Panic, Anxiety, Obsessions and their Disorders (Chapter 6)

Carelessness vs. Anxiousness

• people with too little anxiety have more risk for Type I psychopathology

• infants with low fear and anxiety had lower empathy and conscientiousness

William’s Syndrome

life without social anxiety

• mirror image of autism

• many have perfect pitch

• very talkative

• low IQ

• good language and social skills

  • trouble with peers because they’re intrusive

Anxiety

• a general feeling of apprehension about possible future danger

  • develops later in life because early on we cannot think about our future

• complex blend of unpleasant emotions and cognitions

• has cognitive/subjective, psychological and behavioural components

  • “I am worried about what might happen.”

    • stomach ache

    • increased heart rate

    • tension

    • overarousal

    • general avoidance

• many of our sources of fear and anxiety are learned

  • fear and anxiety are highly conditionable

Fear

• an alarm reaction that occurs in response to immediate danger

• basic emotion

• activation of the “fight or flight” response of the ANS

• has cognitive/subjective, psychological and behavioural components

  • “I am in danger!”

    • increased heart rate

    • sweating

    • desire to escape or run

Panic Attack

• when the fear response occurs in the absence of an obvious external danger

  • subjective sense of impending doom, fears of dying, going crazy, or losing control

    • a lot of people go to the hospital because it feels so awful and they think they’re having a heart attack

Anxiety Disorders

• anxiety disorders are characterized by unrealistic, irrational fears or anxieties that cause significant distress and/or impairments

5 anxiety disorders recognized in the DSM

• specific phobia

• social anxiety disorder (social phobia)

• panic disorder

• agoraphobia

• generalized anxiety disorder

Commonalities in causes across anxiety disorders

• high neuroticism

• limbic system (hippocampus and others)

• GABA (mainly generalized anxiety), Norepinephrine (phasic-attention vs. tonic-high during panic attack or anxiety disorders)

• people who feel they are out of control over their environment and their emotions are more vulnerable

• sociocultural environment in which people are raised

Commonalities across effective treatments

• graduated exposure to feared cues, objects, or situations is the single most powerful treatment

• cognitive restructuring often combined with conditioning

• medications can be effective in treating all disorders except phobias and fall into 2 categories (anti-anxiety and antidepressants)

Phobia

• a persistent and disproportionate fear of some specific object or situation

• presents little or no actual danger and yet leads to a great deal of avoidance of those feared situations

Specific Phobias

• strong/persistent fear

• triggered by a specific object or situation

• significant distress and/or impairment in a person’s ability to function

Blood-Injection-Injury Phobias

• seeing blood or an injury

• receiving an injection

• seeing a person in a wheelchair

  • typically experience as much disgust as fear

  • unique physiological response when confronted with the sight of blood or injury

  • initial heart acceleration is followed by dramatic drop in heart rate and blood pressure

Animal Phobias

• snakes

• spiders

• dogs

• insects

• birds

Natural Environment Phobias

• storms

• height

• water

Situational Phobias

• public transportation

• tunnels

• bridges

• elevators

• flying

• driving

• enclosed spaces

Other Specific Phobias

• choking

• vomiting

• “space phobia”

Space Phobia

• fear of falling down if away from walls or other support

Prevalence and Gender Differences for Specific Phobias

• specific phobias are common

  • 12% lifetime prevalence (probably more)

  • more common in women than in men

    • about 90-95% of those with animal phobias are women (probably closer to 50-50 with men they just don’t admit it)

Age of Onset for Animal, Dental and Blood-Injection-Injury Phobias

• usually childhood

Age of Onset for Other Phobias

• tend to begin in early adolescence/early childhood

Psychological Causal Factors of Specific Phobias

• Psychoanalytical (psychodynamic) viewpoint

• phobias as learned behaviour

Psychoanalytical (Psychodynamic) Viewpoint — Specific Phobias

• phobias represent a defense against anxiety that stems from repressed impulses from the id

• too dangerous to “know” the repressed id impulse

• anxiety displaced onto some external object or situation with symbolic relationship to real object of anxiety

Phobias as Learned Behaviour — Specific Phobias

• with classical conditioning, a fear response can be conditioned to previously neutral stimuli when paired with traumatic/painful events

• vicarious conditioning

  • observing a phobic person (parent) behaving fearfully with their phobic object

  • can result in fear being transmitted from one person to another

• individual differences in learning

  • differences in life experiences strongly affect whether conditioned dears or phobias develop

    • some life experiences may serve as risk factors

    • other experiences may serve as protective factors

  • our thoughts help maintain our phobias once they have been acquired

• evolutionary preparedness for learning certain fears and phobias

  • preparedness learning

Preparedness Learning

• when primates and humans are evolutionarily prepared to associate certain objects with frightening events

  • Little Albert

Biological Cause Factors — Specific Phobias

• genetic and temperamental variables also affect the speed and strength of the conditioning of fear

• several behaviour genetic studies also suggest a modest genetic contribution

  • large twin studies show that identical twins are more likely to share animal phobias and situational phobias then were nonidentical twins

Treatments — Specific Phobias

• exposure therapy

• participant modeling

• medication (ineffective by themselves)

Exposure Therapy

• a form of behaviour therapy that involves controlled exposure to the stimuli that elicit phobic fear

  • gradual exposure or flooding

Participant Modeling

• the therapist calmly models ways of interacting with the phobic stimulus or situation

Types of Exposure Therapy

• real life

• imagined

• virtual reality

• interoceptive

Real Life Exposure Therapy

• being exposed to a fear in real life

Imagined Exposure Therapy

• vividly imagining a fear

Virtual Reality Exposure Therapy

• using virtual reality to be exposed to a fear

Interoceptive Exposure Therapy

• bringing sensations into play in an effect to disconfirm the idea that physical sensations will lead to harmful events

Social Anxiety Disorder

• characterized by disabling fears of 1 or more specific social situations

  • underlying fear of exposure to scrutiny and potential negative evaluation by others

  • 2 subtypes

    • performance (e.g., public speaking)

    • nonperformance (e.g., eating in public)

Prevalence, Age of Onset, and Gender Differences in Social Anxiety

• about 12% of the population meets the diagnostic criteria at some point in their lives

• typically begins in adolescence or early adulthood (most commonly begins in middle school)

• more common in women

• often present along with other anxiety disorders and/or use of alcohol to cope with social situations

Psychological Causal Factors of Social Anxiety

• Social Anxiety as Learned Behaviour

• Social Fears and Phobia in and Evolutionary Context

• Perceptions of Uncontrollability and Unpredictability

• Cognitive Biases

Social Anxiety as Learned Behaviour

• originates from direct or vicarious classical conditioning

  • being or witnessing someone else being a target of anger or criticism

  • experiencing or witnessing social defeat or humiliation

Social Fears and Phobia in an Evolutionary Context

• evolutionarily based predisposition to acquire fears of social stimuli that signal dominance/aggression

  • evolved as by-product of dominance hierarchies among primates

Perceptions of Uncontrollability and Unpredictability

• lead to submissive and unassertive behaviour

• especially likely if the person has experienced an actual social defeat

• diminished sense of personal control

  • in part due to somewhat overprotective parents

Cognitive Biases — Social Anxiety

• people with social anxiety tend to expect that other people will reject or negatively evaluate them

  • are preoccupied with bodily responses and negative self-images in social situations

Biological Causal Factors

• the most important temperamental variable is behavioural inhibition

• children assessed as being high on behavioural inhibition between 2-6 years

  • 3x more likely to be diagnosed with social phobia

• modest (lots of) genetic contribution to social phobia

• overlap with ASD

Treatments for Social Anxiety

• cognitive and behavioural therapies

• medication

Cognitive and Behavioural Therapies — Social Anxiety

• prolonged and graduated exposure to the feared situation has proven to be a very effective treatment

  • cognitive restructuring

Cognitive Restructuring

• therapist attempts to help client identify their underlying negative thoughts and change them

Medications — Social Anxiety

• sometimes effective for treating social anxiety

  • antidepressants (target serotonin) are most effective/wildly used

• cognitive-behavioural therapies generally produce more long-lasting improvements with very low relapse rates

Panic Disorder

• occurrence of panic attacks that often come “out of the blue”

• DSM-5TR Criteria

  • must experience recurrent, unexpected attacks

  • must have been persistently concerned about having another attack for at least a month (anticipatory anxiety)

  • most symptoms are physical

    • panic attack includes abrupt onset of at least 4 of 13 symptoms

  • symptoms don’t often appear to be provoked by identifiable situation

    • may occur in seemingly least likely situations, such as during relaxation or sleep (nocturnal panic)

• often not correctly diagnosed for years

Agoraphobia

• fear of “open gathering places” (in greek, agora)

  • anxiety about being in places that would be difficult to escape, or where immediate help would be unavailable

  • at most debilitating, may involve inability to leave home

  • a frequent complication of panic disorder

    • however, many patients with agoraphobia do not experience panic

    • listed in DSM-5 as a distinct disorder

Symptoms of Agoraphobia

• leaving home alone

• enclosed spaces, such as movie theatres, elevators or small stores

• crowds or waiting in line

• open spaces, such as parking lots, bridges or malls

• using public transportation, such as bus, train or plane

Prevalence, Age of Onset, and Gender Differences in Panic Disorder

• panic disorder with or without agoraphobia typically begins between 20s and 40s, sometimes in teen years

• panic disorder and agoraphobia are both twice as prevalent in females as in males

  • percentage of females increases as extent of agoraphobic avoidance increases

  • sociocultural factors explain the gender disparity

Association Between Sex and Lifetime Risk of Agoraphobia

• 2x more likely in females

Association Between Sex and Lifetime Risk of Specific Phobia

• 2x more likely in females

Association Between Sex and Lifetime Risk of Panic Disorder

• 1.9x more likely in females

Association Between Sex and Lifetime Risk of Generalized Anxiety Disorder

• 1.7x more likely in females

Association Between Sex and Lifetime Risk of Social Anxiety Disorder

• 1.3x more likely in females

Comorbidity with Other Disorders — Panic Disorders

• the majority of people with panic disorder have at least one comorbid disorder

  • most often generalized anxiety disorder, social anxiety, specific phobia, PTSD, depression, and substance-use disorders

  • panic disorder is associated with increased risk for suicidal ideation

The Timing of a First Panic Attack

• a first panic attack frequently occurs following feelings of distress or some highly stressful life circumstance

• most adults who have experienced at least one panic attack in their lifetimes do not develop full-blown panic disorder

Biological Causal Factors of Panic Disorders

• Genetic Factors

• Panic and the Brain

• Biochemical Abnormalities

Genetic Factors — Panic Disorder

• moderate heritable component

• 30-34% of the variance in liability to symptoms is due to genetic factors

Panic and the Brain — Panic Disorder

• amygdala: collection of nuclei in front of the hippocampus

  • critically involved in the emotion of fear

Biochemical Abnormalities — Panic Disorder

• more likely to get panic attacks when exposed to various biological challenge procedures (e.g., inhaling air with altered amounts of CO2)

  • panic provocation procedures produce panic attacks in panic disorder clients at a much higher rate than normal subjects

  • noradenergic and serotonergic systems are most implicated in panic attacks

  • GABA has recently been shown to be implicated in anticipatory anxiety

Psychological Causal Factors — Panic Disorder

• Cognitive Theory of Panic

• Comprehensive Learning Theory of Panic Disorder

• Anxiety Sensitivity and Perceived Control

• Safety Behaviours and the Persistence of Panic

Cognitive Theory of Panic

• proposes that people with panic disorder are hypersensitive to their bodily sensations

• tendency to catastrophize about the meaning of bodily sensations (thinking one is having a heart attack if one’s heart is racing)

  • automatic thoughts — triggers of panic

Comprehensive Learning Theory of Panic Disorder

• panic attacks become associated with initially neutral internal and external cues through an interoceptive conditioning process

  • can also be conditioned through exteroceptive cues but interoceptive is more likely

• anxiety conditioned to internal or external cues sets the stage for anticipatory anxiety and sometimes agoraphobic fears

• panic attacks themselves are likely conditioned to certain internal cues

Anxiety Sensitivity and Perceived Control

• anxiety sensitivity: a trait-like belief that certain bodily symptoms may have harmful consequences

  • predict the development of panic attacks and other social anxiety disorders

  • having a sense of perceived control reduces anxiety and blocks panic

    • how likely is it that your friend has been kidnaped and killed because she’s not answering texts? What are more likely explanations?

Safety Behaviours and the Persistance of Panic

• people with panic disorder frequently engage in safety behaviours (e.g., breathing slowly) before or during an attack

  • attribute lack of catastrophe to having engaged in the safety behaviour

  • important during treatment to identify these safety behaviours

    • social anxiety safety behaviour — can’t go to party without friend

Cognitive Biases and the Maintenance of Panic

• people with panic disorder show greater activation to threat words than typical people

• fMRI data confirm that areas of the brain associated with threat show greater activation

• these things may play a role in maintaining the disorder

Behavioural and Cognitive-Behavioural Treatments — Panic Disorder

• prolonged exposure treatments are effective in 60-75% of people with agoraphobia

  • interoceptive exposure

• panic control treatment (PCT) targets agoraphobic avoidance and panic attacks

• magnitude of improvement is often greater with these cognitive and behavioural treatments than with medications

Medications — Panic Disorder

• many people are prescribed anxiolytics from the benzodiazepine category (e.g., Xanex or Klonopin)

  • act very quickly; useful in acute situations of intense panic of anxiety

  • also have side effects such as drowsiness and sedation

• the other category of drugs used is antidepressant (SSRIs)

  • takes 4 weeks to be beneficial

  • can alleviate comorbid depressive disorders

  • side effects

Xanex

• target GABA

• well-liked because they have an immediate effect

• can be addictive

  • get habituated so it takes a higher dose to feel an effect

Generalized Anxiety Disorder

• worry about many different aspects of life

• becomes chronic, excessive, and unreasonable

• people with GAD live in future-oriented mood state of anxious apprehension, chronic tension, worry and diffuse uneasiness that they cannot control

• frequently engage in subtle avoidance activities like checking and procrastination

Generalized Anxiety Disorder Prevalence

• about 3% of population in any 1 year

• tends to be chronic

• most people continue to function, despite their symptoms

Generalized Anxiety Disorder Gender Differences

• 2x more common in females than males

Generalized Anxiety Disorder Age of Onset

• there isn’t really a specific age

Comorbidity of GAD with Other Disorders

• GAD often co-occurs with other disorders, especially other anxiety and mood disorders

• many people experience occasional panic attacks without qualifying for a diagnosis of panic disorder

The Psychoanalytic Viewpoint — GAD

• generalized or free-floating anxiety results from an unconscious conflict between ego and id impulses

• defense mechanisms do not work with GAD

• theory is not testable and has largely been abandoned

Perceptions of Uncontrollability and Unpredictability — GAD

• people with GAD may have a history of experiencing important events in their lives as unpredictable or uncontrollable

• also may be more likely to have had a history of trauma in childhood

• people with GAD have far less tolerance for uncertainty

A Sense of Mastery: The Possibility of Immunizing Against Anxiety

• parents’ responsiveness to their children’s needs directly influences their children’s needs directly influences their children’s development of a sense of mastery (control)

• a person’s history of control over important aspects of their environment is another significant experiential variable

  • affects reactions to anxiety-provoking situations

The Reinforcing Properties of Worry

• people with GAD think the benefits of worrying are:

  • superstitious avoidance of catastrophe

  • avoidance of deeper emotional topics

  • coping and preparation

• when people with GAD worry, emotional and physiological responses to aversive imagery are suppressed

  • because worry suppresses physiological responding, it also insulates the person from fully experiencing or processing the topic that she or he is worrying about, so the anxiety continues

The Negative Consequences of Worry — GAD

• worrying can lead to a greater sense of danger and anxiety

• people who worry tend to subsequently have more negative and intrusive thoughts 

  • attempts to control thoughts and worry may lead to increased experiences intrusive thoughts

Cognitive Biases for Threatening Information — GAD

• people with GAD process threatening information in a biased, likely due to prominent danger schemas 

  • are more likely to think that bad things are likely to happen in the future

  • tend to interpret ambiguous stimuli as threats

Genetic Factors — GAD

• heritability estimate of approximately 30%

• neuroticism is part of the common genetic predisposition

Neurotransmitter and Neurohormonal Abnormalities — GAD

• GABA is functionally deficient in the highly anxious

• serotonin and norepinephrine also play a role

• Corticotropin-releasing hormone (CRH) also plays a major role

GABA

• neurotransmitter related to brain’s inhibition of anxiety

Serotonin

• helps people feel protected

  • people with high levels don’t get affected by things as easily

Neurobiological Differences Between Anxiety and Panic — GAD

• generalized anxiety (or anxious apprehension) is a more diffuse emotional state than acute fear or phobia

• fear, panic and anxiety have different neurobiological bases

  • brain area, neurotransmitters, and hormones implicated are different

• people with GAD have been found to have a smaller left hippocampal region (similar is found in major depression)

constant state of anxiety → release many stress hormones (cortisol) → have an effect on brain

anxiety and depression overlap → if anxious for a long time, brain gets exhausted

Cognitive-Behavioural Treatments for GAD

• involves a combination of behavioural techniques

• CBT approaches have resulted in large changes to most symptoms measured

Medications for GAD

• benzodiazepines are used for tension relief, reduction of other somatic symptoms and relaxation

• buspirone can be used (may be addictive)

• several categories of antidepressants are also used — first line of defense paired with occasional xanex

Obsessive-Compulsive and Related Disorders

• OCD

• Body Dysmorphic Disorder

• Hoarding Disorder

• Trichotillomania

Obsessive-Compulsive Disorder

• defined by the occurrence of obsessive thoughts and compulsive behaviours in an attempt to neutralize such thoughts

• many compulsive thoughts involve contamination fears, fears of harming oneself and others, and pathological doubt

Obsessions

• persistent, recurrent intrusive thoughts/images

Compulsions

• overt repetitive behaviours performed as lengthy rituals

Prevalence of OCD

• approximately 2-3% lifetime prevalence

• of 90% of treatment-seeking people with OCD experience both obsessions and compulsions

• divorced and unemployed people are overrepresented

Gender Differences in OCD

• little to no gender difference in adults

Age of Onset for OCD

• in most cases the disorder has a gradual onset

• once it becomes serious, it tends to be chronic

Comorbidity of OCD with Other Disorders

• most frequently co-occurs with other anxiety disorders

  • social phobia, panic disorder, GAD and PTSD

• approximately 25-50% of people with OCD experience major depression

The Vicious Cycle of OCD

Obsessive Thought → Anxiety → Compulsive Behaviour → Temporary Relief → Obsessive Thought…

OCD as a Learned Behaviour

• exposure to feared objects or situations should be useful in treating OCD if the exposure is followed by prevention of the ritual

  • Mowrer’s two-process theory of avoidance learning:

    • neural stimuli become associated with frightening thoughts/experiences through classical conditioning

    • come to elicit anxiety — compulsive behaviour reduces the anxiety

OCD and Preparedness

• preparedness concept that considers the evolutionary adaptive nature of fear and anxiety

  • also helps us undertstand the occurrence and persistence of OCD

• displacement activities

  • activities many species engage in under situations of conflict or high arousal that resemble the compulsive rituals seen in people with OCD

The Effects of Attempting to Suppress Obsessive Thoughts — OCD

• people with normal and abnormal obsessions differ primarily in the degree to which they resist their own thoughts and find them unacceptable

Appraisals of Responsibility for Intrusive Thoughts — OCD

• inflated sense of responsibility can be associated with:

  • beliefs that simply having a thought about something is morally equivalent to actually doing it or that thinking about a behaviour increases the chances of actually doing it (thought-action fusion)

  • compulsive behaviours to try to reduce percieved likelihood of harm