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Chapter Four:Chapter Four:
Anxiety DisordersAnxiety Disorders
Rick Grieve, Ph.D.Rick Grieve, Ph.D.
PSY 440PSY 440
Western Kentucky UniversityWestern Kentucky University
Anxiety Anxiety
FutureFuture--oriented mood state characterized byoriented mood state characterized by
marked negative affectmarked negative affect
Somatic symptoms ofSomatic symptoms of tension & arousaltension & arousal
ApprehensionApprehension about future danger orabout future danger or
misfortunemisfortune
May occur in the absence of realistic dangerMay occur in the absence of realistic danger
Fear Fear
PresentPresent--oriented mood state, markedoriented mood state, marked
negative affectnegative affect
ImmediateImmediate fight or flightfight or flight response toresponse to
danger or threatdanger or threat
StrongStrong avoidance/escapistavoidance/escapist tendenciestendencies
Involves abrupt activation of theInvolves abrupt activation of the
sympathetic nervous systemsympathetic nervous system
Panic Panic
(^) PanicPanic
Sudden & unexpected fight/flightSudden & unexpected fight/flight responseresponse
Absence of obvious danger or threatAbsence of obvious danger or threat
(^) Anxiety, Fear & Panic are NormalAnxiety, Fear & Panic are Normal
Emotional StatesEmotional States
Components of AnxietyComponents of Anxiety
Response SystemsResponse Systems
PhysicalPhysical
Fight/flight responseFight/flight response
CognitiveCognitive
Attentional shiftAttentional shift & hypervigilance,& hypervigilance, nervousness, difficulty concentratingnervousness, difficulty concentrating
(^) BehavioralBehavioral –– aggression and/oraggression and/or avoidanceavoidance
Common Fears Common Fears
BirthBirth -- 1 Year1 Year : loud noises, loss of support,: loud noises, loss of support,
strangers.strangers.
1 1--2 Years2 Years :: Separation from parent, injury,Separation from parent, injury,
toilet, strangers, loud noises, animals.toilet, strangers, loud noises, animals.
3 3--5 Years5 Years :Animals, the dark, separation from:Animals, the dark, separation from
parent, masks,parent, masks, ““badbad”” people.people.
6 6 -- 12 Years12 Years : Bodily injury,supernatural: Bodily injury,supernatural
events(ghosts,witches), sleeping alone,events(ghosts,witches), sleeping alone,
social embarrassment, fear of failure.social embarrassment, fear of failure.
13 13--18 Years18 Years : Personal appearance, safety,: Personal appearance, safety,
school, animals, social embarrassment.school, animals, social embarrassment.
(Adapted from Mash, & Wolfe, 2002, p 166)(Adapted from Mash, & Wolfe, 2002, p 166)
Fig. 4.4, p. 134
Figure 5.3Figure 5. ClientsClients’’ answers to intervieweranswers to interviewer’’s question,s question, ““Do you worryDo you worry excessively about minor things?excessively about minor things?””
Generalized Anxiety Disorder:Generalized Anxiety Disorder:
TheThe ““BasicBasic”” Anxiety DisorderAnxiety Disorder
FactsFacts and Statisticsand Statistics
4% of the general population meet criteria4% of the general population meet criteria Females 2:1 over malesFemales 2:1 over males Onset often insidious, beginning early adulthoodOnset often insidious, beginning early adulthood ^ Tendency to be anxious runs in familiesTendency to be anxious runs in families
Associated FeaturesAssociated Features
Persons with GADPersons with GAD areare ““autonomic restrictorsautonomic restrictors”” (^) Fail to process emotional component of thoughts andFail to process emotional component of thoughts and imagesimages
OnsetOnset
GAD: Etiology GAD: Etiology
(^) Three major contributorsThree major contributors
Genetic/biological predispositionGenetic/biological predisposition
Early experiences that foster anxiousEarly experiences that foster anxious
temperamenttemperament
More specific experiences that focusMore specific experiences that focus
anxietyanxiety
Often due to a single stressorOften due to a single stressor
But, more severe GAD may not beBut, more severe GAD may not be
GAD: Etiology GAD: Etiology
Severely stressful childhoodSeverely stressful childhood environments are associated withenvironments are associated with GADGAD
Multifaceted model of developmentMultifaceted model of development
GAD: Comorbid GAD:Comorbid DisordersDisorders
The development of GAD serves asThe development of GAD serves as a risk factor for the development ofa risk factor for the development of other psychological disordersother psychological disorders
Mood disorders, substance abuseMood disorders, substance abuse
disorders, other anxiety disordersdisorders, other anxiety disorders
(except Social Phobia)(except Social Phobia)
CRITERIA FOR CRITERIA FOR PANIC ATTACKPANIC ATTACK Discrete period of intense fear or discomfortDiscrete period of intense fear or discomfort with 4 or more owith 4 or more off thethe symptoms below; symptoms develop abruptly & peak within 10 min.symptoms below; symptoms develop abruptly & peak within 10 min. && diminish within 30 minutediminish within 30 minute
Palpitations, pounding heart,Palpitations, pounding heart, or accelerated heart rateor accelerated heart rate ^ SweatingSweating Trembling or shakingTrembling or shaking Sensations of shortness ofSensations of shortness of breath or smotheringbreath or smothering Feeling of chokingFeeling of choking Chest pain or discomfortChest pain or discomfort ^ Chills or hot flushesChills or hot flushes (Based on DSM(Based on DSM--IVIV--TR, 2000 by APA)TR, 2000 by APA)
Nausea or abdominalNausea or abdominal distressdistress (^) Feeling dizzy, unsteady,Feeling dizzy, unsteady, lightheaded or faintlightheaded or faint Derealization orDerealization or depersonalizationdepersonalization (^) Fear of losing control orFear of losing control or going crazygoing crazy Fear of dyingFear of dying
Situations Avoided by People with Situations Avoided by People with
AgoraphobiaAgoraphobia
Shopping mallsShopping malls Cars (driver or passenger)Cars (driver or passenger) (^) BusesBuses TrainsTrains SubwaysSubways (^) Wide StreetsWide Streets TunnelsTunnels RestaurantsRestaurants TheatersTheaters Source:Source: Barlow & Durand, 2002, p. 124Barlow & Durand, 2002, p. 124
Being far from homeBeing far from home Staying at home aloneStaying at home alone ^ Waiting in lineWaiting in line SupermarketsSupermarkets StoresStores (^) CrowdsCrowds PlanesPlanes ElevatorsElevators EscalatorsEscalators
Panic Disorder:Panic Disorder:^ Associated FeaturesAssociated Features ^ Associated FeaturesAssociated Features
Nocturnal panic attacksNocturnal panic attacks –– 60% experience60% experience
panicpanic
Catastrophic misinterpretation ofCatastrophic misinterpretation of
symptoms, loss of important interpersonalsymptoms, loss of important interpersonal
relationships may precipitaterelationships may precipitate
ComorbidityComorbidity
Panic Disorder: Etiology Panic Disorder: Etiology
(^) ConditioningConditioning
PersonalityPersonality
UncontrollabilityUncontrollability
Learning historyLearning history
Panic Disorder: TreatmentPanic Disorder: Treatment
Medication Treatment of Panic DisorderMedication Treatment of Panic Disorder
(^) AntidepressantsAntidepressants TCAsTCAs (^) SSRIsSSRIs (e.g., Prozac and(e.g., Prozac and PaxilPaxil))
- – Relapse rates are high following medicationRelapse rates are high following medication discontinuationdiscontinuation benzodiazepine (benzodiazepine (alprazolamalprazolam //XanaxXanax))
Psychological Treatments of Panic DisorderPsychological Treatments of Panic Disorder
In vivoIn vivo exposureexposure
Cognitive TherapyCognitive Therapy CBTCBT
Combined Treatment of Panic DisorderCombined Treatment of Panic Disorder
Overview and Defining FeaturesOverview and Defining Features
^ Extreme and irrational fear of a specific object orExtreme and irrational fear of a specific object or situationsituation Markedly interferes with one's ability to functionMarkedly interferes with one's ability to function Cues are environmental in natureCues are environmental in nature Recognize fears are unreasonable; go to great lengthsRecognize fears are unreasonable; go to great lengths to avoid phobic objectsto avoid phobic objects
Facts and StatisticsFacts and Statistics
7- 7 -11% general population meet diagnostic criteria for11% general population meet diagnostic criteria for specific phobiaspecific phobia ^ Females are again over-Females are again over-representedrepresented Phobias run a chronic course, with onset beginningPhobias run a chronic course, with onset beginning between 15 and 20 years of agebetween 15 and 20 years of age
Specific Phobias:Specific Phobias: An OverviewAn Overview
Social Phobia Social Phobia
Overview and Defining FeaturesOverview and Defining Features
Extreme and irrational fear/shyness in social andExtreme and irrational fear/shyness in social and
performance situationsperformance situations
Markedly interferes with one's ability to functionMarkedly interferes with one's ability to function
Often avoid social situations or endure them withOften avoid social situations or endure them with
great distressgreat distress
Subtypes:Subtypes:
Generalized subtypeGeneralized subtype
Specific subtypeSpecific subtype
Social Phobia Social Phobia
More debilitating than other phobiasMore debilitating than other phobias
(^) Facts and StatisticsFacts and Statistics
13% of the general population meet criteria13% of the general population meet criteria
Females are slightly more represented than malesFemales are slightly more represented than males
Onset: adolescence w/peak age at about 15 yearsOnset: adolescence w/peak age at about 15 years
Social Phobia Social Phobia
(^) CausesCauses
Biological and evolutionary vulnerabilityBiological and evolutionary vulnerability
Direct conditioningDirect conditioning
observational learningobservational learning
information transmissioninformation transmission
Perceived uncontrollabilityPerceived uncontrollability
Social Phobia Social Phobia
^ Medication Treatment of Social PhobiaMedication Treatment of Social Phobia
TricyclicTricyclic antidepressants and monoamineantidepressants and monoamine
oxidaseoxidase (MAO) inhibitors reduce social anxiety(MAO) inhibitors reduce social anxiety
SSRISSRI PaxilPaxil is FDA approved for treatment ofis FDA approved for treatment of
social anxiety disordersocial anxiety disorder
Relapse rates are high following medicationRelapse rates are high following medication
discontinuationdiscontinuation
Psychological Treatment of SocialPsychological Treatment of Social PhobiaPhobia
Cognitive-Cognitive-behavioral treatmentbehavioral treatment –– Exposure,Exposure,
rehearsal, role-rehearsal, role-play in a group settingplay in a group setting
Cognitive-Cognitive-behavior therapies are highlybehavior therapies are highly
effectiveeffective
Social PhobiaSocial Phobia
Posttraumatic Stress Disorder (PTSD):Posttraumatic Stress Disorder (PTSD):
An OverviewAn Overview
Overview and Defining FeaturesOverview and Defining Features
^ Requires exposure to an event resulting in extremeRequires exposure to an event resulting in extreme fear, helplessness, or horrorfear, helplessness, or horror Person continues toPerson continues to rere--experienceexperience the event (e.g.,the event (e.g., memories, nightmares, flashbacks)memories, nightmares, flashbacks) ^ AvoidanceAvoidance of cues that remind person of eventof cues that remind person of event EmotionalEmotional numbingnumbing and interpersonal problems are commonand interpersonal problems are common IncreasedIncreased ArousalArousal Markedly interferes with one's ability to functionMarkedly interferes with one's ability to function (^) PTSD diagnosis cannot be made earlier than 1 monthPTSD diagnosis cannot be made earlier than 1 month postpost--traumatrauma
PTSD Comorbidity PTSDComorbidity
(^) 88% of men and 79% of women with88% of men and 79% of women with PTSD meet diagnostic criteria forPTSD meet diagnostic criteria for another psychological disorderanother psychological disorder
Drug/alcohol abuse/dependenceDrug/alcohol abuse/dependence
Major Depressive DisorderMajor Depressive Disorder
Borderline Personality DisorderBorderline Personality Disorder
PhobiasPhobias
Panic DisorerPanicDisorer
Social MisconductSocial Misconduct
Psychological Treatment of PTSDPsychological Treatment of PTSD
Cognitive-Cognitive-behavioral treatment involvesbehavioral treatment involves
graduated or abrupt imaginalgraduated or abruptimaginal exposureexposure
Increase positive coping skills and socialIncrease positive coping skills and social
supportsupport
Cognitive-Cognitive-behavior therapies are highlybehavior therapies are highly
effectiveeffective
PTSD:PTSD: TreatmentTreatment
Overview and Defining FeaturesOverview and Defining Features
^ ObsessionsObsessions –– Intrusive and nonsensical thoughts,Intrusive and nonsensical thoughts, images, or urges that one tries to resist or eliminateimages, or urges that one tries to resist or eliminate CompulsionsCompulsions –– Thoughts or actions to suppress theThoughts or actions to suppress the thoughts and provide reliefthoughts and provide relief ^ Most persons with OCD display multiple obsessionsMost persons with OCD display multiple obsessions Most persons with OCD present with cleaning andMost persons with OCD present with cleaning and washing or checking ritualswashing or checking rituals Cues that trigger anxiety (or compulsions) areCues that trigger anxiety (or compulsions) are cognitive in naturecognitive in nature
ObsessiveObsessive--Compulsive DisorderCompulsive Disorder
(OCD):(OCD): An OverviewAn Overview
OCDOCD -- ObsessionsObsessions
Obsessions:Obsessions: Anxiety provoking thoughts; mayAnxiety provoking thoughts; may
come income in ““attacksattacks”” oror ““waveswaves””; persist despite the; persist despite the
individual recognizing that the thought is silly,individual recognizing that the thought is silly,
however it is accompanied by feelings ofhowever it is accompanied by feelings of
considerable intensity.considerable intensity.
obsessions produce substantial mental distressobsessions produce substantial mental distress Young children may be less aware of the senselessYoung children may be less aware of the senseless nature of obsessional thoughts & might seem unsurenature of obsessional thoughts & might seem unsure about whether the thoughts are unrealistic.about whether the thoughts are unrealistic.
OCD:OCD: CompulsionsCompulsions
^ Compulsions:Compulsions:^ Purposeful behavior or thoughts thatPurposeful behavior or thoughts that
are performed in an attempt to relieve the anxietyare performed in an attempt to relieve the anxiety
associated with a specific obsession;associated with a specific obsession;
typically performed in a ritualistic fashiontypically performed in a ritualistic fashion can be behavioral [washing hands] or mental (intentionalcan be behavioral [washing hands] or mental (intentional thoughts or cognitive rituals]thoughts or cognitive rituals] compulsive thoughts are done actively with intent andcompulsive thoughts are done actively with intent and purpose whereas obsessional thought just seems topurpose whereas obsessional thought just seems to happen.happen.
Related Obsessions- Related Obsessions-CompulsionsCompulsions
OBSESSIONOBSESSION COMPULSIONCOMPULSION
Contamination/germsContamination/germs^ Washing/cleaningWashing/cleaning
Concern re bodily harmConcern re bodily harm^ CheckingChecking
Fear of disease/illnessFear of disease/illness Seeking reassuranceSeeking reassurance
Need for symmetryNeed for symmetry ArrangingArranging
Need to know, rememberNeed to know, remember QuestioningQuestioning
Fear of embarrassing actsFear of embarrassing acts AvoidanceAvoidance
Fear of losing thingsFear of losing things^ HoardingHoarding
Summary of AnxietySummary of Anxiety--RelatedRelated
DisordersDisorders
Anxiety Disorders Are the Largest Domain ofAnxiety Disorders Are the Largest Domain of
PsychopathologyPsychopathology
From a Normal to a Disordered Experience ofFrom a Normal to a Disordered Experience of
Anxiety and FearAnxiety and Fear
Requires consideration of biological, psychological,Requires consideration of biological, psychological, experiential, and social factorsexperiential, and social factors Fear and anxiety persist to bodily or environmental nonFear and anxiety persist to bodily or environmental non-- dangerous cuesdangerous cues (^) Symptoms and avoidance cause significant distress andSymptoms and avoidance cause significant distress and impair functioningimpair functioning
^ Psychological Treatments Are Generally Superior inPsychological Treatments Are Generally Superior in
the Long-the Long-TermTerm
Biological Contributions toBiological Contributions to
Anxiety and PanicAnxiety and Panic
DiathesisDiathesis--StressStress
Inherit vulnerabilities for anxiety and panic, not anxietyInherit vulnerabilities for anxiety and panic, not anxiety disordersdisorders ^ Stress and life circumstances activate the underlyingStress and life circumstances activate the underlying vulnerabilityvulnerability
Biological Causes & Inherent VulnerabilitiesBiological Causes & Inherent Vulnerabilities
^ Anxiety and brain circuitsAnxiety and brain circuits –– GABA, noradrenergic andGABA, noradrenergic and serotonergicserotonergic systemssystems CorticotropinCorticotropin releasing factor (CRF) and the HYPAC axisreleasing factor (CRF) and the HYPAC axis Limbic (Limbic (amygdalaamygdala) and the) and the septalseptal--hippocampalhippocampal systemssystems Behavioral inhibition (BIS) and fight/flight (FF)Behavioral inhibition (BIS) and fight/flight (FF) systemssystems
Psychological Contributions to Psychological Contributions to
Anxiety and FearAnxiety and Fear
Began with FreudBegan with Freud
^ Anxiety is a psychic reaction to dangerAnxiety is a psychic reaction to danger (^) Anxiety involves reactivation of an infantile fear situationAnxiety involves reactivation of an infantile fear situation
^ Behavioral ViewsBehavioral Views
^ Anxiety and fear result from direct classical and operantAnxiety and fear result from direct classical and operant conditioning and modelingconditioning and modeling
Psychological ViewsPsychological Views
^ Early experiences with uncontrollability and unpredictabilityEarly experiences with uncontrollability and unpredictability
Social ContributionsSocial Contributions
Stressful life events as triggers of biological/psychologicalStressful life events as triggers of biological/psychological vulnerabilitiesvulnerabilities ^ Many stressors are familial and interpersonalMany stressors are familial and interpersonal
Toward an Integrated ModelToward an Integrated Model
Integrative ViewIntegrative View
Biological vulnerability interacts with psychological,Biological vulnerability interacts with psychological, experiential, and social variables to produce an anxietyexperiential, and social variables to produce an anxiety disorderdisorder ^ Consistent with diathesisConsistent with diathesis--stress modelstress model
Common Processes:Common Processes: ComorbidityComorbidity
^ ComorbidityComorbidity is common across the anxiety disordersis common across the anxiety disorders (^) About 50% patients have 2 or more secondary diagnosesAbout 50% patients have 2 or more secondary diagnoses Major depression most common secondary diagnosisMajor depression most common secondary diagnosis ComorbidityComorbidity suggestssuggests common factors across anxiety disorderscommon factors across anxiety disorders relation between anxiety and depressionrelation between anxiety and depression
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