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ANXIETY DISORDERS

• GENERALIZED ANXIETY DISORDER

• PANIC ATTACKS AND PANIC DISORDER
• PHOBIC DISORDERS
• OBSESSIVE-COMPULSIVE DISORDER
• POSTTRAUMATIC STRESS DISORDER
• ACUTE STRESS DISORDER

Anxiety Disorders categorize a large number of disorders where the primary feature is abnormal or
inappropriate anxiety. The disorders in this category include Panic Disorder, Agoraphobia, Specific
Phobias, Social Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, and Generalized
Anxiety Disorder.
All people experience fear and anxiety. Fear is an emotional, physiological, and behavioural response to
a recognized external threat—for example, an intruder or a runaway car. Anxiety is an unpleasant
emotional state that has a less clear source. Anxiety is often accompanied by physiological and
behavioural changes similar to those caused by fear. Because of these similarities, people often use the
terms anxiety and fear interchangeably. Anxiety is a response to stress, such as the breakup of an
important relationship or exposure to a life-threatening disaster. Anxiety can arise suddenly, as in panic,
or gradually over minutes, hours, or days. The anxiety itself can last for any length of time, from a few
seconds to years. Anxiety ranges in intensity from barely noticeable qualms to full-blown panic. Anxiety
serves as one element in a wide range of flexible responses that are essential for people to survive in a
dangerous world. A certain amount of anxiety introduces an appropriate element of caution in potentially
dangerous situations. Most of the time, a person’s level of anxiety makes appropriate and imperceptible
shifts along a spectrum of consciousness from sleep through alertness to anxiety and fear and back again.
Sometimes, however, a person’s anxiety response system operates improperly or is overwhelmed by
events; in this case, an anxiety disorder can arise.
People react differently to situations. For example, some people find speaking before a group exhilarating,
while others dread it. The ability to tolerate anxiety varies among people, and determining what constitutes
abnormal anxiety can be difficult. However, when anxiety occurs at inappropriate times or is so intense
and long-lasting that it interferes with a person’s normal activities, then it is properly considered a
disorder. Anxiety disorders can be so distressing and interfere so much with a person’s life that they can
lead to depression. Some people have an anxiety disorder and depression at the same time. Others develop
depression first and an anxiety disorder later.
How Anxiety Affects Performance
Anxiety disorders are the most common type of psychiatric disorder. The diagnosis of an anxiety disorder
is based largely on its symptoms. However, symptoms identical to those of an anxiety disorder can be
Clinical Psychology Anxiety Disorders 10
caused by a medical condition (for example, an overactive thyroid gland) or by the use of a prescribed or
illicit drug (for example, corticosteroids or cocaine). A family history of an anxiety disorder may help the
doctor make the diagnosis, since the predisposition to a specific anxiety disorder as well as a susceptibility
to anxiety disorders in general often is hereditary. Accurate diagnosis is important, since treatment varies
from one disorder to another. Depending on the disorder, behavioural therapy, drugs, or psychotherapy,
alone or in appropriate combinations, can significantly relieve the distress and dysfunction for most
people.

GENERALIZED ANXIETY DISORDER

Generalized anxiety disorder consists of excessive, almost daily anxiety and worry (lasting 6 months or
longer) about a variety of activities or events. The anxiety and worry of generalized anxiety disorder are
so extreme that they become difficult to control. Worries are general in nature; common worries include
work responsibilities, money, health, safety, car repairs, and chores. The severity, frequency, or duration
of the worries is disproportionately greater than the situation calls for. Generalized anxiety disorder is
common; about 3 to 5 percent of adults have it at some time during a given year. Women are twice as
likely as men to have the disorder. It often begins in childhood or adolescence but may start at any age.
For most people, the condition fluctuates, worsening at times (especially during times of stress), and
persists over many years.
Symptoms
• restlessness or feeling keyed up or on edge
• being easily fatigued
• difficulty concentrating or mind going blank
• irritability
• muscle tension
• sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
Treatment
Drugs are the primary treatment for generalized anxiety disorder. Antianxiety drugs such as
benzodiazepines are usually prescribed. Buspirone is another effective drug for many people with
generalized anxiety disorder. Its use apparently doesn’t lead to physical dependence. Behaviour therapy
isn’t usually beneficial because no clear-cut situations trigger the anxiety. Relaxation and biofeedback
techniques may be of some help. Generalized anxiety disorder may be associated with underlying
psychological conflicts. Such conflicts are frequently related to insecurities and self-critical attitudes that
are self-defeating. For some people, psychotherapy may be effective in helping to understand and resolve
internal psychological conflicts.

PANIC ATTACKS AND PANIC DISORDER

Panic is acute and extreme anxiety with accompanying physiological symptoms. Panic attacks may occur
in any anxiety disorder, usually in response to a specific situation tied to the main characteristic of the
disorder. For example, a person with a phobia of snakes may panic when encountering a snake. However,
Clinical Psychology Anxiety Disorders 11
these situational panics differ from the spontaneous, unprovoked ones that define a person’s problem as
panic disorder. Panic attacks are common, occurring in more than a third of adults each year. Women are
two to three times more likely than men to have panic attacks. Panic disorder is uncommon and is
diagnosed in slightly less than 1 percent of the population. Panic disorder usually begins in late
adolescence and early adulthood.
Symptoms
A panic attack involves the sudden appearance of at least four of the following symptoms:
• Shortness of breath or sense of being smothered
• Dizziness, unsteadiness, or faintness
• Palpitations or accelerated heart rate
• Trembling or shaking
• Sweating
• Choking
• Nausea, stomachache, or diarrhea
• Feelings of unreality, strangeness, or detachment from the environment
• Numbness or tingling sensations
• Flushing or chills
• Chest pain or discomfort
• Fear of dying
• Fear of “going crazy” or losing control
Treatment
Most people recover from panic attacks without treatment; a few develop panic disorder. Recovery
without treatment is possible even for those who have recurring panic attacks or anticipatory anxiety,
particularly if they are repeatedly exposed to the provocative stimulus or situation. People who don’t
recover on their own or who don’t seek treatment continue to have panic attacks off and on indefinitely.
People respond better to treatment when they understand that panic disorder involves both biological and
psychological processes. Drugs and behavioural therapy can generally control the symptoms. In addition,
psychotherapy may help resolve any psychological conflicts that might underlie the anxious feelings and
behaviour. When a drug is effective, it prevents or greatly reduces the number of panic attacks. A drug
may have to be taken for long periods of time if panic attacks return once the drug is stopped.
Exposure therapy, a type of behaviour therapy in which the person is exposed repeatedly to whatever
triggers a panic attack, often helps to diminish the fear. Exposure therapy is practised until the person
develops a high level of comfort with the anxiety-provoking situation. In addition, people who are afraid
they will faint during a panic attack can practice an exercise in which they spin in a chair or breathe
quickly (hyperventilate) until they feel faint. This exercise teaches them that they won’t actually faint
during a panic attack. Practising slow, shallow breathing (respiratory control) helps many people who tend
to hyperventilate.
Psychotherapy with a view to gaining insight and better understanding of any underlying psychological
conflicts may also be useful. Less intensive, supportive psychotherapy is always appropriate because a
therapist can provide general information about the disorder, its treatment, realistic hope for improvement,
Clinical Psychology Anxiety Disorders 12
and the support that comes from a trusting relationship with a therapist.

PHOBIC DISORDERS

Phobias involve persistent, unrealistic, intense anxiety in response to specific external situations, such as
looking down from heights or coming near a small dog. People who have a phobia avoid situations that
trigger their anxiety, or they endure them with great distress. However, they recognize that their anxiety
is excessive and therefore are aware that they have a problem.
Agoraphobia
Although agoraphobia literally means fear of the marketplace or open spaces, the term more specifically
describes the fear of being trapped without a graceful and easy way to leave if anxiety should strike.
Typical situations that are difficult for people with agoraphobia include standing in line at a bank or
supermarket, sitting in the middle of a long row in a theatre or classroom, and riding on a bus or train.
Some people develop agoraphobia after experiencing a panic attack in one of these situations. Other
people simply feel uncomfortable in these settings and may never, or only later, develop panic attacks.
Agoraphobia often interferes with daily living, sometimes so drastically that it leaves the person
housebound. Agoraphobia is diagnosed in 3.8 percent of women and 1.8 percent of men during any
6-month period. The disorder most often begins in the early 20s; a first appearance after age 40 is unusual.
Symptoms
• Anxiety about being in places or situations from which escape might be difficult (or embarrassing)
or in which help may not be available in the event of having an unexpected or situationally
predisposed Panic Attack or panic-like symptoms.
• Fears typically involve characteristic clusters of situations that include being outside the home
alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or
automobile.
• The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or
with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a
companion.
Treatment
The best treatment for agoraphobia is exposure therapy, a type of behaviour therapy. With the help of a
therapist, the person seeks out, confronts, and remains in contact with what s/he fears until her/his anxiety
is slowly relieved by familiarity with the situation (a process called habituation). Exposure therapy helps
more than 90 percent of the people who practice it faithfully.
If agoraphobia isn’t treated, it usually waxes and wanes in severity and may even disappear without formal
treatment, possibly because the person has conducted some personal form of behaviour therapy.
People with agoraphobia who are deeply depressed may need to take an antidepressant. Substances that
depress the central nervous system, such as alcohol or large doses of antianxiety drugs, may interfere with
behaviour therapy and are tapered off gradually before therapy is begun.
As with panic disorder, the anxiety in some people who have agoraphobia may have its roots in underlying
psychological conflicts. In such cases, psychotherapy (in which the person develops a better understanding
of the underlying conflicts) may be helpful.
Clinical Psychology Anxiety Disorders 13
Specific Phobias
Specific phobias are the most common of the anxiety disorders. About 7 percent of women and 4.3 percent
of men have a specific phobia during any 6-month period. Some specific phobias, such as the fear of large
animals, the dark, or strangers, begin early in life. Many phobias stop as the person gets older. Other
phobias, such as fear of insects, storms, water, heights, flying, or enclosed places, typically develop later
in life. At least 5 percent of people are to some degree phobic about blood, injections, or injury, and these
people can actually faint, which does not happen with other phobias and anxiety disorders. In contrast,
many people with anxiety disorders hyperventilate, which can cause feelings of faintness, but they
virtually never faint.
Symptoms
• The person experiences a strong, persistent fear that is excessive or unreasonable. It is set off
(cued) by a specific object or situation that is either present or anticipated.
• The phobic stimulus almost always immediately provokes an anxiety response, which may be
either a panic attack or symptoms of anxiety that do not meet criteria for a panic attack.
• The fear is unreasonable or out of proportion, and the person realizes this.
• The person either avoids the phobic stimulus or endures it with severe anxiety or distress.
• Persons under the age of 18 must have the symptoms for 6 months or longer.
• Either there is marked distress about this fear or it markedly interferes with the person’s usual
routines or social, job or personal functioning.
Treatment
A person can often cope with a specific phobia by avoiding the feared object or situation. For example,
a city dweller who is afraid of snakes may have no trouble avoiding them. However, the city dweller who
fears crowd will have a problem travelling. Exposure therapy, a type of behaviour therapy in which the
person is gradually exposed to the feared object or situation, is the best treatment for a specific phobia.
A therapist can help ensure that the therapy is carried out properly, although it can be done without a
therapist. Even people with a phobia of blood or needles respond well to exposure therapy. For example,
a person who faints while blood is drawn can have a needle brought close to a vein and then removed
when the heart rate begins to slow down. Repeating this process allows the heart rate to return to normal.
Eventually, the person can have blood drawn without fainting. Drugs aren’t very useful in helping people
overcome specific phobias. However, antianxiety drugs may give a person short-term control over a
phobia, such as the fear of flying. Psychotherapy, with a view toward gaining insight and understanding
of internal conflicts, may be helpful in identifying and treating the conflicts that may underlie a specific
phobia.
Social Phobia
A person’s ability to relate comfortably with others affects many aspects of life, including early family
relationships, education, work, leisure, dating, and mating. Although some anxiety in social situations is
normal, people with social phobia have so much anxiety that they either avoid social situations or endure
them with great distress. Recent research shows that about 13 percent of people have a social phobia
sometime in their lives. Situations that commonly trigger anxiety among people with social phobia include
public speaking; performing publicly, such as acting in a play or playing a musical instrument; eating in
front of others; signing a document before witnesses; and using a public bathroom. People with social
Clinical Psychology Anxiety Disorders 14
phobia are concerned that their performance or actions will seem inappropriate. Often they worry that their
anxiety will be obvious--that they’ll sweat, blush, vomit, or tremble or that their voice will quiver; they’ll
lose their train of thought; or they won’t be able to find the words to express themselves. A more general
type of social phobia is characterized by anxiety in almost all social situations. People with a general
social phobia are usually concerned that if their performance falls short of expectations, they will feel
humiliated and embarrassed. Some people are shy by nature and show timidness early in life that later
develops into social phobia. Others first experience anxiety in social situations at puberty. Social phobia
often persists if left untreated, causing many people to avoid activities in which they would otherwise like
to participate.
Symptoms
• A marked and persistent fear of one or more social or performance situations.
• The individual fears that s/he will act in a way (or show anxiety symptoms) that will be
humiliating or embarrassing.
• Exposure to the feared social situation almost invariably provokes anxiety, which may take the
form of a situationally bound or situationally predisposed Panic Attack.
• In children, there must be evidence of the capacity for age-appropriate social relationships with
familiar people and the anxiety must occur in peer settings, not just in interactions with adults.
Treatment
Exposure therapy, a type of behaviour therapy, works well for social phobia, but arranging for exposure
to last long enough to permit habituation and comfort may not be easy. For example, a person who is
afraid of speaking in front of her/his boss may not be able to arrange a series of speaking sessions in front
of that boss. Substitute situations may help, such as joining an organization for those who have anxiety
about speaking in front of an audience or reading a book to a group. Substitute sessions may or may not
reduce anxiety during conversations with the boss. Psychotherapy, which involves talking with a therapist
to better understand underlying conflicts, may be particularly helpful for people who are capable of
examining their own behaviour and making changes in the way they think about and react to situations.

OBSESSIVE-COMPULSIVE DISORDER

Obsessive-compulsive disorder is characterized by the presence of recurrent, unwanted, intrusive ideas,

images, or impulses that seem silly, weird, nasty, or horrible (obsessions) and an urge or compulsion to
do something that will relieve the discomfort caused by an obsession. The pervading obsessional theme
is harm, risk, or danger. Common obsessions include concerns about contamination, doubt, loss, and
aggressiveness. Typically, people with obsessive-compulsive disorder feel compelled to perform
rituals--repetitive, purposeful, intentional acts. Rituals used to control an obsession include washing or
cleaning to be rid of contamination, checking to allay doubt, hoarding to prevent loss, and avoiding the
people who might become objects of aggression. Most rituals, such as excessive hand washing or repeated
checking to make sure a door has been locked, can be observed. Other rituals are mental, such as repetitive
counting or making statements intended to diminish danger. Obsessive-compulsive disorder is different
from obsessive-compulsive personality disorder.
People can become obsessional about anything, and their rituals aren’t always logically connected to the
Clinical Psychology Anxiety Disorders 15
discomfort that these rituals relieve. For example, a person who has been worried about contamination
may have felt her/his discomfort decrease once when s/he happened to put her/his hand in her/his pocket.
Since then, any time obsessions about contamination arise, s/he repeatedly puts her/his hand in her/his
pocket. Most people with obsessive-compulsive disorder are aware that their obsessions don’t reflect
actual risks. They realize that their physical and mental behaviour is excessive to the point of being
bizarre. Obsessive-compulsive disorder thus differs from psychotic disorders, in which people lose contact
with reality. Obsessive-compulsive disorder affects about 2.3 percent of adults and occurs about equally
in men and women. Because people with this disorder are afraid they’ll be embarrassed or stigmatized,
they often perform their rituals secretly, even though the rituals may occupy several hours each day. About
one third of the people with obsessive-compulsive disorder are depressed at the time the disorder is
diagnosed. Altogether, two thirds become depressed at some point.
Symptoms
Obsessions as defined by:
• recurrent and persistent thoughts, impulses, or images that are experienced, at some time during
the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
• the thoughts, impulses, or images are not simply excessive worries about real-life problems
• the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them
with some other thought or action
• the person recognizes that the obsessional thoughts, impulses, or images are a product of her/his
own mind (not imposed from without as in thought insertion)
Compulsions as defined by:
• repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying,
counting, repeating words silently) that the person feels driven to perform in response to an
obsession, or according to rules that must be applied rigidly
• the behaviours or mental acts are aimed at preventing or reducing distress or preventing some
dreaded event or situation; however, these behaviours or mental acts either are not connected in
a realistic way with what they are designed to neutralize or prevent or are clearly excessive
At some point during the course of the disorder, the person has recognized that the obsessions or
compulsions are excessive or unreasonable.
Treatment
Exposure therapy, a type of behaviour therapy, often helps people with obsessive-compulsive disorder.
In this type of therapy, the person is exposed to the situations or people that trigger obsessions, rituals, or
discomfort. The person’s discomfort or anxiety will gradually diminish if s/he prevents her/himself from
performing the ritual during repeated exposure to the provocative stimulus. In this way, the person learns
that the ritual isn’t needed to decrease discomfort. The improvement usually persists for years, probably
because those who have mastered this self-help approach continue to practice it as a way of life without
much effort after formal treatment has ended. Psychotherapy, with a view toward gaining insight and
understanding of underlying conflicts, has generally not been effective for people with
obsessive-compulsive disorder. Ordinarily, a combination of drugs and behaviour therapy is the best
treatment. Drugs can also help many people with obsessive-compulsive disorder.
Clinical Psychology Anxiety Disorders 16
POSTTRAUMATIC STRESS DISORDER

Posttraumatic stress disorder is an anxiety disorder caused by exposure to an overwhelming, traumatic

event, in which the person later repeatedly reexperiences the event. Experiences that threaten death or
serious injury can affect people long after the experience is over. Intense fear, helplessness, or horror can
haunt a person. The traumatic situation is repeatedly reexperienced, usually in nightmares or flashbacks.
The person persistently avoids things that are reminders of the trauma. Sometimes symptoms don’t begin
until many months or even years after the traumatic event took place. The person has a numbing of general
responsiveness and symptoms of increased arousal (such as difficulty falling asleep or being easily
startled). Symptoms of depression are common. Posttraumatic stress disorder affects at least 1 percent of
people sometime during their life. People at high risk, such as combat veterans and victims of rape or other
violent acts, have a higher incidence. Chronic posttraumatic stress disorder doesn’t disappear but often
becomes less intense over time even without treatment. Nevertheless, some people remain severely
handicapped by the disorder indefinitely.
Symptoms
The traumatic event is persistently reexperienced in one (or more) of the following ways:
• recurrent and intrusive distressing recollections of the event, including images, thoughts, or
perceptions.
• recurrent distressing dreams of the event. Note: In children, there may be frightening dreams
without recognizable content.
• acting or feeling as if the traumatic event were recurring (includes a sense of reliving the
experience, illusions, hallucinations, and dissociative flashback episodes, including those that
occur on awakening or when intoxicated).
• intense psychological distress at exposure to internal or external cues that symbolize or resemble
an aspect of the traumatic event physiological reactivity on exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not
present before the trauma), as indicated by three (or more) of the following:
• efforts to avoid thoughts, feelings, or conversations associated with the trauma
• efforts to avoid activities, places, or people that arouse recollections of the trauma
• inability to recall an important aspect of the trauma
• markedly diminished interest or participation in significant activities
• feeling of detachment or estrangement from others
• restricted range of affect (e.g., unable to have loving feelings)
• sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a
normal life span)
Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more)
of the following:
• difficulty falling or staying asleep
• irritability or outbursts of anger
Clinical Psychology Anxiety Disorders 17
• difficulty concentrating
• hypervigilance
• exaggerated startle response
Treatment
Treatment of posttraumatic stress disorder involves behaviour therapy, drugs, and psychotherapy. In
behaviour therapy, the person is exposed to situations that may trigger memories of the painful experience.
After some initial increase in discomfort, behaviour therapy usually lessens a person’s distress. Refraining
from rituals, such as excessive washing to feel clean after a sexual assault, is also helpful.
Antidepressant and antianxiety drugs appear to provide some benefit. Because of the often intense anxiety
associated with traumatic memories, supportive psychotherapy plays an especially important role. The
therapist is openly empathic and sympathetic in recognizing the person’s psychological pain. The therapist
reassures the person that her/his response is valid but encourages her/him to face her/his memories during
behavioural desensitization therapy. The person also is taught ways to control anxiety, which helps to
modulate and integrate the painful memories into her/his personality.
People with posttraumatic stress disorder often feel guilty. For example, they may have behaved in ways
that they believe were unacceptably aggressive and destructive during combat, or they may have survived
a traumatic experience in which family members or friends died and experience survivor guilt. If so,
insight-oriented psychotherapy can help people understand why they are punishing themselves and help
rid them of guilt feelings. This psychotherapeutic technique may be needed to help the person retrieve key
traumatic memories that had been repressed, so that the memories can be dealt with constructively.

ACUTE STRESS DISORDER

Acute stress disorder is similar to posttraumatic stress disorder, except that it begins within 4 weeks of the
traumatic event and lasts only 2 to 4 weeks. A person with acute stress disorder has been exposed to a
terrifying event. The person mentally reexperiences the traumatic event, avoids things that remind her/him
of it, and has increased anxiety.
Symptoms
The person also has three or more of the following symptoms:
• A sense of numbing, detachment, or lack of emotional responsiveness
• Reduced awareness of surroundings (for example, being dazed)
• A feeling that things aren’t real
• A feeling that s/he her/himself isn’t real
• Inability to remember an important part of the traumatic event
Treatment
Many people recover from acute stress disorder once they are removed from the traumatic situation and
given appropriate support in the form of understanding, empathy for their distress, and an opportunity to
describe what happened and their reaction to it. Many people benefit from describing their experience
several times. Sleep aids may be helpful, but other drugs can interfere with the natural healing process.