Chapter 4 Anxiety Disorders Chapter 4 Anxiety Disorders

Nature of Anxiety and Fear 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

Nature of Anxiety and Fear 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

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

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

The Phenomenology of Panic Attacks (continued) DSM-IV-TR Subtypes of Panic Attacks Situationally bound (cued) Unexpected (uncued) Situationally predisposed

Figure 4.1 The relationships among anxiety, fear, and panic attack Fig. 4.1, p. 126

Biological Contributions to Anxiety and Panic Genetic Vulnerability Anxiety and brain circuits Depleted levels of GABA Corticotropin releasing factor (CRF) and HYPAC axis

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

Psychological Contributions to Anxiety and Fear Began with Freud Anxiety is a psychic reaction to fear Anxiety involves reactivation of an infantile fear situation

Psychological Contributions to Anxiety and Fear (continued) Behavioral and Cognitive Views Invokes conditioning and cognitive explanations Anxiety and fear are learned responses Catastrophic thinking and appraisals play a role

Psychological Contributions to Anxiety and Fear (continued) Early Childhood Contributions Experiences with uncontrollability and unpredictability Social Contributions Stressful life events trigger vulnerabilities

An Integrated Model Integrative View – Triple Vulnerability Model Generalized biological vulnerability Generalized psychological vulnerability Specific psychological vulnerability

An Integrated Model (continued) Common Processes: The Problem of Comorbidity Comorbidity is common across the anxiety disorders Major depression is the most common secondary diagnoses

An Integrated Model (continued) About half of patients have two or more secondary diagnoses Comorbidity Suggests Common factors A relation between anxiety and depression

The Anxiety Disorders: An Overview Generalized Anxiety Disorder Panic Disorder with and without Agoraphobia Specific Phobias Social Phobia Posttraumatic Stress Disorder Obsessive-Compulsive Disorder

“Do you worry excessively about minor things?” Figure 4.3 Clients’ answers to interviewer’s question, “Do you worry excessively about minor things?” (From “A Description of Patients Diagnosed with DSM-III-R Generalized Anxiety Disorder,” by W.C. Sanderson and D.H. Barlow, 1990, Journal of Nervous and Mental Disease, 178, p.590. Copyright© 1990 by Lippincott, Williams & Wilkins) Fig. 4.3, p. 132

Generalized Anxiety Disorder: The “Basic” Anxiety Disorder Overview and Defining Features Excessive uncontrollable anxious apprehension and worry Coupled with strong, persistent anxiety Persists for 6 months or more Somatic symptoms differ from panic (e.g., muscle tension)

Generalized Anxiety Disorder: The “Basic” Anxiety Disorder (continued) Statistics Affects about 4% 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

Generalized Anxiety Disorder: Associated Features and Treatment Persons with GAD have been called “autonomic restrictors” Fail to process emotional component of thoughts and images Treatment of GAD: Generally Weak Benzodiazapines – Often Prescribed Psychological interventions – Cognitive- Behavioral Therapy Combined treatments – Acute vs. Long- Term Outcomes

Figure 5.4 An integrative model of generalized anxiety disorder Fig. 4.4, p. 134

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

Panic Disorder With and Without Agoraphobia (continued) Facts and Statistics Affects about 3.5% of the general population Onset is often acute, beginning between 25 and 29 years of age 75% of individuals with agoraphobia are female

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

Panic Disorder: Associated Features and Treatment (continued) Psychological and Combined Treatments Cognitive-behavior therapies are highly effective No evidence that combined treatment produces better outcome Best long-term outcome is with cognitive- behavior therapy alone

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

Specific Phobias: An Overview (continued) Facts and Statistics Females are again over-represented Affects about 11% of the general population Phobias tend to run a chronic course

Specific Phobias: Associated Features and Treatment Associated Features and 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

Specific Phobias: Associated Features and Treatment (continued) Causes of Phobias Biological and evolutionary vulnerability Three pathways -- Conditioning, observational learning, information Psychological Treatments of Specific Phobias Cognitive-behavior therapies are highly effective – Exposure

Figure 4.8 A model of the various ways a specific phobia may develop (From Barlow, 2002) Fig. 4.8, p. 150

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

Social Phobia: An Overview (continued) Facts and Statistics Affects about 13% of the general population Prevalence is slightly greater in females than males Onset is usually during adolescence Peak age of onset at about 15 years

Social Phobia: Associated Features and Treatment Causes Biological and evolutionary vulnerability Similar learning pathways as specific phobias Psychological Treatment Cognitive-behavioral treatment Cognitive-behavior therapies are highly effective

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

Posttraumatic Stress Disorder (PTSD): An Overview Overview and Defining Features Main etiologic characteristics – Trauma exposure and response Reexperiencing (e.g., memories, nightmares, flashbacks) Avoidance

Posttraumatic Stress Disorder (PTSD): An Overview (continued) Emotional numbing and interpersonal problems Markedly interferes with one's ability to function PTSD diagnosis – Only after 1 month post- trauma

Posttraumatic Stress Disorder (PTSD): An Overview (continued) Statistics Combat and sexual assault are the most common traumas About 7.8% of the general population meet criteria for PTSD

Posttraumatic Stress Disorder (PTSD): Causes and Associated Features Subtypes and Associated Features of PTSD Acute – May be diagnosed 1-3 months post trauma Chronic – Diagnosed after 3 months post trauma Delayed onset – Onset 6 months or more post trauma Acute stress disorder – PTSD immediately post-trauma

Posttraumatic Stress Disorder (PTSD): Causes and Associated Features (continued) 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

Posttraumatic Stress Disorder (PTSD): Treatment Psychological Treatments Cognitive-behavior therapies (CBT) are highly effective CBT may include graduated or massed (e.g., flooding) imaginal exposure Aim of CBT for PTSD

Obsessive-Compulsive Disorder (OCD): An Overview Overview and Defining Features Obsessions - Intrusive and nonsensical thoughts, images, or urges Compulsions - Thoughts or actions to neutralize thoughts Vicious cycle of obsessions and compulsions Cleaning and washing or checking rituals are common

Obsessive-Compulsive Disorder (OCD): Causes and Associated Features Statistics Affects about 2.6% of the general population Most with OCD are female Onset is typically in early adolescence or young adulthood OCD tends to be chronic

Obsessive-Compulsive Disorder (OCD): Causes and Associated Features (continued) 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

Obsessive-Compulsive Disorder (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

Obsessive-Compulsive Disorder (OCD): Treatment (continued) Psychological Treatment Cognitive-behavioral therapy is most effective CBT involves exposure and response prevention Combining CBT with medication -- No better than CBT alone

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

Summary of the Anxiety Disorders (continued) Psychological Treatments are Generally Superior in the Long-Term Similar treatments for different anxiety disorders Suggests that anxiety-related disorders share common processes