Anxiety Disorders, General Flashcards
Anxiety Disorders Commonalities
Overestimation of danger
cognitive bias –focus on danger related cues
Lack of acceptance/intolerance of anxiety
Anxiety sensitivity
Intolerance of uncertainty
Increased Vulnerability / Unwillingness to accept existential realities
Avoidance of thoughts, stimuli and affect
Systematic Biases
Confirmatory bias
- -seek out information that confirms thinking
- -mood-congruent processing
- drives processing to be consistent with mood o
Evolutionary function – attention biased toward perceived threat
Prevalence of Anxiety Disorders
24% (1 in 4) Lifetime Prevalence of Anxiety Disorders
Associated with significant functional impairment
The prevalence of anxiety disorders seems to be increasing (stress, media influences)
DSM-5 Anxiety Disorders
Panic Disorder
Agoraphobia (now sty not needed?)
GAD
Specific Phobias
Social Phobia
Selective Mutism (IV-childhood disorder)
Separation Anxiety Disorder (IV-childhood disorder)
DSM-5 Other Categories Anxiety Disorders
OCRD: OCD BDD (IV- somatoform) Hoarding Disorder (new) Trichotillomania (IV- impulse control) Excoriation Disorder (new)
Trauma and Stress Related Disorders:
PTSD Acute Stress Disorder
Adjustment Disorders (IV-adjustment disorders)
Reactive Attachment Disorder (child)
Somatic Symptom Disorders:
Illness Anxiety Disorder (hypochondriasis)
Cognitive mechanisms in anxiety disorders:
- Overestimation of danger (cognitive bias)
- Focus of attention on danger-related cues (hypervigilance)
- Lack of acceptance/tolerance of anxiety (anxiety sensitivity)
- Unwillingness to accept existential realities (tolerance of uncertainty, risk)
- Avoidance of anxiety provoking thoughts/affect (cognitive avoidance, thought suppression)
Treatment Strategies:
Cognitive Content
ANXIETY
REDUCTION
*Corrective Information
(psychoeducation)
*Cognitive
Reappraisal
*Modify Schema
Psychoeducation
“Correcting” content
Understanding the nature of emotions (anxiety) and their meaning
Corrective information about perceived dangers (somewhat disorder specific)
Discussion of risk perception: Possibility vs probability
Cognitive Reappraisal
Cognitive therapy – e.g., Clark and Beck
Modify content of immediate appraisals
Focus on logical analysis
Utilize corrective information
Note theme(s) of cognitions (schema) – to be addressed later if relevant
Existential Aspect: Anxiety and the Human Condition (e.g., Yalom, May)
Existential Therapy:
Anxiety = inability to confront and accept existential realities:
inevitability of death
physical dangers
social rejection
failure
Goal:
Acceptance of risk, uncertainty, danger as a necessary part of living
Schema-Focused Therapy (Young)
Focus is on identifying and modifying deeply entrenched beliefs that tend to be central to one’s sense of self or view of the world.
Goal: Insight into, and awareness of, “biased” information processing will allow for correction
Emotion Driven Responses
(Maladaptive Action Tendencies)
Maladaptive responses that allow the individual to avoid, escape, or reduce the emotion (action tendency) – thereby reinforcing these maladaptive responses.
Avoidance: prevents activation of emotion
Escape: terminates activation of emotion
Reduce: lessens the intensity of the emotion (e.g., safety behaviors)
Cognitive: Modification of the thought process
Meta-Cognitive Strategies:
Cognitive Defusion–acceptance of thought as thought, nothing else
Cognitive Processing–exposure to thoughts instead of avoidance or suppression
Attention Refocusing/Modification
- direct attention away from threat
- alternative environmental cues
Cognitive Processing
Focus on decreasing cognitive avoidance and facilitating
processing/integration
Exposure to anxiety provoking thoughts
e.g.
worry
post-trauma reactions
catastrophic thoughts,
social rejection
Attention Refocus/Modification
Focus attention away from threat cues to disrupt biased information processing
Increase presence in situation – focus on external details (awareness)
Focused on nonthreatening stimuli in situation (e.g., friendly face)
Focus on neutral stimulus (breathing)
Proposed Sequence of Cognitive Interventions
PSYCHOEDUCATION
(Corrective Information)
COGNITIVE REAPPRAISAL
CORE BELIEFS (Insight)
Schema Modification
Existential Acceptance
META-COGNITIVE - ACCEPTANCE BASED
Cognitive Defusion
Cognitive Processing
Attention Refocus
AFFECTIVE Emotion Driven Responses
Maladaptive responses that allow the individual to avoid, escape, or reduce affect.
e.g.
Avoiding watching a tense movie because it will cause anxious affect
Not fully paying attention to a news story because it evokes a negative emotion
Avoiding a roller coaster because it produces anxious affect
Taking a tranquilizer to reduce anxiety during a presentation
Drinking alcohol to reduce anxious affect at a party
PHYSIOLOGICAL Emotion Driven Responses
Maladaptive responses that allow the individual to avoid, escape, or reduce physiological responses.
examples:
avoidance of caffeinated beverages
avoidance of exercise
avoidance of the heat, humidity, and various weather conditions
sitting down at a party to avoid feeling unsteady
BEHAVIORAL Emotion Driven Responses
Maladaptive responses that allow the individual to avoid, escape, or reduce anxiety in phobic situations.
Avoidance of phobic situations
Escape from phobic situations
Reduction strategies are more subtle:
Asking for reassurance about one’s health status
Wearing gloves on the train to avoid touching the
Sitting down when at a party to avoid feeling unsteady
Always being with someone in case one had a heart attack
EXPOSURE: Treatment of Emotion Driven Responses
Exposure: Undoing the process of negative reinforcement
Identification of Emotion Driven Responses:
Fear and Avoidance Hierarchy
Imaginal and In-vivo
a. inoculation prior to an in vivo exposure
b. cognitive processing (exposure) to confront cognitive avoidance, thought suppression, distraction
c. implosive therapy (feared fantasy, disastrous consequences) to facilitate
habituation, facilitate corrective processing
In-vivo
a. Systematic (gradual) vs flooding
b. self-directed, other-assisted, therapist-assisted
Additional behavioral strategies
Behavioral Activation (depression)
Skills building when indicated: assertiveness training social skills enhancement sleep hygiene relaxation strategies organizational skills and goal setting stress management problem-solving
General Vulnerability Model
A negative schema can always be present but these mechanisms only activate from stressful life events
If a parent has a specific anxiety, their child is more vulnerable to acquire any anxiety disorder
*Not just specifically the same type the parent has
Imaginal Exposure
Inoculation prior to an in vivo exposure
Cognitive processing (exposure) -confront cognitive avoidance, thought suppression, distraction
Implosive therapy
- feared fantasy
- disastrous consequences
- -facilitate habituation
- -facilitate corrective processing
In-vivo Exposure
Systematic (gradual) vs flooding
Self-directed, other-assisted, therapist-assisted
Role of Cognitive Appraisals
Schemas are responsible for processing information
Inaccurate appraisals stem from faulty schemas (outside conscious awareness)
In treatment we attempt to redirect these faulty attentional biases
- task is to to hold old and new schemas in the current mind
- requires cognitive flexibility
- slowly separate from old schemas towards the new ones
Common thoughts related to specific emotions
Anger = cognitions of being mistreated, unfairness
Anxiety = cognitions of risk/danger
Sad = cognitions of loss
Guilt = cognitions of doing wrong
Shame = thoughts of moral imperative
Behavioral Experiments
Design experiments to test validity of anxious predictions
Focus on facilitating disconfirmation of negative thoughts
Extinction really is inhibitory learning of new associations
Continued exposure strengthens this newly learned associations = inhibitory learning
Behavioral Experiments: Increase chance of success
Set up exposure aimed at disconfirming expectations
Label emotions during exposure
Use items that can be used as a later retrieval cue to recall exposures
Why anxiety disorders don’t self-correct
High road being hijacked by the low road amygdala
Lack of problem solving
Biases
Mood-congruent processing
- autopilot versus manual pilot
- mindfulness, get out of autopilot being caught up in the jet stream
*mindfulness as a distraction
or, more accurately, distraction from the distractions
Treatment Strategies:
Cognitive Process
Cognitive Defusion
(acceptance)
Existential Acceptance
Redirect Attention
Mindfulness
Cognitive Processing
Thought Records
Utility
Identify emotions and triggers
Identify cognitive distortions
Identify rationale responses
