Transcript Anxiety Disorders - People Server at UNCW

Anxiety Disorders
Dr. Kayj Nash Okine
What is Anxiety?



Physiological – bodily rxns, such as
rapid heartbeat, muscle tension,
queasiness, dry mouth, or sweating
Behavioral – may sabotage your ability
to act, express yourself, or deal with
situations effectively
Psychological – subjective state of
apprehension, uneasiness, fearfulness
Normal “Everyday” Anxiety
vs. Clinical Anxiety
Clinical Anxiety:
 Is more intense
 Lasts longer
 Interferes with your life
 Is out of proportion to the situation
 May not be directed to any concrete
situation or event
The Anxiety Disorders










Panic Disorder
Agoraphobia
Specific Phobia
Social Phobia
Generalized Anxiety Disorder
Obsessive Compulsive Disorder
Posttraumatic Stress Disorder/Acute Stress Disorder
Anxiety Disorder Due to a General Medical Condition
Substance-Induced Anxiety Disorder
Anxiety Disorder Not Otherwise Specified
Panic Attacks

Sudden episodes of acute
apprehension or intense fear
that occur out of the blue
and are accompanied by at
least 4 of the following:
– Heart palpitations
– Numbness, tingling
sensation
– Trembling, shaking
– Chills, hot flashes
– Sweating
– Shortness of breath,
smothering sensation
–
–
–
–
Choking sensation
Chest pain or discomfort
Nausea, upset stomach
Feeling dizzy, faint,
lightheaded, unsteady
– Feeling detached, out of
touch with self
– Fear of losing control,
going crazy,
– Fear of having a heart
attack or dying
Sx typically develop
abruptly & reach a peak
rapidly within 10 mins
3 Types of Panic Attacks



Unexpected panic attacks (uncued):
absence of situational triggers; most
associated with panic disorder
Situationally-bound panic attacks (cued):
presence of “invariable” triggers; most
associated with social phobia & specific
phobias
Situationally-predisposed panic attacks:
presence of triggers; most associated with
GAD & PTSD
Panic Disorder:
Diagnostic Criteria




Presence of recurrent, unexpected panic attacks (at
least 2)
At least 1 panic attack is followed by a month or more
of:
– Apprehension about having another panic attack
– Worry about the possible implications of an attack,
such as losing control, “going crazy,” having a
heart attack, or dying
– A significant behavioral change related to the
attacks
Possible medical causes or the effects of substances
have been ruled out
Specify absence or presence of agoraphobia
Agoraphobia:
Diagnostic Criteria

Anxiety about being in places or situations
where:
– Escape may be difficult or embarrassing
– Help may not be available

These situations:
– Are avoided
– Are endured with marked distress or anxiety
– Require the presence of a companion (a “safe
person”

The anxiety and phobic avoidance is not
better accounted for by another
psychological disorder
Agoraphobia:
Common Feared Situations







Being outside the home
Being home alone
Crowded public places – restaurants,
theaters, malls, stores, supermarkets
Enclosed or confined spaces – escalators,
tunnels, elevators
Public transportation – buses, trains,
subways, planes
Open spaces
Driving or riding in cars
Agoraphobia & Panic
Disorder


Panic Disorder with Agoraphobia:
agoraphobia is due to the fear of
experiencing a full panic attack
Agoraphobia without a history of Panic
Disorder: fear of being incapacitated
or humiliated due to unpredictable,
sudden panic sx, such as dizziness or
diarrhea
Panic Disorder &
Agoraphobia: Causes


Heredity
Overly-sensitized & reactive “fear system”
– includes the amygdala, hippocampus, locus
ceruleus, hypothalamus, periacqueductal gray
region, & parabrachial nucleus
– results from the fear system’s being activated too
frequently &/or intensely due to acute stress or the
long-term result of multiple stressors over time


Chemical imbalances in the brain: deficiencies
in serotonin & norepinephrine
Classical/associative conditioning
Panic Disorder &
Agoraphobia: Causes






Growing up with parents who: are overly
critical & perfectionistic; are overprotective;
are overly anxious; communicate that the
world is a dangerous place
Tendency to interpret normal physical
sensations in a catastrophic way
Personal stress level
Sudden losses
Major life changes
Exposure to stimulants or withdrawal from
narcotics, barbiturates, & tranquilizers
Panic Disorder &
Agoraphobia: Facts & Figures



Onset: late adolescence or 20’s
Prevalence: 1-3.5% of the population;
5% of the population has panic
attacks with agoraphobia
Gender Differences: 2-3x as common
in women as men; approximately 7580% of agoraphobics are women
Panic Disorder & Agoraphobia:
Current Treatments




Relaxation Training – deep breathing, muscle
relaxation
Panic Control Therapy (interoceptive
desensitization) – repeatedly exposing oneself
to the unpleasant physical sx of panic via
induction techniques until the sx are no longer
frightening
Graded Exposure – avoided situations are
gradually confronted through a process of
small, incremental steps
Medication – SSRI’s, tricyclics antidepressants,
benzodiazepines
Panic Disorder & Agoraphobia:
Current Treatments




Cognitive Therapy: identifying & modifying
catastrophic thoughts that tend to trigger
panic attacks
Assertiveness Training
Group Therapy
Lifestyle & Personality Changes – stress
mgt, regular exercise, eliminating stimulants
& sugar, creating downtime, slowing down,
altering attitudes about perfectionism,
needing to please, and needing to control
Specific Phobia:
Diagnostic Criteria
A.
B.
C.
D.
E.
F.
Strong, persistent fear of specific objects or
situations
Exposure to feared object or situation provokes an
immediate anxiety response
Recognition that fear is excessive or unreasonable
(except for children)
The person avoids the feared object or situation or
endures it with dread
The avoidance, fear, or anxious anticipation
interferes significantly with the person’s functioning
or causes significant distress
Duration of at least 6 months
Specific Phobia: Specifiers





Animal Type – snakes, insects, rats
Natural Environment Type – storms, heights,
water
Blood-Injection-Injury Type – blood, injury,
injection, medical procedures
Situational Type – public transportation,
tunnels, bridges, elevators, flying, driving,
enclosed spaces
Other Type – choking, vomiting, contracting
an illness, loud sounds
Specific Phobia:
Facts & Figures




Prevalence: Affects 10-11% of
population
Gender Differences: 4x more common
for women
Only a minority seek treatment
Course: decline with old age
Specific Phobia: Causes






Childhood fears that were never outgrown
Vicarious learning – modeling, being warned
about a potential danger
Experiencing a traumatic event
Experiencing a false alarm in a specific
situation
Classical conditioning – conditioning by
association
Conditioning by avoidance
Specific Phobia:
Current Treatments



Relaxation training
Cognitive therapy
Systematic desensitization via imagery
&/or real life exposure
Social Phobia:
Diagnostic Criteria







Intense, persistent fear of being embarrassed, humiliated,
or negatively evaluated in social or performance situations
Exposure to the feared social or performance situation
typically provokes an immediate anxiety response
Recognition that the fear is excessive or unreasonable
(except for children)
The social or performance situation is avoided or endured
with considerable anxiety or distress
The avoidance, fear, or anxious anticipation interferes
significantly with the person’s functioning or causes the
person considerable distress
Symptoms must have persisted for at least 6 months
Specifier: Generalized – fear in a wide range of social
situations
Social Phobia:
Common Fears









Public speaking
Blushing
Choking on or spilling food while eating in
public
Being watched
Using public restrooms
Writing or signing documents in the
presence of others
Crowds
Taking exams
Performing
Social Phobia:
Facts & Figures



Prevalence: affects 2-13% of the US
population
Gender Differences: roughly equivalent
rates for men and women
Onset: late childhood or adolescence
Social Phobia:
Causal & Associated Features







Hypersensitivity to criticism, negative
evaluation, or rejection
Difficulty being assertive
Low self esteem, feelings of inferiority
Poor social skills
Lack of social support
Childhood history of social inhibition,
shyness, or stressful or humiliating social
experiences
Parents are more socially fearful and
concerned with the opinions of others
Social Phobia:
Current Treatments







Relaxation training
Cognitive therapy
Imaginal & real life exposure
Group therapy – ideal treatment format
Medication – beta-blockers, tricyclic
antidepressants, MAO inhibitors, SSRI’s
Social skills training
Assertiveness training
Generalized Anxiety
Disorder: Diagnostic Criteria
A.
B.
C.
Chronic anxiety & worry persist for at least 6 months &
focuses on 2+ stressful life circumstances
The anxiety and worry are difficult to control and are
out of proportion to the actual likelihood of feared
events happening
The anxiety and worry are associated with 3+ of the
following sx, which occur a majority of days during a 6month period (only 1 item is required in children):
1.
2.
3.
4.
5.
6.
Restlessness, feeling keyed up or on edge
Easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Difficulties with sleep
GAD: Diagnostic Criteria
D. The focus of the anxiety & worry is
not confined to the features of
another Axis I disorder, e.g. such as
anxiety about gaining weight in
anorexia nervosa
E. The anxiety, worry, or physical sx
cause significant distress or
impairment in functioning
GAD: Facts & Figures




Affects approximately 4% of the
American Population
More common in females than males
(55-67%)
Onset: earlier and more gradual onset
than most other anxiety disorders
Course: chronic
GAD: Causes





Heredity
A disturbance in the functioning of the
benzodiazepine/GABA system of the brain, which is
associated with the body’s natural calming response
Predisposing childhood experiences – e.g. excessive
parental expectations, parental abandonment or
rejection
Maladaptive attitudes – perfectionism, excessive need
to please others, excessive need to control, oversensitivity to threat
“Basic fears” that Sustain GAD: fear of losing control,
fear of not being able to cope, fear of rejection or
abandonment, fear of death or disease
GAD: Current Treatments






Relaxation Training
Cognitive Therapy – fearful self talk underlying worry
themes are identified, challenged, & replaced with more
realistic, optimistic thinking
Problem Solving – focus on solutions rather than
worrying, learn to accept what you can’t change
Distraction Techniques
Medication – benzodiazepines, tricyclics, SSRI’s, SNRI’s
Lifestyle & Personality Changes – stress management,
increased downtime, regular exercise, eliminating
sweets & stimulants from diet, resolving interpersonal
conflicts
Obsessive Compulsive
Disorder: Diagnostic Criteria
Obsessions:
 Recurring, intrusive, senseless ideas, thoughts or
images that can’t seem to be suppressed
 Not merely excessive worries about real-life
problems; in fact, are usually unrelated to real-life
problems
 Person recognizes that these thoughts, fears,
images are irrational
 Most common: aggressive impulses, fear of
contamination, sexual thoughts, somatic concerns,
the need for symmetry and exactness
 25% of people only have obsessions
OCD: Diagnostic Criteria
Compulsions:
 Behaviors or rituals the person feels compelled to
perform in order to dispel the anxiety brought up by
obsessions
 E.g. washing hands numerous times to dispel fear of
being contaminated, checking windows and doors
over and over again to make sure they’re locked
 Most common: washing, checking, counting,
ordering and arranging
 Person recognizes that the rituals are unreasonable
 Conflict between desire to be free of the compulsive
ritual and the irresistible desire to perform it 
anxiety, shame, despair
OCD: Facts & Figures


Prevalence: 2-3% of general population
Gender Differences:
–
–
–
–


Affect men & women in equal numbers
Men outnumber women as checkers
Women outnumber men as washers and cleaners
Age of onset is earlier in men than women
Onset: half of cases begin in childhood; half
begin in adolescence or young adulthood
Often accompanied by, and may wax & wane
with, depression
OCD: Causes







Deficiency in serotonin
Associated with excessive activity in certain parts of
the brain (orbitofrontal cortex, the cingulated gyrus,
& the caudate nuclei)
The tendency to develop anxiety over having
additional obsessive thoughts
Being taught that certain thoughts are dangerous
and unacceptable and must be suppressed
Thought-action fusion: equating thoughts with their
corresponding actions
Attitudes of excessive responsibility and
perfectionism
Compulsions develop to suppress or neutralize
obsessions
OCD: Current Treatments






Relaxation Training
Cognitive Therapy – fearful, superstitious, or
guilty thoughts associated with the
obsessions are identified, challenged, and
replaced
Exposure & Response Prevention
Medication – SSRI’s, clomipramine
Life Style & Personality Changes
Psychosurgery – surgical lesion to the
cingulate bundle (cingulotomy)
Posttraumatic Stress
Disorder: Diagnostic Criteria
EXPOSURE TO A TRAUMATIC EVENT
 The person has been exposed to a traumatic
event which
– involved threats to personal integrity, serious
injury, or death.
– produced intense fear, helplessness, or horror
– for children: produced disorganized or agitated
behavior

e.g. earthquakes, tornadoes, auto accidents,
combat, rape, physical assault, violent crime
PTSD: Diagnostic Criteria
RE-EXPERIENCING
 The traumatic event is persistently reexperienced in 1+ of the following ways:
– Repetitive, distressing thoughts or images about
the event
– Nightmares related to the event
– Intense flashbacks
– Intense psychological distress &/or physiological
reactivity to stimuli associated with the trauma
– For children: frightening dreams without
recognizable content, repetitive play relating to
the trauma, trauma reenactment
PTSD: Diagnostic Criteria
AVOIDANCE
 Persistent avoidance of stimuli
associated with the trauma:
– efforts to avoid thoughts, feelings, or
conversations associated with the trauma
– efforts to avoid activities, places, or
people that arouse recollections of the
trauma
PTSD: Diagnostic Criteria
NUMBING
 Numbing of general responsiveness (not
present before the trauma)
– inability to recall an important aspect of the
trauma
– losing interest in activities that used to give
pleasure
– feeling detached or estranged from others
– emotional numbness – being out of touch with
feelings
– sense of foreshortened future, e.g. not expecting
to have a career, marriage, children, or normal
life span
PTSD: Diagnostic Criteria
INCREASED AROUSAL
 Persistent symptoms of increased arousal
(not present before the trauma), as
indicated by 2+ of the following:
–
–
–
–
–
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
startling easily
PTSD: Diagnostic Criteria



Duration of the disturbance is more than
one month
The disturbance causes significant distress
or impairment in important areas of
functioning
Specify if:
– Acute – if duration of symptoms is < 3 months
– Chronic – if duration of symptoms is 3+ months
– Delayed onset – if onset of symptoms is at least
6 months after the stressor
PTSD: Facts & Figures


Can occur at any age
Prevalence:
–
–
–
–

3-8% of the general population
18% of women experiencing trauma
32% of rape victims
15-20% of those experiencing serious auto
accidents
Often accompanied by anxiety & depression
PTSD: Causes






Person personally experiences a trauma and
develops an array of symptoms that “recreate” the
original trauma
Distressing recollections & dreams about the
trauma are the mind’s attempt to gain control of
the original event & to neutralize the emotional
charge it carries
Family history of anxiety
Family instability
Lack of social support
Elevated corticotropin-releasing factor (CRF) and
heightened activity in the HPA axis resulting from
the trauma
PTSD: Current Treatments







Relaxation Training
Cognitive Therapy
Exposure Therapy – imaginal exposure
Medication – SSRI’s
Support Groups
EMDR – Eye Movement Desensitization &
Reprocessing
Hypnotherapy
Acute Stress Disorder:
Diagnostic Criteria

The person has been exposed to a traumatic event
which:
– involved threat to personal integrity, serious injury, or death
– produced intense fear, helplessness, or horror

Either during or after the traumatic incident, the
person has 3+ of the following dissociative
symptoms:
– numbing, detachment, or absence of emotional
responsiveness
– reduced awareness of one’s surroundings (e.g. being in a
daze)
– feelings of unreality or depersonalization
– dissociative amnesia (i.e. inability to recall an important
aspect of the trauma)
Acute Stress Disorder:
Diagnostic Criteria

The traumatic event is persistently re-experienced in at
least one of the following ways:
– recurrent images, thoughts, dreams, flashbacks
– a sense of reliving the experience
– distress on exposure to stimuli associated with traumatic event



Marked avoidance of anything that reminds the person of
the trauma (e.g. thoughts, feelings, conversations,
activities, places, people)
The disturbance causes the person significant distress or
impairment in important areas of functioning
The disturbance occurs within 4 weeks of traumatic event
& lasts for a minimum of 2 days and a maximum of 4
weeks
Anxiety Due to a General Medical
Condition: Diagnostic Criteria

Significant anxiety, panic attacks, or
generalized anxiety are a direct physiological
effect of a specific medical condition:
– Endocrine conditions – hyperthyroidism,
hypothyroidism, pheochromocytoma,
hypoglycemia
– Cardiovascular conditions – congestive heart
failure, pulmonary embolism
– Metabolic conditions – vitamin B12 deficiency,
porphyria
– Neurological conditions – vestibular problems,
encephalitis
Substance-Induced
Anxiety Disorder

Significant anxiety, panic attacks, or
generalized anxiety are a direct
physiological effect of a substance:
– a medication
– drug of abuse
– toxin exposure

Anxiety may be due to exposure to the
substance or withdrawal from it
Long-Term, Predisposing Causes of
Anxiety Disorders

Heredity
– Having the same genetic makeup as someone with
phobias or anxiety makes it more than 2x as likely that
you will have a similar problem
– Inherit a reactive, excitable nervous system and
personality that predisposes you to anxiety

Childhood Circumstances
– Parents communicate an overly cautious view of the world.
– Parents are overly critical & perfectionistic and set
excessively high standards
– Experiencing neglect, rejection, abandonment (e.g. via
divorce or death), physical abuse, sexual abuse, alcoholic
parent(s)  emotional insecurity & excessive dependency
– Parents suppress your ability to express your feelings &
assert yourself
Long-Term, Predisposing
Causes of Anxiety Disorders

Cumulative and/or Enduring Stress
– Over time, stress can affect the
neuroendocrine regulatory systems of the
brain, which play an important role in
depression and anxiety
– Stress is nonspecific in its action – it has
the greatest impact on the weakest
point(s) in one’s system

Biological Causes
Long-Term, Predisposing
Causes of Anxiety Disorders

Medical Conditions:
– Hyperventilation syndrome – rapid, shallow breathing can
produce light-headedness, dizziness, feelings of unreality,
trembling, tingling, shortness of breath
– Hypoglycemia – anxiety, shakiness, dizziness, weakness,
disorientation
– Hyperthyroidism – heart palpitations, sweating, generalized
anxiety
– Mitral valve prolapse – causes heart palpitations
– Premenstrual syndrome
– Inner ear disturbances – dizziness, light-headedness,
unsteadiness
– Acute reactions to cocaine, amphetamines, caffeine, or other
stimulants
– Withdrawal from alcohol, sedatives, or tranquilizers
Short-Term Triggering Causes
of Anxiety Disorders

Stressful events/circumstances that
precipitate panic attacks:
– Significant personal loss – death, divorce,
separation, loss of employment, illness, financial
reversal, etc
– Significant life change – getting married, having
a baby, going off to college, moving, changing
jobs, etc

Exposure to stimulants and withdrawal from
narcotics, barbiturates, tranquilizers
Maintaining Causes of
Anxiety Disorders











Avoidance of feared situations
Anxiety-provoking self-talk
Mistaken beliefs about yourself, others, and the
world
Withheld feelings – denying feelings of anger,
sadness, frustration, excitement
Lack of assertiveness
Lack of self-nurturing skills
Muscle tension  feel “uptight”
Stimulants
Dietary factors – sugar, food additives
High stress lifestyle
Lack of meaning or sense of purpose in life