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Chapter 6

Ch. 6 Anxiety disorders.pdf

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McMaster University
Richard B Day

 Anxiety disorders  25 - 30% = lifetime prevalence o Most common category of psych disorders  16% of women and 9 % of men = annual prevalence  Cost 42.3 billion in direct and indirect costs in 1990  History  Neurotic behaviour = maladaptive and self-defeating, but they aren't out of touch with reality, incoherent or dangerous  Freud o Neurosis - intrapsychic conflict produced significant anxiety o DSM 3 dropped the term neurosis  Most commoncategory of disorders in all but one country (Ukraine) o 2.4 - 18.2 % prevalence range  Fear and anxiety responsepatterns  Hard to differentiate  Fear; clear and obvious source that most people would consider as real  Anxiety; can't specify the danger, unpleasant inner state where we think something bad will happen that wouldn't be predictable from our actual circumstances  Basic fear and anxiety are highly conditionable o Normal and adaptive… but can lead to clinically significant fears and anxieties  Fearorpanic o Shared by many animals o Fight or flight response of the sympathetic nervous system o Fear is adaptive to escape from danger o Panic occurs without an external threat and is a misfiring of this response system o 3 components Cognitive/subjective component - I'm going to die   Physiological component - fast heart beat  Behavioural component - need to run away o Fear  Instantaneous reaction to an imminent threat o Panic attack  Fear/ panic occurs in the absence of obvious external danger  Accompanied by later cognitive feelings of impending doom  Anxiety o Blend of unpleasant emotions and cognitions oriented towards the future and more diffused than fear o Same 3 components  Negative mood, chronic over arousal and tension, situation avoidance o No activation of fight or flight response, but primes it and gets it ready o Adaptive value Helps us plan and prepare for possible threats   Can be helpful and adaptive in mild or moderate degrees o Maladaptive if chronic or severe  Overviewofanxietydisordersand their commonalities  Unrealistic, irrational fears or anxieties of disabling intensity  The varied disorders differ in the quality of fear/panic versus anxiety and the kinds of objects or situations that concern them o Panic: social, specific; panic; gad; ocd; ptsd  Biological causes o Genetic vulnerability at the psychological level = neuroticism  Proneness to have negative mood o Limbic system o Neurotransmitters: GABA, norepinephrine and serotonin  Psychologicalcauses o Classical conditioning to a range of stimuli o Having a perception of uncontrollability in life - more vulnerable o Some parenting styles can affectwhat you become fearful of  Treatments o Make them understand their distorted thinking and how the patterns can be changed  Graduated exposure to feared cues - behavioural  Cognitive restructuring of thoughts  Not always helpful  Understand their distorted patterns of thought and explore how patterns can be changed o Drugs  Anti-anxiety or anti-depressants  Higher relapse rates than CBT methods  PhobicDisorders  Most common anxiety disorder  Persistent and disproportionate fear of a specific object or situation that has no actual danger yet causes severe avoidance  3 main types o Specific phobia o Social phobia o Agoraphobia  SpecificPhobia  Show fear response resembling a panic attack when encounter the specific feared object o Continues to be reinforced; every time they avoid a fear, their anxiety reduces  Recognized the fear is excessive or unreasonable -- DSM 4  5 main phobia types o Blood-injection-injury phobia  3 - 4% of the population  Unique physiological response o Initial heart rate increase, followed by a dramatic drop in heart rate and blood pressure o Accompanied by nausea and fainting o Only happens in the presence of blood and injury, not other feared objects o Adaptive  Reduce bleeding and fainting can stop further attack  Age of onsetandgender o 12% lifetime prevalence o 75% with one specific phobia have another o More common in women, but gender ratios vary to the type of specific phobia o Usually originates in childhood  But it varies widely depending on the type  Animal (50% female), blood-injection (90% female) and dental phobias begin in childhood  Psychosocialfactors o Psychodynamic  Phobia = defense against anxiety stemming from repressed impulses from the id o Learning  Classical conditioning  Fear response to a neutral stimuli which can then generalize to similar objects or situations  Overestimating the likelihood that the event with reoccur is likely to maintain or strengthen conditioned fears over time o Vicarious conditioning  Transmitted from someone  Watching a phobic person being fearful with the object can be distressing and cause them to take on the fear too  Rhesus monkey expt o Monkeys rapidly learned a fear of snakes by watching a video of a monkey being scared o Took 4 - 8 minutes of exposure to learn the fear o Fear didn't diminish after 3 months o t/f media can have a role of creating fears and people o Sources of individual differences  Protective factors before o Non-traumatic, positive experiences with the fear before the bad event  During o Having the fearful event being inescapable and uncontrollable is much worse than the opposite  After o Inflation effect  Having something negative happen directly after the mild feared object  Get in a car accident, then get physically assaulted  Verbal information that makes the dangerousness of the previous trauma more  Your lucky to be alive, the guy who hit you had killed people drunk driving before  Cognitions o Phobic people are always on the alert for the feared thing  Overestimate that the feared object will be followed by a negative event o Non phobics try to not pay attention to it o Evolutionary preparedness  The primates and humans who rapidly acquired fears of life threatening things had a selective advantage  Supported o Fear is more easily conditioned to a snake than a flower  Geneticandtemperamentalcausalfactors o Affect the speed and strength of conditioning fear o Behaviourally inhibited at 21 months were at higher risk forat age 7 to 8 than uninhibited kids (35% vs. 5 %) o Modest genetic contribution  Shared phobias for MZ more so than DZ o But non-shared environmental factorsalso play a big role  Treatment o Exposure therapy  Best treatment for specific phobias  Controlled exposure to the fear  Gradually placed (imagine or real) in increasingly feared situations  Expose forlong enough that the fear subsides  Participant modeling o More effective than exposure alone o Therapist calmly models the interaction  Too soon to draw conclusions about virtual reality vs. live exposure efficacy o Cognitive techniques alone and in addition to behavioural do not produces as good results o Not the best to treat with medication  Some evidence anti anxiety meds may interfere with benefits of exposure therapy  D-cycloserine  Used to facilitate extinction of conditioned fear in animals  May enhance the effectiveness of exposure therapy for fear of height  SocialPhobia  Public speaking is the most common one  Attribute events in their lives to external factors  Generalized social phobia o People have big fears of most social situations, not just a few o Comorbid for avoidant personality disorder  Epidemiology o 3 - 7.2% report symptoms meeting the criteria yearly o 12% lifetime incidence rate o More common in women (60% of people with the disorder of women) o Begin later in adolescence or early adulthood o >50% have 1+ additional anxiety disorders o 50% have depressive disorder too o 33% abuse alcohol  Interactionofpsychosocialandbiological causalfactors o Social phobias are generally learned and occur in people who are genetically or temperamentally at risk o Causal factor Statistics  56 - 58% can identify a direct traumatic experience as the origin of their phobia  92% report severe childhood teasing o Vs. 35% with OCD  13% recall vicarious conditioning  96% remember a socially traumatic experience that was linked to their own current image of themselves in socially phobic situations o Memories include:  Being criticized for appearing anxious  Feeling self-conscious or uncomfortable due to bullying  Evolutionarycontext o Evolved as a by-product of dominance hierarchies  Established through aggressive encounters between members of a social group  The defeated is fearful and submissive, but rarely tries to escape the situation entirely o Evolutionary based predisposition to acquire fears of social stimuli that signal dominance and aggression  Process expressions of anger or contempt more readily than happy or neutral facialexpressions o Stronger conditioned responses with angry faces and shocks than other faces  Geneticandtemperamentalfactors o Genetic and environmental factors are equal contributors o Most important temperament variable is  Behavioural inhibition o Easily distressed by unfamiliar stimuli, shy and avoidant o 4x more likely to develop socialphobia  Uncontrollabilityandunpredictability o Lead to submissive and unassertive behaviour o Especially if it stems from social defeat o Diminished sense of personal control  May be related to having overprotective parents  Cognitivevariables o Expect that others will reject and negatively evaluate them o Expect they will be awkward and think they'll be rejected or made fun of o Preoccupied with bodily responses and overestimate how easily other will detect their anxiety o Intense inward self-preoccupation during social situations o Their weirdness may lead to others being less welcoming, which just confirms their expectations  Treatment o Cognitive behavioural therapy  Identify underlying negative automatic thoughts  Logically reanalyze the distortions  Videotaped feedback to help modify their distorted self image  Produce much more long-lasting improvements with very low relapse rates o Unlike specific phobias, it can be sometimes treated with medications  Antidepressants  Comparable to CBT o But higher risk of relapse and must be taken for longer o The combination of meds and CBT works as well as either approach alone, for short term at least  Panic Disorderwithor without agoraphobia  Unexpected or uncued - don't appear to be provoked by the immediate situation  Reach peak intensity in 10 minutes and subside in 20 - 30 minutes, rarely last over 1 hour  85% repeatedly show up at emergency rooms convinced they have a medical problem  Prompt diagnosis and treatment is necessary o Panic disorders have a huge impact on functioning and can worsen many medical problems  Epidemiologyforpanicdisorderwith orwithoutagoraphobia o 4.7% have panic disorder with or without agoraphobia -->lifetime prevalence o Increase in lifetime prevalence estimates from 3.5 to 4.7 since 1995  1.6% from panic disorders  0.7% from agoraphobia o Prevalence is increasing in younger generations o Age of onset is between 15 or 24 and can be higher for women o Chronic and disabling course although intensity varies over time  Agoraphobia o Fear of… Agora = public places of assembly o Streets, crowded places and standing in line is the most commonly feared and avoided places o Why develop?  Frequent complication of having panic attacks in 1+ situations  Scared they'll get an attack in a situation where escape would be very challenging or embarrassing o Progression  Starts by avoiding places where the attack occurred, but then avoidance gradually generalizes o 80 - 90% of people with severe agoraphobia are women  Sociocultural reason o More acceptable for women to avoid situations they fear and get someone to accompany them through the fear o The less masculine one scored on the scale, the more extensive their agoraphobic avoidance - both genders o Agoraphobia without panic  Rare, 1.4% lifetime prevalence  Usually more spread out fearfulness to many parts of the environment  Comorbidity o 50% have an additional diagnoses o 30 - 50% will have serious depression in their lives o May meet avoidant or dependent personality disorder criteria o Little evidence that panic disorder increases the risk forsuicide  Timing offirst panicattack o 80 - 90% report their first panic attack occurred after 1+ negative life event  Highly stressful: death, loss of relationship, job, criminal victim etc. o 7 - 30% who've experienced one panic attack, go on to develop full blown panic disorder o Panic attacks are more frequent than panic disorders  Causal factorsof panic disorder o Biological  Genetic o Moderate heritability component o 2 h = 33 - 43 % of variance due to genetics o Suggest there is overlap in genetic vulnerability with phobias  Biochemical abnormalities o Panic attacks are alarm reactions caused by biochemical dysfunctions  Supported for 40 years via biological challenge procedures  Infusion of X substance produced panic attacks in panic disorder clients at a much higher rate than normal subjects  Panic provocation agents  No single neurobiological mechanism can be implicated  Biological agents put stress on the system which then creates these intense physical symptoms  Exp. Sodium lactate, carbon dioxide, caffeine, CCK-4 o Neurotransmitters  Noradrenergic system  Can trigger cardiovascular symptoms  Serotonergic systems  SSRI's increase serotonin which can decrease noradrenergic activity  GABA  Implicated in the anticipatory anxiety  Abnormally low in people with panic disorder o Panic and the brain  FIRST thought  Locus ceruleus  If stimulated in rhesus monkeys they had panic attack  If removed there was an inability to experience fear  NOW thought  Amygdala  Abnormally sensitive fear networks that get activated too readily to be adaptive  Central area of the fear network  Also activates the locus ceruleus  Triggers autonomic, neuroendocrine and behavioural responses that occur in panic attacks  Hippocampus  Needed to explain the conditioned anxiety towards having another attack o BehaviouralandCognitiveCausalFactors Fear of fear hypothesis  o Early hypothesis forthe origins of agoraphobia o Psychological o Interoceptive conditioning  Initial internal bodily sensations become the CS associated with high levels of anxiety  Minimal signs of sympathetic arousal come to signal more intense levels of arousal such that slight changes in autonomic activity become triggers for panic attacks  Comprehensive learning theory o For panic disorder  3 components  Anticipatory anxiety, agoraphobic fears, panic attacks o Initial panic attack becomes associated with initially neutral stimuli (interoceptive) and external cues  More intense the panic, the more robust the conditioning o Conditioning to internal or external cues can now lead to the development of:  Anticipatory anxiety and agoraphobic fears 3. Anxious apprehension can occur if conditioning occurs to multiple different kinds of cues - generalization 4. Panic attack themselves are likely to be conditioned to certain internal cues  Panic attacks that come out of the blue  Also explains why not everyone with attacks go on to develop a disorder Need certain vulnerabilities to have stronger conditioning  Cognitive theory of panic   The panic circle  Panic clients are hyper sensitive to their bodily sensations and catastrophize about their meanings  The automatic catastrophizing thoughts are the triggers of panic  Only people with this catastrophizing thought pattern can develop panic disorders  Support - panic provocation study  Given cognitive explanation about what to physically expect from sodium lactate infusion and not to worry  Rationale = 30% likely to experience a panic attack vs. 90% likely when not told  Does not explain nocturnal panic attacks or attacks that occur without any preceding negative automatic thoughts  Explanations: learning versus cognitive theory  Panic provocation agents can produce arousal that mimic the cues that usually precede a panic attack  People with panic disorder already start at higher levels of arousal  Learning theory Cognitive theory Better explains panic attacks that occur Emphasis on the meaning without any preceding negative people place on their bodily automatic thoughts and also nocturnal sensations - only experience panic attacks panic if they catastrophize  Anxiety and panic attacks can be Misinterpret and negatively triggered by unconscious intero- or catastrophize high arousal as the exteroceptive cues start of a panic attack  Anxiety sensitivity and perceived control  Anxiety sensitivity  Trait-like belief that certain bodily symptoms may have harmful consequences  Predictor of panic attacks  Development is influenced by both genetic and environmental factors  Relative importance depends on gender and severity  Genetics is more for women and severe AS  Military Training study  High levels of anxiety sensitivity are more prone to developing panic attacks and then disorders
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