Anxiety Disorders Overview

Anxiety Disorders Overview

• Anxiety is apprehension about a future threat.
• Fear is a response to an immediate threat.
• Both involve physiological arousal (sympathetic nervous system).
• Both have adaptive functions; fear triggers fight or flight, anxiety increases preparedness.
• The Yerkes-Dodson Curve (1908) illustrates the relationship between anxiety and performance.

Yerkes-Dodson Curve

• A "U-shaped" curve.
• Low anxiety: poor performance due to lack of focus and motivation.
• Moderate anxiety: optimal performance because the individual is alert, engaged, and ready to respond.
• High anxiety: poor performance due to excessive arousal impairing concentration and decision-making.

DSM-5 Anxiety Disorders

• Specific phobias
• Social anxiety disorder
• Panic disorder
• Agoraphobia
• Generalized anxiety disorder (GAD)
• Phobias are the most common psychiatric disorders.
• 28% of people report anxiety symptoms.

Phobias

• Disruptive fear of specific objects/situations.
• Fear is out of proportion to the threat.
• Awareness of excessive fear.
• Severe enough to cause distress/interfere with life.
• Involve avoidance.
• Examples include fear of flying, snakes, heights.
• Types include animal, natural environment, blood/injection/injury, situational, and other.

Social Anxiety Disorder (Social Phobia)

• Causes more life disruption than other phobias.
• More intense and extensive than shyness.
• Exposure to trigger leads to anxiety about being humiliated or embarrassed socially.
• Persistent fear and avoidance of social situations
• Fear of negative evaluation or scrutiny.
• Onset often in adolescence.
• Comorbidity: 33% diagnosed with Avoidant Personality Disorder.

Panic Disorder

• Frequent, unexpected panic attacks.
• Intense apprehension and urge to flee.
• Symptoms peak within 10 minutes.
• Physical symptoms: labored breathing, heart palpitations, nausea, upset stomach, chest pain, feelings of choking and smothering, dizziness, sweating, lightheadedness, chills, heat sensations, and trembling; as well as 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).
• Uncued panic attacks occur unexpectedly and without warning.
• Cued panic attacks are triggered by specific situations.

Agoraphobia

• Anxiety about being unable to escape or receive help in anxiety-provoking situations (e.g., crowds, stores, malls, churches, trains, bridges, tunnels).
• Causes significant impairment in daily functioning.
• DSM-5 Criteria: marked and disproportionate fear of at least two situations where escape or help is difficult. - Being outside of the home alone. - Traveling on public transportation. - Being in open spaces. - Being in enclosed spaces. - Standing in line or being in a crowd.
• A subtype of panic disorder (DSM-IV-TR).

Generalized Anxiety Disorder (GAD)

• Chronic, excessive, and uncontrollable worry about various aspects of life.
• Worry lasts at least 6 months and interferes with daily functioning.
• Associated symptoms: restlessness, feeling keyed up, poor concentration, fatigue, muscle tension, irritability, and sleep disturbances.
• Common worry domains: relationships, health, finances, daily hassles, work, or school.
• Often begins in adolescence or earlier.
• GABA deficits contribute to hyperarousal.

Comorbidity of Anxiety Disorders

• 50% of individuals with an anxiety disorder meet criteria for another anxiety disorder.
• 75% of individuals with an anxiety disorder meet criteria for another psychological disorder.
• Common comorbid disorders: depression, substance abuse, personality disorders, medical disorders (e.g., coronary heart disease).

Cultural Factors

• Culture shapes the expression of anxieties and fears.
• Some anxieties are culturally specific syndromes (e.g., Taijin kyofusho in Japan, Kayak-angst in Inuit culture).
• Cultural influences vary in symptom presentation.

Anxiety Disorder Prevalence

• Specific phobia (10.1% 12-month prevalence; 13.8% lifetime prevalence)
• Social anxiety disorder (8.0% 12-month; 13% lifetime)
• Panic disorder (3.1% 12-month; 5.2% lifetime )
• Agoraphobia (1.7% 12-month prevalence, 2.6% lifetime prevalence)
• Generalized anxiety disorder (GAD) (2.9% 12-month; 6.2% lifetime).

Etiology of Specific Phobias

• Mowrer's Two-Factor Model: Fear acquisition (classical conditioning) and fear maintenance (operant conditioning)
  • Classical conditioning: associating a neutral stimulus with an aversive unconditioned stimulus leads to fear, e.g., dog bite with dogs.
  • Operant conditioning: avoidance behavior is reinforces since it relieves /reduces fear and anxiety.
  • Modeling and verbal instruction can also contribute.

Etiology of Anxiety Disorders (general)

• Family history of anxiety
• Neurobiological factors: deficits in areas like medial prefrontal cortex, and reduced inhibitory signaling (GABA), hyperactive amygdala.
• Fear circuit overactivity in the amygdala.
• Neurotransmitter dysregulation in serotonin, norepinephrine, and GABA.
• Personality factors: behavioral inhibition, neuroticism
• Cognitive factors, including sustained negative beliefs, attention bias.

Etiology of Panic Disorder

• Neurobiological factors: locus coeruleus (major source of norepinephrine leading to nervous system activity), sensitivity to norepinephrine triggering drugs, and potential imbalances in neurotransmitter regulation.
• Behavioral factors: interoceptive conditioning (classical conditioning of panic to internal bodily sensations)
• Cognitive factors: catastrophic misinterpretations (e.g., "I'm having a heart attack!”), anxiety sensitivity, and attention bias.
• Genetic factors.

Etiology of Agoraphobia

• Fear-of-fear hypothesis: catastrophic expectations about public panic attacks (e.g., "What will people think of me?").
• Social anxiety and safety behaviors might lead to avoidance of certain situations.

Etiology of Generalized Anxiety Disorder (GAD)

• Neurobiological factors: GABA deficits.
• Cognitive factors: Worry as a distraction, avoidance of arousal, negative beliefs about potential future events.

Treatment of Anxiety Disorders

• Exposure therapy (facing the anxiety trigger in a controlled setting).
• Systematic desensitization (relaxation techniques with imaginal exposure).
• Cognitive behavioral therapy (CBT) approaches (increasing confidence in coping abilities, challenging negative expectations).
• Medication (benzodiazepines, antidepressants, DCS, and other anxiolytics).
• Exposure therapy (in vivo exposure).