CLP CH5

Definitions

Anxiety: A mood state characterized by marked negative affect and bodily symptoms of tension in which a person apprehensively anticipates future danger or misfortune.

Fear: The emotion of an immediate alarm reaction to present danger or life-threatening emergencies.

Causes

Depleted levels of gamma-aminobutyric acid (GABA), part of the GABA–benzodiazepine system, are associated with increased anxiety, although the relationship is not quite so direct

Corticotropin-releasing factor (CRF)

neuropeptide

plays a significant role in the body's stress response

elevated levels of CRF are strongly linked to increased anxiety

high CRF activity can contribute to the development and manifestation of anxiety disorders;

when under stress, CRF is released in the brain and can trigger anxiety-like behaviors

The area of the brain most often associated with anxiety is the limbic system which acts as a mediator between the brain stem and the cortex.

Jeffrey Gray’s behavioral inhibition system (BIS): Brain circuit in the limbic system that responds to threat signals by inhibiting activity and causing anxiety

The more primitive brain stem monitors and senses changes in bodily functions and relays these potential danger signals to higher cortical processes through the limbic system.

Fear activates the amygdala, which signals the sympathetic nervous system to trigger the body's "fight-or-flight" response. This response prepares the body to either fight or flee from a threat

Fight/flight system: originates in the brainstem and travels through the amygdala, hypothalamus, and the central gray matter.

The primary neurotransmitter that activates during the "fight or flight" response is norepinephrine (noradrenaline), which is released alongside epinephrine (adrenaline) from the adrenal glands when the body perceives a threat; both are considered key players in this physiological response.

Comorbidities of Anxiety and Related Disorders

• High rates of comorbidity

  • 55% to 76%

  • 55% of the patients who received a principal diagnosis of an anxiety or depressive disorder had at least one additional anxiety or depressive disorder at the time of the assessment.

  • Major depressive disorder - 50% of those diagnosed with anxiety

• Commonalities

  • Features: major depression in 50% of those with anxiety

  • Vulnerabilities: shared vulnerabilities with those who have depression

• Links with physical disorders

• Suicide attempt rates

  • Similar to major depression

  • 20% of people with panic disorder attempt suicide

Generalized Anxiety Disorder (GAD) (1 of 2)

Clinical description of generalized anxiety disorder* (terms with an asterisk are key terms)

Shift from possible crisis to crisis

Worry about minor, everyday concerns like job, family, chores, appointments

Accompanied by symptoms such as sleep disturbance and irritability

Leads to behaviors like procrastination, overpreparation

GAD in children

Need only one physical symptom

Worry about academic, social, athletic performance

Generalized Anxiety Disorder (GAD), (2 of 2)

Statistics

3.1% annual prevalence

5.7% lifetime prevalence

Similar rates worldwide

Insidious onset

Early adulthood

Chronic course

About twice as many individuals with GAD are female than male in epidemiological studies (where individuals with GAD are identified from population surveys), which include people who do not necessarily seek treatment

In the United States, the prevalence of the disorder is significantly lower among Asian Americans, Hispanic, and Black adults compared to White adults (Grant et al., 2005).

GAD is quite prevalent among older adults in the United States. In the large national comorbidity study and its replication, GAD was found to be most common in the group over 45 years of age and least common in the youngest group, ages 15 to 24

Treatments of GAD

Pharmacological

Benzodiazepines - relatively modest therapeutic effect,

Risks versus benefits - seem to impair cognitive and motor functioning and cause psychological and physical dependence, leading to potential withdrawal symptoms upon discontinuation.

Antidepressants

Psychological

Similar benefits to drugs and better long-term results

Cognitive-behavioral treatments

Meditation

Panic Disorder and Agoraphobia (1 of 2)

Clinical description of panic disorder* and agoraphobia*

Unexpected panic attacks

Anxiety, worry, or fear of another attack

Persists for 1 month or more

Agoraphobia:

Fear or avoidance of situations/events; can be persistent

Concern about being unable to escape or get help

Use and misuse of drugs and alcohol

Interoceptive avoidance

Panic Disorder and Agoraphobia (2 of 2)

Statistics

PD 2.7% annual prevalence

PD 4.7% lifetime prevalence

Female: male = 2:1

Acute onset, most common in young adulthood (e.g. ages 20-24)

Prevalence rates for panic disorder show some degree of cross-cultural variability, with Asian and African countries usually showing the lowest rates. These findings mirror cross-ethnic comparisons within the United States, with Asian Americans showing the lowest, and White Americans showing the highest prevalence rates

Treatment

• Medications

  • Benzodiazepines or SSRIs

  • High relapse rates after discontinuation of medication

• Psychological intervention

  • Cognitive behavioral therapy (CBT)

    • Panic control treatment*

• Combined psychological and drug treatments

  • Combined treatment is no better than CBT or drugs alone

  • CBT = better long-term results

high-potency benzodiazepines, the newer selective-serotonin reuptake inhibitors (SSRIs) such as Prozac and Paxil, and the closely related serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine

Exposure therapy

Panic Control Treatment: Cognitive-behavioral treatment for panic attacks, involving gradual exposure to feared somatic sensations and modification of perceptions and attitudes about them.

Highly effective

Specific Phobias (1 of 2)

• Clinical description of specific phobia*

  • Extreme and irrational fear of a specific object or situation

  • Feared situation almost always provokes anxiety

  • Significant impairment or distress

• Types of specific phobias:

  • Blood–injection–injury phobia* - average onset 9yrs

  • Situational phobia* - midteens to mid 20s

  • Natural environment phobia* - peak onset of 7years

  • Animal phobia* - years

  Notice also that the sex ratio among common fears is overwhelmingly female with a couple of exceptions. Among these exceptions is fear of heights, for which the sex ratio is approximately equal.

Specific Phobias (2 of 2)

• Statistics

  • 8.7% annual prevalence; 12.5% lifetime prevalence

  • Female : Male = 4:1

  • Chronic course

  • Onset = Most often childhood

Treatment of Phobias

• Cognitive-behavior therapies

  • Exposure

    • Graduated

    • Structured

  • Relaxation – used to be practiced more, now often not a part of empirically supported treatment

Panic disorder vs. PTSD: Post-Traumatic Stress Disorder (PTSD) involves the re-experiencing of traumatic events, leading to significant distress and impairment, and requires a different therapeutic approach compared to panic disorder.

While panic disorder is characterized by recurrent unexpected panic attacks and the fear of future attacks, PTSD treatment often focuses on trauma-focused therapies such as Eye Movement Desensitization and Reprocessing (EMDR) or Cognitive Processing Therapy (CPT).

Separation Anxiety Disorder

• Clinical description of separation anxiety disorder*

  • Characterized by unrealistic and persistent worry that something will happen to self or loved ones when apart (e.g., kidnapping, accident) as well as anxiety about leaving loved ones

  • 4.1% of children meet criteria, 6.6% of adults

Social Anxiety Disorder (1 of 2)

• Clinical description of social anxiety disorder*

  • Extreme/irrational concern about being negatively evaluated by other people

  • Sometimes (not always) manifests as shyness

  • Leads to significant impairment and/or distress

  • Avoidance of feared situations, or endurance with extreme distress

  • Subtype

    • Performance only: Anxiety only in performance situations (e.g., public speaking)

Social Anxiety Disorder (2 of 2)

• Statistics

  • 6.8% annual prevalence; 12.1% lifetime prevalence)

  • Female : Male = 1:1

  • Onset = usually adolescence

    • Peak age of onset = 13

  • More common in people who are young (18 to 29 years), undereducated, single, and of low socioeconomic class

  • 13.6% prevalence in ages 18 to 29

  • 6.6% prevalence in ages 60+

Treatment of Social Anxiety Disorder

• Medications

  • Beta blockers, benzodiazepines, SSRIs, D-cycloserine

• Psychological

  • Cognitive-behavioral treatment

    • Challenging of anxious thoughts about the consequences of social judgment

    • Exposure to anxiety-provoking situations

    • Rehearsal

    • Role-play

  • Highly effective

Posttraumatic Stress Disorder (PTSD) (1 of 2)

• Clinical description of posttraumatic stress disorder*

  • Trauma exposure

  • Continued re-experiencing

  • Avoidance

  • Emotional numbing

  • Reckless or self-destructive behavior

  • Interpersonal problems

• Refers to problems that persist for more than one month after the trauma

  • Acute stress disorder* may be diagnosed in first month after trauma

Posttraumatic Stress Disorder (PTSD) (2 of 2)

• Statistics

  • 3.5% annual prevalence; 6.8% lifetime prevalence

• Most people who experience traumatic events do not develop PTSD

  • Type of trauma

  • Proximity to trauma

Treatment of PTSD

• Cognitive-behavioral treatment

  • Imaginal exposure to memories of traumatic event

    • Graduated or massed

  • Increase positive coping skills

  • Increase social support

  • Highly effective

• Medications

  • SSRIs

Other Diagnoses Related to Stressors

• Prolonged grief disorder* : prolonged adaptation to the loss of a loved one; grief may even intensify with time

• Adjustment disorders* : anxious or depressive reactions to life stress that are generally milder than would be seen in acute stress disorder or PTSD but still impairing

• Attachment disorders* : disturbed and developmentally inappropriate behaviors in children

  • Reactive attachment disorder* : child does not bond to or seek out caregiver

  • Disinhibited social engagement disorder* : child shows no inhibitions around adults

Obsessive-Compulsive Disorder (OCD) (1 of 2)

• Clinical description of obsessive-compulsive disorder*

  • Obsessions*

    • Intrusive and nonsensical

    • Thoughts, images, or urges

    • Attempts to resist or eliminate

  • Compulsions*

    • Thoughts or actions

    • Provide relief from obsessive thoughts

  Symmetry obsessions: Accounts for most obsessions and involves keeping things in perfect order or doing something a specific way.

• Forbidden obsessions: urges to harm self or others.

• Cleaning/contamination obsessions: Fear or germs or contaminants.

• Hoarding obsessions:

Obsessive-Compulsive Disorder (OCD) (2 of 2)

• Statistics

  • 1% annual prevalence; 1.6% to 2.3% lifetime prevalence

  • Female = Male

  • Chronic

  • Onset = childhood to 30s

Treatment of OCD

• Medications

  • SSRIs

    • High relapse when discontinued

  • Psychosurgery (cingulotomy) in intractable cases

• Cognitive-behavioral therapy

  • Exposure and ritual prevention (ERP)

    • Highly effective

    • No added benefit from combined treatment with drugs