Anxiety Disorders

Fear and apprehension run

amok

Definitions
Anxiety apprehension over an
anticipated problem
Fear reaction to immediate
danger
Both involve sympathetic nervous
system arousal
Both are adaptive but when they
arise inappropriately misery can
follow

Many suffer
Most common mds 28% at some
point
Phobias strike the most
Pervasive costs
1) 2x the medical cost
2) greater risk of heart and other
illnesses
3) 2x suicide risk
4) troubles socially and at work

DSM IV TR to DSM 5
Most disorders remain unchanged
Panic Disorder (DSM IV TR) now split
into Panic disorder and Agoraphobia
OCD and Trauma/Stress disorders
(PTSD) are given their own chapters

General Diagnostic Criteria

Major functional trouble/distress
Drugs or medical condition not
causal
Lots of overlap between the specific
disorders
Most (except GAD) involve intense
fear

Description Specific
phobias
A disproportionate fear caused by a
specific object or situation
Recognizing that the fear is not
realistic no longer necessary in DSM
5
Object or situation are avoided
High chance that a victim will more
than 1

Social Anxiety Disorder

Persistent, unrealistically intense fear
of social situations involving
appraisal or even contact with
unfamiliar people
Formerly social phobia disorder
Great fear of public speaking, talking
in class or to authority figures,
meeting new people
Way beyond simple shyness
Can severely limit jobs and

Social Anxiety Disorder

cont.
1/3 are comorbid w/ avoidant
personality disorder, w/ genetic
overlap, but less severe
Can begin in childhood, but usually in
teens
Chronic w/out treatment
Fears can range from a few to very
many
More fears, more likely comorbid w/
depression and alcohol abuse

Panic Disorder
Frequent panic attacks unrelated to any specific
trigger and the worry of more to come
Panic attack sudden wave of intense terror
accompanied by at least four other symptoms
Symptoms could include shortness of breath,
racing heart, sweat, fainting, chills, nausea,
trembling, dizziness, numbness/tingling

Panic Disorder:
psychological symptoms
Derealization fear that the world
is not real
Depersonalization a feeling of
being outside of your body
Also, fear of losing control, of going
crazy, of dying
90% report these type of symptoms
Many want to run away as fast as
possible

Recurrence is crucial
Attacks must be recurrent for at least
a month
Many (more than 25%) have endured
one attack
Few suffer repeatedly
Devastating to employment many
cannot keep a job

Agoraphobia
Fear of places or situations from
which it would be hard to escape
Crowds, shopping malls, trains,
games
Many, as a result, dont leave the
house
And, if they do, its only with great
distress
Formerly under Panic Disorder, but
few endure panic attacks

Generalized Anxiety Disorder (GAD)

Excessive worry on more days than
not about any kind of events
Worries are common for everyone
but these are excessive in terms of
intensity and time
Must last for at least 6 months, many
chronic
Symptoms include trouble
concentrating, fatigue, irritability,
restlessness, muscle tension

If youve got one

More than half get another anxiety
diagnosis at some point
Especially true for GAD 80%!
Many others have subthreshold
symptoms
Why such high comorbidity?
1) symptom overlap, and
2) many causal factors increase
risk for more than 1 disorder

More comorbidity
Above and beyond other anxiety
disorders, they have high
comorbidity with many other types of
mds
75% meet criteria for another md!
60% for depression alone
Many suffer from substance abuse
and/or personality disorders
Also great risk for concurrent medical
woes

Does Gender matter?

Yes women are 2x more likely to suffer.
Why?
a) More likely to report
b) Men think they have control
c) Men are often forced to face fears
exposure
d) Sadly, women are more often
sexually abused
e) Women seem more physiologically
vulnerable

How about culture?

Significant variation depending upon
what a culture values, or fears
Taijin kyofusho Japanese syndrome
involving deep fear of displeasing others
Manifests by fear of eye contact,
blushing, body odor or deformity
Similar to SAD but the emphasis on
the feelings of others distinguishes
Arises from extreme, traditional
concern for others feelings?

More cultural variants

Kayak-angst Inuit seal hunters can
endure special type of panic disorder
Features intense fear, disorientation
Alone in a harsh, unforgiving
environment
Koro Asian phenomenon, grave fear
of penis disappearing into body
Shenkui Chinese fear of losing
semen due to masturbation or too
much sex

Other aspects of cultural

variation
Low incidence of anxiety disorders in
Japan bias against reporting?
Lots of panic disorder in Cambodia
lingering effects of Khmer rouge
genocide? PTSD?
While some cultural variations have
been explained away, others,
including the nature of complaints do
vary from culture to culture

Common Risk factors for all Anxiety

Disorders
Helps explain high comorbidity
Big factor arises from the classical
conditioning (CC) of fear responses
Other factors genes, personality
traits, cognitive factors influence
how and when conditioning takes
hold

Fear Conditioning Mowrers Two

Factor Model
Mowrers theory
1) through CC we learn to fear a
neutral stimulus (CS) that is
repeatedly paired with an always
averse stimulus (UCS)
2) through operant conditioning
(OC) we feel better, doge stress, by
avoiding the CS. Avoiding the CS
becomes more and more likely
(reinforcing) because it reduces fear.

Example Claustrophobia &

elevators
A child is stuck in an elevator for a long
period of time and develops a phobia of
elevators
She has learned to link elevators (CS) with
being trapped in a small space (UCS)
The child becomes anxious every time she
sees or even thinks about an elevator (CR)
Avoiding elevators produces great relief
(reinforcement) so it continues no
exposure

How could this start?

Direct experience a snake bit you
and it hurt
Modeling you saw another person
bitten or terrified and it made an
impression on you
Verbal instruction someone told you
hoe horrible it is to be bitten by a
snake

Two other factors

People who suffer from anxiety
disorders share two qualities
1) they are more susceptible to
CC of fear responses
2)their fears are resistant to
extinction exposure to extinction
trials (CS not followed by UCS) does
not lead to extinction

Genetic influence
Twin studies reveal a heritability of
20-40% for anxiety disorders besides
panic disorder
Panic disorder 50%
It seems that some genes predispose
to all anxiety disorders while others
point to specific disorders

Neurobiological
Inappropriate activation and persistence of
the fear circuit is associated with anxiety
disorders
The amygdala is a major player assigning
excessive fear to stimuli and triggering the
circuit
Worse yet, the medial prefrontal area,
which can override the too sensitive
amygdala, tends to be compromised in
anxiety disorders

Neurobio II
Neurotransmitters also play a role
Serotonin problems, or too much
norepinephrine, are linked to anxiety
woes
GABA usually inhibits activity and
anxiety throughout the brain, deficits
could hurt

Personalitys Influence
If yearlings show behavioral
inhibition, fearful reaction to novel
stimuli, they often (45%) show
anxiety at 7.
Genetic can manifest at four
months
Especially predictive of Social
Anxiety Disorder
Neuroticism ultra-senrsitivity to
adverse stimuli, another strong

Cognitive three theories

Sustained Negative Beliefs about the
Future the pervasive conviction
that only bad things are coming
Common among anxiety disorders
Maintained by safety behaviors,
avoidance measures that prevent
beliefs from reality testing

Perceived Control
The belief that you have no control
over your future is characteristic of
many anxiety disorders
Rough times as a kid may encourage
this outlook
70% of anxiety sufferers can identify
a crisis within months of onset
Backed up by animal studies

Specific Causes - Phobias

Classical Conditioning phobias are a
conditioned response maintained by
avoidance behavior
Could arise from personal trauma,
modeling, or verbal instruction
When asked though, about dont
remember
Says more about the failings of
memory, than the viability of the
theory

Phobia etiology II
Many are unaffected by experiences
that cause phobias to develop in
others
Why? risk factors neurotransmitter
deficits, personality traits, high fear
circuit activation
But only some things cause phobias
to arise things we have feared for
millennia like dogs, snakes, heights
Prepared Learning

Causes of Social Anxiety

Disorder
Similar to phobias developed by
CC, maintained by OC
Safety behaviors make the
problem worse
From the Cognitive perspective:
1) negative beliefs Im a dork &
all know it
2) too conscious of internal
cues so alert to their reactions,
they ignore their partner

Panic Disorder Why do we

exaggerate bodily changes?
Neurobiological locus coruleus
turns on too easily causing
unnecessary sympathetic nervous
system arousal
Classical Conditioning signs of
arousal lead to panic attack, and
then become a CS, with the
subsequent panic attack becoming a
CR also called interoceptive
conditioning

Cognitions role in Panic

Disorder
Interpreting somatic changes as
impending doom
When someone is warned that
somatic changes are coming, they
dont experience panic attacks
When they dont know, they have
catastrophic interpretations and can
sustain panic attacks

Agoraphobia causes
Fear of Fear victims overestimate
how badly they will react to stress in
public
Afraid their unease will go viral

Etiology of GAD: Why worry so

much?
GAD is so often a comorbid condition,
general predictors of anxiety
disorders are key
Also, cognitive factors appear crucial
Worry can be reinforced because it
distracts them from its source, which
is more upsetting
Many have histories of severe
trauma
Worry decreases arousal

Treatment
Sadly, few seek treatment fewer
than 20%
Do they think thats just the way
they are?
Also, they need specialized help
General Practitioners under-prescribe
and break off treatment too early

Treatment You have to face it

Exposure is the key
Systematic Desensitization works
well, even w/out relaxation
CBT is successful, especially if it
includes many aspects of triggering
stimuli
Behaviorists say that we learn a new
response, instead of erasing the old
Virtual reality technology can help

Specific treatments
Phobias in vivo (real life) exposure
works even better than systematic
desensitization
Only a few hours can be enough
GAD exposure, starting with roleplaying exercises
Social skills training helps, especially
if safety behaviors are recognized
and overcome

Panic Disorder
Psychodynamic treatment:
1) id the emotions & causes
2) gain insight
Small studies revealed this to be
effective and to prevent relapse
Panic Control Therapy triggering
sensations are elicited, coping
techniques are taught, ability to
create & overcome weakens effect

More treatments
Agoraphobia systematic exposure
w/ partner, who will not enable works
GAD all treatments feature a mix
of behavioral and cognitive
components
typically, relaxation exercises are
used
attempts to better cope w/
uncertainty

Medications
Two basic types
Benzodiazepines such as Valium and
Xanax
Antidepressants
tricyclics
selective serotonin reuptake inhibitors
serotonin-norepinephrine reuptake
inhibitors
All provide relief from anxiety disorders

Which to choose?
Antidepressants lack severe
withdrawal effects, they arent
addictive
All have side-effects
Benzodiazepines cause cognitive and
motor problems, even memory
lapses
Tricyclics can cause jitteriness,
weight gain, and others

Why SSRIs?

Preferred meds for anxiety disorders

50% stop tricyclics
SSRIs have fewer side-effects
But they can occur
Include restlessness, sleep and
sexxproblems, and headaches

But it doesnt last

While meds work, once they arent
taken, relapse usually follows
Accordingly, psychological
treatments featuring exposure are
preferred
Exception GAD, which can be
treated by buspirone (BuSpar)

Combining meds and psych

treatments
Surprisingly, combining works less
than exposure treatments, of
whatever type, alone
Possibly because meds can impair
facing the fear source