Anxiety Disorders PDF

ANXIETY DISORDERS o Associated thoughts or beliefs. INTRODUCTION  Disorders characterized by excessive fear, COMORBIDITY: anxiety, and related behavioral...

ANXIETY DISORDERS o Associated thoughts or beliefs. INTRODUCTION  Disorders characterized by excessive fear, COMORBIDITY: anxiety, and related behavioral o Anxiety disorders are highly disturbances. comorbid, but differentiation is based on specific situations and FEAR VS. ANXIETY (DSM-5-TR DEFINITIONS) thoughts. FEAR: DISTINCTION FROM NORMAL OR TRANSIENT FEAR/ANXIETY o Emotional response to real or perceived imminent threat. DEVELOPMENTALLY NORMATIVE ANXIETY: FEAR/ANXIETY: o Anticipation of future threat. o Anxiety disorders differ by being excessive or persisting beyond normal development stages. KEY DIFFERENCES: Fear: TRANSIENT FEAR/ANXIETY:  Often linked to autonomic o Anxiety disorders are persistent arousal (fight or flight), (typically lasting 6+ months), immediate danger, escape unlike transient stress-induced behaviors. anxiety. Anxiety: DURATION AND FLEXIBILITY OF SYMPTOM  Associated with muscle tension, vigilance for future DURATION: danger, cautious or avoidant behaviors. o Generally lasts for 6 months or more, but this is a guideline, with PANIC ATTACKS flexibility for children (e.g., separation anxiety, selective mutism). PANIC ATTACKS: o Prominent feature of anxiety CLINICIAN’S ROLE IN DIAGNOSIS disorders. o Can also appear in other mental EXCESSIVENESS: disorders. o Overestimation of danger is common in individuals with o Not exclusive to anxiety anxiety disorders. disorders. o Clinicians determine if TYPES OF ANXIETY DISORDERS fear/anxiety is excessive, considering cultural contexts. DIFFERENTIATED BY: DEMOGRAPHICS AND PREVALENCE o Objects or situations that trigger fear, anxiety, or avoidance. AGE OF ONSET:  o Many anxiety disorders begin in SPECIFIC PHOBIA: childhood and tend to persist o Fear or anxiety about specific without treatment. objects or situations (e.g., animals, heights, blood, flying). GENDER: o Fear, anxiety, or avoidance is o More common in girls than boys (approximately 2:1 ratio). immediate, persistent, and out of proportion to the actual danger. DIAGNOSTIC CRITERIA o No specific cognition associated, unlike other anxiety disorders. EXCLUSION: o Types of phobias include: o Anxiety disorders are diagnosed when symptoms are not caused  Animal by substance use, medication, or another medical condition.  Natural environment (e.g., heights, storms) o Symptoms cannot be better explained by another mental  Blood-injection-injury disorder.  Situational (e.g., elevators, flying) ANXIETY DISORDERS OVERVIEW  Other situations (e.g., SEPARATION ANXIETY DISORDER: choking, loud sounds). o Fearful or anxious about separation from attachment SOCIAL ANXIETY DISORDER: figures (e.g., parents, caregivers). o Fearful or anxious about social interactions and situations o Fear of harm coming to involving scrutiny. attachment figures or events leading to separation. o Common situations include meeting unfamiliar people, o Reluctance to be away from eating/drinking in front of others, attachment figures, nightmares, or performing in public. and physical distress. o Concern about being negatively o Symptoms typically start in evaluated, humiliated, or childhood but can persist into rejected. adulthood, even without prior childhood separation anxiety. PANIC DISORDER: SELECTIVE MUTISM: o Recurrent unexpected panic attacks. o Consistent failure to speak in social situations (e.g., school), o Persistent worry about future despite speaking in other panic attacks or maladaptive situations. behavior changes (e.g., avoidance). o Impairs social communication and academic/occupational o Panic attacks: Sudden surges of achievement. intense fear or discomfort, reaching a peak within minutes.   Can be expected (in o Difficulty controlling worry. response to feared situations) or SUBSTANCE/MEDICATION- unexpected (without INDUCED ANXIETY DISORDER: clear trigger). o Anxiety symptoms caused by  Limited-symptom panic substance intoxication, attacks: Fewer than four withdrawal, or medication symptoms. treatment. o Panic attacks act as a marker for ANXIETY DISORDER DUE TO severity and comorbidity of ANOTHER MEDICAL CONDITION: various disorders (e.g., depression, substance use). o Anxiety symptoms that are a physiological consequence of another medical condition. AGORAPHOBIA: o Fear and anxiety about multiple ASSESSMENT TOOLS situations, typically requiring two or more of the following: DISORDER-SPECIFIC SCALES:  Using public transport o Scales designed to assess the severity of each anxiety disorder.  Being in open or enclosed spaces o Focus on behavioral, cognitive, and physical symptoms relevant  Standing in line or to each disorder. crowds o Standardized formats across  Being outside home disorders for ease of use, alone especially for individuals with o Fears that escape might be multiple anxiety disorders. difficult or help unavailable if panic-like or incapacitating ANXIETY AND SUICIDE RISK symptoms occur. INCREASED SUICIDE RISK: o These situations often induce avoidance or require a o Individuals with anxiety disorders companion. may be more likely to have suicidal thoughts, attempts, and death by suicide. GENERALIZED ANXIETY DISORDER (GAD): o Disorders most strongly o Persistent and excessive anxiety associated with transitioning and worry about various domains from suicidal thoughts to (e.g., work, school, health). attempts: o Physical symptoms include:  Panic Disorder  Restlessness, fatigue,  Generalized Anxiety difficulty concentrating, Disorder irritability, muscle tension, sleep  Specific Phobia disturbances. SEPARATION ANXIETY DISORDER DIAGNOSTIC FEATURES CRITERIA o The essential feature of separation Individuals with separation anxiety disorder have anxiety disorder is excessive fear or symptoms that meet at least three of the anxiety concerning separation from following criteria: home or attachment figures. o The anxiety exceeds what may be expected given the individual’s developmental level (Criterion A). DIAGNOSTIC CRITERIA FOR SEPARATION ANXIETY DISORDER A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following: 1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures. 2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death. 3. 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. 4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation. 5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. 6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. 7. Repeated nightmares involving the theme of separation. 8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated. 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. C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.  School-age girls have higher PREVALENCE prevalence rates than school-age boys. o The 6- to 12-month prevalence of separation anxiety disorder in o In adolescents in the United States, children is estimated to be the 12-month prevalence is 1.6%. approximately 4%.  Separation anxiety disorder  In a community sample of decreases in prevalence from toddlers, separation anxiety childhood through disorder is equally adolescence and adulthood. represented among girls and  In clinical samples of boys. children, the disorder is equally common in boys and  girls, whereas in community o Adults with separation anxiety disorder: samples, it is more frequent in girls. o Are typically overconcerned about their offspring, spouses, o For adults, the 12-month prevalence parents, and pets. in the United States ranges from 0.9% to 1.9%. o Experience marked discomfort  Among adults with when separated from these separation anxiety disorder, figures. women tend to have higher o May experience significant prevalence rates in both disruption in work or social clinical and community experiences due to needing to studies. continuously check on the  Across 18 countries, the whereabouts of a significant mean 12-month prevalence other. in adults is 1.0%, with a range of < 0.1% to 2.7% (e.g., 0.3% in Romania, 2.7% in Colombia).  A higher prevalence was observed in women compared with men in this total sample (1.3% compared with 0.8%). DEVELOPMENT AND COURSE o Onset of separation anxiety disorder may occur as early as preschool age and may develop at any time during childhood or adolescence. o Manifestations of separation anxiety disorder vary with age: o Younger children may be more reluctant to go to school or may avoid school altogether. o Younger children may not express worries or specific fears but instead show anxiety only during separation. o As children age, they may express worries about specific dangers (e.g., accidents, kidnapping, death) or vague concerns about not being reunited with attachment figures. o In adults, separation anxiety disorder may limit their ability to cope with changes in circumstances (e.g., moving, getting married). SELECTIVE MUTISM PREVALENCE  General Prevalence: DIAGNOSTIC FEATURES o Selective mutism is a relatively  Lack of Speech in Social Situations: rare disorder and has not been included as a diagnostic category o Children with selective mutism in epidemiological studies of do not initiate speech or childhood disorders. reciprocally respond when spoken to by others in social  Point Prevalence: interactions. o Using various clinic or school o Lack of speech occurs in social samples, point prevalence in the interactions with both children United States, Europe, and Israel and adults. ranges between 0.03% and 1.9%, depending on the setting and  Speech in Non-Social Settings: ages of the sample. o Children will speak in their home  Gender Distribution: with immediate family members. o Studies in community-based o They may not speak in front of and treatment-seeking samples close friends or second-degree show an equal gender relatives, such as grandparents distribution for selective mutism, or cousins. although there is evidence that it  Social Anxiety: is more common among girls than boys. o The disturbance is typically marked by high social anxiety.  Race/Ethnicity: o Children with selective mutism o Prevalence does not seem to vary may refuse to speak at school, significantly by race/ethnicity. which can cause academic or o However, individuals who need to educational impairment (e.g., speak in a non-native language difficulty assessing reading (e.g., children of immigrant skills). families) may have a greater risk  Nonverbal Communication: for developing the disorder. o The lack of speech may interfere  Age: with social communication. o The disorder is more likely to o Children may use nonspoken or manifest in young children than nonverbal means to in adolescents and adults. communicate, such as grunting, pointing, or writing. DEVELOPMENT AND COURSE o Some children may be willing or  Age of Onset: eager to perform in social o The onset of selective mutism is situations where speech is not usually before age 5 years. required, such as nonverbal parts in school plays. o The disturbance may not come to clinical attention until entry into school, where there is an  increase in social interaction o The longitudinal course of the and performance tasks (e.g., disorder is largely unknown. reading aloud).  Long-Term Symptoms:  Persistence of the Disorder: o In most cases, the mutism may o The persistence of selective fade, but symptoms of social mutism is variable. anxiety disorder often remain. o Many individuals with the disorder may outgrow selective mutism. DIAGNOSTIC CRITERIA FOR SELECTIVE MUTISM 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. B. The disturbance interferes with educational or occupational achievement or with social communication. C. The duration of the disturbance is at least 1 month (not limited to the first month of school). 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. 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  Fear, anxiety, or avoidance must be persistent and significantly impair daily functioning. The SPECIFIERS response differs from normal, o Multiple Phobias: transient fears that occur in the general population.  It is common for individuals with specific phobia to have fears of PREVALENCE multiple objects or situations. On average, individuals with specific o 12-month Prevalence: phobia fear about three objects  In the U.S., specific phobia or situations. affects approximately 8%–12%  If multiple phobias are present, of the population. each specific phobia is  In European countries, diagnosed separately. prevalence is similar (~6%), but Example: lower in Asian, African, and Latin American countries (2%–  Specific Phobia, Natural 4%). Environment (e.g., thunderstorms) o Children:  Specific Phobia,  Prevalence in children is Situational (e.g., flying) estimated around 5% across various countries, with a range of 3%–9%. DIAGNOSTIC FEATURES o Key Feature: o Adolescents:  Fear or anxiety is circumscribed  Prevalence in U.S. adolescents to a particular object or situation (ages 13–17) is about 16%. (the phobic stimulus). This fear is excessive and out of proportion o Adults: to the actual danger posed by the  Prevalence in adults is lower situation or object (Criterion A). (3%–5%), which may indicate a  Phobic Stimuli Categories: reduction in severity over time.  Animal (e.g., dogs, insects) o Gender:  Natural Environment (e.g.,  Women are more frequently heights, storms) affected than men, with a 2:1 female-to-male ratio.  Blood-Injection-Injury (e.g., blood, needles) DEVELOPMENT AND COURSE  Situational (e.g., elevators, o Onset: flying)  Specific phobia typically  Other (e.g., choking, loud develops in early childhood, noises) with the majority of cases occurring before age 10. The o Diagnosis: median age of onset is between 7–11 years, with an average onset around 10 years.  o Triggers for Onset:  Specific phobia can begin suddenly and may persist for  Specific phobias may develop many years. The severity may after a traumatic event (e.g., decrease with age, but some animal attack, being stuck in an individuals continue to avoid elevator), observing others feared situations throughout experience trauma (e.g., adulthood. watching someone drown), unexpected panic attacks in  Although specific phobias may feared situations, or through diminish over time, social informational transmission anxiety and avoidance (e.g., media coverage of a plane behaviors often remain, crash). especially in cases where multiple phobias are present. o Course: DIAGNOSITIC CRITERIA FOR SPECIFIC PHOBIA A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. B. The phobic object or situation almost always provokes immediate fear or anxiety. C. The phobic object or situation is actively avoided or endured with intense fear or anxiety. 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. E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 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 (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder). Specify if: Code based on the phobic stimulus:  F40.218 Animal (e.g., spiders, insects, dogs).  F40.228 Natural environment (e.g., heights, storms, water).  F40.23x Blood-injection-injury (e.g., needles, invasive medical procedures). o F40.230 fear of blood; o F40.231 fear of injections and transfusions; o F40.232 fear of other medical care; or o F40.233 fear of injury.  F40.248 Situational (e.g., airplanes, elevators, enclosed places).  F40.298 Other (e.g., situations that may lead to choking or vomiting; in children, e.g., loud sounds or costumed characters). Coding note: When more than one phobic stimulus is present, code all ICD-10-CM codes that apply (e.g., for fear of snakes and flying, F40.218 specific phobia, animal, and F40.248 specific phobia, situational).  o Safety Behaviors: SOCIAL ANXIETY DISORDER  To avoid drawing attention to themselves, individuals with SAD often engage in safety OVERVIEW behaviors, which may include:  Avoiding eye contact o Social anxiety disorder (SAD),  Talking less sometimes referred to as social  Sitting alone phobia, involves an intense fear of  Holding a glass tightly to being scrutinized or doing something prevent hand tremors embarrassing or humiliating in the  Wearing makeup to hide presence of others (Sue et al., 2016). blushing (Moukheiber et o The fear is often out of proportion to al., 2010) the actual situation, leading to o Social Submission: avoidance of social situations or experiencing intense fear or anxiety  Individuals with SAD are often when enduring them. socially submissive in an effort to avoid conflicts with others CORE FEATURES (Russell, Moskowitz, Zuroff, Bleau, & Young, 2010). o Self-Consciousness: o Interpersonal Issues:  Individuals with SAD are so self- conscious that they feel  SAD is associated with stressful physically sick with fear at the interpersonal relationships prospect of social activities. (Rodebaugh, 2009).  This disorder often involves high  Among romantic couples, those levels of anxiety in most social with high levels of social anxiety situations, though some often focus more on negative individuals may only experience information, show less interest in anxiety in specific situations and support for their partners, where they must speak or and make fewer supportive perform publicly (referred to as comments in response to shared the performance-only type). positive events.  The most common fears in SAD  As a result, these couples are involve public speaking and more likely to end their meeting new people (APA, relationship after six months 2013). (Kashdan, Ferssizidis, Farmer, Adams, & McKnight, 2013). o Fear of Negative Evaluation: SPECIFIERS  People with high social anxiety tend to believe that others are o Performance Only Type: evaluating them negatively (Cody & Teachman, 2011). o Individuals with the performance-only type of  They are constantly on the social anxiety disorder lookout for “threat” cues, such experience fears that are as signs of disapproval or typically most impairing in criticism (Shorey & Stuart, 2012). professional settings (e.g.,  musicians, dancers,  Some individuals fear offending performers, athletes) or in others or being rejected as a roles that require public result of their anxiety. speaking.  Fear of offending others, such as o Performance fears may also through a gaze or by showing arise in work, school, or anxiety symptoms, is more academic settings that common in cultures with strong involve regular public collectivistic orientations. presentations.  Specific fears include: o People with performance- only SAD do not fear or avoid  Fear of trembling hands, non-performance social leading to avoidance of situations. drinking, eating, writing, or pointing in public. DIAGNOSTIC FEATURES  Fear of sweating, leading to avoiding activities like o Intense Fear of Social Situations: shaking hands or eating  The primary feature of social spicy foods. anxiety disorder is marked or  Fear of blushing, causing intense fear or anxiety about avoidance of public social situations in which the performance, bright individual might be scrutinized by lights, or discussions of others. intimate topics.  In children, the fear or anxiety  Fear of urinating in public must occur in peer settings, not restrooms when other just during interactions with individuals are present adults (Criterion A). (known as paruresis or o Fear of Negative Evaluation: shy bladder syndrome).  When exposed to social o Fear or Anxiety in Social Situations: situations, the individual fears  The social situations almost being negatively evaluated. always provoke fear or anxiety  They worry that they will be (Criterion C). judged as anxious, weak, crazy,  An individual who experiences stupid, boring, unlikable, or anxiety only occasionally in dirty. certain social situations would  They fear acting in a certain way not be diagnosed with social or showing anxiety symptoms anxiety disorder. (e.g., blushing, trembling,  The fear may manifest as sweating, stumbling over words, anticipatory anxiety (anxiety staring) that will be negatively before the event) or as a panic evaluated by others (Criterion B). attack. o Fear of Offending or Being Rejected:  Anticipatory anxiety can occur weeks or days before the event (e.g., worrying daily for weeks  about attending a social event or  In clinical samples, gender rates repeating a speech in are either equal or slightly higher preparation). in men, which may reflect social expectations and gender roles  In children, the fear may be that influence help-seeking expressed through behaviors behavior. such as crying, tantrums, freezing, clinging, or shrinking o Ethnic Differences: in social situations.  In the United States, the prevalence of social anxiety PREVALENCE disorder is lower in individuals of o United States: Asian, Latinx, African American, and Caribbean Black  The 12-month prevalence descent compared to non- estimate for social anxiety Hispanic Whites. disorder in the U.S. is approximately 7%. DEVELOPMENT AND COURSE o Global Prevalence: o Age of Onset:  Lower prevalence estimates are  The median age at onset of found in other parts of the world, social anxiety disorder in the U.S. typically clustering around 0.5%– is 13 years. 2.0%.  Approximately 75% of individuals  The median prevalence in Europe have an age at onset between 8 is 2.3%. and 15 years. o Prevalence Trends: o Childhood History:  The prevalence appears to be  The disorder may develop out of increasing in the U.S. and East a childhood history of social Asian countries. inhibition or shyness, according to studies from the U.S. and  The 12-month prevalence in Europe. adolescents (ages 13–17 years) is roughly half of that in adults.  Early childhood onset is also possible.  Prevalence rates decrease after age 65, with rates in older adults o Triggers for Onset: in North America, Europe, and Australia ranging from 2% to 5%.  Social anxiety disorder may develop after a stressful or o Gender Differences: humiliating experience (e.g., bullying, vomiting during a public  Women are more frequently speech). affected than men in the general population, with odds ratios  The onset can also be insidious, ranging from 1.5 to 2.2. developing slowly over time.  The gender difference is more o First Onset in Adulthood: pronounced in adolescents and young adults.   First onset in adulthood is o Persistence: relatively rare and typically follows a stressful or  Among individuals seeking humiliating event or significant clinical care, social anxiety life changes that require new disorder tends to be particularly social roles (e.g., marriage, job persistent and chronic. promotion).  Social anxiety may diminish after life changes such as marriage, but can reemerge after events like divorce. DIAGNOSITIC CRITERIA FOR SOCIAL ANXIETY DISORDER A. Marked fear or anxiety about one 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). Note: In children, the anxiety must occur in peer settings and not just during interactions with adults. B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., humiliating or embarrassing; will lead to rejection or offend others). C. The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. D. The social situations are avoided or endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. 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. I. 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. J. 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 excessive.  Course of Worry GENERALIZED ANXIETY DISORDER  The focus of worry in GAD may shift over time from one concern to another. An individual may start out worrying about DIAGNOSTIC FEATURES work, then shift to worrying about family, Core Feature health, or other issues. o Excessive Anxiety and Worry: PREVALENCE The primary feature of GAD is excessive anxiety and worry (referred to as General Prevalence apprehensive expectation) about a wide  12-month prevalence in the United variety of events or activities. This worry is: States: o Adolescents: 0.9%  Out of proportion to the actual o Adults: 2.9% likelihood or impact of the  Global Prevalence: anticipated event. The global mean for 12-month prevalence  Individuals find it difficult to control of GAD is 1.3%, with a range from 0.2% to the worry, and the worrisome 4.3%. thoughts can interfere with their Lifetime Morbidity Risk ability to focus on daily tasks or activities.  The lifetime morbid risk for developing GAD in the United States is 9.0%. Content of Worry Gender Differences ADULTS:  Women are twice as likely as men to develop GAD, a pattern that is observed Adults with GAD commonly worry about across both adolescents and adults. routine life circumstances, such as:  This gender difference is particularly  Job responsibilities pronounced in the adolescent and young  Health concerns (themselves adult populations. or loved ones) Age Differences  Financial matters  Older Adults: The 12-month prevalence  Misfortunes affecting family for older adults, including those aged 75 members or children and older, is approximately 2.8% to 3.1%  Minor issues like household in countries like the United States, Israel, chores or being late for and Europe. appointments.  The prevalence of GAD decreases with age, particularly after the age of 65. CHILDREN: Ethnic and Geographic Variations Children with GAD typically focus on  Ethnicity: Individuals of European worries about their competence or the descent tend to report higher rates of quality of their performance. For example: GAD symptoms compared to those of  Worries about how well they Asian or African descent. perform in school or during  Geography: Individuals from high- sporting events (even when income countries are more likely to they are not being evaluated report experiencing symptoms that meet by others). criteria for GAD compared to individuals  They may have concerns from low- and middle-income countries. about punctuality and performing tasks perfectly. DEVELOPMENT AND COURSE o Those who develop GAD earlier in life tend to have more Age of Onset comorbidity (e.g., depression,  Mean Age at Onset: other anxiety disorders) and The mean age at onset for GAD in North greater impairment. America is around 35 years, which is later than for most other anxiety disorders, AGE-APPROPRIATE WORRY CONTENT which often start in childhood or  The content of worry is often age- adolescence. appropriate and tends to change as the o Adolescence is a common age individual ages. for the onset of GAD, but it can start at any time across the life Children and Adolescents: span.  Anxieties in children and adolescents often focus on their performance at school or in o Early Onset: Symptoms of sports, even if they are not being directly excessive worry may occur earlier evaluated. in life but might present as an anxious temperament rather  They may also worry excessively about than full-blown GAD. catastrophic events (e.g., natural disasters, war). o Rare Onset in Adulthood: Although less common, GAD can  Children with GAD may display traits like sometimes first emerge in being overly conforming, perfectionistic, adulthood, often following a and unsure of themselves, often stressful life event or major life reworking tasks because of changes. dissatisfaction with anything less than perfect performance. Course of the Disorder  Chronic Course: Elderly Individuals: GAD tends to have a chronic course, with  In the elderly, chronic physical health symptoms waxing and waning over time. issues (e.g., arthritis, heart disease) can Many individuals experience fluctuations trigger excessive worry. between full-blown symptoms and subsyndromal forms of the disorder.  For frail older adults, concerns about safety—especially the risk of falling—can  Persistence: significantly limit daily activities and increase anxiety. o In lower-income countries, the course of GAD tends to be more SUMMARY OF KEY POINTS persistent, with fewer periods of symptom remission. o Core Feature: Excessive, uncontrollable anxiety about everyday life events and o In higher-income countries, activities. while the disorder may persist, individuals tend to report higher o Prevalence: More common in women and levels of impairment. adolescents; highest in high-income countries. Remission: o Course: Chronic, with symptoms o Full remission from GAD is rare, fluctuating between full-blown and and the disorder tends to subsyndromal forms. fluctuate across a person’s life.  o Age of Onset: Typically begins in childhood or adolescence but can emerge at any age, particularly in response to stress. o Treatment Implications: Early onset and chronic course are associated with more severe impairment and comorbidity, which may require long-term treatment approaches. DIAGNOSTIC CRITERIA FOR GENERALIZED ANXIETY DISORDER 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). B. The individual finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): 1. Restlessness or feeling keyed up or on edge. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). Note: Only one item is required in children. D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 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). F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder, contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder). UNDERSTANDING ANXIETY DISORDERS  Two main biological factors influence the FROM A MULTIPATH PERSPECTIVE (SUE development of anxiety disorders: 1. Fear circuitry in the brain ET AL., 2016) 2. Genetics  Anxiety often produces tension, worry, and physiological reactivity. FEAR CIRCUITRY IN THE BRAIN  Anxiety is frequently an anticipatory o Various brain structures and emotion—a sense of unease about a processes are involved in fear and dreaded event or situation that has not yet anxiety responses. occurred. o The amygdala (a part of the brain  From an evolutionary perspective, anxiety responsible for forming and storing may be adaptive, producing bodily memories related to emotional reactions that prepare us for “fight or events) plays a central role in flight.” triggering fear or anxiety responses. o Mild or moderate anxiety prevents GENETIC INFLUENCES us from ignoring danger and allows us to cope with potentially o Genes modestly contribute to anxiety hazardous circumstances. disorders, particularly when genetic factors interact with other important  Fear is a more intense emotion environmental influences (Bienvenu, experienced in response to a threatening Davydow, & Kendler, 2011). situation. o Serotonin, a neurotransmitter, is o In some cases, fear and anxiety implicated in both depressive and occur even when no danger is anxiety disorders. present. o A variation in the serotonin o Unfounded fear or anxiety that transporter gene (5-HTTLPR) has interferes with day-to-day been a focus of research, as it may functioning and produces influence vulnerability to anxiety clinically significant distress or disorders. life impairment is a sign of an anxiety disorder. PSYCHOLOGICAL DIMENSION THE MULTIPATH MODEL OF ANXIETY  An individual’s psychological DISORDERS characteristics can interact with biological predispositions to produce BIOLOGICAL DIMENSION anxiety symptoms.  For phobias and all anxiety disorders, it is  Negative appraisal (interpreting events, important to rule out possible medical or even ambiguous ones, as threatening) physical causes of anxiety symptoms, increases the likelihood of developing an such as: anxiety disorder. o Hyperthyroidism (overactive thyroid)  Anxiety sensitivity (a tendency to o Cardiac arrhythmias interpret physiological changes as signs of o Asthma medications danger) may make someone more o Stimulants (e.g., excessive vulnerable to anxiety symptoms (M. W. caffeine intake) Gallagher et al., 2013). o Withdrawal from alcohol (Yates,  Adaptive emotional regulation can help 2014) reduce anxiety symptoms. For instance:  o Reappraisal (minimizing negative o High levels of self-reported anxiety responses by looking at situations have been noted among Native from various perspectives) has Americans and Asian American been shown to reduce anxiety undergraduate students (De Coteau, symptoms (Miu, Vulturar, Chiş, Anderson, & Hope, 2006; Okazaki, Liu, Ungureanu, & Gross, 2013). Longworth, & Minn, 2002). o Individuals with a strong sense of o Exposure to discrimination and self-control and mastery tend to prejudice increases anxiety for have a reduced susceptibility to individuals from marginalized groups, anxiety (M. G. Gallagher, including ethnic minorities, people Naragon-Gainey, & Brown, 2014). with disabilities, and sexual minorities.  Psychological characteristics, such as negative thinking patterns and lack of o Culture can influence how anxiety is emotional regulation, can contribute to expressed: the vulnerability to anxiety disorders. o In the United States and SOCIAL AND SOCIOCULTURAL other Western countries, DIMENSIONS social anxiety is often linked to fear of embarrassment or  Daily environmental stress can produce self-presentation. anxiety, particularly in individuals who have biological or psychological o In some Asian countries, vulnerabilities. social anxiety may be more related to the fear of being offensive to others, including GENDER AND ANXIETY concerns such as: o Females are more likely to experience anxiety disorders than males.  Having an unpleasant odor o Women’s higher rates of emotional  Staring disorders may be attributed to: inappropriately  Displaying unusual o Lack of power and status facial expressions (S. o Stressors associated with F. Hofmann, poverty, lack of respect, and Asnaani, & Hinton, limited choices (Nolen- 2010) Hoeksema, 2004) o These social factors contribute to the production of stress hormones that may increase vulnerability to anxiety and depression. o The interaction of psychological, social, and biological factors may help explain why women are more likely to develop anxiety disorders. CULTURAL FACTORS AND ANXIETY o Acculturation conflicts contribute to anxiety disorders in ethnic minorities. TREATMENT OF ANXIETY DISORDERS o Gradually introduces the individual to the feared situation or object until the PHARMACOLOGICAL (BIOLOGICAL) fear dissipates. TREATMENTS SYSTEMATIC DESENSITIZATION: BENZODIAZEPINES o Combines exposure techniques (a class of antianxiety medication) with an additional response, such as o Efficacy: Shown evidence of relaxation. efficacy for Social Anxiety Disorder (SAD) and specific COGNITIVE RESTRUCTURING: phobias. o Common Examples: o Focuses on identifying and changing  Long-acting irrational or anxiety-arousing benzodiazepines (e.g., thoughts associated with the diazepam [Valium]) used phobia. for generalized anxiety and longer-term MODELING THERAPY: treatment needs. o Involves viewing another person’s o Side Effects: successful interactions with the  Dependence feared object or situation.  Withdrawal symptoms  Paradoxical reactions (e.g., increased talkativeness, excessive movement, hostility, rage) o Risks for Older Adults:  Increased risk of developing dementia  Increased risk of falls and fractures SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) o Efficacy: Often prescribed for chronic forms of anxiety due to fewer side effects than benzodiazepines. o Action:  Alter brain chemistry after the very first dose.  Requires 4 to 6 weeks to begin reducing symptoms. COGNITIVE-BEHAVIORAL TREATMENTS (CBT) EXPOSURE THERAPY: