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Chapter 8 Anxiety Disorders: Panic Disorder, Agoraphobia, Generalized Anxiety Disorder, Social Anxiety Disorder and Specific Phobias Anxiety Disorders • Much of what we know is based on studies using criteria the predate DSM-5 • Anxiety disorders are prevalent and quite debilitating • In the United States, almost one-third of individuals will meet criteria for at least one anxiety disorder in their lifetimes – Prevalence rate is secondary only to substance use disorders Panic Attacks • A panic attack is defined as a discrete period of intense fear or discomfort that begins abruptly and reaches the peak within 10 minutes (plus at least four other symptoms) • Panic attacks may be expected (cued) or unexpected (uncued) • Panic attacks may occur in the nonclinical populations and in those with a comorbid psychiatric disorder Panic Attack Symptoms 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint Derealization (feelings of unreality) or depersonalization (being detached from oneself) Fear of losing control or going crazy Fear of dying Paresthesias (numbness or tingling sensations) Chills or hot flushes Panic Disorder: DSM-5 • The diagnosis of panic disorder requires recurrent and unexpected (uncued) panic attacks • Followed by one month of concern about: — Additional attacks or implication of the attack — Changes in behavior • DSM-5 does not recognize subtypes of panic disorder (respiratory, nocturnal) Agoraphobia: DSM-5 • Agoraphobia is a fear of being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available if a panic attack occurred • Patients with agoraphobia avoid (or endure with marked distress) certain situations (large stores, crowded places; traveling in a bus, train, or automobile) and being far away from home • Previously viewed as a frequent but secondary feature of panic disorder • Independent diagnosis in DSM-5 Generalized Anxiety Disorder (GAD): DSM-5 • Characterized by worry, which is typically defined as repetitive thinking about potential future threat, imagined catastrophes, uncertainties, and risks; patients with GAD spend an excessive amount of time worrying and feeling anxious about a variety of topics and find it difficult to control the worry • Associated with three (or more) of the following six symptoms: 1. Restlessness or feeling keyed up or on edge 2. Being easily fatigued 3. Difficulty concentrating or mind going blank 4. Irritability 5. Muscle tension 6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) Social Anxiety Disorder (SAD): DSM-5 • Marked and persistent fear of social or performance situations in which embarrassment may occur • Exposure to or anticipation of the situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack • Situations are avoided or endured with intense anxiety or distress • Clinician judgment that the fear is excessive or unreasonable • Interferes significantly with normal functioning, or there is marked distress about having the phobia. Specific Phobias: DSM-5 • Marked and persistent fears of clearly discernible, circumscribed objects or situations • Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack • Five subtypes are recognized in DSM-5: – Animals (snakes, spiders); natural environment (storms); blood/injection/injury; situations (elevators, flying); and other (choking, vomiting, falling) • Situation is avoided or is endured with intense anxiety or distress Epidemiology: Panic Disorder • Prevalence (based on panic disorder with agoraphobia) – 1.5% to 5% lifetime; 1% to 2.7% 12-month prevalence • Gender – 2:1 ratio of females to males • Age of onset – Average of 26.5 years of age • Comorbidity – 59% mood or anxiety disorder – 23% major depressive disorder • Clinical course – 12-month remission rate is approximately 17%, and the 5year remission rate is 39% Epidemiology: GAD • Prevalence – 5.7% lifetime prevalence; 12-month prevalence is 3.1% • Gender – 2:1 ratio of females to males • Age of onset – Later than other anxiety disorder, 50% by age 31 • Comorbidity – 26% also meet criteria for major depressive disorder – Also highly comorbid with other anxiety disorders • Clinical course – Longitudinal study found that 42% who had GAD at baseline were still symptomatic at 12-year follow-up – Even with CBT, only 50% achieve high end-state functioning Epidemiology: SAD • Prevalence – 5.0% to 13.3% lifetime; 12-month is 2.8% to 6.8% • Sex – Relatively equal between genders, 1.4:1 females to males • Age of onset – Average age is 15; median age is 12.5 years • Comorbidity – 45% mood or anxiety disorder – 28% anxiety disorder alone – 14% major depressive disorder • Clinical course – The 12-month remission rate is approximately 7%, and the 5-year remission rate is approximately 27% Epidemiology: Specific Phobia • Prevalence – 2% to 12.5% lifetime; 1.8% to 8.7% for 12-month • Gender – 4:1 ratio of females to males • Age of onset – Between 9 and 16 years of age • Comorbidity – Only 24.4% of individuals with specific phobias have a single specific phobia – 34% meet criteria for an additional disorder, with mood and anxiety disorders most common • Clinical course – The 15-month full remission rate is estimated to be approximately 19% Pharmacological Treatment • Benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), and tricyclic antidepressants • A growing body of research suggests that SSRIs and SNRIs should be considered the front-line pharmacological agents for panic disorder and social anxiety disorder • The use of pharmacological agents in the treatment of specific phobias is limited Cognitive-Behavioral Treatments • Panic disorder – CBT that incorporates psychoeducation, interoceptive and in vivo exposures, and cognitive restructuring have been very successful – Interoceptive exposure: Feared arousal-related sensations are provoked to facilitate habituation and allow for disconfirmation of feared catastrophes associated with such sensations in the absence of maladaptive responses, such as avoidance • Generalized anxiety disorder – CBT shown to be effective; exposure is not used to treat worry; instead nonadaptive patterns of awareness, physiology, behavior, and cognition are targeted – Less successful treatment for GAD than other anxiety disorders Cognitive-Behavioral Treatments cont. • Social anxiety disorder – Psychoeducation, exposure, and cognitive restructuring – In exposure therapy, individuals engage in feared social-evaluative situations to allow for disconfirmation of feared catastrophes associated with such situations – Newer formulations incorporate manipulation of self-focused attention, dropping of safety behaviors, reevaluation of social costs, and change in self-perceptions • Specific phobias – Exposure therapy is typically used for specific phobias – In the absence of avoidance responses, exposure leads to habituation Assessment • Clinical interviews – Anxiety Disorders Interview Schedule (ADIS) – Structured Clinical Interview (SCID) • Clinician- and self-report measures – – – – – Panic Disorder Severity Scale Generalized Anxiety Disorder Questionnaire Agoraphobic Cognitions Questionnaire Social Phobia and Anxiety Inventory Fear Survey Schedule • Behavioral tests – Behavioral Approach Test (BAT) – Self-monitoring • Biological assessment – CT and MRI for structural assessment – SPECT fMRI and PET for functional assessment Etiology: Behavioral Genetics • 20% of the variance is attributable to heritable genetics • Familial factors (i.e., environmental factors shared by twins and siblings) account for less than 10% of the variance • The majority of the variance (perhaps as much as 70%) is attributed to unique environmental factors and measurement error • Compared to other psychological disorders, these anxiety disorders appear to be relatively less influenced by heritable genetics and more influenced by environment or by gene– environment Etiology: Biological Considerations • Fight or flight: Designed to prevent or avoid physical danger and harm; involves a fast and efficient response • Amygdala hypothalamus releases corticotropin-releasing factor (CRF) triggers the pituitary to release adrenocorticotropic hormone (ACTH) triggers the adrenal cortex to release hormones, including cortisol • Hypothalamus also activates the sympathetic nervous system, which perpetuates other changes associated with the fight-or-flight response • These physiological changes constitute the physical symptoms of a panic attack Etiology: Personality and Temperament • Anxiety sensitivity – Dispositional trait that is characterized by a fear of autonomic arousal and the physical sensations associated with anxiety states – “Fear of fear” is often viewed as the key feature of panic disorder • Behavioral inhibition and shy temperament – An enduring tendency to respond to unfamiliar events with anxiety – Relative stability of socially inhibited behavior from the first years of life until adulthood is consistent with the view of social anxiety disorder as rooted in relatively unchangeable traits – A substantial number of children classified as BI do not go on to develop social anxiety disorder Etiology: Behavioral Considerations • Classical conditioning – Little Albert: fears can be acquired through a repeated process of paired learning • Operant conditioning – Avoidance behavior that accompanies phobic fear is maintained through a process of negative reinforcement • Vicarious conditioning – Observational learning or learning by modeling • Informational acquisition – Development of a fear as a result of receiving information, such as from a parent or doctor Etiology: Cognitive Considerations • Situation-specific cognitions and related variables – Expectancies, concerns, automatic thoughts, catastrophic thoughts, and catastrophic misinterpretations – Overestimations of fear and danger – Self-efficacy • Attentional biases – Anxiety is associated with biases in various attentional processes, namely orienting, engagement, and disengagement. – Occur in all anxiety disorders • Self-focused attention – Tendency for socially anxious individuals to attend to internal stimuli rather than external, social stimuli – Important factor in the maintenance of social anxiety Culture, Socialization, and Social Environment • Parental messages about the importance of interoceptive sensations; parental reinforcement of illness behavior • Reciprocal effects between the individual and the social environment – Modeling; informational acquisition; selection, creation, and interpretation of social opportunities; and the internalization of messages that one receives about one’s social value • Cultural variations in the disorders – Ataque de nervios – Taijin Kyofusho • Life events – Individuals with social anxiety disorder retrospectively report greater incidence of traumatic social events than do healthy controls – Latent inhibition