Anxiety Disorders. Importance of Anxiety Disorders Associated with considerable suffering and impaired functioning Some anxiety sufferers are housebound;

Anxiety Disorders

Importance of Anxiety Disorders

Associated with considerable suffering and impaired functioning Some anxiety sufferers are housebound; many are

unable to work

Prevalence Among the most common psychiatric disorders 1 year prevalence: 12-17% (one or more anx disorder) Leading cause for seeking mental health services

Total economic costs (% of psychiatric health care budget)

Anxiety disorders (32%) > mood disorders (22%) > schizophrenia (21%)

Approaches to Classification

lumpers vs. splittersDSM-III began the process of “splitting”

the anxiety disorders into many smaller categories

Fundamental Features of Anxiety Disorders

Unwanted emotions panic attacks chronic anxiety excessive fear

Unwanted thoughts obsessions excessive worries intrusive recollections

Unwanted actions avoidance, escape, distraction compulsions

Major Anxiety Disorders in DSM-IV

Panic disorderAgoraphobiaSpecific phobiaSocial phobia (social anxiety disorder)Generalized anxiety disorderObsessive-compulsive disorderPosttraumatic stress disorderAcute stress disorder

DSM-IV Criteria for Panic Disorder

recurrent unexpected panic attacks at least 1 attack followed by at least a month of

1 or more of the following: persistent concern about having additional

panic attacks worry about implications of the attack significant change in behaviour related to the

attacks

Panic Attack: Defining Features

Discrete period of intense fear or discomfort:abrupt onsetpeaks within 10 minpeak intensity lasts an average of 20 mincan occur during waking hours or during sleepfour or more symptoms required to define a

DSM-IV panic attackattacks with fewer than four symptoms are

called “limited symptom” panic attacks

Panic Attack Symptoms

Palpitations Sweating Trembling or shaking Dyspnea Choking sensations Chest pain or

discomfort Nausea or GI distress Chills or hot flushes

Paresthesias (numbness or tingling)

Dizziness or faintness Derealization or

depersonalization Fear of losing control

or going crazy Fear of dying

DSM-IV Criteria for Agoraphobia

anxiety about being in places or situations from which escape might be difficult

or in which help may not be available if panic attacks or panic-like symptoms occur

the agoraphobic situations are avoided (e.g., travel is restricted) or else endured with marked distress

Agoraphobia: Situations Commonly Feared and Avoided

Travelling Being far from homeEnclosed spacesWide open spacesSupermarket line-

upsHigh placesBeing alone

Specific Phobia

Severe, excessive, and persistent fear Exposure to phobic object evokes fear or panic Person typically avoids phobic object Recognizes the fear is unreasonable Subtypes:

animals natural environment stimuli (e.g., heights,

water) situations (e.g., enclosed spaces) blood-injection-injury other

Social Phobia

same basic criteria as specific phobia social or performance situations in which the

person is exposed to unfamiliar people or to possible scrutiny by others

person fears acting in a way that will be humiliating or embarrassing

Social Phobia: Examples of Feared Situations

giving a speech musical performances

playing a musical instrument singing

one-to-one conversations authority figures people of the opposite sex

eating in a restaurant urinating in a public restroom

Generalized Anxiety Disorder

excessive anxiety and worry occurring on most days for at least 6 months

person worries about a number of events or activities

person finds it difficult to control worry

Obsessive-Compulsive Disorder

Either obsessions or compulsions Obsessions

recurrent, persistent thoughts, impulses, or images

intrusive, unwanted distressing not simply excessive worries

Compulsions repetitive behaviours or mental acts aimed at reducing distress or preventing harm often in response to obsessions

Examples of Obsessions

violent impulses and imagessexual thoughtsblasphemous thoughts

Examples of Compulsions

compulsive cleaning compulsive checkinghoarding of possessionsordering and arranging objects

Traumatic Stress Disorders

Posttraumatic stress disorderAcute stress disorderDiscussed in the following lecture

Lifetime Prevalence (%)

Panic disorder 1-2Agoraphobia 1-2Specific phobia 7-11Social phobia 3-13Posttraumatic stress disorder 8Acute stress disorder 14-33*Obsessive-compulsive disorder 2.5Generalized anxiety disorder 5

* Among people exposed to traumatic events

Untreated Course of Anxiety Disorders

Often arise in the context of stressful life events Typically chronic, but some remit without

treatment Severity tends to wax and wane, often in response

to life stressors For a given disorder, different symptoms can

follow different courses; e.g., panic attacks may decrease in frequency as

agoraphobia becomes more severe obsessions may decrease in frequency as

compulsions becomes more severe

Gender Differences and Age of Onset

Most anxiety disorders: Gender ratio (F:M) ranges from 2:1 to 3:1

OCD: no gender differencesAge of onset

varies with disorder varies with exposure to stressors trends:

many anxiety disorders arise in adolescencephobias often arise in childhood

Comorbidity

Current vs. lifetime comorbidity Anxiety disorders are often comorbid with

one another mood disorders substance-use disorders eating disorders personality disorders

Why are anxiety disorders so often comorbid with other disorders?

Relation Between Anxiety and Depression

both defined in terms of negative emotional experience

both triggered by stressful experiences both respond to similar treatment methods

(SSRIs, cognitive-behaviour therapy)

Clark and Watson’s Model of Anxiety and Depression

two dimensions of mood: positive and negative affect

negative affect: high = upset; low = relaxed descriptive adjectives such as angry, guilty,

afraid, sad, disgusted, or worried positive affect:

high = energetic; low = tired descriptive adjectives such as delighted,

interested, enthusiastic, proud

Clark and Watson’s Model of Anxiety and Depression

general distress: depressed people and anxious people both experience high levels of negative affect

they are distinguished on the basis of positive affect

depressed people are low on positive affect (e.g., loss of interest; fatigue; anhedonia)

anxious people also experience high levels of physiological arousal

Clark and Watson’s Model

High negative affect

Low negative affect

High positive affectLow positive affect

Environmental and Genetic Factors in Anxiety Disorders

Anxiety disorders appear to arise from combination of: disorder specific genetic factors disorder specific environmental factors disorder non-specific genetic factors disorder specific environmental factors

Genetic factors appear to influence the sorts of environment a person chooses e.g., genes for sensation-seeking --> exposure to

traumatic events

Role of Life Events in Anxiety and Depression

people with anxiety disorders have experienced more stressful life events

DANGER EVENTS: lead to anxietyLOSS EVENTS: lead to depression

Role of Learning

Conditioned fear reactions classical (Pavlovian) conditioning operant conditioning (e.g., avoidance learning) role in PTSD, phobias

Maladaptive beliefs different mechanism to Pavlovian conditioning? prominent role in panic disorder appear to play a role in other anxiety disorders

Classical Conditioning (Pavlov)

UCS (meat powder) --> UCR (salivation) CS (ringing a bell) --> CR (salivation) original version: any neutral stimulus can be

paired with the UCS and eventually lead to the CR

the case of Little Albert

Preparedness Version of Learning Theory

problems with traditional theory conditioned fear responses are easy to

extinguish phobias that develop after trauma are usually

learned in only one trial (not in labs) why are phobias only associated with certain

kinds of stimuli?

Preparedness Theory of Phobias

organisms are biologically prepared to learn certain kinds of associations quickly

biological constraints on learning cannot use simply any neutral stimulus as the

CS in classical conditioning organism’s “wiring” shaped by evolutionary

pressures prepared associations are learned in one trial

and are very difficult to extinguish

Trigger Stimulus(internal or external)

BodySensations

Perceived Threat

ApprehensionInterpretation ofSensations asCatastrophic

Clark’s Cognitive Model of Panic Attacks

Trigger Stimulus: Internal or External(Dizziness caused by standing up quickly)

Sensations(Palpitations, stronger

dizziness)

Perceived Threat(‘I could pass out’)

Anxiety or PanickyFeelings

CatastrophicMisinterpretations

(‘Something really bad ishappening; I could die’)

Examples of Links Between Sensations and Misinterpretations

Sensation Catastrophic misinterpretation

Palpitations “I am having a heart attack”

Depersonalization “I am going insane”

Shortness of breath “I am suffocating”

Numbness andtingling

“My nervous system iscollapsing”

People with panic disorder can catastrophically misinterpret all sorts of stimuli, including visual illusions

Trigger Stimulus(internal or external)

BodySensations

Perceived Threat

ApprehensionInterpretation ofSensations asCatastrophic

How does the Cognitive Model Explain Unexpected Panic Attacks?

Empirically Supported Treatments for Anxiety Disorders

Drug therapies SSRIs: e.g., Prozac High potency benzodiazepines: e.g.,

Xanax

Cognitive-behavioural therapies exposure therapy cognitive restructuring

Important considerations Patient preference High addiction potential for some drugs

(e.g., Xanax) Relapse rates: higher for drugs than for

CBT

Cognitive Symptoms in Anxiety Disorders (Beck)

Sensory-Perceptual “Mind”: hazy, cloudy, foggy, dazed. Self-conscious Hypervigilant

Thinking Difficulties Can’t recall important things Confused Unable to control thinking

Cognitive Symptoms in Anxiety Disorders (Beck)

Conceptual Cognitive distortions Fear of losing control Fear of negative evaluations