Anxiety Flashcards
1
Q
Definition of Anxiety
A
- Often labelled ‘fear’ ‘panic’
- The experience of anxiety is the same in normal and abnormal anxiety
- Activated in response to perceived threat
- Three interrelated anxiety systems:
- Physical system.
- Cognitive system.
- Behavioural system.
2
Q
Physical system
Anxiety
A
- Fight/flight: sympathetic nervous system.
- Mobilises resources to deal with threat.
- Symptoms: sweating, heart rate, trembling etc
3
Q
Cognitive system
Anxiety
A
- perception of threat,
- attentional shift and hypervigilance,
- difficulty concentrating on other information.
4
Q
Cognitive system
Anxiety
A
- Escape/avoidance tendencies
- Aggression
5
Q
Importance of normal anxiety
A
- Normal anxiety is necessary for survival.
- Eliciting conditions:
- Realistic/objective threat to self.
- Physical vs social threat
- specific ‘prepared’ stimuli
- dangerous during the course of human evolution
- insects, animals, heights, enclosed places, anger
- novel stimuli.
- Realistic/objective threat to self.
- Threat appraisal >> Expectancy of harm >> Automatically Elicits Anxiety.
6
Q
Threat Appraisal
A
Generates expectancy of harm
- Situation: public transport
- Outcome: embarrassment
- Outcome: accident, death
- Outcome: germs, illness
Product of:
- perceived probability
- perceived cost
Often based on past
- Experience
- conditioning, reinforcement
- Observational learning
- Instruction
7
Q
Abnormal Anxiety/Anxiety Disorders
A
Individual differences in
- Trait anxiety
- Tendency to perceive threat in ambiguous situations
- Extent to which anxiety response is activated
- Specific fears
>> ‘abnormal’ anxiety
8
Q
How does Abnormal Anxiety differ from Normal Anxiety?
A
Abnormal anxiety is not qualitatively different from normal anxiety
- Same three aspects:
- physical,
- cognitive,
- behavioural
- BUT: Excessive or inappropriate occurrence
- Characterised by overestimation of threat:
- Cost or probability of harmful outcome
- Physical fears: mainly probability overestimation
- Social fears: mainly cost overestimation
- Characterised by overestimation of threat:
9
Q
General definitions of Anxiety Disorders
A
- Involve experience of anxiety/ fear/ panic
- Physical
- Cognitive
- Behavioural
- Reflect an internal dysfunction
- anxiety in response to situations that are not objectively dangerous
-
Socially inappropriate/harmful/unexpected
- Interfere with everyday social or occupational activities
- Categorised according to focus of anxiety
10
Q
DSM-IV Comorbidity
Anxiety Disorders
A
Anxiety disorders are highly comorbid with each other, depression, substance use
- Generalised biological vulnerabilities
- Genetics, Neuroticism
- Generalised psychological vulnerabilities
- Trait anxiety, low perceived control
- >> Any anxiety disorder, depression
- Trait anxiety, low perceived control
-
Specific psychological vulnerabilities
- Focus of threat-related beliefs
- Direct experience, observation, instruction
- >> Specific Anxiety Disorders
- Direct experience, observation, instruction
- Focus of threat-related beliefs
11
Q
Biological Treatments
Anxiety Disorders
A
Barbiturates (Amobarbital, Phenobarbital)
- Quick acting, but relapse very common (80-90%)
- Highly addictive, can lead to OD, interact with alcohol
Benzodiazepines (Valium, Xanax, Rohypnol)
- Quick acting, but relapse very common
- Less addictive, but interact with alcohol
SSRIs (antidepressants, e.g., Prozac, Zoloft)
- Slower acting
- Fewer side effects
- Relapse common (20-60%)
12
Q
CBT
Anxiety Disorders
A
- Aim to reduce (biased) threat appraisal
- How likely is it that the event will happen?
- How bad would it be if it did happen?
- Increase (biased) coping appraisal
- Cognitive Techniques:
- Thought-diaries to identify automatic thoughts (mixed with mindfulness)
- Thought challenging:
- Socratic questioning
- What’s the evidence (against) the thought/belief?
- Pros and Cons of having the thought/belief
13
Q
Behavioural Techniques
Anxiety Disorders Treatments
A
- Behavioural techniques:
- Exposure to feared stimuli (public transport)
- Exposure to feared outcomes (negative evaluation)
- in vivo vs imaginary exposure
- Flooding vs Systematic desensitisation
-
Reduce (biased) threat appraisal:
- Exposure to feared stimuli:
- Reduces judgments of likelihood of harm
- Exposure to feared outcomes:
- Reduces judgments of cost
- Exposure to feared stimuli:
-
Exposure is essential in anxiety treatment
- Avoidance maintains anxiety by stopping the person from learning that a specific stimulus/situation is not objectively dangerous
14
Q
DSM5 Trauma- and Stressor-Related Disorders
A
- Posttraumatic Stress Disorder
- Acute Stress Disorder
- Adjustment Disorders
- Reactive Attachment Disorder
- Disinhibited Social Engagement Disorder
15
Q
DSM-5 Obsessive-Compulsive and Related Disorders
A
- Obsessive-Compulsive Disorder
- Hoarding Disorder
- used to be a subtype of OCD
- BUT respond to treatments differently
- Trichotillomania (Hair-Pulling Disorder)
- used to be classified as an Impulse-Control Disorder (along with gambling)
- Excoriation (Skin-Picking) Disorder
- Body Dysmorphic Disorder
16
Q
DSM-5 Anxiety Disorders
A
- Separation Anxiety Disorder
- Selective Mutism
- Specific Phobia
- Social Anxiety Disorder (Social Phobia)
- Panic Disorder
- Agoraphobia
- Generalized Anxiety Disorder
>> Ordered in the order of developmental progression
17
Q
DSM-5 Panic Attack
A
- Extremely severe anxiety/fear reaction
- Can occur in the context of any anxiety disorder
-
Expected (cued) panic attack
- Usually occur in context of other anxiety disorders
- Specific phobias
- Social phobia
- Post-Traumatic Stress Disorder
-
Unexpected (uncued/spontaneous) panic attack
- Person can not identify the source of fear
- Occur in context of Panic Disorder
- Two unexpected Panic Attacks are needed for diagnosis
-
Expected (cued) panic attack
18
Q
DSM-5 Panic Disorder
A
- At least two unexpected panic attacks
- Persistent concern or worry about additional panic attacks or their consequences
- A significant maladaptive change in behaviour related to the attacks
- Symptoms persist one month or more
- 12-month prevalence: 2-3 %
- median age of onset: 20-29 years
- Course: chronic but waxing and waning
- Comorbid with other anxiety disorders, alcohol use, and depression: 10-65%
19
Q
Cognitive Theory of Panic
A
- Panic results from fear of bodily sensations
-
Misinterpreting their consequences
- dizziness = impending stroke,
- heart palpitations = impending heart attack
-
Misinterpreting their consequences
- Bodily sensations can arise from anger, caffeine ingestion, physical activity, etc
- Risk factors: neuroticism, anxiety sensitivity
- Maintenance of misinterpretations:
- ‘safety behaviours’
- Protective actions to prevent harmful event
- e.g., tense muscles, have friend present, etc
- Protective actions to prevent harmful event
- ‘safety behaviours’
20
Q
Agoraphobia: DSM-IV vs DSM-5
A
DSM-IV Agoraphobia: response to panic
DSM-5 Agoraphobia:
A. Marked fear or anxiety about two (or more) of :
- Using public transportation (cars, buses, trains, planes).
- Being in open spaces (parking lots, markets, bridges).
- Being in enclosed places (shops, theatres, cinemas).
- Standing in line or being in a crowd.
- Being outside of the home alone.
B. Escape might be difficult or help might not be available in the event of developing panic-like, or other incapacitating or embarrassing symptoms
21
Q
Possible causes of Agoraphobia
A
- High degree of dependent behaviour
- Weaker beliefs in own coping ability
- Separation Anxiety, Shcool Phobia
- Physical concerns
- Dizziness
- Fainting
- More social evaluative concerns
22
Q
Biological Treatment of Panic - Agoraphobia
A
- Anxiolytics, (Barbiturates, Benzos)
- Antidepressants
23
Q
Psychological Treatment of Panic - Agoraphobia
A
Cognitive-Behavioural
- Cognitive restructuring
- Exposure
- To interoceptive stimuli (Panic)
- To avoided situations (Agoraphobia)
- Reducing safety seeking behaviours
- CBT is effective in 80-85% of clients with PD
24
Q
Generalised Anxiety Disorder (GAD)
A
- First introduced in DSM-III-R (1980)
- DSM-IV (1994) and DSM-5 (2013) definition:
- Excessive, uncontrollable worry about a variety of events / outcomes
- Occurs more days than not
- For at least 6 months
- At least 3 of 6 somatic symptoms:
- Restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
- Does not include autonomic arousal
- Restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
- Need to distinguish from other disorders that also involve excessive worry
25
Normal Worry (GAD)
* Occurs in response to perceived threat
* **Focus:**
* mainly **social** **threat** in ***adults***
* more about **physical** **threat** in ***older adults***
* Contains **more verbal thought** vs. imagery
* Perceived positive aspects:
* motivates action
* helps to problem solve
* avoid negative outcomes
* distract from more distressing topics
* Worry control:
* Problem-solving, distraction, social support
26
Problem Solving Theories (GAD)
* Worrying involves problem-solving attempts
* Problem-solving attempts of pathological worriers are **‘thwarted’**
* biased threat perception
* don't result in a solution
* **Social Problem Solving**
* Problem definition
* Generation of alternative solutions
* Solution evaluation (positive / negative)
* Solution selection
* **Last two stages** are problematic in high worriers
* Evaluate solutions more negatively
* Can never choose a satisfying solution
27
Metacognitive Theory (GAD)
Worry (Type 1) and Metaworry (Type 2)
* **Type 1 Worry:**
* Perception of threat + positive beliefs about worry \>\> worry to cope with threat
* possible exit by problem-solving or reassurance
* **Type 2 Metaworry:**
* Worry + negative beliefs about worry \>\> metaworry \>\> ineffective thought-control strategies \>\> increased anxiety and worry
* Excessive and uncontrollable worry
* Employ ineffective methods to suppress worry, BUT usually only exacerbates worry
28
Avoidance Theory (GAD)
Worry: more verbal thought than imagery
* Images of possible negative event are
* highly aversive
* cause anxiety symptoms (= sympathetic arousal)
* Anxiety symptoms are highly aversive
* **Reduced imagery =\> reduced arousal/anxiety**
* Verbal thinking is much less aversive
* GAD is associated with tension symptoms
* Worry = cognitive avoidance
* Cognitive avoidance **interferes with emotional processing**
* Fear structures are maintained =\> keep worrying
29
Experiential avoidance (GAD)
* Worry is associated with
* Fear of anxiety/Anxiety sensitivity
* Distress intolerance
* Experiential avoidance
* Worriers **avoid internal experiences**
* **Difficulties in emotion regulation**
* Worriers have difficulties in
* clearly identifying emotion
* tolerating emotion
* modulating emotion
30
Intolerance of Uncertainty Theory (GAD)
* Uncertainty:
* reflects badly on a person
* causes frustration and stress
* prevents action
* **Worry to reduce uncertainty**
* Leads to preoccupation with details
* **Interferes** with problem-solving
* Worriers aim to **reduce uncertainty to zero**
* only stops once zero uncertainty is achieved
* not possible
31
Treatments of GAD
* **Biased threat perception**
* probability and cost judgments
* **‘Problem-solving’**
* Structured problem-solving training
* **‘Metacognitive’**
* Challenge beliefs about worry (positive and negative)
* **‘Avoidance’**
* Exposure to vivid images of feared event
* Exposure to emotional experience / distress (role for mindfulness)
* Exposure to uncertainty
* **Treatment effects have been modest**
* About 50 – 60 % improvement at follow-up
32
DSM-5 Trauma- and Stressor-Related Disorders
* Posttraumatic Stress Disorder
* Acute Stress Disorder
* Adjustment Disorders (e.g. new job, someone dies, a baby is born)
* Reactive Attachment Disorder (childhood)
* Disinhibited Social Engagement Disorder (childhood)
33
DSM-5 Post-Traumatic Stress Disorder
**A. Exposure to actual or threatened death, serious injury, or sexual violence** in one (or more) of the following ways:
* Directly experiencing the traumatic event(s).
* Witnessing, in person, the event(s) as it occurred to others.
* Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
* Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse)
\>\> Different to other disorders: **there has to be a CAUSE**
**B. Intrusion symptoms** (1 or more needed)
* Memories, dreams, flashbacks of the event
**C. Persistent avoidance of stimuli** (1+)
* memories etc, or external reminders of the event
**D. Negative changes in cognition, mood** (2+)
* Fear, negative beliefs about self, others, the world
**E. Changes in arousal, reactivity** (2 +)
* Anger, recklessness, self-destructive acts, sleep disturbance
**Duration of symptoms is 1 month or more**
34
Immediate post-trauma phase of PTSD
* 50-60% of people experience traumatic event
* About 25% develop post-traumatic problems
* PTSD, depression, anxiety, substance abuse.
* PTSD prevalence: 5-11%
* **Normative response to trauma is to get over it**.
* People are distressed immediately after traumatic event
* A perfectly normal reaction
* Distress drops substantially within 3 months in about 75% of people.
* Even for the 25% who develop PTSD also get better by themselves over time
* Medication helps speed up the recovery process
35
Pre-trauma factors
Risk for later problems in PTSD
* Childhood trauma
* Prior psychiatric history
* Family instability
* Substance abuse
* Social/economic disadvantage
36
Trauma factors
Risk for later problems in PTSD
* Degree of life threat (injury, death) or loss
* Severity of exposure to traumatic elements
* Location of trauma (safe place vs elsewhere)
* Individual’s role in the trauma (victim, helper)
* Meaning (e.g., uncontrollability)
37
Post-trauma factors
Risk for later problems in PTSD
* Social support
* Coping style
* Ongoing stressors
38
Biological Treatments for PTSD
* Benzodiazephines
* Antidepressants
39
Cognitive Behavioural Therapies for PTSD
* Core treatment components
* Assess suitability
* Psychoeducation
* Anxiety management techniques
* Cognitive restructuring
* Prolonged exposure
* CBT is more effective than medication or supportive psychotherapy
40
Eye Movement Desensitization and Reprocessing (EMDR)
PTSD
* Now used to treat a variety of anxiety disorders
* Eye movements are the crucial components of the procedure and essential for its effectiveness
* Training has to be provided by EMDR Institute
* Research evidence:
* EMDR is best seen as an exposure technique
* Eye movements are **not necessary for effectiveness**
