Anxiety Disorders

Cornelia Pinnell, Ph.D. Argosy University/Phoenix Lecture Outline n Researchers n Definitions n Epidemiology of disorders n Course and Prognosis n Etiological Models n Anxiety Disorders – diagnostic criteria n Assessment issues Researchers of anxiety n Barlow n Emmelkamp n Foa n Klein n Marks n Rachman n Wolpe Definition of Fear n Present-oriented mood state characterized by marked negative affect n Abrupt activation of the sympathetic nervous system n Immediate fight or flight (or freeze) response to danger or threat n Strong avoidance/escapist tendencies Definition of Anxiety n Characteristic unpleasant emotional state, distinguished from others by a unique combination of factors: ¨ Experiential/psychological : worryness, nervousness, apprehension ¨ Physiological : sympathetic arousal - increased heart rate, sweatiness, hyperventilation, nausea, tremor, dry mouth Anxiety as future-oriented fear n Anticipation of future danger or misfortune, characterized by marked negative affect & somatic symptoms of tension n Sense of uncontrollability related to self- schema of personal incompetence, inability to deal effectively with events in one ’s life Definition of n Phobia = excessive fear of a specific object, circumstance, or situation Definition of a Panic Attack n A discrete period of intense fear or discomfort, in which four or more of the following sxs develop abruptly and reached a peak within 10 minutes: ¨ Somatic symptoms : palpitations, sweating, trembling, shortness of breath, sensations of choking or smothering, chest pains, nausea, gastrointestinal distress, dizziness or lightheadedness, tingling sensations, chills, blushing, ‘hot flashes’ ¨ Cognitive symptoms : fear of dying, ‘gong crazy’, losing control of emotions or behavior n Abrupt onset, intense, building up to maximum intensity within 10-15 minutes (lasts 30) - episodic Panic Attacks n Can be described as unexpected, situationally bound or situationally predisposed n There are attenuated or ‘limited symptom’ forms n Not limited to Panic Disorder n Occur commonly in other anxiety disorders: social phobia, generalized anxiety disorder, & in major depressive disorder n May occur in up to 10% of healthy individuals The Phenomenology of Panic Attacks

Figure 5.1 The relationships among anxiety, fear, and panic attack. Panic Disorder & Culture

Galanti (1991): Bruja ¨ 22yo Mexican American inmate of a county jail was admitted for emergency services with sxs of a heart attack – no cardiac abnormalities found; instead - state of panic & terror, he believed he was dying ¨ A nurse asked him whether he believed in God & gave him a picture of Jesus to hold over his heart ¨ He calmed down – he had believed that a bruja , paid by his former lover, had cursed him & God saved him ‘Mixed Anxiety-Depression’ n Donald Klein (1987) postulated a common biological vulnerability for anxiety & depression n Coryell (1988) noted high co -morbidity rates n Clark & Watson (1991) proposed a new category ‘mixed anxiety-depression ’ Epidemiology of Anxiety Disorders n 25% of participants in the National Comorbidity Study met dx criteria for at least one anxiety disorder n Lifetime prevalence of anxiety disorders: 30.5% for women & 19.2% for men n Specific phobia: 5-10% (6 months prevalence) n Social phobia – women to men ratio 1:1; high comorbidity with other anx. disorders & ETOH abuse Epidemiology of Anxiety Disorders n Social phobia – women to men ratio 1:1; high comorbidity with other anx. disorders & ETOH abuse n Panic Disorder – lifetime prevalence 1.5%-5%; women to men ratio is 2-3 : 1 n OCD – lifetime prevalence 2.5% n PTSD – lifetime prevalence 1%-3% in general population Course of Anxiety Disorders n Relatively early onset n Chronic course n Relapsing or recurrent episodes n Periods of disability n Panic Disorder with agoraphobia – there is an increased risk of attempted suicide Comorbidity of Anxiety Disorders

n Mood Disorders n Substance Abuse Disorders Etiological Models - Biological n Physiological vulnerability may be: ¨ inherited ¨ acquired through exposure to traumatic experiences n ‘Biological preparedness ’ (Seligman) – hardwired fear responses serve adaptive purposes (e.g., darkness, spiders, snakes) – easier to acquire & extinguish n Possibility of genetic (polygenic) transmission of hyperarousal & other vulnerabilities – common predisposition for anxiety & depression Etiological Models - Biological

Neurobiology of the brain : n Neurochemical factors & brain circuits : low GABA levels are associates with high anxiety; noradrenergic and systems - role of serotonin unclear Etiological Models - Biological

Neurobiology of the brain : n Neuroanatomical factors : inconsistent data n Other biological explanations : ¨ Limbic system : 1) BIS ( behavioral inhibitions system – ‘freezing’) 2) FFS ( fight-of-flight system – ‘alarm & escape’) ¨ ‘Kindling effect ’ (Marks) – sensitization of the organism Etiological Models - Behavioral n Mowrer’s (1939) 2 stage theory for the acquisition & maintenance of fear and avoidance behavior ¨ Classical conditioning – higher order conditioning (an initially neutral stimulus is associated with high anxiety during stressful experiences) ¨ Operant conditioning – maintains avoidance responses through arousal reduction n Foa (1993) – little empirical support for Mowrer’s theory (except for OCD) Etiological Models - Cognitive n Carr (1974), Turner (1985) – patients with OCD have abnormally high subjective estimates of probability of unfavorable outcomes n McFall & Wollershein (1979) – erroneous beliefs – perfectionistic ideals, ritual to prevent catastrophies n Beck (1991) – cognitive specificity for various disorders; OCD (danger & doubt) Social phobia (high need for approval) GAD (worry) Etiological Models-Psychodynamic

Freud – “Danger signal ” theory of anxiety: n Objective anxiety/fear – anxiety is an appropriate response signaling a real objective danger n Neurotic anxiety – anxiety is a disproportionate reaction to an internal source (e.g., in OCD, compulsions appear as a symbolic ritual to avoid repressed material that threatens to become conscious) Etiological Models – Psychodynamic

n Anxiety signals that forbidden unconscious impulses threaten to break into consciousness n Panic attacks arise from unsuccessful defense against anxiety-provoking impulses; themes : difficulty tolerating anger, vicious cycle of anger at parental rejection & anxiety that the anger will destroy the parent Etiological Models – Interactional n Barlow (1990): Anxiety = A loose cognitive- affective cybernetic structure with a feedback loop consisting of: ¨Negative affect & cognitions ¨Chronic hyperarousal & hypervigilance – with attention narrowed onto sources of potential threat ¨Anxious apprehension & mobilization of a preparatory coping set to deal with the potential threat Etiological Models– Interactional n Barlow (1990) proposed a tripartite model of anxiety : ¨ Biological vulnerability (possible genetic transmission across many neurobiological systems; hx of physical illness; family hx of psychiatric illness) ¨ Psychological vulnerability (childhood experiences, cognitions of unpredictability & uncontrollability) ¨ Negative life events (stressors) – 3 types of alarms – true, false, learned/conditioned Etiological Models – Interactional n Clark & Watson (1991) proposed the existence of 2 mood dimensions : ¨ Negative Affect (NA) – depression, anxiety, anger, guilt; the absence of NA is experienced as feeling calm & relaxed ¨ Positive Affect (PA) – active, delighted, interested, enthusiastic, proud; the absence of PA is experienced as feeling tired & sluggish Etiological Models – Interactional n Clark & Watson (1991)- a tripartite model of anxiety & depression : ¨Physiological hyperarousal (anxious, fearful, muscular tension) – Anxiety/A ¨Absence of positive affect (anhedonia, anergia, fatigue) – Depression/D ¨General negative affects , demoralization, somatopsychic distresscommon to both A & D Etiological Models – Interactional

n Clark & Watson (1991) described patients who meet criteria for both Anxiety & Depression (‘ mixed anxiety -depression ’) as a distinct group, with more severe clinical presentation, higher general distress, greater chronicity, significantly poorer treatment response & poorer outcome A s s o c i a t

Figure 5.5 An integrative model of generalized anxiety disorder e d Anxiety Disorders n 300.01 Panic Disorder (PD) W ithout Agoraphobia n 300.21 Panic Disorder (PD) W ith Agoraphobia n ¨ 300.29 Specific Phobia (formerly simple) ¨ 300.23 Social Phobia ¨ 300.22 Agoraphobia Without History of Panic Disorder n 300.02 Generalized Anxiety Disorder (GAD) n 300.3. Obsessive Compulsive Disorder (OCD) n 308.3 Acute Stress Disorder n 309.81 Post Traumatic Stress Disorder (PTSD) Anxiety Disorders n 293.84 Anxiety Disorder Due to a General Medical Condition n 293.84 Substance-Induced Anxiety Disorders n 300.00 Anxiety Disorder NOS (Mixed Anxiety- Depressive Disorder) Consider : Adjustment Disorder with Anxious Features 300.01 Panic Disorder Without Agoraphobia - Dx Criteria n A. Both (1) and (2) 1. Recurrent unexpected Panic Attacks unexpected panic attacks 2. At least one of the attacks is followed by 1 month (or more) of one (or more) of the following: a) Persistent concern about having additional attacks b) Worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”) c) Significant change in behavior related to the attacks n B. Absence of Agoraphobia n C. The Panic Attacks are not due to the direct physiological effects of a substance or general medical condition n D. The Panic Attacks are not better accounted for by another mental disorder 300.01 Panic Disorder With Agoraphobia - Dx Criteria n A. Both (1) and (2) 1. Recurrent unexpected Panic Attacks unexpected panic attacks 2. At least one of the attacks is followed by 1 month (or more) of one (or more) of the following: a) Persistent concern about having additional attacks b) Worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”) c) Significant change in behavior related to the attacks n B. The presence of Agoraphobia n C. The Panic Attacks are not due to the direct physiological effects of a substance or general medical condition n D. The Panic Attacks are not better accounted for by another mental disorder Panic Disorder Co-morbidity n Comorbidity of Panic Disorder with: ¨ Major Depressive Disorder (50-65% lifetime comorbidity rates) ¨ Alcoholism and substance abuse (20 -30% lifetime comorbidity rates) ¨ Other Anxiety Disorders: Social Phobia (30%), GAD (up to 25%), Specific Phobia (up to 20%), OCD (up to 10%) Phobias n Phobia = excessive fear of a specific object, circumstance, or situation n Specific phobia = strong, persistent fear of an object or situation n Social phobia = strong, persistent fear of situations in which embarrassment can occur 300.29 Specific Phobia -Dx Criteria n A. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation n B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack 300.29 Specific PhobiaDx Criteria n C. The person recognizes that the fear is excessive or unreasonable n D. The phobic situation(s) is avoided or else is endured with intense anxiety or distress. n E. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia Specific Phobias Subtypes n Animal Type : animals (e.g., snakes, rodents, birds, dogs) or insects (e.g., spiders, bees, hornets) – childhood onset n Natural Environment Type : heights, water, storms – childhood onset n Blood-Injection-Injury Type : blood, injections, surgery, medical procedures (strong vasovagal response) – highly familial n Situational Type : public transportation, tunnels, bridges, elevators, flying, automobile driving – bimodal age distribution n Other Type : fear of choking, vomiting, contracting an illness Terms used for Specific Phobias n Acrophobia = high places/heights n Algophobia = pain n Astraphobia = storms, thunder, and lightning n Claustrophobia = closed places n Hematophobia = blood n Monophobia = being alone n Mysophobia = contamination or germs n Nyctophobia = darkness n Ocholophobia = crowds n Pyrophobia = fire n Syphilophobia =syphilis n Zoophobia = animals or some particular animal 300.23 Social Phobia – Dx Criteria n A. Marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. n B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of situationally bound or situationally predisposed Panic Attacks 300.23 Social Phobia – Dx Criteria n C. The person recognizes that the fear is excessive and unreasonable n D. The feared social or performance situation are avoided or else are endured with intense anxiety or distress. n E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia 300.23 Social Phobia – Dx Criteria n F. In individuals under age 18 years, the duration is at least 6 months n G. The fear or avoidance is not due to the direct physiological effect of a substance or general medical condition n H. If a general medical condition or another mental disorder is present, the fear is unrelated to it n Specify : Generalized (if in most social situations) Obsessions n Obsessions are recurrent intrusive thoughts, impulses or images that are perceived as inappropriate, grotesque, of forbidden (‘ego- alien’ or ‘ego -dystonic’) – uncontrollable & fear of losing control; elicit marked distress n Common themes : contamination with germs or body fluids, pathological doubt, order or symmetry, loss of control of violent or sexual impulses Compulsions

n Compulsions are repetitive (overt) behaviors (e.g., hand washing, checking) or mental acts (e.g., counting or praying) that reduce the anxiety that accompanies an obsession or ‘prevent’ some dreaded event from happening n Compulsive rituals may take up long periods of time – even hours – to complete 300.3 Obsessive-Compulsive Disorder n A. Either obsessions or compulsions: Obsessions as defined by 1, 2, 3 and 4 1. Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress 2. The thoughts, impulses, or images are not simply excessive worries bout real-life problems 300.3 Obsessive-Compulsive Disorder n A. Either obsessions or compulsions: Obsessions defined (continued) 3. The person attempts to ignore or suppress such thoughts, impulses, or images or to neutralize them with some other thought or action 4. The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind 300.3 Obsessive-Compulsive Disorder

Compulsions as defined by 1 and 2 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly 2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation ; these are not connected in a realistic way with what they are designed to neutralize 300.3 Obsessive-Compulsive Disorder n B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. n C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour/day), or significantly interfere with the person’s normal routine 300.3 Obsessive-Compulsive Disorder n D. If another Axis I disorder is present, the content of the obsessions or compulsion is not restricted to it n E. The disturbance is not due to the direct physiological effect of a substance or a general medical condition n Specify : With Poor Insight OCD & Culture

Common compulsions include: n Ritual washing n Checking and ordering objects n Praying & meditating n Counting n Repeating words silently OCD & Culture

Egypt, Israel, India – high value on ritual purity n Thoughts of contamination & ritual washing may be normative (e.g., Egyptian Moslems are required to pray 5x/day, preceded by ritual washing to purify the worshipper – belief of contamination by contact with opposite gender bodily fluids) Disorders within OCD spectrum n Tourette’s disorder n Trichotillomania n Compulsive shoplifting n Compulsive gambling n Sexual behavior disorders Hollander, 1996 n Body Dysmorphic Disorder Phillips, 1991 300.02 Generalized Anxiety Disorder n A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance) n B. The person finds it difficult to control the worry. 300.02 Generalized Anxiety Disorder

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children. 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 (difficulty falling or staying asleep, or restless unsatisfying sleep) 300.02 Generalized Anxiety Disorder n D. The focus of the anxiety and worry is not confined to features of an Axis I disorder n E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. n F. The disturbance is not due to the direct physiological effects of a substance… Assessment instruments n Hamilton Anxiety Rating Scale n Beck Anxiety Inventory n STAI (Spielberger ’s State -Trait Anxiety Inventory) n Anxiety Disorders Interview Schedules - Revised (DiNardo & Barlow, 1988) n SCL-90 (Derogatis) Assessment for OCD treatment n Foa (1993) – identify: ¨ Threat cues a) tangible objects , situations , or places (external) & b) thoughts, images, impulses (internal) – highly idiosyncratic ¨ Introduce a Subjective Units of Discomfort Scale (SUDs ranging from 0 to 100) ¨ Identify passive avoidance (e.g. not preparing meals, not entering public bathrooms, etc.) ¨ Rituals (overt & covert) ¨ Feared consequences Assessment for the treatment of Panic Disorder (PD) n Barlow (1993): ¨ Functional behavioral analysis – a cognitive- behavioral profile ¨ Medical evaluation ¨ Self-report inventories ¨ Standardized/Individually tailored behavioral test (e.g., walking or driving a particular route) – max. levels of anxiety & degrees of approach ¨ Physiological measures (can identify discrepancy between self-report and actual arousal) PD self-report inventories n The Mobility Inventory (exposure hierarchies) n The Anxiety Sensitivity Index n Body Sensations and Agoraphobia Cognitions Questionnaires n STAI / BAI n Dyadic Adjustment Scale n Marital Happiness Scale Treatment for Anxiety Disorders n Pharmacotherapy : ¨ Social Phobia – MAOI ¨ Agoraphobia – Imipramine ¨ Panic Disorder – Imipramine, Xanax (Alprazolam), Zoloft (), (Paxil); superiority of SSRIs and (Anafranil) over benzodiazepines, MAOIs and ticyclics ¨ GAD - anxiolytics - benzodiazepines; Buspirone ¨ OCD - Clomipramine & Xanax, Luvox Treatment for Anxiety Disorders n Psychodynamic ¨ Uncovering unconscious conflicts will result in the disappearance of symptoms ¨ Emotional understanding should accompany intellectual insight ¨ Substitution of symptoms is possible (depression may follow loss of symptoms) ¨ Explore the meaning of loss of sxs & improvement (secondary gains) Treatment for Anxiety Disorders n Behavioral ¨Systematic desensitization (Wolpe) ¨Biofeedback ¨Exposure to feared cues – in vivo modeling, flooding, self-exposure; exposure with response prevention ¨Aversion therapy ¨Modeling & enactive mastery (Bandura) ¨Stress management Treatment for Anxiety Disorders n Cognitive-behavioral : ¨Thought-stopping – was found ineffective; Wegner (1994): “the ‘ironic’ operation of mental monitoring: attempts to suppress neutral or socially inappropriate topics backfire ...by thinking more about the undesired thoughts (e.g., violence, sexuality, personal shortcomings, self-doubts, grief) Treatment for Anxiety Disorders n Cognitive-behavioral : ¨Barlow’s (1985) anxiety management package – for tx of PD/PDA: 1) Exposure to somatic sensations associated with the panic attack (exercise, hyperventilation, or imagined cues); 2) Reframing/cognitive restructuring; 3) Relaxation/breathing retraining Treatment for Anxiety Disorders n Cognitive-behavioral : ¨Butler’s (1987) anxiety management package for tx of GAD: 1) Coping skills – focus on the ‘here -and -now’, self -reinforcement, relaxation, distraction procedures; 2) Avoidance addressed via increase in pleasant activities & focus on areas of accomplishment Treatment for Anxiety Disorders n Cognitive Therapy : ¨Self-statements – cognitive restructuring following guided exposure, realistic interpretations of normal physiologic responses ¨Self-efficacy (Bandura) – enactive mastery Treatment for Anxiety Disorders n Cognitive Therapy : ¨Emmelkamp (1988) – cognitive expectancy model – improvement results from both expectation for improvement & from self - observation of improvement Where to get help for OCD n The Obsessive-Compulsive Foundation, Inc. – tel. 203-878-5669 n National Information Center for Children and Youth with Disabilities ¨www.nichcy.org ¨1-800-695-0285 n National Alliance for the Mentally Ill ¨1-800-950-NAMI (6264) CultureCulture--BoundBound Syndromes n Ataques de nervios – Latin America n Dhat - India n Hwa -Byung - Korea n Koro – Malayesia & Southern Asia n Susto – Latin America n Taijin Kyofusho – Japan Ataques de Nervios --LatinLatin America n Attributed to a loss of key personal relationships n Characterized by a chronic and generalized sense of emotional distress n Somatic symptoms : headaches, body aches, heart palpitations, heat in the chest, irritability, gastrointestinal disturbances, insomnia, nervousness, inability to concentrate, persistent worrying, trembling, and dizziness Dhat Syndrome --IndiaIndia n Male patients report that they suffer from premature ejaculation or impotence, and believe that they are passing semen in their urine - anxiety about ‘loosing too much semen’ (‘vital energy’) n Symptoms of fatigue, physical weakness, insomnia, head and body aches, various symptoms of GAD Koro ––Malayesia,ChinaMalayesia,China, SE Asia

n Sensation that penises or breasts retract into the body – the belief that if the retraction process is allowed to proceed it will be followed by death SustoSusto//EspantoEspanto --LatinLatin America n Attributed to soul loss resulting from frightful or traumatic experiences n Characterized by loss of appetite and weight, physical weakness, restlessness in sleep, depression, introversion, and apathy, lethargy, lack of motivation, insomnia, and diarrhea n Usually treated through spiritual means, ritual cleansings, and herbal teas Taijin Kyofusho --JapanJapan n Intense fear that one’s appearance, body odor, facial expression, or bodily movements may be offensive – lead to social withdrawal and avoidance n It is a pathological amplification of cultural concerns about the self in social interactions = social anxiety/phobia References n American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders , (4th ed., Text Revision). Washington, DC: Author. n Castillo, Richard J. (1997). Culture & mental illness. A client-centered approach . Pacific Grove: Brooks/Cole Publishing Company. References n Sadock, B. J., & Sadock, V. A. (2007). Kaplan & Sadock’s synopsis of psychiatry (10th ed .). Baltimore, Maryland: Williams and Wilkins.