Chapter 5 Anxiety, Trauma, & Obsessive-Compulsive Disorders PDF

Anxiety, Trauma- and Stressor- 5 Related, and Obsessive-Compulsive and Related Disorders ChaptEr OutLinE the Complexity of anxiety Disorders Anxiety, Fear, and Panic: Some Definitions Causes of Anxiety and Related Disorders Comorbidity of Anxiety and...

Anxiety, Trauma- and Stressor- 5 Related, and Obsessive-Compulsive and Related Disorders ChaptEr OutLinE the Complexity of anxiety Disorders Anxiety, Fear, and Panic: Some Definitions Causes of Anxiety and Related Disorders Comorbidity of Anxiety and Related Disorders Comorbidity with Physical Disorders Suicide anxiety Disorders Generalized anxiety Disorder Clinical Description Statistics Causes Treatment panic Disorder and agoraphobia Clinical Description Statistics Causes Treatment Specific Phobia Clinical Description Statistics Causes Treatment Social Anxiety Disorder (Social Phobia) Clinical Description Statistics Causes Treatment Trauma- and Stressor-Related Disorders Posttraumatic Stress Disorder Clinical Description Statistics Causes Treatment Obsessive-Compulsive and Related Disorders Obsessive-Compulsive Disorder Clinical Description Statistics Causes Treatment Body Dysmorphic Disorder Ivan Hunter/Getty Images Plastic Surgery and Other Medical Treatments Other Obsessive-Compulsive and Related Disorders Hoarding Disorder Trichotillomania (Hair Pulling Disorder) and Excoriation (Skin Picking Disorder) 126 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203  Student LearnIng OutcOmeS* Use scientific reasoning to interpret behavior: Identify basic biological, psychological, and social components of behavioral explanations (e.g., inferences, observations, operational definitions and interpretations) [APA SLO 2.1a] (see textbook pages 129–132) Engage in innovative and integrative thinking and Describe problems operationally to study them empirically problem solving: [APA SLO 2.3A, 2.4b] (see textbook pages 128, 134–135, 141–142, 147–148, 155–156, 163, 169, 173) Describe applications of psychology: Correctly identify antecedents and consequences of behavior and mental processes [APA SLO 1.3b] (see textbook pages 129–132, 136–138, 143–144, 151–153, 156–157, 162–165, 171–173). Describe examples of relevant and practical applications of psychological principles to everyday life [APA SLO 1.3a] (see textbook pages 127–129, 153–155) * Portions of this chapter cover learning outcomes suggested by the American Psychological Association (2012) in their guidelines for the undergraduate psychology major. Chapter coverage of these outcomes is identified above by APA Goal and APA Suggested Learning Outcome (SLO). The Complexity of Anxiety Disorders humans, much of the research has been done with animals. For Anxiety is complex and mysterious, as Sigmund Freud realized example, we might teach laboratory rats that a light signals an many years ago. In some ways, the more we learn about it, the impending shock. The animals certainly look and act anxious more baffling it seems. “Anxiety” is a specific type of disorder, when the light comes on. They may fidget, tremble, and perhaps but it is more than that. It is an emotion implicated so heavily cower in a corner. We might give them an anxiety-reducing drug across the full range of psychopathology that our discussion and notice a reduction of anxiety in their reaction to the light. explores its general nature, both biological and psychologi- But is a rat’s experience of anxiety the same as that of a human? It cal. Next, we consider fear, a somewhat different but clearly seems to be similar, but we don’t know for sure. It could even be related emotion. Related to fear is a panic attack, which we pro- argued that any emotional experience in humans, including fear pose is fear that occurs when there is nothing to be afraid of and anxiety, involves consciousness. This would obviously limit and, therefore, at an inappropriate time. With these important what we can say about human emotions when studying animals ideas clearly in mind, we focus on specific anxiety and related (LeDoux, 2015). Thus, anxiety remains a mystery, and we are only disorders. beginning our journey of discovery. Anxiety is also closely related to depression (Barlow, 2000, 2002; Brown & Barlow, 2005, 2009; Clark, 2005; Craske et al., 2009; Kessler, Petukhova, Sampson Anxiety, Fear, and Panic: Some Definitions Zaslavsky, & Wittchen, 2012), so much of what we say here is rel- Have you ever experienced anxiety? A silly question, you might evant to Chapter 7. say, because most of us feel some anxiety almost every day of our Anxiety is not pleasant, so why do we seem programmed lives. Did you have a test in school today for which you weren’t to experience it almost every time we do something impor- “perfectly” prepared? Did you have a date last weekend with some- tant? Surprisingly, anxiety is good for us, at least in moderate body new? And how about that job interview coming up? Even amounts. Psychologists have known for over a century that we thinking about that might make you nervous. But have you ever perform better when we are a little anxious (Yerkes & Dodson, stopped to think about the nature of anxiety? What is it? What 1908). You would not have done so well on that test the other day causes it? if you had had no anxiety. You were a little more charming and Anxiety is a negative mood state characterized by bodily lively on that date last weekend because you were a little anxious. symptoms of physical tension and by apprehension about the And you will be better prepared for that upcoming job interview future (American Psychiatric Association, 2013; Barlow, 2002). if you are anxious. In short, social, physical, and intellectual per- In humans, it can be a subjective sense of unease, a set of behav- formances are driven and enhanced by anxiety. Without it, few of iors (looking worried and anxious or fidgeting), or a physiological us would get much done. Howard Liddell (1949) first proposed response originating in the brain and reflected in elevated heart this idea when he called anxiety the “shadow of intelligence.” He rate and muscle tension. Because anxiety is difficult to study in thought the human ability to plan in some detail for the future thE CoMPlExity of anxiEty disordErs 127 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203 was connected to that gnawing feel- Panic Disorder: Steve mood state, characterized by apprehen- ing that things could go wrong and we sion because we cannot predict or con- had better be prepared for them. This is trol upcoming events. Fear, on the other why anxiety is a future-oriented mood hand, is an immediate emotional reac- state. If you were to put it into words, tion to current danger characterized you might say, “Something might go by strong escapist action tendencies wrong, and I’m not sure I can deal with and, often, a surge in the sympathetic it, but I’ve got to be ready to try. Maybe branch of the autonomic nervous sys- I’d better study a little harder (or check tem (Barlow, Brown, & Craske, 1994; the mirror one more time before my Craske et al., 2010). date, or do a little more research on that What happens if you experience the company before the interview).” alarm response of fear when there is noth- But what happens when you have “First time it happened to me, I was driving ing to be afraid of—that is, if you have a too much anxiety? You might actually down the highway, and I had a kind of a knot false alarm? Consider the case of Gretchen, fail the exam because you can’t con- in my chest. I felt like I had swallowed some- who appeared at one of our clinics. centrate on the questions. All you can thing and it got stuck, and it lasted pretty This sudden overwhelming reaction think about when you’re too anxious much overnight.... I felt like I was having a came to be known as panic, after the is how terrible it will be if you fail. You heart attack.... I assumed that’s what was Greek god Pan who terrified travelers might blow the interview for the same happening. I felt very panicky. A flushed feel- with bloodcurdling screams. In psycho- reason. On that date with a new person, ing came over my whole body. I felt as though pathology, a panic attack is defined as an you might spend the evening perspir- I was going to pass out.” abrupt experience of intense fear or acute ing profusely, with a sick feeling in your discomfort, accompanied by physical stomach, unable to think of even one symptoms that usually include heart pal- Go to MindTap at www.cengagebrain. reasonably interesting thing to say. Too com to watch this video. pitations, chest pain, shortness of breath, much of a good thing can be harmful, and, possibly, dizziness. and few sensations are more harmful than severe anxiety that is out of control. What makes the situation worse is that severe anxiety usually Gretchen... Attacked by Panic doesn’t go away—that is, even if we “know” there is nothing to be afraid of, we remain anxious. One example of this kind of irratio- was 25 when I had my first attack. It was a few weeks after nality involves John Madden, the retired sports announcer and former professional football coach, who suffers from claustro- I I’d come home from the hospital. I had had my appendix out. The surgery had gone well, and I wasn’t in any danger, phobia. He has written about his anxiety and used it as a source which is why I don’t understand what happened. But one of humor in several television commercials. Madden, who dur- night I went to sleep and I woke up a few hours later—I’m ing his career had to announce a game in New York one Sunday not sure how long—but I woke up with this vague feeling and in San Francisco the next, cannot travel by air because of of apprehension. Mostly I remember how my heart started his claustrophobia. For a long time he took trains around the pounding. And my chest hurt; it felt like I was dying—that country; later, he used a well-equipped private bus. Madden and I was having a heart attack. And I felt kind of queer, as if I countless other individuals who suffer from anxiety-based disor- were detached from the experience. It seemed like my bed- ders are well aware that there is little to fear in the situations they room was covered with a haze. I ran to my sister’s room, but find so stressful. Madden must have realized long ago that flying I felt like I was a puppet or a robot who was under the con- is in fact the safest way to travel, and it was in his best interest to trol of somebody else while I was running. I think I scared fly to save time and help maintain his lucrative career. And yet he her almost as much as I was frightened myself. She called an could not abandon his self-defeating behavior. ambulance (Barlow, 2002). All the disorders discussed in this chapter are characterized by excessive anxiety, which takes many forms. In Chapter 2 you saw that fear is an immediate alarm reaction to danger. Like anxi- Two basic types of panic attacks are described in DSM-5: ety, fear can be good for us. It protects us by activating a massive expected and unexpected. If you know you are afraid of high response from the autonomic nervous system (increased heart places or of driving over long bridges, you might have a panic rate and blood pressure, for example), which, along with our sub- attack in these situations but not anywhere else; this is an jective sense of terror, motivates us to escape (flee) or, possibly, to expected (cued) panic attack. By contrast, you might experience attack (fight). As such, this emergency reaction is often called the unexpected (uncued) panic attacks if you don’t have a clue when flight or fight response. or where the next attack will occur. We mention these types of There is much evidence that fear and anxiety reactions differ attacks because they play a role in several anxiety disorders. psychologically and physiologically (Barlow, 2002; Bouton, 2005; Unexpected attacks are important in panic disorder. Expected Craske et al., 2010; Tovote, Fadok, & Lüthi, 2015; Waddell, Morris, attacks are more common in specific phobias or social anxiety & Bouton, 2006). As noted earlier, anxiety is a future-oriented disorder (see E Figure 5.1). 128 CHAPTER 5 a n x i E t y, t r a U M a - a n d s t r E s s o r - r E l at E d , a n d o B s E s s i v E - C o M P U l s i v E a n d r E l at E d d i s o r d E r s Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203  including similarities in reports of the experience of fear and panic, DSM TABLE 5.1 similar behavioral tendencies to escape, and similar underlying Diagnostic Criteria for Panic Attack neurobiological processes. Over the years we have recorded panic attacks during physio- 5 An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the logical assessments of our patients (see, for example, Alpers, 2009; following symptoms occur: Hofmann & Barlow, 1996; Meuret et al., 2011). The physiological 1. Palpitations, pounding heart, or accelerated heart rate surge recorded in one patient is shown in E Figure 5.2. Notice the 2. Sweating sudden dramatic increase in heart rate from minute 11 through 3. Trembling or shaking minute 13, accompanied by increases in muscle tension (frontalis 4. Sensations of shortness of breath or smothering EMG) and finger temperature. This massive autonomic surge peaked and subsided within 3 minutes. The panic attack in the 5. Feeling of choking laboratory occurred quite unexpectedly from the patient’s point of 6. Chest pain or discomfort view and from ours. As the figure shows, fear and panic are expe- 7. Nausea or abdominal distress rienced suddenly, which is necessary to mobilize us for instanta- 8. Feeling dizzy, unsteady, lightheaded, or faint neous reaction to impending danger. 9. Chills or heat sensations 10. Paresthesias (numbness or tingling sensations) 11. Derealization (feelings of unreality) or depersonalization (being Causes of Anxiety and Related Disorders detached from oneself) You learned in Chapters 1 and 2 that excessive emotional reactions 12. Fear of losing control or going crazy have no simple one-dimensional cause but come from multiple 13. Fear of dying sources. Next, we explore the biological, psychological, and social contributors and how they interact to produce anxiety and related From American Psychiatric Association. (2013). Diagnostic and statistical manual of disorders. mental disorders (5th ed.). Washington, DC. Remember that fear is an intense emotional alarm accompa- Biological contributions nied by a surge of energy in the autonomic nervous system that Increasing evidence shows that we inherit a tendency to be tense, motivates us to flee from danger. Does Gretchen’s panic attack uptight, and anxious (Barlow et al., 2014; Clark, 2005; Eysenck, sound as if it could be the emotion of fear? A variety of evidence 1967; Gray & McNaughton, 2003). The tendency to panic also suggests it is (Barlow, 2002; Craske & Barlow, 2014; Bouton, 2005), seems to run in families and probably has a genetic component Anxiety Negative affect Somatic symptoms of tension Future-oriented Feelings that one cannot predict or control upcoming Emotional events State Fear Negative affect Strong sympathetic nervous system arousal Immediate alarm reaction characterized by strong escapist tendencies in response to present danger or life-threatening emergencies iStockphoto.com/Manuel Lohninger Panic Attack Fear occurring at an inappropriate time Two types: Expected Unexpected E FIGURE 5.1 The relationships among anxiety, fear, and panic attack. thE CoMPlExity of anxiEty disordErs 129 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203  Baseline Relaxation Panic Kendler, 2006; Owens et al., 2012; Rutter, Moffitt, & Caspi, 2006; Smoller, 2013). 100 Onset of panic attack Anxiety is also associated with specific brain circuits 96 (Domschke, & Dannlowski, 2010; Hermans, Henckens, Joels, & 92 Fernandez, 2014; Tovote et al., 2015) and neurotransmitter sys- Heart rate (BPM) 88 tems (Durant, Christmas, & Nutt, 2010). For example, depleted 84 levels of gamma-aminobutyric acid (GABA), part of the GABA– 80 benzodiazepine system, are associated with increased anxiety, 76 although the relationship is not quite so direct. The noradrenergic 72 system has also been implicated in anxiety (Hermans et al., 68 2011), and evidence from basic animal studies, as well as stud- 64 ies of normal anxiety in humans, suggests the serotonergic neu- rotransmitter system is also involved (Canli & Lesch, 2007). But 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 increasing attention in the past several years is focusing on the Time in minutes role of the corticotropin-releasing factor (CRF) system as central 46 to the expression of anxiety (and depression) and the groups of 42 genes that increase the likelihood that this system will be turned 38 on (Essex, Klein, Slattery, Goldsmith, & Kalin, 2010; Durant et al., Frontalis EMG ( V) 34 2010; Khan, King, Abelson, & Liberzon, 2009; Smoller, Yamaki, & Fagerness, 2005; Sullivan, Kent, & Coplan, 2000). This is because 30 CRF activates the hypothalamic–pituitary–adrenocortical (HPA) 26 axis, described in Chapter 2, which is part of the CRF system, and 22 this CRF system has wide-ranging effects on areas of the brain 18 implicated in anxiety, including the emotional brain (the limbic 16 system), particularly the hippocampus and the amygdala; the 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 locus coeruleus in the brain stem; the prefrontal cortex; and the Time in minutes dopaminergic neurotransmitter system. The CRF system is also directly related to the GABA–benzodiazepine system and the 72.8 serotonergic and noradrenergic neurotransmitter systems. 72.6 The area of the brain most often associated with anxiety is the Temperature 72.4 limbic system (Britton & Rauch, 2009; Gray & McNaughton, 2003; 72.4 Hermans et al., 2011; LeDoux, 2002, 2015; see Figure 2.7c), which 72.2 acts as a mediator between the brain stem and the cortex. The 72.0 more primitive brain stem monitors and senses changes in bodily 71.8 functions and relays these potential danger signals to higher corti- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 cal processes through the limbic system. The late Jeffrey Gray, a Time in minutes prominent British neuropsychologist, identified a brain circuit in E FIGURE 5.2 the limbic system of animals that seems heavily involved in anxi- Physiological measurements during a panic attack. BPM, beats ety (Gray & McNaughton, 2003) and may be relevant to humans. per minute; EMG, electromyography. (Reprinted, with permis- This circuit leads from the septal and hippocampal area in the sion, from Cohen, A. S., Barlow, D. H., & Blanchard, E. B. (1985). limbic system to the frontal cortex. (The septal–hippocampal Psychophysiology of relaxation-associated panic attacks. Journal of system is activated by CRF and serotonergic- and noradrenergic- Abnormal Psychology, 94, 98, © 1985 by the American Psychological mediated pathways originating in the brain stem.) The system that Association.) Gray calls the behavioral inhibition system (BIS) is activated by signals from the brain stem of unexpected events, such as major changes in body functioning that might signal danger. Danger sig- that differs somewhat from genetic contributions to anxiety nals in response to something we see that might be threatening (Barlow, 2002; Craske & Barlow, 2014; Kendler, 2001; Ollendick & descend from the cortex to the septal–hippocampal system. The Muris, 2015). As with almost all emotional traits and psychologi- BIS also receives a big boost from the amygdala (LeDoux, 1996, cal disorders, no single gene seems to cause anxiety or panic or 2002, 2015). When the BIS is activated by signals that arise from any other psychiatric disorder (Gratten, Wray, Keller, & Visscher, the brain stem or descend from the cortex, our tendency is to 2014). Instead, contributions from collections of genes in several freeze, experience anxiety, and apprehensively evaluate the situa- areas on chromosomes make us vulnerable when the right psy- tion to confirm that danger is present chological and social factors are in place. Furthermore, a genetic The BIS circuit is distinct from the circuit involved in panic. vulnerability does not cause anxiety and/or panic directly. That Gray and McNaughton (2003) and Graeff (2004) identified what is, stress or other factors in the environment can “turn on” these Gray and others call the fight/flight system (FFS). This circuit genes, as we reviewed in Chapter 2 (Gelernter & Stein, 2009; originates in the brain stem and travels through several midbrain 130 CHAPTER 5 a n x i E t y, t r a U M a - a n d s t r E s s o r - r E l at E d , a n d o B s E s s i v E - C o M P U l s i v E a n d r E l at E d d i s o r d E r s Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203 structures, including the amygdala, the ventromedial nucleus of awareness that events are not always in our control (Chorpita & the hypothalamus, and the central gray matter. When stimulated Barlow, 1998; Gallagher, Bentley, & Barlow, 2014). The continuum in animals, this circuit produces an immediate alarm-and-escape of this perception may range from total confidence in our control response that looks very much like panic in humans (Gray & of all aspects of our lives to deep uncertainty about ourselves and McNaughton, 2003). The FFS is activated partly by deficiencies our ability to deal with upcoming events. If you are anxious about in serotonin, suggest Gray and McNaughton (2003) and Graeff schoolwork, for example, you may worry you will do poorly on (2004). As is true for other anxiety disorders (such as social anxi- the next exam, even though all your grades have been A’s and B’s. ety disorder, which we will discuss later), activation of a network A general “sense of uncontrollability” may develop early as a func- that involves the prefrontal cortex and the amygdala while per- tion of upbringing and other disruptive or traumatic environmen- forming certain tasks, can predict response to CBT (Hahn et al., tal factors. 2015). It is likely that factors in your environment can change the Interestingly, the actions of parents in early childhood seem sensitivity of these brain circuits, making you more or less sus- to do a lot to foster this sense of control or uncontrollability ceptible to developing anxiety and its disorders, a finding that (Barlow, Ellard et al., 2014; Bowlby, 1980; Chorpita & Barlow, 1998; has been demonstrated in several laboratories (Francis, Diorio, Gunnar, Hostinar, Sanches, Tottenam, & Sullivan, 2015). General- Plotsky, & Meaney, 2002; Stein, Schork, & Gelernter, 2007). For ly, it seems that parents who interact in a positive and predictable example, one important study suggested that cigarette smoking as way with their children by responding to their needs, particularly a teenager is associated with greatly increased risk for developing when the child communicates needs for attention, food, relief anxiety disorders as an adult, particularly panic disorder and gen- from pain, and so on, perform an important function. These par- eralized anxiety disorder (Johnson et al., 2000). Nearly 700 ado- ents teach their children that they have control over their environ- lescents were followed into adulthood. Teens who smoked 20 or ment and their responses have an effect on their parents and their more cigarettes daily were 15 times more likely to develop panic environment. In addition, parents who provide a “secure home disorder and 5 times more likely to develop generalized anxiety base” but allow their children to explore their world and develop disorder than teens who smoked less or didn’t smoke. The com- the necessary skills to cope with unexpected occurrences enable plex interaction between smoking and anxiety disorders has been their children to develop a healthy sense of control (Chorpita & confirmed in more recent research (Leventhal & Zvolensky, 2015). Barlow, 1998). In contrast, parents who are overprotective and The current thinking about the link between smoking and anxi- overintrusive and who “clear the way” for their children, never ety is that anxiety sensitivity (the general tendency to fear bodily letting them experience any adversity, create a situation in which sensations, which we will briefly discuss later), distress tolerance children never learn how to cope with adversity when it comes (how much distress a person can tolerate), and anhedonia (the along. Therefore, these children don’t learn that they can con- inability to feel pleasure) all contribute to smoking, which could trol their environment. A variety of evidence has accumulated be one reason why so many people with anxiety find it very diffi- supporting these ideas (Barlow, 2002; Chorpita & Barlow, 1998; cult to quit smoking. Brain-imaging procedures are yielding more Dan, Sagi-Schwartz, Bar-haim, & Eshel, 2011; Fulton, Kiel, Tull, & information about the neurobiology of anxiety and panic (Britton Gratz, 2014; Gallagher et al. 2014; Gunnar & Fisher, 2006; White, et al, 2013; Shin & Liberzon, 2010). For example, there is now gen- Brown, Somers, & Barlow, 2006). A sense of control (or lack of eral agreement that in people with anxiety disorders, the limbic it) that develops from these early experiences is the psychological system, including the amygdala, is overly responsive to stimula- factor that makes us more or less vulnerable to anxiety in later life. tion or new information (abnormal bottom-up processing); at Another feature among patients with panic is the general ten- the same time, controlling functions of the cortex that would dency to respond fearfully to anxiety symptoms. This is known as down-regulate the hyperexcitable amygdala are deficient (abnor- anxiety sensitivity, which appears to be an important personality mal top-down processing), consistent with Gray’s BIS model trait that determines who will and who will not experience prob- (Ellard, 2013; Britton & Rauch, 2009; Ochsner et al., 2009). Despite lems with anxiety under certain stressful conditions (Reiss, 1991). these biological abnormalities, psychological treatments, and in Most psychological accounts of panic (as opposed to anxiety) particular CBT, can effectively treat these disorders across the invoke conditioning and cognitive explanations that are difficult age range (Kendall & Peterman, 2015; Hofmann, Asnaani, Vonk, to separate (Bouton, Mineka, & Barlow, 2001). Thus, a strong fear Sawyer, & Fang, 2012). response initially occurs during extreme stress or perhaps as a result of a dangerous situation in the environment (a true alarm). This emotional response then becomes associated with a variety Psychological contributions of external and internal cues. In other words, these cues, or con- In Chapter 2, we reviewed some theories on the nature of psycho- ditioned stimuli, provoke the fear response and an assumption of logical causes of anxiety. Remember that Freud thought anxiety danger, even if the danger is not actually present (Bouton, 2005; was a psychic reaction to danger surrounding the reactivation of Bouton et al., 2001; Mineka & Zinbarg, 2006; Razran, 1961), so it an infantile fearful situation. Behavioral theorists thought anxi- is really a learned or false alarm. This is the conditioning process ety was the product of early classical conditioning, modeling, or described in Chapter 2. External cues are places or situations simi- other forms of learning (Bandura, 1986). But, new and accumu- lar to the one where the initial panic attack occurred. Internal cues lating evidence supports an integrated model of anxiety involv- are increases in heart rate or respiration that were associated with ing a variety of psychological factors (see, for example, Barlow, the initial panic attack, even if they are now the result of normal 2002; Barlow, Ellard et al, 2014). In childhood, we may acquire an circumstances, such as exercise. Thus, when your heart is beating thE CoMPlExity of anxiEty disordErs 131 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203 fast, you are more likely to think of and, perhaps, experience a up believing the world is dangerous and out of control and you panic attack than when it is beating normally. Furthermore, you might not be able to cope when things go wrong based on your may not be aware of the cues or triggers of severe fear; that is, they early experiences. If this perception is strong, you have a general- are unconscious as recently demonstrated in patients with panic ized psychological vulnerability to anxiety. The third vulnerabil- disorder (Meuret et al., 2011). This is most likely, as demonstrated ity is a specific psychological vulnerability in which you learn from in experimental work with animals, because these cues or triggers early experience, such as being taught by your parents, that some may travel from the eyes directly to the amygdala in the emotional situations or objects are fraught with danger (even if they really brain without going through the cortex, the source of awareness aren’t). For example, if one of your parents is afraid of dogs, or (Bouton et al., 2001; LeDoux, 2002, 2015). expresses anxiety about being evaluated negatively by others, you may well develop a fear of dogs or of social evaluation. These triple vulnerabilities are presented in E Figure 5.3 and revisited when Social contributions we describe each anxiety and related disorder. If you are under a Stressful life events trigger our biological and psychological lot of pressure, particularly from interpersonal stressors, a given vulnerabilities to anxiety. Most are social and interpersonal in stressor could activate your biological tendencies to be anxious nature—marriage, divorce, difficulties at work, death of a loved and your psychological tendencies to feel you might not be able one, pressures to excel in school, and so on. Some might be physical, to deal with the situation and control the stress. Once this cycle such as an injury or illness. starts, it tends to feed on itself, so it might not stop even when the The same stressors can trigger physical reactions, such as particular life stressor has long since passed. Anxiety can be gen- headaches or hypertension, and emotional reactions, such as eral, evoked by many aspects of your life. But it is usually focused panic attacks (Barlow, 2002). The particular way we react to stress on one area, such as social evaluations or grades (Barlow, 2002). seems to run in families. If you get headaches when under stress, As noted above, panic is also a characteristic response to stress chances are other people in your family also get headaches. If you that runs in families and may have a genetic component that is have panic attacks, other members of your family probably do separate from anxiety. Furthermore, anxiety and panic are closely also. This finding suggests a possible genetic contribution, at least related (Barlow, 2002; Barlow, Ellard et. al., 2014; Suárez et al., to initial panic attacks. 2009): anxiety increases the likelihood of panic. This relationship makes sense from an evolutionary point of view, because sens- ing a possible future threat or danger (anxiety) should prepare an Integrated model us to react instantaneously with an alarm response if the danger Putting the factors together in an integrated way, we have becomes imminent (Bouton, 2005). Anxiety and panic need not described a theory of the development of anxiety called the tri- occur together, but it makes sense that they often do. ple vulnerability theory (Barlow, 2000, 2002; Barlow, Ellard et al., 2014; Brown & Naragon-Gainey, 2013). The first vulnerability (or diathesis) is a generalized biological vulnerability. We can see that Comorbidity of Anxiety and Related a tendency to be uptight or high-strung might be inherited. But Disorders a generalized biological vulnerability to develop anxiety is not Before describing the specific disorders, it is important to note sufficient to produce anxiety itself. The second vulnerability is a that the disorders often co-occur. As we described in Chapter 3, generalized psychological vulnerability. That is, you might also grow the co-occurrence of two or more disorders in a single individual Biological vulnerability Generalized psychological (heritable contribution to vulnerability negative affect) (sense that events are uncontrollable/unpredictable) Specific psychological vulnerability (e.g., physical sensations are potentially dangerous) “Glass is half empty” Tendency toward Irritable lack of self-confidence Driven Low self-esteem Inability to cope Anxiety about health? Nonclinical panic? E FIGURE 5.3 The three vulnerabilities that contribute to the development of anxiety disorders. If individuals possess all three, the odds are greatly increased that they will develop an anxiety disorder after experiencing a stressful situation. (From Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York: Guilford Press.) 132 CHAPTER 5 a n x i E t y, t r a U M a - a n d s t r E s s o r - r E l at E d , a n d o B s E s s i v E - C o M P U l s i v E a n d r E l at E d d i s o r d E r s Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203 is referred to as comorbidity. The high rates of comorbidity among anxiety and related disorders (and depression) emphasize how all of these disorders share the common features of anxiety and panic described here. They also share the same vulnerabilities— biological and psychological—to develop anxiety and panic. The various disorders differ only in what triggers the anxiety and, per- haps, the patterning of panic attacks. Of course, if each patient with an anxiety or related disorder also had every other anxiety disorder, there would be little sense in distinguishing among the specific disorders. But this is not the case, and, although rates of comorbidity are high, they vary somewhat from disorder to dis- order (Allen et al., 2010; Bruce et al., 2005; Tsao, Mystkowski, Zucker, & Craske, 2002). A large-scale study completed at one of our centers examined the comorbidity of Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV-TR) anxiety and mood disorders (Brown & Barlow, 2005; Brown, Campbell, © Image Point Fr/Shutterstock.com Lehman, Grisham, & Mancill, 2001). Data were collected from 1,127 patients carefully diagnosed using a semistructured inter- view in our center. If we examine just rates of comorbidity at the time of assessment, the results indicate that 55% of the patients who received a principal diagnosis of an anxiety or depressive dis- order had at least one additional anxiety or depressive disorder at the time of the assessment. If we consider whether the patient met People with certain physical conditions, like asthma, are often at criteria for an additional diagnosis at any time in his or her life, higher risk for anxiety disorders. rather than just at the time of the assessment, the rate increases to 76%. By far the most common additional diagnosis for all anxi- about having an anxiety disorder might cause, or contribute to ety disorders was major depression, which occurred in 50% of the cause of, the physical disorder. Finally, if someone has both the cases over the course of the patient’s life, probably due to an anxiety disorder and one of the physical disorders mentioned the shared vulnerabilities between depression and anxiety dis- earlier, that person will suffer from greater disability and a poorer orders in addition to the disorder-specific vulnerability. Con- quality of life from both the physical problem and the anxiety sistent with this notion are the results by Blanco and colleagues problem than if that individual had just the physical disorder (Blanco, Rubio, Wall, Wang, Jiu, & Kendler, 2014) who reported alone (Belik, Sareen, & Stein, 2009; Comer et al., 2011; Sareen that the risks for anxiety disorders and depression are mediat- et al., 2006). Other studies have also found the same relationship ed partially by a latent variable underlying both disorders (e.g., between anxiety disorders, particularly panic disorders, and car- low self-esteem and childhood sexual abuse), and partially by diovascular (heart) disease (see, for example, Gomez-Caminero, disorder-specific effects (e.g., a family history of depression as a Blumentals, Russo, Brown, & Castilla-Puentes, 2005). Also, risk factor for depression in the children). This becomes impor- DSM-5 now makes it explicit that panic attacks often co-occur tant when we discuss the relationship of anxiety and depression with certain medical conditions, particularly cardio, respira- later in this chapter. Also important is the finding that additional tory, gastrointestinal, and vestibular (inner ear) disorders, even diagnoses of depression or alcohol or drug abuse makes it less though the majority of these patients would not meet criteria for likely that you will recover from an anxiety disorder and more panic disorder (Kessler et al., 2006). likely that you will relapse if you do recover (Bruce et al., 2005; Ciraulo et al., 2013 Huppert, 2009). Suicide Based on epidemiological data, Weissman and colleagues found Comorbidity with Physical Disorders that 20% of patients with panic disorder had attempted suicide. Anxiety disorders also co-occur with several physical conditions They concluded that such attempts were associated with panic dis- (Kariuki-Nyuthe & Stein, 2015). An important study indicated order. They also concluded that the risk of someone with panic that the presence of any anxiety disorder was uniquely and sig- disorder attempting suicide is comparable to that for individuals nificantly associated with thyroid disease, respiratory disease, with major depression (Johnson, Weissman, & Klerman, 1990; gastrointestinal disease, arthritis, migraine headaches, and Weissman, Klerman, Markowitz, & Ouellette, 1989). This finding allergic conditions (Sareen et al., 2006). Thus, people with these was alarming because panic disorder is quite prevalent and clini- physical conditions are likely to have an anxiety disorder but cians had generally not been on the lookout for possible suicide are not any more likely to have another psychological disorder. attempts in such patients. The investigators also found that even Furthermore, the anxiety disorder most often begins before the patients with panic disorder who did not have accompanying physical disorder, suggesting (but not proving) that something depression were at risk for suicide. thE CoMPlExity of anxiEty disordErs 133 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203  The Weissman study suggests that having any anxiety or Anxiety Disorders related disorder, not just panic disorder, uniquely increases the Disorders traditionally grouped together as anxiety disorders chances of having thoughts about suicide (suicidal ideation) or include generalized anxiety disorder, panic disorder and agorapho- making suicidal attempts (Sareen et al., 2006), but the relation- bia, specific phobia, and social anxiety disorder, as well as two new ship is strongest with panic disorder and posttraumatic stress disorders, separation anxiety disorder and selective mutism. These disorder (Nepon, Belik, Bolton, & Sareen 2010; Sareen, 2011). specific anxiety disorders are complicated by panic attacks or other Whereas earlier studies have suggested that panic disorder is not features that are the focus of the anxiety. But in generalized anxi- associated with suicidal behavior in the absence of other risk fac- ety disorder, the focus is generalized to the events of everyday life. tors (e.g., Warshaw, Dolan, & Keller, 2000), a later epidemiologi- Therefore, we consider generalized anxiety disorder first. cal study reported that all anxiety disorders are associated with an increased risk for suicide attempts and suicidal ideations, even after accounting for mood disorders, such as dysthymia, major Generalized Anxiety Disorder depressive disorder, and bipolar disorder, as well as substance use Is somebody in your family a worrywart or a perfectionist? disorders (Thibodeau, Welch, Sareen, & Asmundson, 2013). These Perhaps it is you! Most of us worry to some extent. As we have said, findings are consistent with the results of another epidemiologi- worry can be useful. It helps us plan for the future, make sure that cal study showing that all anxiety disorders are associated with we’re prepared for that test, or double-check that we’ve thought suicide attempts with intent to die (Chartrand, Sareen, Toews, & of everything before we head home for the holidays. But what if Bolton, 2012). People with generalized anxiety disorder and social you worry indiscriminately about everything? Furthermore, what anxiety disorder who engaged in deliberate self-harm were espe- if worrying is unproductive? What if no matter how much you cially more likely to engage in this behavior multiple times, and at worry, you can’t seem to decide what to do about an upcoming least one of those times was a suicide attempt. problem or situation? And what if you can’t stop worrying, even if Clearly, many questions about the relationship between suicide you know it is doing you no good and probably making everyone and mood and anxiety disorders remain unanswered. We now turn else around you miserable? These features characterize general- to descriptions of the individual anxiety and related disorders. But ized anxiety disorder (GAD). Consider the case of Irene. keep in mind that approximately 50% of individuals with these dis- orders will present with one or more additional anxiety or depres- sive disorders and, perhaps, some other disorders, particularly substance abuse disorders, as described later. For this reason, we Irene... Ruled by Worry also consider new ideas for classifying and treating anxiety disor- ders that move beyond just looking at single disorders. rene was a 20-year-old college student with an engaging I personality but not many friends. She came to the clinic complaining of excessive anxiety and general difficulties in controlling her life. Everything was a catastrophe for Irene. Concept Check 5.1 Although she carried a 3.7 grade point average, she was convinced she would flunk every test she took. As a result, Complete the following statements about anxiety and its she repeatedly threatened to drop courses after only sev- causes with the following terms: (a) comorbidity, (b) panic eral weeks of classes because she feared that she would not attack, (c) expected, (d) neurotransmitter, (e) brain circuits, understand the material. Irene worried until she dropped out of the first college and (f) stressful. she attended after 1 month. She felt depressed for a while 1. A _____________ is an abrupt experience of intense and then decided to take a couple of courses at a local junior fear or acute discomfort accompanied by physical college, believing she could handle the work there better. symptoms, such as chest pain and shortness of breath. After achieving straight A’s at the junior college for 2 years, 2. An _____________ panic attack often occurs in she enrolled once again in a 4-year college as a junior. After certain situations but not anywhere else. a short time, she began calling the clinic in a state of extreme agitation, saying she had to drop this or that course because 3. Anxiety is associated with specific _____________ she couldn’t handle it. With great difficulty, her therapist (for example, behavioral inhibition system or fight/ and parents persuaded her to stay in the courses and to seek flight system) and _____________ systems (for example, further help. In any course Irene completed, her grade was noradrenergic). between an A and a B-minus, but she still worried about every test and every paper, afraid she would fall apart and be 4. The rates of _____________ among anxiety and unable to understand and complete the work. related disorders are high because they share the Irene did not worry only about school. She was also con- common features of anxiety and panic. cerned about relationships with her friends. Whenever she 5. _____________ life events can trigger biological and was with her new boyfriend, she feared making a fool of psychological vulnerabilities to anxiety. herself and losing his interest. She reported that each date 134 CHAPTER 5 a n x i E t y, t r a U M a - a n d s t r E s s o r - r E l at E d , a n d o B s E s s i v E - C o M P U l s i v E a n d r E l at E d d i s o r d E r s Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203  children, only one physical symptom is required for a diagnosis went extremely well, but she knew the next one would prob- of GAD, and research validates this strategy (Tracey, Chorpita, ably be a disaster. As the relationship progressed and some Douban, & Barlow, 1997). People with GAD mostly worry about sexual contact seemed natural, Irene was worried sick that minor, everyday life events, a characteristic that distinguishes her inexperience would make her boyfriend consider her GAD from other anxiety disorders. When asked, “Do you worry naive and stupid. Nevertheless, she reported enjoying the excessively about minor things?” 100% of individuals with GAD early sexual contact and admitted that he seemed to enjoy it respond “yes,” compared with approximately 50% of individu- also, but she was convinced that the next time a catastrophe als whose anxiety disorder falls within other categories (Barlow, would happen. 2002). Major events quickly become the focus of anxiety and Irene was also concerned about her health. She had minor worry, too. Adults typically focus on possible misfortune to their hypertension, probably because she was somewhat over- children, family health, job responsibilities, and more minor things weight. She was also very worried about eating the wrong such as household chores or being on time for appointments. types or amounts of food. She became reluctant to have Children with GAD most often worry about competence in aca- her blood pressure checked for fear it would be high or to demic, athletic, or social performance, as well as family issues weigh herself for fear she was not losing weight. She severely (Albano & Hack, 2004; Furr, Tiwari, Suveg, & Kendall, 2009; restricted her eating and as a result had an occasional epi- Weems, Silverman, & La Greca, 2000). Older adults tend to focus, sode of binge eating, although not often enough to warrant understandably, on health (Wetherell et al., 2010; Beck & Averill, concern. 2004; Person & Borkovec, 1995); they also have difficulty sleeping, Although Irene had an occasional panic attack, this was which seems to make the anxiety worse (Beck & Stanley, 1997; not a major issue to her. As soon as the panic subsided, she Brenes, Miller, Stanley, Williamson, Knudson, & McCall, 2009). focused on the next possible catastrophe. In addition to high blood pressure, Irene had tension headaches and a “nervous stomach,” with a lot of gas, occasional diarrhea, and some Statistics abdominal pain. Irene’s life was a series of impending catas- Although worry and physical tension are common, the severe gen- trophes. Her mother reported that she dreaded a phone call eralized anxiety experienced by Irene is quite rare. Approximately from Irene, let alone a visit, because she knew she would 3.1% of the population meets criteria for GAD during a given have to see her daughter through a crisis. For the same rea- son, Irene had few friends. Even so, when she temporarily gave up her anxiety, she was fun to be with. DSM TABLE 5.2 Diagnostic Criteria for Generalized Anxiety Disorder Clinical Description 5 A. Excessive anxiety and worry (apprehensive expectation), occur- ring more days than not for at least 6 months about a number Irene suffered from GAD, which is, in many ways, the basic syn- of events or activities (such as work or school performance). drome that characterizes every anxiety and related disorder con- B. The individual finds it difficult to control the worry. sidered in this chapter (Brown, Barlow, & Liebowitz, 1994). The C. The anxiety and worry are associated with at least three (or DSM-5 criteria specify that at least 6 months of excessive anxiety more) of the following six symptoms (with at least some symp- and worry (apprehensive expectation) must be ongoing more days toms present for more days than not for the past 6 months) than not. Furthermore, it must be difficult to turn off or control [Note: Only one item is required in children]: the worry process. This is what distinguishes pathological wor- 1. Restlessness or feeling keyed up or on edge rying from the normal kind we all experience occasionally as we 2. Being easily fatigued prepare for an upcoming event or challenge. Most of us worry for 3. Difficulty concentrating or mind going blank a time but can set the problem aside and go on to another task. 4. Irritability Even if the upcoming challenge is a big one, as soon as it is over, 5. Muscle tension the worrying stops. For Irene, it never stopped. She turned to the 6. Sleep disturbance (difficulty falling or staying asleep or next crisis as soon as the current one was over. restless, unsatisfying sleep) The physical symptoms associated with generalized anxi- D. The anxiety, worry or physical symptoms cause clinically ety and GAD differ somewhat from those associated with panic significant distress or impairment in social, occupational, or attacks and panic disorder (covered next). Whereas panic is asso- other important areas of functioning. ciated with autonomic arousal, presumably as a result of a sym- E. The disturbance is not due to the direct physiological effects pathetic nervous system surge (for instance, increased heart rate, of a substance (e.g., a drug of abuse, a medication) or a general palpitations, perspiration, and trembling), GAD is characterized medical condition (e.g., hyperthyroidism). by muscle tension, mental agitation (Brown, Marten, & Barlow, F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in 1995), susceptibility to fatigue (probably the result of chronic panic disorder, negative evaluation in social anxiety disorder). excessive muscle tension), some irritability, and difficulty sleep- ing (Campbell-Sills & Brown, 2010). Focusing one’s attention is From American Psychiatric Association. (2013). Diagnostic and statistical manual of difficult, as the mind quickly switches from crisis to crisis. For mental disorders (5th ed.). Washington, DC. gEnEralizEd anxiEty disordEr 135 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203 1-year period (Kessler, Chiu, Demler, & Walters, 2005) and 5.7% at some point during their lifetime (Kessler, Berglund, Demler, Jin, & Walters, 2005). For adolescents only (ages 13–17), the one-year prevalence is somewhat lower at 1.1% (Kessler et al., 2012). This is still quite a large number, making GAD one of the most com- mon anxiety disorders. Similar rates are reported from around the world, for example, from rural South Africa (Bhagwanjee, Parekh, Paruk, Petersen, & Subedar, 1998). Relatively few people © berna namoglu/Shutterstock.com with GAD come for treatment, however, compared with patients with panic disorder. Anxiety clinics like ours report that only approximately 10% of their patients meet criteria for GAD com- pared with 30% to 50% for panic disorder. This may be because most patients with GAD seek help from their primary care doc- tors, where they are found in large numbers (Roy-Byrne & Katon, 2000; Wittchen, 2002). About twice as many individuals with GAD are female than Approximately one in ten older adults suffers from generalized male in epidemiological studies (where individuals with GAD are anxiety disorder. identified from population surveys), which include people who do not necessarily seek treatment (Grant et al., 2005). But this sex ratio may be specific to developed countries. In the South African with cognitive function and put the elderly at greater risks for study mentioned here, GAD was more common in males. In the falling down and breaking bones, particularly their hips (Barlow, United States, the prevalence of the disorder is significantly lower 2002). Major difficulties that hamper the investigation of anxiety among Asian, Hispanic, and Black adults compared to Whites in the elderly include the lack of good assessment instruments (Grant et al., 2005). and treatment studies, largely because of insufficient research Some people with GAD report onset in early adulthood, interest (Ayers, Thorp, & Wetherell, 2009; Beck & Stanley, 1997; usually in response to a life stressor. Nevertheless, most studies Campbell-Sills & Brown, 2010). find that GAD is associated with an earlier and more gradual In a classic study, Rodin and Langer (1977) demonstrated that onset than most other anxiety disorders (Barlow, 2002; Brown older adults may be particularly susceptible to anxiety about fail- et al., 1994; Beesdo, Pine, Lieb, & Wittchen, 2010; Sanderson & ing health or other life situations that begin to diminish whatever Barlow, 1990). The median age of onset based on interviews is 31 control they retain over events in their lives. This increasing lack (Kessler, Berglund, Demler, Jin, & Walters, 2005), but like Irene, of control, failing health, and gradual loss of meaningful functions many people have felt anxious and tense all their lives. Once it may be a particularly unfortunate by-product of the way the elderly develops, GAD is chronic. One study found only an 8% probabil- are treated in Western culture. The result is substantial impair- ity of becoming symptom free after 2 years of follow-up (Yonkers ment in quality of life in older adults with GAD (Wetherell et al., et al., 1996). Bruce and colleagues (2005) reported that 12 years 2004). If it were possible to change our attitudes and behavior, we after the beginning of an episode of GAD, there was only a 58% might well reduce the frequency of anxiety, depression, and early chance of recovering. But 45% of those individuals who recovered death among elderly people. were likely to relapse later. This suggests that GAD, like most anxi- ety disorders, follows a chronic course, characterized by waxing and waning of symptoms. Causes GAD is prevalent among older adults. In the large national What causes GAD? We have learned a great deal in the past several comorbidity study and its replication, GAD was found to be most years. As with most anxiety disorders, there seems to be a general- common in the group over 45 years of age and least common in ized biological vulnerability. This is reflected in studies examining the youngest group, ages 15 to 24 (Wittchen, Zhao, Kessler, & a genetic contribution to GAD, although Kendler and colleagues Eaton, 1994; Byers, Yaffe, Covinsky, Friedman, & Bruce, 2010); (1995; Hettema, Neale, & Kendler, 2001; Hettema, Prescott, Myers, reported prevalence rates of GAD in older adults were as high Neale, & Kendler, 2005) confirmed that what seems to be inher- as 10%. We also know that the use of minor tranquilizers in the ited is the tendency to become anxious rather than GAD itself. In elderly is high. For example, in 2008 5.2% of adults in the United support of this finding, heritability has been found for a particular States used benzodiazepines, and the percentage increased with trait, called anxiety sensitivity, which is the tendency to become age (Olfson, King, & Schoenbaum, 2015). The study showed that distressed in response to arousal related sensations, arising from only 2.6% of the 18 to 35 year olds, but 8.7% of the 65 to 80 year beliefs that these anxiety-related sensations have harmful conse- olds filled at least one prescription of benzodiazepines during the quences (Davies, Verdi, Burri, Trzaskowski, Lee, Hettema, Jansen, year. It is not entirely clear why drugs are prescribed with such Boomsma, & Spector, 2015). frequency for the elderly. One possibility is that the drugs may For a long time, GAD has posed a real puzzle to investiga- not be entirely intended for anxiety. Prescribed drugs may be pri- tors. Although the definition of the disorder is relatively new, marily for sleeping problems or other secondary effects of medical originating in 1980 with DSM-III, clinicians and psychopatholo- illnesses. In any case, benzodiazepines (minor tranquilizers) interfere gists were working with people with generalized anxiety long 136 CHAPTER 5 a n x i E t y, t r a U M a - a n d s t r E s s o r - r E l at E d , a n d o B s E s s i v E - C o M P U l s i v E a n d r E l at E d d i s o r d E r s Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203 before diagnostic systems were developed. For years, clinicians How do mental processes link up with the tendency of indi- thought that people who were generally anxious had simply not viduals with GAD to be autonomic restrictors? Tom Borkovec and focused their anxiety on anything specific. Thus, such anxiety his colleagues noticed that although the peripheral autonomic was described as “free floating.” But now scientists have looked arousal of individuals with GAD is restricted, they showed intense more closely and have discovered some interesting distinctions cognitive processing in the frontal lobes as indicated by EEG activ- from other anxiety disorders. ity, particularly in the left hemisphere. This finding would suggest The first hints of difference were found in the physiological frantic, intense thought processes or worry without accompa- responsivity of individuals with GAD. It is interesting that indi- nying images (which would be reflected by activity in the right viduals with GAD do not respond as strongly to stressors as indi- hemisphere of the brain rather than the left) (Borkovec, Alcaine, viduals with anxiety disorders in which panic is more prominent. & Behar, 2004). Borkovec suggests that this kind of worry may Several studies have found that individuals with GAD show less be what causes these individuals to be autonomic restrictors responsiveness on most physiological measures, such as heart rate, (Borkovec, Shadick, & Hopkins, 1991; Roemer & Orsillo, 2013). blood pressure, skin conductance, and respiration rate (Borkovec That is, they are thinking so hard about upcoming problems that & Hu, 1990; Roemer & Orsillo, 2013), than do individuals with they don’t have the attentional capacity left for the all-important other anxiety disorders. Moreover, GAD patients often show a process of creating images of the potential threat, images that comparatively low cardiac vagal tone (the vagus nerve is the larg- would elicit more substantial negative affect and autonomic activ- est parasympathetic nerve innervating the heart and decreasing ity. In other words, they avoid images associated with the threat its activity), leading to autonomic inflexibility, because the heart is (Borkovec et al., 2004; Fisher & Wells, 2009). But from the point less responsive to certain tasks (Hofmann, Moscovitch, Litz, Kim, of view of therapy, it is important to “process” the images and Davis, & Pizzagalli, 2005). Therefore, people with GAD have been negative affect associated with anxiety (Craske & Barlow, 2006; called autonomic restrictors (Barlow, Chorpita, & Turovsky, 1996; Zinbarg, Craske, & Barlow, 2006). Because people with GAD do Thayer, Friedman, & Borkovec, 1996). not seem to engage in this process, they may avoid much of the When individuals with GAD are compared with nonanxious unpleasantness and pain associated with the negative affect and “normal” participants, the one physiological measure that consis- imagery, but they are never able to work through their problems tently distinguishes the anxious group is muscle tension—people and arrive at solutions. Therefore, they become chronic worriers, with GAD are chronically tense (Andrews et al., 2010; Marten, with accompanying autonomic inflexibility and quite severe mus- Brown, Borkovec, Shear, & Lydiard, 1993). To understand this cle tension. Thus, intense worrying for an individual with GAD phenomenon of chronic muscle tension, we may have to know may act as avoidance does for people with phobias. It prevents the what’s going on in the minds of people with GAD. With new person from facing the feared or threatening situation, so adapta- methods from cognitive science, we are beginning to uncover tion never occurs. This is one major deficit in the way people with the sometimes-unconscious mental processes ongoing in GAD GAD attempt to regulate their intense anxiety (Etkin & Schatzberg, (Teachman, Joormann, Steinman, & Gotlib, 2012. 2011). In summary, some people inherit a tendency to be tense The evidence indicates that individuals with GAD are highly (generalized biological vulnerability), and they develop a sense sensitive to threat in general, particularly to a threat that has per- early on that important events in their lives may be uncontrollable sonal relevance. That is, they allocate their attention more readily and potentially dangerous (generalized psychological vulnerabil- to sources of threat than do people who are not anxious (Aikins ity). Significant stress makes them apprehensive and vigilant. This & Craske, 2001; Roemer & Orsillo, 2013; Bradley, Mogg, White, sets off intense worry with resulting physiological changes, lead- Groom, & de Bono, 1999). This high sensitivity may have arisen ing to GAD (Roemer, Orsillo, & Barlow, 2002; Turovsky & Barlow, in early stressful experiences where they learned that the world 1996). Time will tell if the current model is correct, although there is dangerous and out of control, and they might not be able to is much supporting data (Borkovec, Alcaine, & Behar, 2004; Mineka cope (generalized psychological vulnerability). Furthermore, & Zinbarg, 2006). In any case, it is consistent with our view of anx- this acute awareness of potential threat, particularly if it is per- iety as a future-oriented mood state focused on potential danger sonal, seems to be entirely automatic or unconscious. Using the or threat, as opposed to an emergency or alarm reaction to actual Stroop color-naming task described in Chapter 2, MacLeod and present danger. A model of the development of GAD is presented Mathews (1991) presented threatening words on a screen for only in E Figure 5.4. 20 milliseconds and still found that individuals with GAD were slower to name the colors of the words than were nonanxious indi- viduals. Remember that in this task, words in colored letters are pre- Treatment sented briefly and participants are asked to name the color rather GAD is quite common, and available treatments, both drug and than the word. The fact that the colors of threatening words were psychological, are reasonably effective. Benzodiazepines are most named more slowly suggests the words were more relevant to peo- often prescribed for generalized anxiety, and the evidence indi- ple with GAD, which interfered with their naming the color—even cates that they give some relief, at least in the short term. Few though the words were not present long enough for the individu- studies have looked at the effects of these drugs for a period als to be conscious of them. Investigators using other paradigms longer than 8 weeks (Mathew & Hoffman, 2009). But the thera- and in different anxiety populations have come to similar conclu- peutic effect is relatively modest. Furthermore, benzodiazepines sions (Bar-Haim, Larry, Pergamin, Bakermans-Kranenburg, Van carry some risks. First, they seem to impair both cognitive and Ijzendoorn, 2007; Sheppes, Luria, Fukuda, & Gross, 2013). motor functioning (see, for example, Hindmarch, 1990; van Laar, gEnEralizEd anxiEty disordEr 137 Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203  Generalized psychological Generalized biological Allen, & Basden, 2007; Newman et al., 2011; Roemer & Orsillo, vulnerability vulnerability 2013). Recent reports of innovations in brief psychological treat- ments are encouraging. Because we now know that individuals Possible with GAD seem to avoid “feelings” of anxiety and the negative Stress false Due to life events alarms affect associated with threatening images, clinicians have designed treatments to help patients with GAD process the threatening information on an emotional level, using images, so that they Anxious apprehension (including increased muscle tension and vigilance) will experience (rather than avoid feeling) the emotion associ- ated with the images. These treatments have other components, such as teaching patients how to relax deeply to combat tension. Worry process Borkovec and his colleagues found such a treatment to be sig- A failed attempt to cope and problem solve nificantly better than a placebo psychological treatment, not only at posttreatment but also at a 1-year follow-up (Borkovec & Costello, 1993). In the early 1990s, we developed a cognitive-behavioral Intense cognitive processing Avoidance of imagery treatment (CBT) for GAD in which patients evoke the worry process during therapy sessions and confront threatening images and thoughts head-on. The patient learns to use cognitive therapy and other coping techniques to counteract and control Inadequate Restricted autonomic problem-solving skills response the worry process (Craske & Barlow, 2006; Wetherell, Gatz, & Craske, 2003). In a major study, a brief adaptation of this treat- ment was also used successfully to decrease anxiety and improve quality of life in a primary care office (family doctors and nurses) Generalized where GAD is a frequent complaint (Rollman et al., 2005). anxiety Cuijpers and colleagues (Cuijpers, Sijbrandi, Koole Huibers, disorder Berking, & Andersson, 2014) recently reviewed 41 studies with 2,132 patients meeting criteria for GAD and found large treat- ment effects of psychotherapy, which primarily consisted of CBT, as compared to control conditions, which were primarily E FIGURE 5.4 waitlist groups. An integrative model of GAD. Despite this success, it is clear we need more powerful treat- ments, both drug and psychological, for this chronic, treatment- resistant condition. Recently, a new psychological treatment for Volkerts, & Verbaten, 2001). Specifically, people don’t seem to GAD has been developed that incorporates procedures focus- be as alert on the job or at school when they are taking benzo- ing on acceptance rather than avoidance of distressing thoughts diazepines. The drugs may impair driving, and in older adults and feelings in addition to cognitive therapy. Meditational and they seem to be associated with falls, resulting in hip fractures mindfulness-based approaches help teach the patient to be more (Ray, Gurwitz, Decker, & Kennedy, 1992; Wang, Bohn, Glynn, tolerant of these feelings (Hofmann, Sawyer, Witt, & Oh, 2010; Mogun, & Avorn, 2001). More important, benzodiazepines Khoury et al., 2013; Orsillo & Roemer, 2011; Roemer & Orsillo, seem to produce both psychological and physical dependence, 2009; Roemer et al., 2002). Results from a clinical trial reported making it difficult for people to stop taking them (Mathew & some of the highest success rates yet to appear in the literature Hoffman, 2009; Noyes, Garvey, Cook, & Suelzer, 1991; Rickels, (Hayes-Skelton, Roemer, & Orsillo, 2013). Schweizer, Case, & Greenblatt, 1990). There is reasonably wide There is particularly encouraging evidence that psychological agreement that the optimal use of benzodiazepines is for the treatments are effective with children who suffer from general- sh