Lecture 5 - Anxiety Disorders Flashcards
anxiety
a general feeling of apprehension about possible future danger
fear
an alarm reaction that occurs in response to immediate danger
Anxiety vs. Fear
distinction is whether a clear and obvious source of danger is present that would be regarded as real by most people
- fear - source is obvious
- anxiety - cannot specify clearly what the danger is
Fear vs. Panic
in both Fear and Panic, the individual may experience sympathetic arousal, but in Panic there is often a cognitive component of fears of dying, going crazy or losing control
- these cognitive components do not usually accompany fear state
components of fear
cognitive: “I am in danger”
physiological: activation of fight/flight - increased heart rate, sweating
behavioral: desire to escape or run
components of anxiety
cognitive: “I am worried about what might happen”
- negative mood, worry
about possible future threat or danger, self-preoccupation, and a sense of being unable to predict the future threat or to control it if it occur
physiological: tension, chronic overarousal
- creates a sense of tension and chronic over-arousal
- no flight/flight, but primed for the response should danger occur
behavioral: general avoidance
- may lead to avoidance, but no immediate behavioral urge to flee as in fear
anxiety treatment interventions
involve changes in all components (cognitive, physiological, behavioral)
adaptive value of anxiety
helps us to plan and prepare for possible threat
- in mild to moderate degrees it can enhance learning and performance, it is adaptive
- if chronic and severe, anxiety is maladaptive
characteristics of anxiety disorders
- unrealistic, irrational fears or anxieties
- cause significant distress and/or impairments in functioning, disabling intensity
similarities in anxiety disorders
there are similarities in basic causes (biological and psychological) and effective treatments
common biological causes of anxiety disorders
- Genetics: personality trait of Neuroticism (disposition for negative mood states)
- Brain structures: Limbic System, Cortex
- Neurotransmitters: GABA , NE, 5HT
common psychological causes of anxiety disorders
- Classical conditioning
- Perceived lack of control over environment
- Distorted cognitions
common effective treatments of anxiety disorders
- Graduated exposure
- Cognitive restructuring
- Medications
anxiety disorders differ in terms of:
- preponderance of fear/panic versus anxiety symptoms that they experience
- kinds of object or situations
DSM-IV-TR recognized ___ primary types of anxiety disorders
7
- Specific phobia
- Social Anxiety Disorder (Social phobia)
- Panic disorder w/ or w/o agoraphobia
- Generalized anxiety disorder
- Obsessive-compulsive disorder
- Acute stress disorder
- Post-traumatic stress disorder
DSM-5 anxiety disorders
5 instead of 7
OCD removed, (DSM-5 listed in Obsessive Compulsive and Related Disorders)
Acute Stress and PTSD removed (DSM-5 listed in Trauma and Stressor Related Disorders)
- Specific Phobia
- Social Anxiety Disorder (Social Phobia)
- Panic Disorder
- Agoraphobia
- Generalized Anxiety Disorder
phobia
persistent and disproportionate fear of a specific object or situation that presents little or no actual danger; leads to avoidance of these feared situations
- most common anxiety disorder
- three categories: specific phobia, social phobia (social anxiety), agoraphobia
specific phobia
- a strong and persistent fear that is recognized as excessive or unreasonable and is triggered by a specific object or situation
- anxiety is experienced when in contact with the object or when imagining encountering the object or situation
- avoidance is a cardial characteristic
DSM-5 subtypes of specific phobia
- Animal: snakes, spiders, rats, dogs
- Natural environment: storms, heights, water, the forest
- Blood-injection-injury: seeing blood or injury, receiving an injection
- Situational: public transportation, tunnels, bridges, driving
- Other: choking, vomiting
phobic response
if an individual approaches the feared object,
- fear, anxiety, apprehension, distress and sympathetic activation result
- the behavior is then reinforced every time the person avoids the situation, anxiety decreases
Blood-Injection Injury Phobia
- Primary emotions are disgust and fear
- Rather than sympathetic activation, people show an initial acceleration followed by a dramatic drop in heart rate and blood pressure
- Nausea, dizziness and fainting unique to this specific phobia
- From an evolutionary perspective, fainting may promote survival when attacked
Psychological Causal Factors of specific phobias
psychoanalytic viewpoint (from Freud: a defense against anxiety stemming from repressed Id impulses; displacement on an external object, but this is too speculative) vs. phobias as learned behavior
phobias as learned behavior
- Wolpe and Rachman (1960): Classical conditioning
- Vicarious conditioning
- Individual differences in learning (risk and protective factors)
- Evolutionary preparedness
biological causal factors of specific phobias
- genetics (variants of genes)
- temperament (behaviorally inhibited temperament is linked to higher vulnerability to phobias): excessively timid, shy, easily distressed
treatment of specific phobias
exposure therapy is the treatment of choice for specific phobias
- participant modeling
- virtual reality
- exposure combined w/ medication and cognitive approaches may be more beneficial than either along
social phobia (social anxiety disorder)
disabling fears of one or more specific social situations; person fears that they may be exposed to the scrutiny and potential negative evaluation of others and to humiliation or embarrassment
- fear of public speaking is most common
two DSM-5 subtypes of social phobia
- performance, specific (public speaking)
- non-performance situations, more general (eating in public) (often comorbid w/ Avoidant Personality Disorder)
psychological causal factors of social phobia
- learned behavior: classical conditioning that is direct or vicarious in nature
- evolutionary factors: predisposition based on social (dominance) hierarchies; fear of predators
- perceptions of uncontrollability and unpredictability: lead to submissive and unassertive behavior; expectations of lack of personal control related to overprotective parenting
- cognitive biases of individuals w/ social anxiety disorder: Beck (1985) -
Expectations of rejection; Danger Schemas - lead
them to expect that
they will behave in an
awkward an unacceptable fashion, resulting in rejection and loss of status; negatively biased
interpretations of
ambiguous stimuli
biological causal factors of social phobia
genetics, temperament (behavioral inhibition)
treatment of social phobia
- cognitive therapy: cognitive restructuring to change distorted automatic thoughts
- behavior therapy: exposure to social situations that evoke fear
- medications: antidepressants (MAOIs, SSRIs); relapse rate w/ medication is higher than w/ therapy, particularly CBT approach
agoraphobia
anxiety about being in places from which escape might be difficult or embarrassing combined w/ fear of a panic attack or getting sick in the following situations:
- crowds
- theaters
- malls
- cars, buses, trains, planes
- standing in line
- elevators
- other similar situations
panic disorder
characterized by the occurrence of panic attacks that often seem to come “out of the blue”
- recurrent, unexpected attacks and worry about additional attacks
- 13 possible symptoms of panic attacks, 10 of which
are physical and 3 of which are cognitive - attacks are brief but intense
- at least one of the attacks has been followed by 1 month (or more) of one or both of the following: Persistent Concern or worry about additional panic attacks or their consequences, and a significant maladaptive change in behavior related to the attacks (e.g. avoidance)
symptoms of panic attacks
an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time 4 (or more) of the following symptom:
- Palpitations, pounding heart or accelerated heart rate
- Sweating
- Trembling or shaking
- Sensations of shortness of breath or smothering
- Feelings of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, light-headed, or faint
- Chills or heat sensations
- Numbness or tingling sensations
- Derealization (feeling of unreality) or depersonalization (being detached from oneself)
- Fear of losing control or going crazy
- Fear of dying
comorbidity and panic disorder
83% of people w/ panic disorder have at least one comorbid disorder (most commonly-GAD, Social Phobia, Specific Phobia, PTSD, Depression and Substance Use Disorder)
- 50-70% will experience depression at some point in their lives
- may also meet criteria for Dependent or Avoidant Personality Disorder
- increased risk for suicidal ideation and attempts
timing of first panic attack
attack may appear to be “out of the blue,” first attack frequently occurs when distressed or following a stressful event
not all people who have a panic attack will develop panic disorder
- panic attacks are more frequent than panic disorder
- anxiety attacks are not the equivalent of a panic attack
biological causal factors of panic disorder
panic disorder has a moderate heritable component
- several areas of the brain implicated in panic attacks: amygdala, hippocampus (develop conditioned anxiety about having another panic attack), higher cortical centers (overreactions to dangers)
neurotransmitter systems most implicated in panic attacks
norepinephrine, serotonin, GABA
- medications: selective serotonin reuptake inhibitors (SSRIs), anxiolytics
behavioral and cognitive causal factors of panic disorder
- Cognitive Theory of Panic
- Comprehensive learning theory of panic disorder
- Anxiety sensitivity and perceived control
- Safety behaviors and the persistence of panic
- Cognitive biases and the maintenance of panic
Cognitive Theory of Panic
People w/ panic disorder are hypersensitive to their bodily sensations and interpret them negatively
Anxiety sensitivity and perceived control
- Anxiety Sensitivity: a trait-like belief certain bodily sensations may have harmful consequences
- having a sense of perceived control reduces anxiety
- accompaniment by a “safe” person when undergoing a panic provocation procedure shows less distress
Safety behaviors and the persistence of panic - Why maintained if the experience of the panic attack doesn’t lead to a catastrophe?
- Breathing and Medication believed to be the reason that the catastrophe didn’t occur
- Dropping safety behaviors may be best for treatment
Cognitive biases and the maintenance of panic
- interpret ambiguous bodily sensations and situations as threatening
cognitive theory of panic: the panic circle
- panic cycle starts w/ a trigger stimulus (internal or external); triggers either perceived threat or body sensations
perceived threat –> apprehension or worry (e.g. about having panic attack or about any distressing situation) –> body sensations –> interpretation of sensations as catastrophic –> cycle begins again …
comprehensive learning theory of panic disorder
- initial panic attacks become associated w/ initially neutral internal (interoceptive) and external (exteroceptive) cues through a conditioning process
- anxiety becomes conditioned to these CSs, and the more intense the panic attack, the more robust the conditioning that will occur
- panic attacks themselves are likely to be conditioned to certain internal and external cues
- explains anticipatory anxiety, agoraphobic fears, panic attacks
treatments of panic disorder
- exposure therapy
- interoceptive exposure targeting panic attacks: deliberate exposure to feared internal sensations., stay w/ the sensation until it subsides, habituation
- cognitive restructuring: Panic Control Treatment (PCT) targets agoraphobic, avoidance and panic attacks (education, breathing, automatic thought challenge, exposure)
- medications: anxiolytics (Xanax, Klonopin) are GABA agonists, however they cause drowsiness and potential dependence/withdrawal effects; antidepressants (Paxil, Zoloft) are tricyclics, SSRIs, and SNRIs, but while combined treatment may have an initial benefit, there is a high likelihood of relapse when medication is stopped
generalized anxiety disorder (GAD)
anxiety or worry about many different aspects of life (including minor events); it is chronic, excessive and disproportionate
- must occur more days than not for a 6-month period, and must be experienced as difficult to control
- anxiety or worry is associated with 3 or more of the following six symptoms: restlessness, easily fatigued, difficulty concentrating
or mind going blank, irritability, muscle tension, sleep disturbance - the worry must be about a number of different events or activities
- content cannot be exclusively related to the worry associated w/ another concurrent disorder, such as the possibility of having a panic attack (this is panic disorder)
individual characteristics of GAD
- individuals live in future-oriented mood state of anxious apprehension, chronic tension, worry, and diffuse uneasiness
- vigilance for signs of threat
- engagement in subtle avoidance activities (procrastination, checking, excessive calling)
- anxious apprehension is the hallmark
- constant worry results in discouragement
- difficulty making decisions
- rarely experience the present moment
psychological causal factors of GAD
- psychoanalytic viewpoint
- perceptions of uncontrollability, unpredictability and uncertainty
- a sense of mastery
- worry
- cognitive biases for threatening information
psychoanalytic viewpoint of GAD
Conflict between id and ego, deficient defense mechanisms
- Freud: primarily sexual and aggressive impulses that are blocked or punished
a sense of mastery (GAD)
patient has a history of control over their environment
worry (Borkovec et al) (GAD)
- benefits noted by individuals w/ GAD: superstitious avoidance of catastrophe, avoidance of deeper issues, coping and preparation
- negative consequences: worry can lead to a greater sense of danger, increased intrusive thoughts
cognitive biases for threatening information (GAD)
vigilance to threatening cues
biological causal factors of GAD
- it is modestly heritable
- the neurotransmitters GABA, serotonin, and perhaps norepinephrine all play a role in anxiety
- neuroendocrine systems may play a role
treatments for GAD
considered one of the most difficult anxiety disorders to treat b/c have multiple stressors (anxious about everything)
- medications: anxiolytics, antidepressants
- cognitive-behavioral therapy (CBT): muscle relaxation and cognitive processing
“normal” anxiety treatment
cognitive, physiological, behavioral
