Anxiety Disorders

1. Anxiety Disorders Phobias Panic Disorders Generalized Anxiety Disorder Obsessive-Compulsive Disorder Post-trauma disorders Other anxiety disorders

2. Symptoms of anxiety • Gastrointestinal • Genitourinary • Cardiovascular • Skin • Ocular • Musculoskeletal • Mental/cognitive Fear is a response to a perceived danger or threat. Anxiety is the anticipation of a possible threat.

3. 1. Phobias • General characteristics of phobias • Fear sensations • Avoidance behavior • Cognitive recognition that the fear is out of proportion to the stimulus

4. 1A. Specific Phobia: Objects or situations • Lifetime prevalence: • 7% men, 16% women • Types of specific phobias • Animal Type • Natural Environment Type • Blood-Injection-Injury Type • Predictive validity: Treat with muscle tension, not relaxation • Situational Type • Other Type

5. Specific phobias in other cultures • Pa-feng and pa-leng • Jin-kyofu-sho or taijin-kyofu-sho

6. 1B. Social Phobia (Social Anxiety Disorder): People’s scrutiny • Lifetime prevalence: 11% M; 15% F • Fear of scrutiny • Fear of evaluation • Fear of doing or saying something humiliating or embarrassing • In USA, fear of personal embarrassment • In Japan, fear of embarrassing others • Adolescent onset

7. 2. Panic Disorder • With Agoraphobia • Without Agoraphobia • Recurrent, unexpected (uncued) panic attacks followed by persistent worry • situationally cued phobias vs. situationally predisposed Panic Disorder • (DSM-IV also lists Agoraphobia without History of Panic Disorder)

8. Panic attack: At least 4 symptoms within 10 minutes • Heart: racing, palpitations, pounding • Dizzy, lightheaded, faint, unsteady • Skin: sweating • paresthesias • chills or hot flashes • Muscles: Trembling, shaking • Respiratory: shortness of breath, smothering • choking feeling • Chest pain or discomfort • Gastrointestinal: nausea or distress • Cognitive/mental:derealization/depersonalization • fear of losing control/going crazy • fear of dying

9. 3. Generalized Anxiety Disorder/ Overanxious Disorder of Childhood • Excessive anxiety and worry • More than half of the time • Lasting at least 6 months • Focussing on several topics • Hard to control • At least three symptoms (one in children) out of: restlessness, rapid fatigue, mind wandering or blanking, irritability, tense muscles, sleep problems

10. 4. Obsessive-Compulsive Disorder • Repeated, distressing obsessions (thoughts, impulses, images, doubts) or compulsions (rituals; yielding or controlling) • Take up at least 1 hour per day • Are done to relieve or prevent anxiety • Adults recognize the symptoms as extreme; children may not. • Resistance is futile. • Seen in religious people as scrupulosity.

11. OCD Distribution • 80% of normal people report obsessions; 54% report compulsions • Lifetime prevalence 2 - 3% • No gender difference • Begins either before age 10 or 18-30 • Less common among African Americans and Mexican Americans • More common in divorced, separated, or unemployed people

12. OCD ramifications • Is there a connection to self-injury? • Are so-called sexual addictions examples of OCD? • Are obsessions ever the re-experiencing events of post-trauma disorders? (Freeman & Leonard, 2000) • Are eating disorders like OCD? • Is there a connection to tic disorders?

13. 5. Post-trauma disorders • Acute Stress Disorder: Within 1 month • Posttraumatic Stress Disorder: > 1 mo. • Acute, chronic, and delayed specifiers • Extreme trauma • Threat of death or serious injury • Witnessing trauma to others • Learning about violent death, harm, or threat to a loved one or close friend • Worse if caused by human design • Reexperiencing, arousal, and avoidance

14. Post-trauma disorders… • Lifetime incidence between 1 and 14% in the general population, but between 3 and 58% in those exposed to trauma • PTSD is third only to Depression and Substance Abuse disorders among young adults (Breslau, Davis, Andreski, & Peterson, 1991), and is more common among young people than older folks (Norris, 1992)

15. Post-trauma disorders… • Comorbid with Substance-Related Disorders, Panic Disorders, Obsessive-Compulsive Disorder, Phobias, Depression, and Somatization Disorder • Often experience survivor guilt, broken relationships • Especially common in war-torn areas and in migrants from such nations

16. 6. Other anxiety disorders • Anxiety Disorder Due to a General Medical Condition • Examples: Hyperthyroidism, hypoglycemia, congestive heart failure, pneumonia, B12 deficiency, encephalitis • Substance-Induced Anxiety Disorder • May be during intoxication or withdrawal • Examples: Alcohol, amphetamines, caffeine, cocaine, marijuana, many medications, heavy metals, CO, CO2 • Anxiety Disorder NOS

17. Etiologies of anxiety disorders • Psychoanalysis: Phobias • Freud: Defense against id-triggered anxiety • Arieti: Specific placement of general mistrust • Phobic object is symbolic • Behavioral theories: All anxiety disorders • Classical conditioning and operant avoidance • About half of people recall appropriate trauma experiences; half do not (Kendler, Myers, & Prescott, 2002) • But Loftus (1993) found that 25% of 1500 people who had been hospitalized in the last year had no recall memory of it. • Recall of painful childhood events is particularly poor. • Role of extinction, contingency, and preparedness • Focus on UCR, not UCS

18. More etiologies • Gender and culture • All anxiety disorders but OCD are more often diagnosed in women, usually twice as often. Gender may be a marker variable. • Modeling and imitation: All anxiety disorders • Vicarious conditioning and consequences to the model • Mineka’s monkeys (1984, 1989) • Limited generality: Most people with phobias report no such modeling

19. Cognition: All anxiety disorders • Rumination and self-awareness • Attendance to threat and perceived control • Negativity and pessimism in self-evaluation • Unconscious processes: Subliminal stimulation provokes fear in people with phobias (Ohman & Soares, 1994) • Social skills and social phobia

20. The Ohman & Soares study

21. Biological theories • ANS reactivity or lability • Genetic factors • Familiality: • 64% concordance vs 3% of population for blood and injection type of Specific Phobia • 20 – 40% heritability for phobias, GAD, and PTSD • 48% heritability for panic disorder • Temperament • Correlational data

22. Neurological factors • Elevated responsiveness in the amygdala, part of the fear circuit of the limbic system • Poor functioning of serotonin (5-HT) and GABA, and elevated levels of norepinephrine (NE), perhaps caused by a surge in the fear circuit, which includes the locus ceruleus.

23. Personality factors • Behavioral inhibition • Highly reactive infants (14 months old) were more likely (45%) to show anxiety symptoms at age 7.5 than those with low infant reactions (15%) • High neuroticism doubles the risk of anxiety disorders • About half of adults with anxiety disorders had evidence of psychiatric disorders in childhood, usually anxiety disorders (33%) or depression (Gregory et al., 2007)

24. Treatment • Psychoanalysis • Uncover the repression • Confront the fear

25. Behavioral approaches • Confront with relaxation: Systematic desensitization • Confront with tension: Blood and injection phobias • Counter parasympathetic overshoot • Flooding, in vivo, vicarious, and imaginal • Social skills training

26. Cognitive approaches • Cognitive restructuring not effective with specific phobias • Some effectiveness for social phobia, if combined with social skills training

27. Biological treatments • Anxiolytic drugs: Benzodiazepines • Antidepressants may be useful for social phobia. • Riddle (2001) found fluvoxamine (Luvox) effective in children with social phobia and OCD • Confronting the feared stimulus is essential for all of the treatment approaches, but anxiolytic drugs may lessen the effectiveness of exposure therapies.