Lecture 5 - Anxiety disorders

Question 1

What is state anxiety?

Answer 1

Transient experience with a temporarily increased sympathetic nervous system response & feelings of intense tension, worry, & apprehension - physiological component as well as cognitive/affective component

Question 2

What is trait anxiety?

Answer 2

Tendency to be more anxious in life

Question 3

What are four characteristics of people with high levels of trait anxiety?

Answer 3

• behaviourally inhibited
• wary in novel situations
• cautious about risks
• more likely to experience anxious states

Question 4

Are state and trait anxiety mapped differently in the human brain?

Answer 4

Yes
State anxiety is a shortcut network to keeping you safe

Question 5

What three factors identify clinically relevant anxiety?

Answer 5

a) disproportionate (e.g. phobia of spiders)
b) severe/enduring (long lasting)
c) linked with impairments in functioning

So, in anxiety disorders:
- excessive fear, anxiety, (cognitive and affective component) and avoidance (behavioural component) of perceived threats
- enduring and impairing
- often involves autonomic arousal or other physical and cognitive symptoms

Question 6

Do separation anxiety disorder and selective/elective mutism only occur in childhood?

Answer 6

Yes

Question 7

Are PTSD and OCD considered anxiety disorders?

Answer 7

Not any more, no

Question 8

What are categories A and B for DSM criteria for GAD?

Answer 8

A. Excessive anxiety/worry on more days than not for ≥6 months, about several events or activities
B. Difficult to control the worry (worry is in control of them)

Question 9

For GAD DSM criteria, section C states:

C. Anxiety/worry linked to ≥3 symptoms below, with at least some symptoms present for more days than not for at least 6 months:

What are these six symptoms?

Answer 9

i. Restless/ keyed-up or on edge
ii. Easily fatigued
iii. Difficulty concentrating / mind going blank
iv. Irritable
v. Muscle tension
vi. Sleep disturbance.

Question 10

What are sections D E and F for DSM criteria of GAD?

Answer 10

D. Clinically significant distress or functional impairment
E. Not attributable to effects of a substance or another health condition
F. Not better explained by another mental health condition

Question 11

What is the main GAD specifier?

Answer 11

Panic attack

Question 12

What is a panic attack?

Answer 12

• A sudden episode of intense fear / discomfort
• Physical symptoms include: rapid heartbeat, shaking, sweating, nausea, breathlessness, chills or hot flushes, dizziness, chest pain and disorientation
• Often occur without warning, no specific trigger

Question 13

What proportion of people with GAD experience panic attacks?

Answer 13

Around 1 in 5

Question 14

What is the first diagnostic criterion of panic disorder?

Answer 14

A. Recurrent unexpected panic attacks: abrupt surge of intense fear / discomfort that peaks within minutes

4 or more present out of:
i. Palpitations / pounding heart / accelerated heart rate
ii. Sweating
iii. Trembling/shaking
iv. Sensations of shortness of breath / smothering
v. Feelings of choking
vi. Chest pain / discomfort
vii. Nausea / abdominal distress
viii. Feeling dizzy, unsteady, disoriented or faint
ix. Chills / heat sensations
x. Paresthesias (numbness/tingling)
xi. Derealisation / depersonalization (outside of yourself and looking in) (world around you does not seem real)
xii. Fear of losing control / going crazy
xiii. Fear of dying

Question 15

For a diagnosis of panic disorder, what needs to occur in addition to panic attacks?

Answer 15

B. At least one attack has been followed by ≥1 month of
(a) persistent concern about additional panic attacks or their consequences, and/or
(b) significant maladaptive behaviour change related to the attacks (people often remove themselves from situations that could cause panic - could stop going outside)

Also:
C. Disturbance not attributable to a substance or other condition
D. Disturbance not better explained by another mental health condition

Question 16

What neurotransmitter/hormone in what brain area is thought to cause panic attacks?

Answer 16

Amygdala - SNS - adrenaline - HR and breathing rate - way past what would be useful in dangerous situation

Question 17

What neurotransmitter in what brain area slows HR after a panic attack?

Answer 17

Frontal cortex - acetylcholine

Question 18

What six conditions do GAD and PD have comorbidity with?

Answer 18

Major depressive episode
Manic/hypomanic episode
Dysthymia
OCD
ADHD
PTSD
Alcohol use disorder

Question 19

What percent of people with anxiety disorders also fulfil criteria for 2 or more disorders?

Answer 19

40-70%

Question 20

What is the estimate of lifetime prevalence of anxiety disorders by Remes et al. (2016)?

Answer 20

Prevalence of anxiety disorders (grouped together) ranged from 3.8–25%; most reviews’ estimates tended towards the lower end (i.e., 4 to 11%)

Question 21

Are rates of anxiety higher or lower in women and young adults?

Answer 21

Higher

Question 22

Are rates of anxiety lower in people with chronic diseases?

Answer 22

No - higher

Question 23

Are anxiety rates higher in people who are lesbian, gay, bisexual or transgender?

Answer 23

Yes
Particularly high in transgender men

Question 24

Are anxiety rates higher amongst people who were or have recently been pregnant?

Answer 24

Yes

Question 25

What is anxiety prevalence in transgender people?

Answer 25

Varied from 17% to 68%

Question 26

Why might prevalence estimates not be representative?

Answer 26

Vary in how anxiety diagnosis is done, vary in clinical cut off - not all ppts might have GAD Gender, age, pregnancy, LGBT+ identity and illness can all affect anxiety

Question 27

Which cultures have highest anxiety rates?

Answer 27

Euro/Anglo cultures

Question 28

What could confound the finding that non-Western cultures have lower rates of anxiety?

Answer 28

Could be confounds in terms of how anxiety is measured e.g. western nature of DSM, greater reluctance to report symptoms in some cultures

Question 29

What is the difference in anxiety prevalence for people in zones of war and persecution?

Answer 29

60% greater risk in zones of war and persecution - some studies indicate more anxiety for non-conflict

Question 30

Is there higher 12 month and lifetime prevalence in women compared to men for every anxiety disorder?

Answer 30

Yes Including: Panic disorder Agoraphobia GAD Social anxiety disorder Specific phobia

Question 31

For every 1 man, how many women receive the same diagnosis of an anxiety disorder?

Answer 31

1.7 women

Question 32

Are women with an anxiety disorder more likely to be diagnosed with MDD or bulimia nervosa?

Answer 32

Yes

Question 33

Are women with an anxiety disorder more likely to be diagnosed with a substance use disorder, ADHD, or intermittent explosive disorder?

Answer 33

No Men are.

Question 34

Do a higher proportion of women with lifetime incidence of an anxiety disorder meet the criteria for an additional anxiety disorder compared to men?

Answer 34

Yes 44.8% of women 34.2% of men

Question 35

What is the mean age of onset for all anxiety disorders?

Answer 35

21 years

Question 36

What is earlier age of anxiety onset associated with?

Answer 36

Suicide

Question 37

Does the probability of remission increase over time for all anxiety disorders?

Answer 37

Yes

Question 38

Is there a high likelihood of recurrence for anxiety disorders?

Answer 38

Yes

Question 39

What is the mean duration of illness for anxiety, and what % of people show a chronic course?

Answer 39

16 months 42%

Question 40

What is the mean duration of illness for comorbid depression and anxiety, and what % of people show a chronic course?

Answer 40

24 months 57%

Question 41

What % of people with anxiety switched to depression or had comorbid depression?

Answer 41

7% switched to depression and 16% developed comorbid depression

Question 42

What four factors are predictors of poorer diagnostic and symptom trajectory outcomes for anxiety?

Answer 42

(a) severity and duration of the baseline episode (b) comorbid depression–anxiety (c) earlier age of onset (d) older age overall

Question 43

What is the odds ratio of getting anxiety if a family member has it?

Answer 43

4 to 6 (4 to 6 times more likely to get it yourself)

Question 44

What is the heritability of anxiety?

Answer 44

About 30–50%

Question 45

For anxiety, are there a large number of genes with small effects, or a small number of genes with large effects?

Answer 45

Large number with small effects

Question 46

Is there a shared genetic risk between different anxiety disorders?

Answer 46

Yes No evidence that children of parents with particular anxiety disorders were at increased risk for the same particular anxiety disorders

Question 47

What are the risk ratios for anxiety and depression when your parents have an anxiety disorder?

Answer 47

People whose parents have an anxiety disorder are more likely to have - anxiety (risk ratio [RR] = 1.76) - depressive disorders (RR = 1.31) than people whose parents do not have an anxiety disorder

Question 48

What is behavioural inhibition and what type of anxiety disorder is behavioural inhibition a particular risk factor for?

Answer 48

Behavioural inhibition is a temperament style characterised by shyness, fear, and avoidance of novel stimuli/situations. Fear mediated behavioural style Particular risk factor for social anxiety disorders Longitudinally predicts anxiety disorders

Question 49

What is the odds ratio for anxiety disorders when you have behavioural inhibition?

Answer 49

Overall odds ratio = 2.80

Question 50

What are issues with identifying children who are behaviourally inhibited and doing a preventative intervention?

Answer 50

Probably not straightforward - where do you draw the line between disordered behaviour or just shyness? Also, variation between children in terms of developmental milestones. Also, deterministic - not all children with this will go on to develop anxiety disorders

Question 51

What are psychosocial risk factors in early life for anxiety?

Answer 51

- Prenatal stressors, notably maternal stress, depression, & anxiety - childhood maltreatment (e.g., childhood sexual abuse) - physical punishment in childhood - socioeconomic deprivation - stressful life events, particularly in early life

Question 52

How is inflammation increased in anxiety disorders and how does inflammation contribute to anxiety?

Answer 52

Dysregulation of the HPA axis, in the face of the increased sympathetic tone and decreased parasympathetic activity characteristic of anxiety disorders. This increases inflammation and contributes to increased symptoms by having direct effects on brain regions critical for the regulation of fear and anxiety. Constant low level inflammatory response - keeps anxious cycle going

Question 53

What are psychosocial risk factors for anxiety in adulthood?

Answer 53

- cigarette smoking frequency, alcohol use, cannabis use (varies between disorders), negative appraisals of life events, avoidance, and occupational factors (stress)

Question 54

What are protective factors against anxiety disorders in adulthood?

Answer 54

Social support, coping skills, and physical activity

Question 55

What is an issue when investigating risk factors without longitudinal data?

Answer 55

A lack of longitudinal data made establishing temporal precedence difficult - did anxiety come first or did risk factors come first? Drugs as self-medicating existing anxiety or making anxiety worse?

Question 56

What cognitive processes have been implicated in the development and maintenance of anxiety?

Answer 56

- Perceived lack of control - Intolerance of uncertainty - Positive and negative beliefs about worry - worry helps people to plan or help problem solving, however this gets perpetuated and repeats - people think of worry as very harmful esp with body-related symptoms, this creates more anxiety, worrying about worrying - Cognitive biases

Question 57

What 5 types of medication are used to treat GAD?

Answer 57

- SNRIs and SSRIs (e.g., duloxetine, venlafaxine, escitalopram) - Anticonvulsants (e.g., pregabalin, gabapentin) - Atypical antidepressants (e.g., mirtazapine (an NaSSA) & agomelatine (a melatonin agonist)) - Azapirones (e.g., buspirone) - Antipsychotics (e.g., quetiapine)

Question 58

What is the positive and negative of benzodiazepines?

Answer 58

Are effective but side effect profiles less acceptable (addictive potential - have to be used in short durations, however help a lot with physical symptoms)

Question 59

What key questions are asked in a cognitive behavioural case formulation for PD? Predisposing Precipitating Presenting problems Perpetuating Protective

Answer 59

What made the patient vulnerable in the first place (predisposing)? What triggered the current episode / escalation of symptoms (precipitating)? What is the ‘problem’ itself e.g. functional impairment (presenting problems)? What keeps the problem going? (perpetuating / maintenance cycles) What protective factors are in place? (key - social support) - Modifiable vs. non-modifiable factors - Plan which aspects of the presenting problem to target, how, and in what order

Question 60

What is the cognitive model of panic?

Answer 60

This theory states that people who experience recurrent panic attacks do so because they tend to misinterpret benign bodily sensations as symptoms of an “immediately impending physical or mental catastrophe”. For example, rapid heartbeat might be interpreted as evidence of a heart attack about to happen. This increases anxiety, which, in turn, heightens anxiety-related sensations. These sensations support the premise of a heart attack - and so on.

Question 61

What is the aim of CBT for anxiety?

Answer 61

Challenging people to identify their triggers: Internal triggers e.g. change to body sensations; thought or image comes ‘spontaneously’ to mind External triggers e.g. encountering a feared situation; asked to talk about the experience of panic Results in initially mild levels of anxiety, with concomitant physical changes

Question 62

Why are safety behaviours reinforced in anxiety when 'the worst' never happens?

Answer 62

Belief that safety behaviours are the reason that the worst doesn’t happen E.g. “I lay down just in time” “If I wasn’t at home resting, I probably would have had a heart attack” “If I wasn’t keeping a close eye on my heart and breathing, I would have missed that they were going too fast”

Question 63

What is involved in CBT for panic disorder?

Answer 63

- Identification of anxiety triggers - Training to reduce biases in the perception of threat - Learning techniques to reduce physiological arousal (e.g. breathing or relaxation exercises) - Reducing avoidance and safety behaviours, and replacing them with more adaptive approach and coping behaviours

Question 64

How effective is CBT for anxiety disorders?

Answer 64

Overall large positive effect of CBT for GAD (Hedges g=0.80) (although effect sizes vary according to study quality) Larger effects for PD compared to GAD or social anxiety disorder (although this was based on change in generic symptom scores and small number of studies)

Question 65

Are combined psychological and pharmacological approaches for anxiety and depression more effective than individual therapies?

Answer 65

Yes Symptom reduction effect size for the comparison was: 0.47 (0.23-0.71) for disorders in general 0.54 (0.25-0.82) for PD CBT & medication had particularly clear evidence of effectiveness More effectiveness for panic disorder