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Anxiety Disorders Fear and apprehension run amok.

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Presentation on theme: "Anxiety Disorders Fear and apprehension run amok."— Presentation transcript:

1 Anxiety Disorders Fear and apprehension run amok

2 Definitions Anxiety – apprehension over an anticipated problem Fear – reaction to immediate danger Both involve sympathetic nervous system arousal Both are adaptive but when they arise inappropriately misery can follow

3 Many suffer Most common mds – 28% at some point Phobias strike the most Pervasive costs 1) 2x the medical cost 2) greater risk of heart and other illnesses 3) 2x suicide risk 4) troubles socially and at work

4 DSM IV TR to DSM 5 Most disorders remain unchanged Panic Disorder (DSM IV TR) now split into Panic disorder and Agoraphobia OCD and Trauma/Stress disorders (PTSD) are given their own chapters

5 General Diagnostic Criteria Major functional trouble/distress Drugs or medical condition not causal Lots of overlap between the specific disorders Most (except GAD) involve intense fear

6 Description – Specific phobias A disproportionate fear caused by a specific object or situation Recognizing that the fear is not realistic no longer necessary in DSM 5 Object or situation are avoided High chance that a victim will more than 1

7 Social Anxiety Disorder Persistent, unrealistically intense fear of social situations involving appraisal or even contact with unfamiliar people Formerly – social phobia disorder Great fear of public speaking, talking in class or to authority figures, meeting new people Way beyond simple shyness Can severely limit jobs and advancement

8 Social Anxiety Disorder cont. 1/3 are comorbid w/ avoidant personality disorder, w/ genetic overlap, but less severe Can begin in childhood, but usually in teens Chronic w/out treatment Fears can range from a few to very many More fears, more likely comorbid w/ depression and alcohol abuse

9 Panic Disorder Frequent panic attacks unrelated to any specific trigger and the worry of more to come Panic attack – sudden wave of intense terror accompanied by at least four other symptoms Symptoms could include shortness of breath, racing heart, sweat, fainting, chills, nausea, trembling, dizziness, numbness/tingling

10 Panic Disorder: psychological symptoms Derealization – fear that the world is not real Depersonalization – a feeling of being outside of your body Also, fear of losing control, of going crazy, of dying 90% report these type of symptoms Many want to run away as fast as possible

11 Recurrence is crucial Attacks must be recurrent for at least a month Many (more than 25%) have endured one attack Few suffer repeatedly Devastating to employment – many cannot keep a job

12 Agoraphobia Fear of places or situations from which it would be hard to escape Crowds, shopping malls, trains, games Many, as a result, don’t leave the house And, if they do, it’s only with great distress Formerly under Panic Disorder, but few endure panic attacks Significantly impairs day to day function

13 Generalized Anxiety Disorder (GAD) Excessive worry on more days than not about any kind of events Worries are common for everyone but these are excessive in terms of intensity and time Must last for at least 6 months, many chronic Symptoms include trouble concentrating, fatigue, irritability, restlessness, muscle tension

14 If you’ve got one … More than half get another anxiety diagnosis at some point Especially true for GAD – 80%! Many others have subthreshold symptoms Why such high comorbidity? 1) symptom overlap, and 2) many causal factors increase risk for more than 1 disorder

15 More comorbidity Above and beyond other anxiety disorders, they have high comorbidity with many other types of mds 75% meet criteria for another md! 60% for depression alone Many suffer from substance abuse and/or personality disorders Also great risk for concurrent medical woes

16 Does Gender matter? Yes – women are 2x more likely to suffer. Why? a) More likely to report b) Men think they have control c) Men are often forced to face fears – exposure d) Sadly, women are more often sexually abused e) Women seem more physiologically vulnerable

17 How about culture? Significant variation depending upon what a culture values, or fears Taijin kyofusho – Japanese syndrome involving deep fear of displeasing others Manifests by fear of eye contact, blushing, body odor or deformity Similar to SAD but the emphasis on the feelings of others distinguishes Arises from extreme, traditional concern for other’s feelings?

18 More cultural variants Kayak-angst – Inuit seal hunters can endure special type of panic disorder Features intense fear, disorientation Alone in a harsh, unforgiving environment Koro – Asian phenomenon, grave fear of penis disappearing into body Shenkui – Chinese fear of losing semen due to masturbation or too much sex

19 Other aspects of cultural variation Low incidence of anxiety disorders in Japan – bias against reporting? Lots of panic disorder in Cambodia – lingering effects of Khmer rouge genocide? PTSD? While some cultural variations have been explained away, others, including the nature of complaints do vary from culture to culture

20 Common Risk factors for all Anxiety Disorders Helps explain high comorbidity Big factor arises from the classical conditioning (CC) of fear responses Other factors – genes, personality traits, cognitive factors – influence how and when conditioning takes hold

21 Fear Conditioning – Mowrer’s Two Factor Model Mowrer’s theory 1) through CC we learn to fear a neutral stimulus (CS) that is repeatedly paired with an always averse stimulus (UCS) 2) through operant conditioning (OC) we feel better, doge stress, by avoiding the CS. Avoiding the CS becomes more and more likely (reinforcing) because it reduces fear.

22 Example – Claustrophobia & elevators A child is stuck in an elevator for a long period of time and develops a phobia of elevators She has learned to link elevators (CS) with being trapped in a small space (UCS) The child becomes anxious every time she sees or even thinks about an elevator (CR) Avoiding elevators produces great relief (reinforcement) so it continues – no exposure

23 How could this start? Direct experience – a snake bit you and it hurt Modeling – you saw another person bitten or terrified and it made an impression on you Verbal instruction – someone told you hoe horrible it is to be bitten by a snake

24 Two other factors People who suffer from anxiety disorders share two qualities 1) they are more susceptible to CC of fear responses 2)their fears are resistant to extinction – exposure to extinction trials (CS not followed by UCS) does not lead to extinction

25 Genetic influence Twin studies reveal a heritability of 20-40% for anxiety disorders besides panic disorder Panic disorder – 50% It seems that some genes predispose to all anxiety disorders while others point to specific disorders

26 Neurobiological Inappropriate activation and persistence of the fear circuit is associated with anxiety disorders The amygdala is a major player assigning excessive fear to stimuli and triggering the circuit Worse yet, the medial prefrontal area, which can override the too sensitive amygdala, tends to be compromised in anxiety disorders

27 Neurobio II Neurotransmitters also play a role Serotonin problems, or too much norepinephrine, are linked to anxiety woes GABA usually inhibits activity and anxiety throughout the brain, deficits could hurt

28 Personality’s Influence If yearlings show behavioral inhibition, fearful reaction to novel stimuli, they often (45%) show anxiety at 7. Genetic – can manifest at four months Especially predictive of Social Anxiety Disorder Neuroticism – ultra-senrsitivity to adverse stimuli, another strong predictor of both anxiety and depression

29 Cognitive – three theories Sustained Negative Beliefs about the Future – the pervasive conviction that only bad things are coming Common among anxiety disorders Maintained by safety behaviors, avoidance measures that prevent beliefs from reality testing

30 Perceived Control The belief that you have no control over your future is characteristic of many anxiety disorders Rough times as a kid may encourage this outlook 70% of anxiety sufferers can identify a crisis within months of onset Backed up by animal studies

31 Specific Causes - Phobias Classical Conditioning – phobias are a conditioned response maintained by avoidance behavior Could arise from personal trauma, modeling, or verbal instruction When asked though, about ½ don’t remember Says more about the failings of memory, than the viability of the theory

32 Phobia etiology II Many are unaffected by experiences that cause phobias to develop in others Why? risk factors – neurotransmitter deficits, personality traits, high fear circuit activation But only some things cause phobias to arise – things we have feared for millennia like dogs, snakes, heights – Prepared Learning Other stimuli cause reactions, but soon fade

33 Causes of Social Anxiety Disorder Similar to phobias – developed by CC, maintained by OC Safety behaviors make the problem worse From the Cognitive perspective: 1) negative beliefs – I’m a dork & all know it 2) too conscious of internal cues – so alert to their reactions, they ignore their partner

34 Panic Disorder – Why do we exaggerate bodily changes? Neurobiological – locus coruleus turns on too easily causing unnecessary sympathetic nervous system arousal Classical Conditioning – signs of arousal lead to panic attack, and then become a CS, with the subsequent panic attack becoming a CR’ also called interoceptive conditioning

35 Cognition’s role in Panic Disorder Interpreting somatic changes as impending doom When someone is warned that somatic changes are coming, they don’t experience panic attacks When they don’t know, they have catastrophic interpretations and can sustain panic attacks

36 Agoraphobia causes Fear of Fear – victims overestimate how badly they will react to stress in public Afraid their unease will go viral

37 Etiology of GAD: Why worry so much? GAD is so often a comorbid condition, general predictors of anxiety disorders are key Also, cognitive factors appear crucial Worry can be reinforced because it distracts them from its source, which is more upsetting Many have histories of severe trauma Worry decreases arousal But then fears don’t extinguish and linger

38 Treatment Sadly, few seek treatment – fewer than 20% Do they think that’s just the way they are? Also, they need specialized help General Practitioners under-prescribe and break off treatment too early

39 Treatment – You have to face it Exposure is the key Systematic Desensitization works well, even w/out relaxation CBT is successful, especially if it includes many aspects of triggering stimuli Behaviorists say that we learn a new response, instead of erasing the old Virtual reality technology can help

40 Specific treatments Phobias – in vivo (real life) exposure works even better than systematic desensitization Only a few hours can be enough GAD – exposure, starting with role-playing exercises Social skills training helps, especially if safety behaviors are recognized and overcome

41 Panic Disorder Psychodynamic treatment: 1) id the emotions & causes 2) gain insight Small studies revealed this to be effective and to prevent relapse Panic Control Therapy – triggering sensations are elicited, coping techniques are taught, ability to create & overcome weakens effect

42 More treatments Agoraphobia – systematic exposure w/ partner, who will not enable works GAD – all treatments feature a mix of behavioral and cognitive components typically, relaxation exercises are used attempts to better cope w/ uncertainty “worry” exercises to weaken its impact

43 Medications Two basic types Benzodiazepines such as Valium and Xanax Antidepressants tricyclics selective serotonin reuptake inhibitors serotonin-norepinephrine reuptake inhibitors All provide relief from anxiety disorders

44 Which to choose? Antidepressants lack severe withdrawal effects, they aren’t addictive All have side-effects Benzodiazepines cause cognitive and motor problems, even memory lapses Tricyclics can cause jitteriness, weight gain, and others

45 Why SSRI’s? Preferred meds for anxiety disorders 50% stop tricyclics SSRIs have fewer side-effects But they can occur Include restlessness, sleep and sexxproblems, and headaches

46 But it doesn’t last While meds work, once they aren’t taken, relapse usually follows Accordingly, psychological treatments featuring exposure are preferred Exception – GAD, which can be treated by buspirone (BuSpar)

47 Combining meds and psych treatments Surprisingly, combining works less than exposure treatments, of whatever type, alone Possibly because meds can impair facing the fear source


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