Anxiety Disorders Cornelia Pinnell, Ph.D. Argosy University/Phoenix Lecture Outline n Researchers n Definitions n Epidemiology of anxiety 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 Phobia 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 serotonergic 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 Phobias ¨ 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