Anxiety Disorders Flashcards
What is Anxiety?
Fear/Panic
Response to threat
Three systems of Anxiety
Physical: Fight/Flight, SNS activation –> mobilising response
Cog
Behavioural
Eliciting conditions for Anxiety
Realistic/objective threat to self
Specific “prepared” stimuli
Novel Stimuli
Threat appraisal –> Expectancy of harm –> Anxiety
Threat appraisal
Generates expectancy of harm (e.g. public transport)
Product of perceived probability and perceived cost
Often based on past experience (cond, rft), obs learning, and instruction
Separation Anxiety
Anxious about being away from primary caregiver
Specific phobias
Excessive and Inappropriate fear about specific targets
Social phobia
Fear of negative social evaluation
General Anxiety Disorder (GAD)
Excessive & Uncontrollable worry about a range of outcomes
Panic disorder
Unexpected/spontaneous panic attacks
Anxiety about having more panic attacks
Agoraphobia (fear of public/open places) - can result from excessive avoidance of places where panic attacks have previously occurred. Complication of Panic Disorder
OCD
Obsession: Intrusive Thoughts/impulses
- Hard to avoid thought
- Belief: Think thought –> bad event will happen
Compulsion: Ritualistic behaviour that relieves anxiety caused by obsession
PTSD
Intrusive thoughts/memories about past traumatic event
Anxiety: Comorbid conditions
Anxieties comorbid with each other, depression & substance abuse
General bio vulnerabilities: Genetics, Neuroticism
General psych vulnerabilities: Trait anxiety, low perceived control
Specific psych vulnerabilities: Focus of threat-related beliefs
Biological treatment for Anxiety Disorders?
Barbituates - quick, common relapse, but addictive & interacts with alcohol
Benzodiazepines - quick, common relapse, interacts with alcohol
SSRIs/antidepressants - slower, common relapse, less side effects
Psychological treatment for Anxiety Disorders/CBT? (Cog + behavioural techniques)
CBT:
Aim: To reduce (biased) threat appraisal by reducing perceived probability and cost of event while increasing (biased) coping appraisal.
Cognitive techniques:
- Thought diaries –> increased awareness of anxious thoughts
- Thought challenging - leading questions –> self-realisation of irrationality of thoughts
Behavioural techniques: EXPOSURE
- Exposure: in vivo or imaginary exposure
- Either flooding (highest fear level) or systematic desensitisation
-
Anxiety Disorders: Changes from DSM-IV to DSM-V
Selective mutism added
PTSD, OCD and Acute Stress Disorder have their own chapters now
DSM-V: Which disorders are in the chapter of Obsessive Compulsive and Related Disorders?
OCD Hoarding Disorder Trichotillomania Excoriation Disorder Body Dysmorphic Disorder
Hoarding Disorder
Excessive hoarding - unwilling to discard items, regardless of value
Trichotillomania
Excessive hair-pulling, to relieve anxiety caused by intrusive thoughts/images
Excoriation Disorder
Excessive skin-picking, to relieve anxiety caused by intrusive thoughts/images
Body Dysmorphic disorder
Preoccupation with perceived defects/flaws in physical appearance. Extreme manifestation of vanity
Panic Attack (mention >4 symptoms)
Influx of fear/discomfort within minutes, reflective of >4 symptoms:
- increased HR/palpitations
- sweating
- Trembling
- Choking sensation
- shortness of breath
- dizziness
- nausea
- Chill/heat sensation
- Fear of losing control
- Fear of dying
Panic Attack: two types of attack
Expected (cued) attack: - Trigger: specific or social phobias - Context: most anxiety disorders Unexpected (uncued) attack: - Unidentifiable trigger - Context: Panic Disorder - >2 unexpected attacks --> Panic Disorder
Panic Disorder
> 2 unexpected attacks
Persistent concern/worry about having another attack
Significant maladaptive change in behaviour related to attacks
Symptoms for >1 mth
Panic Disorder: Other information (e.g. comorbidity, etc.)
One-year incidence: 2-3%
Median age onset: 20-29
Course: Chronic, but waxing/waning
Comorbid: Other anxieties, Depression, alcohol use (10-65%)
Cognitive Theory of Panic (Clark, 1988)
Panic comes from fear of bodily sensations –> misinterpret their consequences (e.g. heart palpitations –> impending heart attack) - positive feedback between increased anxiety and increased symptoms
Misinterpretations are maintained by safety behaviours: protective actions to prevent harmful events
- prevents learning that bodily sensations are safe
Risk factors: neuroticism, anxiety sensitivity
Agoraphobia - DSM edition changes, Symptoms
DSM edition changes:
- DSM-IV: Always accompanied Panic Disorder
- DSM-V: Separate entity, as often occurs without panic
Symptoms:
- Avoidance of public transport, open/enclosed public places, being part of a crowd/line, and being outside alone
- Anxiety that they would not be able to escape when panic-like symptoms will occur
- Not like normal phobias: added fear of embarrassment/incontinence, etc, on top of panic symptoms
Why does Agoraphobia develop?
(Social fears)
- heightened childhood dependence
- lowered perception of self-coping ability
- History of separation anxiety & social phobia
- physical concerns that weakness –> Panic –> embarrassment/incontinence
- has increased social evaluative concerns
Treatment of Panic/Agoraphobia
Biological: Anxiolytics (Barbiturates, Benzos) and Antidepressants
Psych/Cog-behav:
- Cog restructuring
- Exposure to: Interoceptive stim (Panic) or Avoided situations (Agoraphobia)
- decrease safety behaviours
- CBT: Effective in 80-85% of Panic Disorder Patients
GAD Diagnostic criteria
Excessive, uncontrollable worry about a variety of events/outcomes
occurs more days than not, for >6mths
>3-6 somatic symptoms: Restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance - NO SNS AROUSAL
What is normal worry?
Response to perceived threat
Focus: Adults: Social threat, Older adults: Physical threat
Contains verbal thought (vs imagery)
Perceived positive aspects: e.g. motivates actions, etc.
Worry control: Problem solving, distraction, social support
Normal Worry –> problem solving attempts
Pathological worry –> No solution, due to thwarted problem solving - biased threat perception
What are some Problem Solving Theories? Social Problem Solving
- Define problem
- Generate alternative solutions
- Solution evaluation (pos/negative)
- Solution selection
- Pathological worriers: Steps 3-4 do not occur
- Step 3: only generate negative solutions –> don’t want to select a solution –> No chosen solution
What are some Problem Solving Theories? Metacognitive Worry
Type 1 Worry: Perception of threat + Positive beliefs about worry –> Worry to cope with threat
- Possible exit: Problem solving or reassurance
Type 2 Metaworry: Worry + negative beliefs about worrying –> Metaworry –> Ineffective thought-control strategies –> Increased anxiety and worry
- Excessive and uncontrollable worry
What are some Problem Solving Theories? Avoidance Theory
Worry: More verbal thought than imagery, because
- Images of possible negative event are highly aversive, and cause anxiety symptoms (= sympathetic arousal)
- Anxiety symptoms are highly aversive
- Reduced imagery –> Reduced arousal/anxiety
- – GAD associated with tension symptoms
- Worry = cognitive avoidance: Interferes with emotional processing
- Fear structures are maintained –> Keep worrying
What are some Problem Solving Theories? Experiential Avoidance
Worry is associated with: - Fear of anxiety/anxiety sensitivity - Distress intolerance - Experiential avoidance: Worriers avoid internal experiences Difficulties in emotional regulation: Worriers have difficulties with - Clearly identifying emotion - Tolerating emotion - Modulating emotion
What are some Problem Solving Theories? Intolerance of Uncertainty Theory
Uncertainty reflects badly on a person –> frustration and stress, and prevents action
- Worry to reduce uncertainty
- Leads to preoccupation with details
- Interferes with problem solving
- Worries aim to reduce uncertainty to 0 - not possible
Treatment of GAD: 4 approaches
- Biased threat perception: Prob/cost judgements
- Problem solving: Structured problem solving training
- Metacog: Challenge beliefs about worry (pos/neg)
- Avoidance: Exposure to:
- Vivid images of feared event
- Emotional experience/distress
- Uncertainty
Treatment effects have been modest: 50-60% improvement at follow-up (not very good)
PTSD: Diagnostic Criteria
A. Exposure to actual/threatened death, serious injury, or sexual violence in >1 of the following ways
- Direct experience
- Witnessing event as it occurs
- Learning about traumatic event to close family/friend
- Experience repeated/extreme exposure to aversive details of traumatic event
B. Intrusion symptoms (1+: memories, dreams, flashback)
C. Persistent Avoidance of stimuli (1+)
D. Negative changes in cog/mood (2+): Fear, negative beliefs about self, others, world
E. Changes in arousal, reactivity (2+): Anger, recklessness, self-destructive acts, sleep-disturbance
Duration of symptoms >1 month
What normally happens in immediate post-trauma phase?
50-60% of people experience traumatic event
25% develop post-traumatic problems: PTSD, depression, anxiety, substance abuse.
- PTSD prevalence: 5-11% Western countries
Normative response to trauma: Get over it.
- Distress immediately after traumatic event is normal
- Distress drops substantially within 3 months in about 75% of people
Risk factors Pre-trauma:
Childhood trauma, Prior psychiatric history, family instability, substance abuse, social-economic disadvantage (limited resources to deal with trauma)
Risk factors During trauma:
Degree of life threat/loss, Severity of exposure to traumatic elements, Location of trauma (safe place/elsewhere), Individual role in trauma (victim, helper), Meaning
Risk factors post-trauma:
Social support, coping style, ongoing stressors
Treatments For PTSD
Biological: Benzo’s, antidepressants
CBT: Core treatment components include
- Assess suitability for treatment
- Psychoeducation
- Anxiety management techniques (prep for exposure)
- Cog restructuring of biased thoughts
- Prolonged exposure - great detail of reporting of event, being willing to be exposed to associated objects/symbols
CBT more effective than medication or supportive psychotherapy
EMDR (Eye-Movement Desensitisation and Reprocessing)
- Eye movements as critical components of procedure and essential for its effectiveness
- EMDR as exposure technique
- Eye mvt not necessary for effectiveness
