Anxiety Disorders

Unit II
Abnormal Psychology
Ms. Nishita Agrawal
Outline
• Definition of anxiety
• Clinical picture and management (in brief) of the
following conditions-
– Generalized anxiety disorder
– Social anxiety
– Obsessive-compulsive disorders
– Panic disorder
– Phobias
Overview - Anxiety Disorders
• Among the most prevalent disorders in the world.
• Associated with significant co-morbidity
• Chronic.
• Interplay of biology + experiences.
• Risk factor: personality trait of neuroticism—a proneness or
disposition to experience negative mood states.
• Evolutionary value - helps us plan and prepare for a possible
threat.
• So, when is it maladaptive?
Maladaptive when..
• Persistent and chronic i.e. lasts longer than needed.
• High intensity.
• Causing significant personal distress.
• Impairment in functioning.
GENERALIZED ANXIETY DISORDER
• “Basic anxiety disorder”
GAD
• Worry about many different aspects of life.
• Living in a constant, future-oriented mood state of anxious
apprehension, chronic tension, worry, and diffuse uneasiness that
they cannot control.
• Marked vigilance for possible signs of threat in the environment and
engaging in subtle avoidance activities such as procrastination,
checking, or calling a loved one frequently to see if he or she is safe.
• Chronic muscle tension.
DSM-5 Criteria
• A- Excessive anxiety and worry (apprehensive expectation), occurring more days
than not for at least 6 months, about a number of events or activities (such as
work or school performance).
• B- The individual finds it difficult to control the worry.
• C- The anxiety and worry are associated with three (or more) of the following six
symptoms (with at least some symptoms having been present for more days than
not for the past 6 months): Note: Only one item is required in children.
• Restlessness or feeling keyed up or on edge.
• Being easily fatigued.
• Difficulty concentrating or mind going blank.
• Irritability.
• Muscle tension.
• Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying
sleep).
DSM-5 Criteria
• D- The anxiety, worry, or physical symptoms cause clinically
significant distress or impairment in social, occupational, or
other important areas of functioning.
• G- The disturbance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication) or
another medical condition (e.g., hyperthyroidism).
• F- The disturbance is not better explained by another mental
disorder.
Specific Phobia
DSM 5 Criteria
• A- Marked fear or anxiety about a specific object or situation (e.g., flying, heights,
animals, receiving an injection, seeing blood).
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing,
or clinging.
• B - The phobic object or situation almost always provokes immediate fear or anxiety.
• C- The phobic object or situation is actively avoided or endured with intense fear or
anxiety.
• D- The fear or anxiety is out of proportion to the actual danger posed by the specific
object or situation and to the sociocultural context.
• E- The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
DSM 5 Criteria
• F- The fear, anxiety, or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
• G- The disturbance is not better explained by the symptoms of another
mental disorder, including fear, anxiety, and avoidance of situations
associated with panic-like symptoms or other incapacitating symptoms (as in
agoraphobia); objects or situations related to obsessions (as in
obsessive-compulsive disorder); reminders of traumatic events (as in
post-traumatic stress disorder); separation from home or attachment figures
(as in separation anxiety disorder); or social situations (as in social anxiety
disorder)
Case
• Mr. S was a successful lawyer who presented for treatment after his firm, to
which he had previously been able to walk from home, moved to a new
location that he could only reach by driving. Mr. S reported that he was
“terrified” of driving, particularly on highways. Even the thought of getting
into a car led him to worry that he would die in a fiery crash. His thoughts
were associated with intense fear and numerous somatic symptoms,
including a racing heart, nausea, and sweating. Although the thought of
driving was terrifying in and of itself, Mr. S became nearly incapacitated
when he drove on busy roads, often having to pull over to vomit.
Social Phobia/ Social Anxiety Disorder
DSM 5 Criteria
• A- Marked fear or anxiety about one or more social situations in which the individual is
exposed to possible scrutiny by others. Examples include social interactions (e.g., having a
conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and
performing in front of others (e.g., giving a speech).
Note: In children, the anxiety must occur in peer settings and not just during interactions
with adults.
• B- The individual fears that he or she will act in a way or show anxiety symptoms that will be
negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or
offend others).
• C- The social situations almost always provoke fear or anxiety. Note: In children, the fear or
anxiety may be expressed by crying, antrums, freezing, clinging, shrinking, or failing to speak
in social situations.
• D- The social situations are avoided or endured with intense fear or anxiety.
DSM 5 Criteria
• E- The fear or anxiety is out of proportion to the actual threat posed by the social situation
and to the sociocultural context.
• F- The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
• G- The fear, anxiety, or avoidance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
• H- The fear, anxiety, or avoidance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical condition.
• I- The fear, anxiety, or avoidance is not better explained by the symptoms of another mental
disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
• J- If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns
or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
Case
• Ms. B was a 29-year-old computer programmer who presented for treatment after she was offered a
promotion to a managerial position at her firm. Although she wanted the raise and the increased
responsibility that would come with the new job, which she had agreed to try on a probationary basis,
Ms. B reported that she was reluctant to accept the position because it required frequent interactions
with employees from other divisions of the company, as well as occasional public speaking. She stated
that she had always felt nervous around new people, whom she worried would ridicule her for “saying
stupid things” or committing a social faux pas. She also reported feeling “terrified” to speak before
groups. These fears had not previously interfered with her social life and job performance. However,
since starting her probationary job, Ms. B reported that they had become problematic. She noted that
when she had to interact with others, her heart started racing, her mouth became dry, and she felt
sweaty. At meetings, she had sudden thoughts that she would say something very foolish or commit a
terrible social gaffe that would cause people to laugh. As a consequence, she had skipped several
important meetings and left others early.
• https://www.youtube.com/watch?v=XH2tF8oB3cw&pp=ygUic2
9jaWFsIGFueGlldHkgZGlzb3JkZXIgY2FzZSBzdHVkeQ==
PANIC DISORDER
DSM Criteria
A - Recurrent Panic Attacks: The individual experiences recurrent and unexpected panic attacks. A panic attack is an
abrupt surge of intense fear or discomfort that reaches a peak within minutes and includes at least four of the following
symptoms:

– Palpitations, pounding heart, or accelerated heart rate

– Sweating
– Trembling or shaking
– Sensations of shortness of breath or smothering
– Feelings of choking
– Chest pain or discomfort
– Nausea or abdominal distress
– Dizziness, light-headedness, or feeling faint
– Chills or heat sensations
– Paresthesias (numbness or tingling sensations)
– Derealization (feelings of unreality) or depersonalization (being detached from oneself)
– Fear of losing control or "going crazy"
– Fear of dying
DSM Criteria
B - At Least One of the Attacks is Followed by a Month (or More) of One (or More) of the Following:

– Persistent concern or worry about additional panic attacks or their consequences (e.g.,
losing control, having a heart attack, “going crazy”)
– A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed
to avoid having panic attacks, such as avoiding exercise or unfamiliar situations.

C - The Panic Attacks are Not Attributed to a Substance or Another Medical Condition: The panic
attacks are not due to the physiological effects of a substance (e.g., a drug of abuse, a medication) or
another medical condition (e.g., hyperthyroidism).

D - The Panic Attacks are Not Better Explained by Another Mental Disorder: The panic attacks are not
exclusively associated with another mental disorder, such as social anxiety disorder, specific phobia,
obsessive-compulsive disorder, post-traumatic stress disorder, or separation anxiety disorder.
Case Study
Ravi is a 30-year-old software engineer from Bangalore. He recently got promoted to a managerial
position at work, which has significantly increased his responsibilities. Although he was excited at
first, the pressure of leading a team and meeting tight deadlines has been overwhelming. One
afternoon while stuck in traffic on his way to work, Ravi suddenly feels his heart racing, his chest
tightening, and a wave of dizziness. He panics, thinking he’s about to die, and manages to pull
over to the side of the road.

This experience leaves him shaken. Over the next few weeks, Ravi starts having similar
episodes—his heart pounds, he feels short of breath, and his hands get clammy, even when he is
simply sitting at his desk. He becomes extremely anxious about being stuck in traffic or crowded
places like malls, fearing he might have another attack. Eventually, he starts avoiding these
situations altogether and asks his boss to work from home more often, which he knows is hurting
his performance.
Case Study
Family and Social Context: Ravi lives with his parents, who are supportive but don’t fully
understand his condition. His mother believes it's related to his late marriage prospects and
encourages him to consult an astrologer, while his father dismisses it as "work stress" and advises
him to "toughen up." This causes Ravi to feel more isolated, and he avoids discussing his condition
with friends, fearing they will think he is weak.

Current Symptoms:

● Episodes of intense fear with heart palpitations, shortness of breath, sweating, and
dizziness.
● Persistent worry about having another attack, particularly in traffic or crowded places.
● Avoidance of situations where he fears an attack might occur, like traffic jams or busy social
events.
● Constant anxiety and hypervigilance about his bodily sensations.
Panic Attack - Immediate Management
• Ice cube/ Cold water
• Rubberband
• Grounding - literally lying down on the floor
• 54321
• Deep breathing
• Visualization
• Safety kit
OBSESSIVE COMPULSIVE DISORDER
Overview
• Characterised by Obsessions and Compulsions.
• Obsessions - Recurrent, persistent thoughts, impulses or images experienced as
intrusive or inappropriate and cause distress.
• Compulsions - Repetitive behaviours or mental acts performed in response to the
obsessions to reduced distress.
• Compulsions involve an element of magical thinking.
• All OCD patients fear the terrible that can happen to self/others for which they are
responsible (What-If Illness).
• Compulsions usually reduce the anxiety (Briefly at least)
Common Obsessions Their Compulsions

Contamination Washing, cleaning

Repeated doubts Checking, assurances

Order and symmetry Ordering, arranging

Aggressive Praying

Sexual Counting
• O and C are time consuming, cause significant distress and functional impairment.
• Insight about compulsions can be:
• With good insight
• Poor insight
• Absent insight
• C can be mild (washing hands for 15 minutes) to extreme (washing hands with a
disinfectant for hours).
• The performance of the compulsive act or the ritualized series of acts usually brings
a feeling of reduced tension and satisfaction, as well as a sense of control.
DSM 5 criteria
• A- Presence of obsessions or compulsions or both.
• B- O and C are time consuming (eg take more than 1 hour a day)
or cause clinically significant distress or impairment.
• C- The obsessive-compulsive symptoms are not attributable to
the physiological effects of a substance or another medical
condition.
• D- The disturbance is not better explained by the symptoms of
another mental disorder.
Management
Medications
Benzodiazepines, Antidepressants: selective
Specific Phobia serotonin reuptake inhibitors (SSRIs), Paroxetine
(Paxil)
Antidepressants [including the monoamine oxidase
Social Phobia
inhibitors (MAOIs) and SSRIs]
Benzodiazepines [alprazolam (Xanax) or clonazepam
Panic Disorder
(Klonopin)], antidepressants
Benzodiazepines, antidepressants + a new medicine
GAD
called buspirone

OCD Antidepressants, but high relapse

Behavioral Treatments
• Exposure therapy (mainly for phobias): a form of
behavior therapy that involves controlled exposure to
the stimuli or situations that elicit phobic fear. Eg.
systematic desensitization, flooding, modelling.
• Exposure and response prevention (for OCD): the
clients are asked to expose themselves repeatedly to
stimuli that will provoke their obsession and then are
asked to not engage in the rituals that they ordinarily
would engage in. to reduce the anxiety or distress
provoked by their obsession.
CBT
• Start with psychoeducation, breathing techniques &
progressive relaxation.
• Relaxing imagery.
• Identifying automatic negative thoughts.
• Cognitive restructuring.
• Examining the evidence.
– eg. Social anxiety- Do I know for certain that I won‘t have
anything to say? Does being nervous have to lead to or equal
looking stupid?