Psychopathology Notes

Anxiety Disorders II

September 16, 2015Psych 755

Housekeeping

• No class next week• 15 min today for group formation• Topics/groups due next class (sept 30; hard

copy of group and topic—approval/discuss first is better)

• Next class: Childhood-onset disorders

Learning Objectives for Anxiety Disorders II

• Develop understanding of the epidemiology, phenomenology, recommended treatment and mental health service use of Social Anxiety Disorder (SOP) and Specific Phobia (SIP)

• Ability to identify and describe symptoms of SOP and SIP

• Ability to identify and describe natural course and comorbidity associated with SOP and SIP

• Ability to identify key diagnostic feature of each

Social Anxiety Disorder (formerly known as Social Phobia)

• DSM-5 Criteria• DSM Changes• Prevalence• Risk factors• Natural course• Outcomes• Treatment available/gold-standard• Mental health service utilization

DSM-5 Social Anxiety Disorder (Social Phobia)

A. Marked fear of 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 other (e.g., giving a speech).

Note: in children the anxiety must occur in peer settings and not just be during interactions with adults.

SOP (cont)

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, anxiety or fear may be expressed by crying, tantrums, freezing, clinging, shrinking or failing to speak in social situations.

SOP (cont)

D. The social situations are avoided or endured with intense fear or anxiety.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.

SOP (cont)

H. The fear, anxiety or avoidance is not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medication) or another medical conditionJ. The fear, anxiety or avoidance is not betterexplained by symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder or autism spectrum disorderK. 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.SPECIFY if PERFORMANCE ONLY (speaking/performing)

Social Anxiety Disorder changes

• Essentially the same• Removed requirement that those over 18 recognize that the

fear is excessive or unreasonable• Duration criterion of 6 months or more now applies to all ages• Generalized specifier was deleted and replaced with

“performance only” specifier• Generalized was not helpful because “most social situations”

was too vague• Performance only (public speaking, performing) seem to be a

distinct subtype in terms of etiology, onset, physiological response and treatment response

SOP focus of fear

Fear of acting in a way that will be humiliating or embarrassing

Prevalence

• 1.4-13.3%• NCS-R: 6.7% lifetime; 2.3% past 12-month• Public speaking and test taking are most

common• Generalized and specific types• Onset rare after age 30

Risk factors

• Familial (but modest genetic)• Traumatic events• Peer relationships/bullying• Social skills deficits• Social cognition/information processing• Female• Not SES, race/ethnicity, urban

Natural course

• Mean duration 16.3 years• Wax and wanes• Depression and other anxiety disorders• Substance use—specific with cigarettes/ND,

but protective from other types of substances• PC study said prob of recovery in 5 years is

40%

Predictors of persistence to 10 yrs

• early onset• generalized subtype• number of anxiety cognitions• degree of avoidance and impairment, as well

as co-occurring panic) • parental SP and depression• behavioral inhibition, harm avoidance

Predictors of persistence/stability

• Female• Early onset• Longer duration• Lifetime/prior hx of anxiety disorder• Current anxiety/depressive disorder• Lower GAF• lower role functioning• Generalized subtype

Treatment

• CBT• Interpersonal Psychotherapy (IPT)• Medications—antidepressants and anti-

anxiety

MH service use

• 18.48% of adolescents• 23.7% of adults• It is a barrier in itself…

Specific Phobia

• DSM-5 Criteria• Changes in DSM• Prevalence• Risk factors• Natural course• Outcomes• Treatment available/gold-standard• Mental health service utilization

DSM-5 Specific Phobia (SIP)

A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

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 6 months or more.

DSM-5 SIP (cont)

F. The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.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 of situations related to obsessions (as in OCD); reminders of traumatic events (as in PTSD); separation from home or attachment figure (AS in SAD) or social situations (as in SOP).Note: can be expressed in tantrums, crying, freezing or clinging in children

SIP Types

• Animal• Natural Environment• Blood-Injection• Situational (e.g., elevators, airplanes, enclosed

places)• Other type (e.g., phobic avoidance of situations

that may lead to choking, vomiting, or contracting an illness; in children: avoidance of loud sounds or costumed characters)

Specific Phobia DSM changes

• Essentially the same• Those over 18 no longer must recognize that

fear is excessive or unreasonable• Duration of 6 months now applies to all ages• “types” are now called “specifiers” and they

are essentially the same

SIP focus of fear

• Phobic object

Prevalence

• 12% past 12 month• 15% lifetime• Most common anxiety disorder• Earliest onset• Animal phobia most common and earliest

onset• Situational has later onset

Risk factors

• Female (except blood-injection)• Younger (decreases with age)• Phobia/anxiety disorders in family

Natural course

• Very stable over time (10 years)• Most stable (41% continuity)

Outcomes

• Frequently co-occur (multiple phobias and specific fears)

• Depression predicted by SIP• Substance use disorders• Other anxiety disorders

Treatment

• Exposure therapies/CBT• Not good long term treatment outcomes

Mental health services

• <25%