chapter 6: anxiety disorders ch 6. anxiety disorders anxiety refers to an unpleasant feeling of fear...
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Chapter 6: Anxiety Disorders
Ch 6
Anxiety Disorders• Anxiety refers to an unpleasant feeling of fear and
apprehension– Neuroses is a former term that refers to a group of disorders involving
unrealistic anxiety, assumed to be due to unconscious conflicts
• Anxiety disorders reflect the clear presence of symptoms of anxiety – Anxiety is not specific to anxiety disorders– Comorbidity: A person may be diagnosed with more than one
disorder
• Distinguishing stress, fear, and anxiety– Stress is the perception of an external demand, or challenge
Ch 6.1
Abrupt and Aversive CNS Response to Real Threat or Danger
Prepares Organisms for Immediate Action
Action Tendency “Fight” or “Flight”
Abrupt and Aversive CNS Response to Real Threat or Danger
Prepares Organisms for Immediate Action
Action Tendency “Fight” or “Flight”
More Diffuse Response About Impending Real or Imagined “Future” Threat or Danger
No Threat
AdaptiveTrue AlarmTrue AlarmTrue AlarmTrue Alarm
False AlarmFalse AlarmFalse AlarmFalse AlarmMaladaptive
Real Threat
EtiologyEtiology“Disordered” or “Maladaptive”
Experience of Anxiety or Fear
“Disordered” or “Maladaptive”Experience of
Anxiety or Fear
“Normal” or “Adaptive”Experience of
Anxiety or Fear
“Normal” or “Adaptive”Experience of
Anxiety or Fear
Phobias
• A phobia is a fear-mediated avoidance that is out of proportion to the object or situation– Phobias involve intense distress– Phobias are disruptive– Person recognizes that the fear is
groundless
Ch 6.2
Classes of Phobias• Specific phobias are unwarranted fears caused by
the presence of a specific object or situation– Blood, injuries, or injections– Situations (planes, elevators)– Animals– Natural environment (water, heights)
• Social phobia involves a persistent fear linked to the presence of other people
Ch 6.4
Irrational Fear of Specific Objects or Situations
Markedly Interferes With Functioning
Irrational Fear of Specific Objects or Situations
Markedly Interferes With Functioning
Clinical Description Clinical Description
Animal Type Natural Environment Type Blood-Injection Injury Type Situational Type Other
Animal Type Natural Environment Type Blood-Injection Injury Type Situational Type Other
Four Major Subtypes Four Major Subtypes
Unusual Reaction Vasovagal Response to Blood Drop in Blood Pressure Fainting Runs in Families Onset Early Childhood
Unusual Reaction Vasovagal Response to Blood Drop in Blood Pressure Fainting Runs in Families Onset Early Childhood
Blood-Injection Injury Type Blood-Injection Injury Type
Fears of Specific Situations
Planes, Transportation, Heights Response Similar to Panic Onset Early 20’s
Fears of Specific Situations
Planes, Transportation, Heights Response Similar to Panic Onset Early 20’s
Situational Type Situational Type
Fears of Animals and Insects Common in Population, but
Different From Normal Revulsion Early Onset (About 7 yrs of Age)
Fears of Animals and Insects Common in Population, but
Different From Normal Revulsion Early Onset (About 7 yrs of Age)
Animal Type Animal Type
Fears of Natural Events
Heights, Storms, Water Usually More Than One Fear Peak Onset (About 7 yrs of Age)
Fears of Natural Events
Heights, Storms, Water Usually More Than One Fear Peak Onset (About 7 yrs of Age)
Natural Environment Type Natural Environment Type
Fears Contracting Disease / Illness
Illness Phobia Fear of Choking
Avoid Swallowing Pills or Foods
Fears Contracting Disease / Illness
Illness Phobia Fear of Choking
Avoid Swallowing Pills or Foods
Other Type Other Type
Facts and Statistics Facts and Statistics
Occurs in 11% of Population Top Fears: Heights and Snakes Females > Males (4:1 Ratio) Runs a Chronic Course Many Do Not Seek Treatment:
WHY?
Occurs in 11% of Population Top Fears: Heights and Snakes Females > Males (4:1 Ratio) Runs a Chronic Course Many Do Not Seek Treatment:
WHY?
Causes Causes Direct Traumatic Conditioning Observational Learning Information and Language Having a Panic Attack (“False
Alarm”) Probably Some Evolutionary Basis
Direct Traumatic Conditioning Observational Learning Information and Language Having a Panic Attack (“False
Alarm”) Probably Some Evolutionary Basis
Etiology of Anxiety Disorders• Psychoanalytic theory: phobias result from anxiety produced by
repressed id impulses• Biological/Genetic theory: Heritability of panic disorder, and
evolutionary basis of phobias• Behavioral theories: focus on learning as the etiological basis of
phobias– Phobias are learned avoidance responses– Phobias may be acquired through modeling– We are biologically prepared to learn certain fears (e.g. taste with nausea)
• Cognitive theory: Thought processes result in high levels of anxiety
Ch 6.5
Treating Phobias
• Psychoanalytic therapy attempts to uncover repressed conflicts using free association
• Behavioral approaches use systematic desensitization and in vivo exposures to reduce anxiety responses to phobic stimuli and situations– Flooding: exposure to a phobic stimulus at full intensity
(now graded exposure is used more)
• Cognitive approaches focus on altering irrational beliefs (using socratic dialogue to disconfirm and reconstruct automatic thoughts, images)
Ch 6.6a
Treating Phobias
• Biological approach uses drugs to eliminate anxiety symptoms – Anxiolytic drugs such as the benzodiazepines (Valium)
can reduce anxiety but are also addictive and give rise to withdrawal symptoms upon termination
– MAO inhibitors such as phenelzine reduce the degradation of norepinephrine and serotonin
• MAO inhibitors can have adverse side effects
– Selective serotonin reuptake inhibitors (SSRI’s) (fluoxetine) increase brain serotonin
Ch 6.6b
Exposure and More Exposure Exposure and More Exposure Structured and Consistent Confront Objects of Fear Extinguish Anxious Responding Disrupt Avoidance / Escape Blood-Injury /Injection Differs
Exercises to Offset Fainting
Structured and Consistent Confront Objects of Fear Extinguish Anxious Responding Disrupt Avoidance / Escape Blood-Injury /Injection Differs
Exercises to Offset Fainting
“ “ People with social phobia aren’t People with social phobia aren’t necessarily shy at all. They can be necessarily shy at all. They can be completely at ease with people most of completely at ease with people most of the time, but in particular situations, the time, but in particular situations, they feel intense anxiety.”they feel intense anxiety.”
“ “ People with social phobia aren’t People with social phobia aren’t necessarily shy at all. They can be necessarily shy at all. They can be completely at ease with people most of completely at ease with people most of the time, but in particular situations, the time, but in particular situations, they feel intense anxiety.”they feel intense anxiety.”
Marked and Persistent Fear of One or More...
Social or Performance Situations Most Common Type of Social Fear?
Public Speaking Interferes With Life Functioning
Marked and Persistent Fear of One or More...
Social or Performance Situations Most Common Type of Social Fear?
Public Speaking Interferes With Life Functioning
Clinical Description Clinical Description
Facts and Statistics Facts and Statistics
Occurs in 13.3% of Population Most Prevalent Disorder Males > Females Begins in Adolescence Presents Differently in Some
Cultures (e.g., Japan)
Occurs in 13.3% of Population Most Prevalent Disorder Males > Females Begins in Adolescence Presents Differently in Some
Cultures (e.g., Japan)
Causes Causes
Similar to Panic and Specific Phobia Interaction of
Biological Vulnerability
Psychological Vulnerability
Learning Experiences Can be Quite Disabling
Similar to Panic and Specific Phobia Interaction of
Biological Vulnerability
Psychological Vulnerability
Learning Experiences Can be Quite Disabling
Psychological Interventions Psychological Interventions
Similar to Panic and Specific Phobia Cognitive-Behavioral Approaches
Rehearsal and Skills Training
Cognitive Restructuring
Similar to Panic and Specific Phobia Cognitive-Behavioral Approaches
Rehearsal and Skills Training
Cognitive Restructuring
Drug Treatments Drug Treatments
Antidepressants for Severe Anxiety SSRIs (e.g., Paxil)
MAO Inhibitors
Relapse is Common
Antidepressants for Severe Anxiety SSRIs (e.g., Paxil)
MAO Inhibitors
Relapse is Common
Panic Disorder• Panic disorder involves
– an attack of labored breathing, nausea, chest pain, dizziness and intense apprehension (terror)
– Depersonalization: the feeling of being outside of one’s body
– Derealization: the feeling that the world is not real
• Lifetime prevalence for panic disorder is 2% for men and 5% for women
Ch 6.7
Panic Disorder Panic Disorder
“ “ You may genuinely believe you’re having You may genuinely believe you’re having a heart attack, losing your mind, or on the a heart attack, losing your mind, or on the verge of death. Attacks can occur any verge of death. Attacks can occur any time, even during nondream sleep ”time, even during nondream sleep ”
“ “ You may genuinely believe you’re having You may genuinely believe you’re having a heart attack, losing your mind, or on the a heart attack, losing your mind, or on the verge of death. Attacks can occur any verge of death. Attacks can occur any time, even during nondream sleep ”time, even during nondream sleep ”
“ “ For me, a panic attack is a most violent experience For me, a panic attack is a most violent experience …I feel as though I’m losing control and going …I feel as though I’m losing control and going insane. ”insane. ”
“ “ For me, a panic attack is a most violent experience For me, a panic attack is a most violent experience …I feel as though I’m losing control and going …I feel as though I’m losing control and going insane. ”insane. ”
An Unexpected Panic Attack Develop Anxiety Over
the Next Attack orThe Implications of the Attack
and Consequences
An Unexpected Panic Attack Develop Anxiety Over
the Next Attack orThe Implications of the Attack
and Consequences
Clinical Description Clinical Description
Clinical Description Clinical Description
Agoraphobia is Common “Fear of the Marketplace”,
avoidance of “unsafe” places where panic attack may recur
Consequence of Severe Unexpected Panic Attacks
Can Have a Life of its Own
Agoraphobia is Common “Fear of the Marketplace”,
avoidance of “unsafe” places where panic attack may recur
Consequence of Severe Unexpected Panic Attacks
Can Have a Life of its Own
Facts and Statistics Facts and Statistics
Occurs in 3.5% of Population 75% are Women Onset Between (25-29 yrs) Initial attack often begins at puberty 20% Attempt Suicide Average 37 Medical Visits / Year
Occurs in 3.5% of Population 75% are Women Onset Between (25-29 yrs) Initial attack often begins at puberty 20% Attempt Suicide Average 37 Medical Visits / Year
Cultural Influences Cultural Influences Occurs Worldwide Prevalence in U.S. is Similar Across
Ethnic Groups Cultural variants: susto, ataques de
nervios (Latin America, Caribbean) Somatic symptoms emphasized in
3rd world cultures
Occurs Worldwide Prevalence in U.S. is Similar Across
Ethnic Groups Cultural variants: susto, ataques de
nervios (Latin America, Caribbean) Somatic symptoms emphasized in
3rd world cultures
Nocturnal Panic Nocturnal Panic
60% Cases Panic While Asleep! Usually Between 1:30 - 3:30am Occur During Deep Sleep “Delta” Do Not Occur During REM Sleep Isolated sleep paralysis (common in
African-Americans with PD)
60% Cases Panic While Asleep! Usually Between 1:30 - 3:30am Occur During Deep Sleep “Delta” Do Not Occur During REM Sleep Isolated sleep paralysis (common in
African-Americans with PD)
Symptoms of a Panic Attack Symptoms of a Panic Attack Palpitations / Sweating Trembling / Shaking Shortness of Breath Feeling of Choking, Loss of Control Derealization, Feeling of Dying
Palpitations / Sweating Trembling / Shaking Shortness of Breath Feeling of Choking, Loss of Control Derealization, Feeling of Dying
Etiology of Panic Disorder• Biological theories focus on the observations
– that panic disorder runs in families– that panic disorder can be induced experimentally
using • Hyperventilation may activate the autonomic nervous
system• Infusions of lactate can induce panic attack
• Panic attack may result from an exaggerated central response to arousal
Ch 6.8
Etiology of Panic Disorder
• The Fear-of-fear hypothesis of panic disorder suggests that some people have an overly aroused nervous system and a tendency to be upset by the sensations generated by their nervous system– Eventually, worry about a panic attack makes
a future attack more likely (vicious circle) – Panic attacks as “false alarm” reactions
Ch 6.9
Anxiety Sensitivity Index (ASI)
•Measures the extent to which individuals become apprehensive in response to their bodily sensations. •Developed by Peterson & Reiss (1987) •High scorers on the ASI were more likely than low scorers to experience panic attacks, especially if they had been told they would feel relaxed instead of aroused (Telch & Harrington, 1992) (D&N, Table 6.3).
Panic Disorder Treatments
• Biological treatments include use of antidepressant and anxiolytic drugs– Require long-term use, symptoms return upon drug
cessation; risk of addiction to anxiolytics
• Psychological treatments emphasize exposure to stimuli that accompany panic– Barlow’s therapy includes a combination of breathing re-
training, cognitive interventions, and exposure to the internal cues that elicit panic. Patient learns to relax and reinterpret these sensations as non-threatening and controllable
Ch 6.10
The Panic Attack The Panic Attack Abrupt Autonomic Surge Unexpected Uncontrollable Absence of Threat “False Alarm”
Abrupt Autonomic Surge Unexpected Uncontrollable Absence of Threat “False Alarm”
10 Minutes10 Minutes
Laboratory Panic Provocation Laboratory Panic Provocation Lactate Infusion Hyperventilation CO2 Inhalation Caffeine
Lactate Infusion Hyperventilation CO2 Inhalation Caffeine
10 Minutes10 Minutes
Causes Causes
General Biological & Psychological Vulnerability
General Biological & Psychological Vulnerability
False AlarmFalse Alarm
Involuntary physical or cognitive anxiety cues trigger learned alarms unpredictably
Involuntary physical or cognitive anxiety cues trigger learned alarms unpredictably
STRESSSTRESS
Bodily CuesBodily Cues
Specific Psychological Vulnerability: Anxious apprehension focusing on future alarms (e.g., body sensations are dangerous)
Specific Psychological Vulnerability: Anxious apprehension focusing on future alarms (e.g., body sensations are dangerous)
Learned AlarmLearned Alarm
Biological Causes Biological Causes Runs in Families GABA-BZ Circuit Limbic System
Runs in Families GABA-BZ Circuit Limbic System
ANXIETY Behavioral Inhibition System (BIS) FEAR / PANICFight / Flight System (FF)
ANXIETY Behavioral Inhibition System (BIS) FEAR / PANICFight / Flight System (FF)
Uncontrollable
Unpredictable
Psychological Causes Psychological Causes
Controllable
Predictable
Pharmacologic Treatments Pharmacologic Treatments
Block Panic Antidepressants (e.g., Imipramine,
Paxil, Prozac)20-50% Relapse
Benzodiazapines (e.g., Xanax)90% Relapse
Block Panic Antidepressants (e.g., Imipramine,
Paxil, Prozac)20-50% Relapse
Benzodiazapines (e.g., Xanax)90% Relapse
Psychological Interventions Psychological Interventions
Cognitive-Behavior Therapies Brief and Time Limited (12 Sessions) Graded Exposure + Coping Skills Panic Control Treatment (PCT) 80-100% Panic Free After Treatment
Cognitive-Behavior Therapies Brief and Time Limited (12 Sessions) Graded Exposure + Coping Skills Panic Control Treatment (PCT) 80-100% Panic Free After Treatment
Combined Treatment Combined Treatment
Multisite Study Imipramine Alone PCT Alone Imipramine + PCT Placebo Alone Placebo + PCT
Multisite Study Imipramine Alone PCT Alone Imipramine + PCT Placebo Alone Placebo + PCT
THE RESULT THE RESULTCombined Tx
is Better in Short Term
Combined Tx is Better in
Short Term
PCT Alone is Better in
Long Term
PCT Alone is Better in
Long Term
• Generalized Anxiety Disorder (GAD) involves persistent anxiety and chronic (uncontrollable) worry
• The lifetime prevalence of GAD is 5%
• Women are twice as likely to develop GAD as are men
Generalized Anxiety Disorder
Ch 6.11
Generalized Anxiety Disorder:The “Basic” Anxiety Disorder?
Figure 5.3
Clients’ answers to interviewer’s question, “Do you worry excessively about minor things?”
Etiology of GAD • Psychoanalytic view: generalized anxiety results
from unconscious conflicts between ego and id impulses
• Cognitive behavioral view: anxiety results from conditioning of anxiety to external stimuli
• Biological view: the transmitter GABA inhibits anxiety, anxiolytic drugs enhance the release of GABA in brain; evidence for heritability is mixed.
Ch 6.12
Worrywart? Perfectionist? Tense and keyed up most of the time? Cross bridges before you get to them? Worry unproductive? Trouble Controlling Worry?
Worrywart? Perfectionist? Tense and keyed up most of the time? Cross bridges before you get to them? Worry unproductive? Trouble Controlling Worry?
Worry About Everything Worrying is Unproductive Cannot Stop Worrying Mental Agitation and Muscle Tension Interferes With Life Functioning Must Last for at Least 6 Months
Worry About Everything Worrying is Unproductive Cannot Stop Worrying Mental Agitation and Muscle Tension Interferes With Life Functioning Must Last for at Least 6 Months
Clinical Description Clinical Description
Facts and Statistics Facts and Statistics
Occurs in 4% of Population Women twice as likely to develop
GAD Early Gradual (“insidious”) Onset Runs a Chronic Course Few Seek Treatment: WHY?
Occurs in 4% of Population Women twice as likely to develop
GAD Early Gradual (“insidious”) Onset Runs a Chronic Course Few Seek Treatment: WHY?
Causes Causes
Unclear and Puzzling? Tend to show
Autonomic Restriction
Heightened Muscle Tension
High Sensitivity to Threat in General
Threat Sensitivity is Automatic Avoid Negative Affect Related to Threat
Unclear and Puzzling? Tend to show
Autonomic Restriction
Heightened Muscle Tension
High Sensitivity to Threat in General
Threat Sensitivity is Automatic Avoid Negative Affect Related to Threat
Intense Cognitive
Processing
Intense Cognitive
Processing
General Biological & Psychological Vulnerability
General Biological & Psychological Vulnerability
Worry ProcessWorry
Process
Specific Psychological Vulnerability
(Anxious Apprehension)
Specific Psychological Vulnerability
(Anxious Apprehension)
STRESSSTRESS
Imagery AvoidanceImagery
Avoidance
Restricted Autonomic Response
Restricted Autonomic Response
Most Interventions are Weak Most Interventions are Weak
Benzodiazepines
Frequently Prescribed
Provide Some Relief Cognitive-Behavioral Approaches
Process Avoided Emotional Material
Relaxation Training
Does as Well as Medication
Benzodiazepines
Frequently Prescribed
Provide Some Relief Cognitive-Behavioral Approaches
Process Avoided Emotional Material
Relaxation Training
Does as Well as Medication
Therapies for GAD• Psychoanalytic therapy for GAD is similar to
that of phobia (reveal sources of conflict)• Behavioral therapy involves a combination of
relaxation training and cognitive intervention• Biological therapy uses administration of
anxiolytic drugs to reduce anxiety– Drug therapy is effective while the drugs are taken
Ch 6.13
Obsessive-Compulsive Disorder (OCD)
• Obsessions are intrusive and recurring thoughts
• Compulsions are repetitive behaviors or mental actions that are repeated over and over in order to reduce anxiety
• The lifetime prevalence of OCD is 1-2 %– Women are more likely than men to develop OCD
Ch 6.14
Common Compulsions
• Pursuing cleanliness
• Avoiding particular objects (e.g. cracks in a sidewalk)
• Performing repetitive, magical, protective practices
• Checking (e.g. “is the gas off?”)
• Performing a particular act (e.g. chewing slowly)
Ch 6.15
Etiology of OCD
• The psychoanalytic view is that OCD reflects arrest of personality development at the anal stage
• Behavioral accounts of OCD point to learned behaviors reinforced by fear reduction
• The biological view of OCD has focused on activation of the frontal lobes and basal ganglia
Ch 6.16
The Basal Ganglia
Ch 6.17
OCD Therapy
• Psychoanalytic procedures are not effective
• ERP: Exposure and Response Prevention involves exposing the OCD client to situations that elicit a compulsion and then restraining the client from performing the compulsion
• Biological treatment involves drugs that increase brain serotonin activity (Prozac)
Ch 6.18
Culmination of All Anxiety Disorders Obsessions: Intrusive Thoughts,
Images, or Urges That the Person Tries to Suppress or Eliminate
Compulsions: Thoughts or Actions to Suppress the Obsessions and Provide Relief
Culmination of All Anxiety Disorders Obsessions: Intrusive Thoughts,
Images, or Urges That the Person Tries to Suppress or Eliminate
Compulsions: Thoughts or Actions to Suppress the Obsessions and Provide Relief
Clinical Description Clinical Description
Facts and Statistics Facts and Statistics
Occurs in 2.6% of Population Most Common Obsessions
Contamination & Aggression Most Common Compulsions
Checking & Washing Almost Equal Sex Ratio (F > M) Onset Early Adolescence to Mid-20s
Occurs in 2.6% of Population Most Common Obsessions
Contamination & Aggression Most Common Compulsions
Checking & Washing Almost Equal Sex Ratio (F > M) Onset Early Adolescence to Mid-20s
Causes Causes Anxiety Focused on Unwanted Thoughts Thoughts are Unacceptable
When Fighting to Control One’s
Psychology Creates More
Psychopathology
Anxiety Focused on Unwanted Thoughts Thoughts are Unacceptable
When Fighting to Control One’s
Psychology Creates More
Psychopathology
Psychological Interventions Psychological Interventions Cognitive-Behavioral Treatments Response Prevention
Rituals are Actively Prevented Exposure
Systematic and Gradual Exposure to Feared Thoughts or Situations
May Require Hospitalization
Cognitive-Behavioral Treatments Response Prevention
Rituals are Actively Prevented Exposure
Systematic and Gradual Exposure to Feared Thoughts or Situations
May Require Hospitalization
Drug Therapies Drug Therapies Medications Show Promise Most Effective Medications
Inhibit Reuptake of Serotonin May Benefit 60% of Patients
Medications Show Promise Most Effective Medications
Inhibit Reuptake of Serotonin May Benefit 60% of Patients
Posttraumatic Stress Disorder
• Posttraumatic Stress Disorder (PTSD) refers to an extreme response to an extreme stressor
• PTSD symptoms may include:– Increased anxiety and arousal– Re-experiencing the traumatic event– Avoidance of stimuli associated with the trauma
Ch 6.19
Exposure to Traumatic Events
War and Combat
Rape and Assault
Car Accidents
Natural Disasters Reexperiencing, Flashbacks, Numbing Sleep Disturbance, Chronic Arousal
Exposure to Traumatic Events
War and Combat
Rape and Assault
Car Accidents
Natural Disasters Reexperiencing, Flashbacks, Numbing Sleep Disturbance, Chronic Arousal
Clinical Description Clinical Description
Acute
1-3 Months After the Trauma Chronic
Symptoms Last > 3 Months
Acute
1-3 Months After the Trauma Chronic
Symptoms Last > 3 Months
Subtypes Subtypes
Facts and Statistics Facts and Statistics
Occurs in 7.8% of Population Most Common Traumas?
Combat and Assault Trauma is Necessary, not Sufficient Severity of Response Seems Important Runs a Chronic Course
Occurs in 7.8% of Population Most Common Traumas?
Combat and Assault Trauma is Necessary, not Sufficient Severity of Response Seems Important Runs a Chronic Course
Causes Causes
Only Disorder With Clear Etiology Biological Vulnerability Experience With Events That are...
Uncontrollable and Unpredictable Severity of Trauma and One’s Reaction
True Alarm! Social Support Helps
Only Disorder With Clear Etiology Biological Vulnerability Experience With Events That are...
Uncontrollable and Unpredictable Severity of Trauma and One’s Reaction
True Alarm! Social Support Helps
Psychological Interventions Psychological Interventions
Face the Original Trauma
Imaginal Reexposure
Flooding Arrange for Corrective Emotional
Learning Problem of Secondary Gain
Disability and Compensation
Face the Original Trauma
Imaginal Reexposure
Flooding Arrange for Corrective Emotional
Learning Problem of Secondary Gain
Disability and Compensation
New Treatment Approaches for PTSD
• EMDR (Eye Movement Desensitization & Reprocessing
• TFT (Thought Field Therapy)
• New Paradigms or Pseudo-Science?