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Title: Anxiety Disorders GAD, Specific Phobias, Social Phobias


1
Anxiety Disorders
  • GAD, Specific Phobias, Social Phobias, OCD, Panic
    Disorder, Agoraphobia, PTSD, Acute Stress Disorder

2
Three Components of Anxiety
  • Physical symptoms
  • Cognitive component
  • Behavioral component

3
Physiology of Anxiety Physical System
  • Perceived danger
  • Brain sends message to autonomic nervous system
  • Sympathetic nervous system is activated (all or
    none phenomena)
  • Sympathetic nervous system is the fight/flight
    system
  • Sympathetic nervous system releases adrenaline
    and noradrenalin (from adrenal glands on the
    kidneys).
  • These chemicals are messengers to continue
    activity

4
Parasympathetic Nervous System
  • Built in counter-acting mechanism for the
    sympathetic nervous system
  • Restores a realized feeling
  • Adrenalin and noradrenalin take time to destroy

5
Cardiovascular Effects
  • Increase in heart rate and strength of heartbeat
    to speed up blood flow
  • Blood is redirected from places it is not needed
    (skin, fingers and toes) to places where it is
    more needed (large muscle groups like thighs and
    biceps)
  • Respiratory Effects-increase in speed and dept of
    breathing
  • Sweat Gland Effects-increased sweating

6
Behavioral System
  • Fight/flight response prepares the body for
    action-to attack or run
  • When not possible behaviors such as foot tapping,
    pacing, or snapping at people

7
Cognitive System
  • Shift in attention to search surroundings for
    potential threat
  • Cant concentrate on daily tasks
  • Anxious people complain that they are easily
    distracted from daily chores, cannot concentrate,
    and have trouble with memory

8
U Shaped Function of Anxiety
  • Useful part of life
  • Expressed differently at various age levels

9
Anxiety Disorders
  • Generalized Anxiety Disorder
  • GAD

10
Generalized Anxiety Disorder
  • Unfocused worry

11
Generalized Anxiety Disorder Diagnostic Criteria
  • Excessive anxiety or worry occurring more days
    than not for at least 6 months about a number of
    events or activities
  • Difficulty controlling worry
  • 3 of 6 symptoms are present for more days than
    notrestlessness, easily fatigued, difficulty
    concentrating, irritability, muscle tension,
    sleep disturbance

12
Generalized Anxiety Disorder (GAD) Prevalence
  • 4 of the population (range from 1.9 to 5.6)
  • 2/3 of those with GAD are female in developed
    countries
  • Prevalent in the elderly (about 7)

13
Generalized Anxiety Disorder Genetics
  • Familial studies support a genetic model (15 of
    the relatives of those with GAD display it
    themselves-base rate is 4 in general population)
  • Risk of GAD was greater for monozygotic female
    twin pairs than for dizygotic twins.
  • The tendency to be anxious tends to be inherited
    rather than GAD specifically
  • Heritability estimate of about 30

14
Generalized Anxiety Disorder Neurotransmitters
  • Finding that benzodiazepines provide relief from
    anxiety (e.g. valium)
  • Benzodiazepine receptors ordinarily receive GABA
    (gamma-aminobutyric acid)
  • GABA causes neuron to stop firing (calms things
    down)

15
Generalized Anxiety Disorder Neurotransmitters
  • Getting Anxious
  • Hypothesized Mechanism
  • Normal fear reactions
  • Key neurons fire more rapidly
  • Create a state of excitability throughout the
    brain and body perspiration, muscle tension etc.
  • Excited state is experienced as anxiety
  • Calming Down
  • Feedback system is triggered
  • Neurons release GABA
  • Binds to GABA receptors on certain neurons and
    orders neurons to stop firing
  • State of calm returns
  • GAD problem in this feedback system

16
GABA Problems?
  • Low supplies of GABA
  • Too few GABA receptors
  • GABA receptors are faulty and do not capture the
    neurotransmitter

17
Generalized Anxiety Disorder Cognitions
  • Intense EEG activity in GAD patients reflecting
    intense cognitive processing
  • Worrying as a form of avoidance
  • restrict their thinking to thoughts but do not
    process the negative affect
  • Worry hinders complete processing of more
    disturbing thoughts or images
  • Content of worry often jumps from one topic to
    another without resolving any particular concern

18
Generalized Anxiety Disorder Treatment
  • Short term-benzodiazepine (valium)
  • Cognitive Therapy (focus on problem)

19
Anxiety Disorders
  • Phobias Specific Social

20
Phobia Diagnostic Criteria
  • Marked persistent unreasonable fear of object
    or situation
  • Anxiety response
  • Unreasonable
  • Object or situation avoided or endured with
    distress

21
Differential Diagnosis of Specific Phobia
  • Vs. SAD not related to fear of separation
  • Vs. Social Phobia not related to fear of a
    social situation or fear of humiliation
  • Vs. Agoraphobia fear not related to closed
    places
  • Vs. PTSD fear not related to a specific past
    traumatic event

22
Phobias Types
  • Specific phobias
  • Blood-Injection Injury phobias
  • Situational phobia
  • Natural environment phobia
  • Animal phobia
  • Pa-leng (Chinese) colpa daria (Italian)
  • Germs
  • Choking phobia..

23
Developmentally Normal Fears
24
Phobias Prevalence
  • Fears are very prevalent
  • Phobias occur in about 11 of the population
  • More common among women
  • Tends to be chronic

25
Etiology of Phobias Genetics
  • 31 of first degree relatives of phobics also had
    a phobia (compared to 11 in the general
    population)
  • Relatives tended to have the same type of phobia
  • Not clear if transmission is environmental or
    genetic

26
Specific Phobia Behavioral Perspective
  • Case of Little Albert
  • Two-factor model
  • Acquisition-classical conditioning
  • Maintenance-operant conditioning

27
Specific Phobia Behavioral Perspective
  • Classical conditioning
  • Modeling
  • Stimulus generalization

28
Evolutionary Preparedness
  • Predilection (or preparedness inherited from
    ancient ancestors) to be afraid of hazards
  • Good evolutionary reasons to be afraid of some
    things (snakebites, falls from large heights, and
    being trapped in small places)

29
Biological Preparedness Exercise
  • Write down an object or situation of which you
    are particularly afraid
  • Write down the events that led to the fear
  • As a group, tally the feared objects and the
    percentage of times the person could recall the
    beginning of the fear
  • As a group, indicate which group of fears are
    associated with dangerous consequences, e.g. fear
    of snakes

30
Hypothesis
  • According to biological preparedness theory,
    objects of phobic fear are nonrandomly
    distributed to objects or situations that were
    threatening to the survival of the species.
  • Hypothesis More threatening objects or
    situations (that are threatening) will be listed
    than those that are not threatening

31
Specific Phobia Cognitive Perspective
32
Specific Phobia Social and Cultural Factors
  • Predominantly female
  • Unacceptable in cultures around the world for men
    to express fears

33
Specific Phobia Treatment
  • Systematic Desensitization

34
Social Phobia
  • Fearful apprehension
  • Social situations

35
Social Phobia Diagnostic Criteria
  • Marked or persistent fear in one or more social
    or performance situations
  • Exposure to fear situation is associated with
    extreme anxiety
  • Person recognizes that fear is excessive or
    unreasonable
  • Feared social and performance situations are
    avoided or endured with intense anxiety

36
Social Phobia Prevalence
  • 13 of the general population
  • About equally distributed in males and females,
    however, males more often seek treatment
  • Usually begins around age 15
  • Equally distributed among ethnic groups

37
Etiology of Social Phobia
  • Biological vulnerability to develop anxiety or be
    socially inhibited. May increase under stress or
    when the situation is uncontrollable
  • Unexpected panic attack during a social situation
    or experience a social trauma resulting in
    conditioning (i.e. a learned alarm).
  • Modeling of socially anxious parents
  • Preparedness

38
Kagans theory inhibited temperament
  • Inhibited temperament risk factor in social
    phobia
  • Behaviorally inhibited children at age 2 remained
    inhibited at age 7 and 12

39
Biological Basis of Temperament
  • Kagan proposed temperamental differences related
    to inborn differences in brain structure and
    chemistry
  • He found inhibited children have
  • Higher resting heart rates
  • Greater increase in pupil size in response to
    unfamiliar
  • Higher levels of cortisol (released with stress)

40
KagansTemperamental/Biological Theory and
Prevention
  • Early identification of at risk children
  • Parental training
  • Avoid overprotecting
  • Encourage children to enter new situations
  • Help kids to develop coping skills
  • Avoid forcing the child

41
Social Phobia Treatment
  • Cognitive-Behavioral Therapy
  • Assess which social situations are problematic
  • Assess their behavior in these situations
  • Assess their thoughts in these situations
  • Teaches more effective strategies
  • Rehearse or role play feared social situations in
    a group setting
  • Medication
  • Tricyclic antidepressants
  • Monoamine oxidase inhibitors
  • SSRI (Paxil) approved for treatment
  • Relapse is common with medications are
    discontinued

42
Phobias content vs. function
  • Psychoanalysts believe content is important
  • Phobic stimulus has symbolic value
  • Little Hans the horse
  • Behaviorists believe function is important
  • All phobias acquired in same manner can be
    treated in same manner
  • All means of avoidance, treat with exposure

43
Psychoanalytic Etiology
  • Phobias as defenses against anxiety from id
    impulses
  • Anxiety taken from id impulse and placed onto
    symbolic representation of the impulse
  • Ex Little Hans fear of his father (i.e. Oedipal
    conflict) displaced onto horses
  • Horses symbolized his father

44
Behavioral Etiology Phobias are learned. But
how?
  • Avoidance-conditioning model classical
    conditioning results in fear
  • Ex fear of heights following a bad fall
  • Problem 1 phobias can develop without prior
    exposure to the feared stimulus
  • Ex snake phobics
  • Problem 2 many have frightening experiences
    without developing a phobia
  • Ex car accidents

45
Avoidance-conditioning cont.
  • Fewer problems if preparedness of stimuli
    considered
  • Preparedness phobias may result from stimuli to
    which an organism is prepared to have a fear
    reaction
  • Evolutionary prepared fear response
  • Snakes, spiders, heights
  • Vs. electrical outlets, lambs
  • Ohmans studies
  • Provides method of addressing findings that
    feared stimuli are not random
  • Mc Nally against the A-C model

46
Behavioral cont Modeling
  • Phobias learned by watching reactions of others
  • vicarious learning
  • Can also be learned by listening to warnings
  • Mineka the rhesus monkeys
  • Teen monkeys placed with snake phobic adults
    developed fear of snakes
  • Monkeys shown videos of a monkey reacting
    fearfully to neutral vs. prepared stimuli
  • Only monkeys exposed to prepared stimulus
    developed phobia

47
Cognitive Theories
  • Anxiety due to attending to negative stimuli to
    believing negative events likely to occur
  • Social phobics thoughts focused on image they
    present and negative evaluation
  • I think I am boring when I talk to others
  • Fears seem irrational to phobics
  • Maybe b/c the fear is unconscious
  • Ohman Soares study
  • Increased response to pictures matching their
    phobia

48
Anxiety Disorders
  • Obsessive Compulsive Disorder (OCD)

49
Obsession and Compulsions
  • Obsession Unwanted repetitive intrusive
    thoughts, images or urges
  • Exs contamination, sexual impulses, /or
    hypochondriacal fears
  • Compulsion Repeated thoughts or actions designed
    to provide relief
  • Ex cleanliness, checking, avoiding certain
    objects
  • Perceived of as irrational or silly

50
Relationship between Compulsion and Obsession
  • The most common obsession- germs and dirt is
    related to the most common compulsion handwashing
  • Obsessions create considerable anxiety
  • Compulsions are an attempt to cope with the
    anxiety.
  • Repeating rituals (second most common compulsion)
    is often a way-in their mind-to avoid harm (eg.
    step on the crack game)
  • Children recognize that compulsions are
    unreasonable and will attempt to hide the
    behavior with nonfamily members

51
OCD Diagnostic Criteria
  • A. Either obsession or compulsions
  • B. Recognition that obsessions or compulsions are
    excessive or unreasonable (does not apply to
    children)\
  • C. The obsession or compulsions cause marked
    distress, and are time consuming (take over one
    hour a day) or significantly interfere with the
    persons normal functioning
  • D. If another Axis I disorder is present, the
    content of the obsession or compulsion is not
    restricted to it (preoccupation in food in eating
    disorder, concern with drugs in Substance Abuse
    disorder)
  • E. The disturbance is not due to the direct
    effects of drugs, medication or a physical
    condition
  • Specifier With poor insight if, most of the
    time, the person does not recognize the
    obsessions and compulsions are unreasonable

52
OCD Prevalence
  • 2.6 (may be a bit of an overestimate)
  • 10 to 15 of normal college students engage in
    clinically significant checking behavior
  • More common in females (reversed in childhood)
  • Age of onset is in teens to young adulthood
  • Chronic course

53
OCD Etiology Psychoanalytic
  • Obsessions and compulsions as a reaction to
    instinctual, Id, impulses
  • Due to harsh toilet training
  • Fixation in anal stage
  • Id vs. defense mechanisms (ego)
  • Id obsessions
  • Ego compulsions
  • Adler feel incompetent as a child, create
    control over environment through compulsions

54
OCD Etiology Cognitive Behavioral
  • Compulsions
  • learned behaviors based on consequences
  • Reduced fear after completing compulsions
  • But not obsessions
  • Poor memories?
  • Compulsive checkers have poor recall for whether
    they had completed the compulsion (e.g. turning
    off lights) previously
  • Obsessions
  • Thought suppression paradoxical effect
  • Increased prreoccupation and negative mood

55
Etiology OCD Biological Explanations
  • Neurotransmitter (low serotonin)
  • Brain structures/areas

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OCD Treatment
  • Medication SSRIs (serotonin reuptake inhibitors)
  • Average treatment gain with medication is
    moderate and relapse occurs when medication is
    discontinued
  • Exposure and ritual prevention (ERP)
  • Psychosurgery

60
Anxiety Disorders
  • Panic Disorder with and without agoraphobia

61
Panic Disorder
  • Attack occurs suddenly, unexpectedly, peaking
    within a few minutes and lasting around ten
    minutes
  • Heart palpitations, nausea, chest pain, choking,
    dizziness, apprehension
  • Depersonalization feeling outside your body
  • Derealization feeling world is unreal
  • Fear losing control, dying, going insane
  • Interoceptive avoidance
  • Can develop agoraphobia

62
Panic Disorder Diagnostic Criteria
  • Recurrent unexpected panic attacks( A discrete
    period of intense fear of discomfort in which
    four or more somatic/anxiety symptoms developed
    abruptly and reached a peak within 10 minutes)
  • At least one of the attacks has been followed by
    conern for additional attacks and significant
    change in behavior
  • Not due to physiological effects of medications,
    drugs, or medical conditions
  • Not accounted for by another disorder

63
Three Types of Panic Attacks
  • Unexpected out of the blue
  • Situationally bound almost always occur in
    certain contexts
  • Situationally predisposed or cued occur in
    certain contexts but not all the time
  • If only cued or situational, could be phobia

64
Panic Disorder
  • Prevalence 2 men, 5 women
  • Average age of onset is between 25 and 29
  • Commonly paired with a traumatic experience
  • With or without agoraphobia
  • Fears of public places and inability to escape
    from them (shopping malls, crowds)
  • Fear having a panic attack in public
  • Often dont leave the house
  • if avoidance widespread, agoraphobia results

65
Etiology Panic Disorder Biological Explanations
  • Neurotransmitters
  • Biological vulnerability neurotransmitters
    norepinephrine
  • Not clear whether the problem is excessive or
    deficient activity or some other form of
    dysfunction related to norepinephrine
  • Genetics
  • One study found 24 concordance among identical
    twins and 11 concordance in fraternal twins.
    (baserate is 3.5)

66
Fear of fear hypothesis
  • Goldstein Chambless
  • Agoraphobia as a fear of having a panic attack in
    public
  • Panic disorder patients misinterpret bodily
    signs/symptoms catastrophically
  • Anxiety sensitivity focus on their bodily
    sensations and inability to assess these
    sensations logically

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Comorbidities
  • Panic attacks found in 80 of those diagnosed
    with an anxiety disorder other than PD
  • Not frequent enough to meet PD criteria
  • MDD, GAD, phobias, substance abuse

69
Panic Disorder Treatment
  • Medication
  • Antidepressant medications associated with some
    improvement in 80 of patients with 40 to 60
    recovering markedly or fully
  • Improvements contingent on medications
  • Benzodiazepines (such as Xanax) have also been
    empirically effective
  • Cognitive
  • Emphasis on correcting misinterpretations of body
    sensations
  • Educating about panic attacks
  • Teach more accurate interpretations
  • Exposure
  • 70 of patients improve but few are cured

70
Panic Combined Treatment
  • Short Term
  • Combined treatment no more effective than
    individuals treatments in the short term
  • Long Term
  • Those receiving CBT alone maintained most of
    their treatment gains
  • Those taking medication (alone or in combination)
    deteriorated somewhat

Recommendation Psychological treatment offered
first, followed by medication
71
Anxiety Disorders
  • Post Traumatic Stress Disorder
  • PTSD

72
PTSD
  • Extreme response to a stressor
  • Anxiety, avoidance of similar stimuli, emotional
    flattening
  • Significant impairment
  • Person must have experienced or witnessed event
    involving actual/threatened death or serious
    injury to self or others
  • 25 experiencing a trauma develop PTSD

73
PTSD VS. Acute Stress Disorder
  • Acute Stress Disorder
  • Reaction to trauma, significant impairment
  • Lasts up to one month
  • Normal reaction to trauma
  • 60 recover without experiencing PTSD
  • PTSD
  • Acute stress disorder lasting greater than one
    month

74
PTSD Symptoms
  • Symptoms in each category gt 1 month
  • Reexperiencing recalling the event, nightmares,
    emotional distress w/ similar stimuli or on
    anniversaries
  • Avoidance/numbing attempt to avoid thinking
    about the event, amnesia, decreased ability to
    feel positive emotions, decreased
    contact/interest in others
  • Go back and forth between 1 2

75
PTSD Symptom Cont.
  • Increased arousal sleep difficulties, low
    concentration, hypervigilance, exaggerated
    startle response
  • Comorbidities MDD, anxiety disorders, marital
    problems, substance abuse, suicidality, somatic
    complaints
  • Prevalence 1 3 general population
  • 20 in Vietnam veterans
  • 94 rape victims

76
PTSD in kids
  • Different manifestation of symptoms
  • Nightmares (monsters)
  • Behavioral changes
  • Quiet to aggressive, outgoing to withdrawn
  • Regression
  • Loss of acquired skills (toilet training, speech)
  • Difficulty discussing traumatic event

77
Risk Factors for PTSD
  • Given exposure to a trauma,
  • Female gender
  • Early separation from parents
  • Family history
  • Preexisting mental illness
  • Increased severity of trauma
  • Initial reaction to trauma
  • Depressed, anxious, dissociative symptoms

78
PTSD Etiology Behavioral
  • Classical conditioning to fear
  • Ex woman fears parking lots (CS) b/c she was
    shot in one (UCS)
  • Avoidance builds due to negative reinforcement
    (i.e. reduction in fear by avoiding parking lots)

79
Other PTSD Etiologies
  • Psychodynamic memories so painful they are
    repressed
  • Person tries to reintegrate memories into
    consciousness
  • Biology twin studies support a genetic diathesis
  • Heightened norepinephrine
  • Increased startle
  • Evidence still mixed
  • No good evidence for why some develop PTSD
    others do not

80
General Etiology of Anxiety Disorders
  • Biological Contributions
  • Evidence that suggests individuals inherit the
    tendency to be anxious or highly emotional
  • What could be inherited?
  • Specific brain circuits and neurotransmitter
    systems (GABA noradrenergic serotonergic
    systems)
  • Over production of corticotropin releasing factor
    (CRF) which is associated with activation of the
    HPA axis
  • Functional systems gone awry

81
Role of the Behavioral Inhibition System (BIS)
  • Functional system proposed by Jeffrey Gray
  • BIS is activated by brain stem signals of
    unexpected events or danger signals from the
    cortex
  • Leads to anxiety
  • Corresponds to the Limbic system
  • Specifically, the septo-hippocampal system
    innervated by both serotonergic circuits and
    noradrenergic circuits

82
Fight/Flight Systems
  • Also proposed by Jeffrey Gray
  • Originates in the brain stem, activates the
    amygdala, and results in an immediate
    alarm-and-escape response in animals that looks a
    lot like panic
  • Most likely associated with Panic Disorder

83
Etiology of Anxiety Disorders (contd)
  • Psychological Contributions
  • Freud anxiety as a psychic reaction to danger
    surrounding the reactivation of an infantile fear
    situations
  • Behaviorists anxiety as a by product of
    conditioning experience
  • More recent view children initially obtain a
    perception that events are not under their
    control and this is dangerous
  • Sense of control develops via interactions with
    parents
  • Important psychological contribution

84
Etiology of Anxiety Disorders (contd)
  • Stressful life events
  • Many stressors activate biological and
    psychological vulnerabilities to anxiety
  • Integrated model
  • Interaction between biological, psychological,
    experiential, and social variables

85
Etiology for Specific Anxiety Disorders?
  • Why would it be hard to derive etiologies for
    specific types of anxiety disorders?

86
Comorbidity in Anxiety
  • Within anxiety disorders due to
  • Overlapping symptoms
  • Ex fast heart rate is a symptom of PTSD, Panic
    disorder, and GAD
  • Overlapping etiologies
  • Ex helplessness as a theory for both phobias
    and GAD
  • Across other DSM-IV disorders
  • Spectrum idea
  • Depression on a continuum with anxiety
  • Common symptoms lack of sleep, lack of
    concentration, worry
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