Anxiety Disorders

1. Anxiety Disorders Dr. Kayj Nash Okine

2. What is Anxiety? • Physiological – bodily rxns, such as rapid heartbeat, muscle tension, queasiness, dry mouth, or sweating • Behavioral – may sabotage your ability to act, express yourself, or deal with situations effectively • Psychological – subjective state of apprehension, uneasiness, fearfulness

3. Normal “Everyday” Anxiety vs. Clinical Anxiety Clinical Anxiety: • Is more intense • Lasts longer • Interferes with your life • Is out of proportion to the situation • May not be directed to any concrete situation or event

4. The Anxiety Disorders • Panic Disorder • Agoraphobia • Specific Phobia • Social Phobia • Generalized Anxiety Disorder • Obsessive Compulsive Disorder • Posttraumatic Stress Disorder/Acute Stress Disorder • Anxiety Disorder Due to a General Medical Condition • Substance-Induced Anxiety Disorder • Anxiety Disorder Not Otherwise Specified

5. Sudden episodes of acute apprehension or intense fear that occur out of the blue and are accompanied by at least 4 of the following: Heart palpitations Numbness, tingling sensation Trembling, shaking Chills, hot flashes Sweating Shortness of breath, smothering sensation Choking sensation Chest pain or discomfort Nausea, upset stomach Feeling dizzy, faint, lightheaded, unsteady Feeling detached, out of touch with self Fear of losing control, going crazy, Fear of having a heart attack or dying Sx typically develop abruptly & reach a peak rapidly within 10 mins Panic Attacks

6. 3 Types of Panic Attacks • Unexpected panic attacks (uncued): absence of situational triggers; most associated with panic disorder • Situationally-bound panic attacks (cued): presence of “invariable” triggers; most associated with social phobia & specific phobias • Situationally-predisposed panic attacks: presence of triggers; most associated with GAD & PTSD

7. Panic Disorder: Diagnostic Criteria • Presence of recurrent, unexpected panic attacks (at least 2) • At least 1 panic attack is followed by a month or more of: • Apprehension about having another panic attack • Worry about the possible implications of an attack, such as losing control, “going crazy,” having a heart attack, or dying • A significant behavioral change related to the attacks • Possible medical causes or the effects of substances have been ruled out • Specify absence or presence of agoraphobia

8. Agoraphobia: Diagnostic Criteria • Anxiety about being in places or situations where: • Escape may be difficult or embarrassing • Help may not be available • These situations: • Are avoided • Are endured with marked distress or anxiety • Require the presence of a companion (a “safe person” • The anxiety and phobic avoidance is not better accounted for by another psychological disorder

9. Agoraphobia: Common Feared Situations • Being outside the home • Being home alone • Crowded public places – restaurants, theaters, malls, stores, supermarkets • Enclosed or confined spaces – escalators, tunnels, elevators • Public transportation – buses, trains, subways, planes • Open spaces • Driving or riding in cars

10. Agoraphobia & Panic Disorder • Panic Disorder with Agoraphobia: agoraphobia is due to the fear of experiencing a full panic attack • Agoraphobia without a history of Panic Disorder: fear of being incapacitated or humiliated due to unpredictable, sudden panic sx, such as dizziness or diarrhea

11. Panic Disorder & Agoraphobia: Causes • Heredity • Overly-sensitized & reactive “fear system” • includes the amygdala, hippocampus, locus ceruleus, hypothalamus, periacqueductal gray region, & parabrachial nucleus • results from the fear system’s being activated too frequently &/or intensely due to acute stress or the long-term result of multiple stressors over time • Chemical imbalances in the brain: deficiencies in serotonin & norepinephrine • Classical/associative conditioning

12. Panic Disorder & Agoraphobia: Causes • Growing up with parents who: are overly critical & perfectionistic; are overprotective; are overly anxious; communicate that the world is a dangerous place • Tendency to interpret normal physical sensations in a catastrophic way • Personal stress level • Sudden losses • Major life changes • Exposure to stimulants or withdrawal from narcotics, barbiturates, & tranquilizers

13. Panic Disorder & Agoraphobia: Facts & Figures • Onset: late adolescence or 20’s • Prevalence: 1-3.5% of the population; 5% of the population has panic attacks with agoraphobia • Gender Differences: 2-3x as common in women as men; approximately 75-80% of agoraphobics are women

14. Panic Disorder & Agoraphobia: Current Treatments • Relaxation Training – deep breathing, muscle relaxation • Panic Control Therapy (interoceptive desensitization) – repeatedly exposing oneself to the unpleasant physical sx of panic via induction techniques until the sx are no longer frightening • Graded Exposure – avoided situations are gradually confronted through a process of small, incremental steps • Medication – SSRI’s, tricyclics antidepressants, benzodiazepines

15. Panic Disorder & Agoraphobia: Current Treatments • Cognitive Therapy: identifying & modifying catastrophic thoughts that tend to trigger panic attacks • Assertiveness Training • Group Therapy • Lifestyle & Personality Changes – stress mgt, regular exercise, eliminating stimulants & sugar, creating downtime, slowing down, altering attitudes about perfectionism, needing to please, and needing to control

16. Specific Phobia: Diagnostic Criteria • Strong, persistent fear of specific objects or situations • Exposure to feared object or situation provokes an immediate anxiety response • Recognition that fear is excessive or unreasonable (except for children) • The person avoids the feared object or situation or endures it with dread • The avoidance, fear, or anxious anticipation interferes significantly with the person’s functioning or causes significant distress • Duration of at least 6 months

17. Specific Phobia: Specifiers • Animal Type – snakes, insects, rats • Natural Environment Type – storms, heights, water • Blood-Injection-Injury Type – blood, injury, injection, medical procedures • Situational Type – public transportation, tunnels, bridges, elevators, flying, driving, enclosed spaces • Other Type – choking, vomiting, contracting an illness, loud sounds

18. Specific Phobia: Facts & Figures • Prevalence: Affects 10-11% of population • Gender Differences: 4x more common for women • Only a minority seek treatment • Course: decline with old age

19. Specific Phobia: Causes • Childhood fears that were never outgrown • Vicarious learning – modeling, being warned about a potential danger • Experiencing a traumatic event • Experiencing a false alarm in a specific situation • Classical conditioning – conditioning by association • Conditioning by avoidance

20. Specific Phobia: Current Treatments • Relaxation training • Cognitive therapy • Systematic desensitization via imagery &/or real life exposure

21. Social Phobia: Diagnostic Criteria • Intense, persistent fear of being embarrassed, humiliated, or negatively evaluated in social or performance situations • Exposure to the feared social or performance situation typically provokes an immediate anxiety response • Recognition that the fear is excessive or unreasonable (except for children) • The social or performance situation is avoided or endured with considerable anxiety or distress • The avoidance, fear, or anxious anticipation interferes significantly with the person’s functioning or causes the person considerable distress • Symptoms must have persisted for at least 6 months • Specifier: Generalized – fear in a wide range of social situations

22. Social Phobia: Common Fears • Public speaking • Blushing • Choking on or spilling food while eating in public • Being watched • Using public restrooms • Writing or signing documents in the presence of others • Crowds • Taking exams • Performing

23. Social Phobia:Facts & Figures • Prevalence: affects 2-13% of the US population • Gender Differences: roughly equivalent rates for men and women • Onset: late childhood or adolescence

24. Social Phobia:Causal & Associated Features • Hypersensitivity to criticism, negative evaluation, or rejection • Difficulty being assertive • Low self esteem, feelings of inferiority • Poor social skills • Lack of social support • Childhood history of social inhibition, shyness, or stressful or humiliating social experiences • Parents are more socially fearful and concerned with the opinions of others

25. Social Phobia:Current Treatments • Relaxation training • Cognitive therapy • Imaginal & real life exposure • Group therapy – ideal treatment format • Medication – beta-blockers, tricyclic antidepressants, MAO inhibitors, SSRI’s • Social skills training • Assertiveness training

26. Generalized Anxiety Disorder: Diagnostic Criteria • Chronic anxiety & worry persist for at least 6 months & focuses on 2+ stressful life circumstances • The anxiety and worry are difficult to control and are out of proportion to the actual likelihood of feared events happening • The anxiety and worry are associated with 3+ of the following sx, which occur a majority of days during a 6-month period (only 1 item is required in children): • Restlessness, feeling keyed up or on edge • Easily fatigued • Difficulty concentrating • Irritability • Muscle tension • Difficulties with sleep

27. GAD: Diagnostic Criteria • The focus of the anxiety & worry is not confined to the features of another Axis I disorder, e.g. such as anxiety about gaining weight in anorexia nervosa • The anxiety, worry, or physical sx cause significant distress or impairment in functioning

28. GAD: Facts & Figures • Affects approximately 4% of the American Population • More common in females than males (55-67%) • Onset: earlier and more gradual onset than most other anxiety disorders • Course: chronic

29. GAD: Causes • Heredity • A disturbance in the functioning of the benzodiazepine/GABA system of the brain, which is associated with the body’s natural calming response • Predisposing childhood experiences – e.g. excessive parental expectations, parental abandonment or rejection • Maladaptive attitudes – perfectionism, excessive need to please others, excessive need to control, over-sensitivity to threat • “Basic fears” that Sustain GAD: fear of losing control, fear of not being able to cope, fear of rejection or abandonment, fear of death or disease

30. GAD: Current Treatments • Relaxation Training • Cognitive Therapy – fearful self talk underlying worry themes are identified, challenged, & replaced with more realistic, optimistic thinking • Problem Solving – focus on solutions rather than worrying, learn to accept what you can’t change • Distraction Techniques • Medication – benzodiazepines, tricyclics, SSRI’s, SNRI’s • Lifestyle & Personality Changes – stress management, increased downtime, regular exercise, eliminating sweets & stimulants from diet, resolving interpersonal conflicts

31. Obsessive Compulsive Disorder: Diagnostic Criteria Obsessions: • Recurring, intrusive, senseless ideas, thoughts or images that can’t seem to be suppressed • Not merely excessive worries about real-life problems; in fact, are usually unrelated to real-life problems • Person recognizes that these thoughts, fears, images are irrational • Most common: aggressive impulses, fear of contamination, sexual thoughts, somatic concerns, the need for symmetry and exactness • 25% of people only have obsessions

32. OCD: Diagnostic Criteria Compulsions: • Behaviors or rituals the person feels compelled to perform in order to dispel the anxiety brought up by obsessions • E.g. washing hands numerous times to dispel fear of being contaminated, checking windows and doors over and over again to make sure they’re locked • Most common: washing, checking, counting, ordering and arranging • Person recognizes that the rituals are unreasonable • Conflict between desire to be free of the compulsive ritual and the irresistible desire to perform it  anxiety, shame, despair

33. OCD: Facts & Figures • Prevalence: 2-3% of general population • Gender Differences: • Affect men & women in equal numbers • Men outnumber women as checkers • Women outnumber men as washers and cleaners • Age of onset is earlier in men than women • Onset: half of cases begin in childhood; half begin in adolescence or young adulthood • Often accompanied by, and may wax & wane with, depression

34. OCD: Causes • Deficiency in serotonin • Associated with excessive activity in certain parts of the brain (orbitofrontal cortex, the cingulated gyrus, & the caudate nuclei) • The tendency to develop anxiety over having additional obsessive thoughts • Being taught that certain thoughts are dangerous and unacceptable and must be suppressed • Thought-action fusion: equating thoughts with their corresponding actions • Attitudes of excessive responsibility and perfectionism • Compulsions develop to suppress or neutralize obsessions

35. OCD: Current Treatments • Relaxation Training • Cognitive Therapy – fearful, superstitious, or guilty thoughts associated with the obsessions are identified, challenged, and replaced • Exposure & Response Prevention • Medication – SSRI’s, clomipramine • Life Style & Personality Changes • Psychosurgery – surgical lesion to the cingulate bundle (cingulotomy)

36. Posttraumatic Stress Disorder: Diagnostic Criteria EXPOSURE TO A TRAUMATIC EVENT • The person has been exposed to a traumatic event which • involved threats to personal integrity, serious injury, or death. • produced intense fear, helplessness, or horror • for children: produced disorganized or agitated behavior • e.g. earthquakes, tornadoes, auto accidents, combat, rape, physical assault, violent crime

37. PTSD: Diagnostic Criteria RE-EXPERIENCING • The traumatic event is persistently re-experienced in 1+ of the following ways: • Repetitive, distressing thoughts or images about the event • Nightmares related to the event • Intense flashbacks • Intense psychological distress &/or physiological reactivity to stimuli associated with the trauma • For children: frightening dreams without recognizable content, repetitive play relating to the trauma, trauma reenactment

38. PTSD: Diagnostic Criteria AVOIDANCE • Persistent avoidance of stimuli associated with the trauma: • efforts to avoid thoughts, feelings, or conversations associated with the trauma • efforts to avoid activities, places, or people that arouse recollections of the trauma

39. PTSD: Diagnostic Criteria NUMBING • Numbing of general responsiveness (not present before the trauma) • inability to recall an important aspect of the trauma • losing interest in activities that used to give pleasure • feeling detached or estranged from others • emotional numbness – being out of touch with feelings • sense of foreshortened future, e.g. not expecting to have a career, marriage, children, or normal life span

40. PTSD: Diagnostic Criteria INCREASED AROUSAL • Persistent symptoms of increased arousal (not present before the trauma), as indicated by 2+ of the following: • difficulty falling or staying asleep • irritability or outbursts of anger • difficulty concentrating • hypervigilance • startling easily

41. PTSD: Diagnostic Criteria • Duration of the disturbance is more than one month • The disturbance causes significant distress or impairment in important areas of functioning • Specify if: • Acute – if duration of symptoms is < 3 months • Chronic – if duration of symptoms is 3+ months • Delayed onset – if onset of symptoms is at least 6 months after the stressor

42. PTSD: Facts & Figures • Can occur at any age • Prevalence: • 3-8% of the general population • 18% of women experiencing trauma • 32% of rape victims • 15-20% of those experiencing serious auto accidents • Often accompanied by anxiety & depression

43. PTSD: Causes • Person personally experiences a trauma and develops an array of symptoms that “recreate” the original trauma • Distressing recollections & dreams about the trauma are the mind’s attempt to gain control of the original event & to neutralize the emotional charge it carries • Family history of anxiety • Family instability • Lack of social support • Elevated corticotropin-releasing factor (CRF) and heightened activity in the HPA axis resulting from the trauma

44. PTSD: Current Treatments • Relaxation Training • Cognitive Therapy • Exposure Therapy – imaginal exposure • Medication – SSRI’s • Support Groups • EMDR – Eye Movement Desensitization & Reprocessing • Hypnotherapy

45. Acute Stress Disorder: Diagnostic Criteria • The person has been exposed to a traumatic event which: • involved threat to personal integrity, serious injury, or death • produced intense fear, helplessness, or horror • Either during or after the traumatic incident, the person has 3+ of the following dissociative symptoms: • numbing, detachment, or absence of emotional responsiveness • reduced awareness of one’s surroundings (e.g. being in a daze) • feelings of unreality or depersonalization • dissociative amnesia (i.e. inability to recall an important aspect of the trauma)

46. Acute Stress Disorder: Diagnostic Criteria • The traumatic event is persistently re-experienced in at least one of the following ways: • recurrent images, thoughts, dreams, flashbacks • a sense of reliving the experience • distress on exposure to stimuli associated with traumatic event • Marked avoidance of anything that reminds the person of the trauma (e.g. thoughts, feelings, conversations, activities, places, people) • The disturbance causes the person significant distress or impairment in important areas of functioning • The disturbance occurs within 4 weeks of traumatic event & lasts for a minimum of 2 days and a maximum of 4 weeks

47. Anxiety Due to a General Medical Condition: Diagnostic Criteria • Significant anxiety, panic attacks, or generalized anxiety are a direct physiological effect of a specific medical condition: • Endocrine conditions – hyperthyroidism, hypothyroidism, pheochromocytoma, hypoglycemia • Cardiovascular conditions – congestive heart failure, pulmonary embolism • Metabolic conditions – vitamin B12 deficiency, porphyria • Neurological conditions – vestibular problems, encephalitis

48. Substance-Induced Anxiety Disorder • Significant anxiety, panic attacks, or generalized anxiety are a direct physiological effect of a substance: • a medication • drug of abuse • toxin exposure • Anxiety may be due to exposure to the substance or withdrawal from it

49. Long-Term, Predisposing Causes of Anxiety Disorders • Heredity • Having the same genetic makeup as someone with phobias or anxiety makes it more than 2x as likely that you will have a similar problem • Inherit a reactive, excitable nervous system and personality that predisposes you to anxiety • Childhood Circumstances • Parents communicate an overly cautious view of the world. • Parents are overly critical & perfectionistic and set excessively high standards • Experiencing neglect, rejection, abandonment (e.g. via divorce or death), physical abuse, sexual abuse, alcoholic parent(s)  emotional insecurity & excessive dependency • Parents suppress your ability to express your feelings & assert yourself

50. Long-Term, Predisposing Causes of Anxiety Disorders • Cumulative and/or Enduring Stress • Over time, stress can affect the neuroendocrine regulatory systems of the brain, which play an important role in depression and anxiety • Stress is nonspecific in its action – it has the greatest impact on the weakest point(s) in one’s system • Biological Causes