Chapter 4 Anxiety Disorders. Nature of Anxiety and Fear Fear – The Present-Oriented Mood State...

Chapter 4Anxiety Disorders

Nature of Anxiety and Fear

• Fear – The Present-Oriented Mood State

– Immediate fight or flight response to danger or threat

– Involves abrupt activation of the sympathetic nervous system

– Strong avoidance/escapist tendencies

– Marked negative affect

Nature of Anxiety and Fear

• Anxiety – The Future-Oriented Mood State

– Apprehension about future danger or misfortune

– Somatic symptoms of tension

– Characterized by marked negative affect

• Anxiety and Fear are Normal Emotional States

From Normal to Disordered Anxiety and Fear

• Characteristics of Anxiety Disorders

– Pervasive and persistent symptoms of anxiety and fear

– Involve excessive avoidance and escape

– Cause clinically significant distress and impairment

The Phenomenology of Panic Attacks

• What is a Panic Attack?

– Abrupt experience of intense fear or discomfort

– Several physical symptoms (e.g., breathlessness, chest pain)

– Fear as an alarm response

The Phenomenology of Panic Attacks (continued)

• DSM-IV-TR Subtypes of Panic Attacks

– Situationally bound (cued)

– Unexpected (uncued)

– Situationally predisposed

Fig. 4.1, p. 126

Biological Contributions to Anxiety and Panic

• Genetic Vulnerability

• Anxiety and brain circuits

– Depleted levels of GABA

• Corticotropin releasing factor (CRF) and HYPAC axis

Biological Contributions to Anxiety and Panic (continued)

• Limbic (amygdala) and the septal-hippocampal systems

• Behavioral inhibition (BIS)

– Anxiety

• Fight/flight (FF) systems

– Fear

Psychological Contributions to Anxiety and Fear

• Began with Freud

– Anxiety is a psychic reaction to fear

– Anxiety involves reactivation of an infantile fear situation

Psychological Contributions to Anxiety and Fear (continued)

• Behavioral and Cognitive Views

– Invokes conditioning and cognitive explanations

– Anxiety and fear are learned responses

– Catastrophic thinking and appraisals play a role

Psychological Contributions to Anxiety and Fear (continued)

• Early Childhood Contributions

– Experiences with uncontrollability and unpredictability

• Social Contributions

– Stressful life events trigger vulnerabilities

An Integrated Model

• Integrative View – Triple Vulnerability Model

– Generalized biological vulnerability

– Generalized psychological vulnerability

– Specific psychological vulnerability

An Integrated Model (continued)

• Common Processes: The Problem of Comorbidity

– Comorbidity is common across the anxiety disorders

– Major depression is the most common secondary diagnoses

An Integrated Model (continued)

– About half of patients have two or more secondary diagnoses

– Comorbidity Suggests

• Common factors

• A relation between anxiety and depression

The Anxiety Disorders: An Overview

• Generalized Anxiety Disorder

• Panic Disorder with and without Agoraphobia

• Specific Phobias

• Social Phobia

• Posttraumatic Stress Disorder

• Obsessive-Compulsive Disorder

“Do you worry excessively about minor things?”

Fig. 4.3, p. 132

Generalized Anxiety Disorder: The “Basic” Anxiety Disorder

• Overview and Defining Features

– Excessive uncontrollable anxious apprehension and worry

– Coupled with strong, persistent anxiety

– Persists for 6 months or more

– Somatic symptoms differ from panic (e.g., muscle tension)

Generalized Anxiety Disorder: The “Basic” Anxiety Disorder (continued)

• Statistics

– Affects about 4% of the general population

– Females outnumber males approximately 2:1

– Onset is often insidious, beginning in early adulthood

– Very prevalent among the elderly

– Tends to run in families

Generalized Anxiety Disorder: Associated Features and Treatment

• Associated Features

– Persons with GAD have been called “autonomic restrictors”

– Fail to process emotional component of thoughts and images

• Treatment of GAD: Generally Weak

– Benzodiazapines – Often Prescribed

– Psychological interventions – Cognitive-Behavioral Therapy

– Combined treatments – Acute vs. Long-Term Outcomes

Fig. 4.4, p. 134

Panic Disorder With and Without Agoraphobia


– Experience of unexpected panic attack (i.e., a false alarm)

– Develop anxiety, worry, or fear about another attack

– Many develop agoraphobia

Panic Disorder With and Without Agoraphobia (continued)

• Facts and Statistics

– Affects about 3.5% of the general population

– Onset is often acute, beginning between 25 and 29 years of age

– 75% of individuals with agoraphobia are female

Panic Disorder: Associated Features and Treatment

• Associated Features

– Nocturnal panic attacks – 60% panic during deep non-REM sleep

– Interoceptive/exteroceptive avoidance

• Medication Treatment

– Target serotonergic, noraadrenergic, and GABA systems

– SSRIs (e.g., Prozac and Paxil) are preferred drugs

– Relapse rates are high following medication discontinuation

Panic Disorder: Associated Features and Treatment (continued)

• Psychological and Combined Treatments

– Cognitive-behavior therapies are highly effective

– No evidence that combined treatment produces better outcome

– Best long-term outcome is with cognitive-behavior therapy alone

Specific Phobias: An Overview


– Extreme irrational fear of a specific object or situation

– Persons will go to great lengths to avoid phobic objects

– Most recognize that the fear and avoidance are unreasonable

– Markedly interferes with one’s ability to function

Specific Phobias: An Overview (continued)


– Females are again over-represented


– Phobias tend to run a chronic course

Specific Phobias: Associated Features and Treatment

• Associated Features and Subtypes of Specific Phobia

– Blood-injury-injection phobia – Unusual vasovagal response

– Situational phobia – Trains, planes, automobiles, closed spaces

– Natural Environment phobia – Natural events (e.g., heights, storms)

– Animal phobia – Animals and insects

– Separation Anxiety – Seen in children

Specific Phobias: Associated Features and Treatment (continued)

• Causes of Phobias

– Biological and evolutionary vulnerability

– Three pathways -- Conditioning, observational learning, information

• Psychological Treatments of Specific Phobias

– Cognitive-behavior therapies are highly effective – Exposure

Fig. 4.8, p. 150

Social Phobia: An Overview


– Extreme and irrational fear in social/performance situations

– Markedly interferes with one’s ability to function

– Often avoid social situations or endure them with great distress

– Generalized subtype – Affects many social situations

Social Phobia: An Overview (continued)



– Prevalence is slightly greater in females than males

– Onset is usually during adolescence

– Peak age of onset at about 15 years

Social Phobia: Associated Features and Treatment

• Causes

– Biological and evolutionary vulnerability

– Similar learning pathways as specific phobias

• Psychological Treatment

– Cognitive-behavioral treatment

– Cognitive-behavior therapies are highly effective

Social Phobia: Associated Features and Treatment (continued)


– Tricyclic antidepressants and monoamine oxidase inhibitors

– SSRIs Paxil, Zoloft, and Effexer – Are FDA approved

– Relapse rates are high following medication discontinuation

Posttraumatic Stress Disorder (PTSD): An Overview


– Main etiologic characteristics – Trauma exposure and response

– Reexperiencing (e.g., memories, nightmares, flashbacks)

– Avoidance

Posttraumatic Stress Disorder (PTSD): An Overview (continued)

– Emotional numbing and interpersonal problems

– Markedly interferes with one's ability to function

– PTSD diagnosis – Only after 1 month post-trauma

Posttraumatic Stress Disorder (PTSD): An Overview (continued)

• Statistics

– Combat and sexual assault are the most common traumas

– About 7.8% of the general population meet criteria for PTSD

Posttraumatic Stress Disorder (PTSD): Causes and Associated Features

• Subtypes and Associated Features of PTSD

– Acute – May be diagnosed 1-3 months post trauma

– Chronic – Diagnosed after 3 months post trauma

– Delayed onset – Onset 6 months or more post trauma

– Acute stress disorder – PTSD immediately post-trauma

Posttraumatic Stress Disorder (PTSD): Causes and Associated Features

(continued)

• Causes of PTSD

– Intensity of the trauma and one's reaction to it (i.e., true alarm)

– Learn alarms -- Direct conditioning and observational learning

– Biological vulnerability

– Uncontrollability and unpredictability

– Extent of social support, or lack thereof post-trauma

Posttraumatic Stress Disorder (PTSD): Treatment

• Psychological Treatments

– Cognitive-behavior therapies (CBT) are highly effective

– CBT may include graduated or massed (e.g., flooding) imaginal exposure

– Aim of CBT for PTSD

Obsessive-Compulsive Disorder (OCD): An Overview


– Obsessions - Intrusive and nonsensical thoughts, images, or urges

– Compulsions - Thoughts or actions to neutralize thoughts

– Vicious cycle of obsessions and compulsions

– Cleaning and washing or checking rituals are common

Obsessive-Compulsive Disorder (OCD): Causes and Associated Features

• Statistics

– Affects about 2.6% of the general population

– Most with OCD are female

– Onset is typically in early adolescence or young adulthood

– OCD tends to be chronic

Obsessive-Compulsive Disorder (OCD): Causes and Associated Features

(continued)

• Causes of OCD

– Parallels the other anxiety disorders

– Early life experiences

– Learning that some thoughts are dangerous/unacceptable

– Thought-action fusion -- The thought is similar to the action

Obsessive-Compulsive Disorder (OCD): Treatment


– Clomipramine and other SSRIs – Benefit up to 60% of patients

– Relapse is common with medication discontinuation

– Psychosurgery (cingulotomy) is used in extreme cases

Obsessive-Compulsive Disorder (OCD): Treatment (continued)

• Psychological Treatment

– Cognitive-behavioral therapy is most effective

– CBT involves exposure and response prevention

– Combining CBT with medication -- No better than CBT alone

Summary of the Anxiety Disorders

• Most Common Forms of Psychopathology

• From a Normal to a Disordered Experience of Anxiety and Fear

– Triple Vulnerabilities – Bio-psycho-social

– Fear and anxiety – Non-dangerous bodily or environmental cues

– Symptoms and avoidance – Significant distress and impairment

Summary of the Anxiety Disorders (continued)

• Psychological Treatments are Generally Superior in the Long-Term

– Similar treatments for different anxiety disorders

– Suggests that anxiety-related disorders share common processes

Chapter 4 Anxiety Disorders. Nature of Anxiety and Fear Fear – The Present-Oriented Mood State...

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