Page 1 Chapter 4 Anxiety Disorders Nature of Anxiety and Fear Anxiety Somatic symptoms of tension Future oriented mood state characterized by marked negative affect Apprehension about future danger or misfortune Fear Immediate fight or flight response to danger or threat Involves abrupt activation of the sympathetic nervous system Strong avoidance escapist tendencies Present oriented mood state marked negative affect Nature of Anxiety and Fear part 2 Anxiety and Fear are Normal Emotional States From Normal to Disordered Anxiety and Fear Characteristics of Anxiety Disorders Psychological disorders Pervasive and persistent symptoms of anxiety and fear Involve excessive avoidance and escapist tendencies Symptoms and avoidance causes clinically significant distress and impairment The Phenomenology of Panic Attacks What is a Panic Attack Abrupt experience of intense fear or discomfort Accompanied by several physical symptoms e g breathlessness chest pain DSM IV Subtypes of Panic Attacks Situationally bound cued panic Expected and bound to some situations Unexpected uncued panic Unexpected out of the blue without warning Situationally predisposed panic May or may not occur in some situations Panic is Analogous to Fear as an Alarm Response Page 2 The Phenomenology of Panic Attacks cont Figure 5 1 The relationships among anxiety fear and panic attack Biological Contributions to Anxiety and Panic Diathesis Stress Inherit vulnerabilities for anxiety and panic not anxiety disorders Stress and life circumstances activate the underlying vulnerability Biological Causes and Inherent Vulnerabilities Anxiety and brain circuits GABA Corticotropin releasing factor CRF and HYPAC axis Limbic amygdala and the septal hippocampal systems Behavioral inhibition BIS and fight flight FF systems Psychological Contributions to Anxiety and Fear Began with Freud Anxiety is a psychic reaction to fear Anxiety involves reactivation of an infantile fear situation Behavioral Views Anxiety and fear result from direct classical and operant conditioning and modeling Psychological Views Early experiences with uncontrollability and unpredictability Social Contributions Stressful life events as triggers of biological psychological vulnerabilities Many stressors are familial and interpersonal Page 3 An Integrated Model Integrative View Biological vulnerability interacts with psychological experimental and social variables to produce an anxiety disorder Consistent with diathesis stress model Common Processes The Problem of Comorbidity Comorbidity is common across the anxiety disorders Major depression is the most common secondary diagnoses About half of patients have two or more secondary diagnoses Comorbidity suggests common factors across anxiety disorders Comorbidity suggests a relation between anxiety and depression The Anxiety Disorders An Overview Generalized Anxiety Disorder Panic Disorder with and without Agoraphobia Specific Phobias Social Phobia Posttraumatic Stress Disorder Obsessive Compulsive Disorder Generalized Anxiety Disorder The Basic Anxiety Disorder Overview and Defining Features Excessive uncontrollable anxious apprehension and worry about life events Coupled with strong persistent anxiety Persists for 6 months or more Somatic symptoms differ from panic e g muscle tension fatigue irritability Statistics 4 of the general population meet diagnostic criteria for GAD Females outnumber males approximately 2 1 Onset is often insidious beginning in early adulthood Tendency to be anxious runs in families Generalized Anxiety Disorder The Basic Anxiety Disorder cont Figure 5 3 Clients answers to interviewer s question Do you worry excessively about minor things Page 4 Generalized Anxiety Disorder Associated Features and Treatment Associated Features Persons with GAD have been called autonomic restrictors Fail to process emotional component of thoughts and images Treatment of GAD Benzodiazapines Often Prescribed Psychological interventions Cognitive Behavioral Therapy Generalized Anxiety Disorder cont Figure 5 4 An integrative model of generalized anxiety disorder Panic Disorder With and Without Agoraphobia Overview and Defining Features Experience of unexpected panic attack i e a false alarm Develop anxiety worry or fear about having another attack or its implications Agoraphobia Fear or avoidance of situations events associated with panic Symptoms and concern about another attack persists for 1 month or more Facts and Statistics 3 5 of the general population meet diagnostic criteria for panic disorder Two thirds with panic disorder are female Onset is often acute beginning between 25 and 29 years of age Panic Disorder Associated Features and Treatment Associated Features Nocturnal panic attacks 60 experience panic during deep non REM sleep Interoceptive avoidance catastrophic misinterpretation of symptoms Page 5 Medication Treatment of Panic Disorder Target serotonergic noraadrenergic and benzodiazepine GABA systems SSRIs e g Prozac and Paxil are currently the preferred drugs Relapse rates are high following medication discontinuation Psychological and Combined Treatments of Panic Disorder Cognitive behavior therapies are highly effective Combined treatments do well in the short term Best long term outcome is with cognitive behavior therapy alone Specific Phobias An Overview Overview and Defining Features Extreme irrational fear of a specific object or situation Markedly interferes with one s ability to function Persons will go to great lengths to avoid phobic objects while recognizing that the fear and avoidance are unreasonable Facts and Statistics Females are again over represented About 11 of the general population meet diagnostic criteria for specific phobia Phobias run a chronic course with onset beginning between 15 and 20 years of age Specific Phobias Associated Features and Treatment Associated Features and Subtypes of Specific Phobia Blood injury injection phobia Vasovagal response to blood injury or injection Situational phobia Public transportation or enclosed places e g planes Natural Environment phobia Events occurring in nature e g heights storms Animal phobia Animals and insects Other phobias Do not fit into the other categories e g fear of choking vomiting Causes of Phobias Biological and evolutionary vulnerability direct conditioning observational learning information transmission Psychological Treatments of Specific Phobias Cognitive behavior therapies are highly effective Structured and