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Samenvatting Fear, Anxiety and Related disorders
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From anxiety to anxiety disorderHirshfeld-Becker et al. (2008). High risk studies and developmental antecendents of
anxiety disorders
Background information: Arguments for considering the anxiety disorders as a single category
include considerable comorbidity between the disorders, evidence from twin and family
studies suggesting shared genetic variability for several, and similarities in brain regions
underlying the disorders and in effective treatment approaches (cognitive-behavioral as well
as pharmacological). Arguments for regarding the anxiety disorders as discrete entities
include their distinct ages of onset, courses, phenomenologies, and, in some cases, distinct
patterns of association. In the present review, we include studies of risk for anxiety disorders
in general, as well as more detailed consideration of the antecedents of several well-studied
discrete disorders.
Goal of the research: Provide a detailed overview of high-risk studies, early diagnostic
predictors, and temperamental antecedents, and a broad summary of the environmental factors
associated with onset of anxiety disorders; discuss the strengths and limitations of these
studies; and highlight areas for further inquiry.
High-risk offspring studies: Rates of ‘‘any anxiety disorder’’ or ‘‘two or more anxiety
disorders’’ between offspring of parents with anxiety and offspring of non-affected controls
differed significantly in all but two of the studies, with rates of ‘‘any anxiety disorder’’
ranging from 21% to 68% in the at-risk offspring as contrasted with 0–26% in the control
offspring.
Evidence for specificity of transmission is mixed, with some studies showing transmission of
the same disorder from parent to child, for panic disorder, social phobia, or specific phobia,
but with most also showing that parental anxiety disorders confer risk for a spectrum of
disorders in the offspring.
In addition, several studies have also found elevated risk for anxiety disorders among
offspring of parents with major depressive disorder and bipolar disorder, although others have
not. In complementary fashion, several studies found elevated rates of depression among
offspring of parents with anxiety disorders.
These findings dovetail with retrospective accounts by adults presenting clinically with panic
disorder and social phobia, of whom at least half report having had one of these three
childhood disorders. a lot of anxiety disorders have a childhood onset
Early symptomatic antecendents: Early anxiety symptoms or disorders significantly increase
the risk of meeting criteria for anxiety disorders later in life. Also, evidence suggests that
childhood major depression may also increase the risk for development of subsequent anxiety
disorders. Thus, having a childhood anxiety disorder, particularly separation anxiety disorder,
overanxious disorder/GAD, or social or specific phobia appears significantly to heighten the
risk for a range of later anxiety disorders.
Temperamental antecendents: The temperamental construct most widely studied as a potential
antecedent to diagnosable anxiety disorders is behavioral inhibition to the unfamiliar (BI). BI
refers to the persistent tendency to exhibit restraint, withdrawal, and reticence when faced
with novel or unfamiliar situations and people. It is found in 10–15% of children and is
moderately stable from toddlerhood through the early elementary school years, with higher
stability among children more extreme in BI. BI is hypothesized to be rooted in a lower
threshold to limbic arousal, specifically to higher reactivity of the amygdalae and their
,projections to the striatum, hypothalamus, sympathetic chain, and cardiovascular system. BI
has been shown to have moderate heritability which is even higher among children rated as
extreme in BI. BI appears prospectively associated with social anxiety in particular.
Studies suggest that BI is most predictive of anxiety disorders when it is found among
offspring of parents with anxiety disorders and when it remains stable across early childhood.
It seems clear that BI measured in the preschool years is a marker of risk for social anxiety
disorder in early and middle childhood and early adolescence, especially in children whose
parents have anxiety disorders. Although not all inhibited preschoolers develop social anxiety
by early adolescence, a substantial proportion (34–44%) do.
Other temperamental and cognitive risk factors: The construct with the most empirical
support as a precursor to panic disorder and possibly other anxiety disorders is AS.
Neuroticism, in particular, is associated with a wide range of disorders, and harm avoidance,
shyness, and AS have also been associated cross-sectionally with other disorders (e.g., mood
disorders).
Efforts to refine the prediction of anxiety from neuroticism/negative affectivity (NA) have had
some success. For example, (1) high NA in the absence of low positive affectivity
differentiates anxiety from depression in a wide number of cross-sectional studies; (2) high
NA in the presence of low effortful control (EC)—the capacity for active voluntary regulation
of attention or behavior -- shows links to anxiety and attentional bias for threat in some
studies; and (3) subcomponents of NA such as fear and anger have shown differential
association with anxiety and disruptive behaviors in some studies, but not others. However,
more work needs to be done to define under what circumstances NA (even with normal
positive affectivity, high EC, or fearful as opposed to angry affect) leads to anxiety rather than
to other outcomes.
Physiological markers of risk for anxiety disorder: Infants and young offspring at risk for
anxiety disorders show markers of higher physiologic arousal, including elevated heart rates
under stress, salivary cortisol, increased startle responsivity, and disturbed sleep.
Abnormal ventilatory responses, history of respiratory problems and astma may also be
markers for panic disorders.
Hypothesized environmental risk factors: Studies suggest that parents of anxious children tend
to be more overprotective and less granting of autonomy or less warm and accepting than
parents of non-anxious children.
Lower warmth and responsiveness are theorized to foster poorer emotional regulation,
whereas overprotection and high parental control are hypothesized to lead to lower self-
efficacy. Other studies have suggested that parents of anxious children tend to model anxiety,
particularly in the case of specific phobias, and that they tend to encourage or reinforce
anxious avoidance.
parenting behaviors account for only 4% of the total variance in measures of child anxiety
symptoms or disorders. Parental autonomy granting accounted for the greatest proportion of
variance in childhood anxiety, whereas parental warmth accounted for the least.
Life events: Links between health problems, divorce, abuse, and loss at ages 6–7, parental
separation, conduct disorder in a father or stepfather, and poverty before age 5, poor academic
performance in first grade and increased odds of anxiety disorder. Another study found no
relationship between parental divorce and anxiety disorders 10 years later.
,Peer factors: Being left out or rejected by peers accounted for significant variance in later
social phobia symptoms, whereas being teased or bullied did not.
Perinatal factors: Retrospective studies of children found associations between pregnancy or
birth complications and anxiety problems during pregnancy and childhood anxiety. However,
a retrospective study of adults found no associations for most anxiety disorders, and a lower
rate of pregnancy complications for social phobia.
Conclusion: Parental psychopathology, early anxiety disorders, and behavioral inhibition
appear to have moderate associations with subsequent anxiety disorders, whereas parenting
factors show small to moderate associations, and perinatal factors may show relatively small
associations.
Hofmann & Smits (2008). Cognitice-behavioral therapy for adult anxiety disorders: A
meta-analysis of randomized placebo-controlled trials
Goal of the research: Review the efficacy of CBT versus placebo for adult anxiety disorders
(including only randomized controlled trials).
Background: CBT refers tot he class of interventions that are based on the basic premis that
emotional disorders are maintained by cognitive factors and that psychological treatment
leads to changes in these factors through cognitive (cognitive restructuring) and behavioral
(e.g., exposure, behavioral experiments, relaxation training, social skills training) techniques.
Method: People between 18-65 and meet DSM criteria for an anxiety disorder.
Discussion: As reflected by medium to large effect sizes for measures of anxiety disorder
severity, CBT yields significantly greater benefits than placebo treatments. This effect was
significantly greater for ASD relative to all other disorders with exception of OCD. CBT for
OCD was more effective than CBT for panic disorder (surprising because the general notion
is that OCD is the most treatment-resistant anxiety disorder).
CBT significantly outperformed placebo in reducing depression only in PTSD and OCD.
These findings support the specificity of CBT for most of the anxiety disorders.
Mathews & MacLeod (2005). COGNITIVE VULNERABILITY TO EMOTIONAL
DISORDERS
Emotional processing biases: Negative cognitive bias is a contributory cause of emotional dis-
orders. In an earlier review, we suggested that anxiety disorders—but not depression— are
characterized by selective attention favoring threatening information. Conversely, we pro-
posed that biases in explicit memory favoring negative self-related information are character-
istic of depression, but not anxiety. Recent evidence has revealed exceptions to this general
claim, however, in that both biases can occur across disorders, albeit in different forms.
Biased attention in anxiety and depression
To investigate if there is an attentional bias toward negative information, tasks can be used
involving a central task to be performed while ignoring emotional distracters (Stroop task). It
is reasoned that attention to emotionally negative distracters will interfere with performance
, on the central task, and such interference is indeed a common finding in emotionally disturbed
populations.
Attentional probe methods: measures of attentional distribution by briefly presenting emo-
tional stimuli to alternative locations on a computer screen, and then assessing how rapidly
participants can discriminate the identity of small visual probes subsequently displayed in
these locations. Attentional bias operates rapidly in anxiety, occurring even under exposure
conditions that restrict stimulus awareness, but in depression this only happens when more
time is permitted for stimulus processing (the word needs to be on the screen long enough).
High-trait-anxious groups attend more to faces with threatening expressions, whereas dyspho-
ria was associated only with avoidance of happy faces. Faster initial eye movements toward
threatening faces in GAD participants, but found no such effect in a depressed group, even
though most also had a comorbid diagnosis of GAD. This suggests that depression may some-
times inhibit attention toward emotional cues that might otherwise have been observed. , In
contrast, if attentional bias to mood-congruent cues is assessed under prolonged exposure con-
ditions, depression is sometimes associated with selective orientation even when anxiety is
not (depressed participants attend selectively tos ad faces).
We suggest that the process leading to attention to threat cues in anxiety disorders typically
begins at an early, nonconscious, stage of processing. This early sensitivity to threat cues may
be inhibited in depression, and replaced by slower and strategically directed attention to
mood-congruent information.
This transition to faster probe detection occurred at moderate threat levels for high-trait-anx-
ious participants, but only at high levels in the low-trait-anxious group. à the transition from
attentional avoidance to active attention occurring at a lower level of stimulus threat in those
prone to anxiety.
Anxiety depends on the interaction of two opposing tendencies: bottom-up activation of threat
representations by a threat-detection system and top-down activation of competing representa-
tions related to other goals by an attentional control system.
Several experiments suggest that anxiety is particularly associated with difficulty disengaging
attention from threat. We suppose, therefore, that disengagement difficulties predominate
when threats are encountered incidentally, but anxious individuals also actively search for and
engage locations associated with potential threat.
Biased memory in anxiety and depression
Autobiographical memory in individuals prone to depression often consists of general events
rather than specific incidents. This may be due to their retrieval strategy, which can be altered
by widening their thinking perspective or encouraging a less analytic self-focus. On the other
hand, depression is associated with enhanced memory for negative information, which cannot
be explained solely by retrieval processes.
Implicit memory, which is the effect of past experiences on behavior without conscious inten-
tion, also shows differences in depression. Depressed individuals exhibit biased memory in
certain implicit tasks, suggesting increased conceptual processing of negative information. In
contrast, the evidence for memory bias in anxiety disorders, except for panic disorder, is in-
conclusive. Although anxiety is associated with selective attention to threats, it does not con-
sistently translate into memory biases in implicit tasks.
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