lesson 7 (ch 6): anxiety disorders Flashcards
anxiety vs fear
anxiety: apprehension about a future threat
fear: a reaction to immediate danger
anxiety involves moderate arousal/ sympathetic nervous system activity, fear involves higher arousal, fight or flight
how can anxiety be helpful?
small amount of anxiety can help us notice/ plan for future threats, but too much can be paralyzing
U-shaped curve with performance- no anxiety is a problem, a little is good, a lot is detrimental
DSM-5 major anxiety disorders (5)
- specific phobias
- social anxiety disorder
- panic disorder
- agoraphobia
- generalized anxiety disorder
how common are anxiety disorders?
- anxiety disorders are the most common psychiatric disorders
- 28% report anxiety symptoms, may be more
- most common are phobias
- 9th leading cause of disability
(?) DSM-5 Criteria for diagnosis for anxiety disorders
(?)
- symptoms interfere w important areas of functioning/ cause marked distress
- symptoms not caused by drug or medical condition
- symptoms persist for at least 6 months, 1 month for panic disorder
- distinct from symptoms of another anxiety disorder
specific phobias
disruptive fear of a particular object or situation
- fear out of proportion to actual threat
- awareness that fear is excessive but still goes through great lengths to avoid
- must be severe enough to cause distress or interfere w job or social life
most common phobias
- acrophobia and claustrophobia
- most specific phobias cluster around a few feared objects/situations
- high comorbidity of specific phobias
social anxiety disorder
- persistent intense fear and avoidance of social situations
- fear of negative evaluation/scrutiny
- exposure to trigger leads to anxiety about being evaluated negatively
- called social phobia in DSM-IV-TR
comorbidity in social anxiety
- 33% of those w/ social anxiety also diagnosed w/ avoidant personality (overlap in genetic vulnerability for both)
- those with broader array of fears are more likely to experience comorbid depression and alcohol abuse
panic disorder
frequent panic attacks unrelated to specific situations
panic attack
sudden attack of intense apprehension, terror, and feelings of impending doom, accompanied by at least 4 other symptoms
- wanting to flea
- possible physical symptoms: shortness of breath, heart palpitations, nausea, upset stomach, chest pains, feeling of choking/smothering, dizziness, lightheaded, faintness, sweating, chills, heat, numbness/tingling, trembling
- can involve depersonalization (feeling outside ones body), derealization (feeling like world isn’t real)
- fears of going crazy/losing control/ dying
- experience sympathetic nervous system arousal as if life threatened
- usually peak intensity around 10 mins
DSM-5 criteria for panic disorder
- recurrent panic attacks
- at least 1 month of worry about more panic attacks, or maladaptive behavioral changes
types of panic attacks
uncued attacks:
- unexpected
- panic disorder diagnosis requires recurrent uncued attacks
- causes worry about future attacks
cued attacks
- triggered by specific situations, more likely a phobia
agoraphobia
- agora = marketplace
- anxiety about inability to flee anxiety-provoking situations, like crowds or crowded places
- causes significant impairment- virtually unable to leave house, or can only do so with great distress
- in DSM-IV-TR was a subtype of panic disorder, but at least half agoraphobics don’t have panic attacks
DSM-5 Criteria of Agoraphobia
- disproportionate fear/anxiety about at least 2 situations where it would be difficult to escape/receive help
- these situations consistently provoke fear or anxiety
- these situations are avoided, require presence of a companion, or are endured w intense fear/anxiety
- symptoms last at least 6 months
Generalized Anxiety Disorder (GAD)
-involves chronic, excessive, uncontrollable worry
- lasts at least 6 months
-interferes w/ daily life (often paralyzed- can’t decide on solution/ course of action)
other symptoms:
- restlessness, poor concentration, tiring easily, restlessness, irritability, muscle tension
common worries:
- relationships, health, finances, daily hassles
often begins in adolescence or earlier “i’ve always been this way”
DSM-5 criteria for GAD (generalized anxiety disorder)
- excessive anxiety and worry at least 50% of days about at least 2 life domains
- worry sustained for at least 6 months
- anxiety and worry associated w at least 3:
- restlessness or feeling on edge
- easily fatigued
- difficulty concentrating/ mind going blank
- irritability
- muscle tension
- sleep disturbance
what do people with GAD avoid or do due to their worry?
- avoid situations where neg. outcomes could occur
- time and effort preparing for situations that may have negative outcome
- marked procrastination
- difficulty making decisions due to worry, or repeatedly seeking assurance
when does GAD (generalized anxiety disorder) onset typically?
adolescence, typically, and is chronic
comorbidity in anxiety disorders
80% anxiety disorder meet criteria for another anxiety disorder
- subthreshold symptoms very common
75% anxiety disorder meet criteria for another psychological disorder
- 60% anxiety also have depression
- substance abuse
- personality disorders
- medical disorders, e.g. coronary heart disease
comorbidity associated w/ greater severity and poorer outcomes
reasons/ causes of comorbidity in GAD
- symptoms used to diagnose anxiety disorders overlap
(ex: social anxiety and agoraphobia both have fear of crowds) - etiological factors may increase risk for more than on anxiety disorder
Prevalence of anxiety disorder
US 12 month prevalence: 18%
lifetime prevalence: 28%
severe: 4% of population, 23% of cases
demographics of lifetime prevalence of anxiety disorders
sex: women 60% more likely
race: non-hispanic white most likely
age: most common in young and middle adulthood
gender differences- anxiety disorder
women twice as likely
why?
- women may be more likely to report symptoms
- men might be encouraged more to face fears
- women more likely to experience childhood sexual abuse
- women show more biological stress reactivity
culutural anxiety disorders
kayak-angst:
inuit (Greenland), similar to panic disorder, lone seal hunters’ fear/ disorientation/concerns of drowning
taijin kyofusho:
japan, fear of displeasing or embarrassing others, overlaps w social anxiety but w/ focus on OTHERS
koro:
south/east asia, fear genitals will recede into body
shenkui:
china, anxiety of loss of semen
susto:
Latin America, fright causes soul to leave body
List of factors that may increase risk for more than one anxiety disorder
- behavioral conditioning
- genetic vulnerability
- increased activity in fear circuit of brain
- decreased func. of GABA and serotonin; increased norepinephrine activity
- behavioral inhibition
- neuroticism
- cognitive factors (including sustained neg beliefs, perceived lac of control, and attention to cues of threat)
Two-factor model of behavioral conditioning (Mowrer’s two-factor model)
- conditioned responses to threat
(classical conditioning- fear neutral stimulus after pairing w averse stimulus) - sustained by avoidance or ‘safety behaviors’
(gains relief by avoiding CS- through operant conditioning, avoidant response is maintained b/c it is reinforcing)
problems w/ Mowrer’s two factor model of behavior conditioning (for anxiety)
2 reasons
- most don’t remember exposure to a threatening event
- many people who experience threats don’t develop anxiety disorders
extension of Mowrer’s two factor model of behavior conditioning (for anxiety)
- classical conditioning can occur in different ways:
- direct experience
- modeling (seeing something happen)
- verbal instruction
- also some people are more vulnerable to anxiety disorders than others
Neutral predictable unpredictable (NPU) threat task
experimental approach for testing responses to unpredictability (anxiety disorders)
- neutral condition
- predictable condition (warning of aversive stimulus)
- unpredictable condition (no warning aversive stimulus
people w/ anxiety disorder fare worse in unpredictable threat conditions
genetic risk factors for anxiety disorder
twin studies suggest heritability estimate of .5 to .6% for anxiety disorders (means that genes may explain 50-60% of risk for anxiety disorders in population
- 20-40% for phobias, and GAD
- 50% for panic disorder
relative w phobia increases risk for other anxiety disorders in addition to phobia
Neurobiolobical risk factors for anxiety
- fear circuit overactivity
- amygdala (sends signals to brain structures involved in fear circuit. elevated activity may be linked to anxiety disorders
- medial prefrontal cortex deficits (helps regulate amygdala activity)
-neurotransmitters
- poor functioning of serotonin and GABA
- higher levels of norepinephrine
Neumonic: brain anxiety park: fear circuit roller coaster, GABA, Prozac sad and an epipen having fun
Risk factors Personality for anxiety disorders
- behavioral inhibition
- neuroticisim
behavioral inhibition
tendency to be agitated, distressed/ cry in unfamiliar/ novel settings
- observed in infants as young as 4 months
- may be inherited
predicts anxiety in childhood and social anxiety in adolescence
Neumonic: beehive acting shy in new environment
Neuroticism
- personality trait- tendency to experience frequent or intense negative affect
- linked to anxiety and depression
- higher levels linked to double the likelihood of developing anxiety disorders
cognitive risk factors for anxiety (4)
- sustained neg beliefs about future
- perceived lack of control
- over-attention to signs of threat
- intolerance of uncertainty
sustained negative beliefs about future
- bad things will happen
- engage in safety behaviors
perceived lack of control
- belief they lack control over environment
- more vulnerable to developing anxiety disorder
- childhood trauma or punitive parenting may foster beliefs
- serious life events can threaten sense of control
attention to threat
- tendency to notice negative environmental cues
- selective attention to signs of threat
- used dot-probe test to test
intolerance of uncertainty
-people who have hard time accepting ambiguity are more likely to develop anxiety disorders
- predicts increases in worry over time
- also a difficulty for those with major depressive disorder and obsessive compulsive disorder
What do psychological treatments of anxiety all emphasize?
EXPOSURE:
face the situation/object that triggers anxiety
- in CBT, client would make a list of triggers, create an “exposure hierarchy,” and gradually face them
- should include as many features of the trigger as possible
- conducted in as many settings as possible
- 70-90% effective
systematic desensitization
- relaxation plus (initially) imaginal exposure
cognitive approaches (added to exposure therapy)
- increase belief in ability to cope w/ the anxiety trigger
- challenge expectations about negative outcomes
behavioral view of exposure
- works by extinguishing fear response
- doesn’t erase underlying fear, rather, newly learned associations inhibit activation of fear
-learning, not forgetting
psychological treatment of social anxiety disorder
Exposure
- starting with role-playing/ practicing w therapist
social skill training
- reduce use of safety behaviors (avoiding eye contact)
Clark’s cognitive therapy for social anxiety:
- stop focusing attention internally
- helps them combat negative images of how others will react them
- more effective than medication or exposure
Neumonic: Clark has social anxiety
psychological treatment of panic disorder (CBT, cognitive, psychodynamic)
CBT for panic disorder also focuses on exposure
- based on tendency of people w diagnosis to overreact to bodily sensations
PANIC CONTROL THERAPY
- exposure therapy to somatic symptoms of panic in safe space (breathing rapidly for 3 mins)
- gives coping tactics for dealing with somatic symptoms
- relaxation, deep breathing
benefits maintained after treatment ends
cognitive treatment:
- therapist helps patient identify and challenge thoughts that make physical sensations threatening
psychodynamic:
- identifying emotions and meanings surrounding panic attacks
psychological treatment of Generalized Anxiety Disorder
behavioral technique: relaxation training (to promote calmness)
CBT- strategies to improve problem solving and to address thought patterns that contribute to GAD:
- Challenge and modify neg thoughts
- strategies to tolerate uncertainty
- worry only during “scheduled” times
- focus on present
Medications that reduce Anxiety
called anxiolytics
- Benzodiazepenes
- Valium
- Xanax
- Antidepressants
- tricyclics
- SSRIS
- SNRIS (serotonin-norepinephrine reuptake inhibitors)
- D-cycloserine (DCS)
- enhances learning during exposure treatment
prepared learning
- evolution may have “prepared” our fear circuit to learn fear of stimuli (that could be life-threatning ) very quickly and automatically
Neumonic: I am prepared to be terrified of that snake
specific phobias: prevalence
12 month prevalence 8.7% of US adults
severe: 21.9% of cases are classified as severe
etiology of specific phobias
- conditioning
- Mowrer’s two-factor model
- pairing of stimulus w aversive UCS leads to fear (classical conditioning)
- avoidance maintained through negative reinforcement (operant conditioning)
extensions of the two-factor model of conditioning
- modeling: seeing another person harmed by stimulus
- verbal instruction: being told something is dangerous
- prepared learning: evolutionary preparation to fear certain stimuli
social anxiety disorder prevalence
12 month prevalence: 6.8%
severe: 29.9% of cases
age: drops off in older adulthood
etiology of social anxiety disorder- cognitive factors
- unrealistic negative beliefs about consequences of behaviors
- excessive attention to internal cues
- fear of neg evaluation by others (expect others to dislike them)
- neg self evaluation (harsh, punitive self-judgement)
GAD- General Anxiety disorder- Prevalence
12 month: 3.1
severe: 32.3%
age: goes up until senior
Etiology of GAD (Generalized anxiety disorder)
- GABA system deficits
Borkovec’s cognitive model:
- worry reinforcing b/c distracts from neg emotions and images
- allows avoidance of more disturbing emotions (previous trauma)
- worrying decreases Psychophysiological arousal
- avoidance prevents extinction of underlying anxiety
textbook calls it CONTRAST AVOIDANCE model
- avoids volatile shifts in emotions by constantly worrying
Panic Disorder Prevalence
12 month: 2.7%
severe: 44.8% of cases
age: goes up until senior
Etiology of Panic Disorders- Neurobiological factors
- heritability of panic is fairly high
- Locus ceruleus
- major source of norepinephrine
- trigger for nervous system activity
Neumonic: a locust having a panic attack
Etiology of Panic Disorders- Behavioral factors
classical conditioning- could be response to either the situation that triggers anxiety, or somatic changes in the body (interoceptive conditioning)
Interoceptive conditioning
- classical conditioning of panic in response to internal bodily sensations
Neumonic: inception- hands tingling
Etiology of Panic Disorders- cognitive factors
catastrophic misinterpretations of somatic changes
- interpreted as impending doom (heart attack, etc)
- beliefs increase anxiety and arousal
- creates cycle
anxiety sensitivity index measures fear of bodily sensations
anxiety sensitivity index
anxiety sensitivity index measures fear of bodily sensations
- high scores predict development of panic disorders
Agoraphobia: prevalence
12 month: 0.8%
severe: 40.6% of cases
etiology of agoraphobia
principle cognitive model for etiology of agoraphobia:
fear-of-fear hypothesis:
- expectations of the catastrophic consequence of having a public panic attack
Psychological treatment of agoraphobia
Cognitive Behavioral Therapy (CBT)
- systematic exposure to feared situations
- self-guided treatment effective
