Anxiety Disorders

Dr Jo Billings
UCL Division of Psychiatry
Clinical Mental Health Module
MSc Clinical Mental Health Sciences / Mental Health Sciences Research

What is anxiety?

What does it feel like to feel anxious?

What does it feel like to feel anxious?

Anxiety

Is a normal and natural reaction, essential to keep us safe

Is an emotional prediction of danger
Physical, emotional and cognitive experience
Although there is some evidence for innate fear in
humans (e.g. Van Strien et al., 2014) most anxiety is
learnt
Anxiety disorders are where this anxiety is out of
proportion to the actual risk and is constant or intrusive
enough to cause significant disability

Anxiety equation (Greenberger & Padesky)

6Fs of Anxiety Response (Schauer & Elbert, 2010)

BABCP 2015 Andy Pike & Kerry Young

The anxiety disorders

Panic disorder
Agoraphobia
Specific Phobia
Generalised Anxiety Disorder
Social anxiety
Health anxiety
Obsessive compulsive disorder (OCD)

Panic Disorder
Recurrent unexpected panic attacks, at least one of
which has been followed by at least a month of one of
the following:
persistent concern about having additional attacks
worry about the implications of the attack or its
consequences (eg losing control, having a heart
attack, going crazy
a significant change in behaviour related to the
attacks.

Panic Disorder
Refers to a discrete period of intense fear of discomfort, in which at least
four of the following symptoms developed abruptly and reached a peak
within 10 minutes.

Heart racing, pounding, fluttering or skipping beats

Sweating, trembling, shaking
Trouble catching breath / feeling like being smothered
Feel like choking
Chest pain, pressure, tightness or discomfort
Nausea, sickness, gastrointestinal difficulty
Dizzy, light-headed, unsteady or faint
Feelings of unreality or in a dream-like state
Feeling as if going crazy or might lose control
A fear they might die
Feeling of numbness or tingling in fingers or feet
Have hot flashes or chills

Panic Disorder

Lifetime prevalence 4.8%

Onset is usually in late teens or early 20s

Higher rates in women

High comorbidity with depression (50-60%) and

Agoraphobia (33%-50%) (Yates, 2009)

Agoraphobia

Anxiety about being in (or anticipating) situations from which escape

might be difficult

2 important features:
Panic attacks
Anxious cognitions about fainting and loss of control

DSM-5 requires at least 2 of the 5 situations present for a diagnosis:

1)
2)
3)
4)
5)

Using public transport e.g. buses

Being in open spaces e.g. bridges
Being in enclosed spaces e.g. shops
Standing in line or being in a crowd
Being outside the home alone

Agoraphobia

Prevalence rates difficult to interpret

Lifetime prevalence of Agoraphobia without Panic
Disorder 0.8% (Kessler et al., 2006)
rates in women; onset later (mid-late 20s)
Etiological theories of onset similar to Panic
Etiological theories of maintenance include
personality and family influences

Specific Phobia

Excessive fear or anxiety of a particular object or

situation
Avoided or endured
Exposure gives acute severe anxiety
Interferes with functioning
DSM-5 identifies 5 subtypes:

animals; blood/injection/injury; nature/environment; situational; other

Specific Phobia

Lifetime prevalence rates approx 4% men and

13% women
Age of onset typically in childhood or early
adolescence
High comorbidity of specific phobias

Generalised Anxiety Disorder

Excessive anxiety and worry occurring more days than not for at least 6
months, about a number of events or activities
Worry feels difficult to control (worry about worry)
Anxiety and worry are associated with at least 3/6 following symptoms (with at
least some symptoms present for more days than not for the past 6 months)

feeling restless, fidgety, jittery, keyed up, on edge; tiring easily; difficulty concentrating; feeling irritable; tense, aching or soreness in
muscles; have problems falling or staying asleep.

The anxiety, worry or physical symptoms cause clinically significant distress or

impairment in social, occupational or other important areas of functioning.
Exclude if focus of anxiety confined to particular symptoms or situation or if
symptoms are a direct physiological effects of a substance or a general
medical condition or are better accounted for by one of the other anxiety
diagnosis

GAD

Lifetime prevalence rates 4.3-5.9%

Higher rates in women than men

High comorbidity with depression

Low remission rates

Social Anxiety

Marked and persistent fear of one or more social or performance

situations in which a person is exposed to unfamiliar people or to
possible scrutiny by others. The individual fears that he or she will act
in a way (or to show anxiety symptoms) that will be humiliating or
embarrassing.
Exposure to feared social situation almost invariably provokes
anxiety, which may take the form of a situationally specific panic
attack.
The person recognises that the fear is excessive or unreasonable.
The feared social or performance situations are avoided or else
endured with intense anxiety or distress.

Social Anxiety

Symptoms must be persistent lasting 6 months or longer.

The avoidance, anxious anticipation, or distress in the feared social
performance situation interferes significantly with the persons normal
routine, occupational functioning, or social activities or relationships,
or there is marked distress about having the phobia.
Exclude diagnosis if symptoms are a direct physiological effects of a
substance (e.g. drugs, alcohol, medication) or a general medical
condition or are better accounted for by one of the other anxiety
diagnosis
Exclude the diagnosis if the fear is related to another psychiatric or
physical disorder (eg fear of panic attack, stuttering etc)

Social Anxiety

Lifetime prevalence 13.3%

Onset often in adolescence
Chronic
High comorbidity with other psychiatric disorders
(around 50%)

Health Anxiety

Preoccupation with fears of having, or the idea that one has, a

serious disease based on the person's misinterpretation of
bodily symptoms.
The preoccupation persists despite appropriate medical
evaluation and reassurance.
The belief in Criterion A is not of delusional intensity and is not
restricted to a circumscribed concern about appearance
The preoccupation causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
The duration of the disturbance is at least 6 months.

Obsessive compulsive disorder

Recurrent and persistent thoughts, impulses, or images that

are experienced, at some time during the disturbance, as
intrusive and inappropriate and that cause marked anxiety or
distress
The thoughts, impulses, or images are not simply excessive
worries about real-life problems
The person attempts to ignore or suppress such thoughts,
impulses, or images, or to neutralize them with some other
thought or action
The person recognizes that the obsessional thoughts,
impulses, or images are a product of his or her own mind
Cause significant impairment to functioning

Anxiety vs Depression?

Anxiety vs Depression?

Tiredness
Sleep problems
Irritability
Worry
Negative thoughts

Concentration problems
Forgetfulness
Somatic problems
Loss of appetite
Restlessness

Anxiety vs Depression?

66% of those with depressive disorder also have

anxiety, worry or panic symptoms

Common mental disorder?

Anxiety vs Depression?

Overlapping genetic factors

Overlapping benefits of medication
every major class of current psychotropic drugs,
antidepressants, antipsychotics, anti-anxiety medications,
target the same receptors and neurotransmitters

Similar risk factors

Stressful life events, childhood adversity and abuse, bullying,
negative schema, parenting style

Similar maintenance factors

What are the defining features of

the anxiety disorders?

Fear
Psychological Threat
Anticipatory future focused
Physiological arousal
Response out of proportion to threat
Avoidance
Safety behaviours

Aetiology of anxiety disorders?

Genetics
Neurobiological factors
Stressful life events
Early Experience
Conditioning
Beliefs
Personality

Models and Treatment of

Anxiety Disorders

Models and treatment of anxiety

disorders
1.
2.

Neurological and pharmacological

Psychological
Behavioural
Cognitive

Neurological Models

You can see both the automatic / unconscious

learnt anxiety responses and the conscious /
appraisal based learning reflected in brain
circuitry

Two Main Neural Pathways To Fear

The neural circuits of the fear system are complex
but there are two key pathways
Subcortical and cortical pathways
Both pass through the amygdala, a small complex
region in the limbic system
It is often described as a fear centre but it is
widely involved in emotion
However it seems particularly specialised for fear
and anxiety

Subcortical Fear Pathway

Includes sensory cortices, dorsal thalamus,
amygdala and physical response systems
Fast, sensitive, without significant conscious
evaluation
Leads to immediate arousal and avoidance
responses

Subcortical Fear Pathway

Cortical Fear Pathway

Includes significant cortical networks involved in
Executive working memory
Affective appraisal system
Heavy involvement of the prefrontal cortex in
addition to subcortical structures (Etkin and
Wager, 2010)
Slower, evaluative, subjective to more conscious
control

Neurotransmitter Systems
As anxiety is so complex, many neurotransmitter
systems have been implicated
Research has focused on two
GABA (gamma-aminobutyric acid)
Serotonin

Gamma-Aminobutyric Acid (GABA)

Main inhibitory neurotransmitter, important in
reducing neural excitability
Increase in GABA function tends to reduce
anxiety, arousal, muscle tone, alertness,
cognitive function
Fast acting system, effects felt in minutes to hours

Direct GABA Modulating Drugs

Typically bind to GABAA or GABAB receptors
Benzodiazepines (Vallium most well known)
Barbituates (now only for specialist uses)
Alcohol
GHB
The nervous system adapts (tolerance) meaning
they have a tendency to be addictive
Danger of overdose and rebound

Serotonin (5-HT)
Released by the raphe nuclei in the brainstem but
affects virtually whole of brain
Gradual level changes leads to slower modulation
of other brain circuits, particularly those involved
in emotion
14 different serotonergic receptors

Serotinergic Drugs in Anxiety

Most antidepressants affect the serotonin system
and also have anxiolytic (anti-anxiety) effects
Selective serotonin reuptake inhibitors (SSRIs)
tend to prevent serotonin from being reabsorbed
and so increase its level
Most well known fluoxetine or Prozac

Psychological treatment for anxiety disorders in England NICE

Behavioural Models & Treatment

Based on theory of classical/operant conditioning

Treatment based on habituation rationale
Graded exposure

Classical conditioning

Anxiety becomes associated with an originally nonthreatening stimuli due to co-occurrence with anxietyinducing situation
e.g. someone who experiences violence and fear when
partner is drunk may develop fearful response to the smell
of alcohol

Operant conditioning

After a behaviour, the outcome can encourage or

discourage the future use of the behaviour
Anxiety can act as a punishment (decreases likelihood of
doing the same thing)
Or a reinforcer if the behaviour leads to an escape from
the anxiety (increases likelihood)
e.g. checking the light switch reduces anxiety about house
burning down, but encourages more checking through
anxiety-relief reinforcement

Extinction

These associations fade over time as:

The newly anxiety-provoking stimuli appears enough times
without original anxiety-provoking event (e.g. smell of
alcohol is no longer accompanied by violence)
Or the behaviour is no longer reinforced and slowly
declines (e.g. the person doesnt check the switch and
nothing bad happens)

Graded exposure example

Goal: To travel alone by train to the city and back
1.
2.
3.
4.
5.
6.
7.

Travelling one stop, at a quiet time of day

Travelling two stops, at a quiet time of day
Travelling two stops, during rush hour
Travelling five stops, at a quiet time of day
Travelling five stops, during rush hour
Travelling all the way, at a quiet time of day
Travelling all the way, during rush hour

Cognitive Models and Treatment

Anxiety can be triggered by our appraisals about an event,

even if it is something we havent experienced before
Appraisals will be shaped by pre-existing beliefs and rules,
which are shaped by previous experiences, the beliefs of
important others, society, media etc.
People who have a tendency to evaluate or appraise
situations as threatening are likely to feel more anxiety
Treatment therefore involves challenging and testing out
peoples anxious predictions

Cognitive Models and Treatment

Thought records
Identifying and challenging cognitive
distortions/biases
Behavioural experiments

Whats the worst that could

happen?
https://www.youtube.com/watch?v=LoR2qr0d3Gc

Treatment of anxiety and

depression in primary care

Layard and the development of

IAPT Services

Improving Access for Psychological Therapy (IAPT) is the first ever provision
of talking therapy on a mass scale by a government.

Before IAPT, the NHS spent just 3% of its mental health budget on talking
therapy. IAPT has doubled that budget

Aimed to train 6,000 new therapists in CBT by 2014, who will treat 900,000
people for depression and anxiety annually in England and Wales.

The biggest expansion of mental health services anywhere in the world, ever

Layard and the development of

IAPT Services

A chance meeting at a British Academy tea party in 2003!

Lord Richard Layard unemployment economist at LSE, made a fellow of the
British Academy
Interest in depression and happiness, inherited, perhaps, from his father,
anthropologist John Layard, who suffered from depression, shot himself in the
head, survived, was analysed by Carl Jung, and then re-trained as a Jungian
psychologist.
Became interested in a new field in economics that tried to measure
individuals happiness, and use the data to guide public policy.
Layard wondered: what if governments started to take happiness data as
seriously as they took unemployment or inflation?

Layard and the development of

IAPT Services

At the British Academy tea party, Layard struck up a conversation with the
man standing next to him, David Clark.

Layard asked Clark if he happened to know anything about mental health.

Clark explained to Layard that trials of CBT showed similar results for
depression, anxiety and other emotional disorders as medication. He also
explained that there was very little CBT (or any other talking therapy)
available on the NHS for common problems like depression and anxiety.

Layard decided he wanted to get something done about mental health.

So, at the age of 70, that is what he did.

Layard and the development of

IAPT Services

Layard and Clark assembled a powerful argument for the British government
to increase its spending on CBT.
Depression and anxiety affect one in six of the population and costs the
economy 4 billion a year in lost productivity and incapacity benefits.
This problem has a solution. NICE recommended CBT for depression and
anxiety in 2004. Yet the NHS spent just 80 million a year on talking therapies
out of a total NHS annual budget of 100 billion
Layard and Clark recommended doubling the budget, so that 15% of adults
with depression and anxiety would get access to psychological therapy
Many would get off incapacity benefits in the process so the service would
pay for itself.

Layard and the development of

IAPT Services

Layard and Clark presented their recommendations in a paper at 10 Downing

Street in January 2005.
Their ideas included in New Labours manifesto for the 2005 election
Following Labours election victory, they were then faced with the task of
turning these ideas into reality
Two pilot centres established (Newham and Doncaster)
Allowing GP and self-referral to stepped-care model of NICE-recommended
evidence-based therapies, mainly CBT
Centres would measure outcomes at every therapy session, and make this
data available online, so both patients and politicians could see the results.

IAPT today

Success of initial pilot sites led to rolling out of IAPT programme nationally

2008-date development of hundreds of IAPT services across England and

Wales

4,000 new therapists trained in CBT

NHS spend on mental health services doubled from 0.3% to 0.6% of NHS
annual budget

Recovery rate 45% for depression and anxiety

Expansion into child services and for those with severe mental illness

IAPT today costs and

challenges

Cuts to secondary care/specialist service provision

Skills and experience of new therapists

Mission creep

Excessive focus on (brief) CBT

Inevitable cuts in local service provision in current economic climate

Freemarket competition under Coalition government commissioners able to

commission any qualified provider to provide mental health services in their
area.

Questions