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Anxiety disorders

ANXIETY DISORDERS NOTES

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Anxiety disorders

  1. 1. ANXIETY DISORDERS ● In the DSM-IV, obsessive-compulsive disorder was included in the anxiety disorders classification. ● In the DSM-5, anxiety disorders and obsessive-compulsive and related disorders are now two separate classifications. ● Humans, as well as most mammalian species, are born with the innate capacity to experience fear. ● A distinction is sometimes made between the responses of fear and anxiety. ○ Fear is an adaptive state for dealing with a real threat or danger. ○ Anxiety is the apprehensive anticipation of future danger or misfortune. ● Fear is inferred indirectly from three kinds of data: ○ Subjective experiences of apprehension such as dread, fright, tension, inability to concentrate, the desire to flee a particular situation, and physical sensations ○ Behavioral manifestations such as flight, disorganization of speech, motor incoordination, impairment of performance on complex problem-solving tasks, or sometimes immobilization ○ Physiological responses such as rapid and irregular heartbeat and breathing, palmar sweating, dry mouth, dilated pupils, and muscular trembling ● Sympathetic nervous system: rapid and irregular heartbeat and breathing, palmar sweating, dry mouth, dilated pupils, and muscular trembling ● Parasympathetic nervous system: diarrhea, increased frequency of urination, and fainting—The fainting response is likely to occur only in strong, acute fear states. ● The fear response in humans, regardless of whatever unlearned tendencies exist for certain stimuli to elicit fear, is a highly learnable response that can become associated with almost any situation or stimulus (external or internal) that happens to be present when the fear occurs. ● It is also powerfully influenced by observational learning. ● The DSM-5 classifies the different anxiety disorders in part based on the occurrence of certain components of the anxiety symptom complex. ● Two such components are the following: ○ Panic attacks ○ Agoraphobia ● Many of the anxiety disorders in the DSM-5 involve one or both of these components, but all involve intensely uncomfortable fear or anxiety as the main presenting symptom. PANIC ATTACK ❖ A panic attack involves a rapidly developing sense of intense fear and anxiety. ❖ People undergoing a panic attack feel intense discomfort; some think during the first such experience that they are dying. ❖ Panic attacks are relatively rare in children; they are much more common in adults (1 in 9 adults in a 12-month period). ❖ Panic attacks are not, themselves, diagnosable disorders, but they play a role in several anxiety disorders. ❖ Symptoms (at least 4 required): ➢ Heart palpitations or accelerated heart rate ➢ Trembling or shaking ➢ Sweating ➢ Chest pain ➢ Shortness of breath or sensation of suffocation ➢ Feelings of choking ➢ Dizziness ➢ Numbness or tingling sensations ➢ Chills or heat sensations ➢ Nausea ➢ Derealization or depersonalization ➢ Fear of losing control ➢ Fear of dying REFERENCES: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed). Author. Barlow, D. H., Durand, V. M, & Hofmann, S. G. (2018). Abnormal psychology: An integrative approach (8th ed.). Cengage.
  2. 2. REFERENCES: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed). Author. Barlow, D. H., Durand, V. M, & Hofmann, S. G. (2018). Abnormal psychology: An integrative approach (8th ed.). Cengage. DISORDERS KEY SYMPTOMS DURATION ETIOLOGY DIFFERENTIAL TREATMENT Separation Anxiety Disorder A person experiences developmentally inappropriate and excessive fear or anxiety associated with separation from home or from primary caregivers. The disturbance must last at least 4 weeks in children, and 6 months or more in adults. Generalized Anxiety Disorder:​ if separation from attachment figures do not predominate clinical picture. Agoraphobia:​ if they are anxious about being trapped or incapacitated in which escape is perceived to be difficult Conduct Disorder:​ if the anxiety about separation is not responsible for school absences Social Anxiety Disorder:​ school avoidance must be due to the fear of being judged negatively Posttraumatic Stress Disorder:​ the central concern must be about intrusions and avoidance of memories associated with the traumatic event Illness Anxiety Disorder​: must be concerned about medical diagnosis Bereavement:​ yearning and longing for the deceased Depressive and Bipolar Disorders: low motivation for engaging with the outside world Oppositional Defiant Disorder:​ if behavior is persistently oppositional CBT appears to be effective for separation anxiety disorder in children. Parents are often included to help structure the exercises and to address parental reaction to childhood anxiety
  3. 3. REFERENCES: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed). Author. Barlow, D. H., Durand, V. M, & Hofmann, S. G. (2018). Abnormal psychology: An integrative approach (8th ed.). Cengage. and unrelated to the anticipation/occurrence of separation Psychotic Disorders:​ if there is a misperception of an actual separation Dependent Personality Disorder: indiscriminate tendency to rely on others Borderline Personality Disorder​: there must be problems in identity, self-direction, interpersonal functioning, and impulsivity Selective Mutism A persistent failure to speak in situations where speaking is expected, such as social and school settings. The individual does speak in other situations, however. After the first month in a new social situation, selective mutism can be diagnosed if the failure to speak persists one month and is not due to lack of knowledge about the language, comfort with the spoken language, embarrassm ent about speaking Communication Disorders​: the speech disturbance is not restricted to specific conditions Neurodevelopmental Disorders & Schizophrenia and Psychotic Disorders:​ deficits in social communication and inappropriately speaking in social situations Social Anxiety Disorder​: the social anxiety may be associated. Thus, both diagnosis may be given Behavioral interventions including reinforcement, shaping and stimulus control of speech, perhaps combined with modeling, appear to be the treatments of choice for the condition. Antidepressants may be useful.
  4. 4. REFERENCES: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed). Author. Barlow, D. H., Durand, V. M, & Hofmann, S. G. (2018). Abnormal psychology: An integrative approach (8th ed.). Cengage. connected to a communicati on disorder such as stuttering, or a pervasive developmen tal disorder or psychotic disorder. Specific Phobia This involves intense and persistent fear triggered by specific objects or situations. The fear reaction is excessive. Most individuals with phobias realize that their reactions are excessive or unreasonable, but this realization does not reduce the phobic response. The DSM-5 provides for including subtype indicators in the diagnosis of specific phobia: It must last for at least 6 months and interferes significantly with a person’s life or is associated with marked distress. BIOLOGICAL: Specific phobias are more common in families in which other members have phobias. Monozygotic twins show higher concordance rates for specific phobias than dizygotic twins. There seems to be an innate preparedness to fear certain stimuli evolutionarily associated with real dangers – animals, the dark, heights. BEHAVIORAL: Classical/operant conditioning Two-factor theory of phobia ● Pavlovian conditioning in which object or situation is paired with a traumatic event or a strong sensation of fear ● Operant conditioning in which avoidance behavior Agoraphobia:​ if two or more agoraphobic situations are feared Social Anxiety Disorder:​ if negative evaluation is feared Separation Anxiety Disorder:​ if separation from a primary caregiver or attachment figure is the main manifestation Panic Disorder:​ if there is an experience of uncued panic attacks Obsessive-compulsive Disorder:​ if the primary fear/anxiety is an object or situation as a result of obsessions Trauma and Stressor Related Disorders:​ if the phobia occurs following a traumatic event Eating Disorders:​ avoidance behavior is limited to the avoidance of food and food-related cues In the case of specific phobia, no pharmacological intervention has been shown to be effective. Nearly all empirically-supported therapies for specific phobias involve exposure to the feared stimulus: ● Systematic desensitization ● Participant modeling Exposure therapies involving actual, rather than imagined, contact appear to be the most effective approaches.
  5. 5. REFERENCES: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed). Author. Barlow, D. H., Durand, V. M, & Hofmann, S. G. (2018). Abnormal psychology: An integrative approach (8th ed.). Cengage. ● Animal type ● Natural environment type ● Blood-injectio n-injury type ● Situational type ● Other types (fear of choking, clowns, noises) is negatively reinforced by the reduction in fear that avoidance produces Observational learning PSYCHOANALYTIC: The psychoanalytic theory of phobia formation emphasizes some initial repression of an anxiety-arousing conflict, the projection of the conflict onto the external world, and then displacement of the anxiety onto some other target. Social Anxiety Disorder The symptoms are connected to situations in which the person is exposed to unfamiliar people, or to the scrutiny of others, and fears acting in a way that might prove embarrassing or humiliating. Exposure to these situations almost immediately triggers distressing fear symptoms, which at times may escalate into panic attacks. At least 6 months Social anxiety disorder runs in families; first degree relatives of sufferers have two to six times greater risk of developing the condition. The amygdala may respond differently to novel faces rather than to familiar faces in people with social anxiety disorder. Learning models assume social anxiety disorder develops in similar ways as other phobias, involving a conditioned association between social cues and unpleasant or embarrassing events or social defeats. ● There is no information Agoraphobia:​ if escape might be difficult or might not be available Panic Disorder:​ concerned with the panic attacks Generalized Anxiety Disorder:​ social worries is focused on the nature of ongoing relationships Separation Anxiety Disorder​: may avoid social settings due to the concerns of being separated from attachment figures, but it must be deemed developmentally inappropriate Specific Phobia:​ if fear about negative evaluations in other settings is not generalized Benzodiazepines appear to be effective in short-term relief for social anxiety. SNRIs have also been used effectively. Cognitive-behavioral therapies are effective treatments. ● These techniques typically involve systematic exposure to feared social situations, often combined with relaxation training or desensitization. ● Newer CBT applications, including virtual reality technologies that provide computer-generated scenarios of public speaking situations, also appear promising for treating social anxiety.
  6. 6. REFERENCES: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed). Author. Barlow, D. H., Durand, V. M, & Hofmann, S. G. (2018). Abnormal psychology: An integrative approach (8th ed.). Cengage. It involves shyness and social anxiety that is severe enough to interfere with normal life in terms of occupational, academic, or interpersonal functioning and which has occurred for at least six months. The diagnosis can be sub-typed as performance only if the fear is limited to performing or speaking in public. that establishes a relationship between the disorder and childhood maltreatment or adversity. Psychodynamic models tend to emphasize internal conflicts that produce anxiety (as in the other phobias) as the probable cause of social anxiety disorder. Selective Mutism:​ there must be no fear of negative evaluations in social situations where no speaking is required Major Depressive Disorder:​ feelings of being bad or unworthy must be present Body Dysmorphic Disorder:​ if social fears is due to beliefs about personal appearance Delusional Disorder:​ if beliefs are out of proportion to the actual threat posed by the social situation Autism Spectrum Disorder: ​if the client does not have an adequate age-appropriate social relationship and social communication capacity Avoidant Personality Disorder:​ a broader sense of avoidance must be present Oppositional Defiant Disorder:​ refusal to speak must be due to opposition to authority figures Panic Disorder It is characterized by recurrent, spontaneous and unexpected panic attacks with anxiety about future attacks and their Must be followed by one month or more of persistent concern that the attacks BIOLOGICAL: Panic disorder is known to run in families, with first-degree relatives of panic disorder victims up to 8 times more likely to also show the disorder. Other specified/Unspecified Anxiety Disorder​: the client must experience limited symptom unexpected panic attack Antidepressant medications, especially the SSRIs, have been used effectively in treating panic disorder without the risk of dependence of the benzodiazepines.
  7. 7. REFERENCES: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed). Author. Barlow, D. H., Durand, V. M, & Hofmann, S. G. (2018). Abnormal psychology: An integrative approach (8th ed.). Cengage. consequences. The panic attacks are not due to another medical condition or the effects of a substance. will recur or lead to significant changes in behavior related to avoiding another attack. Potential oversensitivity of the fear network in the brain; for example, the amygdala. Low levels of GABA activity in some parts of the cortex are detected. Panic attacks can be triggered in those who are prone to them by several stimuli: ● Sodium lactate ● Stimulants (such as caffeine) ● Carbon dioxide There is an increased risk for panic disorder in those who smoke and those with respiratory disturbances such as asthma. COGNITIVE: There is a tendency to make catastrophic misinterpretations of physiological sensations. These catastrophic thoughts and expectations then generate the full-blown panic attack, which in turn justifies the original catastrophic interpretation. BEHAVIORAL: Early panic attacks are preceded by internal Behavioral and cognitive-behavioral therapies typically involve exposure to feared interoceptive or exteroceptive stimuli. ● These treatments have been quite successful, and they appear to be more effective and less subject to relapse than pharmacological methods.
  8. 8. REFERENCES: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed). Author. Barlow, D. H., Durand, V. M, & Hofmann, S. G. (2018). Abnormal psychology: An integrative approach (8th ed.). Cengage. physiological (interoceptive) cues, as well as exteroceptive cues in the environment. The anxiety associated with the attack becomes conditioned to those early cues, especially in people with an associative history of uncontrollable or unpredictable negative events. Anxiety then becomes a conditioned stimulus predicting of the next panic attack, which further increases anxiety, spiraling into panic disorder PSYCHODYNAMIC: Psychodynamic models of panic disorder emphasize internal conflicts. Freud’s original focus was on the sexual and aggressive impulses that produced anxiety in the ego. Ego defenses normally contain the anxiety through defense mechanisms, but these are overwhelmed if the unconscious conflict is too threatening.
  9. 9. REFERENCES: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed). Author. Barlow, D. H., Durand, V. M, & Hofmann, S. G. (2018). Abnormal psychology: An integrative approach (8th ed.). Cengage. Agoraphobia It involves anxiety about being in places or situations from which escape would be difficult, embarrassing, or impossible in the event of having a panic attack or panic-like symptoms. NOTE:​ Panic attacks can occur with or without accompanying agoraphobia. Agoraphobia can also occur without a history of panic attacks, thus in the DSM-5 it was elevated to a stand-alone diagnosis. ● Both diagnoses (agoraphobia and panic disorder) are given for those who have both sets of symptoms. At least 6 months Stressful events may be associated with the onset of agoraphobia, but there is also a relatively strong genetic link to phobias Specific Phobia, Situational Type​: If the fear, anxiety, or avoidance is not limited to an agoraphobic situation Separation Anxiety Disorder:​ the thoughts are about detachment from significant others and the home environment Social Anxiety Disorder:​ the focus is on fear of being negatively evaluated Panic Disorder: if the avoidance does not extend to two or more agoraphobic situations Acute Stress Disorder and Posttraumatic Stress Disorder: if the fear, anxiety, or avoidance reminds the client of a traumatic event Major Depressive Disorder: may leave due to apathy, loss of energy, low self-esteem, and anhedonia Behavioral and cognitive-behavioral interventions ● Exposure-based CBT ● Virtual-reality exposure therapy Pharmacological treatment SSRI anti-depressants Generalized Anxiety It is characterized by a nearly At least 6 months BIOLOGICAL: Several brain pathways also Social Anxiety Disorder:​ a preoccupation of social situations Both medical and psychological treatments can be helpful for
  10. 10. REFERENCES: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed). Author. Barlow, D. H., Durand, V. M, & Hofmann, S. G. (2018). Abnormal psychology: An integrative approach (8th ed.). Cengage. Disorder constant state of worry and apprehension about a wide variety of events or activities, on most days over a 6-month period. Several symptoms of autonomic arousal are present, including disturbed sleep and concentration, muscle tension, irritability, and fatigue, to the extent that they interfere with daily life. People with GAD find their worries difficult to control, distressing, and physically troublesome. However, they do not progress into panic attacks. active in other anxiety disorders, including the amygdala and the limbic system and the prefrontal cortex, are implicated in GAD. Inhibition of these pathways, mediated by the neurotransmitter GABA, is assumed to be deficient in GAD sufferers. Genetic evidence is mixed; its modest heritability may be somewhat smaller than that for other anxiety disorders. COGNITIVE-BEHAVIORAL: Similar to that for panic disorder, interoceptive and exteroceptive stimuli become predictive of worry and apprehension to the point that widespread anxiety occurs as a conditioned response. This would be most likely to occur in people who have a history of uncontrollable and unpredictable events, and who would also be less likely to identify periods of safety from threat, resulting in hypervigilance. This results in a cognitive where they will be performing and be evaluated by others Obsessive-Compulsive Disorder: must be intrusive and unwanted thoughts, urges, or images Adjustment Disorder:​ the anxiety occurs in response to an identified stressor within 3 months at its onset Depressive, Bipolar, and Psychotic Disorder:​ separate diagnosis if the excessive worry has occurred under such episode GAD but rarely result in total symptom remission. Effective medications include GABA stimulants such as the benzodiazapines and buspirone for short-term treatments. Antidepressants, especially the SSRIs, may be more helpful both in the longer term and with concomitant depression. Psychotherapy for GAD can be helpful as well, and appears to be at least as effective as pharmacological treatment. There is some disagreement about the effectiveness of CBT in controlled clinical trials. ● Some literature reviews found CBT to be helpful in the short-term for GAD, but lacked evidence of sustained improvement. ● Others indicate CBT is consistently clinically effective for both anxiety and depressio​n.
  11. 11.   REFERENCES: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed). Author. Barlow, D. H., Durand, V. M, & Hofmann, S. G. (2018). Abnormal psychology: An integrative approach (8th ed.). Cengage. tendency to over-appraise and attend to threatening interoceptive and exteroceptive cues, and such an interpretive bias can increase vulnerability to anxiety disorders PSYCHOANALYTIC: Anxiety is created by unconscious conflict, which overwhelms the ego defenses with unacceptable impulses and produces a widespread overt anxiety reaction.

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