CHAPTER SIX Anxiety Disorders

Overview Notice that the lectures for this chapter are organized differently than the textbook Notice that the lectures for this chapter are organized differently than the textbook The book focuses on anxiety as a mood, whereas the lectures focus on anxiety disorders The book focuses on anxiety as a mood, whereas the lectures focus on anxiety disorders You are responsible for knowing both information from the book and from the lectures You are responsible for knowing both information from the book and from the lectures

Anxiety Disorders Anxiety, Fear, and Depression Anxiety, Fear, and Depression Overview of Anxiety Treatment Overview of Anxiety Treatment Generalized Anxiety Disorder Generalized Anxiety Disorder Obsessive-Compulsive Disorder Obsessive-Compulsive Disorder Panic Disorder and Agoraphobia Panic Disorder and Agoraphobia Specific Phobia Specific Phobia Social Phobia Social Phobia Epidemiology Epidemiology

Common Features of Anxiety Disorders What do anxiety disorders have in common? People with anxiety disorders share a preoccupation with or persistent avoidance of thoughts and situations that provoke fear or anxiety. People with anxiety disorders share a preoccupation with or persistent avoidance of thoughts and situations that provoke fear or anxiety.

Anxiety vs. Fear Anxiety Anxiety May mostly involve anticipation of future negative events (worry) May mostly involve anticipation of future negative events (worry) May mostly involve somatic arousal May mostly involve somatic arousal Can be adaptive if not excessive Can be adaptive if not excessive Fear Fear Experienced when a person is faced with real and immediate danger Experienced when a person is faced with real and immediate danger Mostly involves somatic symptoms (e.g. increased heart rate) Mostly involves somatic symptoms (e.g. increased heart rate) Present-oriented Present-oriented Can be adaptive Can be adaptive

Prevalence & Comorbidity Prevalence Prevalence Anxiety disorders are more common than any other form of mental disorder. Anxiety disorders are more common than any other form of mental disorder. Highly Comorbid Highly Comorbid Between different anxiety disorders Between different anxiety disorders Between anxiety and depression Between anxiety and depression Between anxiety and substance abuse Between anxiety and substance abuse What do anxiety and depression have in common? Both defined in terms of negative emotional experience Both defined in terms of negative emotional experience Both triggered by stressful experiences Both triggered by stressful experiences

Affect in Anxiety & Depression Positive Affect Negative Affect CheerfulSad ExcitedAngry InspiredGuilty EnthusiasticAshamed ProudScared Emotionality: tendency to feel an emotion Two Dimensions

Depression/Anxiety Comorbidity: Conceptual and Clinical Overlap “pure” Anxiety “pure” Depression Negative Affect Positive Affect Somatic Arousal ComorbidDep/Anx “General Distress”

Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Overview of Anxiety Treatment Generalized Anxiety Disorder Obsessive-Compulsive Disorder Panic Disorder and Agoraphobia Specific Phobia Social Phobia Epidemiology

Overview of Treatment for Anxiety Exposure (in vivo = direct) Exposure (in vivo = direct) Systematic Desensitization Systematic Desensitization the client is taught to relax and while in a relaxed state they are presented with items on a fear hierarchy, starting with the least threatening Flooding Flooding exposure to the most threatening or frightening stimuli first

Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Generalized Anxiety Disorder Generalized Anxiety Disorder Obsessive-Compulsive Disorder Panic Disorder and Agoraphobia Specific Phobia Social Phobia Epidemiology

Anxiety in GAD focuses on everyday events (worry + physical symptoms) Anxiety in GAD focuses on everyday events (worry + physical symptoms) DSM-IV-TR criteria for GAD include: DSM-IV-TR criteria for GAD include: Excessive worry occurring more days than not Excessive worry occurring more days than not Person finds it difficult to control the worry Person finds it difficult to control the worry Restlessness, easy fatigue, difficulty concentrating, muscle tension, sleep disturbance, irritability Restlessness, easy fatigue, difficulty concentrating, muscle tension, sleep disturbance, irritability Generalized Anxiety Disorder

GAD is characterized by anxious apprehension (worry) GAD is a state of High negative affect and chronic over- arousal Sense of uncontrollability Sense of uncontrollability Focus on threat-related stimuli that may indicate future negative events Focus on threat-related stimuli that may indicate future negative events

GAD: Hypothesized Etiological Factors Anxiety as trait does seem to run in families, but GAD results less conclusive Anxiety as trait does seem to run in families, but GAD results less conclusive Intolerance of uncertainty Intolerance of uncertainty Belief that worry is adaptive Belief that worry is adaptive Avoidance of threatening information Avoidance of threatening information

The three main facets: Considering thoughts as hypotheses rather than facts that can be supported (or not) by evidence Considering thoughts as hypotheses rather than facts that can be supported (or not) by evidence Utilizing past and present evidence to examine the validity of the belief Utilizing past and present evidence to examine the validity of the belief Exploring and generating all possible predictions or interpretations of an event Exploring and generating all possible predictions or interpretations of an event GAD: Cognitive Therapy

Step 1: Awareness Provide clients with overview of how their cognitions work Step 2: Interpretation Make clients understand the nature of inappropriate anxiety and the role of their interpretation of situations that create negative affect. Step 3: Specific Negative Prediction Identify the specific interpretations or negative predictions that the clients are making and challenge them.

Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Generalized Anxiety Disorder Obsessive-Compulsive Disorder Obsessive-Compulsive Disorder Panic Disorder and Agoraphobia Specific Phobia Social Phobia Epidemiology

Educational Objectives To gain a clearer understanding of the difference between obsessions and compulsions To see how symptoms and the course of OCD vary for different clients OCD: Video

Must have obsessions with or without compulsions Obsessions Intrusive & nonsensical thoughts, images, urges that one tries to resist or eliminate Compulsions Thoughts or actions designed to suppress the thoughts & provide relief from anxiety caused by obsessions Obsessive-Compulsive Disorder

Compulsions cannot exist without obsessions but obsessions can exist without compulsions Most people with OCD have both Most individuals with OCD do recognize that their obsessions and compulsions are unreasonable and try to avoid doing them Obsessive-Compulsive Disorder

Typical obsessions include: contamination aggressive impulses sexual content somatic concerns symmetry Obsessions are often about normal concerns (e.g., germs, neatness), but differ in intensity level compared to people without OCD Onset: early adolescence to young adulthood Course: typically chronic Obsessive-Compulsive Disorder

OCD: Rebound Effect 1. Born with a predisposition to be very emotionally reactive 2. Emotional Trigger/Event 3. You try to suppress emotional response 4. But, the more you suppress, the more aware you become uh oh chill... OBSESSIONS & COMPULSIONS

Step 1 Information gathering Step 2 Exposure & response Step 3 Record keeping Step 4 Homework assignments Step 5 Support OCD Treatment: Exposure & Response Prevention

Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Generalized Anxiety Disorder Obsessive-Compulsive Disorder Panic Disorder and Agoraphobia Panic Disorder and Agoraphobia Specific Phobia Social Phobia Epidemiology

Palpitations, pounding or accelerated heart rate Palpitations, pounding or accelerated heart rate Sweating Sweating Trembling and shaking Trembling and shaking Sensations of shortness of breath or smothering Sensations of shortness of breath or smothering Feeling of choking Feeling of choking Chest pain or discomfort Chest pain or discomfort Nausea or abdominal distress Nausea or abdominal distress Panic Attack: Criteria

Feeling dizzy, unsteady or faint Feeling dizzy, unsteady or faint Derealization (feelings of unreality) or depersonalization (being detached from oneself) Derealization (feelings of unreality) or depersonalization (being detached from oneself) Fear of losing control or going crazy Fear of losing control or going crazy Fear of dying Fear of dying Paresthesias (numbness or tingling sensations) Paresthesias (numbness or tingling sensations) Chills or hot flushes Chills or hot flushes Panic Attack: Criteria (cont’d)

Involves an abrupt Involves an abrupt experience of intense fear or acute discomfort Accompanied by physical Accompanied by physical symptoms (e.g., heart palpitations, chest pain) Symptoms develop suddenly and reach a peak within 10 minutes Symptoms develop suddenly and reach a peak within 10 minutes Can experience panic attacks with each of the anxiety disorders Can experience panic attacks with each of the anxiety disorders Panic Attack

Three types: Three types: Situationally bound (cued) Situationally bound (cued) Panic only when see a spider Unexpected (uncued) Unexpected (uncued) Out of the blue Situationally predisposed Situationally predisposed a person more likely to have a panic attack where s/he had one before (e.g., crowded restaurant), but having one isn’t inevitable Panic Attack: Types

Panic Disorder is the presence of: Recurrent, unexpected panic attacks followed by at least 1 month of persistent concern about having another attack Recurrent, unexpected panic attacks followed by at least 1 month of persistent concern about having another attack Worry about the possible implications of the panic attacks Worry about the possible implications of the panic attacks Significant behavioral change related to the attacks. Significant behavioral change related to the attacks. Panic Disorder: Criteria

The essential feature of agoraphobia is anxious apprehension about being in places or situations from which: Escape might be difficult or embarrassing Escape might be difficult or embarrassing Help may not be available if one has a panic attack Help may not be available if one has a panic attack Agoraphobia: Criteria

NoYes No No disorder Panic Disorder without Agoraphobia Yes Agoraphobia without Panic Disorder Panic Disorder with Agoraphobia PANIC DISORDER AGORAPHOBIAAGORAPHOBIAAGORAPHOBIAAGORAPHOBIA Panic Disorder & Agoraphobia

predisposition to be overreactive to stress stressful event False Alarm! (becomes a Learned Alarm) “unexplained physical sensations are dangerous” “unexplained physical sensations are dangerous” worry focused on somatic sensations Panic Disorder Developing Agoraphobia Panic Disorder with Agoraphobia Panic Attack: Barlow & White (1988)

Step 1 A person misinterprets bodily sensations (e.g., rapid heart rate) associated with anxiety as a serious threat Step 2 This leads to increased awareness of biological reactions Step 3 Misinterprets these sensations as catastrophic events (e.g., I’m going crazy, I’m going to die) Panic Attack: Catastrophic Misinterpretation

Biological Factors Neurochemistry One theory suggests that several neurotransmitter systems may be “hyperactive” in people with panic disorder. Panic Attack: Etiology

Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Generalized Anxiety Disorder Obsessive-Compulsive Disorder Panic Disorder and Agoraphobia Specific Phobia Specific Phobia Social Phobia Epidemiology

Excessive or unreasonable fear related to a specific object/situation that interferes with functioning (e.g., fear of snakes) Excessive or unreasonable fear related to a specific object/situation that interferes with functioning (e.g., fear of snakes) DSM-IV-TR’s Five Types DSM-IV-TR’s Five Types Animal Animal Natural environment Natural environment Blood/injury Blood/injury Situational Situational Other Other Specific Phobia

Evolutionary adaptation Evolutionary adaptation Negative information Negative information Classical conditioning Classical conditioning Etiology of Phobia

Exposure Therapy (in vivo) Components Phobic learning history – create new learning history Phobic learning history – create new learning history Stimulus exposure  anxiety  relaxation  decreased anxiety Stimulus exposure  anxiety  relaxation  decreased anxiety Fear & Avoidance Hierarchy (FAH) Fear & Avoidance Hierarchy (FAH) Subjective Units of Distress Scale (SUDS) Subjective Units of Distress Scale (SUDS) Specific Phobia: Treatment

1. Thinking about a spider 2. Seeing a picture of a spider far away 3. Seeing a picture of a very close-up spider 4. Seeing a spider in a cage far away 5. Seeing a spider in a cage close up 6. Seeing al spider loose far away 7. Seeing a spider close-up 8. Holding a spider Fear Hierarchy Example (25) (40) (45) (60) (75) (85) (95) (100) (SUDS)

Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Generalized Anxiety Disorder Obsessive-Compulsive Disorder Panic Disorder and Agoraphobia Specific Phobia Social Phobia Social Phobia Epidemiology Special Topic: Anxiety in Children

Characterized by fear of humiliation by either performing badly or by displaying visible symptoms of anxiety. Characterized by fear of humiliation by either performing badly or by displaying visible symptoms of anxiety. More than shyness More than shyness If the fears include most social situations, it is considered generalized social phobia If the fears include most social situations, it is considered generalized social phobia Social Phobia

Marked and persistent fear of one or more social or performance situations in which a person is exposed to unfamiliar people or possible scrutiny by others Marked and persistent fear of one or more social or performance situations in which a person is exposed to unfamiliar people or possible scrutiny by others Exposure to the feared social situation invariably provokes anxiety Exposure to the feared social situation invariably provokes anxiety The person realizes that the fear is excessive or unreasonable The person realizes that the fear is excessive or unreasonable The feared situation is avoided or endured with great distress The feared situation is avoided or endured with great distress Social Phobia: Criteria

Attention Attention what people attend to Memory Memory what people remember Judgment Judgment how people judge things (e.g., how likely certain outcomes are) and their judgments of what the costs and benefits would be of various outcomes Social Phobia: Cognitive Biases

2 kinds of judgment biases in individuals with anxiety disorders: 2 kinds of judgment biases in individuals with anxiety disorders: exaggerated estimates of the occurrence of negative events exaggerated estimates of the occurrence of negative events exaggerated estimates of the cost (valence) of negative events exaggerated estimates of the cost (valence) of negative events Social phobia is more distinguished by exaggerated cost Social phobia is more distinguished by exaggerated cost Social Phobia: Etiology

Step 1 Simulated exposure to feared situations in the session Step 2 Cognitive rethinking about the social cost of behavior Step 3 Homework assignments for in vivo exposure that is developed in the session and is relevant to the person’s life Social Phobia: Cognitive & Exposure Treatment

Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Generalized Anxiety Disorder Obsessive-Compulsive Disorder Panic Disorder and Agoraphobia Specific Phobia Social Phobia Epidemiology Epidemiology

Disorder Age Of Onset High Risk Groups Panic late adolescence, mid-30s separated, divorced, women Agoraphobia20s-40s separated, divorced, African Americans GAD childhood - adolescence separated, divorced, women, unemployed, African Americans Social Phobiaadolescence low income, Asian Americans, women OCD adolescence - early adult separated, divorced Epidemiology of Anxiety Disorders

Lifetime Prevalence Rates by Gender

One-Year Prevalence Rates by Gender

One-Year Prevalence Rates by Race

CHAPTER SIX Anxiety Disorders Optional Slides

Relaxation Demonstration The goal of this activity was to help you understand the process of relaxation treatments The goal of this activity was to help you understand the process of relaxation treatments You may find this technique effective in relieving your own stress and anxiety You may find this technique effective in relieving your own stress and anxiety

Step 1 Using the major muscle groups, clients are taught to discriminate and detect early signs of muscle tension Step 2 Relaxation deepening techniques are employed including diaphragmatic breathing GAD: Relaxation Treatment

Step 3 Clients learn to alleviate the physiological components of anxiety by interrupting the learned association between over-arousal and worry Step 4 Clients model relaxation in the session and then practice it at home with tapes of the session GAD: Relaxation Treatment

FRED IS AFRAID OF SNAKES FRED IS AFRAID OF SNAKES How do we know if this is a phobia or not? How do we know if this is a phobia or not? Fred would be very upset/fearful if Fred would be very upset/fearful if he were thrown into a pit of cobras he were thrown into a pit of cobras someone put a large snake around his neck someone put a large snake around his neck he had to walk by a snake in a cage he had to walk by a snake in a cage he had to watch Raiders of the Lost Ark he had to watch Raiders of the Lost Ark Specific Phobia

Systematic Desensitization I will be showing some pictures of spiders and talking about how an actual systematic desensitization would work with a spider phobia. If you have a fear/phobia of spiders, you may leave the room or just close your eyes. For each picture I want you to rate how creepy you feel according to your SUDS. A) 1-20 B) C) D) E)

How creepy would you feel? A) 1-20 B) C) D) E)

How creepy would you feel? A) 1-20 B) C) D) E)

How creepy would you feel? How creepy would you feel? A) 1-20 B) C) D) E)

How creepy would you feel? How creepy would you feel? A) 1-20 A) 1-20 B) B) C) C) D) D) E) E)

How creepy would you feel? How creepy would you feel? A) 1-20 B) C) D) E)

What did the SUDS reveal?

There is evidence that social phobia runs in families There is evidence that social phobia runs in families Modeling of socially anxious parents has an effect on children Modeling of socially anxious parents has an effect on children In particular, overprotective and rejecting behavior increase the odds of developing social phobia In particular, overprotective and rejecting behavior increase the odds of developing social phobia Social Phobia: Etiology

Asian Americans score consistently higher on measures of social anxiety than white Americans or any other ethnic group. Asian Americans score consistently higher on measures of social anxiety than white Americans or any other ethnic group. Why? Why? Hypothesis 1 Hypothesis 1 Asian Americans experience higher levels of generalized distress. Asian Americans experience higher levels of generalized distress. Hypothesis 2 Hypothesis 2 Cultural norms and values make Asian Americans particularly prone to social phobia. Cultural norms and values make Asian Americans particularly prone to social phobia. Social Phobia & Culture

Independent vs. Interdependent Self Independent Self Independent Self Putting self before others; making one’s own decisions for personal benefit (strongly valued in American society) Interdependent Self Interdependent Self Attending to others; fitting in with others; maintaining harmony with others (more valued in Asian societies)

Okazaki Study (1997) Asian Americans scored significantly higher on measures of distress (anxiety and depression) compared to White Americans. Asian Americans scored significantly higher on measures of distress (anxiety and depression) compared to White Americans. When comorbidity between social anxiety and depression was taken into account, Okazaki (1997) found that social anxiety (not depression) was associated with how Asians view themselves (self-construal).When comorbidity between social anxiety and depression was taken into account, Okazaki (1997) found that social anxiety (not depression) was associated with how Asians view themselves (self-construal). More consistent with Hypothesis 2 More consistent with Hypothesis 2

Self-construal and ethnicity are linked to social anxiety (not depression) measures Self-construal and ethnicity are linked to social anxiety (not depression) measures Social anxiety appeared to be a particularly salient form of distress for Asian Americans Social anxiety appeared to be a particularly salient form of distress for Asian Americans Asian American ethnicity predicted levels of social anxiety above and beyond individual subjects’ values of independence and interdependence. Asian American ethnicity predicted levels of social anxiety above and beyond individual subjects’ values of independence and interdependence. Results

Critical Thinking Activity Get into groups of 4-5 people. Get into groups of 4-5 people. You will be given one cultural variable to discuss. You will be given one cultural variable to discuss. Discuss how and why there might be differences in prevalence rates of the following disorders depending on that cultural factor. Discuss how and why there might be differences in prevalence rates of the following disorders depending on that cultural factor. Please be appropriate. Please be appropriate. The disorders are: MDD, OCD, and substance abuse The disorders are: MDD, OCD, and substance abuse