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 ResponsePage 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 interpersonalPage 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 symptomsPage 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: