ANXIETY D/O

ICE BREAKER
• Break into pairs.
• Discuss with your pair (6 mins.)
• Think about a time you experienced fear. What were the
circumstances? What did you feel physically? What were
you thinking?
• Now think about a time you experienced anxiety. What were
the circumstances? What did you feel physically? What
were you thinking?
DISCUSSION
• Prepare 1 question each pair to ask the reporters.
• Ask the question/s after the discussion.
ANXIETY D/O

1. Panic D/o
2. Agoraphobia
3. Specific phobia
4. Social anxiety d/o
5. Selective mutism
6. Generalized anxiety d/o
7. Separation anxiety d/o
ANXIETY D/O
• Agoraphobia. Characterized by disproportionate, persistent
anxiety about being in places or situations from which escape
might be difficult in the event of panic symptoms or other
unpleasant physical symptoms (e.g., incontinence).

• Panic disorder. Recurrent unexpected panic attacks

accompanied by concern about future attacks and/or a
lifestyle change to avoid future attacks (e.g. avoiding hot,
stuffy places)
❏ ACTIVITY (INTEROCEPTIVE AWARENESS):
• Close your hands and squeeze them tight as if making a fist
• Run in place for 1 minute (discouraged for those with heart
problems or respiratory difficulties due to colds, asthma etc.)
• Look down at your feet and spin 3 times
Video Clip: Panic Attacks
❏ DISCUSSION POINT:
What is the relationship between agoraphobia and panic
disorder? How might these conditions also lead to other
comorbid conditions?
ANXIETY D/O

• Specific phobia. Unreasonable fear of a specific object or

situation that markedly interferes with daily life functioning
(e.g. animals; storms; heights; blood; airplanes; being closed
in; or any situation that may lead to vomiting, choking, or
developing an illness).
❏ ACTIVITY (PREPAREDNESS):
Write down an object or situation that you are particularly
afraid of, including what event(s) you think led to the
development of this top fear.
❏ DISCUSSION POINT:
Do you have any severe fears? What would you use as a way
of assessing whether that fear is or is not a phobia?
ANXIETY D/O

• Social anxiety disorder. Extreme, enduring, irrational fear

and avoidance of social or performance situations.
Video Clip
ANXIETY D/O

• Selective mutism. Individual elects not to talk, except when

alone or with select intimates.
• Generalized anxiety disorder. Although they experience no
episodes of acute panic, these patients feel tense or anxious
much of the time and worry about many different issues.
• Separation anxiety disorder. Excessive, enduring fear in
some individuals that harm will come to them or their loved
ones when they are apart.
Video Clip
Quantitative Structural Model
• alternative taxonomy of anxiety and mood disorders based on
factor-analytic findings
• assumes broad factor underlying internalizing d/o: General
Distress
• two subfactors beneath it: (1) Distress (MDD, dysthymia,
GAD, and PTSD); (2) Fear (PD, agoraphobia, SAD, and SP)
• narrow factors as basis for differentiating individual d/o from
each other
DIFFERENTIAL DX
CASELET 5

“I’d rather have her with me, if that’s all right.” Lucy was
responding to the clinician’s suggestion that her mother wait
outside the office. “By now, I don’t have any secrets from her.”
Since age 18, Lucy hadn’t gone anywhere without her mother. In
fact, in those 6 years she’d hardly been anywhere at all. “There’s
no way I could go out by myself—it’s like entering a war zone. If
someone’s not with me, I can barely stand to go to doctor
appointments and stuff like that. But I still feel awfully nervous.”
CASELET 5

A. Lucy avoided a variety of situations and places, including

supermarkets, malls, buses, and trains

B. she couldn’t state exactly what might happen—only that it

would be awful and embarrassing (she might even lose bladder
control) and that help might not be available

C. the situations almost always provoke anxiety

D. if she did go, she required a companion

CASELET 5

E. inordinate and out of proportion to the actual danger

F. More than 6 months

G. the patient experiences clinically important distress or

impairment

H. diabetes itself isn’t associated with agoraphobic fear

CASELET 5

I. Sx were too varied for specific phobia or social anxiety

disorder. Her problem wasn’t that she feared being left alone, as
would be the case with separation anxiety disorder (although
when she was five she clearly had had elements of that
diagnosis). She hadn’t had a major trauma, as would be the case
in PTSD (the death of her father was traumatic, but her own
symptoms didn’t focus on reliving this experience). There is no
indication that she had OCD

F40.00 Agoraphobia
DIFFERENTIAL DX

Separation Anxiety Disorder

• Conduct disorder (e.g. truancy)
• Illness anxiety disorder (e.g. worry about medical illnesses)
• Prolonged grief disorder
• Depressive and bipolar disorders (e.g. reluctance to leave
home)
• Oppositional defiant disorder (e.g. oppositional against
separation)
• Personality disorders (e.g. DP, BPD)
DIFFERENTIAL DX

Selective Mutism
• Silent period in immigrant children learning a second
language
• Communication disorders
• Neurodevelopmental disorders and schizophrenia and other
psychotic disorders
• Social anxiety disorder (associated)
DIFFERENTIAL DX

Specific Phobia
• Obsessive-compulsive disorder
• Eating disorders (i.e. avoidance exclusively to food)
DIFFERENTIAL DX

Social Anxiety D/o

• Normative shyness
• Major depressive disorder (i.e. worthlessness vs physical sx)
• Body dysmorphic disorder (i.e. perceived flaws/appearance)
• Delusional disorder (i.e. good insight in SAD)
• Autism spectrum disorder
• Oppositional defiant disorder (i.e. refusal to talk to authority
figures)
DIFFERENTIAL DX

Panic D/o
• Only limited-symptom panic attacks
• Anxiety disorder due to another medical condition
• Substance/medication-induced anxiety disorder
• Other mental disorders with panic attacks as an associated
feature (e.g., other anxiety disorders and psychotic disorders)
DIFFERENTIAL DX

Agoraphobia
• Specific phobia, situational type (i.e. limited to one situation;
reason of fear)
• Major depressive disorder (i.e. avoidance of leaving home)
DIFFERENTIAL DX

Generalized Anxiety D/o

• Illness anxiety disorder and somatic symptom disorder
• Obsessive-compulsive disorder
• Depressive, bipolar, and psychotic disorders (commonly
associated)
ETIOLOGY
ETIOLOGY

BEHAVIORAL GENETICS
• Heritability
• Gene-environment interactions
• Genetic factors are shared across many anxiety disorders
• Neuroticism as phenotype of genetic factors
ETIOLOGY

BIOLOGICAL CONSIDERATIONS
• Hypothalamic–Pituitary–Adrenal Axis: alterations of the
HPA axis (e.g. anxious patients had a significantly higher
cortisol awakening response)
• Short alleles of 5-HTTLPR gene
• Hyperactive amygdala
ETIOLOGY

PERSONALITY & TEMPERAMENT

• Anxiety sensitivity (i.e. fear of fear)

• Behavioral inhibition and shy temperament (i.e. developmental

precursor to and facet of neuroticism)

• Neuroticism
ETIOLOGY

BEHAVIORAL CONSIDERATIONS
• Classical conditioning (i.e. repeated paired learning)
• Operant conditioning (i.e. avoidance/escape behaviors)
• Vicarious conditioning
• Informational acquisition
• Preparedness Theory
• Interoceptive conditioning
ETIOLOGY

COGNITIVE CONSIDERATIONS
• Content-specific cognitions and related variables (i.e.
anxiety sensitivity, core beliefs, fear of negative evaluation,
intolerance of uncertainty; self-focused attention –
interoceptive sensations & negative self-image;
overestimations of fear/danger; poor self-efficacy)
• Cognitive processes and related variables (i.e. attentional
bias, interpretative bias, repetitive negative thought)
ETIOLOGY

SOCIALIZATION & THE SOCIAL ENVIRONMET

• overcontrolling and less emotionally supportive parenting
style; parental anxiety
• social factors (i.e. bullying, peer victimization)
LIFE EVENTS
• Stress
TREATMENT
❏ DISCUSSION POINT:
How might you address etiological factors to treat anxiety d/o?
TX: PANIC D/O

• Pharmacological
• Cognitive-Behavioral: psychoeducatIon, interoceptive,
cognitive restructuring and in vivo exposures)
TX: GAD

• Pharmacological
• Cognitive-Behavioral: targeting nonadaptive behavioral
patterns, exposure experiments, teaching relaxation and
problem-solving strategies
TX: SAD

• Pharmacological
• Cognitive-Behavioral: psychoeducation, exposure to feared
social-evaluative situations for habituation and disconfirmation
of catastrophic thinking, social skills training, cognitive
restructuring
TX: SPECIFIC PHOBIA

• Pharmacological
• Cognitive-Behavioral: systematic exposure to feared stimuli,
preventing avoidance responses
OTHER TX

• Acceptance and Commitment Therapy

• Mindfulness-based interventions