Anxiety Disorders

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Chapter 6

• Anxiety Disorders

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Outline of Chapter 6

• Fear, Anxiety, and Panic Attacks
• Panic Disorder with without Agoraphobia
• Generalized Anxiety Disorder
• Specific Phobia
• Social Phobia
• Obsessive-Compulsive Disorder

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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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Epidemiology of Anxiety

• Prevalence Anxiety disorders are more common
  than any other form of mental disorders.
• Comorbidity High comorbidity among different
  anxiety disorders. High level of comorbidity
  between anxiety and depression.

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Why the comorbidity?

• Anxiety and depression
• both defined in terms of negative emotional
  experience
• both triggered by stressful experiences

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Clark and Watson model

• 2 dimensions of experience positive affect and
  negative affect
• Both anxiety and depression have high negative
  affect
• Anxiety has high positive affect
• Depression has low positive affect

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High negative affect
Depression
Anxiety
High arousal/positive affect
Low arousal/positive affect
Low negative affect
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Anxiety versus fear

• ANXIETY
• -anxious apprehension and worry that is a more
  general reaction that is out of proportion to
  threats in environment
• -future oriented
• -can be adaptive if not excessive

• FEAR
• -Experienced when a person is faced with real and
  immediate danger.
• -Present-oriented
• -Can be adaptive

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A new model of anxiety
ANXIETY
ANXIOUS APPREHENSION
ANXIOUS AROUSAL
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Anxiety a new model

• Anxious apprehension
• characterized by concern for the future and
  verbal rumination about negative expectancies or
  fears
• often accompanied by muscle tension, restlessness
  and fatigue
• Important variable in GAD

• Anxious arousal
• -characterized by a set of somatic symptoms
  including shortness of breath, pounding heart,
  dizziness, sweating and feelings of choking
• -important variable in panic attacks

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Panic Attack

• Panic attack abrupt experience of intense fear
  or acute discomfort , accompanied by physical
  symptoms (e.g., heart palpitations, chest pain,
  shortness of breath, dizziness).
• Symptoms develop suddenly and reach a peak within
  10 minutes

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Criteria for panic attack

1. Palpitations, pounding heart, or accelerated
   heart rate
2. Sweating
3. Trembling and shaking
4. Sensations of shortness of breath or smothering
5. Feeling of choking
6. Chest pain or discomfort

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Criteria for panic attack (contd.)

• 7) Nausea or abdominal distress
• 8) Feeling dizzy, unsteady or faint
• 9) Derealization (feelings of unreality) or
  depersonalization (being detached from oneself)
• 10) Fear of losing control or going crazy
• 11) Fear of dying
• 12) Paresthesias (numbness or tingling
  sensations)
• 13) Chills or hot flushes

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Panic Attacks

• Three types of Panic Attacks
• Situationally bound (cued) panic only when see a
  spider
• Unexpected (uncued) unexpected, out of the blue
• Situationally predisposed you are more likely to
  have a panic attack where you have had one before
  (crowded restaurant), but it isnt inevitable--
  you dont know if it will happen today

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Agoraphobia

• 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

• 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.
• Panic disorder can be present with or without
  agoraphobia.

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Panic attacks etiological factors

• What is Catastrophic misinterpretation?
• Step 1 A person misinterprets bodily sensations
  such as rapid heart rate associated with anxiety
  as serious
• Step 2this leads to increased awareness of
  biological reactions
• Step 3 misinterprets these sensations as
  catastrophic events (Im going crazy, Im going
  to die)

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Panic attacks etiological factors

• Neurochemistry
• - Another biological vulnerability to anxiety
  disorders may involve neurochemicals.
• -One theory suggests that several
  neurotransmitter systems may be hyperactive in
  people with panic disorder.

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A systems model for panic attacks

• Kleins False Suffocation Alarms Model
  incorporates biological and psychological factors
  to explain panic attacks and agoraphobia.
• -the brain may have a suffocation monitoring
  system but people prone to panic attacks are
  hypersensitive and may have false alarms
• -the threshold for a persons suffocation alarm
  can be influenced by biological, social and
  psychological factors such as stressful life
  events.

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Obsessive-Compulsive Disorder

• 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 from obsessions

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Obsessive-Compulsive Disorder

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

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Obsessive-Compulsive Disorder

• The vast majority of people with OCD exhibit both
  obsessions and compulsions
• However, according to the DSM, compulsions cannot
  exist without obsessions but obsessions can exist
  without compulsions
• Some individuals with OCD do recognize that their
  obsessions and compulsions are unreasonable

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OCD etiology

• Cognition
• -Thought suppression. People who worry
  excessively try to control their thoughts.
• However, trying to control thoughts may make
  the thought more intrusive and increase the
  emotions associated with the thoughts

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OCD Treatment

• Exposure and response prevention
• Step 1 Information gathering about rituals to
  enable the client to monitor them effectively
• Step 2 repeated, prolonged exposure to
  situations that provoke anxiety and instructions
  to refrain from ritual behaviors

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OCD Treatment

• Step 3patients must keep an accurate record of
  ritualistic behavior during treatment
• Step 4 homework assignments to expose oneself to
  anxiety-provoking stimuli

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OCD Treatment

• Step 5 support person must be encouraging and
  remind the patient of rationale of response
  prevention
• Mental rituals must be prevented as much as overt
  rituals, even though they are much harder to
  address

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Specific Phobia

• Excessive or unreasonable fear related to a
  specific object/situation
• Most common are snakes heights
• Some anxiety is maladaptive, high levels are
  maladaptive
• often have associated panic attacks

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Specific Phobia

• FRED HATES 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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Specific Phobia Treatment

• Exposure therapy (in vivo) components
• 1) phobic learning history create new learning
  history
• 2) Stimulus exposure gt anxiety gtrelaxation gt
  decreased anxiety
• 3) Fear Avoidance Hierarchy (FAH)
• 4) Subjective Units of Distress Scale (SUDS)

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Generalized Anxiety Disorder

• anxiety focuses on everyday events (worry
  physical symptoms)
• DSM criteria for GAD include
• --Excessive worry occurring more days than not
• --person finds it difficult to control the worry
• --restlessness, easy fatigue, muscle tension,
  sleep disturbance

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Generalized Anxiety Disorder

• Characterized by anxious apprehension, a state of
• high negative affect and chronic overarousal
• sense of uncontrollability
• focus on threat-related stimuli that may indicate
  future negative events

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Generalized Anxiety Disorder

• Etiology -- variety of contributing factors
• Anxiety as trait does seem to run in families but
  GAD results less conclusive
• The course of GAD has also been related to the
  presence or absence of life stressors.
• There is a high level of comorbidity with other
  anxiety and mood disorders.

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Treatment of GAD

• Targets of treatment
• Cognitive symptoms (e.g. ,excessive worry) have
  been addressed by cognitive therapy
• Somatic symptoms (e.g., muscle tension) have been
  addressed by relaxation treatments

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Treatment of GAD

• Example of cognitive therapy
• Step 1 provide client with overview of how
  his/her cognitions work, including
• their automatic anxious thoughts
• situation-specific nature of anxious predictions
  about the future
• how cognitions responsible for anxiety are not
  challenged by client

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Treatment of GAD

• Step 2 make client understand the nature of
  inappropriate anxiety and the role of his/her
  interpretation of situations that create negative
  affect.

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Treatment of GAD cognitive

• Step 3
• Identify the specific interpretations/ negative
  predictions that your client is making and
  challenge them. Two types are particularly
  important
• Probability overestimation
• Catastrophic thinking

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Treatment of GAD cognitive

• The three main facets of such an approach are
• 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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Treatment of GAD Relaxation

• Step 1
• Using the 16 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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Treatment of GAD Relaxation

• Step 3
• Clients rationalize that relaxation is aimed at
  alleviating the physiological components of
  anxiety by interrupting the learned association
  between overarousal 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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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
• Exposed 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

• 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 etiology

• Cognitive biases that impact social phobia
• Attentional bias what people attend to
• Memory bias what people remember
• Judgment bias 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 judgment bias

• 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 etiology

• There is also 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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Treatment Cognitive and exposure

• 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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Special topic

• Cross-cultural differences in social phobia

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Culture and social phobia

• Researchers have consistently found that Asian
  Americans score higher on measures of social
  anxiety than White Americans
• This has been found in both college (e.g.,
  Okazaki, 1997) and community samples (e.g., Ying,
  1988)
• In fact, Asian Americans have been found to have
  the highest rates of social anxiety of any racial
  group

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Sue et al, 1990 study

• The students were asked to role-play a series of
  13 situations requiring assertion with either an
  Asian experimenter or a White experimenter.
• The Chinese-American students were as assertive
  as the White Americans on all behavioral
  measures.
• However, one self-report measure revealed a
  significant difference between the two groups,
  suggesting that Chinese Americans were more
  apprehensive than White Americans in social
  situations.

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Why these differences?

• Hypothesis 1 a higher level of generalized
  distress among Asian Americans
• This could be due to political experiences that
  Asian Americans face (e.g., racism) (Kuo, 1984)
• Acculturative stress of being recent immigrants,
  including financial difficulties associated with
  moving to a new country and finding new
  employment, and learning a new language for
  personal and professional communication

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Why these differences?

• Hypothesis 2
• Cultural values and norms for functioning and
  distress.
• Identify differences in cultural norms and how
  they predict emotional distress for Asian
  Americans and White Americans.

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Cultural norms about the self

• The role of self-construal
• People socialized by values from Asian societies
  are more likely to have an interdependent
  self-construal.
• definition includes attending to others, fitting
  in and harmonious interdependence with others
  (Markus Kitayama, 1991)

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Cultural norms about the self

• Independent self-construal is valued by
  mainstream American society
• Includes viewing oneself as an independent person
  and making ones own decisions for personal
  benefit

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Okazaki study (1997)

• subjects who held less independent self-construal
  were found to be more socially anxious
• also found that Asian Americans high reports of
  distress persisted on a measure of social anxiety
  but not on depression, after taking into account
  the comorbidity between social anxiety and
  depression.

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Results

• Social anxiety appeared to be a particularly
  salient form of distress for Asian Americans.
• This would make sense given the value placed on
  interpersonal sensitivity in Asian cultures.

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Cultural norms about functioning

• Depending on cultural norms about social anxiety,
  a person may feel less or more distressed by
  his/her experience of it

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Cultural norms about functioning

• Okazaki (2002) examined cultural norms in
  functioning would contribute to reports of
  psychological distress
• Asian Americans found reports of social anxiety
  less distressing
• Cultural norms significantly predicted how
  socially anxious they were, compared to White
  Americans.

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Conclusions

• raises questions about the cultural validity of
  commonly used assessment tools with different
  groups
• Understanding cultural norms and standards in
  behavior may further our understanding of
  distress in different groups.

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Prevalence rates for anxiety disorders (lifetime)

• Disorder Males Females
• Panic 2 5
• GAD 4 7
• Social phobia 11 16
• OCD 1.9 2
• All 19 31

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Prevalence rates for anxiety disorders (12 month)

• Disorder Males Females
• Panic 1.3 3.2
• GAD 2 4
• Social phobia 7 9
• OCD 1.9 1.4
• All 12 23