Anxiety Disorders Anxiety vs Fear Anxiety Apprehension about

Anxiety Disorders

Anxiety vs. Fear Anxiety Apprehension about a future threat Fear Response to an immediate threat Both Sympathetic nervous system Both involve physiological arousal can be adaptive Fear triggers “flight or fight” May save life Anxiety increases preparedness Moderate 2 levels improve performance

Persamaan Cemas dan Takut (Rahman, 1998) Anticipation of danger or discomfort Tense apprehensiveness Elevated arousal Negative affect Uneasiness Future oriented Accompanied by bodily sensations 3

Perbedaan Cemas dan Takut (Rahman, 1998) Anxiety Source of threat is elusive Uncertain connection between anxiety and threat Prolonged Pervasive uneasiness Can be objectless Uncertain onset Persistent Uncertain offset Without clear borders Threat seldom imminent Heightened vigilance Bodily sensation of vigilance Puzzling quality Fear Specific focus of threat Understandable connection between threat and fear Usually episodic Circumscribed tension Identifiable threat Provoked by threat cues Declines with removal of threat Offset is detectable Circumscribed area of threat Imminent threat Quality of emergency Bodily sensation of an emergency Rational quality 4

Anxiety Disorders DSM-IV-TR Specific and social phobias Panic disorder and agoraphobia Generalized anxiety disorder Obsessive compulsive disorder Posttraumatic stress disorder Most common psychiatric disorders 28% report anxiety symptoms Most common are phobias (Kessler et al. , 2005) 5

Table 5. 1 Summary of Major Anxiety Disorders 6

Phobias Disruptive fear of a particular object or situation Fear out of proportion to actual threat Awareness that fear is excessive Must be severe enough to cause distress or interfere with job or social life Avoidance Two types: Specific Social 7

Specific Phobia Unwarranted, excessive fear of specific object or situation Snakes, How blood, flying, spiders, etc. likely are you to be bitten by a spider? Most specific phobias cluster around a few feared objects and situations (Table 5. 3) Trigger or feared object is avoided or endured with intense anxiety High comorbidity of specific phobias 8

Social Phobia Persistent, Fear More intense fear of social situations of negative evaluation or scrutiny intense and extensive than shyness More appropriate diagnostic label? Social anxiety disorder Exposure to trigger leads to anxiety about being humiliated or embarrassed socially. Onset often adolescence Diagnosed as either generalized or specific 33% also diagnosed with Avoidant Personality Disorder Overlap in genetic vulnerability for both disorders 9

Panic Disorder Frequent panic attacks unrelated to specific situations Panic attack Sudden, intense episode of apprehension, terror, feelings of impending doom Accompanied by at least 4 other symptoms: Symptoms reach peak intensity within 10 minutes Sweating, nausea, labored breathing, dizziness, heart palpitations, upset stomach, lightheadedness, etc. Other symptoms may include: Depersonalization Derealization Fear of going crazy, losing control, or dying 10

Panic Disorder Uncued attacks Occur unexpectedly without warning Panic disorder diagnosis requires recurrent uncued attacks. Cued attacks Triggered by specific situations (e. g. , tunnel) More likely a phobia Panic Disorder with Agoraphobia Avoidance of situations in which escape would be difficult or embarrassing Panic disorder with agoraphobia tends to be more chronic. 11

Panic Disorder Often begins in adolescence 25% unemployed for more than 5 years because of symptoms (Leon et al. , 1995) Prognosis worse when agoraphobia is present 12

Generalized Anxiety Disorder (GAD) Involves chronic, excessive, uncontrollable worry Other symptoms: Common worries: Lasts at least 6 months Interferes with daily life Restlessness, poor concentration, irritability, muscle tension, tires easily, sleep disturbance Relationships, daily hassles health, finances, Often begins in adolescence or earlier I’ve always been this way 13

Obsessive-Compulsive Disorder (OCD) Obsessions Intrusive, persistent, and uncontrollable thoughts or urges Experienced as irrational Most common: Contamination, sexual & aggressive impulses, body problems Compulsions Impulse to repeat certain behaviors or mental acts to avoid distress e. g. , cleaning, checking, hoarding, repeating a word, counting Extremely difficult to resist the impulse May involve elaborate behavioral rituals 14

Obsessive-Compulsive Disorder (OCD) Develops either before age 10 or during late adolescence/early adulthood Men Early onset more common Women Cleaning common OCD compulsions and later onset more often chronic 15

Post Traumatic Stress Disorder (PTSD) Extreme response to severe stressor Anxiety, avoidance of stimuli associated with trauma, emotional numbing Exposure to a traumatic event that involves actual or threatened death or injury e. g. , war, rape, natural disaster Trauma leads to intense fear or helplessness Symptoms present for more than a month Women and PTSD Rape most common type of trauma (Creamer et al. , 2001) 16

Post Traumatic Stress Disorder (PTSD) Three categories of symptoms : Re-experiencing the traumatic event 1. Nightmares, intrusive thoughts, or images » Avoidance of stimuli 2. » e. g. , Refuse to walk on street where rape occurred » Numbing » » » Increased arousal 3. » Decreased interest in others Distant or estranged from others Unable to experience positive emotions Insomnia, irritability, hypervigilance, exaggerated startle response Tends to be chronic 2005) (Perkonigg et al. , 17

Acute Stress Disorder (ASD) Symptoms similar to PTSD Duration varies Short term reaction Symptoms occur between 2 days and 1 month after trauma As many as 90% of rape victims experience ASD (Rothbaum et al. , 1992) More than 2/3 of those with ASD develop PTSD within 2 years (Harvey & Bryant, 2002) 18

Comorbidity ¾ of those with anxiety disorder meet criteria for another disorder 60% meet criteria for major depression (Brown et al. , 2001) Other disorders commonly comorbid with anxiety: Substance abuse Personality disorders Avoidant Dependent Histrionic Medical disorders e. g. , coronary heart disease 19

Gender & Sociocultural Factors Women are 2 x as likely as men to have anxiety disorder except for OCD Possible explanations Women may be more likely to report symptoms Women more likely to experience childhood sexual abuse Women show more biological stress reactivity Sociocultural factors Focus of anxiety varies Taijin kyofusho Japanese fear of offending or embarrassing others Kayak-angst Inuit disorder in seal hunters at sea similar to panic Ratio of somatic to psychological symptoms appears similar across cultures 20 2001) (Kirmayer,

Etiology of Specific Phobias Conditioning Mowrer’s two-factor model Pairing of stimulus with aversive UCS leads to fear (Classical Conditioning) Avoidance maintained though negative reinforcement (Operant Conditioning) 21

Etiology of Specific Phobias Problems with two-factor model (see table 5. 6) Many people never experience aversive interaction with phobic object People with phobias tend to fear only certain types of objects (prepared learning) Snakes, insects, blood, heights, etc. Even phobias linked to modeling influenced by prepared learning Monkeys acquired fear after watching another monkey exhibit fear to snake but not flower (Cook & Mineka, 1989) 22

Etiology of Social Phobia Two factor model Avoidance or safety behaviors Avoid eye contact, appear aloof, stand apart from others in social settings Cognitive factors Negative self evaluation Harsh, punitive self-judgment Fear of negative evaluation by others Expect others to dislike them Excessive attention to internal cues e. g. , heart rate 23

Neurobiological factors Locus ceruleus Major source of norepinephrine A trigger for nervous system activity Multiple drugs can induce panic attacks Typically only in those who are overly concerned about bodily changes 24

Etiology of Panic Interoceptive conditioning Classical conditioning of panic in response to bodily sensations People with panic disorder sustain classically conditioned fears longer (Michael et al. , 2007) 25

Etiology of Panic Cognitive factors Lack of perceived control can trigger panic Fear of bodily changes Interpreted as impending doom I must be having a heart attack! Beliefs increase anxiety and arousal Creates vicious cycle 26

Etiology of Agoraphobia Fear-of-fear hypothesis (Goldstein & Chambless, 1978) Expectations about the catastrophic consequences of having a public panic attack. What will people think of me? !? ! 27

Etiology of GAD GABA system deficits Borkovec’s cognitive model: Worry reinforcing because it distracts from negative emotions and images Allows avoidance of more disturbing emotions e. g. , distress of previous trauma Avoidance prevents extinction of underlying anxiety Individuals with GAD less able to identify their own negative feelings (Mennin et al. , 2002) 28

Etiology of OCD: Neurobiological Factors OCD symptoms common in certain neurological disorders Huntington’s chorea Hyperactive regions of the brain: Orbitofrontal cortex Caudate nucleus Anterior cingulate Loss of neuronal function and underlying biochemical abnormality (Yücel et al. , 2007) 29

Etiology of OCD: Behavioral & Cognitive Factors Operant reinforcement Compulsions negatively reinforced by the reduction of anxiety Cognitive factors Lack of a satiety signal Yadasentience Subjective feeling of completion Knowing that you have thought enough or cleaned enough Individuals with OCD have a yadasentience deficit Attempts to suppress intrusive thoughts Trying to suppress thoughts may make matters worse 30

Etiology of PTSD Severity and type of trauma Neurobiological Smaller hippocampal volume linked to PTSD Disruption of verbal vs. nonverbal memory Supersensitivity to cortisol Behavioral Two factor model Psychological Perception of control Avoidance coping, dissociation, memory suppression Intelligence and ability to grow from the experience enhance coping 31

Common Aspects of Psychological Treatment Psychological treatments emphasize Exposure Face the situation or object that triggers anxiety Should include as many features of the trigger as possible Should be conducted in as many settings as possible Systematic desensitization Relaxation plus imaginal exposure 32

Common Aspects of Psychological Treatment Cognitive approaches Increase belief in ability to cope with the anxiety trigger Challenge expectations about negative outcomes 33

Medications Anxiolytics Drugs that reduce anxiety Two common types of medications used to treat anxiety Benzodiazepenes Valium, Xanax Antidepressants Tricyclics, Selective Serotonin Reuptake Inhibitors (SSRIs), and Serotonin Reuptake Inhibitors (SRIs) 34

Medications Demonstrated effectiveness as compared to placebo Clomipramine Medication for OCD does not seem to help hoarding Beta blockers commonly prescribed for social phobia although no demonstrated effectiveness Side effects Withdrawal Weight Relapse from benzodiazepenes gain, nervousness, high blood pressure from SSRIs 35 common after medication discontinuation