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Published on December 17, 2008

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Anxiety Disorders (Chapter 4) : Anxiety Disorders (Chapter 4) The Nature of Anxiety : The Nature of Anxiety -Basic emotional experience -Future-oriented Apprehension Munch - Anxiety The Nature of Fear/Panic : The Nature of Fear/Panic Also - a basic emotional response IMMEDIATE “Alarm” response activated in the context of threat Leads to Action Tendency - escape/avoidance Key Components of Anxiety/Fear : Key Components of Anxiety/Fear Basic Emotion - behavioral/emotional response to threat (Fight/Flight) Biological Process - Somatic Features - cause or consequence Cognitive Process - perception of threat Anxiety = Normal, Protective System Major Theories of Anxiety : Major Theories of Anxiety Neurobiological Models Brain Systems (Limbic system, Locus Coeruleus) Neurotransmitters (5-HT, GABA) Normal vs Pathological Responding = Defect in the System Psychological Models of Anxiety : Psychological Models of Anxiety Cognition Expectancies of Harm are Necessary Learning Expectancies are Learned The Adaptive Nature of Fear : The Adaptive Nature of Fear Fear can sometimes be a useful emotion. For instance, let's say you're an astronaut on the moon and you fear that your partner has been turned into Dracula. The next time he goes out for the moon pieces, wham!, you just slam the door behind him and blast off. He might call you on the radio and say he's not Dracula, but you just say, "Think again, bat man.” - Jack Handy Difference bw Normal and Pathological Anxiety : Difference bw Normal and Pathological Anxiety Fear is Viewed as Excessive/Unrealistic Creates Significant Distress/Disturbance DSM Anxiety Disorders : DSM Anxiety Disorders Common Features = Anxiety, Worry, Avoidance Clinically Significant Distress/Impairment Specific Features - Fear Domain Panic attack = PD Social Scrutiny = Social Phobia Snakes = Specific Phobia Anxiety Disorders: Epidemiology : Anxiety Disorders: Epidemiology Among most prevalent mental disorders Women twice the risk Comorbidity (Psychiatric/Medical) Depression, Cardiopulmonary Quality of Life Impact Comparable to serious medical conditions Anxiety Disorders:Video : Anxiety Disorders:Video National Anxiety Disorders Screening Day Freedom from Fear FFFNADS@aol.com Panic Disorder: Clinical Description : Panic Disorder: Clinical Description Hallmark Feature: Recurrent, Spontaneous Panic Attacks, PLUS Panic-related Worry or Avoidance What is a Panic Attack? : What is a Panic Attack? A discrete period of intense fear or discomfort, peaking within 10 minutes Includes four or more symptoms of fear (e.g., racing heart, suffocation, sweating, derealization, numbness,fear of dying, going crazy) About 2 out of every 5 people will experience a panic attack during their lifetime Did you know that... What does a Panic Attack Feel Like? : What does a Panic Attack Feel Like? Same as any True Threat Situation Spontaneous panic occurs frequently in nonclinical samples? Panic Simulation: Hyperventilate (2 min) Studying the Pathogenesis of Anxiety/Panic : Studying the Pathogenesis of Anxiety/Panic Challenge Paradigm Methods for Simulating & Studying Panic Allows for Controlled Study of Various Factors contributing to Fear Attentional Focus during a 35% CO2 Challenge : Attentional Focus during a 35% CO2 Challenge Experimental Study designed to assess the direct relationship between attentional focus and fearful responding in Panic Disorder Challenge Paradigm: 35%CO2/65%O2 Manipulation: Direct Attention toward/away from Internal Sxs Hyp: Internal Focus should Increase Anxiety and External Focus should Decrease Anxiety Slide 17: Diagnostic Status, Attentional Focus, and Subjective Anxiety Panic Phobic Avoidance - Agoraphobia : Phobic Avoidance - Agoraphobia About 1/3 to 1/2 of patients with PD receive this additional Diagnosis Agoraphobia = Coping Strategy Avoid Situations where panic occurs, escape difficult Typical Situations: driving, supermarkets, malls, crowds PD - Prevalence/Demographics : PD - Prevalence/Demographics Typical Onset in Young Adulthood 2% Lifetime Prevalence 50/50 Male/Female for PD w/out AG Higher % of Females with Agoraphobia Chronic, fluctuating course if untreated Etiological Models of PD : Etiological Models of PD Biological Models Pharmacological Dissection of PD (Klein) Biological Challenge Studies Sodium Lactate, CO2, CCK Faulty Suffocation Monitor Theory Evidence: Dyspnea Sxs, Pulmonary Conditions Risk Factors, Ondine’s Curse (CCHS) Cognitive Model of Panic : Cognitive Model of Panic Physical Arousal Triggers Physical Sensations “Faulty” Threat Interpretation PANIC Treating Panic Disorder : Treating Panic Disorder Pharmacological Treatments Antidepressants Tricyclics Serotonin Reuptake Inhibitors (SSRIs) Benzodiazepines Low Potency (Valium) High Potency (Xanax, Klonopin) Efficacy Data Cognitive Behavioral Therapy : Cognitive Behavioral Therapy Behaviorally-based Treatment (older) In vivo Exposure Provide pt with evidence that situation is not objectively dangerous Anxiety Management Skills Breathing Retraining, PMR Provide pts with a coping skill to manage anxiety Treating Anxiety: In vivo Exposure : Treating Anxiety: In vivo Exposure Designing Effective Exposure Pt must experience Some Anxiety Anxiety Must be Reduced Exposure Parameters Specificity Hierarchy (Moderate Fear Level) Repeated Trials Duration Sufficient for Habituation Fear Extinction: Exposure : Fear Extinction: Exposure Exposure Example : Exposure Example Video Safety Aids Treating Anxiety: Anxiety Management Skills : Treating Anxiety: Anxiety Management Skills Diaphragmatic Breathing Simple, easy to teach, use Step 1. Education - Role of Hyperventilation in Anxiety Physiology of Hyperventilation Step 2. Breathing Assessment Step 3. Breathing Exercises Newer CBT for Panic Disorder : Newer CBT for Panic Disorder More focused on Cognitive Model Cognitive Restructuring Changing ideation believed to be responsible for panic Interoceptive Exposure Correcting conditioned association between internal sensations and fear/panic response Treating Anxiety: Cognitive Therapy : Treating Anxiety: Cognitive Therapy Step 1. Education Groundwork for the Therapy How Most Treatment Protocols Start “All you need to know” - remainder of TX designed to “convince” Cognitive Therapy : Cognitive Therapy Step 2 Cognitive Restructuring Identify Anxiogenic Ideation Describe Thinking Errors Overestimation Catastrophization Dispute with Reason/Logic Dispute with Additional Evidence Behavioral Experiments Cognitive Therapy for Test Anxiety : Cognitive Therapy for Test Anxiety Imagine you have a test coming up What thoughts do you have that provoke anxiety? Critically Evaluating the Thoughts Interoceptive Exposure : Interoceptive Exposure Assumes Conditioned Association between internal sxs and fear - development of a “Body Phobia” Designed to correct this association Procedure: Repeated Exposure to any sensation that provokes fear response Interoceptive Exposure : Interoceptive Exposure Example Video - roller coaster Interoceptive Assessment : Interoceptive Assessment Exercises Designed to Induce Strong Sensations Spinning Running in Place Hyperventilation Straw Breathing Caffeine Heat Repeated Exposure Social Phobia (Social Anxiety Disorder) : Social Phobia (Social Anxiety Disorder) Clinical Description (more than Shyness) Fear of Social Scrutiny/Evaluation Fear actions will lead to Humiliation Avoidance of Social Situation Social Interaction (Gatherings, Meeting New people) Performance Situations Social Phobia Subtypes : Social Phobia Subtypes Performance Fears vs Social Interaction Fears Performance - Speech, Eating, Working in front of others Social Interaction - Meeting, talking with people Generalized versus Specific Generalized - Many Situations Specific - one area (Public Speaking) Social Skills Deficits? : Social Skills Deficits? Are social phobics less socially skilled or just more anxious? Data are mixed Many pts appear to “know” what to do - but are reluctant, unable Generalized Subtype - most likely to have deficit (lack knowledge of appropriate social behavior) Social Phobia: Prevalence/Demographics : Social Phobia: Prevalence/Demographics Typical Onset Mid-Late Teens 50% report social fears by age 10 Age at Presentation = 30 Slow to present 3 - 13% Lifetime Prevalence 1.4:1 Female:Male but Males more likely to seek Treatment Chronic, lifetime course if untreated Social Phobia: Comorbidity : Social Phobia: Comorbidity High - 50% Substance Abuse (20%) Self-medicating social anxiety ETOH reduces social threat Depression Etiology: Biological Aspects : Etiology: Biological Aspects Biologically “Prepared” to Fear Angry Faces Temperment (Kagan) - Shyness and behavioral inhibition People high on either or both of these dimension would be at risk Psychological Aspects: Social Threats : Psychological Aspects: Social Threats “I am likely to behave in an inept or unacceptable way” (High Perceived Threat Likelihood) “My (inept) behavior will create disastrous consequences” (Threat Severity Estimate) Social Phobia Vicious Cycles : Social Phobia Vicious Cycles Anxiety - Self-focused Attention - Social Ineptness Anxiety - Social Avoidance - Social Skill Deficits Pharmacological Tx (Social Phobia) : Pharmacological Tx (Social Phobia) Antidepressants MAOIs - effective but problematic side effects (Phenelzine) SSRIs - also effective, fewer side effects Benzodiazepines (Clonazepam) Beta Blockers - public speaking subtype (Atenelol, Propranolol) Minimizes cardiac arousal Psychological Tx (Social Phobia) : Psychological Tx (Social Phobia) CBT is treatment of choice Components - many same as PD Information, Cognitive Restructuring, Exposure to Feared Situations Social Skills Training (Eye contact, posture) Involves modeling the behavior, behavioral rehearsal, corrective feedback CBT Treatment Efficacy for Social Phobia : CBT Treatment Efficacy for Social Phobia Very Effective 75% show improvement 50% show very high levels of change Tx Gains Maintained at Follow-up CBT outperforms pharmacotherapy Specific Phobias : Specific Phobias Arachibutyrophobia- Fear of peanut butter sticking to the roof of the mouth. Automatonophobia- Fear of ventriloquist's dummies Linonophobia- Fear of string. Novercaphobia- Fear of your step-mother. Papaphobia- Fear of the Pope. Specific Phobia : Specific Phobia Phenomenology/Clinical Description Intense Fear of Specific Objects Flying, Heights, Animals, Blood injury/injection Cannot be related to another Anxiety Disorder (e.g., PD & flying) Distress & Impairment (Avoidance) needed for a Diagnosis Specific Phobia: Prevalence/Demographics : Specific Phobia: Prevalence/Demographics Very common in childhood Onset in Childhood common Lifetime Prevalence 14% in females and 8% in males Do not commonly present for Tx (only extreme cases) Etiological Models of Specific Phobia : Etiological Models of Specific Phobia To me, clowns aren't funny. In fact, they're kind of scary. I've wondered where this started and I think it goes back to the time I went to the circus, and a clown killed my dad. - Jack Handy Etiological Models of Specific Phobia : Etiological Models of Specific Phobia Learning Theory & Preparedness Account of Specific Phobia Learning Theory Phobias created by Ordinary Learning Processes Mechanisms include: (1) Traumatic Conditioning (rat - shock) (2) Observational Learning (baby watches mother) Problems with Learning Theory : Problems with Learning Theory No (unknown) Knowledge of Critical Incident Delayed Onset - phobia occurs months, years after “incident” Persistence/intensification of Fear - despite no re-conditioning Revision of Learning Theory : Revision of Learning Theory Learning is NOT sufficient to produce phobias: genetic x E Biological Disposition: Evolution favors anxious genes Selection for anxiety: protect against threat Anxious cavemen ran away, nonanxious ones were eaten Support for Preparedness Theory : Support for Preparedness Theory What are people afraid Of? “Evolutionary Significance” Animals, heights, closed spaces vs light sockets Variability in Conditioning Baby monkeys learn to fear snakes but not flowers Theory of Preparedness : Theory of Preparedness Preparedness Continuum Some stimuli (snakes) more readily acquire fear conditioning relative to “non prepared” stimuli (flowers) Rapid Acquisition/ Slow Extinction of Prepared Associations Treating Specific Phobias : Treating Specific Phobias Pharmacology - no notable txs Psychological Treatment (CBT) CBT is Tx of choice Similar interventions to those described for PD (Fear Hierarchy) Education, Exposure, Cognitive Restructuring Efficacy High, Treatment Gains Maintained Genetic Risk Factors (Phobic Anxiety Disorders) : Genetic Risk Factors (Phobic Anxiety Disorders) Three Possible Pathways Individual/Specific Event (critical incident) Ex. Bitten by dog Family Environment (general E) Ex. How parents treated you growing up Genetics - specific genetic factors give rise to phobias G vs E Contributions to Phobias : G vs E Contributions to Phobias 33% Genes Remainder - Unique E Little evidence for Shared E Generalized Anxiety Disorder : Generalized Anxiety Disorder Intense Worry Excessive (out of proportion) Pervasive (most days > 6 months) Uncontrollable GAD - Phenomenology : GAD - Phenomenology Typical Worry Domains Work “I’ll lose my job” Finances “My family will be living in the gutter” Health “I’ll catch an incurable disease” Family “My kids will get in accidents” Physical Sxs: restlessness, fatigue, irritability, muscle tension, sleep and concentration problems Worry not from another Anxiety Dx GAD - Prevalence/Demographics : GAD - Prevalence/Demographics Typical Onset Gradual - full blown dx in young to mid adulthood but many report being worriers from young age Fairly Prevalent - 5% lifetime 2:1 female:male Appears to be more common in the elderly Worry increases with age? GAD - Subtypes : GAD - Subtypes Early Onset vs Late Onset - 2 Types of Worriers? Early Onset (prior to 20) More extensive psychiatric hx Higher levels of psychopathology (anxiety, depression) Appears to be more severe form Late Onset (21+) Triggered by stressful events Less severe GAD - Comorbidity : GAD - Comorbidity Very High % have another psychiatric Dx Examples Substance Abuse Panic Disorder Mood Disorder High Comorbidity Problem - Is this truly a separate disorder? Etiological Models of GAD : Etiological Models of GAD Adaptive Nature of Worry Most Worry is Useful/Productive Some Worry is only partially Productive GAD Worry is Unproductive (it’s intensity leaves no energy/attentional capacity for the useful components of worry) Model of Generalized Anxiety Disorder : Model of Generalized Anxiety Disorder Genetic Liability to react to threat High Level of Worry (so much that it avoids scary images) avoiding negative affect produced by images No resources left over for problem-solving Genetics of GAD : Genetics of GAD Heritability around 30% Family aggregation studies indicate GAD can be separated from PD GAD and Depression appear to share common genetic diathesis However, Environmental determinants appear to be distinct Treating GAD : Treating GAD Pharmacological Treatments Tricyclics Benzodiazepines Efficacy of antidepressants and Benzos about equal Overall efficacy fair to good Psychological Tx for GAD : Psychological Tx for GAD CBT is treatment of choice Skills similar to those for PD Education, Cognitive Restructuring Exposure (to Aversive internal state) Exposure to Worry Triggers Efficacy - not as high as phobic anxiety conditions Obsessive Compulsive Disorder : Obsessive Compulsive Disorder Phenomenology/Clinical Description Diagnostic Criteria Recurrent Obsessions (thoughts and images) Compulsions (thoughts or actions designed to neutralize) Time Consuming Typical Obsessions & Compulsions : Typical Obsessions & Compulsions Contamination Washing/Cleaning Aggressive Impulse Checking Safety Doubts Checking Symmetry Ordering Fear of Needing St Hoarding OCD: Prevalence/Demographics : OCD: Prevalence/Demographics Bimodal onset: childhood (30-50%) and adolescence/young adulthood Lifetime prevalence: 2.5% 2:1 female:male Males have earlier onset, more severe course Course is chronic Treatment presentation lags onset - embarrassment Etiological Models of OCD : Etiological Models of OCD Neuropsychiatric Perspective Certain brain regions appear to be involved in behavior regulation Some of these areas responsible for behaviors relevant to neatness, orderliness, collecting, hoarding In OCD, these areas are dysregulated Evidence for Biological Model : Evidence for Biological Model Neuroimaging Studies Basal ganglia (involved in behavior regulation), frontal cortex differentially activated Neurosurgery to Basal Ganglia 65% show significant sxs remission, only 12% unchanged/worse Evidence for Biological Model : Evidence for Biological Model Association bw OCD and Tourette’s Syndrome About 50% of TS pts also get OCD dx Association between OCD and Physical trauma (birth, head) as well as Disease (epilepsy, meningitis) OCD and Genetics : OCD and Genetics Evidence surprisingly weak Few genetics studies - low prevalence Few Twin studies Evidence for familial association Higher risk in 1st degree relatives Psychological Aspects of OCD : Psychological Aspects of OCD Disturbing Thought/Image (common) Excessive Responsibility/Guilt Behavior to “Neutralize” Treating OCD : Treating OCD Pharmacological Treatments SRIs (25 - 75% improvement) Clomipramine (Anafranil) Floxetine (Prozac) Fluvoxamine (Luvox) Psychological Treatments CBT - Exposure + Response Prevention Effective for 50-75% who can tolerate it Efficacy not as High as phobic anxiety Combined SRI + Psych Tx Posttraumatic Stress Disorder : Posttraumatic Stress Disorder Phenomenology/Clinical Description Diagnostic Criteria Experiencing a Trauma/Stressor EX. Seeing someone killed, being raped Defining the Stressor No longer just a Dx for Combat Vets DSM-III-R “outside range of normal experience” Problem: rape, assault not unusual Acute Stress Disorder (1st month after exposure to trauma) PTSD: Symptom Domains : PTSD: Symptom Domains Intrusive Component Trauma is “relived” “flashbacks” Intrusive thoughts, images Phobic Avoidance Avoid stimuli associated with trauma Numbing/Detachment Isolate, detach from others Hyperarousal Hypervigilance, exaggerated startle PTSD: Classification Questions : PTSD: Classification Questions Anxiety vs Dissociative vs Other Several features of anxiety disorders and dissociative disorders Other = Trauma Disorder Etiological Uniqueness - Only condition in the DSM with Etiology specified Currently, evidence for separation not compelling PTSD: Prevalence/Demographics : PTSD: Prevalence/Demographics Lifetime Prevalence - 8% fairly prevalent 30% of male Vietnam vets 40% of vets assigned to high war-zone stress 2:1 female:male in general population Comorbidity Substance abuse, mood disorders PTSD Course : PTSD Course Acute Group PTSD immediately but resolves quickly (common) Delayed Onset Group PTSD appears 1+ year following trauma Chronic Group Persistent, Recurrent sxs for years PTSD Risk Factors : PTSD Risk Factors Previous Adversity Lower lvl of Education Poor Social support Certain personality traits (neuroticism) Nature of the Trauma High Magnitude Stressors Rape - 65% (men), 50% (women) Non Sexual Assault - 22% Chronic vs One Time traumas Biological Aspects of PTSD : Biological Aspects of PTSD Hypothalamic-Pituitary-Adrenal (HPA) Axis Abnormalities Hippocampus - Memory problems in PTSD Genetics of PTSD : Genetics of PTSD Heritability levels comparable to phobic anxiety disorders - approx 30% Treating PTSD : Treating PTSD Pharmacological Treatments Antidepressants TCAs MAOIs Beta Blockers Psychological Treatments (CBT) Imaginal Exposure Moderately Effective “Eye Movement Desensitization”

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