1. PSY4080 6.0 D Anxiety Disorders 1

2. PSY4080 6.0 D Anxiety Disorders 2 Anxiety Disorders: Prevalence, general information Anxiety disorders - most prevalent disorders of childhood and adulthood (Prevalence of 1 -25% - Gelfland, 2002) To be a disorder, it must interfere with daily functioning. Most prevalent: 1.Obsessive compulsive disorder (OCD) 2.Generalized anxiety disorder (GAD) 3.Social Phobias and Panic Disorders

3. PSY4080 6.0 D Anxiety Disorders 3 About Anxiety Disorders Physical Aspect Stress: generally a physiological state associated with anxiety - heightened arousal with physical symptoms Stress: generally a physiological state associated with anxiety - heightened arousal with physical symptoms Psychological Aspect Anxiety: a feeling of anticipation (negative) or worry in a particular context - no specific target is necessary Anxiety: a feeling of anticipation (negative) or worry in a particular context - no specific target is necessary Fear: often used interchangeably - usually used in reference to a specific target Fear: often used interchangeably - usually used in reference to a specific target Axiogenic: anxiety producing Axiogenic: anxiety producing Axiolytic: anxiety reducing Axiolytic: anxiety reducing

4. PSY4080 6.0 D Anxiety Disorders 4 The Stress Response Hypothalamic-Pituitary-Adrenal (HPA) Axis Hypothalamus releases of corticotropin releasing hormone (CRH) Hypothalamus releases of corticotropin releasing hormone (CRH) Pituitary gland releases (adreno)corticotropin hormone Pituitary gland releases (adreno)corticotropin hormone Cortisol (and other adrenal hormones) released from adrenal glands Cortisol (and other adrenal hormones) released from adrenal glands Increasing energy, awareness in response to a threatIncreasing energy, awareness in response to a threat Increase heart rate, sweating, heavier breathing, increase in muscle tension, etc.Increase heart rate, sweating, heavier breathing, increase in muscle tension, etc. Preparation of fight or flightPreparation of fight or flight

5. PSY4080 6.0 D Anxiety Disorders 5

6. PSY4080 6.0 D Anxiety Disorders 6 The Stress Response The hypothalamus is a the centre of the stress response via the sympathetic nervous system. The hypothalamus is a the centre of the stress response via the sympathetic nervous system. However, projections from the amygdala and prefrontal areas to the hypothalamus influence how threatening situations are interpreted and, hence, regulated However, projections from the amygdala and prefrontal areas to the hypothalamus influence how threatening situations are interpreted and, hence, regulated Structures involved in establishing classical and operant learningStructures involved in establishing classical and operant learning

7. PSY4080 6.0 D Anxiety Disorders 7 The Stress Response CRH receptors found throughout the brain: Prefrontal, cingulate, amygdala, nucleus accumbens, locus coerelius CRH receptors found throughout the brain: Prefrontal, cingulate, amygdala, nucleus accumbens, locus coerelius Of course, epinephrine and norepinephrine also act in similar areas. Of course, epinephrine and norepinephrine also act in similar areas.

8. PSY4080 6.0 D Anxiety Disorders 8 Development and Maintenance of Fear Two Factor Theory 1.Fears develop by classical conditioning: A neutral event is associated with a fearful event A neutral event is associated with a fearful event Fear elicited by neutral event Fear elicited by neutral event 2. Fear is maintained by operant conditioning Avoidance of fear inducing situation (negative reinforcement) Avoidance of fear inducing situation (negative reinforcement)

9. PSY4080 6.0 D Anxiety Disorders 9 Neuropathology: Learning Anxiety Producing Behaviours  The amygdala and pre-frontal areas play an important role in learning of fear-based behaviours 1.Amygdala: contextual learning and (re- )consolidation. 2. Frontal lobe: extinction memory.  Both areas implicated in processing incoming conditioned stimulus information.  Anxiety producing behaviours associated with increased hippocampal and reduced frontal activation.

10. PSY4080 6.0 D Anxiety Disorders 10 Neuropathology: Learning Anxiety Producing Behaviours Neurotransmitter Systems 1.Glutamate (NMDA receptor)  NMDA receptor is ionotropic: slow, long lasting depolarization.  Present in amygdala and prefrontal areas  Also a number of brainstem areas associated with stress response (locus coeruleus, ventral tegmental area, periadaqueductal grey matter)

11. PSY4080 6.0 D Anxiety Disorders 11 Neuropathology: Learning Anxiety Producing Behaviours Neurotransmitter Systems 2.GABA (A-receptor subtype)  Implied through the effects of GABA A agonist benzodiazapine  Sedative used in the treatment of anxiety and insomnia  Large occipital reductions in GABA concentrations  Receptor disruption through other modulator steroids

12. PSY4080 6.0 D Anxiety Disorders 12 Neuropathology: Learning Anxiety Producing Behaviours Neurotransmitter Systems 3. Norepinephrine  Locus coeruleus: Arousal, vigilance  Limbic and frontal cortex: elaboration, adaptive responses to stress  Long term potentiation in medial PFC  Sustained stress producing reduction in number of NE 2 receptors

13. PSY4080 6.0 D Anxiety Disorders 13 Neuropathology: Learning Anxiety Producing Behaviours Neurotransmitter Systems 4. Corticotropin Releasing Hormone  Mediation of response to stress  In amygdala: occurrence of fear related behaviours  In cortex: reduction reward expectation  Memory systems may be particularly sensitive to the effects of CRH in early life.

14. PSY4080 6.0 D Anxiety Disorders 14 Obsessive-Compulsive Disorder: DSM-IV Criteria A. 1. recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress 2. the thoughts, impulses, or images are not simply excessive worries about real-life problems

15. PSY4080 6.0 D Anxiety Disorders 15 OCD: DSM-IV Criteria 3. the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action (compulsion) 4.the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

16. PSY4080 6.0 D Anxiety Disorders 16 OCD: DSM-IV Criteria Compulsions 1. repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently)  person feels driven to perform in response to an obsession  according to rules that must be applied rigidly 2. behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation;  not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

17. PSY4080 6.0 D Anxiety Disorders 17 OCD: DSM-IV Criteria B. At some point, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children. C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.

18. PSY4080 6.0 D Anxiety Disorders 18 OCD: DSM-IV Criteria D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g, preoccupation with food in the presence of an Eating Disorder; preoccupation with drugs in the presence of a Substance Use Disorder. E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

19. PSY4080 6.0 D Anxiety Disorders 19 More information  Obsessions are very difficult to repress despite their unpleasant nature.  Obsessions and compulsions can occur independently.  Common compulsions include washing, checking behaviours, order, and symmetry.

20. PSY4080 6.0 D Anxiety Disorders 20 Generalized Anxiety Disorder: DSM-IV A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B. The person finds it difficult to control the worry.

21. PSY4080 6.0 D Anxiety Disorders 21 GAD: DSM-IV Criteria C. The anxiety and worry are associated with three (or more) of the following six symptoms : 1.muscle tension 2.being easily fatigued 3.Irritability 4.sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) 5.restlessness or feeling keyed up or on edge 6.difficulty concentrating or mind going blank

22. PSY4080 6.0 D Anxiety Disorders 22 GAD: DSM-IV Criteria D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in a Panic Disorder), being embarrassed in public (as in Social Phobia). E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

23. PSY4080 6.0 D Anxiety Disorders 23 GAD: DSM-IV Criteria F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

24. PSY4080 6.0 D Anxiety Disorders 24 Social Phobia Fear is centred on some aspect of the social situation. Children fear a teacher, being called on in class, or even entering the classroom. Adults may fear public speaking, social interaction, or initiation of conversations Symptoms are similar to fear response associated with all phobias.

25. PSY4080 6.0 D Anxiety Disorders 25 Social Phobia: DSM-IV A. Marked and persistent fear of one or more social and performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.

26. PSY4080 6.0 D Anxiety Disorders 26 Social Phobia: DSM-IV B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people. C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent Note: In children, this feature may be absent

27. PSY4080 6.0 D Anxiety Disorders 27 Social Phobia: DSM-IV D. The feared social or performance situation are avoided or else are endured with intense anxiety or distress E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. F. In individuals under age 18 years, the duration is at least 6 months

28. PSY4080 6.0 D Anxiety Disorders 28 Social Phobia: DSM-IV G. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder. H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it. Usually refers to realistic fears Usually refers to realistic fears

29. PSY4080 6.0 D Anxiety Disorders 29 Panic Disorder When panic attacks due to anxiety and fear occur regularly, may have panic disorder Sudden feelings of terror that occur suddenly and without warning Symptoms vary but may include: Chest pain.Chest pain. Heart palpitationsHeart palpitations Shortness of breath.Shortness of breath. Dizziness.Dizziness. Abdominal distressAbdominal distress

30. PSY4080 6.0 D Anxiety Disorders 30 Some Etiology  Begins in young adulthood--may or may not be linked to a particular traumatic experience  Evidence that heightened fear response begins in early childhood  Related to neurological syndromes, like epilepsy, Tourette’s, lesions (encephalitis, TBI)  Some patients have damage or dysfunction of basal ganglia, cingulate gyrus, prefrontal cortex (Giedd et al., 1995; Robinson et al., 1995)  Difficulty with extinction