chapter 6: anxiety disorders ch 6. anxiety disorders anxiety refers to an unpleasant feeling of fear...

Chapter 6: Anxiety Disorders

Ch 6

Anxiety Disorders• Anxiety refers to an unpleasant feeling of fear and

apprehension– Neuroses is a former term that refers to a group of disorders involving

unrealistic anxiety, assumed to be due to unconscious conflicts

• Anxiety disorders reflect the clear presence of symptoms of anxiety – Anxiety is not specific to anxiety disorders– Comorbidity: A person may be diagnosed with more than one

disorder

• Distinguishing stress, fear, and anxiety– Stress is the perception of an external demand, or challenge

Ch 6.1

Abrupt and Aversive CNS Response to Real Threat or Danger

Prepares Organisms for Immediate Action

Action Tendency “Fight” or “Flight”

Abrupt and Aversive CNS Response to Real Threat or Danger

Prepares Organisms for Immediate Action

Action Tendency “Fight” or “Flight”

More Diffuse Response About Impending Real or Imagined “Future” Threat or Danger

No Threat

AdaptiveTrue AlarmTrue AlarmTrue AlarmTrue Alarm

False AlarmFalse AlarmFalse AlarmFalse AlarmMaladaptive

Real Threat

EtiologyEtiology“Disordered” or “Maladaptive”

Experience of Anxiety or Fear

“Disordered” or “Maladaptive”Experience of

Anxiety or Fear

“Normal” or “Adaptive”Experience of

Anxiety or Fear

“Normal” or “Adaptive”Experience of

Anxiety or Fear

Phobias

• A phobia is a fear-mediated avoidance that is out of proportion to the object or situation– Phobias involve intense distress– Phobias are disruptive– Person recognizes that the fear is

groundless

Ch 6.2

Classes of Phobias• Specific phobias are unwarranted fears caused by

the presence of a specific object or situation– Blood, injuries, or injections– Situations (planes, elevators)– Animals– Natural environment (water, heights)

• Social phobia involves a persistent fear linked to the presence of other people

Ch 6.4

Irrational Fear of Specific Objects or Situations

Markedly Interferes With Functioning

Irrational Fear of Specific Objects or Situations

Markedly Interferes With Functioning

Clinical Description Clinical Description

Animal Type Natural Environment Type Blood-Injection Injury Type Situational Type Other

Animal Type Natural Environment Type Blood-Injection Injury Type Situational Type Other

Four Major Subtypes Four Major Subtypes

Unusual Reaction Vasovagal Response to Blood Drop in Blood Pressure Fainting Runs in Families Onset Early Childhood

Unusual Reaction Vasovagal Response to Blood Drop in Blood Pressure Fainting Runs in Families Onset Early Childhood

Blood-Injection Injury Type Blood-Injection Injury Type

Fears of Specific Situations

Planes, Transportation, Heights Response Similar to Panic Onset Early 20’s

Fears of Specific Situations

Planes, Transportation, Heights Response Similar to Panic Onset Early 20’s

Situational Type Situational Type

Fears of Animals and Insects Common in Population, but

Different From Normal Revulsion Early Onset (About 7 yrs of Age)

Fears of Animals and Insects Common in Population, but

Different From Normal Revulsion Early Onset (About 7 yrs of Age)

Animal Type Animal Type

Fears of Natural Events

Heights, Storms, Water Usually More Than One Fear Peak Onset (About 7 yrs of Age)

Fears of Natural Events

Heights, Storms, Water Usually More Than One Fear Peak Onset (About 7 yrs of Age)

Natural Environment Type Natural Environment Type

Fears Contracting Disease / Illness

Illness Phobia Fear of Choking

Avoid Swallowing Pills or Foods

Fears Contracting Disease / Illness

Illness Phobia Fear of Choking

Avoid Swallowing Pills or Foods

Other Type Other Type

Facts and Statistics Facts and Statistics

Occurs in 11% of Population Top Fears: Heights and Snakes Females > Males (4:1 Ratio) Runs a Chronic Course Many Do Not Seek Treatment:

WHY?

Occurs in 11% of Population Top Fears: Heights and Snakes Females > Males (4:1 Ratio) Runs a Chronic Course Many Do Not Seek Treatment:

WHY?

Causes Causes Direct Traumatic Conditioning Observational Learning Information and Language Having a Panic Attack (“False

Alarm”) Probably Some Evolutionary Basis

Direct Traumatic Conditioning Observational Learning Information and Language Having a Panic Attack (“False

Alarm”) Probably Some Evolutionary Basis

Etiology of Anxiety Disorders• Psychoanalytic theory: phobias result from anxiety produced by

repressed id impulses• Biological/Genetic theory: Heritability of panic disorder, and

evolutionary basis of phobias• Behavioral theories: focus on learning as the etiological basis of

phobias– Phobias are learned avoidance responses– Phobias may be acquired through modeling– We are biologically prepared to learn certain fears (e.g. taste with nausea)

• Cognitive theory: Thought processes result in high levels of anxiety

Ch 6.5

Treating Phobias

• Psychoanalytic therapy attempts to uncover repressed conflicts using free association

• Behavioral approaches use systematic desensitization and in vivo exposures to reduce anxiety responses to phobic stimuli and situations– Flooding: exposure to a phobic stimulus at full intensity

(now graded exposure is used more)

• Cognitive approaches focus on altering irrational beliefs (using socratic dialogue to disconfirm and reconstruct automatic thoughts, images)

Ch 6.6a

Treating Phobias

• Biological approach uses drugs to eliminate anxiety symptoms – Anxiolytic drugs such as the benzodiazepines (Valium)

can reduce anxiety but are also addictive and give rise to withdrawal symptoms upon termination

– MAO inhibitors such as phenelzine reduce the degradation of norepinephrine and serotonin

• MAO inhibitors can have adverse side effects

– Selective serotonin reuptake inhibitors (SSRI’s) (fluoxetine) increase brain serotonin

Ch 6.6b

Exposure and More Exposure Exposure and More Exposure Structured and Consistent Confront Objects of Fear Extinguish Anxious Responding Disrupt Avoidance / Escape Blood-Injury /Injection Differs

Exercises to Offset Fainting

Structured and Consistent Confront Objects of Fear Extinguish Anxious Responding Disrupt Avoidance / Escape Blood-Injury /Injection Differs

Exercises to Offset Fainting

“ “ People with social phobia aren’t People with social phobia aren’t necessarily shy at all. They can be necessarily shy at all. They can be completely at ease with people most of completely at ease with people most of the time, but in particular situations, the time, but in particular situations, they feel intense anxiety.”they feel intense anxiety.”

“ “ People with social phobia aren’t People with social phobia aren’t necessarily shy at all. They can be necessarily shy at all. They can be completely at ease with people most of completely at ease with people most of the time, but in particular situations, the time, but in particular situations, they feel intense anxiety.”they feel intense anxiety.”

Marked and Persistent Fear of One or More...

Social or Performance Situations Most Common Type of Social Fear?

Public Speaking Interferes With Life Functioning

Marked and Persistent Fear of One or More...

Social or Performance Situations Most Common Type of Social Fear?

Public Speaking Interferes With Life Functioning



Occurs in 13.3% of Population Most Prevalent Disorder Males > Females Begins in Adolescence Presents Differently in Some

Cultures (e.g., Japan)

Occurs in 13.3% of Population Most Prevalent Disorder Males > Females Begins in Adolescence Presents Differently in Some

Cultures (e.g., Japan)

Causes Causes

Similar to Panic and Specific Phobia Interaction of

Biological Vulnerability

Psychological Vulnerability

Learning Experiences Can be Quite Disabling

Similar to Panic and Specific Phobia Interaction of

Biological Vulnerability

Psychological Vulnerability

Learning Experiences Can be Quite Disabling

Psychological Interventions Psychological Interventions

Similar to Panic and Specific Phobia Cognitive-Behavioral Approaches

Rehearsal and Skills Training

Cognitive Restructuring

Similar to Panic and Specific Phobia Cognitive-Behavioral Approaches

Rehearsal and Skills Training

Cognitive Restructuring

Drug Treatments Drug Treatments

Antidepressants for Severe Anxiety SSRIs (e.g., Paxil)

MAO Inhibitors

Relapse is Common

Antidepressants for Severe Anxiety SSRIs (e.g., Paxil)

MAO Inhibitors

Relapse is Common

Panic Disorder• Panic disorder involves

– an attack of labored breathing, nausea, chest pain, dizziness and intense apprehension (terror)

– Depersonalization: the feeling of being outside of one’s body

– Derealization: the feeling that the world is not real

• Lifetime prevalence for panic disorder is 2% for men and 5% for women

Ch 6.7

Panic Disorder Panic Disorder

“ “ You may genuinely believe you’re having You may genuinely believe you’re having a heart attack, losing your mind, or on the a heart attack, losing your mind, or on the verge of death. Attacks can occur any verge of death. Attacks can occur any time, even during nondream sleep ”time, even during nondream sleep ”

“ “ You may genuinely believe you’re having You may genuinely believe you’re having a heart attack, losing your mind, or on the a heart attack, losing your mind, or on the verge of death. Attacks can occur any verge of death. Attacks can occur any time, even during nondream sleep ”time, even during nondream sleep ”

“ “ For me, a panic attack is a most violent experience For me, a panic attack is a most violent experience …I feel as though I’m losing control and going …I feel as though I’m losing control and going insane. ”insane. ”

“ “ For me, a panic attack is a most violent experience For me, a panic attack is a most violent experience …I feel as though I’m losing control and going …I feel as though I’m losing control and going insane. ”insane. ”

An Unexpected Panic Attack Develop Anxiety Over

the Next Attack orThe Implications of the Attack

and Consequences

An Unexpected Panic Attack Develop Anxiety Over

the Next Attack orThe Implications of the Attack

and Consequences



Agoraphobia is Common “Fear of the Marketplace”,

avoidance of “unsafe” places where panic attack may recur

Consequence of Severe Unexpected Panic Attacks

Can Have a Life of its Own

Agoraphobia is Common “Fear of the Marketplace”,

avoidance of “unsafe” places where panic attack may recur

Consequence of Severe Unexpected Panic Attacks

Can Have a Life of its Own


Occurs in 3.5% of Population 75% are Women Onset Between (25-29 yrs) Initial attack often begins at puberty 20% Attempt Suicide Average 37 Medical Visits / Year

Occurs in 3.5% of Population 75% are Women Onset Between (25-29 yrs) Initial attack often begins at puberty 20% Attempt Suicide Average 37 Medical Visits / Year

Cultural Influences Cultural Influences Occurs Worldwide Prevalence in U.S. is Similar Across

Ethnic Groups Cultural variants: susto, ataques de

nervios (Latin America, Caribbean) Somatic symptoms emphasized in

3rd world cultures

Occurs Worldwide Prevalence in U.S. is Similar Across

Ethnic Groups Cultural variants: susto, ataques de

nervios (Latin America, Caribbean) Somatic symptoms emphasized in

3rd world cultures

Nocturnal Panic Nocturnal Panic

60% Cases Panic While Asleep! Usually Between 1:30 - 3:30am Occur During Deep Sleep “Delta” Do Not Occur During REM Sleep Isolated sleep paralysis (common in

African-Americans with PD)

60% Cases Panic While Asleep! Usually Between 1:30 - 3:30am Occur During Deep Sleep “Delta” Do Not Occur During REM Sleep Isolated sleep paralysis (common in

African-Americans with PD)

Symptoms of a Panic Attack Symptoms of a Panic Attack Palpitations / Sweating Trembling / Shaking Shortness of Breath Feeling of Choking, Loss of Control Derealization, Feeling of Dying

Palpitations / Sweating Trembling / Shaking Shortness of Breath Feeling of Choking, Loss of Control Derealization, Feeling of Dying

Etiology of Panic Disorder• Biological theories focus on the observations

– that panic disorder runs in families– that panic disorder can be induced experimentally

using • Hyperventilation may activate the autonomic nervous

system• Infusions of lactate can induce panic attack

• Panic attack may result from an exaggerated central response to arousal

Ch 6.8

Etiology of Panic Disorder

• The Fear-of-fear hypothesis of panic disorder suggests that some people have an overly aroused nervous system and a tendency to be upset by the sensations generated by their nervous system– Eventually, worry about a panic attack makes

a future attack more likely (vicious circle) – Panic attacks as “false alarm” reactions

Ch 6.9

Anxiety Sensitivity Index (ASI)

•Measures the extent to which individuals become apprehensive in response to their bodily sensations. •Developed by Peterson & Reiss (1987) •High scorers on the ASI were more likely than low scorers to experience panic attacks, especially if they had been told they would feel relaxed instead of aroused (Telch & Harrington, 1992) (D&N, Table 6.3).

Panic Disorder Treatments

• Biological treatments include use of antidepressant and anxiolytic drugs– Require long-term use, symptoms return upon drug

cessation; risk of addiction to anxiolytics

• Psychological treatments emphasize exposure to stimuli that accompany panic– Barlow’s therapy includes a combination of breathing re-

training, cognitive interventions, and exposure to the internal cues that elicit panic. Patient learns to relax and reinterpret these sensations as non-threatening and controllable

Ch 6.10

The Panic Attack The Panic Attack Abrupt Autonomic Surge Unexpected Uncontrollable Absence of Threat “False Alarm”

Abrupt Autonomic Surge Unexpected Uncontrollable Absence of Threat “False Alarm”

10 Minutes10 Minutes

Laboratory Panic Provocation Laboratory Panic Provocation Lactate Infusion Hyperventilation CO2 Inhalation Caffeine

Lactate Infusion Hyperventilation CO2 Inhalation Caffeine

10 Minutes10 Minutes

Causes Causes

General Biological & Psychological Vulnerability


False AlarmFalse Alarm

Involuntary physical or cognitive anxiety cues trigger learned alarms unpredictably

Involuntary physical or cognitive anxiety cues trigger learned alarms unpredictably

STRESSSTRESS

Bodily CuesBodily Cues

Specific Psychological Vulnerability: Anxious apprehension focusing on future alarms (e.g., body sensations are dangerous)

Specific Psychological Vulnerability: Anxious apprehension focusing on future alarms (e.g., body sensations are dangerous)

Learned AlarmLearned Alarm

Biological Causes Biological Causes Runs in Families GABA-BZ Circuit Limbic System

Runs in Families GABA-BZ Circuit Limbic System

ANXIETY Behavioral Inhibition System (BIS) FEAR / PANICFight / Flight System (FF)

ANXIETY Behavioral Inhibition System (BIS) FEAR / PANICFight / Flight System (FF)

Uncontrollable

Unpredictable

Psychological Causes Psychological Causes

Controllable

Predictable

Pharmacologic Treatments Pharmacologic Treatments

Block Panic Antidepressants (e.g., Imipramine,

Paxil, Prozac)20-50% Relapse

Benzodiazapines (e.g., Xanax)90% Relapse

Block Panic Antidepressants (e.g., Imipramine,

Paxil, Prozac)20-50% Relapse

Benzodiazapines (e.g., Xanax)90% Relapse


Cognitive-Behavior Therapies Brief and Time Limited (12 Sessions) Graded Exposure + Coping Skills Panic Control Treatment (PCT) 80-100% Panic Free After Treatment

Cognitive-Behavior Therapies Brief and Time Limited (12 Sessions) Graded Exposure + Coping Skills Panic Control Treatment (PCT) 80-100% Panic Free After Treatment

Combined Treatment Combined Treatment

Multisite Study Imipramine Alone PCT Alone Imipramine + PCT Placebo Alone Placebo + PCT

Multisite Study Imipramine Alone PCT Alone Imipramine + PCT Placebo Alone Placebo + PCT

THE RESULT THE RESULTCombined Tx

is Better in Short Term

Combined Tx is Better in

Short Term

PCT Alone is Better in

Long Term

PCT Alone is Better in

Long Term

• Generalized Anxiety Disorder (GAD) involves persistent anxiety and chronic (uncontrollable) worry

• The lifetime prevalence of GAD is 5%

• Women are twice as likely to develop GAD as are men

Generalized Anxiety Disorder

Ch 6.11

Generalized Anxiety Disorder:The “Basic” Anxiety Disorder?

Figure 5.3

Clients’ answers to interviewer’s question, “Do you worry excessively about minor things?”

Etiology of GAD • Psychoanalytic view: generalized anxiety results

from unconscious conflicts between ego and id impulses

• Cognitive behavioral view: anxiety results from conditioning of anxiety to external stimuli

• Biological view: the transmitter GABA inhibits anxiety, anxiolytic drugs enhance the release of GABA in brain; evidence for heritability is mixed.

Ch 6.12

Worrywart? Perfectionist? Tense and keyed up most of the time? Cross bridges before you get to them? Worry unproductive? Trouble Controlling Worry?

Worrywart? Perfectionist? Tense and keyed up most of the time? Cross bridges before you get to them? Worry unproductive? Trouble Controlling Worry?

Worry About Everything Worrying is Unproductive Cannot Stop Worrying Mental Agitation and Muscle Tension Interferes With Life Functioning Must Last for at Least 6 Months

Worry About Everything Worrying is Unproductive Cannot Stop Worrying Mental Agitation and Muscle Tension Interferes With Life Functioning Must Last for at Least 6 Months



Occurs in 4% of Population Women twice as likely to develop

GAD Early Gradual (“insidious”) Onset Runs a Chronic Course Few Seek Treatment: WHY?

Occurs in 4% of Population Women twice as likely to develop

GAD Early Gradual (“insidious”) Onset Runs a Chronic Course Few Seek Treatment: WHY?

Causes Causes

Unclear and Puzzling? Tend to show

Autonomic Restriction

Heightened Muscle Tension

High Sensitivity to Threat in General

Threat Sensitivity is Automatic Avoid Negative Affect Related to Threat

Unclear and Puzzling? Tend to show

Autonomic Restriction

Heightened Muscle Tension

High Sensitivity to Threat in General

Threat Sensitivity is Automatic Avoid Negative Affect Related to Threat

Intense Cognitive

Processing

Intense Cognitive

Processing



Worry ProcessWorry

Process

Specific Psychological Vulnerability

(Anxious Apprehension)

Specific Psychological Vulnerability

(Anxious Apprehension)

STRESSSTRESS

Imagery AvoidanceImagery

Avoidance

Restricted Autonomic Response

Restricted Autonomic Response

Most Interventions are Weak Most Interventions are Weak

Benzodiazepines

Frequently Prescribed

Provide Some Relief Cognitive-Behavioral Approaches

Process Avoided Emotional Material

Relaxation Training

Does as Well as Medication

Benzodiazepines

Frequently Prescribed

Provide Some Relief Cognitive-Behavioral Approaches

Process Avoided Emotional Material

Relaxation Training

Does as Well as Medication

Therapies for GAD• Psychoanalytic therapy for GAD is similar to

that of phobia (reveal sources of conflict)• Behavioral therapy involves a combination of

relaxation training and cognitive intervention• Biological therapy uses administration of

anxiolytic drugs to reduce anxiety– Drug therapy is effective while the drugs are taken

Ch 6.13

Obsessive-Compulsive Disorder (OCD)

• Obsessions are intrusive and recurring thoughts

• Compulsions are repetitive behaviors or mental actions that are repeated over and over in order to reduce anxiety

• The lifetime prevalence of OCD is 1-2 %– Women are more likely than men to develop OCD

Ch 6.14

Common Compulsions

• Pursuing cleanliness

• Avoiding particular objects (e.g. cracks in a sidewalk)

• Performing repetitive, magical, protective practices

• Checking (e.g. “is the gas off?”)

• Performing a particular act (e.g. chewing slowly)

Ch 6.15

Etiology of OCD

• The psychoanalytic view is that OCD reflects arrest of personality development at the anal stage

• Behavioral accounts of OCD point to learned behaviors reinforced by fear reduction

• The biological view of OCD has focused on activation of the frontal lobes and basal ganglia

Ch 6.16

The Basal Ganglia

Ch 6.17

OCD Therapy

• Psychoanalytic procedures are not effective

• ERP: Exposure and Response Prevention involves exposing the OCD client to situations that elicit a compulsion and then restraining the client from performing the compulsion

• Biological treatment involves drugs that increase brain serotonin activity (Prozac)

Ch 6.18

Culmination of All Anxiety Disorders Obsessions: Intrusive Thoughts,

Images, or Urges That the Person Tries to Suppress or Eliminate

Compulsions: Thoughts or Actions to Suppress the Obsessions and Provide Relief

Culmination of All Anxiety Disorders Obsessions: Intrusive Thoughts,

Images, or Urges That the Person Tries to Suppress or Eliminate

Compulsions: Thoughts or Actions to Suppress the Obsessions and Provide Relief



Occurs in 2.6% of Population Most Common Obsessions

Contamination & Aggression Most Common Compulsions

Checking & Washing Almost Equal Sex Ratio (F > M) Onset Early Adolescence to Mid-20s

Occurs in 2.6% of Population Most Common Obsessions

Contamination & Aggression Most Common Compulsions

Checking & Washing Almost Equal Sex Ratio (F > M) Onset Early Adolescence to Mid-20s

Causes Causes Anxiety Focused on Unwanted Thoughts Thoughts are Unacceptable

When Fighting to Control One’s

Psychology Creates More

Psychopathology

Anxiety Focused on Unwanted Thoughts Thoughts are Unacceptable

When Fighting to Control One’s

Psychology Creates More

Psychopathology

Psychological Interventions Psychological Interventions Cognitive-Behavioral Treatments Response Prevention

Rituals are Actively Prevented Exposure

Systematic and Gradual Exposure to Feared Thoughts or Situations

May Require Hospitalization

Cognitive-Behavioral Treatments Response Prevention

Rituals are Actively Prevented Exposure

Systematic and Gradual Exposure to Feared Thoughts or Situations

May Require Hospitalization

Drug Therapies Drug Therapies Medications Show Promise Most Effective Medications

Inhibit Reuptake of Serotonin May Benefit 60% of Patients

Medications Show Promise Most Effective Medications

Inhibit Reuptake of Serotonin May Benefit 60% of Patients

Posttraumatic Stress Disorder

• Posttraumatic Stress Disorder (PTSD) refers to an extreme response to an extreme stressor

• PTSD symptoms may include:– Increased anxiety and arousal– Re-experiencing the traumatic event– Avoidance of stimuli associated with the trauma

Ch 6.19

Exposure to Traumatic Events

War and Combat

Rape and Assault

Car Accidents

Natural Disasters Reexperiencing, Flashbacks, Numbing Sleep Disturbance, Chronic Arousal

Exposure to Traumatic Events

War and Combat

Rape and Assault

Car Accidents

Natural Disasters Reexperiencing, Flashbacks, Numbing Sleep Disturbance, Chronic Arousal


Acute

1-3 Months After the Trauma Chronic

Symptoms Last > 3 Months

Acute

1-3 Months After the Trauma Chronic

Symptoms Last > 3 Months

Subtypes Subtypes


Occurs in 7.8% of Population Most Common Traumas?

Combat and Assault Trauma is Necessary, not Sufficient Severity of Response Seems Important Runs a Chronic Course

Occurs in 7.8% of Population Most Common Traumas?

Combat and Assault Trauma is Necessary, not Sufficient Severity of Response Seems Important Runs a Chronic Course

Causes Causes

Only Disorder With Clear Etiology Biological Vulnerability Experience With Events That are...

Uncontrollable and Unpredictable Severity of Trauma and One’s Reaction

True Alarm! Social Support Helps

Only Disorder With Clear Etiology Biological Vulnerability Experience With Events That are...

Uncontrollable and Unpredictable Severity of Trauma and One’s Reaction

True Alarm! Social Support Helps


Face the Original Trauma

Imaginal Reexposure

Flooding Arrange for Corrective Emotional

Learning Problem of Secondary Gain

Disability and Compensation

Face the Original Trauma

Imaginal Reexposure

Flooding Arrange for Corrective Emotional

Learning Problem of Secondary Gain

Disability and Compensation

New Treatment Approaches for PTSD

• EMDR (Eye Movement Desensitization & Reprocessing

• TFT (Thought Field Therapy)

• New Paradigms or Pseudo-Science?

chapter 6: anxiety disorders ch 6. anxiety disorders anxiety refers to an unpleasant feeling of fear...

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