Understanding Anxiety Disorders: Fear, Panic, and Their Complexities

1. Chapter 4 Anxiety Disorders

2. Fear • 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. Anxiety • 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 Fear and Anxiety • 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 • 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 • DSM-IV-TR subtypes of panic attacks • Situationally bound (cued) • Unexpected (uncued) • Situationally predisposed • Cultural influences on anxiety

7. The Complexity of Anxiety Disorders

8. Biological Contributions to Anxiety and Panic • Genetic vulnerability • Anxiety and brain circuits • Depleted levels of GABA • Behavioral inhibition system (BIS) • Limbic system – responds to threat signals by inhibiting activity and causing anxiety • Fight/flight system (FF) • Fear

9. Psychological Contributions to Anxiety and Fear • Early childhood Experiences • Uncontrollability and unpredictability • Observational learning/modeling • 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

11. An Integrated Model • Integrative view – triple vulnerability model • Generalized biological vulnerability • Generalized psychological vulnerability • Specific psychological vulnerability

12. An Integrated Model

13. An Integrated Model – Comorbidity • Common processes: the problem of comorbidity • Comorbidity is common across the anxiety disorders • Major depression is the most common secondary diagnosis • About half of patients have two or more secondary diagnoses • Comorbidity suggests • Common factors • A relation between anxiety and depression

14. 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)

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

16. Difficulty concentrating

17. Generalized Anxiety Disorder: The “Basic” Anxiety Disorder

18. Generalized Anxiety Disorder: The “Basic” Anxiety Disorder • Statistics • Affects about 3.1% 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

19. Generalized Anxiety Disorder: Associated Features and Treatment • Associated features • Genetics – not GAD, but the tendency to become anxious • Chronically tense – high muscle tension • Highly sensitive to personal threat • “Automatic restrictors” • Individuals with GAD show less responsiveness on most physiological measures (e.g., heart rate, blood pressures) than individuals with other anxiety disorders • Intense “cognitive processing” in frontal lobes • Results in constant worrying = fail to process emotional component of thoughts and images (i.e., mental avoidance)

20. Generalized Anxiety Disorder: Associated Features and Treatment • Treatment of GAD: Generally weak • Benzodiazepines – often prescribed • Antidepressants – SSRIs; may be treatment of choice • Psychological interventions – cognitive-behavioral therapy • Meditation therapy • Psychological treatments are typically more effective in the long-term

21. 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 • Fear of being in places where escape might be difficult, or where help might not be available • Typically results in being “housebound” or only being able to leave your house within a certain radius

24. Panic Disorder With and Without Agoraphobia

25. 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% of individuals with agoraphobia are female • Causes • Triad – biological, psychological, social • Theme for most disorders… • Vulnerability to stress = strong “alarm” system • Interpret normal physical sensations in catastrophic way; then get more anxious… “vicious cycle”

26. Panic Disorder With and Without Agoraphobia sweating racing heart chest pain shortness of breath dizziness nausea hot flashes/chills trembling terror desire to escape PANIC! PANIC! PANIC! PANIC!

27. Panic Disorder: Associated Features and Treatment • Associated features • Nocturnal panic attacks – 60% panic during deep non-REM sleep • Interoceptive/exteroceptive avoidance • Avoid situations/activities that may elicit certain physiological arousal • Medication treatment • Target serotonergic, noradrenergic, and GABA systems • SSRIs (e.g., Prozac and Paxil) are preferred drugs • Relapse rates are high following medication discontinuation

28. Panic Disorder: Associated Features and Treatment • Psychological and combined treatments • Cognitive-behavioral therapies are highly effective • No evidence that combined treatment produces better outcome • Best long-term outcome is with cognitive-behavioral therapy alone

29. Specific Phobias • 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

31. Specific Phobias

32. Specific Phobias • Facts and statistics • Females are again over-represented (varies by phobia) • Affects about 12.5% of the general population • One of the most common psychological disorders in the U.S. and around the world • Phobias tend to run a chronic course • Only the most severe cases seek treatment • Mildly affected people tend to work around their phobias

34. Specific Phobias: Associated Features and Treatment • Subtypes of specific phobia • Blood-injury-injection – seeing blood or receiving an injection • Situational – e.g., bridges, elevators, flying, driving, enclosed places • Natural environment – e.g., storms, heights, water • Animal phobia – animals and insects • Other – e.g., fear of chocking, vomiting, contracting an illness • *[Separation anxiety – seen in children]

35. Specific Phobias: Associated Features and Treatment • Causes of phobias • Traumatic conditioning • Direct experience – real danger or pain results in a true alarm response • Vicarious – observational learning • Information transmission – receive information/warned • Prepared tendency • Biological and evolutionary vulnerability • Thoughts/worry that the event will happen again • Psychological treatments of specific phobias • Cognitive-behavior therapies are highly effective – exposure-based

36. Social Phobia • 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

38. Social Phobia

39. Social Phobia • 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 • Onset is usually during adolescence • Peak age of onset at about 13 years

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

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

42. Posttraumatic Stress Disorder (PTSD) • 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 • Acute Stress Disorder – symptoms begin within four weeks of event and last for less than one month

44. Posttraumatic Stress Disorder (PTSD)

45. Posttraumatic Stress Disorder (PTSD): • Statistics • Many individuals who experience trauma do not go on to develop PTSD • i.e., lower than expected rates in trauma victims • Affects about 6.8% of the general population • Combat and sexual assault are the most common traumas

46. PTSD: Associated Features and Treatment • 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

47. PTSD: Associated Features and Treatment • Causes of PTSD • Intensity of the trauma and one's reaction to it (i.e., true alarm) • Learned alarms – direct conditioning and observational learning • Biological vulnerability • Uncontrollability and unpredictability • Extent of social support, or lack thereof, post-trauma

48. PTSD: Associated Features and Treatment

49. PTSD: Associated Features and Treatment • Psychological treatments • Cognitive-behavioral therapies (CBT) are highly effective • CBT may include graduated or massed (e.g., flooding) imaginal exposure • Specific approach: Trauma-Focused CBT • Aim of CBT for PTSD • SSRIs

50. Obsessive-Compulsive Disorder (OCD) • Overview and defining features • Obsessions – intrusive and nonsensical thoughts, images, or urges • Symmetry, forbidden thoughts, cleaning and contamination, safety-memory, [hording 15.4%] • Compulsions – thoughts or actions to neutralize thoughts (i.e., reduces anxiety for a short period) • Cleaning; checking; order/balance; touching, verbal, and/or counting • Vicious cycle of obsessions and compulsions • Cleaning and washing or checking rituals are common