Anxiety Disorders Flashcards
Anxiety
Apprehension over an anticipated problem, moderate arousal (restless energy)
Fear
A reaction to immediate danger, higher arousal (overpowering urge to run)
… seems to misfire in some anxiety disorders
Fear
describe the the “U-Shaped” Curve that shows how anxiety increases preparedness
Absence of anxiety interferes with performance
Moderate levels of anxiety improve performance
High levels of anxiety are detrimental to performance
Name all 5 DSM-5 Anxiety Disorders
Specific phobias
Social anxiety disorder Panic disorder
Agoraphobia
Generalized anxiety disorder
Define: 1) Specific phobia 2 )Social anxiety disorder 3) Panic disorder 4) Agoraphobia 5) Generalized anxiety disorder
1) Fear of objects or situations that is out of proportion to any real danger
2) Fear of unfamiliar people or social scrutiny
3) Anxiety about recurrent panic attacks
4) Anxiety about being in places where escaping or getting help would be difficult if anxiety symptoms occurred
5) Uncontrollable worry
4 DSM-5 Criteria for Anxiety Disorders
-Symptoms interfere with important areas of functioning or
cause marked distress
- Symptoms are not caused by a drug or a medical condition
- Symptoms persist for at least 6 months or at least 1 month for panic disorder
- The fears and anxieties are distinct from the symptoms of another anxiety disorder
DSM-5 Criteria for specific Phobias
- Disproportionate fear caused by a specific object or situation
\+Awareness that fear
is excessive
\+Great lengths taken
to avoid feared
object or situation
- Most specific phobias cluster around a few feared objects and situations
-High comorbidity among specific phobiasWhich is the specific phobia and when does it start
1) Snakes, insects
2) Storms, heights, weather
3) Blood, injection, injury
4) Public transportation, tunnels, bridges, elevators, flying, driving, closed spaces
1) Animal
Generally begins during childhood
2) Natural Environment
Generally begins during childhood
3)Blood, injury, injections, or other invasive medical procedures
Runs in families; profile of heart rate slowing and possible fainting when facing feared stimulus
4) Situational
Tends to begin in either childhood or in mid-20s
5) Other
Choking, contracting an illness, etc. Children’s fears of loud sounds, clowns, etc.
DSM-5 Criteria for Social Anxiety
- Persistent, unrealistically intense fear of social situations that might involve being scrutinized by or exposed to unfamiliar people
+ Fear of negative
evaluation or scrutiny
leads to avoidance of
social situations - Common fears include: public speaking, meeting new people, talking to people in authority
- 33% also diagnosed with Avoidant Personality Disorder
+ Overlap in genetic
vulnerability for both
disorders - Marked and disproportionate fear consistently triggered by exposure to potential social scrutiny
- Exposure to the trigger leads to intense anxiety about being evaluated negatively
- Trigger situations are avoided or else endured with intense anxiety
DSM-5 Criteria for Panic Attacks
What are Physical Symptoms
- Sudden attack of intense apprehension, terror, and feelings of impending doom
- Accompanied by at least four other symptoms:
+Physical symptoms can include:
Shortness of breath, heart palpitations, nausea, upset, stomach, chest pain, feelings of choking and smothering,dizziness, lightheadedness, faintness, sweating, chills, heat sensations, numbness or tingling sensations, and trembling
- Depersonalization - (feeling of being outside one’s body)
- Derealization (feeling of the world not being real)
- Fears of going crazy, losing control, or dying
- Symptoms come on rapidly and peak in intensity within 10 minutes
-Many people interpret symptoms as having a heart attack
- Misfiring of the fear system
+Physiological
response similar to what
most experience when
faced with immediate
threat
- Depersonalization
feeling of being outside one’s body
- Derealization
feeling of the world not being real
DSM-5 Criteria for Panic Disorder
- Recurrent panic attacks unrelated to specific situations
- Worry about having more panic attacks
- Panic attacks triggered by specific situations (e.g., phobia) should not be considered in diagnosing panic disorder
- 25% of people will experience a single panic attack !
+ Not the same as
panic disorder - Recurrent unexpected panic attacks
- At least 1 month of concern about the possibility of more attacks occurring or the consequences of an attack, or maladaptive behavioral changes because of the attacks
DSM-5 Criteria for Agrophobia
- Anxiety about situations in which it would be embarrassing or difficult to escape if anxiety symptoms occurred
\+E.g., crowds, stores,
malls, churches,
trains, bridges,
tunnels, etc.
- Causes significant impairment
\+Unable to leave
house or leaves house
with great distress
- About half of people with agoraphobia experience panic attacks
- Disproportionate and marked fear or anxiety about at least 2 situations where it would be difficult to escape or receive help in the event of incapacitation, embarrassing symptoms, or panic- like symptoms
- These situations consistently provoke fear or anxiety
- These situations are avoided, require the presence of a
companion, or are endured with intense fear or anxiety
DSM-5 Criteria for Generalized Anxiety Disorder (GAD)
- Excessive, uncontrollable, and long-lasting worry about minor thingsWorry
Cognitive tendency to chew on a problem and to be unable to let go of itCommon worries: - Relationships, health, finances, daily hassles
- Also includes: difficulty concentrating, tiring easily, restlessness,
irritability, and muscle tension - Typically begins in adolescence
- Excessive anxiety and worry at least 50% of days about a number of events or activities (e.g., family, health, finances, work, and school)
- The person finds it hard to control the worry
- The anxiety and worry are associated with at least three (or
one in children) of the following:
+Restlessness or feeling keyed up or on edge
+ Easily fatigued.
+ Difficulty concentrating or mind going blank
+ Irritability.
+ Muscle tension
+Sleep disturbance
Worry
Cognitive tendency to chew on a problem and to be unable
to let go of it
Name Factors that Increase General Risk for Anxiety Disorder
- Behavioral conditioning
- Genetic vulnerability
- Disturbances in the activity in the fear circuit of the brain
- Decreased functioning of gamma-aminobutyric acid (GABA) and serotonin; increased
norepinephrine activity - Increased cortisol awakening response -
- (CAR) Behavioral inhibition
- Neuroticism
- Cognitive factors, including sustained negative beliefs, perceived lack of control, over-attention to cues of threat, and intolerance of uncertainty
Describe disturbances in activity in the brain for people at risk of an anxiety disorder, What happens with GABA, Serotonin, Norepinephrin, Cortisol
- Disturbances in the activity in the fear circuit of the brain
- Decreased functioning of gamma-aminobutyric acid (GABA) and serotonin; increased
norepinephrine activity - Increased cortisol awakening response -
- (CAR) Behavioral inhibition
Fear Conditioning: Describe Mowrer’s Two-Factor Model
Classical Conditioning
-A person learns to fear a neutral stimulus (CS) that is paired with an intrinsically aversive stimulus (UCS)
Operant Conditioning
-A person gains relief by avoiding the CS
- Avoidance maintained though negative reinforcement
Classical conditioning can occur in different ways:
- Direct experience
- Modeling
+Seeing someone else experience feared situation - Verbal instruction
E.G., hearing a parent say dogs are dangerous
According to Mowrer’s Model
People with anxiety disorders…
- Acquire fears more readily through classical conditioning
- Experience more persistent fears once conditioned
- Are sensitive to unpredictable treats
- Neutral predictable unpredictable (NPU) threat task
+People with anxiety disorders show high physiological arousal to unpredictable threat conditions compared to health controls
What do twin Studies suggest about anxiety disorder?
heritability of about 50 to 60%
describe neurobiological factors in the Fear Circuit:
1) Amygdula:
2) Medial prefrontal cortex
3) Neurotransmitters:
1)Amygdula: Assigns emotional significance, Involved in the conditioning of fear
2)Medial prefrontal cortex Regulates amygdala activity
Involved in extinguishing fears Processes anxiety and fear
3) Disruptions in serotonin and GABA Norepinephrine
Increased levels and changes in sensitivity of receptors
Behavioral inhibition
- Tendency to become agitated, distressed, and cry in
unfamiliar or novel settings - Observed in infants as young as 4 months ! May be inherited
- Predicts social anxiety in adolescence
Neuroticism
- Tendency to experience frequent or intense negative affect
- Predicts onset of anxiety disorder and depression
- People with high levels are twice as likely to develop anxiety disorders than those with low levels
what are to personality factors related to anxiety
Neuroticism and Behavioral Inhibition
What are Cognitive Factors related to Anxiety Disorders
- Sustained negative beliefs about future
\+ Bad things are likely
to happen
\+ Engage in safety
behaviors, which
maintain negative
cognitions
- Belief that one lacks control over environment \+ Negative childhood experiences (e.g., abuse) and severe life events may foster the belief that life is uncontrollable
- Attention to threat
+ Tendency to notice negative environmental cues
+Selective attention to signs of threat
+ Attention training interventions show promise for reducing
In which Anxiety Disorder does the Locus Coeruleus play a role and which ?
- Major source of
norepinephrine - People with panic disorder are more sensitive to drugs that trigger the release of norepinephrine
What is Interoceptive conditioning and where does it play a role?
- Classical conditioning of panic in response to internal bodily sensations
+ A person experiences somatic signs of anxiety
+ Followed by a panic attack
+Panic attacks become a conditioned response to somatic changes
Describe the vicious circle in Panic disorder
- Catastrophic misinterpretations of somatic changes
- Interpreted as impending doom
- I must be having a heart attack!
- Beliefs increase anxiety and arousal -> Creates vicious cycle
Describe Anxiety Sensitivity Index
- Measures intensity of fear in response to bodily sensations
- High scores predict onset of panic attacks and anxiety disorders
“Unusual body sensations scare me.”
describe Fear-of-fear hypothesis and for which anxiety disorder is it relevant?
Agoraphobia
- Negative thoughts about the consequences of
experiencing anxiety in public
- Catastrophic beliefs that anxiety will lead to socially unacceptable consequences
Describe
Contrast Avoidance Model and for which Anxiety disorder is it relevant
- People with GAD find it highly aversive to
experience shifts in emotions - To avoid shifts, they prefer a constant state of worry
- Helps them feel as if they are preparing for the worst
- Worry can help a person keep a more stable
emotional, albeit uncomfortable, state
Explain the two factor model of behavioural conditioning for specific phobias, (similar for social anxiety disorder)
Classical conditioning
-Phobias are a conditioned response to threat
Operant conditioning
-Sustained by avoidant behaviors
Exposure
What is it, how effective?
!
Face the situation or object that triggers anxiety
! E.g., exposure hierarchy: graded exposure to a list of triggers
! Effective for 70-90% of clients
Exposure:
1) Behavioral view:
2) Cognitive view:
Behavioral view: Newly learned associations inhibit fear
Cognitive view: Corrects mistaken beliefs
What is more effective
Virtual reality vs. in-vivo exposure
equally effective
What is Habituation?
Mechanisms of action of exposure therapy 1
Decrease of an emotional and physiological reaction with prolonged and/or repeated presentation of a stimulus (“habituation”)
- For example, a patient with agoraphobia experiences a decrease in his anxiety and physiological responses (e.g., palpitations) after a half-hour in-store visit.
Describe the cognitive changes as a mechanism of action of exposure therapy
-Change of dysfunctional thoughts
+Dysfunctional cognition: “My heart is racing, I’m sure to faint.”
+ Through exposure: uncovering the difference between negative expectations (“I’ll certainly faint right away”) and reality (nothing happened).
- Increase in expected self-efficacy : Patient can manage the symptoms by himself, e.g. through more functional thoughts.
What are possible Contraindications of exposure therapy
- Lack of consent, lack of motivation of the patient ! Psychotic symptoms, history of psychosis
- Cardiovascular disease
- Short time intervals for sessions
- Lack of embedding in therapeutic context
What are the approaches of First wave: Behavioral therapy
e. g., Systematic
desensitization: Phobic Stimulus & Relaxation
What are the approaches of Second wave: Cognitive therapy
Cognitive restructuring: alteration of dysfunctional thoughts
What are the approaches of First wave: Third wave: CBT + X
Acceptance and Commitment Therapy (ACT): Cognitive Defusion: dissociate from thoughts
Psychological Treatment of Phobias
Exposure
Psychological Treatment of Social Anxiety Disorder
CBT for Social Anxiety
- Graded hierarchy of exposure
- Involves role playing or practicing with a small group
Social skills training
- Provides extensive modeling of behaviors
- Reduces use of safety behaviors (e.g., poor eye contact)
Clarks’ cognitive therapy for social anxiety
- Reduce internal focus of attention
- Challenge negative images of how others will react
Psychological Treatment of Agoraphobia
CBT for agoraphobia
- Systematic exposure to feared situations
- Coached to gradually leave home and engage in community activities for short periods of time
- Enhanced by involving patient’s partner
Psychological Treatment of GAD
Relaxation training to promote calmness
Cognitive behavioral methods :
+ Improve problem-solving
+Challenge and modify negative thoughts
+Increase ability to tolerate uncertainty
+ Worry only during “scheduled” times
+ Focus on present moment
Name the Medications for anxiety disorders and their disadvantage
Anxiolytics: drugs that reduce anxiety
-Benzodiazepines (e.g.,
Valium, Xanax)
-Can be addictive and
cause severe
withdrawal symptoms
- Side effects: cognitive and motor difficulties
Antidepressants (e.g., Tricyclics, SSRIs, SNRIs)
-Side effects: jitteriness, weight gain, elevated heart rate
Most people relapse once they stop taking medications
Psychological treatments are considered the preferred treatment of most anxiety disorders
Effects of D-cycloserine in phobic patients undergoing exposure therapy
D-cycloserine: agonist of the N-methyl-D-aspartate receptor; seems to improve deletion of anxiety, especially works in memory consolidation
- Effect decreases over time and with repeated administration.
- Best effect when given directly before or after exposure.
