LECTURE 3

Anxiety Disorders

Nature of Anxiety and Fear Fear Immediate, present-oriented Sympathetic nervous system activation Anxiety Apprehensive, future-oriented Somatic symptoms = tension Both: Negative affect

Nature of Anxiety, Fear, and Panic Panic attacks abrupt experience of intense fear Symptoms: palpitations, chest pain, dizziness Three types Situationally-bound/cued Unexpected/uncued Situationally predisposed

Nature of Anxiety, Fear, and Panic

Causes of Anxiety - Biological Contributions Increased physiological vulnerability Polygenetic influences Corticotropin releasing factor (CRF) Brain circuits and neurotransmitters GABA noradrenergic serotonergic systems CRF and the HPAC axis

Causes of Anxiety - Biological Contributions Limbic system Behavioral inhibition system (BIS) Brain stem Septal-hippocampal system Amygdala

Fight/flight (FF) system Panic circuit Alarm and escape response

Causes of Anxiety - Biological Contributions Brain circuits are shaped by environment Ex. teenage cigarette smoking Interactive relationship with somatic symptoms

Psychological Contributions Freud Anxiety = psychic reaction to danger Reactivation of infantile fear situation Behaviorists Classical and operant conditioning Modeling

Psychological Contributions Integrated psychological model Early experiences and perceptions Controllability Dangerousness

Parental actions/modeling
Associations or cues to stimuli

Social Contributions Biological vulnerabilities triggered by stressful life events Familial Interpersonal Occupational Educational

An Integrated Model Triple Vulnerability Generalized biological vulnerability Diathesis Generalized psychological vulnerability Beliefs/perceptions

Specific psychological vulnerability Learning/modeling

An Integrated Model

Comorbidity of Anxiety Disorders High rates of comorbidity 55% to 76% Commonalities Features Vulnerabilities Links with physical disorders

Anxiety Disorders and Disability

Panic Disorder and Suicide Suicide attempt rates Similar to major depression 20% Increases for all anxiety disorders Comorbidity with depression??

The Anxiety Disorders: An Overview Generalized Anxiety Disorder Panic Disorder with and without Agoraphobia Specific Phobias Social Phobia Posttraumatic Stress Disorder Obsessive-Compulsive Disorder

Generalized Anxiety Disorder Clinical Description Excessive apprehension and worry Uncontrollable Strong, persistent anxiety Somatic symptoms (e.g., muscle tension, fatigue, mental agitation) 6 months or more

Generalized Anxiety Disorder Clinical Description (cont.) Shift from possible crisis to crisis Worry about minor, everyday concerns Job, family, chores, appointments Problems sleeping GAD in Children Need only one physical symptom Worry = academic, social, athletic performance

Generalized Anxiety Disorder Statistics 3.1% (year) 5.7% (lifetime) Similar rates worldwide Female : Male = ~2 : 1 Insidious onset Early adulthood Chronic course

Generalized Anxiety Disorder GAD in the Elderly Worry about failing health, loss Up to 7% prevalence Use of minor tranquilizers - 17-50% Medical problems? Sleep problems? Falls Cognitive impairments

GAD : Causes Inherited tendency to become anxious Neuroticism? Less responsiveness autonomic restrictors Threat sensitivity Frontal lobe activation Left vs. right

GAD : Causes

GAD : Treatments Pharmacological Benzodiazepines Risks versus benefits Antidepressants

GAD : Treatments Psychological Cognitive-behavioral treatments Exposure to worry process Confronting anxiety-provoking images Coping strategies Acceptance Meditation Similar benefits Better long-term results

Panic Disorder with and without Agoraphobia Clinical Description Unexpected panic attacks Anxiety, worry, or fear of another attack Persists for 1 month or more Agoraphobia Fear or avoidance of situations/events

Panic Disorder with and without Agoraphobia Clinical Description (cont.) Avoidance can be persistent Use and abuse of drugs and alcohol Interoceptive avoidance

Panic Disorder with and without Agoraphobia

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Panic Disorder with and without Agoraphobia Statistics 2.7% (year) 4.7% (life) Female : male = 2:1 Acute onset, ages 20-24

Panic Disorder - Special Populations Children Hyperventilation Cognitive development Elderly Health focus Changes in prevalence

Panic Disorder: Cultural Influences Social/Gender roles ~75% of those with agoraphobia are female Similar prevalence rates Variable symptom expression Somatic symptoms

Panic Disorder: Cultural Influences Culture-bound syndromes Ataque de nervios Susto Kyol goeu

Panic Disorder: Nocturnal Panic 60% with PD experience nocturnal attacks non-REM sleep Delta wave Caused by deep relaxation, Sensations of letting go Sleep terrors

Isolated sleep paralysis

Panic Disorder: Causes Generalized biological vulnerability Alarm reaction to stress Cues get associated with situations Conditioning occurs Generalized psychological vulnerability Anxiety about future attacks Hypervigilance Increase interoceptive awareness

Panic Disorder: Causes

Panic Disorder: Treatment Medications Multiple systems serotonergic noradrenergic benzodiazepine GABA SSRIs (e.g., Prozac and Paxil) High relapse rates when d/cd

Panic Disorder: Treatment Psychological Exposure- based Reality testing Relaxation Breathing Panic Control Treatment Exposure to interoceptive cues Cognitive therapy Relaxation/breathing High degree of efficacy

Panic Disorder: Treatment

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Panic Disorder: Treatment Combined Medication/Psychological No better than individual tx CBT = better long term

Panic Disorder: Treatment

Specific Phobias Clinical Description Extreme and irrational fear of a specific object or situation Significant impairment Recognizes fears as unreasonable Avoidance

Specific Phobias Blood-Injection-Injury Phobia Decreased heart rate and blood pressure Fainting Inherited vasovagal response Onset = ~ 9

Specific Phobias Situational Phobia Fear of specific situations Transportation, small places No uncued panic attacks Onset = early to mid 20s

Specific Phobias Natural Environment Phobia Heights, storms, water May cluster together Associated with real dangers Onset = ~7

Specific Phobias Animal Phobia Dogs, snakes, mice May be associated with real dangers Onset = ~7

Other Phobias Illness

Choking
Separation Anxiety Disorder School phobia

Specific Phobias: An Overview Statistics 12.5% (life); 8.7% (year) Female : Male = 4:1 Chronic course Onset = 7 (median)

Specific Phobias: Causes Inherited vulnerability Biological and evolutionary Traumatic exposure Direct conditioning Observational learning Information transmission Social and Gender Roles

Specific Phobias: Causes

Specific Phobias: Treatment Cognitive-behavior therapies Exposure Graduated Structured Consistent Relaxation Blood-injury-injection Tensing

Social Phobia Clinical Description Extreme and irrational fear/shyness Social/performance situations Significant impairment Avoidance or distressed endurance Generalized subtype

Social Phobia Statistics 12.1%(life); 6.8% (year) Female : male = 1.4:1.0 Onset = adolescence Peak age of 15

Social Phobia: Cultural Considerations Japan - taijin kyofusho Fear of offending others Symptoms Female : Male = 2:3

Social Phobia: Causes Inherited vulnerability Biological and evolutionary Traumatic exposure (social) Direct conditioning Observational learning Information transmission Family influence

Social Phobia: Causes

Social Phobia: Treatment Medications Beta blockers Tricyclic antidepressants MAOI SSRI (Paxil) D-cycloserine High relapse rates when d/cd

Social Phobia: Treatment (cont.) Psychological Cognitive-behavioral treatment Exposure Rehearsal Role-play Group settings Highly effective

Social Phobia: Treatment

Posttraumatic Stress Disorder (PTSD) Clinical Description Trauma exposure Extreme fear, helplessness, or horror Continued re-experiencing (e.g., memories, nightmares, flashbacks) Avoidance Emotional numbing Interpersonal problems Dysfunction 1+ month post-trauma

Posttraumatic Stress Disorder (PTSD) Subtypes Acute Chronic Delayed onset Acute stress disorder

Posttraumatic Stress Disorder (PTSD) Statistics 6.8% (life); 3.5% (year) Prevalence varies Type of trauma Proximity Most Common Traumas Sexual assault Accidents Combat

Posttraumatic Stress Disorder (PTSD)

PTSD : Causes Trauma intensity

Generalized biological vulnerability Twin studies Reciprocal gene-environment interactions

Generalized psychological vulnerability Uncontrollability and unpredictability Social support

PTSD : Causes Neurobiological model

Threatening cues activate CRF system

CRF system activates fear and anxiety areas Locus cereleus Amygdala (central nucleus) Increased HPA axis activation cortisol

PTSD : Causes

PTSD : Treatment Cognitive-behavioral treatment Exposure Imaginal Graduated or massed Increase positive coping skills Increase social support Highly effective

PTSD : Treatment Medications SSRIs

Obsessive-Compulsive Disorder (OCD) Clinical Description Obsessions Intrusive and nonsensical Thoughts, images, or urges Attempts to resist or eliminate Compulsions Thoughts or actions Suppress obsessions Provide relief

Obsessive-Compulsive Disorder (OCD)

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OCD : Obsessions 60% have multiple obsessions Contamination Aggressive impulses Sexual content Somatic concerns Need for symmetry

OCD : Compulsions Four major categories Checking Ordering Arranging Washing/cleaning Association with obsessions Hoarding

Obsessive-Compulsive Disorder Statistics 1.6% (life); 1% (year) Female > Male Reversed in childhood Chronic Onset = depends Male = 13 to 15 Female = 20 to 24

Obsessive-Compulsive Disorder : Causes Similar generalized biological vulnerability

Specific psychological vulnerability Early life experiences and learning Thoughts are dangerous/unacceptable Thought-action fusion
Distraction temporarily reduces anxiety Increases frequency of thought

Obsessive-Compulsive Disorder : Causes

OCD : Treatment Medications SSRIs 60% benefit Psychosurgery (cingulotomy) 30% benefit High relapse when d/cd

OCD : Treatment Cognitive-behavioral therapy Exposure Response prevention Reality testing Highly effective 86% benefit No added benefit from combined treatment

Future Directions Improving combined treatments D-cycloserine