1. Chapter 6 Anxiety Disorders Copyright © 2006 Pearson Education Canada Inc.

2. 2 Overview Most common type of abnormal behaviour 12 - 17% of adults have some form of anxiety disorder in any given year Significant social and occupational impairment Commonalities with mood disorders - i.e., negative emotional responses (guilt, worry) Bio-Psycho-Social are factors

3. Copyright © 2006 Pearson Education Canada Inc. 3 Symptoms and Associated Features People with anxiety disorders share a preoccupation with or persistent avoidance of, thoughts or situations that provoke fear or anxiety.

4. Copyright © 2006 Pearson Education Canada Inc. 4 Symptoms and Associated Features Fear - response to real, immediate danger Anxiety – different from fear - more general and diffuse emotional reaction – low levels can be adaptive Maladaptive anxiety – high levels of diffuse negative emotion – pessimistic thoughts and feelings – sense of uncontrollability - in future situations – shift in attention to state of self-preoccupation

5. Copyright © 2006 Pearson Education Canada Inc. 5 Symptoms and Associated Features Excessive Worry – common in anxiety – relatively uncontrollable sequence of negative thoughts and images anticipating future threats of danger – pathological worry high quantity and negative, unrealistic content (i.e., negative self talk

6. Copyright © 2006 Pearson Education Canada Inc. 6 DSM-IV-TR Approach emphasis on description – little consideration on etiology Eight Specific Subtypes - i.e., Panic Attack, Agoraphobia, Panic Disorder, Specific Phobia, Social Phobia,OCD, Acute Stress Disorder, Generalized Anxiety Disorder

7. Copyright © 2006 Pearson Education Canada Inc. 7 Panic Attack Sudden overwhelming experience of terror involving somatic and cognitive symptoms. Symptoms are more intense, focused, and sudden than anxiety Symptoms include hear palpitations, sweating, dizziness, loss of control, heart attack, feeling like one is going to die

8. Copyright © 2006 Pearson Education Canada Inc. 8 Panic Attack: Somatic Symptoms DSM-IV-TR requires at least 4 of 13 symptoms: – Palpitations – sweating – trembling/shaking – sensations of shortness of breath/smothering – feelings of choking – chest pain/discomfort – nausea – feeling dizzy/light-headed – derealization or depersonalization – fear of losing control/going crazy – fear of dying – tingling/numbness of extremities – chills/hot flushes

9. Copyright © 2006 Pearson Education Canada Inc. 9 Panic Disorder recurrent unexpected panic attacks persistent concern about additional attacks for one month with or without agoraphobia

10. Copyright © 2006 Pearson Education Canada Inc. 10 Phobias persistent, excessive, unrealistic fear of a specific object/situation avoidance behaviour  Specific Phobia: fear of specific objects or situations For example: public speaking, elevators, animals etc.

11. Copyright © 2006 Pearson Education Canada Inc. 11 Specific Phobia Fear of specific objects or situations For example: public speaking, elevators, animals etc. Types: Animal Type, Natural/Environmental, Blood- Injection, Situational Type, Other

12. Copyright © 2006 Pearson Education Canada Inc. 12 Agoraphobia  Agoraphobia: fear of public spaces fear becomes more intense as the distance between the person and his/her familiar surrounding increases fear is more intense when the individual when avenues of escape are perceived to be closed off For Example: crowded rooms, streets Can accompany panic disorder

13. Copyright © 2006 Pearson Education Canada Inc. 13 Social Phobia fear of social situations – performance anxiety – interpersonal interactions rooted in fear of negative evaluations most common fears - speaking in public, dealing with authority, using public washroom (Stein et al., 2000)

14. Copyright © 2006 Pearson Education Canada Inc. 14 Obsessive-Compulsive Disorder (OCD) presence of obsessions or compulsions or both attempts to suppress thoughts or impulses What amount of specific behaviour defines abnormality?

15. Copyright © 2006 Pearson Education Canada Inc. 15 Obsessions and Compulsions OBSESSIONS – repetitive thoughts, images, impulses – obsessions are unwelcome - come “out of the blue” – person realizes their unreasonable nature (not delusional) – themes of usually unacceptable such as: sex, violence, contamination COMPULSIONS – behavioural responses to obsessions (“tension reduction”) – repetitive behaviours, rituals (e.g., hand-washing, checking) – mental acts (counting) – individual often attempts to reduce performing the compulsion – considered by the person to be senseless or irrational

16. Copyright © 2006 Pearson Education Canada Inc. 16 Generalized Anxiety Disorder (GAD) excessive, uncontrollable worry majority of days than not for at least 6 months affective, cognitive, & somatic symptoms symptoms include: feeling on edge, fatigued, difficulty concentrating, irritability, muscle tension, poor sleep patterns

17. Copyright © 2006 Pearson Education Canada Inc. 17 Historical Perspective Freud’s etiological description : – psychological conflicts – biological impulses  focus on sex and aggression

18. Copyright © 2006 Pearson Education Canada Inc. 18 Prognosis for Anxiety Disorders chronic conditions individual differences in recovery

19. Copyright © 2006 Pearson Education Canada Inc. 19 Epidemiology Gender - higher prevalence in females Age - lower prevalence in the elderly Cross-cultural studies – similar prevalence rates – different symptom patterns

20. Copyright © 2006 Pearson Education Canada Inc. 20 Etiology of Anxiety Disorders: Social Factors Stressful (dangerous) life events Childhood abuse/neglect Insecure attachment

21. Copyright © 2006 Pearson Education Canada Inc. 21 Etiology of Anxiety Disorders: Psychological Factors preparedness through evolution observational learning

22. Copyright © 2006 Pearson Education Canada Inc. 22 Etiology of Anxiety Disorders: Cognitive Factors perceived control versus helplessness Clark’s “catastrophic misinterpretation” anxiety sensitivity – focus on threat-related stimuli paradox of thought suppression – “try to not think of a white bear”

23. Copyright © 2006 Pearson Education Canada Inc. 23 Etiology of Anxiety Disorders: Biological Factors strong genetic component – family and twin studies two genetic factors identified – GAD/major depression – panic disorder/phobias

24. Copyright © 2006 Pearson Education Canada Inc. 24 Etiology of Anxiety Disorders: Biological Factors neuroanatomy – thalamus-amygdala circuit – OCD: caudate nucleus/orbital prefrontal cortex/anterior cingulate cortex

25. Copyright © 2006 Pearson Education Canada Inc. 25 Psychological Interventions Systematic Desensitization involves teaching relaxation techniques, then presenting items of the fear hierarchy while the patient is in the relaxed state Direct exposure (in vivo) works better than imagined ones in most cases

26. Copyright © 2006 Pearson Education Canada Inc. 26 Psychological Interventions Flooding involves exposure to most frightening stimuli rather than working from the least to most frightening Has shown high success rates

27. Copyright © 2006 Pearson Education Canada Inc. 27 Psychological Interventions Relaxation and Breathing involves teaching the client to alternate between relaxing and tensing muscle groups while breathing slowly and deeply

28. Copyright © 2006 Pearson Education Canada Inc. 28 Exposure and Response Prevention prolonged exposure to the situation that increases anxiety with prevention of the person’s typical compulsive response used primarily with OCD

29. Copyright © 2006 Pearson Education Canada Inc. 29 Cognitive Therapy and CBT similar to treatment used in depression identify maladaptive cognitions and beliefs and try to reconstruct mental sets Virtual Reality Therapy

30. Copyright © 2006 Pearson Education Canada Inc. 30 Biological Interventions I antianxiety medications – Benzodiazapines (Valium, Xanax) – Serious side effect: sedation. withdrawal, addiction

31. Copyright © 2006 Pearson Education Canada Inc. 31 Biological Interventions II Antidepressant medications – SSRIs (Prozac, Zoloft, Paxil) preferred – less side effects – tricyclics OK but serious side effects – clomipramine for OCD

32. Copyright © 2006 Pearson Education Canada Inc. 32 Case Study: Panic Disorder with Agoraphobia Johanna Schneller – freelance writer describes debilitating panic attacks – nausea, dizziness, shortness-of-breath, feelings of doom, and fear of escape – progressive fear of leaving her home negative effects of life – relationships – employment