Anxiety Disorders

Fundamental Features of Anxiety Disorders Fear and Threat Fear and Threat Effortful Avoidance Effortful Avoidance Compulsions or Rituals Compulsions or Rituals Detachment Detachment Experiential Avoidance Experiential Avoidance A person is unwilling to remain in contact with particular private experiences (e.g., bodily sensations, emotions, thoughts, memories, images, behavioral predispositions) and takes steps to alter the form or frequency of these experiences or the contexts that occasion them, even when these forms of avoidance cause behavioral harm A person is unwilling to remain in contact with particular private experiences (e.g., bodily sensations, emotions, thoughts, memories, images, behavioral predispositions) and takes steps to alter the form or frequency of these experiences or the contexts that occasion them, even when these forms of avoidance cause behavioral harm

Multidimensional Construct Three Categories Three Categories Subjective Distress (Cognitive Symptoms) Subjective Distress (Cognitive Symptoms) Worry about specific events harm/danger Worry about specific events harm/danger Broader constellation of anxious cognitions Broader constellation of anxious cognitions Physiological Responses Physiological Responses Sympathetic nervous system Sympathetic nervous system Tachycardia Tachycardia Tremulousness Tremulousness Dizziness Dizziness Lightheadedness Lightheadedness Parathesias Parathesias Dyspnea Dyspnea Avoidance or Escape Behaviors Avoidance or Escape Behaviors

Anxiety symptom baserates 1/3 of nonclinical populations have had symptoms of a panic attack at some time in their lifetimes 1/3 of nonclinical populations have had symptoms of a panic attack at some time in their lifetimes 90% of nonclinical populations have had obsessive thoughts no different from OCD 90% of nonclinical populations have had obsessive thoughts no different from OCD

Types of Anxiety Disorders Panic Disorder (w/o Agoraphobia) Panic Disorder (w/o Agoraphobia) Agoraphobia without panic Agoraphobia without panic Social Anxiety Disorder Social Anxiety Disorder Specific Phobia Specific Phobia Obsessive Compulsive Disorder Obsessive Compulsive Disorder Posttraumatic Stress Disorder Posttraumatic Stress Disorder Acute Stress Disorder Acute Stress Disorder Generalized Anxiety Disorder Generalized Anxiety Disorder Other Anxiety Conditions secondary to medical conditions Other Anxiety Conditions secondary to medical conditions

Medical Conditions and Other Etiologies Mitral valve prolapse Mitral valve prolapse Hypothyroidism Hypothyroidism Cardiovascular problems Cardiovascular problems Vestibular abnormalities Vestibular abnormalities Hyperthyroidism Hyperthyroidism Cushing’s Syndromes Cushing’s Syndromes Alcohol, caffeine, amphetamines, cannabis, cocaine, hallucinogens, inhalants, phencyclidine, sedatives, hypnotics, anxiolytics and a host of medications Alcohol, caffeine, amphetamines, cannabis, cocaine, hallucinogens, inhalants, phencyclidine, sedatives, hypnotics, anxiolytics and a host of medications

Comorbidity ½ of patients with an anxiety disorder have had at least one other clinically significant anxiety or depressive disorder diagnosis ½ of patients with an anxiety disorder have had at least one other clinically significant anxiety or depressive disorder diagnosis Panic Disorder with Agoraphobia had the highest comorbidity rates Panic Disorder with Agoraphobia had the highest comorbidity rates GAD and Social Phobia had the highest rates as assignments to other disorders (e.g. depression or other anxiety disorders) GAD and Social Phobia had the highest rates as assignments to other disorders (e.g. depression or other anxiety disorders)

Prevalence Anxiety disorders are very prevalent second only to substance abuse (LT) and highest (past year) Anxiety disorders are very prevalent second only to substance abuse (LT) and highest (past year) 31% lifetime rate; 18.7% past year rate 31% lifetime rate; 18.7% past year rate Most common are social phobia and specific phobia Most common are social phobia and specific phobia Women experience anxiety dx 2x rate of men Women experience anxiety dx 2x rate of men Exceptions are that social phobia is disproportionate but not as great Exceptions are that social phobia is disproportionate but not as great OCD rates are roughly comparable for men and women OCD rates are roughly comparable for men and women

Diatheses Evidence for heritability for the broad category of anxiety disorders and Evidence for heritability for the broad category of anxiety disorders and Specific category for panic, agoraphobia, social phobia and OCD (less evidence for GAD and specific phobia) Specific category for panic, agoraphobia, social phobia and OCD (less evidence for GAD and specific phobia) Depression and anxiety may share common genetic factors Depression and anxiety may share common genetic factors Modest support for genetic markers for AD, better evidence for genetic marker for temperament Modest support for genetic markers for AD, better evidence for genetic marker for temperament

Personality Children who were more inhibited at earlier ages evidenced more social inhibition as adults Children who were more inhibited at earlier ages evidenced more social inhibition as adults

Theories Mower’s Two Factor Theory Mower’s Two Factor Theory Exposure Therapy Exposure Therapy Guidelines for Exposure Guidelines for Exposure Identify the entire stimulus complex (including verbal processes) Identify the entire stimulus complex (including verbal processes) Avoid small exposures that potentiate fear Avoid small exposures that potentiate fear Be attuned to escape behavior Be attuned to escape behavior When escape is blocked watch out for frustration/anger When escape is blocked watch out for frustration/anger Reconditioning of fear occurs more rapidly than the original conditioning Reconditioning of fear occurs more rapidly than the original conditioning

Panic Disorder: Phenomenology Misinterpretation of bodily sensations. Fear of physical sensations. Misinterpretation of bodily sensations. Fear of physical sensations. A panic attack appears at inappropriate or unexpected times with no apparent stimulus. A panic attack appears at inappropriate or unexpected times with no apparent stimulus. Intense fear and discomfort Intense fear and discomfort Palpitations Palpitations Smothering Smothering Dizziness Dizziness Losing Control Losing Control Fear of dying or going crazy Fear of dying or going crazy Peak within 10 minutes often within 1-5 minutes Peak within 10 minutes often within 1-5 minutes

Physiology of Panic Panic is an emergency response Panic is an emergency response If safe, look for explanation of symptoms If safe, look for explanation of symptoms Sympathetic system either runs its course or the parasympathetic system takes our and stops the response Sympathetic system either runs its course or the parasympathetic system takes our and stops the response Cardiovascular effects Cardiovascular effects Respiratory effects Respiratory effects Sweat glands Sweat glands Effect of overbreathing Effect of overbreathing