• Anxiety = apprehension over an anticipated problems
  • Fear = a reaction to immediate danger
  • Both fear and anxiety can involve arousal or sympathetic nervous system activity *both can be adaptive
  • Anxiety involves moderate arousal, fear involves high arousal
  • Fear is fundamental for fight or flight reactions
  • Anxiety disorders – fear system misfires, when there is no real immediate danger
  • Anxiety is adaptive in helping us plan for future threats
  • Small degree of anxiety improves performance on laboratory tasks
  • Anxiety has an inverse-U shaped relationship with test performance
  • Most common type of psyc disorder, phobias in particular *28% report anxiety symptoms

 

Associated with twice the average rate of medical costs, higher risk of cardiovascular disease, twice the risk of suicidal ideation and attempt

Clinical Description of Anxiety Disorders

1) Symptoms interfere with important areas of functioning or cause marked distress

2) Symptoms are not caused by a drug or a medical condition

3) Symptoms persist for at least 6 months or at least 1 month for a panic disorder

4) The fear and anxieties are distinct from the symptoms of another anxiety disorder

Specific Phobias

  • Specific phobia = a disproportionate fear caused by a specific object or situation
  • Recognizes fear is excessive, goes to great lengths to avoid feared object/situation  May elicit intense disgust
  • Must be severe enough to cause distress/interfere with job or social life *avoidance
  • Common: Claustrophobia and Acrophobia (fear of heights)  Specific phobias are highly comorbid  Criteria:
    • Marked and disproportionate fear consistently triggered by specific objects or situations o The object or situation is avoided or else endured with intense anxiety o Symptoms persist for at least 6 months Social Anxiety Disorder
  • Social anxiety disorder = a persistent, unrealistically intense fear of social situations that might involve being scrutinized by, or even exposed to, unfamiliar people
  • Labeled as social phobia in DSM-IV-TR
  • Feel as though all eyes are watching them, others waiting to evaluate them and record embarrassing acts
  • Avoid social situations, feel social discomfort and experience symptoms for longer time than people who are shy
  • Common fears: public speaking, speaking up in meetings or classes, meeting new people, talking to people in authority
  • Those with broader array of fears more likely to experience comorbid depression and alcohol abuse
  • Often work in occupations far below their talents
  • 1/3 meet the criteria for avoidant personality disorder
  • Generally begins during adolescence when peer relationships become particularly important  Tends to be chronic without treatment  Critera:
    • Marked and disproportionate fear consistently triggered by exposure to potential social scrutiny
    • Exposure to the trigger leads to intense anxiety about being evaluated negatively o Trigger situations are avoided or else endured with intense anxiety o Symptoms persist for at least 6 months Panic Disorder
  • Panic disorder = characterized by recurrent panic attacks that are unrelated to specific situations and by worry about having more panic attacks
  • Panic attack = a sudden attack of intense apprehension, terror and feelings of impending doom, accompanied by at least 4 other symptoms
  • Physical symptoms: shortness of breath, head palpitations, nausea, upset stomach, chest pain, feelings of choking and smothering, dizziness, light headedness, faintness, sweating/chills, heat sensation, numbness/tingling and trembling

Depersonalization = a feeling of being outside one’s body

  • Derealization = feeling of the world not being real
  • Fear of losing control, going crazy or even dying
  • Intense urge to flee
  • Symptoms come on rapidly and peak within 10 minutes
  • Feel amount of sympathetic nervous system arousal compared to normal when faced with immediate threat to life
  • Must experience recurrent panic attacks that are unexpected
  • Must worry about the attacks for at least 1 month
  • Onset typically in adolescence, symptoms wax and wane over time  Criteria:
    • Recurrent unexpected panic attacks
    • At least 1 month of concern about the possibility of more attacks, worry about the consequences of an attack, or maladaptive behavioral changes because of the attacks

Agoraphobia

  • Agoraphobia = anxiety about situations in which it would be embarrassing or difficult to escape if anxiety symptoms occurred *e.g. crowds, crowded places or situations (trains, bridges, road trips)
  • Unable to leave home
  • Coded as subtype panic disorder in DSM-IV-TR
  • At least half of people with agoraphobia do not experience symptoms of panic attacks  Related to significant impairment in daily functioning  Criteria:
    • Disproportionate and marked fear or anxiety about at least 2 situations where it would be difficult to escape or receive help in the event of incapacitation or panic-like symptoms, such as:
      • Being outside of the home alone; traveling on public transportation; open spaces such as parking lots and marketplaces; being in shops, theaters, or cinemas; standing in line or being in a crowd
      • These situations consistently provoke fear or anxiety
      • These situations are avoided, require the presence of a companion, or are endured with intense fear or anxiety
    • Symptoms last at least 6 months

Generalized Anxiety Disorder

  • GAD = central feature is worry, persistently worried often about minor things
  • Worry = cognitive tendency to chew on a problem and to be unable to let go of it
  • Cannot settle on a solution to the problem  Worry is excessive, uncontrollable and long-lasting  DSM Criteria:
    • 1) Excessive anxiety and worry at least 50% of days about a number of events or activities
    • 2) The person finds it hard to control the worry
    • 3) The anxiety and worry are associated with at least 3 (or 1 in children) of the following:
      • Restlessness/feeling keyed up/on edge, easily fatigued, difficulty concentrating/mind going blank, irritability, muscle tension, sleep disturbance
    • Typically begins in adolescence, often chronic
    • More strongly related to marital dissatisfaction than any other anxiety disorder

Comorbidity in Anxiety Disorders

  • More than 50% meet criteria for another anxiety disorder during lifetime

Highly comorbid with other disorders (75%)

  • ¾ meet criteria for some other psyc disorder
  • 60% meet criteria for MDD (others: substance abuse, personality disorders, medical disorders) Gender and Cultural Factors in the Anxiety Disorders

Gender

  • Women are more vulnerable than men (2:1 gender ratio)
  • Women are more likely to report their symptoms, gender roles play a role
  • Men face more pressure to face fears
  • Women more likely to experience childhood sexual abuse
  • Women show more biological reactivity to stress than men (HPA)

Culture

  • Culture and environment influence what people tend to fear
  • Japan – fear of displeasing others
  • Inuit – fear of being alone at sea and drowning
  • Koro – fear that genitals will recede into body
  • Shenkui – fear of loss of semen due to masturbation
  • Susto – fear that fright has caused soul to leave body
  • Rate of anxiety disorders varies by culture, ration of somatic to psychological symptoms is similar Common Risk Factors Across the Anxiety Disorders

Fear Conditioning

  • Mowrer’s two-factor model = suggests 2 steps in the development of an anxiety disorder:
    • 1) Classical conditioning – a person learns ot fear a neutral stimulus (CS) that is paired with an intrinsically aversive stimulus (UCS)
    • 2) A person gains relief by avoiding CS, through operant conditioning, this avoidant response is maintained because it is reinforcing (reduces fear) *helps maintain phobia  Different ways in which classical conditioning could occur:
    • 1) Direct experience (e.g. dog bite)
    • 2) Modeling (e.g. witnessing a dog bite someone)
    • 3) Verbal instruction (e.g. hearing a parent warn that dogs are dangerous)
  • People with anxiety disorders acquire fears through classical conditioning more readily, and show slower extinction once fear is acquired

Genetic Factors

  • Heritability of 20-40% for specific phobias, social anxiety disorder and GAD  50% for panic disorder

Neurobiological Factors: The Fear Circuit and the Activity of Neurotransmitters

  • Fear circuit = set of brain structures that are engaged when people feel anxious or fearful
  • Includes the amygdala (temporal lobe) – involved in assigning emotional significance to stimuli
  • Medial prefrontal cortex = helps to regulate activity of amygdala, involved in extinguishing fears and appears to be engaged when people are regulating their emotions o Less activity when viewing appraising threatening stimuli in anxiety disorders
  • Pathway connecting medial prefrontal cortex and amygdala may be deficient
  • Disruptions in serotonin and GABA receptors
  • GABA is believed to help inhibit anxiety
  • Increased levels of norepinephrine and changes in receptor sensitivity o Key in activation of SNS, for fight or flight responses

Personality: Behavioural Inhibition and Neuroticism

Behavioural inhibition = tendency to become agitated and cry when faced with novel toys, people, or other stimuli

  • May be inherited and set the stage for later development of anxiety disorders
  • Strong predictor of social anxiety disorder
  • Neuroticism = personality trait defined by tendency to experience frequent/intense negative affect o Predicts onset of anxiety disorders and depression, 2x as likely with high levels

Cognitive Factors

  • Sustained Negative Beliefs About the Future:
    • Believe that bad things are going to happen
    • Safety behaviours = behaviours that maintain feared beliefs (e.g. stop all physical activity if believe they will die from fast heart rate)
    • Believe only their safety behaviours are what have kept them alive  Perceived Lack of Control:
    • May be promoted by childhood traumatic events, punitive parenting or abuse o Often develop after serious life events that threaten the sense of control over one’s life o More than 70% report serious life event before onset of disorder  Attention to Threat:
    • Pay more attention to negative cues in environment than those w/o anxiety disorder o Heightened attention to threatening stimuli *automatically and quickly
    • Stay focused on threatening object longer than others do

Etiology of Specific Anxiety Disorders

Etiology of Specific Phobias

  • 2-factor model of behavioural conditioning (classical and operant)
  • Specific phobias seen as a conditioned response that develops after a threatening experience and is maintained by avoidant behaviour
  • Phobias could be conditioned by direct trauma, modeling, or verbal instruction
  • People may forget conditioning experiences that lead to phobia
  • Only certain kinds of stimuli and experiences will contribute to the development of a phobia o Could have evolutionary/adaptability basis
    • Prepared learning = evolution may have prepared our fear circuit to learn fear of certain stimuli very quickly and automatically

Etiology of Social Anxiety Disorder

  • Behavioural Factors: Conditioning of Social Anxiety Disorder:
    • 2-factor conditioning model
    • Negative social experience can lead to conditioned fear of stimulus, person avoids those situations/stimuli
    • Safety behaviours: avoiding eye contact, disengaging from conversation, standing apart from others
  • Cognitive Factors: Too Much Focus on Negative Self-Evaluations:
    • Unrealistically negative beliefs about the consequences of their behaviour
    • Attend more to how they are doing in social situations and their own internal sensations than most people do
    • Overly negative in evaluating their social performance
    • Attend more to internal cues than external

Etiology of Panic Disorder

  • Neurobiological Factors:
    • Locus coeruleus = major source of norepinephrine in the brain

 

  • Surges of norepinephrine are a natural response to stress, associated with increased activity of sympathetic nervous system
    • Faster heart rate, other fight or flight responses o W/anxiety disorder, show more dramatic biological response to drugs that trigger release of norepinephrine
  • Drugs that increase activity in locus coeruleus can trigger panic attacks, decrease (clonidine and antidepressants) decrease risk of panic attacks

Behavioural Factors: Classical Conditioning

  • Panic attacks are often triggered by internal bodily sensations of arousal
  • Panic attacks are classically conditioned responses to situations that trigger anxiety or internal bodily sensations of arousal
  • Interoceptive conditioning = classical conditioning of panic attacks in response to bodily sensations  Cognitive Factors in a Panic Disorder:
    • Focus on catastrophic misinterpretations of somatic changes
    • Panic attacks develop when a person misinterprets bodily sensations as signs of impeding doom (increased heart rate = heart attack)
    • Anxiety sensitivity index = measures the extent to which people respond fearfully to their bodily sensations
      • Can predict onset of panic attacks in longer-term studies
    • Putting it All Together: A Gene that Influences Neurobiological and Psychological Risk Factors for Panic Disorder:
      • Polymorphism in gene guiding neuropeptide S function – NPSR1 gene – tied to increased risk of panic disorder
      • Neuropeptide S related to anxiety-like behaviours in mice
      • NPSR1 gene related to increased amygdala response to threat stimuli, larger cortisol response to stressor, higher anxiety sensitivity scores

Etiology of Agoraphobia

  • Related to genetic vulnerability and life events
  • Fear-of-fear hypothesis = agoraphobia is driven by negative thoughts about the consequences of experiencing anxiety in public

Etiology of GAD

  • Tends to co-occur with other anxiety disorders
  • People who meet diagnostic criteria are much more likely to experience episodes of MDD
  • Seems to involve general tendency to experience general distress more than a specific pattern of intense fear
  • Related to a more amorphous profile of general distress
  • Worry is reinforcing because it distracts people from more powerful negative emotions and images
  • Worry does not involve powerful visual images and doesn’t produce the physiological changes that accompany emotion
  • More of a repetitive self-talk about bad things that might happen
  • Worrying decreases psycho-physiological arousal
  • Maltreatment predicts a 4 fold risk of developing GAD *worry distracts from remembering trauma
  • People with GAD may be avoiding emotions
  • People who have a hard time accepting ambiguity are more likely to worry and develop GAD

Treatment of Anxiety Disorders

  • Most individuals visit a family doctor for treatment and are prescribed benzodiazepines Commonalities Across Psychological Treatments

Common focus: exposure

  • CBT begins by making a list of triggers = situations and activities that might elicit anxiety or fear
  • Create an exposure hierarchy = a graded list of the difficulty of these triggers
  • Begin with exposure to less challenging triggers
  • Exposure treatment is effective for 70-90% of clients

1) Exposure should include as many features of the feared objects as possible

2) Exposure should be conducted in as many different contexts as possible

  • Works by extinguishing the fear response
  • Extinction involves learning new associations to stimuli related to the feared stimulus *which inhibit activation of fear
  • Extinction involves learning not forgetting
  • Cognitive – Exposure helps people correct their mistaken beliefs that they are unable to cope with the stimulus o Relieves symptoms by allowing people to believe that they can tolerate aversive situations o Focus on: 1) Challenging a person’s beliefs about the likelihood of negative outcomes if he faces an anxiety-evoking situation, and 2) Challenging the expectation that he will be unable to cope
  • Exposure to simulated situations can be just as effective as in-vivo exposure

Psychological Treatments of Specific Anxiety Disorders  Psychological Treatment of Phobias:

  • Exposure treatment including in-vivo exposure to feared objects o Brief treatments lasting only a couple hours can be very effective  Psychological Treatment of Social Anxiety Disorder:
  • Exposure therapy
  • Begin with role playing with therapist or small therapy group o Prolonged exposure can typically extinguish anxiety
  • Teach clients to stop using safety behaviour (e.g. avoiding eye contact) o Learn not to focus attention internally  Psychological Treatment of Panic Disorder:
  • CBT focuses on exposure
  • Panic control therapy (PCT) = based on the tendency of people with panic disorder to over react to the bodily sensations
    • Therapist uses exposure – persuades client to deliberately elicit bodily sensations associated with panic
    • Learn to stop seeing physical symptoms as signals of los of control  Psychological Treatment of Agoraphobia:
  • CBT focuses on exposure – systematic exposure to feared situations
  • Gradually coached to tackle leaving home, driving a couple miles away, sitting in a public place for a short amount of time
  • Enhanced results when patient’s partner is involved in exposure  Psychological Treatment of GAD:
  • Behavioural technique – relaxation training to promote calmness o g. muscle relaxation or generating calming images
  • Cognitive therapies to target worry – asking them to worry only during scheduled times

Medications That Reduce Anxiety

  • Anxiolytics = drugs that reduce anxiety

Benzodiazepines e.g. Valium, Xanax & antidepressants e.g. SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs)

  • Benzodiazepines referred to as mild tranquilizers/sedatives
  • Provide more benefits than placebos
  • Use buspirone for GAD
  • Antidepressants are preferred over benzodiazepines *severe withdrawal symptoms due to addictiveness, cognitive and motor side effects, increased risk of car accidents
  • Compared to tricyclic antidepressants, SSRIs and SNRIs tend to have fewer side effects *first choice o Can experience: restlessness, insomnia, headache, diminished sexual functioning
  • Many people relapse once they stop taking medications
  • Psychological treatment is preferred method with exception of for GAD

Medication to Enhance Learning During Psychological Treatment

  • D-cycloserine (DCS) = a drug that enhances learning *used to bolster exposure treatment