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Allyn & Bacon copyright 20001 Panic, Anxiety, and Their Disorders Panic, Anxiety, and Their Disorders

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The Fear and Anxiety Response Patterns Fear & Panic A basic emotion that involves the activation of the fight or flight response of the SNS. Anxiety A general feeling of apprehension about possible danger; much more diffuse than fear.

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Anxiety Disorder Any mental disorder characterized by unrealistic, irrational fear or anxiety of disabling intensity. DSM-IV-TR (Seven Types) Specific Phobia Social Phobia Panic Disorder with Agoraphobia Panic without Agoraphobia Generalized Anxiety Obsessive Compulsive Disorder Post-Traumatic Disorder

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Overview of Anxiety Disorders Anxiety Disorders as a group are the most common diagnosis for women. Phobias in females are second in prevalence to Depression Phobias are the fourth most common diagnosis for men (etoh abuse, etoh dependency, major depression, phobias)

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Phobic Disorders Phobias Specific phobias Fears of other species or environment Social phobia Fear of social situations in which a person is exposed to the scrutiny of others and is afraid of acting in a humiliating or embarrassing way. Agoraphobia Anxiety about having a panic attack in situations where escape might prove difficult or embarrassing.

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Specific Phobia Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation. (e.g., flying, seeing blood). Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed The person recognizes that the fear is excessive or unreasonable. The phobic situation(s) is avoided or else is endured with intense anxiety or distress. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. In individuals under age 18 years, the duration is at least 6 months.

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Specific Phobias Five Subtypes Animal Natural Environment Blood-injection Situational (flying) Atypical (choking)

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Phobias (cont.) Most common fears include in order: snakes, being in high exposed places, mice, flying on an airplane, being closed in a small place, spiders and insects, thunder and lightning, being alone in a house at night, and dogs. Blood-Injection-Injury Phobia has unique physiological response Age of onset and gender differences in specific phobias: Lifetime Prevalence: Women 16% Men 7% Onset typically in childhood. Animal phobias are equal in boys and girls but boys tend to outgrow them In adulthood 90-95% of people with animal phobias are women. Sex ratio is less than 2 to 1 for blood-injection.

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Specific Phobias: Psychosocial Causal Factors Symbolic displacement of repressed id impulse Learned (classical conditioning-generalized) Vicarious / Observational Classical Conditioning Experiences before, during, and after exposure are determinants of the strength of the phobia Cognitive Bias Maintain and Strengthen Phobia Availability Heuristic Genetic and temperamental causal factors Temperament and Personality (Behaviorally Inhibited; shy & timid) Evolutionary Factors Selective Advantage

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Treatment of Specific Phobias Exposure Controlled with Gradual Exposure Expose for long enough time that fear begins to subside Participant Modeling Therapist models interacting with the feared situation or object in a calm and non-fearful manner.

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Social Phobia General characteristics Lifetime Prevalence Women 15% Men 11% during their lifetime Over 50% suffer from another anxiety disorder. Approximately 40% suffer from a depressive disorder at some point. Approximately 1/3 abuse etoh at one point Onset Adolescence and Early Adulthood

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Social Phobia: Psychosocial and Biological Causal Factors Learned Behavior Direct and Vicarious Classical Conditioning) Social Fears and Phobias: Evolutionary Context Dominance and Aggression) Genetic and Temperamental factors Behavioral Inhibition (shy) Perceptions of Uncontrollability Cognitive variables (vicious cycle) Experience Fear- Avoidant or Odd Behavior Results- Others Avoid or Become Less Friendly-Confirmation of Expectations and Beliefs

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Treatment for Social Phobia Medications Beta-Blockers (used for high blood pressure) Anti-depressants and Anxiolytics High relapse rates with discontinuation of meds Behavioral Therapy Social Skills Training Counter-Conditioning Cognitive Therapy Challenge Negative Automatic Thoughts Cognitive-Behavioral Therapy

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Panic Disorder and Agoraphobia Panic Disorder Unexpected panic attacks that occur suddenly Panic versus Anxiety Distinguished by Brevity and Intensity Reach peek in 10 min. Subside at 20-30 min. Agoraphobia Fear of being in a place or situation from which escape would be physically difficult or psychologically embarrassing, or in which immediate help would be unavailable Usually develops as a result of panic attacks

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Panic Disorder An anxiety disorder marked by a minutes-long episode of intense dread in which a person experiences terror and accompanying chest pain, choking, or other frightening sensations. The person must have experienced recurrent unexpected attacks and must have been consistently concerned about having another attack or worried about the consequences of having another attack for at least one month. To be considered a full blown panic attack the episode must involve the abrupt onset of at least 4 of 13 symptoms e.g.: Shortness of breath Heart palpitations Sweating Dizziness Depersonalization (feeling detached from ones body) Derealization (feeling that the outside world is unreal) Fear of dying, going crazy, losing control

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Panic Disorder Prevalence and age of onset Age 15-24 but also in 30s & 40s (Women) Typically follows a chronic course More prevalent in women (2-4 x) Comorbidity with other disorders GAD, Depression, Alcohol Abuse Timing of a first panic attack Frequently follows a distressing event

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Panic: Biological Causal Factors High Noripinephrine activity in the Locus Coeruleus Altering Serotonin levels also decreases panic.

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Panic Disorder: Cognitive & Behavioral Causal Factors 1) Interoceptive Conditioning Model Interoceptive Fears Fears focused on various internal bodily functions Introreceptive Conditioning (bodily sensations become associated with panic attacks and then acquire the capacity to invoke panic) 2) Cognitive Model Focuses on the meaning placed on physiological sensations. See next slide>

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Panic Circle Hypersensitivity to bodily sensations Dire Thought with Catastrophizing Thought fuels increase in bodily response Vicious out-of-control cycle

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Panic Disorder: Cognitive Theory II. Perceived Control as a blocker to panic Pre-existing Anxiety Sensitivity High level of belief that certain bodily symptoms may have harmful consequences

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Treating Panic Disorder and Agoraphobia Medications Benzodiazepine (Xanax) Behavioral and CBT Exteroceptive Exposure Exposure to external situations Interoceptive Exposure Exposure to internal bodily sensations Relapse greater with combination with Meds. (likely due to attribution to med.)

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Generalized Anxiety Disorder Prevalence and age of onset Two-thirds diagnosed are women 60-80% Report having had anxiety since childhood. Unlike phobias, generalized anxiety disorder involves the person not being able to identify the cause of the anxiety. Smokers have a fourfold risk of a first-time panic attack.

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Generalized Anxiety Disorder DSM-IV Criteria are as Follows: Includes chronic excessive worry about a number of events and activities (not identified) Must occur more days than not for at least 6 months Worry must be accompanied by at least 3 of the following Restlessness or feelings of being keyed up or on edge A sense of being easily fatigued Difficulty concentrating or mentally going blank Irritability Muscle tension Sleep disturbance

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Generalized Anxiety Disorder: Psychosocial Causal Factors Psychoanalytic Viewpoint Classical Conditioning (many stimuli) History of Unpredictable & Uncontrollable Events Content of Anxious Thoughts Maladaptive Negative and Automatic Thoughts Focus on the Positive Function of Worry Worry for them suppresses their emotional and physiological responses to aversive stimuli. This reinforces worrying. Cognitive Biases for Threatening Iinformation

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Generalized Anxiety Disorder: Biological Causal Factors Genetic Factors Scientists have identified a specific gene related to anxiety and neuroticism A functional deficiency of GABA Xanax, Valium, and Librium stimulate the action of gaba.

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Obsessive Compulsive Disorder Obsessions- persistent and recurrent intrusive thoughts, images, or impulses that are experienced as disturbing and inappropriate. Compulsions- overt repetitive behaviors (such as hand washing, checking or ordering) or covert mental acts (such as counting, praying, or saying certain words silently). The person feels driven to perform the compulsive behavior in response to an obsession. The person must recognize that the obsession is a product of their own mind rather than from external sources The involuntary behavior must cause marked distress, consume excessive time, or interfere with occupational or social functioning.

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Obsessive-Compulsive Disorder Prevalence and age of onset Characteristics of OCD Types of compulsions Consistent themes Comorbidity with other disorders

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Obsessive-Compulsive Disorder: Psychosocial Causal Factors Psychoanalytic viewpoint Behavioral viewpoint OCD and preparedness The role of memory Attempting to suppress obsessive thoughts

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Obsessive-Compulsive Disorder: Biological Causal Factors Genetic influences Abnormalities in brain function The role of serotonin

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General Sociocultural Causal Factors For All Anxiety Disorders Cultural differences in sources of worry Taijin Kyofusho

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UNRESOLVED ISSUES Interdisciplinary research on the anxiety disorders