Anxiety Disorders

1. Anxiety Disorders Chapter 6

2. Anxiety Disorders • Def: behaviors that include phobias, obsessions, compulsions and extreme worry. People with an anxiety disorder share a pre-occupation with , or persistent avoidance of thoughts or situations that provoke fear or anxiety, and frequently have a negative impact on aspects of a person’s life. • Similarities with mood disorders: • Both are defined in terms of negative emotional responses • Both involve feelings of guilt, worry, and anger. • Common etiological features, such as cognitive distortions, triggers by stressful life events, and biological factors such as neurotransmitter imbalances. • Close relationship of symptoms for anxiety and mood disorder suggests the possibility of common causal features (e.g. stressful life events)

3. Anxiety as a Mood vs. a Syndrome • Fear-experienced in the face of real or immediate danger, builds quickly and helps organize a person’s behavioral responses to threats from the environment. • Anxious Mood-general or diffuse emotional reaction that is beyond simple fear and out of proportion to threats in the environment. • Not always directed at the person’s present circumstance  can be associated with the anticipation of future problems. • Adaptive at low levels as it signals a person must prepare for an upcoming event. • Anxious apprehension- a pervasively anxious mood associated with pessimistic thoughts, negative self-evaluation and negative concern for future events.

4. Symptoms of Anxiety Disorders • Excessive Worry- • Panic Attacks- • Phobias- persistent, irrational narrowly defined fears that are associated with a specific object or situation. • Obsessions and Compulsions • Obsessions (def)-repetitive unwanted, intrusive cognitive events that may take the form of thoughts images or impulses and lead to an increase in subjective anxiety. • Compulsions-repetitive behaviors or mental acts that are used to reduce anxiety.

5. Excessive Worry • Cognitive activity associated with anxiety that manifests as a relatively uncontrollable sequence of negative, emotional thoughts that are concerned with possible future threats or dangers. • Lack of perceived control • Negative Affect • Quantity

6. Panic Attacks • Panic attacks- sudden overwhelming experience of terror or fright. More focused than anxiety believed to be a normal fear response triggered at an inappropriate time. • Physical sensations of which the patient must experience at least four, which develop suddenly and reach peak intensity within 10 minutes: • Heart palpitations • Sweating • Trembling or shaking • Sensation of shortness of breath • Choking feeling • Chest pain • Nausea or abdominal distress • Dizziness • Feelings of unreality or detachment from oneself • Fear of losing control or going crazy • Fear of dying • Numbness or tingling sensation • Chills or hot flushes

7. Phobias • Persistent, irrational narrowly defined fears that are associated with a specific object or situation. • Avoidance • Agoraphobia-Fear becomes more intense as the distance between the person and his or her familiar surroundings increases, or as avenues of escape are closed off.

8. Obsessions and Compulsions • Obsessions and Compulsions- • Obsessions (def)-repetitive unwanted, intrusive cognitive events that may take the form of thoughts images or impulses and lead to an increase in subjective anxiety. • Compulsions-repetitive behaviors or mental acts that are used to reduce anxiety. • Obsessions • Seem to come out of the blue • Content of obsessions • Compulsions-Must perform the ritual to keep something “bad” from happening. • Most common are cleaning and checking

9. Diagnostic Systems of Anxiety Disorders (DSM-IV-TR) • Panic Disorder • Recurrent unexpected panic attacks with at least half of the attacks followed by a period of one month or more in which the person fears having another attack. (fear of fear) • Avoidance of the situation (change in behavior) • Agoraphobia • Avoid the situation or endure it with great distress • Insist on being accompanied by a safe person. • Specific Phobia-marked and persistent fear that is excessive or unreasonable, cued by the presence of specific object or situation. • Exposure produces immediate fear response • Awareness that fear is unreasonable • Avoidance

10. History of Anxiety as a Disorder • Early classification of Anxiety disorders were under the classification of neurosis. • Distinguished from the psychotic disorders as the patient has awareness. • Contemporary classification of anxiety disorder includes: • Panic disorder • Phobic Disorder • Obsessive Compulsive Disorder • Post Traumatic Stress Disorder • Acute Stress Disorder

11. Diagnostic Systems of Anxiety Disorders (DSM-IV-TR) • Panic Disorder-recurrent unexpected panic attacks . For one month or more following at least one attack, the person must experience persistent concern about having another attack, worry about implications of the attack or a significant change in behavior due to the attack. Two Categories: • With or Without Agoraphobia • Agoraphobia-complication that follows experience of panic attacks in which the person fears the inability to escape the situation. With agoraphobia, the person must either avoid the agoraphobic situation, endure it with great distress, or insist they be accompanied by another person who can offer comfort or security.can exist in the absence of panicP disorder (rare) • Phobic Disorders: • Specific Phobia-marked and persistent fear that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation. • Social Phobia-identical to specific phobia, except must be afraid of social categories. Fear of being humiliated lies at the heart of the disorder. Two Categories: • Performance Anxiety • Interpersonal Interactions

12. DSM Classification • Generalized Anxiety Disorder-excessive anxiety or worry that lead to significant distress or impairment in occupational or social functioning. Free-floating anxiety must be accompanied by at least three of the following symptoms: • Restlessness or feeling on edge • Fatigue • Difficulty concentrating • Irritability • Muscle Tension • Sleep Disturbance • Obsessive-Compulsive Disorder-defined in terms of the presence of either obsessions or compulsions. • Obsessions-thoughts must not be excessive worries about real problems must be unreasonable • Compulsions-rituals that cause marked distress if not performed, take more than an hour a day to perform or interfere with normal occupational and social functioning. • Post traumatic Stress Disorder (Chapter 7) • Acute Stress Disorder (Chapter 7) • Separation Anxiety- (Chapter 16)

13. Course and outcome • Chronic conditions Research based predictive course and outcomes: Long term outcome unpredictable • Panic Disorder-Greatest predictor of poor outcomes was onset of symptoms at a relatively young age and the presence of agoraphobia with panic disorder. • Social phobia-Symptoms usually appear first in early adolescence and remain stable over time, indicating chronic condition.

14. Course and Outcome • OCD-follows a pattern of improvement mixed with some persistent symptoms. Longitudinal study shows 50% of patients exhibit symptoms for over 30 years. However, more than 80% of the patients showed improved levels of functioning considered a chronic condition.

15. Frequency • Only about 25% of people who qualify for a diagnosis of anxiety disorder ever seek psychological treatment. Therefore estimates of the frequency and severity of these problems are likely inaccurate.

16. Prevalence • Anxiety disorders more common than any other mental disorder in the U.S. • Specific phobia-most common-9% • Social phobia-7% • Panic Disorder and GAD-3% • OCD and Agoraphobia-1% • Gender Differences • Women have much higher incidence of anxiety disorders than men, except for OCD which is relatively equal. Women also three times more likely to relapse.

17. Etiology • Evolutionary Theoretical Perspective • Social Factors • Psychological Factors • Biological Factors

18. Evolutionary Theoretical Perspective • Suggests that generalized forms of anxiety probably evolved to prepare for threats that could not be clearly defined. More specific forms of anxiety and fear probably evolved to provide more effective responses to certain types of danger. For example: • Fear of heights is associated with a freezing of muscles which could lead to a fall • Social threats were likely seen as establishment of dominance hierarchies within pack behavior and were likely to provoke responses such as shyness or embarrassment. • The evolutionary model views each type of anxiety as a dysregulation of a mechanism that evolved to deal with a particular kind of danger.

19. Social Factors • Stressful life events that involve danger, interpersonal conflicts or parent-child relationships are thought to contribute to vulnerability to the development of anxiety disorders. • Childhood Adversity • Attachment Relationships and Separation Anxiety

20. Psychological Factors • Learning Processes and Phobias • Preparedness Model-theory that brain contans certain modules or circuitry that has been shaped by evolution to serves some adaptive purpose. • Operate at maximal speed and perform without conscious awareness. • Humans develop intense persistent fears to only a select set of objects or situations. • Development of social and specific phobias could be related to evolutionary lag. • Observational Learning • Social Learning Theory • Cognitive Factors: Perception and Memory Four General Areas that play a role in anxiety Disorders. • Perception of Control • Catastrophic Misinterpretation • Attention to Threat and Biased Information Processing • Thought Suppression (OCD)

21. Biological Factors • Family Studies-relatives of people with panic disorder show an elevated risk of panic disorder, but not GAD, and vice versa. • Twin Studies • Neuroanatomy-brain circuitry involved in fear and conditioning • Emotional Stimuli follows two primary pathways both of which involve the amygdala.

22. Pathway One • Fastest and represents the evolved fear module for conditioned fear. • Has direct connections to the amygdale which registers danger and then projects to the hypothalamus which activates fight or flight behavioral responses. • This pathway does not involve higher level cognitive function such as conscious memory and decisions via the cortical areas. • However the amygdale does store unconscious emotional memories such as those generated through prepared learning.

23. First Pathway: Fear and Conditioning Stimulus Thalamus Amygdala Hypothalmus FLIGHT OR FIGHT RESPONSE

24. Second Complementary Pathway • Pathway from the thalamus leads to higher cortical areas and provides a detailed and slower analysis of the information. • Once the pattern has been identified in the appropriate modality the data would be integrated with additional information from memory about is emotional significance. • The message would then be sent to the amygdala which would tiger an organized response to threat as well as to other cortical areas that also initiate plans against dangers. • Second pathway takes longer than the first. • Sensitivity of the first pathway (fear module) is thought to be more sensitive than the second.

25. Second Pathway Stimulus Identification and recognition of stimulus Lobe Thalamus Emotionality Amygdala Somatosensory cortex Planned Voluntary Movements Hypothalamus Motor Cortex FLIGHT OR FIGHT RESPONSE

26. Neurotransmitters • Various pharmacological challenge studies suggest the influence of serotonin, NE, GABA, and DA in triggering panic attacks. • Efficacy of drug treatments affecting these neurotransmitters suggest they may be involved (convergent evidence)

27. Treatment • Psychological Interventions • Insight therapy-Freudian analysis of unconscious motives that presumably lie at the heart of the symptoms. • Behavioral Therapies • Systematic Desensitization-client is first taught progressive relaxation. Then the therapist constructs a hierarchy of feared stimuli, beginning with those items that provoke only small amounts of fear and progressing through items that are more frightening then while the client the client is in a relaxed state, he or she imagine the lowest item on the hierarchy. This item is mentally presented until the thought of the object or situation is no longer anxiety producing. The client moves systematically up the hierarchy sequentially confronting stimuli that were originally rated as being more frightening. • Flooding- exposure to the most frightening experience without avoidance. • Interoceptive Exposure- have patient engage in exercises known to produce physical sensations associated with panic attacks such as increased heart rate, respiration or dizziness and attempt to reduce the person’s fear of the symptoms.

28. Treatment • Cognitive Therapy • Identify faulty logic such as over-generalizations and jumping to conclusions. • Decatastrophisizing-imagine the worst case scenario and confront the negative predictions, and gross exaggerations based on cognitive errors. • Extensive practice, homework and journaling.

29. Treatment • Biological Therapy • Anti-Anxiety Medications. • Benzodiazepenes--reduce anxiety symptoms primarily by inhibiting GABA neuron activity. Drug of choicexanax. • Panic attacks and agoraphobia • Problems: high rate of addiction and dependence. Many patients relapse after discontinuation of medication • Azapirones-inhibit serotonin activity. BusParGAD Does not work as quickly • Antidepressants-often preferred over anti-anxiety drugs due to problems with addiction. • SSRI’s- first line treatment due to tolerability of side effects. • SNUB-Effexor, Cymbalta • Tricyclics-used for the longest period of time. Work as well as the SSRI’s but range of side effects leads to non-compliance. • Anafranil (OCD)-tricyclic especially helpful with OCD, not used with any other panic disorder, however relapse is common after discontinuation of the drug.

30. Case Study: Paula Paula: 27 year old white female • Single • Education: BA –economics • Occupation: Securities and Bond Trader Presentation: • Blunted Affect, Good eye contact, fidgety • Extremely uncomfortable talking about painful subjects in the past, Before the end of the first session, patient became so uncomfortable discussing a subject, she left the session early.

31. Reason for appointment • Recurring attacks that she thought were heart attacks. • Patient experienced chest pains, dizziness and shortness of breath resulting in multiple trips to the emergency room. • Cardiology testing • Zanax prescribed • Acceleration of symptoms and avoidance behaviors • Medical leave from job.

32. Family Background • Mother: Homemaker • Father: Deceased five years from Congestive heart Failure • Siblings: younger brother born with multiple birth defects including severe heart problems The died when he was three years old and the family still grieved his loss. • Maternal Grandfather: Alcoholic

33. Evaluation • Assessment Tools • Unstructured Interview • Psychiatric Evaluation Symptoms: • Onset : shortly after entering college where she experienced adjustment problems. • Unresolved grief. • Acceleration of symptoms • Avoidance Behaviors • Abuse of alcohol and over the counter drugs for a short period • Suicidal Ideations • Irrational thoughts • Anger at Mother

34. Etiology • Learningnegative reinforcement • Irrational thinking • Biological

35. Treatment: • Group Therapy • Medication: zoloft • Relaxation Therapy • Hypnosis • Duration: 7 months • Prognosis-good

36. DSM IV TR • Axis One: Panic Disorder with Agoraphobia • Axis Two: • Axis Three: • Axis Four: • Axis Five: