Anxiety Disorders

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Anxiety Disorders
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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) gt mood disorders (22)
  gt schizophrenia (21)

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Approaches to Classification

• lumpers vs. splitters
• DSM-III began the process of splitting the
  anxiety disorders into many smaller categories

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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

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Major Anxiety Disorders in DSM-IV

• Panic disorder
• Agoraphobia
• Specific phobia
• Social phobia (social anxiety disorder)
• Generalized anxiety disorder
• Obsessive-compulsive disorder
• Posttraumatic stress disorder
• Acute stress disorder

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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

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Panic Attack Defining Features

• Discrete period of intense fear or discomfort
• abrupt onset
• peaks within 10 min
• peak intensity lasts an average of 20 min
• can occur during waking hours or during sleep
• four or more symptoms required to define a DSM-IV
  panic attack
• attacks with fewer than four symptoms are called
  limited symptom panic attacks

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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

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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

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Agoraphobia Situations Commonly Feared and
Avoided

• Travelling
• Being far from home
• Enclosed spaces
• Wide open spaces
• Supermarket line-ups
• High places
• Being alone

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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

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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

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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

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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

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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

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Examples of Obsessions

• violent impulses and images
• sexual thoughts
• blasphemous thoughts

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Examples of Compulsions

• compulsive cleaning
• compulsive checking
• hoarding of possessions
• ordering and arranging objects

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Traumatic Stress Disorders

• Posttraumatic stress disorder
• Acute stress disorder
• Discussed in the following lecture

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Lifetime Prevalence ()
Among people exposed to traumatic events
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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

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Gender Differences and Age of Onset

• Most anxiety disorders Gender ratio (FM) ranges
  from 21 to 31
• OCD no gender differences
• Age of onset
• varies with disorder
• varies with exposure to stressors
• trends
• many anxiety disorders arise in adolescence
• phobias often arise in childhood

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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?

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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)

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Clark and Watsons 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

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Clark and Watsons 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

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Clark and Watsons Model
High negative affect
High positive affect
Low positive affect
Low negative affect
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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 --gt exposure to
  traumatic events

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Role of Life Events in Anxiety and Depression

• people with anxiety disorders have experienced
  more stressful life events
• DANGER EVENTS lead to anxiety
• LOSS EVENTS lead to depression

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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

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Classical Conditioning (Pavlov)

• UCS (meat powder) --gt UCR (salivation)
• CS (ringing a bell) --gt CR (salivation)
• original version any neutral stimulus can be
  paired with the UCS and eventually lead to the CR
• the case of Little Albert

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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?

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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
• organisms wiring shaped by evolutionary
  pressures
• prepared associations are learned in one trial
  and are very difficult to extinguish

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Clarks Cognitive Model of Panic Attacks
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Examples of Links Between Sensations and
Misinterpretations
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People with panic disorder can catastrophically
misinterpret all sorts of stimuli, including
visual illusions
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How does the Cognitive Model Explain Unexpected
Panic Attacks?
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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

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Cognitive Symptoms in Anxiety Disorders (Beck)

• Sensory-Perceptual
• Mind hazy, cloudy, foggy, dazed.
• Self-conscious
• Hypervigilant
• Thinking Difficulties
• Cant recall important things
• Confused
• Unable to control thinking

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Cognitive Symptoms in Anxiety Disorders (Beck)

• Conceptual
• Cognitive distortions
• Fear of losing control
• Fear of negative evaluations