Disorders

Anxiety Disorders Overview n What is anxiety? n Categories of anxiety disorders n Generalized n n Specific /Social Phobia n Obsessive Compulsive Disorder n DSM-IV diagnoses n Treatments

Anxiety n Probably experienced some of this during the exam n What does it feel like? n When is it a “disorder?” n What is the difference between and anxiety? n Anxiety defined as n uneasiness stemming from the anticipation of danger n Fear defined as n a reaction to a specific threat from the real, physical world

1 Anxiety n Anxiety is an evolutionary useful feeling n part of the flight or fight response n useful to have a response of energizing to get out of a situation

n sometimes this gets in our way

n feels not so adaptive

Anxiety n Diagnosing n For a person to be diagnosed as having anxiety, the anxiety must be out of proportion to the perceived threat n The anxiety is recognized by the individual seeking treatment to be excessive or unreasonable

Anxiety Disorders n Several types/different diagnoses n Based on formal (topographical) features n Should be distinct n Will see much overlap within a category (e.g. within Anxiety) n Also see overlap between other categories (e.g., OCD and eating disorders)

2 Anxiety Disorders n Six disorders: n Generalized anxiety disorder (GAD) n Obsessive-compulsive disorder (OCD) n n Panic disorder ______n n Post-traumatic stress disorder (PTSD)

Generalized Anxiety Disorder (GAD)

GAD n One of the most common diagnoses in outpatient treatment settings n to be diagnosed with GAD it must interfere with normal functioning n also see drug and alcohol abuse to control the anxiety

3 GAD n Characterized by chronic, unrealistic and excessive anxiety about 2 or more areas of functioning n key is chronic, excessive, & 2 or more areas n Behaviors n nervousness, rumination n hyperactive nervous system (sweating, dry mouth) n concentration problems n hypervigilance n sleeping problems

GAD n Symptoms are often misunderstood by others n Sufferers are accused of “looking for” worries n The disorder is common in Western society n Affects ~4% of U.S. and ~3% of Britain’s population n Usually first appears in childhood or adolescence n Women are diagnosed more often than men by a 2:1 ratio n Various theories have been offered to explain the development of the disorder

4 GAD: The Psychodynamic Perspective n Freud believed that all children experience anxiety n Realistic anxiety when faced with actual danger n Neurotic anxiety when prevented from expressing id impulses n Moral anxiety when punished for expressing id impulses n One can use ego defense mechanisms to control these forms of anxiety, but when they don’t work…GAD develops.

GAD: The Cognitive Perspective

n Those with GAD hold unrealistic silent assumptions that imply imminent danger:

n Any strange situation is dangerous

n A situation/person is unsafe until proven safe

n It is best to assume the worst

n My security depends on anticipating and preparing myself at all times for any possible danger

GAD: The Behavioral Perspective n Excessive worry is learned the way any other behavior is learned n Behavior is reinforced directly n Negative reinforcement seems present n Lack of coping skills

5 GAD: The Biological Perspective n GABA inactivity (GABA = NT “anxiety brakes”)

n In the normal fear reaction: § Key neurons fire more rapidly, creating a general state of excitability experienced as fear or anxiety § A feedback system is triggered; brain and body activities work to reduce excitability § Some neurons release GABA to inhibit neuron firing, thereby reducing the experience of fear or anxiety

n Problems with the feedback system are believed to cause GAD

n Possible reasons: GABA too low, too few receptors, ineffective receptors

GAD Treatments

n Psychological n Cognitive therapies n Target maladaptive assumptions n Behavioral therapies n Behavioral rehearsal, relaxation n Acceptance based strategies n Psychodynamic therapies n Help patients identify and settle early relationship conflicts n Biological n 1950s: Benzodiazepines (Valium, Xanax ) found to reduce anxiety n Not typically thought of as a good long-term solution

Obsessive Compulsive Disorder (OCD)

6 OCD n Characterized by obsessions and/or compulsions n Obsessions which are persistent thoughts, impulses, or ideas; person recognizes this in her or his mind, but they can't control the thoughts n e.g., images of unacceptable sexual behaviors, thoughts of dying, belief that they are somehow contaminated

OCD n Compulsions are behaviors that are repetitive and intentional or rituals that are performed in response to the obsession in order to relieve the anxiety n e.g., checking behaviors, hand washing (door closing and breathing) n there is a magical quality to controlling the obsessive thoughts n "compulsive gambling", "compulsive eating" are not compulsions, these are "pleasurable" to people while engaging in them

7 OCD n Classified as an anxiety disorder because obsessions cause anxiety, while compulsions are aimed at preventing or reducing anxiety n Anxiety rises if obsessions or compulsions are avoided n ~2% of U.S. population has OCD in a given year n Ratio of women to men is 1:1

Theories of OCD n Psychoanalytic theory n ID: impulses n Ego: competing impulses, compulsions to “erase” Id impulses n Behavioral theory n Two factor learning theory n classically conditioned n maintained by avoidance behavior n Biological explanation n involves the neurotransmitter serotonin n this has lead to the use of antidepressants for the treatment of OCD

OCD: The Biological Perspective n Two lines of research: n Role of NT serotonin

n Evidence that serotonin-based antidepressants reduce OCD symptoms n Brain abnormalities

n OCD linked to orbital region of frontal cortex and caudate nuclei § Compose brain circuit that converts sensory information into thoughts and actions § Either area may be too active, letting through troublesome thoughts and actions

8 OCD: The Biological Perspective n Biological therapies n Serotonin-based antidepressants

n Anafranil, Prozac, Luvox

n Up to 3 times depression dose

n Bring improvement to 50–80% of those with OCD n Relapse occurs if medication is stopped n Research suggests that combination therapy (medication + cognitive behavioral therapy approaches) may be most effective

n May have same effect on the brain

OCD Treatment n Most effective treatment: in vivo treatment n Exposure and response prevention (ERP)

n Clients are repeatedly exposed to anxiety-provoking stimuli and prevented from responding with compulsions

n Therapists often model the behavior while the client watches § Homework is an important component

n Treatment is offered in individual and group settings

n Treatment provides significant, long-lasting improvements for most patients

OCD Treatment n Symptom Substitution: n Psychoanalysts criticize this treatment on the grounds that if you treat the symptom, and not the underlying cause - another symptom will pop up n There is NO evidence for symptom substitution n this behaviorally based treatment of exposure with response prevention is successful

n other symptoms do not "pop up"

9 Phobias Specific (Simple) Phobias Social Phobia

Phobias n related to specific kind of situations or objects n We all have fears in our lives. What makes these fears distinctive? n generally this fear is considered irrational by self and others n the fear is way out of perspective, or proportion, to the real danger n Greater desire to avoid the feared object or situation n Distress that interferes with functioning

10 Phobias n n Also known as simple phobia n refers to persistent fear of one or two objects n common simple phobias

n Animals type (snakes, dogs, spiders)

n Natural environment type § e.g. heights (acrophobia)

n Blood-injection-injury type

n Situational type § e.g. closed spaces (claustrophobia)

Social Phobia n Social Phobia n separate diagnosis n fear related to being in social situations where you might be evaluated by others

n public speaking falls here n develops in late childhood or early adolescence

11 Explanation of phobias

n Not good at finding biological explanation – yet… n Psychoanalytic theories n phobias are displaced anxiety n some id impulse is so threatening that the ego displaces anxiety onto something else

n displacement is a defense mechanism n Behavioral theories n Mowrer's 2 factor learning theory n Classically condition to feared stimulus, then n avoidance is negatively reinforced

Classical Conditioning of Phobia

UCS UCR Dog bite Fear

UCS UCR + Dog bite Fear

CS = CR Fear

Avoid dogs to avoid getting bitten. This is negatively reinforced

12 Phobia Treatments

n Exposure treatments n Most important factor in the treatment of phobias n Need to have presentation of CS without UCS so that CS no longer elicits CR n Call this extinction paradigm through exposure n Eg. Dog (CS) without the dog bite (UCS) n Note that we need to prevent the operant escape response, too n Systematic or gradual n Flooding or rapid

Phobia Treatments

n Systematic desensitization n Joseph Wolpe n develop hierarchy around the feared situation n rank stages from lowest levels of anxiety to highest n teach relaxation techniques n have the client relax while they imagine the frightening situations n gradually desensitize to feared stimulus n this is imaginary n need to then transfer to real life

Phobia Treatments n Flooding n real life or “in vivo” n put person into situation and don't let them escape n person is flooded with anxiety n this extinguishes the fear n Both flooding and systematic desensitization have been empirically shown to be effective n Key point in exposureis that you don't let the client escape during their anxiety or the escape response will be negatively reinforced

13 Panic Disorder With Without Agoraphobia

Panic Disorder n Profound episodes of terror n Last from a few minutes to an hour (or more) n Appear to come out nowhere to the person, there is no identifiable cause to the attack

What does a Feel Like?

14 DSM Criteria for Panic Attack n A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

n feeling dizzy, unsteady, n palpitations, pounding heart, or accelerated heart lightheaded, or faint rate n derealization (feelings of n sweating unreality) or n depersonalization (being n trembling or shaking detached from oneself) n sensations of shortness of breath or smothering n fear of losing control or going crazy n feeling of choking n fear of dying n chest pain or discomfort n paresthesias (numbness or n nausea or abdominal tingling sensations) distress n chills or hot flushes

Panic Disorder

n two types of panic disorder n with agoraphobia - afraid to go out of the house n specifically, agoraphobiais the fear of being in public places from which escape might be difficult or help not available in case of incapacitation n restricting where they will go: gradual closing in - only leave house with "safe person" or never leave at all n without agoraphobia

n Fear of panic attacks but not same level of avoidance

15 Panic Disorder n you must rule-out (R/O) certain physiological abnormalities which symptomalogically look a lot like panic disorder n R/O - hyperthyroidism

n may mimic panic attacks feeling n R/O - mitral valve prolapse

n heart valve problem due to congenital abnormality - leads to panic symptoms in some people n R/O - Amphetamine intoxication

n you must rule out a chemical cause

Cognitive Model of Panic

Physical Arousal Triggers

Physical Sensations

“Faulty” Threat Interpretation

PANIC

Cognitive-Behavioral Perspective n Cognitive therapy n Attempts to correct people’s misinterpretations of their bodily sensations n Step 1: Educate clients § About panic in general § About the causes of bodily sensations § About their tendency to misinterpret the sensations n Step 2: Teach clients to apply more accurate interpretations (especially when stressed) n Step 3: Teach clients skills for coping with anxiety § Induce panic attack § Use relaxation, breathing

16 Cognitive-Behavioral Perspective n Cognitive-behavioral therapy is often helpful in panic disorder n 85% panic-free for two years vs. 13% of control subjects n Only sometimes helpful for panic disorder with agoraphobia n At least as helpful as antidepressants

Biological Perspective n What biological factors contribute to panic disorder? n NT at work is norepinephrine

n Irregular in people with panic attacks § Research suggests that panic reactions are related to changes in norepinephrine activity in the locus ceruleus n While norepinephrine is clearly linked to panic disorder, what goes wrong isn’t exactly understood

n May be excessive activity, deficient activity, or some other defect n Other NTs are likely involved

Biological Perspective n Drug therapies n Antidepressants are effective at preventing or reducing panic attacks n Function at norepinephrine receptors in the locus ceruleus n Bring at least some improvement to 80% of patients with panic disorder § ~40–60% recover markedly or fully n Require maintenance of drug therapy; otherwise relapse rates are high n Some benzodiazepines (especially Xanax and Valium) have also proved helpful

17 Panic Treatment n Psychological and Pharmacological equally effective n If applied separately n Psychological and Pharmacological combinations n Worse outcome than separate w/ Benzodiazepines n Why would this occur? n Unclear now what will occur with SSRIs and therapy combinations

Anxiety Disorders Summary n Most common mental disorders in the U.S. n In any given year, 19% of the adult population in the U.S. experience one or another of the six DSM-IV anxiety disorders (including PTSD and Acute Stress Disorder, discussed next)

n Most individuals with one anxiety disorder suffer from a second as well n Anxiety disorders cost $42 billion each year in health care, lost wages, and lost productivity

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