Anxiety Disorders
Anxiety Disorders Overview n What is anxiety? n Categories of anxiety disorders n Generalized Anxiety Disorder n Panic Disorder n Specific Phobia/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 fear 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 Phobias n Panic disorder ______n Acute stress disorder 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 Fears 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 Specific phobia 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 Agoraphobia 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 Panic Attack 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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