What is a Psychological

UNIT 2 DISORDERS OF ANXIETY, Disorder?

FEAR, PANIC, AND

OBSESSIONS-I*

Structure
2.0 Introduction
2.1 Difference Among Fear, Panic, and Anxiety
2.2 Clinical Features of Phobia
2.3 Why do Phobias Develop?
2.4 Treatment of Phobias
2.5 Clinical Features of Social Phobia
2.6 Causal Factors of Social Phobia
2.7 Treatment for Social Phobia
2.8 Clinical Aspects of Panic Disorder
2.9 Causal Factors for Panic Disorder
2.10 Treatment of Panic Disorder
2.11 Summary
2.12 Keywords
2.13 Review Questions
2.14 References and Further Reading
2.15 Web Resources
Learning Objectives
After reading this Unit, you will be able to:
Differentiate between panic, fear, anxiety and obsession;
Describe the clinical aspects of anxiety disorders recognised in DSM-5;
Explain the causal factors of specific phobia and agoraphobia and their
treatment; and
Elucidate the causal factors of social anxiety disorder and panic disorder
and their treatment.

2.0 INTRODUCTION
We often become anxious in our day to day life situations, such as, when we
have to appear for an exam/job interview, or caught in a traffic jam while
already running late, trying to meet the deadlines etc. Our level of anxiety
decreases once we come out of such situations, However, it is important to
look at certain situations when the individual remains anxious irrespective of
the situation and is unable to cope with it.When this happens, the person is
said to be suffering from anxiety disorder/s. There are several anxiety
disorders that have been identified by DSM-5, like generalized anxiety
disorder, specific phobia, social phobia, panic disorder, and agoraphobia. In
this Unit, you will learn the clinical aspects, causal factors and treatment of
specific phobia, social phobia, panic
* Dr. Gulgoona Jamal, Assistant Professor, Zakhir Hussain College, University of Delhi, New 47
Delhi
 Introducton to Psychological
Disorders & Disorders of disorder, and agoraphobia. You will learn about generalized anxiety disorder
Anxiety and Obsessions and obsessive-compulsive disorders in the subsequent unit. But before we
delve further into these disorders, let us first understand about anxiety and
other similar conditions such as fear and panic.

2.1 DISTINCTION BETWEEN ANXIETY, FEAR,

AND PANIC
The most common way to distinguish fear and anxiety has been in the terms of
an actual external stimulus that is perceived as a real danger/threat by most
people. Fear is experienced in the presence of real danger/threat whereas
anxiety is experienced only in anticipation of danger/threat when such a
danger/threat is not present or cannot be specified. Several researchers have
distinguished between fear, panic, and anxiety in terms of cognitive/subjective,
physiological, and behavioral components (e.g., Barlow, 2002; Bouton, 2005;
& Grillon, 2008). These components are loosely associated, i.e., every
individual may not necessarily experience all the three components. Thus,
someone having fear or anxiety may experience cognitive and physiological
component with greater intensity than the behavioral component and vice versa
(Carson, Butcher, Mineka, & Holley, 2013).

Cognitive/Subjective: “I am afraid”

Physiological: Increased heart rate, fast and heavy breathing

Behavioral: Strong urge to escape from the situation

Fig. 2.1 Components of fear

Panic, like fear has all the above three components. However, additionally,
panic attack is characterised by subjective feelings of impending doom, fear of
dying, going crazy and losing control. Anxiety on the other hand is a more
diffused, future-oriented state that comprises of a complex blend of cognitions
and emotions.

Cognitive/Subjective: negative mood, worry about possible future danger/threat, self-preoccupation, inability to predict and/or control the occurrence of future d

Physiological: chronic tension and over arousal, full-fledged fight or flight response is not there as in fear but the person is primed for fight or flight response for the a

Behavioral: avoidance of anticipated dangerous/threatening situations but there is no immediate urgency to

Fig.2.2 Components of anxiety

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 Disorders of Anxiety, Panic
Check Your Progress 1 and Obsessions-I
1) Differentiate between panic, anxiety and fear.
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2) List the main components of anxiety.
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2.2 CLINICAL FEATURES OF PHOBIA

“A phobia is a persistent and disproportionate fear of a specific object or
situation that presents little or no actual danger to a person” (Carson, Butcher,
& Mineka, 2003). DSM-5 has identified three categories of phobias: specific
phobia, social phobia and agoraphobia.

According to DSM-5 Specific Phobia, previously known as simple phobia, has

five sub types: animals (e.g., snakes, spiders, dogs); natural environment (e.g.,
water, heights, storms); blood-injection-injury; situational (bridges, tunnels);
others (vomiting, choking, ‘space phobia’ where the person has a fear of
falling down if he/she is away from walls or support).

Social Phobia is a fear of social situations. A person is afraid of acting in a

humiliating or embarrassing way when he/she is exposed to the scrutiny of
others. Social phobia may be specific to a situation such as fear of public
speaking or generalised as in fear of many different social interactions.

Agoraphobia was traditionally thought to be a fear of “agora”, Greek word for

public places of assembly (Marks, 1987). It is a fear of crowded places such as
shopping malls, theaters etc. It can also be a fear of having a panic attack in
situations where escape might prove to be difficult or embarrassing.

Now, we will discuss the above mentioned phobias, separately.

Specific Phobias

Specific phobia is diagnosed when a person shows strong and persistent fear
which is triggered by a specific object or situation. On encountering a phobic
stimulus, the person with specific phobia show an immediate fear response
that resembles a panic attack except for the presence of a clear external trigger
(APA, 2013). She/he experiences anxiety on anticipation of the phobic
stimulus and go to great lengths to avoid it. The person is fearful and avoids
even the mere representations (picture/model) of the phobic stimulus. Most
often, the person has an insight about one’s condition, that is, the person
recognizes that the response to a phobic stimulus is unreasonable or excessive.

4
Introducton to Psychological
Disorders & Disorders of Box 2.1: Criteria for Specific Phobia according to DSM-5 (APA, 2013)
Anxiety and Obsessions
A. Marked and persistent fear that is excessive or unreasonable, cued by
the presence or anticipation of a specific object or situation (e.g.,
flying, heights, animals, receiving an injection, seeing blood).
B. Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response, which may take the form of a
situationally bound or situationally predisposed Panic Attack.
Note: In children, the anxiety may be expressed by crying, tantrums,
freezing, or clinging.
C. The person recognizes that the fear is excessive or unreasonable.
Note: In children, this feature may be absent.
D. The phobic situation(s) is avoided or else is endured with intense
anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared
situation(s) interferes significantly with the person’s normal routine,
occupational (or academic) functioning, or social activities or
relationships, or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The anxiety, panic attacks, or phobic avoidance associated with the
specific object or situation are not better accounted for by another
mental disorder, such as Obsessive-Compulsive Disorder (e.g., fear
of dirt in someone with an obsession about contamination),
Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated
with a severe stressor), Separation Anxiety Disorder (e.g., avoidance
of school), Social Phobia (e.g., avoidance of social situations because
of fear of embarrassment), Panic Disorder with Agoraphobia, or
Agoraphobia without history of Panic Disorder.

Types of Specific Phobias

DSM- 5 defines five types of specific phobias:
1) Animal Type: These include fears of animals such as dogs, cats, spiders,
bugs, mice, rats, birds,fish, and snakes.

2) Natural Environment Type: These include fears of heights, storms, and

being near water.

3) Blood-Injection-Injury Type: These include fears of seeing blood,

receiving a blood test or injection, watching medical procedures on
television, and for some individuals, even just talking about medical
procedures.

4) Situational Type: These include fears of situations such as driving, flying,

elevators, and enclosed places.

5) Other Type: These include other specific fears, including fears of choking
or vomiting after eating certain foods, fears of balloons breaking or other
5
loud sounds,
or fears of
clowns.

5
 Comorbidity: People who suffer from specific phobia are likely to suffer two variants on the
from other anxiety disorders also (Crum and Pratt,2001). serotonin-transporter
gene which is linked
Prevalence, age of onset, and gender differences: Lifetime prevalence for to high neuroticism
specific phobias is 12 percent which implies that these phobias are quite are more likely to be
common (Kessler, Chiru et al., 2005c). In India, however, prevalence rate has conditioned to fear
been reported to be 4.2 percent which is significantly lower as compared to stimuli (Lonsdorf et
other countries (Chandrashekhar & Reddy, 1998). Despite being very al., 2009). Related to
common, people with specific phobias are less likely to seek treatment than these
people with other anxiety disorders. The most common specific phobias are
fears of spiders, snakes, and heights. Phobias also depend on culture, e.g., in
China, “Paleng” is a fear of cold, in which the person fears that loss of body
heat may be life threatening.

The age of onset for specific phobias varies depending on the fear. Animal
phobias, storm phobias, blood-injection-injury phobias and dental phobias
typically begin in early childhood. The average age of onset for height phobias
is in the teens, whereas specific phobias of enclosed places (claustrophobia)
and driving phobia often begin in adolescence and early adulthood (Barlow,
2002a).

Some specific phobias (e.g., spiders, storms) are much more common among
women than men, whereas others (e.g., blood phobias) are more equally found
in men and women. Lifetime prevalence is about 7 percent for men and 16
percent for women (Kessler et al., 1994).

General Characteristics of People with phobias

People with phobias usually know that their fears are somewhat
irrational, but they cannot help themselves;

If they attempt to approach the phobic situation, they are overcome with
fear or anxiety, which may vary from mild feelings of apprehension and
distress to a full-fledged activation of the fight or flight response very
similar to panic attack;

Phobic behavior tends to be reinforced by the reduction in anxiety that

occurs each time a feared situation is avoided; and

Phobias may sometimes be maintained by secondary gains, such as,

increased attention, sympathy, and some control over the behavior of
others. These benefits are usually not in awareness of the sufferer.

2.3 WHY DO PHOBIAS DEVELOP?

The causes of specific phobias are complex, involving biological factors, a
history of negative experiences in the feared situation as well as other
psychological factors, and evolutionary factors.

Biological Perspective
Genetic Factors: The speed and strength of conditioning of fear is determined
by genetic and temperamental variables (Hettema, et al., 2003; Oehlberg &
Mineka, 2011). This means that phobias are acquired as a result of genetic
makeup or temperament and personality. People who are carriers of one of the
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Disorders of Anxiety, Panic
and Obsessions-I

5
Introducton to Psychological
Disorders & Disorders of findings, Kagan et al. (2001) reported that behaviorally inhibited (shy, timid)
Anxiety and Obsessions toddlers showed a higher risk for the development of multiple specific phobias
at 7-8 years of age than were uninhibited toddlers. Studies have also indicated
a modest genetic contribution, for example, Fyer et al. (1995) reported an
elevated risk of specific phobias in first-degree relatives of those who had been
diagnosed with specific phobia. Twin studies on females and males found a
higher concordance rate for animal phobias in MZ than DZ twins (Kendler et
al., 1999; Hettema et al., 2005). The same studies have also reported the effect
of the non shared environment on the origin of specific phobias which implies
the role of other factors, such as psychological and socio-cultural in the
acquisition of specific phobias.

Psychological Perspective
Psychoanalytic Viewpoint: According to Freud, phobias represent a defense
against anxiety that stems from repressed impulses of the id. As it is too
dangerous to know the repressed id impulse, the anxiety is displaced (defense
mechanism: displacement) onto an external object or situation that has some
symbolic relationship to the feared object. Freud (1909) explained the
development of phobia with the case study of little Hans, a five-year old boy
with a phobia of horses. Freud suggested that Hans’s phobia was developed as
a result of anxiety due to Oedipus complex. Hans unconsciously hated his
father and wanted to kill him and possess his mother. This led to a fear in Hans
that his father would kill or castrate him for having such negative feelings.
Since these unconscious conflicting thoughts were not acceptable to the
conscious mind, the anxiety created was displaced onto horses as these
symbolically represented his father. This explanation was criticized as being
far too speculative by many researchers and an alternative explanation of
Hans’ phobia in terms of the learning theory was provided by behavioral
theorists.

Behavioral Perspective: In the development of phobias, the behavioral

theorists focus on;

Learned Behavior: Wolpe and Rachman in 1960 suggested that Hans’

horse phobia originated from an instance of traumatic classical
conditioning. He had witnessed an accident in which a horse was badly
hurt. It upset him so much that he started to avoid leaving the house so as
not to encounter the horses in the street. Several research studies by other
theorists also supported the role of classical conditioning principals in
acquisition of phobias. An individual learns to fear a previously neutral
stimulus which is paired with a noxious object or event. Once a phobia is
acquired it gets generalized to similar objects or events. In a survey
conducted by Osr and Hugdahl (1981), fifty eight percent of the
respondents attributed their phobia to a traumatic conditioning situation.
Further, direct conditioning may be especially common in the onset of
dental phobia (Kent, 1997), claustrophobia (Rachman, 1997), and
accident phobia (Kuch, 1997).

Vicarious or Observational Learning: Phobias can be acquired by merely

observing another person who acts fearfully to a given object or situation
(Ost & Hugdahl, 1981). For example, lab reared rhesus monkeys who
were not initially afraid of snakes rapidly developed phobia of snakes
52 after observing their wild reared counterparts behaving fearfully with
snakes (Mineka & Cook, 1993). Similar observations were reported when
lab reared monkeys watched the videotape of wild reared monkeys
behaving
fearfully

5
 with snakes. This implies that phobias can be developed through mass Systematic
media also (Mineka & Sutton, 2006). This involves informational learning
where an individual learns to fear a particular object or situation by
hearing or reading that the situation is dangerous, for example, learning to
fear flying by hearing about plane crashes in the news, or learning to fear
driving by continually receiving warnings from others that driving is
dangerous.

Cognitive Perspective: Cognitive factors, such as attention, memory,

cognitive biases help to maintain the phobias that have been acquired.
Generally, people with specific phobias tend to pay more attention to
threatening information that relates to their fear (Mineka, 1992). For
example, individuals with spider phobias are often the first people to spot
a spider if there is one in the room. People with phobias also tend to have
distortions in their memories for encounters with the objects and
situations they fear. For example, people with an animal phobia may
remember the animal that they have encountered as larger, faster, or more
frightening than it was. Further, people with specific phobias tend to hold
beliefs and to interpret situations in such a way as to maintain or
increase their anxiety (Ohman & Mineka, 1999). For example, people
with a fear of height may assume that they are more likely to fall. People
who fear enclosed places, such as elevators, may believe that they will run
out of air, or that they will be unable to escape. Lastly, avoidance of
feared situations prevents people with specific phobias from learning that
the situations they fear are not as “dangerous” as they feel. In addition,
relying on “safety behaviors” (e.g., driving extra slowly to avoid an
accident, always wearing shoes to prevent insects from touching one’s
feet) can also help to maintain a person’s fears.

Evolutionary Perspective
Our evolutionary history has affected which stimuli are likely to be
feared, e.g., snakes, water, heights, enclosed spaces are more likely to be
objects of fear than bicycles, knives, cars, even though the latter objects
may be at least as likely to be associated with trauma. Primates and
humans have a biological preparedness to rapidly associate certain kinds
of objects- such as snakes, spiders, water and enclosed spaces with
aversive events. It has been suggested that this preparedness may have
been a selective advantage (e.g., helped in survival) for our ancestors in
the course of evolution (Mineka & Ohman, 2002). Ohman (1996) has
provided two lines of evidence to support the preparedness theory of
phobias. First, in case of human participants, fear was conditioned more
effectively to fear relevant stimuli such as snakes and spiders than to fear
irrelevant stimuli such as flowers and vegetables. In case of primates, lab
reared monkeys with no prior experience to fear relevant stimuli also
showed conditioning for fearing relevant than irrelevant stimuli.

2.4 TREATMENT OF PHOBIA

The main treatment options for phobia are as follows:

Exposure Therapy:
The client is exposed to the feared object, animal, or place in a controlled
environment (Choy et al., 2007). There are various forms of the exposure
therapy, for example, systematic desensitization, flooding, virtual reality.
Disorders of Anxiety, Panic
and Obsessions-I

53
Introducton to Psychological
Disorders & Disorders of desensitization is based on the premise that one cannot be anxious and relaxed
Anxiety and Obsessions at the same time. It is conducted in several steps. Firstly, with the help of
client, a hierarchy of the fear eliciting situation is formed, beginning from the
least fear producing to the most fear producing situation, e.g., dog barking in
the next lane to the dog barking just in front of the client. Secondly, the client is
taught relaxation exercises, such as progressive muscle relaxation, deep
breathing. Then the person is asked to relax and imagine the fear producing
situation in the ascending order of the hierarchy, beginning from the least fear
producing situation. Gradually, the client learns to relax in the most fear
producing situation, thereby extinguishing phobia. An opposite of this
technique is flooding, where the client is exposed to the most fear producing
situation and is taught that he/she can go through the fear producing situation
without being harmed contrary to his/her expectation of getting hurt. Earlier
therapists used the real situations or imagination (if the situation was
hazardous), whereas now therapists use virtual reality. In this type of therapy,
the therapists with the help of computers and other equipment simulate the fear
producing situation, e.g., heights, air travel and the client is exposed to the
simulation exercise. Through all these techniques, the client realizes the
irrationality of his/her fear and thus the fear gets extinct.
Modeling:
Based on Bandura’s (1977) vicarious learning theory, the client either observes
another person (sometimes the therapist) in real life or in a movie, acting
fearlessly in a situation that causes phobia in the client. By watching another
person acting fearlessly and calmly, the client also learns that the phobic
situation or the stimulus is harmless, which helps to treat phobia.
While the behavior therapies have been found to be effective in treating
phobia, medication and cognitive techniques, such as cognitive restructuring,
have not been found to be effective. According to the recent findings, a drug,
called d- cycloserine, when used in conjunction with exposure therapies like
virtual reality, has been found to increase the effectiveness of exposure
therapies (Norberg et al., 2008).

Check Your Progress 2

1) What are phobias?
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2) Explain modelling as the way to treat phobia.

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2.5 CLINICAL FEATURES OF SOCIAL ANXIETY

DISORDER (SOCIAL PHOBIA)
Social phobia is a persistent, irrational fear generally linked to the presence of
54 other people. It can be extremely debilitating.What is the difference between
Social Phobia and Social Anxiety Disorder?The difference between social Disorders of Anxiety, Panic
phobia and social anxiety disorder (SAD) is largely chronological, in that and Obsessions-I
social phobia is the former term and SAD is the current term for the disorder.
The official psychiatric diagnosis of social phobia was introduced in the third
edition of the Diagnostic and Statistical Manual (DSM-III). Social phobia was
described as a fear of performance situations and did not include fears of less
formal situations such as casual conversations.

DSM-5 describes social anxiety disorder as “disabling fears of one or more

specific social situations (such as public speaking, urinating in a public
bathroom, or eating or writing in public) where the person fears of being
exposed to the scrutiny and potential negative evaluation of others or that
he/she may act in an embarrassing or humiliating manner”. Therefore, the
person tries to avoid such social situations or when avoidance is not possible
endures them with great distress. There are two subtypes of SAD according to
DSM-5, one is specific to performance situations, e.g., public speaking, and
the other is general or in non- performance situations, e.g., eating in public.

Box 2.2: Criteria for Social Anxiety Disorder according to DSM-5

(APA, 2013)
A. A marked or persistent fear of one or more social or performance
situations in which the person is exposed to unfamiliar people or to
possible scrutiny by others. The individual fears that he or she will act
in a way (or show anxiety symptoms) that will be humiliating or
embarrassing.
Note: 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.
B. Exposure to the feared social situation almost invariably provokes
anxiety, which may take the form of a situationally bound or
situationally predisposed Panic Attack.
Note: In children, the anxiety may be expressed by crying, tantrums,
freezing, or shrinking from social situations with unfamiliar people.
C. The person recognizes that the fear is excessive or unreasonable.
Note: In children, this feature may be absent.
D. The feared social or performance situations are avoided or else are
endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared social or
performance situation(s) interferes significantly with the person’s
normal routine, occupational (academic) functioning, or social
activities or relationships, or there is marked distress about having the
phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The fear or avoidance is not due to the direct physiological effects of
a substance (e.g., a drug of abuse, a medication) or a general medical
condition and is not better accounted for by another mental disorder
(e.g., Panic Disorder With or Without Agoraphobia, Separation
Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive
Developmental Disorder, or Schizoid Personality Disorder).
55
Introducton to Psychological
Disorders & Disorders of H. If a general medical condition or another mental disorder is present,
Anxiety and Obsessions the fear in Criterion A is unrelated to it, e.g., the fear is not of
Stuttering, trembling in Parkinson’s disease, or exhibiting abnormal
eating behaviour in Anorexia Nervosa or Bulimia Nervosa.
Comorbidity: People who suffer from SAD are also likely to suffer from
one or more anxiety disorders and depressive disorder (Ruscio et al., 2008).
Generalized SAD has been found to be comorbid with depression and
alcohol abuse (Wittchen, Stein, & Kessler, 1999). Specific SAD is comorbid
with GAD, specific phobias, panic disorder, avoidant personality disorder,
mood disorders and alcohol abuse (Crum & Pratt, 2001).

Prevalence, age of onset, gender differences and cultural factors: SAD is

common and found even in public celebrities, for example, Barbara Streisand
(American actor and singer). Its lifetime prevalence is 12 percent of a given
population (Ruscio et al., 2008). In India, prevalence rate of 12.8 percent has
been found in the adolescents (Mehatalia & Vankar, 2004). It is a persistent
disorder with spontaneous recovery shown by only 37 percent of the sufferers
over 12 years (Bruce et al., 2005).

SAD usually begins during early or middle adolescence or early adulthood

(Ruscio et al., 2008). SAD is more common among women than men as 60
percent of the women have been reported to suffer from the disorder. SAD is
also affected by cultural factors. Example, in Japan, fear of giving offense to
others is very important, whereas in USA, fear of being negatively evaluated
by others is a source of social anxiety.

General Characteristics of People with SAD

The individual usually tries to avoid situations in which she /he might be
evaluated and reveal signs of anxiousness or behave in an embarrassing
way;

Fears concerning excessive sweating or blushing are common;

Speaking, performing in public, eating in public, using public lavatories,
etc. can elicit extreme anxiety; and

They often work in occupations or professions far below their talent or

intelligence because their extreme social sensitivity does not allow them
to work in situations which involve interactions with people.

2.6 CAUSAL FACTORS FOR SOCIAL ANXIETY

DISORDER
Let us understand the casual factors for social anxiety diorder.
Biological Perspective
Genetic and Temperamental Factors: Results from a very large study of
female twins suggests a variance of 30 percent due to genetic component in
development of SAD (Smoller et al., 2008). Family studies also show that first
degree relatives of probands were more than two to three times as likely to
also share a diagnosis. Further, infants easily distressed by unfamiliar stimuli
are at an increased risk for becoming fearful during childhood and by
adolescence, show increased risk
56 of developing social phobia (Kagan, 1997).
Psychological Perspective participants develop
Behavioural Explanation: SAD in many cases is a result of direct or vicarious stronger conditioned
classical conditioning. In a study, 56 percent of people with specific SAD and responses when slides
44 percent with generalized SAD reported direct traumatic conditioning of angry faces are
experiences (Townsley et al., 1995). People with generalized SAD may be paired with mild
especially likely to have grown up with parents who were socially isolated or electric shock than
who devalued sociability, thus providing ample opportunity for vicarious when happy or neutral
learning (Rosenbaum et al., 1994). Also, many people with social phobia faces are paired with
reported to develop it while having problems in fitting in within their peer the same shocks.
group (Harvey et al., 2005).

Cognitive Factors: Socially anxious people are more concerned about

evaluation than people who are not anxious (Goldfried, Padawer, & Robins,
1984) and are more aware of the image they present to others (Bates, 1990).
They tend to view themselves negatively even when they have actually
performed well in social interactions (Wallace & Alden, 1997). In a study by
Davison & Zighelboim (1987) which used articulated thoughts in simulated
situations, it was reported that people with social phobia showed more negative
articulated thoughts in a stressful situation in comparison to people without
social phobia. Persistent and irrational fears actually occurs because fear is
elicited through early automatic processes that are not available to conscious
awareness. After this initial processing the stimulus is avoided, so it is not
processed fully enough to allow the fear to extinguish (Amir, Foa, & Coles,
1998).

Social Skills Deficit Model: According to this model, inappropriate behaviour

or a lack of social skills is the cause of social anxiety. The individual has not
learned how to behave so that he/she feels comfortable with others. The person
repeatedly commits faux pas (tactless mistake), person is awkward and
socially inept often criticized by social companions. Support for this model
comes from findings that socially anxious people are indeed rated as being low
in social skills (Twentyman & McFall, 1975).

Perception of Uncontrollability and Unpredictability: Submissive and

unassertive behaviour which is a characteristic feature of people with social
phobia is a result of uncontrollability and unpredictability in life situations.
People with social phobia have a diminished sense of personal control over
events in their lives (Cloitre et al., 1992).

Evolutionary perspactive: According to Ohman et al., 1985, social phobias

may have developed as a “by-product of dominance hierarchies”. Aggressive
encounters between members of a social group establish dominance
hierarchies where a defeated individual usually displays fear and submissive
behavior but rarely escapes from the situation. Thus, people with social phobia
are more likely to endure being in the feared situation than to run away.
Perhaps, social phobias develop mostly in adolescence and early adulthood
when dominance conflicts are most prominent.

Preparedness and Social Phobia: Ohman and colleagues (1985) have

suggested that we humans may have an evolutionary based predisposition to
acquire fears of social stimuli that signal dominance and aggression (e.g.,
anger or contempt) from other humans. The researchers have reported that

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 Disorders of Anxiety, Panic
and Obsessions-I

5
Introducton to Psychological
Disorders & Disorders of Further, even very brief presentations of the angry face that are not
Anxiety and Obsessions consciously perceived are sufficient to activate the conditioned responses
(Ohman, 1996).

2.7 TREATMENT OF SOCIAL PHOBIA

Main treatment options used by people for social phobia are:
Cognitive-Behavioral Therapy:
Cognitive restructuring along with behavioral techniques has been proved
to be more effective as compared to lone use of behavioral therapy
(Barlow et al., 2007). The distorted cognitions of client that lead to social
phobia, such as, “nobody likes me”; “people do not find me attractive” are
identified and the therapist helps the client to restructure such negative
cognitions through reanalysis. During the reanalysis, the client is
educated about the origin of cognitive distortions, the automatic negative
thoughts and how these affect the client’s social behavior and
restructuring such thoughts by cognitive techniques, for example,
questioning the validity of such negative thoughts, taking negative
thoughts as hypotheses and logically testing those hypotheses. The clients
are also encouraged to do exercises where they are taught to shift their
focus from self to others and the situations. Videotaping their social
interactions has also been successfully used as a feedback mechanism
(Mörtberg et al., 2007).

Medications:
Research has also shown that medications such as antidepressants (e.g.,
Monoamine Oxidase Inhibitors, or MAOIs and Selective Serotonin
Reuptake Inhibitors, or SSRIs) have been proved to be effective treatment
for social phobia (Ipser et al., 2008). However, further comparative
research in this area has reported the cognitive-behavior therapy to be
more effective than the medications as it does not involve side effects and
relapse rates are also low (Stein & Stein, 2008). Lastly, researchers such
as Guastella et al. (2008) have reported that a medication, named D-
Check Your Progress
cycloserine taken in 3conjunction with cognitive-behavior therapy led to
1)faster ratesareofthe
What successful treatment.
characteristics of social phobia?
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2) Why does social phobia develop?
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3) How does cognitive-behaviour therapy help in the treatment of
social phobia?
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5
 substance
2.8 CLINICAL ASPECTS OF PANIC DISORDER (e.g., a drug
of abuse, a
DSM-5 defines a panic attack as a discrete period of intense fear or medication)
discomfort, in which at least four from a list of 13 standard symptoms develop or another
abruptly and reach a peak within 10 minutes. Although the symptoms must medical
peak within 10 minutes, the attacks often peak within a few seconds and the condition
symptoms gradually subside over a period lasting from a few minutes to about (e.g.,
a half hour. hyperthyroid
ism,
Box 2.3: Criteria for Social Phobia according to DSM-
cardiopulmo
5 (APA, 2013)
nary
A. Recurrent unexpected panic attacks. A panic attack is anabrupt surge disorders).
of intense fear or intense discomfort that reaches a peak within
minutes, and during which time four (or more) of the following
symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state.
1) Palpitations, pounding heart, or accelerated heart rate.
2) Sweating.
3) Trembling or shaking.
4) Sensations of shortness of breath or smothering.
5) Feelings of choking.
6) Chest pain or discomfort.
7) Nausea or abdominal distress.
8) Feeling dizzy, unsteady, light-headed, or faint.
9) Chills or heat sensations.
10) Paresthesias (numbness or tingling sensations).
11) Derealization (feelings of unreality) or depersonalization (being
detached from oneself).
12) Fear of losing control or “going crazy.”
13) Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache,
uncontrollable screaming or crying) may be seen. Such symptoms should
not count as one of the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of
one or both of the following:
1) Persistent concern or worry about additional panic attacks or their
consequences (e.g., losing control, having a heart attack, “going
crazy”).
2) A significant maladaptive change in behavior related to the attacks
(e.g., behaviors designed to avoid having panic attacks, such as
avoidance of exercise or unfamiliar situations).
C) The disturbance is not attributable to the physiological effects of a
6
Disorders of Anxiety, Panic
and Obsessions-I

6
Introducton to Psychological
Disorders & Disorders of D) The disturbance is not better explained by another mental disorder
Anxiety and Obsessions (e.g., the panic attacks do not occur only in response to feared social
situations, as in social anxiety disorder; in response to circumscribed
phobic objects or situations, as inspecific phobia; in response to
obsessions, as in obsessive-compulsive disorder; in response to
reminders of traumatic events, as in posttraumatic stress disorder; or
in response to separation from attachment figures, as in separation
anxiety disorder).
It is clear from the above list that out of 13, majority (1 to 10) of the symptoms
are physical whereas only last three are cognitive symptoms. In addition to
these symptoms, panic attacks may be accompanied by other symptoms as
well (e.g., blurred vision).

Panic attacks are experienced across all the anxiety disorders, triggered by a
feared situation object/situation/thought/worry. Many people without an
anxiety disorder may experience panic attacks from time to time (e.g., when
giving a formal presentation or taking an exam, or upon encountering some
other stressful situation). Panic attacks occur frequently in the general
population, with some studies showing that up to a third of individuals
experience a panic attack during a given year. Unlike most panic attacks,
which are typically triggered by stress, worries, or feared situations, the panic
attacks that occur in panic disorder often occur out of the blue, without any
obvious trigger or cause.

Table 2.1: Distinguishing features between Panic and Anxiety

Panic Attack Anxiety
Symptoms develop abruptly Does not have an abrupt onset
Usually reach peak intensity Symptoms are not as intense as
within 10 minutes subside in 20 in panic
to 30 minutes
Rarely last more than an hour It is long lasting

Types of Panic Attacks

Cued or situationally predisposed panic attacks: Panic attacks linked to
specific situations such as, driving a car. They are strongly associated with
situational triggers.

Uncued panic attacks: Attacks may occur in unexpected or benign states or in

the absence of any provocation, e.g., in sleep which is known as nocturnal
panic.

In case of some people, panic disorder may lead to agoraphobia. In DSM-5

panic disorder is diagnosed as with or without agoraphobia. The term
agoraphobia comes from the Greek word, agora which means market; hence it
means a “fear of the marketplace.” Though it implies a fear of open spaces,
however, people having agoraphobia are much more fearful of enclosed
spaces, such as tunnels, small rooms, and elevators. Some people with panic
disorder develop a concern that they will not be able to make an exit from a
crowded place if they have a panic attack. Hence, they avoid going to places
where they believe that their escape would be difficult in an emergency (i.e.,
6
panic attack) and it would cause embarrassment to them. At first, people avoid
those situations where they developed agoraphobia but soon it gets generalized
and they begin to avoid not

6
 only places outside home, such as market, elevators, public transport but Disorders of Anxiety, Panic
sometimes places within home also, e.g., attic, terrace which they believe and Obsessions-I
would be difficult to escape from. Most but not all, people with panic disorder
develop at least some degree of agoraphobia. In extreme cases, an individual
with panic disorder and agoraphobia may not leave the house at all. Usually
people with agoraphobia are able to leave the house, if someone they know
accompanies them whom they believe will be able to help them in making a
safe exit in case of a panic attack.
Comorbidity: Many people (83 percent approximately) suffering from panic
disorder with or without agoraphobia also have some other psychological
disorder such as GAD, specific phobia, social phobia, depression, substance
use disorder (such as smoking and alcohol consumption) and avoidant
personality disorder (Bernstein et al., 2006).
Prevalence, gender differences and age of onset: Lifetime prevalence for
panic disorder with or without agoraphobia has been reported to be 4.7
percent, but panic disorder without agoraphobia is more prevalent. Prevalence
varies cross- culturally, e.g., in Africa; it was diagnosed in about 1percent of
men and 6 percent of women (Hollifield et al., 1990). In Taiwan, prevalence is
quite low, perhaps because of a stigma about reporting a mental problem
(Weissman et al., 1997). Among the Eskimo of west Greenland, e.g., Kayak
Angst occurs in seal hunters who are alone at sea. Attacks involve intense fear,
disorientation, and concerns about drowning.
Panic Disorder with and without agoraphobia is more prevalent in women than
in men with a prevalence of 5 percent and 2 percent, respectively (Kessler,
Chiu, et al., 2005c). About 80 to 90 percent of patients with agoraphobia are
reported to be women (White & Barlow, 2002). However, evidence has been
found that men with agoraphobia often indulge in self-medication with
nicotine and alcohol to endure panic attacks and often do not develop
avoidance behavior as has been found in agoraphobia (Starcevic et al., 2008).
Panic disorder is a debilitating disorder. Though its symptoms may increase or
decrease at times however, it has a chronic course. Recovery may take a long
time (12 years as reported in a longitudinal study) with recurrence in 58
percent of the patients (Bruce et al., 2005).
The age of onset has been found to be 23 to 34 years on an average. For
women it usually starts in 30s or 40s (Kessler, Chiu, et al., 2006). Its onset is
associated with stressful life experiences (Pollard, Pollard, & Corn, 1989).

2.9 CAUSAL FACTORS FOR PANIC DISORDER

The causes of panic disorder involves the interplay of many factors.
Biological Perspective
Genetic Variables: Family and twin studies have pointed toward a genetic
component in the development of panic disorder. Kendler et al. (2001)
reported a variance of 33 to 43 percent due to genetic factors in a large twin
study that analyzed the factors for inheritability of panic disorder. Like other
anxiety disorders, people with neuroticism are more likely to develop panic
disorder. Recently, researchers have attempted to find specific genes that are
responsible for inheriting panic disorder. However, Strug et al., 2010; Klauke
et al., 2010, found no unequivocal results.
6 61
Introducton to Psychological
Disorders & Disorders of Brain Activity: Earlier theories suggested the role of locus coeruleus (LC) in
Anxiety and Obsessions the brain stem and norepinephrine, a neurotransmitter particularly involved in
the activity of LC in causing panic attacks. Stimulation of this area in the
monkeys causes a panic attack. Hence, it was suggested that naturally
occurring attacks might be due to over activation of norepinephrine in LC
(Redmond, 1977). Research with humans also found that Yohimbine, a drug
that stimulates activity in LC could elicit panic attack in patients with panic
disorder (Charney et al., 1987). However, more recent research is not
consistent with this position, for example, drugs that block firing in the LC
were unable to treat patients with panic disorder (McNally, 1994). Later
research found that an overactive amygdala rather than LC is implicated in
panic disorder. Amygdala consisting of a group of nuclei is located in front of
the hippocampus in the limbic system and its role in emotion of fear has been
established through empirical research. Stimulation of amygdala stimulates LC
and other autonomic responses occurring during panic attack (Gorman et al.,
2000). Amygdala is said to be at the center of the “fear network” and is
connected to the lower brain areas like LC as well as higher cortical areas like
prefrontal cortex. Hence, panic attacks may occur either due to stimulation of
lower or higher areas of brain.

Dysfunctional Biochemistry: Klein (1981) and Sheehan (1982) hypothesized

that biochemical dysfunctions lead to panic attacks which are the alarm
reactions. For more than two decades this hypothesis was supported by several
studies. These studies showed that in comparison to normative group, when
people with panic disorder are exposed to panic provocation procedure, they
are more likely to suffer from panic attacks. The panic provocation procedure
involves exposure to biological challenges, such as inhaling air with higher
than normal level of carbon dioxide (Woods et al., 1987), taking large amounts
of caffeine (Uhde, 1990), infusing sodium lactate into the body (Gorman et al.,
1989), to induce intense physical symptoms such as palpitations, high blood
pressure and hyperventilation that is likely to evoke a panic attack. The
noradrenergic and serotonergic systems are known to be involved in panic
attacks (Graeff & Del- Ben, 2008). The noradrenergic system gets activated
due to stress and in turn leads to cardiovascular symptoms which provoke
panic attack. On the other hand, serotonergic system’s activation decreases the
noradrenergic activity. This has been supported by the medication results, as
drugs used for treatment of panic disorder not only decrease the noradrenergic
activity, but it also increases the serotonergic activity. Another
neurotransmitter, GABA, which has an inhibitory effect on anxiety has also
been found to be abnormally low in people with panic disorder. Thus, such
people suffer from anxiety in anticipation of suffering from another panic
attack.

Psychological Perspective
Behavioral Factors: Several researchers have suggested that a comprehensive
learning theory can account for the development of panic disorder (Bouton,
2005; Mineka & Zinbarg, 2006). Goldstein and Chambless (1978) have
studied the effect of interoceptive (internal to body) and exteroceptive
(external to body) stimuli in conditioning of panic disorder. Through classical
conditioning interoceptive cues, like heart palpitations, stomach ache and
exteroceptive cues such as a place or presence of specific people that were
present during the initial panic attack gets associated with it and later on act as
62 triggers for anxiety about future panic attacks (Acheson et al., 2007). In simple
words, people end up developing a “panic” about a “panic attack”! This also
explains the
agoraphobic
avoidance of places like markets or shopping malls as these serve as e.g.,
exteroceptive cues for an oncoming panic attack. Inhibitory learning which is
required for extinction of a conditioned response has been suggested to be
impaired in panic disorder, thus people with panic disorder are unable to learn
to discriminate the conditioned stimulus as a safety cue (Lissek et al., 2009).
However, panic attacks sometimes seem to be uncued, i.e., no trigger, internal
or external, seems to be present before the panic attack. This is because panic
attack in some cases result from the internal cues that are unconsciously
experienced by the individual. This can be understood with an example of a
person frightened of a racing heart and who while feeling happy and excited
gets a panic attack and is unable to understand the reason of it as he/she was
happy. The panic attack in this case occurred because while feeling happy and
excited the person’s heart raced which served as a cue (though not in
awareness of that person) for the panic attack (Mineka & Zinbarg, 2006).
Cognitive factors: People with panic disorder have hypersensitivity for their
bodily sensations which are interpreted by them as a sign of an impending
panic attack (Beck & Emery, 1985; D. M. Clark, 1986, 1997). The tendency to
interpret bodily sensations as a sign of impending catastrophe such as a heart
attack, tumors etc. has been called catastrophizing by Clark.
Such frightening thoughts start the vicious cycle as it increases the already
present physical symptoms of anxiety which in turn increase the catastrophic
thoughts which in turn triggers the panic attack. It should be noted that the
person may be unaware about catastrophizing as these thoughts are out of
consciousness (Rapee, 1996). Beck has called these thoughts as automatic
thoughts which actually trigger the panic attack. However, the cause of
developing catastrophizing thoughts is not known, nevertheless only those
people who have a tendency for catastrophizing develop panic disorder
(e.g., Clark, 1997). Evidence has been found in line with this theory, e.g.,
Clark (1997) and Teachman et al. (2007) have reported that individuals with
panic disorder have a greater tendency to catastrophize their bodily sensations.
This cognitive theory of panic disorder also predicts that model also predicts
that the panic can be reduced or prevented by changing people’s cognitions
about their bodily sensations. Further, likelihood of panic attacks was
significantly reduced when people suffering from panic disorder were given a
detailed explanation of what physical symptoms to expect when injected with
sodium lactase in a panic provocation study (Clark, 1997; Schmidt et al.,
2006).
Both learning and cognitive theories provide explanations about panic attack,
however the main difference between the two theories is the emphasis that the
cognitive theory puts on the meaning that people with panic disorder give to
their bodily sensations. Such interpretation of bodily sensations is not
necessary for conditioning as the interoceptive or exteroceptive stimuli could
be outside the realm of awareness (Bouton et al., 2001). In the light of this
difference, learning theory is better able to account for uncued panic attacks as
well as panic attacks while sleeping as both occur in the absence of automatic
cognitions.
Anxiety Sensitivity and Perceived Control: Several explanations have been
provided that can find support in both learning and cognitive perspectives. For
example, McNally (2002) and Pagura et al. (2009) found that people with
hypersensitivity to anxiety are more likely to develop panic attacks and
subsequently panic disorder. Interestingly, some studies have also shown the
role of perceived control in reduction and even prevention of panic attacks,
Disorders of Anxiety, Panic
and Obsessions-I

63
Introducton to Psychological
Disorders & Disorders of in a panic provocation study if a person has a control over inhalation of carbon-
Anxiety and Obsessions dioxide (inhalation of CO2 is known to bring on panic), the possibility of suffering
from a panic attack is reduced significantly or even blocked (e.g., Sanderson et
al., 1989; Zvolensky et al., 1998, 1999). Further, Bentley et al. (2012) have
shown that anxiety sensitivity interacts with perceived control for the
development of panic attack, i.e., lower the perceived control, greater was the
effect of anxiety effect on panic disorder. Lastly, higher the perceived control
over emotions and threatening situations, lower was the agoraphobic
avoidance as the person feels in control of the situation (Suarez et al., 2009;
White et al., 2006).

Safety Behaviors and the Persistence of Panic: Panic disorder once developed
is maintained despite contrary evidence. That is, someone who has always
suffered from a panic attack about having a heart attack on finding his/her
heart racing but never actually had a heart attack should understand that a
racing heart does not lead to a heart attack. But this logic does not prevent a
panic attack because each time the person was apprehending a heart attack
he/she indulged in a “safety behavior” like slow breathing and believed that
this “safety behavior” prevented the heart attack. Thus, the “safety behaviors”
maintain the panic disorder. Thus, people with panic disorder should be
persuaded to abandon the “safety behaviors” so that they could realize that their
indulgence in safety behaviors does not prevent the heart attack or any other
impending fatality like fainting (Clark, 1997; Salkovskis et al., 1996).
Research suggests that dropping of safety behaviors by people with panic
disorder increased the effectiveness of the treatment (Rachman et al., 2008).
Cognitive Biases and the Maintenance of Panic: People with panic disorder
have a tendency for processing the threating information in a biased manner.
For example, such people interpret the ambiguous bodily sensations as well as
other ambiguous situations as more threatening than the people in the control
group (Clark, 1997; Teachman et al., 2006). Also, such people have a biased
attention also as they focus more on the threatening information, such as words
indicating panic like palpitations, numbness, fainting etc. (Lim & Kim, 2005;
Mathews & MacLeod, 2005).). fMRI studies have shown greater activation of
memory areas that are involved in processing information about threatening
stimuli in people with panic disorder than the normative group (Maddock et
al., 2003). However, the role of biased information processing as a cause or as
a symptom of panic disorder remains unclear.
Overall, it can be concluded that both biological and psychosocial factors have
been found to play a role in the development of panic disorder and neither of
the two in isolation can explain its development.

2.10 TREATMENT OF PANIC DISORDER

The approches to treatment of panic disorder are as follows:

Exposure Therapy:

As explained in the above section on phobias, exposure therapy for

agoraphobia and panic involves exposing the client to the feared situation for a
long period of time often in the presence of the therapist or a family member.
The underlying idea is that the client on being exposed to the feared situation
6
for a long time without eliciting any harmful effects help him/her to realize the
futility of his/her
 agoraphobia with panic attacks. This exercise has been shown to be effective Disorders of Anxiety, Panic
in treating 60 to 75 percent of people with agoraphobia and a maintenance rate and Obsessions-I
of 2-4 years (Barlow et al., 2007). A limitation of this therapy was that it did
not deal with panic disorder specifically. Hence, another technique, known as
interceptive exposure was devised to deal with panic attacks in 1980s. This
technique involves causing internal bodily sensations such as spinning head,
nausea, breathlessness which are associated with panic attacks with the help of
activities like seating a client in a spinning or rocking chair. When the client
undergoes a prolonged exposure to such situations without getting a panic
attack, the association of the internal bodily cues to panic attacks gets extinct.

Integrative technique:

Cognitive restructuring integrated with exposure therapy used specifically to

treat panic disorder is known as panic control treatment. It involves educating
the client about the role of catastrophic automatic thoughts in causing and
maintaining the panic disorder. During the therapy, the client is taught to
identify the negative automatic thoughts and dispute those in a logical manner,
using techniques like hypotheses testing and humor. Then the client is exposed
to the panic eliciting situations (both internal bodily sensations and external
cues) to develop tolerance against the discomfort caused by such situations.
This helps the client to deal with panic causing situations efficiently. Research
evidence has shown the integrative technique to be more effective than using
either the exposure or cognitive restructuring technique alone (Arch & Craske,
2009). It has proven to be effective in 70-90 percent of clients and
maintenance rate of 1 to 2 years has also been reported (McCabe & Gifford,
2009).
Medications:
Medicines like anxiolytics (anti-anxiety drugs) and antidepressants have also
shown to be effective in treating agoraphobia and panic. Researches, however
conclude that both drugs have advantages and disadvantages also. Anxiolytics
which belong to the category of benzodiazepines include drugs like alprazolam
or clonazepam which have been shown to treat acute episodes of extreme
anxiety as these drugs work quickly (within 30-60 minutes). However, these
also have side effects such as drowsiness, sedation, impaired cognitive as well
as motor performance. Additionally, physiological dependence may also
develop because of prolonged use and lead to withdrawal symptoms like sleep
disturbance, dizziness and panic attacks. Relapse rate is also quite high
(Pollack & Simon, 2009). Antidepressants including tricyclics, SSRIs and
SNRIs (Serotonin- Norepinephrine Reuptake Inhibitors) used for treating
panic disorder and agoraphobia also have advantages and disadvantages in
comparison to anxiolytics. Some advantages of antidepressants are that these
treat the comorbid depression and do not lead to physiological dependence
(Pollack & Simon, 2009). However, a disadvantage of antidepressants is that
in comparison to anxiolytics, these take longer time (approx. 4 weeks) to act,
hence, cannot be used in acute cases of panic disorder. Other side effects
include, dry mouth, severe constipation, blurred vision etc. Lastly, relapse rates
are quite high when discontinued (Roy-Byrne & Cowley, 2007).
Though a combination of cognitive-behavior therapy and medication therapy
has found to be slightly more effective (Barlow et al., 2007). However, it has
been found that once the medication is discontinued, relapse is common as
6 perhaps many of the clients attribute their treatment gains to medication 65
(Mitte, 2005).
Introducton to Psychological
Disorders & Disorders of Nevertheless, a drug named D-cyloserine used in combination of CBT has shown
Anxiety and Obsessions promising results (Otto et al., 2009).
Check Your Progress 4
1) List the clinical features of a panic attack.
.............................................................................................................
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.............................................................................................................
2) Mention the cognitive factors that lead to development of panic attacks.
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3) How does integrative technique help in the treatment of panic disorder?
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2.11 SUMMARY
Now that we have come to the end of this unit, let us list all the major points that
we have already learnt.

The main anxiety disorders that have been identified by DSM-5, are
generalized anxiety disorder, specific phobia, social phobia, panic
disorder, and agoraphobia.
A phobia is a persistent and disproportionate fear of a specific object or
situation that presents little or no actual danger to a person.

According to DSM-5, Specific phobia, previously known as simple

phobia, has five sub types: animals (e.g., snakes, spiders, dogs); natural
environment (e.g., water, heights, storms); blood-injection-injury;
situational (bridges, tunnels); others (vomiting, choking, ‘space phobia’
where the person has a fear of falling down if he/she is away from walls
or support).
Phobias develop as a result of psychological, behavioural, biological,
evolutionary, or cognitive factors.
A social phobia is a persistent, irrational fear generally linked to the
presence of other people. It can be extremely debilitating.

The difference between social phobia and social anxiety disorder (SAD) is
largely chronological, in that social phobia is the former term and SAD is
the current term for the disorder.
6
Panic disorders are characterised by panic attack which are a discrete period
 of intense fear or discomfort, in which at least four from a list of 13 Disorders of Anxiety, Panic
standard symptoms develop abruptly and reach a peak within 10 minutes. and Obsessions-I

Panic attacks are experienced across all the anxiety disorders. Cognitive-
behaviour therapy and medication is found to be effective in the treatment
of panic disorder.

2.12 KEYWORDS
Anxiety: Feeling experienced only in anticipation of danger/threat when such
a danger/threat is not present or cannot be specified

Comorbidity: When two or more disorders or illnesses that occur in the same
person

Panic: Subjective feelings of impending doom, fear of dying, going crazy and
losing control.
Panic attack: Discrete period of intense fear or discomfort, in which at least
four from a list of 13 standard symptoms develop abruptly and reach a peak
within 10 minutes
Gamma Amino Butyric Acid or GABA: Inhibitory neurotransmitter that
helps to keep the feeling of anxiety away
Corticotropin Releasing Hormone (CRH): The CRH plays a role in GAD as
it is an anxiety producing hormone.
Phobia: A phobia is a persistent and disproportionate fear of a specific object
or situation that presents little or no actual danger to a person
Social phobia: A persistent, irrational fear generally linked to the presence of
other people. It can be extremely debilitating.
Agoraphobia: A fear of “agora”, Greek word for public places of assembly or
marketplace. It is a fear of crowded places.

2.13 REVIEW QUESTIONS

1) Panic control treatment to treat panic disorder combines .
2) Medications such as antidepressants (e.g., Monoamine Oxidase Inhibitors,
and Selective Serotonin Reuptake Inhibitors) have been proved to be
effective
treatment for .
3) Phobias represent a defense against anxiety that stems from repressed
impulses of the id. This is the perspective of phobia.
4) Fear of public speaking or generalized as in fear of many different social
interactions is known as .
5) Agoraphobia refers to the fear of and .
6) Define anxiety and give the characteristics of anxiety disorders.
7) What is the DSM-5 criteria of a panic attack?
8) Discuss the causes of social anxiety disorder.
9) What are the different kinds of phobias?
6 67
10) Discuss the treatment of panic disorder.
Introducton to Psychological
Disorders & Disorders of
Anxiety and Obsessions
2.14 REFERENCES AND FURTHER READING
Amin, N., Foa, E.B., Coles, M.E. (1998).Negative interpretation bias in social
phobia. Behav Res Ther. 36(10),945-57.
Barlow, D. H., Shannon S.,Jenna, R. C., Kristen, K. E. (1998).The Nature,
Diagnosis, and Treatment of Neuroticism: Back to the Future. Clinical
Psychological Science,DOI: 10.1177/2167702613505532.
Barlow, D. H. (Ed.). (2002). Anxiety and its disorders:The nature and
treatment of anxiety and panic(2nd ed.). New York: Guilford.
Barlow, D. H., Allen, L. B., &Basden, S. L. (2007).Psychological treatments
for panic disorder, phobias,and generalized anxiety disorder. In P. E. Nathan
andJ.
M. Gorman (Eds.), A guide to treatments that work. New York: Oxford University
Press, pp. 351–94.
Barlow, D. H., Raffa, S. D., & Cohen, E. M. (2002). Psychosocial treatments
for panic disorders, phobiasand generalized anxiety disorders. In P. E. Nathan
&J.
M. Gorman (Eds.), A guide to treatments that work(2nd ed., pp. 301–36). New
York: Oxford UniversityPress.
Beck, A., Emery, G., & Greenberg, R. (1985). Anxiety Disorders and Phobias.
A Cognitive Perspective (pp. 300-368). New York: Basic Books.
Bentley, K. H., Gallagher, M. W., Boswell, J. F., Gorman, J. M., Shear, M. K.,
Scott, W. W., &Barlow, D. H. (2012). The Interactive Contributions of
Perceived Controland AnxietySensitivity in Panic Disorder: A
TripleVulnerabilities Perspective. Journal of Psychopathology and Behavioral
Assessment, 35, 57- 64.
Bernstein, G. A., & Layne, A. E. (2006). Separationanxiety disorder and
generalized anxiety disorder.In M. K. Dulcan& J. M. Wiener (Eds.),
Essentialsof child and adolescent psychiatry (pp. 415–39).Washington, DC:
American Psychiatric Publishing.
Borkovec, T. D., &Newman, M. G. (1998). Worry and generalized anxiety
disorder. In P. Salkovskis(Ed.), Comprehensive Clinical Psychology (pp. 157-
178). Oxford: Elsevier.
Bouton, M. E., Mineka, S., & Barlow, D. H. (2001).A modern learning theory
perspective on the etiologyof panic disorder.Psychol. Rev., 108, 4–32.
Bradley,B. P., Mogg,K., Millar,N., & White, J. (1995). Selective processing of
negative information: Effects of clinical anxiety, concurrent depression, and
awareness.Journal of Abnormal Psychology, 104 (3), 532.
Brown, R., Taylor, J., & Matthews, B. (2001). Qualityof life: Aging and Down
syndrome. Down Syndrome:Research & Practice, 6, 111–16.
Bruce, S. E., Yonkers, K. A., Otto, M. W., Eisen, J. L.,Weisberg, R. B., Pagano,
M., et al. (2005). Influenceof psychiatric comorbidity on recovery and
recurrencein generalized anxiety disorder, social phobia,and panic disorder: A
12-year prospective study. American Journal of Psychiatry, 162(6), 1179–87.

6
Butcher, J. N.,
Hooley, J. M.,
Mineka, S. &
Dwivedi, C. B.
(2017). Abnormal
Psychology (16th
Ed.). Pearson,
India.

6
 Butler, G. & Matthews, J.(1983). Cognitive processes in anxiety. Advances in Davison, G. C., Neale,
Behavior Research and Therapy, 5, 51-62. J. M. &Kring, A. M.
(2004). Abnormal
Carson R., Butcher J., &Mineka S. (2003). Psychologiazaburzeñ (vol.2). psychology (9th Ed.).
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2.15 WEB RESOURCES

Watch the video on ' what is social Anxiety Disorder?' ( Health Matters,
University of california TV).

https://m.youtube.com/watch? v = 4truuD_xMPO

Answers to the Fill in the Blanks (1-5)

1) cognitive restructuring integrated with exposure therapy
2) social phobia
3) psychoanalytical
4) social phobia
5) enclosed spaces, such as tunnels, small rooms, and elevators.