chapter 5 anxiety disorders

1. Chapter 5Anxiety Disorders

3. From Normal to Disordered Anxiety and Fear Characteristics of Anxiety Disorders Psychological disorders � Pervasive and persistent symptoms of anxiety and fear Involve excessive avoidance and escapist tendencies Causes clinically significant distress and impairment

4. The Phenomenology of Panic Attacks What Is a Panic Attack? Abrupt experience of intense fear or discomfort Accompanied by several physical symptoms DSM-IV Subtypes of Panic Attacks Situationally bound (cued) panic Unexpected (uncued) panic Situationally predisposed panic

5. The Phenomenology of Panic Attacks Attacks must build to a climax quickly (2 min) and the acute part of the attack must end within 10-15 minutes. A panic attack is different from strong anxiety. 4 of these symptoms must be present:hyperventilation, feelings of choking, sweating, heart racing, hot and cold flashes, nausea, trembling or shaking, faint feelings, feelings of unreality, prickling sensations, beliefs that one is going crazy or dying.

6. Biological Contributions to Anxiety and Panic Diathesis-Stress Inherit vulnerabilities for anxiety and panic, not disorders Stress and life circumstances activate vulnerability Biological Causes and Inherent Vulnerabilities Anxiety and brain circuits � GABA, noradrenergic and serotonergic systems Corticotropin releasing factor (CRF) and the HPAC axis Limbic (amygdala) and the septal-hippocampal systems Behavioral inhibition (BIS) and fight/flight (FF) systems

7. Psychological Contributions to Anxiety and Fear Began with Freud Anxiety is a psychic reaction to danger Anxiety involves reactivation of an infantile fear situation Behavioristic Views Anxiety and fear result from classical and operant conditioning and modeling Psychological Views Early experiences with uncontrollability / unpredictability Social Contributions Stressful life events trigger vulnerabilities Many stressors are familial and interpersonal

8. Toward an Integrated Model Integrative View Biological vulnerability interacts with psychological, experiential, and social variables to produce an anxiety disorder Consistent with diathesis-stress model Common Processes: The Problem of Comorbidity Comorbidity is common across the anxiety disorders About half of 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

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

10. 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

11. 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

12. Panic Disorder with and without Agoraphobia Overview and Defining Features Experience of unexpected panic attack 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

13. Panic Disorder with and without Agoraphobia Panic is caused in part by a personality trait called anxiety sensitivity, which is the tendency to overattend to, and catastrophically misinterpret, the symptoms of anxiety�

14. Panic Disorder with and without Agoraphobia Cognitive Model of Panic � the individual overattends to bodily sensations such as a racing heart, interprets them catastrophically (�maybe I�m having a heart attack�), the catastrophic thoughts bring about more sensations of anxiety, the individual continues to focus on the sensations and interpret them catastrophically (�my heart is beating even faster now�), negative interpretations bring about more sensations of anxiety, eventually this upward spiral causes intense anxiety, panic attack.

15. Panic Disorder with and without Agoraphobia People with panic disorder present repeatedly to emergency rooms during attacks. They believe that they might be having a heart attack or dying, despite the fact that they might have had dozens of such attacks in the past, and they should know that this is just another panic attack. People with panic use faulty logic, a.k.a. the �gamblers fallacy�: They believe that all those previous times they were �just lucky� that the attack was not a heart attack; they believe that their luck will soon �run out� and they will have a fatal attack. They don�t believe that the exact same symptoms constitute just another panic attack!

16. Panic Disorder: Associated Features and Treatment 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 In fact, meds can lead to a rebound of even worse anxiety! 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

17. Panic Disorder: Associated Features and Treatment CBT for panic involves bringing on the symptoms of a panic attack on purpose, so that the client learns that they are not dangerous and builds up immunity to them. Called �symptom induction.� To bring on the symptoms, the therapist and client engage in vigorous physical exercises, such as spinning around quickly to bring on dizziness, turning the heat up in the room to cause sweating, breathing through a thin drinking straw to restrict air flow, shaking head from side to side to bring on disorientation, running in place to increase heart rate. Hyperventilate for 20 seconds

18. Panic Disorder: Associated Features and Treatment We also use situational exposure combined with symptom induction to treat agoraphobic avoidance. For example: I have hyperventilated on the subway, Spun around in circles while waiting in line at the market, and Engaged in straw breathing in a crowded movie theater. Taken together, symptom induction and situational exposure lead to improvement in 75% of panic patients.

19. 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 Specific Phobias: An Overview

20. 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

21. 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

22. 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

23. 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 -- Are ineffective 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

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

25. Phobia Treatment

26. 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

27. 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

28. Post Traumatic Stress

29. 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

30. 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 Posttraumatic Stress Disorder (PTSD): Treatment

31. 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 Obsessive-Compulsive Disorder (OCD): An Overview

32. Chuck

33. 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 Obsessive-Compulsive Disorder (OCD):Causes and Associated Features

34. 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

35. Obsessive-Compulsive Disorder (OCD): Treatment Surgery only used for very severe cases that do not respond to any other treatments. Psychosurgery (cingulotomy) � a probe is used to burn portions of the cingulate cortex (a part of the frontal lobe that may contribute to repetitive behaviors) guided by MRI. Side effects � memory deficits, urinary disturbances, decreased energy and seizure disoder. CBT following cingulotomy appears to work better than CBT before - very interesting finding!

36. Obsessive-Compulsive Disorder (OCD): Treatment CBT involves exposure to the obsessional fear, after which the patient resists engaging in the compulsive behavior. The period of resistance gets longer and longer until it is completely elimiated. Exposure to obsessions is sort of like �tempting fate�� Some examples of things I have done to treat OCD: Left little pieces of paper with my home address on them strewn about a public office building; Left my refrigerator door wide open overnight then ate some of the food. Dipped my hand in urine, blood; Spit repeatedly on graves in a graveyard!

37. Summary of Anxiety-Related Disorders Anxiety Disorders Are the Largest Domain of Psychopathology From a Normal to a Disordered Experience of Anxiety and Fear Requires consideration of biological, psychological, experiential, and social factors Fear and anxiety in the absence of real threat or danger Develop avoidance, restricted life functioning Cause significant distress and impairment in functioning Psychological Treatments Are Generally Superior in the Long-Term Treatments include similar components Suggests that anxiety disorders share common processes

38. Exploring Anxiety Disorders

39. Exploring Anxiety Disorders (cont.)

40. Exploring Anxiety Disorders (cont.)

41. Exploring Anxiety Disorders (cont.)

42. Exploring Anxiety Disorders (cont.)