American Psychiatric Association (1994) definition of "anxiety
- a negative mood state characterized by bodily symptoms of
physical tension and apprehension about the future.
Anxiety's 3 dimensions
- Verbal reports of subjective experiences ("saying/thinking")
- Behavioral responses ("acting")
- Physiological responses ("what your body is doing")
Anxiety =
a multidimensional experience
Abnormal Anxiety
1. Persistent anxiety
2. Involves excessive avoidance and escapist tendencies
3. Causes clinically significant distress and impairment ("good prognostic indicator")
Fear
� Immediate, present-oriented
� Sympathetic nervous system activation
� Negative affect
Anxiety
� Apprehensive, future-oriented
� Somatic symptoms = tension
� Negative affect
Anxiety affects approximately
29% of the US population at some point in their lives
Anxiety Statistics
Most common category of disorders for women
Earliest age of onset of all the mental disorders
People with anxiety disorders are very high users of medical
services
Biological Intervention
Barbiturates, benzodiazepines
� SYSTEMATIC DESENSITIZATION
� RELAXATION TRAINING
� FEAR HIERARCHY
� FLOODING
Etiology
Biological vulnerability interacts with other variables (psychological,
experiential, social) to produce an anxiety disorder
Consistent with Diathesis Stress Model:
- you inherit vulnerabilities for anxiety, not disorders
- stress activates the vulnerability
Problem of comorbidity:
High rates of comorbidity (55% to 76%) - more than half of patients have two or more secondary diagnoses.
- Major depression is the most common second diagnosis
Biological Factors
Family studies
Sociocultural Factors ("a wild card")
Environmental situations of danger or insecurity
Cognitive Factors: unique to specific disorders
- "Poor Perception of Control" - good predictor of a panic attack
- "Attention to threat"- obsessive compulsive disorder
Generalized Anxiety Disorder
- Excessive uncontrollable anxious apprehension and worry
- Coupled with strong, persistent anxiety
- Somatic symptoms differ from panic (e.g. muscle tension, fatigue,
irritability)
- Persists for 6 months or more
Associated features of GAD
- Called "autonomic restrictors"
- Fail to process emotional component - thoughts/images
Facts and Stats of GAD
- GAD affects 5.7% of the population at some point in their lives
- Females outnumber males approximately 2:1
- Tends to be chronic
- Often develops in older adults for whom it is the most common disorder
GAD and the Elderly
� Worry about failing health, loss
� Up to 7% prevalence
� Use of minor tranquilizers: 17-50%
Generalized Anxiety Disorder
(DSM 5)
Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6
months, about a number of events or activities (such as work or school performance).
The person finds it difficult to control the worry.
GAD symptoms
(1) restlessness or feeling keyed up or on edge
(2) being easily fatigued
(3) difficulty concentrating or mind going blank
(4) irritability
(5) muscle tension
(6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
Treatment of GAD
Pharmacological:
Benzodiazepines
Antidepressants
Treatment of GAD
Psychological:
Cognitive-behavioral treatments
Exposure to worry process
Confronting anxiety-provoking images
Coping strategies
Meditation
Similar benefits
Good long-term results
Panic Attack
A discrete period of intense fear or discomfort
Panic attack symptoms include:
(1) palpitations, pounding heart, or accelerated heart rate
(2) sweating
(3) trembling or shaking
(4) sensations of shortness of breath or smothering
(5) feeling of choking
(6) chest pain or discomfort
(7) nausea or abdominal distress
(8) feeling dizzy, u
Panic Disorder: Defining Features
- Unexpected panic attack
- Agoraphobia frequent complication - Fear or avoidance of
situations/events in which attacks occurred
- Anxiety, worry or fear about having another attack
- Symptoms and concern persists for 1 month or more
Panic Disorder: Facts and Stats
- Panic Disorder affects about 4.7% of the adult population
- Female: male = 2:1
- Typically begins in the 20s to the 40s
Panic Disorder : Clinical Description
- Avoidance can be persistent
- Use and abuse of drugs and alcohol (more common in men versus
women)
Panic Disorder : Associated Features
Interoceptive avoidance: avoids internal physical stimuli
Agoraphobia
A frequent complication of panic disorder
Why does DSM 5 now list Agoraphobia as a distinct disorder?
1. As Agoraphobia develops, fearfulness spreads to more and more aspects of the
environment.
2. Lifetime prevalence rates of agoraphobia WITHOUT panic is 1.4% (National
Comorbidity Survey - Replication)
Panic Disorder : Medication Treatment
SSRIs (e.g. Prozac and Paxil) - preferred drugs
�Relapse rates are high following medication
discontinuation
Psychological and Combined Treatments (with
medication) of Panic Disorder
�Cognitive Behavior Therapies are highly effective
�No long-term advantage for combined treatments
�Best long term outcome - Cognitive Behavior Therapy
alone (e.g. see reading assignment)
Specific Phobia (DSM)
Marked and persistent fear that is excessive and unreasonable, cued by the presence
or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving
an injection, seeing blood)
Phobos
Greek God of fear
Agoraphobia
fear of open spaces
Cynophobia
fear of dogs
Genphyrophobia
fear of bridges
Nyctophobia
fear of darkness
Xenophobia
fear of strangers
Cyberphobia
fear of computers or working on a computer.
OCD (Obsessive Compulsive Disorder)
A condition characterised by obsessions and/or compulsive behaviour
Obsessive Compulsive and Related Disorders are:
Hoarding disorder
Excorciation disorder (skin picking)
Body Dysmorphic disorder (obsessed with perceived physical flaw)
Trichotillomania (hair pulling)
Obsessive Compulsive disorder
OCD Facts and Stats
- Approximately 2-3 percent of people meet criteria for OCD at some point in
their lifetime
- Some studies show little or no gender differences
- OCD tends to be chronic
- Onset is typically in late adolescence or adulthood, but can occur in children
OCD Causes
- Early life experiences and learning that some thoughts are
dangerous/unacceptable
- Thought action fusion - the thought is like the action
Medication Treatment of OCD
- Clomipramine and other SSRIs - benefit about 60%
- Relapse is common with medication discontinuation
Psychological Treatment of OCD
- Cognitive Behavioral Therapy - most effective for
OCD
- CBT involves exposure and response prevention
- Combined Treatments - Not better than CBT alone
Types of Behavior Therapy
? Assumption is that maladaptive behavior is learned and can
be unlearned.
? Re-Exposure is critical for new learning
? Problems with re-exposure in treatment?
Use of Virtual Reality for
Acrophobia
�New approach (i.e. Ralph Lamsen)
�Use of virtual reality to treat Acrophobia
�Helmet, glove and hand grip present challenges relevant
to the phobic situation
�Subjects are presented with a plank they must cross
�40 minute sessions
�60 clients participate
Systematic Desensitization
STEP 1: CREATE A FEAR HIERARCHY
STEP 2: LEARN TO RECOGNIZE TENSION AND TO MAKE YOUR BODY RELAX
STEP 3: GRADUALLY INCREASE THE FEAR