Anxiety Disorders Overview PDF

So first, specific phobias, then panic disorder and agoraphobia, which are actually two separate disorders, although they often go together and it makes sense to sort of talk about them together. Then social anxiety disorder, and finally, generalized anxiety disorder. So, general issues, let's start...

So first, specific phobias, then panic disorder and agoraphobia, which are actually two separate disorders, although they often go together and it makes sense to sort of talk about them together. Then social anxiety disorder, and finally, generalized anxiety disorder. So, general issues, let's start there. First of all, there's some sort of terms that we need to be clear on that are not always, these definitions are not always adhered to or agreed upon in the field, but more or less, they are. So, these are the ones we should sort of work with. The idea of fear versus anxiety. So, we could define fear as an immediate alarm reaction triggered by a perceived danger. And when it does that, it basically is preparing the body for dealing with the danger by either basically running away or standing and fighting. So, you've heard of the fight or flight response, which we'll come back to in just a minute. Anxiety could be defined as apprehension about a future event. And so, again, you can think of the distinction sort of being immediate versus future. Although there are some disorders considered anxiety disorders where people are afraid of what's happening right now, for example, panic disorder, but they're also afraid of what will happen in the future, that they might die or or go crazy or have a heart attack or something like that. Other terms, true alarms and false alarms. So, true alarm is when the fear is in response to a direct danger. So, your body can have a fear response when it should be having one. So, if you're being chased by some kind of wild animal or if you've ever done something like skydiving, go jump out of the plane and your body will immediately do all sorts of things because it knows it's falling. So, if it's happening at the right point in time, then it's a true alarm. False alarm is basically when the same thing happens, but there's no direct threat. So, someone may have the same reaction as if they are being chased by an animal in the wild or falling from an airplane, but yet they're simply sitting in a classroom or on a job interview or trying to meet someone for the first time. And if you have that reaction in those other situations, it can obviously cause all kinds of problems. And it's these false alarms that are the hallmark of anxiety disorders, particularly according to probably the most well-known anxiety disorders researcher, David Barlow. So, yes, the false alarm. So, what's on this slide is also related to Barlow, his triple vulnerability model. The idea that people can have vulnerabilities to anxiety coming from different areas, so different types of vulnerabilities. So, you can have a biological vulnerability. So, for example, some people may inherit a predisposition toward anxiety. It may be something to do with neurotransmitters, maybe something genetic, a combination, who knows for sure, but some sort of biological vulnerability. Then there might be general or generalized psychological vulnerabilities. For example, the belief that the world is a dangerous place. If you either grew up in a place where it was quite dangerous and it left you with that sort of lasting belief, or through social learning, through family members telling you all sorts of stuff, if you grew up believing the world's a very dangerous place, then you may be more likely to develop fears of specific things, which is what anxiety disorders basically are. The third type of vulnerability, specific psychological vulnerability. So, someone might have, for example, a learning experience. It's noted there through conditioning or through classical learning, where perhaps they had a bad experience with an animal or something and ended up developing a phobia. So, the point is that those three things together, as illustrated in this figure, may lead to the development of an anxiety disorder. It's probably not enough just to have one. So, if someone had the specific learning experience, like a bad experience with a dog, but they didn't have any sort of biological or psychological vulnerability, they'd probably be less likely to develop a phobia than someone who did have those other vulnerabilities. So, just a few other things to sort of summarize about anxiety and fear, but also to make an important point. They both involve physiological arousal. So, your body's doing something in response to both of them. Typically, this is associated with the sympathetic nervous system. This is quite important. Both can be adaptive. So, anxiety in of itself is not a bad thing. This is something that you try to teach people who have problems with anxiety. They think the sheer fact that they're having this reaction means something is wrong with them. And it's not the case. Again, it's the issue of the false alarm, where it's the timing and the place that's the problem. So, in the right situation, these things may save someone's life. That's the whole point of the fight or flight sort of response. Another thing to keep in mind, and a lot of people don't realize this, is that some degree of anxiety actually increases performance. So, for example, if someone's going to do a test, if you have really, really bad anxiety, you probably wouldn't perform real well. But if you have absolutely none, just completely calm, you actually may do worse than someone who has some degree of anxiety because it sort of prepares the mind to deal with the challenge. And this is another thing you kind of tell people that are worried about having anxiety, that in some ways it can actually help you. This is just illustration of, you've heard of this before, I'm sure, in other classes, the fight or flight response, showing how your body is sort of preparing to deal with some sort of danger, breathing faster, release of adrenaline. And you could go through these and talk about how each one of them sort of makes someone better prepared to deal with the danger. Sweating, not only does it cool down the body, one can make an argument that if someone tried to grab you and you were sweating, you could slip away easier. So, again, all these things trying to prepare someone to deal with some sort of danger. But again, the point is, if this is happening when there is no danger, that's when we're talking about some sort of disorder. So, it's not the fact that you have anxiety, it's the fact that when it's either excessive and or appropriate. So, excessive just means that there may be a reason to have some anxiety, but the person has more than the situation calls for. Inappropriate would be when it doesn't even call for it at all. Again, it's like someone is sound asleep and they have a panic attack, or you're out with someone trying to have an intimate moment together and all of a sudden you have a panic attack. And again, it's just happening at an inappropriate time. So, it's when it's excessive and or inappropriate, that's when we consider it a disorder. What are the disorders? This table is from your text and it's those included in the anxiety disorders chapter of the DSM-5, which are the same as the ones in the 5TR. And that's pretty much the same for everything. So, I may not keep repeating that. This is a good little table as a review, sort of if you want to remind yourself of the essential features or the description of each disorder. There's a couple others that I'll mention, but they're more associated with children. We'll come back to them later. But again, I won't go through them in great detail here because this is sort of just a summary chapter. We're about to talk about each of them individually. This figure illustrates some changes in the DSM from the last version of the 4 to the 5. And as far as I'm aware, there's nothing different in the 5TR compared to what I have here. But the point is, going back in time, there used to be a larger group of disorders conceptualized and considered to be anxiety disorders. With the DSM-5, they moved some of them into their own category. So, obsessive compulsive disorder moved into its own chapter with some other related disorders. And post-traumatic stress disorder and acute stress disorder both moved into the trauma and stressor-related disorders chapter. The reason just to mention this is, I mean, sometimes you'll see data where they just refer to anxiety disorders and they might include OCD and PTSD. And clearly, those disorders are still related to anxiety. And some of the ideological theories are still somewhat similar. And we will talk about them close together. First, we'll go through the ones that are technically anxiety disorders still, which are the ones at the top right there. And then in the next week, we will talk about collectively, I think, OCD-related disorders and post-traumatic or trauma and stressor-related disorders. I did say there's a couple others that we won't really spend much time on now because you'll have a class later in the term specifically on childhood disorders. But the ones I'm referring to here, separation anxiety disorder and selective mutism. So, again, they are in the category, but we're not going to talk about them today because they're specific childhood disorders. I just said that. Okay. So, we've now gone through those general issues. Let's talk about the specific disorders. I'll talk about four different areas. First, a general description. So, what does these things look like? Diagnostic criteria, differential diagnosis, for example. Then we'll talk about epidemiology, which generally refers to things like prevalence, incidence, the sort of way these disorders are distributed in the population. Then we'll talk about aaetiology, a complicated word for causes, so what causes each disorder. And then we'll talk about treatment, at least what we know about treatment. So, we have to start somewhere. Let's start with the specific phobias. Used to be called the simple phobias, but they changed the name because they're really not, it sort of implied that they were just, it made them sound too non-problematic, just calling something simple. So, specific is a better name. Now, there are actually three disorders that have the word phobia in their names. I've mentioned specific phobias, and then there's a disorder that goes by two names, really, social phobia or social anxiety disorder, and then agoraphobia, which I've mentioned a couple of times. So, obviously, they all have a phobic component. But if you use the word phobia, if you say someone has a phobia, what that really typically means is you're referring to a specific phobia. So, just general description of specific phobias. They are characterized by a marked and consistent fear when specific object or situation is encountered. Marked basically means it's like visible to other people, it's obvious, other people can see it. I'll give you an example here shortly. Consistent, you know what that means, but in this context, it means that it happens all or most of the time when someone encounters it. It's not like it occasionally does it. It does it pretty much most of the time. It's got to be out of proportion to the danger posed by the object or situation, which isn't always easy to determine. In years past, this used to be worded as it's an irrational fear. And that's hard to determine too. So, they've gotten away from that wording. So, it's just really that it's excessive, which again, it's hard to determine because there are lots of objects or situations that should pose some degree of fear. Certain animals, you know, really high places that you could fall and kill yourself or something is dangerous. But it's when someone has a fear of an animal, either that's not dangerous or the fear is just much more than is appropriate for the particular animal. That's what we mean by out of proportion. And some people can't even go up a flight of stairs or climb up anywhere in terms of a height. So, that's what we mean by out of proportion. It also has to cause emotional, social, and or occupational disruption. In other words, it causes you problems. And again, an example I'll show you shortly, a woman talks about how it affects her ability, her life in numerous ways. So, it might be your job. So, for example, if you had a fear of flying and your job required you to fly, then you basically would either have to find another job or travel some other way. It could affect personal relationships where the fear just is a constant problem with a partner of some kind or family. And then just emotional, makes a person feel very, very bad, very upset when encountering the situation or the object. Yeah, as noted there, the feared object is either avoided or endured with intense anxiety. I mean, there are times when people, even people that might have a flying phobia might do it. They don't always avoid it, but while they're doing it, they're experiencing intense anxiety. Often, they may take medication just to help them cope with it or drink too much on the plane or something like that. Now, when we talk about intense anxiety, it's hard to describe that just in words. It's a little bit easier to show you. So, I'm going to show you a clip from a video that is part of your tutorial, which would be next week's tutorial. And I'll show you the entire or your tutor will show you the entire video next week, but I'm just going to show you a bit of it now to talk about the things we've already talked about. So, in that clip, you hopefully can see a couple things that I had already talked about. One, the intense anxiety. So, not just sort of going like, I don't really like snakes, just a real strong physical, emotional response. She also talked about, as I said earlier, about how it affected her. So, it affected her ability to all sorts of things. And because it did, and because of the intense fear, she would probably meet the criteria for specific phobia. Here are the criteria. And more or less, you don't need to memorize these, but they're good to have to look at some of the specific sorts of diagnostic issues. And a lot of this gets at what I've already talked about. So, criterion A, fear about a specific object or a situation. B, it almost always provokes it. So, again, it's something that's getting to the consistency. They either avoid it or they endure it. It's out of proportion. The one thing I hadn't talked about, it's an official criterion here, is how long does it have to go on? It has to be at least six months. So, if someone just reported a fear of something that just started, wouldn't necessarily meet these criteria. If it persisted, then it would be. And then F, it's got to cause them problems. And G, it's not explained by another mental disorder. Now, this is a sort of complicated issue that gets into what we refer to as differential diagnosis, where you're trying to say, which disorder is it? Is it specific phobia or is it another disorder? And one of them, for example, that I'll come back to in a little while would be something like agoraphobia, where someone might avoid the same thing as someone with a specific phobia, but for a different reason. So, some people avoid flying. They avoid airplanes. And the question is, why do they avoid it? And if they avoid it because they have sort of an irrational fear that it's going to crash and they're going to die, that would be more of a specific phobia. If they avoid it for some other reason, it could be a different disorder. And I'll come back to what those reasons are when we talk about agoraphobia. Also, panic disorder is relevant to that too. Now, still on the subject of specific phobias, at least in the DSM, there are five subtypes. These aren't necessarily scientifically derived, but they are there for just to be more specific. And it does allow us to study them. You can see they're a mixture of objects and situations. So, you got the animal subtype. So, it could be a dog or a snake or technically any animal, although there's a lot of animals that people just don't become phobic towards. Then you got the natural environment types where it could be heights, water, something like that. Blood injection injury. This is the person who, two things really, typically they have a different reaction to the feared object than someone would to other types of phobia. So, what I mean by that is instead of their blood pressure going up, it typically goes down and they might pass out. So, some people pass out at the sight of blood or even giving blood, but that in and of itself is not a phobia because if it doesn't affect you and you still do it and it doesn't cause you impairment, then it would be a reaction that you have, but not necessarily a phobia. Like if I go give blood, I have to lay down or I'll pass out and I'm not exactly sure why, but I don't consider that a phobia. But if the person did, then avoid going to the doctor, avoid medical procedures, avoid all sorts of stuff, then it could meet the criteria for that subtype. Then the other subtype, situational, where it could be things like airplanes and closed spaces and other kinds of examples. This is just a little table that elaborates on what I just said, the different types of specific phobias. And if we did want to sort of study them scientifically and say, are these typologies valid? Remember what it means for something to be valid. Then the distinction is probably most valid is the distinction between the blood injection injury subtype and all the other subtypes. Because as I said, there's something very different that happens associated with that one where people's physiological responses are quite different. It notes there it may run in families. There is some evidence that some of the other ones run in families too, though. So, not sure how necessarily critical that is. Now, it's also worth noting, I mentioned the four subtypes in the previous slide. There's an other category, sort of a residual category. So, if someone has a phobia, but it's not of an animal, natural environment, blood injection, situational, you can still put them into the other category. And there are quite a few things that would fall in there. The interesting one is noted there is like clowns or costumed characters. I mean, obviously, when you got movies like It going around that there are people that are sort of concerned about clowns. But there are particularly kids I've seen that have this extremely strong fear reaction to costume characters and to the point where it really affects them. So, for example, you go to a birthday party and all the kids are inside, except one kid's afraid to come in and he's outside hiding behind a tree. Why is that? Well, it's because there's a clown in the house. And so, in the kids context, that is social impairment or they might not even go. And I mean, I've seen kids shaking physically when encountering a costumed character, even though you tell them it's just a person in there. So, that would be an example of a phobia that doesn't fall into the four categories. It would just be other. So, I've talked, that's the general description about specific phobias, epidemiology. This is actually a table from a study in Australia. And notice at the top, it refers to 12-month anxiety disorders, prevalence of 12-month anxiety disorders, anxiety disorders by type and sex. So, first of all, keep in mind that it has some things in there that are no longer considered anxiety disorders. And also, phobias aren't in there. So, we can't even use this study to tell us a whole lot about the prevalence of specific phobias, social phobias in there. And we'll come back to that one in a few minutes. So, come back to this table. So, we do have some data regarding epidemiology of specific phobias. Lifetime prevalence, at least in the US, estimated to be around 12%, which is quite high. So, that makes it one of the most common psychological disorders that there is. Your textbook refers to there being 7% to 9% lifetime prevalence, but I looked that one up, and that should actually be 12-month prevalence. So, keep in mind that prevalence rates are going to differ depending on how they're reported. So, 12-month prevalence means the percentage of people that have a disorder during a 12-month period of time. Lifetime prevalence would be the percentage they have across their entire lifetime. So, lifetime is going to be higher. And again, this makes phobias probably one of the most common psychological disorders that there are. However, as I mentioned regarding the previous slide, we don't have clear data regarding the prevalence in Australia. I would imagine it's fairly similar to the US numbers, but we can't say with certainty. Probably female to male ratio around 2 to 1, which is something you see for several of the anxiety and anxiety-related disorders. Most of these begin in childhood and early adolescence. Some of them grow out of them, and they still have them long enough to actually be considered a phobia. But because they grow out of them, the prevalence of phobias is greater among children than adults, but they do persist. And I'm pretty sure the 12 percent above was based on adults. So, even among adults, it's a fairly common disorder. The prevalence rates would probably be higher if we limited them just to kids. In fact, I know they would be higher. Another interesting thing about phobias is that people rarely seek treatment. So, even though it causes them problems, either they think it's normal or they just don't want to face the fear. And they often know that going to treatment would involve facing your fear. I mean, there's not like a magic pill or you can't wave a magic wand and make it go away. The most effective treatments, which I'll get to shortly, are really exposure. So, a lot of people just don't want to do that. Or they may go into treatment for something else. Like, often phobias are often comorbid with other disorders. So, someone might come into treatment for panic disorder, agoraphobia, whatever. And you might learn during the course of working with them, they also have phobias. And you might get around to treating them, you might not. But they often wouldn't come in for that particular reason. So, we've talked about the general description, epidemiology. Let's talk about aetiology or causes of phobias. So, there are many theories of aetiology of specific phobias, and we can't talk about all of them. We'll talk about the ones that seem to have the most evidence base and the ones sort of accepted by the field. There is some degree of evidence that there's a heritable component. In other words, something's genetic. And I mentioned earlier with regards to the blood injection phobia subtype, but I've looked at the data, and there appear to be actually a similar heritable component for other subtypes of phobias too. So, in other words, you may be inheriting a predisposition to develop a specific phobia. Conditioning learning plays a role. So, here we're talking about really two things. We're talking about classical learning and operant learning. If you remember in last week's class, well, associated with chapter one, we talked about both types of learning, both classical and operant learning. And there's a theory that is quite influential in terms of explaining anxiety disorders and other kinds of problems. That's called two-factor theory, Maurer's two-factor theory. And the two factors are basically classical learning and operant learning. So, as noted there on the slide, the idea is that the fear is acquired through classical learning, but then it's maintained through operant learning, specifically negative reinforcement. Remember last week I talked a lot about the importance of negative reinforcement in terms of its relation to psychopathology. So, specifically regarding a phobia, someone might have a bad experience with dogs, for example, then they develop this fear of dogs. And then you say, well, why doesn't it go away when they're around safe dogs? And if you think, if you go back to Pavlov's research, which was actually with dogs, but in a different context, the idea that if you expose them to ringing the bell after you had already conditioned them to have a salivation response to ringing the bell, if you just expose them to the bell without exposing them to food, it would gradually, the response would go away. That's called classical extinction. But you have to actually expose them to it. If they avoid the exposure, then extinction will never occur. And that's the idea of the operant side of things. There's two things happening. One, if they avoid whatever it is they're afraid of, in this case, we're talking about dogs, then extinction never occurs. And the avoidance behavior gets reinforced because their fear goes away when they get away from the dog or whatever it is they're afraid of. So, again, it's this combination of classical and operant learning that is viewed as being one of the major theories of the aetiology of specific phobias. Has a couple of problems though. The second part of it, there's probably more empirical support for that, the operant side of things. Regarding the classical learning part of it, a lot of people will tell you that they've actually never had an initial learning experience. So, people who are dog phobics may say they've always been this way. Same with snakes. It's not like they had some bad encounter with a snake when they were not fearful prior to it. They'll say they've always been this way. So, that's one particular problem with the theory. It doesn't mean they never do. I'll show you some data in just a minute where it depends on the type of fear we're talking about, how common it is to not have a learning experience. But it's certainly not the case that all people report having had a conditioning experience for phobias. It's also interesting that people with phobias tend to develop fears for only certain types of objects, even though there's other things that are perhaps more dangerous. They tend to develop fears for things that sort of, from an evolutionary standpoint, might be more dangerous. So, dangerous animals, snakes, insects, blood, heights. Whereas technology has come up with a whole lot of things that are quite dangerous. Like, I once stuck, when I was a kid, a fork into an electrical outlet and electrocuted myself. But you don't hear people developing phobias of that, even though it's quite dangerous. So, the idea of this is that there's some sort of, this is sort of an evolutionary theory, there's some sort of prepared learning that we inherit. And it makes it more likely that you'll develop fears of certain things than other things. There's even interesting research showing that if you look at social learning, we mentioned this last week, how you can learn to be afraid of something from seeing other people showing that fear. And even animals can show this response sometimes. So, as noted there, monkeys, if they see other monkeys showing fear toward an object, these other monkeys who've never seen the object might develop a fear of it, but only under certain circumstances. So, if you do this sort of thing, you could show monkeys developing a fear of snakes, but not to a flower. So, you'd have to use some sort of CG or something where it looked like monkeys were afraid of flowers, and then show them to other monkeys, and the other monkeys would just not develop the fear. It's like somehow they're hardwired to also be more likely to develop a fear to something that really is dangerous, and not to something that can't be dangerous. Here's just the table I was talking about with some data on the percentage of people reporting that they do or do not have experience with something before the onset of it. So, if you look out to the right, it's probably the most interesting column, no memory conditioning experience at all. And not everything in this table is a specific phobia. It's got agoraphobia and social phobia in there, too. But animal situational and blood injection are in there. And, I mean, there's still 30-some-odd percent report no memory. So, that means close to 70 percent did report a memory. But still, that's a large number, the 30-some-odd percent. And they're even larger for the other disorders, agoraphobia and social phobia, social anxiety disorder. So, it's still the learning perspective, keeping in mind that there's probably a prepared side of things is still a pretty prevalent theory, but it doesn't explain everything. Treatment, a lot of things have been tried. The treatments that seem to work the best are basically exposure-based treatments. This is one of my favorite cartoons. They left out enclosed spaces, too, simultaneously confronting fear of heights, snakes, and the dark. So, as I said, exposure-based treatments are probably most effective for specific phobias. Here, we're talking primarily about in vivo exposure, live exposure, where you do it in person. Although, sometimes imaginal exposure can be done either by itself or prior to doing in vivo exposure. And as I think I said, you'll have a whole tutorial about this next week about treatment of phobias, and you'll see exposure in action, the same video we saw before. But we'll see her get to where she started to get to being able to do all the things that she was able to do. You also saw in the video, you'll see how it happens. And why it happens is the question that we don't completely know the answer to. And you'll talk about this a bit in your tutorial. And there's a reading that I've made available that's not required, but it's optional. And it's a pretty deep reading, but it's a helpful thing if you're really interested in learning more about this. They may work through extinction. That's the idea originally. You remember learning about classical learning with Pavlov and Pavlov's dogs, and you could reach classical extinction by presenting the conditioned stimulus in the absence of the unconditioned stimulus. And it seems to be consistent with that, but there could be other mechanisms at work. Like it could be more of a cognitive issue where people sort of learn to challenge their expectations of danger and their self-efficacy may be involved. There's a whole lot of different possible explanations for it. And again, the tutorial, but also that reading will help go through some of those. And that's all I'm going to say for now about specific phobias. We're going to move on now to panic disorder and agoraphobia, which, as I've already said, are two different disorders, but they make sense to talk about them together. So, I'm going to do that. And again, we'll talk about these different types of information. So, let's talk about the general description of panic disorder and agoraphobia. So, I'm going to talk about panic disorder first. And the key feature here is frequent panic attacks unrelated to specific situations. Now, the unrelated part is actually important. And I'll come back to that later. But the point is, if they were related to specific situations, then we'd be probably talking about phobias because people who have phobias may also panic when confronted with a phobia. But here, we're talking about panic attacks that are not related to a specific trigger situation. So, I'll come back to that in a minute. But the important part of this slide is what is a panic attack? So, what is a panic attack? Well, it's, as noted there, sudden, intense episode of panic. And what is panic? Apprehension, terror, feelings of impending doom. A lot of ways you could try to describe it. But what's important here is that it's sudden and it's intense. So, it's not like someone just says they're anxious all the time or someone says they're panicking, but yet they're not really feeling anything. I mean, that's not what we're talking about with panic attack. We're talking about something that is sudden and very intense. As noted there, symptoms probably reaching peak intensity quickly, like within 10 minutes. It might be more like within a minute. But not, again, something that just lasts over a period of hours. Like you can't really have a panic attack for hours because your body can't keep it up. We're talking about your sympathetic nervous system kicking in. And after a certain period of time, the parasympathetic will basically bring it back down. So, it's an intense reaction that is typically fairly brief. During that, you have to have a group of symptoms. It might be a lot of what's listed there, which are basically symptoms of anxiety. So, sweating, nausea, difficulty breathing, dizziness, heart palpitations, lightheadedness. And what's important to realize is that a lot of those symptoms are actually frightening in and of themselves. So, heart palpitations, people might think they're having a heart attack. There's other ones that you might have. I'll show you the full criteria in just a minute. So, they're having symptoms of anxiety, and then often they get worried about the symptoms of anxiety. They may also have some other cognitive kinds of symptoms, particularly the ones listed there. These are terms I don't think we've encountered yet, and we will see them in other disorders too, but I'll briefly define them here. Depersonalization, this is when the perception of the self seems to be changed or abnormal in some kind of way. Like your body may seem different. You might look down and your feet look really small, or your body may feel as if you're not real. Some cases, having a sort of out-of-body experience, looking back at the body, is an extreme example of depersonalization. Derealization is similar, but it's more referring to your surroundings. So, when your surroundings seem unreal, that would be derealization. And so, sometimes people experience those during episodes of panic. They also may have the specific fears that I have listed there below. So, these aren't fears associated with a phobia. These are fears of something else. So, going crazy, losing control, or dying. So, again, if they think they're having a heart attack or a stroke or something, that would be why they would feel a fear that they're going to die. This just goes along with the idea of a panic attack. Here's some data just illustrating how the body responds associated with a panic attack. So, this is actually had people hooked up to a variety of psychophysiological equipment and showing that during a panic attack, you can see how quickly this person's heart rate goes up and then also comes back down relatively quickly. EMG, just another measure, another physiological measure of anxiety, same sort of thing, goes up from a relatively low level to a very high level and then comes back in a relatively short period of time. Now, this isn't to say that the person's baseline level may be somewhat elevated. It may be that people that have panic disorder also have sort of baseline levels of anxiety that are higher than people who don't have panic disorder. But the panic attack itself, again, is a dramatic increase in the level of anxiety that the person is feeling. Now, if I can find a way to include this video into the video, into the recording, I will. It's just a brief illustration. If we were having this in class, I would just show it to you. If I am not able to do it, then there'll be nothing else here. The first time it happened to me, I was driving down the highway and I had a kind of a knot in my chest. It felt like I had swallowed something and it got stuck. And it lasted pretty much overnight and it was really starting to upset me. And then all of a sudden, I felt like I was having a heart attack. I mean, I don't know what a heart attack feels like, but I assume that's what was happening because of all the signs. I felt lightheaded. I felt very panicky. A flushed feeling came over my whole body. I felt as though I was going to pass out. So, that's typically how it was. Okay, let's get a little bit more details about exactly what sensations occur in one of those attacks. Did you feel short of breath, for example? Not too short of breath, but somewhat, yeah. I wasn't breathing as though I couldn't breathe. I mean, it was more of a feeling like I thought I was just going to pass out. That's how I felt. Did you feel like you needed to get some air? I did. I stopped. I pulled off the side of the road. I got out of the truck. I walked around. My girlfriend was with me and she had no idea what was going on. I mean, I just stopped on the side of the highway and just walked out, got out of the truck and walked around. Did you break out in a sweat? I was feeling kind of nauseous and sweaty. No idea what was going on. Did you notice anything about your heart? Was your heart pounding or racing? Not excessively, no. I really didn't feel that, even though it could have been occurring. That wasn't one of the symptoms that stuck out for me. What did it feel like in terms of psychological symptoms? Did you feel afraid? Oh, I was definitely afraid. I think that's the worst part of it, is not knowing what is happening to you and assuming the worst. I mean, you think all kinds of thoughts about what's, you know, I've got something definitely wrong here and I assumed it was a heart attack. So we did. We went to an emergency room and I got checked out for a heart attack and they assumed that I was, but everything came back negative. Now, I said I would come back to this because this is quite important that what distinguishes panic disorder from like specific phobias that we already talked about and some other disorders that we'll be talking about is that these people have uncued attacks. What uncued means is that the panic comes on without any expectation, without warning. So a person could be just minding their own business, sitting at home and all of a sudden they have a panic attack. It's the presence of these kinds of attacks that really is unique to panic disorder. And they have to have either recurrent attacks or at least fear about having additional ones after they've had them. They may also have cued attacks, which means you're going to have it when it's triggered by a specific situation. But if that's all you have, then that would not be meeting the criteria for panic disorder. That would be most likely a phobia. Or if it's related to something else, PTSD for example, people might have a panic attack when they're reminded of something traumatic. There's a lot of other examples. But the key here again is that sort of not connected to an obvious trigger. Another phrase that used to be used or sometimes still is, is they seem to come out of the blue. Even sometimes while people are asleep. Here are the official criteria. Again, you don't have to memorize them, but they're good to sort of talk through and note it there at the beginning, recurrent, unexpected panic attacks. So something they're not expecting. And you can notice all the up to really number 10, those are all pretty much physiological symptoms of anxiety. And again, they may in themselves be frightening. So choking, paresthesia is number 10, numbness and tingling sensation. So they may feel like they're having a stroke, some sort of neurological kind of problem, even though they're not. And then again, the ones there toward the end, the ones we already talked about, the dissociation, depersonalization, derealization, and the cognitive sorts of symptoms. Now, lots of people actually have panic attacks that don't go on to develop panic disorder. To be considered panic disorder, you have to have a couple other things which are noted here. So basically, after a person's had one or more, it has to affect them in one or more ways. So either they start having persistent concern or worry about having additional panic attacks, or it affects their behavior and that they start changing their behavior to try to avoid having them in some problematic kinds of ways. Now, I'll show you a clip of the same guy talking about how his behavior began to change after having his first attacks. Just to note there, a couple other criteria, similar to what we saw for panic disorder, excuse me, for specific phobias, there's that last one that doesn't, it's not better explained by another mental disorder, which could include a whole bunch of different ones. And there's a new one there that I don't think we saw with specific phobias that it's not attributable to the physiological effects of a substance. So it's not caused purely by some sort of drug or medication that someone's taking or a medical condition. So there are certain medical conditions that could mimic panic disorder, like hyperthyroidism, that sort of thing. So let me show you the other clip here. There were days where I would have a number of them in a single day, and they would come on me sporadically. I had no idea when it would occur. I could be driving down the road. I was on the highway a number of times, and these attacks would hit. And it's so scary because I always felt as though I was going to pass out. That was my worst fear, and run off the road, kill somebody, kill myself. But it was funny, after talking to my mother about it, she said, well, you haven't passed out. And that stuck in my mind. Well, she's right there, you know. So I don't need to fear it as much as I had been. And so I learned to kind of get through it, even though it was a very frightening experience every time. Did you ever have one at night that woke you up out of sleep? I did have some episodes where I would wake up with that feeling in my chest, although it wasn't the flushed kind of a feeling, which would typically make me feel as though I was going to pass out. That rushed feeling coming up through my body. But I did have instances where it would wake me up. Just wake you up out of a dead sleep? Out of a sleep. I would wake up with the chest. Is there anything that you could do or not do that would make these attacks more or less frequent? You know, it was kind of strange. When I first started having these, I was working at a fairly physically strenuous job. And as long as I was keeping busy and working out hard, I didn't notice them that much. But the minute I'd stop and we'd take a break or whatever, I'd start having those feelings again. But as long as I was physically active, I didn't really notice them. Once you'd had these for a while, did you begin to worry about them, worry about when you were going to have the next one? Oh, yeah. Oh, yeah. That was a definite concern. I tend to stay away from crowded places. I tend to not go out. I've never had a fear of heights or a fear of closed-in places or any type of phobias like that. But it's funny that now I do have a problem with heights. Now, I've said that these disorders are technically different, but they often go together. And so that's why I'm talking about them together. So if someone has panic disorder with agoraphobia, that's referring to basically a lot of avoidance. So it's avoidance of situations in which escape would be difficult or embarrassing. And you might say escape from what? Well, it's basically escape in case someone had to have or in case someone had a panic attack. So that's why they often go together. People often with panic disorder will also have agoraphobia because they'll start avoiding places where they might have an attack. And it could be a lot of different kinds of situations. I'll give you a list here in a minute. But you could avoid either because it would be difficult, like an airplane, for example, or embarrassing like a classroom. So if you had to get up and run out of the class, then that might be embarrassing. So that's the general definition of agoraphobia. And just some other things there in those other bullet points, that panic disorder with agoraphobia tends to be more chronic than panic disorder without agoraphobia. And as I said, this and FIRE, they have moved it to a separate disorder. You can, in theory, be diagnosed with agoraphobia without panic disorder, which means someone's never really had panic attacks and they may avoid all these situations for some other reason. And there are cases like that. But again, more often than not, it seems that they go together. And that's why talking about them this way, it seems to make sense. I said I'd give you a list earlier. Here it is. Typical situations avoided by people with agoraphobia. And again, you can see what they have in common. They're all situations that if you were there, it would be hard to escape or it'd be embarrassing to escape. So people will talk about, sometimes people misunderstand agoraphobia and they talk about it as being the opposite of claustrophobia. I've heard that before, where agoraphobia is the fear of wide open spaces. And notice that it is in there, is one of those is wide open spaces, but right next to it is closed in spaces. So someone can actually have agoraphobia and have what appears to be claustrophobia. Now, remember even earlier, I was talking about when we were talking about phobias, that someone may have the same behavior, but it may be a different disorder depending on why they're doing what they're doing. So notice that airplanes is in this list. And remember I said someone could have a specific phobia associated with flying, and it could be for a variety of reasons. If it was more related to the fear of the plane crashing, then it might be more of a specific phobia. But if it was the fear of having a panic attack and not being able to escape, then that would really be agoraphobia. So again, the point in trying to understand these things is not just to think about what someone fears and avoids, but why do they avoid it? Like what specifically is it about it that makes them want to avoid it? And it may point to the fear being related to agoraphobia as opposed to a specific phobia or something else. It could be other reasons why someone would avoid anything, including things like airplanes. Here are the official criteria for agoraphobia. They used to just define it in terms of that general definition of avoidance of places where escape might be difficult or embarrassing. Now they've tried to define it a little bit more clearly. And I'm not sure that that really helps, but you can see what the criteria are. So people have fear, anxiety, at least two of the areas. So using transportation, being in open spaces, enclosed spaces, standing in line, being outside. They may have a bunch of other ones, but they have to have at least two or more of these to meet the criteria for agoraphobia. And again, the B one is getting at why do they avoid these things, or at least why they're afraid. Fear avoids because of thoughts that escape might be difficult if help was not available, or there may be, like it might be embarrassing. So this is their attempt to sort of systematically list the criteria that I just gave you the more general definition earlier. C and D, it's just got to always provoke the fear. And, or excuse me, C is always, and D, these things are actively avoided. Or this is kind of interesting, require the presence of a companion or are endured with intense anxiety. So someone can force themself to do these things, but if they still feel tremendous fear, it would still meet the criteria. And then the presence of a companion is quite interesting. The idea that sometimes these people have like a safe person, that as long as they're with them, they may feel safe doing these things. But if the person's not there, then the person with agoraphobia couldn't do it. And so you might be working with somebody and they have to have that safe person come to therapy with them, at least at the beginning. There are actually more criteria here, and this is just specifying a few other things. So it's got to be out of proportion, the actual danger. So, you know, there might be some situation where a lot of people would want to avoid it, but this has to be worse than that. It does have a time limit, so it's got to be at least six months or more, and it has to cause the person significant distress or impairment. Typically, agoraphobia can cause people a lot of distress or a lot of impairment, like they might be completely unable to function. The H criterion is just related to what if they have a real reason why they want to avoid, for example, crowds or something like that. So what if they have IBD, or you could come up with other sorts of things. Well, it just has to be excessive beyond what would be considered reasonable, and that takes quite a bit of judgment. But the point is, if someone had a real reason, you wouldn't automatically say, well, then we're not going to diagnose agoraphobia. But you also wouldn't ignore that reason. You'd try to make clear in your own mind, is there really both going on? And then also the last one, most disorders, we've seen it already with phobias, it's not better explained by something else. And we've already been talking about this, like is it a specific phobia or is it agoraphobia or is it something else? So the idea there is to make sure that it's this disorder, not something else. So we've talked about the general description. What about epidemiology? So here's the same study I showed you earlier. You can see panic disorder and agoraphobia in terms of 12-month prevalence, 2.6, 2.8. So not the highest, not the lowest either. And these are separated, so it's kind of hard to say what percentage have both. Here are some data. Panic disorder, somewhere around 3.5 percent. That's lifetime prevalence for agoraphobia, a little bit lower. So you can see that not everyone with panic disorder also has agoraphobia. So they go together often, but not always. Both disorders more common among women. And the gender difference increases basically as the severity of the agoraphobia increases. So if you were to find a subset of people with severe agoraphobia, they'd be much more likely to be women than men. Just some other epidemiological data, often begins adolescence. As I said before, it can be quite debilitating. So you might have like a quarter of them unemployed for a very long time, up to five years because of the symptoms of the disorder. The agoraphobia is more debilitating. That's why I noted there prognosis is worse if agoraphobia is present. So in terms of aetiology, which again means causes, as with the other disorders, at least some of them that we are talking about, you can think in terms of the triple vulnerability model. So you have a generalized biological vulnerability, which could be something like biologically based proneness towards anxiety, a generalized psychological vulnerability, which in this case might be something like anxiety sensitivity, and something specific, which would be something like catastrophizing physical sensations. It might look like this in a figure, just showing how those three vulnerabilities interact, and also shows that sort of feedback from the panic attack to the psychological vulnerability. In other words, having panic attacks might make people more sensitive to anxiety. Exactly what anxiety sensitivity means, I'll talk about in just a minute. One of them is the idea of interceptive conditioning. Interceptive refers to things that are like internal states and feelings. So it could refer to a lot of things, but with regard to panic disorder, we're talking about all the physical sensations associated with panic. Remember, some of them are like diagnostic criteria, but it could be, for example, the heart palpitations or numbness and tingling in someone's extremities, or many of the things on the list. So once someone has those sensations and then have a panic attack, those sensations can become basically conditioned stimuli for having another attack. So that's sort of the role of classical conditioning. And apparently, some research showing that people with panic disorder can sustain classically conditioned fears longer. So they may have these classically conditioned reactions to those physiological sensations, the interceptive cues, and it may take longer for them to basically unlearn them. So another important factor is basically the sort of cognitive mechanism. Remember, we talked in, I guess it was last week or week two, week one or two, the cognitive mechanism, the idea that people are affected not by events, but how they interpret events. And so that's quite important with regards to panic disorder. The idea that people have these sensations, physiological sensations that we were talking about in the previous slide, and many people basically would just say it's nothing. They dismiss it. Whereas people with problems with panic basically interpret them as meaning something really bad. So interpreting it as impending doom, something really bad is going to happen because of the way I'm feeling. It could be something specific. I must be having a heart attack or I might be having a stroke, or sometimes it's just more vague. Something terrible is going to happen. I'm not sure what it is. But then when you have these feelings, it increases the anxiety and arousal, and you get in this sort of vicious cycle. Sort of illustrated here, something could just be an innocuous situation could be happening and person just starts to feel unusual, dizziness or any of the things that I've been talking about before. And instead of going, it's nothing, or I'm tired or had a long day, there's something wrong. Maybe I'll panic. Maybe I'm going to have a heart attack. Maybe I'm going to have whatever. And it makes the person more anxious. And then because they become more anxious, and these are actually signs of anxiety, they begin to increase the severity of those symptoms. And again, they get in this cycle where more symptoms, more fearful reaction, more fearful reaction, more symptoms. And as different as some people with panic disorder may be, they all seem to report something along the lines of what I'm describing here, where they detect the symptoms, then they have that reaction of, oh no, here we go again, something bad's going to happen. And then the symptoms get worse and the fears get worse. And again, it's that vicious cycle. I've mentioned anxiety, sensitivity. This is just, I think it's somewhere in your text. If not, you have it right here. Sort of a trait-like phenomenon associated with being very sensitive to anxiety. So, these are from a test where questions such as unusual body sensations scare me. When I notice my heart is beating rapidly, I worry that I might have a heart attack. It scares me when I feel faint. So, a lot of people just say no to these things. They don't scare them. Some people like unusual bodily sensations. I mean, why do people go on roller coasters and watch scary movies and things like that? They actually enjoy feeling very scared. And again, some people seek that out, or I've mentioned skydiving earlier, or obviously some people do drugs to try to get these sensations. But there are other people who just do not like these sensations. So, they avoid things that will trigger them. And when they do experience them, they may panic in response to experiencing them. And talking about agoraphobia, remember that it's often linked to panic disorder. And so, one of the main ideological theories associated with agoraphobia does link it to panic disorder, which of course doesn't explain cases of agoraphobia that are not in the context of panic disorder. But at least they explain many of the cases. And I've mentioned Maurer's two-factor theory before, mentioned in the context of phobias. So, here we see it again. In this case, the original conditioning sort of experience may be the panic attack itself. But we've talked about it being associated with internal cues. That's that interoceptive conditioning. It can also be associated with external stimuli. So, even though the panic itself may come out of the blue, if you're in a mall at the time that it happens, then you may associate the panic with being in the mall or being in an airplane, public transportation, whatever. So, you may have had these panic attacks in those situations. Then there's also the cognitive sort of mechanism of just choosing to avoid places where it would be difficult to escape, potentially embarrassing. And then if people do avoid these things, remember two-factor theory, as the name implies, has two factors. So, what I've just talked about is really the first factor. Second factor, remember what that is, is a negative reinforcement. So, people avoid, let's say, again, you had a panic attack in a shopping mall. Now, you leave the mall and you feel better. And that avoidance behavior, that leaving the mall gets negatively reinforced. And then someone says, you want to go to the mall next week? And you say, no. So, that's avoidance also. And you're basically avoiding fear, which is also negatively reinforced. The problem with all that is that person, for example, the person who leaves the mall believes that their anxiety went away because they left the mall. If they actually stayed in the mall, their anxiety might also come down. And that's why treatments involve taking people to malls or things like that. But anyways, that's Maurer's two-factor theory in action with regards to agoraphobia. As I said, it doesn't explain everything. Like, it doesn't explain cases where people do not seem to have panic attacks. And there may be some more of a trait-like predisposition for agoraphobia that is playing more of a role there. Oh, I forgot to add, because of, this is another learning-based sort of thing, stimulus generalization. Remember when you've had a classically conditioned reaction and then you can have the same reaction to things similar to it. I mean, go all the way back to the little Albert study where they allegedly conditioned him to be afraid of a white rat. And then they argued it generalized to other things, including like a Santa Claus mask. And regardless of what you think about the little Albert study, there's plenty of research with classical learning showing that, yes, stimulus generalization does occur. So, if stimulus generalization occurs for people with these sort of agoraphobic fears, you can see how they would spread. So, someone had a panic attack in a mall, then it sort of generalizes to all similar places where there's a lot of people. If they had one in a bus, it might generalize to other types of public transportation. And so, you can see how people gradually become fearful of more and more situations. And sometimes people with agoraphobia end up housebound, where they basically avoid everything except being in their house. So, that's all I'm going to say for now in terms of aetiology. I mean, there's a few other things in your text, but I've tried to hit some of the highlights. Treatment, talk a little bit separately, panic disorder, followed by agoraphobia. There are medications people use. If you were to go see just a GP or a psychiatrist, they might put you on some kind of anti-anxiety medication. They, particularly the ones, the anxiolytics like Valium or something like that, I mean, they're quick-acting. The problem is people can become quite dependent upon them. And you stop taking them and the problems often come back. There are some other medications like antidepressants that seem to work a little bit better in the sense that people at least don't get as dependent upon them. But still, you stop taking them and often the problems come back. Psychoeducation is quite important. For some people, this is all they really need. Psychoeducation is often part of cognitive behavioral approaches. I'll give you some more details in just a minute. But for some people, again, that's all they really need. So, it basically means educating them about why are they having this problem and educating the anxiety. Some of the things I was talking about earlier in the lecture, that anxiety is not a bad thing. These are false alarms. You're not dying. You're not having a heart attack. And this is assuming the person has actually been checked out by a physician. But giving them realistic feedback about what's happening can be very useful. Then there are variants of cognitive behavior therapy that are used with both panic disorder and agoraphobia. As noted there, including graded exposure to feared situations or feared stimuli might be a better word because the question you should ask yourself is, what do you expose people to if they have panic disorder? I mean, if someone is a snake phobic, you expose them to snakes. If they're fear of heights, then you know what to expose them to. But what about with people that have panic attacks? I will answer that question. But first, here's just a little more I said I would show you about psychoeducation. This is in your text. And there's nothing magical here. It's more or less the same information that I was giving you earlier and just how you might explain it to a person if you're working with someone with panic disorder. So, you know, I was talking about the false alarm. Some alarms are false alarms. You may have seen a shop alarm go off, although you weren't trying to steal anything, the alarm still reacts as though you're a burglar. The problem is that the alarm is too sensitive. In the same way, anxiety problems start when the fight or flight response is too sensitive. When the alarm is too sensitive, the fight or flight response is triggered at the wrong times. If your anxiety alarm goes off too easily, you'll be more likely to become anxious in situations where other people would not feel anxious. So that's just part of it. I mean, that's talking about the sensitivity issue and the false alarm. There's a lot more you can get into depending on the person's level of knowledge about the sympathetic, parasympathetic system. And you can see that's from a clinical psychology for trainees. So this would be something that clinical psychology students are sort of taught to teach people while they're working with someone with panic disorder. Now, what I was getting at a couple of slides ago was the question of what do you expose people to if their fear is basically fear itself? I mean, that's one of the names for panic disorder and or agoraphobia, fear of fear. They're actually afraid of the panic attack or they're afraid of the symptoms associated with it. Remember all those interoceptive cues. So a while back, Barlow, again, notice we keep coming back to him in the context of anxiety disorders, along with someone named Michelle Krask, came up with something called panic control therapy, which is basically based on the logic of let's expose people with panic disorder to the very things that they're afraid of, which are basically all those physiological sensations. So what you do is you basically, there's a whole list of things that you can do to try to get someone to experience the very symptoms that lead them to have panic attacks. So it could be all these things, increased heart rate, rapid breathing, dizziness. And so how do you come up with those things? Like you can get people to hyperventilate, you can get people to exercise in the room with you, spin around in the chair to create dizziness. To get that feeling, if you can't get air, one of my favorites was breathing through a straw. So like take a straw and cover up your nose and then breathe through the straw and you feel like you can't get enough air. And it's, you know, it's a sort of frightening sort of feeling, but that's what people with panic disorder sometimes feel like. And there's a whole list of these things, including some things that might not be quite obvious, like staring at a spot on the wall to sort of induce derealization. Or again, you can pick the physiological sensation, you can come up with an exercise to try to induce it. So you do that to try to basically desensitize people to those cues. And you often do this in combination with strategies to control their symptoms. That's the other part I have up there. So you teach them relaxation skills, you teach them deep breathing exercises to, these are basically to manage their anxiety, but to really desensitize them to these things. It involves exposure to those very cues that trigger the panic attack. And this is something that's believed to be one of the most effective treatments for panic disorder, where the benefits seem to be maintained, at least for a sizable number of people after treatment ends. This is considered a variant of cognitive behavior therapy. I just have this on a different slide. I think your text talks about it, perhaps slightly different context. But there's a more traditional cognitive behavior therapy, where you basically are focusing on people's interpretations associated with those physical sensations. So remember the idea that they have a sensation and they start having these thoughts of, oh no, I'm going to die, and all these sort of catastrophic thoughts. So the point here is to identify and challenge those sensations. And you might do it along with the exposure to the physiological sensations, or you might not, depending on exactly what you were trying to do. But as noted there, the person's trying to identify and challenge and change their maladaptive cognitions, beliefs, thoughts, all that sort of constructs. You can also, so at this point, I've been mainly talking about panic disorder, but this sort of approach is also useful for agoraphobia. The point here, though, is that what you're exposing people to is often the external cue. So if someone's avoiding the shopping mall, for example, you get them back to the mall. They're avoiding public transportation. You get them back to public transportation. And as noted there, that's just a sort of tidbit that goes along with these sort of treatments that it may work better when the person's spouse or significant others stop catering to their avoidance. In other words, many times, family members of people with a lot of problems, they're trying to do what's best just to sort of help the person. But they may actually make the problem worse sometimes by making it too easy for the person to avoid. So instead of the person going out to get stuff from the mall, just stay home. It'll be okay. I'll do it for you. Seems nice, but you may actually be encouraging the person's avoidance. And we'll see that in the context of some other disorders too, like obsessive compulsive disorder, where people might do stuff that sort of makes their symptoms worse. This is just an example of how exposure might go. Exposure can be done in different ways. As you will see in your video this week for treatment of phobias, it can be done in a real flooding sort of approach where sort of very quickly you take someone very high up their hierarchy of fears, but it can also be done more gradually. So this is an example of a graded exposure hierarchy where the person was afraid of public transportation. So instead of taking him all the way to the top where he just may not be ready to do, you work your way up. Step one, standing at the bus stop, watching bus go by for an hour, and that's it. And then the next step is to do a little bit more and then a little bit more, and then gradually you work your way up. Both of these approaches can work. It just depends on what the person is sort of willing to do, how much time they have, how much discomfort they're willing to endure. A general principle for these sorts of treatments is that the client, patient, whichever term we want to use, has to be willing to experience some discomfort. And if he or she is not, then it's going to be hard to do anything. How much the person is willing to sort of dictates whether you do it in terms of a graded exposure or a more rapid sort of flooding approach. So that's pretty much all I'm going to say then about panic disorder and agoraphobia. It seems like a really challenging disorder, but it's actually kind of challenging to work with. You can help people quite a bit with it, and often many different parts of the treatment may work for different people. Next, we'll talk about social anxiety disorder, which is also known as social phobia. And again, I'll go through this order of talking about description, epidemiology, aetiology, treatment. Description, if we had to come up with a quick description of what people with this disorder are afraid of, the one that you would see most probably in the literature is fear of negative evaluation. Although there's some recent research suggesting that it's probably more accurately described as fear of any evaluation. So that people obviously don't want to be evaluated negatively, but they don't like being evaluated at all. So it is noted there, persistent intense fear of social situations involving evaluation. A lot of people would say they are sort of shy and they don't really like certain social situations, but this is more than that. And it is like a phobia in that exposure to these situations really leads to a strong anxiety reaction. It, as with other sorts of phobic sorts of things, may have an onset adolescence. There used to be different subtypes and it used to be sort of a specific and a generalized subtype. They got rid of that distinction because it made it overlap too much with avoidant personality disorder, but there's still a performance only subtype. So this would be someone who can basically be normal in most social situations. But if you put them in a situation where they had to, for example, had to get up and give a public, a speech in public, or might even be like a musician. Sometimes I've encountered people like that where they had to, they were musicians on stage. It was their livelihood and they were having trouble functioning because of performance anxiety. So that's the performance only subtype, or you could have people that just sort of have wide ranging social fears and are basically afraid of all social situations or anything in between. I mentioned earlier that possible overlap with something called avoidant personality disorder. If you've taken personality, which most of you, I think, have, you probably would have remembered that one. And we'll also come back to it when we hopefully get to the personality disorders later in the term. But around a third of people with social anxiety disorder may also be diagnosed with avoidant personality disorder. Technically they're different disorders, so you can be diagnosed with both, but they clearly overlap quite a bit, not just in the symptoms, but perhaps in terms of the genetic vulnerability also. Here are the official criteria. And as before, you don't have to memorize them, but just a few things that are worth talking about. Some interesting examples in there. So having a conversation, meeting unfamiliar people, but also things like being observed, some people don't like eating in front of people. And the person will never go out to dinner with somebody else or whatever. And you're like, well, why is that? And they actually have a fear that they'll embarrass themselves by choking on their food or spitting out food or something like that. And it's not eating disorder related. So it's not like they are worried that people will think they're eating too much. But it's, again, something to do with embarrassing themselves as I said, performing in front of people, giving a speech is another example. There's a note there about children, and we'll come back to that when we talk about childhood disorders, but it has to be with their peers too. It's too normal for kids to be anxious about being evaluated by adults. So if there's a kid who's worried about his teacher, that's basically sort of in the normal realm. And so we wouldn't diagnose social anxiety disorder but if the kid was also extremely anxious about being evaluated by peers, then the person might qualify for diagnosis. The B criterion there is also interesting that it's not just fear of being evaluated, but it's also that they have a fear of showing signs of anxiety. So they seem to feel that particularly looking anxious in front of people is really bad. And so like if you look, if you show anxiety, then that's doubly bad because you are anxious, but you're also showing it. And so they're afraid that being anxious is actually what will embarrass them. As with anything, the D criterion there, they either avoid it or they endure it. So you got some people that will try, but a lot of people really just can't, and it may really significantly affect their ability to function. Then you got all these other ones that just sort of help clarify it. It's out of proportion to the social situation. So again, a lot of people don't like getting up and giving a speech, but we're talking about something worse than that. It's got to last at least six months. So if someone just says they've had this problem and started a week ago, like that's not social anxiety disorder. It might turn into it, but it has to last for longer before you can officially diagnose that. And G again, it's got to cause significant distress or impairment, and it can be very debilitating. I mean, I've seen people that had a really hard time functioning in school. Like some of them might sign up for a class and immediately check to see did it have any kind of oral presentation or anything that involved having to talk with people or particularly present something. And if it did, they just dropped the class. And you can see how that would make it really hard to get a degree. Certain jobs you couldn't get. And then of course, meeting people, social life, all that sort of stuff. So it can severely affect people's lives. The last few are just, it's not due to something else, or at least the next couple, it's not due to drugs or something. Like someone's not just taking a bunch of drugs and making them anxious because they're doing that. Although interestingly enough, sometimes people with this problem will take drugs or alcohol as a way of coping with it. For example, they might, before going out to meet people, they might drink a bunch of alcohol thinking that it'll make them calmer and more sociable, but then they might actually embarrass themselves by getting too intoxicated and making the whole problem worse. The I criterion there, everything is, most of these disorders, you got to make sure it's not due to another disorder. So some of these are a little bit, I mean, it could be anything. The ones that are mentioned there are panic disorder, and that's an actual challenge because people with social anxiety disorder may have panic attacks in front of people. But with panic disorder, what's triggering the panic? It's sort of coming out of the blue and they're afraid of dying or they're afraid of whatever else. With panic, excuse me, with social anxiety disorder, they're really more afraid of the social interaction, social evaluation. Body dysmorphic disorder, we haven't gotten to that one yet, but that's like if they're really more focused on their appearance than anything else. Autism spectrum disorder is something quite different, but they might avoid people. It might look a bit like social anxiety disorder. The last one is also, this is something we talked about earlier with regards to another disorder. And the idea here is what if they have a real problem that makes them more likely to be evaluated negatively. So Parkinson's disease, people have a tremor and they're worried about other people, how they would react to that, or someone may have some sort of disfigurement or really a long list of things that might apply here. The point is if it's really there, I mean, if there's a reason why a person might be afraid of the reaction from other people, are their fears excessive? I mean, is it sort of realistic? Is it normal? And this takes a lot of judgment and it's hard to determine this one, but you're trying to factor that in and determining is there a disorder on top of this, or is this just sort of a normal reaction to having some sort of problem that other people might react negatively to it. This, I think this picture's in your book, just pointing out that there are many well-known people who have reported having either social anxiety disorder, or at least being extremely shy, which may or may not be the same thing. This was a swimmer who apparently said something along the lines of didn't want to win races because if you win a race, then you have to like talk to people and that would be facing your fears. I've known many athletes who have come forward talking about having social anxiety disorder. There was a fairly famous American football player who, you know, in American football, you wear those helmets and some of them have like a tinted glass shield over the front, I guess it's plastic or whatever. And when people would interview him, he'd still have the helmet on with the tinted plastic tinted so you couldn't see his face. And I mean, he was clear about this, that he had problems with social anxiety disorder. So you see it among athletes, you see it among some other entertainers like singers and musicians that it may affect their ability to function, but they also may have figured a way to get around it. And so you can be quite successful with this, but it's still at the same time may significantly affect people's ability to function. Epidemiology, it's at least in the US, social anxiety disorder is one of the most common, not just anxiety disorders, but one of the most common disorders. There are data suggesting that it's not as common here. I'm not exactly sure why, but it's still relatively common. Just some other points there, you know, a lot of them report onset prior to age 12 and lifetime prevalence rate there, somewhere around 8%. I've seen higher estimates, but I mean, these are all estimates, so we don't know for certain. Here's our same study of anxiety disorders or anxiety related disorders in Australia. Remember social phobia, social anxiety disorder mean the same thing. So you can see that social phobia is actually of the anxiety disorders in this table, the highest. Now you might go, isn't PTSD higher? But remember PTSD is currently not considered an anxiety disorder anymore. So the top four on here are, and of course the one that's missing is specific phobias, and that's quite high too. But the bottom line would be the most prevalent anxiety disorders in Australia are probably social anxiety disorder and specific phobias. aetiology of social anxiety disorder. As you might imagine, our good friend two-factor theory shows up again. And it's kind of, it's more obvious to see how the first factor would play a role. Like someone can have a really bad conditioning experience where they were really embarrassed in front of people. And that's the first factor. The second factor is always the avoidance. So the negative reinforcement. And what's not so clear is obviously people can just avoid social situations. That's pretty clear. But the point here is that they can also avoid it in more subtle ways, where things like avoiding eye contact, standing apart from people. And so it may then actually sort of backfire on them because they actually get evaluated in a somewhat negative way because they're avoiding, and other people are actually interpreting it differently. Like thinking that the person's very aloof and not interested in talking to them, but they're really avoiding because of social anxiety. Then there's also a little bit of overlap with panic disorder and that people with this disorder may have excessive attention to these internal cues, but they interpret them differently. So it's not like they are worried about dying or losing control or something like that, as someone with panic disorder would. They're worried about showing signs of anxiety. Oh, no, I'm getting anxious again. I'm going to look stupid in front of somebody. So it's a similar process, slightly different fear. So also about ideology, social anxiety disorder, there's probably some degree of a genetic component, so genetic vulnerability. It may be not necessarily specific to this disorder. It may be sort of a broader vulnerability, but it still is a vulnerability. Family environmental factors may play a role. So as noted there, excessive parental criticism may undermine an individual's self-confidence. I've worked with people, I remember one young person who said the message he got from his family was that, particularly from his dad, was that no one would ever care to listen to anything you had to say. So if you grew up with that belief, that nothing you had was worth listening to, nothing you had to say was worth listening to, you could understand why you would be somewhat afraid of people's reactions to what you had to say. And as with all disorders, I mean, there's sort of cognitive aspects of them that are a bit unique to the disorder. We talked about panic recently. With here, with social anxiety disorder, it's some of the cognitive stuff I have noted here, where there's sort of a negative self-evaluation of themselves, so negative evaluation of themselves, plus the sort of always expecting that other people are going to think negatively of them, dislike them. So you would imagine that all of that cognitive material, things that you target in treatment, but because this is an anxiety disorder, often the main focus is exposure. And as with the other disorders, we talked about what you expose them to. With phobias, it was the phobic object. With panic disorder, it was the symptoms of panic. Here, what is it? Well, it's social situations. So different types of treatment, but cognitive behavior therapy does seem to be quite effective for this. It can be done individually or in groups. And the interesting thing about groups is, what did I just say? That exposure to people can be particularly therapeutic, given that that's what they're afraid of. So you'll tell people with this disorder, say, we have a group starting tomorrow. We'd like you to join it. And they're like, are you kidding me? I don't want to join a group because I'm afraid of people. But the whole point is the group itself is exposure. So you would think that it would actually work better. The data seem to suggest that individual and group therapy seem to work similarly. They may have different aspects of them that work better. So for individual, obviously, you're getting more one-on-one sort of attention. But in a group, again, the mere fact that you're in the group is functioning as exposure. Plus, it's a good way to test one's cognitions. So for example, you think how you interpret events, you get all these other people in a group giving their interpretations, showing that not everyone interprets the same thing the same way. In these groups, there's a lot of things that can be done. Psychoeducation in the same way we talked about with panic disorder, just different in the sense that what you're educating them about is slightly different. Challenging the negative cognitions, as I mentioned, having other people there can be useful for that. But you sort of teach them to identify their thinking, whether it's rational or not, and respond to the irrational thinking. And then again, exposure to feared social situations. So it can be, I mean, the group, again, as I've said, is part of the exposure. But then you would have like homework assignments where the person would be to go out and do all these forms of social exposure. The last thing on there is a little bit different. And it's based almost on treatments for PTSD, where the view is sort of like social anxiety is almost a variant of post-traumatic stress disorder and that these people have had social things that become like social traumas. And it's a matter of sort of going back and reprocessing those events and perhaps re-scripting them. It's a little bit more experimental, but it's an interesting direction in terms of treatment of social anxiety disorder. Okay. So now in terms of the specific disorders, we've talked about four of the five. Remember that panic disorder and agoraphobia are two separate disorders. So now we're going to talk about the last one for this week, which is generalized anxiety disorder. And again, I'll go through this description or this order in terms of general description. This disorder used to be viewed as sort of a residual category. In other words, the name talks about generalized, meaning people are sort of anxious in general. So you had sort of the phobic disorders, and then you had generalized anxiety disorder. But in recent years, we've probably refined our understanding of the disorder. And currently, it's more viewed as being a disorder based on excessive worry being the primary feature. Now, a lot of the other ones had worry also, but they were about something specific. So phobias, they would be worried about a specific object. Panic disorder, they'd be worried about having panic attacks, dying. Social anxiety disorder would be worried about social evaluation. Here, the point is they're worried about basically everything. And the point that makes this different from not having a disorder is more the degree to which they feel they cannot control it. So again, it's not that they're worried about different things than people without GAD worry about, but it's the excessive worry and the inability to control it. It's something that's been going on for at least six months. Most of these people will talk about having been this way like their whole life. And so it's viewed as a very chronic sort of thing, but at least for the DSM, they have a six months minimum criterion. And then it's also associated with the sort of physiological symptoms of anxiety, such as sleep problems, agitation. So again, worry combined with physiological symptoms. Some of these other things, restlessness, trouble concentrating, irritability, muscle tension, tiring easily, sleep disturbance. But here are the official criteria, which is more or less what I already said. So again, six months, excessive worry, and person finds it hard to control. That's the second or the B criterion. And then it's associated with all these other types of generally physiological symptoms of anxiety. As with anything, it has to cause distress or impairment, and it's not due to the effects of a substance. And we've mentioned this for other disorders and you might go, well, what would cause this? This is actually one where there's quite a few things that could cause it. It could be a drug or medication. When we talk about a drug, it could be a legal drug or an illegal drug, an illicit drug. So even something like caffeine. I mean, some people may, I remember having one anxiety disorder treatment program and interviewing a few people. One woman talked about drinking 18 cups of coffee a day and was there for problems with anxiety. I mean, it's almost like you can't even rule out, you can't determine whether or not the person has a disorder until you rule out that it's possibly just due to overusing something like caffeine. Could also be other drugs, illicit drugs, amphetamines, or something like that. Also certain medical conditions, hyperthyroidism is mentioned there. And that's one that I could have mentioned in the context of panic disorder too. Sometimes people that are having panic-related problems have hyperthyroidism. And it doesn't mean that they don't have panic disorder necessarily. If you treat the hyperthyroidism and it goes away, then yes, they didn't have either panic disorder or just case generalized anxiety disorder. Sometimes though you treat it and they still have the anxiety-related problem. So the point is to rule out that it's purely caused by something physiological. In some cases it may be, other cases it may just be part of the whole picture. And then the last one is not explained by another mental disorder, which again could be any of the disorders that we've talked about or some that we will talk about next week like post-traumatic stress disorder where people are tense a lot of the time and have a lot of the same anxiety-related problems, but it's more related to something traumatic that happened to them. Epidemiology. So back to our same study of prevalence of anxiety disorders in Australia, you can see GAD as it's sometimes called there, fourth on the list, 2.7, 12-month prevalence. The female to male ratio is basically 1.75 to 1, so not quite 2 to 1, but more common among women. Lifetime prevalence, that figure is apparently from Australia, so 6.1%. And obviously again, lifetime prevalence is going to be higher than 12-month prevalence, which is what was in the previous slide. As noted, it's more common among women and it does seem to be something that has a fairly chronic course where people will basically say, I've always been this way. In terms of aetiology, so in your text there are, I believe, four different psychological models or theories related to GAD. It's probably worth knowing all of them. I'm going to focus on one of them for time's sake, but the four that I mentioned there, information processing model, the metacognitive model by Adrian Wells, the avoidance theory, and the intolerance of uncertainty model. As I said, I'm going to talk a little bit more about metacognitive model because a couple aspects of it are a little bit interesting and different. First, the two bullet points. So the first being that people with GAD seem to hold both positive and negative beliefs about worry. So with most of the disorders we've been talking about, people have largely negative beliefs about it. Like they don't want to be doing what they're doing. They don't want to be feeling what they're feeling. But with people with GAD, again, they seem to have these positive beliefs about worry. So they, in other words, they believe worrying helps them or worrying is a good thing. It might make them a better person. So like if a parent, for example, would argue that if I don't worry all the time about my kids, A, something bad might happen to them, and B, it might mean I'm a bad parent. And it makes it hard to treat sometimes because you're trying to help them change, but yet they're arguing with you about why they should continue to be the way they are. But that's all about the positive beliefs. They also have the negative beliefs, which basically they believe that worrying is going to drive them crazy. They can't control it. And so it's almost like they have this sort of love-hate relationship with worry that they want to do it, but then it drives them crazy. At least that's in their interpretation. So that's the one unique aspect of it, the positive and negative beliefs about worry. The other, which is sort of related, is the idea of type one and type two worry. So in other words, two kinds of worry. And this is sort of why this is called a metacognitive model. Meta means sort of at a higher level. So you're talking about like a meta-analysis, which you've probably seen before. It's where you analyze already existing data. So you're analyzing the research at a higher level. So one of these types of worry, type two worry, is basically called meta-worry. So it's basically worry about worry. Type one is just sort of normal worry. It's the same kind of worry that all people may do, the same sorts of events. But then the type two is worrying about the fact that you're worrying. So you put all that together, and here's an illustration sort of the metacognitive model in action. Something may happen. Again, it could be like a parent gets news, something they don't know where their kid is, hasn't come home yet. The positive meta-beliefs get activated. I need to worry about this. I can do something about this. Good parents worry. So then the person worries about where their kid is. Then the negative meta-beliefs get kicked in about worry is going to drive me crazy, or I'm not going to be able to control it. And that leads to the type two worry. Again, notice it says meta-worry. So worry about worry. Then that leads to all the behavioral, cognitive, and emotional components of the disorder, which may also, as you notice, the arrows go both ways. So trying to control their thoughts, the emotions they feel, doing things like checking constantly or whatever, all these things might sort of backfire and make the type two worry worse. So again, one of the interesting theories about GAD, and your book makes the point that the positive beliefs aren't necessarily unique to GAD. But in my experience, you don't really see this too much among people with different kinds of anxiety disorders. It's really, it seems to be this group where they really sort of, again, almost will sort of defend the fact that they think worry is a good thing, but yet the worry is driving them crazy at the same time. So again, there's some other ones to look at. For time's sake, we're going to move on to treatment here. And I will say that with most of the anxiety-related disorders, we talk about cognitive and behavioral therapies having pretty good track record. It's probably not as good for GAD as it is for some of the other disorders, partially because one of the components of the cognitive behavioral therapies we've talked about thus far is exposure. With phobias, you expose people to the object or the situation. And even with panic disorder, social anxiety. So with GAD, when they're sort of worried about everything, where's the exposure component? And that may be why it's a bit harder to treat. Now, there are therapies designed to do something called worry exposure, and that sort of gets to that avoidance theory of worry that I mentioned in the previous slide. But historically, I'll just say that it's almost like we've tried a whole bunch of different things with GAD. And I mean, they're reasonably effective, but still probably not to the level that they're effective with other anxiety-related disorders. There's also a variety of other treatments in addition to CBT. So if you go see a GP or a psychiatrist and just talk about you're having problems with anxiety, they're going to give you some sort of medication fairly often. And this has been something that's been that way for a long time. You could talk to someone, a grandparent or something, they'll tell you about their nerve pills or something like that, which is something that the doctor would have given them a long time ago. And I mentioned this in the context of panic disorder. These might be anxiolytic medications like Valium, or they might be antidepressant medications. The anxiolytic medications work more quickly to reduce anxiety right at the time. But as I said before, they have a downside of people becoming dependent upon them. And then when they stop, basically, the problems seem to come back. So although they're quite commonly prescribed, they really shouldn't be considered probably a frontline treatment for this, perhaps something going along with some kind of active psychological treatment. Again, cognitive behavior therapy, a variety of things. It can include some basic skills like relaxation training, teaching people to relax, can involve exposure. So again, like worry exposure, exposing people to the things that they're worried about and not allowing them to avoid it. Then there's a couple other treatments, interpersonal psychotherapy. We would have talked about this briefly in week one or two, sort of a psychodynamic variant of therapy focusing on addressing people's interpersonal problems. So you really don't focus on the symptoms themselves. You focus on the interpersonal problems. And often with a lot of disorders, a lot of times the symptoms are related to these interpersonal problems. And with GAD, it'd be fairly common that they have a worry related to interpersonal problems. And so by addressing those problems, you're sort of indirectly addressing the therapy. And interpersonal therapy does seem to work fairly well. Some other variants that have been studied, mindfulness is sort of a variant of a cognitive therapy these days where people are taught to sort of, it's based on sort of a meditation-based approach and teaching people to be more present focused, allowing their thoughts to not control them and letting the thoughts pass rather than trying to control them. So it's a different sort of cognitive intervention. And there's some evidence for its effectiveness. In terms of the specific drugs, I've mentioned them on the previous slide. So I just add a little bit here. I mentioned the anxiolytics. So benzodiazepines would basically be the ones that are specifically designed to reduce anxiety at the time. As I said, Valium has been around forever, more recent ones like Xanax, and then some of the antidepressants that would be used. Just mentioned some of them there. Tricyclics, SSRIs, or SRIs, serotonin reuptake inhibitors. So just a little bit more about psychological treatments for GAD. Early on, a lot of the treatments were really just focusing on helping people learn to relax. So you had like progressive muscle relaxation, autogenic training, those sorts of things. Really, it was based on that earlier conceptualization of GAD just as a sort of residual category that didn't really have the phobic component. So all we could really do is try to help them relax. Newer understandings, though, of GAD have expanded the behavioral and cognitive behavioral approaches. So typically these days, cognitive behavioral methods would include some of the things that are listed here. Challenging and modifying negative thoughts. I think your book gives a sort of a dialogue between a therapist and a client. This would be similar to what we would have talked about with, well, we talked a little bit about panic disorder, and we'll come back to it with the depressive disorders, but helping clients identify their irrational thoughts, learning to challenge them, also learning to tolerate more uncertainty, because that seems to be one of the areas in which these clients have difficulty. You can also do sort of behavioral exercises like allowing them to worry on scheduled times. They feel like they can't control it, but if you say, actually, we're going to allow you to worry between this time and this time, it's sort of paradoxically showing them that they actually can control it. Focusing on the present moment, that's sort of the mindfulness idea that having people stay in the moment as opposed to always worrying about these things that might happen in the future. And the last one there, worry exposure, is based on that sort of avoidance theory of worry, that the idea that people are avoiding frightening images by engaging in cognitive worry, which is less threatening. And so by exposing them to those images, you're basically trying to, in the same way you expose people with phobic disorders, trying to sort of desensitize them to it and not reinforce the worry by avoidance of those frightening images. So, again, it's a bit of a mixed bag and probably not as effective. And when I say it, cognitive behavioral method is not as effective as for other anxiety-related disorders, but still probably consid