Anxiety Disorders

Anxiety Disorders

Anxiety vs. Fear • Anxiety • Apprehension about a future threat • Fear • Response to an immediate threat • Both involve physiological arousal • Sympathetic nervous system • Both can be adaptive • Fear triggers “flight or fight” • May save life • Anxiety increases preparedness • Moderate levels improve performance

Persamaan Cemas dan Takut (Rahman, 1998) Anticipation of danger or discomfort Tense apprehensiveness Elevated arousal Negative affect Uneasiness Future oriented Accompanied by bodily sensations 3

Perbedaan Cemas dan Takut (Rahman, 1998) Anxiety Source of threat is elusive Uncertain connection between anxiety and threat Prolonged Pervasive uneasiness Can be objectless Uncertain onset Persistent Uncertain offset Without clear borders Threat seldom imminent Heightened vigilance Bodily sensation of vigilance Puzzling quality Fear Specific focus of threat Understandable connection between threat and fear Usually episodic Circumscribed tension Identifiable threat Provoked by threat cues Declines with removal of threat Offset is detectable Circumscribed area of threat Imminent threat Quality of emergency Bodily sensation of an emergency Rational quality 4

Anxiety Disorders • DSM-IV-TR • Specific and social phobias • Panic disorder and agoraphobia • Generalized anxiety disorder • Obsessive compulsive disorder • Posttraumatic stress disorder • Most common psychiatric disorders • 28% report anxiety symptoms (Kessler et al., 2005) • Most common are phobias

Table 5.1 Summary of Major Anxiety Disorders

Phobias • Disruptive fear of a particular object or situation • Fear out of proportion to actual threat • Awareness that fear is excessive • Must be severe enough to cause distress or interfere with job or social life • Avoidance • Two types: • Specific • Social

Unwarranted, excessive fear of specific object or situation Snakes, blood, flying, spiders, etc. How likely are you to be bitten by a spider? Most specific phobias cluster around a few feared objects and situations (Table 5.3) Trigger or feared object is avoided or endured with intense anxiety High comorbidity of specific phobias Specific Phobia

Social Phobia • Persistent, intense fear of social situations • Fear of negative evaluation or scrutiny • More intense and extensive than shyness • More appropriate diagnostic label? • Social anxiety disorder • Exposure to trigger leads to anxiety about being humiliated or embarrassed socially. • Onset often adolescence • Diagnosed as either generalized or specific • 33% also diagnosed with Avoidant Personality Disorder • Overlap in genetic vulnerability for both disorders

Panic Disorder • Frequent panic attacks unrelated to specific situations • Panic attack • Sudden, intense episode of apprehension, terror, feelings of impending doom • Symptoms reach peak intensity within 10 minutes • Accompanied by at least 4 other symptoms: • Sweating, nausea, labored breathing, dizziness, heart palpitations, upset stomach, lightheadedness, etc. • Other symptoms may include: • Depersonalization • Derealization • Fear of going crazy, losing control, or dying

Panic Disorder • Uncued attacks • Occur unexpectedly without warning • Panic disorder diagnosis requires recurrent uncued attacks. • Cued attacks • Triggered by specific situations (e.g., tunnel) • More likely a phobia • Panic Disorder with Agoraphobia • Avoidance of situations in which escape would be difficult or embarrassing • Panic disorder with agoraphobia tends to be more chronic .

Panic Disorder • Often begins in adolescence • 25% unemployed for more than 5 years because of symptoms (Leon et al., 1995) • Prognosis worse when agoraphobia is present

Generalized Anxiety Disorder (GAD) • Involves chronic, excessive, uncontrollable worry • Lasts at least 6 months • Interferes with daily life • Other symptoms: • Restlessness, poor concentration, irritability, muscle tension, tires easily, sleep disturbance • Common worries: • Relationships, health, finances, daily hassles • Often begins in adolescence or earlier • I’ve always been this way

Obsessive-Compulsive Disorder (OCD) • Obsessions • Intrusive, persistent, and uncontrollable thoughts or urges • Experienced as irrational • Most common: • Contamination, sexual & aggressive impulses, body problems • Compulsions • Impulse to repeat certain behaviors or mental acts to avoid distress • e.g., cleaning, checking, hoarding, repeating a word, counting • Extremely difficult to resist the impulse • May involve elaborate behavioral rituals

Obsessive-Compulsive Disorder (OCD) • Develops either before age 10 or during late adolescence/early adulthood • Men • Early onset more common • Women • Cleaning compulsions and later onset more common • OCD often chronic

Post Traumatic Stress Disorder (PTSD) • Extreme response to severe stressor • Anxiety, avoidance of stimuli associated with trauma, emotional numbing • Exposure to a traumatic event that involves actual or threatened death or injury • e.g., war, rape, natural disaster • Trauma leads to intense fear or helplessness • Symptoms present for more than a month • Women and PTSD • Rape most common type of trauma (Creamer et al., 2001)

Post Traumatic Stress Disorder (PTSD) • Three categories of symptoms : • Re-experiencing the traumatic event • Nightmares, intrusive thoughts, or images • Avoidance of stimuli • e.g., Refuse to walk on street where rape occurred • Numbing • Decreased interest in others • Distant or estranged from others • Unable to experience positive emotions • Increased arousal • Insomnia, irritability, hypervigilance, exaggerated startle response • Tends to be chronic (Perkonigg et al., 2005)

Acute Stress Disorder (ASD) • Symptoms similar to PTSD • Duration varies • Short term reaction • Symptoms occur between 2 days and 1 month after trauma • As many as 90% of rape victims experience ASD (Rothbaum et al., 1992) • More than 2/3 of those with ASD develop PTSD within 2 years (Harvey & Bryant, 2002)

Comorbidity • ¾ of those with anxiety disorder meet criteria for another disorder • 60% meet criteria for major depression (Brown et al., 2001) • Other disorders commonly comorbid with anxiety: • Substance abuse • Personality disorders • Avoidant • Dependent • Histrionic • Medical disorders e.g., coronary heart disease

Gender & Sociocultural Factors • Women are 2x as likely as men to have anxiety disorder except for OCD • Possible explanations • Women may be more likely to report symptoms • Women more likely to experience childhood sexual abuse • Women show more biological stress reactivity • Sociocultural factors • Focus of anxiety varies • Taijinkyofusho • Japanese fear of offending or embarrassing others • Kayak-angst • Inuit disorder in seal hunters at sea similar to panic • Ratio of somatic to psychological symptoms appears similar across cultures (Kirmayer, 2001)

Conditioning Mowrer’s two-factor model Pairing of stimulus with aversive UCS leads to fear (Classical Conditioning) Avoidance maintained though negative reinforcement (Operant Conditioning) Etiology of Specific Phobias

Etiology of Specific Phobias • Problems with two-factor model • Many people never experience aversive interaction with phobic object (see table 5.6) • People with phobias tend to fear only certain types of objects (prepared learning) • Snakes, insects, blood, heights, etc. • Even phobias linked to modeling influenced by prepared learning • Monkeys acquired fear after watching another monkey exhibit fear to snake but not flower (Cook & Mineka, 1989)

Etiology of Social Phobia • Two factor model • Avoidance or safety behaviors • Avoid eye contact, appear aloof, stand apart from others in social settings • Cognitive factors • Negative self evaluation • Harsh, punitive self-judgment • Fear of negative evaluation by others • Expect others to dislike them • Excessive attention to internal cues • e.g., heart rate

Neurobiological factors Locus ceruleus Major source of norepinephrine A trigger for nervous system activity Multiple drugs can induce panic attacks Typically only in those who are overly concerned about bodily changes Etiology of Panic

Interoceptive conditioning Classical conditioning of panic in response to bodily sensations People with panic disorder sustain classically conditioned fears longer (Michael et al., 2007) Etiology of Panic

Cognitive factors Lack of perceived control can trigger panic Fear of bodily changes Interpreted as impending doom I must be having a heart attack! Beliefs increase anxiety and arousal Creates vicious cycle Etiology of Panic

Etiology of Agoraphobia • Fear-of-fear hypothesis (Goldstein & Chambless, 1978) • Expectations about the catastrophic consequences of having a public panic attack. • What will people think of me?!?!

Etiology of GAD • GABA system deficits • Borkovec’s cognitive model: • Worry reinforcing because it distracts from negative emotions and images • Allows avoidance of more disturbing emotions • e.g., distress of previous trauma • Avoidance prevents extinction of underlying anxiety • Individuals with GAD less able to identify their own negative feelings (Mennin et al., 2002)

OCD symptoms common in certain neurological disorders Huntington’s chorea Hyperactive regions of the brain: Orbitofrontal cortex Caudate nucleus Anterior cingulate Loss of neuronal function and underlying biochemical abnormality (Yücel et al., 2007) Etiology of OCD: Neurobiological Factors

Etiology of OCD: Behavioral & Cognitive Factors • Operant reinforcement • Compulsions negatively reinforced by the reduction of anxiety • Cognitive factors • Lack of a satiety signal • Yadasentience • Subjective feeling of completion • Knowing that you have thought enough or cleaned enough • Individuals with OCD have a yadasentience deficit • Attempts to suppress intrusive thoughts • Trying to suppress thoughts may make matters worse

Etiology of PTSD • Severity and type of trauma • Neurobiological • Smaller hippocampal volume linked to PTSD • Disruption of verbal vs. nonverbal memory • Supersensitivity to cortisol • Behavioral • Two factor model • Psychological • Perception of control • Avoidance coping, dissociation, memory suppression • Intelligence and ability to grow from the experience enhance coping

Common Aspects of Psychological Treatment • Psychological treatments emphasize Exposure • Face the situation or object that triggers anxiety • Should include as many features of the trigger as possible • Should be conducted in as many settings as possible • Systematic desensitization • Relaxation plus imaginal exposure

Common Aspects of Psychological Treatment • Cognitive approaches • Increase belief in ability to cope with the anxiety trigger • Challenge expectations about negative outcomes

Medications • Anxiolytics • Drugs that reduce anxiety • Two common types of medications used to treat anxiety • Benzodiazepenes • Valium, Xanax • Antidepressants • Tricyclics,Selective Serotonin Reuptake Inhibitors (SSRIs), and Serotonin Reuptake Inhibitors (SRIs)

Medications • Demonstrated effectiveness as compared to placebo • Clomipramine for OCD • Medication does not seem to help hoarding • Beta blockers commonly prescribed for social phobia although no demonstrated effectiveness • Side effects • Withdrawal from benzodiazepenes • Weight gain, nervousness, high blood pressure from SSRIs • Relapse common after medication discontinuation

Anxiety Disorders