26.8 - Anxiety Disorders and Psychological Therapies

Question 1

What is anxiety?

Answer 1

A survival mechanism for dealing with real dangers.

Question 2

What are the features of anxiety?

Answer 2

• Attention focuses on the perceived danger
• Increase in arousal ( heart rate, sweating, butterflies in stomach, more blood to muscles) in preparation for flight/ fight
• Strong urge to avoid

Question 3

When does anxiety become problematic?

Answer 3

When the danger that triggers it is imagined.

Question 4

When are anxiety disorders diagnosed?

Answer 4

When the anxiety is:

• Out of proportion to the danger
• Persistent
• Disabling

Question 5

What are the main types of anxiety?

[IMPORTANT]

Answer 5

• Generalised anxiety
• Panic disorder
• Social anxiety
• Phobic anxiety (specific)
• PTSD
• OCD

Question 6

What is generalised anxiety disorder?

[IMPORTANT]

Answer 6

When a person has excessive worry about several different things.

Question 7

What is panic disorder?

[IMPORTANT]

Answer 7

When a person has repeated unexpected attacks of anxiety.

Question 8

What is social anxiety?

[IMPORTANT]

Answer 8

A type of phobias characterised by marked fear and avoidance of social interaction.

Question 9

What is phobic anxiety?

Answer 9

A type of phobia characterised by marked fear and avoidance of a specific thing, such as spiders, etc.

Question 10

What is PTSD?

[IMPORTANT]

Answer 10

A form of anxiety characterised by unwanted, distressing memories of a traumatic event.

Question 11

What is OCD?

Answer 11

A type of anxiety characterised by distressing thoughts or images with “putting right” actions.

Question 12

What is the prevalence of anxiety disorders?

Answer 12

10%-18% prevalence in 12 month period (common)

Question 13

What fraction of people with anxiety disorders require treatment?

Answer 13

Around 2/3rds

Question 14

What are some gender differences in anxiety disorders?

Answer 14

There are higher rates in women than men for community samples (but not some clinical samples).

Question 15

What are some common co-morbidities with anxiety disorders?

Answer 15

They are commonly seen alongside depression and substance abuse.

Question 16

Are anxiety disorders genetic?

Answer 16

• They do sometimes run in families
• But genetic vulnerability is broader than just anxiety disorders. It can be across many different mental illnesses.

Question 17

Give some clinical data regarding the recovery of patients with anxiety disorders.

Answer 17

• The recovery varies based on the type of anxiety disorder:
• It varies from 33% to 70% over 12 years (Bruce, 2005)

Question 18

Give some experimental data regarding the cost to society of untreated anxiety disorders and depression.

Answer 18

It is around 7% of GNP (Layard & Clark, 2014)

Question 19

Describe how you can test whether a treatment for anxiety disorders works.

Answer 19

Run a randomised control trial:

• Develop a measure of symptoms for pre-treatment and post-treatment -> It is best to include patient and independent assessor
• Compare the treatment group with a placebo group (and possibly also a group taking an existing treatment)
• Assess the participants at pre-treatment, post-treatment and at follow-up

Note: The trial must be pre-registered, to prevent investigators/companies hiding negative results.

Question 20

What are the main treatments for anxiety disorders?

Answer 20

Medications:

• Benzodiazopines (only for short-term distress, due to high risk of developing dependence)
• Anti-depressants (especially SSRIs and SNRIs)

Psychological Treatments:

• Cognitive-behaviour therapy & cognitive therapy

Question 21

What is cognitive behaviour therapy (CBT) and how can it be used in treating anxiety disorders?

Answer 21

• Brief (8-16 sessions) program where the patient is very active
• Based on cognitive model of emotional disorders
• It aims to change problematic beliefs (e.g. that a certain stimulus is triggering) and related behaviours (rather than original causes).

Question 22

Describe the symptoms of panic disorder.

Answer 22

• Repeated attacks of anxiety, accompanied by marked bodily sensations
• Attacks come out of the blue

Question 23

Describe a theory for how panic disorder arises.

Answer 23

Cognitive theory of panic disorder (Clark, 1986):

• Panic attacks result from catastrophic misinterpretation of benign body sensations
• Sensations that are misinterpreted are mainly those involved in normal anxiety responses (e.g. a fast heart rate caused by runnin)
• Misinterpretation involves believing the sensations indicate an immediate physical or mental disaster (e.g. the fast heart rate caused by running may be misinterpreted as a sign of danger)

On the diagram, the “Interpretation of Sensations as Catastrophic” is crucial for the deleterious cycle to continue.

Question 24

What are some reasons why panic disorders may persist?

Answer 24

• Selective attention to bodily cues -> The people become more attentive to their bodily cues, so that they are more sensitive to triggers of another panic attack
• Safety behaviours -> Safety behaviours (e.g. lying down and taking deep breaths during a suspected heart attack) may reinforce the idea that the threat perceived during the panic attack was real and that the individual was ok only because of their safety behaviour

Question 25

Describe how cognitive behavioural therapy can be used for panic disorders.

Answer 25

* Identify catastrophic interpretations of bodily sensation (e.g. identifying that the patient perceives a fast heart beat as a heart attack) * Generate alternative, non-catastrophic interpretations of bodily sensations (e.g. identifying that the fast heart beat may be caused by exertion, not by a heart attack) * Test out validity of catastrophic and noncatastrophic interpretations by discussion & behavioural experiments.

Question 26

Draw an example of the cycle of panic attacks that a patient with panic disorder may have.

Answer 26

Question 27

Give some examples of behavioural experiments that can be used to treat panic disorders.

Answer 27

* Inducing the fear sensations (e.g. fast heart beat) to show the patient that they have an innocuous cause -\> e.g. Showing the patient word pairs like "breathless-suffocate" can cause them to have a panic attack, proving to them that this is not a dangerous situation * Convincing the patient to drop their safety behaviours (e.g. lying down) during fear sensations to prove that they are not dangerous -\> e.g. Going for a run to increase heart rate

Question 28

Give an example of a RCT for panic disorder treatment.

Answer 28

Question 29

What are some reasons why social anxiety persists?

Answer 29

Clark and Wells (1995) suggest: * Shift to internal focus of attention * Use of internal information to infer how one appears to others (images and feelings) * Safety behaviours (e.g. Using a certain tactic to be more interesting, and then believing that this was the only reason why the social interaction didn't 'go wrong'. Also can be harmful because the safety behaviour may actually make the social interaction less natural.)

Question 30

Describe how cognitive behavioural therapy works for social anxiety. What are the different steps?

Answer 30

* Developing a personal version of the model that explains how the patient is trapped in a cycle of social anxiety * Experiential exercise -\> Have the patient have a conversation with someone using their normal safety behaviours, and then try again using the opposite of their safety behaviours * Video feedback -\> To correct negative self-image * Attention training -\> To shift the patient's focus on to the other person * Behavioural experiments -\> To test the patient's fearful predictions in social situations while dropping safety behaviours and/or enacting feared outcomes * Surveys -\> To discover other people’s view of feared outcomes * Memory work -\> To reduce impact of early social trauma.

Question 31

What are some types of treatment that cognitive therapy is more effect than in treating anxiety disorders?

Answer 31

Question 32

Describe the risk factors for anxiety disorders.

Answer 32

* Anxiety disorders are a result of both genetic and environmental factors, with genetic heritability for general anxiety disorder estimated to be 31.6% (Hettema, 2001). * The mechanism for this is not yet fully understood, but it may involve variation in genes such as glutamic decarboxylase 1, which may influence GABA production. * In terms of environmental factors, childhood events and experiences are likely to underlie later life outcomes. * Namely, these include trauma, parenting style (with more overprotective parents often raising more anxious children), exposure to fears that can be learned, and attachment to parents/carers. The risk factors and causes of each of the different types of anxiety disorder also differ, such as the trauma that precedes PTSD.

Question 33

What therapy is given for PTSD?

Answer 33

-Exposure therapy (expose to situations which cue recall trauma) -Group therapy (safe place to relive trauma) -SSRIs to reduce depressive symptoms that accompany it -Anxiolytics to reduce heightended arousal -Sleep aids

Question 34

What biological factors contribute to PTSD development? (6)

Answer 34

-Amplification of HPA axis = changes to endocrine signalling and prolonged stress -Increased hippocampal activity = flashbacks -deficits in arousal and regulating sleep -family history -endogenous opioid system which regulates pain = dsyfunction -increased SNS activation rather than cortisol = acute and instense state for extended periods of time

Question 35

What are the risk factors for PTSD?

Answer 35

Children who have gone through extreme trauma are more likely to develop PTSD based off another trauma Experiencing trauma itself Genetic (60% concordance)

Question 36

Which types of trauma are more likely to lead to PTSD?

Answer 36

Interpersonal trauma - Rape - violent muggings (unlike accidents or environmental disorders)

Question 37

How does PTSD present differently in children than adults?

Answer 37

Children are less likely to show distress and instead use play to express their memories.

Question 38

What are the clinical symptosm of PTSD? (General + 6)

Answer 38

Symptoms of an acute stress response persist for over a month -presents with disturbing thoughts, feelings, or dreams related to a prior mental or physical trauma (ranging from traffic collisions and warfare to abuse) experienced by the patient -intrusive thoughts -avoidance of environments which remind them of trauma -hyperarousal or vigilance -insomnia -irritability

Question 39

What is the prevalence of PTSD in the population?

Answer 39

8-9%

Question 40

What are the risk factors for a phobia?

Answer 40

genetic link traumatic events

Question 41

What are possible clinical symptoms of phobias?

Answer 41

*Catastrophise *Sweating *Trembling *Increased HR *Increased avoidance of associated location

Question 42

What percentage of the population have phobias?

Answer 42

most common anxiety disorder (10%)