Anxiety, Fear, and Anxiety Disorders

• Study notes for students reviewing anxiety, fear, and related disorders.

Nature of Anxiety and Fear

• Anxiety is a future-oriented mood state characterized by negative affect, somatic tension, and apprehension about future danger.
• Fear is a present-oriented mood state involving an immediate fight or flight response to danger.
• Both anxiety and fear are considered normal emotional states.
• Anxiety disorders involve pervasive and persistent symptoms, excessive avoidance, and significant distress or impairment.

Biological Contributions to Anxiety and Panic

• Diathesis-stress model explains that people inherit vulnerabilities for anxiety and panic, not anxiety disorders themselves, but these can be activated by stress.
• Anxiety is related to brain circuits involving GABA (lower levels/sensitivity leading to more anxiety), noradrenergic (higher levels leading to more anxiety), and serotonergic systems.
• The Behavioral Inhibition System (BIS) is activated by signals of unexpected events or potential danger, causing freezing, anxiety, and environmental evaluation for threats.
• The Fight or Flight System produces an immediate alarm and escape response when aroused.
• Environmental factors can alter the sensitivity of brain circuits, influencing the likelihood of developing an anxiety disorder.

Psychological Contributions to Anxiety and Panic

• Freud suggested anxiety is a psychological reaction to danger rooted in early childhood fears.
• Behaviorist views attribute anxiety and fear to classical and operant conditioning, and vicarious learning (modeling).
• Psychological perspectives emphasize the role of early experiences with uncontrollability and unpredictability, influenced by parental behavior.

Social Contributions to Anxiety and Panic

• Stressful life events, particularly familial or interpersonal stressors, can trigger vulnerabilities to anxiety and panic.

Comorbidity of Anxiety Disorders

• Comorbidity, the co-occurrence of multiple mental health conditions, is common among anxiety disorders.
• Approximately 50% of patients with an anxiety disorder have a secondary diagnosis, with major depression being the most common.
• Comorbidity suggests shared underlying factors among anxiety disorders, and between anxiety and mood disorders, indicating a strong link between anxiety and depression.

Generalized Anxiety Disorder (GAD)

• GAD involves excessive, uncontrollable worry about various events or activities, interfering with functioning and causing distress, and must persist for 6 months or more.
• Symptoms include restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.
• GAD differs from normal worry by being more pervasive, distressing, lasting longer, occurring without triggers, and involving physical symptoms.
• Additional somatic symptoms include GI distress and exaggerated startle response.
• GAD affects about 3% of the general population, with females outnumbering males 2:1, onset is often gradual, with a median age of 30.
• Prevalence peaks in middle age and declines later in life, with symptoms tending to fluctuate and full remission being rare.
• Earlier onset of GAD is associated with greater comorbidity and impairment.
• Genetic factors account for 30% of the variability of GAD.
• Temperamental factors include high behavioral inhibition and neuroticism.
• Cognitive factors involve high sensitivity to threat, particularly those with personal relevance, and automatic attention allocation to threat cues.
• Treatments for GAD include benzodiazepines (for short-term relief but with dependence risk), antidepressants (with fewer side effects), and cognitive-behavioral therapy (CBT) for long-term benefits.
• CBT challenges automatic, irrational thoughts that lead to anxiety.

Panic Disorder

• Panic disorder features recurrent, unexpected panic attacks with four or more symptoms like palpitations, sweating, trembling, shortness of breath, chest pain, chills or heat sensations, numbness/tingling, nausea, dizziness, and fear of dying.
• At least one attack must be followed by one month or more of persistent worry about future attacks or their consequences, and/or a significant maladaptive change in behavior related to the attacks.
• 12 month prevalence is 2-3%.
• Two-thirds of people with panic disorder are female.
• Onset typically occurs between ages 20-24.
• Symptoms wax and wane but the disorder tends to be chronic if untreated.
• Nocturnal panic attacks involve waking from sleep with panic symptoms, not usually due to dreams.
• Many with panic disorder have general physical/health concerns, sensitivity to medication side effects, concerns about their ability to function, excessive substance use, and avoidance of panic cues.
• Biological predisposition involves being "overreactive" to life events, with an "emergency alarm reaction" to stressors.
• Individuals are internally vigilant and fearful of physiological changes, misinterpreting symptoms as catastrophic.
• Treatment involves medications targeting serotonergic, noradrenergic, and GABA systems, such as SSRIs, though relapse rates are high after discontinuation.
• Cognitive-behavioral therapies are highly effective, using exposures for agoraphobia and panic, paired with cognitive techniques.
• It is recommended to stop taking anti-anxiety medications during the process.
• Cognitive-behavior therapy alone yields the best long-term outcomes.

Specific Phobias

• Specific phobias are characterized by extreme and irrational fear of a specific object or situation.
• The object/situation almost always provokes intense fear and anxiety that is out of proportion to the actual danger, causing significant distress/impairment.
• Individuals go to great lengths to avoid phobic objects or endures with great distress
• 12 month prevalence: 7-9%, females more represented.
• Phobias run a chronic course with early onset (childhood).
• Blood-injury-injection phobia involves a unique physiological response (drop in blood pressure and heart rate) and a susceptibility to fainting.
• Other subtypes include situational phobia, natural environment phobia, and animal phobia.
• Phobias can result from direct conditioning, experiencing a panic attack in a specific situation, vicarious learning, or information transmission.
• There is an inherited tendency to fear things that have always been dangerous to humans such as snakes, storms and heights.
• Cognitive-behavior therapies are highly effective.
• Exposure therapy involves building an anxiety hierarchy and gradually exposing the individual to increasingly threatening stimuli.

Social Anxiety Disorder

• Marked fear/anxiety about one or more social situations in which individual is exposed to scrutiny/judgment of others.
• Fears of acting in a way or showing anxiety symptoms that will be negatively evaluated.
• Social Situations must almost always provoke fear or anxiety, so situations are avoided or endured with intense distress.
• Fear is out of proportion and the disorder Causes distress and impairment and lasts for 6 months or more.
• 12 month prevalence of about 7%, Onset is usually during adolescence (median onset = 13).
• Evolutionary and biological vulnerabilities include fearing disapproving faces and having a shy, inhibited temperament.
• Psychological factors include being taught that social evaluation is important and/or dangerous, and can result from direct conditioning, observational learning or information transmission.
• Medications: SSRI Paxil – FDA approved for social anxiety disorder but Relapse rates are high following medication discontinuation.
• Therapists challenge underlying automatic thoughts regarding phobic activities.
• Exposure portion appears to be the most important component.

Obsessive Compulsive Disorder (OCD)

• Obsessions are persistent, recurrent, intrusive thoughts, images, or urges that one tries to resist or eliminate, often involving contamination, doubts, order, or aggressive/sexual imagery.
• Compulsions: repetitive thoughts or actions that a person feels driven to perform according to rigid rules.
• The "Goal” of compulsions is to prevent or reduce distress associated with the obsession.
• Obsessions and compulsions are time consuming or cause distress or impairment.
• Specifiers include good to fair insight, poor insight, or absent insight/delusional.
• 12 month prevalence is 1.2%.
• Most persons with OCD are female, and the disorder tends to be chronic, especially if untreated.
• Onset is typically in early adolescence or adulthood (mean age = 20).
• Causes of OCD include genetic factors, greater neuroticism, internalizing symptoms, early life experiences, and learning that some thoughts are dangerous/unacceptable.
• Thought-action fusion relates to excessive sense of responsibility and resulting guilt; difficulty tolerating uncertainty.
• Treatment includes Clomipramine and other SSRIs which benefits about 60%, and cognitive-behavioral therapy (CBT) involving exposure and response prevention, combined treatments are not better than CBT alone.

Posttraumatic Stress Disorder (PTSD)

• Requires exposure to actual or threatened death, serious injury, or sexual violence through direct experience, witnessing events, learning of events that occurred to close family member/friend, experiencing repeated or extreme exposure to aversive details of traumatic events
• Intrusive symptoms include recurrent, intrusive involuntary memories, distressing dreams, dissociative reactions (flashbacks), intense distress at cues of events, and physiological reaction to cues.
• Avoidance of stimuli associated with events involves memories, thoughts, and feelings.
• Negative alterations in thoughts or mood include inability to remember important details, exaggerated negative beliefs, distorted cognitions, negative emotional states, diminished interest, detachment, and anhedonia.
• Alterations in arousal/reactivity includes irritability/anger, recklessness/self-destructive behavior, hypervigilance, exaggerated startle, and sleep/concentration problems.
• Disturbance lasts 1 month or more.
• Lifetime prevalence: 8.7%; 12 month = 3.5%
• Higher rates among veterans; certain vocations (police; EMT); survivors of rape, combat, captivity, etc.
• Symptoms usually begin within 3 months of trauma.
• Risk factors include childhood emotional problems, other mental disorders, lower education, lower socioeconomic status, prior trauma, female gender and younger age at time of trauma.
• Psychological Treatment of PTSD: Cognitive-behavioral treatment involves graduated or massed imaginal exposure and challenges thoughts and emotions attached to the event.
• Medications: SSRIs may be effective in reducing the anxiety and panic associated with PTSD.