Chapter 5.docx

**Chapter 5: Anxiety** **What is anxiety?** - A common emotion characterized by physical symptoms, future-oriented thoughts, and escape or avoidance behaviour - Occurs when people encounter a new situation or anticipate a life-changing event - Usually is time-limited and ends when...

**Chapter 5: Anxiety** **What is anxiety?** - A common emotion characterized by physical symptoms, future-oriented thoughts, and escape or avoidance behaviour - Occurs when people encounter a new situation or anticipate a life-changing event - Usually is time-limited and ends when the event is over **Components of anxiety** - Components of anxiety: 1. Physiological -- heightened level of arousal and physiological activation. E.g., shortness of breath, dry mouth 2. Cognitive -- subjective perception of anxious arousal and associated cognitive processes e.g., worry and ruminations 3. Behavioural -- ( clinicians often add this component) 'safety' behaviours; escape/avoidance **Normal anxiety vs. Abnormal anxiety** - Things to consider: - Feeling anxious occasionally is normal - Situational factors -- truly upsetting situations or actual threats -\> normal to feel anxious - Chronically anxious people -- tendency to perceive threat and to be worried when there is no objective threat or the situation is ambiguous - The anxiety must be chronic, relatively intense, and causing impairment and significant distress for self or others **Anxiety, fear, panic** - **Anxiety --** a negative mood state characterized by bodily symptoms of physical tension and apprehension about the future - **Fear --** an immediate alarm reaction to dangerous or life-threatening situations - **Panic attack --** an abrupt experience of intense fear or acute discomfort accompanied by physical symptoms (you get same feeling as fear however there is no present threat) - Expected (cued) panic attack (more expected in specific phobias or social anxiety disorders) - Unexpected (uncued) panic attack (more expected in panic disorders) **Causes of anxiety (remember what neurotransmitter and routes are involved)** **Biological contributions** - People inherit the tendency to be anxious or highly emotional - No single gene - Anxiety -- associated with: - Neurotransmitter systems - Low levels of GABA -- less inhibition of the brain structures involved in threat response -\> anxiety; not a direct relationship - Noradrenergic system is also implicated - Corticotropin-releasing factor (CRF) system - CRF activates the HPA axis - Also directly related to the GABA, serotonergic and noradrenergic neurotransmitter systems. - The limbic system -- mediator between the brain stem and cortex - **Behavioural inhibition system (BIS)** in animals (Jeffrey gray) -\> tendency to freeze, experience anxiety, and apprehensively evaluate the situation to confirm the presence of danger - this circuit leads from the septal and hippocampal areas in the limbic system to the frontal cortex - bis is activated by - signals from the brain stem of unexpected events, such as major changes in body functioning that might signal danger - danger signals from the cortex to the septal-hippocampus area - distinct form the fight/flight system (originates in the brainstem and travels through several midbrain structures) -- immediate alarm and escape response - involved in panic **psychological contributions** - anxious behaviour starts in childhood - overprotective and overintrusive parents - feeling of no control over environment - personality traits - anxiety sensitivity -- tendency to fear the physiological symptoms of anxiety, such as rapid heartbeat or sweating - behaviourists view -- anxiety a product of conditioning or modelling **social contributions** - focus on the relation between stressful life events as triggers for biological and psychological vulnerabilities for anxiety and panic - stressful life events - social and interpersonal (marriage, work life), physical (illness, injury) - see figure 5.3 -- the triple vulnerability model An integrated model - the first vulnerability (or diathesis) is a generalized biological vulnerability - biological vulnerability (tendency to see the negative) - the second vulnerability is generalized psychological vulnerability - specific psychological vulnerability (specific to an object) (e.g., insects) - the third vulnerability is a specific psychological vulnerability - generalized psychological vulnerability (not specific to anything)(e.g., word is a dangerous place) - if you are under a lot of pressure, particularly from interpersonal sterssors, a given stressor could activate your biological tendencies to be anxious and you psychological tendencies to feel you might not be able to deal with the situation and control the stress. - Once the cycle starts, it tends to feed on itself, so it might not stop even when the particular life stressor has long since passed **comorbidity** - comorbidity - occurrence of two or more disorders in a single person - major depression and anxiety disorders most commonly comorbid - 57% of people diagnosed with one anxiety disorder also have another anxiety disorder or depression - Additional diagnoses of depression, alcohol, drug abuse make recovering from anxiety difficult **Comorbidity with physical disorders** - Anxiety disorders co-occur with several physical conditions - Thyroid disease, respiratory disease, arthritis, migraine headaches, allergies - Anxiety precedes physical disorder - Both together lead to poor quality of life **Suicide** - 20% of panic disorder patients attempt suicide - Comparable to people with depression - Suicidal ideation common - Suicide attempts common - More likely by those who inflict self-harm (GAS, SAD) **Anxiety disorders** - A group of disorders characterized by heightened physical arousal, cognitive distress, and behavioural avoidance of feared objects/situations/events - Anxiety disorders are the most common psychological disorders - Anxiety disorders -- more common in women than in men across all age groups. - Becomes a disorder when it starts interfering with life **Generalized anxiety disorder** - Features that characterize **generalized anxiety disorder (GAD):** - Uncontrollable, unproductive worrying about everyday events, small and bug - Does not have as much physiological symptoms - Feeling impending catastrophe even after successes - Inability to stop the worry - Not enjoying everyday activities - Anxious all the time - Know minimum occurrence and so forth - The DSM-5-TR criteria specify that at least six months of excessive anxiety and worry must be ongoing more days than not. - Characterized by: - Muscle tension, mental agitation, susceptibility to fatigue, irritability, difficulty sleeping, difficulty concentrating - Don't see physiological arousal - See table 5.1 **Statistics** - 12- month prevalence rate aged 15 and older 5.2% (2022) - More common in women than men - Relatively few people with GAD come for treatment, compared with patients with panic disorder - Stressful life events play role in onset - Most common in people over 45 years (US study) - An earlier and more gradual onset than most other anxiety disorders - It is difficult to treat GAD successfully -- difficult to achieve a full remission of symptoms **Causes** - Possibility of a genetic cause - GAD runs in families - Greater risk for monozygotic twins - Anxiety sensitivity -- tendency to become distressed in response to arousal-related sensations, arising from beliefs that these anxiety-related sensations have harmful consequences. - Learning theories - Anxiety regarded as having been classically conditioned to external stimuli, but with a broader range of conditioned stimuli - Cognitive theories - Focus on control and helplessness - Emphasize the perception of not being in control as a central characteristic of all forms of anxiety - Attentional bias -- the attention of people with GAD is easily drawn to stimuli that suggest possible physical harm or social misfortune - Interpreting ambiguous stimuli as threatening. - Cognitive characteristics of GAD: 1. Intolerance of uncertainty not knowing makes people with GAS more nervous 2. Positive beliefs about worry; believe worrying helps solve them problem, unhealthy schema - Worrying helps solve a problem 3. Poor problem orientation (threats to be avoided) ; avoid situations that are threatening to them 4. Cognitive avoidance (avoiding negative affect associated with the threat); thinking to much on the anxiety, they often forget what they are worried about without images of threat **Treatment** - Drugs: benzodiazepines -- no more than a week or two (long term use -- effectiveness had not been empirically supported), antidepressants (Paxil) - Psychological: cognitive behavioural treatment (CBT) - Focus on the worry proves and avoidance of feelings of anxiety and negative affect. - Effective with children with older adults - Mindfulness-based approaches **Panic disorder and agoraphobia** **Panic disorder (PD)** - Sensation of dying or of losing control, unexpected panic attacks - Person suffers a sudden and often inexplicable attack of alarming symptoms: - Rapid or laboured breathing, heart palpitations - Nausea and chest pain; - Feelings of choking; - Dizziness and trembling; - Intense apprehension and feelings that disaster is imminent - May experience depersonalization and derealization - Person may also experience: - Depersonalization - Derealization - See table 5.2 - In many cases PD accompanied by: agoraphobia **Agoraphobia** - The term agoraphobia was coined in 1871 by karl Westphal - Greek word-fear of the marketplace -- fear and avoidance of situations: unsafe and inescapable - A cluster of fears centering on public places and being unable to escape or find help should one become incapacitated - Safe place or safe person - People develop agoraphobia as they never know when the panic like or other embarrassing symptoms may occur - Diagnosis requires anxiety in at least 2 of 5 situations: 1. Public transportation 2. Open spaces 3. Enclosed spaces 4. Lines/crowds 5. Being out of the house alone - Many people with agoraphobia are unable to leave the house or do so only with great distress - Many people with panic disorder go on to develop agoraphobia but not everyone with panic disorder has agoraphobia - Avoidant behaviours are displayed - Could lead to drug and alcohol abuse/dependence - See table 5.3 Interoceptive avoidance - Removing self from situation/activities leading to arousal ; e.x., working out causes same physiological symptoms, so may avoid it. Must require anxiety in 2/5 situations 1. Public transportation 2. Open spaces 3. Enclosed spaces 4. Lines/crowds 5. Being out of house alone **Statistics (for PD)** - Canadian medical health association -- 4% of Canadians will experience panic disorder in their lifetime - Canadian women higher (4.6%) rate than men (2.8%) - Mean age of onset: 25-29 years - Most initial attacks begin at or after puberty - Gender differences - Cultural explanation - Accepted for women to report fear; men -- to be stronger and braver - Women -- more fearful of anxiety - Males -- alcohol **Cultural influences** - PD exists worldwide - Lowest rates in Asian and African countries - Expression of PD varies - Latin American -- susto -- a fright disorder - Inuit of northern Canada and western Greenland -- kayak-angst **Nocturnal panic** - Panic attacks most frequently occur between 1:30 am and 3:30 am - Delta (slow-wave) sleep; happens during slow wave sleep - Isolated sleep paralysis **Causes** **Biological theories** - Panic disorder runs in families - Identical-twins pairs vs. fraternal twins - An increased risk of 5-16% among relatives of those with panic disorder - Genetic diathesis - Noradrenergic activity theory -- panic is caused by overactivity in the noradrenergic system: - Stimulation of the locus coeruleus causes monkeys to have "panic attack" - In humans yohimbine (drug that stimulates activity in the locus coeruleus) can elicit panic attacks - The role of Gamma-aminobutyric acid (GABA) in panic: - Gaba generally inhibit noradrenergic activity - Position emission tomography (PET) study found fewer GABA-receptor binding sites in people with panic disorder **Psychological theories** - Misinterpretation of physiological arousal symptoms - Overly active ANS + psychological tendency to become very upset by these sensations -\> danger signal - A vicious cycle in Panic disorder -- panic attack -\> fear -\> fearing another panic attack -\> increased autonomic activity -\> catastrophic ways of interpreting these symptoms -\> raise the anxiety level -\> a full-blown panic attack - Anxiety sensitivity **Treatment** **Medication** - Most widely used drugs: benzodiazepines, SSRIs, SNRIs - Relapse closer to 90% if medication stopped - Benzodiazepine adversely affect cognitive and motor functions to some degree **Psychological intervention** - Exposure based therapies -- concentrated on reducing agoraphobic avoidance - Exposure to feared situation - Gradual exposure exercises combined with relaxation or breathing retraining - CBT psychological intervention: panic control treatment (PCT) - Therapist creates "mini" attacks -- exposing patients with panic disorder to the cluster of interoceptive sensations that remind them of their panic attacks - Identify and modify the basic attitudes and perceptions concerning the dangerousness of the feared but objectively harmless situations. **Combined psychological and drug treatments** - Research -- no advantage to combining drugs and CBT initially psychological treatments perform better in the long term - Stepped care approach: adding another treatment to exisiting treatment (CBT, drugs) **Specific phobia** **Clinical description** - An irrational fear of a specific object or situation that markedly interferes with an individual's ability to function - Unwarranted fears caused by the presence or anticipation of a specific object or situation - The fear and avoidance is out of proportion to the danger actually posed - The fear is recognized by the sufferer as groundless - New phobias tned ot emerge in keeping with societal change - To name a specific phobia, the suffix 'phobia' is preceded by a Greek word for the feared object or situation - The suffix itself is derived from the name of the Greek god Phobos, who frightened his enemies - Example of specific phobias: - Claustrophobia, fear of closed spaces - Acrophobia, fear of heights - New phobias tend to emerge in keeping with societal changes - Nomophobia - A pathological fear of remaining out of touch with technology that is experienced by people who have become overly dependent on using their mobile phones or personal computers. **Coronaphobia** - An excessive triggered response of fear of contracting the virus causing COVID-19, leading to - Accompanied excessive concern over physiological symptoms - Significant stress about personal and occupational loss increased reassurance and safety seeking behaviours - Avoidance of public places and situations - Marked impairment in daily life functioning Major subtypes - Blood-injury-injection phobia - Situational phobias - Natural environment phobias - Animal phobias - Other phobias Statistics - The lifetime prevalence around the world -- 3% to 15% - Fears and phobias concerning heights and animals -- the most common - 6.4% of Canadian population - 8.9% women, 4.1% men - Paradox: common and treatable yet goes untreated - Most work around their phobias -- only the most severe cases seek treatment Causes - Traumatic experiences/traumatic conditioning; something you experience personally - Prepared learning; bear in front of you - Vicarious experience; observe someone getting stung by a lot of bees, you are now afraid of bees - Information transmission - Panic attack (false alarm) -- phobia of that situation - Anxiety over the possibility of another traumatic event or false alarm - Social and cultural factors - Most reported specific phobias occur in women Treatment - Exposure-based exercises - Change brain functioning by modifying neural circuitry in amygdala, insula, cingulate cortex - Virtual reality exposure therapy, a newer approach, is effective - Purely cognitive approach is not recommended **Separation anxiety disorder** - Child's unrealistic and persistent worry something will happen to parents or other people important to child - Afraid to go to school; had nightmares - 35% can extend into adulthood if not treated in childhood - Adults with this disorder have been overlooked - Sometimes the onset is in adulthood rather than carrying over form childhood Causes - Biological vulnerability - Parent-child attachment -- insecure or anxious attachment styles - Traumatic events and significant life changes - Divorce - Death - Life transitions **Treatment** - Gradual exposure: gradual exposure to the separation situations in a controlled manner - Cognitive restructuring: challenging and changing irrational thoughts about separation - Relaxation training: teaching coping strategies and relaxation techniques to manage anxiety - Parent-child interaction therapy (PCIT): to improve parent-child interactions and reinforce positive behaviours. **Social anxiety disorder (social phobia)** **Clinical description** - Persistent, irrational fears of being judged by other people - Tend to avoid situations in which they might be evaluated - Concerns that blushing, shaking, and sweating (physiological signs of anxiety) will be observed by others - Social situations 1. Speaking or performing in public (e.g., public speaking) 2. Social interactions 3. Being observed in public Statistics - 12-month prevalence rate -- 7.1% of Canadians - SAD usually begins during adolescence (peak age:15 years) - More prevalent in young, less educated, single economically disadvantaged individuals - Females are slightly more represented than males. - Japan (taijin kyofusho -- TKS) -- fear of offending or embarrassing others - Olfactory reference syndrome (north America) -- embarrassing oneself and offending others with a foul body odour **Causes** - Prepared learning (angry faces) -- react to angry faces with grater activation of the amygdala and less cortical control than people without anxiety - Biological vulnerability to develop anxiety and/or to social inhibition - Panic attack in a social situation - Anxiety -- additional panic attacks in the same/similar social situation - Experience of a real social trauma -\> true alarm -\> anxiety in the same/similar social situations - Childhood experiences - Cognitive characteristics - Attentional bias to focus on negative social information - Perfectionistic standards for accepted social performances - High degree of public self-consciousness - Post-event processing (PEP) of negative social experiences - rumination - Alden's interpersonal transaction cycle - Individua's interaction with people in the social environment contribute to or maintain social anxiety - Biased social perceptions -\> maladaptive behaviour in social situations -\> elicits negative reactions from others - Upward and downward social comparisons **Treatment** - CBT - Cognitive-behavioural group therapy (CBGT) -- includes cognitive restructuring as well as rehearsal or role-play of feared situations in a group setting - More effective than psychoeducation - Social mishap exposure - CBT -\> changes in the brain activity associated with emotional processing. - SSRIs (Paxil, Zoloft) - CBT and SSRI -- both effective but the combination was no better than the two individual treatment **Selective mutism** - DSM-5-TR includes SM with anxiety disorders - Rare childhood disorder characterized by lack of speech in setting where public speech is expected - Related to social anxiety - Speechless in selective situation only (school) - Lack of speech must for more than one month and cannot be limited to the first month of school **Causes** - Genetic contribution - Traumatic life events - Overprotective parents **Treatment** - Emphasize activities that promote verbal participation and spontaneous speaking - Behavioural techniques -- modelling, shaping combined with reinforcement for participation in the treatment.