Anxiety Disorders

· Unpleasant feeling of fear & apprehension with no danger

FEAR OR ANXIETY:

· Cognitive (worry)

· Behavioral (avoidance)—freeze, flee, flight

· Physiological (sweat, heart rate, dizziness)

ANXIETY DISORDERS

1. Phobias : specific and social

2. Panic disorder

3. Generalized Anxiety disorder

4. Obsessive-compulsive disorder

5. Posttraumatic Stress disorder

Phobias

· Fear-mediated avoidance that is out of proportion to the object or situation = disordered fear

· Intense anxiety

· Avoidance causes dysfunction

· Person recognizes that the fear is groundless

· Many specific fears are not phobias because

(a) they are in proportion to the feared stimulus

or

(b) they do not cause dysfunction

Phobias con’d

Classes of Phobias

Specific phobias:

· Blood, injuries, or injections

· Situations (planes, elevators)

· Animals

· Natural environment (water, heights)

Social phobia

Phobias con’d

· Unrealistic fear can generalize to other similar stimuli to impair functioning

· Lifetime prevalence rate estimates

· 10% for specific

· 3% to 13% for social

Etiology of Phobias

Biological/medical: genetic preparedness

Psychoanalytic: defense mechanism displacement

Humanistic: impeded self-actualization

Cognitive-behavioral: learning fear in situations without danger VIA classical conditioning, operant avoidance with negative reinforcement, and modeling

Treatments (Tx’s) for Phobias

· Biological/medical: Anti-anxiety drugs

e.g., benzodiazepines (Valium)

Reduces:

Muscle tension

Worry

Apprehension

Helplessness

Headache

Nausea

Diarrhea

Rapid heart rate

Rapid breathing

Tremors

Restlessness

Biological/medcial Tx’s for Phobias

Side effects of anti-anxiety drugs:

Sedation

Drowsiness

Lethargy

Mental confusion

Motor impairments (ataxia; poor coordination)

Cognitive impairments

Disorientation

Slurred speech

Amnesia (forgetting and failure to learn)

Sleep disturbance

Dependence and withdrawal (agitation, insomnia, restlessness, seizures)

-effective while psychoactive drug is taken only EXCEPT avoidance

Txs for Phobias con’d

· Psychoanalytic therapy: free association & dream analysis

-ineffective

· Humanistic therapy: empathy, understanding, acceptance, and unconditional positive regard

-necessary but not sufficient

Treatments for Phobias con’d

· Cognitive-behavioral therapies:

-systematic desensitization

-flooding

-social skills training

-modeling

-cognitive restructuring

-effective for long-term

ANXIETY DISORDERS

1. Phobias : specific and social

2. Panic disorder

3. Generalized Anxiety disorder

4. Obsessive-compulsive disorder

5. Posttraumatic Stress disorder

Anxiety Disorders con’d

Panic Disorder

· Panic disorder = extreme fear 5+ minutes:

o An attack of labored breathing, nausea, chest pain, dizziness, nausea, heart palpitations, sweating, trembling, sense of choking, numbness, chills or hot flashes, & intense apprehension (terror) of losing control or dying

o Depersonalization: feeling of being outside of one’s body

o Derealization: feeling the world is not real

Panic Disorder con’d

· Frequent occurrence of attack (i.e, once per week)

· Attack may or may not be associated with a situation (cued vs uncued); cued only = phobia

· Attack may or may not lead to agoraphobia

· Lifetime prevalence estimates for panic disorder

2% for men

5% for women

Etiology of Panic Disorder

Biological/ medical paradigm

· Family concordance (genetic?)

· Can be induced experimentally using

o Hyperventilation to activate the autonomic nervous system

o Infusions of lactate

· Exaggerated central response to arousal

Etiology of Panic Disorder con’d

Psychoanalytic

· The panic attack is a defense mechanism

Humanistic/Existential

· As with all disorders, self-actualization is impeded

Etiology of Panic Disorder con’d

Cognitive-behavioral

· Fear-of-fear hypothesis (irrational cognitions)

· Classical conditioning of words (worry of losing

control) as conditioned stimuli that elicit fear

(Agoraphobia = fear of having a panic attack in public = generalization)

Tx’s for Panic Disorder

Biological/medical

· Use of antidepressant and antianxiety drugs

· Symptoms return upon drug cessation

· Side effects: jitteriness, weight gain, elevated heart rate & blood pressure, memory lapses, difficulty driving vehicle, addiction

· 50% do not comply with taking medication, so effectivness unknown

Tx’s for Panic Disorder con’d

Cognitive-behavioral

· exposure to environmental stimuli when have panic

· relaxation training

· exposure to internal cues that elicit panic and perhaps agoraphobia

· successive approximation with exposure

· cognitive interventions

· Treatment can involve spouse/partner in successive approximation

-Effective in long-term

Anxiety Disorders con’d

ANXIETY DISORDERS

1. Phobias : specific and social

2. Panic disorder

3. Generalized Anxiety disorder

4. Obsessive-compulsive disorder

5. Posttraumatic Stress disorder

Generalized Anxiety Disorder (GAD)

· Persistent anxiety and chronic (uncontrollable) worry more days than not for 6 months

· Restlessness, fatigue, irritability, muscle tension, sleep disturbance, and impairment in functioning or severe distress

· Anxiety & worry not due to medications or recreational substance use

· The lifetime prevalence of GAD is 5%

· Women are 2x as likely to develop GAD as men

Etiology of GAD

Biological/medical

Deficient neurotransmitter GABA, which inhibits fear and may be an inherited condition

Psychoanalytic

· Generalized anxiety results from unconscious

conflicts between ego and id impulses

· Sexual and aggressive impulses from any stage of psychosexual development in conflict with ego

· Defenses fail to displace anxiety onto an object

Etiology of GAD con’d

Cognitive-behavioral

-conditioning of fear to external stimuli that have generalized

- irrational cognitions (fear of losing control, anticipation of danger & disaster)

Tx’s for GAD

Biological/medical

-anti-anxiety and anti-depressant drugs

-effective only while the drugs are taken

-side effects

Cognitive-behavioral therapy

-relaxation training

-cognitive restructuring to change helplessness to competence (self-efficacy) & reduce catastrophizing

ANXIETY DISORDERS

1. Phobias : specific and social

2. Panic disorder

3. Generalized Anxiety disorder

4. Obsessive-compulsive disorder

5. Posttraumatic Stress disorder

Obsessive-Compulsive Disorder (OCD)

· Obsessions

= Intrusive and recurring thoughts that are not related to real-life problems
(e.g., contamination, doubts about performance, need for orderliness, aggressive impulses, sexual imagery)

· Compulsions

= Purposeless behaviors / mental rituals repeated over & over

· The lifetime prevalence of OCD is 1-2 %

· Women are more likely than men to develop OCD

OCD con’d

Common Compulsions

· Pursuing cleanliness (e.g., chronic handwashing until hands are raw)

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

· Performing repetitive, magical, protective practices (e.g., counting backwards)

· Checking (e.g. "is the stove off?")

· Performing a particular act (e.g. chewing each bite of food exactly 27 times)

Etiology of OCD

Biological/medical

o Activation of the frontal lobes and basal ganglia perhaps due to genetic disposition

Psychoanalytic

o OCD reflects arrest of personality development at anal stage due to severely harsh toilet training; obsessions & compulsions are defense mechanisms (often displacement or projection or reaction formation)

Etiology of OCD

Cognitive-behavioral

-Overgeneralized behaviors that could avoid danger become compulsive rituals reinforced by fear reduction (negative reinforcement)

-Negative & intrusive schema = obsessions, which are danger-related thoughts that overgeneralize

Tx’s for OCD

Biological/medical

Antidepressant drugs (rituals can lead to loss and then sadness)

-effectiveness unknown

Cognitive-behavioral

-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 for 90 minutes over 15 sessions; 25% drop out of treatment

-Cognitive restructuring of control beliefs

-effective if complete tx

Anxiety Disorders

1. Phobias : specific and social

2. Panic disorder

3. Generalized Anxiety disorder

4. Obsessive-compulsive disorder

5. Posttraumatic Stress disorder

Posttraumatic Stress Disorder (PTSD)

· An extreme response to extreme danger/stressor

(50% of American adults experience at least one traumatic event in their lifetime)

· Stressor involved actual or threatened death or serious injury to self or others

· Response to stressor involved intense fear, helplessness, or horror

(In children, agitation)

PTSD Symptoms

Symptoms include 1 month+ at least 1 of the following:

· Increased anxiety and arousal

· Reexperiencing the traumatic event

· Recurring dreams or thoughts about the event

· Avoidance of stimuli associated with the trauma

PTSD Symptoms con’d

3+ of the following 6 for more than 1 month:

· Avoidance of reminders of the event

· Inability to recall an important aspect of the trauma

· Diminished interest in activities

· Feeling detached from others

· Restricted range of affect (e.g., unable to feel love)

· Sense of foreshortened future (e.g., does not expect to have a career or normal life span)

PTSD Symptoms con’d

ALSO 2+ of the following 5 for more than 1 month:

· Difficulty falling or staying asleep

· Irritability or outbursts of anger

· Difficulty concentrating

· Hypervigilance

· Exaggerated startle response

Prevalence of PTSD

Lifetime prevalence estimates:

· 1% to 3% in general population (true after 9/11)

· 9% in at-risk populations (e.g., combat veterans, victims of volcanic eruptions or criminal violence)

Point prevalence estimates:

-woman abused by male partner before/after his tx: 50% before and 30% after tx for male

-veterans of Vietnam war with 3 tours of duty = 100%; fewer tours = 15%

-veterans of Iraqi was 30% in 2005

Etiology of PTSD

· Compared to other anxiety disorders, causal variables more empirically than theoretically derived

· Research has ID’d risk factors given exposure to a trauma:

o Sex (females more at risk)

o Early separation from parents

o Family or personal history of a behavioral disorder

Etiology of PTSD con’d

Biological/medical

Inherited smaller hippocampus in brain

Psychoanalytic: repression of trauma

Cognitive-behavioral

Trauma is a US & classical conditioning & operant avoidance conditioning occurs

Tx’s for PTSD

· Biological: anxiety & depression medication

-effective in short-term only of fear symptom only

· Cognitive-behavioral therapy

-imaginal exposure to thoughts & imagery of trauma

-relaxation

-cognitive restructuring (e.g., of survivor guilt; blames self; feeling inadequate; trust issues)

-effective in long-term

Tx’s for PTSD con’d

Eclectic psychoanalytic and cognitive behavioral

Crisis intervention = Critical Incident Stress Debriefing

-recreating event and discussing it with mental health professionals ASAP after the trauma

-research (e.g. McNally et al., 2003) has shown it may be iatrogenic (e.g, firefighters after 9/11)