HD 3700 Prelim 2- Anxiety disorders

Anxiety

• emotional state marked by anticipation of danger/misfortune, intense distress, bodily tension, and nervousness

Where does anxiety stem from?

• response to perceived threat

• vital role in survival

  • high prevalence stems form ancestors that had the keenest reactions to threat

• creates physical change (fight/flight)

Anxiety Disorders

• levels of enxuety that are frequent, debilitating and disproportionate to the circumstances

• among the most prevalent psychological disorders 

• 1/3 will experience 

• commonly start in childhood

More criteria:

• fear or anxiety is out of proportion

• persistent

• clinically significant distress or impairment in social, occupational, or other important areas of functioning

  • failure to meet this last criteria is why most of our normal fears are not considered phobias

Physical Signs of anxiety

• derived from fight/flight

• prioritize directing energy to most essential functions for survival

• same symptoms regardless of the circumstances that bring them on —reflecting the fight/flight is effective against many types of threat

some physical reactions

• rapid heart rate

• shortness of breath

• sweating

• slowed digestion

• dilated pupils

• redistribution of blood flow

• muscle tension

2 main cognitive symptoms

• perception of threat or danger  

  • `when we are anxious, we perceive ourselves as in danger, even though we are physically safe

• worry: repetitive negative thoughts about the possibility of the future danger, misfortune, or hardship

• both often illusionary

How is fear and worry different?

• related, but fear tends to present-oriented, worry is future-oriented

Anxiety disorders in DSM 5

 

comorbidity

• anxiety disorders are highly comorbid with each other 

• people may often have predisposition towards anxiety, but will have different anxiety disorders at different points in their lives 

Specific Phobia

• marked fear and anxiety about a specific object or situation

• phobic object or situation almost always provokes immediate fear or anxiety

• the phobic object or situation is actively avoided or endured with intense fear or anxiety

Main Phobia Categories

• blood, injection, injury

• situations (enclosed spaces, airplanes)

• natural environment (storms, heights)

• animals

Avoidance

• the main behavioral symptoms of anxiety

• is a paradox:

  • reduces anxiety short-term

  • increases anxiety long-term

  • solidifies beliefs around phobic stimulus

  • limits opportunity to learn that seemingly threatening circumstances are not dangerous

• provides negative reinforcement

Treating Phobias 

• eliminate reinforcement associated with avoidance 

• if we consciously modify an avoidant behavior, we can change the beliefs that maintain anxiety and anxious feelings themselves 

Exposures (CBT)

• exposure to fear-provoking stimulus, but limiting the anxiety-reducing response

• habituate occurs: body acclimates to the feeling of anxiety 

• forms new beliefs about the feared situation and their ability to cope with it 

• without avoidance, anxiety WILL be experienced 

Fear and Avoidance Hiearchy

• developed collaboratively with therapist

• ordered list of situations in which a client experiences fear of phobic stimulus

• this is used as a guide for exposures in therapy; clients work from least feared to most feared stimulus

• each situation is rated in terms of how much feared it generates and the lengths to which a client will go to avoid that situation

• every hierarchy is individualized to client’s specific fears

Steps of Effective Exposures

• identity thoughts about situation before exposure occurs

• rate level of distress before exposure

• during exposure..

  • continue to rate distress every 5 minutes

  • do not try to distract self

  • maintain objective awareness of physical symptoms and thoughts

• continue exposure until anxiety goes down- 3or 4 on a scale of 10 is optimal

• after exposure, rate level of distress and evaluate thoughts again

What’s the most important rule of anxiety treatment?

NEVER stop an exposure before habituation occurs

What can exposures be?

• in session

• in vivo (or in life)

• imaginal

What is the goal of the anxiety?

• to decrease the uncomfortableness

Social Anxiety disorder/ social phobia 

• fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others 

• Diagnostic criteria:

  • way person will act or show symptoms will be negatively evaluated

  • almost always provoke fear or anxiety

  • avoided or endured with intense fear or anxiety

  • fear or anxiety is out of proportion

  • last >6 months

Is social anxiety disorder Shyness?

• shy people don’t show avoidant behaviors, fear of negatice evaluation, physical symptoms of anxiety in social situations, or impairment

• 12% consider themselves shy and 10% of thise described as shy by thier family members meet criteria for

What is the correlation between social anxiety and age?

• foten in adolescence

• prevalence: 9-13% and in more in females

  • twice in ages 18-29

  • less in collectivist cultures

  • more in individualistic cultures

Taijin Kyofusho

• form of social anxiety present in japan but not in america, centered on concerns of embarrassing other vs. embarrassing oneself

Treatment for Social Anxiety?

• CBT

• fear and avoidance hierarchy

  • exposure to anxiety provoking social situations or events and re-evaluation of cognitions around these situations

  • group and individual treatments are equally effective

What is accompanied by panic attacks?

• phobias and social anxiety disorder

What’s a panic attack?

• abrupt surge of intense fear/discomfort that reaches a peak within minutes, and during which time four or more of the symptoms occur:

• are time-limited, reach peak in about 10 minutes then decline

What does Social anxiety feel like?

• “trouble catching breath”

• “brain was trying to climb out of my head”

• “it was like my body was trying to say to me- you’re about to die”

What are the 2 types of Panic Attacks?

• situationally bound: clear triggers, part of experience of specific and social phobia for some people

  • snakes, bugs, flying, social situations

  • can be reduced by treating phobic stimuli that precede them

• Not situationally bound: out of the blue

  • can even occur at night (panic disorder)

What is the frequency of panic attacks? (non situational)

• varies widely

• some daily, some multiple a day

• can go weeks/ months without attack, but worry about having one and sho lots of avoidant behavior

Panic Disorder

• recurrent panic attacks

• at least 2 one of the attacks has been followed by >1 months:

  • persistent concern or worry about additional panic attacks or their consequences

  • significant maladaptive change in behavior related to the attacks

Agoraphobia

• another DSM5-TR anxiety disorder

• anxiety about being in places or situations from which escape might be difficult or in which hep may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms

• panic attacks may occur with or without comorbid agoraphobia

examples of avoidance

• restriction of caffeine

• doing certain activities which safety mechanisms are there

catastrophic misinterpretations of physical sensations

• associated with panic are believed to be the biggest reason some people develop panic disorder and other do not

Fear or Fear Model

Treatments for Panic Disorder

• blend exposures with cognitive restructuring re panic

• pyschoeducation

Why doe we make people more anxious in order to make them less anxious?

• symptoms are exacerbated and maintained by avoidant behavior

  • exposures are a technique to extinguish the reinforcement associated with avoidance

• with panic, people are trying to avoid the physical sensations of panic

Stage 1: Interoceptive exposures

• designed to mimic the physical sensations of panic in a controlled, intentional way

• fear and avoidance hierarchy is constructed from these symptoms

examples)

• breath through straw

• head rolling

• running in space

interoceptive

perception of physical states

Stage 2: In Vivo exposures

• therapist and client construct and follow fear and avoidance hierarchy for situations which typically bring on panic outside of therapy sessions

generalized anxiety disorder

• excessive anxiety and worry occurring more days than not for at least 6 months

• difficult to control the worry

• restlessness

• easily fatigued

• difficulty concentrating or mind going blank

• irritability muscle tension

• sleep disturbance

• anxiety, worry, or physical symptoms cause clinically significant stress or impairment in important areas of functioning

• disturbance not attributable to other medical conditions of physiological effects of a substance

• not better explained by another mental disorder

How is GAD different from other anxiety disorders?

• GAD: worry about everyday events 

  • focus of worries shifts frequently

• meta worry

• fewer “fight/flight’ symptoms: ore muscle tension

• 30-31 yrs old

• less likely to present for treatment

• more common in females

• highly comorbid (MDD and other anxiety disorders)

• chronic

• more common is higher income countries

meta worry

• worry about not being able to control worry

Newman’s contrast avoidance model

• suggest people with GAD are extremely sensitive to shifts in emotional state

• worrying keeps people in one state and prevents sharp increases in negative emotions

• reframes worry from a passive thought process but to a logical adaptive coping response

Treatments of GAD 

• SSRIs, SNRIs 

• SBT or third adaptations to CBT

• equally effective in short term