CHAPTER SIX

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CHAPTER SIX

• Anxiety Disorders

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Overview

• Notice that the lectures for this chapter are
  organized differently than the textbook
• The book focuses on anxiety as a mood, whereas
  the lectures focus on anxiety disorders
• You are responsible for knowing both information
  from the book and from the lectures

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Anxiety Disorders

• Anxiety, Fear, and Depression
• Overview of Anxiety Treatment
• Generalized Anxiety Disorder
• Obsessive-Compulsive Disorder
• Panic Disorder and Agoraphobia
• Specific Phobia
• Social Phobia
• Epidemiology

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Common Features of Anxiety Disorders

• What do anxiety disorders have in common?
• People with anxiety disorders share a
  preoccupation with or persistent avoidance of
  thoughts and situations that provoke fear or
  anxiety.

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Anxiety vs. Fear

• Fear
• Experienced when a person is faced with real and
  immediate danger
• Mostly involves somatic symptoms (e.g. increased
  heart rate)
• Present-oriented
• Can be adaptive

• Anxiety
• May mostly involve anticipation of future
  negative events (worry)
• May mostly involve somatic arousal
• Can be adaptive if not excessive

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Prevalence Comorbidity

• Prevalence
• Anxiety disorders are more common than any other
  form of mental disorder.
• Highly Comorbid
• Between different anxiety disorders
• Between anxiety and depression
• Between anxiety and substance abuse
• What do anxiety and depression have in common?
• Both defined in terms of negative emotional
  experience
• Both triggered by stressful experiences

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Affect in Anxiety Depression
Emotionality tendency to feel an emotion
Two Dimensions
Positive Affect Negative Affect
Cheerful Sad
Excited Angry
Inspired Guilty
Enthusiastic Ashamed
Proud Scared
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Depression/Anxiety ComorbidityConceptual and
Clinical Overlap
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Anxiety Disorders

• Anxiety, Fear, and Depression
• Overview of Anxiety Treatment
• Generalized Anxiety Disorder
• Obsessive-Compulsive Disorder
• Panic Disorder and Agoraphobia
• Specific Phobia
• Social Phobia
• Epidemiology

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Overview of Treatment for Anxiety

• Exposure (in vivo direct)
• Systematic Desensitization
• the client is taught to relax and while in a
  relaxed state they are presented with items on a
  fear hierarchy, starting with the least
  threatening
• Flooding
• exposure to the most threatening or frightening
  stimuli first

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Anxiety Disorders

• Anxiety, Fear, and Depression
• Overview of Anxiety Treatment
• Generalized Anxiety Disorder
• Obsessive-Compulsive Disorder
• Panic Disorder and Agoraphobia
• Specific Phobia
• Social Phobia
• Epidemiology

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Generalized Anxiety Disorder

• Anxiety in GAD focuses on everyday events (worry
  physical symptoms)
• DSM-IV-TR criteria for GAD include
• Excessive worry occurring more days than not
• Person finds it difficult to control the worry
• Restlessness, easy fatigue, difficulty
  concentrating, muscle tension, sleep disturbance,
  irritability

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Generalized Anxiety Disorder

• GAD is characterized by anxious apprehension
  (worry)
• GAD is a state of High negative affect and
  chronic over-arousal
• Sense of uncontrollability
• Focus on threat-related stimuli that may indicate
  future negative events

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GAD Hypothesized Etiological Factors

• Anxiety as trait does seem to run in families,
  but GAD results less conclusive
• Intolerance of uncertainty
• Belief that worry is adaptive
• Avoidance of threatening information

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GAD Cognitive Therapy

• The three main facets
• Considering thoughts as hypotheses rather than
  facts that can be supported (or not) by evidence
• Utilizing past and present evidence to examine
  the validity of the belief
• Exploring and generating all possible predictions
  or interpretations of an event

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GAD Cognitive Therapy

• Step 1 Awareness
• Provide clients with overview of how their
  cognitions work
• Step 2 Interpretation
• Make clients understand the nature of
  inappropriate anxiety and the role of their
  interpretation of situations that create negative
  affect.
• Step 3 Specific Negative Prediction
• Identify the specific interpretations or
  negative predictions that the clients are making
  and challenge them.

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Anxiety Disorders

• Anxiety, Fear, and Depression
• Overview of Anxiety Treatment
• Generalized Anxiety Disorder
• Obsessive-Compulsive Disorder
• Panic Disorder and Agoraphobia
• Specific Phobia
• Social Phobia
• Epidemiology

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OCD Video

• Educational Objectives
• To gain a clearer understanding of the difference
  between obsessions and compulsions
• To see how symptoms and the course of OCD vary
  for different clients

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Obsessive-Compulsive Disorder

• Must have obsessions with or without compulsions
• Obsessions
• Intrusive nonsensical thoughts, images, urges
  that one tries to resist or eliminate
• Compulsions
• Thoughts or actions designed to suppress the
  thoughts provide relief from anxiety caused by
  obsessions

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Obsessive-Compulsive Disorder

• Compulsions cannot exist
• without obsessions but
• obsessions can exist
• without compulsions
• Most people with OCD
• have both
• Most individuals with OCD do recognize that their
  obsessions and compulsions are unreasonable and
  try to avoid doing them

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Obsessive-Compulsive Disorder

• Typical obsessions include
• contamination
• aggressive impulses
• sexual content
• somatic concerns
• symmetry
• Obsessions are often about normal concerns (e.g.,
  germs, neatness), but differ in intensity level
  compared to people without OCD
• Onset early adolescence to young adulthood
• Course typically chronic

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OCD Rebound Effect
1. Born with a predisposition to be very
emotionally reactive
2. Emotional Trigger/Event
OBSESSIONS COMPULSIONS
uh oh
3. You try to suppress emotional response
chill...
4. But, the more you suppress, the more aware you
become
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OCD Treatment Exposure Response Prevention

• Step 1
• Information gathering
• Step 2
• Exposure response
• Step 3
• Record keeping
• Step 4
• Homework assignments
• Step 5
• Support

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Anxiety Disorders

• Anxiety, Fear, and Depression
• Overview of Anxiety Treatment
• Generalized Anxiety Disorder
• Obsessive-Compulsive Disorder
• Panic Disorder and Agoraphobia
• Specific Phobia
• Social Phobia
• Epidemiology

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Panic Attack Criteria

• Palpitations, pounding or accelerated heart rate
• Sweating
• Trembling and shaking
• Sensations of shortness of breath or smothering
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress

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Panic Attack Criteria (contd)

• Feeling dizzy, unsteady or faint
• Derealization (feelings of unreality) or
  depersonalization (being detached from oneself)
• Fear of losing control or going crazy
• Fear of dying
• Paresthesias (numbness or tingling sensations)
• Chills or hot flushes

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Panic Attack

• Involves an abrupt
• experience of intense fear
• or acute discomfort
• Accompanied by physical
• symptoms (e.g., heart
• palpitations, chest pain)
• Symptoms develop suddenly and reach a peak within
  10 minutes
• Can experience panic attacks with each of the
  anxiety disorders

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Panic Attack Types

• Three types
• Situationally bound (cued)
• Panic only when see a spider
• Unexpected (uncued)
• Out of the blue
• Situationally predisposed
• a person more likely to have a panic attack
  where s/he had one before (e.g., crowded
  restaurant), but having one isnt inevitable

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Panic Disorder Criteria

• Panic Disorder is the presence of
• Recurrent, unexpected panic attacks followed by
  at least 1 month of persistent concern about
  having another attack
• Worry about the possible implications of the
  panic attacks
• Significant behavioral change related to the
  attacks.

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Agoraphobia Criteria

• The essential feature of agoraphobia is anxious
  apprehension about being in places or situations
  from which
• Escape might be difficult or embarrassing
• Help may not be available if one has a panic
  attack

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Panic Disorder Agoraphobia
PANIC DISORDER
AGORAPHOBIA
No Yes
No No disorder Panic Disorder without Agoraphobia
Yes Agoraphobia without Panic Disorder Panic Disorder with Agoraphobia
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Panic Attack Barlow White (1988)
predisposition to be overreactive to stress
stressful event
False Alarm! (becomes a Learned Alarm)
unexplained physical sensations are dangerous
worry focused on somatic sensations
Panic Disorder
Developing Agoraphobia
Panic Disorder with Agoraphobia
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Panic Attack Catastrophic Misinterpretation

• Step 1
• A person misinterprets bodily sensations (e.g.,
  rapid heart rate) associated with anxiety as a
  serious threat
• Step 2
• This leads to increased awareness of biological
  reactions
• Step 3
• Misinterprets these sensations as catastrophic
  events (e.g., Im going crazy, Im going to die)

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Panic Attack Etiology

• Biological Factors Neurochemistry
• One theory suggests that several
  neurotransmitter systems may be hyperactive in
  people with panic disorder.

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Anxiety Disorders

• Anxiety, Fear, and Depression
• Overview of Anxiety Treatment
• Generalized Anxiety Disorder
• Obsessive-Compulsive Disorder
• Panic Disorder and Agoraphobia
• Specific Phobia
• Social Phobia
• Epidemiology

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Specific Phobia

• Excessive or unreasonable fear related to a
  specific object/situation that interferes with
  functioning (e.g., fear of snakes)
• DSM-IV-TRs Five Types
• Animal
• Natural environment
• Blood/injury
• Situational
• Other

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Etiology of Phobia

• Evolutionary adaptation
• Negative information
• Classical conditioning

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Specific Phobia Treatment

• Exposure Therapy (in vivo) Components
• Phobic learning history create new learning
  history
• Stimulus exposure ? anxiety ? relaxation ?
  decreased anxiety
• Fear Avoidance Hierarchy (FAH)
• Subjective Units of Distress Scale (SUDS)

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Fear Hierarchy Example
(SUDS)

1. Thinking about a spider
2. Seeing a picture of a spider far away
3. Seeing a picture of a very close-up spider
4. Seeing a spider in a cage far away
5. Seeing a spider in a cage close up
6. Seeing al spider loose far away
7. Seeing a spider close-up
8. Holding a spider

(25)
(40)
(45)
(60)
(75)
(85)
(95)
(100)
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Anxiety Disorders

• Anxiety, Fear, and Depression
• Overview of Anxiety Treatment
• Generalized Anxiety Disorder
• Obsessive-Compulsive Disorder
• Panic Disorder and Agoraphobia
• Specific Phobia
• Social Phobia
• Epidemiology
• Special Topic Anxiety in Children

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Social Phobia

• Characterized by fear of humiliation by either
  performing badly or by displaying visible
  symptoms of anxiety.
• More than shyness
• If the fears include most social situations, it
  is considered generalized social phobia

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Social Phobia Criteria

• Marked and persistent fear of one or more social
  or performance situations in which a person is
  exposed to unfamiliar people or possible scrutiny
  by others
• Exposure to the feared social situation
  invariably provokes anxiety
• The person realizes that the fear is excessive or
  unreasonable
• The feared situation is avoided or endured with
  great distress

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Social Phobia Cognitive Biases

• Attention
• what people attend to
• Memory
• what people remember
• Judgment
• how people judge things (e.g., how likely
  certain outcomes are) and their judgments of what
  the costs and benefits would be of various
  outcomes

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Social Phobia Cognitive Biases
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Social Phobia Etiology

• 2 kinds of judgment biases in individuals with
  anxiety disorders
• exaggerated estimates of the occurrence of
  negative events
• exaggerated estimates of the cost (valence) of
  negative events
• Social phobia is more distinguished by
  exaggerated cost

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Social Phobia Cognitive Exposure Treatment

• Step 1
• Simulated exposure to feared situations in the
  session
• Step 2
• Cognitive rethinking about the social cost of
  behavior
• Step 3
• Homework assignments for in vivo exposure that
  is developed in the session and is relevant to
  the persons life

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Anxiety Disorders

• Anxiety, Fear, and Depression
• Overview of Anxiety Treatment
• Generalized Anxiety Disorder
• Obsessive-Compulsive Disorder
• Panic Disorder and Agoraphobia
• Specific Phobia
• Social Phobia
• Epidemiology

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Epidemiology of Anxiety Disorders
Disorder Age Of Onset High Risk Groups
Panic late adolescence, mid-30s separated, divorced, women
Agoraphobia 20s-40s separated, divorced, African Americans
GAD childhood - adolescence separated, divorced, women, unemployed, African Americans
Social Phobia adolescence low income, Asian Americans, women
OCD adolescence - early adult separated, divorced
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Lifetime Prevalence Rates by Gender
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One-Year Prevalence Rates by Gender
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One-Year Prevalence Rates by Race
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CHAPTER SIX

• Anxiety Disorders
• Optional Slides

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Relaxation Demonstration

• The goal of this activity was to help you
  understand the process of relaxation treatments
• You may find this technique effective in
  relieving your own stress and anxiety

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GAD Relaxation Treatment

• Step 1
• Using the major muscle
• groups, clients are taught
• to discriminate and detect
• early signs of muscle tension
• Step 2
• Relaxation deepening techniques are employed
  including diaphragmatic breathing

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GAD Relaxation Treatment

• Step 3
• Clients learn to alleviate the physiological
  components of
• anxiety by interrupting the
• learned association between
• over-arousal and worry
• Step 4
• Clients model relaxation in the session and then
  practice it at home with tapes of the session

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Specific Phobia

• FRED IS AFRAID OF SNAKES
• How do we know if this is a phobia or not?
• Fred would be very upset/fearful if
• he were thrown into a pit of cobras
• someone put a large snake around his neck
• he had to walk by a snake in a cage
• he had to watch Raiders of the Lost Ark

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Systematic Desensitization

• I will be showing some pictures of spiders and
  talking about how an actual systematic
  desensitization would work with a spider phobia.
• If you have a fear/phobia of spiders, you may
  leave the room or just close your eyes.
• For each picture I want you to rate how creepy
  you feel according to your SUDS.
• A) 1-20
• B) 21-40
• C) 41-60
• D) 61-80
• E) 81-100

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How creepy would you feel? A) 1-20 B) 21-40 C)
41-60 D) 61-80 E) 81-100
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How creepy would you feel? A) 1-20 B) 21-40 C)
41-60 D) 61-80 E) 81-100
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How creepy would you feel? A) 1-20 B)
21-40 C) 41-60 D) 61-80 E) 81-100
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How creepy would you feel? A) 1-20 B)
21-40 C) 41-60 D) 61-80 E) 81-100
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How creepy would you feel? A) 1-20 B)
21-40 C) 41-60 D) 61-80 E) 81-100
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What did the SUDS reveal?
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Social Phobia Etiology

• There is evidence that social phobia runs in
  families
• Modeling of socially anxious parents has an
  effect on children
• In particular, overprotective and rejecting
  behavior increase the odds of developing social
  phobia

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Social Phobia Culture

• Asian Americans score consistently higher on
  measures of social anxiety than white Americans
  or any other ethnic group.
• Why?
• Hypothesis 1
• Asian Americans experience higher levels of
  generalized distress.
• Hypothesis 2
• Cultural norms and values make Asian Americans
  particularly prone to social phobia.

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Independent vs. Interdependent Self

• Independent Self
• Putting self before others making ones own
  decisions for personal benefit (strongly valued
  in American society)
• Interdependent Self
• Attending to others fitting in with others
  maintaining harmony with others (more valued in
  Asian societies)

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Okazaki Study (1997)

• Asian Americans scored significantly higher on
  measures of distress (anxiety and depression)
  compared to White Americans.
• When comorbidity between social anxiety and
  depression was taken into account, Okazaki (1997)
  found that social anxiety (not depression) was
  associated with how Asians view themselves
  (self-construal).
• More consistent with Hypothesis 2

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Results

• Self-construal and ethnicity are linked to social
  anxiety (not depression) measures
• Social anxiety appeared to be a particularly
  salient form of distress for Asian Americans
• Asian American ethnicity predicted levels of
  social anxiety above and beyond individual
  subjects values of independence and
  interdependence.

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Critical Thinking Activity

• Get into groups of 4-5 people.
• You will be given one cultural variable to
  discuss.
• Discuss how and why there might be differences in
  prevalence rates of the following disorders
  depending on that cultural factor.
• Please be appropriate.
• The disorders are MDD, OCD, and substance abuse