Anxiety Disorders

1. Anxiety Disorders

2. Anxiety: negative mood state characterized by bodily symptoms of tension and apprehension about the future

3. What does anxiety feel like? • Heart racing/pounding • Sweating • Being out of breath • Shaking • Upset stomach • Being “frozen”

4. Normal: Motivation Avoiding danger Preparation for uncertainty Abnormal: When it interferes with performance E.g. exams E.g. socially When is Anxiety Normal/Abnormal?

5. When is Anxiety Helpful/Not Helpful? • As arousal increases performance increases, to a point • After the optimal point of arousal performance deteriorates as anxiety continues to increase • This is called: Yerkes-Dodson Law

6. Yerkes-Dodson Law • The optimal point of arousal varies by task • For easy tasks: we can tolerate a lot of anxiety and still do well • For hard tasks: we can’t tolerate much anxiety

7. When is anxiety an Anxiety Disorder? • When the feelings of anxiety constantly interfere with functioning • Generalized Anxiety Disorder • Panic Disorder & Agoraphobia • Specific Phobias • Social Phobia • Post-traumatic Stress Disorder • Obsessive-Compulsive Disorder

8. Causes of Anxiety Disorders • Biological • Psychological • Social

9. Biological Causes of Anxiety Disorders • Genetic influences • Diathesis X Stress models appy • Changes in neurotransmitters • Sensitivity of brain circuits to fear

10. Psychological Causes of Anxiety Disorders • Behavioralists see anxiety as the result of learning • Cognitions regarding danger or uncontrollability • Parenting – overprotective and lack of adverse experiences

11. Social Contributions to Anxiety Disorders • Reactions to stressful events • Social learning

12. Comorbidity of Anxiety Disorders • Often co-occuring • Share same vulnerabilities • 55% comorbidity with depression • 50% with additional anxiety disorder

13. 1. Generalized Anxiety Disorder • Excessive anxiety/worry about a number of events/activities • Worry is difficult to control or stop • Worry is not helpful • Often about minor things

14. Restlessness tense muscles concentration problems sleep problems Irritability Fatigue Difficulty focusing attention Generalized Anxiety Disorder

15. Generalized Anxiety Disorder • Lifetime prevalence = 5% • 2x more likely in women • Develops early in adulthood • Most people do not seek treatment from therapist • Is GAD a personality style? Or personality disorder? A risk factor? • 80-90% qualify for another disorder

16. What Causes GAD? • Genes -> first degree relatives 5x likely • Differences in physiology • Less responsive • Except muscle tension • Cognitive Influences • Drawn to threat cues

17. How do we treat GAD? • Medication • Benzodiazepines • Early = Valium, new = Xanax, Ativan • Central nervous system depressants • Relieve anxiety but impair thinking, motor performance, induce sleep • Many people feel addicted (symptoms quickly return)

18. Psychological Treatments for GAD • Lots of treatment but little effectiveness • Psychoanalytical: insight & Client centered • Several Cognitive treatments • Cognitive Therapy – confront worry with images coping strategies • Beck & automatic thoughts* • Borkovec - confronting worry* • Craske’s hybrid treatment*

19. 2. Panic Disorder & Agoraphobia • Chills or hot flashes • Palpitations, pounding/accelerated heart beat • Sweating • Trembling/shaking • Sensations of smothering/choking • Chest pain/discomfort • Nausea or other abdominal distress • Feeling dizzy, light headed, faint • Fear of losing control/going crazy/dying • Numbness/tingling sensations

20. What is Panic Disorder? • Recurrent and unexpected panic attacks (cued or uncued) • Anxiety re: having other attacks (escape/embarrassment) • Patients avoid situations where panic attacks may happen (agoraphobia) • Withdrawal reduces anxiety • Negative reinforcement***

21. Panic Disorder • Lifetime prevalence = 3.5% (without) • 2-3x more likely in women • Develops during late adolescence/early adulthood • Chronic without treatment • Many experience panic attacks (8-12%) but no disorder develops

22. Causes of Panic Disorder • Genetic influences • Biology

23. Psychological Factors in Panic • Personality/trait like variables of risk • Some people have attacks, no disorder • 3 Proposed Variables: • A tendency to fear panic attacks • A tendency to over interpret unusual body sensations • Tendency to respond to fear w/ anxiety symptoms

24. Psychological Factors in Panic • A tendency to fear fear • Hypervigilant about physiology (looking for fear) • May trigger panic attacks • Misinterpret body signals as impending panic (e.g. during a walk) • Focus on own body, not possible danger

25. Psychological Factors in Panic 3. Anxiety Sensitivity • Respond fearfully to symptoms of anxiety • Overreact then avoid, then hypervigilant • May trigger a panic attack • What's the converging info? Reaction to panic makes panic more likely!!!

26. Avoiding Panic (Agoraphobia) • Why is withdrawal so bad for panic? • Opportunities for corrective feedback are nil • How can you know something works if you don’t test it?

27. Treating Panic & Agoraphobia • There are 2 ways: • Medication • Cognitive Behavioral Therapy

28. Medication • Antidepressants can reduce panic attacks • So do benzodiazepines (anti-anxiety) but they have problems: • Symptoms return quickly (short 1/2 life) • If stop too quickly, can be worse • Thus, can produce dependence

29. Medication • 66% do well, if stay on medication • 20-50% relapse after discontinuing antidepressants • 90% after discontinuing benzodiazepines

30. Cognitive Behavioral Treatment A number of elements: • Psychoeducation • Anxiety reducing techniques (a toolbox) • Diaphragmatic breathing • Progressive muscle relaxation • Distraction, labeling anxiety as safe, challenging thoughts • Exposure (!!!)

31. Cognitive Behavioral Therapy • We give our clients a “toolbox” • Education + techniques + challenges • Then we give them a chance to use them • Exposures • Sometimes we desensitize to internal feelings (e.g. running in place)

32. Panic Control Treatment (PCT) • Exposure to sensations that remind of panic • Also receive cognitive therapy • Address the cognitions re: dangerousness of feared, yet harmful, situations • Examples: • Shaking head from side to side loosely for 30 sec • Breathe through thin straw for 1 minute • Hyperventilate for 1 minute

33. 3. Specific Phobias • Unreasonable fears of objects, places, situations • Anxiety response triggered by specifics • Functioning beyond phobia is fine • www.phobialist.com

34. Specific Phobias • In theory, anything can = phobia • Small # account for most: • Animal phobias (zoophobia) = 40% • Environmental situations (e.g. heights - hysphobia) • Blood-injection-injury** (vasovagal response) • Avg age of onset = 9 years • Situational (planes, elevators)

35. Specific Phobias • Lifetime prevalence rate = 11% • Children experience more • Some may be developmentally normal • E.g. strangers, separation, the dark, etc • Culture can impact • Gender ratio 4:1 (women higher) • Except heights (equal) • Chronic across lifecourse

36. Separation Anxiety Disorder • Unrealistic and persistent worry that something will happen to parents • OR something will separate child from parents • School refusal • Nightmares, difficulty sleeping alone

37. Causes of Specific Phobias • Not traumatic experiences • Often panic attacks trigger • Vicariously from others • Also genetic role – 31% of people with 1st degree relatives • Specific to subtype

38. Behavioral Factors & Specific Phobias • Classical conditioning - Little Albert • Phobias are learned • May not need direct experience • “modeling” fear of parents • Many phobics show no related experience • 50% of dog phobics no experience • Many people don’t develop after experience

39. Evolution, Learning & Specific Phobias • Are we predisposed to certain phobias? • Can we learn phobias from others?

40. Evolution, Learning, & Specific Phobias • Are we prepared to be phobic of certain things? • E.g. snakes • Arbitrary objects do not often = phobia (despite danger or instructions) • Electric outlets, stoves, hammers • Bicycles, etc

41. Evolution, Learning, & Specific Phobias • Mineka’s monkeys (1984, Experiment 2) • Can lab-born monkeys learn snake phobia from their wild-born parents? • Study 1 established that wild-born monkeys were more fearful than their offspring • Offspring observed parental response to: real snake, toy snake, neutral objects

42. Behavioral Avoidance of Snakes

43. Evolution, Learning & Specific Phobias • Offspring learned phobias by watching parents • Results were intense & rapid (one try) • In evolutionary terms, we don’t have several “tries” with a fatal object • Retention 3 months later

44. Evolution, Learning, & Specific Phobias • Mineka’s follow-up (Cook & Mineka, 1991) • Spliced videos so it appears parent monkeys are reacting to flowers • Observer monkeys did not learn flower-phobia • This is consistent with the idea that we are prepared for certain phobias

45. How do we treat a specific phobia? • Exposure! • Two types of exposure: • Systematic desensitization • Flooding

46. Systematic Desensitization • Imaginal vs. in vivo exposure • In vivo treats well (75-95% of patients) • Create a hierarchy of feared experiences • Teach progressive muscle relaxation • Combine • Note: this is gradual

47. Flooding • This is not gradual • Intense & prolonged exposure • E.g. stay on the roof until you are calm • Usually in vivo • Emotionally draining • Can make anxiety worse if quit early

48. In Vivo • Different sizes of spiders • Patients stand in room, approach, touch jar, change size of spider, touch spider • 3 hour treatment • What about imaginal? • Some people have problems imagining • Imagined spiders might not be scary

49. Virtual Reality Treatment for Anxiety(Garcia-Palacios et al., 2001) • Phobias are extremely common & easy to treat • but most people never seek treatment • Less than 15% of the 10% of the pop. with a phobia

50. Why do VR therapy? • 25% refuse exposure-based therapy • Too afraid to confront • Ost (a spider pioneer) - 90% of spider phobic patients refuse one-session tx • How can we improve therapy? • Make it less intimidating • Use virtual reality!