Chapter 6_Anxiety Disorders %28compass%29

Chapter 6_Anxiety Disorders %28compass%29 - As requested,...

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Unformatted text preview: As requested, I’ve uploaded this chapter as a power-point. I’ll do this from now on. If you don’t want to use up all of your black ink, be sure to print in “black and white” instead of color or greyscale. -Nancy CHAPTER SIX Anxiety Disorders Overview Notice that the lectures for this chapter are organized differently than the textbook You are responsible for knowing both information from the book and from the lectures Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Generalized Anxiety Disorder Obsessive­Compulsive Disorder Panic Disorder and Agoraphobia Specific Phobia Social Phobia Epidemiology Common Features of Anxiety Disorders What do anxiety disorders have in common? People with anxiety disorders share a preoccupation with or persistent avoidance of thoughts and situations that provoke fear or anxiety. Anxiety vs. Fear Fear Experienced when a person is faced with real and immediate danger Mostly involves somatic symptoms (e.g. increased heart rate) Anxiety May mostly involve anticipation of future negative events (worry) Present­oriented Can be adaptive May mostly involve somatic arousal Can be adaptive if not excessive Prevalence & Comorbidity Prevalence Anxiety disorders are more common than any other form of mental disorder. Highly Comorbid Between different anxiety disorders Between anxiety and depression Between anxiety and substance abuse What do anxiety and depression have in common? Both defined in terms of negative emotional experience Both triggered by stressful experiences Depression/Anxiety Comorbidity: Conceptual and Clinical Overlap Positive Affect “pure” Depression Negative Affect “General Distress” Comorbid Dep/Anx Somatic Arousal “pure” Anxiety Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Generalized Anxiety Disorder Obsessive­Compulsive Disorder Panic Disorder and Agoraphobia Specific Phobia Social Phobia Post Traumatic Stress Disorder Epidemiology Overview of Treatment for Anxiety Exposure (in vivo = direct) Systematic Desensitization the client is taught to relax and while in a relaxed state they are presented with items on a fear hierarchy, starting with the least threatening Flooding exposure to the most threatening or frightening stimuli first Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Generalized Anxiety Disorder Obsessive­Compulsive Disorder Panic Disorder and Agoraphobia Specific Phobia Social Phobia pidemiology Generalized Anxiety Disorder Anxiety in GAD focuses on everyday events (worry + physical symptoms) DSM­IV­TR criteria for GAD include: Excessive worry occurring more days than not Person finds it difficult to control the worry Restlessness, easy fatigue, difficulty concentrating, muscle tension, sleep disturbance, irritability Generalized Anxiety Disorder GAD is characterized by anxious apprehension (worry) GAD is a state of High negative affect and chronic over­arousal Feeling that the worrying is out of control Focus on threat­related stimuli that may indicate future negative events (hyper­ vigilance) GAD: Hypothesized Etiological Factors Anxiety as trait does seem to run in families, but GAD results less conclusive Intolerance of uncertainty Belief that worry is adaptive (prevents panic) Avoidance of threatening information GAD: Cognitive Therapy The three main facets: The three main facets: Considering thoughts as hypotheses rather than facts that can be supported (or not) by evidence Utilizing past and present evidence to examine the validity of the belief Exploring and generating all possible predictions or interpretations of an event GAD: Cognitive Therapy Step 1: Awareness Provide clients with overview of how their cognitions work Step 2: Interpretation Make clients understand the nature of inappropriate anxiety and the role of their interpretation of situations that create negative affect. Step 3: Specific Negative Prediction Identify the specific interpretations or negative predictions that the clients are making and challenge them. Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Generalized Anxiety Disorder Obsessive­Compulsive Disorder Panic Disorder and Agoraphobia Specific Phobia Social Phobia Epidemiology Obsessive-Compulsive Disorder Can have obsessions or compulsions or both Obsessions Intrusive thoughts, images, urges that one tries to resist or eliminate They are inappropriate to the situation Compulsions Mental acts or behaviors a person feels driven to carry out in response to an obsession Aimed at preventing or reducing distress or preventing some dreaded situation Obsessive-Compulsive Disorder Compulsions can exist without obsessions and obsessions can exist without compulsions Most people with OCD have both Most individuals with OCD do recognize that their obsessions and compulsions are unreasonable and try to avoid doing them Obsessive-Compulsive Disorder Typical obsessions include: contamination doubts order losing control possible need Obsessions are often about normal concerns (e.g., germs, neatness), but differ in intensity level compared to people without OCD Onset: early adolescence to young adulthood Course: typically chronic Video OCD: Rebound Effect 1. Born with a predisposition to be very emotionally reactive 2. Emotional Trigger/Event oh uh 3. You try to suppress emotional response OBSESSIONS & COMPULSIONS .. ll. i ch 4. But, the more you suppress, the more aware you become OCD Treatment: Exposure & Response Prevention Step 1 Step 1 Information gathering Step 2 Exposure & response Step 3 Record keeping Step 4 Homework assignments Step 5 Support Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Generalized Anxiety Disorder Obsessive­Compulsive Disorder Panic Disorder and Agoraphobia Specific Phobia Social Phobia Epidemiology Panic Attack: Criteria Palpitations, pounding or accelerated heart rate Sweating Trembling and shaking Sensations of shortness of breath or smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Panic Attack: Criteria (cont’d) Feeling dizzy, unsteady or faint Derealization (feelings of unreality) or depersonalization (being detached from oneself) Fear of losing control or going crazy Fear of dying Paresthesias (numbness or tingling sensations) Chills or hot flushes Panic Attack Involves an abrupt experience of intense fear or acute discomfort Accompanied by physical symptoms (e.g., heart palpitations, chest pain) Symptoms develop suddenly and reach a peak within 10 minutes Can experience panic attacks with each of the anxiety disorders Panic Attack: Types Three types: Situationally bound (cued) Panic only when you see a spider Unexpected (uncued) Out of the blue Situationally predisposed a person more likely to have a panic attack where s/he had one before (e.g., crowded restaurant), but having one isn’t inevitable Panic Disorder: Criteria Panic Disorder is the presence of: Panic Disorder Recurrent, unexpected panic attacks and 1 more more of the following symptoms: At least 1 month of persistent concern about having another attack Worry about the possible implications of the panic attacks Significant behavioral change related to the attacks. Agoraphobia: Criteria The essential feature of agoraphobia is anxious The essential feature of agoraphobia is apprehension about being in places or situations from which: Escape might be difficult or embarrassing Help may not be available if one has a panic attack Panic Disorder & Agoraphobia PANIC DISORDER A G O R A P H O B I A No No Yes No No disorder Panic Disorder without Yes Agoraphobia without Panic Disorder Agoraphobia Panic Disorder with Agoraphobia Panic Attack: Catastrophic Misinterpretation Step 1 Step 1 A person misinterprets bodily sensations associated with anxiety (e.g., rapid heart rate) as dangerous Step 2 This leads a person to become more vigilant to interoceptive cues of anxiety (hyper­vigilance & anxiety sensitivity) Step 3 This hyper­vigilance leads to increased awareness of biological reactions and bodily sensations (i.e., muscle tension) Step 4 Misinterprets these sensations as catastrophic events (e.g., I’m sick, I’m going crazy, I’m going to die) Neuro Psycho Social Fear of Fear: Anxiety is dangerous (false alarms) Catastrophic Thinking & Anxiety Misinterpreting sensitivity/ bodily sensations: Hypervigilanc Bodily sensations e: To bodily characteristic of sensations anxiety indicate an unknown illness Bodily Sensations: i.e. muscle tension, headaches (learned alarms) Panic Attacks Panic Attack: Barlow & White (1988) predisposition to be overreactive to stress predisposition to be overreactive to stress stressful event False Alarm! (becomes a Learned Alarm) “unexplained physical sensations are dangerous” worry focused on somatic sensations Panic Disorder Developing Agoraphobia (avoidance) Panic Disorder with Agoraphobia Bio Psycho Social Fear of Fear: Anxiety is dangerous (false alarms) Brain Systems, Neural Comm., Genetics (Predisposition to be anxious) Catastrophic Thinking & Anxiety Misinterpreting sensitivity/ bodily sensations: Hypervigilanc Bodily sensations e: To bodily characteristic of sensations anxiety indicate an unknown illness Bodily Sensations: i.e. muscle tension, headaches (learned alarms) Panic Attack: Etiology Biological Factors Biological Factors Neurochemistry One theory suggests that several neurotransmitter systems may be “hyperactive” in people with panic disorder. Bio Stressful Life Event: Initial attack years ago during dangerous situation (true alarm) Family/Gender/ Culture Brain Systems, Neural Comm., Genetics (Predisposition to be anxious) Stressors: Work/School & Relationships Psycho Social Fear of Fear: Anxiety is dangerous (false alarms) Catastrophic Thinking & Anxiety Misinterpreting sensitivity/ bodily sensations: Hypervigilanc Bodily sensations e: To bodily characteristic of sensations anxiety indicate an unknown illness Bodily Sensations: i.e. muscle tension, headaches (learned alarms) Avoidance of triggering stimuli: Afraid to drive, be home alone, …… Panic Attacks Panic Disorder: Psychological Treatment Cognitive Methods Cognitive Restructuring (Coupled with psycho­ education) Behavior Methods Relaxation Breathing Re­training Exposure (Imaginal, In­vivo, Interoceptive) Interoceptive Exposure i.e., shake head (30 sec), breathe through a straw (60 sec), tense body muscles (60 sec), Stare at object of mirror (90 sec) Panic Disorder: Other Treatments Targeting Neurological Factors Antidepressants (i.e., SNRIs or SSRIs), TCAs, Benzodiazepines (i.e. Valium & Xanax), Azapirones (BuSpar) Targeting Social Factors Group Therapy Self­help or with a therapist Focus specifically on panic disorder and agoraphobia Meeting with others with similar difficulties may help lessen sense of isolation and shame Psychoeducation, Cognitive rStressful Life estructurin g* Event: Initial attack years ago while driving resulting in car accident (true alarm) Family/Gender/ Culture Brain Systems, Neural Comm., Genetics (Predisposition to be anxious) Breathing reStressors: training, Work/School relaxation & Relationships Bio Psycho Social Fear of Fear & Catastrophic Thinking : Anxiety is dangerous & the bodily sensations characteristic of anxiety Interoceptive indicate an unknown exposure * illness (false alarms) Misinterpreting bodily sensations: Viewed as symptoms of illness Anxiety sensitivity/ Hypervigilanc e: To bodily sensations Bodily Sensations: i.e. muscle tension, headaches (learned alarms) Avoidance of triggering Stimuli: Afraid to drive, be home alone, …… * Exposure to agoraphobiarelated stimuli Panic Attacks Treatments Targeting Psychological Factors: Changes thoughts, feelings, & behaviors *CBT Bio Psycho Social Stressful Life Event: Initial attack years ago while driving resulting in car accident (true alarm) Family/Gender/ Culture Brain Systems, Neural Comm., Genetics (Predispostion Predisposition to be anxious) Stressors: Work/School & Relationships Fear of Fear & Catastrophic Thinking : Anxiety is dangerous & the bodily sensations characteristic of anxiety indicate an unknown Medication: illnessSSRIs,alarms) (false SNRIs, Misinterpreting bodily sensations: Viewed as symptoms of illness TCAs, benzodiazepines Anxiety sensitivity/ Hypervigilanc e: To bodily sensations Bodily Sensations: i.e. muscle tension, headaches (learned alarms) Avoidance of triggering Stimuli: Afraid to drive, be home alone, …… Panic Attacks Treatments Targeting Neurological Factors: Changes neural activity Bio Psycho Social Stressful Stressful Life Event: Initial attack years ago d hile driving wuring dangerous situation in car resulting (true accident (true larm) alarm) Family/Gender/ Family/Gender/ Culture Brain Systems, Neural Comm., Genetics (Predisposition to be anxious) Stressors: Work/School & Relationships Fear of Fear & Catastrophic Thinking : Anxiety is dangerous & the bodily sensations Group Therapy characteristic of anxiety Couples or indicate an unknown illness Family Therapy (false alarms) Misinterpreting bodily sensations: Viewed as symptoms of illness Anxiety sensitivity/ Hypervigilanc e: To bodily sensations Bodily Sensations: i.e. muscle tension, headaches (learned alarms) Avoidance of triggering Stimuli: Afraid to drive, be home alone, …… Panic Attacks Treatments Targeting Social Factors: Decreases shame/ isolation; Increases family members’ Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Generalized Anxiety Disorder Obsessive­Compulsive Disorder Panic Disorder and Agoraphobia Specific Phobia Social Phobia Epidemiology Specific Phobia Excessive or unreasonable fear related to a specific object/situation that interferes with functioning (e.g., fear of snakes) DSM­IV­TR’s Five Types Animal Natural environment Blood/injury Situational Other Etiology of Phobia Evolutionary adaptation Preparedness Model Negative information Classical conditioning Specific Phobia: Treatment Exposure Therapy (in vivo) Components Exposure Therapy Phobic learning history – create new learning history Stimulus exposure anxiety relaxation decreased anxiety Fear & Avoidance Hierarchy (FAH) Subjective Units of Distress Scale (SUDS) Fear Hierarchy Example 1. 1. 2. 3. 4. 5. 6. 7. 8. (SUDS) (25) Thinking about a spider (40) Seeing a picture of a spider far away Seeing a picture of a very close­up spider Seeing a spider in a cage far away (60) Seeing a spider in a cage close up (75) (85) Seeing a spider loose far away (95) Seeing a spider close­up (100) Holding a spider (45) Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Generalized Anxiety Disorder Obsessive­Compulsive Disorder Panic Disorder and Agoraphobia Specific Phobia Social Phobia Epidemiology Social Phobia Characterized by fear of humiliation by either performing badly or by displaying visible symptoms of anxiety. More than shyness If the fears include most social situations, it is considered generalized social phobia Social Phobia: Criteria Marked and persistent fear of one or more social or performance situations in which a person is exposed to unfamiliar people or possible scrutiny by others Exposure to the feared social situation invariably provokes anxiety The person realizes that the fear is excessive or unreasonable The feared situation is avoided or endured with great distress Social Phobia: Cognitive Biases Attention what people attend to Memory what people remember Judgment how people judge things (e.g., how likely certain outcomes are) and their judgments of what the costs and benefits would be of various outcomes Social Phobia: Cognitive Biases Social Phobia: Etiology 2 kinds of judgment biases in individuals with anxiety disorders: exaggerated estimates of the occurrence of negative events exaggerated estimates of the cost (valence) of negative events Social phobia is more distinguished by exaggerated cost Social Phobia: Cognitive & Exposure Treatment Step 1 Step 1 Simulated exposure to feared situations in the session Step 2 Cognitive rethinking about the social cost of behavior Step 3 Homework assignments for in vivo exposure that is developed in the session and is relevant to the person’s life Anxiety Disorders Anxiety, Fear, and Depression Overview of Anxiety Treatment Generalized Anxiety Disorder Obsessive­Compulsive Disorder Panic Disorder and Agoraphobia Specific Phobia Social Phobia Epidemiology Epidemiology of Anxiety Disorders Disorder Panic Agoraphobia GAD Social Phobia OCD Age Of Onset High Risk Groups late adolescence, separated, divorced, women mid­30s 20s­40s 10­19, 40’s adolescence adolescence ­ early adult separated, divorced, African Americans separated, divorced, women, unemployed, African Americans low income, Asian Americans, women separated, divorced Lifetime Prevalence Rates by Gender 20 15 10 5 0 5 2.3 Panic 6.6 3.6 GAD Females 15.5 11.1 Social Phobia Males 2.8 2.4 OCD One-Year Prevalence Rates by Gender 10 8 6 4 2 0 3.2 1.3 Panic 4 2 GAD Females 9 7 Social Phobia Males 1.4 1.9 OCD One-Year Prevalence Rates by Race 10 8 6 4 2 2.68 Whites 3.39 2.46 5.21 9.19 5.37 African Americans Latinos 1.7 OC D 3.66 or ap ho bia 6.09 Ag 3.47 ho bia 0.66 So c ia lP 1 GA D 0.9 Pa nic 0 1.41 0.77 ...
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