Theme 5: Internalizing Disorders
Internalizing Disorders being covered: Fear Disorder, Trauma and PTSD, Depression
Fear...
Is Essential for survival:
Helps in avoiding dangerous situations.
Can turn into an anxiety disorder:
Chronic and disabling condition.
General Facts about Anxiety Disorders:
Most prevalent disorders as a group = This phrase is referring to the most common or widespread
disorders when considered as a whole group – looking at disorders as a collective category and
identifying which ones are most frequently occurring.
Exists worldwide and is the most prevalent psychiatric disorder.
Often has an early onset.
Occurs at a 2:1 female to male ratio.
Comorbidity: High comorbidity with other mood disorders and other anxiety types.
Impact: High individual impairment, including:
Lower educational attainment.
Lower occupational status.
Marital problems.
Anxiety is the 6th most disabling disease globally !!
Progression of Anxiety...
1. Adaptive Behavior:
Definition: Normal and functional, enabling an individual to adjust effectively to their
environment.
Most children have 1-2 fears that are appropriate to their age.
2. Problematic Behavior:
Definition: Begins to interfere with an individual's daily activities, life, and healthy
development, though not necessarily harmful.
3. Pathological Behavior:
Definition: Extreme behavior often indicating a serious mental disorder due to significant
distress or disability.
Characteristics of anxiety:
Intensity, Duration, Pervasiveness:
Anxiety disorders are marked by these three characteristics.
The greater the intensity, duration, and pervasiveness, the more pathological the problem.
People with anxiety experience the 4 D’s: Danger, Deviance, Distress and Dysfunction.
Shared characteristics of anxiety disorders:
1. Excessive Fear and Anxiety: All anxiety disorders involve a higher level of fear or worry than
what's considered normal – This can be about specific things like spiders, flying, or it can be a
, general sense of unease and nervousness about everything.
2. Behavioural Disturbances: These fears and worries aren't just in the person's mind; they also
affect their behavior.
For example, someone might avoid certain places or activities because they're too anxious. It
can interfere with their daily life and ability to function properly.
3. Not attributable to physiological effects of medication/substances or a medical condition
Since these could lead to anxiety as a bi-product.
Fear: Emotional response to a real or Anxiety: Related to muscle tension and
perceived imminent threat [Associated environmental scanning, resulting in lingering
with anatomical arousal]. tension [Anticipation of a future threat].
Differences Between Anxiety Disorders
1. Different Fears: Different anxiety disorders come with different fears. Like someone with a phobia
may be scared of spiders, but someone with social anxiety might be scared of big crowds.
2. Different Thoughts: The things people worry about can also be different.
a. Like someone with panic disorder might think they're having a heart attack when they're not.
b. But someone with obsessive-compulsive disorder might think something bad will happen if
they don't do something in a certain way.
DSM-5 Anxiety Disorders:
1. Separation Anxiety Disorder (Childhood): Non-age appropriate anxiety or anticipation of going
away from home or leaving attachment figures.
Long-lasting and/or occurs at a later age (after 3 years] than appropriate.
Excessive worry that caregivers may be harmed.
Persistent refusal to go anywhere that may cause separation.
Frequent nightmares about separation.
Recurrent physical complaints when not in close proximity to attachment figures [real or
imagined].
2. Selective Mutism (Childhood): Consistent failure to speak in specific social situations where
there is an expectation to speak (e.g., school) despite speaking in other situations.
Interferes with educational, occupational, and social achievement and interaction.
Duration of at least one month (not limited to the first month of school).
Not attributable to lack of knowledge or comfort with the language.
Not better explained by other disorders (e.g., ASD, communication disorder).
Often coexists with social anxiety disorder.
This disorder is a coping mechanism for fear, but can be mistaken for oppositional behavior.
3. Specific Phobia: Intense fear of a certain object or situation that interferes with the person’s
ability to function.
Five categories: animals, natural environments, blood/injection/injury, situational (e.g., flying,
elevators), and other (e.g., fear of vomiting, costumes).
Phobic object almost always evokes immediate anxiety.
, Phobic object/situation is actively avoided or endured with intense fear.
Fear is out of proportion (irrational) and persistent (>6 months).
Not better explained by another disorder.
Facts:
75% of people have more than one specific phobia.
Starts at a very young age (around 8 years) and often persists for years.
60% have at least one comorbid disorder (other anxiety or mood disorder).
What are some ways in which Specific Phobia can develop?
Traumatic Event: Sometimes a really scary experience can lead to a specific phobia. For
example, if someone has a car accident, they might develop a phobia of driving.
Informational Transmission: This is when someone develops a phobia after hearing or
reading about something dangerous or scary. Like, if a person hears a lot about plane
crashes, they might become afraid of flying.
Observational Learning: This is when someone develops a phobia by seeing someone else
being scared. For example, if a child sees their parent being afraid of spiders, they might
also become afraid of spiders.
What is the two-factor theory in the context of phobias?
The two-factor theory states that phobias are maintained through two types of learning -
classical conditioning and operant conditioning.
Classical conditioning occurs when a neutral object (the conditioned stimulus) is paired with
an object that naturally elicits a response (an unconditioned stimulus that elicits an
unconditioned response) until the neutral object elicits the same response (now called the
conditioned response).
Operant conditioning helps maintain the fear. Most people who develop a phobia try to avoid
their feared object, which might otherwise extinguish the phobia. When they encounter their
feared object, they experience extreme fear and often flee. This avoidance behavior is
reinforced through the reduction of fear, maintaining the phobic response.
Main Treatment Options:
1. Systematic Desensitization: This involves compiling a list of feared situations or objects, ranked
from the most to the least feared. Clients learn relaxation techniques and gradually expose
themselves to the items on their fear hierarchy, starting with the least feared.
2. Modeling: In this technique, clients observe someone else (the model) confront the feared object
or situation without showing fear, demonstrating that the feared object is not actually harmful.
, 3. Flooding: In this intense exposure technique, the client is directly and intensively exposed to the
feared object or situation until the associated anxiety response diminishes.
1. Generalized Anxiety Disorder (GAD): Excessive anxiety and worry, more days than not, for at
least 6 months about a number of events or activities (often regular, day-to-day things).
Difficulty controlling the worry.
Key characteristic: is uncontrollable worry.
Associated with three or more symptoms: chronic fatigue, irritability, difficulty
concentrating, difficulty sleeping, muscle tension, edginess, and restlessness.
Clinically significant distress or impairment.
Not attributable to medication, substances, or other medical or mental disorders.
Facts:
Prevalence: 3%.
Age of onset: 25-30 years (often report lifelong anxiety).
66% have a comorbid disorder (another anxiety or mood disorder
Finding: People with GAD often report experiencing intense negative emotions and have a
heightened response to negative events, often feeling as though their emotions are
uncontrollable or unmanageable – Neuroimaging studies have shown increased reactivity to
emotional stimuli in the amygdala. Physiologically, they demonstrate chronic activation of
their sympathetic nervous system and an exaggerated response to threatening stimuli.
Cognitive impairments also exist in GAD, including maladaptive assumptions related to
worries about losing control or an inability to tolerate uncertainty. These maladaptive
assumptions lead to anxiety-inducing automatic thoughts and a state of hypervigilance when
confronted with various situations.
2. Social Anxiety Disorder: Anxiety about social situations where one is exposed to possible scrutiny
by others.
Fear of acting in a way or showing anxiety symptoms that will be negatively evaluated,
causing humiliation, rejection, or offending others.
Social situations are avoided or endured with intense fear/anxiety.
Persistent fear for more than 6 months and clinically significant distress.
Not attributable to substances, medication, or another disorder.
Situations include: social interactions, being observed, performing – (Children also need
to display this fear when with peers, not just adults)
Facts:
Prevalence: 2-5%.
Age of onset: Adolescence (10-15 years).
Panic attacks may occur.
3. Panic Disorder: Recurrent and unexpected panic attacks (abrupt surges of intense
fear/discomfort reaching a peak within 10 minutes).
