Anxiety New

Question 1

Specific phobia

Answer 1

Marked fear or anxiety about a specific object or situation

Question 2

Anxiety: Epidemiology (Prevalence, cross-culturally, gender, age, comorbidity)

Answer 2

• Prevalence: Specific phobia 10%, social 9%, GAD 6%, PTSD 6%, panic 3%, agro 1%, OCD 1%
• Lower in developing countries (besides agrophobia)
• 2:1 female:male
• High comorbidity
• School anx = 14years, panic = 20s, agrophobia =before 35, specific phobia= before 10

Question 3

Anxiety risk factors

Answer 3

• Genetic 1/3 risk
• Temperamental: neuroticism, harm avoidance, behavioural inhibition, anxiety sensitivity
• Physiological: Amygdala hyperactivity
• Environmental: negative events in childhood, abuse and trauma, overprotective parents, low warmth and sensitivity
  
  • (smoking = panic, trauma with fear = specific anxiety)

Siohban
Better Not Should At Anxious People Today

Better - Behavioural inhibition
Not - Negative affectivity
Shout - Genetics – shy temperament
At – insecure attachment
Anxious – Anxiety sensitivity
People – Parental modelling
Today – Trauma

Question 4

Anxiety: Psychometric

Answer 4

• SPAI social phobia and anxiety inventory: differentiate panic disorder, agoraphobia, and social phobia
• GADS generalised anxiety disorder: – weekly check-in 8 QS
• MASC: multidenominational anxiety scale for children
• Beck Anxiety Inventory: discriminates anxiety and depression

Question 5

Specific phobia: Treatment

Exposure based,
systematic desensitization,
cognitive strategies,
EMDR,
injection,
problems with Tx

Answer 5

Exposure based
- In vivo – Create exposure hierarchy - directly facing – a therapist can model first – expose self-till reduced, approach feared stimulus when anxiety has reduced, conclude when anxiety reduced by 50%
o Limitations of in vivo = breaking confidentially during public places, lack of control over stimuli, financial cost, care for stimuli (e.g., animal)
- Imaginal exposure (describe the traumatic experience) – In Vivo more effect this can be combined as a warm-up – good when in vivo not practical let’s say flying – involves conducting scenes like movie-like images, therapist guide through evoke anxiety and discomfort – instructed to sit back and “watch” – scene recorded for the client to listen to for HW
- Virtual reality exposure (when in-vivo not practical)
- Interoceptive exposure: bringing on physical sensations

No relaxation training before graded exposure

Systematic desensitization
- Train to physically relax, establish hierarchy, counter conditioning relaxation as a response to each feared step
- Can use biofeedback instruments to make sure they are relaxed, can be paired with modelling

Cognitive strategies
- Decreasing focusing on the perceived threat – use distractions setting up Behavioural Experiments to evaluate the consequences of reducing the amount of time spent checking or anticipating the worst.
- Reduce safety behaviours: graded behavioural experiments
- Addressing misinterpretation: teaching cognitive reappraisal

EMDR – some evidence for the effectiveness

For injection:
* applied tension was significantly more effective than exposure
* tense muscles (in body then untense) till warm in the face, indicating increased blood pressure, do this 5x in session and for HW
* Expose to images of blood and use tensing when they feel faint
* Face more difficult situations using tension coping

Problems;
- Individuals may have trouble accessing predictions and may need to go into a feared situation to elicit - Get them to use SUDS subject unit of distress while exposed to the feared stimulus
- High dropout rate – do in one 3 hr session, In vivo and modelling BUT need a client to be motivated and tolerant of a high degree of anxiety
- Secondary cognitions – feel embarrassed can do BE for this – survey to see not only one scared
- Dealing with high anxiety – therapist should remain calm, give breaks, and use coping techniques (distraction, relaxation) but need to be dropped ASAP so not safety behaviours
- Avoidance – people who avoid can do during exposure – not look ignore etc – BUT study found that distracted exposure had better outcomes, maybe because of perceived control during exposure

Question 6

Specific phobia: Models

Answer 6

Mowrer: Fear acquired via classical conditioning, maintained via operant conditioning

Rachman added 3 pathways: direct conditioning, modelling/vicarious acquisition, informational and instructional (misinformation)

Seligman preparedness: Evolution-predisposed organisms to learn easily associations that facilitate survival – rapidly acquired, resistant to extinction, irrational, associated with evolutionary significance. E.g., Monkeys who watched another monkey showing fears could acquire fear of crocodiles but not flowers

Reiss expectancy model:
* 3 fundamental fears: 1. Fear of anxiety (related sensations, that arises from the belief that these lead to somatic, psychological, or social consequences) 2. Fear of illness, injury or death, 3. Fear of negative evaluation.
* In order to have a phobia need BOTH: expectation (what you think will happen) and sensitivity (the reason you fear that happening) toward each of the 3 fundamental fears.
* Example danger expectancy x sensitivity to injury and death + anxiety expectancy x sensitivity to anxiety + expectancy of social disaster x their sensitivity to negative evaluation by others

Question 7

Agoraphobia Models

Answer 7

• 2-factor model
• Expectancy model

Question 8

Agoraphobia and panic Treatment

overall
Cognitive evaluation
Behavioural experiment

Answer 8

– Shared formulation
- Psychoeducation
- Coping strategy
- Cognitive evaluation of beliefs and generation of alternative beliefs
- Behavioural experiments to examine evidence
- Address safety behaviours
- Relapse prevention

Cognitive evaluation of beliefs and alternative beliefs
- Go through recent experience and formulate it
- Match up bodily sensations with cognitions
- Try to discover triggers for unexpected attacks (e.g., coffee, consolidate alternative perspective)
- In what other situation might you feel these sensations? (exercise, coffee)
- Difference between anger, excitement, and anxiety? (misinterpretation of other emotional states)
- How might safety behaviours influence sensations (show placebo)
- What about selective attention (thinking about heart rate makes it faster)
- Education around beliefs (e.g., the brain makes you breathe (try breathing through a straw it’s constricted but can still breathe)

THEN use behavioural experiments to validate these ideas
- E.g., get them to dress warm and sit in a hot room to see that being hot doesn’t lead to fainting
- Practice doing things without safety behaviours

Efficacy – very successful for mild to moderate agoraphobic avoidance – also improves the quality of life and comorbid conditions

Question 9

Criteria for all anxiety BUT panic

Answer 9

1. 6+ months
2. Almost always provokes immediate fear or anxiety
3. Out of proportion to the actual danger/threat posed
4. Actively avoided or endured with intense fear or anxiety
5. Causes clinically significant distress or impairment
6. Not better explained by another disorder

Question 10

Panic criteria

Answer 10

A. 1+ Recurrent unexpected panic attacks (An abrupt surge of intense fear or intense)
B. 4 or more symptoms:
* Palpitations, pounding heart, or accelerated heart rate, Sweating, Trebling or shaking, Sensations of shortness of breath or smothering, Feelings of choking, Chest pain or discomfort, Nausea or abdominal distress, Feeling dizzy, unsteady, light-headed, or faint, Chills or heat sensations 10, numbness or tingling, Fear of losing control or “going crazy”, Fear of dying.
C. The attack followed by 1+ month of either: persistent concern about additional attacks and their consequences AND/OR significant maladaptive change in behaviour (avoidance)
D. Not due to substance or medical
E. Not better explained by another disorder

Question 11

Panic models

Answer 11

• Clark catastrophic misinterpretation:
  o Panic attacks result from the catastrophic misinterpretation of bodily sensations associated with a normal anxiety response
  o Trigger (internal or external)  perceived threat  apprehension  body sensations  interpretation of sensations as catastrophic  perceived threat (cycle)
• Barlow integrated cognitive model:
  o Biological vulnerability experience stress more  negative life events  initial panic (not a problem unless person becomes anxious about having another = false alarm)
  o Physical symptoms associated with false alarm through classical conditioning so become learned alarm
  o Learned alarms = psychological vulnerability where one is anxious about future alarms
  o develops fears of the physical sensations associated with autonomic arousal (anticipatory anxiety, avoidance)

Question 12

Panic treatment

Answer 12

Goals: reduce sensitivity to sensations, weaken catastrophic misinterpretation, enhance cognitive reappraisals for the explanation for distressing symptoms, eliminate avoidance and safety behaviours, increase tolerance for anxiety
1. Psychoeducation based on the formulation of maintaining factors
2. Interoceptive and situational exposure
3. Cognitive restructuring
4. Behavioural experiments and graded exposure to anxiety-provoking situations
5. Symptom tolerance and safety reinterpretation
6. Relapse prevention
7. Breathing training
8. Mindfulness/ACT
9. Medication

Question 13

GAD criteria

Answer 13

CRIM[f]S

• The presence of excessive anxiety and worry, more often than not, about a variety of topics, events, or activities
• The worry is experienced as difficult to control
• 3+ symptoms (In children, only 1):
  Edginess or restlessness
  Fatigue
  Impaired concentration
  Irritability
  Increased muscle aches or soreness
  Difficulty sleeping

Question 14

GAD models

Answer 14

• Wells metacognitive model: Type 1 worry & Type 2 ‘worry about worry’ (leading to changes in emotion, behaviour and thought control)
• Cognitive Avoidance (Borkovec) - Worry is an avoidant response (trying to avoid physical symptoms of anxiety) - verbal worry is reinforcing short term, but long term not effective problem solving strategy (negates opportunity to process emotions)

Question 15

Anxiety assessment

Answer 15

• Broad - comorbidities and differentials
• Risk
• Developmental, family history
• Collateral
• Symptoms, cognitions, FIDO, ABCs
• Fear cues and triggers
• Avoidance and safety behaviours
• Physical symptoms
• Impact distress and impairment
• Medical evaluation
• Cognitions: type 1 or 2 worry
• Beliefs about the ability to cope
• Self-monitoring dairy

Question 16

GAD treatment

Answer 16

Based on meta-cognitive therapy by Wells
1. Psychoeducation – what is anxiety, triggers, maintenance (pink elephant experiment), beliefs about worry
2. Challenge beliefs about uncontrollable/danger: evidence for and against, behavioural experiments against coping strategies
3. Challenge positive beliefs: evidence for and against, behavioural experiment (normal activities while worrying more or less and impact on coping/productivity), what if worst case scenario plays out
4. Alternative strategies:
a. mindfulness and acceptance: acknowledge the presence of worry and let it go, compassionate, non-judgemental, separate self from experience,
b. graded exposure for safety behaviours, relaxation progressive relaxing,
c. Accepting uncertainty – intolerance
d. Problem-solving vs worry (worry time)
5. Relapse prevention – what to watch out for, what to do
6. Family sessions: psychoeducation, relaxation technique, reward programme, ignoring worry talk, help child challenge, test and reinforce non-threatening interpretation using cognitive restructuring techniques

Question 17

Transdiagnostic appraoch

Answer 17

Anxiety disorders share common underlying processes and some commonalities in effective treatment interventions

Common to anxiety people experience: trigger –> perceived threat –> inappropriate anxiety response –> unhelpful coping reaction (e.g., avoidance) –> strategy does not fully resolve situation –> anxiety remains (cycle)

LEARN: trigger –> perceived threat –> anxiety response –> successful coping –> resolution of anxiety

• Dropping safety-seeking behaviours
• Decreasing avoidance,
• carrying out behavioural experiments (scary so can use relaxation to aid but need to be temporary so that they do not become safety behaviours)
• redirecting attention,
• challenging negative cognitions, cutting out rumination and worry
• reflecting on input from memory in the form of images and memories

Good to use individual models but also important to look at common processes across disorders
(to understand how one problem relates to another, and to broader background issues - learning in one area can productively generalize to others)

Question 18

Agoraphobia criteria

Answer 18

A. Marked fear of 2+: using public transport, open spaces, enclosed spaces, standing in line or crowd, outside of the home
B. feared because of:
* escape might be difficult or help might not be available
* in the event of developing panic-like or other incapacitating or embarrassing
Symptoms

Question 19

Social anxiety criteria

Answer 19

• Marked fear or anxiety about 1+ social situations in which the individual is exposed to possible scrutiny by others
• The individual fears that he/she will act in a way or show anxiety symptoms that will be negatively evaluated

Question 20

Social anxiety models

Answer 20

Cognitive Model of SA (Clark & Wells) - assumptions get activated in social situations that lead to sense of current danger, resulting in engaging in self focus, physical sensations of anxiety, and safety behaviours (maintain)

Cognitive Behavioural (Rapee & Heimberg) - person with SA creates and compares internal representations of how they appear to others with others expectations of them - If discrepancy; think about the consequences - leads to increased Ax symptoms & reduced social performance

Question 21

Social anxiety treatment

overall steps
Attention training
Behavioural experiments
Do not…..

Answer 21

Assessment
Shared formulation
Attention training
Safety behaviours
Video feedback
Shift attention from internal to external
Behavioural experiments
Anticipatory anxiety
Scripting old memories
Address any remaining assumptions
Relapse preventing

Behavioural experiment
Go through a recent example
Behavioural experiments with and without safety behaviours and film this
Can exaggerate doing the thing they are scared of to play out worst case scenario
Do almost every session (test negative predictions)
Specify predictions and beliefs then purposefully engage in feared behaviours in social settings, re-rate belief following this
Specify what would be evidence (not feelings)
Can do experiments at home or sessions

DO NOT – exposure habituation/exposure hierarchies/

rating anxiety in feared situations (makes them internally focused) /

thought records (don’t write NATS but use positive cognitions of social interactions)/

Usually skilled just anxious but if not skilled can use social skills training

Use attention rating +3 (internal immersed in thought) to -3 (external fully in the world)
- Help them use grounding techniques to focus externally – notice different things they can see, hear, touch, smell, and ask them to rate their attention
- Attention training to show them that they can control their attention
- Sound training (6 noises – close and far from them )
- Put a tap on, clock, laptop etc
- 1. Focus on the sound for 5-10 sec then switch to the next sound, 2. Rapid attention switching switch but faster, 3. Listen to everything like a symphony at once not priorities any sound over the other
- This is not relaxation but helps them realise they have control over their attention but don’t make it. A safety behaviour

Question 22

Transdiagnostic treatment

Answer 22

TRANSDIAGNOSTIC:
Breathing:
- Psychoeducation: Because your breath directly controls your nervous system, it’s the remote control to instantly calm your brain and body.
- How to: hand on chest hand on stomach Ensure that you are sitting on a comfortable chair or laying on a bed, Take a breath in for 4 seconds (through the nose if possible, Hold the breath for 2 seconds, Release the breath taking 6 seconds (through the nose if possible)., then pause slightly before breathing in again.
Progressive muscle relaxation
- tensing (5sec) and releasing (10 sec) of 16 muscle groups.
Assess safety behaviours
- “At that time, was there anything you tried to do to make the panic better?”
- “Did you do anything to try to stop (the catastrophe) from occurring?”
- “What did you think, at that time, was the worst thing that could have happened if you hadn’t done that?”
Behavioural experiments
- Different to exposure therapy – not to gain habituation to feared stimuli but rather cognitive strategy to obtain new information to test the validity of patients’ beliefs
- Useful for people who say “I can see that this is a more logical way of looking at things but I don’t feel it”
- Hypothesis A (what they think) Hypothesis B (alternative belief) can carry out both or generally test A
- Can be active (they do it) or observational (therapist modelling, surveys, information from books or the internet)
- Setting up: need sound rationale of why they are doing it, time to set up, the client must be on board, identify the cognitions that need to be tested, note negative predictions, ask to rate how strongly they believe cognitions, consider safety and risk, need to be challenging but not too challenging, plan for things that don’t go according to the plan
- Debrief: what happened, what does it tell clients that they didn’t know before? Follow-up experiments? Can it be generalised? Re rate strength of the belief and compare the rating
- Need to watch out for our own cognitions (do we think that they can do it), we don’t want to become safety behaviour for them (think they can only do stuff with us)