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Anxiety Disorders Chapter 6 Anxiety Disorders: Defining Fear • Fear functions to protect us from danger • Anxiety – Future-oriented response to perception of anticipated threat • Fear – Response to immediate threat • Worry – Mental strategy used to avoid future danger • Examples of normal fear responses Anxiety consequences • Physiological arousal – Sympathetic nervous system – “fight or flight” • Emotional symptoms • Cognitive – Worry, attentional shifts • Behavioral responses – Fight – Flee (Escape/avoidance) Adaptive • Fear triggers “fight or flight” – May save life • Anxiety increases preparedness – “U-shaped” curve (Yerkes & Dodson, 1908) when normal anxiety goes awry • Most experience excessive anxiety • Excessive Worry – Feels uncontrollable, can be less realistic concerns • Phobias – Irrational/unreasonable fear of specific objects/situations – Avoidance and/or extreme distress • Panic Attacks The Anxiety Disorders and Their Commonalities • Anxiety disorders have unrealistic, irrational fears or anxieties of disabling intensity as their most obvious manifestation 6 The Anxiety Disorders and Their Commonalities • The DSM-5 recognizes five primary types of anxiety disorders Specific phobias Social anxiety disorder Panic disorder Agoraphobia Generalized anxiety disorder 7 Figure 6.1: Diagnoses of Anxiety Disorders The DSM-IV-TR Anxiety Disorders have been divided into three chapters in the proposed DSM-5: Anxiety Disorders, ObsessiveCompulsive and Related Disorders, and Traumaand Stressor-Related Disorders. Agoraphobia has been changed from a subtype of panic disorder to a diagnosis in its own right. Table 6. 1: DSM-IV-TR and DSM-5 Diagnoses of Anxiety Disorders More specific criteria for children Body’s response to fear • The hypothalamus (in the brain) triggers a series of reactions in response to arousal and fear • Two systems are activated – Autonomic nervous system • Sympathetic-adrenomedullary (SAM) – Endocrine system • Hypothalamic-pituitary adrenocortical (HPA) ANS • Autonomic nervous system – Network of nerve fibers that connects the CNS to the organs of the body – Regulates involuntary actions • • • • Heartbeat Breathing Blood pressure Perspiration – Two pathways: • Sympathetic nervous system • Parasympathetic nervous system Sympathetic nervous system • “Flight or fight” response – Discharge of adrenaline – Heart rate increased – Pupils dilated – Skin constricts – Blood sugar increases • Neurotransmitters involved – Norepinephrine, serotonin, and dopamine HPA axis 1. Stressors 2. Hypothalamus signals the pituitary gland to secrete ACTH 3. Adrenal glands are stimulated, triggering release of corticosteroids 4. Long-term impact DSM Panic Attacks: Defined by 4 or more of the following 13 symptoms 11 Somatic Symptoms • Increased heart rate • Shortness of breath • Chest pain • Choking sensation • Trembling • Sweating • Nausea • Dizziness • Numbness/Tingling • Hot flashes or chills • Depersonalization 2 Cognitive Symptoms • Fear of dying • Fear of losing control Types of Panic Attacks • Unexpected (uncued) – Not associated with situational trigger • Situationally bound (cued) – Exposure to, or in anticipation of, a trigger • Situationally pre-disposed – More likely to occur on exposure to trigger, but not invariably associated; do not necessarily occur immediately Panic Disorder • Recurrent unexpected panic attacks Criterion B • Worry about future attacks • Worry about the consequences of the attack (i.e., having a heart attack) • Substantial behavioral changes in response to the attacks Panic Disorder • The two features of panic attacks that distinguish them from other types of anxiety are Their characteristic brevity Their intensity • Associated symptoms: – General anxiety – Hypersensitive to physical cues – Demoralization – Major depressive disorder – Substance related disorders – High comorbidity – Visits to ER Panic Disorder • 3.5 percent of the adult population have had panic disorder at some time in their lives • It’s twice as prevalent in women as men • 50 percent of people with panic disorder have additional diagnoses • DSM-5 – 2-3% 12 month prevalence • NCS – 1.5-4.7% 19 Panic Disorder • Age of onset • Course • Differential diagnosis Case example • Abby, a 29 year old female, reports unexpected panic attacks and describes increased heart rate, lightheadedness, shortness of breath, and tingling sensations in her arms. When she experiences these episodes, she believes that she is going to faint; she describes fainting as both embarrassing and dangerous. She worries about having these episodes when in public places and places where getting help would be difficult. Because of her fear, she avoids going to public places alone and always carries her cell phone in case she needs to call for help. Biological Causal Factors • Panic disorder has a moderate heritable component • There is a broad range of biochemical panic provocation agents • There are also several areas of the brain implicated in panic attacks 22 Panic and the Brain The anticipatory anxiety about future panic attacks is thought to arise from activity in the limbic system Phobic avoidance may involve activity of the hippocampus Panic attacks may arise from abnormal activity in the amygdala 23 Panic Disorder- Cognitive-Behavioral Model • Attuned to cues • Interoceptive fears – Interoceptive conditioning • Cognitive component • Leads to cycle 24 Core Patterns in Panic Disorder • Fears of symptoms of anxiety (anxiety sensitivity) – Risk for onset of panic attacks – Risk for biological provocation of panic – Risk for panic disorder relapse (McNally , 2002) Common Catastrophic Thoughts in Panic Disorder • Fears of death or disability – Am I having a heart attack? – I am having a stroke! – I am going to suffocate! • Fears of losing control/insanity – I am going to lose control and scream – I am having a nervous breakdown – If I don’t escape, I will go crazy • Fears of humiliation or embarrassment – People will think something is wrong with me – They will think I am a lunatic – I will faint and be embarrassed Cognitive-Behavioral Model of Panic Disorder Stress Biological Diathesis Alarm Reaction Rapid heart rate, heart palpitations Shortness of breath, smothering sensations Chest pain or discomfort, numbness or tingling Increased anxiety and fear Conditioned Fear of Somatic Sensations Catastrophic misinterpretations of symptoms Hypervigilance to symptoms Anticipatory anxiety Memory of past attacks Integrated Model Biological Vulnerability to hypersensitive fight or flight response Tendency to engage in catastrophic cognitions about physiological symptoms Panic attacks and hypervigiliance for signs of panic DSM-5 Criteria for Agoraphobia • Disproportionate and marked fear or anxiety about at least 2 situations where it would be difficult to escape or receive help in the event of incapacitation or paniclike symptoms, such as: – being outside of the home alone; traveling on public transportation; open spaces such as parking lots and marketplaces; being in shops, theaters, or cinemas; standing in line or being in a crowd • These situations consistently provoke fear or anxiety • These situations are avoided, require the presence of a companion, or are endured with intense fear or anxiety • Symptoms last at least 6 months Agoraphobia • 1.7% 12 month prevalence • 75-80% of people with severe agoraphobia are female. • Elderly – usually traced to an illness or injury • Usually develops within one year of panic attacks when associated with panic disorder. Etiology of Agoraphobia • Fear-of-fear hypothesis (Goldstein & Chambless, 1978) – Expectations about the catastrophic consequences of having a public panic attack • What will people think of me?!?! © 2012 John Wiley & Sons, Inc. All rights reserved. Treating Panic Disorder and Agoraphobia • Medications – Benzodiazepine – Antidepressants- SSRIs • Behavioral and cognitive-behavioral treatments – Information – Cognitive interventions – Interoceptive exposure – In vivo exposure 32 Information Interventions • May include handouts or patient manuals • Distinguishes between symptoms, thoughts, and behaviors – and introduces the cascade between these elements • Introduces the notion and consequences of catastrophic thoughts • Addresses the role of escape and avoidance in maintaining fear • Helps the patient adopt an informed and active role in treatment Cognitive Restructuring - General • Identify the nature of thoughts: they don’t have to be true to affect emotions • Learn about common biases in thoughts • Treat thoughts as “guesses” or “hypotheses” about the world Cognitive Restructuring - Specific • Increase awareness of thinking patterns – Over-estimating the probability of negative outcomes – Assuming the consequence will be unmanageable • Monitor relationship between thinking and panic episodes • Challenge thinking – Evaluating evidence for the thought – Evaluating the cost of the feared outcome • Establish adaptive thinking patterns – Reality based thinking and not just positive thinking Exposure! • Provide clients with a way to unlearn their fears • Learn to master situations that cause anxiety • Habituation to anxiety at each step – Biggest trap is to flee a step at height of fear – Reinforces association between situation and fear – Confront fear regularly and frequently Exposure Interventions • Provide rationale for confronting feared situations • Establish a hierarchy of feared situations • Provide accurate expectations • Repeat exposure until fear diminishes • Attend to the disconfirmation of fears (“What was learned from the exposure?”) Common Interoceptive Exposure Procedures • Headrolling – 30 seconds - dizziness, disorientation • Hyperventilation – 1 minute - produces dizziness lightheadedness, numbness, tingling, hot flushes, visual distortion • Stair running – a few flights – produces breathlessness, a pounding heart, heavy legs, trembling • Full body tension – 1 minute – produces trembling, heavy muscles, numbness • Chair spinning – several times around – produces strong dizziness, disorientation • Mirror (or hand) staring – 1 minute – produces derealization Relative Comfort Panic Cycle Uh oh! What if: •Notice the sensation •This gets worse? •I lose control? •This is a stroke? I have to control this! •Do nothing to control it. •Relax WITH the sensation Learning Safety in Panic Interoceptive exposure • Feared sensations become safe sensations – in the office with the therapist – at home – independent of the treatment context Situational Exposures • Rationale: – Providing a new learning opportunity to examine negative predictions about feared outcomes – Increasing tolerance to internal sensations in feared situations Situational Exposure Guidelines • Prior to completing in-vivo exposures, create a fear hierarchy identifying feared and avoided situations • Identify safety behaviors- actions taken to avoid, prevent, or manage a potential threat – Avoidance – Checking (pulse, exits, hospitals) – Carrying aids (rescue medications, cellular phones) Example hierarchy • • • • • • • Traveling one stop, quiet time of day Traveling two stops, quiet time Traveling two stops, rush hour Traveling five stops, quiet time Traveling five stops, rush hour Traveling all of the way, quiet time Traveling all of the way, rush hour Exposure • Common situations include bridges, malls, theaters Phobic Disorders • A phobia is a persistent and disproportionate fear of some specific object or situation that presents little or no actual danger • Severity • The DSM-5: – Specific phobia – Social anxiety disorder 46 Specific Phobia • Marked and persistent fear of a specific object or situation – Other than those associated with agoraphobia or social anxiety disorder • Anticipated harm • Fear of losing control, panicking, or fainting • Exposure to feared stimulus produces a panic attack or anxiety response – avoidance Specific Phobia • • • • Insight in adults Must interfere or caused marked distress Onset Rates Table 6.3: Types of Specific Phobias Specific Phobias- Behavioral Explanations • Direct conditioning • Vicarious learning • Mowrer’s 2 factor theory – Classical conditioning – Avoidance conditioning 50 Etiology of Specific Phobias • Conditioning • Mowrer’s two-factor model – Pairing of stimulus with aversive UCS leads to fear (Classical Conditioning) – Avoidance maintained though negative reinforcement (Operant Conditioning) Etiology of Specific Phobias • Extensions of the two-factor model – Modeling • Seeing another person harmed by the stimulus – Verbal instruction • Parent warning a child about a danger – Those with anxiety tend to acquire fear more readily • And to be more resistant to extinction © 2012 John Wiley & Sons, Inc. All rights reserved. Specific Phobias- etiology • Cognitive variables • Genetic • Biological preparedness – We may be biologically prepared to rapidly associate some objects with aversive consequences Treating Specific Phobias • Exposure therapy is the most commonly used treatment for specific phobias • Other therapies include – Participant modeling – Virtual reality therapies – Combining cognitive techniques with exposurebased therapies 54 Social Anxiety Disorder • Involves disabling fears of one or more discrete social situations in which a person fears that she or he may be exposed to the scrutiny and potential negative evaluation of others 55 Common fears • • • • Public speaking Attending parties Speaking to authority figures Writing/eating in public Social Anxiety Disorder: Associated features • • • • • • Self-medication Depression Hypersensitivity to criticism Problems being assertive Social skills underachievement Social Anxiety Disorder • Social phobias generally involve learned behaviors – Such learning is most likely to occur in people who are genetically or temperamentally at risk • Cognitive factors – Unrealistic negative beliefs about consequences of behaviors – Excessive attention to internal cues – Fear of negative evaluation by others • Expect others to dislike them – Negative self evaluation • Harsh, punitive self-judgment 58 Social Anxiety Disorder • Treatments for social phobias include – Behavior therapy – Cognitive-behavioral therapy – Medications • Beta blockers • SSRIs • Anxiolytics – Benzodiazepine – Others- BuSpar 59 Generalized Anxiety Disorder • Excessive anxiety and worry at least 50 percent of days about at least two life domains (e.g., family, health, finances, work, and school) • The worry is sustained for at least 3 months • The anxiety and worry are associated with at least three of the following: – – – – – – 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 • The anxiety and worry are associated with marked avoidance of situations in which negative outcomes could occur, marked time and effort preparing for situations that might have a negative outcome, marked procrastination, difficulty making decisions due to worries, or repeatedly seeking reassurance due to worries – Note: Italics reflect changes introduced in DSM-5. 60 GAD • Each year 3% of the population experiences GAD • It is twice as common in women as in men • It often co-occurs with other AXIS I disorders Generalized Anxiety Disorder: Psychosocial Causal Factors • It may occur in people who have had extensive experience with uncontrollable events • 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 – Worrying decreases psychophysiological arousal – Avoidance prevents extinction of underlying anxiety 62 Figure 6.8: The Excessive Worry of GAD May be an Attempt to Avoid Intense Emotions Generalized Anxiety Disorder: Biological Causal Factors • It is modestly heritable • The neurotransmitters GABA, serotonin, and perhaps norepinephrine all play a roll in anxiety • CRH also plays a role • Neurobiological factors implicated in panic disorders and GAD are not the same 64 Treating Generalized Anxiety Disorder • Drugs such as Valium are often misused • Buspirone seems effective and nonaddictive • Cognitive-behavioral therapy has become increasingly effective 65 Table 6.4: Percent of People Who Meet Diagnostic Criteria for Anxiety Disorders in the Past Year and in Their Lifetime © 2012 John Wiley & Sons, Inc. All rights reserved. Epidemiology • NCSR – Median age of onset Specific Phobia: 7 SAD: 13 OCD: 19 Agoraphobia w/o panic: 20 Panic Disorder: 24 GAD 31 Any anxiety disorder: 11 16 14 18-29 30-44 45-59 60+ 12 10 8 6 4 2 0 Panic disorder Specific phobia Social phobia GAD OCD Epidemiology • Gender – Women more likely to experience all anxiety disorders – Women more likely to relapse – Women may be more vulnerable to substance misuse – Why? • • • • Women may be more likely to report symptoms Men more likely to be encouraged to face fears Women more likely to experience childhood sexual abuse Women show more biological stress reactivity Comorbidity • 80% of those with anxiety disorder meet criteria for another anxiety disorder – Subthreshold symptoms (do not meet full DSM) very common – Causes of comorbidity • Symptoms used to diagnose the various anxiety disorders overlap: – Social anxiety and agoraphobia might both involve a fear of crowds • Etiological factors may increase risk for more than one anxiety disorder • 75% of those with anxiety disorder meet criteria for another psychological disorder – Disorders commonly comorbid with anxiety: • • • • 60% with anxiety also have depression Substance abuse Personality disorders Medical disorders, e.g. coronary heart disease Diagnostic Considerations • High rates of comorbidity among the anxiety disorders – Are they truly unique disorders? • High rates of comorbidity with depression – Are anxiety d/o separate from mood d/o? – Both are characterized by high levels of negative emotion, but depression is also characterized by low positive emotion whereas anxiety is not. The Anxiety Disorders and Their Commonalities • There are some important similarities among – The basic biological causes of these disorders – The basic psychological causes of these disorders – The effective treatments for these disorders 71 Etiology in general • Biological factors • Social factors • Psychological factors Table 6.5: Factors that May Increase the Risk for More than One Anxiety Disorder • • • • Behavioral conditioning Genetic vulnerability Increased activity in the fear circuit of the brain Decreased functioning of GABA and serotonin; increased norepinephrine activity • Behavioral inhibition • Neuroticism • Cognitive factors, including sustained negative beliefs, perceived lack of control, and attention to cues of threat Etiology – Biological factors Genes • Family studies Proband Diagnosis Panic Disorder GAD SAD OCD 1st degree relatives with Disorder 15% 19% 16% 2% NCSR Lifetime Prevalence 4.7% 5.7% 12.1% 1.6% • Twin studies – Concordance rates significantly higher in MZ vs DZ twins (Kendler et al., 1992) Etiology – Biological factors Nervous system • Fear circuit overactivity • Amygdala • Medial prefrontal cortex deficits • Neurotransmitters are thought to play a role • Poor functioning of serotonin and GABA • Higher levels of norepinephrine Risk Factors: Personality • Behavioral inhibition – Tendency to be agitated, distressed, and cry in unfamiliar or novel settings • Observed in infants as young as 4 months • May be inherited – Predicts anxiety in childhood and social anxiety in adolescence • Neuroticism – React with negative affect – Linked to anxiety and depression – Higher levels linked to double the likelihood of developing anxiety disorders Etiology – Social Factors • Stressful life events – Prospective data indicate may increase anxiety d/o vulnerability – How differ from depression? • Dangerous event -> anxiety • Severe loss -> depression Table 6.6: Percent of People Reporting Conditioning Experiences Before the Onset of a Phobia Etiology – Psychological Factors Learning • Observational Learning • Preparedness model (Mineka & Ohman, 2002) – It is easier for us to learn and maintain CR to dangerous stimuli (e.g., snake) than nondangerous ones (e.g., flower) Etiology – Psychological Factors Cognitions • Sustained negative beliefs about future – Bad things will happen – Engage in safety behaviors • Perceived lack of control – More vulnerable to developing anxiety disorder • Childhood trauma or punitive parenting may foster beliefs • Serious life events can threaten sense of control • Attentional biases to threat • Maladaptive attempts at thought suppression Medications, continued • Antidepressant medications – Selective serotonin reuptake inhibitors (SSRI) – preferred medication treatment for most anxiety disorders. – Tricyclics (e.g., imipramine) – also effective but more side effects Treatment - Behavioral Exposure • Types – Prolonged • In vivo • Imaginal – Flooding – Interoceptive exposure – treatment for panic disorder, exposure to anxious provoking physiological symptoms (e.g., sweating, dizziness). Treatment – Cognitive • Usually combined with behavioral techniques • Addresses present cognitive distortions – Catastrophizing – Fortune telling • What if? – Overestimation of negative probabilities Treatment – what works for what • Some Meta-analytical findings (Butler et al., 2006; Butler et al., 2004; Mitte, 2005; Eddy et al., 2004) Panic (treatment vs. placebo condition) Effect Size Antidepressants Benzodiazapines Behavior therapy Cognitive therapy .82 .29 1.36 .75 Generalized Anxiety disorder CBT vs. no treatment CBT vs. placebo CBT vs. medications .82 .57 .33 Treatment – Cognitive-Behavioral • Some evidence that combining meds and psychosocial treatments less effective than singular treatments for some anxiety disorders