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Anxiety Disorders Flashcards

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1
Q

Anxiety disorders are…

A
  • Extremes of normal anxiety
  • Evidence of autonomic nervous system dysregulation - excessive, inappropriate or deficient
  • Common - Lifetime prevalence 15 -20%
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2
Q

Types of anxiety disorder

A
  • Generalized Anxiety Disorder (GAD)
  • Panic Disorder
  • Agoraphobia
  • Social Anxiety Disorder (previously social phobia)
  • Specific Phobias
  • Obsessive Compulsive Disorder (OCD)
  • Body Dysmorphic Disorder (BDD)
  • Post Traumatic Stress Disorder (PTSD)
  • Selective Mutism
  • Separation Anxiety Disorder
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3
Q

What is the DSM-5 criteria for anxiety disorder

A

The DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder (which is included with the obsessive-compulsive and related disorders) or posttraumatic stress disorder and acute stress disorder (which is included with the trauma- and stressor-related disorders). However, the sequential order of these chapters in DSM-5 reflects the close relationships among them.

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4
Q

What are the shared features of anxiety disorders?

A
  • Primarily stress linked
  • Reality testing remains intact
  • Symptoms are experienced as distressing
  • Disorders tend to be enduring or recurrent
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5
Q

What is aetiology of anxiety disorders

A

• Genetic
– SLC6A4; short version transports serotonin less effectively (see Smoller et al., 2009)
• Lowered neurotransmitter levels
– 5HT, NA, GABA
• Hypothalamic pituitary adrenal (HPA) axis dysregulation

• Social factors
– Early life adversity
– Stressful events especially those involving threat
– Lack of support network

• Personality factors
– Some personality traits predispose to certain anxiety disorders e.g. avoidant & perfectionistic

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6
Q

Parasympathetic Nervous System

Feed and Breed

A

ANABOLIC PROCESS

Decreased: cardiac rate and output, BP,
respiration rate, glycogenolysis,
peripheral diversion of blood,
catecholamines and cortisol.

Increased: gut function, kidney function,
immune surveillance, fat stores,
sex steroids

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7
Q

Sympathetic Nervous System

Fight or Flight

A

CATABOLIC PROCESS

Increased: cardiac rate and output, BP,
respiration rate, glycogenolysis,
peripheral diversion of blood,
catecholamines and cortisol.

Decreased: gut function, kidney function,
immune surveillance, fat stores,
sex steroids

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8
Q

“Fight or Flight”

A

• Physiological response to a stressor is mediated through the hypothalamus
• Initial activation of the sympathetic nervous system
• Subsequent activation of the pituitary adrenal axis
• Terminated by negative feedback and the parasympathetic system
NB ACTH is adrenocorticotropic hormone

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9
Q

Amygdala and Neurotransmitters

A
  • Amygdala responds to emotional stimuli
  • Produce changes in the HPA axis and sympathetic ns.
  • GABA inhibits anxiety by modulating the amygdala and hypothalamus synapses e.g. benzodiazepines and alcohol act on same receptors.
  • Serotonin and beta-blockers also have an effect on anxiety
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10
Q

Post traumatic stress disorder (PTSD)

A

• Delayed or protracted response to trauma (often involving threat to life)
• Onset usually within 6 months of event
• Core symptom is “reliving the event”
– Flashbacks, nightmares, waking dreams
• Emotional numbness and detachment
• Avoidance of activities, situations that remind person of trauma

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11
Q

Symptoms of PTSD

A
  • Increased autonomic arousal (including exaggerated startle response, hypervigilance and sleep disturbance)
  • Avoidance & emotional numbing
  • Re-experiencing (flashbacks & nightmares)
  • Lifetime prevalence of 3-8%
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12
Q

DSM-IV-TR Diagnostic Criteria for PTSD

A
  • The person has been exposed to a traumatic event
  • The traumatic event is persistently re-experienced
  • Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness
  • Persistent symptoms of increased arousal
  • Duration of the disturbance is more than 1 month
  • The disturbance causes clinically significant distress or impairment
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13
Q

Traumatic events that may precipitate PTSD

A 
•	Rape (90% develop PTSD symptoms)
•	Torture (70-90%)
•	Prisoners of war (>50%)
•	Earthquake & flood (20-25%)
•	Road traffic accidents (15%)
              (Davey, 2014)
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14
Q

It’s not all bad news though…

A

• > 50% of people will
experience at least one trauma in
their lifetime – not all will develop
PTSD

• Following trauma, women are
more likely to develop PTSD
than men (ratio of 2.4:1)

•	Some will experience post-
     traumatic growth (Joseph, 2012 )
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15
Q

The aetiology of PTSD

A
  • Vulnerability factors
  • Theory of shattered assumptions
  • Conditioning theory
  • Emotional processing theory
  • Mental defeat
  • Dual representation theory
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16
Q

Vulnerability factors

A

• What makes people vulnerable to developing PTSD?
– Tendency to take personal responsibility for the trauma
– Environmental factors such as unstable family life
– A family history of PTSD
– Existing high levels of anxiety or a pre-existing psychopathology

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17
Q

Theory of shattered assumptions

A
  • Argues that trauma will shatter a person’s belief in the world as a safe place
  • Individual is left in a state of shock and conflict
  • However, paradoxically it is those who already view the world as an unsafe place that are most likely to develop PTSD (Resick, 2001)
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18
Q

Conditioning theory

A
  • Trauma (UCS) becomes associated with situational cues associated with the place and time of the trauma (CS) (Keane et al., 1985)
  • PTSD is therefore a conditioned fear reaction to cues associated with the trauma
  • However, does not explain why some people who experience trauma do not develop PTSD
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19
Q

Emotional processing theory

A
  • Trauma creates a representation of the trauma in memory that is associated with situational cues (Foa et al., 1989)
  • Explains how fear memories are laid down and activated in fear networks in the brain
  • Has given rise to influential exposure treatments for PTSD
20
Q

Dual representation theory

A
  • Views PTSD as a hybrid disorder involving two separate memory systems (Brewin, 2001; Dalgleish, 2004)
  • The verbally accessible memory (VAM) system consciously processes memories of the event
  • The situationally accessible memory (SAM) system records information that is too brief to take in consciously
  • The SAM system is responsible for the vivid uncontrollable flashbacks experienced in PTSD
21
Q

Mental defeat

A

• A frame of mind that makes individuals vulnerable to PTSD (Ehlers & Clark, 2000)
• Individuals who develop PTSD tend to:
– See themselves as a victim
– Process information about the trauma negatively
– View themselves as unable to act effectively
– Do not believe they have the coping skills to overcome the traumatic experience
– Believe the trauma has permanently changed their life

22
Q

PTSD management includes

A 
•	SSRIs
•	Behavioural therapy
•	Stress innoculation training
•	Trauma focused CBT *
•	Eye movement desensitisation and reprocessing (EMDR) *
•	Debriefing after traumatic event *
–	no clear evidence base for this
Narrative exposure therapy
23
Q

Trauma focused CBT

A 
•	See Ehlers & Clark (2000)
•	Psycho-education
•	Exposure; imaginal and/or In vivo
•	Reliving with cognitive restructuring
•	Behavioural experiments
–	Drop safety behaviours
–	Stimulus discrimination
–	Experience emotions
•	Imagery work
24
Q

EMDR

A
  • Developed by Francine Shapiro in the 1980s
  • Involves bilateral stimulation of the brain whilst recalling the traumatic event (dual attention)
  • Aims to desensitise the client to distress and reprocess ‘frozen’ traumatic memories so that the associated cognitions can become more adaptive - adaptive information processing Shapiro, 2007)
  • Works towards the installation of a positive cognition
25
Q

Debriefing

A
  • A structured way of trying to intervene immediately after trauma to prevent the development of PTSD
  • Also called Critical Incident Stress management (CISM) (Everly et al., 2000)
  • A form of post-event counselling for victims
  • Limited evidence that it is effective in preventing PTSD (McNally et al., 2003)
26
Q

Narrative Exposure Therapy

A
  • Development of testimony therapy (Cienfuegos & Monelli, 1983)
  • A short term approach
  • Developed for use with people who have experienced a series of traumatic events, resulting in PTSD (Schauer et al., 2005)
  • Aims to enable a coherent and meaningful narrative of events to be developed, influencing fear networks
  • Has been adapted for use with children – KIDNET (Onyut et al., 2005)
27
Q

Anxiety Disorders in Children are…

A

 Anxiety disorders are one of the most prevalent emotional problems of childhood (e.g., Barrios & Hartmann, 1997)

 However, specific fears and anxieties are also one of the normal developmental challenges that face maturing individuals

28
Q

The Features & Characteristics of Childhood Anxiety Problems

A

 Behavioural, cognitive and emotional aspects

 Primarily manifested as withdrawn behaviour (internalizing)

 Children avoid activities and are clinging and demanding of parents and carers

 Anxious children report significantly more somatic complaints (Hofflich et al., 2006)

29
Q

The Aetiology of Childhood Anxiety Problems

A

 Genetic Factors

 Trauma & Stress Experiences

 Modelling & Exposure to Information

 Parenting Style & Parent-Child Interaction

30
Q

Genetic Factors of anxiety problems in children

A

 Twin studies suggest a significant but modest inherited component

 Both heritable and environmental factors appear to be important (Lichtenstein & Annas, 2000)

 May be different for specific anxiety disorders

 State vs. trait anxiety (Lau et al., 2006)

31
Q

Trauma & Stress Experiences

A

 There are clear links between extreme stressful experiences (e.g. childhood physical and sexual abuse) and childhood anxiety (Feerick & Snow, 2005)

 Events such as living with illness, the death of a pet, and minor road accidents can cause significant childhood anxiety

32
Q

Modelling & Exposure to Information

A

 Exposure to information about threats can cause children to develop fears and phobias without direct experience (Field, 2006)

 For e.g., observation of parents reactions and behaviour patterns, or listening to parents explanations (Barrett et al., 1996)

33
Q

Parenting Style and childhood anxiety

A

 Overprotective and overanxious parents may invoke anxiety in the child (Rapee, 1997)

 Overprotective parenting may increase the child’s perception of threat and reduce their sense of control (Van der Bruggen et al., 2008)

 Children who experience rejecting or detached parents also show increased levels of anxiety (Chartier, Walker & Stein, 2001)

34
Q

Childhood Anxiety Disorders

A

 Generalized Anxiety Disorder (GAD)

 Obsessive-Compulsive Disorder (OCD)

 Specific Phobias (e.g., School Phobia)

	Separation Anxiety Disorder (SAD)
Selective Mutism (SM)
35
Q

Separation Anxiety

A

 An intense and developmentally inappropriate fear of being separated from parents or carers

 May develop exaggerated fears that parents may become ill, die or be unable to look after them

 Consequences include reluctance to attend school or to require parents to stay with them until they fall sleep

36
Q

Changes in the DSM 5 for childhood anxiety

A

 Acceptance of SAD in adulthood:

  • Age of onset after 18 years
  • Modification of criteria wording (e.g., attachment figures, workplace)
  • Duration criteria: ‘typically lasting 6 months or more’
37
Q

SAD and Parenting Style

A

Parental intrusiveness is linked to SAD in children predisposed to or currently experiencing anxiety (Wood, 2006)
Intrusiveness involves:

 Unnecessary assistance with daily self-help tasks

 Infantilising behaviour (e.g., excessive affection)

 Invasions of privacy
Developmentally inappropriate for the child’s age

38
Q

Selective Mutism

A

A persistent failure to speak in certain social situations

  • Excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism
  • May involve temper tantrums or oppositional behaviour, particularly at home
39
Q

Diagnostic Criteria

A

 Lasts at least a month (but not the first month of school)

 Cannot be better accounted for by a communication disorder

 Interferes with educational or occupational achievement, or with social communication

 Does not occur exclusively within the course of a pervasive developmental or psychotic disorder

40
Q

Key Issues

A

 A relatively rare and under-researched disorder

 Complicated co-morbidity issues

 Rather than an oppositional disorder, SM is increasingly considered as an anxiety disorder (a specific childhood manifestation of social phobia; Anstendig, 1999; Kristensen, 2000).

 Aphasia voluntaria > elective mutism (ICD-10) > selective mutism (DSM-IV-TR)> DSM 5 now classified as an anxiety disorder

41
Q

General Treatment Issues

A

 Pharmacological: use of antidepressant or anti-anxiety medications? (e.g., Sertraline)

 Psychotherapeutic: wide use of and support for CBT (Hirshfeld et al., 2010)

 Combined approach? (See Ginsburg et al., 2011 CAMS study)

42
Q

Childhood CBT: Key features

A

 Involves use of Psychoeducation

 Developmentally appropriate tools and materials

 Focus upon identification of symptoms

 Imaginal exercises and relaxation techniques

 Exposure is crucial (Barlow, 1988; Blagg & Yule, 1984)

43
Q

Parental Involvement

A

 Parent as ‘coach’ who is directly involved with behavioural management.

 Identify problem, break it down, try a strategy, then evaluate strategy

 Parental involvement differs between programs,. Can be associated with improved outcomes (e.g., Barrett, Dadds, & Rapee, 1996; Mendelowitz et al., 2002) but results are not consistent (e.g., Nauta et al., 2001; 2003).

44
Q

Treatment of Selective Mutism

A

 Traditionally considered to be difficult to treat (e.g., Kolvin & Fundudis, 1981)

 Treatment reconsidered in light of reappraisal as an anxiety disorder

 Successful use of behavioural approaches(e.g., contingency management, stimulus fading, systematic desensitisation and self modelling)

 Promising use of CBT approaches (Fung et al., 2002)

 Limited and methodologically weak research in this area

 Multi-modal, multi-agency approach seems most appropriate (Standart & Le Couteur, 2003)

 Treatment should continue after the achievement of speech

45
Q

Alternative Methods: Computerised CBT (See Kendall et al., 2011)

A

 Computer-assisted or computer based

 Preliminary research to support use in the treatment of adult anxiety disorders (e.g., Anderson, Jacobs & Rothbaum, 2004)

 Camp-Cope-A-Lot (CCAL) for 7-12 year olds

psychology (28 decks)

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