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ANXIETY DISORDERS

Anxiety and fear play significant role in this group of disorders

NATURE OF ANXIETY AND FEAR
 Anxiety is a negative mood state characterized by bodily symptoms of physical
tension and by apprehension about the future
 Future-oriented
 marked negative affect
 Somatic symptoms of tension
 Apprehension about future danger or misfortune
 Fear is an immediate alarm reaction to danger.
 Present-oriented mood state, marked negative affect
 Immediate fight or flight response to danger or threat
 avoidance/escapist behaviour
 Anxiety and Fear are Normal Emotional States
From Normal to Disordered Anxiety and Fear
 Characteristics of Anxiety Disorders
 Persistent symptoms of anxiety and fear
 Involve excessive avoidance and escapist tendencies
 Causes clinically significant distress and impairment
Generalized Anxiety Disorder:
People with generalized anxiety disorder experience excessive anxiety under
most circumstances and worry about practically anything.
Diagnostic Criteria
 A. Excessive anxiety and worry (apprehensive expectation) about a number of events
or activities (such as work or school performance).
 B. The person finds it difficult to control the worry.
 C. The anxiety and worry are associated with at least three (or more) of the following
six symptoms
 1. Restlessness or feeling keyed up or on edge
 2. Being easily fatigued
 3. Difficulty concentrating or mind going blank
 4. Irritability
 5. Muscle tension
 6. Sleep disturbance (difficulty falling or staying asleep or restless, unsatisfying
sleep)
Causes
 Generalized biological-vulnerability
 Generalized psychological vulnerability.
Some people inherit a tendency to be tense (generalized biological vulnerability),
and they develop a sense early on that important events in their lives may be
uncontrollable and potentially dangerous (generalized psychological vulnerability).
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 Significant stress makes them apprehensive and vigilant. This sets off intense worry
with resulting physiological changes, leading to GAD.
 Time will tell if the current model is correct, although supporting data continue to
come in.
Specific Phobia:
A phobia (from the Greek word for “fear”) is a persistent and unreasonable fear
of a particular object, activity, or situation. People with a phobia become fearful if
they even think about the object or situation they dread, but they usually remain
comfortable as long as they avoid it or thoughts about it.
 Irrational fear of a specific object or situation
 Markedly interferes with one's ability to function
 Recognize fears are unreasonable
 Still go to great lengths to avoid phobic objects
 Onset beginning between 7-15 years of age
 Specific Phobias: Subtypes
 Blood-injury-injection phobia
 • Situational phobia - Public transportation or enclosed places (e.g., planes)
 Natural environment phobia - Events occurring in nature (e.g., heights, storms)
 Animal phobia - Animals and insects
 Other phobias - Do not fit into the other categories (e.g., fear of choking,
 vomiting)
 Causes of Phobias
 Biological and evolutionary vulnerability, direct conditioning, observational
learning, information transmission
Social Phobia
Severe, persistent, and irrational anxiety about social or performance situations in which they
may face scrutiny by others and possibly feel embarrassment
 Generalized type - Anxiety across many social situations; extremely and painfully
shy in almost all social situations
Criteria
 Marked, persistent fear triggered by exposure to unfamiliar people or social scrutiny
 Exposure to the trigger leads to intense anxiety about being humiliated or
embarrassed
 The person recognizes the fear is unrealistic
 Trigger situations are avoided or else endured with intense anxiety
 The avoidance, anxious anticipation, or distress in the feared social or performance
situation(s) interferes significantly with the person's normal routine, occupational
(academic) functioning, or social activities or relationships, or there is marked
distress about having the phobia.
 Facts and Statistics
 Affects about 13% of the general population at some point
 Females are slightly more represented than males
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 Onset is usually during adolescence

 Peak age of onset at about 13 years
Social Phobia: causes
 Biological and evolutionary vulnerability
 Direct conditioning, observational learning, information transmission
Agoraphobia
 Fear or avoidance of situations/events where escape might be difficult or help
unavailable. People with agoraphobia are afraid to leave the house and travel
to public places or other locations.
 Agoraphobia :Typical Situations Avoided
 Shopping malls Being far from home, Cars (driver /passenger) Staying at
home alone, Buses, Waiting in line, Trains, Supermarkets, Subways, Stores,
Wide streets, Crowds, Tunnels, Planes, Restaurants, Elevators, Theatres,
Escalators.
Panic Attacks
 Abrupt experience of intense fear or discomfort
 Accompanied by several physical symptoms (usually include heart palpitations, chest
pain, shortness of breath, and, possibly, dizziness)
Diagnostic Criteria for Panic Attack
 The predominant complaint is a discrete period of intense fear or discomfort in which
at least four (or more) of the following symptoms developed abruptly and reached a
peak within 10 minutes:
1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheaded, or faint
9. Derealization (feelings of unreality) or depersonalization (being detached from
oneself)
10. Fear of losing control or going crazy
11. Fear of dying
12. Paresthesias (numbness or tingling sensations)
13. Chills or hot flushes
Panic Disorder
An anxiety disorder marked by recurrent and unpredictable panic attacks
Associated Features and Treatment
 Nocturnal panic attacks - 60% panic during non-REM sleep
 Interoceptive/exteroceptive avoidance,
 Catastrophic misinterpretation of symptoms
Panic with agoraphobia. If it causes panic attack.
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Biological Contributions to Anxiety and Panic

 Diathesis-Stress
 Inherit vulnerabilities for anxiety and panic, not disorders
 Stress and life circumstances activate vulnerability
Psychological Contributions to Anxiety and Fear
 Began with Freud
 psychic reaction to danger
 reactivation of an infantile fear situation
 Behaviouristic Views
 classical and operant conditioning and modeling
 Psychological Views
 Early experiences with uncontrollability / unpredictability
 Social Contributions
 Stressful life events trigger vulnerabilities
 Many stressors are familial and interpersonal
Toward an Integrated Model
 Integrative View
 Biological vulnerability interacts with psychological, experiential, and social
variables to produce an anxiety disorder
 Consistent with diathesis-stress model
Common Processes
 The Problem of Comorbidity
 Comorbidity is common across the anxiety disorders
 About half of patients have 2 or more secondary diagnoses
 Major depression is the most common secondary diagnosis

Medication Treatment of Panic Disorder
 Prozac and Paxil - Preferred drugs
 Relapse rates are high following medication discontinuation
 Cognitive-behavior therapies are highly effective
Posttraumatic Stress Disorder (PTSD)
A disorder in which a person continues to experience fear and related symptoms long after a
traumatic event.
Criteria
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of
the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as they occurred to others.
3. Learning that the event(s) occurred to a close relative or close friend. In cases of actual or
threatened death of a family member or friend, the event(s) must have been violent or
accidental.
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4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)

(e.g., first responders collecting human remains; police officers repeatedly exposed to details
of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television, movies,
or pictures, unless this exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the
traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary and intrusive distressing memories of the traumatic event(s). Note:
In young children, repetitive play may occur in which themes or aspects of the traumatic
event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to
the traumatic event(s). Note: In children, there may be frightening dreams without
recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the
traumatic event(s) were recurring. (Such reactions occur on a continuum, with the most
extreme expression being a complete loss of awareness of present surroundings.) Note: In
young children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect
of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the
traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, feelings, or
conversations about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations,
activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or
closely associated with the traumatic event(s).
3. Inability to recall an important aspect of the trauma
4. Markedly diminished interest or participation in significant activities
5. Feeling of detachment or estrangement from others
6. Restricted range of affect (e.g., unable to have loving feelings)
7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children,
or a normal life span)
D. Negative alterations in cognitions and mood associated with the traumatic event(s),
beginning or worsening after the trau-matic event(s) occurred, as evidenced by two (or more)
of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due to
dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the
world (e.g., “I am bad,” “no one can be trusted,” “the world is completely dangerous,” “My
whole nervous system is permanently ruined”).
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3. Persistent distorted cognitions about the cause or consequences of the traumatic event(s)
that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience
happiness, satisfaction, or loving feelings).
E. Duration of the disturbance (Criteria B, C, D and E) is more than one month.
F . The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Specify if:
With delayed expression: If the diagnostic threshold is not exceeded until at least 6 months
after the event (although it is under-stood that onset and expression of some symptoms may
be immediate).
Specify if:
With Dissociative Symptoms: The individual’s symptoms meet the criteria for posttraumatic
stress disorder, and in addition, in
response to the stressor, the individual experiences persistent or recurrent symptoms of
depersonalization or derealization. (DSM 5)
Facts and Statistics
 Affects about 7.8% of the general population
 Most Common Traumas: Sexual assault, Accidents, Combat
Obsessive-Compulsive Disorder (OCD)
Characterized by persistent and uncontrollable thoughts or urges or images (obsessions) and
by the need to repeat certain acts again and again (compulsions).
Most persons display multiple obsessions: Many cleaning, washing, and/or checking rituals
Criteria
Presence of obsessions, compulsions or both:
Obsessions are defined by 1 and 2:
1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time
during the disturbance, as intrusive and inappropriate and that in most individuals cause
marked anxiety or distress
2. The individual attempts to ignore or suppress such thoughts, impulses, or images, or to
neutralize them with some other thought or action
Compulsions are defined by 1 and 2:
1. Repetitive behaviours (e.g., handwashing, ordering, checking) or mental acts (e.g.,
praying, counting, repeating words silently) that the individual feels driven to perform in
response to an obsession, or according to rules that must be applied rigidly
2. The behaviours or mental acts are aimed at preventing or reducing distress or preventing
some dreaded event or situation; however, these behaviours or mental acts either are not
connected in a realistic way with what they are designed to neutralize or prevent or are
clearly excessive
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B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day),
or cause clinically significant distress or impairment in social, occupational or other
important areas of functioning.
C. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug
of abuse, a medication)
or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g.,
excessive worries, as in generalized anxiety disorder, or preoccupation with appearance, as
in body dysmorphic disorder).
Specify if:
With good or fair insight: the individual recognizes that obsessive-compulsive disorder
beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably
true.
With absent insight/delusional: the person is completely convinced that obsessive-compulsive
disorder beliefs are true.
Specify if:
Tic-related: The individual has a current or past history of a tic disorder
Facts and Statistics
 Affects about 2.6% of the population at some point
 Most persons with OCD are female
 OCD tends to be chronic
 Onset is typically in early adolescence or adulthood
Causes of OCD
 Parallel the other anxiety disorders
 Early life experiences and learning that some thoughts are dangerous/unacceptable
 Thought-action fusion – equating thought with action
Treatment
Medication Treatment of OCD
 Clomipramine and other SSRIs – Benefit about 60%
 Psychosurgery (cingulotomy) – Used in extreme cases
 Relapse is common with medication discontinuation
Psychological Treatment of OCD
 Cognitive-behavioral therapy – Most effective for OCD
 CBT involves exposure and (ritual) response prevention
Scrupulosity has been described as a psychological disorder primarily characterized by
pathological guilt or obsession associated with moral or religious issues that is often
accompanied by compulsive moral or religious observance and is highly distressing and
maladaptive.
-Compulsive Confession & restitution seeking
-Pathological doubt and questioning
-So overwhelmed with moral and religious concerns that they are actually incapable of fully
processing all of their thoughts, which contributes to poor awareness.
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Obsessive-Compulsive and Related Disorders

New in DSM-5. New disorders include hoarding disorder, excoriation (skin-picking)
disorder, substance-/medication-induced obsessive-compulsive and related disorder, and
obsessive-compulsive and related disorder due to another medical condition. Trichotillomania
(hair-pulling disorder) and has been moved from a DSM-IV classification of impulse-control
disorders not elsewhere classified to obsessive-compulsive and related disorders in DSM-5.