Chapter 5 Flashcards
Definition and symptoms of Anxiety
- Future-oriented mood state characterized by marked negative affect
- Includes somatic symptoms of tension
muscle tightness, tension headaches - Apprehension about future danger or misfortune exhibited through any of: behaviors, feelings, and thoughts
Definition and symptoms of Fear
- Present-oriented mood state characterized by marked negative affect
- Involves abrupt activation of the sympathetic nervous system
- Immediate fight or flight response to danger or threat
- Strong tendency to avoid or escape
signs of an anxiety disorder
- characterized by pervasive and persistent symptoms of anxiety and fear
- involve excessive tendencies to avoid and escape
- anxiety symptoms and avoidance cause clinically significant distress and impairment
Definition of a panic attack
- abrupt experience of intense fear or discomfort
- attacks occur (at least initially) out of the blue and are not cued by obvious triggers
Diagnosing panic disorder
- the presence of 4 or more of the 13 symptoms
- abruptly, reaching peak w/in 10 minutes
- at least 2 unexpected attacks are required
- at least one of the panic attacks must be followed by persistent concerns lasting at least one month about having another attack
Symptoms of a panic attack
1- palpitations, pounding heart, or fast heart rate
2- sweating
3- trembling and shaking
4- sensations of shortness of breath or smothering
5- feelings of choking
6- chest pain or discomfort
7- feeling dizzy, unsteady, lightheaded, or faint
chills or hot flashes
8- nausea or abdominal distress
9- derealisation (feelings of unreality) or depersonalisation (being detached from oneself)
10- fear of losing control or going crazy
11- paresthesias (numbness or tingling sensations)
12- fear of dying
13- chills or hot flashes
DSM-IV subtypes of panic attacks
Situationally bound (cued) = panic that occurs only in certain situations; expected
Unexpected (uncued) = panic that is not associated with specific situations; comes unexpectedly, “out of the blue”
Situationally predisposed = panic that may or may not occur in certain situations
diathesis-stress model for anxiety disorders
people inherit vulnerabilities for anxiety and panic, not anxiety disorders
stress and life circumstances activate the underlying biological vulnerability
Biological contributions to anxiety disorders
GABA, noradrenergic and serotonergic brain systems are implicated in anxiety
corticotropin releasing factor (CRF) and the HPA axis
limbic and the septal-hippocampal systems
amygdala
behavioural inhibition system (BIS)
fight-flight system
Freud’s perspective on anxiety
- anxiety is a psychic reaction to danger
- anxiety involves reactivation of an infantile fear situation
behaviouristic perspective on anxiety
anxiety and fear result from direct classical and operant conditioning and modelling
psychological perspective on anxiety
early experiences with uncontrollability and unpredictability
social perspective on anxiety
- stressful life events as triggers of biological and psychological vulnerabilities
- many stressors are familial and interpersonal
integrative perspective on anxiety
- biological vulnerability interacts with psychological, experiential, and social variables to produce an anxiety disorder
- consistent with diathesis-stress model
6 anxiety disorders
generalised anxiety disorder (GAD) specific phobias panic disorder with and without agoraphobia (PD) social phobia posttraumatic stress disorder (PTSD) obsessive-compulsive disorder (OCD)
Anxiety disorder changes from DSM 4 to DSM 5
DSM 5 moved PTSD and OCD to separate categories
Separation anxiety disorder added
Agoraphobia
fear or avoidance of situations or events where it might be difficult to escape or in which you would not have help available if you have a panic attack
If avoidance is persistent and pervasive the diagnosis is panic disorder with agoraphobia if it is not present than the diagnosis is panic disorder without agoraphobia
Proposal for the DSM 5 that panic and agoraphobia be considered separate disorders
Panic disorder facts and statistics
3.5% of the general population
2/3 of people with panic disorder are women
onset is often acute, usually beginning between 25 and 29 years of age
- 21% of Canadians aged 15+ experience at least one panic attack in their lifetime but only 1.5% of the Canadian population meets criteria for panic disorder
- Develops in late teen/early adulthood but treatment is usually not sought till 30s
- Women 2X more likely to be effected
medications for panic disorder
- target serotonergic, noradrenergic, and GABA systems
- SSRIs are currently the preferred drugs
relapse rates are high following medication discontinuation
psychological and combined treatments for panic disorder
cognitive-behavioural therapies are highly effective
Combined treatments do well in the short term
best long-term outcome is with cognitive-behaviour therapy alone
Specific phobias according to DSM
extreme and irrational fear of a specific object or situation
Exposure leads to anxiety response
recognition that fears are excessive
avoidance or endure with intense distress
interference with daily functioning
duration of 6+ months
Specific phobias stats and facts
11% of the general population meet diagnostic criteria for specific phobia
tend to be chronic , with onset beginning between 15 and 20 years of age
Considerably more common among women
Women have 90-95% animal phobias
Women have twice as many B-I-I phobias
subtypes of specific phobias
- Blood-injury-injection = vasovagal response to blood, injury, or injection
- Situational = public transportation or enclosed places; e.g., planes
- Natural environment = events occurring in nature; e.g., heights, storms
- Animal = animals and insects
- Illness = bodily related; e.g., developing cancer
- Other = do not fit into the other categories; e.g., fear of choking, vomiting
Specific Phobias Etiology
potential contributing factors
- Biological and evolutionary vulnerability
- Direct conditioning
- Observational learning
- Equipotentiality vs nonassociative models (the amount of learning required to develop that fear; the potential for that stimuli to become a phobia)
- Disgust sensitivity (the degree to which people are susceptible to being disgusted by a stimuli)
facts and statistics for Social Phobia
- 13% of the general population meet lifetime criteria for S.P.
- women are slightly more represented than men
- onset around age 15
- 81% of people with S.P. have comorbidity (Specific phobia, Depression, Substance abuse)
Social Phobia
same criteria as specific phobia except fear of one or more social or performance situations where exposed to unfamiliar people or scrutiny
Social situations are avoided or endured with great distress
generalized subtype = social phobia across numerous social situations
Deleted for DSM 5
Social Phobia and Genetics
Genetic contribution 30-50% (predisposition)
Social Phobia and Environment
Parental criticism, abuse/neglect, bullying
Social Phobia and Temperament
Behavioral inhibition in children increases risk
Social Phobia and Cognition
Perfectionistic; self-critical tendencies
Social Phobia Medications
- beta blockers are ineffective
- tricyclic antidepressants and monoamine oxidase inhibitors reduce social anxiety
- SSRIs are medication of choice; e.g., paroxetine (Paxil) is FDA approved for treatment of social anxiety disorder
- relapse rates are high following medication discontinuation
Social Phobia and psychological treatment
- cognitive-behavioural treatment
- psychoeducation, exposure, rehearsal , role-play in a group setting
- cognitive-behavioural therapies are highly effective
- Best therapy is group therapy
- CBT skills are key for anxiety
PTSD signs and diagnosis
- requires exposure to an event resulting in extreme fear, helplessness, or horror
- re-experiencing of the event (e.g., memories, nightmares, flashbacks)
- avoidance of cues that are reminders of the event
- emotional numbing and interpersonal problems or feel like no one really understands them
- marked interference with functioning
- diagnosis cannot be made earlier than 1 month post-trauma
Liklihood of PTSD after a traumatizing event
Most people cope with trauma
No PTSD in 65% of soldiers surviving traumatic events
No PTSD in 40-80% of rape survivors
facts and statistics for PTSD
- 7.8% of the general population have PTSD
- combat and sexual assault are the most common traumas
- 50% of us will experience trauma
- 10% of these women and 5% of these men will develop PTSD
Subtypes of PTSD
Acute = PTSD one to three months post trauma
Chronic = PTSD onset more than three months post trauma
Delayed onset= PTSD onset six months or more post trauma
Acute stress disorder = (not PTSD) PTSD symptoms immediately post-trauma
Mediators of PTSD Intensity
- intensity of the trauma and the reaction to it
- uncontrollability and unpredictability
- social support post-trauma
- direct conditioning and observational learning
Ex. of PTSD and Classical conditioning (Mowrer’s 2-factor theory)
Violent car crash leads to fear of driving (CS)
Person then avoids driving or being in vehicles, and this reduction in anxiety is reinforced
Ex. of PTSD and Psychodynamic theory
Memories of trauma suppressed or repressed but things in your environment bring them up
Treatment for PTSD
Short-term crisis counselling Post-disaster debriefing sessions Group therapy Exposure therapy Expressive writing Psychotropic medications
OCD: DSM Criteria
A. either obsessions or compulsions
B. recognition of symptoms as excessive or unreasonable
C. distress or interference with functioning
Obsessions
Recurrent, persistent thoughts, images, impulses that are persistent and distressing … and
Not simply excessive worries … and
Person attempts to ignore or suppress them … and
Person recognizes they are product of mind
Compulsions
Repetitive behaviors the person feels driven to perform in response to obsessions … and
Behaviors or acts aimed at preventing or reducing stress or dreaded event
OCD subtypes
Contamination Subtype, Checking Subtype, Hoarding Subtype, Order/Symmetry Subtype
OCD facts and statistics
- 2.6% of people get OCD in their lifetime
- most people with OCD are women
- OCD tends to be chronic
- onset is typically in early adolescence or young adulthood
Biological Perspective on OCD
- tends to run in families
- often accompanies other brain insult (e.g., encephalitis) or neurological problem (e.g., Tourette’s syndrome)
- responds to serotonergic drug treatment
SSRIs
Psychodynamic Perspective on OCD
associated with fixation at anal stage of development (Freud) or feelings of inferiority (Adler)
understanding based on clinical case studies
Behaviourist Perspective on OCD
obsessions are learned anxieties
acquired by classical and operant conditioning
compulsions are reinforced through anxiety reduction
Cognitive Perspective on OCD
paradoxical effect of trying to suppress particular thoughts
belief that certain thoughts are unacceptable
memory failure and checking behaviour (did I really turn of the stove?)
Thought suppression/ rebound effect present in OCD
trying to suppress obsessional thoughts can have the paradoxical effect of increasing their frequency (trying not to think of something will only cause you to think of it more)
medication for OCD
clomipramine and other SSRIs seem to benefit up to 60% of patients
psychosurgery (cingulotomy) is used in extreme cases
relapse is common with medication discontinuation
contributors to OCD
similar to the other anxiety disorders
early life experiences and learning that some thoughts are dangerous or unacceptable
thought-action fusion = tendency to view the thought as similar to the action
psychological treatment OCD
cognitive-behavioural therapy is most effective with OCD
CBT involves exposure and response prevention
combining medication with CBT does not work as well as CBT alone
Generalised Anxiety Disorder
excessive, uncontrollable anxious apprehension and worry about life events (a wide spectrum of things)
accompanied by strong, persistent anxiety
somatic symptoms differ from panic
e.g., muscle tension, fatigue, irritability
persists for 6 months or more
Generalised Anxiety Disorder facts and stats
- 4% of people meet diagnostic criteria for GAD
- women outnumber men approximately 2:1
- onset often begins in early adulthood
- tendency to be anxious runs in families
associated features of generalised anxiety disorder
- people with GAD have been called “autonomic restrictors” – restrict the activation of their autonomic system (sweat, fast heart beat, etc. does not happen)
- fail to process emotional component of thoughts and images
- intolerance of uncertainty
treatment of GAD
medical: benzodiazepines are often prescribed
psychological: cognitive-behavioural therapy
Hard because you do not have one idea or thought to focus on eliminating
Cant bring about anxiety because they do not get fast heart beat etc. when they are anxious
Mowrer’s two-factor theory
suggests that fears develop through the process of classical conditioning and are maintained through operant conditioning
Interpersonal factors - Attachment theorists
- An anxious-ambivalent attachment style in infancy is a predictor for anxiety problems in children around age 17 years.
- Anxiety in parents may contribute to a general psychological vulnerability to anxiety in children
“triple vulnerability” etiological model of anxiety
generalized biological (genetic predisposition), nonspecific psychological (low self-esteem and sense of control), and specific psychological (experiences) vulnerabilities interact to increase risk
The most common of all mental disorders
anxiety disorders
Behavioural avoidance test (BAT)
patients are asked to enter situations that they would typically avoid. They provide a rating of their deggree of anticipatory anxiety and the actual level of anxiety that they experience.
Psychophysiological assessment strategies
include the monitoring of heart rate, breathing, blood pressure, and galvanic skin response while a patient is approaching a feared situation or experiencing a panic attack.
Cognitive theories and panic disorder
focus on the idea that individuals with panic disorder catastrophically misinterpret bodily sensations such as getting dizzy or out of breath as a sign of something being wrong
A fear of letting go or loosing control may lead to panic attacks
Anxiety Sensitivity
- the belief hat the somatic symptoms related to anxiety will have negative consequences that extend beyond the panic episode itself
- ex. When I feel pain in my chest, I worry that I’m having a heart attack; I worry that other people will notice my anxiety
- found in Panic disorder and PTSD
Alarm theory
true alarm - body reacts to a real danger
false alarm - system is activated by emotional cues rather than real danger and the situation that triggered it then becomes associated with neutral cues through classical conditioning and the person may begin to fear internal sensations or external stimuli
Generalized vs Nongeneralized Social Phobia
Generalized: involves the fear of most social settings and interactions
Non-generalized: fear of specific social situations or activities
Social Phobia vs Agoraphobia
The anxiety that characterizes social phobia involves a fear of being negatively evaluated or embarrassed in social situations
The anxiety that characterizes agoraphobia involves a fear of not being able to escape or not have help available if you have a panic attack
Neutralizations
behavioural or mental acts that are used to try to prevent, cancel, or undo the feared consequences and distress caused by an obsession
Thought-action fusion (TAF)
The belief that (1) having a particular though increases the probability that the thought will come true and (2) having a particular thought is the moral equivalent of doing it
Neurobiological model of OCD
implicate the basal ganglia and frontal cortex
Cognitive-behavioural model of OCD
posits that problematic obsessions are caused by the person’s reaction to intrusive thoughts
Why do compulsions persist?
because they tend to lower the severity of anxiety, lower the frequency of obsessions, and prevent obsessions from coming true
Risk factors for developing PTSD
pre-trauma: low socio-economic status, education, having a previous psychiatric history, experiencing childhood abuse
post-trauma: severity of the event, lack of social support, additional stressful experiences after the traumatic event, exposure to interpersonal traumas (physical violence or sexual abuse)
Genetics and PTSD
- functioning of the hypothalamic-pituitary-adrenal
- decreased cortisol and/or enhanced negative feedback of adrenal function
- reduced hippocampal volume
Cognitive psychological theory on PTSD
- traumatic experiences can affect the mind on multiple levels and is stored and retrieved in different ways
- thoughts that lead to feelings of generalized threat, despite the fact thta the event is in the past, are cognitive factors that partly cause and maintain PTSD
The most widely used drugs for treating states of tension associated with anxiety disorders
minor tranquilizers
The type of exposure therapy involving relaxation in an anxiety-provoking situation is
systematic desensitization
Before the development of antidepressants what were the most widely prescribed psychiatric medication for anxiety disorders
benzodiazepines
Systematic desensitization
one of the earliest forms of exposure developed by Joseph Wolpe. Patient imagine the lowest feared stimulus and combining this with a relaxation response, they work their way up till they can learn to handle increasingly distressing stimuli
Flooding
or intense exposure is a treatment for anxiety disorders that involves rapid and intense exposure to the object of fear
Online test questions
Compare and contrast social and specific phobias.
What are the symptoms of agoraphobia and why can the disorder become so incapacitating?
Discuss the role of regions of the brain and neurochemistry in anxiety disorders.
What are the primary differences between anxiety, fear, and panic? Give an example of how each can be adaptive and maladaptive.
What are obsessions and compulsions and what is a full-blown OCD like? What kind of treatment is usually helpful?
What is GAD? What are the symptoms and treatments?
Discuss the general concepts of cognitive-behavioural theories with regard to etiology and treatment of anxiety disorders
The main psychological treatment for OCD
involved exposure and ritual prevention
