anxiety and fear: moods (normal!), symptoms, and syndromes
TRANSCRIPT
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NatureofAnxietyandFear
• AnxietyandFear:moods(normal!),symptoms,andsyndromes
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NatureofAnxietyandFear
• Fear– Fightorflight– Sympathe>cac>va>on– Avoidance&escape– Present‐oriented
NatureofAnxietyandFear
• Anxiety– Tension– Unpredictable– Uncontrollable– Future‐oriented
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AnxietyandPerformance:TheYerkes‐DodsonInverted“U”
Anxiety Level
Perf
orm
ance
Low High
AnxietyDisorders
• Pervasiveandpersistentanxietyandfear• Excessiveavoidanceandescapisttendencies
• Clinicallysignificantdistressandimpairment
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WhatisaPanicAQack?• Abrupt,intensefearordiscomfort
• Severalphysicalsymptoms
• Analogoustofearasanalarmresponse
DSM‐IVSubtypesofPanicAQacks
• Situa>onallybound(cued)–Expectedandboundtospecificsitua>ons
• Unexpected(uncued)–“outoftheblue”
• Situa>onallypredisposed–Mayormaynotoccurinspecificsitua>ons
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BiologicalContribu>onstoAnxietyandPanic
• Diathesis‐Stress– Inheritedvulnerabili>esforanxietyandpanic
– Stressandlifecircumstancesdeterminetype
BiologicalContribu>onstoAnxietyandPanic
• GABAcircuits• Cor>cotropinreleasingfactor(CRF)andHPAaxis
• Limbic(amygdala)andtheseptal‐hippocampalsystems
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BiologicalContribu>onstoAnxietyandPanic
• Fight/flight(FF)system– Serotonin?– Brainstem‐amygdala‐hypothal.
• Behavioralinhibi>onsystem(BIS)– Brainstem‐amygdala‐septal‐hippocampalsystem
PsychologicalContribu>onstoAnxietyandFear
• BeganwithFreud– Reac>va>onofaninfan>lefearsitua>on
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PsychologicalContribu>onstoAnxietyandFear
• BehavioralViews– Classicalandoperantcondi>oning– modeling
• PsychologicalViews– Earlyexperienceswithuncontrollabilityandunpredictability
PsychologicalContribu>onstoAnxietyandFear
• SocialContribu>ons– Stressfullifeeventstriggerbiological/psychologicalvulnerabili>es
– Familialandinterpersonal
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AnIntegratedModel
• Biologicalvulnerability• Psychologicalvulnerabili>es– Nega>veSchemas
• Experiences
CommonProcesses:TheProblemofComorbidity
• 55%haveconcurrentdx• Majordepressionmostcommon
• Commonfactorsacrossanxietyandmooddisorders
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TheAnxietyDisorders• GeneralizedAnxietyDisorder• PanicDisorderwithandwithoutAgoraphobia• SpecificPhobias• SocialPhobia• PosQrauma>cStressDisorder
• Obsessive‐CompulsiveDisorder
GeneralizedAnxietyDisorder:The“Basic”AnxietyDisorder
• DefiningFeatures– Excessiveuncontrollableanxiousapprehensionandworry
– Lasts>=6months
– Soma>csymptomsdifferfrompanic(muscletension,fa>gue,irritability…)
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“Doyouworryexcessivelyaboutminorthings?”
GeneralizedAnxietyDisorder
• Sta>s>cs– 4%prevalence;Oneofthemostcommon
– Females2:1
– Insidiousonsetinearlyadulthood– Tendenciesruninfamilies
– Chronic
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GeneralizedAnxietyDisorder
• “autonomicrestrictors”
• Emo>onalavoidance
• Chronicworriers• Muscletension
GeneralizedAnxietyDisorder
• Treatment:Modesthelp– Benzodiazapines• Cogni>veeffects• Highlyaddic>ve
– Psychologicalinterven>ons–Cogni>ve‐BehavioralTherapy
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PanicDisorderWithandWithoutAgoraphobia
• OverviewandDefiningFeatures– UnexpectedpanicaQack(i.e.,afalsealarm)
– Developanxiety,worry,orfearabouthavinganotheraQackoritsimplica>onsthatpersistfor1monthormore
PanicDisorderWithandWithoutAgoraphobia
• OverviewandDefiningFeatures– Agoraphobia–Fearoravoidanceofsitua>ons/eventsassociatedwithpanic
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PanicDisorderWithandWithoutAgoraphobia
• FactsandSta>s>cs– 3.5%ofthegeneralpopula>onmeetdiagnos>ccriteriaforpanicdisorder
– Female2:1
– Onsetisomenacute,beginningbetween25and29yearsofage
PanicDisorder• AssociatedFeatures– NocturnalpanicaQacks–60%experiencepanicduringdeepnon‐REMsleep
– Interocep>ve/exterocep>veavoidance,catastrophicmisinterpreta>onofsymptoms
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PanicDisorder:Treatment• Medica>on– Targetserotonergic,noradrenergic,andbenzodiazepineGABAsystems
– SSRIs(e.g.,ProzacandPaxil)arecurrentlythepreferreddrugs
– Relapseratesarehighfollowingmedica>ondiscon>nua>on
PanicDisorder:Treatment• PsychologicalandCombinedTreatments– Cogni>ve‐behaviortherapiesarehighlyeffec>ve(PCT)
– Combinedtreatmentsdowellintheshortterm
– Bestlong‐termoutcomeiswithcogni>ve‐behaviortherapyalone
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SpecificPhobias:AnOverview
• Extremeirra>onalfearofaspecificobjectorsitua>on
• Markedlyinterfereswithone’sabilitytofunc>on
• Avoidanceoffearedobject• Knowsthatthefearandavoidanceareunreasonable
SpecificPhobias:AnOverview• FactsandSta>s>cs– Femalesareagainover‐represented
– About11%ofthegeneralpopula>on– Chroniccourse,withonsetbeginningbetween15and20yearsofage
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SpecificPhobias:AssociatedFeaturesandSubtypes
• Blood‐injury‐injec>onphobia–Vasovagalresponsetoblood,injury,orinjec>on
• Allothersubtypesarelessmeaningful
SpecificPhobias:Causes
• Biologicalandevolu>onaryvulnerability• Directcondi>oning• Observa>onallearning• Informa>ontransmission
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SpecificPhobias:Treatment
• PsychologicalTreatments– CBTsarehighlyeffec>ve
– Systema>cdesensi>za>on– Flooding
PosQrauma>cStressDisorder(PTSD):AnOverview
• OverviewandDefiningFeatures– Requiresexposuretoaneventresul>nginextremefear,helplessness,orhorror
– Reexperiencing
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PosQrauma>cStressDisorder(PTSD):AnOverview
• OverviewandDefiningFeatures– Avoidanceofcues– Emo>onalnumbingand/orarousal
– Markedlyinterfereswithone'sabilitytofunc>on
– Symptoms>1month
PosQrauma>cStressDisorder(PTSD):AnOverview
• Sta>s>cs– Combatandsexualassaultarethemostcommontraumas
– About7.8%ofthegeneralpopula>onmeetcriteriaforPTSD
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PosQrauma>cStressDisorder(PTSD):Subtypes
• AcutePTSD‐1‐3monthsposttrauma• ChronicPTSD‐>3monthsposttrauma• DelayedonsetPTSD‐Onset>6months• Acutestressdisorder‐Immediatelypost‐trauma
PosQrauma>cStressDisorder(PTSD):Causes
• Intensityofthetraumaandone'sreac>ontoit
• Uncontrollabilityandunpredictability• Directcondi>oningandobserva>onallearning
• Moderator:Socialsupport
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PosQrauma>cStressDisorder(PTSD):Treatment
• PsychologicalTreatment• CBT’sarehighlyeffec>ve– Graduatedormassed(e.g.,flooding)imaginalexposure
Obsessive‐CompulsiveDisorder(OCD):AnOverview
• Obsessions‐Intrusiveandnonsensicalthoughts,images,orurgesthatonetriestoresistoreliminate– Contamina>on
– Aggression– Symmetry
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Obsessive‐CompulsiveDisorder(OCD):AnOverview
• Compulsions‐Thoughtsorac>onstosuppresstheobsessions– Overt:cleaningandwashing,checkingrituals
– Covert:sequencing,repe>>on
Obsessive‐CompulsiveDisorder(OCD):Obsessions
• Types(Akhtaretal.,1975):– Doubts(74%)– Thinking(34%)– Fears(26%)– Impulses(17%)– Images(7%)– Other(2%)
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Obsessive‐CompulsiveDisorder(OCD):Obsessions
• Doubt‘DidIlockthedoor’(M,28)
• Thought/Fearthathehadcancer(M,46)
• Thought/Imagethathehadknockedsomeonedowninhiscar(M,29)
Obsessive‐CompulsiveDisorder(OCD):Obsessions
• Impulse+thoughttoshoutobsceni>esinchurch(F,19)
• Imageofcorpseroxngaway(F,27)
• Impulsetodrinkfrominkpotandtostrangleson(M,41)
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Obsessive‐CompulsiveDisorder:Sta>s>csandFeatures• About2.6%life>meprevalence
• Mostlyfemale• Onsetinearlyadolescenceoryoungadulthood• Tendstobechronic
Obsessive‐CompulsiveDisorder:Causes
• Paralleltheotheranxietydisorders(biopsychosocialinterac>ons)• Earlylifeexperiencesandlearning– Somethoughtsaredangerousbutcontrollable
• Thought‐ac>onfusion– Moralvs.Likelihood
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Mul>siteOCDStudyFoaandLiebowitz(1997)
• Primaryaim– Compareindependentandcombinedeffectsofclomipramineandexposure‐responsepreven>on(ERP)
• TreatmentCondi>ons– Clomipranine(CMI)alone– ERPalonealone– Clomipranine+ERP– Pillplaceboalone
Mul>siteOCDStudy• Sample– 99pa>entsmee>ngDSM‐III‐Rcriteriaforobsessivecompulsivedisorder
• 2PhasesoftheStudy– Acutephase(12weeks)– Notreatmentfollow‐up(6months)
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Mul>‐SiteOCDAcuteTreatmentResponse
Data taken from Foa & Liebowitz,(1997)
Mul>‐SiteOCDRelapseatFollow‐up
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SummaryofAnxiety‐RelatedDisorders
• Anxietydisordersrepresentsomeofthemostcommonformsofpsychopathology
SummaryofAnxiety‐RelatedDisorders
• Fromanormaltoadisorderedexperienceofanxietyandfear– Fearandanxietypersisttobodilyorenvironmentalnon‐dangerouscues– Symptomsandavoidancecausedistressandimpairment– Considera>onofbiological,psychological,experien>al,andsocialfactors
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SummaryofAnxiety‐RelatedDisorders
• Psychologicaltreatmentsaregenerallysuperiorinthelong‐term– Mosttreatmentsinvolveexposure
– Suggeststhatanxiety‐relateddisorderssharecommonprocesses