Anxiety and Fear: moods (normal!), symptoms, and syndromes

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NatureofAnxietyandFear

•  AnxietyandFear:moods(normal!),symptoms,andsyndromes

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•  Fear– Fightorflight– Sympathe>cac>va>on– Avoidance&escape– Present‐oriented


•  Anxiety– Tension– Unpredictable– Uncontrollable– Future‐oriented

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AnxietyandPerformance:TheYerkes‐DodsonInverted“U”

Anxiety Level

Perf

orm

ance

Low High

AnxietyDisorders

•  Pervasiveandpersistentanxietyandfear•  Excessiveavoidanceandescapisttendencies

•  Clinicallysignificantdistressandimpairment

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WhatisaPanicAQack?•  Abrupt,intensefearordiscomfort

•  Severalphysicalsymptoms

•  Analogoustofearasanalarmresponse

DSM‐IVSubtypesofPanicAQacks

•  Situa>onallybound(cued)–Expectedandboundtospecificsitua>ons

• Unexpected(uncued)–“outoftheblue”

•  Situa>onallypredisposed–Mayormaynotoccurinspecificsitua>ons

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BiologicalContribu>onstoAnxietyandPanic

•  Diathesis‐Stress– Inheritedvulnerabili>esforanxietyandpanic

– Stressandlifecircumstancesdeterminetype


• GABAcircuits•  Cor>cotropinreleasingfactor(CRF)andHPAaxis

•  Limbic(amygdala)andtheseptal‐hippocampalsystems

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•  Fight/flight(FF)system– Serotonin?– Brainstem‐amygdala‐hypothal.

•  Behavioralinhibi>onsystem(BIS)– Brainstem‐amygdala‐septal‐hippocampalsystem

PsychologicalContribu>onstoAnxietyandFear

•  BeganwithFreud– Reac>va>onofaninfan>lefearsitua>on

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•  BehavioralViews– Classicalandoperantcondi>oning– modeling

•  PsychologicalViews– Earlyexperienceswithuncontrollabilityandunpredictability


•  SocialContribu>ons– Stressfullifeeventstriggerbiological/psychologicalvulnerabili>es

– Familialandinterpersonal

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AnIntegratedModel

•  Biologicalvulnerability•  Psychologicalvulnerabili>es– Nega>veSchemas

•  Experiences

CommonProcesses:TheProblemofComorbidity

•  55%haveconcurrentdx•  Majordepressionmostcommon

•  Commonfactorsacrossanxietyandmooddisorders

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TheAnxietyDisorders•  GeneralizedAnxietyDisorder•  PanicDisorderwithandwithoutAgoraphobia•  SpecificPhobias•  SocialPhobia•  PosQrauma>cStressDisorder

•  Obsessive‐CompulsiveDisorder

GeneralizedAnxietyDisorder:The“Basic”AnxietyDisorder

•  DefiningFeatures– Excessiveuncontrollableanxiousapprehensionandworry

– Lasts>=6months

– Soma>csymptomsdifferfrompanic(muscletension,fa>gue,irritability…)

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“Doyouworryexcessivelyaboutminorthings?”

GeneralizedAnxietyDisorder

•  Sta>s>cs– 4%prevalence;Oneofthemostcommon

– Females2:1

–  Insidiousonsetinearlyadulthood– Tendenciesruninfamilies

– Chronic

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•  “autonomicrestrictors”

•  Emo>onalavoidance

•  Chronicworriers• Muscletension


•  Treatment:Modesthelp– Benzodiazapines• Cogni>veeffects• Highlyaddic>ve

– Psychologicalinterven>ons–Cogni>ve‐BehavioralTherapy

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PanicDisorderWithandWithoutAgoraphobia

•  OverviewandDefiningFeatures– UnexpectedpanicaQack(i.e.,afalsealarm)

– Developanxiety,worry,orfearabouthavinganotheraQackoritsimplica>onsthatpersistfor1monthormore


•  OverviewandDefiningFeatures– Agoraphobia–Fearoravoidanceofsitua>ons/eventsassociatedwithpanic

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•  FactsandSta>s>cs– 3.5%ofthegeneralpopula>onmeetdiagnos>ccriteriaforpanicdisorder

– Female2:1

– Onsetisomenacute,beginningbetween25and29yearsofage

PanicDisorder•  AssociatedFeatures– NocturnalpanicaQacks–60%experiencepanicduringdeepnon‐REMsleep

–  Interocep>ve/exterocep>veavoidance,catastrophicmisinterpreta>onofsymptoms

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PanicDisorder:Treatment•  Medica>on– Targetserotonergic,noradrenergic,andbenzodiazepineGABAsystems

– SSRIs(e.g.,ProzacandPaxil)arecurrentlythepreferreddrugs

– Relapseratesarehighfollowingmedica>ondiscon>nua>on

PanicDisorder:Treatment•  PsychologicalandCombinedTreatments– Cogni>ve‐behaviortherapiesarehighlyeffec>ve(PCT)

– Combinedtreatmentsdowellintheshortterm

– Bestlong‐termoutcomeiswithcogni>ve‐behaviortherapyalone

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SpecificPhobias:AnOverview

•  Extremeirra>onalfearofaspecificobjectorsitua>on

•  Markedlyinterfereswithone’sabilitytofunc>on

•  Avoidanceoffearedobject•  Knowsthatthefearandavoidanceareunreasonable

SpecificPhobias:AnOverview•  FactsandSta>s>cs– Femalesareagainover‐represented

– About11%ofthegeneralpopula>on– Chroniccourse,withonsetbeginningbetween15and20yearsofage

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SpecificPhobias:AssociatedFeaturesandSubtypes

•  Blood‐injury‐injec>onphobia–Vasovagalresponsetoblood,injury,orinjec>on

•  Allothersubtypesarelessmeaningful

SpecificPhobias:Causes

•  Biologicalandevolu>onaryvulnerability•  Directcondi>oning•  Observa>onallearning•  Informa>ontransmission

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SpecificPhobias:Treatment

•  PsychologicalTreatments– CBTsarehighlyeffec>ve

– Systema>cdesensi>za>on– Flooding

PosQrauma>cStressDisorder(PTSD):AnOverview

•  OverviewandDefiningFeatures– Requiresexposuretoaneventresul>nginextremefear,helplessness,orhorror

– Reexperiencing

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• OverviewandDefiningFeatures– Avoidanceofcues– Emo>onalnumbingand/orarousal

– Markedlyinterfereswithone'sabilitytofunc>on

– Symptoms>1month


•  Sta>s>cs– Combatandsexualassaultarethemostcommontraumas

– About7.8%ofthegeneralpopula>onmeetcriteriaforPTSD

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PosQrauma>cStressDisorder(PTSD):Subtypes

•  AcutePTSD‐1‐3monthsposttrauma•  ChronicPTSD‐>3monthsposttrauma•  DelayedonsetPTSD‐Onset>6months•  Acutestressdisorder‐Immediatelypost‐trauma

PosQrauma>cStressDisorder(PTSD):Causes

•  Intensityofthetraumaandone'sreac>ontoit

• Uncontrollabilityandunpredictability•  Directcondi>oningandobserva>onallearning

• Moderator:Socialsupport

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PosQrauma>cStressDisorder(PTSD):Treatment

•  PsychologicalTreatment•  CBT’sarehighlyeffec>ve– Graduatedormassed(e.g.,flooding)imaginalexposure

Obsessive‐CompulsiveDisorder(OCD):AnOverview

• Obsessions‐Intrusiveandnonsensicalthoughts,images,orurgesthatonetriestoresistoreliminate– Contamina>on

– Aggression– Symmetry

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Obsessive‐CompulsiveDisorder(OCD):AnOverview

•  Compulsions‐Thoughtsorac>onstosuppresstheobsessions– Overt:cleaningandwashing,checkingrituals

– Covert:sequencing,repe>>on

Obsessive‐CompulsiveDisorder(OCD):Obsessions

•  Types(Akhtaretal.,1975):– Doubts(74%)– Thinking(34%)– Fears(26%)– Impulses(17%)– Images(7%)– Other(2%)

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•  Doubt‘DidIlockthedoor’(M,28)

•  Thought/Fearthathehadcancer(M,46)

•  Thought/Imagethathehadknockedsomeonedowninhiscar(M,29)


•  Impulse+thoughttoshoutobsceni>esinchurch(F,19)

•  Imageofcorpseroxngaway(F,27)

•  Impulsetodrinkfrominkpotandtostrangleson(M,41)

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Obsessive‐CompulsiveDisorder:Sta>s>csandFeatures•  About2.6%life>meprevalence

• Mostlyfemale• Onsetinearlyadolescenceoryoungadulthood•  Tendstobechronic

Obsessive‐CompulsiveDisorder:Causes

•  Paralleltheotheranxietydisorders(biopsychosocialinterac>ons)•  Earlylifeexperiencesandlearning– Somethoughtsaredangerousbutcontrollable

•  Thought‐ac>onfusion– Moralvs.Likelihood

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Mul>siteOCDStudyFoaandLiebowitz(1997)

•  Primaryaim– Compareindependentandcombinedeffectsofclomipramineandexposure‐responsepreven>on(ERP)

•  TreatmentCondi>ons– Clomipranine(CMI)alone– ERPalonealone– Clomipranine+ERP– Pillplaceboalone

Mul>siteOCDStudy•  Sample– 99pa>entsmee>ngDSM‐III‐Rcriteriaforobsessivecompulsivedisorder

•  2PhasesoftheStudy– Acutephase(12weeks)– Notreatmentfollow‐up(6months)

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Mul>‐SiteOCDAcuteTreatmentResponse

Data taken from Foa & Liebowitz,(1997)

Mul>‐SiteOCDRelapseatFollow‐up

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SummaryofAnxiety‐RelatedDisorders

•  Anxietydisordersrepresentsomeofthemostcommonformsofpsychopathology


•  Fromanormaltoadisorderedexperienceofanxietyandfear– Fearandanxietypersisttobodilyorenvironmentalnon‐dangerouscues– Symptomsandavoidancecausedistressandimpairment– Considera>onofbiological,psychological,experien>al,andsocialfactors

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•  Psychologicaltreatmentsaregenerallysuperiorinthelong‐term– Mosttreatmentsinvolveexposure

– Suggeststhatanxiety‐relateddisorderssharecommonprocesses

Anxiety and Fear: moods (normal!), symptoms, and syndromes

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