Anxiety Disorders

• Fear


  A reaction to immediate danger, a threat that's happening now, involves rapid changes in sympathetic nervous system, higher arousal
• Anxiety


  An apprehension over an anticipated problem, about a future threat, helps planning for future threats, improves preparedness, involves moderate arousal
• Both fear and anxiety play an important role in anxiety disorders
• Anxiety Disorders (DSM IV)

  • Specific phobia
  • Social phobia
  • Obsessive-compulsive disorder
  • Acute stress disorder
  • Posttraumatic stress disorder
• Anxiety Disorders (DSM 5)

  • Obsessive-compulsive and related disorder
  • Trauma- and Stressor- related disorder
  • Specific phobia
  • Social anxiety disorder
  • Panic disorder
  • Agoraphobia
  • Generalized anxiety disorder
• Anxiety disorders


  • Excessively high or frequent anxiety
  • Tendencies to experience unusually intense fear (except for generalized anxiety disorder)
  • Symptoms must interfere with important areas of functioning and/or cause distress
  • Symptoms are not caused by a drug or a medical condition
  • Symptoms persist for at least 6 months, or at least 1 month for panic disorder
• Specific phobia


  Fear of objects or situations that is out of proportion to any real danger
• Specific phobia


  • The object or situation is avoided or else endured with intense anxiety
  • The symptoms persist for at least six months
  • The person recognizes that the fear is excessive (not a criterion in DSM 5)
• Social anxiety disorder


  Fear of unfamiliar people or social scrutiny
• Social anxiety disorder


  • Trigger situations are avoided or else endured with intense anxiety
  • The symptoms persist for at least six months
  • The most common fears include public speaking, meeting new people, and talking to people in authority
  • It normally begins during adolescence when social interactions become more important
• Panic disorder


  Anxiety about recurrent panic attacks
• Panic disorder


  • Recurrent unexpected panic attacks, unrelated to specific situations
  • At least 1 month of concern about the possibility of more attacks, their consequences, or maladaptive behavioral changes because of the attacks
  • Panic attack: a sudden attack of intense apprehension, terror, and feelings of impending doom, accompanied by at least four other symptoms
  • The symptoms tend to come on very rapidly and reach a peak within 10 minutes
  • The onset is typically during adolescence
  • Lifetime prevalence: 6%
• Agoraphobia


  Anxiety about being in places where escaping or getting help would be difficult if anxiety symptoms occurred
• Agoraphobia


  • Disproportionate and marked fear or anxiety about at least two situations where it would be difficult to escape or receive help
  • Situations are avoided or are endured with intense fear or anxiety
  • Symptoms last at least six months
  • Half of the people with agoraphobia do not have panic attacks
• Generalized anxiety disorder


  Uncontrollable worry
• Generalized anxiety disorder


  • Excessive anxiety and worry at least 50% of days about a number of events
  • The person finds it hard to control the worry
  • The anxiety or worry is associated with at least three physical symptoms
  • Symptoms last at least six months
  • Patients worry about general issues such as relationships, health, finances, and daily hassles- but much more than would be considered adequate and this interferes with daily life
  • It typically begins in adolescence, and is often chronic
• Life-time Prevalence of Anxiety Disorders as a group: ≈ 28%
• Anxiety disorders as a group are the most common type of psychiatric diagnosis and more common than for instance MDD
• Percentage of adults (18-64 years) in the general population who meet diagnostic criteria for anxiety disorders

  • Specific phobia: 13.8%
  • Social anxiety disorder: 13.0%
  • Panic disorder: 5.2%
  • Agoraphobia: 2.6%
  • Generalized anxiety disorder: 6.2%
• More than half of people with one anxiety disorder meet the criteria for another anxiety disorder
• 75% of people with an anxiety disorder have at least one other psychological disorder
• About 60% of people with an anxiety disorder also meet the diagnostic criteria for depression
• Comorbidity is associated with poorer outcomes
• Gender as a risk factor for anxiety disorders

  • Women are twice as likely as men to be diagnosed
  • Women may be more likely to report their symptoms
  • Men may believe more in their personal control over situations (protective)
  • Gender roles: men may experience more social pressure to face fears
  • Women may experience different life circumstances
• Cultures with recent war, revolution, large-scale prosecution or poverty have higher levels of anxiety disorders
• Culture and environment influence what people come to fear
• Mowrer's two factor model of anxiety disorders

  1. Classical conditioning: a person learns to fear a neutral stimulus (CS) that is paired with an intrinsically aversive stimulus (UCS)

  2. Operant conditioning: a person gains relief by avoiding the CS
• It is rarely clear that classical conditioning has occurred by direct experience
• Many people with anxiety disorders do not remember a specific incident; many people who experience threats do not develop anxiety
• Ways how anxiety/fear might develop

  • Direct experience. Observation of another person harmed or frightened by a stimulus (modeling)

  Verbal instruction or even thoughts (cognitive factors)
• Some people seem to acquire fears more readily and to show a slower extinction of fears once they are acquired
• People with anxiety disorders are particularly sensitive to unpredictable threats
• Genetic factors may explain 50 to 60% of the risk for anxiety disorders in the population
• Having a family member with phobia is related to increased risk of developing not only phobia, but other anxiety disorders
• Neurobiological factors in anxiety disordersElevated activity in the amygdala

  Less activity in the medial prefrontal cortex

  Disruption in serotonin levels

  Changes in the function of the GABA system

  Increased levels of norepinephrine and changes in the sensitivity to norepinephrine receptors
• Behavioural inhibition in infants

  Tendency to become agitated and cry when faced with novel stimuli
• Hippocampus


  • Encoding the context in which feared stimuli occur
• Medial prefrontal cortex


  • Regulates the amygdala
  • Involved in extinction of fears
  • Regulates emotions: conscious processing of fear and anxiety
• Serotonin


  Disruption in levels in people with anxiety disorders
• GABA system


  • Changes in function
  • Involved in modulating the activity in the amygdala and fear circuit