Case 5: Thought suppression & Obsessive compulsive disorder & Case 6 PTSD

Question 1

What is OCD?

Answer 1

Individual has uncontrollable, reoccurring thoughts (“obsessions”) and/or behaviors (“compulsions”) that they feel urge to repeat over and over.

Question 2

What is the DSM-5 of OCD?

Answer 2

1. Presence of obsessions (O), compulsions (C), or both
2. O/C are time-consuming (e.g., take more than 1 hour per day) or cause significant distress or impairment in social, occupational, or other important areas of functioning.
3. OC symptoms not attributable to physiological effects of a substance or another medical condition;
4. disturbance is not better explained by the symptoms of another mental disorder.

Question 3

What do obsessions & compulsions do for OCD?

Answer 3

Obsessions and compulsions make OCD → self-reinforcing.

Question 4

What are obessions according to DSM-5?

Answer 4

1. Recurrent and persistent thoughts, urges, or images that are intrusive & unwanted & in individuals cause marked anxiety or distress.
2. Individual attempts to ignore/suppress such thoughts, urges, or images, or neutralise them with some other thought or action (i.e., by performing a compulsion).

Question 5

What are compulsions according to the DSM-5?

Answer 5

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that individual feels driven to perform in response t obsession/according to fixed rules
2. Behaviors/mental acts aimed at preventing/reducing anxiety/distress, or preventing some dreaded event or situation; BUT behaviors/mental acts NOT connected in a realistic way with what they are designed to neutralize/prevent, or are clearly excessive.

Individual may attempt to resist the compulsion, but drive to perform the ritual becomes so great the individual finally gives into the compulsive urge. (NOT DSM)

Question 6

What do most common obsessions deal with?

Answer 6

• themes of dirt/contamination & pathological doubt over one’s actions (e.g., locking the door, turning off the stove or water taps),
• order/symmetry
• Repugnant thoughts of sex, immorality, religion, harm or aggression to self or others.
• Guilt is often associated with obsessions, especially when the obsessions are repugnant.
• Individuals may try to conceal their obsessive thinking from others due to embarrassment or fear of some negative consequence

Question 7

What is the difference between worry and obsessions?

Answer 7

Obsessions
* =ego-dystonic → focus on fears & concerns that are unrealistic, irrational or imaginary (e.g. obsessed with having cyanide on one’s hands) → intrusive
* Obsessions likely to = overt compulsions and to be judged as entirely unacceptable by individual

Worry
* = ego-syntonic → focus on everyday negative outcomes involving finances, work, family, health, etc (worry belongs to person).
* Worries related to realistic experiences of everyday life

Differences in focus, underlying beliefs & associated response strategies are best for differentiating worry vs obsessions

Question 8

What is worry & what are the characteristics of worry?

Answer 8

• (a) Worries = cognitive phenomenon experienced as aversive, people worry about future events and potential catastrophes, and worries are very hard to control.
• (b) Worries more frequently triggered & occur in form of thoughts, whereas obsessions occur as images and impulses.
• (c) Although both are experienced as uncontrollable, worries are not as strongly resisted as obsessions.

Question 9

What are covert compulsions?

Answer 9

carrying out of mental actions, as opposed to physical ones.

Examples include mental counting, compulsive visualisation and substitution of distressing mental images or ideas with neutralising alternatives.

Question 10

What are overt compulsions?

Answer 10

Overt compulsions typically include checking, washing, hoarding or symmetry of certain motor actions

Question 11

What are other forms of neutralisation?

Answer 11

cognitive strategies (e.g., reassurance seeking, rationalization, distraction, thought stopping & thought suppression) even more than compulsive rituals to neutralize the obsession.

Question 12

What are 2 motivations for compulsions?

Answer 12

Some patients with OCD engage in compulsions to manage & reduce inner & diffuse feelings of incompleteness (INC) or experiences that things are not just right (NJREs), until they achieve a state or feeling of perfection.

Question 13

What is common for individuals with long-standing OCD?

Answer 13

to give into the compulsive ritual quite automatically with only a minimal degree of resistance

Question 14

What is the criteria for determing whether a repeated instrusive thought, image or impulse is a clincial obsession?

Answer 14

• Frequency
• Distress
• Associated control or suppression effort
• Presence of compulsion
• Extensive avoidance
• Trigger by inappropriate contextual cues
• Appraisals of control to avoid perceived negative consequences (e.g., thought-action fusion).

Question 15

Are obsessions and compulsions functionally related?

Answer 15

• E.g. obsessional fears of dirt or contamination = with cleaning and washing compulsions
• Doubting obsessions are accompanied by repeating and checking rituals.

Question 16

What is the difference between obsessions & rumination?

Answer 16

Depressive rumination
* = repetitive & persistent negative thoughts, self-critical evaluations & dwelling on past/present problems/failures.
* Often focuses on themes of: personal inadequacy, self-worth, regrets, or negative interpretations of events.

Obsessions
* = intrusive & distressing thoughts, images, or urges typically unrelated to the individual’s mood

Question 17

Why was OCD considered an anxiety disorder?

Answer 17

• most obsessions elicit subjective anxiety or distress;
• a compulsion is analogous to an escape response;
• like fears, obsessions are provoked by internal or external triggers;
• compulsions usually (but not always)= anxiety reduction;
• reassurance seeking, threat overestimation, and other underlying beliefs are common in anxiety and OCD;
• avoidance & safety behaviours are evident in OCD and other anxiety disorders;
• certain disruptive events can interfere or invalidate the compulsion.

Question 18

Why is OCD now not considered an anxiety disorder?

Question 19

What are the subtypes of OCD?

Answer 19

1. sexual, aggressive, religious, or somatic obsessions and checking compulsions
2. ordering, symmetry, and arranging
3. contamination obsessions and cleaning compulsions
4. hoarding - but is separate from the DSM

Question 20

Why is hoarding seperate from the DSM?

Answer 20

• Hoarding disorder requires specialized interventions, different from those used for OCD.
• Recognizing hoarding disorder as a separate diagnosis improves diagnostic accuracy & allows for specific treatment approaches
• Separation enables focused research on hoarding symptoms & deeper understanding of factors.

Question 21

What is aetiology & epidemiology of OCD?

Answer 21

Age & gender
* Adulthood age differences with OCD more prevalent among 20- to 44-year-olds and least prevalent among adults over 65 years
* Ratio of women to men suffering from OCD varies with the age group.
* Men with OCD have an earlier onset than women
* Adulthood: prevalence higher in women
* Older adults: ratio may be reversed, men higher prevalence of OCD

Question 22

What are the cultural differences involved in the aetiology of OCD?

Answer 22

• Cultural differences may influence the relative frequency of different OCD symptom domains, the content of obsessions, and degree of impairment
• Even though contamination & doubt obsessions, & washing & checking compulsions are most prevalent symptoms in most countries, social & cultural factors can influence the function and consequences of OC symptoms.
  E.g. individuals might develop contamination and washing symptoms related to their Islamic or Judaic religious beliefs about the sinfulness of being unclean, whereas individuals in other societies that value cleanliness for health reasons might develop washing compulsions because they fear physical disease

Question 23

What are predictors of course of OCD?

Answer 23

• Age of onset, presence of comorbidity, and symptom severity are all risk factors affect- ing the course of OCD.
• Earlier onset decreases the likelihood of full remission, whereas late onset is associated with an episodic course.
• E.g. earlier onset → less likelihood of full remission, late onset → episodic course.

Question 24

What is the impairment of OCD?

Answer 24

• Severity of OC symptoms is correlated with poorer social functioning, personal relationships, and professional performance
• often experience low self-esteem, shame & humiliation because of their symptoms and this can have a negative impact on social functioning
• Women with OCD have lower sexual desire, less sexual contact with their partners, and are less satisfied with their sexual lives than controls
• QoL generally lower

Question 25

What is the difference between normal and abnormal obsessions?

Answer 25

• distinguished more by intensity/ severity instead of any distinct characteristic.
• clinical obsessions are more frequent, distressing, unacceptable, subjectively uncontrollable, resisted, and ego-dystonic
• OCD individuals more likely to use compulsions & other maladaptive control strategies in response to their obsessions, avoid perceived triggers & exhibit thought-action fusion and over importance of thought control appraisals

Question 26

What is the difference between normal vs abnormal obsessiosn?

Answer 26

• Threshold of acceptibility is higher for abnormal obsessions.
• Normal obsessions are easier to dismiss.
• Abnormal obsessions last longer-overall,
• Abnormal obsessions are more intense.
• Produce more discomfort.
• More frequent.
• More ego-alien.
• More strongly resisted.
• More likely to be of known onset.
• Provoke more urges to neutralize.

normal and abnormal obsessions are similar in form and content, but differ in frequency, intensity and in their consequences.

Question 27

Different kinds of compulsions?

Answer 27

• Cleaning
• washing
• checking
• repeating
• reassurance seeking
• avoidance

Question 28

What is inflated responsibility?

Answer 28

• Cognitive behavioural therapy suggests that individuals with OCD have inflated perception of responsibility for harm to self or to others
• often feel responsible for possible harm/negative outcomes associated with their obsessions = marked distress and neutralising (compulsive) behaviours.
• E.g. a patient who fears leaving the oven on may suffer from an inflated perception of responsibility for the safety of his/her family = repeated checking behaviours to ascertain that the oven has been turned off.

Question 29

How does the catastrophic misinterpretation such as inflated responsibility contribute to OCD?

Answer 29

• Inflated perception of responsibility is mostly associated with checking compulsions. But inflated responsibility is NOT a common feature to all individuals with OCD.
• OCD patients have higher responsibility assumptions and higher responsibility appraisals. They also have more frequent high responsibility interpretations and greater belief in those interpretations.

Question 30

What is thought suppression & how does it maintain OCD?

Answer 30

• Thought suppression → motivated forgetting when an individual consciously attempts to stop thinking about a particular thought.
• Suppression terminates exposure to unwanted thoughts = preventing habituation = means that thought will remain **emotionally relevant ** & a target of attentional focus (increase in frequency)

Question 31

**Why does suppression result in frequent occurences of those thoughts?

Answer 31

• hyperaccessibility of other, negative thoughts for use as distracters which will be particularly salient cues for the depressive thoughts targeted for suppression
• general tendency for depressed individuals to perform with reduced cognitive effort in cognitive tasks, of which thought suppression would qualify
• because deliberate attempts at changing one’s mood makes cues that the desired mood state is not being achieved (i.e. the presence of negative thoughts) more salient, so that suppressing a negative mood by attempting to instate a positive one will be counterproductive

Question 32

What is the relationship between the emotional impact of an event, tendency to suppress and subsequent frequency of intrusions immediately afterwards?

Answer 32

• Short term intrusions: preexisting tendency to suppress unwanted thoughts + more negative affective state predicted more frequent intrusions;
• Long-term intrusions: might best be predicted by tendency to suppress immediately after the occurrence of a traumatic event, which is influenced by negative beliefs about the event.

Question 33

What is the rebound effect of suppression?

Answer 33

deliberate thought suppression can result in a later increase in frequency of thoughts.

Question 34

What is controlled disaster search?

Answer 34

1st process required in suppression of a thought = deliberate & conscious search for thoughts that are not the to-be- suppressed or, ‘target’ thought & to maintain chosen replacement thought in consciousness.

Question 35

What is automatic target search?

Answer 35

2nd process required in thought suppression → some sort of monitoring for presence o target thought in order to alert controlled distracter search to failures in the suppression attempt.

Question 36

What processes are involved in thought suppression?

Answer 36

1. Controlled disaster search
2. Automatic target search

Question 37

What could attentioanl bias found in anxiety disorders be caused by?

Answer 37

Attentional bias found in anxiety disorders may actually be caused by attempts at cognitive avoidance: as soon as suppression efforts are activated, there is an immediate hypervigilance (= enhanced state of sensory sensitivity) to threat cues.

Question 38

How do people with OCD take control or “feel” like they have control?

Answer 38

Through compulsions

Question 39

How does perfectionism related to OCD?

Answer 39

Perfectionism → also related to OCD, people with OCD have higher standards, easier to feel failure and feel more responsible.

Question 40

What is PTSD?

Answer 40

psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances.

Question 41

What is the DSM for PTSD?

Answer 41

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) ways.
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning/worsening after the traumatic event(s) occurred, as evidenced by 2 (or more) of the following:
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. Disturbance is not attributable to the physiological effects of a substance
(e.g., medication, alcohol) or another medical condition.

Question 42

Explain DSM criteria “A” of PTSD

Answer 42

Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
* Directly experiencing the traumatic event(s).
* Witnessing, in person, the event(s) as it occurred to others.
* Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual/threatened death of a family member or friend, the event(s) must have been violent or accidental.
* Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains: police officers repeatedly exposed to details of child abuse).

Question 43

Explain DSM criteria “B” of PTSD

Answer 43

Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

• Recurrent, involuntary & intrusive distressing memories of the traumatic event(s).
• Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s)
• Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.
• Intense/prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
• Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Question 44

Explain DSM criteria “C” of PTSD

Answer 44

Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
* Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s);
* Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

Question 45

Explain DSM criteria “D” of PTSD

Answer 45

Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by 2 (or more) of the following:

• Inability to remember important aspect of traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
• Persistent & exaggerated negative beliefs or expectations about oneself, others, or the world.
• Persistent, distorted cognitions about cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
• Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
• Markedly diminished interest/participation in significant activities.
• Feelings of detachment/estrangement from others.
• Persistent inability to experience positive emotions.

Question 46

Explain DSM criteria “E” of PTSD

Answer 46

Marked alterations in arousal & reactivity associated with traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

• Irritable behavior & angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
• Reckless or self-destructive behavior.
• Hypervigilance.
• Exaggerated startle response.
• Problems with concentration.
• Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

Question 47

What 2 specifiers allows coding the presence of dissociative symptoms?

Answer 47

(depersonalization / derealization) and / or a delayed onset of expression.

Question 48

What is depersonalisation?

Answer 48

Depersonalization = the perception of being an outside observer of oneself as well as a sense of unreality or detachment.

check if correct

Question 49

What is derealization?

Answer 49

Derealization = the perception of being detached from one’s surroundings or the perception that one’s environment has a sense of unreality.

check if correct

Question 50

What is not considered a trauma?

Answer 50

• Emotional neglect → when a person needs to take care of a family member
• Emotional abuse → being yelled at, punished cruelly
• Physical neglect → basic needs not met (food, shelter, clothing, etc)
• People do not have to experience feelings of helplessness, anxiety etc. during the trauma

check if correct

Question 51

What are the subtypes of PTSD?

Question 52

What is the prevalence of PTSD?

Answer 52

• PTSD is unique because it requires a specific etiological component. PTSD can only be diagnosed following a traumatic event.
• Men are exposed to more traumatic events during their lifetime than women.
• men and women experience different types of traumatic events.

is this correct???

Question 53

What kinds of traumatic events are prevalent for men and women?

Answer 53

Men:
* War-zone and combat traumas;
* Physical assaults;
* Accidents;

Women:
* Child sexual abuse;
* Molestation;
* Rape;
* Intimate partner violence.

→ women are twice as likely as men to meet criteria for PTSD.

Question 54

What are the impairments of PTSD?

Answer 54

1. Occupational and academic functioning
2. Marital and family functioning
3. parenting
4. Friendships & socializing
5. Overall QoL

Question 55

How does PTSD impair occupational and academic functioning?

Answer 55

• Unemployment, work loss;
• Increased cut back days, calling in sick;
• Annual productivity loss;
• Limitations in the type of work they performed;
• More difficulty performing at work;
• Academic impairment (difficulties in school)

Question 56

How does PTSD impair marital and family functioning?

Answer 56

• Greater marital dissatisfaction;
• Marital separation and divorce;
• Poor conflict resolution skills → poor communication → relationship problems.

Question 57

How does PTSD impair parenting?

Answer 57

• Offspring internalizing problems;
• Parental physical aggression towards children;
• Impaired attachment to children;
• Child behaviour problems;
• Decreased parenting satisfaction.

Question 58

How does PTSD impair friendships & socialising?

Answer 58

• More impaired subjective social support;
• Greater erosion in perceived support from non-veteran friends.

Question 59

How does PTSD impair overall QoL?

Answer 59

• Homelessness;
• Financial loss;
• Subjective well-being.

Question 60

What is the comorbidity for PTSD?

Answer 60

• PTSD has highest rate of comorbodities, more than 90% of individuals diagnosed with ptsd have also diagnosed with other disorders: depression, substance abuse disorder, GAD
• Pre-existing disorders may increase risk for PTSD

Question 61

What are the difference in experiencing a trauma when child or adult?

Answer 61

• → It is worse when you have a trauma as a child.
• Patients who experience childhood abuse are much more likely to experience PTSD, which = treatment (exposure therapy) being more difficult because they are lacking skills to effectively handle the emotions triggered by therapy sessions.

Question 62

Why is PTSD no longer considered an anxiety disorder?

Answer 62

• most anxiety disorders are associated with the fear of the future, but PTSD is more associated with trauma from the past. It is also more mood inclined (depression).
• trauma aspect: in other anxiety disorders, the aversive event that starts the disorder is not as important as it is in PTSD, as the trauma is a big part of the diagnosis in PTSD. trauma can rather be seen as stressors than fear related events.
• PTSD → only anxiety disorder where patients actually need to experience a traumatic event or be exposed to a traumatic event (criteria A).
• In anxiety disorders → no need for exposure.

Question 63

**What are the risk factors/ susceptibility factors for developing PTSD?

Answer 63

• Distal factors
• Proximal factors
  *

Question 64

What are the 4 symptom trajectories of trauma?

Answer 64

• Resilience
• Recovery
• Chronic
• Delayed

Question 65

Explain resilience as a symtpom trajectory of trauma

Answer 65

ability to maintain equilibrium after a trauma

Question 66

Explain recovery as a symptom trajectory of trauma

Answer 66

individuals experience moderate disruptions in normal functioning after a traumatic event

Question 67

Explain chronic as a symptom trajectory of trauma

Answer 67

individuals who experienced severe disruptions in functioning immediately after the traumatic event and maintained these high symptom levels over time

Question 68

Explain delayed as a symptom trajectory of trauma

Answer 68

individuals who initially demonstrated moderate disruptions in functioning, and whose symptoms steadily increased to severe levels over time.

E.g. combat veterans → first positive moods due to homecoming

Question 69

What are the criticisms of the delayed symptom trajectory of trauma?

Answer 69

there is some debate about the validity of the delayed onset trajectory, which was identified in a number of studies. PTSD could not be detected at first because of other confounding variables. Furthermore, individuals with PTSD could have recovered from their initial symptoms and had then been reactivated by another traumatic event. It is also possible that people develop coping strategies that reduce symptoms in the short term, when these methods stop working, the symptoms re-emerge. There is also a lack of clarity about the definition of this trajectory.

Question 70

What is. thefragmented memory and how does it maintain PTSD?

Answer 70

• On the one hand, patients often have difficulty in intentionally retrieving a complete memory of the traumatic event. Their intentional recall is fragmented and poorly organized, details may be missing and they have difficulty recalling the exact temporal order of events.
• On the other hand, patients report a high frequency of involuntarily triggered intrusive memories involving reexperiencing aspects of the event in a very vivid/realistic and emotional way.

Question 71

What is EMDR?

Answer 71

Eye movement desensitisation and reprocessing (EMDR) → effective treatment for alleviating trauma symptoms, and the positive effects of this treatment have been scientifically confirmed under well-controlled conditions.

Question 72

Explain EMDR

Answer 72

• Crucial part of the procedure involves the patient recalling traumatic memories while simultaneously making horizontal eye movements → dual tasks.
• Patient has to rate the memory in terms of vividness and emotionality.
• With this the nervous system will be rebalanced & leads to a shift in information that is dysfunctionally locked in the nervous system.
• Briefly recalling the traumatic memory, without a dual task, does not change the memory (so eye movement is crucial for effectivity).

Question 73

How does the workiing memory theory explain the workings of EMDR?

Answer 73

• According to the WM theory, flash-forwards and flashbacks are similarly affected by eye movements.
• The WM theory also allows researchers to predict which individuals will benefit a lot or very little from EMDR.
• People with low working memory capacity benefit from the dual task approach.
• If a memory is difficult to recall (e.g., for people with low working memory capacity), the speed of the eye movements can be reduced or a less taxing task can be presented.
• Vivid memories require dual tasks with moderate levels of cognitive load, but if a traumatic memory is relatively vague, less taxing tasks should yield better effects.
• Rather than eye movements and beeps, other tasks can be used that require working memory capacity: counting out loud for instance.
• Imagination can strengthen the vividness, emotionality, and even the credibility of a mental image through imagination inflation.
• The WM study suggests that EMDR practitioners have bumped into a technique that brings about the reverse: imagination deflation.

Question 74

What are different ways of doing EMDR?

Answer 74

• Cognitive lights;
• Sounds, beeps (does not work as well / at all);
• Fingers;
• Task needs to be simple so the patient can still recall memory and visualize it

Question 75

What is the effect of exposure therapy on PTSD & what problems are there while treating PTSD?

Question 76

What is imagery rescripting?

Answer 76

Imagery Rescripting (ImRs) = technique that targets the meanings and schemas resulting from traumatic childhood memories’.

Question 77

How does imagery rescripting work?

Answer 77

• Patient imagines the (onset of a) traumatic experience and subsequently changes the original course of events by imaging different interventions and outcomes = allowing for change of original schematic representations and cognitions.
• ImRs is supposed to change meaning of original trauma memory, guided within the imagery by experience of what one needed in situation & getting those needs met in fantasy.
• ImRs can be understood as a way of enhancing previously failed emotional processing.
• Method implies changing the traumatic imagery to correct the situation in fantasy, and to produce a more favorable outcome (without denying the trauma), imagining having control over the situation and being able to act according to one’s needs, to express one’s feelings and action tendencies. The patient is stimulated to express emotions, impulses and needs experienced during imaginal reliving of trauma → This often leads not only to (imagined) expression of inhibited emotions and actions, but also to new viewpoints bringing about a change in meaning of the traumatic event.

Question 78

What is mental imagery?

Question 79

What are flashforwards?

Answer 79

• Flashforwards = intrusive vivid images of future catastrophe.
• Flashforwards are important in social fears, like performance anxiety