CHAPTER 2 ANXIETY DISORDERS

AIMS AND OBJECTIVES Describe the nature of fear and anxiety disorders Discuss the range of anxiety disorders Provide information about diagnosis, epidemiology, and treatment for each disorder

THE NATURE OF FEAR AND ANXIETY Flight or fight response (Cannon, 1929) Body reacts to danger by releasing adrenaline through blood stream Related behaviours include: Freezing – to appraise danger Flight – escape Fight – if danger is unavoidable “True alarms” (direct danger) versus “false alarms” (no immediate threat) False alarms are the hallmark of anxiety disorders

THE NATURE OF FEAR AND ANXIETY Triple vulnerability model (Barlow, 2002)

THE NATURE OF FEAR AND ANXIETY Fear can be acquired in several ways: Conditioning – pairing of a conditioned stimulus with an aversive event Informational pathway Vicarious acquisition These all contribute to the expectation that an aversive outcome is probable

THE NATURE OF FEAR AND ANXIETY Conditioning US (bitten by dog) UR (fear) CS (dog) pair with CR (fear)

SPECIFIC PHOBIA DSM-IV-TR Diagnosis includes: Epidemiology Marked fear that is excessive or unreasonable Cued by presence or anticipation of phobic object/situation Causes interference/impairment in life or marked distress Four subtypes: Animal Natural Environment (i.e., storms, heights, water) Blood-Injection – Injury (i.e., blood, operation scenes, injections, fainting common) Situational (i.e., planes, elevators) Epidemiology Lifetime prevalence 4-8%, female to male ratio 2:1

SPECIFIC PHOBIA Aetiology Phobias may be acquired by classical conditioning E.g., A neutral CS (white rat) is paired with a US (loud noise) that produces fear Problems with classical conditioning account Many people with specific phobias do not remember an initial traumatic event (Menzies & Clark, 1993) Preparedness: Some stimulus can be conditioned more easily (Seligman, 1971)

SPECIFIC PHOBIA Treatment Exposure-based treatments are the most effective (Choy et al., 2007) In vivo exposure – facing phobic stimulus in real life Imaginal or virtual exposure Exposures may work through extinction Fear decreases over repeated presentations of the CS in the absence of the US They may also work by challenging expectations of danger, increasing self-efficacy, and increasing perception of control

PANIC DISORDER AND AGORAPHOBIA DSM-IV-TR Diagnosis for Panic Disorder includes: Recurrent, unexpected panic attacks At least one attack has been followed by >1 month of: Persistent concern about having additional attacks Worry about the implications/consequences of the attack, e.g., losing control, dying A significant change in behavior Agoraphobia – anxiety about being in places from which escape might be difficult or embarrassing in the event of having a panic attack Panic disorder can occur with or without agoraphobia Lifetime prevalence of panic disorder = 5%

PANIC DISORDER AND AGORAPHOBIA Aetiology Generalised psychological vulnerability High anxiety sensitivity – fear of sensations Specific psychological vulnerability Catastrophic misinterpretation of physical sensations Treatment Pharmacological – SSRIs, benzodiazepines Psychological – Cognitive behaviour therapy Address avoidance of internal and external cues using behavioural and cognitive techniques

SOCIAL PHOBIA DSM-IV-TR Diagnosis includes: Epidemiology Marked, persistent fear of social situations Person recognises the fear as unreasonable Feared social situations are avoided Interference or distress Epidemiology Lifetime prevalence 10-16%, female to male ratio 1:1 Chronic course Delay in seeking treatment

SOCIAL PHOBIA Aetiology Treatment Genetic vulnerability: 2-3x increased risk among relatives Psychosocial factors Excessive parental criticism Cognitive dysfunctions Hypersensitivity to criticism Treatment Psychological– Cognitive behaviour therapy Cognitive restructuring of negative thoughts (e.g., I am boring) Exposure to feared social situations

OBSESSIVE COMPULSIVE DISORDER (OCD) DSM-IV-TR Diagnosis includes: Obsessions – recurrent thoughts, images or impulses experienced as inappropriate or distressing Compulsions – repetitive behaviours that the person feels compelled to perform in response to obsession or according to rigid rules Person recognizes that obsessions or compulsions are excessive/irrational Marked distress/interference, time-consuming (>1 hour/day) Several subtypes: Washing Checking Hoarding Obsessional slowness Epidemiology Lifetime prevalence 2-3% Often chronic if untreated

OBSESSIVE COMPULSIVE DISORDER (OCD) Aetiology Neuropsychological model (Baxter et al., 2000) Failure of inhibitory pathways in the basal ganglia to stop “behavioural macros” in response to internal/external stimuli Cognitive model OCD thoughts not different from those in general population Difference is how OCD sufferers interpret the thoughts Treatment Psychological– Cognitive behaviour therapy Exposure and response prevention Cognitive restructuring Pharmacological therapy

POSTTRAUMATIC STRESS DISORDER (PTSD) DSM-IV-TR Diagnosis includes: Exposure to a traumatic event Re-experiencing symptoms Avoidance symptoms Arousal symptoms Symptoms present for at least one month Epidemiology Despite high frequency of exposure to traumatic stressors, relatively few develop PTSD (4%) Research attempts to identify who is at risk for developing PTSD after exposure to a trauma

POSTTRAUMATIC STRESS DISORDER (PTSD) Aetiology Cognitive models Focus on individual’s maladaptive appraisals of the event, his/her response to the event, and the environment Learning accounts Emphasis on classical conditioning Biological accounts Propose that extreme sympathetic arousal at the time of trauma results in strong fear conditioning Across accounts, avoidance of trauma reminders maintains PTSD Treatment Pharmacological therapy Cognitive-behavioural therapy Psychoeducation, anxiety management, cognitive restructuring, imaginal / in vivo exposure, and relapse prevention Prevention of PTSD – applying CBT to survivors after trauma exposure

GENERALISED ANXIETY DISORDER (GAD) DSM-IV-TR Diagnosis includes: Excessive worry about a number of events or activities E.g, health, finances, relationships Worries are difficult to control Present on most days for at least 6 months Associated symptoms such as irritability, fatigue, difficulty concentrating, and muscle tension Epidemiology Commonly experienced, lifetime prevalence of 5% Early age of onset and chronic course

GENERALISED ANXIETY DISORDER (GAD) Aetiology Moderate genetic predisposition Cognitive models Information processing model – biased toward threat Metacognitive model – positive and negative meta-beliefs about worry Avoidance theory– worry to avoid imagery and underlying concerns Intolerance of uncertainty model – need to control Treatment Pharmacological therapy Cognitive-behavioural therapy Cognitive restructuring, relaxation, behavioural experiments Some symptom improvement, yet only 50% of sufferers end up in non-clinical range

SUMMARY Nature of Fear and Anxiety Flight or fight response Triple vulnerability model Acquisition of expectation of fear Diagnosis, Epidemiology, Aetiology, and Treatment of: Specific Phobia Panic Disorder and Agoraphobia Social Phobia Obsessive-Compulsive Disorder Posttraumatic Stress Disorder Generalised Anxiety Disorder