Chapter 6 : Anxiety Disorders

Interoceptive Exposure

A behavioral Therapy method in which patients intentionally elicit the bodily sensations associated with panic so that they can habituate to those sensations and not respond with fear.

Anxiety

A sense of agitation or nervousness, which is often focused on an upcoming possible danger.

Social Factors of GAD

Relationship

Habituation

The process by which the emotional response to a stimulus that elicits fear or anxiety is reduced by exposing the patient to the stimulus repeatedly.

Social Treatment for Panic Disorder & Agoraphobia

Therapy groups Couple therapy or family therapy

Table 6.7 Agoraphobia Facts at a Glance

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Locus Coeruleus

A small structure in the brainstem that produces norepinephrine. Body's alarm system

Muscle Relaxation Training

Requires patients to become aware of early signs of muscle tension, a symptoms of GAD in some people, and then to relax those muscles.

Breath Retraining

Requires patients to become aware of their breathing and to try to control it by taking deep, relaxing breaths.

Table 6.5 Panic Disorder Facts at a Glance

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Comorbidity of Anxiety Disorders

- Mood Disorders - Body Dysmorphic Disorder - Anorexia Nervosa (anxiety for gaining weight) -Clinician must determine whether the anxiety and avoidance symptoms are the primary cause of the disturbance or a by-product of another type of problem. - About 50% of people with an anxiety disorder are also depressed. - 10-20% of people who have anxiety also abuse alcohol.

Social Factors of Social Phobia

- Overprotected Childhood - Asian / Western culture

Social Factors of Panic Disorder & Agoraphobia

- People have higher-than-average number of such stressful events during childhood and adolescence. - 80% developed after stressful life event

Cognitive Methods for Treating GAD

- Psychoeducation : The process of educating patients about research findings and therapy procedures to their situation. ex) Educating them about the nature of worrying and GAD symptoms and about available treatment options and their possible advantages and disadvantages. - Meditation : Helps patients to learn to "let go" of thoughts and reduce the time spent thinking about worries. - Self-Monitoring : Helps patients to become aware of cues that lead to anxiety and worry. ex) patients may be asked to complete a daily log about their worries, identifying events or stimuli that lead them to worry more or worry less. - Problem-solving : Involves teaching the patient to think about worries in very specific termsㅡ rather than global onesㅡ so that they can be addressed through cognitive restructuring. - Cognitive Restructuring : Involves helping patients lean to identify and shift automatic, irrational thoughts related to worries.

Psychological Factors of Social Phobia

1. Cognitive Biases and Distortions : - Particular biases and distortions. - More attention to critical faces. - Fear of being evaluated. - Emotional Reasoning: they will be judged negatively 2. Classical Conditioning 3. Operant Conditioning

Psychological Factors of GAD

1. People with GAD pay a lot of attention to stimuli in their environment, searching for possible threats. 2. People with GAD typically feel that their worries are out of control and that they can't stop or alter the pattern of their thoughts, no matter what they do. 3. The mere act of worrying prevents anxiety from becoming panic, and thus the act of worrying is negatively reinforcing. The worrying does not help the person to cope with the problem at hand, but it does give him or her the illusion of coping, which temporarily decrease anxiety about the perceived threat. Some people think that if they worry, they are actively addressing a problem. But they do notㅡ worrying is not the same thing as effective problem solving; the original concern isn't reduced by the worrying, and it remains a problem, along with the additional problem of chronic worrying.

Three Types of Social Situations Associated with Social Phobia

1. Social Interactions (such as a conversation) 2. Being observed (such as when eating or using public restrooms) 3. Performing (such as giving a speech)

Exposure

A behavioral technique that involves repeated contact with a feared or arousing stimulus in a controlled setting, bringing about habituation. 1. Imaginal Exposure : Relies on forming mental images of the stimulus 2. Virtual Reality Exposure : Consists of exposure to a computer-generated (often very realistic) representation of the stimulus; and 3. In Vivo Exposure : Is direct exposure to the actual stimulus.

Anxiety Disorder

A category of psychological disorders in which the primary symptoms involve fear, extreme anxiety, intense arousal, and/or extreme attempts to avoid stimuli that lead to fear and anxiety. - Most common mental disorder in the U.S. -15% of people will have some type of anxiety disorder in their lifetimes. - Women are twice as likely as men to be diagnosed -- Can be hormonal / cultural

Table 6.3 DSM-5 Criteria for a Panic Attack

A discrete period of intense fear or discomfort, in which at least four of the following symptoms develop abruptly and reach a peak within minutes: - Palpitations, pounding heart, or accelerated heart rate - Sweating - Trembling or shaking - Sensations of shortness of breath or something - Feeling of choking - Chest pain or discomfort - Nausea or abdominal distress - Feeling dizzy, unsteady, lightheaded, or faint - Chills or hear sensations - Paresthesias (numbness or tingling sensations) - Derealization (feelings of unreality) or depersonalization (being detached from oneself) - Fear of losing control or going crazy - Fear of dying.

Hypervigilance

A heightened search for threats.

Panic Attack

A specific period of intense fear or discomfort, accompanied by physical symptoms, such as a pounding heart, shortness of breath, shakiness, and sweating, or cognitive symptoms, such as a fear of losing control. cued and uncued Nocturnal Panic Attack - while sleeping 30% of adults at some point in their lives.

Biofeedback

A technique in which a person is trained to bring normally involuntary or unconscious bodily activity, such as heart rate or muscle tension, under voluntary control.

Table 6.1 DSM-5 Diagnostic Criteria for Generalized Anxiety Disorder (GAD)

A. 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). B. The individual finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item is required in children. 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). D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition (e.g. hyperthyroidism). F. The disturbance is not better explained by another mental disorder (e.g. anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional belief in schizophrenia or delusional disorder.

DSM-5 Diagnostic Criteria for Social Anxiety Disorder

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g. a conversation, meeting unfamiliar people) being observed (e.g. eating or drinking) and performing in front of others (e.g. giving a speech) Note: In children, the anxiety must occur in peer settings and not just during interactions with adults B. The individual fears that he or she will act in a way or show anxiety symptoms what will be negatively evaluated (i.e. will be humiliating or embarrassing; will lead to rejection or offend others). C. The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or falling to speak in social situations. D. The social situations are avoided by endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. G. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. H. The fear, anxiety or avoidance is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition. I. not better explained by others J. another medical conditions.

Table 6.6 DSM-5 Diagnostic Criteria for Agoraphobia

A. Marked fear or anxiety about two (or more) of the following five siguations; 1. Using public transportation (e.g. automobiles, buses, trains, ships, planes) 2. Being in open spaces (e.g. parking lots, marketplaces, bridges) 3. Being in enclosed places (e.g. shops, theaters, cinemas) 4. Standing in line or being in a crowd. 5. Being outside of the home alone. B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g. fear of falling in the elderly; fear of incontinence) C. The agoraphobic situations almost always provoke fear or anxiety. D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context. F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational or other important areas of functioning. H. If another medical condition (e.g. inflammatory bowel disease, Parkinson's disease) is present, the fear, anxiety or avoidance is clearly excessive. I. The fear, anxiety or avoidance is not better explained by another mental disorder (e.g. the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in obsessive-compulsive disorder); perceived defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder)

Table 6.4 DSM-5 Criteria for Panic Disorder

A. Recurrent unexpected panic attacks B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1. Persistent concern or worry about additional panic attacks or their consequences (e.g. losing control, having a heart attack, "going crazy") 2. A significant maladaptive change in behavior related to the attacks (e.g. behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations.) C. The disturbance is not attributable to the psychological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition (e.g. hyperthyroidism, cardiopulmonary disorders) D. The disturbance is not better explained by another mental disorder (e.g. panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder, in response to reminders of traumatic events, as in posttraumatic stress disorder, or in response to separation from attachment figures, as in separation anxiety disorder).

Specific Phobia

An anxiety disorder characterized by excessive or unreasonable anxiety about or fear related to a specific situation or object

Panic Disorder

An anxiety disorder characterized by frequent, unexpected panic attacks, along with fear of further attacks and possible restrictions of behavior in order to prevent such attacks. - Lasting at least 1 month - Changes in breathing and heart rate occur over 30 minutes before the onset of a panic attack.

Social Anxiety Disorder (Social Phobia)

An anxiety disorder characterized by intense fear of public humiliation or embarrassment; also called social phobia.

Agoraphobia

An anxiety disorder characterized by persistent avoidance of situations that might trigger panic symptoms of form which help would be difficult to obtain. - 1/2 of people with agoraphobia have panic disorder, and most of the other 1/2 experience panic symptoms. - Person avoids only specific stimuli is not diagnosed with agoraphobia

Generalized Anxiety Disorder (GAD)

An anxiety disorder characterized by uncontrollable worry and anxiety about a number of events or activities, which are not solely the result of another disorder. - Worry about family, finances, work, and illness. - Chronic (lasting at least 6 months) - Highly comorbid with Depression. - Only 27% eventually experience remission among people who have both disorders - 48% who had only GAD and 41% who had only depression.

Phobbia

An exaggerated fear of an object or a situation, together with an extreme avoidance of the object or situation.

Panic

An extreme sense (or fear) of imminent doom, together with an extreme stress response

Neurological Treatment for Panic Disorder & Agoraphobia

Antidepressants - SNRI, an SSRI, or TCAs such as clomipramine (Anafranil) are better long term medication and considered "first-line" Benzodiazepine: - Short-term remedy - alprazolam (Xanax) and clonazepam (Klonapin) affect the targeted symptoms within 36 hours, and they need not be taken regularly. - Side effects : drowsiness and slowed reaction times, and suffer withdrawl or need to take increasingly larger doses when these drugs are take for a long term -Medications can take up to 10 days to have an effect

Behavioral Methods for Treating GAD

Behavioral Methods : Three Main Areas - Awareness and control of breathing - Awareness and control of muscle tension and relaxation, and - Elimination, reduction, or prevention of worries and behaviors associated with worries.

Medications of Social Phobia

Blocks epinephrine and norepinephrine SSRIs SNRIs NaSSAs Affect the amygdala and locus coeruleus CBT

Neurological Factors of Social Phobia

Brain System and Neural Communicatinos: - active Amygdala (especially for negative face) - Less activation in brain area that rely on dopamine. - Too little serotonin (SSRIs sometimes help patients) Genetics - 37% - Extremely shy as a children - Behavioral Inhibition

Neurological Factors of Panic Disorders & Agoraphobia

Brain Systems <Only in person with panic disorder> - Hyperventilate(decreasing carbon dioxide) triggers panic attacks -> low threshold for detecting decrease oxygen in the blood. - Injections of sodium lactate (medically safe substances) and caffeine, also produced attacks Neural Communication - Norepinephrine, too much of which is apprently produced in people who have anxiety disorders. - Too sensitive Los Coeruleus - SSRIs can reduce the frequency and intensity of panic attacks Genetics - First degree biological relatives : up to 8 times more risk and 20 times more if the relative developed before age 20. - 24% Concordance for monozygotic and 11% for dizygotic

Neurological Treatment for GAD

Buspiron - Only helps anxiety SNRI (venlafaxine) (fist-line medication) and certain selective serotonin reuptake inhibitors (SSRIs), such as paroxetine (Paxil) and excitalopram (Lexapro), releive both anxiety and depression.

Treating Psychological Factors of Social Phobia

CBT Exposure

Psychological Treatment for Panic Disorder & Agoraphobia

CBT :first line treatment Behavioral Methods : - Breathing retraining, Relaxation training, Exposure. - Interoceptive Exposure Cognitive Methods : - Psychoeducation - Cognitive Restructuring

Psychological Treatment for GAD

Goals - To increase the person's sense of control over thoughts and worries - To allow the person to assess more accurately how likely and dangerous perceived threats, actually are, and - To decrease muscle tension.

Treating social Factors of Social Phobia

Group Therapy Cognitive-behavioral group therapy : uses exposure and cognitive restructuring in a group setting. As effective as medication

Psychological Factors of Panic Disorder & Agoraphobia

Learning - A true alram to learned alarm - Develops fear of fear Cognitive Explanations: - Catastrophic Thinking: Arises in part from anxiety sensitivity, which is a tendency to fear bodily sensations that are related to anxiety along with the belief that such sensations indicate that harmful consequences will follow.

Social Treatment for GAD

None of them succeed so far.

Neurological Factors of GAD

Parasympathetic nervous system plays a special role in GAD Brain Systems - Associated with decrease arousal that arises from an unusually responsive parasympathetic nervous system. - Worry reduces arousal : suppresses negative emotions and produces muscle tension. Neural Communication - Dopamine in the frontal lobes does not function normally. - GABA(hamma-aminobutryic acid), serotonin and norepinephrine, may not function properly. - Above neurotransmitters affects people's response to reward, their motivation, and how effectively they can pay attention to stimuli and events. Genetics - GAD has a genetic components - Equally heritable for men and women. - One member has, another family member highly risk

Fight-or-flight Response (stress response)

The automatic neurological and bodily response to a perceived threat; also called the stress response. - Increasing your heart rate and breathing rate (more oxygen to muscles and brain) - Increasing the sweat on your palms. - Dilating your pupils.

Concordance Rate

The probability that both twins will have a characteristic or disorder, given that one of them has it.

Figure 6.1 Tripartite Model of Anxiety and Depression

[Anxiety] Physiological hyper arousal - General Distress (high level of negative emotions) - Lack of enjoyment (low level of positive emotions) [Depression]