Transcript CHAPTER SIX
Anxiety Disorders Symptoms Diagnosis Frequency Causes Treatment FEAR Experienced in the face of real, immediate danger Builds quickly in intensity Helps organize the person’s behavioral responses to threats Fight/Flight response sympathetic n.s. ANXIETY Anticipation of future problems Prepares us to take action Involves more general or diffuse emotional reactions At the same time, we can also worry too much, feel anxious too often or be afraid at inappropriate times. The questions is: how maladaptive are these behaviors and to what extent do they interfere in one’s ability to function normally? Most common type of abnormal behavior Share similarities with mood disorders: Both defined in terms of negative emotional responses (Case of Johanna, inter and/or intrapersonal?) Close relationship between symptoms of anxiety and depression (e.g., guilt, worry, anger). May share similar causal features: ▪ stress, cognitive factors, biological. People with anxiety disorders share a preoccupation with, or persistent avoidance of, thoughts or situations that provoke fear or anxiety. The diagnosis of anxiety disorders depends on several types of symptoms. David Barlow’s anxious apprehension: 1) High levels of diffuse negative emotion 2) Sense of uncontrollability 3) Shift in attention to a primary self focus or state of self preoccupation The emotional experience is out of proportion to the threat Excessive Worry Cognitive activity associated with anxiety. A relatively uncontrollable sequence of negative, emotional thoughts that are concerned with possible future threats or danger. ? ? Excessive Worry Worriers are preoccupied with “self-talk” Worry Distinctions hinges on quantity and quality of worrisome thoughts and the negativity of content. Panic Attacks Discrete episode of acute terror in the absence of real danger A sudden, intense, overwhelming experience of terror or fright Emotional response more focused A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, 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 Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,Text Revision. Panic Attacks (continued) Misinterpretations of bodily sensations lies at the core of panic disorder ▪ Heart palpitations ▪ Racing thoughts heart attacks lose their mind Panic Attacks (continued) Described in situations in which they occur: ▪ Cued: if expected, or if it occurs only in the presence of a particular stimulus ▪ Unexpected: panic attacks appears without warning or expectation, as if “out of the blue.” OBSESSIONS COMPULSIONS Unwanted, anxietyprovoking thoughts/images “out of the blue” May seem silly or crazy, socially inappropriate or horrific Compulsions cannot be resisted without distress Reduce (neutralize) anxiety, but do not produce pleasure Irrational rituals stress disorder ▪ Recurrent, unexpected panic attacks ▪ At least one of the attacks must be followed by a period of 1 month or more with persistent concerns about having additional attacks. ▪ Divided into two subtypes: presence of absence of agoraphobia Defined as intense, persistent, irrational, fear and avoidance of a specific object or situation Reactions are unreasonable. Agoraphobia ▪ Fear of public places in which individual fears that s/he cannot escape. ▪ Typical situations ▪ Crowded streets, shops ▪ Public transportation ▪ Wide open areas Fears are focused on social situations where there is a possibility of being judged/observed/humiliated/embarrassed Two broad headings: Performance Anxiety Interpersonal interaction ▪ A “marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation.” ▪ Exposure to phobic stimulus must be followed by an immediate fear response. ▪ “Catchall” category 1) Animals 2) Natural Environmental 3) Blood/Injury/Injection 4) Situational ▪ ▪ ▪ ▪ Chronic (>6 mos),debilitating, excessive anxiety and worry Trouble controlling the worries Worries lead to significant distress Pervasive: worries must be about different events or activities ▪ Includes three or more of the following: Restlessness Sleep disturbance Fatigue Irritability Muscle Tension Difficulty concentrating ▪ Recognition that the obsessions or compulsions are excessive or unreasonable. ▪ Attempts to ignore, suppress, or neutralize the unwanted thoughts or impulses. ♀ > ♂ 2-3 times Relapse rates: higher for ♀ OCD: no significant gender differences Specific phobia: ♀ are three times more likely Panic disorder, agoraphobia (without panic disorder): ♀ about twice as likely Social phobia: more common among ♀ Evolutionary perspective focuses on significance of anxiety and fear. Fear/Anxiety may mobilize. Help the person survive in the face of both immediate danger and long-range threats Adaptive and Maladaptive Fears ▪ Preparedness Model (preconditioning theory) ▪ Research results appear to support that conditioned responses to fear-relevant stimuli (e.g., spiders, snakes) are more resistant to extinction that those to fear-irrelevant stimuli (e.g., flowers). Causal patterns are complex. Multicausal. Stressful life events, particularly involving danger and interpersonal conflict, can trigger the onset of certain kinds of anxiety disorders and depression. Nature of the event: important factor Anxiety: danger Depression: severe loss (lack of hope) Maternal prenatal stress (higher cortisol levels at birth) Multiple maternal partner changes Parental indifference (neglect) Physical abuse. more likely to develop anxiety disorders Anxiety is an innate response to separation, or threat of separation. People with anxiety disorders more likely to have had attachment problems as children. Specific fears might be learned through classical conditioning. http://www.mathxl.com/info/MediaPopup.aspx?origin=1&disciplineGroup=5&type=Watch&loc=MPLspvideo@ babyal.flv%20&width=-1&height=-1&autoh=yes¢erwin=yes Watson and Rayner (1920) “Little Albert” study Conditioned fears “persist and modify personality throughout life” Mary Cover Jones (1924) later used classical conditioning to remove fears in another boy White rat no reaction (NS) Loud Noise (UCS) White Rat + Loud Noise (NS) White rat (CS) (UCS) Fear (UCR) Fear (UCR) Fear (CR) Perceptions, memory, and attention all influence reaction to events. ▪ Four aspects: ▪ Perception of controllability ▪ Catastrophic misinterpretation ▪ Attentional biases ▪ Thought suppression Control events in their environments: less likely to show anxiety than people who believe they are helpless. Feelings of lack of control = onset of panic attacks Anxiety Control Catastrophic Misinterpretation ▪ Panic attacks can be precipitated by internal stimuli, such as bodily sensations, thoughts, or images. ▪ Misinterpret bodily sensations = catastrophic event. ▪ Automatic, negative thoughts lead to behaviors that are expected to increase safety, when they are in fact counterproductive. Attention to Threat and Biased Information Processing ▪ Unusually sensitive to cues that signal the existence of future threats. ▪ Recognition of danger triggers maladaptive, self-perpetuating cycles that quickly spin out of control. Trying to rid one’s mind of a distressing or unwanted thought can have the unintended effect of making the thought more intrusive (especially for OCD). Thalamus Amygdala Flight or Fight (behavioral responses coordinated through the hypothalamus) Endocrine glands & Autonomic Nervous System (FIGURE 6-3) Thalamus Visual Cortex Amygdala (triggers an organized response to threat). Psychoanalytic psychotherapy ▪ Fosters insight regarding the unconscious motives that presumably lie at the heart of the patient’s symptoms. Relaxation Skills Training ▪ Teaching alternately to tense and relax specific muscle groups while breathing slowly and deeply. Breathing Retraining ▪ Education about the physiological effects of hyperventilation and practice in slow breathing. ▪ Learn to control breathing through repeated practice using muscles of the diaphragm, rather than the chest. Systematic Desensitization ▪ Systematic maintained exposure to the feared stimuli. ▪ Progressive relaxation ▪ A hierarchy of feared stimuli Exposure Treatments ▪ Situational Exposure: used to treat agoraphobic avoidance ▪ Involves repeatedly confronting the situations that have been previously avoided. ▪ Interoceptive Exposure: aimed at reducing the person’s fear of internal, bodily sensations frequently associated with panic Cognitive Therapy ▪ Identify thoughts that are relevant to their problems. ▪ Recognize the relation between these thoughts and maladaptive emotional responses. ▪ Examine evidence that supports or contradicts these beliefs. ▪ Teach more useful ways of interpreting events. Antianxiety Medications—Anxiolytics Work on GABA ▪ Most frequently used types of minor tranquilizers -- benzodiazepines. ▪ Valium and Xanax ▪ Reduce many symptoms of anxiety, especially vigilance and somatic sensations. ▪ Have less effect on worry and rumination. Benzodiazepines ▪ Shown to be effective in the treatment of GAD and social phobias ▪ Not typically beneficial for specific phobias or OCD ▪ Many with panic disorder and agoraphobia relapse if they discontinue taking medication. Side Effects ▪ Sedation accompanied by mild psychomotor and cognitive impairments ▪ Problems in attention and memory, especially among elderly ▪ Potential for addiction Antidepressant Medications ▪ Selective Serotonin Reuptake Inhibitors (SSRIs) ▪ Zoloft ▪ Paxil ▪ Prozac ▪ Luvox SSRIs ▪ Reduce symptoms of various anxiety disorders. ▪ Fewer unpleasant side effects and are safer to use. ▪ Withdrawal reactions are less prominent ▪ First-line medication for treating panic disorder, social phobias, and OCD Antidepressant Medications: Tricylics (norepinephrine) Used less frequently than the SSRIs because they produce several unpleasant side effects ▪ Anafranil: OCD ▪ Improvement in see in 50% receiving clomipramine, but relapse is common if medication is discontinued. Buspar—drug mechanisms are unknown. May work on serotonin or dopamine systems Less potent, but less addictive with less side effects. Often treated with a combination of psychological and biological procedures. Selection of specific treatment components depends on presenting symptoms.