Chapter 6: Anxiety Disorders

1. Chapter 6: Anxiety Disorders Ch 6

2. Anxiety Disorders • Anxiety refers to an unpleasant feeling of fear and apprehension • Neuroses is a former term that refers to a group of disorders involving unrealistic anxiety, assumed to be due to unconscious conflicts • Anxiety disorders reflect the clear presence of symptoms of anxiety • Anxiety is not specific to anxiety disorders • Comorbidity: A person may be diagnosed with more than one disorder • Distinguishing stress, fear, and anxiety • Stress is the perception of an external demand, or challenge Ch 6.1

3. The Nature of Fear and Anxiety • Abrupt and Aversive CNS Response to Real Threat or Danger • Prepares Organisms for Immediate Action • Action Tendency “Fight” or “Flight” Fear

4. The Nature of Fear and Anxiety • More Diffuse Response About Impending Real or Imagined “Future” Threat or Danger Anxiety

5. The Nature of Fear and Anxiety Real Threat True Alarm Maladaptive Adaptive False Alarm No Threat

6. The Anxiety Disorders Etiology “Disordered” or “Maladaptive” Experience of Anxiety or Fear “Normal” or “Adaptive” Experience of Anxiety or Fear

7. Phobias • A phobia isa fear-mediated avoidance that is out of proportion to the object or situation • Phobias involve intense distress • Phobias are disruptive • Person recognizes that the fear is groundless Ch 6.2

8. Classes of Phobias • Specific phobias are unwarranted fears caused by the presence of a specific object or situation • Blood, injuries, or injections • Situations (planes, elevators) • Animals • Natural environment (water, heights) • Social phobia involves a persistent fear linked to the presence of other people Ch 6.4

9. Specific Phobias • Clinical Description • Irrational Fear of Specific Objects or Situations • Markedly Interferes With Functioning

10. Specific Phobias • Four Major Subtypes • Animal Type • Natural Environment Type • Blood-Injection Injury Type • Situational Type • Other

11. Specific Phobias • Blood-Injection Injury Type • Unusual Reaction • Vasovagal Response to Blood • Drop in Blood Pressure • Fainting • Runs in Families • Onset Early Childhood

12. Specific Phobias • Situational Type • Fears of Specific Situations Planes, Transportation, Heights • Response Similar to Panic • Onset Early 20’s

13. Specific Phobias • Animal Type • Fears of Animals and Insects • Common in Population, but Different From Normal Revulsion • Early Onset (About 7 yrs of Age)

14. Specific Phobias • Natural Environment Type • Fears of Natural Events Heights, Storms, Water • Usually More Than One Fear • Peak Onset (About 7 yrs of Age)

15. Specific Phobias • Other Type • Fears Contracting Disease / Illness Illness Phobia • Fear of Choking Avoid Swallowing Pills or Foods

16. Specific Phobias • Facts and Statistics • Occurs in 11% of Population • Top Fears: Heights and Snakes • Females > Males (4:1 Ratio) • Runs a Chronic Course • Many Do Not Seek Treatment: WHY?

17. Specific Phobias • Causes • Direct Traumatic Conditioning • Observational Learning • Information and Language • Having a Panic Attack (“False Alarm”) • Probably Some Evolutionary Basis

18. Etiology of Anxiety Disorders • Psychoanalytic theory: phobias result from anxiety produced by repressed id impulses • Biological/Genetic theory: Heritability of panic disorder, and evolutionary basis of phobias • Behavioral theories: focus on learning as the etiological basis of phobias • Phobias are learned avoidance responses • Phobias may be acquired through modeling • We are biologically prepared to learn certain fears (e.g. taste with nausea) • Cognitive theory: Thought processes result in high levels of anxiety Ch 6.5

19. Treating Phobias • Psychoanalytic therapy attempts to uncover repressed conflicts using free association • Behavioral approaches use systematicdesensitization and in vivo exposures to reduce anxiety responses to phobic stimuli and situations • Flooding: exposure to a phobic stimulus at full intensity (now graded exposure is used more) • Cognitive approaches focus on altering irrational beliefs (using socratic dialogue to disconfirm and reconstruct automatic thoughts, images) Ch 6.6a

20. Treating Phobias • Biological approach uses drugs to eliminate anxiety symptoms • Anxiolytic drugs such as the benzodiazepines (Valium) can reduce anxiety but are also addictive and give rise to withdrawal symptoms upon termination • MAO inhibitors such as phenelzine reduce the degradation of norepinephrine and serotonin • MAO inhibitors can have adverse side effects • Selective serotonin reuptake inhibitors (SSRI’s) (fluoxetine) increase brain serotonin Ch 6.6b

21. Treatment of Specific Phobias • Exposure and More Exposure • Structured and Consistent • Confront Objects of Fear • Extinguish Anxious Responding • Disrupt Avoidance / Escape • Blood-Injury /Injection Differs Exercises to Offset Fainting

22. Social Phobia “ People with social phobia aren’t necessarily shy at all. They can be completely at ease with people most of the time, but in particular situations, they feel intense anxiety.”

23. Social Phobia • Clinical Description • Marked and Persistent Fear of One or More... Social or Performance Situations • Most Common Type of Social Fear? Public Speaking • Interferes With Life Functioning

24. Social Phobia • Facts and Statistics • Occurs in 13.3% of Population • Most Prevalent Disorder • Males > Females • Begins in Adolescence • Presents Differently in Some Cultures (e.g., Japan)

25. Social Phobia • Causes • Similar to Panic and Specific Phobia • Interaction of Biological Vulnerability Psychological Vulnerability Learning Experiences • Can be Quite Disabling

26. Treatment of Social Phobia • Psychological Interventions • Similar to Panic and Specific Phobia • Cognitive-Behavioral Approaches Rehearsal and Skills Training Cognitive Restructuring

27. Treatment of Social Phobia • Drug Treatments • Antidepressants for Severe Anxiety SSRIs (e.g., Paxil) MAO Inhibitors Relapse is Common

28. Panic Disorder • Panic disorder involves • an attack of labored breathing, nausea, chest pain, dizziness and intense apprehension (terror) • Depersonalization: the feeling of being outside of one’s body • Derealization: the feeling that the world is not real • Lifetime prevalence for panic disorder is 2% for men and 5% for women Ch 6.7

29. The Anxiety Disorders • Panic Disorder “ You may genuinely believe you’re having a heart attack, losing your mind, or on the verge of death. Attacks can occur any time, even during nondream sleep ” “ For me, a panic attack is a most violent experience …I feel as though I’m losing control and going insane. ”

30. Panic Disorder • Clinical Description • An Unexpected Panic Attack • Develop Anxiety Over • the Next Attack or • The Implications of the Attack and Consequences

31. Panic Disorder • Clinical Description • Agoraphobia is Common • “Fear of the Marketplace”, avoidance of “unsafe” places where panic attack may recur • Consequence of Severe Unexpected Panic Attacks • Can Have a Life of its Own

32. Panic Disorder • Facts and Statistics • Occurs in 3.5% of Population • 75% are Women • Onset Between (25-29 yrs) • Initial attack often begins at puberty • 20% Attempt Suicide • Average 37 Medical Visits / Year

33. Panic Disorder • Cultural Influences • Occurs Worldwide • Prevalence in U.S. is Similar Across Ethnic Groups • Cultural variants: susto, ataques de nervios (Latin America, Caribbean) • Somatic symptoms emphasized in 3rd world cultures

34. Panic Disorder • Nocturnal Panic • 60% Cases Panic While Asleep! • Usually Between 1:30 - 3:30am • Occur During Deep Sleep “Delta” • Do Not Occur During REM Sleep • Isolated sleep paralysis (common in African-Americans with PD)

35. Panic Disorder • Symptoms of a Panic Attack • Palpitations / Sweating • Trembling / Shaking • Shortness of Breath • Feeling of Choking, Loss of Control • Derealization, Feeling of Dying

36. Etiology of Panic Disorder • Biological theories focus on the observations • that panic disorder runs in families • that panic disorder can be induced experimentally using • Hyperventilation may activate the autonomic nervous system • Infusions of lactate can induce panic attack • Panic attack may result from an exaggerated central response to arousal Ch 6.8

37. Etiology of Panic Disorder • The Fear-of-fear hypothesis of panic disorder suggests that some people have an overly aroused nervous system and a tendency to be upset by the sensations generated by their nervous system • Eventually, worry about a panic attack makes a future attack more likely (vicious circle) • Panic attacks as “false alarm” reactions Ch 6.9

38. Anxiety Sensitivity Index (ASI) • Measures the extent to which individuals become • apprehensive in response to their bodily sensations. • Developed by Peterson & Reiss (1987) • High scorers on the ASI were more likely than • low scorers to experience panic attacks, especially • if they had been told they would feel relaxed • instead of aroused (Telch & Harrington, 1992) (D&N, • Table 6.3).

39. Panic Disorder Treatments • Biological treatments include use of antidepressant and anxiolytic drugs • Require long-term use, symptoms return upon drug cessation; risk of addiction to anxiolytics • Psychological treatments emphasize exposure to stimuli that accompany panic • Barlow’s therapy includes a combination of breathing re-training, cognitive interventions, and exposure to the internal cues that elicit panic. Patient learns to relax and reinterpret these sensations as non-threatening and controllable Ch 6.10

40. Panic Disorder • The Panic Attack • Abrupt Autonomic Surge • Unexpected • Uncontrollable • Absence of Threat • “False Alarm” 10 Minutes

41. Panic Disorder • Laboratory Panic Provocation • Lactate Infusion • Hyperventilation • CO2 Inhalation • Caffeine 10 Minutes

42. Panic Disorder • Causes General Biological & Psychological Vulnerability STRESS False Alarm Bodily Cues Learned Alarm Involuntary physical or cognitive anxiety cues trigger learned alarms unpredictably Specific Psychological Vulnerability: Anxious apprehension focusing on future alarms (e.g., body sensations are dangerous)

43. Panic Disorder • Biological Causes • Runs in Families • GABA-BZ Circuit • Limbic System • ANXIETY Behavioral Inhibition System (BIS) • FEAR / PANIC Fight / Flight System (FF)

44. Panic Disorder • Psychological Causes Predictable Uncontrollable Controllable Unpredictable

45. Treatment of Panic Disorder • Pharmacologic Treatments • Block Panic • Antidepressants (e.g., Imipramine, Paxil, Prozac) • 20-50% Relapse • Benzodiazapines (e.g., Xanax) • 90% Relapse

46. Treatment of Panic Disorder • Psychological Interventions • Cognitive-Behavior Therapies • Brief and Time Limited (12 Sessions) • Graded Exposure + Coping Skills • Panic Control Treatment (PCT) • 80-100% Panic Free After Treatment

47. Treatment of Panic Disorder • Combined Treatment THE RESULT Combined Tx is Better in Short Term • Multisite Study • Imipramine Alone • PCT Alone • Imipramine + PCT • Placebo Alone • Placebo + PCT PCT Alone is Better in Long Term

48. Generalized Anxiety Disorder • Generalized Anxiety Disorder (GAD) involves persistent anxiety and chronic (uncontrollable) worry • The lifetime prevalence of GAD is 5% • Women are twice as likely to develop GAD as are men Ch 6.11

49. Generalized Anxiety Disorder:The “Basic” Anxiety Disorder? Figure 5.3 Clients’ answers to interviewer’s question, “Do you worry excessively about minor things?”

50. Etiology of GAD • Psychoanalytic view: generalized anxiety results from unconscious conflicts between ego and id impulses • Cognitive behavioral view: anxiety results from conditioning of anxiety to external stimuli • Biological view: the transmitter GABA inhibits anxiety, anxiolytic drugs enhance the release of GABA in brain; evidence for heritability is mixed. Ch 6.12