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Chapter 6: Anxiety Disorders Ch 6 Anxiety Disorders • Anxiety refers to an unpleasant feeling of fear and apprehension – Neuroses is a former term that refers to a group of disorders involving unrealistic anxiety, assumed to be due to unconscious conflicts • Anxiety disorders reflect the clear presence of symptoms of anxiety – Anxiety is not specific to anxiety disorders – Comorbidity: A person may be diagnosed with more than one disorder • Distinguishing stress, fear, and anxiety – Stress is the perception of an external demand, or challenge Ch 6.1 Abrupt and Aversive CNS Response to Real Threat or Danger Prepares Organisms for Immediate Action Action Tendency “Fight” or “Flight” More Diffuse Response About Impending Real or Imagined “Future” Threat or Danger Real Threat True Alarm Adaptive Maladaptive False Alarm No Threat Etiology “Disordered” or “Maladaptive” Experience of Anxiety or Fear “Normal” or “Adaptive” Experience of Anxiety or Fear Phobias • A phobia is a fear-mediated avoidance that is out of proportion to the object or situation – Phobias involve intense distress – Phobias are disruptive – Person recognizes that the fear is groundless Ch 6.2 Classes of Phobias • Specific phobias are unwarranted fears caused by the presence of a specific object or situation – Blood, injuries, or injections – Situations (planes, elevators) – Animals – Natural environment (water, heights) • Social phobia involves a persistent fear linked to the presence of other people Ch 6.4 Clinical Description Irrational Fear of Specific Objects or Situations Markedly Interferes With Functioning Four Major Subtypes Animal Type Natural Environment Type Blood-Injection Injury Type Situational Type Other Blood-Injection Injury Type Unusual Reaction Vasovagal Response to Blood Drop in Blood Pressure Fainting Runs in Families Onset Early Childhood Situational Type Fears of Specific Situations Planes, Transportation, Heights Response Similar to Panic Onset Early 20’s Animal Type Fears of Animals and Insects Common in Population, but Different From Normal Revulsion Early Onset (About 7 yrs of Age) Natural Environment Type Fears of Natural Events Heights, Storms, Water Usually More Than One Fear Peak Onset (About 7 yrs of Age) Other Type Fears Contracting Disease / Illness Illness Phobia Fear of Choking Avoid Swallowing Pills or Foods Facts and Statistics Occurs in 11% of Population Top Fears: Heights and Snakes Females > Males (4:1 Ratio) Runs a Chronic Course Many Do Not Seek Treatment: WHY? Causes Direct Traumatic Conditioning Observational Learning Information and Language Having a Panic Attack (“False Alarm”) Probably Some Evolutionary Basis Etiology of Anxiety Disorders • Psychoanalytic theory: phobias result from anxiety produced by repressed id impulses • Biological/Genetic theory: Heritability of panic disorder, and evolutionary basis of phobias • Behavioral theories: focus on learning as the etiological basis of phobias – Phobias are learned avoidance responses – Phobias may be acquired through modeling – We are biologically prepared to learn certain fears (e.g. taste with nausea) • Cognitive theory: Thought processes result in high levels of anxiety Ch 6.5 Treating Phobias • Psychoanalytic therapy attempts to uncover repressed conflicts using free association • Behavioral approaches use systematic desensitization and in vivo exposures to reduce anxiety responses to phobic stimuli and situations – Flooding: exposure to a phobic stimulus at full intensity (now graded exposure is used more) • Cognitive approaches focus on altering irrational beliefs (using socratic dialogue to disconfirm and reconstruct automatic thoughts, images) Ch 6.6a Treating Phobias • Biological approach uses drugs to eliminate anxiety symptoms – Anxiolytic drugs such as the benzodiazepines (Valium) can reduce anxiety but are also addictive and give rise to withdrawal symptoms upon termination – MAO inhibitors such as phenelzine reduce the degradation of norepinephrine and serotonin • MAO inhibitors can have adverse side effects – Selective serotonin reuptake inhibitors (SSRI’s) (fluoxetine) increase brain serotonin Ch 6.6b Exposure and More Exposure Structured and Consistent Confront Objects of Fear Extinguish Anxious Responding Disrupt Avoidance / Escape Blood-Injury /Injection Differs Exercises to Offset Fainting “ People with social phobia aren’t necessarily shy at all. They can be completely at ease with people most of the time, but in particular situations, they feel intense anxiety.” Clinical Description Marked and Persistent Fear of One or More... Social or Performance Situations Most Common Type of Social Fear? Public Speaking Interferes With Life Functioning Facts and Statistics Occurs in 13.3% of Population Most Prevalent Disorder Males > Females Begins in Adolescence Presents Differently in Some Cultures (e.g., Japan) Causes Similar to Panic and Specific Phobia Interaction of Biological Vulnerability Psychological Vulnerability Learning Experiences Can be Quite Disabling Psychological Interventions Similar to Panic and Specific Phobia Cognitive-Behavioral Approaches Rehearsal and Skills Training Cognitive Restructuring Drug Treatments Antidepressants for Severe Anxiety SSRIs (e.g., Paxil) MAO Inhibitors Relapse is Common Panic Disorder • Panic disorder involves – an attack of labored breathing, nausea, chest pain, dizziness and intense apprehension (terror) – Depersonalization: the feeling of being outside of one’s body – Derealization: the feeling that the world is not real • Lifetime prevalence for panic disorder is 2% for men and 5% for women Ch 6.7 Panic Disorder “ You may genuinely believe you’re having a heart attack, losing your mind, or on the verge of death. Attacks can occur any time, even during nondream sleep ” “ For me, a panic attack is a most violent experience …I feel as though I’m losing control and going insane. ” Clinical Description An Unexpected Panic Attack Develop Anxiety Over the Next Attack or The Implications of the Attack and Consequences Clinical Description Agoraphobia is Common “Fear of the Marketplace”, avoidance of “unsafe” places where panic attack may recur Consequence of Severe Unexpected Panic Attacks Can Have a Life of its Own Facts and Statistics Occurs in 3.5% of Population 75% are Women Onset Between (25-29 yrs) Initial attack often begins at puberty 20% Attempt Suicide Average 37 Medical Visits / Year Cultural Influences Occurs Worldwide Prevalence in U.S. is Similar Across Ethnic Groups Cultural variants: susto, ataques de nervios (Latin America, Caribbean) Somatic symptoms emphasized in 3rd world cultures Nocturnal Panic 60% Cases Panic While Asleep! Usually Between 1:30 - 3:30am Occur During Deep Sleep “Delta” Do Not Occur During REM Sleep Isolated sleep paralysis (common in African-Americans with PD) Symptoms of a Panic Attack Palpitations / Sweating Trembling / Shaking Shortness of Breath Feeling of Choking, Loss of Control Derealization, Feeling of Dying Etiology of Panic Disorder • Biological theories focus on the observations – that panic disorder runs in families – that panic disorder can be induced experimentally using • Hyperventilation may activate the autonomic nervous system • Infusions of lactate can induce panic attack • Panic attack may result from an exaggerated central response to arousal Ch 6.8 Etiology of Panic Disorder • The Fear-of-fear hypothesis of panic disorder suggests that some people have an overly aroused nervous system and a tendency to be upset by the sensations generated by their nervous system – Eventually, worry about a panic attack makes a future attack more likely (vicious circle) – Panic attacks as “false alarm” reactions Ch 6.9 Anxiety Sensitivity Index (ASI) •Measures the extent to which individuals become apprehensive in response to their bodily sensations. •Developed by Peterson & Reiss (1987) •High scorers on the ASI were more likely than low scorers to experience panic attacks, especially if they had been told they would feel relaxed instead of aroused (Telch & Harrington, 1992) (D&N, Table 6.3). Panic Disorder Treatments • Biological treatments include use of antidepressant and anxiolytic drugs – Require long-term use, symptoms return upon drug cessation; risk of addiction to anxiolytics • Psychological treatments emphasize exposure to stimuli that accompany panic – Barlow’s therapy includes a combination of breathing re-training, cognitive interventions, and exposure to the internal cues that elicit panic. Patient learns to relax and reinterpret these sensations as nonthreatening and controllable Ch 6.10 The Panic Attack Abrupt Autonomic Surge Unexpected Uncontrollable Absence of Threat “False Alarm” 10 Minutes Laboratory Panic Provocation Lactate Infusion Hyperventilation CO2 Inhalation Caffeine 10 Minutes Causes General Biological & Psychological Vulnerability STRESS False Alarm Bodily Cues Learned Alarm Involuntary physical or cognitive anxiety cues trigger learned alarms unpredictably Specific Psychological Vulnerability: Anxious apprehension focusing on future alarms (e.g., body sensations are dangerous) Biological Causes Runs in Families GABA-BZ Circuit Limbic System ANXIETY Behavioral Inhibition System (BIS) FEAR / PANIC Fight / Flight System (FF) Psychological Causes Predictable Uncontrollable Controllable Unpredictable Pharmacologic Treatments Block Panic Antidepressants (e.g., Imipramine, Paxil, Prozac) 20-50% Relapse Benzodiazapines (e.g., Xanax) 90% Relapse Psychological Interventions Cognitive-Behavior Therapies Brief and Time Limited (12 Sessions) Graded Exposure + Coping Skills Panic Control Treatment (PCT) 80-100% Panic Free After Treatment Combined Treatment THE RESULT Multisite Study Imipramine Alone PCT Alone Imipramine + PCT Placebo Alone Placebo + PCT Combined Tx is Better in Short Term PCT Alone is Better in Long Term Generalized Anxiety Disorder • Generalized Anxiety Disorder (GAD) involves persistent anxiety and chronic (uncontrollable) worry • The lifetime prevalence of GAD is 5% • Women are twice as likely to develop GAD as are men Ch 6.11 Generalized Anxiety Disorder: The “Basic” Anxiety Disorder? Figure 5.3 Clients’ answers to interviewer’s question, “Do you worry excessively about minor things?” Etiology of GAD • Psychoanalytic view: generalized anxiety results from unconscious conflicts between ego and id impulses • Cognitive behavioral view: anxiety results from conditioning of anxiety to external stimuli • Biological view: the transmitter GABA inhibits anxiety, anxiolytic drugs enhance the release of GABA in brain; evidence for heritability is mixed. Ch 6.12 Worrywart? Perfectionist? Tense and keyed up most of the time? Cross bridges before you get to them? Worry unproductive? Trouble Controlling Worry? Clinical Description Worry About Everything Worrying is Unproductive Cannot Stop Worrying Mental Agitation and Muscle Tension Interferes With Life Functioning Must Last for at Least 6 Months Facts and Statistics Occurs in 4% of Population Women twice as likely to develop GAD Early Gradual (“insidious”) Onset Runs a Chronic Course Few Seek Treatment: WHY? Causes Unclear and Puzzling? Tend to show Autonomic Restriction Heightened Muscle Tension High Sensitivity to Threat in General Threat Sensitivity is Automatic Avoid Negative Affect Related to Threat General Biological & Psychological Vulnerability STRESS Specific Psychological Vulnerability (Anxious Apprehension) Worry Process Imagery Avoidance Intense Cognitive Processing Restricted Autonomic Response Most Interventions are Weak Benzodiazepines Frequently Prescribed Provide Some Relief Cognitive-Behavioral Approaches Process Avoided Emotional Material Relaxation Training Does as Well as Medication Therapies for GAD • Psychoanalytic therapy for GAD is similar to that of phobia (reveal sources of conflict) • Behavioral therapy involves a combination of relaxation training and cognitive intervention • Biological therapy uses administration of anxiolytic drugs to reduce anxiety – Drug therapy is effective while the drugs are taken Ch 6.13 Obsessive-Compulsive Disorder (OCD) • Obsessions are intrusive and recurring thoughts • Compulsions are repetitive behaviors or mental actions that are repeated over and over in order to reduce anxiety • The lifetime prevalence of OCD is 1-2 % – Women are more likely than men to develop OCD Ch 6.14 Common Compulsions • Pursuing cleanliness • Avoiding particular objects (e.g. cracks in a sidewalk) • Performing repetitive, magical, protective practices • Checking (e.g. “is the gas off?”) • Performing a particular act (e.g. chewing slowly) Ch 6.15 Etiology of OCD • The psychoanalytic view is that OCD reflects arrest of personality development at the anal stage • Behavioral accounts of OCD point to learned behaviors reinforced by fear reduction • The biological view of OCD has focused on activation of the frontal lobes and basal ganglia Ch 6.16 The Basal Ganglia Ch 6.17 OCD Therapy • Psychoanalytic procedures are not effective • ERP: Exposure and Response Prevention involves exposing the OCD client to situations that elicit a compulsion and then restraining the client from performing the compulsion • Biological treatment involves drugs that increase brain serotonin activity (Prozac) Ch 6.18 Clinical Description Culmination of All Anxiety Disorders Obsessions: Intrusive Thoughts, Images, or Urges That the Person Tries to Suppress or Eliminate Compulsions: Thoughts or Actions to Suppress the Obsessions and Provide Relief Facts and Statistics Occurs in 2.6% of Population Most Common Obsessions Contamination & Aggression Most Common Compulsions Checking & Washing Almost Equal Sex Ratio (F > M) Onset Early Adolescence to Mid-20s Causes Anxiety Focused on Unwanted Thoughts Thoughts are Unacceptable When Fighting to Control One’s Psychology Creates More Psychopathology Psychological Interventions Cognitive-Behavioral Treatments Response Prevention Rituals are Actively Prevented Exposure Systematic and Gradual Exposure to Feared Thoughts or Situations May Require Hospitalization Drug Therapies Medications Show Promise Most Effective Medications Inhibit Reuptake of Serotonin May Benefit 60% of Patients Posttraumatic Stress Disorder • Posttraumatic Stress Disorder (PTSD) refers to an extreme response to an extreme stressor • PTSD symptoms may include: – Increased anxiety and arousal – Re-experiencing the traumatic event – Avoidance of stimuli associated with the trauma Ch 6.19 Clinical Description Exposure to Traumatic Events War and Combat Rape and Assault Car Accidents Natural Disasters Reexperiencing, Flashbacks, Numbing Sleep Disturbance, Chronic Arousal Subtypes Acute 1-3 Months After the Trauma Chronic Symptoms Last > 3 Months Facts and Statistics Occurs in 7.8% of Population Most Common Traumas? Combat and Assault Trauma is Necessary, not Sufficient Severity of Response Seems Important Runs a Chronic Course Causes Only Disorder With Clear Etiology Biological Vulnerability Experience With Events That are... Uncontrollable and Unpredictable Severity of Trauma and One’s Reaction True Alarm! Social Support Helps Psychological Interventions Face the Original Trauma Imaginal Reexposure Flooding Arrange for Corrective Emotional Learning Problem of Secondary Gain Disability and Compensation New Treatment Approaches for PTSD • EMDR (Eye Movement Desensitization & Reprocessing • TFT (Thought Field Therapy) • New Paradigms or Pseudo-Science?