10/16/25-10/21/25 Anxiety disorders

What is anxiety?

Emotional state marked by the anticipation of danger of misfortune, intense distress, bodily tension, and nervousness

• Accompanied by physical sensations

Why are people anxious?

It is a functional response- lack of anxiety is problematic, since it emerges in response to perceived threat

• Throughout human history, anxiety played a pivotal role in the survival of our species

• Creates physical change (aka fight or flight response) that mobilizes us to guard against or escape from danger successfully

What is the effect of anxiety being part of our evolutionary heritage?

We will all always experience it

What do anxiety disorders entail?

Levels of anxiety that are frequent, debilitating, and disproportionate to the circumstances

General prevalence of anxiety disorders

Among the most prevalent psychological disorders, ~1/3 of people will experience an anxiety disorder at some point

When does an anxiety disorder commonly start?

In childhood

What is one explanation for the high prevalence of anxiety disorders?

Humans who are alive today are the ones whose ancestors developed the keenest reactions to threats

How does evolution explain the early onset of anxiety?

Even a very young child needs to be prepared for fight or flight

What are physical signs of anxiety derived from?

Derived from fight-or-flight response, it prioritizes directing energy to the most essential functions for survival

Does anxiety bring on the same or different symptoms depending on the circumstances?

The same symptoms manifest in you, regardless of the circumstances that bring them on, reflecting how fight-or-flight is effective against many types of threat

Examples of physical reactions / purpose for fight or flight / other associated feelings

2 main cognitive symptoms of anxiety

1. Fear/Perception of threat or danger- when we are anxious, we perceive ourselves as in danger even though we are physically safe

2. Worry- repetitive negative thoughts about the possibility of future danger, misfortune, or hardship

Are worry and perception of threat short-term or long-term?

Both worry and the perception of threat are often illusory

How are fear and worry different?

Fear and worry are related, but fear tends to be present-oriented (right now) whereas worry tends to be future oriented (anticipation)

• “I’ve had a lot of worries in my life — most of which have never happened.” -Mark Twain

7 anxiety disorders in the DSM-5

Comorbidity and anxiety disorders

Anxiety disorders are highly comorbid with each other.

People may often have predisposition towards anxiety, but will have different anxiety disorders at different points in their lives

Specific Phobia criteria

• Marked fear or anxiety about a specific object or situation (e.g. flying, heights, animals, needles, blood, etc.)

• Phobic object or situation almost always provokes immediate fear or anxiety. It is actively avoided or endured with intense fear or anxiety. 

• The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.

• The fear, anxiety, or avoidance is persistent, typically lasting 6+ months.

• The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational or other important areas of functioning

  • Failure to meet the functioning criteria is why most of our normal fears are not considered phobias

Specific Phobia: main phobia categories

• Blood, injection, injury

• Situations (e.g. enclosed spaces, airplanes, elevators, bridges)

• Natural environment (e.g. storms, heights)

• Animals

In terms of evolutionary psychology, what is a theory about the main phobia categories?

These stimuli are things that posed a consistent threat to human survival throughout history, such as poisonous animals, dangerous environmental situations, and events that could cause injury or infection, like bleeding

Specific Phobia: if a phobic stimulus is encountered, what will happen?

The person will experience immediate fear/horror

What is the main behavioral symptom of anxiety?

Avoidance, because people do not want to feel that level of fear/distress

How is avoidance a paradox?

It reduces anxiety short-term, but will increase anxiety long-term, because it solidifies beliefs around phobic stimulus.

It also limits the opportunity to learn that seemingly threatening circumstances are not dangerous, so there is no formation of new beliefs or experiences.

Avoidant behavior provides negative reinforcement

Each time you engage in avoidant behavior, you eliminate aversive feelings of anxiety, making it more likely that you will engage in that behavior again/repeat it in the future

Treating phobias

The core of treatment is to eliminate reinforcement associated with avoidance.

If we consciously modify an avoidant behavior, we can change the beliefs that maintain anxiety and anxious feelings themselves

How can we eliminate the reinforcement associated with avoidance?

Through exposure therapy

Exposures (aka CBT for Specific Phobia)

The most effective treatments for phobias all involve exposure to a fear-provoking stimulus, but limiting the anxiety-reducing response (avoidance)

With prolonged exposure, people habituate (body acclimates to the feeling of anxiety), affirming that they can deal with a situation like this

Exposures help people form new beliefs about the feared situation and their ability to cope with it

What happens when confronting the phobic stimulus without avoidance?

Anxiety will be experienced → through this, exposure therapy is essentially making people more anxious right now, so that they will become less anxious in general

Fear and Avoidance Hierarchy

Part of exposure therapy

• Developed collaboratively with therapist

• Ordered list of situations in which a client experiences fear of phobic stimulus

• Used as a guide for exposures in therapy, clients will work from least feared to most feared stimulus

• Each situation gets rated in terms of how much fear it generates and the lengths to which a client will go to avoid that situation

How are Fear and Avoidance Hierarchies individualized?

Every hierarchy is individualized to the client’s specific fears

Steps for effective exposure

1. Identify thoughts about situation before exposure occurs

2. Rate level of distress before exposure begins

3. During exposure, continue to rate distress every 5 minutes

4. During exposure, stay focused, do not try to distract self (avoidant behavior)

5. During exposure, maintain objective awareness of physical symptoms and thoughts

6. Continue exposure until anxiety goes down, 3 or 4 on a scale of 10 is optimal aka manageable feelings

7. After exposure, rate level of distress and evaluate thoughts again

Most important rule of anxiety treatment in general

Never stop an exposure before habituation occurs.

Otherwise, all that is reinforced is the sense that the anxiety producing stimulus is something that should be feared.

What are the 3 ways that exposures be conducted?

1. In session

2. In vivo (in life) - return to the place where the stimulus occurred

3. Imaginal

Goal for anxiety treatment

Realization that even though anxiety is uncomfortable, the risks of anxiety are minimal.

The goal is not to “get rid of anxiety”

Social Anxiety Disorder/Social Phobia (SAD) criteria

• Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (ex. having a conversation, meeting unfamiliar people), being observed (ex. eating or drinking), and performing in front of others (ex. giving a speech)

• Fear that you will act in a way or show anxiety symptoms that will be negatively evaluated (i.e. it will be humiliating or embarrassing, it will lead to rejection or offend others)

• The social situations almost always provoke fear or anxiety

• The social situations are avoided or endured with intense fear or anxiety

• The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context

• The fear anxiety or avoidance:

  • is persistent, typically lasting 6+mo

  • causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

  • not attributable to substances or another medical condition

  • not better explained by the symptoms of another mental disorder (ex. panic, body dysmorphic, or autism spectrum)

  • if another medical condition (ex. Parkinson’s obesity, disfigurement from burns or injury) is present, the fear/anxiety/avoidance is clearly unrelated or excessive

SAD vs shyness

People who are shy do not show:

• avoidant behaviors

• fear of negative evaluation

• physical symptoms of anxiety in social situations

• impairment

Only about 12% of people who consider themselves shy and 10% of those described as shy by their family members meet criteria for SAD

SAD age of onset, prevalence

Early onset, often in adolescence

9-13% in the US, possibly more prevalent in females

Prevalence wanes over time

• 2x prevalent in people aged 18-29 years as in people over 60 years

SAD around the world

Some cultural components to SAD (the self vs the community)

• less prevalent or presents in a different way in collectivist cultures (ex. many East Asian nations) which prioritize the well-being of the entire group, over individualistic cultures, which value independence, autonomy, and personal accomplishments

• differing expectations for behavior

Example of culture interacting with SAD: Taijin kyofusho

A form of social anxiety present in Japan but not in the US, primarily centered around fear of offending or embarrassing others, rather than being embarrassed oneself

Treatment for SAD

CBT is first line treatment

• Fear and avoidance hierarchy, focused on exposure to anxiety provoking social situations or events and re-eval of cognitions around these situations

• Group and individual treatments are equally effective

How well does CBT work for SAD?

CBT worked better than Prozac+self exposure and Placebo+self exposur

• cognitive therapy reduced symptoms more quickly and to a greater degree

• gains were maintained at 1 and 5 year follow ups

Phobias and social anxiety disorder are often accompanied by what?

Accompanied by panic attacks

Panic attack

Abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time 4 or more of the following symptoms occur:

• Palpitations, pounding heart, or accelerated heart rate

• Sweating

• Trembling or shaking

• Sensations or shortness of breath or smothering

• Feelings of choking

• Chest pain or discomfort

• Nausea or abdominal distress

• Feeling dizzy, unsteady, light-headed, or faint

• Chills of heat sensations

• Paresthesias (numbness or tingling sensations)

• Derealization (feelings of unreality) or depersonalization (being detached from oneself)

• Fear of losing control or “going crazy”

• Fear of dying

Time limited aspect of panic attacks

Symptoms typically reach a peak in about 10 minutes and then decline

What do panic attacks feel like? Example from Kevin Love, pro basketball player

• Heart racing

• Trouble catching breath

• Everything was spinning

• Brain was trying to climb out of his head

• Air felt thick and heavy

• Body was trying to tell him he is about to die

2 types of panic attacks

1. Situationally bound: clear triggers like snakes, bugs, flying, social situations, etc.; part of the experience of Specific Phobia and SAD for some people

2. Not situationally bound: out of the blue, can even occur in the middle of the night, is a sign that you might have panic disorder

How can situationally bound panic attacks be reduced?

By treating the phobic stimuli that precede them

Frequency of panic attacks

Varies widely

• some people have them daily, or even more than once a day

• other people can go weeks or months without an attack, but worry about having one and show lots of avoidant behavior

Panic Disorder

Characterized by recurrent unexpected panic attacks

At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

• Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).

• A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations)

Agoraphobia

Anxiety about being in places in situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms

• Panic attacks may occur with or without comorbid agoraphobia

What are some forms of avoidance behaviors (to not panic) besides agoraphobia?

Restriction of caffeine and exercise (which increase heart rate)

Only doing certain activities when safety mechanisms are there (only driving with meds, only going certain places with a certain person, etc)

How common are panic attacks?

Panic attacks are common, 1/3 of people will experience a panic attack at some point during the lifespan

What percent of people who have a panic attack go on to develop panic disorder?

Only about 5%

Catastrophic Misinterpretations of Bodily Sensations

The tendency to interpret normal or innocuous physical feelings, such as a fast heartbeat or dizziness, as signs of a severe and dangerous medical condition, often leading to panic attacks

• Believed to be the biggest reason some people develop panic disorder and others do not

Fear of Fear Model

1. Bodily sensations (heart pounding, rapid breathing, sweating, muscle tension, dizzy/lightheaded)

2. Uh oh reaction (I am having a heart attack, what if other people notice, what if I fall down or die)

3. Increased anxiety (worry about possibility of future panic, excessive focus on small changes in bodily state)

4. More symptoms (thoughts about the meaning of physical sensations keep body at high level of physiological arousal)

5. repeat

Treating Panic Disorder

Effective treatments for panic disorder blends exposures with cognitive restructuring about panic

• if I panic, I won’t be able to handle it

• I’m dying

Psychoeducation

• what does a heart attack really feel like? 

• what are the evolutionary origins of panic symptoms

With panic, why do people perform avoidant behaviors?

People are trying to avoid the physical sensations of panic.

When treating panic, what should the focus of exposures be?

Exposures are a technique to extinguish the reinforcement associated with avoidance, so the focus for panic should be the same/similar kinds of physical sensations brought on by panic

Exposures for panic (2 stages)

Stage 1: Interoceptive exposures

• exposures which are designed to mimic the physical sensations of panic in a controlled, intentional way

• a Fear and Avoidance Hierarchy is constructed from these symptoms, rated according to intensity of symptom and similarity to panic

• ex. breathing thru straw, head rolling, running in place, breath holding, body tensing, spinning in a swivel chair, hyperventilating, etc.

Stage 2: In vivo exposures

• therapist and client construct/follow a new Fear and Avoidance Hierarchy for situations which typically bring on panic outside of therapy sessions

Generalized Anxiety Disorder (GAD) criteria

• Excessive anxiety and worry (apprehensive expectation), occurring more days than not for 6+ months, about a number of events or activities (such as work or school performance)

• Difficult to control the worry

• Anxiety and worry are associated with 3 or more of the following 6 symptoms, with at least some symptoms having been present for more days than not for the past 6 months:

  • Restlessness or feeling keyed up/on edge

  • Being easily fatigued

  • Difficulty concentrating or mind going blank

  • Irritability

  • Muscle tension

  • Sleep disturbance (difficulty falling or staying asleep, or restless/unsatisfying sleep)

• Anxiety, worry or physical symptoms cause clinically significant distress or impairment…

• Disturbance not attributable to substance or medical condition

• Not better explained by other mental disorders

How is GAD distinct from other anxiety disorders?

• People with GAD mainly worry about everyday events (ex. chores, being late, family health or misfortunate, job)

• Focus of worries shifts frequently

• Meta worry: worry about not being able to control worry

• Fewer “fight or flight” symptoms, more muscle tension

• Less likely to present for treatment than other anxiety disorders, although some evidence that they may be more treated by primary care doctors than mental health field

• More common in middle aged and older adults (avg age of onset is around 30yo)

GAD gender prevalence

More common in females

GAD comorbidity

Highly comorbid, especially with MDD and other anxiety disorders

Is GAD an acute or chronic disorder?

Chronic, with few remissions (when the signs and symptoms lessen or disappear)

GAD around the world

A huge study looking at 150k+ people across 26 different nations found that:

• GAD is more common in higher income countries than lower or middle income ones

• More impairment associated with GAD in higher income countries

• Within high income countries, GAD is more prevalent in people with lower SES

Newman’s Contrast Avoidance Model

Suggests people with GAD are extremely sensitive to shifts in emotional state

Worrying keeps people in one emotional state and prevents sharp increases in negative emotions

The model reframes worry from a passive thought process to a logical, adaptive coping response

GAD and intolerance of uncertainty

Discomfort with not knowing the outcome of events, tends to be very high in people with GAD

Treatment of GAD

SSRIs, SNRIs are the biggest ones

Also CBT or third wave adaptations to CBT

• these 2 treatments are equally effective in short term, but meds typically do not have benefits once discontinued and CBT is associated with reduced symptoms in the long term