Anxiety and Mood Disorders

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Anxiety Disorders
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The Nature of Fear and Anxiety

• Abrupt and Aversive CNS Response to Real Threat
  or Danger
• Prepares Organisms for Immediate Action
• Action Tendency Fight or Flight

Fear
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The Nature of Fear and Anxiety

• More Diffuse Response About
• Impending Real or Imagined
• Future Threat or Danger

Anxiety
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The Nature of Fear and Anxiety
Real Threat
True Alarm
Maladaptive
Adaptive
False Alarm
No Threat
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The Anxiety Disorders
Etiology
Disordered or Maladaptive Experience of
Anxiety or Fear
Normal or Adaptive Experience of Anxiety or
Fear
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The Anxiety Disorders
Process
Onset, Maintenance, and Course
Successful Treatment Response and Outcome
Psychobiological Experiential Processes
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The Anxiety Disorders
Outcome
Panic Disorder
Agoraphobia
What Treatments, by Whom, are Most
Effective, and WHY?
Specific Phobias
Anxiety NOS
Social Phobias
OCD
PTSD
GAD
Acute Stress
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The Anxiety Disorders

• Panic Disorder
• PD With Agoraphobia
• Agoraphobia
• Specific Phobias
• Social Phobias
• Generalized Anxiety Disorder
• Post-Traumatic Stress Disorder
• Obsessive Compulsive Disorder

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The Anxiety Disorders

• Panic Disorder

You may genuinely believe youre having a
heart attack, losing your mind, or on the verge
of death. Attacks can occur any time, even during
nondream sleep
For me, a panic attack is a most violent
experience I feel as though Im losing control
and going insane.
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Panic Disorder

• Clinical Description

• An Unexpected Panic Attack
• Develop Anxiety Over
• the Next Attack or
• The Implications of the Attack and Consequences

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Panic Disorder

• Clinical Description

• Agoraphobia is Common
• Fear of the Marketplace
• Consequence of Severe Unexpected Panic Attacks
• Can Have a Life of its Own

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Panic Disorder

• Facts and Statistics

• Occurs in 3.5 of Population
• 75 are Women
• Onset Between (25-29 yrs)
• Attacks Often Begin at Puberty
• 20 Attempt Suicide
• Average 37 Medical Visits / Year

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Panic Disorder

• Cultural Influences

• Occurs Worldwide
• Prevalence in U.S. is Similar Across Ethnic Groups

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Panic Disorder

• Nocturnal Panic

• 60 Cases Panic While Asleep!
• Usually Between 130 - 330am
• Occur During Deep Sleep Delta
• Do Not Occur During REM Sleep

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Panic Disorder

• Symptoms of a Panic Attack

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

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Panic Disorder

• The Panic Attack

• Abrupt Autonomic Surge
• Unexpected
• Uncontrollable
• Absence of Threat
• False Alarm

10 Minutes
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Panic Disorder

• Laboratory Panic Provocation

• Lactate Infusion
• Hyperventilation
• CO2 Inhalation
• Caffeine

10 Minutes
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Panic Disorder

• Causes

Biological Vulnerability
STRESS
False Alarm
Bodily Cues
Learned Alarm
Involuntary Symptoms
Psychological Vulnerability
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Panic Disorder

• Biological Causes

• Runs in Families
• GABA-BZ Circuit
• Limbic System

• ANXIETY
• Behavioral Inhibition System (BIS)
• FEAR / PANIC
• Fight / Flight System (FF)

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Panic Disorder

• Psychological Causes

Predictable
Uncontrollable
Controllable
Unpredictable
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Treatment of Panic Disorder

• Pharmacologic Treatments

• Block Panic
• Antidepressants (e.g., Imipramine, Paxil, Prozac)
• 20-50 Relapse
• Benzodiazapines (e.g., Xanax)
• 90 Relapse

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Treatment of Panic Disorder

• Psychological Interventions

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

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Treatment of Panic Disorder

• Combined Treatment

THE RESULT
Combined Tx is Better in Short Term

• Multisite Study
• Imipramine Alone
• PCT Alone
• Imipramine PCT
• Placebo Alone
• Placebo PCT

PCT Alone is Better in Long Term
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The Anxiety Disorders

• Specific Phobias

...arent just extreme fear they are
irrational fear. You may be able to ski the
worlds tallest mountain with ease but feel panic
going above the 10th floor of an office
building.
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Specific Phobias

• Clinical Description

• Irrational Fear of Specific Objects or Situations
• Markedly Interferes With Functioning

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Specific Phobias

• Four Major Subtypes

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

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Specific Phobias

• Blood-Injection Injury Type

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

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Specific Phobias

• Situational Type

• Fears of Specific Situations
• Planes, Transportation, Heights
• Response Similar to Panic
• Onset Early 20s

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Specific Phobias

• Animal Type

• Fears of Animals and Insects
• Common in Population, but Different From Normal
  Revulsion
• Early Onset (About 7 yrs of Age)

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Specific Phobias

• Natural Environment Type

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

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Specific Phobias

• Other Type

• Fears Contracting Disease / Illness
• Illness Phobia
• Fear of Choking
• Avoid Swallowing Pills or Foods

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Specific Phobias

• Facts and Statistics

• Occurs in 11 of Population
• Top Fears Heights and Snakes
• Females gt Males (41 Ratio)
• Runs a Chronic Course
• Hispanics gt Caucasian Americans
• Many Do Not Seek Treatment WHY?

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Specific Phobias

• Causes

• Direct Traumatic Conditioning
• Observational Learning
• Information and Language
• Having a Panic Attack
• Probably Some Evolutionary Basis

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Treatment of Specific Phobias

• 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

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Social Phobia
People with social phobia arent necessarily
shy at all. They can be completely at ease with
people most of the time, but in particular
situations, they feel intense anxiety.
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Social Phobia

• Clinical Description

• Marked and Persistent Fear of One or More...
• Social or Performance Situations
• Most Common Type of Social Fear?
• Public Speaking
• Interferes With Life Functioning

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Social Phobia

• Facts and Statistics

• Occurs in 13.3 of Population
• Most Prevalent Disorder
• Males gt Females
• Begins in Adolescence
• Presents Differently in Some Cultures (e.g.,
  Japan)

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Social Phobia

• Causes

• Similar to Panic and Specific Phobia
• Interaction of
• Biological Vulnerability
• Psychological Vulnerability
• Learning Experiences
• Can be Quite Disabling

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Treatment of Social Phobia

• Psychological Interventions

• Similar to Panic and Specific Phobia
• Cognitive-Behavioral Approaches
• Rehearsal and Skills Training
• Cognitive Restructuring

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Treatment of Social Phobia

• Drug Treatments

• Antidepressants for Severe Anxiety
• MAO Inhibitors
• Relapse is Common

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Generalized Anxiety Disorder

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

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Generalized Anxiety Disorder

• Clinical Description

• 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

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Generalized Anxiety Disorder

• Facts and Statistics

• Occurs in 4 of Population
• 50-65 are Female
• Early Gradual (insidious) Onset
• Runs a Chronic Course
• Few Seek Treatment WHY?

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Generalized Anxiety Disorder

• 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

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Generalized Anxiety Disorder
Biological Vulnerability
STRESS
Psychological Vulnerability (Anxious Apprehension)
Worry Process
Imagery Avoidance
Intense Cognitive Processing
Restricted Autonomic Response
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Treatment of Generalized Anxiety Disorder

• Most Interventions are Weak

• Benzodiazepines
• Frequently Prescribed
• Provide Some Relief
• Cognitive-Behavioral Approaches
• Process Avoided Emotional Material
• Relaxation Training
• Does as Well as Medication

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Posttraumatic Stress Disorder

• Clinical Description

• Exposure to Traumatic Events
• War and Combat
• Rape and Assault
• Car Accidents
• Natural Disasters
• Reexperiencing, Flashbacks, Numbing
• Sleep Disturbance, Chronic Arousal

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Posttraumatic Stress Disorder

• Subtypes

• Acute
• 1-3 Months After the Trauma
• Chronic
• Symptoms Last gt 3 Months

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Posttraumatic Stress Disorder

• Facts and Statistics

• 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

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Posttraumatic Stress Disorder

• Causes

• Only Disorder With Clear Etiology
• Biological Vulnerability
• Experience With Events That are...
• Uncontrollable and Unpredictable
• Severity of Trauma and Ones Reaction
• True Alarm!
• Social Support Helps

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Treatment of Posttraumatic Stress Disorder

• Psychological Interventions

• Face the Original Trauma
• Imaginal Reexposure
• Flooding
• Arrange for Corrective Emotional Learning
• Problem of Secondary Gain
• Disability and Compensation

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Obsessive-- Compulsive Disorder

• Clinical Description

• Culmination of All Anxiety Disorders
• Obsessions Intrusive Thoughts, Images, or Urges
  That the Person Trys to Suppress or Eliminate
• Compulsions Thoughts or Actions to Suppress the
  Obsessions and Provide Relief

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Obsessive-- Compulsive Disorder

• Facts and Statistics

• Occurs in 2.6 of Population
• Most Common Obsessions
• Contamination Aggression
• Most Common Compulsions
• Checking Washing
• Almost Equal Sex Ratio (F gt M)
• Onset Early Adolescence to Mid-20s

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Obsessive-- Compulsive Disorder

• Causes

• Anxiety Focused on Unwanted Thoughts
• Thoughts are Unacceptable
• When Fighting to Control Ones
• Psychology Creates More
• Psychopathology

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Treatment of Obsessive--Compulsive
Disorder

• Psychological Interventions

• Cognitive-Behavioral Treatments
• Response Prevention
• Rituals are Actively Prevented
• Exposure
• Systematic and Gradual Exposure to Feared
  Thoughts or Situations
• May Require Hospitalization

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Treatment of Obsessive--Compulsive
Disorder

• Drug Therapies

• Medications Show Promise
• Most Effective Medications
• Inhibit Reuptake of Serotonin
• May Benefit 60 of Patients