Chapter 4 Anxiety Disorders The Complexity of Anxiety

Chapter 4 Anxiety Disorders

The Complexity of Anxiety Disorders • Anxiety – the future-oriented mood state – Apprehension about future danger or misfortune – Somatic symptoms of tension – Characterized by marked negative affect • Anxiety and fear are normal emotional states

The Complexity of Anxiety Disorders • Fear – the present-oriented mood state – Immediate fight or flight response to danger or threat – Involves abrupt activation of the sympathetic nervous system – Strong avoidance/escapist tendencies – Marked negative affect

From Normal to Disordered Anxiety and Fear • Characteristics of anxiety disorders – Pervasive and persistent symptoms of anxiety and fear – Involve excessive avoidance and escape – Cause clinically significant distress and impairment

The Phenomenology of Panic Attacks • What is a panic attack? – Abrupt experience of intense fear or discomfort – Several physical symptoms (e. g. , breathlessness, chest pain) – Fear as an alarm response

The Phenomenology of Panic Attacks • DSM-IV-TR subtypes of panic attacks – Situationally bound (cued) – Unexpected (uncued) – Situationally predisposed • Cultural influences on anxiety

Biological Contributions to Anxiety and Panic • Genetic vulnerability • Anxiety and brain circuits – Depleted levels of GABA

Biological Contributions to Anxiety and Panic (continued) • Limbic (amygdala) and the septal-hippocampal systems • Behavioral inhibition system (BIS) – Anxiety • Fight/flight system (FF) – Fear

Psychological Contributions to Anxiety and Fear • Integrated model – Early childhood - Experiences with uncontrollability and unpredictability

Psychological Contributions to Anxiety and Fear • Behavioral and cognitive views – Invokes conditioning and cognitive explanations – Anxiety and fear are learned responses – Catastrophic thinking and appraisals play a role

Psychological Contributions to Anxiety and Fear • Social contributions – Stressful life events trigger vulnerabilities

An Integrated Model • Integrative view – triple vulnerability model – Generalized biological vulnerability – Generalized psychological vulnerability – Specific psychological vulnerability

An Integrated Model • Common processes: the problem of comorbidity – Comorbidity is common across the anxiety disorders – Major depression is the most common secondary diagnosis – About half of patients have two or more secondary diagnoses – Comorbidity suggests • Common factors • A relation between anxiety and depression

The Anxiety Disorders: An Overview • Generalized anxiety disorder (GAD) • Panic disorder with and without agoraphobia (PDA) • Specific phobias • Social phobia (SAD) • Posttraumatic stress disorder (PTSD) • Obsessive-compulsive disorder (OCD)

Generalized Anxiety Disorder: The “Basic” Anxiety Disorder • Overview and defining features – Excessive uncontrollable anxious apprehension and worry – Coupled with strong, persistent anxiety – Persists for six months or more – Somatic symptoms differ from panic (e. g. , muscle tension)

Generalized Anxiety Disorder: The “Basic” Anxiety Disorder • Statistics – Affects about 3. 1% of the general population – Females outnumber males approximately 2: 1 – Onset is often insidious, beginning in early adulthood – Very prevalent among the elderly – Tends to run in families

Generalized Anxiety Disorder: Associated Features and Treatment • Associated features – Persons with GAD have been called “autonomic restrictors” – Fail to process emotional component of thoughts and images • Causes – factors influencing – Genetics – Muscle tension – Personal threat – Automatic restrictors

Generalized Anxiety Disorder: Associated Features and Treatment • Treatment of GAD: Generally weak – Benzodiazapines – often prescribed – Antideprancents – Psychological interventions – cognitive-behavioral therapy – Meditation therapy – Combined treatments – acute vs. long-term outcomes

Panic Disorder With and Without Agoraphobia • Overview and defining features – Experience of unexpected panic attack (i. e. , a false alarm) – Develop anxiety, worry, or fear about another attack – Many develop agoraphobia

Panic Disorder With and Without Agoraphobia • Facts and statistics – Affects about 2. 7% of the general population – Onset is often acute, mean onset between 20 and 24 years of age – 66% of individuals with agoraphobia are female • Cultural influences • Causes – Triple – 8% to 12% has occasional attacks vulnerability

Panic Disorder: Associated Features and Treatment • Associated features – Nocturnal panic attacks – 60% panic during deep non-REM sleep – Interoceptive/exteroceptive avoidance • Medication treatment – Target serotonergic, noradrenergic, and GABA systems – SSRIs (e. g. , Prozac and Paxil) are preferred drugs – Relapse rates are high following medication discontinuation

Panic Disorder: Associated Features and Treatment • Psychological and combined treatments – Cognitive-behavioral therapies are highly effective – No evidence that combined treatment produces better outcome – Best long-term outcome is with cognitivebehavioral therapy alone

Panic Disorder: Associated Features and Treatment • Panic control treatment (PCT) • Combined psychological and drug treatments • Innovative approaches – Psychological (CBT) treatment followed by drug treatments – D-cycloserine (DCS)

Specific Phobias: An Overview • Overview and defining features – Extreme irrational fear of a specific object or situation – Persons will go to great lengths to avoid phobic objects – Most recognize that the fear and avoidance are unreasonable – Markedly interferes with one’s ability to function

Specific Phobias: An Overview • Facts and statistics – Females are again over-represented – Affects about 12. 5% of the general population – Phobias tend to run a chronic course

Specific Phobias: Associated Features and Treatment • Subtypes of specific phobia – Blood-injury-injection phobia – unusual vasovagal response – Situational phobia – trains, planes, automobiles, closed spaces – Natural environment phobia – natural events (e. g. , heights, storms) – Animal phobia – animals and insects – Separation anxiety – seen in children

Specific Phobias: Associated Features and Treatment • Causes of phobias – Direct experience – Biological and evolutionary vulnerability – traumatic conditioning, prepared tendency, event will happen again • Psychological treatments of specific phobias – Cognitive-behavior therapies are highly effective – exposure • Cultural factors

Social Phobia: An Overview • Overview and defining features – Extreme and irrational fear in social/performance situations – Markedly interferes with one’s ability to function – Often avoid social situations or endure them with great distress – Generalized subtype – affects many social situations

Social Phobia: An Overview • Facts and statistics – Affects about 12. 1% of the general population, 6. 8% in 1 -year period – Prevalence is slightly greater in females than males – Second only to specific phobia in the anxiety disorders – Onset is usually during adolescence – Peak age of onset at about 13 years

Social Phobia: Associated Features and Treatment • Causes – Biological and evolutionary vulnerability – Similar learning pathways as specific phobias • Psychological treatment – Cognitive-behavioral treatment (CBT) – Cognitive-behavioral group treatment (CBGT) – Cognitive-behavioral therapies are highly effective

Social Phobia: Associated Features and Treatment • Medication treatment – Tricyclic antidepressants and monoamine oxidase inhibitors – SSRIs Paxil, Zoloft, and Effexer – are FDA approved – Relapse rates are high following medication discontinuation

Posttraumatic Stress Disorder (PTSD): An Overview • Overview and defining features – Main etiologic characteristics – trauma exposure and response – Reexperiencing (e. g. , memories, nightmares, flashbacks) – Avoidance – Emotional numbing and interpersonal problems – Markedly interferes with one's ability to function – PTSD diagnosis – only after one month posttrauma

Posttraumatic Stress Disorder (PTSD): An Overview • Statistics – Combat and sexual assault are the most common traumas – Lower than expected prevalence rates in trauma victims

PTSD: Causes and Associated Features • Subtypes and associated features of PTSD – Acute – may be diagnosed one-three months post trauma – Chronic – diagnosed after three months post trauma – Delayed onset – onset six months or more post trauma – Acute stress disorder – PTSD immediately posttrauma

PTSD: Causes and Associated Features • Causes of PTSD – Intensity of the trauma and one's reaction to it (i. e. , true alarm) – Learn alarms – direct conditioning and observational learning – Biological vulnerability – Uncontrollability and unpredictability – Extent of social support, or lack thereof, posttrauma

PTSD: Treatment • Psychological treatments – Cognitive-behavioral therapies (CBT) are highly effective – CBT may include graduated or massed (e. g. , flooding) imaginal exposure – Aim of CBT for PTSD – SSRIs

Obsessive-Compulsive Disorder (OCD): An Overview • Overview and defining features – Obsessions – intrusive and nonsensical thoughts, images, or urges • Symmetry 26. 7%, forbidden thoughts 21%, cleaning and contamination 15. 9% and hording 15. 4% – Compulsions – thoughts or actions to neutralize thoughts – Vicious cycle of obsessions and compulsions – Cleaning and washing or checking rituals are common

Obsessive-Compulsive Disorder (OCD): An Overview • Overview and defining features – Tic disorder and OCD – Hoarding

OCD: Causes and Associated Features • Statistics – Affects about 1. 6% of the general population – Most with OCD are female – Onset is typically in early adolescence or young adulthood – OCD tends to be chronic

OCD: Causes and Associated Features • Causes of OCD – Parallels the other anxiety disorders – Early life experiences – Learning that some thoughts are dangerous/unacceptable – Thought-action fusion – the thought is similar to the action

OCD: Treatment • Medication treatment – Clomipramine and other SSRIs – benefit up to 60% of patients – Relapse is common with medication discontinuation – Psychosurgery (cingulotomy) is used in extreme cases

OCD: Treatment • Psychological treatment – Cognitive-behavioral therapy is most effective – CBT involves exposure and response prevention – Combining CBT with medication – no better than CBT alone – Exposure and ritual prevention (ERP) – more effective than drugs

Summary of the Anxiety Disorders • Most common forms of psychopathology • From a normal to a disordered experience of anxiety and fear – Triple vulnerabilities – bio-psycho-social – Fear and anxiety – non-dangerous bodily or environmental cues – Symptoms and avoidance – significant distress and impairment

Summary of the Anxiety Disorders • Psychological treatments are generally superior in the long-term – Similar treatments for different anxiety disorders – Suggests that anxiety-related disorders share common processes

DSM-5 Proposed Changes • http: //www. dsm 5. org/Proposed. Revisions/Pag es/Anxiety. Disorders. aspx