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ANXIETY DISORDERS LECTURE OUTLINE Panic and anxiety – background and history Etiology – theoretical perspectives Types of anxiety disorders and their treatment Treatments
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ANXIETY DISORDERS Who is afraid of ? small insect animal, reptile speaking to a large audience speaking in front of a small group of familiar people meeting new people attending social gatherings
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Background and history
ANXIETY DISORDERS Background and history experience of anxiety – cognitive, somatic, behavioural, emotional panic – discrete period of intense fear or discomfort (brief and intense) palpitations, shaking, chest pain, fear of dying, going crazy, losing control anxiety – negative affect, sense of uncontrollability of future threat, self-preoccupation
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Background and history
ANXIETY DISORDERS Background and history panic attacks occur spontaneously both panic and anxiety can be “normal” experiences they become maladaptive when they become excessive, chronic, and in absence of any real danger
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Background and history
ANXIETY DISORDERS Background and history Prevalence 25% of population may be expected to have an anxiety disorder at some time in their lives Ontario Health Supplement – 1-year prevalence rates of 9% for men, 16% for women
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Background and history
ANXIETY DISORDERS Background and history 1800s and early 1900s – neuroses, Freudian perspective 1920s – Watson, classical conditioning model, Little Albert later 1900s – Eysenck – neuroticism as a basic personality dimension – strong emotions, moody, restless, anxious
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Psychodynamic perspective
ANXIETY DISORDERS Etiology Psychodynamic perspective realistic, neurotic, moral anxiety defense mechanisms origins in early parent-child relationships neurotic paradox – contradicts pleasure principle
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ANXIETY DISORDERS Etiology Neurotic styles – Shapiro inhibition of assertion/aggression inhibition of responsibility/independence inhibition of compliance/submission inhibition of trust/intimacy
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Biological perspective - Genetics
ANXIETY DISORDERS Etiology Biological perspective - Genetics family studies show up to 25% have an immediate family member with an anxiety disorder twin studies - higher concordance rates for MZ than DZ twins genetics may operate through behavioural inhibition
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Biological perspective - Neuroanatomy
ANXIETY DISORDERS Etiology Biological perspective - Neuroanatomy locus ceruleus amygdala one form of peptide (combo of amino acids), CCK4, related to panic; CCK4 is found in amygdala, hippocampus, cerebral cortex, brain stem
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Biological perspective - Neurotransmitters
ANXIETY DISORDERS Etiology Biological perspective - Neurotransmitters norepinephrine (NE) – concentrated in locus ceruleus serotonin dopamine in social phobia and OCD interactions – serotonin affects locus ceruleus (where NE is produced) and may also influence GABA
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Etiology – Limitations of 2-factor theory
ANXIETY DISORDERS Etiology – Limitations of 2-factor theory cannot explain all phobias – some seem to develop without conditioning difficult to create some fears in the lab cannot explain why some stimuli are more likely to become feared than others
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Etiology – Rachman’s revised theory
ANXIETY DISORDERS Etiology – Rachman’s revised theory classical conditioning modelling informational or instructional transmission
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Etiology – Biological preparedness theory
ANXIETY DISORDERS Etiology – Biological preparedness theory Seligman – evolutionary significance of stimuli that are easily conditioned Bandura – properties of stimuli themselves (unpredictability and uncontrollability) and the cognitive processing that defines their threatening nature
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Etiology – Cognitive theories
ANXIETY DISORDERS Etiology – Cognitive theories Bandura – low perceived self-efficacy Beck – experiences, beliefs, appraisals Ellis – irrational beliefs, catastrophization
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Etiology – Biopsychosocial perspective
ANXIETY DISORDERS Etiology – Biopsychosocial perspective emotion biology environment behaviour cognition
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Types – Specific phobia
ANXIETY DISORDERS Types – Specific phobia animal environmental blood, injury, injection specific situation – elevators, flying other
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Types – Specific phobia – Diagnostic features
ANXIETY DISORDERS Types – Specific phobia – Diagnostic features marked and persistent fear and avoidance of specific stimulus or situation must interfere significantly with person’s life must be considered excessive or unrealistic ANS arousal
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Types – Specific phobia
ANXIETY DISORDERS Types – Specific phobia prevalence rates from 7-11% often emerge during adolescence, usually earlier than age 25 tend to be chronic, but may fluctuate over life course usually assessed with self-report conditioning theories systematic desensitization
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Systematic desensitization (SD) for specific phobia
ANXIETY DISORDERS Systematic desensitization (SD) for specific phobia Wolpe (1958) – reciprocal inhibition and SD 3 components of SD construction of stimulus hierarchy progressive (deep muscle) relaxation training progress through the hierarchy while practicing relaxation response
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Panic disorder - Elements
ANXIETY DISORDERS Panic disorder - Elements recurrent, unexpected panic attacks persistent concern, preoccupation with having another attack worry about consequences of attack significant behaviour change in response to attacks
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Panic disorder – Other clinical features
ANXIETY DISORDERS Panic disorder – Other clinical features often accompanied by avoidance behaviours (agoraphobia) possible to have agoraphobia without panic attacks onset around late adolescence, early adulthood more women than men high rates of service utilization, poor quality of life
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Clark’s cognitive model of panic disorder)
ANXIETY DISORDERS Clark’s cognitive model of panic disorder) catastrophic misinterpretation of arousal-related bodily sensations agoraphobia (avoidance) as way of coping
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Obsessive-compulsive disorder (OCD) - Elements
ANXIETY DISORDERS Obsessive-compulsive disorder (OCD) - Elements recurrent obsessions, compulsion, or both obsessesions – thoughts, images, impulses, that are persistent, markedly distressing compulsion – repetitive behaviours performed in response to an obsession
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Obsessive-compulsive disorder (OCD) - Elements
ANXIETY DISORDERS Obsessive-compulsive disorder (OCD) - Elements common obsessions – violence, sex, contamination, order common compulsions – washing, cleaning, checking, seeking reassurance, ordering or arranging objects cleaners vs. checkers – focus on harm vs. order
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Obsessive-compulsive disorder (OCD) - Background
ANXIETY DISORDERS Obsessive-compulsive disorder (OCD) - Background very rare – 2.5% lifetime prevalence rate little gender difference high overlap with depression and Tourette’s syndrome
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Obsessive-compulsive disorder (OCD) – Psychodynamic perspective
ANXIETY DISORDERS Obsessive-compulsive disorder (OCD) – Psychodynamic perspective anal fixation – “Does anal-retentive have a hyphen?” reaction formation, undoing, displacement
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Obsessive-compulsive disorder (OCD) –Treatments
ANXIETY DISORDERS Obsessive-compulsive disorder (OCD) –Treatments Prozac - SSRIs Exposure and response prevention
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Post-traumatic stress disorder (PTSD) –Description
ANXIETY DISORDERS Post-traumatic stress disorder (PTSD) –Description Person has been exposed to traumatic event 3 symptom clusters recurrent re-experiencing of event avoidance of trauma-related stimuli and numbing increased arousal Persists for at least 1 month after trauma
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Post-traumatic stress disorder (PTSD) –Etiology
ANXIETY DISORDERS Post-traumatic stress disorder (PTSD) –Etiology Cognitive theories expectations and appraisals fear structure in long-term memory fear conditioning
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Generalized anxiety disorder (GAD) –Description
ANXIETY DISORDERS Generalized anxiety disorder (GAD) –Description Core feature is worrying – worries are unrealistic, difficult to control, excessive “Free floating” anxiety Verbal thoughts rather than images as in OCD Motor tension, vigilance, scanning “What if?” – background of intolerance of uncertainty
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Generalized anxiety disorder (GAD) –Description
ANXIETY DISORDERS Generalized anxiety disorder (GAD) –Description 3 key features uncontrollability intolerance of uncertainty ineffective problem-solving skills
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Treatments - Pharmacotherapy
ANXIETY DISORDERS Treatments - Pharmacotherapy 3 main drugs Xanax Paxil Zoloft SSRIs, bezodiazepines, tricyclic anti-depressants, MAOs
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ANXIETY DISORDERS Treatments - Exposure
flooding, response prevention confrontation with anxiety-producing stimulus developing more adaptive internal representations of the stimuli and their non-threatening consequences
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Treatments – Cognitive restructuring
ANXIETY DISORDERS Treatments – Cognitive restructuring identify maladaptive cognitions challenge maladaptive cognitions develop more adaptive cognitions
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Treatments – Relaxation training
ANXIETY DISORDERS Treatments – Relaxation training decreases physiological arousal through: deep muscle relaxation positive imagery meditation deep breathing
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Treatments – Problem-solving training
ANXIETY DISORDERS Treatments – Problem-solving training What is my problem? What is my goal? What solutions can I generate to solve the problem? What might be the consequences of each solution? Try a solution particularly relevant to GAD divides problems into manageable units
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ANXIETY DISORDERS SUMMARY both biological and psychological factors involved in etiology of anxiety disorders – biopsychosocial model shift away from Freudian perspective on “neuroses” both biological and psychological treatments for the various disorders
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