Comprehensive Study Notes on Panic, Anxiety, Obsessions, and Their Disorders

Distinction Between Fear and Anxiety Response Patterns

• Historical Perspective on Neurosis: Historically, anxiety disorders were called neurotic disorders. The term "neurosis" was dropped from the $DSM$ in $1980$. Freud formulated these disorders as developing from intrapsychic conflict between the id (primitive desires) and the ego/superego (prohibitions), resulting in overt or masked anxiety.
• General Definitions:
  • Fear: A basic emotion shared by animals, involving the activation of the "fight-or-flight" response of the autonomic nervous system in response to an imminent threat. Its adaptive value is as a primitive alarm allowing for escape. Specifically, it involves a clear and obvious source of danger.
  • Anxiety: A complex blend of unpleasant emotions and cognitions that is more future-oriented and diffuse than fear. It involves general apprehension about possible future danger and a sense of being unable to predict or control it.
• Components of Fear and Panic:
  • Cognitive/Subjective: Thoughts like "I am in danger!" or "I’m going to die."
  • Physiological: Physical reactions such as increased heart rate and heavy breathing.
  • Behavioral: A strong urge to flee or escape.
  • Loosely Coupled: As noted by Lang ($1985$), these three components do not always occur together with the same intensity; one might show physiological signs without a subjective sense of panic.
• Components of Anxiety:
  • Cognitive/Subjective: Negative mood, worry, self-preoccupation, and a sense of uncontrollability over future threats.
  • Physiological: State of tension and chronic overarousal, representing a readiness or priming for the fight-or-flight response.
  • Behavioral: General avoidance of situations where danger might be encountered, without the immediate urge to flee.
• Adaptive Value: Fear allows for rapid response to immediate predators or threats. Mild to moderate anxiety is adaptive as it enhances learning and preparedness (e.g., preparing for an exam or athletic match). It becomes maladaptive when it is chronic or severe.

Overview of Anxiety Disorders and Their Commonalities

• Prevalence: Anxiety disorders affect approximately $29\%$ of the $U.S.$ population at some point. They are the most common category for women and second most common for men. In any $12\,month$ period, about $18\%$ of adults suffer from at least one.
• Primary Disorders in DSM-5:
  1. Specific phobia
  2. Social anxiety disorder (social phobia)
  3. Panic disorder
  4. Agoraphobia
  5. Generalized anxiety disorder ($GAD$)
• Biological Causal Factors:
  • Genetics: Contributes to all these disorders; some vulnerability is nonspecific but manifested through the personality trait of neuroticism (a proneness to negative mood states).
  • Brain Structures: Centrally involves the limbic system (the "emotional brain") and certain parts of the cortex.
  • Neurotransmitters: Primarily Gamma Aminobutyric Acid ($\text{GABA}$), norepinephrine, and serotonin.
• Psychological Causal Factors:
  • Classical Conditioning: Fear/panic/anxiety are often conditioned to various stimuli.
  • Perceptions of Control: Vulnerability increases for those who feel a lack of control over their environment or emotions, often influenced by parenting styles (e.g., overprotective/intrusive).
  • Cognitive Distortions: Faulty or distorted patterns of thinking (cognitive schemas).
• Treatment Commonalities: Graduated exposure to feared cues and situations until the fear begins to habituate. Cognitive restructuring helps change distorted thoughts. Medications include anxiolytics (antianxiety) and antidepressants.

Specific Phobia

• Definition: A persistent and disproportionate fear of a specific object or situation that presents little real danger, leading to significant distress or impairment. The avoidance must last typically $6\,months$ or more to meet $DSM-5$ criteria.
• Subtypes Table ($6.2$):
  • Animal: Snakes, spiders, dogs, insects, birds.
  • Natural Environment: Storms, heights, water.
  • Blood-Injection-Injury: Seeing blood/injury, receiving an injection ($3$ to $4\%$ prevalence; unique for causing a drop in heart rate/blood pressure and fainting).
  • Situational: Public transport, tunnels, bridges, elevators, flying, driving.
  • Other: Choking, vomiting, "space phobia."
• Prevalence and Onset: Lifetime prevalence is about $12\%$. More common in women than men. Animal and blood-injection-injury phobias usually begin in childhood; situational phobias (like driving or claustrophobia) often begin in adolescence or early adulthood.
• Case Study: Mary: A $47\,year-old$ mother suffered from claustrophobia and acrophobia (heights) stemming from being locked in closets by siblings. It became disabling when she wanted to join the workforce and use her husband's airline perks.
• Causal Factors:
  • Learning Theory: Wolpe and Rachman ($1960$) proposed classical conditioning. Vicarious conditioning (watching others) also plays a role (e.g., a boy witnessing a grandfather die while vomiting developed emetophobia).
  • Preparedness Theory: Seligman ($1971$) argued humans are evolutionarily prepared to associate certain stimuli (snakes, water, heights) with threat because it offered a survival advantage. Experiments by %C3%96hman show fear is more easily conditioned to "fear-relevant" stimuli (spiders) than "fear-irrelevant" ones (mushrooms).
  • Genetics: Monozygotic twins are more likely to share phobias. The $s$ allele of the serotonin-transporter gene is linked to superior fear conditioning.
• Treatments: Exposure therapy is most effective. Participant modeling involves the therapist demonstrating interaction with the stimulus. Virtual reality exposure is used for heights/flying. Medication ($d-cycloserine$) may facilitate the extinction of fear when added to exposure.

Social Phobia (Social Anxiety Disorder)

• Definition: Disabling fear of social situations (public speaking, eating in public, urinating in public bathrooms) where one might be scrutinized or evaluated negatively. Intense fear of public speaking is the most common form.
• Prevalence: Lifetime prevalence is $12\%$. $60\%$ of sufferers are women. Typically begins in adolescence or early adulthood. Often comorbid with other anxiety disorders ($2/3$) or depression ($50\%$).
• Case Study: Barry: A $22\,year-old$ student with a $10\,year$ history of social phobia. He avoided class presentations due to fears of ridicule and rejection, possibly exacerbated by the early loss of his mother and peer teasing.
• Causal Factors:
  • Evolutionary: Proposed as a byproduct of dominance hierarchies. Angry/critical faces are processed faster to signal threat. Social phobics show greater amygdala activation to negative facial expressions.
  • Cognitive Biases: Danger schemas lead to expectations of rejection. Self-preoccupation during social interactions interferes with social skill usage.
  • Behavioral Inhibition: A temperamental trait where infants are shy and easily distressed; it is a significant risk factor ($22\%$ risk vs $8\%$ for low inhibition).
• Treatments:
  • Cognitive-Behavioral Therapy ($CBT$): Cognitive restructuring focused on logical reanalysis of automatic negative thoughts ($15\%$ weekly sessions for Barry).
  • Medications: Antidepressants ($MAOIs$ and $SSRIs$) are effective but require long-term use to prevent relapse.

Panic Disorder and Agoraphobia

• Panic Disorder Criteria: Recurrent, unexpected panic attacks (onset reaching peak in under $10\,minutes$) followed by at least $1\,month$ of persistent concern about more attacks (anticipatory anxiety).
• Agoraphobia: Marked fear or anxiety about situations where escape is difficult (public transport, open spaces, crowds). In $DSM-5$, agoraphobia is a distinct diagnosis, though often comorbid with panic.
• Case Study: Jackson: A student whose attacks came "out of the blue," leading to avoidance of dining halls and morning classes.
• Case Study: John D.: A $45\,year-old$ who developed agoraphobia after a panic attack while driving, eventually avoiding elevators and wide-open spaces.
• Prevalence and Gender: Panic disorder lifetime prevalence is $4.7\%$. It is twice as common in women. Agoraphobia without panic is about $1.4\%$. Severe agoraphobia is $80$ to $90\%$ female, potentially due to sociocultural norms allowing women to express avoidance more than men.
• Biological Causal Factors:
  • Brain Areas: The amygdala is central to the "fear network" and panic attacks. The hippocampus is involved in conditioned anxiety/agoraphobic avoidance. Higher cortical centers mediate cognitive symptoms (fear of dying).
  • Neurotransmitters: Noradrenergic activity (cardiovascular symptoms) and serotonergic activity. $\text{GABA}$ is often low in people with panic disorder.
  • Nocturnal Panic: Waking from sleep in a state of panic ($50$ to $60\%$ of patients); occurs during non-$REM$ Stage $2$ and early Stage $3$ sleep, unlike nightmares ($REM$) or night terrors (Stage $4$).
• Psychological Causal Factors:
  • Cognitive Theory: Tendency to catastrophize bodily sensations (e.g., heart racing interpreted as a heart attack) creating a "Panic Circle."
  • Comprehensive Learning Theory: Interoceptive conditioning where internal cues (heart rate) become conditioned stimuli ($CS$) that trigger a panic attack ($CR$).
  • Safety Behaviors: Carrying a bottle of water or medications; these prevent the "disconfirmation" of catastrophic thoughts because the person attributes survival to the behavior rather than the fact that panic is non-lethal.
• Treatments:
  • Panic Control Treatment ($PCT$): Involves education, controlled breathing, cognitive reanalysis, and interoceptive exposure (e.g., spinning in a chair to habituate to dizziness).
  • Medications: Benzodiazepines (Xanax, Klonopin) act fast but cause dependence. Antidepressants ($SSRIs$, Tricyclics) take $4\,weeks$ to work and are better tolerated than benzodiazepines.

Generalized Anxiety Disorder (GAD)

• Definition: Excessive anxiety and worry occurring on more days than not for at least $6\,months$ about various events. It must be difficult to control.
• Physical Symptoms: Muscle tension, restlessness, fatigue, difficulty concentrating, irritability, and sleep disturbance.
• Prevalence: $3\%$ in a given year; $5.7\%$ lifetime. Twice as common in women. Often insidious onset; many report being "worriers all their lives."
• Case Study: Rodney: A graduate student who worried about his health, grades, and social image to the point of procrastination and muscle tension.
• Causal Factors:
  • Perceptions of Uncontrollability: History of unpredictable trauma may foster vulnerability. People with $GAD$ have a low tolerance for uncertainty.
  • Benefits of Worry: Some believe worry avoids deeper emotional topics or serves as "superstitious avoidance" of catastrophe. Worry suppresses physiological responses to imagery, which prevents emotional processing and extinction.
  • Biological: Modest heritability ($15$ to $20\%$). Shared genetic link with major depression (neuroticism). Deficiency in $\text{GABA}$. Corticotropin-releasing hormone ($CRH$) also implicated.
• Treatments: $\text{CBT}$ involving applied relaxation and cognitive restructuring. Medications include Benzodiazepines, Buspirone (non-sedating), and antidepressants.

Obsessive-Compulsive Disorder (OCD)

• Evolution in DSM-5: OCD was moved from the anxiety category to "Obsessive-Compulsive and Related Disorders." Reasons include: anxiety is not the primary indicator of severity, distinct neurobiological circuits (frontal-striatal), and selective response to $SSRIs$.
• Definitions:
  • Obsessions: Persistent, intrusive thoughts, images, or impulses (e.g., contamination, harming others, need for symmetry).
  • Compulsions: Repetitive, ritualistic behaviors or mental acts performed to reduce distress or prevent a dreaded event (e.g., hand washing, checking, counting, ordering).
• Diagnosis: Rituals must take at least $1\,hour$ per day. Prevalence is $2$ to $3\%$ lifetime. Gender ratio is roughly equal in adults, though earlier onset is more common in boys.
• Case Study: Mark: A talented artist whose obsessions about harming others led to excessive checking (driving back to intersections for hours) and needing a tape recorder to record any "confessions."
• Causal Factors:
  • Mowrer’s Two-Process Theory: Neutral stimuli (doorknob) associated with fear (contamination) through conditioning; washing hands reduces anxiety and is reinforced.
  • Cognitive: Thought Suppression: Attempts to suppress unwanted thoughts leads to a paradoxical increase in those thoughts.
  • Thought-Action Fusion: The belief that having a thought is morally equivalent to doing the act or increases the chance of it happening.
  • Neurobiology: Abnormalities in the basal ganglia, particularly the caudate nucleus. High activity in the orbital frontal cortex (source of primitive urges) and the cingulate gyrus. Dysfunctional cortico-basal-ganglionic-thalamic circuit.
• Treatments:
  • Exposure and Response Prevention ($ERP$): Patients are exposed to obsession-triggering stimuli and prevented from performing the ritual. Anxiety must be allowed to dissipate naturally.
  • Medications: Clomipramine (Anafranil) and $SSRIs$ (Prozac). These affect the serotonin system but take $6$ to $12\,weeks$ for significant improvement.