Anxiety Disorder

Threatening stimulus: Stressful life events or other personal concerns

Core appraisal: Fear of possible future adverse/threatening life outcomes

threatening stimulus: social, public situations

Core appraisal: Fear of negative evaluation from others (e.g. embarrassment, humiliation, ..)

threatening stimulus: unacceptable intrusive thoughts, images, impulses

core appraisal: fear of losing mental/behavioral control or otherwise being responsible for a negative outcome to self/others

threatening stimulus; memories, sensations, external stimuli associated with past traumatic experiences

core appraisal: Fear of thoughts, memories, symptoms, or stimuli associated with the traumatic event

- among adults 25-30% lifetime prevalence

- most frequent: specific phobia, GAD, separation anxiety

- childhood prevalence 6-17% (6 months)

- increased chance during adolescence: social phobia, panic, GA

- most common disorder across most countries (except Ukraine)

- girls suffer higher rates

- often attention to GP: unexplained physical symptoms (faintness, chest pain,...)

- 55% depression & anxiety (76 % when considering life-time)

- certain Anxiety disorders increase risk for depression later (phobia, OCD, panic attacs)

- substance use, especially alcohol

- within Anxiety Disorders: PTSD usually accompanied by other (panic/GAD); often after social phobia/GAD other coming

depression, alcohol abuse, other anxiety disorders

the expression of anxiety symptoms

- reduced QOL

- work loss days

- financial dependence

- social & daily fct.

- marital distress

- mental health visits

--> family physician likely to not recognize anxiety disorder (50% primary healthcare patients missed)

- economic cost (costs in services & lost productivity) for state

- physiological symptoms (increased heart rate, shortness of breath, ...)

- Cognitive symptoms (fear of losing control/unable to cope, fear of death, fear of 'going crazy', ...)

- Behavioral symptoms (avoiding threat cues/situations, escape, freezing, ...)

- Affective symptoms (tense, frightened, edgy, frustrated, impatient, ...)

basal arousal level heightened & slower habituation (less autonomic flexibility)

--> more likely to misinterpret persistent state of hyperarousal as 'evidence for threat'

(unclear whether anxiety state is caused by SNS activation and withdrawal of vagal activity OR

SNS is suppressed and PNS remains normal)

*SNS = hyperarousal symptoms (increased strength, heart rate, (nor)epinephrine,...)

*PNS = tonic immobility, drop in blood pressure, fainting, ('conservation-withdrawal')

- type

- frequency

- severity

- physiological symptoms

(- interpretation)

30-40% heritability (greater vulnerability/genetic predisposition --> interacts with environmental & cognitive factors)

- seperate genetic risk for depression/GAD vs. short phobia/panic

--> As clinician ask for family member's prevalence

- amygdala (emotional processing, memory, evaluating stimuli value --> appraisal) --> acquisition of conditioned fear responce

- emotional brain: evaluates affective significance of stimuli (thoughts, physical, external)

- LeDoux pathways:

1) Direct 'low-road': (sensory) Thalamo-amygdala (CN) --> (cond.) fear respinse

2) Indirect 'high-road', when complex stimuli (via cortices) (e.g. 2 similar tones --> only one predicts danger)

- CN (central nucleus) of amygdala --> projects to hyp., hip., cortex, brainstem, VTA, nuclei.. --> experience of anxiety

- neural substrates of cognition (e.g. mPFC, ftOFC, ...) influence emotiional functioning (at later stage & anticipatory) --Y can 'override' fear response! --> rationale behind Cognitive Therapy to treat Anxiety Disorder

- Seretonin = neurochemical break on behavior --> blocking Se-receptors leads to anxiety (low levels of Se in anxious state) --> Se regulates anxiety(amygdala, hippocampal, PFC) maybe via other neurotransmitter systems

- GABA (inhibitory neurotransmitter) with benzodiazepine receptor --> when molecule bound to that receptor then more GABA effect --> Drugs (benzodiazepine) often work

- threat stimuli --> amygdala, hip., PFC --> release CRH (corticotropin-releasing hormone) (from PVN(paraventricular nuclei)) --> stimulates ACTH-release (adrenocorticotropic hormone) (from pituitary gland) --> more cortisol production (stress hormone)  !still unknown how exactly works!

Classical conditioning (cannot explain persistence of human fears in absence of repeated UCS-CS pairings!)

2 factor model (= 2 stage model): (1) fear-acquisition (like CC) (2) persistence of fear (through avoidance & negative reinforcement)

fear avolved as defense against survival-threats (in our ancestors)

fear module = indep. behavioral, mental, neural system to solve adaptive problems in life-threat-situations

Characteristics:

- only responds (stronger) to evolutionary relevant stimuli (this selection is unconscious)

- automatic (SCR activation..)

- encapsulation ('unstopable'/penetrates/biases cognition&other systems)

- specific neural circuitry (amygdala)

--> evolutionary psychologists argue that 'exagerrated beliefs' in danger play role in maintaining anxiety but they are consequence not cause of fear!

Cognitive appraisal/misinterpretation of stimuli/situation (causing unadequate fear/anxiety)

- fear stimuli are processed also preconscious (automatic, not reportable,..)

- cognitive processes in fear acquisition (mediator to explain persistence, individual reappraisal influences trauma, outcome expectancy influences conditioning)

- conscious cognitive processes can alter fear responses (e.g. information can reduce fear response)

- amygdala not fear specific (facial emotion recognition, negative arousal, emotional valence assigning, positive valenced stimuli:)!) & can be influenced by cognitive processes (mPFC can override amygdala-fear-response) :)

- higher order cortical regions have a role in fear (i.e. LeDoux indirect pathway)

-psychoeducation

- intentional activation of body sensations

-  cognitive restructuring/reattributing the misinterpretation of bodily sensations

- graded situational exposure homework

- increased tolerance & acceptance of anxiety, risk, and uncertainty

- physiological hyperarousal (actually not abnormal) --> misinterpretaion (catastrophic ideation) --> high discomfort --> intense fear of such episodes (panic attacks) again

- panic attack between 10 & 20 minutes, reaches peak within 10 minutes, hightened anxiety can linger on afterwords

-highly comorbid with agoraphobia (95% agoraphobic people also have panic)

- often identifiable stressor (internal or external) --> situational avoidance/safety-seeking behavior

- perceived lack of control/ feeling overwhelmed by anxiety --> focus only at panicogenic sensations (cannot reason anymore)

1) spontaneous panic (unexpected sudden onset without triggers)

2) Situationally cued panic (particular sit. leads to panic)

3) Nocturnal panic (sudden awaking at night in state of terror)

4) limited-symptom panic (less than four panic attack symptoms, still a period of intense fear in not real danger)

5) Nonclinic panic (occasional, in general pop., often in stressful/evaluative situations, fewer panic symptoms, less worry/apprehension of panic)

avoidance or endurance with distress of public/social places where escape/help might be difficult (often devellops after some panic attacks)

major depression, GAD, substance abuse, personality disorder (borderline, dependent, schizoid, schizotypal pd)

- practically nonexistent

- often cardiac disease, hypertension, asthma, ulcers, migraines; higher mortality rates (to elevated cardio-risk) --> produce similar symptoms/sensations! --> can contruibute to disorder

- negative life events, past/current stressors, negative coping style, psychosocial impairment

- twice as common in women

- targets maladaptive beliefs about negative social evaluation by others, reliance on escape & avoidance to manage anxiety --> in vivo exposure to moderately anxious social situation

- persistent fear of social/performance situations which may lead to embarrassment/humiliation

- fear of negative evaluation by others

- highly self-conscious, self-critical in feared social situation (high internal standard of social performance)

- inhibitory behavior (rigid, stiff, verbally inarticulate, not thinking freely)

(often no problem with family --> mainproblem with strangers!)

public speaking, parties, meetings, speaking to authority, (in)formal speaking

--> avoid social interaction (greater physical awareness/arousal during social situations)

to meet social phobia-requirements, individual MUST have some awareness of the excessive & unreasonable nature of his social fears (not like paranoid people who really believe that others intend to harm them)

quantitative difference (shyness is weaker variant) but 'social phobia should not be considered an extreme form of shyness' (people with social phobia not always include/meet criteria for shyness!)

- difference in severity (fear of how many different situations? how great impairement/distress thus? greater symptom severity, avoidance, fear of negative evaluation, chronicity, earlier onset, ...)

- majority has GSP

- GSP overaps withAPD (avoidant personality disorder) --> both pervasive discomfort, inhibition, fear of neg evaluation --> almost all ADP's meet criteria for social phobia --> those with both have greater severity & poorer social skills! (difference: ADP low self-esteem)

- 3rdcommon among all mental disorders (7,9% prevalence, 13,3%life-time)

- 3:2 ratio of women to men (equal number seek treatment) (difference in Turkey: 78%men)

TKS in Japan ('taijin kyofu-sho') = persistent/irrational fearof causing embarrassment/harm to others

- early to mid-adolescence onset (peak at 13 years!) (50-80% of patients report onset in childhood) (the earlier the more severe/chronic!)

- comorbid with APD, major depression, GAD, specific phobia, agoraphobia, substance use

--> Lowest rate of treatment utilization !! (duration of delay of treatment-seeking ~16 years (!), fewer medical visits, undetected by physicians/medical health care..

- heritability 30%, signific association with traumatic childhood events (parents/abuse)

- social skill deficit ? or wrong perception (hand in hand) --> leads to more negative social experience/reaction from others

- Worry

(excessive worry & anxiety, concerning number of events/parts of life, over 6 months, symptoms occur most of the days, distress, impairment)

high probability of affective disturbance (co-occuring deppressive disorder)