Anxiety Disorders

The Nature of Fear and Anxiety Chapter 5 • Fear • Anxiety – Yerkes–Dodson Anxiety Disorders • Panic Attack – Situationally bound (cued) – Unexpected (uncued) – Situationally predisposed Biological Contributions of Anxiety • Genetic contributions • Contributions of specific brain circuits & neurotransmitter systems Real Threat Fear – GABA-Benzodiazepine Circuit True Alarm Adaptive False Alarm No Threat Maladaptive – Noradrenergic & serotonergic systems • Corticotropin releasing factor (CRF) system Anxiety • HPA (hypothalamic-pituitary-adrenocortical) axis • wide–ranging effects on limbic system, esp. the hippocampus & amygdala, locus cereleus in the brainstem, prefrontal cortex, & dopaminergic neurotransmitter system Biological Contributions of Anxiety • Limbic System • Jeffrey Gray – Behavioral Inhibition System (BIS) • brain circuit leading from the septal & hippocampal area in the limbic system to the frontal cortex – Fight/flight System (FFS) • Originates in the brain stem & travels through several mid–brain structures including the amygdala, ventromedial nucleus of the hypothalamus, & the central gray matter • Factors in the environment can change the sensitivity of these brain circuits – Cigarette smoking as a teenager Integrated Model of Etiology biological vulnerability + psychological vulnerability + pressure 1 Generalized Anxiety Disorder Clinical Description • Generalized Anxiety Disorder • Panic Disorder • Excessive Anxiety & Worry • PD With Agoraphobia • Difficult to Control the Worrying • Specific Phobias • Associated with (at least 3): • Social Phobias • Post-Traumatic Stress Disorder • Obsessive Compulsive Disorder Restlessness Being easily fatigued Difficulty concentrating Irritability Muscle tension Sleep Disturbance • Interferes With Life Functioning • Occurs More Days than Not for at Least 6 Months Treatment of GAD • Clinical Description for Children • Worry mostly about minor, everyday life events • Facts and Statistics • Causes Pharmacological Interventions • Benzodiazepines • Antidepressants – imipramine – Venlafaxine CBT Psychological Interventions • focus on what is actually threatening • train in thought balancing & other coping techniques • relaxation training Panic Disorder The Panic Attack • • • • • Abrupt Autonomic Surge Unexpected Uncontrollable Absence of Threat “False Alarm” •10 Minutes Symptoms of a Panic Attack (4 or more) • • • • • • • • Palpitations / Sweating Trembling / Shaking Shortness of Breath / Smothering Feeling of Choking / Chest pain Nausea / Abdominal distress Dizziness / Chills / Hot flushes Fear of Loss of Control or going crazy Derealization / Fear of Dying 2 Treatment of Panic Disorder • Subtypes – Panic attacks without panic disorder – Panic disorder with agoraphobia (PDA) – Panic disorder without agoraphobia (PD) • Clinical Description – Avoidance • Agoraphobic avoidance • Interoceptive avoidance • Facts and Statistics • Cultural Influences – Ataques de nervios • Nocturnal Panic Combined Treatment Multisite Study • Imipramine Alone (IMI) • IMI + CBT • Placebo Alone (PBO) • Placebo + CBT At the end of 3 months, 1) all treatments were better than PBO. 2) IMI alone was a little better than CBT alone. 3) Combined treatment was no better than indiv. tx Four Major Subtypes • Animal Type • Natural Environment Type • Blood-Injection–Injury Type • Situational Type • Other • Psychological Interventions – Panic Control Treatment (PCT) • Exposure to interoceptive sensations + • Cognitive therapy identifying & modifying basic attitudes & perceptions + • Teach Breathing retraining and/or relaxation training + • Exposure exercises • Causes • CBT Alone • Pharmacologic Treatments – Tricyclic Antidepressants (e.g., Imipramine) – Benzodiazapines (e.g., Xanax) – SSRIs (e.g., Prozac, Paxil) Specific Phobias Clinical Description • Irrational Fear of Specific Objects or Situations • Markedly Interferes With Functioning Blood-Injection Injury Type • Physiological Reaction is different – Strong Vasovagal Response to Blood, Injury, or Injection Situational Type • Fears of Specific Situations – Planes, Transportation, small enclosed places 3 Natural Environment Type Separation Anxiety Disorder • Fears of Natural Events – Heights, Storms, Water • Characterized by a child’s unrealistic & persistent worry that something will happen to his parents or other important people in his life, or that something will happen to the child that will separate him from his parents • Often results in school refusal Animal Type •Fears of Animals and Insects Other Phobias Treatment • Facts and Statistics • Causes • Social & Cultural Factors Social Phobia Clinical Description • Marked and persistent fear of social or performance situations in which embarrassment may occur • Exposure to the social or performance situation almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack • The feared social or performance situations are avoided or endured with intense anxiety or distress • Interferes with life functioning, or marked distress about having the phobia • • • • • Exposure–based exercises Confront objects of fear Extinguish anxious responding Disrupt avoidance / escape Blood-Injury /Injection differs • Facts and Statistics • Causes • Drug Treatments – Antidepressants for Severe Anxiety • MAO Inhibitors • Tricyclic antidepressants • Paxil (SSRI) 4 Psychological Interventions Posttraumatic Stress Disorder • Group therapy (exposure) + Clinical Description • Intensive cognitive therapy aimed at uncovering & • Exposure to a traumatic events during which changing automatic perceptions of danger (cognitive restructuring) one feels fear, helplessness, or horror – War and Combat – Rape and Assault – Car Accidents – Natural Disasters • Persistent re–experiencing of the event (1 or more) – Flashbacks / Dreams – Memories / Distress at exposure to cues • Persistent avoidance of stimuli associated with the trauma & numbing of general responsiveness (3 or more) – Inability to recall important aspect of trauma – Feeling of detachment or estrangement • Persistent symptoms of increased arousal (2 or more) Subtypes • Acute • Chronic • Delayed Onset • Acute Stress Disorder (different dx) – Sleep Disturbance / Irritability or anger / Startle response – Difficulty concentrating / Hypervigilance • Facts and Statistics • Causes – elevated corticotropin–releasing factor (CRF) which indicates heightened activity in HPA (hypothalamic –pituitary –adrenal cortical) axis • Bessel van der Kolk: – Decreased hippocampal volume (memory) – Excessive activation of the amygdala & related structures during flashbacks (emotional dysregulation) – Activation of sensory areas during flashbacks – Decreased activation of Broca’s area (region of left frontal lobe involved in production of language) during flashbacks – Marked right–hemispheric lateralization • Brain circuit for PTSD is very similar to the brain circuit for panic attacks & originates in the locus coeruleus in the brain stem • The alarm reaction is much the same in both panic disorder & PTSD – But the alarm is false in panic disorder, while – in PTSD, the initial alarm is true 5 Treatment • SSRIs • Prolonged Exposure (PE) – Edna Foa – Confront the Original Trauma through imaginal exposure • Anxiety Management Training – Teach the client how to control intense anxiety through relaxation & cognitive restructuring Obsessive–Compulsive Disorder Clinical Description • Has either obsessions or compulsions. These are excessive or unreasonable. They cause marked distress, are time consuming or interfere with the normal routine or functioning. • Obsessions: Intrusive thoughts, images, or urges that the person tries to resist or eliminate • Compulsions: Thoughts or actions used to suppress the obsessions and provide relief • Actions: handwashing, checking • Mental: counting, mantras • Facts and Statistics • Causes • Drug & Medical Treatment – SSRI Medications – Cingulotomy (lesion to cingulate bundle) • EMDR – Eye movement desensitization & reprocessing – Form of exposure with a strong cognitive component accompanied by saccadic eye movements. – The client imagines a scene from the trauma, focuses on the accompanying thoughts & physiological arousal, & tracks the therapist’s rapidly moving finger. – The sequence is repeated until the client no longer reports anxiety, at which point the client is instructed to adopt a more positive thought while imagining the trauma & continuing the eye movements. • It seems so hopeless to gain any control or predictability over the dangers in life, that one resorts to magic and rituals • OCD often is associated with severe generalized anxiety, recurrent panic attacks, debilitating avoidance, & major depression along with the obsessive–compulsive symptoms • The dangerous event is a thought, image, or impulse the client attempts to avoid Psychological Interventions • Exposure & Response Prevention (ERP) – Systematic and gradual exposure to feared thoughts or situations – Rituals are actively prevented – The client learns at an emotional level that no harm will result whether or not s/he carries out the rituals – Kozak, Liebowitz & Foa, 2000 6