Powerpoint Outline for Chapter 5: Anxiety

Slide 1: Time to think...

• Seligman & Binek (1977) think we learn what places are "safe" for us and which predict danger (panic).  What are some "safety signals" for you -- places where you can relax completely?  Why are these safe?

Slide 2: Fear or anxiety?

• Fear
• Anxiety

Slide 3: Four components

1. Cognitive
2. Emotional
3. Somatic
4. Behavioral

Slide 4: Figure 04.14

Slide 5: When is fear a problem?

Slide 6: When is no fear a problem?

Slide 7: Times like this…

Slide 8: Phobias

• Specific, identifiable stimulus
• Disproportionate and unrealistic
• Prepared?

Slide 9: Figure 05.01

Slide 10:

• Your first client, Miriam S. Tressed (29), walked into your office shaking.  "I'm always so panicky," she complained, and said that these "attacks" happen all the time and any where.  Confused about what's happening, you asked a series of open questions.  In response to these she admitted that she worries all the time and "about almost anything."  She said she often feels "shaky," and sometimes feels like her "heart is pounding in [her] ear."  She couldn't easily attribute her "fears" to any specific thing but, in her words, "everything.”
• What information would you want to gather to help you make a decision about diagnoses?  Which diagnoses would you want to consider?  Exclude?  Why?

Slide 11: Generalized anxiety disorder (APA, 1994)

(A) excessive anxiety and worry, occurring for more days than not for at least 6 mo., about a number of events or    activities;
(B) the person finds it difficult to control the worry;
(C) the anxiety and worry are associated with 3+ of following 6 symptoms (with at least some symptoms present for more days than not for the past 6 mo.)

(1) restlessness or feeling keyed up or on edge;
(2) being easily fatigued;
(3) difficulty concentrating or mind going blank;
(4) irritability;
(5) muscle tension;
(6) sleep disturbance (difficulty falling or staying asleep, or   restless unsatisfying sleep);

(D) the focus of the anxiety and worry is not confined to features of an Axis I disorder, being embarrassed in public, being contaminated, being away from home or close relatives, having multiple physical complaints, or having a serious illness, and the anxiety and worry do not occur exclusively during post traumatic stress disorder;
(E)  the anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning;
the disturbance is not due to the direct physiological effects of a substance or a general medical condition and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder.
p. 203

Slide 12: Treatment of GAD: Drugs

• Benzodiazepines
• Generally increase release of GABA
• Clear reduction of symptoms -- as long as taken
• Addictive & high overdose potential
• Side effects: Memory loss and depression
• Buspar
• Does not affect GABA
• Clear reduction of symptoms -- as long as taken
• nonaddictive & high overdose potential

Slide 13: Treatment of GAD: Cognitive-behavioral therapies

• Combined treatments (cognitive restructuring, relaxation, imagery)
• Long-lasting changes
• Can learn to prevent anxiety

Slide 14: Panic disorder with agoraphobia (APA, 1994)

A. Both (1) and (2):

(1) recurrent unexpected Panic Attacks
(2) at least one of the attacks has been followed by 1 month (or more of  one (or more) of the following:
(a) persistent concern about having additional attacks
(b) worry about the the implications of the attacks or its consequences   (e.g., losing control, having a heart attack, "going crazy")
B. The presence of Agoraphobia
C. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).
D. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social conditions), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive Compulsive Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).

Slide 15: Panic attacks (APA, 1994)

A discrete period of intense fear or discomfort;  symptoms developed
abruptly , reaching a peak within 10 minutes (4+);
(1)  palpitations, pounding heart, or accelerated heart rate;
(2)  sweating;
(3)  trembling or shaking;
(4)  sensations of shortness of breath or smothering;
(5)  feeling of choking;
(6)  chest pain or discomfort;
(7)  nausea or abdominal distress;
(8)  feeling dizzy, unsteady, lightheaded, or faint;
(9)  derealization (feelings of unreality) or depersonalization (being   detached from oneself);
(10) fear of losing control or going crazy;
(11) fear of dying;
(12) paresthesias (numbness or tingling sensations);
(13) chills or hot flushes.

Slide 16: Sudden and brief (Cohen et al., 1985)

Slide 17: Agoraphobia (APA, 1994)

(A) Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms; fears typically involve characteristic clusters of situations that include being outside the home alone, being in a crowd or standing in a line, being on a bridge, and traveling in a bus, train, or automobile.
(B) The situations are avoided (i.e. travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion.
(C) The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as social phobia, specific phobia, obsessive-compulsive disorder, post traumatic stress disorder, or separation anxiety disorder.

Slide 18: Panic: Biological approach

• Why?
• Induced with sodium lactate or low CO2
• Panic tends to be heritable
• Changes in locus coeruleus
• Treated with antidepressants or benzodiazepines
• Good response, but very high relapse rate

Slide 19: Panic: Cognitive approach

• Why?
• Misinterpret bodily events
• Low CO2    (Schwartz, 2000)
• Anxiety ("I can't breathe!")
• circle of panic
• Hyperventilate.......Even more anxiety (I'm dying!!!)
• Teach about panic and anxiety, to reinterpret bodily events
• Excellent response, relapse still frequent

Slide 20: Panic: A personal perspective

• Since that first attack, I have had five or six similar attacks.  They are always extremely frightening, but now that I understand what's happening and know that I'll get over it and won't die or something, it's not quite as bad.  Having the attacks can be very embarrassing, and I worry that sometime I am really going to make a fool out of myself somewhere.  Fortunately, most times people just think I am getting sick and are very sympathetic. (quoted in Holmes, 2001, p. 147)

Slide 21: Time to think...

• What do you think would be a “normal” way to respond to some sort of extraordinary trauma like the terrorist attacks?  Why?

Slide 22: What's normal?

• Acute stress disorder: less than one mo.

PTSD: Greater than one mo.

Slide 23: Some PTSD Symptoms for Marcie and her siblings

                                              Jeff   Marcie   Cathy   Susan
Repetitive play (trauma)           x          x           x
Nightmares                             x          x           x           x
Reexperiencing                                   x
Distress to similar S                x          x           x           x
Avoidance of talk of trauma                x           x
Regressive behavior                x          x
Detachment                              x          x
Restricted affect                       x          x
Sleep disturbance                     x          x          x           x
Anger outbursts                       x          x
Hypervigilance                        x          x
Met DSM-III-R criteria            x          x

Miller, Albano & Barlow, 1992

Slide 24: Posttraumatic Stress disorder (APA, 1994)

A. The person has been exposed to a traumatic event in  which both of the following were present:

(1)  the person 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)  the person’s response involved intense fear,    helplessness, or horror.  Note:  In children, this   may be expressed instead by disorganized or    agitated behavior.
B.  The traumatic event is persistently reexperienced in one (or more) of the  following ways:
(1) recurrent and intrusive distressing recollections of the event, including    images, thoughts, or perceptions.  Note:  In young children, repetitive    play may occur in which themes or aspects of the trauma are expressed.
(2) recurrent distressing dreams of the event.  Note:  In children, there may    be frightening dreams without recognizable content.
(3) acting or feeling as if the traumatic event were recurring (includes a    sense of reliving the experience, illusions, hallucinations, and     dissociative flashback episodes, including those that occur on awakening or   when intoxicated).   Note:  In young children, trauma-specific reenactment   may occur.
(4) intense psychological distress at exposure to internal or external cues    that symbolize or resemble an aspect of the traumatic event
(5) physiological reactivity on exposure to internal or external cues that    symbolize or resemble an aspect of the traumatic event
C.  Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
(1)  efforts to avoid thoughts, feelings, or conversations associated   with the trauma
(2)   efforts to avoid activities, places, or people that arouse    recollections of the trauma
(3)   inability to recall an important aspect of the trauma
(4)   markedly diminished interest or participation in significant   activities
(5)   feeling of detachment or estrangement from others
(6)   restricted range of affect (e.g., unable to have loving feelings)
(7)   sense of a foreshortened future (e.g., does not expect to have   a career, marriage, children, or a normal life span)
D.  Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1)  difficulty falling or staying asleep
(2)  irritability or outbursts of anger
(3)  difficulty concentrating
(4)  hypervigilance
(5)  exaggerated startle response
E.  Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F.  The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
p. 182

Slide 25: "Natural" recovery from trauma

Slide 26: What puts people at risk?

• Greater trauma???
• Genetics
• MZ: concordance between .28 and .41
• DZ: concordance between .11 and .24
• History of early problems or experiences with uncontrollable events
• Low intelligence
• Were able to see their behavior as appropriate or blamed external event/person
• Poor social support

Slide 27: Treatment of choice

• Exposure therapy (talk about trauma)
• About 60% moderately improved
• May take weeks to months of treatment
• Low relapse rates
• Medication (antidepressants and anxiolytics)
• Only marginal improvement, with frequent relapse

Slide 28: Systematic desensitization

1. The client learns relaxation skills
2. Creates a hierarchy of fear-producing stimuli
3. Practices the relaxation skills while therapist describes scenes from hierarchy

Slide 29: Marcie's avoidance hierarchy

                                                               Pre    Post
Being strapped on papoose board            4         0
Having an EKG                                       4         0
Getting an x-ray                                       4         0
Lying on examination table                      3         0
Having therapist apply band-aid              2         0
Letting therapist list to heart                     1         0
Having pulse taken                                  1          0
Giving doll an injection                           0          0

Miller, Albano, & Barlow, 1992

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Last modified September 26, 2001.