Anxiety Disorders Flashcards
Anxiety disorders are…
- Extremes of normal anxiety
- Evidence of autonomic nervous system dysregulation - excessive, inappropriate or deficient
- Common - Lifetime prevalence 15 -20%
Types of anxiety disorder
- 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
What is the DSM-5 criteria for anxiety disorder
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.
What are the shared features of anxiety disorders?
- Primarily stress linked
- Reality testing remains intact
- Symptoms are experienced as distressing
- Disorders tend to be enduring or recurrent
What is aetiology of anxiety disorders
• 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
Parasympathetic Nervous System
Feed and Breed
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
Sympathetic Nervous System
Fight or Flight
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
“Fight or Flight”
• 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
Amygdala and Neurotransmitters
- 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
Post traumatic stress disorder (PTSD)
• 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
Symptoms of PTSD
- Increased autonomic arousal (including exaggerated startle response, hypervigilance and sleep disturbance)
- Avoidance & emotional numbing
- Re-experiencing (flashbacks & nightmares)
- Lifetime prevalence of 3-8%
DSM-IV-TR Diagnostic Criteria for PTSD
- 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
Traumatic events that may precipitate PTSD
• Rape (90% develop PTSD symptoms)
• Torture (70-90%)
• Prisoners of war (>50%)
• Earthquake & flood (20-25%)
• Road traffic accidents (15%)
(Davey, 2014)It’s not all bad news though…
• > 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 )
The aetiology of PTSD
- Vulnerability factors
- Theory of shattered assumptions
- Conditioning theory
- Emotional processing theory
- Mental defeat
- Dual representation theory
Vulnerability factors
• 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
Theory of shattered assumptions
- 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)
Conditioning theory
- 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
Emotional processing theory
- 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
Dual representation theory
- 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
Mental defeat
• 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
PTSD management includes
• 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
Trauma focused CBT
• 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
EMDR
- 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
Debriefing
- 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)
Narrative Exposure Therapy
- 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)
Anxiety Disorders in Children are…
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
The Features & Characteristics of Childhood Anxiety Problems
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)
The Aetiology of Childhood Anxiety Problems
Genetic Factors
Trauma & Stress Experiences
Modelling & Exposure to Information
Parenting Style & Parent-Child Interaction
Genetic Factors of anxiety problems in children
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)
Trauma & Stress Experiences
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
Modelling & Exposure to Information
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)
Parenting Style and childhood anxiety
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)
Childhood Anxiety Disorders
Generalized Anxiety Disorder (GAD)
Obsessive-Compulsive Disorder (OCD)
Specific Phobias (e.g., School Phobia)
Separation Anxiety Disorder (SAD) Selective Mutism (SM)
Separation Anxiety
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
Changes in the DSM 5 for childhood anxiety
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’
SAD and Parenting Style
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
Selective Mutism
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
Diagnostic Criteria
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
Key Issues
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
General Treatment Issues
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)
Childhood CBT: Key features
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)
Parental Involvement
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).
Treatment of Selective Mutism
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
Alternative Methods: Computerised CBT (See Kendall et al., 2011)
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
