Chapter 2: Anxiety Disorders PDF

CHAPTER 2 Anxiety disorders Peter McEvoy Maree Abbott CHAPTER OUTLINE & The nature and types of anxiety disorders & Specific phobias & Panic disorder and agoraphobia & Social anxiety disorder & Generalised anxiety disorder (GAD) & Summary LEARNING OBJECTIVES (LO) 2.1...

CHAPTER 2 Anxiety disorders Peter McEvoy Maree Abbott CHAPTER OUTLINE & The nature and types of anxiety disorders & Specific phobias & Panic disorder and agoraphobia & Social anxiety disorder & Generalised anxiety disorder (GAD) & Summary LEARNING OBJECTIVES (LO) 2.1 Describe the nature of anxiety and models regarding the aetiology of anxiety disorders. 2.2 Describe the diagnostic criteria, epidemiology, aetiology and treatments for specific phobias. 2.3 Describe the diagnostic criteria, epidemiology, aetiology and treatments for panic disorder and agoraphobia. 2.4 Describe the diagnostic criteria, epidemiology, aetiology and treatments for social anxiety disorder. 2.5 Describe the diagnostic criteria, epidemiology, aetiology and treatments for generalised anxiety disorder. ANXIETY DISORDERS: AN AUSTRALASIAN FOCUS Anxiety is a common and normal emotion that, like all emotions, can provide us with useful information. In fact, anxiety is so useful that our survival depends on it. When we perceive a threat in our environment, the symptoms of anxiety help us to respond to the threat in a way that maximises our chances of survival. Anxiety is accompanied by bodily symptoms (such as muscle tension and increased respiration rate), cognitions (such as thoughts or images of past, present and/ or future danger) and behaviours (freezing to appraise the threat, fighting the threat or fleeing from the threat). Anxiety disorders arise when the perception of threat, and therefore the persistence or intensity of the anxiety response, is clearly out of proportion to the actual threat. The threshold for determining whether someone’s anxiety could meet criteria for an anxiety disorder is if they are debilitated in some important way—for instance, if the anxiety interferes with their ability to maintain positive social relationships, complete their studies or perform at work. The most recent National Survey of Mental Health and Wellbeing included Australian adults aged 16–85 years, and found that 45 per cent of Australians will experience a mental disorder in their lifetime, with anxiety disorders being the most common (Australian Bureau of Statistics, 2008; Slade, Johnston, Oakley, Andrews, & Whiteford, 2009). In 2016, Mission Australia conducted a survey of nearly 22 000 young Australians aged 15–19 years (Bailey et al., 2016). While this survey did not include any questions about anxiety specifically, it did look at the related construct of stress and found that coping with stress was the most important issue concerning young people. In fact, almost half (44%) of young people stated that they were either very or extremely concerned about this issue. Thus, coping with stress outranked many other important issues facing young people such as study problems, body image, depression and family conflict. Given the high rates of anxiety disorders and stress, these conditions clearly do not discriminate, affecting people of all genders, ages, professions and socioeconomic circumstances. For example, Australian swimmer and Olympic gold continued rie66620_ch02_041-072.indd 41 08/02/17 06:48 AM  42 Abnormal psychology 4e medallist Susie O’Neill has spoken and written extensively about her experiences with severe social anxiety. Despite all her success, Susie still feared speaking to strangers and being the centre of attention while standing on the podium after winning a race. Australian actors Rebecca Gibney and Garry MacDonald have also spoken about their crippling anxiety and panic attacks. Although these famous Australians have spoken out, many others from all walks of life are suffering in silence. Many assume that they are alone or that their anxiety reflects negatively on them. Yet many people suffer from anxiety, and the fact that they continue to achieve their life goals, even with anxiety, is a sign of considerable strength and fortitude. DAL Given this reluctance to seek help, it is perhaps not surprising that only one in five people with anxiety as their Anxiety disorders are the most common class of principal complaint consult with a health professional for mental disorders according to the most recent their mental health problem, and only half of these people National Survey of Mental Health and Wellbeing. receive treatments known to be effective for anxiety disorders (Issikadis & Andrews, 2002). Treatments for anxiety disorders can be highly effective, but recognition and acceptance of the symptoms is the first critical step to seeking help. The Australian national depression initiative, beyondblue, is one organisation aiming to help people recognise if they have an anxiety disorder and encouraging them to seek help (www.beyondblue.org.au/the-facts/anxiety). The present chapter will first describe the nature of fear and anxiety disorders. The range of anxiety disorders will then be discussed, including specific phobias, panic disorder, agoraphobia, social anxiety disorder and generalised anxiety disorder. For each disorder, information regarding its diagnosis, epidemiology, aetiology and treatment will be presented. LO 2.1 Fear and anxiety disorders The nature of fear and anxiety disorders Fear is the immediate alarm reaction triggered by a perceived danger. Cannon (1929) described the fight or flight fear reaction to danger as the fight or flight response. As shown in Figure 2.1, this is an alarm response response in which the body reacts to prepare itself to deal with danger. The hormone adrenaline (also known Physiological as epinephrine) is released through the bloodstream to initiate bodily changes. For instance, blood changes in the pressure increases, with blood flow diverted towards the large muscle groups, and breathing increases human body that to provide extra oxygen for both the brain and muscles. Vision becomes more acute as the pupils dilate, occur in response to a perceived hearing improves and immediately unnecessary activities, such as digestion and immune responses, threat, including are inhibited. Together these responses allocate the body’s resources so that it can use the appropriate elevated heart behaviours of freezing (while the danger is appraised), flight (when the danger is approaching) and rate, metabolism, fight (if the danger is unavoidable). blood pressure, Acknowledging the capacity of the fight or flight response to prepare an organism to deal more breathing and effectively with a threat, Barlow (2002) has described it as a ‘true alarm’. That is, fear occurs in muscle tension; response to a direct danger, such as the impending attack of a wild animal. True alarms can be these changes prepare the body contrasted with ‘false alarms’ in which the fight or flight response occurs in situations that do not for resisting or represent an immediate physical threat. False alarms are the hallmark of anxiety disorders. fleeing from the Individuals differ in terms of the ease with which the alarm reaction is triggered (Andrews et al., source of threat. 2003) and three separate but related vulnerabilities have been identified that increase the sensitivity of the alarm trigger. This triple vulnerability includes (1) biological factors, (2) generalised psychological factors and (3) specific psychological factors (Barlow, 2002). A generalised biological vulnerability comprises the first component of this triple vulnerability. One example of a biological vulnerability is the fact that individuals seem to inherit a general rie66620_ch02_041-072.indd 42 08/02/17 06:48 AM  Chapter 2 Anxiety disorders 43 Focus mind Adrenaline release Pupils dilate Breathe faster Heart rate and Sweat blood pressure Clotting increases increase Digestion decreases Close bowel and bladder Muscles tense FIGURE 2.1 The fight or flight response predisposition towards anxiety and depressive disorders (Andrews, Stewart, Morris-Yates, & Holt, 1990). This clustering of emotional disorders around a common genetic vulnerability has been called ‘the general neurotic syndrome’. The second factor entails a generalised psychological vulnerability. This includes beliefs that the world is generally a dangerous place combined with broad expectations that events are beyond one’s control. For example, early life experiences of stress and loss have been found to foster a sense within the individual that s/he has minimal control over life events (Chorpita, Brown, & Barlow, 1998), and individuals who worry that life events are beyond their control have been found to be more prone to anxiety (Craig, Franklin, & Andrews, 1984). The third component refers to a specific psychological vulnerability. These are psychological factors that are specific to particular objects or situations and include factors that influence the expectation of a negative outcome when confronted with a specific object or event. Conditioning is one way to acquire such an expectation. During the paired occurrence of a conditioned stimulus and an aversive event (the unconditioned stimulus), an expectation of an aversive outcome develops and fear, as a conditioned response, occurs (Lovibond & Shanks, 2002). For example, if a person is bitten by a dog, then the processes of conditioning would result in the individual anticipating injury if confronted by that dog negative in the future. The individual would be increasingly likely to be afraid in the presence of the dog and reinforcement would avoid it if possible. The relief from anxiety caused by escape and avoidance would increase the Increasing the probability that future avoidance would occur through the process of negative reinforcement. In other frequency of words, the behaviours of escape and avoidance have been negatively reinforced (i.e., rewarded) as a a behaviour result of the reduction in anxiety. In addition, the process of generalisation would ensure that the fear (e.g., escape or avoidance) and avoidance would extend beyond the particular dog to other dogs and signals of the presence of through the dogs (e.g., parks). The initial response to the dog would be a true alarm, but thereafter many of the removal of alarms would be false. an aversive Conditioning is a direct way to learn about potential dangers, but indirect pathways include experience information and vicarious acquisition (Rachman, 1991). For example, individuals can acquire a fear (e.g., anxiety). rie66620_ch02_041-072.indd 43 08/02/17 06:48 AM  44 Abnormal psychology 4e of wolves and bears even though there is limited opportunity to experience aversive outcomes with these animals. The informational pathway describes the development of fear following the verbal transmission of danger-related information from others. In a study by researchers from the University of Queensland and Macquarie University, New South Wales, Barrett, Rapee, Dadds, and Ryan (1996) found that anxious children were even more avoidant of feared stimuli after discussing a potentially threatening situation with a parent. Thus, there is an interaction between the child and the parent, such that overly protective parental responses (e.g., warnings of danger) can amplify the anxiety reaction. In vicarious acquisition, fear is acquired through the process of modelling, whereby an individual observes another responding with fear to a threatening object or situation. The role of modelling has been demonstrated in the work of Cook and Mineka (1990) with rhesus monkeys. This research involved an experimental paradigm in which laboratory-reared monkeys (which have no fear of snakes) observed wild-reared monkeys (which exhibit a fear of snakes) in the presence of a snake. Following a single training session, the observer monkeys acquired a lasting fear of snakes. The common thread running through the conditioning, informational and vicarious acquisition pathways to fear is that, despite their differences, they all contribute to an individual developing an expectation that, given a particular set of circumstances, an aversive outcome is probable. This expectation of a negative outcome is, in turn, associated with the fear and avoidance of feared situations characterising anxiety disorders. Putting these three independent vulnerabilities together, anxiety disorders are caused by generalised biological, generalised psychological and specific psychological vulnerabilities that lower the threshold for the triggering of a false alarm reaction (i.e., a fear reaction to benign environmental occurrences). Barlow’s (2002) triple vulnerability model is shown in Figure 2.2. It is important to recognise that the specific vulnerabilities are relative rather than complete. That is, many of the specific psychological vulnerabilities will be associated with most anxiety disorders because comorbidity is the norm rather than the exception in clinical samples (i.e., it is likely that individuals will have more than one anxiety disorder), and the specific vulnerabilities are likely to be correlated with general distress, which is a common feature across emotional disorders. However, the specific vulnerabilities are thought to be more strongly associated with, and to play a more important role in maintaining, particular disorders (Brown & Naragon-Gainey, 2013). Generalised biological vulnerability Specific psychological ANXIETY vulnerability DISORDER Generalised psychological vulnerability FIGURE 2.2 Characterisation of Barlow’s (2002) triple vulnerability leading to an anxiety disorder While the triple vulnerability model emphasises similarities between the various anxiety disorders, other approaches seek to identify areas of both similarity and difference across these conditions. One such approach is to focus on three dimensions of emotions, namely, negative affectivity, positive rie66620_ch02_041-072.indd 44 08/02/17 06:48 AM  Chapter 2 Anxiety disorders 45 affectivity and autonomic arousal. Watson and Clark (1984) distinguished the tendency to experience autonomic negative affect from both positive affect and arousability of the autonomic nervous system (see the nervous system coloured ovals in Figure 2.3). Negative affectivity is subjective distress involving anxiety, disgust Part of the and anger. Positive affectivity involves feeling enthusiastic, active and alert. Therefore, low positive peripheral nervous system affectivity describes feelings of sadness and lethargy. These dimensions appear important in identifying that regulates factors that are shared across the anxiety disorders as well as those that are unique. involuntary functions such as heart rate, digestion, respiration rate Negative and perspiration; affectivity includes the sympathetic and parasympathetic nervous systems. Low Autonomic positive arousal affectivity Panic & Social GAD OCD Depression agoraphobia phobia FIGURE 2.3 The relationships between three dimensions of emotion across the anxiety disorders and depression as found by Brown and Barlow (2009) One example of this research is described by Brown and Barlow (2009) and the results are displayed in Figure 2.3. Each of the emotional disorders investigated (i.e., anxiety disorders, OCD and depression) share a common feature: they are all associated with elevations in negative affectivity (indicated by the arrows from the oval depicting negative affectivity). Thus, people with these disorders are high on trait anxiety (one aspect of negative affectivity) and hence are more likely to experience false alarms. Yet the disorders can also be distinguished from each other in terms of these emotional dimensions. Specifically, social phobia and depression are distinguished from the other disorders by the absence of positive affectivity in addition to the elevated negative affectivity (indicated by the arrows from the oval reflecting low positive affectivity). In addition, agoraphobia and panic disorder are distinguishable by their association with elevations in autonomic arousal (indicated by an arrow from the oval depicting autonomic arousal). One important feature of this research is that it shows both the common and the unique features of psychological disorders by revealing the extent to which they appear to be extreme variants on three underlying dimensions of emotion. Types of anxiety disorders Among the anxiety disorders listed in the current and fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) are specific phobia, panic disorder, agoraphobia, social anxiety disorder and generalised anxiety disorder. Each of these conditions is briefly described in Table 2.1. Prior to the DSM-5, obsessive-compulsive disorder and posttraumatic stress disorder were also classified as anxiety disorders, but each of these conditions is now contained in a separate category. rie66620_ch02_041-072.indd 45 08/02/17 06:48 AM  46 Abnormal psychology 4e TABLE 2.1 A summary of the anxiety and related disorders from the DSM-5 included in this chapter DISORDER DESCRIPTION Specific phobia Marked and persistent fear in response to the presence or anticipation of a specific object or situation Panic disorder Recurrent unexpected panic attacks Agoraphobia Anxiety about being in situations in which escape might be difficult or help may not be available (e.g., public transport, open spaces, enclosed spaces, crowds, outside home alone) in the event of experiencing panic symptoms Social anxiety disorder (social phobia) Marked fear of social situations where the person is exposed to possible scrutiny by others (e.g., social interactions, being observed, performing) Generalised anxiety disorder Excessive anxiety and worry about a number of events or activities Source: Adapted from the Diagnostic and Statistical Manual of Mental Disorders (5th ed.), copyright 2013, American Psychiatric Association. The tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10; World Health Organization, 1992) is an alternative classification system that contains a chapter for the neurotic, stress-related and somatoform disorders, and includes anxiety disorders. The ICD-10 distinguishes phobic anxiety disorders (e.g., specific phobias, agoraphobia and social phobia) from other anxiety disorders (e.g., panic disorder, generalised anxiety disorder, and mixed anxiety and depressive disorder). ‘Phobic anxiety disorders’ are described as those where the anxiety is evoked predominantly in specific situations that are not currently dangerous, but which are nonetheless avoided or endured with dread. For example, someone with social phobia feels extreme anxiety only when in social situations, and someone with a dog phobia feels extreme anxiety only when encountering a dog. ‘Other anxiety disorders’ are described as those for which the anxiety is not restricted to any particular situations. For example, panic attacks within panic disorder may occur in a variety of situations, and generalised anxiety disorder typically involves worry about all manner of things rather than any specific situation. The ICD is currently under review and a revised version (ICD-11) is due to be published in 2018. LO 2.2 Specific phobias The diagnosis of specific phobias specific phobia According to the DSM-5 (APA, 2013), the major feature of a specific phobia is a marked (intense), Anxiety disorder consistent (almost every time the trigger is encountered) and persistent (over a period of at least six characterised by months) fear reaction to the presence or anticipation of a specific object or situation. The individual extreme fear of attempts to avoid the phobic stimulus or endures it with intense anxiety. The fear must be out of a specific object or situation, proportion to the actual danger of the object or situation with respect to the person’s culture. The fear which results in and avoidance is severe to the point of causing emotional, social or occupational disruptions. Thus, the individual although phobic-type fears are common (Agras, Sylvester, & Oliveau, 1969), they become a phobic avoiding the disorder when the responses are disproportionate to the objective threat and the disruption to the object or person’s life is excessive. situation. The DSM-5 specifies four subtypes of phobias according to the primary focus of the fear: animal; natural environment (e.g., heights, storms and water); blood, injection and injury; and situational rie66620_ch02_041-072.indd 46 08/02/17 06:48 AM  Chapter 2 Anxiety disorders 47 (e.g., planes, elevators and enclosed places). This subtyping can be useful for treatment. For instance, for blood, injection and injury phobias there are distinct treatment implications stemming from the unique properties of this disorder (Marks, 1988; Page, 1994a). Individuals with this disorder may experience a decrease (rather than the usual increase) in blood pressure when faced with blood and injury and are thus prone to fainting. Fainting appears to have a separate inherited predisposition (Page & Martin, 1998) and may involve emotions such as disgust in addition to fear (Page, 2003). Treatment needs to address the fainting and for this reason additional techniques such as applied tension have been developed to give individuals greater control over their physiology and make fainting less likely (Vogele, Coles, Wardle, & Steptoe, 2003). Applied tension involves the deliberate application of muscle tension to raise blood pressure and therefore prevent fainting (Öst & Sterner, 1987). CASE STUDY: SPECIFIC PHOBIA John, a 35-year-old father of two children living in Western Australia, sought treatment for his dog phobia. The reason for presenting for treatment was that his children desperately wanted a dog and he was embarrassed that his fear would stop them from owning a pet. John was also very keen for his children to feel more comfortable around animals than he had been throughout most of his life. He described himself as a relatively social child, but he had been afraid of dogs since he was around 6 years of age. He remembers playing outside as a young child when he was devastated by seeing his family’s much-loved dog run over in front of him. His family then got another dog from the local pound, but this dog bit John on the face. He remembers the red rag used to soak up what seemed like ‘litres of blood’, and that he needed to go to the hospital to get stitches on his cheek and forehead. From that point on, John was highly distrustful of dogs and he started to shake whenever he encountered one at the park or in the street. He learnt to live with this fear by avoiding parks, but he reported becoming extremely anxious and panicky when he took his young children to the park and could not escape quickly if a dog appeared. He feared that he would not be able to protect his children if a dog approached them, so he eventually began avoiding taking his children to parks at all. John also actively avoided pursuing friendships with people who had pets, or insisted on meeting them at restaurants or cafes so that they could not bring their pets. John’s wife attends fitness classes with a personal trainer at the local park and John would like to start joining her, but he currently feels that this is impossible. He makes sure that he is locked inside his house when he knows there are going to be fireworks (e.g., on New Year’s Eve), because he finds the sound of the local dogs barking highly distressing. He will also listen to music using his sound-attenuating headphones until the fireworks are over and the dogs have settled down. He relies on his wife to let him know when ‘it’s all over’ and he becomes very angry if he is interrupted while the fireworks are still on. John also made sure that he bought an apartment after getting married in which neighbours were not allowed to have pets—this meant that when he eventually had his own family he had a good excuse not to own a dog. However, as his family grows, they need more space so he would like to buy a house and allow his children to own a pet. He is ashamed to tell his children that they cannot own a dog as a result of his phobia of dogs. The epidemiology of specific phobias As the case study demonstrates, most specific phobias begin in childhood and early adolescence (Öst, 1987). The prevalence of phobias is greater among children than among adults, suggesting that as children mature, many phobias tend to remit without treatment. The typical age of onset varies across the different phobias. For instance, claustrophobia tends to develop after adolescence, whereas animal phobias develop at about the age of 7 (Öst, 1987). The estimated lifetime prevalence of specific phobias is 7–9 per cent, with a female-to-male ratio of 2:1 (APA, 2013). Less than 1 per cent of individuals with a specific phobia seek treatment, even though, in adults, phobias tend to be chronic if untreated. The aetiology of specific phobias There is good evidence that phobias have a heritable component (Torgersen, 1979). In terms of psychological factors, Freud suggested that specific phobias arose from unresolved unconscious sexual conflict (see Eysenck, 1990, for a critique). However, the contemporary understanding of the origins rie66620_ch02_041-072.indd 47 08/02/17 06:48 AM  48 Abnormal psychology 4e of phobias can be traced back to Watson and Raynor (1920), who reported being able to classically condition a fear of a white rat (and related objects) in the infant ‘Little Albert’ by contingently pairing a tame white rat with a loud noise. While the notion that specific fears are classically conditioned has a strong empirical basis (Bouton, Mineka, & Barlow, 2001), there are data that call into question its ability to provide a complete explanation. For example, Di Nardo, Guzy, and Bak (1988) found that while nearly two-thirds of individuals with a dog phobia reported a conditioning event in which they had experienced a negative encounter involving a dog, an equivalent number of individuals without such a phobia reported a similar pairing of dogs with aversive events. Thus, even if the conditioning event is a necessary cause, it does not appear to be sufficient on its own to produce a phobia. Yet Menzies and Clarke (1995) even question the necessity of conditioning events, noting that the majority of phobic individuals cannot recall having experienced the pairing of an aversive event with their phobic object or situation. Thus indirect (information or vicarious transmission) learning pathways are also likely to be involved in the development of specific phobias. A further challenge to the notion that classical conditioning provides a complete account of the development of specific phobias is Seligman’s (1971) notion of ‘preparedness’. Seligman noted that prepared phobic fears were not evenly distributed across all possible stimuli. He explained the clustering of classical phobias around the dark, water, heights, insects or small animals by noting that each of these posed a conditioning significant biological threat to the ancestors of the species, thus suggesting a biological evolutionary Theory that basis for phobic fears. According to prepared classical conditioning, it should be easier to learn evolution has prepared people to associate fear with snakes and spiders rather than flowers and computers (despite some people to be easily believing they are technophobes!), and more difficult for these fears to be extinguished. Seligman’s conditioned to account inspired much research, including a study by Öhman, Erixon, and Löfberg (1975) in which fear objects or an aversive stimulus (electric shock) was contingently paired with pictures of prepared (snakes) situations that and unprepared (human faces and houses) stimuli. The researchers then examined extinction of were dangerous fear as indexed by the skin conductance response (SCR). The SCR is a measure of the amount of in prehistoric moisture on the hands, and the greater the fear, the more moisture should be reflected in a larger times. SCR. As expected, they found greater resistance to extinction of responses to the prepared compared exposure therapy to the unprepared stimuli. Specifically, the SCR demonstrated very little reduction over 10 trials Behavioural in which shock was no longer paired with snake pictures, whereas the SCR to the faces/houses technique in pictures disappeared immediately after shock was no longer given. Thus, while individuals may have which the client conditioning histories that influence the development of phobias, preparedness theory suggests that confronts the there are biological constraints on the type of stimuli for which phobias can be acquired (Mineka & feared stimuli that Zinbarg, 1996). s/he has avoided until his/her To summarise, specific phobias are false alarms—that is, instances of the fight or flight response anxiety reduces; triggered inappropriately or excessively in the presence of specific objects or situations. The fear there are various may have its origins in an accurate appraisal of a past dangerous event (e.g., a dog bite) that is then types of exposure inaccurately applied to a current innocuous event. The direct (conditioning) and indirect (information such as in vivo or vicarious transmission) pathways involve cognitions that certain stimuli will probably result in versus imaginal. certain negative outcomes. This learning occurs against a backdrop of a biological vulnerability in the in vivo exposure form of a genetic diathesis. In addition, phobias of certain stimuli may have a biological basis given Technique their evolutionary significance. of behaviour therapy in which clients The treatment of specific phobias confront their If specific phobias represent false alarms in which the fight or flight response is being triggered feared objects/ situations in real inappropriately because people have come to expect relatively innocuous objects and situations life (as opposed to signal danger, then effective treatment must involve procedures that modify these expectations. to imaginal Exposure-based treatments serve this function. In exposure therapy, the person with a phobia exposure). gradually faces the phobic stimulus in real life (known as in vivo exposure), by imagining it (known as rie66620_ch02_041-072.indd 48 08/02/17 06:48 AM  Chapter 2 Anxiety disorders 49 ‘imaginal exposure’), or by experiencing computer-generated virtual realities (Pull, 2005). Sometimes flooding exposure to phobic situations involves confronting the most fearful object or situation and continuing Behavioural the exposure until the anxiety has decreased, a procedure referred to as flooding. However, since the technique in which the client highly anxiety-provoking nature of flooding may not be acceptable to individuals, exposure therapy is intensively usually takes place according to a hierarchy, progressing from the least to the most feared objects and exposed to a situations. During the exposure session, the individual’s experience of anxiety is typically monitored feared object by the therapist using a Subjective Units of Discomfort Scale (SUDS), ranging from a score of 0 until his/ (no anxiety) to 100 (extreme anxiety). The individual continues to confront the phobic situation until her anxiety the SUDS scores decrease from the high range (70–100) to the lower range (10–40). Repeated exposure diminishes. results in reductions in anxiety both within an exposure session and from one exposure session to the extinction next. Following sufficient anxiety reduction, the person will begin exposure to the next item on the In learning theory, exposure hierarchy. Sometimes exposure is combined with anxiety management techniques such as elimination of relaxation training. a classically Reviews of treatment studies continue to find that in vivo exposure is the most effective treatment conditioned for specific phobias (Wolitzky-Taylor, Horowitz, Powers, & Telch, 2008). Moreover, treatment gains response by removal of the are generally maintained over the following year and can improve further if exposure continues after unconditioned treatment. While the effectiveness of exposure therapy for phobias is not disputed, the mechanisms stimulus or the responsible for anxiety reduction during exposure are the focus of much research, with the debate elimination of focusing on whether exposure works through behavioural and/or cognitive processes. A behavioural an operantly mechanism that may account for the effectiveness of exposure therapy is extinction. That is, through conditioned confronting conditioned feared stimuli (e.g., a dog) in the absence of any unconditioned stimuli (e.g., response by being bitten by the dog), the conditioned fear response gradually decreases. removal of the reinforcement. Habituation, whereby the intensity of fearful responding reduces upon repeated exposures to the feared stimulus, is one proposed mechanism of exposure therapy. According to the habituation model habituation of treatment, reductions in fear during and across exposure trials are necessary for treatment to be Lessening of effective. However, an important challenge to the habituation model is that the level of fear reduction an organism’s during exposure therapy does not predict fear responding in the long term. This suggests that other response with repetition of the factors are more important in consolidating new, non-fearful learning. stimulus. Contemporary behavioural accounts suggest that during exposure therapy the original association learnt between the conditioned stimulus (dog) and unconditioned stimulus (dog bite) is not erased, inhibitory but rather new inhibitory learning about the conditioned and unconditioned stimuli occurs (Craske, learning Treanor, Conway, Zbozinek, & Vervliet, 2014). Specifically, the new learning is that a conditioned Learning that stimulus no longer predicts an unconditioned stimulus. Rather than habituation, inhibitory learning occurs when new associations approaches emphasise the need to maximise expectancy violations during exposure. Expectancy between violation refers to the difference (i.e., prediction error) between an individual’s expectations of a conditioned situation (‘I will be bitten by the dog’) and the actual outcome (‘Wow! The dog was friendly and just stimuli (CS) and wanted a pat’). The greater the prediction error (the ‘wow factor’), the stronger the new inhibitory unconditioned learning. The implication of the inhibitory learning approach is that exposure therapy is guided by stimuli (US) are what the individual needs to learn about the feared stimulus based on their fear expectancies, rather developed during than whether anxiety reduces during that learning (as in the habituation model). From the case study exposure therapy. The original of John with a dog phobia, this would mean exposing him to dogs he believes will bite him, in a associations way that will maximally violate this expectation— dogs of different sizes, breeds, familiarity and between the CS apparent friendliness (within reason). The therapist would be less concerned about whether John’s and US are not anxiety reduces within or across exposure sessions, but would instead design exposure sessions that erased. will maximise his surprise when his feared outcome does not eventuate. self-efficacy Possible cognitive processes accounting for the effectiveness of exposure therapy include Person’s belief challenging expectations that danger will occur when confronted with the phobic stimulus. This that s/he has the increases self-efficacy (i.e., the level of confidence that the individual can cope in the phobic ability to succeed situation) by increasing perceptions of control over the phobic stimulus and the anxiety (Johnstone & in a specific Page, 2004). situation. rie66620_ch02_041-072.indd 49 08/02/17 06:48 AM  50 Abnormal psychology 4e LO 2.3 Panic disorder and agoraphobia The diagnosis of panic disorder and agoraphobia Earlier editions of the DSM grouped all disorders that involved escape or avoidance of particular feared objects or situations together and distinguished the ‘simple’ phobias, now called specific phobias, agoraphobia from the ‘complex’ phobia called agoraphobia. From the Greek, meaning ‘fear of the marketplace’, Anxiety disorder agoraphobia is frequently misunderstood as a fear of open spaces. However, agoraphobia is anxiety characterised about being in places where escape might be difficult or embarrassing, or in which help may not by a fear of be available, in the event of having a panic attack or panic symptoms (APA, 2013). As a result of situations in which it would anxiety, these situations are avoided, endured with extreme distress or require the presence of a be difficult to companion. Typical agoraphobic situations include being outside the home alone, travelling alone, escape or in tunnels, bridges, crowds and open spaces. Given the seemingly random clustering of feared situations, which help may it was understandable that agoraphobia was deemed to be a ‘complex phobia’. However, the apparent not be readily complexity became understandable once the unifying principle had been identified. This unifying available (such as principle was that the focus of the fear in agoraphobia was not the external environment, but rather the enclosed places fear of panic and its consequences in these environments. and crowds) A panic attack is defined as an episode of intense fear or discomfort in which there is a rapid increase in the event of experiencing in symptoms such as a pounding or racing heart; sweating; trembling; dizziness or faintness; choking/ panic symptoms. smothering sensations or shortness of breath; chills or heat sensations; and fears of dying, going crazy or losing control (APA, 2013). Panic disorder is diagnosed when the sufferer is plagued by recurrent panic attack unexpected panic attacks, with at least one month of (a) persistent concern or worry about additional Episode during which panic attacks or their consequences (e.g., the individual fearing that s/he is at risk of a heart attack) and/ an individual or (b) significant changes in behaviour related to the attack (e.g., avoiding any exercise because it may experiences a increase heart rate) (APA, 2013). Earlier versions of the DSM described diagnoses of ‘panic disorder rapid increase in with agoraphobia’ or ‘panic disorder without agoraphobia’, but the DSM-5 (APA, 2013) has separated the physiological panic disorder and agoraphobia so that they can be given together or on their own. Agoraphobia is and cognitive diagnosed when the sufferer experiences marked fear or anxiety about at least two of the following five symptoms of situations: (1) using public transport, such as buses and trains, (2) being in open spaces, such as car intense fear and discomfort. parks, (3) being in enclosed spaces, such as theatres and cinemas, (4) standing in queues or being in a crowd, and (5) being outside of home alone. The agoraphobic situations almost always trigger fear and panic disorder anxiety; they are actively avoided or are endured with intense fear or anxiety for at least a period of six Anxiety disorder months; and the fear or anxiety is out of proportion with the situation and cultural context. characterised by recurrent, unexpected panic The epidemiology of panic disorder and agoraphobia attacks. In the American National Comorbidity Survey, the lifetime prevalence of panic disorder was 4.7 per cent (Kessler et al., 2005). In the Australian National Survey of Mental Health and Wellbeing, the lifetime prevalence was 3.5 per cent for panic disorder and 2.3 per cent for agoraphobia (McEvoy, Grove, & Slade, 2011). One of the limitations of retrospective epidemiological surveys is that not everyone has passed through the risk period when they complete the survey. That is, a 20-year-old who completes the survey may not have developed the disorder as yet, but s/he may develop one later in life. When McEvoy and colleagues (2011) accounted for this statistically, the projected lifetime risk (i.e., the proportion of people likely to experience the disorder in their lifetime), the proportions were 5.0 per cent for panic disorder and 2.9 per cent for agoraphobia. The median ages of onset are 30 years and 22 years for panic disorder and agoraphobia, respectively. As with most other anxiety disorders, panic disorder occurs somewhat more often among females, with the proportion of females to males increasing as the severity of agoraphobia increases. Although the course of panic disorder tends to be chronic, its severity waxes and wanes over time. Given that most individuals with panic disorder do not seek treatment immediately (with the average duration until seeking treatment being 10 years), it is important for psychologists to become more proactive rie66620_ch02_041-072.indd 50 08/02/17 06:48 AM  Chapter 2 Anxiety disorders 51 in encouraging the prevention, early detection and treatment of panic disorder. Agoraphobia is also typically a chronic disorder unless it is actively treated, with only around 10 per cent of cases remitting on their own (APA, 2013). CASE STUDY: PANIC DISORDER AND AGORAPHOBIA Suzanne is a 24-year-old office worker who arrived at the clinic presenting as quiet and shaky. During her assessment by a psychologist, she reported an eight-year history of panic attacks, which she now experiences several times a week. The attacks interfere with virtually all aspects of her life, including her ability to leave the house, attend work and socialise with family and friends. She stated that she feels very depressed and hopeless about her future. Suzanne reported being a quiet child and adolescent who was somewhat wary of new situations, but she managed her uneasiness by focusing her attention on her studies and by reading books. She reported experiencing her first panic attack at the age of 16 when she was on a bus and was late for work. The first thing she noticed was that her heart was beating very fast and she had a sharp pain in her chest. The more she focused on these symptoms the more intense they felt, to the point where she thought she was having a heart attack. Suzanne immediately got off the bus and asked her father to pick her up and take her to the emergency department of the local hospital. The doctors ran a range of tests but could not find any medical reason for Suzanne’s symptoms, which led them to diagnose her as having had a panic attack. Despite the doctor’s reassurance, Suzanne was not so sure and she continued to keep a close eye on her symptoms. From that point on, she started noticing more symptoms, such as shortness of breath, a hastened pulse rate and dizziness. Suzanne started visiting her GP more and more regularly for checkups as the panic attacks became more frequent. She now understands that she is experiencing anxiety, but she fears having more panic attacks because they are such terrifying experiences, and when the symptoms are intense she still worries that her heart will ‘explode’. Suzanne’s panic attacks are now triggered by using public transport, being in places where help might not be available if she has another panic attack and, more recently, just by leaving the house. She also experiences panic attacks without warning that seem to come ‘out of the blue’. Suzanne has tried to use drugs and alcohol to manage her anxiety, but she now knows that the relief is temporary and that the next day her anxiety is worse. So after a long struggle, she has finally sought help from a psychologist to manage her anxiety. The aetiology of panic disorder and agoraphobia As displayed in Figure 2.4, the origins of panic disorder involve all three aspects of the triple vulnerability model (Barlow, 2002). It is theorised that individuals with a generalised biological vulnerability react more strongly to everyday stressors. As a consequence, the alarm reaction is Generalised psychological Anxious vulnerability PANIC ATTACK apprehension (e.g., anxiety sensitivity) Specific psychological Stressful life Flight or fight vulnerability: event alarm catastrophic misinterpretation of sensations Generalised biological vulnerability (e.g., neuroticism) FIGURE 2.4 The interaction of vulnerabilities giving rise to panic disorder rie66620_ch02_041-072.indd 51 08/02/17 06:48 AM  52 Abnormal psychology 4e neuroticism triggered at lower intensities of stress. Similar to other anxiety disorders, it has been proposed that the Personality inherited factor includes anxiety proneness, which is evident in constructs such as neuroticism (trait trait entailing anxiety). a tendency to However, the experience of false alarms is not sufficient to cause panic disorder. In fact, experience negative approximately 10 per cent of the general population experience occasional panic attacks, but only emotional states. about 3 per cent go on to develop panic disorder (Mattis & Ollendick, 2002). The psychological vulnerabilities account for the progression from having a panic attack to developing panic disorder. A generalised psychological vulnerability exacerbates the experience of a false alarm, and one such anxiety vulnerability is anxiety sensitivity (Reiss, Peterson, Gursky, & McNally, 1986). Individuals who are sensitivity high in anxiety sensitivity have a fear of arousal-related sensations in their body stemming from their Belief that the belief that these bodily sensations are dangerous. bodily symptoms The final element is a specific psychological vulnerability in which the individual specifically fears of anxiety the sensations of panic. According to Clark’s (1986) cognitive model of panic disorder, individuals have harmful consequences. misinterpret the physical sensations accompanying panic in a catastrophic manner (e.g., ‘I am going to have a heart attack’ or ‘I am going crazy’). These catastrophic misinterpretations will elicit the fight or flight response, which generates additional physical sensations. These physical sensations in turn become a focus of further misinterpretation. In short, the panic escalates in a spiral of arousal, tricyclic misinterpretation of the arousal as an indication of danger, and hence further arousal. Finally, the antidepressants psychological vulnerabilities increase further as the person worries about the possible occurrence (TCAs) of more panic attacks in the future. Such beliefs increase the likelihood of further arousal, which Class of is misinterpreted as a sign of impending catastrophe. Thus, the individual moves beyond a single antidepressant isolated panic attack to frequent panic attacks. drugs such as A study by Sanderson, Rapee, and Barlow (1989) tested the cognitive model of panic disorder by imipramine and examining the role of one particular catastrophic thought in producing panic attacks, namely, thoughts amitriptyline. regarding loss of control. In this study, individuals with panic disorder inhaled carbon dioxide, which selective induces body sensations similar to those occurring during a panic attack. Participants were told that serotonin when a light was on, they could reduce the amount of carbon dioxide they inhaled by turning a dial and reuptake thereby control the intensity of their bodily sensations. The light was on throughout the experiment inhibitors (SSRIs) for half of the participants but was never on for the remaining participants. However, unknown to the Class of participants was the fact that the dial was inoperative—that is, they had no actual control over the antidepressant amount of carbon dioxide they inhaled and hence the intensity of their bodily sensations. Of those drugs (such participants with the illusion of control, only 20 per cent panicked, whereas 80 per cent of participants as fluoxetine) who believed they had no control panicked. This study supports the role of a particular catastrophic that inhibit the reuptake of thought (the thought that one has no control over his/her experience) in producing panic attacks. serotonin. Agoraphobia can develop as a complication of panic disorder. Around 30 per cent of community samples and over 50 per cent of clinical samples report a history of panic attacks or panic disorder benzodiazepines prior to developing agoraphobia. People with panic attacks come to fear situations in which panic may Drugs (such as Valium and occur. Situations feared with phobic intensity include confined spaces such as lifts and trains (because Xanax) that escape may be difficult or help may not be available in case of panic) or crowded places such as movie reduce anxiety theatres and supermarkets (because escape may be difficult or embarrassing in case of panic). and insomnia. cognitive behaviour The treatment of panic disorder and agoraphobia therapy (CBT) Effective pharmacological treatments for panic disorder include tricyclic antidepressants (TCAs), Type of selective serotonin reuptake inhibitors (SSRIs) and high-potency benzodiazepines. These medications psychological can have various disadvantages that must be weighed up against their benefits. For instance, the treatment that benzodiazepines are dependence producing, the tricyclics can produce unpleasant side effects such as combines both cognitive and dizziness and a dry mouth, and the SSRIs may lead to sexual dysfunctions. behavioural Cognitive behaviour therapy (CBT) is an effective psychological treatment for panic disorder and concepts and agoraphobia (Andrews et al., 2003). A major aim of CBT is to address phobic avoidances, which can techniques. be external or internal. External phobic avoidances (e.g., supermarkets) are treated with graded in rie66620_ch02_041-072.indd 52 08/02/17 06:48 AM  Chapter 2 Anxiety disorders 53 vivo exposure, in which people first confront less fear-provoking shopping situations (such as a local newsagent) until only minimal fear is produced. They then proceed through a hierarchy of phobic situations until they are able to confront the most fear-provoking situation (such as waiting in a lengthy queue at a crowded supermarket). An example of a hierarchy is shown in Table 2.2. TABLE 2.2 Graded exposure hierarchy James feared travelling on public transport. He developed the following steps to achieve his goal, which was to travel to and from work on the bus. Step 1: Stand at the bus stop and watch buses come and go for 1 hour. Step 2: Travel one stop on a bus at a quiet time of day (10 am) Step 3: Travel two stops on a bus at a quiet time of day (10 am) Step 4: Travel two stops on a bus at a busy time of day (9 am) Step 5: Travel three stops on a bus at a quiet time of day (10 am) Step 6: Travel three stops on a bus at a busy time of day (9 am) Step 7: Travel 30 minutes on a bus at a busy time of day (9 am) Step 8: Travel 30 minutes on a bus at busy times of the day in the morning (9 am) and afternoon (5 pm) Step 9: Travel on the bus to and from work From an inhibitory learning perspective, it is less important whether an individual’s anxiety reduces during the exposure task or if the exposure is graded, although grading might help the individual tolerate treatment. Instead, the emphasis would be on maximising prediction errors by creating a situation that directly violates the individual’s expectations of the feared situation (e.g., ‘If I travel on a bus, I will panic and I will have to jump off or I will go crazy’). If Suzanne, from the case study on panic disorder, takes the risk of riding on a bus during therapy and discovers that (a) she is far less likely to panic than she thought, and/or (b) even if she does panic she can cope with this without having to jump off the bus or her heart exploding, this new learning will be most important for helping to reduce her anxiety in the longer term. Phobic avoidance can also be internal, in which the person is overly afraid of and avoids bodily sensations that may signal panic. This fear and avoidance can be treated using behavioural or cognitive techniques. As an example of the behavioural technique of interoceptive exposure, a person may fear interoceptive the sensations of hyperventilation (overbreathing) since hyperventilation paradoxically produces a exposure sensation of being short of breath. To confront these sensations in exposure therapy, the person is Behavioural asked to deliberately and repeatedly generate the feelings of hyperventilation by overbreathing until technique that entails exposing the fear of the sensations decreases. From an inhibitory learning perspective, the client is learning the individual to decouple physical sensations (shortness of breath) from feared expectancies (these symptoms will to the physical definitely lead to panic or death). To maximise the prediction error, the therapist might encourage sensations of a the client to intensely and repeatedly hyperventilate until the client is convinced that the physical panic attack. sensation is extremely unlikely (e.g., less than 5% likely) to lead to panic or death. Clients might also believe that even if the symptoms do not lead to panic or death, they are intolerable. This belief can also be tested through repeated exposure, with the therapist guiding the client to continually test their expectancies about what they can and cannot tolerate. Prediction errors can be maximised by encouraging the client to push themselves well beyond what they think they can tolerate (e.g., hyperventilate more intensely, more frequently and for longer durations). The degree to which clients are willing to take these risks will determine the rate of improvement and the likelihood of long-term improvement. rie66620_ch02_041-072.indd 53 08/02/17 06:48 AM  54 Abnormal psychology 4e The fear of panic can also be addressed with cognitive techniques that aim to change the false beliefs a person has about panic and its sensations. Common beliefs associated with panic are that the symptoms signal that the person is about to die, go crazy or lose control. In cognitive restructuring, the person learns to challenge false beliefs by examining the evidence supporting and disconfirming these beliefs. Psychoeducation is one way of achieving this aim, whereby the psychologist provides corrective information about the true basis of panic attacks. For instance, as shown in Table 2.3, information may be given to teach the person about the nature of panic attacks as false alarms rather than being a sign of a real danger. Psychoeducation is usually the first step in effective treatments. If the client understands the alternate, more benign explanation for their symptoms, and believes the explanation is plausible, then they will be much more willing to start confronting their fears in order to learn to manage their symptoms in more helpful ways. TABLE 2.3 An example of psychoeducation for panic disorder Some alarms are false alarms. You may have seen a shop alarm go off. Although you weren’t trying to steal anything, the alarm still reacts as though you’re a burglar. The problem is that the alarm is too sensitive. In the same way, anxiety problems start when the fight or flight response is too sensitive. When the alarm is too sensitive, the fight or flight response is triggered at the wrong times. If your anxiety alarm goes off too easily, you will be more likely to become anxious in situations where other people would not feel anxious. Source: Adapted from Page, A. C., & Stritzke, W. G. K. (2006). Clinical psychology for trainees: Foundations of science-informed practice. Cambridge: Cambridge University Press. These cognitive-behavioural treatments for panic and agoraphobia have been found to be highly effective. For instance, Craske, Brown, and Barlow (1991) found that over 80 per cent of the participants treated with CBT remained panic-free up to two years after treatment. Effective treatment of panic disorder has been found to involve a combination of exposure, relaxation training, breathing retraining (i.e., teaching clients to slow their breathing to stop hyperventilation from intensifying their anxiety symptoms), homework assignments to consolidate positive changes and to generalise these changes to new situations, and a follow-up program to ensure that improvements are maintained over time (Sanchez-Meca, Rosa-Alcazar, Marin-Martinez, & Gomez-Conesa, 2010). In order to find out which components of CBT are most effective, one study compared four treatments: (1) interoceptive exposure alone, (2) interoceptive exposure with cognitive restructuring (i.e., learning how to challenge the catastrophic misinterpretations of the physical sensations), (3) interoceptive exposure plus diaphragmatic breathing (i.e., learning how to reverse the uncomfortable physical sensations of hyperventilation by actively slowing one’s breathing rate) and (4) a control condition involving expressive writing (Deacon et al., 2012). Interoceptive exposure alone was superior to the control condition in reducing anxiety sensitivity and symptoms. Somewhat surprisingly, adding cognitive restructuring or diaphragmatic breathing did not provide additional benefits to interoceptive exposure alone. This study suggests that gradual and regular exposure to panic-like physical sensations is a powerful technique to reduce vulnerability to panic attacks and anxiety symptoms. Thus, regularly experiencing the uncomfortable physical sensations during interoceptive exposure, in the absence of a catastrophic consequence (e.g., having a heart attack, panic attack or going crazy), may be a powerful strategy for disconfirming the individual’s catastrophic misinterpretations of benign physical sensations that lead to full-blown panic attacks. Inhibitory learning approaches suggest that using coping strategies such as diaphragmatic breathing can actually undermine the effectiveness of exposure because they reduce the magnitude of the prediction error. For example, clients might believe that as long as they are controlling their breathing they are safe, and therefore they may not be as surprised that they could cope with their symptoms. If clients learn that they are unlikely to panic even without coping strategies, and even if they do, nothing terrible happens, this is likely to generate a larger prediction error and therefore better long-term outcomes. rie66620_ch02_041-072.indd 54 08/02/17 06:48 AM  Chapter 2 Anxiety disorders 55 LO 2.4 Social anxiety disorder The diagnosis of social anxiety disorder Humans are social beings, with social interactions being central to human activity. Therefore, problems with social anxiety have a far-reaching impact. According to the DSM-5 (APA, 2013), the key features of social anxiety disorder (also known as social phobia) involve marked fear or anxiety in social anxiety social situations in which the person faces potential scrutiny by others, including social interactions, disorder (social being observed and performing in front of others. The key fear is that the individual will act in a phobia) humiliating or embarrassing manner (e.g., his/her anxiety symptoms will be obvious to others), which Anxiety disorder will lead to negative evaluation and rejection. Entering situations such as initiating or maintaining characterised by an extreme fear conversations, being observed eating, writing, using public toilets or public speaking provoke anxiety of being judged and panic that is excessive given the level of actual threat. As a result, social situations may be avoided or embarrassed entirely. The anxiety or avoidance interferes with the individual’s functioning (e.g., the ability to form in front of relationships or give presentations at work) and/or causes considerable distress. The DSM-5 specifies others, causing ‘performance only’ social anxiety disorder, where the fear is restricted to speaking or performing the individual in public. Individuals are more likely to present with this subtype when their work performance is to avoid social significantly impaired, such as musicians, athletes or public speakers (APA, 2013). situations. Even though the symptoms of the fight or flight response are similar among people with social phobia to those with other anxiety disorders, the sensations that are most troubling to individuals are those that are visible to others (e.g., sweating, blushing, shaking) since they may elicit negative evaluation from others (Page, 1994b). Likewise, even though the situations avoided (e.g., crowded shopping malls) may be similar to other anxiety disorders, the reasons for avoidance revolve around a fear of negative evaluation from others. The epidemiology of social anxiety disorder The most recent Australian National Survey of Mental Health and Wellbeing found that the diagnostic criteria for social anxiety disorder were met for over 8 per cent of Australian adults across their lifetime, which translated to over 1.3 million people (McEvoy, Grove, & Slade, 2011). In the general population, around 1.5 as many women meet criteria for social anxiety disorder compared to men (ABS, 2008), but the gender rates are approximately equal in clinical samples (APA, 2013). Apart from specific phobias, social anxiety disorder is one of the most common and earliest onset anxiety disorders, with half of sufferers reporting the onset prior to 12 years of age (McEvoy et al., 2011). CASE STUDY: SOCIAL ANXIETY DISORDER Jason is a 28-year-old single man. He works as an accountant and lives at home with his parents. He presented to the clinic for assistance with his nervousness when meeting people. Jason reported being shy for ‘as long as I can remember’ and as a child he recalls hiding behind his parents when meeting strangers or visiting family friends. He was able to form a small group of friends at school, but he always felt ‘on the outer’ because he avoided getting too involved in their conversations. He was known as the ‘quiet one’ and teachers would sometimes refer to him as ‘Mr Chatty’ as a joke. After leaving school, Jason made no effort to remain in contact with his schoolfriends and they eventually stopped calling him after he kept making excuses for why he could not go out with them. He found it difficult to form friendships at university and, although he played soccer, he avoided attending any soccer-related social events other than training and the games. When Jason could not avoid social events he would make sure he had a few alcoholic drinks before going. Although he believed this helped him to relax, he tended to feel more anxious the next day. He also started to rely heavily on alcohol and he began to worry that he would he make a fool of himself by being drunk. In the lead-up to social situations, Jason would worry about what he would say, how anxious he would look and whether the other continued rie66620_ch02_041-072.indd 55 08/02/17 06:48 AM  56 Abnormal psychology 4e people would be critical of him, so he felt highly anxious even before he arrived. When he was in the social situation, he became very self-focused and aware that his heart was racing, he was sweating, his mouth was dry and his cheeks were blushing. He described a vivid self-image in which he imagines his cheeks are glowing bright red, sweat is pouring from his face, he is stammering over his words, and others are looking at him with a confused expression on their face. Jason is aware that this image is probably exaggerated, but whenever he notices these physical symptoms within social situations, he expects that others will also notice them, think he is a fool and reject him. At this point, he usually looks for a way to escape the situation and heads straight home. Afterwards, Jason undergoes a ‘cognitive post-mortem’, where he reviews the situation in his mind, criticises himself for how he behaved and feels really down. At work, he isolates himself and, whenever possible, will email colleagues rather than speak to them. He is frustrated that he is stuck at a lower level than that for which he is qualified because he thinks he could not cope with a job interview. He would like to have a relationship and a family in the future, but he cannot see how this is possible if he cannot even speak to women without breaking into a drenching sweat. In the absence of effective treatment, the course of social anxiety disorder tends to be chronic, with one study finding a median duration of 25 years without treatment (DeWit, Ogborne, Offord, & MacDonald, 1999). Unfortunately, the average delay between the onset of social anxiety disorder and attendance for therapy has been found to be as long as 14 years (Dingemans, van Vliet, Couvee, & Westenberg, 2001). Part of the reluctance to seek treatment stems from the disorder itself, with individuals being embarrassed about their condition. The delay in seeking treatment is cause for concern, given that social anxiety disorder tends to be comorbid with other anxiety disorders, depression and substance abuse. The comorbidity between social anxiety disorder and depression appears to be particularly strong (Mineka, Watson, & Clark, 1998). Those individuals with more comorbid conditions tend to be more severely afflicted, with a ‘cascade of comorbidity’ increasing the level of disability across various aspects of their lives (Brunello et al., 2000, p. 61). Perhaps because most people feel anxious in social situations, the severity of the disorder in terms of its impact on functioning tends to be under-acknowledged. Yet 9 out of 10 individuals with social anxiety disorder indicate that the problem has significantly interfered with their academic, occupational and interpersonal functioning (Beidel, Turner, & Dancu, 1985). People with social anxiety disorder often perform below predicted levels of achievement in education and occupation and they are less likely to marry (reflecting their dearth of close personal relationships). The aetiology of social anxiety disorder A range of biological, psychological and social factors has been implicated in the aetiology of social anxiety disorder. Supporting a genetic vulnerability, there is a two- to three-fold increased risk of social anxiety disorder among the relatives of people with the disorder (Tillfors, Furmark, Ekselius, & Fredrikson, 2001). The results of twin studies are consistent with these findings, estimating that a third of the variability in the familial transmission of social phobia is due to genetic factors (Kendler, Neale, Kessler, Heath, & Eaves, 1992). Among the psychosocial factors, excessive parental criticism may reduce the child’s self- confidence. In addition, the child may learn from his/her parents to be overly concerned with the opinions of others. The social withdrawal associated with lacking self-confidence and being concerned with the opinions of others may in turn elicit dislike and rejection from others during adolescence (Neal & Edelmann, 2003). Cognitive dysfunctions will also increase the likelihood of experiencing anxiety in social situations. For example, an excessive self-focus, in which attention is disproportionately focused on real or imagined failures of the self during social interactions, not only increases anxiety but also diverts attention away from engaging in the prosocial behaviours rie66620_ch02_041-072.indd 56 08/02/17 06:48 AM  Chapter 2 Anxiety disorders 57 (e.g., smiling) necessary for successful social encounters (Woody, 1996). Rapee and Heimberg (1997) argue that the core psychological vulnerabilities for social phobia involve the distorted way in which people perceive how they are evaluated by an audience. Specifically, they propose that people with social phobia assume that others are inherently critical and likely to form negative evaluations of them. For example, people with social anxiety disorder require fewer facial cues to identify a face as threatening (Coles, Heimberg, & Schofield, 2008) and they make less optimistic assessments about their ability to communicate effectively (Fay, Page, Serfaty, Tai, & Winkler, 2008). Moreover, individuals with social phobia attach considerable importance to the evaluations of others. These cognitive factors increase the probability that performance in social situations will trigger a false alarm, which is perceived by the individual as evidence of his/her social ineptness and contributes to the intensification of anxiety in social situations. The aversive nature of the social anxiety drives future avoidance of these situations. Unfortunately, this avoidance deprives the individual of opportunities to develop confidence in his/her social skills and to challenge dysfunctional beliefs regarding social situations, thus maintaining the disorder. Spence, Donovan, and Brechman Toussaint (1999) found that children with social anxiety disorder initiate fewer interactions, speak less, interact for shorter durations, and are rated by themselves and others as being less socially competent compared to non-anxious controls, suggesting that they have a social skills deficit. However, contrary to what people with social anxiety disorder often believe about themselves, adults with this disorder are not always assessed as being less socially skilled than non-clinical controls, suggesting that they do not necessarily have a social skills deficit but rather that their social skills are inhibited by the anxiety (Rapee & Lim, 1992). Therefore, if the social anxiety is effectively treated, people with social anxiety disorder can usually interact skilfully. In other words, a large part of the problem is that they believe they are socially incompetent, not that they are necessarily socially incompetent. The treatment of social anxiety disorder Psychological treatments for social anxiety disorder specifically target the cognitive vulnerabilities and the behavioural avoidances. The most common and evidence-supported treatment for social phobia is cognitive behaviour therapy, either in groups or individually. Group treatment has the advantage of providing a social context within which clients can practise their skills, and around two- thirds of patients achieve substantial improvement (McEvoy, Erceg-Hurn, Saulsman, & Thibodeau, 2015; McEvoy, Nathan, Rapee, & Campbell, 2012). Treatment involves psychoeducation about the factors maintaining social phobia, skills for challenging negative thoughts and images, behavioural experiments designed to directly challenge the negative cognitions (e.g., providing a tutorial presentation to test the belief that the individual will faint during the presentation), reducing reliance on safety behaviours (i.e., subtle avoidance behaviours such as averting eye gaze, not contributing to conversations or using alcohol), video-feedback to challenge negative self-images, attention training (to distract attention from a negative focus on the self) and challenging entrenched negative core beliefs about one’s self (e.g., ‘I am inadequate’) and others (e.g., ‘People are highly critical’). There is evidence that adding a cognitive rationale for exposure tasks (i.e., that the individual confronts the feared social situation in order to challenge the reality of his/her fear-based thoughts) increases the effectiveness compared to exposure alone (Mattick, Peters, & Clarke, 1989). Researchers have recently started to investigate imagery-based techniques for social anxiety disorder, such as imagery rescripting, which may further enhance treatment outcomes (Lee & Kwon, 2013). Imagery rescripting involves identifying recurrent negative images, which may have formed during early socially traumatic experiences (e.g., bullying at school), and working to modify the meaning of the images so that they no longer negatively influence the person’s cognitions, emotions and behaviour in the here-and-now. rie66620_ch02_041-072.indd 57 08/02/17 06:48 AM  58 Abnormal psychology 4e LO 2.5 Generalised anxiety disorder (GAD) The diagnosis of generalised anxiety disorder generalised According to the DSM-5 (APA, 2013), the main feature of generalised anxiety disorder (GAD) is anxiety disorder excessive anxiety and worry (anxious expectation) about a number of events or activities such as (GAD) work, health, finances, relationships or educational performance. The anxiety and worry must have Anxiety disorder been present on most days for a period of at least six months. These worries must be difficult to characterised control, meaning that the individual finds it difficult to stop and cannot easily dismiss these thoughts by chronic worry from his/her mind. in daily life accompanied Unlike other anxiety disorders where worries are contained in a few closely related themes (e.g., by physical the fear of having a panic attack in panic disorder), the worries that characterise GAD include a symptoms of more diverse range of future-focused fears. Core worries in GAD are broadly categorised into those tension. that relate to social threat and physical threat, with sufferers typically experiencing worries that fall into both categories. Social threat fears centre on work performance (e.g., worrying about making mistakes) and interpersonal relationships (e.g., worrying about not pleasing or being liked by others). Physical threat fears typically involve health problems (e.g., worrying about developing cancer) and fears about the impact of world events (e.g., worrying about being a victim of a terrorist attack). Irrespective of whether worry scenarios focus on perceived social or physical threat, individuals with GAD tend to engage in a catastrophising style of thinking that typically ends in imagining ‘worst-case scenarios’, causing considerable anxiety. The process of catastrophising seems to occur automatically, such that fears of being reprimanded for arriving slightly late at work, for example, can quickly transform into a scenario of experiencing criticism from colleagues, losing one’s job, becoming destitute and not being able to support one’s family. This type of worry scenario, which activates significant anxiety, is not uncommon in those with GAD and may be triggered by seemingly benign events (such as when an individual with GAD is stuck in traffic on the way to work). Those with GAD also believe that if their fears were to eventuate, they would lack the necessary resources and capacity to cope. In short, individuals with GAD tend to over-estimate the likelihood of catastrophic events happening while under-estimating their ability to cope with negative events should they occur. In addition, the DSM-5 criteria specify that the individual experiences a range of associated symptoms in relation to his/her worries such as feelings of irritability, fatigue, difficulties concentrating, sleep problems, restlessness/agitation and muscle tension. The anxiety and these associated symptoms also cause the individual high levels of distress and interfere with his/her ability to function in important areas of life such as relationships and work. At a personal level, GAD interferes with the sufferer’s social, work and interpersonal functioning. Some GAD sufferers become rigidly focused on over-achievement to the exclusion of other pursuits to avoid fears of inadequacy being confirmed by themselves or others. In contrast, others with GAD tend to avoid perceived challenges due to fears of failure and poor confidence in being able to complete the task to a high standard. The chronic worrying and autonomic arousal experienced by people with GAD impacts strongly on their enjoyment and quality of life and interpersonal functioning, with close relationships characterised by stress and dependence (Stein & Heimberg, 2004). The DSM-5 diagnostic criteria for GAD remain unchanged from the previous edition of the DSM (DSM-IV-TR; APA, 2000). This is despite the fact that several changes to the criteria had been recommended on the basis of empirical data, cognitive models and clinical expertise. The proposed changes included (1) identifying excessive worry about two life areas and removing the criterion that worry should be difficult to control, (2) suggesting that excessive worry be present for three, rather than six, months, (3) retaining fewer associated symptoms and (4) including the presence of behavioural symptoms such as time spent avoiding or planning for potential threat, procrastinating or seeking reassurance because of worrying (Andrews et al., 2010). rie66620_ch02_041-072.indd 58 08/02/17 06:48 AM  Chapter 2 Anxiety disorders 59 CASE STUDY: GENERALISED ANXIETY DISORDER The case of Lisa illustrates the DSM-5 criteria for GAD. Lisa recently made an appointment to see a clinical psychologist. She described being a worrier for as long as she can remember, ever since childhood. Her worries became more difficult to control during adolescence and were accompanied by periods of low mood where she found it difficult to summon the energy and motivation to complete her schoolwork. Lisa sought help for depression in her teens, which was very helpful, and is now keen to address her worrying, which she feels is intensifying to the point that it places undue stress on her body and is likely to cause her some serious illness. She reported a number of stressors over the past year that have intensified her stress levels. She says she’s now ‘worrying all the time’. Lisa has worked for the past 10 years as a secretary in a local school office. She is friendly and polite and always makes an effort to get on well with the other office staff and teachers. However, of late, there has been tension in the workplace between senior office staff, and Lisa feels that she is being forced to take sides and worries about the effect this will have on her work relationships. She is also struggling at home, where she has been taking time off work to care for her mother who is undergoing treatment for cancer. Her husband has been supportive, but Lisa’s stress levels and increased irritability have placed pressure on their relationship. Lisa and her husband had wanted to start a family but have put these plans on hold until her mother’s health improves. Lisa worries that the amount of tension and stress she is experiencing would make it difficult to conceive and worries that she will never have a normal family life like oth