anxiety

Question 1

clinical features of anxiety

Answer 1

Negative mood state, physical tension & apprehension about the future
→ ‘future oriented

• Symptoms interfere with important areas of functioning or cause marked distress.
• not caused by a drug or a medical condition.
• Symptoms persist for at least six months or at least one month for panic disorder.
• distinct from the symptoms of another anxiety disorder.
• some have specifiers

Question 2

fear

Answer 2

• ‘immediate’ aspect of fear (a present threat)

- Strong escapist action tendencies – Present-oriented

Question 3

anxiety and fear are adaptive

Answer 3

Both involve arousal or sympathetic nervous system activity.

Fear = ‘fight-or-flight’ reactions — it triggers rapid changes in the sympathetic nervous system to prepare the body for escape or fighting

Anxiety Good for us in moderate amounts
o plan for future threats — increase our preparedness
o a small degree of anxiety has been found to improve performance on laboratory tasks
* U-shaped curve with performance
No anxiety → unprepared
Little anxiety → adaptive
Too much anxiety → detrimental

Question 4

specific phobias

Answer 4

• disproportionate fear caused by a specific object or situation (can elicit disgust)
• claustrophobia (fear of closed spaces) and acrophobia (fear of heights).
• tend to cluster around a small number of feared objects and situations but may be comorbid (a specific phobia for one type of object/situation can move to other objects/sitch)

Almost always provokes immediate fear/anxiety
Actively avoided or endured with intense fear/anxiety

Question 5

4 major types of specific phobias

Answer 5

Blood, injection, injury (runs in family)
 Situational (mid 20’s or childhood)
 Animals & insects (during childhood)
 Natural environments (childhood)

Question 6

Physiology of anxiety, fear, panic

Answer 6

Primary response of HPA axis is to regulate the stress response

• Pituitary gland releases hormones into the blood stream to reach a variety of targets (travel down to the kidneys) and influences secretion of hormones from the endocrine glands (called adrenal glands)
• Hypothalamus releases corticotropin- releasing hormone (CRH) –> signals the pituitary gland –> which signals the release of adrenocorticotropic hormone (ACTH) –> cortisol

release of cortisol causes a number of changes to help the body deal with stress

Question 7

Pituitary gland:

Answer 7

hormone secreting gland below the hypothalamus

Question 8

Hypothalamus

Answer 8

(neuroendocrine structure) controls the release of hormones from the pituitary gland

Question 9

neurobiological factors to anxiety

Answer 9

o GABA (small amounts of GABA leads to more anxiety)
o norepinephrine - more of this leads to increase in locus corrélées
o serotonin - decrease in serotonin and increase in anxiety

o Corticotropin-releasing factor system – Activates HPA axis
o Hypothalamus, pituitary gland, adrenal glands
o Limbic system most associated (stress anxiety and panic) overly responsive to stimulation = abnormal bottom-up processing (longer circuit= rumination occurs with GAD –> usually how we deal with our anxiety adaptively but only if we don’t get stuck in the longer circuit)
o Short circuit more likely to go wrong (quick short changes)
o Amygdala centrally involved
o Medial prefrontal cortex – Fails to down-regulate hyper-excitable amygdala = abnormal top-down processing

Question 10

personality factors to anxiety

Answer 10

Personality:

 Behavioural inhibition: a tendency to become agitated and cry when faced with novel toys, people or other stimuli. (in infants as young as four months old, may be inherited and may set the stage for the later development of anxiety disorders)
- strong predictor of social anxiety disorder:
– Strong predictor of social phobia

 Neuroticism:
– Tendency to react with greater negative affect
– High levels = strong predictor of an anxiety disorder

Question 11

cognitive factors to anxiety

Answer 11

Sustained negative beliefs about the future

• People with anxiety disorders often report believing that bad things are likely to happen.
• these beliefs are sustained because they engage in safety behaviours to protect themselves

Perceived lack of control

• traumatic events, punitive and restrictive parenting or abuse, after serious life events
• Other life experiences may shape the sense of control over the feared stimulus.

Attention to threat

• people with anxiety disorders pay more attention to negative cues in their environment than do people without anxiety disorders
• Once a threatening object captures their attention, anxious people have a difficult time pulling their attention away from that object;
• Anxiety related information can be created.

Behaviourist theories:
– Classical & operant conditioning
– Modeling
- people with anxiety disorders seem to acquire fears more readily through classical conditioning and to show a slower extinction of fears once they are acquired

Question 12

Fear conditioning

Mowrer’s two-factor model of anxiety disorders

Answer 12

1) CC= person learns to fear a neutral stimulus (the conditioned stimulus or CS) that is paired with an intrinsically aversive stimulus (the unconditioned stimulus or UCS).
2) A person gains relief by avoiding the CS. (operant conditioning)

Modification to his theory

• modelling (e.g., seeing a dog bite a man or watching a video of a vicious dog attack)
• verbal instruction (e.g., hearing a parent warn that dogs are dangerous).

Question 13

genetic factors of anxiety

Answer 13

• heritability of 20–40% for specific phobias, social anxiety disorder and GAD, and about 50% for panic disorder
• having a family member with a phobia is related to increased risk of developing not only a phobia but also other anxiety disorders

Question 14

The medial prefrontal cortex

Answer 14

• helps to regulate amygdala activity and involved extinguishing fears
• engaged when people are regulating their emotions

o people with anxiety display less activity in the medial prefrontal cortex when threatening stimuli arises
o The pathway, or connectivity, linking the amygdala and the medial prefrontal cortex may be deficient which in turn may interfere with the effective regulation and extinction of anxiety

Question 15

aetiology of specific phobia

two-factor model of behavioural conditioning

Answer 15

• phobias could be conditioned by direct trauma, modelling or verbal instruction.

risk factors; genetic vulnerability, neuroticism, negative cognition and affinity for fear conditioning –> operate as diatheses

Question 16

prepared learning

Answer 16

evolutionary- learned to react strongly to stimuli hence preparing our fear circuit to certain stimuli (prepared learning –> exposure helps

Question 17

social anxiety disorder

Answer 17

persistent fear or anxiety about social situations that might involve being scrutinised by, or even just exposed to, unfamiliar people (“social phobia”)

 Exposure to the trigger leads to intense anxiety about being evaluated negatively
 Almost always provoke fear/anxiety
 Trigger situations are avoided or endured with intense fear/anxiety
 Disproportionate to actual threat
 In presence of another medical condition, fear/anxiety is unrelated or excessive

• work in occupations far below their talents because of their extreme social fears.
• ppl w/ social anxiety disorder, at least a third have avoidant personality disorder
• Social anxiety disorder generally begins during adolescence
• Chronic

Question 18

Aetiology of social anxiety disorder

Answer 18

Behavioural factors: conditioning

• person has a negative social experience (directly, through modelling or through verbal instruction) and become classically conditioned to fear similar situations, which the person then avoids. (operant conditioning)

safety behaviour
o avoiding eye contact
o disengaging from conversation and standing apart from others.
o Other people tend to disapprove of these types of avoidant behaviours, which then intensifies the problem

Cognitive factors: focus on negative self-evaluations

1) Unrealistic and negative beliefs about the consequences of their social behaviours —believe that others will reject them if they blush or pause while speaking.
2) attend more to themselves in social situations and their own internal sensations than other people do.
3) attend more to internal cues than to external (social) cues  Eg. spend more time monitoring for signs of their own anxiety.

Generalised biological vulnerability
– Stress increases anxiety & self-focused attention
 Under stress → panic attack
– Social situation associated with panic
 Real social trauma → true alarm
– Anxiety in similar situations
 Belief that social evaluation can be dangerous
– Parental concern about opinion of others (Lieb eta l, 2000)

Question 19

social anxiety prevalence

Answer 19

 Prevalence: 3-13%
 50:50 gender ratio
 Generally begins in adolescence – Most prevalent in young, undereducated,low SES singles
 Diagnosed as performance only or generalised
 Comorbidities: – Other anxiety disorders, depression,
alcohol abuse

Question 20

panic disorder

Answer 20

• recurrent panic attacks, unrelated to specific situations and worry about having more
• accompanied by at least four other panic symptoms.

shortness of breath, heart palpitations, nausea, upset stomach, chest pain, feelings of choking and smothering, dizziness, lightheadedness, faintness, sweating, chills, heat sensations, numbness or tingling sensations, and trembling.

flee situation

*tend to come on very rapidly and reach a peak of intensity within 10 minutes.

Question 21

DSM-5 criteria for panic disorder

Answer 21

At least 1 of the attacks followed by ≥ 1 month of one or both:

1. Persistent concern or worry about further attacks or their consequences
2. Significant maladaptive behavioural changes because of the attacks.

Methods of avoiding panic attacks:
– Drug & alcohol use /abuse
– ‘Endure’ fear

Interoceptive avoidance:
– Remove self from situations that might produce physiological arousal
 Exercise
 Saunas
 Watching sport

Question 22

Misfire of the system panic attack

Answer 22

physiologically, the person experiences a level of sympathetic nervous system arousal matching what most people might experience when faced with an immediate threat to life.

• 40% + experience at least one panic attack (onset- adolescence)
• The symptoms of panic disorder tend to wax and wane over time

Question 23

Panic Disorder

Answer 23

 5% of people at some time - 2/3 female
 Onset early adulthood (mid-teens to ~40)
 60% experience nocturnal attacks:
– During delta wave (slow wave) sleep
– deepest sleep

 Sleep terrors:
– Occurs in children – don’t wake, no memory
– At later stage of sleep

 Isolated sleep paralysis:
– Transition between sleep & wake (REM)
– Unable to move, vivid hallucinations
– History of trauma

Question 24

Aetiology of panic disorder

Answer 24

Neurobiological factors

• fear circuit
• locus coeruleus –> neurotransmitter norepinephrine in the brain which activates the HPA axis and triggers the sympathetic NS
• dramatic biological response to drugs that trigger norepinephrine
• Drugs that increase activity in the locus coeruleus can trigger panic attacks, and drugs that decrease activity in the locus coeruleus, including clonidine and some antidepressants, decrease the risk of panic attacks

Behavioural factors: classical conditioning

• panic attacks are classically conditioned responses to either the situations or…..
• interoceptive conditioning: classical conditioning of panic attacks in response to bodily sensations –> panic attacks then become a conditioned response to the somatic changes

Cognitive factors in panic disorder

• exposing people to air with high levels of carbon dioxide;
• People who develop panic attacks after being exposed to these agents differ to others— the extent to which they are frightened by the bodily changes
• when heart rate is monitored using psychophysiological equipment, people with panic disorder are more accurate than other people in knowing when an arrhythmia occurs and in detecting changes in their heart rate during periods of stress and arousal

Question 25

treatment for panic disorder

Answer 25

Biological:
– SSRIs & SNRIs
– Benzodiapepines (GABA) Most widely used
– Addictive, affect motor /cognitive function
– 60% free of panic, but relapse high (50-90%)
once stopped

Cognitive behaviour treatment most successful
– Focus on exposure – combined with relaxation, breathing retraining
– Panic control therapy
– Exposure to interoceptive sensation e.g. by spinning in a chair
– Mimics panic attack
– Perceptions of danger identified & modified = symptoms less frightening

Question 26

treatment for social anxiety disorder

Answer 26

Exposure therapy:
– Role-play /practice in small groups → public

Cognitive therapy:
– Challenges beliefs re: appraisal & worthlessness
– Effective where added to exposure therapy

Drug therapy:
– Antidepressants such as Tricyclic Antidepressants & MAO inhibitors are effective

Combined treatments:
– Adding D-cycloserine to CBT significantly enhances effect of treatment

Question 27

agoraphobia

Answer 27

• Agoraphobia (agora= ‘marketplace’) = anxiety about situations in which it would be embarrassing or difficult to escape if anxiety symptoms occurred)
• DSM-5 now includes agoraphobia as a separate diagnosis.
• at least half of people with agoraphobia symptoms do not experience panic attacks (concerned about what will happen if other anxiety symptoms develop)
• related to significant impairment in daily functioning.
• The effects of agoraphobia on quality of life are as severe as those observed for the other anxiety disorders

Question 28

DSM-5 criteria for agoraphobia

Answer 28

• experience a disproportionate and marked fear or anxiety about at least two situations where it would be difficult to escape or receive help
• These situations consistently provoke fear or anxiety.
• These situations are avoided, require the presence of a companion, or are endured with intense fear or anxiety.

Question 29

Generalised anxiety disorder

Answer 29

• worry about minor things
• excessive, uncontrollable –> relationships, health, finances and daily hassles
• symptoms : difficulty concentrating, tiring easily, restlessness, irritability and muscle tension.

-GAD is not diagnosed if a person worries only about concerns driven by another psychological disorder; for example, a person with claustrophobia who only worries about being in closed spaces would not meet the criteria for GAD.

Question 30

worry

Answer 30

cognitive tendency to chew on a problem and to be unable to let go of it (cannot settle on a solution)

Question 31

DSM-5 criteria for generalised anxiety disorder

Answer 31

• experience excessive anxiety and worry at least 50 percent of days about a number of events or activities (e.g., family, health, finances, work and school).
• The person finds it hard to control the worry.
• the anxiety and worry are associated with at least three (or one in children) of the following:
   restlessness or feeling keyed up or on edge
   easily fatigued
   difficulty concentrating or mind going blank
   irritability
   muscle tension
   sleep disturbance.
• GAD typically begins in adolescence, (many a tendency to worry all their lives)
• often chronic;
• GAD is more strongly related to marital dissatisfaction than any other anxiety disorder and people diagnosed with GAD report having few friendships compared to others

Question 32

comorbidity w/ anxiety disorders

Answer 32

More than half meet the criteria for another anxiety disorder

• highly comorbid with other disorders.
• 3/4 of people have another psychological disorder
• 60% percent have major depression
• comorbid with substance abuse and personality disorders
• comorbidity is associated with greater severity and poorer outcomes of the anxiety disorders

Question 33

DSM5 for agoraphobia

Answer 33

Marked fear or anxiety about ≥2 situations
 Public transport, open spaces, enclosed spaces, in line or in crowd, outside of home alone
 Fears because escape might be difficult or help not available
 Almost always provokes fear or anxiety
 These situations are avoided, require the presence of a companion, or endured with intense fear or anxiety
 Out of proportion to actual danger

Question 34

aetiology of agoraphobia

Answer 34

 Genetic vulnerability (heritability 61%) ; life events

 Fear-of-fear hypothesis:
– Driven by negative thoughts about the consequences of experiencing anxiety in public

Treatment:
 Systematic exposure to feared situations:
– More effective with a partner – stop enabling!

Question 35

aetiology of GAD

Answer 35

 Genetic vulnerability
– Tends to run in families

 Autonomic restrictors
– Less responsive on physiological measures
– Instead → chronically tense

 Highly sensitive to threat → unconscious
– Restricted autonomic arousal but intense frontal lobe activity
– Frantic, thought processes proposed to reflect avoidance of unpleasant emotions that would be more powerful than worry

Question 36

prevalence GAD

Answer 36

• 5.7% of the population meets criteria for GAD at some point in their lifetime

– One of the most common anxiety disorders
- 2/3 female
– May reflect a reporting bias
- Associated with an earlier & more gradual onset than most other disorders
– Many report feeling anxious & tense all their lives
 Chronic course characterised by waxing & waning

 Prevalent among older adults
– May be particularly susceptible to anxiety about failing health or other life situations that begin to diminish whatever control they have over their lives

Question 37

function of worry in GAD

Answer 37

• worrying actually decreases psychophysiological signs of arousal
• use worrying to avoiding emotions that would be more unpleasant and more powerful than worry. But as a consequence of this avoidance, their underlying anxiety does not extinguish.
  may be that worry distracts people with GAD from the distress of remembering these past traumas.
• people who have a hard time accepting ambiguity are more likely to worry (that something bad might happen) and to develop GAD

Question 38

Treatment of GAD

Answer 38

 Benzodiazepines most commonly prescribed
– Short-term relief, temporary crisis

 Psychological treatments more effective long term
– Challenging negative thoughts
– Confronting anxiety-provoking thoughts
– Acceptance rather than avoidance of distressing thought
– ‘Scheduling’ worry

Question 39

Comorbidity of Anxiety Disorders

Answer 39

• > 50% of people with one anxiety disorder diagnosed with a second anxiety disorder
  – Overlapping symptoms
  – Shared vulnerabilities
  – Different triggers & pattern of panic attacks

Around 75% of people diagnosed with an anxiety disorder also meet criteria for another disorder
– 60% meet criteria for major depression
– Less likely to recover, more likely to relapse

Other comorbidities:
– Substance abuse
– Personality disorders
 Physical disorders:
– Anxiety disorder uniquely & significantly associated with:
– Thyroid disorder
– Respiratory disease
– Gastrointestinal disease
– Migraine & allergies
– Anxiety often precedes physical disorder – cause/contribute?
– Poorer quality of life than physical disorder alone
– Same relationship with cardiovascular disease
– Especially panic disorder