Transcript Anxiety and Mood Disorders

Abrupt and Aversive CNS Response
to Real Threat or Danger
Prepares Organisms for Immediate
Action
Action Tendency “Fight” or “Flight”
 More Diffuse Response About
Impending Real or Imagined
“Future” Threat or Danger
Real Threat
True Alarm
Adaptive
Maladaptive
False Alarm
No Threat
Etiology
“Disordered” or “Maladaptive”
Experience of
Anxiety or Fear
“Normal” or “Adaptive”
Experience of
Anxiety or Fear
Process
Onset,
Maintenance, and Course
Successful Treatment
Response and Outcome
Psychobiological
&
Experiential Processes
Outcome
Panic Disorder
Agoraphobia
Anxiety NOS
What Treatments,
by Whom,
are Most Effective,
and WHY?
OCD
Specific Phobias
Social Phobias
PTSD
GAD
Acute Stress
 Panic Disorder
 PD With Agoraphobia
 Agoraphobia
 Specific Phobias
 Social Phobias
 Generalized Anxiety Disorder
 Post-Traumatic Stress Disorder
 Obsessive Compulsive Disorder
 Panic Disorder
“ You may genuinely believe you’re having a
heart attack, losing your mind, or on the
verge of death. Attacks can occur any time,
even during nondream sleep ”
“ For me, a panic attack is a most violent experience
…I feel as though I’m losing control and going
insane. ”
 Clinical Description
 An Unexpected Panic Attack
 Develop Anxiety Over
 the Next Attack or
 The Implications of the Attack
and Consequences
 Clinical Description
 Agoraphobia is Common
 Fear of the Marketplace
 Consequence of Severe Unexpected
Panic Attacks
 Can Have a Life of its Own
 Facts and Statistics
 Occurs in 3.5% of Population
 75% are Women
 Onset Between (25-29 yrs)
 Attacks Often Begin at Puberty
 20% Attempt Suicide
 Average 37 Medical Visits / Year
 Cultural Influences
 Occurs Worldwide
 Prevalence in U.S. is Similar Across
Ethnic Groups
 Nocturnal Panic
 60% Cases Panic While Asleep!
 Usually Between 1:30 - 3:30am
 Occur During Deep Sleep “Delta”
 Do Not Occur During REM Sleep
 Symptoms of a Panic Attack
 Palpitations / Sweating
 Trembling / Shaking
 Shortness of Breath
 Feeling of Choking, Loss of Control
 Derealization, Feeling of Dying
 The Panic Attack
 Abrupt Autonomic Surge
 Unexpected
 Uncontrollable
 Absence of Threat
 “False Alarm”
10 Minutes
 Laboratory Panic Provocation
 Lactate Infusion
 Hyperventilation
 CO2 Inhalation
 Caffeine
10 Minutes
 Causes
Biological Vulnerability
STRESS
False Alarm
Bodily Cues
Learned Alarm
Involuntary Symptoms
Psychological Vulnerability
 Biological Causes
 Runs in Families
 GABA-BZ Circuit
 Limbic System
 ANXIETY
Behavioral Inhibition System (BIS)
 FEAR / PANIC
Fight / Flight System (FF)
 Psychological Causes
Predictable
Uncontrollable
Controllable
Unpredictable
 Pharmacologic Treatments
 Block Panic
 Antidepressants (e.g., Imipramine,
Paxil, Prozac)
 20-50% Relapse
 Benzodiazapines (e.g., Xanax)
 90% Relapse
 Psychological Interventions
 Cognitive-Behavior Therapies
 Brief and Time Limited (12 Sessions)
 Graded Exposure + Coping Skills
 Panic Control Treatment (PCT)
 80-100% Panic Free After Treatment
 Combined Treatment
THE RESULT
 Multisite Study
 Imipramine Alone
 PCT Alone
 Imipramine + PCT
 Placebo Alone
 Placebo + PCT
Combined Tx
is Better in
Short
Term
PCT Alone is
Better in
Long Term
 Specific Phobias
“ ...aren’t just extreme fear; they are
irrational fear. You may be able to ski the
world’s tallest mountain with ease but feel
panic going above the 10th floor of an
office building.”
 Clinical Description
 Irrational Fear of Specific Objects
or Situations
 Markedly Interferes With
Functioning
 Four Major Subtypes
 Animal Type
 Natural Environment Type
 Blood-Injection Injury Type
 Situational Type
 Other
 Blood-Injection Injury Type
 Unusual Reaction
 Vasovagal Response to Blood
 Drop in Blood Pressure
 Fainting
 Runs in Families
 Onset Early Childhood
 Situational Type
 Fears of Specific Situations
Planes, Transportation, Heights
 Response Similar to Panic
 Onset Early 20’s
 Animal Type
 Fears of Animals and Insects
 Common in Population, but
Different From Normal Revulsion
 Early Onset (About 7 yrs of Age)
 Natural Environment Type
 Fears of Natural Events
Heights, Storms, Water
 Usually More Than One Fear
 Peak Onset (About 7 yrs of Age)
 Other Type
 Fears Contracting Disease / Illness
Illness Phobia
 Fear of Choking
Avoid Swallowing Pills or Foods
 Facts and Statistics
 Occurs in 11% of Population
 Top Fears: Heights and Snakes
 Females > Males (4:1 Ratio)
 Runs a Chronic Course
 Hispanics > Caucasian Americans
 Many Do Not Seek Treatment:
WHY?
 Causes
 Direct Traumatic Conditioning
 Observational Learning
 Information and Language
 Having a Panic Attack
 Probably Some Evolutionary Basis
 Exposure and More Exposure
 Structured and Consistent
 Confront Objects of Fear
 Extinguish Anxious Responding
 Disrupt Avoidance / Escape
 Blood-Injury /Injection Differs
Exercises to Offset Fainting
“ People with social phobia aren’t
necessarily shy at all. They can be
completely at ease with people most of
the time, but in particular situations,
they feel intense anxiety.”
 Clinical Description
 Marked and Persistent Fear of One
or More...
Social or Performance Situations
 Most Common Type of Social Fear?
Public Speaking
 Interferes With Life Functioning
 Facts and Statistics
 Occurs in 13.3% of Population
 Most Prevalent Disorder
 Males > Females
 Begins in Adolescence
 Presents Differently in Some
Cultures (e.g., Japan)
 Causes
 Similar to Panic and Specific Phobia
 Interaction of
Biological Vulnerability
Psychological Vulnerability
Learning Experiences
 Can be Quite Disabling
 Psychological Interventions
 Similar to Panic and Specific Phobia
 Cognitive-Behavioral Approaches
Rehearsal and Skills Training
Cognitive Restructuring
 Drug Treatments
 Antidepressants for Severe Anxiety
MAO Inhibitors
Relapse is Common
 Worrywart?
 Perfectionist?
 Tense and keyed up most of the time?
 Cross bridges before you get to them?
 Worry unproductive?
 Trouble Controlling Worry?
 Clinical Description
 Worry About Everything
 Worrying is Unproductive
 Cannot Stop Worrying
 Mental Agitation and Muscle Tension
 Interferes With Life Functioning
 Must Last for at Least 6 Months
 Facts and Statistics
 Occurs in 4% of Population
 50-65% are Female
 Early Gradual (“insidious”) Onset
 Runs a Chronic Course
 Few Seek Treatment: WHY?
 Causes
 Unclear and Puzzling?
 Tend to show
Autonomic Restriction
Heightened Muscle Tension
High Sensitivity to Threat in General
Threat Sensitivity is Automatic
 Avoid Negative Affect Related to Threat
Biological Vulnerability
STRESS
Psychological Vulnerability
(Anxious Apprehension)
Worry Process
Imagery Avoidance
Intense
Cognitive Processing
Restricted
Autonomic Response
 Most Interventions are Weak
 Benzodiazepines
Frequently Prescribed
Provide Some Relief
 Cognitive-Behavioral Approaches
Process Avoided Emotional Material
Relaxation Training
Does as Well as Medication
 Clinical Description
 Exposure to Traumatic Events
War and Combat
Rape and Assault
Car Accidents
Natural Disasters
 Reexperiencing, Flashbacks, Numbing
 Sleep Disturbance, Chronic Arousal
 Subtypes
 Acute
1-3 Months After the Trauma
 Chronic
Symptoms Last > 3 Months
 Facts and Statistics
 Occurs in 7.8% of Population
 Most Common Traumas?
Combat and Assault
 Trauma is Necessary, not Sufficient
 Severity of Response Seems Important
 Runs a Chronic Course
 Causes
 Only Disorder With Clear Etiology
 Biological Vulnerability
 Experience With Events That are...
Uncontrollable and Unpredictable
 Severity of Trauma and One’s Reaction
True Alarm!
 Social Support Helps
 Psychological Interventions
 Face the Original Trauma
Imaginal Reexposure
Flooding
 Arrange for Corrective Emotional
Learning
 Problem of Secondary Gain
Disability and Compensation
 Clinical Description
 Culmination of All Anxiety Disorders
 Obsessions: Intrusive Thoughts,
Images, or Urges That the Person Trys
to Suppress or Eliminate
 Compulsions: Thoughts or Actions to
Suppress the Obsessions and Provide
Relief
 Facts and Statistics
 Occurs in 2.6% of Population
 Most Common Obsessions
Contamination & Aggression
 Most Common Compulsions
Checking & Washing
 Almost Equal Sex Ratio (F > M)
 Onset Early Adolescence to Mid-20s
 Causes
 Anxiety Focused on Unwanted Thoughts
 Thoughts are Unacceptable
When Fighting to Control One’s
Psychology Creates More
Psychopathology
 Psychological Interventions
 Cognitive-Behavioral Treatments
 Response Prevention
Rituals are Actively Prevented
 Exposure
Systematic and Gradual Exposure to
Feared Thoughts or Situations
 May Require Hospitalization
 Drug Therapies
 Medications Show Promise
 Most Effective Medications
Inhibit Reuptake of Serotonin
 May Benefit 60% of Patients