Week 2 - Anxiety Disorders PSY3032 2023 PDF

PSY3032 Semester 2, 2023 Week 2: Anxiety disorders Daniel Bennett [email protected] image: ʻMasculine waveʼ by Katsushika Hokusai source: https://twitter.com/JapanTraCul/status/1531217856356024323 Lecture learning outcomes 1. Describe the clinical features of the anxiety disorders 2....

PSY3032 Semester 2, 2023 Week 2: Anxiety disorders Daniel Bennett [email protected] image: ʻMasculine waveʼ by Katsushika Hokusai source: https://twitter.com/JapanTraCul/status/1531217856356024323 Lecture learning outcomes 1. Describe the clinical features of the anxiety disorders 2. Describe how the anxiety disorders tend to co-occur and understand how gender and culture influence the prevalence of anxiety disorders 3. Recognise commonalities in aetiology across the anxiety disorders, as well as the factors that shape the expression of specific anxiety disorders 4. Describe treatment approaches that are common across the anxiety disorders and how treatment approaches are modified for the specific anxiety disorders Weekly reading Kring, Chapter 4 PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Overview of this weekʼs videos Mini-lecture 1: The phenomenology of anxiety disorders Mini-lecture 2: Shared risk factors for anxiety disorders Mini-lecture 3: The aetiology, diagnosis, and treatment of generalised anxiety disorder Mini-lecture 4: The aetiology, diagnosis, and treatment of panic disorder Mini-lecture 5: The aetiology, diagnosis, and treatment of agoraphobia Mini-lecture 6: The aetiology, diagnosis, and treatment of specific phobia Mini-lecture 7: The aetiology, diagnosis, and treatment of social anxiety disorder Mini-lecture 8: Summary PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett The phenomenology of anxiety disorders Fear, anxiety, panic, and worry Dolendi modus, timendi non item [“There is a limit to suffering, but there is no limit to fear”] Francis Bacon, ʻOf Seditions and Troublesʼ, 1625 PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Case study Mabel is 67 years old. She lives in a small house in an outer suburb of the city. She has not left her house in more than 20 years, because she is afraid that if she leaves, she will have a panic attack in public and not be able to obtain assistance. Mabel vividly feels that she has wasted years of her life, but nevertheless she continues to struggle in the face of adversity and to make the best she can of her limited routine. For Mabel, even areas in her apartment signal the potential for terrifying panic attacks. She has not answered the door herself for the past 15 years because she is afraid to look into the hallway. She can enter her kitchen and go into the areas containing the stove and fridge, but for the past 10 years she has not been to the parts of the room that look out onto the backyard or the back verandah. Thus, her life for the past decade had been confined to her bedroom, her living room, and the front half of her kitchen. She relies on her adult daughter to bring groceries and visit once a week. Her only other visitor is the local priest, who comes to deliver communion to Mabel every 2 to 3 weeks. Her only other contact with the outside world is through TV and the radio. Mabelʼs husband died about 10 years ago, after a long battle with liver cancer caused by years of alcohol abuse. Early in her stressful and unhappy marriage, Mabel had her first terrifying panic attack, and she gradually withdrew from the world thereafter. As long as she stays in her apartment, she is relatively free of panic. Therefore, and because in her mind there are few reasons left near the end of her life to venture out, she declines treatment. Case study adapted from Barlow, Durand & Hoffman: Abnormal Psychology, An Integrated Approach (8th edition, 2017) PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Why do we feel fear and anxiety? Link to video: https://www.youtube.com/watch?v=agi4geKb8v8 (watch first 30 seconds) Ø Across species, fear is associated with a range of immediate survival-related behavioural responses Ø ʻFight or flightʼ response (Cannon, 1929); modern taxonomies add ʻfreezeʼ and ʻfaintʼ Ø Rapid shifts in the autonomic nervous system (increased heart rate and blood pressure, reduced digestion) PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Why do we feel fear and anxiety? Ø Non-pathological anxiety occurs in situations when we are anticipating an event that has the potential to go badly Ø Sitting an exam Ø Giving a presentation in class Ø A job interview Ø A first date Ø Howard Liddell (1949): Anxiety is the “shadow of intelligence” Ø Yerkes & Dodson (1908): optimal performance occurs with a moderate degree of physiological arousal PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett What would happen if we didnʼt feel fear? PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett What would happen if we didnʼt feel fear? Ø S.M. (born 1965) is an American woman who has a rare disease called Urbach-Wiethe disease Ø In her case, the disease entirely lesioned both of her amygdalae Ø S. M. (usually) does not experience fear or recognise fear in other peopleʼs faces Ø As a result, she often puts herself into dangerous situations Ø She approaches poisonous snakes/spiders out of curiosity Ø She has been mugged several times PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett The strength of fear and anxiety Ø Why are fear and anxiety such powerful motivators of behaviour? Ø From an evolutionary perspective, the answer lies in the asymmetry of possible outcomes Real danger No danger (object is a snake) (object is a cucumber) Strong fear reaction Successfully escape Look stupid on YouTube Weak fear reaction Death Go about your day Ø ʻHealthyʼ anxiety can be metaphorically likened to a well-calibrated smoke alarm (Barlow, 2002) Ø Pathological anxiety is more like an overly sensitive smoke alarm PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Some definitions Ø Fear is the negative emotional and physiological response to real or perceived imminent threat Ø Anxiety is a negative emotional state characterised by apprehension about the future and feelings of unease and physical tension Ø Worry is the cognitive component of anxiety, the future-oriented thoughts related to the occurrence and prevention of future threat Ø ʻWhat if...ʼ thoughts Ø Contingency planning Ø A panic attack is a specific syndrome related to anxiety and fear, involving a distinctive set of cognitions and bodily sensations Ø “An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes” (DSM5) Ø Can occur in multiple psychological disorders, not just anxiety disorders PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Characteristics of anxiety disorders From the ICD-11: Ø Anxiety and fear-related disorders are characterised by excessive fear and anxiety and related behavioural disturbances Ø Symptoms are severe enough to result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning Ø A key differentiating feature among the anxiety and fear-related disorders are disorder-specific foci of apprehension, that is, the stimulus or situation that triggers the fear or anxiety Ø The clinical presentation of anxiety and fear-related disorders typically includes specific associated cognitions that can assist in differentiating among the disorders by clarifying the focus of apprehension PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Overview of anxiety disorders Ø As a group, anxiety disorders are the most common psychological disorder in Australia Ø 14% of the Australian population over a 12-month period (ABS, 2008) Anxiety disorders in the DSM-5: Ø Separation anxiety disorder Ø Selective mutism Ø Specific phobia Ø Social anxiety disorder Ø Panic disorder Ø Agoraphobia Ø Generalised anxiety disorder Ø Substance- or medication-induced anxiety disorder Ø Anxiety disorder due to another medical condition Ø Other specified anxiety disorder Ø Unspecified anxiety disorder PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett The disorders in bold are the ones that we will be focusing on this week Shared risk factors for anxiety disorders The aetiology of anxiety disorders Ø The anxiety disorders as a whole share a number of risk factors PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Genetic risk factors for anxiety disorders Ø Twin studies suggest that anxiety has a substantial genetic component Ø Heritability of 20-40% for specific phobias, social anxiety, and generalised anxiety disorder Ø About 50% for panic disorder Ø Genetic liability is shared across anxiety disorders Ø Having a family member with social anxiety disorder increases your likelihood of developing not just social anxiety but also specific phobia, agoraphobia, generalised anxiety disorder... Ø The one exception to this is panic disorder, which might have unique genetic liability Ø There is no one ʻanxiety geneʼ Ø Genetic vulnerability to anxiety disorders is highly polygenic Ø The genetic component does not cause anxiety disorders directly Ø Different genes relate to distinct biological and psychological factors that each independently confer risk PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Biological factors: prefrontal-amygdala connectivity Ø The limbic system is most associated with anxiety Ø Amygdala centrally involved Ø Amygdala is associated with fear and fight/flight responses, and assigns emotional significance more broadly Ø In anxiety, the medial prefrontal cortex fails to down-regulate an over-excitable amygdala Ø People with anxiety disorders show greater amygdala activation in response to pictures of angry faces (a signal of threat) PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Biological factors: neurotransmitter dysfunction Ø There is inconsistent evidence implicating a variety of neurotransmitters in anxiety disorders Ø Deficits within the serotonin system (Chang, Cloak & Ernst, 2003) serotonin Ø Higher-than-normal levels of norepinephrine (Geracioti et al., 2001) Ø GABA acts to inhibit neural activity, and produces decreased anxiety (Sinha et al., 2004) norepinephrine Ø But overall, findings of neurotransmitter dysfunction in anxiety disorders are inconsistent and difficult to interpret gamma-aminobutyric acid (GABA) PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Personality factors Several personality dimensions have been associated with increased risk for anxiety disorders: Ø Neuroticism (Barlow et al., 2002) Ø The tendency to experience frequent and intense negative emotions Ø Behavioural inhibition (Gray & McNaughton, 2003) Ø The tendency to experience novel/unfamiliar stimuli and situations as potentially threatening Ø Intolerance of uncertainty (Carleton et al., 2007) Ø Finding it unpleasant to be uncertain in general (even in familiar situations) Ø Perfectionism (Shafran et al., 2010) Ø The tendency to self-impose extremely high standards and appraise self-worth by whether standards are met PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Behavioural factors: conditioned fear Ø The behaviourist theory of anxiety disorders focuses on the phenomenon of conditioned fear Ø Exemplified by Mowrerʼs two-factor model of anxiety (1947) Factor 1: classical conditioning of fear when a neutral stimulus (CS) is paired with an aversive stimulus (UCS) Factor 2: operant conditioning of avoidance behaviours via relief from anxiety elicited by the CS Ø Behavioural therapies for anxiety involve extinction of either or both of Factor 1 and Factor 2 PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Cognitive factors: beliefs regarding vulnerability Ø Cognitive theories of anxiety focus on the role played by our beliefs Ø Particularly our beliefs about our vulnerability to threat Ø Beck (1985): theories of anxiety should remember that anxiety is a symptom, not a cause Ø Just as stomach pain is a symptom (not a cause) of appendicitis Ø Anxiety is a survival mechanism designed to attract attention and promote safety-seeking behaviour Ø But what if the danger is not real but misperceived or exaggerated? Ø For Beck, underlying mechanism is the cognitive structures that cause us to believe that we are vulnerable to threats Ø e.g., sustained negative beliefs about the future Aaron T. Beck (1921-2021) Perceived lack of control Ø Those who believe they lack control over their environment are at greater risk of anxiety disorders Ø If you canʼt control the environment, you canʼt protect yourself from threats Ø Our sense of control over the world develops over childhood Ø Children whose needs are met a predictable way foster a sense of control over the environment Ø A secure ʻhome baseʼ from which you can explore the world helps to develop a sense of competence, thereby contributing to perceptions of control Ø Insel et al. (1988) reared two groups of monkeys apart Ø Control group had access to toys and food treats at will Ø ʻYokedʼ group had equivalent access to toys/treats, but not under own control Ø ʻYokedʼ group showed more anxiety when exposed to a stressor at age 3 PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Excessive attention to threat Ø Attending more to threat information in the environment is a risk factor for anxiety Ø Paying attention to a threat may increase its perceived likelihood, and therefore our perceived vulnerability Ø Attention to threat can be measured in the lab with the ʻdot probeʼ task Ø Responses following threatening images are faster in participants with high anxiety Ø Once a threatening image attracts attention, those with anxiety have more difficulty disengaging attention PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Generalised anxiety disorder Phenomenology of generalised anxiety disorder DSM-5 (2013) Ø Essential feature is excessive anxiety and worry about a number of different events Ø Often about everyday events like job responsibilities, health and finances Ø The excessive anxiety is out of proportion to the actual impact of the anticipated event Ø May be about minor matters like being late for appointments, doing household chores Ø We all have anxiety and worry, but we donʼt all have GAD! Ø Worries in GAD are pervasive, uncontrollable, have a longer duration, and often occur in the absence of precipitating events Ø Worries in GAD are also more likely to be associated with somatic symptoms like sweating, nausea, and diarrhoea PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Singer Zayn Malik has been public about his struggles with generalised anxiety DSM-5-TR diagnostic criteria for generalised anxiety disorder 1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance) 2. The individual finds it difficult to control the worry 3. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): a) Restlessness or feeling keyed up or on edge b) Being easily fatigued c) Difficulty concentrating or mind going blank d) Irritability e) Muscle tension f) Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep) 4. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 5. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism) 6. The disturbance is not better explained by another mental disorder PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Specific aetiology of generalised anxiety disorder Ø Generalised anxiety disorder is in some ways the prototypical anxiety disorder Ø All the shared risk factors discussed previously apply to GAD Ø GAD is more likely to be comorbid with major depression than other anxiety disorders Ø Anxiety and worry in GAD are ʻfree-floatingʼ Ø Other anxiety disorders more associated with strong physiological threat responses to specific types of stimuli Ø Cognitive theories of GAD emphasise worry as a cognitive strategy for dealing with uncertainty and avoiding negative emotions PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Treatment of generalised anxiety disorder Ø Medication is commonly prescribed for short-term relief, as a kind of crisis management Ø Benzodiazepines (increase GABA levels throughout the brain) Ø Selective serotonin reuptake inhibitors (SSRIs) and serotonin & noradrenaline reuptake inhibitors (SNRIs) Ø In the long run, psychological treatments are more effective Ø Cognitive behavioural therapies focus on adjusting cognitive processes directly Ø Challenging negative thoughts Ø Confronting anxiety-provoking thoughts rather than avoiding them Ø ʻSchedulingʼ time for worry Ø Third-wave psychotherapies focus on acceptance and mindfulness of oneʼs own cognitions Ø Acceptance and Commitment Therapy (ACT) focuses on letting go of attempts to rid oneself of unpleasant thoughts Ø Metacognitive Therapy (MCT) focuses on our thoughts about thinking, emphasising positive metacognitions (e.g., ʻWorrying helps me to be prepared for the futureʼ) rather than negative (ʻMy anxiety is bad for my healthʼ) Panic disorder Panic as the physiological state of extreme fear “With all or almost all animals, even with birds, terror causes the body to tremble. The skin becomes pale, sweat breaks out, and the hair bristles ... The heart beats quickly, wildly, and violently; but whether it pumps the blood more efficiently through the body may be doubted, for the surface seems bloodless and the strength of the muscles soon fails ... The mental faculties are much disturbed. Utter prostration soon follows, and even fainting ... I once caught a robin in a room, which fainted so completely, that for a time I thought it dead.” Charles Darwin, ʻOn the Expression of the Emotions in Man and Animalsʼ, 1872 PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Panic attacks Ø A panic attack is a specific syndrome related to anxiety and fear, involving a distinctive set of cognitions and bodily sensations The actor Emma Stone has spoken publicly about her experience of panic attacks PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Figure adapted from Barlow et al., 2018 Physiological measurements during a panic attack Ø Sudden increase in heart rate Ø Sudden increase in muscle tension Ø Slower fluctuations in body temperature figures from Barlow et al. (2018) DSM-5-TR diagnostic criteria for panic disorder 1. Recurrent unexpected panic attacks 2. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: a) Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”) b) A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations) 3. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders) 4. The disturbance is not better explained by another mental disorder PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Specific aetiology of panic disorder Ø Behavioural and cognitive models of panic disorder focus on conditioned associations and beliefs related to internal bodily sensations Ø There is also a stronger biological sensitivity to norepinephrine in people with panic disorder Treatment of panic disorder Ø Cognitive behavioural therapy treatment is the most successful approach Ø Focus on exposure, combined with relaxation, breathing retraining Ø Panic control treatment involves exposure to interoceptive sensations Ø Mimics panic attack, and perceptions of danger identified & modified. Leads to less fear at somatic changes in future Ø Pharmacological treatment is best used as an adjunct to CBT Ø SSRIs, SNRIs, benzodiazepines (GABA) Ø Benzodiazepines are the most widely used Ø Addictive, and negative side effects on motor /cognitive function Ø 60% free of panic, but relapse high (50-90%) once medication is discontinued PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Panic in the laboratory Feinstein et al. (Nature Neuroscience, 2013) Ø Panic attacks can be reliably induced in the laboratory by inhalation of air with 35% CO2 Ø This is true even among patients like S.M. who have bilateral amygdala lesions Agoraphobia DSM-5-TR diagnostic criteria for agoraphobia 1. Marked fear or anxiety about two (or more) of the following five situations: a) Using public transportation (e.g., automobiles, buses, trains, ships, planes) b) Being in open spaces (e.g., parking lots, marketplaces, bridges) c) Being in enclosed places (e.g., shops, theaters, cinemas) d) Standing in line or being in a crowd e) Being outside of the home alone 2. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence) 3. The agoraphobic situations almost always provoke fear or anxiety 4. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety 5. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context 6. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett DSM-5-TR diagnostic criteria for agoraphobia (continued) 7. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning 8. If another medical condition (e.g., inflammatory bowel disease, Parkinsonʼs disease) is present, the fear, anxiety, or avoidance is clearly excessive 9. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Changing diagnoses: agoraphobia and panic disorder A new instruction for clinicians in the DSM-5: Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individualʼs presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned. Ø In the DSM-IV and previously, agoraphobia was considered a subtype of panic disorder Ø Panic disorder with agoraphobia vs. panic disorder without agoraphobia Ø But at least half of people with symptoms of agoraphobia do not experience panic attacks Ø For these people, agoraphobia can develop for other reasons Ø fear of falling in the elderly Ø fear of public incontinence in those with bladder and bowel issues PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Specific aetiology of agoraphobia Ø A prominent cognitive model of agoraphobia is the fear-of-fear hypothesis Ø Symptoms driven by beliefs about the consequences of experiencing anxiety/embarrassment/panic in public Ø Catastrophic beliefs that public anxiety/panic will lead to socially unacceptable consequences PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Treatment of agoraphobia Ø As with panic disorder, exposure therapy is the first-line psychotherapy for agoraphobia Ø This involves ʻreality-testingʼ beliefs about the likelihood and consequences of public anxiety Ø Usually involves graded exposure Ø Like panic disorders, medications are typically used as an adjunct or for short periods at the beginning of therapy PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Specific phobia DSM-5-TR diagnostic criteria for specific phobia 1. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood) 2. The phobic object or situation almost always provokes immediate fear or anxiety 3. The phobic object or situation is actively avoided or endured with intense fear or anxiety 4. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context 5. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more 6. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning 7. The disturbance is not better explained by the symptoms of another mental disorder PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett DSM-5-TR diagnostic criteria for specific phobia Ø Available specifiers for specific phobia: Ø Animal (e.g., spiders, insects, dogs) Ø Natural environment (e.g., heights, storms, water) Ø Blood/injection/injury (e.g., needles, invasive medical procedures, dentists) Ø Situational (e.g., airplanes, elevators, enclosed places) Ø Prepared learning refers to the fact that our minds are faster to form fear associations with certain kinds of stimuli (snakes, spiders, heights, etc.) Ø Adult monkeys can be conditioned to fear snakes and crocodiles but no flowers or rabbits Ø “The main quality of a phobia is that it involves the appraisal of a high degree of risk in a situation that is relatively safe” (Beck, Emery & Greenberg, 1985) Sociocultural context and phobia Ø Fear/anxiety must be out of proportion to the actual danger posed and to the sociocultural context Ø Sociocultural context: the shared beliefs and practices of the social or cultural groups to which an individual belongs Ø This criterion is intended to prevent clinicians from diagnosing specific phobia on the basis of cultural features that they disagree with or are unaware of A Hamsa amulet in Tunisia PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Specific aetiology of specific phobia Ø Early behavioural models emphasised classical conditioning in the development of phobia Ø This is still a major factor for some phobias; e.g., most people with a choking phobia have had a choking experience Ø But fear can also develop via observational learning, instruction, or misattributed experience of panic Ø Not all terrifying experiences produce phobia. Why not? Ø Generalised biological and psychological factors predispose people to developing phobias Ø Certain phobias (especially blood/injection/injury) are strongly heritable PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Treatment of specific phobia Ø There is consensus that treatment of phobias involves tailored, gradual, consistent exposure Ø This works best under therapeutic supervision Ø Those who try to carry out exposure alone often go too fast Ø Triggering an unexpected panic attack can set the process back Ø In some cases, new therapies treat phobias in a single session of 2-6 hours with graded exposure Ø One example would be coprophobia (fear of faeces) PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Social anxiety disorder Phenomenology of social anxiety disorder Ø Contrary to popular perceptions, social anxiety is not the same thing as shyness or introversion Ø At the core of social anxiety disorder is a fear of being negatively appraised or evaluated by others Ø People with social anxiety disorder typically avoid social settings in which this might occur Ø or else endure social settings with intense discomfort Ø Lifetime prevalence is between 3 and 13% of adults Ø Onset is commonly in adolescence Ø In the DSM: Ø Social anxiety disorder used to be called ʻsocial phobiaʼ Ø ʻPerformance-relatedʼ is a specifier available to clinicians PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett DSM-5-TR diagnostic criteria for social anxiety disorder 1. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech) 2. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated 3. The social situations almost always provoke fear or anxiety 4. The social situations are avoided or endured with intense fear or anxiety 5. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context 6. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more 7. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning 8. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition 9. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder 10. If another medical condition (e.g., Parkinsonʼs disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive Specific aetiology of social anxiety disorder Ø Demographic risk factors Ø Gender (girls/women experience social anxiety more than boys/men) Ø Age (younger people experience social anxiety more than older people) Ø Education and SES (people from a low SES background experience more social anxiety) Ø Relationship status (singles experience more social anxiety than those in a relationship) Ø Behavioural theories: two-factor conditioning Ø An initial set of negative social experiences leads to conditioned fear Ø Avoidance of social settings and social cues (e.g., eye contact) is reinforced when it brings relief from anxiety Ø Cognitive theories: excessive focus on negative self-evaluations Ø More unrealistically negative beliefs about the consequences of social behaviours (e.g., blushing) Ø Perception of oneself as socially awkward, and belief in negative consequences of social awkwardness PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Treatment of social anxiety disorder Ø Behavioural exposure therapy Ø Role-play with therapist -> practice in small groups -> public settings Ø Cognitive therapy Ø Challenging beliefs regarding likelihood and consequences of negative evaluations by others Ø Identifying negative self-talk Ø Most effective when added to exposure therapy Ø Medication Ø Similar to other anxiety disorders (benzodiazepines, SSRIs, SNRIs) Ø May accelerate the process of recovery, but unlikely to actually amplify the effect PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Summary Case study Mabel is 67 years old. She lives in a small house in an outer suburb of the city. She has not left her house in more than 20 years, because she is afraid that if she leaves, she will have a panic attack in public and not be able to obtain assistance. Mabel vividly feels that she has wasted years of her life, but nevertheless she continues to struggle in the face of adversity and to make the best she can of her limited routine. For Mabel, even areas in her apartment signal the potential for terrifying panic attacks. She has not answered the door herself for the past 15 years because she is afraid to look into the hallway. She can enter her kitchen and go into the areas containing the stove and fridge, but for the past 10 years she has not been to the parts of the room that look out onto the backyard or the back verandah. Thus, her life for the past decade had been confined to her bedroom, her living room, and the front half of her kitchen. She relies on her adult daughter to bring groceries and visit once a week. Her only other visitor is the local priest, who comes to deliver communion to Mabel every 2 to 3 weeks. Her only other contact with the outside world is through TV and the radio. Mabelʼs husband died about 10 years ago, after a long battle with liver cancer caused by years of alcohol abuse. Early in her stressful and unhappy marriage, Mabel had her first terrifying panic attack, and she gradually withdrew from the world thereafter. As long as she stays in her apartment, she is relatively free of panic. Therefore, and because in her mind there are few reasons left near the end of her life to venture out, she declines treatment. Case study adapted from Barlow, Durand & Hoffman: Abnormal Psychology, An Integrated Approach (8th edition, 2017) PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Post-quiz Ø Mabel most likely has agoraphobia Ø She would likely benefit most from behavioural exposure therapy PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Figure adapted from Barlow et al., 2018 Comorbidities Ø Anxiety disorders are highly comorbid with one another Ø More than half of people with one anxiety disorder meet criteria for another at some point in their lives Ø Anxiety disorders are also highly comorbid with other psychiatric disorders Ø About 75% of people with an anxiety disorder meet criteria for at least one type of psychological disorder Ø About 60% of people with an anxiety disorder meet criteria for major depression Ø Increased comorbidity is associated with greater symptom severity and poorer outcomes overall PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett Gender differences Ø Women are much more likely to be diagnosed with anxiety disorders than men Ø 21% of women vs. 12% of men in Australia (ABS, 2022) Ø There are a number of factors that may contribute to this difference Ø Social factors (gender roles) may mean that women may be more likely to form beliefs about vulnerability Ø Women may have increased biological reactivity to stress relative to men Ø Men may experience more social pressure than women to confront their fears Ø Reporting bias - men may be less willing to endorse symptoms or seek treatment for anxiety disorders PSY3032 ‒ Anxiety disorders ‒ Daniel Bennett The triple vulnerability model Diathesis Barlow et al. (2002) Generalised biological vulnerability + - Prefrontal-amgydala connectivity - Neuroticism - Tendency to panic Stress + Generalised psychological vulnerability - Ease of fear conditioning - Lack of control - Attention to threat Stressful life event + Specific psychological vulnerability Focus of anxiety (e.g., physical sensations are dangerous, social evaluation is dangerous, etc.)