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Chapter 5 Anxiety Disorders Review Summary pg 167 The Complexity of Anxiety Disorders 0 Difference between anxiety fear and panic 0 Anxiety a negative mood state characterized by bodily symptoms of physical tension and by apprehension about the future 0 Fear an immediate alarm reaction to danger 0 Panic attack an abrupt experience of intense fear or acute discomfort accompanied by physical symptoms that usually include heart palpitations chest pain shortness of breath and dizziness 0 Three basic types of panic attacks 0 Situationally bound if you know you are afraid of heights you might have a panic attack only in these situations more common in specific phobias o Unexpected no idea when or where the next attack will occur more common in panic disorder 0 Situationally predisposed you are more likely to but will not inevitably have an attack where you have had one before more common in panic disorder 0 Causes of Anxiety Disorders 0 Biological Contributions I We inherit a tendency to be tense uptight and anxious I A genetic vulnerability does not cause anxiety or panic directly Stress or other factors in the environment can tum on these genes I Neurotransmitters related to anxiety 0 Depleted levels of GABA 0 Serotonin 0 Noradrenergic 0 Corticotropin releasing factor CRF I The area of the brain most often associated with anxiety is the limbic system I Behavioral inhibition system is activated by signals from the brain stem of unexpected events such as major changes in body functioning that might signal danger Danger signals in response to something we see that might be threatening descent from the cortex to the septal hippocampal system I When the BIS is activated by signals that arise from the brain stem or descend from the cortex our tendency is to freeze experience anxiety and apprehensively evaluate the situation to confirm that danger is present I Flightfight system FFS produces an immediate alarm and escape response that looks very much like panic Activated partly by deficiencies in serotonin o Psychological Contributions I A general sense of uncontrollability may develop early as a function of upbringing and other disruptive or traumatic environmental factors I Parents who interact in a positive and predictable way with their children by responding to their needs teach their children that they have control over their environment and their responses have an effect on their parents and their environment Parents who provide a secure home base but allow their children to explore their world and develop the necessary skills to cope with unexpected occurrences enable their children to develop a healthy sense of control Most psychological accounts of panic as opposed to anxiety invoke conditioning and cognitive explanations that are difficult to separate cues or conditioned stimuli provoke the fear response and an assumption of danger even if the danger is not actually present so it is really a learned or false alarm Extemal cues are places or situations similar to the one where the initial panic attack occurred Internal cues are increases in heart rate or respiration that were associate with the initial panic attack even if they are now the result of normal circumstances These cues or triggers travel from the eyes directly to the amygdala in the emotional brain without going throw the cortex the source of awareness making them unconscious 0 Social Contributions Stressful life events trigger our biological and psychological vulnerabilities to anxiety Most are social and interpersonal divorce work death but some may be physical injury or illness 0 An Integrated Model Triple vulnerability theory 1 general biological vulnerability 2 general psychological vulnerability 3 specific psychosocial vulnerability 0 Comorbidity of Anxiety Disorders 0 O O Comorbidity the cooccurrence of two or more disorders in a single individual The various anxiety disorders differ only in what triggers the anxiety and the patterning of panic attacks Results indicate that 76 of patients who receive a principal diagnosis of anxiety or depressive disorder had at least one additional anxiety or depressive disorder in his or her life Most common additional diagnosis for all anxiety disorders was major depression Drug or alcohol abuse makes it less likely that you will recover from an anxiety disorder and more likely that you will relapse if you do 0 Comorbidity with Physical Disorders 0 Studies show that the presence of any anxiety disorder is uniquely associated with thyroid disease respiratory disease gastrointestinal disease arthritis migraines and allergic conditions 0 People with these physical conditions are likely to have an anxiety disorder 0 Anxiety disorders most often begin before the physical disorder suggesting that something about having an anxiety disorder might cause the physical disorder Suicide 0 20 of patients with panic disorder had attempted suicide 0 The risk of someone with panic disorder attempting suicide is comparable to that for individuals with major depression Generalized Anxiety Disorder 0 Clinical Description 0 Definition no matter how much you Worry you cant seem to decide What to do about an upcoming problem or situation 0 At least 6 months of excessive anxiety and Worry must be ongoing more days than not o Physical symptoms are generally muscle tension mental agitation susceptibility to fatigue irritability and difficulty sleeping 0 Statistics 0 GAD is one of the most common anxiety disorders 0 23 Women except in south Africa GAD more common in males 0 Onset in early adulthood usually in response to a life stressor However GAD is associated with an earlier and more gradual onset than most other anxiety disorders 0 Is chronic after 12 years after the beginning of an episode of GAD there was only a 58 chance of recovering o GAD is most common in groups over 45 years of age and least common in the youngest group ages 1524 0 Causes 0 Biological Tends to run in families The tendency to be anxious runs more in families than GAD itself 0 Individuals with GAD show less physiological responses heart rate blood pressure respiration rate etc than do individuals with other anxiety disorders and therefore have been called autonomic restrictors 0 Muscle tension is the principle physical symptom in diagnosis GAD o Are highly sensitive to threats in general May have arisen in early stressful experiences Where they earned that the world is dangerous and out of control and may not be able to cope o Intense cognitive processing in the frontal lobes particularly in the left hemisphere This suggests frantic intense thought processes or Worry Without accompanying images Which would be re ected in the right hemisphere o Are thinking so hard about upcoming problems that they don t have the attentional capacity left for the process of creating images of the threat They avoid images of the threat 0 Because people with GAD do not seem to engage in this process they may avoid much of the unpleasantness and pain associated with the negative affect and imagery but they are never able to Work through their problems and arrive at solutions Adaptation never occurs 0 Treatment 0 Benzodiazepines I Are most often prescribed for generalized anxiety and they usually give short term relief I Impair both cognitive and motor functioning People are less alert and may impair driving Older people tend to fall more resulting in hip fractures Also addictive I For these reasons generally used for short term anxiety relief associated with a temporary crisis or stressful event 0 Antidepressants o Psychological treatments I Seem to be more effective in the long term I Clinicians have designed treatments to help patients With GAD process the threatening information on an emotional level using images so that they Will feel rather than avoid feeling anxious I Teaching patients how to relax deeply to combat tension 0 Meditation 0 Cognitive Behavioral Treatment CBT I Patients evoke the worry process during therapy sessions and confront anxiety provoking images and thought head on I Learn to counteract and control the Worry process I Successfully decreased anxiety and improved the quality of life Panic Disorder with and without Agoraphobia 0 Panic disorder with agoraphobia PDA individuals experience severe unexpected panic attacks 0 Because they never know when an attack might occur they develop agoraphobiathe fear and avoidance of situations in Which they would feel unsafe in the event of a panic attack or symptoms 0 Clinical Description 0 Anxiety and panic are combined with phobic avoidance 0 Panic disorder without agoraphobia PDanxiety and panic Without developing agoraphobia o A person must experience an unexpected panic attack and develop substantial anxiety over the possibility of having another attack or about the implications of the attack or its consequences 0 The Development of Agoraphobia 0 Almost all agoraphobic avoidance behavior is simply a complication of severe unexpected panic attacks 0 Anxiety is diminished for individuals with agoraphobia if they think a location or person is safe even if there is nothing effective the person could do if something bad did happen 0 An individual who has not had a panic attack for years may still have strong agoraphobic avoidance O 0 Some individuals do not avoid agoraphobic situations but endure them with intense dread Interoceptive avoidanceremoving yourself from situations or activities that might produce the physiological arousal that somehow resembles the beginnings of a panic attack Many individuals with agoraphobia avoid daily activities that may remind them of having a panic attack Sweating getting involved in debates exercising saunas etc 0 Statistics 0 O 27 of the population meet criteria for PD or PFA during a given 1 year period and 47 met them at some point during their lives 14 develop agoraphobia without ever having a full blown panic attack This is called agoraphobia without a history of panic disorder but it looks much the same as PDA and is treated with the same treatments Onset usually occurs in early adult life midteens through about 40 Many prepubertal children who are seen buy general medical practitioners haves symptoms of hyperventilation that may well be panic attacks However these children do not report fear of dying or losing control perhaps because they are not at a stage of their cognitive development where they can make these attributions For the elderly the primary phobia is agoraphobia which had a late onset and was often related to a stressful life even In general the prevalence of PD or PDA decreases among the elderly from 57 at ages 3044 to 20 or less after age 60 75 of those who suffer from agoraphobia are women It is more accepted for women to report fear and to avoid numerous situations Men however are expected to be stronger and braver A large proportion of males with unexpected panic attacks cope in a culturally acceptable way they drink 0 Cultural In uences O O O In Lesotho Africa the prevalence of panic disorder was found to be equal to or greater than in all of North America Rates are similar among different ethnic groups in the US However panic disorder often cooccurs with hypertension in African American patients 0 Nocturnal Panic O 0 Panic attacks occur more often between 130 AM and 330 AM thanany other time For this reason some people are afraid to go to sleep at night Nocturnal panics occur during delta wave or slow wave sleep which typically occurs several hours after we fall asleep and is the deepest stage of sleep People with panic disorder often begin to panic when they start sinking into delta sleep then they awaken amid an attack The change in stages of sleep to slow wave sleep produces physical sensations of letting go that are frightening to an individual with PD 0 Causes 0 Strong evidence indicates that agoraphobia develops after a person has unexpected panic attacks but Whether agoraphobia develops and how severe it becomes seem to be socially and culturally determined We all inherit a vulnerability to stress which is a tendency to be generally neurobiologically overreactive to the events of daily life But some people are also more likely than others to have an emergency alarm reaction when confronted with stress producing events An individual must be susceptible to developing anxiety over the possibility of having another panic attack That is he or she thinks the physical sensations associated with the panic attack mean something terrible is about to happen This is What creates PD Anxiety sensitivity index an instrument used to measure one aspect of psychological vulnerability Although We all typically experience rapid heartbeat after exercise if you have a psychological or cognitive vulnerability you might interpret the response as dangerous and feel a surge of anxiety This anxiety in tum produces more physical sensations because of the action of the sympathetic nervous system you perceive these addition sensations as even more dangerous and a vicious cycle begins that result in a panic attack Because of this David Clark believes that the cognitive process is most important in panic disorder Women who had a history of having various physical disorders and Were anxious about their health tended to develop PD rather than another anxiety disorder Another hypothesis that PD and agoraphobia evolve from psychodynamic causes suggested that early object loss andor separation anxiety might predispose someone to develop the condition as an adult 0 Treatment 0 O A large number of drugs affecting the noradrenergic serotonergic or GABA neurotransmitter systems seem effective in treating PD SSRIs are currently the indicated drug for panic disorder although sexual dysfunction seems to occur in 75 or more of people taking these medications On the other hand high potency benzodiazepines such as Xanax Work quickly but are hard to stop taking because of psychological and physical dependence and affect cognitive and motor functions to some degree Relapse rates are very high if an individual stops the drug before treatment is done 0 Psychological Intervention O 0 Originally treatments concentrated on reducing agoraphobic avoidance using strategies based on exposure to feared situations Gradual exposure exercises sometimes combined with anxiety reducing coping mechanisms relaxation or breathing retraining have proved effective in helping as many as 70 of patients overcome agoraphobic behavior However few are actually cured because many still experience some anxiety and panic attacks although at a less severe level Panic control treatment PCT concentrates on exposing patients with PD to the cluster of physical sensations that remind them of their panic attacks The therapist attempts to create mini panic attacks in the office Patients also receive cognitive therapy where basic attitudes and perceptions concerning the dangerousness of the feared but harmless situations are identified and modified bc many of these are unconscious to the patient 0 Combined Psychological and Drug Treatments 0 Combined treatment proved to be no better than individual treatments 0 Many studies show that drugs particularly benzodiazepines may interfere with the effects of psychological treatments 0 Conclusions from another study suggest no advantage to combining drugs and CBT because nay incremental effect of combined treatment seems to be a placebo effect not a true drug effect 0 Psychological treatment seemed to perform better in the long run This suggest the psychological treatment for those patients who do not respond adequately or for whom psychological treatment is not available Speci c Phobia 0 Clinical Description 0 An irrational fear of a specific object or situation that markedly interferes with an individual s ability to function 0 These fears are extremely disabling o Marked and persistent fear that is set off by a specific object or situation Fear must be excessive or unreasonable 0 Four major subtypes of specific phobia have been identified 1 Blood injury injection type 2 Situational type 3 Natural environment type 4 Animal type A fth category other includes phobias that do not fit any of the four major subtypes 0 BloodInjuryInfection Phobia 0 Those with this phobia almost always differ in their physiological reaction from people with other types of phobia 0 Runs in families more strongly than any phobic disorder we know This is probably beacuse people with this phobia inherit a strong vasovagal response to blood injury or the possibility of an injection all of which cause a drop in blood pressure and a tendency to faint o Onset is aprox 9 years old 0 Situational Phobia o Phobias characterized by fear of public transportation or enclosed places 0 Both situational phobia and PDA tend to emerge from midteens to mid 20s 0 Also tends to run in families 0 Main difference between situational phobia and PDA is that people with situational phobia never experience panic attacks outside the context of their phobic object or situation 0 Natural Environment Phobia 0 Very young people develop fears of situations or events occurring in nature 0 Major examples are heights storms and water 0 If you fear one situation or event you are likely to fear another 0 Onset is aprox 7 years 0 Animal Phobia O O O Fears of animals and insects The fear experienced by people with animal phobias is different from an ordinary mild revulsion Onset peaks around 7 years 0 Separation Anxiety Disorder 0 Identified more closely with children 0 Characterized by chi1dren s unrealistic and persistent worry that something will happen to their parents or other important people in their life or that something will happen to the children themselves that will separate them from their parents o Important to differentiate separation anxiety from school phobia In school phobia the fear is clearly focused on something specific to the school situation In separation anxiety the act of separating from the parent provokes anxiety and fear 0 Can extend into adulthood in aprox 25 of cases 0 Occurs in aprox 66 of the adult population over the course of a lifetime 0 Statistics 0 Fears of snakes and heights are the most common o The sex ratio among common fears is overwhelmingly female with a couple of exceptions 0 Specific phobias is one of the most common psychological disorders in the US and around the World 0 41 of children have separation anxiety 0 Only the most severe cases require treatment because most people with phobias Work around their fears 0 Once a phobia develops it tends to last a lifetime thus the issue of treatment becomes important 0 Hispanics are two times more likely to report specific phobias than White Americans 0 Causes o Phobias acquired from I Direct experience is a phobia that is developed after an event Where real danger or pain results in an alarm response Many phobias are acquired from a person having a panic attack in a specific situation perhaps related to current life stress A phobia of that situation may then develop I Experiencing a false alarm panic attack in a specific situation I Observing someone else experience severe fear vicarious experience emotions are contagious I Being told about danger 0 Information transmission hearing about something being a threat and being so dangerous Without ever actually having experienced it o Terrifying experiences alone do not create phobias As We have said a true phobia also requires anxiety over the possibility of another extremely traumatic event occurring again and We are likely to avoid situations in which it might occur 0 Several things must occur to develop a phobia 1 A traumatic conditioning experience often plays a role 2 Fear is more likely to develop if we are prepared we se seem to carry an inherited tendency to gear situations that have always been dangerous to the human race 3 We have to be susceptible to developing anxiety about the possibility that the event will happen again 0 Treatment 0 Almost everyone agrees that specific phobias require structured and consistent exposure based exercises 0 Most patients who expose themselves gradually to What they fear must be under therapeutic supervision o For separation anxiety parents are often included to help structure the exercises and also to address parental reaction to childhood anxiety 0 In cases of bloodinjuryinjection phobia individuals must tense various muscle groups during exposure exercises to keep their blood pressure sufficiently high to complete the practice 0 It is clear based on brain imaging work that these treatments change brain functioning by modifying neural circuitry Social Phobia Social Anxiety Disorder 0 Clinical Description 0 also called social anxiety disorder SAD 0 individuals who are extremely and painfully shy in almost all social situations meet the criteria for the subtype social phobia generalized type It is particularly prominent in children 0 Statistics 0 As many as 121 of the general population suffer from social phobia at some point in their lives 0 2nd most prevalent anxiety disorder 0 Unlike other anxiety disorders for which females predominate the sex ratio for social phobia is about 5050 0 Peaks during adolescence with onset age at 13 o More prevalent in young undereducated single and of low socioeconomic class But distribute equally among different races 0 Causes 0 In a study people with social phobia were more likely to remember faces with critical expressions and people Without the phobia were more likely to remember the faces with kind expressions 0 Some infants are born with a temperamental profile or trait of inhibition or shyness They become more agitated and cry more frequently There is now evidence that children with excessive behavioral inhibition are at increased risk for developing phobic behavior 0 Bullying or severe taunting 0 Similar to the development of PD or specific phobia because I Someone could inherit a generalized biological vulnerability to be socially inhibited or to have anxiety or both I When under stress someone might have an unexpected panic attack in a social situation that would become associatedconditioned to social cues I Someone might experience a real social trauma resulting in a true alarm Anxiety would then be conditioned in similar social situations 0 Treatment 0 Medications I Beta blockers I Antidepressants I Tricyclic antidepressants I MAOI I SSRI Paxil I High relapse rates when discontinued o Psychological I Cognitivebehavioral treatment I Exposure Rehearsal I Role play 0 Group settings I 84 substantially helped 0 Combined treatments I CBT SSRIs I CBT Dcycloserine PostTraumatic Stress Disorder 0 Clinical Description 0 Exposure to actual or threatened death severe injury or sexual assault 0 All of the following must last for 1 or more months post trauma and be related to the trauma I Involuntary intrusive distressing memories I Nightmares Flashbacks I Severe long lasting distress if around cues or symbol of the trauma Clear physiological reaction to cues or symbols of the trauma 0 Avoidance of either or both I Feelings memories or thoughts related to the trauma I Activities conversations objects people or situations related to the trauma 0 Persistent disturbances in thinking or mood must have at least 2 I Dissociative amnesia of important aspects of the trauma I Exaggerated negative beliefs about self others or the World I Distorted thinking that results in blaming self or others I Prolonged negative emotions eg fear guilt horror shame etc I Diminished interest in doing things I Unable to relate to others I Unable to experience positive emotions 0 Clearly increased arousal and reactivity due to the trauma 3 2 I Verbal or physical aggression with little or no provocation I Self destructive or reckless behavior I Hypervigilance I Heightened startle response I Concentration difficulties I Sleep disturbances o Clinically significant distress or impairment 0 Subtypes 0 With dissociative symptoms 0 Depersonalization separation of body and mind o Derealization the World isnt quite real foggy o Delayed onset event is over and symptoms don t occur for 6th months after the trauma 0 Statistics 0 68 life 35 year 0 Prevalence varies 0 Type of trauma 0 Proximity 0 Most Common Traumas 0 Sexual assault 0 Accidents 0 Combat 0 Causes 0 Generalized psychological vulnerability o Generalized biological vulnerability to anxiety 0 Neurobiological model I Threatening cues activate CRF system I CRF system activates fear and anxiety areas 0 Locus cereleus 0 Amygdala central nucleus I Results in increased coritsol and therefore Chronic increased cortisol damages thegt less control of stress hormones 0 Treatments 0 Cognitivebehavioral treatment I Exposure 0 Imaginal first maybe only 0 Often in form of a narrative 0 Graduated or massed I Increase positive coping skills I Increase social support 0 Highly effective 0 Medications I SSRIs 0 Support Groups often very helpful Reactive Attachment Disorder gt The following are seen before a child is 5 I Rarely seeks comfort when distressed I Has no to minimal reduction in distress when comforted I Generally socially and emotionally disturbed Minimally responsive to others Little or no positive affect Unexplained fearfulness irritability or sadness I Caused by the child receiving extremely insufficient care such as Persistent lack of basic affection comfort and stimulation Repeated change of caregivers Reared in an institution with high child to caregiver ratio 0 V Very rare Disinhibited Social Engagement Disorder A child on her or his own approaches and interacts with an unknown adult in an overly familiar way possibly including going away with the adult Does not check in with adult care giver in unfamiliar situations Caused by the child receiving extremely insufficient care such as from Persistent lack of basic affection comfort and stimulation Repeated change of caregivers Reared in an institution with high child to caregiver ratio V Very rare Obsessive Compulsive Disorder 0 Clinical Description 0 With insight acknowledge that what you re doing is weird and not normal but you can t help yourself 0 Without insight think that your rituals are reasonable and don t understand why others don t do that o Obsessions contamination symmetry somatic concerns sexual content aggressive content I Intrusive unwanted thoughts images or urges I Attempts to resist or eliminate through a compulsion I Make person anxious o Compulsions checking ordering arranging washingcleaning I Repetitive thoughts or actions I Feels compelled by obsessions to perform I According to rigid rules I May provide E temporary relief from obsessions 0 Statistics 0 In USA 16 life 12 year 0 Female gt Male 0 0 Causes 0 Generalized biological vulnerability I Internalizing and neurotic temperament I Difficulties in orbitofrontal cortex anterior cingulate gyrus and striatum 0 Specific psychological vulnerability I Early life experiences and leaming I Thoughts are dangerousunacceptable I Suppressor effect once you re trying not to think about anything and it makes it impossible not to think about I Though action fusion 0 Treatment 0 Medications I SSRIs I 60 benefit I High relapse when discontinued o Neurosurgery I Cingulotomy I 30 benefit 0 Cognitivebehavioral therapy I Exposure with reality testing I 86 benefit 0 Combined treatment I No added benefit from combined treatment of CBT and SSRIs I But combining CBT and Dcycloserine helps ALL UNDER THE CATEGORY OF OCD Body Dysmorphic Disorder 0 Clinical Description o Preoccupation with selfimage Repeatedly engages in some related behavior fixation on or avoidance of mirrors Checkingcompensating rituals Comparisons to others Ideas of reference Impaired social and occupational functioning or personal distress Suicidal ideation and behavior 0 Higher if delusional or if earlier onset 0 Statistics o Prevalence Females 25 Males 22 Onset 23 before 18 years old Most have greatly School or Lifelong chronic course OOOOOOO O O O O 0 Causes 0 O 0 Little scientific knowledge I More likely if first degree relatives with OCD I Correlated with childhood abuse and neglect Similarities with OCD I Intrusive I Rituals I Age of onset and course Cultural imperatives I Body size I Skin color 0 Treatments 0 OOOOO Similar to OCD SSRIs 53 successful Exposure and response prevention as high as 82 successful Plastic surgery is often unhelpful Excoriation Disorder Repeatedly picks at skin producing lesions Picking continues despite repeated attempts to stop Lifetime Prevalence 14 Female Male 31 Hoarding Disorder Extreme difficulty throwing away things of no value Possessions take over the home leading to congestion Specify excessive if keeps items that are no longer needed and for which there is no available space 80 90 of all people who hoard Prevalence 2 6 Gender differences contradictory evidence Increase among those over age 55 Trichotillomania Repeatedly pulls out hair Unsuccessfully attempts to reduce or stop May be triggered by anxiety boredom tension or itchy tingling in scalp Sometimes leads to pleasure or sense of relief Prevalence 1 2 Female Male 101