Anxiety Disorders

Fear and apprehension run amok

Definitions

• Anxiety – apprehension over an anticipated problem

• Fear – reaction to immediate danger• Both involve sympathetic nervous system

arousal• Both are adaptive but when they arise

inappropriately misery can follow

Many suffer

• Most common mds – 28% at some point• Phobias strike the most• Pervasive costs 1) 2x the medical cost 2) greater risk of heart and other illnesses 3) 2x suicide risk 4) troubles socially and at work

DSM IV TR to DSM 5

• Most disorders remain unchanged

• Panic Disorder (DSM IV TR) now split into Panic disorder and Agoraphobia

• OCD and Trauma/Stress disorders (PTSD) are given their own chapters

General Diagnostic Criteria

• Major functional trouble/distress• Drugs or medical condition not causal

• Lots of overlap between the specific disorders• Most (except GAD) involve intense fear

Description – Specific phobias

• A disproportionate fear caused by a specific object or situation

• Recognizing that the fear is not realistic no longer necessary in DSM 5

• Object or situation are avoided

• High chance that a victim will more than 1

Social Anxiety Disorder

• Persistent, unrealistically intense fear of social situations involving appraisal or even contact with unfamiliar people

• Formerly – social phobia disorder• Great fear of public speaking, talking in class

or to authority figures, meeting new people• Way beyond simple shyness• Can severely limit jobs and advancement

Social Anxiety Disorder cont.

• 1/3 are comorbid w/ avoidant personality disorder, w/ genetic overlap, but less severe

• Can begin in childhood, but usually in teens• Chronic w/out treatment• Fears can range from a few to very many• More fears, more likely comorbid w/

depression and alcohol abuse

Panic Disorder

• Frequent panic attacks unrelated to any specific trigger and the worry of more to come

• Panic attack – sudden wave of intense terror accompanied by at least four other symptoms

• Symptoms could include shortness of breath, racing heart, sweat, fainting, chills, nausea, trembling, dizziness, numbness/tingling

Panic Disorder: psychological symptoms

• Derealization – fear that the world is not real• Depersonalization – a feeling of being outside

of your body• Also, fear of losing control, of going crazy, of

dying• 90% report these type of symptoms• Many want to run away as fast as possible

Recurrence is crucial

• Attacks must be recurrent for at least a month

• Many (more than 25%) have endured one attack

• Few suffer repeatedly

• Devastating to employment – many cannot keep a job

Agoraphobia

• Fear of places or situations from which it would be hard to escape

• Crowds, shopping malls, trains, games• Many, as a result, don’t leave the house• And, if they do, it’s only with great distress• Formerly under Panic Disorder, but few

endure panic attacks• Significantly impairs day to day function

Generalized Anxiety Disorder (GAD)

• Excessive worry on more days than not about any kind of events

• Worries are common for everyone but these are excessive in terms of intensity and time

• Must last for at least 6 months, many chronic• Symptoms include trouble concentrating,

fatigue, irritability, restlessness, muscle tension

If you’ve got one …

• More than half get another anxiety diagnosis at some point

• Especially true for GAD – 80%!• Many others have subthreshold symptoms• Why such high comorbidity? 1) symptom overlap, and 2) many causal factors increase risk for more

than 1 disorder

More comorbidity

• Above and beyond other anxiety disorders, they have high comorbidity with many other types of mds

• 75% meet criteria for another md!• 60% for depression alone• Many suffer from substance abuse and/or

personality disorders• Also great risk for concurrent medical woes

Does Gender matter?

Yes – women are 2x more likely to suffer. Why? a) More likely to report b) Men think they have control c) Men are often forced to face fears –

exposure d) Sadly, women are more often sexually

abused e) Women seem more physiologically

vulnerable

How about culture?• Significant variation depending upon what a

culture values, or fears• Taijin kyofusho – Japanese syndrome involving

deep fear of displeasing others Manifests by fear of eye contact, blushing,

body odor or deformity Similar to SAD but the emphasis on the

feelings of others distinguishes Arises from extreme, traditional concern for

other’s feelings?

More cultural variants

• Kayak-angst – Inuit seal hunters can endure special type of panic disorder

Features intense fear, disorientation Alone in a harsh, unforgiving environment• Koro – Asian phenomenon, grave fear of penis

disappearing into body• Shenkui – Chinese fear of losing semen due to

masturbation or too much sex

Other aspects of cultural variation

• Low incidence of anxiety disorders in Japan – bias against reporting?

• Lots of panic disorder in Cambodia – lingering effects of Khmer rouge genocide? PTSD?

• While some cultural variations have been explained away, others, including the nature of complaints do vary from culture to culture

Common Risk factors for all Anxiety Disorders

• Helps explain high comorbidity • Big factor arises from the classical

conditioning (CC) of fear responses• Other factors – genes, personality traits,

cognitive factors – influence how and when conditioning takes hold

Fear Conditioning – Mowrer’s Two Factor Model

• Mowrer’s theory 1) through CC we learn to fear a neutral

stimulus (CS) that is repeatedly paired with an always averse stimulus (UCS)

2) through operant conditioning (OC) we feel better, doge stress, by avoiding the CS. Avoiding the CS becomes more and more likely (reinforcing) because it reduces fear.

Example – Claustrophobia & elevators

• A child is stuck in an elevator for a long period of time and develops a phobia of elevators

• She has learned to link elevators (CS) with being trapped in a small space (UCS)

• The child becomes anxious every time she sees or even thinks about an elevator (CR)

• Avoiding elevators produces great relief (reinforcement) so it continues – no exposure

How could this start?

• Direct experience – a snake bit you and it hurt

• Modeling – you saw another person bitten or terrified and it made an impression on you

• Verbal instruction – someone told you hoe horrible it is to be bitten by a snake

Two other factors

• People who suffer from anxiety disorders share two qualities

1) they are more susceptible to CC of fear responses

2)their fears are resistant to extinction – exposure to extinction trials (CS not followed by UCS) does not lead to extinction

Genetic influence

• Twin studies reveal a heritability of 20-40% for anxiety disorders besides panic disorder

• Panic disorder – 50%

• It seems that some genes predispose to all anxiety disorders while others point to specific disorders

Neurobiological

• Inappropriate activation and persistence of the fear circuit is associated with anxiety disorders

• The amygdala is a major player assigning excessive fear to stimuli and triggering the circuit

• Worse yet, the medial prefrontal area, which can override the too sensitive amygdala, tends to be compromised in anxiety disorders

Neurobio II

• Neurotransmitters also play a role

• Serotonin problems, or too much norepinephrine, are linked to anxiety woes

• GABA usually inhibits activity and anxiety throughout the brain, deficits could hurt

Personality’s Influence

• If yearlings show behavioral inhibition, fearful reaction to novel stimuli, they often (45%) show anxiety at 7.

• Genetic – can manifest at four months• Especially predictive of Social Anxiety Disorder• Neuroticism – ultra-senrsitivity to adverse

stimuli, another strong predictor of both anxiety and depression

Cognitive – three theories

• Sustained Negative Beliefs about the Future – the pervasive conviction that only bad things are coming

• Common among anxiety disorders• Maintained by safety behaviors, avoidance

measures that prevent beliefs from reality testing

Perceived Control

• The belief that you have no control over your future is characteristic of many anxiety disorders

• Rough times as a kid may encourage this outlook

• 70% of anxiety sufferers can identify a crisis within months of onset

• Backed up by animal studies

Specific Causes - Phobias

• Classical Conditioning – phobias are a conditioned response maintained by avoidance behavior

• Could arise from personal trauma, modeling, or verbal instruction

• When asked though, about ½ don’t remember• Says more about the failings of memory, than

the viability of the theory

Phobia etiology II

• Many are unaffected by experiences that cause phobias to develop in others

• Why? risk factors – neurotransmitter deficits, personality traits, high fear circuit activation

• But only some things cause phobias to arise – things we have feared for millennia like dogs, snakes, heights – Prepared Learning

• Other stimuli cause reactions, but soon fade

Causes of Social Anxiety Disorder

• Similar to phobias – developed by CC, maintained by OC

• Safety behaviors make the problem worse• From the Cognitive perspective: 1) negative beliefs – I’m a dork & all know it 2) too conscious of internal cues – so alert to

their reactions, they ignore their partner

Panic Disorder – Why do we exaggerate bodily changes?

• Neurobiological – locus coruleus turns on too easily causing unnecessary sympathetic nervous system arousal

• Classical Conditioning – signs of arousal lead to panic attack, and then become a CS, with the subsequent panic attack becoming a CR’ also called interoceptive conditioning

Cognition’s role in Panic Disorder

• Interpreting somatic changes as impending doom

• When someone is warned that somatic changes are coming, they don’t experience panic attacks

• When they don’t know, they have catastrophic interpretations and can sustain panic attacks

Agoraphobia causes

• Fear of Fear – victims overestimate how badly they will react to stress in public

• Afraid their unease will go viral

Etiology of GAD: Why worry so much?

• GAD is so often a comorbid condition, general predictors of anxiety disorders are key

• Also, cognitive factors appear crucial• Worry can be reinforced because it distracts

them from its source, which is more upsetting• Many have histories of severe trauma• Worry decreases arousal• But then fears don’t extinguish and linger

Treatment

• Sadly, few seek treatment – fewer than 20%• Do they think that’s just the way they are?

• Also, they need specialized help• General Practitioners under-prescribe and

break off treatment too early

Treatment – You have to face it

• Exposure is the key • Systematic Desensitization works well, even

w/out relaxation• CBT is successful, especially if it includes many

aspects of triggering stimuli• Behaviorists say that we learn a new response,

instead of erasing the old• Virtual reality technology can help

Specific treatments

• Phobias – in vivo (real life) exposure works even better than systematic desensitization

• Only a few hours can be enough

• GAD – exposure, starting with role-playing exercises

• Social skills training helps, especially if safety behaviors are recognized and overcome

Panic Disorder

• Psychodynamic treatment: 1) id the emotions & causes 2) gain insight• Small studies revealed this to be effective and

to prevent relapse• Panic Control Therapy – triggering sensations

are elicited, coping techniques are taught, ability to create & overcome weakens effect

More treatments

• Agoraphobia – systematic exposure w/ partner, who will not enable works

• GAD – all treatments feature a mix of behavioral and cognitive components

typically, relaxation exercises are used attempts to better cope w/ uncertainty “worry” exercises to weaken its impact

Medications

• Two basic types• Benzodiazepines such as Valium and Xanax• Antidepressants tricyclics selective serotonin reuptake inhibitors serotonin-norepinephrine reuptake

inhibitors• All provide relief from anxiety disorders

Which to choose?

• Antidepressants lack severe withdrawal effects, they aren’t addictive

• All have side-effects• Benzodiazepines cause cognitive and motor

problems, even memory lapses• Tricyclics can cause jitteriness, weight gain,

and others

Why SSRI’s?

• Preferred meds for anxiety disorders• 50% stop tricyclics• SSRIs have fewer side-effects• But they can occur• Include restlessness, sleep and sexxproblems,

and headaches

But it doesn’t last

• While meds work, once they aren’t taken, relapse usually follows

• Accordingly, psychological treatments featuring exposure are preferred

• Exception – GAD, which can be treated by buspirone (BuSpar)

Combining meds and psych treatments

• Surprisingly, combining works less than exposure treatments, of whatever type, alone

• Possibly because meds can impair facing the fear source