Task 3 - Social Anxiety Disorder and Panic Attacks

Question 1

What is social anxiety disorder?

Answer 1

People with social anxiety disorder become so anxious in social situations and are so afraid of being rejected, judged, or humiliated in public that they are preoccupied with worries about such events to the point that their lives may become focused on avoiding social encounters

Question 2

Prevalence of social anxiety disorder

Answer 2

• 1-7% internationally
• 12% in the US
• women tend to have more severe social fears than men
• develops in early preschool years or adolescence

Question 3

Comorbidities of social anxiety disorder

Answer 3

• mood disorders
• other anxiety disorders
• 70% comorbidity

Question 4

DSM-5 Criteria social anxiety disorder

Answer 4

A Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others –> social interactions, being observed, performing in front of others
B The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated
C The social situation almost always provoked fear or anxiety
D The social situations are avoided or endured with intense fear or anxiety
E The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context
F The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more

Performance only: if the fear is restricted to speaking or performing in public

Question 5

Social performance deficits in SAD

Answer 5

Patients with SAD show performance problems during a conversation

• a conversation is unstructured, bidirectional, and requires interaction
• a conversation asks for more interpersonally sensitive social behavior –> making contact, listening, showing interest, being responsive, and interacting

Question 6

interpretation bias and judgmental bias

Answer 6

interpretation bias = the interpretation of ambiguous events as negative

judgmental bias = the overestimation of the costs and/or probability of a negative event

• SPs interpret social events as more negative and judge social events as more threatening
• interpretation bias of social phobia is a negative interpretation of all social events, irrespective of valence

Question 7

Clark and Wells Model

Answer 7

People with social anxiety disorder interpret social situations in a threatening way because of a range of dysfunctional beliefs they have about themselves, others, and the social world

• use of safety behaviors
• pre-event rumination
• post-even rumination

Question 8

pre-event rumination

Answer 8

thoughts regarding past failures partly account for SAD maintenance and lead to anticipatory anxiety and predictions of poor performance

Question 9

past-event rumination

Answer 9

typically begins after the social situation and revolves around intrusive images and thoughts regarding perceived failures and of adverse images of themselves that were experienced during the event

Question 10

Rapee and Heimberg Model

Answer 10

• when a social situation is anticipated or encountered, people with social anxiety disorder form a mental representation of their external appearance, based on memories of past social situations and internal and external cues

Question 11

Hoffman Model

Answer 11

• people with social anxiety disorder are apprehensive of social situations due to having unrealistic social standards and poorly defined social goals

–> combines the Clark/Wells Model and the Rapee/Heimberg model and expands them further

Question 12

Causes SAD: Genetic

Answer 12

brain areas of the amygdala, hippocampus, and prefrontal cortex are involved

Question 13

Causes SAD: Cognitive

Answer 13

• excessively high standards
• focus on negative aspects of interactions
• harsh evaluation of themselves
• rumination about one’s performance
• family environment

–> safety behaviors

Question 14

safety behaviors

Answer 14

= coping mechanisms used to reduce anxiety and fear when the individual feels threatened

–> engaging in safety behaviors increases self-focused attention, reduces the ability to attend to objective social information, and may cause the feared result

• avoidance of social situations
• escaping social situations
• trying not to attract the gaze of others

Question 15

Treatment SAD: Cognitive Behavioral Therapy

Answer 15

Behavioral Component:
- exposing clients to social situations that make them anxious (from least to most)
- role-playing, relaxing techniques, eliminating safety behaviors, experiments

Cognitive component:
- identifying negative cognitions clients have about themselves and about social situations and teaching them how to dispute these cognitions

Question 16

Treatment SAD: Medication

Answer 16

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs)
- efficacious in reducing symptoms
- symptoms return when medication is stopped

Benzodiazepines
Antiepileptics
Antipsychotics
Oxytocin

Question 17

Treatment SAD: Mindfulness-Based Interventions

Answer 17

• teach individuals to be less judgmental about their own thoughts and reactions and more focused on, and relaxed in, the present moment

Acceptance and Commitment Therapy (ACT):
- builds on CBT techniques to emphasize mindfulness, acceptance, and values

–> third-wave approaches of CBT

Question 18

What is Panic Disorder?

Answer 18

Most commonly, panic attacks arise in certain situations but not every time: They are terrifying experiences, causing a person intense fear or discomfort, the physiological symptoms of anxiety, and the feeling of losing control, going crazy, or dying

Question 19

Prevalence of panic disorder

Answer 19

• 3-5% will develop panic disorder at some time
• onset is usually between late adolescence and the mid-thirties
• more common in women
• chronic

Question 20

Comorbidities of panic disorder

Answer 20

• chronic generalized anxiety disorder
• depression
• alcohol abuse
• increased risk of suicide

Question 21

DSM-5 Criteria Panic Disorder

Answer 21

A Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:
1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed, or faint
9. Chills or heat sensations
10. Paresthesias (numbness or tingling sensations)
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
12. Fear of losing control or “going crazy”
13. Fear of dying

B 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 panic attacks or their consequences
2. A significant maladaptive change in behavior related to the attacks

Question 22

Catastrophic misinterpretation in PD

Answer 22

= autonomic arousal/bodily sensations are interpreted as more dangerous than they are

• patients interpret ambiguous stimuli as threatening, particularly when the stimuli are related to symptoms of bodily arousal
• the actual or presumed presence of bodily changes is associated with danger schemas

Question 23

Catastrophic cognitions in PD

Answer 23

= catastrophic cognitions with themes of danger are experienced as a result of misinterpretation

• themes of danger, disaster, and physical or mental catastrophe are more marked during elevated anxiety and panic

Question 24

Cognitive Mediation via Biological Challenge Tests

Answer 24

Biological challenge tests = pharmacological and physiological procedures can reliably induce panic attacks in panic disorder patients

Biological challenge tests that influence the panic response:
- inhalation of CO2
- infusion of soduim lactate
- voluntary hyperventilation

Cognitive modifications that guide the panic response:
- subjects’ expectations about the distress and anxiety they might experience
- interpretation of sensations
- perceived control over the procedure

Question 25

Causes of PD: Biological

Answer 25

• heritability: 43-48%
• poorly regulated fight-or-flight response
  –> poorly regulated neurotransmitters:
  norepinephrine, serotonin, GABA, CCK
• triggers: hyperventilation, carbon dioxide, caffeine, sodium lactate
• limbic system that is involved in the stress response: amygdala, hippocampus, and hypothalamus
• dysregulation of locus ceruleus: pathways to the limbic system
  –> poor regulation may cause panic attacks

Question 26

Causes of PD: Cognitive

Answer 26

anxiety sensitivity: unfounded belief that bodily symptoms have harmful consequences

interoceptive awareness: a heightened awareness of bodily cues that may signal a coming panic attack

interoceptive conditioning: bodily cues are conditioned stimuli signaling new attacks

Question 27

Conditioned avoidance response

Answer 27

By avoiding places/situations that are associated with certain symptoms of panic, they reduce their symptoms, thereby reinforcing their avoidance behavior

Question 28

Agoraphobia

Answer 28

confining to safe places and avoiding a wide range of places that one feels are unsafe

Question 29

Treatment PD: Biological

Answer 29

• SSRIs, SNRIs, and tricyclic antidepressants –> affecting serotonin and norepinephrine systems
• benzodiazepines suppress the CNS and influence functioning in the GABA, norepinephrine, and serotonin systems
  –> work quickly to reduce panic attacks
  –> addictive

–> relapse of symptoms when drug therapies are discontinued

Question 30

Treatment PD: CBT

Answer 30

Clients confront the situations or thoughts that arouse anxiety

• relaxation and breathing exercises
• identifying the catastrophizing cognitions
• systematic desensitization therapy –> gradual exposure to the feared situation