Comprehensive Notes on Anxiety, Disorders, and Coping

Anxiety: Key Concepts and Disorders

• Anxiety is a normal, adaptive response to perceived danger or threat. It can be a healthy, growth-promoting reaction when proportionate to the situation.
• Mild anxiety is common and can heighten learning, awareness, focus, and performance.
• When anxiety becomes excessive, it can be problematic and may constitute an anxiety disorder.
• Anxiety and stress are related; small amounts can enhance learning and resilience, but excessive anxiety impairs functioning.
• Mood and affect: mood is internal and affects how you feel inside; affect is outward expression of emotion. Anxiety can influence both mood and affect.

Levels of Anxiety and Symptoms

• Mild anxiety: generally manageable; vitals typically normal; some muscle tension.

• Moderate anxiety: increased arousal; vitals up; resembles “signal anxiety” or anticipatory stress before an event (e.g., race, exam).

• Severe anxiety: narrowed attention, difficulty thinking clearly, impaired problem-solving, slowed perception of time; disorganized thoughts; absorption of details is reduced.

• Panic anxiety: extreme, overwhelming arousal; sympathetic nervous system dumps large amounts of epinephrine; symptoms can include paleness, BP changes, poor muscle coordination, inability to tolerate more stimuli, sense of losing control, fear of dying.

• Example: during a highway incident, someone may perceive time as slowing down, increasing the sense of danger, which reflects a distorted perception under severe anxiety.

Panic Attacks and Panic Disorder

• Panic attacks are intense surges of anxiety with physical and cognitive symptoms: pounding heart, shortness of breath, dizziness, fear of losing control or dying, overwhelming doom.
• Two broad categories of panic disorders: agoraphobic and non-agoraphobic (panic with or without avoidance of open or crowded places).
• Some individuals may experience panic-like symptoms without meeting full criteria for a panic disorder.

Anxiety vs Depression and Mood/Feelings

• Anxiety and depression are related and can co-occur; symptoms can overlap (aches, pains, nonspecific physical complaints, difficulty concentrating).
• Anxiety can contribute to sleep disturbance and concentration problems, and vice versa.

Types of Anxiety Disorders (Overview)

• Separation anxiety disorder: excessive fear of separation from attachment figures; can occur in children and persist into adolescence.
• Generalized anxiety disorder (GAD): persistent, excessive worry about a variety of events or activities; chronic and difficult to control.
• Panic disorder: recurrent panic attacks with or without fear of continued attacks or their consequences.
• Social anxiety disorder (social phobia): intense fear of social situations or performance where one may be scrutinized.
• Obsessive-compulsive disorder (OCD): presence of obsessions (intrusive, unwanted thoughts) and/or compulsions (repetitive behaviors or mental acts) aimed at reducing distress.
• Post-traumatic stress disorder (PTSD): anxiety following exposure to a traumatic event, with symptoms including flashbacks, hypervigilance, avoidance, and intrusive memories.
• COVID-related anxiety: pandemic-specific stress responses.
• Phobias: irrational fears that are disproportionate to actual danger and lead to avoidance.

Defense Mechanisms and Coping Strategies

• Defense mechanisms are coping strategies to reduce uncomfortable emotions.
• Dissociation: a separation of thoughts, memories, or identity from conscious awareness; used as a coping mechanism in some individuals.
• Conversion (somatization): psychological distress expressed as a physical symptom or disorder.
• Somatization: multiple, recurrent physical symptoms with no clear medical cause.
• Crisis: when coping strategies fail to manage distress; seeking support and changing strategies is critical.
• Self-awareness and mindfulness: recognizing one’s own anxiety and choosing calmer responses; anxiety can be contagious, so calm, deliberate responses can influence others.

Populations at Risk and Epidemiology

• Anxiety affects all ages and backgrounds; risk varies by age, income, environment, and genetics.
• Lifetime prevalence is highest in adults aged roughly 30\text{ to }50 years; i.e., 30 \le \text{age} \le 50.
• Lower income is associated with higher rates of depressive mood and anxiety.
• Risk factors include temperament (baseline personality), environmental factors (city living, lifestyle demands), genetics, and physiological factors (endocrine disorders, thyroid disorders, pheochromocytoma).
• Anxiety can manifest differently across the lifespan: childhood and adolescence may show phobias, separation anxiety, or OCD symptoms; adults may show generalized anxiety or panic with risk of comorbid depression.

Childhood, Adolescence, and Developmental Considerations

• Separation anxiety is normal in early development but becomes a disorder if pervasive and persistent into later childhood.
• Adolescents may show anxiety that appears as stress responses; COVID-related stress has been a notable contributor.
• Early intervention with pediatric psychology/therapy improves coping skills and reduces long-term impairment.

Phobias: Categories and Examples

• Phobias are irrational, persistent fears that lead to avoidance and distress. They are distinct from rational fears in that the fear is disproportionate and persistent.
• Categories of phobias:
  • Nature: fear of natural environments (dark, storms, heights).
  • Water: aquaphobia and related fears.
  • Animals: arachnophobia (spiders), ophidiophobia (snakes), etc.
  • Blood, injections, injury (vasophobia, tripanophobia).
  • Flying: fear of flight (aviophobia).
  • Public speaking: glossophobia (fear of speaking in public).
  • Nosophobia: fear of disease.
  • Nosocomial-related fears (hospital environments) and other unusual phobias (e.g., arachibutyrophobia—the fear of peanut butter sticking to the roof of the mouth).
  • Agoraphobia: fear of being outside or in large, open spaces; often leads to avoidance of crowded places or leaving home.
  • Acrophobia: fear of heights.
  • Chirophobia (hand phobia): fear of hands.
  • Omphalophobia: fear of belly buttons.
  • Touraphobia: fear of cheese.
  • Panophobia: fear of everything or a vague sense of doom.
  • Hylophobia: fear of forests.
  • Hymophobia: fear of birds.
  • Allodoxaphobia: fear of opinions.
• Note: Exposure therapy is a common treatment approach for phobias.
• Impact: phobias can severely limit life activities (work, social life) if not treated.

Exposure Therapy

• Gradual, systematic exposure to the feared stimulus in steps:
  • Start with distant or non-threatening exposure (e.g., image or video).
  • Progress to in-room exposure, then closer proximity (toy or contained object).
  • Move to real-world exposure in controlled settings.
  • The goal is to reduce avoidance and anxiety through repeated, safe contact with the feared cue.

Obsessive-Compulsive Disorder (OCD)

• Obsessions: intrusive, persistent thoughts or impulses that cause distress.
• Compulsions: repetitive behaviors or mental acts performed to reduce distress or prevent a feared outcome.
• Common patterns involve contamination fears, counting, checking (back doors, stoves, clocks), orderliness, and ritualized routines.
• Distinction from ordinary habits: OCD involves unwanted thoughts that the person cannot ignore, causing significant distress and impairment.
• Treatments: psychotherapy (including CBT, exposure with response prevention) and pharmacotherapy (SSRIs). In some cases, benzodiazepines are used short-term for anxiety, but not as a long-term OCD solution.

PTSD and Trauma-Related Anxiety

• PTSD features flashbacks and hypervigilance after exposure to trauma.
• During acute flashbacks, touching the person or others can be perceived as dangerous; do not touch someone experiencing a flashback unless they indicate otherwise.
• PTSD symptoms can complicate cognitive-behavioral therapies due to intense re-experiencing, requiring careful, trauma-informed approaches.

Treatments: Psychology and Pharmacology

• Two-pronged approach for most anxiety-related conditions:

  • Psychotherapy (behavioral therapies, cognitive-behavioral therapy, coping strategies, stress management, mindfulness, psychotherapy’s role in behavior change).
  • Pharmacotherapy (medication) to reduce symptoms and facilitate therapy.

• Common pharmacologic options:

  • SSRIs (e.g., Lexapro) for long-term management; take several weeks to show effect; may have initial side effects; can be associated with increased suicidal ideation early in treatment for some individuals, which requires monitoring.
  • Benzodiazepines (e.g., Ativan, lorazepam) for short-term relief; risk of dependence; generally not recommended for long-term use.
  • Tricyclic antidepressants (TCAs) in select cases.
  • Beta-blockers (e.g., propranolol) for performance-type or situational anxiety to blunt physical symptoms; can be used to reduce sympathetic arousal.

• Grapefruit interaction: grapefruit juice can inhibit hepatic enzymes (notably CYP3A4) and increase levels of certain medications, potentially causing toxicity. Do not consume grapefruit with some meds; consult a pharmacist for specific interactions (

  • Note: grapefruit effect is about enzyme inhibition, not absorption.

• Counseling approaches:

  • Exposure therapy and systematic desensitization for phobias and OCD.
  • Cognitive-behavioral therapy (CBT) as a core treatment for many anxiety disorders.
  • Relaxation techniques, meditation, and the use of therapy animals as adjuncts.
  • Psychoeducation for patients and families to foster supportive environments and reduce stigma.

Common Misconceptions and Nuances

• SSRIs and suicidality: early in treatment, some individuals may experience increased suicidal thoughts; this is not universally the case, and not related to homicidal ideation. It requires close monitoring.
• Anxiety and its management are not just about “staying calm” but about identifying triggers, understanding coping styles, and learning healthier strategies.

Practice and Application: Case Concepts and Exam-Style Prompts

• When assessing anxiety:
  • Identify if symptoms are situational, trait-based, or a persistent disorder.
  • Determine if panic symptoms are present and whether agoraphobia is involved.
  • Assess for comorbid conditions (depression, PTSD, OCD, substance use).
• Behavioral goals: e.g., by the third session, the client will list triggers and plan coping strategies to mitigate anxiety.
• Sample questions you might see:
  • A teenager with high COVID-related stress; how to assess and support?
  • A patient with generalized anxiety: what are the two prongs of treatment?
  • A client with OCD describing repetitive checking: what are obsessions vs compulsions?
  • A patient who avoids social interactions due to social anxiety: what pharmacologic and psychotherapeutic options could help?

Quick Review: Key Takeaways

• Anxiety exists on a spectrum from normal to disorder; the line is the level of impairment and distress.
• Panic involves acute, extreme arousal with physical symptoms and cognitive disruption; treatment includes therapy and cautious pharmacology.
• Phobias are irrational fears that lead to avoidance; exposure therapy is a cornerstone treatment.
• OCD centers on obsessions and compulsions; CBT and SSRIs are common treatments.
• PTSD requires trauma-informed care; exposure and CBT play major roles; avoidance in therapy can exacerbate symptoms if not handled carefully.
• The two-pronged treatment model (psychotherapy + pharmacotherapy) applies broadly across anxiety disorders.
• Grapefruit can interact with several medications by inhibiting hepatic enzymes, increasing medication levels; consult healthcare providers.
• Self-awareness, calmness, and mindful coping strategies can be contagious and beneficial in group settings.