Anxiety Disorders

Generalized Anxiety Disorder

learning objective : describe the features and characteristic symptoms of anxiety disorders (generalized anxiety disorder, panic disorder, phobias), obsessive-compulsive disorder and post traumatic stress disorder; differentiate these anxiety from each other

anxiety : the nervousness or agitation that we sometimes experience, often about something that is going to happen

anxiety is an important and useful human emotion; it is associated with the activation of the sympathetic nervous system and the physiological and behavioral responses that help protect us from danger
too much anxiety can be debilitating

anxiety disorders : psychological disturbances marked by irrational fears, often of everyday objects and situations

generalized anxiety disorder (GAD) : a psychological disorder diagnosed in situations in which a person has been excessively worrying about money, health, work, family life, or relationships for at least 6 months, even though they know that the concerns are exaggerated, and when the anxiety causes significant distress and dysfunction.

People Who Suffer From GAD May Also Experience A Variety of Physical Symptoms Including :

irritability
sleep troubles
difficulty concentrating
muscle aches
trembling
perspiration
hot flashes

the cannot deal with what is causing the anxiety, nor avoid it, because there is no clear cause for anxiety
the sufferer frequently knows, at least cognitively, that there is really nothing to worry about
about 10 million Americans suffer from GAD
two thirds of those who suffer from GAD are women
GAD is likely to develop between 7 and 40 years
in some cases GAD may lessen with age

DSM-5 Criteria for Generalized Anxiety Disorder

Excessive anxiety about a number of events or activities, occurring more days than not, for at least 6 months.
The person finds it difficult to control the worry.

The anxiety and worry are associated with at least three of the following six symptoms (with at least some symptoms present for more days than not, for the past 6 months):

Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or general medical condition (hyperthyroidism).
The disturbance is not better explained by another mental disorders (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder).

Overall : The defining feature of Generalized Anxiety Disorder is excessive worry, which is accompanied by physical symptoms like insomnia and muscle tension. The symptoms need to be present more days than not for at least six months in order to meet the diagnostic criteria for Generalized Anxiety Disorder.

Panic Disorder

panic disorder : a psychological disorder characterized by sudden attacks of anxiety and terror that have led to significant behavioral changes in the person’s life.

Symptoms of a panic attack :

shortness of breath
heart palpitations
trembling
dizziness
choking sensations
nausea
intense feeling of dread or impending doom

panic attacks can can often be mistaken for heart attacks or other serious physical illnesses
may lead the person experiencing them to go to a hospital or emergency room
panic attacks may last up to 20 minutes, but often subside within about 10 minutes
sufferers are often anxious about experiencing another attack, focusing on the thoughts and images of their fears, becoming excessively sensitive to cues that signal the possibility of threat
they may be unsure of the cause, and may misattribute the cause to a completely unrelated subject
as a result, the sufferer may begin avoiding places where attacks have occurred in the past, such as driving, using an elevator, or being in public places
panic disorder affects about 3% of the American population in a given year

DSM-5 Criteria for Panic Disorder

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: Note: The abrupt surge can occur from a calm state or an anxious state.

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 stress.
Feeling dizzy, unsteady, light-headed, or faint.
Chills or heat sensations.
Paresthesias (numbness or tingling sensations).
Derealization (feelings of unreality) or depersonalization (being detached from one-self).
Fear of losing control or “going crazy.”
Fear of dying.

Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

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).

The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).

The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; or in response to reminders of traumatic events, as in post traumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).

In Summary : A period of time characterized by sudden anxiety and terror is known as a panic attack. These usually last about 10 minutes. Sufferers of panic attacks exhibit significant change in behavior as a result of feeling fear about having another panic attack and its consequences.

Phobias

phobia : a specific fear of a certain object, situation, or activity

fear experience can range from a sense of unease to a full-blown panic attack
most people learn to live with their phobias but for others, the fear can be so debilitating that they go to extremes to avoid the fearful situation
phobias are characterized by their specificity and their irrationality

social phobia : a common phobia where one has extreme shyness around people or discomfort in social situations

social phobia may be specific to a certain event or it can be a more generalized anxiety toward almost all people outside of close family and friends

People With Social Phobia Will Often Experience Physical Symptoms in Public, Such As :

sweating profusely
blushing
stuttering
nausea
dizziness

they are convinced that everybody around them notices these symptoms as they are occurring
women are more likely than men to suffer from social phobia

agoraphobia : anxiety about being in places or situations from which escape might be difficult or embarrassing, or in which help may not be available

often occurs with panic disorder
the individual may be concerned about having a panic attack in the feared situation

Typical Places That Provoke Panic Attacks Are :

parking lots
crowded streets
crowded shops
bridges
tunnels
expressways

people who suffer from agoraphobia may have great difficulty leaving their homes and interacting with other people
phobias affect 9% of American adults
phobias are twice as prevalent in women as in men
in most cases phobias appear in childhood and persist into adulthood

DSM-5 Criteria for Specific Phobia

Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

The phobic object or situation almost always provokes immediate fear or anxiety. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.

The phobic object or situation 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 or more.

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

The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety and avoidance of: situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in post traumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).

DSM Criteria for Social Anxiety Disorders (Social Phobia)

Marked fear or anxiety about one or more social situations in which the person is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation; meeting unfamiliar people), being observed (e.g., eating or drinking), or performing in front of others (e.g., giving a speech). Note: In children, the anxiety must occur in peer settings and not just in interactions with adults.

The individual fears that they will act in a way, or show anxiety symptoms, that will be negatively evaluated (i.e., will be humiliating, embarrassing, lead to rejection or offend others).

The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

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 for 6 months or more.

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

The fear, anxiety or avoidance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

The fear, anxiety or avoidance is not better explained by the symptoms of another medical disorder, such as panic disorder (e.g., anxiety about having a panic attack) or separation anxiety disorder (e.g., fear of being away from home or a close relative).

If another medical condition (e.g., stuttering, Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety or avoidance is clearly unrelated or is excessive.

Specify if: Performance only: If the fear is restricted to speaking or performance in public.

DSM-5 Criteria for Agoraphobia

Marked fear or anxiety about two or more of the following five situations: Public transportation, open spaces, enclosed places, standing in line or being in a crowd, being outside the home alone.

The individual fears or avoids these situations due to the thoughts that escape might be difficult or help may not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly, fear of incontinence).

The agoraphobic situations almost always provoke fear or anxiety.

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

The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations, and to the sociocultural context.

The fear, anxiety or avoidance is persistent, typically lasting for 6 months or more.

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

If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety or avoidance is clearly excessive.

The fear, anxiety or avoidance is not better explained by the symptoms of another mental disorder, e.g., the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder) and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived deficits or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in post traumatic stress disorder), or fear of separation (as in separation anxiety disorder).

Phobia :	Description :
agoraphobia	fear of not being able to escape from a situation
social phobia	incapacitating fear of social situations
claustrophobia	fear of enclosed spaces
acrophobia	fear of heights

In Summary : A phobia is a specific fear regarding a certain object, situation, or activity. The level of anxiety and fear significantly interferes with normal routine, occupational functioning, or social relationships.

Obsessive-Compulsive and Related Disorders

learning objective : Describe the features and characteristic symptoms of anxiety disorders (generalized anxiety disorder, panic disorder, phobias), obsessive-compulsive disorder and post traumatic stress disorder; differentiate these anxiety disorders from each other.

obsessive-compulsive disorder ( OCD ) : a psychological disorder that is diagnosed when an individual continuously experiences obsessions (distressing, intrusive, or frightening thoughts), and engages in compulsions (repetitive behaviors or mental acts) in an attempt to calm these obsessions

OCD is diagnosed when the obsessive thoughts are so disturbing and the compulsive behaviors are so time consuming that they cause distress and significant dysfunction in a person’s everyday life
the sufferers know that these rituals are senseless, but they cannot bring themselves to stop them, in part because the relief they feel after they perform the acts as a reinforcer, making the behavior more likely to occur again
sufferers of OCD may avoid certain places that trigger the obsessive thoughts or may use alcohol or drugs to try to calm themselves down
OCD has a low prevalence rate in relation to other anxiety disorders
usually develops in adolescence or early adulthood
symptoms can come and go, decrease, or worsen over time

DSM-5 Criteria for Obsessive-Compulsive Disorder

Presence of obsessions, compulsions or both:

Obsessions are defined by:

Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that in most individuals cause marked anxiety or distress
The individual attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action

Compulsions are defined by:

Repetitive behaviors (e.g., handwashing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day), or cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder, or preoccupation with appearance, as in body dysmorphic disorder).

In Summary : Obsessive-compulsive disorder is characterized by obsessions, which are repetitive, distressing thoughts and/or compulsions, which are repetitive behaviors. The obsessions or compulsions cause marked distress, take up more than one hour a day, or significantly interfere with the person’s normal routine, occupation, or usual social activities.

Posttraumatic Stress Disorder (PTSD)

learning objective : Describe the features and characteristic symptoms of anxiety disorders (generalized anxiety disorder, panic disorder, phobias), obsessive-compulsive disorder and posttraumatic stress disorder; differentiate these anxiety disorders from each other.

through much of the 20th century ptsd was called shell shock and combat neurosis because its symptoms were observed in soldiers who had engaged in wartime combat
by the late 1970's it became clear that people who had faced sexual traumas often experienced the same set of symptoms as soldiers
the term ptsd was developed given that those symptoms could happen to anyone who experienced psychological trauma

A Broader Definition of PTSD

ptsd is listed among the ‘trauma and stressor related disorders’ in the DSM-5
for a person to be diagnosed with PTSD, they must be exposed to, witness, or experience the details of a traumatic experience, one that involves ‘actual or threatened death, serious injury, or sexual violence’
These experiences can include : combat, threatened or actual physical attack, sexual assault, natural disasters, terrorist attacks, and automobile accidents
this criteria makes ptsd the only disorder listen in the DSM in which a cause is explicitly specified

Symptoms of PTSD Include :

intrusive and distressing memories of the event
flashbacks
avoidance of stimuli connected to the event
persistently negative emotional states
feelings of detachment from others
irritability
proneness toward outbursts
exaggerated startle response

flashbacks : states that can last from a few seconds to several days, during which the individual relives the event and behaves as if the event were occurring at that moment

for ptsd to be diagnosed these symptoms need to be present for at least one month
roughly 7% of adults in the United States experience ptsd in their lifetime
there are higher rates among people exposed to mass trauma and people whose jobs involve duty-related trauma exposure
nearly 21% of residents of areas affected by Hurricane Katrina suffered from ptsd
12.6% of Manhattan residents had ptsd 2-3 years after 9/11
women are highly more likely to experience ptsd in their lifetime

Risk Factors for PTSD

Several Factors Strongly Predict the Development of PTSD :

trauma experience
greater trauma severity
lack of immediate social support
more subsequent life stress

traumatic events that involve harm by others carry greater risk than other traumas
factors that increase the risk of ptsd in the female gender are low socioeconomic status, low intelligence, personal history of mental disorders, family history of mental disorders, and history of childhood adversity
personality characteristics such as neuroticism and have been shown to elevate the risk of ptsd
people who experience childhood adversity o traumatic experiences during adulthood are at significantly higher risk of developing ptsd if they possess one or two short versions of a gene that regulates the neurotransmitter serotonin
ptsd’s development is influenced by the interaction of psychosocial and biological factors

Support for Sufferers of PTSD

research has shown that social support following a traumatic event can reduce the likelihood of ptsd

social support : the comfort, advice, and assistance received from relatives, friends, and neighbors.

social support can help individuals cope during difficult times by allowing them to discuss feelings and experiences and providing a sense of being loved and appreciated

DSM-5 Criteria for Posttraumatic Stress Disorder

Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

Directly experiencing the traumatic event(s).
Witnessing, in person, the event(s) as they occurred to others.
Learning that the events(s) occurred to a close relative or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
Experiencing repeated or extreme exposure to details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: This criterion does not apply to exposure through electronic media, television, movies, unless this exposure is work related.

Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

Recurrent, involuntary and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content.
Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings). Note: In children, trauma-specific reenactment may occur in play.
Intense or prolonged psychological distress or exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame themselves or others.
Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
Markedly diminished interest or participation in significant activities.
Feelings of detachment or estrangement from others.
Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
Reckless or self-destructive behavior.
Hyper-vigilance.
Exaggerated startle response.
Problems with concentration.
Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

Duration of the disturbance (previous four criteria) is more than 1 month.

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol), or another medical condition.

Is This A Symptom of PTSD?

Symptom :	Y :	N :
reduced anger response		no
flashbacks of the event	yes
insomnia	yes
terror	yes
depressed mood	yes
compulsions		no
avoiding reminders of the event	yes

Explaining Anxiety Disorders

learning objective : Identify and differentiate the underlying causes for these anxiety disorders (generalized anxiety disorder, panic disorder, phobias), obsessive-compulsive disorder and posttraumatic stress disorder.

both nature and nurture contribute to the development of anxiety disorders
humans have evolved to fear dangerous situations
our evolutionary experience can account for some modern fears
anxiety disorders and PTSD are heritable, and molecular genetics studies have found a variety of genes that are important in the expression of such disorders
neuroimaging studies have found that anxiety disorders are linked to areas of the brain that are associated with emotion, blood pressure, heart rate, decision making and action monitoring
people who experience PTSD also have a somewhat smaller hippocampus in comparison with those who do not, and this difference leads them to have a very strong sensitivity to traumatic events
whether or not genetic predisposition to anxiety becomes expressed as a disorder depends on environmental factors
People who were abused in childhood are more likely to be anxious than those who had normal childhoods, even with the same genetic disposition to anxiety sensitivity.
anxiety disorders stem from perceived, rather than actual, threats to our well-being
anxieties are learned through classical and operant conditioning
classical conditioning may be accompanied by stimulus generalization
people’s responses to their anxieties are often reinforced
behaviors become compulsive because they provide relief from the torment of anxious thoughts
leaving or avoiding fear inducing stimuli leads to feelings of calmness or relief, which reinforces phobic behavior

In Summary :

The reason that people tend to have phobias about things like heights and the dark suggests an evolutionary explanation of anxiety

The fact that people with PTSD have differences in their hippocampus compared to people without PTSD may be evidence for a genetic contribution to the development of PTSD