Anxiety Disorders Flashcards
Mood and Anxiety Disorders:
Similarities
Mood and anxiety disorders are not fully separate categories. Both (1) center on disruptions of emergency or negative emotional states that under normal circumstances serve important adaptive functions, (2) share physiological and neurobiological features, (3) frequently co-occur in clinical cases, and (4) often respond to similar somatic treatments.
Anxiety: Definition
The apprehensive anticipation of danger or misfortune accompanied by a feeing of dysphoria and/or somatic symptoms of tension. The focus of the anticipated danger may be internal or external
Three components to Anxiety
(1) Subjective: reports of tension, apprehension, sense of impending danger and expectations of inability to cope
(2) Behavioral: responses of avoidance of situation at hand, impaired speech and motor functioning, and impaired performance on complex tasks
(3) Physiological: increased muscle tension, increased heart rate, blood pressure, rapid breathing, nausea, diarrhea, and frequent urination
“What Ifs”
“What Ifs” are posed through hypothetical-deductive reasoning and come with a cost.
Future What Ifs: dread, trepidation, apprehension
Past: guilt, self condemnation, feelings of failure and loss
Under conditions of uncontrollable/unpredictable stress, Anxiety:
(1) Anxiety is the first response to a stressful situation and (2) is replaced by depression if it is concluded by a clinician that the situation is uncontrollable.
Emotions and Moods
Emotions/moods are (1) primitive classification tools that have evolved because they have proven useful for survival. (2) Neither emotional responses nor emotional emotional expression are under voluntary control, and (3) are tired together fairly rigidly with their stimulus triggers. (4) They correspond to Freud’s ID.
Emotional Classification System
Our higher cognitive functions are integrated with, and built upon, our primitive emotional classification system. It is therefore possible for us to have strong emotional responses to REPRESENTATIONS of The Distant Past and the Imagined Future (hypotheses).
These cognitive functions permit us to transcend the present and free ourselves from being controlled solely by cues in the immediate environment. This provides greater flexibility in behavior and a sense of self-determination and choice (or perhaps the illusion of choice)
We can ANTICIPATE, IMAGINE, and REMEMBER environments that make us feel bad or good, and THEORIZE about why we feel the way we do.
Role of Schemata
Due to the emotional classification system, we can ANTICIPATE, IMAGINE, and REMEMBER environments that make us feel bad or good, and THEORIZE about why we feel the way we do.
Schemata are internal causal models of the world, which human beings use to try to maximize pleasure and minimize un-pleasure by: (1) selective environments (i.e., that better fit existing skills), (2) shaping environments (i.e., to better fit with existing skills), and (3) changing themselves (i.e., learning new skills)
(This is one definition of intelligence, i.e., self government)
Feedback: Key Points
(1) Feedback systems are the backbone of successful adaptation
(2) All biological and psychological systems rely on feedback for effective self regulation and stability
(3) Almost all forms of psychopathology involved compromised feedback operations of some sort (i.e., faulty error detection and/or error correction)
Neurosis
Until recently, the categories of Anxiety Disorder, Somatoform Disorder and Dissociative Disorder were lumped into this single diagnostic category: Neurosis
The term Neurosis was coined in the 19th century by William Cullen, who viewed neurosis as a biologic disorder. This was replaced in the 20th century by Freud’s Psychogenic view, which viewed Anxiety as a danger signal that repressed memories threatened to break into consciousness
Anxiety Disorders:
DSM IV to DSM 5 Changes
(1) Many of the disorders that were previously listed in the Anxiety Disorders chapter in DSM IV have been moved to separate chapters titled Obsessive-Compulsive and Related Disorders and Trauma and Stressor Related Disorders
Agoraphobia
Agoraphobia is now a separate, codable diagnosis rather than a dx that occurs solely within the context of Panic Disorder (i.e., Panic Disorder with Agoraphobia)
Basics of Anxiety Disorders in DSM IV
(a) Panic Attacks:
(1) unexpected (uncued), (2) situationally bound (cued), and (3) situationally predisposed
(b) Agoraphobia
Panic Attacks in DSM IV
Sudden onset of a discrete period of intense apprehension, fearfulness, or terror and sometimes a sense of potential doom
Criteria: 4 or more appear abruptly within 10 mins: palpitations, sweating, trembling, shortness of breath, choking, chest pain, nausea, dizziness, derealization, depersonalization, fear of going crazy, fear of dying, parathesias, chills or hot flashes
“Situationally predisposed panic attacks” are no longer included in DSM 5. There are now only (1) unexpected panic (uncured) attacks and (2) situationally bound (cued) panic attacks
Agoraphobia
Anxiety about, or avoidance of, places or situations: (1) from which escape might be difficult (or embarrassing) in the event of a panic attack or panic-like symptoms, or (2) in which help might not be available in the event of a panic attack or panic-like symptoms.
Endorsement of fears from two or more agoraphobia situations required in order to distinguish from Specific Phobia.
No requirement that the individual recognize that the fear is unreasonable- fear just as to be out of proportion
Duration of at least 6 months
Agoraphobia is now a separate, codable diagnosis rather than a dx that occurs solely within the context of Panic Disorder (i.e., in DSM IV there is Panic Disorder with Agoraphobia or Agoraphobia Without History of Panic Disorder)
Panic Attacks in DSM 5
There are only two types: expected and unexpected.
Panic attacks can now be listed as a specifier for ALL DSM disorders. Rationale: marker and prognostic factor for severity of diagnosis, course, and comorbidity across an array of disorders.
Panic Disorder in DSM IV
Characterized by recurrent UNEXPECTED panic attacks, and (for at least 1 month), either: persistent concern about future attacks; worry about the implications/consequences of the attacks; or changes in behavior related to the attacks
Panic Disorder without Agoraphobia
Panic Disorder with Agoraphobia
Agoraphobia without history of Panic Disorder
Panic Disorder in DSM 5
Panic Disorder is now a separate diagnosis from Agoraphobia, which means individuals may be diagnosed with both.
Being diagnosed with both is more disabling that Panic Disorder alone or Agoraphobia w/o Panic Disorder
Panic Disorder: Facts
(1) Expression of panic disorder can be influenced by culture (e.g., involves intense fear of witchcraft)
(2) Prevalence = Panic Attcks 5%; Panic Disorder 2%
(3) PD with Agoraphobia is 3x women to men; PD w/o Agoraphobia is 2x women to men
(4) Panic Attacks can be induced by caffeine, CO2 or lactate infusion
(5) PD is often associated with Hypothyroidism, Hypoglycemia, and Mitral Valve prolapse
(6) Genetic component: first degree relatives are at a 4 to 7x greater risk
TXs:
(1) Antidepressants (TCAs, MAOs, SSRIs), sedatives (benzos)
(2) Cognitive Behavioral tx (reframing) (equal to somatic txs)
(3) Behavioral: in vivo exposure tx and relaxation training
Panic Disorder: Key Findings
(1) Patients with Panic Disorder have a high rate of history of sexual and/or physical abuse
(2) Panic symptoms during remission are indicative of an increased risk of relapse, but the absence of panic symptoms during remission is but predictive of even near term stability
Specific Phobia: Criteria in DSM IV/5
Clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidance behavior. The anxiety is out of proportion to the actual risk taking contextual and cultural factors into account.
Stimulus exposure almost always provokes anxiety response.
May take the form of Situationally Bound panic attacks
The fear is recognized as being unreasonable in DSM IV, which was eliminated from DSM 5 criteria. Rationale: phobics often overestimate the level of danger and elderly individuals often misattribute fears to aging
At least 6 month duration
Often interferes with functioning
Specific Phobia Subtypes
Subtypes are now listed as Specifiers in the DSM 5
(1) Animal type: usually onset in childhood. 70-90% female
(2) Blood injection-Injury type: cued by blood, injury, or invasive medical procedure. vasovagal response. 55-70% female
(3) Situational type: cued by a specific non-natural environment situation, such as the subway and elevators (Note: later age of onset and more unexpected panic attacks than other subtypes)
(4) Other
Specific Phobias: Facts
Content of phobias vary by culture
Common in general population but only about 9% come to clinical attention, although it is more common in community samples
Often triggered by (1) traumatic events, (2) observation of responses of others in a traumatic situation (modeling), (3) social transmission of information (e.g., parental warning), or (4) panic attacks in the feared situation (classical conditioning)
Feared objects tend to be objects or events that have a real threat (e.g., snakes) or could have had a real threat at some point in human evolution (e.g., storms)
Phobias that persist into adulthood tend to remind only infrequently (about 20%)
Evidence of genetic transmission. Aggregation within families by type of phobia
Specific Phobia:
Etiology/Causal Explanations
(1) Genetic component probable: aggregate in families by type of phobia (especially blood-injection-injury type)
(2) Psychoanalytic: Little Hans. Instinctual drive causing conflict > signal > anxiety to ego > use of repression as the primary defense > use of displacement or symbolization as secondary defenses > development of phobia
(3) Behavioral: classical conditioning associates formerly inert stimulus with an innate fear response; avoidance responses become reinforced through operant conditioning (negative reinforcement; case ex: Little Albert)
Specific Phobia: Treatment
(1) Psychosocial tx (i.e., Behavioral, Cog Behavioral): in vivo exposure, relaxation training, self-talk, self-hypnosis
(2) Biological: benzos are helpful adjunct to behavioral/cognitive tx but not necessary and not effective if used alone
Social Phobia
Clinically significant anxiety provoked by exposure to certain types of social or performance situations, often leading to avoidance behavior
Involves fear of one or more social or performance situations in which there is exposure to unfamiliar people or to possible scrutiny of others
Fear that he/she will act in a way that is embarrassing or humiliating
No requirement that the fears be recognized as being unreasonable, however, anxiety must be out of proportion to the actual threat
Duration of at least 6 months
*Social phobics are less likely to recognize happy faces compared to non-social phobics (note: all individuals, including phobics, have a bias toward happy faces vs. sad or angry faces, but social phobics have less of a bias)
Social Phobia: Facts
Prevalence = as much as 13% but only about 2% seen clinically
Usually emerges out of a shy childhood
Expression may vary by culture (ex: TAIJIN KYOFUSHO in Japan)
The important differential diagnosis is with Avoidant Personality Disorder and to a lesser extent, Agoraphobia
Negative Evaluation Focus in Social Phobia is moderately heritable
Social Phobia:
Etiology/Causal Explanation and Treatment
Etiology: (1) Genetic predisposition: occurs more frequently among 1st degree relatives
Treatment: (1) Biological: responds well to beta blockers such as propranolol; (2) Behavioral/Cog Behavioral: in vivo exposure with relaxation training, self-hypnosis, self-talk
Generalize Anxiety Disorder
Characterized by at least six months of persistent and excessive anxiety and worry (apprehensive expectation)
Anxiety associated with 3 or more symptoms: restlessness, rapid fatigue, difficulty concentration (mind going blank), muscle tension, sleep disturbance
Generalized Anxiety Disorder: Facts
Prevalence = 5%
More common in women than men
Some evidence of a genetic link with Major Depression (may exist on a continuum with MDD)
Tends to co-occur with Mood Disorders, other Anxiety Disorders, and Substance Related Disorders
Some Cultures express anxiety in somatic symptoms
Additional Comments on Etiology/Causal Explanations
For Mood and Anxiety Disorders
Anxiety and Aging:
The Locus Ceoruleus, a portion of the Medulla Oblongata, is responsible for much of the norepinephrine production in the nervous system. Medulla Oblongata is involved in the control of critical functions such as breathing and heart rate.
The LC acts as a sort of alarm system by producing increased amounts of NE in the face of real and imagined threats. High activity levels of LC is associated with Panic Attacks; Low activity of LC activity is associated with reckless behavior. As we age, many of the LC cells die off, thus reducing its level of activity.
This may explain why there is a decline in certain anxiety disorders, bulimia, and even drug addiction in middle age
