anxiety disorders- lecture 4

Kring chapter 6

anxiety disorders symptoms:

anxiety= worry in anticipation of fearful situation

fear= immediate reaction to fearful stimuli

both are associated with high arousal - activation of sympathetic nervous system

both are adaptive for survival but can also impair functioning.

facts about anxiety disorders:

• twice as common in women, than men

• 9th leafing cause of disability worldwide

• increased risk of suicide (4x)

• 28% of people meet the clinical criteria for an anxiety disorder during their life time (Kessler et al, 2021)

• high co-morbidity with MDD (around 60%) and also between different anxiety disorders ( around 50%)

specific phobias

a disproportionate fear caused by specific object or situation:

• specific phobias often comorbid but clustered around specific objects

• the object or situation is avoided or else endured with intense anxiety.

DSM-5 criteria for specific phobias:

marked and disproportionate fear consistently triggered by specific objects or situations.

the object or situation is avoided or else endured with intense anxiety

symptoms persist for at least 6 months

social anxiety disorder

a persistent intense fear of social situations that might involve being scrutinised by or even just exposed to, unfamiliar people

• intense feelings of shame and humiliation with regard to social interactions

• avoidance or severe anxiety about social situations, public speaking, meetings classes etc

• can impair work and relationships and is often comorbid with substance abuse and avoidant personality disorder

DSM-5 criteria in social anxiety disorder

marked and disproportionate fear consistently triggered by exposure to potential social scrutiny.

exposure to the trigger leads to intense anxiety about being evaluated negatively

trigger situations are avoided or else endured with intense anxiety

symptoms persist for at least 6 months

panic disorder

depersonalisation- a feeling of being outside one’s body

derealisation- a feeling of the world not being real

fears of losing control, going crazy or dying

intense urge to escape

symptoms come on rapidly and usually peak relatively quickly

DSM-5 criteria

panic disorder involves frequent panic attacks which are not in response to fearful external events/stimuli

DSM criteria also specify that the person must worry about the onset of further attacks or change his or her behaviour because of the attacks for at least 1 months.

recurrent unexpected panic attacks

at least 1 month of concern about, worry about the consequences of an attack, or maladaptive behavioural changes because of the attacks.

agoraphobia

anxiety about situations in which it would be embarrassing or difficult to escape if anxiety symptoms occurred.

• public places, crowds and crowded places, shops, classrooms, transport

• in severe cases, individuals are virtually unable to leave their home.

• 50% also experience panic attacks

• ‘fear-of fear’ hypothesis, suggests agoraphobia is driven by negative thoughts about the consequences of experiencing anxiety in public

DSM-5 criteria for agoraphobia

disproportionate and marked fear or anxiety about at least 2 situations where it would be difficult to escape or receive help in the event of incapacitation, embarrassing symptoms, or panic.

these situations consistently provoke fear or anxiety

these situations are avoided, require the presence of a companion. or are endured with intense fear or anxiety

symptoms least at least 6 months ger

generalised anxiety disorder

excessive uncontrollable. and long lasting rumination and worry about everyday life events

worry about relationships, health, finances, and daily hassles - but they worry about these issues constantly

DSM-5 criteria for generalised anxiety:

excessive anxiety and worry at least 50% of days about a number of events or activities (family, health, finances, work and school).

the person finds it hard to control the worry

the anxiety and worry are associated with at least 3 (or 1 in children) of the following:

• restlessness or feeling keyed up or on edge

• easily fatigued

• difficulty concentrating or mind going blank

• irritability

• muscle tension

• sleep disturbance

psychological theories of anxiety disorders: fear conditioning

Orval Hobert Mowrer proposed a two- factor model in the development of an anxiety disorder

stage 1- classical conditioning

• person learns to fear a neutral stimulus (the conditioned stimulus, or CS) that is paired with an intrinsically aversive stimulus (the unconditioned stimulus, or UCS).

• a person gains relief by avoiding the CS. through operant conditioning, this avoidant response is maintained because it is reinforcing (it reduces fear)

step 2 - operant conditioning

what is fear conditioning?

classical conditioning can occur in different ways:

• direct experience (like the dog bite in the example above)

• modelling (eg seeing a dog bite a man or watching a video of a vicious dog attack)

• verbal instruction (eg hearing a parent warn that dogs are dangerous)

• evolutionary relevance

however, not everyone who is exposed to a major threat goes on to develop an anxiety disorder. Research has shown that individuals with anxiety disorders.

• are more easily conditioned to fear stimuli

• sustain conditioned fear responses for longer

psychological theories: personality & cognitive factors

behavioural inhibition: a trait evident in early childhood characterised by an aversion to novel situations, people and objects

• particularly strong predictor of social anxiety disorder

neuroticism: people with high levels of neuroticism are more than twice as likely to develop an anxiety disorder and/or depression than those with low levels

sustained negative beliefs about the future

perceived lack of control

intolerance to uncertainty

attention to threat:

people with anxiety disorders pay more attention to negative cues in their environment than do people without anxiety disorders

genes: etiology and anxiety disorders

twins studies suggest a heritability of around 20-40% for specific phobias, social anxiety disorder and GAD, and around 50% for panic disorder.

this indicated that genes may explain about 20-50% of the risk for anxiety disorders in population

the elevated risk is not tightly linked to individual anxiety disorders, suggesting shared etiology between different disorders.

neurobiology: the fear circuit and the anxiety of neurotransmitters:

amygdala: small, almond-shaped structure in the temporal lobe involved in assigning emotional significance to stimuli.

found to be hyperactive in anxiety disorders.

medial prefrontal cortex: involved in extinguishing fears and engaged during emotion regulation

found to be hyperactive in anxiety disorders

neurobiology

Serotonin: regulation of mood 
→ GABA: modulates activity in the amygdala and fear circuit 

→ Norepinephrine: key neurotransmitter in the activation of the sympathetic nervous system for “fight-or-flight” responses 
→ anxiety disorders (particularly Panic Disorder) are associated with increased levels of norepinephrine and changes in the sensitivity of norepinephrine receptors 

→ Hypothalamic-pituitary-adrenocortical (HPA) axis: increased levels of cortisol (stress hormone) 

treatments: biological

drugs that reduce anxiety are known as anxiolytics

• benzodiazepines, minor tranquilisers/sedatives (eg Valium Xanax)

• addictive, sever withdrawal symptoms, side-effects include memory loss and drowsiness

biological treatments

beta blockers: downregulate activation of sympathetic nervous system

anti-depressant: tricyclics, SSRIs, SNRIs

tend to be preferred long term medication option for anxiety disorders

SSRIs, SNRIs often first-line treatment due to fewer side-effects than tricyclis

because psychological treatments are often very successful in anxiety disorders and OCD they are often the preferred long term option

in severe cases, medication often needed alongside psychological intervention

psychological: treatments

relaxation training: including muscle relaxation, mediation.

cognitive behavioural therapy (CBT):

typically focus on challenging (1) a persons beliefs about the likelihood of negative outcomes if he or she faces an anxiety-provoking object or situation and (2) the expectation that he or she will be unable to cope.

identifying and challenging negative automatic patterns

distinguishing ‘productive’ from ‘unproductive’ worrying

exposure therapy has proven effective in 70-90% of individuals, and the effects have been shown to endure over the long term

• however, ERP demanding therapy for both patient and therapist

• requires committed adherence to difficult exercises.