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Chapter 4

Chapter 4. Anxiety Disorders. Cause clinically significant distress and impairment. The Complexity of Anxiety Disorders. Anxiety – future-oriented mood state Apprehension about future danger or misfortune; especially inability to control Somatic and behavior symptoms of tension

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Chapter 4

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  1. Chapter 4 Anxiety Disorders • Cause clinically significant distress and impairment

  2. The Complexity of Anxiety Disorders • Anxiety – future-oriented mood state • Apprehension about future danger or misfortune; especially inability to control • Somatic and behavior symptoms of tension • Characterized by negative affect • Anxiety and fear are normal emotional states

  3. The Complexity of Anxiety Disorders • Fear – the present-oriented mood state • Immediate fight or flight response to danger or threat • Involves sympathetic nervous system • Strong avoidance/escapist tendencies • Marked negative affect

  4. Biological Contributions to Anxiety and Panic • Genetic vulnerability • Anxiety and brain circuits • Depleted levels of GABA

  5. Biological Contributions to Anxiety and Panic (continued) • Limbic (amygdala) • septal-hippocampal systems to frontal cortex called the Behavioral inhibition system (BIS) • Anxiety • Fight/flight system (FF) • panic

  6. Psychological Contributions to Anxiety • Integrated model • Early childhood - Experiences with uncontrollability and unpredictability • Especially how parents respond to child’s needs • “secure base” vs. overprotective parents

  7. Psychological Contributions to Fear • Behavioral and cognitive views • Invokes conditioning and cognitive explanations • Anxiety and fear are learned responses • Catastrophic thinking and appraisals play a role • Social contributions • Stressful life events trigger vulnerabilities

  8. An Integrated Model • Comorbidity is common across the anxiety disorders (about 50%) • Major depression is the most common secondary diagnosis

  9. The Anxiety Disorders: An Overview • Generalized anxiety disorder (GAD) • Panic disorder with and without agoraphobia (PDA) • Specific phobias • Social phobia (SAD) • Posttraumatic stress disorder (PTSD) • Obsessive-compulsive disorder (OCD)

  10. Generalized Anxiety Disorder: The “Basic” Anxiety Disorder • Excessive uncontrollable, unfocused, anxious apprehension and worry, persistent anxiety • Difficulties in controlling the worry • Persists for six months or more • Somatic symptoms differ from panic (e.g., muscle tension)

  11. Generalized Anxiety Disorder: The “Basic” Anxiety Disorder • Statistics • about 3.1% of the general population • Females outnumber males approximately 2:1 • Onset is often insidious, beginning in early adulthood (median age is 31) • Very prevalent among the elderly • Tends to run in families

  12. 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 • Causes – factors influencing • Genetics • Muscle tension • Personal threat • Automatic restrictors

  13. Generalized Anxiety Disorder: Associated Features and Treatment • Treatment of GAD: Generally weak • Benzodiazapines – often prescribed • Antidepressents (may be more effective than benzos) • Psychological interventions – cognitive-behavioral therapy • Meditation therapy

  14. The Phenomenology of Panic Attacks • 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

  15. DSM-IV for Panic Attack • Intense fear or discomfort, in which four (or more) symptoms developed abruptly and reached a peak within 10 minutes: • 1) palpitations, pounding heart, or accelerated heart rate • 2) sweating • 3) trembling or shaking • 4) sensations of shortness of breath or smothering • 5) feeling of choking • 6) chest pain or discomfort • 7) nausea or abdominal distress • 8) feeling dizzy, unsteady, lightheaded, or faint • 9) derealization (feelings of unreality) or depersonalization (being detached from oneself) • 10) fear of losing control or going crazy • 11) fear of dying • 12) paresthesias (numbness or tingling sensations) • 13) chills or hot flushes

  16. The Phenomenology of Panic Attacks • DSM-IV-TR subtypes of panic attacks • Situationally bound (cued) • Unexpected (uncued) • Situationally predisposed • Cultural influences on anxiety

  17. 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

  18. Panic Disorder With and Without Agoraphobia • Facts and statistics • Affects about 2.7% of the general population • Onset is often acute, mean onset between 20 and 24 years of age • 66% female • Cultural influences • Associated features • Nocturnal panic attacks – 60% panic during deep non-REM sleep • Interoceptive/exteroceptive cues avoidance

  19. Panic Disorder: Associated Features and Treatment • Causes • Biological, psychological and social (triad) • 8% to 12% of people have occasional panic attacks • Medication treatment • Effective in 60% • Target serotonergic, noradrenergic, and GABA systems • SSRIs (e.g., Prozac and Paxil) are preferred drugs • Relapse rates (90%)

  20. Panic Disorder: Associated Features and Treatment • Psychological and combined treatments • Cognitive-behavioral therapies highly effective – 70% • No evidence that combined treatment produces better outcome • Best long-term outcome is with cognitive-behavioral therapy alone (6 months after tx terminated)

  21. Panic Disorder: Associated Features and Treatment • Panic control treatment (PCT) • Innovative approaches • Psychological (CBT) treatment followed by drug treatments • D-cycloserine (DCS)

  22. 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

  23. Some phobias (from phobialist.com) Iatrophobia- Fear of going to the doctor or of doctors.Ichthyophobia- Fear of fish.Ideophobia- Fear of ideas.Illyngophobia- Fear of vertigo or feeling dizzy when looking down.Iophobia- Fear of poison.Insectophobia - Fear of insects.Isolophobia- Fear of solitude, being alone.Isopterophobia- Fear of termites, insects that eat wood.Ithyphallophobia- Fear of seeing, thinking about or having an erect penis.Japanophobia- Fear of Japanese.Judeophobia- Fear of Jews.Radiophobia- Fear of radiation, x-rays.Ranidaphobia- Fear of frogs.Rectophobia- Fear of rectum or rectal diseases.Rhabdophobia- Fear of being severely punished or beaten by a rod, or of being severely criticized. Also fear of magic.(wand)Rhypophobia- Fear of defecation.Rhytiphobia- Fear of getting wrinkles.Rupophobia- Fear of dirt.Russophobia- Fear of Russians.

  24. Specific Phobias: Associated Features and Treatment • Subtypes of specific phobia 1) Blood-injury-injection phobia – unusual vasovagal response 2) Situational phobia – trains, planes, automobiles, closed spaces 3) Natural environment phobia – natural events (e.g., heights, storms) 4) Animal phobia – animals and insects • Other • Separation anxiety – seen in children

  25. Specific Phobias: An Overview • Facts and statistics • Females are again over-represented (4:1) • Affects about 12.5% of the general population • Phobias tend to last a lifetime

  26. Specific Phobias: Associated Features and Treatment • Causes of phobias • Direct experience or traumatic conditioning, prepared tendency, event will happen again • Psychological treatments of specific phobias • Cognitive-behavior therapies are highly effective – exposure therapy

  27. Social Phobia: An Overview • 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

  28. Social Phobia: An Overview • Facts and statistics • Affects about 12.1% of the general population • Prevalence is slightly greater in females than males • Second only to specific phobia in the anxiety disorders • Peak age of onset at about 13 years

  29. Social Phobia: Associated Features and Treatment • Causes • Biological and evolutionary vulnerability • Similar learning pathways as specific phobias • Psychological treatment • CBT highly effective • Cognitive-behavioral group treatment (CBGT)

  30. Social Phobia: Associated Features and Treatment • Medication treatment • Tricyclic antidepressants and monoamine oxidase inhibitors • SSRIs - Paxil, Zoloft, or Effexor (SNRI) • Relapse rates high following medication discontinuation

  31. Posttraumatic Stress Disorder (PTSD): An Overview • Overview and defining features • Main etiologic characteristics – trauma exposure and response • Reexperiencing (e.g., memories, nightmares, flashbacks) • Avoidance • Emotional numbing and interpersonal problems • Markedly interferes with one's ability to function • PTSD diagnosis – only after one month post-trauma

  32. Posttraumatic Stress Disorder (PTSD): An Overview • Statistics • Combat and sexual assault are the most common traumas • Lower than expected prevalence rates in trauma victims

  33. PTSD: Causes and Associated Features • Subtypes and associated features of PTSD • Acute – may be diagnosed one-three months post trauma • Chronic – diagnosed after three months post trauma • Delayed onset – onset six months or more post trauma • Acute stress disorder – PTSD immediately post-trauma

  34. PTSD: Causes and Associated Features • 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

  35. PTSD: Treatment • Psychological treatments • Cognitive-behavioral therapies (CBT) are highly effective • CBT may include graduated or massed (e.g., flooding) imaginal exposure • SSRIs

  36. Obsessive-Compulsive Disorder (OCD): An Overview • Overview and defining features • Obsessions – intrusive and nonsensical thoughts, images, or urges • Symmetry 26.7%, forbidden thoughts 21%, cleaning and contamination 15.9% and hording 15.4% • Compulsions – thoughts or actions to neutralize thoughts • Cleaning and washing or checking rituals are common

  37. Obsessive-Compulsive Disorder (OCD): An Overview • Overview and defining features • Tic disorder and OCD • Hoarding

  38. OCD: Causes and Associated Features • Statistics • Affects about 1.6% of the general population • Most with OCD are female • Onset usually in early adolescence or young adulthood • chronic

  39. OCD: Causes and Associated Features • 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

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