Anxiety Disorders

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ANXIETY ANXIETY DISORDERSDISORDERS

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Mood SymptomsMood Symptoms

Tension Tension

Anxiety AnxietyAnxiety Anxiety

Fear Fear Fear FearFear Fear Fear Fear

Dread Dread Dread DreadDread Dread Dread Dread

Panic Panic Panic PanicPanic Panic Panic Panic

!!!! T E R R O R !!!!!!!! T E R R O R !!!!

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Cognitive SymptomsCognitive Symptoms

Expectation of future harmExpectation of future harm• Fear - clear, specific dangerFear - clear, specific danger• Anxiety - unknown, diffuse dangerAnxiety - unknown, diffuse danger

Lack of ConcentrationLack of Concentration Self-focused preoccupationSelf-focused preoccupation

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Behavioral/Somatic Behavioral/Somatic SymptomsSymptoms

Autonomic arousalAutonomic arousal Behavior - startle, restlessnessBehavior - startle, restlessness AvoidanceAvoidance

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Post-Traumatic Stress Post-Traumatic Stress Disorder (PTSD)Disorder (PTSD)

Traumatic event exposureTraumatic event exposure• Death or serious injury/threatDeath or serious injury/threat• Reaction of intense fear, Reaction of intense fear,

helplessness, horrorhelplessness, horror

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Event is re-experiencedEvent is re-experienced• Intrusive thoughtsIntrusive thoughts• DreamsDreams• FlashbacksFlashbacks• TriggersTriggers

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Avoidance or numbingAvoidance or numbing• Avoid remindersAvoid reminders• Detachment/diminished interestDetachment/diminished interest• Foreshortened futureForeshortened future

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Persistent arousalPersistent arousal• Sleep disturbanceSleep disturbance• IrritabilityIrritability• Hypervigilance/exaggerated Hypervigilance/exaggerated

startlestartle Impairment in functioningImpairment in functioning

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PTSDPTSD

Symptoms > 1 monthSymptoms > 1 month

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Acute Stress DisorderAcute Stress Disorder

Symptoms 2 days - 1 monthSymptoms 2 days - 1 month

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Combat PTSDCombat PTSD

Goals of trainingGoals of training• Fighter identityFighter identity

•Entering Vietnam soldiersEntering Vietnam soldiers•19.2 years old19.2 years old

• Shut down feelingsShut down feelings• Dehumanize enemyDehumanize enemy

Clash with realities of warClash with realities of war

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Combat PTSD Risk FactorsCombat PTSD Risk Factors

Pre-morbid psychological Pre-morbid psychological vulnerabilityvulnerability• But majority of PTSD have no But majority of PTSD have no

pre-morbid history pre-morbid history

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More combat exposureMore combat exposure• Goldberg et al. (1990) - MZ twins in Goldberg et al. (1990) - MZ twins in

VietnamVietnam•No combat exposure 8-12% PTSDNo combat exposure 8-12% PTSD•Combat exposure 16-31% PTSDCombat exposure 16-31% PTSD

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More death exposureMore death exposure More moral values conflict - More moral values conflict -

more perceived responsibilitymore perceived responsibility Less identification with Less identification with

unit/leaderunit/leader

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More return to non-supportive More return to non-supportive environmentenvironment• VietnamVietnam

•Rapid HomecomingRapid Homecoming•Social rejectionSocial rejection

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Prevalence of PTSDPrevalence of PTSD

8-15% lifetime in general 8-15% lifetime in general populationpopulation

20% prevalence in response to 20% prevalence in response to traumatrauma• 20% Combat PTSD20% Combat PTSD• 11-80% range11-80% range

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Prevalence of PTSDPrevalence of PTSD

Many have isolated symptomsMany have isolated symptoms• 68% combat veterans had 68% combat veterans had

frequent nightmares 5 years frequent nightmares 5 years laterlater

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Treatment of PTSDTreatment of PTSD

Immediately after traumaImmediately after trauma Education/reassurance Education/reassurance

regarding symptomsregarding symptoms Discuss details of incident Discuss details of incident

(exposure)(exposure) Identify and process areas of Identify and process areas of

impactimpact

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Generalized Anxiety Generalized Anxiety Disorder (Neurosis)Disorder (Neurosis)

Excessive anxiety/ worry/ Excessive anxiety/ worry/ anxious apprehensionanxious apprehension• Regarding several Regarding several

events/activitiesevents/activities• >> 6 months 6 months

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Generalized Anxiety Generalized Anxiety Disorder (Neurosis)Disorder (Neurosis)

Difficult to control worry - Difficult to control worry - “What if?” - vague future prbs. “What if?” - vague future prbs.

Autonomic arousalAutonomic arousal Impairs functioningImpairs functioning 6.6% females6.6% females 3.6% males3.6% males

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Panic DisorderPanic Disorder

Unexpected, recurrent panic Unexpected, recurrent panic attacksattacks• 4 in 4-week period4 in 4-week period

Panic attacks - sudden onset, Panic attacks - sudden onset, peak within 10 minutespeak within 10 minutes• Physical - shortness of breath, Physical - shortness of breath,

heart races, chest pain, dizzy/faintheart races, chest pain, dizzy/faint

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• Emotional - terror, Emotional - terror, derealization/depersonalizationderealization/depersonalization

• Cognitions - out of controlCognitions - out of control

die or go crazydie or go crazy

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Persistent concern about Persistent concern about future attacksfuture attacks

Worry about implicationsWorry about implications Avoidant behaviorsAvoidant behaviors With or without agoraphobiaWith or without agoraphobia 4% lifetime prevalence4% lifetime prevalence

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Phobic DisordersPhobic Disorders

Persistent fear of specific Persistent fear of specific situation/objectsituation/object• recognize fear is excessiverecognize fear is excessive

Avoid object/situationAvoid object/situation Interfere with functioning or Interfere with functioning or

distress about phobiadistress about phobia

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Phobic Disorders - Phobic Disorders - AgoraphobiaAgoraphobia

Fear of marketplace - escape Fear of marketplace - escape difficult or help unavailabledifficult or help unavailable

Avoid situations or insist on Avoid situations or insist on companioncompanion

7% female, 3.5% male lifetime 7% female, 3.5% male lifetime prevalenceprevalence

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Phobic Disorders - Phobic Disorders - Social PhobiaSocial Phobia

Fear of situations involving Fear of situations involving potential negative evaluation potential negative evaluation by othersby others

Avoidance or intense anxietyAvoidance or intense anxiety Interferes with functioning or Interferes with functioning or

distress about phobiadistress about phobia

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Phobic Disorders - Phobic Disorders - Social PhobiaSocial Phobia

15% female, 11% male15% female, 11% male 60% recall specific experience 60% recall specific experience

+ 13 % vicarious experience+ 13 % vicarious experience

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Phobic Disorders - Phobic Disorders - Specific PhobiaSpecific Phobia

Fear of specific stimulusFear of specific stimulus Avoidance or intense anxietyAvoidance or intense anxiety Interfere with functioning or Interfere with functioning or

distress about phobiadistress about phobia 16% female, 7% male16% female, 7% male

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Specific PhobiasSpecific Phobias

Animal - childhoodAnimal - childhood Inanimate objects/natural Inanimate objects/natural

environment - any ageenvironment - any age Illness/injury - onset middle ageIllness/injury - onset middle age

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Obsessive Compulsive Obsessive Compulsive Disorder (OCD)Disorder (OCD)

ObsessionsObsessions• Recurrent, intrusive thoughtsRecurrent, intrusive thoughts• Experienced as inappropriate Experienced as inappropriate

(ego-dystonic) (ego-dystonic) • Cause distressCause distress• Themes - contamination, violenceThemes - contamination, violence• Attempt to ignore/neutralizeAttempt to ignore/neutralize

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Obsessive Compulsive Obsessive Compulsive Disorder (OCD)Disorder (OCD)

CompulsionsCompulsions• Repetitive, purposeful behavior in Repetitive, purposeful behavior in

response to obsessions or rulesresponse to obsessions or rules• Designed to prevent discomfortDesigned to prevent discomfort• Anxiety if don’t performAnxiety if don’t perform

•No pleasure, but tension releaseNo pleasure, but tension release• Common - cleaning, counting, Common - cleaning, counting,

checkingchecking

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Obsessions and Obsessions and CompulsionsCompulsions

Cause distressCause distress Consume timeConsume time Interfere with functioningInterfere with functioning Begin in adolescenceBegin in adolescence 2.5% lifetime prevalence2.5% lifetime prevalence Males = femalesMales = females

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ETIOLOGY OF ETIOLOGY OF ANXIETY DISORDERSANXIETY DISORDERS

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Hereditary InfluencesHereditary Influences

MZ > DZ concordanceMZ > DZ concordance• Overall 35% MZ vs 10% DZ Overall 35% MZ vs 10% DZ

concordanceconcordance• OCD 68% MZ vs 15% DZOCD 68% MZ vs 15% DZ• Agoraphobia - 39% MZAgoraphobia - 39% MZ• Generalized anxiety disorder - Generalized anxiety disorder -

30% MZ30% MZ

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Disorder-Specific Disorder-Specific Biological InfluencesBiological Influences

Generalized Anxiety DisorderGeneralized Anxiety Disorder• Low GABA --> Low inhibitory Low GABA --> Low inhibitory

neuron activity --> high neuronal neuron activity --> high neuronal activity in limbic systemactivity in limbic system

• High arousal can enhance High arousal can enhance conditioningconditioning

• Anxiolytics increase GABA and Anxiolytics increase GABA and decrease anxietydecrease anxiety

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Panic DisorderPanic Disorder• Oversensitive respiratory control Oversensitive respiratory control

center in brain stemcenter in brain stem

•Minor oxygen debt (high COMinor oxygen debt (high CO22) )

--> false alarm re suffocation --> false alarm re suffocation

--> panic--> panic

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•Challenge testsChallenge tests•Sodium-lactate infusion (converted to Sodium-lactate infusion (converted to COCO22) -->) -->

•Panic history --> 54-90% panic Panic history --> 54-90% panic attackattack

•Panic history --> 5-36% panic Panic history --> 5-36% panic to placeboto placebo

•No panic history --> 0-25% panicNo panic history --> 0-25% panic

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•Carbon dioxide inhalation --> panic if panic history

•Hyperventilation --> panic if panic history

•Antidepressants --> increase 5-HT --> inhibits respiratory control center --> decrease panic

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Obsessive-Compulsive DisorderObsessive-Compulsive Disorder• Serotonin dysregulationSerotonin dysregulation

•Antidepressants (SSRIs) effective Antidepressants (SSRIs) effective for 50% OCDfor 50% OCD

•Dogs on ProzacDogs on Prozac• Minimal brain damageMinimal brain damage• Higher activity in orbitalfrontal Higher activity in orbitalfrontal

cortexcortex

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Psychological EtiologyPsychological Etiology

Psychoanalytic theoryPsychoanalytic theory• Objective anxiety - threat from Objective anxiety - threat from

external worldexternal world• Moral anxiety - unconscious fear Moral anxiety - unconscious fear

of punishment by superegoof punishment by superego

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• Neurotic anxietyNeurotic anxiety•Unconscious conflict threatens Unconscious conflict threatens consciousness --> neurotic consciousness --> neurotic anxiety --> defense anxiety --> defense mechanisms and symptoms --mechanisms and symptoms --> reduce anxiety (primary > reduce anxiety (primary gain) and interpersonal reward gain) and interpersonal reward (secondary gain) (secondary gain)

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•Wish to harm son --> neurotic anxiety --> door checking

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More uncontrollable stressful More uncontrollable stressful life eventslife events

Previous anxiety disorder + Previous anxiety disorder + stress --> relapsestress --> relapse

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Behavioral ExplanationBehavioral Explanation

Classical conditioningClassical conditioning• Little AlbertLittle Albert

•Rat (neutral stimulus) paired Rat (neutral stimulus) paired with noise (unconditioned with noise (unconditioned stimulus) --> startle, cry (UCR)stimulus) --> startle, cry (UCR)

•Rat (conditioned stimulus) --> Rat (conditioned stimulus) --> fear (conditioned response)fear (conditioned response)

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• Extinction should occur rapidly, Extinction should occur rapidly, but phobias persistbut phobias persist•Why? Why?

•Avoid feared stimulus --> Avoid feared stimulus --> reward --> maintain phobiareward --> maintain phobia

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•Mowrer two-factor theory•Classical conditioning initiates phobia

•Operant conditioning maintains phobia

•Stimulus generalization and vicarious conditioning also contribute to initiation and maintenance

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Questions for Behavioral Questions for Behavioral AccountAccount

Selectivity of phobiasSelectivity of phobias• Why spider but not lamb phobia?Why spider but not lamb phobia?• Why dark but not electric outlet Why dark but not electric outlet

phobia?phobia?

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• Prepared classical conditioningPrepared classical conditioning•Natural selection favored Natural selection favored specific fearsspecific fears

•Evolutionally prepared stimuli:Evolutionally prepared stimuli:•Fear conditioning occurs Fear conditioning occurs rapidlyrapidly

•Fear extinction occurs slowlyFear extinction occurs slowly

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Susceptibility to phobiasSusceptibility to phobias• Physiological vulnerability Physiological vulnerability

(higher neurological activity)(higher neurological activity)• Lack of rewarding history with Lack of rewarding history with

stimulistimuli• Threat-enhancing cognitive setThreat-enhancing cognitive set

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Cognitive ExplanationCognitive Explanation

Threat-enhancing cognitive setThreat-enhancing cognitive set• Expect threat in environmentExpect threat in environment• Selective attention to threatsSelective attention to threats• Selective recall of threatsSelective recall of threats

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Threat-Enhancing Threat-Enhancing Cognitive SetCognitive Set

““They discussed the priest’s They discussed the priest’s convictions”convictions”

““The men watched as the chest was The men watched as the chest was opened”opened”

““The doctor examined little Emma’s The doctor examined little Emma’s growth”growth”

Interpret neutral stimuli as Interpret neutral stimuli as threateningthreatening

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Questions for Cognitive Questions for Cognitive ExplanationExplanation

Causality?Causality? Does not explain spontaneous Does not explain spontaneous

anxietyanxiety How do cognitive sets develop?How do cognitive sets develop?

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TREATMENT OF ANXIETY TREATMENT OF ANXIETY DISORDERSDISORDERS

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Biological TreatmentsBiological Treatments

BenzodiazapinesBenzodiazapines• Generalized Anxiety Disorder and Generalized Anxiety Disorder and

PhobiasPhobias• Valium, XanaxValium, Xanax• Increase GABA --> Increase Increase GABA --> Increase

inhibitory neuron activityinhibitory neuron activity• 70% individuals show symptom 70% individuals show symptom

reductionreduction

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Problems With Problems With BenzodiazapinesBenzodiazapines

Side EffectsSide Effects Psychological and Physical Psychological and Physical

DependenceDependence Anxiety returns when stop Anxiety returns when stop

medsmeds

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AntidepressantsAntidepressants

Panic, Agoraphobia, OCDPanic, Agoraphobia, OCD AnafranilAnafranil Effective for 50% OCD patientsEffective for 50% OCD patients

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Surgery for OCD

Cingulotomy• partially cut cingulate gyrus• connects lower brain structures with

orbitalfrontal cortex• effective in 50%

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Psychological TreatmentsPsychological Treatments

Commonality = confrontation Commonality = confrontation of fearof fear

Cognitive-Behavior TherapyCognitive-Behavior Therapy• Challenge threat-magnifying Challenge threat-magnifying

cognitive setscognitive sets

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Behavioral TreatmentsBehavioral Treatments

• Extinction of anxiety through Extinction of anxiety through exposure and development of exposure and development of incompatible responsesincompatible responses•Systematic DesensitizationSystematic Desensitization

•Progressive muscle Progressive muscle relaxationrelaxation

•Exposure to fear hierarchyExposure to fear hierarchy

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Psychological Treatment Psychological Treatment EffectivenessEffectiveness

Review of Panic Disorder Review of Panic Disorder studiesstudies• 75-95% panic-free after 3 75-95% panic-free after 3

months of CBTmonths of CBT Generalized Anxiety DisorderGeneralized Anxiety Disorder

• CBT more effective than ValiumCBT more effective than Valium• CBT + Valium most effectiveCBT + Valium most effective

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Psychological Treatment Effectiveness

OCD• Exposure + response prevention

• 50% patients improve• = effectiveness vs. medications

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Psychological Treatment Effectiveness

THE END

Health & Medicine

Anxiety Disorders