Lecture 3 - Anxiety Flashcards
Define stress, worry and anxiety
STRESS
- physical/psych response to real/perceived threat
- fight v flight
WORRY
- thinking/imagining
- past or future focussed
- +ve: resolve/avoid threats; avoid emotions
- -ve: learned behaviour
- attempt for mental prob-solving (outcome uncertain but 1+ negative outcomes)
ANXIETY
- feeling of dread
- physical sensations
- triggered by limbic system
Define fear
- immediate alarm response to present danger
- strong escapist tendencies
- can be adaptive (flight/fight)
- sympathetic NS arousal
Define panic
- abrupt intense fear
- physical symptoms (heart palpitations, chest pain, shortness of breath, dizziness)
Explain and neurobiological aspects of anxiety
- neurocircuitry: hippocampus, amygdala, cingulate cortex
- ANS: sympathetic (fight/flight) and parasympathetic (mobilise, calm down)
- HPA axis: hypothalamus, anterior pituitary, adrenal gland (cortisol); feedback process
What is the prevalence of anxiety disorders?
14.4% (most common)
Panic 2.6% Agorophobia 2.8% Social 4.7% GAD 2.7% OCD 1.9% PTSD 6.4%
What are the gender differences in anxiety disorders?
- more in females
WHY?
- genetics? heritability of neuroticism?
- hormonal diffs (cortisol, reproductive)
- higher anxiety sensitivity?
- gender-specific trauma
- ruminate more
- more sensitive to social cues
- gender socialisation about confronting fears
- higher appraisals of threats
- other sociocultural factors
What is the burden and impact of anxiety disorders?
- 4 days/mth out of role (1.5 days in those without anxiety)
- 47% not in labor force (19% without anx)
- reduced job-seeking
- those who are working: 2+ jobs, self-employed/employers, work extreme hours, less satisfied with work accomplishments
How many people with anxiety seek help?
38%
What is the comorbidity of anxiety disorders?
50% have another dx (others say up to 81%)
GAD (82%) and panic with agoraphobia (72%) have highest comorbidities
Depression. 50%.
Why? interconnections in brain regions, partly shared genetic etiology, shared personality traits (neuroticism)
What are the 6 risk factors for anxiety?
- female
- illness
- temperament
- parenting style (over-protective)
- early life experiences (bullying)
- genetics (30-40%)
What are the selective attention/attentional biases in anxiety?
attentional system sensitive and biased in favour of threat-related stimuli
selective attention to aspects of environment that agree with thier threat
What are the types of safety behaviours?
- direct avoidance
- escape
- subtle avoidance
- restorative v. preventative
What is Cognitive Attentional Syndrome?
- based on Wells’ meta-cognition
- using coping strategies that involve controlling thoughts»_space; issues in psychological wellbeing
- meta-cognition is central to this process
- meta-cognition: monitor, control, appraise thoughts/learning/memory
- CAS is caused by extended thinking
What are the diagnostic features of GAD?
- 6mths
- excessive anxiety and worry more days than not
- unable to control worry
3+ of
- restlessness
- fatigue
- difficulty concentrating
- irritable
- muscle tension
- sleep disturbance
What is the GAD prevalence, onset and course?
- prev: 2% (2x women)
- onset: <25
- course: usually chronic
- low rate of treatment-seeking
Explain the comorbidity of GAD. Does it occur first or second in most cases?
68% comorbid
- usually precedes others MIs
suicide: 17% attempt, 18% ideation
panic: 50%
depression: 25-30%
substance use: 60%
What are the 4 key psychological features of GAD
- biases in thinking and reasoning (intolerant of uncertainty)
- worry as avoidance
- beliefs about worry (worry is helpful)
- meta-cognition (meta-worry)
Explain the meta-cognitive model of GAD
Positive beliefs about worry > worry will help me solve problems/allow me to be prepared and cope with the threat
Type 1 worry:
- external daily events
- non-cognitive internal events
Type 2 worry:
- worry about nature/occurence of thoughts
- worry about worry
- unable to function due to worry
- “worrying is harmful”
- “my worries will take over and control me”
- outcomes: behaviour (avoidance, distraction), thought control (attempts to suppress), emotion (anxiety, frustration)
- cog + somatic symptoms viewed as evidence of loss of control or of harmful effects of worry > vicious cycle
What is a panic attack?
- abrupt surge of intense fear or intense discomfort
- peak within minutes
- 4+ of: increased HR, sweat, tremble, shortness of breath, choking, chest pain, nausea, feel dizzy/lightheaded, chills/hot flushes, numb/tingling, derealisation or depersonalisation, fear losing control/going crazy, fear dying
What are the 3 types of panic attack?
- unexpected / spontaneous: uncued, random
- expected / situationally bound
- situationally predisposed
What are the alternative contributors to a panic attack?
- CNS stimulants
- withdrawal from CNS depressants
- medical conditions
- exercise
- stress
- hyperventilation
What is the relationship between panic and hyperventilation?
- hyperventilation has been considered to be a cause, correlate and consequence of panic attacks
- hypercapnic = too much CO2 in blood
- hyperventilation model: HPV symptoms lead to fear, which fuels further HPV (anx caused by hypercapnic breathing)
- false suffocation alarm hypothesis: HPV serves as a way to avoid the anxiety caused by hypercapnic breathing
Explain the cognitive model of panic
- PA result from catastrophic misinterpretation of bodily sensations
- anxiety sensitivity is a vulnerability factor
- safety behaviours > persistence of panic
- cognitive biases > maintain panic
Maintenance of panic:
- selective attention to bodily events
- safety behaviours
- avoidance of anxiety-provoking situations
How was Clark’s model of panic extended?
BANDURA
- self-efficacy plays a central role (perception of ability to cope)
- reduce panic by changing self-efficacy, NOT reducing misinterpretations of bodily sensations
BECK
- catastrophic misinterpretations of bodily sensations
- individual vulnerability > perceived likelihood of danger + level of coping abilities
What is panic disorder?
- recurrent, unexpected panic attacks
- persistent apprehension over their recurrence/consequences
- 1 month
- sig. maladaptive change in behaviour related to the attacks (eg. avoidance)
What is the prev and onset of panic disorder?
- 40% of young people have had 1+ PA
- 12mth prev: 1.1%
- onset: 15-25yrs
(onset after 40 suggests depression or possible somatic cause)
What is the comorbidity of panic disorder?
substances medical conditions (eg. hyperthyroidism) phobias (incl. agoraphobia 33-50%) OCD PTSD separation anxiety
What are the myths of panic disorder?
going crazy
losing control
heart attack
What is agoraphobia?
- marked fear/anxiety about 2+: public transport, open space, enclosed space, line/crown, outside home alone
- fears/avoids situations bc. they think escape might be difficult/help not available if they need it
- family or friend company may increase no. of situations that can be endured
- often become discouraged, depressed and demoralised by the constriction in their lives
What is the course and gender split in agoraphobia?
75% women
course: usually chronic, can wax and wane
What are the risk factors for agoraphobia?
- general vulnerability common to all anxiety disorders
- personality: neuroticism, perfectionism
- genetics: -ve affectivity
- catastrophic misinterpretations
- anxiety sensitivity: interpret anxiety sensations as harmful
- Barlow: bio and psych vulnerability factors
How can the cognitive model of panic be adapted for agoraphobia?
- panic is strongly associated with the cognition that autonomic arousal is dangerous and can lead to harmful consequences
- agoraphobia: fear of the dangerous and disastrous consequences is associated with specific situations
- avoidance is a key maintaining factor in both
What is the cognitive model of agoraphobia, according to Clark?
- individual fears/avoids situations where they have had a panic attack
- situations which are avoided then grow in number and breadth
What are the predictors of agoraphobia?
- severity of PA + anticipatory fears about consequences of attacks
- earlier age onset = longer illness
- experience of particular panic symptoms (eg. personalisation, chest pain, dyspnea, trembling)
- anticipated panic «_space;key role, strongest correlate
- perfectionism
What is a specific phobia?
- irrational fear
- markedly interferes with functioning
- exposure: anxiety response
- phobic stimulus avoided or endured
What are the subtypes of specific phobia?
- animal
- natural environment
- blood-injection-injury
- situational
- other
** most people with phobias have multiple phobias of different subtypes
What is the prevalence and gender split of phobias?
- prev: 9%
- M:F = 1:4
- only severe seek treatment
What are the 4 proposed aetiological factors of phobias?
PSYCHODYNAMIC
- Freud, Little Hans
- castration anxiety + Oedipal complex
- fear = misplaces fear/conflict
CONDITIONING
- Little Albert
- associated threatening stimulus with non-threatening
- fear maintained by avoidance (lack of ‘testing’)
SOCIAL LEARNING
- observe trauma in others
- learnt by hearing about others’ experiences
- modelled or ‘instructed’
NON-ASSOCIATIVE FEAR
- feared stimulus represents long-standing danger to species
- fear/avoidance increases reproductive opps
- fear/avoidance partly under genetic control
- biologically relevant
- people who develop phobias do not ‘habituate’ to overcome ‘innate’ fears
- habituation depends on: opps for exposure at critical developmental periods + individual diffs in rate of habituation
What is the problem with the proposed aetiological factors of phobias?
- many have no clear environmental cause (direct or indirect) > 56% children’s phobias; 68% adult
66% of people without phobia had experienced a conditioning event
What is Social Anxiety Disorder according to the DSM-5?
- fear situations with exposure to possible scrutiny by others
- fear embarrassment and humiliation
- fear acting in a way that will show anxiety > negative social evaluation
- social sits almost always provoke fear/anx
- social sits avoided or endured
- fear/anxiety out of proportion to actual threat posed
- persistent (6+ mths)
What is the prevalence and gender split of social phobia?
lifetime prev: 7-13%
- shyness: 20-48%
- more in shy people (18%) relative to non-shy (3%)
- studies suggest prev is increasing
- on continuum: shyness > mild social fear > generalised social phobia > avoidant PD
GENDER
- epidemiological studies: more F
- clinical studies: equal F/M
What is the onset, course, suicide rate and comorbidity of social phobia?
- onset: early-mid teens (95% before age 20)
- onset of more severe/generalised types especially early
- course: usually stable and chronic (can fluctuate w life stressors)
- suicide: 2x general population
COMORBIDITY
- other anxiety disorders
- mood disorders
- substance use
- social phobia usually precedes other dx
What are the internal and environmental risk factors for social anxiety?
INTERNAL
- genetics: heritability
- cognitive: -ve appraisal of social situations
- social skills deficit (chicken vs egg?)
- temperament: behavioural inhibition; self-conscious shyness
ENVIRONMENTAL
- parent-child interaction: high control + protection, less warmth
- aversive social experience: teased, bullied, ridiculed
- negative life events: esp in childhood (parental divorce/death, parent mental illness, family conflict, sexual abuse)
What are the 3 key features of the cognitive model of social anxiety?
SAFETY BEHAVIOURS
- exacerbate unwanted symptoms
- contaminate social situations (seems unfriendly, aloof, uninterested)
- support attributional bias (non-occurrence of catastrophe attributed to SB not distorted appraisals)
- avoid eye contact, say little, let partner talk, plan what to say, pretend to be interested in something else
ANTICIPATORY + POST-EVENT PROCESSING
- rumination
- plan + rehearse conversations
- ‘post-mortem’
- selective abstraction
ASSUMPTIONS AND BELIEFS
3 CORE SCHEMA:
- core self-beliefs (I’m boring)
- conditional assumptions (If I show I’m anxious, people will judge me)
- rigid rules for social performance (I must always sound intelligent)
- NATs: ‘I don’t know what to say. People must think I’m stupid’
- self-processing: image of self as plain, unintelligent etc.
What is the issue with defining anxiety disorders?
boundary b/w normal and pathological anxiety cannot be drawn with great precision or confidence
