Nature of Anxiety and Fear Differences between Anxiety and Fear Normal Emotional States? Roller Coaster Ride Driving on the freeway Taking a test

Yerkes-Dodson Law

Characteristics of Anxiety Disorders Pervasive and persistent symptoms of anxiety and fear Excessive avoidance and escape tendencies Clinically significant distress and impairment Are the most common forms of psychopathology

Biological Aspects of Anxiety Genetic vulnerability Anxiety and brain circuits Depleted levels of GABA Corticotropin releasing factor (CRF) and HYPAC axis Limbic System (and subsystems) Behavioral inhibition (BIS) Fight/flight (FF) systems

Psychological Factors of Anxiety Began with Freud Anxiety is a psychic reaction to fear Anxiety involves reactivation of an infantile fear situation Repression Behavioral and Cognitive Aspects Invokes conditioning and cognitive explanations Anxiety and fear are learned responses Catastrophic thinking and appraisals play a role Early Childhood Contributions Experiences with uncontrollability and unpredictability Social Contributions Stressful life events trigger vulnerabilities Cultural Expectations

Triple Vulnerability Model Figure 4.2 The three vulnerabilities that contribute to the development of anxiety disorders. If individuals possess all three, the odds are greatly increased that they will develop an anxiety disorder after experiencing a stressful situation. (Barlow, D. H., 2002. Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic, 2nd ed. New York: Guilford Press.)

Comorbidity Comorbidity is common across the anxiety disorders Major depression is the most common secondary diagnosis About half of patients have two or more secondary diagnoses Comorbidity suggests Common factors A relation between anxiety and depression Substance Abuse Disorders

Anxiety Disorders Categories Generalized Anxiety Disorder Panic Disorder with and without Agoraphobia Specific Phobias Social Phobia Posttraumatic Stress Disorder Obsessive-Compulsive Disorder

Generalized Anxiety Disorder Worry About Everything Worrying is Unproductive (Interferes with Functioning) Strong, Persistent Uncontrollable Somatic symptoms Differ from panic (e.g., muscle tension, fatigue, irritability)

“Do you worry excessively about minor things?”

Figure 4.3 An integrative model of GAD.

Treatment of GAD Generally Weak Benzodiazepines Most often prescribed Offers some relief Psychological interventions Cognitive-Behavioral Therapy Including “exposure” to worries

Panic “You may genuinely believe you’re having a heart attack, losing your mind, or on the verge of death. Attacks can occur any time, even during sleep.” “For me, a panic attack is a most violent experience … I feel as though I’m losing control and going insane.” 13

Symptoms of Panic Attacks Palpitations / Sweating Trembling / Shaking Shortness of Breath Feeling of Choking Feeling of Dying Loss of Control Derealization Connection to? 14

Panic Attack Abrupt Autonomic Surge Intense Fear or Discomfort Unexpected and Uncontrollable Absence of Actual Threat “False Alarm” 15

Panic Disorder An Unexpected Panic Attack Develop Anxiety Over: The Next Attack or The Implications of the Attack and Consequences Agoraphobia is Common “Fear of the Marketplace” Consequence of Unexpected Panic Attacks Can be a separate disorder 16

Figure 4.5 A model of the causes of panic disorder with or without agoraphobia. (Reprinted, with permission, from White, K. S., & Barlow, D. H., 2002. Panic disorder and agoraphobia. In D. H. Barlow, Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic, 2nd ed. New York: Guilford Press, © 2002 by Guilford Press.)

Panic Disorder Treatment Medication Treatment of Panic Disorder Benzodiazepines Relapse and avoidance SSRIs Preferred drugs Relapse rates are high following medication discontinuation Psychological and Combined Treatments Cognitive-behavior therapies seem highly effective Panic Control Treatment Graded Exposure plus Coping Skills Combined treatments do well in the short term Some indication that CBT alone is most effective 18

Figure 4.6 Responders (as indicated by lower scores) based on the panic disorder severity scale average item score after acute and after maintenance conditions. (Adapted from Barlow, D. H., Gorman, J. M., Shear, K. M., & Woods, S. W., 2000. Cognitive–behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. Journal of the American Medical Association, 283(19), 2529–2536.)

Specific Phobias Rather common Any examples? HUGE list! Diagnosable?

Types of Specific Phobia Natural Environment Water, spaces, storms, etc. Often more than one Peak onset about 7 years old Animals Snakes, spiders, dogs, etc. Blood-Injection Injury Situational Planes, heights, etc. Separation anxiety/school phobia Others, including…

Specific Phobia Diagnosis Extreme and irrational fear of a specific object or situation Go to great lengths to avoid phobic objects Often recognize fears are unreasonable Markedly interferes with one's ability to function

Figure 4.7 A model of the various ways a specific phobia may develop. (Barlow, D. H., 2002. Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic, 2nd ed. New York: Guilford Press.)

Treatment of Specific Phobias Psychological Treatments Cognitive-behavior therapies are highly effective Graduated exposure-based exercises Structured and consistent Systematic Desensitization Prevent Avoidance/Escape Blood/Injection Phobia Different Actually Increase Tension to Prevent Fainting

Social Phobia Diagnosis Marked and Persistent Fear of Social or Performance Situations Often avoid social situations or endure them with great distress Most Common Type of Social Fear? Public Speaking Interferes with Life Functioning

Figure 4.8 A model of the various ways a social phobia may develop. (Barlow, D. H., 2002. Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic, 2nd ed. New York: Guilford Press.)

Treatment for Social Phobia Medication Treatment of Social Phobia Antidepressants Tricyclics and MAO Inhibitors SSRIs Paxil, Zoloft, Effexor FDA approved High relapse rates following discontinuation Psychological Treatment Cognitive-behavioral treatment Exposure, rehearsal, role-play in a group setting Highly effective

Posttraumatic Stress Disorder (PTSD) Exposure to a traumatic event War and Combat Rape and Assault Car Accidents Natural Disasters Re-experience the event (e.g., memories, nightmares, flashbacks) Avoidance of cues that remind person of event Emotional numbing, sleep disturbance, hyperarousal, and interpersonal problems are common Markedly interferes with one's ability to function

Subtypes of Post Traumatic Stress Acute Stress Disorder Immediately post-trauma Acute PTSD 1-3 months post trauma Chronic PTSD 3+ months post trauma Delayed Onset PTSD Onset of symptoms 6 months or more post trauma

Figure 4.10 A model of the causes of PTSD. (Barlow, D. H., 2002. Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic (2nd ed.). New York: Guilford Press, © 2002 Guilford Press.) Fig. 4-10, p. 153

PTSD Treatment Psychological Treatment of PTSD Face the Original Trauma—under positive conditions Imaginal Reexposure Corrective Emotional Learning and Catharsis Virtual Reality Increase positive coping skills and social support Cognitive-behavior therapies are highly effective Eye Movement Desensitization and Retraining (EMDR) Controversial, but has research support

Obsessive-Compulsive Disorder Culmination of All Anxiety Disorders Obsessions Intrusive Thoughts, Images, or Urges Attempts to Suppress or Eliminate Compulsions Thoughts or Actions Attempts to Suppress the Obsessions Attempts to Obtain Relief Most people with OCD display multiple obsessions Most Common Problem? Cleaning and washing or checking rituals NOT the same as Obsessive-Compulsive Personality Disorder

Figure 4.11 A model of the causes of obsessive-compulsive disorder. (Reprinted, with permission, from Steketee, G., & Barlow, D. H., 2002. Obsessive-compulsive disorder. In Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic (2nd ed., p. 536). New York: Guilford Press, © 2002 Guilford Press.) Fig. 4-11, p. 157

Treatment for OCD Biological Interventions Psychological Treatment SSRIs seem to benefit up to 60% of patients Limited extent of help Relapse is common with medication discontinuation Psychosurgery (cingulotomy) is used in extreme cases Psychological Treatment Cognitive-behavioral therapy is most effective with OCD Exposure and response prevention Combining medication with CBT may be no better than CBT alone

Factors in Treating Anxiety Disorders Biological Interventions Cognitive-Behavioral Interventions What about: Psychoanalytic Interventions Existential Interventions Humanistic Interventions Constructivist Interventions And, then again, what about: Social Interventions Cultural Interventions

Integrative View of Anxiety-Related Disorders

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