Download Generalized Anxiety Disorder

Prepared by:
Ashlea R. Smith, Ph.D.
Argosy University – Phoenix
Second Edition
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Anxiety Disorders
Chapter 4
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Chapter Outline
What Is Anxiety?
What Are the Anxiety Disorders?
The Etiology of Anxiety Disorders
The Treatment of Anxiety Disorders
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What Is Anxiety?
A common emotion characterized by
physical symptoms, future-oriented
thoughts, and escape or avoidance
behaviors
-Occurs when people encounter a new situation or
anticipate a life-changing event
-Usually is time-limited and ends when the event is
over
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Fight-or-Flight Response
Activation of the SNS triggered by fear
or stress
-Sympathetic nervous system (SNS): increases
heart rate and respiration allowing body to
perform at peak efficiency
-Allows you to use all available resources to
escape
-Parasympathetic nervous system (PNS): slows
down the heart rate and respiration, thus
returning the body to a resting state
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Fight or flight response…
Adapted from Lilienfeld, et al., Psychology: From
Inquiry to Understanding (p.121). Pearson/Allyn and
Bacon. Copyright © 2009 Pearson Education, Inc.
Reprinted by permission of Pearson Education, Inc.
Figure 4.1 The
Sympathetic and the
Parasympathetic nervous
system
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You are walking
on a path at a
local park and all
of a sudden you
see a snake
slither out in
front of you.
Just how it works…
As soon as you see
the snake, your
heart starts racing
and your breathing
increases (body’s
response).
What if the snake strikes
me and it’s poisonous?
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You scream for
help or run in the
other direction.
Figure 4.2: The Elements
of Anxiety
Figure 4.3 Negative Reinforcement Increases
Avoidance Behavior and Anxiety
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Normal Anxiety vs. Abnormal Anxiety
Things to consider:
Feeling anxious occasionally is normal
Functional impairment
Developmental age
 Cognitive development, not actual chronological age
Sociodemographic factors
 Sex, race/ethnicity, and SES)
Women and men seek treatment at equal
rates if fear is severe
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Table 4.1 Typical
Fears at Different
Developmental
Ages
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What Are the Anxiety Disorders?
 Group of disorders
characterized by
heightened physical
arousal, cognitive
distress, and behavioral
avoidance of feared
objects/situations/events
How does comorbidity relate to anxiety
disorders?
57% of people diagnosed with one
anxiety disorder also have another
anxiety disorder or depression.
-Panic Attacks
-Panic Disorders and
Agoraphobia
-Generalized Anxiety Disorder
-Social Phobia
-Specific Phobia
-Obsessive Compulsive
Disorder
-Post-traumatic Stress Disorder
-Separation Anxiety Disorder
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The “Facts” about Anxiety Disorders
31.2% of American adults will suffer at some
point in their lives
Most common disorder among all age groups
Onset is around age 11 years old
Equally distributed among Hispanics, nonHispanic blacks, and non-Hispanic whites
Significant economic burden: $42.3 billion
Frequent comorbidity issues
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Fact Or Fiction?
Panic attacks tend to only occur in
people diagnosed with a panic disorder.
Generalized Anxiety Disorder (GAD) is
found to be more common in individuals
from lower socioeconomic status (SES).
Fact or fiction?
Fact or fiction?
No. Actually, 28.3% of adults report having had
a panic attack, but only 4.7% of adults have
panic disorder.
Yes, because populations from lower SES have more
legitimate things to worry about, such as unsafe
living conditions, lower income, poor health care,
and more medical conditions.
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Panic Attacks
Discrete period of intense fear and
physical arousal, which develops abruptly
Symptoms peak in about ten minutes
-Somatic and cognitive symptoms
-Common occurrence
Three types of attacks
-Situationally-bound attacks
-Situationally-cued attacks
-Uncued attacks
Remember, as many as 28.3% of
adults report having had a panic
attack, although only 4.7% of
adults have panic disorder.
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Panic Disorder With or Without Agoraphobia
and Agoraphobia Without Panic Attacks
 Panic Disorder without Agoraphobia: a person has had
at least one panic attack and worries about having more
 Panic Disorder with Agoraphobia: panic attacks
combined with avoidance of places, where escape may be
difficult or impossible.
 Example: shopping malls
 Agoraphobia without History of Panic Disorder:
intense fear and/or avoidance of public places
(agoraphobia) without any past panic attacks
 50% of people with panic disorder live off unemployment,
disability, welfare, or social security
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Generalized Anxiety Disorder (GAD)
Excessive worry about future events, past
transgressions, financial status, and the
health of oneself and loved ones
Lasts at least six months
Onset late teens early adulthood (20s)
More likely to
Account for 12% of PCP visits occur
in adults
than children.
Common in lower SES
With the current state of the economy, do you think we will see a
dramatic increase in people with reported GAD for the future?
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Social Phobia
 The third most common
 Intense fear that others
psychiatric disorder
will detect anxiety
 A pervasive pattern of
 Social situations that
social timidity characterized create distress:
by fear that the person will
speaking, eating,
behave in a way that will be drinking, or writing in
humiliating or embarrassing the presence of others,
engaging in social
 Two subtypes:
interactions, and
 Nongeneralized (specific
subtype)
initiating conversations
 generalized subtype
More than 50% of people with social
phobia have additional anxiety disorders.
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Table 4.2 Developmental Differences in Distressful
Social Situations
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Real People, Real Disorders:
Ricky Williams
Heisman trophy winner
1st round college draft
pick for the NFL
Conducted interviews
with his helmet on
How would life change for
you to live with a social
phobia?
Difficulty interacting
with others
At times unable to
leave the house to run
errands
Is it easier to mask social phobia or
phobias in general if you are not in the
limelight?
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Specific Phobias
Severe and persistent fears of
circumscribed events, objects, or situations
that led to significant disruption in areas of
functioning
Four groups
-Animal phobias
-Natural environment phobias
-Blood/injection/injury phobias (vasovagal syncope)
-Situational phobias
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Adapted from Stinson FS, Dawson DA, Patricia Chou S, et al. "The epidemiology of DSM-IV specific
phobia in the USA: results from the National Epidemiologic Survey on Alcohol and Related Conditions."
Psychological Medicine, 37, 7, pp. 1047-1059, 2007 © Cambridge Journals, published by Cambridge
University Press, reproduced with permission.
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Figure 4.4: Vasovagal Response in Blood-Injury-Illness Phobias
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Obsessive-Compulsive Disorder
A condition involving obsessions
(intrusive thoughts), often combined with
compulsions (repetitive behaviors), that
can be extensive, time consuming, and
distressful
Obsessions vs. Compulsions
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Is Trichotillomania a Variant of
OCD?
• Facts: Defined as repetitive
hair pulling that results in
noticeable hair loss, which
individuals feel powerless to
stop the pulling.
Let’s Examine the
Evidence:
-Both are characterized by
repetitive behavior that is
used to decrease anxiety
-Both are associated with
high rates of anxiety and
depression
• -Higher rates of OCD occur
in people with TTM
• -Obsessive thoughts exist in
both OCD and TTM
• -Antidepressants used to
treat both
• Conclusion: TTM and
OCD share common
features, but studies suggest
differences related to
treatment, symptoms, and
features
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Post-Traumatic Stress Disorder
(PTSD)
After an event that involves actual or
threatened death, serious injury, or a threat to
physical integrity, emotional distress leads to
avoidance of stimuli associated with the
trauma
Persistent symptoms of increased SNS arousal
Classic symptoms associated with PTSD
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Research Hot Topic:
9/11 Trauma, Grief, PTSD, and Resilience
 Experiences lived by inner
city adolescents
-Stabbings
-Shootings
-Murder
 90% of Americans have
been exposed to trauma,
but only 5 to 11% develop
PTSD as a result
 What are some
“protective factors” that
shield one from
developing PTSD?
 What does the word
“resilience” mean?
How can we
use this
information to
understand
PTSD?
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Exposure to
trauma is not
enough to
develop PTSD!
Separation Anxiety Disorder (SAD)
Severe and unreasonable fear of
separation from a parent or caregiver
3 to 5% of all children suffer
More common among girls
Children from all ethnic backgrounds are
equally likely to suffer from SAD
Think back to your childhood when you first started preschool
or kindergarten. Do you remember experiencing some
separation anxiety from your parent or guardian?
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Stop and Think!
Do animals experience separation anxiety
like humans? Why or why not? How
would we define the symptoms? Are
there things pet owners do to cause this,
or how can it be prevented?
Key Points
Tennant (2003) outlined that the separation anxiety usually arises as a youngster, when a pet
is “spoiled or not conditioned to accept an appropriate routine” (p. 70). He further stated that,
“the bottom line is that we actually cause the problem ourselves by misguided acts of
kindness” (p. 70).
Tennant, C. (2003). Breaking Bad Habits in Dogs. Hauppauge, NY: Barron’s
Educational Series, Inc.
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How do anxiety disorders develop?
Biology says:
Behavioral inhibition =
withdrawal from people,
objects, or situations.
-Hereditary factors
-Trait anxiety (personality traits)
-Differences in brain functioning and brain structure
-Neurotransmitters, particularly serotonin (responsible
for mood, thoughts, behavior, and appetitive) and
GABA (the body’s natural way to decrease anxiety,
“natural valium”)
-Corticotrophin-releasing factor (CRF)
-Adrenocorticotropic hormone (ACTH)
-Temperament
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Figure 4.5: Stress May Affect Brain Functioning
Adapted from Biological Psychiatry,
46, Heim, C., & Nemeroff, C. "The
impact of early adverse experiences
on brain systems involved in the
pathophysiology of anxiety and
affective disorders." pp. 1509-1522,
Copyright © 1999 Society of
Biological Psychiatry with permission
from Elsevier Science Inc.
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How do anxiety disorders develop?
Freud says:
-A conflict exists between the id (“childish” wants) and
ego (“adult” ways of thinking)
-Sexual and aggressive impulses
-Defense mechanisms, especially repression and
displacement, result in phobias
-Little Hans
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How do anxiety disorders develop?
Behavioral theories
-Learned behavior; one becomes classically
conditioned
-Vicarious learning theory
-Information transmission
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Figure 4.7: The Fear of Fear Model
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How do anxiety disorders develop?
Cognitive theories
-Information is processed differently, leading to the
development of anxiety
-Aaron Beck and maladaptive thoughts
-Fear of Fear model
-One is hypersensitive to bodily sensations
-Anxiety sensitivity
-Distorted cognitions or “faulty beliefs”
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Quick Recap
1. _____ is a pervasive pattern of social
timidity characterized by fear that the
person will behave in a way that will be
humiliating or embarrassing.
(a) Generalized anxiety disorder
(b) Panic disorder
(c) Social phobia
(d) Obsessive-compulsive disorder
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Quick Recap
2. ______consists of intrusive thoughts
and repetitive behaviors that are
extensive, time consuming, and
distressful.
(a) Post-traumatic stress disorder
(b) Separation anxiety disorder
(c) Obsessive-compulsive disorder
(d) Specific phobia
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Biological Treatment Options
Medication
-Use of Selective Serotonin Reuptake Inhibitors (SSRIs)
for the depletion of serotonin in the neural synapses
(Prozac, Luvox, and Zoloft)
-Use of Benzodiazepines to allow GABA to transmit
nerve signals more effectively, which reduces anxiety
(Valium and Xanax)
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Figure 4.8: How SSRIs Work
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Biological Treatment Options
Psychosurgery
-Only considered if a patient has failed to benefit from
medication and therapy
-Cingulotomy: more common option, involves inserting
thin probes into the portion of the brain called the
cingulate bundle where the probes burn selective
portions of the brain tissue
-Capsulotomy: gamma knife surgery (form of radiation
treatment) which makes precise lesions in the brain
tissue without opening the skull
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Psychological Treatment Options
Psychodynamic
-Uses free association and dream interpretation as a
reflection of the patient’s experience in the “outside
world”
-Little knowledge of the effectiveness of treatment
-Interpersonal Psychotherapy (IPT) targets interpersonal
disputes and conflicts, interpersonal role transitions, and
complicated grief reactions for social phobias, PTSD,
and panic disorder
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Psychological Treatment Options
Behavioral
-Well-researched approach
-Exposure: a client faces fears to get over them
-Exposure therapy
-Imaginal exposure
-70% improve after this treatment, with remission rates of
93% after two years and 62% after ten years, excluding
combat-related PTSD
-Virtual reality exposure
-Social skills training (SST)
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Research HOT Topic:
Virtual Reality Therapy
 Behavior therapy most
effective with some
element of exposure
 Patient fitted with a headmounted display that has
screens for eye,
earphones, and a device
that tracks movement
 Used to treat specific
phobias
 Sounds, noises, and
vibrations are added
 Now being used with
veterans
What are your thoughts on the
use of this technology?
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Psychological Treatment Options
Cognitive Behavioral Therapy (CBT)
-Well-researched approach
-Exposure in combination with cognitive restructuring to
change negative cognitions
-Hypothesis testing (to see whether this “worst thing”
actually happens)
-Generate positive coping cognitions to counteract the
negative thoughts
-70% of patients improve
-Relaxation training and biofeedback
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I Object or Accept!
What are your thoughts?
“Our society rewards people who deal with
stress by working harder and faster to
produce more in a shorter time”
(Davis, M., Eshelman, E. R., & McKay, M. (2000). The Relaxation & Stress Reduction
Workbook, 5th Ed. Oakland, CA: New Harbinger Publications, Inc., p. 9)
In essence, do you think as a
society we are fostering the
development of anxiety
disorders as a means to cope?
Does this relate to formulating
theories about anxiety
disorders? Why or why not?
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Reviewing Learning Objectives
1. Anxiety consists of three parts: physiological,
cognitive, and the behavior.
2. Anxiety is a common occurrence. However, to be
diagnosed, the fear or anxiety must cause impairment.
3. When considering the expression of anxiety, it is
important to assess one’s cognitive maturity, gender,
race/ethnicity, age, and SES, as well as sociocultural
implications.
4. Many different types of anxiety disorders exist, such as
panic disorder, GAD, OCD, phobias, PTSD, and SAD.
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Reviewing Learning Objectives
5. Anxiety disorders can develop in many different ways,
but it is becoming clear that neuroanatomical and
neurochemical alterations lead to anxiety disorders.
6. The most appropriate approach to understanding the
etiology of the disorder is to take into account a
biopsychosocial approach including biological and
psychological/environmental factors.
7. Anxiety disorders can be treated through the use of
medication or behavioral or cognitive behavioral
interventions.
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