Week 5 Anxiety Disorders

What is the size of the gender ratio in anxiety disorders?

2 to 1

In epidemiological studies that conduct just one interview with people about whether they met diagnostic criteria for an anxiety disorder, the estimated lifetime prevalence of anxiety disorders is: ______________.

28%

How heritable are the obsessive compulsive and related disorders?

40-50%

Hoarding disorder

Acquisition of an excessive number of objects Inability to part with those objects

Anxiety about being in places where escaping or getting help would be difficult if anxiety symptoms occurred

Agoraphobia

Defined as apprehension over an anticipated problem.

Anxiety involves moderate arousal At the low end, a person experiencing anxiety may feel no more than restless energy and physiological tension is adaptive in helping us notice and plan for future threats—that is, to increase our preparedness, to help people avoid potentially dangerous situations, and to think through potential problems before they happen

Etiology of Agoraphobia

Because agoraphobia was only recognized as a distinct disorder with the DSM-5, less is known about its etiology. As with other anxiety disorders, risk of agoraphobia appears to be related to genetic vulnerability and life events. One major model of how these symptoms evolves focuses on cognition. The principal cognitive model for the etiology of agoraphobia is the fear-of-fear hypothesis, which suggests that agoraphobia is driven by negative thoughts about the consequences of experiencing anxiety in public. Research findings indicate that people with agoraphobia tend to think the consequences of public anxiety would be horrible. They seem to have catastrophic beliefs that their anxiety will lead to socially unacceptable consequences.

Psychological Treatment of Agoraphobia

CBT of agoraphobia also focuses on systematic exposure to feared situations. The person with agoraphobia may be coached to gradually tackle leaving home, then driving a couple of miles from home, then sitting in a movie theatre for 5 minutes, and then staying for the full duration of a movie in a crowded theater. Exposure treatment of agoraphobia can be enhanced by involving the patient's partner. The partner without agoraphobia is taught that recovery rests upon exposure. Many will have sheltered the person from facing their fears, and through treatment, partners learn to foster exposure rather than avoidance

Treatment of the Obsessive-Compulsive and Related Disorders

Each of these disorders responds to antidepressant medications. The major psychological approach for each of these disorders is exposure and response prevention, although this treatment is tailored for the specific conditions. Even though good treatments are available, many people do not receive state of-the-art care. As is all too common with many disorders, individuals from ethnic minority groups are less likely to receive treatment for OCD

Psychological Treatment of Phobias

Many different types of exposure treatments have been developed for phobias. Exposure treatments often include in vivo (real-life) exposure to feared objects. For phobias involving fear of animals, injections, or dental work, very brief treatments lasting only a couple of hours have been found to be highly effective

What is the chief difference between obsessions and compulsions?

Obsessions involve a repetitive and intrusive thought, urge, or image; compulsions involve either a thought or a behavior that the person feels the need to engage in to ward off threats or the anxiety associated with obsessions.

Fear of unfamiliar people or social scrutiny

Social anxiety disorder

A. Recurrent pulling out of one's hair, resulting in hair loss. B) attempts to stop C) distress or impairment D) R/O medical E) R /O Body Dysmorphic Disorder

Trichotillomania (Hair-Pulling Disorder)

Anxiety and fear are not necessarily "bad"; in fact, both are adaptive: True or False

True

Anxiety and fear are usually adaptive. True or False

True

Culture influences the focus of fears, the ways that symptoms are expressed, and even the prevalence of diff erent anxiety disorders. True or False

True

Natural environment Storms, heights, and water phobias generally begins during childhood True or False

True

Situational Public transportation, tunnels, bridges, elevators, flying, driving, closed spaces phobias tends to begin either in childhood or in mid-20s True or False

True

The central feature of generalized anxiety disorder (GAD) is worry. True or False

True

Women are much more likely than men to report an anxiety disorder. True or False

True

GAD

avoidance of powerful changes in negative emotions

The key symptom of GAD is: ______________

worry

Social anxiety disorder

too much of a focus on one's own flaws

Cognitive Factors Attention to Threat

A large body of research indicates that people with anxiety disorders pay more attention to negative cues in their environment than do people without anxiety disorders

Common Risk Factors Across the Anxiety Disorders: Genetic Factors

A large-scale twin study suggested a heritability estimate of .5 to .6 percent for anxiety disorders. This indicates that genes may explain about 50-60 percent of the risk for anxiety disorders in the population. Some genes may elevate risk for several diff erent types of anxiety disorder. For example, having a family member with a phobia is related to increased risk of developing not only a phobia but also other anxiety disorders, perhaps because those genes increase the risk for neuroticism. Other genes may elevate risk for a specific type of anxiety disorder

Neurobiological Factors: The Fear Circuit and the Activity of Neurotransmitters

A set of brain structures is engaged when people feel anxious or fearful. This set of regions has been called the fear circuit, although it is important to note that these structures are also activated during processing of other types of salient stimuli and are also implicated in other disorders involving emotion disturbances, such as the mood disorders. The medial prefrontal cortex helps to regulate amygdala activity—it is involved in extinguishing fears and is engaged when people are regulating their emotions. The medial prefrontal cortex is involved in the conscious processing of anxiety and fear. Researchers have found that adults who meet diagnostic criteria for anxiety disorders display less activity in the medial prefrontal cortex when viewing and appraising threatening stimuli and when asked to regulate their emotional responses to threatening stimuli. The pathway, or connectivity, linking the amygdala and the medial prefrontal cortex may be deficient among those with anxiety disorders. These deficits in connectivity between these two regions may interfere with the effective regulation and extinction of anxiety

Medications That Reduce Anxiety

Drugs that reduce anxiety are referred to as anxiolytics (the suffix -lytic comes from a Greek word meaning "to loosen or dissolve"). Two types of medications are most commonly used for the treatment of anxiety disorders: benzodiazepines (e.g., Valium and Xanax) and antidepressants, including tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs) Benzodiazepines are sometimes referred to as minor tranquilizers or sedatives. A large number of studies have confirmed that antidepressants provide more benefit than do placebos. Although few studies are available that compare benzodiazepenes to placebos, research does indicate that benzodiazepenes are more powerful than wait list controls for anxiety disorders

Virtual reality is sometimes used to simulate feared situations such as flying, heights, and even social interactions. True or False

Findings of small randomized controlled trials indicate that exposure to these simulated situations appears to be as effective as in vivo (real-life) exposure. In addition to virtual reality programs, Internet-based programs have been developed to guide clients in CBT for the anxiety disorders. Internet CBT programs for social anxiety disorder, panic disorder, and GAD achieve large effects compared with control conditions, and these effects appear to be sustained when clients are reassessed 6 months after they finish the program. These programs seem to work best when at least some human contact is provided. Even with this type of support, these programs substantially reduce the amount of professional contact time required to provide exposure treatment.

Cognitive Factors Intolerance of Uncertainty

People who have a hard time accepting ambiguity, that is, who find it intolerable to think that something bad might happen in the future, are more likely to develop anxiety disorders. This intolerance of uncertainty can predict increases in worry over time. People with anxiety disorders, but also those with major depressive disorder and obsessive-compulsive disorder tend to struggle when the future is uncertain.

Body dysmorphic disorder (BDD)

Preoccupation with imagined flaw in one's appearance Excessive repetitive behaviors or acts regarding appearance (e.g., checking appearance, seeking reassurance)

Fear of objects or situations that is out of proportion to any real danger

Specific phobia

Percent of Adults Ages 18-64 in the General Population Who Meet Diagnostic Criteria for Anxiety Disorders in the Past Year and in Their Lifetime 12-Month Prevalence Estimate Lifetime:

Specific phobia 12- Month Prevalence 10.1 Lifetime Prevalence 13.8 Social anxiety disorder 12- Month Prevalence 8.0 Lifetime Prevalence 13.0 Panic disorder 12- Month Prevalence 3.1 Lifetime Prevalence 5.2 Agoraphobia 12- Month Prevalence 1.7 Lifetime Prevalence 2.6 Generalized anxiety disorder 12- Month Prevalence Lifetime Prevalence2.9

Psychological Treatment of Generalized Anxiety Disorder

The most widely used behavioral technique involves relaxation training to promote calmness. Relaxation techniques can involve relaxing muscle groups one by one or generating calming mental images. With practice, clients typically learn to relax rapidly. Studies suggest that relaxation training is more effective than nondirective treatment or no treatment. Broader forms of CBT have also been developed, which include strategies to help improve problem solving and to address the thought patterns that contribute to GAD. One form of cognitive therapy includes strategies to help people tolerate uncertainty, as people with anxiety disorders seem to be distressed by uncertainty. Other cognitive behavioral strategies used to target worry include asking people to worry only during scheduled times, asking people to test whether worry "works" by keeping a diary of the outcomes of worrying, helping people focus their thoughts on the present moment instead of worrying, and helping people address core fears.

Animal Snakes, and insects phobias generally begins during childhood True or False

True

A key structure in the fear circuit is the: a. cerebellum b. amygdala c. occipital cortex d. inferior colliculi

b

Research suggests that genes can explain _________ percent of the variance in anxiety disorders. a. 0-20 b. 20-40 c. 40-60 d. 60-80

c

Describe the most typical course of obsessive-compulsive and related disorders over time.

chronic

Agoraphobia

fear of fear

Uncontrollable worry

generalized anxiety disorder

Specific phobias

prepared learning

A. Recurrent skin picking resulting in skin lesions. B. attempts to decrease or stop skin picking. C) distress or impairment D) R/O medical or substance E) R/O psychotic, Body Dysmorphic Disorder * Also called "dermatillomania"

Excoriation (SKin-Picking) Disorder

Commonalities Across Psychological Treatments

Exposure is a core component of cognitive behavioral treatment (CBT). In a typical approach to exposure treatment, the therapist and the client make a list of triggers—situations and activities that might elicit anxiety or fear, and they create an "exposure hierarchy," a graded list of the difficulty of these triggers. Exposure treatment is effective for 70-90 percent of clients. Although much of the research has been conducted with samples of majority individuals, CBT also has been shown to be helpful for non-Latino white clients. The effects of CBT endure when follow-up assessments are conducted 6 months after treatment, but in the years after treatment, many people experience some return of their anxiety symptoms. A couple of key principles appear important in protecting against relapse. First, exposure should include as many features of the feared object as possible. For example, exposure for a person with a spider phobia might include exposure to diff erent spiders, but also a focus on diff erent features of those spiders such as the hairy legs and the beady eyes. Second, exposure should be conducted in as many different contexts as possible. As an example, it might be important to expose a person to a spider in an office and outside in nature. An elevator phobic might be urged to ride elevators in many diff erent buildings.

What is the most common strategy used in CBT for anxiety disorders?

Exposure sometimes supplemented with cognitive apparches

Fear often involves moderate arousal, and anxiety involves higher arousal. True or False

False

____________is defined as a reaction to immediate danger.

Fear involves higher arousal at the high end, a person experiencing fear may sweat profusely, breathe rapidly, and feel an overpowering urge to run is fundamental for "fight-or-flight" reactions—that is, fear triggers rapid changes in the sympathetic nervous system to prepare the body for escape or fighting fear saves lives: (Imagine a person who faces a bear and doesn't marshal energy to run quickly!)

Obsessive-compulsive disorder (OCD)

Repetitive, intrusive, uncontrollable thoughts or urges (obsessions) Repetitive behaviors or mental acts that a person feels compelled to perform (compulsions)

List four reasons to consider OCD, BDD, and hoarding as related conditions

(a) all share symptoms of uncontrollable repetitive thoughts and behavior; (b) the syndromes often cooccur; (c) the genetic vulnerability for these conditions overlaps; (d) fronto-striatal circuits are involved in all three syndromes.

List two reasons psychological treatment is a better option than medication for anxiety disorders.

1. Medications have significant side effects 2. Relapse is common once medications are discontented

List two reasons that antidepressant medications are preferred to benzodiazepines for the treatment of anxiety disorders.

1. Side effects aew more serve with nexodaipines compared with antidepressants medications 2. there is a risk of addiction with benzodiampines

Deep Brain Stimulation: A Treatment in Development for OCD

About 10 percent of those with OCD will not respond to multiple pharmacological treatments. For those patients, randomized controlled trials support the efficacy of deep brain stimulation, a treatment that involves implanting electrodes into the brain. For the treatment of OCD, electrodes are typically implanted into one of several regions in the basal ganglia. About half of patients treated with deep brain stimulation attain significant relief with a couple months of treatment. Because of the limited data and the chance of severe side effects from electrode implantation, this treatment is considered only for those with severe OCD that has failed to respond to standard treatments, and only after a board carefully reviews the case history. Nonetheless, the gains from this approach provide support for neurobiological models of OCD

A. Marked fear or anxiety about two (or more) of the following five situations: Using public transportation (e.g., automobiles, buses, trains, ships, planes). Being in open spaces (e.g., parking lots, marketplaces, bridges). Being in enclosed places (e.g., shops, theaters, cinemas). Standing in line or being in a crowd. Being outside of the home alone. B. 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. almost always provoke fear or anxiety. D. are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. E. out of proportion to the actual danger F. persistent, typically lasting for 6 months or more. G. distress or impairment H. R/O substance or medical I. R/O other anxiety & PTSD

Agoraphobia Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual's presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.

Medications: Obsessive-Compulsive and Related Disorders

Antidepressants are the most commonly used medications for obsessive-compulsive and related disorders. Although they were developed to treat depression, randomized controlled trials support their effectiveness in the treatment of OCD. Clomipramine (Anafranil), a serotonin-norepinephrine reuptake inhibitor (SNRI) and selective serotonin reuptake inhibitors (SSRIs) are helpful. Because they have fewer side effects, SSRIs are recommended as a first-line treatment approach Some caution is warranted. SSRIs may require more time (up to 12 weeks) and higher doses to treat OCD as compared with depression. Most people with OCD continue to experience at least mild symptoms after antidepressant treatment. Even more caution is warranted about medication treatment of hoarding disorder. Results of two small nonrandomized trials suggest that the symptoms of hoarding disorder decrease with antidepressant treatment, but no randomized controlled trials of medications are available for hoarding disorder. Much of the research focuses on hoarding symptoms among OCD patients.

Etiology of Social Anxiety Disorder

As with social anxiety disorder, behavioral perspectives on specific phobias are based on a two-factor conditioning model. That is, a person could have a negative social experience (directly, through modeling, or through verbal instruction) and become classically conditioned to fear similar situations, which the person then avoids. The next step involves operant conditioning: avoidance behavior is reinforced because it reduces the fear the person experiences. There are few opportunities for the conditioned fear to be extinguished because the person tends to avoid social situations. The evidence is clear that people with social anxiety disorder are overly negative in evaluating their social performance, even when they are not socially awkward, and they form powerful visual images of being rejected. Evidence also indicates that people with social anxiety disorder attend more to internal cues than to external (social) cues. For example, people with social anxiety disorder appear to spend more time than other people do monitoring for signs of their own anxiety. Hence, rather than keeping their eye on potential external threats, people with this disorder tend to be busy monitoring their own anxiety levels.

Factors That Increase General Risk for Anxiety Disorders

Behavioral conditioning (classical and operant conditioning) Genetic vulnerability Disturbances in the activity in the fear circuit of the brain Decreased functioning of gamma-aminobutyric acid (GABA) and serotonin; increased norepinephrine activity Increased cortisol awakening response (CAR) Behavioral inhibition Neuroticism Cognitive factors, including sustained negative beliefs, perceived lack of control, over-attention to cues of threat, and intolerance of uncertainty

A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. B. performs repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns. C) distress or impairment D) R/O medical E) R/O eating disorder

Body Dysmorphic Disorder Specify if: With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case. Specify if: Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g., "I look ugly" or "I look deformed"). With good or fair insight: The individual recognizes that the body dysmorphic disorder beliefs are definitely or probably not true or that they may or may not be true. With poor insight: The individual thinks that the body dysmorphic disorder beliefs are probably true. With absent insight/delusional beliefs: The individual is completely convinced that the body dysmorphic disorder beliefs are true.

Psychological Treatment of Social Anxiety Disorder

CBT of social anxiety has shown efficacy compared with wait list controls and supportive treatment. CBT appears to be more cost effective than medications for the treatment of social anxiety. As with other anxiety disorders, exposure is a core aspect of CBT for social anxiety. To provide a graded hierarchy of exposure, such treatments often begin with role playing or practicing with the therapist or in small therapy groups before undergoing exposure in more public social situations. Social skills training, in which a therapist might provide extensive modeling of behavior, can help people with social anxiety disorder who may not know what to do or say in social situations. Remember that safety behaviors, like avoiding eye contact, are believed to interfere with the extinction of social anxiety. Consistent with this idea, the effects of exposure treatment seem to be enhanced when people with social anxiety disorder are taught to stop using safety behaviors. The therapist helps people learn not to focus their attention internally. The therapist also helps them combat their very negative images of how others will react to them. This cognitive therapy has been shown to be more effective than fluoxetine (Prozac) or than exposure treatment plus relaxation

Cognitive Factors Perceived Lack of Control

Childhood experiences, such as traumatic events, punitive and restrictive parenting, or abuse, may promote a view that life is not controllable. Beyond childhood experiences, more recent life events can threaten the sense of control over one's life. Indeed, about half of people with anxiety disorders report a history of childhood physical or sexual abuse, and more than 70 percent of people report a severe life event before the onset of an anxiety disorder. Other life experiences may shape the sense of control over the feared stimulus. For example, people who are used to dogs and feel comfortable about controlling dogs' behavior are much less likely to develop a phobia after a dog bite. On the whole, the degree to which a person experiences control over their environment can influence whether an anxiety disorder develops.

In regard to neurobiological risk, OCD, BDD, and hoarding disorder seem to involve?

Cognitive Behavioral Model of Obsessions and Compulsions

Cognitive Factors: Etiology of Panic Disorder

Cognitive perspectives on panic disorder focus on catastrophic misinterpretations of somatic changes. According to this model, panic attacks develop when a person interprets bodily sensations as signs of impending doom. For example, the person may interpret the sensation of an increase in heart rate as a sign of an impending heart attack. Obviously, such thoughts will increase the person's anxiety, which produces more physical sensations, creating a vicious circle.

Theory focuses on several different ways in which cognitive processes might intensify social anxiety:

First, people with social anxiety disorders appear to have unrealistically harsh views of their social behaviors and overly negative beliefs about the consequences of their social behaviors—for example, they may believe that others will reject them if they blush or pause while speaking. Second, they attend more to how they are doing in social situations and their own internal sensations than other people do. Instead of attending to their conversation partner, they are often thinking about how others might perceive them (e.g., "He must think I'm an idiot"). Men with social anxiety were much more likely to verbalize thoughts about their own performance than were those without social anxiety. Of course, good conversation requires a focus on the other person, so too much thinking about inner feelings and evaluation can foster social awkwardness. The resultant anxiety interferes with their ability to perform well socially, creating a vicious circle. For example, the socially anxious person doesn't pay enough attention to others, who then perceive the person as not interested in them.

Gender Factors in the Anxiety Disorders

Gender Women are more vulnerable to anxiety disorders than are men, with several studies documenting a 2 to 1 gender ratio. When present, anxiety disorders also appear related to more functional impairment for women compared with men Many different theories have been proposed to explain these gender differences. First, women may be more likely to report their symptoms. Social factors, such as gender roles, are also likely to play a role. For example, men may experience more social pressure than women to face fears—as you will see below, facing fears is the basis for one of the most effective treatments available. Women may also experience different life circumstances than do men. For example, women are much more likely than men to be sexually assaulted during childhood and adulthood. These traumatic events may interfere with developing a sense of control over one's environment, and, as we will see below, having less control over one's environment may set the stage for anxiety disorders. Men may be raised to believe more in their personal control over situations as well. It also appears that women show more biological reactivity to stress than do men, perhaps as a result of these cultural and psychological influences.

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. difficult to control the worry. C. 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): Restlessness or feeling keyed up or on edge. Being easily fatigued. Difficulty concentrating or mind going blank. Irritability. Muscle tension. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). D. distress or impairment E. R/O substance or medical F. R/O other anxiety, OCD, PTSD, anorexia, somatic sx, body dysmorphic, illness anxiety disorder

Generalized Anxiety DIsorder

Given the many effective treatments for anxiety, how does one decide which medication to use?

Generally, antidepressants are preferred over benzodiazepines. This is because people may experience severe withdrawal symptoms when they try to stop using benzodiazepines— that is, they can be addictive. Benzodiazepines can have significant cognitive and motor side effects, such as memory lapses and drowsiness, and the side effects have been found to have real-world significance: benzodiazepines are related to an increased risk of car accidents/ Antidepressants tend to have fewer side effects than benzodiazepines. Nonetheless, as many as half of people discontinue tricyclic antidepressants because of side effects such as jitteriness, weight gain, elevated heart rate, and high blood pressure Compared with tricyclic antidepressants, SSRIs and SNRIs tend to have fewer side effects. As a result, SSRIs and SNRIs are considered the first choice medication treatments of most anxiety disorders. Some people, however, do experience side effects from SSRIs and SNRIs, including gastrointestinal distress, restlessness, insomnia, headache, and diminished sexual functioning. Many people stop taking anxiolytic medications because of the side effects.

A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. B. due to a perceived need to save the items and to distress associated with discarding them. C. results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use.. D) distress or impairment E) R/O medical F) R/O: OCD, MDD, psychotic, dementia, ASD

Hoarding Disorder Criteria C: If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities) Specify if: With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space. Specify if: With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic. With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

Etiology of Specific Phobias

In the behavioral model, specific phobias are seen as a conditioned response that develops after a threatening experience and is sustained by avoidant behavior. In one of the first illustrations of this model, John Watson and his graduate student Rosalie Rayner published a case report in 1920 in which they demonstrated creating an intense fear of a rat (a phobia) in an infant, Little Albert, using classical conditioning. Little Albert was initially unafraid of the rat, but after repeatedly seeing the rat while a very loud noise was made, he began to cry when he saw the rat. Although this type of experiment would likely not be approved by modern ethics boards, the experiment provided important evidence that intense fears could be conditioned. Although conditioning experiences were common, about half of the people in the study could not remember any such experiences. Obviously, if many phobias start without a conditioning experience, this is a big problem for the behavioral model. Even among those who have had a threatening experience, many do not develop a phobia. How might we understand this? To begin, the risk factors we have described, such as genetic vulnerability, neuroticism, negative cognition, and propensity toward fear conditioning, probably operate as diatheses—vulnerability factors that shape whether or not a phobia will develop in the context of a conditioning experience. It also is believed that only certain kinds of stimuli and experiences will contribute to development of a phobia. Mowrer's original two-factor model suggests that people could be conditioned to be afraid of all types of stimuli. But people with phobias tend to fear certain types of stimuli. Typically, people do not develop phobias of flowers, lambs, or lamp shades! But phobias of insects or other animals, natural environments, and blood are common. As many as half of women report a fear of snakes; moreover, many diff erent types of animals also fear snakes Evolution may have "prepared" our fear circuit to learn fear of certain stimuli very quickly and automatically; hence, this type of learning is called prepared learning. In support of this idea of evolutionarily adaptive fears, researchers have shown that monkeys can be conditioned to fear snakes and crocodiles but not flowers and rabbits.

The goal of cognitive behavioral theory is to understand why a person with OCD continues to show the behaviors or thoughts used to ward off an initial threat well after that threat is gone. To gather data on how people with OCD respond once a threat is gone, researchers conducted a two-phase experiment

In the first phase, they created a threat by placing electrodes on participants' wrists and then teaching participants that they would receive a shock (an unconditioned stimulus) when a certain shape (the conditioned stimulus) appeared on the computer screen. To avoid the shock, participants had to press a foot pedal (the conditioned response). In this first phase, participants with and without OCD learned equally well to press the foot pedal to avoid shock. In the key second phase of the study, researchers unhooked the wrist electrodes so the participants could see that the threat of shock was gone. Even though they knew the threat was removed and even showed little psychophysiological response to the stimulus, many people with OCD either pressed the foot pedal or felt a strong urge to press the foot pedal when the conditioned stimulus (the shape) appeared on the screen. In contrast, people without OCD quit pressing the foot pedal, and most didn't have an urge to press the foot pedal. The authors argue that for those with OCD, previously functional responses for reducing threat become habitual and therefore difficult to override after the threat was gone. Consistent with this idea, other researchers have found that once someone with OCD develops a conditioned response to a stimulus, they are slower to change their response to that stimulus after it is no longer rewarded

Psychological Treatment of Panic Disorder

Like the behavioral treatments for phobias already discussed, CBT for panic disorder focuses on exposure. CBT for panic disorder is based on the tendency of people with this diagnosis to overreact to bodily sensations. That is, the therapist uses exposure techniques—he or she persuades the client to deliberately elicit the bodily sensations associated with panic. For example, a person whose panic attacks begin with hyperventilation is asked to breathe rapidly for 3 minutes. When sensations such as dizziness, dry mouth, light-headedness, increased heart rate, and other somatic signs of panic begin, the person experiences them under safe conditions; in addition, the person practices coping tactics for dealing with somatic symptoms (e.g., breathing from the diaphragm to reduce hyperventilation). With practice and encouragement from the therapist, the person learns to stop seeing physical sensations as signals of loss of control and to see them instead as intrinsically harmless and controllable sensations. The person's ability to create these physical sensations and then cope with them makes them seem more predictable and less frightening. In cognitive treatment for panic disorder, the therapist helps the person identify and challenge the thoughts that make the physical sensations threatening. For example, if a person with panic disorder imagines that he or she will collapse, the therapist might help the person examine the evidence for this belief and develop a diff erent image of the consequences of a panic attack.

Comorbidity in Anxiety Disorders:

More than half of people with one anxiety disorder meet the criteria for another anxiety disorder during their lives. Anxiety disorders are also highly comorbid with other disorders: Three-quarters of people with an anxiety disorder meet the diagnostic criteria for at least one other psychological disorder. More specifically, about 60 percent of people in treatment for anxiety disorders meet the diagnostic criteria for major depression. Obsessive compulsive disorder also commonly co-occurs with anxiety disorders. As with many disorders, comorbidity is associated with greater severity and poorer outcomes of the anxiety disorders.

A. Presence of obsessions, compulsions, or both: Obsessions are defined by (a) and (b): Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions are defined by (a) and (b): Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts. B. time-consuming (e.g., take more than 1 hour per day) or cause distress or impairment C. R/O substance or medical D. R/O: GAD, ED, other OCD, SMD, BDD, Substance addiction, illness anxiety, paraphilia, impulse control disorder, MDD, psychotic disorders, ASD

Obsessive-Compulsive Disorder Specify if: With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true. With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true. With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true. Specify if: Tic-related: The individual has a current or past history of a tic disorder.

Note: Symptoms are presented for the purpose of identifying a panic attack; however, panic attack is not a mental disorder and cannot be coded. For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier. An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: Palpitations, pounding heart, or accelerated heart rate. Sweating. Trembling or shaking. Sensations of shortness of breath or smothering. Feelings of choking. Chest pain or discomfort. Nausea or abdominal distress. Feeling dizzy, unsteady, light-headed, or faint. Chills or heat 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. Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

Panic Attack Specifier Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (e.g., depressive disorders, posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (e.g., "posttraumatic stress disorder with panic attacks").

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: Palpitations, pounding heart, or accelerated heart rate. Sweating. Trembling or shaking. Sensations of shortness of breath or smothering. Feelings of choking. Chest pain or discomfort. Nausea or abdominal distress. Feeling dizzy, unsteady, light-headed, or faint. Chills or heat 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. B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy"). 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. R/O substance or medical D. R/O other anxiety & PTSD

Panic Disorder Note: The abrupt surge can occur from a calm state or an anxious state. Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

Anxiety about recurrent panic attacks

Panic disorder

Cultural Factors in the Anxiety Disorders

People in every culture seem to experience problems with anxiety disorders, but culture and environment influence what people come to fear. "If you live near a volcano you're going to fear lava. If you live in the rainforest you're going to fear malaria" (Smith, 2012, p. 72). Kayak-angst, a disorder that is similar to panic disorder, occurs among the Inuit people of western Greenland; seal hunters who are alone at sea may experience intense fear, disorientation, and concerns about drowning. In Japan a syndrome called taijin kyofusho involves fear of displeasing or embarrassing others; people with this syndrome typically fear making direct eye contact, blushing, having body odor, or having a bodily deformity. The symptoms of this disorder overlap with those of social anxiety disorder, but the focus on others' feelings is distinct Koro (a sudden fear that one's genitals will recede into the body—reported in southern and eastern Asia), shenkui (intense anxiety and somatic symptoms attributed to the loss of semen, as through masturbation or excessive sexual activity—reported in China and similar to other syndromes reported in India and Sri Lanka), and susto (fright-illness, the belief that a severe fright has caused the soul to leave the body—reported in Latin America and among Latinos in the United States), also involve symptoms similar to those of the anxiety disorders defined in the DSM. As with the Japanese syndrome taijin kyofusho, the objects of anxiety and fear in these syndromes relate to environmental challenges as well as to attitudes that are prevalent in the cultures where the syndromes occur.

Cognitive Factors Sustained Negative Beliefs About the Future

People with anxiety disorders often report believing that bad things are likely to happen. For example, people with panic disorder might believe that they will die when their heart begins to pound, whereas people with social anxiety disorder might believe that they will suffer humiliating rejection if they blush. the key issue is not why people think so negatively initially but, rather, how these beliefs are sustained. For example, by the time a person survives 100 panic attacks, you might expect the belief "this attack means I am about to die" would fade. One reason these beliefs might be sustained is that people think and act in ways that maintain these beliefs. That is, to protect against feared consequences, they engage in safety behaviors. For example, people who fear they will die from a fast heart rate stop all physical activity the minute they feel their heart race. They come to believe that only their safety behaviors have kept them alive. Hence, safety behaviors allow a person to maintain overly negative cognitions.

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., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). B. act in a way/show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others). C. provoke fear or anxiety. D. are avoided or endured with intense fear or anxiety. E. out of proportion to the actual threat posed by the social situation and to the sociocultural context. F. persistent, typically lasting for 6 months or more. G. distress or impairment H. 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 the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder. J. R/O substance or medical

Social Anxiety Disorder (Social Phobia) Note (Criteria A): In children, the anxiety must occur in peer settings and not just during interactions with adults. Note (Criteria C): In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. Specify if: Performance only: If the fear is restricted to speaking or performing in public. Must occur in Peer Settings

Personality: Behavioral Inhibition and Neuroticism

Some infants show the trait of behavioral inhibition, a tendency to become agitated and cry when faced with novel toys, people, or other stimuli. This behavioral pattern, which has been described in infants as young as 4 months old, may be inherited and may set the stage for the later development of anxiety disorders. One study followed infants from 14 months through 7.5 years; 45 percent of those who showed elevated behavioral inhibition levels at 14 months showed symptoms of anxiety at age 7.5, compared with only 15 percent of those who had shown low behavioral inhibition levels (Kagan & Snidman, 1999). Behavioral inhibition is a particularly strong predictor of social anxiety disorder: infants showing elevated behavioral inhibition were 3.79 times as likely as those with low behavioral inhibition to develop social anxiety disorder by adolescence. Neuroticism is a personality trait defined by the tendency to experience frequent or intense negative affect.

A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). B. provokes immediate fear or anxiety. C. actively avoided or endured with intense fear or anxiety. D. out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. E. persistent, typically lasting for 6 months or more. F. distress or impairment G. R/O other anxiety & PTSD

Specific Phobia Note (Criteria A): In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. The average individual with specific phobia fears three objects or situations, and approximately 75% of individuals with specific phobia fear more than one situation or object. Specify if: Code based on the phobic stimulus: 300.29 (F40.218) Animal (e.g., spiders, insects, dogs). Zoophobia 300.29 (F40.228) Natural environment (e.g., heights, storms, water). 300.29 (F40.23x) Blood-injection-injury (e.g., needles, invasive medical procedures). Coding note: Select specific ICD-10-CM code as follows: F40.230 fear of blood; F40.231 fear of injections and transfusions; F40.232 fear of other medical care; F40.233 fear of injury. 300.29 (F40.248) Situational (e.g., airplanes, elevators, enclosed places). 300.29 (F40.298) Other (e.g., situations that may lead to choking or vomiting; in children, e.g., loud sounds or costumed characters).

Etiology of Generalized Anxiety Disorder

Tends to co-occur with other anxiety disorders. Because the comorbidity is so high, researchers believe that many of the factors involved in predicting anxiety disorders in general are particularly important for understanding GAD. People who meet diagnostic criteria for GAD are much more likely to experience episodes of MDD than those with other anxiety disorders are. This suggests that some of the risk factors involved in MDD are also likely to be important in GAD. Worry is the core feature of GAD. Worry is associated with negative affect, and with modest increases in psychophysiological arousal. When instructed to worry, participants with and without GAD experience an increase in negative affect and small shifts in psychophysiological arousal—that is, they look distressed. Worry is such an unpleasant experience that one might ask why anyone would worry a lot. The contrast avoidance model may help explain why some people worry more than others do. Core to this model is the finding that people diagnosed with GAD find it highly aversive to experience rapid shifts in emotions. According to this theory, to ward off sudden shifts in emotion, people with GAD find it preferable to sustain a chronic state of worry and distress: A worrier confronted with a stressor has less room for a large shift in mood and psychophysiological arousal. Consistent with this theory, when people with GAD are presented with a laboratory stressor, they show less of an increase in mood and psychophysiological arousal than do those without GAD. The point isn't that worriers are happier or calmer during stress, but that they demonstrate less volatility. This is in contrast with other anxiety disorders, which tend to be related to very intense psychophysiological responses to threatening stimuli. Taken together, these findings suggest that worry could help a person sustain a more stable emotional state, even if it is an uncomfortable one!

Which countries have the highest rates of anxiety disorders?

The United States and Eorupean Countries

The symptoms of panic disorder tend to wax and wane over time True or False

True

There is a moderate genetic contribution to OCD, hoarding, and BDD. Heritability accounts for 40 to 50 percent of the variance in whether each of these conditions develops True or False

True

Psychological Treatment: Body Dysmorphic Disorder

The basic principles of ERP are tailored in several ways to address the symptoms of BDD. For example, to provide exposure to the most feared activities, therapists might ask clients to interact with people who could be critical of their looks. For response prevention, therapists might ask clients to avoid activities they use to reassure themselves about their appearance, such as looking in mirrors. Multiple trials have shown that ERP produces a major decrease in BDD symptoms compared with control conditions and that effects are maintained in the months after treatment ends (Harrison, Fernández de la Cruz, et al., 2016). Early evidence indicates that an Internet-based version of ERP can be helpful for BDD, with about half of those treated showing a symptom reduction that was sustained at 6-month follow-up. Caution is warranted, though, because many people continue to experience at least mild symptoms after treatment, whether it is offered in person or online.

Psychological Treatment: Obsessive-Compulsive and Related Disorders

The most widely used psychological treatment for obsessive-compulsive and related disorders is exposure and response prevention (ERP). We'll describe this cognitive behavioral treatment (CBT) for OCD, and then how it has been adapted for BDD and hoarding disorder. Many OCD sufferers hold an almost magical belief that their compulsive behavior will prevent awful things from happening. In the exposure component of ERP, clients expose themselves to situations that elicit obsessions and related anxiety. At the same time, for the response-prevention component of ERP, clients refrain from performing any compulsive ritual during the exposure. For instance, a client is asked to touch a dirty dish and then refrain from washing his or her hands. Not only does a client need to refrain from overt compulsive behaviors like hand washing, he or she must also refrain from compulsive thoughts, such as covertly counting to 10. The reasoning behind this approach goes like this: 1. Not performing the ritual exposes the person to the full force of the anxiety provoked by the stimulus. 2. The exposure promotes the extinction of the conditioned response (the anxiety). Randomized clinical trials indicate that ERP is more powerful than control conditions such as anxiety management and relaxation treatment, and as powerful as antidepressants in the treatment of OCD. About 69-75 percent of people who receive this treatment show significant improvement, although mild symptoms often persist. Despite the strong evidence to support ERP, it is a demanding therapy for the clients— refraining from performing a ritual is extremely unpleasant for people with OCD. (To get some idea of how unpleasant, try delaying for a minute or two before scratching an itch.) About a third of people diagnosed with OCD are not willing to begin ERP, and among those who do enroll, about a third drop out. The challenging nature of this treatment may help explain why so few therapists offer it

For items 1-4, match the word to the definition. 1. fear 2. Anxiety 3. worry 4. phobia

a. an emotional response to immediate danger (1) b. an excessive fear of a specific object or situation that causes distress or impairment (4) c. a state of apprehension often accompanied by mild autonomic arousal (2) d. thinking about potential problems, often without settling on a solution (3)

Etiology of Hoarding Disorder

The question, though, is how these basic instincts become so uncontrollable for some people. The cognitive behavioral model suggests several factors might be involved. According to this model, people with hoarding disorder have poor organizational abilities, unusual beliefs about possessions, and avoidance behaviors. Let's review each of these factors, considering how they might lead to excessive acquisition as well as difficulties getting rid of objects. People with hoarding disorder have several different types of problems with cognitive organizational abilities. Problems with attention interfere with staying focused on the task at hand and once they do focus on dealing with their possessions, they have difficulty categorizing their objects and making decisions. When asked to sort objects into categories in laboratory studies, many people with hoarding disorder are slow, generate more categories than others do, and find the process highly anxiety-provoking These difficulties in paying attention, organizing objects, and making decisions influence almost every aspect of acquiring objects, organizing the home, and removing excessive acquisitions. Faced with decisions about which object is the better one to acquire, many will go ahead and get two, three, or more of the same type of object. Many patients find it excruciatingly hard to sort through their objects and figure out what to discard, even with a supportive therapist present. They can spend hours per day churning through their possessions without being able to discard a single object. They report feeling comforted by their objects, feeling frightened by the idea of losing an object, and seeing the objects as core to their sense of self and identity. They hold a deep sense of responsibility for taking care of those objects. Many feel grief when forced to part with an object. These attachments may be even stronger when animals are involved. People who hoard animals often describe their animals as their closest confidants These beliefs about the importance of each and every object interfere with any attempt to tackle the clutter. In the face of the anxiety of all these decisions, avoidance is common. Many with this disorder find organizing their clutter so overwhelming that they delay tackling the chaos. This avoidance maintains the clutter.

Thought Suppression: A Cognitive Model of Obsessions

To rid themselves of these uncomfortable thoughts, people with OCD are more likely to attempt thought suppression. Unfortunately, it is hard to suppress thoughts. Consider the findings of one study in which researchers asked people to suppress a thought. College students in an experimental group were asked not to think about a white bear, and a control group was asked to think about a white bear. Both groups were told to ring a bell every time they thought about a white bear. Attempts to avoid thinking about the white bear did not work—students in the experimental group thought about the bear more than once a minute when trying not to do so (more than the control group did). Beyond that, there was a rebound effect—after students tried to suppress thoughts about the bear for 5 minutes, they thought about the bear much more often during the next 5 minutes than the control group did. Trying to suppress a thought had the paradoxical effect of inducing preoccupation with it. Indeed, in one experimental study, suppressing thoughts even briefly led to more intrusions of that thought over the next four days. , thought suppression is not a very good way to control obsessions.

Neurobiological Factors: Etiology of Panic Disorder

We have seen that the fear circuit appears to play an important role in many of the anxiety disorders. Now we will see that a particular part of the fear circuit is especially important in panic disorder: the locus coeruleus. The locus coeruleus is the major source of the neurotransmitter norepinephrine in the brain. Surges in norepinephrine are a natural response to stress, and when these surges occur, they are associated with increased activity of the sympathetic nervous system, reflected in a faster heart rate and other psychophysiological responses that support the fight-or-flight response. People with panic disorder show a more dramatic biological response to drugs that trigger releases of norepinephrine. Drugs that increase activity in the locus coeruleus can trigger panic attacks, and some imaging research is consistent with a role of norepinephrine in panic disorder as well

Examples of safety behaviors in social anxiety disorder include?

avoiding eye contact, disengaging from conversation, and standing apart from others. Although these behaviors are used to avoid negative feedback, they create other problems. Other people tend to disapprove of these types of avoidant behaviors, which then intensifies the problem. (Think about how you might respond if you were trying to talk to someone who looks at the floor, fails to answer your questions, and leaves the room in the middle of the conversation.)

Cognitive factors found to correlate with anxiety disorders include: a. low self-esteem b. attention to signs of threat c. hopelessness d. lack of perceived control

b;d

The first step in Mowrer's two-factor model includes _________ conditioning, and the second step involves _________ conditioning. a. operant, operant b. classical, classical c. classical, operant d. operant, classical

c

_________ is a personality trait characterized by a tendency to experience frequent and intense negative affect. a. Extraversion b. Neurosis c. Neuroticism d. Psychosis

c

Other symptoms that may occur during a panic attack include _____________(a feeling of being outside one's body); ________(a feeling of the world not being real); and fears of losing control, of going crazy, or even of dying.

depersonalization;derealization

Cognitive approaches to treatment of anxiety disorders typically focus on challenging people's beliefs about (1) the likelihood of negative outcomes if they face an anxiety-provoking object or situation, and (2) their ability to cope with the anxiety. Thus, cognitive treatments typically involve:

exposure in order to help people learn that they can cope with these situations. Because both behavioral and cognitive treatments involve exposure and learning to cope differently with fears, it is not surprising that most studies suggest that adding a cognitive therapy component to exposure therapy for anxiety disorders does not bolster results..

In regard to neurobiological risk, OCD, BDD, and hoarding disorder seem to involve?

fronto-striatal circuits. Brain-imaging studies indicate that three regions of the fronto-striatal circuits are unusually active in people with OCD): the orbitofrontal cortex (an area of the medial prefrontal cortex located just above the eyes), the caudate nucleus (part of the basal ganglia), and the anterior cingulate. When people with OCD are shown objects that tend to provoke symptoms (such as a soiled glove for a person who fears contamination), activity in these three areas increases. The functional connectivity, or synchronization of activity between these regions, when viewing objects that tend to provoke symptoms also appears to differentiate those with OCD from controls. Successful treatment, whether through cognitive behavioral therapy or antidepressant medication, reduces activation of the orbitofrontal cortex and caudate nucleus. These same fronto-striatal regions also are implicated in BDD and hoarding. When people with BDD observe pictures of their own face, hyperactivity of the orbitofrontal cortex and the caudate nucleus is observed. When people with hoarding disorder are faced with decisions about whether to keep or discard their possessions such as old mail, hyperactivity in the orbitofrontal cortex and the anterior cingulate is observed compared with a control group.

several treatments have been developed to help people take a more reflective, less reactive stance toward their intense anxiety and other emotions. These treatments include components such as

mindfulness meditation and skills to promote acceptance of emotions. Most typically, these are used in combination with other CBT techniques, such as exposure treatment. Although few randomized trials are available, mindfulness meditation and acceptance treatments appear to be more powerful in reducing anxiety symptoms than are placebos and have fared as well as CBT in the treatment of mixed anxiety disorders and GAD

Common Risk Factors Across the Anxiety Disorders: Fear Conditioning

model of anxiety disorders, published in 1947, continues to influence thinking in this area. Mowrer's model suggests two steps in the development of an anxiety disorder: 1. Through classical conditioning, a person learns to fear a neutral stimulus (the conditioned stimulus, or CS) that is paired with an intrinsically aversive stimulus (the unconditioned stimulus, or UCS). 2. A person gains relief by avoiding the CS. Through operant conditioning, this avoidant response is maintained because it is reinforcing (it reduces fear).

Etiology of Body Dysmorphic Disorder

people with BDD are usually detail oriented, and this characteristic influences how they look at facial features. Instead of considering the whole, they examine one feature at a time, which makes it more likely that they will become engrossed in considering a small flaw. They also consider attractiveness vastly more important than do control participants. Indeed, many people with BDD believe that their self-worth is exclusively dependent on their appearance