Anxiety and Fear: Understanding the Difference

• Fear is the body's response to a specific and serious threat to one's well-being
• Anxiety is the body's response to a vague sense of being in danger
• Fear and anxiety, although unpleasant, can be useful in "fight or flight" situations

Everyday Anxiety vs. Anxiety Disorder

• Everyday anxiety involves worry about paying bills, landing a job, romantic breakups, or other important life events
• Anxiety disorder involves constant and unsubstantiated worry that causes significant distress as well as interferes with daily life
• Everyday anxiety includes embarrassment or self-consciousness in an uncomfortable or awkward social situation
• Anxiety disorder involves avoiding social situations for fear of being judged, embarrassed, or humiliated
• Everyday anxiety might involve a case of nerves or sweating before a big test, business presentation, stage performance, or other significant event
• Anxiety Disorder involves seemingly out-of-the-blue panic attacks along with preoccupation with the fear of having another one

Anxiety Disorders

• Anxiety disorders are the most common mental disorders in the U.S.
• Yearly, 19% of adult population experiences one of the anxiety disorders according to the DSM-5
• Only 1/3 of these individuals receive treatment
• DSM-5-TR Anxiety Disorders include Generalized Anxiety Disorder (GAD), Phobias, Social Anxiety Disorder, and Panic Disorder
• Phobias include Specific Phobias and Agoraphobia

Generalized Anxiety Disorder (GAD)

• GAD involves excessive anxiety under most circumstances with worries about practically anything
• GAD is sometimes called "free-floating" anxiety
• GAD is common in Western society
• 4% of the US population in any given year has GAD
• GAD usually first appears in childhood or adolescence
• Women are more often diagnosed with GAD than men by a 2:1 ratio

GAD: The Sociocultural Perspective

• GAD is most likely to develop in people who have faced truly dangerous situations, such as Hurricane Ian 2022 and the Winter storms of 2022
• Higher rates of GAD occur in lower SES groups
• Other models attempt to explain in more depth why some people develop GAD, but others do not

GAD: The Psychodynamic Perspective

• Freud believed that all children experience anxiety
• Realistic anxiety occurs when they face actual danger
• Neurotic anxiety occurs when they are prevented from expressing id impulses
• Moral anxiety occurs when they are punished for expressing id impulses
• Inadequate defense mechanisms used to lead to the development of GAD
• Psychodynamic theorists today believe that the disorder can be traced to inadequate parent-child relationships
• Psychodynamic theory states therapy can identify and settle early relationship problems that continue to produce anxiety in adulthood
• People with GAD are particularly likely to use defense mechanisms, especially repression
• Adults, who as children suffered extreme punishment for expressing id impulses, have higher levels of anxiety later in life
• Psychodynamic treatments have show modest help to persons diagnosed with GAD

GAD: The Cognitive Perspective

• Psychological problems may be caused by dysfunctional ways of thinking
• Theorists have also come up with the idea that GAD is caused by maladaptive assumptions
• Albert Ellis identified core irrational assumptions:
  • One must be loved or approved of by virtually every person in their community
  • It is awful and catastrophic when things are not the way one wants them to be
• Aaron Beck theorized that people with GAD hold silent assumptions that imply imminent danger
  • A situation/person is unsafe until proven safe
  • It is always best to assume the worst
• Some researchers state that people with GAD hold maladaptive and silent assumptions, particularly about dangerousness

GAD: New Wave Cognitive Explanations

• Metacognitive theory: GAD individuals worry about worrying (meta-worry)
• Intolerance of uncertainty theory: Individuals consider it unacceptable that negative events may occur, and they constantly worry in an effort to find “correct” solutions
• Avoidance theory: People with GAD have unusually high levels of bodily arousal, and the the "positive" function of worrying serves to reduce unpleasant physical symptoms
• New wave cognitive explanations have received research support

GAD: Cognitive Perspective Treatment

• Treatments involve changing maladaptive assumptions
• Treatments are based on the work of Albert Ellis and Aaron Beck
• Treatments help clients understand the role that worrying plays, thus becoming more skilled at identifying worry, and then learning more constructive ways of coping

GAD: The Biological Perspective

• Biological theorists believe that biological factors cause GAD
• GAD is supported by genetic studies
• Biological relatives are more likely to have GAD (~15%) than general population (~4%)
• Possibly, home environment is a factor
• GABA inactivity is related to GAD
• GABA carries inhibitory messages, and when received, a neuron stops firing
• In the 1950s – Benzodiazepines (e.g. Valium) were discovered to reduce anxiety
• Benzodiazepines enhance the action of gamma-aminobutyric acid (GABA)
• Recent research has complicated the picture of GAD, because not only brain circuits but also amygdala (fear circuit) have to be taken into consideration

GAD: Biological treatments

• Antianxiety drug therapy can be used to regulate anxiety
• Early 1950s therapies involved Barbiturates (sedative-hypnotics)
• Late 1950s therapies used Benzodiazepines
• Benzodiazepines have the potential to cause physical dependence, produce undesirable effects (e.g. drowsiness), mix badly with certain other drugs (especially alcohol), and only provide temporary relief
• More recent therapies involve Antidepressant and antipsychotic medications (fast acting)
• Relaxation training is a non-chemical biological technique that helps treat GAD
• Research indicates that relaxation training is more effective than placebo or no treatment
• Biofeedback measures muscle tension with electromyograph (EMG) which provides feedback about muscle tension, and is best used with other approaches to treat certain related medical problems

Phobias

• Phobias are from the Greek word for “fear”
• Formal names for Phobias are also often from the Greek
• Common types of Phobias include specific animals or insects, heights, enclosed spaces, thunderstorms, and blood
• Most phobias technically are categorized as "specific”
• Each year 9% of the US population is diagnosed with phobias
• Many individuals suffer from more than one phobia at a time
• Women outnumber men at least 2:1 in reported diagnoses
• Most people with a specific phobia avoid seeking treatment
• People with agoraphobia are afraid of being in situations where escape might be difficult, should they experience panic
• In any given year, 1% of adults experience agoraphobia, and women are more likely to get it vs men (2:1)
• The behavioral explanation for what causes phobias is mostly supported, compared to others
• Phobias develop through conditioning
• Behaviorists propose a classical conditioning model, and after the fear has developed, the individuals avoid the object or situation they fear
• Phobias develop through modeling from observation and imitation
• Phobias may develop into GAD when a person acquires a large number of them (stimulus generalization from the Little Albert experiment)

How Are Specific Phobias Treated

• Each model offers treatment approaches but behavioral techniques are most widely used, including desensitization, flooding, as well as modeling, which are known as “exposure treatments”
• Systematic desensitization is used by professionals in the field
• Systematic desensitization technique was developed by Joseph Wolpe, involving teaching relaxation skills, creating a fear hierarchy, then pairing relaxation with what is feared
• The two types of systematic desensitization include In vivo desensitization (live), and Covert desensitization (imagined)
• Another kind of behavioral treatment is Flooding, which involves a forced non-gradual exposure
• Modeling involves a therapist who confronts the feared object while the fearful person observes
• Clinical research supports each of these treatment methods
• Virtual reality is an increasingly useful tool for therapists

How Is Agoraphobia Treated

• Behavioral therapy using an exposure approach is the most common and effective treatment
• Therapists also use support groups and home-based self-help programs
• Around 70% of clients with simple phobias or agoraphobia who receive exposure treatment show significant lasting improvement

Social Anxiety Disorder

• Social Anxiety Disorder involves severe anxiety about social or performance situations in which scrutiny by others as well as embarrassment might occur
• Someone might experience Narrow (talking, eating, using the restroom, writing in public) social anxiety
• Or someone might experience Broad (general fear of functioning poorly in front of others) social anxiety
• 7% of people in the U.S. (60% of them female) are diagnosed with social anxiety at some point
• Social anxiety often begins in childhood and may continue into adulthood
• Social anxiety can greatly interfere with life

What Causes Social Anxiety Disorder

• Cognitive theory is the leading explanation for social anxiety
• Cognitive theory suggests that social beliefs and that expectations work against them, including:
  • Unrealistic expectations of perfect social performance
  • Views of themselves as unattractive and socially unskilled
  • Expectations for social disasters

Treatments for Social Anxiety Disorder

• Overwhelming social fear and lack of social skills must be addressed in treatment
• Overwhelming social fear can be addressed behaviorally with exposure
• Lack of social skills be addressed with social skills and assertiveness trainings which have proved helpful
• Group therapy is often used
• Social fears are sometimes reduced through medication (particularly antidepressants)
• Psychotherapy does prove to be as effective, or slightly more effective than medication
• People treated with psychotherapy are less likely to relapse than people treated with drugs alone

Panic Disorder

• Panic can result when a real threat suddenly emerges
• Panic attacks, are experienced uniquely though
• 3.1% of the U.S. population is affected with panic disorder at some point
• Panic disorder tends to devedop in late adolescence and early adulthood
• Women are at least twice as likely as men to be affected
• Panic disorder is often (but not always) accompanied by agoraphobia
• Panic disorder sets the stage to develop agoraphobia

Panic Disorder: The Biological Perspective

• Biological factors contribute, including
  • Neurotransmitters that work Norepinephrine, serotonin and GABA
  • Brain circuits and the amygdala as the more complex root of the biological problems
• Genetic factors are included, such as twins with panic disorder
• Among monozygotic (identical) twins, the rate of panic disorder is as high as 31%
• Drug therapies can include Antidepressants which prove effective at preventing or reducing panic attacks and provide at least some improvement to 80% of patients - These improvements often require maintenance of drug therapy
• Some benzodiazepines (especially Xanax [alprazolam]) prove to be helpful

Panic Disorder: The Cognitive Perspective

• Full panic reactions are experienced by people who misinterpret bodily events
• Cognitive treatment is aimed at correcting such misinterpretations
• Step 1: Educate clients about condition
• Step 2: Teach clients to apply more accurate interpretations (especially when stressed)
• Step 3: Teach clients skills for coping with anxiety, like relaxation and specific breathing practices
• Cognitive treatments often help people with panic disorder
• At least 70% of treated patients stay panic-free for two years compared with 13% of control subjects, and cognitive treatment is at least as helpful as antidepressants
• Combination therapy may be most effective overall

Obsessive-Compulsive Disorder

• Obsessive-Compulsive Disorder is made up of Obsessions and Compulsions
• Obsessions involve persistent thoughts, ideas, impulses, or images that seem to invade a person's consciousness
• Compulsions involve repetitive and rigid behaviors or mental acts that people feel they must perform to prevent or reduce anxiety
• An OCD diagnosis is given when obsessions and compulsions feel excessive or unreasonable, cause great distress, take up much time, and interfere with daily functions
• Between 1% and 2% of U.S. population suffers from OCD in a given year
• OCD is equally common in men and women and among different racial and ethnic groups

Features of Obsessions

• Attempts to ignore or resist obsessions can trigger anxiety
• Common themes of obsessions involve Dirt/contamination, violence and aggression, orderliness, religion, and sexuality
• Most compulsions people recognize that their behaviors are unreasonable
• Compulsions often develop into rituals
• Common forms/themes of rituals include Cleaning, checking, order or balance, touching, verbal, and/or counting

OCD: The Cognitive-Behavioral Perspective

• OCD sufferers blame themselves for repetitive, unwanted, intrusive thoughts, and expect terrible things to happen
• As a result, neutralizing involves changing thoughts or actions to alleviate the sense of anxiety
• The neutralizing act helps to avoid or reduce anxiety and creates a cycle
• Treatment involves a cognitive component for education, where the professional identifies and challenges distorted cognitions
• Treatment also often involves a behavioral component, with exposure as well as response prevention (ERP), where homework is an important ongoing component
• 50 and 70 percent of clients improve considerably with treatment

OCD: The Biological Perspective

• Cortico-striato-thalamo-cortical brain circuit is in a state of Hyperactivity
• Biological therapies generally use Serotonin-based antidepressants
• Serotonin-based antidepressants bring improvement to 50-60% of those with OCD
• Relapse occurs if medication is stopped
• Combination therapy to treat OCD is best

Obsessive-Compulsive Related Disorders:

• Hoarding Disorder involves the extraordinary accumulation of items
• Trichotillomania involves repeatedly pulling out hair from different parts of the body
• Excoriation involves compulsively picking of skin, resulting in sores and wounds
• Body Dysmorphic Disorder involves preoccupation with perceived defects of flaws in one's physical appearance