CHAPTER 5 ANXIETY DISORDERS (PP )

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CHAPTER 5 ANXIETY DISORDERS (PP. 128-179) 1 Anx, Fear, Panic Clin. Descr. Complexity Statistics GAD Suicide & Physical Comorbid Clin. Descr. Treatment Stats Anxiety Disorders Panic Treat. Clin. Descr. Phobia Stats Clin.

130-133) 4 Anxiety Disorders Pervasive and persistent symptoms of Anxiety and Fear Involve excessive avoidance and escapist tendencies Symptoms and avoidance cause clinically significant distress and

response to danger or threat, avoidance/escapist tendencies, activation of sympathetic nervous system Anxiety and fear are normal emotional states Adaptive: protect us from danger But AD involve fear

Abrupt (+1) experience of intense fear or discomfort Accompanied by several physical symptoms (e.g.

1 CHAPTER 5 ANXIETY DISORDERS (PP ) 1 Anx, Fear, Panic Clin. Descr. Complexity Statistics GAD Suicide & Physical Comorbid Clin. Descr. Treatment Stats Anxiety Disorders Panic Treat. Clin. Descr. Phobia Stats Clin. Descr. Clin. Descr. Treat. Stats OCD Stats PTSD Clin. Descr. Social Phobia Stats 2 Last Treat. Treat. Treat. ANXIETY, FEAR, AND PANIC (PP ) 3 THE PHENOMENOLOGY OF PANIC ATTACKS (PP ) 4 Anxiety Disorders Pervasive and persistent symptoms of Anxiety and Fear Involve excessive avoidance and escapist tendencies Symptoms and avoidance cause clinically significant distress and impairment Anxiety: future-oriented negative affect, somatic symptoms of tension, apprehension of future danger or misfortune Fear: present-oriented negative affect, immediate fight or flight response to danger or threat, avoidance/escapist tendencies, activation of sympathetic nervous system Anxiety and fear are normal emotional states Adaptive: protect us from danger But AD involve fear and anxiety that occurs too often, is too severe, is triggered too easily, or lasts too long What Is Panic Attack? Abrupt (+1) experience of intense fear or discomfort Accompanied by several physical symptoms (e.g., breathlessness, chest pain, +2) DSM-IV Subtypes of Panic Attacks Situationally bound (cued): Expected and bound to some situations; common in specific and social phobias Unexpected (uncued): Unexpected out of the blue without warning; common in Panic Disorder Situationally predisposed: May or may not occur in some situations; common in Panic Disorder Panic Is analogous to fear as an alarm response 5 6 1

Vulnerabilities Anxiety and brain circuits: GABA, noradrenergic and serotonergic systems Corticotropin releasing factor (CRF) and HYPAC axis Limbic (amygdala) and septal-hippocampal systems

2 THE PHENOMENOLOGY OF PANIC ATTACKS (P. 131) 7 CAUSES Integrated BioPsychoSocial model proposes multiple causes: Biological Contributions Psychological Contributions Social Contributions Integrated Perspective Biology Psychology Social 8 CAUSES: BIOLOGICAL (PP ) Biological Contributions Diathesis-Stress Inherit vulnerabilities for anxiety and panic Stress and life circumstances activate underlying vulnerability Biological and Inherent Vulnerabilities Anxiety and brain circuits: GABA, noradrenergic and serotonergic systems Corticotropin releasing factor (CRF) and HYPAC axis Limbic (amygdala) and septal-hippocampal systems Behavioural inhibition (BIS) and fight/flight (FF) systems Sensitivity influenced by environment Adolescent smokers became more prone to panic attacks 9 CAUSES: PSYCHOLOGICAL (PP. 133) Freud Anxiety is psychic reaction to danger Reactivation of infantile fear situation Behaviourism Classical and operant conditioning and modeling Psychological Views Early experience with uncontrollability and unpredictability Right Startle response to threat 10 CAUSES: SOCIAL CONTRIBUTIONS Social Contributions Stressful life events trigger biological / psychological vulnerabilities Many stressors familial and interpersonal Marriage, divorce, work problems, death of loved one, including social pressures related to school, peers, Economic wellbeing correlated with stress levels (+1) Familial influences seem particularly strong in development of anxiety disorders

Consistent with diathesis-stress model Anxiety?? Stress Level Low Medium High Low No No No? Diathesis Medium No No? Yes Level High No?

across anxiety disorders About half of patients have two or more secondary diagnoses Major depression is most common secondary diagnosis (+1)

3 CAUSES: INTEGRATED MODEL (P ) Integrative View Biological vulnerability interacts with psychological, experiential, and social variables to produce anxiety disorder Consistent with diathesis-stress model Anxiety?? Stress Level Low Medium High Low No No No? Diathesis Medium No No? Yes Level High No? Yes Yes 13 COMORBIDITY Comorbidity Co-occurrence of two or more disorders or sub-types of disorder Anxiety + Depression Phobia + GAD Common problem across anxiety disorders About half of patients have two or more secondary diagnoses Major depression is most common secondary diagnosis (+1) Comorbidity suggests Some relationship between disorders Perhaps common causal factors / underlying processes GENERALIZED ANXIETY DISORDER: THE BASIC ANXIETY DISORDER (PP ) Defining Features Strong, persistent (6 mths or more), uncontrollable anxious apprehension & worry about life events; Do you worry excessively about minor things? (right) Somatic symptoms differ from panic (muscle tension, fatigue) Facts and Statistics ~3.5% of general population Females outnumber males 2:1 Onset insidious, early adulthood Tendency to anxiety runs in families GENERALIZED ANXIETY DISORDER (P. 139) 3

GENERALIZED ANXIETY DISORDER: ASSOCIATED FEATURES AND TREATMENT (PP.

140) 20 Associated Features Persons with GAD have been called autonomic restrictors Fail to process emotional component

Cognitive-Behavioural Therapy (+1) PANIC DISORDER WITH AND WITHOUT 21 22 AGORAPHOBIA (PP.

view and Defining Features Experience of unexpected panic attack (i.e., false alarm) Develop anxiety, worry, or fear

4 GENERALIZED ANXIETY DISORDER: ASSOCIATED FEATURES AND TREATMENT (PP ) 19 GENERALIZED ANXIETY DISORDER: THE BASIC ANXIETY DISORDER (P. 140) 20 Associated Features Persons with GAD have been called autonomic restrictors Fail to process emotional component of thoughts and images Treatment of GAD: Generally Weak Benzodiazapines often prescribed Psychological interventions: Cognitive-Behavioural Therapy (+1) PANIC DISORDER WITH AND WITHOUT AGORAPHOBIA (PP ) Overview and Defining Features Experience of unexpected panic attack (i.e., false alarm) Develop anxiety, worry, or fear about having another attack or its implications (DSM +1) Agoraphobia: fear or avoid situations/events associated with panic (+2) Symptoms and concern about another attack persist for one month or more Facts and Statistics 3.5% of general population meet diagnostic criteria for PD Two thirds with PD are female Onset often acute, between 25 and 29 years of age

PANIC DISORDER: ASSOCIATED FEATURES 25 26 AND TREATMENT (PP.

misinterpretation of symptoms Medication Treatment of Panic Disorder Targe

, Prozac and Paxil) are currently preferred drugs Relapse rates high following medication discontinuation Psychological and Combined Treatments of Panic Disorder

5 PANIC DISORDER: ASSOCIATED FEATURES AND TREATMENT (PP ) Associated Features Nocturnal panic attacks: 60% experience panic during deep non-rem sleep Interoceptive/exteroceptive avoidance, catastrophic misinterpretation of symptoms Medication Treatment of Panic Disorder Target serotonergic, noradrenergic, and benzodiazepine GABA systems SSRIs (e.g., Prozac and Paxil) are currently preferred drugs Relapse rates high following medication discontinuation Psychological and Combined Treatments of Panic Disorder Cognitive-behaviour therapies highly effective Combined treatments do well in short term Best long-term outcome is with cognitive-behaviour therapy alone Sample results ( ) 27 TELEPHONE-ADMINISTERED CBT OTHER PSYCHOLOGICAL TREATMENTS Exposure Therapy T5.3 (right) Panic Control Treatment Produce minipanics (T5.4, right) and learn to control 29 SPECIFIC PHOBIAS: OVERVIEW (PP. 150) Overview and Defining Features Extreme and irrational fear of specific object or situation Markedly interferes with ability to function Recognize fears unreasonable, but go to great lengths to avoid phobic objects Facts and Statistics ~11% of general population meet diagnostic criteria (+1) Females over-represented Phobias run chronic course, onset between 15 and 20 years of age Some fears very common (+2 +3) 30 5

phobias (+1) Blood-injury-injection: vasovagal

Situational: public transportation or enclosed

, planes) Natural environment: events occurring

, heights, storms) Animal: animals and insects

PHOBIAS: ASSOCIATED FEATURES AND TREATMENT of

vulnerability, direct conditioning, observational

6 SPECIFIC PHOBIAS 34 (PP ) 33 Associated Features and Subtypes MANY phobias (+1) Blood-injury-injection: vasovagal response to blood, injury, or injection Situational: public transportation or enclosed places (e.g., planes) Natural environment: events occurring in nature (e.g., heights, storms) Animal: animals and insects Other: do not fit into other categories (e.g., fear of choking, vomiting) SPECIFIC PHOBIAS: ASSOCIATED FEATURES AND TREATMENT of Phobias Biological and evolutionary vulnerability, direct conditioning, observational learning, information transmission (+1) Psychological Treatments of Specific Phobias Cognitive-Behaviour Therapies highly effective (+2) Structured and consistent graduated exposure-based exercises Virtual Reality methods used today 6

SPECIFIC PHOBIAS: ASSOCIATED FEATURES AND TREATMENT (P.

co-morbidity and also reduced comorbid anxiety and other symptoms SOCIAL PHOBIA: AN OVERVIEW (PP.

interferes with ability to function Avoid social situations or endure with great distress Generalized subtype: social phobia across

represented than males Onset usually during adolescence with peak age of onset at about 15 years SOCIAL PHOBIA: ASSOCIATED FEATURES

160-161) of Phobias Biological and evolutionary vulnerability (+1) Direct conditioning, observation, information transmission

7 SPECIFIC PHOBIAS: ASSOCIATED FEATURES AND TREATMENT (P. 155) 37 TREATMENT OF PHOBIA 38 Ollendick et al (2010) Single session CBT for Specific Phobias in adolescents Worked irrespective of co-morbidity and also reduced comorbid anxiety and other symptoms SOCIAL PHOBIA: AN OVERVIEW (PP ) Overview and Defining Features Extreme and irrational fear/shyness in social and performance situations Markedly interferes with ability to function Avoid social situations or endure with great distress Generalized subtype: social phobia across numerous social situations Facts and Statistics About 13% of general population meet lifetime criteria (+1) Females slightly more represented than males Onset usually during adolescence with peak age of onset at about 15 years SOCIAL PHOBIA: ASSOCIATED FEATURES AND TREATMENT (PP ) of Phobias Biological and evolutionary vulnerability (+1) Direct conditioning, observation, information transmission Medication Treatment of Social Phobia Beta blockers are ineffective Tricyclic antidepressants and monoamine oxidase inhibitors reduce social anxiety SSRI Paxil is approved treatment of social anxiety disorder Relapse rates high following medication discontinuation Psychological Treatment of Social Phobia CBT: exposure, rehearsal, role-play in group setting CBT highly effective (+2 +3) 7

43 CBT AND SOCIAL PHOBIA 44 44 POSTTRAUMATIC

161-164) Overview and Defining Features Event

Re-experience event (memories, nightmares,

interferes with one's ability to function

8 43 CBT AND SOCIAL PHOBIA POSTTRAUMATIC STRESS DISORDER (PTSD): AN OVERVIEW (PP ) Overview and Defining Features Event causes extreme fear, helplessness, or horror Re-experience event (memories, nightmares, flashbacks) Avoidance of cues that remind person of event Emotional numbing and interpersonal problems common Markedly interferes with one's ability to function Diagnosis cannot be made before 1 month post-trauma Facts and Statistics ~7.8% of population meet criteria (+1 +2) for PTSD Combat and sexual assault most common traumas (+3-+7)

ASSESSMENT OF PTSD 49 PTSD Checklist (PCL, Weathers, et al.

thoughts subscale (items 1-5) Avoidance behaviour subscale (items 6-12) Graph shows scores of patients

9/11 & PTSD: Proximity NB (+1) 50 51 52 51 PTSD: CAUSES AND ASSOCIATED FEATURES 53 (PP.

Chronic PTSD: Diagnosed after 3 months post trauma Delayed onset: Onset 6 months or more post trauma

(i.e., true alarm) Exposure to traumatic events (+1) Qualities of Events (+2) Uncontrollability and

9 ASSESSMENT OF PTSD 49 PTSD Checklist (PCL, Weathers, et al., 1993) 17 item scale with each item rated from 1 to 5 Sum gives overall score: from 17 to 85 Intrusive thoughts subscale (items 1-5) Avoidance behaviour subscale (items 6-12) Graph shows scores of patients admitted to PTSD clinic Graph shows rates for WW II prisoners of war (POWs) in Europe, Korea, or Japan 9/11 & PTSD: Proximity NB (+1) PTSD: CAUSES AND ASSOCIATED FEATURES 53 (PP ) Subtypes and Associated Features of PTSD Acute PTSD: May be diagnosed 1-3 months post trauma Chronic PTSD: Diagnosed after 3 months post trauma Delayed onset: Onset 6 months or more post trauma Acute stress disorder: PTSD immediately post-trauma of PTSD Intensity of trauma and one s reaction to it (i.e., true alarm) Exposure to traumatic events (+1) Qualities of Events (+2) Uncontrollability and unpredictability Extent of social support, or lack thereof post-trauma Direct conditioning and observational learning Risk factors for development of PTSD (+3) Integrated Model (+4) 54 9

55 56 QUALITIES OF TRAUMATIC EVENTS AND PTSD 56 57

TREATMENT graduated or (P167-168) abrupt imaginal

social support CBT highly effective Modelling (+1)

OBSESSIVE-COMPULSIVE DISORDER (OCD): AN OVERVIEW (PP.

and nonsensical thoughts, images, or urges that one tries

to suppress thoughts and provide relief Most persons with

10 55 56 QUALITIES OF TRAUMATIC EVENTS AND PTSD Psychological 58 Treatment of PTSD: PTSD CBT involves TREATMENT graduated or (P ) abrupt imaginal exposure (graph) Increase positive coping skills and social support CBT highly effective Modelling (+1) Constructivist Narrative EMDR CISM (Activity 3) 59 OBSESSIVE-COMPULSIVE DISORDER (OCD): AN OVERVIEW (PP. 168) Overview and Defining Features Obsessions: intrusive and nonsensical thoughts, images, or urges that one tries to resist or eliminate Compulsions: thoughts or actions to suppress thoughts and provide relief Most persons with OCD display multiple obsessions Most present with cleaning and washing or checking rituals 60 10

OBSESSIVE-COMPULSIVE DISORDER (OCD): 61 62 CAUSES AND ASSOCIATED FEATURES (PP. 168-173) Facts and Statistics ~2.

Parallel other anxiety disorders Early life experiences and learning that some thoughts are dangerous / unacceptable

and other SSRIs benefit up to 60% of patients Psychosurgery (cingulotomy) used in extreme cases (yellow dot in image) Relapse

11 OBSESSIVE-COMPULSIVE DISORDER (OCD): CAUSES AND ASSOCIATED FEATURES (PP ) Facts and Statistics ~2.6% of general population meet criteria (+1) in lifetime Most female Tends to be chronic Onset typically in early adolescence or young adulthood Non-clinical samples have obsessions and compulsions but not severe enough (i.e., intense, persistent) to interfere with functioning (+2) of OCD Parallel other anxiety disorders Early life experiences and learning that some thoughts are dangerous / unacceptable Thought-action fusion: view thought as similar to action Integrated Model (+3) Medication Treatment of OCD Clomipramine and other SSRIs benefit up to 60% of patients Psychosurgery (cingulotomy) used in extreme cases (yellow dot in image) Relapse common with medication discontinuation Psychological Treatment CBT most effective Exposure and response prevention (+1) Combining medication not as good as CBT alone OCD: TREATMENT (P ) 65 CBT MODEL FOR OCD (FROM FOA) 66 11

experiential, and social factors (+1) Fear and anxiety persist to bodily or environmental nondangerous cues Symptoms and avoidance cause significant distress

12 SUMMARY OF ANXIETY-RELATED 67 INTEGRATED MODEL OF ANXIETY DISORDERS 68 DISORDERS (PP ) Anxiety disorders largest domain of psychopathology From normal to disordered experience of anxiety and fear Consider biological, psychological, experiential, and social factors (+1) Fear and anxiety persist to bodily or environmental nondangerous cues Symptoms and avoidance cause significant distress and impair functioning Psychological treatments generally superior in longterm Most treatments for different anxiety disorders involve similar components Suggests that disorders share common processes TREATMENT OF ANXIETY DISORDERS 69 12

Anxiety Disorders. Fear & Anxiety. Anxiety Disorder? 26/5/2014. J. H. Atkinson, M.D. Fear. Anxiety. An anxiety disorder is present when

Anxiety Disorders. Fear & Anxiety. Anxiety Disorder? 26/5/2014. J. H. Atkinson, M.D. Fear. Anxiety. An anxiety disorder is present when Anxiety s J. H. Atkinson, M.D. HIV Neurobehavioral Research Center University of California, San Diego Department of Psychiatry & Veterans Affairs Healthcare System, San Diego Materials courtesy of Dr.