Anxiety

Question 1

Learning objectives:

Answer 1

1. Be able to describe the features of ‘normal’ anxiety and ‘anxiety disorders’
2. Describe the typical psychological features that are associated with experiencing threat
3. Describe the basic psychological mechanisms associated with the aetiology and maintenance of anxiety with a particular focus on the role played by learning theories and cognitive biases

Need to know the psychological theories, diagnosis and pros and cons of diagnosis, have an awareness of the role of cognitive factors (biases) in particular

Question 2

1. Be able to describe the features of ‘normal’ anxiety and ‘anxiety disorders’

Anxiety is normal, when does it become maladaptive?

Answer 2

Anxiety and stress are common features of everyday living

• adaptive emotion, anxiety can help us prepare to deal effectively with anticipated threats by increasing our arousal and reactivity, focusing our attention and helping us to solve problems
• maladaptive emotion - when we have difficulty managing anxiety and it starts to feel uncontrollable and distressing

Question 3

1. Be able to describe the features of ‘normal’ anxiety and ‘anxiety disorders’

Generally debilitating symptoms:

Answer 3

Anxiety generally can have debilitating symptoms including;

• panic attacks
• lack of appetite
• scary or uncontrollable thoughts
• thoughts about physical ailments
• suicidal ideation anxiety

Question 4

1. Be able to describe the features of ‘normal’ anxiety and ‘anxiety disorders’

Cognitive symptoms:

Answer 4

Cognitive features of anxiety include feelings of apprehension or fear, resulting from the anticipation of a threat, usually accompanied by intrusive thoughts and catastrophic bouts of worrying (and sometimes flashbacks)

Question 5

1. Be able to describe the features of ‘normal’ anxiety and ‘anxiety disorders’

Physical symptoms:

Answer 5

• muscle tension
• dry mouth
• perspiring
• trembling
• difficulty swallowing
  (in extreme cases);
• dizziness
• chronic fatigue
• sleeping difficulties
• rapid or irregular heartbeat
• diarrhoea or persistent need to urinate
• sexual problems
• nightmares

Question 6

1. Be able to describe the features of ‘normal’ anxiety and ‘anxiety disorders’

Behavioural symptoms:

Answer 6

• avoidance
• escape
• coping when anxious (various behaviours)

Question 7

1. Be able to describe the features of ‘normal’ anxiety and ‘anxiety disorders’

When anxiety becomes maladaptive, what is this usually down to?

3 factors…

Answer 7

When anxiety becomes maladaptive and unmanageable - anxiety disorder develops.

In an AD, the anxiety response may;

(1) Proportionality - out of proportion to the threat
(2) Frequency - be a state that the individual constantly finds themselves and, and it might not be attributable to a specific threat
(3) Disruptive - persists chronically, and is so disabling that it causes constant emotional distress, unable to go about that day to day lives unhindered - might not be able to keep a job, maintain relationships, etc.

Question 8

Anxiety as a co-morbid condition…

Answer 8

Anxiety disorders are more often than not diagnoses in conjunction with another form of anxiety disorder

When their disorders are comorbid they tend to have an earlier age of onset, are more chronic, and are likely to be associated with depression, and greater social disability

80% of GAD cases have a co-morbid anxiety diagnosis

Anxiety is also commonly comorbid with - depression, substance abuse, eating disorders and mood disorders.

Question 9

Why are anxiety disorders so often co-morbid?

Answer 9

Some common cross disorder phenomena that may lead to anxiety comorbidity include;

(1) the physiological symptoms of panic are not only found in panic disorder, but also in reactions to phobic stimuli in specific phobias
(2) cognitive biases that tend to cause anxious people to selectively attend to threatening stimuli are common across most of the anxiety disorders
(3) A number of prominent psychopathologies are characterised by the dysfunctional and uncontrollable persevering of certain thoughts, behaviours and activities e.g. pathological worrying in GAD, compulsions in OCD and rumination in depression, might be a mechanism that underlies all this dysfunctional thinking.

Question 10

Briefly(!) outline the four main types of anxiety disorders

Specific phobias

Answer 10

Specific phobias are defined as a marked fear or anxiety about a specific object or situation

• trigger usually expert elicits extreme fear and panic that usually means the individual develops avoidance strategies to try and minimise any possible contact with that trigger
• phobics are usually aware that their fear is excessive or unreasonable, but they do acquire a strong set of phobic beliefs that appear to control their behaviour, normally information about why they think the phobia is threatening and how to react when they’re in a situation that elicits fear (avoid it)

DSM five specifies five subgroups of specific phobias;

(1) animal phobias
(2) natural environment phobias
(3) blue blood injection injury phobias
(4) situational phobias
(5) other phobias

Cultural differences in phobias acquired

Question 11

Briefly(!) outline the four main types of anxiety disorders

Social Anxiety Disorder

Answer 11

Social anxiety disorders is a severe and persistent fear of social or performance situations.

The social phobic tries to avoid any kind of social situation in which they believe they may behave in an embarrassing way, or a way in which they will be negatively evaluated
- might avoid having conversations, eating and drinking in front of others, or performing, because they’re scared that they will show anxiety symptoms that will be negatively evaluated, or they might offend somebody.
Individuals with social anxiety disorder, almost always experienced symptoms of anxiety;
- palpitations, tremors, sweating, gastrointestinal discomfort, diarrhoea, muscle tension, blushing and confusion. In severe cases, these symptoms might turn into a full blown panic attack.

Question 12

Briefly(!) outline the four main types of anxiety disorders

Panic Disorder and Agoraphobia

Answer 12

Panic disorder and agoraphobia are related, but separable anxiety-based problems, around one third of those suffering from panic disorder, also suffer agoraphobia.

People usually have panic disorder first (around half have panic attacks) then agoraphobic symptoms usually develop as a fear of the consequences of having a panic attack in public

> Panic disorder is characterised by recurrent unexpected panic attacks that keep occurring and are followed by at least one month of persistent concerns about having a panic attack

> Agoraphobia is the fear or anxiety of any place where the sufferer does not feel safe or feels trapped, accompanied by the strong urge to escape to a safe place e.g. home. Often this urge to escape is associated with the fear of having a panic attack, and the embarrassment that it might cause, which is why the two disorders are so often co-morbid

Question 13

Briefly(!) outline the four main types of anxiety disorders

Generalised Anxiety Disorder

Answer 13

GAD is characterised by continual apprehension and anxiety about future events, leading to chronic and pathological worrying about this event.

All people worry, some people find it useful. However, worrying for the individual with GAD has a number of features that make it distressing, beyond the adaptive worry that most people experience;

(1) worrying is chronic, pathological and not only directed at major life issues, but also minor, day to day issues
(2) worry is perceived as uncontrollable
(3) worry is closely associated with catastrophizing of worries, that is, bouts of worrying persist for longer and are associated with increasing levels of anxiety and distress, as the bout continues, worrying seems to make problems worse rather than better

Question 14

Theories of Anxiety

Learning theories (conditioning)

Answer 14

Classical conditioning

> Classical conditioning and phobias
– Little Albert Study (Watson and Rayner (1920)
Conditioned an 11mo baby into having a specific phobia for his white pet rat via classical conditioning – learned to associate the rat (CS) with a loud noise (UCS) which made him upset and would cry (CR), then when the rat was presented alone he would cry without the sound (UCR).

Learning theory
Most treatments for anxiety use behavioural elements – exposure is crucially important, possibly because it leads to extinction and maybe because it leads to over-learning (writing over previously learned responses)

Extinction: The gradual decrease of the conditioned response

• Happens through repeated presentation of the CS in the absence of the UCS, try to get them to do things that they will succeed at (if they avoid it reinforces the anxiety)
• However, extinction is not simply unlearning – it’s a new form of learning that changes the associations they have with the anxiety trigger

Operant conditioning - safety behaviours

Question 15

Theories of Anxiety

Critique of Learning theories

Answer 15

Criticisms of conditioning accounts;

• Many people with phobias cannot recall a traumatic event in the history of their phobia
• Not all people who have a traumatic conditioning experience develop a phobia
• Phobias only appear to develop in relation to certain stimuli and events (e.g. heights, snakes, etc.)
• A conditioning model cannot account for the phenomenon of incubation – for some cases exposure doesn’t work, it makes it worse
• treats all stimuli as equally likely to elicit fear

Question 16

Theories of Anxiety

Evolutionary Theories

Answer 16

The fact that phobias tend to focus on a limited set of fears that have evolutionary significance has led some people to suggest that we might be biologically pre-wired to acquire certain phobias, like heights, water, spiders, snakes, blood etc  substantiated by the fact that we rarely develop phobias over life threatening stimuli that have only appeared more recently in our phylogenetic past, like guns and electricity.

—> Biological preparedness

> Seligman (1971)
Evolutionary selection pressures have developed biological predispositions that enable us to learn to quickly fear certain stimuli that were hazardous to our ancestors (e.g. snakes)

> Cook & Mineka (1990)
Supported by studies of conditioned snake fear in laboratory-bred rhesus monkeys

> Colton and Menzies (2002)

• non-associative fear acquisition model – suggest that fear of a set of biologically relevant stimuli develops
• no specific trauma experiences are needed
• repeated exposures to the stimuli the person should acclimatise
• explains adult phobias as instances where these developmental phobias have failed to habituate properly.

The “moth effect”
– ancient anticipation drives attentional biases
– modern life creates all sorts of unhelpful triggers (dwelling, rumination, self-criticisation etc)

Question 17

Theories of Anxiety

Critique of Evolutionary Theories

Answer 17

• Very difficult to verify whether a phobic stimulus was ever an important selection pressure in the evolutionary past – easy to propose hard to substantiate or nullify due to historical nature of theory
• Evolutionary accounts can be constructed in a post hoc manner and may be just adaptive stories (McNally, 1995)

Question 18

Theories of Anxiety

Cognitive theories of anxiety

1. Anxiety sensitivity

Answer 18

Panic disorder sufferers become very anxious when they detect cues (internal or external) that might indicate a panic attack… what determines whether someone will panic in response to unusual body sensations? Researchers have proposed that some individuals have pre-existing beliefs that bodily sensations may predict harmful consequences
> Anxiety sensitivity refers to fears of anxiety symptoms that are based on beliefs that these symptoms have harmful consequences. For example, that increasing heart rate predicts an impending heart attack
- Developed an anxiety sensitivity index, testing anxiety sensitivity - found that individuals with panic disorder had significantly higher scores on it than non-clinically diagnosed controls

Question 19

Theories of Anxiety

Cognitive theories of anxiety

2. Catastrophic misinterpretation of bodily sensations

Answer 19

Clark (1996/ 88) built on anxiety sensitivity theory, developed an influential model of panic disorder in which he hypothesised that panic attacks are precipitated by the individual catastrophically misinterpreting their bodily sensations, as threatening
- many bodily sensations are ambiguous, like skipping a heartbeat could either mean that you’re going to have a panic attack or that somebody you fancy has just walked past, but PD individuals tend to catastrophically misinterpret these signals.
- have a cognitive bias towards accepting more threatening interpretations of the sensations and positive ones
- vicious cycle: apprehension is interpreted threateningly, increases the perceived threat, escalation of anxiety symptoms, causes a panic attack, increases likelihood of perceiving ambiguous cues as threatening etc etc.
> EVIDENCE Individuals with panic disorder, were told that they will be given a co2 challenge, but we’re actually given compressed air, but they still had a panic attack. So that’s suggested it was just the expectancy of that attack that was enough to trigger one, rather than the actual symptoms that they did or, in this case, didn’t experience.

Question 20

Theories of Anxiety

Cognitive theories of anxiety

3. Safety behaviours

Answer 20

Some PD suffers have had hundreds of panic attacks in their lifetime, and they still misinterpret the physical symptoms in a catastrophic

One reason for this is that they engage in safety behaviours, which is any behaviour that is designed to reduce anxiety in a situation that triggers anxiety, usually this is avoidance – act to reinforce belief that this safety behaviour is what saved them from a catastrophic outcome, because their anxiety went down when they engaged in this behaviour - tend to not ever deal with anxiety or challenge the outcomes, because they aren’t experiencing them - reinforces the whole cycle.

As a result of this, and treatments for panic disorder, usually focus on safety behaviours. And they manipulate and eliminate them in both behavioural and cognitive therapies for the disorder.

Question 21

Theories of Anxiety

Cognitive theories of anxiety

4. Information Processing biases

Answer 21

Series of information processing biases, which appear to maintain their hypervigilance for threat and create further sources for worry, which maintains their anxiety.

• preferentially attend to threatening stimuli and more threatening information and have a threat interpretation bias  more likely to attend to threatening stimuli, and they’re more likely to interpret ambiguous stimuli as threatening
• bias towards expecting negative outcomes following predictive cues as in those classical conditioning studies

It might be that these biases cause anxiety, but it also might be that the anxiety causes the biased interpretations. It’s kind of a chicken and the egg situation. Either way, if these biases, cause anxiety or if the results of, they still should be a focus of intervention. So, attentional bias modification or ABM is a focus in treatment

Question 22

Theories of Anxiety

Cognitive theories of anxiety

5. Beliefs, meta-beliefs, and the function of worrying

Answer 22

Individuals with God persist chronically with their worrying, even though it causes them a lot of distress - suggests that worrying might serve a particular function for individuals, this function might outweigh the negative effects of worrying.

Some theories emphasise the functional aspects of worrying:

> GAD individuals hold strong beliefs that worrying is a necessary process to avoid future catastrophes
- motivates them to persist with worrying.

> A second view is taken by metacognitive theories
- metacognition is an overarching cognitive process responsible for appraising, monitoring and controlling thinking (thoughts about thoughts) - they have an important influence on what we think about and how long that we persist in thinking about things.
- metacog theorists argue that individuals with GAD, worry in response to negative thoughts
… what if I lose my job? Then they worry about it as a means to try and anticipate problems and avoid them or find a solution. This process drives worrying and fuels distress
- these include obviously negative thoughts about worrying but also positive ones like the worrying will help me, so, the contradiction between these two sets of beliefs causes that distress associated with worrying.
If it was just positive, or just negative they would either persist, and not find it distressing, or they would cease in that behaviour

> Secondly, there is growing evidence that worrying might be reinforced because it distracts the worrier from experiencing other negative emotions – evidenced as worrying produces very little physiological or emotional arousal - might just be that worrying is the lesser of several emotional evils, if you will.

Question 23

Theories of Anxiety

Cognitive theories of anxiety

6. Dispositional characteristics of worriers

Answer 23

Worriers are intolerant of uncertainty, high on perfectionism and have feelings of responsibility for negative outcomes

• these characteristics will drive them to attempt to think about resolving problematic issues. However, they have problem solving confidence, and their worries reflect on personal inadequacies and insecurities
• So, they want to try and fix something and they want to get it right, but they have these feelings of personal responsibility and uncertainty that mean that if they did try, they wouldn’t see themselves as doing a very good job, which, again, is the maintaining factor in their worrying and anxiety

Question 24

Theories of Anxiety

Cognitive theories of anxiety

Becks cognitive theory of anxiety

Answer 24

Beck emphasised the importance of

• core beliefs/ schemas – early experiences and critical incidences activate the schemas
• distortion of information processing and negative automatic thoughts
• maintenance cycles of emotions, thoughts, behaviours

Schemas:
Beliefs – core and unconditional in nature e.g. spiders are dangerous
Assumptions – conditional statements (‘if-then’) that link self-appraisal to events e.g., If I see a spider I will die

In anxiety schemas are characterised by:
> OVERESTIMATION OF DANGER
> UNDERESTIMATION OF ABILITY TO COPE
… so we can see how therapies might help to develop coping strategies and correct these biases

The specific content of schemas differ between the various anxiety disorders

• Panic - emphasis is on the danger of the anxiety symptoms themselves
• GAD - belief about general inability to cope
• Social anxiety - fear of rejection/negative reaction

Unhelpful thought content:

• The thought content is a manifestation of the schema when activated
• Often unreasonable but follows logically from the schematic beliefs
• Can conscious or unconscious
• Can be verbal or take the form of an image