psyc 3230 chapter 5

• Anxiety disorders include anxiety, obsessive-compulsive and related disorders, and trauma- and stressor-related disorders

Nature of Anxiety and Fear

• Anxiety is a future-oriented mood state characterized by negative affect, somatic symptoms of tension, and apprehension about future danger or misfortune
• Fear is a present-oriented mood state with an immediate fight-or-flight response to danger or threat, strong avoidance tendencies, and abrupt sympathetic nervous system activation
• Anxiety and fear are normal emotional states

From Normal to Disordered Anxiety and Fear

• Anxiety disorders have pervasive and persistent symptoms of anxiety and fear
• Anxiety disorders involve excessive avoidance and escapist tendencies
• Anxiety disorders cause clinically significant distress and impairment

Biological Contributions to Anxiety and Panic

• Diathesis–stress involves inherited vulnerabilities for anxiety and panic, which are activated by stress and life circumstances
• Biological causes and inherent vulnerabilities in anxiety and brain circuits include GABA, noradrenergic, and serotonergic systems
• Lower levels or sensitivity of GABA/serotonin are associated with more anxiety, while higher levels of noradrenaline are associated with less anxiety
• The Behavioral Inhibition System (BIS) is activated by signals from the brain stem of unexpected events or bodily functioning changes that might signal danger
• When the BIS is activated, individuals tend to freeze, experience anxiety, and anxiously evaluate environment for signs of danger
• The BIS is thought to be distinct from the circuit involved with panic
• The fight-or-flight system produces an immediate ‘alarm and escape’ response when aroused
• Environmental factors may change the sensitivity of brain circuits, affecting one's likelihood of developing an anxiety disorder

Psychological Contributions to Anxiety and Panic

• Freud suggested anxiety is a psychological reaction to danger tied to early infant/childhood fears
• Behaviorist views suggest anxiety and fear result from classical and operant conditioning and modeling (vicarious learning)
• Psychological views suggest early experiences with uncontrollability and predictability influence anxiety
• Parents can pass on the lesson that the child can cope with a world that is unpredictable through their behaviour
• Social contributions to anxiety involve stressful life events triggering vulnerabilities, with many stressors being familial or interpersonal

Comorbidity of Anxiety Disorders

• Comorbidity is common across anxiety disorders
• Approximately 50% of patients with an anxiety disorder have another secondary diagnosis
• Major depression is the most common secondary diagnosis
• Comorbidity suggests common factors across anxiety disorders, possibly between anxiety and mood disorders
• Evidence suggests a strong link between anxiety and depression

DSM-5 Anxiety Disorders

• Generalized anxiety disorder
• Panic disorder
• Agoraphobia
• Specific phobias
• Social anxiety disorder
• Selective mutism
• Separation anxiety disorder

DSM-5 Obsessive-Compulsive and Related Disorders

• Obsessive-compulsive disorder
• Body dysmorphic disorder
• Hoarding disorder
• Trichotillomania
• Excoriation disorder

DSM-5 Trauma- and Stressor-Related Disorders

• PTSD
• Reactive attachment disorder

Generalized Anxiety Disorder (GAD): Overview and Defining Features

• GAD involves excessive, uncontrollable anxious apprehension and worry about a number of events and activities
• Worry and anxiety interfere with the ability to function and/or cause distress
• GAD persists for 6 months or more
• restlessness or feeling keyed up, being easily fatigued, difficulty concentrating/mind going blank, irritability, muscle tension, and sleep disturbance.
• GAD is more pervasive and distressing than “normal” worries
• GAD lasts longer than normal worries and occurs without triggers
• Worries come with physical and somatic symptoms such as GI distress and exaggerated startle response

Generalized Anxiety Disorder (GAD): Facts and Statistics

• GAD affects 3% of the general population
• Females outnumber males approximately 2:1
• The onset of GAD is often insidious
• The median age of onset is 30
• The prevalence of GAD peaks in middle age and declines in later life
• Symptoms tend to wax and wane across life, and full remission is rare
• Earlier onset is associated with greater comorbidity and impairment

Causes of GAD

• Genetic factors account for 30% variability in GAD
• Temperamental factors include high behavioral inhibition and neuroticism
• Environmental factors include overprotection and childhood adversities
• Cognitive factors include being highly sensitive to threat and allocating more attention to threat cues in an automatic manner

Treatment of GAD

• Both drug and psychological interventions are effective for GAD
• Benzodiazepines provide immediate, short-term relief, but can impair motor and cognitive functioning and produce dependence and may have abuse potential
• Antidepressants are useful in the treatment of GAD with lower side effects
• Psychological interventions like cognitive-behavioral therapy offer better long-term benefits
• Cognitive-behavioral Therapy evokes and confronts anxiety-provoking images and thoughts, and challenge the irrational ones that lead to anxiety

Panic disorder: Overview and Defining Features

• Panic disorder is a disorder where there are Recurrent unexpected panic attacks (discrete periods of intense fear or discomfort with four or more symptoms)
• Symptoms include palpitations, sweating, trembling, sensation of shortness of breath, choking, chest pain, chills, heat sensations, numbness, nausea, feeling dizzy, feeling like you are dying)
• At least one of the attacks must be followed by 1 month or more of persistent worry about having additional attacks or their consequences
• Also includes a significant maladaptive change in behaviour related to attacks (eg- avoidance of triggers)

Panic disorder: Facts and Statistics

• 12 month prevalence: 2-3%
• two thirds with panic disorder are female
• onset is often acute, beginning between ages 20-24
• symptoms often wax and wane over lifespan but tends to be chronic (if untreated)

Panic disorder: Associated features

• nocturnal panic attacks (waking from sleep while experiencing panic symptoms, not usually due to dreams)
• many have general physical/health concerns
• tend to be sensitive to medication side effects
• concerns about ability to function due to panic
• avoidance of panic cues
• may see excessive substance use to control panic
• biological predisposition to be "overactive" to life events (emergency alarm reaction as a response to a stressor)Internally vigilant and fearful of physiological changes
• Predisposition to developing catastrophic misinterpretations of symptoms of panic
• Intense focus on internal cues followed by misinterpretation which makes symptoms worse

Panic disorder: Treatment

• Treat via medication (serotonergic, noradrenergic, and benzodiazepine GABA systems) SSRIs (preferred drugs) or via psychological methods
• Relapse rates are high following medication discontinuation
• Cognitive-behavior therapies are high effective

Panic disorder: Psychological and combined treatments

• Cognitive Behavioral Therapies: Exposures for agoraphobia (sometimes paired with relaxation strategies) or mini panic attacks in session as exposure-paired with cognitive therapy techniques like spinning in chair, exercise, hyperventilate, breathe through straw
• Should stop taking anti-anxiety meds (Ie- Benzos) during the process. Best long term treatment -cognitive behavioral therapy alone

Specific Phobias: Overview and defining Features

• extreme and irrational fear of a specific object or situation
• object/situation almost always provokes intense fear and anxiety
• fear is out of proportion with actual danger
• causes significant distress/impairment
• avoidance of phobic objects

Specific Phobias: Facts and Statistics

• 12-month prevalence: 7-9%
• females are again over-represented
• phobias run a chronic course; early onset (childhood)

Specific Phobias: Features

• Blood-injury-injection phobia – Drop in bp and hr. Strong heritability and unique susceptibility to fainting
• Situational phobia - public transportation or enclosed places (planes)
• Natural environment phobia -events occurring in nature (Heights)
• Animal phobia – animals and insects
• Other phobias – do not fit into the other categories (vomit)

Specific Phobias: Causes and Treatment

• Causes of Phobias: direct conditioning. Experiencing a panic attack in a specific situation. (Vicarious learning) observing someone else's fear or being told about danger
• Biological and evolutionary vulnerability: a predisposition to fear things that have always been dangerous to humans (eg, snakes, storms, heights)
• Probably need to be psychologically prone to anxiety. Individuals may be unaware of the cause.
• Psychological Treatments of Specific Phobias Cognitive -Behavior therapies
• Exposure therapy can build on anxiety hierarchy or start with least or most threatening. Counter-Conditioning and modeling can help too.

Social Anxiety Disorder: Overview & Facts

• Marked fear/anxiety about social situations where an individual is exposed to scrutiny/judgement (social/performance situations: speaking, eating, using restroom, writing, typing)
• Fears of acting in a way that would show anxiety, resulting in negative evaluations by others
• Situations must almost always provoke fear or anxiety which results in distress and impairment
• Situations are completely avoided or endured with intense distress
• 12 month prevalence: 7%. Onset is usually during adolescence
• Females are slightly more represented then males

Social Anxiety Disorder: Causes and Treatment

• Evolutionary and biological vulnerability and some are born with shy, inhibited temperament and are introverted
• Psychological Factors: learned that social evaluation is important/dangerous. Direct conditioning, observational learning, information transmission
• Medication: Beta blockers (ineffective), tricyclic antidepressants/monoamine oxidase inhibitors/SSRI Paxil (reduce social anxiety),
• Cognitive-behavioral treatment - exposure, rehearsal, role-play in a group setting. therapists challenge underlying automatic thoughts regarding phobic activities The exposure portion appears to be most important component

Obsessive-Compulsive Disorder (OCD): Obsessions

• persistent, recurrent, and intrusive thoughts, images, or urges that one tries to resist or eliminate
• common obsessions involve contamination, doubts (stove), order, aggressive or sexual imagery
• Ego-dystonic – feels intrusive and out of one's control and is not consistent with "regular" though content

Obsessive-Compulsive Disorder (OCD): Compulsions

• repetitive thoughts or behaviors that a person feels driven to perform due to rigid rules
• "Goal" of compulsions is to prevent or reduce distress associated with the obsession. compulsions are either not connected in a realistic way to what they are designed to neutralize.
• Obsessions and compulsions are time consuming or cause distress or impairment.
• Specifier: good to fair insight (recognizes OCD relief may not be true); poor insight (OCD beliefs probably true); absent insight/delusional (convinced OCD beliefs are true)

Obsessive-Compulsive Disorder (OCD): Facts, causes and Treatment

• 12 month prevalence: 1.2% and most persons with OCD are female (although more males are disorder in childhood)
• typically chronic, esp if untreated and onset is typically in early adulthood (mean age is 20)
• high comorbidity with tic disorders
• genetic factors, greater neuroticism; internalizing symptoms, early life experiences and learning that some thoughts are dangerous/unacceptable
• places too much importance on thoughts which can lead to thought action fusion
• medication- clomipramine and other SSRIs- benefit about 60% or psychosurgery- used in very extreme cases
• psychological- cognitive-behavior therapy which is most effective for OCD, CBT involves exposure and response prevention

Posttraumatic Stress Disorder (PTSD): Symptoms

• Requires exposure to actual or threatened death, serious injury, or sexual violence such as directly experiencing events, witnessing events or learning of events that occurred to close family member or friend etc
• Intrusive symptoms include recurrent, intrusive, involuntary memories, distressing dreams, dissociative reactions/flashbacks), intense distress at cues of events, physiological reactions to certain cues
• Avoidance of stimuli associated with events like memories, thoughts, feeling or reminders
• negative alterations in thoughts or mood (inability to remember important details, exaggerated negative beliefs about oneself, others or the world) and distorted cognitions about cause, negative emotional states and diminished interest or participation in significant activities
• Alterations in arousal/reactivity associated with traumatic events like irritability/anger, recklessness/self-destructive behavior, hypervigilance, exaggerated startle, sleep and concentration problems
• must also have a disturbance disturbance that lasts 1+ months.
• specifiers include depersonalization and derealization.
• is found at higher rates among veterans, certain vocations(police), survivors of rape/combat/captivity
• lifetime prevalence= 8.7% vs 13 month prevalence= 3.5%
• Symptoms usually begin within 3 months of trauma, although delayed expression (DSM-IV: Delayed Onset) is not uncommon

Posttraumatic Stress Disorder (PTSD): Risk Factors and Treatments

• risk factors can include prior and during traumas
• risk factors prior to trauma are : childhood emotional problems, other mental disorders, lower education/IQ/socioeconomic status, prior trauma, women, and younger age of trauma
• risk factors during trauma: severity of trauma, perceived life threat, personal injury, dissociation, for veterans, killing the enemy, witnessing atrocities
• Most Common Traumas are from sexual assault, accidents, combat and natural disasters
• to treat PTSD include psychological treatments (cognitive behavioral treatment involves graduated or massed imaginal exposure, challenge thoughts and emotions attached to the event) aim to reduce negative emotions like shame, guilt, or anger, increase coping skills and social skills. C
• CBT is highly effective
• medications include SSRIs which may be effective in reducing the anxiety and panic associated with PTSD