Anxiety Disorders

Generalized Anxiety Disorder

• In Generalized Anxiety Disorder, worry and fear are learned and repeated to avoid negative reinforcement
• Experiencing successful avoidance of a negative outcome makes the behavior more likely to be repeated in future situations.
• For example, reading about an air disaster might increase an individual's fear of air travel
• This is known as negative reinforcement.

Anxiety and The Fight-or-Flight Response

• Anxiety disorders are characterized by excessive or persistent anxiety beyond what is typical for a person's age.
• They are sometimes considered an inappropriate activation of the stress response system (known as “fight-or-flight”)
• The fight-or-flight response is triggered by the amygdala, which signals distress to the hypothalamus
• The hypothalamus releases epinephrine (adrenaline) from the adrenal glands, triggering physiological changes such as increased heart rate, blood pressure, and breathing rate
• If the perceived threat continues, the hypothalamus also activates the HPA axis, which releases hormones like CRH, ACTH, and cortisol, sustaining alertness and energy levels
• Once the threat subsides, the parasympathetic nervous system helps the body calm down, reducing the fight-or-flight response
• For individuals with anxiety disorders, the parasympathetic system may not be effective at reducing the stress response, leading to persistent anxiety.

Neurotransmitters Involved in Anxiety

• Increased activity of adrenaline and noradrenaline is associated with anxiety
• Decreased activity of serotonin and GABA are associated with anxiety.

Catastrophic Misinterpretations

• Many anxiety disorders, particularly panic disorders, may be caused by catastrophic misinterpretations of normal bodily sensations.
• Vulnerable individuals may experience heightened alarm responses to normal or slightly abnormal sensations, leading to sympathetic and autonomic arousal.
• This heightened arousal then generates more bodily sensations (like rapid heartbeat or sweating), creating a feedback loop of anxious thoughts and physical symptoms, perpetuating the cycle of anxiety.

Clinical Features of Anxiety

• Many individuals with anxiety experience both psychological anxiety and somatic (bodily) symptoms.
• Somatic symptoms may resemble those of genuine physical abnormalities, affecting various organ systems.
• Common somatic symptoms include:
  • Neurological/Autonomic: Diaphoresis (sweating), warm/cold flushes, dizziness or fainting, headache, tingling in extremities, numbness around the mouth, mydriasis (pupil dilation)
  • Gastrointestinal: Sensation of choking, dyspepsia (indigestion), nausea, diarrhea, abdominal bloating or pain
  • Cardiorespiratory: Palpitations (subjective experience of tachycardia), chest pain, dyspnea (difficulty breathing) or sensation of being smothered
  • Genitourinary: Urinary frequency or urgency.

Diagnosing Anxiety Disorders

• Diagnosing anxiety disorders requires a comprehensive assessment, including both etiologic (cause) and syndromic (syndrome) perspectives.
• It is essential to ascertain whether the anxiety disorder is primary (idiopathic) or secondary to factors such as systemic or neurological conditions, drug intoxication, or withdrawal.
• This assessment involves physical examinations, laboratory tests, and a detailed review of the patient's history and mental status.

Specific Phobias

• Specific phobias are characterized by:
  • Intense and persistent fear of a specific environmental stimulus
  • Pathological anxiety response when exposed to the stimulus
  • Avoidance of the stimulus or distress when forced to endure it
• Specific phobias can be triggered by traumatic events, panic attacks, or exposure through media, but often the cause is unknown.
• The onset typically occurs in early childhood, usually before the age of 10.
• Specific phobias are categorized according to the type of stimulus that elicits the phobic response.

Specific Phobia: Key Features

• Persistent and intense fear, anxiety, or avoidance lasting at least six months, leading to significant distress or impairment in various areas of life.
• Individuals with specific phobia experience heightened physiological arousal when exposed to their phobic object or situation.
• Physiological responses can include sympathetic nervous system arousal or a vasovagal fainting response.
• Abnormal brain activity in areas such as the amygdala, anterior cingulate cortex, thalamus, and insula is associated with specific phobia.
• Situational phobias tend to onset later than other types of phobias.
• Childhood phobias may fluctuate over time but often persist into adulthood.

Panic Attacks

• Many anxiety disorders involve sudden, intense episodes of symptoms called panic attacks.
• The typical age of onset for panic attacks in the United States is around 22-23 years among adults.