Week 4 Anxiety Disorder

Question 1

Fear vsx Anxiety

Answer 1

Fear: Stress response from immediate danger
Anxiety: Stress response just from thoughts

Question 2

Fear

Answer 2

Experienced in the face of
real, immediate danger
 Usually builds quickly in
intensity
 Helps motivate behavioral
responses to real threats

Question 3

Anxiety

Answer 3

 Associated with the
anticipation of future
problems
 Involves more general or
diffuse emotional reaction
 The emotional experience
is out of proportion to the
threat (?)

Question 4

Nature of Anxiety

Answer 4

Everyone experiences anxiety
* Anxiety can be helpful
* Signals that threat is imminent
* Cues to attend to important stimuli
* Signals for us to activate protective responses

Question 5

Where can anxiety be unhelpful?

Answer 5

When it restricts living
This usually occurs when anxiety is very intense or long
lasting and/or
Out of proportion with the threat
The resulting impacts may then warrant an anxiety-related
disorder diagnosis

Question 6

Features of anxiety

Answer 6

 Subjective feeling of Anxiety
 Physiological symptoms
 Avoidance symptoms
 Disturbances in
thinking/attention
Intrusive thoughts
Attentional biases
[Re-experiencing symptoms]

Question 7

Anxiety-related disorders

Answer 7

1. Anxiety Disorders
2. Obsessive-compulsive & related disorders
3. Trauma & Stressor-related Disorders

Question 8

Anxiety disorders

Answer 8

Specific Phobia
Social Anxiety Disorder
Panic Disorder
Agoraphobia
Generalised Anxiety Disorder

Question 9

Specific phobia

Answer 9

Essential Features:
 Marked fear or anxiety about a specific object or situation
 Exposure to the phobic stimuli almost always provokes immediate fear or
anxiety
 Phobic stimuli is actively avoided or endured with intense fear or anxiety
 Fear or anxiety is out of proportion to the actual danger posed and to the
sociocultural context
 The fear, anxiety, or avoidance is persistent, typically lasting for 6 months
or more
 Causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
Prevalence
7-9% prevalence rate
Females more affected 2:1
Rates vary across phobic stimuli

Question 10

Specific phobia specifiers

Answer 10

Specific Phobia Specifiers
Animal
 e.g. spiders, snakes, insects, dogs
Natural environment
 e.g. storms, thunder, heights, water
Situational
 e.g. public transport, tunnels, bridges,
elevators, airplanes, enclosed places
Other e.g. choking, vomiting, loud sounds,
costume characters
Blood-injection injury
 e.g. seeing blood, seeing injury, receiving an
injection, needles

Question 11

Social Anxiety Disorder

Answer 11

Essential Features:
- Marked fear or anxiety about one or more social situations in
which the person is exposed to possible scrutiny by others
- Fears that they will act in a way or show anxiety that will be
negatively evaluated (humiliation, embarrassment, rejection,
offend)
- Social situations almost always provoke fear or anxiety…
- Out of proportion, Last 6 months or more, impairment
- Can be performance only
Prevalence
* 7% in 2022; 4.7% in community sample (NSMHW, 2007) 1

Question 12

Common feared situations for sad

Answer 12

Speaking in public
 Eating/drinking in public
 Writing
 Using public toilets
 Being in a social situation in which the individual thinks
they may do or say something foolish

Question 13

Clinical features of SAD

Answer 13

 Belief that others see them as inept, stupid, foolish
 Hypersensitive/alert to criticism
 “Safety” behaviours
 Focus on internal sensations
 Non-assertive behaviour
 Low self-esteem
 Can demonstrate a vicious cycle

Question 14

Panic Disorder

Answer 14

DSM-5 Criteria
Recurrent unexpected panic attacks
At least one attack has been followed by one month or more of the
following:
Persistent concern about additional attacks or their consequences
Significant maladaptive change in behaviour (to avoid a PA)
Rule out specific phobia/other conditions/attacks that are the direct
result of a substance
Prevalence
 3.7% in 2022; 2.6 percent – Panic Disorder (NSMHW, 2007)
 3 –5% of population experience panic attacks without meeting criteria for
panic disorder
 Panic attacks ≠ panic disorder

Question 15

Panic Attack

Answer 15

 Palpitations/pounding heart or accelerated heart rate
 Sweating
 Trembling/shaking
 Sensation of shortness of breath or smothering
 Feelings of choking
 Chest pain or discomfort
 Nausea or abdominal distress
 Feeling dizzy, unsteady, light-headed or faint
 Chills or heat sensations
 Paresthesias (numbness/tingling)
 Derealisation (unreality)/Depersonalization (detached from one self)
 Fear of losing control or “going crazy”
 Fear of dying

Question 16

Panic Disorder

Answer 16

 Panic disorder can develop
when people
 Become stuck in the “fear-offear” cycle
 Catastrophize physical
sensations
 Tend to avoid situations that
may produce changes in
physical sensations (e.g.
caffeine, exercise, walking up
stairs)

Question 17

Agoraphobia

Answer 17

Essential Features:
 Marked fear or anxiety about two (or more) of the following:
 Using public transport
 Being in open spaces
 Being in enclosed places
 Standing in line or being in a crowd
 Being outside of the home alone
 Anxiety about being in places because of thoughts that escape might
be difficult or help not available in the event of panic-like or other
incapacitating or embarrassing symptoms
 Almost always provoke anxiety….6 mths and impairment
Prevalence
 4.6% in 2022; 2.8 percent (NSMHW, 2007)

Question 18

Generalised Anxiety Disorder Criteria

Answer 18

DSM-5 criteria:
Excessive anxiety & worry more days than not for at least 6 months
about a number of events or numerous events or activities
Difficulty in controlling worry
Experience three (or more) of the following:
 Restlessness/on edge
 Easily fatigued
 Difficulty concentrating / mind blank
 Irritability
 Muscle tension
 Sleep disturbance
Anxiety, worry or physical symptoms cause significant interference
Prevalence
3.8% (up from 2.7 percent) (NSMHW, 2007)

Question 19

Generalised anxiety disorder

Answer 19

 What is the fear?
 Individuals with GAD:
 Significantly less tolerance for uncertainty than comparison
groups
 Overestimate the likelihood of negative consequences
 Underestimate their ability to cope with difficult or
ambiguous circumstances
 Early experiences of uncontrollability and unpredictable
negative events may contribute to the development of GAD

Question 20

Other Anxiety Disorders

Answer 20

 Separation anxiety disorder
 Selective mutism
 Substance / Medication Induced Anxiety Disorder
 Anxiety Disorder Due to another medical condition
 Other specified anxiety disorder
 Unspecified Anxiety Disorder

Question 21

OCD related

Answer 21

Obsessive compulsive disorder
 Body dysmorphic disorder
 Hoarding disorder
 Trichotillomania
 Excoriation
 Substance/medication-induced obsessive-compulsive and related
disorder
 Obsessive-compulsive and related disorder due to another medical
condition
 Other specified obsessive-compulsive & related disorder
 Unspecified obsessive-compulsive & related disorder

Question 22

What are obsessions?

Answer 22

Recurrent and persistent
 Thoughts, urges or images
 intrusive and unwanted (at some point during disturbance)
 Cause anxiety or distress
 Attempts to ignore, suppress or neutralize with some thought
or action

Question 23

Common obsessions

Answer 23

 Contamination
 Need for symmetry
 Harm/doubt
 Harm to self/others
 Forbidden or taboo thoughts
 Aggressive
 Sexual
 Religious
 Other

Question 24

Compulsion

Answer 24

 Compulsions (aka “neutralising” behaviour)
 Repetitive behaviors (handwashing, ordering, checking) or
mental acts (praying, counting, repeating words)
 Aimed at preventing or reducing anxiety or distress or
preventing some dreaded event or situation.
 However, they are not connected in a realistic way with
what they are designed to neutralize or prevent, or are
clearly excessive

Question 25

Common Compulsions

Answer 25

Checking
Washing (decontaminating)
Counting
Symmetry/Precision
Ritual behaviours
Hoarding

Question 26

OCD

Answer 26

DSM-5 Criteria
 Presence of obsessions, compulsions, or both
 Obsessions or compulsions are time consuming (>1 hour/day),
or clinically significant distress or impairment
 Content of obsession or compulsion is not restricted to another
Axis I disorder (e.g., food obsession in an eating disorder)
 Specify if with good or fair insight, with poor insight, with
absent insight/delusional beliefs
 Not due to a substance or medical condition

Prevalence
 3.1% (2022 – up from 1.9% NSMHW, 2007)
 Females affected at a slightly higher rate
 Onset childhood, teenage; after 35 years rare
 Gradual, insidious onset
 Chronic, constant or waxing/waning course
Only 15% describe periods of > 3 months symptom free

Question 27

Trauma & Stress related disorders

Answer 27

 Posttraumatic Stress Disorder (PTSD)
 Acute Stress Disorder
 Prolonged Grief Disorder (introduced in DSM-TR)
 Adjustment Disorder
 Other specified trauma and stress-related disorders
 Unspecified trauma and stressor-related disorders

History
 ‘Shell shock’, ‘combat fatigue’, ‘war neurosis’ …
 Earlier editions of DSM referred to ‘gross stress reaction’
 “PTSD” introduced in DSM-III (1980)
Prevalence
5.7% in 2022 (6.4% general population (NSMHW, 2007)
Up to 18-20% for veterans or those returning from combat
High comorbidity
More likely to experience depression, anxiety disorders,
substance abuse
Common Characteristics but not required for diagnosis
The presence of fear, hopelessness, horror

Question 28

Psychodynamic perspective historical

Answer 28

 Anxiety arises from psychic conflict between
unconscious sexual or aggressive wishes, and
corresponding threats from the superego
 i.e. anxiety is a signal that indicates that an impulse
(sexual or aggressive) is about to be acted on – signal
triggers defences (e.g. repression) to prevent recognition
of the impulse and reduce anxiety
 When impulse is too strong, anxiety overwhelms system
and person may develop an anxiety disorder

Question 29

Evolutionary perspective of anxiety

Answer 29

 Anxiety developed in response to
threat - protective behaviour
activated at appropriate times – fight
vs flight
 Anxiety part of an adaptive system
 Anxiety disorders – problems in
regulation of system which evolved
to deal with particular threat

Question 30

Biological Perspective of anxiety

Answer 30

Biological Factors
 Genetic Predisposition
 Neurobiology

Question 31

Genetic predisposition - anxiety

Answer 31

Twin Studies
 Higher concordance rates for anxiety disorders for monozygotic
compared to dizygotic twins (34 vs 17%)
 Anxiety disorders are modestly to moderately heritable
 Different heritability estimates (Antony & Stein, 2009):
 Panic Disorder ~ 44%
 GAD ~ 32%
 Agoraphobia ~ 61%
 Social Phobia ~ 24-51%
 OCD ~ 27-47%

Question 32

Neuroanatomy/biology anxiety

Answer 32

Animal (and human) studies show pathways in brain
responsible for detecting and responding to threats or
danger:
1 – A subcortical pathway which activates “fight or
flight” response
2 – A path which leads to cortex and provides for
slower, more detailed analysis of information
 These particular brain regions thought to play a role in
phobic disorders and panic disorders – e.g., a particular
fear pathway may be triggered at an inappropriate time
 Serotonin & GABA function to dampen stress
responses
 When levels of these are increased, anxiety is reduced

Question 33

Psychological Perspective - anxiet

Answer 33

Stressful life events (danger; threat to sense of security;
interpersonal conflict)
 Childhood Adversity (neglect; abuse)
 Parenting style (overprotection /control & rejection /negativity)
 Child temperament & behavioural inhibition
 Attachment Relationships & Separation Anxiety – (insecure
attachment may increase vulnerability to threats in interpersonal
conflicts)

Question 34

Current Psychosoical Perspective - anxiety

Answer 34

Learning theory and processes
 Classical conditioning (Little Albert)
 Operant/instrumental Conditioning
 Vicarious conditioning/Observational learning
 Information transmission

Question 35

Classical Conditioning

Answer 35

 Association between an unconditioned stimulus and a
conditioned stimulus (Pavlov’s dog)
 Fear and phobias develop as a result of pairing between a
“neutral” stimulus (e.g., a dog) and an aversive experience (e.g.,
being bitten by the dog) which provokes a fear reaction
 Model offers insight into development of a fear or phobia; but
does not explain maintenance of fear response and why some
develop it and others do not

Question 36

Operant/instrumental conditioning

Answer 36

 Learning through the consequences of one’s own actions in a
particular setting
 Escape and avoidance behaviours are negatively reinforced
 Avoidance maintains anxiety as don’t have the opportunity to
learn can tolerate anxiety, situation not as threatening as thought,
can cope etc

Question 37

Vicarious/observational learning

Answer 37

 Conditioning fails to explain how
some individuals develop anxiety
disorders in the absence of a
directly aversive experience
 Learning through modeling
 Learn to avoid stimuli if modelling
by significant others

Question 38

Cognitive processes & anxiety disorders

Answer 38

Perceptions, memory, attention can play an important role in
development & maintenance of anxiety disorders
Catastrophic Misinterpretation: overestimate or interpret neutral
stimuli as threatening
 Fear of fear in panic disorder
Attentional Bias to Threat
 Sensitive/hypervigilant to cues that signal future threats
 Once attention is focussed on cues; performance of adaptive,
problem-solving behaviours disrupted; worry cycle activated
Chronic Thought Suppression
 Struggling to suppress, control thoughts which provoke anxiety
 Rebound effects

Question 39

Fear of fear modeal (david clark - 1986

Answer 39

Physical Sensation > Catastrophic
misinterpretation
of physical
sensationsions > Panic attack >Increased
physical arousal
and worry about
another attack > Vigilance of body symptoms

Question 40

Biological treatments - anxiety

Answer 40

Anxiety associated with a
depletion of serotonin in the
neural synapses
SSRIs block the neuron’s
normal reuptake mechanism.

Question 41

Biological Treatments continued -

Answer 41

Benzodiazepines (GABA transmission)
 Widely used prior to 1990s (e.g., Valium, Xanax)
 Effects evident early in Tx, longer term effects less evident
 Side effects include sedation, mild impairment in psychomotor skills and
cognitive abilities such as attention and memory
 Most significant adverse effect is risk of addiction
 Tricyclics
 Have shown benefits but side effects too significant – i.e. weight gain, dry
mouth, difficulty sleeping, feeling nervous
 Antidepressants (target depletion of serotonin)
 SSRIs (e.g. Prozac, Luvox, Zoloft)
 Fewer unpleasant side effects than tricyclics

Question 42

Psychodynamic treatments

Answer 42

 Free association and dream interpretation
 Fear and phobias – signs of internal conflicts
 Psychoanalysis – discover and work through conflicts
 Limited empirical evidence
 Interpersonal psychotherapy
 Targets interpersonal conflicts, role transitions, and grief in more
structured and skills-based way
 Found to be effective for Social anxiety disorder (Lipsitz, et al 1997)
and PTSD (Bleiberg & Markowitz, 2005)

Question 43

Cognitive & behavioural therapy

Answer 43

 Psychoeducation
 De arousal strategies
 Exposure Therapy
 Cognitive Therapy

Question 44

Psychoeducation

Answer 44

 Anxiety is common, typically short-lived and normal
 Anxiety can be adaptive and functional
 Can never eliminate anxiety altogether
 Flight or fight response
 Hyperventilation
 Safety behaviours
 …

Question 45

De arousal strategies

Answer 45

 Addresses the physiological component of anxiety
 Variety of relaxation techniques:
 Progressive Muscle Relaxation
 Imagery/visualisation
 Abdominal breathing
 Relaxation is a skill, pick the right time
 Make the time, keep it short and simple
 Create a relaxing environment
 Become a “lifestyle” strategy

Question 46

Exposure therapy

Answer 46

 Addresses the physiological component of anxiety
 Variety of relaxation techniques:
 Progressive Muscle Relaxation
 Imagery/visualisation
 Abdominal breathing
 Relaxation is a skill, pick the right time
 Make the time, keep it short and simple
 Create a relaxing environment
 Become a “lifestyle” strategy

Question 47

Cognitive therapy

Answer 47

 Addresses the cognitive component of anxiety (appraisals)
 ABC model (cognitions as mediators)
 Identification of anxiety-provoking cognitions (thought
monitoring)
 Cognitive restructuring/behavioural experiments
 Threat, awfulness and coping
 Identify the meaning of symptoms/situations