Anxiety Disorders

Question 1

The nature of fear and anxiety disorders

Answer 1

Fear is an immediate alarm reaction triggered by a perceived danger which prepares the body for either fight or flight (or freeze).
A true alarm is when fear is in response to a direct danger.
A false alarm occurs when there is no direct threat.
False alarms are the hallmark of anxiety disorders.
Three seperate but related vulnerabilities have been identified that increase sensitivity of the alarm trigger.

Question 2

Generalised biological vulnerability

Answer 2

Individuals seem to inherit a general predisposition towards anxiety and depressive disorders.

Question 3

Generalised psychological vulnerability

Answer 3

Includes beliefs that the world is generally a dangerous place combined with broad expectations that events are beyond one’s control.

Question 4

Specific psychological vulnerability

Answer 4

Psychological factors that are specific to particular objects or situations and include factors that influence that expectation of a negative outcome when confronted with a specific object or event.
Eg conditioning. Behaviours of escape are negatively reinforced to reduce anxiety.

Question 5

Types of anxiety disorders

Answer 5

DSM-5
Specific phobia
Panic disorder
Agoraphobia 
Social anxiety disorder
Generalised anxiety disorder

Question 6

The diagnosis of specific disorders

Answer 6

Major feature is marked and consistent fear when a specific object or situation is encountered.
Fear is out of proportion to the danger posed by the object or situation.
Fear causes emotional, social, and/or occupational disruption.

Question 7

Epidemiology of specific phobias

Answer 7

Prevalence is greater among children than adults, suggesting that phobias tend to remit without treatment.
Typical age of onset varies depending on different phobias. Eg claustrophia develops after adolescence, animal phobias develop about age 7.
Lifetime prevalence is 7-9%
Female to male ratio is 2:1
Less than 1% of individuals with a phobia seek treatment (more reported by females)

Question 8

The four subtypes of phobias - DSM-5

Answer 8

Animal (dog, spider)
Natural environment (heights, water)
Blood, injection, and injury
Situational (airplanes, enclosed spaces)

Question 9

Aetiology of specific phobias

Answer 9

Evidence phobias have a heritable component.
Phobias may be acquired through classical conditioning - but some people have same experience eg dog biting them, and don’t develop phobia.
So phobias probably develop through learning against a backdrop of biological vulnerability in the form of a genetic diathesis.

Question 10

Treatment of specific phobias: behavioural

Answer 10

Exposure therapy: in real life (in vivo exposure), imagining (imaginal exposure).
Flooding: not usually very useful, better to expose hierarchically
Extinction
Habituation
Inhibitory learning (new learning is that a conditioned stimulus no longer predicts an unconditioned stimulus).

Question 11

Treatment of specific phobias: cognitive

Answer 11

Challenging expectations that danger will occur when confronted with the phobic stimulus increases self-efficacy (level of confidence that the individual can cope in the phobic situation). Increasing perceptions of control over the phobic stimulus and the anxiety.

Question 12

Diagnosis of panic disorder: DSM-5 criteria

Answer 12

Recurring uncontrolled panic attacks as well as persistent worry about having additional attacks and their consequences (Worried about it happening again).
Presence of significant changes in behaviour related to panic, eg. avoiding exercise because it may increase heart rate.

Question 13

Diagnosis of agoraphobia: DSM-5 criteria

Answer 13

Marked fear or anxiety about being in places from which escape is difficult eg. public transport, enclosed spaces
Feared situations are actively avoided or endured with intense fear.

Question 14

Prevalence of panic disorder

Answer 14

Lifetime prevalence is 3.5%
Panic disorder is somewhat more common among females
Median age of onset is 30 years

Question 15

Prevalence of agoraphobia

Answer 15

Lifetime prevalence is 2.3%
The proportion of females to males increases as the severity of agoraphobia increases
Median age of onset is 22 years
Only 10% of cases remit on their own

Question 16

Aetiology of panic disorder

Answer 16

Triple vulnerability model: generalised biological vulnerability (eg neuroticism), generalised psychological vulnerability (eg anxiety sensitivity - belief that bodily symptoms of anxiety are harmful), specific psychological vulnerability (misinterpreting panic as indication of danger which increases arousal).
Worries about future panic attacks which increases anxiety/panic, resulting in frequent panic attacks).

Question 17

Aetiology of agoraphobia

Answer 17

Can develop as a complication of panic disorder.

Many people who have agoraphobia previously had panic disorder.

Question 18

Treatment of panic disorder and agoraphobia: pharmacological

Answer 18

Tricyclic antidepressants (TCAs)
SSRI
Benzodiazepines (slow down activity of CNS eg heart - slows down anxiety)
All have side effects and various disadvantages.

Question 19

Treatment of panic disorder and agoraphobia: CBT

Answer 19

Address phobic avoidances, external or internal.
External phobic avoidances are treated with graded in vivo experience.
Internal treated with introspective exposure, cognitive restructuring (challenge false beliefs), psychoeducation.

Question 20

Introspective exposure

Answer 20

Behavioural technique for treating panic disorder.
Entails exposing the individual to the physical sensations of a panic attack (eg hyperventilate) and showing them it’s very unlikely to result in panic or death

Question 21

Diagnosis of social anxiety disorder

Answer 21

Marked fear or anxiety in social situations.
Fear of negative evaluation by others.
The anxiety interferes with the individual’s functioning.
Fear of doing something embarrassing in front of others and receiving judgement.

Question 22

Epidemiology of social anxiety disorder

Answer 22

One of the most common and earliest in onset of the anxiety disorders.
Half of all suffers report onset prior to 12 years of age.
Lifetime prevalence is 8%.
More common in females than males.

Question 23

Aetiology of social anxiety disorder

Answer 23

Twin studies support a genetic vulnerability.
Excessive parental criticism may undermine self-confidence.
Cognitive dysfunctions may distort the way in which people perceive how others evaluate them.

Question 24

Treatment of social anxiety disorder

Answer 24

CBT, either individually or in groups.
Psychoeducation about the disorder.
Challenging negative cognitions.
Exposure to feared social situations.

Question 25

Generalised anxiety disorder diagnosis

Answer 25

Excessive anxiety and worry about a number of events such as work, relationships, health etc.
Worry or anxiety must have been present on most days for at least 6 months.
Worry is difficult to control and is associated with symptoms such as sleep problems and agitation.

Question 26

Epidemiology of GAD

Answer 26

Lifetime prevalence is 6.1%.
More common in women.
Early age of onset.
Chronic course that is unlikely to improve without treatment.

Question 27

Aetiology of GAD: information processing model

Answer 27

People with GAD are vigilant for potential threats.
Overestimate the probability of negative events and their consequences.
Also underestimate their own abilities to cope with negative events.

Question 28

Aetiology of GAD: meta-cognitive model

Answer 28

Worrying about worry.
People with GAD hold both positive (worrying about others means I care) and negative beliefs (I’ll go crazy with worry) about worry.

Question 29

Aetiology of GAD: the avoidance theory of worry

Answer 29

People with GAD use worry as a strategy to avoid fears or concerns.

Question 30

Aetiology of GAD: Intolerance of uncertainty model

Answer 30

Situations and events that involve uncertain outcomes trigger negative emotional, cognitive, and behavioural responses in people with GAD.
People with GAD have a need to control.

Question 31

Treatment of GAD: pharmacological

Answer 31

Benzodiazepines 
Azapirones
Tricyclic antidepressants 
SSRI
Medications only used when necessary, and with psychological interventions.

Question 32

Treatment of GAD: psychological

Answer 32

CBT: psychoeducation about worry and teach realistic thinking skills to help clients reappraise negative predictions about threat, beliefs about worry and negative self-beliefs.
Cognitive restructuring: identify worry-related beliefs and evaluate their accuracy.
Challenge beliefs of helpfulness and accuracy of worry-related beliefs.
Relaxation techniques.
Graded exposure.
Interpersonal psychotherapy (address interpersonal problems to improve psychological symptoms)

Question 33

Diagnosis of obsessive compulsive disorder

Answer 33

Presence of obsessions (recurrent and persistent thoughts, impulses or images that are experienced as intrusive and inappropriate or distressing).
Presence of compulsions (repetitive behaviours the person feels compelled to perform).
Disorder must cause marked distress, is time/consuming or significantly interferes with a person’s functioning.

Question 34

The presentation of OCD

Answer 34

Varies considerably from case to case.
Common obsessions include: fear of contamination/germs, fire, robbery, rape or assault, becoming insane, insulting others, engaging in paedophillic act etc.
Almost any behaviour can become a compulsion: checking power points, blinking eyes, counting objects, saying a mantra, tapping a surface, hopping, arranging objects on a desk etc.
Common compulsions include excessive washing/cleaning and checking.

Question 35

Epidemiology of OCD

Answer 35

Relatively common disorder.
Prevalence rate of about 2-3%.
Can be associated with a lifetime of impairment.
Average age of onset is 10.3 years.

Question 36

Aetiology of OCD: neuropsychological model

Answer 36

OCD results from a failure of inhibitory pathways in the basal ganglia to stop ‘behavioural macros’ being triggered in response to internal or external stimuli.
Behavioural macros: complex sets of behaviours eg checking.

Question 37

Aetiology of OCD: cognitive model

Answer 37

OCD results from the misinterpretation or intrusive thoughts.
OCD suffers give intrusive thoughts significance, rather than simply ignoring them as do the rest of the general population.
Interpret an intrusive thought to indicate that danger may occur to themselves and others, and that they could be personally responsible for bringing about it preventing this danger.

Question 38

Treatment of OCD

Answer 38

CBT is the treatment of choice
Exposure and response prevention (exposed to feared stimuli and prevented from utilising response).
Cognitive restructuring.
Behavioural experiment: participated in a planned activity to test accuracy of beliefs eg I will lash out if bumped in a crowd.
Medication: only 40-60% of suffers benefit from medication.

Question 39

Hoarding disorder

Answer 39

Persistent difficulty in discarding possessions, with a high level of distress associated with removing the items.
Prevalence is about 2-6%
Risks to health and safety eg death from house fires stemming from hoarded newspapers.

Question 40

Body dysmorphic disorder

Answer 40

Obsessive concern regarding a part of the body the individual believes is defective.
Can display compulsive mirror checking, excessive grooming, or reassurance seeking.
Prevalence is 2.5%, with similar numbers of males and females.
Believe cosmetic surgery will fix, but often makes it worse.

Question 41

Trichotillomania (hair pulling)

Answer 41

Recurrent pulling out of one’s own hair, resulting in hair loss.
Urge to remove hair is often associated with anxiety or worry.
12 month prevalence is 1-2%
Estimated female to male ratio is 10:1.

Question 42

Excoriation (skin picking)

Answer 42

Often comorbid with OCD or trichotillmania.
Recurrent skin picking resulting in lesions (often on face, hands or arms).
Lifetime prevalence is approx 1.5%.
Up to 75% of suffers are female.
Scan surface of skin for imperfections, bumps or unevenness and target with picking.

Question 43

Treatment of OCD related disorders

Answer 43

CBT procedures are central to managing these disorders: exposure and response prevention, cognitive restructuring (target unhelpful thoughts, beliefs and attitudes.
Medications that increase availability of serotonin are also widely used.