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CHAPTER 2 ANXIETY DISORDERS. AIMS AND OBJECTIVES. Describe the nature of fear and anxiety disorders Discuss the range of anxiety disorders Provide information about diagnosis, epidemiology, and treatment for each disorder. THE NATURE OF FEAR AND ANXIETY.

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CHAPTER 2ANXIETY DISORDERS


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AIMS AND OBJECTIVES

Describe the nature of fear and anxiety disorders

Discuss the range of anxiety disorders

Provide information about diagnosis, epidemiology, and treatment for each disorder


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THE NATURE OF FEAR AND ANXIETY

Flight or fight response (Cannon, 1929)

Body reacts to danger by releasing adrenaline through blood stream Related behaviours include:

Freezing – to appraise danger

Flight – escape

Fight – if danger is unavoidable

“True alarms” (direct danger) versus “false alarms” (no immediate threat)

False alarms are the hallmark of anxiety disorders


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THE NATURE OF FEAR AND ANXIETY

Triple vulnerability model (Barlow, 2002)


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THE NATURE OF FEAR AND ANXIETY

Fear can be acquired in several ways:

Conditioning – pairing of a conditioned stimulus with an aversive event

Informational pathway

Vicarious acquisition

These all contribute to the expectation that an aversive outcome is probable


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THE NATURE OF FEAR AND ANXIETY

US (bitten by dog)

UR (fear)

pair with

CR (fear)

CS (dog)

Conditioning


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SPECIFIC PHOBIA

DSM-IV-TR Diagnosis includes:

Marked fear that is excessive or unreasonable

Cued by presence or anticipation of phobic object/situation

Causes interference/impairment in life or marked distress

Four subtypes:

Animal

Natural Environment (i.e., storms, heights, water)

Blood-Injection – Injury (i.e., blood, operation scenes, injections, fainting common)

Situational (i.e., planes, elevators)

Epidemiology

Lifetime prevalence 4-8%, female to male ratio 2:1


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SPECIFIC PHOBIA

Aetiology

Phobias may be acquired by classical conditioning

E.g., A neutral CS (white rat) is paired with a US (loud noise) that produces fear

Problems with classical conditioning account

Many people with specific phobias do not remember an initial traumatic event (Menzies & Clark, 1993)

Preparedness: Some stimulus can be conditioned more easily (Seligman, 1971)


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SPECIFIC PHOBIA

Treatment

Exposure-based treatments are the most effective (Choy et al., 2007)

In vivo exposure – facing phobic stimulus in real life

Imaginal or virtual exposure

Exposures may work through extinction

Fear decreases over repeated presentations of the CS in the absence of the US

They may also work by challenging expectations of danger, increasing self-efficacy, and increasing perception of control


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PANIC DISORDER AND AGORAPHOBIA

DSM-IV-TR Diagnosis for Panic Disorder includes:

Recurrent, unexpected panic attacks

At least one attack has been followed by >1 month of:

Persistent concern about having additional attacks

Worry about the implications/consequences of the attack, e.g., losing control, dying

A significant change in behavior

Agoraphobia – anxiety about being in places from which escape might be difficult or embarrassing in the event of having a panic attack

Panic disorder can occur with or without agoraphobia

Lifetime prevalence of panic disorder = 5%


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PANIC DISORDER AND AGORAPHOBIA

Aetiology

Generalised psychological vulnerability

High anxiety sensitivity – fear of sensations

Specific psychological vulnerability

Catastrophic misinterpretation of physical sensations

Treatment

Pharmacological – SSRIs, benzodiazepines

Psychological – Cognitive behaviour therapy

Address avoidance of internal and external cues using behavioural and cognitive techniques


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SOCIAL PHOBIA

DSM-IV-TR Diagnosis includes:

Marked, persistent fear of social situations

Person recognises the fear as unreasonable

Feared social situations are avoided

Interference or distress

Epidemiology

Lifetime prevalence 10-16%, female to male ratio 1:1

Chronic course

Delay in seeking treatment


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SOCIAL PHOBIA

Aetiology

Genetic vulnerability: 2-3x increased risk among relatives

Psychosocial factors

Excessive parental criticism

Cognitive dysfunctions

Hypersensitivity to criticism

Treatment

Psychological– Cognitive behaviour therapy

Cognitive restructuring of negative thoughts (e.g., I am boring)

Exposure to feared social situations


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OBSESSIVE COMPULSIVE DISORDER (OCD)

DSM-IV-TR Diagnosis includes:

Obsessions – recurrent thoughts, images or impulses experienced as inappropriate or distressing

Compulsions – repetitive behaviours that the person feels compelled to perform in response to obsession or according to rigid rules

Person recognizes that obsessions or compulsions are excessive/irrational

Marked distress/interference, time-consuming (>1 hour/day)

Several subtypes:

Washing

Checking

Hoarding

Obsessional slowness

Epidemiology

Lifetime prevalence 2-3%

Often chronic if untreated


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OBSESSIVE COMPULSIVE DISORDER (OCD)

Aetiology

Neuropsychological model (Baxter et al., 2000)

Failure of inhibitory pathways in the basal ganglia to stop “behavioural macros” in response to internal/external stimuli

Cognitive model

OCD thoughts not different from those in general population

Difference is how OCD sufferers interpret the thoughts

Treatment

Psychological– Cognitive behaviour therapy

Exposure and response prevention

Cognitive restructuring

Pharmacological therapy


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POSTTRAUMATIC STRESS DISORDER (PTSD)

DSM-IV-TR Diagnosis includes:

Exposure to a traumatic event

Re-experiencing symptoms

Avoidance symptoms

Arousal symptoms

Symptoms present for at least one month

Epidemiology

Despite high frequency of exposure to traumatic stressors, relatively few develop PTSD (4%)

Research attempts to identify who is at risk for developing PTSD after exposure to a trauma


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POSTTRAUMATIC STRESS DISORDER (PTSD)

Aetiology

Cognitive models

Focus on individual’s maladaptive appraisals of the event, his/her response to the event, and the environment

Learning accounts

Emphasis on classical conditioning

Biological accounts

Propose that extreme sympathetic arousal at the time of trauma results in strong fear conditioning

Across accounts, avoidance of trauma reminders maintains PTSD

Treatment

Pharmacological therapy

Cognitive-behavioural therapy

Psychoeducation, anxiety management, cognitive restructuring, imaginal / in vivo exposure, and relapse prevention

Prevention of PTSD – applying CBT to survivors after trauma exposure


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GENERALISED ANXIETY DISORDER (GAD)

DSM-IV-TR Diagnosis includes:

Excessive worry about a number of events or activities

E.g, health, finances, relationships

Worries are difficult to control

Present on most days for at least 6 months

Associated symptoms such as irritability, fatigue, difficulty concentrating, and muscle tension

Epidemiology

Commonly experienced, lifetime prevalence of 5%

Early age of onset and chronic course


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GENERALISED ANXIETY DISORDER (GAD)

Aetiology

Moderate genetic predisposition

Cognitive models

Information processing model – biased toward threat

Metacognitive model – positive and negative meta-beliefs about worry

Avoidance theory– worry to avoid imagery and underlying concerns

Intolerance of uncertainty model – need to control

Treatment

Pharmacological therapy

Cognitive-behavioural therapy

Cognitive restructuring, relaxation, behavioural experiments

Some symptom improvement, yet only 50% of sufferers end up in non-clinical range


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SUMMARY

Nature of Fear and Anxiety

Flight or fight response

Triple vulnerability model

Acquisition of expectation of fear

Diagnosis, Epidemiology, Aetiology, and Treatment of:

Specific Phobia

Panic Disorder and Agoraphobia

Social Phobia

Obsessive-Compulsive Disorder

Posttraumatic Stress Disorder

Generalised Anxiety Disorder


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