Anxiety Disorders Flashcards
anxiety and fear is..
normal
evolutionary important
bothe are important motivators
what is fear
fight or flight
sympathetic activation
avoidance and escape
present-orientated
what is anxiety
tension unpredictable uncontrollable future-orientated mood state
what is the yerkes-dodson inverted U
anxiety and performace relation curve
we perform best with a moderate level of anxiety
too little or too mych = bad
what general symptoms make up an anxiety disorder
pervasive ad persistent anxiety and fear fear disproportionate to threat excessive avoidance and escapist tendencies clinical sig distress and impariment 6 months
what is a panic attack
abrupt, intense fear or discomfort
several physical symptoms = sympathetic response = fight or flight mode on
analogous to fear as an alarm response
name and explain the 2 DSM5 types of panic attacks
expected - expected and bound to specific situations (phobias)
unexpected (uncued) - out of the blue
gender difference in panic attacks?
no
explain the panic attack cycle
1 symptom (eg dizzy or slight shortness of breath)
2 ask yourself is this a panic attack -> yes it must be
3 more symptoms
4 full panic attack (back to 1)
how to break the panic attack cycle
this is not a panic attack
i will be fine
deep breathing (but avoid hyperventilization)
re-attribute physical symptoms
also grounding eg stamp feet or squeeze fists
mindfullness, progressive muscle relaxation
diathesis stress model of anxiety and panic
inherited vulnerabilities
stress and life circumstances determine type
bio contributions to anxiety and panic (specifics!)
GABA circuits - depleted
Corticotropin releasing factor (CRF) and HPA axis
limbic (amygdala) and septal-hippocampal system (emtional valence of incoming info) - central to expression of enxiety and depression
noredrenergic and serotinergic implicated
GABA circuit
too little = anxious, tense, hyperarousal
valium, benzodiazepines = GABA agoinst
fight or flight (FF) systems as contributing to anxiety and panic
brainstem -> amygdala -> hypothalamus
activated by deficits in serotonin
immediate alarm and escape
Behavoiural Inhibition System (BIS) as contributing to anxiety and panic
Brainstem -> amygdala -> septal-hippocampal system
low serotonin, high norepinephrine
brain circuit in the limbic system that responds to threat signals by activating and causing anxiety
tendency to freeze and apprehensively evaluate the situation
overview of psych contributions to anxiety and fear
Freud - defense mechanisms
Behaviourists - classical and operant conditioning, modelling
Psychological - early uncontrolability/ unpredictability, assumtions/ interpretations of biology (not understanding our own bodies)
social contributions to anxiety and panic
stressful life events trigger bio/ psych vulnerabliities
family (how we react to stress tends to run in families) and interpersonal differences
integrated theory for anxiety and panic =
triple vulnerability theory
bio - uptight, highy strung
generalized psych - world is out of your control
specific psych experiences - trigger
problem of comorbidity of anxiety and panic
55% = concurrent diagnosis
major depression most common
so maybe not a stand alone disorder?
name the 7 DSM5 anxiety disorders
generalized anxiety disorder panic disorder agoraphobia specific phobia social phobia separation anxiety dis selective mutism
defining features of generalized anxiety disorder
the basic anxiety dis
excessive uncontrollable anxious apprehension and worry
more than 6 months
somatic symptoms (different to panic) = muslce tension, fatigue, irratibility
most likely of all to response yes to do you worry excessuvely about minor things
stats of general anxiety disorder
- how common of anxiety dis
- gender ration
- onset
- course
one of the most common anixety disorders females 2:1 insidious onset in ealy adulthood runs in families (often) chronic tend to seek primary physcian first
characteristics of people with generalized anxiety disorder
autonomic restrictors - just get the worry (lower bp, galvanic skin response etc)
emotional avoidance
chronic worriers
muscle tension
focusing attention is difficult and often just switch from crisis to crisis
treatment of GAD
some help from meds
-benzodiazepines = short term as addictive (basically feel drunk the whole time so big congitive effects - falling down the stairs etc)
-SSRIs are less good but less side effects so good 2nd choice
psych = CBT
-confront emotions
-acceptance of distressing thoughts not avoidance
-meditation / MBCT
panic disorder overview and features
in DSM5 no longer linked to agoraphobia
recurrent unexpected panic attacks - so false alarms
worry about next panic attack or what they mean
just a panic attack does not equal panic disorder
interoceptive and exteroceptive avoidance of situations
catastrophic misinterpretation of symptoms (clinical conditioning model)
so post panic attack = persist concern or worry about it or a significant maladaptive change in behvaiour
panic disorder
- gender
- onset
female 2:1 (even higher female in severe cases), maybe as men just cope by alcohol and drugs
acite onset
early/ mid 20s
panic attacks begin during puberty usually
decrease in elderly - prehaps less concern over health and vitality
in panic disorder explain nocturnal panic attacks
effect about 60%
during non-REM sleep
interoceptive vs exteroceptive
intero - heart rate, breathing etc
extero - crowed places for example
medications used to treat panic disorder
target serotniergic, noradrenergic and benzo GABA systems
SSRIs = preferred
relapse rates - high (50%) following discontinuation but all good if stay on meds
idea of pill as a crutch - reverse to placebo when meds stopped?
SNRIs (serotonin, neuropinephrine reuptake inhibitors)
psych and combined treamtments for panic dis
cognitive behaviour therapies = highly effective = PCT or panic control treatment goal is to break the link between cue and panic / catastrophic event = gradual exposure and modification of perceptions and attitudes
combined treatments do well in the short term
best long term = CBT alone
drugs can interefere with CBT = so sequential treatment may be best ie if one approach doesn’t work try another
also must balance rapid repsonse of meds compared to psych can be worth it
may already be taking drugs = best to add in CBT, stepped approach
what is agoraphobia
fear or avoidance of situations / events assocaited with panic
situation / event evokes disproportionate anxiety almost always
active avoidance
6 months
clinical sig
info transmission - don’t have to have a panic attack in that place to think you might
can be relatively independent of panic attacks
agora = marketplace
alcohol and drug abuse can occur but some od manage to work
how likely is it to faint during a panic attack
pretty impossible as fight or flight is on so bp = high, heart rate = high etc
agoraphobia
- gender
- onset
female 2:1
acite onset
25-29 yo
30-50% = preceeding panic attacks
overview of specific phobias
disproportionate fear of specific object or situation
marked interference with functioning
avoidance of feared object
used to be know fear and avoidance is unreasonable but no longer required in DSM5
6 month duration
specific phobias
- gender
- onset and course
female 2:1
onset 15-20 yo
chronic course
blood-injury injection phobia
vasovagal response (bp and heart rate drop = faint) to blood, injury or injection
causes of specific phobias
bio and evolutionary vulnerability - eg is advantageous to learn snakes are dangerous
direct conditioning
observational learning
info transmission
runs most highly in families compared to other anxiety dis = can inherit a strong vasovagal repsonse for exmaple
treatment of specific phobias
CBT = highly effective - challnege thoughts
exposure treatment:
-systematic desensitization = learn to relax, bottom of hierarchy (least feared situation), bring down to relaxed state, continue to move up the hierarchhy training to stay relaxed in each situation. can be done in one day like snake video or over the course of several weeks
-flooding = all at once emersion, no gradual exposure, risky as what if something does actually go wrong = set back
agoraphobia vs Panic dis
agoraphobia = panic/ fear tied to situations, cognition about not being able to escape / get help if panic attack occurs
panic dis = attacks and concerns about attacks, unexpected attacks and recurrent attacks
agoraphobia requires 2 of the following 5…
list the 5 situations
using public transport (inc planes, bus, train, boat) being in open spaces being in enclosed spaces standing in line or being in a crowd being outside of home alone
4 subtypes of specific phobias
blood-injury-injection
situatoin
natural environment
animal
PTSD DSM5 overview (now trauma and stressor related disorders)
exposure to actual or threatend serious danger
re-experiencing = intrusive thoughts, nightmares. flashbacks are different = re-living, is a form of dissociation
avoidance / numbing - not ocnnected to family and friends anymore
cognitive decline and or negative mood
arousal symptoms for more than 1 month
PTSD stats
33-50% combat, sexual assualt of captivity exposure
3.5% general pop
high levels social, occupational and physical disability
what is re-experiencing
flashbacks, nightmares, intrusive thoughts
what is avoidance / numbing associated with PTSD
avoid activities / situations, psychogenic amnesia, apathy, detatchment
what is arousal associated with PTSD
hypervigilance, increased startle response, trouble falling asleep
what is cognitive decline and or negative mood associated with PTSD
guilt / blame, estrangement from others
PTSD and the brain
all limbic
hypoactive prefrontal cortex
hyperactive amygdala (actively looking for threats, fires too easily)
shrinking hippocampus
3 PTSD subtypes / onset
delayed expression - full criteria for more than 6 months
acute stress disorder - immediately post-trauma but only more than 1 month (made to get round insurance problems to help those who are struggling)
dissociative phenotypes - more difficult to treat, less physiological arousal and more feelings of unreality
causes of PTSD
intensity of the trauma and ones reaction to it
uncontrollabilty and unpredictability
direct conditioning and observational learning
moderator = social support, if good social support hugely beneficial, eg vietnam = unpopular war = high incidence PTSD, lack of social support?
common problems with PTSD
alcoholism and substance abuse suicide depression chornic pain traumatic brain injury (veterans and domestic violence cases)
treatment of PTSD
CBT = highly effective
-just world belief system = i was a soldier so i deserve this
-adress cognitive distortions
exposure therapy = not to erase memories but manage them and take back control over them
-graduated or massed (eg flooding) through imaginal exposure
VA approves cognitive processing therapy, EMDR (weird wave finger side to side, wasn’t peer reviewed, $$$), prolonged exposure therapy
how type of stressor promting PTSD differs with treatment
single stressor eg raped once responds better to treatment than prolonged eg years of sexual abuse or in a war zone
what are obsessions
intrusive, anxiety producing thoughts, images or urges
what are compulsions
repetitive behaviours or mental acts to counteract anxiety or prevent occurence of dreaded event
-overt = washing etc
-covert = sequencing, repetition, counting
more than 1 hour a day
aimed at reducing anxiety or distress or prevent some dreaded situation = excessive, not realistic
stats OCD -gender -onset -course note on tics
slightly more women than men (boys earlier onset)
onset in early adolescence or young adulthood
tends to be chronic
tics are not compulsions but 10-40% of children and adolesence with OCD = tic disorders at some point
looks very similar accross cultures
OCD causes
biopsychosocial like other anxiety dis
early life experiences and learning - some thoughts are dangerous but controllable
thought-action fusion - moral vs likelihood eg thinking about abortion is the same as having an abortion
multisite study of OCD treatment mentioned in lectures
aim - compare independent and combined effects of clomipramine and exposure-response prevention (ERP)
drug alone
ERP alone
drug + ERP
pill placebo alone
all were good short term compared to placebo. but drug alone = very high relapse rates once drugs stopped, ERP alone = no significant relapse, combined treatment was somewhere in the middle
body dysmorphic disorder overview / clinical description
now part of obsessive compulsive and related dis
preoccupation with imagined defect
fixation or avoidance or mirrors
suicidality
ideas of reference - everything in the world relates to me
always relevant to cultural standards so maybe just an exaggeration of what is culturally determined?
BDD course, onset and gender
lifelong and chronic
more common than thought
seen equally in males and females ( more severe in men)
onset usually early 20s - higher in college students and arty/design people
most remain single, seek out plastic surgery, dermatology etc
used to be considered somatic but intrusive thought problems = more OCD like
suicide ideation typical
ideas of reference problems
poor life - not married, suicide, depression etc
causes BDD
unknown
runs in families
OCD relation
treatment of BDD
SSRIs = some relief CBT / ERP exposure and response prevention plastic surgery = usually unhelpful outcomes very similar to OCD
what is panic
sudden overwhelming fear or terror
environmental factors in sensitivity of brain circuits
can make you more sensitive so more susceptible
eg smoking cigarettes as a teenager associated with increased risk for developing anxiety disorders as an adult (paritcularly panic and GAD) = chronic exposure to nicotine triggers additional anxiety and panic so bio vulnerability increases
limibic brain in anxiety patients
overly responsive to stimulation or new info = abnormal bottom up processing
at the same time controlling functions of the cortex that would down regulate the hyperexcited amygdala are deficient (so abnormal top-down processing)
=consistent with BIS
cultural differences in reporting anxiety
tiny in china, large in mexico
reporting differences?
psych manifestations differ - so using western standards = not applicable
willingness to report anxiety in some cultures eg in the west men often turn to alcoholism insteas
childhood awareness events not always in our control….
general sense of uncontrollability can develop early
parents foster this = eg good if parents respond to needs in a predictable way and positive interactions as this teaches children they have control over their environment. also allowing a secure home base child can explore themself from = healthy
anxiety and sleep
difficulty sleeping seems to make anxiety worse
GAD and age
insidious onset
tends to be diagnosed around age 30
but is definitely and older disease
maybe related to how we care / see elderly in our culture
also must watch benzo use in eldery - falling down the stairs, fragility etc
study of autonomic restrictors in GAD but cognitive processes
did restrict autonomic arousal but
showed intense cognitive processing in frontal lobes (EEG), particularly left hemisphere
= thought process without imagery as imagery = right hemisphere
don’t have mental capacity to create images which would elicit ANS
so therapy = force imagery
2 studies for treating GAD
primary care setting treated nurses and doctors where GAD = frequent complaint
-used CBT to deal with provoked worry in therapy then applied outside
-brief cognitive treatment altered unconscious biases of those with GAD
94 9-13 yo
CBT or waitlist
based on teacher ratings, 70% of treated children were functioning normally after treatment with gain maintained for 1 year after
panic disorders in other cultures
same incidence world wide
greater emphasis on somatic symptoms in third world countries (emotions not always a big part of their culture)
ataques de nervios - carribbean, hispanic americans = more shouting and tears
kyol goeu - cambodian wind overload
when are panic attacks most liekly to occur
1:30am - 3:30 am as delta or slow wave sleep = deepes stage of sleep
awaken during panic of falling into deepest sleep = most think they are dying
what causes nocturnal panic
changes in stages of sleep produce physical sensation of letting go = frightening for someone with a panic dis
nightmares during REM do not dreams
sleep terrors
children scream and get out of bed but report no memory
but nocturnal panic is remembered so is different
sleep terrors tend to occur in a late stage of sleep - stage 4, a stage also associated with sleep walking
isolated sleep paralysis
culturally determined
transtional stage between sleeping and waking
during this period individual unable to move = surge of terror resembling panic attack, can be accompanied by vivid hallucinations
REM spilling into waking?
sig higher in aa with panic dis
clark cognitive theories
emphasises specific psych vulnerabilities of people with this disorder to interpret normal physical sensations in a catastrophic way
anxiety = more of a physical sensation as increased action of sympathetic nervous system = more danger and viscious cycle
Clark = cognitive processes as most important in panic dis
4 major subtypes of phobias
blood-injection-injury
situational (planes, elevators, encolsed places)
natural environment
animal type
fifth = other
people tend to have mutliple phobias of different types
situation phobia
originally thought similar to agoraphobia
mid teens / 20s (like agoraphobia)
similar familial as agoraphobia
but no panic attacks outside of specific phobia
natural environment phobia
fear of situations or events in nature, esp heights, storms and weather
must substantially interefere to be a phobia remember
7 yo onset
animal phobia
unrealistic enduring fear of animals/insects
develops early in life
again intereferes with functioning
stats of specific phobia
most common psych dis in US and around the world
4:1 female:male
only most severe need treatment / come for treatment, most simply avoid phobic situations
chronic
decline with old age
hispanics = x2 more likely than other americans
pa-leng - chinese fear of cold
how you can cause a specific phobia
direct experience
experience a false alarm in given situation
viacrious experience - watch someone elses severe fear
information transmission - being told about it
phobias in families
“breed true” so exact specific phobia is passed down through families (genes or modelling?)
how to treat blood-injection-injury phobia
taught how to increase bp, often 2-6 hour therapy session
continue to practice at home
phobia dissapears and vasovagal response at sight of blood lessens considerably = brain rewiring as diminished responses in fear sensisive network
separation anxiety disorder
excessive, enduring fear about being apart from caregiving loved ones such as spout or parent
something bad will happen
children might refuse to go to sleep alone or school
all young children experience this at some point but tends to decrease as you get older = clinican must judge if getting abnormal
must distinguish from school phobia
if severe can continue into adulthood
=new DSM5 category
treatment of separation anxiety disorder
parents included - their reactions might need to change
some try therapist coaching parent in earpiece
social anxiety disorder
extreme, enduring, irrational fear and avoidance of social or performance situation - also called social phobia
the social situation must almost always produce fear / be endured with intense fear / anxiety
must be out of context to social situation / culture
subtype = performance anxiety
stats of social disorder we care about (onset, gender etc)
equal male to female adolescent onset (peak 13yo) young, uneducated, single, low SES much less common in elderly white americans = most likey americans japanese have own version = more male, fear of body odour / their body will upset others - olfactory reference syndrome
causes of social phobia
we learn more quickly to fear angry expressions than other facial expressions & fear diminishes more slowly
- even more true in those with social anxiety
evolutionary basis we think
study showed some babies are born with a tempermament profile of inhibition or shyness that is evident at 4 months
severe bullying as teenager
emphasis on social evaluation
treatment of social phobia - psych
therapy program emphasising real-life experiences to dipose automatic assumptions of danger
IPT - interpersonal psychotherapy
maintains as they avoid / enagage in safety behaviours - so social mishap behaviour = directly challenge beliefs
CBT in adolescence (families if parents have anxiety dis too)
treatment of social phobia - drugs
assumed beta-blockers would help - did not
SSRIs
mixed results on studies trying to understand conbined treatments
DCS drug in rats
worked on the amygdala, unlike SSRIs this drug worked to facilitate extinction of anxiety by modifying neurotransmitter flow in glutamate system
selective mutism
developmental disorder characterised by a consisitent failure to speak in specific social situations despite speaking in other situations
-driven by social anxiety (high morbidity with social phobia)
-must occur for more than 1 month and this cannot be the first month of a new school
parents at fault - they talk for them?
treatment = CBT, highly specialised programs eg camps
trauma and stressor related disorders are distinct
origin in stressful events
PTSD - trauma exposure study
9/11 the closer lived to building coming down = greater incidence of PTSD
=have to be close encounter with trauma
PTSD twins study
same amount of combat exposure, MZ twins are more likely to develop PTSD than DZ twins if other twin had PTSD
= some genetic influence
also stress diathesis model
study of female undergrads who withnessed shooting
all experience same traumatic event
serotonin transporter gene ss = increased probability of becoming depressed and experiencing symptoms of acute stress
tendency to be anxious as well as minimal education predicted exposure to traumatic events and therefore increased risk of PTSD (don’t think this was found in shootout study but is relevant)
when do vulnerabilities matter in PTSD
when stress levels arent high as when very high = PTSD
so vulnerabilities only relevant at medium / low levels
some protective PTSD factors
family stability
strong social support = broad and deep
positive coping strategies
impact of broad and deep social system - brain wise
loved ones reduce cortisol secretion and HPA axis activity in children during stress
maybe why vietnam vets so high PTSD as unsupported war
brain damage / change in gulf war and holocaust survivors with PTSD
hippocampus = role in regulating HPA axis + learning and memory damage so if damaged = presistent and chronic arousal
-these deficts are present compared to those from same group but no PTSD
watch must therapist be prepared for when treating PTSD
sudden flooding can occur = scary but must be managed appropriately
when is best to treat PTSD
structured interventions as soon as possible after the treatment is best - prevent the PTSD if possible
but just single debrief where they are forced to express their emotions = bad
adjustment disorder
prolonged negative emotional reaciton following a major life stressor
anxious / depressive reactions to life stressors that are milder than PTSD but still impairing
in adolesence = condict problems
if still their after 6 months after removal of stress = chronic
attachment disorder
childhood (pre 5 yo) mental dis characterised by difficulty forming normal relationships, usually as a direct result of inadequate care giving relationships
- eg multiple changes in foster parents or neglect at home
- pathological reaction to severe stress
reactive attachment disorder
in children, a pattern of inhibited withdrawn behavoiur towards adult caregivers
fearfulness, sadness
disinhibited social engagement disorder
in children a pattern of abnormally extroverted behaviour towards
4 types of obsessions
symmetry obsessions - most common
forbidden thoughts or actions
clearing and contamination
hoarding
thought action fusion
when people with OCD equate thoughts with specific actions or activity represented by the thoughts
-excessive reponsibilty / guilt during childhood so even a bad thought = evil intent
strenght of religious belief (but not type) = associated with thought-action fusion and severity of OCD
behaviour = was to control these thoughts
OCD treatment
SSRIs but relapse common when drug discontinued
highly structured psych but not available
ERP = exposure and ritual prevention - in severe cases must hospitalise to ensure this (that patient is systemtically and gradually exposed to feared thoughts or situation). facilitates reality testing
cognitive treatments focus on the overestimations of threat of intrusive thoughts
psychosurgery and deep brain stimulation can be used as last ditch resort
hoarding
more than just strange OCD
prevalence x2 higher than OCD
fire related hospitalizations = 1/4 related to hoarding
tend to enjoy aquisition of stuff as teenagers - retail therapy, but then stress and anxiety about throwing stuff away
separated in DSM 5 from OCD
more research is needed
trichotillomania - what
hair pulling
may have specific genetic mutation
excortiation - what
skin picking
trichotillomania and excortiation both
result in noticeable physical deficits + significant social impairments
more females
under impulse control
habit reversal training = carefully taught to be aware of their behaviours and then apply a substitute behaviour eg chew gum
SSRIs (best with trichotillomania)
