Anxiety Disorders
Jan 21, 2016
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