Chapter 5

Question 1

Anxiety

Answer 1

Anxiety
- a negative mood state characterized by physical tension and apprehension about the future
- can be a subjective sense of unease, a set of behaviours (looking worried and anxious, fidgeting), or a physiological response originating in the brain and reflected in elevated heart rate and muscle tension.
- related to depression

Physical and intellectual performances are driven and enhanced by anxiety. Without it, very few of us would get much done.
anxiety is good for us, at least in moderate amounts. Psychologists have known for over a century that we perform better when we are a little anxious

Severe anxiety usually doesn’t go away
- even if we “know” we really have nothing to be afraid of, we remain anxious
- cannot seem to shake excessive fear

50% of individuals with anxiety disorders will present with one or more additional anxiety or depressive disorder

Question 2

Fear

Answer 2

Fear is an immediate alarm reaction to danger. Like anxiety, fear can be good for us.
- It protects us by activating a massive response from the autonomic nervous system (increased heart rate and blood pressure), which, along with our subjective sense of terror, motivates us to escape or attack.
- this emergency reaction is often called the flight-or-fight response.

Question 3

Anxiety vs Fear

Answer 3

Although not all emotion theorists agree, much evidence shows that fear and anxiety reactions differ psychologically and physiologically
- anxiety is a future-oriented mood state, characterized by apprehension because we cannot predict or control upcoming events.
- In contrast, fear is an immediate emotional reaction to current danger characterized by strong escapist action tendencies and, often, a surge in the sympathetic branch of the autonomic nervous system.

Panic is also a characteristic response to stress that runs in families and may have a genetic component that is separate from anxiety.
- Furthermore, anxiety and panic are closely related—anxiety increases the likelihood of panic.

Question 4

Panic attacks

Answer 4

What happens if you experience the alarm response of fear when you have nothing to be afraid of? There may be unexpected crying, shaking, and feeling faint

This sudden overwhelming reaction came to be known as panic, after the Greek god Pan who terrified travellers with blood-curdling screams.

In psychopathology, a panic attack is defined as an abrupt experience of intense fear or acute discomfort, accompanied by physical symptoms that usually include heart palpitations, chest pain, shortness of breath, and, possibly, dizziness

Two basic types of panic attacks are described in the DSM-5: expected and unexpected.
- If you know you are afraid of high places or of driving over long bridges, you might have a panic attack in such a situation but not anywhere else; this is an expected (cued) panic attack.
- By contrast, you might experience unexpected (uncued) panic attacks if you don’t have a clue when or where the next attack will occur.

We mention these types of attacks because they play a role in several anxiety disorders.
- Unexpected attacks are important in panic disorder.
- Expected attacks are more common in specific phobias or social anxiety disorder

Question 5

Causes of Anxiety

Answer 5

biological, psychological, and social contributors

Question 6

Biological - Cause of Anxiety

Answer 6

Increasing evidence shows that we inherit a tendency to be tense, uptight, and anxious, and some people more so than others

The tendency to panic also seems to run in families and probably has a genetic component that differs somewhat from genetic contributions to anxiety

No single gene seems to cause anxiety or panic or any other psychiatric disorder
- Instead, contributions from collections of genes in several areas on chromosomes make us vulnerable when certain psychological and social factors are in place.

Anxiety is also associated with specific brain circuits and neurotransmitter systems
- depleted levels of gamma aminobutyric acid (GABA), part of the GABA-benzodiazepine system, are associated with increased anxiety
- The noradrenergic system and serotonergic neurotransmitter system are also implicated in anxiety

There is large focus on the corticotropin-releasing factor (CRF) system as a cause for anxiety and depression
- CRF activates the hypothalamic–pituitary–adrenocortical (HPA) axis, which is part of the CRF system
- this CRF system has wide-ranging effects on areas of the brain implicated in anxiety, including the emotional brain (the limbic system), particularly the hippocampus and the amygdala; the locus coeruleus in the brain stem; the prefrontal cortex; and the dopaminergic neurotransmitter system.
- The CRF system is also directly related to the GABA–benzodiazepine system and the serotonergic and noradrenergic neurotransmitter systems

The area of the brain most associated with anxiety is the limbic system, which acts as a mediator between the brain stem and the cortex.
- The more primitive brain stem monitors and senses changes in bodily functions and relays these potential danger signals to higher cortical processes through the limbic system.

The late Jeffrey Gray, a British neuropsychologist, identified a brain circuit in the limbic system of animals that seems heavily involved in anxiety and may be relevant to humans.
- This circuit leads from the septal and hippocampal area in the limbic system to the frontal cortex.
- The septal–hippocampal system is activated by CRF and serotonergic-mediated and noradrenergic-mediated pathways originating in the brain stem
- The system that Gray called the behavioural inhibition system (BIS) is activated by signals from the brain stem of unexpected events, such as major changes in body functioning that might signal danger.
- Danger signals in response to something threatening will descend from the cortex to the septal–hippocampal system.
- The BIS also receives a big boost from the amygdala
- When the BIS is activated by signals that arise from the brain stem or descend from the cortex, our tendency is to freeze, experience anxiety, and apprehensively evaluate the situation to confirm that danger is present.

The BIS circuit is distinct from the circuit involved in panic.

The fight/flight system (FFS).
- This circuit originates in the brain stem and travels through several midbrain structures, including the amygdala, the ventromedial nucleus of the hypothalamus, and the central grey matter.
- When stimulated in animals, this circuit produces an immediate alarm-and-escape response that looks very much like panic in humans

Factors in your environment change the sensitivity of brain circuits, making you more or less susceptible to developing anxiety
- cigarette smoking as a teenager is associated with increased risk for anxiety as an adult, particularly panic disorder and generalized anxiety disorder
- Teens who smoked 20 or more cigarettes daily were 15 times as likely to develop panic disorder and 5 times as likely to develop generalized anxiety disorder
- anxiety sensitivity (the general tendency to fear bodily sensations), distress tolerance (how much distress a person can tolerate), and anhedonia (the inability to feel pleasure) all contribute to smoking, which could be one reason why people with anxiety find it difficult to quit smoking.

Brain-imaging procedures are yielding more information about the neurobiology of anxiety and panic
- there is now general agreement that in people with anxiety disorders, the limbic system, including the amygdala, is overly responsive to stimulation or new information (abnormal bottom-up processing)
- at the same time, controlling functions of the cortex that would down-regulate the hyperexcitable amygdala are deficient (abnormal top-down processing), consistent with Gray’s BIS model

Question 7

Psychological - Cause of Anxiety

Answer 7

Freud thought anxiety was a psychic reaction to danger surrounding the reactivation of an infantile fearful situation.

Behavioural theorists thought anxiety was the product of early classical conditioning, modelling, or other forms of learning.

But evidence shows an integrated model of anxiety involving a variety of psychological factors.
- In childhood, we may acquire an awareness that events are not always in our control. The continuum of this perception may range from total confidence in our control of all aspects of our lives TO deep uncertainty about ourselves and our ability to deal with upcoming events.
- A general sense of uncontrollability may develop early as a function of upbringing and other disruptive or traumatic environmental factors.

The actions of parents in early childhood foster a sense of control or a sense of uncontrollability
- parents who interact in a positive and predictable way with their children by responding to their needs teach their children that they have control over their environment and that their behaviours have an effect on their parents and their environment.
- also, parents who provide a secure home base but allow their children to explore their world and develop the necessary skills to cope with unexpected occurrences enable their children to develop a healthy sense of control.
- In contrast, parents who are overprotective and overintrusive and who clear the way for their children, never letting them experience any adversity, create a situation in which children never learn how to cope with adversity when it comes along. Therefore, these children don’t learn that they can control their environment.
- A sense of control (or lack of it) that develops from these early experiences is the psychological factor that makes us more or less vulnerable to anxiety in later life.

Another feature of some panic patients is the general tendency to respond fearfully to anxiety symptoms.
- This is known has anxiety sensitivity, which is an important personality trait that determines who will and who will not experience problems with anxiety under certain stressful conditions.

Most psychological accounts of panic (as opposed to anxiety) invoke conditioning and cognitive explanations that are difficult to separate.
- Thus, a strong fear response initially occurs during extreme stress or perhaps as a result of a dangerous situation in the environment (a true alarm).
- This emotional response then becomes associated with a variety of external and internal cues.
- In other words, these cues, or conditioned stimuli, provoke the fear response and an assumption of danger, even if the danger is not actually present, so it is really a learned or false alarm.
- External cues are places or situations similar to the one where the initial panic attack occurred.
- Internal cues are increases in heart rate or respiration that were associated with the initial panic attack, even if they are now the result of normal circumstances, such as exercise.
- Thus, when your heart is beating fast you are more likely to think of and, perhaps, experience a panic attack than when it is beating normally.
- Furthermore, you may not be aware of the cues or triggers of severe fear. These cues or triggers may travel from the eyes directly to the amygdala in the emotional brain without going through the cortex, the source of awareness

Question 8

Social - Cause of Anxiety

Answer 8

Stressful life events trigger our biological and psychological vulnerabilities to anxiety.
- Most are social and interpersonal in nature—marriage, divorce, difficulties at work, death of a loved one, pressures to excel in school, etc
- Some might be physical, such as an injury or illness.

The same stressors can trigger physical reactions, such as headaches or hypertension, and emotional reactions, such as panic attacks.

The particular way we react to stress seems to run in families.
- If you get headaches when under stress, chances are other people in your family also get headaches.
- If you have panic attacks, other members of your family probably do also.

This finding suggests a possible genetic contribution, at least to initial panic attacks.

Question 9

An integrated model - causes of Anxiety

Answer 9

Putting the factors together in an integrated way, we have described a theory of the development of anxiety called the triple vulnerability theory

1. The first vulnerability (or diathesis) is a generalized biological vulnerability.
   - We can see that a tendency to be uptight or high-strung might be inherited.
   - But a generalized biological vulnerability to develop anxiety is not sufficient to produce anxiety itself.
2. The second vulnerability is a generalized psychological vulnerability.
   - You might also grow up believing the world is dangerous and out of control and you might not be able to cope when things go wrong based on your early experiences.
   - If this perception is strong, you have a generalized psychological vulnerability to anxiety.
3. The third vulnerability is a specific psychological vulnerability in which you learn from early experience, such as being taught by your parents, that some situations or objects are fraught with danger (even if they really aren’t).
   - For example, if one of your parents is afraid of dogs or expresses anxiety about being evaluated negatively by others, you may well develop a fear of dogs or of social evaluation.

Question 10

Comorbidity of anxiety

Answer 10

According to the 2016 Canadian Community Health Survey (CCHS), 8.6% of Canadians ages 12 or older had a diagnosed anxiety disorder, with a greater proportion of women reporting this diagnosis than men (10.7% versus 6.4%)
- However, the survey excludes persons living on reserves and other Indigenous settlements in the provinces, full-time members of the Canadian Forces, the institutionalized population, children ages 12 to 17 living in foster care, and persons living in the Québec health regions of Nunavik and Terres-Cries-de-la-Baie-James.

Another survey helps to fill in these critical gaps.
- The First Nations Regional Health Survey (First Nations Information Governance Centre, 2018), a survey conducted in 2015–2016 among First Nations people living on reserves and in northern communities, documented similar proportions of adults (8.9%) and youth (8.2%) with a diagnosed anxiety disorder.

The different anxiety disorders often co-occur.
- The co-occurrence of 2 or more disorders in a single individual is referred to as COMORBIDITY.

Rates of comorbidity among anxiety disorders and between anxiety and depression are high.
- The 2014 Survey on Living with Chronic Diseases in Canada (SLCDC) revealed that among adult Canadians living with anxiety or mood disorders, almost one-third, 31%, report being diagnosed with both conditions
- The 2014 SLCDC covers the population of Canadians 18 years of age or older living with a diagnosed anxiety and/or mood disorders and represents 97% of this group while excluding similar groups to the 2016 CCHS described above.

The rates of comorbidity emphasize the fact that all anxiety disorders share the common features of anxiety and panic
- They also share the same vulnerabilities— biological and psychological—for developing anxiety and panic.
- They differ only in the focus of anxiety (what they are anxious about) and, perhaps, the patterning of panic attacks.

If each patient with an anxiety or a related disorder also had every other anxiety disorder, distinguishing among the specific disorders would make little sense.
- It would be enough to say, simply, that the patient had an anxiety disorder. But this is not the case
- although rates of comorbidity are high, they vary somewhat from disorder to disorder.

A large-scale study examined the comorbidity of Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV-TR) anxiety and mood disorders
- If we examine just rates of comorbidity at the time of assessment, the results indicate that 55% of the patients who received a principal diagnosis of an anxiety or a depressive disorder had at least one additional anxiety or depressive disorder at the time of the assessment.
- If we consider whether the patient met the criteria for an additional diagnosis at any time in his or her life, rather than just at the time of the assessment, the rate increases to 76%.

The most common additional diagnosis for all anxiety disorders was major depression, which occurred in 50% of the cases over the course of the patient’s life.

Also, additional diagnoses of depression or alcohol or drug abuse makes it less likely that the person will recover from an anxiety disorder and more likely that there will be a relapse after recovery

Question 11

Comorbidity with Physical Disorders

Answer 11

Anxiety disorders also co-occur with several physical conditions
- the presence of any anxiety disorder was uniquely and significantly associated with thyroid disease, respiratory disease, gastrointestinal disease, arthritis, migraine headaches, and allergic conditions
- Thus, people with these physical conditions are more likely to have an anxiety disorder but are not any more likely to have a different type of psychological disorder.
- The anxiety disorder most often begins before the physical disorder, suggesting that something about having an anxiety disorder might cause, or contribute to the cause of, the physical disorder

If someone has both an anxiety disorder and one of the physical disorders mentioned earlier, that person will suffer from greater disability and a poorer quality of life from both the physical problem and the anxiety problem than if that individual had just the physical disorder alone

Other studies have also found the same relationship between anxiety disorders, particularly panic disorders, and cardiovascular (heart) disease
- The DSM-5 now makes it explicit that panic attacks often co-occur with certain medical conditions, particularly cardiovascular, respiratory, gastrointestinal, and vestibular (inner ear) disorders, even though the majority of these patients would not meet criteria for panic disorder

The 2014 SLCDC survey of adult Canadians living with a mood and/or anxiety disorder documented the prevalence of limitations and restrictions among those living with only an anxiety disorder
- Almost 30% reported a severe level of disability, 44% required accommodations at work to continue working, and 24% had stopped working altogether at some point.
- For those Canadians with both an anxiety and a mood disorder the proportions were higher: 50% reported a severe level of disability, 66% required work accommodations, and 48% had experienced a stop in work.

Question 12

Suicide

Answer 12

20% of patients with panic disorder had attempted suicide. Such attempts were associated with panic disorder.
- the risk of someone with panic disorder attempting suicide is comparable to that for individuals with major depression
- Even patients with panic disorder who did not have accompanying depression were at risk for suicide.

having any anxiety disorder, not just panic disorder, uniquely increases the chances of having thoughts about suicide (suicidal ideation) or making suicidal attempts
- but the increase is strongest with panic disorder and post-traumatic stress disorder

All anxiety disorders are associated with an increased risk for suicide attempts and suicidal ideations after accounting for mood disorders, such as dysthymia, major depressive disorder, and bipolar disorder, as well as substance use disorders

People with generalized anxiety disorder and social anxiety disorder who engaged in deliberate self-harm were more likely to engage in this behaviour multiple times, and at least one of those times was a suicide attempt.

Having even subthreshold levels of generalized anxiety disorder (i.e., only meeting two of the three diagnostic criteria necessary for a diagnosis) was related to suicide ideation.

Question 13

Generalized Anxiety Disorder

Answer 13

Disorders traditionally grouped together as anxiety disorders include generalized anxiety disorder, panic disorder and agora-phobia, specific phobia, and social anxiety disorder, as well as two new disorders, separation anxiety disorder and selective mutism.
- These specific anxiety disorders are complicated by panic attacks

In generalized anxiety disorder, the focus is generalized to the events of everyday life

Features of generalized anxiety disorder (GAD):
- worry indiscriminately about everything
- worrying that is unproductive
- no matter how much you worry, you can’t seem to decide what to do about an upcoming problem or situation
- you can’t stop worrying, even if you know it is doing you no good and probably making everyone else around you miserable

Subtopics:
- Clinical description
- statistics
- causes
- treatment

Question 14

clinical description - Generalized Anxiety Disorder

Answer 14

The DSM-5 criteria specify that at least six months of excessive anxiety and worry (apprehensive expectation) must be ongoing more days than not
- Furthermore, it must be difficult to turn off or control the worry process.
- This is what distinguishes pathological worrying from the normal kind we all experience occasionally as we prepare for an upcoming event or challenge

The physical symptoms associated with generalized anxiety and GAD differ somewhat from those associated with panic attacks and panic disorder
- panic is associated with autonomic arousal, presumably as a result of a sympathetic nervous system surge (for instance, increased heart rate, palpitations, perspiration, and trembling)

GAD is characterized by muscle tension, mental agitation, susceptibility to fatigue (probably the result of chronic excessive muscle tension), some irritability, and difficulty sleeping
- Focusing attention is difficult, as the mind quickly switches from crisis to crisis.
- For children, only one physical symptom is required for a diagnosis of GAD, and research validates this strategy

People with GAD mostly worry about minor, everyday life events, a characteristic that distinguishes GAD from other anxiety disorders.
- When asked, “Do you worry excessively about minor things?” 100% of individuals with GAD respond “yes,” compared with approximately 50% of individuals whose anxiety disorder falls within other categories

Major events quickly become the focus of anxiety and worry, too.
- Adults typically focus on possible misfortune to their children, family health, job responsibilities, and more minor things, such as household chores or being on time for appointments.

Children with GAD most often worry about competence in academic, athletic, or social performance, as well as family issues

Older adults tend to focus on health.
- They also have difficulty sleeping, which seems to make the anxiety worse

Question 15

statistics - Generalized Anxiety Disorder

Answer 15

3% of Canadians met the criteria for GAD in 2012, with 9% meeting the criteria at some point during their lifetime
- An additional 2.3% of Canadians had subthreshold levels GAD in 2012

Among those Canadians meeting the criteria for GAD, 50% also had symptoms of major depressive episode

Similar rates of GAD are reported from around the world

Although GAD is one of the most common anxiety disorders, relatively few people with GAD come for treatment, compared with patients with panic disorder.
- Anxiety clinics report that only approximately 10% of their patients meet criteria for GAD, compared with 30% to 50% percent for panic disorder.
- This may be because most patients with GAD seek help from their primary care doctors

About two-thirds of individuals with GAD are female
- For Canadians 15 years of age or older, there is a greater proportion of women reported GAD than men
- But this sex ratio may be specific to developed countries. In the South African study, GAD was more common in males. In the United States, the prevalence of the disorder is significantly lower among Asian, Hispanic, and black adults compared with whites

Some people with GAD report onset in late adolescent and early adulthood, and others report an onset in older age.
- Stressful life events may play some role in the development of GAD. A person with GAD is likely to have experienced an excess of life stressors compared with someone without this disorder.
- most studies find that GAD is associated with an earlier and more gradual onset than most other anxiety disorders

Once it develops, GAD most often is chronic.
- there is only an 8% probability of becoming symptom-free after 2 years of follow-up
- patients with GAD retained their symptoms more consistently over 5 years than patients with panic disorder

In USA, GAD is prevalent among seniors. GAD is most common in the group over 45 years of age, and least common in the youngest group, ages 15 to 24
- In Canada, however, those over 65 years old had the lowest past-year prevalence

The use of minor tranquilizers in seniors is very high.
- in 2008, 5% of adults in the United States used benzodiazepines, and the percentage increased with age
- only 3% of the 18- to 35-year-olds, but 9% of the 65- to 80-year-olds filled at least one prescription for benzodiazepines during the year.
- It is not entirely clear why drugs are prescribed with such frequency for older adults. One possibility is that the drugs may not be entirely intended for anxiety. Prescribed drugs may be primarily for sleeping problems or other secondary effects of medical illnesses.
- benzodiazepines interfere with cognitive function and put older adults at greater risk for falling down and breaking bones, particularly their hips

Major difficulties that hamper the investigation of anxiety in seniors include the lack of good assessment instruments and treatment studies, largely because of insufficient research interest.

Question 16

causes - Generalized Anxiety Disorder

Answer 16

There may be a genetic contribution.
- GAD tends to run in families.
- Twin studies strengthen this suggestion.
- The risk of GAD is somewhat greater for monozygotic (identical) female twins when one twin already had GAD than in dizygotic female twins.
- What seems to be inherited is the tendency to become anxious rather than GAD itself

Heritability has been found for a particular trait, called anxiety sensitivity, which is the tendency to become distressed in response to arousal-related sensations, arising from beliefs that these anxiety-related sensations have harmful consequences

For a long time, GAD has posed a real puzzle to investigators.
- For years, clinicians thought that people who were generally anxious had simply not focused their anxiety on anything specific. Thus, such anxiety was described as free floating.
- But now, scientists have looked more closely and have discovered some very interesting distinctions.

The first hints of difference between GAD and other anxiety disorders were found in the physiological responsivity of individuals with GAD.
- individuals with GAD do not respond as strongly as individuals with anxiety disorders in which panic is more prominent.
- individuals with GAD show less responsiveness on most physiological measures, such as heart rate, blood pressure, skin conductance, and respiration rate than do individuals with other anxiety disorders.

When individuals with GAD are compared with nonanxious normal participants, the one physiological measure that consistently distinguishes the anxious group is muscle tension— people with GAD are chronically tense
- To understand this phenomenon of chronic muscle tension, we may have to know what’s going on in the minds of people with GAD. With new methods from cognitive science, we are beginning to uncover the mental processes ongoing in GAD

Four distinct cognitive characteristics of people with GAD are outlined in a model developed by Québec researchers Michel Dugas and Robert Ladouceur and their colleagues:
- (1) intolerance of uncertainty
- (2) positive beliefs about worry
- (3) poor problem orientation
- (4) cognitive avoidance

Although unpredictable events are known to produce anxiety in humans and animals, people with GAD are less tolerant of situations involving uncertainty than people with other anxiety disorders
- People with GAD also hold stronger erroneous beliefs that worrying is effective in avoiding negative outcomes and promoting positive outcomes—beliefs that might maintain their worry.
- People with GAD also have a poor orientation toward problems. For example, they tend to view problems as threats to be avoided rather than as challenges to be met
- The fourth cognitive characteristic of GAD pertains to the possibility that worry may serve an avoidance function. People with GAD engage in frantic, intense thought processes or worry without accompanying images. This kind of worry may be exactly what causes these individuals to show less responsiveness on physiological measures. They are thinking so hard about upcoming problems, they don’t have the attentional capacity left for the all-important process of creating images of the potential threat—images that would elicit more substantial negative affect and autonomic activity. In other words, they avoid all the negative affect associated with the threat. Although people with GAD may avoid much of the unpleasantness and pain associated with the negative affect and imagery, the avoidance means that they are never able to work through their problems and arrive at solutions.
- Therefore, they become chronic worriers, with accompanying autonomic inflexibility and quite severe muscle tension.
- Thus, intense worrying for an individual with GAD may serve the same maladaptive purpose as avoidance does for people with phobias. It prevents the person from facing the feared situation, and so adaptation never occurs.

Recent studies have tested various aspects of Ladouceur and Dugas’s cognitive model of GAD.
- Patrick Gosselin and his colleagues showed that, consistent with model predictions, adolescents who are frequent worriers also hold more erroneous beliefs about worry and use more avoidance strategies.
- Another study by Dugas, Marchand, and Ladouceur showed that intolerance of uncertainty was related to GAD but not to panic disorder with agoraphobia, providing some support for the diagnostic specificity of this cognitive characteristic to GAD.

Individuals with GAD are highly sensitive to threat in general, particularly to a threat that has personal relevance.
- They allocate their attention much more readily to sources of threat than do people who are not anxious
- Furthermore, this acute awareness of potential threat, particularly if it is personal, seems to be entirely automatic or unconscious

In summary, some people inherit a tendency to be tense, and they develop a sense early on that important events in their lives may be uncontrollable and potentially dangerous.
- Significant stress makes them apprehensive and vigilant.
- These emotions set off intense worry, which helps the individual avoid anxious
images and physiological arousal in the short term but eventually leads to the disorder of GAD.
- Cognitive factors, such as intolerance of uncertainty, positive beliefs about worry, and poor problem orientation, also play contributing roles in causing and maintaining GAD.

Question 17

treatment - Generalized Anxiety Disorder

Answer 17

Available treatments for GAD, both drug and psychological, are reasonably effective.

Benzodiazepines are most often prescribed for generalized anxiety, and the evidence indicates that they give some relief, at least in the short term.
- The therapeutic effect is relatively modest.

Furthermore, benzodiazepines carry some risks.
- First, they impair both cognitive and motor functioning. People don’t seem to be as alert on the job or at school when they are taking benzodiazepines. The drugs may impair driving and it may be associated with falls and hip fractures in older people
- benzodiazepines produce dependence, making it difficult for people to stop taking them. The optimal use of benzodiazepines is for the short-term relief of anxiety associated with a temporary crisis or stressful event, such as a family problem. Under these circumstances, a physician may prescribe a benzodiazepine until the crisis is resolved but for no more than a week or two.

There is stronger evidence for the usefulness of antidepressants in the treatment of GAD, such as paroxetine and venlafaxine (also called Effexor)
- These drugs may prove to be a better choice

In the short term, psychological treatments seem to confer about the same benefit as drugs in the treatment of GAD, but psychological treatments are more effective in the long term
- Because we now know that individuals with GAD seem to avoid feelings of anxiety and the negative affect associated with threatening images, clinicians have designed treatments to help patients with GAD process the threatening information on an emotional level, using images, so that they will feel anxious (rather than avoid the anxious feeling).
- These treatments have other components, such as teaching patients how to relax deeply to combat tension.
- Borkovec and his colleagues found such a treatment to be significantly better than a placebo psychological treatment, not only at post-treatment but also at a one-year follow-up

In the early 1990s, we developed a cognitive-behavioural treatment (CBT) for GAD in which patients evoke the worry process during therapy sessions and confront threatening images and thoughts head-on.
- The patient learns to use cognitive therapy and other coping techniques to counteract and control the worry process
- This decreases anxiety and improve quality of life

Ladouceur and colleagues made important in-roads in the development of effective psychosocial interventions for GAD
- They developed and tested a GAD psychosocial treatment that targeted the four factors in their cognitive model of GAD
- For example, to combat positive beliefs about worry, the therapist used cognitive-behavioural strategies to help patients re-evaluate the actual usefulness of worry.
- Those who received treatment had significant change in self-report, clinician, and significant-other ratings of GAD symptoms at post-treatment.
- Gains were maintained at 6-month and 12-month follow-ups.
- Also, 77% of the patients no longer met GAD diagnostic criteria following treatment.
- A subsequent study by this research team showed that this intervention is also effective when delivered in a group format, thereby increasing its cost-effectiveness (Dugas).
- Dugas also showed that although their CBT package was equally effective as applied relaxation in the short term, only people who received CBT continued to improve UP TO 2 years after treatment.

Borkovec and Ruscio (2001) reviewed 13 controlled studies evaluating CBT treatments for GAD and found substantial gains compared with no treatment or alternative treatment, such as psychodynamic therapy.

Moreover, a meta-analysis that focused specifically on the effects of CBT on excessive worry—the cardinal feature of GAD—demonstrated large overall effect sizes, suggesting that current CBT packages target the characteristic features of the disorder.
- Studies indicate that brief psychological treatments alter the sometimes unconscious cognitive biases associated with GAD

Recent studies also suggest that psychological interventions with GAD are effective to the extent that they focus on increasing the patient’s ability to tolerate uncertainty

A new psychological treatment for GAD has been developed that incorporates procedures focusing on acceptance of distressing thoughts and feelings in addition to cognitive therapy.
- Meditational and mindfulness-based approaches help teach the patient to be more tolerant of these feelings
- Results from a clinical trial reported some of the highest success rates yet to appear in the literature

There is particularly encouraging evidence that psychological treatments are effective with children who suffer from generalized anxiety
- In a major clinical trial, CBT and the antidepressant drug sertraline (Zoloft) were equally effective immediately following treatment compared with taking placebo pills for children with GAD and other related disorders, but the combination of CBT and sertraline was even better, with 80% showing substantial improvement versus 24% on placebo
- Follow-up analyses showed that more severe and impairing anxiety, greater caregiver strain, and a principal diagnosis of social anxiety disorder were associated with less favourable outcomes
- Mindfulness-based therapies for GAD are now also being adapted and tested with youth, with some indications of success

Similarly, progress is being made in adapting psychological treatments for older adults
- One large clinical trial demonstrated the efficiency of this treatment for adults over 60 compared with the usual care they received

Question 18

Panic Disorder And Agoraphobia

Answer 18

Panic disorder (PD) - individuals experience severe unexpected panic attacks; they may think they’re dying or otherwise losing control.
- In many cases, but not all, panic disorder is accompanied by a closely related disorder called agoraphobia, which is fear and avoidance of situations in which a person feels unsafe or unable to escape to get home or to a hospital in the event of developing panic symptoms or other physical symptoms, such as loss of bladder control.
- People develop agoraphobia because they never know when these symptoms might occur.
- In severe cases, people with agoraphobia are totally unable to leave the house, sometimes for years on end

Subtopics:

1. clinical description
   - The Development of Agoraphobia
2. statistics
   - Cultural Influences
   - Nocturnal Panic
3. Causes
4. Treatment
   - Medication
   - Psychological Intervention
   - Combined Psychological and Drug Treatments

Question 19

Clinical description - Panic Disorder And Agoraphobia

Answer 19

In the DSM-IV, panic disorder and agoraphobia were integrated into one disorder called panic disorder with agoraphobia, but investigators discovered that many people experienced panic disorder without developing agoraphobia and that some people develop agoraphobia in the absence of panic disorder
- Often, however, they go together

In panic disorder, anxiety and panic are combined in an intricate relationship
- Many people who have panic attacks do not necessarily develop panic disorder.

To meet the criteria for panic disorder, a person must experience an unexpected panic attack and develop substantial anxiety over the possibility of having another attack or about the implications of the attack or its consequences

The DSM-5 diagnostic 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, theatres, 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 dis- tress or impairment in social, occupational, or other important areas of functioning.

H. If another medical condition is present (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 symp- toms 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 deficits or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in post-traumatic stress disorder), or fear
of separation (as in separation anxiety disorder).

Question 20

The Development of Agoraphobia - Panic Disorder And Agoraphobia

Answer 20

The term agoraphobia was coined in 1871 by Karl Westphal, a German physician, and, in the original Greek, refers to fear of the marketplace.
- This is a very appropriate term because the agora, the Greek marketplace, was a very busy, bustling area.
- One of the most stressful places for individuals with agoraphobia today is the shopping mall, the modern-day agora.

As noted by University of British Columbia professor Stanley J. Rachman, “the consequences of panic can constitute a more serious problem than the panic itself”
- Most agoraphobic avoidance behaviour is a complication of severe, unexpected panic attacks.
- anxiety is diminished for individuals with agoraphobia if they think a location or person is safe, even if the person could do nothing effective if something bad did happen

Even if agoraphobic behaviour is initially closely tied to the occasions of panic, it can become relatively independent of panic attacks
- an individual who has not had a panic attack for years may still have strong agoraphobic avoidance
- agoraphobic avoidance seems to be determined by the extent to which you think or expect you might have another attack rather than by how many attacks you have actually had or how severe they have been.
- thus, agoraphobic avoidance is simply one way of coping with unexpected panic attacks.

Other methods of coping with panic attacks include using (and sometimes abusing) alcohol or drugs.
- A high comorbidity exists between panic disorder and alcohol abuse or dependence
- panic-prone individuals may be more susceptible than others to the anxiety-reducing effects of alcohol when they are experiencing panic-like bodily sensations.
- This may explain why these individuals are more likely to develop alcohol abuse and dependence.
- intervening with panic-prone individuals’ fear of anxiety leads to reductions in their problematic drinking

Some individuals do not actually avoid agoraphobic situations but endure them with intense dread.
- For example, people who must go to work each day or travel as part of the job will endure untold agonies of anxiety and panic simply to achieve their goals.
- Thus, the DSM-5 notes that agoraphobia may be characterized either by avoiding the situations or by enduring them with intense fear and anxiety.

Canadian hockey player Shayne Corson, a forward who played 20 NHL seasons, won a Stanley Cup, and served as a member of Canada’s 1998 Olympic hockey team, experienced crippling panic attacks.
- His panic attacks would come on suddenly and unexpectedly.
- He experienced uncomfortable sensations in his chest that he worried might be signs of a heart attack.
- Corson would try to distract himself, but he found these attacks extremely distressing.
- When out at a restaurant or nightclub, he reportedly wouldn’t last more than four to five minutes before he would flee, fearful that he might experience a panic attack in public.
- Corson’s panic attacks often occurred right on the Maple Leafs bench in front of unsuspecting teammates and fans.
- Corson was prescribed antianxiety medication and saw a psychiatrist for treatment of his panic attacks
- Unfortunately, his symptoms re-emerged and interfered so much with the effectiveness of his game that Corson decided to quit the Maple Leafs team during the 2003 playoffs
- Corson eventually recovered sufficiently to return to his hockey career in 2004

Most patients with panic disorder and agoraphobic avoidance also display another cluster of avoidant behaviours that we call interoceptive avoidance or avoidance of internal physical sensations
- These behaviours involve removing oneself from situations or activities that might produce the physiological arousal that somehow resembles the beginnings of a panic attack.
- Some patients might avoid exercise because it produces increased cardiovascular activity or faster respiration, which reminds them of panic attacks.
- researchers McWilliams and Asmundson showed that panic-prone university males reported engaging in exercise less frequently than other university males, consistent with the possibility that they might be avoiding exercise because of their fear of arousal sensations.
-Other patients might avoid sauna baths or any rooms in which they might perspire.

A list of situations or activities typically avoided within the interoceptive cluster are:
- Running up flights of stairs
- Walking outside in intense heat
- Having showers with the doors and windows closed
- Hot, stuffy stores or shopping malls
- Walking outside in very cold weather
- Aerobics
- Lifting heavy objects
- Dancing
- Eating chocolate
- Standing quickly from a sitting position
- Watching exciting movies or sports events
- Getting involved in “heated” debates
- Hot, stuffy rooms
- Hot, stuffy cars
- Having a sauna
- Hiking
- Sports
- Drinking coffee or any caffeinated beverages
- Sexual relations
- Watching horror movies
- Eating heavy meals
- Getting angry

Question 21

statistics - Panic Disorder And Agoraphobia

Answer 21

Panic disorder is fairly common.
- 3.5% of the U.S. population meet the criteria for panic disorder at some point during their lives, and 75% of them women and another 5.3% meet the criteria for agoraphobia

The rates of agoraphobia may be overestimated as a result of methodological difficulties, but most people with panic disorder do have agoraphobic avoidance.

According to the 2002 CCHS—Mental Health and Wellbeing, 1.5% of Canadians 15 years of age or older had experienced panic disorder in the past 12 months, with 3.7% experiencing panic disorder in their lifetime
- The rates among Canadian women were higher than for men (4.6% versus 2.8% lifetime; 2.0% versus 1.0% in the past 12 months).

Onset of panic disorder usually occurs in early adult life— from mid-teens through about 40 years of age.
- The mean age of onset is between 25 and 29
- Analysis of the 2002 CCHS data showed that the average age of onset was 25 years of age and that three-quarters of the people with panic disorder had developed the disorder by 33 years of age
- Generally, panic disorder seems less pervasive among older adults, but our estimates are not yet firm

Most initial unexpected panic attacks begin at or after puberty.
- Furthermore, many prepubertal children who are seen by general medical practitioners have symptoms of hyperventilation that may well be panic attacks.
- These children do not report fear of dying or losing control, however, perhaps because they are not at a stage of their cognitive development where they can make these attributions

75% or more of those who have agora- phobia are women.
- the higher the severity of agoraphobic avoidance, the greater the proportion of women.

For a long time, we didn’t know why agoraphobia is more common in women, but now it seems the most logical explanation is cultural
- It is more accepted for women to report fear and to avoid numerous situations. Men, however, are expected to be stronger and braver—to tough it out.
- Another possible reason pertains to gender differences in fear of anxiety. Research conducted at Dalhousie University and at the Royal Ottawa Hospital has shown that women are more fearful of anxiety symptoms than are men, with women proving particularly fearful of the physical consequences of anxiety sensations (e.g., fearing an imminent heart attack).
- These gender differences are even observed in children
- Women with panic disorder have greater agoraphobia because they believe panic attacks are more likely and because they are more afraid of the potential negative consequences of a panic attack

What happens to men who have severe unexpected panic attacks? Is cultural disapproval of fear in men so strong that most of them simply endure panic?
- The answer seems to be “no.”
- A large proportion of males with unexpected panic attacks cope in a culturally acceptable way: They consume large amounts of alcohol
- A study by clinical psychologist Brian Cox and his colleagues compared 74 men and 162 women with panic disorder. Although the women reported higher levels of agoraphobic avoidance, the men reported higher levels of weekly alcohol intake and greater beliefs in alcohol as an effective way to cope with anxiety.
- a study conducted by researchers at the University of Québec at Montréal showed that the lower agoraphobic avoidance of men with panic disorder was associated with their alcohol use
- The problem is that these men with panic disorder can become dependent on alcohol, and many begin the long downward spiral into serious addiction

Thus, males may end up with an even more severe problem than panic disorder with agoraphobia.
- Because these men are so impaired by alcohol abuse, clinicians may not realize they also have panic disorder and agoraphobia.
- And even if they are successfully treated for their addiction, the anxiety disorder still requires treatment

Question 22

Cultural Influences - Panic Disorder And Agoraphobia

Answer 22

Panic disorder exists worldwide, although
its expression may vary from place to place

Prevalence rates for panic disorder show some degree of cross-cultural variability with Asian and African countries showing the lowest rates
- These findings mirror cross-ethnic comparisons within the United States, with Asian Americans showing the lowest, and white American showing the highest prevalence rates

Furthermore, rates of recovery from panic disorder are lower among African Americans as compared to non-Latino white individuals

In addition to differences in prevalence rates and chronicity, cross-cultural studies also showed interesting differences in the expression of anxiety
- there is a fright disorder that is called susto in Latin America and is characterized by sweating, increased heart rate, and insomnia, but not by reports of anxiety or fear, even though severe fright is the cause

An anxiety-related, culturally defined syndrome prominent among Hispanic people, particularly those from the Caribbean, is called ataques de nervios
- the symptoms of an ataque seem quite similar to those of panic attacks, although such manifestations as shouting uncontrollably or bursting into tears may be associated more frequently with an
ataque than with panic.

Another culture-bound syndrome that bears some relation to panic disorder occurs among the Inuit of northern Canada and Western Greenland.
- This syndrome is called kayak-angst and involves episodes of intense fear, worries about drowning, physical arousal sensations (rapid heartbeat and trembling), and intense disorientation that occur when a seal hunter or fisher is alone at sea
- Like the relation of panic disorder to agoraphobic avoidance, kayak-angst can cause the hunter or fisher to avoid travel in the kayak, which can lead to impairment in their livelihood

Question 23

Nocturnal Panic - Panic Disorder And Agoraphobia

Answer 23

Approximately 60% of people with panic disorder have experienced such nocturnal attacks

Panic attacks occur more frequently between 1:30 a.m. and 3:30 am than at any other time
- people are afraid to go to sleep at night

These people are not having nightmares though

Nocturnal attacks are studied in a sleep laboratory.
- Patients spend a few nights sleeping while attached to an electroencephalograph (EEG) that monitors their brain waves
- during sleep, we go through stages that are reflected by different patterns on the EEG
- nocturnal panic attacks occur during delta wave or slow-wave sleep, which typically occurs several hours after we fall asleep and is the deepest stage of sleep
- People with panic disorder often begin to panic when they start sinking into delta sleep, and then awaken in the middle of an attack.
- Because there is no obvious
reason for them to be anxious or panicky when they are sound asleep, most of these people think they are dying

What causes nocturnal panic?
- maybe, the change in stages of sleep to slow-wave sleep produces physical sensations of “letting go” that are very frightening to a person with panic disorder
- Several other events also occur during sleep that resemble nocturnal panic and are mistakenly thought to be the cause of nocturnal panic by some
- initially, it was thought to be nightmares but this is not true because nightmares and other dream-like activity occur during rapid eye movement (REM sleep).
- people are not dreaming during nocturnal panics
- Some therapists are not aware of the stage of sleep associated with nocturnal panic attacks and so assume that patients are repressing their dream material, perhaps because it might relate to an early trauma too painful to be admitted to consciousness. This is likely not true

A fascinating condition that at first glance appears similar to nocturnal panic is called isolated sleep paralysis.
- awake at night, unable to move, heart rate pounding
- If you were from Newfoundland and Labrador, you would refer to this experience as being visited by the “Old Hag”
- if you were from an African or Caribbean culture, this experience would be captured by the expression
“the witch is riding you”
- if you were from China you would believe this experience is the result of being pressed down upon by a ghost
- isolated sleep paralysis occurs during the transitional state between sleep and waking.
- During this period the individual is unable to move and experiences a surge of terror that resembles a panic attack; occasionally, the person also has vivid hallucinations.
- One possible explanation is that REM sleep is spilling over into the waking cycle. This seems likely because one feature of REM sleep is atonia, or lack of muscle strength. Another is vivid dreams, which could account for the experience of hallucination.

Question 24

Causes - Panic Disorder And Agoraphobia

Answer 24

Biological, psychological, and social

Evidence indicates that agoraphobia often develops after a person has unexpected panic attacks (or panic-like sensations), but whether agoraphobia develops and how severe it becomes seem to be socially and culturally determined

Panic attacks and panic disorder seem to be related most strongly to biological and psychological factors and their interaction.

We all inherit—some more than others—a vulnerability to stress, which is a tendency to be generally neurobiologically overreactive to the events of daily life (generalized biological vulnerability).
- But some people are also more likely than others to have an emergency alarm reaction (unexpected panic attack) when confronted with stress-producing events.
- Other people might be more likely to have headaches or high blood pressure in response to the same kinds of stress.

Particular situations quickly become associated in an individual’s mind with external and internal cues that were present during the panic attack
- The next time the person’s heart rate increases during exercise, she might assume she is having a panic attack (conditioning).
- Harmless exercise is an example of an internal cue or a conditioned stimulus for a panic attack.

Being in a movie theatre when panic first occurred would be an external cue that might become a conditioned stimulus for future panics.
- Because these cues become associated with several different internal and external stimuli through a learning process, we call them learned ALARMS

An individual must be susceptible to developing anxiety over the possibility of having another panic attack.
- They must think the physical sensations associated with the panic attack mean something terrible is about to happen, perhaps death. This is what creates panic disorder.
- This tendency to believe that unexpected bodily sensations are dangerous reflects a specific psychological vulnerability to develop panic and related disorders.

8% to 12% of the population has an occasional unexpected panic attack, often during a period of intense stress over the previous year
- Most of these people do not develop anxiety
- Only a few will develop anxiety over future panic attacks and thereby meet the criteria for panic disorder.
- What happens to those individuals who don’t develop anxiety? They seem to attribute the attack to events of the moment, such as an argument with a friend, and perhaps experiencing an occasional panic attack when they are under stress again.

The above was illustrated by professional golfer Charlie Beljan, known to his friends as a fun-loving, free-spirited guy.
- But in late 2012, on his way to winning his first Professional Golfers Association tournament, he experienced a panic attack that he thought was a heart attack.
- Determined to finish, and with paramedics following him in a golf cart, Beljan staggered from shot to shot, sometimes having to sit down on the fairway.
- Nevertheless, he had his best round of the year and, after finishing, took an ambulance to the hospital where he was diagnosed as having a panic attack

The influential cognitive theories of David Clark explicate in more detail some cognitive processes that may be ongoing in panic disorder.
- Clark emphasizes the specific psychological vulnerability of people with this disorder to interpret normal physical sensations in a catastrophic way. Although we typically experience rapid heartbeat after exercise, if you have a psychological or cognitive vulnerability, you might interpret the response as dangerous and feel a surge of anxiety. This anxiety, in turn, produces more physical sensations because of the action of the sympathetic nervous system; you perceive these additional sensations as even more dangerous, and a vicious cycle begins that results in a panic attack.
- Thus, Clark emphasizes the cognitive process as most important in panic disorder.

Why would some people think something terrible is going to happen when they have an attack but others wouldn’t?
- An important study prospectively followed young women at risk for developing anxiety disorders for several years.
- Those women who had a history of various physical disorders and were anxious about their health tended to develop panic disorder rather than another anxiety disorder such as social anxiety disorder
- Thus, these women may have learned in childhood that unexpected bodily sensations may be dangerous—whereas other people experiencing panic attacks do not.

Question 25

Treatment - Panic Disorder And Agoraphobia

Answer 25

Research on the effectiveness of new treatments is important to psychopathology.

Responses to certain treatments, whether drug or psychological, may indicate the causes of the disorder.

We now discuss the benefits and some drawbacks of medication, psychological interventions, and a combination of these two treatments.

Question 26

Medication - Panic Disorder And Agoraphobia

Answer 26

A large number of drugs affecting the noradrenergic, serotonergic, or GABA–benzodiazepine neurotransmitter systems or some combination are effective in treating panic disorder, including high-potency benzodiazepines, the newer selective-serotonin reuptake inhibitors (SSRIs), such as Prozac and Paxil, and the closely related serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine

Each class of drugs has advantages and disadvantages.
- SSRIs are currently the indicated drug for panic disorder. Although sexual dysfunction seems to occur in 75% or more of people taking these medications
- On the other hand, high-potency benzodiazepines, such as alprazolam (Xanax), commonly used for panic disorder, work quickly but are hard to stop taking because of dependence. Therefore, they are not recommended as strongly as the SSRIs.
- All benzodiazepines also adversely affect cognitive and motor functions to some degree. Therefore, people taking them in high doses often find their ability to drive a car or study somewhat reduced.
- Nevertheless, benzodiazepines remain the most widely used class of drugs in practice and their use continues to increase

Approximately 60% of patients with panic disorder are free of panic as long as they stay on an effective drug
- but 20% or more stop taking the drug before treatment is done and relapse rates are high (approximately 50%) once the medication is stopped
- The relapse rate is closer to 90% for those who stop taking benzodiazepines

Question 27

Psychological Intervention - Panic Disorder And Agoraphobia

Answer 27

Psychological treatments have proved quite effective for panic disorder.

Originally, such treatments concentrated on reducing agoraphobic avoidance, using strategies based on exposure to feared situations.
- The strategy of exposure-based treatments is to arrange conditions in which the patient can gradually face the feared situations and learn there is nothing to fear.
- Most patients with phobias are well aware of this rationally, but they must be convinced on an emotional level as well by reality testing the situation and confirming that nothing dangerous happens.
- Sometimes the therapist accompanies the patients on their exposure exercises.
- At other times, the therapist simply helps patients structure their own exercises and provides them with a variety of psychological coping mechanisms to help them complete the exercises, which are typically arranged from least to most difficult.

Gradual exposure exercises, sometimes combined with anxiety-reducing coping mechanisms such as relaxation or breathing retraining, have proved effective in helping patients overcome agoraphobic behaviour whether associated with panic disorder or not
- As many as 70% of patients undergoing these treatments substantially improve as their anxiety and panic are reduced and their agoraphobic avoidance is greatly diminished.
- Few, however, are cured, because many still experience some anxiety and panic attacks, although at a less severe level.

Effective psychological treatments have recently been developed that treat panic disorder directly even in the absence of agoraphobia
- Panic control treatment (PCT) developed at one of our clinics concentrates on exposing patients with panic disorder to the cluster of interoceptive sensations that remind them of their panic attacks.
- The therapist attempts to create “mini” panic attacks in the office by having the patients exercise to elevate their heart rates or perhaps by spinning them in a chair to make them dizzy.
- Patients also receive cognitive therapy. Basic attitudes and perceptions concerning the dangerousness of the feared but objectively harmless situations are identified and modified.
- Many of these attitudes and perceptions are beyond the patient’s awareness.
- Uncovering these unconscious cognitive processes requires a great deal of therapeutic skill.
- In addition to exposure to interoceptive sensations and cognitive therapy, patients are taught relaxation or breathing retraining to help them cope with increases in anxiety and to reduce excess arousal.

These psychological procedures are highly effective for panic disorder.
- Follow-up studies of patients who receive PCT indicate that most of them remain better after at least 2 years
- Remaining agoraphobic behaviour can then be treated with more standard exposure exercises.

Still, some people relapse over time, so our multisite collaborative team began investigating long-term strategies in the treatment of panic disorder, including the usefulness of providing booster sessions after therapy is complete to prevent relapse.
- Booster sessions produced lower relapse rates (5%) and reduced work and social impairment compared with no booster sessions (18%)
- thus, booster sessions aimed at reinforcing acute treatment gains to prevent relapse and offset disorder recurrence improved long-term outcome for panic disorder and agoraphobia, even in those patients who responded well to treatment initially.
- Similar treatments have also been successfully used in children and older adults

Researchers have also begun attempting to understand which aspects of PCT (i.e., exposure to interoceptive sensations, cognitive therapy, and relaxation and breathing retraining) are the most or least important components of the treatment.
- As described by Hamilton researchers Martin Antony and Randi McCabe, concerns have been raised about the breathing retraining component of PCT in that it does not seem to add to the effectiveness of PCT and may in fact lead to a poorer outcome for some patients by preventing them from learning that their catastrophic beliefs are unfounded.
- Steven Taylor recommends that therapists must exercise caution when using breathing retraining to ensure that it is not misused by panic patients as a means of escaping from or avoiding their feared bodily sensations.

Question 28

Combined Psychological and Drug Treatments - Panic Disorder And Agoraphobia

Answer 28

Partly because primary care physicians are usually the first clinicians to treat those suffering from panic disorder, and psychological treatments are not available in those settings, when patients do get referred for psychological treatment, they are often already taking medications.

So, important questions are as follows: How do these treatments compare with each other? And do they work together?

One major study sponsored by the U.S. National Institute of Mental Health looked at the separate and combined effects of psychological and drug treatments
- The data indicate that all treatment groups responded significantly better than the placebo group, but approximately the same number of patients responded to both treatments.
- Combined treatment was no better than individual treatments.
- After 6 additional months of maintenance treatment (9 months after treatment was initiated), during which patients were seen once per month, the results looked much as they did after initial treatment, except there was a slight advantage for combined treatment at this point and the number of people responding to placebo had diminished.
- A later follow-up, 6 months after treatment was discontinued (15 months after it was initiated), revealed that patients on medication, whether combined with CBT or not, had deteriorated somewhat, and those receiving CBT without the drug had retained most of their gains

Some studies show that drugs, particularly benzodiazepines, may interfere with the effects of psychological treatments
- Furthermore, benzodiazepines taken over a long period are associated with cognitive impairment

^^^ Because of this, our multisite collaborative team asked whether a sequential strategy in which one treatment was delayed until later and only given to those patients who didn’t do as well as hoped would work better than giving both treatments at the same time.
- In this study, Payne studied patients treated with CBT who did not respond adequately to the initial treatment and randomized these patients to a study where they either received continued CBT or the SSRI drug paroxetine.
- Paroxetine was administered for up to 12 months, whereas the CBT was delivered for three months.
- At the end of three months, patients receiving paroxetine responded better than those receiving continued CBT, but these differences had disappeared by the one-year follow-up.
- Specifically, 53% of the inadequate responders receiving paroxetine became responders, compared with 33% receiving continued CBT, but at 12 months the results were 56% and 53%, respectively.
- So clinicians must judge whether the more rapid response among some patients is worth trying drug treatment, given that subsequent improvement will be about the same at a later date.
- For some patients, the more rapid response will be very important. Others may be less enthusiastic about taking a drug and enduring the potential side effects, knowing that they are likely to improve over time without the drug.

What about those patients already taking drugs?
- In the primary care setting, adding CBT to the treatment of patients already on medications resulted in significant further improvement compared with those patients on medication who did not have CBT added

Both of the studies we just discussed indicate that a stepped care approach in which the clinician begins with one treatment and then adds another if needed may be superior to combining treatments from the beginning.

General conclusions from these studies suggest no advantage to combining drugs and CBT initially for panic disorder and agoraphobia.
- Furthermore, the psychological treatments seemed to perform better in the long run (6 months after treatment had stopped).

This suggests the psychological treatment should be offered INITIALLY, followed by drug treatment for those patients who do not respond adequately or for whom psychological treatment is not available.

Question 29

Specific phobia

Answer 29

Subtopics:

1. Clinical description
   a. Blood-Injury-Injection Phobia
   b. Situational Phobia
   c. Natural Environment Phobia
   d. Animal Phobia
   e. Other Phobias
2. statistics
3. Causes
4. treatment
   a. Separation Anxiety Disorder

Question 30

Clinical description - Specific phobia

Answer 30

A specific phobia is an irrational fear of a specific object or situation that markedly interferes with an individual’s ability to function.
- In earlier versions of the DSM, this category was called “simple” phobia to distinguish it from the more complex agoraphobia condition, but we now recognize there is nothing simple about it.

Surveys indicate that specific fears of a variety of objects or situations occur in a majority of the population
- But the very commonness of fears, even severe fears, often causes people to trivialize the more serious psychological disorder known as a specific phobia.
- These phobias can be extremely disabling

In contrast to the devastating effects of phobias for some people, for others, phobias are simply a nuisance— sometimes an extremely inconvenient nuisance, but they can adapt to life with a phobia by simply working around it somehow.

DSM-5 criterion of fear and anxiety about a specific object or situation.
- recognize that their fear and anxiety are out of proportion to any actual danger.
- go through considerable lengths to avoid situations where their phobic response might occur

There are many phobias
- The variety of Greek and Latin names contrived to describe phobias stuns the imagination.

Before the publication of DSM-IV in 1994, no meaningful classification of specific phobias existed.

Four major subtypes of specific phobia have been identified:
(1) animal type
(2) natural environment type (e.g., heights, storms, and water)
(3) blood- injury-injection type
(4) situational type (such as planes, elevators, or enclosed places).

A fifth category, “other,” includes phobias that do not fit any of the four major subtypes (e.g., situations that may lead to choking, vomiting, or contracting an illness; or, in children, avoidance of loud sounds or costumed characters).

Most people who suffer from phobia tend to have multiple phobias of several types

Question 31

Blood-Injury-Injection Phobia - Specific phobia

Answer 31

Those with blood-injury-injection phobias almost always differ in their physiological reaction from people with other types of phobia
- people with Blood-Injury-Injection Phobia experience a marked drop in heart rate and blood pressure and fainted as a consequence.
- In contrast, many people who have other types of phobias and experience panic attacks in their feared situations report that they feel like they are going to faint but they never do, because their heart rate and blood pressure are actually increasing.

Blood-injury-injection phobia runs in families more strongly than any phobic disorder we know.
- This is probably because people with this phobia inherit a strong vasovagal response to blood, injury, or the possibility of an injection, all of which cause a drop in blood pressure and a tendency to faint

The phobia develops over the possibility of having this response.
- The average age of onset for this phobia is 9 years old

Question 32

Situational Phobia - Specific phobia

Answer 32

Phobias characterized by fear of public transportation or enclosed places are called situational phobias.

Situational phobia tends to emerge around age 20 to 25 and has been shown to run in families

The main difference between situational phobia and panic disorder with agoraphobia is that people with situational phobia never experience panic attacks outside the context of their phobic object or situation
- Therefore, they can relax when they don’t have to confront their phobic situation.

Question 33

Natural Environment Phobia - Specific phobia

Answer 33

Sometimes very young people develop fears of situations or events occurring in nature.
- These fears are called natural environment phobias.
- The major examples are heights, storms, and water.
- These fears also seem to cluster together: If you fear one situation or event, such as deep water, you are likely to fear another, such as storms.

Many of these situations have some danger associated with them and, therefore, mild to moderate fear can be very adaptive.
- It is entirely possible that we are somewhat prepared to be afraid of these situations; something in our genetic makeup makes us very sensitive to these situations if any sign of danger is present.

These phobias have a peak age of onset of 7 years age.
- They are not phobias if they are only passing fears.
- They have to be persistent (lasting at least 6 months) and interfere substantially with the person’s functioning, leading to avoidance of boat trips or summer vacations in the mountains where there might be a storm.

Question 34

Animal Phobia - Specific phobia

Answer 34

Fears of animals and insects are called animal phobias.

These fears are common but become phobic only if severe interference with functioning occurs.

There are many places that these people are unable to go, even if they want to very much, such as to the country to visit someone.

The fear experienced by people with animal phobias is very different from an ordinary mild revulsion.
- The age of onset for these phobias, like that of natural environment phobias, peaks at around 7 years old

Question 35

Other phobias - Specific phobia

Answer 35

Several additional types of phobias appear in considerable numbers and can cause substantial problems.

For example, if you are afraid of contracting a disease and go to excessive and irrational lengths to avoid exposure to that disease, you may have an illness phobia.
- In these cases, the individuals do not believe they have the disease but are afraid they might acquire it in any number of ways
- When this fear occurs in severe form it can be very incapacitating, because individuals with illness phobia may avoid all contact with people or places where they might catch something
- Illness phobia likely became more prevalent during the SARS epidemic, just as it became more prevalent during the AIDS epidemic
- During the SARS epidemic, some people who had no reason to believe they would contract SARS avoided public gatherings, restaurants, and any contact whatsoever with strangers who displayed signs of a cold (or people who had recently travelled to China or Toronto) for fear of contracting the disease
- Illness phobia can also resemble other disorders, such as obsessive-compulsive disorder or illness anxiety disorder, but is sufficiently different to be classified as a type of specific phobia.

Question 36

Statistics - Specific phobia

Answer 36

Specific fears occur in a majority of people.
- fears of snakes and heights rank near the top.
- the sex ratio among common fears is overwhelmingly female with a couple of exceptions. Among these exceptions is fear of heights, for which the sex ratio is approximately equal.
- Very few people who report specific fears
qualify as having a phobia, but for 6.4% of the Canadian population, their fears are at some point severe enough to be classified as disorders and earn the label “phobia”
- As with common fears, the sex ratio for specific phobias is overwhelmingly female.
- the lifetime prevalence rate was about twice as high in women as in men (i.e., 8.9% for women and 4.1% for men).

Once a phobia develops, it tends to run a chronic course

Specific phobias represent an interesting paradox
- Despite the fact that specific phobia is a common, treatable, and well-understood condition, people with this condition present for treatment only rarely.
- only 6% received a principal diagnosis of specific phobia.
- Diagnoses of panic disorder, social anxiety disorder, and obsessive-compulsive disorder were much more common as primary diagnoses.

Thus, even though phobias may interfere with an individual’s functioning, only the most severe cases actually come for treatment, because affected people tend to work around their phobias.
- For example, someone with a fear of heights arranges her life so she never has to be in a tall building

People with situational phobias of such things as driving or small, enclosed places most frequently come for treatment.

However, we have reason to believe that blood-injury-injection phobias are quite prevalent in the population
- people with this phobia might seek help if they knew good treatments were available.

Although most anxiety disorders look much the same in adults and children, clinicians must be very aware of the types of normal fears and anxieties experienced throughout childhood so they can distinguish them from specific phobias
- Infants, for example, show marked fear of loud noises and strangers.
- At 1 to 2 years of age, children quite normally are very anxious about separating from parents, and fears of animals and the dark also develop and may persist into the fourth or fifth year of life.
- Fear of various monsters and other imaginary creatures may begin at age 3 and last for several years.
- At age 10, children may fear evaluation by others and feel anxiety over their physical appearance.

Generally, reports of fear decline with age, although performance-related fears of such activities as taking a test or talking in front of a large group may increase with age.
- Specific phobias seem to decline with old age

The prevalence of specific phobias varies from one culture to another.
- A variant of phobia in Chinese cultures is called Pa-leng, sometimes frigo phobia or “fear of the cold.” Pa-leng can be understood only in the context of traditional ideas—in this case the Chinese concept of yin and yang. Chinese medicine holds that there must be a balance of yin and yang forces in the body for health to be maintained. Yin represents the cold, dark, windy, energy-sapping aspects of life; yang refers to the warm, bright, energy-producing aspects of life.
- Individuals with Pa-leng have a morbid fear of the cold. They ruminate over loss of body heat and may wear several layers of clothing even on a hot day. They may complain of belching and flatulence, which indicate the presence of wind and therefore of too much yin in the body.

Question 37

Causes - Specific phobia

Answer 37

For a long time we thought that most specific phobias began with an unusual traumatic event.
- We now know this is not necessarily the case
- This is not to say that traumatic conditioning experiences do not result in subsequent phobic behaviour.

An individual with claustrophobia who recently reported being trapped in an elevator for an extraordinarily long time.
- These are examples of phobias acquired by direct experience, where real danger or pain results in an alarm response (a true alarm).
- such direct conditioning is merely one way of developing a phobia.

There are at least 2 other pathways: observing someone else experience severe fear (vicarious experience) or, under the right conditions, being told about danger.
- In fact, vicarious and informational transmission of fears can take place in the absence of any direct contact with the phobic object or situation.

People develop phobias in at least 1 other way: by experiencing a false alarm (panic attack) in a specific situation.
- Studies show that many people with phobias do not necessarily experience a true alarm resulting from real danger at the onset of their phobia.
- Many initially have an unexpected panic attack in a specific situation, related, perhaps, to current life stress. A phobia of that situation may then develop.

^^ This was evident in a study with driving phobia - Although only a minority (14%) met criteria for panic disorder, the majority (81%) of people with excessive fear of driving an automobile reported having had panic attacks.
- When asked about the primary reason for their phobia, only 15% attributed it to an accident, whereas 53% attributed it to the possibility of having panic attacks.
- These people were also more concerned about anxiety symptoms while driving than phobic patients who gave other, non-accident-related reasons for their driving phobia.

We also learn fears vicariously.
- Seeing someone else have a traumatic experience or endure intense fear may be enough to instill a phobia in the watcher.
- Emotions are very contagious.
- fear can also be acquired through vicarious learning even after watching a brief film clip.
- Sometimes just being warned repeatedly about a potential danger is sufficient for someone to develop a phobia
- We call this mode of developing a phobia information transmission.

A true phobia also requires anxiety over the possibility of another extremely traumatic event or false alarm.
- when we are anxious, we persistently anticipate something terrible, and we are likely to avoid situations where that terrible thing might occur.
- If we don’t develop anxiety, our reaction would presumably be in the category of normal fears experienced by more than half the population.
- Normal fear can cause mild distress, but it is usually ignored and forgotten.

In summary, several things have to occur for a person to develop a phobia.
- First, a traumatic conditioning experience often plays a role (even hearing about a frightening event is sufficient for some individuals).
- Second, fear is more likely to develop if we are “prepared”; that is, we seem to carry an inherited tendency to fear situations that have been dangerous to humans over evolutionary time, such as being threatened by wild animals or trapped in small places.
- Third, we also have to be susceptible to developing anxiety by focusing on the possibility that the event will happen again.

Finally, social and cultural factors are very strong determinants of who ultimately develops and reports a specific phobia.
- In most societies around the world, it is almost unacceptable for males to express fears and phobias.
- Thus, the overwhelming majority of reported specific phobias occur in women.

What happens to the males?
- Very possibly they work hard to overcome their fears by repeatedly exposing themselves to their feared situations.
- Another more likely possibility is that they simply endure their fears without telling anyone about them and without seeking any treatment

Pierce and Kirkpatrick asked male and female college students to report their fears on 2 occasions before watching a videotape of something frightening.
- Before the second evaluation, subjects were told their heart rate would be monitored to assess the “truthfulness” of their report.
- Reports from women were the same on both occasions, but men reported substantially more fear when it was important to be truthful.

Question 38

Treatment - Specific phobia

Answer 38

Although the development of phobias is relatively complex, the treatment is fairly straightforward.

Almost everyone agrees that specific phobias require structured and consistent exposure- based exercises.

Most patients who expose themselves gradually to what they fear must be under therapeutic supervision.
- individuals who attempt to carry out the exercises alone often attempt to do too much too soon and end up escaping the situation, which may strengthen the phobia.
- In addition, if a patient fears having another unexpected panic attack in this situation, it is helpful to direct therapy at panic attacks in the manner described for panic disorder.
- In cases of blood-injury-injection phobia, where fainting is a real possibility, graduated exposure-based exercises must be done in specific ways. Individuals must tense various muscle groups during exposure exercises to keep their blood pressure sufficiently high to complete the practice

New developments make it possible to treat many specific phobias,
including blood phobia, in a single session taking anywhere from approximately 2 to 6 hours
- The therapist spends most of the session with the individual, working through exposure exercises with the phobia object or situation.
- The patient then practises approaching the phobic situation at home, checking in occasionally with the therapist.
- It is interesting that in these cases not only does the phobia disappear, but in blood phobia the tendency to experience the vasovagal response at the sight of blood also lessens considerably.

It is now clear based on brain- imaging work that these treatments change brain functioning in an enduring way by modifying neural circuitry in such areas as the amygdala, insula, and cingulate cortex

After treatment, responsiveness is diminished in this fear-sensitive network but increased in prefrontal cortical areas, suggesting that more rational appraisals were inhibiting emotional appraisals of danger.
- Thus, these treatments “rewire” the brain

A new approach to the treatment of phobias is virtual reality exposure therapy.
- Virtual reality technology has recently gained interest as an effective medium for administering exposure therapy by putting phobic patients into an environment that simulates their real-world feared situation
- The Cyberpsychology Lab at the University du Québec en Outaouais is an interdisciplinary laboratory involved in some of the most innovative virtual reality phobia treatment research in the world.
- Several studies have shown this new form of exposure therapy to be effective in the treatment of phobias of heights, spiders, flying, and small spaces

In vivo exposure therapy has some risks and limitations in the treatment of driving phobia (e.g., real-world driving situations are unpredictable and hard to control, presenting difficulties in allowing for graduated exposure to increasingly more anxiety-provoking driving situations).
- These risks and limitations make virtual reality a promising alternative modality for treating driving phobias.

Question 39

Separation Anxiety Disorder - Specific phobia

Answer 39

All the anxiety disorders described may occur during childhood, and one additional anxiety disorder is unique to children.

Separation anxiety disorder is characterized by a child’s unrealistic and persistent worry that something will happen to his or her parents or other important people in the child’s life, or that something will happen to the child himself or herself that will separate him or her from his or her parents (e.g., the child will be lost or hurt in an accident).
- The child often refuses to go to school or to leave home, not because the child is afraid of school but because he or she is afraid of separating from loved ones.
- These fears can result in nightmares involving possible separation and by physical symptoms, distress, and anxiety

All young children experience separation anxiety to some extent; this fear usually decreases as the child grows older.
- Therefore, a clinician must judge whether the separation anxiety is greater than would be expected at that particular age
- It is also important to differentiate separation anxiety from school phobia.

In school phobia, the fear is clearly focused on something specific to the school situation; the child can leave the parents or other attachment figures to go somewhere other than school.

In separation anxiety, the act of separating from the parent or attachment figure provokes anxiety and fear.
- There is now evidence that separation anxiety, if untreated, can extend into adulthood in 35% of cases

Furthermore, very recent evidence suggests that we have overlooked this disorder in adults and that it occurs in 7% of the adult population over the life-time
- In some cases, the onset is in adulthood rather than carrying over from childhood.
- The focus of anxiety in adults is the same: That harm may befall loved ones during separation

For the treatment of separation anxiety, parents are often included to help structure the exercises and also to address parental reaction to childhood anxiety
- More recently, an intensive one-week program for girls ages 8 to 11 developed at one of our clinics in which the girls end up having a sleepover at the clinic has proved highly successful

Question 40

Social Anxiety Disorder (Social Phobia)

Answer 40

A much smaller number of people, who suffer severely around others, have social anxiety disorder (SAD), also called social phobia

Subtopics:

1. clinical description
2. statistics
3. Causes
4. Treatment
   a. Selective Mutism

Question 41

clinical description - Social Anxiety Disorder

Answer 41

SAD is more than exaggerated shyness

Can occur in athletes, and performers
- Actress Scarlett Johansson avoided doing Broadway for many years because of intolerable performance anxiety, in this case also called “stage fright.”
- The inability of a skilled athlete to throw a baseball to first base or a seasoned performer to appear on stage certainly does not match the concept of “shyness” with which we are all familiar.
- Many of these performers may well be among our more gregarious citizens.

And what if when you’re with other people you continually worry about a physical reaction you have that is very noticeable to others, but difficult to control? What if you blush to the extent that you’re so embarrassed that you can’t socialize? Or if your palms sweat so much that you’re reluctant to shake hands?

Individuals with just performance anxiety, which is a subtype of SAD, usually have no difficulty with social interaction, but when they must do something specific in front of people, anxiety takes over and they focus on the possibility that they will embarrass themselves.
- The most common type of performance anxiety, to which most people can relate, is public speaking.
- Other situations that commonly provoke performance anxiety are eating in a restaurant or signing a paper or cheque in front of a person or people who are watching.

Anxiety-provoking physical reactions include blushing, sweating, trembling, or, for males when urinating in a public restroom, “bashful bladder” or paruresis.
- Males with this problem must wait until a stall is available, a difficult task at times.

What these examples have in common is that the individual is very anxious only while others are present and maybe watching and, to some extent, evaluating their behaviour.
- This is truly SAD because the people have no difficulty eating, writing, or urinating in private.
- Only when others are watching does the behaviour deteriorate.

Question 42

statistics - Social Anxiety Disorder

Answer 42

According to the National Comorbidity Survey in the United States, as many as 13.3% of the general population experience SAD at some point in their lives
- This makes SAD the most prevalent psychological disorder in the United States.

Similarly, high rates of SAD were revealed in a Canadian community survey by Stein, Torgrud, and Walker
- They interviewed about 2000 people in Winnipeg, Calgary, Edmonton, and rural Alberta and found a one-year prevalence of 7.2% for SAD.
- According to the 2002 CCHS—Mental Health and Wellness, 8.1% of Canadians reported SAD at one point in their lifetime, with 3% indicating they had experienced SAD during the past year
- The sex ratio favours females only somewhat (1.4:1.0), unlike other anxiety disorders where females predominate more drastically
- This distribution differs a bit from the sex ratio of people with SAD who appear at clinics, which is nearly 50–50, suggesting that males may seek help more frequently, perhaps because of career-related issues.

SAD usually begins during adolescence, with a peak age of onset at 15 years old.
- SAD also tends to be more prevalent in people who are young (18 to 29 years old), undereducated, single, and of low socioeconomic class.
- Prevalence declines slightly among seniors. Considering their difficulty meeting people, it is not surprising that a greater percentage of individuals with SAD are single than in the population at large.
- The Ontario Mental Health Survey further suggests that individuals with this disorder are more likely to drop out of school

SAD distributes relatively equally among different ethnic groups
- In a cross-national study of the rates of SAD in Canada, the United States, Puerto Rico, and Korea, the authors found that the lifetime prevalence of the disorder was quite similar across the four countries surveyed.
- They did find, however, some different expressions of SAD cross-culturally
- In the United States, white Americans are typically more likely to be diagnosed with SAD (as well as GAD and panic disorder) than African Americans, Hispanic Americans, and Asian Americans
- Cross-national data suggest that Asian cultures show the lowest rates of SAD, whereas Russian and U.S. samples show the highest rates
- In Japan, the clinical presentation of anxiety disorders is best summarized under the label shinkeishitsu. One of the most common subcategories is referred to as taijin kyõfushõ, which resembles SAD in some of its forms. Japanese people with this form of SAD strongly fear embarrassing others, because they believe some aspect of their personal presentation (blushing, stuttering, body odour, etc.) will appear reprehensible. Thus, the focus of anxiety in this disorder is on offending or embarrassing others rather than embarrassing themselves, as in SAD. Japanese males with this disorder outnumber females by a three-to-two ratio. More recently, it has been established that this syndrome is found in many cultures around the world but predominantly in Asian cultures (Vriends et al., 2013).
- Nevertheless, one manifestation of this set of symptoms called “olfactory reference syndrome” has been reported in North America. The key feature is preoccupation with a belief that one is embarrassing oneself and offending others with a foul body odour. As such, it seems to resemble obsessive-compulsive disorder more than SAD, and seems to respond to psychological treatments used to treat obsessive-compulsive disorder

Although it makes intuitive sense that cross-cultural differences in social norms may relate to differences in the extent of social anxiety, cultural factors are rarely investigated in research on SAD.
- Heinrichs conducted a cross-cultural study that showed that collectivistic countries (e.g., Japan, Spain, and Korea) were more accepting toward socially reticent and withdrawn behaviours than were individualistic countries (e.g., Canada, Australia, the Netherlands, Germany, and the United States).
- Collectivistic countries also reported more social anxiety and greater fear of blushing.
- The more that attention-avoiding behaviours were accepted in a given culture, the greater were the levels of social anxiety.
- These fascinating results suggest that variations in SAD rates across countries may be related to differences in cultural norms

Question 43

causes - Social Anxiety Disorder

Answer 43

Wwe learn more quickly to fear angry expressions than other facial expressions, and this fear diminishes much more slowly than other types of learning.
- Lundh and Öst demonstrated
that people with SAD who saw a number of pictures of faces were likely to remember critical expressions.
- Mogg and colleagues showed that socially anxious individuals more quickly recognized angry faces than nonanxious individuals, who themselves remembered the accepting expressions.
- Other studies show that individuals with SAD react to angry faces with greater activation of the amygdala and less cortical control or regulation than nonanxious individuals
- Fox and Damjanovic demonstrated that the eye region specifically is the threatening area of the face.

Why should we inherit a tendency to fear angry faces?
- Our ancestors probably avoided hostile, angry, domineering people who might attack or kill them.
- in all species, dominant, aggressive individuals high in the social hierarchy tend to be avoided.
- Possibly, individuals who avoided people with angry faces were more likely to survive and pass their genes down to us

Jerome Kagan and his colleagues have demonstrated that some infants are born with a temperamental profile or trait of inhibition or shyness that is evident as early as 4 months of age.
- Four-month-old infants with this trait become more agitated and cry more frequently when presented with toys or other age-appropriate stimuli than infants without the trait.
- There is now evidence that individuals with excessive behavioural inhibition are at increased risk for developing phobic behaviour

A model of the etiology of SAD would look somewhat like models of panic disorder and specific phobia.

3 pathways to SAD are possible:

1. Someone could inherit a generalized biological vulnerability to develop anxiety, a biological tendency to be socially inhibited, or both.
   - The existence of a generalized psychological vulnerability—such as the belief that events, particularly stressful events, are potentially uncontrollable—would increase an individual’s vulnerability.
   - When under stress, a person could have anxiety and self-focused attention could increase to the point of disrupting performance, even in the absence of a false alarm (panic attack).
2. When under stress, someone might have an unexpected panic attack in a social situation that would become associated (conditioned) to social cues.
   - The individual would then become anxious about having additional panic attacks in the same or similar social situations.
3. Someone might experience a real social trauma resulting in a true alarm.
   - Anxiety would then develop (be conditioned) in the same or similar social situations.
   - Traumatic social experiences may also extend back to difficult periods in childhood.
   - Early adolescence—usually ages 12 through 15—is when children may be brutally taunted by peers who are attempting to assert
   their own dominance.
   - This experience may produce anxiety and panic that are reproduced in future social situations.

92% of adults with SAD experienced severe teasing and bullying in childhood, compared with only 35% to 50% percent among people with other anxiety disorders.

Lynn Alden is a leading expert in interpersonal processes that contribute to SAD.
- She has outlined an interpersonal transaction cycle whereby individuals’ interactions with people in their social environment contribute to and maintain social anxiety.
- More specifically, people with SAD have biased social perceptions and expectations that lead them to behave in certain maladaptive ways in social situations.
- The social behaviour of the socially anxious person in turn elicits negative reactions from others, which confirms the biased perceptions

Alden and others have conducted considerable research on the various aspects of this hypothesized interpersonal cycle.
- For example, in some situations, people with SAD incorrectly interpret others’ behaviour as cold or unfriendly and they selectively attend to negative social information and to anxiety-related symptoms that are noticeable to others, such as blushing
- People with SAD also make more “upward comparisons” (i.e., assessments that someone else is superior to them) and fewer “downward comparisons” than others, and that the upward comparisons that people with SAD make cause them more anxiety and distress
- Although people with SAD do not always show maladaptive social behaviour, in certain situations they do. For example, when they are faced with a critical, controlling person, people who have SAD avert their eyes, talk less, and engage in less personal disclosure. In turn, this behaviour evokes distinct negative reactions from other people: Socially anxious individuals are rated more negatively by others on a variety of measures, including being rated as less intelligent by peers during social interactions, and other people are less likely to desire future interactions with a socially anxious person after a first encounter
- Even when socially anxious individuals are not rated more negatively by others, they are perceived less accurately—thus, they are more difficult to get to know
- These reactions from other people likely loop back to reinforce the biased social perceptions of people with social anxiety. And so the cycle continues.

But one more factor must fall into place to label it SAD.
- The individual with the vulnerabilities and experiences described must also have learned that social evaluation specifically can be dangerous.
- evidence indicates that some people with SAD are predisposed to focusing their anxiety on events involving social evaluation.
- Some investigators suggest that the parents of people with SAD are significantly more socially fearful and concerned with the opinions of others than are the parents of patients with panic disorder and that they pass this concern on to their children.

Fyer, Mannuzza, Chapman, Liebowitz, and Klein reported that the relatives of people with SAD had a significantly greater risk of developing the disorder than the relatives of individuals without SAD (16% versus 5%)—thus, specific psychological vulnerability.

Interestingly, this psychological vulnerability factor may itself have a biological basis.
- A twin study by Stein, Jang, and Livesley showed that the tendency to fear being negatively evaluated by others is moderately heritable.

Thus, as you can see, a combination of biological, psychological, and interpersonal events seem to lead to the development of SAD.

Question 44

treatment - Social Anxiety Disorder

Answer 44

Effective treatments have been developed for SAD

Rick Heimberg developed a cognitive-behavioural group therapy program in which groups of patients rehearse or role-play their socially phobic situations in front of one another
- The group members participate in the role-playing, for example, acting as an audience for someone who has extreme difficulty giving a speech.
- At the same time, the therapist conducts rather intensive cognitive therapy aimed at uncovering and changing the automatic or unconscious perceptions of danger that the socially phobic client assumes to exist.
- These treatments have proven to be more effective than comparison treatments involving education about anxiety and social phobia and social support for stressful life events.
- More important, a follow-up after 5 years indicates that the therapeutic gains are maintained

Virtual reality technology can also be used with socially anxious individuals, and this approach may be even more efficient and cost-effective than treatment involving in vivo exposure

Clark evaluated a new and improved cognitive therapy program that emphasized more real-life experiences during therapy to disprove automatic perceptions of danger.
- This program substantially benefited 84% of individuals receiving treatment, and these results were maintained at a one-year follow-up.
- This outcome is the best yet for this difficult condition and significantly better than previous approaches to which it has been compared.
- Subsequent studies indicated that this treatment was clearly superior to a second very credible treatment, interpersonal psychotherapy (IPT), both immediately after treatment and at a one-year follow-up, even when delivered in a centre specializing in treatment with IPT

A similar approach was developed at our centre. This treatment specifically targets the different factors that are maintaining the disorder.
- One important reason why SAD is maintained in the presence of repeated exposure to social cues is because individuals with SAD engage in a variety of avoidance and safety behaviours to reduce the risk of rejection and, more generally, prevent patients from critically evaluating their catastrophic beliefs about how embarrassed and foolish they will look if they attempt to interact with somebody.
- Social mishap exposures directly target the patients’ beliefs by confronting them with the actual consequences of such mishaps, such as what would happen if you spilled something all over yourself while you were talking to somebody for the first time
- As a group intervention, this treatment was associated with an 82% completion rate and a 73% response rate, which was maintained at six-month follow-up
- Brain-imaging studies showed that brain measures before treatment can strongly predict the extent to which CBT reduces symptoms in patients with SAD and that CBT leads to changes in brain activity associated with emotional processing

We have adapted these protocols for use with adolescents, directly involving parents in the group treatment process.
- Results of numerous studies suggest that severely socially anxious adolescents can attain relatively normal functioning in school and other social settings after receiving CBT
- Several clinical trials have now compared individual and family-based treatment approaches for youth with social anxiety; while both treatment approaches appear to be equally efficacious,. family-based treatment appears to outperform individual treatment when the child’s parents also have an anxiety disorder
- A more recent long-term follow-up study indicates that youth who receive a parent component as part of anxiety treatment are significantly more likely to be diagnosis-free 3 years following treatment; and a family-based intervention can even prevent the onset of anxiety disorders in the children of anxious parents
- OVERALL, once the child develops an anxiety disorder, early treatment with CBT can be successful to treat the symptoms or prevent future problems with anxiety, with a slight advantage of family-based CBT over child-based CBT

Effective drug treatments have been discovered as well
- For a time, clinicians assumed that beta- blockers (drugs that lower heart rate and blood pressure, such as Inderal) would work, particularly for performance anxiety, but the evidence did not seem to support that contention
- Since 1999, the SSRIs Paxil, Zoloft, and Effexor have received approval for treatment of SAD—based on studies showing effectiveness compared with placebo

Several major studies have compared psychological and drug treatments.
- One study compared Clark’s cognitive therapy with the SSRI drug Prozac, along with instructions to the patients with SAD to attempt to engage in more social situations (self-exposure).
- Another group received placebo plus instructions to attempt to engage in more social activities.
- Both treatments did well, but the psychological treatment was substantially better at all times, with most patients improving with few remaining symptoms.
- Gains made during cognitive therapy were maintained when assessed after 5 years

The evidence is mixed on the usefulness of combining SSRIs or related drugs with psychological treatments.
- Davidson, Foa, and Huppert found that a CBT and an SSRI were comp rable in efficacy but that the combination was no better than the 2 individual treatments.

Question 45

selective mutism - Social Anxiety Disorder

Answer 45

Now grouped with the anxiety disorders in the DSM-5, selective mutism is a rare childhood disorder characterized by a lack of speech in one or more settings in which speaking is socially expected.
- it seems driven by social anxiety, since the failure to speak is not because of a lack of knowledge of speech or any physical difficulties, nor is it due to another disorder in which speaking is rare or can be impaired such as autism spectrum disorder.

Speech in SM commonly occurs in some settings, such as home, but not others, such as school—hence, the term “selective.”

To meet diagnostic criteria for SM, the lack of speech must occur for more than 1 month and cannot be limited to the first month of school.
- Further evidence that this disorder is strongly related to social anxiety is found in the high rates of comorbidity of SM and anxiety disorders, particularly SAD
- In fact, in one study nearly 100% of a series of 50 children with SM also met the criteria for SAD
- Another recent study found substantially more social anxiety in children with SM than a matched control group without SM
- Estimates of the prevalence of SM average about 0.5% of children, with girls more affected than boys

Why does lack of speech in certain situations emerge as the specific symptom in SM instead of other socially anxious behaviours?
- It is not entirely clear yet, but there is some evidence that well-meaning parents enable this behaviour by being more readily able to intervene and “do their talking for them”

Treatment employs many of the same cognitive-behavioural principles used successfully to treat social anxiety in children but with a greater emphasis on speech

For example, in one of our clinics we run a specialized program called the Boston University Brave Buddies Camp.
- This is a week-long intensive group treatment program for children ages 4 to 8 who have been diagnosed with SM or have difficulty speaking in social or school situations with familiar or unfamiliar peers and adults.
- The BU Brave Buddies Camp provides guided opportunities for children to interact with a number of new children and adults, participate in classroom-like activities (e.g., morning meeting, circle time, show and tell, group creative projects), engage in field trips (e.g., to the library, the park), and play socializing games that promote verbal participation (“brave talking”) and spontaneous speaking.
- This approach uses behavioural interventions such as modelling, stimulus fading, and shaping that allow for gradual exposure to the speaking situation; these techniques are combined with a behavioural reward system for participation in treatment
- Results from this program have been very encouraging: 80% of 15 children who participated in this camp were successfully initiating speech and maintaining speech productivity at a two-year follow-up.
- Unfortunately, these highly specialized programs are not readily available yet

Question 46

Anxiety, Fear, and Panic

Answer 46

Anxiety is a negative mood state characterized by bodily symptoms of physical tension and apprehension about the future (American Psychiatric Association, 2013; Barlow, 2002).

Fear is an immediate alarm reaction to dangerous or life-threatening situations.

A panic attack is an abrupt experience of intense fear or acute discomfort accompanied by physical symptoms such as heart palpitations, chest pain, shortness of breath, and dizziness.

Rates of comorbidity among anxiety and related disorders (and depression) are high. Anxiety disorders also co-occur with several physical conditions.

Having any anxiety or a related disorder uniquely increases the chances of having thoughts about suicide (suicidal ideation) or making suicidal attempts, but the relationship is strongest with panic disorder and post-traumatic stress disorder.

Question 47

Causes of Anxiety

Answer 47

1. Biological Contributions
   Anxiety associated with:
   Specific brain circuits
   Neurotransmitter systems
   Corticotropin-releasing factor (CRF) system
   Behavioural inhibition system (BIS)
   fight/flight system (FFS)

Biological contributions for anxiety and panic suggest that people inherit the tendency to be anxious or highly emotional.

Depleted levels of gamma aminobutyric acid (GABA), part of the GABA–benzodiazepine system, are associated with increased anxiety, although the relationship is not quite so direct. The noradrenergic system has also been implicated in anxiety (Hermans et al., 2011).

CRF activates the hypothalamic–pituitary–adrenocortical (HPA) axis. The CRF system is also directly related to the GABA–benzodiazepine system and the serotonergic and noradrenergic neurotransmitter systems.

Behavioural inhibition system (BIS) is activated by signals from the brain stem of unexpected events, such as major changes in body functioning that might signal danger.

2. Psychological Contributions
   Anxious behaviour starts in childhood
   Feeling of no control over environment
   Overprotective and overintrusive parents
   Personality traits
   Anxiety sensitivity
   Conditioning develops
   Psychological contributions for anxiety and panic originated with Freud, who saw anxiety as a psychic reaction to danger surrounding the reactivation of an infantile fear situation. Behaviourists view anxiety as a product of classical conditioning or modelling.
3. Social Contributions
   Stressful life events
   Social, interpersonal, physical
   Lead to physical reactions
   Genetic contribution
   Social contributions focus on the relation between stressful life events as triggers for biological and psychological vulnerabilities for anxiety and panic.
4. An Integrated Model
   Triple vulnerability theory
   Generalized biological vulnerability
   Generalized psychological vulnerability
   Specific psychological vulnerability
   An integrated model of etiological risk factors considers the complex interaction among biological, psychological, experiential, and social variables.

Three Vulnerabilities Model
Figure 5.3, Page 126: The three vulnerabilities that contribute to the development of anxiety disorders. If individuals possess all three, the odds are greatly increased that they will develop an anxiety disorder after experiencing a stressful situation.