Anxiety Disorders

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Anxiety Disorders

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

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Three Components of Anxiety

• Physical symptoms
• Cognitive component
• Behavioral component

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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

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Parasympathetic Nervous System

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

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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

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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

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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

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U Shaped Function of Anxiety

• Useful part of life
• Expressed differently at various age levels

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Anxiety Disorders

• Generalized Anxiety Disorder
• GAD

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Generalized Anxiety Disorder

• Unfocused worry

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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

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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)

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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

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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)

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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

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GABA Problems?

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

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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

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Generalized Anxiety Disorder Treatment

• Short term-benzodiazepine (valium)
• Cognitive Therapy (focus on problem)

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Anxiety Disorders

• Phobias Specific Social

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Phobia Diagnostic Criteria

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

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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

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Phobias Types

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

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Developmentally Normal Fears
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Phobias Prevalence

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

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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

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Specific Phobia Behavioral Perspective

• Case of Little Albert
• Two-factor model
• Acquisition-classical conditioning
• Maintenance-operant conditioning

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Specific Phobia Behavioral Perspective

• Classical conditioning
• Modeling
• Stimulus generalization

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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)

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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

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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

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Specific Phobia Cognitive Perspective
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Specific Phobia Social and Cultural Factors

• Predominantly female
• Unacceptable in cultures around the world for men
  to express fears

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Specific Phobia Treatment

• Systematic Desensitization

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Social Phobia

• Fearful apprehension
• Social situations

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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

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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

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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

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Kagans theory inhibited temperament

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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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Anxiety Disorders

• Obsessive Compulsive Disorder (OCD)

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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

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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

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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

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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

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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

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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

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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

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Anxiety Disorders

• Panic Disorder with and without agoraphobia

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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

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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

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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

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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

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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)

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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

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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

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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
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Anxiety Disorders

• Post Traumatic Stress Disorder
• PTSD

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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

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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

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PTSD Symptoms

• Symptoms in each category 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

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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Etiology for Specific Anxiety Disorders?

• Why would it be hard to derive etiologies for
  specific types of anxiety disorders?

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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