Transcript Anxiety Disorders - University of Delaware

Anxiety Disorders

Anxiety: negative mood
state characterized by
bodily symptoms of tension
and apprehension about
the future
What does anxiety feel like?
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Heart
racing/pounding
Sweating
Being out of breath
Shaking
Upset stomach
Being “frozen”
When is Anxiety
Normal/Abnormal?
Normal:
 Motivation
 Avoiding danger
 Preparation for
uncertainty
Abnormal:
 When it interferes with
performance
 E.g. exams
 E.g. socially
When is Anxiety Helpful/Not
Helpful?
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As arousal increases performance increases, to a
point
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After the optimal point of arousal performance
deteriorates as anxiety continues to increase
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This is called: Yerkes-Dodson Law
Yerkes-Dodson Law
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The optimal point of arousal varies by task
For easy tasks: we can tolerate a lot of
anxiety and still do well
For hard tasks: we can’t tolerate much
anxiety
When is anxiety an Anxiety
Disorder?
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1.
2.
3.
4.
5.
6.
When the feelings of anxiety constantly
interfere with functioning
Generalized Anxiety Disorder
Panic Disorder & Agoraphobia
Specific Phobias
Social Phobia
Post-traumatic Stress Disorder
Obsessive-Compulsive Disorder
Causes of Anxiety Disorders
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Biological
Psychological
Social
Biological Causes of Anxiety
Disorders
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Genetic influences
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Diathesis X Stress models appy
Changes in neurotransmitters
Sensitivity of brain circuits to fear
Psychological Causes of
Anxiety Disorders
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Behavioralists see anxiety as the result of
learning
Cognitions regarding danger or
uncontrollability
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Parenting – overprotective and lack of adverse
experiences
Social Contributions to
Anxiety Disorders
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Reactions to stressful events
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Social learning
Comorbidity of Anxiety
Disorders
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Often co-occuring
Share same vulnerabilities
55% comorbidity with depression
50% with additional anxiety disorder
1. Generalized Anxiety
Disorder
Excessive anxiety/worry about a number of
events/activities
Worry is difficult to control or stop
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Worry is not helpful
Often about minor things
Generalized Anxiety Disorder
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Restlessness
tense muscles
concentration
problems
sleep problems
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Irritability
Fatigue
Difficulty focusing
attention
Generalized Anxiety Disorder
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Lifetime prevalence = 5%
2x more likely in women
Develops early in adulthood
Most people do not seek treatment from
therapist
Is GAD a personality style? Or personality
disorder? A risk factor?
80-90% qualify for another disorder
What Causes GAD?
1.
2.
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3.
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Genes -> first degree relatives 5x likely
Differences in physiology
Less responsive
Except muscle tension
Cognitive Influences
Drawn to threat cues
How do we treat GAD?
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Medication
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Benzodiazepines
Early = Valium, new = Xanax, Ativan
Central nervous system depressants
Relieve anxiety but impair thinking, motor
performance, induce sleep
Many people feel addicted (symptoms quickly
return)
Psychological Treatments for
GAD
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Lots of treatment but little effectiveness
Psychoanalytical: insight & Client centered
Several Cognitive treatments
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Cognitive Therapy – confront worry with images
coping strategies
Beck & automatic thoughts*
Borkovec - confronting worry*
Craske’s hybrid treatment*
2. Panic Disorder &
Agoraphobia
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Chills or hot flashes
Palpitations, pounding/accelerated heart beat
Sweating
Trembling/shaking
Sensations of smothering/choking
Chest pain/discomfort
Nausea or other abdominal distress
Feeling dizzy, light headed, faint
Fear of losing control/going crazy/dying
Numbness/tingling sensations
What is Panic Disorder?
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Recurrent and unexpected panic attacks (cued or
uncued)
Anxiety re: having other attacks
(escape/embarrassment)
Patients avoid situations where panic attacks may
happen (agoraphobia)
Withdrawal reduces anxiety
Negative reinforcement***
Panic Disorder
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Lifetime prevalence = 3.5% (without)
2-3x more likely in women
Develops during late adolescence/early
adulthood
Chronic without treatment
Many experience panic attacks (8-12%) but
no disorder develops
Causes of Panic Disorder
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Genetic influences
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Biology
Psychological Factors in Panic
Personality/trait like variables of risk
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1.
2.
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Some people have attacks, no disorder
3 Proposed Variables:
A tendency to fear panic attacks
A tendency to over interpret unusual body
sensations
Tendency to respond to fear w/ anxiety
symptoms
Psychological Factors in Panic
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A tendency to fear fear
Hypervigilant about physiology (looking for
fear)
May trigger panic attacks
Misinterpret body signals as impending
panic (e.g. during a walk)
Focus on own body, not possible danger
Psychological Factors in Panic
3. Anxiety Sensitivity
 Respond fearfully to symptoms of anxiety
 Overreact then avoid, then hypervigilant
 May trigger a panic attack
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What's the converging info? Reaction to
panic makes panic more likely!!!
Avoiding Panic (Agoraphobia)
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Why is withdrawal so bad for panic?
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Opportunities for corrective feedback are nil
How can you know something works if you don’t
test it?
Treating Panic & Agoraphobia
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There are 2 ways:
Medication
Cognitive Behavioral Therapy
Medication
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Antidepressants can reduce panic attacks
So do benzodiazepines (anti-anxiety) but
they have problems:
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Symptoms return quickly (short 1/2 life)
If stop too quickly, can be worse
Thus, can produce dependence
Medication
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66% do well, if stay on
medication
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20-50% relapse after
discontinuing
antidepressants
90% after discontinuing
benzodiazepines
Cognitive Behavioral
Treatment
A number of elements:
1. Psychoeducation
2. Anxiety reducing techniques (a toolbox)
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Diaphragmatic breathing
Progressive muscle relaxation
Distraction, labeling anxiety as safe,
challenging thoughts
Exposure (!!!)
Cognitive Behavioral Therapy
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We give our clients a “toolbox”
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Then we give them a chance to use them
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Education + techniques + challenges
Exposures
Sometimes we desensitize to internal feelings
(e.g. running in place)
Panic Control Treatment (PCT)
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Exposure to sensations that remind of panic
Also receive cognitive therapy
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Address the cognitions re: dangerousness of
feared, yet harmful, situations
Examples:
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Shaking head from side to side loosely for 30 sec
Breathe through thin straw for 1 minute
Hyperventilate for 1 minute
3. Specific Phobias
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Unreasonable fears of objects, places,
situations
Anxiety response triggered by specifics
 Functioning beyond phobia is fine
www.phobialist.com
Specific Phobias
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In theory, anything can = phobia
Small # account for most:
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Animal phobias (zoophobia) = 40%
Environmental situations (e.g. heights hysphobia)
Blood-injection-injury** (vasovagal response)
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Avg age of onset = 9 years
Situational (planes, elevators)
Specific Phobias
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Lifetime prevalence rate = 11%
Children experience more
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Culture can impact
Gender ratio 4:1 (women higher)
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Some may be developmentally normal
E.g. strangers, separation, the dark, etc
Except heights (equal)
Chronic across lifecourse
Separation Anxiety Disorder
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Unrealistic and persistent worry that
something will happen to parents
OR something will separate child from
parents
School refusal
Nightmares, difficulty sleeping alone
Causes of Specific Phobias
Not traumatic experiences
Often panic attacks trigger
Vicariously from others
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Also genetic role – 31% of people with 1st
degree relatives
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Specific to subtype
Behavioral Factors & Specific
Phobias
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Classical conditioning - Little Albert
Phobias are learned
May not need direct experience
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“modeling” fear of parents
Many phobics show no related experience
50% of dog phobics no experience
Many people don’t develop after experience
Evolution, Learning & Specific
Phobias
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Are we
predisposed to
certain phobias?
Can we learn
phobias from
others?
Evolution, Learning, & Specific
Phobias
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Are we prepared to be phobic of certain
things?
E.g. snakes
Arbitrary objects do not often = phobia
(despite danger or instructions)
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Electric outlets, stoves, hammers
Bicycles, etc
Evolution, Learning, & Specific
Phobias
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Mineka’s monkeys (1984, Experiment 2)
Can lab-born monkeys learn snake phobia
from their wild-born parents?
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Study 1 established that wild-born monkeys were
more fearful than their offspring
Offspring observed parental response to: real
snake, toy snake, neutral objects
Behavioral Avoidance of
Snakes
60
50
40
Parent
Chld Pre
Cld Post
30
20
10
0
Real
Toy
Model
Neutral
Evolution, Learning & Specific
Phobias
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Offspring learned phobias by watching
parents
Results were intense & rapid (one try)
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In evolutionary terms, we don’t have several
“tries” with a fatal object
Retention 3 months later
Evolution, Learning, & Specific
Phobias
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Mineka’s follow-up (Cook & Mineka, 1991)
Spliced videos so it appears parent monkeys
are reacting to flowers
Observer monkeys did not learn flowerphobia
This is consistent with the idea that we are
prepared for certain phobias
How do we treat a specific
phobia?
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Exposure!
Two types of
exposure:
Systematic
desensitization
Flooding
Systematic Desensitization
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Imaginal vs. in vivo exposure
In vivo treats well (75-95% of patients)
Create a hierarchy of feared experiences
Teach progressive muscle relaxation
Combine
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Note: this is gradual
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Flooding
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This is not gradual
Intense & prolonged exposure
E.g. stay on the roof until you are calm
Usually in vivo
Emotionally draining
Can make anxiety worse if quit early
In Vivo
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Different sizes of spiders
Patients stand in room, approach, touch jar,
change size of spider, touch spider
3 hour treatment
What about imaginal?
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Some people have problems imagining
Imagined spiders might not be scary
Virtual Reality Treatment for
Anxiety
(Garcia-Palacios et al., 2001)
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Phobias are extremely common & easy to
treat
but most people never seek treatment
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Less than 15% of the 10% of the pop. with a
phobia
Why do VR therapy?
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25% refuse exposure-based therapy
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Too afraid to confront
Ost (a spider pioneer) - 90% of spider phobic
patients refuse one-session tx
How can we improve therapy?
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Make it less intimidating
Use virtual reality!
VR Therapy for Phobias
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The illusion of in vivo
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Position tracking devices
Changing orientation
Tactile augmentation
“cyber-heft”
Present separate images to each eye
Why is VR “better”?
More control over feared object
Therapist controls “fright level”
In Vivo can be expensive
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E.g in vivo for flying phobias
In Vivo can breach confidentiality
VR can treat “residual” fears
4. Social Phobia/Social Anxiety
Disorder
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www.socialphobia.org
Lifetime prevalence
rate is more than 13%
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3rd most common
disorder
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That’s 2340 UD students!
(depression, alcohol)
Men outnumber women
(1.4:1)
Social Phobia
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Fear of evaluation socially
E.g. public speaking (specific)
More common in women
Common problems:
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Meeting new people & talking to authority figures
Performing in front of others
Dating!
Causes of Social Phobia
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Tend to run in families (nature or nurture?)
Generalized may be trait-like
Vs. avoidant personality disorder
May be classically conditioned
May actually be less skilled & more awkward
Causes of Social Phobia
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People with social phobia:
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Often do things to maintain their anxiety
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Overestimate negative consequences
Think social costs are worse
“safety behaviors”
Often focus on themselves, not the
environment
Treatment of Social Phobia:
Medications
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Beta-blockers
(lower heart rate,
blood pressure)
antidepressants
Treatment of Social Phobia
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CBT + Exposure
May include roleplaying, skills training
Often done in groups
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Problems inherent to
group therapy
5. Post-Traumatic Stress
Disorder
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Long-term response to life-threatening
danger (war, rape, robbery, etc)
Symptoms can last for years
Derealization (emotional numbing)
Depersonalization
Flashbacks
Hyperarousal, agitation, irritable, jumpy
3 Major Types of Symptoms
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Avoidance
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Hypervigilance
3.
Re-experiencing
PTSD
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Lifetime prevalence = 8%
More common in women
Many do not develop (so PTSD different)
Most events interpersonal
Causes of PTSD
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Nature of the trauma
Biological Factors
Psychological Factors
1. Nature of the Trauma
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More traumatic = more PTSD likelihood
Level of trauma depends on:
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Physical reality of the event
Individual experience, including closeness to
event
2. Biological Factors in PTSD
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Family history of anxiety disorders
Personal history of any disorder
Physical symptoms suggest physiological
dysfunction
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Dysregulation of natural opiods
Changed sleep cycles
Immune/metabolic suppresion
3. Psychological Factors
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Previous trauma
Social support is a buffer
Lots of individual differences
Treating PTSD
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Antianxiety drugs + sleep aids
(control physiological symptoms)
Psychological treatment
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Exposure
Rethinking of experience
Can be done in groups
6. Obsessive-Compulsive
Disorder
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Obsessions: unwanted, intrusive thoughts
that cannot be controlled
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Compulsions: Behaviors one feels compelled
to perform (may reduce obsessions)
OCD
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Compulsions can also
be called rituals
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Obsessions increase
anxiety, compulsions
temporarily reduce
OCD
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We used to believe this was extremely rare
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Hiding symptoms
Many can appear to function normally
Most did not seek treatment
Lifetime prevalence 2.6%
As common in children
Some normal (10-15% college students)
OCD
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Common Compulsions:
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Washing
Checking & Counting rituals
Common Obsessions:
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Harming others (Sexually, physically)
Safety of others
Contamination of self & others
Principal Symptom Factors
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Aggressive, sexual, and religious
obsessions with checking compulsions
2.
Symmetry/Order obsessions with ordering,
arranging, and repeating compulsions
(Leckman et al., 1997)
Principal Symptom Factors
3.
Contamination
obsessions with
washing and cleaning
compulsions
4.
Hoarding and Saving
symptoms
OCD
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Usually aware of “silliness” but can’t stop
(anxiety will skyrocket)
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Subtype with a lack of insight
Some things not to misunderstand:
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Compulsions are not set (can change)
Some people can have obsessions OR
compulsions
Causes of OCD
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3.
Psychodynamic Factors
Biological Factors
Cognitive & Behavioral Factors
Biological Factors
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5-10x more likely in first degree relatives
Rates in identical twins 20x general pop.
Found in Tourettes (a strong genetic
component)
Brain dysfunction: failure to filter repetitive
impulses?
Cognitive-Behavioral Factors
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Black & White thinking?
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E.g. contamination risks (if no guarantee, then I’m
not touching it)
The ‘normal’ level of acceptance of risk is too
high
Magical Thinking
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Thoughts/actions have specific consequences
“If I don’t do this, my partner will die”
Cognitive Factors
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Thought-action fusion
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Thoughts are equated with the actions or activity
represented by the thoughts
How do we treat OCD?
1.
2.
3.
Medication
Exposure/Response Prevention
Psychosurgery
Medication for OCD
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Antidepressants (in higher doses)
This means serotonin is likely involved
Most people respond well
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Also a subset who will not respond
Exposure/Response
Prevention
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Exposure is key to almost all anxiety
treatments
When we do something scary over and over
and over and over and over and over and
over again, is it still scary?
Exposure/Response
Prevention
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Put clients in an anxiety provoking situation
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Block their response (compulsion)
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E.g. touching public toilets/sinks
Forbid them to wash their hands
The more you give into OCD, the stronger the
symptoms become
The more you resist, the weaker they
become
Special Cases of OCD:
Hoarding
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Hoarding: acquisition of, and inability to
discard, worthless items, though they appear
to have no value (18-24% of OCD patients)
Also common in other disorders:
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Schizophrenia
Dementia
Eating disorders
Mental retardation
Features Associated with
Hoarding
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Indecisiveness
Perfectionism
Procrastination
Difficulty organizing tasks
Avoidance
Obsessions: losing important items, distortion
re: importance, emotional attachment to
items
Treatment of Hoarding
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Worse prognosis & more disability
Intensive CBT (e.g., daily)
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ERP
Excavation of saved material (w/ rules - no
sorting, grab first pile) & with help
Decision-making training - what to keep?
Immediately needs a place
Cognitive restructuring - nothing terrible happens
Anxiety Disorders Conclusions
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Anxiety disorders, combined, are relatively
prevalent
Easy to treat
Many people do not seek treatment
Usually treated with exposure (and
maintained by avoidance and negative
reinforcement)