Chapter 6: Anxiety Disorders

Chapter 6: Anxiety Disorders Fall, 2012 Dr. Mary L. Flett, Instructor

Overview • Various forms of anxiety disorders are most common type of abnormal behavior • Similarity to mood disorders suggests common causal features • stress • cognitive factors • biological

Symptoms • Definition: Preoccupation with, or persistent avoidance of, thoughts or situations that provoke fear or anxiety • “Anxiety” can refer to a mood or a syndrome • Fear is experienced in the face of real, immediate danger • Anxiety involves a more general (diffuse) emotional reaction our of proportion to the threats from the environment -- anticipatory

Symptoms • Excessive Worry • A relatively uncontrollable sequence of negative, emotional thoughts that are concerned with possible future threats or danger • Worriers emphasize verbal material rather than images • Panic Attack • A sudden, overwhelming experience of terror fright • Largely described in terms of somatic responses (heart attacks, shortness of breath, sweating • Cognitive experiences include feeling as if they are going to die or go crazy • Situational cues (public speaking, driving on freeways)

Symptoms • Phobias • Persistent, irrational, narrowly defined fears associated with a specific object or situation • Avoidance is important component • Agoraphobia (“fear of the marketplace”; fear of open spaces) • Key belief is not being able top escape • Clinicians describe phobia as a “fear of fear” • Individual becomes adept at monitoring self, but makes errors in judgment when identifying what those symptoms mean

Symptoms • Obsessions & Compulsions • Obsessions are repetitive, unwanted, intrusive cognitive events that may take the form of thoughts, images, or impulses that lead to an increase in subjective anxiety • Come from “out of the blue” • Socially unacceptable themes such as sex, violence, disease/contamination

Symptoms • Obsessions & Compulsions • Compulsions are repetitive behaviors or mental acts used to reduce anxiety. They are considered senseless or irrational by the individual, but they cannot be resisted • Associated with diminished control • Two most common forms are cleaning and checking

Diagnosis • Freud was responsible for first extensive clinical descriptions of pathological anxiety states • Grouped under “neurosis”; not psychotic • Freud’s theory is that the ego (the moderator) cannot successfully deal with impulses of the id and the demands of the super ego • Signal anxiety triggers the defenses • If defenses work, then learning occurs and anxiety diminishes • If defenses don’t work, then individual becomes neurotic

Diagnosis • DSM uses descriptive features to distinguish among subtypes • Panic Disorder • Phobic Disorders • Obsessive-Compulsive disorder • Generalized Anxiety Disorder • Post-traumatic Stress Disorder (Acute Stress Disorder) – discuss later in Chapter 7

Diagnosis • Panic Disorder • Recurrent, unexpected panic attacks • Usually not seen first by psychologist; rather referred after many visits to the ER • Two types: with or without Agoraphobia • Agoraphobia includes avoidance and distress • Typical situation includes travel away from home • May require someone to travel with to help deal with distress • Avoidance of a wide variety of situations including social events and common errands

Diagnosis • Specific Phobia • Fear of heights, bugs, snakes, bridges, storms, blood, trains, planes, closed places (closet, elevator) • Must recognize fear is unreasonable • Avoid the situation • Experience distress • Social Phobia • Identical for specific phobia, but includes being afraid of social situations (performance) • Fear of being humiliated or embarrassed (giving a speech, eating in front of people • May be extremely shy

Diagnosis • Generalized Anxiety Disorder • Defined as excessive anxiety and worry resulting in impairment in functioning or significant distress • One of the most controversial • overlaps many of the other anxiety disorders • may be more useful to think of as a trait rather than a pathology

Diagnosis • OCD • Most individuals exhibit both obsessions and compulsions, but some have one or the other • Difficult to define “normal” obsession or compulsion, but is easier to identify when using functional impairment as criteria

Diagnosis: Course & Outcome • Often chronic conditions • Some people do recover • Conclusion: outcome is mixed and unpredictable

Diagnosis: Course & Outcome • Often chronic conditions • Some people do recover • Conclusion: outcome is mixed and unpredictable • Medications do make a difference

Diagnosis: Frequency • Prevalence • More common than any other disorder • Specific phobias most common subtype • Social phobia next common • Panic DO, and GAD affect approximately 3% of population • OCD affects approximately 1%

Diagnosis: Frequency • Comorbidity among anxiety disorders is high • Anxiety and depression frequently go together • Substance dependence is quite high • May increase risk of onset of anxiety • Cause and effect is not clear

Diagnosis: Frequency • Gender Differences • Women 3X more likely to experience anxiety • Social phobia more common among women • No gender difference in OCD – hmmmmm! • May be explained in terms of child-rearing practices or responses to stressful events • May be due to hormone or neurotransmitter activity

Diagnosis: Frequency • Lifespan Issues • Increased anxiety in the later years may be due to loneliness, increased dependency, declining physical & cognitive functioning, & changes in social and economic conditions • Elders with anxiety have most likely had it for a long time • Need to rule out underlying physiological conditions such as COPD, CHF, hearing loss, and dementia

Diagnosis: Frequency • Cross-cultural Comparisons • Westerners typically express anxiety in relation to work performance; Easterners in relation to family or religious issues • Prevalence rate appears to be same across cultures; descriptors are different

Diagnosis: Causes • Adaptive & Maladaptive Fears • What is the evolutionary significance of the fight or flight response? • Survival • When it become maladaptive, then response is pathological • Generalized forms prepare for vague threats • Specific fears evolved in response to certain types of danger

Diagnosis: Causes • Social Factors • Stressful life events • Different types of environmental stressors (family, natural disaster, work) lead to anxiety response • Childhood Adversity/Resilience • Abuse and neglect • Exposure to violence • maternal pre-natal stress • Not all abused children have anxiety

Diagnosis: Causes • Psychological Factors • Learning Process • Specific fears as a learned response (Little Albert) • Fear “modules” (specialized adaptive circuits in brain) • May have natural selection advantage • Preparedness model • Interpret anger in a face • Interpret danger in an unfamiliar environment • Bandura’s Learning Theory • Observational learning of fears

Diagnosis: Causes • Psychological Factors • Cognitive Factors • Perception (locus) of Control • People who believe they are able to control events in the environment are less likely to be anxious than those who feel helpless • Catastrophic Misinterpretation • Body sensations lead to automatic negative thoughts which, in turn, trigger counter productive behaviors, exaggerating the fear response • Doesn’t account for panic attacks while dreaming

Diagnosis: Causes • Psychological Factors • Cognitive Factors • Attention to Threat & Biased Information Processing • Sensitive individuals scan the environment • Threatening information is encoded and reactivated by generalized situations • Problem-solving behaviors do not work • Rehearsal of fearful outcomes leads to triggering of encoded memories • Thought Suppression: OCD • May actually increase symptoms in persons with OCD (rebound effect)

Diagnosis: Causes • Biological Factors • Genetic Factors • Genetic risk factors are neither specific or non-specific • Genetic factors have been identified for GAD, panic disorder & agoraphobia, and specific phobias • Environmental risk factors unique to the individual play a role in anxiety • Environmental risk factors shared by all members of the family do not seem to have an important influence

Diagnosis: Causes • Biological Factors • Neurobiology • Two biological pathways involved in fear conditioning exist in the brain • Evolved fear module (fast) – evolved as an adaptive response • Cortical processing (slow) – evolved as a learned response • Parts of the brain associated with these pathways include • amygdala • thalamus • HPA axis

Diagnosis: Causes • Biological Factors • Neurobiology • Pathways associated with fear conditioning (panic disorder) may be triggered at an inappropriate time • Sensitivity varies among individuals • Subcortical pathway between thalamus and amygdala may be responsible for misinterpretation of stimuli • Multiple pathways are associated with OCD, making it neurologically quite different from other anxiety disorders • basal ganglia, orbital prefrontal cortex, anterior cigulate cortex • Neurotransmitters such as GABA, serotonin are “inhibitory” (dampen response); psychopharma increases availablity thereby decreasing experience of anxiety

Diagnosis: Treatment • Psychological Interventions • Systematic Desensitization & Interoceptive Exposure • Exposure & Response Prevention • Relaxation & Breathing Retraining • Cognitive Therapy

Diagnosis: Treatment • Biological Interventions • Antianxiety (anxiolitics) medications • Tranquilizers • Benzodiazepines • Side effects may be worse than problem • Sedation • Addiction • Azapirones • Buspar • Takes a bit longer; but not addictive

Anxiety Treatment: Overview

Diagnosis: Treatment • Biological Interventions • Antidepressants • SSRIs • Tricyclics • Clomipramine (Anafranil) • Best Practices • Combination of therapy and medication

Chapter 6: Anxiety Disorders