Chapter 5 Anxiety Disorders

 OVERVIEW
o Anxiety disorders
 Generalized anxiety disorder
 Panic disorder and agoraphobia
 Specific phobias
 Social anxiety disorder
 Separation anxiety disorder
 Selective mutism
o Trauma and stressor related disorders
 PTSD
o Obsessive compulsive and related disorders
 OCD
 Body dysmorphic disorder
 FEAR VS ANXIETY
o Fear
 Immediate, present oriented
 sympathetic nervous system activation
o Anxiety
 Apprehensive, future oriented
 Somatic symptoms: muscle tension, restlessness, elevated heart rate
o Panic attacks
 Specifier- clarifies something about a diagnosis
 Abrupt experience of acute fear
 Physical symptoms: heart palpitations, chest pain, dizziness, sweating,
chills or heat sensations etc
 Cognitive symptoms: fear of losing control, dying, or going crazy
 Types: cued and uncued
o Biological contributions
 Hyper-sensitive limbic system/ fear response
 Behavioral inhibition system (BIS)
o Brainstem activates in face of unexpected events; signals
from the cortex about perceived danger
 Fight/flight system (FFS)
 Depleted GABA—increased sensitivity to anxiety or a fear
response
o Psychological contributions
 Freud- anxiety=psychic reaction to danger
 Behaviorists- learned associations (cc/oc)
 Modern examples (multiple factors)
 Out of control feeling
  Anxiety sensitivity (fearful response to internal anxiety cues)
 Conditioning
 Generalized Anxiety Disorder (GAD)
o Excessive anxiety and worry occurring more days than not for at least 6 months
o Difficulty controlling the worry
o Physical sxs(symptoms); muscle aches and pains
o Distress/impairment
o Rule out substance use and medical causes
o EPIDEMIOLOGY
 5.7% lifetime prevalence (over the lifetime who will meet the criteria for
the disorder)
 More women diagnosed than men
 More specifically in a western context
 Onset—early adulthood
 Chronic impairment
o CAUSES
 Inherited tendency to become anxious
 Threat sensitivity
 Less responsiveness- “autonomic restrictions”
 Frontal lobe activation- higher thinking of the worry truly immerses you in
the fear and helps to distance you from parts of the phobia making it feel
more real
o TREATMENT
 Pharmacological—benzodiazepines
 Fast acting, but lead to minor cog / motor impairment
 Little research on long term use
 Risk for dependence
 Psychological—CBT
 Exposure to worry process
 Coping tools
 Similar benefits to drugs; sustained results
 Long term effects attributed to this kind of treatment
 Specific Phobias
o Prevalence- 8.7% (1 yr); 12.5% (lifetime)
o Demographics- higher rates in women
 4:1 female to male
 Adolescents- 15.8%
o Onset- usually childhood (except situational—mid 20s)
o DIAGNOSTIC
 Marked fear in response to specific situation / event
 Avoidance or endurance with extreme distress; impairment
  Persistent (~6 months)
 Disproportionate to situation
 Types—blood-injection-injury (needles, getting blood drawn, seeing
blood; usually see a drop in autonomic responses leads to fainting);
animal (afraid of a dog or snake); natural environment (thunderstorms);
situational (being afraid of an elevator)
 Cultural variants: pa-leng (fear of cold or heat loss) / frigo-phobia
(Chinese culture)
o CAUSES (chart in text book)
 Generalized biological vulnerability
 Specific psychological vulnerability
 Generalized psychological vulnerability
 Stress due to life events
o TREATMENTS
 Psychological interventions
 Exposure
o Gradual
o Structured
 Less-often: relaxation
 Separation anxiety disorder- something will happen that I will not see my mother again or
I will not see my child again; being really anxious and texting parent, if parent doesn’t
text back then scared that they have died
 Social anxiety disorder
o Prevalence- 6.8% (year); 12.1% (life)
o Demographics
 1:1 female to male
o Onset- usually adolescents
o Diagnosis
 Extreme concern about negative valuation
 Distress; interference; avoidance
 Subtype: performance only
o TREATMENT
 Psychological
 Challenge maladaptive cognitions about consequences to social
judgement
 Exposure (social mishaps; eliminate safety behaviors)
 Rehearsal / role-play
 Medication
 Beta blockers (lower hr/bp- not great results)
 SSRI (Paxil, zoloft) some efficacy
 D- cycloserine (may enhance exposure treatment via faster
extinction)
 Selective mutism
o Rare childhood disorder characterized by a lack of speech
o 1+ month; not first month of school
o Intensive treatment, analog settings  strong results
 PTSD
o Prevalence- 3.5% (year); 6.8% (life)
o Most people who undergo traumatic events do NOT develop PTSD
o Type of trauma matters
o Proximity to trauma matters
o DIAGNOSIS- with or without dissociative symptoms, at least one month
 Exposure to actual / threatened death, serious injury or sexual violence
 what counts as exposure?
o Direct experience
o Learning of occurrence
o Witnessing
o Repeated exposure to details (not media)
 Reexperiencing symptoms: memories, dreams, dissociative flashbacks,
physiological reactions to reminders/triggers
 Avoidance
 Negative beliefs, emotions, detachment, anhedonia
 Hypervigilance, startle
o TREATMENTS
 Cognitive-behavioral treatment
 Imaginal exposure to memories of traumatic event
 Increase positive coping skills
 Increased social support
 Highly effective
 SSRIs can be helpful to relived heightened anxiety
 D-cycloserine (DCS) results mixed
 PD / Agoraphobia
o Prevalence 2.7% (1yr); 4.6% (lifetime)
o Onset- 20-24 (median)
o Demographics- highest among White Americans
 2:1 Female to male
o DIAGNOSIS PD
 Recurrent / unexpected PAs
 Persistent worry for at least one month
 Worry focused on having PA or consequences
 Other clinical features
 Sudden / acute rush of fear
 Intense physiological symptoms
  Catastrophic conditions
 Interoceptive avoidance
o AGOROPHOBIA
 Marked by fear / anxiety in 2 or more settings
 Public transportation, open / enclosed spaces, being outside the
home alone
 Avoidance or endurance with distress
DISCUSSION QUESTIONS:
1. Do you think that Joe’s panic attacks began because the first may have been linked to
something he experienced when he was in Vietnam? Knowing from later discussion that
this is true, why was the plane ride the inciting incident?
2. Joe’s attacks seem to be unrelated to me, first in a confined space, then in public. Is there
a link between them? How was the psychologist able to diagnose him so easily and
quickly?
3. Should Joe come back for follow up later in his life? Would you expect this to be a
persistent problem for him and possibly in new situations?
 Psych Ch. Notes Continued
 OCD
o Prevalence 1% (year); 1.6% to 2.3% (life)
o Female = male
o Onset- childhood
o DIAGNOSIS
 Obsessions- thoughts, images, or urges; intrusive and nonsensical; expect
reality testing will be on track; attempts to resist or eliminate
 Compulsions- thoughts or actions provide relief from obsessive
thoughts; presence of obsessions, compulsions or both; must be time
consuming
 Types of obsessions-compulsion
 Symmetry- just right, most common, think they must do things
repeatedly until just right; results in ordering, repetition
 Forbidden thought or behavior- obsession—anxiety; urge to harm;
fear of offending god; compulsion—checking, avoidance, seeking
reassurance
 Contamination- obsession with germs and contaminants;
compulsion with washing, gloves and masks
 Hoarding- obsession with a fear of throwing things away;
compulsion with saving objects of little value
o TREATMENT
 Psychological
 Exposure and response/ritual prevention (ERP)
 Exposure to cues that would trigger obsessions prevent
compensatory compulsions
 Medications
 SSRIs ~50-60% effective; high relapse after drug is discontinued
o RELATED DISORDERS
 Body dysmorphic disorder
 Preoccupation with one or more physical defect/flaw; repetitive
behaviors
 Treatments SSRIs; ERP
 Hoarding disorder
 Problem areas
o Accumulation
o Discarding
o Disordered habituation
 Treatment: CBT (promising—limited data)
 Trichotillomania- urge to pull body hair
 Excoriation- urge to pick skin
 Treatment for both is HRT
o Awareness training- when, where, how often, details of
behavior
o Competing response- incompatible, always available,
inconspicuous
 Long enough for urge to pass
 Help get through urge not avoid it
 Exposure therapy
o Creating a fear and avoidance hierarchy- FAH
o Order low-level and high-level scenarios
 Treating distorted cognitions
o Identify maladaptive cognitions- patterns of thinking that
are not helpful to ones goals
o Recognize the patterns of thoughts
o Try to relieve the spiral of thoughts by objectively and
logically labeling it