Welcome to Unit 5: Welcome to Unit 5: Anxiety DisordersAnxiety Disorders

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AnxietyAnxiety

What is anxiety?What is anxiety?

AnxietyAnxiety

Anxiety: A state characterized by Anxiety: A state characterized by negative affect, bodily tension, arousal negative affect, bodily tension, arousal and apprehension about the future.and apprehension about the future.

Is anxiety always a bad thing?Is anxiety always a bad thing?

FearFear

Fear: Distress about a specific dangerous Fear: Distress about a specific dangerous object or situation. It is caused by need object or situation. It is caused by need for immediate action and is usually short-for immediate action and is usually short-lived.lived.

Protects us by triggering the “fight or flight” Protects us by triggering the “fight or flight” response.response.

Anxiety DisordersAnxiety Disorders

All anxiety disorders can be thought of as All anxiety disorders can be thought of as extremely exaggerated versions of normal extremely exaggerated versions of normal feelings such as fear, anxiety and panic.feelings such as fear, anxiety and panic.

Case Study: NealCase Study: Neal Neal is a 32 year-old IT specialist. He reports that for Neal is a 32 year-old IT specialist. He reports that for

the past 18 months he constantly feels keyed-up, the past 18 months he constantly feels keyed-up, and unable to relax. He worries about everything, and unable to relax. He worries about everything, from his health, to the economy, to whether he is a from his health, to the economy, to whether he is a good enough husband. He feels emotionally and good enough husband. He feels emotionally and physically exhausted. Even though he is worn out, physically exhausted. Even though he is worn out, he can’t sleep. He often spends hours in bed at he can’t sleep. He often spends hours in bed at night ruminating about possible disasters or things night ruminating about possible disasters or things he might have done to offend people at work. He is he might have done to offend people at work. He is having problems focusing at work, and is afraid he is having problems focusing at work, and is afraid he is going to be fired because of it. going to be fired because of it.

Generalized Anxiety Disorder Generalized Anxiety Disorder (GAD)(GAD)

DSM-IV Criteria:DSM-IV Criteria: Excessive anxiety & worry most days for at least 6 Excessive anxiety & worry most days for at least 6

months, related to numerous areas of life.months, related to numerous areas of life. Difficult to control the worry.Difficult to control the worry. 3 or more symptoms:3 or more symptoms:

• Restlessness/feeling “keyed up”Restlessness/feeling “keyed up”• Easily fatiguedEasily fatigued• Problems concentrating, mind going blankProblems concentrating, mind going blank• Muscle tensionMuscle tension• Sleep problemsSleep problems

Prevalence of GADPrevalence of GAD

Past-year prevalence is about 2%.Past-year prevalence is about 2%. Lifetime prevalence is about 5%.Lifetime prevalence is about 5%. More common in women than men.More common in women than men. Rate is 2x higher in very low income Rate is 2x higher in very low income

groups.groups.

Course of GADCourse of GAD

Gradual onset typically in late teens or Gradual onset typically in late teens or early adulthood.early adulthood.

Tends to be persistent if not treated.Tends to be persistent if not treated.

Etiology of GADEtiology of GAD Mildly heritable.Mildly heritable. May be related to chronic activation of the May be related to chronic activation of the

behavioral inhibition system (BIS).behavioral inhibition system (BIS). The BIS causes us to freeze, feel anxious and The BIS causes us to freeze, feel anxious and

nervously evaluate the environment to find the threat. nervously evaluate the environment to find the threat. ““Kindling Effect”: Groups of neurons that fire Kindling Effect”: Groups of neurons that fire

often have lower activation thresholds, and fire often have lower activation thresholds, and fire more easily in the future. more easily in the future.

Fear leads to fear.Fear leads to fear.

Treatment of GADTreatment of GAD

Cognitive-Behavioral Therapy (CBT):Cognitive-Behavioral Therapy (CBT): Superior to medication, long lasting effects.Superior to medication, long lasting effects. Learn to identify and control anxious thoughts.Learn to identify and control anxious thoughts. Progressive muscle relaxation.Progressive muscle relaxation.

Case Study: AllyCase Study: Ally Ally is a 42 year-old preschool teacher. In the last Ally is a 42 year-old preschool teacher. In the last

year she has been experiencing “spells” that last year she has been experiencing “spells” that last about 10 minutes. She gets short of breath, her about 10 minutes. She gets short of breath, her heart races, she feels dizzy, her fingers and toes heart races, she feels dizzy, her fingers and toes tingle and she experiences fear that she is losing tingle and she experiences fear that she is losing her mind. They “come out of the blue.” She went her mind. They “come out of the blue.” She went to the emergency room during her last spell to the emergency room during her last spell because she thought she was having a heart because she thought she was having a heart attackattack. The doctor said she was healthy, . The doctor said she was healthy, and referred her to see a therapist. and referred her to see a therapist.

Panic AttacksPanic Attacks DSM-IV Criteria:DSM-IV Criteria:

Discrete period of intense fear/discomfort with four or more Discrete period of intense fear/discomfort with four or more symptoms that symptoms that develop quicklydevelop quickly and and peak within ten minutespeak within ten minutes..

• Heart palpitations/racing heartHeart palpitations/racing heart• SweatingSweating• Trembling/shakingTrembling/shaking• Shortness of breath/feeling like chokingShortness of breath/feeling like choking• Chest painChest pain• NauseaNausea• Dizziness, lightheadednessDizziness, lightheadedness• Derealization (feelings of unreality) or depersonalization (being detached from oneself)Derealization (feelings of unreality) or depersonalization (being detached from oneself)• Fear of losing control/going crazyFear of losing control/going crazy• Fear of dyingFear of dying• Numbness/tinglingNumbness/tingling• Chills or hot flushesChills or hot flushes

AgoraphobiaAgoraphobia

Literally “fear of the marketplace.”Literally “fear of the marketplace.” Agoraphobia is fear and avoidance of Agoraphobia is fear and avoidance of

situations where it would be perceived to situations where it would be perceived to be unsafe to have a panic attack.be unsafe to have a panic attack.

Panic DisorderPanic Disorder

DSM-IV Criteria:DSM-IV Criteria: Recurrent unexpected panic attacks.Recurrent unexpected panic attacks. At least 1 attack followed by 1 month of at At least 1 attack followed by 1 month of at

least 1 symptom:least 1 symptom: Persistent concern about having other attacks.Persistent concern about having other attacks. Worry about implications/consequences of Worry about implications/consequences of

attack.attack. Significant change in behavior related to the Significant change in behavior related to the

attacks.attacks.

Prevalence of Panic Disorder Prevalence of Panic Disorder

Lifetime Prevalence is 3.5%Lifetime Prevalence is 3.5% 12-month prevalence is 2.3%12-month prevalence is 2.3% More common in women, especially with More common in women, especially with

agoraphobia.agoraphobia. Men likely to cope with alcohol.Men likely to cope with alcohol. Prevalence similar across U.S. ethnic Prevalence similar across U.S. ethnic

groups.groups.

Course of Panic DisorderCourse of Panic Disorder

Onset in early adulthood, mean age is Onset in early adulthood, mean age is 25-29.25-29.

Panic attacks don’t usually occur before Panic attacks don’t usually occur before puberty.puberty.

Etiology of Panic DisorderEtiology of Panic Disorder

Due to an interaction of psychological and Due to an interaction of psychological and biological factors.biological factors.

Some people are genetically predisposed Some people are genetically predisposed to panic—they have an easily triggered to panic—they have an easily triggered “fight or flight response”.“fight or flight response”.

Seem to be more likely to catastrophically Seem to be more likely to catastrophically interpret bodily sensations.interpret bodily sensations.

Etiology of Panic DisorderEtiology of Panic Disorder

Upon the experience of such panic, Upon the experience of such panic, psychological factors determine whether psychological factors determine whether they expect subsequent attacks.they expect subsequent attacks.

Agoraphobia is socially or culturally Agoraphobia is socially or culturally determined after someone has a panic determined after someone has a panic attack.attack.

Treatment of Panic DisorderTreatment of Panic Disorder

Psychological Treatment:Psychological Treatment: Panic Control TherapyPanic Control Therapy

Highly effective (80-100% panic free after 12 Highly effective (80-100% panic free after 12 weeks!)weeks!)

Purposeful induction of panic.Purposeful induction of panic. Cognitive therapy.Cognitive therapy. Breathing exercises, progressive muscle Breathing exercises, progressive muscle

relaxation.relaxation. Gradual exposure to agoraphobic situations.Gradual exposure to agoraphobic situations.

Case Study: LucyCase Study: Lucy Lucy is a 19 year-old college student. Two months Lucy is a 19 year-old college student. Two months

ago, she was raped by her ex-boyfriend in a car after ago, she was raped by her ex-boyfriend in a car after a football game. Since the rape, she can’t stop a football game. Since the rape, she can’t stop thinking about what happened. She has nightmares thinking about what happened. She has nightmares about it, and sometimes feels as though she is in the about it, and sometimes feels as though she is in the back of the car again. Whenever she sees a car like back of the car again. Whenever she sees a car like the one her ex-boyfriend drives she experiences the one her ex-boyfriend drives she experiences paralyzing fear. She finds that he is having trouble paralyzing fear. She finds that he is having trouble sleeping, and constantly feels on edge, like she sleeping, and constantly feels on edge, like she needs to be scanning the room for men who might needs to be scanning the room for men who might try to harm her. try to harm her.

PTSD CriteriaPTSD Criteria

Exposure to a traumatic event where:Exposure to a traumatic event where: Person saw, experienced or was Person saw, experienced or was

confronted with events that involved actual confronted with events that involved actual or threatened death or serious injury, or a or threatened death or serious injury, or a threat to physical integrity of self or others. threat to physical integrity of self or others. ANDAND

Person felt fear, helplessness or horrorPerson felt fear, helplessness or horror..

PTSD CriteriaPTSD Criteria

The event is repeatedly re-experienced The event is repeatedly re-experienced in 1 or more ways:in 1 or more ways: Intrusive memories, thoughts, imagesIntrusive memories, thoughts, images NightmaresNightmares Re-living the experienceRe-living the experience Intense physical or physiological distress Intense physical or physiological distress

when exposed to cues that remind of when exposed to cues that remind of event.event.

PTSD CriteriaPTSD Criteria

Persistent avoidance of stimuli Persistent avoidance of stimuli associated with the trauma.associated with the trauma.

Numbing of general responsivenessNumbing of general responsiveness Persistent increased arousal (problems Persistent increased arousal (problems

sleeping, irritability/anger, sleeping, irritability/anger, hypervigilance, exaggerated startle hypervigilance, exaggerated startle response, etc.)response, etc.)

All symptoms must last more than 1 All symptoms must last more than 1 month.month.

PTSD PTSD

About 8% of people will experience About 8% of people will experience PTSD.PTSD. Most cases are due to combat or sexual Most cases are due to combat or sexual

assault.assault. PTSD may last from months to a PTSD may last from months to a

lifetime.lifetime.

Etiology of PTSDEtiology of PTSD

Trauma.Trauma. May be a genetic vulnerability to anxiety May be a genetic vulnerability to anxiety

that that risk for PTSD. risk for PTSD. This vulnerability is more important when This vulnerability is more important when

the trauma is less severe.the trauma is less severe.

Treatment of PTSDTreatment of PTSD

Psychotherapy is most effective Psychotherapy is most effective treatment.treatment.

Therapy generally focuses on reliving Therapy generally focuses on reliving and describing traumatic events and and describing traumatic events and experiencing feelings about it.experiencing feelings about it.

Case Study: MikeCase Study: Mike Mike is a 39 year-old landscaper. He often worries Mike is a 39 year-old landscaper. He often worries

about the possibility that his wife and children will be about the possibility that his wife and children will be killed in a car accident. He can’t help thinking horrible killed in a car accident. He can’t help thinking horrible thoughts about it, often imagining how their dead bodies thoughts about it, often imagining how their dead bodies would look. Whenever he has these thoughts, he recites would look. Whenever he has these thoughts, he recites three “Hail Mary” prayers and performs a discreet finger three “Hail Mary” prayers and performs a discreet finger tapping ritual. If he does not say the prayers perfectly or tapping ritual. If he does not say the prayers perfectly or tap his fingers evenly and without error he has to start tap his fingers evenly and without error he has to start over, or else his family may be killed. Sometimes, if the over, or else his family may be killed. Sometimes, if the thoughts are especially bad, he also has to recite all of thoughts are especially bad, he also has to recite all of the prime numbers backward from 100, 100 times. He the prime numbers backward from 100, 100 times. He often spends hours each day doing these rituals.often spends hours each day doing these rituals.

OCD CriteriaOCD Criteria

Characterized by Characterized by obsessionsobsessions or or compulsions compulsions (often both).(often both).

Causes distress, is time-consuming (1 Causes distress, is time-consuming (1 hr/day or more), or interferes with daily hr/day or more), or interferes with daily functioning.functioning.

ObsessionsObsessions Obsessions are nonsensical thoughts, Obsessions are nonsensical thoughts,

images or urges that the person tries to images or urges that the person tries to resists or eliminate.resists or eliminate. ContaminationContamination ImpulsesImpulses Sexual ideasSexual ideas Somatic (bodily) concernsSomatic (bodily) concerns Need for symmetryNeed for symmetry

CompulsionsCompulsions

Compulsions are thoughts or actions used Compulsions are thoughts or actions used to suppress obsessions and provide relief to suppress obsessions and provide relief from them. from them.

Also can be due to rigid internal rules, Also can be due to rigid internal rules, often to prevent a dreaded event.often to prevent a dreaded event. May be behaviors (like hand-washing, May be behaviors (like hand-washing,

checking) or mental (like counting, praying checking) or mental (like counting, praying etc.)etc.)

DemographicsDemographics

Lifetime prevalence about 3%. Lifetime prevalence about 3%. More common in adult women, but in kids More common in adult women, but in kids

more common in boys.more common in boys. Age of onset is adolescence to mid-20’s.Age of onset is adolescence to mid-20’s. Onset is usually gradual but may be Onset is usually gradual but may be

sudden after a trauma (such as rape).sudden after a trauma (such as rape). Typically a chronic disorder.Typically a chronic disorder.

Etiology of OCDEtiology of OCD

Certain people more likely to be anxious.Certain people more likely to be anxious. People with OCD more likely to have People with OCD more likely to have

anxious relatives.anxious relatives. Early experiences teaches certain Early experiences teaches certain

thoughts are dangerous/unacceptable.thoughts are dangerous/unacceptable. Seems to be related to fundamentalist Seems to be related to fundamentalist

religious beliefs.religious beliefs.

Psychosocial Treatment of OCDPsychosocial Treatment of OCD

Exposure and response-preventionExposure and response-prevention Based on the idea of “reality testing.”Based on the idea of “reality testing.”

Questions or comments?Questions or comments?