PSY110P-Chapter-5a-Anxiety-Disorders.pptx

Anxiety Disorders Anxiety Disorders    Anxiety is defined as apprehension over an anticipated problem. Fear is defined as a reaction to immediate danger. Anxiety Disorder – A group of disorder that share high or frequent anxiety. Except for generalized anxiety disorder, the anxiety disorders...

Anxiety Disorders Anxiety Disorders    Anxiety is defined as apprehension over an anticipated problem. Fear is defined as a reaction to immediate danger. Anxiety Disorder – A group of disorder that share high or frequent anxiety. Except for generalized anxiety disorder, the anxiety disorders involve tendencies to experience unusually intense fear. › Symptoms must interfere with important areas of functioning or cause marked distress. › Symptoms are not caused by a drug or a medical condition. › The fears and anxieties are distinct from the symptoms of another anxiety disorder. Panic - after the Greek god Pan who terrified travelers with bloodcurdling screams.  panic attack is defined as an abrupt experience of intense fear or acute discomfort, accompanied by physical symptoms that usually include heart palpitations, chest pain, shortness of breath, and, possibly, dizziness.  Panic Attack A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:       (1) palpitations, pounding heart. or accelerated heart rate (2) sweating (3) trembling or shaking (4) sensations of shortness of breath or smothering (5) feeling of choking (6) chest pain or      (8) feeling dizzy, unsteady, lightheaded, or faint (9) dereali zation (feelings of unreality) or depersonalization (being detached from oneself) (10) fear of losing control or going crazy (11) fear of dying (12) paresthesias Types of Panic Attacks  Situationally bound (cued) Panic Attacks are defined as those that almost invariably occur immediately on exposure to, or in anticipation of, the situational cue or trigger (e.g., a person with Social Phobia having a Panic Attack upon entering into or thinking about a public speaking engagement). Situationally predisposed Panic Attacks are similar to situationally bound Panic Attacks but are not invariably associated with the cue and do not necessarily occur immediately after the exposure (e.g., attacks are more likely to occur while driving, but there are times when the individual drives and does not have a Panic Attack or times when the Panic Attack occurs after driving for a half hour). Causes of Anxiety and Related Disorders  Biological › › › ›  Behavioral Inhibition System Fight or Flight System Fear Circuit of the Brain Imbalance of Neurotransmitters Psychological › Behavioral › Cognitive › Personality Type  Social – stressful life events Fear Circuit of the brain    One part of the fear circuit that seems particularly activated among people with anxiety disorders is the amygdala. The medial prefrontal cortex appears to be important in helping to regulate amygdala activity—it is involved in extinguishing fears as well as using emotion regulation strategies to control emotions. Researchers have found that people who meet diagnostic criteria for anxiety disorders display less activity in the medial prefrontal cortex. Personality: Behavioral Inhibition and Neuroticism    Behavioral inhibition - a tendency to become agitated and cry when faced with novel toys, people, or other stimuli. Behavioral inhibition appears to be a particularly strong predictor of social anxiety disorder: 30 percent of infants showing elevated behavioral inhibition developed social anxiety disorder by adolescence. People with high levels of neuroticism were more than twice as likely to develop an anxiety disorder as those with low levels. Imbalance in the Neurotransmitters  Persons with anxiety disorders has low levels of GABA and Serotonin, while Norepinephrine is in higher than normal levels. Common Risk Factors across the Anxiety Disorders    Mowrer’s two-factor model 1. Through classical conditioning, a person learns to fear a neutral stimulus (the CS) that is paired with an intrinsically aversive stimulus (the UCS). 2. Through operant conditioning, a person gains relief by avoiding the CS. This avoidant response is maintained because it is reinforcing (it reduces fear). Biological behavioral inhibition system (BIS) activated by signals from the brain stem of unexpected events, such as major changes in body functioning that might signal danger.  Danger signals in response to something we see that might be threatening descend from the cortex to the septal– hippocampal system. The BIS also receives a big boost from the amygdala.  Cognitive Factors 1. Sustained Negative Beliefs about the Future  People with anxiety disorders often report believing that bad things are likely to happen.  To protect themselves against feared consequences, they engage in safety behaviors.  They come to believe that only their safety behaviors have kept them alive. Hence, safety behaviors allow a person to maintain overly negative cognitions. 2. Perceived Control  A lack of control over the environment can promote anxiety. 3. Attention to Threat  People with anxiety disorders have been found to pay more attention to negative cues in their environment than do people without anxiety disorders Comorbidity   By far the most common additional diagnosis for all anxiety disorders was major depression, which occurred in 50% of the cases over the course of the patient’s life. People with thyroid disease, respiratory disease, gastrointestinal disease, arthritis, migraine headaches, and allergic conditions are likely to have an anxiety disorder but are not any more likely to have another psychological disorder. Suicide and Anxiety Disorder  Having any anxiety or related disorder uniquely increases the chances of having thoughts about suicide (suicidal ideation) or making suicidal attempts but the relationship is strongest with panic disorder and posttraumatic stress disorder DSM IV TR and DSM 5 Generalized Anxiety Disorder    People with GAD are persistently worried, often about minor things. Worry - refers to the cognitive tendency to chew on a problem and to be unable to let go of it. The worries of people with GAD are similar in focus to those of most people: they worry about relationships, health, finances, and daily hassles but they worry more about these issues, and these persistent worries interfere with daily life. GAD Common among Elders (45 and above)  Women (2/3)  Men in South Africa  Etiology of GAD    worry is actually reinforcing because it distracts people from more powerful negative emotions and images. worry does not involve powerful visual images and does not produce the physiological changes that usually accompany emotion many people with GAD report past traumas involving death, injury, or illnes, which they might have been avoiding.  Statistics › › › › 3.1% (year) 5.7% (lifetime) Similar rates worldwide Insidious onset  Early adulthood › Chronic course Inherited tendency to become anxious  “Neuroticism”  Less responsiveness  › “Autonomic restrictors” Threat sensitivity  Frontal lobe activation  › Left vs. right Treatment  Pharmacological › Benzodiazepines  Risks (inattention) versus benefits › Antidepressants  Psychological › Cognitive-behavioral treatments  Exposure to worry process  Confronting anxiety-provoking images  Coping strategies › Acceptance › Meditation › Similar benefits › Better long-term results Panic Disorder and agoraphobia  To meet criteria for panic disorder, a person must experience an unexpected panic attack and develop substantial anxiety over the possibility of having another attack or about the implications of the attack or its consequences. › In other words, the person must think that each attack is a sign of impending death or incapacitation. Etiology of Panic Disorder   Neurobiological Factors Hyperactive Locus Ceruleus › The locus ceruleus is the major source of the neurotransmitter norepinephrine in the brain, and norepinephrine plays a major role in triggering sympathetic nervous system activity. › In humans, drugs that increase activity in the locus ceruleus can trigger panic attacks, and drugs that decrease activity in the locus ceruleus, and some antidepressants, decrease the risk of panic attacks.   Behavioral Factors: Classical Conditioning Classical conditioning of panic attacks in response to bodily sensations has been called interoceptive conditioning: a person experiences somatic signs of anxiety, which are followed by the person’s first panic attack; panic attacks then become a conditioned response to the somatic changes Interoceptive Conditioning Cognitive Factors in Panic Disorder  Catastrophic misinterpretations of somatic changes › According to this model, panic attacks develop when a person interprets bodily sensations as signs of impending doom › The person may interpret the sensation of an increase in heart rate as a sign of an impending heart attack. Obviously, such thoughts will increase the person’s anxiety, which produces more physical sensations, creating a vicious circle. Psychological Treatment for Panic Disorder A psychodynamic treatment for panic disorder has been developed. The treatment involves 24 sessions focused on identifying the emotions and meanings surrounding panic attacks.  Therapists help clients gain insight into areas believed to relate to the panic attacks, such as issues involving separation, anger, and autonomy.  Panic control therapy (PCT) is based on the tendency of people with panic disorder to overreact to the bodily sensations discussed.  In PCT, the therapist uses exposure techniques—that is, he or she persuades the client to deliberately elicit the sensations associated with panic.     For example, a person whose panic attacks begin with hyperventilation is asked to breathe rapidly for 3 minutes, or someone whose panic attacks are associated with dizziness might be requested to spin in a chair for several minutes. When sensations such as dizziness, dry mouth, lightheadedness, increased heart rate, and other signs of panic begin, the person experiences them under safe conditions; in addition, the person practices coping tactics for dealing with somatic symptoms (e.g., breathing from the diaphragm to avoid hyperventilation The person’s ability to create these physical sensations and then cope with them makes them seem more predictable and less frightening Agoraphobia   Agoraphobia (from the Greek agora, meaning “marketplace”) is defined by anxiety about situations in which it would be embarrassing or difficult to escape if anxiety symptoms occurred. Commonly feared situations include crowds and crowded places such as grocery stores, malls, and churches. Sometimes the situations are those that are difficult to escape from, such as trains, bridges, or long road trips. In the DSM-IV-TR, agoraphobia is coded as a subtype of panic disorder.  DSM-5 instead includes agoraphobia as a separate diagnosis.  Agoraphobia Agoraphobia  Clinical description › Avoidance can be persistent › Use and abuse of drugs and alcohol › Interoceptive avoidance Etiology of Agoraphobia  Cognitive Factors: The Fear-of-Fear Hypothesis › Agoraphobia is driven by negative thoughts about the consequences of experiencing anxiety in public. › They seem to have catastrophic beliefs that their anxiety will lead to socially unacceptable consequences. Statistics for Agoraphobia and Panic Disorder  Statistics › › › › 2.7% (year) 4.7% (life) Female: male = 2:1 Acute onset, ages 20-24 Psychological Treatment of Agoraphobia    Cognitive behavioral treatments of agoraphobia also focus on exposure—specifically, on systematic exposure to feared situations. Exposure treatment of agoraphobia is more effective when the partner is involved. The partner without agoraphobia is encouraged to stop catering to the partner’s avoidance of leaving home. There is also good support for self-guided treatment, in which those with agoraphobia use a manual to conduct their own step-by-step exposure treatment Cultural bound syndromes associated with panic disorder    Susto - a fright disorder in Latin America that is characterized by sweating, increased heart rate, and insomnia but not by reports of anxiety or fear, even though a severe fright is the cause. Ataque de nervios – An anxiety-related, culturally defined syndrome prominent among Hispanic Americans, particularly those from the Caribbean Kyol goeu – ‘wind overload’ – among Khmer (Cambodian) panic attacks are associated with orthostatic dizziness (dizziness from standing up quickly) and “sore neck.” Nocturnal Panic › 60% with panic disorder experience nocturnal attacks  non-REM sleep  Delta wave › Caused by deep relaxation,  Sensations of “letting go” › Sleep terrors › Isolated sleep paralysis Specific Phobia  Clinical description › Extreme and irrational fear of a specific object or situation › Significant impairment › Recognizes fears as unreasonable › Avoidance Types of Specific Phobia  Blood-injection-injury phobia › › › ›  Decreased heart rate and blood pressure Fainting Inherited vasovagal response Onset = ~ 9 Situational phobia › Fear of specific situations  Transportation, small places › No uncued panic attacks › Onset = early to mid 20s  Natural environment phobia › › › ›  Heights, storms, water May cluster together Associated with real dangers Onset = ~7 Animal phobia › Dogs, snakes, mice, insects › May be associated with real dangers › Onset = ~7 Object of Fear Phobia Anything new Neophobia Asymmetrical things Asymmetriphobia Books Bibliophobia Children Pedophobia Dancing Chorophobia Englishness Anglophobia Garlic Alliumphobia Peanut butter sticking to the roof of the mouth Arachibutyrophobia Technology Technophobia Mice Musophobia Pseudoscientific Terms Hellenophobia Object of Fear Phobia Dark Nyctophobia High places Acrophobia Open places Algophobia Spiders Aracnophobia Thunder, lightning, storms Astraphobia Cold Cheimophobia Closed spaces Claustrophobia Drinking Dipsophobia Home Ecophobia/Oikophobia Electricity Electrophobia Blushing Erythrophobia Marriage Gamophobia Blood Hematophobia Thoughts Ideaphobia Crowd Ochlophobia Object of Fear Phobia Disease Pathophobia Phobia Phobophobia Eating Sitophobia Buried Alive Taphophobia Heat Thermophobia Strangers Xenophobia Dirt Rypophobia Clowns Coulrophobia Erotic Love Erotophobia Good News Euphobia 13 Triskaidekaphobia Rejection Kakorrhaphiophobia Specific Phobia  Statistics › › › › 12.5% (life); 8.7% (year) Female : Male = 4:1 Chronic course Onset = ~ 7 Etiology of Specific Phobia 1. Behavioral Factors: Conditioning of Specific Phobias  Behavioral theory suggests that phobias could be conditioned by direct trauma, modeling, or verbal instruction.  Phobias are seen as a conditioned response that develops after a threatening experience and is sustained by avoidant behavior. Little Albert’s Case  Watson and his graduate student Rosalie Rayner published a case report in 1920 in which they demonstrated creating an intense fear of a rat (a phobia) in an infant, Little Albert, using classical conditioning. Little Albert was initially unafraid of the rat, but after repeatedly seeing the rat while a very loud noise was made, he began to cry when he saw the rat. 2. Prepared Learning  Our fear circuit may have been “prepared” by evolution to learn fear of certain stimuli.  As researchers have tested this model, some have discovered that people can be initially conditioned to fear many different types of stimuli. 3. Development of anxiety about the possibility that the event will happen again. 4. Social and cultural factors  Social and cultural factors are strong determinants of who develops and reports a specific phobia. In most societies, it is almost unacceptable for males to express fears and phobias. Thus, the overwhelming majority of reported specific phobias occur in women (Arrindell et al., 2003b; LeBeau et al., 2010). Treatment  Cognitive-behavior therapies › Exposure  Graduated  Structured › Relaxation Psychological Treatment of Specific Phobia   In vivo (real-life) exposure - As applied in psychology, taking place in a real-life situation. Systematic Desensitization - A major behavior therapy procedure that has a fearful person, while deeply relaxed, imagine a series of progressively more fearsome situations, such that fear is dispelled as a response incompatible with relaxation; useful for treating psychological problems in which anxiety is the principal difficulty. Separation Anxiety Disorder  Clinical Description › Characterized by children’s unrealistic and persistent worry that something will happen to their parents or other important people in their life or that something will happen to the children themselves that will separate them from their parents (for example, they will be lost, kidnapped, killed, or hurt in an accident) › 4.1% meet criteria for children, 6.6% for adults Social Anxiety Disorder  Clinical description › › › › › Extreme and irrational fear/shyness Social/performance situations Significant impairment Avoidance or distressed endurance Generalized subtype Social Anxiety Disorder   SAD is a persistent, unrealistically intense fear of social situations that might involve being scrutinized by, or even just exposed to, unfamiliar people. Although this disorder is labeled social phobia in the DSM-IV-TR, the term social anxiety disorder in the DSM-5 because the problems caused by it tend to be much more pervasive and to interfere much more with normal activities than the problems caused by other phobias.   People with social anxiety disorder usually try to avoid situations in which they might be evaluated, show signs of anxiety, or behave in embarrassing ways. The most common fears include public speaking, speaking up in meetings or classes, meeting new people, and talking to people in authority (Ruscio et al., 2008). Although this may sound like shyness, people with social anxiety disorder avoid more social situations, feel more discomfort socially, and experience these symptoms for longer periods of their life than people who are shy (Turner, Beidel, & Townsley, 1990).  Statistics › 12.1% (life); 6.8% (year) › Female : Male = 1:1 › Onset = adolescence  Peak age of 13 › Young (18–29 years), undereducated, single, and of low socioeconomic class, 13.6% › Over 60, 6.6% Cultural Syndrome Associated with Social Anxiety Disorder  Japan—taijin kyofusho › Fear of offending others › Symptoms › Female : Male = 2:3 Etiology of Social Anxiety Disorder Behavioral Factors: Conditioning of Social Anxiety Disorder  Behavioral perspectives on the causes of social anxiety disorder are similar to those on specific phobias, insofar as they are based on a two-factor conditioning model.  A person could have a negative social experience (directly, through modeling, or through verbal instruction) and become classically conditioned to fear similar situations, which the person then avoids. Through operant conditioning, this avoidance behavior is maintained because it reduces the fear the person experiences. Cognitive Factors:  Too Much Focus on Negative Self-Evaluations › People with social anxiety disorders appear to have unrealistically negative beliefs about the consequences of their social behaviors. › They attend more to how they are doing in social situations and their own internal sensations than other people do.  Too much attention to internal cues rather than external (social) cues. › people with social anxiety disorder appear to spend more time than other people do monitoring for signs of their own anxiety. Psychological Treatment of Social Anxiety Disorder   Exposure also appears to be an effective treatment for social anxiety disorder; such treatments often begin with role playing or practicing with the therapist or in small therapy groups before undergoing exposure in more public social situations. Social skills training, in which a therapist might provide extensive modeling of behavior, can help people with social anxiety disorder who may not know what to do or say in social situations. Selective Mutism (SM)  Clinical description › Rare childhood disorder characterized by a lack of speech › Must occur for more than one month and cannot be limited to the first month of school › Comorbidity with SAD › Treatment  Cognitive-Behavioral like the treatment for social anxiety best