Midterm 2 Psych 300 Ch. 5 Anxiety Disorders PDF

## Anxiety Disorders ### Physiological Arousal - A universal human experience - Innate fear system - Marked by HPA activation - Affects multiple brain regions - Affects every organ system in the body - Essential for survival ### Concepts Related to HPA Activation 1. **Stress**...

## Anxiety Disorders ### Physiological Arousal - A universal human experience - Innate fear system - Marked by HPA activation - Affects multiple brain regions - Affects every organ system in the body - Essential for survival ### Concepts Related to HPA Activation 1. **Stress** - Response to perceived demands (problems) - Objectively demonstrable problem - Outweigh coping abilities 2. **Fear** - Present-oriented - Response to actual danger - Compared to stress, there is something to actually fear - Surge in sympathetic nervous system (fight/flight response) - Strong urge to escape 3. **Panic** - Sudden rush of intense fear and physiological symptoms (fight or flight) - Short, intense HPA activation - No objective danger - False alarm 4. **Anxiety** - Also known as apprehension/apprehensive anxiety - Future-oriented - Possible future threat - Physical tension ### Anxiety vs Anxiety Disorders - When it's very: - Intense - Frequent - Excessive or unreasonable (reaction is exaggerated; exaggerated threat perception) - You have to experience distress and/or impairment ### Importance of Anxiety Disorders 1. **Prevalence** - They're the most prevalent condition - Single largest mental health problem in North America - General population (DSM-III) - 24.9% lifetime prevalence ### DSM-V said GAD is a form of depression ### Speculation that GAD occurs in people with underactive GABA-benzodiazepine system ### Cognitive-Behavioural Models - **Maintaining factors:** cognitive avoidance (Borkovec) - People with GAD used cognition to avoid thinking about things that are very important - Found that people with GAD have less physiological reactivity/arousal except for muscle tension compared to people with panic disorder - Although they are worried, they have less arousal than other anxiety disorders - Worry about images - more verbal than pictorial - Focus on future not present events serves as distraction from fear - Talking to yourself (e.g., "What am I gonna wear? What if I'm early? What if I'm late?") and worrying verbally distracts yourself from serious events that may be happening in life (e.g., if a family member is sick) - Came up with the idea of using cognitions to avoid genuine emotions - **Intolerance of uncertainty (Durgas)** - People get anxious when there are uncertain situations - People with GAD often have erroneous beliefs about worry - more likely to believe that worry is useful - Poor problem orientation - people with GAD could generate solutions to problems but afraid to implement them - Also emphasize cognitive avoidance - people worry to avoid a deeper fear - Came up with the Why Worry questionnaire - Found that people with GAD believe that if they worry, they will be less upset when something actually happens, but it actually has no protective function at all (therefore a dysfunctional belief) - They also believe that worrying has a planning function, but found that this actually keeps individuals from actually implementing problem solutions - In reality, if you worry about something, you're more likely to procrastinate - **Safety behaviors of people with GAD:** overpreparation ### Treatment - **Dugas & Robichaud: CBT for GAD** - Have people keep track of their worries and then ask them to divide those worries - Worry discrimination: Type 1 (controllable) and Type 2 (uncontrollable hypothetical situations) - Type 1: exercise problem solving - Type 2: focus on increasing tolerance for uncertainty - Exercises to engage in actions without preparation - Reduce reassurance-seeking - Exposure to most feared outcome - E.g., visualizing your fear/writing out a loved one getting into a car accident and reading it over and over till emotion drains out of the imagined scenario ### Panic Disorder (PD) - Pan: Greek god who would leap out and yell at those who disturbed his nap - **Unexpected terror** - 30% of people will have a panic attack at some point in their lives, but may not develop PD - **Diagnostic features** - Recurrent, unexpected panic attacks - Panic attack: sudden rush of symptoms, intense, peaks within minutes (goes away fairly quickly) - **Physiological** - Palpitations, pounding heart, or accelerated heart rate; chest pain - Shortness of breath, smothering; feeling of choking - Dizzy, unsteady, lightheaded, faint - Nausea or abdominal distress - Trembling or shaking - Sweating - Paresthesias (numbness or tingling) - Chills or hot flushes - **Psychological** - Derealization (feelings of unreality) - Depersonalization (being detached from oneself) - Fear of losing control, going crazy, or dying - **You can also condition yourself to be afraid of things or learn fears in different ways** - **Panic attacks - have a panic attack in a situation can produce fear even if it's fairly benign** - **Problems with 2-step learning theory** - Often conditioning event is absent - Individual differences in conditionability - Stimuli specificity - does not explain why we aren't afraid of everything - Humans tend to develop fears of certain objects (e.g., people do not typically have a fear of a bottle of water) - **Cognitive interpretations influence fear** - **Integrative models - aetiology** - Interaction between innate vulnerability (biological predispositions whether genetics or evolutionary) and learning experiences - Results in exaggerated threat perceptions - people with phobias tend to have maladaptive thought processes regarding the object/situation they're afraid of - Leads to avoidance and other safety behaviours - **Contemporary models - safety behaviours** - Deliberate - Adopted to prevent negative outcome - Unnecessary - Exercising of safety behaviours reinforces the belief - **First line treatment** - Cognitive modification - to change maladaptive thought processes - In vivo (in real life) exposure - Graduated (step-wise) - Virtual reality exposure - **Treatment - hypothesised mechanisms (why does it work?)** - Reconsolidation: reactivate the fear memory & store with fewer emotion connections - Extinction learning: (aka inhibitory learning) develop new memory store associated with fear stimulus - Cognitive change: reduce selective attention to threat through safety learning, i.e., not focus on the fear ### Panic Itself Subsides But Feelings Of Anxiety May Stay - A critical symptom: sense of choking or unable to get enough air ### Diagnosis Requires - At least 5 symptoms listed above - Before: anticipatory anxiety - After: worry about the consequences of the attack - Significant behaviour change - Situational - avoid situations they associate with triggers for panic attacks - Internal sensations - if someone feels a symptom associated with panic attacks, they think another one will occur, e.g. avoid walking up the stairs to avoid a faster beating heart/getting out of breath - Safety behaviours - e.g. carrying anti-anxiety medication ### Subtypes Of Panic Attacks - Cued (situationally bound - confined to certain situations with certain triggers) - Situationally predisposed (e.g., someone with social anxiety may only have panic attacks in certain situations) - Unexpected - required for diagnosis of panic disorder - Limited symptom attacks - people may have some symptoms of a panic, but no enough to be diagnosed ### Prevalence - 1 in 3 people experience a panic attack - Only 3% meet the criteria for panic disorder ### Biological Contributions - **Biological challenge studies - manipulations that increase CO2** - Infusions of lactic acid - Carbon dioxide inhalation - **Biological theorists** - Neurochemical disturbance - 30-40% genetically transmitted - E.g., suffocation false alarm theory: hypersensitivity to detecting carbon dioxide (chemoreceptors) ### Cognitive Contributions - In biological challenge studies, if told "sensations are not harmful," they are less likely to panic - Catastrophic misinterpretations of one's physical sensations (fear of fear) - person associates bodily sensations with bad things = spiralling of anxiety which surmounts to a panic attack - E.g., interpreting heart beating as dangerous and something bad is going to happen = get more anxious = breathe less properly ### Cognitive Model - Trigger (internal or external) - Catastrophic misinterpretations - Perceived threat - Apprehension - Bodily sensations (anxiety) ### Treatment - Medications may have side effects, i.e., bodily sensations which could trigger panic attacks - CBT is the first line of treatment - Education - e.g. recognizing signs of panic attacks and acknowledging that it is nothing dangerous ### Agoraphobia - Anxiety about being in places/situations where escape might be difficult or embarrassing, or where help may not be available - Differs from simple phobias because it can occur in multiple situations - These situations are either avoided completely, entered only with a "safe person" (very dependent on that person) and/or endured with marked distress - **Commonly avoided situations** - Buses/subways - Bridges - Enclosed spaces - Crowds - Malls - Movie theatres - Standing in line-ups - **Controversy to agoraphobia** - Recall: people who have had panic attacks avoid situations that elicit bodily sensations that resemble panic attacks - According to Barlow, agoraphobia almost always follows panic/PD - European researchers disagree - So is it with or without panic disorder? - 46-80% don't report panic - Clinically ### Social Phobia/Social Anxiety Disorder (SAD) - Marked or persistent fear of one or more social or performance situations - Performance: e.g. eating in public; public speaking (but since so many people are afraid of public speaking, many question if it should be considered a disorder) - Fears doing something humiliating or embarrassing and being negatively evaluated - Subtype: performance only - E.g., singing in public ### Prevalence - 4th most prevalent disorder after depression, alcoholism and specific phobias - High prevalence in North America - 8.1% of Canadians - Lower elsewhere - Europe = 2.3% - Prevalence is the same in children (one of the most difficult childhood disorders to treat along with OCD), adolescents and adults - Onset at age 13 (pubescent age being the peak of bullying or heightening of self-awareness) but can begin earlier ### Gender - More prevalent in women in community populations - Men are more likely to seek treatment ### Culture Influences - Taijin kyofusho: fear of offending other people via behaviour, body odour, intense gaze etc. (Japan, Korea) - Hikikomori: severe social withdrawal (aka failure to launch) (Japan) - People from Asian cultures (especially China and Korea) report more social anxiety but have lower rates of social phobia - more accepting of being shy, quiet and reserved = less stigma so it doesn't impair them as much ### Impairment - Social: avoidant personality (people and other things like novel things), hikikomori (60% of men with social phobia don't marry), less social support, fewer friends, lonelier - Education: may choose professional career based on interaction with people - Occupational: underemployment (tend to go less far in their jobs than they should) - Comorbidity: risk factor for depression (usually precedes onset of depression), substance abuse (most strongly predicts marijuana abuse/dependence - 25% of those who use marijuana have SAD) ### Prevalence - 16.4% 12 month prevalence - Patients in primary care settings (who go to the doctor) (DSM-III) - 18% (even excluding specific phobias) - Non-cardiac chest pain: 40% have panic disorder (PD) - Focal epilepsy: 19% develop comorbid anxiety disorder (e.g., anxious they will have another seizure, or social phobia of having a seizure in public) ### Present in All Cultures But Prevalence Varies - 12 month prevalence (DSM-IV) - Europe: 8.4% - USA: 22% - Australia: 5.6% - China: 13% - Canada: 5.8% (PD, Agoraphobia, SAD only) - Francophone: 3.85, Anglophone: 4.89 - More common in European especially those with Anglophone backgrounds - Could be because these typically are wealthier countries where mental health care is more readily available - Tiwari & Wang (2006) - Examined cultural groups within Canada - Canadian Community Health Survey - Residents > 13 years old - Self-reported heritage - 33,399 Euro (10% immigrants) - 733 Chinese (84.5% immigrants) - 1,113 other Asian (86%) - Found that people of European backgrounds seemed to be at higher risk of anxiety disorders than other groups in Canada - Consistent in anxiety disorders and depression ### Issues with Research - Definitions of culture, ethnic heritage - Any gold standard? - Ethnicity vs culture - A lot of Canadians consider themselves bi-culture - Controlling for generational status - By third generation, people resemble Canadian culture more than their ethnic culture - Grouping of heritage groups - "Asian" vs "European" - Lumping all Asian cultures together etc. disguises differences - Southern European cultures differ from Northern European cultures in anxiety disorders - Emotion terms don't translate well from one language to another - E.g., social anxiety disorder (SAD) - Some cultures it means fear of other people, or paranoia - Interestingly, generalized anxiety disorder, or worry, seems to be universal ### Often Chronic ### Cause Significant Personal Impairment ### Risk Factors for Other Disorders - 31% comorbid for another anxiety disorder - 50% also have depression - Increased risk of substance disorder - Possible links with suicide - Multiple health conditions ### Economic Burden for Society