Anxiety DisordersAnxiety Disorders

““The Dark side of Fear”The Dark side of Fear”

What is Anxiety?What is Anxiety?  

The unpleasant feeling of fear or The unpleasant feeling of fear or apprehension we experience in response to apprehension we experience in response to some event or situation. some event or situation.

Duration & intensity of anxietyDuration & intensity of anxiety --more --more severe in people with anxiety disorders than severe in people with anxiety disorders than in people without. in people without.

Anxiety Disorders:Anxiety Disorders:  

PhobiasPhobias panic disorderpanic disorder generalized anxiety disordergeneralized anxiety disorder obsessive-compulsive disorderobsessive-compulsive disorder posttraumatic stress disorderposttraumatic stress disorder acute stress disorderacute stress disorder

Comorbidity of other anxiety Comorbidity of other anxiety disorders is high!!disorders is high!!

1.Symptoms of various anxiety disorders 1.Symptoms of various anxiety disorders are not disorder specific.are not disorder specific.

   2.) Cause of one disorder may be cause of 2.) Cause of one disorder may be cause of

another disorder. another disorder.

A. A. PhobiasPhobias – an irrational fear out of – an irrational fear out of proportion to the danger posed by the proportion to the danger posed by the object or situation.object or situation.

   Person Person knowsknows fear is irrational fear is irrational, but avoids object , but avoids object

or situation anyway.or situation anyway.   Phobia may not be debilitating enough to warrant Phobia may not be debilitating enough to warrant

seeking treatment.seeking treatment.   (e.g., A fear of snakes in the city is less a problem (e.g., A fear of snakes in the city is less a problem

than in the country)than in the country)

Two kinds of phobias:Two kinds of phobias: 1. 1. Specific phobias - fSpecific phobias - fears caused by the presence ears caused by the presence

or anticipation of a specific object or situation. or anticipation of a specific object or situation.

BloodBlood injuries & injectionsinjuries & injections situations (planes, elevators)situations (planes, elevators) animals (dogs, spiders)animals (dogs, spiders) natural environment (heights, water, tornadoes)natural environment (heights, water, tornadoes)

Lifetime prevalence: 7% (men) and 16% (women).Lifetime prevalence: 7% (men) and 16% (women).

2. 2. Social phobias-Social phobias- Fear linked to the presence of other peopleFear linked to the presence of other people

Person avoids situation in which he or she could behavior in Person avoids situation in which he or she could behavior in embarrassing way.embarrassing way.

   Speaking or performing in publicSpeaking or performing in public eating in publiceating in public Using public bathroomUsing public bathroom

Lifetime prevalence: 11% (men) & 15% (women)Lifetime prevalence: 11% (men) & 15% (women)  

  

What causes phobias?What causes phobias? Data show we Data show we learn phobiaslearn phobias, they are not innate., they are not innate.

   We learn phobias by:We learn phobias by:

   1. Classical & operant conditioning (avoidance 1. Classical & operant conditioning (avoidance

learning)learning)

   2. Modeling (observational learning)2. Modeling (observational learning)

  

Modeling:Modeling:

We learn phobias by observing others’ fear to We learn phobias by observing others’ fear to the object or event.the object or event.

Do we need to observe the person’s fear Do we need to observe the person’s fear response to the stimulus & the stimulus response to the stimulus & the stimulus itself?itself?

Yes!!!!Yes!!!!

Mineka study:Mineka study: Had Had lab-reared monkeyslab-reared monkeys view view wild-reared monkeyswild-reared monkeys

responses to a snake. responses to a snake.    A barrier was in place to block the lab-reared monkeys A barrier was in place to block the lab-reared monkeys

from seeing the object of the wild-reared monkey’s from seeing the object of the wild-reared monkey’s fear.fear.

   Later when shown the snake, the lab-reared monkey Later when shown the snake, the lab-reared monkey

didn’t show fear to the snakes.didn’t show fear to the snakes.   You need to see the other person’s response to the You need to see the other person’s response to the

feared stimulus & the stimulus itself for phobia feared stimulus & the stimulus itself for phobia formation.formation.

Therapy for phobias:Therapy for phobias:

Systematic desensitization Systematic desensitization

Flooding Flooding

B. Generalized Anxiety Disorder (GAD)B. Generalized Anxiety Disorder (GAD) Symptoms: Symptoms: persistent anxietypersistent anxiety chronic worrychronic worry focus on health/daily hasslesfocus on health/daily hassles difficulty concentrating; irritabledifficulty concentrating; irritable tire easily; restlesstire easily; restless

Lifetime prevalence: 5% in populationLifetime prevalence: 5% in population Onset: midteens; comorbidity with other anxiety Onset: midteens; comorbidity with other anxiety

disorders & mood disorders. disorders & mood disorders.

Causes of GADCauses of GAD::

   we develop GAD when confronted with painful we develop GAD when confronted with painful

stimuli over which we have no control. stimuli over which we have no control.    Perception Perception of not being in control may be enough of not being in control may be enough

for anxiety.for anxiety.   we develop GAD when we misperceive events to we develop GAD when we misperceive events to

be out of our control & potentially threatening or be out of our control & potentially threatening or harmful.harmful.

Locus of control- we feel less anxiety Locus of control- we feel less anxiety when we can control our lives.when we can control our lives.

Our “perception” of control may be more important than Our “perception” of control may be more important than “actual” control to reducing unwanted anxieties in patients “actual” control to reducing unwanted anxieties in patients with GAD.with GAD.

*Unpredictable events produce more anxiety than predictable *Unpredictable events produce more anxiety than predictable ones.ones.

  Patients with GAD are easily drawn to stimuli associated with Patients with GAD are easily drawn to stimuli associated with

negative emotional content (traumas, physical harm, etc.)negative emotional content (traumas, physical harm, etc.)    

Worry as a tool to control emotion!!Worry as a tool to control emotion!!

   Patients with GAD use worry to distract Patients with GAD use worry to distract themselves from thinking about negative themselves from thinking about negative events.events.

   Worrying keeps us from focusing on Worrying keeps us from focusing on

negative emotions.negative emotions.   Worrying is negatively reinforcing because Worrying is negatively reinforcing because

it blocks us from processing emotional it blocks us from processing emotional stimuli, & keeps the cycle of anxiety going.stimuli, & keeps the cycle of anxiety going.

Biological Causes of GADBiological Causes of GAD

There may be a genetic component.There may be a genetic component.

   We may have a defect in the GABA system so that We may have a defect in the GABA system so that

fear is not brought under control.fear is not brought under control.

   Benzodiazipines, which enhance the inhibitory Benzodiazipines, which enhance the inhibitory

neurotransmitter, GABA, reduce anxiety.neurotransmitter, GABA, reduce anxiety.

  

Therapies for GADTherapies for GAD

1. Transfer global anxiety into a phobia & treat phobia.1. Transfer global anxiety into a phobia & treat phobia.   *Systematic desensitization may be used if anxiety can be *Systematic desensitization may be used if anxiety can be

linked to an identifiable source.linked to an identifiable source.

2. Relaxation training2. Relaxation training Have patients focus on relaxing during low-level anxiety.Have patients focus on relaxing during low-level anxiety.      

Treat worry!!!Treat worry!!!

Here, therapists require that patients extend Here, therapists require that patients extend & exaggerate their anxieties.& exaggerate their anxieties.

   Because patient remains in a fearful Because patient remains in a fearful

situation, anxiety is believed to extinguish.situation, anxiety is believed to extinguish.   Patient learns his or her cognitions are Patient learns his or her cognitions are

illogical and unfounded.illogical and unfounded.

C. Panic DisorderC. Panic Disorder – – characterized by characterized by attacks.attacks.

Increased HRIncreased HR heart palpitationsheart palpitations nauseanausea chest painchest pain trembling; sweating, terrortrembling; sweating, terror

Usually physiological symptoms occur without link Usually physiological symptoms occur without link to cause (with exceptions)to cause (with exceptions)

  Lifetime prevalence: 2 % (men) & 5 % (women). Lifetime prevalence: 2 % (men) & 5 % (women).

DSM-IV diagnosis:DSM-IV diagnosis:

Recurrent uncued attacks & worry about having attacks Recurrent uncued attacks & worry about having attacks in the future are required.in the future are required.

   Is diagnosed as panic disorder with or without Is diagnosed as panic disorder with or without

agoraphobia.agoraphobia.   Comorbidity between panic disorder &Comorbidity between panic disorder &major depression, GAD, phobias, alcoholism, & major depression, GAD, phobias, alcoholism, &

personality disorders is high.personality disorders is high.    

What causes panic disorder?What causes panic disorder?11.There may be symptoms of an illness that leads to .There may be symptoms of an illness that leads to

panic attackspanic attacks..   (e.g., mitral valve prolapse causes heart palpitations, (e.g., mitral valve prolapse causes heart palpitations,

dizziness, etc.)dizziness, etc.)   2. Panic may be caused by overactivity in a nucleus 2. Panic may be caused by overactivity in a nucleus

in the pons called the locus ceruleus (LC).in the pons called the locus ceruleus (LC).    In humans, a drug called Yohimbine, a drug that In humans, a drug called Yohimbine, a drug that

stimulates the LC, can elicit panic attacks in patients stimulates the LC, can elicit panic attacks in patients with panic disorder.with panic disorder.

  

Causes (panic):Causes (panic):

However blocking activation in the LC has However blocking activation in the LC has not been found to reduce panic attacks.not been found to reduce panic attacks.

33.Creating panic attacks experimentally.Creating panic attacks experimentally::

   Using hyperventilation to induce panic Using hyperventilation to induce panic

attacks has produced mixed results.attacks has produced mixed results.

Psychological theories:Psychological theories:

Patients with panic disorder may have an autonomic Patients with panic disorder may have an autonomic nervous system that is predisposed to be overly nervous system that is predisposed to be overly active.active.

People misconstrue internal bodily changes as People misconstrue internal bodily changes as signals they may be in jeopardy or dying.signals they may be in jeopardy or dying.

With repeated exposures to attacks, patients worry With repeated exposures to attacks, patients worry about future attacks thereby making them more about future attacks thereby making them more likely to occur.likely to occur.

  Therapies for Panic disorder and agoraphobiaTherapies for Panic disorder and agoraphobia

Biological:Biological:1. Antidepressants & anxiolytics can reduce frequency 1. Antidepressants & anxiolytics can reduce frequency

of attacks.of attacks.

PsychologicalPsychological: Barlow’s therapy (well validated):: Barlow’s therapy (well validated):3 components:3 components:

1. Relaxation training- 1. Relaxation training- 2. A combination of Ellis & Beck type cognitive 2. A combination of Ellis & Beck type cognitive

behavioral interventionsbehavioral interventions3. Exposure to the internal cues that trigger panic3. Exposure to the internal cues that trigger panic  

D. Obsessive-Compulsive Disorder D. Obsessive-Compulsive Disorder (OCD):(OCD):

persistent unwanted thoughts & compulsive persistent unwanted thoughts & compulsive behaviors that impair normal functioning.behaviors that impair normal functioning.

Lifetime prevalenceLifetime prevalence: 1-2 % of general pop.: 1-2 % of general pop. More common in women than menMore common in women than men   Age of onsetAge of onset: early adulthood: early adulthood MalesMales: : checkingchecking rituals most common rituals most common FemalesFemales: : cleaningcleaning rituals most common rituals most common  

Components of OCD:Components of OCD: 1. 1. ObsessionsObsessions--intrusive & recurring thoughts & images intrusive & recurring thoughts & images

that appear irrational & uncontrollable to the individual that appear irrational & uncontrollable to the individual experiencing them.experiencing them.

Frequency & force of thoughts always interfere with Frequency & force of thoughts always interfere with functioning. functioning.

  Fears of contaminationFears of contamination Fears of expressing sexual or aggressive impulsesFears of expressing sexual or aggressive impulses hypochondriahypochondria   2. 2. CompulsionsCompulsions- - repetitive behaviors performed over & repetitive behaviors performed over &

over to reduce distress associated with the unwanted over to reduce distress associated with the unwanted thoughts.thoughts.

Causes of OCDCauses of OCD 1. Behavioral & cognitive theories1. Behavioral & cognitive theories   Compulsions are learned behaviors reinforced by fear Compulsions are learned behaviors reinforced by fear

reduction (negative reinforcement).reduction (negative reinforcement).

E.g., frequency of hand washing increases to reduce or E.g., frequency of hand washing increases to reduce or eliminate the aversive fear of dirt.eliminate the aversive fear of dirt.

Compulsive checking may be the result of memory deficit. Compulsive checking may be the result of memory deficit.         

Therapies for OCDTherapies for OCD Exposure and response prevention (ERP)Exposure and response prevention (ERP)Victory Meyer (1966)Victory Meyer (1966)  1.Patients with OCD expose (flooding) themselves to 1.Patients with OCD expose (flooding) themselves to

situations that elicit compulsions. situations that elicit compulsions. E.g., touching a dirty dishE.g., touching a dirty dish   2.  Person is instructed to refrain from performing 2.  Person is instructed to refrain from performing

compulsions (extinguish anxiety & compulsions).compulsions (extinguish anxiety & compulsions).   Treatment is partially effective in half of OCD Treatment is partially effective in half of OCD

patients.  patients.  

E. Posttraumatic Stress disorder E. Posttraumatic Stress disorder (PTSD)(PTSD)

A traumatic event or witness to an event in which A traumatic event or witness to an event in which there is perceived or actual threat of death, serious there is perceived or actual threat of death, serious injury, or other personal harm. injury, or other personal harm.

The event must have created intense fear, horror, The event must have created intense fear, horror, or a sense of helplessness. or a sense of helplessness.

(May 3(May 3rdrd, 1999-OK), 1999-OK)Symptoms of PTSD fall into 3 major categories. Symptoms of PTSD fall into 3 major categories.

Symptoms in each must occur longer than 1 Symptoms in each must occur longer than 1 month.month.

What happens?What happens? 1. 1. Reexperiencing the traumatic eventReexperiencing the traumatic event Person frequently recalls the event (has nightmares Person frequently recalls the event (has nightmares

about the event). about the event).

2. 2. Avoidance of stimuli associated with the event or Avoidance of stimuli associated with the event or numbing of responsivenessnumbing of responsiveness

   Person tries to avoid thinking about the trauma or Person tries to avoid thinking about the trauma or

encountering stimuli that will bring it to mind.encountering stimuli that will bring it to mind.    3. 3. Symptoms of increased arousalSymptoms of increased arousaldifficulty concentrating (sleeping), hypervigilancedifficulty concentrating (sleeping), hypervigilance

PTSD: General StatsPTSD: General Stats

General prevalence: 1-3 % in the general pop. General prevalence: 1-3 % in the general pop.

   3% for civilians exposed to a physical attack3% for civilians exposed to a physical attack 20 % among people wounded in Vietnam20 % among people wounded in Vietnam 50 % of all rape victims 50 % of all rape victims

Women twice as likely to develop PTSD as men.Women twice as likely to develop PTSD as men.

F. Acute Stress DisorderF. Acute Stress Disorder

an individual encounters a traumatic an individual encounters a traumatic experience that causes problems with social experience that causes problems with social or occupational functioning for less than 1 or occupational functioning for less than 1 month.month.