Chapter 8. Anxiety Disorders
Two fundamental criteria for anxiety disorders
1. Panic Attack: A discrete period of intense fear or discomfort, in which four or more of the following symptoms developed abruptly and reached a peak within 10 minutes.
(a) Chest pain, (b) chills/hot flushes, (c) de-realization (feelings of uncertainty)/depersonalization (being detached from oneself), (d) fear of dying, (e) fear of losing control, (f) feeling dizzy/faint, (g) feeling of choking, (h) nausea, (i) paresthesias (numbness), (j) pounding heart, (k) shaking, (l) shortness of breath, and (m) sweating.
2. Agoraphobia
(a) Anxiety about being in places or situations from which escape might be difficult or in which help may not be available.
(b) The situations are intentionally avoided or else endured with marked distress
Panic disorder without Agoraphobia
1. Recurrent unexpected panic attacks and at least one-month duration of one or more of the following symptoms.
2. Persistent concern about having additional attacks.
3. Worry about the implications of the attack or its consequences (i.e., going crazy, lose control)
4. Significant behavior change related to the attacks.
5. No symptoms of agoraphobia
Panic disorder with agoraphobia
1. Recurrent panic attacks and at least one-month duration of one or more of the following symptoms.
2. Persistent concern about having additional attacks.
3. Worry about the implications of the attack or its consequences (i.e., going crazy, lose control)
4. Significant behavior change related to the attacks.
5. Presence of agoraphobia
Agoraphobia without history of panic disorder
1. The presence of Agoraphobia related to fear of developing panic-like symptoms (i.e., dizziness)
2. Criteria have never met for panic disorder
Specific Phobia
1. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation.
2. An immediate anxiety/fear response when exposed to the phobic stimulus.
3. The person recognizes that the fear is excessive or unreasonable.
Four subtypes: (a) Animal (i.e., insects), (b) natural environment (i.e., storms, heights, water), (c) blood-injection-injury (i.e., invasive medical procedure), or (d) situational (i.e., bridge, tunnels, elevators, public transportation) types.
Social Phobia
1. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others (i.e., expects that the person will act in a way that will be humiliating or embarrassing).
2. Exposure to the feared social situation almost invariably provokes anxiety.
3. The person recognizes the fear is excessive and unreasonable.
4. In individuals under 18, the duration is at least 6 month.
5. Specify Generalized if the fears include most social situations.
Obsessive-Compulsive Disorder (OCD)
1. Either Obsessions: (a) recurrent and persistent thoughts, impulses, images causing marked anxiety or distress, (b) the thoughts or images are not simply excessive worries about real-life problems (i.e., money, school, job), (c) attempt to suppress or ignore the thoughts or images, and (d) recognition that the obsessive thoughts are a product of one’s own mind (not thought insertion by others) OR
2. Compulsions: (a) Repetitive behaviors (i.e., hand washing, ordering, checking) or mental acts (i.e., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession and (b) The behaviors or mental acts are aimed to reduce or prevent distress caused by obsessions.
3. Recognize that the obsessions or compulsions are excessive or unreasonable (i.e., take more that 1 hour per day).
4. Specify “With Poor Insight.”
Posttraumatic Stress disorder (PTSD)
1. Has been exposed to a traumatic event (i.e., experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others).
2. Response to the event(s) involves intense fear, helplessness, or horror.
3. The traumatic event is persistently re-experienced in (a) dreams, images, thoughts, and/or plays, (b) acting/feeling as if the event were recurring, and (c) intense psychological distress at exposure to internal or external cues symbolizing or resemble to the event.
4. Persistent avoidance stimuli associated with the trauma (i.e., avoidance of conversations, thoughts, and activities resembling the trauma, inability to remember the trauma, feelings of detachment from others, restricted range of affect, and sense of foreshortened future.
5. Persistent symptoms of increased arousal (i.e., sleep disturbance, irritability/anger outburst, difficulty concentrating, hypervigilance, and exaggerated startle response.
6. At least one-month duration of the disturbance.
Treatment
1. Psychodynamic therapy
ID-Ego-Superego. Defense Mechanisms (i.e., reaction formation, undoing).
(EX) “I hate my children.” “I should not feel this way—Feel guilty and anxious” “To reduce the anxiety, keep checking their children while they are sleeping.” Thus deal with resentment toward her children.
2. Behavioral therapy
(a) Systematic desensitization: Systematically exposure to worry-provoking images and real situations (in vivo exposure)
(b) Implosive therapy: Exposure to therapist-controlled images causing worry.
(c) Flooding: not gradually, but immediately exposure to high-intensity and prolonged stimuli causing worry.
(d) Modeling: Help the patient learn social skills and acquire competence/self-efficacy.
3. Cognitive therapy
(a) Aaron Beck: Cognitive restructuring
-Mutually identify unrealistic/distorted thoughts (i.e., a negative view of the self, a negative view of the world and others, a negative view of the future) and faulty information processing (i.e., Arbitrary inference, selective abstraction, over-generalization, magnification/minimization, personalization, absolustic/dichotomous thinking, perfectionism, catastrophic thoughts) that are related to anxiety or occurring during distress.
-Restructure their cognitions or information processing.
(b) Thought stopping: Ask the patient to focus on one’s obsessive thoughtsSTOP!
(c) Cognitive rehearsal: Cognitively rehearse adaptive approaches to problematic situations.
(d) Worry exposure: Worst outcome?
4. Biological (Medications)
-Bi-directional (i.e., experience <-->biology)
-(EX) Limbic system: A doughnut-shaped neural system.
-Hypothalamus: Controls eating, drinking, body temperature, and also stimulates pituitary gland to secrete hormones.
-Amygdala: Tow almond-shaped clusters that are components of limbic system. Controls aggression and fear.
-Hippocampus: Controls memory.
-(EX) PTSD patients show decreases in blood flow in the limbic system while they were exposed to slides or sounds related to traumatizing events (i.e., self-defensive suppression?).
(a) Benzodiazepines: Tranquilizers (i.e., Librium, Valium) have most frequently prescribed for treatment of anxiety disorders. Side effects: drowsiness, lethargy, motor impairment, or lack of concentration.
(b) Alprazolam: Popular for treating panic disorders. Side effects: Drowsiness, or withdrawal symptoms.
(c) Antidepressants (i.e., imipramine, clomipramine): Effective for treating OCD.
Why antidepressants? May be due to comorbidity (co-occurrence of more than a disorder).