ANXIETYIN GENERAL SharedFeaturesof all AnxietyDisorders: 1. Pervasive and persistent symptoms of anxiety and fear 2. Excessive avoidance and/or escape 3. Avoidance maintains the anxiety & fear. 4. Clinically significant distress and/or impairment Development of Anxiety Disorders • Why do we come to fear certain objects/situations? o Preparedness o But what about… • Learned (Conditioned) Anxiety o Food (UCS), Salivation (UCR) o Bell (Neutral) + Food (UCS) Salivation (UCR) o Bell (CS). Salivation (CR) o o o o o Trapped (UCS). Fear /”true alarm” (UCR) Elevator (Neutral) + Trapped (UCS). Fear /”true alarm” (UCR) Elevator (CS). Panic/ “false alarm” (CR) Sweating (Neutral) + Trapped (UCS). Fear /”true alarm” (UCR) Sweating (CS). Panic/ “false alarm” (CR) • This process is known as Classical Conditioning
What impacts how strong the anxiety response will be? • Numberof pairings o The more often a neutral stimulus (elevator) is paired with the unconditioned stimulus (being trapped), the greater the anxiety response will be. • Intensityof fear o Strong feelings of fear when the neutral stimulus is paired with the unconditioned stimulus elicits a stronger anxiety response. Maintenance of Anxiety Disorders • Operant conditioning- learning and behavior can be explained via rewards and punishments. • Negative reinforcement o Taking away a negative experience or unpleasant stimulus is a reward. o In anxiety disorders, the person “takes away” anxiety by avoiding certain triggers. o The more an individual avoids certain triggers and thus avoids anxiety, avoidance is strengthened as a coping skill because it works to stops anxiety. • • Anxiety obtainedthrough classicalconditioning . Maintainedthrough negativereinforcementwhich is an operantconditioning principle.
Problems with Avoidance as a Coping Skill • Avoidance eliminates opportunities to learn how to tolerate or overcome anxiety provoking stimuli. • Avoidance prevents an individual from having new experiences that might help them challenge and unlearn faulty beliefs. • People can lead very limited lives in an effort to continue avoidance and not be faced with anxiety provoking stimuli. The Developmentof AnxietyDisorders • Anxious Apprehension • “Trigger” • Negative Affect • Attention shift. • Intensifies negative affect • Intensifies hypervigilance • Decreases performance. Increases Negative Affect Attempts to cope: • Avoidance • Worry Summary of anxiety disorders:
Anxiety Disorders
Components • Fear and anxiety • Avoidance • Significant distress and impairment • Psychological Treatments are Generally • Superior in the Long-Term • Similar treatments for different anxiety disorders • Role of Exposure
Anxiety Disorders
PANICDISORDER& AGORAPHOBIA DSM-5 Criteria for PanicDisorder A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four (or more) of the following symptoms occur: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 1. 12. 13. B. Palpitations, pounding heart, accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering. Feelings of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint Chills or heat sensations. Paresthesias (numbness or tingling sensations) Derealization (feelings of unreality) or depersonalization (being detached from oneself). Fear of losing control or “going crazy.” Fear of dying
At least one of the attacks has been followed by 1 month (or more) of one (or both) of the following: 1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy") 2. A significant change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations.
DSM-5 Criteria for Agoraphobia300.22 A. Marked fear or anxiety about two (or more) of the following five situations: 1. Using public transportations (e.g. automobiles, buses, trains, ships, planes). 2. Being in open spaces (e.g. parking lots, marketplaces, bridges) 3. Being in enclosed places (e.g. shops, theaters, cinemas). 4. Standing in line or being in a crowd. 5. Being outside of the home alone B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms. The agoraphobic situations almost always provokes fear or anxiety.
C.
Relationship between Panic Disorder and Agoraphobia: • What is the connection between Panic Disorder & Agoraphobia? o Panic attacks typically occur before agoraphobia. o Expectation of panic in particular situations leads to agoraphobia. Panic Disorder ClinicalCharacteristics • Prevalence o Lifetime prevalence of PDA = 2%-3% o Psychiatric samples = 10% • Median age of onset = 24 years • Most unexpected panic attacks begin after puberty • Course o Chronic & disabling o Remission rates are low (37% for PD and 17% for PDA) • Twice as common among women as men • Costs o High utilizers of medical resources o More likely to be hospitalized for physical problems than any other psychiatric group. • Comorbidity o Over half with additional psychiatric disorders • 80% of sample had comorbid Mood, Anxiety, or Somatoform Disorders -Rubio & Lopez-Ibor (2007) o Suicide rare, but increases with comorbidity o Nocturnal panic (panicking while sleeping) o Occurs in approximately 25%-50% of individuals with panic disorder on a regular basis
Anxiety Disorders
Panic Disorder Treatment: • Medication o Benzodiazepines o TCA (clomipramine) o SSRIs Relapse rates are high following medication discontinuation • Psychotherapy o Panic Control Treatment o Psychoeducation o Relaxation Training o Cognitive restructuring o Interoceptive Exposure
Anxiety Disorders
SPECIFICPHOBIA DSM-5 Criteria for SpecificPhobia A. Marked fear or anxiety, about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). a. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. B. The phobic object or situation almost invariably provokes immediate fear or anxiety. C. The phobic object or situation is avoided or else is endured with intense fear or anxiety. D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social occupational, or other important areas of functioning. G. The disturbance is not better explained by the symptoms of another mental disorder including fear, anxiety, and avoidance of situations associated with panic-like or other incapacitating symptoms… Specify Type: • Animal Type • Natural Environment Type o (e.g., heights, storms, water) • Blood-Injection-Injury Type • Situational Type o (e.g., airplanes, elevators, enclosed places) • Other Type o (e.g., situations that may lead to choking, vomiting, or contracting an illness; in children, avoidance of loud sounds or costumed characters) Specific Phobia: Clinical Characteristics • Prevalence o Lifetime prevalence rate =7.2 - 11.3% o Community samples = 4.0 - 8.8% o Only 5-6% of referrals to an anxiety clinic have specific phobia as a primary diagnosis. • Course o Mean age of onset 10 years old. Symptoms increase with age, peaking 24-54. • Comorbidity o Specific phobias commonly co-occur with other disorders. • Genderdifferences o Phobias of animals, natural environment and situational phobias more common for women than men. o No sex differences in blood-injury- injection phobias. • PhysiologicalResponse o For most phobic situations: alarm reaction (fast heart rate, muscle tension, rapid breathing, etc.) o For Blood-Injection Type: diphasic response • Initial increase in HR & BP • activity of the vagus nerve leads to a sudden drop in heart rate and blood pressure • faint • individuals become anxious over fainting Treatment of Specific Phobias • Medication o Little evidence is available to suggest that medications are helpful • Psychotherapy o in vivo exposure is the treatment of choice New development… virtual reality Sample Fear Hierarchy: Thinking about traveling by plane - booking your seat - Packing your luggage- Traveling to the airport - Arriving at the airport - Checking in - Going into the departure area -Boarding the plane - The doors closing - The safety drill - Taxiing Taking off - Climbing - Experiencing turbulence - Changes in plane speed - Changes in engine noise - The plane maneuvering - Beginning descent - Final approach - Touch down - Decelerating
Anxiety Disorders
SOCIALANXIETYDISORDER(aka SOCIALPHOBIA) DSM-5 Criteria for Social AnxietyDisorder A. Marked fear or anxiety about one or more social situations in which the person is exposed to possible scrutiny by others. B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e. humiliating or embarrassing; will lead to rejection or offend others). C. The social situations almost always provoke fear or anxiety. D. The social situations are avoided or endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. F. Lasts 6 months or more. G. Causes clinically significant distress or impairment. H. Interferes with social, occupational or other areas of functioning. I. Not attributed to drug use or medical condition. J. Fear, anxiety or avoidance not better explained by another condition. Specify if: Performance only: Fear is restricted to speaking or performing in public. Social Phobia: Commonly Feared and/or Avoided Situations • Public speaking • Meeting new people • Initiating/maintaining conversation • Eating in public • Dating • Being assertive • Using public restrooms • Speaking to authority figures • Writing in public Social Phobia: Clinical Characteristics • Prevalence o Lifetime prevalence in general population= 13.3% o 3:2 female to male ratio • Course o Onset is typically during adolescence o Mean age for getting treatment is 30 years old Only half of people with Social Anxiety Disorder seek treatment. • Comorbidity o Approximately 50% have comorbidity (other anxiety disorders, depression, & substance use disorders) • FunctionalImpairmentAssociated with Social Phobia in Primary Care o Diminished productivity, past 30 days Work days missed, past 30 days Work Days Lost o Deficits in social skills? o Discrepancy between perception of self & actual display Social Phobia Treatment • Medication o SSRIs (paroxetine; sertraline; fluvoxamine) • Psychotherapy o Cognitive Behavior Therapy (CBT) o In vivo exposure o Habituation: allows patient to experience natural reduction in anxiety (without avoidance) o Practice behavioral/social skills o Test the reality of dysfunctional beliefs • Cognitive Therapy techniques o Challenges the patient’s beliefs, assumptions, expectations to see if realistic/helpful
Anxiety Disorders
GENERALIZEDANXIETYDISORDER(GAD) DSM-5 Criteria for GeneralizedAnxietyDisorder(GAD) A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B. The person finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children. (1) Restlessness or feeling keyed up or on edge. (2) Being easily fatigued. (3) Difficulty concentrating or mind going blank. (4) Irritability (5) Muscle tension (6) Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) What do individuals with GAD worry about? • Own Health • Health of family & friends • Finances • Social conditions/ world events • Natural disasters or weather • Work/ school • Little things Why worry? • Maintained by positive beliefs: o I need to worry to be prepared. o Worry motivates me. o Worry protects me. o I can't stand uncertainty. o I look for the perfect solution. o Worry is a sign of being responsible. o If I let my guard down, something bad could happen. Worry and Problem Solving PS: Adaptive process of identifying potential threats & actively preparing to cope with those threats. Worry: Anxiety-laden; generation of multiple potential future negative events in the absence of effective attempts to actively solve problems/cope with outcome. Usually future oriented. PROBLEM-SOLVING (CONCRETE) VS WORRY (ABSTRACT) The Consequences of Worry 1. Detracts from successful problem-solving. 2. Interferes with confronting what is feared. 3. Interferes with ability to respond flexibly to current environment. GAD Clinical Characteristics • Prevalence is 2.9% for adults • 2:1 female to male ratio • Individuals from developed countries more likely to experience. • Course: o Chronic course with low remission rates o Median age of onset is 30, which is much later than for other anxiety disorders. o More likely to experience experience nausea, diarrhea, headache vs. short of breath, rapid heartbeat, dizziness (more common in panic attacks). • Comorbidity o 65-75% have comorbid psychological disorder, Social phobia (36%), panic disorder (18%), and major depressive disorder (26%) o Impairment social functioning, life satisfaction o Significantly lower ratings of quality of life o Decreased work productivity Assessment Questions: • Do you worry about things that you recognize most people do not worry about (such as little things around your home)?
Anxiety Disorders
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Do you find it very difficult to stop worrying, and cannot relax as a result? Does your worry rarely result in your reaching a possible solution for a particular problem? Do you believe that if you do not worry a terrible event will happen? Do you worry about not being worried, or worry when everything is going well in your life?
GAD Treatment • Medication o Benzodiazepines – effective, but SSRIs are favored (dependence) o SSRIs – “1st line drug treatment” • Psychotherapy o Cognitive Behavioral Therapy Psychoeducation Self-Monitoring Applied relaxation o Imaginal and in vivo exposure/coping skills rehearsal o Cognitive restructuring o Newer CBT treatments using a mindfulness/acceptance-based approach (Roemer & Orsillo)
Anxiety Disorders
OBSESSIVECOMPULSIVEDISORDER(OCD) DSM-5 Criteria for OCD A. Presence of obsessions, compulsions or both: Obsessionsas defined by (1) and (2) : 1. Recurrent and persistent thoughts, urges or images that are experienced, at some time during the disturbance as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2. The person attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e. performing a compulsion). Compulsionsas defined by (1) and (2): 1. Repetitive behaviors (handwashing, ordering, checking) or mental acts (praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. B. The obsessions or compulsions are timeconsuming(take more than 1 hour a day), or cause clinically significant distress or impairment in social, occupational or other important areas of functioning. Specifiers: • With good or fair insight: The individual recognizes that obsessive-compulsive disorders or beliefs are definitely or probably not true or that they may or may not be true. • With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true. • With absent insight / delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true. OCD versus Panic Disorder • Panic Disorder= Worry about physical sensations • OCD= Worry about thoughts OCD versus Specific Phobia • OCD is chronic, pervasive and debilitating. Specific phobia is circumscribed to feared object or event. • No rituals present in specific phobia. GAD versus OCD - How can you tell the difference? • Worry o Egosyntonic o Rational but exaggerated o thoughts may be seen as useful and are seldom resisted • Obsessions o Egodystonic o May be considered bizarre to the person o thoughts are unwanted and provoke resistance o Often have a magical or irrational quality. Associated Features of OCD • Perfectionism • Rigidity • Inflated sense of responsibility • Overestimate threat • Overestimate the importance of having a “bad” thought and the need to control it. Is it normal to have intrusive thoughts? • 80% - 90% of “normals” report intrusive thoughts • Intrusions of “normals” and people with OCD are similar. How can you tell an obsession from a “normal” intrusive thought? • Obsessions… o have greater frequency, intensity and discomfort o viewed as less acceptable o can be highly distracting o more strongly resisted o more difficult to dismiss
Anxiety Disorders
Clinical Characteristics • Prevalence o 1.2% • Comorbidity o Depression (50%+), other anxiety disorders (24%), personality disorders (10%) Koran et al. (1998) o Comorbid eating disorder more common in women. • Course o Modal age of onset: 6-15 for males, 20-29 for females. Males have earlier onset o Mean age of onset 19.5 o Females are more likely to be diagnosed with OCD as adults, boys are more likely to be diagnosed with OCD as children. o Reduced quality of life- many social and occupational impairments. o Some show symptom improvement over time, if untreated the course is typically chronic . o Highly debilitating o Earlier onset = more impairment • Obsessions o Most common: contamination (55%) aggressive impulses (50%) sexual content (32%) somatic concerns (35%) need for symmetry (37%) o 60% have multiple obsessions • Compulsions o Most common: checking (53%) cleaning (50%) counting (36%) needing to ask or confess (31%) symmetry (28%) o 48% have multiple compulsions Treatment • Psychotherapy o GOLDSTANDARD : Exposure and Response Prevention (ExRP) Exposing individual to situations that provoke discomfort and blocking mental and behavioral rituals. • Self-help o Brain Lock (Schwartz, 1997) o Stop Obsessing (Foa & Wilson, 2001) • Medication o SSRIs –high doses more effective for OCD treatment.
Anxiety Disorders
HOARDINGDISORDER DSM-5 Criteria for Hoarding Disorder A. Persistent difficulty discarding or parting with possessions, regardless of actual value. B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them. C. This difficulty results in the accumulation of possessions that congest and clutter active living ares and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g. family members, cleaners, authorities). D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self or other). Features related to hoarding: • Indecisiveness • Perfectionism • Procrastination/Avoidance o Important symptom that predicts poor treatment response in OCD Reasons for hoarding: 1. Don’t want to waste things: • I might not ever need it, but I’m prepared in case I do. 2. Fear of losing important information • Keep large quantities of newspapers / magazines so they can review information at a later date. • Throwing away= losing opportunities 3. Emotional Meaning of Objects • Objects have sentimental associations with important peoples, places or events • Person perceives the object as part of their identity- getting rid of object = losing part of self. 4. Characteristics of Objects • Attracted to shape, color or texture of objects. • Save items for art or projects. 80% have a first degree relative with hoarding. Often triggered by a loss or trauma Collecting vs. Hoarding • Collecting o Organized o Able to display o Person can locate specific items • Hoarding o Disorganized o Not able to display o Cannot locate specific items o Blocks entrances, makes rooms unusable OCD vs. Hoarding • Estimated 20-40% of people with hoarding also have OCD • In OCD symptoms are experienced as intrusive, unpleasant and unwanted. In hoarding accumulating possessions creates feelings of safety, wellbeing and even euphoria. Distress comes from the actual volume of things, or thoughts of discarding possessions, not fromthe symptomsthemselves . Very treatmentresistant Extremely avoidant Very poor insight CBT interventions are most promising.
Anxiety Disorders
POSTTRAUMATICSTRESSDISORDER(PTSD) DSM-5 Criteria for PTSD: A. Experience Trauma (1 or more) May be to self or others B. Re-Experience Trauma via Intrusion Symptoms (1 or more) • Dreams Thoughts Flashbacks Psychological or Physical distress when exposed to reminders C. Persistent Avoidance of Stimuli associated with traumatic event (1 or both) • Avoid internal stimuli: o Memories o Thoughts • Avoid external stimuli • People Places Things • Conversations • Situations D. Negative alterations in cognitions and mood (2 or more) • Can’t remember important info about trauma • Negative beliefs about self, the world, future • Blaming thoughts • Persistent negative emotional state (fear, anger, guilt, shame) • Diminished interest or participation in activities • (Numbing) • Detachment or estrangement from others • Persistent inability to experience positive emotions (happiness, satisfaction, loving feelings) E. Alterations of arousal and reactivity (increased arousal) • Irritable and angry outbursts • Reckless or self destructive behavior • Hypervigilance • Exaggerated startle response • Problems with concentration • Sleep disturbance F. Lasts 1 month G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specifiers: • Depersonalizationo Feeling detached from one’s mental processes or body • Derealization o World around is experienced as unreal, dreamlike, distant or distorted. • With delayed expression: o Full criteria are not met until at least 6 months after the event. Clinical Characteristics • Lifetime prevalence = 7.8% (community samples) • Type of trauma matters: o Combat and sexual assault most likely to lead to PTSD o 32% of people who have been raped develop PTSD o 9% of people who experience a natural disaster develop • Women who join the military are more likely when compared to women in the civilian world to have been sexually abused as children. In the service, they may deal with sexual violence again: 71 percent of women who ask for VA disability benefits for PTSD say they've been sexually assaulted while in the military. • Course o Symptoms may wax/wane & become reactivated • Impairment o Medical: use more medical dollars inappropriately o Occupational: make less money and change jobs more often o Social: divorce more often, have more problems raising their children o Legal: have more legal problems o Quality of life: report low life satisfaction • Risk Factors o Pre-event variables Gender- Females at greater risk than males Hx or presence of psychiatric illness Family hx of psychiatric illness Previous exposure to trauma o Event variables
Anxiety Disorders
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Type of event (direct exposure vs. vicarious, rape vs. natural disaster) Event severity (perceived threat of death, serious bodily injury or threat to bodily integrity). Extent of exposure 1x event, vs. prolonged, repeated trauma Post-event variables o Coping (social support is key) Treatment o Psychotherapy Exposure techniques In vivo exposure- returning to the scene of the trauma Imaginal Exposure- Recalling details of the event Exposure techniques help to reduce avoidance and increase mastery over cues. o Cognitive Behavioral Therapy Relaxation techniques- breathing exercises Education about symptoms associated with traumatic experiences. Address key cognitive distortions Safety Trust Self Esteem Power o Exposure and Cognitive Behavioral Therapy has best outcome.
Anxiety Disorders
ACUTESTRESSDISORDER DSM-5 Criteria for Acute Stress Disorder: A. Exposure to actual or threatened death, serious injury, or sexual violation in one or more of the following ways: 1. Directly experiencing the traumatic event (s) 2. Witnessing, in person, the event(s) as it occurred to others 3. Learning that the event(s) occurred to a close family member or close friend. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event B. Presence of 9 (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal. Symptoms similar to PTSD except: Dissociative Symptoms (does not show) 6. An altered sense of the reality of one’s surroundings or oneself (being in a daze, time slowing) C. Duration of symptoms is 3 daysto 1 month after trauma exposure. • • • Acute Stress Disorder Rates range from 14% to 33% in individuals exposed to a severe trauma. 80% of people with Acute Stress Disorder go on to develop PTSD. The severity, duration and proximity of an individuals exposure to the traumatic event are important factors in determining the development of ASD.
UNSPECIFIEDTRAUMAANDSTRESSORRELATEDDISORDER 309.9 - Clinician has concluded that symptoms characteristic of a trauma and stressor related disorder are present, but do not meet the full criteria for any other disorder in this category. Includes presentations where there is insufficient information for a specific diagnosis