Anxiety Disorders Part 1: General Concepts, Etiology, and Intro to GAD, Panic, Agoraphobia, Specific Phobia, Social Anxiety, Separation Anxiety, and Selective Mutism
Anxiety Disorders Part 1: General Concepts, Etiology, and Intro to Disorders
Overview
Part 1 covers anxiety-related disorders; Part 2 covers trauma- and OCD-related disorders.
Anxiety is the central component across these disorders; expect substantial behavioral overlap (e.g., avoidance).
There are many supplemental materials on Canvas to deepen understanding.
The lecture is long; pause and take breaks as needed. No quiz this week; will occur after both anxiety sections are covered.
What is anxiety?
Anxiety is a mood state (a sustained, future-oriented emotional state) rather than a fleeting emotion.
Contrast with fear: fear is a temporary, immediate alarm reaction (fight/flight) activated by actual threat; anxiety is future-focused and long-lasting.
Anxiety can be adaptive in moderation (Yerkes–Dodson law): some arousal improves performance on difficult tasks, but too little or too much impairs performance.
Real-world example: paper due in six weeks vs. procrastination; optimal arousal varies with task difficulty.
Co-occurrence: fear and anxiety can occur simultaneously (e.g., public speaking can trigger both immediate fear and future-oriented worry).
Distinction: fear is about current threat; anxiety involves expectations about future outcomes.
Biopsychosocial model of anxiety (etiology)
Biological variables:
Polygenic inheritance: multiple genes contribute to a tendency toward anxiety (trait anxiety).
Neurotransmitters: lower GABA activity often implicated; other neurotransmitters may be involved.
Limbic system involvement (amygdala, etc.) mediates between brainstem (physiological arousal) and cortex (thinking, memory, executive function).
Behavioral inhibition system (BIS) vs. fight/flight system: BIS prompts caution and evaluation; fight/flight drives immediate action.
Gene–environment interactions: early stressors can sensitize systems (environmental factors turn on certain genes, affecting learning and fear response).
Psychological variables:
Continuum of control (parent–child relationship): developmentally appropriate independence vs. helicopter or neglectful parenting can influence later anxiety.
Conditioning processes:
Classical conditioning (Pavlovian): neutral stimuli paired with aversive events → conditioned anxiety responses.
Reinforcement (operant conditioning): negative reinforcement (avoidance) maintains anxiety by reducing exposure to feared stimuli.
Modeling and observational learning: parental reactions shape child fear expectations (e.g., fear of roaches if parent reacts dramatically).
Curious learning (vicarious learning): hearing about others’ fear can transfer to one’s own fear (e.g., cousin fearful of dogs due to father’s bite).
Cognitive vulnerabilities: maladaptive thoughts (catastrophizing, future-telling, overgeneralization) become entrenched when they consistently fail to help.
Social/environmental factors:
Stress-diathesis model: life stressors interact with biological and psychological vulnerabilities to precipitate anxiety.
Triple vulnerability theory: biological vulnerability + generalized psychological vulnerabilities + specific psychological vulnerabilities interact with environmental stress.
Biological vulnerability: inherited tendencies toward negative affect, poor emotion regulation, sensitivity to threats.
Specific psychological vulnerability: tendency to interpret physical sensations as dangerous (e.g., misinterpreting heart racing as an imminent medical crisis).
Generalized psychological vulnerability: external locus of control, low self-esteem, poor coping, and learned fears.
Interaction of anxiety with comorbidity and health
Anxiety disorders are highly comorbid with Major Depressive Disorder (MDD): about in a one-year period and lifetime prevalence; comorbidity with MDD occurs in about of anxiety cases.
Comorbidity implications: worse prognosis and higher relapse risk; shared vulnerability and overlapping symptomatology explain common co-occurrence.
Anxiety and physical illness: anxiety disorders often precede physical illnesses (correlational data) and may contribute to risk via chronic stress hormones (e.g., cortisol) and immune function effects.
Differential diagnosis and clinical reasoning
Anxiety must be distinguished from other disorders with overlapping symptoms (e.g., ADHD symptoms like inattention/concentration problems can be anxiety-driven).
Differential diagnosis is critical to avoid over-diagnosis and ensure comprehensive assessment.
Common misattributions: symptoms of anxiety can resemble other disorders; vice versa, anxiety may be secondary to another condition.
Core disorders in this lecture (anxiety-related disorders)
Generalized Anxiety Disorder (GAD)
Panic Disorder and Agoraphobia
Specific Phobia
Social Anxiety Disorder
Separation Anxiety Disorder
Selective Mutism
Generalized Anxiety Disorder (GAD): overview and criteria
Definition: excessive anxiety and worry about a number of events or activities, more days than not, for at least .
Key features:
Worry about multiple events or activities (beyond a single trigger).
Difficulty controlling the worry; efforts to suppress worry can worsen it.
Worry is persistent and difficult to turn off.
Diagnostic criteria (adult): at least 3 of the following symptoms, present most days for the past (children: only 1 needed):
Restlessness or feeling "on edge";
Easily fatigued;
Difficulty concentrating or mind going blank;
Irritability;
Muscle tension;
Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
Criteria D: clinically significant distress or impairment.
Epidemiology:
Prevalence: in a 1-year period; lifetime.
Sex difference: about 2x more likely in females.
Onset: can occur at any point in the lifespan; average around age .
Course: typically chronic without intervention; often seen in primary care settings due to convenience and screening practices.
Etiology (GAD specifics): polygenic component; lower GABA activity; autonomic features may include tense, brace-for-impact response rather than high arousal; cognitive patterns include avoidance and imagery avoidance; internal bodily sensations may be avoided to prevent escalation, though imagery can be therapeutic by allowing mental practice of handling outcomes.
Treatment approaches for GAD:
Pharmacology: Benzodiazepines (short-term, crisis use) to rapidly reduce symptoms; risks include sedation, cognitive/motor impairment, withdrawal and dependence with long-term use; GABA agonists for longer-term use with aversive side effects; beta blockers for somatic symptoms; barbiturates rarely used; antidepressants (SSRIs, SNRIs) as first-line long-term treatment.
Psychotherapy: CBT-based approaches with cognitive restructuring; ACT (acceptance and commitment therapy) as a third-wave CBT; mindfulness-based strategies; exposure-based components to reduce avoidance; focus on reducing avoidance, understanding triggers, and coping skills.
Core rationale: medications can help tolerate anxiety and open door for exposure/therapy, but long-term outcomes are typically better with therapy or combined treatment that builds skills for managing anxiety.
Summary gap: no single treatment fits all; consider safety, comorbidity, and patient preferences (pregnancy, other meds, etc.).
Panic phenomena: panic attacks and panic disorder
Panic attack: a discrete, abrupt surge of intense fear or discomfort with at least four of 13 possible symptoms, peaking within minutes. Not a disorder by itself; a symptom that can occur in multiple conditions.
Panic attack symptoms (examples):
Autonomic arousal: tachycardia/palpitations, sweating, trembling or shaking, shortness of breath, choking sensation, chest pain, nausea, dizziness, chills or heat sensations, paresthesias (numbness/tingling).
Cognitive/psychological: fear of losing control or dying, derealization, depersonalization.
Panic attack timing: can be expected (cue-triggered) or unexpected.
Nocturnal panic attacks: occur during deep sleep; may wake the person mid-attack with remembered experience; distinct from night terrors (these involve complete unawareness during the event).
Panic disorder: recurrent, unexpected panic attacks plus at least one month of persistent concern about additional attacks or their consequences, or a significant maladaptive change in behavior related to the attacks.
Important note: panic attacks are not a disorder themselves; panic disorder is diagnosed when attacks are persistent and pervasive.
Agoraphobia (as related to panic) and specific phobias
Agoraphobia description: fear or anxiety in two or more of the following situations, often stemming from fears about having a panic attack and not being able to escape or obtain help: public transport; open spaces; enclosed spaces; standing in a crowd; being outside the home alone.
Central feature (Criterion B): fear or anxiety about not being able to escape or get help if a panic attack occurs.
Duration/impairment: fear is out of proportion to the actual danger; must be present for at least 6 months and cause distress or impairment; avoidance or extreme fear in these situations.
Etiology (panic–agoraphobia link): panic-sensitivity and bodily-sensation interpretation can generalize to fear of situations where escape would be difficult; avoidance maintains impairment.
Specific phobia
Definition: marked fear or anxiety about a specific object or situation (could be more than one, but is specific to certain sources).
Immediate fear or anxiety provoked by the phobic cue; phobic stimulus is actively avoided or endured with intense fear.
Intensity disproportionate to actual danger; context matters (developmental considerations).
Duration: fear persistent for at least ; clinically significant distress or impairment.
Epidemiology: lifetime prevalence around ; more common in women; social/cultural factors influence reporting and exposure.
Etiology: direct experience (e.g., dog bite); vicarious learning (seeing others react fearfully); information transmission (hearing about incidents); inherited preparedness; exposure-based treatments are effective (gradual exposure or flooding; relaxation training to manage fear responses).
Social Anxiety Disorder (Social Phobia)
Definition: marked fear or anxiety about one or more social situations where scrutiny by others is possible; fear of negative evaluation.
Situations provoke fear or anxiety and are avoided or endured with intense fear.
Fear is out of proportion to actual threat and context; duration of at least ; distress or impairment.
Subtypes: performance-only subtype (e.g., public speaking).
Epidemiology: prevalence rates similar across genders; multiple etiologies including generalized psychological vulnerabilities, memory bias toward negative interactions, and prior bullying experiences.
Treatments: CBT including cognitive restructuring and exposure; group therapy is highly effective due to real social exposure; role-play to develop social skills; SSRIs can be used but therapy tends to be more effective.
Separation Anxiety Disorder
Definition: developmentally inappropriate or excessive fear or anxiety concerning separation from caregivers, with three or more of several symptoms (e.g., distress at anticipated separation, excessive worry about caregiver harm or loss, fear of events that separate them, reluctance to leave home, reluctance to sleep away from caregivers, nightmares with separation themes, physical symptoms on separation).
Prevalence: primarily seen in children/adolescents (duration criteria: at least in kids/adolescents; at least in adults).
Context: developmentally appropriate in young children; pathology assessed by impairment and distress.
Selective Mutism
Definition: extreme form of social anxiety where certain children do not speak in specific social settings (e.g., school) despite speaking in other settings (e.g., home).
Diagnostic considerations: limited to situations where speaking would be expected; not due to a speech or language disorder.
Treatment emphasis: safety and adaptive communication skills first (nonverbal communication tools, alternative means to seek help); collaboration with speech-language pathologists; exposure-based social practice (group settings) as part of exposure therapy.
Exposures and treatment planning (key themes across anxiety disorders)
Exposure therapy is central to treating anxiety disorders; avoidance maintains anxiety and should be gradually reduced.
Exposure planning requires patient buy-in and consent (to avoid traumatisation).
Tools used in exposure:
Hierarchy of avoidance: start from least distressing to most distressing items; create a stepwise plan toward the top of the hierarchy (e.g., talking about a dog, reading about dogs, seeing a dog from a distance, being near a dog, petting a dog).
SUDS scale (Subjective Units of Distress Scale): e.g., 0–100 scale, with practice targeting a 40–50 range during in-session exposures and gradual progression at home.
The goal is to practice coping with anxiety and demonstrate that anxiety does not catastrophically worsen; over time, the brain learns to tolerate and regulate fear responses.
Flooding (all-at-once exposure) is effective but often challenging to implement; gradual exposure is more common and tolerable.
Exposure requires creativity when real-world access to feared stimuli is limited (e.g., telehealth, virtual exposure, controlled environments).
Medication vs. psychotherapy
Anti-anxiety medications (anxiolytics) include:
Benzodiazepines: fast-acting, short-term relief; risks include sedation, cognitive/motor impairment, dependence, withdrawal; not recommended for long-term use; may be used in crisis or short-term management.
GABA agonists: long-term use with aversive side effects; less commonly used.
Beta blockers: help with somatic symptoms (e.g., tachycardia) in performance anxiety or situational arousal.
Barbiturates: largely obsolete; used only in specific fast-sedation contexts.
Antidepressants used for anxiety (though labeled antidepressants, effective for anxiety disorders): SSRIs and SNRIs; used as first-line long-term pharmacotherapy; often combined with psychotherapy for best outcomes.
Benzodiazepines and other sedatives risk dependency and withdrawal; long-term use not ideal; short-term use in crises or bridging therapy.
Psychotherapy options with strong empirical support:
Cognitive Behavioral Therapy (CBT): core cognitive restructuring and behavioral strategies to reduce worry and avoidance.
Acceptance and Commitment Therapy (ACT): a third-wave CBT focusing on accepting thoughts and feelings while committing to adaptive actions.
Mindfulness-based approaches: enhance awareness of present-moment experiences and reduce avoidance.
Exposure-based therapies: central across disorders; aim to reduce avoidance and increase tolerance to feared cues.
Rationale for psychotherapy emphasis: builds long-term skills, reduces relapse risk, and can reduce reliance on medication. Combining pharmacotherapy with psychotherapy often yields the best outcomes; medications can facilitate engagement in therapy by reducing acute distress.
Special notes on treatment goals and outcomes
The goal is to reduce avoidance and develop adaptive coping, not to eradicate all anxiety.
Therapeutic alliance and patient consent (“buy-in”) are essential for successful exposure-based treatment.
Treatments are tailored to developmental level, comorbidities, and life context (e.g., school, work, family).
Summary and practical implications
Anxiety disorders show substantial overlap in symptoms and etiologies but are distinguished by patterns of impairment, duration, and context.
A thorough assessment considers biological, psychological, and social factors and differentiates anxiety from other disorders with similar presentations.
Treatments combine pharmacological and psychological approaches, with a strong emphasis on exposure and skills-based therapies to promote long-term resilience.
It is common to see multiple anxiety disorders in a single patient; differential diagnosis should focus on predominant symptoms and functional impairment, while acknowledging potential comorbidity.
Quick reference: quick facts and numbers
Generalized Anxiety Disorder (GAD): prevalence about in a 1-year period; lifetime ~; more common in females (about 2x).
Specific phobia: lifetime prevalence ~; more common in women; often developmentally related.
Panic attacks: not a disorder by itself; require at least 4 of 13 symptoms in an abrupt onset to be considered a panic attack.
Panic disorder: requires recurrent unexpected panic attacks and at least one month of concern about additional attacks or behavioral changes related to attacks.
Agoraphobia: fear/anxiety in multiple situations (2+); concerns about escape or access to help; six-month duration for adults; impairment present.
Separation anxiety: four weeks (children) or six months (adults); multiple separation-related symptoms and distress/impairment.
Selective mutism: persistent failure to speak in specific social settings for at least one month (not limited to the first month of school); safety and communication skills prioritized in treatment.
Closing reminder
Review this material and connect it to other sections (trauma and OCD next week). Use exposure hierarchies, SUDS, and the tripartite vulnerability framework to integrate understanding across disorders.
There is no quiz this week; plan study time accordingly to cover both anxiety sections before the next assessment.