ANXIETY

DISORDERS

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 Mood Symptoms

Tension
Anxiety Anxiety
Fear Fear Fear Fear
Dread Dread Dread Dread
Panic Panic Panic Panic
!!!! T E R R O R !!!!
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 Cognitive Symptoms

 Expectation of future harm

• Fear - clear, specific danger
• Anxiety - unknown, diffuse danger
 Lack of Concentration
 Self-focused preoccupation

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 Behavioral/Somatic
Symptoms
 Autonomic arousal
 Behavior - startle, restlessness
 Avoidance

4
 Post-Traumatic Stress
Disorder (PTSD)
 Traumatic event exposure
• Death or serious injury/threat
• Reaction of intense fear,
helplessness, horror

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 Post-Traumatic Stress
Disorder (PTSD)
 Event is re-experienced
• Intrusive thoughts
• Dreams
• Flashbacks
• Triggers

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 Post-Traumatic Stress
Disorder (PTSD)
 Avoidance or numbing
• Avoid reminders
• Detachment/diminished interest
• Foreshortened future

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 Post-Traumatic Stress
Disorder (PTSD)
 Persistent arousal
• Sleep disturbance
• Irritability
• Hypervigilance/exaggerated
startle
 Impairment in functioning

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 PTSD

 Symptoms > 1 month

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 Acute Stress Disorder

 Symptoms 2 days - 1 month

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 Combat PTSD

 Goals of training
• Fighter identity
• Entering Vietnam soldiers
• 19.2 years old
• Shut down feelings
• Dehumanize enemy
 Clash with realities of war
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Combat PTSD Risk Factors

 Pre-morbid psychological
vulnerability
• But majority of PTSD have no
pre-morbid history

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Combat PTSD Risk Factors

 More combat exposure

• Goldberg et al. (1990) - MZ twins in
Vietnam
• No combat exposure 8-12% PTSD
• Combat exposure 16-31% PTSD

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Combat PTSD Risk Factors

 More death exposure

 More moral values conflict -

more perceived responsibility

 Less identification with

unit/leader

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Combat PTSD Risk Factors

 More return to non-supportive

environment
• Vietnam
• Rapid Homecoming
• Social rejection

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 Prevalence of PTSD

 8-15% lifetime in general

population
 20% prevalence in response to

trauma
• 20% Combat PTSD
• 11-80% range

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 Prevalence of PTSD

 Many have isolated symptoms

• 68% combat veterans had
frequent nightmares 5 years later

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 Treatment of PTSD

 Immediately after trauma

 Education/reassurance

regarding symptoms
 Discuss details of incident

(exposure)
 Identify and process areas of

impact
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 Generalized Anxiety
Disorder (Neurosis)
 Excessive anxiety/ worry/
anxious apprehension
• Regarding several
events/activities
• > 6 months

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 Generalized Anxiety
Disorder (Neurosis)
 Difficult to control worry -
“What if?” - vague future prbs.

 Autonomic arousal
 Impairs functioning
 6.6% females 3.6% males

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 Panic Disorder

 Unexpected, recurrent panic

attacks
• 4 in 4-week period
 Panic attacks - sudden onset,
peak within 10 minutes
• Physical - shortness of breath,
heart races, chest pain, dizzy/faint
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 Panic Disorder

• Emotional - terror,
derealization/depersonalization
• Cognitions - out of control
die or go crazy

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 Panic Disorder

 Persistent concern about future

attacks
 Worry about implications
 Avoidant behaviors
 With or without agoraphobia
 4% lifetime prevalence

23
 Phobic Disorders

 Persistent fear of specific

situation/object
• recognize fear is excessive
 Avoid object/situation
 Interfere with functioning or

distress about phobia

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 Phobic Disorders -
Agoraphobia
 Fear of marketplace - escape
difficult or help unavailable
 Avoid situations or insist on

companion
 7% female, 3.5% male lifetime

prevalence

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 Phobic Disorders -
Social Phobia
 Fear of situations involving
potential negative evaluation by
others
 Avoidance or intense anxiety

 Interferes with functioning or

distress about phobia

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 Phobic Disorders -
Social Phobia
 15% female, 11% male
 60% recall specific experience

+ 13 % vicarious experience

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 Phobic Disorders -
Specific Phobia
 Fear of specific stimulus
 Avoidance or intense anxiety
 Interfere with functioning or

distress about phobia

 16% female, 7% male

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 Specific Phobias

 Animal - childhood
 Inanimate objects/natural

environment - any age

 Illness/injury - onset middle age

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 Obsessive Compulsive
Disorder (OCD)
 Obsessions
• Recurrent, intrusive thoughts
• Experienced as inappropriate
(ego-dystonic)
• Cause distress
• Themes - contamination, violence
• Attempt to ignore/neutralize

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 Obsessive Compulsive
Disorder (OCD)
 Compulsions
• Repetitive, purposeful behavior in
response to obsessions or rules
• Designed to prevent discomfort
• Anxiety if don’t perform
• No pleasure, but tension release
• Common - cleaning, counting,
checking
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 Obsessions and
Compulsions
 Cause distress
 Consume time
 Interfere with functioning

 Begin in adolescence

 2.5% lifetime prevalence

 Males = females

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 ETIOLOGY OF
ANXIETY DISORDERS

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 Hereditary Influences

 MZ > DZ concordance
• Overall 35% MZ vs 10% DZ
concordance
• OCD 68% MZ vs 15% DZ
• Agoraphobia - 39% MZ
• Generalized anxiety disorder -
30% MZ

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 Disorder-Specific
Biological Influences
 Generalized Anxiety Disorder
• Low GABA --> Low inhibitory
neuron activity --> high neuronal
activity in limbic system
• High arousal can enhance
conditioning
• Anxiolytics increase GABA and
decrease anxiety
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 Disorder-Specific
Biological Influences
 Panic Disorder
• Oversensitive respiratory control
center in brain stem
• Minor oxygen debt (high CO2)
--> false alarm re suffocation
--> panic

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 Disorder-Specific
Biological Influences

• Challenge tests
• Sodium-lactate infusion (converted
to CO2) -->
• Panic history --> 54-90%
panic attack
• Panic history --> 5-36%
panic to placebo
• No panic history --> 0-25% panic
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 Disorder-Specific
Biological Influences
• Carbon dioxide inhalation -->
panic if panic history
• Hyperventilation --> panic if panic
history
• Antidepressants --> increase 5-HT
--> inhibits respiratory control center
--> decrease panic

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 Disorder-Specific
Biological Influences
 Obsessive-Compulsive Disorder
• Serotonin dysregulation
• Antidepressants (SSRIs)
effective for 50% OCD
• Dogs on Prozac
• Minimal brain damage
• Higher activity in orbitalfrontal
cortex
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 Psychological Etiology

 Psychoanalytic theory
• Objective anxiety - threat from
external world
• Moral anxiety - unconscious fear
of punishment by superego

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 Psychological Etiology

• Neurotic anxiety
• Unconscious conflict threatens
consciousness --> neurotic
anxiety --> defense mechanisms
and symptoms --> reduce
anxiety (primary gain) and
interpersonal reward (secondary
gain)
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Psychological Etiology

• Wish to harm son --> neurotic

anxiety --> door checking

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 Psychological Etiology

 More uncontrollable stressful

life events
 Previous anxiety disorder +

stress --> relapse

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 Behavioral Explanation

 Classical conditioning
• Little Albert
• Rat (neutral stimulus) paired
with noise (unconditioned
stimulus) --> startle, cry (UCR)
• Rat (conditioned stimulus) -->
fear (conditioned response)

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 Behavioral Explanation

• Extinction should occur rapidly,

but phobias persist
• Why?
• Avoid feared stimulus -->
reward --> maintain phobia

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Behavioral Explanation

• Mowrer two-factor theory

• Classical conditioning initiates
phobia
• Operant conditioning maintains
phobia
• Stimulus generalization and
vicarious conditioning also
contribute to initiation and
maintenance
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 Questions for Behavioral
Account
 Selectivity of phobias
• Why spider but not lamb phobia?
• Why dark but not electric outlet
phobia?

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Questions for Behavioral
Account
• Prepared classical conditioning
• Natural selection favored
specific fears
• Evolutionally prepared stimuli:
• Fear conditioning occurs
rapidly
• Fear extinction occurs slowly

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 Questions for Behavioral
Account
 Susceptibility to phobias
• Physiological vulnerability (higher
neurological activity)
• Lack of rewarding history with
stimuli
• Threat-enhancing cognitive set

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 Cognitive Explanation

 Threat-enhancing cognitive set

• Expect threat in environment
• Selective attention to threats
• Selective recall of threats

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 Threat-Enhancing
Cognitive Set
 “They discussed the priest’s
convictions”
 “The men watched as the chest was
opened”
 “The doctor examined little Emma’s
growth”
 Interpret neutral stimuli as
threatening
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 Questions for Cognitive
Explanation
 Causality?
 Does not explain spontaneous

anxiety
 How do cognitive sets develop?

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TREATMENT OF ANXIETY
DISORDERS

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 Biological Treatments

 Benzodiazapines
• Generalized Anxiety Disorder and
Phobias
• Valium, Xanax
• Increase GABA --> Increase
inhibitory neuron activity
• 70% individuals show symptom
reduction
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 Problems With
Benzodiazapines
 Side Effects
 Psychological and Physical

Dependence
 Anxiety returns when stop

meds

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 Antidepressants

 Panic, Agoraphobia, OCD

 Anafranil
 Effective for 50% OCD patients

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 Surgery for OCD

 Cingulotomy
• partially cut cingulate gyrus
• connects lower brain structures with
orbitalfrontal cortex
• effective in 50%

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 Psychological Treatments

 Commonality = confrontation of
fear
 Cognitive-Behavior Therapy
• Challenge threat-magnifying
cognitive sets

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 Behavioral Treatments

• Extinction of anxiety through

exposure and development of
incompatible responses
• Systematic Desensitization
• Progressive muscle relaxation
• Exposure to fear hierarchy

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 Psychological Treatment
Effectiveness
 Review of Panic Disorder
studies
• 75-95% panic-free after 3 months
of CBT
 Generalized Anxiety Disorder
• CBT more effective than Valium
• CBT + Valium most effective

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 Psychological Treatment
Effectiveness
 OCD
• Exposure + response prevention
• 50% patients improve
• = effectiveness vs. medications

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Psychological Treatment
Effectiveness

THE END

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