Other research has explored the interpersonal effects of constant reassurance seeking (Joiner,

1995). More than most, people who are depressed seek reassurance that others truly care about them. But
even when others express support, they are only temporarily satisfied. Their negative self-concept causes
them to doubt the positive feedback, and their constant efforts to obtain reassurance come to irritate others.
People experiencing depression actually elicit negative feedback (e.g., by asking questions like “How do
you truly feel about me?” after the other person has already given support); eventually, other people’s
responses can confirm the person’s negative self-concept. Ultimately, the person’s excessive reassurance
seeking can lead to rejection (Joiner & Metalsky, 1995).
Many of the negative social behaviors, such as excessive reassurance seeking, could be the result
of depression. If some of these same social problems are present before symptoms appear, can the
problems increase the risk for depression? Research suggests that the answer is yes. Among a group of
undergraduates who were not initially depressed, those who were high in reassurance seeking were more
likely to develop depressive symptoms over a 10-week period (Joiner & Metalsky, 2001). Similarly research
using high-risk samples, identified before the onset of depression, suggest that interpersonal problems may
precede depression. For example, the behavior of elementary school children of parents with depression
was rated negatively by both peers and teachers (Weintraub, Prinz, & Neale, 1978); low social competence
predicted the concept of depression among elementary school children (Cole, Martin, Powers, et al., 1990);
and poor interpersonal problem-solving skills predicted increases in depression among adolescence
(Davila, Hammer, Burge, et al., 1995). Interpersonal problems are one risk factor for depression.
Psychological Factors in Depression
Manny different psychological factors may play a role in depressive disorders. In this section, we
discuss personality and cognitive factors. Personality and cognitive theories describe different diatheses
that might increase the risk of responding to negative life events with depressive episode.
Neuroticism several longitudinal studies suggest that neuroticism, a personality trait that involves
the tendency to react to events with greater-than-average negative effect, predicts the onset of depression
(Jorm, Christensen, Henderson, et al., 2000). A large study of twins suggests that neuroticism explains at
least part of the generic vulnerability to depression (Fanuos, Prescott, & kindler, 2004). As you would
expect, neuroticism is associated with anxiety as well as dysthymia (Kutov, Gamez, Schmidt, et al., 2010).
We discuss the overlap of anxiety and depression in focus in discovery 5.5.
Cognitive theories in cognitive theories, negative thoughts and beliefs are seen as major causes of
depression. Pessimistic and self-critical thoughts can torture the person with depression. We will describe
three cognitive theories. Beck’s theory and hopelessness theory both emphasize these types of negative
thoughts, although the theories differ in some important ways. Rumination theory emphasizes the tendency
to dwell on negative moods and thoughts.
Bek’s theory Aaron Beck (1967) argued that depression is associated with negative triad: negative views
of the self, the world, and the future (see figure 5.9). The “world” part of the depressive triad refers to the
person’s own corner of the world-the situations he or she faces. For example, people might think “I cannot
possibly cope with all these demands and responsibilities” as opposed to worrying about problems in the
broader world outside of their life.
According to this model, in childhood, people with depression acquired negative schema through
experiences such as loss of a parent, the social rejection of peers, or the depressive attitude of a parent.
Schemas are different from conscious thoughts-they are an underlying set of beliefs that operate outside of
a person’s awareness to shape the way a person makes sense of his or her experiences. The negative
schema is activated whenever the person encounters situations similar to those that originally caused the
schema to form.
In this section, we cover psychological treatments of depressive disorders and bipolar disorder.
Then we turn to biological treatments of depressive disorders and bipolar disorder.
Psychological treatment of depression
Several different forms of psychological treatment have been shown to help relieve depression. As with
studies of etiology, most of the research has focused on MDM. We note when treatments have been shown
to be effective in the treatment of dysthymia.
Interpersonal psychotherapy a treatment known as interpersonal psychotherapy (IPT) has fared well in
clinical trials. As we described in chapter 2, IPT builds on the idea that depression is closely tied to
interpersonal problems (Klerman, Weissman, Rounsaville, & Chevron, 1984). The core of the therapy is to
examine major interpersonal problems, such as role transitions, interpersonal conflicts, bereavement, and
interpersonal isolation. Typically, the therapist and the patient focus on one or two such issues, with the
goal of helping the person identify his or her feelings about these issues, make important decisions, and
make changes to resolve problems related to these issues. Like cognitive behavioral treatments, IPT is
typically brief (e.g., 16 sessions). Techniques include discussing interpersonal problems, exploring negative
feelings and encouraging their expression, improving both verbal and nonverbal communications, problem
solving, and suggesting new and more satisfying modes of behavior.
Several studies have found that IPT is effective in relieving MDD (Elkin, Shea, Watkins, et. al.,
1989) and that it prevents relapse when continued after recovery (Frank, Kupfer, Perel, et. al, 1990). In
addition, studies indicate that IPT can be effective in treating MDD among adolescents (Mufson,
Weissman, Moreau, et. al., 1999) and postpartum women (O’Hara, Stuart, Gorman, et. al., 2000; Zlotnick,
Johnson, Miller, et. al., 2001). In a study among villagers in Uganda, group sessions of IPT provided relief
from depressive symptoms (Bolton, Bass, Neugebauer, et. al., 2003). IPT has also been found to be
effective in the treatment of dysthymia (Markowitz, 1994). For many different groups, then, IPT appears to
be helpful in relieving depression.
Cognitive theory in keeping with their theory that depression is caused by negative schema and cognitive
biases, Beck and associates devised a cognitive therapy (CT) aimed at altering maladaptive thought
patters. The therapist tries to help the person with depression to change his or her opinions about the self.
When a person states that he or she is worthless because “nothing goes right, and everything I try to do
end in a disaster,” the therapist helps the person look for evidence that contradicts this overgeneralization,
such as abilities that the person is overlooking or discounting. The therapist also teaches the person to
monitor self-talk and to identify thought patterns that contribute to depression. The therapist then teaches
the person to challenge negative beliefs and to learn strategies that promote making realistic and positive
assumptions. Often, the client is asked to monitor their thoughts each day and to practice challenging
overly negative thoughts (see Table 5.6 for an example of a thought monitoring home-work assignments).
Beck’s emphasis is on cognitive restructuring (i.e., persuading the person to think less negatively).
Beck also includes a behavioral technique in his therapy called behavioral activation (BA), in which
people are encouraged to engage in pleasant activities that might bolster positive thoughts about one’s self
and life. For example, the therapist encourages patients to schedule positive events such as going for a
walk and taking with friends.
More than 75 randomized controlled trials have been conducted on CT for depression (Gloagen,
Cottraux, Cucherat, et. al., 1998). Many studies have demonstrated the efficacy of cognitive therapy for
relieving symptoms of MDD (Hollon, Haman, & Brown, 2002). With modifications, CT is promising in the
treatment of dysthymia (Hollon, Haman, & Brown, 2002). The strategies that clients learn in CT help
diminish the risk of relapse even after therapy ends, an important issue given how common relapse is in
MDD (Vittengl, Clark, Dunn, et. al., 2007). CT is particularly helpful in preventing relapse for those who
need this protection the most-people with at least five episodes of previous depression gain protection from
relapse through CT (Bockting, Schene, Spinhoven, et. al., 2005).
VERY FEW OF US go through even a week of our lives without experiencing anxiety or fear. In this
chapter, we focus on a group of disorders called anxiety disorders. Both anxiety and fear play a significant
role in these disorders, so it is important to understand some of the similarities and differences between
these two emotions.
Anxiety is defined as apprehension over an anticipated problem. In contrast, fear is defined as
reaction to immediate danger. Psychologist focus on the “immediate” aspect of fear versus the “anticipated”
aspect of anxiety-fear tends to be about a threat that’s happening now, whereas a college student
concerned about the possibility of unemployment after graduation experiences anxiety.
Both anxiety and fear can involve arousal, or sympathetic nervous system activity. Anxiety often
involves moderate arousal, and fear involves higher arousal. At the low end, a person experiencing anxiety
may feel no more than restless energy and physiological tension; at the high end, a person experiencing
fear may sweat profusely, breathe rapidly, and feel an overpowering urge to run.
Anxiety and fear are not necessarily “Bad”-in fact, both are adaptive. Fear is fundamental for “fight-
or-fight” reactions-that is, fear triggers rapid changes in the sympathetic nervous systems that prepare the
body for escape or fighting. In the right circumstances, fear saves lives. (Imagine a person who faces a
bear and experiences no impulse to flee, no surge in energy, and no marshaling of that energy to run
quickly!) in some anxiety disorders, though , the fear system seems to misfire-a person experiences fear at
a time when there is no danger in the environment (see the discussion of panic attacks later in this
chapter).
Anxiety is adaptive in helping us notice and plan for future threats-that is, to increase our
preparedness, to help people avoid potentially dangerous situations, and to think through potential
problems before they happen. In laboratory studies first conducted 100 years ago and since verified many
times over, a small degree of anxiety has been found to improve performance on laboratory tasks (Yerkes
& Dodson, 1908). Ask anyone with extreme test anxiety, then, provides a classic example of a U-shaped
curve with performance-an absence of anxiety is a problem, a little anxiety is adaptive, and a lot of anxiety
is detrimental.
In this chapter, we examine the major anxiety disorders included in DSM-5: specific phobias, social
anxiety disorder, panic disorder, agoraphobia, and generalized anxiety disorder. Obsessive-compulsive
disorder and trauma-related disorders share a good deal in common with the anxiety disorders but are also
distinct in some important ways. To recognize those distinctions, the DSM-5 places these conditions in new
chapters next to anxiety disorders. We will cover obsessive-compulsive and trauma-related disorders in
chapter 7. See figure 6.1 for an overview of how DSM-IV-TR and DSM-5 organize the various anxiety
disorders into chapters.
Anxiety disorders as a group are the most common type of psychiatric diagnosis. For example, in
one study of over 8,000 adults in the United States, approximately 28 percent of people reported having
experienced symptoms at some point during their life that met the DSM-IV-TR criteria for diagnosis of an
anxiety disorder (Kessler, Berlund, Demler, et. al., 2005). Phobias are particularly common. As a group,
anxiety disorders are very costly to society and to people with the disorders. These disorders are
associated with twice the average rate of medical costs (Simon, Ormel, Vonkroff, et. al., 1995), higher risk
of cardiovascular disease and other medical conditions (Roy-Brrne, Davidson, Kessler, et. al., 2008;
Smoller, Pollack, Wassertheil-Smoller, et. al., 2007), twice the risk of suicidal ideation and attempts
compared to people without a psychiatric diagnosis (Sareen et. al., 2005), difficulties in employment
(American psychiatric Association, 2000), and serious interpersonal concerns (Zatzick, Marmer, Weiss, et.
al., 1997). All of the anxiety disorders are associated with substantial decrements in the quality of life
(Olatunji, Cisler, & Tolin, 2007).
We begin by defining the symptoms of the anxiety disorders before turning to the common themes
in the etiology for the anxiety disorders as a group. We then describe specific etiological factors that shape
whether a specific anxiety disorder develops. Like most disorders, many different paradigms have helped
shed light on the anxiety disorders. Hence, throughout our discussions of etiology we look at issues from
various perspectives, with particular focus on generic, neurobiological, personality, cognitive, and
behavioral research. Finally, we consider the treatment of the anxiety disorders. We describe
commonalities in the psychological treatment