Anxiety Disorders Lecture Notes

Anxiety Disorders

Introduction to Anxiety

• Anxiety disorders are a category of mental illnesses.
• Everyone experiences a range of emotions, from feeling great to feeling awful.
• Mental health exists on a continuum; everyone has it and can take steps to improve it.
• Mental illness is a diagnosable condition requiring support from mental health specialists.

Diagnosing Mental Illness

• Diagnosis can be made by a general practitioner, psychologist, or psychiatrist.
• Tests are conducted to rule out other medical issues.
• Assessment tools include external observation and self-reporting.
• The primary tool for classification and diagnosis is the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Components of Anxiety

• Physiological: Heightened arousal (e.g., increased heart rate, shortness of breath).
• Cognitive: Subjective perception of arousal and worry.
• Behavioral: Safety behaviors and avoidance.

Prevalence of Anxiety Disorders

• Anxiety disorders are the most common psychological disorders.
• Gender differences exist; 16% of women and 9% of men suffer from anxiety disorders.
• The highest prevalence is in women aged 15 to 24.

Types of Anxiety Disorders

• Separation Anxiety: Anxious arousal and worry about losing contact with significant others.
• Specific Phobia: Fear and avoidance of objects or situations that pose no real danger.
• Social Anxiety Disorder: Fear of social situations due to possible negative evaluation.
• Panic Disorder: Recurrent panic attacks with physiological symptoms and feelings of doom.
• Agoraphobia: Fear of public places where escape may be difficult.
• Generalized Anxiety Disorder: Persistent worry about everyday life events without obvious reason.

Separation Anxiety

• Excessive fear or anxiety concerning separation from attachment figures.
• Prevalence:
  • Children: approximately 4% in the US.
  • Adolescents: 1.6% in the US.
  • Adults: 0.9% to 1.9% in the US.

Diagnostic Criteria (DSM 5 - TR)

1. Inappropriate and excessive fear or anxiety about separation, evidenced by at least three of:
   • Recurrent distress when anticipating or experiencing separation.
   • Persistent worry about losing attachment figures or harm to them.
   • Worry about experiencing an event that causes separation.
   • Reluctance to go out, away from home, to school, or work due to fear of separation.
   • Fear of being alone without attachment figures.
   • Reluctance to sleep away from home or without being near an attachment figure.
   • Repeated nightmares involving separation.
   • Physical symptoms when separation occurs or is anticipated.
2. The fear, anxiety, or avoidance lasts at least 4 weeks in children/adolescents and 6 months or more in adults.
3. Causes clinically significant distress or impairment.
4. Not better explained by another mental disorder.

Specific Phobias

• Unwarranted fears caused by the presence or anticipation of a specific object or situation.
• The fear and avoidance are disproportionate to the actual danger.
• Causes intense distress and impairment.
• Prevalence:
  • United States: 8%–12%.
  • European countries: approximately 6%.
  • Asian, African, and Latin American countries: 2-4%.
  • Children: approximately 5%.
  • Adolescents: approximately 16%.
  • Adults: 3-5%.
  • More common in women than men (2:1).

Subtypes of Phobias

• Blood-Injection-Injury

  • getting shot, donating blood, going to the doctor or dentist, getting a needle

• Situations

  • enclosed spaces, elevators, planes

• Animals

  • insects, dogs, snakes

• Natural Environments

  • storms, water, heights

• Other

  • choking, vomiting, clowns

• Specific phobias tend to be long-lasting (mean duration of 20 years).

• Only 8% of people with a specific phobia received treatment.

Common Phobia Subtypes

1. Animal phobias.
2. Heights.
3. Closed spaces.
4. Flying.
5. Water.
6. Dentist.
7. Blood/injections.
8. Storms.

Diagnostic Criteria (DSM 5 - TR)

1. Marked fear or anxiety about a specific object or situation.
2. The phobic object or situation almost always provokes immediate fear or anxiety.
3. Actively avoided or endured with intense fear or anxiety.
4. Fear or anxiety is out of proportion to the actual danger.
5. Persistent, typically lasting 6 months or more.
6. Causes clinically significant distress or impairment.
7. Not better explained by another mental disorder.

Social Anxiety Disorder

• Fearful or anxious about social interactions involving possible negative evaluation.
  • Meeting unfamiliar people, eating or drinking in public, performing in front of others.
• Concerns about physiological signs of anxiety being observed.

Types

• Speaking or performing in public.
• Social interactions.
• Being observed in public.

Prevalence

• Onset during adolescence, though can occur in children.
• Lifetime prevalence in Canada: 7.5% in men and 8.7% in women.
• Average age of onset: 13 years, with an average duration of symptoms of 20 years.
• Higher prevalence among those never married, divorced, with lower education/income, unemployed, lacking social support, low quality of life, or chronic physical conditions.

Diagnostic Criteria (DSM 5 - TR)

1. Marked fear or anxiety about social situations involving possible scrutiny.
2. Fears of acting in a way or showing anxiety symptoms that will be negatively evaluated.
3. Social situations almost always provoke fear or anxiety.
4. Avoided or endured with intense fear or anxiety.
5. Fear or anxiety is out of proportion to the actual threat.
6. Persistent, typically lasting 6 months or more.
7. Causes clinically significant distress or impairment.
8. Not attributable to substance use or another medical condition.
9. Not better explained by another mental disorder.
10. If another medical condition is present, the fear, anxiety, or avoidance is unrelated or excessive.

• Specify if: Performance only (fear is restricted to speaking or performing in public).

Theories of Causes of Specific Phobias and Social Anxiety

Behavioral Theories

• Disorders are 'learned'.
  • Avoidance conditioning.
  • Modeling.
  • Prepared learning.
  • Social Skills Deficits

Avoidance Conditioning

• Reactions are learned avoidance responses.
  • Classical conditioning: neutral stimulus (CS) paired with a frightening event.
  • Operant conditioning: fear maintained by escaping or avoiding the CS.

Modelling

• Person can learn fear through imitating the reaction of others (vicarious learning).

Prepared Learning

• Some fears reflect classical conditioning to stimuli to which an organism is physiologically prepared to be sensitive.

Social Skills Deficits

• Inappropriate behavior or lack of social skills causes social anxiety.

Cognitive Theories

• People’s thought processes can serve as a diathesis and thoughts can maintain a phobia or anxiety.
• People who experience phobias or social anxiety are more likely to:
  • attend to negative stimuli;
  • interpret ambiguous information as threatening; and
  • believe that negative events are more likely than positive ones to re-occur.

Cognitive-Behavioral Models of SAD

• Attentional bias to focus on negative social information.
• Perfectionistic standards for accepted social performances.
• High degree of public self-consciousness.

Post-Event Processing (PEP)

• A form of rumination about previous experiences, particularly negative social experiences; the core thematic fear being “the self is deficient”.

Biological Theories

• Predisposing Biological Factors
  • Greater activity in the amygdala and the insula
• Autonomic lability
  • Individuals have autonomic systems that are readily aroused by a wide range of stimuli.
  • Autonomic lability is to some degree genetically determined
• Genetic Factors
  • Heredity may have a significant role in the development of phobias.
  • Jerome Kagan has focused on the trait of behavioural inhibition or shyness.

Psychoanalytic Theories

• Phobias are a defense against the anxiety produced by repressed id impulses.
• Anxiety is displaced from the feared id impulse and moved to an object or situation that has some symbolic connection to it.
• By avoiding them the person is able to avoid dealing with repressed conflicts.

Panic Disorder

• Sudden and often inexplicable attack of alarming symptoms:
  • Rapid or labored breathing, heart palpitations, nausea, and chest pain.
  • Feelings of choking and smothering.
  • Dizziness, sweating, and trembling.
  • Intense apprehension, terror, and feelings of impending doom.
  • Depersonalization, Derealization.

Diagnostic Criteria (DSM 5 - TR)

1. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:
   • Palpitations.
   • Pounding heart, or accelerated heart rate.
   • Sweating, trembling or shaking.
   • Sensations of shortness of breath or smothering.
   • Feelings of choking.
   • Chest pain or discomfort.
   • Nausea or abdominal distress.
   • Feeling dizzy, unsteady, light-headed, or faint.
   • Chills or heat sensations.
   • Paresthesias.
   • Derealization or depersonalization.
   • Fear of losing control or "going crazy".
   • Fear of dying.
2. 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
   * A significant maladaptive change in behavior related to the attacks
3. The disturbance is not attributable to the physiological effects of a substance or another medical condition.
4. The disturbance is not better explained by another mental disorder.

Prevalence

• The 12-month prevalence of panic attacks is 6.4%.
• Women are more affected than men (2:1).
• Prevalence is low before 14, rates increase in adolescence, peak during adulthood, and decline in older adults.

Panic Disorder with or without Agoraphobia

• Agoraphobia is a cluster of fears centering on public places and being unable to escape or find help.
• Requires anxiety in at least 2 of 5 situations: public transportation, open spaces, enclosed spaces, lines/crowds, being out of the house alone.

Diagnostic Criteria for Agoraphobia (DSM 5 - TR)

1. Marked fear or anxiety about two (or more) of the following five situations:
   • Using public transportation.
   • Being in open spaces.
   • Being in enclosed places.
   • Standing in line or being in a crowd.
   • Being outside of the home alone.
2. 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.
3. The agoraphobic situations almost always provoke fear or anxiety.
4. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
5. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.
6. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
7. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational,or other important areas of functioning.
8. If another medical condition is present, the fear, anxiety, or avoidance is clearly excessive.
9. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder

Generalized Anxiety Disorder (GAD)

• Persistently anxious and overly concerned about minor items.
• Chronic, uncontrollable worries about everything.
• Difficulty concentrating, tiring easily, restlessness, irritability, and muscle tension.
• Typically begins in mid-teens.
• 12-month prevalence - 0.9% among adolescents and 2.9% among adults in the general community of the United States.

Diagnostic Criteria (DSM 5 - TR)

1. Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities.
2. The individual finds it difficult to control the worry.
3. The anxiety and worry are associated with three (or more) of the following six symptoms:
   • Restlessness.
   • Being easily fatigued.
   • Difficulty concentrating.
   • Irritability.
   • Muscle tension.
   • Sleep disturbance.
4. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment.
5. The disturbance is not attributable to the physiological effects of a substance or another medical condition.
6. The disturbance is not better explained by another medical disorder.

Therapies for Anxiety Disorders

• People with anxiety disorders are much less likely than people with other disorders to seek treatment.
• Lack of information about anxiety was cited as a reason for non-treatment seeking behavior.

Systematic Desensitization

• Create an anxiety hierarchy rating of fears.
• Relax and then start with the smallest fear and work up to conquering the greatest fears.

In Vivo and Virtual Reality Exposure

• In vivo exposure outperformed other modes of exposure at post-treatment.
• VR exposure is just as effective as in vivo exposure.

Blood and Injection Phobias

• Relaxation tends to make matters worse.
• Clients are now encouraged to tense rather than relax their muscles when confronting the fearsome situation.

Social Skills Training for SAD

• Learning social skills can help people with SAD.
• Role-playing interpersonal encounters.

Behavioral Therapy for GAD

• Generalized treatment (intensive relaxation training).
• Clients are taught to relax away low-level tensions.

Cognitive Treatments for Phobias

• The phobic fear is recognized by the individual as excessive or unreasonable.
• There is no evidence that the elimination of irrational beliefs alone, without exposure to the fearsome situations, reduces phobic avoidance

Exposure-based Treatments for Panic Disorders

• Panic-control therapy.
  • relaxation training
  • a combination of Ellis-and-Beck-type CBT
  • exposure to the internal cues that trigger panic

Psychoanalytic Approaches to Anxiety Treatment

• Attempt to uncover the repressed conflicts.
• Direct attempts to reduce phobic avoidance were contraindicated.

Biological Treatments for Anxiety Disorders