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Chapter 5
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
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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
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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
PLAY VIDEO
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/c’d
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
PLAY VIDEO
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/c’d
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)
PLAY VIDEO
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/c’d
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