ANXIETY Week 2

DISORDERS
§ Development across the lifecycle
§ Other Life Cycles
§ Conceptualization

INTERACTIVITY: In groups of 4 (3 groups)

§ Classification system
§ What are some advantages/ disadvantages to the classification system?
§ Time: 10 mins
§ Categorical terms avoid unreliable intrapsychic variables.
§ Organic and/ or psychosocial etiological factors are used to define disorders.
§ Comorbidity.

§ From a biomedical approach: identify causes of conditions and specific treatments.

§ Administration and funding of clinical work and research is based on ICD and DSM.

§ Broadly accepted by professionals, media, and public.

§ Subjective interpretation is presented as objective fact
§ Lack of reliability
§ Lack of validity
§ Lack clinical utility
§ Overemphasis on biological factors
§ Lack of emphasis on contextual factors
§ Lack of sensitivity to cultural and other types of diversity
§ Leads to discrimination and social exclusion
§ Leads to stigmatization which has a negative impact on identity
§ Marginalizes knowledge from lived experience
§ Rejection of diagnoses elicits negative responses from mental health
professionals
§ Disempowers service users
§ Leads to over-reliance on medication
 Leaving Home

Parents nearing Forming a

Death couple

Caring for Early

Aging parents Parenthood

Launching Adolescent
children/Midlife parenting
6
§ Fear: Emotional response to real or perceived threat
§ More associated with autonomic arousal (fight/ flight), immediate danger, and escape
behaviors.
§ Anxiety: Anticipation of future threat
§ Muscle tension and vigilance in preparation for future danger and avoidant behaviors.

§ Panic Attacks: A particular type of fear response (not only limited to anxiety
disorders)
§ Epidemiology
§ Study of distribution (e.g., prevalence) and determinants (e.g., causes, risk factors) of
disease or condition
§ Etiology
§ Study of causes of disease or condition

§ DSM-5 and ICD-11

⊹ What do you FEAR?
⊹ What happens to you ________________when you
experience fear?
× Physiologically
× Cognitively
× Emotionally
× Behaviorally

⊹ Reflect for 5 mins & share with the class

§ Excessive or persisting beyond developmentally appropriate periods.
§ Excessive or not: Primarily determined by the clinician.
§ More frequently occurring in females than males (2:1)

§ Most develop in childhood and tend to persist to adulthood if not treated.

§ Symptoms are not attributed to effects of substance/ medication or medical
condition or not better explained by another mental disorder.
§ ICD-11 codings are in RED
§ Separation Anxiety Disorder
§ Selective Mutism
§ Specific Phobia

§ Social Anxiety Disorder

§ Panic Disorder

§ Agoraphobia
§ Generalized Anxiety Disorder

In PAIRS, discuss HOW you think these disorders manifest?

 (6BO3)
§ Marked fear or anxiety about a specific
object or situation.
§ Provokes immediate fear or anxiety.
§ Actively avoided or endured with
intense fear/ anxiety.
§ Fear/ anxiety is out of proportion to
actual danger.
§ Persistent and lasting 6 months or more.
§ Not better explained by another mental
disorder.
§ Marked and excessive fear or anxiety that
consistently occurs upon exposure or
anticipation of exposure to one or more
specific objects or situations
§ The phobic object or situation is actively
avoided or else endured with intense fear
or anxiety
§ A pattern of fear, anxiety, or avoidance
related to specific objects or situations is
not transient
§ The symptoms are not better accounted for
by another mental disorder
§ If functioning is maintained, it is only
through significant additional effort.
§ Animal (e.g. cats, spider)
§ Natural Environment (e.g. heights, water etc)
§ Blood-injection-injury (e.g. needles, invasive procedures etc)

§ Situational (e.g. airplane, enclosed spaces etc)

§ Other (e.g. clowns, loud sounds etc)

ICD 10 seems to have separate coding for each, ICD-11 does not
§ Prevalence: 7%-9% (US); 3%-5% in adults; Female ratio 2:1 (blood-injection-
injury phobia nearly equally by both genders)
§ Majority of cases developing prior to 10 years old, with median onset 7-11 years
and a mean at about 10 years old.
§ Situational specific phobias have a later onset.
§ Prevalence of specific phobia lower in older populations but is the more commonly
experienced disorders in late life.
§ Specific phobia tends to co-occur with medical concerns in older individuals (e.g.,
Coronary Heart Disease).
§ Older individuals may manifest anxiety in atypical manner

§ In older individuals, associated with decreased quality of life and risk factor for
neurocognitive disorder.
§ Can develop at any age often as a result of traumatic experiences.
§ Temperament: negative affectivity, behavioral inhibition
§ Environmental: parental overprotectiveness, parental loss and separation, physical/
sexual abuse, seeing a caregiver demonstrate fear towards phobic stimulus
§ Genetic/ physiological: genetic susceptibility to a certain category of specific
phobia (e.g., phobia of animals compared to other specific phobias).
§ Differentiate from culturally accepted phobias
 BOUNDARIES
§ Agoraphobia – two or more agoraphobic situations are feared (1= specific
phobia).
§ Social anxiety disorder – situation feared due to negative evaluation

§ Separation anxiety disorder – situation feared due to separation from caregiver

§ Panic disorder – panic attacks that were unexpected (not due to specific object or
situation
§ OCD – Primary fear/ anxiety is due to object/ situation of an obsession, and other
criteria for OCD met.
 BOUNDARIES
§ Trauma- and Stressor- related disorders – phobia develops following traumatic
event, as opposed to phobia preceding trauma.
§ Eating disorders – avoidance behavior not exclusively avoidance of food/ food-
related cues.
§ Schizophrenia spectrum and other psychotic disorders – fear and avoidance
are due to delusional thinking.
§ Marked fear or anxiety about one or more social situations in which individual is
exposed to possible scrutiny by others.
§ Individual fears acting or showing anxiety symptoms that will be negatively
evaluated.
§ Social situations almost always provoke fear or anxiety.
§ Social situations avoided or endured with intense fear/ anxiety.
§ Fear/ anxiety out of proportion to actual threat faced.
§ 6 months or more.
§ Clinically significant impairment in functioning.
§ Not better explained by substance, medical condition, symptoms or another mental
disorder.
(6B04) SOCIAL ANXIETY DISORDER (SAD)
§ Marked and excessive fear or anxiety that occurs consistently in one or more social situations
such as social interactions (e.g., having a conversation), doing something while feeling observed
(e.g., eating or drinking in the presence of others), or performing in front of others (e.g., giving a
speech).
§ The individual is concerned that he or she will act in a way, or show anxiety symptoms, that will be
negatively evaluated by others (i.e., be humiliating, embarrassing, lead to rejection, or be
offensive).
§ Relevant social situations are consistently avoided or endured with intense fear or anxiety.
§ The symptoms are not transient; that is, they persist for an extended period of time (e.g., at least
several months).
§ The symptoms are not better accounted for by another mental disorder (e.g., Agoraphobia, Body
Dysmorphic Disorder, Olfactory Reference Disorder).
§ The symptoms result in significant distress about experiencing persistent anxiety symptoms or
significant impairment in personal, family, social, educational, occupational, or other important
areas of functioning. If functioning is maintained, it is only through significant additional effort.
§ Prevalence: ~7%, comparable between child/ teens and adults, higher rates in
females than males (1.5 – 2.2 ratio), males higher in clinical samples (assumed
gender roles and social expectations).
§ Median age of onset is 13 years old, 75% onset between 8-15 years old.
§ Onset following stressful or humiliating experience, through a slow development,
or life changes with new social roles.
§ Disorder persistent among those presenting to clinical care.
§ Adolescents endorse broader pattern of fear and avoidance compared to younger
children.
§ Older adults express social anxiety at lower levels, but broader range of situations.

§ Younger adults express higher levels of social anxiety for specific situations.
§ The most frequently occurring comorbid conditions are mood disorders, with rates
ranging from 35–70% for major depressive disorder (MDD) and 3–21% for bipolar
disorder (Perugi et al., 1999, 2001).
§ This comorbidity is higher in older adults (APA, 2013).

§ Clients with SAD note the depressing impact of prolonged social isolation and
frequent, perceived social failures and losses.
§ Underlying beliefs and assumptions
§ Excessively high standards for social performance.
§ Conditional beliefs regarding the consequences of acting in certain ways.
§ Unconditional negative beliefs about the self.

§ Shift in attention and negative image of self

§ Safety behaviours
§ Reviews and previews
§ Previewing: refers to the negative anticipatory, catastrophising cognitive processing
engaged in prior
§ Reviewing: The ruminative cognitive processing that occurs after
§ Temperamental: underlying traits of behavioral inhibition and fear of negative
evaluation
§ Environmental: childhood mistreatment, early-onset psychosocial adversity.

§ Genetic/ physiological: high behavioral inhibition more susceptible to

environmental influences; 2-6 times likelihood of first-degree relative having social
anxiety disorder
§ The Social Phobia Inventory (SPIN;
Connor et al., 2000)
§ The Liebowitz Social Anxiety Scale
(LSAS; Heimberg et al.,1999; Liebowitz,
1987)
§ Building a formulation of the
client’s unique experience of
social anxiety
§ Safety behaviour experiment

§ Shifting attention and testing

negative predictions
§ Modifying dysfunctional
assumptions
§ Recovery blueprint
 BOUNDARIES
Universal criteria = fear of negative evaluation in social situations
§ Normative shyness – may be culturally accepted; doesn’t affect functioning
§ Agoraphobia
§ Panic Disorder
§ GAD

§ Separation Anxiety Disorder

§ Specific phobias – do not fear negative evaluation in other social situations
(except for embarrassment from fainting while blood being drawn)
§ Selective mutism – do not fear negative evaluation
 BOUNDARIES
§ MDD- fear due to perceived badness/ unworthiness of being liked
§ Body dysmorphic disorder – social fear only caused by beliefs about their
appearance.
§ Delusional disorder – individuals with social anxiety disorder have insight that it
is out of proportion
§ ASD – social anxiety and social communication deficits.
§ Personality disorders – avoidant PD have a broader avoidance pattern than those
with social anxiety disorder
§ Oppositional defiant disorder- refusal to speak as a sign of opposition
§ Recurrent unexpected panic attacks (abrupt surge of intense fear along with four
or more panic symptoms).
§ ACTIVITY: EXAGERATE YOUR PHYSIOLOGICAL RESPONSE TO ANXIETY
§ Thoughts, Feelings, Physiological Changes

§ At least 1 attack have been followed by 1 month (or more) of one or both of:
§ Persistent concern about additional attacks or consequences
§ Maladaptive change in behavior (e.g., avoidance)

§ Not due to physiological effects of substance or medication condition

§ Not better explained by another mental disorder
 (6B01) PANIC DISORDER
§ Recurrent panic attacks, which are discrete episodes of intense fear or
apprehension characterized by the rapid and concurrent onset of several
characteristic symptoms.
§ At least some of the panic attacks are unexpected.
§ Panic attacks are followed by persistent concern or worry (e.g., for several weeks)
about their recurrence or their perceived negative significance (e.g., that the
physiological symptoms may be those of a myocardial infarction), or behaviours
intended to avoid their recurrence (e.g., only leaving the home with a trusted
companion).
§ Panic attacks are not limited to anxiety-provoking situations in the context of
another mental disorder.
§ The symptoms are not a manifestation of another medical condition
§ The symptoms result in significant impairment in personal, family, social,
educational, occupational, or other important areas of functioning. If functioning is
maintained, it is only through significant additional effort.
§ Prevalence: 2%-3% in adults and adolescents, females: males (2:1), overall low
prevalence in children <14 years.
§ Gradual increase during adolescence, especially females, peaking in adulthood.

§ Rates decline in older individuals, possibly diminishing severity to subclinical

levels.
§ Median onset 20-24 years.
§ If untreated, waxes and wanes but chronic.
§ May have episodic outbreaks with years in remission; while others have continuous
severe symptomatology
§ No difference in clinical presentation between adolescents and adults; but
adolescents less worried about additional panic attacks.
§ Lower prevalence in older adults possibly due dampening of autonomic nervous
system response.
§ Older individuals tend to attribute panic attacks to certain stressful situations (e.g.,
medical procedure, social settings).
§ Temperamental: negative affectivity, anxiety sensitivity, history of “fearful spells”
§ Environmental: hx of sexual/ physical abuse, smoking (risk factor), identifiable
stressor(s) months before first panic attack
§ Genetic/ physiological: multiple genes confer vulnerability; increased risk for
offspring of parents with anxiety, depressive, bipolar disorders
§ Cognitive Model
§ Biological Model
§ Neurotransmitters role: serotonin,
noradrenalin, adenosine, γ-
aminobutyric acid and
cholecystokinin-4, play a role in panic
disorder
§ Brain Structures: Amygdala, frontal
lobe & hippocampus
§ Gene-environment interactions may be
important, whereby a genetic
vulnerability interacts with stressful life
events
§ Psychodynamic Model
§ people at risk for panic disorder have
§ (1) a neurophysiological vulnerability
to panic attacks and/or
§ (2) multiple experiences of
developmental trauma
§ Child frightened of unfamiliar and
excessively dependent on caregiver;
fearful dependency
§ Unconscious conflicts about dependency
& anger
§ Activate concious/unconscious
fantasies of catastrophic dangerà PA
§ Other specified or unspecified anxiety disorder – panic disorder must have full-
symptom (unexpected) panic attacks.
§ Anxiety disorder due to another medical condition

§ Substance/ medication-induced anxiety disorder

§ Other mental disorders with panic attacks as an associated feature

It is possible to have panic attacks and NOT have Panic Disorder (repeated panic
attacks are required but not SUFFICIENT for diagnosis)
§ Marked fear or anxiety about two (or more) of the following five situations:
§ Using public transportation
§ Being in open spaces
§ Being in enclosed places
§ Standing in line or being in a crowd
§ Being outside the home alone

§ Fears/ avoids because of thoughts that escape might be difficult/ help not available.
§ Provoke fear or anxiety, actively avoided, or endured with intense fear/ anxiety.

§ Out of proportion to actual danger

§ Persisting 6 months or more, significant impairment in functioning

§ Not attributed to another medical condition or another mental disorder.
(6B02 AGORAPHOBIA)
§ Marked and excessive fear or anxiety that occurs in, or in anticipation of, multiple
situations where escape might be difficult or help might not be available
§ The individual is consistently fearful or anxious about these situations due to a fear of
specific negative outcomes such as panic attacks, symptoms of panic, or other
incapacitating (e.g., falling) or embarrassing physical symptoms (e.g., incontinence).
§ The situations are actively avoided, are entered only under specific circumstances (e.g.,
in the presence of a companion), or else are endured with intense fear or anxiety.
§ The symptoms are not transient, that is, they persist for an extended period of time
(e.g., at least several months).
§ The symptoms are not better accounted for by another mental disorder (e.g., paranoid
ideation in Delusional Disorder; social withdrawal in Depressive Disorders).
§ The symptoms result in significant distress about experiencing persistent anxiety
symptoms or significant impairment in personal, family, social, educational,
occupational, or other important areas of functioning. If functioning is maintained, it is
only through significant additional effort.
§ Prevalence: ~1.7% of adolescents and adults, females twice as likely, peaks in late
adolescence to early adulthood.
§ Two-thirds of cases has initial onset before 35 years old.
§ First onset in childhood is rare.
§ Mean age of onset is 17 years, age of onset with preceding panic attacks/ disorder
is 25-29 years.
§ Relatively consistent across the lifespan.
§ Lower in children possibly due to difficulties in symptom reporting.
§ Adolescents may be less willing to discuss symptoms than adults.
§ In older adults, comorbid somatic symptom disorders and motor disturbance
frequently mentioned as reason for fear/ avoidance.
§ Temperamental: behavioral inhibition and neurotic disposition, anxiety sensitivity
§ Environmental: negative events in childhood, reduced warmth and increased
overprotection in family
§ Genetic/ physiological: 61% heritability, as strongest genetic factor association
among various phobias.
Universal: both diagnoses assigned when diagnostic criteria for both disorders
met UNLESS the agoraphobic symptoms are attributable to the other disorder.
Specific phobia – only limited to one situation
Separation anxiety disorder- detachment from significant others
Social anxiety disorder – negative social evaluation
Panic disorder – agoraphobia is not diagnosed when panic attacks do not extend to
two or more agoraphobic situations.
Acute Stress Disorder/ PTSD – only to situations that remind of traumatic event
MDD – anhedonia, low mood
Other Medical Conditions – physiological consequence to a medical condition.
Realistic concerns of being incapacitated
§ Panic Attacks Symptom Questionnaire (PASQ; Clum et al., 1990),
§ Panic-related cognitions, with the Agoraphobic Cognitions Questionnaire (ACQ;
Chambless et al., 1984)
§ Body Sensations Questionnaire (BSQ; Chambless et al.,1984),
§ Anxiety Sensitivity Index-3 (Reiss et al., 2008; Taylor et al., 2008)

§ Brief Dimensional Scales for Anxiety Disorders (LeBeau et al., 2012)

§ Panic attack records
§ Excessive anxiety and worry for at least 6 months about several events and activities
§ Difficulty controlling worry
§ Three or more of these symptoms:
§ Restlessness/ on he edge
§ Easily fatigued
§ Difficulty concentrating/ mind going blank
§ Irritability
§ Muscle tension
§ Sleep disturbance
§ Significant impairment in functioning
§ Not due to substance or medical condition
§ Not explained by another mental disorder
 (6B00) GENERALISED ANXIETY
DISORDER
§ Marked symptoms of anxiety manifested by either:
§ General apprehensiveness that is not restricted to any particular environmental circumstance (i.e., ‘free-floating anxiety’); or
§ Excessive worry (apprehensive expectation) about negative events occurring in several different aspects of everyday life (e.g.,
work, finances, health, family).
§ Anxiety and general apprehensiveness or worry are accompanied by additional characteristic symptoms, such as:
§ Muscle tension or motor restlessness.
§ Sympathetic autonomic overactivity as evidenced by frequent gastrointestinal symptoms such as nausea and/or abdominal
distress, heart palpitations, sweating, trembling, shaking, and/or dry mouth.
§ Subjective experience of nervousness, restlessness, or being ‘on edge’.
§ Difficulty concentrating.
§ Irritability.
§ Sleep disturbances (difficulty falling or staying asleep, or restless, unsatisfying sleep).

§ The symptoms are not transient and persist for at least several months, for more days than not.
§ The symptoms are not better accounted for by another mental disorder (e.g., a Depressive Disorder).
§ The symptoms are not a manifestation of another medical condition (e.g., hyperthyroidism) and are not due to the effects of
a substance or medication on the central nervous system (e.g., caffeine, cocaine), including withdrawal effects (e.g., alcohol,
benzodiazepines).
§ The symptoms result in significant distress about experiencing persistent anxiety symptoms or significant impairment in
personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is
only through significant additional effort.
§ Prevalence: 0.9% among adolescents and 2.9% among adults (US), females twice
as likely, peaks in middle age and declines in later years.
§ Relatively consistent expression across the lifespan, with primary difference across
age group is the content of worry.
§ Children/ adolescents: school and sporting performance

§ Older adults: well-being of family, physical health.

§ Younger adults more symptom severity than older adults.
§ The earlier in life the diagnosis, the more impaired and more comorbidity they
likely to have.
§ Temperamental: behavioral inhibition, negative affectivity, harm avoidance
§ Environmental: childhood adversity, parental overprotection are associated, but not
necessary or sufficient
§ Genetic/ physiological: 1/3 is genetic, overlaps with neuroticism and shared with
other anxiety and mood disorders
§ Two structured interview schedules :
§ the Structured Clinical Interview for DSM-IV (SCID; First et al., 1997), Anxiety Disorders
Interview Schedule (ADIS; DiNardo et al., 1994).
§ The Generalized Anxiety Disorder Questionnaire (GAD-Q; Roemer et al., 1995)
§ Penn State Worry Questionnaire (PSWQ; Meyer et al., 1990)

§ Anxious Thoughts Inventory (AnTI; Wells, 1994).

§ Beck Anxiety Inventory (BAI; Beck et al., 1988)
§ State-Trait Anxiety Inventory (Spielberger et al., 1983),
Metacognitive
Model of GAD
§ HOMEWORK
§ Read and note important elements of this therapy
§ To be discussed next week
§ Anxiety Disorder due to another medical condition
§ Substance/ medication-induced anxiety disorder
§ Social Anxiety Disorder – worry due to being evaluated by others

§ OCD – inappropriate ideas in intrusive and unwanted thoughts, while GAD is about
forthcoming problems with excessive worries.
§ PTSD
§ Adjustment disorders – identifiable stressor, does not persist for more than 6
months after termination of stressor.
§ Depressive, bipolar, psychotic disorders – GAD should not be diagnosed
separately if it occurred only during the course of these conditions.
DSM 5 (UPDATE, OCT 2017)
§ As printed
§ Depressive, bipolar, and psychotic disorders. Generalized anxiety/worry is a common
associated feature of depressive, bipolar, and psychotic disorders and should not be
diagnosed separately if the excessive worry has occurred only during the course of these
conditions.
§ As updated
§ Depressive, bipolar, and psychotic disorders. Although Generalized anxiety/worry is a
common associated feature of depressive, bipolar, and psychotic disorders, generalized
anxiety disorder may be diagnosed comorbidly if the anxiety/worry is sufficiently severe to
warrant clinical attention. and should not be diagnosed separately if the excessive worry has
occurred only during the course of these conditions.
§ Reason for update
§ This update resolves a discrepancy between the diagnostic criteria and the text. In
certain cases, generalized anxiety disorder may be diagnosed with depressive, bipolar,
and psychotic disorders as noted above, consistent with the diagnostic criteria.
§ Substance/ Medication Induced Anxiety Disorder
§ Anxiety/panic attacks due to intoxication, withdrawal, or exposure.
§ Significant impairment in functioning
§ Not better explained by another anxiety disorder

§ Anxiety disorder due to another medical condition

§ Direct consequence of another medical condition
§ Significant impairment in functioning
§ Not better explained by another mental disorder

§ Other specified anxiety disorder

§ Significant impairment, do not meet full criteria (e.g., limited symptom attack; generalized
anxiety occurring not most days than not)
§ Biological
§ Interplay of anxious feelings, abnormal processing of information, and inadequate coping
strategies.
§ Alarm circuits (A): primary structure being the amygdala
§ Beliefs (B): abnormal processing of information related to “threats” associated with the
basal ganglia, cingulum, corticostriatal connections
§ Abnormal Coping (C ): cortical networks
§ Neurotransmitters: Extensive interrelationships and feedback among various
neurotransmitters – GABA, serotonin, dopamine, norepinephrine.
§ Behavioral
§ Classical and Operant Conditioning
§ Classical: object is paired with aversive event
§ Operant: fear is maintained by operant conditioning (e.g., positive reinforcement from
avoidance)
§ Safety/ avoidance behaviors

§ Cognitive
§ Catastrophic misinterpretation
§ Dysfunctional Beliefs
§ Cognitive-Behavioral Therapy (CBT) has the greatest amount of empirical support.
§ CBT and SSRIs: First line treatment of choice.
§ Exposure therapy

§ “Third wave” cognitive approaches: MBCT, ACT

5 mins
§ In pairs/ triads:
§ Decide who is going to be the Client/ Therapist
§ Client: Share your experience with anxiety
§ Therapist: Ask relevant questions to understand their concerns
§ As a pair, develop your 4 P + BioPsychoSocialSpiritual
conceptualization
§ Present to the class
§ Time 20mins