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