Anxiety Disorders Overview

Size: px

Start display at page:

Download "Anxiety Disorders Overview"

Marsha Ross
6 years ago
Views:

1 Anxiety Disorders Anxiety Disorders Overview What is anxiety? Categories of anxiety disorders Generalized Anxiety Disorder Panic Disorder Specific Phobia/Social Phobia Obsessive Compulsive Disorder DSM-IV diagnoses Treatments Anxiety Probably experienced some of this during the exam What does it feel like? When is it a disorder? What is the difference between fear and anxiety? Anxiety defined as uneasiness stemming from the anticipation of danger Fear defined as a reaction to a specific threat from the real, physical world 1

2 Anxiety Anxiety is an evolutionary useful feeling part of the flight or fight response useful to have a response of energizing to get out of a situation sometimes this gets in our way feels not so adaptive Anxiety Diagnosing For a person to be diagnosed as having anxiety, the anxiety must be out of proportion to the perceived threat The anxiety is recognized by the individual seeking treatment to be excessive or unreasonable Anxiety Disorders Several types/different diagnoses Based on formal (topographical) features Should be distinct Will see much overlap within a category (e.g. within Anxiety) Also see overlap between other categories (e.g., OCD and eating disorders) 2

3 Anxiety Disorders Six disorders: Generalized anxiety disorder (GAD) Obsessive-compulsive disorder (OCD) Phobias Panic disorder Acute stress disorder Post-traumatic stress disorder (PTSD) Generalized Anxiety Disorder (GAD) GAD One of the most common diagnoses in outpatient treatment settings to be diagnosed with GAD it must interfere with normal functioning also see drug and alcohol abuse to control the anxiety 3

GAD Characterized by chronic, unrealistic and excessive anxiety about 2 or more areas of functioning key is chronic, excessive, & 2 or more areas Behaviors nervousness, rumination hyperactive nervous

4 GAD Characterized by chronic, unrealistic and excessive anxiety about 2 or more areas of functioning key is chronic, excessive, & 2 or more areas Behaviors nervousness, rumination hyperactive nervous system (sweating, dry mouth) concentration problems hypervigilance sleeping problems GAD Symptoms are often misunderstood by others Sufferers are accused of looking for worries The disorder is common in Western society Affects ~4% of U.S. and ~3% of Britain s population Usually first appears in childhood or adolescence Women are diagnosed more often than men by a 2:1 ratio Various theories have been offered to explain the development of the disorder 4

5 GAD: The Psychodynamic Perspective Freud believed that all children experience anxiety Realistic anxiety when faced with actual danger Neurotic anxiety when prevented from expressing id impulses Moral anxiety when punished for expressing id impulses One can use ego defense mechanisms to control these forms of anxiety, but when they don t work GAD develops. GAD: The Cognitive Perspective Those with GAD hold unrealistic silent assumptions that imply imminent danger: Any strange situation is dangerous A situation/person is unsafe until proven safe It is best to assume the worst My security depends on anticipating and preparing myself at all times for any possible danger GAD: The Behavioral Perspective Excessive worry is learned the way any other behavior is learned Behavior is reinforced directly Negative reinforcement seems present Lack of coping skills 5

6 GAD: The Biological Perspective GABA inactivity (GABA = NT anxiety brakes ) In the normal fear reaction: Key neurons fire more rapidly, creating a general state of excitability experienced as fear or anxiety A feedback system is triggered; brain and body activities work to reduce excitability Some neurons release GABA to inhibit neuron firing, thereby reducing the experience of fear or anxiety Problems with the feedback system are believed to cause GAD Possible reasons: GABA too low, too few receptors, ineffective receptors GAD Treatments Psychological Cognitive therapies Target maladaptive assumptions Behavioral therapies Behavioral rehearsal, relaxation Acceptance based strategies Psychodynamic therapies Help patients identify and settle early relationship conflicts Biological 1950s: Benzodiazepines (Valium, Xanax ) found to reduce anxiety Not typically thought of as a good long-term solution Obsessive Compulsive Disorder (OCD) 6

7 OCD Characterized by obsessions and/or compulsions Obsessions which are persistent thoughts, impulses, or ideas; person recognizes this in her or his mind, but they can't control the thoughts e.g., images of unacceptable sexual behaviors, thoughts of dying, belief that they are somehow contaminated OCD Compulsions are behaviors that are repetitive and intentional or rituals that are performed in response to the obsession in order to relieve the anxiety e.g., checking behaviors, hand washing (door closing and breathing) there is a magical quality to controlling the obsessive thoughts "compulsive gambling", "compulsive eating" are not compulsions, these are "pleasurable" to people while engaging in them 7

8 OCD Classified as an anxiety disorder because obsessions cause anxiety, while compulsions are aimed at preventing or reducing anxiety Anxiety rises if obsessions or compulsions are avoided ~2% of U.S. population has OCD in a given year Ratio of women to men is 1:1 Theories of OCD Psychoanalytic theory ID: impulses Ego: competing impulses, compulsions to erase Id impulses Behavioral theory Two factor learning theory classically conditioned maintained by avoidance behavior Biological explanation involves the neurotransmitter serotonin this has lead to the use of antidepressants for the treatment of OCD OCD: The Biological Perspective Two lines of research: Role of NT serotonin Evidence that serotonin-based antidepressants reduce OCD symptoms Brain abnormalities OCD linked to orbital region of frontal cortex and caudate nuclei Compose brain circuit that converts sensory information into thoughts and actions Either area may be too active, letting through troublesome thoughts and actions 8

9 OCD: The Biological Perspective Biological therapies Serotonin-based antidepressants Anafranil, Prozac, Luvox Up to 3 times depression dose Bring improvement to 50 80% of those with OCD Relapse occurs if medication is stopped Research suggests that combination therapy (medication + cognitive behavioral therapy approaches) may be most effective May have same effect on the brain OCD Treatment Most effective treatment: in vivo treatment Exposure and response prevention (ERP) Clients are repeatedly exposed to anxiety-provoking stimuli and prevented from responding with compulsions Therapists often model the behavior while the client watches Homework is an important component Treatment is offered in individual and group settings Treatment provides significant, long-lasting improvements for most patients OCD Treatment Symptom Substitution: Psychoanalysts criticize this treatment on the grounds that if you treat the symptom, and not the underlying cause - another symptom will pop up There is NO evidence for symptom substitution this behaviorally based treatment of exposure with response prevention is successful other symptoms do not "pop up" 9

Phobias Specific (Simple) Phobias Social Phobia Phobias Fears related to specific kind of situations or objects We all have fears in our lives. What makes these fears distinctive?

10 Phobias Specific (Simple) Phobias Social Phobia Phobias Fears related to specific kind of situations or objects We all have fears in our lives. What makes these fears distinctive? generally this fear is considered irrational by self and others the fear is way out of perspective, or proportion, to the real danger Greater desire to avoid the feared object or situation Distress that interferes with functioning 10

Phobias Specific phobia Also known as simple phobia refers to persistent fear of one or two objects common simple phobias Animals type (snakes, dogs

11 Phobias Specific phobia Also known as simple phobia refers to persistent fear of one or two objects common simple phobias Animals type (snakes, dogs, spiders) Natural environment type e.g. heights (acrophobia) Blood-injection-injury type Situational type e.g. closed spaces (claustrophobia) Social Phobia Social Phobia separate diagnosis fear related to being in social situations where you might be evaluated by others public speaking falls here develops in late childhood or early adolescence 11

Explanation of phobias Not good at finding biological explanation yet Psychoanalytic theories phobias are displaced anxiety some id impulse is so threatening that the ego displaces anxiety onto

12 Explanation of phobias Not good at finding biological explanation yet Psychoanalytic theories phobias are displaced anxiety some id impulse is so threatening that the ego displaces anxiety onto something else displacement is a defense mechanism Behavioral theories Mowrer's 2 factor learning theory Classically condition to feared stimulus, then avoidance is negatively reinforced Classical Conditioning of Phobia UCS Dog bite UCR Fear + UCS Dog bite UCR Fear CS = CR Fear Avoid dogs to avoid getting bitten. This is negatively reinforced 12

13 Phobia Treatments Exposure treatments Most important factor in the treatment of phobias Need to have presentation of CS without UCS so that CS no longer elicits CR Call this extinction paradigm through exposure Eg. Dog (CS) without the dog bite (UCS) Note that we need to prevent the operant escape response, too Systematic or gradual Flooding or rapid Phobia Treatments Systematic desensitization Joseph Wolpe develop hierarchy around the feared situation rank stages from lowest levels of anxiety to highest teach relaxation techniques have the client relax while they imagine the frightening situations gradually desensitize to feared stimulus this is imaginary need to then transfer to real life Phobia Treatments Flooding real life or in vivo put person into situation and don't let them escape person is flooded with anxiety this extinguishes the fear Both flooding and systematic desensitization have been empirically shown to be effective Key point in exposureis that you don't let the client escape during their anxiety or the escape response will be negatively reinforced 13

14 Panic Disorder With Agoraphobia Without Agoraphobia Panic Disorder Profound episodes of terror Last from a few minutes to an hour (or more) Appear to come out nowhere to the person, there is no identifiable cause to the attack What does a Panic Attack Feel Like? 14

DSM Criteria for Panic Attack A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptlyand reached a peak within 10 minutes: palpitations,

15 DSM Criteria for Panic Attack A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptlyand reached a peak within 10 minutes: 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 Panic Disorder two types of panic disorder with agoraphobia - afraid to go out of the house specifically, agoraphobiais the fear of being in public places from which escape might be difficult or help not available in case of incapacitation restricting where they will go: gradual closing in - only leave house with "safe person" or never leave at all without agoraphobia Fear of panic attacks but not same level of avoidance 15

16 Panic Disorder you must rule-out (R/O) certain physiological abnormalities which symptomalogically look a lot like panic disorder R/O - hyperthyroidism may mimic panic attacks feeling R/O - mitral valve prolapse heart valve problem due to congenital abnormality - leads to panic symptoms in some people R/O - Amphetamine intoxication you must rule out a chemical cause Cognitive Model of Panic Physical Arousal Triggers Physical Sensations Faulty Threat Interpretation PANIC Cognitive-Behavioral Perspective Cognitive therapy Attempts to correct people s misinterpretations of their bodily sensations Step 1: Educate clients About panic in general About the causes of bodily sensations About their tendency to misinterpret the sensations Step 2: Teach clients to apply more accurate interpretations (especially when stressed) Step 3: Teach clients skills for coping with anxiety Induce panic attack Use relaxation, breathing 16

17 Cognitive-Behavioral Perspective Cognitive-behavioral therapy is often helpful in panic disorder 85% panic-free for two years vs. 13% of control subjects Only sometimes helpful for panic disorder with agoraphobia At least as helpful as antidepressants Biological Perspective What biological factors contribute to panic disorder? NT at work is norepinephrine Irregular in people with panic attacks Research suggests that panic reactions are related to changes in norepinephrine activity in the locus ceruleus While norepinephrine is clearly linked to panic disorder, what goes wrong isn t exactly understood May be excessive activity, deficient activity, or some other defect Other NTs are likely involved Biological Perspective Drug therapies Antidepressants are effective at preventing or reducing panic attacks Function at norepinephrine receptors in the locus ceruleus Bring at least some improvement to 80% of patients with panic disorder ~40 60% recover markedly or fully Require maintenance of drug therapy; otherwise relapse rates are high Some benzodiazepines (especially Xanax and Valium) have also proved helpful 17

18 Panic Treatment Psychological and Pharmacological equally effective If applied separately Psychological and Pharmacological combinations Worse outcome than separate w/ Benzodiazepines Why would this occur? Unclear now what will occur with SSRIs and therapy combinations Anxiety Disorders Summary Most common mental disorders in the U.S. In any given year, 19% of the adult population in the U.S. experience one or another of the six DSM-IV anxiety disorders (including PTSD and Acute Stress Disorder, discussed next) Most individuals with one anxiety disorder suffer from a second as well Anxiety disorders cost $42 billion each year in health care, lost wages, and lost productivity 18

Anxiety, Stress and Health Disorders. Mr. Mattingly Abnormal Psychology

Anxiety, Stress and Health Disorders Mr. Mattingly Abnormal Psychology What is Anxiety? Anxiety = state of apprehension, tension or worry AKA: Fearful Behavior Distinction: Adaptive Fear vs. Maladaptive