3) Fear, Anxiety Flashcards
Function of fear and anxiety
= natural nhuman reaction with basic survival function
- signal to avoid danger
- learning function
- present in humans and animals
- prepares for fight, flight or freeze/avoidance response
- fast and automatic
- direct signalling to amygdala (lower cognitive function) –> concious thought only in related cortex
- adaptive funtion is short term
Components of anxiety
affective and cognitive
- fear - ‘I am in danger’
- panic - ‘ I could die’
- shame - ‘ I could embarrass myself’
physiological
- increased heart-rate
- sweating
- shortness of breath
- dizziness
- …
behavioural
- flight
- fight
- freeze
- avoidance
- …
Pathological anxiety
= when …
… arousal system is hypersensitive and responds to only minor stimuli
… there is extreme anxiety in the absence of actual danger
… intensity, duration, and/or frequency of anxiety become distressful and chronic
–> severe interference in a person’s well-being and everyday functioning
- develops due to patient thinking that the anxiety they experience represents a danger therefore taking measures to counter-act it leading to an anxiety disorder –> fear of having fear
- long term: chronic fear/axiety, PTSD
Agoraphobia
= anxiety in situations or places (eg public transport, lifts, shopping malls, crowds, cinema, aeroplane, long journeys or distances from home)
- places are difficult to escape and/or get help
- fear of something happening, multitude of ‘somethings’
- leads to avoidance and/or safety behaviour (like always positioning close to an exit)
- Agoraphobia without panic disorder: F40.00
- Agoraphobia with panic disorder: F40.01
Anxiety disorders and phobias
- there are phobias and anxiety disorders (F40 and F41, ICD-10)
- agoraphobia
- panic disorder
- social disorder
- specific disorder
- generalised anxiety disorder
- depending on particular classification system you can further distinguish disorders included in the group of axniety disorders (obsessive-compulsive disorder, adjustement disorder, post-traumatic stress disorder, etc.)
Panic disorder
= recurrent and unpredictable panic attacks
- sudden onset and rapid increase of anxiety
- symptoms related to the autonomic nervous system (palpitations, chest pain, shortness of breath, sweating, tremor, dizziness, feelings of unreality, etc)
- secondary: fear of dying, losing control, going mad
- anticipatory anxiety with impariment of functioning and behaviour change for at least 1 month
- F41.0
Specific phobia
= exaggerated fear restricted to specific situations or objects
- avoidance and/or safety behaviour
- fainting only in blood-injection-injury phobias (may be beneficial for survival/re-set: centering and calming)
- F40.2
- when patients complain about phobia and always fainting, they are usually scared of faining and their object of fear/not their obejct of fear
Subtypes
- animal phobias
- natural environment phobias
- blood-injection-injury phobias
- situational phobias
- other phobias (eg clowns, vomiting, etc…)
Social phobia
= fear of scrunity (critical observation/examination) by other people in social situations, eg speaking, eating, drinking in public or just in contact with other people
- F40.1
- fear to embarass him/herself, being criticised or humiliated (particularly by the presence of anxiety symptoms, eg. blushin, sweating, tremor…)
- avoidance and/or safety behaviour (eg talking fast, breathing techniques, etc…)
–> relaxation methods for treatment BUT can be dysfunctional in applying them in moments of fear
Generalised anxiety disorder
= exaggerated anxiety and worries that are generalised to many different topics of everyday life (‘free-floating’)
- for at least 6 months and > 50% of time per day
- F41.1
- difficulty to control or stop the worrying
- multiple physiological complaints such as muscular tensions, tembling, sweating, palpitations, dizziness, epigastric discomfort, etc …
- concentration problems, nervousness, insomnia, irritability
Health care costs
direct cost
- treatment (62% of costs/year)
- in Europe: more women (2/3) than men (1/3)
indirect cost
- missing work/work loss (38% of all costs/year)
Pathogenesis
Biological basis, predisposition
- typical brain structures, neurotransmitter system
- learning history and neurobiology always interacting –> Diathesis-Stress-Model
- twin studies: determine heritablity and to differentiate from learnt behaviour
- heritability ~ 30 - 67 %
Diathesis-Stress-Model
Treatment: Options and decision parameters
Psychopharmacotherapy
- antidepressants
Psychotherapy
- Cognitive Behavioural Therapy (CBT)
Psychoeducation, relaxation, exercise/sport
Decision parameters in treatment selection
- expectations of patient
- diagnosis/symptomatology
- severity
- pre-treatment
- concomitant illness and medication
- availability of therapists
- competencies/ressources of patient
Treatment: Revelant neurotransmitters
Serotonin and noradrenaline
–> antidepressants
- selective serotonin reuptake inhibitors (SSRI)
- selective serotonin norepinephrine reuptake inhibitors (SSNRI)
- Tricyclic antidepressants (TCA)
GABA and glutamte
- calcium channel modulators (eg Pregabaline, ketamine, D-cycloserine)
- benzodiazepines
Treatment: Cognitive behaviour therapy - aim and procedure
Aim
= reduction of avoidance and safety behaviour to allow for a corrective experience
–> confronting repeatedly the anxiety provoking stimulus without the feared catastrophe
Procedure
- step-wise integration of this new and functional experience in the patient’s everyday life
- experience of anxiety until it decreases by itself
- repetition for long-term effects –> repeated confrontation/exposure to most feared situation
- can only take place when patient is sufficiently informed and motivated
Treatment: Cognitive behaviour therapy - methods and working mechanims
Methods
- therapeutic alliance
- psychoeducation
- cognitive strategies
…
Working mechanisms
- emotional learning ‘corrective experience’
1. habituation
2. extinction
-research indicating a stronger learning effect in exposures with high anxiety
modern CBT does embrace multiple other techniques applicable in patients with more complex types of anxiety or disorders
- cognitive therapy
- schema therapy
- experience oriented methods
- biography work
- emotion focused therapy
- ACT …
