5. Anxiety disorders and OCD Flashcards
Historical perspectives of anxiety disorders
Concepts related to the Anxiety Disorders (as we now know them) were discussed/explored in 19th & 20th centuries
• by Freud / the psychanalysts (the concept of “anxiety neuroses”)
• by Pavlov and Skinner (“fear conditioning”).
• In pharmaceutical development studies (from 1980’s)
DSM’s historical view of anxiety disorders
- DSM-I (1952) & DSM-II (1968): Anxiety categorised under “Neuroses”
- DSM-III (1980): “Anxiety” becomes a new disorder category
- DSM-III-R to DSM-IV-TR (2000): Disorder criteria refined.
- DSM-5 (2013): major changes…
fear
the emotional resonse to real (or perceived) immediate danger threat; builds quickly; facilitates behavioural response to threat
anxiety
anticipation of future threat; a more general or diffuse emotional state
worry
a relatively uncontrollable sequence of negative emotional thoughts, that are concerned with possible future threats or danger
panic attacks
sudden, overwhelming experiences of terror or fright, can be distinguished from anxiety in four major ways: more focused, less diffuse, more intense, and sudden onset; physiological symptoms dominant
anxiety versus Anxiety
anxiety: the feeling of intense apprehension & worry that is
• in response to a realistic source of danger, and;
• is of “appropriate” intensity
Anxiety with a capital A A clinical disorder; a generalised/diffuse negative emotional reaction that is • Maladaptive • Irrational • Uncontrollable • Disruptive • Disproportionate
phobias
Narrowly defined fears – associated with a specific object or situation. Focused anxiety or fear that is “out of proportion” to the actual or perceived threat or danger, after taking into account all the factors of the environment and situation. Associated with panic, terror and avoidance
Phobias distinguished from fear
In phobias the pattern of fear/avoidance is “persistent” (present
for at least 6 months).
DSM-5 categories of phobias
specific phobia
social phobia
agoraphobia
Specific phobia
- Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).
- almost always provokes immediate fear or anxiety.
- actively avoided or endured with intense fear or anxiety.
- out of proportion to the actual danger
- lasting for 6 months or more.
- significant distress or impairment in social, occupational, or other important areas of functioning.
Social phobia
or social anxiety disorder
Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others.
Examples of social phobia
– social interactions (e.g., having a conversation, meeting unfamiliar people),
– being observed (e.g., eating or drinking),
– performing in front of others (e.g., giving a speech)
what is it that a person fears if they have social anxiety disorder?
The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).
Agoraphobia
Marked fear or anxiety about two (or more) of the following five situations:
- Using public transportation (e.g., automobiles, buses, trains, ships, planes).
- Being in open spaces (e.g., parking lots, marketplaces, bridges).
- Being in enclosed places (e.g., shops, theaters, cinemas).
- Standing in line or being in a crowd.
- Being outside of the home alone.
what causes the fear or avoidance on agoraphobia?
Fear or avoidance is due to concern that escape might be difficult or help
might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence)
Generalised anxiety disorder
Persistent & excessive anxiety & worry (apprehensive
expectation) that is:
• generalised [about several events or activities],
• difficult to control
Symptoms of GAD
3 or more of these symptoms •restlessness, feeling keyed-up/on edge •fatiguing easily •difficulty concentrating / mind blanks •irritability •muscle tension •sleep disturbance
GAD compared to normal worry
Not a fleeting nor rare sensation: occurs almost daily, for at least 6 months
Panic Attacks
A sudden unexpected & overwhelming (but short-lived) period of intense fear or discomfort; surges abruptly, peaks within minutes.
Panic attacks may:
• be understood as a normal incorrectly triggered fear response – a false alarm
• May have situational cues or triggers
• Or can be unexpected – no clear reason
Panic Attacks compared to anxiety
Distinct from anxiety in two ways: – Greater intensity – More rapid onset. Not a disorder in itself Can occur as a part of any of the anxiety disorders
Symptoms of panic attacks
4 or more symptoms:
– Palpitations, pounding, racing heart rate
– Sweating
– Trembling, shaking
– Feeling short of breath, difficulty breathing
– Chills or hot flushes
– Feelings of derealisation or depersonalisation
– Fear of dying;
– parethesias (numbness or tingling),
– fear of losing control or going crazy,
– feeling dizzy, unsteady, lightheaded or faint,
– chest pain or discomfort.
Reaching a peak within minutes
Panic disorder
Recurrent panic attacks PLUS one attack that had “lasting” effects
i.e., it led to one month of
- Persistent concerns about attacks and/or
- A significant, maladaptive, behaviour change (e.g. avoidance)
Not occurring in relation to a specific stimulus as in phobias
Distinctions of anxiety disorders
There are some strong similarities between the disorders in this group.
• Two keys to distinguishing amongst them:
– Duration (of episode and the “disorder”)
– Scope of fear/avoidance (one or many objects; a relatively narrowly defined fear (as for phobias) or a generalised fear (as for GAD))
Course of anxiety disorders
Often chronic conditions – long term evidence of anxiety, worry and avoidance
“General conclusion is that the long term outcome
for anxiety disorders is mixed and somewhat
unpredictable”
treat-ability of anxiety disorders
highly treatable – often good response to intervention
causes of poor treatment outcomes of anxiety disorders
Poorer outcomes associated with earlier age of onset and lack of treatment
Cross-cultural affects of anxiety disorder symptoms
People in non-Western cultures are more likely to present with somatic symptoms
• Focus of anxiety differs across cultures
– Western cultures – work performance
– Nigeria – family or religious experience
Prevalence of anxiety disorders
Anxiety is the most common mental health condition
• Lifetime prevalence
– 1 in 4 people
– 1 in 3 women and 1 in 5 men
• Prevalence is highest in younger adults
• But there is also a peak in the aged (70+) – w
Comorbidity of anxiety disorders and substance abuse
45% of people with an anxiety disorder also have an affective disorder or substance abuse (ABS, 1998)
Comorbidity of anxiety disorders and depression
50% of individuals with an anxiety disorder also meet the criteria of at least one other anxiety disorder or depression (Brown & Barlow, 1992)
three theories of anxiety disorder causes (etiology)
biological
conditioning and learning
cognitive
Biological theories of anxiety disorder etiology
- Genetic predisposition, anxiety sensitivity
- an “Evolved” / selected genotype
- Neurochemical changes
Conditioning and learning theories of anxiety disorder etiology
- Acquired through classical conditioning or observational learning
- Maintained through operant conditioning
Cognitive theories of anxiety disorder etiology
Cognitive theories emphasise the cognitive overlay applied to bodily sensations (cognitive bias/interpretive error, e.g., “catastrophic” misinterpretation) and the interpretation of events
Bioligical factors contribution to anxiety disorders
• Twin studies suggest modest heritability for anxiety disorders
– Concordance rates for MZ significantly higher than DZ twins for anxiety disorders suggesting some genetic component
– Heritability estimates are 20–30 percent for GAD
• Greatest genetic influence found for agoraphobia; least for specific phobias
Neurochemistry of anxiety disorders
- Serotonin and GABA are inhibitory neurotransmitters that serve to dampen stress responses
- when these neurotransmitter levels are reduced, increased fear and anxiety may result.
Biological Fear response process
- The amygdala stores unconscious, emotional memories
- When a threat is perceived, the limbic systems triggers the threat response activating the adrenal system and mobilizing physical resources to fight, flee or freeze
- Automatic, non-rational, non-cognitive process
- Sensitivity of pathways is influenced by genetics, hormone levels, stress, childhood experiences, social & psychological factors
learning as a cause of phobias
Specific fears might be learned through classical conditioning
classical conditioning of fears
• A neutral stimulus paired with an intense fear reaction may
lead to a learned fear
• Many (but not all) specific phobias seem to develop this way
• Human beings seem to be prepared to develop intense, persistent fears only to a select set of objects or situations (see over)
observational learning as a cause of fears
vicarious learning of fear through
seeing others respond fearfully to certain situations
Operant principles of anxiety
Operant principles can also help to make sense of maintenance of anxiety
• Avoidance of feared stimuli — reduction in anxiety (negative reinforcement)
Evolution as an explanation for fears
The process by which fears are learned suggests that the process is guided by a module, or specialized circuit (Ohman & Mineka, 2001).
We have an inbuilt tendency to more easily acquire phobias about things that would have posed a threat to our ancestors, (e.g., snakes, spiders, heights) than to modern threats (e.g., electrical outlets)
• Conditioned responses to fear relevant stimuli (snakes) are more resistant to extinction that fear-irrelevant stimuli (e.g. flowers)
Fear as an adaptive survival technique
Emotional fear responses can be adaptive - Mobilize responses that help the person survive in the face of both immediate danger and long-range threats
Fear as a maladaptive function
If triggered at inappropriate times or places, these responses may become maladaptive
Survival and evolution as an explanation for anxiety disorders
- Generalised anxiety prepared humans for unidentified threats
- Specific anxiety prepared humans to respond effectively to certain types of danger, e.g., freezing when at a great height
Childhood adversity as a social factor of anxiety
higher levels of adversity, more likely to develop an anxiety disorder (Moffitt et al., 2007; Phillips et al., 2005)
Insecure/disorganised attachment as a social factor of anxiety
Several studies have found that people with anxiety disorders are more likely to have had insecure or disorganised attachment as children (Cassidy & Mohr, 2001; Dozier et al., 2008; Lewinsohn et al., 2008).
what do frequent experiences of unsolvable fear shape?
- Emotion regulation
- Information processing
- Sensitization of threat pathways
stressful life events as a social factor of anxiety
environmental stress increases risk of anxiety disorders
Why do some negative life events lead to depression while others lead to anxiety?
– The nature of the event may be an important factor in determining the type of mental disorder that appears (McLaughlin & Hatsenbuehler, 2009; Updegraff & Taylor, 2000).
– For anxiety, an event involving danger is more likely to have occurred (e.g. exposure to DV)
– For depression, an event involving severe loss (lack of hope) is more likely to have occurred.
Cognitive factors of anxiety
Three main cognitive processes highlighted by cognitive theory
– Perception of controllability
– Catastrophic misinterpretation
– Attention to Threat and Biased Information Processing
PERCEPTION OF CONTROLLABILITY as a cognitive factor of anxiety
- Sense of helplessness, low control, low efficacy
* Underestimate protective factors and personal resources
CATASTROPHIC MISINTERPRETATION as a cognitive factor of anxiety
- Misreading benign experiences as threatening
* Predicting worse outcome than is probable and realistic
ATTENTION TO THREAT AND BIASED INFORMATION PROCESSIING as a cognitive factor of anxiety
- Hypervigilance and attentional narrowing
- Overidentification of threat cues
- Fleeting danger triggers off a cascade of worry (what if”?) that increases anxiety and further vigilance
Types of Biological therapies for anxiety
- Antianxiety medications (anxiolytics)
* Antidepressants often used – preferred treatment
Antianxiety medications (anxiolytics)
- A class of drugs known as the benzodiazepines;
- Examples: Diazepam (Valium) - relatively long half life and Lorazepam (Ativan)
- Enhance GABA activity
- Provide short term relief
- Side effects, withdrawal problems, & addictiveness
Antidepressants often used – preferred treatment
- SSRIs – first line medication for Panic Disorder and Social Anxiety
- Good evidence for effectiveness
- Fewer side effects than anxiolytics
Types of behavioural therapies for anxiety
• Relaxation training – progressive muscle relaxation
• Breathing retraining – slow, diaphragmatic
breathing;
• Physical exercise
• Attention to dietary factors (e.g., caffeine)
• Behavioural experiments – testing predictions
• Exposure therapy
Exposure therapies for anxiety
Grounded in learning theory – conditioning a new response
• Education: Understanding the ‘fight-flight’ cycle; new cognitive interpretations of “bodily” symptoms.
• Exposure can be imagined, in vivo, or virtual
Types of exposure therapies
- systematic de-sensitistaion
- Interoceptive exposure
- flooding
Systematic de-sensitisation
work through a hierarchy of feared situations whilst practicing relaxation
Interoceptive exposure
deliberate inducement of panic symptoms to reduce fear of inner sensations
Flooding
exposure until response subsides
Types of cognitive therapies for anxiety
- Psychoeducation – recognizing anxiety
- Cognitive restructuring
- Distraction
- Practice & homework are important
Cognitive restructuring
- Increase awareness of irrational, negative, catastrophic, predictive, or otherwise unhelpful cognitions (self-talk)
- Differentiating productive and unproductive worry
- Decatastrophising
- Examine & challenge faulty logic
OCD as an anxiety disorder?
OCD no longer an “Anxiety” disorder
A “new” disorder category (Obsessive Compulsive and Related Disorders)
prevalence of OCD compared to Anxiety disorders
A relatively “low” prevalence disorder compared to the Anxiety Disorders (ABS data)
Classes of OC and related disoders
• This chapter includes – OCD – Body Dysmorphic Disorder – Hoarding Disorder – Trichotillomania – Excoriation Disorder
Body Dysmorphic Disorder
preoccupation with perceived deficits in personal appearance
Hoarding Disorder
– persistent difficulties in getting rid of possessions, regardless off real value
Trichotillomania
Recurrent pulling out own hair despite attempts to stop
Excoriation Disorder
– persistent picking of one’s skin despite attempts to stop
Criteria A of OCD
Presence of obsession, compulsions or both
Obsessions
repetitive, uncontrollable, intrusive, unwanted thoughts/urges/images that usually provoke “marked anxiety”
• Intrude suddenly into consciousness
• The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action
Compulsions
a repetitive behaviour or mental act or ritual that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly
• that is undertaken with the intent to reduce anxiety or distress or to prevent some dreaded situation (but is unlikely to do so) or is “clearly excessive
Criterion B of OCD
• The obsessions or compulsions (or both) occupy a considerable amount of time (>1 hour per
day).
OR
• Cause clinically significant impairment in functioning
Examples of obsessions
- Contamination obsession
- Symmetry obsession
- Aggressive obsessions – fear of harming someone, self, fear of stealing something
- Superstitious obsessions – fear of saying particular words, passing/touching particular items
- Sexual obsessions
examples of compulsions
• Checking compulsions • Cleaning compulsions • Repeating compulsions – completing something over and over, perhaps a certain number of times • Counting compulsions • Tapping/touching compulsions • Ordering/arranging compulsions • Other mental rituals – repetitive prayers, mantras • Avoiding objects • Ritualised behaviours- using particular hands for things, eating in a particular order
Diagnostic specifiers of OCD
With good or fair insight
With poor insight
with absent insight/delusional belieffs
OCD With good or fair insight
The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
OCD With poor insight
The individual thinks obsessive-compulsive
disorder beliefs are probably true.
OCD with absent insight/delusional beliefs
The individual is completely convinced that obsessive-compulsive disorder beliefs are true.
Course of OCD
Typically follows a pattern of some improvement along with some persistent symptoms
onset of OCD
Onset tends to be gradual but can be acute
Age of onset for OCD
• In the United States, the mean age at onset of OCD is 19.5 years,
and 25% of cases start by age 14 years (Kessler et al. 2005; Ruscio et al. 2010).
• Onset after age 35 years is unusual but does occur
• Males have an earlier age at onset than females: nearly 25% of males have onset before age 10 years (Ruscio et al. 2010).
• Earlier onset appears to be associated with a longer course
Functional consequences of OCD
• OCD can be highly debilitating
• Impairment may result from
– Time spent engaging in compulsions
– Avoidance of particular contexts – e.g. family/friends, hospitals/GPs
– Reduced work output – e.g. Need for symmetry/rigid expectations with projects/writing
– Physical complications – e.g. dermatological problems from hand washing
Prevalence of OCD in Ausralia
– 3% lifetime prevalence
– 2% in a 12 month period
• Higher rates in females in adulthood, higher rates in males in childhood
• Occurs at similar rates across cultures
• Nature of obsessions and compulsions tends to be similar cross culturally
Cognitive model of the aertiology of OCD
Many individuals with OCD have ‘dysfunctional beliefs’
– inflated sense of responsibility
– the tendency to overestimate threat
– perfectionism and intolerance of uncertainty
– over-importance of thoughts (e.g., believing that having a forbidden thought is as bad as acting on it) and the need to control thoughts
Rebound from thought suppression
– Attempt to suppress unwanted/threatening thoughts
– Rebound tends to occur – resurge with greater intensity and
frequency
Learning theories of OCD
• “Maladaptive learning/associations”
– Intrusive thought/image is relieved by compulsive behaviour
– Creates an erroneous connection between behaviour and reduction in anxiety (i.e. negative reinforcement of compulsion)
biological factors of OCD
- Higher rates in first degree relatives
- Higher concordance for MZ twins than DZ twins
- Multiple brain regions associated with OCD
Brain regions associated with OCD
– Basal ganglia
– Orbital prefrontal cortex
– Anterior cingulate cortex
• in those with OCD, heightened activity is observed in these regions in response to stimuli associated with obsessions
Treatment for OCD
• Medication is often utilised
• Exposure + response prevention
• Combination therapies – medication and
psychotherapy often used together
Exposure and response prevention as a treatment for OCD
– Exposure to situations that evoke distress
– Prevention of compulsive response
– Typically hierarchical exposure
medication as a treatment for OCD
Typically an antidepressant, such as SSRIs, TCAs
