8 anxiety

Anxiety Disorders

Fear and Anxiety - Functions and Importance

  • Fear/Anxiety Exist for Good Reason:
    • Alert and orient us to acute, potential, or sustained threats.
    • Motivate and organize our response to threats.
    • Behavioral Responses:
    • Fight
    • Flight
    • Freeze
    • Physiological Responses:
    • Increased heart rate
    • Sweating
    • Cognitive Responses:
    • Appraisal of danger
    • Overall Purpose: Avoid or mitigate dangers and communicate danger to conspecifics (members of the same species).
    • Survival Advantage: These emotions have helped us to survive through evolutionary processes.

Fear vs. Anxiety

  • Fear:
    • Response to objectively threatening events.
    • Example: Fear of failing a class after failing the midterm.
    • Severity and Duration:
    • Appropriate severity given the threat (concern due to necessity for graduation).
    • Subsides once the threat has passed (relaxation upon realizing a grading error).
    • Leads to adaptive behaviors to confront or avoid threats (asking for extra work to improve grades).
    • Potential Diagnostic Criteria for Anxiety Disorder:
    • Fear is moderately unrealistic (e.g., fearing a car accident on Friday the 13th).
    • The reaction is more than warranted (excessive nervousness).
    • Fear persists after threat's passing (worrying about the next Friday the 13th).
    • Results in potentially dangerous behaviors (skipping class to avoid driving).
    • Distinction Between Functional and Dysfunctional Fear:
    • Functional Fear:
      • May be somewhat unrealistic.
      • Slightly excessive compared to threat severity.
      • Persists after the threat, but manageable.
      • Leads to slightly inappropriate behaviors (such as using tranquilizers).
    • Dysfunctional Fear (meets diagnostic criteria):
      • Completely unrealistic fears (e.g., believing every ache means terminal illness).
      • Excessive fear reaction given the actual threat.
      • Long-lasting fear with anticipatory anxiety (e.g., believing one is terminally ill despite reassurances).
      • Leads to dangerous behavior (pursuing unnecessary medical procedures).

Clinical Description and Epidemiology

  • Personal Experiences of Anxiety:
    • Anonymous quotes describing the impact of anxiety on personal life, self-worth, relationships, and mental state.

DSM-5 Anxiety Disorders

  • Key Disorders Defined in the DSM-5:
    • Specific Phobia: Fear of objects or situations disproportionate to actual danger.
    • Social Anxiety Disorder: Fear of social scrutiny and interaction.
    • Panic Disorder: Anxiety relating to recurrent panic attacks.
    • Agoraphobia: Anxiety regarding public spaces and escaping difficult circumstances.
    • Generalized Anxiety Disorder: Uncontrollable and persistent worry.

DSM-5 Criteria for Specific Phobia

  • Criteria A: Marked fear or anxiety about a specific object or situation (examples include flying, heights, animals).
  • Criteria B: The phobic object or situation provokes immediate fear or anxiety.
  • Criteria C: The object or situation is actively avoided or endured with intense fear.
  • Criteria D: The fear is out of proportion to actual danger posed.
  • Criteria E: The fear is persistent, typically lasting for 6 months or more.
  • Criteria F: Causes clinically significant distress or impairment in functioning.
  • Criteria G: Not better explained by another mental disorder.

DSM-5 Criteria for Social Anxiety Disorder (Social Phobia)

  • Criteria A: Marked fear or anxiety in one or more social situations due to potential scrutiny.
  • Criteria B: Fear of acting in a way that leads to negative evaluation.
  • Criteria C: Social situations provoke anxiety.
  • Criteria D: Situations avoided or endured with anxiety.
  • Criteria E: Fear is out of proportion to actual threat.
  • Criteria F: Persistent fear lasting 6 months or more.
  • Criteria G: Significant distress or impairment in functioning.
  • Criteria H: Not attributable to substance use or another medical condition.
  • Criteria I: Not better explained by another mental disorder.
  • Criteria J: Unrelated excessive fear due to another medical condition.

DSM-5 Criteria for Panic Disorder

  • Criteria A: Recurrent, unexpected panic attacks characterized by intense fear or discomfort within minutes, with four or more specific symptoms.

    • Symptoms Include:
    • Palpitations, accelerated heart rate.
    • Sweating, trembling, shortness of breath.
    • Chest pain, nausea, dizziness.
    • Fear of losing control, fear of dying.

  • Criteria B: One of the attacks followed by at least 1 month of persistent concern regarding future attacks or behaviors to avoid them.

  • Criteria C: Not attributable to substance use or medical conditions.

  • Criteria D: Not better explained by another mental disorder.

Agoraphobia

  • Definition: Marked fear of being in crowded public spaces.
  • Comorbidity: Often coexists with panic attacks.
  • Hypothesis: Expectations of catastrophic outcomes during panic attacks (Goldstein & Chambless, 1978).
  • Historical Classification: Previously a specifier for panic disorder; not always paired with it.

DSM-5 Criteria for Generalized Anxiety Disorder

  • Criteria A: Excessive anxiety more days than not for at least 6 months about multiple events/activities.
  • Criteria B: Difficulty controlling worry.
  • Criteria C: Anxiety associated with at least three of the following (for most days over 6 months):
    • Restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance.
  • Criteria D: Causes clinically significant distress or impairment in functioning.
  • Criteria E: Not attributable to substance use or medical conditions.
  • Criteria F: Not better explained by another mental disorder.

Common Features Across Anxiety Disorders

  • Excessiveness:
    • Anxiety regarded as disproportionate.
  • Avoidance:
    • Overt or subtle forms of avoidance can inhibit learning and problem-solving methods.
  • Clinical Distress:
    • Important for diagnosis; difficulty finding the line between helpful anxiety and problematic avoidance.

Epidemiology of Anxiety Disorders

  • Prevalence:
    • 12-month prevalence rate of approximately 18% among US adults.
    • Lifetime prevalence around 29%.
  • Gender Differences:
    • Disorders are somewhat more common in women than in men.
  • Treatment Access:
    • Most individuals with anxiety disorders do not receive treatment, despite significant impacts on quality of life and functioning.

Comorbidity in Anxiety Disorders

  • Anxiety Disorders Co-occurrence:
    • 80% of individuals with an anxiety disorder meet criteria for another anxiety disorder.
  • Common Comorbid Conditions:
    • Commonly comorbid with depressive disorders, substance use disorders, and personality disorders.

Risk Factors and Etiological Models - Part 1

  • Conditioned Learning of Fears (Mowrer Model):
    • Step 1: Classical conditioning (e.g., fear response after a dog bite).
    • Step 2: Linking the conditioned response to ongoing fears of stimuli.
    • Response Mechanism: Operant conditioning reinforces avoidance behavior due to strong fear responses.

Additional Insights on Conditioning and Fear learning

  • Table of Conditioning Experiences:
    • Statistics on types of fears reported by individuals and their conditioning background.
  • Extensions of Mowrer’s Model:
    • Consideration of unique panic attacks, context, and individual differences in susceptibility to fear acquisition and extinction.

Genetics and Anxiety Disorders

  • Heritability Estimates:
    • Twin studies suggest a heritability range of 20-50%.
  • Environmental Factors:
    • Non-shared environmental factors play a crucial role; genetic influences are complex and polygenic.

Neurobiological Aspects of Anxiety

  • Fear Circuit:
    • Neural network centered around the amygdala involving other brain regions.
  • Complexity:
    • The concept of a singular "fear circuit" is questioned, suggesting diverse circuits for different fear responses.
  • Neurotransmission:
    • Involvement of various neurotransmitters such as GABA and serotonin, and regulation by corticotropin-releasing hormone (CRH).

Personality and Temperament in Anxiety Disorders

  • Negative Affectivity:
    • Major risk factor for various mental health conditions, including anxiety.
  • Behavioral Inhibition:
    • Shyness in early childhood has ties to social anxiety traits.

Cognitive Factors in Anxiety

  • Perceived Unpredictability:
    • Lack of control over the environment reinforces anxiety.
  • Cognitive Biases:
    • Information processing biases can result in a heightened sense of danger, negatively impacting behavior.
  • Influence of Adverse Events:
    • Childhood trauma can foster negative beliefs and biases regarding threat perception.

Gender and Sociocultural Factors

  • Gender Gap Explanations:
    • Possible reasons for differences in anxiety reports between men and women, including socialization and experiences of adversity.
  • Cultural Variations:
    • Variations in anxiety manifestations, including triggers, across different cultures.

Risk Factors and Etiological Models - Part 2

  • Applications to Specific Anxiety Disorders:
    • Understanding anxiety within its evolutionary context emphasizes social importance for relationships.
    • Learning about traumatic social experiences plays a significant role in shaping social anxiety disorders.
    • Cognitive factors intrinsic to social anxiety include unrealistic beliefs, self-evaluation fears, and attention to social threat cues.

Panic: Neurobiology and Sensitivity

  • Panic Circuit:
    • Connection between brain areas responsible for panic and broader fear circuitry.
  • Anxiety Sensitivity Definition:
    • A tendency to interpret bodily sensations as harmful, increasing panic risks.

Generalized Anxiety Disorder Characteristics

  • Problem Orientation:
    • Viewing challenges as threats fosters anxious responses.
  • Functional Models of Worry:
    • Complexity of trying to control worry and meta-worries that arise while managing anxiety.

Treatment Approaches to Anxiety Disorders

  • Exposure Therapy:
    • This approach promotes facing fears rather than avoiding them, using habituation and the inhibitory learning model.
  • Sample Exposure Hierarchy:
    • Concrete examples demonstrate varying levels of anxiety when facing specific fears.
  • Cognitive Components:
    • Techniques include challenging unhelpful beliefs and increasing coping abilities and mindfulness.
  • Relaxation Training:
    • Techniques such as diaphragmatic breathing and progressive muscle relaxation are included, but not as effective alone compared to CBT.
  • Unified Protocol Possibilities:
    • Integration of treatments for anxiety disorders has shown efficacy.
  • Medication:
    • Benzodiazepines provide rapid relief but have drawbacks, with SSRIs and SNRIs showing better long-term efficacy.

Closing Thoughts on Anxiety Disorders

  • Vital Functions of Anxiety:
    • While anxiety and fear play important adaptive roles, they can become problematic and warrant treatment.
  • Comorbidities and Shared Features:
    • Shared features among anxiety disorders raise questions about diagnostic boundaries and how we approach treatment.
  • Future Considerations:
    • Exploring whether anxiety disorders should be viewed separately or as part of a continuum.