ANXIETY DISORDER

Dr. Hilwa Abdullah @ Mohd. Nor

15th October 2019
SKPX 3143
ANXIETY, FEAR, PANIC
Nature of Anxiety and Fear
 Anxiety
 Future-orientedmood state
 Characterized by marked negative affect
 Somatic symptoms of tension
 Apprehension about future danger or misfortune

 Fear
 Present-oriented mood state, marked negative affect
 Immediate fight or flight response to danger or threat
 Strong avoidance/escapist tendencies
 Abrupt activation of the sympathetic nervous system

 Anxiety and Fear are Normal Emotional States

From Normal to Disordered Anxiety
and Fear
 Characteristics of Anxiety Disorders
 Psychological disorders – Pervasive and persistent
symptoms of anxiety and fear
 Involve excessive avoidance and escapist tendencies

 Causes clinically significant distress and impairment

The Phenomenology of Panic Attacks

 What Is a Panic Attack?

 Abruptexperience of intense fear or discomfort
 Accompanied by several physical symptoms

 DSM-IV Subtypes of Panic Attacks

 Situationally bound (cued) panic
 Unexpected (uncued) panic

 Situationally predisposed panic

PANIC ATTACK
 Situationally bound – panic attack in certain situations but
not anywhere else.
Eg : afraid of high places / driving along bridges
 Unexpected – you don’t have a clue when or where the next
attack will occur.
 Situationally predisposed – Certain situations or places
could make someone with panic disorder or another anxiety
disorder more likely to have a panic attack, but they might
not always have panic attacks in these situations or places.
Eg : Someone with panic disorder might occasionally
experience panic attacks while driving. They don’t have
panic attacks every time they drive, and they don’t have a
specific fear of driving itself. Driving simply increases their
chances of having a panic attack.
 The Phenomenology of Panic Attacks

Figure 5.1 The relationships among anxiety, fear, and panic attack.
Biological Contributions to Anxiety and
Panic
 Inherit a tendency to be tense or uptight (Eysenck, 1967;
Gray & McNaughton, 1996).
 Stress and life circumstances activate vulnerability to
anxiety.
 Anxiety associated with specific brain circuits and
neurotransmitter systems – depleted levels of GABA
associated with increased anxiety.
 Limbic system – area of the brain that most associated with
anxiety.
 Behavioral inhibition system (BIS) is activated by signals
from the brain stem of unexpected events – major changes
in body functioning that might signal danger.
Limbic System
Psychological Contributions to Anxiety and
Fear
 Began with Freud
 Anxiety is a psychic reaction to danger surrounding the
reactivation of an infantile fearful situation.
 Behavioral theorists
 View anxiety as a product of early classical conditioning,
modeling, or other forms of learning (Bandura, 1986)
 Psychological Views
 Early experiences with uncontrollability / unpredictability –
children should have a sense of control.
 Parents interact positively and predictable way with their
children by responding to children’s needs – develop a
healthy sense of control.
Social Contributions To Anxiety and Fear

 Stressful life events trigger vulnerabilities to

anxiety.
 Many stressors are familial and interpersonal –
marriage, divorce, difficulties at work, death of a
loved one.
 Social pressures – have to excel in school – stress to
trigger anxiety.
The Anxiety Disorders: An Overview

 DSM-5 Anxiety Disorders

 Specific phobias

 Social anxiety disorder

 Panic disorder

 Agoraphobia

 Generalized anxiety disorder

 Most common psychiatric disorders

 Most common are phobias
 GENERALIZED ANXIETY DISORDER:
The “Basic” Anxiety Disorder
 Facts and Statistics
 GAD affects 4% of the general population.

 More prevalent in females and elderly.

 Onset is often insidious, beginning in early adulthood – in

response to life stressor.
 Tendency to be anxious runs in families

 People with general nervousness, depression, inability to

tolerate frustration, and feelings of being inhibited are
more likely to be shown in GAD patients.
 GENERALIZED ANXIETY DISORDER:
Causes and Treatment
 Causes
 GAD tends to run in families (Noyes, Clarkson, 1987).
 Psychological and social contribution – life stress events.

 Treatment of GAD
 Benzodiazapines – Often prescribed (give some relief
in the short term)
Disadvantages = impair both cognitive and motor
functioning, pt don’t see alert, produce psychological
and physical dependency.
 GENERALIZED ANXIETY DISORDER:
Treatment
 Psychological interventions – Cognitive-Behavioral
Therapy (CBT)
- which involves a therapist working with the patient
to understand how thoughts and feelings influence
behavior.
- goal of the therapy = to change negative thought
patterns that lead to the patient's anxiety, replacing
them with positive, more realistic ones.
- CBT can be used alone or in conjunction with
medication.
AN INTEGRATIVE MODEL OF GENERALIZED ANXIETY DISORDER
 Frequent panic attacks unrelated to specific situations
 Panic attack

Sudden, intense episode of apprehension, terror, feelings of impending doom

Intense urge to flee
Symptoms reach peak intensity within 10 minutes
Physical symptoms can include:
Labored breathing,
heart palpitations,
nausea,
upset stomach,
chest pain,
feelings of choking and smothering,
dizziness,
sweating,
lightheadedness,
chills,
heat sensations,
trembling
 Uncued attacks
 Occur unexpectedly without warning
 Panic disorder diagnosis requires recurrent uncued attacks
 Causes worry about future attacks
 Cued attacks
 Triggered by specific situations (e.g., seeing a snake)
 More likely a phobia
PANIC ATTACK
 Situationally bound – panic attack in certain situations but
not anywhere else.
Eg : afraid of high places / driving along bridges
 Unexpected – you don’t have a clue when or where the next
attack will occur.
 Situationally predisposed – Certain situations or places
could make someone with panic disorder or another anxiety
disorder more likely to have a panic attack, but they might
not always have panic attacks in these situations or places.
Eg : Someone with panic disorder might occasionally
experience panic attacks while driving. They don’t have
panic attacks every time they drive, and they don’t have a
specific fear of driving itself. Driving simply increases their
chances of having a panic attack.
 From the Greek word “agora” or
marketplace
 Anxiety about inability to flee
anxiety- provoking situations
 E.g., crowds, stores, malls,
churches, trains, bridges,
tunnels, etc.
 Causes significant impairment
 SPECIFIC PHOBIAS:
An Overview
 Overview and Defining Features
 Extreme and irrational fear of a specific object or
situation that markedly interferes with one's ability to
function.
 Recognize fear and anxiety are excessive or
unreasonable.
 Facts and Statistics
 Affectsabout 11% of the general population
 Females are again over-represented
 Phobias run a chronic course
 Onset beginning between 15 and 20 years of age
 Marked and disproportionate fear consistently triggered by specific objects
or situations
 The object or situation is avoided or else endured with intense anxiety
 Symptoms persist for at least 6 months
 Note: The DSM-IV-TR criterion that the person recognizes that the fear is
unrealistic is not included in DSM-5.
 DSM-IV-TR includes the duration criterion only for those under age 18
 SPECIFIC PHOBIAS:
Associated Features and Treatment
 Associated Features and Subtypes of Specific Phobia
1. Blood-injury-injection phobia – Vasovagal response
2. Situational phobia – Public transportation or enclosed
places (e.g., planes)
3. Natural environment phobia – Events occurring in nature
(e.g., heights, storms)
4. Animal phobia – Animals and insects
5. Other phobias – Do not fit into the other categories
(e.g., fear of choking, vomiting)
 Separation anxiety disorder – Children’s worry that
something will happen to parents or to themselves that
will separate them from their parents.
Phobias beginning with “A”

Term Fear of:

Acarophobia Insects, mites
Achluophobia Darkness, night
Acousticophobia Sounds
Acrophobia Heights
Agyiophobia Crossing the street
Aichmophobia Sharp, pointed objects, knives
Ailurophobia Cats
Amathophobia Dust
Aphephobia Physical contact, being touched
Antlophobia Floods
 SPECIFIC PHOBIAS:
Causes
 Causes of Specific Phobias
- direct experience – trapped in the elevator (
claustrophobia)
- experiencing a panic attack in specific situation.
- vicarious experience - observing someone else
experience severe fear – fear of dental situations
(overheard the scream while waiting for his turn).
 SPECIFIC PHOBIAS:
Treatment
 Psychological Treatments of Specific Phobias
 Cognitive-behavior therapies are highly effective

 Structured and consistent graduated exposure-

based experience.
 Marked and disproportionate fear consistently triggered by exposure to
potential social scrutiny
 Exposure to the trigger leads to intense anxiety about being evaluated
negatively
 Trigger situations are avoided or else endured with intense anxiety
 Symptoms persist for at least 6 months.
 Note: DSM-IV-TR labels this disorder as social phobia

 The DSM-IV-TR, but not the DSM-5, specifies that the person recognizes
the fear is unrealistic
 DSM-IV-TR includes the duration criterion only for those under age 18
 SOCIAL ANXIETY:
An Overview
 Overview and Defining Features
 Extreme and irrational fear/shyness

 Focused on social and/or performance situations

 Markedly interferes with one's ability to function

 May avoid social situations or endure them with distress

 Generalized subtype – Anxiety across many social situations

 Facts and Statistics

 Affects about 13% of the general population at some point

 Females are slightly more represented than males

 Onset is usually during adolescence

 Peak age of onset at about 15 years, later than specific

phobias but earlier than panic disorder.
 Summary of Anxiety-Related
Disorders
 Anxiety Disorders Are the Largest Domain of Psychopathology
 From a Normal to a Disordered Experience of Anxiety and
Fear
 Requires consideration of biological, psychological,
experiential, and social factors
 Fear and anxiety in the absence of real threat or danger
 Develop avoidance, restricted life functioning
 Cause significant distress and impairment in functioning
 Psychological Treatments
 Are Generally Superior in the Long-Term
 Treatments include similar components
 Suggests that anxiety disorders share common processes
Exploring Anxiety Disorders
Exploring Anxiety Disorders
Exploring Anxiety Disorders
Exploring Anxiety Disorders (cont.)
Exploring Anxiety Disorders (cont.)
 Psychological treatments emphasize
Exposure
 Face the situation or object that triggers anxiety
 Shouldinclude as many features of the trigger as possible
 Should be conducted in as many settings as possible
 70-90% effective
 Systematic desensitization
 Relaxation plus imaginal exposure

 Cognitive approaches
 Increase belief in ability to cope with the anxiety
trigger
 Challenge expectations about negative outcomes
 Phobias
 Exposure
 In vivo (real-life) exposure more effective than systematic desensitization

 Social Anxiety Disorder

 Exposure
 Role playing or small group interaction
 Social skills training
 Reduce use of safety behaviors
 Cognitive therapy
 Clark’s (2003) cognitive therapy more effective than medication or exposure
 Systematic desensitization is a type of behavioral therapy based on the
principle of classical conditioning. It was developed by Wolpe during the
1950s.
 This therapy aims to remove the fear response of a phobia, and substitute a
relaxation response to the conditional stimulus gradually using counter
conditioning. There are three phases to the treatment:
 First, the patient is taught a deep muscle relaxation technique and breathing
exercises. E.g. control over breathing, muscle detensioning or meditation. This
step is very important because of reciprocal inhibition, where once response is
inhibited because it is incompatible with another. In the case of phobias, fears
involves tension and tension is incompatible with relaxation.
 Second, the patient creates a fear hierarchy starting at stimuli that create the
least anxiety (fear) and building up in stages to the most fear provoking
images. The list is crucial as it provides a structure for the therapy.
 Third, the patient works their way up the fear hierarchy, starting at the least
unpleasant stimuli and practising their relaxation technique as they go. When
they feel comfortable with this (they are no longer afraid) they move on to the
next stage in the hierarchy. If the client becomes upset they can return to an
earlier stage and regain their relaxed state.
 The client repeatedly imagines (or is confronted by) this situation until it fails to
evoke any anxiety at all, indicating that the therapy has been successful. This
process is repeated while working through all of the situations in the anxiety
hierarchy until the most anxiety-provoking.
 Thus, for example, a spider phobic might regard one small, stationary spider 5
meters away as only modestly threatening, but a large, rapidly moving spider
1 meter away as highly threatening. The client reaches a state of deep
relaxation, and is then asked to imagine (or is confronted by) the least
threatening situation in the anxiety hierarchy.
 Panic Control Therapy (PCT; Craske & Barlow, 2001)
 Exposure to somatic sensations associated with panic attack in
a safe setting
 Increased heart rate, rapid breathing, dizziness
 Use of coping strategies to control symptoms
 Relaxation
 Deep breathing
 PCT benefits maintained after treatment ends

https://www.psychotherapy.net/video/CBT-anxiety
 Cognitive Behavioral Therapy (CBT)
 Systematic exposure to feared situations
 Self-guided treatment effective
 Relaxation training
 Cognitive Behavioral methods
 Challenge and modify negative thoughts
 Increase ability to tolerate uncertainty
 Worry only during “scheduled” times
 Focus on present moment
 Anxiolytics: drugs that reduce anxiety
 Benzodiazepenes

 Valium
 Xanax
 Antidepressants

 Tricyclics
 Selective Serotonin Reuptake Inhibitors (SSRIs)
 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
 D-cycloserine (DCS)

 Enhances learning during exposure treatment