Anxiety and Related Disorders

How does DSM/clinical psychology distinguish ANXIETY from FEAR?

Anxiety = apprehension over an anticipated (future) problem, involving moderate arousal.

Fear = a reaction to immediate danger, involving higher autonomic arousal.

What adaptive response does FEAR trigger, and what system drives it?

The fight-or-flight response — rapid changes in the sympathetic nervous system that prepare the body for escape or combat.

List the adaptive functions of ANXIETY.

Helps notice & plan for future threats; increases preparedness

Describe the relationship between anxiety level and performance (inverted-U).

No anxiety = underpreparedness; moderate anxiety = adaptive/performance-enhancing (inverted-U curve); excessive anxiety = detrimental to performance.

When does anxiety/fear become PATHOLOGICAL (a disorder)?

When it is excessive, persistent, and causes significant impairment or distress.

What are the GENERAL DSM-5 criteria shared by all anxiety disorders?

• Symptoms interfere with functioning or cause marked distress

• Consistant

• Persist ≥ 6 months (except panic disorder → 1 month minimum)

• Out of proportion

• Avoidance of stimuli

What is the minimum duration requirement for PANIC DISORDER vs other anxiety disorders?

Panic disorder requires only 1 month minimum; all other anxiety disorders require 6 months.

Summarize the prevalence facts about anxiety disorders. (Gender rates, Onset and overall disorder prevalence)

• The most common psychological disorders

• Women > men

• Onset: Adolescence

DSM-5 criteria for specific phobia?

Marked fear or anxiety about a specific object or

situation

Key features of specific phobia (3).

• Person recognizes the fear as excessive
• May involve intense disgust in addition to fear
• Specific phobias are highly comorbid with one another

Define SOCIAL ANXIETY DISORDER.

A persistent, unrealistically intense fear of social situations involving potential scrutiny by others.

How does social anxiety disorder differ from ordinary shyness?

Involves intense shame and humiliation that is more severe and longer-lasting than shyness

Comorbidity of social anxiety disorder?

Highly comorbid with avoidant personality disorder.

Define PANIC DISORDER.

Recurrent, unexpected panic attacks PLUS ≥ 1 month of ongoing worry about future attacks or behavioral changes due to the attacks.

What is a PANIC ATTACK and how many symptoms are required?

A sudden attack of intense apprehension, terror, and impending doom, accompanied by 4 or more physical/cognitive symptoms.

Name the cognitive/dissociative symptoms of a panic attack. (Define Depersonalization and derealization)

Depersonalization (feeling outside one’s body); derealization (world feels unreal); fear of losing control, going crazy, or dying.

How quickly do panic attack symptoms peak?

Within 10 minutes.

Why is a panic attack described as a “misfire of the fear system”?

Physiological arousal matches a real threat, but there is no external trigger / no real danger.

DSM-5 criteria for agoraphobia (how many situations & which)?

Marked fear or anxiety about 2 (or more) situations → where it would be difficult to escape or receive help (This is the worry)

Key facts about agoraphobia (leaving home, panic, DSM status).

• Many sufferers are virtually unable to leave home
• About half also experience panic attacks
• Recognized as a distinct disorder only in DSM-5 (previously seen as secondary to panic disorder)

DSM-5 criteria for GAD (frequency + associated symptoms).

• Excessive uncontrollable worry ≥ 50% of days about multiple life areas;

• Associated with 3 or more: restlessness/on edge, easy fatiguability, difficulty concentrating/mind going blank, irritability, muscle tension, sleep disturbance.

What is “worry” in GAD?

The cognitive tendency to chew on a problem without resolution — being unable to find a solution.

What is the gender difference in anxiety disorders?

Women are twice as likely as men to develop anxiety disorders and experience more functional impairment.

List explanations for the higher rate of anxiety disorders in women.

• More willing to report symptoms
• Men face more social pressure to confront fears (acts as exposure)
• Women have higher rates of childhood/adult sexual trauma (undermines control)
• Greater biological reactivity to stress
• Socialization differences in perceived control

How does culture + setting influence anxiety?

• Culture shapes what people come to fear (e.g., living near a volcano → fear lava).

• Setting (medical vs psychological clinic) can influence somatic vs psychological symptom expression.

Which regions show higher anxiety disorder prevalence?

Countries with recent war/revolution/persecution show higher rates; Europe & the US have higher overall prevalence than most other regions.

Explain Mowrer’s TWO-FACTOR MODEL of fear (1947).

Step 1 – Classical conditioning: neutral stimulus (CS) paired with aversive stimulus (UCS) → conditioned fear (CR).
Step 2 – Operant conditioning: avoiding the CS is negatively reinforced (reduces fear), which prevents extinction.

What are the limitations of the original two-factor model?

• Many people with anxiety disorders cannot recall a conditioning experience
• Many people who experience threatening events do NOT develop anxiety disorders

Three ways classical conditioning of fear can occur (model extensions).

Direct experience (personal exposure); Modeling (observing others); Verbal instruction (being told something is dangerous).

Three ways people with anxiety disorders differ in fear conditioning.

1) Acquire conditioned fears more readily (lower threshold)
2) Sustain conditioned fears longer (slower extinction)
3) More reactive to unpredictable threats

What does the NPU (Neutral-Predictable-Unpredictable) Threat Task show?

People with anxiety disorders show elevated psychophysiological arousal during unpredictable threat vs controls.

State evidence for heritability of anxiety disorders?

Heritability of 50–60%. Offspring of affected parents show slower extinction of conditioned fears.

Role of the AMYGDALA in the fear circuit?

Assigns emotional significance to stimuli; critical for fear conditioning.

Role of the MEDIAL PREFRONTAL CORTEX (mPFC) in the fear circuit? What is the activity level in anxiety disorders?

Regulates amygdala activity; involved in fear extinction & emotion regulation; underactive in anxiety disorders.

What does the amygdala–mPFC connectivity deficit cause?

Deficient connectivity may interfere with effective regulation and extinction of anxiety.

Which neurotransmitters are implicated in anxiety disorders and how?

GABA – modulates amygdala/fear circuit; reduced functioning.
Serotonin – modulates emotions; disrupted levels.
Norepinephrine – key to fight-or-flight; increased activity & receptor sensitivity.

What HPA-axis finding predicts onset of anxiety disorders?

Elevated Cortisol Awakening Response (CAR) in adolescents predicted onset of anxiety disorders

What is BEHAVIORAL INHIBITION and what does it predict?

A trait visible in infants as young as 4 months: agitation/crying to novel stimuli. Especially predicts social anxiety disorder

What is NEUROTICISM and its link to anxiety?

A trait marked by frequent/intense negative affect; predicts onset of both anxiety disorders and depression

Cognitive factor: how do sustained negative beliefs + SAFETY BEHAVIORS maintain anxiety?

• People expect bad outcomes (e.g., “racing heart = I’m dying”).

• Safety behaviors prevent disconfirmation of negative beliefs, maintaining the disorder.

Cognitive factor: how does PERCEIVED LACK OF CONTROL relate to anxiety?

• Less sense of control → higher risk.

• (Insel monkeys: no control → more anxious.)

Cognitive factor: describe ATTENTION BIAS TO THREAT and its evidence.

• People selectively attend to threatening cues;

• bias is automatic & preconscious.

Cognitive factor: what is INTOLERANCE OF UNCERTAINTY?

Difficulty accepting ambiguity raises anxiety risk

Etiology of specific phobias — main model

Primarily the two-factor conditioning model.

What is PREPARED LEARNING (Seligman, 1971)?

Evolution has “prepared” humans to readily learn fears of evolutionarily significant stimuli (heights, snakes, angry faces).

Cognitive factors in the etiology of social anxiety disorder.

• Harsh self-evaluations;

• excessive internal focus

• overestimate how much they blush/stumble even when unnoticed.

Neurobiological etiology of panic disorder.

The locus coeruleus (major norepinephrine source) is central; norepinephrine surges → sympathetic activation → panic-like symptoms. Drugs stimulating the locus coeruleus can trigger attacks.

What is INTEROCEPTIVE CONDITIONING in panic disorder?

Panic attacks become classically conditioned to internal bodily sensations of arousal (e.g., slight dizziness triggers panic).

Explain CATASTROPHIC MISINTERPRETATION (cognitive model of panic).

Normal bodily sensations are interpreted as signs of impending doom (racing heart = heart attack) → more fear → more sensations → vicious cycle.

What is the ANXIETY SENSITIVITY INDEX and what does it predict?

Measures fear of bodily sensations; predicts onset of panic attacks and anxiety disorders.

What is the FEAR-OF-FEAR HYPOTHESIS (agoraphobia)?

Agoraphobia is driven by catastrophic negative beliefs about experiencing anxiety in public (e.g., “I’ll go crazy,” “I’ll lose control”).

Explain the CONTRAST AVOIDANCE MODEL of GAD

• People with GAD find sudden shifts in emotion especially aversive.

• Chronic worry maintains a steady (if uncomfortable) negative state, preventing sudden emotional surges.

What is the cornerstone psychological treatment for all anxiety disorders?

Exposure therapy

Two key principles of exposure therapy to prevent relapse.

1) Include as many features of the feared object as possible (e.g., different spiders/features).
2) Conduct exposure in multiple different contexts.

List additional (non-classic) psychological approaches for anxiety.

• Mindfulness/acceptance-based (comparable to CBT in GAD & mixed anxiety)
• Virtual reality exposure (comparable to in vivo)
• Internet-based CBT (best with some therapist involvement)

Disorder-specific treatment: SPECIFIC PHOBIAS.

In vivo exposure to feared objects

Disorder-specific treatment: SOCIAL ANXIETY DISORDER.

Exposure (role play & small groups before public situations); social skills training

Disorder-specific treatment: PANIC DISORDER.

Interoceptive exposure → so they are learned as harmless

Plus cognitive techniques challenging catastrophic thoughts.

Disorder-specific treatment: AGORAPHOBIA.

Systematic graded exposure to feared places (starting short distances from home);

partner involvement → enhance outcomes

Disorder-specific treatment: GENERALIZED ANXIETY DISORDER.

Relaxation training

What are the two main medication classes (anxiolytics) for anxiety disorders?

Benzodiazepines and Antidepressants

Profile of BENZODIAZEPINES for anxiety.

Rapid relief but highly addictive; significant withdrawal

Profile of ANTIDEPRESSANTS for anxiety.

First-line medications; SSRIs/SNRIs

Which medications are first-choice and why are benzodiazepines avoided?

SSRIs/SNRIs (antidepressants) are first-choice; benzodiazepines are avoided due to addiction risk and side effects.

Why is psychological treatment generally preferred over medication?

Relapse is common once medication is stopped, and CBT & medication show comparable efficacy

In what anxiety disorder do medication and psychological treatment equivalent

GAD — medication & psychological treatment are roughly equivalent.

What does the behavioral part of exposure therapy do? (Explain why it works)

Behavioral: exposure does NOT erase fear memories (they can resurface);

Promotes extinction = learning new associations that inhibit the fear.

What does the cognitive mechanism of exposure therapy do? (Explain why it work)

Cognitive: exposure corrects mistaken beliefs — people learn they can tolerate the stimulus without losing control.

If people with agoraphobia can endure two situations only with a companion given that the fear help or escape would not be possible, would it still count as a diagnosis?

Yes, they simply have to show: Avoidance, distress, or require presence of companion

Are the results from NPU specific to anxiety disorders?

Yes

When is the amygdala hyperactive in anxiety disorders?

hyperactive in anxiety disorders when viewing threat cues (e.g., angry faces).

How do fears of prepared stimuli relate to conditioning?

Fears of prepared stimuli are more sustained after conditioning; others fade faster.