ANXIETY DISORDERS

Central defining feature

❧
❧ A future oriented and global response, involving
both cognitive and emotional components
❧ The individual is inordinately tense, apprehensive
and uneasy about the prospect of something terrible
happening
TYPES OF ANXIETY
DISORDERS
 SYMPTOMS OF ANXIETY

❧
SOMATIC EMOTIONAL COGNITIVE BEHAVIOURAL

■ Goosebumps ■ Sense of dread ■ Anticipation of ■ Escape

■ Muscle tense ■ Terror harm ■ Avoidance
■ Heart rate ■ Restlessness ■ Exaggeration ■ Aggression
rise ■ Irritability
of danger ■ Freezing
■Increased ■ Problems in
■ Reduced
respiration concentration appetite
■Pupils dilate ■
■ Increased
■Perspiration Hypervigilance aversive
rises ■ Worry responding
■Adrenaline ■ Rumination
secreted ■ Fear losing
■Bladder control
relaxes ■ Fear of Dying
■ Sense of
 Separation Anxiety
Disorder
❧
❧ Intense and inappropriate Anxiety concerning
separation from home and care giver
❧ Avoid situations in which they part from figure of
attachment
❧ Prior to any such event they get distressed
❧ When separated, they feel something terrible will
happen to them or their loved ones
❧ Prevelance – 4.1% of children
 Theories of Separation
Anxiety Disorder
❧

❧ Higher rate - genetically vulnerable

individuals growing up in low income
environments
❧ In response to Natural /man made
disaster
Treatment of Separation
Anxiety Disorder
❧
❧ Systematic desensitization
❧ Prolonged exposure
❧ Modelling
❧ CBT
 Selective Mutism
❧
❧ Refusing to talk in specific situations
❧ Capable of using normal language but…..
❧ .2 to 2 % - prevelance
❧ Found equally in boys and girls
❧ Treatment:
❧ Shaping and exposure
❧ Contingency management
 Specific Phobias
❧
❧ An irrational and unabating fear of a particular
object, activity, or situation that provokes an
immediate anxiety response, disrupts functioning,
and results in avoidance behavior.
 Specific Phobias
❧
❧ Hematophobia - Blood
❧ Ephidophobia - Snakes
❧ Claustrophobia - Closed spaces
❧ Acrophobia - Heights
❧ Aerophobia - Flying
❧ Death-related phobia - Funerals, corpses, and
cemeteries
 Specific Phobias
❧
❧ Extreme fear of a specific living thing, object or
situation.
 Criteria
❧
❧ Individual experiences excessive and persistent fear of a
specific object or situation and has feelings of anxiety, fear,
or panic right when encountering it
❧ The person knows that their reaction of fear is unreasonable
❧ Individual’s fear, anxiety, or avoidance causes significant
distress or it interferes with the person’s day to day life
❧ In children younger than 18 years old, the problem must be
present for at least six months before diagnosing a specific
phobia
❧ The person’s fear, panic, and avoidance aren’t better
explained by another disorder
 Types
❧
❧ Animal- fear of animals
❧ Natural Environment- fear of heights, storms and
being near water
❧ Blood-Injection/Injury- fear of seeing blood,
having a blood test or injection, watching medical
procedures
❧ Situational- driving, flying, elevators, enclosed
places
❧ Other- other specific fears
 Causes
❧
❧ Direct learning experiences- can begin following a
traumatic experience
❧ Observational learning experiences- learn to fear a
situation by watching others show signs of a fear in
the same situation
❧ Informational Learning- learning to fear an object or
situation by hearing or reading that the situation is
dangerous
 Causes
❧
❧ People with specific phobias tend to pay more attention
to threatening information that relates to the fear
❧ Also tend to have distortions in their memories for
encounters of fear
❧ People with specific phobias tend to hold beliefs and to
interpret situations in a way that increases anxiety
❧ Avoidance of fear prevents people with specific
phobias from learning that the situations they fear are
not as “dangerous” as they think it is
❧ Sometimes a phobia may run in the family and genetics
may play a role
 Treatment
❧
❧ Systematic Desensitization
❧ Flooding
❧ Imaginal Flooding
❧ Graduated Exposure
❧ Thought Stopping
❧ Exposure to feared situations
❧ Applied muscle tension
❧ Virtual reality software is sometimes used to treat
people with phobias such as fear of heights or flying.
Social Anxiety Disorder
❧
❧ A social phobia involves a fear in virtually all social
situations.
People with social phobia:
❧ recognize their own fears as unreasonable
❧ show low self-esteem
❧ underestimate their own abilities
❧ ruminate about how they could have
acted differently in a social event.
Theories and Treatment
❧
❧ Genetic links with shyness and Neuroticism

❧ In Vivo Exposure
❧ Cognitive Restructuring
❧ Social Skills Training
❧ Sometimes alternate methods like
❧ Motivational interviewing
❧ ACT
❧ Mindfulness meditation
❧ Drugs used- SSRI’s and SNRI’s
PANIC DISORDER
SYMPTOMS

HEART PALPITATIONS
NUMBNESS OR TINGLING
CHILLS OR HOT FLUSHES
SWEATING
TREMBLING OR SHAKING
SHORTNESS OF BREATH
FEELING OF CHOKING
CHEST PAIN OR DISCOMFORT
NAUSEA OR STOMACH DISCOMFORT
DIZZY, LIGHTHEADEDNESS OR FAINT
FEAR OF LOSING CONTROL
FEAR OF DYING
 Types of Panic Attacks
❧
❧ Unexpected ( uncued)
❧ Situationally bound (cued)
❧ Situationally predisposed
 EPIDEMIOLOGICAL DATA
❧
❧ PREVELANCE: 1.5 TO 4% ( LIFETIME)

❧ AGE OF ONSET: LATE ADOLESCENCE TO MID THIRTIES

❧ COURSE: CHRONIC ( 92% PATIENTS CONTINUE

TO EXPERIENCE THE SYMPTOMS FOR
ATLEAST A YEAR)

❧ RELAPSE RATE: 41% WITHIN A YEAR

❧ OTHER IMP INFO: 50% MAY DEVELOP AGORAPHOBIA

ALONG WITH PANIC
THEORIES OF PANIC DISORDER
NEUROTRANSMITTER:

Poor regulation of
❧ Norepinephrine
❧ Serotonin
❧ GABA
THEORIES OF PANIC DISORDER
KINDLING MODEL:

❧ Poor regulation in the Locus

Ceruleus causes Panic Attack,
❧ That stimulates and kindles
the Limbic system
❧ Which in turn lowers the
threshhold of diffuse and
chronic anxiety
❧ Poorly regulated flight or fight
response, therefore easily
indusable panic attacks.
THEORIES OF PANIC DISORDER
SUFFOCATION,
FALSE ALARM
MODEL

❧ Brains of people with PD are

hypersensitive to CO2 and
induce the flight or fight
response with small increases
in CO2
THEORIES OF PANIC DISORDER

GENETIC THEORIES:
❧ Runs in families
❧ 10% of first degree relatives of
PD also have PD
❧ Disordered Genes increase the
risk for Panic Disorder
 THEORIES OF PANIC DISORDER
COGNITIVE THEORIES:

❧ People prone to Panic attacks

1. Pay very close attention to their
bodily sensations
2. Misinterpret theses sensations
3. Engage in snowballing,
catastrophising.
❧ Can avoid a Panic attack if a Safe
person is around.
❧ Vulnerability Stress Model
Agoraphobia:
Intense anxiety about being trapped or
stranded in a situation without help if a panic
attack occurs.
 TREATMENT OF ANXIETY
Biological
❧ Tricyclic Antidepressants
➢ Reduces panic attacks in 45
❧
to 70% pts ❧ Selective serotonin
➢ Improves norepinephrine reuptake inhibiters
functioning ➢ Increase the functional
➢ Side effects: blurred vision, level of serotonin
dry mouth, constipation, ➢ Side effects:
increased heart rate, sleep gastrointestinal upset,
disturbances, hypotension, irritability, insomnia,
sexual dysfunction tremor & sexual
➢ Overdose can lead to death dysfunction.
 TREATMENT OF ANXIETY
Biological
❑ Benzodiazapines
➢ Supress the central
nervous system
➢ Influences functioning in
the GABA,
Norepinephrine and
Serotonin
Neurotransmitter systems
➢ Disadv:
1. Addictive
2. Interfere with cognitive
and motor functioning
3. 90% relapse rate.
 TREATMENT OF ANXIETY
cognitive Behavioural Therapy
❧
➢ Steps in CBT
1. Relaxation and breathing exercize
2. Identifying the catastrophizing cognitions
3. Practice using relaxation and breathing while
experiencing panic symptoms in the clinic
4. Challenging catastrophizing thoughts
5. Systematic desensitization
 Generalized Anxiety
Disorder
❧
❧ Generalized Anxiety Disorder:
❧ An anxiety disorder characterized by anxiety that
is not associated with a particular object, situation, or
event, but seems to be a constant feature of a
person's day-to-day existence.
❧ Symptoms
❧ Restlessness
❧ Sleep disturbances
❧ Fatigue
❧ Irritability
❧ Muscle tension
Theories and Treatment
❧
❧ Disturbances in GABA, serotonergic and
noradrenergic systems
❧ Product of cognitive distortions
❧ Magnify daily problems
❧ Become unduly apprehensive
❧ Worry about their worry
❧ Inefficient due to anxiety
❧ Low self efficacy
CBT
 Obsessive-Compulsive
Disorder
❧
❧ Obsessive-Compulsive Disorder:
❧ An anxiety disorder characterized by recurrent
obsessions or compulsions that are inordinately time-
consuming or that cause significant distress or
impairment.
❧ Obsession: A persistent and intrusive idea, thought,
impulse, or image.
❧ Compulsion: A repetitive and seemingly purposeful
behavior performed in response to uncontrollable urges
or according to a ritualistic or stereotyped set of rules.
 Obsessive-Compulsive
Disorder
❧
❧ Compulsions
❧ Repetition (washing, cleaning, counting,
checking….)
❧ Rituals (making certain signs…..)
❧ Four major dimentions
❧ Obsessions associated with checking compulsions.
❧ Need for symmetry and order.
❧ Obsessions about cleanliness associated with
washing compulsions.
❧ Hoarding-related behaviors.
Theories and Treatment
❧
❧ So far, treatment with clomipramine or other
serotonin reuptake inhibiting medications, such a
fluoxetine (Prozac), is the most effective biological
treatment available for OCD.
❧ Neurosergery
❧ Deep brain Stimulation
❧ CBT
❧ Thought stopping
❧ Response prevention after exposure
❧ Satiation Therapy
Body Dysmorphic Disorder
❧
❧ Individuals are preoccupied with the idea that a part
of their body is ugly or defective.
❧ Check themselves constantly and groom themselves
execcessively or constantly seek assurance from
others about how they look.
❧ 29% college students are preoccupied with their
looks only 14% of them meet the criteria for BDD
❧ Prevelance in 2.5% for women and 2.2% for men
❧ Women – size of Breasts, eyes, nose & weight
❧ Men – hair thinning, size of Penis, body built
Theories and Treatment
❧
❧ People with BDD have suicide rates 45 times higher
than general population
❧ Childhood teasing
❧ Negative body image
❧ Excessive self focus

❧ SSRIs
❧ CBT
❧ Appearance only one part
❧ Response prevention
❧ Address low self esteem
 Trichotillomania
❧
❧ Hair pulling in response to excessive tension or urge
and relief on doing it.
❧ Social , occupational or other areas are impaired due
to this disorder
❧ Results in bald patches and lost eyebrows, eyelashes,
armpit hair or pubic hair
❧ May develop trichobezoars causing nausea,
vomiting, pain, weakness or weight loss.
❧ May develop skin infections, scalp pain, bleeding
❧ Begins early And continues into adulthood.
 Cont….
❧
❧ DSM-V changed the name to Hair Pulling Disorder
❧ Prevelance rate is .6%
❧ Two types – 1. focussed type and 2. automatic type
Theories and Treatment
❧chromosome no. 1 known
❧ Abnormalities in gene on
as SLTRK1. ( linked to tourette’s disorder)
❧ On Gene SAPAP3 related to Glutamate- involved in
OCD
❧ Abnormalities in neural pathways involved in
generating and suppressing motor habits.
❧ Antidepressants / atypical antipsychotics / lithium
/ Neltrexone
❧ Side effects – obesity, diabetes, neurotoxicity,
delirium, tremors or hyperthyroidism.
❧ Habit reversal training
Excoriation ( Skin Picking) Disorder
❧
❧ Repeatedly pick on their own skin
 TRAUMA
❧
❧ Reactive Attachment Disorder
❧ Severe disturbances in the way they relate to others.
❧ Emotionally withdrawn and inhibited
❧ Do not seek support when distressed.
❧ Disinhibited Social Engagement Disorder
❧ Culturally inappropriate, overly familiar behaviour

❧ Found in children with history of Abuse/neglect/

repeated change of primary caregivers
 ❧
❧ Acute Stress Disorders
❧ Exposure to near death experience/threatened
serious injury / sexual violation may lead to it.
❧ symptoms
❧ Intrusions
❧ Dissociative feelings and numbing
❧ Avoidance
❧ Hyper arousal
❧ Lasts from a few days to a month.
 ❧
❧ Post-Traumatic Stress Disorder:
❧ More than a month after a traumatic event, stress
interferes with the individual’s ability to function.
❧ Lifetime prevalence -6.8%
❧ In addition to above symptoms,
❧ Loss of memory
❧ Excessive self blame
❧ distancing from others
❧ Inability to experience positive emotions
 Perspectives on Trauma-Induced
Disorders
❧
❧ Brain Changes (alterations in Hippocampus)
❧ prime the brain for further danger
❧ may be unable to distinguish between relatively
harmless (fireworks) & traumatic events
❧ Biased information processing style
❧ Personality & coping styles
❧ high neuroticism
❧ negativity, affectivity
❧ prior psychological symptoms
❧ history of childhood abuse
❧ Conditioned Fear
 Treatment of Trauma-Induced
Disorders
❧
❧ Medication
❧ SSRIs ( 60% improve, only 20-30% - full remmission)
❧ CBT
❧ Relaxation and cognitive restructuring
❧ “Covering” & “Uncovering”
❧ EMDR (Eye Movement Desensitization
Reprocessing)
 Anxiety Disorders:
The Biopsychosocial Perspective
❧
❧ These disorders intermingle biological,
psychological, and sociocultural phenomena.
❧ Relatively straightforward behaviorally based
treatments can alleviate symptoms.
That’s it.