TOPIC 5ANXIETY DISORDERS

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Anxiety disorder

Anxiety is a generalized state of apprehension

The focus of anxiety is more internal than external

It seems to be a response to a vague or unrecognized danger

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Anxiety is a physiological, behavioral and psychological reaction all at once

Therefore intervention programs in general should focus on:

- to reduce physiological reactivity- to eliminate avoidance behavior - to change subjective reaction

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Free-floating anxietyAnxiety that comes out of blue

Situational Anxietyanxiety arises only in response to a specific situation but it is unrealisticsituational anxiety will eventually become phobic when you start to avoid the situation

Anticipatory anxietythinking about one particular situation

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Anticipatory anxiety is closely associated with the way you are thinking.

With panic disorder, thoughts are generally focused on worrying about having a panic attack in a situation that will result in embarrassment, extreme discomfort, a heart attack or even worse.

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Different types of anxiety disorders defined by DSM-IV-TR

Panic disorders Agoraphobia Social Phobia Generalized Anxiety Disorder Obsessive Compulsive Disorder Post Traumatic Stress Disorder

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Panic Disorder

Characterized by sudden episodes of acute apprehension or intense fear that occur “out of blue” without any apparent

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Symptoms of panic disorder- Shortness of breath or a feeling of being smothered - Heart palpitations – pounding heart or accelerated heart rate - Dizziness, unsteadiness- Trembling or shaking- Feeling of choking - Sweating - Nausea or abdominal distress- Feeling of unreality- Numbness or tingling in hands and feet- Hot and cold- Chest pain or discomfort - Fears of going crazy or losing control - Fear of dying

Panic Disorder

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Your symptoms would be diagnosed as panic disorders if:

You have had two or more panic attacks

At least one of these attacks has been followed by one month (or more) of persistent concern about having another panic attack.

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The panic doesn’t occur because you are thinking about, approaching or actually entering a phobic situation

It happens spontaneously and unexpectedly for no apparent reason

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The causes of panic disorder

Heredity

chemical imbalances in the brain personal distress

major life changes may trigger the onset of panic attacks

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TreatmentMedication antidepressant drugs such as tofranil and paxil

Personal wellness program regular exercise daily practice of deep relaxation good nutrition a shift in attitude to a calmer and easy-going

approach

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Generalized Anxiety Disorder Characterized by persistent feelings of

anxiety that are not triggered by any specific object, situation or activity

GAD having at least three of the following six symptoms - Restlessness- Being easily fatigued- Difficulty concentrating - Irritability- Muscle tension - Difficulties with sleep

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No specific phobias associated with GAD but it is sustained by basic fears

- Fear of losing control- Fear of not being able to cope- Fear of failure- Fear of rejection- Fear of death and disease

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Phobic Disorders

The word phobia derives from the Greek phobos meaning fear

Phobic disorders are irrational fears of objects or situations

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Specific Phobias Persistent and excessive fears of specific

objects or situations

The DSM-IV groups specific phobias within 5 subtypes

- Animal Type- Natural Environment Type - Blood Injection Injury Type- Situational Type - Other Type

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Social Phobia

Fear of embarrassment or humiliation in situations where you are exposed to the scrutiny of others

Typically your concern is that you will say or do something that will cause others to judge you as being anxious, weak, crazy or stupid

The most common - Fear of Public Speaking

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Agoraphobia The word agoraphobia means fear of open

spaces / market places

Afraid of being in situations from which escape might be difficult or unavailable

Fear of embarrassment plays a key role

The most common feature of agoraphobia is anxiety about being far away from home or far from a “safe person”

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Agoraphobia appears to be engendered by panic disorder

Different level of agoraphobia

- mild case- moderate case- severe case

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Obsessive Compulsive Disorder

Obsessions are recurring ideas, thoughts, images or impulses

Compulsions are repetitive behaviors or behaviors or rituals that you perform to dispel the anxiety brought up by obsessions

Obsessions may occur by themselves without necessarily being accompanied by compulsions

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The most common compulsions include washing, checking and counting

Obsessive compulsive disorder is often accompanied by depression

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Post Traumatic Stress Disorder

The essential feature of post traumatic stress disorder is the development of disabling psychological symptoms following a traumatic event

The traumatic event involves either actual or threatened death or serious physical injury or threat to one’s own or another’s physical safety

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Symptoms of PTSD

Repetitive, distressing thoughts about the event Nightmares related to the event Flashbacks so intense that you feel or act as though the trauma

were occurring all over again An attempt to avoid thoughts or feelings associated with the

trauma An attempt to avoid activities or external situations associated

with the trauma Emotional numbness Feeling of detachment or estrangement from others Losing interest in activities that used to give you pleasure Persistent symptoms of increased anxiety, such as difficulty

falling or staying asleep, difficulty concentrating

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To receive a diagnosis of PTSD, these symptoms need to have persisted at least 1 month

Less than 1 month’s duration, the appropriate diagnosis is “acute stress disorder”

In addition, the disturbance must be causing you significant distress, interfering with social, vocational or other important areas of your life

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Theoretical Perspectives Psychodynamic perspective

- anxiety disorders are viewed as neurosis- the anxiety experienced in neurosis reflects;

1 – the efforts of unacceptable, repressed impulses to break into consciousness

2 – fear as what might happen if they do

Stress on the roles of defense mechanisms

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Phobias develop through the use of defense mechanism of projection and displacement

A phobic reaction is believed to represent the projection of the person’s own threatening impulses onto the phobic object.

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Learning Perspectives

Anxiety disorders are acquired through conditioning

Phobia - Classical conditioning- Operant conditioning - Observational learning – modeling

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Generalized anxiety- a product of stimulus generalization

Obsessive compulsive disorder- compulsive behavior are operant responses that are negatively reinforced by relief of the anxiety that is engendered by obsessional thoughts

PTSD - classical conditioning 28

Cognitive PerspectivesOverprediction of fear Irrational beliefsOversensitivity to threatsAnxiety sensitivityMisattribution for panic sensationLow self-efficacy expentancies

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Biological Perspectives

Genetic Factors

Neurotransmitter - Gammaaminobutyric acid (GABA)

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TREATMENT FOR ANXIETY DISORDERS

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The specific treatment approach depends on the type of anxiety disorder and its severity. But in general, most anxiety disorders are treated with cognitive-behavioral therapy, medication, or some combination of the two.

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SYSTEMATIC DESENSITIZATION

Systematic desensitization is a technique which is used to help people manage and eventually conquer phobias

An individual learn to handle progressively more disturbing stimuli while they remain relaxed

About 10 – 20 stimuli are arranged in a hierarchy (fear stimulus hierarchy)

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Assumption (Joseph Wolpe, 1958) – maladaptive anxiety responses, like other behaviors are learned or conditioned. They can be unlearned by conterconditioning.

Advantages of systematic desensitization are:- enhance self-efficacy expectancies- lower catecholamine levels- help people overcome phobias through a stepwise approach of actual exposure to the phobic stimuli

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The procedures of systematic desensitization

1. Begins with the collection of a history of the patient’s problem

2. The problem is explained to the patient3. Explain the rationale of systematic

desensitization4. Train the patient with relaxation

techniques5. Establish an anxiety hierarchy6. Imagery desensitization

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Phobia About Driving on Freeways

1. Watching from a distance as cars drive past on the freeway

2. Riding in a car on the freeway with someone else driving 3. Driving on a freeway the distance of one exit with a

friend sitting next to you at a time when there is a little traffic

4. Driving the distance of one exit with a friend when the freeway is busier

5. Repeat step 3 alone6. Repeat step 4 alone

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7. Driving the distance of two exits with a friend sitting next to you at a time when there is little traffic

8. Driving the distance of two exits with a friend sitting next to you at a time when there is moderate traffic

9. Repeat step 7 alone10. Repeat step 8 alone

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Phobia about giving presentation

1. Preparing a talk which you don’t give2. Preparing a talk and delivering it in front of one friend3. Preparing a talk and delivering it in front of three friend4. Giving a brief presentation to three or four people at work who

you know well5. Same as Step 4 but a longer presentation6. Giving a brief presentation to 10 -15 people 7. Same as Step 6 but a longer presentation8. Giving a brief presentation to 3 or 4 strangers9. Same as step 8 but a longer presentation10. Giving a brief presentation to 10 – 15 strangers 11. Giving a brief presentation to 50 strangers

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Cognitive Techniques

Rational restructuring Much maladaptive behavior is determined by the assumptions people make about the world

In this rational restructuring, argument or discussion may be used in an attempt to get patients to see the irrationality of their belief

The therapist may attempt to teach them to modify their internal sentences

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Rational Emotive Therapy (RET) Ellis (1962)

RET aims to change behavior by altering the way the patient thinks about things

ABC – Beliefs (B) about activating events or situations (A) that determine the problematic emotional or behavioral consequences (C)

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Behavioral Treatment of Social PhobiaFlooding Method (exposure therapy)

Behavioral Treatment of AgoraphobiaExposure Therapy - gradual exposure to fear-inducing stimuli

Behavioral Treatment to PTSDExposure Therapy

Behavioral Treatment for OCDExposure with response prevention

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Complementary treatments for anxiety disorders Exercise – Exercise is a natural stress buster and anxiety reliever.

Research shows that as little as 30 minutes of exercise three to five times a week can provide significant anxiety relief. To achieve the maximum benefit, aim for at least an hour of aerobic exercise on most days.

Relaxation techniques – When practiced regularly, relaxation techniques such as mindfulness meditation, progressive muscle relaxation, controlled breathing, and visualization can reduce anxiety and increase feelings of relaxation and emotional well-being.

Biofeedback – Using sensors that measure specific physiological functions—such as heart rate, breathing, and muscle tension—biofeedback teaches you to recognize the body’s anxiety response and learn how to control them using relaxation techniques.

Hypnosis – Hypnosis is sometimes used in combination with cognitive-behavioral therapy for anxiety. While you’re in a state of deep relaxation, the hypnotherapist uses different therapeutic techniques to help you face your fears and look at them in new ways.

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