Transcript Chapter 4 lecture slides

Chapter 4
Anxiety Disorders
The Complexity of Anxiety Disorders
• Anxiety – the future-oriented mood state
– Apprehension about future danger or misfortune
– Somatic symptoms of tension
– Characterized by marked negative affect
• Anxiety and fear are normal emotional states
The Complexity of Anxiety Disorders
• Fear – the present-oriented mood state
– Immediate fight or flight response to danger or
threat
– Involves abrupt activation of the sympathetic
nervous system
– Strong avoidance/escapist tendencies
– Marked negative affect
From Normal to Disordered Anxiety and
Fear
• Characteristics of anxiety disorders
– Pervasive and persistent symptoms of anxiety and
fear
– Involve excessive avoidance and escape
– Cause clinically significant distress and impairment
The Phenomenology of
Panic Attacks
• What is a panic attack?
– Abrupt experience of intense fear or discomfort
– Several physical symptoms
(e.g., breathlessness, chest pain)
– Fear as an alarm response
The Phenomenology of
Panic Attacks
• DSM-IV-TR subtypes of panic attacks
– Situationally bound (cued)
– Unexpected (uncued)
– Situationally predisposed
• Cultural influences on anxiety
Biological Contributions to Anxiety and
Panic
• Genetic vulnerability
• Anxiety and brain circuits
– Depleted levels of GABA
Biological Contributions to Anxiety and
Panic (continued)
• Limbic (amygdala) and the
septal-hippocampal systems
• Behavioral inhibition system (BIS)
– Anxiety
• Fight/flight system (FF)
– Fear
Psychological Contributions to Anxiety
and Fear
• Integrated model
– Early childhood - Experiences with
uncontrollability and unpredictability
Psychological Contributions to Anxiety
and Fear
• Behavioral and cognitive views
– Invokes conditioning and cognitive explanations
– Anxiety and fear are learned responses
– Catastrophic thinking and appraisals play a role
Psychological Contributions to Anxiety
and Fear
• Social contributions
– Stressful life events trigger vulnerabilities
An Integrated Model
• Integrative view – triple vulnerability model
– Generalized biological vulnerability
– Generalized psychological vulnerability
– Specific psychological vulnerability
An Integrated Model
• Common processes: the problem of
comorbidity
– Comorbidity is common across the anxiety
disorders
– Major depression is the most common secondary
diagnosis
– About half of patients have two or more
secondary diagnoses
– Comorbidity suggests
• Common factors
• A relation between anxiety and depression
The Anxiety Disorders:
An Overview
• Generalized anxiety disorder (GAD)
• Panic disorder with and without agoraphobia
(PDA)
• Specific phobias
• Social phobia (SAD)
• Posttraumatic stress disorder (PTSD)
• Obsessive-compulsive disorder (OCD)
Generalized Anxiety Disorder: The
“Basic” Anxiety Disorder
• Overview and defining features
– Excessive uncontrollable anxious apprehension
and worry
– Coupled with strong, persistent anxiety
– Persists for six months or more
– Somatic symptoms differ from panic
(e.g., muscle tension)
Generalized Anxiety Disorder: The
“Basic” Anxiety Disorder
• Statistics
– Affects about 3.1% of the general population
– Females outnumber males approximately 2:1
– Onset is often insidious, beginning in early
adulthood
– Very prevalent among the elderly
– Tends to run in families
Generalized Anxiety Disorder:
Associated Features and Treatment
• Associated features
– Persons with GAD have been called “autonomic
restrictors”
– Fail to process emotional component of thoughts
and images
• Causes – factors influencing
– Genetics
– Muscle tension
– Personal threat
– Automatic restrictors
Generalized Anxiety Disorder:
Associated Features and Treatment
• Treatment of GAD: Generally weak
– Benzodiazapines – often prescribed
– Antideprancents
– Psychological interventions –
cognitive-behavioral therapy
– Meditation therapy
– Combined treatments – acute vs. long-term
outcomes
Panic Disorder With and Without
Agoraphobia
• Overview and defining features
– Experience of unexpected panic attack (i.e., a false
alarm)
– Develop anxiety, worry, or fear about another
attack
– Many develop agoraphobia
Panic Disorder With and Without
Agoraphobia
• Facts and statistics
– Affects about 2.7% of the general population
– Onset is often acute, mean onset between 20 and
24 years of age
– 66% of individuals with agoraphobia are female
• Cultural influences
• Causes
– Triple
– 8% to 12% has occasional attacks vulnerability
Panic Disorder: Associated Features and
Treatment
• Associated features
– Nocturnal panic attacks – 60% panic during deep
non-REM sleep
– Interoceptive/exteroceptive avoidance
• Medication treatment
– Target serotonergic, noradrenergic, and GABA
systems
– SSRIs (e.g., Prozac and Paxil) are preferred drugs
– Relapse rates are high following medication
discontinuation
Panic Disorder: Associated Features and
Treatment
• Psychological and combined treatments
– Cognitive-behavioral therapies are highly effective
– No evidence that combined treatment produces
better outcome
– Best long-term outcome is with cognitivebehavioral therapy alone
Panic Disorder: Associated Features and
Treatment
• Panic control treatment (PCT)
• Combined psychological and drug treatments
• Innovative approaches
– Psychological (CBT) treatment followed by drug
treatments
– D-cycloserine (DCS)
Specific Phobias: An Overview
• Overview and defining features
– Extreme irrational fear of a specific object or
situation
– Persons will go to great lengths to avoid phobic
objects
– Most recognize that the fear and avoidance are
unreasonable
– Markedly interferes with one’s ability to function
Specific Phobias: An Overview
• Facts and statistics
– Females are again over-represented
– Affects about 12.5% of the general population
– Phobias tend to run a chronic course
Specific Phobias: Associated Features
and Treatment
• Subtypes of specific phobia
– Blood-injury-injection phobia – unusual vasovagal
response
– Situational phobia – trains, planes, automobiles,
closed spaces
– Natural environment phobia – natural events (e.g.,
heights, storms)
– Animal phobia – animals and insects
– Separation anxiety – seen in children
Specific Phobias: Associated Features
and Treatment
• Causes of phobias
– Direct experience
– Biological and evolutionary vulnerability
– traumatic conditioning, prepared tendency, event
will happen again
• Psychological treatments of specific phobias
– Cognitive-behavior therapies are highly effective –
exposure
• Cultural factors
Social Phobia: An Overview
• Overview and defining features
– Extreme and irrational fear in social/performance
situations
– Markedly interferes with one’s ability to function
– Often avoid social situations or endure them with
great distress
– Generalized subtype – affects many social
situations
Social Phobia: An Overview
• Facts and statistics
– Affects about 12.1% of the general population,
6.8% in 1-year period
– Prevalence is slightly greater in females than
males
– Second only to specific phobia in the anxiety
disorders
– Onset is usually during adolescence
– Peak age of onset at about 13 years
Social Phobia: Associated Features and
Treatment
• Causes
– Biological and evolutionary vulnerability
– Similar learning pathways as specific phobias
• Psychological treatment
– Cognitive-behavioral treatment (CBT)
– Cognitive-behavioral group treatment (CBGT)
– Cognitive-behavioral therapies are highly effective
Social Phobia: Associated Features and
Treatment
• Medication treatment
– Tricyclic antidepressants and monoamine oxidase
inhibitors
– SSRIs Paxil, Zoloft, and Effexer – are FDA approved
– Relapse rates are high following medication
discontinuation
Posttraumatic Stress Disorder (PTSD):
An Overview
• Overview and defining features
– Main etiologic characteristics – trauma exposure
and response
– Reexperiencing (e.g., memories, nightmares,
flashbacks)
– Avoidance
– Emotional numbing and interpersonal problems
– Markedly interferes with one's ability to function
– PTSD diagnosis – only after one month posttrauma
Posttraumatic Stress Disorder (PTSD):
An Overview
• Statistics
– Combat and sexual assault are the most common
traumas
– Lower than expected prevalence rates in trauma
victims
PTSD: Causes and Associated Features
• Subtypes and associated features of PTSD
– Acute – may be diagnosed one-three months post
trauma
– Chronic – diagnosed after three months post
trauma
– Delayed onset – onset six months or more post
trauma
– Acute stress disorder – PTSD immediately posttrauma
PTSD: Causes and Associated Features
• Causes of PTSD
– Intensity of the trauma and one's reaction to it
(i.e., true alarm)
– Learn alarms – direct conditioning and
observational learning
– Biological vulnerability
– Uncontrollability and unpredictability
– Extent of social support, or lack thereof, posttrauma
PTSD: Treatment
• Psychological treatments
– Cognitive-behavioral therapies (CBT) are highly
effective
– CBT may include graduated or massed (e.g.,
flooding) imaginal exposure
– Aim of CBT for PTSD
– SSRIs
Obsessive-Compulsive Disorder (OCD):
An Overview
• Overview and defining features
– Obsessions – intrusive and nonsensical thoughts,
images, or urges
• Symmetry 26.7%, forbidden thoughts 21%, cleaning
and contamination 15.9% and hording 15.4%
– Compulsions – thoughts or actions to neutralize
thoughts
– Vicious cycle of obsessions and compulsions
– Cleaning and washing or checking rituals are
common
Obsessive-Compulsive Disorder (OCD):
An Overview
• Overview and defining features
– Tic disorder and OCD
– Hoarding
OCD: Causes and Associated Features
• Statistics
– Affects about 1.6% of the general population
– Most with OCD are female
– Onset is typically in early adolescence or young
adulthood
– OCD tends to be chronic
OCD: Causes and Associated Features
• Causes of OCD
– Parallels the other anxiety disorders
– Early life experiences
– Learning that some thoughts are
dangerous/unacceptable
– Thought-action fusion – the thought is similar to
the action
OCD: Treatment
• Medication treatment
– Clomipramine and other SSRIs – benefit up to 60%
of patients
– Relapse is common with medication
discontinuation
– Psychosurgery (cingulotomy) is used in extreme
cases
OCD: Treatment
• Psychological treatment
– Cognitive-behavioral therapy is most effective
– CBT involves exposure and response prevention
– Combining CBT with medication – no better than
CBT alone
– Exposure and ritual prevention (ERP) – more
effective than drugs
Summary of the Anxiety Disorders
• Most common forms of psychopathology
• From a normal to a disordered experience of
anxiety and fear
– Triple vulnerabilities – bio-psycho-social
– Fear and anxiety – non-dangerous bodily or
environmental cues
– Symptoms and avoidance – significant distress and
impairment
Summary of the Anxiety Disorders
• Psychological treatments are generally
superior in the long-term
– Similar treatments for different anxiety disorders
– Suggests that anxiety-related disorders share
common processes
DSM-5 Proposed Changes
• http://www.dsm5.org/ProposedRevisions/Pag
es/AnxietyDisorders.aspx