6- Anxiety Flashcards
Fear vs Anxiety
Fear: Specific, Here and Now
- Evolutionary Adaptive Reactions: Triggers fight-or-flight defense
Anxiety: Diffuse, Future oriented
- Plan and prepare for possible future threats => if overreactive then not good
DSM-5: Specific Phobia *1
Before DSM-III, phobias were a single dx category
Split up in DSM-IIII into 3 categories *Diff ages of onset and diff tx responses:
- Social
- Specific
- Agoraphobia (without panic)
DSM-5 *Most diagnosed
Marked fear or anxiety about a specific object or situation => Exposure provokes fear and anxiety
- Avoidance of phobic object/situation
- Interferes with functioning
- 5 types of phobias => Animals, Natural Env, Blood-Injection-Injury, Situational, Other (Ex: choking, vomiting, illness, loud noises)
*Fear is not of the object itself => fear is of some dire outcome of interacting with the object ex: Fear of being BITTEN by a snake
Epidemio
- 12.5% Prevalence rate with 2F:1M
- Age of onset in childhood (animal & blood-injury onset earlier), situational later
- High comorbidity (other anx or mood dx)
- Most children outgrow specific fears *not true for other anx dx
DSM-5: Social Anxiety Dx *2
Marked fear or anxiety about social situation => Fear that they will be negatively evaluated/Act in an embarrassing way/Show anxiety sx
Feared and avoided situations (see ppx):
- Social interactions
- Public speaking
- Observation fear
- Eating/drinking in public
Epidemio
- Second most common anxiety disorder
- 3rd most common psychiatric disorder
- 12% prevalence rate
- Age of onset in adolescence (16 y.o)
- High comorbidity => Other anxiety dx, Mood dx, Substance use dx
=> SAD as a risk factor for developing SUD because reliance on substances to manage underlying anxiety
*Maybe not two distinct dx, but part of the same problem
=> Depression and SAD = ruminative styles, hallmark of depression and also common in social anx
*Chronic isolation and withdrawal among socially anxious can result in depressed mood (so SAD as risk factor for MDD)
Epidemio
- 4-6% lifetime prevalence for panic dx
- 2F: 1M
- Age of onset (~24 years old) => Narrower range of onset: Rarely before adolescence or after middle age (13 – 34 range)
- Abrupt onset (go from nothing to panic symptoms)
DSM-5: Panic Dx *3
Recurrent unexpected panic attacks + Worry about future panic attack OR beh to avoid panic attack
- Physical symptom: palpitations, sweating, shaking, chest pain, dizzy, chills/heat, etc.
- Cognitive symptoms: Fear of losing control, going crazy, or dying
Panic must be uncued (Spontaneous)
- Stimulus-bound panic = phobia => Respond reliably to the stimulus with panic
- Situationally-bound panic = agoraphobia => Panic disorder can occur with or without agoraphobia
DSM-5: Agoraphobia *4
Marked anxiety about:
- Using public transportation
- Being in open spaces
- Being in enclosed spaces
- Standing in line or being in a crowd
- Being outside of the home alone
Fears or avoids situations due to thoughts that escape might be difficult OR help may not be available in the event they develop panic-like sx or other “embarrassing sx”
Differential Dx Panic Dx and Agoraphobia
Panic vs. Agoraphobia
- Both involve fear of panic
- But only panic dx requires you to have full blown panic attack
- Panic is uncued vs. Agoraphobia is situationally-bound
Social or simple phobia can involve avoidance of
similar situations => Motivation is different
Example: Avoid taking bus
- Simple phobias: fears bus will crash
- Social phobias: fears embarrassing themselves
- Agoraphobia: fears not being able to escape
DSM-5: Generalized Anxiety Dx *5
Excessive anxiety and worry that is difficult to control (about family, society, school, work, etc)
Symptoms:
- Restlessness or feeling keyed up or on edge
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance
*Worry = GAD = futur vs Rumination = Dep = past
Problems:
- Associated with increased health care utilization => More frequent visits to doctor
- Increased health care costs => Greater chance of concurrent physical illness
- And significant social, academic, and vocational impairment => Days lost at work/school, Damage to relationships
Epidemio
- Prevalence: 5-6% lifetime and 3.1% 12-month
- Most commonly diagnosed Axis I dx in primary care
- Gender difference: 2F: 1M
- Onset typically adolescence (gradual)
- Chronic course => Personality disorder? 58% recovery rate, but high recurrence
- High comorbidity (As many as 90% of diagnosed cases meet criteria for another dx)
- Negative affectivity? Vulnerability marker?
Biological Factors
Genetic Influence => All anxiety dx show at least a moderate level of heritability (~30- 50%) *Evidence from family and twin studies
- Individuals with family member diagnosed with anxiety dx are 4-6X more likely to have anxiety dx (vs to those without family history)
Heritable Traits
- Genetic risk seems to be fairly non-specific => Except maybe panic disorder *inconclusive findings
- More likely passing on broader traits: Trait anxiety, Neuroticism, Beh inhibition
No clear genes identified yet
*Role of nonshared environmental factors even larger => supports more psychological theories of anxiety
Psychological Factors (4)
1- Learning Theory => Anxiety and fear and acquired through learning history
Mowrer’s Two-Factor Theory:
- Fear develops through classical conditioning
- Fears are maintained through operant conditioning *Negative reinforcement
Some limitations with Learning Theory
- Onset of phobias should be linked to some sort of traumatic experience BUT only 50% can report traumatic experience => Forgetting? Vicarious learning?
Equipotentiality premise => Assume that all stimuli have equal potential to become phobias But, feared associations are selective
2- Catastrophic Misinterpretation => Catastrophic misinterpretations of bodily sensations (Heart palpitation = heart attack)
- Increases physiological arousal (Vicious cycle) => Panic disorder = fear of fear
- Symptoms usually internally-generated, but could come from caffeine, cocaine, anger
=> Doesn’t account for cases where there is no interpretation ex: nocturnal panic attacks
3- Trait Anxiety Sensitivity => Trait-like differences in how fearful one is about physiological sensations of anxiety
People high on trait more likely to experience panic when they experience anxiety
4- Interoceptive Conditioning ( Learning theory model) => Spontaneous panic attacks that are paired with awareness of early panic sx
- Low level sensations become CS+
- When unrecognized CS+ is present, panic attack
- Appears spontaneous, but the conditioned link was there (subconscious)
Psychological Factors (Worry)
1- Most prominent cognitive theory of worry in GAD comes from Tom Borkovec
Worry = avoidance strategy
Decreases physiological arousal => Worry involves verbal thought and little imagery
Positive Beliefs about worry =>
- Worry is often negatively reinforcement (ex: elephant, think worry prevented that)
- But can also be positively reinforced (ex: midterm)
Consequences of worry =>
- People with GAD try to control or suppress the worry => Paradoxically, this increases intrusive thoughts related to worry (ex: White Bear)
- Inability to control thoughts increases their perception of uncontrollability
- Cycle of worry that perpetuates itself
2- Intolerance of uncertainty
- Individual’s discomfort with ambiguity and uncertainty
- GAD tend to have lower threshold of future uncertainty
- Exacerbates “what if” questions about the future
Perceptions of Uncontrollability
Uncontrollable and unpredictable stressful events create more fear and anxiety (More likely to have history of unpredictable life events)
- Phobias
- Social anxiety
- GAD
Cognitive Theories of Social Anxiety (1-2)
1- Social situations activate core set of values or beliefs => Self = not socially competent AND Others = rejecting
Interpret social situations as dangerous => And therefore enter situation already in distressed state
=> Creates vicious cycle
Triggers self-focused attention => Focus on symptoms of anxiety and fear, Worry others will detect this => Creates more somatic symptoms! (interferes with ability to socialize)
- Engage in safety beh =>Behaviors designed to avoid or prevent feared outcome, Fail to benefit from non- catastrophe
- Perpetuates negative interpersonal consequences and maintains feared beliefs
2- Biases in External Info Processing
Socially anxious individuals will also show negative biases in their social information processing => Attentional biases (Stroop studies and Dot probe studies) and Interpretation biases
=> Emotional Stroop Task (task takes longer to resp to threatening words)
=> Attentional bias towards social threat (socially anxious show bias for emotional faces (ex: angry, disgusted, rejecting) or words on the dot probe task) *Sometimes find pattern of hyper vigilance or patterns of avoidance
Cognitive Theories of Social Anxiety (3-4)
3- Vigilance-Avoidance Hypothesis (maintains anxiety)
Need to consider time-course of attentional bias => How long you present stimuli for
- Initially show pattern of hypervigilance in early stages of selective attention (attend toward threat)
- Followed by pattern of avoidance (look away from threat)
*Bias specificity => Attentional biases are present in all kinds of anxiety dx and Threat-related attentional bias = specific
4- Interpretation Biases: Socially anxious individuals interpret ambiguous social situations negatively and catastrophize even mildly negative social events (ex: vignettes)
Evolutionary Factors (4)
Fear is part of a defensive beh system that helps organism survive and deal with threat => Motivates to protect and escape danger quickly
1- Evolutionary Preparedness Theory => Evolved a sensitivity to certain stimuli (Certain fears were adaptive at one point and these fears were selected for)
- Not innate, but easily acquired over course of evolution
- More readily acquire fears that were threats to our ancestors (ex: predators, heights) => More so than fears related to modern life (ex: guns)
Study: Monkeys and toy snake vs toy flower => Condition fear with certain stimuli (even if monkey scared of flower, don’t learn that but if scared of snake learn that) + vicarious learning
2- Social Stimuli => Expressions of human emotion represent biologically evolved adaptations (Anger = threat signal, Smile = affiliative signal)
- Fear-response to angry faces are more easily acquired
3- Fundamental Need to Belong => social connection is critical to survival (can form bonds easily)
- Real, potential, or imagined changes in one’s belongingness status will produce emotional responses
- Fairly large and well-replicated effects of social exclusion on mental and physical health
- Threats to belongingness produce negative affect: Anxiety, Sadness, Anger, Jealousy
4- Social Exclusion as a Prepared Fear => Fear of being excluded from social groups is innately prepared
Evidence?
- Fundamental and universal
- Easily conditioned
- Difficult to extinguish
What adaptive function does this serve?
- Prevent further exclusion (ex: self- regulation)
- Increase likelihood of inclusion (ex: social attractiveness)
Treatments
Psychopharmacology:
- Benzodiazepines provide rapid, short-term relief from physiological sx of anxiety (Bind to GABA receptor sites in brain) *Many side effects and Withdrawal sx in long- term use
Some argue against use of benzos for long-term
anxiety tx:
- Perpetuates pathological view of anxiety sx
- And negative reinforcement!
- Evidence that benzo use increases hypervigilance & reduces memory for therapy
- SSRIs: Less physiological dependence, not as useful in acute situation (ex: panic attacks) *benefits for social anxiety
Psychotherapy:
Most effective treatment in anxiety dx *Administered as first-line treatment:
- Cognitive restructuring
- Exposure => Exposure therapy: Systematic desensitization through a fear hierarchy (anxiety is learned response => By facing anxiety-provoking stimuli, fears become extinguished) Vs. Flooding / Intense exposure *Need to account for safety beh
Cognitive Restructuring:
Rationale is that unhelpful cognitions about self, others, world, and future maintain anxiety
- Identify negative automatic thoughts and core beliefs
- Develop more evidence-based thoughts
