DSM-5 TR:

ANXIETY
DISORDERS
LOUISSE NOREEN T. TAPIZ
ANXIETY
Topics Covered
• Causes of Anxiety and
Related Disorders

• Comorbidity of Anxiety
and Related Disorders

• Anxiety Disorders
 ANXIETY
future-oriented negative mood state characterized by bodily
symptoms of physical tension and by apprehension about the
future
FEAR
an immediate alarm reaction to
danger

PANIC
an abrupt experience of intense fear or acute discomfort,
accompanied by physical symptoms
proposed this idea when he called
anxiety the “shadow of
intelligence”

He thought the human ability to

plan in some detail for the future
was connected to that gnawing
feeling that things could go wrong
and we had better be prepared for
them. Howard Liddell (1949)
But what
happens when
you have too
much anxiety?
severe anxiety usually doesn’t go
away
 ANXIETY
future-oriented negative mood state characterized by bodily
symptoms of physical tension and by apprehension about the
future
FEAR
an immediate alarm reaction to
danger

PANIC
an abrupt experience of intense fear or acute discomfort,
accompanied by physical symptoms
 EXPECTED
you know you are
afraid of high places
or of driving over

Two basic long bridges, you

might have a panic

types of attack in these

situations but not
panic anywhere else
UNEXPECTED
attacks you don’t have a clue
when or where the
next attack will occur
Causes of
Anxiety and
Related
Disorders
excessive emotional reactions
have no simple one-dimensional
cause but come from multiple
sources
 BIOLOGICAL
1
CONTRIBUTIONS

Causes of PSYCHOLOGICAL
2
Anxiety and CONTRIBUTIONS

Related
3 SOCIAL CONTRIBUTIONS
Disorders
4 AN INTEGRATED MODEL
BIOLOGICAL
CONTRIBUTIONS
The tendency to panic also seems to run in
families and probably has a genetic
component that differs somewhat from
genetic contributions to anxiety.
BIOLOGICAL
CONTRIBUTIONS
Low levels of gamma-aminobutyric acid
(GABA) within the GABA–benzodiazepine
system are linked to heightened anxiety

The area of the brain most often associated

with anxiety is the limbic system which acts
as a mediator between the brain stem and
the cortex.
BIOLOGICAL
CONTRIBUTIONS
The fight/flight system (FFS) begins in the
brain stem and passes through various
midbrain structures, including the amygdala,
the ventromedial nucleus of the
hypothalamus, and the central gray matter.
BIOLOGICAL
CONTRIBUTIONS
Environmental factors can alter the
sensitivity of these brain circuits, potentially
increasing or decreasing susceptibility to
anxiety disorders.
PSYCHOLOGICAL CONTRIBUTIONS
New and accumulating evidence supports an
integrated model of anxiety involving a
variety of psychological factors.
PSYCHOLOGICAL CONTRIBUTIONS
The actions of parents in early childhood
seem to do a lot to foster this sense of
control or uncontrollability.

A sense of control (or lack of it) that

develops from these early experiences is the
psychological factor that makes us more or
less vulnerable to anxiety in later life.
PSYCHOLOGICAL CONTRIBUTIONS
ANXIETY SENSITIVITY

general tendency to respond fearfully to

anxiety symptoms
PSYCHOLOGICAL CONTRIBUTIONS
INTERNAL OR EXTERNAL CUES PROVOKE
THE FEAR RESPONSE AND AN ASSUMPTION
OF DANGER, EVEN IF THE DANGER IS NOT
ACTUALLY PRESENT SO IT IS REALLY A
LEARNED OR FALSE ALARM
SOCIAL CONTRIBUTIONS
STRESSFUL LIFE EVENTS TRIGGER OUR
BIOLOGICAL AND PSYCHOLOGICAL
VULNERABILITIES TO ANXIETY.

The same stressors can trigger physical

reactions, such as headaches or
hypertension, and emotional reactions, such
as panic attacks
INTEGRATED MODEL
PUTTING THE FACTORS TOGETHER IN AN
INTEGRATED WAY, WE HAVE DESCRIBED A
THEORY OF THE DEVELOPMENT OF ANXIETY
CALLED THE TRIPLE VULNERABILITY THEORY:

• generalized biological vulnerability

• generalized psychological vulnerability
• specific psychological vulnerability
Comorbidity of
Anxiety and
Related
Disorders
co-occurrence of two or more
disorders in a single
individual
Comorbidity with other disorders
THE HIGH RATES OF COMORBIDITY AMONG
ANXIETY AND RELATED DISORDERS (AND
DEPRESSION) EMPHASIZE HOW ALL OF
THESE DISORDERS SHARE THE COMMON
FEATURES OF ANXIETY AND PANIC
DESCRIBED HERE.
Comorbidity with other disorders
BY FAR THE MOST COMMON ADDITIONAL
DIAGNOSIS FOR ALL ANXIETY DISORDERS
WAS MAJOR DEPRESSION, WHICH
OCCURRED IN 50% OF THE CASES OVER THE
COURSE OF THE PATIENT’S LIFE
Comorbidity with Physical Disorders
THE PRESENCE OF ANY ANXIETY DISORDER
WAS UNIQUELY AND SIGNIFICANTLY
ASSOCIATED WITH THYROID DISEASE,
RESPIRATORY DISEASE, GASTROINTESTINAL
DISEASE, ARTHRITIS, MIGRAINE HEADACHES,
AND ALLERGIC CONDITIONS
Comorbidity with Physical Disorders
THE ANXIETY DISORDER MOST OFTEN
BEGINS BEFORE THE PHYSICAL DISORDER,
SUGGESTING (BUT NOT PROVING) THAT
SOMETHING ABOUT HAVING AN ANXIETY
DISORDER MIGHT CAUSE OR CONTRIBUTE
TO THE CAUSE OF THE PHYSICAL DISORDER
Comorbidity with Physical Disorders
THE DSM-5 NOW MAKES IT EXPLICIT THAT
PANIC ATTACKS OFTEN CO-OCCUR WITH
CERTAIN MEDICAL CONDITIONS,
PARTICULARLY CARDIO, RESPIRATORY,
GASTROINTESTINAL, AND VESTIBULAR
(INNER EAR) DISORDERS
Suicide
20% OF PATIENTS WITH PANIC DISORDER
HAD ATTEMPTED SUICIDE AND THAT THE
RISK OF SOMEONE WITH PANIC DISORDER
ATTEMPTING SUICIDE WAS COMPARABLE TO
THAT FOR INDIVIDUALS WITH MAJOR
DEPRESSION
Suicide
PEOPLE WITH GENERALIZED ANXIETY
DISORDER AND SOCIAL ANXIETY DISORDER
WHO ENGAGED IN DELIBERATE SELF-HARM
WERE ALSO LIKELY TO ENGAGE IN THIS
BEHAVIOR MULTIPLE TIMES, AND AT LEAST
ONE OF THOSE TIMES WAS A SUICIDE
ATTEMPT.
GENERALIZED ANXIETY DISORDER

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GENERALIZED ANXIETY
DISORDER
• EXCESSIVE ANXIETY AND WORRY AT LEAST 50 % OF DAYS
ABOUT A NUMBER OF EVENTS OR ACTIVITIES
• THE PERSON FINDS IT HARD TO CONTROL THE WORRY
• THE WORRY IS SUSTAINED FOR AT LEAST 6 MONTHS
• THE ANXIETY AND WORRY ARE ASSOCIATED WITH AT
LEAST THREE (OR ONE IN CHILDREN) OF THE FOLLOWING:
• RESTLESSNESS OR FEELING KEYED UP OR ON EDGE;
EASILY FATIGUED; DIFFICULTY CONCENTRATING OR MIND
GOING BLANK; IRRITABILITY; MUSCLE TENSION; SLEEP
DISTURBANCE
GENERALIZED ANXIETY
DISORDER
It must be difficult to turn off or control the
worry process.

Most of us worry for a time but can set the

problem aside and go on to another task.
GENERALIZED ANXIETY
DISORDER
GAD is characterized by muscle tension,
mental agitation, susceptibility to fatigue
(probably the result of chronic excessive
muscle tension), some irritability, and
difficulty sleeping
GENERALIZED ANXIETY
DISORDER
People with GAD mostly worry about minor,
everyday life events, a characteristic that
distinguishes GAD from other anxiety
disorders.
GENERALIZED ANXIETY
DISORDER
For years, clinicians thought that people who
were generally anxious had simply not
focused their anxiety on anything specific.
GENERALIZED ANXIETY
DISORDER
Individuals with GAD allocate their attention
more readily to sources of threat than do
people who are not anxious
GENERALIZED ANXIETY
DISORDER
People with GAD are thinking so hard about
upcoming problems that they don’t have the
attentional capacity left for the all-important
process of creating images of the potential
threat
GENERALIZED ANXIETY
DISORDER
Many people with GAD also inherit a
tendency to be tense and they develop a
sense early on that important events in their
lives may be uncontrollable and potentially
dangerous, especially under stress.
GENERALIZED ANXIETY
DISORDER
Treatment:
Benzodiazepines are most often prescribed
for generalized anxiety, and the evidence
indicates that they give some relief, at least
in the short term.
GENERALIZED ANXIETY
DISORDER
Treatment:
In the early 1990s, cognitive-behavioral
treatment (CBT) was developed for GAD in
which patients evoke the worry process
during therapy sessions and confront
threatening images and thoughts head-on.
GENERALIZED ANXIETY
DISORDER
Treatment:
Other promising new strategies are to help
educate patients in increasing their
tolerance to uncertainty about the future
and changing their beliefs about worrying
PANIC DISORDER AND
AGORAPHOBIA

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PANIC DISORDER
• RECURRENT UNEXPECTED PANIC ATTACKS
• At least 1 month of concern about the
possibility of more attacks, worry about
the consequences of an attack, or
maladaptive behavioral changes because
of the attacks
AGORAPHOBIA
• DISPROPORTIONATE AND MARKED FEAR OR ANXIETY
ABOUT AT LEAST 2 SITUATIONS WHERE IT WOULD BE
DIFFICULT TO ESCAPE OR RECEIVE HELP IN THE EVENT
OF INCAPACITATION, EMBARRASSING SYMPTOMS, OR
PANIC-LIKE SYMPTOMS
– SUCH AS BEING OUTSIDE OF THE HOME ALONE;
TRAVELING ON PUBLIC TRANSPORTATION; BEING IN
OPEN SPACES SUCH AS PARKING LOTS AND
MARKETPLACES; BEING IN ENCLOSED SPACES SUCH AS
SHOPS, THEATERS, OR CINEMAS; OR STANDING IN LINE
AGORAPHOBIA
• THOSE SITUATIONS CONSISTENTLY
PROVOKE FEAR OR ANXIETY
• THESE SITUATIONS ARE AVOIDED, REQUIRE
THE PRESENCE OF A COMPANION, OR ARE
ENDURED WITH INTENSE FEAR OR ANXIETY
• SYMPTOMS LAST AT LEAST 6 MONTHS
AGORAPHOBIA
THE TERM AGORAPHOBIA WAS COINED IN
1871 BY KARL WESTPHAL, A GERMAN
PHYSICIAN, AND, IN THE ORIGINAL GREEK,
REFERS TO FEAR OF THE MARKETPLACE.
AGORAPHOBIA
PANIC DISORDER AND AGORAPHOBIA
MOST PATIENTS WITH PANIC DISORDER AND
AGORAPHOBIC AVOIDANCE ALSO DISPLAY
ANOTHER CLUSTER OF AVOIDANT
BEHAVIORS THAT WE CALL INTEROCEPTIVE
AVOIDANCE
PANIC DISORDER AND AGORAPHOBIA
PANIC DISORDER AND AGORAPHOBIA
PD IS FAIRLY COMMON.

Some develop agoraphobia without ever

having a full-blown panic attack

Onset of panic disorder usually occurs in

early adult life
PANIC DISORDER AND AGORAPHOBIA
IT IS MORE ACCEPTED FOR WOMEN TO
REPORT FEAR AND TO AVOID NUMEROUS
SITUATIONS.

A large proportion of males with unexpected

panic attacks cope in a culturally acceptable
way: They consume large amounts of
alcohol.
PANIC DISORDER AND AGORAPHOBIA
PANIC DISORDER EXISTS WORLDWIDE,
ALTHOUGH ITS EXPRESSION MAY VARY FROM
PLACE TO PLACE.
PANIC DISORDER AND AGORAPHOBIA
APPROXIMATELY 60% OF THE PEOPLE WITH
PANIC DISORDER HAVE EXPERIENCED SUCH
NOCTURNAL ATTACKS

Research indicates that they are not having

nightmares.
PANIC DISORDER AND AGORAPHOBIA
SOME THERAPISTS ARE NOT AWARE OF THE
STAGE OF SLEEP ASSOCIATED WITH
NOCTURNAL PANIC ATTACKS AND SO
ASSUME THAT PATIENTS ARE “REPRESSING”
THEIR DREAM MATERIAL
PANIC DISORDER AND AGORAPHOBIA
SOME THERAPISTS ASSUME THAT PATIENTS
WITH NOCTURNAL PANIC might have a
breathing disorder called sleep apnea
PANIC DISORDER AND AGORAPHOBIA
A RELATED PHENOMENON OCCURRING IN
CHILDREN IS CALLED SLEEP TERRORS
PANIC DISORDER AND AGORAPHOBIA
ISOLATED SLEEP PARALYSIS OCCURS DURING
THE TRANSITIONAL STATE BETWEEN SLEEP
AND WAKING, WHEN A PERSON IS EITHER
FALLING ASLEEP OR WAKING UP, BUT
MOSTLY WHEN WAKING UP
PANIC DISORDER AND AGORAPHOBIA
STRONG EVIDENCE INDICATES THAT
AGORAPHOBIA OFTEN DEVELOPS AFTER A
PERSON HAS UNEXPECTED PANIC ATTACKS
(OR PANIC-LIKE SENSATIONS)
PANIC DISORDER AND AGORAPHOBIA
BUT SOME PEOPLE ARE ALSO MORE LIKELY
THAN OTHERS to have an emergency alarm
reaction (unexpected panic attack) when
confronted with stress-producing events.
PANIC DISORDER AND AGORAPHOBIA
BUT SOME PEOPLE ARE ALSO MORE LIKELY
THAN OTHERS to have an emergency alarm
reaction (unexpected panic attack) when
confronted with stress-producing events.
PANIC DISORDER AND AGORAPHOBIA
Treatment: Medication
A large number of drugs affecting the
noradrenergic, serotonergic, or GABA–
benzodiazepine neurotransmitter systems, or
some combination, including high-potency
benzodiazepines, the newer selectives erotonin
reuptake inhibitors and the closely related
serotonin-norepinephrine reuptake inhibitors
PANIC DISORDER AND AGORAPHOBIA
Treatment:
Approximately 60% of patients with panic
disorder are free of panic as long as they stay on
an effective drug
but 20% or more stop taking the drug before
treatment is done and relapse rates are high
(approximately 50%)
once the medication is stopped.
PANIC DISORDER AND AGORAPHOBIA
Treatment: Psychological Intervention
The strategy of exposure-based treatments is to
arrange conditions in which the patient can
gradually face the feared situations and learn
there is nothing to fear.
PANIC DISORDER AND AGORAPHOBIA
Treatment: Psychological Intervention
Panic control treatment (PCT) developed at one
of our clinics concentrates on exposing patients
with panic disorder to the cluster of
interoceptive (physical) sensations that remind
them of their panic attacks.
PANIC DISORDER AND AGORAPHOBIA
Treatment: Combined
The data indicate that all treatment groups
responded significantly better than the placebo
group, but approximately the same number of
patients responded to both drug and
psychological treatments.

Combined treatment was no better than

SPECIFIC PHOBIA

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SPECIFIC PHOBIA
• MARKED AND DISPROPORTIONATE FEAR CONSISTENTLY
triggered by specific objects or situations
• The object or situation is avoided or else endured with
intense anxiety
• Symptoms persist for at least 6 months
• The fear, anxiety, or avoidance causes clinically
significant distress or impairment in social, occupational, or
other important areas of
functioning.
• Not better explained by the symptoms of another mental
disorder
SPECIFIC PHOBIA
SPECIFY TYPE:
1. ANIMAL (E.G., SPIDERS, INSECTS, DOGS)
2. NATURAL ENVIRONMENT (E.G., HEIGHTS, STORMS, AND
WATER)
3. BLOOD–INJECTION–INJURY (E.G., NEEDLES, INVASIVE
MEDICAL PROCEDURES)
4. SITUATIONAL (E.G., PLANES, ELEVATORS, OR ENCLOSED
PLACES)
5. OTHER (E.G., SITUATIONS THAT MAY LEAD TO CHOKING
OR VOMITING; IN CHILDREN, E.G., LOUD SOUNDS OR
COSTUMED CHARACTERS)
 BLOOD-
INJECTION-
INJURY PHOBIA
SPECIFIC
PHOBIA
SITUATIONAL
PHOBIA
SITUATIONAL PHOBIA
THE MAIN DIFFERENCE BETWEEN SITUATIONAL
PHOBIA
and panic disorder is that people with
situational phobia never experience panic
attacks outside the context of their phobic
object or situation.
 NATURAL
ENVIRONMENT
PHOBIA
SPECIFIC
PHOBIA
ANIMAL PHOBIA
SPECIFIC
PHOBIA
SPECIFIC PHOBIA
THE MEDIAN AGE OF ONSET FOR SPECIFIC
PHOBIA IS 7 YEARS OF AGE, THE YOUNGEST OF
ANY ANXIETY DISORDER EXCEPT SEPARATION
ANXIETY DISORDER
SPECIFIC PHOBIA
A VARIANT OF PHOBIA IN CHINESE CULTURES IS
CALLED PA-LENG, SOMETIMES FRIGOPHOBIA OR
“FEAR OF THE COLD.”
SPECIFIC PHOBIA
FOR A LONG TIME, WE THOUGHT THAT MOST
SPECIFIC PHOBIAS BEGAN WITH A TRAUMATIC
EVENT
• direct experience
• experiencing a false alarm
• vicarious experience
• being told about danger
SPECIFIC PHOBIA
TERRIFYING EXPERIENCES ALONE DO NOT
CREATE PHOBIAS.

If we don’t develop anxiety, our reaction would

presumably be in the category of normal fears
experienced by more than half the population.
SPECIFIC PHOBIA
IN SUMMARY, SEVERAL THINGS HAVE TO
OCCUR FOR A PERSON TO DEVELOP A PHOBIA.
• FIRST, A TRAUMATIC CONDITIONING EXPERIENCE OFTEN
PLAYS A ROLE.
• SECOND, FEAR IS MORE LIKELY TO DEVELOP IF WE ARE
“PREPARED.”
• Third, we also have to be susceptible to developing
anxiety about the possibility that the event will happen
again.
• Finally, social and cultural factors are strong
determinants of who develops and reports a specific
SPECIFIC PHOBIA
SPECIFIC PHOBIA
TREATMENT:
specific phobias require structured and
consistent
exposure-based exercises

the therapist spends most of the session with

the individual, working through exposure
exercises with the phobia object or situation.
Separation Anxiety Disorder
characterized by children’s unrealistic and
persistent worry that something will happen to
their parents or other important people in their
life or that something will happen to the
children themselves that will separate them
from their parents
Separation Anxiety Disorder
It is also important to differentiate separation
anxiety from school phobia.
Separation Anxiety Disorder
Several years ago, it was discovered that
separation anxiety, if untreated, can extend
into adulthood in approximately 35% of cases

Furthermore, evidence suggests that we have

overlooked this disorder in adults and that it
occurs in approximately 6.6% of the adult
population over the course of a lifetime
Separation Anxiety Disorder
Treatment:

In treating separation anxiety in children,

parents are often included to help structure the
exercises and also to address parental reaction
to childhood anxiety
SOCIAL ANXIETY DISORDER /
SOCIAL PHOBIA

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SOCIAL ANXIETY DISORDER
• MARKED AND DISPROPORTIONATE FEAR
CONSISTENTLY TRIGGERED BY exposure to
potential social scrutiny
• Exposure to the trigger leads to intense
anxiety about being evaluated negatively
• Trigger situations are avoided or else
endured with intense anxiety
• Symptoms persist for at least 6 months
SOCIAL ANXIETY DISORDER
• The fear, anxiety, or avoidance causes
clinically significant distress or impairment in
social, occupational, or other important areas of
functioning.
• Not better explained by the symptoms of
another mental disorder
• If another medical condition is present, the
fear, anxiety, or avoidance is clearly unrelated
SOCIAL ANXIETY DISORDER
It is when the people have no difficulty eating,
writing, or urinating in private.

Only when others are watching does the

behavior deteriorate.
SOCIAL ANXIETY DISORDER
SAD second only to specific phobia as the most
prevalent anxiety disorder

SAD usually begins during adolescence, with

a peak age of onset around 13 years
SOCIAL ANXIETY DISORDER
Taijin kyofusho of Japan resembles SAD in some
of its forms

strongly fear that some aspect of their personal

presentation (blushing, stuttering, body odor,
and so on) will appear reprehensible, causing
other people to feel embarrassed
SOCIAL ANXIETY DISORDER
socially anxious individuals more quickly
recognized angry faces than non-anxious
individuals whereas non-anxious individuals
remembered the accepting expressions
SOCIAL
ANXIETY
DISORDER
SOCIAL ANXIETY DISORDER
Traumatic social experiences may also extend
back to difficult periods in childhood.

This experience may produce anxiety and panic

that are reproduced in future social situations.
SOCIAL ANXIETY DISORDER
Treatment:
cognitive therapy program that emphasized
real-life experiences during therapy to disprove
automatic perceptions of danger
SOCIAL ANXIETY DISORDER
Treatment:
SSRIs Paxil, Zoloft, and Effexor have received
approval from the Food and Drug
Administration for treatment of SAD based on
studies showing effectiveness compared with
placebo
Selective Mutism
• Characterized by a consistent failure to speak
in social situations in which there is an
expectation to speak (e.g., school) even though
the individual speaks in other situations.
• This interferes with normal social
communication.
• The duration of the disturbance is at least 1
month
Selective Mutism
• The failure to speak is not attributable to a
lack of knowledge of, or comfort with, the
spoken language required in the social situation
• The disturbance is not better explained by a
communication disorder (e.g., childhoodonset
fluency disorder) and does not occur
exclusively during the course of autism
spectrum disorder, schizophrenia, or another
Selective Mutism
Treatment:
Employs many of the same cognitive-behavioral
principles used successfully to treat social
anxiety in children but with a greater emphasis
on speech