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