CHAPTER 5A

What are Fear and Anxiety?

HPA Axis and Anxiety

  • Hypothalamus (Control Centre):

    • Detects threat.

    • Sends alarm signal.

  • Pituitary Gland (Messenger):

    • Releases ACTH (adrenocorticotropic hormone).

    • Carries message to adrenal glands.

  • Adrenal Glands (Responders):

    • Release cortisol and adrenaline.

    • Fuel the “fight or flight” response.

  • Putting it Together:

    • In fear: Short-term, adaptive activation that shuts off once the threat passes.

    • In anxiety disorders: The alarm keeps ringing even without a real threat, leading to chronic stress.

Nervous System and Anxiety

  • Peripheral Nervous System:

    • Components: Somatic nervous system, Autonomic nervous system.

    • Sympathetic Nervous System (SNS): Activated when fearful.

    • Parasympathetic Nervous System (PNS): Returns body to normal resting state.

Fear vs. Anxiety

  • Fear:

    • Immediate response to a real, present threat.

    • Short-lived, activates fight-or-flight.

    • Adaptive in the moment (keeps us safe).

  • Anxiety:

    • Future-oriented response to possible threats.

    • Longer-lasting, involves worry and tension.

    • Can be adaptive (preparation) or maladaptive (false alarms).

  • Key Points:

    • Fear acts as an emergency brake when danger is present.

    • Anxiety serves as a warning light concerning potential future events.

The Elements of Anxiety

  • Physiological Components:

    • Heightened level of arousal and physiological activation.

    • Symptoms include higher heart rate, shortness of breath, dry mouth.

  • Cognitive Components:

    • Subjective perception of arousal.

    • Symptoms include worry and rumination with a future focus.

  • Behavioural Components:

    • Evocation of avoidance behaviors and safety-seeking behaviors.

Adaptive vs. Maladaptive Fear and Anxiety

  • Most symptoms of psychopathology stem from normal experiences.

  • Distinction between adaptive (functional) and maladaptive (dysfunctional) fear and anxiety.

Typical vs. Atypical Anxiety

  • Most anxieties are transient and can be adaptive.

  • They may become excessive or inappropriate when:

    • Functionality is impaired.

    • Developmental considerations arise.

    • Sociodemographic factors are influenced.

Gender Differences in Anxiety Disorders

  • Women report more fears and anxiety than men.

  • Despite these reports, physiological reactions in anxiety-provoking situations are similar between genders.

  • Discussion: What societal factors may explain this difference?

Overview of Anxiety Disorders

  1. Specific Phobia

  2. Panic Disorder and Agoraphobia

  3. Generalized Anxiety Disorder

  4. Social Anxiety Disorder

Epidemiological Considerations in Anxiety Disorders

  • Prevalence in Canada and the US:

    • Lifetime prevalence rate: 31% (Katzman et al., 2014).

    • Common psychological disorder.

  • Youth Prevalence:

    • Rates between 8.6% - 15.7% (Costello et al., 2003; Essau et al., 2000).

    • Average onset age: 11 years (Kessler et al., 2005).

  • Comorbidity:

    • High rates of co-occurring conditions, personal suffering, compromised quality of life, and social functioning issues.

    • Linked to lower educational attainment and increased help-seeking behaviors, including medication use.

    • Financial costs are significant.

Common Phobias

  • Illness/Injury

  • Storms

  • Animals

  • Agoraphobia

  • Death

  • Crowds

  • Heights

Specific Phobia

  • Key Feature: Irrational fear of specific objects or situations that markedly interferes with functions.

  • Prevalence: 12.5% of adults (Kessler et al., 2005).

  • Criteria for Phobia:

    1. Significant emotional distress.

    2. Functional impairment in daily activities.

    3. If no impairment exists, phobia diagnosis may not apply.

Subtypes of Specific Phobia

  • Blood-Injury-Injection Phobia

    • Symptoms: vasovagal syncope.

  • Situational Phobias

    • Examples: using public transport, driving through tunnels, flights, being in enclosed spaces.

  • Natural Environment Phobias

    • Examples: storms, heights, water.

  • Animal Phobias

    • Examples include common phobias related to animals or insects.

DSM-5 Criteria for Specific Phobia

A. Marked and out of proportion fear in environmental/situational context regarding specific object/situation.
B. Exposure provokes immediate anxiety response; possible panic attacks (situationally bound or predisposed).
C. Phobic situation often avoided or reacted to with intense anxiety/distress.
D. The person recognizes fear is out of proportion.
E. Fear/anxiety/avoidance persists for at least 6 months.
F. The avoidance, anxious anticipation, or distress notably interferes with normal routine, functioning, or social relationships.

Panic Attacks

  • Definition: Abrupt intense fear experience with physical symptoms.

  • Development:

    • Sudden onset, peaks within minutes.

  • Symptoms:

    • Somatic symptoms (physical) and cognitive symptoms (mental).

  • Statistics:
    As many as 28.3% of adults experience a panic attack; however, only 4.7% have panic disorder (Kessler et al., 2006).

  • Types:

    • Cued (expected) or Uncued (unexpected; false alarm).

  • Misinterpretation of panic attack can lead individuals to seek emergency services.

DSM-5 Criteria for Panic Attack

  • Criteria: An abrupt surge of intense fear or discomfort reaching maximum within minutes while experiencing four or more of the following:

    1. Palpitations, pounding heart, or accelerated heart rate.

    2. Sweating.

    3. Trembling or shaking.

    4. Shortness of breath or sensations of smothering.

    5. Feelings of choking.

    6. Chest pain or discomfort.

    7. Nausea or abdominal distress.

    8. Feeling dizzy, lightheaded, or faint.

    9. Chills or heat sensations.

    10. Paresthesias (numbness or tingling).

    11. Derealization or depersonalization.

    12. Fear of losing control or going crazy.

    13. Fear of dying.

Panic Disorder

  • Key Feature: At least one panic attack followed by persistent worry regarding potential future attacks.

    • Concerns include health implications (e.g., "Am I developing a heart condition?") and mental health (e.g., "Am I losing my mind?").

    • Behavioral changes may occur due to fear of panic attacks, including avoidance behaviors in daily life.

DSM-5 Criteria for Panic Disorder

A. Recurrent unexpected panic attacks.
B. At least one attack is followed by one month or more of either:

  1. Persistent concern regarding additional attacks and their consequences.

  2. Significant maladaptive behavior change (e.g., avoidance).
    C. Disturbance not attributable to substance effects or a medical condition.
    D. Not better explained by another mental disorder.

Agoraphobia

  • Definition: Fear of situations where escape might be difficult or help unavailable, leading to avoidance behaviors.

  • Symptoms:

    • Intense fear/anxiety in certain situations; not all individuals with agoraphobia experience panic attacks.

DSM-5 Criteria for Agoraphobia

A. Marked fear/anxiety regarding two or more situations from the following:

  1. Using public transport (e.g., buses, subways).

  2. Being in open spaces (e.g., markets, bridges).

  3. Being in enclosed spaces (e.g., theaters, elevators).

  4. Standing in line or being in a crowd.

  5. Being outside of the home alone.
    B. Fear or avoidance occurs due to thoughts that escape might be difficult or help unavailable.
    C. Agoraphobic situations generally provoke fear/anxiety.
    D. Actively avoided, requires a companion, or endured with intense fear/anxiety.
    E. Fear/anxiety is disproportionate to actual danger posed.
    F. Persistence of fear/anxiety/avoidance for at least 6 months.
    G. Causes significant distress or impairment in functioning.
    H. If other medical conditions exist, they must not account for the fear/anxiety.
    I. Not better explained by symptoms of another mental disorder.

Panic Disorder & Agoraphobia Statistics

  • According to Kessler et al., 2005:

    • 3.7% of adults have panic disorder without agoraphobia.

    • 1% of adults have panic disorder with agoraphobia.

    • 1.4% of adults have agoraphobia without panic disorder.

  • Gender Differences:

    • Females are more likely to experience panic disorders/panic attacks.

  • Cultural considerations: Includes conditions such as Ataque de nervios, Khyal, and Trung Gio.

  • Associated mental health concerns: Sadness, depression, suicidal ideation.

Generalized Anxiety Disorder (GAD)

  • Key Feature: Excessive anxiety and worry occurring most days for a minimum of 6 months.

  • Symptoms:

    • Muscle tension, mental agitation, fatigue, irritability, difficulty sleeping.

    • Common experience: "I always find something to worry about."

  • Epidemiology:

    • Prevalence in community and clinical samples: 5-10% (Maier et al., 2000; Wittchen & Hoyer, 2001).

    • More common among females and adults as opposed to children.

DSM-5 Criteria for Generalized Anxiety Disorder

A. Excessive anxiety and worry occurring more days than not for at least 6 months regarding various events or activities.
B. Difficulty controlling the worry.
C. Anxiety and worry associated with three or more of the following six symptoms (at least some symptoms have been present more days than not for the past 6 months):

  1. Restlessness or feeling keyed up.

  2. Being easily fatigued.

  3. Difficulty concentrating or mind going blank.

  4. Irritability.

  5. Muscle tension.

  6. Sleep disturbances (issues falling/staying asleep, or unsatisfying sleep).
    D. Anxiety/worry/physical symptoms cause clinically significant distress or impairments in social/occupational functioning.
    E. Not attributable to substance effects or another medical condition.
    F. Not better explained by another mental disorder.

Social Anxiety Disorder

  • Statistic: A survey indicating average person's greatest fear is public speaking, ranked higher than death.

  • Key Feature: Fear of social situations involving scrutiny from others.

  • Prevalence: 12-month prevalence rate: 7%; average onset: ages 11-13.

  • Detection: Can be identified as early as age 8.

  • Distressing social situations include:

    • Speaking, eating, drinking, and writing in the presence of others; engaging in conversations at social gatherings.

  • Impact: Fear of rejection due to perceived anxiety leading to impairment in educational, occupational, and social functioning.

  • Behavioral Coping: Many rely on alcohol to reduce social distress.

DSM-5 Criteria for Social Anxiety Disorder

A. Marked fear/anxiety regarding one or more social situations exposing individual to scrutiny by others (e.g., interactions, observations, performances).
B. Fear that anxiety symptoms will be negatively evaluated (e.g., humiliation, embarrassment, offending others).
C. Social situations almost always provoke fear/anxiety.
D. Situations avoided or endured with significant anxiety.
E. Fear/anxiety disproportionate to actual threat posed.
F. Fear/anxiety/avoidance persists for at least 6 months.
G. Causes clinically significant distress or impairment in key areas of functioning.
H. Not attributable to substance effects or another medical condition.
I. Not better explained by symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
J. Specify if: Performance only if fear is limited to speaking or performing in public.

Developmental Trajectory of Social Anxiety Disorder

  • Patterns:

    • Negative developmental trajectory, chronic, pervasive.

  • Consequences:

    • Avoidance prevents the learning of appropriate social behaviors.

Etiology of Anxiety Disorders

Biological Perspective

Family and Genetic Studies

  • Inheritance Patterns: Relatives of individuals with anxiety disorders have a higher likelihood of developing anxiety themselves.

  • Twin Studies:

    • Concordance rates for monozygotic twins: 34%; dizygotic twins: 17%.

  • Heritability: Approximately 20-40%, indicating individual genetic influences, but no disorder is 100% inherited.

  • Inherited Factors: General vulnerability to anxiety and trait anxiety.

Neuroanatomy

  • Stress activates the amygdala and hippocampus, which may play roles in developing anxiety disorders.

  • Different disorders linked to distinct brain areas:

    • Social Anxiety Disorder: Amygdala, insula.

    • OCD: Orbital prefrontal cortex, caudate nucleus.

  • Longitudinal Studies: Needed to elucidate neuroanatomical contributions.

Neurotransmitters

  • Key Neurotransmitters:

    • Serotonin: Regulation of mood, thoughts, and behaviors; significant role in anxiety.

    • GABA: Inhibits postsynaptic activity, reducing anxiety responses.

  • Brain Imaging Technologies:

    • CT, fMRI, SPECT, PET being explored, research is ongoing.

Psychological Perspective

Behavioral Theories of Fear Acquisition

  • Direct Conditioning Theory:

    • e.g., Little Albert experiment illustrates learned fears.

  • Observational Learning/Vicarious Conditioning:

    • Anxiety can develop through observation of others (e.g., friends, parents).

  • Protective Factors: Positive experiences may serve as protective buffers against anxiety.

  • Information Transmission:

    • Through instruction, individuals learn to fear certain situations or objects.

Cognitive Theories of Fear Acquisition

  1. Maladaptive Thoughts:

    • Inaccurate interpretations of internal events (e.g., "My heart is racing, thus I may have a heart attack").

    • Inaccurate interpretations of external events (e.g., "My boss is yawning during my speech; I must be boring").

    • Negative automatic thoughts perpetuating anxiety without evidence checks.

  2. Fear of Fear Model:

    • Post-panic attack sensitivity towards physiological symptoms and misinterpretation of normal change as panic attack signals.

Integrated Model - Triple Vulnerability Model

  • Contributions to Anxiety Disorders:

    • Biological vulnerability (heritable traits towards negative affectation).

    • Specific psychological vulnerability (associating physical sensations as dangerous).

    • Generalized psychological vulnerability (sense of lack of control/unpredictability).

Diagram:

  • If individuals possess all three vulnerabilities, their chances of developing an anxiety disorder significantly increase after a stressful event.

Treatment of Anxiety Disorders

Biological Treatments

Medication

  • Certain anxiety disorders linked to serotonin depletion.

  • Selective Serotonin Reuptake Inhibitors (SSRIs):

    • Examples: Prozac, Zoloft, Paxil.

    • Effective for panic disorder (with or without agoraphobia), social anxiety disorder, generalized anxiety disorder.

    • More effective than placebos but not universally effective.

  • Considerations: Relapse is common after medication withdrawal; phobias may be resistant to medication.

  • Child Specifics: Caution with SSRIs in children and adolescents due to risk of increased suicidal ideation.

GABA and Benzodiazepines

  • GABA’s Role: Related to anxiety regulation.

  • Benzodiazepines:

    • Examples: Valium, Xanax.

    • Effective for panic disorder, generalized anxiety disorder, and social anxiety disorder.

    • Risk of psychological dependence; medical supervision necessary for withdrawal to prevent seizure risks.

    • Not a first-line treatment option.

Somatic Therapies

  • Transcranial Magnetic Stimulation: Non-invasive procedure with magnetic stimulation of brain nerve cells.

  • Deep Brain Stimulation: Involves implanting a device that sends electrical impulses to specific brain targets.

  • Research ongoing on the efficacy of these therapies.

Psychological Treatments

Behavioral and Cognitive-Behavioral Treatment

  • First-line treatment for anxiety, OCD, and trauma-related disorders in children, adolescents, and adults.

  • Approximately 70% of patients demonstrate improvement when administered correctly.

  • Modalities include:

    • Exposure therapy (facing fears directly).

    • Real-life exposure (in vivo).

    • Imaginal exposure.

    • Interoceptive exercises designed to expose sensations associated with anxiety.

Additional Strategies

  • Relaxation Training and Biofeedback: Aims to reduce physiological arousal levels.

  • Cognitive Restructuring: Facing anxiety-inducing situations while reflecting on negative thoughts.

    • Determine if perceived worst outcomes occur.

    • Construct positive cognitions to counteract negative thoughts.

Virtual Reality Exposure Therapy

  • Utilizes virtual reality environments to expose individuals to anxiety issues tied specifically to phobias or social circumstances.

Conclusion

  • Treatment of anxiety disorders can utilize a combination of psychotherapy, medication, or both approaches.

  • Among psychotherapeutic interventions, Cognitive Behavioral Therapy (CBT) shows the most significant evidence for successful outcomes.

  • Psychodynamic therapy is recommended as a second-line treatment option.