TOPIC 5 ANXIETY DISORDERS

1. TOPIC 5 ANXIETY DISORDERS

2. Anxiety disorder • Anxiety is a generalized state of apprehension • The focus of anxiety is more internal than external • It seems to be a response to a vague or unrecognized danger

3. Anxiety is a physiological, behavioral and psychological reaction all at once • Therefore intervention programs in general should focus on: - to reduce physiological reactivity - to eliminate avoidance behavior - to change subjective reaction

4. Free-floating anxiety Anxiety that comes out of blue • Situational Anxiety anxiety arises only in response to a specific situation but it is unrealistic situational anxiety will eventually become phobic when you start to avoid the situation • Anticipatory anxiety thinking about one particular situation

5. Anticipatory anxiety is closely associated with the way you are thinking. • With panic disorder, thoughts are generally focused on worrying about having a panic attack in a situation that will result in embarrassment, extreme discomfort, a heart attack or even worse.

6. Different types of anxiety disorders defined by DSM-IV-TR • Panic disorders • Agoraphobia • Social Phobia • Generalized Anxiety Disorder • Obsessive Compulsive Disorder • Post Traumatic Stress Disorder

7. Panic Disorder • Characterized by sudden episodes of acute apprehension or intense fear that occur “out of blue” without any apparent

8. Panic Disorder • Symptoms of panic disorder - Shortness of breath or a feeling of being smothered - Heart palpitations – pounding heart or accelerated heart rate - Dizziness, unsteadiness - Trembling or shaking - Feeling of choking - Sweating - Nausea or abdominal distress - Feeling of unreality - Numbness or tingling in hands and feet - Hot and cold - Chest pain or discomfort - Fears of going crazy or losing control - Fear of dying

9. Your symptoms would be diagnosed as panic disorders if: • You have had two or more panic attacks • At least one of these attacks has been followed by one month (or more) of persistent concern about having another panic attack.

10. The panic doesn’t occur because you are thinking about, approaching or actually entering a phobic situation • It happens spontaneously and unexpectedly for no apparent reason

11. The causes of panic disorder • Heredity • chemical imbalances in the brain • personal distress major life changes may trigger the onset of panic attacks

12. Treatment Medication • antidepressant drugs such as tofranil and paxil Personal wellness program • regular exercise • daily practice of deep relaxation • good nutrition • a shift in attitude to a calmer and easy-going approach

13. Generalized Anxiety Disorder • Characterized by persistent feelings of anxiety that are not triggered by any specific object, situation or activity • GAD having at least three of the following six symptoms - Restlessness - Being easily fatigued - Difficulty concentrating - Irritability - Muscle tension - Difficulties with sleep

14. No specific phobias associated with GAD but it is sustained by basic fears - Fear of losing control - Fear of not being able to cope - Fear of failure - Fear of rejection - Fear of death and disease

15. Phobic Disorders • The word phobia derives from the Greek phobos meaning fear • Phobic disorders are irrational fears of objects or situations

16. Specific Phobias • Persistent and excessive fears of specific objects or situations • The DSM-IV groups specific phobias within 5 subtypes - Animal Type - Natural Environment Type - Blood Injection Injury Type - Situational Type - Other Type

17. Social Phobia • Fear of embarrassment or humiliation in situations where you are exposed to the scrutiny of others • Typically your concern is that you will say or do something that will cause others to judge you as being anxious, weak, crazy or stupid • The most common - Fear of Public Speaking

18. Agoraphobia • The word agoraphobia means fear of open spaces / market places • Afraid of being in situations from which escape might be difficult or unavailable • Fear of embarrassment plays a key role • The most common feature of agoraphobia is anxiety about being far away from home or far from a “safe person”

19. Agoraphobia appears to be engendered by panic disorder • Different level of agoraphobia - mild case - moderate case - severe case

20. Obsessive Compulsive Disorder • Obsessions are recurring ideas, thoughts, images or impulses • Compulsions are repetitive behaviors or behaviors or rituals that you perform to dispel the anxiety brought up by obsessions • Obsessions may occur by themselves without necessarily being accompanied by compulsions

21. The most common compulsions include washing, checking and counting • Obsessive compulsive disorder is often accompanied by depression

22. Post Traumatic Stress Disorder • The essential feature of post traumatic stress disorder is the development of disabling psychological symptoms following a traumatic event • The traumatic event involves either actual or threatened death or serious physical injury or threat to one’s own or another’s physical safety

23. Symptoms of PTSD • Repetitive, distressing thoughts about the event • Nightmares related to the event • Flashbacks so intense that you feel or act as though the trauma were occurring all over again • An attempt to avoid thoughts or feelings associated with the trauma • An attempt to avoid activities or external situations associated with the trauma • Emotional numbness • Feeling of detachment or estrangement from others • Losing interest in activities that used to give you pleasure • Persistent symptoms of increased anxiety, such as difficulty falling or staying asleep, difficulty concentrating

24. To receive a diagnosis of PTSD, these symptoms need to have persisted at least 1 month • Less than 1 month’s duration, the appropriate diagnosis is “acute stress disorder” • In addition, the disturbance must be causing you significant distress, interfering with social, vocational or other important areas of your life

25. Theoretical Perspectives • Psychodynamic perspective - anxiety disorders are viewed as neurosis - the anxiety experienced in neurosis reflects; 1 – the efforts of unacceptable, repressed impulses to break into consciousness 2 – fear as what might happen if they do Stress on the roles of defense mechanisms

26. Phobias develop through the use of defense mechanism of projection and displacement • A phobic reaction is believed to represent the projection of the person’s own threatening impulses onto the phobic object.

27. Learning Perspectives • Anxiety disorders are acquired through conditioning • Phobia - Classical conditioning - Operant conditioning - Observational learning – modeling

28. Generalized anxiety - a product of stimulus generalization • Obsessive compulsive disorder - compulsive behavior are operant responses that are negatively reinforced by relief of the anxiety that is engendered by obsessional thoughts • PTSD - classical conditioning

29. Cognitive Perspectives • Overprediction of fear • Irrational beliefs • Oversensitivity to threats • Anxiety sensitivity • Misattribution for panic sensation • Low self-efficacy expentancies

30. Biological Perspectives • Genetic Factors • Neurotransmitter - Gammaaminobutyric acid (GABA)

31. TREATMENT FOR ANXIETY DISORDERS

32. The specific treatment approach depends on the type of anxiety disorder and its severity. But in general, most anxiety disorders are treated with cognitive-behavioral therapy, medication, or some combination of the two.

33. SYSTEMATIC DESENSITIZATION • Systematic desensitization is a technique which is used to help people manage and eventually conquer phobias • An individual learn to handle progressively more disturbing stimuli while they remain relaxed • About 10 – 20 stimuli are arranged in a hierarchy (fear stimulus hierarchy)

34. Assumption (Joseph Wolpe, 1958) – maladaptive anxiety responses, like other behaviors are learned or conditioned. They can be unlearned by conterconditioning. • Advantages of systematic desensitization are: - enhance self-efficacy expectancies - lower catecholamine levels - help people overcome phobias through a stepwise approach of actual exposure to the phobic stimuli

35. The procedures of systematic desensitization • Begins with the collection of a history of the patient’s problem • The problem is explained to the patient • Explain the rationale of systematic desensitization • Train the patient with relaxation techniques • Establish an anxiety hierarchy • Imagery desensitization

36. Phobia About Driving on Freeways • Watching from a distance as cars drive past on the freeway • Riding in a car on the freeway with someone else driving • Driving on a freeway the distance of one exit with a friend sitting next to you at a time when there is a little traffic • Driving the distance of one exit with a friend when the freeway is busier • Repeat step 3 alone • Repeat step 4 alone

37. Driving the distance of two exits with a friend sitting next to you at a time when there is little traffic • Driving the distance of two exits with a friend sitting next to you at a time when there is moderate traffic • Repeat step 7 alone • Repeat step 8 alone

38. Phobia about giving presentation • Preparing a talk which you don’t give • Preparing a talk and delivering it in front of one friend • Preparing a talk and delivering it in front of three friend • Giving a brief presentation to three or four people at work who you know well • Same as Step 4 but a longer presentation • Giving a brief presentation to 10 -15 people • Same as Step 6 but a longer presentation • Giving a brief presentation to 3 or 4 strangers • Same as step 8 but a longer presentation • Giving a brief presentation to 10 – 15 strangers • Giving a brief presentation to 50 strangers

39. Cognitive Techniques • Rational restructuring Much maladaptive behavior is determined by the assumptions people make about the world In this rational restructuring, argument or discussion may be used in an attempt to get patients to see the irrationality of their belief The therapist may attempt to teach them to modify their internal sentences

40. Rational Emotive Therapy (RET) Ellis (1962) RET aims to change behavior by altering the way the patient thinks about things ABC – Beliefs (B) about activating events or situations (A) that determine the problematic emotional or behavioral consequences (C)

41. Behavioral Treatment of Social Phobia Flooding Method (exposure therapy) • Behavioral Treatment of Agoraphobia Exposure Therapy - gradual exposure to fear-inducing stimuli • Behavioral Treatment to PTSD Exposure Therapy • Behavioral Treatment for OCD Exposure with response prevention

42. Complementary treatments for anxiety disorders • Exercise – Exercise is a natural stress buster and anxiety reliever. Research shows that as little as 30 minutes of exercise three to five times a week can provide significant anxiety relief. To achieve the maximum benefit, aim for at least an hour of aerobic exercise on most days. • Relaxation techniques – When practiced regularly, relaxation techniques such as mindfulness meditation, progressive muscle relaxation, controlled breathing, and visualization can reduce anxiety and increase feelings of relaxation and emotional well-being. • Biofeedback – Using sensors that measure specific physiological functions—such as heart rate, breathing, and muscle tension—biofeedback teaches you to recognize the body’s anxiety response and learn how to control them using relaxation techniques. • Hypnosis – Hypnosis is sometimes used in combination with cognitive-behavioral therapy for anxiety. While you’re in a state of deep relaxation, the hypnotherapist uses different therapeutic techniques to help you face your fears and look at them in new ways.