Anxiety Disorders - SAD, specific phobia, panic disorder

What are similarities between fear and anxiety? What are differences?

• Both involve negative affect

• Fear = sympathetic NS arousal; Anxiety = somatic symptoms of tension

• Fear = urge to escape/act in response to present danger; anxiety = future orientated

• Anxiety has a sense of unpredictability or uncontrollability of upcoming events

What is panic?

A sudden episode of intense fear that triggers severe physical rxns, when there is no real danger or apparent cause

What is worry? What does it represent?

A chain of thoughts + images, negatively affect-laden and relatively uncontrollable

Represents an attempt to engage in mental problem-solving on an issue whose outcome is uncertain but contains possibility of negative outcomes

What is the psychodynamic theory of anxiety?

Anxiety is a conflict between id and ego. Repressed drives break through repression and cause danger, with anxiety as the signal.

Triangle - three points are defense, anxiety, and hidden feelings

According to Freud, anxiety is a psychic rxn to danger

What is the cognitive theory of anxiety?

Feelings, thoughts, behaviours

Anxiety caused by tendency to overestimate the potential for danger + cognitive misinterpretations

What is the behavioural model of anxiety?

Classical conditioning, operant learning, and modelling cause anxiety disorders

A dog bite + contiguous pairings lead to a classically conditioned fear of dogs. A strong fear response acts as a stimulus or drive and results in an overt avoidance response, acting as operant conditioning

What is the prevalence and sequelae of anxiety disorders? (2)

Highly prevalent - up to one third of people will have at least one

Sequelae - poor educational outcomes; underemployment/social welfare

What are the two themes across anxiety disorders?

Over-estimation of threat - feared outcomes as highly likely to happen

Underestimation of ability to cope - thoughts = “I will not be able to cope” and “I will fall apart”

DSM criteria for Specific Phobia (A-G)

A. Marked fear or anxiety about a specific object or situation

The object or situation

B. Almost always provokes immediate fear or anxiety

C. is actively avoided or endured with intense fear or anxiety

The fear or anxiety

D. Is out of proportion to the actual danger posed and to the sociocultural context

E. Is persistent (>6 mth)

F. Causes clinically significant distress or impairment

G. not better explained

Specific Phobia Specifiers (5)

Animal (spiders, insects, dogs)

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

Blood-injection injury (e.g., needles, invasive medical procedures)

Situational (e.g., airplanes, lifts, enclosed places)

Other (e.g., situations that might lead to choking or vomiting)

How do fears differ from phobias?

Development of fears are normal but transient at various developmental stages

• Separation from caregivers (6-22m)

• Animals/darkness/imaginary creatures (2-6y)

Common fears in adulthood - illness/injury/death, animals, environmental hazards

In phobias, fear is intense/severe, immediate, response is excessive; more likely to be chronic and causes significant distress or impairment

Epidemiology of Specific Phobia

12-m prevalence 6-9% in US, Europe; 2-24% in Asia, Afria, S America

2:1 females:males except BII

Peak in teenagers (5% in children, 16% in teens, 3-5% in older adults)

Multiple common (75% fear more than one, on average 3)

High comorbidity and severe role impairment

What are risk factors for specific phobia?

Genetic (including to category — BII Higher)

Physiological

Temperamental

Environmental

What are physiological risk factors for specific phobia?

• Amygdala hyperactivity to feared stimuli

• Unique propensity to fainting in BII

What are temperamental risk factors for specific phobia?

• Negative affectivity (neuroticism)

• Anxiety sensitivity (fear of fear)

• Behavioural inhibition

• Emotional regulation and distress tolerance

What are environmental risk factors for specific phobia?

Parental overprotectiveness

Parental loss and separation

Physical/sexual abuse

Traumatic encounters (with feared object or situations)

What is Mowrer’s two factor model for specific phobia?

1. Fear acquired via classical conditioning

2. Fear maintained via operant conditioning

Stimulus generalisation also implicated

Avoidance and escape negatively reinforced by removing aversive affective states

What’s Rachman’s revised two-factor model?

1. Direct conditioning

2. Modeling/vicarious acquisition due to observational learning

3. Informational and instructional acquisition (i.e., receiving mis information from others)

What is Seligman’s preparedness theory of specific phobia?

Evolution predisposed organisms to learn easily associations that facilitate survival

When compared to lab-conditioned fears, phobias are:

1. Rapidly acquired

2. Resistant to extinction

3. Non-cognitive/irrational

4. Differentially associated with stimuli of evolutionary significance

What is Reiss’s Expectancy Model’s three types of sensitivity/fundamental fears?

Three types of sensitivity/fundamental fears

1. Anxiety sensitivity - the fear of anxiety-related sensations, arising from belief sensations have averisve somatic, psychological, or social consequences

2. Fear of illness, injury, or death

3. Fear of negative evaluation

According to Reiss’s expectancy model, human motivation to avoid a feared stimulus is a function of what two classes of variables?

1. Expectation (what you think will happen)

2. Sensitivity (the reasons you fear that happening)

Phobic fear + motivation to avoid feared stimulus = involves BOTH

What is the expectancy model formula?

1. Total danger expectancy in relation to all objective disasters that could be associated with stimulus x sensitivity to injury/death

2. Total anxiety expectancy in relation to all components of anxiety reaction associated with stimulus x sensitivity to anxiety

3. Total expectancy of social disaster in relation to all that could be associated with the stimulus x their sensitivity to negative evaluation by others

i.e., each step involves probablility/expectancy x sensitivity to consequences

What maintains phobias?

Anxious predictions (based on exaggerated estimates of harm/danger)

Physiological arousal (focus for further anxious predictions)

Hypervigilance for cues (scanning, attention to physiology)

Safety behaviours

What is a cognitive behavioural model of specific phobia?

Focus on threat (selection attention and hypervigilance) → trigger (for ex., seeing a dog) → cycle of: anxious prediction → anxiety → safety seeking behaviour and avoidance → failure to learn the worst does not happen, maintaining hypervigilance → belief remains unchanged → feeds into focus on threat

What are the DSM-5 Symptoms of Social Anxiety Disorder?

A. Marked fear or anxiety about one or more social situations in whcih the individaul is exposed to possible scrutiny by others.

B. The individual fears they will act in a way or show anxiety sx that will be negatively evaluated

The social situations…

• C. Almost always provoke fear or anxiety

• D. Are avoided or endured with intense fear or anxiety

E. Fear or anxiety is out of proportion to actual threat + sociocultural context

Fear, anxiety or avoidance…

F. Is persistent, >6 mths

Causes clinically significant distress or impairment

What is the prevalence of Social Anxiety Disorder?

One of the most prevalent in the US, lower other places (7 vs 2.3%)

Median age of onset is at 13yr, with 75% between 8 and 15

Rates in children and adolescents similar to adults, with decrease in older adulthood

More females than males

Highest rates among Native Americans, then whites

What are risk factors for social anxiety disorder?

Genetic

• 1st degree relatives 2-6x greater chance of SAD

• Behavioural inhibition, a predisposing trait which is strongly genetically influenced and subject to gene-environment interaction

Temperamental

• Behavioural inhibition

• Fear of negative evaluation

Environment

• Childhood maltreatment and adversity

What is behavioural inhibition?

A temperament of young children, defined by fearful style of reacting/inhibited reaction when confronted with novel situations, adults, and peers.

It also is associated with higher levels of withdrawal, clinging, hypervigilance, and avoidance

What are cognitive themes of Social Anxiety?

I will behave in a way that is unacceptable,

AND

This will lead to rejection, loss of status or worth, failure

What are beliefs and assumptions associated with Social Anxiety Disorder?

Extremely high standards for social performance

Conditional beliefs

Unconditional beliefs about the self

What are beliefs and assumptions associated with social anxiety related to extremely high standards for social performance?

Beliefs/assumptions one must always appear confident or never falter in conversations

What are examples of conditional beliefs seen in Social Anxiety Disorder?

If I make a mistake, I will come across as an idiot

If I forget someone’s name, they will reject me

What are examples of unconditional beliefs about the self seen in Social Anxiety Disorder?

I am boring/stupid/incompetent/weird/unlikable

What are behavioural themes associated with social anxiety disorder?

Behaviors intended to reduce the feared outcome (safety behaviours)

• Minimal eye contact, Speaking quietly or quickly, wearing neutral clothing, asking questions to keep focus on others, using alcohol/drugs before social situations

• Avoidance

• Pre-event rehearsal and post-event “social autopsy”

How do safety behaviors relate to fears and beliefs in social anxiety?

The person fears rejection, loss of status/worth, failure

People will reject me, think I’m an idiot, or think I am a failure if I behave in an unacceptable way

What is the paradox of safety behaviours in Social Anxiety?

Socially anxious people often do safety behaviours they think will reduce the feared outcome, such as being judged or noticed. However, in many cases, they often do the opposite

For ex., not looking at someone might seem rude, it is harder to interact with someone who appears withdrawn, they can cause feared sx to occur, bring attention to the safety behaviours themselves or oneself, increase internal self focus, and prevent disconfirmation of negative beliefs.

What maintains social anxiety?

Safety behaviours

Avoidance

Internal focus of attention

Internal information to judge how one appears to others

Anticipatory and post event processing

Assumptions and self schemas

What is the focus in Clark & Well’s Cognitive Model of Social Phobia?

What prevents those with SAD from changing their beliefs regarding danger in social situations

What are key components of Clark and Well’s Cognitive model of social phobia?

Self focused attention as impression of self as a social object (i.e., centering self as object and focus of attention)

Anxiety induced performance deficits and their effect on others

Maintaining role of safety behaviours

What is Rapee & Heimberg’s model of SAD?

Distortions and biases in processing/evaluative information

Person with SAD creates and compares internal representations of:

1. How they appear to others, and

2. other’s expectations/standards

Anxiety symptoms result from them perceiving a discrepancy between these and the consequences of this

What are the DSM-5 criteria for Panic disorder?

A. Recurrent, unexpected panic attacks

B. At least one of the attacks has been followed by 1 month or more of either/both of:

1. Persistent concern or worry about additional panic attacks or their consequences

2. A significant maladaptive change in behaviour related to the attacks

C & D - standard substance and medical condition and mental health disorder exclusions

What is the prevalence of Panic disorder?

2-3% 12 month prevalence

2:1 females:males

Panic attacks can occur in children, but PD prevalence in children is low.

Gradually increases from adolescence, peaks in adulthood, then declines

Mean age of onset 20-24

Highest rates among whites and native americans

What are risk factors for panic disorder?

Genetic

• Multiple genes thought to be related to vulnerability

• Increased risk if parents have anxiety, depressive, or bipolar

Physiological

• Amygdala

• Respiratory disturbance e.g., asthma

Temperamental

• Negative affectivity (i.e., neuroticism)

• Anxiety sensitivity

Environmental

• Physical/sexual abuse - more comon in PD than other anxiety disorders

• Smoking

• Stressors

What is Clark’s theory of Catastrophic Misinterpretation?

Panic attacks result from catastrophic misinterpretation of bodily sensations associated with a normal anxiety response (e.g., palpitations, breathlessness, dizziness)

Catastrophic misinterpretation - perceiving them as much more dangerous than they are

What maintains panic?

Misinterpretation of physical and psychological symptoms

Safety behaviours

Effects of these on beliefs

Avoidance (preventing exposure) and escape (exiting fear-provoking situation) which are highly reinforcing