4th edition as of August 2026

 

Module Overview

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 to 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).

 

Module Outline

• • 7.1. Clinical Presentation

• • 7.2. Epidemiology

• • 7.3. Comorbidity

• • 7.4. Etiology

• • 7.5. Treatment

 

Module Learning Outcomes

• Describe how anxiety disorders present.
• Describe the epidemiology of anxiety disorders.
• Describe comorbidity in relation to anxiety disorders.
• Describe the etiology of anxiety disorders.
• Describe treatment options for anxiety disorders.

 

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7.1. Clinical Presentation

 

Section Learning Objectives

• Describe how generalized anxiety disorder presents.
• Describe how specific phobia presents.
• Describe how agoraphobia presents.
• Describe how social anxiety disorder presents.
• Describe how panic disorder presents.

 

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.

 

7.1.1. Generalized Anxiety Disorder

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).

 

7.1.2. Specific Phobia

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).

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).

 

7.1.3. Agoraphobia

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.

 

7.1.4. Social Anxiety Disorder

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.

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.

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.

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.

 

7.1.5. Panic Disorder

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.

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).

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.

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).

 

 

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7.2. Epidemiology

 

Section Learning Objectives

• Describe the epidemiology of generalized anxiety disorder.
• Describe the epidemiology of specific phobia.
• Describe the epidemiology of agoraphobia.
• Describe the epidemiology of social anxiety disorder.
• Describe the epidemiology of panic disorder.

 

7.2.1. Generalized Anxiety Disorder

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).

 

7.2.2. Specific Phobia

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.

 

7.2.3. Agoraphobia

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%.

 

7.2.4. Social Anxiety Disorder

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

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.

 

 

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7.3. Comorbidity

 

Section Learning Objectives

• Describe the comorbidity of generalized anxiety disorder.
• Describe the comorbidity of specific phobia.
• Describe the comorbidity of agoraphobia.
• Describe the comorbidity of social anxiety disorder.
• Describe the comorbidity of panic disorder.

 

7.3.1. Generalized Anxiety Disorder

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).

 

7.3.2. Specific Phobia

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).

 

7.3.3. Agoraphobia

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).

 

7.3.4. Social Anxiety Disorder

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.

 

7.3.5. Panic disorder

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).

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.

 

 

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7.4. Etiology

 

Section Learning Objectives

• Describe the biological causes of anxiety disorders.
• Describe the psychological causes of anxiety disorders.
• Describe the sociocultural causes of anxiety disorders.

 

7.4.1. Biological

            7.4.1.1. Biological – Genetic influences. Research consistently demonstrates that anxiety disorders have a significant genetic component; however genetic vulnerability alone does not determine whether an individual develops an anxiety disorder. Current models emphasize the gene-environment interaction, in which genetics and inherited vulnerabilities combine with stressful life experiences, developmental factors and environmental influences increase risk for anxiety symptoms (Meier & Deckert, 2019).

Early genetic research focused on individual genes, specifically the serotonin transporter gene (5-HTTLPR) which was believed to influence serotonin regulation and emotional reactivity (REF). While initial studies found associations between mutation of the 5-HTTLPR gene and an increase in anxiety-related personality traits, more recent research suggests that anxiety disorders are influenced by many genes of small effect rather than a single gene mutation (Gottschalk & Domschke, 2017; Lindholm et al., 2020). Additional research suggests that environmental experiences may influence genetic expression through epigenetic mechanisms, meaning stressful experiences can alter how genes involved in stress regulation are expressed without changing the underlying DNA sequence (Meier & Deckert, 2019).

            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 plays a role in detecting potential threats, assigning emotional significance to stimuli and initiating physiological responses associated with fear (Babaev et al., 2018). When a threat or fearful situation is detected, the amygdala activates stress response systems, including the hypothalamic-pituitary-adrenal (HPA) axis, resulting in release of stress hormones that prepare the body for immediate action (Tafet & Nemeroff, 2020).  The amygdala also activates 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. Individuals with anxiety disorders often demonstrate increased amygdala reactivity combined with reduced prefrontal regulation, resulting in heightened threat sensitivity and difficulty reducing fear responses once activated (Tafet & Nemeroff, 2020).

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 public (Gorman et al., 2000). However, panic disorder cannot be explained by norepinephrine activity alone. More recent research emphasizes the involvement of a broader neurobiological network, including the amygdala, insula, hippocampus and prefrontal cortex (Kyriakoulis & da Rocha Freire, 2025). Additionally, heightened sensitivity to internal bodily sensations (interoception) may contribute to panic symptoms by increasing the likelihood that normal physiological changes are interpreted as threatening (Jenkinson et al., 2024).

 

 7.4.2. Psychological

            7.4.2.1. Psychological – Cognitive. The cognitive perspective on the development of anxiety related disorders centers around maladaptive information processing patterns that influence how individuals interpret and respond to potential threats. More specifically, individuals with anxiety disorders often demonstrate cognitive biases characterized by overestimating danger, underestimating their ability to cope, and selectively attending to threatening information (Bredemeier & Berenbaum, 2020). These negative appraisals, in combination with a biological predisposition to anxiety, likely contribute to the development of anxiety symptoms (Gallagher et al., 2013).

A key component of contemporary cognitive models is threat appraisal. Individuals with anxiety disorders often interpret ambiguous situations as threatening and may engage in excessive worry or avoidance to reduce distress (Britton et al., 2011). Additionally, intolerance of uncertainty, or the tendency to view uncertain situations as unacceptable or threatening, has been identified as an important cognitive vulnerability across multiple anxiety disorders (Carleton, 2016; Milne et al., 2019). These cognitive processes may maintain anxiety by reinforcing avoidance behaviors and preventing individuals from learning that feared outcomes are often unlikely.

Cognitive models specific to panic disorder emphasize the role of catastrophic misinterpretation of physiological sensations. Individuals with panic disorder may experience normal bodily sensations—such as increased heart rate, dizziness, or shortness of breath—but interpret them as signs of imminent danger (Clark, 1986). These interpretations increase fear and physiological arousal, creating a feedback loop in which anxiety intensifies the sensations that are being feared.

Anxiety sensitivity, of the fear of anxiety-related sensations themselves, may also be a risk factor for panic disorder. Individuals high in anxiety sensitivity may be more likely to interpret normal physiological changes as dangerous, increasing vulnerability to panic symptoms (Kyriakoulis & Kyrios, 2023).

Social Anxiety Disorder is also primarily explained by cognitive theorists. Individuals with social anxiety disorder tend to hold unattainable or extremely high social beliefs regarding social evaluation, including assumptions that they must perform perfectly or that mistakes will lead to rejection or humiliation (Rozen & Aderka, 2023). These beliefs contribute to increased self-focused attention rather than focusing on the interaction itself. Additionally, anticipation of negative social interactions leads to safety behaviors, such as avoiding eye contact, rehearsing statements, or limiting social interactions to avoid social encounters and prevent embarrassment (Evans et al., 2021). Individuals with social anxiety disorder will also evaluate the social interaction after it has taken place, often obsessively reviewing the details, focusing on perceived mistakes, which reinforces negative beliefs about future social situations.

            7.4.2.2. Psychological – Behavioral. The behavioral perspective explains anxiety as a learned response that develops through interactions between environmental experiences and learning processes. While behavioral theories are particularly useful for understanding specific phobias and social anxiety disorder, learning principles also contribute to the development and maintenance of other anxiety disorders. According to respondent conditioning – a previously neutral stimulus can become associated with fear after being paired with an aversive or threatening event (see Module 2 for a more detailed explanation of respondent conditioning).

One of the earliest demonstrations of respondent conditioning was Watson and Rayner’s (1920) infamous Little Albert experiment in which Little Albert developed a fear of white rats by repeatedly pairing a white rat with a loud sound. This experiment, although lacking ethical standards, was groundbreaking in the development of learned behaviors. Since then, 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 acquisition of fear (Sturmey et al., 2020).

Behavioral theorists also emphasize operant conditioning in maintaining anxiety disorders. Avoidance behaviors temporarily reduce fear and distress, making individuals more likely to continue avoid feared situations in the future. This process, known as negative reinforcement, prevents individuals from learning that the feared stimulus is often safe or less threatening than anticipated, therefore, maintaining anxiety over time (Craske et al., 2014.

            7.4.2.3. Psychological – In addition to direct learning experiences, anxiety can develop through observational learning (modeling). 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 learn to respond with similar fear, even without experiencing a negative event themselves (Askew & Field, 2008; Szczepanik et al., 2020). Likewise, observing another individual being criticized or rejected in a social situation may increase one’s own fear of negative evaluation and contribute to the development of social anxiety disorder. Individuals may also acquire fears through verbal or informal learning, such as repeatedly being told that certain situations are dangerous or hearing about traumatic experiences (Field & Purkis, 2011).

Behavioral theories also emphasize that anxiety disorders are maintained through avoidance behaviors, which temporarily reduce fear and distress, providing immediate relief and negatively reinforcing behavior. Although the short-term reduction in anxiety is rewarding, it prevents individuals from learning that the feared object or situation is often safe or less threatening. As a result, avoidance strengthens anxiety over time and contributes to the persistence of many anxiety disorders (Craske et al., 2014).

Early behavioral therapists propose that stimulus generalization, or the tendency for the conditioned stimulus to evoke similar responses to other stimuli, could explain how fears broaden over time. For example, an individual who develops a fear of one aggressive dog may later become fearful of all dogs, or even other animals. While research supports the role of stimulus generalization in fear response, GAD is viewed as resulting from a more complex interaction among learning experiences, genetic vulnerability, cognitive biases, and difficulties tolerating uncertainty rather than stimulus generalization alone (Craske et al., 2017; Dymond et al., 2015).

 

7.4.3. Sociocultural

Although biological and psychological factors contribute substantially to anxiety disorders, social and environmental influences also play an important role in determining who develops anxiety and how symptoms are maintained. Chronic stressors such as poverty, financial insecurity, neighborhood violence, adverse childhood experiences, and exposure to traumatic events have all been associated with an increased risk for developing anxiety disorders (Holly, 2024).

            7.4.3.1. Gender. As previously discussed, anxiety disorders are diagnosed approximately twice as often in women as in men, a pattern that emerges during adolescence and persists through adulthood (Craske et al., 2017). This difference is unlikely to be explained by a single factor. Instead, researchers propose that biological influences interact with psychological and sociocultural factors, placing women at an increased risk for anxiety related symptoms. Compared to men, women are more likely to experience certain forms of interpersonal trauma, including sexual assault and intimate partner violence, both of which increased risk for anxiety disorders (Craske et al., 2017). Additionally, women often experience unique stressors related to caregiving responsibilities, gender-based discrimination, and societal expectations, all of which may contribute to chronic stress and anxiety (Howard et al., 2024; Stall et al., 2023).

            7.4.3.2. Discrimination and Minority Stress. Experiences of discrimination, prejudice, and social exclusion are associated with increased anxiety symptoms. Chronic exposure to racism, sexism, homophobia, ableism, and other forms of discrimination can create ongoing psychological stress that contributes to hypervigilance, fear, and emotional distress. According to the minority stress model, individuals from marginalized groups experience unique chronic stressors in addition to everyday life stress, increasing their vulnerability to anxiety and other mental health disorders (Frost & Meyer, 2023). Repeated experiences of discrimination and prejudice may also lead individuals to avoid certain social situations or environments, reinforcing anxiety and limiting opportunities to experience positive interactions.

 

 

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7.5. Treatment

 

Section Learning Objectives

• Describe treatment options for generalized anxiety disorder.
• Describe treatment options for specific phobia.
• Describe treatment options for agoraphobia.
• Describe treatment options for social anxiety disorder.
• Describe treatment options for panic disorder.

 

7.5.1. Generalized Anxiety Disorder

            7.5.1.1. Psychopharmacology. Benzodiazepines, a class of sedative-hypnotic medications, were wildly prescribed for anxiety disorders because of their rapid onset of action and effectiveness in reducing acute anxiety symptoms. Although they are generally safer than the barbiturates they replaced, benzodiazepines can produce adverse effects including impaired coordination, cognitive slowing, tolerance, physical dependence, and withdrawal symptoms, particularly with long-term use. For these reasons, current clinical guidelines recommend benzodiazepines for short-term treatment or as an adjunct while longer-acting treatments begin to take effect (Bandelow, 2020).

Due to these negative effects, selective serotonin-reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are considered to be first-line pharmacological treatment for those with anxiety disorders (Bandelow, 2020; Katzman et al., 2014). Clinical trials and meta-analyses indicate approximately 50-60% of patients experience a positive response rate with these psychopharmacological interventions, although response varies across individuals and anxiety disorders (Slee et al., 2019).

While medications can substantially reduce anxiety symptoms, relapse is common after treatment is discontinued, particularly without accompanying psychotherapy. Consequently, cognitive-behavioral therapy (CBT) is often recommended either alone or in combination with medication because it provides individuals with long-term coping skills that may reduce the likelihood of relapse (Bandelow, 2020).

            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 emotional distress is influenced not simply by life events themselves, but by the irrational beliefs individuals hold about those events. These maladaptive beliefs often contribute to persistent anxiety, depression, and other forms of psychological distress. The primary goal of rational emotive therapy is to identify irrational, self-defeating assumptions, evaluate the evidence supporting those beliefs by challenging the rationality of those assumptions, and to replace them with new, more productive thoughts and feelings. As individuals develop healthier cognitive patterns, they often experience reductions in anxiety symptoms and improvements in emotional functioning (David et al., 2018).

            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. Numerous randomized controlled trials and meta-analyses have demonstrated that CBT produces moderate to large reductions in anxiety symptoms, with many individuals maintaining these improvements months to years after treatment (Cuijpers et al., 2014; Carpenter et al., 2018). Current clinical practice guidelines recommend CBT as a first-line treatment for GAD, either alone or in combination with medication (Bandelow et al., 2023).

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 (Carpenter et al., 2018).

            7.5.1.4. Biofeedback. Biofeedback is a therapeutic technique that helps individuals learn to regulate physiological processes with stress and anxiety by providing real-time information about their bodily responses. During biofeedback training, sensors measure specific physiological signals and provide immediate feedback through visual, auditory or digital displays. By observing these physiological changes, individuals learn to develop greater control over responses that are typically automatic such as muscle tension, heart rate, and breathing patterns.

There are several forms of biofeedback used in clinical practice. Electromyography (EMG) measures muscle activity by placing electrodes on the skin above a muscle group. 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. During treatment, clinicians often combine biofeedback with relaxation techniques such as diaphragmatic breathing, progressive muscle relaxation, or mindfulness exercises. The goal is not to just reduce physiological arousal in the moment, but to also help individuals recognize early signs of stress and develop greater control over their physiological responses. Research on the use of biofeedback in individuals with anxiety suggest biofeedback is more superior to wait list, it has not been shown to be superior to other active psychological treatments (Tolin et al., 2020).

7.5.2. Specific Phobias

            7.5.2.1. Exposure treatments. While there are many treatment options for specific phobias, research routinely supports exposure-based therapies as the most effective treatment strategies (Parker et al., 2018). Based on behavioral theories, phobias are understood as learned fear responses that are maintained through avoidance. Avoidance provides immediate relief from anxiety, thus negatively reinforcing the behavior and preventing individuals from learning that the feared object or subject is less dangerous than anticipated. The goal of exposure therapy is to reduce the maladaptive fear response by helping individuals gradually and repeatedly encounter feared stimuli while learning that anxiety can decrease without avoidance or escape behaviors (Craske et al., 2014). Exposure treatments are based on inhibitory learning theory, which suggests that exposure does not erase the original fear association, but rather creates new learning that competes with the original fear memory. Therefore, through repeated exposure individuals learn to tolerate their anxiety, thus reducing fear responses over time (Craske et al., 2014).

Exposure-based treatments can be completed in several formats including in vivo exposure—direct exposure to the feared stimulus; imaginal exposure—imagining the feared stimulus, and virtual reality exposure—using computer-generated simulations of feared stimulus. In vivo has been shown to be the most effective approach, when possible, as it provides direct corrective experiences; however, imaginal and virtual reality exposures can be valuable treatment options, particularly when direct exposure is unsafe or difficult to create (Parker et al., 2018; Van Loenen et al., 2022).

Exposure treatment almost always involves graduated exposure. In this approach, the individual works with the clinician to develop a fear hierarchy which is a list of feared situations ranging from least distressing to most distressing. The individual then gradually encounters items on the hierarchy while practicing coping skills and remaining in contact with the feared stimulus long enough to experience new learning. While systematic desensitization was traditionally paired with exposure to teach individuals relaxation strategies to employ during exposure, recent research has focused more broadly on increasing tolerance of anxiety and developing new expectations about feared situations, rather than teaching the individual to reduce physiological responses to the feared stimulus (Craske et al., 2014).

Another exposure technique, flooding, does not utilize the gradual treatment approach, but rather, immediately exposes the individual to the feared stimulus. Although flooding can be effective, it is not often used as it causes high levels of distress and may increase treatment refusal or dropout.  

            7.5.2.2. Modeling. Exposure treatments may also incorporate modeling, where an individual observes another person interacting with the feared stimulus without experiencing negative consequences. Modeling can help individuals learn that the stimulus is safe and increase confidence in their ability to cope with the situation. This treatment approach is particularly useful for children and individuals who are initially unwilling to engage in direct exposure (Askew & Field, 2008).

 

7.5.3. Agoraphobia

Similar to the treatment approaches for specific phobias, exposure-based techniques are among the most effective treatment options for individuals with agoraphobia. Compared with specific phobias, treatment for agoraphobia can be more complex because symptoms often involve multiple feared situations, extensive avoidance patterns, and high rates of comorbidity with other anxiety disorders, particularly panic disorder. When panic symptoms are present, treatment typically incorporates cognitive strategies to address catastrophic interpretations of bodily sensations along with exposure exercises targeting both internal sensations and avoided situations (Barlow et al., 2017).

For individuals with agoraphobia, CBT with exposure is considered the first-line psychological treatment. Treatment generally includes psychoeducation about anxiety, cognitive restructuring of fearful beliefs, gradual exposure to avoided situations, and relapse-prevention strategies. Although many individuals experience improvement with these strategies, some continue to experience residual avoidance or anxiety symptoms following treatment, highlighting the importance of continued treatment (Craske & Barlow, 2022).

 

7.5.4. Social Anxiety Disorder

            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. As discussed previously, research emphasizes inhibitory learning, in which the individual develops new associations and beliefs about social situations rather than simply waiting for anxiety to decrease (Craske et al., 2014). During treatment, the clinician works with the individual to identify feared social situations and develop a hierarchy of increasingly challenging exposures. These exposures may include initiating conversations, speaking in front of others, making phone calls, ordering food, or even participating in unfamiliar social settings.

In addition to real-world exposure, the clinician may use behavioral experiments, in which patients test specific predictions about social interactions. For example, “If I make a mistake, everyone will laugh at me.” Repeated exposure to these behavioral experiments helps the individual reduce avoidance, increase confidence, and develop more realistic expectations about social interactions (Bandelow et al., 2017).

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

            7.5.4.3. Cognitive restructuring. Cognitive restructuring is a key component of CBT for social anxiety disorder. Individuals with SAD often engage in distorted interpretations of social situations, including overestimating the likelihood of rejection, assuming others are evaluating them negatively, and underestimating their ability to cope with social discomfort. During treatment, the clinician will work with the individual to identify and challenge these negative, automatic thoughts that contribute to the distress in social situations and replace them with more balanced interpretations (Van Dis et al., 2020).

 

7.5.5. Panic Disorder

            7.5.5.1. Cognitive Behavioral Therapy (CBT). CBT is considered one of the most effective treatment options for individuals with panic disorder. CBT for panic disorder typically includes several core components including psychoeducation, self-monitoring, cognitive restructuring, and exposure-based interventions (Craske & Barlow, 2022). Meta-analytic research indicates that CBT produces substantial reductions in panic symptoms, with many individuals experiencing long-term improvement (Papola et al., 2023).

Psychoeducation. Treatment begins by educating the individual 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, 2022). Individuals learn that panic symptoms represent an activation of the body’s natural threat system rather than evidence of immediate danger. 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.

Self-monitoring. Self-monitoring, or the act of observing and recording physical sensations through thoughts, emotions and behaviors, is essential to the CBT treatment process for panic disorder. By tracking panic symptoms, the individual is taught to identify patterns and becomes more aware of the relationship between bodily sensations, catastrophic interpretations and anxiety responses. This awareness provides the foundation for later CBT components including cognitive restructuring and exposure (Craske & Barlow, 2022).

Relaxation training. CBT may include relaxation strategies such as diaphragmatic breathing and progressive muscle relaxation to help individuals regulate physiological arousal. Current research suggests that these techniques should be used to promote overall emotional regulation rather than to immediately stop or avoid panic symptoms. Historically, relaxation strategies were used to address panic symptoms and prevent attacks, however, research has found that this strategy may inadvertently maintain anxiety by reinforcing the belief that bodily sensations are dangerous (Blakey & Abramowitz, 2016; Craske & Barlow, 2014).

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. Rather than accepting automatic thoughts as factual, individuals learn to evaluate the evidence supporting these beliefs and develop more realistic interpretations of their physical symptoms. By repeatedly testing these beliefs against actual experiences, individuals become less likely to catastrophize normal physiological sensations, reducing fear and anticipatory anxiety (Papola et al., 2023; Rabasco et al., 2023).

Exposure. As discussed in detail in the specific phobia section, exposure-based interventions are a central component of CBT for panic disorder. Interoceptive exposure involves intentionally inducing panic-specific symptoms, such as dizziness, increased heart rate, shortness of break, through structured exercises (e.g., spinning in a chair, running in place, or breathing through a straw).  The goal of this treatment approach is to help individuals learn through experience that these sensations, while uncomfortable, are not necessarily dangerous (Craske & Barlow, 2014).

In vivo exposure targets situations that individuals have begun to avoid because they fear having a panic attack, such as driving in a car, shopping, or being in crowded places. During exposure, individuals are encouraged to reduce safety behaviors and remain engaged with the experience long enough to test catastrophic predictions. As previously discussed, current research emphasizes the role of inhibitory learning, in which exposure creates new, corrective learning that competes with previous fear-based associations rather than erasing them. Through repeated practice, individuals develop greater confidence in their ability to tolerate panic-related sensations and experience significant reductions in panic symptoms over time (Craske et al., 2014).

            7.5.5.2. Pharmacological interventions. Many individuals begin psychological treatment while already taking medication. Current research identifies SSRIs and SNRIs as the first-line of pharmacological treatment for panic disorder because of their effectiveness and relatively favorable safety profiles (Bandelow et al., 2020; Craske & Barlow, 2022).

While CBT and medication are both effective treatment options for panic disorder, research indicates that CBT often produces more durable treatment gains after therapy has ended, whereas symptoms are more likely to recur following discontinuation of medication (Ziffra, 2021). A combination treatment approach may be beneficial for individuals with more severe symptoms or significant comorbid conditions, as well as those who are initially resistant to CBT/exposure-based treatment plans. Given this, treatment decisions should be individualized, assessing symptom severity, individual preference, previous treatment response, and access to evidence-based psychotherapy.

 

 

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Module Recap

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.

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End Module 7

4th edition as of August 2026