Chapter 5 Anxiety Disorders

Nature of Anxiety and Fear  Fear  Immediate, present-oriented  Sympathetic nervous system activation  Anxiety  Apprehensive, future-oriented  Somatic symptoms = tension  Both: Negative affect

Nature of Anxiety, Fear, and Panic  Panic attacks –abrupt experience of intense fear  Symptoms: palpitations, chest pain, dizziness  Three types  Situationally-bound/cued  Unexpected/uncued  Situationally predisposed

Nature of Anxiety, Fear, and Panic

Causes of Anxiety - Biological Contributions  Increased physiological vulnerability  Polygenetic influences  Corticotropin releasing factor (CRF)  Brain circuits and neurotransmitters  GABA  noradrenergic  serotonergic systems  CRF and the HPAC axis

Causes of Anxiety - Biological Contributions  Limbic system  Behavioral inhibition system (BIS)  Brain stem  Septal-hippocampal system  Amygdala  Fight/flight (FF) system  Panic circuit  Alarm and escape response

Causes of Anxiety - Biological Contributions  Brain circuits are shaped by environment  Ex. teenage cigarette smoking  Interactive relationship with somatic symptoms

Psychological Contributions  Freud  Anxiety = psychic reaction to danger  Reactivation of infantile fear situation  Behaviorists  Classical and operant conditioning  Modeling

Psychological Contributions  Integrated psychological model  Early experiences and perceptions  Controllability  Dangerousness  Parental actions/modeling  Associations or cues to stimuli

Social Contributions  Biological vulnerabilities triggered by stressful life events  Familial  Interpersonal  Occupational  Educational

An Integrated Model  Triple Vulnerability  Generalized biological vulnerability  Diathesis  Generalized psychological vulnerability  Beliefs/perceptions  Specific psychological vulnerability  Learning/modeling

An Integrated Model

Comorbidity of Anxiety Disorders  High rates of comorbidity  55% to 76%  Commonalities  Features  Vulnerabilities  Links with physical disorders

Anxiety Disorders and Disability

Panic Disorder and Suicide  Suicide attempt rates  Similar to major depression  20%  Increases for all anxiety disorders  Comorbidity with depression??

The Anxiety Disorders: An Overview  Generalized Anxiety Disorder  Panic Disorder with and without Agoraphobia  Specific Phobias  Social Phobia  Posttraumatic Stress Disorder  Obsessive-Compulsive Disorder

Generalized Anxiety Disorder  Clinical Description  Excessive apprehension and worry  Uncontrollable  Strong, persistent anxiety  Somatic symptoms  (e.g., muscle tension, fatigue, mental agitation)  6 months or more

Generalized Anxiety Disorder  Clinical Description (cont.)  Shift from possible crisis to crisis  Worry about minor, everyday concerns  Job, family, chores, appointments  Problems sleeping  GAD in Children  Need only one physical symptom  Worry = academic, social, athletic performance

Generalized Anxiety Disorder  Statistics  3.1% (year)  5.7% (lifetime)  Similar rates worldwide  Female : Male = ~2 : 1  Insidious onset  Early adulthood  Chronic course

Generalized Anxiety Disorder  GAD in the Elderly  Worry about failing health, loss  Up to 7% prevalence  Use of minor tranquilizers %  Medical problems?  Sleep problems?  Falls  Cognitive impairments

GAD : Causes  Inherited tendency to become anxious  “Neuroticism”?  Less responsiveness  “autonomic restrictors”  Threat sensitivity  Frontal lobe activation  Left vs. right

GAD : Causes

GAD : Treatments  Pharmacological  Benzodiazepines  Risks versus benefits  Antidepressants

GAD : Treatments  Psychological  Cognitive-behavioral treatments  Exposure to worry process  Confronting anxiety-provoking images  Coping strategies  Acceptance  Meditation  Similar benefits  Better long-term results

Panic Disorder with and without Agoraphobia  Clinical Description  Unexpected panic attacks  Anxiety, worry, or fear of another attack  Persists for 1 month or more  Agoraphobia  Fear or avoidance of situations/events

Panic Disorder with and without Agoraphobia  Clinical Description (cont.)  Avoidance can be persistent  Use and abuse of drugs and alcohol  Interoceptive avoidance

Panic Disorder with and without Agoraphobia PLAY VIDEO

Panic Disorder with and without Agoraphobia  Statistics  2.7% (year)  4.7% (life)  Female : male = 2:1  Acute onset, ages 20-24

Panic Disorder - Special Populations  Children  Hyperventilation  Cognitive development  Elderly  Health focus  Changes in prevalence

Panic Disorder: Cultural Influences  Social/Gender roles  ~75% of those with agoraphobia are female  Similar prevalence rates  Variable symptom expression  Somatic symptoms

Panic Disorder: Cultural Influences  Culture-bound syndromes  Ataque de nervios  Susto  Kyol goeu

Panic Disorder: Nocturnal Panic  60% with PD experience nocturnal attacks  non-REM sleep  Delta wave  Caused by deep relaxation,  Sensations of “letting go”  Sleep terrors  Isolated sleep paralysis

Panic Disorder: Causes  Generalized biological vulnerability  Alarm reaction to stress  Cues get associated with situations  Conditioning occurs  Generalized psychological vulnerability  Anxiety about future attacks  Hypervigilance  Increase interoceptive awareness

Panic Disorder: Causes

Panic Disorder: Treatment  Medications  Multiple systems  serotonergic  noradrenergic  benzodiazepine GABA  SSRIs (e.g., Prozac and Paxil)  High relapse rates when d/c’d

Panic Disorder: Treatment  Psychological  Exposure- based  Reality testing  Relaxation  Breathing  Panic Control Treatment  Exposure to interoceptive cues  Cognitive therapy  Relaxation/breathing  High degree of efficacy

Panic Disorder: Treatment PLAY VIDEO

Panic Disorder: Treatment Combined Medication/Psychological  No better than individual tx  CBT = better long term

Panic Disorder: Treatment

 Clinical Description  Extreme and irrational fear of a specific object or situation  Significant impairment  Recognizes fears as unreasonable  Avoidance Specific Phobias

 Blood-Injection-Injury Phobia  Decreased heart rate and blood pressure  Fainting  Inherited vasovagal response  Onset = ~ 9 Specific Phobias

 Situational Phobia  Fear of specific situations  Transportation, small places  No uncued panic attacks  Onset = early to mid 20s Specific Phobias

 Natural Environment Phobia  Heights, storms, water  May cluster together  Associated with real dangers  Onset = ~7 Specific Phobias

 Animal Phobia  Dogs, snakes, mice  May be associated with real dangers  Onset = ~7 Specific Phobias

 Illness  Choking  Separation Anxiety Disorder  School phobia Other Phobias

 Statistics  12.5% (life); 8.7% (year)  Female : Male = 4:1  Chronic course  Onset = 7 (median) Specific Phobias: An Overview

Specific Phobias: Causes  Inherited vulnerability  Biological and evolutionary  Traumatic exposure  Direct conditioning  Observational learning  Information transmission  Social and Gender Roles

Specific Phobias: Causes

Specific Phobias: Treatment  Cognitive-behavior therapies  Exposure  Graduated  Structured  Consistent  Relaxation  Blood-injury-injection  Tensing

Social Phobia  Clinical Description  Extreme and irrational fear/shyness  Social/performance situations  Significant impairment  Avoidance or distressed endurance  Generalized subtype

Social Phobia  Statistics  12.1%(life); 6.8% (year)  Female : male = 1.4:1.0  Onset = adolescence  Peak age of 15

Social Phobia: Cultural Considerations  Japan - taijin kyofusho  Fear of offending others  Symptoms  Female : Male = 2:3

Social Phobia: Causes  Inherited vulnerability  Biological and evolutionary  Traumatic exposure (social)  Direct conditioning  Observational learning  Information transmission  Family influence

Social Phobia: Causes

Social Phobia: Treatment  Medications  Beta blockers  Tricyclic antidepressants  MAOI  SSRI (Paxil)  D-cycloserine  High relapse rates when d/c’d

 Psychological  Cognitive-behavioral treatment  Exposure  Rehearsal  Role-play  Group settings  Highly effective Social Phobia: Treatment (cont.)

Social Phobia: Treatment

Posttraumatic Stress Disorder (PTSD)  Clinical Description  Trauma exposure  Extreme fear, helplessness, or horror  Continued re-experiencing  (e.g., memories, nightmares, flashbacks)  Avoidance  Emotional numbing  Interpersonal problems  Dysfunction  1+ month post-trauma

Posttraumatic Stress Disorder (PTSD)  Subtypes  Acute  Chronic  Delayed onset  Acute stress disorder

Posttraumatic Stress Disorder (PTSD)  Statistics  6.8% (life); 3.5% (year)  Prevalence varies  Type of trauma  Proximity  Most Common Traumas  Sexual assault  Accidents  Combat

Posttraumatic Stress Disorder (PTSD)

PTSD : Causes  Trauma intensity  Generalized biological vulnerability  Twin studies  Reciprocal gene-environment interactions  Generalized psychological vulnerability  Uncontrollability and unpredictability  Social support

PTSD : Causes  Neurobiological model  Threatening cues activate CRF system  CRF system activates fear and anxiety areas  Locus cereleus  Amygdala (central nucleus)  Increased HPA axis activation  cortisol

PTSD : Causes

 Cognitive-behavioral treatment  Exposure  Imaginal  Graduated or massed  Increase positive coping skills  Increase social support  Highly effective PTSD : Treatment

 Medications  SSRIs PTSD : Treatment

Clinical Description  Obsessions  Intrusive and nonsensical  Thoughts, images, or urges  Attempts to resist or eliminate  Compulsions  Thoughts or actions  Suppress obsessions  Provide relief Obsessive-Compulsive Disorder (OCD)

PLAY VIDEO Obsessive-Compulsive Disorder (OCD)

 60% have multiple obsessions  Contamination  Aggressive impulses  Sexual content  Somatic concerns  Need for symmetry OCD : Obsessions

 Four major categories  Checking  Ordering  Arranging  Washing/cleaning  Association with obsessions  Hoarding OCD : Compulsions

 Statistics  1.6% (life); 1% (year)  Female > Male  Reversed in childhood  Chronic  Onset = depends  Male = 13 to 15  Female = 20 to 24 Obsessive-Compulsive Disorder

 Similar generalized biological vulnerability  Specific psychological vulnerability  Early life experiences and learning  Thoughts are dangerous/unacceptable  Thought-action fusion  Distraction temporarily reduces anxiety  Increases frequency of thought Obsessive-Compulsive Disorder : Causes

OCD : Treatment  Medications  SSRIs  60% benefit  Psychosurgery (cingulotomy)  30% benefit  High relapse when d/c’d

OCD : Treatment  Cognitive-behavioral therapy  Exposure  Response prevention  Reality testing  Highly effective  86% benefit  No added benefit from combined treatment

Future Directions  Improving combined treatments  D-cycloserine