1. Chapter 4 Anxiety Disorders

2. The Complexity of Anxiety Disorders Anxiety – the future-oriented mood state – Apprehension about future danger or misfortune – Somatic symptoms of tension – Characterized by marked negative affect Anxiety and fear are normal emotional states

3. The Complexity of Anxiety Disorders Fear – the present-oriented mood state – Immediate fight or flight response to danger or threat – Involves abrupt activation of the sympathetic nervous system – Strong avoidance/escapist tendencies – Marked negative affect

4. From Normal to Disordered Anxiety and Fear Characteristics of anxiety disorders – Pervasive and persistent symptoms of anxiety and fear – Involve excessive avoidance and escape – Cause clinically significant distress and impairment

5. The Phenomenology of Panic Attacks What is a panic attack? – Abrupt experience of intense fear or discomfort – Several physical symptoms (e.g., breathlessness, chest pain) – Fear as an alarm response

6. The Phenomenology of Panic Attacks DSM-IV-TR subtypes of panic attacks – Situationally bound (cued) – Unexpected (uncued) – Situationally predisposed Cultural influences on anxiety

8. Biological Contributions to Anxiety and Panic Genetic vulnerability Anxiety and brain circuits – Depleted levels of GABA

9. Biological Contributions to Anxiety and Panic (continued) Limbic (amygdala) and the septal-hippocampal systems Behavioral inhibition system (BIS) – Anxiety Fight/flight system (FF) – Fear

10. Psychological Contributions to Anxiety and Fear Integrated model – Early childhood - Experiences with uncontrollability and unpredictability

11. Psychological Contributions to Anxiety and Fear Behavioral and cognitive views – Invokes conditioning and cognitive explanations – Anxiety and fear are learned responses – Catastrophic thinking and appraisals play a role

12. Psychological Contributions to Anxiety and Fear Social contributions – Stressful life events trigger vulnerabilities

13. An Integrated Model Integrative view – triple vulnerability model – Generalized biological vulnerability – Generalized psychological vulnerability – Specific psychological vulnerability

14. An Integrated Model Common processes: the problem of comorbidity – Comorbidity is common across the anxiety disorders – Major depression is the most common secondary diagnosis – About half of patients have two or more secondary diagnoses – Comorbidity suggests Common factors A relation between anxiety and depression

15. The Anxiety Disorders: An Overview Generalized anxiety disorder (GAD) Panic disorder with and without agoraphobia (PDA) Specific phobias Social phobia (SAD) Posttraumatic stress disorder (PTSD) Obsessive-compulsive disorder (OCD)

17. Generalized Anxiety Disorder: The “Basic” Anxiety Disorder Overview and defining features – Excessive uncontrollable anxious apprehension and worry – Coupled with strong, persistent anxiety – Persists for six months or more – Somatic symptoms differ from panic (e.g., muscle tension)

18. Generalized Anxiety Disorder: The “Basic” Anxiety Disorder Statistics – Affects about 3.1% of the general population – Females outnumber males approximately 2:1 – Onset is often insidious, beginning in early adulthood – Very prevalent among the elderly – Tends to run in families

19. Generalized Anxiety Disorder: Associated Features and Treatment Associated features – Persons with GAD have been called “autonomic restrictors” – Fail to process emotional component of thoughts and images Causes – factors influencing – Genetics – Muscle tension – Personal threat – Automatic restrictors

20. Generalized Anxiety Disorder: Associated Features and Treatment Treatment of GAD: Generally weak – Benzodiazapines – often prescribed – Antideprancents – Psychological interventions – cognitive-behavioral therapy – Meditation therapy – Combined treatments – acute vs. long-term outcomes

22. Panic Disorder With and Without Agoraphobia Overview and defining features – Experience of unexpected panic attack (i.e., a false alarm) – Develop anxiety, worry, or fear about another attack – Many develop agoraphobia

23. Panic Disorder With and Without Agoraphobia Facts and statistics – Affects about 2.7% of the general population – Onset is often acute, mean onset between 20 and 24 years of age – 66% of individuals with agoraphobia are female Cultural influences Causes – Triple – 8% to 12% has occasional attacks vulnerability

26. Panic Disorder: Associated Features and Treatment Associated features – Nocturnal panic attacks – 60% panic during deep non-REM sleep – Interoceptive/exteroceptive avoidance Medication treatment – Target serotonergic, noradrenergic, and GABA systems – SSRIs (e.g., Prozac and Paxil) are preferred drugs – Relapse rates are high following medication discontinuation

27. Panic Disorder: Associated Features and Treatment Psychological and combined treatments – Cognitive-behavioral therapies are highly effective – No evidence that combined treatment produces better outcome – Best long-term outcome is with cognitive- behavioral therapy alone

28. Panic Disorder: Associated Features and Treatment Panic control treatment (PCT) Combined psychological and drug treatments Innovative approaches – Psychological (CBT) treatment followed by drug treatments – D-cycloserine (DCS)

30. Specific Phobias: An Overview Overview and defining features – Extreme irrational fear of a specific object or situation – Persons will go to great lengths to avoid phobic objects – Most recognize that the fear and avoidance are unreasonable – Markedly interferes with one’s ability to function

31. Specific Phobias: An Overview Facts and statistics – Females are again over-represented – Affects about 12.5% of the general population – Phobias tend to run a chronic course

33. Specific Phobias: Associated Features and Treatment Subtypes of specific phobia – Blood-injury-injection phobia – unusual vasovagal response – Situational phobia – trains, planes, automobiles, closed spaces – Natural environment phobia – natural events (e.g., heights, storms) – Animal phobia – animals and insects – Separation anxiety – seen in children

34. Specific Phobias: Associated Features and Treatment Causes of phobias – Direct experience – Biological and evolutionary vulnerability – traumatic conditioning, prepared tendency, event will happen again Psychological treatments of specific phobias – Cognitive-behavior therapies are highly effective – exposure Cultural factors

35. Social Phobia: An Overview Overview and defining features – Extreme and irrational fear in social/performance situations – Markedly interferes with one’s ability to function – Often avoid social situations or endure them with great distress – Generalized subtype – affects many social situations

36. Social Phobia: An Overview Facts and statistics – Affects about 12.1% of the general population, 6.8% in 1-year period – Prevalence is slightly greater in females than males – Second only to specific phobia in the anxiety disorders – Onset is usually during adolescence – Peak age of onset at about 13 years

38. Social Phobia: Associated Features and Treatment Causes – Biological and evolutionary vulnerability – Similar learning pathways as specific phobias Psychological treatment – Cognitive-behavioral treatment (CBT) – Cognitive-behavioral group treatment (CBGT) – Cognitive-behavioral therapies are highly effective

39. Social Phobia: Associated Features and Treatment Medication treatment – Tricyclic antidepressants and monoamine oxidase inhibitors – SSRIs Paxil, Zoloft, and Effexer – are FDA approved – Relapse rates are high following medication discontinuation

40. Posttraumatic Stress Disorder (PTSD): An Overview Overview and defining features – Main etiologic characteristics – trauma exposure and response – Reexperiencing (e.g., memories, nightmares, flashbacks) – Avoidance – Emotional numbing and interpersonal problems – Markedly interferes with one's ability to function – PTSD diagnosis – only after one month post- trauma

41. Posttraumatic Stress Disorder (PTSD): An Overview Statistics – Combat and sexual assault are the most common traumas – Lower than expected prevalence rates in trauma victims

42. PTSD: Causes and Associated Features Subtypes and associated features of PTSD – Acute – may be diagnosed one-three months post trauma – Chronic – diagnosed after three months post trauma – Delayed onset – onset six months or more post trauma – Acute stress disorder – PTSD immediately post- trauma

43. PTSD: Causes and Associated Features Causes of PTSD – Intensity of the trauma and one's reaction to it (i.e., true alarm) – Learn alarms – direct conditioning and observational learning – Biological vulnerability – Uncontrollability and unpredictability – Extent of social support, or lack thereof, post- trauma

46. PTSD: Treatment Psychological treatments – Cognitive-behavioral therapies (CBT) are highly effective – CBT may include graduated or massed (e.g., flooding) imaginal exposure – Aim of CBT for PTSD – SSRIs

48. Obsessive-Compulsive Disorder (OCD): An Overview Overview and defining features – Obsessions – intrusive and nonsensical thoughts, images, or urges Symmetry 26.7%, forbidden thoughts 21%, cleaning and contamination 15.9% and hording 15.4% – Compulsions – thoughts or actions to neutralize thoughts – Vicious cycle of obsessions and compulsions – Cleaning and washing or checking rituals are common

49. Obsessive-Compulsive Disorder (OCD): An Overview Overview and defining features – Tic disorder and OCD – Hoarding

50. OCD: Causes and Associated Features Statistics – Affects about 1.6% of the general population – Most with OCD are female – Onset is typically in early adolescence or young adulthood – OCD tends to be chronic

51. OCD: Causes and Associated Features Causes of OCD – Parallels the other anxiety disorders – Early life experiences – Learning that some thoughts are dangerous/unacceptable – Thought-action fusion – the thought is similar to the action

53. OCD: Treatment Medication treatment – Clomipramine and other SSRIs – benefit up to 60% of patients – Relapse is common with medication discontinuation – Psychosurgery (cingulotomy) is used in extreme cases

54. OCD: Treatment Psychological treatment – Cognitive-behavioral therapy is most effective – CBT involves exposure and response prevention – Combining CBT with medication – no better than CBT alone – Exposure and ritual prevention (ERP) – more effective than drugs

55. Summary of the Anxiety Disorders Most common forms of psychopathology From a normal to a disordered experience of anxiety and fear – Triple vulnerabilities – bio-psycho-social – Fear and anxiety – non-dangerous bodily or environmental cues – Symptoms and avoidance – significant distress and impairment

56. Summary of the Anxiety Disorders Psychological treatments are generally superior in the long-term – Similar treatments for different anxiety disorders – Suggests that anxiety-related disorders share common processes

57. DSM-5 Proposed Changes http://www.dsm5.org/ProposedRevisions/Pag es/AnxietyDisorders.aspx http://www.dsm5.org/ProposedRevisions/Pag es/AnxietyDisorders.aspx