5.anxiety_disorders2per

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Unformatted text preview: 10/20/10 Nature
of
Anxiety
and
Fear
 •  Anxiety
and
Fear:

moods
(normal!),
symptoms,
 and
syndromes
 1 10/20/10 Nature
of
Anxiety
and
Fear
 •  Fear
 – Fight
or
flight
 – Sympathe>c
 ac>va>on
 – Avoidance
&
escape
 – Present‐oriented
 Nature
of
Anxiety
and
Fear
 •  Anxiety
 – Tension
 – Unpredictable
 – Uncontrollable
 – Future‐oriented
 2 10/20/10 Anxiety
and
Performance:
 The
Yerkes‐Dodson
Inverted
“U”
 Performance Low Anxiety Level High Anxiety
Disorders
 •  Pervasive
and
persistent
anxiety
and
 fear
 •  Excessive
avoidance
and
escapist
 tendencies
 •  Clinically
significant
distress
and
 impairment
 3 10/20/10 What
is
a
Panic
AQack?
 •  Abrupt,
intense
fear
 or
discomfort
 •  Several
physical
 symptoms
 •  Analogous
to
fear
as
 an
alarm
response
 DSM‐IV
Subtypes
of
Panic
AQacks
 •  Situa>onally
bound
(cued)–
Expected
 and
bound
to
specific
situa>ons
 •  Unexpected
(uncued)–
“out
of
the
 blue”
 •  Situa>onally
predisposed–
May
or
may
 not
occur
in
specific
situa>ons
 4 10/20/10 Biological
Contribu>ons
to
Anxiety
 and
Panic
 •  Diathesis‐Stress
 – Inherited
vulnerabili>es
 for
anxiety
and
panic
 – Stress
and
life
 circumstances
determine
 type

 Biological
Contribu>ons
to
 Anxiety
and
Panic
 •  GABA
circuits
 •  Cor>cotropin
releasing
factor
(CRF)
and
 HPA
axis
 •  Limbic
(amygdala)
and
the
septal‐ hippocampal
systems
 5 10/20/10 Biological
Contribu>ons
to
Anxiety
 and
Panic
 •  Fight/flight
(FF)
system
 – Serotonin?
 – Brainstem
‐
amygdala
‐
hypothal.

 •  Behavioral
inhibi>on
system
(BIS)
 – Brainstem
‐
amygdala
‐
septal‐hippocampal
 system

 Psychological
Contribu>ons
to
 Anxiety
and
Fear
 •  Began
with
Freud
 –  Reac>va>on
of
an
 infan>le
fear
situa>on
 6 10/20/10 Psychological
Contribu>ons
to
 Anxiety
and
Fear
 •  Behavioral
Views
 – Classical
and
operant
condi>oning
 – 
modeling
 •  Psychological
Views
 – Early
experiences
with
uncontrollability
 and
unpredictability
 Psychological
Contribu>ons
to
 Anxiety
and
Fear
 •  Social
Contribu>ons
 –  Stressful
life
events
trigger
biological/psychological
 vulnerabili>es
 –  Familial
and
interpersonal
 7 10/20/10 An
Integrated
Model
 •  Biological
vulnerability
 •  Psychological
vulnerabili>es
 –  Nega>ve
Schemas
 •  Experiences
 Common
Processes:

The
 Problem
of
Comorbidity
 •  55%
have
concurrent
dx
 •  Major
depression
most
common
 •  Common
factors
across
anxiety
and
mood
 disorders
 8 10/20/10 The
Anxiety
Disorders
 •  •  •  •  •  •  Generalized
Anxiety
Disorder
 Panic
Disorder
with
and
without
Agoraphobia
 Specific
Phobias
 Social
Phobia
 PosQrauma>c
Stress
Disorder
 Obsessive‐Compulsive
Disorder
 Generalized
Anxiety
Disorder:

The
 “Basic”
Anxiety
Disorder
 •  Defining
Features
 –  Excessive
 uncontrollable
 anxious
apprehension
 and
worry
 –  Lasts
>=
6
months
 –  Soma>c
symptoms
 differ
from
panic
 (muscle
tension,
 fa>gue,
irritability…)
 9 10/20/10 “Do
you
worry
excessively
about
 minor
things?”
 Generalized
Anxiety
Disorder
 •  Sta>s>cs
 –  4%
prevalence;
One
of
the
most
common
 –  Females

2:1
 –  Insidious
onset
in
early
adulthood
   Tendencies
run
in
families
 –  Chronic
 10 10/20/10 Generalized
Anxiety
Disorder
 •  “autonomic
 restrictors”
 •  Emo>onal
 avoidance
 •  Chronic
worriers
 •  Muscle
tension
 Generalized
Anxiety
Disorder
 •  Treatment:

Modest
help
 – Benzodiazapines
 •  Cogni>ve
effects
 •  Highly
addic>ve

 – Psychological
interven>ons
–
Cogni>ve‐ Behavioral
Therapy
 11 10/20/10 Panic
Disorder
With
and
Without
 Agoraphobia

 •  Overview
and
Defining
Features
 –  Unexpected
panic
aQack
(i.e.,
a
false
alarm)
 –  Develop
anxiety,
worry,
or
fear
about
having
another
 aQack
or
its
implica>ons
that
persist
for
1
month
or
 more
 Panic
Disorder
With
and
Without
 Agoraphobia

 •  Overview
and
Defining
Features
 –  Agoraphobia
–
Fear
or
avoidance
of
situa>ons/events
 associated
with
panic
 12 10/20/10 Panic
Disorder
With
and
Without
 Agoraphobia

 •  Facts
and
Sta>s>cs
 –  3.5%
of
the
general
popula>on
meet
diagnos>c
criteria
 for
panic
disorder
 –  Female
2:1
 –  Onset
is
omen
acute,
beginning
between
25
and
29
 years
of
age
 Panic
Disorder
 •  Associated
Features
 –  Nocturnal
panic
aQacks
–
60%
experience
 panic
during
deep
non‐REM
sleep
 –  Interocep>ve/exterocep>ve
avoidance,
 catastrophic
misinterpreta>on
of
symptoms
 13 10/20/10 Panic
Disorder:
Treatment
 •  Medica>on
 –  Target
serotonergic,
noradrenergic,
and
 benzodiazepine
GABA
systems
 –  SSRIs
(e.g.,
Prozac
and
Paxil)
are
currently
the
 preferred
drugs
 –  Relapse
rates
are
high
following
medica>on
 discon>nua>on
 Panic
Disorder:
Treatment
 •  Psychological
and
Combined
Treatments
 – Cogni>ve‐behavior
therapies
are
highly
 effec>ve
(PCT)
 – Combined
treatments
do
well
in
the
short
 term
 – Best
long‐term
outcome
is
with
cogni>ve‐ behavior
therapy
alone
 14 10/20/10 
Specific
Phobias:

An
Overview
 •  Extreme
irra>onal
fear
of
a
specific
 object
or
situa>on
 •  Markedly
interferes
with
one’s
ability
 to
func>on
 •  Avoidance
of
feared
object
 •  Knows
that
the
fear
and
avoidance
are
 unreasonable

 
Specific
Phobias:

An
Overview
 •  Facts
and
Sta>s>cs
 – Females
are
again
over‐represented
 – About
11%
of
the
general
popula>on
 – Chronic
course,
with
onset
beginning
 between
15
and
20
years
of
age
 15 10/20/10 Specific
Phobias:

Associated
 Features
and
Subtypes
 •  Blood‐injury‐injec>on
phobia
–
Vasovagal
 response
to
blood,
injury,
or
injec>on
 •  All
other
subtypes
are
less
meaningful
 Specific
Phobias:

Causes
 •  •  •  •  Biological
and
evolu>onary
vulnerability
 Direct
condi>oning
 Observa>onal
learning
 Informa>on
transmission
 16 10/20/10 Specific
Phobias:

Treatment
 •  Psychological
 Treatments
 – CBTs
are
highly
 effec>ve
 – Systema>c
 desensi>za>on
 – Flooding
 PosQrauma>c
Stress
Disorder
 (PTSD):

An
Overview
 •  Overview
and
Defining
Features
 –  Requires
exposure
to
an
event
resul>ng
in
 extreme
fear,
helplessness,
or
horror
 –  Reexperiencing
 17 10/20/10 PosQrauma>c
Stress
Disorder
 (PTSD):

An
Overview
 •  Overview
and
Defining
Features
 – Avoidance
of
cues
 – Emo>onal
numbing
and/or
arousal
 – Markedly
interferes
with
one's
ability
 to
func>on
 – Symptoms
>
1
month
 PosQrauma>c
Stress
Disorder
 (PTSD):

An
Overview
 •  Sta>s>cs
 – Combat
and
sexual
assault
are
the
 most
common
traumas
 – About
7.8%
of
the
general
popula>on
 meet
criteria
for
PTSD
 18 10/20/10 PosQrauma>c
Stress
Disorder
(PTSD):
 Subtypes
 •  Acute
PTSD
‐
1‐3
months
post
trauma
 •  Chronic
PTSD
‐
>
3
months
post
 trauma
 •  Delayed
onset
PTSD
‐
Onset
>
6
 months
 •  Acute
stress
disorder
‐
Immediately
 post‐trauma
 PosQrauma>c
Stress
Disorder
 (PTSD):
Causes
 •  Intensity
of
the
trauma
and
one's
 reac>on
to
it
 •  Uncontrollability
and
unpredictability
 •  Direct
condi>oning
and
observa>onal
 learning
 •  Moderator:

Social
support
 19 10/20/10 PosQrauma>c
Stress
Disorder
 (PTSD):

Treatment
 •  
Psychological
Treatment
 •  CBT’s
are
highly
effec>ve
 –  Graduated
or
massed
(e.g.,
flooding)
imaginal
 exposure
 
Obsessive‐Compulsive
Disorder
(OCD):

 An
Overview
 •  Obsessions
‐
Intrusive
and
nonsensical
 thoughts,
images,
or
urges
that
one
 tries
to
resist
or
eliminate
 – Contamina>on
 – Aggression
 – Symmetry
 20 10/20/10 
Obsessive‐Compulsive
Disorder
 (OCD):

An
Overview
 •  Compulsions
‐
Thoughts
or
ac>ons
to
 suppress
the
obsessions
 – Overt:
cleaning
and
washing,
checking
 rituals
 – Covert:
sequencing,
repe>>on
 
Obsessive‐Compulsive
Disorder
 (OCD):
Obsessions
 •  Types
(Akhtar
et
al.,
1975):
 – Doubts
(74%)
 – Thinking
(34%)
 – Fears
(26%)
 – Impulses
(17%)
 – Images
(7%)
 – Other
(2%)
 21 10/20/10 
Obsessive‐Compulsive
Disorder
 (OCD):
Obsessions
 •  Doubt
‘Did
I
lock
the
door’
(M,
28)
 •  Thought/Fear
that
he
had
cancer
(M,
46)
 •  Thought/Image
that
he
had
knocked
 someone
down
in
his
car
(M,
29)
 
Obsessive‐Compulsive
Disorder
 (OCD):
Obsessions
 •  Impulse
+
thought
to
shout
 obsceni>es
in
church
(F,
19)
 •  Image
of
corpse
roxng
away
(F,
27)
 •  Impulse
to
drink
from
inkpot
and
to
 strangle
son
(M,
41)
 22 10/20/10 •  About
2.6%
life>me
prevalence
 •  Mostly
female
 •  Onset
in
early
adolescence
or
young
 adulthood
 •  Tends
to
be
chronic

 Obsessive‐Compulsive
Disorder:

 Sta>s>cs
and
Features
 Obsessive‐Compulsive
Disorder:

 Causes
 •  Parallel
the
other
anxiety
disorders
 (biopsychosocial
interac>ons)
 •  Early
life
experiences
and
learning

 – Some
thoughts
are
dangerous
but
 controllable
 •  Thought‐ac>on
fusion
 – Moral
vs.
Likelihood
 23 10/20/10 Mul>site
OCD
Study
 Foa
and
Liebowitz
(1997)
 •  Primary
aim
 – Compare
independent
and
combined
 effects
of
clomipramine
and
exposure‐ response
preven>on
(ERP)
 •  Treatment
Condi>ons
 – Clomipranine
(CMI)
alone
 – ERP
alone
alone
 – Clomipranine
+
ERP
 – Pill
placebo
alone
 Mul>site
OCD
Study
 •  Sample
 – 99
pa>ents
mee>ng
DSM‐III‐R
 criteria
for
obsessive
compulsive
 disorder
 •  2
Phases
of
the
Study
 – Acute
phase
(12
weeks)
 – No
treatment
follow‐up
(6
months)
 24 10/20/10 Mul>‐Site
OCD
 Acute
Treatment
Response
 Data taken from Foa & Liebowitz,(1997) Mul>‐Site
OCD
 Relapse
at
Follow‐up
 25 10/20/10 Summary
of
Anxiety‐Related
 Disorders
 •  Anxiety
disorders
represent
some
of
the
most
 common
forms
of
psychopathology

 Summary
of
Anxiety‐Related
 Disorders
 •  From
a
normal
to
a
disordered
 experience
of
anxiety
and
fear
 – Fear
and
anxiety
persist
to
bodily
or
 environmental
non‐dangerous
cues
 – Symptoms
and
avoidance
cause
 distress
and
impairment
 – Considera>on
of
biological,
 psychological,
experien>al,
and
social
 factors
 26 10/20/10 Summary
of
Anxiety‐Related
 Disorders
 •  Psychological
treatments
are
generally
 superior
in
the
long‐term
 – Most
treatments
involve
exposure
 – Suggests
that
anxiety‐related
disorders
 share
common
processes
 27 ...
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This note was uploaded on 11/15/2010 for the course PSYC PSYC 163 taught by Professor Mickeys,l during the Fall '09 term at UCSD.

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