Anxiety Disorders PDF

Anxiety Disorders  Anxiety vs. Fear: Anxiety: Apprehension about a future threat. Fear: Response to an immediate threat. Both involve physiological arousal (sympathetic nervous system). Both have Adaptive Functions, Fear triggers "fight or...

Anxiety Disorders  Anxiety vs. Fear: Anxiety: Apprehension about a future threat. Fear: Response to an immediate threat. Both involve physiological arousal (sympathetic nervous system). Both have Adaptive Functions, Fear triggers "fight or flight," which may save life, Anxiety increases preparedness. Yerkes-Dodson Curve (1908): Anxiety and Performance: This model describes how anxiety affects performance in 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 because excessive arousal impairs concentration and decision-making.  DSM-5 Anxiety Disorders: Specific phobias, Social anxiety disorder, Panic disorder, Agoraphobia Generalized anxiety disorder (GAD) Prevalence: Most common psychiatric disorders, 28% report anxiety symptoms, Phobias are the most common. Criteria for Diagnosis: Symptoms interfere with functioning or cause distress. Not caused by drugs or medical conditions. Persist for at least 6 months (1 month for panic disorder). Fears/anxieties distinct from other disorders. Phobias Characteristics:  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.  Involves avoidance.  Specific Phobia: Examples: Fear of flying, snakes, heights. DSM-5 Criteria: Marked, disproportionate fear triggered by specific objects/situations. Avoidance or enduring with intense anxiety. Symptoms persist for 6+ months. Social Anxiety Disorder ( Social Phobia ): Features:  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. Table 6.2: Types of Specific Phobias DSM-5 Criteria: Marked and disproportionate fear consistently triggered by exposure to potential social scrutiny. Exposure to the trigger leads to intense anxiety about being evaluated negatively. Trigger situations are avoided or else endured with intense anxiety. Symptoms persist for at least 6 months. Panic Disorder Features: 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. Other symptoms may include: Depersonalization, Derealization, Fears of going crazy, losing control, or dying. N.B: 25% of people will experience a single panic attack (not the same as panic disorder)  Uncued Panic Attacks: Occur unexpectedly and without warning. Not triggered by any specific situation or event. Diagnosis requires recurrent uncued attacks. Causes worry about future attacks.  Cued Panic Attacks: Triggered by specific situations (e.g., seeing a snake). More likely to be associated with a specific phobia rather than panic disorder. DSM-5 Criteria for Panic Disorder:  Recurrent unexpected panic attacks.  At least 1 month of: Concern about the possibility of more attacks. Worry about the consequences of an attack (e.g., losing control, dying). Maladaptive behavioral changes (e.g., avoidance of situations where attacks have occurred). Agoraphobia: From the Greek word "agora" meaning marketplace. Anxiety about being unable to escape or receive help in anxiety-provoking situations, Common situations include crowds, stores, malls, churches, trains, bridges, tunnels, etc, Causes significant impairment in daily functioning. DSM-IV-TR: Previously a subtype of Panic Disorder, At least half of individuals with agoraphobia do not experience panic attacks. DSM-5 Criteria for Agoraphobia:  Marked and disproportionate fear or anxiety: about at least 2 situations where escape or help may be difficult in the event of incapacitation or panic-like symptoms, such as: Being outside of the home alone. Traveling on public transportation. Being in open spaces (e.g., parking lots, marketplaces). Being in enclosed spaces (e.g., shops, theaters, cinemas). Standing in line or being in a crowd.  Consistent triggering of fear or anxiety in these situations. These situations are: Avoided, Require a companion, Endured with intense fear or anxiety.  Symptoms last for at least 6 months. 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, Individuals often struggle to make decisions or determine solutions. Associated Symptoms:  Restlessness or feeling keyed up.  Poor concentration or mind going blank.  Fatigue and muscle tension.  Irritability and sleep disturbances. Common Worry Domains: Relationships, health, finances, daily hassles, work , or school. Typical Onset:  Often begins in adolescence or earlier.  Individuals may describe themselves as always having been this way.  DSM-5 Criteria for Generalized Anxiety Disorder:  Excessive anxiety and worry occurring on at least 50% of days about at least two life domains (e.g., family, health, finances, work , school).  The person finds it difficult to control the worry.  The worry is sustained for at least 3 months.  The anxiety and worry are associated with at least three of the following symptoms (one in children):  Restlessness or feeling keyed up or on edge.  Being easily fatigued.  Difficulty concentrating or mind going blank.  Irritability.  Muscle tension.  Sleep disturbance (difficulty falling/staying asleep or restless sleep).  The anxiety and worry lead to marked behavioral impacts, such as:  Avoidance of situations with potential negative outcomes.  Excessive time and effort preparing for feared outcomes.  Procrastination, difficulty making decisions, or seeking reassurance repeatedly. 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: Present in 60% of those with anxiety disorders. Substance abuse. Personality disorders. Medical disorders: e.g., coronary heart disease. Gender and Sociocultural Factors in Anxiety Disorders Women are twice as likely as men to have an anxiety disorder. Possible explanations:  Women may be more likely to report symptoms.  Men may be encouraged to face their fears.  Women are more likely to experience childhood sexual abuse.  Women exhibit more biological stress reactivity. Cultural Factors: Cultural Influence:  Culture shapes the expression of anxieties and fears.  Some anxieties are culturally specific syndromes, for example:  Taijin kyofusho (Japan): Fear of offending or embarrassing others.  Kayak-angst (Inuit): Panic-like disorder experienced by seal hunters at sea. Symptom Presentation Across Cultures: Rates of anxiety disorders vary across cultures. The ratio of somatic to psychological symptoms appears similar across cultures (Kirmayer, 2001). Factors that May Increase the Risk for More than One Anxiety Disorder: Behavioral conditioning (classical and operant conditioning) Genetic vulnerability, Increased activity in the fear circuit of the brain. Decreased functioning of GABA and serotonin; increased norepinephrine activity Behavioral inhibition, Neuroticism. Cognitive factors, including sustained negative beliefs, perceived lack of control, and attention to cues of threat Table 6.3: Percent of People Who Meet Diagnostic Criteria for Anxiety Disorders in the Past Year and in Their Lifetime Etiology of Specific Phobias: Conditioning ◐ Mowrer’s Two-Factor Model 1.Fear Acquisition (Classical Conditioning): A neutral stimulus becomes associated with an aversive unconditioned stimulus (UCS). This pairing leads to the development of fear. Example: A dog (neutral stimulus) paired with a bite (aversive UCS) results in fear of dogs. 2.Fear Maintenance (Operant Conditioning): Avoidance behavior is reinforced because it reduces fear and anxiety. This is an example of negative reinforcement, where removing the aversive experience strengthens avoidance behavior. Example: Avoiding dogs reduces anxiety, reinforcing the avoidance  ◐ Extensions of the Two-Factor Model: Modeling involves learning through observation rather than direct interaction. If someone observes another person experiencing harm or distress caused by a particular stimulus, they may develop a fear of that stimulus. Modeling: Observing another person harmed by the stimulus. Verbal Instruction: Hearing warnings (e.g., parents warning children). ◐ Cognitive Factors: People with anxiety acquire fear more readily and are resistant to extinction. ◐ Prepared Learning: Evolutionary predisposition to fear life-threatening stimuli (e.g., heights, snakes). Etiology of Social Anxiety Disorder: ◐ Behavioral Factors:Similar to specific phobia: Classical and operant conditioning. ◐ Cognitive Factors: 1. Negative Beliefs: Unrealistic beliefs about the consequences of social behaviors. 2. Fear of Evaluation: Excessive fear of negative judgment by others. 3. Self-Evaluation: Harsh and punitive self-judgment. 4. Attention Bias: Excessive focus on internal cues (e.g., heart rate, sweating). Etiology of Panic Disorder: ◐ Neurobiological Factors: Locus Coeruleus: Major source of norepinephrine, triggers nervous system activity. People with panic disorder are sensitive to norepinephrine-triggering drugs. ◐ Behavioral Factors: Interoceptive Conditioning: Classical conditioning of panic to internal bodily sensations. ◐ Cognitive Factors: Catastrophic Misinterpretations: Misinterpreting somatic changes as impending doom (e.g., "I’m having a heart attack!"). Anxiety Sensitivity Index: High scores predict panic (e.g., "Unusual body sensations scare me."). ◐ Genetic Factors: NPSR1 Gene: Linked to amygdala activity, cortisol response, and anxiety sensitivity. Etiology of Agoraphobia: ◐ Fear-of-Fear Hypothesis (Goldstein & Chambless, 1978): Catastrophic expectations about public panic attacks (e.g., "What will people think of me?!"). Etiology of Generalized Anxiety Disorder (GAD): ◐ Neurobiological Factors: GABA Deficits: Reduced inhibitory signaling contributes to hyperarousal. ◐ Cognitive Factors: Borkovec’s Cognitive Model:  Worry as a Distraction:Worrying distracts from more distressing emotions and memories.  Avoidance of Arousal:Worrying prevents extinction of underlying anxiety. General Risk Factors for Anxiety Disorders:  Genetic Risk:  Heritability: ○ Phobias, GAD, PTSD: 20-40%. ○ Panic Disorder: ~50%.  Family history: of anxiety disorders increases risk.  Neurobiological Factors:  Fear Circuit Overactivity: Hyperactive amygdala and deficits in medial prefrontal cortex.  Neurotransmitter Dysregulation: Poor functioning of serotonin and GABA & Increased norepinephrine levels.  Personality Factors:  Behavioral Inhibition: Early childhood tendency to be distressed in unfamiliar settings, Predicts childhood anxiety and adolescent social anxiety.  Neuroticism: Reacting with frequent negative affect, Doubles risk of anxiety disorders.  Cognitive Factors:  Negative Beliefs: Sustained beliefs that bad things will happen, Engage in safety behaviors.  Lack of Control: Fosters vulnerability, especially with childhood trauma or punitive parenting.  Attention Bias: Heightened attention to negative or threatening cues. Etiology of Panic Disorder Figure 6.8: The Excessive Worry of GAD May Be an Attempt to Avoid Intense Emotions Etiology of Panic Disorder Treatment of Anxiety Disorders:  Psychological Treatments  Exposure Therapy: Face the anxiety trigger in a controlled setting. Include as many features of the trigger as possible. Conduct exposure in varied settings for generalization. Effectiveness: 70-90%.  Systematic Desensitization: Combines relaxation techniques with imaginal exposure.  Cognitive Approaches: Increase confidence in coping abilities. Challenge negative outcome expectations. Disorder-Specific Psychological Treatments Treatment of Phobias:  Exposure Therapy: In Vivo Exposure: Real-life exposure is more effective than imaginal exposure. Treatment of Social Anxiety Disorder:  Exposure Therapy: Role-playing or small group interactions.  Social Skills Training: Target reduction in safety behaviors.  Cognitive Therapy: Clark’s (2003) cognitive therapy outperforms medication and exposure. Treatment of Panic Disorder:  Panic Control Therapy (PCT; Craske & Barlow, 2001): Exposure to bodily sensations associated with panic in a safe environment. Coping Strategies: Relaxation and deep breathing. Effectiveness: Benefits maintained post-treatment. Treatment of Agoraphobia:  Cognitive Behavioral Therapy (CBT): Systematic exposure to feared situations. Self-guided treatment can be effective. Treatment of Generalized Anxiety Disorder (GAD): Relaxation Training: Focus on reducing physiological arousal.  Cognitive Behavioral Methods: Challenge and modify negative thoughts. Increase tolerance for uncertainty. Use scheduled worry periods. Focus on the present moment (mindfulness). Medications for Anxiety Disorders: Anxiolytics (Anti-Anxiety Medications): 1.Benzodiazepines: Examples: Valium, Xanax. Caution: Risk of dependence and side effects. 2.Antidepressants: Tricyclics, SSRIs, SNRIs: Effective but may cause side effects. 3.D-Cycloserine (DCS): Enhances learning during exposure therapy and improves treatment effectiveness.