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Chapter 12

Ch. 12 - Anxiety Disorders.docx

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PSYC 208
Paul Wehr

Anxiety Disorders 11/21/2012 11:29:00 AM Anxiety Disorders  Class of disorders distinguished by feelings of excessive apprehension, anxiety, or fear o Panic Disorder, Agoraphobia and Social Anxiety Disorder o Generalized Anxiety Disorder o Phobic Disorder o Obsessive-Compulsive Disorder (OCD) o Post-Traumatic Stress Disorder (PTSD)  Must cause significant distress or impairment of social occupational functioning  Can’t be caused by a substance Panic Disorder  Discreet (clear beginning and clear end), recurrent, sudden and unexpected (no well-defined stimulus) attacks of overwhelming anxiety o Tachycardia (elevated heart rate, 100 beats/minute+), palpitations or chest pain o Sweating o Trembling or shaking o Hyperventilation, shortness of breath, or smothering  Nausea or dizziness  Numbness or tingling o Feelings of choking o Derealization or depersonalization o Fear of losing control or of dying  Apprehensive about being in public Agoraphobia and Social Anxiety Disorder (Types of Panic Attacks)  Agoraphobia: fear of places or situations where escape would be difficult or embarrassing (in the event of a panic attack) o Fear of “marketplace”: outside of home, crowds o Prisoner in own home o Will venture outside with a confidante  Social Anxiety Disorder: persistent fear of one or more social performance situations o Exposed to unfamiliar people or potential scrutiny by others o Specific social situation(s) or most situations (generalized) o Avoids situation that invariably provokes anxiety o Recognizes that fear is excessive Phobic Disorder  Persistent and irrational fear of an object or situation; imagination is sufficient to provoke anxiety o Acrophobia (fear of height) o Claustrophobia (fear of enclosed spaces) o Hydrophobia (fear of water) o Animal and insect phobias  Preparedness: prepared by evolution to acquire some fears more readily than others o Snakes and spiders vs. cars and electrical outlets  One of the most common and least treated anxiety disorders Generalized Anxiety Disorder  Chronic, high level anxiety tied to no specific threat o Restlessness or insomnia o Easily fatigued o Difficulty concentrating o Irritability o Muscle tension o Worry constantly about everything o Avoid decisions and brood endlessly o Always elevated  Anxiety is less intense compared to panic attack of phobia  Onset is gradual Obsessive-Compulsive Disorder  Obsessions: persistent, uncontrollable intrusions of unwanted thoughts that produce anxiety o Often reflect real dangers (contamination; security; safety) but not always (symmetry)  Compulsions: urges to engage in ritual behavior (rigid set of repetitive behaviors or mental acts) that relieves anxiety o Often related to obsession (e.g. cleanliness; checking; counting and organizing)  Recognizes obsessions/compulsions are unreasonable  Onset before age 35  Heterogeneous disorder o Checking: concerned with safety or security o Symmetry and order: concerned with being equal on both sides, organization o Cleanliness and washing: clean a lot o Hoarding: can’t throw anything away, shopping addictions Post-Traumatic Stress Disorder  Elicited by experience with traumatic event o Direct experience (rape, assault, combat) o Witnessing a traumatic event (murder) o Witnessing the aftermath of traumatic event (natural disaster)  Onset can be delayed months or years after event  Event is re-experienced: flashbacks (involuntary) or nightmares; feed as thought he event were recurring  Avoidance of cues to event and numbing of general responsiveness o Avoidance of thoughts or activities associated with event o Inability to recall important aspects of event o Diminished interest or participation in important activities  Person loses interest in their own lives o Restricted affect or estrangement from others  Increased arousal o Insomnia o Irritability o Difficulty concentrating o Hypervigilance: tend to monitor their environments more than average o Exaggerated startle response  Acute (less than 3 months) vs. chronic (longer than 3 months) Epidemiology  Prevalence for anxiety disorders o Lifetime prevalence – 30% o One year prevalence – 12% o Ratio of women to men – 2:1 o Cultural variability  Anxiety disorder – 12 month prevalence o Specific phobia – 6.2-8.0% o Social phobia – 6.7% o OCD – 1.8% o Generalized anxiety – 1.1% o Panic disorder – 0.7%  Onset usually in early adolescence/adulthood  Peaks at age 30  PTSD: situation dependent o 60% of men and 50% of women experience traumatic event o 5% of men and 10% of women lifetime prevalence Risk Factors  Genetic risk factors o Panic Disorder shares genetic risk with Agoraphobia and specific phobic disorders o OCD shares genetic risk with Tourette’s syndrome and chronic tic (involuntary movements) disorders  Motor tics: involuntary, repetitive, non-rhythmic physical movements  Phonic tics: involuntary utterances  Have both of them  Tourette’s o Generalized Anxiety Disorder (GAD) shares genetic risk with PTSD and Depression  GAD has lowest heritability  Environmental risk factors o Early traumatization: emotional/sexual abuse, parental neglect, heightened anxiety in parents (insecure attachment) Pathophysiological Mechanisms  Neurotransmitter activity o Serotonin activity depends on the receptor type  SSRI relieves anxiety  LSD heightens anxiety o Norepinephrine: understimulation of alpha-adrenergic neurons: overstimulation of beta-adrenergic neurons  Alpha-receptor agonists relieve anxiety  Beta-blockers relieve anxiety o Decreased GABA activity  Benzodiazepines and alcohol (GABA agonists) relieve anxiety  GABA goes up  nervous system activity goes down  Alcohol boosts GABA activity  Brain functioning: amygdala and reciprocal connections with orbitofrontal cortex and hippocampus o Basal ganglia abnormalities in OCD  Disinhibition to select motor activities o Reduced volume in hippocampus in PTSD  Chronic activation of HPA in PTSD o Orbitofrontal cortex assesses stimulus  goes to amygdala (let fear go or cancel it)  Oh, it’s a snake, oh, it’s a rubber snake, let’s cancel the fear response  Orbitofrontal cortex: evaluation of emotional stimuli and fear conditioning Comorbidity  Depression and substance abuse o Panic disorder: 50-70% have depression o Comorbid cases more severe and onset is earlier o Alcohol abuse and dependence – 30%  Risk of suicide increased by magnitude of 10 o Higher in comorbid cases  High rates of comorbidity o Social anxiety, agoraphobia, and panic disorder o PTSD and phobic disorder o OCD and Parkinson’s, Huntington’s, Tourette’s and tic disorders (basal ganglia) Outcome and Treatment  Outcome: typically chronic with incomplete remissions. Panic disorder and agoraphobia typically decline in severity after 40 years  Psychopharmacological treatment o Acute cases: benzodiazepines (GABA agonist) o Antidepressants (serotonin or monoamine agonist) o OCD: higher doses of antidepressants + low-dose antipsychotics (reduce obsessions and compulsions) o PTSD: mood stabilizers + antipsychotics (reduce intrusive thoughts)  Psychotherapy: cognitive behavioral therapy Systematic Desensitization  Used to treat phobias and other anxiety disorders with counter-conditioning o Anxiety response acquired through classical conditioning o Goal is to replace anxiety response with relaxation  Four-step process o Anxiety hierarchy o Deep muscle relaxation o Imagine each item on anxiety hierarchy while remaining relaxed o Confront real stimulus Evolutionary Synthesis  Fear responses reflect persistent dangers encountered in the EEA; motivate adaptive responses to threat (flight, immobility, submission, or aggression) o Smoke-detector principle: low threshold for fear response due to asymmetry of costs associated with perceptual errors (false negatives > false positives) o Biological predisposition to fear evolutionary significant stimuli that pose threats to fitness (predator, rival, embarrassment)  Not born afraid of snakes, but children observe adults fear snakes o Conditioning and observational learning augment fear response (e.g. fear of snakes in chimpanzees)  Anxiety disorders reflect exaggerated fear responses to cues of danger or threat (real or imagined) o Could be a real threat, but fear response is disproportionate o Could be imaginary  Fear is an adaptive response; anxiety is maladaptive Evolution of Human Fears  Common sources of fear with corresponding adaptive problem o 5-6 months: crawling  Snakes (venoms)  Spiders (poison)  Heights (fall) o Panic (predation rival): response to almost imminent death o Agoraphobia (crowded places) o 2 years  Small animal phobias (disease) o Hypochondriasis (disease): general fear of disease o 9-13 months  Separation Anxiety (vulnerability)  Stranger Anxiety (dangerous males) o Fear of blood injury o Sex differences: women experience more intense anxiety; have unique fear (rape) o Fears emerge when they are most needed (most likely to adversely affect fitness) Fear Relevance and Attention  Fear relevant stimuli are attended to more quickly than fear neutral stimuli o Task: identify if all objects from same category or if one object was discrepant o Discrepant object was either threat relevant or threat neutral o Fear relevant targets had either high or low evolutionary significance o There conditions: photographs, drawings, perceptual similarities  Threat relevant stimuli detected faster than threat neutral stimuli regardless of evolutionary significance  Emotional vs. attentional responses Maratos, Mogg & Bradley  Rapid Serial Visualization Paradigm (RSVP) – present two stimuli in rapid succession o First stimulus masks the second unless the second has strong emotional meaning Evolutionary Synthesis  Early experiences lead to a mistrustful inner working model of the world as a dangerous place o Insecurely attached infants more likely to develop anxiety disorders (loss, rejection, neglect)  Early experiences sensitize the fear response o Amygdalae more responsive to fearful stimuli in patients with PTSD and SAD o Diminished communication with orbito-frontal cortex (emotional evaluation) and hippocampus (memory) o Novel but benign environments perceived as dangerous  Humans might be particularly susceptible (high prevalence rates) o Humans are social, but physically vulnerable; selection for greater vigilance; neuroanatomical structures involved in evaluating threat increased in size over evolutionary time o Human juveniles are vulnerable for an extended period; greater dependence on secure attachment; hypervigilance could be adaptive response in the event of insecure attachment o Human capacity to anticipate future events, including future threats o Modern environment poses few real threats; neurobiological response lacks “training” to respond accurately o Threat come from inside and outside social group; threats to physical wellbeing and status o Anticipating future events is adaptive (e.g. conserving food) o Strangers were ancestral environment were real threats; not really nowadays Evolutionary Synthesis of Specific Disorders  Panic Disorder: lowered threshold leads to false suffocation alarm o Symptoms: hyperventilation, shortness of breath, smothering o Carbon dioxide inhalation can induce panic in vulnerable individuals o Panic more likely to occur when pCO2 levels a
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