Take a minute to answer this question

What is anxiety? What words do

you use to describe anxiety?
 Anxiety Disorders
 Anxiety disorders include disorders that share features of excessive fear and
anxiety and related behavioral disturbances.
 Fear is the emotional response to real or perceived imminent threat, whereas
anxiety is anticipation of future threat.
 Obviously, these two states overlap, but they also differ, with fear more often
associated with surges of autonomic arousal necessary for fight or flight,
thoughts of immediate danger, and escape behaviors, and anxiety more often
associated with muscle tension and vigilance in preparation for future danger
and cautious or avoidant behaviors.
 Sometimes the level of fear or anxiety is reduced by pervasive avoidance
behaviors. Panic attacks feature prominently within the anxiety disorders as a
particular type of fear response. Panic attack
Dimensions of Anxiety: Symptoms in four
arenas
Dimensions of Anxiety: Symptoms in four
arenas
 Somatic
- Hyperventilation - Tachycardia
- trembling - palpitations
- shakiness - swallowing
- sweating - lump in throat
- flushing - urgency to urinate
-nausea - hair raising
- dizziness - tinnitus
- wobbling legs
Dimensions of Anxiety: Symptoms in four
arenas
 Cognitive
- Specific fears
- Embarrassment or shame is
intolerable
- Something awful will happen
- I am going crazy
- I will lose control
- I am going to die
Dimensions of Anxiety: Symptoms in four
arenas
 Behavioral
 Withdrawal

 Avoidance

 Escape

 Clinging

 Aggression
Dimensions of Anxiety: Symptoms in four
arenas
 Emotional
- Tense - Nervous
- Worried - On edge
- Panicky - Feelings of unreality
- Terrified - Hypervigilant
- Scared - Depressed
- Anxious
When to be concerned

 Avoidance of school (refuses to go)

 Frequent stomachaches or headaches in the morning before school
 Avoidance of activities
 Easily upset – distress out of proportion
 Parent or teacher reports they spent a lot of time comforting the child and/or
urging her/him to participate in regular activities
 Parent or teacher reports family/classroom functioning is being disrupted by your
child's fears and worries, or meltdowns.
 Intense worries or fears that interfere with daily activities
When to be concerned

 Sudden overwhelming fear for no reason, often with difficulty breathing and
racing or pounding heart
 Decline in school performance
 Wanting to avoid school
Anxiety

 Anxiety disorders are the most common mental health disorders.

 Up to 6% of children and youth have an anxiety disorder severe enough to need
treatment.
 Children may have more than one kind of anxiety disorder.
 Many anxiety disorders start in childhood and if untreated, they may persist into
adulthood.
Anxiety Disorders

 Anxiety Disorders:
- intensity
- duration
- impairment
 Types of Anxiety

1. Separation anxiety 11. Anxiety not due to

medical condition
2. Selective mutism
12. Other specified anxiety
3. Specific phobia
disorders
4. Situational Anxiety
13. Unspecified anxiety
5. Other disorder
6. Social Anxiety
7. Panic Disorder
8. Agoraphobia
9. Generalized anxiety
disorder
10. Substance Induced
Anxiety
Separation Anxiety Disorder

 Child is afraid of leaving their parent(s)

 They may worry that something bad will happen to the parent or to someone
they love or to themselves

 May refuse to go to school

 May have stomachaches, headaches, or throw up if they fear separation
 May refuse to go to playdates at other people’s houses

 Diagnosed if it causes problems at school or socially and has been going on at

least 4 weeks
Generalized Anxiety Disorder

 Children with this kind of anxiety may:

 Have lots of worries and fears
 Have problems sleeping because of worries
 Have trouble concentrating
 Get tired easily or have tension headaches
 Be tense or restless
 Be perfectionist
 Have an anxious desire for approval
Panic Disorder

 Happens less often with younger children

 People with this kind of anxiety have panic attacks
 Feel very scared
 Heart pounding, hard to breathe
 May feel shaky, dizzy, or sick
 May feel like they are going crazy or something really awful is going to happen
 Sometimes they avoid school or want to stay in the house

 Frequent panic attacks = panic disorder

Selective Mutism

 Children may not talk to anyone who is not close to them, such as immediate
family
 They may look down, withdraw, turn red if required to talk
 Often they whisper if they do speak in a situation where they are anxious
 Up to 2% of school age children may have these symptoms
 Some kids outgrow it; some go on to have social phobia
Social Anxiety/Social Phobia

 Happens more in teens than in young children

 Fear and worry about social situations
 Going to school
 Speaking in class
 Social events including recess and lunch
 Shy, self-conscious
 Easily embarrassed
 These kids tend to be sensitive to criticism and find it hard to be assertive
 Panic Attack Specifier
 Note: Symptoms are presented for the purpose of 2. Sweating.
identifying a panic attack; however, panic attack is
3. Trembling or shaking.
not a mental disorder and cannot be coded. Panic
attacks can occur in the context of any anxiety 4. Sensations of shortness of breath or smothering.
disorder as well as other mental disorders (e.g., 5. Feelings of choking.
depressive disorders, posttraumatic stress disorder,
substance use disorders) and some medical conditions 6. Chest pain or discomfort.
(e.g., cardiac, respiratory, vestibular, 7. Nausea or abdominal distress.
gastrointestinal). When the presence of a panic
attack is identified, it should be noted as a specifier 8. Feeling dizzy, unsteady, light-headed, or faint.
(e.g., “posttraumatic stress disorder with panic 9. Chills or heat sensations.
attacks”). For panic disorder, the presence of panic
attack is contained within the criteria for the disorder 10. Paresthesias (numbness or tingling sensations).
and panic attack is not used as a specifier. An abrupt 11. Derealization (feelings of unreality) or
surge of intense fear or intense discomfort that depersonalization (being detached from oneself).
reaches a peak within minutes, and during which time
four (or more) of the following symptoms occur: 12. Fear of losing control or “going crazy.”
 Note: The abrupt surge can occur from a calm state 13. Fear of dying.
or an anxious state. 14. Note: Culture-specific symptoms (e.g., tinnitus, neck

1. Palpitations, pounding heart, or accelerated heart

soreness, headache, uncontrollable screaming or
rate. crying) may be seen. Such symptoms should not count
 Agoraphobia
 A. Marked fear or anxiety about two (or more) of the following five situations:
1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).
2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
3. Being in enclosed places (e.g., shops, theaters, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.
 B. The individual fears or avoids these situations because of thoughts that escape
might be difficult or help might not be available in the event of developing panic-
like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of
falling in the elderly; fear of incontinence).
 C. The agoraphobic situations almost always provoke fear or anxiety.
 D. The agoraphobic situations are actively avoided, require the presence of a
companion, or are endured with intense fear or anxiety.
 E. The fear or anxiety is out of proportion to the actual danger posed by the
agoraphobic situations 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. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease)
is present, the fear, anxiety, or avoidance is clearly excessive.
 I. The fear, anxiety, or avoidance is not better explained by the symptoms of another
mental disorder—for example, the symptoms are not confined to specific phobia,
situational type; do not involve only social situations (as in social anxiety disorder); and
are not related exclusively to obsessions (as in obsessive-compulsive disorder),
perceived defects or flaws in physical appearance (as in body dysmorphic disorder),
reminders of traumatic events (as in posttraumatic stress disorder), or fear of
separation (as in separation anxiety disorder).
 Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an
individual’s presentation meets criteria for panic disorder and agoraphobia, both
diagnoses should be assigned.
 Substance/Medication-Induced Anxiety Disorder
 A. Panic attacks or anxiety is predominant in the clinical picture.
 B. There is evidence from the history, physical examination, or laboratory findings of
both (1) and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication or
withdrawal or after exposure to a medication.
2. The involved substance/medication is capable of producing the symptoms in Criterion
A.
 C. The disturbance is not better explained by an anxiety disorder that is not substance/
medication-induced. Such evidence of an independent anxiety disorder could include
the following:
The symptoms precede the onset of the substance/medication use; the symptoms persist
for a substantial period of time (e.g., about 1 month) after the cessation of acute
withdrawal or severe intoxication; or there is other evidence suggesting the existence of
an independent non-substance/medication-induced anxiety disorder (e.g., a history of
recurrent non-substance/medication-related episodes).
 D. The disturbance does not occur exclusively during the course of a delirium.
 E. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
 Note: This diagnosis should be made instead of a diagnosis of substance intoxication
or substance withdrawal only when the symptoms in Criterion A predominate in the
clinical picture and they are sufficiently severe to warrant clinical attention.
 Specify if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for
diagnoses associated with substance class):
 With onset during intoxication: This specifier applies if criteria are met for
intoxication with the substance and the symptoms develop during intoxication.
 With onset during withdrawal: This specifier applies if criteria are met for
withdrawal from the substance and the symptoms develop during, or shortly after,
withdrawal.
 With onset after medication use: Symptoms may appear either at initiation of
medication or after a modification or change in use.
 Anxiety Disorder Due to Another Medical Condition

 A. Panic attacks or anxiety is predominant in the clinical picture.

 B. There is evidence from the history, physical examination, or laboratory findings that
the disturbance is the direct pathophysiological consequence of another medical
condition.
 C. The disturbance is not better explained by another mental disorder.
 D. The disturbance does not occur exclusively during the course of a delirium.
 E. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
 Coding note: Include the name of the other medical condition within the name of the
mental disorder (e.g., 293.84 [F06.4] anxiety disorder due to pheochromocytoma). The
other medical condition should be coded and listed separately immediately before the
anxiety disorder due to the medical condition (e.g., 227.0 [D35.00] pheochromocytoma;
293.84 [F06.4] anxiety disorder due to pheochromocytoma.
Comorbidity
 50% of those with anxiety disorder meet criteria for another anxiety disorder
 75% of those with anxiety disorder meet criteria for another psychological disorder
 Disorders commonly comorbid with anxiety:
 60% with anxiety also have depression
 Substance abuse
 Personality disorders
 Medical disorders, e.g. coronary heart disease

© 2015 John Wiley & Sons, Inc. All rights reserved.

Gender and
Sociocultural Factors
 Women are twice as likely as men to have anxiety disorder
 Possible explanations
 Women may be more likely to report symptoms
 Men more likely to be encouraged to face fears
 Women more likely to experience childhood sexual abuse
 Women show more biological stress reactivity

 Cultural factors
 Culture can shape anxieties and fears
 Culturally specific syndromes
 Taijin kyofusho
 Japanese fear of offending or embarrassing others
 Kayak-angst
 Inuit disorder in seal hunters at sea similar to panic
 Rate of anxiety disorders varies by culture, but ratio of somatic to psychological symptoms appears similar (Kirmayer, 2001)
© 2015 John Wiley & Sons, Inc. All rights reserved.
Table 6.3: Percent of People Who Meet Diagnostic Criteria for
Anxiety Disorders in the Past Year and in Their Lifetime

© 2015 John Wiley & Sons, Inc. All rights reserved.

Table 6.5: Factors that May Increase the Risk for
More than One Anxiety Disorder
 Behavioral conditioning (classical and operant conditioning)
 Genetic vulnerability
 Increased activity in the fear circuit of the brain
 Decreased functioning of GABA and serotonin; increased norepinephrine activity
 Behavioral inhibition
 Neuroticism
 Cognitive factors, including sustained negative beliefs, perceived lack of control, and
attention to cues of threat

© 2015 John Wiley & Sons, Inc. All rights reserved.

Etiology of Specific Phobias
 Conditioning
 Mowrer’s two-factor
model
 Pairing of stimulus with
aversive UCS leads to
fear (Classical
Conditioning)
 Avoidance maintained
though negative
reinforcement (Operant
Conditioning)

© 2015 John Wiley & Sons, Inc. All rights reserved.

Etiology of Specific Phobias
 Extensions of the two-factor model
 Modeling
 Seeing another person harmed by the stimulus
 Verbal instruction
 Parent warning a child about a danger
 Those with anxiety tend to acquire fear more readily
 And to be more resistant to extinction

© 2015 John Wiley & Sons, Inc. All rights reserved.

Risk Factors
 Genetic
 Twin studies suggest heritability
 About 20-40% for phobias, GAD, and PTSD
 About 50% for panic disorder
 Relative with phobia increases risk for other
anxiety disorders in addition to phobia
 Neurobiological
 Fear circuit overactivity
 Amygdala
 Medial prefrontal cortex deficits
 Neurotransmitters
 Poor functioning of serotonin and GABA
 Higher levels of norepinephrine

© 2015 John Wiley & Sons, Inc. All rights reserved.

Risk Factors: Personality
 Behavioral inhibition
 Tendency to be agitated, distressed, and cry in unfamiliar or
novel settings
 Observed in infants as young as 4 months
 May be inherited
 Predicts anxiety in childhood and social anxiety in adolescence
 Neuroticism
 Tendency to react with frequent negative affect
 Linked to anxiety and depression
 Higher levels linked to double the likelihood of developing
anxiety disorders
© 2015 John Wiley & Sons, Inc. All rights reserved.
Risk Factors: Cognitive
 Sustained negative beliefs about future
 Bad things will happen
 Engage in safety behaviors
 Belief that one lacks control over environment
 More vulnerable to developing anxiety disorder
 Childhood trauma or punitive parenting may foster beliefs
 Serious life events can threaten sense of control
 Attention to threat
 Tendency to notice negative environmental cues
 Selective attention to signs of threat

© 2015 John Wiley & Sons, Inc. All rights reserved.

Etiology of Specific Phobias

 Two-factor model of behavioral conditioning

 Conditioned responses to threat
 Sustained by avoidance or safety behaviors
 Avoid eye contact, appear aloof, stand apart from others in social settings
 Risk factors act as diatheses
 Vulnerabilities influence development of phobias
 Prepared learning
 Evolutionary preparation to fear certain stimuli
 Potentially life-threatening (heights, snakes, etc.)

© 2015 John Wiley & Sons, Inc. All rights reserved.

Etiology of Social Anxiety Disorder

 Behavioral factors
 Factors similar to specific phobia (i.e., classical and operant conditioning)
 Cognitive factors
 Unrealistic negative beliefs about consequences of behaviors
 Excessive attention to internal cues
 Fear of negative evaluation by others
 Expect others to dislike them
 Negative self-evaluation
 Harsh, punitive self-judgment

© 2015 John Wiley & Sons, Inc. All rights reserved.

Etiology of Panic Disorder
 Neurobiological factors
 Locus coeruleus
 Major source of norepinephrine
 A trigger for nervous system activity
 People with panic disorder more sensitive
to drugs that trigger the release of
norepinephrine

© 2015 John Wiley & Sons, Inc. All rights reserved.

Etiology of Panic Disorder
 Behavioral factors:
 Interoceptive conditioning
 Classical conditioning of panic in response to
internal bodily sensations

© 2015 John Wiley & Sons, Inc. All rights reserved.

Etiology of Panic Disorder
 Cognitive factors
 Catastrophic misinterpretations of somatic
changes
 Interpreted as impending doom
 I must be having a heart attack!
 Beliefs increase anxiety and arousal
 Creates vicious cycle
 Anxiety Sensitivity Index
 High scores predict development of panic
 “Unusual body sensations scare me.”
 “When I notice that my heart is beating rapidly, I
worry that I might have a heart attack.”

© 2015 John Wiley & Sons, Inc. All rights reserved.

Etiology of Panic Disorder

 Genetic risk
 Polymorphism in a gene guiding neuropeptide S function, the NPSR1 gene, has been
tied to an increased risk of panic disorder and is associated with:
 Amygdala response to threat
 Cortisol response
 Higher anxiety sensitivity scores
 Genetic risk shapes stress responses and hypersensitivity to somatic changes, and
this may then increase the risk for panic disorder.

© 2015 John Wiley & Sons, Inc. All rights reserved.

Etiology of Agoraphobia

 Fear-of-fear hypothesis (Goldstein & Chambless, 1978)

 Expectations about the catastrophic consequences of having a public panic attack
 What will people think of me?!?!

© 2015 John Wiley & Sons, Inc. All rights reserved.

Etiology of GAD

 GABA system deficits

 Borkovec’s cognitive model:
 Worry reinforcing because it distracts from negative emotions and images
 Allows avoidance of more disturbing emotions
 e.g., distress of previous trauma
 Worrying decreases psychophysiological arousal
 Avoidance prevents extinction of underlying anxiety

© 2015 John Wiley & Sons, Inc. All rights reserved.

Figure 6.8: The Excessive Worry of GAD May
Be an Attempt to Avoid Intense Emotions

© 2015 John Wiley & Sons, Inc. All rights reserved.

Assessment

 Listand clarify all symptoms

 Look at history: family, drug use, mental health,
medical health.
 Analysis of current lifestyle status: stress,
nutrition, exercise, sleep, medications. List
problem areas.
 Rule out physical and other psychiatric causes,
getting medical results.
Assessment
Medical Rule Outs
 Shortness of breath  Palpitations
 Heart  Tachycardia
 Respiration  Thyroid
 Dizziness  Hypoglycemia
 Anemia, BPV, BP
 Chest pain
 Numbness
 Heart conditions
 Circulatory
 respiratory  Autoimmune
 CFS
 Fibromyalgia
 Epstein-Barr
Assessment cont’
– Drug Usage Rule Outs
 Alcohol  OTC drugs
  Diet pills
Kindling
 Laxatives
 Neural excitement
during withdrawal  Caffeine
 aspartame
 Cocaine
 Other medications
 Kindling
 Disulfiram
 Drug-induced panic
 Drugs to treat thyroid and
 Other stimulants endocrine
Treatment

 Anxiety disorders can be treated!

 The most common treatment is cognitive behavior therapy (CBT) in groups or
individually
 In CBT children learn relaxation and stress management plus
Gradual exposure to things that make them anxious, to decrease the
fear
Coping strategies to reduce anxiety
Treatment

CBT is first choice, but medication may be needed in severe situations

 Teach relaxation strategies such as belly breathing and muscle relaxation

 Teach visualize or imagine a pleasant, relaxing “happy place”

Cycle of Anxiety
Treatment –
Psychotherapy
 Subjective Rating Scales Use
 Explain concepts of SUDs
 Discuss the meaning of the ratings 0 – 10
 No comparison to other people are ever involved, self-assessment tool
 No internal competition: observing only
 Grounding!

Look around you. Find 5 things you can

see, 4 things you can touch, 2 things you
can smell and 1 thing you can taste. This
is called “grounding” It is helpful to do
when you are anxious.
Daily Record of Breathing or Relaxation

Time Assign- SUD – Duration SUD –

ment Outset completion
Treatment –
Medication Consideration
 Benzodiazepines:  Antidepressants
 For panic, acute  Misnamed
anxiety symptoms  Used for chronic
 To enhance early tx anxiety and depressed
 Short term use e.g. 30 moods
days  Long term use
 Daily, regular use  Bolsterwith lifestyle
 Rarely used PRN changes and
psychotherapy
Treatment –
Medication Choices

Benzodiazepine Sedative/ Antidepressants

Hypnotic
- Valium
- Xanax - Barbiturates - SSRI’s
- Librium - MAOIs
- Ativan - Tri-cyclics

Effects: Effects: Effects:

- Mood altering - Insomnia relief - Not mood altering
- Reduce anxiety sx - Addictive - Not addictive
- Addictive - Lethal OD - have side effects
Whew- Questions?