Abnormal Psychology - Anxiety Disorders PDF

# Abnormal Psychology (PSY 3101) ## Anxiety Disorders - Anxiety Disorders are a group of mental disorders characterized by significant feelings of anxiety and fear, including generalized anxiety disorders, specific phobias, panic disorder, and posttraumatic stress disorder. - Anxiety is a worry ab...

# Abnormal Psychology (PSY 3101) ## Anxiety Disorders - Anxiety Disorders are a group of mental disorders characterized by significant feelings of anxiety and fear, including generalized anxiety disorders, specific phobias, panic disorder, and posttraumatic stress disorder. - Anxiety is a worry about future events, and fear is a reaction to current events. - These feelings may cause significant somatic symptoms as well. ### Separation Anxiety Disorder - Separation Anxiety Disorder is a mental disorder characterized by an excessive fear or anxiety concerning separation from a home or attachment figure(s). - The anxiety exceeds what is expected at the individual’s developmental level. #### Prognosis - Separation anxiety disorder can occur as early as during preschool age and can occur at any time during childhood and more rarely in adolescence. - Symptoms can wax or wane over the course of the disorder. - The vast majority of children with separation anxiety disorder do not have impairing anxiety over the course of their lifetimes, and many as adults do not recall history of anxiety. - Separation anxiety is actually a protective factor against substance use. #### Risk Factors - Risk factors include major life stressors such as the death of a relative or a pet, illness of a loved one, parental divorce, change of schools, immigration, and disasters that involve separation. - Parental overprotection and intrusiveness is also associated with separation anxiety disorder. - Separation anxiety disorder in children may be heritable (estimated 73% in a community sample of twins). #### Cultural - There is significant variation in countries and cultures on the age where one expects the offspring should leave the parental home. - Thus, it is important to assess separation anxiety disorder within a cultural context. ## Diagnostic Criteria ### Criterion A - Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least 3 of the following: - Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures. - Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death. - Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure. - Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation. - Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. - Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. - Repeated nightmares involving the theme of separation. - Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated. ### Criterion B - The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults. ### Criterion C - The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. ### Criterion D - The disturbance is not better explained by another mental disorder, such as: - Refusing to leave home because of excessive resistance to change (autism spectrum disorder) - Delusions or hallucinations concerning separation (psychotic disorders) - Refusal to go outside without a trusted companion (agoraphobia) - Worries about ill health or other harm befalling significant others (generalized anxiety disorder) - Concerns about having an illness (illness anxiety disorder) ## Signs and Symptoms - Note that heightened separation anxiety from attachment figures are part of normal early childhood development and can indicate the development of secure attachment relationships (e.g., around 1 year of age, when infants develop stranger anxiety). - When separated from major attachment figures such as their parents, children with separation anxiety disorder may show apathy, sadness, social withdrawal, or difficulty concentrating. - This can lead to school refusal, academic difficulties, and social isolation. - When alone (typically in the evening or the dark), young children may report unusual perceptual experiences (e.g., seeing people peering into their room, creatures reaching for them, or feeling there are eyes staring at them). - In children, individuals may present as demanding, intrusive, and in need of constant attention. - When this continues into adulthood, individuals can appear dependent and overprotective. - Adults with separation anxiety are usually worried about their children and spouses and experience significant discomfort when separated from them (e.g., will continuously check on the whereabouts of love one). ## Treatment ### Psychotherapy - Separation anxiety disorder responds well to cognitive behavioural therapy. ### Pharmacotherapy - Psychological therapies are always preferred over pharmacotherapy. - Generally speaking, selective serotonin reuptake inhibitors and tricyclic antidepressants are the most commonly studied medications for anxiety disorders in children. - Fluoxetine, fluvoxamine, and sertraline have been studied. - Benzodiazepines should never be used (no better than placebo). ## Selective Mutism - Selective Mutism is a mental disorder where individuals (most commonly children) do not initiate speech or reciprocally respond when spoken to by others. - This lack of speech occurs in both social interactions with children or adults. - Children will however, speak in their home in the presence of immediate family members. ### Prognosis - The onset of selective mutism usually begins before age 5 years. - It often comes to clinical attention when the school age years begin and there is a need for social interactions and performance tasks. - This can lead to severe impairment in social or school functioning, or teasing from peers. - The course of selective mutism is unclear, but most individuals will outgrow the symptoms. - Social anxiety symptoms may continue however, and individuals may continue to meet criteria for this disorder. ### Risk Factors - Children may model parents who have social inhibition, which increases risk for selective mutism. - Parents who are described as overprotective may have children at increased risk for selective mutism. ### Diagnostic Criteria #### Criterion A - Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations. #### Criterion B - The disturbance interferes with educational or occupational achievement or with social communication. #### Criterion C - The duration of the disturbance is at least 1 month (cannot be during first month of school). #### Criterion D - The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation. #### Criterion E - The disturbance is not better explained by a communication disorder (e.g., childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder. ## Specific Phobia - Specific Phobia is an anxiety disorder characterized by intense fear or anxiety in the presence of a particular situation or object (phobic stimulus). - The four major types of fear are animals, environments, medical procedures, and situations (e.g., elevators, planes, enclosed spaces). ### Prognosis - Specific phobia can often develop following a traumatic event (e.g., being bitten than an animal), observing others going through a traumatic event (e.g., watching someone drown). - Most individuals however, are unable to recall a specific trigger for their phobia. - The majority of cases of specific phobia prior to age 10. - Specific phobia in childhood and adolescence tend to wax and wane, but if they persist into adulthood, it is rare for them to remit. - Depending on the phobic stimulus, it can have a varied impact on the individual: e.g., fear of falling leading to individual staying at home, e.g., fear of choking leading to individual reducing food and dietary intake. - The impact of specific phobias worsen with an increasing number of phobias present. ### Risk Factors - Overprotective parenting, early childhood trauma/abuse, parental loss and separation, are risk factors. - Having experienced a traumatic event with the feared object event can also (but does not always) precedes the development of a specific phobia. - Having a first-degree relative with a specific phobia also increases the risk for the individual to develop the same specific phobia. ### Cultural - The individual’s sociocultural context should always be taken into account. - For example, fears of the dark may be reasonable in a context of ongoing violence, and fear of insects may be more disproportionate in settings where insects are consumed in the diet. ### Diagnostic Criteria #### Criterion A - Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). - The specific object or situation is called a phobic stimulus. - In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. #### Criterion B - The phobic object or situation almost always provokes immediate fear or anxiety. #### Criterion C - The phobic object or situation is actively avoided or endured with intense fear or anxiety. #### Criterion D - The fear or anxiety is out of proportion to the actual danger posed by the specific object, or situation and to the sociocultural context. #### Criterion E - The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. #### Criterion F - The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. #### Criterion G - The disturbance is not better explained by the symptoms of another mental disorder, including: - Fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (agoraphobia) - Objects or situations related to obsessions (obsessive-compulsive disorder) - Reminders of traumatic events (posttraumatic stress disorder) - Separation from home or attachment figures (separation anxiety disorder) - Social situations (social anxiety disorder) ### Specifiers - Specify based on the phobia: - Animal (e.g., spiders, insects, dogs) - Natural environment (e.g., heights, storms, water) - Blood-injection-injury (e.g., needles, invasive medical procedures) - Situational (e.g., airplanes, elevators, enclosed places) - Other (e.g., situations that may lead to choking or vomiting: in children, e.g., loud sounds or costumed characters) ### Signs and Symptoms - Individuals with certain specific phobia (situational, natural environment, and animal specific phobias) usually experience an increase in sympathetic nervous system arousal in anticipation of or during exposure to a phobic object or situation. - However, individuals with blood-injection-injury specific phobias often demonstrate a vasovagal fainting or near-fainting response. - There may be an initial brief acceleration of heart rate and elevation of blood pressure followed by a quick deceleration of heart rate and a drop in blood pressure. ### Treatment #### Psychotherapy - Cognitive behavioural therapy with exposure is the first line treatment for specific phobias. - Both in vivo (in real life) and virtual reality exposure (VRE) are superior than imaginal therapy. - Exposure therapy is more effective when sessions are grouped closely together and the exposure is real, and there is some degree of therapist involvement. - There is no difference between “flooding” and gradual (graded) exposure in specific phobias. - Treatment with CBT and exposure therapies provides sustained long-term benefits. ### Pharmacotherapy - There is a limited role for the use of pharmacotherapy in the treatment of specific phobias, and there is little research on its role. - This is because exposure based therapies are very successful. - Benzodiazepines may sometimes be used in clinical practice for acute symptom relief, or in cases where there is a very specific feared situation that would warrant one-time medication use (e.g., claustrophobia in MRI machine, or fear of flying for an unexpected urgent flight). ## Social Anxiety Disorder (Social Phobia) - Social Anxiety Disorder (also known as social phobia), is an anxiety disorder characterized by a significant amount of fear in one or more social situations, causing significant distress and impaired ability to function in some aspects of daily life. - These fears can be triggered by perceived or actual scrutiny, or negative evaluation from others. ### Prognosis - About 30% of individuals experience remission within 1 year, and about 50% experience remission within several years. - For those not receiving treatment, about 60% of individuals take several more years to achieve remission. - Individuals are more likely to be unemployed, single, unmarried, or divorced and childless, particularly among men. - Only about half of individuals seek treatment, and typically after 15 to 20 years of experiencing symptoms. ### Risk Factors - Temperamental traits such as high behavioural inhibition and fear of negative evaluation is a risk factor. - First degree relatives of individuals with social anxiety disorder have a two to six times higher chance of having social anxiety disorder. ### Cultural - Fear of offending others by a gaze or by showing anxiety symptoms may be the predominant fear in individuals from cultures with strong collectivistic orientations. - In Japan and Korea, this is known as taijin kyofusho, where the individual believes their gaze is upsetting others, and so others look away from them. - Sometimes, this fear can attain a delusional intensity. - The North American equivalent of this syndrome is termed "olfactory-reference syndrome." ### Diagnostic Criteria #### Criterion A - Marked fear or anxiety about 1 or more social situations in which the individual is exposed to possible scrutiny by others. - Examples include: social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). - In children, the anxiety must occur in peer settings and not just during interactions with adults. #### Criterion B - The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others). #### Criterion C - The social situations almost always provoke fear or anxiety. - In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. #### Criterion D - The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. #### Criterion E - The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. #### Criterion F - The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. #### Criterion G - The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. #### Criterion H - The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder. #### Criterion I - If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive. ### Specifiers - Performance only: If the fear is restricted to speaking or performing in public. ### Signs and Symptoms - The anticipatory anxiety in social anxiety can sometimes occur far in advance of upcoming situations (e.g., worrying every day for weeks before the social event). - Individuals often overestimate the negative consequences of the social situations, but the sociocultural context always needs to be taken into account by the clinician. - Individuals (e.g., public speakers, musicians, dancers, performers, athletes) with the performance only type of social anxiety disorder will have performance fears that are typically most impairing during their careers or professional lives. - Importantly, in performance only type, individuals do not fear or avoid non-performance social situations. - Some individuals may have a fear of public restrooms and avoid urinating when other individuals are present (this is also called paruresis, or “shy bladder syndrome”). - This is more common in males. - Blushing is considered a hallmark response for social anxiety disorder. ### Treatment #### Psychotherapy - Cognitive behavioural therapy with exposure is a first-line, gold-standard treatment for social anxiety disorder. - Importantly, the gains from CBT are longer lasting and more enduring than those achieved through medication treatment, and includes several components: - Education - about disorder and treatment, recommends self-help materials - Exposure - offers imaginal exposure to situations that are difficult to practice regularly in real life, offers in-vivo exposure to situations that provoke social anxiety during treatment sessions and homework, provides exposure role-play simulations, reduces safety behaviours in social situations #### Pharmacotherapy - In performance-type social anxiety disorder only, beta-blockers have been used for performance anxiety. - If response to a medication is inadequate, dosing should be optimized and compliance assessed before switching to another agent. - In patients who have inadequate response to optimal dosages of a first line agent or in whom the agent is not tolerated, switch to another first-line agent. - Titrate up to higher doses of medication, as social anxiety typically responds only partially to antidepressants and usually requires the upper end of the dose range. - Switch to a second line medication after 2 failed trials of first-line. - While benzodiazepines are a second-line treatment, they may be used at any time if there is an acute and severe exacerbation of agitation or anxiety in individuals with SAD who do not have co-morbid alcohol or substance abuse. - However, they should be used as a short term solution only (1/4 of patients with generalized SAD have co-morbid substance use). ## Panic Disorder - Panic Disorder is a condition where there are recurrent unexpected panic attacks, in the absence of triggers. - It is marked by persistent concern about additional panic attacks and/or maladaptive change in behaviour related to the attacks. ### Prognosis - Youth with panic attacks may go on to develop mood disorders such as bipolar disorder and major depressive disorder, other anxiety disorders, eating disorders, psychotic disorders, and personality disorders. - Panic disorder can have a negative impact on physical and psychological function, in addition to stress on the individual’s interpersonal functioning (especially with their family members). - Typically, panic disorder has a chronic waxing and waning course over the individual’s lifetime. - Individuals with panic disorder are at a higher risk for suicide. ### Risk Factors - Adverse childhood experiences can increase the risk for panic disorder. - Smoking is a risk factor for panic attacks and panic disorder. - Most individuals with panic attacks are also able to identify a stressor in the months prior to their panic attack. - Panic disorder is more prevalent in patients with medical conditions, including thyroid disease, cancer, chronic pain, cardiac disease, irritable bowel syndrome, migraine, as well as allergic and respiratory diseases compared with the general population. - Agents such as sodium lactate, yohimbine, caffeine, isoproterenol, carbon dioxide, and cholecystokinin, can provide panic attacks in individuals with panic disorder more so than in healthy controls (but this is not a diagnostic marker). ### Cultural - Panic attacks can have various cultural interpretations and is linked to various cultural syndromes. - Having an understanding of the cultural concepts of disease and mental disorders is important when assessing panic attack symptoms in a cultural context. - In Hispanic individuals, ataque de nervios (“attack of nerves”) is a cultural syndrome used frequently to describe symptoms of intense emotional upset including acute anxiety, anger, or grief, screaming and shouting uncontrollably, attacks of crying, trembling, feeling of heat in the chest rising into the head, and verbal and physical aggression. - Some individuals may even report dissociative episodes. - In Cambodians, “Khyâl attacks” (khyâl cap) or “wind attacks” include palpitations, shortness of breath, dizziness, and cold extremities. - Individuals also have other symptoms of anxiety and autonomic arousal such as neck soreness and tinnitus. ### Diagnostic Criteria #### Criterion A - Recurrent unexpected panic attacks. - A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time at least 4 of the following symptoms occur (Note: The abrupt surge can occur from a calm state or an anxious state): - Sweating - Trembling or shaking - Unsteady, dizziness, light-headed, or faint - Derealization (feelings of unreality) or depersonalization (being detached from one self) - Excessive/accelerated heart rate, palpitations, or pounding heart - Nausea or abdominal distress - Tingling, numbness, parathesesias - Shortness of breath - Fear of losing control or “going crazy” - Fear of dying - Choking feelings - Chest pain or discomfort - Chills or heat sensations #### Note for Criterion A: - A panic attack is a single, discrete episode of intense fear and discomfort. - A panic attack can be expected or unexpected, but in order to diagnose panic disorder, there must be at least one unexpected panic attack! - A panic attack must peak abruptly (rapid onset of under 10 minutes), and must be accompanied by a cluster of physical symptoms. - A typical panic attack is relatively short and lasts no more than 15 minutes. #### Mnemonic for Criterion A: - The mnemonic STUDENTS FEAR the 3 C’s can be used to remember the panic disorder criteria: - S - Sweating - T - Trembling - U - Unsteadiness, dizziness - D - Depersonalization, derealization - E - Excessive heart rate, palpitations - N - Nausea - T - Tingling - S - Shortness of breath - FEAR of dying - FEAR of losing control - FEAR of going crazy - C - Chest pain - C - Chills - C - Choking #### Criterion B - At least 1 of the attacks has been followed by at least 1 month of at least 1 of the following: - Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”). - A significant maladaptive change in behavior-related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations) #### Criterion C - The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders). #### Criterion D - The disturbance is not better explained by another mental disorder: - The panic attacks do not occur only in response to feared social situations (social anxiety disorder) - In response to circumscribed phobic objects or situations (specific phobia) - In response to obsessions (obsessive-compulsive disorder) - In response to reminders of traumatic events (post-traumatic stress disorder) - In response to separation from attachment figures (separation anxiety disorder) ### Signs and Symptoms - 50% of individuals with panic disorder have expected panic attacks in addition to unexpected panic attacks. - Thus, having expected panic attacks does not rule out the diagnosis of panic disorder. - However, at least one unexpected full symptom panic attack is required for the diagnosis of panic disorder (as per Criterion Α). - The frequency and severity of panic attacks can differ greatly between people. - Moderate frequency can be one per week for several months, or individuals may have “bursts” of frequent daily panic attacks and then weeks or months without any attacks. - Individuals also may have maladaptive behaviours to minimize or avoid panic attacks or the consequences of the panic attacks (e.g., avoiding physical exertion, restricting usual activities, avoiding agoraphobia-type situations, reorganizing routines to ensure that help is available in the event of a panic attack; severe restrictions on food intake or medications for fear it may trigger attacks). - Between 1/3 to 1/4 of individuals may also have nocturnal panic attacks that wake them from sleep. ### Treatment #### Psychotherapy - Cognitive behavioural therapy has been extensively studied in panic disorder and is very efficacious in the treatment for panic disorder agoraphobia, and is preferred by patients. - The addition of exposure makes the therapy even more effective. - Psychodynamic therapy has also been used in the treatment of panic disorder. - Since the evidence is so strong for psychotherapy, it should be offered as a first line treatment alone, or in combination with medications. #### Pharmacotherapy - Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, paroxetine CR, sertraline, venlafaxine XR ### Panic Attack (Specifier) - Recurrent unexpected panic attacks. - An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time at least 4 of the following symptoms occur (Note: The abrupt surge can occur from a calm state or an anxious state): - Sweating - Trembling or shaking - Unsteady, dizziness, light-headed, or faint - Derealization (feelings of unreality) or depersonalization (being detached from one self) - Excessive/accelerated heart rate, palpitations, or pounding heart - Nausea or abdominal distress - Tingling, numbness, parathesesias - Shortness of breath - Fear of losing control or “going crazy” - Fear of dying - Choking feelings - Chest pain or discomfort - Chills or heat sensations #### Note: - The symptoms presented in this specifier are for the purpose of identifying a panic attack. - However, panic attacks are not a mental disorder. - Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (e.g., depressive disorders, posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal). - When the presence of a panic attack is identified, it should be noted as a specifier (e.g., "social anxiety disorder with panic attacks”). - For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier. ## Agoraphobia - Agoraphobia is an anxiety disorder where an individual has intense fears about at least two different types of situations, with the fear being that escape may be difficult or help may be unavailable if panic-like symptoms occur. ### Prognosis - The course of agoraphobia is usually persistent and chronic. - If untreated, the remission rate is around 10%. ### Risk Factors - More than 33% of individuals with agoraphobia are homebound and unable have gainful employment - Anxiety disorders, depressive disorders, substance use disorders, and personality disorders, can be comorbid with agoraphobia. - Temperamental factors such as anxiety sensitivity (belief that anxiety symptoms are harmful). - Environmental factors such as reduced warmth and increased overprotection by parental figures, and adverse childhood events are risk factors. - The heritability for agoraphobia is is 61%, and has the most genetic association of the phobias. ### Cultural - What counts as avoidance is difficult to judge across cultures and sociocultural contexts (e.g., it may be socioculturally appropriate for orthodox Muslim women to avoid leaving the house alone, and this is not indicative of agoraphobia) ### Diagnostic Criteria #### Criterion A - Marked fear or anxiety about at least 2 of the following 5 situations: - Public transportation (e.g., automobiles, buses, trains, ships, planes) - Open spaces (e.g., parking lots, malls, marketplaces, bridges) - Enclosed places (e.g., rooms, shops, theatres, cinemas) - Crowds or standing in line - Being outside of home alone #### Criterion B - The individual fears or avoids these situations because of thoughts that: - Escape might be difficult, or - Help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling or fear of incontinence in the elderly). #### Criterion C - The agoraphobic situations almost always provoke fear or anxiety. #### Criterion D - The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. #### Criterion E - The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context. #### Criterion F - The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. #### Criterion G - The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. #### Criterion H - If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly excessive. #### Criterion I - The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder: - The symptoms are not confined to a specific phobia, situational type - Do not involve only social situations (social anxiety disorder) - Do not relate exclusively to obsessions (obsessive-compulsive disorder) - Do not relate to defects or flaws in physical appearance (body dysmorphic disorder) - Do not relate to reminders of traumatic events (post-traumatic stress disorder) - Do not relate to fear of separation (separation anxiety disorder). ### Signs and Symptoms - Individuals with agoraphobia frequently believe that escape from such their feared situations might be difficult (e.g., “I won’t be able to get out of here”) or that help might be unavailable (e.g., “There will be nobody there to help me”) when the panic-like symptoms or other incapacitating or embarrassing symptoms occur. - Beyond the panic attack symptoms (see above), other incapacitating or embarrassing symptoms include symptoms such as: Vomiting and inflammatory bowel symptoms, in older adults, a fear of falling, in children, a sense of disorientation and getting lost. ### Treatment - The treatment for agoraphobia is similar to treatment for panic disorder. ## Generalized Anxiety Disorder - Generalized Anxiety Disorder (GAD) is mental disorder characterized by excessive anxiety and worry about multiple events or activities (e.g., school or work difficulties, relationships, finances) on a majority of days over at least half a year. - There are also associated symptoms, such as restlessness, muscle tension, fatigue, poor concentration, irritability, and sleep changes. ### Prognosis - Many individuals with GAD report a life-long history of anxiety and nervousness - GAD tends to wax and wane over the course of of the lifespan, and rates of full remission are very low. - This suggests the GAD may not be a “mental disorder” per se, but rather a diagnostic construct that spans across different dimensions, including other mental disorders, personality disorders, and temperament. ### Risk Factors - Temperamental traits including behavioural inhibition, negative affectivity (neuroticism), and harm avoidance are risk factors for GAD. - Adverse childhood events and parental overprotection are associated with GAD. ### Cultural - There is significant variation in the expression of generalized anxiety disorder across the world. - In some cultures, somatic symptoms may be the predominant presentation, whereas cognitive symptoms may predominate in others. ### Diagnostic Criteria #### Criterion A - Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). #### Criterion B - The individual finds it difficult to control the worry. #### Criterion C - The anxiety and worry are associated with at least 3 of the 6 symptoms (with at least some symptoms present for more days than not for the past 6 months); Only 1 item is required in children; - Blanking out or difficulty concentrating - Easily fatigued - Sleep changes (difficulty falling or staying asleep, or restless, unsatisfying sleep) - Keyed up, on edge, or restless - Irritability - Muscle tension #### Criterion D - The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. #### Criterion E - The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). #### Criterion F - The disturbance is not better explained by another mental disorder: - Anxiety or worry about having panic attacks (panic disorder) - Negative evaluation (social anxiety disorder) - Contamination or other obsessions (obsessive-compulsive disorder) - Separation from attachment figures (separation anxiety disorder) - Reminders of traumatic events (post-traumatic stress disorder) - Gaining weight (anorexia nervosa) - Physical complaints (somatic symptom disorder) - Perceived appearance flaws (body dysmorphic disorder) - Having a serious illness (illness anxiety disorder) - The content of delusional beliefs (schizophrenia or delusional disorder) ### Signs and Symptoms - Individuals may report muscle tension, trembling, twitching, feeling shaky, muscle aches. - Somatic symptoms such as sweating, nausea, diarrhea, and headaches may also occur. ### Treatment #### Psychotherapy - Cognitive behavioural therapy (CBT) is an effective first-line option for the treatment of GAD and is as effective as pharmacotherapy. - Internet-based and computer-based CBT have also demonstrated efficacy. - The evidence does not support the routine combination of CBT and pharmacotherapy, but when patients do not benefit from CBT, a trial of pharmacotherapy is advisable, and vice versa. #### Pharmacotherapy - Monotherapy: agomelatine, duloxetine, escitalopram, paroxetine, paroxetine CR, pregabalin, sertraline, venlafaxine XR ### Substance/Medication-Induced Anxiety Disorder - Substance/medication-induced anxiety disorder is diagnosed after an individual uses a substance (e.g., a drug of abuse, a medication, or a toxin exposure) that leads to prominent symptoms of panic or anxiety. ### Other Specified Anxiety Disorders - Other Specified Anxiety Disorders is a category of DSM diagnoses that applies to individuals who have symptoms characteristic of an anxiety disorder but do not meet the full criteria for any of them. - This category in anxiety disorders also includes disorders with cultural components. - “Other Specified” diagnoses are not limited to these disorders and are used throughout the DSM to capture presentations where individuals have significant clinical impairment but do not meet standard criteria.