Psyc336-spring2013-rev00

Chapter 5: Anxiety Disorders
Outline : Anxiety Disorders
" Anxiety, Fear, and Panic" Causes of Anxiety Disorders" Comorbidity " GAD: Generalized Anxiety Disorder" PD / PDA: Panic Disorder with / without Agoraphobia" Specific Phobia" Social Phobia" PTSD: Post Traumatic Stress Disorder" OCD: Obsessive-Compulsive Disorder Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 Anxiety, Fear and Panic
" bodily symptoms: physical tension, mild/moderate arousal " future focused: worry about what may happen later " feelings / cognitions: control / predict future events " inverted U-shaped performance curve " bodily symptoms: moderate/extreme arousal (heart rate, blood pressure). The “Fight or Flight” response " Present-focused: worry about what is happening now " feelings/cognitions: escape current situation Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 Anxiety, Fear and Panic
Ethology, Evolutionary Psychology
! Ethology: scientific study of animal behavior.
" Intense Fear occurring at wrong time " focused on cross-species similarities " Emotions + strong Physical sensations ! Evolutionary Psychology: study of animal & human psychology from an evolutionary perspective " Both biological (genetic) evolution and cultural evolution ! how did this behavior evolve?! how did this behavior confer a survival advantage to Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 Ethological / Evolutional Perspective
Optimal level of arousal
! Fear, Anxiety, Panic are normal states for the human animal! What purpose do they serve? ! the “shadow of intelligence”, worry about future ! freeze / evaluate situation before acting ! Will a hurricane come again next year? ! Tiger in the grass walking away from you ! attack / defend with extra strength when avoidance is ! Tiger in the grass running towards your child Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 From normal behavior to Disorder
Biological Contributions to Anxiety & Panic
! Disorder = normal behaviors gone awry. Malfunction.
" Diathesis: Inherited vulnerabilities " Involve excessive avoidance and escapism " Stress / Environment trigger and activate these " Clinically significant distress and/or impairment Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 Biology: Neurotransmitter Systems
Biology: Neuroendocrine system
" CRH: Corticotropin Releasing Hormone ! secreted by hypothalamus in response to stress, also in ! also in T-lymphocytes (immune system) and in Placenta " HPA : Hypothalamic Pituitary Adrenal Axis ! Feelings of Security, openness, happiness, ability to ! Pituitary : secretes ACTH (aka Corticotropin)! ACTH causes adrenal cortices to secrete " epinephrine (adrenaline) - fight or flight" cortisol - response to stress, restore homeostasis Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 Biology: Brain Structures
Psychology of Anxiety & Fear
" “mediator” between the primitive Brain Stem and the " Anxiety, fear stem from classical and operant conditioning, " BIS - Behavioral Inhibition System: Activation causes: " Reinforcement, punishment, negative reinforcement ! Psychodynamic Theories (Freud & others) " focus attention & evaluate situation to confirm danger " Anxiety : psychic reaction to danger, infantile fear " brain stem -> amygdala -> hypothalamus -> central grey " The human condition, existential fear (death) " Early experiences : control of environment, predictability, ! alarm & escape in animals, panic in humans " Parental styles: allow exploration & failure but provide Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 Psychology of Anxiety & Fear 2
Integrated Model : Triple Vulnerability
" genetic heritability of negative affect " sense that events/world is unpredictable and " Biological predisposition, genetics " Low self confidence, self esteem, poor coping skills " familial styles, observational learning, coping mechanisms " belief / feelings that physical sensation are dangerous" hypochondriac? nonclinical panic? Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 Comorbidity of Anxiety Disorders
Overview of Anxiety Disorders
! Incidence: % of subjects developing disorder (usually per ! PD / PDA: Panic Disorder with / without Agoraphobia ! Prevalence: % of subjects with the disorder " two or more disorders occurring in same person" in psychology is often the rule, rather than the exception " Any 2 anxiety disorders: 55% (point in time), 75% (lifetime)" Anxiety disorder + Depression: 50% (lifetime) Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 GAD: “basic” anxiety disorder
DSM IV : GAD
! Excessive anxiety and worry, more days than not, > 6 months, " Excessive uncontrollable anxious apprehension and worry multiple concerns (e.g. work, school, etc) " Coupled with strong, persistent anxiety ! 3 or more of these SX: restlessness, easily fatigued, poor " Somatic symptoms differ from panic (e.g., muscle tension, concentration, irritability, muscle tension, sleep disturbance ! Focus of worry is not confined to another Axis I disorder ! Causes clinically significant distress, OR impairment ! Not due to drug, GMD, other Axis I disorder or PDD " GAD affects 4% of the general population (1-year)" Females outnumber males approximately 2:1" Onset is often insidious, beginning in early adulthood" Tendency towards anxiety runs in families" Tend to seek help from GPs rather than Psychologists Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 GAD Treatments - Pharmacological
GAD Treatments - Pharmacological
" short term: effective, immediate relief " short term: effective, immediate relief " long term: poor choice, rebound anxiety, dependence & " long term: poor choice, rebound anxiety, dependence & " short term: low effectiveness, slow relief " short term: low effectiveness, slow relief " long term: ? may be more effective, fewer dependence / " long term: ? may be more effective, fewer dependence / " comorbidity with depression - also effective " comorbidity with depression - also effective Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 Psychodynamic Psychotherapy
CBT: Cognitive / Behavioral Therapy
! Theory: symptoms / behavior are the problem and can be ! Theory: problematic behaviors are symptoms of deeper underlying issue(s). Conflicts between id, ego, supergo, and ! Problems may have originated in early learning experiences, but current issues are the focus of treatment.
! Treating symptoms would only lead to symptom substitution.
! Theory: faulty cognitions, beliefs, operant conditioning ! Method - ignore symptoms, target underlying issues, e.g. ! Identify behaviors & cognitions to target. Meta cognition.
! Symbolic content, Dream Analysis, poetic ! Present focused, relationship between therapist and client is ! Relationship between therapist & patient as proxy for ! Therapist is directive, guiding, practical relationship with parents. “Transference” ! Therapy often scientific - quantify & track behaviors over ! Therapist is neutral, blank, non-directive Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 Panic Disorder with / without Agoraphobia
PD/A Features
" Experience unexpected panic attack, e.g. “false alarm” " Persistent anxiety, worry about having another PA " not a nightmare -- people are not in REM sleep ! worry is partially irrational (e.g. fear of death or going " Agoraphobia - fear & avoidance of situations /events " International Prevalences are similar ! Latin America: “susto”, “ataques de nervios” " Prevalence about 3.5% for PD (lifetime). (yet 8-12% have ! Khmer: “sore neck”/ “wind overload” ! isolated sleep paralysis : more common in African " 75% women. Men don’t get PD? No, they tend to cope " Suicide may be higher risk in non-treated? Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 PD/A Causes
PD/A Treatment
! Vulnerabilities (biological, general psychological) " unlike with GAD, Benzos don’t seem as effective in PD/A ! Association with somatic sensations (Interoceptive clues) " perhaps a different biological system? " pounding heart, sweating, etc.
" high potency BDZs like alprazolam (Xanax) show short term ! Learned alarm (situation -> somatic sensations ?-> PA) effectiveness, but extreme discontinuation problems, e.g. ! Specific Psychological vulnerability: unexplained sensations " current medical treatment of choice " Anxious apprehension, focused on somatic sensations " Up to 60% of patients with PD can be panic-free if " Optional: development of agoraphobia (avoidance of " Medication side effects non-trivial, include sexual dysfunction (anorgasmia) in up to 75% of patients taking them.
Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 CBT Treatment of PD/A
PD/A: Comparing CBT with Medication
! Focus on Exposure with Response Prevention, Cognitive " Exposure: gradually increase levels of fear-inducing stimuli " Response Prevention: prevent patient from engaging in behaviors that reduce or escape anxiety / situation " Some anxiety reduction techniques (relaxation training) may be used, but not too much -- experiencing (and dealing with) anxiety is key part of treatment " Target dysfunctional cognitions: “if I have a panic attack I may die”, “if my heart beats fast it means a panic attack is coming”, and “if I’m outside my home I won’t be safe” ! Treatment can be reality-based, imaginal, or virtual using Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 Specific Phobia : Overview
Specific Phobia : Subtypes
! Blood-injury-injection phobia – Vasovagal response " Extreme and irrational fear of a specific object or situation ! Situational phobia – Public transportation or enclosed places " Markedly interferes with one's ability to function " Recognize fears are unreasonable, yet….
! Natural environment phobia – Events occurring in nature " Still go to great lengths to avoid phobic objects " About 11% of population (lifetime prevalence) ! Other phobias – Do not fit into the other categories (e.g., " 80% women, seems consistent around the world. Men encouraged to “tough it out” which may be cure? ! Separation anxiety disorder – Children’s worry that something " Cultural-- % rates differ, types of phobias differ" Many never get treatment, arranging their life to avoid the " One of the most treatable psychological disorders! Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 Specific Phobia : Etiology
Phobia Treatment
! Originally believed to be due to traumatic experience " dog bites you --> phobia of dogs ! Statistics don’t support this. % of people reporting a bad ! Treatment is usually brief (e.g. a few weeks), and in some ! Vicarious experiences can trigger phobias ! Video: if you have a snake phobia you may not wish to watch " seeing a traumatic event happen to another " being repeatedly warned (e.g. by parent) ! General biological & psychological vulnerability! Runs in families (31% of relatives of phobics are phobic, vs. 11% of general population) -- specific type of phobia if familial. Biological or social? Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 Social Phobia: Overview
Social Phobia: Features & Treatment
" Extreme and irrational fear/shyness " Biological and evolutionary vulnerability " Focused on social and/or performance situations " Direct conditioning, observational learning " Markedly interferes with one's ability to function " May avoid social situations or endure them with distress " Beta blockers -- not very effective " Generalized subtype – Anxiety across many social situations " Tricyclic antidepressants -- somewhat effective " Monoamine oxidase inhibitors – effective " SSRIs Paxil, Zoloft, Effexor – FDA approved for SAD " Females are slightly more represented than males " Relapse rates – High following medication discontinuation " Onset is usually during adolescence ! Psychological Treatment of Social Phobia " Peak age of onset at about 15 years " Cognitive-behavioral treatment – Exposure, rehearsal, role- ! Cognitive-behavior Group therapies are highly effective Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 Social Phobia Treatment
PTSD: Post-traumatic Stress Disorder
" Experience extreme fear, helplessness, or horror " Continue to Re-experience the event (intrusive memories, " Avoidance of stimuli which remind one of trauma " < 1 month: Acute Stress Disorder (not PTSD) " lasting > 3 months : Chronic PTSD " appearing > 6 months : with late onset Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 PTSD: Prevalence by Threat Level
PTSD: Stats & Etiology
" Most common after direct, violent insult to a person’s integrity (body or mind). Combat, Rape, Assault, and Automobile accidents (around 20-50%) " Gender: women 3x - 5x men? research lacking " Around 50% of people experiencing trauma do not get PTSD " Trauma - direct or closely observed " who does and doesn’t get it -- unclear " Bio/psych predisposition?" Social support after trauma may prevent/reduce disorder? Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 PTSD: Treatment
OCD: Obsessive-Compulsive Disorder
! Therapy: General agreement that one must confront or face the original trauma -- exposure to it, similar to Simple ! Intrusive, unwanted, nonsensical thoughts images or " Can’t/Don’t want to recreate actual trauma urges. Not simply excessive worries about real-life issues " Use associated stimuli (reminders of the trauma) ! Actions (thoughts or behaviors) taken to suppress " Guided imagery & remembering in therapeutic setting obsessive thoughts, often stereotyped or ritualized " Insight : (in adults) recognition that Os or Cs are " Experimental: Psychedelic Treatments " Marked distress, > 1 hour/day, or impairs functioning" Not due to other Axis I, med, or GMC Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 OCD: Stats & Etiology
OCD: Treatment
" Lifetime prevalence : 2.6%. About 60% women.
" Common Obsessions: 55% contamination, 50% aggressive " Clomipramine and other SSRIs – Benefit about 60% impulses, 37% symmetry, 35% somatic, 32% sexual " Psychosurgery (cingulotomy) – Used in extreme cases " Common Compulsions: Cleaning, washing, checking, " Relapse is common with medication discontinuation " Cognitive-behavioral therapy – Most effective for OCD " Theory that vulnerability & development similar to other " CBT involves exposure and response prevention " Combined treatments – Not better than CBT alone " In OCD, overvaluation of thoughts as dangerous. “thought- ! Kozal et al (2000) studied long-term followup of ERP " Magical, religious thinking associated (though which causes Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013 Anxiety Disorders: Summary
Hoarding Disorder
! Anxiety Disorders largest (by %) domain of psychopathology " Persistent difficulty discarding or parting with possessions, ! Similar overall rates across cultures, though expression of This difficulty is due to strong urges to save items and/or distress associated with discarding ! Women more than men (from a few %, to as much as 5x) " The symptoms result in the accumulation of a large number of ! Triple-Threat model of vulnerabilities: general biological, possessions that fill up and clutter active living areas of the home general psychological, specific psychological or workplace to the extent that their intended use is no longer possible.[…] ! Anxiety, Fear, Panic : natural, healthy, useful " The symptoms cause clinically significant distress or impairment[…] ! Ethology / evolutionary psychology perspective useful " The hoarding symptoms are not due to a general medical condition (e.g., brain injury, cerebrovascular disease).
" The hoarding symptoms are not restricted to the symptoms of " CBT probably more effective long-term ! GAD, PD/A, Specific Phobia, Social Phobia, PTSD, OCD Psychology 336 Abnormal Psychology Fall 2013 Psychology 336 Abnormal Psychology Fall 2013

Source: http://courses.csusm.edu/psyc336md/2013-Spring-25936-25938/notes/lecture/pdf/Psyc336-Ch05-Spring2013.pdf