Anxiety Disorders

learning objectives 6

·  6.1 What are the essential features of anxiety disorders?

·  6.2 Describe the clinical features of specific and social phobias.

·  6.3 Why do anxiety disorders develop?

·  6.4 What are the clinical features of panic disorder?

·  6.5 What factors are implicated in the development of panic disorder?

·  6.6 Describe the clinical aspects of generalized anxiety disorder.

·  6.7 How are anxiety disorders treated?

·  6.8 What are the clinical features of obsessive-compulsive disorder and how is this disorder treated?

·  6.9 Describe three obsessive-compulsive related disorders.

Leni: Worried About Worrying So Much Leni is a 24-year-old graduate student. Although she is doing exceptionally well in her program, for the past year she has worried constantly that she will fail and be thrown out. When her fellow students and professors try to reassure her, Leni worries that they are just pretending to be nice to her because she is such a weak student. Leni also worries about her mother becoming ill and about whether she is really liked by her friends. Although Leni is able to acknowledge that her fears are excessive (she has supportive friends, her mother is in good health, and, based on her grades, Leni is one of the top students in her program), she still struggles to control her worrying. Leni has difficulty sleeping, often feels nervous and on edge, and experiences a great deal of muscle tension. When her friends suggested she take a yoga class to try and relax, Leni even began to worry about that, fearing that she would be the worse student in the class. “I know it makes no sense,” she says, “But that’s how I am. I’ve always been a worrier. I even worry about worrying so much!”

Anxiety  involves a general feeling of apprehension about possible future danger, and  fear  is an alarm reaction that occurs in response to immediate danger. Today the DSM has identified a group of disorders—known as the anxiety disorders—that share obvious symptoms of clinically significant fear or anxiety. Anxiety disorders affect approximately 25 to 29 percent of the U.S. population at some point in their lives and are the most common category of disorders for women and the second most common for men (Kessler et al.,  1994 ; Kessler, Berglund, Delmar, et al.,  2005 ). In any 12-month period, about 18 percent of the adult population suffers from at least one anxiety disorder (Kessler, Chiu, et al.,  2005c ). Anxiety disorders create enormous personal, economic, and health care problems for those affected. Some years ago several studies estimated that the anxiety disorders cost the United States somewhere between $42.3 billion and $47 billion in direct and indirect costs (about 30 percent of the nation’s total mental health bill of $148 billion in 1990; Greenberg et al.,  1999 ; Kessler & Greenberg,  2002 ). The figure is no doubt even higher now. Anxiety disorders are also associated with an increased prevalence of a number of medical conditions including asthma, chronic pain, hypertension, arthritis, cardiovascular disease, and irritable bowel syndrome (Roy-Byrne et al.,  2008 ) and people with anxiety disorders are very high users of medical services (e.g., Chavira et al.,  2009 ).

In this chapter, we describe a number of different anxiety disorders. We also focus on  obsessive-compulsive disorder (OCD) . Obsessions  are persistent and highly recurrent intrusive thoughts or images that are experienced as disturbing and inappropriate. People affected by such obsessions try to resist or suppress them, or to neutralize them with some other thought or action. Compulsions are repetitive behaviors (such as hand-washing or checking) that the person feels must be performed in response to the obsession. Compulsions are sometimes performed as lengthy rituals. These behaviors have the goal of preventing or reducing distress or preventing some dreaded outcome from occurring.

Historically, anxiety and obsessive-compulsive disorders were considered to be classic neurotic disorders. Although individuals with neurotic disorders  show maladaptive and self-defeating behaviors, they are not incoherent, dangerous, or out of touch with reality. To Freud, these neurotic disorders developed when intrapsychic conflict produced significant anxiety. Anxiety was, in Freud’s formulation, a sign of an inner battle or conflict between some primitive desire (from the id) and prohibitions against its expression (from the ego and superego). Sometimes this anxiety was overtly expressed (as in those disorders known today as the anxiety disorders). In certain other neurotic disorders, however, he believed that the anxiety might not be obvious, either to the person involved or to others, if psychological defense mechanisms were able to deflect or mask it. The term neurosis was dropped from the DSM in 1980. In addition, in DSM-III, some disorders that did not involve obvious anxiety symptoms were reclassified as either dissociative or somatoform disorders (some neurotic disorders were absorbed into the mood disorders category as well—see  Chapters 7  and  8 ). This change was made to group together smaller sets of disorders that shared more obvious symptoms and features. In DSM-5 this trend has gone a step further. Obsessive-compulsive disorder is no longer classified as an anxiety disorder. Instead, it is now listed in a new DSM-5category called  obsessive-compulsive and related disorders  (see Thinking Critically about DSM-5).

We begin by discussing the nature of fear and anxiety as emotional and cognitive states and patterns of responding, each of which has an extremely important adaptive value but to which humans at times seem all too vulnerable. We will then move to a discussion of the anxiety disorders. Finally, we consider OCD and other disorders from the new obsessive-compulsive and related disorders category.

The Fear and Anxiety Response Patterns

There has never been complete agreement about how distinct the two emotions of fear and anxiety are from each other. Historically, the most common way of distinguishing between the fear and anxiety response patterns has been whether there is a clear and obvious source of danger that would be regarded as real by most people. When the source of danger is obvious, the experienced emotion has been called fear (e.g., “I’m afraid of snakes”). With anxiety, however, we frequently cannot specify clearly what the danger is (e.g., “I’m anxious about my parents’ health”).

Fear

In recent years, however, many prominent researchers have proposed a more fundamental distinction between the fear and anxiety response patterns (e.g., Barlow,  1988 ,  2002 ; Bouton,  2005 ; Grillon,  2008 ; McNaughton,  2008 ). According to these theorists, fear is a basic emotion (shared by many animals) that involves activation of the “fight-or-flight” response of the autonomic nervous system. This is an almost instantaneous reaction to any imminent threat such as a dangerous predator or someone pointing a loaded gun.

Its adaptive value as a primitive alarm response to imminent danger is that it allows us to escape. When the fear response occurs in the absence of any obvious external danger, we say the person has had a spontaneous or uncued  panic attack . The symptoms of a panic attack are nearly identical to those experienced during a state of fear except that panic attacks are often accompanied by a subjective sense of impending doom, including fears of dying, going crazy, or losing control. These latter cognitive symptoms do not generally occur during fear states. Thus fear and panic have three components: