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Anxiety Disorders

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  • 1. ANXIETY DISORDERS
  • 2. Mood Symptoms
    • Tension
    • Anxiety Anxiety
    • Fear Fear Fear Fear
    • Dread Dread Dread Dread
    • Panic Panic Panic Panic
    • !!!! T E R R O R !!!!
  • 3. Cognitive Symptoms
    • Expectation of future harm
      • Fear - clear, specific danger
      • Anxiety - unknown, diffuse danger
    • Lack of Concentration
    • Self-focused preoccupation
  • 4. Behavioral/Somatic Symptoms
    • Autonomic arousal
    • Behavior - startle, restlessness
    • Avoidance
  • 5. Post-Traumatic Stress Disorder (PTSD)
    • Traumatic event exposure
      • Death or serious injury/threat
      • Reaction of intense fear, helplessness, horror
  • 6. Post-Traumatic Stress Disorder (PTSD)
    • Event is re-experienced
      • Intrusive thoughts
      • Dreams
      • Flashbacks
      • Triggers
  • 7. Post-Traumatic Stress Disorder (PTSD)
    • Avoidance or numbing
      • Avoid reminders
      • Detachment/diminished interest
      • Foreshortened future
  • 8. Post-Traumatic Stress Disorder (PTSD)
    • Persistent arousal
      • Sleep disturbance
      • Irritability
      • Hypervigilance/exaggerated startle
    • Impairment in functioning
  • 9. PTSD
    • Symptoms > 1 month
  • 10. Acute Stress Disorder
    • Symptoms 2 days - 1 month
  • 11. Combat PTSD
    • Goals of training
      • Fighter identity
        • Entering Vietnam soldiers
          • 19.2 years old
      • Shut down feelings
      • Dehumanize enemy
    • Clash with realities of war
  • 12. Combat PTSD Risk Factors
    • Pre-morbid psychological vulnerability
      • But majority of PTSD have no pre-morbid history
  • 13. Combat PTSD Risk Factors
    • More combat exposure
      • Goldberg et al. (1990) - MZ twins in Vietnam
        • No combat exposure 8-12% PTSD
        • Combat exposure 16-31% PTSD
  • 14. Combat PTSD Risk Factors
    • More death exposure
    • More moral values conflict - more perceived responsibility
    • Less identification with unit/leader
  • 15. Combat PTSD Risk Factors
    • More return to non-supportive environment
      • Vietnam
        • Rapid Homecoming
        • Social rejection
  • 16. Prevalence of PTSD
    • 8-15% lifetime in general population
    • 20% prevalence in response to trauma
      • 20% Combat PTSD
      • 11-80% range
  • 17. Prevalence of PTSD
    • Many have isolated symptoms
      • 68% combat veterans had frequent nightmares 5 years later
  • 18. Treatment of PTSD
    • Immediately after trauma
    • Education/reassurance regarding symptoms
    • Discuss details of incident (exposure)
    • Identify and process areas of impact
  • 19. Generalized Anxiety Disorder (Neurosis)
    • Excessive anxiety/ worry/ anxious apprehension
      • Regarding several events/activities
      • > 6 months
  • 20. Generalized Anxiety Disorder (Neurosis)
    • Difficult to control worry - “What if?” - vague future prbs.
    • Autonomic arousal
    • Impairs functioning
    • 6.6% females 3.6% males
  • 21. Panic Disorder
    • Unexpected, recurrent panic attacks
      • 4 in 4-week period
    • Panic attacks - sudden onset, peak within 10 minutes
      • Physical - shortness of breath, heart races, chest pain, dizzy/faint
  • 22. Panic Disorder
      • Emotional - terror, derealization/depersonalization
      • Cognitions - out of control
        • die or go crazy
  • 23. Panic Disorder
    • Persistent concern about future attacks
    • Worry about implications
    • Avoidant behaviors
    • With or without agoraphobia
    • 4% lifetime prevalence
  • 24. Phobic Disorders
    • Persistent fear of specific situation/object
      • recognize fear is excessive
    • Avoid object/situation
    • Interfere with functioning or distress about phobia
  • 25. Phobic Disorders - Agoraphobia
    • Fear of marketplace - escape difficult or help unavailable
    • Avoid situations or insist on companion
    • 7% female, 3.5% male lifetime prevalence
  • 26. Phobic Disorders - Social Phobia
    • Fear of situations involving potential negative evaluation by others
    • Avoidance or intense anxiety
    • Interferes with functioning or distress about phobia
  • 27. Phobic Disorders - Social Phobia
    • 15% female, 11% male
    • 60% recall specific experience
      • + 13 % vicarious experience
  • 28. Phobic Disorders - Specific Phobia
    • Fear of specific stimulus
    • Avoidance or intense anxiety
    • Interfere with functioning or distress about phobia
    • 16% female, 7% male
  • 29. Specific Phobias
    • Animal - childhood
    • Inanimate objects/natural environment - any age
    • Illness/injury - onset middle age
  • 30. Obsessive Compulsive Disorder (OCD)
    • Obsessions
      • Recurrent, intrusive thoughts
      • Experienced as inappropriate (ego-dystonic)
      • Cause distress
      • Themes - contamination, violence
      • Attempt to ignore/neutralize
  • 31. Obsessive Compulsive Disorder (OCD)
    • Compulsions
      • Repetitive, purposeful behavior in response to obsessions or rules
      • Designed to prevent discomfort
      • Anxiety if don’t perform
        • No pleasure, but tension release
      • Common - cleaning, counting, checking
  • 32. Obsessions and Compulsions
    • Cause distress
    • Consume time
    • Interfere with functioning
    • Begin in adolescence
    • 2.5% lifetime prevalence
    • Males = females
  • 33. ETIOLOGY OF ANXIETY DISORDERS
  • 34. Hereditary Influences
    • MZ > DZ concordance
      • Overall 35% MZ vs 10% DZ concordance
      • OCD 68% MZ vs 15% DZ
      • Agoraphobia - 39% MZ
      • Generalized anxiety disorder - 30% MZ
  • 35. Disorder-Specific Biological Influences
    • Generalized Anxiety Disorder
      • Low GABA --> Low inhibitory neuron activity --> high neuronal activity in limbic system
      • High arousal can enhance conditioning
      • Anxiolytics increase GABA and decrease anxiety
  • 36. Disorder-Specific Biological Influences
    • Panic Disorder
      • Oversensitive respiratory control center in brain stem
        • Minor oxygen debt (high CO 2 )
          • --> false alarm re suffocation
          • --> panic
  • 37. Disorder-Specific Biological Influences
        • Challenge tests
          • Sodium-lactate infusion (converted to CO 2 ) -->
            • Panic history --> 54-90% panic attack
            • Panic history --> 5-36% panic to placebo
            • No panic history --> 0-25% panic
  • 38. Disorder-Specific Biological Influences
          • Carbon dioxide inhalation --> panic if panic history
          • Hyperventilation --> panic if panic history
        • Antidepressants --> increase 5-HT --> inhibits respiratory control center --> decrease panic
  • 39. Disorder-Specific Biological Influences
    • Obsessive-Compulsive Disorder
      • Serotonin dysregulation
        • Antidepressants (SSRIs) effective for 50% OCD
        • Dogs on Prozac
      • Minimal brain damage
      • Higher activity in orbitalfrontal cortex
  • 40. Psychological Etiology
    • Psychoanalytic theory
      • Objective anxiety - threat from external world
      • Moral anxiety - unconscious fear of punishment by superego
  • 41. Psychological Etiology
      • Neurotic anxiety
        • Unconscious conflict threatens consciousness --> neurotic anxiety --> defense mechanisms and symptoms --> reduce anxiety (primary gain) and interpersonal reward (secondary gain)
  • 42. Psychological Etiology
        • Wish to harm son --> neurotic anxiety --> door checking
  • 43. Psychological Etiology
    • More uncontrollable stressful life events
    • Previous anxiety disorder + stress --> relapse
  • 44. Behavioral Explanation
    • Classical conditioning
      • Little Albert
        • Rat (neutral stimulus) paired with noise (unconditioned stimulus) --> startle, cry (UCR)
        • Rat (conditioned stimulus) --> fear (conditioned response)
  • 45. Behavioral Explanation
      • Extinction should occur rapidly, but phobias persist
        • Why?
          • Avoid feared stimulus --> reward --> maintain phobia
  • 46. Behavioral Explanation
        • Mowrer two-factor theory
          • Classical conditioning initiates phobia
          • Operant conditioning maintains phobia
          • Stimulus generalization and vicarious conditioning also contribute to initiation and maintenance
  • 47. Questions for Behavioral Account
    • Selectivity of phobias
      • Why spider but not lamb phobia?
      • Why dark but not electric outlet phobia?
  • 48. Questions for Behavioral Account
      • Prepared classical conditioning
        • Natural selection favored specific fears
        • Evolutionally prepared stimuli:
          • Fear conditioning occurs rapidly
          • Fear extinction occurs slowly
  • 49. Questions for Behavioral Account
    • Susceptibility to phobias
      • Physiological vulnerability (higher neurological activity)
      • Lack of rewarding history with stimuli
      • Threat-enhancing cognitive set
  • 50. Cognitive Explanation
    • Threat-enhancing cognitive set
      • Expect threat in environment
      • Selective attention to threats
      • Selective recall of threats
  • 51. Threat-Enhancing Cognitive Set
    • “ They discussed the priest’s convictions”
    • “ The men watched as the chest was opened”
    • “ The doctor examined little Emma’s growth”
    • Interpret neutral stimuli as threatening
  • 52. Questions for Cognitive Explanation
    • Causality?
    • Does not explain spontaneous anxiety
    • How do cognitive sets develop?
  • 53. TREATMENT OF ANXIETY DISORDERS
  • 54. Biological Treatments
    • Benzodiazapines
      • Generalized Anxiety Disorder and Phobias
      • Valium, Xanax
      • Increase GABA --> Increase inhibitory neuron activity
      • 70% individuals show symptom reduction
  • 55. Problems With Benzodiazapines
    • Side Effects
    • Psychological and Physical Dependence
    • Anxiety returns when stop meds
  • 56. Antidepressants
    • Panic, Agoraphobia, OCD
    • Anafranil
    • Effective for 50% OCD patients
  • 57. Surgery for OCD
    • Cingulotomy
      • partially cut cingulate gyrus
      • connects lower brain structures with orbitalfrontal cortex
      • effective in 50%
  • 58. Psychological Treatments
    • Commonality = confrontation of fear
    • Cognitive-Behavior Therapy
      • Challenge threat-magnifying cognitive sets
  • 59. Behavioral Treatments
      • Extinction of anxiety through exposure and development of incompatible responses
        • Systematic Desensitization
          • Progressive muscle relaxation
          • Exposure to fear hierarchy
  • 60. Psychological Treatment Effectiveness
    • Review of Panic Disorder studies
      • 75-95% panic-free after 3 months of CBT
    • Generalized Anxiety Disorder
      • CBT more effective than Valium
      • CBT + Valium most effective
  • 61. Psychological Treatment Effectiveness
    • OCD
      • Exposure + response prevention
        • 50% patients improve
        • = effectiveness vs. medications
  • 62. Psychological Treatment Effectiveness THE END