPsychosocial Causal FactorsBiological Causal FactorsTreating Obsessive-Compulsive Disorder

SOCIOCULTURAL CAUSAL FACTORS FOR ALLANXIETY DISORDERSCultural Differences in Sources of WorryTaijin Kyofusho

s we noted in Chapter 5, even stable, well-adjusted people may break down ifforced to face extensive combat stress, torture, or devastating natural disaster. Butfor some people, simply performing everyday activities can be stressful. Faced withthe normal demands of life-socializing with friends, waiting in line for a bus, beingon an airplane, touching a doorknob-they become seriously fearful or anxious. Inthe most severe cases, people with anxiety problems may be unable even to leavetheir homes for fear of having a panic attack, or may spend much of their time inmaladaptive behavior such as constant hand washing.

Anxiety-a general feeling of apprehension about possible danger-was, inFreud's formulation, a sign of an inner battle or conflict between some primitivedesire (from the id) and prohibitions against its expression (from the ego and super-ego). Today the DSM has identified a group of disorders that share obvious symp-toms and features of fear and anxiety. These anxiety disorders, as they are known,affect approximately 25 to 29 percent of the U.s. population at some point in theirlives (over 23 million Americans) and are the most common category of disorders forwomen and the second most common for men (Kessler et aI., 1994; Kessler, Berglund,et aI., 2005b). In any 12-month period, about 23 percent of women and 12 percent ofmen suffer from at least one anxiety disorder (Kessler et aI., 1994). Anxiety disorderscreate enormous personal, economic, and health care problems for those affected.For example, in 1990 anxiety disorders cost the United States $42.3 billion in directand indirect costs, with 90 percent of these being direct costs (about 30 percent ofthe nation's total mental health bill of $148 billion in 1990; Greenberg et aI., 1999).

Consider the following case of an anxious electrician:

A 27-year-old married electrician complains of dizziness,sweating palms, heart palpitations, and ringingof the earsof more than 18 months' duration. Hehas also experienceddry mouth and throat, periods of extreme muscle tension,and a constant "edgy" and watchful feeling that has ofteninterfered with his ability to concentrate. These feelingshave been present most of the time during the previous 2years ... Because of these symptoms the patient has seena family practitioner, a neurologist, a neurosurgeon, a chi-ropractor, and an ear-nose-throat specialist. ... Healso hasmany worries. He constantly worries about the health ofhis parents ... Healso worries about whether he is a "goodfather," whether his wife will ever leave him (there is noindication that she is dissatisfied with the marriage), andwhether he is liked by co-workers on the job. Although herecognizes that his worries are often unfounded, he can'tstop worrying. Forthe past 2 years the patient has had fewsocial contacts because of his nervous symptoms ... hesometimes has to leave work when the symptoms becomeintolerable. (Adapted fromSpitzer et aI., 2002.)

Source: Adapted with permission from the DSM-/V- TR Casebook(Copyright 2000.) American Psychiatric Publishing, Inc.)

The physicians this man consulted could not determinethe cause of his physical symptoms, and one of themfinally referred him for treatment at a mental health clinic,where he was diagnosed as having generalized anxiety dis-order-one of seven primary anxiety disorders.

Historically, cases like this and other cases of anxietydisorders were considered to be classic examples ofneurotic behavior. Although neurotic behavior is mal-adaptive and self-defeating, a neurotic person is not out oftouch with reality, incoherent, or dangerous. To Freud,neuroses were psychological disorders that resulted whenintrapsychic conflict produced significant anxiety. Some-times this anxiety was overtly expressed (as in those dis-orders known today as the anxiety disorders). In certainother neurotic disorders, however, he believed that theanxiety might not be obvious, either to the person involvedor to others, if psychological defense mechanisms wereable to deflect or mask it. In 1980 the DSM -III dropped theterm neurosis and reclassified most of these disorders thatdid not involve obvious anxiety symptoms as either disso-ciative or somatoform disorders (see Chapter 8). DSM-IIImade this change in order to group together smaller sets ofdisorders that share more obvious symptoms and features.

We begin by discussing the nature of fear and anxietyas emotional states, both of which have an extremelyimportant adaptive value but to which humans at timesseem all too vulnerable. We will then move to a discussionof the anxiety disorders.

THE FEAR AND ANXIETY__ RESPONSE PATTERNS

It is difficult to define fear and anxiety, and there hasnever been complete agreement about how distinct thetwo emotions are from each other. Historically, the mostcommon way of distinguishing between fear and anxietyhas been whether there is a clear and obvious source ofdanger that would be regarded as real by most people.When the source of danger is obvious, the experiencedemotion has been called fear (e.g., ''I'm afraid of snakes").With anxiety, however, we frequently cannot specifyclearly what the danger is (e.g., ''I'm anxious about myparents' health"). Intuitively, anxiety seems to be experi-enced as an unpleasant inner state in which we are antic-ipating something dreadful happening that is not entirelypredictable from our actual circumstances (e.g., Barlow,2002a).

FEAR In recent years, many prominent researchers haveproposed a more fundamental distinction between fear andanxiety (e.g., Barlow, 1988, 2002a; Gray & McNaughton,1996). According to these theorists, fear or panic is a basicemotion (shared by many animals) that involves activationof the "fight-or-flight" response of the sympathetic ner-vous system. This is an almost instantaneous reaction toany imminent threat such as a dangerous predator orsomeone pointing a loaded gun. Its adaptive value is that itallows us to escape from imminent danger. When thefear/panic response occurs in the absence of any obviousexternal danger, we say the person has had a spontaneousor uncued panic attack. The symptoms of a panic attackare nearly identical to those experienced during a state offear except that panic attacks are often accompanied by asubjective sense of impending doom, including fears ofdying, going crazy, or losing control. These latter cognitivesymptoms do not generally occur during fear states. Thusfear and panic have three components:

1. cognitive/subjective components ("I feelafraid/terrified"; ''I'm going to die");

2. physiological components (such as increased heartrate and heavy breathing);

3. behavioral components (a strong urge to escape orflee; Lang, 1968, 1971).

These components are only "loosely coupled" (Lang,1985), which means that someone might show, for exam-ple, physiological and behavioral indications of fear with-out much of the subjective component, or vice versa. As aprimitive alarm response to danger, the fear response mustbe activated with great speed to serve its adaptive purpose:enabling us to escape or avoid danger. Indeed, we oftenseem to go from a normal state to a state of intense fearalmost instantaneously.

Fear or panic is a basic emotion that is shared by many animals,including humans, and may activate the "fight-or-flight" responseof the sympathetic nervous system. This allows us to respondrapidly when faced with a dangeraus situation, such as beingthreatened by a predator. In humans who are having a panicattack, there is no external threat; panic occurs because of somemisfiring of this response system.

ANXIETY In contrast to fear and panic, anxiety is acomplex blend of unpleasant emotions and cognitionsthat is both more oriented to the future and much morediffuse than fear (Barlow, 1988, 2002a). But like fear, ithas not only cognitive/subjective components but alsophysiological and behavioral components. At thecognitive/subjective level, anxiety involves negativemood, worry about possible future threat or danger, self-preoccupation, and a sense of being unable to predict thefuture threat or to control it if it occurs. At a physiologicallevel, anxiety often creates a state of tension and chronicoverarousal, which may reflect readiness for dealing withdanger should it occur ("Something awful may happenand I had better be ready for it if it does"). Although thereis no activation of the fight-or-flight response as in fear,anxiety does prepare or prime a person for the fight-or-flight response should the anticipated danger occur. At abehavioral level, anxiety may create a strong tendency toavoid situations where danger might be encountered, butthere is not the immediate urge to flee with anxiety asthere is with fear (Barlow, 1988, 2002a). Support for theidea that anxiety is descriptively and functionally distinct

from panic comes both from complex statistical analysesof subjective reports of panic and anxiety, and from agreat deal of neurobiological evidence (e.g., Bouton,Mineka, & Barlow, 2001; Gorman et aI., 2000).

The adaptive value of anxiety may be that it helps usplan and prepare for possible threat. In mild to moderatedegrees, anxiety actually enhances learning and perfor-mance. For example, a mild amount of anxiety about howyou are going to do on your next exam, or in your next ten-nis match, can actually be helpful. But although anxiety isoften adaptive in mild or moderate degrees, it is maladap-tive when it becomes chronic and severe, as we see in peo-ple diagnosed with anxiety disorders.

Although there are many threatening situations thatprovoke fear or anxiety unconditionally, many of oursources of fear and anxiety are learned. Years of humanand nonhuman animal experimentation have estab-lished that the basic fear and anxiety response patternsare highly conditionable. That is, previously neutral andnovel stimuli that are repeatedly paired with, and reliablypredict, frightening or unpleasant events such as variouskinds of physical or psychological trauma can acquire thecapacity to elicit fear or anxiety themselves. Such condi-tioning is a completely normal and adaptive process thatallows all of us to learn to anticipate upcoming frighten-ing events if they are reliably preceded by a signal. Yet thisnormal and adaptive process can also lead in some casesto the development of clinically significant fears and anx-ieties, as we will see.

For example, a girl named Angela sometimes sawand heard her father physically abuse her mother in theevening. After this happened four or five times, Angelastarted to became anxious as soon as she heard herfather's car arrive in the driveway at the end of the day. Insuch situations a wide variety of initially neutral stimulimay accidentally come to serve as cues that somethingthreatening and unpleasant is about to happen-andthereby come to elicit fear or anxiety themselves. Ourthoughts and images can also serve as conditioned stim-uli capable of eliciting the fear or anxiety response pat-tern. For example, Angela came to feel anxious even whenthinking about her father.

In ReVIew~ Compare and contrast fear or panic with

anxiety, making sure to note that bothemotions involve three response systems.

~ Explain the significance of the fact that bothfear and anxiety can be classicallyconditioned.

OVERVIEW OF THEANXIETY DISORDERSAND THEIRCOMMONALITIES _

Anxiety disorders all have unrealistic, irrational fears oranxieties of disabling intensity as their principal and mostobvious manifestation. DSM -IV-TR recognizes seven pri-mary types of anxiety disorders:

phobic disorders of the "specific" or of the"social" type;

panic disorder with or without agoraphobia;generalized anxiety disorder;

obsessive-compulsive disorder;

post-traumatic stress disorder (discussed in Chapter 5).

People with these varied disorders differ from oneanother both in terms of the relative preponderance offear/panic versus anxiety symptoms that they experience,and in the kinds of objects or situations that they are mostconcerned about. For example, people with specific orsocial phobias exhibit many anxiety symptoms about thepossibility of encountering their phobic situation, but theymay also experience a fear/panic response when they actu-ally encounter the situation. People with panic disorderexperience both frequent panic attacks and intense anxietyfocused on the possibility of having another one. By con-trast, people with generalized anxiety disorder mostlyexperience a general sense of diffuse anxiety and worryabout many potentially bad things that may happen; somemay also experience an occasional panic attack, but it is nota focus of their anxiety. Finally, people with obsessive-compulsive disorder experience intense anxiety or distressin response to intrusive thoughts or images and feel com-pelled to engage in compulsive, ritualistic activities thattemporarily help to reduce the anxiety. It is also importantto note that many people with one anxiety disorder willexperience at least one more anxiety disorder and/ordepression either concurrently or at a different point intheir lives (e.g., Brown & Barlow, 2002; Kessler, Berglund,et aI., 2005c; see also Developments in Thinking 7.2).

Given these commonalities across the anxiety disor-ders, it should come as no surprise that there are someimportant similarities in the basic causes of these disor-ders (as well as many differences). Among biologicalcauses, we will see that there are modest genetic contribu-tions to each of these disorders, and that at least part ofthe genetic vulnerability may be nonspecific, or commonacross the disorders (e.g., Barlow, 2002a). The commongenetic vulnerability is manifested at a psychological levelby the personality trait called neuroticism-a proneness toexperience negative mood states. The brain structures

most centrally involved are generally in the limbic system(often known as the emotional brain), and the neurotrans-mitter substances that are most centrally involved areGABA, norepinephrine, and serotonin (see Chapter 3).

Among common psychological causes, we will see thatclassical conditioning of fear/panic and/or anxiety to arange of stimuli plays a prominent role in most of thesedisorders (Mineka & Zinbarg, 1996, 2006). In addition,people who have perceptions of a lack of control over theirenvironments and/or their own emotions seem more vul-nerable to developing anxiety disorders. The developmentof such perceptions of un controllability depends heavilyon the social environment people are raised in (Chorpita &Barlow, 1998; Mineka & Zinbarg, 1996). Finally, the socio-cultural environment that people are raised in also hasprominent effects on the kinds of things people becomeafraid of, or anxious about. Moreover, parenting styles cansignificantly influence the likelihood that children willdevelop phobic fears and other anxiety disorders (e.g.,Craske & Waters, 2005; Rapee, 2002). Ultimately what wemust strive for is a good biopsychosocial understanding ofhow all these different kinds of causes interact with oneanother in the development of these disorders. Now wewill turn to a more detailed discussion of each disorder tohighlight both their common and distinct features, as wellas what is known about their causes.

Finally, there are many commonalities across the effec-tive treatments for these different anxiety disorders, as wewill see (e.g., Barlow, 2002a, 2004). For each disorder, grad-uated exposure to feared cues, objects, and situations-until fear/anxiety begins to habituate-constitutes thesingle most powerful therapeutic ingredient. Further, forcertain disorders the addition of cognitive-restructuringtechniques can provide added benefit, although for otherdisorders the addition of these techniques does not seem tobe especially beneficial. What these cognitive-restructuringtechniques for different disorders have in common is thatthey help the individual understand his or her distortedpatterns of thinking about anxiety-related situations andhow these patterns can be changed. Medications can alsobe useful for all disorders except specific phobias, andnearly all tend to fall into two primary medication cate-gories: benzodiazepines (known as anti-anxiety drugs)and antidepressants. The advantages of behavioral and cog-nitive-behavioral treatments over medications are that theyproduce much lower relapse rates than medications oncethey are discontinued, and they do not have unpleasant sideeffects that medications often have.

We start with the phobic disorders, which are are themost common anxiety disorders. A phobia is a persistentand disproportionate fear of some specific object or situ-ation that presents little or no actual danger and yet leadsto a great deal of avoidance of these feared situations. Aswe will see in DSM-IV-TR, there are three main cate-gories of phobias: (1) specific phobia, (2) social phobia,and (3) agoraphobia.

In ReVIew~ What is the central feature of all anxiety

disorders? That is, what do they have incommon?

~ What differentiates the anxiety disordersfrom one another?

~ What are some common kinds of biologicaland psychosocial causes of the differentanxiety disorders?

~ What is the most important commonalityacross effective psychosocial treatments forthe anxiety disorders?

SPECIFIC PHOBIASA person is diagnosed as having a specific phobia if sheor he shows strong and per-sistent fear that is excessiveor unreasonable and is trig-gered by the presence of aspecific object or situation(see DSM table on page 184).When individuals with spe-cific phobias encounter aphobic stimulus, they oftenshow an immediate fearresponse that often resem-bles a panic attack exceptfor the existence of a clearexternal trigger (APA,DSM-IV-TR, 2000). Notsurprisingly, such individu-als go to great lengths toavoid encounters with theirphobic stimulus and some-times even avoid seeminglyinnocent representations ofit such as photographs ortelevision images. For exam-ple, claustrophobic personsmay go to great lengths toavoid entering a closet or anelevator, even if this meansclimbing many flights ofstairs or turning down jobsthat might require them totake an elevator. This avoid-ance is a cardinal character-istic of phobias; it occursboth because the phobic

People with claustrophobia may findelevators so frightening that they goto great lengths to avoid them. Ifforsome reason they have to take anelevator, they will be very frightenedand may have thoughts about theelevator falling, the doors neveropening, or there not being enoughair to breathe.

response itself is so unpleasant and because of the phobicperson's irrational appraisal of the likelihood that somethingterrible will happen. Table 6.1 lists the five subtypes of spe-cific phobias in DSM -IV- TR, along with some examples.

The following case is typical of specific phobia:

Mary, a married mother of three, was 47 at the time shefirst sought treatment for both claustrophobia and acro-phobia. She reported having been intensely afraid ofenclosed spaces and of heights since her teens. Sheremembered having been locked in closets by her oldersiblings when she was a child; the siblings also confinedher under blankets to scare her and added to her fright byshowing her pictures of spiders after releasing her fromunder the blankets. She traced the onset of her claustro-phobia to those traumatic incidents, but she had no ideawhy she was afraid of heights. While her children hadbeen growing up, she had been a housewife and hadmanaged to live a fairly normal life in spite of her two spe·cific phobias. However, her children were now grown, andshe wanted to find a job outside her home. This was prov-ing to be very difficult, however, because she could nottake elevators and was not comfortable being on any-thing other than the first floor of an office building. More-over, her husband had for some years been working foran airline, which entitled him to free airline tickets. Thefact that Mary could not fly (due to her phobias) hadbecome a sore point in her marriage because they bothwanted to be able to take advantage of these free ticketsto see distant places. Thus, although she had had thesephobias for many years, they had become truly disablingonly in recent years as her life circumstances hadchanged and she could no longer easily avoid heights orenclosed spaces.

DSM-IV-TR

A. Marked or persistent fear that is excessive orunreasonable, cued by the presence or anticipation of aspecific object or situation.

B. Exposure to phobic stimulus almost invariably provokesan immediate anxiety response or panic attack.

C. Person recognizes that the fear is excessive orunreasonable.

D. Phobic situation avoided or endured with intense anxietyor distress.

E. Symptoms interfere significantly with normal functioning,or there is marked distress about the phobia.

F. Duration of at least 6 months.

Source: Adapted with permission from the Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition,TextRevision(Copyright 2000). American Psychiatric Association.

Although people who suffer from phobias usuallyknow that their fears are somewhat irrational, they saythat they cannot help themselves. If they attempt toapproach the phobic situation, they are overcome withfear or anxiety, which may vary from mild feelings ofapprehension and distress (usually while still at some dis-tance) to full-fledged activation of the fight-or-flightresponse. Regardless of how it begins, phobic behaviortends to be reinforced because every time the person witha phobia avoids a feared situation, his or her anxietydecreases. In addition, the benefits derived from being dis-abled, such as increased attention, sympathy, and somecontrol over the behavior of others, may also sometimesreinforce a phobia.

Phobia TypeAnimalNatural EnvironmentBlood- Injection- InjurySituationalOther

ExamplesSnakes, spiders, dogs, insects, birdsStorms, heights, waterSeeing blood or an injury, receiving an injection, seeing a person in a wheelchairPublic transportation, tunnels, bridges, elevators, flying, driving, enclosed spacesChoking, vomiting, "space phobia" (fear of falling down if away from walls or othersupport)

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (Copyright2000). American Psychiatric Association.