Anxiety Disorders, Trauma- and Stressor-Related, Anxiety = psychic reaction to danger

and Obsessive-Compulsive and Related Disorders Reactivation of infantile fear

The Complexity of Anxiety Disorders situation
Fear Behaviorists
Immediate, present-oriented Classical and operant conditioning
Sympathetic nervous system Modeling
activation Social Contributions
Anxiety Biological vulnerabilities triggered by
Apprehensive, future-oriented stressful life events
Somatic symptoms = tension Family
Both: Negative affect Interpersonal
Anxiety, Fear, and Panic: Some Definitions Occupational
Panic attacks abrupt experience of intense Educational
fear An Integrated Model
Symptoms: palpitations, chest pain, Triple vulnerability
dizziness Generalized biological vulnerability
Two types Diathesis
Expected Generalized psychological
Unexpected vulnerability
Anxiety, Fear, and Panic: Some Definitions Beliefs/perceptions
Biological Contributions Specific psychological vulnerability
Increased physiological vulnerability Learning/modeling
Polygenetic influences An Integrated Model
Corticotropin releasing Comorbidity of Anxiety and Related
factor (CRF) Disorders
Brain circuits and neurotransmitters High rates of comorbidity
GABA 55% to 76%
Noradrenergic Commonalities
Serotonergic systems Features
CRF and the HPAC axis Vulnerabilities
Biological Contributions Links with physical disorders
Limbic system Physical disorders
Behavioral inhibition system Suicide
(BIS) Suicide attempt rates
Brain stem Similar to major depression
Septal-hippocampal 20%
system Increases for all anxiety disorders
Amygdala Comorbidity with depression?
Fight/flight (FFS) system The Anxiety Disorders
Panic circuit Types of anxiety disorders
Alarm and escape Generalized Anxiety Disorder
response Panic Disorder and Agoraphobia
Biological Contributions Specific Phobias
Brain circuits are shaped by Social Anxiety Disorder
environment Separation Anxiety Disorder
Example: teenage cigarette Selective Mutism
smoking Generalized Anxiety Disorder (GAD)
Interactive relationship with Clinical description
somatic symptoms Shift from possible crisis to crisis
Psychological Contributions Worry about minor, everyday
Freud concerns
 Job, family, chores, Unexpected panic attacks
appointments Anxiety, worry, or fear of another
Problems sleeping attack
GAD in children Persists for 1 month or more
Need only one physical symptom Agoraphobia
Worry = academic, social, athletic Fear or avoidance of
performance situations/events
Generalized Anxiety Disorder (GAD) Panic Disorder and Agoraphobia
Statistics Panic Disorder and Agoraphobia
3.1% (year) Clinical description
5.7% (lifetime) Avoidance can be persistent
Similar rates worldwide Use and abuse of drugs and alcohol
Insidious onset Interoceptive avoidance
Early adulthood Statistics
Chronic course 2.7% (year)
Generalized Anxiety Disorder (GAD) 4.7% (life)
GAD in the elderly Female: male = 2:1
Worry about failing health, loss Acute onset, ages 20-24
Up to 10% prevalence Panic Disorder and
Use of minor tranquilizers: 17-50% Agoraphobia
Medical problems? Special populations
Sleep problems? Children
Falls Hyperventilation
Cognitive impairments Cognitive development
Causes Elderly
Inherited tendency to become anxious Health focus
Neuroticism Changes in prevalence
Less responsiveness Panic Disorder and
Autonomic restrictors Agoraphobia
Threat sensitivity Social/gender roles
Frontal lobe activation ~75% of those with
Left vs. right agoraphobia are female
Causes Similar prevalence rates
Treatments Variable symptom expression
Pharmacological Somatic symptoms
Benzodiazepines Cultural Influences
Risks versus benefits Culture-bound syndromes
Antidepressants Susto
Treatments Ataque de nervios
Psychological Kyol goeu
Cognitive-behavioral treatments Nocturnal Panic
Exposure to worry process 60% with panic disorder experience
Confronting anxiety- nocturnal attacks
provoking images non-REM sleep
Coping strategies Delta wave
Acceptance Caused by deep relaxation,
Meditation Sensations of letting go
Similar benefits Sleep terrors
Better long-term results Isolated sleep paralysis
Panic Disorder and Agoraphobia Nocturnal Panic
Clinical description Causes
 Generalized biological vulnerability
Alarm reaction to stress
Cues get associated with situations
Conditioning occurs
Generalized psychological
vulnerability
Anxiety about future attacks
Hypervigilance
Increase interoceptive awareness
Causes
Treatment
Medications
Multiple systems
serotonergic
noradrenergic
benzodiazepine GABA
SSRIs (e.g., Prozac and Paxil)
High relapse rates
Treatment
Psychological intervention
Exposure- based
Reality testing
Relaxation
Breathing
Panic control treatment (PCT)
Exposure to interoceptive cues
Cognitive therapy
Relaxation/breathing
High degree of efficacy
Treatment
Combined psychological and drug
treatments
No better than individual
CBT = better long term
Treatment
Specific Phobias
Clinical description
Extreme and irrational fear of a
specific object or situation
Significant impairment
Recognizes fears as unreasonable
Avoidance
Specific Phobias
Blood-injection-injury phobia
Decreased heart rate and blood
pressure
Fainting
Inherited vasovagal response
Onset = ~ 9
Situational phobia
Fear of specific situations
Transportation, small places
No uncued panic attacks
Onset = early to mid 20s
Natural environment phobia
Heights, storms, water
May cluster together
Associated with real dangers
Onset = ~7
Animal phobia
Dogs, snakes, mice, insects
May be associated with real dangers
Onset = ~7
Statistics
12.5% (life); 8.7% (year)
Female : Male = 4:1
Chronic course
Onset = ~ 7
Causes
Direct experience
Vicarious experience
Information transmission
Prepared
Causes
Treatment
Cognitive-behavior therapies
Exposure
Graduated
Structured
Relaxation
Separation Anxiety Disorder
Clinical Description
Characterized by childrens
unrealistic and persistent worry that
something will happen to their
parents or other important people in
their life or that something will
happen to the children themselves
that will separate them from their
parents (for example, they will be
lost, kidnapped, killed, or hurt in an
accident)
4.1% meet criteria for children, 6.6%
for adults
Social Anxiety Disorder (Social Phobia)
Clinical description
Extreme and irrational fear/shyness
Social/performance situations
Significant impairment
Avoidance or distressed endurance
Generalized subtype
Statistics
 12.1% (life); 6.8% (year) (e.g., memories, nightmares,
Female : Male = 1:1 flashbacks)
Onset = adolescence Avoidance
Peak age of 13 Emotional numbing
Young (1829 years), Reckless or self-destructive behavior
undereducated, single, and of low Interpersonal problems
socioeconomic class, 13.6% Dysfunction
Over 60, 6.6% One month
Japantaijin kyofusho Posttraumatic Stress Disorder (PTSD)
Fear of offending others Posttraumatic Stress Disorder (PTSD)
Symptoms Statistics
Female : Male = 2:3 6.8% (life); 3.5% (year)
Causes Prevalence varies
Generalized psychological vulnerability Type of trauma
Generalized- biological vulnerability Proximity
Causes Most common traumas
Treatment Sexual assault 2.4 to 3.5 increase
Medications Accidents
Beta blockers Combat
SSRI (Paxil, Zoloft, and Effexor) Causes
D-cycloserine Trauma intensity
Treatment Generalized biological vulnerability
Treatment Twin studies
Psychological Reciprocal gene-environment
Cognitive-behavioral treatment interactions
Exposure Generalized psychological vulnerability
Rehearsal Uncontrollability and
Role-play unpredictability
Highly effective one study 84% Social support
improvement Causes
Selective Mutism (SM) Causes
Clinical description Causes
Rare childhood disorder Neurobiological model
characterized by a lack of speech Threatening cues activate CRF
Must occur for more than one system
month and cannot be limited to the CRF system activates fear and
first month of school anxiety areas
Comorbidity with SAD Amygdala (central nucleus)
Treatment Increased HPA axis activation
Cognitive-Behavioral like the Cortisol
treatment for social anxiety Treatment
best Cognitive-behavioral treatment
Trauma and Stressor-Related Disorders Exposure
Attachment disorders Imaginal
Posttraumatic stress disorder Graduated or massed
Posttraumatic Stress Disorder (PTSD) Increase positive coping skills
Clinical description Increase social support
Trauma exposure Highly effective
Extreme fear, helplessness, or horror Psychoanalytic therapy, catharsis
Continued re-experiencing Treatment
Medications
 SSRIs Causes
Adjustment Disorders Tic disorder
Anxious or depressive reactions to life stress Tic disorder is characterized by involuntary
that are generally milder than one would see movement (sudden jerking of limbs, for
in acute stress disorder or PTSD but are example), to co-occur in patients with OCD
nevertheless impairing in terms of Obsessive-Compulsive Disorder
interfering with work or school performance, (OCD)
interpersonal relationships, or other areas of Statistics
living 1.6% to 2.3%(life); 1% (year)
Attachment Disorders Female = Male
Disturbed and developmentally Chronic
inappropriate behaviors in children, Onset = childhood to 30s medial 19
emerging before five years of age, in which Causes
the child is unable or unwilling to form Similar generalized biological vulnerability
normal attachment relationships with Specific psychological vulnerability
caregiving adults Early life experiences and learning
Reactive Attachment Disorder Thoughts are
The child will very seldom seek out a dangerous/unacceptable
caregiver for protection, support, and Thought-action fusion
nurturance and will seldom respond to offers Distraction temporarily reduces
from caregivers to provide this kind of care anxiety
Disinhibited Social Engagement Disorder Increases frequency of thought
A pattern of behavior in which the child Causes
shows no inhibitions whatsoever to Treatment
approaching adults Medications
Obsessive-Compulsive Disorder (OCD) SSRIs
Clinical description 60% benefit
Obsessions High relapse when
Intrusive and nonsensical discontinued
Thoughts, images, or urges Psychosurgery (cingulotomy)
Attempts to resist or 30% benefit
eliminate Treatment
Compulsions Cognitive-behavioral therapy
Thoughts or actions Exposure and ritual prevention (ERP)
Suppress obsessions Highly effective
Provide relief 86% benefit
Causes No added benefit from combined
Obsessions treatment with drugs
60% have multiple obsessions Body Dysmorphic Disorder BDD)
Need for symmetry A preoccupation with some imagined defect
Forbidden thoughts or actions in appearance by someone who actually
Cleaning and contamination looks reasonably normal
Hording Comorbid with OCD 10%
Causes Course lifelong
Compulsions Onset early adolescence through
Four major categories 20s
Checking Reaction to a horrible or grotesque
Ordering feature
Arranging Two treatments
Washing/cleaning SSRIs
Association with obsessions
 Exposure and response
prevention
Causes
Causes
Plastic Surgery and Other Medical
Treatments
Fully 76.4% had sought this type of
treatment and 66% were receiving it
8% to 25% of all patients who request plastic
surgery may have BDD
Hoarding Disorder
Estimates of prevalence range between 2%
and 5% of the population, which is twice as
high as the prevalence of OCD
Men = women
Individuals usually begin acquiring
things during their teenage years
and often experience great pleasure,
even euphoria, from shopping or
otherwise collecting various items
OCD tends to wax and wane,
whereas hoarding behavior can
begin early in life and get worse with
each passing decade
Trichotillomania (Hair Pulling Disorder) and
Excoriation (Skin Picking Disorder)
The urge to pull out ones own hair from
anywhere on the body, including the scalp,
eyebrows, and arms, is referred to as
trichotillomania
Excoriation (skin picking disorder) is
characterized by repetitive and compulsive
picking of the skin, leading to tissue damage
1- 5%
Habit reversal training, show best
results
Reference:
Duran, Barlow (2014) Abnormal Psychology, 7 th Ed.