Anxiety Disorders

1. What is anxiety? When does it become a disorder?

What Happens When People Feel Anxious?

Physiological: Cognitive: Behavioral:

• Racing heart • Anticipate harm • Escape
• Difficulty breathing • Worry • Avoidance
• GI distress • Exaggerate danger • Irritability
• Sweating • Difficulty concentrating

• Tense muscles • Hypervigilance

• Trembling / shaking

Flight or Fight Response!

When our brain detects danger, it sends a signal to mobilize our body to prepare
• Sympathetic nervous system activates the body for fight or flight

• To mobilize our body to respond to a perceived

threat

• It is necessary for survival, adaptive

The problem with anxiety, is that our brain sounds

the alarm bell regardless of whether a threat is
actually there.

What is “Anxiety”?

Anxiety: Response to perceived or anticipated threat (vs. actual immediate threat – fear)
• Misfiring of the alarm response

• Panic attack: Full fight or flight response (no immediate threat or danger)

Anxiety can also be helpful – prepare or motivate us

• Yerkes-Dodson Law
◦Suggests if we don’t have anxiety to a certain level, we are not paying attention, it
doesn’t engage our interest we are not taking any action.
 The issue is in anxiety disorders is when a
person is operating at the extreme level
chronically

At medium level of arousal, we have optimal

arousal for optimal performance.

When Does Anxiety Become a Disorder?

• When symptoms arise in absence of real threat and it is:
◦Excessive or inappropriate, pervasive

◦Causes significant distress and/or impairment

What Maintains Anxiety?

In general... if anxiety disorders involve fears of situations that are not really dangerous,
why doesn’t the fear go away over time?

Avoidance
• Key mechanism across anxiety disorders that explains why they are maintained

• Avoidance can reduce anxiety in the moment

• But it prevents the natural decline of anxiety

Avoidance:

It feels good in the moment to escape or avoid an anxious situation. That’s what’s
reinforcing about it and keeps people in the cycle of anxiety

What are consequences of avoidance?

• It prevents learning of new information about the consequences of the feared event
◦Example: Fumbling over words in a presentation does not result in failure or
rejection

Safety Behaviors

Overt or covert actions performed in order to reduce distress associated with feared cues

Safety behaviors maintain anxiety by misattributing safety that prevent the challenge of
maladaptive beliefs

Reinforced because it “works” – feels better in the moment

Safety Behaviors: Examples in Social Anxiety?
• Drinking alcohol in social situations

• Bringing a “safe” person to any social interactions

• Rehearsing exactly what to say during a casual conversation

• Not making eye contact

Safety Behaviors: Examples in Panic Disorder?

• Taking pulse

• Reassurance seeking from doctor - many individuals visit the ER!

• Medication

• Sitting close to an exit

DSM-5 Anxiety Disorders:

• Specific Phobia

• Social Anxiety Disorder

• Generalized Anxiety Disorder

• Panic Disorder

• Agoraphobia

Etiology of Anxiety Disorders

Biological Factors:
• Genetics

• Overreactive fear circuitry

• Abnormalities in Neurotransmitters

Behavioral Factors:
• conditioning experiences

• Modelling

Cognitive Factors:
• negative cognitive appraisal

• anxiety sensitivity
Biological Factors

Genetic influences -moderate heritability

• Temperament/personality:
◦Behavioral inhibition-> tendency to withdraw from unknown

◦Neuroticism (GAD) – tendency to experience negative affect

• Brain structures implicated in anxiety disorders

◦Overactivation of:
‣ Amygdala, hippocampus, prefrontal cortex, locus ceruleus (panic)

• Gamma-Aminobutyric acid (GABA) deficiency

Behavioral Factors

Classical conditioning:
• Conditioned fear response to previously neutral
stimulus

• Conditioned stimuli elicit fear in absence of

danger

• Stimulus generalization → more feared stimuli

Operant conditioning:
• Negative reinforcement

• Maladaptive behaviors(avoidance or safety behaviors) maintain fear

Modeling of feared response:

• a person can learn fears through imitating the reaction of others.

• vicarious learning
◦The learning of fear by observing others

• Anxious rearing model

◦Is based on the premise that anxiety disorders in children are due to constant
parental warnings that increase anxiety in the child.
Cognitive Factors:

• Incorrectly interpreting events (even ambiguous ones) as threatening

• Common maladaptive cognitions:

◦Overestimation of likelihood: Exaggerating the likelihood of a feared outcome

◦Overestimation of severity (catastrophizing): exaggerating the severity of a feared

outcome if it were to occur

• Biased information processing

◦Increased attention toward threat

◦More quickly to notice feared cue(s), even at low levels

◦Results in selective attention -> threat-focused

• Anxiety sensitivity
◦Fear of physiological changes within
the body

◦Predicts development of panic

attacks and anxiety disorders

The DSM: Specific Phobia

• should last 6 months or more

• cause significant stress or impairment

Common Specific Phobias

Blood injection/injury

Situations (elevators, planes, enclosed spaces)

Animals (insects, dogs, or snakes)

Natural environment (storms, height, water)

Other (clowns, vomiting, or chocking)

Prevalence of Specific Phobias

• Kessler et al 2005:
◦lifetime prevalence of 12.5%

• A mean duration of 20 years

• X2 common in women

• only 8% receive treatment

Etiology of Specific Phobias:

• Biology
◦Genetics

◦Overactivation of amygdala and insula

◦Autonomic lability
‣ How labile or reactive one’s autonomic nervous system is.
• Labile = is when your autonomic nervous system is readily aroused by wide
range of stimuli

• Behavioral
◦Phobia is a learned behavior (classical & operant conditioning)

◦Modelling of behavior

◦Prepared Learning
‣ Humans are naturally inclined to acquire fear to certain things more than others
• Spiders, snakes, heights

• Cognitive
◦After a negative experience, believing that they are not in control or other
catastrophic thoughts
Social Anxiety Disorder (SAD): DSM-5 Criteria

• last 6 months or more

• cause significant
distress or
impairment

Prevalence & Course of SAD

• Lifetime prevalence 12.1%

• Average age of onset 13 years old

• Average duration 20 years

• Prevalence roughly equivalent across sexes

• Prevalence higher for:

◦Never married or divorced

◦Lower SES

◦Low social support

Etiology of SAD:

• Biology
◦Genetics

◦Overactivation of amygdala and insula

◦Autonomic lability
‣ How labile or reactive (vs. stable) one’s autonomic nervous system
• Labile = autonomic nervous system readily aroused by wide range of
stimuli

• Behavioral
◦Social skills deficits: Lack of social skills or inappropriate behavior leads to
discomfort in social situations

◦Individual may be criticized

•Specific cognitive processes linked to social anxiety

◦Attention focus on negative social information

◦Interpret ambiguous social situations as negative and reflect their own

 shortcomings

◦Perfectionistic standards

◦Core belief of “self is deficient or inadequate”

◦Post-event processing of negative

experiences (rumination)

DSM Criteria: Panic Disorder:

What’s a Panic Attack?

Abrupt surge of intense fear/discomfort, reaches peak within minutes, with ≥4 symptoms:

• Palpitations, pounding heart, accelerated heart rate

• Trembling/shaking

• Sensations of shortness of breath

• Feelings of choking

• Chest pain or discomfort

• Nausea, abdominal distress

• chills/heat sensations

• Feeling dizzy, unsteady, light-headed, sweating

• Paresthesia (numbness/tingling sensations)

• Derealization or depersonalization

• Fear of losing control, going crazy, or of dying

Prevalence & Course of Panic Disorder

• Lifetime prevalence 4.7%

• Isolated panic attacks: 22.7%

• 80-90% report first panic attack after negative life event

• 2x more prevalent in women than men

• Panic attacks may be marker of severe psychopathology

DSM Criteria: Agorphobia

• last 6 months

• Cause significant
stress or
impairment

Prevalence of Agoraphobia

• Lifetime prevalence 1.3% adults

• 2x more prevalent in women than men

Etiology of Panic & Agoraphobia

• Biology
◦Genetics

◦Panic is caused by overactivity in the noradrenergic system (locus ceruleus)

◦Fewer GABA-receptor among individuals with panic disorder

◦Hypersensitivity to Cholecystokinin (CCK) peptide

• Behavioral
◦Interoceptive conditioning

◦Classical conditioning of interoceptive cues (sensations within the body)

• Cognitive
◦Misinterpretation of physiological arousal (catastrophizing)
◦E.g., interpreting racing heart as sign of great danger

◦Overtime, person develops fear of these internal sensations