4- Anxiety Disorders

Anxiety and Fear

Chapter 4a

Anxiety Disorders

• Anxiety – a negative mood state with somatic symptoms and apprehension due to unpredictability and lack of control over future events • Fear – alarm reaction to danger with strong escapist tendencies due to present danger or life-threatening emergencies

Anxiety and Fear • Both can be adaptive – Performance enhanced by a little anxiety – Fear prepares us for life-saving action • “fight or flight”

• Problem is that excessive anxiety, false alarms can disrupt normal functioning

Anxiety Disorders • Symptoms of anxiety disorders involve: – Cognitions: apprehension about the future – Bodily responses: muscle tension and sympathetic reactivity – Behavior: avoidance of anxiety- evoking stimuli or performing rituals – Insight: understanding that symptoms are irrational – Impairment: lowered functioning

Types of Anxiety Disorders • • • • • • •

Panic Disorder Panic Disorder with Agoraphobia (PDA) Generalized Anxiety Disorder (GAD) Specific Phobia Social Phobia Posttraumatic Stress Disorder (PTSD) Obsessive- Compulsive Disorder (OCD)

Statistics and Demographics • Yearly Incidence is 18.1% of American adults • 29% of people develop it at some point – But, only 20% of sufferers seek treatment

• People with anxiety disorders – 81% have more than one type of anxiety – 90% have more than one psychological disorder

Statistics and Demographics • All, except OCD, are more common in women • Childhood and adolescent onsets are likely, except in Panic Disorder • Costs society about $42 billion/year in health care costs, lost wages, and productivity

Causes of Anxiety Disorders • General biological vulnerability – Behavioral inhibition system • limbic system misinterprets threat signals

– GABA depletion – Genetic influences – Personality factors • Pessimistic, irritable, driven

– Evolutionary preparedness • Fear snakes, spiders, angry rejecting people

Causes of Anxiety Disorders • General psychological vulnerability – Lack of self-esteem and inability to cope – External locus of control – Dangerous or life threatening living environments • 9-11 • Race / Poverty • Aging

Panic Disorder • DSM Checklist – Recurrent unexpected Panic Attacks – A month or more of one (1) of the following • Persistent concern about having additional attacks • Worry about the implications/consequences of an attack • Significant change in behavior related to the attacks

Causes of Anxiety Disorders • Specific psychological vulnerability – We are taught what to situations to fear by our parents – Sometimes phobic behavior linked to specific experiences: • Attacked by dog • Bad public speaking experience

– Learned alarms associate true cues for danger with innocuous cues

Panic Attack • Panic Attack- periodic short bouts of panic that occur suddenly, reach a peak within 10 minutes, and gradually pass • Edward Munch’s “The Scream” immortalizes his own panic attack on a bridge at sunset

Panic Attacks • Three basic types: – Situationally bound (cued) only occurs in the stimulus environment • Specific or Social phobia

– Unexpected (uncued) occurs without a stimulus – Situationally predisposed an increased likelihood of occurrence in stimulus environment • Panic Disorder

Panic Disorder • Agoraphobia sometimes develops as a consequence of extreme phobic avoidance of panic attacks • Though initially tied to panic, it can become relatively independent of it • Also related to introceptive avoidance – Avoiding activities that might trigger somatic sensations of panic

Agoraphobia • “Fear of the marketplace” or fear of public areas • Anxiety about being in situation where escape difficult or embarrassing or where help not available in case of panic attack • Sample situations: outside home alone, in crowd, bridges, freeways, tunnels, on a bus, etc.

Panic Disorder • Physiological Findings – Higher rates of: • Mitral valve prolapse – Awareness of heart pounding

• Hypothyroidism • Hypoglycemia • Vestibular function (motion sickness due to inner ear)

– Induce panic attacks by CO2 inhalation, hyperventilation, and caffeine ingestion

Cognitive Theory Trigger Stimulus (i.e. cue)

Precieved Threat

Apprehension or Worry

Catastrophic Interpretation

Body Sensations Trigger Stimulus (i.e.caffeine)

Biological Theory • The circuit of the brain that produces panic reactions – Amygdala, Ventromedial nucleus, central gray matter, and locus ceruleus • Indicates that norepinephrine activity is irregular • Different from people with Anxiety which is due to GABA inactivity • The system only shares the amygdala (responsible for fear and other emotions)

Statistics and Demographics • 2.3 % of the U.S. population suffer from Panic Disorder (Weissman et al., 1997) a worldwide incidence rates are similar – Susto, ataques de nervios, and Kyol goeu

• > 75% of PDA sufferers are women

Chapter 4b

Anxiety Disorders

– Culturally accepted for women to express fear and panic

• 60% have nocturnal panic occuring during Delta wave (deep sleep)

Generalized Anxiety Disorder • DSM Checklist – Excessive or ongoing anxiety and worry for at least six months, about numerous events or activities – Difficulty controlling the worry – At least three (3) of the following • Restlessness • Fatigue • Irritability

•Muscle tension •Sleep disturbance

Generalized Anxiety Disorder • Sometimes called “free floating” anxiety or the “what if?” disorder • Diagnosed after ruling out all other Axis I disorders as source of anxiety • Often chronic and worsens with stress • Probably the least studied anxiety disorders

– SDI

Statistics and Demographics of GAD • Yearly incidence is about 4%, it is the most common anxiety disorder • Occurs more commonly in Western cultures but in 3- 4% of worldwide population (3.5% W, 6% AA) • Usually first appears in childhood but can occur at any age due to a stressor and may get worse in the elderly • Sex ratio more likely in women, 2:1

GAD Theories • Sociocultural – Societal dangers and economic stress

• Psychodynamic – Excessive anxiety and poor defenses

• Humanistic – Failure to receive unconditional positive regard and are overcritical of themselves

Cognitive Theories • Maladaptive assumptions and beliefs “life is dangerous unless proven safe” • Power and value of worrying – Worry about worrying (negative view of worry) – Worry about unknown – Worry reduces arousal

Specific Phobia • DSM Checklist – At least six months of marked and persistent fear of a specific object or situation – Immediate anxiety from exposure – Recognition that the fear is excessive or unreasonable – Avoidance of the object – SDI

Specific Phobia • Named after their Greek word origins – Some interesting phobias • • • • • • •

Ailurophobia (animals) Astraphobia (natural) Haptephobia (bii) Gephyrophobia (situational) Coulrophobia (other) Hexakosioihexekontahexaphobia (other) Anatidaephobia (other)

Biological Theory • Hashimoto’s thyroiditis (Hypothyroidism) – Levels of hormone waiver to try and avoid the condition

• Hypothalamic-pituitary-axis – Associated with an abnormal response to stress – Increased sensitivity of neurons to firing

Subtypes of Specific Phobia • Animal (onset ~7 years) – Fear of animals or insects that usually develop in childhood

• Natural (onset ~7 years) – Fear of situations or events in nature (i.e. storms, heights, water, etc.); tend to cluster together

• Blood injection-injury (onset ~9 years) – Fear of blood, injury, or possibility of an injection, unlike other phobias usually results in a lowering in BP

• Situational (onset early to mid 20s) – Fear of enclosed spaces (i.e. claustrophobia) or public transportation (i.e. flying, trains) which is atypical

• Other – Fear of choking, vomiting, contracting an illness, loud sounds, or costumed characters

Statistics and Demographics • Phobias affect up to 9% of population • Approximately 11% of people will have severe enough specific fears at some point in life to classify as phobia • Females > Males (4:1 worldwide prevalence), except for some exceptions (i.e. heights, dentists) • More frequent with Hispanics than Whites • Onset: childhood (may remit adolescence or decline in old age) but tends to run a chronic course (lasts a lifetime)

Etiology

Specific Phobia General Biological Vulnerability

• Direct Experience - only 50% • False alarm - panic attack with situation • Observational learning - learning fears vicariously • Informational transmission - repeated warnings and cautions • General Biological Vulnerability (Seligman’s evolutionary “preparedness” model) – Distribution of phobias does not correspond with distribution of traumatic learning experiences but rather evolutionary dangers

Separation Anxiety Disorder • A related anxiety disorder that is unique to children: – Excessive, enduring fear that separation from parent or guardian will result in harm to themselves or their parents (i.e. lost, kidnapped, killed, etc.) – Manifests as distress and anxiety which results in a refusal to go school, leave home, or even sleep alone

Social Phobia • Subtype: – Generalized: fear most social situations, which is often confused with panic disorder with agoraphobia; Often emerges out of childhood – Fear of doing something in public (i.e. eating, writing, speaking) – Fear public places (restrooms, restaurants) – Fear of social interactions (speaking to strangers, dating)

Direct Experience

STRESS

Vicarious Experience True Alarm

False Alarm Learned Alarm

Specific Psychological Vulnerability SPECIFIC PHOBIA

General Psychological Vulnerability

Social Phobia • DSM Checklist – At least six months of marked and persistent fear of social or performance situations involving exposure to unfamiliar people/scrutiny. Concerned about embarrassment – Anxiety produced by exposure – Recognition that the fear is excessive or unreasonable – Avoidance of situation and SDI

Statistics and Demographics • Social phobia affects up to 8% of population; up to 13% will experience this problem at some point – Most common psychological disorder affecting ~35 million people in the U.S. – Most prevalent in adults age 18-29, low SES, single, and undereducated; decreases with elderly

• Sex ratio slightly favors women; 1.4:1.0 – Females > Males in community samples; but roughly equal in clinical samples

• Begins in late childhood / adolescence ~15 years

Etiology General Psychological Vulnerability

PTSD General Biological Vulnerability

• DSM Checklist

STRESSORS

1st No Alarm

3rd

2nd False Alarm

True Alarm Learned Alarm

– Exposure to actual or threatened death/injury (to self or others) – At least 1 month of Core Symptoms (3 Major Categories): • Psychological re-experiencing – Recurrent recollections of the event, dreams, flashbacks – Triggered by seemingly innocuous event

Anxious Apprehension Specific Psychological Vulnerability

SOCIAL PHOBIA

PTSD • Avoidance (“psychic numbing” or emotional anesthesia) – Avoidance of reminders of event (avoid news, reading)

• Increased Arousal – Pronounced startle reflex; hypervigilance

– Some Associated Symptoms

Types of PTSD • Delayed Subtype – symptoms occur 6 months after a traumatic event

• Acute Stress Disorder – Symptoms occur < 1 month

• Survivor guilt • Sense of foreshortened future (impending catastrophe) • “Omen formation” (sense can predict omen; most common in kids)

Statistics and Demographics

Etiology General Psychological Vulnerability

General Biological Vulnerability

• PTSD Risk factors: – Duration, proximity, and severity of traumatic event – Alcoholism – Other anxiety disorders – Child abuse – Low social support

• Onset: usually within 3 months of the stressor; delayed subtype (at least 6 months after stressor; highly controversial) • Can be exacerbated or reactivated years later

TRAUMA True Alarm Learned Alarm Anxious Apprehension

Avoidance or numbing of emotional response Moderated by social support And ability to cope

PTSD

Obsessive- Compulsive Disorder • DSM Checklist – Recurrent obsessions or compulsions – Past or present recognition that the obsessions or compulsions are excessive or unreasonable – Significant distress and impairment in functioning and relationships, or disruption by symptoms for more than one hour a day

Common Themes in OCD • Obsessive thoughts, wishes, impulses, images or ideas about: – – – – –

Dirt and Germs (Louis Pasteur) Aggression and violence Orderliness Religion Sex

• Compulsive or ritualistic behavior or thoughts that reduce anxiety such as: – – – –

Hand washing or cleaning (Beethoven) Checking, order, and balance (stacking) Touching Verbal rituals and counting

Statistics and Demographics • As many as 2- 3 % have OCD in U.S. and other countries in a given year (~ 5 million people in the U.S.) • Equally common in men and women and races/ethnic groups (slightly more common in adult females; in childhood sex ratio is reversed) • Usually begins in young adulthood (mid-20’s) and persists over time but intensity may fluctuate – Peaks earlier in males (13-15) than females (20-24)

OCD • Obsessions are intrusive and mostly nonsensical thoughts, images, or urges that the individual resists or attempts to eliminate • Compulsions are thoughts or actions used to suppress the obsessions and provide relief. Can be behavioral or mental

Comorbidity • In conjunction with obsessions and compulsions, a person with OCD may experience: – Generalized anxiety – Panic attacks – Debilitating avoidance – Major depression

OCD Theories • Rituals are a way to neutralize any negative effect caused by thinking or to suppress the thinking itself so that anxiety is temporarily relieved • Thought-action fusion – Thoughts are equated with the specific action or activity represented – Caused by attitudes of excessive responsibility

OCD Theories

Etiology General Psychological Vulnerability

• Psychodynamic – Battle of Id impulses (obsessions) and ego defenses (counterthoughts/rituals)

General Biological Vulnerability STRESS

Intrusive thoughts, images, or impulses

• Cognitive Behaviorists Specific Psychological Vulnerability

– Obsessions grow from normal human tendency to have unwanted and unpleasant thoughts

• Biological Theory – Low serotonin and abnormal functioning – Abnormal orbitofrontal cortex and caudate nuclei • Converts sensory information into action

Anxious Apprehension Cognitive or Behavioral Rituals to neutralize or suppress thoughts

False Alarms Learned Alarm

OCD

Treatments • Behavioral Therapy – Ideas are derived from basic learning principles of classical and operant conditioning – Involves cognitive restructuring • Chest pain is interpreted as “I’m having a heart attack” restructured to “This is uncomfortable but not dangerous”

– Found to be as effective as drug treatments but less invasive, so it is the first choice

Treatments • Behavioral Treatments – Flooding • Exposure (prolonged contact with feared stimulus); must be sure anxiety is fully extinguished/habituated before removal, otherwise symptoms will worsen • Response Prevention (preventing response that minimizes anxiety) – Prevent execution of ritual, thought stopping – EMDR facilitates exposure (does not work better than other exposure treatments) – Effective for phobias, OCD and perhaps PTSD

Treatments • Behavioral Treatments – Modeling • Handle feared object in front of person

– Systematic desensitization • Relaxation and anxiety are incompatible – Deep muscle relaxation (physiological state that is incompatible with anxiety) – Anxiety hierarchy of stimuli (least to most threatening) – In vivo or imaginally (effective in ~90% of phobias) – Works via reciprocal inhibition

Treatments • Biological Treatments – Tricyclic and SSRI Antidepressants (Imipramine, Prozac, Lexapro) • Especially effective with panic disorder and OCD (Lexapro) • Not effective for social phobias

– Benzodiazapines (Xanax, Valium. Librium) • Effective for GAD (short-term) • Addictive

– Chlomipramine • OCD

– Buspirone • GAD

Review • Anxiety and Fear are adaptive, but in excess and in the absence of true danger are considered disorders • Anxiety disorders – Panic Disorder • Panic Attack Features and Subtypes

– Panic Disorder with Agoraphobia (PDA) • Panic attacks with a strong phobic avoidance of future attacks, consequences of attacks, significant change of behavior to avoid attacks

– Generalized Anxiety Disorder (GAD) • “Free floating” anxiety

Types of Anxiety Disorders • • • • • • •

Panic Disorder Panic Disorder with Agoraphobia (PDA) Generalized Anxiety Disorder (GAD) Specific Phobia Social Phobia Posttraumatic Stress Disorder (PTSD) Obsessive- Compulsive Disorder (OCD)

Review • Symptoms of anxiety disorders involve: – Cognitions, Bodily responses, Behavior, Insight, and Impairment

• Etiology – General Biological Vulnerability – General Psychological Vulnerability – Specific Psychological Vulnerability

• Shared vulnerabilities often results in comorbidities – An Additional Anxiety Disorder, Major Depression, Alcoholism or Substance Abuse Disorders, and Panic Attacks