dr.erlyn Anxiety disorders 2011.pptx

ANXIETY DISORDER

Erlyn Limoa

Three Components of Anxiety

Physical symptoms Cognitive component Behavioral component

Physiology of Anxiety: Physical System

Perceived danger Brain sends message to autonomic nervous system Sympathetic nervous system is activated (all or none

phenomena) Sympathetic nervous system is the fight/flight system Sympathetic nervous system releases adrenaline and

noradrenalin (from adrenal glands on the kidneys). These chemicals are messengers to continue activity

Parasympathetic Nervous System

Built in counter-acting mechanism for the sympathetic nervous system

Restores a realized feeling Adrenalin and noradrenalin take time to

destroy

Cardiovasular Effects

Increase in heart rate and strength of heartbeat to speed up blood flow

Blood is redirected from places it is not needed (skin, fingers and toes) to places where it is more needed (large muscle groups like thighs and biceps)

Respiratory Effects-increase in speed and dept of breathing

Sweat Gland Effects-increased sweating

Behavioral System

Fight/flight response prepares the body for action-to attack or run

When not possible behaviors such as foot tapping, pacing, or snapping at people

Cognitive System

Shift in attention to search surroundings for potential threat

Can’t concentrate on daily tasks Anxious people complain that they are easily

distracted from daily chores, cannot concentrate, and have trouble with memory

“U” Shaped Function of Anxiety

Useful part of life Expressed differently at various age levels

Generalized Anxiety Disorder

Unfocused worry

Generalized Anxiety Disorder: Diagnostic Criteria

Excessive anxiety or worry occurring more days than not for at least 6 months about a number of events or activities

Difficulty controlling worry 3 of 6 symptoms are present for more days

than not:restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance

Generalized Anxiety Disorder (GAD): Prevalence

~ 4% of the population (range from 1.9% to 5.6%)

2/3 or those with GAD are female in developed countries

Prevalent in the elderly (about 7%)

Generalized Anxiety Disorder: Genetics

Familial studies support a genetic model (15% of the relatives of those with GAD display it themselves-base rate is 4% in general population)

Risk of GAD was greater for monozygotic female twin pairs than dizygotic twins.

The tendency to be anxious tends to be inherited rather than GAD specifically

Heritability estimate of about 30%

Generalized Anxiety Disorder: Neurotransmitters

Finding that benzodiazepines provide relief from anxiety (e.g. valium)

Benzodiazepine receptors ordinarily receive GABA (gamma-aminobutyric acid)

GABA causes neuron to stop firing (calms things down)

Generalized Anxiety Disorder: Neurotransmitters

Getting Anxious

Hypothesized Mechanism:

Normal fear reactions

Key neurons fire more rapidly

Create a state of excitability throughout the brain and body –perspiration, muscle tension etc.

Excited state is experiences as anxiety

Calming Down

Feedback system is triggered

Neurons release GABA

Binds to GABA receptors on certain neurons and “orders” neurons to stop firing

State of calm returns

GAD: problem in this feedback system

GABA Problems?

Low supplies of GABA Too few GABA receptors GABA receptors are faulty and do not capture

the neurotransmitter

Generalized Anxiety Disorder: Cognitions

Intense EEG activity in GAD patients reflecting intense cognitive processing: low levels of imagery

Worrying is a form of avoidance They restrict their thinking to thoughts but do not

process the negative affect Worry hinders complete processing of more disturbing

thoughts or images Content of worry often jumps from one topic to another

without resolving any particular concern

Generalized Anxiety Disorder: Treatment

Short term-benzodiazepine (valium) Cognitive Therapy (focus on problem)

Phobia: Diagnostic Criteria

Marked & persistent unreasonable fear of object or situation

Anxiety response Unreasonable Object or situation avoided or endured with

distress

Differential Diagnosis of Specific Phobia

Vs. SAD: not related to fear of separation Vs. Social Phobia: not related to fear of a

social situation or fear of humiliation Vs. Agoraphobia: fear not related to closed

places Vs. PTSD: fear not related to a specific past

traumatic event

Phobias: Types

Specific phobias Blood-Injection Injury phobias Situational phobia Natural environment phobia Animal phobia Pa-leng (Chinese) colpa d’aria (Italian) Germs Choking phobia…..

What are your fears???

Developmentally Normal Fears

Age Normal Fear

Birth- 6 Months Loud noises, loss of physical support, rapid position changes, rapidly approaching other objects

7-12 Months Strangers, looming objects, unexpected objects or unfamiliar people

1-5 Year Strangers, storms, animals, dark, separation from parents, objects, machines loud noises, the toilet

6-12 Year Supernatural, bodily injury, disease, burglars, failure, criticism, punishment

12-18 Performance in school, peer scrutiny, appearance, performance

Normal Rituals and Behaviors

Even some ritualistic behaviors are normal Any rituals?

Phobias: Prevalence

Fears are very prevalent Phobias occur in about 11% of the population More common among women Tends to be chronic

Etiology of Phobias: Genetics

31% of first degree relatives of phobics also had a phobia (compared to 11% in the general population)

Relatives tended to have the same type of phobia

Not clear if transmission is environmental or genetic

Specific Phobia: Behavioral Perspective

Case of Little Albert

Two-factor model: Acquisition-classical

conditioning Maintenance-operant

conditioning

Specific Phobia: Behavioral Perspective

Classical conditioning Modeling Stimulus generalization

Specific Phobia: Behavioral-Evolution Perspective (Preparedness)

Discussion Section Topic

Specific Phobia: Cognitive Perspective

Specific Phobia: Social and Cultural Factors

Predominantly female Unacceptable in cultures around the world for

men to express fears

Specific Phobia: Treatment

Systematic Desensitization

Social Phobia

Fearful apprehension Social situations

Social Phobia: Diagnostic Criteria

Marked or persistent fear in one or more social or performance situations

Exposure to fear situation is associated with extreme anxiety

Person recognizes that fear is excessive or unreasonable

Feared social and performance situations are avoided or endured with intense anxiety

Social Phobia: Prevalence

13% of the general population About equally distributed in males and females,

however, males more often seek treatment Usually begins around age 15 Equally distributed among ethnic groups

Etiology Social Phobia: Emotions

Temperament and Biological Theories (Kagan) Behaviorally inhibited children 2 remained inhibited at

age 7 and 12 (see video)

Biological preparedness We are prepared to fear rejecting people Social phobics more likely to foucs on critical facial

experessions

Biological Basis of Temperament

Kagan proposed temperamental differences related to inborn differences in brain structure and chemistry:

He found inhibited children have: Higher resting heart rates Greater increase in pupil size in response to

unfamiliar Higher levels of cortisol (released with stress)

Temperament and Anxiety Disorders

Inhibited temperament: risk factor in social phobia

Kagan’s Temperamental/Biological Theory and Prevention

Early identification of at risk children Parental training Avoid overprotecting Encourage children to enter new situations Help kids to develop coping skills Avoid forcing the child

Encouraging Shy Children: helpful hints

Use rewards Arrange don’t push No nagging

Social Phobia: Treatment

Cognitive-Behavioral Therapy Assess which social situations are problematic Assess their behavior in these situations Assess their thoughts in these situations Teaches more effective strategies Rehearse or role play feared social situations in a group setting

Medication Tricyclic antidepressants Monoamine oxidase inhibitors SSRI (Paxil) approved for treatment Relapse is common with medications are discontinued

Panic attacks

Episode of intense fear that something horrible is about to happen

During a panic attack, people may fear they are– Having a heart attack– Dying

Panic attacks

Very fast heartbeat Shortness of breath Choking sensations Trembling Dizziness

Panic disorder

After several panic attacks, person can develop panic disorder.

Fear of the panic attacks themselves Avoidance of anything possibly linked with the

panic attack

Obsessive-compulsive disorder (OCD)

Anxiety disorder characterized by unwanted repetitive thoughts (obsessions) and/or actions (compulsions)

Obsessive-compulsive disorder (OCD)

Mind is flooded with persistent and uncontrollable thoughts

Individual is compelled to repeat certain acts again and again

Causes stress and interferes with everyday functioning.

Obsessions (repetitive thoughts)

Concern with dirt, germs, toxins Something terrible will happen if I don’t do

something Symmetry, order, exactness

Compulsions (repetitive behaviors)

Excessive hand washing, bathing, tooth brushing, grooming

Repeating rituals– In/out of a door, up/down from a chair

Checking– Doors, locks, appliances, car e-brake, homework

Obsessive-compulsive disorder (OCD)

Usually person performs the behavior (compulsion) to try to get the thought (obsession) to go away

Behavior is negatively reinforcing because it gets unpleasant thoughts to temporarily go away

Obsessive-compulsive disorder (OCD)

Example: checking lock repeatedly to get rid of thought that a burglar might get in and rob the house