M4. Lesson 4.2: Anxiety & Related Disorders

Question 1

What can anxiety be defined as?

Answer 1

Anxiety can be defined as a negative mood state that is accompanied by bodily symptoms such as increased heart rate, muscle tension, a sense of unease, and apprehension about the future (APA, 2013; Barlow, 2002).

Question 2

What makes anxiety good?

Answer 2

Anxiety is what motivates us to plan for the future, and in this sense, anxiety is actually a good thing. It’s that nagging feeling that motivates us to study for that test, practice harder for that game, or be at our very best on that date.

Question 3

When does anxiety become a bad thing?

Answer 3

Some people experience anxiety so intensely that it is no longer helpful or useful. They may become so overwhelmed and distracted by anxiety that they actually fail their test, fumble the ball, or spend the whole date fidgeting and avoiding eye contact.

Question 4

When is anxiety considered a disorder?

Answer 4

If anxiety begins to interfere in the person’s life in a significant way, it is considered a disorder.

Question 5

Where do anxiety and closely related disorders emerge from?

Answer 5

Anxiety and closely related disorders emerge from “triple vulnerabilities,” a combination of biological, psychological, and specific factors that increase our risk for developing a disorder (Barlow, 2002; Suárez, Bennett, Goldstein, & Barlow, 2009).

Question 6

What are biological vulnerabilities?

Answer 6

Biological vulnerabilities refer to specific genetic and neurobiological factors that might predispose someone to develop anxiety disorders. No single gene directly causes anxiety or panic, but our genes may make us more susceptible to anxiety and influence how our brains react to stress (Drabant et al., 2012;Gelernter & Stein, 2009; Smoller, Block, & Young, 2009).

Question 7

What are psychological vulnerabilities?

Answer 7

Psychological vulnerabilities refer to the influences that our early experiences have on how we view the world. If we were confronted with unpredictable stressors or traumatic experiences at younger ages, we may come to view the world as unpredictable and uncontrollable, even dangerous (Chorpita & Barlow, 1998; Gunnar & Fisher, 2006).

Question 8

What are specific vulnerabilities?

Answer 8

Specific vulnerabilities refer to how our experiences lead us to focus and channel our anxiety (Suárez et al., 2009).

Question 9

What are examples of specific vulnerabilties?

Answer 9

If we learned that physical illness is dangerous, maybe through witnessing our family’s reaction whenever anyone got sick, we may focus our anxiety on physical sensations. If we learned that disapproval from others has negative, even dangerous consequences, such as being yelled at or severely punished for even the slightest offense, we might focus our anxiety on social evaluation. If we learn that the “other shoe might drop” at any moment, we may focus our anxiety on worries about the future.

Question 10

Biological, psychological, and specific vulnerabilities directly cause anxiety disorder on their own. True or False.

Answer 10

False. None of these vulnerabilities directly causes anxiety disorders on its own—instead, when all of these vulnerabilities are present, and we experience some triggering life stress, an anxiety disorder may be the result (Barlow, 2002; Suárez et al., 2009).

Question 11

People with generalized anxiety disorder (GAD) have a difficult time with turning off their worries. True or False.

Answer 11

True.

Most of us worry some of the time, and this worry can actually be useful in helping us to plan for the future or make sure we remember to do something important. Most of us can set aside our worries when we need to focus on other things or stop worrying altogether whenever a problem has passed. However, for someone with generalized anxiety disorder (GAD), these worries become difficult, or even impossible, to turn off.

Question 12

What do people with GAD usually worry about?

Answer 12

They may find themselves worrying excessively about a number of different things, both minor and catastrophic.

Question 13

What are the symptoms of GAD?

Answer 13

Their worries come with a host of other symptoms such as muscle tension, fatigue, agitation or restlessness, irritability, difficulties with sleep (either falling asleep, staying asleep, or both), or difficulty concentrating.

Question 14

How long does the person have to experience anxiety to be diagnosed with GAD according to the DSM-5?

Answer 14

The DSM-5 criteria specify that at least six months of excessive anxiety and worry of this type must be ongoing, happening more days than not for a good proportion of the day, to receive a diagnosis of GAD.

Question 15

What makes a person with GAD worry more than the average person?

Answer 15

1. Research shows that individuals with GAD are more sensitive and vigilant toward possible threats than people who are not anxious. This may be related to early stressful experiences, which can lead to a view of the world as an unpredictable, uncontrollable, and even dangerous place.
2. Some have suggested that people with GAD worry as a way to gain some control over these otherwise uncontrollable or unpredictable experiences and against uncertain outcomes (Dugas, Gagnon, Ladouceur, & Freeston, 1998). By repeatedly going through all of the possible “What if?” scenarios in their mind, the person might feel like they are less vulnerable to an unexpected outcome, giving them the sense that they have some control over the situation (Wells, 2002).
3. Others have suggested people with GAD worry as a way to avoid feeling distressed (Borkovec, Alcaine, & Behar, 2004). For example, Borkovec and Hu (1990) found that those who worried when confronted with a stressful situation had less physiological arousal than those who didn’t worry, maybe because the worry “distracted” them in some way.

Question 16

What is the problem of “what if”-ing for people with GAD?

Answer 16

The problem is, all of this “what if?”-ing doesn’t get the person any closer to a solution or an answer and, in fact, might take them away from important things they should be paying attention to in the moment, such as finishing an important project.

Question 17

What happens when a catastrophic event that someone with GAD was worrying about doesn’t materialize?

Answer 17

Many of the catastrophic outcomes people with GAD worry about are very unlikely to happen, so when the catastrophic event doesn’t materialize, the act of worrying gets reinforced (Borkovec, Hazlett-Stevens, & Diaz, 1999).

Question 18

What is an example of the cycle of worry being perpetuated within someone with GAD?

Answer 18

For example, if a mother spends all night worrying about whether her teenage daughter will get home safe from a night out and the daughter returns home without incident, the mother could easily attribute her daughter’s safe return to her successful “vigil.” What the mother hasn’t learned is that her daughter would have returned home just as safe if she had been focusing on the movie she was watching with her husband, rather than being preoccupied with worries. In this way, the cycle of worry is perpetuated, and, subsequently, people with GAD often miss out on many otherwise enjoyable events in their lives.

Question 19

What is a “fight or flight” response?

Answer 19

Have you ever gotten into a near-accident or been taken by surprise in some way? You may have felt a flood of physical sensations, such as a racing heart, shortness of breath, or tingling sensations. This alarm reaction is called the “fight or flight” response (Cannon, 1929) and is your body’s natural reaction to fear, preparing you to either fight or escape in response to threat or danger.

Question 20

What is an “unexpected” panic attack or false alarm?

Answer 20

It’s likely you weren’t too concerned with these worrying sensations, because you knew what was causing them. But imagine if this alarm reaction came “out of the blue,” for no apparent reason, or in a situation in which you didn’t expect to be anxious or fearful. This is called an “unexpected” panic attack or a false alarm.

Question 21

What may people who experience these unexpected alarm reactions end up doing?

Answer 21

Because there is no apparent reason or cue for the alarm reaction, people might react to the sensations with intense fear, maybe thinking they are having a heart attack, or going crazy, or even dying. They might begin to associate the physical sensations they felt during this attack with this fear and may start to go out of your way to avoid having those sensations again.

Question 22

What symptom is at the heart of panic disorder (PD)?

Answer 22

Unexpected panic attacks are at the heart of panic disorder (PD).

Question 23

While unexpected panic attacks are at the heart of a panic disorder, what other symptoms must be present to receive a diagnosis of PD?

Answer 23

To receive a diagnosis of PD, the person must not only have unexpected panic attacks but also must experience continued intense anxiety and avoidance related to the attack for at least one month, causing significant distress or interference in their lives.

Question 24

What do people with a panic disorder tend to do?

Answer 24

People with panic disorder tend to interpret even normal physical sensations in a catastrophic way, which triggers more anxiety and, ironically, more physical sensations, creating a vicious cycle of panic (Clark, 1986, 1996). The person may begin to avoid a number of situations or activities that produce the same physiological arousal that was present during the beginnings of a panic attack. For example, someone who experienced a racing heart during a panic attack might avoid exercise or caffeine. Someone who experienced choking sensations might avoid wearing high-necked sweaters or necklaces.

Question 25

What is interoceptive avoidance?

Answer 25

Avoidance of internal bodily or somatic cues for panic has been termed interoceptive avoidance.

Question 26

What else can people with PD experience aside from continuous anxiety and avoidance?

Answer 26

The individual may also have experienced an overwhelming urge to escape during the unexpected panic attack.

Question 27

What can the urge for escape lead to in terms of PD?

Answer 27

This can lead to a sense that certain places or situations—particularly situations where escape might not be possible—are not “safe.” These situations become external cues for panic.

Question 28

What case does the person have to have to be considered for agoraphobia?

Answer 28

If the person begins to avoid several places or situations, or still endures these situations but does so with a significant amount of apprehension and anxiety, then the person also has agoraphobia.

Question 29

What can agoraphobia cause?

Answer 29

Agoraphobia can cause significant disruption to a person’s life, causing them to go out of their way to avoid situations, such as adding hours to a commute to avoid taking the train or only ordering take-out to avoid having to enter a grocery store.

Question 30

Why is agoraphobia considered as a separate disorder from PD in the DSM-5?

Answer 30

In some cases, agoraphobia develops in the absence of panic attacks and therefore is a separate disorder in DSM-5. But agoraphobia often accompanies panic disorder.

Question 31

What does a person need to meet criteria for a specific phobia?

Answer 31

To meet criteria for a diagnosis of specific phobia, there must be an irrational fear of a specific object or situation that substantially interferes with the person’s ability to function.

Question 32

What is an example of a specific phobia?

Answer 32

For example, a patient at our clinic turned down a prestigious and coveted artist residency because it required spending time near a wooded area, bound to have insects. Another patient purposely left her house two hours early each morning so she could walk past her neighbor’s fenced yard before they let their dog out in the morning.

Question 33

What are the four major subtypes of a specific phobia?

Answer 33

The list of possible phobias is staggering, but four major subtypes of specific phobia are recognized: blood-injury-injection (BII) type, situational type (such as planes, elevators, or enclosed places), natural environment type for events one may encounter in nature (for example, heights, storms, and water), and animal type.

Question 34

Aside from the main four, what is the fifth category?

Answer 34

A fifth category “other” includes phobias that do not fit any of the four major subtypes (for example, fears of choking, vomiting, or contracting an illness).

Question 35

What do most phobic reactions cause?

Answer 35

Most phobic reactions cause a surge of activity in the sympathetic nervous system and increased heart rate and blood pressure, maybe even a panic attack.

Question 36

How are people with BII type phobias different from others with other types of phobia?

Answer 36

People with BII type phobias usually experience a marked drop in heart rate and blood pressure and may even faint. In this way, those with BII phobias almost always differ in their physiological reaction from people with other types of phobia (Barlow & Liebowitz, 1995; Craske, Antony, & Barlow, 2006; Hofmann, Alpers, & Pauli, 2009; Ost, 1992).

Question 37

BII phobia is not genetic at all. True or False.

Answer 37

False. BII phobia also runs in families more strongly than any phobic disorder we know.

Question 38

SAD and shyness is the same. True or False.

Answer 38

False. Many people consider themselves shy, and most people find social evaluation uncomfortable at best, or giving a speech somewhat mortifying. Yet, only a small proportion of the population fear these types of situations significantly enough to merit a diagnosis of social anxiety disorder (SAD)(APA, 2013). SAD is more than exaggerated shyness (Bogels et al., 2010; Schneier et al., 1996).

Question 39

What should a person have to receive a diagnosis of SAD?

Answer 39

To receive a diagnosis of SAD, the fear and anxiety associated with social situations must be so strong that the person avoids them entirely, or if avoidance is not possible, the person endures them with a great deal of distress. Further, the fear and avoidance of social situations must get in the way of the person’s daily life, or seriously limit their academic or occupational functioning.

Question 40

What can lead to great isolation?

Answer 40

Fears of negative evaluation might make someone repeatedly turn down invitations to social events or avoid having conversations with people, leading to greater and greater isolation.

Question 41

What are the specific social situations that trigger SAD?

Answer 41

The specific social situations that trigger anxiety and fear range from one-on-one interactions, such as starting or maintaining a conversation; to performance-based situations, such as giving a speech or performing on stage; to assertiveness, such as asking someone to change disruptive or undesirable behaviors.

Fear of social evaluation might even extend to such things as using public restrooms, eating in a restaurant, filling out forms in a public place, or even reading on a train. Any type of situation that could potentially draw attention to the person can become a feared social situation.

Question 42

What is the diagnosis if the fear of social situations is only limited to performance-based situations?

Answer 42

If the fear is limited to performance-based situations, such as public speaking, a diagnosis of SAD performance only is assigned.

Question 43

What causes someone to fear social situations to such a large extent?

Answer 43

1. The person may have learned growing up that social evaluation in particular can be dangerous, creating a specific psychological vulnerability to develop social anxiety. For example, the person’s caregivers may have harshly criticized and punished them for even the smallest mistake, maybe even punishing them physically.
2. Or, someone might have experienced a social trauma that had lasting effects, such as being bullied or humiliated. Interestingly, one group of researchers found that 92% of adults in their study sample with social phobia experienced severe teasing and bullying in childhood, compared with only 35% to 50% among people with other anxiety disorders

Question 44

People with SAD can have unexpected panic attacks. True or False.

Answer 44

True. Someone else might react so strongly to the anxiety provoked by a social situation that they have an unexpected panic attack. This panic attack then becomes associated (conditioned response) with the social situation, causing the person to fear they will panic the next time they are in that situation.

Question 45

Why are unexpected panic attacks from SAD not considered PD as well?

Answer 45

Unexpected panic attacks due to social situations is not considered PD, however, because the person’s fear is more focused on social evaluation than having unexpected panic attacks, and the fear of having an attack is limited to social situations.