Anxiety Disorders and Medications

1. Anxiety Disorders and Medications

2. Anxiety and Fear • Anxiety • Future-oriented mood state • Characterized by marked negative affect • Somatic symptoms of tension • Apprehension about future danger or misfortune • Fear • Present-oriented mood state, marked negative affect • Immediate fight or flight response to danger or threat • Strong avoidance/escapist tendencies • Abrupt activation of the sympathetic • nervous system

3. Anxiety Disorders • Anxiety and fear are normal emotional states; however, anxiety may start to cause distress and hinder normal functioning. • Are among most diagnosed disorders found in DSM. • Represent a broad heterogeneous group of problems. For example, Specific Phobia can be conditioned …Social Phobia appears to have strong genetic component…PTSD can be brought on by single event.

4. Anxiety Symptoms • Anxiety symptoms equated w/ “neurosis”-phobias, indecision, panic, gastric problems. • In past, anxiety disorders were not viewed as serious disorders…viewed as normal and protective. Example- if I am taking a test a little anxiety is helpful (Conversely, depression is rarely seen as benign0.

5. Yerkes-Dodson Law (1908) • Describes a relationship between anxiety and performance. • As person becomes a bit more tense and alert- performance of skilled tasks improves. • Then it plateaus • Beyond this, it interferes w/ performance.

6. Current Thought • However, current conceptualization is to see them as more serious and chronic. • One problem is comorbidity • About half of anxiety patients have > 2 or more secondary diagnoses • Major depression is the most common secondary diagnosis • Comorbidity suggests common factors across anxiety disorders • Anxiety and depression are closely related

7. Anxiety Disorders • Generalized Anxiety Disorder • Panic Disorder with and without Agoraphobia • Specific Phobias • Social Phobia • Posttraumatic Stress Disorder • Obsessive-Compulsive Disorder

8. Anxiety/Cognition/Personality Andrews et al (1994)- see adversity as the trigger stimulus to arousal leading to symptoms. Arousal dependent on 2 factors: 1) appraisal (perception of degree of threat) 2) the extent to which the individual responds w/ high arousal (how reactive is nervous system?) Item 2 suggests a “personality” characteristic

9. Trait Anxiety • Psychologists like Hans Eysenck,and Charles Spielberger (State-Trait Anxiety Inventory) see proneness to anxiety as a stable personality trait that could influence behavior. • STAI determines anxiety in a specific situation and as a general trait.

10. Trait Anxiety and Appraisal • Trait Anxiety implies differences between people in the disposition to respond to stressful situations with varying amounts of State Anxiety. • Whether or not people who differ in T-Anxiety will show corresponding differences in S-Anxiety depends on the extent to which each of them perceives a specific situation as psychologically dangerous or threatening,

11. Fight or Flight • Hard-wired nerve pathway system for adaptive dealing w/potential danger. • When triggered initiates a multilevel neurochemical and hormonal reaction. • Nonessential physiological processes (e.g., digestion) shut down. • Stressful event perceived at cortical level (or hijacked by Amygdala)

12. Fight or Flight • Lower brain put on alert- “limbic alert.” • Locus coeruleus has role here since LC nerve cells project in to limbic system and a burst of cell excitation leads to limbic activation. • Limbic system and hypothalamus impact Pituitary and other endocrine glands and sympathetic nervous system. • Body now prepared to deal w/ stressor

13. Anxiety Medications • First Benzodiazepine- Librium 1957 • Used as sedative (anxiety) and hypnotic (insomnia) • Benzos were much better at reducing anxiety than previous meds- barbiturates such as Miltown and Doriden amongst others • More importantly less lethality in overdose

14. Benzos for Anxiety • For anxiety: Valium Librium Ativan Tranxene Xanax

15. Benzos for Insomnia • Restoril • Dalmane • Ambien • Halcion

16. Half-Life • One of the main differences between different benzodiazepines is the half-life • Amount of time serum level reduced by half • Those with longer half-life tend to build up quicker • This becomes important if liver is deceased

17. Types of Anti-anxiety Drugs • Benzodiazepines • Atypical Benzos • Buspirone • Anthitamines • Beta Blockers • Clonidine • Gabitril

18. Benzos • Interact w/ benzo receptors • Several types of benzo receptors • Current meds are not selective as to type • Heavy concentration of benzo receptors in limbic system • Binding of a benzo at BZ receptor enhances the effect of GABA neurotransmitter

19. GABA & Chloride Ions • Chloride ion channels appear on the surface of many nerve cells. • They carry a slight negative charge. • These ion channels can be activated (opened) • They are opened when stimulated by GABA. • Negative ions are drawn in to the cell

20. GABA & Chloride Ions • Cells electrical characteristics are altered resulting in decreased excitability. • This works as a braking system dampening “limbic alert” • Calms overall brain excitation…calming effect…reduce anxiety

21. 0 The Anxiety Disorders: An Overview • Generalized Anxiety Disorder • Panic Disorder with and without Agoraphobia • Specific Phobias • Social Phobia • Posttraumatic Stress Disorder • Obsessive-Compulsive Disorder

22. 0 Generalized Anxiety Disorder:The “Basic” Anxiety Disorder • Overview and Defining Features • Excessive uncontrollable anxious apprehension and worry • Coupled with strong, persistent anxiety • Somatic symptoms differ from panic (e.g., muscle tension, fatigue, irritability) • Persists for 6 months or more • Facts and Statistics • GAD affects 4% of the general population • Females outnumber males approximately 2:1 • Onset is often insidious, beginning in early adulthood • Tendency to be anxious runs in families

23. 0 Generalized Anxiety Disorder:Associated Features and Treatment • Associated Features • Persons with GAD -- Called “autonomic restrictors” • Fail to process emotional component -- thoughts / images • Treatment of GAD • Benzodiazapines – Often prescribed • Psychological interventions – Cognitive-Behavioral Therapy

24. 0 Panic Disorder with and without Agoraphobia • Overview and Defining Features • Experience of unexpected panic attack – A false alarm • Anxiety, worry, or fear about having another attack • Agoraphobia – Fear or avoidance of situations/events • Symptoms and concern persists for 1 month or more • 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 25 -29

25. 0 Panic Disorder: Associated Features and Treatment • Associated Features • Nocturnal panic attacks – 60% panic during non-REM sleep • Interoceptive/exteroceptive avoidance, catastrophic misinterpretation of symptoms • Medication Treatment of Panic Disorder • Target serotonergic, noradrenergic, and benzodiazepine GABA systems • SSRIs (e.g., Prozac and Paxil) – Preferred drugs • Relapse rates are high following medication discontinuation • Psychological and Combined Treatments of Panic Disorder • Cognitive-behavior therapies are highly effective • No long-term advantage for combined treatments • Best long-term outcome – Cognitive-behavior therapy alone

26. 0 Specific Phobias: An Overview • 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 • Facts and Statistics • Affects about 11% of the general population • Females are again over-represented • Phobias run a chronic course • Onset beginning between 15 and 20 years of age

27. 0 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

28. 0 Specific Phobias: AssociatedFeatures and Treatment (cont.) • Causes of Phobias • Biological and evolutionary vulnerability, direct conditioning, observational learning, information transmission • Psychological Treatments of Specific Phobias • Cognitive-behavior therapies are highly effective • Structured and consistent graduated exposure

29. 0 Social Phobia: An Overview • 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 • 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

30. 0 Social Phobia: Associated Features and Treatment • Causes of Phobias • Biological and evolutionary vulnerability • Direct conditioning, observational learning, information transmission • Medication Treatment of Social Phobia • Beta blockers – Not that useful • 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

31. 0 Social Phobia: Associated Features and Treatment (cont.) • Psychological Treatment of Social Phobia • Cognitive-behavioral treatment – Exposure, rehearsal, role-play in a group setting • Cognitive-behavior therapies are highly effective

32. 0 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

33. 0 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

34. 0 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

35. 0 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

36. 0 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

37. 0 Obsessive-Compulsive Disorder (OCD):Causes and Associated Features • Facts and Statistics • Affects about 2.6% of the population at some point • Most persons with OCD are female • OCD tends to be chronic • Onset is typically in early adolescence or adulthood • Causes of OCD • Parallel the other anxiety disorders • Early life experiences and learning that some thoughts are dangerous/unacceptable • Thought-action fusion – The thought is like the action

38. 0 Obsessive-Compulsive Disorder (OCD): Treatment • Medication Treatment of OCD • Clomipramine and other SSRIs – Benefit about 60% • Psychosurgery (cingulotomy) – Used in extreme cases • Relapse is common with medication discontinuation • Psychological Treatment of OCD • Cognitive-behavioral therapy – Most effective for OCD • CBT involves exposure and response prevention • Combined treatments – Not better than CBT alone