Week 4 Anxiety Disorder Flashcards
Fear vsx Anxiety
Fear: Stress response from immediate danger
Anxiety: Stress response just from thoughts
Fear
Experienced in the face of
real, immediate danger
Usually builds quickly in
intensity
Helps motivate behavioral
responses to real threats
Anxiety
Associated with the
anticipation of future
problems
Involves more general or
diffuse emotional reaction
The emotional experience
is out of proportion to the
threat (?)
Nature of Anxiety
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
Where can anxiety be unhelpful?
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
Features of anxiety
Subjective feeling of Anxiety
Physiological symptoms
Avoidance symptoms
Disturbances in
thinking/attention
Intrusive thoughts
Attentional biases
[Re-experiencing symptoms]
Anxiety-related disorders
- Anxiety Disorders
- Obsessive-compulsive & related disorders
- Trauma & Stressor-related Disorders
Anxiety disorders
Specific Phobia
Social Anxiety Disorder
Panic Disorder
Agoraphobia
Generalised Anxiety Disorder
Specific phobia
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
Specific phobia specifiers
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
Social Anxiety Disorder
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
Common feared situations for sad
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
Clinical features of SAD
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
Panic Disorder
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
Panic Attack
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
Panic Disorder
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)
Agoraphobia
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)
Generalised Anxiety Disorder Criteria
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)
Generalised anxiety disorder
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
Other Anxiety Disorders
Separation anxiety disorder
Selective mutism
Substance / Medication Induced Anxiety Disorder
Anxiety Disorder Due to another medical condition
Other specified anxiety disorder
Unspecified Anxiety Disorder
OCD related
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
What are obsessions?
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
Common obsessions
Contamination
Need for symmetry
Harm/doubt
Harm to self/others
Forbidden or taboo thoughts
Aggressive
Sexual
Religious
Other
Compulsion
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
Common Compulsions
Checking
Washing (decontaminating)
Counting
Symmetry/Precision
Ritual behaviours
Hoarding
OCD
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
Trauma & Stress related disorders
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
Psychodynamic perspective historical
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
Evolutionary perspective of anxiety
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
Biological Perspective of anxiety
Biological Factors
Genetic Predisposition
Neurobiology
Genetic predisposition - anxiety
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%
Neuroanatomy/biology anxiety
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
Psychological Perspective - anxiet
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)
Current Psychosoical Perspective - anxiety
Learning theory and processes
Classical conditioning (Little Albert)
Operant/instrumental Conditioning
Vicarious conditioning/Observational learning
Information transmission
Classical Conditioning
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
Operant/instrumental conditioning
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
Vicarious/observational learning
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
Cognitive processes & anxiety disorders
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
Fear of fear modeal (david clark - 1986
Physical Sensation > Catastrophic
misinterpretation
of physical
sensationsions > Panic attack >Increased
physical arousal
and worry about
another attack > Vigilance of body symptoms
Biological treatments - anxiety
Anxiety associated with a
depletion of serotonin in the
neural synapses
SSRIs block the neuron’s
normal reuptake mechanism.
Biological Treatments continued -
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
Psychodynamic treatments
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)
Cognitive & behavioural therapy
Psychoeducation
De arousal strategies
Exposure Therapy
Cognitive Therapy
Psychoeducation
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
…
De arousal strategies
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
Exposure therapy
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
Cognitive therapy
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
