Download Anxiety Disorders

Anxiety Disorders
Anxiety Disorders


Def: behaviors that include phobias, obsessions,
compulsions and extreme worry. People with an
anxiety disorder share a pre-occupation with , or
persistent avoidance of thoughts or situations that
provoke fear or anxiety, and frequently have a negative
impact on aspects of a person’s life.
Similarities with mood disorders:




Both are defined in terms of negative emotional responses
Both involve feelings of guilt, worry, and anger.
Common etiological features, such as cognitive distortions,
triggers by stressful life events, and biological factors such as
neurotransmitter imbalances.
Close relationship of symptoms for anxiety and mood disorder
suggests the possibility of common causal features (e.g.
stressful life events)
Anxiety as a Mood vs. a Syndrome


Fear-experienced in the face of real or immediate
danger, builds quickly and helps organize a person’s
behavioral responses to threats from the environment.
Anxious Mood-general or diffuse emotional reaction
that is beyond simple fear and out of proportion to
threats in the environment.



Not always directed at the person’s present circumstance 
can be associated with the anticipation of future problems.
Adaptive at low levels as it signals a person must prepare for
an upcoming event.
Anxious apprehension- a pervasively anxious mood
associated with pessimistic thoughts, negative selfevaluation and negative concern for future events.
Symptoms of Anxiety Disorders

Excessive WorryPanic AttacksPhobias- persistent, irrational narrowly defined fears that are

Obsessions and Compulsions


associated with a specific object or situation.


Obsessions (def)-repetitive unwanted, intrusive cognitive
events that may take the form of thoughts images or impulses
and lead to an increase in subjective anxiety.
Compulsions-repetitive behaviors or mental acts that are used
to reduce anxiety.
Excessive Worry

Cognitive activity associated with anxiety
that manifests as a relatively
uncontrollable sequence of negative,
emotional thoughts that are concerned
with possible future threats or dangers.



Lack of perceived control
Negative Affect
Quantity
Panic Attacks


Panic attacks- sudden overwhelming experience of terror or fright. More
focused than anxiety believed to be a normal fear response triggered at an
inappropriate time.
Physical sensations of which the patient must experience at least
four, which develop suddenly and reach peak intensity within 10
minutes:













Heart palpitations
Sweating
Trembling or shaking
Sensation of shortness of breath
Choking feeling
Chest pain
Nausea or abdominal distress
Dizziness
Feelings of unreality or detachment from oneself
Fear of losing control or going crazy
Fear of dying
Numbness or tingling sensation
Chills or hot flushes
Phobias

Persistent, irrational narrowly defined
fears that are associated with a specific
object or situation.


Avoidance
Agoraphobia-Fear becomes more intense as the
distance between the person and his or her familiar
surroundings increases, or as avenues of escape are
closed off.
Obsessions and Compulsions

Obsessions and Compulsions


take the form of thoughts images or impulses and lead to an increase in
subjective anxiety.
Compulsions-repetitive behaviors or mental acts that are used to reduce
anxiety.
Obsessions



Obsessions (def)-repetitive unwanted, intrusive cognitive events that may
Seem to come out of the blue
Content of obsessions
Compulsions-Must perform the ritual to keep something
“bad” from happening.

Most common are cleaning and checking
Diagnostic Systems of Anxiety Disorders (DSM-IV-TR)

Panic Disorder



Agoraphobia



Recurrent unexpected panic attacks with at least half of the
attacks followed by a period of one month or more in which
the person fears having another attack. (fear of fear)
Avoidance of the situation (change in behavior)
Avoid the situation or endure it with great distress
Insist on being accompanied by a safe person.
Specific Phobia-marked and persistent fear that is
excessive or unreasonable, cued by the presence of
specific object or situation.



Exposure produces immediate fear response
Awareness that fear is unreasonable
Avoidance
History of Anxiety as a Disorder



Early classification of Anxiety disorders were under the
classification of neurosis.
Distinguished from the psychotic disorders as the patient
has awareness.
Contemporary classification of anxiety disorder includes:
 Panic disorder
 Phobic Disorder
 Obsessive Compulsive Disorder
 Post Traumatic Stress Disorder
 Acute Stress Disorder
Diagnostic Systems of Anxiety Disorders (DSM-IV-TR)

Panic Disorder-recurrent unexpected panic attacks . For one month or more following at least
one attack, the person must experience persistent concern about having another attack, worry
about implications of the attack or a significant change in behavior due to the attack. Two
Categories:



With or Without Agoraphobia
Agoraphobia-complication that follows experience of panic attacks in which the
person fears the inability to escape the situation. With agoraphobia, the person
must either avoid the agoraphobic situation, endure it with great distress, or
insist they be accompanied by another person who can offer comfort or
security.can exist in the absence of panicP disorder (rare)
Phobic Disorders:
 Specific Phobia-marked and persistent fear that is excessive or unreasonable
cued by the presence or anticipation of a specific object or situation.
 Social Phobia-identical to specific phobia, except must be afraid of social
categories. Fear of being humiliated lies at the heart of the disorder. Two
Categories:
 Performance Anxiety
 Interpersonal Interactions
DSM Classification

Generalized Anxiety Disorder-excessive anxiety or worry that lead to significant
distress or impairment in occupational or social functioning. Free-floating anxiety
must be accompanied by at least three of the following symptoms:







Obsessive-Compulsive Disorder-defined in terms of the presence of either obsessions
or compulsions.





Restlessness or feeling on edge
Fatigue
Difficulty concentrating
Irritability
Muscle Tension
Sleep Disturbance
Obsessions-thoughts must not be excessive worries about real problems must be
unreasonable
Compulsions-rituals that cause marked distress if not performed, take more than an hour a
day to perform or interfere with normal occupational and social functioning.
Post traumatic Stress Disorder (Chapter 7)
Acute Stress Disorder (Chapter 7)
Separation Anxiety- (Chapter 16)
Course and outcome

Chronic conditions Research based predictive
course and outcomes: Long term outcome
unpredictable


Panic Disorder-Greatest predictor of poor outcomes
was onset of symptoms at a relatively young age
and the presence of agoraphobia with panic
disorder.
Social phobia-Symptoms usually appear first in early
adolescence and remain stable over time, indicating
chronic condition.
Course and Outcome

OCD-follows a pattern of improvement mixed
with some persistent symptoms. Longitudinal
study shows 50% of patients exhibit symptoms
for over 30 years. However, more than 80% of
the patients showed improved levels of
functioning considered a chronic condition.
Frequency

Only about 25% of people who qualify for
a diagnosis of anxiety disorder ever seek
psychological treatment. Therefore
estimates of the frequency and severity of
these problems are likely inaccurate.
Prevalence






Anxiety disorders more common than any other
mental disorder in the U.S.
Specific phobia-most common-9%
Social phobia-7%
Panic Disorder and GAD-3%
OCD and Agoraphobia-1%
Gender Differences
 Women have much higher incidence of
anxiety disorders than men, except for OCD
which is relatively equal. Women also three
times more likely to relapse.
Etiology

Evolutionary Theoretical Perspective

Social Factors

Psychological Factors

Biological Factors
Evolutionary Theoretical Perspective

Suggests that generalized forms of anxiety
probably evolved to prepare for threats that could
not be clearly defined. More specific forms of
anxiety and fear probably evolved to provide
more effective responses to certain types of
danger. For example:



Fear of heights is associated with a freezing of muscles
which could lead to a fall
Social threats were likely seen as establishment of
dominance hierarchies within pack behavior and were
likely to provoke responses such as shyness or
embarrassment.
The evolutionary model views each type of anxiety as a
dysregulation of a mechanism that evolved to deal with
a particular kind of danger.
Social Factors

Stressful life events that involve danger, interpersonal
conflicts or parent-child relationships are thought to
contribute to vulnerability to the development of
anxiety disorders.

Childhood Adversity

Attachment Relationships and Separation Anxiety
Psychological Factors

Learning Processes and Phobias





Observational Learning


Preparedness Model-theory that brain contans certain modules or circuitry that
has been shaped by evolution to serves some adaptive purpose.
Operate at maximal speed and perform without conscious awareness.
Humans develop intense persistent fears to only a select set of objects or
situations.
Development of social and specific phobias could be related to evolutionary lag.
Social Learning Theory
Cognitive Factors: Perception and Memory Four General Areas that play a
role in anxiety Disorders.




Perception of Control
Catastrophic Misinterpretation
Attention to Threat and Biased Information Processing
Thought Suppression (OCD)
Biological Factors



Family Studies-relatives of people with panic
disorder show an elevated risk of panic
disorder, but not GAD, and vice versa.
Twin Studies
Neuroanatomy-brain circuitry involved in fear
and conditioning

Emotional Stimuli follows two primary pathways
both of which involve the amygdala.
Pathway One

Fastest and represents the evolved fear
module for conditioned fear.



Has direct connections to the amygdale which registers
danger and then projects to the hypothalamus which
activates fight or flight behavioral responses.
This pathway does not involve higher level cognitive
function such as conscious memory and decisions via the
cortical areas.
However the amygdale does store unconscious emotional
memories such as those generated through prepared
learning.
First Pathway: Fear and Conditioning
Stimulus
Thalamus
Amygdala
Hypothalmus
FLIGHT OR FIGHT RESPONSE
Second Complementary Pathway






Pathway from the thalamus leads to higher cortical areas and
provides a detailed and slower analysis of the information.
Once the pattern has been identified in the appropriate
modality the data would be integrated with additional
information from memory about is emotional significance.
The message would then be sent to the amygdala which would
tiger an organized response to threat as well as to other
cortical areas that also initiate plans against dangers.
Second pathway takes longer than the first.
Sensitivity of the first pathway (fear module) is thought to be
more sensitive than the second.
Second Pathway
Stimulus
Lobe
Identification and recognition
of stimulus
Thalamus
Emotionality
Amygdala
Hypothalamus
FLIGHT OR FIGHT RESPONSE
Somatosensory cortex
Motor Cortex
Planned
Voluntary
Movements
Neurotransmitters


Various pharmacological challenge studies
suggest the influence of serotonin, NE,
GABA, and DA in triggering panic attacks.
Efficacy of drug treatments affecting these
neurotransmitters suggest they may be
involved (convergent evidence)
Treatment

Psychological Interventions


Insight therapy-Freudian analysis of unconscious motives
that presumably lie at the heart of the symptoms.
Behavioral Therapies



Systematic Desensitization-client is first taught progressive
relaxation. Then the therapist constructs a hierarchy of feared
stimuli, beginning with those items that provoke only small
amounts of fear and progressing through items that are more
frightening then while the client the client is in a relaxed state,
he or she imagine the lowest item on the hierarchy. This item is
mentally presented until the thought of the object or situation
is no longer anxiety producing. The client moves systematically
up the hierarchy sequentially confronting stimuli that were
originally rated as being more frightening.
Flooding- exposure to the most frightening experience without
avoidance.
Interoceptive Exposure- have patient engage in exercises
known to produce physical sensations associated with panic
attacks such as increased heart rate, respiration or dizziness
and attempt to reduce the person’s fear of the symptoms.
Treatment

Cognitive Therapy
Identify faulty logic such as overgeneralizations and jumping to conclusions.
 Decatastrophisizing-imagine the worst case
scenario and confront the negative
predictions, and gross exaggerations based
on cognitive errors.
 Extensive practice, homework and
journaling.

Treatment

Biological Therapy

Anti-Anxiety Medications.



Antidepressants-often preferred over anti-anxiety drugs
due to problems with addiction.




Benzodiazepenes--reduce anxiety symptoms primarily by
inhibiting GABA neuron activity. Drug of choicexanax.
 Panic attacks and agoraphobia
 Problems: high rate of addiction and dependence. Many
patients relapse after discontinuation of medication
Azapirones-inhibit serotonin activity. BusParGAD Does not
work as quickly
SSRI’s- first line treatment due to tolerability of side effects.
SNUB-Effexor, Cymbalta
Tricyclics-used for the longest period of time. Work as well as
the SSRI’s but range of side effects leads to non-compliance.
Anafranil (OCD)-tricyclic especially helpful with OCD, not
used with any other panic disorder, however relapse is
common after discontinuation of the drug.
Case Study: Paula
Paula: 27 year old white female



Single
Education: BA –economics
Occupation: Securities and Bond Trader
Presentation:


Blunted Affect, Good eye contact, fidgety
Extremely uncomfortable talking about painful
subjects in the past, Before the end of the first
session, patient became so uncomfortable
discussing a subject, she left the session early.
Reason for appointment






Recurring attacks that she thought were
heart attacks.
Patient experienced chest pains, dizziness
and shortness of breath resulting in multiple
trips to the emergency room.
Cardiology testing
Zanax prescribed
Acceleration of symptoms and avoidance
behaviors
Medical leave from job.
Family Background




Mother: Homemaker
Father: Deceased five years from
Congestive heart Failure
Siblings: younger brother born with
multiple birth defects including severe
heart problems The died when he was
three years old and the family still grieved
his loss.
Maternal Grandfather: Alcoholic
Evaluation

Assessment Tools


Unstructured Interview
Psychiatric Evaluation
Symptoms:








Onset : shortly after entering college where she experienced
adjustment problems.
Unresolved grief.
Acceleration of symptoms
Avoidance Behaviors
Abuse of alcohol and over the counter drugs for a short
period
Suicidal Ideations
Irrational thoughts
Anger at Mother
Etiology



Learningnegative reinforcement
Irrational thinking
Biological
Treatment:





Group Therapy
Medication: zoloft
Relaxation Therapy
Hypnosis
Duration: 7 months

Prognosis-good
DSM IV TR





Axis
Axis
Axis
Axis
Axis
One: Panic Disorder with Agoraphobia
Two:
Three:
Four:
Five: