Anxiety Disorders

What are anxiety and fear, and how do they affect performance?

• Anxiety

  • Anticipated fear (future-focused)

  • Increases preparedness

  • Follows a U-shaped curve with performance:

    • Low anxiety → poor performance

    • Moderate anxiety → optimal performance

    • High anxiety → impaired performance

• Fear

  • Response to immediate real or perceived danger

  • Triggers fight-or-flight response

  • Can be life-saving

• Shared features

  • Both involve high physiological arousal

  • Sympathetic nervous system activation

  • Adaptive for survival but can become maladaptive when overactive

GAD/Generalised Anxiety Disorder

• core experience: chronic/pervasive worry without clear trigger + worry shifts instead of staying fixed

• cognitive style: persistent rumination, worry feels necessary/protective, difficulty disengaging from “what if” thinking

• everyday impact: mental fatigue, reduced concentration, constant sense of tension

• course: often begins in adolescence, long standing + fluctuating

DSM-5 GAD

• excessive worry/anxiety about multiple life domains, difficulty controlling worry, present for =6/+ months

• 3 associated symptoms (=1+ in children): restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance

Comorbidity

• anxiety disorders rarely occur in isolation

• over half of individuals w/ anxiety disorder meet criteria for at least one other mental disorder (commonly major depressive disorder, but also OCD/related disorders)

• comorbidity associated w/: greater symptom severity, poorer prognosis, more complex treatment needs

Gender Factors

• prevalence; women : men = 2 : 1

• women on average report greater functional impairment

• causes for gender difference?: women more likely to report/recognise symptoms, socialisation may impact how fear/distress/control are expressed, women disproportionately exposed to certain forms of interpersonal disorders

• stress reactivity: some evidence for greater physiological/emotional reactivity to stress

• women score higher on neuroticism (trait linked to anxiety risk)

Cultural Factors

• cultural concepts of distress vary:

→ kayak angst: panic like reactions reported among Inuit seal hunters at sea; context-specific fear linked to isolation, environmental threat and survival risk

→ taijin kyofusho: Japanese fear of offending/embarrassing others; considered cultural variant of social anxiety disorder in DSM-5-TR

• cross cultural prevalence: anxiety prevalence varies across cultures (3-19%); reported prevalence highest in Europe/USA

Mowrer’s two-factor model (1947)

• classical conditioning: person learns to fear neutral stimulus (CS) that is paired with intrinsically aversive stimulus (US)

• operant conditioning: person gains relief by avoiding CS; avoidance maintained through negative reinforcement

Little Albert (Watson and Rayner, 1920)

• classical conditioning to condition emotional response → 9 month old “Albert” exposed to stimuli (and observed) → white rat paired w/ loud noise → Albert conditioned to fear white rat

• some fears can be acquired as shown above but reproduction of experiment has not been successful

• critique: never reconditioned, experimental errors, neurological problems, hydrocephalus (died age 6)

Little Hans (Freud, 1909)

• 3 to 5 years old, based on correspondence with parents

• Freud made major leap in interpretation combining reports from parents + his own interpretations

• (most likely) little Hans had short-term fear of horse after negative experience (horse tipped over while out for a walk)

Behavioural theories - Anxiety

• direct experience: supports Mowrer model, but anxiety/phobias not limited to past traumatic event

• modelling: fear learnt by imitating others (vicarious learning) e.g. Bandura and Rosenthal (1966) watching others exposed to painful stimuli paired w/ sound of buzzer, will react emotionally to buzzer

• verbal instruction: e.g. mother tells child to be wary of dogs

Phylogenetically prepared learning

• for rats, taste is powerful CS to associate w/ nausea, electroshock is not

• (Ohman et al., 1975) humans - electroshock with pictures of houses/snakes; extinction fast for houses but slow for snakes

• (Cook and Mineka, 1989) rhesus monkeys watching others show fear to snake + crocodile acquire the fear, while fear to rabbit or other objects is not acquire fear

Cognitive diathesis

• not just experience

• 50% of people with dog phobia, 50% without report traumatic dog-related experiences

• key difference: expectation that similar harm will occur again → cognitive diathesis (threat expectancy)

Social Factors/Maintenance

• some individuals show poorer social skills/confidence

• leads to stressful interactions + negative feedback

• reinforces anxiety/avoidance over time

• e.g. keeps happening and I can’t stop it => depression, this will happen again and I must prevent it => anxiety

Personality and Cognitive Factors

• behavioural inhibition: trait evident in early childhood characterised by aversion to novel situations, people + objects

• strong predictor of social anxiety disorder

• (Kagan) shyness at 4 months predicts phobias later in life

• behavioural inhibition at 14 months id predictor for later social anxiety disorder (30% developed disorder)

• neuroticism: people with high levels of neuroticism are over 2x to develop anxiety disorder/depression than those w/ low levels

Personality and Cognitive Factors (2)

• sustained negative beliefs about future/perceived lack of control

• traumatic life events:

→ 50% have history of childhood physical/sexual abuse (Cougle, Timpano et al.,2010)

→ 70% have severe life event before onset of anxiety disorder (Finlay-Jones, 1989)

• attention to threat: more attention to negative environmental cues than those w/o anxiety disorders

• intolerance of uncertainty

Genetic Factors

• twin studies: heritability of about 30-60%

• some genes may elevate risk for several anxiety disorders e.g. family member w/ phobia associated w/ increased risk of developing a phobia and other anxiety disorders

• blood/injury phobia: 64% of patients have first-degree relative affected, while 3-4% in population

• genetic vulnerability of anxiety/depression may overlap

Neurobiology

• amygdala: assigns emotional significance, involved in fear conditioning

• medial prefrontal cortex: regulates amygdala activity, involved in extinguishing fears, processes anxiety and fear

Panic Disorder - Neurobiological Etiology

• serotonin dysregulation: supported by SSRI effectiveness

(unf)

Panic Disorder - Behavioural Factors

• classical conditioning of panic in response to internal bodily sensations

→ person experiences somatic signs of anxiety → followed by panic attack → panic attacks become conditioned response to somatic changes such as those indicating poor oxygen flow → slower to extinguish than non bodily stimuli

Panic Disorder - Cognitive Influences

• misinterpretations of somatic changes: impending doom interpretation e.g. belief you are having heart attack → increases anxiety/arousal → cycle

• anxiety sensitivity index:

→ measures intensity of fear in response to bodily sensations

→ higher among those w/ anxiety disorders

→ high scores predict onset of panic attacks/anxiety disorders

• 18 items split into 3 categories (physical concerns, cognitive concerns, social concerns)

Therapies

• psychoanalytic approach: explores repressed conflict underlying extreme fear e..g free association, dreams; (indirect approach) defence protects patient

• behavioural approach:

→ systemic desensitisation: increasingly frightening images related to the phobia are shown in relaxation

→ flooding: exposure by feared stimulus with full intensity

→ learning social skills: role-play, rehearse social encounters

→ modelling: watching movies/demos of others interacting fearlessly with the phobic objects (playing with dogs)

Anxiety disorders - Treatments

• relaxation training: muscle relaxation/meditation

• CBT: addresses individual’s beliefs about negative outcomes in anxiety provoking object/situation → expectation that they will be unable to cope → identifying/challenging negative automatic thought patterns → distinguishing ‘productive’ vs ‘unproductive’ worrying

Exposure + response prevention (ERP) therapy

• exposure: face situation/object triggering anxiety

→ exposure hierarchy: graded exposure to list of triggers

→ virtual reality vs in vivo (real life) equally effective

→ behavioural view: newly learned associations to inhibit fear

→ cognitive view: corrects mistaken beliefs

• effective in 70-90% of individuals in short and long term; however, is demanding for patient and therapist, requires committed adherence to difficult exercises

Systemic desensitisation

• interview: what is cause of anxiety (time, other people present, where, length of time, method for previously overcoming?)

• construct hierarchy: list of anxiety-producing situations and order them (therapist then presents them to patient least → most, progressing when patient does not feel anxiety to stimulus)

• systemic desensitisation procedure: patient relaxes (scale 1-100), signal when feeling anxious → describes triggers in relaxation (let patient imagine it) → continue up hierarchy

Social Anxiety Disorder - Psychological Treatment

• CBT: graded hierarchy of exposure, involves role playing/practicing with small group

• Social skills training: provides extensive modelling of behaviours, reduces use of safety behaviours (e.g. poor eye contact)

Social Anxiety Disorder - Treatment (II)

• fear of being evaluated is stubborn: cognitive/behavioural tasks often combined

• probe maladaptive beliefs: if one only remembers negative social events, ask to write down instances of positive social events

• given a task that elicits embarrassment (e.g. dropping book in class on purpose), goal to realise most people take little to no notice and reduce self-consciousness

Agoraphobia - Psychological Treatment

• CBT: systemic exposure to feared situations

→ coached to gradually leave home and engage in community activities for short periods of time

→ enhanced by invoking patient’s partner who may have helped enable patient’s fears

• the 5 R’s: react, retreat, relax, recover, repeat

Generalised Anxiety Disorder - Psychological Treatment

• relaxation treatment to promote calmness

• cognitive behavioural methods:

→ improve problem solving

→ challenge/modify negative thoughts

→ increase ability to tolerate uncertainty

→ worry only during ‘scheduled’ times

→ focus on present moment

What are the main DSM-5-TR anxiety disorders and their core features?

• Specific Phobia

  • Excessive, irrational fear of a specific object or situation

• Social Anxiety Disorder

  • Fear of social situations or scrutiny by others

• Panic Disorder

  • Persistent anxiety about recurring panic attacks

• Agoraphobia

  • Fear of situations where escape/help may be difficult during anxiety symptoms

• Generalized Anxiety Disorder (GAD)

  • Chronic, uncontrollable worry across many areas

What are the DSM-5 criteria and key features of anxiety disorders?

• Core symptom

  • Excessive anxiety or fear (subjectively experienced)

• Clinical impact

  • Causes significant distress

  • Interferes with daily functioning

• Duration

  • Typically ≥ 6 months

  • Panic disorder: ≥ 1 month

• Disorder differences

  • Fear/anxiety content varies across specific disorders

• Limitations of diagnosis

  • Many symptoms are not disorder-specific (e.g., somatic symptoms)

• Underlying factors

  • Shared etiological factors across disorders

  • Involvement of perceived control over stress situations

What are the core features and types of phobias?

• Core features

  • Marked fear with avoidance behaviour

  • Fear is disproportionate to actual danger

  • Often recognised as excessive (but not always)

  • Reality testing remains intact

• Types

  • Specific phobia (can involve virtually any object or situation)

  • Social Anxiety Disorder (fear of negative evaluation or embarrassment)

  • Agoraphobia (classified separately; fear of being unable to escape/help unavailable)

What are the DSM-5-TR criteria and key features of phobias?

• Core definition

  • Excessive, unreasonable, persistent fear of specific objects or situations

• Response pattern

  • Exposure triggers anxiety

  • Avoidance of feared stimulus

• Duration

  • Persists for at least 6 months

• Gender differences

  • Higher prevalence in women (~2:1)

  • Influenced by:

    • Socialisation of fear expression

    • Differences in help-seeking/reporting

    • Perceived control and coping expectations

What are the DSM-5-TR features of Social Anxiety Disorder?

• Core fear

  • Fear of unfamiliar people or social scrutiny

• Anxiety response

  • Intense fear of humiliation or embarrassment when exposed

  • Social situations are avoided or endured with high anxiety

• Duration

  • Persists for at least 6 months

• Comorbidity

  • ~1/3 co-occurs with Avoidant Personality Disorder

  • Often associated with early onset, pervasive symptoms, and high shyness

What are the generalized vs specific types of Social Anxiety Disorder (DSM-5-TR) and their outcomes?

• Generalized Social Anxiety Disorder

  • Early onset

  • Fear present in most social situations

  • More severe course

  • High comorbidity (depression, alcohol/substance use disorders)

  • Functional impairment:

    • Underachievement academically and occupationally

    • Avoidance of promotions or speaking tasks

    • Poor performance in evaluative situations

• Specific Social Anxiety Disorder

  • Fear limited to certain situations

  • Example: speaking in public

What are the consequences and comorbidities of Social Anxiety Disorder?

• Core consequences

  • Chronic avoidance of social situations

  • Academic and occupational underachievement

  • Reduced social networks and relationship difficulties

  • Increased risk of panic attacks

• Hidden consequences

  • Symptoms often concealed

  • May be misinterpreted as “uninterested,” “aloof,” or “arrogant”

• Comorbidities

  • Major Depressive Disorder (MDD)

  • Substance use (alcohol/drugs)

  • Other anxiety disorders (e.g. panic disorder)

  • Avoidant Personality Disorder

• Risk

  • Increased risk of suicide

What are the DSM-5-TR criteria for Panic Disorder?

• Core feature

  • Recurrent, unexpected panic attacks

• Ongoing concern (≥ 1 month)

  • Worry about additional attacks

  • Worry about consequences (e.g. dying, losing control)

  • Maladaptive behavioural changes (e.g. avoidance, reassurance seeking)

• Exclusions

  • Not due to substances or medical conditions

  • Not better explained by another mental disorder

What are the features of a panic attack (DSM-5-TR)?

• Core definition

  • Intense terror with ≥ 4 physical/cognitive symptoms

• Common symptoms

  • Laboured breathing, palpitations, chest pain

  • Nausea, dizziness, trembling, choking sensation

  • Fear, impending doom

  • Intense urge to escape

• Dissociative symptoms

  • Depersonalization (feeling outside the body)

  • Derealization (world feels unreal / “going crazy”)

• Types of panic attacks

  • Cued (triggered by situations, still sudden onset)

  • Uncued (unexpected, may occur during sleep)

• Underlying mechanism

  • Misfiring of the fear system (false threat response)

What are the DSM-5-TR criteria and core features of Agoraphobia?

• Core feature

  • Marked fear of ≥2 situations where escape may be difficult, help unavailable, or panic-like symptoms would be embarrassing/dangerous

• Behavioural response

  • Situations avoided or endured with intense distress

  • Often requires a companion to cope

• Duration

  • Persists for at least 6 months

• Diagnostic note

  • Classified as a separate disorder in DSM-5 (previously linked to panic disorder)