Slide 1 ___________________________________ - - PDF document

Slide 1

Anxiety Disorders

Chapter 6

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 2

Anxiety Disorders

 Def: behaviors that include phobias, obsessions,

compulsions and extreme worry. People with an anxiety disorder share a pre-occupation with , or persistent avoidance of thoughts or situations that provoke fear or anxiety, and frequently have a negative impact on aspects of a person’s life.

 Similarities with mood disorders:

 Both are defined in terms of negative emotional responses  Both involve feelings of guilt, worry, and anger.  Common etiological features, such as cognitive distortions,

triggers by stressful life events, and biological factors such as neurotransmitter imbalances.

 Close relationship of symptoms for anxiety and mood disorder

suggests the possibility of common causal features (e.g. stressful life events)

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 3

Anxiety as a Mood vs. a Syndrome

 Fear-experienced in the face of real or immediate

danger, builds quickly and helps organize a person’s behavioral responses to threats from the environment.

 Anxious Mood-general or diffuse emotional reaction

that is beyond simple fear and out of proportion to threats in the environment.

 Not always directed at the person’s present circumstance 

can be associated with the anticipation of future problems.

 Adaptive at low levels as it signals a person must prepare for

an upcoming event.

 Anxious apprehension- a pervasively anxious mood

associated with pessimistic thoughts, negative self- evaluation and negative concern for future events.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 4

Symptoms of Anxiety Disorders

 Excessive Worry-  Panic Attacks-  Phobias- persistent, irrational narrowly defined fears that are

associated with a specific object or situation.

 Obsessions and Compulsions

 Obsessions (def)-repetitive unwanted, intrusive cognitive

events that may take the form of thoughts images or impulses and lead to an increase in subjective anxiety.

 Compulsions-repetitive behaviors or mental acts that are used

to reduce anxiety.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 5

Excessive Worry

 Cognitive activity associated with anxiety

that manifests as a relatively uncontrollable sequence of negative, emotional thoughts that are concerned with possible future threats or dangers.

 Lack of perceived control  Negative Affect  Quantity

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 6

Panic Attacks



Panic attacks- sudden overwhelming experience of terror or fright. More focused than anxiety believed to be a normal fear response triggered at an inappropriate time.



Physical sensations of which the patient must experience at least four, which develop suddenly and reach peak intensity within 10 minutes:

 Heart palpitations  Sweating  Trembling or shaking  Sensation of shortness of breath  Choking feeling  Chest pain  Nausea or abdominal distress  Dizziness  Feelings of unreality or detachment from oneself  Fear of losing control or going crazy  Fear of dying  Numbness or tingling sensation  Chills or hot flushes

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 7

Phobias

 Persistent, irrational narrowly defined

fears that are associated with a specific

• bject or situation.

 Avoidance  Agoraphobia-Fear becomes more intense as the

distance between the person and his or her familiar surroundings increases, or as avenues of escape are closed off.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 8

Obsessions and Compulsions

 Obsessions and Compulsions-

 Obsessions (def)-repetitive unwanted, intrusive cognitive events that may

take the form of thoughts images or impulses and lead to an increase in subjective anxiety.

 Compulsions-repetitive behaviors or mental acts that are used to reduce

anxiety.  Obsessions

 Seem to come out of the blue  Content of obsessions

 Compulsions-Must perform the ritual to keep something

“bad” from happening.

 Most common are cleaning and checking

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 9

Diagnostic Systems of Anxiety Disorders (DSM-IV-TR)

 Panic Disorder

 Recurrent unexpected panic attacks with at least half of the

attacks followed by a period of one month or more in which the person fears having another attack. (fear of fear)

 Avoidance of the situation (change in behavior)

 Agoraphobia

 Avoid the situation or endure it with great distress  Insist on being accompanied by a safe person.

 Specific Phobia-marked and persistent fear that is

excessive or unreasonable, cued by the presence of specific object or situation.

 Exposure produces immediate fear response  Awareness that fear is unreasonable  Avoidance

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 10

History of Anxiety as a Disorder

 Early classification of Anxiety disorders were under the

classification of neurosis.

 Distinguished from the psychotic disorders as the patient

has awareness.

 Contemporary classification of anxiety disorder includes:  Panic disorder  Phobic Disorder  Obsessive Compulsive Disorder  Post Traumatic Stress Disorder  Acute Stress Disorder

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 11

Diagnostic Systems of Anxiety Disorders (DSM-IV-TR)



Panic Disorder-recurrent unexpected panic attacks . For one month or more following at least

• ne attack, the person must experience persistent concern about having another attack, worry

about implications of the attack or a significant change in behavior due to the attack. Two Categories:

 With or Without Agoraphobia  Agoraphobia-complication that follows experience of panic attacks in which the

person fears the inability to escape the situation. With agoraphobia, the person must either avoid the agoraphobic situation, endure it with great distress, or insist they be accompanied by another person who can offer comfort or security.can exist in the absence of panicP disorder (rare)



Phobic Disorders:

 Specific Phobia-marked and persistent fear that is excessive or unreasonable

cued by the presence or anticipation of a specific object or situation.

 Social Phobia-identical to specific phobia, except must be afraid of social

• categories. Fear of being humiliated lies at the heart of the disorder. Two

Categories:

 Performance Anxiety  Interpersonal Interactions

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 12

DSM Classification



Generalized Anxiety Disorder-excessive anxiety or worry that lead to significant distress or impairment in occupational or social functioning. Free-floating anxiety must be accompanied by at least three of the following symptoms:



Restlessness or feeling on edge



Fatigue



Difficulty concentrating



Irritability



Muscle Tension



Sleep Disturbance



Obsessive-Compulsive Disorder-defined in terms of the presence of either obsessions

• r compulsions.



Obsessions-thoughts must not be excessive worries about real problems must be unreasonable



Compulsions-rituals that cause marked distress if not performed, take more than an hour a day to perform or interfere with normal occupational and social functioning.



Post traumatic Stress Disorder (Chapter 7)



Acute Stress Disorder (Chapter 7)



Separation Anxiety- (Chapter 16)

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 13

Course and outcome

 Chronic conditions Research based predictive

course and outcomes: Long term outcome unpredictable

 Panic Disorder-Greatest predictor of poor outcomes

was onset of symptoms at a relatively young age and the presence of agoraphobia with panic disorder.

 Social phobia-Symptoms usually appear first in early

adolescence and remain stable over time, indicating chronic condition.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 14

Course and Outcome

 OCD-follows a pattern of improvement mixed

with some persistent symptoms. Longitudinal study shows 50% of patients exhibit symptoms for over 30 years. However, more than 80% of the patients showed improved levels of functioning considered a chronic condition.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 15

Frequency

 Only about 25% of people who qualify for

a diagnosis of anxiety disorder ever seek psychological treatment. Therefore estimates of the frequency and severity of these problems are likely inaccurate.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 16

Prevalence

 Anxiety disorders more common than any other

mental disorder in the U.S.

 Specific phobia-most common-9%  Social phobia-7%  Panic Disorder and GAD-3%  OCD and Agoraphobia-1%  Gender Differences  Women have much higher incidence of

anxiety disorders than men, except for OCD which is relatively equal. Women also three times more likely to relapse.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 17

Etiology

 Evolutionary Theoretical Perspective  Social Factors  Psychological Factors  Biological Factors

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 18

Evolutionary Theoretical Perspective

 Suggests that generalized forms of anxiety

probably evolved to prepare for threats that could not be clearly defined. More specific forms of anxiety and fear probably evolved to provide more effective responses to certain types of

• danger. For example:

 Fear of heights is associated with a freezing of muscles

which could lead to a fall

 Social threats were likely seen as establishment of

dominance hierarchies within pack behavior and were likely to provoke responses such as shyness or embarrassment.

 The evolutionary model views each type of anxiety as a

dysregulation of a mechanism that evolved to deal with a particular kind of danger.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 19

Social Factors

 Stressful life events that involve danger, interpersonal

conflicts or parent-child relationships are thought to contribute to vulnerability to the development of anxiety disorders.

 Childhood Adversity  Attachment Relationships and Separation Anxiety

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 20

Psychological Factors



Learning Processes and Phobias



Preparedness Model-theory that brain contans certain modules or circuitry that has been shaped by evolution to serves some adaptive purpose.



Operate at maximal speed and perform without conscious awareness.



Humans develop intense persistent fears to only a select set of objects or situations.



Development of social and specific phobias could be related to evolutionary lag.



Observational Learning



Social Learning Theory



Cognitive Factors: Perception and Memory Four General Areas that play a role in anxiety Disorders.



Perception of Control



Catastrophic Misinterpretation



Attention to Threat and Biased Information Processing



Thought Suppression (OCD)

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 21

Biological Factors

 Family Studies-relatives of people with panic

disorder show an elevated risk of panic disorder, but not GAD, and vice versa.

 Twin Studies  Neuroanatomy-brain circuitry involved in fear

and conditioning

 Emotional Stimuli follows two primary pathways

both of which involve the amygdala.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 22

Pathway One

 Fastest and represents the evolved fear

module for conditioned fear.

 Has direct connections to the amygdale which registers

danger and then projects to the hypothalamus which activates fight or flight behavioral responses.

 This pathway does not involve higher level cognitive

function such as conscious memory and decisions via the cortical areas.

 However the amygdale does store unconscious emotional

memories such as those generated through prepared learning.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 23

First Pathway: Fear and Conditioning

Stimulus Thalamus Amygdala Hypothalmus FLIGHT OR FIGHT RESPONSE

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 24

Second Complementary Pathway

 Pathway from the thalamus leads to higher cortical areas and

provides a detailed and slower analysis of the information.

 Once the pattern has been identified in the appropriate

modality the data would be integrated with additional information from memory about is emotional significance.

 The message would then be sent to the amygdala which would

tiger an organized response to threat as well as to other cortical areas that also initiate plans against dangers.

 Second pathway takes longer than the first.  Sensitivity of the first pathway (fear module) is thought to be

more sensitive than the second.



___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 25

Second Pathway

Stimulus Thalamus Amygdala Hypothalamus FLIGHT OR FIGHT RESPONSE Lobe Identification and recognition

• f stimulus

Emotionality Somatosensory cortex Motor Cortex Planned Voluntary Movements

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 26

Neurotransmitters

 Various pharmacological challenge studies

suggest the influence of serotonin, NE, GABA, and DA in triggering panic attacks.

 Efficacy of drug treatments affecting these

neurotransmitters suggest they may be involved (convergent evidence)

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 27

Treatment

 Psychological Interventions

 Insight therapy-Freudian analysis of unconscious motives

that presumably lie at the heart of the symptoms.

 Behavioral Therapies  Systematic Desensitization-client is first taught progressive

• relaxation. Then the therapist constructs a hierarchy of feared

stimuli, beginning with those items that provoke only small amounts of fear and progressing through items that are more frightening then while the client the client is in a relaxed state, he or she imagine the lowest item on the hierarchy. This item is mentally presented until the thought of the object or situation is no longer anxiety producing. The client moves systematically up the hierarchy sequentially confronting stimuli that were

• riginally rated as being more frightening.

 Flooding- exposure to the most frightening experience without

avoidance.

 Interoceptive Exposure- have patient engage in exercises

known to produce physical sensations associated with panic attacks such as increased heart rate, respiration or dizziness and attempt to reduce the person’s fear of the symptoms.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 28

Treatment

 Cognitive Therapy

 Identify faulty logic such as over-

generalizations and jumping to conclusions.

 Decatastrophisizing-imagine the worst case

scenario and confront the negative predictions, and gross exaggerations based

• n cognitive errors.

 Extensive practice, homework and

journaling.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 29

Treatment

 Biological Therapy

 Anti-Anxiety Medications.  Benzodiazepenes--reduce anxiety symptoms primarily by

inhibiting GABA neuron activity. Drug of choicexanax.

 Panic attacks and agoraphobia  Problems: high rate of addiction and dependence. Many

patients relapse after discontinuation of medication

 Azapirones-inhibit serotonin activity. BusParGAD Does not

work as quickly

 Antidepressants-often preferred over anti-anxiety drugs

due to problems with addiction.

 SSRI’s- first line treatment due to tolerability of side effects.  SNUB-Effexor, Cymbalta  Tricyclics-used for the longest period of time. Work as well as

the SSRI’s but range of side effects leads to non-compliance.

 Anafranil (OCD)-tricyclic especially helpful with OCD, not

used with any other panic disorder, however relapse is common after discontinuation of the drug.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 30

Case Study: Paula

Paula: 27 year old white female

 Single  Education: BA –economics  Occupation: Securities and Bond Trader

Presentation:

 Blunted Affect, Good eye contact, fidgety  Extremely uncomfortable talking about painful

subjects in the past, Before the end of the first session, patient became so uncomfortable discussing a subject, she left the session early.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 31

Reason for appointment

 Recurring attacks that she thought were

heart attacks.

 Patient experienced chest pains, dizziness

and shortness of breath resulting in multiple trips to the emergency room.

 Cardiology testing  Zanax prescribed  Acceleration of symptoms and avoidance

behaviors

 Medical leave from job.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 32

Family Background

 Mother: Homemaker  Father: Deceased five years from

Congestive heart Failure

 Siblings: younger brother born with

multiple birth defects including severe heart problems The died when he was three years old and the family still grieved his loss.

 Maternal Grandfather: Alcoholic

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 33

Evaluation

 Assessment Tools

 Unstructured Interview  Psychiatric Evaluation

Symptoms:

 Onset : shortly after entering college where she experienced

adjustment problems.

 Unresolved grief.  Acceleration of symptoms  Avoidance Behaviors  Abuse of alcohol and over the counter drugs for a short

period

 Suicidal Ideations  Irrational thoughts  Anger at Mother

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 34

Etiology

 Learningnegative reinforcement  Irrational thinking  Biological

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 35

Treatment:

 Group Therapy  Medication: zoloft  Relaxation Therapy  Hypnosis  Duration: 7 months

 Prognosis-good

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 36

DSM IV TR

 Axis One: Panic Disorder with Agoraphobia  Axis Two:  Axis Three:  Axis Four:  Axis Five:

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________