ANXIETY & RELATED DISORDERS
ARTICLE SUMMARY
Before starting the articles, just a little reminder of the basic principles of conditioning
so it’s all fresh in your mind:
CS (Conditioned Stimulus): This is a neutral stimulus that initially does not elicit a
response but, after repeated association with an unconditioned stimulus (US), begins
to elicit a response.
o An example could be: CS: A bell tone
US (Unconditioned Stimulus): This is a stimulus that naturally elicits a certain
response without prior training.
o An example could be: US: Food
CR (Conditioned Response): This is the response elicited by the conditioned
stimulus (CS) after association with the unconditioned stimulus (US).
o An example could be: CR: Salivation upon hearing the bell tone even in the
absence of food
UR (Unconditioned Response): This is the natural response to the unconditioned
stimulus (US) before conditioning has taken place.
o An example could be: UR: Salivation upon seeing food
So, in this example, initially, a dog would salivate (UR) upon seeing food (US). After repeated
association of a bell tone (CS) with the food (US), the dog starts to salivate (CR) upon
hearing the bell tone, even if no food is present.
, WEEK 1
OVERVIEW AND HISTORY OF EXPOSURE THERAPY FOR
ANXIETY
Candidates common to most, if not all psychological treatments for clinical fear and
anxiety include:
Therapeutic relationship
The milieu in which the patient is treated
The patient’s and therapist’s expectations of improvement
Another common principle of change derives from the observation that alterations in
thoughts, feelings and behavior appear to occur following a strong emotional response to
material presented within the context of therapy.
Exposure therapy The process of helping a patient approach and engage with anxiety-
provoking stimuli that objectively pose no more than everyday risk without the use of anxiety-
reduction “coping” skills.
Anxiety-evoking stimuli can be:
Alive (snakes, clowns)
Inanimate (balloons, toilets)
Situational (bridges)
Cognitive (memories of traumatic event, ideas of committing heinous acts)
Physiological (heart racing, dizziness)
Learning takes place when a person repeatedly confronts a feared stimulus (dog) in the
absence of the expected feared consequence (dog does not bite). Each time an individual
effectively handles a previously feared situation without relying on safety cues, a new
behavioral repertoire is cultivated and strengthened.
ANXIETY: NORMAL AND ABNORMAL
Anxiety An organism’s response to the perception of threat.
No actual threat needs to be present in order to experience anxiety
It’s also possible to be in danger, but not become anxious because the threat is not
perceived
Normal Anxiety
The anxiety (fear) response appears to be implemented in various brain structures. The
brain stimulates the release of adrenaline from the adrenal glands this activates the
sympathetic nervous system initiates the flight or fight response.
Body’s built-in way of priming the individual for reacting to perceived threat by
attacking or running
Three levels of the fight-or-flight response:
, Physiological level Body prepares for physical exertion by enriching the blood
with oxygen, converted to energy for the muscles
Cognitive level Automatic shift in attention toward the perceived threat (and
ways to seek safety from it). Serves as a constant reminder of the potential for harm
and allows for early detection of threats and escaping them.
Behavioral level Individual is compelled to take actions that are geared toward
fighting, avoiding or escaping the feared stimulus.
Fight-or-flight is critical to survival of humankind.
Abnormal Anxiety
When anxiety occurs in the absence of danger or when it is out of proportion relative to
the actual threat. Excessive anxiety stems from the misperception of a safe situation as
dangerous. The fight-or-flight response is triggered unnecessarily and may worsen the
situation by leading to more negative thoughts.
Misperceiving safe stimuli as dangerous has two consequences:
1. Vicious cycle of perception of threat due to emotional reasoning bias We
interpret situations based on how we feel.
Increases the perception of threat
Maintains physiological responding
Thereby creating a vicious cycle of perception of threat anxiety responding
more threat perception
2. Development of strategies for avoiding these fear cues
Passive avoidance Completely avoiding
o Not raising your hand to avoid the situation of being laughed at
Active avoidance When a stimulus cannot be avoided completely, the individual
develops strategies that serve as an escape from the feelings of anxiety that
accompany exposure to these triggers.
o Compulsive washing to prevent illness after handling money
o Remaining close to a safe person for protection
In both forms of avoidance, a person never has the opportunity to learn that such stimuli are
objectively safe. The person cannot correct their misperception of the fear trigger, and they
keep believing that the situation is dangerous.
Efforts to escape and avoid perceived threats prevent clinical anxiety from self-correcting
over time and may worsen the very problems they are intended to alleviate. Much of the
devastating effects of clinical anxiety result from the extreme lengths to which people go in
trying to keep themselves safe by avoiding and escaping from (largely nonthreatening) fear
cues.
DSM-5 Diagnoses Characterized by Anxiety
Limitations of the DSM-diagnostic approach for anxiety:
It’s categorical and doesn’t focus on the underlying psychological mechanisms
of the disorders
o Topographical differences in anxiety disorders have the same fundamental
psychological mechanism, that is: relatively safe stimuli are misperceived as
dangerous, leading to unnecessary anxiety and what amount to unwarranted
avoidance or escape behaviors that perpetuate the problem.
, o Arbitrary severity distinction: You either have an anxiety disorder or not.
However, anxiety is not that categorially, but it is rather a spectrum on which
anyone can be low or high on symptoms.
Transdiagnostic approach The same basic principles of exposure therapy can be
applied to any patient’s anxiety problem, regardless of which DSM diagnostic category best
describes it.
ETIOLOGY VERSUS MAINTENANCE
Comprehensive Etiological Model of Anxiety (Mineka & Zinbarg)
Early learning experiences
Occurrence and context of stressful events
Genetic or temperamental vulnerability
Exposure therapies are focused on psychological processes that maintain the
problem:
Maintenance factors in anxiety are well understood, while factors that dictate why
some people are more vulnerable to developing such problems are not
Psychological treatments cannot undo the etiological factors, like genetics and
temperamental predispositions, but can address maintenance factors (phenomena
that interfere with the natural process of overcoming a fear)
Three elements necessary for successful and durable treatment of clinical fear and
anxiety
1. Patients must be presented with information that is incompatible with their
maladaptive beliefs about the dangerousness or intolerability of feared stimuli
2. Behaviors that interfere with the acquisition and consolidation of this new
information must be eliminated
3. This new information must be strengthened in memory and generalized as broadly
as possible so that it is recalled in diverse contexts and over time
CONTEMPORARY EXPOSURE THERAPY: AN OVERVIEW
No two anxious individuals present with the same fears and avoidance patterns, and
therefore, no two exposure therapy programs will be exactly the same.
This need for a patient-specific or idiosyncratic approach is one important challenge and a
key characteristic of exposure therapy.
Assessment and Treatment Planning
Exposure therapy begins with a thorough assessment of the patient’s problem with anxiety
(functional or behavioral assessment):
Focuses on understanding:
1. The contexts in which anxiety is triggered
2. The anticipated feared consequences of encountering fear triggers
3. The strategies used to seek safety from harm and reduce anxiety by avoiding
and escaping from these triggers
,Rationale about the therapy includes:
a clear explanation of the problem in terms that are understandable to the patient,
information about how exposure therapy is commonly experienced, including the
provocation of distress and the importance of learning that anxiety is safe and
tolerable.
the therapist’s role as a coach and ally.
The preparatory stage of therapy also introduces the patient to the importance of eliminating
subtle and not-so-subtle avoidance and escape (i.e., “coping”) strategies that prevent the
natural extinction of fear, that is, response prevention.
Practicing Exposure
Exposure stimuli do not need to be encountered in a particular order. They might be
confronted according to the patient’s priorities.
Exposure might occur in imagination when the feared stimulus is a thought or memory.
When physiological states are the feared stimuli, the preferred method is interoceptive
exposure in which the patient purposely elicits such internal stimuli.
The aim is to engage the patient with the fear stimulus in a systematic way and without
the use of safety seeking or anxiety reducing coping strategies, so that the patient can
learn that the feared outcome is not as likely or as severe as was predicted and that feelings
of anxiety are safe and manageable regardless of their intensity or duration.
Each individual exposure exercise concludes when the patient’s expectations of the danger
and/or intolerability of the stimulus have been contradicted to the fullest possible
extent.
Learning is focused on
whether the expected negative outcome occurred
how manageable it was if it did occur
the degree to which the patient’s distress was tolerable.
A HISTORY OF EXPOSURE THERAPY
Systematic Desensitization
Systematic Desinsitization (SD) was one of the first forms of exposure to emerge.
SD Involves weakening the association between anxiety and an objectively non-
dangerous phobic stimulus by pairing the phobic stimulus with a physiological state that is
incompatible with anxiety.
Goal of SD: for the patient to become completely relaxed while in the presence of
their phobic stimuli
The patient and therapist develop a fear hierarchy list of patient’s phobic situations and
objects, ordered from least to most fear-provoking.
Next, the therapist helps the patient to become relaxed. Then, the anxiety-provoking stimuli
are either gradually visualized or actually presented to the patient while he or she is in the
relaxed state. Stimuli are confronted in order from the least to the most distressing.
Imagined exposure to feared stimuli expands the range of phobic stimuli that can be
addressed by SD.
Phobic responses (in animals and humans) can be weakened if a response that was the
opposite of anxiety (and incompatible with it) occurred in the presence of the phobic stimulus.
,Reciprocal inhibition anxiety inhibits a positive stimulus and the positive stimulus inhibits
anxiety.
Flooding and Implosive Therapy
Flooding Nongraduated approach in which the patient rapidly confronts his or her most
feared stimuli, either in imagination or real life, while minimizing escape from the fear-
provoking context (response prevention).
A child with a phobia of large dogs might be placed in a room with such a dog and
prevented from leaving until their anxiety subsides.
Implosive therapy Variation of flooding with differences:
All presentations of fear-evoking situations are done in imagination
Imagined scenes are exaggerated or impossible situations to provoke as much
anxiety as possible
Contains psychodynamic elements: scenes often based on dynamic sources of
anxiety such as hostility, rejection, sex, death wishes
As fear reduction strategies, flooding and implosive therapy derive from the well-established
laboratory principle of extinction, in which the repetition of the feared stimulus in the
absence of the feared consequence and any escape or avoidance behaviors will result in
the reduction of the fear.
Flooding and implosive therapy led to the development of gradual exposure therapy which
excludes the relaxation component of SD and psychodynamic element of implosive therapy.
Cognitive-Behavioral Therapy
Exposure along with strategies to manage or reduce anxiety, such as cognitive restructuring,
controlled breathing, and relaxation training.
Many therapists emphasize anxiety-reducing coping skills with their anxious patients due to
concerns that exposure is dangerous, intolerable, and unethical. However, anxiety is
universal and safe, and more intensive exposure approaches that do not include coping
skills are highly effective.
Promoting Fear Tolerance and Inhibitory Learning
Anxiety reduction (i.e., habituation) within and between sessions has been considered a key
indicator of therapeutic change. This has limitations:
Fear levels during exposure are not consistently reliable or valid indices of long-term
fear extinction.
Gradual exposure and fear reduction (habituation) shames the experience of anxiety;
reinforces the maladaptive belief that fear and other forms of distress are inherently
bad, dangerous, or intolerable; and promotes the detrimental idea that exposure
therapy is only successful if one is anxiety-free.
A more updated model to account for the effects of exposure focuses on inhibitory learning
mechanisms to explain the discrepancies between performance during exposure and
postexposure levels of fear.
Inhibitory learning Fear-based cognitions (thunderstorms are dangerous) are not
removed during extinction, but remain intact as new learning about the feared stimulus
occurs (thunderstorms are safe).
The feared stimulus possesses two meanings following successful exposure:
The original fear-based (excitatory) meaning
, The safety based (inhibitory) meaning.
Even if fear subsides following successful exposure, the original fear-based meaning is
retained in memory and may be recovered under certain circumstances, such as a change in
context or the passage of time (i.e., spontaneous recovery).
Aim of exposure therapy, based on this perspective, is to help patients develop:
New nonthreatening cognitions
Ways of enhancing the accessibility of these new safety-based cognitions
(relative to the older fear-based cognitions) in different contexts over time.
Exposure is used to promote fear tolerance, give that fear and anxiety are universal,
inevitable and safe.
Fear tolerance is accomplished by introducing desirable difficulties for example
restricting the use of coping strategies:
Difficult because they present challenges for the patient during exposure
Desirable because they help maximize long-term learning by introducing real-world
challenges that have the benefit of maximizing th retrieval of newly learned
information.
Desirable difficulties strengthen fear tolerance as patients learn that fear is an opportunity to
practice managing distress.
4.
,
, WEEK 1
ANXIETY DISORDERS: WHY THEY PERSIST AND HOW TO
TREAT THEM
Anxiety disorders result from distorted beliefs about the dangerousness of certain situations,
sensations and/or mental events. Such over-estimates are disorder specific: each anxiety
disorder has a specific type of negative belief.
The persistence of fear seems irrational: despite what might appear to an outsider to
be disconfirmation of their fears, their thinking does not change.
There are six different maintaining processes in anxiety disorders: safety-seeking
behaviors, attentional deployment, spontaneous imagery, emotional reasoning, certain types
of memory processes and the nature of threat representations.
THE SIX DIFFERENT MAINTAINING PROCESSES IN ANXIETY DISORDER
1. SAFETY SEEKING BEHAVIOR
Safety-seeking behavior A behavior which is performed in order to prevent of minimize a
feared catastrophe.
Explains why the non-occurrence of a feared event fails to change patients’ negative
beliefs.
Panic patients engage in safety behaviors of the sort which could maintain their negative
beliefs:
In a study with dropping the behaviors and not-dropping the behaviors, patients who
dropped their safety behavior had significantly larger decrease in negative beliefs and
greater improvement in anxiety.
The Clark & Wells cognitive model of social phobia was strongly influenced by the safety
behaviour analysis and highlights several additional features of safety behaviour.
Features of safety behaviors in Clark & Wells Cognitive Model of Social Phobia:
Often the ‘behaviors’ are internal mental processes
o For example, patients with social phobia often report memorizing what they
have said and comparing it with what they are about to say whilst speaking. If
everything goes well, patients are likely to think that it only went well because
they did all the memorizing.
It’s common to engage in a large number of different safety behaviors while in a
feared situation
Safety behaviors can create some of the symptoms that social phobics fear
o Trying to hide underarm sweating by wearing a jacket generates more
sweating
Safety behaviors can draw other people’s attention to the patient
Some safety behaviors influence other people in a way which partially confirms
social phobics’ fear.
o Continuous monitoring of what was said and how one comes across can
cause them to be distant which can be interpreted by others as not liking them
, 2. ATTENTIONAL DEPLOYMENT
Attention Towards Threat Cues
Selective attention towards threat cues may play a role in the maintenance of anxiety
disorders by enhancing the perception of threat.
Panic disorder and hypochondriacs are obvious candidates for a possible attentional bias
towards threat:
Their fears lead them to focus attention on their bodies and as a consequence of this
attentional deployment, they become aware of benign bodily sensations that other
people do not notice. The presence of the sensations could be taken as evidence that
a serious physical illness has been missed.
Cardiac concerned patients with panic disorder and hypochondriasis will notice cardiac
changes and slight increases in breathlessness that other people would not notice.
Attention Away from Threat Cues
In social phobias, attention away from threat cues play an important role in the maintenance
of the disorder. Two findings:
Socially anxious students show attentional bias away from faces, but towards objects
Socially anxious patients show attentional bias away from faces.
Clark and Wells Model of Social Phobia
Social phobia is associated with reduced attention to external social cues.
Reduced processing of other people would mean that social phobics would have less chance
to observe other people's responses in detail and, therefore, would be unlikely to collect from
other people's reactions information that would help them see that they generally come
across more positively than they think.
Why should patients with spider phobia, panic disorder and hypochondriasis show an
attentional bias towards threat cues that are relevant to their concerns, whereas patients with
social phobia show some evidence of an attentional bias away from others’ facial
expressions?
In spider phobia or panic disorder/hypochondria, looking away does not remove the
threat.
In social phobia, looking away from others faces and avoiding eye contact reduces
some aspects of threat for a social phobic (it’s more difficult to engage them in
conversation)
Also: looking away from faces is an evolutionary gesture triggered by unwanted
attention from someone who is perceived as more dominant
Clark & Wells say that they only have attention away from threats.
3. SPONTANEOUSLY OCCURING IMAGES
Spontaneously occurring mental images in which patients see their fears realized are
common in anxiety disorder and play an important role in enhancing the perception of threat.
Panic disorder patients Images of physical and mental catastrophes (heart attack, losing
control).
If social phobics attend less to external cues, what makes them think they come across
badly? Clark & Wells suggest self-imagery, in particular, it was suggested that when in a
social situation, social phobics are prone to experience spontaneously occurring images in
