Anxiety Disorders

1. Anxiety Disorders ”Neuroses” Experienced Anxiety Anxiety Related Disorders Cato Grønnerød PSY2600

2. Brain Circuits in Anxiety Responses 1. Thalamus receives stimulus and sends to both amygdala and cortex 4. More considered response based on cortical processing Sensory input 2. Amygdala registers danger 3. Amygdala triggers fast response

3. Brain Circuits in Anxiety Responses • Behavioral Inhibition System (BIS) • Gray (1982, 1985), L&B Ch.7, pp.201-206 • Locus coeruleus, part of the limbic system, prefrontal cortex • Responsive to cues to punishment, frustration, uncertainty • Motivates ceasing, inhibiting, or avoidance behavior • Inhibits behavior during threat, produces anxiety reactions

4. Sources of Anxiety • Freud • Conflict between opposing desires • Conflict between desires and restrictions • Rogers • Development and fulfillment of the self is blocked • Kelly • We cannot assign meaning to events and experiences

5. Anxiety as a Disorder? • A normal human response to objects, situations or events that are threatening • Different from fear due to its cognitive component • Can be helpful and adaptive • Becomes a disorder when it is • Unrealistic • Out of proportion • Persistent • Significantly interfering with life functioning

6. Anxiety Disorders • Highly treatable yet also resistant to extinction • Often begins early in life • Reported more by women than men • Reported more in Western countries • Often comorbid both with other anxiety diagnoses and with other disorder groups • Mood disorders • Psychoses

7. Anxiety Disorders • Phobias • Specific phobia • Social phobia • Panic Disorder • Agoraphobia • Generalized Anxiety Disorder (GAD) • Obsessive-Compulsive Disorder (OCD) • Post-Traumatic Stress Disorder (PTSD)

8. Anxiety Disorders II • Somatoform disorders • Conversion • Somatization • Hypochondriasis • Body Dysmorphic Disorder • Dissociative disorders • Dissociative Amnesia • Dissociative Fugue • Dissociative Identity Disorder • Depersonalization

9. Specific Phobias • Animals • Cats, dogs, spiders, snakes, birds • Natural • Heights, dirt, darkness, water • Situational • Bridges, elevators, planes, enclosed spaces • Body • Blood, injections • Choking, vomiting, contracting illnesses

10. Specific Phobias • Selective, automatic, persistent and out of proportion • Includes cognition that leads to behavioural response, whether or not the threat is present • May be genetically, neurologically or experientially based • Maintained through the processes of classical and operant conditioning

11. Social Phobia • A more pervasive, highly cognitive type of phobia • Distinguishing feature is the fear of doing something in front of others • Fear of one’s own behaviour causing negative attention from others • Humiliating, embarrassing, panic attack • May be situation or context (e.g. performance versus interaction anxiety) specific

12. Aetiology of Phobias • Biology • Heritable: 31% of family members • Abnormalities in the serotonine and dopamine pathways • Low leves of GABA • Behavioral • Conditioned response • Prepared classical conditioning • Resist extinction

13. Treatment of Phobia • Behavioural and/or cognitive techniques • Systematic desensitization • With or without relaxation training • Exposure (flooding) • With or without relaxation training • Modelling • Cognitive restructuring, skills training, gradual exposure • Applied tension • Medication (mainly social phobia) • MOAIs, SSRIs

14. Panic Disorder • Panic attack • Emotional • Overwhelmed with intense apprehension, terror or depersonalization • Physical • Emergency reaction, shortness of breath, heart palpitations, sweating • Cognitive • Feels like a heart attack, going crazy, dying • Begins abruptly, usually peaks within ten minutes, then subsides

15. Panic Disorder • Two major types: with or without agoraphobia • Pattern of recurring panic attacks • Main fear is of losing control • Consequence = dying, going crazy, embarrassment, not being able to get help • The fear of having a panic attack becomes a problem in itself • Agoraphobia: fear of open spaces, places of assembly, crowds etc.

16. Aetiology of Panic Disorder • Debate about the extent to which Panic Disorder is biological versus psychological • Genetic and medication studies support biological view • Can be induced in laboratories • Moderate heritability • Medication is quite effective • Traceable to specific brain areas

17. Treatment of Panic Disorder • Cognitive approach • Catastrophic misinterpretation of bodily sensations • Misinterprets signs of anxiety as impending disaster • Basis for highly effective treatment • Psychological approach can subsume all biological arguments

18. Generalised Anxiety Disorder (GAD) • Characterised by persistent and global worry • Worry about “everything”, “worry about worry” • Distinguished from normal worry by severity, interference, irrationality • Chronic BIS activation

19. Generalised Anxiety Disorder (GAD) • Emotional • Jittery, restless, tense, vigilant • Cognitive • Expecting something awfull to happen, but not sure what • Physical • Chronic muscle tension • Behavior • Looking for relief

20. Treatment of GAD • Medication • Benzodiazepines • SSRIs used more for GAD than other anxiety disorders • Behavioural techniques • Difficult to implement due to global nature of GAD • Cognitive therapy • Apparently most useful but still shows limited success

21. Obsessive Compulsive Disorder (OCD) • Classified as anxiety disorder, but with unique presentation • Characterised by obsessions and compulsions (in most cases) • Compulsions may be physical or mental • Severity • Frequency • Capacity to resist • Interference with normal functioning • High comorbidity with depression

22. Obsessive Compulsive Disorder (OCD) • Obsessions • Thoughts, images, impulses that invade consciousnes • Impulses to be violent, sexual impulses, blasphemic ideas, feeling of being dirty • Compulsions • Rigid rituals or mental acts aimed at removing the obsessive intrusions • Checking appliances, washing, avioding objects, locked in doubt

23. Aetiology of OCD • Psychoanalytical theories • Defense against anxiety produced by unconscious or unacceptable thoughts • Primary process content • Displacement • Cognitive theories • Assumes that we all experience obsessional thoughts • OCD differs in that the obsessional thoughts cannot be kept out of consciousness

24. Aetiology of OCD • Biological theories • OCD can develop after brain injury, trauma or acute disease • OCD patients show poor fine motor coordination • Dysfunction in filtering of mental content • Evolutionary basis? • SSRI alleviate symptoms in OCD

25. Treatment of OCD • Medical • Particularly high doses of SSRIs • Cognitive-behavioural therapy • Exposure and response prevention • Thought-stopping not generally effective alone • Therapies are effect specific, does not help depression, adjustment and related problems • Psychoanalysis

26. Post Traumatic Stress Disorder (PTSD) • Main diagnostic criteria • Witness or experience of an event that involved actual or threatened death or injury to self or others, and • Relives the event in some way • Numbness, avoidance, detachment • Hyperarousal or mood instability • Unable to remember an important part of the trauma • Usually persisting for at least three months

27. Post Traumatic Stress Disorder (PTSD) • WWI: Shell shock • Inclusion in DSM-III due to awareness of symptoms in Vietnam veterans • Severity most determined by perceived threat • Delayed onset and lack of insight • Past experience may increase vulnerability • Past trauma, psychological issues, personality • No good data to suggest some more likely to develop than others, although prognoses may differ

28. Types and Aetiology of PTSD • Acute versus Chronic • < 3 months versus > 3 months • May be caused by personal encounters, war, natural event/disaster, extreme events, rape • May develop slowly or rapidly, acutely or after a long time • Can be difficult to recognise or diagnose

29. Aetiology of PTSD • Women more likely than men to be diagnosed with PTSD • Cultural factors • PTSD fit with traditional feminine roles? • Biological factors • Shrinking of the hippocampus • Lower cortisol levels after accident increased risk for PTSD

30. Aetiology of PTSD • Trauma experience • Severity, duration, proximity • Social support • Shattered assumptions • Invulnerability, meaningfulness, justice • Distress, anxiety • Neuroticism, maltreatment • Coping styles • Self-destructive, avoidant

31. Treatment of PTSD • Medication • Treats the symptoms, but minimally effective • Exposure Therapy • Critical Incident Stress Debriefing • Contraindicated? • Supportive psychotherapy • “Opening up”

32. Treatment of PTSD • Eye Movement Desensitisation and Reprogramming (EMDR) • Rapid saccadic eye movements coupled with exposure and positive thought • Huge movement, also non-psychologist doing treatment • Has attracted much criticism due to its secrecy and lack of controlled studies • Mechanisms still not known

33. Complex PTSD • Judith Herman: “Trauma & Recovery” (1992) • Argument for a new PTSD classification • Current criteria and understanding do not ‘fit’ with those in situations of chronic, ongoing abuse or subjugation • Symptoms are entrenched, prognosis tends to be poorer • Often present as other ‘disorders’ • Personality, mood, dissociative, other anxiety

34. Complex PTSD • A history of subjection to totalitarian control over a prolonged period (months to years) • Hostages • Prisoners of war • Concentration-camp survivors and survivors of some religious cults • Subjected to totalitarian systems in sexual and domestic life • Survivors of domestic battering • Childhood physical or sexual abuse • Organized sexual exploitation

35. Treatment of Complex PTSD • Ongoing concern of how best to deal therapeutically with this type of presentation • Very difficult cases to work with: complexity, severity, disturbance to sense of self • Long term treatment probably best, although may be delivered in short courses • Difficult to study outcomes based on current research methodology