Chapter 6 - Anxiety Disorders

Anxiety

fear, worry, nervousness, stress

• mood state with marked negative affect and bodily symptoms of tension

• subjective sense of unease, apprehension of future danger

• future oriented mood state

Fear

emotion of immediate alarm as reaction to potential danger

• sympathetic nervous system

• immediate reaction to current danger

Worry

specific and rational state

Anxiety Disorders

characterized by excessive levels of fear or anxiety

• avoidance

• distress/impairement

Prevalence of anxiety disorders

• 31.1% lifetime prevalence

• more common in women

• genetic

• varying onset age

• culturally specific anxiety

Comorbidity

having more than 1 diagnosis at once

• common in anxiety disorders

• major depression - most common secondary diagnosis

Anxiety can be useful

• motivation

• react to bad situations

• increased physiological response

Types of anxiety disorders

• specific phobia

• panic disorder

• agoraphobia

• social anxiety

• selective mutism

• separation anxiety

• substance induced anxiety

• anxiety related to a medical condition

Characteristics of anxiety disorders

• affect: anxious, fearful

• cognitive: inability to concentrate

• behavioral: avoidance

• psychophysiological: sweating, shaking, heart racing

Specific Phobia

unreasonable fear of specific object or situation that interferes with daily life functioning

• 9%/yr

• onset in early childhood

• treatment: exposure therapy

Specific phobia symptoms

A. Marked fear or anxiety about a specific object or situation typically lasting for 6

months or more.

B. The phobic object or situation almost always provokes immediate fear or

anxiety

C. The phobic object is avoided or endured with intense fear or anxiety.

D. The fear or anxiety is out of proportion to the actual danger posed by the

specific object or situation, and to the sociocultural context.

E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

F. The fear, anxiety, or avoidance causes clinically significant distress or

impairment in social, occupational, or other important areas of functioning.

G. Rule Out: The disturbance is not better explained by the symptoms of

another mental disorder.

Panic Attack

abrupt experience of intense fear or discomfort with physical symptoms

• can be expected or unexpected

Panic attack symptoms

sweating, shaking, shortness of breath, high heart rate, nausea, numbness, dizziness, fear of death

Panic Disorder

severe, unexpected panic attacks sometimes accompanied by agoraphobia

• 5% lifetime prevalence

• more common in females

• onset: early adulthood

• treatments: SSRIs, benzodiazapines, psychosocial treatment 

Panic control treatments

exposure to panic attack symptoms, reducing worry cognitions

Panic disorder symptoms

A. Recurrent unexpected panic attacks are present. Four (or more) of the

following symptoms (look at symptoms on last slide) occur

B. At least one of the attacks has been followed by 1 month of more of one

or both of the following: a) persistent concern or worry about

additional panic attacks or their consequences or b) A significant

maladaptive change in behavior related to the attacks.

C. The disturbance is not attributable to the physiological effects of a

substance (e.g., a drug of abuse, a medication)

D. The disturbance is not attributable to another medical condition and is not

better explained by another mental disorder.

Agoraphobia 

fear/avoidance of situations viewed as unsafe

• often occurs with panic disorder

• avoidance used to cope with panic attacks

• dread about feared situations

Agoraphobia Symptoms

A. Marked fear or anxiety about two (or more) of the following five situations:

1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).

2. Being in open spaces (e.g., parking lots, marketplaces, bridges).

3. Being in enclosed places (e.g., shops, theaters, cinemas).

4. Standing in line or being in a crowd.

5. Being outside of the home alone.

B. The individual fears or avoids these situations because of thoughts that escape might be difficult or

help might not be available in the event of developing panic-like symptoms or other incapacitating

or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence).

C. The agoraphobic situations almost always provoke fear or anxiety.

D. The agoraphobic situations are actively avoided, require the presence of a companion, or are

endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations

and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The symptoms cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning. (Will always be

considered)

Rule Outs

H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s

disease) is present, the fear, anxiety, or avoidance is clearly excessive.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another

mental disorder

Panic disorder and agoraphobia statistics

• 2.7% per year

• more common in women

• onset: early adulthood

• nocturnal panic attacks common

Social Anxiety

extreme enduring fear and avoidance of social or performance situations

• fear of being negatively evaluated

• 2nd most common anxiety disorder

• equal between genders

• onset: adolescence/early adulthood

• precedes depression and other disorders

• on a spectrum

Social anxiety symptoms

A. Marked fear or anxiety about one or more social situations in which the

person is exposed to possible scrutiny by others, with the fear that one will

act in a way, or show anxiety symptoms, that will be negatively evaluated.

B. The individual fears that he or she will act in a way or show anxiety

symptoms that will be negatively evaluated (i.e., will be humiliating or

embarrassing; will lead to rejection or offend others).

C. The social situations almost always provoke fear or anxiety

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social

situation and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or

more

G. The symptoms cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning. (Will

always be considered)

Rule Outs

H. The fear, anxiety, or avoidance is not attributable to the physiological

effects of a substance

I. The fear, anxiety, or avoidance is not better explained by the

symptoms of another mental disorder

J. If another medical condition (e.g., inflammatory bowel disease,

Parkinson’s disease) is present, the fear, anxiety, or avoidance is

clearly excessive.

Social anxiety treatment

• CBT - incorporates feared situations to disprove automatic perceptions of danger

• SSRIs

Generalized anxiety disorder

characterized by intense, uncontrollable, unfocused, chronic, continuous worry that is distressing and unproductive about multiple areas of life

• physical symptoms: tenseness, irritability, restlessness

• 6% lifetime prevalence

• onset: adolescence

• more common in females

• less physiological stress response than other anxiety disorders

Generalized anxiety disorder symptoms

A. Excessive anxiety and worry (apprehensive expectation), occurring more

days than not for at least six months about a number of events or

activities (such as work or school performance).

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with at least three (or more) of the

following symptoms (with at least some symptoms present for more days

than not for the past 6 months):

1. restlessness or feeling keyed up or on edge,

2. being easily fatigued,

3. difficulty concentrating or mind going blank,

4. irritability,

5. muscle tension

6. sleep disturbance.

D. The anxiety, worry, or physical symptoms cause clinically significant

distress or impairment in social, occupational, or other important areas of

functioning.

Rule Out

E. The disturbance is not due to the direct physiological effects of a

substance (e.g., a drug of abuse, a medication)

F. The disturbance is not due to a general medical condition and is not better

explained by another mental disorder.

Influences on anxiety disorders

Mower’s 2 factor model - fear conditioning

behavioral influences on anxiety disorders

1. classical conditioning

        - learns to fear neutral stimulus when paired with intrinsically aversive stimuli

2. operant conditioning

        - gain relief by avoiding conditioned stimulus

limitations:

• people with anxiety disorders often cannot remember what triggered symptoms

• many who experience significant threats do not develop anxiety disorders - could be based in underlying vulnerability

People with anxiety disorders

• more easily conditioned to fear stimuli

• sustain conditioned fears longer

• respond more strongly to unpredictable threats

Genetic influences on anxiety disorders

• heritability ~0.5-0.6

• genetic vulnerability to anxiety disorders and major depressive disorder

Brain region and neurotransmitter influences on anxiety disorders

• activation of amygdala when anxious/fearful

• medial prefrontal cortex: reduced activity when someone with anxiety disorder views threatening stimulus

• disruption of serotonin levels

• higher norepinephrine levels

Personality influences on anxiety disorders

neuroticism and behavioral inhibition are predictors

Behavioral Inhibition

tendency to become agitated toward certain stimuli

• strong predictor of social anxiety disorder

Cognitive influences on anxiety disorders

sustained negative beliefs about future

• safety behaviors: behaviors used to avoid feeling anxious

perceived lack of control

• early life experiences show life is not controllable

intolerance of uncertainty

• more susceptible to anxiety disorders, MDD, OCD

attention to threat

• pay more attention to negative cues in environment

Integrative model - triple vulnerability threat

1. biological vulnerability: heritable contribution to negative affect

2. specific psychological vulnerability

3. generalized psychological vulnerability: sense that events are unpredictable/uncontrollable

Etiology of panic disorder and agoraphobia

• genetic contributions to anxiety

• psychological vulnerability to developing anxiety, experiencing negative emotional states, lack of sense of control

• associations of bodily sensations with danger

• anxiety sensitivity: fear of fear (panic disorder)

Etiology of social anxiety

• evolutionary: avoid threatening people

• biological vulnerability: to anxiety, shyness

psychological vulnerability: think stressful events are uncontrollable

• stress → anxiety → self focus → worse performance

• stress → unexpected panic attack → conditioning to social cues

• social trauma → conditioned to social cues

Etiology of generalized anxiety disorder

• higher psychophysiological arousal because of worry

contrast avoidance model

• people with GAD highly aversive to rapid emotion shifts

• to stop shifts - think it is better to have chronic state of worry and distress

Treatment for anxiety disorders

common theme: stopping avoidance, learning to respond to fear in different ways

• ACT

• CBT

• breathing skills

• medication

• systematic desensitization

ACT (acceptance and commitment therapy)

comfortability with uncontrollability of life

Exposure Therapy

exposure to feared stimuli to reduce associated anxiety response

• can be imaginal or direct

• often used for specific phobia

Treatments for panic disorders and agoraphobia

• SSRIs, benzodiazapines

• panic control treatment

• relaxation techniques

Panic control treatment

therapy for panic attacks that gradually exposes clients to somatic sensations associated with panic attacks, modification of attitudes about them

Treatment for social anxiety

CBT for social anxiety/phobia

• track avoidance, worry about panic, anxiety, stress, depressive feelings

Cognitive behavioral framework

Treatment for GAD

exposure therapy (CBT)

• behavioral: worry breaks, relaxation exercises

• cognitive: challenge thoughts, face source of worry