Download Anxiety Disorders

Anxiety Disorders
Pertemuan ke-5
Anxiety vs. Fear
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Anxiety
» Apprehension about a future threat
Fear
» Response to an immediate threat
Both involve physiological arousal
» Sympathetic nervous system
Both can be adaptive
» Fear triggers “flight or fight”
–May save life
» Anxiety increases preparedness
–Moderate levels improve performance
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Persamaan Cemas dan
Takut (Rahman, 1998)
Anticipation of danger or discomfort
 Tense apprehensiveness
 Elevated arousal
 Negative affect
 Uneasiness
 Future oriented
 Accompanied by bodily sensations
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Perbedaan Cemas dan Takut
(Rahman, 1998)
Fear
Anxiety
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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
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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
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Anxiety Disorders
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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 (Kessler et al., 2005)
 Most common are phobias
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Table 5.1 Summary of Major
Anxiety Disorders
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Phobias
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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
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Two types:
» Specific
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Specific Phobia
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Unwarranted, excessive fear of specific object or
situation
» Snakes, blood, flying, spiders, etc.
–How 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
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Social Phobia
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Persistent, intense fear of social situations
» Fear of negative evaluation or scrutiny
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More intense and extensive than shyness
» More appropriate diagnostic label?
– Social anxiety disorder
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» 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
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Panic Disorder
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Frequent panic attacks unrelated to
specific situations
Panic attack
» Sudden, intense episode of apprehension,
terror, feelings of impending doom
– Symptoms reach peak intensity within 10 minutes
» Accompanied by at least 4 other symptoms:
– Sweating, nausea, labored breathing, dizziness, heart
palpitations, upset stomach, lightheadedness, etc.
» Other symptoms may include:
– Depersonalization
– Derealization
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Panic Disorder
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Uncued attacks
» Occur unexpectedly without warning
» Panic disorder diagnosis requires recurrent
uncued attacks.
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Cued attacks
– Triggered by specific situations (e.g., tunnel)
– More likely a phobia
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Panic Disorder with Agoraphobia
» Avoidance of situations in which escape
would be difficult or embarrassing
» Panic disorder with agoraphobia tends to be
more chronic .
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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
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Generalized Anxiety Disorder (GAD)
Involves chronic, excessive,
uncontrollable worry
» Lasts at least 6 months
» Interferes with daily life
 Other symptoms:
» Restlessness, poor concentration,
irritability, muscle tension, tires easily,
sleep disturbance
 Common worries:
» Relationships, health, finances, daily
hassles
 Often begins in adolescence or earlier
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Obsessive-Compulsive Disorder (OCD)
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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
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Obsessive-Compulsive Disorder (OCD)
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Develops either before age 10 or during late
adolescence/early adulthood
Men
» Early onset more common
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Women
» Cleaning compulsions and later onset more
common
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OCD often chronic
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Post Traumatic Stress Disorder (PTSD)
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Extreme response to severe stressor
» Anxiety, avoidance of stimuli associated with
trauma, emotional numbing
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Exposure to a traumatic event that
involves actual or threatened death or
injury
» e.g., war, rape, natural disaster
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Trauma leads to intense fear or
helplessness
Symptoms present for more than a month
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Post Traumatic Stress Disorder (PTSD)
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Three categories of symptoms :
1. Re-experiencing the traumatic event
» Nightmares, intrusive thoughts, or images
2. Avoidance of stimuli
» e.g., Refuse to walk on street where rape
occurred
» Numbing
» Decreased interest in others
» Distant or estranged from others
» Unable to experience positive emotions
3. Increased arousal
» Insomnia, irritability, hypervigilance,
exaggerated startle response
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Acute Stress Disorder (ASD)
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Symptoms similar to PTSD
Duration varies
» Short term reaction
» Symptoms occur between 2 days and 1 month
after trauma
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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)
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Comorbidity
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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
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Gender & Sociocultural Factors
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Women are 2x as likely as men to have anxiety
disorder except for OCD
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Possible explanations
» Women may be more likely to report symptoms
» Women more likely to experience childhood sexual abuse
» Women show more biological stress reactivity
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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 (Kirmayer, 2001)
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Etiology of Specific Phobias
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Conditioning
Mowrer’s two-factor
model
» Pairing of stimulus with
aversive UCS leads to
fear (Classical
Conditioning)
» Avoidance maintained
though negative
reinforcement (Operant
Conditioning)
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Etiology of Specific Phobias
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Problems with two-factor model
» Many people never experience aversive interaction
with phobic object (see table 5.6)
» 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)
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Etiology of Social Phobia
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Two factor model
» Avoidance or safety behaviors
– Avoid eye contact, appear aloof, stand apart
from others in social settings
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Cognitive factors
» Negative self evaluation
– Harsh, punitive self-judgment
» Fear of negative evaluation by others
– Expect others to dislike them
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Excessive attention to internal cues
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Etiology of Panic
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Neurobiological
factors
» Locus ceruleus
– Major source of
norepinephrine
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A trigger for
nervous system
activity
» Multiple drugs can
induce panic
attacks
– Typically only in
those who are overly
concerned about
bodily changes
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Etiology of Panic
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Interoceptive
conditioning
» Classical conditioning of
panic in response to
bodily sensations
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People with panic
disorder sustain
classically conditioned
fears longer (Michael et al.,
2007)
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Etiology of Panic
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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
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Etiology of Agoraphobia
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Fear-of-fear hypothesis (Goldstein &
Chambless, 1978)
» Expectations about the catastrophic
consequences of having a public panic
attack.
–What will people think of me?!?!
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Etiology of GAD
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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)
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Etiology of OCD: Neurobiological Factors
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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)
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Etiology of OCD:
Behavioral & Cognitive Factors
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Operant reinforcement
» Compulsions negatively reinforced by the
reduction of anxiety
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Cognitive factors
» Lack of a satiety signal
» Yadasentience
– Subjective feeling of completion
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Knowing that you have thought enough or cleaned
enough
– Individuals with OCD have a yadasentience
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Etiology of PTSD
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Severity and type of trauma
Neurobiological
» Smaller hippocampal volume linked to PTSD
– Disruption of verbal vs. nonverbal memory
» Supersensitivity to cortisol
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Behavioral
» Two factor model
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Psychological
» Perception of control
» Avoidance coping, dissociation, memory suppression
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Intelligence and ability to grow from the experience
enhance coping
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Common Aspects of
Psychological Treatment
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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
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Systematic desensitization
» Relaxation plus imaginal exposure
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Common Aspects of
Psychological Treatment
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Cognitive approaches
» Increase belief in ability to cope with
the anxiety trigger
» Challenge expectations about
negative outcomes
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Medications
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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)
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Medications
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Demonstrated effectiveness as compared to
placebo
» Clomipramine for OCD
» Medication does not seem to help hoarding
» Beta blockers commonly prescribed for social phobia
although no demonstrated effectiveness
Side effects
» Withdrawal from benzodiazepenes
» Weight gain, nervousness, high blood pressure from SSRIs
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Relapse common after medication discontinuation
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