EXAM 1 - ch4 - Anxiety Disorders Flashcards
Anxiety Disorders
Generalized Anxiety Disorder
Panic Disorder and Agoraphobia
Specific Phobias
Social Anxiety Disorder
Anxiety Disorders typicalities
High Incidence Rate: 17% of U.S. Adults
High Comorbidity, particularly with the mood disorders (depression)
Fear
Immediate, present-oriented
Sympathetic nervous system activation
(e.g., jump out of the way if you see a snake)
Anxiety
Apprehensive, future-oriented
Somatic symptoms: muscle tension, restlessness, elevated heart rate
(e.g. worrying you might see a snake on a future hike)
Panic attack –abrupt experience of intense fear
Physical symptoms: heart palpitations, chest pain, dizziness, sweating, chills or heat sensations, etc.
Cognitive symptoms: Fear of losing control, having a heart attack, dying, or going crazy
Two types
Expected
Unexpected
Panic attack –abrupt experience of intense fear
Panic attacks come on suddenly, they typically reach a peak within 10 minutes, and they are accompanied by uncomfortable physical sensations and catastrophic thoughts.
People may also experience “limited symptom episodes”, or panic attacks that have only a few symptoms (less than 4 total).
Panic attacks are very common. Most people have at least one panic attack in their lives. People with severe anxiety may have multiple panic attacks every day.
Unexpected attacks occur out of the blue – they could come up when you’re just watching TV at home. Expected attacks may be cued by certain situations (e.g., public speaking), especially in places where a person has had an attack in the past (e.g., while driving in the location of a previous panic attack)
Lot of people have anxiety disorder without panic attacks
Physical sensations are present until 12-15 minutes they don’t last very long unless you keep worrying about them
Expected – where you can tell why you had one
Unexpected – whe you don’t know why it happened / for no apparent reason
Biological Contributions to Anxiety
Limbic system
Behavioral Inhibition System (BIS)
Receives danger signals from:
The Brainstem (senses changes in bodily function and communicates danger signals to the cortex)
Then these signals travel to the Septal-hippocampal system
Then we tend to freeze, experience anxiety, and approach a situation with apprehension
Fight/flight (FFS) system (may be triggered, in part by low serotonin)
Panic circuit
Originates in the brain stem
Then travels through midbrain structures, including the amygdala, the ventromedial nucleus of the hypothalamus, and the central gray matter
Triggers an Alarm and escape response
Brain circuits are shaped by the environment too
Example: teenage cigarette smoking – teenage smoking is linked to increased risk for developing anxiety and panic
Interactive relationship with somatic symptoms
Psychological Contributions to Anxiety
Behaviorists
Classical and operant conditioning – symptoms are a result of learned associations
Modeling – anxious behavior
Beliefs about control over environment are shaped by early life experiences
Social Contributions to Anxiety
Biological vulnerabilities triggered by stressful life events Family Interpersonal Occupational Educational
An Integrated Model: Anxiety Disorders
Triple vulnerability
Generalized biological vulnerability Diathesis Generalized psychological vulnerability Beliefs/perceptions Specific psychological vulnerability Learning/modeling
Links with physical disorders
People with GI conditions, migraines, arthritis, allergies and more likely to have anxiety
Suicide
Suicide attempt rates
Similar to major depression
20% of panic patients attempt suicide
The Anxiety Disorders
Types of anxiety disorders Generalized Anxiety Disorder Panic Disorder and Agoraphobia Specific Phobias Social Anxiety Disorder Separation Anxiety Disorder Selective Mutism
Generalized Anxiety Disorder (GAD)
excessive amount of worrying (apprehensive expectation) occurring more than not for at least 6 months about a number of events or activities (such as work or school performance).
the individual finds it difficult to control the worry
the anxiety and the worry are associated with at least three or more of the following six symptoms present for more days than not for the past 6 months. (only one item is required of children.
-restlessness
being easily fatigued
difficulty concentrating or mind going blank
irritability
muscle tension
sleep disturbance
The anxiety or worry or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
the disturbance is not due to the direct physiological effects of a substance or a general medication
the disturbance is not better explained by another mental disorder
GAD-Clinical description
Shift from possible crisis to crisis
Worry about minor, everyday concerns
Job, family, chores, appointments
Accompanied by symptoms such as sleep disturbance and irritability
Leads to behaviors like procrastination, overpreparation
Generalized Anxiety Disorder (GAD) Statistics
3.1% (year)
5.7% (lifetime)
Similar rates worldwide
Insidious onset
Early adulthood
Chronic course
GAD in the elderly
Worry about failing health, loss
Up to 10% prevalence
Use of minor tranquilizers: 17-50%
Sometimes prescribed for medical problems or sleep problems
Increase risk for falls and cognitive impairments
Medications for GAD
Antidepressants
These can be effective and are nonaddictive (ex., zoloft, effexor, prozac) particularly when paired with exposure therapies
Anxiolytics
Benzodiazepines (ex., Valium, Librium, Xanax)
These are very addictive
Psychological Treatments for GAD
Psychological
Similar benefits to medications and better long-term results
Cognitive-behavioral treatments
Exposure to worry process
Confronting anxiety-provoking images
Interoceptive exposure to physical sensations
Active Coping strategies (reduce avoidance)
Acceptance therapies
Meditation/Mindfulness
Panic Disorder and Agoraphobia
They are now two diagnoses in DSM-5 although panic attacks typically precede the development of agoraphobia
Panic Disorder
Unexpected panic attacks
Anxiety, worry, or fear of another attack
Persists for 1 month or more
Agoraphobia
Fear or avoidance of situations/events
Concern about being unable to escape or get help in the event of panic symptoms or other unpleasant physical symptoms (e.g., incontinence, vomiting, falling)
Panic Disorder
Recurrent unexpected panic attack are present
at least one of these attacks have been followed by 1 month or more of one or both of the following:
persistent concern or worry about additional p panic attacks or their consequences
a significant maladaptive change in behavior related to the attacks
signed to avoid having panic attacks such as avoidance of exercise or unfamiliar situations
THE disturbance is not attributable to the physiological effects of a substance
THE disturbance is not better explained by another mental disorder
Diagnostic Criteria for AGOROPHOOBIA
MARKED fear or anxiety about 2 or more of the following five situations: PUBLIC transportation OPEN spaces ENCLOSED places STANDING in line or being in a crowd BEING outside the home alone
THE individual fears or avoids these situations due to thoughts that escape might be difficult or help might not be available in the vent of developing panic-like symptoms or other incapacitating or embarrassing symptoms
THE agoraphobic situations almost always provoke fear or anxiety
THE agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety
THE fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context
THE fear anxiety or avoidance is persistent typically lasting for 6 moths or more
THE fears anxiety or avoidance causes clinically significant distress or impairment in social occupational or other important areas of functioning
IF another medical condition is present the fear anxiety or avoidance is clearly excessive
THE fear anxiety or avoidance is not better explained by the symptoms of another mental disorder, do not involve only social situations and are not related exclusively to obsessions perceived deficits or flaws in physical appearance, reminders of traumatic events or fear separation
Agoraphobia: situational avoidance
shopping malls, buses, trains. subways, wide streets, tunnels, restaurants, theaters, being far from home, , staying home alone, waiting in line, stores, crowds, planes, elevators, escalators
Agoraphobia: Interoceptive Avoidance
activities that increase heart rate
Panic Disorder and Agoraphobia Causes
Generalized biological vulnerability Alarm reaction to stress Cues get associated with situations Conditioning occurs Generalized psychological vulnerability Anxiety about future attacks Hyper-vigilance Increase interoceptive awareness
Agoraphobia Causes-Generalized biological vulnerability
Alarm reaction to stress
Agoraphobia Causes-Cues get associated with situations
Conditioning occurs
Agoraphobia Causes-Generalized psychological vulnerability
Anxiety about future attacks
Hypervigilance
Increase interoceptive awareness
Agoraphobia Causes-Generalized psychological vulnerability
Anxiety about future attacks
Hypervigilance
Increase interoceptive awareness
Agoraphobia Treatment
MEDICATION
Multiple systems affected by medication serotonergic noradrenergic GABA Benzodiazepines (e.g. Ativan) SSRIs (e.g., Prozac, Effexor, and Paxil) SNRIs (e.g. Cymbalta) High relapse rates after discontinuation of medication
Agoraphobia Treatment
PSYCHOLOGICAL
Psychological interventions
Exposure- based
Reality testing (testing patient’s beliefs that they can’t handle some situations and survive them)
Cognitive Therapy (e.g., decatastrophizing)
Relaxation and breathing skills
Example: Panic control treatment (PCT)
Exposure to interoceptive cues (this is very effective)
Cognitive therapy
Relaxation/breathing
High degree of efficacy
Agoraphobia Treatment
Combined psychological and drug treatments
No better than CBT or drugs alone
CBT = better long term remission
Phobias
Irrational Fears
The fears are maintained through negative reinforcement
Avoidance of and reduction of anxiety-provoking stimuli typically perpetuates phobias
Exposure treatments most effectively reduce phobias
Specific Phobias
MARKED fear or anxiety about specific objects or situations (animals,height, recieveing injections)
THE phobic object or situation almost always provokes immediate fear or anxiety: note in children the anxiety may be expressed by crying, tantrums, freezing, or clinging.
THE phobic object or situation is actively avoided or endured with intense fear or anxiety
THE fear anxiety or avoidance causes clinically significant distress or impairment in social, occupational or other important areas of functioning
THE disturbance is not better explained by symptoms of other mental disorders, including fear anxiety and avoidance of situations associated with panic-like symptoms or other incaptivating sympotms ; objects or situations related to obsessions , separation from home or attachement figures, or social situations.
SPECIFIC type:
animals
natural environment
blood-injury-injection
situational
PREVaLENCE OF INTENSE FEAR
snakes heights flying enclosures illness death injury storms dentists being alone
Treatment: Phobias
Cognitive-behavior therapies Exposure Graduated Structured Relaxation – used to be practiced more, now often not a part of empirically supported treatment
Separation Anxiety Disorder
Clinical Description
Characterized by unrealistic and persistent worry that something will happen to self or loved ones when apart (e.g., kidnapping, accident) as well as anxiety about leaving loved ones
4.1% of children meet criteria, 6.6% for adults
Social Anxiety Disorder (Social Phobia)
Clinical description
Extreme/irrational concern about being negatively evaluated by other people
Sometimes (not always) manifests as shyness
Leads to significant impairment and/or distress
Avoidance of feared situations, or endurance with extreme distress
Subtype
Performance only: Anxiety only in performance situations (e.g. public speaking)
DIAGNOSTIC CRITERIA FOR Social Anxiety Disorder
MARKED fear or anxiety about one or more social situations in which the person is exposed to possible scrutiny by others. Examples: include social interactions, having conversations, meeting with new people, performing infront of others,
in children anxiety must occur in peer settings and not just in interactions with adults.
THE individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated
THE social situations almost always provoke fear or anxiety. NOTEL in children fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
THE social situations are avoided or endured with intense fear or anxiety
THE fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
THE fear anxiety or avoidance is persistent typically lasting for 6 or more months
THE fear anxiety or avoidance causes clinically significant distress or impairment in social occupational or other important areas of functioning
THE fear anxiety or avoidance is not better explained by the symptoms of another mental disorder such as panic disorder, or separation anxiety.
IF another medical condition disease obesity Parkinson’s disease is present fear anxiety or avoidance is clearly unrelated or is excessive
Social Anxiety Disorder (Social Phobia)
Statistics
Statistics 12.1% (life); 6.8% (year) Female : Male = 1:1 Onset = usually adolescence Peak age of onset = 13 More common in people who are young (18–29 years), undereducated, single, and of low socioeconomic class, 13.6% prevalence in ages 18-29 6.6% prevalence in ages 60+
Treatment: Social Anxiety Disorder
Medications
Medications
Beta blockers
Benzodiazepines (not typically recommended)
SSRIs (e.g., Paxil, Zoloft, Luvox, and Effexor)
D-cycloserine: an antibiotic that improves extinction learning, which occurs during exposure therapy (it modifies neurotransmitter flow in the glutamate system)
At post-treatment, it doesn’t affect remission rates of the CBT. It mainly might speed up the tx process.
Treatment: Social Anxiety Disorder
Psychological
Psychological Cognitive-Behavioral Therapy Challenging of anxious thoughts about the consequences of social judgment Exposure to anxiety-provoking situations Rehearsal Role-play Highly effective
Selective Mutism (SM)
Clinical description
Rare childhood disorder characterized by a lack of speech in certain situations (e.g. school)
Must occur for more than one month and cannot be limited to the first month of school
High comorbidity with SAD
Treatment
CBT most efficacious, similar to treatment for SAD
Risk Factors for Anxiety Disorders
First degree relatives of individuals with some anxiety disorders have a higher incidence of these disorders than controls (with no dx)
Panic Disorder
Generalized Anxiety Disorder
Social Phobia (the generalized type)
In OCD, there is NOT a higher risk of OCD in first degree relatives, but there is a higher risk of some type of anxiety disorder
General Conclusions about Treatment for Anxiety Disorders
There has to be an exposure component (to the anxiety triggering stimuli) for therapy to be most effective Some Medications can sometimes help the patient engage in CBT more easily May include strategies for calming Mindfulness Acceptance Physical relaxation techniques Traditional Cognitive Therapy Refer to examples in the casebook
