Anxiety Disorders II

September 16, 2015

Psych 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 condition
J. The fear, anxiety or avoidance is not better
explained by symptoms of another mental disorder,
such as panic disorder, body dysmorphic disorder or
autism spectrum disorder
K. If another medical condition (e.g., Parkinsons
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 12month
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 usespecific 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)
Medicationsantidepressants 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%