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Module 03 · Anxiety Disorders

Module 7: Anxiety Disorders模块 7：焦虑障碍

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3rd edition as of July 2023
截至 2023 年 7 月的第 3 版

Module Overview 模块概述

In Module 7, we will discuss matters related to anxiety disorders to include their clinical presentation, epidemiology, comorbidity, etiology, and treatment options. Our discussion will include generalized anxiety disorder, specific phobia, agoraphobia, social anxiety disorder, and panic disorder.  Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an overview of the various models to explain psychopathology (Module 2), and descriptions of the various therapies (Module 3).
在模块 7 中，我们将讨论与焦虑障碍相关的问题，包括其临床表现、流行病学、共病、病因和治疗选择。我们的讨论将包括广泛性焦虑障碍、特定恐惧症、广场恐惧症、社交焦虑障碍和恐慌症。请确保您参考模块 1-3 来解释关键术语（模块 1）、各种解释心理病理学的模型概述（模块 2）以及各种疗法的描述（模块 3）。

Module Outline 模块大纲

Module Learning Outcomes 模块学习成果

  • Describe how anxiety disorders present.
    描述焦虑症的表现。
  • Describe the epidemiology of anxiety disorders.
    描述焦虑障碍的流行病学。
  • Describe comorbidity in relation to anxiety disorders.
    描述焦虑障碍的相关共病情况。
  • Describe the etiology of anxiety disorders.
    描述焦虑障碍的病因。
  • Describe treatment options for anxiety disorders.
    描述焦虑症的治疗方案。

7.1. Clinical Presentation 7.1. 临床表现

Section Learning Objectives 章节学习目标

  • Describe how generalized anxiety disorder presents.
    描述广泛性焦虑症的表现。
  • Describe how specific phobia presents.
    描述特定恐惧症的表现。
  • Describe how agoraphobia presents.
    描述广场恐怖症的表现。
  • Describe how social anxiety disorder presents.
    描述社交焦虑症的表现。
  • Describe how panic disorder presents.
    描述惊恐症的表现。

The hallmark symptoms of anxiety-related disorders are excessive fear and anxiety and related behavioral disturbances. How do we distinguish fear from anxiety? The DSM says that fear is an emotional response to a real or perceived imminent threat which leads to “…surges of autonomic arousal necessary for flight or flight, thoughts of immediate danger, and escape behaviors.” Anxiety, on the other hand, is the anticipation of a future threat leading to, “…muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviors” (APA, 2022, pg. 215). The anxiety disorders differ from one another in the types of objects or situations that lead to fear, anxiety, or avoidance behavior. We will cover generalized anxiety disorder, specific phobia, agoraphobia, social anxiety disorder, and panic disorder.
焦虑相关疾病的标志性症状是过度恐惧和焦虑以及相关的行为障碍。我们如何区分恐惧和焦虑？DSM 表示，恐惧是对真实或感知到的即将到来的威胁的情感反应，导致“……自主神经兴奋的激增，这是逃跑或战斗所必需的，对立即危险的思考，以及逃避行为。”另一方面，焦虑是对未来威胁的预期，导致“……肌肉紧张和警觉性，以准备未来的危险，以及谨慎或避免行为”（APA，2022，第 215 页）。焦虑障碍在导致恐惧、焦虑或避免行为的对象或情境类型上彼此不同。我们将介绍广泛性焦虑障碍、特定恐惧症、广场恐惧症、社交焦虑障碍和恐慌障碍。

7.1.1. Generalized Anxiety Disorder 7.1.1. 广泛性焦虑障碍

Generalized anxiety disorder is characterized by an underlying excessive anxiety and worry related to a wide range of events or activities and lasting for more days than not for at least six months. While many individuals experience some degree of worry throughout the day, individuals with generalized anxiety disorder experience worry of greater intensity and for longer periods than the average person (APA, 2022). Additionally, they are often unable to control their worry through various coping strategies, which directly interferes with their ability to engage in daily social and occupational tasks. To receive a diagnosis of generalized anxiety disorder, three or more of the following somatic symptoms must be present in adults as well: restlessness, fatigue, difficultly concentrating, irritability, muscle tension, and problems sleeping (APA, 2022; Gelenberg, 2000).
广泛性焦虑症以与广泛事件或活动相关的潜在过度焦虑和担忧为特征，持续时间超过六个月，大多数时间都在担忧。虽然许多人整天都会感到一定程度的担忧，但广泛性焦虑症患者所经历的担忧程度和持续时间比普通人更长（APA，2022）。此外，他们通常无法通过各种应对策略来控制自己的担忧，这直接干扰了他们参与日常社会和职业任务的能力。要被诊断为广泛性焦虑症，成人必须出现以下三种或更多身体症状：坐立不安、疲劳、难以集中注意力、易怒、肌肉紧张和睡眠问题（APA，2022；Gelenberg，2000）。

7.1.2. Specific Phobia 7.1.2. 特定恐惧症

Specific phobia is distinguished by fear or anxiety specific to an object or a situation. While the amount of fear or anxiety related to the specific object or situation varies among individuals, it also varies related to the proximity of the object or situation. When individuals are face-to-face with their specific phobia, immediate fear is present, and the phobic object or situation is actively avoided or endured. It should also be noted that these fears are excessive and irrational, often severely impacting one’s daily functioning. The fear, anxiety, or avoidance is persistent, lasting at least six months (APA, 2022).
特定恐惧症以对特定物体或情境的恐惧或焦虑为特征。虽然与特定物体或情境相关的恐惧或焦虑程度因人而异，但它也与物体或情境的接近程度有关。当个体面对他们的特定恐惧时，立即产生恐惧，并积极避免或忍受恐惧的物体或情境。还应注意的是，这些恐惧是过度的和不合理的，通常严重地影响一个人的日常生活功能。恐惧、焦虑或回避是持续的，至少持续六个月（APA，2022）。

Individuals can experience multiple specific phobias at the same time. In fact, nearly 75% of individuals with a specific phobia report fear of more than one object and the average individual fears three or more objects or situations (APA, 2022).  When making a diagnosis of specific phobia, it is important to identify the stimulus. Among the most diagnosed specific phobias are animals, natural environment (height, storms, water), blood-injection-injury (needles, invasive medical procedures), or situational (airplanes, elevators, enclosed places). In terms of gender differences, women predominantly experience animal, natural environment, and situational specific phobias while blood-injection-injury phobia is experienced by both men and women equally (APA, 2022).
个人可以同时经历多种特定的恐惧症。事实上，近 75%的特定恐惧症患者报告对多个物体感到恐惧，平均个体对三个或更多物体或情境感到恐惧（APA，2022）。在诊断特定恐惧症时，识别刺激因素很重要。最常见的特定恐惧症包括动物、自然环境（高度、风暴、水）、血液注射伤害（针头、侵入性医疗程序）或情境（飞机、电梯、封闭空间）。在性别差异方面，女性主要经历动物、自然环境和情境特定恐惧症，而血液注射伤害恐惧症在男性和女性中均等（APA，2022）。

7.1.3. Agoraphobia 7.1.3. 阿戈拉恐惧症

Agoraphobia is defined as intense fear or anxiety triggered by two or more of the following: using public transportation such as planes, trains, ships, buses; being in large, open spaces such as parking lots or on bridges; being in enclosed spaces like stores or movie theaters; being in a crowd or standing in line; or being outside of the home alone. The individual fears or avoids these situations because they believe something terrible may occur and due to concern over not being able to escape or help not being available (APA, 2022). Active avoidance of the situations occurs and can be behavioral such as changing daily routines or using delivery to avoid entering a restaurant or cognitive such as using distraction to bear with an agoraphobic situation. The avoidance can result in the person being homebound. The fear or anxiety is out of proportion to the actual danger they pose and has been present for at least six months.
广场恐惧症被定义为由于以下两个或更多因素引起的强烈恐惧或焦虑：使用公共交通工具，如飞机、火车、船只、公交车；身处大型开阔空间，如停车场或桥梁上；身处封闭空间，如商店或电影院；身处人群中或排队；或独自在家外。个人害怕或避免这些情况，因为他们认为可能会发生可怕的事情，以及担心无法逃脱或无法获得帮助（APA，2022）。对情况的主动回避可能发生，可以是行为上的，例如改变日常习惯或使用外卖避免进入餐厅，也可以是认知上的，例如使用分心来忍受广场恐惧症的情况。这种回避可能导致个人被限制在家中。恐惧或焦虑与实际危险不成比例，并且至少持续了六个月。

7.1.4. Social Anxiety Disorder 7.1.4. 社交焦虑障碍

For social anxiety disorder, the anxiety or fear relates to social situations, particularly those in which an individual can be evaluated by others. More specifically, the individual is worried that they will be judged negatively and viewed as stupid, anxious, crazy, boring, or unlikeable, to name a few. Some individuals report feeling concerned that their anxiety symptoms will be obvious to others via blushing, stuttering, sweating, trembling, etc. These fears severely limit an individual’s behavior in social settings and have occurred for six months or more.
对于社交焦虑症，焦虑或恐惧与社会情境有关，尤其是那些个人可能被他人评价的情境。更具体地说，个人担心自己会被负面评价，被视为愚蠢、焦虑、疯狂、无聊或不受欢迎等，仅举几例。有些人报告说，他们担心自己的焦虑症状会通过脸红、结巴、出汗、颤抖等方式被他人察觉。这些恐惧严重限制了个人在社会环境中的行为，并且已经持续了六个月或更长时间。

To explain social anxiety in greater detail, let’s review the story of Mary. Mary reported the onset of her social anxiety disorder in early elementary school when teachers would call on students to read parts of their textbook aloud. Mary stated that she was fearful of making mistakes while reading and to alleviate this anxiety, she would read several sections ahead of the class to prepare for her turn to read aloud. Despite her preparedness, one day in 5th grade, Mary was called to read, and she stumbled on a few words. While none of her classmates realized her mistake, Mary was extremely embarrassed and reported higher levels of anxiety during future read aloud moments in school. In fact, when she was called upon, Mary stated she would completely freeze up and not talk at all. After a few moments of not speaking, her teacher would skip Mary and ask another student to read her section. It took several years and a very supportive teacher for Mary to begin reading aloud in class again.
为了更详细地解释社交焦虑，让我们回顾一下玛丽的故事。玛丽报告说，她在小学初期就出现了社交焦虑症，当时老师会叫学生大声朗读教科书的部分内容。玛丽表示，她害怕在朗读时出错，为了缓解这种焦虑，她会提前阅读几个章节来为她的朗读做准备。尽管她做了准备，但在五年级的一天，玛丽被叫去朗读，她在几个词上卡住了。尽管她的同学都没有意识到她的错误，玛丽感到非常尴尬，并在学校未来的朗读时刻报告了更高的焦虑水平。事实上，当她被叫到时，玛丽说她会完全愣住，一句话也说不出来。几秒钟的沉默后，她的老师会跳过玛丽，让另一个学生朗读她的部分。经过几年的时间和一位非常支持她的老师，玛丽才又开始在课堂上大声朗读。

Like Mary, individuals with social anxiety disorder report that all or nearly all social situations provoke this intense fear. Some individuals even report significant anticipatory fear days or weeks before a social event is to occur. This anticipatory fear often leads to avoidance of social events in some individuals; others will attend social events with a marked fear of possible threats. Because of these fears, there is a significant impact on one’s social and occupational functioning.
与玛丽一样，患有社交焦虑症的人表示，所有或几乎所有社交场合都会引发这种强烈的恐惧。有些人甚至报告说，在社交活动发生前几天或几周，就会有显著的预期恐惧。这种预期恐惧往往导致一些人在社交活动中避免社交；其他人则会带着对可能威胁的明显恐惧参加社交活动。由于这些恐惧，对个人的社交和职业功能产生了重大影响。

It is important to note that the cognitive interpretation of these social events is often excessive and out of proportion to the actual risk of being negatively evaluated. As we saw in Mary’s case, when she stumbled upon her words while reading to the class, none of her peers even noticed her mistake. Situations in which individuals experience anxiety toward a real threat, such as bullying or ostracizing, would not be diagnosed with social anxiety disorder as the negative evaluation and threat are real.
值得注意的是，对这些社会事件的认知解读往往过度，与实际被负面评价的风险不成比例。正如我们在玛丽案例中看到的那样，当她阅读课文时说错话，她的同学们甚至没有注意到她的错误。当个人对真实威胁（如欺凌或排斥）感到焦虑时，不会诊断为社交焦虑症，因为负面评价和威胁是真实的。

7.1.5. Panic Disorder 7.1.5. 惊恐障碍

Panic disorder consists of a series of recurrent, unexpected panic attacks coupled with the fear of future panic attacks. A panic attack is defined as a sudden or abrupt surge of fear or impending doom along with at least four physical or cognitive symptoms. Physical symptoms include heart palpitations, sweating, trembling or shaking, shortness of breath, feeling as though they are being choked, chest pain, nausea, dizziness, chills or heat sensations, and numbness/tingling. Cognitive symptoms may consist of feelings of derealization (feelings of unreality) or depersonalization (feelings of being detached from oneself), the fear of losing control or ‘going crazy,’ or the fear of dying (APA, 2022). While symptoms generally peak within a few minutes, it seems much longer for the individual experiencing the panic attack.
恐慌症包括一系列反复出现的、意外的恐慌发作，伴随对未来恐慌发作的恐惧。恐慌发作被定义为突然或急剧的恐惧或即将到来的厄运感，伴有至少四种身体或认知症状。身体症状包括心悸、出汗、颤抖或颤抖、呼吸困难、感觉像被窒息、胸痛、恶心、头晕、寒战或热感，以及麻木/刺痛。认知症状可能包括非现实感（不真实感）或去人格化（感觉与自我分离），害怕失去控制或“发疯”，或害怕死亡（APA，2022）。尽管症状通常在几分钟内达到顶峰，但对于经历恐慌发作的人来说，似乎要长得多。

There are two key components to panic disorder—the attacks are unexpected, meaning there is nothing that triggers them, and they are recurrent, meaning they occur multiple times. Because these panic attacks occur frequently and are primarily “out of the blue,” they cause significant worry or anxiety in the individual as they are unsure of when the next attack will happen. In contrast to unexpected there are also expected panic attacks, or those that have an obvious trigger. The DSM-5-TR states that presence of expected panic attacks does not rule out the diagnosis of panic disorder as about half of individuals diagnosed with the disorder in the United States and Europe have both types of attacks (APA, 2022).
惊恐障碍有两个关键组成部分——攻击是出乎意料的，这意味着没有任何触发因素，并且它们是反复发生的，这意味着它们会多次发生。由于这些恐慌发作频繁且主要是“突如其来的”，它们会在个人中引起重大的担忧或焦虑，因为他们不确定下一次攻击何时发生。与出乎意料相对的是，还有预期恐慌发作，或那些有明显的触发因素。DSM-5-TR 指出，预期恐慌发作的存在并不排除惊恐障碍的诊断，因为在美国和欧洲，大约一半被诊断为该病的个体都有这两种类型的攻击（APA，2022）。

In some individuals, significant behavioral changes such as fear of leaving their home or attending large events occur as the individual is fearful an attack will happen in one of these situations, causing embarrassment. Additionally, individuals report worry that others will think they are “going crazy” or losing control if they were to observe an individual experiencing a panic attack. Occasionally, an additional diagnosis of agoraphobia is given to an individual with panic disorder *if *their behaviors meet diagnostic criteria for this disorder as well.
在某些个体中，由于担心在这些情况下发生攻击而导致尴尬，会出现诸如害怕离开家或参加大型活动等显著行为变化。此外，个体报告称，如果他人观察到他们经历恐慌发作，会担心别人认为他们“疯了”或失去控制。偶尔，如果个体的行为符合这种疾病的诊断标准，还会对患有恐慌症的个体进行广场恐怖症的诊断。

The frequency and intensity of these panic attacks vary widely among individuals. Some people report panic attacks occurring once a week for months on end, others report more frequent attacks multiple times a day, but then experience weeks or months without any attacks. The intensity of symptoms also varies among individuals, with some patients experiencing four or more symptoms (full-symptom) or less than four (limited-symptom. Furthermore, individuals report variability within their panic attack symptoms, with some panic attacks presenting with more symptoms than others. To be diagnosed with panic disorder, the individual must present with more than one unexpected full-symptom panic attack (APA, 2022).
这些恐慌发作的频率和强度在个体之间差异很大。有些人报告说，连续数月每周发作一次恐慌发作，其他人则报告每天多次发作，但随后数周或数月内没有发作。症状的强度在个体之间也有所不同，一些患者出现四项或更多症状（完全症状）或不到四项（有限症状）。此外，个体报告说他们的恐慌发作症状存在可变性，有的恐慌发作呈现的症状比其他的多。要被诊断为恐慌症，个体必须出现一次以上的意外完全症状恐慌发作（APA，2022）。

Key Takeaways 关键要点

You should have learned the following in this section:
您应该在本节中学到以下内容：

  • All anxiety disorders share the hallmark symptoms of excessive fear or worry related to behavioral disturbances.
    所有焦虑障碍都具备与行为障碍相关的过度恐惧或担忧的标志性症状。
  • Generalized anxiety disorder is characterized by an underlying excessive worry related to a wide range of events or activities and an inability to control their worry through coping strategies.
    广泛性焦虑症以与广泛事件或活动相关的潜在过度担忧以及无法通过应对策略控制担忧为特征。
  • Specific phobia is characterized by fear or anxiety specific to an object or a situation and individuals can experience fear of more than one object.
    特定恐惧症以对特定物体或情境的恐惧或焦虑为特征，个体可能对多个物体感到恐惧。
  • Agoraphobia is characterized by intense fear related to situations in which the individual is in public situations where escape may be difficult and help may not be able to come.
    广场恐怖症的特点是对个体处于可能难以逃脱且无法获得帮助的公共场所的情境产生强烈的恐惧。
  • Social anxiety disorder is characterized by fear or anxiety related to social situations, especially when evaluation by others is possible.
    社交焦虑症以与社交场合相关的恐惧或焦虑为特征，尤其是在可能被他人评价的情况下。
  • Panic disorder is characterized by a series of recurrent, unexpected panic attacks coupled with the fear of future panic attacks.
    恐慌症以一系列反复出现的、意外的恐慌发作，以及对未来恐慌发作的恐惧为特征。

Section 7.1 Review Questions
第 7.1 节复习题

  1. What is the difference between fear and anxiety?
    恐惧和焦虑的区别是什么？
  2. What are the key differences between generalized anxiety disorder and agoraphobia?
    什么是广泛性焦虑症和广场恐怖症的关键区别？
  3. Individuals with social anxiety disorder will experience both physical and cognitive symptoms, particularly when presented with social interactions. What are these symptoms?
    患有社交焦虑症的人将经历身体和认知症状，尤其是在面对社交互动时。这些症状有哪些？
  4. What are the common types of specific phobias?
    常见特定恐惧症有哪些类型？
  5. What are the physical and cognitive symptoms observed during panic disorder?
    恐慌症期间观察到的身体和认知症状有哪些？
  6. What are the key components of panic disorder?
    什么是惊恐症的关键组成部分？

7.2. Epidemiology 7.2. 流行病学

Section Learning Objectives 章节学习目标

  • Describe the epidemiology of generalized anxiety disorder.
    描述广泛性焦虑障碍的流行病学。
  • Describe the epidemiology of specific phobia.
    描述特定恐惧症的流行病学。
  • Describe the epidemiology of agoraphobia.
    描述广场恐怖症的流行病学。
  • Describe the epidemiology of social anxiety disorder.
    描述社交焦虑症的流行病学。
  • Describe the epidemiology of panic disorder.
    描述惊恐障碍的流行病学。

7.2.1. Generalized Anxiety Disorder 7.2.1. 广泛性焦虑障碍

The 12-month prevalence for generalized anxiety disorder is estimated to be 2.9% of the adult general population of the United States while the mean 12-month prevalence around the world is 1.3% (with a range of 0.2% to 4.3%). The disorder occurs more frequently in women and adolescent girls, those of European descent, and those living in high-income countries (APA, 2022).
美国成年普通人群的广泛性焦虑症 12 个月患病率估计为 2.9%，而全球平均 12 个月患病率为 1.3%（范围为 0.2%至 4.3%）。该疾病在女性、青少年女孩、欧洲裔以及高收入国家居民中更为常见（APA，2022）。

7.2.2. Specific Phobia 7.2.2. 特定恐惧症

The prevalence rate for specific phobia is 8-12% in the United States and about 6% in European countries. There is a 2:1 ratio of females to males diagnosed with specific phobia. Prevalence rates are lower in older individuals and those from Asia, Africa, and Latin America.
美国特定恐惧症的患病率为 8-12%，欧洲国家约为 6%。被诊断为特定恐惧症的女男比例为 2:1。老年人和来自亚洲、非洲和拉丁美洲的人的患病率较低。

7.2.3. Agoraphobia 7.2.3. 广场恐怖症

The prevalence rate of agoraphobia worldwide for adolescents and adults is 1% to 1.7%. As with other anxiety disorders, women are twice as likely to be diagnosed with it. Older adults in the United States (aged 65 and up) have a 12-month prevalence of 0.4% and for older adults aged 55 and up in Europe and North America, the prevalence is 0.5%.
全球青少年和成年人广场恐怖症的患病率为 1%至 1.7%。与其他焦虑障碍一样，女性被诊断为该病的可能性是男性的两倍。美国 65 岁及以上的老年人 12 个月患病率为 0.4%，而在欧洲和北美 55 岁及以上的老年人中，患病率为 0.5%。

7.2.4. Social Anxiety Disorder 7.2.4. 社交焦虑障碍

The overall prevalence rate of social anxiety disorder is significantly higher in the United States than in other countries, with an estimated 7% of the U.S. population diagnosed with social anxiety disorder, compared to 0.5% to 2.0% worldwide (median prevalence in Europe is 2.3%). A decrease in the diagnosis of social anxiety disorder among older individuals, aged 65 years and older, has been found. Regarding gender, there is a higher diagnosis rate in females than males. This gender discrepancy is greater among adolescents and young adults. Finally, non-Hispanic whites in the United States have a higher prevalence rate than Asian, Latinx, African American, and Caribbean Black descent (APA, 2022). 

7.2.5. Panic Disorder 7.2.5. 惊恐障碍

The 12-month prevalence for panic disorder in the general population is estimated at around 2-3% in adults and adolescents across the United States and several European countries. Higher rates of panic disorder are found in American Indians and non-Latinx whites. Females are more commonly diagnosed than males with a 2:1 diagnosis rate. Prevalence declines from about 1.2% in adults older than 55 to 0.7% in adults aged 64 and up. 

Key Takeaways 关键要点

You should have learned the following in this section:
您应该在本节中学到了以下内容：

  • Prevalence rates for anxiety disorders range from 1.0% for agoraphobia up to 12% for specific phobia. 
  • For most anxiety disorders, females are twice as likely to be diagnosed. 

Section 7.2 Review Questions 

  1. Create a table of the prevalence rates across the various anxiety related disorders. What are the differences between the disorders? 
  2. How do prevalence rates vary as a function of gender, race, nationality, and age? 

7.3. Comorbidity

Section Learning Objectives

  • Describe the comorbidity of generalized anxiety disorder. 
  • Describe the comorbidity of specific phobia.
    描述特定恐惧症的共病情况。
  • Describe the comorbidity of agoraphobia.
    描述广场恐怖症的共病情况。
  • Describe the comorbidity of social anxiety disorder.
    描述社交焦虑障碍的共病情况。
  • Describe the comorbidity of panic disorder.
    描述惊恐障碍的共病情况。

7.3.1. Generalized anxiety disorder 7.3.1. 广泛性焦虑障碍

There is a high comorbidity between generalized anxiety disorder and the other anxiety-related disorders, as well as unipolar depressive disorders. Comorbidity with substance use, neurodevelopmental, neurocognitive, psychotic, and conduct disorders is less common for those afflicted with generalized anxiety disorder. Generalized anxiety disorder is associated with higher levels of suicidal ideation and behavior and psychological autopsy studies reveal it is the most frequent anxiety disorder diagnosed in suicides (APA, 2022).
焦虑症与其它焦虑相关疾病以及单极抑郁症的共病率较高。对于患有广泛性焦虑症的人来说，与物质使用、神经发育、神经认知、精神和行为障碍的共病较少。广泛性焦虑症与较高的自杀意念和行为相关，心理尸检研究显示，它是自杀中最常被诊断的焦虑症（APA，2022）。

7.3.2. Specific phobia 7.3.2. 特定恐惧症

Other anxiety disorders, depressive and bipolar disorders, substance-related disorders, and somatic symptom disorder are typically comorbid with specific phobia. Additionally, personality disorders, in particular dependent personality disorder, are comorbid. Specific phobia is associated with the transition from suicidal ideation to attempt (APA, 2022).
其他焦虑障碍、抑郁和双相情感障碍、物质相关障碍和躯体症状障碍通常与特定恐惧症共病。此外，人格障碍，特别是依赖性人格障碍，也是共病的。特定恐惧症与从自杀意念到尝试的过渡相关（APA，2022）。

7.3.3. Agoraphobia 7.3.3. 广场恐怖症

As with other anxiety disorders, common comorbid mental disorders include other anxiety disorders and depressive disorders. Agoraphobia is also comorbid with PTSD and alcohol use disorder. For those with comorbid major depressive disorder, the agoraphobia is more treatment-resistant compared to those with agoraphobia alone. About 15% of patients diagnosed with agoraphobia report suicidal thoughts or behavior (APA, 2022).
与其他焦虑障碍一样，常见的共病精神障碍包括其他焦虑障碍和抑郁障碍。广场恐怖症还与 PTSD 和酒精使用障碍共病。对于患有共病重度抑郁症的患者，与仅患有广场恐怖症的患者相比，广场恐怖症更难治疗。大约 15%被诊断为广场恐怖症的患者报告有自杀想法或行为（APA，2022）。

7.3.4. Social Anxiety Disorder 7.3.4. 社交焦虑障碍

Among the most common comorbid diagnoses with a social anxiety disorder are other anxiety-related disorders, major depressive disorder, and substance-related disorders. The high comorbidity rate among anxiety-related disorders and substance-related disorders is likely connected to the efforts of self-medicating to deal with social fears. For example, an individual with social anxiety disorder may consume more alcohol in social settings in efforts to alleviate the anxiety of the social situation. The comorbidity with major depressive disorder may be due to the chronic social isolation associated with social anxiety disorder. Comorbidity has also been found with body dysmorphic disorder and avoidant personality disorder.
在社交焦虑障碍中最常见的共病诊断包括其他焦虑相关障碍、重度抑郁症和物质相关障碍。焦虑相关障碍和物质相关障碍之间的高共病率可能与自我用药以应对社交恐惧的努力有关。例如，患有社交焦虑障碍的个人可能在社交场合中饮用更多酒精，以减轻社交情境的焦虑。与重度抑郁症的共病可能与社会焦虑障碍相关的慢性社交隔离有关。还发现与体象障碍和回避型人格障碍存在共病。

7.3.5. Panic disorder 7.3.5. 惊恐障碍

Panic disorder rarely occurs in isolation, as 80% of individuals report symptoms of other anxiety disorders, major depressive disorder, bipolar I and bipolar II disorder, and possibly mild alcohol use disorder. Some individuals diagnosed with panic disorder also develop a substance-related disorder, likely as an attempt to treat their anxiety with alcohol or other substances.  About 25% of patients report suicidal thoughts and the disorder may increase the risk for future suicidal behaviors but not deaths.  (APA, 2022).
惊恐障碍很少单独发生，因为 80%的人报告有其他焦虑障碍、重度抑郁症、双相情感障碍 I 型和 II 型的症状，以及可能存在轻度酒精使用障碍。一些被诊断为惊恐障碍的人还可能发展出与物质相关的障碍，这可能是他们试图用酒精或其他物质来治疗自己的焦虑。大约 25%的患者报告有自杀念头，这种障碍可能会增加未来自杀行为的风险，但不会增加死亡风险。(APA, 2022)。

Unlike some of the other anxiety disorders, there is a high comorbidity with general medical symptoms. More specifically, individuals with panic disorder are more likely to report somatic symptoms such as dizziness, cardiac arrhythmias, COPD, asthma, irritable bowel syndrome, and hyperthyroidism (APA, 2022). The relationship between panic symptoms and these conditions is unclear.
与其他焦虑障碍不同，与一般医疗症状的共病率较高。更具体地说，患有恐慌症的人更有可能报告身体症状，如头晕、心律失常、COPD、哮喘、肠易激综合症和甲状腺功能亢进（APA，2022）。恐慌症状与这些条件之间的关系尚不明确。

Key Takeaways 关键要点

You should have learned the following in this section:
您应该在本节中学到以下内容：

  • Many anxiety disorders are comorbid with one another.
    许多焦虑障碍相互并存。
  • Other common comorbid disorders include depressive disorders and substance-related disorders.
    其他常见共病包括抑郁障碍和物质相关障碍。
  • Agoraphobia has a high comorbidity with PTSD and panic disorder with general medical symptoms.
    广场恐怖症与 PTSD 和伴有全身症状的惊恐障碍具有较高的共病率。
  • Most anxiety disorders are associated with suicidal thoughts and behaviors, but not always deaths.
    大多数焦虑障碍与自杀想法和行为有关，但并非总是导致死亡。

Section 7.3 Review Questions
第 7.3 节复习问题

  1. What other disorders commonly occur with specific anxiety related disorders and why?
    哪些其他疾病通常与特定的焦虑相关疾病同时发生，以及原因是什么？
  2. What anxiety-related disorder has a high comorbidity with medical symptoms?
    哪些焦虑相关疾病与医疗症状共病率较高？
  3. What is the relationship of the disorders with suicidal ideation and attempts/behaviors? Be specific.
    该疾病与自杀意念和尝试/行为之间的关系是什么？请具体说明。

7.4. Etiology 7.4. 病因

Section Learning Objectives 章节学习目标

  • Describe the biological causes of anxiety disorders.
    描述焦虑障碍的生物原因。
  • Describe the psychological causes of anxiety disorders.
    描述焦虑障碍的心理原因。
  • Describe the sociocultural causes of anxiety disorders.
    描述焦虑障碍的社会文化原因。

7.4.1. Biological 7.4.1. 生物

**     7.4.1.1. Biological – Genetic influences. **While genetics have been known to contribute to the presentation of anxiety symptoms, the interaction between genetics and stressful environmental influences appears to account for more anxiety disorders than genetics alone (Bienvenu, Davydow, & Kendler, 2011). The quest to identify specific genes that may predispose individuals to develop anxiety disorders has led researchers to the serotonin transporter gene (5-HTTLPR). Mutation of the 5-HTTLPR gene is related to a reduction in serotonin activity and an increase in anxiety-related personality traits (Munafo, Brown, & Hairiri, 2008).
7.4.1.1. 生物遗传影响。虽然已知遗传因素会影响焦虑症状的表现，但遗传与环境压力因素的相互作用似乎比单纯的遗传因素更能解释焦虑障碍的发生（Bienvenu, Davydow, & Kendler, 2011）。寻找可能导致个体易患焦虑障碍的特定基因的研究将研究人员引向了 5-HTTLPR 基因。5-HTTLPR 基因的突变与血清素活性的降低和焦虑相关人格特征的增加有关（Munafo, Brown, & Hairiri, 2008）。

**     7.4.1.2. Biological – Neurobiological structures. **Researchers have identified several brain structures and pathways that are likely responsible for anxiety responses. Among those structures is the **amygdala, **the area of the brain that is responsible for storing memories related to emotional events (Gorman, Kent, Sullivan, & Coplan, 2000). When presented with a fearful situation, the amygdala initiates a reaction to ready the body for a response. First, the amygdala triggers the hypothalamic-pituitary-adrenal (HPA) axis to prepare for immediate action— either to fight or flight. The second pathway is activated by the feared stimulus itself, by sending a sensory signal to the hippocampus and prefrontal cortex, to determine if the threat is real or imagined. If it is determined that no threat is present, the amygdala sends a calming response to the HPA axis, thus reducing the level of fear. If a threat is present, the amygdala is activated, producing a fear response.
7.4.1.2. 生物-神经生物学结构。研究人员已经确定了几个大脑结构和通路，这些结构和通路可能负责焦虑反应。其中之一是杏仁核，这是大脑中负责储存与情绪事件相关的记忆的区域（Gorman, Kent, Sullivan, & Coplan, 2000）。当面对恐惧情境时，杏仁核启动反应以使身体准备应对。首先，杏仁核触发下丘脑-垂体-肾上腺（HPA）轴准备立即行动——要么战斗要么逃跑。第二条通路由恐惧刺激本身激活，通过向海马体和前额叶皮层发送感官信号，以确定威胁是真实还是想象。如果确定没有威胁存在，杏仁核向 HPA 轴发送安抚反应，从而降低恐惧水平。如果存在威胁，杏仁核被激活，产生恐惧反应。

Specific to panic disorder is the implication of the locus coeruleus, the brain structure that serves as an “on-off” switch for norepinephrine neurotransmitters. It is believed that increased activation of the locus coeruleus results in panic-like symptoms; therefore, individuals with panic disorder may have a hyperactive locus coeruleus, leaving them more susceptible to experience more intense and frequent physiological arousal than the general public (Gorman, Kent, Sullivan, & Coplan, 2000). This theory is supported by studies in which individuals experienced increased panic symptoms following the injection of norepinephrine (Bourin, Malinge, & Guitton, 1995).
特定于恐慌症的是蓝斑的作用，这是一种作为去甲肾上腺素神经递质“开/关”开关的大脑结构。人们认为，蓝斑的激活增加会导致类似恐慌的症状；因此，患有恐慌症的人可能有一个过度活跃的蓝斑，使他们比普通人更容易经历更强烈和更频繁的生理唤醒（Gorman, Kent, Sullivan, & Coplan, 2000）。这一理论得到了以下研究的支持，即个体在注射去甲肾上腺素后经历了恐慌症状的增加（Bourin, Malinge, & Guitton, 1995）。

Unfortunately, norepinephrine and the locus coeruleus fail to fully explain the development of panic disorder, as treatment would be much easier if *only *norepinephrine was implicated. Therefore, researchers argue that a more complex neuropathway is likely responsible for the development of panic disorder. More specifically, the corticostriatal-thalamocortical (CSTC) circuit, also known as the fear-specific circuit, is theorized as a major contributor to panic symptoms (Gutman, Gorman, & Hirsch, 2004). When an individual is presented with a frightening object or situation, the amygdala is activated, sending a fear response to the anterior cingulate cortex and the orbitofrontal cortex. Additional projection from the amygdala to the hypothalamus activates endocrinologic responses to fear, releasing adrenaline and cortisol to help prepare the body to fight or flight (Gutman, Gorman, & Hirsch, 2004). This complex pathway supports the theory that panic disorder is mediated by several neuroanatomical structures and their associated neurotransmitters.
不幸的是，去甲肾上腺素和蓝斑无法完全解释惊恐障碍的发展，因为如果只有去甲肾上腺素被牵涉其中，治疗将会容易得多。因此，研究人员认为，一个更复杂的神经通路可能负责惊恐障碍的发展。更具体地说，皮质-纹状体-丘脑皮质（CSTC）回路，也称为恐惧特异性回路，被认为是惊恐症状的主要贡献者（Gutman，Gorman，& Hirsch，2004）。当一个人面对一个令人恐惧的物体或情境时，杏仁核被激活，向前扣带回皮层和眶额皮层发送恐惧反应。来自杏仁核到下丘脑的额外投射激活了对恐惧的内分泌反应，释放肾上腺素和皮质醇以帮助身体准备战斗或逃跑（Gutman，Gorman，& Hirsch，2004）。这条复杂的通路支持了惊恐障碍是由多个神经解剖结构和它们相关的神经递质介导的理论。

7.4.2. Psychological 7.4.2. 心理

**     7.4.2.1. Psychological – Cognitive. **The cognitive perspective on the development of anxiety related disorders centers around dysfunctional thought patterns. As seen in depression, maladaptive assumptions are routinely observed in individuals with anxiety-related disorders, as they often engage in interpreting events as dangerous or overreacting to potentially stressful events, which contributes to an overall heightened anxiety level. These negative appraisals, in combination with a biological predisposition to anxiety, likely contribute to the development of anxiety symptoms (Gallagher et al., 2013).
7.4.2.1. 心理 - 认知。关于焦虑相关障碍发展的认知视角集中在功能失调的思维模式上。正如在抑郁症中观察到的那样，焦虑相关障碍个体中通常存在不适应的假设，他们常常将事件解释为危险的或对可能具有压力的事件过度反应，这导致整体焦虑水平升高。这些负面评估与生物倾向的焦虑相结合，可能有助于焦虑症状的发展（Gallagher 等，2013）。

Sensitivity to physiological arousal not only contributes to anxiety disorders in general, but also for panic disorder where individuals experience various physiological sensations and misinterpret them as catastrophic. One explanation for this theory is that individuals with panic disorder are more susceptible to more frequent and intensive physiological symptoms than the general public (Nillni, Rohan, & Zvolensky, 2012). Others argue that these individuals have had more trauma-related experiences in the past, and therefore, are quick to misevaluate their symptoms as a potential threat. This misevaluation of symptoms as impending disaster likely maintain symptoms as the cognitive misinterpretations to physiological arousal creates a negative feedback loop, leading to more physiological changes.
生理唤起的敏感性不仅会导致焦虑障碍，还会导致恐慌障碍，其中个体会经历各种生理感觉并将它们误认为是灾难性的。这一理论的一个解释是，患有恐慌障碍的个体比普通人更容易出现更频繁和更强烈的生理症状（Nillni, Rohan, & Zvolensky, 2012）。另一些人认为，这些个体在过去有更多与创伤相关经历，因此，他们很快就会将症状误评估为潜在的威胁。将症状误评估为即将到来的灾难可能维持症状，因为对生理唤起的认知误解创造了一个负面反馈循环，导致更多的生理变化。

Social anxiety is also primarily explained by cognitive theorists. Individuals with social anxiety disorder tend to hold unattainable or extremely high social beliefs and expectations. Furthermore, they often engage in preconceived maladaptive assumptions that they will behave incompetently in social situations and that their behaviors will lead to terrible consequences. Because of these beliefs, they anticipate social disasters will occur and, therefore, avoid social encounters (or limit them to close friends/family members) in efforts to prevent the disaster (Moscovitch et al., 2013). Unfortunately, these cognitive appraisals are not only isolated to before and during the event. Individuals with social anxiety disorder will also evaluate the social event after it has taken place, often obsessively reviewing the details. This overestimation of social performance negatively reinforces future avoidance of social situations.
社交焦虑也主要被认知理论家解释。患有社交焦虑症的人往往持有无法实现或极高的社会信念和期望。此外，他们经常进行先入为主的非适应性假设，认为自己在社交场合会表现得无能，并且他们的行为会导致可怕后果。由于这些信念，他们预计会发生社交灾难，因此为了避免灾难（Moscovitch 等人，2013 年），会避免社交接触（或将它们限制在亲密朋友/家庭成员之间）。不幸的是，这些认知评估不仅限于事件之前和期间。患有社交焦虑症的人还会在事件发生后评估社交活动，常常过度关注细节。这种对社交表现的过度估计会负面地强化未来避免社交场合的行为。

**     7.4.2.2. Psychological – Behavioral. **The behavioral explanation for the development of anxiety disorders is mainly reserved for phobias—both specific and social phobia. More precisely, behavioral theorists focus on **respondent conditioning **– when two events that occur close together become strongly associated with one another, despite their lack of causal relationship (see Module 2 for an explanation of respondent conditioning). Watson and Rayner’s (1920) infamous Little Albert experiment is an example of how respondent conditioning can be used to induce fear through associations. In this study, Little Albert developed a fear of white rats by pairing a white rat with a loud sound. This experiment, although lacking ethical standards, was groundbreaking in the development of learned behaviors. Over time, researchers have been able to replicate these findings (in more ethically sound ways) to provide further evidence of the role of respondent conditioning in the development of phobias.
7.4.2.2. 心理-行为。焦虑症发展的行为解释主要保留在恐惧症——包括特定恐惧症和社会恐惧症。更确切地说，行为理论家关注应答性条件反射——当两个发生得很近的事件变得强烈关联，尽管它们之间没有因果关系（参见第 2 模块中应答性条件反射的解释）。华生和雷纳（1920 年）臭名昭著的小艾伯特实验是应答性条件反射如何通过联想诱导恐惧的一个例子。在这项研究中，小艾伯特通过与大声响配对白鼠，发展了对白鼠的恐惧。这个实验，尽管缺乏伦理标准，但在学习行为的发展中具有开创性。随着时间的推移，研究人员已经能够以更道德的方式复制这些发现，为应答性条件反射在恐惧症发展中的作用提供进一步证据。

**     7.4.2.3. Psychological – Modeling** is another behavioral explanation of the development of specific and social phobias. In modeling, an individual acquires a fear though observation and imitation (Bandura & Rosenthal, 1966). For example, when a young child observes their parent display irrational fear of an animal, the child may then begin to display similar behavior. Similarly, seeing another individual being ridiculed in a social setting may increase the chances of developing social anxiety, as the individual may become fearful that they would experience a similar situation in the future. It is speculated that the maintenance of these phobias is due to the *avoidance *of the feared item or social setting, thus preventing the individual from learning that the object or situation is not something that should be feared.
7.4.2.3. 心理学 – 模仿是特定和社交恐惧症发展的另一种行为解释。在模仿中，个体通过观察和模仿（Bandura & Rosenthal，1966）获得恐惧。例如，当年幼的孩子观察到他们的父母对动物表现出不理性的恐惧时，孩子可能会开始表现出类似的行为。同样，看到另一个人在社会环境中被嘲笑可能会增加发展社交焦虑的可能性，因为个体可能会害怕自己将来会遇到类似的情况。据推测，这些恐惧症的维持是由于避免恐惧的物品或社会环境，从而阻止个体学习到该物体或情况不是应该被恐惧的东西。

While modeling and respondent conditioning largely explain the development of phobias, there is some speculation that the accumulation of many these learned fears will develop into generalized anxiety disorder. Through **stimulus generalization, **or the tendency for the conditioned stimulus to evoke similar responses to other stimuli, a fear of one stimulus (such as the dog) may become generalized to other items (such as all animals). As these fears begin to grow, a more generalized anxiety will present, as opposed to a specific phobia.
虽然建模和反应条件化在很大程度上解释了恐惧症的发展，但有一些推测认为，许多这些习得性恐惧的积累将发展成为广泛性焦虑症。通过刺激泛化，即条件刺激引起对其他刺激的类似反应的倾向，对某一刺激（如狗）的恐惧可能会泛化到其他物品（如所有动物）。随着这些恐惧开始增长，将出现更广泛的焦虑，而不是特定的恐惧症。

7.4.3. Sociocultural 7.4.3. 社会文化

Seeing how prominent the biological and psychological constructs are in explaining the development of anxiety-related disorders, we also need to review the social constructs that contribute and maintain anxiety disorders. While characteristics such as living in poverty, experiencing significant daily stressors, and increased exposure to traumatic events are all identified as significant contributors to anxiety disorders, additional sociocultural influences such as gender and discrimination have also received considerable attention, mainly due to the epidemiological nature of the disorder.
观察生物和心理结构在解释焦虑相关疾病发展中的突出作用，我们还需要回顾那些导致并维持焦虑障碍的社会结构。虽然生活在贫困中、经历重大日常压力源和增加创伤事件的暴露都被认定为焦虑障碍的重要贡献因素，但性别和歧视等额外的社会文化影响也受到了相当的关注，这主要归因于该疾病的流行病学特性。

Gender has largely been researched within anxiety disorders due to the consistent discrepancy in the diagnosis rate between men and women. As previously discussed, women are routinely diagnosed with anxiety disorders more often than men, a trend that is observed throughout the entire lifespan. One potential explanation for this discrepancy is the influence of social pressures on women. Women are more susceptible to experience traumatic experiences throughout their life, which may contribute to anxious appraisals of future events. Furthermore, women are more likely to use emotion-focused coping, which is less effective in reducing distress than problem-focused coping (McLean & Anderson, 2009). These factors may increase levels of stress hormones within women that leave them susceptible to develop symptoms of anxiety. Therefore, it appears a combination of genetic, environmental, and social factors may explain why women tend to be diagnosed more often with anxiety-related disorders.
性别在焦虑障碍的研究中得到了广泛的关注，因为男性和女性在诊断率上存在一致的差异。正如之前讨论的，女性比男性更频繁地被诊断为焦虑障碍，这一趋势贯穿整个生命周期。这种差异的一个潜在解释是女性受到社会压力的影响。女性在其一生中更容易经历创伤性事件，这可能导致对未来事件的焦虑评估。此外，女性更有可能使用情绪聚焦的应对策略，这种策略在减少压力方面不如问题聚焦的应对策略有效（McLean & Anderson，2009）。这些因素可能导致女性体内压力激素水平升高，使她们容易发展出焦虑症状。因此，似乎遗传、环境和社交因素的组合可以解释为什么女性更容易被诊断为焦虑相关障碍。

Exposure to discrimination and prejudice, particularly relevant to ethnic minorities and other marginalized groups, can also impact an individual’s anxiety level. Discrimination and prejudice contribute to negative interactions, which is directly related to negative affect and an overall decline in mental health (Gibbons et al., 2014). The repeated exposure to discrimination and prejudice over time can lead to fear responses in individuals, along with subsequent avoidance of social situations in efforts to protect themselves emotionally.
歧视和偏见的影响，尤其是针对少数民族和其他边缘群体，也可能影响个人的焦虑水平。歧视和偏见导致负面互动，这与负面情绪和整体心理健康水平的下降直接相关（Gibbons 等人，2014）。随着时间的推移，反复遭受歧视和偏见可能导致个体产生恐惧反应，并随后避免社交场合，以保护自己的情绪。

Key Takeaways 关键要点

You should have learned the following in this section:
您应该在本节中学到以下内容：

  • Biological causes of anxiety disorders include the serotonin transporter gene (5-HTTLPR); brain structures to include the amygdala, hippocampus, and prefrontal cortex; and the locus coeruleus and corticostriatal-thalamocortical (CSTC) circuit in relation to panic disorder.
    生物焦虑障碍的原因包括 5-HTTLPR 血清素转运蛋白基因；涉及杏仁核、海马体和前额叶皮层的脑结构；以及与惊恐障碍相关的蓝斑和皮质纹状体-丘脑皮质（CSTC）回路。
  • Psychological causes of anxiety disorders include maladaptive assumptions, the linking of events through respondent conditioning, modeling, and stimulus generalization as it relates to generalized anxiety disorder.
    焦虑障碍的心理原因包括不适应的假设、通过应答性条件反射、模仿和与广泛性焦虑障碍相关联的刺激泛化来联系事件。
  • Sociocultural causes of anxiety disorders include social pressures leading to a higher rate of diagnosis for women and discrimination and prejudice which affects ethnic minorities and other marginalized groups.
    社会文化因素导致焦虑症的原因包括导致女性诊断率升高的社会压力，以及影响少数民族和其他边缘群体的歧视和偏见。

Section 7.4 Review Questions
第 7.4 节复习问题

  1. Discuss the biological etiology of panic disorders. What brain structures and neurotransmitters are involved?
    讨论惊恐障碍的生物学病因。哪些大脑结构和神经递质参与其中？
  2. How does the cognitive model explain the development and maintenance of anxiety related disorders?
    认知模型如何解释焦虑相关障碍的发展和维持？
  3. What is the difference between emotion-focused and problem-focused coping strategies? How do these two coping strategies explain differences in anxiety related disorders?
    什么是情绪聚焦和问题聚焦应对策略之间的区别？这两种应对策略如何解释焦虑相关障碍的差异？
  4. What are the effects of prejudice and discrimination on the development of anxiety disorders?
    偏见和歧视对焦虑症的发展有何影响？

7.5. Treatment 7.5. 治疗

Section Learning Objectives 章节学习目标

  • Describe treatment options for generalized anxiety disorder.
    描述广泛性焦虑症的治疗方案。
  • Describe treatment options for specific phobia.
    描述特定恐惧症的治疗方案。
  • Describe treatment options for agoraphobia.
    描述广场恐怖症的治疗方案。
  • Describe treatment options for social anxiety disorder.
    描述社交焦虑症的治疗方案。
  • Describe treatment options for panic disorder.
    描述惊恐障碍的治疗方案。

7.5.1. Generalized Anxiety Disorder 7.5.1. 广泛性焦虑障碍

**     7.5.1.1. Psychopharmacology. **Benzodiazepines, a class of sedative-hypnotic drugs that will be discussed in more detail in the substance abuse module, originally replaced barbiturates as the leading anti-anxiety medication due to their less addictive nature, yet equally effective ability to calm individuals at low dosages. Unfortunately, as more research was done on benzodiazepines, serious side effects, as well as physical dependence of benzodiazepines at large dosages, has routinely been documented (NIMH, 2013). Due to these negative effects, selective serotonin-reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are generally considered to be first-line medication options for those with generalized anxiety disorder. Findings indicate a 30-50% positive response rate to these psychopharmacological interventions (Reinhold & Rickels, 2015). Unfortunately, none of these medications continue to provide any benefit once they are stopped; therefore, other effective treatment options such as CBT, relaxation training, and biofeedback are often encouraged before the use of pharmacological interventions. 

**     7.5.1.2. Rational-Emotive therapy. **Albert Ellis developed rational emotive therapy in the mid-1950s as one of the first forms of cognitive-behavioral therapy. Ellis proposed that individuals were not aware of the effect their negative thoughts had on their behaviors and various relationships, and thus, established a treatment to address these thoughts and provide relief to those suffering from anxiety and depression. The goal of rational emotive therapy is to identify irrational, self-defeating assumptions, challenge the rationality of those assumptions, and to replace them with new, more productive thoughts and feelings. By identifying and replacing these assumptions, the individual will experience relief of generalized anxiety disorder symptoms (Ellis, 2014). 

**     7.5.1.3. Cognitive Behavioral Therapy (CBT). **CBT is discussed in detail in the Mood Disorder Module; however, it is also among the most effective treatment options for a variety of anxiety disorders, including generalized anxiety disorder. Findings suggest 60 percent of individuals report a significant reduction/elimination in anxious thoughts one-year post treatment (Hanrahan, Field, Jones, & Davy, 2013). The fundamental goal of CBT is a combination of cognitive and behavioral strategies aimed to identify and restructure maladaptive thoughts while also providing opportunities to utilize these more effective thought patterns through exposure-based experiences. Through repetition, the individual will be able to identify and replace anxious thoughts outside of therapy sessions, ultimately reducing their overall anxiety levels (Borkovec, & Ruscio, 2001). 

**     7.5.1.4. Biofeedback. **Biofeedback provides a visual representation of a patient’s physiological arousal. To achieve this feedback, a patient is connected to a computer that provides continuous information on their physiological states. There are several ways a patient can connect to the computer. Among the most common is electromyography (EMG). EMG measures the amount of muscle activity currently experienced by the individual. An electrode is placed on a patient’s skin just above a major muscle group, usually the forearm or the forehead. Other common areas of measurement are electroencephalography (EEG), which measures the neurofeedback or brain activity; heart rate variability (HRV), which measures autonomic activity such as heart rate or blood pressure; and galvanic skin response (GSR) which measures sweat. 

Once the patient is connected to the biofeedback machine, the clinician can walk the patient through a series of relaxation scripts or techniques as the computer simultaneously measures the changes in muscle tension. The theory behind biofeedback is that in providing a patient with a visual representation of changes in their physiological state, they become more skilled at voluntarily reducing their physiological arousal, and thus, their overall sense of anxiety or stress. While research has identified only a modest effect of biofeedback on anxiety levels, patients do report a positive experience with the treatment due to the visual feedback of their physiological arousal (Brambrink, 2004).
一旦患者连接到生物反馈仪，临床医生可以引导患者通过一系列放松脚本或技巧，同时计算机测量肌肉紧张度的变化。生物反馈的理论在于，通过向患者提供其生理状态变化的视觉表示，他们可以更熟练地自愿降低生理唤醒，从而减轻整体焦虑或压力感。尽管研究仅发现生物反馈对焦虑水平的影响有限，但患者们由于生理唤醒的视觉反馈，报告了治疗过程中的积极体验（Brambrink，2004）。

7.5.2. Specific Phobias 7.5.2. 特定恐惧症

**     7.5.2.1. Exposure treatments. **While there are many treatment options for specific phobias, research routinely supports the behavioral techniques as the most effective treatment strategies. Seeing as the behavioral theory suggests phobias develop via respondent conditioning, the treatment approach revolves around breaking the maladaptive association between the object and fear. This is generally accomplished through exposure treatments. As the name implies, the individual is *exposed *to their feared stimuli. This can be done in several different approaches: *systematic desensitization, flooding, and modeling. *
7.5.2.1. 暴露疗法。尽管有许多针对特定恐惧症的治疗选择，但研究通常支持行为技术是最有效的治疗策略。鉴于行为理论认为恐惧症是通过条件反射发展的，治疗方法围绕打破物体与恐惧之间的不良关联。这通常通过暴露疗法来实现。正如其名所示，个体会接触到他们害怕的刺激。这可以通过几种不同的方法进行：系统脱敏、洪水疗法和模仿。

**Systematic desensitization **is an exposure technique that utilizes relaxation strategies to help calm the individual as they are presented with the fearful object. The notion behind this technique is that both fear and relaxation cannot exist at the same time; therefore, the individual learns how to replace their fearful reaction with a calm, relaxing reaction.
系统脱敏是一种利用放松策略帮助个体在接触恐惧对象时平静下来的暴露技术。这种技术的理念是恐惧和放松不能同时存在；因此，个体学会如何将他们的恐惧反应替换为平静、放松的反应。

To begin, the patient, with assistance from the clinician, will identify a fear hierarchy, or a list of feared objects/situations ordered from least fearful to most fearful. After teaching several different types of relaxation techniques, the clinician will present items from the fear hierarchy, starting from the least fearful object/subject, while the patient practices using the learned relaxation techniques. The presentation of the feared object/situation can be in person—in vivo exposure—or it can be imagined—**imaginal exposure. **Imaginal exposure tends to be less intensive than in vivo exposure; however, it is less effective than in vivo exposure in eliminating the phobia. Depending on the phobia, in vivo exposure may not be an option, such as with a fear of a tornado. Once the patient can effectively employ relaxation techniques to reduce their anxiety to a manageable level, the clinician will slowly move up the fear hierarchy until the individual does not experience excessive fear of all objects on the list.
首先，在临床医生的协助下，患者将确定一个恐惧等级，即按从最不恐惧到最恐惧的顺序排列的恐惧对象/情境列表。在教授几种不同的放松技巧后，临床医生将展示恐惧等级中的项目，从最不恐惧的对象/主题开始，同时患者练习使用学到的放松技巧。恐惧对象/情境的展示可以是亲自体验——现场暴露，或者想象——想象暴露。想象暴露通常比现场暴露的强度低；然而，在消除恐惧方面，它不如现场暴露有效。根据恐惧的类型，现场暴露可能不是一种选择，例如对龙卷风的恐惧。一旦患者能够有效地运用放松技巧将他们的焦虑降低到可管理的水平，临床医生将逐渐提升恐惧等级，直到个人不再对所有列表上的对象感到过度恐惧。

** Flooding **is another exposure technique in which the clinician does not utilize a fear hierarchy, but rather repeatedly exposes the individual to their most feared object or situation. Similar to systematic desensitization, flooding can be done in either in vivo or imaginal exposure. Clearly, this technique is more intensive than systematic or gradual exposure to feared objects. Because of this, patients are at a greater likelihood of dropping out of treatment, thus not successfully overcoming their phobias.
洪水是另一种暴露技术，其中临床医生不利用恐惧等级，而是反复让个体接触他们最害怕的对象或情境。类似于系统脱敏，洪水疗法可以在现实生活中或想象中进行。显然，这种技术比系统或逐步暴露于恐惧对象更为剧烈。因此，患者更有可能放弃治疗，从而未能成功克服他们的恐惧症。

** Modeling **is another common technique used to treat phobias (Kelly, Barker, Field, Wilson, & Reynolds, 2010). In this technique, the clinician approaches the feared object/subject while the patient observes. As the name implies, the clinician models appropriate behaviors when exposed to the feared stimulus, showing that the phobia is irrational. After modeling several times, the clinician encourages the patient to confront the feared stimulus with the clinician, and then ultimately, without the clinician.
建模是治疗恐惧症的一种常见技术（Kelly, Barker, Field, Wilson, & Reynolds, 2010）。在这种技术中，临床医生在患者观察下接近恐惧的对象/主题。正如其名所示，当临床医生面对恐惧的刺激时，会表现出适当的行为，表明恐惧是不合理的。经过几次建模后，临床医生鼓励患者与临床医生一起面对恐惧的刺激，然后最终在没有临床医生的情况下。

7.5.3. Agoraphobia 7.5.3. 广场恐怖症

Similar to the treatment approaches for specific phobias, exposure-based techniques are among the most effective treatment options for individuals with agoraphobia. However, unlike the high success rate in specific phobias, exposure treatment for agoraphobia has been less effective in providing complete relief from the disorder. The success rate may be impacted by the high comorbidity rate of agoraphobia and panic disorder. Because of the additional presentation of panic symptoms, exposure treatments alone are not the most effective in eliminating symptoms as residual panic symptoms often remain (Craske & Barlow, 2014). Therefore, the best treatment approach for those with agoraphobia and panic disorder is a combination of exposure and CBT techniques (see panic disorder  treatment).
与特定恐惧症的治疗方法相似，基于暴露的技术是治疗广场恐怖症最有效的治疗方法之一。然而，与特定恐惧症的高成功率相比，广场恐怖症的暴露治疗在提供完全缓解方面效果较差。成功率可能受到广场恐怖症和恐慌症高共病率的影响。由于恐慌症状的额外表现，仅使用暴露治疗并不是消除症状最有效的方法，因为残留的恐慌症状通常仍然存在（Craske & Barlow，2014）。因此，广场恐怖症和恐慌症的最佳治疗方法是结合暴露和认知行为疗法技术（参见恐慌症治疗）。

For individuals with agoraphobia *without *panic symptoms, the use of group therapy in combination with individual exposure therapy has been identified as a successful treatment option. The group therapy format allows the individual to engage in exposure-based field trips to various community locations, while also maintaining a sense of support and security from a group of individuals whom they know. Research indicates that this type of treatment provides improvement for nearly 60 to 80 percent of patients with agoraphobia; however, there is a relatively high rate of partial relapse, suggesting that long-term treatment or booster sessions should continue for several years at minimum (Craske & Barlow, 2014).
对于没有恐慌症状的广场恐怖症患者，将团体疗法与个体暴露疗法相结合已被确定为一种成功的治疗方案。团体疗法的形式允许个人参与基于暴露的社区地点的实地考察，同时也能从他们认识的一群人中获得支持和安全感。研究表明，这种治疗方式几乎能改善 60%至 80%的广场恐怖症患者；然而，部分复发的比例相对较高，这表明至少应继续进行长期治疗或加强治疗数年（Craske & Barlow，2014）。

7.5.4. Social Anxiety Disorder 7.5.4. 社交焦虑障碍

**     7.5.4.1. Exposure. **A hallmark treatment approach for all anxiety disorders is exposure. Specific to social anxiety disorder, the individual is encouraged to engage in social situations where they are likely to experience increased anxiety. Initially, the clinician will role-play various social situations with the patient so they can practice social interactions in a safe, controlled environment (Rodebaugh, Holaway, & Heimberg, 2004). As the patient becomes habituated to the interaction with the clinician, the clinician and patient may venture outside of the treatment room and engage in social situations with random strangers at various locations such as fast-food restaurants, local stores, libraries, etc. The patient is encouraged to continue with these exposures outside of treatment to help reduce anxiety related to social situations.
7.5.4.1. 暴露疗法。所有焦虑障碍的标准治疗方法是暴露疗法。对于社交焦虑障碍，鼓励个体参与可能导致焦虑增加的社会场合。最初，临床医生将与患者进行角色扮演，模拟各种社交场合，以便他们在安全、可控的环境中练习社交互动（Rodebaugh, Holaway, & Heimberg, 2004）。随着患者习惯于与临床医生的互动，临床医生和患者可以走出治疗室，在快餐店、当地商店、图书馆等不同地点与陌生人进行社交互动。鼓励患者在治疗之外继续这些暴露，以帮助减少与社交场合相关的焦虑。

**     7.5.4.2. Social skills training. **This treatment is specific to social anxiety disorder as it focuses on the patient’s skill deficits or inadequate social interactions that contribute to their negative social experiences and anxiety. During a session, the clinician may use a combination of skills such as modeling, corrective feedback, and positive reinforcement to provide feedback and encouragement to the patient regarding their behavioral interactions (Rodebaugh, Holaway, & Heimberg, 2004). By incorporating the clinician’s feedback into their social repertoire, the patient can engage in positive social behaviors outside of the treatment room and improve their overall social interactions while reducing ongoing social anxiety. 

**     7.5.4.3. Cognitive restructuring. **While exposure and social skills training are suitable treatment options, research routinely supports the need to incorporate cognitive restructuring as an additive component in treatment to provide substantial symptom reduction. Like cognitive restructuring previously discussed in the Mood Disorder module, the clinician will work with the therapist to identify negative, automatic thoughts that contribute to the distress in social situations. The clinician can then help the patient establish new, positive thoughts to replace these negative thoughts. Research indicates that implementing cognitive restructuring techniques before, during, and after exposure sessions enhances the overall effects of treatment of social anxiety disorder (Heimberg & Becker, 2002). 

7.5.5. Panic Disorder 7.5.5. 惊恐障碍

**     7.5.5.1. Cognitive Behavioral Therapy** **(CBT). **CBT is the most effective treatment option for individuals with panic disorder as the focus is on correcting misinterpretations of bodily sensations (Craske & Barlow, 2014). Nearly 80 percent of people with panic disorder report complete remission of symptoms after mastering the following five components of CBT for panic disorder (Craske & Barlow, 2014). 

Psychoeducation. Treatment begins by educating the patient on the nature of panic disorder, the underlying causes of panic disorder, as well as the mechanisms that maintain the disorder such as the physical, cognitive, and behavioral response systems (Craske & Barlow, 2014). This part of treatment is fundamental in correcting any myths or misconceptions about panic symptoms, as they often contribute to the exacerbation of panic symptoms.
心理教育。治疗开始于教育患者了解惊恐障碍的本质、惊恐障碍的潜在原因，以及维持障碍的机制，如生理、认知和行为反应系统（Craske & Barlow，2014）。治疗这部分是纠正关于惊恐症状的任何神话或误解的基础，因为它们往往会导致惊恐症状的加剧。

Self-monitoring*. *Self-monitoring, or the act of self-observation, is essential to the CBT treatment process for panic disorder. In this part of treatment, the individual is taught to identify the physiological cues immediately leading up to and during a panic attack.  Then, the patient is encouraged to recognize and document the thoughts and behaviors associated with these physiological symptoms. By bringing awareness to the symptoms, as well as the relationship between physical arousal and cognitive-behavioral responses, the patient learns the fundamental processes with which they can manage their panic symptoms (Craske & Barlow, 2014).
自我监测。自我监测，或自我观察的行为，对于惊恐障碍的认知行为治疗过程至关重要。在这一治疗部分，个体被教导识别导致和发生在惊恐发作前后的生理线索。然后，鼓励患者识别并记录与这些生理症状相关的思想和行为。通过提高对症状以及身体唤醒与认知行为反应之间关系的认识，患者学会管理他们惊恐症状的基本过程（Craske & Barlow，2014）。

Relaxation training*.* Similar to that in exposure-based treatment for phobias, prior to engaging in exposure training, the individual must learn relaxation techniques to apply during onset of panic attacks. Though breathing training was once included as the relaxation training technique of choice for panic disorder more recent research has failed to support this technique as effective in the use of panic disorder due to the high incidence of hyperventilation during panic attacks (Schmidt et al., 2000). Findings suggest that breathing retraining is more commonly misused as a safety behavior or means for avoiding physical symptoms as opposed to an effective physiological response to stress (Craske & Barlow, 2014).
放松训练。类似于恐惧症基于暴露的治疗方法，在进行暴露训练之前，个人必须学习在恐慌发作时应用的放松技巧。尽管呼吸训练曾经是恐慌症放松训练的首选技术，但最近的研究未能支持这一技术在恐慌症治疗中的有效性，因为恐慌发作期间过度换气的发生率很高（Schmidt 等，2000）。研究发现，呼吸再训练更常被误用为一种安全行为或避免身体症状的手段，而不是对压力的有效生理反应（Craske & Barlow，2014）。

**Progressive muscle relaxation. **To replace the breathing retraining, Craske & Barlow (2014) suggest progressive muscle relaxation (PMR). In PMR, the patient learns to tense and relax various large muscle groups throughout the body. The patient is encouraged to start at either the head or the feet, and gradually work their way through the entire body, holding the tension for roughly 10 seconds before relaxing. The theory behind PMR is that in tensing the muscles for a prolonged period, the individual exhausts those muscles, forcing them (and eventually) the entire body to engage in relaxation (McCallie, Blum, & Hood, 2006).
渐进性肌肉放松。为了替代呼吸再训练，Craske & Barlow (2014)建议渐进性肌肉放松（PMR）。在 PMR 中，患者学会紧张和放松身体上的各个大肌肉群。鼓励患者从头部或脚部开始，逐渐全身放松，紧张大约 10 秒后放松。PMR 的理论是，通过长时间紧张肌肉，个体会耗尽这些肌肉，迫使（最终）整个身体进入放松状态（McCallie, Blum, & Hood, 2006）。

Cognitive restructuring*.* Cognitive restructuring, or the ability to recognize cognitive errors and replace them with alternate, more appropriate thoughts, is likely the most powerful part of CBT treatment for panic disorder, aside from the exposure part. As noted previously, cognitive restructuring involves identifying the role of thoughts in generating and maintaining emotions. The clinician encourages the patient to view these thoughts as “hypotheses” as opposed to fact, which allows the beliefs to be questioned and challenged. This is where the detailed recordings produced by self-monitoring are helpful. By discussing what the patient has recorded for the relationship between physiological arousal and thoughts/behaviors, the clinician can help the patient restructure the maladaptive thought processes to more positive thought processes, which in return, helps to reduce fear and anxiety.
认知重构。认知重构，或识别认知错误并用更合适的思想替代的能力，可能是除了暴露疗法之外，对恐慌症 CBT 治疗最有效的一部分。正如之前所述，认知重构涉及识别思想在产生和维持情绪中的作用。临床医生鼓励患者将这些思想视为“假设”而不是事实，这允许质疑和挑战信念。这就是自我监测产生的详细记录有帮助的地方。通过讨论患者记录的生理唤醒与思想/行为之间的关系，临床医生可以帮助患者重构不适应的思想过程，使其更加积极，从而有助于减少恐惧和焦虑。

Exposure*.* As discussed in detail in the specific phobia section, the patient is next encouraged to engage in a variety of exposure techniques such as in vivo exposure and interoceptive exposure, while also incorporating the cognitive restructuring and relaxation techniques previously learned to reduce and eliminate ongoing distress. ** Interoceptive exposure **involves inducing panic-specific symptoms to the individual repeatedly for a prolonged period, so that maladaptive thoughts about the sensations can be disconfirmed and conditional anxiety responses are extinguished (Craske & Barlow, 2014). Some examples of these exposure techniques include spinning a patient repeatedly in a chair to induce dizziness and breathing in a paper bag to cause hyperventilation. These treatment approaches can be presented gradually; however, the patient must endure the physiological sensations for at least 30 seconds to 1 minute to ensure adequate time for applying cognitive strategies to misappraisal of cognitive symptoms (Craske & Barlow, 2014).
暴露。如特定恐惧症部分详细讨论的那样，接下来鼓励患者参与各种暴露技术，如体内暴露和内感受暴露，同时结合之前学到的认知重构和放松技巧，以减少和消除持续的痛苦。内感受暴露涉及反复诱导个体出现恐慌特异性症状，以长时间持续，从而使对感觉的适应性不良性思维得到否定，条件性焦虑反应被消除（Craske & Barlow，2014）。这些暴露技术的例子包括反复在椅子上旋转患者以引起眩晕和将呼吸吸入纸袋中以引起过度换气。这些治疗方法可以逐渐呈现；然而，患者必须忍受至少 30 秒到 1 分钟的生理感觉，以确保有足够的时间应用认知策略来错误评估认知症状（Craske & Barlow，2014）。

Interoceptive exposure is continued both in and outside of treatment until panic symptoms remit. Over time, the habituation of fear within an exposure session ultimately leads to habituation across treatment and long-term remission of panic symptoms (Foa & McNally, 1996).  Occasionally, panic symptoms will return in individuals who report complete remission of panic disorder. Follow-up booster sessions reviewing the steps above are generally effective in eliminating symptoms again.
内观暴露在治疗内外持续进行，直至恐慌症状缓解。随着时间的推移，暴露会话中恐惧的习得最终导致治疗过程中的习得，并长期缓解恐慌症状（Foa & McNally，1996）。偶尔，报告完全缓解恐慌症的患者恐慌症状会再次出现。回顾上述步骤的后续加强会话通常有效于再次消除症状。

**     7.5.5.2. Pharmacological interventions. **According to Craske & Barlow (2014), nearly half of patients with panic disorder present to psychotherapy already on medication, likely prescribed by their primary care physician. Some researchers argue that anti-anxiety medications impede the progress of CBT treatment as the individual is not able to fully experience the physiological sensations during exposure sessions, thus limiting their ability to modify maladaptive thoughts and maintaining the panic symptoms. Results from large clinical trials suggest *no advantage *during or immediately after treatment of combining CBT and medication (Craske & Barlow, 2014). Additionally, when the medication was discontinued post-treatment, the CBT+ medication groups fared worse than the CBT treatment-only groups, thus supporting the theory that immersion in interoceptive exposure is limited due to the use of medication. Therefore, it is suggested that medications be reserved for those who do not respond to CBT therapy alone (Kampman, Keijers, Hoogduin & Hendriks, 2002).
7.5.5.2. 药物干预。根据 Craske 和 Barlow（2014）的研究，近一半患有恐慌症的病人已经在接受心理治疗时开始服用药物，这些药物很可能是他们的初级保健医生所开具。一些研究人员认为，抗焦虑药物会阻碍认知行为治疗（CBT）的进展，因为个体在暴露治疗期间无法充分体验生理感觉，从而限制了他们修改不适应思维和维持恐慌症状的能力。大型临床试验的结果表明，在治疗期间或治疗结束后，结合 CBT 和药物没有优势（Craske & Barlow，2014）。此外，在治疗后停止服用药物时，CBT+药物组的表现不如仅接受 CBT 治疗的组，从而支持了由于使用药物而限制内观暴露沉浸的理论。因此，建议将药物保留给那些仅接受 CBT 治疗无反应的人（Kampman，Keijers，Hoogduin & Hendriks，2002）。

Key Takeaways 关键要点

You should have learned the following in this section:
您应该在本节中学到以下内容：

  • Treatment options for generalized anxiety disorder include benzodiazepines, rational-emotive therapy, CBT, and biofeedback.
    治疗广泛性焦虑症的方法包括苯二氮䓬类药物、理性情绪疗法、认知行为疗法和生物反馈。
  • Treatment options for specific phobias include exposure treatments such as systematic desensitization, flooding, and modeling.
    针对特定恐惧症的治疗方案包括暴露疗法，如系统脱敏、冲击疗法和模仿疗法。
  • Treatment options for agoraphobia include exposure and CBT techniques.
    治疗广场恐怖症的方法包括暴露疗法和认知行为疗法技术。
  • Treatment options for social anxiety disorder include exposure treatment, social skills training, and cognitive restructuring.
    社交焦虑症的治疗方案包括暴露疗法、社交技能训练和认知重构。
  • Treatment options for panic disorder include CBT, psychoeducation, self-monitoring, relaxation training, cognitive restructuring, exposure, and pharmacological interventions.
    治疗惊恐障碍的方案包括认知行为疗法（CBT）、心理教育、自我监控、放松训练、认知重构、暴露疗法和药物治疗。

Section 7.5 Review Questions
第 7.5 节复习问题

  1. Discuss the types of exposure treatments for individuals with anxiety disorders? Which are most effective? What have been some concerns with exposure treatment?
    讨论焦虑障碍个体的暴露治疗方法类型？哪些最有效？暴露治疗有哪些担忧？
  2. What is biofeedback? How is biofeedback used to treat anxiety related disorders?
    什么是生物反馈？生物反馈是如何用于治疗焦虑相关疾病的？
  3. What are the concerns with using pharmacological interventions in the treatment of anxiety disorders? Is there a time when it is helpful to use this treatment method?
    使用药物治疗焦虑症有哪些担忧？何时使用这种治疗方法是有帮助的？

Module Recap 模块总结

Module 7, the first module of Unit 3, covered the topic of anxiety disorders. This discussion included generalized anxiety disorder, specific phobias, agoraphobia, social anxiety disorder, and panic disorder. As with other modules in this book, we discussed the clinical presentation, epidemiology, comorbidity, and etiology of the anxiety disorders. Treatment options included biological, psychological, and sociocultural options. In Module 8, we will discuss somatic symptom and related disorders.
模块 7，第三单元的第一个模块，涵盖了焦虑障碍的主题。本讨论包括广泛性焦虑障碍、特定恐惧症、广场恐惧症、社交焦虑障碍和惊恐障碍。与其他本书中的模块一样，我们讨论了焦虑障碍的临床表现、流行病学、共病和病因。治疗选择包括生物、心理和社会文化选项。在模块 8 中，我们将讨论躯体症状及相关障碍。

3rd edition  第 3 版

Source: https://opentext.wsu.edu/abnormal-psych/chapter/module-7-anxiety-disorders/