ANXIETY DISORDERS IN ADULTHOOD I

Dr Brooke Swash
b.swash@chester.ac.uk

PS6007
What will we cover in these sessions?

• We will contextualise anxiety disorders

• We will deepen our understanding of the common symptoms of
anxiety, and its aetiology
• We will look in detail at specific diagnoses:
• Generalised anxiety disorders
• Specific phobia
• Social anxiety disorder
• Panic disorder
• Obsessive compulsive disorder
But aren’t we all anxious sometimes?!

• Worries, fear and anxiety are common!

• They are normal reactions to danger or stressful situations

• The bodily, mental and behavioural changes experienced allow us to

cope with dangerous or stressful experiences

• Only become a problem when they are experienced out of context or

become exaggerated
“Normal” anxiety

• sitting an exam • going into hospital • attending an interview •

starting a new job • moving away from home • having a baby • being
diagnosed with an illness • deciding to get married or divorced.

I’m sure you could all generate your own lists…

Symptoms of anxiety
The Stress Response

• Physical changes (create readiness for action)

• Increased muscle tension, increased breathing, raised blood pressure,
digestive changes, release of adrenalin.

• Psychological changes
• Thinking becomes more focussed – can see improvements in concentration
and problem-solving
• Can also see emotional changes such as increased irritability or a heightened
sense of wellbeing

• Behavioural changes
• Fight or flight i.e. escape or increased vigilance
Long-term Stress

• Changes evolved as a temporary and immediate response to stress

• If prolonged – performance is no longer enhanced and begins to deteriorate

• Physical changes – sensations become unpleasant, painful and

embarrassing

• Psychological changes – thinking can become too focussed on worry and

generally thinking negatively. Normal situations are interpreted in a
negative light (catastrophising, black and white thinking, overgeneralising,
ignoring the positive).

• Behavioural changes – prolonged avoidance can lead to a loss of self-

confidence and make things more difficult to face.
FUNCTION
CONTINUUM OR CATEGORICAL?

1) Anxiety is an extension of a normal mood continuum (continuum)

Normal
Disorder
mood

2) Anxiety disorders are distinct entities (categorical)

Disorder Normal mood

ACTIVITY: Case Study

The actual kind of feelings, they, physically you just feel so tired all the
time. Like it, I think it drains your energy a lot, it might be a mental problem
but it definitely physically drains you. Because constantly, well my anxiety
level is constantly worrying about things, it just kind of, your brain’s running
on, like overdrive all the time. And with depression it’s kind of yeah your
brain is running on overdrive, but thinking about what you said like, you
know, it’s, you know,“I hate my life, this is so bad, I hate this, I hate
everything, I hate,” you know it’s just constantly, “I don’t like this, I’m
tired,” it’s just constantly, it’s a bit like endless clockwork it just keeps going.

It does like physically drain you, so if you, if you don’t keep yourself busy
and you just sit there, and you just feel so tired. It, it you know you don’t
feel like, especially when you’re having a low mood, if you can’t get
yourself out of it you can’t do anything that day, it’s just, you know I can’t,
yet sometimes I want to sit in the library and study and if I’m having a bad
day I’ll just start feeling sleepy, I’ll, you just, you just wanna go to sleep, you
don’t feel you want to do anything, you just wanna sleep.
 “You feel like you're going
mad, like you're going to die;
worrying about everything,
feeling out of control,
wondering what you sound
like and what you look like.
The voice in your head, it's
constant. You can't stop it.
It's exhausting.”

A group of disorders characterised by unrealistic anxiety and

other related problems.

Anxiety Disorders
Shared features of anxiety disorders

• Primarily stress linked

• Reality testing remains intact

• Symptoms are experienced as distressing

• Disorders tend to be enduring or recurrent

Aetiology of anxiety disorders: Biological

• No single gene directly causes anxiety or panic, but our genes may make us
more susceptible to anxiety and influence how our brains react to stress
(Drabant et al., 2012; Gelernter & Stein, 2009; Smoller, Block, & Young, 2009).

• Genetic
• SLC6A4; short version transports serotonin less effectively (see Smoller et
al., 2009)

• Lowered neurotransmitter levels

• 5HT, NA, GABA

• Hypothalamic pituitary adrenal (HPA) axis dysregulation

• Heightened amygdala response to fear cues

Aetiology of anxiety disorders: Social

Early life adversity (Chorpita & Barlow, 1998; Gunner &

Fisher, 2006)
• Early experiences of a lack of control are linked to a
cognitive tendency to interpret situations negatively

Stressful events especially those involving threat/trauma

Lack of support network/loneliness (Flensborg-Madson et

al., 2012)
Aetiology of anxiety disorders: Psychological

• Low mood
• Coping styles - increased emotion-focused coping; less
problem-focused coping
• Lower perceived control
• Personality factors
• Some personality traits are thought to predispose to
certain anxiety disorders e.g. avoidant & perfectionistic
Epidemiology of anxiety disorders

Prevalence rates for major anxiety disorders. Kessler et al. (2005),

Kessler, Chiu, Demler, Merikangas, & Walters (2005), Kessler,
Sonnega, Bromet, Hughes, & Nelson (1995), Craske et al. (1996).
Bandelow &
Michaelis, 2015
ACTIVITY: Case study video

• https://www.mind.org.uk/information-support/your-stories/the-phys
ical-effects-of-anxiety/

• Alex’s video blog for Mind

For me, anxiety feels as if everyone in
the world is waiting for me to trip up,
so that they can laugh at me. It
makes me feel nervous and unsure
whether the next step I take is the
best way forward.

Generalised anxiety disorder

GAD (DSM 5)

• Excessive anxiety and worry that the person finds difficult to control,
and that interferes with everyday functioning.

• Worry, or apprehension, must happen most days and persist over

time (at least 6 months).

• Characterised by the following (3 or more):

1. Restlessness
2. Tiring easily
3. Difficulty concentrating
4. Irritability
5. Muscle tension
6. Sleep disturbance
GAD (DSM 5)

• Excessive anxiety and worry that the person finds difficult to control,
and that interferes with everyday functioning.

• Worry, or apprehension, must happen most days and persist over

time.

• Characterised by the following (3 or more):

1. Restlessness
2. Tiring easily
3. Difficulty concentrating
4. Irritability
5. Muscle tension
6. Sleep disturbance
GAD

• The focus of the anxiety is not related to the symptoms of other

disorders e.g. worries about having a panic attack, being
embarrassed in public, intrusive thoughts, or about gaining weight.

• The anxiety causes clinically significant distress and impairs

functioning.

• Anxiety disorders are closely related to mood disorders.

• Up to 90% of people with GAD will have other psychological disorder (Grant
et al., 2005).
GAD – Prevalence and course

• Lifetime prevalence is around 6%.

• In a community sample, the one year prevalence was found to be around 3% (Kessler
& Wang, 2008).

• Twice as common in women than men.

• Lifetime prevalence in Europe is approx. 2.8%; in the USA it is 5.7%.

• Often begins in a person’s mid-teens although many people report having had
problems all of their lives.

• Onset in adulthood is not uncommon – more often triggered by traumatic event.

• GAD is usually chronic but fluctuates and can be worse during stressful periods.
GAD – Associated features and disorders

• Muscle tension may result in trembling, twitching, aches and

soreness.

• Many people experience somatic symptoms (sweating, diarrhoea)

and an exaggerated startle response.

• Depressive symptoms are common.

• Frequently co-occurs with mood disorders, other anxiety disorders,

substance abuse, stress and Irritable Bowel Syndrome.
GAD and genetics

• Heritability for GAD 28% (Bienvenu et al., 2011)

• Actually quite low!

• There is likely to be shared heritability with other disorders: it is

possible that personality traits are inherited that confer increased
risk for psychological disorders (Schienle et al., 2011).

• Genetic link unclear.

The impact of life events

• Traumatic events
• Sexual abuse during childhood increases the risk of developing GAD (Bulik et
al., 2001), as does experiencing the death of a parent.
• BUT, abuse is rare whereas GAD is common…

• Parenting styles
• People with GAD are more likely to report feeling rejected by their parents
(Newman et al., 2013)

• Parent modelling
• Parental anxious behaviour has been found to precede the same in their
children (Kertz & Woodruff-Borden, 2011).
ACTIVITY: Living with GAD

• https://www.youtube.com/watch?v=K6ACzT6PCDw

• Will Wheaton talks about his experiences of living with GAD

Understanding worry
Cognitive Avoidance Model

• Proposes that the function of worry is to suppress the emotional processing

of fear.
• People worry as a way of controlling their negative emotions, and to try and
prevent bad things from happening to them.
• Essentially, the inner voice (worry) calms the mind’s eye (the mental imagery
of bad things happening).
• In order for fear to be extinguished, people must experience this emotional
distress.
• Therefore, worry can be conceptualised as a form of cognitive avoidance.
• Worry is reinforced precisely because it reduces emotional distress.

Borkovec et al., 2004

Evidence to support the Cognitive Avoidance Model

• Worry does seem to be a verbal-linguistic process, rather than being

imagery based (Behar et al., 2009).

• Neurophysiological experiments have shown that worrying leads to

reduced physiological arousal (Borkovec & Hu, 1990) - we’ll come back to
this.

• People with GAD have reported that they engage in worrying, because it
prevents them from thinking in greater detail about the thing or event
that causes fear (Borkovec, 1994).
Contrast Avoidance Model

• Proposes that those with GAD use worry to maintain a negative state, which
will in turn mean that they are prepared for the worst and won’t experience
a negative shift in emotions when the feared event happens.

• Those with GAD are hypersensitive to shifts in negative emotion, and use
worry maintain negativity in an attempt to avoid these shifts.

• This moderates the impact of the event.

Newman & Llera, 2011

Evidence for the Contrast Avoidance Model

• Evidence for or against is limited.

• Debate around whether worry alleviates or increases negative

emotional states between the two models (Stapinski et al., 2010).

• Regardless of the physiological effects of worry, the beliefs

surrounding it may be important in the context of GAD
• Worry may become reinforced as sufferers believe that it serves a purpose.
• A causal relationship may be perceived between worry and a lack of negative
events.
Metacognitive Model

• Worry is a result of maladaptive beliefs

• Distinguishes between Type 1 and Type 2 worries

• We all have Type 1 worries – e.g. work, relationships

• Type 2 worry, is to worry about worrying: meta-worry

• Only people with GAD are thought to have Type 2 worries, and these serve to
maintain the constant cycle of worry

Wells, 1995
Biological impact of worry
Treating GAD
NICE Guidance

https://pathways.nice.org.uk/pathways/generalised-anxi
ety-disorder
The NICE stepped-care model
Focus of the intervention
STEP 4: Complex treatment-
refractory GAD and very marked
functional impairment, such as self-
neglect or a high risk of self-harm
STEP 3: GAD with an inadequate
response to step 2 interventions or
marked functional impairment
STEP 2: Diagnosed GAD that has not
improved after education and active
monitoring in primary care
STEP 1: All known and suspected
presentations of GAD
Nature of the intervention
Highly specialist treatment, such as
complex drug and/or psychological
treatment regimens; input from
multi-agency teams, crisis
services, day hospitals or inpatient
care
Choice of a high-intensity
psychological intervention
(CBT/applied relaxation) or a drug
treatment
Low-intensity psychological
interventions: individual non-
facilitated self-help, individual
guided self-help and
psychoeducational groups
Identification and assessment;
education about GAD and treatment
options; active monitoring
Assessment

GAD-7

Measures the
frequency of
cognitive and
somatic
symptoms.
 Assessment

Penn State Worry

Questionnaire

Measures the
excessiveness and
uncontrollable state of
worry.
 Assessment

Metacognition Questionnaire

Measures individual beliefs,

judgements, and tendencies
across a series of domains.
CBT for GAD

• Education

• Self-monitoring

• Relaxation training

• Cognitive restructuring

• Exposure
Example
exercises:
APPLE

• ACKNOWLEDGE - Notice and acknowledge the uncertainty as it comes to mind.

• PAUSE - Don't react as you normally do. Don't react at all. Just pause, and breathe.

• PULL BACK - Tell yourself this is just the anxiety or depression talking, and this thought or
feeling is only a thought or feeling. Don't believe everything you think! Thoughts are not
statements of fact.

• LET GO - Let go of the thought or feeling. It will pass. You don't have to respond to
them. You might imagine them floating away in a bubble or cloud.

• EXPLORE - Explore the present moment, because right now, in this moment, all is well.
Notice your breathing, and the sensations of breathing. Notice the ground beneath you.
Look around and notice what you see, what you hear, what you can touch, what you can
smell. Right NOW. Then, SHIFT YOUR FOCUS OF ATTENTION to something else - on what
you need to do, on what you were doing before you noticed the worry, or do something
else - mindfully, with your full attention.
Is CBT effective?

• Only 38% of patients have been found to be completely recovered at six-

month follow-up (Durham, 2007), compared to those receiving no treatment.

• Has been shown to be more effective than psychoanalytical therapy (Durham

et al., 1994) and behaviour therapy (Butler et al., 1991).

• Does seem to reduce the attentional biases towards threat that exist for
people with GAD (Mathews et al., 1995).

• Effects of CBT shown to last longer than drug treatment alone (Cuijpers et al.,
2014).
Metacognitive therapy

• Distress results from unhelpful processes of worry, rumination and

strategies of mental control (thinking about thinking).
• Focus not on changing content of thoughts, but the metacognitions
that give rise to the thinking, challenging the beliefs about the
cognitions, not the cognitions.
• Growing evidence (e.g. Wells et al., 2012)
• Some evidence that MCT is more effective than CBT in the long term
(Nordahl et al, 2018)
Acceptance and Commitment Therapy
(ACT)
• Functions via promoting psychological flexibility, encourages
‘defusion’ and acceptance of internal experience, contact with
present moment, values based living.
• Emerging evidence (e.g. Forman et al., 2007, ACT vs. CT, equivocal)
• Changes in “observing” and “describing” one’s experiences
appeared to mediate outcomes for the CT group relative to the ACT
group, whereas “experiential avoidance,” “acting with awareness,”
and “acceptance” mediated outcomes for the ACT group.
• Acceptable and feasible in older adults (Gould et al, 2021)
• Online ACT interventions can also be effective (Kelson et al, 2019)
Drug Treatments

SSRIs

Benzodiazepine
SNRIs
But!

• There is some evidence to suggest that we are more likely to refuse

treatment if we are prescribed drugs alone:

• An average treatment refusal rate of 8.2% was found across all studies.
Patients assigned to pharmacotherapy were 1.76 times more likely to refuse
treatment than those who were offered psychotherapy alone (Swift, 2017).
Combination Therapy

• Combination therapy is recommended when GAD is complex,

refractory, or when functioning is highly impaired.

• BUT!
• Evidence for effectiveness is lacking.
• Side effects and interactions are more likely, especially when combining anti-
depressants.
 End of Session
List of resources is available on the PS6007 Moodle page.

See you next week!