ANXIETY
DISORDERS
•A common dimension of day-to-day
human experiences
•An unpleasant emotion
characterized by a feeling of
vague, unspecified harm.
ANXIETY DISORDERS
• Marked by experience of
physiological arousal, apprehension
or feeling of dread, hyper vigilance,
avoidance and sometimes, a specific
fear or phobia
FEAR VS ANXIETY
FEAR
- immediate alarm reaction to danger
- Response to a known, external,
definite or non-conflictual threat
- Response to an immediate threat
ANXIETY
- Negative mood state characterized by
bodily symptoms of physical tension and
by apprehension about the future
- Response to a threat that is unknown,
internal vague or conflictual
- Apprehension about a future threat
ANXIETY DISORDERS
• Primary determination of whether the fear or
anxiety is excessive or out of proportion is
made by the clinician, taking cultural
contextual factors into account.
• Can develop in childhood and persist into
adulthood if not treated
• Most occur in females than males (2:1)
CAUSE OF ANXIETY DISORDERS
• Biological Contributions
- We inherit a tendency to be tense, uptight, and anxious
- Behavioral Inhibition System (BIS):
- Tendency is to freeze
- Activated by signals from the brain stem of unexpected events
that might signal danger.
- Fight/Flight system (FFS):
- Immediate alarm-and-escape response like panic.
Environment can change the sensitivity of these brain circuits.
- Ex: teenage smoking can lead to early GAD or panic disorder
CAUSE OF ANXIETY DISORDERS
Psychological Contributions
• Freud: anxiety was a psychic reaction to danger surrounding the
reactivation of an infantile fearful situation
• “Sense of uncontrollability” / locus of control: higher, more anxious
• Parents’ actions in childhood: Parents’ positive and predictable
responses: less anxious. Negative/ overprotective: more anxious
Social Contributions
• Marriage, divorce, difficulties at work, death of a loved one,
pressures to excel in school
Triple Vulnerability Theory
COMORBIDITIES
Comorbidity: Co-occurrence of two or more disorders in an individual
• Anxiety disorders with depression/ major depression
• Diagnoses of depression or alcohol or drug abuse makes it less likely
to recover from anxiety disorder and more likely to relapse
Physical Comorbidities:
• Anxiety disorder with thyroid disease, respiratory disease,
gastrointestinal disease, arthritis, migraine headaches
• Panic disorders and cardio, respiratory, gastrointestinal, and
vestibular (inner ear) disorders
SUICIDE
- Weissman study: 20% of patients with panic
disorder had attempted suicide
- Anxiety or related disorder increases the chances of
having thoughts about suicide (suicidal ideation) or
making suicidal attempts
- Strongest with panic disorder and posttraumatic stress
disorder
CLASSIFICATIONS OF ANXIETY DISORDERS
• SEPARATION ANXIETY DISORDER
• SELECTIVE MUTISM
• SPECIFIC PHOBIA
• SOCIAL ANXIETY DISORDERS
• PANIC DISORDER
• AGORAPHOBIA
• GENERALIZED ANXIETY DISORDERS
• SUBSTANCE/MEDICATION INDUCED
ANXIETY DISORDERS
SEPARATION ANXIETY DISORDER
A. Inappropriate and excessive fear or
anxiety concerning separation from
those to whom the individual is
attached
(3 or more)
1. Excessive distress when anticipating or
experiencing separation from home or
from major attachment figures.
SEPARATION ANXIETY…
2. Worry about losing major attachment figures
3. Worry about experiencing an untoward event
from a major attachment figure.
4. Reluctance or refusal to go out because of fear
of separation
5. Excessive fear or reluctance about being alone
without attachment figures at home or in other
settings
SEPARATION ANXIETY…
6. Reluctance or refusal to sleep away from
home or to go to sleep without being near a
major attachment figure.
7. Repeated nightmares involving the theme
of separation.
8. Repeated complaints of physical symptoms
when separation from major attachment
figures occurs or is anticipated.
SEPARATION ANXIETY
b. Fear, anxiety, or avoidance is
persistent lasting for 4 weeks for
children and 6 months or more
for adults
c. Disturbance causes distress
d. Disturbance is not caused by
another disorder
RISKS FACTORS
•Develops after life
stresses, especially loss
(ex. death of a relative
or a pet)
•Parental overprotection
and intrusiveness
SELECTIVE MUTISM
a. Consistent failure to speak in specific social
situations in which there is an expectation for
speaking (e.g., at school) despite speaking in
other situations.
b. Disturbance interferes with educational or
occupational achievement or with social
communication.
SELECTIVE MUTISM
c. Duration of the disturbance is at least 1
month (not limited to the first month of
school).
d. the failure to speak is not attributable to a
lack of knowledge of, or comfort with, the
spoken language required in the social
situation.
e. the disturbance is not better explained by
a communication disorder
ASSOCIATED FEATURES
• Excessive shyness
• Fear of embarrassment
• Social isolation and withdrawal
• Clinging
• Temper tantrums
SPECIFIC PHOBIA
A. Marked fear or anxiety about
a specific object or situation
B. Exposure to the stimulus
provokes an immediate
anxiety
c. Phobic object or situation is
actively avoided or endured
with intense fear or anxiety.
CONT…
d. the fear or anxiety is out of proportion to the
actual danger
e. fear or anxiety or avoidance is persistent
lasting for 6 months
f. fear or anxiety or avoidance causes distress
g. the anxiety is not better explained by another
mental disorder
SPECIFIC PHOBIA
•Animal type
•Natural environment type
•Blood-injection-injury type
•Situational type
•Other types (loud sounds)
Table 5.2
Words Used to Describe Highly Unlikely Phobias
Fear
Phobia
Anything new
Neophobia
Asymmetrical things
Asymmetriphobia
Books
Bibliophobia
Children
Pedophobia
Dancing
Chorophobia
Englishness
Anglophobia
Garlic
Alliumphobia
Peanut butter sticking to the roof of the mouth
Arachibutyrophobia
Technology
Technophobia
Mice
Musophobia
Pseudoscientific terms
Hellenophobia
Table 5.3 Types of Specific Phobias
Type of Phobia
Source of Fear
Associated
Characteristics
Animal
Animals (e.g., snakes, insects)
Generally begins
during childhood
Natural environment Aspects of the natural environment (e.g.,
Generally begins
storms, heights, water)
during childhood
Blood, injection,
Blood, injury, injections, or other invasive
Clearly runs in families
injury
medical procedures
Situational
Specific situations (e.g., public
Tends to begin either
transportation, tunnels, bridges, elevators,
in childhood or in mid-
flying, driving, closed spaces)
20s.
Fear of choking, fear of contracting an
—
Other
illness, etc.; children’s fears of loud sounds,
clowns, etc.
DEVELOPMENT
It can sometime develop:
• After a traumatic event
•Observation of others going through a
traumatic event
•An unexpected panic attack in the feared
situation
•informal transmission
However, many are unable to recall the cause
ETIOLOGY OF SPECIFIC PHOBIAS
• CONDITIONING
• MOWRER’S TWO-FACTOR
MODEL
• PAIRING OF STIMULUS WITH
AVERSIVE UCS LEADS TO FEAR
(CLASSICAL CONDITIONING)
• AVOIDANCE MAINTAINED
THOUGH NEGATIVE
REINFORCEMENT (OPERANT
CONDITIONING)
Copyright 2009 John Wiley & Sons, NY
29
SOCIAL ANXIETY DISORDER
(SOCIAL PHOBIA)
• Starts in mid-teens
• Duration is life long
• Frequently appears
among first degree
biological relatives
CRITERIA FOR SOCIAL
ANXIETY DISORDER
(SOCIAL PHOBIA)
A. Marked fear or anxiety about one or
more social situations in which the
individual is exposed to possible scrutiny
by others. Exposure to the feared social
situation provokes anxiety
B. The individual fears that he or she will act
in a way or show anxiety symptoms that
will be negatively evaluated
CRITERIA FOR SOCIAL PHOBIA
c. Social situations almost always provoke
fear or anxiety.
d. The social situations are avoided or
endured with intense fear or anxiety.
e. Fear or anxiety is out of proportion to
the actual threat posed by the social
situation and to the sociocultural context.
CRITERIA FOR SOCIAL PHOBIA
f. Persistent and lasting for 6 months or more.
g. the fear, causes clinically significant distress or impairment in
important areas of functioning.
h. Not caused by physiological effects of a substance
i. the fear, anxiety, or avoidance is not better explained by the
symptoms of another mental disorder
j. if another medical condition (e.g., parkinson’s disease,
obesity, disfigurement from bums or injury) is present, the fear,
anxiety, or avoidance is clearly unrelated or is excessive.
SPECIFIERS:
• Performance only:
they have performance fears that impairs in their
professional lives
they do not fear or avoid non-performance
situations.
ASSOCIATED FEATURES
• Paruresis “shy bladder syndrome”
• May be inadequately assertive or
excessively submissive
• May overly show rigid body posture
• May be shy or withdrawn
• Seek employment that does not require
social contract
• Men may be delayed in marrying whereas
women prefer to be homemakers
ETIOLOGY OF SOCIAL PHOBIA
• AVOIDANCE OR SAFETY BEHAVIORS
• AVOID EYE CONTACT, APPEAR ALOOF, STAND
APART FROM OTHERS IN SOCIAL SETTINGS
• COGNITIVE FACTORS
• NEGATIVE SELF EVALUATION
• HARSH, PUNITIVE SELF-JUDGMENT
• FEAR OF NEGATIVE EVALUATION BY OTHERS
• EXPECT OTHERS TO DISLIKE THEM
• EXCESSIVE ATTENTION TO INTERNAL CUES
• E.G., HEART RATE
37
PSYCHOLOGICAL TREATMENT OF PTSD
• EXPOSURE TO MEMORIES AND REMINDERS OF THE ORIGINAL TRAUMA
• EITHER DIRECT (IN VIVO) OR IMAGINAL
• TREATMENT MAY INITIALLY INCREASE SYMPTOMS
• MORE EFFECTIVE THAN MEDICATION OR SUPPORTIVE THERAPY
• COGNITIVE THERAPY
• ENHANCE BELIEFS ABOUT COPING ABILITIES
• ADDING CT TO EXPOSURE DOES NOT IMPROVE TREATMENT RESPONSE
• TREATMENT OF ASD MAY PREVENT PTSD
• SHOWS BENEFITS EVEN 5 YEARS AFTER THE TRAUMATIC EVENT
Spectrum Model of Social Phobia and
Avoidant Personality Disorder
PANIC ATTACK
• An abrupt surge of intense fear or intense
discomfort that reaches a peak within minutes
• A panic attack is not a mental disorder
• Can occur in the context of any anxiety
disorder as well as other mental disorders
• When the presence of a panic attack is
identified, it should be noted as a specifier (ex.
“ptsd with panic attacks”).
Uncued / Unexpected attacks
- Occur unexpectedly without
warning
- Panic disorder diagnosis
requires recurrent uncued
attacks.
- Panic Disorders
Cued / Expected attacks
- Triggered by specific situations
(e.g., tunnel, mountain
climbing=heights)
- More likely a phobia
PANIC DISORDER
• Higher risk on women; 2:1 ratio
• Commonly develops in young adults;
• 20 – 24 years old
• 25% unemployed for more than 5 years
because of symptoms
• Prognosis worse when agoraphobia is
present
PSYCHOSOCIAL FACTORS
• Cognitive-behavioral
theories – classical
conditioning
• Psychoanalytic theories –
arise from an unsuccessful
defense against anxietyprovoking impulses.
PANIC DISORDER
• Recurrent unexpected panic attacks.
• (4 or more)
Physical Symptoms
• Palpitations, pounding heart or
accelerated heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath or
smothering
PANIC DISORDER
•Feeling of choking
•Chest pain
•Nausea or abdominal distress
•Feeling dizzy, fainting, lightheaded or faint
PANIC DISORDER
• Chills or heat sensations
• Paresthesias (numbness or tingling
sensations)
• Derealization or depersonalization
• Fear of losing control or going
crazy
• Fear of dying
PANIC DISORDER
• at least one of the attacks has been followed by 1
month (or more) of one or both of the following:
1. Persistent concern or worry about additional attacks
or the consequences
2. Significant change in behavior related to the
attacks
c. Not caused by a substance
d. Not caused by a gmc
RISK FACTORS OF PANIC DISORDERS
•
•
•
•
•
•
•
•
•
negative affectivity
anxiety sensitivity
history of fearful spells
separation anxiety (not a consistent factor)
childhood sexual and physical abuse
smoking
identifiable stressors before the panic attack
offspring of parents with anxiety disorder
respiratory disturbance (asthma)
ETIOLOGY OF PANIC
• INTEROCEPTIVE
CONDITIONING
• CLASSICAL
CONDITIONING OF PANIC
IN RESPONSE TO BODILY
SENSATIONS
• PEOPLE WITH PANIC
DISORDER SUSTAIN
CLASSICALLY
CONDITIONED FEARS
LONGER
ETIOLOGY OF PANIC
• COGNITIVE FACTORS
• LACK OF PERCEIVED
CONTROL CAN TRIGGER
PANIC
• FEAR OF BODILY CHANGES
• INTERPRETED AS IMPENDING
DOOM
• I MUST BE HAVING A
HEART ATTACK!
• BELIEFS INCREASE ANXIETY
AND AROUSAL
• CREATES VICIOUS CYCLE
57
TABLE 5.7 SAMPLE ITEMS FROM ANXIETY
SENSITIVITY INDEX
Table 5.7
Sample Items from the Anxiety Sensitivity Index
Unusual body sensations scare me.
When I notice that my heart is beating rapidly, I worry that I might have a heart
attack.
It scares me when I feel faint.
It scares me when I feel “shaky” (trembling).
Source: Peterson & Reiss, 1987. Note: People respond to each item on a 0 (very little) to 4
(very much) scale.
AGORAPHOBIA
a. Fear or anxiety in two or more
of the following:
1. Public transportation
2. Open spaces.
3. Enclosed places
4. Standing in line or being in a
crowd.
5. Being outside of the home
alone.
AGORAPHOBIA…
b. Fears/ anxiety are due to thoughts that
escape might be difficult
c. Provoke anxiety
d. Avoided or endured with anxiety
e. Fear/anxiety is out of proportion
f. Fear/anxiety is persistent lasting 6 months
g. Fear/anxiety causes distress
h. If a medical condition is present, the fear/
anxiety is in excess
i. Fear/anxiety is not caused by another disorder
ETIOLOGY OF AGORAPHOBIA
• FEAR-OF-FEAR HYPOTHESIS (GOLDSTEIN & CHAMBLESS, 1978)
• EXPECTATIONS ABOUT THE CATASTROPHIC CONSEQUENCES OF HAVING
A PUBLIC PANIC ATTACK.
• WHAT WILL PEOPLE THINK OF ME?!?!
Copyright 2009 John Wiley & Sons, NY
61
GENERALIZED ANXIETY
DISORDER
A. Excessive anxiety and worry
occurring more days than not for 6
months in a number of events or
activities
B. Controlling the worry is difficult
GENERALIZED ANXIETY DISORDER
c. 3 or more of the following (one for
children)
1. Restlessness or feeling keyed up or
on edge.
2. Easily fatigued.
3. Difficulty concentrating or mind
going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling
or staying asleep, or restless,
unsatisfying sleep).
GENERALIZED ANXIETY DISORDER
• Females are twice as likely as males to
experience gad
• 1/3 of the risk of GAD is genetic
• Common worries:
- Relationships, health, finances, daily hassles
• Often begins in adolescence or earlier
GENDER &
SOCIOCULTURAL FACTORS
• WOMEN ARE 2X AS LIKELY AS MEN TO HAVE ANXIETY DISORDER
EXCEPT FOR OCD
• POSSIBLE EXPLANATIONS
• WOMEN MAY BE MORE LIKELY TO REPORT SYMPTOMS
• WOMEN MORE LIKELY TO EXPERIENCE CHILDHOOD SEXUAL ABUSE
• WOMEN SHOW MORE BIOLOGICAL STRESS REACTIVITY
• SOCIOCULTURAL FACTORS
• FOCUS OF ANXIETY VARIES
• TAIJIN KYOFUSHO
•
JAPANESE FEAR OF OFFENDING OR EMBARRASSING OTHERS
• RATIO OF SOMATIC TO PSYCHOLOGICAL SYMPTOMS APPEARS SIMILAR ACROSS
CULTURES
RISK FACTORS: PERSONALITY
• Behavioral inhibition
• Tendency to be agitated, distressed, and cry in
unfamiliar or novel settings
• observed in infants as young as 4 months
• may be inherited
• Predicts anxiety in childhood and social anxiety in
adolescence
• Neuroticism
• React with negative affect
• Linked to anxiety and depression
RISK FACTORS: SOCIAL
• NEGATIVE LIFE EVENTS
• JOB LOSS, END OF RELATIONSHIP, ETC.
• SEVERE STRESSORS OFTEN PRECEDE ONSET
80% WITH PANIC DISORDER
• 70% WITH ANY ANXIETY DISORDER