MODULE 3

ANXIETY DISORDERS
Module Outline
Fear and anxiety;
Anxiety Disorders -Specific Phobias, Social Phobias, Panic disorder,
Agoraphobia, Generalized Anxiety Disorder and separation anxiety disorder.
Causal factors: Biological and psychosocial causal factors.
Treatment and outcome.
Butcher, J. N., Hooley, J. M., &Mineka, S. (2015). Abnormal Psychology
(16thed.)Pages:162-210

Fear is a basic, primal emotion that serves as a natural response to a perceived threat or danger. It
is a vital part of the human experience and plays a crucial role in survival.

Anxiety is a complex and multi-layered emotional state characterized by feelings of unease,

apprehension, worry, or fear about future events or situations.

Fear

Fear is a basic emotion that involves activation of the “fight-or-flight” response of the auto-
nomic nervous system.

This is an almost instantaneous reaction to any imminent threat such as a dangerous

predator or someone pointing a loaded gun.

The fight-or-flight is a physiological reaction that occurs in response to a perceived harmful

event, attack, or threat to survival.

When the fear response occurs in the absence of any obvious external danger, we say the person
has had a spontaneous or uncured panic attack.

Fear and panic have three components:

1. cognitive/subjective components (“I feel afraid/terrified”; “I’m going to die”)

2. Physiological components (such as increased heart rate and heavy breathing)
3. Behavioral components (a strong urge to escape or flee)

Anxiety

In contrast to fear and panic, the anxiety response pattern is a complex blend of unpleasant
emotions and cognitions that is both more oriented to the future and much more diffuse than fear.
But like fear, it has not only cognitive/subjective components but also physiological and
behavioural components.

At the cognitive/subjective level, anxiety involves negative mood, worry about possible
future threats or danger, self-preoccupation, and a sense of being unable to predict the future threat
or to control it if it occurs.

Overview of the Anxiety Disorders And Their Commonalities

Anxiety disorders all have unrealistic, irrational fears or anxieties of disabling intensity as their
principal and most obvious manifestation. Among the disorders recognized in DSM-5 are:

1. Specific phobia
2. Social anxiety disorder (social phobia)
3. Panic disorder
4. Agoraphobia
5. Generalized anxiety disorder

Specific Phobias

A person is diagnosed as having a specific phobia if she or he shows strong and persistent
fear that is triggered by the presence of a specific object or situation.

people with specific phobias recognize that their fear is somewhat excessive or
unreasonable although occasionally they may not have this insight.

Animal phobia: Examples include the fear of dogs, snakes, insects. Animal phobias are the
most common specific phobias.

Situational phobias: These involve a fear of specific situations, such as flying, riding in a
car or on public transportation, driving, going over bridges or in tunnels, or of being in a closed-
in place, like an elevator.

Natural environment phobias: Examples include the fear of storms, heights, or water.

Other phobias: These include a fear of falling down, fear of loud sounds, choking and
vomiting.

Blood-Injection-Injury Phobia, is a specific type of phobia where a person has an intense

and irrational fear of blood, needles, injections, or medical procedures involving these.

It's not just a regular dislike or nervousness, but a strong reaction that can cause anxiety,
panic attacks, and avoidance of situations involving these things. People with this phobia might
feel lightheaded, dizzy, or even faint when confronted with blood or needles.
Criteria of specific phobia in DSM 5
1. Marked fear or anxiety about specific object or situation

2. Phobic object provokes immediate fear

3. The phobic object is actively avoided with intense fear or anxiety

4. The fear is out of proportion to the actual danger caused by the object or situation or sociocultural
context ie; irrational fear

5. The fear, anxiety or avoidance is persistent typically 6 months or more

6. The fear cause clinically significant distress in social, occupational or other important area of
functioning

7. Symptoms associated with panic like symptoms or the disturbance not better explained by
symptoms of another mental disorder

Symptoms of specific phobia –

Physicalsymptoms

Racing heart

Difficulty in breathing

Sweating

Dry mouth

Chest pain

Emotional symptoms

• Feeling overwhelming
• Fear of losing control
• Feeling an intense need to escape
• Knowing that your fear is irrational but feeling powerless

Prevalence, Age of Onset, and Gender Differences

A lifetime prevalence rate of about 12 percent.

The relative gender ratios vary considerably according to the type of specific phobia, but
phobias are always considerably more common in women than in men.
 Animal phobias usually begin in childhood, as do blood-injection-injury phobias and dental
phobias.

Other phobias such as claustro-phobia and driving phobia tend to begin in adolescence or
early adulthood

Psychological Causal Factors

Specific phobias can arise from a mix of psychological factors.

They also depend on individual differences that make some people more prone to
developing fears.

The causes can include unresolved emotional issues, traumatic experiences, and variations
in how people respond to fear-inducing situations.

Psychoanalytic Viewpoint
From a psychoanalytic viewpoint, specific phobias can be understood in terms of unconscious
conflicts and unresolved psychological issues.

According to psychoanalysis, specific phobias might arise as a result of repressed fears or anxieties
that are projected onto an external object or situation.

These fears could be rooted in early childhood experiences or traumas.

The phobic object or situation serving as a symbol for the repressed psychological conflicts
originating from the id.

Phobias as Learned Behaviour

According to this perspective, phobic behaviors can be acquired through the process of
classical conditioning.

A neutral stimulus becomes associated with a traumatic or painful event, leading to the
development of fear.

If a person experiences a distressing event in the presence of a specific object or situation,

they can come to associate that fear response with the previously neutral stimulus.

Vicarious Conditioning

People can develop phobic fears by watching someone else exhibit intense fear or distress
when faced with a specific object or situation. This form of learning is known as vicarious or
observational conditioning.
 For example, if you see a friend reacting with extreme fear to spiders, you might start
feeling fearful of spiders yourself, even if you weren't initially afraid.

Individual differences in learning

Some life experiences may serve as risk factors and make certain people more vulnerable
to phobias than others, and other experiences may serve as protective factors for the development
of phobias. (eg - fear of dogs)

Our cognitions, or thoughts, can help maintain our phobias once they have been developed.

Overall, the development and maintenance of phobias are influenced by a combination of

personal experiences, cognitive processes, and environmental factors. Understanding these
elements helps shed light on why certain individuals are more prone to phobias and how these
irrational fears persist over time.

Biological Causal Factors

The speed and strength of fear conditioning are affected by genetic and temperamental factors.
That is, people are more or less inclined to develop anxieties and phobias based on their genetic
composition, temperament, and personality.

For example, a large female twin study found that monozygotic (identical) twins were more likely
to share animal phobias and situational phobias (such as of heights or water) than were dizygotic
(no identical) twins. Very similar results were later also found for men.

Treatments

Exposure therapy - For certain phobias such as small-animal phobias, flying phobia and
blood-injury phobia, exposure therapy is often highly effective.

Cognitive restructuring techniques – it aims to change negative thought patterns and

behaviors related to the phobia.

Medications - In some cases, medications such as anti-anxiety drugs or beta-blockers may be

prescribed to help manage the symptoms of anxiety associated with the phobia.
Social phobia

Social phobia (or social anxiety disorder), as the DSM-5 describes it, is characterized by
disabling fears of one or more specific social situations (such as public speaking, urinating in a
public bathroom, or eating or writing in public).

Social phobia is a type of anxiety disorder. People who have social phobia experience
extreme and persistent anxiety associated with social or performance situations.

Because of their fears, people with social phobias either avoid these situations or undergo
them with great distress. Strong fear of public speaking is the single most common type of social
phobia.

DSM-5 also identifies two subtypes of social phobia,

- public speaking
- non performance situations (such as eating in public).

Prevalence, Age of Onset, and Gender Differences

✓ 12 percent of the population will qualify for a diagnosis of social phobia

✓ More common among women than men (about 60 percent of sufferers are women)
✓ Social phobias typically begin later, during early or middle adolescence or certainly
by early adulthood
✓ Two-thirds of people with social phobia suffer from one or more additional anxiety
disorders and about 50 percent also suffer from a depressive disorder at the same
time.
✓ Approximately one-third abuse alcohol to reduce their anxiety and help them face
the situations they fear.
✓ Because of their distress and avoidance of social situations, people with social
phobia, on average, have lower employment rates and lower socioeconomic status.
✓ Finally, the disorder is remarkably persistent, with one study finding that only 37
percent recovered spontaneously over a 12-year period.

Criteria for Social Anxiety Disorder

(Social Phobia)

A. Marked fear or anxiety about one or more social situations

B. The individual fears that he or she will act in a way or show anxiety symptoms that will
be negatively evaluated.
C. The social situations almost always provoke fear or anxiety.
D. The social situations are avoided or tolerated with intense fear or anxiety.
 E. The fear or anxiety is out of proportion to the actual threat posed by the social situation
and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not caused by the physiological effects of a substance
(e.g., a drug of abuse, a medication) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental
disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns
or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Psychological Causal Factors

It is important to recognize that not everyone who experiences direct or vicarious

conditioning in social situations, or who grows up with socially avoidant parents, or who
has problems with peers, develops social phobia.
This is because individual differences in experiences play an important role in who
develops social phobia, as is the case with specific phobias.

Perceptions of Uncontrollability and Unpredictability

Being exposed to uncontrollable and unpredictable stressful events (such as parental

separation and divorce, family conflict, or sexual abuse) may play an important role in the
development of social phobia.
Perceptions of uncontrollability and unpredictability often lead to submissive and
unassertive behavior, which is characteristic of socially anxious or phobic people.

Social Fears and Phobias in an Evolutionary Context

Our fear of predators makes us run (fight-or-flight).

Social fears come from dominance hierarchies, where losers stay and show fear.
People with social anxiety might stay in frightening situations because of this.
They may also be more sensitive to angry faces and criticism.

Cognitive Biases

Cognitive factors, including thoughts, beliefs, and interpretations, play a significant role in
both the onset and maintenance of social phobia.
Beck and Emery (1985) suggested that people with social phobia tend to expect that other
people will reject or negatively evaluate them.
Biological Causal Factors
Genetic and Temperamental Factors

Behaviorally inhibited infants who are easily distressed by unfamiliar stimuli and who are
shy and avoidant are more likely to become fearful during childhood and, by adolescence,
to show increased risk of developing social phobia.
Results from several studies, 30 percent of the variance in problem to social phobia is due
to genetic factors.

Treatments

Cognitive-behavior therapy
- As for specific phobias, behavioral treatments were developed first and generally
involve prolonged and graduated exposure to social situations that evoke fear.
Medications
Unlike specific phobias, social phobias can also sometimes be treated with medications.
The most effective and widely used medications are several categories of antidepressants
(including the monoamine oxidase inhibitors [MAOIs] and the selective serotonin reuptake
inhibitors [SSRIs].

PANIC DISORDER
 Panic disorder is a type of anxiety disorder characterized by recurrent and unexpected panic
attacks, as well as ongoing worry and anticipatory anxiety about experiencing further
attacks.
 Panic attacks are sudden and intense episodes of extreme fear or discomfort that often come
on unexpectedly and reach a peak within minutes.
 These attacks can involve a range of physical and psychological symptoms, such as rapid
heartbeat, shortness of breath, sweating, trembling, dizziness, chest pain, and a sense of
impending doom.
 Panic disorder is characterised by the “out of the blue” panic attacks, which are recurrent,
unexpected attacks and the person must be persistently concerned or worried about having
another attack for at least a month. For an attack to meet the criteria of a full-blown episode,
the person must have an abrupt onset of at least 4 of 13 symptoms given in DSM-V criteria.
The panic episode peaks at 10 minutes, lasts for about 20 to 30 minutes maximum but not
later than an hour.
 For a diagnosis of panic disorder, an individual must have experienced recurrent panic
attacks that occur "out of the blue," meaning they are not consistently triggered by a
specific situation or object.
 Criteria for Panic Disorder
 A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or
intense discomfort that reaches a peak within minutes, and during which time four (or
more) of the following symptoms occur:

1. Palpitations, pounding heart, or accelerated heart rate.

2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Numbness or tingling sensations.
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.
 B. At least one of the attacks has been followed by 1 month (or more) of one or both of the
following:

1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing
control, having a heart attack, “going crazy”).

2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to
avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
 C. The disturbance is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism,
cardiopulmonary disorders).
 D. The disturbance is not better explained by another mental disorder (e.g., the panic
attacks do not occur only in response to feared social situations, as in social anxiety
disorder; in response to circumscribed phobic objects or situations, as in specific phobia;
in response to obsessions, as in obsessive-compulsive disorder; in response to reminders
of traumatic events, as in posttraumatic stress disorder; or in response to separation from
attachment figures, as in separation anxiety disorder).
 AGORAPHOBIA
 Historically, agoraphobia was thought to involve a fear of the agora—the Greek word for
“open gathering place.” In agoraphobia the most commonly feared and avoided situations
include streets and crowded places such as shopping malls, movie theaters, and stores.
Standing in line can be particularly difficult. Sometimes, agoraphobia develops as a
complication of having panic attacks in one or more such situations.
 People with agoraphobia are also frightened by their own bodily sensations, so they also
avoid activities that will create arousal such as exercising, watching scary movies, drinking
caffeine, and even engaging in sexual activity.
 Agoraphobia is a frequent complication of panic disorder. However, many patients with
agoraphobia do not experience panic. Recognizing this, in DSM-5 agoraphobia is now
listed as a distinct disorder. The most recent estimate of the lifetime prevalence of
agoraphobia without panic is 1.4 percent (Kessler, Chiu, et al., 2006).
 As agoraphobia first develops, people avoid places where they've had panic attacks. Over
time, they also start avoiding other places where panic attacks could happen.
 In moderately severe cases, people with agoraphobia may be anxious even when they go
outside their homes alone.
 In very severe cases, agoraphobia is an utterly disabling disorder in which a person cannot
go beyond the narrow boundaries of home or even particular parts of the home.
Criteria for agoraphobia
 A. Marked fear or anxiety about two (or more) of the following five situations:

1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).

2. Being in open spaces (e.g., parking lots, marketplaces, bridges).

3. Being in enclosed places (e.g., shops, theaters, cinemas).

4. Standing in line or being in a crowd.

5. Being outside of the home alone.

 B. The individual fears or avoids these situations because of thoughts that escape might be
difficult or help might not be available in the event of developing panic-like symptoms or
other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of
incontinence).

C. The agoraphobic situations almost always provoke fear or anxiety.

D. The agoraphobic situations are actively avoided, require the presence of a companion, or are
endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations
and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.

H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is present,
the fear, anxiety, or avoidance is clearly excessive.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental
disorder—for example, the symptoms are not confined to specific phobia, situational type; do not
involve only social situations (as in social anxiety disorder); and are not related exclusively to
obsessions (as in obsessive-compulsive disorder), perceived defects or flaws in physical
appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic
stress disorder), or fear of separation (as in separation anxiety disorder).
 Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s
presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be
assigned.
Prevalence, Age of Onset, and Gender Differences
 4.7 percent of the adult population has had panic disorder with or without agoraphobia
 Panic disorder with or without agoraphobia often starts in the late teenage years, but the
average age of onset is 23 to 34 years. However, it can begin, especially for women, in a
person’s 30s or 40s.
 Once panic disorder develops, it tends to have a chronic and disabling course.
 Panic disorder is about twice as prevalent in women as in men. Agoraphobia also occurs
much more frequently in women than in men.
 Among people with severe agoraphobia, approximately 80 to 90 percent are female.
 The main reason for the big difference in agoraphobia between genders is because of
society and culture.
 In our culture, and in many others too, it's seen as okay for women with panic to avoid their
fears and have someone with them. But men are often expected to face their fears and be
strong because of how society views them.
 some evidence indicates that men with panic disorder might use smoking or drinking to
deal with panic attacks instead of avoiding going outside.
Comorbidity with Other Disorders
 The National Comorbidity Survey-Replication found that 83 percent of people with panic
disorder have at least one comorbid disorder. Most commonly these include generalized
anxiety disorder, social phobia, specific phobia, PTSD, depression, and substance-use
disorders (especially smoking and alcohol dependence. It is estimated that 50 to 70 percent
of people with panic disorder will experience serious depression at some point in their
lives. They may also meet criteria for dependent or avoidant personality disorder.
  Recent studies have found that panic disorder is associated with increased risk for suicidal
ideation and attempts independent of its relationship with comorbid disorders.
The Timing of a First Panic Attack
 An anxiety attack comes on suddenly. In most cases, symptoms begin, reach their climax
within 10 minutes, and then quickly go away.
 the first one frequently occurs following feelings of distress or some highly stressful life
circumstance such as loss of a loved one, loss of an important relationship, loss of a job, or
criminal victimization
 approximately 80 to 90 percent of clients report that their first panic attack occurred after
one or more negative life events
 23 percent of adults have experienced at least one panic attack in their lifetimes
 People who have other anxiety disorders or major depression often experience occasional
panic attacks as well
Biological Causal Factors
1. Genetic Factors
 According to family and twin studies, panic disorder has a moderate heritable component.
 33 to 43 percent of the variance in liability to panic disorder was due to genetic factors.
 People who are more prone to experiencing negative emotions like anxiety and depression
(a personality trait known as neuroticism) are more likely to have this genetic vulnerability
for panic disorder
 Some specific genes (genetic polymorphisms) have been identified as being related to
panic disorder. These genes might work together with certain types of stressful life events
to increase the risk of developing panic disorder.

2. Panic and the Brain

 the main troublemaker in panic attacks is a part of the brain called the "amygdala." It's like
a control center for fear.
 When it gets active, it sets off a chain reaction. It makes our body respond in different ways
like making our heart race, and it triggers other automatic reactions.
 So, panic attacks happen because the amygdala gets super active and starts a chain reaction
in our body.
 In short, panic attacks are mainly caused by the amygdala in our brain, which acts like a
fear control center, and it sets off reactions in our body.

3. Biochemical Abnormalities
 In panic disorder, there are several biochemical abnormalities that play a role in triggering
and sustaining the symptoms of panic attacks. These abnormalities involve certain
chemicals and neurotransmitters in the brain.
  Norepinephrine is a neurotransmitter that helps regulate emotions and stress responses. In
panic disorder, there can be an overactivity of norepinephrine in certain brain areas,
particularly the amygdala.
 This heightened norepinephrine activity can lead to increased sensitivity to fear and anxiety
triggers.
 In panic disorder, there might not be enough of a calming chemical called GABA in the
brain. This can make it harder for the brain to slow down its busy activity, causing more
anxiety and panic feelings.
 Gamma-aminobutyric acid (GABA) is a neurotransmitter that helps calm down brain
activity. In panic disorder, there might be a deficiency in GABA.
 This shortage can lead to heightened anxiety and difficulty calming your thoughts.
 Panic attacks can cause the body to produce more lactate and create an acidic state. This
can trigger physical sensations like a racing heart or shortness of breath.
 Some people with panic attacks are very sensitive to changes in carbon dioxide levels in
their body. Small changes in breathing can cause panic-like symptoms.
Psychological Causal Factors
[Link] Learning Theory of Panic Disorder

Learning theory argues that the person goes through two types of conditioning – interoceptive and
exteroceptive. The initial attacks become related to the internal and external cues which actually
condition them to anxiety. The more intense the anxiety, more robust the conditioning will occur.
The exteroceptive and interoceptive conditioning can range from heart palpitations, dizziness to
social places like shopping malls. Most of the time a panic attack is “out of the blue” but it is the
internal cues that the person was unconsciously conditioned to generate anxiety (Acheson, 2012).

2. Cognitive Theory of Panic

 People who suffer from panic attacks have a higher sensitivity to their bodily sensations.
As it is a sign of their panic attack, they assign a worry to that bodily sensation along with
the perceived threat of having another panic attack. This leads to more bodily sensations
which are then interpreted as catastrophic threats, resulting into a vicious circle of having
a panic attack. The model proposes that these catastrophic thoughts become automatic soon
after first or second panic attack and escalate the condition.

[Link] Sensitivity and Perceived Control

 Anxiety sensitivity means that some people have a tendency to notice certain bodily
sensations with harmful consequences. These people are more prone to develop panic
disorder. They say statements like “When I feel dizzy, I worry that I might faint”. In
addition to this sensitivity, there is a term called perceived control which means that if there
is an element of safety around a person who is suffering from panic disorder, the
susceptibility of a panic attack becomes low.
4. Safety Behaviours and Persistence of Panic
 Some people may have a panic attack four or five times a week for 20 years, each time
thinking that they might have a heart attack and yet they never do. They have these “safety
behaviours” in response to their perceived threat of having a heart attack or going crazy.
But when the threat does not become a harmful consequence, they do not have the ideal
realisation and persistently worry about having a panic attack.

5. Cognitive Biases and Maintenance of Panic

• People with panic disorder have cognitive biases towards threatening circumstances or
information. They process that threatening information a lot easily and quickly than the
other types of information. They have a tendency to selectively attend to these threatening
circumstances and retrieve such information from long term memory. This leads to an
unconscious cue that automatically provoke the person to have another attack.
Treatments
[Link]
 anxiolytics (antianxiety medications) from the benzodiazepine category such as alprazolam
(Xanax) or clonazepam (Klonopin).
 Antidepressants (including primarily the tricyclics, the SSRIs, and most recently the
serotonin-norepinephrine reuptake inhibitors—SNRIs).

[Link] and Cognitive-Behavioral Treatments

 Basic premise: Thoughts, feelings and behaviors are inter-related, so altering one can help
to alleviate problems.
 Essence of therapy: Cognitive therapy aims to help the person identify, challenge, and
modify dysfunctional ideas related to panic symptoms (e.g., catastrophic consequences of
bodily sensations). Avoidance of panic and panic-cues is targeted through exposure
exercises, including both in vivo (e.g., going to crowded places or driving in traffic) and
interoceptive (e.g., bodily sensations) exposures.
 Length: Approx. 12-16 sessions

GENERALIZED ANXIETY DISORDER

Anxiety is an adaptive emotion that helps us plan and prepare for possible threat.
Some people, anxiety and worry about many different aspects of life including minor events
becomes chronic, excessive, and unreasonable. In these cases, generalized anxiety disorder (GAD)
formerly known as free-floating anxiety may be diagnosed.
Free-floating anxiety refers to a type of anxiety that is not attached to any specific or identifiable
cause or trigger. It's a general feeling of unease, worry, or apprehension that seems to be present
without any particular reason.
Generalized Anxiety Disorder (GAD) is characterized by persistent and excessive worry about a
number of different things.

Muscle tension, restlessness, and difficulty concentrating are all symptoms that people with
generalized anxiety disorder may have.
Such individuals also worry excessively and are hyper vigilant for possible signs of threat in their
environment.
People suffering from generalized anxiety disorder is that they live in a relatively constant future-
oriented mood state of anxious apprehension, chronic tension, worry, and diffuse uneasiness that
they cannot control.
CRITERIA FOR GAD
A. Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number
of events or activities.
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with
at least some symptoms having been present for more days than not for the past 6 months):
Note: Only one item is required in children.
1. Restlessness or feeling keyed up or on edge. (Feeling "keyed up" is an expression used to
describe a state of heightened alertness, tension, or nervousness)
2. Being easily fatigued.

3. Difficulty concentrating or mind going blank.

4. Irritability.
5. Muscle tension

6. Sleep disturbance (difficulty falling or staying asleep, restless, unsatisfying sleep).

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication) or another medical condition (e.g., hyperthyroidism).
F. The disturbance is not better explained by another mental disorder (e.g., panic disorder,
obsessive-compulsive disorder, separation anxiety disorder, posttraumatic stress disorder, illness
anxiety disorder, or in schizophrenia or delusional disorder).
Prevalence, Age of Onset, and Gender Differences
Age of onset is often difficult to determine because 60 to 80 percent of people with GAD remember
having been anxious nearly all their lives and many others report a slow and insidious onset.

GAD often develops in older adults, for whom it is the most common anxiety disorder.
GAD is approximately twice as common in women as in men.
3 percent of the population suffers from GAD in any 1-year period and 5.7 percent at some point
in their lives. It also tends to be chronic.
Many people did not fully overcome their condition, and even among those who initially got better,
a significant portion experienced the return of their symptoms -

However, after age 50 the disorder seems to disappear for many people. If it disappears it tends to
be replaced by a somatic symptom disorder and characterized by physical symptoms and health
concerns.

Comorbidity with Other Disorders

Many people with GAD experience occasional panic attacks without qualifying for a
diagnosis of panic disorder. Nor is it surprising that excessive use of tranquilizing drugs, sleeping
pills, and alcohol often complicates the clinical picture in generalized anxiety disorder.

PSYCHOLOGICAL CAUSAL FACTORS

The Psychoanalytic View Point
According to this viewpoint, generalized or free-floating anxiety results from an unconscious
conflict between ego and id impulses that is not adequately dealt with because the person’s defense
mechanisms have either broken down or have never developed.
Freud believed that it was primarily sexual and aggressive impulses that had been either blocked
from expression or punished upon expression that led to free-floating anxiety.
Defense mechanisms may become overwhelmed when a person experiences frequent and extreme
levels of anxiety, as might happen if id impulses are frequently blocked from expression.
According to this view, the primary difference between specific phobias and free-floating anxiety
is that in phobias, the defense mechanisms of repression and displacement of an external object or
situation actually work, whereas in free-floating anxiety these defense mechanisms do not work,
leaving the person anxious nearly all the time.

Perceptions of uncontrollability and unpredictability

People with GAD may have a history of experiencing many important events in their lives as
unpredictable or uncontrollable.
For example, having a boss or spouse who has unpredictable bad moods or outbursts of temper for
seemingly trivial reasons might keep a person in a chronic state of anxiety.
Although the unpredictable and uncontrollable events involved in GAD are generally not as severe
and traumatic as those involved in the origins of PTSD.
people with GAD may be more likely to have had a history of trauma in childhood than individuals
with several other anxiety disorders.
people with GAD clearly have far less tolerance for uncertainty than non-anxious controls and
then people with panic disorder.
the greater the intolerance of uncertainty, the more severe the GAD.
A sense of mastery: the possibility of immunizing against anxiety
A person’s history of control over important aspects of his or her environment is another important
experiential variable strongly affecting reactions to anxiety-provoking situations.
In human children, experiences with control and mastery often also occur in the context of the
parent–child relationship and so parents’ responsiveness to their children’s needs directly
influences their children’s developing sense of mastery. Unfortunately, parents of anxious children
often have an intrusive, over controlling parenting style, which may serve only to promote their
children’s anxious behaviors by making them think of the world as an unsafe place in which they
require protection and have little control themselves.
The central role of worry and its positive functions
The worry process is now considered the central feature of GAD.
Several of the benefits that people with GAD most commonly think derive from worrying are:
*Superstitious avoidance of catastrophy (“Worrying makes it less likely that the feared event will

occur”).

*Avoidance of deeper emotional topics (“Worrying about most of the things I worry about is a

way to distract myself from worrying about even more emotional things, things that I don’t want

to think about”).

*Coping and preparation (“Worrying about a predicted negative event helps me to prepare for its
occurrence”).
There is some evidence that for a subset of people with GAD, these positive beliefs about worry
play a key role in maintaining high levels of anxiety and worry, especially in early phases of the
development of GAD.
When people with GAD worry, their emotional and physiological responses to aversive imagery
are actually suppressed.
The negative consequences of worry
worry itself is certainly not an enjoyable activity and can actually lead to a greater sense of danger
and anxiety (and lower positive mood) because of all the possible catastrophic outcomes that the
worrier envisions.
people who worry about something tend subsequently to have more negative intrusive thoughts
than people who do not worry.
For example, Wells and Papageorgiou (1995) had people watch a gruesome film. Following the
film, some were told to relax and settle down, some were told to imagine the events in the film,
and some were told to worry in verbal form about the film. Over the next several days, people in
the worry condition showed the most intrusive images from the film.
Attempts to control thoughts and worry may paradoxically lead to increased experience of
intrusive thoughts and enhanced perception of being unable to control them.
These intrusive thoughts can serve as further trigger topics for more worry, and a sense of
uncontrollability over worry may develop in people caught in this cycle that occurs in GAD.
Cognitive biases for threatening information
Anxious people tend to preferentially allocate their attention toward threatening cues when both
threat and non-threat cues are present in the environment.
If a person is already anxious, having her or his attention automatically focused on threat cues in
the environment would seem only to maintain the anxiety or even make it worse.
Several studies have shown that training non-anxious individuals to show an attentional bias
toward threat leads to their showing a greater increase in anxiety in stressful situations.
Generally anxious people are also more likely than non-anxious people to think that bad things are
likely to happen in the future and they have a much stronger tendency to interpret ambiguous
information in a threatening way.
For example, when clinically anxious subjects read a series of ambiguous sentences, they are more
likely than non-anxious controls to remember the threatening interpretation of each sentence. This
tendency to interpret ambiguous information negatively has actually been shown to increase
anxiety in several situations, including watching a stressful video.

In summary, several psychosocial variables seem to promote the onset of generalized

anxiety as well as its maintenance. Experience with unpredictable and/or uncontrollable life events
may create a vulnerability to anxiety and promote current anxiety. People also believe that worry
serves a number of important functions, and it may actually be reinforced because it dampens
physiological arousal. But worry also has some negative consequences, including the fact that
worry begets further worry and creates a sense of perceived uncontrollability over the worry
process, which further enhances anxiety. Finally, anxiety is associated with an automatic
attentional and interpretive bias toward threatening information.
BIOLOGICAL CAUSAL FACTORS
Genetic factors
15 to 20 percent of the variance in liability to GAD is due to genetic factors.
The evidence is increasingly strong that GAD and major depressive disorder have a common
underlying genetic predisposition
Neurotransmitter and neurohormonal abnormalities
A Functional Deficiency in GABA - highly anxious people have a kind of functional deficiency
in GABA, which ordinarily plays an important role in the way our brain inhibits anxiety in stressful
situations.
The Corticotropin-releasing hormone System and Anxiety - An anxiety-producing hormone
called corticotrophin releasing hormone (CRH) has also been strongly implicated as playing an
important role in generalized anxiety and depression.
The CRH hormone may play an important role in generalized anxiety through its effects on the
bed nucleus of the stria terminalis (an extension of the amygdala), which is now believed to be an
important brain area mediating generalized anxiety.
TREATMENTS
Medications
Medications from the benzodiazepine (anxiolytic) category such as Xanax or Klonopin are used
and misused—for tension relief, reduction of other somatic symptoms, and relaxation.
A newer medication called buspirone (from a different medication category) is also effective, and
it neither is sedating nor leads to physiological dependence.
Several categories of antidepressant medications are also useful in the treatment of GAD.
Cognitive Behavioral Therapy
It usually involves a combination of behavioral techniques, such as training in applied muscle
relaxation, and cognitive restructuring techniques aimed at reducing distorted cognitions and
information-processing biases associated with GAD as well as reducing catastrophizing about
minor events.

SEPARATION ANXIETY DISORDER

Separation anxiety disorder, classified under anxiety disorders in DSM-5, is the most common of
the childhood anxiety disorders, reportedly occurring in 2 to 41 percent of children in past
population health studies.
Children with separation anxiety disorder exhibit unrealistic fears, oversensitivity, self-
consciousness, nightmares, and chronic anxiety.
They lack self-confidence, are apprehensive in new situations, and tend to be immature for their
age. Such children are described by their parents as shy, sensitive, nervous, submissive, easily
discouraged, worried, and frequently moved to tears.
Typically, they are overly dependent, particularly on their parents.
The essential feature in the clinical picture of this disorder is excessive anxiety about separation
from major attachment figures, such as their mother, and from familiar home surroundings.
When children with separation anxiety disorder are actually separated from their attachment
figures, they typically become preoccupied with morbid fears, such as the worry that their parents
are going to become ill or die.
Separation anxiety is more common in girls, and the disorder is not very stable over time. However,
some children go on to exhibit school refusal problems (a fear of leaving home and parents to
attend school) and continue to have subsequent adjustment difficulties.
A disproportionate number of children with separation anxiety disorder also experience a high
number of other anxiety-based disorders such as phobia and obsessive – compulsive disorder.
Criteria for Separation Anxiety Disorder
A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those
to whom the individual is attached, as evidenced by at least three of the following:
1. Recurrent excessive distress when anticipating or experiencing separation from home or from
major attachment figures.
2. Persistent and excessive worry about losing major attachment figures or about possible harm to
them, such as illness, injury, disasters, or death.
3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being
kidnapped, having an accident, becoming ill) that causes separation from a major attachment
figure.
4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere
because of fear of separation.
5. Persistent and excessive fear of or reluctance about being alone or without major attachment
figures at home or in other settings.
6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a
major attachment figure.
7. Repeated nightmares involving the theme of separation.
8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting)
when separation from major attachment figures occurs or is anticipated.
B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents
and typically 6 months or more in adults.
C. The disturbance causes clinically significant distress or impairment in social, academic,
occupational, or other important areas of functioning.
D. The disturbance is not better explained by another mental disorder, such as refusing to leave
home because of excessive resistance to change in autism spectrum disorder; delusions or
hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted
companion in agoraphobia; worries about ill health or other harm befalling significant others in
generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.
Causal Factors in Anxiety Disorders
Number of causal factors have been emphasized in explanations of the childhood anxiety
disorders.
Although genetic factors have been thought to contribute to the development of anxiety disorders,
particularly obsessive-compulsive disorder, in children.
social and cultural factors are likely to be influential in resulting in anxiety disorders in children.
Parental behavior and family stress in minority families have been particularly noted as potential
influential factors in the origin of anxiety disorders in children.
The traumatic effect of experiences such as hospitalizations makes such children feel insecure and
inadequate.
The traumatic nature of certain life changes such as moving away from friends and into a new
situation can also have an intensely negative effect on a child’s adjustment.
Overanxious children often have the modeling effect of an overanxious and protective parent who
sensitizes a child to the dangers and threats of the outside world.
Indifferent or detached parents or rejecting parents also foster anxiety in their children.
The role that social-environmental factors might play in the development of anxiety-based
disorders. Cultures that favor inhibition, compliance, and obedience appear to increase the levels
of fear reported.
Last and Perrin (1993) reported that there are some differences between African American and
white children with respect to types of anxiety disorders.
Children who experience a sense of diminished control over negative environmental factors may
become more vulnerable to the development of anxiety than those children who achieve a sense
of efficacy in managing stressful circumstances.
TREATMENTS
Biologically Based Treatments - the efficacy of using fluoxetine in the treatment of a variety of
anxiety-based disorders and found the medication useful
Psychological Treatment – assertiveness training to provide help with mastering essential
competencies and desensitization to reduce anxious behavior.
Behavioral treatment approaches such as desensitization must be explicitly tailored to a child’s
particular problem.
Cognitive behavioral therapy has been shown to be highly effective at reducing anxiety symptoms
in young children.