The document discusses various anxiety disorders including specific phobias, social anxiety disorder, panic disorder, agoraphobia, and generalized anxiety disorder. It covers clinical descriptions of the disorders based on DSM-5 criteria, common risk factors like genetics and personality traits, and potential etiologies such as classical conditioning and cognitive factors. The disorders are highly comorbid with each other and other mental health conditions. Treatment options for anxiety disorders are also mentioned.
2. ANXIETY DISORDERS
I. CLINICAL DESCRIPTIONS OF ANXIETY
DISORDERS
II. COMMON RISK FACTORS ACROSS THE
ANXIETY DISORDERS
III. ETIOLOGY OF SPECIFIC ANXIETY DISORDERS
IV. TREATMENTS OF ANXIETY DISORDERS
3. ANXIETY VS. FEAR
• ANXIETY
• APPREHENSION ABOUT A FUTURE THREAT
• FEAR
• RESPONSE TO AN IMMEDIATE THREAT
• BOTH INVOLVE PHYSIOLOGICAL AROUSAL
• SYMPATHETIC NERVOUS SYSTEM
• BOTH CAN BE ADAPTIVE
• FEAR TRIGGERS “FIGHT OR FLIGHT”
• MAY SAVE LIFE
• ANXIETY INCREASES PREPAREDNESS
• “U-SHAPED” CURVE (YERKES & DODSON, 1908)
• ABSENCE OF ANXIETY INTERFERES WITH PERFORMANCE
• MODERATE LEVELS OF ANXIETY IMPROVE PERFORMANCE
• HIGH LEVELS OF ANXIETY ARE DETRIMENTAL TO PERFORMANCE
4. ANXIETY DISORDERS
• DSM-5 ANXIETY DISORDERS
• SPECIFIC PHOBIAS
• SOCIAL ANXIETY DISORDER
• PANIC DISORDER
• AGORAPHOBIA
• GENERALIZED ANXIETY DISORDER
• MOST COMMON PSYCHIATRIC DISORDERS
• 28% REPORT ANXIETY SYMPTOMS
• MOST COMMON ARE PHOBIAS
5. CRITERIA FOR ANXIETY DISORDERS
• DSM-5 CRITERIA FOR EACH DISORDER:
• SYMPTOMS INTERFERE WITH IMPORTANT AREAS OF FUNCTIONING
OR CAUSE MARKED DISTRESS
• SYMPTOMS ARE NOT CAUSED BY A DRUG OR A MEDICAL
CONDITION
• SYMPTOMS PERSIST FOR AT LEAST 6 MONTHS OR AT LEAST 1
MONTH FOR PANIC DISORDER
• THE FEARS AND ANXIETIES ARE DISTINCT FROM THE SYMPTOMS OF
ANOTHER ANXIETY DISORDER
6. PHOBIAS
• DISRUPTIVE FEAR OF A PARTICULAR OBJECT
OR SITUATION
• FEAR OUT OF PROPORTION TO ACTUAL THREAT
• AWARENESS THAT FEAR IS EXCESSIVE
• MUST BE SEVERE ENOUGH TO CAUSE DISTRESS OR
INTERFERE WITH JOB OR SOCIAL LIFE
• AVOIDANCE
7. SPECIFIC PHOBIA
• DISPROPORTIONATE FEAR OF A PARTICULAR OBJECT OR SITUATION
• COMMON EXAMPLES: FEAR OF FLYING, SNAKES, HEIGHTS, ETC.
• FEAR OUT OF PROPORTION TO ACTUAL THREAT
• AWARENESS THAT FEAR IS EXCESSIVE
• MOST SPECIFIC PHOBIAS CLUSTER AROUND A FEW FEARED OBJECTS AND
SITUATIONS
• HIGH COMORBIDITY OF SPECIFIC PHOBIAS
8. DSM-5 CRITERIA FOR SPECIFIC PHOBIA
• MARKED AND DISPROPORTIONATE FEAR
CONSISTENTLY TRIGGERED BY SPECIFIC OBJECTS OR
SITUATIONS
• THE OBJECT OR SITUATION IS AVOIDED OR ELSE
ENDURED WITH INTENSE ANXIETY
• SYMPTOMS PERSIST FOR AT LEAST 6 MONTHS
10. SOCIAL ANXIETY DISORDER
• PREVIOUSLY CALLED SOCIAL PHOBIA
• CAUSES MORE LIFE DISRUPTION THAN OTHER PHOBIAS
• MORE INTENSE AND EXTENSIVE THAN SHYNESS
• PERSISTENT, INTENSE FEAR AND AVOIDANCE OF SOCIAL SITUATIONS
• FEAR OF NEGATIVE EVALUATION OR SCRUTINY
• EXPOSURE TO TRIGGER LEADS TO ANXIETY ABOUT BEING HUMILIATED OR
EMBARRASSED SOCIALLY
• ONSET OFTEN ADOLESCENCE
• 33% ALSO DIAGNOSED WITH AVOIDANT PERSONALITY
DISORDER
• OVERLAP IN GENETIC VULNERABILITY FOR BOTH DISORDERS
11. DSM-5 CRITERIA FOR SOCIAL ANXIETY DISORDER
• MARKED AND DISPROPORTIONATE FEAR CONSISTENTLY
TRIGGERED BY EXPOSURE TO POTENTIAL SOCIAL SCRUTINY
• EXPOSURE TO THE TRIGGER LEADS TO INTENSE ANXIETY
ABOUT BEING EVALUATED NEGATIVELY
• TRIGGER SITUATIONS ARE AVOIDED OR ELSE ENDURED WITH
INTENSE ANXIETY
• SYMPTOMS PERSIST FOR AT LEAST 6 MONTHS
12. PANIC DISORDER
• FREQUENT PANIC ATTACKS UNRELATED TO SPECIFIC
SITUATIONS
• PANIC ATTACK
• SUDDEN, INTENSE EPISODE OF APPREHENSION, TERROR,
FEELINGS OF IMPENDING DOOM
• INTENSE URGE TO FLEE
• SYMPTOMS REACH PEAK INTENSITY WITHIN 10 MINUTES
• PHYSICAL SYMPTOMS CAN INCLUDE:
• LABORED BREATHING, HEART PALPITATIONS, NAUSEA, UPSET
STOMACH, CHEST PAIN, FEELINGS OF CHOKING AND SMOTHERING,
DIZZINESS, SWEATING, LIGHTHEADEDNESS, CHILLS, HEAT SENSATIONS,
AND TREMBLING
• OTHER SYMPTOMS MAY INCLUDE:
• DEPERSONALIZATION
• DEREALIZATION
• FEARS OF GOING CRAZY, LOSING CONTROL, OR DYING
• 25% OF PEOPLE WILL EXPERIENCE A SINGLE PANIC ATTACK (NOT THE SAME AS
PANIC DISORDER)
13. PANIC DISORDER
• UNCUED PANIC ATTACKS
• OCCUR UNEXPECTEDLY WITHOUT WARNING
• PANIC DISORDER DIAGNOSIS REQUIRES RECURRENT UNCUED
ATTACKS
• CAUSES WORRY ABOUT FUTURE ATTACKS
• CUED PANIC ATTACKS
• TRIGGERED BY SPECIFIC SITUATIONS (E.G., SEEING A SNAKE)
• MORE LIKELY A SPECIFIC PHOBIA
14. DSM-5 CRITERIA FOR PANIC DISORDER
• RECURRENT UNEXPECTED PANIC ATTACKS
• AT LEAST 1 MONTH OF CONCERN ABOUT THE POSSIBILITY OF
MORE ATTACKS, WORRY ABOUT THE CONSEQUENCES OF AN
ATTACK, OR MALADAPTIVE BEHAVIORAL CHANGES BECAUSE OF
THE ATTACKS
15. AGORAPHOBIA
• FROM THE GREEK WORD “AGORA” OR MARKETPLACE
• ANXIETY ABOUT INABILITY TO FLEE ANXIETY- PROVOKING SITUATIONS
• E.G., CROWDS, STORES, MALLS, CHURCHES, TRAINS, BRIDGES, TUNNELS, ETC.
• CAUSES SIGNIFICANT IMPAIRMENT
• IN DSM-IV-TR, WAS A SUBTYPE OF PANIC DISORDER
• AT LEAST HALF OF AGORAPHOBICS DO NOT SUFFER PANIC ATTACKS
16. DSM-5 CRITERIA FOR AGORAPHOBIA
• DISPROPORTIONATE AND MARKED FEAR OR ANXIETY ABOUT AT
LEAST 2 SITUATIONS WHERE IT WOULD BE DIFFICULT TO ESCAPE OR
RECEIVE HELP IN THE EVENT OF INCAPACITATION OR PANIC-LIKE
SYMPTOMS, SUCH AS:
• BEING OUTSIDE OF THE HOME ALONE; TRAVELING ON PUBLIC
TRANSPORTATION; OPEN SPACES SUCH AS PARKING LOTS AND
MARKETPLACES; BEING IN SHOPS, THEATERS, OR CINEMAS; STANDING
IN LINE OR BEING IN A CROWD
• THESE SITUATIONS CONSISTENTLY PROVOKE FEAR OR ANXIETY
• THESE SITUATIONS ARE AVOIDED, REQUIRE THE PRESENCE OF A
COMPANION, OR ARE ENDURED WITH INTENSE FEAR OR ANXIETY
• SYMPTOMS LAST AT LEAST 6 MONTHS
17. GENERALIZED ANXIETY
DISORDER (GAD)
• INVOLVES CHRONIC, EXCESSIVE, GENERALIZED,
UNCONTROLLABLE WORRY
• LASTS AT LEAST 6 MONTHS
• INTERFERES WITH DAILY LIFE
• OFTEN CANNOT DECIDE ON A SOLUTION OR COURSE OF ACTION
• OTHER SYMPTOMS:
• RESTLESSNESS, POOR CONCENTRATION, TIRING EASILY,
RESTLESSNESS, IRRITABILITY, MUSCLE TENSION
• COMMON WORRIES:
• RELATIONSHIPS, HEALTH, FINANCES, DAILY HASSLES
• OFTEN BEGINS IN ADOLESCENCE OR EARLIER
• I’VE ALWAYS BEEN THIS WAY
18. DSM-5 CRITERIA FOR
GENERALIZED ANXIETY DISORDER
• EXCESSIVE ANXIETY AND WORRY AT LEAST 50 PERCENT OF DAYS ABOUT AT LEAST TWO
LIFE DOMAINS (E.G., FAMILY, HEALTH, FINANCES, WORK, AND SCHOOL)
• THE PERSON FINDS IT HARD TO CONTROL THE WORRY
• THE WORRY IS SUSTAINED FOR AT LEAST 3 MONTHS
• THE ANXIETY AND WORRY ARE ASSOCIATED WITH AT LEAST THREE (OR ONE IN
CHILDREN) OF THE FOLLOWING:
• 1. RESTLESSNESS OR FEELING KEYED UP OR ON EDGE
• 2. BEING EASILY FATIGUED
• 3. DIFFICULTY CONCENTRATING OR MIND GOING BLANK
• 4. IRRITABILITY
• 5. MUSCLE TENSION
• 6. SLEEP DISTURBANCE
• THE ANXIETY AND WORRY ARE ASSOCIATED WITH MARKED AVOIDANCE OF SITUATIONS
IN WHICH NEGATIVE OUTCOMES COULD OCCUR, MARKED TIME AND EFFORT PREPARING
FOR SITUATIONS THAT MIGHT HAVE A NEGATIVE OUTCOME, MARKED
PROCRASTINATION, DIFFICULTY MAKING DECISIONS DUE TO WORRIES, OR REPEATEDLY
SEEKING REASSURANCE DUE TO WORRIES
19. COMORBIDITY
• 50% OF THOSE WITH ANXIETY DISORDER MEET CRITERIA FOR ANOTHER
ANXIETY DISORDER
• 75% OF THOSE WITH ANXIETY DISORDER MEET CRITERIA FOR ANOTHER
PSYCHOLOGICAL DISORDER
• DISORDERS COMMONLY COMORBID WITH ANXIETY:
• 60% WITH ANXIETY ALSO HAVE DEPRESSION
• SUBSTANCE ABUSE
• PERSONALITY DISORDERS
• MEDICAL DISORDERS, E.G. CORONARY HEART DISEASE
20. GENDER AND
SOCIOCULTURAL FACTORS
• WOMEN ARE TWICE AS LIKELY AS MEN TO HAVE ANXIETY DISORDER
• POSSIBLE EXPLANATIONS
• WOMEN MAY BE MORE LIKELY TO REPORT SYMPTOMS
• MEN MORE LIKELY TO BE ENCOURAGED TO FACE FEARS
• WOMEN MORE LIKELY TO EXPERIENCE CHILDHOOD SEXUAL ABUSE
• WOMEN SHOW MORE BIOLOGICAL STRESS REACTIVITY
• CULTURAL FACTORS
• CULTURE CAN SHAPE ANXIETIES AND FEARS
• CULTURALLY SPECIFIC SYNDROMES
• TAIJIN KYOFUSHO
• JAPANESE FEAR OF OFFENDING OR EMBARRASSING OTHERS
• KAYAK-ANGST
• INUIT DISORDER IN SEAL HUNTERS AT SEA SIMILAR TO PANIC
• RATE OF ANXIETY DISORDERS VARIES BY CULTURE, BUT RATIO OF SOMATIC TO PSYCHOLOGICAL SYMPTOMS APPEARS
SIMILAR (KIRMAYER, 2001)
21. PERCENT OF PEOPLE WHO MEET DIAGNOSTIC CRITERIA
FOR ANXIETY DISORDERS IN THE PAST YEAR AND IN
THEIR LIFETIME
22. FACTORS THAT MAY INCREASE THE RISK FOR
MORE THAN ONE ANXIETY DISORDER
• BEHAVIORAL CONDITIONING (CLASSICAL AND OPERANT CONDITIONING)
• GENETIC VULNERABILITY
• INCREASED ACTIVITY IN THE FEAR CIRCUIT OF THE BRAIN
• DECREASED FUNCTIONING OF GABA AND SEROTONIN; INCREASED
NOREPINEPHRINE ACTIVITY
• BEHAVIORAL INHIBITION
• NEUROTICISM
• COGNITIVE FACTORS, INCLUDING SUSTAINED NEGATIVE BELIEFS,
PERCEIVED LACK OF CONTROL, AND ATTENTION TO CUES OF THREAT
23. 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)
24. ETIOLOGY OF SPECIFIC PHOBIAS
• EXTENSIONS OF THE TWO-FACTOR MODEL
• MODELING
• SEEING ANOTHER PERSON HARMED BY THE STIMULUS
• VERBAL INSTRUCTION
• PARENT WARNING A CHILD ABOUT A DANGER
• THOSE WITH ANXIETY TEND TO ACQUIRE FEAR MORE READILY
• AND TO BE MORE RESISTANT TO EXTINCTION
25. RISK FACTORS
• GENETIC
• TWIN STUDIES SUGGEST HERITABILITY
• ABOUT 20-40% FOR PHOBIAS, GAD, AND
PTSD
• ABOUT 50% FOR PANIC DISORDER
• RELATIVE WITH PHOBIA INCREASES RISK
FOR OTHER ANXIETY DISORDERS IN
ADDITION TO PHOBIA
• NEUROBIOLOGICAL
• FEAR CIRCUIT OVERACTIVITY
• AMYGDALA
• MEDIAL PREFRONTAL CORTEX DEFICITS
• NEUROTRANSMITTERS
• POOR FUNCTIONING OF SEROTONIN AND
GABA
• HIGHER LEVELS OF NOREPINEPHRINE
27. RISK FACTORS: COGNITIVE
• SUSTAINED NEGATIVE BELIEFS ABOUT FUTURE
• BAD THINGS WILL HAPPEN
• ENGAGE IN SAFETY BEHAVIORS
• BELIEF THAT ONE LACKS CONTROL OVER ENVIRONMENT
• MORE VULNERABLE TO DEVELOPING ANXIETY DISORDER
• CHILDHOOD TRAUMA OR PUNITIVE PARENTING MAY FOSTER BELIEFS
• SERIOUS LIFE EVENTS CAN THREATEN SENSE OF CONTROL
• ATTENTION TO THREAT
• TENDENCY TO NOTICE NEGATIVE ENVIRONMENTAL CUES
• SELECTIVE ATTENTION TO SIGNS OF THREAT
28. ETIOLOGY OF SPECIFIC PHOBIAS
• TWO-FACTOR MODEL OF BEHAVIORAL CONDITIONING
• CONDITIONED RESPONSES TO THREAT
• SUSTAINED BY AVOIDANCE OR SAFETY BEHAVIORS
• AVOID EYE CONTACT, APPEAR ALOOF, STAND APART FROM OTHERS IN
SOCIAL SETTINGS
• RISK FACTORS ACT AS DIATHESES
• VULNERABILITIES INFLUENCE DEVELOPMENT OF PHOBIAS
• PREPARED LEARNING
• EVOLUTIONARY PREPARATION TO FEAR CERTAIN STIMULI
• POTENTIALLY LIFE-THREATENING (HEIGHTS, SNAKES, ETC.)
29. ETIOLOGY OF SOCIAL ANXIETY
DISORDER
• BEHAVIORAL FACTORS
• FACTORS SIMILAR TO SPECIFIC PHOBIA (I.E., CLASSICAL AND OPERANT
CONDITIONING)
• COGNITIVE FACTORS
• UNREALISTIC NEGATIVE BELIEFS ABOUT CONSEQUENCES OF BEHAVIORS
• EXCESSIVE ATTENTION TO INTERNAL CUES
• FEAR OF NEGATIVE EVALUATION BY OTHERS
• EXPECT OTHERS TO DISLIKE THEM
• NEGATIVE SELF-EVALUATION
• HARSH, PUNITIVE SELF-JUDGMENT
30. ETIOLOGY OF PANIC DISORDER
• NEUROBIOLOGICAL FACTORS
• LOCUS COERULEUS
• MAJOR SOURCE OF
NOREPINEPHRINE
• A TRIGGER FOR NERVOUS SYSTEM
ACTIVITY
• PEOPLE WITH PANIC DISORDER
MORE SENSITIVE TO DRUGS THAT
TRIGGER THE RELEASE OF
NOREPINEPHRINE
31. ETIOLOGY OF PANIC DISORDER
• BEHAVIORAL FACTORS:
• INTEROCEPTIVE CONDITIONING
• CLASSICAL CONDITIONING OF PANIC
IN RESPONSE TO INTERNAL BODILY
SENSATIONS
32. ETIOLOGY OF PANIC DISORDER
• COGNITIVE FACTORS
• CATASTROPHIC MISINTERPRETATIONS
OF SOMATIC CHANGES
• INTERPRETED AS IMPENDING DOOM
• I MUST BE HAVING A HEART ATTACK!
• BELIEFS INCREASE ANXIETY AND
AROUSAL
• CREATES VICIOUS CYCLE
• ANXIETY SENSITIVITY INDEX
• HIGH SCORES PREDICT DEVELOPMENT
OF PANIC
• “UNUSUAL BODY SENSATIONS SCARE ME.”
• “WHEN I NOTICE THAT MY HEART IS BEATING
RAPIDLY, I WORRY THAT I MIGHT HAVE A
HEART ATTACK.”
33. ETIOLOGY OF PANIC DISORDER
• GENETIC RISK
• POLYMORPHISM IN A GENE GUIDING NEUROPEPTIDE S FUNCTION,
THE NPSR1 GENE, HAS BEEN TIED TO AN INCREASED RISK OF PANIC
DISORDER AND IS ASSOCIATED WITH:
• AMYGDALA RESPONSE TO THREAT
• CORTISOL RESPONSE
• HIGHER ANXIETY SENSITIVITY SCORES
• GENETIC RISK SHAPES STRESS RESPONSES AND HYPERSENSITIVITY
TO SOMATIC CHANGES, AND THIS MAY THEN INCREASE THE RISK
FOR PANIC DISORDER.
34. 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?!?!
35. ETIOLOGY OF GAD
• GABA SYSTEM DEFICITS
• BORKOVEC’S COGNITIVE MODEL:
• WORRY REINFORCING BECAUSE IT DISTRACTS FROM NEGATIVE
EMOTIONS AND IMAGES
• ALLOWS AVOIDANCE OF MORE DISTURBING EMOTIONS
• E.G., DISTRESS OF PREVIOUS TRAUMA
• WORRYING DECREASES PSYCHOPHYSIOLOGICAL AROUSAL
• AVOIDANCE PREVENTS EXTINCTION OF UNDERLYING ANXIETY
36. FIGURE 6.8: THE EXCESSIVE WORRY OF
GAD MAY BE AN ATTEMPT TO AVOID
INTENSE EMOTIONS
37. TREATMENT OF THE ANXIETY
DISORDERS
• PSYCHOLOGICAL TREATMENTS EMPHASIZE
EXPOSURE
• FACE THE SITUATION OR OBJECT THAT TRIGGERS ANXIETY
• SHOULD INCLUDE AS MANY FEATURES OF THE TRIGGER AS POSSIBLE
• SHOULD BE CONDUCTED IN AS MANY SETTINGS AS POSSIBLE
• 70-90% EFFECTIVE
• SYSTEMATIC DESENSITIZATION
• RELAXATION PLUS IMAGINAL EXPOSURE
• COGNITIVE APPROACHES
• INCREASE BELIEF IN ABILITY TO COPE WITH THE ANXIETY TRIGGER
• CHALLENGE EXPECTATIONS ABOUT NEGATIVE OUTCOMES
38. PSYCHOLOGICAL TREATMENT OF
PHOBIAS
• PHOBIAS
• EXPOSURE
• IN VIVO (REAL-LIFE) EXPOSURE MORE EFFECTIVE THAN
SYSTEMATIC DESENSITIZATION
• SOCIAL ANXIETY DISORDER
• EXPOSURE
• ROLE PLAYING OR SMALL GROUP INTERACTION
• SOCIAL SKILLS TRAINING
• REDUCE USE OF SAFETY BEHAVIORS
• COGNITIVE THERAPY
• CLARK’S (2003) COGNITIVE THERAPY MORE EFFECTIVE
THAN MEDICATION OR EXPOSURE
39. PSYCHOLOGICAL TREATMENT OF
PANIC
• PANIC CONTROL THERAPY (PCT; CRASKE & BARLOW, 2001)
• EXPOSURE TO SOMATIC SENSATIONS ASSOCIATED WITH PANIC
ATTACK IN A SAFE SETTING
• INCREASED HEART RATE, RAPID BREATHING, DIZZINESS
• USE OF COPING STRATEGIES TO CONTROL SYMPTOMS
• RELAXATION
• DEEP BREATHING
• PCT BENEFITS MAINTAINED AFTER TREATMENT ENDS
41. PSYCHOLOGICAL TREATMENT OF
GAD
• RELAXATION TRAINING
• COGNITIVE BEHAVIORAL METHODS
• CHALLENGE AND MODIFY NEGATIVE THOUGHTS
• INCREASE ABILITY TO TOLERATE UNCERTAINTY
• WORRY ONLY DURING “SCHEDULED” TIMES
• FOCUS ON PRESENT MOMENT
42. MEDICATIONS
• ANXIOLYTICS: DRUGS THAT REDUCE ANXIETY
• BENZODIAZEPENES
• VALIUM
• XANAX
• ANTIDEPRESSANTS
• TRICYCLICS
• SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)
• SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)
• SIDE EFFECTS CAN BE PROBLEMATIC WITH CONTINUING
MEDICATION
• D-CYCLOSERINE (DCS)
• ENHANCES LEARNING AND CAN BOLSTERED TREATMENT EFFECTIVENESS