Anxiety Disorders - PowerPoint Presentation

Slide1

Anxiety Disorders

Chapter 6Slide2

Anxiety Disorders

Def:

behaviors

that include phobias, obsessions, compulsions and extreme worry. People with an anxiety disorder share a pre-occupation with , or persistent avoidance of thoughts or situations that provoke fear or anxiety, and frequently have a negative impact on aspects of a person’s life.

Similarities

with mood disorders:

Both are defined in terms of negative emotional responses

Both involve feelings of guilt, worry, and anger.

Common etiological features, such as cognitive distortions, triggers by stressful life events, and biological factors such as neurotransmitter imbalances

.

Close relationship of symptoms for anxiety and mood disorder suggests the possibility of common causal features (e.g. stressful life events)Slide3

Anxiety as a Mood vs. a Syndrome

Fear-experienced in the face of real or immediate danger, builds quickly and helps organize a person’s behavioral responses to threats from the environment.

Anxious Mood-general

or diffuse emotional reaction that is beyond simple fear and out of proportion to threats in the environment.

Not always directed at the person’s present

circumstance



can

be associated with the anticipation of future problems.

Adaptive at low levels as it signals a person must prepare for an upcoming event.

Anxious apprehension- a pervasively anxious mood associated with pessimistic

thoughts, negative self-evaluation and negative concern for future events.Slide4

Symptoms of

Anxiety Disorders

Excessive Worry-

Panic

Attacks

-

Phobias-

persistent

, irrational narrowly defined fears that are associated with a specific object or situation.

Obsessions and Compulsions

Obsessions (def)-repetitive unwanted, intrusive cognitive events that may take the form of thoughts images or impulses and lead to an increase in subjective anxiety.

Compulsions-repetitive behaviors or mental acts that are used to reduce anxiety.

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Excessive Worry

Cognitive activity associated with anxiety that manifests as a relatively uncontrollable sequence of negative, emotional thoughts that are concerned with possible future threats or dangers.

Lack of perceived control

Negative Affect

QuantitySlide6

Panic Attacks

Panic attacks-

sudden overwhelming experience of terror or fright. More focused than anxiety believed to be a normal fear response triggered at an inappropriate time.

Physical

sensations of which the patient must experience at least four, which develop suddenly and reach peak intensity within 10 minutes:

Heart palpitations

Sweating

Trembling or shaking

Sensation of shortness of breath

Choking feeling

Chest pain

Nausea or abdominal distress

Dizziness

Feelings of unreality or detachment from oneself

Fear of losing control or going crazy

Fear of dying

Numbness or tingling sensation

Chills or hot flushesSlide7

Phobias

Persistent, irrational narrowly defined fears that are associated with a specific object or situation.

Avoidance

Agoraphobia-Fear becomes more intense as the distance between the person and his or her familiar surroundings increases, or as avenues of escape are closed off.Slide8

Obsessions and Compulsions

Obsessions

and

Compulsions-

Obsessions

(def)-repetitive unwanted, intrusive cognitive events that may take the form of thoughts images or impulses and lead to an increase in subjective anxiety.

Compulsions

-repetitive behaviors or mental acts that are used to reduce anxiety.

Obsessions

Seem to come out of the

blue

Content of obsessions

Compulsions-Must perform the ritual to keep something “bad” from happening

.

Most common are cleaning and checkingSlide9

Diagnostic Systems of Anxiety Disorders (DSM-IV-TR)

Panic Disorder

Recurrent unexpected panic attacks with at least half of the attacks followed by a period of one month or more in which the person fears having another attack. (fear of fear)

Avoidance of the situation (change in behavior)

Agoraphobia

Avoid the situation or endure it with great distress

Insist on being accompanied by a safe person.

Specific Phobia-marked and persistent fear that is excessive or unreasonable, cued by the presence of specific object or situation.

Exposure produces immediate fear response

Awareness that fear is unreasonable

AvoidanceSlide10

History of Anxiety as a Disorder

Early classification of Anxiety disorders were under the classification of neurosis.

Distinguished from the psychotic disorders as the patient has awareness.

Contemporary classification of anxiety disorder includes:

Panic disorder

Phobic Disorder

Obsessive Compulsive Disorder

Post Traumatic Stress Disorder

Acute Stress DisorderSlide11

Diagnostic Systems of Anxiety Disorders (DSM-IV-TR)

Panic Disorder-recurrent unexpected panic attacks . For one month or more following at least one attack, the person must experience persistent concern about having another attack, worry about implications of the attack or a significant change in behavior due to the attack. Two Categories:

With or Without Agoraphobia

Agoraphobia-complication that follows experience of panic attacks in which the person fears the inability to escape the situation. With agoraphobia, the person must either avoid the agoraphobic situation, endure it with great distress, or insist they be accompanied by another person who can offer comfort or

security.

can

exist in the absence of

panicP

disorder (rare)

Phobic Disorders:

Specific Phobia-marked and persistent fear that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation.

Social

Phobia-identical to specific phobia, except must be afraid of social categories. Fear of being humiliated lies at the heart of the disorder. Two Categories:

Performance Anxiety

Interpersonal InteractionsSlide12

DSM Classification

Generalized Anxiety Disorder-excessive anxiety or worry that lead to significant distress or impairment in occupational or social functioning. Free-floating anxiety must be accompanied by at least three of the following symptoms:

Restlessness or feeling on edge

Fatigue

Difficulty concentrating

Irritability

Muscle Tension

Sleep Disturbance

Obsessive-Compulsive Disorder-defined in terms of the presence of either obsessions or compulsions.

Obsessions-thoughts must not be excessive worries about real problems

 must be unreasonable

Compulsions-rituals that cause marked distress if not performed, take more than an hour a day to perform or interfere with normal occupational and social functioning.

Post traumatic Stress Disorder (Chapter 7)

Acute Stress Disorder (Chapter 7)

Separation Anxiety- (Chapter 16)Slide13

Course and outcome

Chronic conditions

 Research based predictive course and outcomes

: Long term outcome unpredictable

Panic Disorder-Greatest predictor of poor outcomes was onset of symptoms at a relatively young age and the presence of agoraphobia with panic disorder.

Social phobia-Symptoms usually appear first in early adolescence and remain stable over time, indicating chronic condition.Slide14

Course and Outcome

OCD-follows a pattern of improvement mixed with some persistent symptoms. Longitudinal study shows 50% of patients exhibit symptoms for over 30 years. However, more than 80% of the patients showed improved levels of functioning

 considered a chronic condition. Slide15

Frequency

Only about 25% of people who qualify for a diagnosis of anxiety disorder ever seek psychological treatment. Therefore estimates of the frequency and severity of these problems are likely inaccurate.Slide16

Prevalence

Anxiety disorders more common than any other mental disorder in the U.S.

Specific phobia-most common-9%

Social phobia-7%

Panic Disorder and GAD-3%

OCD and Agoraphobia-1%

Gender Differences

Women have much higher incidence of anxiety disorders than men, except for OCD which is relatively equal. Women also three times more likely to relapse.Slide17

Etiology

Evolutionary Theoretical Perspective

Social Factors

Psychological Factors

Biological FactorsSlide18

Evolutionary Theoretical Perspective

Suggests that generalized forms of anxiety probably evolved to prepare for threats that could not be clearly defined. More specific forms of anxiety and fear probably evolved to provide more effective responses to certain types of danger. For example:

Fear of heights is associated with a freezing of muscles which could lead to a fall

Social threats were likely seen as establishment of dominance hierarchies within pack behavior and were likely to provoke responses such as shyness or embarrassment.

The evolutionary model views each type of anxiety as a dysregulation of a mechanism that evolved to deal with a particular kind of danger.Slide19

Social Factors

Stressful life events that involve danger, interpersonal conflicts or parent-child relationships are thought to contribute to vulnerability to the development of anxiety disorders

.

Childhood Adversity

Attachment Relationships and Separation Anxiety Slide20

Psychological Factors

Learning Processes and Phobias

Preparedness Model-theory that brain contans certain modules or circuitry that has been shaped by evolution to serves some adaptive purpose.

Operate at maximal speed and perform without conscious awareness.

Humans develop intense persistent fears to only a select set of objects or situations.

Development of social and specific phobias could be related to evolutionary lag.

Observational Learning

Social Learning Theory

Cognitive Factors: Perception and Memory

 Four General Areas that play a role in anxiety Disorders.

Perception of Control

Catastrophic Misinterpretation

Attention to Threat and Biased Information Processing

Thought Suppression (OCD)Slide21

Biological Factors

Family Studies-relatives of people with panic disorder show an elevated risk of panic disorder, but not GAD, and vice versa.

Twin Studies

Neuroanatomy-brain circuitry involved in fear and conditioning

Emotional Stimuli follows two primary pathways both of which involve the amygdala.Slide22

Pathway One

Fastest and represents the evolved fear module for conditioned fear.

Has direct connections to the amygdale which registers danger and then projects to the hypothalamus which activates fight or flight behavioral responses.

This pathway does not involve higher level cognitive function such as conscious memory and decisions via the cortical areas.

However the amygdale does store unconscious emotional memories such as those generated through prepared learning.Slide23

First Pathway: Fear and Conditioning

Stimulus

Thalamus

Amygdala

Hypothalmus

FLIGHT OR FIGHT RESPONSESlide24

Second Complementary Pathway

Pathway from the thalamus leads to higher cortical areas and provides a detailed and slower analysis of the information.

Once the pattern has been identified in the appropriate modality the data would be integrated with additional information from memory about is emotional significance.

The message would then be sent to the amygdala which would tiger an organized response to threat as well as to other cortical areas that also initiate plans against dangers.

Second pathway takes longer than the first.

Sensitivity of the first pathway (fear module) is thought to be more sensitive than the second.

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Second Pathway

Stimulus

Thalamus

Amygdala

Hypothalamus

FLIGHT OR FIGHT RESPONSE

Lobe

Identification and recognition of stimulus

Emotionality

Somatosensory cortex

Motor Cortex

Planned Voluntary MovementsSlide26

Neurotransmitters

Various pharmacological challenge studies suggest the influence of serotonin, NE, GABA, and DA in triggering panic attacks.

Efficacy of drug treatments affecting these neurotransmitters suggest they may be involved (convergent evidence)Slide27

Treatment

Psychological Interventions

Insight therapy-Freudian analysis of unconscious motives that presumably lie at the heart of the symptoms.

Behavioral Therapies

Systematic Desensitization-

client is first taught progressive relaxation. Then the therapist constructs a hierarchy of feared stimuli, beginning with those items that provoke only small amounts of fear and progressing through items that are more frightening then while the client the client is in a relaxed state, he or she imagine the lowest item on the hierarchy. This item is mentally presented until the thought of the object or situation is no longer anxiety producing. The client moves systematically up the hierarchy sequentially confronting stimuli that were originally rated as being more frightening.

Flooding-

exposure to the most frightening experience without avoidance.

Interoceptive Exposure

- have patient engage in exercises known to produce physical sensations associated with panic attacks such as increased heart rate, respiration or dizziness and attempt to reduce the person’s fear of the symptoms.Slide28

Treatment

Cognitive Therapy

Identify faulty logic such as over-generalizations and jumping to conclusions.

Decatastrophisizing-imagine the worst case scenario and confront the negative predictions, and gross exaggerations based on cognitive errors.

Extensive practice, homework and journaling.Slide29

Treatment

Biological Therapy

Anti-Anxiety Medications.

Benzodiazepenes

--reduce anxiety symptoms primarily by inhibiting GABA neuron activity. Drug of

choice



xanax

.

Panic attacks and agoraphobia

Problems: high rate of addiction and dependence. Many patients relapse after discontinuation of medication

Azapirones

-inhibit serotonin activity.

BusPar



GAD



Does not work as quickly

Antidepressants-often preferred over anti-anxiety drugs due to problems with addiction.

SSRI’s- first line treatment due to tolerability of side effects

.

SNUB-

Effexor

,

Cymbalta

Tricyclics

-used for the longest period of time. Work as well as the SSRI’s but range of side effects leads to non-compliance.

Anafranil

(OCD)-

tricyclic

especially helpful with OCD, not used with any other panic disorder, however relapse is common after discontinuation of the drug.Slide30

Case Study: Paula

Paula: 27 year old white female

Single

Education: BA –economics

Occupation: Securities and Bond Trader

Presentation:

Blunted Affect, Good eye contact, fidgety

Extremely uncomfortable talking about painful subjects in the past, Before the end of the first session, patient became so uncomfortable discussing a subject, she left the session early. Slide31

Reason for appointment

Recurring attacks that she thought were heart attacks.

Patient experienced chest pains, dizziness and shortness of breath resulting in multiple trips to the emergency room.

Cardiology testing

Zanax prescribed

Acceleration of symptoms and avoidance behaviors

Medical leave from job.Slide32

Family Background

Mother: Homemaker

Father: Deceased five years from Congestive heart Failure

Siblings: younger brother born with multiple birth defects including severe heart problems The died when he was three years old and the family still grieved his loss.

Maternal Grandfather: AlcoholicSlide33

Evaluation

Assessment Tools

Unstructured Interview

Psychiatric Evaluation

Symptoms:

Onset : shortly after entering college where she experienced adjustment problems.

Unresolved grief.

Acceleration of symptoms

Avoidance Behaviors

Abuse of alcohol and over the counter drugs for a short period

Suicidal Ideations

Irrational thoughts

Anger at MotherSlide34

Etiology

Learning

negative reinforcement

Irrational thinking

BiologicalSlide35

Treatment:

Group Therapy

Medication: zoloft

Relaxation Therapy

Hypnosis

Duration: 7 months

Prognosis-goodSlide36

DSM IV TR

Axis One: Panic Disorder with Agoraphobia

Axis Two:

Axis Three:

Axis Four:

Axis Five: