Anxiety Disorders

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Anxiety Disorders
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• Anxiety negative mood state characterized by
  bodily symptoms of tension and apprehension about
  the future

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What does anxiety feel like?

• Heart racing/pounding
• Sweating
• Being out of breath
• Shaking
• Upset stomach
• Being frozen

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When is Anxiety Normal/Abnormal?

• Normal
• Motivation
• Avoiding danger
• Preparation for uncertainty

• Abnormal
• When it interferes with performance
• E.g. exams
• E.g. socially

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When is Anxiety Helpful/Not Helpful?

• As arousal increases performance increases, to a
  point
• After the optimal point of arousal performance
  deteriorates as anxiety continues to increase
• This is called Yerkes-Dodson Law

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Yerkes-Dodson Law

• The optimal point of arousal varies by task
• For easy tasks we can tolerate a lot of anxiety
  and still do well
• For hard tasks we cant tolerate much anxiety

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When is anxiety an Anxiety Disorder?

• When the feelings of anxiety constantly interfere
  with functioning
• Generalized Anxiety Disorder
• Panic Disorder Agoraphobia
• Specific Phobias
• Social Phobia
• Post-traumatic Stress Disorder
• Obsessive-Compulsive Disorder

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Causes of Anxiety Disorders

• Biological
• Psychological
• Social

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Biological Causes of Anxiety Disorders

• Genetic influences
• Diathesis X Stress models appy
• Changes in neurotransmitters
• Sensitivity of brain circuits to fear

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Psychological Causes of Anxiety Disorders

• Behavioralists see anxiety as the result of
  learning
• Cognitions regarding danger or uncontrollability
• Parenting overprotective and lack of adverse
  experiences

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Social Contributions to Anxiety Disorders

• Reactions to stressful events
• Social learning

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Comorbidity of Anxiety Disorders

• Often co-occuring
• Share same vulnerabilities
• 55 comorbidity with depression
• 50 with additional anxiety disorder

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1. Generalized Anxiety Disorder

• Excessive anxiety/worry about a number of
  events/activities
• Worry is difficult to control or stop
• Worry is not helpful
• Often about minor things

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Generalized Anxiety Disorder

• Restlessness
• tense muscles
• concentration problems
• sleep problems

• Irritability
• Fatigue
• Difficulty focusing attention

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Generalized Anxiety Disorder

• Lifetime prevalence 5
• 2x more likely in women
• Develops early in adulthood
• Most people do not seek treatment from therapist
• Is GAD a personality style? Or personality
  disorder? A risk factor?
• 80-90 qualify for another disorder

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What Causes GAD?

• Genes -gt first degree relatives 5x likely
• Differences in physiology
• Less responsive
• Except muscle tension
• Cognitive Influences
• Drawn to threat cues

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How do we treat GAD?

• Medication
• Benzodiazepines
• Early Valium, new Xanax, Ativan
• Central nervous system depressants
• Relieve anxiety but impair thinking, motor
  performance, induce sleep
• Many people feel addicted (symptoms quickly
  return)

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Psychological Treatments for GAD

• Lots of treatment but little effectiveness
• Psychoanalytical insight Client centered
• Several Cognitive treatments
• Cognitive Therapy confront worry with images
  coping strategies
• Beck automatic thoughts
• Borkovec - confronting worry
• Craskes hybrid treatment

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2. Panic Disorder Agoraphobia

• Chills or hot flashes
• Palpitations, pounding/accelerated heart beat
• Sweating
• Trembling/shaking
• Sensations of smothering/choking
• Chest pain/discomfort
• Nausea or other abdominal distress
• Feeling dizzy, light headed, faint
• Fear of losing control/going crazy/dying
• Numbness/tingling sensations

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What is Panic Disorder?

• Recurrent and unexpected panic attacks (cued or
  uncued)
• Anxiety re having other attacks
  (escape/embarrassment)
• Patients avoid situations where panic attacks may
  happen (agoraphobia)
• Withdrawal reduces anxiety
• Negative reinforcement

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Panic Disorder

• Lifetime prevalence 3.5 (without)
• 2-3x more likely in women
• Develops during late adolescence/early adulthood
• Chronic without treatment
• Many experience panic attacks (8-12) but no
  disorder develops

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Causes of Panic Disorder

• Genetic influences
• Biology

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Psychological Factors in Panic

• Personality/trait like variables of risk
• Some people have attacks, no disorder
• 3 Proposed Variables
• A tendency to fear panic attacks
• A tendency to over interpret unusual body
  sensations
• Tendency to respond to fear w/ anxiety symptoms

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Psychological Factors in Panic

• A tendency to fear fear
• Hypervigilant about physiology (looking for fear)
• May trigger panic attacks
• Misinterpret body signals as impending panic
  (e.g. during a walk)
• Focus on own body, not possible danger

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Psychological Factors in Panic

• 3. Anxiety Sensitivity
• Respond fearfully to symptoms of anxiety
• Overreact then avoid, then hypervigilant
• May trigger a panic attack
• What's the converging info? Reaction to panic
  makes panic more likely!!!

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Avoiding Panic (Agoraphobia)

• Why is withdrawal so bad for panic?
• Opportunities for corrective feedback are nil
• How can you know something works if you dont
  test it?

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Treating Panic Agoraphobia

• There are 2 ways
• Medication
• Cognitive Behavioral Therapy

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Medication

• Antidepressants can reduce panic attacks
• So do benzodiazepines (anti-anxiety) but they
  have problems
• Symptoms return quickly (short 1/2 life)
• If stop too quickly, can be worse
• Thus, can produce dependence

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Medication

• 66 do well, if stay on medication
• 20-50 relapse after discontinuing
  antidepressants
• 90 after discontinuing benzodiazepines

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Cognitive Behavioral Treatment

• A number of elements
• Psychoeducation
• Anxiety reducing techniques (a toolbox)
• Diaphragmatic breathing
• Progressive muscle relaxation
• Distraction, labeling anxiety as safe,
  challenging thoughts
• Exposure (!!!)

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Cognitive Behavioral Therapy

• We give our clients a toolbox
• Education techniques challenges
• Then we give them a chance to use them
• Exposures
• Sometimes we desensitize to internal feelings
  (e.g. running in place)

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Panic Control Treatment (PCT)

• Exposure to sensations that remind of panic
• Also receive cognitive therapy
• Address the cognitions re dangerousness of
  feared, yet harmful, situations
• Examples
• Shaking head from side to side loosely for 30 sec
• Breathe through thin straw for 1 minute
• Hyperventilate for 1 minute

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3. Specific Phobias

• Unreasonable fears of objects, places, situations
• Anxiety response triggered by specifics
• Functioning beyond phobia is fine
• www.phobialist.com

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Specific Phobias

• In theory, anything can phobia
• Small account for most
• Animal phobias (zoophobia) 40
• Environmental situations (e.g. heights -
  hysphobia)
• Blood-injection-injury (vasovagal response)
• Avg age of onset 9 years
• Situational (planes, elevators)

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Specific Phobias

• Lifetime prevalence rate 11
• Children experience more
• Some may be developmentally normal
• E.g. strangers, separation, the dark, etc
• Culture can impact
• Gender ratio 41 (women higher)
• Except heights (equal)
• Chronic across lifecourse

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Separation Anxiety Disorder

• Unrealistic and persistent worry that something
  will happen to parents
• OR something will separate child from parents
• School refusal
• Nightmares, difficulty sleeping alone

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Causes of Specific Phobias

• Not traumatic experiences
• Often panic attacks trigger
• Vicariously from others
• Also genetic role 31 of people with 1st degree
  relatives
• Specific to subtype

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Behavioral Factors Specific Phobias

• Classical conditioning - Little Albert
• Phobias are learned
• May not need direct experience
• modeling fear of parents
• Many phobics show no related experience
• 50 of dog phobics no experience
• Many people dont develop after experience

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Evolution, Learning Specific Phobias

1. Are we predisposed to certain phobias?
2. Can we learn phobias from others?

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Evolution, Learning, Specific Phobias

• Are we prepared to be phobic of certain things?
• E.g. snakes
• Arbitrary objects do not often phobia (despite
  danger or instructions)
• Electric outlets, stoves, hammers
• Bicycles, etc

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Evolution, Learning, Specific Phobias

• Minekas monkeys (1984, Experiment 2)
• Can lab-born monkeys learn snake phobia from
  their wild-born parents?
• Study 1 established that wild-born monkeys were
  more fearful than their offspring
• Offspring observed parental response to real
  snake, toy snake, neutral objects

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Behavioral Avoidance of Snakes
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Evolution, Learning Specific Phobias

• Offspring learned phobias by watching parents
• Results were intense rapid (one try)
• In evolutionary terms, we dont have several
  tries with a fatal object
• Retention 3 months later

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Evolution, Learning, Specific Phobias

• Minekas follow-up (Cook Mineka, 1991)
• Spliced videos so it appears parent monkeys are
  reacting to flowers
• Observer monkeys did not learn flower-phobia
• This is consistent with the idea that we are
  prepared for certain phobias

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How do we treat a specific phobia?

• Exposure!
• Two types of exposure
• Systematic desensitization
• Flooding

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Systematic Desensitization

• Imaginal vs. in vivo exposure
• In vivo treats well (75-95 of patients)
• Create a hierarchy of feared experiences
• Teach progressive muscle relaxation
• Combine
• Note this is gradual

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Flooding

• This is not gradual
• Intense prolonged exposure
• E.g. stay on the roof until you are calm
• Usually in vivo
• Emotionally draining
• Can make anxiety worse if quit early

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In Vivo

• Different sizes of spiders
• Patients stand in room, approach, touch jar,
  change size of spider, touch spider
• 3 hour treatment
• What about imaginal?
• Some people have problems imagining
• Imagined spiders might not be scary

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Virtual Reality Treatment for Anxiety(Garcia-Palac
ios et al., 2001)

• Phobias are extremely common easy to treat
• but most people never seek treatment
• Less than 15 of the 10 of the pop. with a phobia

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Why do VR therapy?

• 25 refuse exposure-based therapy
• Too afraid to confront
• Ost (a spider pioneer) - 90 of spider phobic
  patients refuse one-session tx
• How can we improve therapy?
• Make it less intimidating
• Use virtual reality!

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VR Therapy for Phobias

• The illusion of in vivo
• Position tracking devices
• Changing orientation
• Tactile augmentation
• cyber-heft
• Present separate images to each eye

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Why is VR better?

• More control over feared object
• Therapist controls fright level
• In Vivo can be expensive
• E.g in vivo for flying phobias
• In Vivo can breach confidentiality
• VR can treat residual fears

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4. Social Phobia/Social Anxiety Disorder

• www.socialphobia.org
• Lifetime prevalence rate is more than 13
• Thats 2340 UD students!
• 3rd most common disorder
• (depression, alcohol)
• Men outnumber women (1.41)

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Social Phobia

• Fear of evaluation socially
• E.g. public speaking (specific)
• More common in women
• Common problems
• Meeting new people talking to authority figures
• Performing in front of others
• Dating!

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Causes of Social Phobia

• Tend to run in families (nature or nurture?)
• Generalized may be trait-like
• Vs. avoidant personality disorder
• May be classically conditioned
• May actually be less skilled more awkward

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Causes of Social Phobia

• People with social phobia
• Overestimate negative consequences
• Think social costs are worse
• Often do things to maintain their anxiety
• safety behaviors
• Often focus on themselves, not the environment

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Treatment of Social Phobia Medications

• Beta-blockers (lower heart rate, blood pressure)
• antidepressants

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Treatment of Social Phobia

• CBT Exposure
• May include role-playing, skills training
• Often done in groups
• Problems inherent to group therapy

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5. Post-Traumatic Stress Disorder

• Long-term response to life-threatening danger
  (war, rape, robbery, etc)
• Symptoms can last for years
• Derealization (emotional numbing)
• Depersonalization
• Flashbacks
• Hyperarousal, agitation, irritable, jumpy

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3 Major Types of Symptoms

1. Avoidance
2. Hypervigilance
3. Re-experiencing

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PTSD

• Lifetime prevalence 8
• More common in women
• Many do not develop (so PTSD different)
• Most events interpersonal

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Causes of PTSD

1. Nature of the trauma
2. Biological Factors
3. Psychological Factors

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1. Nature of the Trauma

• More traumatic more PTSD likelihood
• Level of trauma depends on
• Physical reality of the event
• Individual experience, including closeness to
  event

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2. Biological Factors in PTSD

• Family history of anxiety disorders
• Personal history of any disorder
• Physical symptoms suggest physiological
  dysfunction
• Dysregulation of natural opiods
• Changed sleep cycles
• Immune/metabolic suppresion

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3. Psychological Factors

• Previous trauma
• Social support is a buffer
• Lots of individual differences

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Treating PTSD

• Antianxiety drugs sleep aids
• (control physiological symptoms)
• Psychological treatment
• Exposure
• Rethinking of experience
• Can be done in groups

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6. Obsessive-Compulsive Disorder

• Obsessions unwanted, intrusive thoughts that
  cannot be controlled
• Compulsions Behaviors one feels compelled to
  perform (may reduce obsessions)

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OCD

• Compulsions can also be called rituals
• Obsessions increase anxiety, compulsions
  temporarily reduce

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OCD

• We used to believe this was extremely rare
• Hiding symptoms
• Many can appear to function normally
• Most did not seek treatment
• Lifetime prevalence 2.6
• As common in children
• Some normal (10-15 college students)

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OCD

• Common Compulsions
• Washing
• Checking Counting rituals
• Common Obsessions
• Harming others (Sexually, physically)
• Safety of others
• Contamination of self others

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Principal Symptom Factors

• Aggressive, sexual, and religious obsessions with
  checking compulsions
• Symmetry/Order obsessions with ordering,
  arranging, and repeating compulsions
• (Leckman et al., 1997)

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Principal Symptom Factors

1. Contamination obsessions with washing and
   cleaning compulsions
2. Hoarding and Saving symptoms

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OCD

• Usually aware of silliness but cant stop
  (anxiety will skyrocket)
• Subtype with a lack of insight
• Some things not to misunderstand
• Compulsions are not set (can change)
• Some people can have obsessions OR compulsions

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Causes of OCD

1. Psychodynamic Factors
2. Biological Factors
3. Cognitive Behavioral Factors

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Biological Factors

• 5-10x more likely in first degree relatives
• Rates in identical twins 20x general pop.
• Found in Tourettes (a strong genetic component)
• Brain dysfunction failure to filter repetitive
  impulses?

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Cognitive-Behavioral Factors

• Black White thinking?
• E.g. contamination risks (if no guarantee, then
  Im not touching it)
• The normal level of acceptance of risk is too
  high
• Magical Thinking
• Thoughts/actions have specific consequences
• If I dont do this, my partner will die

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Cognitive Factors

• Thought-action fusion
• Thoughts are equated with the actions or activity
  represented by the thoughts

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How do we treat OCD?

1. Medication
2. Exposure/Response Prevention
3. Psychosurgery

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Medication for OCD

• Antidepressants (in higher doses)
• This means serotonin is likely involved
• Most people respond well
• Also a subset who will not respond

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Exposure/Response Prevention

• Exposure is key to almost all anxiety treatments
• When we do something scary over and over and over
  and over and over and over and over again, is it
  still scary?

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Exposure/Response Prevention

• Put clients in an anxiety provoking situation
• E.g. touching public toilets/sinks
• Block their response (compulsion)
• Forbid them to wash their hands
• The more you give into OCD, the stronger the
  symptoms become
• The more you resist, the weaker they become

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Special Cases of OCD Hoarding

• Hoarding acquisition of, and inability to
  discard, worthless items, though they appear to
  have no value (18-24 of OCD patients)
• Also common in other disorders
• Schizophrenia
• Dementia
• Eating disorders
• Mental retardation

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Features Associated with Hoarding

• Indecisiveness
• Perfectionism
• Procrastination
• Difficulty organizing tasks
• Avoidance
• Obsessions losing important items, distortion
  re importance, emotional attachment to items

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Treatment of Hoarding

• Worse prognosis more disability
• Intensive CBT (e.g., daily)
• ERP
• Excavation of saved material (w/ rules - no
  sorting, grab first pile) with help
• Decision-making training - what to keep?
  Immediately needs a place
• Cognitive restructuring - nothing terrible happens

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Anxiety Disorders - Conclusions

• Anxiety disorders, combined, are relatively
  prevalent
• Easy to treat
• Many people do not seek treatment
• Usually treated with exposure (and maintained by
  avoidance and negative reinforcement)