Comprehensive Notes on Anxiety Disorders (Bullet-Point Summary)
Anxiety Disorders: Comprehensive Notes
Overview definitions
Anxiety: a negative mood state characterized by bodily symptoms of physical tension and apprehension about the future.
Fear: an immediate alarm reaction to danger.
Panic: sudden overwhelming reaction.
Panic attack: abrupt experience of intense fear or acute discomfort with physical symptoms (e.g., heart palpitations, chest pain, shortness of breath, dizziness).
Fear vs Anxiety vs Panic (conceptual distinctions)
FEAR: Instantaneous reaction to real or perceived imminent threat; fight-or-flight response.
ANXIETY: Anticipation of future threat; sense of being unable to predict or control the future; complex blend of unpleasant emotions and cognitions oriented to the future.
PANIC ATTACK: Acute episode of intense fear with physical symptoms; can be expected or unexpected.
Summary of feeling states (from slides)
Anxiety: emotional state with negative affect, somatic tension, future-oriented concerns about predictability/control.
Fear: strong sympathetic arousal, immediate alarm to danger, escapist tendencies.
Panic Attack: fear event; two types: Expected and Unexpected.
Biological contributions to anxiety disorders
Evidence for heritable tendencies toward tense, uptight, and anxious dispositions; panic tendency can run in families with a genetic component distinct from general anxiety genetics.
Key biological factors: Depleted levels of GABA (gamma-aminobutyric acid); Corticotropin-releasing factor (CRF) system as a main expression of anxiety; Limbic system involvement.
Broader implication: biology predisposes toward negative affect and arousal, which interacts with learning and environment.
Psychological and social causes
Psychological: Freud’s view of danger-based psychic reaction; classical conditioning and modeling; anxiety often linked to a sense of uncontrollability.
Social: Stressful life events trigger biological/psychological vulnerabilities; diathesis-stress model (greater vulnerability requires less stress to trigger a disorder).
Integrative model of anxiety (biopsychosocial integration)
Biological vulnerability: heritable contribution to negative affect.
Generalized psychological vulnerability: sense events are uncontrollable/unpredictable (e.g.,
“Glass is half empty” mindset; irritability; driven tendencies).
Specific psychological vulnerability: e.g., physical sensations may be dangerous; health anxiety; lack of self-confidence; low self-esteem; poor coping skills.
Result: Generalized anxiety disorder arises from the interaction of these vulnerabilities and life events.
Illustrative figure concepts (as described in the slides): interactions among biological vulnerability, generalized psychological vulnerability, and specific psychological vulnerability leading to anxiety disorders.
Comorbidity and clinical significance
High comorbidity between anxiety disorders and depression; shared features of anxiety and panic.
Any anxiety disorder uniquely associated with various physical illnesses (thyroid, respiratory, GI, arthritis, migraine, allergies) in some epidemiological data; presence of anxiety often precedes physical disorder.
Panic disorder linked to increased suicide attempts in some studies (~20% in one study).
Generalized Anxiety Disorder (GAD)
Key features:
Excessive anxiety and worry (apprehensive expectation) more days than not for at least 6\text{ months} about a number of events/activities (e.g., work, school performance).
Difficult to control the worry.
Worry is associated with at least three (or more) of the following symptoms (for children, at least one):
Restlessness or being on edge
Easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
Distress/impairment in social, occupational, or other important areas.
Not due to substances or another medical condition; not better explained by another mental disorder.
Note for children: only one symptom is required.
Etiology and risk factors
Heritability for anxiety sensitivity: tendency to become distressed in response to arousal-related sensations, with beliefs that arousal has harmful consequences.
Causes and vulnerabilities (integrative view)
Generalized biological vulnerability: inherited tendencies related to arousal.
Generalized psychological vulnerability: belief that events are uncontrollable/unpredictable; anxious apprehension.
Specific vulnerability: tendency toward health/anxiety about physical sensations.
Treatment
Benzodiazepines often prescribed with some short-term relief; cognitive-behavioral therapy (CBT) is a primary long-term treatment.
Panic Disorder and Agoraphobia
Panic disorder: recurrent unexpected panic attacks; can occur with or without agoraphobia.
Panic attacks: range of physical symptoms (vary by individual).
Diagnostic criteria (DSM-5 style summary):
A. Recurrent unexpected panic attacks.
B. At least one attack followed by 1 month or more of either (a) persistent concern about another attack or its consequences or (b) significant maladaptive change in behavior related to attacks.
C. Not due to physiological effects of a substance or another medical condition.
D. Not better explained by another mental disorder.
Types of panic attacks: unexpected vs. expected.
Agoraphobia: fear/avoidance of situations where escape might be difficult or help unavailable in event of panic-like symptoms; common areas include public transport, open spaces, enclosed spaces, standing in line/crowd, being outside the home alone.
Agoraphobia criteria (summary):
Symptoms persist and cause distress/impairment; not better explained by another mental disorder.
Causes and treatments
Cognitive interpretation of normal sensations as dangerous; pharmacological treatment includes benzodiazepines, SSRIs, SNRIs; exposure-based treatments with gradual exposure and relaxation; psychological treatments often more effective than medications alone.
Case example: Mrs. M. (panic disorder with agoraphobia) – 67-year-old woman confined to home for decades; panic attacks led to severe agoraphobic avoidance; life restricted to bedroom, living room, and front part of kitchen; treatment declined due to perceiving few reasons to venture outside.
Specific Phobia
Definition: irrational fear of a specific object or situation that markedly interferes with functioning.
Major subtypes:
Blood-injection-injury phobia
Situational type
Natural environment type
Animal type
Biological vulnerability: Prepared learning tendency to associate fear with historically dangerous objects/situations; low threshold for defensive reactions (e.g., vasovagal response to blood)
Causes: direct experience, false alarms, learned experience, vicarious experience.
Specific phobia development model: interplay of generalized biological vulnerability, specific psychological vulnerability, and life stressors.
Separation Anxiety Disorder
Children’s anxiety characterized by unrealistically persistent worry about something bad happening to loved ones or to self when separated.
Tends to diminish with age.
Treatment: bravery-directed interaction (BDI).
Social Anxiety Disorder (Social Phobia)
Diagnostic criteria (DSM-5 style summary):
A. Marked fear or anxiety about one or more social situations with possible scrutiny by others.
B. Fear of being negatively evaluated.
C. Social situations almost always provoke fear or anxiety.
D. Situations are avoided or endured with intense fear.
E. Fear/anxiety is out of proportion to actual threat; culturally contextual.
F. Persistent (usually 6+ months).
G. Distress/impairment in functioning.
H. Not due to substances or another medical condition.
I. Not better explained by another disorder (e.g., panic attack in panic disorder).
J. Specifier: Performance only (if fear is restricted to speaking or performing in public).
Causes and treatment
Socially anxious individuals are quick to recognize angry faces; evolutionarily, sensitivity to social threat is somewhat innate.
Treatments include CBT, interpersonal therapy, and combinations like D-cycloserine with CBT.
Developmental models
Integrated vulnerability model (generalized biological vulnerability, generalized psychological vulnerability, specific vulnerability related to social evaluation).
Posttraumatic Stress Disorder (PTSD)
Core components (DSM-style):
A. Exposure to actual/threatened death, serious injury, or sexual violence via direct experience, witnessing, learning about violence to a loved one, or extreme exposure to aversive details.
B. Intrusion symptoms (e.g., distressing memories, dreams, dissociative reactions).
C. Persistent avoidance of stimuli associated with the trauma (memories, thoughts, external reminders).
D. Negative alterations in cognitions/mood (e.g., amnesia for aspects of trauma, persistent negative beliefs, distorted blame, negative emotional state, diminished interest, detachment, inability to experience positive emotions).
E. Marked alterations in arousal/reactivity (irritable behavior, reckless behavior, hypervigilance, exaggerated startle, concentration problems).
F. Sleep disturbance; duration > 1 month (Criteria B-G).
G. Clinically significant distress/impairment.
H. Not attributable to substances or medical condition.
Specifiers: With dissociative symptoms (depersonalization, derealization); With delayed expression (onset not met until >6 months after event).
Pre-traumatic, peri-traumatic, post-traumatic factors
Pre-traumatic: genetics, early experiences, childhood adversity, social support protective.
Peritraumatic: severity, perceived threat, dissociation during trauma.
Post-traumatic: negative appraisals, coping deficits, lack of social support.
Treatment principles
Exposure-based therapies (imaginal exposure, in vivo exposure), narrative processing, cognitive restructuring to correct trauma-related assumptions, and medication options.
Adjustment Disorder
Anxious or depressive reactions to life stress that are milder than acute stress or PTSD but still impair functioning.
If symptoms persist >6 months after removal of stress, the disorder may be considered chronic.
Attachment Disorders
Reactive Attachment Disorder (RAD): lack of seeking/providing care, limited positive affect, fearfulness, and emotional withdrawal.
Disinhibited Social Engagement Disorder (DSED): unusual social approach, lack of hesitation with strangers.
Obsessive-Compulsive Disorder (OCD) and related disorders
OCD: intrusive thoughts (obsessions) and ritualized behaviors (compulsions) aimed at reducing distress; the main danger is the thought/impulse itself, not a real event.
Obsessions: intrusive, unwanted thoughts/images/impulses; attempts to resist.
Compulsions: thoughts or actions performed to suppress obsessions.
Four major types of obsessions:
Symmetry
Forbidden thoughts/actions
Cleaning/contamination
Hoarding
Common conceptual cause: thought-action fusion (the belief that thoughts are equivalent to actions or have dangerous consequences).
Treatments: Exposure and ritual prevention is the most effective; psychosurgery historically referenced in some contexts but not routinely used.
Body Dysmorphic Disorder (BDD)
Also known as imagined ugliness; preoccupation with imagined defect in appearance; often secretive about condition.
Distinctions by gender focus: men on body build, genitals, thinning hair; women on various areas.
Often comorbid with eating disorders.
Causes: introversion, negative body image, perfectionism, heightened aesthetic sensitivity, childhood trauma/neglect.
Typical onset: adolescence.
Treatments: clomipramine and SSRIs (fluoxetine/fluvoxamine) and exposure/response prevention methods; combined approach tends to be more effective.
Hoarding Disorder
Key characteristics: difficulty discarding, living with excessive clutter, excessive acquisition; objects become part of the person’s identity; animal hoarding involves anthropomorphizing animals.
Causes: genetics; traumatic life events; socially withdrawn lifestyle.
Treatments: CBT; antidepressants such as venlafaxine and paroxetine; combined interventions.
Trichotillomania (Hair-Pulling Disorder)
Urge to pull out one's own hair; more common in females; serves to relieve stress though not diagnostic.
Causes: genetics; childhood trauma.
Treatments: habit reversal therapy (awareness training, competing response training); motivation/compliance; relaxation training; generalization.
Excoriation (Skin-Picking) Disorder
Repetitive and compulsive picking of the skin; more common in females; historically categorized under impulse-control disorders.
Causes: injury creates a scab that triggers picking; some pick due to self-grooming or to cope with perceived imperfections.
Treatments: habit reversal training has the strongest evidence base.
Selective Mutism
Child’s lack of speech in one or more settings; “selective” indicates they can talk in some settings.
Duration: must occur for more than one month (not limited to first month of school).
Causes: anxiety; children distressed by separation from guardians.
Treatment: prompting to speak with reinforcement for successful speaking.
Key vignettes from the lectures
Irene (Generalized Anxiety): 20-year-old student with excessive worry about tests, relationships, and daily events; difficulty controlling worry; life disruptions; periods of depression interspersed with attempts to seek help; episodes of panic not major; comorbidity with health anxiety and somatic symptoms.
Mrs. M. (Panic Disorder/Agoraphobia): 67-year-old woman, panic disorder and agoraphobia for 30+ years; lived largely indoors; avoided outside areas; had very limited social contact; refused treatment due to belief that life was near end.
Billy (Social Anxiety Disorder): extremely shy, avoids social and school activities, physical symptoms (nausea) when called on; school functioning impaired; later diagnosed with severe social anxiety disorder.
Additional notes and reminders
DSM criteria references in slides use the standard clinical criteria (A-H for various disorders). For clarity in notes, each DSM-5 criterion is summarized with the lettered subsections and examples when helpful.
Several figures (e.g., Figures 5.4, 5.5, 5.9) illustrate integrative models of vulnerability and development of anxiety disorders; these are described in text in the notes and can be revisited in the source materials for visuals.
Treatments span pharmacological (e.g., benzodiazepines, SSRIs, SNRIs, clomipramine) and psychological approaches (CBT, exposure therapy, ERP, interoceptive exposure, interpersonal therapy, and habit reversal where relevant).
The biopsychosocial approach is emphasized: biological vulnerability interacts with psychological fears and social stressors to produce anxiety disorders.
Quick references to DSM-5 style diagnostic criteria (summary format)
Generalized Anxiety Disorder (GAD):
A. Excessive anxiety and worry about multiple events for at least 6\text{ months}
B. Difficult to control the worry
C. At least three symptoms (restlessness, fatigue, concentration problems, irritability, muscle tension, sleep disturbance)
D. Distress/impairment
E. Not due to substances/medical condition
F. Not better explained by another disorder
Panic Disorder (summary):
A. Recurrent unexpected panic attacks
B. At least one attack followed by >1 month of concern about another attack or behavioral change
C. Not due to substances/medical condition
D. Not better explained by another disorder
Agoraphobia (summary):
Marked fear about 2+ of five situations; fear of escape; avoidance or intense fear; impairment; duration ≥6 months
Social Anxiety Disorder (summary):
Fear of social situations with possible scrutiny; fear of negative evaluation; avoidance or distress; duration ≥6 months
PTSD (summary):
Exposure to trauma (A); intrusion (B); avoidance (C); negative alterations in cognition/mood (D); alterations in arousal/reactivity (E); duration >1 month; impairment; not due to other conditions (F-H)
References to pre-traumatic and post-traumatic risk factors (PTSD)
Pre-traumatic: childhood emotional problems, socioeconomic factors, prior trauma exposure, social support protective
Peritraumatic: trauma severity, perceived life threat, dissociation during trauma
Post-traumatic: coping strategies, social support, ongoing stressors
Quick study prompts (for exam prep)
Differentiate fear, anxiety, and panic in clinical presentations.
Describe how the diathesis-stress model explains the onset of anxiety disorders.
List DSM-5 criteria (A-F) for GAD and compare with Panic Disorder criteria.
Explain the role of exposure-based therapies in OCD and related disorders.
Identify the major subtypes of Specific Phobia and their vulnerabilities.