Anxiety Disorders, Trauma- and Stressor-Related, and Obsessive-Compulsive and Related Disorders

 The Complexity of Anxiety Disorders

 Fear

 Immediate, present-oriented

 Sympathetic nervous system activation

 Anxiety

 Apprehensive, future-oriented

 Somatic symptoms = tension

 Both: Negative affect

 Anxiety, Fear, and Panic: Some Definitions

 Panic attacks –abrupt experience of intense fear

 Symptoms: palpitations, chest pain, dizziness

 Two types

 Expected

 Unexpected

 Anxiety, Fear, and Panic: Some Definitions

 Biological Contributions

 Increased physiological vulnerability

 Polygenetic influences

 Corticotropin releasing factor (CRF)

 Brain circuits and neurotransmitters

 GABA

 Noradrenergic

 Serotonergic systems

 CRF and the HPAC axis

 Biological Contributions

 Limbic system

 Behavioral inhibition system (BIS)

 Brain stem

 Septal-hippocampal system

 Amygdala

 Fight/flight (FFS) system

 Panic circuit

 Alarm and escape response

 Biological Contributions

 Brain circuits are shaped by environment

 Example: teenage cigarette smoking

 Interactive relationship with somatic symptoms

 Psychological Contributions

 Freud

 Anxiety = psychic reaction to danger

 Reactivation of infantile fear situation

 Behaviorists

 Classical and operant conditioning

 Modeling

 Social Contributions

 Biological vulnerabilities triggered by stressful life events

 Family

 Interpersonal

 Occupational
  Educational

 An Integrated Model

 Triple vulnerability

 Generalized biological vulnerability

 Diathesis

 Generalized psychological vulnerability

 Beliefs/perceptions

 Specific psychological vulnerability

 Learning/modeling

 An Integrated Model

 Comorbidity of Anxiety and Related Disorders

 High rates of comorbidity

 55% to 76%

 Commonalities

 Features

 Vulnerabilities

 Links with physical disorders

 Physical disorders

 Suicide

 Suicide attempt rates

 Similar to major depression

 20%

 Increases for all anxiety disorders

 Comorbidity with depression?

 The Anxiety Disorders

 Types of anxiety disorders

 Generalized Anxiety Disorder

 Panic Disorder and Agoraphobia

 Specific Phobias

 Social Anxiety Disorder

 Separation Anxiety Disorder

 Selective Mutism

 Generalized Anxiety Disorder (GAD)

 Clinical description

 Shift from possible crisis to crisis

 Worry about minor, everyday concerns

 Job, family, chores, appointments

 Problems sleeping

 GAD in children

 Need only one physical symptom

 Worry = academic, social, athletic performance

 Generalized Anxiety Disorder (GAD)

 Statistics

 3.1% (year)

 5.7% (lifetime)

 Similar rates worldwide

 Insidious onset

 Early adulthood

 Chronic course

 Generalized Anxiety Disorder (GAD)

 GAD in the elderly

 Worry about failing health, loss

 Up to 10% prevalence

 Use of minor tranquilizers: 17-50%

 Medical problems?

 Sleep problems?

 Falls

 Cognitive impairments

 Causes

 Inherited tendency to become anxious

 “Neuroticism”

 Less responsiveness

 “Autonomic restrictors”

 Threat sensitivity

 Frontal lobe activation

 Left vs. right

 Causes

 Treatments

 Pharmacological

 Benzodiazepines

 Risks versus benefits

 Antidepressants

 Treatments

 Psychological

 Cognitive-behavioral treatments
  Exposure to worry process

 Confronting anxiety-provoking images

 Coping strategies

 Acceptance

 Meditation

 Similar benefits

 Better long-term results

 Panic Disorder and Agoraphobia

 Clinical description

 Unexpected panic attacks

 Anxiety, worry, or fear of another attack

 Persists for 1 month or more

 Agoraphobia

 Fear or avoidance of situations/events

 Panic Disorder and Agoraphobia

 Panic Disorder and Agoraphobia

 Clinical description

 Avoidance can be persistent

 Use and abuse of drugs and alcohol

 Interoceptive avoidance

 Statistics

 2.7% (year)

 4.7% (life)

 Female: male = 2:1

 Acute onset, ages 20-24

  Panic Disorder and Agoraphobia

 Special populations

 Children

 Hyperventilation

 Cognitive development

 Elderly

 Health focus

 Changes in prevalence

 Panic Disorder and Agoraphobia

 Social/gender roles

 ~75% of those with agoraphobia are female

 Similar prevalence rates

 Variable symptom expression

 Somatic symptoms

 Cultural Influences

 Culture-bound syndromes

 Susto

 Ataque de nervios

 Kyol goeu

 Nocturnal Panic

 60% with panic disorder experience nocturnal attacks

 non-REM sleep

 Delta wave

 Caused by deep relaxation,

 Sensations of “letting go”

  Sleep terrors

 Isolated sleep paralysis

 Nocturnal Panic

 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 children’s 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)

 Female : Male = 1:1

 Onset = adolescence

 Peak age of 13

 Young (18–29 years), undereducated, single, and of low socioeconomic class, 13.6%

 Over 60, 6.6%

 Japan—taijin kyofusho
  Fear of offending others

 Symptoms

 Female : Male = 2:3

 Causes

 Generalized psychological vulnerability

 Generalized- biological vulnerability

 Causes

 Treatment

 Medications

 Beta blockers

 SSRI (Paxil, Zoloft, and Effexor)

 D-cycloserine

 Treatment

 Treatment

 Psychological

 Cognitive-behavioral treatment

 Exposure

 Rehearsal

 Role-play

 Highly effective one study 84% improvement

 Selective Mutism (SM)

 Clinical description

 Rare childhood disorder characterized by a lack of speech

 Must occur for more than one month and cannot be limited to the first month of school

 Comorbidity with SAD

  Treatment

 Cognitive-Behavioral like the treatment for social anxiety best

 Trauma and Stressor-Related Disorders

 Attachment disorders

 Posttraumatic stress disorder

 Posttraumatic Stress Disorder (PTSD)

 Clinical description

 Trauma exposure

 Extreme fear, helplessness, or horror

 Continued re-experiencing

 (e.g., memories, nightmares, flashbacks)

 Avoidance

 Emotional numbing

 Reckless or self-destructive behavior

 Interpersonal problems

 Dysfunction

 One month

 Posttraumatic Stress Disorder (PTSD)

 Posttraumatic Stress Disorder (PTSD)

 Statistics

 6.8% (life); 3.5% (year)

 Prevalence varies

 Type of trauma

 Proximity

 Most common traumas

  Sexual assault 2.4 to 3.5 increase

 Accidents

 Combat

 Causes

 Trauma intensity

 Generalized biological vulnerability

 Twin studies

 Reciprocal gene-environment interactions

 Generalized psychological vulnerability

 Uncontrollability and unpredictability

 Social support

 Causes

 Causes

 Causes

 Neurobiological model

 Threatening cues activate CRF system

 CRF system activates fear and anxiety areas

 Amygdala (central nucleus)

 Increased HPA axis activation

 Cortisol

 Treatment

 Cognitive-behavioral treatment

 Exposure

 Imaginal

 Graduated or massed
  Increase positive coping skills

 Increase social support

 Highly effective

 Psychoanalytic therapy, catharsis

 Treatment

 Medications

 SSRIs

 Adjustment Disorders

 Anxious or depressive reactions to life stress that are generally milder than one would see in
acute stress disorder or PTSD but are nevertheless impairing in terms of interfering with work or
school performance, interpersonal relationships, or other areas of living

 Attachment Disorders

 Disturbed and developmentally inappropriate behaviors in children, emerging before five years
of age, in which the child is unable or unwilling to form normal attachment relationships with
caregiving adults

 Reactive Attachment Disorder

 The child will very seldom seek out a caregiver for protection, support, and nurturance and will
seldom respond to offers from caregivers to provide this kind of care

 Disinhibited Social Engagement Disorder

 A pattern of behavior in which the child shows no inhibitions whatsoever to approaching adults

 Obsessive-Compulsive Disorder (OCD)

 Clinical description

 Obsessions

 Intrusive and nonsensical

 Thoughts, images, or urges

 Attempts to resist or eliminate

 Compulsions
  Thoughts or actions

 Suppress obsessions

 Provide relief

 Causes

 Obsessions

 60% have multiple obsessions

 Need for symmetry

 Forbidden thoughts or actions

 Cleaning and contamination

 Hording

 Causes

 Compulsions

 Four major categories

 Checking

 Ordering

 Arranging

 Washing/cleaning

 Association with obsessions

 Causes

 Tic disorder

 Tic disorder is characterized by involuntary movement (sudden jerking of limbs, for example), to
co-occur in patients with OCD

 Obsessive-Compulsive Disorder (OCD)

 Statistics

 1.6% to 2.3%(life); 1% (year)

 Female = Male
  Chronic

 Onset = childhood to 30s medial 19

 Causes

 Similar generalized biological vulnerability

 Specific psychological vulnerability

 Early life experiences and learning

 Thoughts are dangerous/unacceptable

 Thought-action fusion

 Distraction temporarily reduces anxiety

 Increases frequency of thought

 Causes

 Treatment

 Medications

 SSRIs

 60% benefit

 High relapse when discontinued

 Psychosurgery (cingulotomy)

 30% benefit

 Treatment

 Cognitive-behavioral therapy

 Exposure and ritual prevention (ERP)

 Highly effective

 86% benefit

 No added benefit from combined treatment with drugs

 Body Dysmorphic Disorder BDD)

 A preoccupation with some imagined defect in appearance by someone who actually looks
reasonably normal

 Comorbid with OCD 10%

 Course lifelong

 Onset – early adolescence through 20s

 Reaction to a horrible or grotesque feature

 Two treatments

 SSRIs

 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 one’s 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.