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Anxiety Disorders Importance of Anxiety Disorders Associated with considerable suffering and impaired functioning Some anxiety sufferers are housebound; many are unable to work Prevalence Among the most common psychiatric disorders 1 year prevalence: 12-17% (one or more anx disorder) Leading cause for seeking mental health services Total economic costs (% of psychiatric health care budget) Anxiety disorders (32%) > mood disorders (22%) > schizophrenia (21%) Approaches to Classification lumpers vs. splitters DSM-III began the process of “splitting” the anxiety disorders into many smaller categories Fundamental Features of Anxiety Disorders Unwanted emotions panic attacks chronic anxiety excessive fear Unwanted thoughts obsessions excessive worries intrusive recollections Unwanted actions avoidance, escape, distraction compulsions Major Anxiety Disorders in DSM-IV Panic disorder Agoraphobia Specific phobia Social phobia (social anxiety disorder) Generalized anxiety disorder Obsessive-compulsive disorder Posttraumatic stress disorder Acute stress disorder DSM-IV Criteria for Panic Disorder recurrent unexpected panic attacks at least 1 attack followed by at least a month of 1 or more of the following: persistent concern about having additional panic attacks worry about implications of the attack significant change in behaviour related to the attacks Panic Attack: Defining Features Discrete period of intense fear or discomfort: abrupt onset peaks within 10 min peak intensity lasts an average of 20 min can occur during waking hours or during sleep four or more symptoms required to define a DSMIV panic attack attacks with fewer than four symptoms are called “limited symptom” panic attacks Panic Attack Symptoms Palpitations Sweating Trembling or shaking Dyspnea Choking sensations Chest pain or discomfort Nausea or GI distress Chills or hot flushes Paresthesias (numbness or tingling) Dizziness or faintness Derealization or depersonalization Fear of losing control or going crazy Fear of dying DSM-IV Criteria for Agoraphobia anxiety about being in places or situations from which escape might be difficult or in which help may not be available if panic attacks or panic-like symptoms occur the agoraphobic situations are avoided (e.g., travel is restricted) or else endured with marked distress Agoraphobia: Situations Commonly Feared and Avoided Travelling Being far from home Enclosed spaces Wide open spaces Supermarket line-ups High places Being alone Specific Phobia Severe, excessive, and persistent fear Exposure to phobic object evokes fear or panic Person typically avoids phobic object Recognizes the fear is unreasonable Subtypes: animals natural environment stimuli (e.g., heights, water) situations (e.g., enclosed spaces) blood-injection-injury other Social Phobia same basic criteria as specific phobia social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others person fears acting in a way that will be humiliating or embarrassing Social Phobia: Examples of Feared Situations giving a speech musical performances playing a musical instrument singing one-to-one conversations authority figures people of the opposite sex eating in a restaurant urinating in a public restroom Generalized Anxiety Disorder excessive anxiety and worry occurring on most days for at least 6 months person worries about a number of events or activities person finds it difficult to control worry Obsessive-Compulsive Disorder Either obsessions or compulsions Obsessions recurrent, persistent thoughts, impulses, or images intrusive, unwanted distressing not simply excessive worries Compulsions repetitive behaviours or mental acts aimed at reducing distress or preventing harm often in response to obsessions Examples of Obsessions violent impulses and images sexual thoughts blasphemous thoughts Examples of Compulsions compulsive cleaning compulsive checking hoarding of possessions ordering and arranging objects Traumatic Stress Disorders Posttraumatic stress disorder Acute stress disorder Discussed in the following lecture Lifetime Prevalence (%) Panic disorder Agoraphobia Specific phobia Social phobia Posttraumatic stress disorder Acute stress disorder Obsessive-compulsive disorder Generalized anxiety disorder 1-2 1-2 7-11 3-13 8 14-33* 2.5 5 * Among people exposed to traumatic events Untreated Course of Anxiety Disorders Often arise in the context of stressful life events Typically chronic, but some remit without treatment Severity tends to wax and wane, often in response to life stressors For a given disorder, different symptoms can follow different courses; e.g., panic attacks may decrease in frequency as agoraphobia becomes more severe obsessions may decrease in frequency as compulsions becomes more severe Gender Differences and Age of Onset Most anxiety disorders: Gender ratio (F:M) ranges from 2:1 to 3:1 OCD: no gender differences Age of onset varies with disorder varies with exposure to stressors trends: many anxiety disorders arise in adolescence phobias often arise in childhood Comorbidity Current vs. lifetime comorbidity Anxiety disorders are often comorbid with one another mood disorders substance-use disorders eating disorders personality disorders Why are anxiety disorders so often comorbid with other disorders? Relation Between Anxiety and Depression both defined in terms of negative emotional experience both triggered by stressful experiences both respond to similar treatment methods (SSRIs, cognitive-behaviour therapy) Clark and Watson’s Model of Anxiety and Depression two dimensions of mood: positive and negative affect negative affect: high = upset; low = relaxed descriptive adjectives such as angry, guilty, afraid, sad, disgusted, or worried positive affect: high = energetic; low = tired descriptive adjectives such as delighted, interested, enthusiastic, proud Clark and Watson’s Model of Anxiety and Depression general distress: depressed people and anxious people both experience high levels of negative affect they are distinguished on the basis of positive affect depressed people are low on positive affect (e.g., loss of interest; fatigue; anhedonia) anxious people also experience high levels of physiological arousal Clark and Watson’s Model High negative affect Low positive affect High positive affect Low negative affect Environmental and Genetic Factors in Anxiety Disorders Anxiety disorders appear to arise from combination of: disorder disorder disorder disorder specific genetic factors specific environmental factors non-specific genetic factors specific environmental factors Genetic factors appear to influence the sorts of environment a person chooses e.g., genes for sensation-seeking --> exposure to traumatic events Role of Life Events in Anxiety and Depression people with anxiety disorders have experienced more stressful life events DANGER EVENTS: lead to anxiety LOSS EVENTS: lead to depression Role of Learning Conditioned fear reactions classical (Pavlovian) conditioning operant conditioning (e.g., avoidance learning) role in PTSD, phobias Maladaptive beliefs different mechanism to Pavlovian conditioning? prominent role in panic disorder appear to play a role in other anxiety disorders Classical Conditioning (Pavlov) UCS (meat powder) --> UCR (salivation) CS (ringing a bell) --> CR (salivation) original version: any neutral stimulus can be paired with the UCS and eventually lead to the CR the case of Little Albert Preparedness Version of Learning Theory problems with traditional theory conditioned fear responses are easy to extinguish phobias that develop after trauma are usually learned in only one trial (not in labs) why are phobias only associated with certain kinds of stimuli? Preparedness Theory of Phobias organisms are biologically prepared to learn certain kinds of associations quickly biological constraints on learning cannot use simply any neutral stimulus as the CS in classical conditioning organism’s “wiring” shaped by evolutionary pressures prepared associations are learned in one trial and are very difficult to extinguish Clark’s Cognitive Model of Panic Attacks Trigger Stimulus (internal or external) Perceived Threat Interpretation of Sensations as Catastrophic Apprehension Body Sensations Trigger Stimulus: Internal or External (Dizziness caused by standing up quickly) Perceived Threat (‘I could pass out’) Catastrophic Misinterpretations Anxiety or Panicky Feelings (‘Something really bad is happening; I could die’) Sensations (Palpitations, stronger dizziness) Examples of Links Between Sensations and Misinterpretations Sensation Catastrophic misinterpretation Palpitations “I am having a heart attack” Depersonalization “I am going insane” Shortness of breath “I am suffocating” Numbness and tingling “My nervous system is collapsing” People with panic disorder can catastrophically misinterpret all sorts of stimuli, including visual illusions How does the Cognitive Model Explain Unexpected Panic Attacks? Trigger Stimulus (internal or external) Perceived Threat Interpretation of Sensations as Catastrophic Apprehension Body Sensations Empirically Supported Treatments for Anxiety Disorders Drug therapies SSRIs: e.g., Prozac High potency benzodiazepines: e.g., Xanax Cognitive-behavioural therapies exposure therapy cognitive restructuring Important considerations Patient preference High addiction potential for some drugs (e.g., Xanax) Relapse rates: higher for drugs than for CBT Cognitive Symptoms in Anxiety Disorders (Beck) Sensory-Perceptual “Mind”: hazy, cloudy, foggy, dazed. Self-conscious Hypervigilant Thinking Difficulties Can’t recall important things Confused Unable to control thinking Cognitive Symptoms in Anxiety Disorders (Beck) Conceptual Cognitive distortions Fear of losing control Fear of negative evaluations