ANXIETY DISORDERS AND PTSD Flashcards
Definitions
Anxiety – an emotional state characterised by physiological arousal, unpleasant feelings of tension and a sense of apprehension or foreboding
Anxiety disorders – psychological disorders characterised by excessive or maladaptive anxiety reactions
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
CHANGES TO DSM CHPT 5
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.
Shared features of anxiety disorders
Primarily stress linked
Reality testing remains intact
Symptoms are experienced as distressing
Disorders tend to be enduring or recurrent
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
Anxiety affects our……
Physiological
Behavioural
& Cognitive
…………….functioning
Parasympathetic Nervous SystemFeed 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 SystemFight 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
Selye’s General Adaptation Syndrome (1946)
ALARM: fight or flight response
RESISTANCE: mobilisation of defences and adaptive responses.
EXHAUSTION: collapse of adaptive responses resulting in health problems.
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 )
Post-traumatic growth
Enhanced relationships
Altered self-view
Altered life philosophY
The aetiology of PTSD
Vulnerability factors Theory of shattered assumptions Conditioning theory Emotional processing theory Mental defeat Dual representation theory
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)
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
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
Debriefing
A structured way of trying to intervene immediately after trauma to prevent the development of PTSD
Also called Critical Incident Stress management (CISM) (Everly et al., 2000)
A form of post-event counselling for victims
Limited evidence that it is effective in preventing PTSD (McNally et al., 2003)
Narrative Exposure Therapy
Development of testimony therapy (Cienfuegos & Monelli, 1983)
A short term approach
Developed for use with people who have experienced a series of traumatic events, resulting in PTSD (Schauer et al., 2005)
Aims to enable a coherent and meaningful narrative of events to be developed, influencing fear networks
Has been adapted for use with children – KIDNET (Onyut et al., 2005)
