Download Panic Disorder

Chapter Four
Anxiety and Obsessive-Compulsive
and Related Disorders
Understanding Anxiety Disorders
• Anxiety:
– Fundamental human emotion
– A feeling of uneasiness or apprehension
– Anxiety is anticipatory: waiting for a dreaded
event to occur
– Has an adaptive function
• Fear:
– Intense emotion experienced in response to
threatening situation
Understanding Anxiety Disorders
(cont’d.)
• Anxiety disorder:
– Fear or anxiety symptoms that interfere with an
individual’s day-to-day functioning
• Three anxiety disorder covered in chapter
– Phobias
– Panic disorder
– Generalized anxiety disorder
• Obsessive-compulsive and related disorders
also discussed due to similarities with anxiety
disorders
Understanding Anxiety Disorders
(cont’d.)
Figure 4-1 Prevalence of Anxiety Disorders in the United States Anxiety disorders
are the most common mental condition in the United States.
Source: R.C. Kessler, Berglund, Demler, Jin, Merikangas, et al. (2005); R.C. Kessler, Chiu, Demler &
Walters (2005).
Understanding Disorders from a
Multipath Perspective
• Etiological models:
– Developed to explain the cause of a disorder
– Insufficiently explain individual variations in
response to fearful situations
– Various factors play a role
• Biological
• Psychological
• Social and Sociocultural
Understanding Disorders from a
Multipath Perspective (cont’d.)
Figure 4-2 Multipath Model of Anxiety Disorders The dimensions interact with one
another and combine in different ways to result in a specific anxiety disorder. The
importance and influence of each dimension varies from individual to individual.
Biological Dimension
• Two main biological factors:
– Brain function
• Amygdala
• Hippocampus
• Prefrontal cortex
– Genetic influences
• Modest contribution to anxiety disorders
• Interact with other multipath factors
Biological Dimension (cont’d.)
Figure 4-3 Neuroanatomical Basis for Panic and Other Anxiety Disorders The fear
network in the brain is centered in the amygdala, which interacts with the hippocampus
and areas of the prefrontal cortex. Antianxiety medications appear to desensitize the fear
network. Some psychotherapies also affect brain functioning related to anxiety.
Biological Dimension (cont’d.)
• Genetic influences
– Neurotransmitters: chemicals that help transmit
messages between neurons
• Serotonin: regulates mood, sleep, and appetite
– Alleles: gene pair responsible for a specific trait
• Polymorphic variation
– Predisposition: a susceptibility to certain
symptoms or disorders
Interactions Among Factors
• Biological, psychological, social, and
sociocultural factors interact with one another
– Interplay between genetic and environmental
influences
– Environmental variables affect gene expression
– Reducing risk of lifelong anxiety:
• Environmental factors can both contribute to and
protect against behavioral inhibition
Psychological Dimension
• Psychological characteristics can interact with
biological predispositions
• Anxiety sensitivity (a personality variable) may
be a risk factor
• Psychological variables such as one’s sense of
control may also be involved
Social and Sociocultural Dimensions
•
•
•
•
•
•
•
Daily environmental stress
Poverty
Traumatic events
Social support network
Gender
Acculturation factors among minority groups
Discrimination and prejudice
Phobias
• Phobia:
– Strong, persistent, unwarranted fear of a specific
object or situation
– Extreme anxiety or panic is expressed when
phobic stimulus is encountered
– Most common mental disorder in United States
• Comes from Greek word for fear
Social Anxiety Disorder
• Social anxiety disorder (SAD):
– Intense fear of being scrutinized in one or more
social or performance situations
– Generalized type versus performance type
– Comorbid: existing simultaneously with another
condition
– “Threat cues” and “safety behaviors”
– Can be chronic and disabling
Specific Phobias
• Specific phobia:
– Extreme fear of a specific object or situation;
exposure to stimulus nearly always produces
intense anxiety or panic
• Primary types:
– Animal
– Natural environmental
– Blood/injection or injury
– Situational
Specific Phobias (cont’d.)
Figure 4-4 Phobia Onset This graph illustrates the average ages at which 370 people
said their phobias began. Animal phobias began during childhood, whereas the onset of
agoraphobia did not occur until the individuals were in their late 20s. What accounts for
the difference reported in the age of onset for the types of phobias?
Source: Based on Öst (1987, 1992)
Agoraphobia
• Intense fear of at least two of the following:
– Being outside of the home alone
– Traveling in public transportation
– Being in open spaces
– Being in stores or theatres
– Standing in line or being in a crowd
• These situations are feared because escape or
help may not be readily available
• Anxiety over having a panic attack
Etiology of Phobias
Figure 4-5 Multipath Model of Phobias The dimensions interact with one another and
combine in different ways to result in a phobia.
Etiology of Phobias (cont’d.)
• Biological dimension:
– Genetics or biological preparedness
• Psychological dimension:
– Classical conditioning perspective
– Observational learning or modeling perspective
– Negative information perspective
– Cognitive-behavioral perspective
Etiology of Phobias (cont’d.)
• Social dimension:
– Family interaction patterns
– Peer victimization
• Sociocultural dimension:
– Gender
– Child-rearing practices
– Culturally distinctive phobias
Treatment of Phobias
• Biochemical:
– Benzodiazepines and antidepressant SSRIs are
effective in treating social anxiety disorder
– Benzodiazepines also used for specific phobias
– Side effects of medications
•
•
•
•
Dependence
Withdrawal symptoms
Paradoxical reactions
Symptoms recur when medication is discontinued
Treatment of Phobias (cont’d.)
• Behavioral:
– Exposure therapy:
• Gradually introduce increasingly difficult encounters
with feared situation
– Systematic desensitization:
• Uses muscle relaxation to reduce anxiety
– Cognitive restructuring:
• Unrealistic thoughts are altered
– Modeling:
• Patient observes a model coping with, or responding
appropriately to, the feared situation
Treatment of Phobias (cont’d.)
Rapid Behavioral Treatment of a Phobia (Snake Phobia, Fear Conditioning) Watch a
demonstration of exposure therapy that helps a snake phobic overcome her severe
phobic reaction- in just 3 hours. Learn what researchers have to say about this very brief
form treatment and how well the results are maintained over time.
Panic Disorder
• Recurrent unexpected panic attacks in
combination with:
– Apprehension over having another attack or worry
about consequences of an attack
– Changes in behavior or activities designed to avoid
another panic attack
– Reactions must be present for at least one month
Panic Disorder (cont’d.)
Panic Disorder Learn about the symptoms and diagnosis of panic disorder.
Etiology of Panic Disorder
Figure 4-6 Multipath Model of Panic Disorder The dimensions interact with one
another and combine in different ways to result in a panic disorder.
Etiology of Panic Disorder (cont’d.)
• Biological dimension:
– Higher concordance rates found in monozygotic twins
– Modest heritability rate of 32%
– Brain structures (e.g., amygdala) and
neurotransmitters (e.g., serotonin) involved
– Reduction in GABA receptors in hippocampus and
amygdala
Etiology of Panic Disorder (cont’d.)
• Psychological dimension:
– Characteristics associated with panic disorder
– Cognitive behavioral perspective:
• Stresses individual’s misinterpretation of unpleasant bodily
sensations as indicators of impending disaster
• Interoceptive conditioning
Etiology of Panic Disorder (cont’d.)
Figure 4-7 Role of Cognitions in Panic Attacks A positive feedback loop between
cognitions and somatic symptoms leads to panic attacks.
Source: Roy-Byrne, Craske, & Stein (2006), p. 1027
Etiology of Panic Disorder (cont’d.)
• Social and sociocultural dimensions:
– Stressful childhood involving
•
•
•
•
Separation anxiety
Family conflicts
School problems
Loss of loved one
– Major life changes occurring prior to attacks
– Culture plays a role
Treatment of Panic Disorder
• Both medication and cognitive-behavioral
therapies have been effective
– Biochemical:
• Benzodiazepines, antidepressants, and SSRIs
– Cognitive-behavioral:
• Extinction of fear associated with internal bodily
sensations and fear-producing environmental situations
Generalized Anxiety Disorder (GAD)
• Persistent high levels of anxiety and excessive
worry over many life circumstances
– Symptoms must be present for at least three
months
– Develops gradually, beginning in childhood or
adolescence
– Somatic symptoms:
• Muscle tension, restlessness, sleep difficulties, poor
concentration, and avoidance of situations associated
with worry
Generalized Anxiety Disorder (cont’d.)
• 3.1% of adult U.S. population has GAD in any
given year
• Twice as common in women as in men
• Most frequently diagnosed anxiety disorder
worldwide
Etiology of GAD
Figure 4-8 Multipath Model of GAD The dimensions interact with one another and
combine in different ways to result in generalized anxiety disorder (GAD).
Etiology of GAD (cont’d.)
• Biological dimension:
– Small but significant heritability factor
– May disrupt prefrontal cortex modulation of
amygdala
• Psychological dimension:
– Cognitive theories: role of dysfunctional thinking
and beliefs
– Negative schemas: set of beliefs or ideas
Etiology of GAD (cont’d.)
• Social and sociocultural dimensions:
– Children of mothers with GAD may develop
anxiety disorder
– Poverty
– Poor housing
– Prejudice
– Discrimination
– More common in separated, divorced, widowed,
or unemployed individuals
Treatment of GAD
• Biochemical treatment:
– Benzodiazepines, but problems of dependence
– Tricyclic and SSRI antidepressants are medications
of choice due to less risk or dependence
– Newer antianxiety medication: buspirone
• Cognitive-behavioral therapy:
– Only consistently validated psychological
treatment
Obsessive-Compulsive and Related
Disorders
• Have much in common with anxiety disorders
• Include:
– Obsessive-compulsive and related disorders
– Body dysmorphic disorder
– Hair-pulling disorder
– Skin-picking disorder
Obsessive-Compulsive Disorder
• Characterized by:
– Obsessions:
• Intrusive, repetitive thoughts or images that produce
anxiety (e.g., contamination, orderliness, uncertainty)
– Compulsions:
• The need to perform acts or dwell on thoughts to reduce
anxiety (e.g., repetitive behaviors, mental acts)
Obsessive-Compulsive Disorder
(cont’d.)
• Associated thoughts and actions that are out
of character and not under voluntary control
• Recognition that thoughts and impulses are
senseless, but no control
• In a given year, about 1% of U.S. adult
population suffers from OCD
• Onset occurs in childhood or adolescence
• May be underdiagnosed
Body Dysmorphic Disorder (BDD)
• Involves preoccupation with a perceived
physical defect in a normal-appearing person
or excessive concern over a slight physical
defect
• Comes from Greek word for abnormal shape
• Produces marked clinical distress
• Chronic and difficult to treat
• Underdiagnosed
Body Dysmorphic Disorder (cont’d.)
• Compulsive behaviors:
– Frequent mirror checking
– Excessive grooming
– Seeking constant reassurance
• Common concerns:
– Bodily features (e.g., lack of hair, size of nose)
– Muscle dysphoria: believing that one’s body is too
small or insufficiently muscular
Hair-Pulling Disorder
• Hair-pulling disorder (trichotillomania):
– Recurrent and compulsive hair pulling that causes
significant distress and results in hair loss
– Symptoms usually begin before age 17
– 4% of population may be affected
– Four times higher prevalence in women
Skin-Picking Disorder
• Skin-picking disorder:
– Distressing and recurrent compulsive picking of
the skin resulting in skin lesions
– Three-quarters are females
– Often comorbid with body dysmorphic disorder or
trichotillomania
Etiology of Obsessive-Compulsive and
Related Disorders
Figure 4-11 Multipath Model for OCD The dimensions interact with one another and
combine in different ways to result in obsessive-compulsive disorder.
Etiology of Obsessive-Compulsive and
Related Disorders (cont’d.)
• Biological dimension:
– Decision making, planning, and mental flexibility
may be endophenotypes for OCD
– Brain structure:
• Orbitofrontal cortex
• Caudate nuclei
– Genetic studies
– Biochemical abnormalities:
• Serotonin deficiency
Etiology of Obsessive-Compulsive and
Related Disorders (cont’d.)
Figure 4-12 OrbitoFrontal Cortex Individuals with untreated obsessive-compulsive
disorder show a high metabolism rate in this area of the brain. Certain medications
reduce metabolic rates to “normal” levels and also reduce obsessive-compulsive
symptoms.
Etiology of Obsessive-Compulsive and
Related Disorders (cont’d.)
• Psychological dimension:
– Behavioral perspective:
• Obsessive-compulsive behaviors develop because they
reduce anxiety
– Cognitive characteristics:
•
•
•
•
•
Threat estimation
Control
Intolerance of uncertainty
Distrust of own memories and judgment
Disconfirmatory bias
Etiology of Obsessive-Compulsive and
Related Disorders (cont’d.)
• Social and sociocultural dimensions:
– Family variables
• Controlling, overly critical parenting styles
• Low parental warmth
• Discouragement of autonomy
– Being raised in adverse environments
– Ethnic minorities underrepresented in clinical
studies
– Culture may affect how symptoms are expressed
Treatment of Obsessive-Compulsive
and Related Disorders
• Biological treatments:
– SSRI’s have fewer side effects but only 60% of
individuals respond to them
– Rapid return of symptoms
• Behavioral treatments:
– Combination of exposure and response
prevention
• Flooding versus gradual exposure
– Cognitive-behavioral therapy