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Chapter 5

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PSYC 235
Christopher Bowie

Chapter 5: Anxiety Disorders Anxiety: negative mood state characterized by bodily symptoms of physical tension and apprehension about the future. -Subjective sense of unease, behaviours (looking worried, anxious, fidgeting) or physiological response from the brain caused elevated heart rates and muscle tension Fear: an immediate alarm reaction to danger Fear Anxiety -Present-orientated negative mood state -Future-orientated mood state -Immediate FFS response to danger or characterized by negative affect threat -Somatic symptoms of tension -Strong alarm & escape behaviour -Apprehension about future danger or -Abrupt activation of the sympathetic misfortune nervous system -Behavioral inhibition system Yerkes Law: performance increases with moderate levels of anxiety and arousal to a certain point and then decreases (skilled motor movements, complex intellectual tasks, perception of new information) Panic Attack: abrupt experience of intense fear or acute discomfort along with physical symptoms (4 or more that peak within 10 minutes) Palpitations, Pounding heart, Trembling/shaking, Shortness of breath or smothering, Feeling of choking, Chest pain, Nausea, Feeling dizzy or faint, Numbing or tingling sensations, Chills or hot flashes, De-realization, depersonalization, dissociation Sub-types of Panic Attacks 1. Situationally bound (cued) -Expected pain in specific situation -Common in people suffering from specific phobias 2. Unexpected (uncued) -Common in panic disorder 3. Situationally predisposed -Panic may or may not happen in given setting Stress, Drugs, Exercise, Hyperventilation, Relaxation/Meditation, Physical/Medical Biological Contributions  Weak contributions from many genes in several different chromosomes  Depleted levels of GABA (associated with increased anxiety)  Serotonergic neurotransmitter system  GABA benzodiazepine system and the serotonergic and nor-adrenergic neurotransmitter systems Corticotropin releasing factor system (CRF): activates the hypothalamic pituitary adrenocortical axis (HPA) and effects areas of the brain that causes anxiety -> limbic system mediator between brain stem and cortex) -Primitive brain stem sense changes in the body and sends signals of possible danger to higher cortical processes through the limbic system) Behavioral inhibition system (BIS): activated by signals of unexpected events from brain stem such as major changes in body functioning that might signal danger. (Danger signals->cortex->septal-hippocampal system) -Boost from amygdala -People tend to freeze, experiencing anxiety and then evaluate the situation to confirm if danger is present Fight-Flight System (FFS): activated in part by serotonin deficiencies Smoking as a teenager is associated with greatly increasing disk for developing anxiety disorders as an adult (in particular panic disorders) ->Chronic exposure to nicotine (increases anxiety as well as respiratory problems) somehow sensitizes brain circuits associated with anxiety and increase the biological vulnerability to develop sever anxiety disorders Psychological Contributions Freud: anxiety was a psychic reaction to danger surrounding the reactivation of an infantile fearful situation Behavioral theorist: product of early classical conditioning, modeling or other forms of learning ->In childhood we learn that events are not always in our control ->General “sense of uncontrollability” may develop early as function of upbringing and other environmental factors Providing a secure “home base” for children so parents are then when they need them is important Conditioning & Cognitive: emotional response becomes associated with variety of external and internal cues (hard to separate)  Strong fear response occurs during stress/danger  Cues provoke fear response/assumption of danger whether danger or not  External cues are places/situations similar to when initial attack occurred Internal cues are increase in physical changes associated with original attack Social Contributions : stressful life events trigger our biological and psychological vulnerabilities to anxiety ->Way we react to stress runs in family Panic Disorder with Agoraphobia (PDA): experience unexpected panic attacks because they think they are dying or otherwise losing occurs. Because they never know when an attack will occur they develop Agoraphobia (fear/avoidance of situation/events) 1. Unexpected panic attack(s) 2. One month or more of the following: a. Concern about additional attacks b. Worry about consequences c. Change in behavior related to attacks 3. Diagnosed with(out) Agoraphobia 4. Panic not due to medical condition or drugs 5. Not better accounted for by other disorder A) Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or Situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd; or standing in a line; being on a bridge; traveling in a bus, train, or automobile. B) The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion. Biological Factors 1) Genetics:  Family & twin studies suggest a general vulnerability (chronic anxiety) or specific biological vulnerability 2) Neurotransmitter Dysregulation  Norepinephrine poorly regulated by locus ceruleus  Cholecystokinin release linked to anxiety -> hypersensitive sympathetic nervous system 3) Psychological  Cognitive vulnerabilities -High interoceptive awareness of anxiety cues -Anxiety sensitivity (belief about consequence of anxiety- higher in females) -Catastrophic misinterpretations of anxiety symptoms -Beliefs about controllability of anxiety attacks  Behavioral vulnerabilities -Avoidance of situations associated with panic -Lacks behavioral skills to cope Statistics  3.5% of population meets criteria for panic disorder  5.3% meet criteria for agoraphobia  75% usually women -more socially acceptable to be afraid  Onset occurs usually early in adult life (mid teens-40)  Men who experience sudden attacks resort to alcohol consumption to cope Cultural Influences -1 year prevalence of panic disorder is 1% in men and 2% in women -Phobia avoidance more common in panic disorder patients in North America compared to Latin Americans -Fear of dying/choking/smothering sensations more coming in southern countries  Susto: (Latin America) sweating, increased heart rate, insomnia but no anxiety or fear although brought on by fear  Ataques de nervios: (Caribbean): similar to panic attacks, often symptoms such as uncontrollable shouting, bursting into tears  Kayak-angst (Inuit, Greenland): episodes of intense fear, worries of drowning, physical arousal sensation, intense disorientation Nocturnal Panic : occur during delta wave/slow wave sleep (deepest stage) and think that they are dying ->60% of people with panic disorder experience this ->Changes in sleep produce physical sensations of “letting go” ->People are not dreaming when they have nocturnal panics Isolated sleep paralysis: during transitional state between sleep and waking ->Rem sleep is spilling into waking cycle (REM sleep is lack of body movement) ->vivid dreams can account for hallucination Treatment Medication : responses to certain treatments may indicate the cause of disorder ->Relapse rates are high once medication is stopped ->60% panic free after treatment Benzodiazepines  Quick and effective but causes physical dependence/addiction  Affect cognitive and motor functions  90% relapse rate Tricyclic antidepressants  20-50% relapse rate (SSRI) such as Prozac, Paxil (Preferred drug)  75% experience sexual dysfunction GABA-benzodiazepine neurotransmitter systems Psychological Intervention Original Treatment: reducing agoraphobic avoidance, using strategies based on exposure to feared situations, relaxation or breathing (70% improvement rate) Panic Control Treatment (PCT): concentrate on exposing patients to the feelings that remind them of their panic attacks -Attempt to create ‘mini’ panic attacks -Basic attitudes and perceptions of the feared object are identified and modified -Taught breathing retraining and relaxation to lower baseline anxiety Multi-Site Comparative Study for the Treatment of Panic Disorder Barlow, Gorman, Shear & Woods (2000) -Multicenter, randomized controlled trial -312 participants randomized to 1 of 5 treatment conditions 1. Cognitive Behavioral Therapy (CBT) –> Panic control therapy (PCT) -Manualized interoceptive exposure, cognitive reconstructing and breathing retraining 2. Drug Treatment Therapy (Imipramine) 3. CBT + Imipramine 4. Placebo pill 5. CBT + Placebo pill Immediately after treatment  CBT + Drug no better than CBT + Placebo  Drug + CBT no better than CBT alone 6 Months after treatment  CBT better than CBT + Drug OR CBT + Placebo  Many patients who took the drug deteriorated Conclusion: no advantages to combining drug and CBT treatments because any effect seems to be a placebo not true drug effect Psych. treatment should be offered first and then drug (if no adequate response) Problems accessing treatment 1. Travel restrictions (caused by agoraphobia) 2. Specialized clinics only in large urban cities Telephone-administered CBT treatments to reduce barrier to effective treatment -> General success rate Generalized Anxiety Disorder (GAD) 1. Excessive anxiety and worry (over 6 months) about numerous things 2. Difficult to control the worry 3. Associated with at least 3: Restlessness, easily tired, difficulty concentrating or mind going blank, irritability, muscle tension, sleep problems 4. Not only caused by an Axis 1 disorder EX: panic attack (panic disorder), embarrassed in public (social phobia), being contaminated (OCD) gaining weight (anorexia) 5. Significant distress and impairment caused by symptoms & avoidance 6. Not directly due to medical condition or substance abuse Statistics -1.1% of Canadians meet the criteria for GAD (75% female) -Most seek help from the doctors rather than psych. Treatment centers -Can be caused by stressful life events -Earlier and more gradual than most anxiety disorders -Considered chronic (can last longer than 5 years) -Prevalent in elderly (7%) due to the lack of control, failing health, gradual loss of meaningful functions and how they are treated in Western Culture Causes & Characteristics -Possibility of genetic contributions (tends to run in families) ->Twin study indicates the tendency to be anxious rather than GAD -> Patients with GAD do not respond as sternly as people with anxiety disorders in which panic is more prominent ->Less responsive on most physiological measure (heart rate, blood pressure) ->Chronically tense (muscle tension) ->Highly sensitive to threat in general (specially personal relevance) Cognitive characteristics of GAD 1. Intolerance of uncertainty ->More intolerant than anxiety disorders 2. Erroneous beliefs about worry ->worrying is effective in avoiding negative outcomes & promoting positive 3. Poor problem orientation -view problems as avoidable threats rather than challenged 4. Cognitive avoidance -engage in frantic, intense thought processes -avoid all negative affect associated with threat Treatment Benzodiazepines (minor tranquilizers)  Impair both cognitive and motor functioning  Memory & attentional impairments  Slowing psychomotor functions  Psychological and physical dependents Use should only be for emergency and for a short period of time (2 weeks max) -Venlafaxine (antidepressant) no serious potential for dependency Cognitive-Behavioral Treatments: evoke worry process during therapy sessions and confront anxiety-provoking images and thoughts head-on  Focus on what the threat is  Process information on an emotional level using images  Relaxation techniques during combat tension  Learns to use cognitive therapy and other coping techniques to counteract and control the worry process  Psychosocial interventions: combat erroneous beliefs about worry  Cognitive-behavioral strategies to re-evaluate the actual usefulness of worry  Effective in group format; increase cost effectiveness  Alter the unconscious cognitive bias associated with GAD  Increase ability to tolerate uncertainty  Focus on acceptance rather than avoidance of distressing thoughts/feelings  Meditational approaches help teach the patient to be more tolerant 90% of children who used this form of therapy no longer fully GAD Specific Phobia: Irrational fear of a specific object or situation that
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