Chapter 4

Anxiety Disorders

Nature of Anxiety and 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

Nature of Anxiety and Fear

• 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

From Normal to Disordered Anxiety and Fear

• Characteristics of Anxiety Disorders – Pervasive and persistent symptoms of anxiety and fear – Involve excessive avoidance and escape – Cause clinically significant distress and impairment

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

The Phenomenology of Panic Attacks (continued)

• DSM-IV-TR Subtypes of Panic Attacks – Situationally bound (cued) – Unexpected (uncued) – Situationally predisposed

Fig. 4.1, p. 126

Biological Contributions to Anxiety and Panic

• Genetic Vulnerability • Anxiety and brain circuits – Depleted levels of GABA • Corticotropin releasing factor (CRF) and HYPAC axis

Biological Contributions to Anxiety and Panic (continued)

• Limbic (amygdala) and the septal hippocampal systems • Behavioral inhibition (BIS) – Anxiety • Fight/flight (FF) systems – Fear

Psychological Contributions to Anxiety and Fear

• Began with Freud – Anxiety is a psychic reaction to fear – Anxiety involves reactivation of an infantile fear situation

Psychological Contributions to Anxiety and Fear (continued)

• Behavioral and Cognitive Views – Invokes conditioning and cognitive explanations – Anxiety and fear are learned responses – Catastrophic thinking and appraisals play a role

Psychological Contributions to Anxiety and Fear (continued)

• Early Childhood Contributions – Experiences with uncontrollability and unpredictability • Social Contributions – Stressful life events trigger vulnerabilities

An Integrated Model

• Integrative View – Triple Vulnerability Model – Generalized biological vulnerability – Generalized psychological vulnerability – Specific psychological vulnerability

An Integrated Model (continued)

• Common Processes: The Problem of Comorbidity – Comorbidity is common across the anxiety disorders – Major depression is the most common secondary diagnoses

An Integrated Model (continued)

– About half of patients have two or more secondary diagnoses – Comorbidity Suggests • Common factors • A relation between anxiety and depression

The Anxiety Disorders: An Overview

• Generalized Anxiety Disorder • Panic Disorder with and without Agoraphobia • Specific Phobias • Social Phobia • Posttraumatic Stress Disorder • Obsessive-Compulsive Disorder

“Do you worry excessively about minor things?” Fig. 4.3, p. 132

Generalized Anxiety Disorder: The “Basic” Anxiety Disorder

• Overview and Defining Features – Excessive uncontrollable anxious apprehension and worry – Coupled with strong, persistent anxiety – Persists for 6 months or more – Somatic symptoms differ from panic (e.g., muscle tension)

Generalized Anxiety Disorder: The “Basic” Anxiety Disorder (continued)

• Statistics – Affects about 4% 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

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 Treatment of GAD: Generally Weak – Benzodiazapines – Often Prescribed – Psychological interventions – Cognitive Behavioral Therapy – Combined treatments – Acute vs. Long Term Outcomes

Fig. 4.4, p. 134

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

Panic Disorder With and Without Agoraphobia (continued)

• Facts and Statistics – Affects about 3.5% of the general population – Onset is often acute, beginning between 25 and 29 years of age – 75% of individuals with agoraphobia are female

• •

Panic Disorder: Associated Features and Treatment

Associated Features – Nocturnal panic attacks – 60% panic during deep non-REM sleep – Interoceptive/exteroceptive avoidance Medication Treatment – Target serotonergic, noraadrenergic, and GABA systems – SSRIs (e.g., Prozac and Paxil) are preferred drugs – Relapse rates are high following medication discontinuation

Panic Disorder: Associated Features and Treatment (continued)

• Psychological and Combined Treatments – Cognitive-behavior therapies are highly effective – No evidence that combined treatment produces better outcome – Best long-term outcome is with cognitive behavior therapy alone

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

Specific Phobias: An Overview (continued)

• Facts and Statistics – Females are again over-represented – Affects about 11% of the general population – Phobias tend to run a chronic course

Specific Phobias: Associated Features and Treatment

• Associated Features and Subtypes of Specific Phobia – Blood-injury-injection phobia – Unusual vasovagal response – Situational phobia – Trains, planes, automobiles, closed spaces – Natural Environment phobia – Natural events (e.g., heights, storms) – Animal phobia – Animals and insects – Separation Anxiety – Seen in children

Specific Phobias: Associated Features and Treatment (continued)

• Causes of Phobias – Biological and evolutionary vulnerability – Three pathways -- Conditioning, observational learning, information • Psychological Treatments of Specific Phobias – Cognitive-behavior therapies are highly effective – Exposure

Fig. 4.8, p. 150

Social Phobia: An Overview

• 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

Social Phobia: An Overview (continued)

• Facts and Statistics – Affects about 13% of the general population – Prevalence is slightly greater in females than males – Onset is usually during adolescence – Peak age of onset at about 15 years

Social Phobia: Associated Features and Treatment

• Causes – Biological and evolutionary vulnerability – Similar learning pathways as specific phobias • Psychological Treatment – Cognitive-behavioral treatment – Cognitive-behavior therapies are highly effective

Social Phobia: Associated Features and Treatment (continued)

• Medication Treatment – Tricyclic antidepressants and monoamine oxidase inhibitors – SSRIs Paxil, Zoloft, and Effexer – Are FDA approved – Relapse rates are high following medication discontinuation

Posttraumatic Stress Disorder (PTSD): An Overview

• Overview and Defining Features – Main etiologic characteristics – Trauma exposure and response – Reexperiencing (e.g., memories, nightmares, flashbacks) – Avoidance

Posttraumatic Stress Disorder (PTSD): An Overview (continued)

– Emotional numbing and interpersonal problems – Markedly interferes with one's ability to function – PTSD diagnosis – Only after 1 month post trauma

Posttraumatic Stress Disorder (PTSD): An Overview (continued)

• Statistics – Combat and sexual assault are the most common traumas – About 7.8% of the general population meet criteria for PTSD

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Posttraumatic Stress Disorder (PTSD): Causes and Associated Features

Subtypes and Associated Features of PTSD – Acute – May be diagnosed 1-3 months post trauma – Chronic – Diagnosed after 3 months post trauma – Delayed onset – Onset 6 months or more post trauma – Acute stress disorder – PTSD immediately post-trauma

Posttraumatic Stress Disorder (PTSD): Causes and Associated Features (continued)

• 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

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Posttraumatic Stress Disorder (PTSD): Treatment

Psychological Treatments – Cognitive-behavior therapies (CBT) are highly effective – CBT may include graduated or massed (e.g., flooding) imaginal exposure – Aim of CBT for PTSD

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Obsessive-Compulsive Disorder (OCD): An Overview

Overview and Defining Features – Obsessions - Intrusive and nonsensical thoughts, images, or urges – Compulsions - Thoughts or actions to neutralize thoughts – Vicious cycle of obsessions and compulsions – Cleaning and washing or checking rituals are common

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Obsessive-Compulsive Disorder (OCD): Causes and Associated Features

Statistics – Affects about 2.6% of the general population – Most with OCD are female – Onset is typically in early adolescence or young adulthood – OCD tends to be chronic

Obsessive-Compulsive Disorder (OCD): Causes and Associated Features (continued)

• 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

Obsessive-Compulsive Disorder (OCD): Treatment

• Medication Treatment – Clomipramine and other SSRIs – Benefit up to 60% of patients – Relapse is common with medication discontinuation – Psychosurgery (cingulotomy) is used in extreme cases

Obsessive-Compulsive Disorder (OCD): Treatment (continued)

• Psychological Treatment – Cognitive-behavioral therapy is most effective – CBT involves exposure and response prevention – Combining CBT with medication -- No better than CBT alone

Summary of the Anxiety Disorders

• Most Common Forms of Psychopathology • From a Normal to a Disordered Experience of Anxiety and Fear – Triple Vulnerabilities – Bio-psycho-social – Fear and anxiety – Non-dangerous bodily or environmental cues – Symptoms and avoidance – Significant distress and impairment

Summary of the Anxiety Disorders (continued)

• Psychological Treatments are Generally Superior in the Long-Term – Similar treatments for different anxiety disorders – Suggests that anxiety-related disorders share common processes