Anxiety Chapter 5 Nature of Anxiety and Fear • Anxiety • Future-oriented: apprehension about future threat • Fear • Present-oriented: Abrupt activation of the sympathetic NS • Immediate “fight or flight” response to perceived threat • Anxiety and fear = normal, adaptive emotional states experienced by all living organisms system to protect & mobilize for survival • Thought question: What distinguishes normal/adaptive anxiety from abnormal/maladaptive anxiety? See textbook for info about etiology and features of anxiety disorders Panic Attacks • What is a Panic Attack? • Abrupt experience of intense fear/discomfort that reaches a peak within minutes and includes several physical symptoms • e.g., heart racing, sweating, breathlessness, derealization, lightheadedness, fear of losing control/dying/going crazy • Panic is analogous to fear: sympath. nervous system alarm response • In panic, the alarm response occurs at an inappropriate time • Types of Panic Attacks • Expected – Known, specific situations • Unexpected – Occurs “out of the blue”, no warning • Panic attack itself is not a disorder but rather can be a symptom of certain disorders (in particular, panic disorder) DSM-5 Anxiety Disorders • Anxiety Disorders • • • • Specific Phobia Panic Disorder and Agoraphobia (PD/A) Social Anxiety Disorder (SAD) – a.k.a. “social phobia” Generalized Anxiety Disorder (GAD) Treatment of Anxiety Disorders • Medications and CBT: • • • • SSRIs are preferred meds Relapse rates are high following meds discontinuation Exposure is a crucial part of CBT. Combining meds plus CBT can be helpful, but not always How Does Exposure Work? • What are the learning mechanisms underlying exposure? • Anxiety disorders learned association between feared stimulus and feared consequence (“If I face X, then Y will happen”) The feared stimulus acquires a meaning of “danger” • Exposure is designed to change this meaning Repeatedly confronting feared stimulus in absence of feared consequence facilitates learning of new information • Often, new learning that “feared stimulus is not dangerous” does NOT erase old learning that “feared stimulus is dangerous” the two mental representations exist in competition! Consequence = re-emergence of fear within contexts in which old representation becomes salient: retrieval competition Specific Phobia • Primary Symptoms in DSM-5: • Extreme/irrational fear causing significant interference/distress and lasting at least 6 months • Subtypes • • • • • Animal phobia – animals/insects Natural environment phobia – e.g., heights, storms Blood-injection-injury phobia Situational phobia – e.g., claustrophobia Other phobias – e.g., fear of choking, fear of vomiting • CBT: Controlled, systematic exposure to feared stimulus • Treatment success requires disconfirming “catastrophic belief” • Critical to identify catastrophic belief before beginning exposure • Exposure is highly effective … even when things go a bit awry… Panic Disorder and Agoraphobia • Primary Symptoms of Panic Disorder in DSM-5: • History of recurrent, unexpected panic attacks • At least one attack has been followed by 1 month or more of: • • Persistent concern or worry about additional panic attacks or their consequences AND/OR Significant maladaptive changes in behaviour related to the attacks • Primary Symptoms of Agoraphobia in DSM-5: • Excessive and impairing fear/avoidance of specific situations, lasting 6 months or more • Feared situations: individuals are concerned that escape might be difficult or help might be unavailable in these situations if they develop panic-like or other embarrassing/incapacitating symptoms • Typical situations: public transportation, enclosed spaces, crowds • People often require a companion in order to confront the situation Diagnosis and Case Conceptualization of Anxiety Disorders • Differential diagnosis and case conceptualization often require understanding patient’s symptoms within the following domains: 1. Nature of feared stimulus • What exactly is the patient (pt) afraid of? 2. Nature of attentional focus on perceived danger • Where does pt’s focus of attention go under threat? 3. Nature of feared consequences • What is pt afraid will happen if feared stimulus is confronted? 4. Nature of avoidance and safety behaviours • What avoidance strategies does pt use to cope with fear? PD - Core Problem = “physical sensations are dangerous” • Feared stimuli • Physical sensations; cues associated with increase in physical sensations • Self-focused attention directed toward… • Bodily changes indicating increase in physical symptoms • Feared consequences • Life threat: fainting, heart attack, dying, going crazy • No escape: losing control, becoming incapacitated • Avoid… • Activities that produce physical symptoms • Situations in which panic attacks may occur • Safety behaviours • Carrying “life-saving” objects (e.g., heart monitor, oxygen, companion) • Exit strategy (e.g., sit close to aisle) • Body scan (e.g., frequent checking) Interoceptive Exposure for PD • • • • • • • • • Shake head from side to side for 30s Place head between legs for 30s and then lift up quickly Jumping jacks or step-ups Hold breath for 45s Spin in chair around in circle for 30-60s Hyperventilate for 60s Breathe through thin straw for 60s Stare at small spot on wall for 2 mins Etc… Social Anxiety Disorder (SAD) • Primary Symptoms in DSM-5: • Extreme and irrational fear in social/performance situations in which one may be exposed to scrutiny by others; interference/distress = >6 months SAD: Core Features and Differential Diagnosis • Feared stimuli • Aspects of self one wishes to conceal from others • Self-focused attention directed toward… • Negative mental self-image • Domains: social competence, signs of anxiety, physical appearance • Feared consequences • Negative evaluation, humiliation, exclusion, rejection, criticism, ostracism • Avoid… • Social situations where scrutiny and negative evaluation may occur • Safety behaviours • Self-concealment strategies – differ depending on nature of perceived self-flaws CBT for Social Anxiety • CBT for SAD: individual or group format 1. Exercises to challenge negative beliefs about self and inflated estimates of probability and costs of negative social outcomes 2. Dropping safety behaviours (SBs) which “contaminate” social interactions (e.g., avoiding eye contact, self-censorship). 3. Video feedback to correct negative self-image 4. Behavioural experiments: testing out fears in real life situations outside therapy office (including intentional social mishaps) 5. Social skills training? Social skills deficits may be important but perceived skill deficits may be more important Generalized Anxiety Disorder (GAD) • Primary Symptoms in DSM-5: • Excessive uncontrollable worry about a number of life domains • Physical symptoms that differ from panic (e.g., muscle tension, fatigue, irritability, difficulty concentrating/sleeping) • Significant interference/distress lasting at least 6 months GAD: Some Interesting Features 1. Intolerance of uncertainty • Is uncertainty the feared stimulus? • Thought question: if uncertainty is the feared stimulus, what might be the feared consequence? 2. Positive meta-cognitive beliefs about worry • 3. Longstanding beliefs about adaptive functions of worry Worry as an emotional avoidance strategy • Ruminative “what if…?” worry cycles are counter-productive to confronting and solving actual problems CBT for GAD • CBT components: 1. Imaginal exposure to facing and coping with imagined threats 2. Exposure to uncertainty 3. Goal-oriented problem solving to target rumination 4. Challenge maladaptive beliefs 5. Relaxation techniques to target muscle tension 6. Mindfulness and acceptance: non-judgmental acceptance of internal experiences as they arise in the moment Summary • Anxiety disorders: very common but often debilitating • Exposure-based CBT can be very effective • • Effective therapy requires a good CBT conceptualization of each patient’s problem, starting with identifying the feared stimulus QUESTIONS?
