1. Anxiety Disorders “The Dark side of Fear”

2. What is Anxiety? What is Anxiety? The unpleasant feeling of fear or apprehension we experience in response to some event or situation. The unpleasant feeling of fear or apprehension we experience in response to some event or situation. Duration & intensity of anxiety --more severe in people with anxiety disorders than in people without. Duration & intensity of anxiety --more severe in people with anxiety disorders than in people without.

3. Anxiety Disorders: Anxiety Disorders: Phobias Phobias panic disorder panic disorder generalized anxiety disorder generalized anxiety disorder obsessive-compulsive disorder obsessive-compulsive disorder posttraumatic stress disorder posttraumatic stress disorder acute stress disorder acute stress disorder

4. Comorbidity of other anxiety disorders is high!! 1.Symptoms of various anxiety disorders are not disorder specific. 1.Symptoms of various anxiety disorders are not disorder specific. 2.) Cause of one disorder may be cause of another disorder. 2.) Cause of one disorder may be cause of another disorder.

5. A. Phobias – an irrational fear out of proportion to the danger posed by the object or situation. Person knows fear is irrational, but avoids object or situation anyway. Person knows fear is irrational, but avoids object or situation anyway. Phobia may not be debilitating enough to warrant seeking treatment. Phobia may not be debilitating enough to warrant seeking treatment. (e.g., A fear of snakes in the city is less a problem than in the country) (e.g., A fear of snakes in the city is less a problem than in the country)

6. Two kinds of phobias: 1. Specific phobias - fears caused by the presence or anticipation of a specific object or situation. 1. Specific phobias - fears caused by the presence or anticipation of a specific object or situation. Blood Blood injuries & injections injuries & injections situations (planes, elevators) situations (planes, elevators) animals (dogs, spiders) animals (dogs, spiders) natural environment (heights, water, tornadoes) natural environment (heights, water, tornadoes) Lifetime prevalence: 7% (men) and 16% (women).

7. 2. Social phobias- Fear linked to the presence of other people Fear linked to the presence of other people Person avoids situation in which he or she could behavior in embarrassing way. Person avoids situation in which he or she could behavior in embarrassing way. Speaking or performing in public Speaking or performing in public eating in public eating in public Using public bathroom Using public bathroom Lifetime prevalence: 11% (men) & 15% (women) Lifetime prevalence: 11% (men) & 15% (women)

8. What causes phobias? Data show we learn phobias, they are not innate. Data show we learn phobias, they are not innate. We learn phobias by: We learn phobias by: 1. Classical & operant conditioning (avoidance learning) 1. Classical & operant conditioning (avoidance learning) 2. Modeling (observational learning) 2. Modeling (observational learning)

9. Modeling: We learn phobias by observing others’ fear to the object or event. We learn phobias by observing others’ fear to the object or event. Do we need to observe the person’s fear response to the stimulus & the stimulus itself? Do we need to observe the person’s fear response to the stimulus & the stimulus itself? Yes!!!! Yes!!!!

10. Mineka study: Had lab-reared monkeys view wild-reared monkeys responses to a snake. Had lab-reared monkeys view wild-reared monkeys responses to a snake. A barrier was in place to block the lab-reared monkeys from seeing the object of the wild-reared monkey’s fear. A barrier was in place to block the lab-reared monkeys from seeing the object of the wild-reared monkey’s fear. Later when shown the snake, the lab-reared monkey didn’t show fear to the snakes. Later when shown the snake, the lab-reared monkey didn’t show fear to the snakes. You need to see the other person’s response to the feared stimulus & the stimulus itself for phobia formation. You need to see the other person’s response to the feared stimulus & the stimulus itself for phobia formation.

11. Therapy for phobias: Systematic desensitization Systematic desensitization Flooding Flooding

12. B. Generalized Anxiety Disorder (GAD) Symptoms: Symptoms: persistent anxiety persistent anxiety chronic worry chronic worry focus on health/daily hassles focus on health/daily hassles difficulty concentrating; irritable difficulty concentrating; irritable tire easily; restless tire easily; restless Lifetime prevalence: 5% in population Lifetime prevalence: 5% in population Onset: midteens; comorbidity with other anxiety disorders & mood disorders. Onset: midteens; comorbidity with other anxiety disorders & mood disorders.

13. Causes of GAD: we develop GAD when confronted with painful stimuli over which we have no control. we develop GAD when confronted with painful stimuli over which we have no control. Perception of not being in control may be enough for anxiety. Perception of not being in control may be enough for anxiety. we develop GAD when we misperceive events to be out of our control & potentially threatening or harmful. we develop GAD when we misperceive events to be out of our control & potentially threatening or harmful.

14. Locus of control- we feel less anxiety when we can control our lives. Our “perception” of control may be more important than “actual” control to reducing unwanted anxieties in patients with GAD. Our “perception” of control may be more important than “actual” control to reducing unwanted anxieties in patients with GAD. *Unpredictable events produce more anxiety than predictable ones. *Unpredictable events produce more anxiety than predictable ones. Patients with GAD are easily drawn to stimuli associated with negative emotional content (traumas, physical harm, etc.)

15. Worry as a tool to control emotion!! Worry as a tool to control emotion!! Patients with GAD use worry to distract themselves from thinking about negative events. Patients with GAD use worry to distract themselves from thinking about negative events. Worrying keeps us from focusing on negative emotions. Worrying keeps us from focusing on negative emotions. Worrying is negatively reinforcing because it blocks us from processing emotional stimuli, & keeps the cycle of anxiety going. Worrying is negatively reinforcing because it blocks us from processing emotional stimuli, & keeps the cycle of anxiety going.

16. Biological Causes of GAD There may be a genetic component. There may be a genetic component. We may have a defect in the GABA system so that fear is not brought under control. We may have a defect in the GABA system so that fear is not brought under control. Benzodiazipines, which enhance the inhibitory neurotransmitter, GABA, reduce anxiety. Benzodiazipines, which enhance the inhibitory neurotransmitter, GABA, reduce anxiety.

17. Therapies for GAD 1. Transfer global anxiety into a phobia & treat phobia. 1. Transfer global anxiety into a phobia & treat phobia. *Systematic desensitization may be used if anxiety can be linked to an identifiable source. *Systematic desensitization may be used if anxiety can be linked to an identifiable source. 2. Relaxation training 2. Relaxation training Have patients focus on relaxing during low-level anxiety. Have patients focus on relaxing during low-level anxiety.

18. Treat worry!!! Here, therapists require that patients extend & exaggerate their anxieties. Here, therapists require that patients extend & exaggerate their anxieties. Because patient remains in a fearful situation, anxiety is believed to extinguish. Because patient remains in a fearful situation, anxiety is believed to extinguish. Patient learns his or her cognitions are illogical and unfounded. Patient learns his or her cognitions are illogical and unfounded.

19. C. Panic Disorder – characterized by attacks. Increased HR Increased HR heart palpitations heart palpitations nausea nausea chest pain chest pain trembling; sweating, terror trembling; sweating, terror Usually physiological symptoms occur without link to cause (with exceptions) Usually physiological symptoms occur without link to cause (with exceptions) Lifetime prevalence: 2 % (men) & 5 % (women).

20. DSM-IV diagnosis: Recurrent uncued attacks & worry about having attacks in the future are required. Recurrent uncued attacks & worry about having attacks in the future are required. Is diagnosed as panic disorder with or without agoraphobia. Is diagnosed as panic disorder with or without agoraphobia. Comorbidity between panic disorder & Comorbidity between panic disorder & major depression, GAD, phobias, alcoholism, & personality disorders is high.

21. What causes panic disorder? 1.There may be symptoms of an illness that leads to panic attacks. (e.g., mitral valve prolapse causes heart palpitations, dizziness, etc.) (e.g., mitral valve prolapse causes heart palpitations, dizziness, etc.) 2. Panic may be caused by overactivity in a nucleus in the pons called the locus ceruleus (LC). 2. Panic may be caused by overactivity in a nucleus in the pons called the locus ceruleus (LC). In humans, a drug called Yohimbine, a drug that stimulates the LC, can elicit panic attacks in patients with panic disorder. In humans, a drug called Yohimbine, a drug that stimulates the LC, can elicit panic attacks in patients with panic disorder.

22. Causes (panic): However blocking activation in the LC has not been found to reduce panic attacks. However blocking activation in the LC has not been found to reduce panic attacks. 3.Creating panic attacks experimentally: 3.Creating panic attacks experimentally: Using hyperventilation to induce panic attacks has produced mixed results. Using hyperventilation to induce panic attacks has produced mixed results.

23. Psychological theories: Patients with panic disorder may have an autonomic nervous system that is predisposed to be overly active. People misconstrue internal bodily changes as signals they may be in jeopardy or dying. People misconstrue internal bodily changes as signals they may be in jeopardy or dying. With repeated exposures to attacks, patients worry about future attacks thereby making them more likely to occur. With repeated exposures to attacks, patients worry about future attacks thereby making them more likely to occur.

24. Therapies for Panic disorder and agoraphobia Therapies for Panic disorder and agoraphobia Biological: Biological: 1. Antidepressants & anxiolytics can reduce frequency of attacks. Psychological: Barlow’s therapy (well validated): 3 components: 1. Relaxation training- 2. A combination of Ellis & Beck type cognitive behavioral interventions 3. Exposure to the internal cues that trigger panic

25. D. Obsessive-Compulsive Disorder (OCD): persistent unwanted thoughts & compulsive behaviors that impair normal functioning. persistent unwanted thoughts & compulsive behaviors that impair normal functioning. Lifetime prevalence: 1-2 % of general pop. Lifetime prevalence: 1-2 % of general pop. More common in women than men More common in women than men Age of onset: early adulthood Age of onset: early adulthood Males: checking rituals most common Males: checking rituals most common Females: cleaning rituals most common Females: cleaning rituals most common

26. Components of OCD: 1. Obsessions-intrusive & recurring thoughts & images that appear irrational & uncontrollable to the individual experiencing them. 1. Obsessions-intrusive & recurring thoughts & images that appear irrational & uncontrollable to the individual experiencing them. Frequency & force of thoughts always interfere with functioning. Frequency & force of thoughts always interfere with functioning.  Fears of contamination  Fears of contamination  Fears of expressing sexual or aggressive impulses  Fears of expressing sexual or aggressive impulses  hypochondria  hypochondria 2. Compulsions- repetitive behaviors performed over & over to reduce distress associated with the unwanted thoughts. 2. Compulsions- repetitive behaviors performed over & over to reduce distress associated with the unwanted thoughts.

27. Causes of OCD 1. Behavioral & cognitive theories 1. Behavioral & cognitive theories Compulsions are learned behaviors reinforced by fear reduction (negative reinforcement). Compulsions are learned behaviors reinforced by fear reduction (negative reinforcement). E.g., frequency of hand washing increases to reduce or eliminate the aversive fear of dirt. E.g., frequency of hand washing increases to reduce or eliminate the aversive fear of dirt. Compulsive checking may be the result of memory deficit. Compulsive checking may be the result of memory deficit.

28. Therapies for OCD Exposure and response prevention (ERP) Exposure and response prevention (ERP) Victory Meyer (1966) 1.Patients with OCD expose (flooding) themselves to situations that elicit compulsions. E.g., touching a dirty dish E.g., touching a dirty dish 2. Person is instructed to refrain from performing compulsions (extinguish anxiety & compulsions). 2. Person is instructed to refrain from performing compulsions (extinguish anxiety & compulsions). Treatment is partially effective in half of OCD patients. Treatment is partially effective in half of OCD patients.

29. E. Posttraumatic Stress disorder (PTSD) A traumatic event or witness to an event in which there is perceived or actual threat of death, serious injury, or other personal harm. A traumatic event or witness to an event in which there is perceived or actual threat of death, serious injury, or other personal harm. The event must have created intense fear, horror, or a sense of helplessness. The event must have created intense fear, horror, or a sense of helplessness. (May 3 rd, 1999-OK) Symptoms of PTSD fall into 3 major categories. Symptoms in each must occur longer than 1 month.

30. What happens? 1. Reexperiencing the traumatic event 1. Reexperiencing the traumatic event Person frequently recalls the event (has nightmares about the event). Person frequently recalls the event (has nightmares about the event). 2. Avoidance of stimuli associated with the event or numbing of responsiveness 2. Avoidance of stimuli associated with the event or numbing of responsiveness Person tries to avoid thinking about the trauma or encountering stimuli that will bring it to mind. Person tries to avoid thinking about the trauma or encountering stimuli that will bring it to mind. 3. Symptoms of increased arousal 3. Symptoms of increased arousal difficulty concentrating (sleeping), hypervigilance

31. PTSD: General Stats General prevalence: 1-3 % in the general pop. General prevalence: 1-3 % in the general pop. 3% for civilians exposed to a physical attack 3% for civilians exposed to a physical attack 20 % among people wounded in Vietnam 20 % among people wounded in Vietnam 50 % of all rape victims 50 % of all rape victims Women twice as likely to develop PTSD as men. Women twice as likely to develop PTSD as men.

32. F. Acute Stress Disorder an individual encounters a traumatic experience that causes problems with social or occupational functioning for less than 1 month. an individual encounters a traumatic experience that causes problems with social or occupational functioning for less than 1 month.