Transcript CHAPTER SIX - University of Illinois at Urbana–Champaign

CHAPTER SIX
Anxiety Disorders
Overview

Notice that the lectures for this chapter
are organized differently than the
textbook

The book focuses on anxiety as a mood,
whereas the lectures focus on anxiety
disorders

You are responsible for knowing both
information from the book and from the
lectures
Anxiety Disorders
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Anxiety, Fear, and Depression
Overview of Anxiety Treatment
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Panic Disorder and Agoraphobia
Specific Phobia
Social Phobia
Epidemiology
Common Features of
Anxiety Disorders
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.
Anxiety vs. Fear

Fear
 Experienced when a person
is faced with real and
immediate danger

Anxiety
 May mostly involve
anticipation of future
negative events (worry)
Mostly involves somatic
symptoms (e.g. increased
heart rate)

May mostly involve somatic
arousal

Present-oriented

Can be adaptive if not
excessive

Can be adaptive
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Prevalence & Comorbidity
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Prevalence
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Anxiety disorders are more common than any other
form of mental disorder.
Highly Comorbid
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Between different anxiety disorders
Between anxiety and depression
Between anxiety and substance abuse
What do anxiety and depression have in common?
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Both defined in terms of negative emotional experience
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Both triggered by stressful experiences
Affect in Anxiety & Depression
Emotionality: tendency to feel an emotion
Two Dimensions
Positive Affect
Negative Affect
Cheerful
Sad
Excited
Angry
Inspired
Guilty
Enthusiastic
Ashamed
Proud
Scared
Depression/Anxiety Comorbidity:
Conceptual and Clinical Overlap
Positive Affect
Negative Affect
“pure”
Depression
“General Distress”
Comorbid
Dep/Anx
Somatic Arousal
“pure”
Anxiety
Anxiety Disorders
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Anxiety, Fear, and Depression
Overview of Anxiety Treatment
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Panic Disorder and Agoraphobia
Specific Phobia
Social Phobia
Epidemiology
Overview of
Treatment for Anxiety

Exposure (in vivo = direct)
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Systematic Desensitization
the client is taught to relax and while in
a relaxed state they are presented with
items on a fear hierarchy, starting with
the least threatening

Flooding
exposure to the most threatening or
frightening stimuli first
Anxiety Disorders
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Anxiety, Fear, and Depression
Overview of Anxiety Treatment
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Panic Disorder and Agoraphobia
Specific Phobia
Social Phobia
Epidemiology
Generalized Anxiety Disorder

Anxiety in GAD focuses on everyday
events (worry + physical symptoms)
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DSM-IV-TR criteria for GAD include:

Excessive worry occurring more days than
not

Person finds it difficult to control the worry

Restlessness, easy fatigue, difficulty
concentrating, muscle tension, sleep
disturbance, irritability
Generalized Anxiety Disorder
GAD is characterized by
anxious apprehension
(worry)
GAD is a state of High negative
affect and chronic overarousal

Sense of uncontrollability

Focus on threat-related stimuli
that may indicate future negative
events
GAD:
Hypothesized Etiological Factors
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Anxiety as trait does seem to run in
families, but GAD results less conclusive
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Intolerance of uncertainty
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Belief that worry is adaptive
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Avoidance of threatening information
GAD: Cognitive Therapy
The three main facets:

Considering thoughts as hypotheses
rather than facts that can be supported
(or not) by evidence
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Utilizing past and present evidence to
examine the validity of the belief

Exploring and generating all possible
predictions or interpretations of an event
GAD: Cognitive Therapy
Step 1: Awareness
Provide clients with overview of how their cognitions
work
Step 2: Interpretation
Make clients understand the nature of inappropriate
anxiety and the role of their interpretation of
situations that create negative affect.
Step 3: Specific Negative Prediction
Identify the specific interpretations or negative
predictions that the clients are making and
challenge them.
Anxiety Disorders

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
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



Anxiety, Fear, and Depression
Overview of Anxiety Treatment
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Panic Disorder and Agoraphobia
Specific Phobia
Social Phobia
Epidemiology
OCD: Video
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Educational Objectives
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To gain a clearer understanding of the
difference between obsessions and
compulsions
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To see how symptoms and the course
of OCD vary for different clients
Obsessive-Compulsive Disorder
Must have obsessions with or without
compulsions
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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 caused by obsessions
Obsessive-Compulsive Disorder
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Compulsions cannot exist
without obsessions but
obsessions can exist
without compulsions
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Most people with OCD
have both
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Most individuals with OCD do recognize that
their obsessions and compulsions are
unreasonable and try to avoid doing them
Obsessive-Compulsive Disorder
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Typical obsessions include:

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contamination
aggressive impulses
sexual content
somatic concerns
symmetry
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Obsessions are often about normal concerns (e.g.,
germs, neatness), but differ in intensity level
compared to people without OCD
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Onset: early adolescence to young adulthood
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Course: typically chronic
OCD: Rebound Effect
2. Emotional
Trigger/Event
1. Born with a
predisposition to be
very emotionally
reactive
OBSESSIONS &
COMPULSIONS
3. You try to
suppress
emotional
response
4. But, the more
you suppress,
the more aware
you become
OCD Treatment:
Exposure & Response Prevention
Step 1
Information gathering
Step 2
Exposure & response
Step 3
Record keeping
Step 4
Homework assignments
Step 5
Support
Anxiety Disorders
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Anxiety, Fear, and Depression
Overview of Anxiety Treatment
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Panic Disorder and Agoraphobia
Specific Phobia
Social Phobia
Epidemiology
Panic Attack: Criteria
 Palpitations, pounding or accelerated
heart rate
 Sweating
 Trembling and shaking
 Sensations of shortness of breath or
smothering
 Feeling of choking
 Chest pain or discomfort
 Nausea or abdominal distress
Panic Attack: Criteria (cont’d)
 Feeling dizzy, unsteady or faint
 Derealization (feelings of unreality) or
depersonalization (being detached from
oneself)
 Fear of losing control or going crazy
 Fear of dying
 Paresthesias (numbness or tingling
sensations)
 Chills or hot flushes
Panic Attack
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Involves an abrupt
experience of intense fear
or acute discomfort
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Accompanied by physical
symptoms (e.g., heart
palpitations, chest pain)
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Symptoms develop suddenly and reach a
peak within 10 minutes
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Can experience panic attacks with each of
the anxiety disorders
Panic Attack: Types
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Three types:
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Situationally bound (cued)
Panic only when see a spider
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Unexpected (uncued)
Out of the blue
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Situationally predisposed
a person more likely to have a panic
attack where s/he had one before (e.g.,
crowded restaurant), but having one isn’t
inevitable
Panic Disorder: Criteria
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.
Agoraphobia: Criteria
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
Panic Disorder & Agoraphobia
PANIC DISORDER
A
G
O
R
A
P
H
O
B
I
A
No
Yes
No
No disorder
Panic Disorder
without
Agoraphobia
Yes
Agoraphobia
without
Panic Disorder
Panic Disorder
with
Agoraphobia
Panic Attack:
Barlow & White (1988)
predisposition to be overreactive to stress
stressful event
False Alarm! (becomes a Learned Alarm)
“unexplained physical sensations are dangerous”
worry focused on somatic sensations
Panic Disorder
Developing Agoraphobia
Panic Disorder with Agoraphobia
Panic Attack:
Catastrophic Misinterpretation
Step 1
A person misinterprets bodily sensations (e.g.,
rapid heart rate) associated with anxiety as a
serious threat
Step 2
This leads to increased awareness of biological
reactions
Step 3
Misinterprets these sensations as catastrophic
events (e.g., I’m going crazy, I’m going to die)
Panic Attack: Etiology
Biological Factors
Neurochemistry
One theory suggests that
several neurotransmitter
systems may be
“hyperactive” in people with
panic disorder.
Anxiety Disorders








Anxiety, Fear, and Depression
Overview of Anxiety Treatment
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Panic Disorder and Agoraphobia
Specific Phobia
Social Phobia
Epidemiology
Specific Phobia

Excessive or unreasonable fear related to
a specific object/situation that interferes
with functioning (e.g., fear of snakes)
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DSM-IV-TR’s Five Types
 Animal
 Natural environment
 Blood/injury
 Situational
 Other
Etiology of Phobia
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Evolutionary adaptation
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Negative information
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Classical conditioning
Specific Phobia: Treatment
Exposure Therapy (in vivo) Components
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Phobic learning history – create new
learning history
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Stimulus exposure  anxiety  relaxation 
decreased anxiety
Fear & Avoidance Hierarchy (FAH)
Subjective Units of Distress Scale
(SUDS)
Fear Hierarchy Example (SUDS)
1.
2.
3.
4.
5.
6.
7.
8.
Thinking about a spider (25)
Seeing a picture of a spider far away (40)
Seeing a picture of a very close-up spider
Seeing a spider in a cage far away (60)
Seeing a spider in a cage close up (75)
Seeing al spider loose far away (85)
Seeing a spider close-up (95)
Holding a spider (100)
(45)
Anxiety Disorders









Anxiety, Fear, and Depression
Overview of Anxiety Treatment
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Panic Disorder and Agoraphobia
Specific Phobia
Social Phobia
Epidemiology
Special Topic: Anxiety in Children
Social Phobia
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Characterized by fear of humiliation by
either performing badly or by displaying
visible symptoms of anxiety.
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More than shyness
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If the fears include most social situations, it
is considered generalized social phobia
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

Exposure to the feared social situation
invariably provokes anxiety

The person realizes that the fear is excessive
or unreasonable
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The feared situation is avoided or endured
with great distress
Social Phobia: Cognitive Biases
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Attention
what people attend to
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Memory
what people remember
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Judgment
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
Social Phobia: Cognitive Biases
Social Phobia: Etiology
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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
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Social phobia is more distinguished by
exaggerated cost
Social Phobia: Cognitive &
Exposure Treatment
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 person’s life
Anxiety Disorders








Anxiety, Fear, and Depression
Overview of Anxiety Treatment
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Panic Disorder and Agoraphobia
Specific Phobia
Social Phobia
Epidemiology
Epidemiology of
Anxiety Disorders
Disorder
Panic
Age Of Onset
High Risk Groups
late adolescence, separated, divorced,
mid-30s
women
20s-40s
separated, divorced,
African Americans
GAD
childhood adolescence
separated, divorced,
women, unemployed,
African Americans
Social Phobia
adolescence
low income, Asian
Americans, women
adolescence early adult
separated, divorced
Agoraphobia
OCD
Lifetime Prevalence Rates
by Gender
20
15
10
5
0
5
2.3
Panic
6.6
3.6
GAD
Females
15.5
11.1
Social Phobia
Males
2.8
2.4
OCD
One-Year Prevalence Rates
by Gender
10
8
6
4
2
0
3.2
1.3
Panic
4
2
GAD
Females
9
7
Social Phobia
Males
1.4
1.9
OCD
One-Year Prevalence Rates
by Race
10
8
6
4
2
3.66
2.68
Whites
3.39
2.46
5.21
9.19
5.37
African Americans
Latinos
1.7
OC
D
6.09
Ag
or
ap
ho
bia
3.47
ho
bia
0.66
So
cia
lP
1
GA
D
0.9
Pa
nic
0
1.41
0.77
CHAPTER SIX
Anxiety Disorders
Optional Slides
Relaxation Demonstration

The goal of this activity was to help you
understand the process of relaxation
treatments

You may find this technique effective in
relieving your own stress and anxiety
GAD: Relaxation Treatment
Step 1
Using the major muscle
groups, clients are taught
to discriminate and detect
early signs of muscle tension
Step 2
Relaxation deepening techniques are
employed including diaphragmatic
breathing
GAD: Relaxation Treatment
Step 3
Clients learn to alleviate the
physiological components of
anxiety by interrupting the
learned association between
over-arousal and worry
Step 4
Clients model relaxation in the session
and then practice it at home with tapes
of the session
Specific Phobia

FRED IS AFRAID OF 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
Systematic Desensitization
I will be showing some pictures of spiders and talking about
how an actual systematic desensitization would work with
a spider phobia.
If you have a fear/phobia of spiders, you may leave the room
or just close your eyes.
For each picture I want you to rate how creepy you feel
according to your SUDS.
A) 1-20
B) 21-40
C) 41-60
D) 61-80
E) 81-100
How creepy
would you feel?
A) 1-20
B) 21-40
C) 41-60
D) 61-80
E) 81-100
How creepy
would you feel?
A) 1-20
B) 21-40
C) 41-60
D) 61-80
E) 81-100
How creepy
would you
feel?
A) 1-20
B) 21-40
C) 41-60
D) 61-80
E) 81-100
How creepy
would you
feel?
A) 1-20
B) 21-40
C) 41-60
D) 61-80
E) 81-100
How
creepy
would
you feel?
A) 1-20
B) 21-40
C) 41-60
D) 61-80
E) 81-100
What did the SUDS reveal?
Social Phobia: Etiology

There is 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
Social Phobia & Culture

Asian Americans score consistently higher on
measures of social anxiety than white
Americans or any other ethnic group.

Why?

Hypothesis 1
 Asian Americans experience higher levels
of generalized distress.

Hypothesis 2
 Cultural norms and values make Asian
Americans particularly prone to social
phobia.
Independent vs. Interdependent Self

Independent Self
Putting self before others;
making one’s own decisions for
personal benefit (strongly
valued in American society)

Interdependent Self
Attending to others; fitting in
with others; maintaining
harmony with others (more
valued in Asian societies)
Okazaki Study (1997)
• Asian Americans scored
significantly higher on measures of
distress (anxiety and depression)
compared to White Americans.
•When comorbidity between social
anxiety and depression was taken
into account, Okazaki (1997) found
that social anxiety (not depression)
was associated with how Asians
view themselves (self-construal).
• More consistent with Hypothesis 2
Results

Self-construal and ethnicity are linked to
social anxiety (not depression) measures

Social anxiety appeared to be a
particularly salient form of distress for
Asian Americans

Asian American ethnicity predicted levels
of social anxiety above and beyond
individual subjects’ values of
independence and interdependence.
Critical Thinking Activity

Get into groups of 4-5 people.

You will be given one cultural variable to
discuss.

Discuss how and why there might be
differences in prevalence rates of the following
disorders depending on that cultural factor.

Please be appropriate.

The disorders are: MDD, OCD, and substance
abuse