2 Prepared by / Mofida AL-barrak Under supervisor Dr. \ Falah AL-EnizyAssociat 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 attackFive major types of anxiety disorders are:Generalized anxiety disorderPanic disorderPhobias,Posttraumatic stress disorder (PTSD),Obsessive–compulsive disorder (OCD),ConclusionReference
6 IntroductionEveryone 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 AnxietyAnxiety 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.OrAnxiety 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 anxietyAnxiety is often accompanied by physical sensations such as:Sympathetic nervous system (fight)heart palpitationschest painshortness of breathheadache.Papillary dilation
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 FearAnxiety 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 AttackAn abrupt experience of intense fear or acute discomfort accompanied by physical symptoms that include:-Heart palpitationsChest painShortness of breathDizzinessDisorganized 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 phobiaUnexpected (uncued) panic attack"SPONTANEOUS", Without apparent stimulus.Situationally predisposed panic In betweenIncreased 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 DisordersAnxiety disorders are the most common of emotional disorders.Many forms and symptoms may include:Overwhelming feelings of panic and fearUncontrollable obsessive thoughtsPainful, intrusive memoriesRecurring nightmaresPhysical 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 sufferfrom 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-StressInherit vulnerabilities for anxiety and panicThere evidence that genetic contribution to panic and anxiety differ but in both situation genetic valinarabelity particularly in a person with stressStress and life circumstances
18 Biological Causes and Inherent Vulnerabilities Anxiety and brain circuits – GABA, noradrenergic and serotonergic systemsCorticotrophin Releasing Factor (CRF) and the HPA axisLimbic (amygdale) and the septal-hippo campal systemsBehavioral Inhibition System (BIS) and Fight/Flight Systems (FFS)
19 Psychological Contributions to Anxiety and Fear Psychological ViewsEarly experiences with uncontrollability / unpredictabilityBegan with FreudAnxiety is a psychic reaction to dangerAnxiety involves reactivation of an infantile fearful situationBehavioristic ViewsAnxiety and fear result from classical and operant conditioning and modelingSocial ContributionsStressful life events trigger vulnerabilitiesMany stressors are familial and interpersonal
20 An integrated Model Integrative View Biological vulnerability interacts with psychological, experiential, and social variables to produce an anxiety disorderGeneralized 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 DisorderPanic Disorder with and without AgoraphobiaSpecific PhobiasSocial PhobiaPosttraumatic Stress DisorderObsessive-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 offc. The anxiety & worry are associated with at least three or more of the following six symptoms.RestlessnessBeing easily fatiguedDifficult 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 tensionMuscle tension, twitching and shaking, restlessness,ApprehensionFeeling on edge, unable to cope, poor concentration, insomnia, irritabilityAutonomic over-activityLight headedness, sweating, tachycardia, dry mouth, epigastric discomfort
28 Facts and Statistics 4% of the general population meet criteria Females 2:1 over malesOnset often insidious, beginning early adulthoodTendency to be anxious runs in familiesAssociated FeaturesPersons with GAD are “autonomic restrictors”Fail to process emotional component of thoughts &Images.
29 Generalized Anxiety Disorder: The “Basic” Anxiety Disorder Excessive uncontrollable anxious apprehensionUnproductivelyworry about life eventsCoupled with strong, persistent anxietySomatic symptoms differ from panic (e.g., muscletension, 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 dependenceAntidepressantsPsychological TreatmentsCognitive Behavioral Treatments (CBT)
33 2. Panic disorderThe 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 attackDevelop anxiety, worry, or fear about having anotherattack or its implicationsAgoraphobia – Fear and avoidance of situations/eventsescape is difficult associated with panicSymptoms and concern about another attack persists for 1 month or more.
35 DSM IV diagnostic criteria for panic attack PalpitationAccelerated heart rateSweatingTrembling or shakingSensations of shortness of breathFeeling of chokingChest pain
36 DSM IV diagnostic criteria for panic attack cont. Nausea or abdominal distressFeeling dizzy, unsteady, lightheaded, or faintDerealization (feelings of unreality) or depersonalization (being detached from oneself)Fear of losing control or going crazyFear of dyingParesthesias (numbness or tingling sensations)Chills or hot flashes
37 Panic disorder - epidemiology Facts and StatisticsPanic disorder affects about 3.5% of the populationTwo thirds with panic disorder are femaleOnset is often acute, beginning between ages
38 Panic disorder - pharmacological treatment Assess and treat comorbid problemsSSRIs - paroxetine, citalopram - can initially worsen panic attacksBenzodiazepines - good short term relief but high risk of dependency - alprazolamTCAs - imipramine, clomipramineMAOIs - especially in mixed panic depressive states but use limited by ADRHigh rate of relapse on cessation of treatment
39 Panic disorder - psychological treatments Behavioural therapyexposure and response preventionrelaxation techniquesCognitive behaviour therapyEducationRecognition and change of negative thoughts
40 PhobiaA 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 situationMarkedly interferes with one's ability to functionRecognize fears are unreasonableStill go to great lengths to avoid phobic objects
43 Causes of Phobias Genetic vulnerability Evolutionary influences Direct conditioningObservational learningLearning historyInformation transmission
44 Specific Phobias: Associated Features and Treatment Associated Features and Subtypes of Specific PhobiaBlood-injury-injection phobia – Vasovagal responseSituational phobia – Public transportation or enclosed places (e.g., planes)Natural environment phobia – Events occurring in nature (e.g., heights, storms)Animal phobia – Animals and insectsOther 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 Statistics7-11% general population meet diagnostic criteria forspecific phobiaFemales are again over-representedPhobias run a chronic course, with onset beginningbetween 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 attackThe person recognized that the fear is excessive or unreasonable.
47 Specific Phobias: Treatment Psychological Treatments of Specific PhobiasCognitive-behavior therapies are highly effectiveStructured and consistent graduated exposure
48 Social Phobia: Overview and Defining Features Extreme and irrational fear/shynessFocused on social and/or performance situationsMarkedly interferes with one's ability to functionMay avoid social situations or endure them with distress
49 Generalized subtype?Anxiety across many social situations Facts and StatisticsAffects about 13% of the general population at some pointFemales are slightly more represented than malesOnset is usually during adolescencePeak age of onset at about 15 years
50 Social Phobia: Treatment Causes of PhobiasBiological and evolutionary vulnerabilityDirect conditioning, observational learning, information transmission
51 Medication Treatment of Social Phobia Beta blockers -- Are ineffectiveTricyclic antidepressants -- Reduce social anxietyMonoamine Oxidase inhibitors – Reduce reduce anxietySSRI Paxil – FDA approved for social anxiety disorderRelapse rates – High following medication discontinuation
52 Social Phobia: Treatment (cont.) Psychological Treatment of Social PhobiaCognitive-behavioral treatment – Exposure, rehearsal, role-play in a group settingCognitive-behavior therapies are highly effective
53 Agoraphobia Fear of open spaces, crowds or public places. Fear of travelling by public transportFear 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 35Risk factorsStressful life eventsFamily history – 20% relative with agoraphobiaDomestic instability – family or marital difficultiesHistory of childhood fears or enuresisOverprotective family membersDifferential diagnosisDepression, schizophrenia, dementia
55 Agoraphobia - symptoms Autonomic symptoms - faintness, palpitations, SOB, sweatingPanic attacks marker of severityPsychological symptoms - fear, dreadBehavioural symptoms - avoidance to the extent that the person becomes house boundCognitive symptoms - “ I might have died”
56 Agoraphobia - Management and Prognosis Behaviour therapy - graded exposure and systematic desensitisationCBTFamily therapySelf help booksPharmacotherapy - as for panic disorder
57 Situations Avoided by People with Agoraphobia Shopping mallsCars (driver or passenger)BusesTrainsSubwaysWide StreetsTunnelsRestaurantsTheatersSource: Barlow & Durand, 2002, p. 124
58 Cont. Being far from home Staying at home alone Waiting in line SupermarketsStoresCrowdsPlanesElevatorsEscalators
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 ridiculousFeared social situation associated with intense anxiety and distress - blushing, tremor,butterfliesLeads to avoidance of social situations that involve e.g., eating, public speaking - isolationDifferential diagnosisBody dysmorphic disorder, panic disorder, depression, paranoid psychosis
60 Posttraumatic Stress Disorder (PTSD): An Overview Overview and Defining FeaturesRequires exposure to a traumatic eventPerson experiences extreme fear, helplessness, or horrorContinue to re-experience the event (e.g., memories, nightmares, flashbacks)Avoidance of reminders of traumaEmotional numbingInterpersonal problems are commonMarkedly interferes with one's ability to functionPTSD diagnosis – Only 1 month or more post-trauma
61 Posttraumatic Stress Disorder (PTSD): An Overview (cont.) Facts and StatisticsAffects about 7.8% of the general populationMost Common TraumasSexual assaultAccidentsCombat
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 eventThe 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 followingEfforts to avoid thoughts, feelings or conversations associated with the traumaEfforts to avoid activities, places,Inability to recall an important aspect of the traumaFeeling of detachmentRestricted rang of affectSense 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 asleepIrritabilityHpervigilanceExaggerated startle responsee. Duration of the disturbance symptoms in b,c,d is more than one monthf. The disturbance causes clinically significant distress in social, occupational,Acute: if duration of symptoms is less than 3 monthChronic : if duration of symptoms is 3 months or more
66 Posttraumatic Stress Disorder (PTSD): Causes and Associated Features Subtypes and Associated Features of PTSDAcute PTSD – May be diagnosed 1-3 months post traumaChronic PTSD – Diagnosed after 3 months post traumaDelayed onset PTSD – Symptoms begin after 6 months or more post traumaAcute stress disorder – Diagnosis of PTSD immediately post-traumaCauses of PTSDIntensity of the trauma and one’s reaction to itUncontrollability and unpredictabilityExtent of social support, or lack thereof post-traumaDirect conditioning and observational learning
67 PTSD Comorbidity88% of men and 79% of women with PTSD meet diagnostic criteria for another psychological disorderDrug/alcohol abuse/dependenceMajor Depressive DisorderBorderline Personality DisorderPhobiasPanic DisorderSocial Misconduct
68 PTSD - outcome Symptoms fluctuate over time Most intense at times of stress30% complete recovery10 % do badlyPredictors 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 PTSDCognitive-behavioral treatment involves graduated or massed imaginal exposureIncrease positive coping skills and social supportCognitive-behavior therapies are highly effective
70 PTSD - Mx SSRIs, Serotinergic TCAS Behavioural treatment CBT cognitive –behaviour therapy.Family treatmentDebriefing - no clear evidence base
71 Obsessive-Compulsive Disorder (OCD): An Overview Overview and Defining FeaturesObsessionsIntrusive and nonsensical thoughts, images, or urges that one tries to resist or eliminateCompulsionsThoughts or actions to suppress thoughtsProvide reliefMost persons with OCD display multiple obsessionsMany with cleaning, washing, and/or checking rituals
72 OCD Most common obsessions Contamination Aggressive Impulses Sexual ContentSomatic ConcernsNeed for Symmetry
73 OCD Most common compulsions Checking Ordering Arranging Washing CleaningCountingHoarding
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 distress2. The thoughts, impulses, or images are not simply excessive worries about real-life problems3. 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 abruptOften delay of years in seeking txCourse chronic and fluctuatingOften 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 preventionParadoxical injunctionsCBT - less usefulPharmacotherapySSRIs, ClomipramineAugmentation with quetiapine or risperidoneClonazepam
79 Summary of Anxiety-Related Disorders Anxiety Disorders Are the Largest Domain of PsychopathologyFrom a Normal to a Disordered Experience of Anxiety and FearRequires consideration of biological, psychological, experiential, and social factorsFear & anxiety in the absence of real threat or dangerDevelop avoidance, restricted life functioningCause significant distress and impairment in functioningPsychological TreatmentsAre Generally Superior in the Long-TermTreatments include similar componentsSuggests that anxiety disorders share common processes
85 ReferenceSeligman, 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 ,pagesErnst 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):