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Anxiety Disorders.

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Presentation on theme: "Anxiety Disorders."— Presentation transcript:

1 Anxiety Disorders

2 Prepared by / Mofida AL-barrak
Under supervisor Dr. \ Falah AL-Enizy Associat professor in psychology department, King Saud university

3 Objectives At the end of this lecturer the students will be able to:-
Compare & contrast psychological & biological similarities and differences between anxiety, fear, and a panic attack.   Explain the essential features of panic disorder, according to DSM-IV-TR subtypes of panic attack. Describe the essential features of generalized anxiety disorder.

4 Cont. differentiate among agoraphobia, specific phobia, and social phobia.   Discuss the essential features of posttraumatic stress disorder. Identify the essential features of obsessive-compulsive disorder.

5 Out lines Introduction Define the following terms
Anxiety, fear, & panic attack Five major types of anxiety disorders are: Generalized anxiety disorder Panic disorder Phobias, Posttraumatic stress disorder (PTSD), Obsessive–compulsive disorder (OCD), Conclusion Reference

6 Introduction Everyone experiences feelings of anxiety during their lifetime. For example, the person may feel worried and anxious about sitting an examination, or having a medical test, or a job interview. Feeling anxious sometimes is perfectly normal. However, for people with generalized anxiety disorder (GAD), feelings of anxiety are much more constant, and tend to affect their day-to-day life. However, anxiety is not always pathological or maladaptive: it is a common emotion along with fear, anger, sadness, and happiness, and it has a very important function in relation to survival.

7 Anxiety Anxiety is a physiological state characterized by cognitive, somatic, emotional, and behavioral components. These components combine to create the feelings that are typically recognize as fear, apprehension, or worry. Or Anxiety is a negative mood state characterized by bodily symptoms of physical tension, & apprehension about the future (American psychiatric association, 1994; Barlow, 2002)

8 Symptoms of anxiety Anxiety is often accompanied by physical sensations such as: Sympathetic nervous system (fight) heart palpitations chest pain shortness of breath headache. Papillary dilation

9 nausea pale skin sweating trembling, stomach aches diarrhea, & chills.

10 Emotionally, anxiety causes a sense of fear or panic
The cognitive component entails expectation of a diffuse and certain danger. Behaviorally, both voluntary and involuntary behaviors may arise directed at escaping or avoiding the source of anxiety and often maladaptive, being most extreme in anxiety disorders.

11 Anxiety versus Fear Anxiety is a future oriented mood state, characterized by apprehension because one cannot predict or control upcoming events(subjective feeling) Fear is an immediate and current reaction to danger characterized by a strong escapist action (objective feeling)

12 Panic Attack An abrupt experience of intense fear or acute discomfort accompanied by physical symptoms that include:- Heart palpitations Chest pain Shortness of breath Dizziness Disorganized personality & Not able to make decision.

13 Three basic types of Panic Attacks are describe in DSM-IV
Situationally bound (cued) panic attack. are more common in specific phobias or social phobia Unexpected (uncued) panic attack "SPONTANEOUS", Without apparent stimulus. Situationally predisposed panic In between Increased in certain situations (e.g. driving; crowds)

14 The Phenomenology of Panic Attacks
Figure 1.1 The relationships among anxiety, fear, and panic attack.

15 Anxiety Disorders Anxiety disorders are the most common of emotional disorders. Many forms and symptoms may include: Overwhelming feelings of panic and fear Uncontrollable obsessive thoughts Painful, intrusive memories Recurring nightmares Physical symptoms such as feeling sick to the stomach, “butterflies”, heart pounding, and muscle tension

16 Anxiety disorders differ from normal feelings of nervousness.
Untreated anxiety disorders can push people into avoiding situations that trigger or worsen their symptoms. People with anxiety disorders are likely to suffer from depression, and they also may abuse alcohol and other drugs in an effort to gain relief from their symptoms. Job performance, school work, and personal relationships can also suffer.

17 Etiology Biological Contributions to Anxiety and Panic
Diathesis-Stress Inherit vulnerabilities for anxiety and panic There evidence that genetic contribution to panic and anxiety differ but in both situation genetic valinarabelity particularly in a person with stress Stress and life circumstances

18 Biological Causes and Inherent Vulnerabilities
Anxiety and brain circuits – GABA, noradrenergic and serotonergic systems Corticotrophin Releasing Factor (CRF) and the HPA axis Limbic (amygdale) and the septal-hippo campal systems Behavioral Inhibition System (BIS) and Fight/Flight Systems (FFS)

19 Psychological Contributions to Anxiety and Fear
Psychological Views Early experiences with uncontrollability / unpredictability Began with Freud Anxiety is a psychic reaction to danger Anxiety involves reactivation of an infantile fearful situation Behavioristic Views Anxiety and fear result from classical and operant conditioning and modeling Social Contributions Stressful life events trigger vulnerabilities Many stressors are familial and interpersonal

20 An integrated Model Integrative View
Biological vulnerability interacts with psychological, experiential, and social variables to produce an anxiety disorder Generalized biological vulnerability to anxiety is not anxiety itself ,a given stressor could activate biological tendencies to anxiety and psychological tendencies to feel that not be able to deal with situation and control the stress

21 Comorbidity of anxiety disorders
The co-occurrence of two or more disorders in a single individuals is referred to as Comorbidity. If each patient with an anxiety disorder also had every other anxiety disorder, there would be little sense in distinguishing among the specific disorders. It would be enough to say, simply, that the patient had an anxiety disorder.

22 Cont. But this is not the case, & although rates of Comorbidity are high, they vary somewhat from disorder to disorder. A large-scale study was recently completed at one of our centers, examining the Comorbidity of DSM IV anxiety & mood disorders substance abuse disorders, other anxiety disorders (except Social Phobia)

23 Types of Anxiety Disorders
Generalized Anxiety Disorder Panic Disorder with and without Agoraphobia Specific Phobias Social Phobia Posttraumatic Stress Disorder Obsessive-Compulsive Disorder

24 Generalized anxiety disorder
Generalized anxiety disorder is a common chronic disorder that affects twice as many women as men and can lead to considerable impairment (Brawman-Mintzer & Lydiard, 1996, 1997).

25 DSM-IV- Criteria for GAD
The DSM criteria specify that at lest 6 months of excessive anxiety & worry (apprehensive expectation ), occurring more days than not. b. The worry process must be difficult to control or turn off c. The anxiety & worry are associated with at least three or more of the following six symptoms. Restlessness Being easily fatigued Difficult concentration

26 Cont. 4. Irritability 5. Muscle tension 6. Sleep disturbance d. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or others important area of functioning

27 ICD10 classification symptoms present most days for weeks
Motor tension Muscle tension, twitching and shaking, restlessness, Apprehension Feeling on edge, unable to cope, poor concentration, insomnia, irritability Autonomic over-activity Light headedness, sweating, tachycardia, dry mouth, epigastric discomfort

28 Facts and Statistics 4% of the general population meet criteria
Females 2:1 over males Onset often insidious, beginning early adulthood Tendency to be anxious runs in families Associated Features Persons with GAD are “autonomic restrictors” Fail to process emotional component of thoughts & Images.

29 Generalized Anxiety Disorder: The “Basic” Anxiety Disorder
Excessive uncontrollable anxious apprehension Unproductively worry about life events Coupled with strong, persistent anxiety Somatic symptoms differ from panic (e.g., muscle tension, fatigue, irritability) Persists for 6 months or more

30 Generalized Anxiety Disorder: Associated Features and Treatment
Figure 5.5 An integrative model of generalized anxiety disorder


32 Treatment of GAD Medication Benzodiazepines
These drugs impair cognitive and motor functioning and physical and psychological dependence Antidepressants Psychological Treatments Cognitive Behavioral Treatments (CBT)

33 2. Panic disorder The core symptom of panic disorder is the panic attack, an overwhelming combination of physical and psychological distress.

34 Panic Disorder with and without Agoraphobia
Experience of recurrent unexpected panic attack Develop anxiety, worry, or fear about having another attack or its implications Agoraphobia – Fear and avoidance of situations/events escape is difficult associated with panic Symptoms and concern about another attack persists for 1 month or more.

35 DSM IV diagnostic criteria for panic attack
Palpitation Accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath Feeling of choking Chest pain

36 DSM IV diagnostic criteria for panic attack cont.
Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint Derealization (feelings of unreality) or depersonalization (being detached from oneself) Fear of losing control or going crazy Fear of dying Paresthesias (numbness or tingling sensations) Chills or hot flashes

37 Panic disorder - epidemiology
Facts and Statistics Panic disorder affects about 3.5% of the population Two thirds with panic disorder are female Onset is often acute, beginning between ages

38 Panic disorder - pharmacological treatment
Assess and treat comorbid problems SSRIs - paroxetine, citalopram - can initially worsen panic attacks Benzodiazepines - good short term relief but high risk of dependency - alprazolam TCAs - imipramine, clomipramine MAOIs - especially in mixed panic depressive states but use limited by ADR High rate of relapse on cessation of treatment

39 Panic disorder - psychological treatments
Behavioural therapy exposure and response prevention relaxation techniques Cognitive behaviour therapy Education Recognition and change of negative thoughts

40 Phobia A phobia is excessive and persistent fear of a specific object, situation, or activity. These fears cause such distress that some people go to extreme lengths to avoid what they fear.

41 There are three types of phobias:
1. Specific phobia 2. Social phobia 3. Agoraphobia

42 Specific Phobias: Overview and Defining Features
Extreme and irrational fear of a specific object or situation Markedly interferes with one's ability to function Recognize fears are unreasonable Still go to great lengths to avoid phobic objects

43 Causes of Phobias Genetic vulnerability Evolutionary influences
Direct conditioning Observational learning Learning history Information transmission

44 Specific Phobias: Associated Features and Treatment
Associated Features and Subtypes of Specific Phobia Blood-injury-injection phobia – Vasovagal response Situational phobia – Public transportation or enclosed places (e.g., planes) Natural environment phobia – Events occurring in nature (e.g., heights, storms) Animal phobia – Animals and insects Other phobias – Do not fit into the other categories (e.g., fear of choking, vomiting) Separation anxiety disorder – Children’s worry that something will happen to parents

45 Facts and Statistics 7-11% general population meet diagnostic criteria for specific phobia Females are again over-represented Phobias run a chronic course, with onset beginning between 15 and 20 years of age

46 DSM IV for specific phobia
Marked & persistent fear that is excessive or unreasonable, cued by the presence of a specific object or situation (flying, heights, animals, receiving injection, seeing blood) Exposure to be the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situational bound or Situationally predisposed panic attack The person recognized that the fear is excessive or unreasonable.

47 Specific Phobias: Treatment
Psychological Treatments of Specific Phobias Cognitive-behavior therapies are highly effective Structured and consistent graduated exposure

48 Social Phobia: Overview and Defining Features
Extreme and irrational fear/shyness Focused on social and/or performance situations Markedly interferes with one's ability to function May avoid social situations or endure them with distress

49 Generalized subtype? Anxiety across many social situations Facts and Statistics Affects about 13% of the general population at some point Females are slightly more represented than males Onset is usually during adolescence Peak age of onset at about 15 years

50 Social Phobia: Treatment
Causes of Phobias Biological and evolutionary vulnerability Direct conditioning, observational learning, information transmission

51 Medication Treatment of Social Phobia
Beta blockers -- Are ineffective Tricyclic antidepressants -- Reduce social anxiety Monoamine Oxidase inhibitors – Reduce reduce anxiety SSRI Paxil – FDA approved for social anxiety disorder Relapse rates – High following medication discontinuation

52 Social Phobia: Treatment (cont.)
Psychological Treatment of Social Phobia Cognitive-behavioral treatment – Exposure, rehearsal, role-play in a group setting Cognitive-behavior therapies are highly effective

53 Agoraphobia Fear of open spaces, crowds or public places.
Fear of travelling by public transport Fear that it may be difficult to get to a place of safety (home) Situations where an immediately available exit is lacking are avoided.

54 Agoraphobia - epidemiology (similar to panic disorder)
Predominantly females – 75% Age of onset – 15 to 35 Risk factors Stressful life events Family history – 20% relative with agoraphobia Domestic instability – family or marital difficulties History of childhood fears or enuresis Overprotective family members Differential diagnosis Depression, schizophrenia, dementia

55 Agoraphobia - symptoms
Autonomic symptoms - faintness, palpitations, SOB, sweating Panic attacks marker of severity Psychological symptoms - fear, dread Behavioural symptoms - avoidance to the extent that the person becomes house bound Cognitive symptoms - “ I might have died”

56 Agoraphobia - Management and Prognosis
Behaviour therapy - graded exposure and systematic desensitisation CBT Family therapy Self help books Pharmacotherapy - as for panic disorder

57 Situations Avoided by People with Agoraphobia
Shopping malls Cars (driver or passenger) Buses Trains Subways Wide Streets Tunnels Restaurants Theaters Source: Barlow & Durand, 2002, p. 124

58 Cont. Being far from home Staying at home alone Waiting in line
Supermarkets Stores Crowds Planes Elevators Escalators

59 Social Phobia Fear of scrutiny by others in relatively small groups
Fear of acting in a way that will be embarrassing or humiliating or appear ridiculous Feared social situation associated with intense anxiety and distress - blushing, tremor,butterflies Leads to avoidance of social situations that involve e.g., eating, public speaking - isolation Differential diagnosis Body dysmorphic disorder, panic disorder, depression, paranoid psychosis

60 Posttraumatic Stress Disorder (PTSD): An Overview
Overview and Defining Features Requires exposure to a traumatic event Person experiences extreme fear, helplessness, or horror Continue to re-experience the event (e.g., memories, nightmares, flashbacks) Avoidance of reminders of trauma Emotional numbing Interpersonal problems are common Markedly interferes with one's ability to function PTSD diagnosis – Only 1 month or more post-trauma

61 Posttraumatic Stress Disorder (PTSD): An Overview (cont.)
Facts and Statistics Affects about 7.8% of the general population Most Common Traumas Sexual assault Accidents Combat

62 DSM diagnostic criteria for posttraumatic stress disorder
The person has been exposed to a traumatic event in which both of the following were present. The person experience, witnessed, or was confronted with an event The person response involved intense fear, helplessness, b. The traumatic event is persistently reexperienced in one (or more) of the following ways

63 Cont, 1. Recurrent & intrusive distressing recollections of the event, including images, thought, pr perception 2. Recurrent distressing dreams of the event 3. Acting or feeling as if the traumatic event were recurring 4. Intense psychological distress at exposure to internal or external cues that symbolize 5. Physiologic reactivity on exposure to internal or external cues that symbolize

64 Cont. c. Persistent avoidance of stimuli associated with the trauma & numbing of general responsiveness of the following Efforts to avoid thoughts, feelings or conversations associated with the trauma Efforts to avoid activities, places, Inability to recall an important aspect of the trauma Feeling of detachment Restricted rang of affect Sense of a foreshortened future (does not except to have a career, marriage, children, or normal life span)

65 Cont. d. Persistent symptoms of increased arousal
Difficulty falling or staying asleep Irritability Hpervigilance Exaggerated startle response e. Duration of the disturbance symptoms in b,c,d is more than one month f. The disturbance causes clinically significant distress in social, occupational, Acute: if duration of symptoms is less than 3 month Chronic : if duration of symptoms is 3 months or more

66 Posttraumatic Stress Disorder (PTSD): Causes and Associated Features
Subtypes and Associated Features of PTSD Acute PTSD – May be diagnosed 1-3 months post trauma Chronic PTSD – Diagnosed after 3 months post trauma Delayed onset PTSD – Symptoms begin after 6 months or more post trauma Acute stress disorder – Diagnosis of PTSD immediately post-trauma Causes of PTSD Intensity of the trauma and one’s reaction to it Uncontrollability and unpredictability Extent of social support, or lack thereof post-trauma Direct conditioning and observational learning

67 PTSD Comorbidity 88% of men and 79% of women with PTSD meet diagnostic criteria for another psychological disorder Drug/alcohol abuse/dependence Major Depressive Disorder Borderline Personality Disorder Phobias Panic Disorder Social Misconduct

68 PTSD - outcome Symptoms fluctuate over time
Most intense at times of stress 30% complete recovery 10 % do badly Predictors of poor outcome - Hx of childhood trauma, borderline or ontisocial personality traits, poor support network, heavy alcohol intake

69 Posttraumatic Stress Disorder (PTSD): Treatment
Psychological Treatment of PTSD Cognitive-behavioral treatment involves graduated or massed imaginal exposure Increase positive coping skills and social support Cognitive-behavior therapies are highly effective

70 PTSD - Mx SSRIs, Serotinergic TCAS Behavioural treatment
CBT cognitive –behaviour therapy. Family treatment Debriefing - no clear evidence base

71 Obsessive-Compulsive Disorder (OCD): An Overview
Overview and Defining Features Obsessions Intrusive and nonsensical thoughts, images, or urges that one tries to resist or eliminate Compulsions Thoughts or actions to suppress thoughts Provide relief Most persons with OCD display multiple obsessions Many with cleaning, washing, and/or checking rituals

72 OCD Most common obsessions Contamination Aggressive Impulses
Sexual Content Somatic Concerns Need for Symmetry

73 OCD Most common compulsions Checking Ordering Arranging Washing
Cleaning Counting Hoarding

74 DSM diagnostic criteria for obsessive-compulsive disorder
1.Recurrent & persistent thoughts, impulses or images that are experienced, at some time during the disturbance , as intrusive & inappropriate, & cause marked anxiety or distress 2. The thoughts, impulses, or images are not simply excessive worries about real-life problems 3. The person attempts to ignore or suppress such thoughts, impulses, or images, 4. The person recognizes that the obsession thoughts, impulses, or images are a product of his or her own mind.

75 Cont. Compulsions 1.Repetive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently)that the person feels driven to perform in response to an obsession, 2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation, however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent,

76 OCD epidemiology Lifetime prevalence 1 -2% Equal sex incidence
Age of onset 20 - usually abrupt Often delay of years in seeking tx Course chronic and fluctuating Often co-morbid anxiety disorders, (social phobia 25%), depression (67%), eating disorders

77 Causes of OCD Thought action fusion –
Causes a person to not be able to throw the thought away because it is almost as if they are doing it

78 OCD - Management Behaviour therapy CBT - less useful Pharmacotherapy
Exposure and response prevention Paradoxical injunctions CBT - less useful Pharmacotherapy SSRIs, Clomipramine Augmentation with quetiapine or risperidone Clonazepam

79 Summary of Anxiety-Related Disorders
Anxiety Disorders Are the Largest Domain of Psychopathology From a Normal to a Disordered Experience of Anxiety and Fear Requires consideration of biological, psychological, experiential, and social factors Fear & anxiety in the absence of real threat or danger Develop avoidance, restricted life functioning Cause significant distress and impairment in functioning Psychological Treatments Are Generally Superior in the Long-Term Treatments include similar components Suggests that anxiety disorders share common processes

80 Exploring Anxiety Disorders

81 Exploring Anxiety Disorders (cont.)

82 Exploring Anxiety Disorders (cont.)

83 Exploring Anxiety Disorders (cont.)

84 Exploring Anxiety Disorders (cont.)

85 Reference Seligman, M.E.P., Walker, E.F. & Rosenhan, D.L. (2001). Abnormal psychology, (4th ed.) New York: W.W. Norton & Company, Inc. Rosen JB, Schulkin J (1998). "From normal fear to pathological anxiety". Psychol Rev 105 (2): David H. , Barlow, V. & Mark Durand (2002). abnormal psychology an integrative approach third edition chapter 5 ,pages Ernst E. (2002). "The risk-benefit profile of commonly used herbal therapies: Ginkgo, St. John's Wort, Ginseng, Echinacea, Saw Palmetto, and Kava". Ann Intern Med. 136 (1):

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