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ANXIETY DISORDERS - 1 I. Anxiety and its Causes A. Anxiety, fear, and panic 1. Anxiety - mood state characterized by tension, apprehension of future danger or misfortune. In humans, anxiety may be expressed as subjective unease, worried behaviors, and/or physiological responses. a. Normal emotion that is adaptive when experienced in moderate amounts. Helps performance. b. Becomes problematic (psychologically speaking) when excessive and interferences with functioning. 2. Fear - immediate alarm reaction to dangerous or life threatening situations (fight or flight response; emergency or defensive reaction). A present-oriented mood state characterized by strong avoidance and activation of SNS. a. Normal emotional response that is adaptive when experienced in response to real danger or threat. b. Becomes problematic (psychologically speaking) when it excessive, in the absence of real threat or danger, and interferes with important areas of life functioning. c. Textbook case of Gretchen illustrates excessive fear in the absence of real threat or danger. 3. Panic attack - abrupt experience of intense fear or discomfort accompanied by physical symptoms such as heart palpitations, chest pain, shortness of breath, and dizziness. Three types of panic attacks are described in the DSM-IV: a. Situationally bound (cued) panic attack is one that is expected in a given situation and is bound to some situations and not others. This type of panic attack is common in persons suffering from specific phobias and social phobia. b. Unexpected (uncued) panic attack is completely unanticipated in nature, and often occurs without warning. This form of panic attack is common in persons suffering from panic disorder. c. Situationally predisposed panic attack falls between situationally bound and unexpected panic, and is characterized by panic that may be more likely in a certain setting, but not inevitable. This form of panic attack is also common in persons suffering from panic disorder. ANXIETY DISORDERS - 2 B. Causes of anxiety 1. Biological contributions - people inherit the tendency to be anxious or highly emotional. Seems to run in families. Anxiety is associated with specific brain circuits and neurotransmitter systems. 2. Psychological contributions - anxiety results from classical conditioning or modeling. Some studies suggest that a sense of not being able to control things in the environment predisposes a child to anxiety later in life. 3. Social contributions - stressful life events as triggers for biological and psychological vulnerabilities for anxiety and panic. Interpersonal stressors (e.g., marriage, divorce, work problems, death of a loved one, including social pressures related to school, peers). 4. Integrated model - etiological risk factors considers the complex interaction among biological, psychological, experiential, and social variables. One may be born with a biological vulnerability to be anxious, [but this vulnerability then interacts with socialized beliefs that the world is dangerous and that events are uncontrollable]. Such factors, coupled with experience of life stressors and learning experiences, may then activate the diathesis for anxiety and begin a positive spiral that may lead to an anxiety disorder. C. Anxiety disorders often co-occur, and rates of comorbidity among anxiety disorders are high (e.g., a recent study showed that 55% of patients who received a principal diagnosis of an anxiety or depressive disorder had at least one additional anxiety or depressive disorder at the time of assessment). 1. PTSD and GAD have the highest comorbidity rates. 2. Major depression is often the most common secondary diagnosis in persons suffering from anxiety disorders. This fact emphasizes that anxiety disorders (and depression) share common features, including similar vulnerabilities. Anxiety disorders differ with respect to their foci and pattern. ANXIETY DISORDERS - 3 II. Generalized Anxiety Disorder A. Generalized anxiety disorder (GAD) is often considered the "basic" anxiety disorder because it is characterized by intense, unfocused anxiety. Persons with GAD typically worry about minor daily life events, whereas children with GAD worry about academic, athletic, or social competence and physical injury. The elderly tend to focus on health and often report difficulty sleeping. The textbook illustrates the features of GAD with the case of Irene. 1. The DSM-IV criteria specify that excessive anxiety and worry (apprehensive expectation) must be ongoing more days than not for a period of a least 6 months. It must also be difficult to turn off or control the worry process; a feature that distinguishes pathological worry from normal worry. 2. The physical symptoms of GAD differ from panic, and include muscle tension, mental agitation, susceptibility to fatigue, irritability, and difficulty sleeping. Focusing attention is often difficult. B. Approximately 4% of the general population meet criteria for GAD (during a given 6-month period). Quite common in the elderly (perhaps as high as 7%). Few seek treatment compared to those with panic disorder. Male to female ratio for GAD is about 1:2. Onset is usually in early adulthood, usually in response to some life stressor, often more gradual than with other anxiety disorders. C. GAD may be caused by several factors, including a genetic contribution as indicated by twin studies. Probably what is inherited is a tendency to be anxious, not GAD itself. D. Individuals with GAD are less physiologically responsive than persons with anxiety disorders where panic is prominent. Muscle tension is the only autonomic measure that consistently distinguishes persons with GAD from other nonanxious persons. It is believed that autonomic restriction is the result of automatic bias for threat (highly sensitive to threat—allocate attention more readily than nonanxious do), coupled with a limited processing of the associated imagery (intense EEG activity in the left frontal lobe) and the emotional components of that imagery that would normally elicit strong autonomic responses. Perhaps worrying helps them avoid the fear reaction, but also means they never resolve the problem. ANXIETY DISORDERS - 4 E. Treatment of GAD are relatively weak and not well developed. Benzodiazepine drug treatment, although most studies don’t go beyond 8 weeks. Even if for 6 months, relatively modest improvement. Impair cognitive and motor functioning (less alert). Falls for the elderly. (See handout.) Perhaps anti-depressants may be more useful. Psychological treatments focus on the worry process and avoidance of feelings of anxiety and negative affect and seem to work about as well as drugs, perhaps better in the long run (1-year follow-up). Exposure to worrisome thoughts and anxious images is utilized with coping skills training. CBT. III. Panic Disorder A. To meet criteria for panic disorder, a person must experience an unexpected panic attack and develop anxiety about the possibility of another attack or the implications of the attack. Agoraphobia is fear and avoidance of "unsafe" situations where a panic attack may occur. Persons with panic disorder with agoraphobia (PDA) experience severe unexpected panic attacks during which time they feel a loss of control or endangered. Persons may also experience panic disorder without agoraphobia. (The textbook illustrates panic disorder with extreme agoraphobia in the case of Mrs. M.) B. Many persons with panic disorder develop agoraphobia (i.e., fear of the marketplace). Agoraphobic avoidance appears to be one complication of severe unexpected panic attacks. Agoraphobic behavior can become independent of panic attacks (according to fear of the attack, rather than actual number or intensity). According to the DSM-IV, agoraphobia may be characterized either by avoiding situations or enduring them with marked distress. Some forms of agoraphobia involve interoceptive avoidance, particularly of activities that may increase physical symptoms of arousal. (See page 128.) C. Lifetime prevalence of 3.5% in the general population. Two-thirds are women. Mean age of onset between 25 - 29. Most initial unexpected panic attacks begin after puberty. Panic disorder is generally less pervasive among the elderly; though agoraphobia is quite common. ANXIETY DISORDERS - 5 D. Panic disorder exists worldwide, though how it is expressed varies widely across cultures (sometimes focusing more on somatic symptoms than cognitive, sometimes w/shouting and crying). Rates of PD are similar across different ethnic groups in the US. E. Approximately 60% of people with panic disorder experience nocturnal panic attacks (i.e., panic during sleep). Nocturnal panic occurs most often between 1:30 am and 3:30 am than at any other time, and such attacks have been shown to occur during delta wave sleep (the deepest stage of sleep, but not dream sleep). F. The causes of panic disorder are numerous, and include an interaction of psychological, biological, and social-experiential influences. The textbook suggests that a biologically inherited vulnerability to be overreactive to daily events, coupled with stress, may establish a predisposition to associate the response with internal and external cues (i.e., moving from a false to a learned alarm response). Such factors, coupled with a psychological vulnerability to catastrophically misinterpret such events and the development of anxiety over the possibility of future panic attacks may, in turn, lead to panic disorder. (8-12% of people experience a panic attack, usually under intense stress; only 3% develop panic disorder.) ANXIETY DISORDERS - 1 G. Treatment of Panic Disorders 1. Medications for anxiety and panic largely affect the serotonergic, noradrenergic, and benzodiazepine GABA neurotransmitter systems, such as imipramine (tricyclic antidepressant), tend to block panic attacks. SSRIs (Selective Serotonin Reuptake Inhibitors e.g., Prozac and Paxil) are currently the preferred drug for panic disorder; though sexual dysfunction is a common side effect. Relapse rates for panic are high once the medication is discontinued. 2. Psychological interventions, and particularly cognitive- behavior therapies, are quite effective for panic disorder, with as many as 80% to 100% of patients free of panic after about 12 weekly sessions. Treatment typically involves gradual exposure exercises combined with anxiety-reducing coping skills, such as relaxation and breathing retraining. As many as 70% of patients undergoing these treatments substantially improve, but very few are cured. Panic Control Treatment (PCT) is a cognitive-behavioral treatment that arranges for mini-exposures to panic sensations in therapy, and includes cognitive therapy to address attitudes and misperceptions about the feared sensations and situational triggers and relaxation and breathing retraining. 3. Evidence from combined treatments (i.e., medications plus cognitive-behavior therapy) suggest that combined treatment was no better than individual treatments in the short term, however in the long term persons receiving CBT alone maintained most of their treatment gains, whereas those taking medication alone or in combination with CBT deteriorated somewhat. This result led to the recommendation that psychological treatment should be offered initially, followed by drug treatment for those patients who do not respond adequately or for whom psychological treatment is not available. 4. Nutritional Treatment – nutrients play a role. Blood sugar, magnesium, etc. ANXIETY DISORDERS - 2 IV. Phobias A. Specific phobia 1. A specific phobia is an extreme and irrational fear of a specific object or situation that markedly interferes with one's ability to function. Most persons with specific phobias recognize that their fears are unreasonable. Many go to great lengths to avoid the objects of their fear. There are as many phobias as there are objects and situations. The four major subtypes of specific phobia are as follows: a. Persons suffering from blood-injury-injection phobia differ from all the other phobias in that they experience drops in heart rate and blood pressure and increased urges to faint. This vasovagal reaction occurs in response to blood, injury, or the possibility of an injection and has a strong genetic component. The phobia develops over t
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