Fear and anxiety

Fear Vs Anxiety

• Fear: Response to an immediate, real danger (e.g., a predator or an armed individual)

• Anxiety: Diffuse apprehension about possible future threats (e.g., concern over a test or illness)

• Fear activates the fight-or-flight response, while anxiety is more cognitive and anticipatory.

• Panic Attack: Occurs when fear arises in the absence of real danger.

The Adaptive Value of anxiety 

• Anxiety enhances learning and performance when mild.

• Prepares individuals to anticipate and manage future threats.

• Chronic or excessive anxiety becomes maladaptive and may lead to anxiety disorders.

The Anxiety Disorders in DSM-5

• Common features: Excessive fear and/or anxiety, significant distress or impairment. 

  • Anxiety disorders affect 29% of the U.S. population at some point.

  • Five major types:

    • Specific Phobia – Excessive fear of an object/situation.

    • Social Anxiety Disorder – Fear of negative evaluation in social situations.

    • Panic Disorder – Recurrent panic attacks.

    • Agoraphobia – Avoidance of situations where escape may be difficult.

    • Generalized Anxiety Disorder – Chronic, widespread worry.

Social Anxiety Disorder

• Definition: Marked fear of social situations due to concerns of negative evaluation.

  • Core Features:

    • Fear of scrutiny or judgment

    • Avoidance of social situations

    • Distress in everyday interactions

• Prevalence: Affects around 29% of the population at some point.

Causes of Social Anxiety Disorder

• Cognitive Biases:

  • Negative interpretation of social cues.

  • Memory recall is biased toward negative evaluations.

• Biological Factors:

  • Behavioral inhibition as a temperament trait.

  • Amygdala hyperactivity in response to negative facial expressions.

• Perceptions of Uncontrollability:

  • Childhood experiences of unpredictability (e.g., parental separation, family conflict).

  • Leads to submissive and avoidant behaviors.

Treatment of Social Anxiety 

• Cognitive-Behavioral Therapy (CBT):

  • Exposure to feared social situations.

  • Cognitive restructuring to correct negative self-perceptions.

  • Downward arrow method

• Medication:

  • Selective serotonin reuptake inhibitors (SSRIs) (e.g., Prozac, Zoloft).

  • Monoamine oxidase inhibitors (MAOIs) in some cases.

Panic Disorder

• Definition: Recurrent, unexpected panic attacks.

  • Symptoms:

    • Rapid heartbeat, sweating, shortness of breath, dizziness.

    • Fear of losing control or dying.

• Diagnosis: At least one attack followed by a month of worry about future attacks or behavior change.

• Prevalence: Affects approximately 4.7% of adults

The Panic Cycle 

• Trigger stimulus (internal/external) → Body sensations → Catastrophic interpretation → Panic attack → Fear of future attacks → Avoidance behaviors.

Biological Causes of Panic Disorder

• Genetic Contributions:

  • Moderate heritability (~30-34%).

  • Overlap with phobias and separation anxiety.

• Neurobiology:

  • Overactive fear network involving the amygdala and locus coeruleus.

  • Decreased GABA activity, leading to heightened anxiety.

• Neurotransmitters:

  • Serotonin: Regulates mood and anxiety.

  • Norepinephrine: Linked to panic symptoms.

Treatment for Panic Disorder 

• Cognitive-Behavioral Therapy (CBT):

  • Cognitive restructuring to correct catastrophic thoughts.

  • Exposure to feared bodily sensations (interoceptive exposure).

• Medication:

  • SSRIs and benzodiazepines (short-term relief but risk of dependence).

Agrophobia 

• Definition: Fear and avoidance of situations where escape may be difficult.

  • Common Triggers:

    • Public transportation, open spaces, crowded places.

    • Fear of experiencing a panic attack in public.

• Prevalence: More common in women (~80-90% of severe cases).

Generalized Anxiety Disorder (GAD)

• Definition: Chronic, excessive worry about various aspects of life.

  • DSM-5 Criteria:

    • Occurs more days than not for at least 6 months.

    • Difficult to control worry.

    • Associated with at least three of the following:

      •  Restlessness or feeling on edge.

      • Being easily fatigued.

      • Difficulty concentrating.

      • Irritability.

      • Muscle tension.

      • Sleep disturbances.

Clinical Features of GAD

• Persistent, uncontrollable worry about everyday life.

• Symptoms include muscle tension, restlessness, and difficulty concentrating.

• Hypervigilance for threats and avoidance behaviors.

• Affects about 3% of the population annually and 5.7% over a lifetime.

Causes of GAD

• Biological Factors:

  • Genetic predisposition (~30% heritability).

  • Neurotransmitter imbalances: GABA, serotonin, norepinephrine.

  • Overactive corticotropin-releasing hormone (CRH) system.

• Psychological Factors:

  • Low tolerance for uncertainty.

  • Perceptions of uncontrollability and unpredictability.

  • Childhood trauma may increase risk.

  • Reinforcing properties of worry (avoidance of emotional distress).

Treatment of GAD

• Cognitive-Behavioral Therapy (CBT):

  • Focuses on identifying and restructuring worry-related thoughts.

  • Behavioral interventions include muscle relaxation and exposure therapy.

• Medications:

  • SSRIs (e.g., Prozac, Zoloft) preferred due to fewer side effects.

  • Benzodiazepines (e.g., Xanax, Klonopin) provide short-term relief but have dependency risks.

  • Buspirone as a non-addictive alternative.

Obsessive Compulsive Disorder (OCD) 

• Definition: The presence of obsessions, compulsions, or both.

  • Obsessions:

    • Persistent, distressing intrusive thoughts (e.g., contamination fears, fears of harming others). 

  • Compulsions:

    • Repetitive behaviors (e.g., hand washing, checking, counting) or mental acts (counting to 50 or completing 10 prayers) aimed at reducing distress.

• Diagnostic Criteria:

  • Obsessions and/or compulsions cause significant distress.

  • Time-consuming (more than 1 hour per day).

  • Not attributable to substance use or another mental disorder.

Causes of OCD

• Neurobiological Factors:

  • Dysfunction in orbitofrontal cortex, anterior cingulate cortex, and caudate nucleus.

  • Low serotonin levels.

• Cognitive-Behavioral Factors:

  • Mowrer’s two-process theory: Classical conditioning of fear + operant reinforcement of compulsions.

  • Attempts to suppress obsessions paradoxically increase their frequency.

• Evolutionary Perspective:

  • Compulsions like checking and washing may be exaggerated survival behaviors.

Treatment of OCD 

• Exposure and Response Prevention (ERP):

• Patients are exposed to feared stimuli and prevented from engaging in compulsions.

• Highly effective but requires commitment.

• Medications:

  • SSRIs (e.g., fluoxetine, fluvoxamine, sertraline) are the first-line treatment.

  • Antipsychotics may be added for severe cases.

Thought Action Fusion in OCD

• Definition: Belief that having a thought is morally equivalent to acting on it or increases the likelihood of it happening.

  • Example: A mother with intrusive thoughts about harming her infant believes thinking it makes it more likely to happen.

• Results in:

  • Inflated sense of responsibility.

  • Increased compulsive behaviors to prevent harm.

Cognitive Biases and Distorsion in OCD

• Attention bias toward disturbing material related to obsessions.

• Difficulty blocking out negative input → attempts to suppress thoughts, which increases their frequency.

• Memory deficits in OCD:

  • Low confidence in memory for feared situations.

•  Repetitive checking rituals.

• Inhibition deficits:

  • Trouble inhibiting motor responses and ignoring irrelevant information.

Biological Factors in OCD

• Genetic Factors:

  •  Twin studies show moderate genetic heritability.

  • Higher genetic loading for early-onset OCD.

  • Overlap with Tourette’s syndrome (tic-related OCD).

• Brain Structure Abnormalities:

  • Hyperactivity in orbitofrontal cortex, cingulate cortex, and caudate nucleus.

  • Impaired cortico-basal-ganglionic-thalamic circuitry.

  • Basal ganglia dysfunction prevents proper filtering of intrusive thoughts.

Neurotransmitter Abnormalities in OCD

• Serotonin Dysfunction:

  • Increased serotonin activity linked to OCD symptoms.

  • SSRIs (fluoxetine, clomipramine) take 6-12 weeks for significant improvement.

• Other Neurotransmitter Systems:

  • Dopaminergic, GABA, and glutamate systems are also involved.

  • Further research needed to understand their roles

Behavioral and Cognitive-Behavioral Treatments for OCD

• Exposure and Response Prevention (ERP):

  • Repeated exposure to feared stimuli without performing compulsions.

  • Anxiety naturally reduces over time (habituation).

  • 50-70% symptom reduction, long-lasting effects.

• Cognitive Therapy:

  • Targets catastrophic beliefs about obsessions.

  • May enhance ERP effectiveness.

Medication Treatment for OCD 

• SSRIs (e.g., fluoxetine, clomipramine):

  • 40-60% response rate, 25-35% symptom reduction.

  • High relapse rates upon discontinuation.

• Augmentation with Antipsychotics:

  • Small doses help in treatment-resistant cases.

Body Dysmorphic Disorder (BDD)

• Definition: Preoccupation with perceived physical defects not visible or minor to others.

  • Some of the more common locations for perceived defects include skin (73 percent), hair (56 percent), nose (37 percent), eyes (20 percent), breasts/chest/nipples (21 percent), stomach (22 percent), and face size/shape (12 percent)

• Compulsive behaviors:

  • Mirror checking, excessive grooming, reassurance-seeking.

  • Avoidance of social situations due to distress.

• Severe cases:

  • Social isolation, depression, suicidal ideation (63% consider suicide, 14% attempt).

Causes of BDD

• Genetic and Neurobiological Factors:

  • Moderate heritability.

  • Overactivity in the orbitofrontal cortex and caudate nucleus.

• Cognitive Factors:

  • Biased attention toward appearance-related stimuli.

  • Distorted perception of facial symmetry.

  • Emotional abuse/neglect history increases risk.

Treatment for BDD

• Cognitive-Behavioral Therapy (CBT):

  • Exposure and response prevention (reducing mirror checking, avoidance).

  • Challenging distorted beliefs about appearance.

• Medication:

  • SSRIs (higher doses than OCD).

Hoarding Disorder 

• Definition: Persistent difficulty discarding possessions, regardless of value.

• Results in:

  • Extreme clutter, fire hazards, unsanitary conditions.

  • Significant distress and impairment.

• Neurobiological Distinctions:

  • Different brain activation patterns than OCD.

  • Poorer response to standard OCD treatments.

Trichotillomania

Eating Disorders & OCD & BDD

• Both involve obsessions and compulsive behaviors (e.g., mirror checking, reassurance seeking).

• Neurobiological similarities:

  • Both conditions involve serotonin dysfunction.

  • Shared brain structures (orbitofrontal cortex, caudate nucleus).

• Effective treatments for both:

  • SSRIs (selective serotonin reuptake inhibitors).

  • Cognitive-Behavioral Therapy (CBT).

• Similarities Between BDD and Eating Disorders

  • Excessive concern with physical appearance.

  • Dissatisfaction with body image and distorted perception of one's body.

• BDD vs. Anorexia:

  • BDD patients look normal but are obsessed with minor or imagined flaws.

  • Anorexia patients have objective physical changes but still perceive themselves as overweight