Understanding Anxiety Disorders: Nature, Symptoms, and Treatments

1. Chapter 4Anxiety Disorders 0

2. Nature of Anxiety and Fear 0 • Fear – The Present-Oriented Mood State • Immediate fight or flight response to danger or threat • Involves abrupt activation of the sympathetic nervous system • Strong avoidance/escapist tendencies • Marked negative affect

3. Nature of Anxiety and Fear 0 • Anxiety – The Future-Oriented Mood State • Apprehension about future danger or misfortune • Somatic symptoms of tension • Characterized by marked negative affect • Anxiety and Fear are Normal Emotional States

4. From Normal to Disordered Anxiety and Fear 0 • Characteristics of Anxiety Disorders • Pervasive and persistent symptoms of anxiety and fear • Involve excessive avoidance and escape • Cause clinically significant distress and impairment

5. The Phenomenology of Panic Attacks 0 • What is a Panic Attack? • Abrupt experience of intense fear or discomfort • Several physical symptoms (e.g., breathlessness, chest pain) • Fear as an alarm response

6. The Phenomenology of Panic Attacks (continued) 0 • DSM-IV-TR Subtypes of Panic Attacks • Situationally bound (cued) • Unexpected (uncued) • Situationally predisposed

7. 0 Fig. 4.1, p. 126

8. Biological Contributions to Anxiety and Panic 0 • Genetic Vulnerability • Anxiety and brain circuits • Depleted levels of GABA • Corticotropin releasing factor (CRF) and HYPAC axis

9. Biological Contributions to Anxiety and Panic (continued) 0 • Limbic (amygdala) and the septal-hippocampal systems • Behavioral inhibition (BIS) • Anxiety • Fight/flight (FF) systems • Fear

10. Psychological Contributions to Anxiety and Fear 0 • Began with Freud • Anxiety is a psychic reaction to fear • Anxiety involves reactivation of an infantile fear situation

11. Psychological Contributions to Anxiety and Fear (continued) 0 • Behavioral and Cognitive Views • Invokes conditioning and cognitive explanations • Anxiety and fear are learned responses • Catastrophic thinking and appraisals play a role

12. Psychological Contributions to Anxiety and Fear (continued) 0 • Early Childhood Contributions • Experiences with uncontrollability and unpredictability • Social Contributions • Stressful life events trigger vulnerabilities

13. An Integrated Model 0 • Integrative View – Triple Vulnerability Model • Generalized biological vulnerability • Generalized psychological vulnerability • Specific psychological vulnerability

14. An Integrated Model (continued) 0 • Common Processes: The Problem of Comorbidity • Comorbidity is common across the anxiety disorders • Major depression is the most common secondary diagnoses

15. An Integrated Model (continued) 0 • About half of patients have two or more secondary diagnoses • Comorbidity Suggests • Common factors • A relation between anxiety and depression

16. The Anxiety Disorders: An Overview 0 • Generalized Anxiety Disorder • Panic Disorder with and without Agoraphobia • Specific Phobias • Social Phobia • Posttraumatic Stress Disorder • Obsessive-Compulsive Disorder

17. “Do you worry excessively about minor things?” 0 Fig. 4.3, p. 132

18. Generalized Anxiety Disorder: The “Basic” Anxiety Disorder 0 • Overview and Defining Features • Excessive uncontrollable anxious apprehension and worry • Coupled with strong, persistent anxiety • Persists for 6 months or more • Somatic symptoms differ from panic (e.g., muscle tension)

19. Generalized Anxiety Disorder: The “Basic” Anxiety Disorder (continued) 0 • Statistics • Affects about 4% of the general population • Females outnumber males approximately 2:1 • Onset is often insidious, beginning in early adulthood • Very prevalent among the elderly • Tends to run in families

20. Generalized Anxiety Disorder: Associated Features and Treatment • Associated Features • Persons with GAD have been called “autonomic restrictors” • Fail to process emotional component of thoughts and images • Treatment of GAD: Generally Weak • Benzodiazapines – Often Prescribed • Psychological interventions – Cognitive-Behavioral Therapy • Combined treatments – Acute vs. Long-Term Outcomes

21. 0 Fig. 4.4, p. 134

22. Panic Disorder With and Without Agoraphobia • Overview and Defining Features • Experience of unexpected panic attack (i.e., a false alarm) • Develop anxiety, worry, or fear about another attack • Many develop agoraphobia

23. Panic Disorder With and Without Agoraphobia (continued) • Facts and Statistics • Affects about 3.5% of the general population • Onset is often acute, beginning between 25 and 29 years of age • 75% of individuals with agoraphobia are female

24. Panic Disorder: Associated Features and Treatment • Associated Features • Nocturnal panic attacks – 60% panic during deep non-REM sleep • Interoceptive/exteroceptive avoidance • Medication Treatment • Target serotonergic, noraadrenergic, and GABA systems • SSRIs (e.g., Prozac and Paxil) are preferred drugs • Relapse rates are high following medication discontinuation

25. Panic Disorder: Associated Features and Treatment (continued) • Psychological and Combined Treatments • Cognitive-behavior therapies are highly effective • No evidence that combined treatment produces better outcome • Best long-term outcome is with cognitive-behavior therapy alone

26. Specific Phobias: An Overview • Overview and Defining Features • Extreme irrational fear of a specific object or situation • Persons will go to great lengths to avoid phobic objects • Most recognize that the fear and avoidance are unreasonable • Markedly interferes with one’s ability to function

27. Specific Phobias: An Overview (continued) • Facts and Statistics • Females are again over-represented • Affects about 11% of the general population • Phobias tend to run a chronic course

28. Specific Phobias: Associated Features and Treatment • Associated Features and Subtypes of Specific Phobia • Blood-injury-injection phobia – Unusual vasovagal response • Situational phobia – Trains, planes, automobiles, closed spaces • Natural Environment phobia – Natural events (e.g., heights, storms) • Animal phobia – Animals and insects • Separation Anxiety – Seen in children

29. Specific Phobias: Associated Features and Treatment (continued) • Causes of Phobias • Biological and evolutionary vulnerability • Three pathways -- Conditioning, observational learning, information • Psychological Treatments of Specific Phobias • Cognitive-behavior therapies are highly effective – Exposure

30. Fig. 4.8, p. 150

31. Social Phobia: An Overview • Overview and Defining Features • Extreme and irrational fear in social/performance situations • Markedly interferes with one’s ability to function • Often avoid social situations or endure them with great distress • Generalized subtype – Affects many social situations

32. Social Phobia: An Overview (continued) • Facts and Statistics • Affects about 13% of the general population • Prevalence is slightly greater in females than males • Onset is usually during adolescence • Peak age of onset at about 15 years

33. Social Phobia: Associated Features and Treatment • Causes • Biological and evolutionary vulnerability • Similar learning pathways as specific phobias • Psychological Treatment • Cognitive-behavioral treatment • Cognitive-behavior therapies are highly effective

34. Social Phobia: Associated Features and Treatment (continued) • Medication Treatment • Tricyclic antidepressants and monoamine oxidase inhibitors • SSRIs Paxil, Zoloft, and Effexer – Are FDA approved • Relapse rates are high following medication discontinuation

35. Posttraumatic Stress Disorder (PTSD): An Overview • Overview and Defining Features • Main etiologic characteristics – Trauma exposure and response • Reexperiencing (e.g., memories, nightmares, flashbacks) • Avoidance

36. Posttraumatic Stress Disorder (PTSD): An Overview (continued) • Emotional numbing and interpersonal problems • Markedly interferes with one's ability to function • PTSD diagnosis – Only after 1 month post-trauma

37. Posttraumatic Stress Disorder (PTSD): An Overview (continued) • Statistics • Combat and sexual assault are the most common traumas • About 7.8% of the general population meet criteria for PTSD

38. Posttraumatic Stress Disorder (PTSD): Causes and Associated Features • Subtypes and Associated Features of PTSD • Acute – May be diagnosed 1-3 months post trauma • Chronic – Diagnosed after 3 months post trauma • Delayed onset – Onset 6 months or more post trauma • Acute stress disorder – PTSD immediately post-trauma

39. Posttraumatic Stress Disorder (PTSD): Causes and Associated Features (continued) • Causes of PTSD • Intensity of the trauma and one's reaction to it (i.e., true alarm) • Learn alarms -- Direct conditioning and observational learning • Biological vulnerability • Uncontrollability and unpredictability • Extent of social support, or lack thereof post-trauma

40. Posttraumatic Stress Disorder (PTSD): Treatment • Psychological Treatments • Cognitive-behavior therapies (CBT) are highly effective • CBT may include graduated or massed (e.g., flooding) imaginal exposure • Aim of CBT for PTSD

41. Obsessive-Compulsive Disorder (OCD): An Overview • Overview and Defining Features • Obsessions - Intrusive and nonsensical thoughts, images, or urges • Compulsions - Thoughts or actions to neutralize thoughts • Vicious cycle of obsessions and compulsions • Cleaning and washing or checking rituals are common

42. Obsessive-Compulsive Disorder (OCD): Causes and Associated Features • Statistics • Affects about 2.6% of the general population • Most with OCD are female • Onset is typically in early adolescence or young adulthood • OCD tends to be chronic

43. Obsessive-Compulsive Disorder (OCD): Causes and Associated Features (continued) • Causes of OCD • Parallels the other anxiety disorders • Early life experiences • Learning that some thoughts are dangerous/unacceptable • Thought-action fusion -- The thought is similar to the action

44. Obsessive-Compulsive Disorder (OCD): Treatment • Medication Treatment • Clomipramine and other SSRIs – Benefit up to 60% of patients • Relapse is common with medication discontinuation • Psychosurgery (cingulotomy) is used in extreme cases

45. Obsessive-Compulsive Disorder (OCD): Treatment (continued) • Psychological Treatment • Cognitive-behavioral therapy is most effective • CBT involves exposure and response prevention • Combining CBT with medication -- No better than CBT alone

46. Summary of the Anxiety Disorders • Most Common Forms of Psychopathology • From a Normal to a Disordered Experience of Anxiety and Fear • Triple Vulnerabilities – Bio-psycho-social • Fear and anxiety – Non-dangerous bodily or environmental cues • Symptoms and avoidance – Significant distress and impairment

47. Summary of the Anxiety Disorders (continued) • Psychological Treatments are Generally Superior in the Long-Term • Similar treatments for different anxiety disorders • Suggests that anxiety-related disorders share common processes