298 Introduction to Anxiety Disorders

Anxiety is a common and essential process of daily life. It is highly important, evolutionary speaking, as people typically experience anxiety when faced with environmental threats such as encountering a lion (not so common a concern in modern society for most people), scarcity of food or other resources, or acceptance among one’s peers and society at large. This anxiety orients the individual toward anticipating dangers, motivates the person to act in order to avoid events that might cause bodily harm or psychological distress, and prepares the body and mind for taking some sort of action (Zeidner & Matthews, 2011).

A complete lack of anxiety, in contrast, could cause someone to engage in potentially life-threatening and dangerous situations and not even be aware that they are dangerous.

When intense worry or fear begins to disrupt one’s daily functioning, however, it can be detrimental to one’s health. Anxiety disorders have the highest overall prevalence rate among psychiatric problems, with a 12-month rate of 18.1% and a lifetime rate of 28.8% (Kessler, Berglund et al., 2005; Kessler, Chiu, Demler, & Walters, 2005). In any given year, over 40 million people in the U.S. are impacted by anxiety disorders, at a cost of over 46 billion dollars per year in increased medical expenses, lost productivity, and mental health expenditures (DuPont et al., 1996). In fact, anxiety disorders alone account for over 31% of all mental health costs in the U.S. each year.

In addition to the monetary costs of the anxiety disorders, there are enormous impacts on quality of life (QoL) and functioning (Olatunji, Cisler, & Tolin, 2007). For example, studies have shown higher incidence of divorce and martial strife, higher rates of financial problems and reliance on public assistance (e.g., disability, welfare), lowered educational achievement, and increased limitations in the types of jobs one is able to work. Meta-analyses have shown that the most damaging anxiety disorders to overall quality of life are social phobia and post-traumatic stress disorder (PTSD), but that all are associated with high rates of QoL and functional impairment, especially in the areas of mental health and social functioning (Olatunji, Cisler, & Tolin, 2007).

Although highly related, fear and anxiety are different from each other in a number of ways (Craske et al., 2009). Fear is a response to a real danger and directed at a present threat, usually accompanied by escape behaviors, physiological arousal, and thoughts about the imminent threat. It also tends to be a highly biologically adaptive response, allowing one to avoid potential dangers and thus live to continue your genetic line. Anxiety, however, is usually more future-oriented and corresponds to a state of uncertainty or ambiguousness. It is often accompanied by avoidant behaviors, tension, and thoughts about a future threat. Commonalities of the two include the presence of cognitive appraisals of threat or danger and that they are (usually) adaptive to an organism. Also, anxiety often follows a fear reaction and conversely, repeated anxiety experiences can actually generate fear reactions. Many of the anxiety disorders fall onto one side or the other, although persons with social anxiety disorder seem to experience both in almost equal measure.

People who have been diagnosed with an anxiety disorder show a number of differences, both clinically and experimentally, from those without or with different mental disorders (Craske et al., 2009). For instance, elevated sensitivity to threats, preconscious attentional biases towards personally relevant threat stimuli, and biases to interpret ambiguous information in a threat-relevant manner are all highly present in this group. In addition, one can see elevated amygdala responses to specific and general threat cues in the highly anxious compared to control groups.

Culturally, anxiety disorders are seen around the world, although not always in the same way (Lewis-Fernandez et al., 2011). For instance, rates of these disorders are generally similar in U.S. and European samples, but in comparison to non-European countries the U.S. shows higher 12-month prevalence rates of panic disorder, specific phobias, and social anxiety disorder. Interestingly, the lowest measured rates are found in East Asian and African populations, both living in their native region and in the U.S. These differences may be due in part to cultural biases within the DSM criteria that place an emphasis on prototypical Western ways of experiencing anxiety. For example, there is a heavy emphasis placed on the psychological symptoms of worry in generalized anxiety disorder, while in many U.S. minority cultures the most commonly reported symptoms are more physiological. In DSM’s social anxiety disorder, worries about offending others are very uncommon, and instead worries about embarrassing one’s self are seen; this is prototypical of an individualistic, as opposed to collectivistic society. Finally, some research has shown that in cultures outside the U.S., people report panic attacks lasting much longer and being less unexpected than they are defined in the DSM.

As you read about the anxiety disorders, you will notice there are many similarities between them, particularly in terms of the likely causal factors and effective treatments. Generally speaking, there are two classes of efficacious treatments for the anxiety disorders: pharmacology and psychotherapy (Baldwin et al., 2005). Medications that inhibit serotonin reuptake are usually considered the “first line” drugs to prescribe, and are effective for many disorders. In terms of therapy, the research is clear that certain kinds of therapy, in particular the cognitive and behavioral therapies (CBT), are at least as equally effective as medication, and tend to have better long-term outcomes. The three primary CBT techniques are exposure with response prevention, cognitive restructuring, and relaxation training. Unfortunately, there is a large discrepancy between the effectiveness of treatments and the access to effective treatments, particularly CBT (Gunter & Whitall, 2010). More detail on treatment will be given with each discussed disorder.

The remainder of this section of the book will be devoted to specific anxiety disorders. For each disorder, the following information will be presented:

1. DSM-IV criteria (as reported in the DSM-IV-TR, published by the American Psychiatric Association in 2000)
2. Associated features (those things that are not part of the criteria, but are often seen in this population, commonly comorbid disorders, and impact of disorder on quality of life and functioning)
3. Child versus adult presentation (if and how the disorder presents different across the lifespan)
4. Gender and cultural differences (if and how the disorder varies between the sexes and around the world)
5. Epidemiology (the prevalence patterns of the disorder)
6. Etiology (what is known about the causes of the disorder)
7. Empirically supported treatments (those pharmacological and psychotherapeutic methods that have scientific evidence to back their use)
8. DSM-5 criteria revisions (when appropriate, there will be discussion of the reasons why the revisions are being proposed; full proposed diagnostic criteria can be viewed online at DSM5.org)

Key References

Baldwin, D.S., Anderson, I.M., Nutt, D.J., Bandelow, B., Bond, A. et al. (2005). Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 19, 567–596.

Baloğlu, M. Abbasi, A., & Masten, W.G. (2007). A cross-cultural comparison of anxiety among college students. College Student Journal, 41, 977-984.

Craske, M.G., Rauch,M.D., Ursano, R., Prenoveau, J., Pine, D.S., & Zinbarg, R.E. (2009). What is an anxiety disorder? Depression & Anxiety, 26, 1066-1085.

Davis, T.E., May, A., & Whiting, S.E. (2011). Evidence-based treatment of anxiety and phobia in children and adolescents: Current status and effects on the emotional response. Clinical Psychological Review, 31, 592-602.

Gunter, R.W., & Whittal, M.W. (2010). Dissemination of cognitive-behavioral treatments for anxiety disorders: Overcoming barriers and improving patient access. Clinical Psychological Review, 30, 194-202.

Kessler, R.C., Demler, O., Walters, E.E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 62, 617-627.

Lewis-Fernandez, R., Hinton, D.E., Laria, A.J., Patterson, E.H., Hofmann, S.G. et al. (2010). Culture and anxiety disorders: Recommendations for the DSM-V. Depression & Anxiety, 27, 212-229.

Lowe, P.A. & Reynolds, C.R. (2005). Do relationships exist between age, gender, and education and self-reports of anxiety among older adults? Individual Differences Research, 3 (4), 239-259.

Olatunji, B.O., Cisler, J.M., & Tolin, D.F. (2007). Quality of life in the anxiety disorders: A meta-analytic review. Clinical Psychology Review, 27, 572-581.

Stein, D.J., Phillips, K.A., Bolton, D., Fulford, K.W.M., Sadler, J.Z., & Kendler, K.S. (2010). What is a mental/psychiatric disorder? From DSM-IV to DSM-V. Psychological Medicine, 40, 1759-1765.