week 3 -. Anxiety Disorders Flashcards
The DSM-5 Anxiety, OC, and Trauma-Related Disorders
7 of them
Panic Disorder Agoraphobia Social Anxiety Disorder Specific Phobia Generalized Anxiety Disorder Obsessive-Compulsive Disorder Posttraumatic Stress Disorder
The Nature of Anxiety
Normal vs ‘Pathological’ Anxiety
Anxiety as normal reaction to threat stimuli
Anxiety as functional, adaptive mechanism
No qualitative difference between normal and pathological anxiety
-Difference is one of degree
Anxiety symptoms can be psychological, social, medical, or substance related.
Panic Attacks!(not a diagnosable disorder)
Panic Attack (3-5% prevalence – Norton et al., 1992)
Note that panic attacks do not constitute any particular disorder, but are a feature common to many anxiety (and other) disorders.
Panic Attacks (historically…)
Historically three types of panic attacks are recognized:
- Unexpected (“Uncued”) panic attacks
- -E.g., panic attack occurs out of the blue
Situationally bound (“Cued”) panic attacks --E.g., shopping mall almost always triggers panic attack
Situationally predisposed panic attacks
–E.g., shopping mall sometimes triggers panic attacks
Panic Attack definition
An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:
Palpitations, pounding heart, or accelerated heart rate.
Sweating.
Trembling 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.
Paresthesias (numbness or tingling sensations).
Derealization (feelings of unreality) or depersonalization (being detached from oneself).
Fear of losing control or “going crazy.”
Fear of dying.
Panic Attack - Crescendo
very quick and intense onsent, relatively long abatement
Panic Disorder
Description
panic attacks
One of the attacks is followed by one month or more of
- Persistent concern about additional attacks
- Worry about the implications of the attack or its consequences
- Significant related maladaptive behaviour change
Panic Disorder CBT Model
Normal phys changes > catastrophic auto thoughts > anxiety increases > exhaustion & anxiety decreases > hyper-vigilance > oversensitivity to small physical changes > oversensitivity to small physical changes > (back to normal phys changes which is the trigger)
Panic Cycle = anxiety increasing becoming hyper aware of normal physical changes then going on to the automatic negative thoughts
Agoraphobia
Previously (DSM-IV) not coded as a separate disorder
DSM-5 now allows diagnosis of agoraphobia “irrespective of the presence of panic disorder
Agoraphobia (diagnostic conditions)
(A).Marked fear or anxiety about two (or more) of the following five situations:
- Using public transportation
- Being in open spaces
- Being in enclosed places
- Standing in line or being in a crowd.
- Being outside of the home alone.
(B)The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available
(C)Agoraphobic situations almost always provoke fear or anxiety.
(D)Agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
(E)Fear or anxiety is out of proportion to the actual danger
(F)Typically lasting for 6 months or more.
(G)Clinically significant distress or impairment in functioning.
(H)If another medical condition is present, the fear, anxiety, or avoidance is clearly excessive.
(I)Not better explained by the symptoms of another mental disorder
Social Anxiety Disorder(Social Phobia)
Description:
-Marked fear of social / performance situations in which the patient is exposed to possible scrutiny of others
- Individual fears that they will act in a way or show anxiety symptoms that will be negatively evaluated
- Exposure to the feared situation invariably provokes anxiety, which may escalate to panic.
- Feared situations are avoided or endured with anxiety.
- Duration of at least six months
Specifiers
–“Performance Only” – Only speaking/performing in public
CBT model of social phobia
see slide 18 of lecture
Specific Phobia
Description
Marked fear, cued by presence or anticipation of a specific object or situation.
Exposure to the phobic stimuli almost always provokes an anxiety response
Avoidance or endurance with extreme anxiety
Fear is out of proportion, excessive or unreasonable.
Distress and impairment
Specific Phobia subtypes
5
Animal Type
e.g. spiders, snakes, insects, dogs, etc.
Natural Environment Type
e.g. storms, thunder, heights, water, etc.
Blood-Injection-Injury Type
e.g. seeing blood, seeing injury, receiving an injection
Situational Type
e.g. public transport, tunnels, bridges, elevators
Other Type
e.g. choking, vomiting, etc.
Common Specific Phobias
Acrophobia - Fear of heights Arachnophobia – Fear of Spiders Aviophobia - Fear of flying Brontophobia - Fear of storms or thunder Emetophobia - Fear of vomiting Entomophobia - Fear of insects Hematophobia - Fear of blood Hydrophobia - Fear of water Pnigophobia - Fear of choking / being smothered Traumatophobia - Fear of injury Zoophobia - Fear of animals
Specific Phobia (stats)
Statistics
Gender ratio: 2:1 Females to Males
- Animal & Natural Type: 75-90% female
- -Fear of heights: 55-70% female
- Situational Type: 75-90% female
- Blood-Injection Type: 55-70% female
Prevalence
-Community sample, current prevalence: 4.0% - 8.8%
-Community sample, lifetime prevalence: 7.2% - 11.3%
Prevalence rates decline in elderly populations
Specific Phobia (formulation models)
Classical conditioning model
- Watson & Raynor’s (1920) classically conditioned fear of a white rat in Little Albert.
- First use of in-vivo exposure to decondition phobias in 1924.
Biological Preparedness
-Seligman noted that phobias tend to be of stimuli that are of threat to evolving human ancestors.
Problems with Conditioning models
-Retrospective histories have difficulty finding initial pairings of stimuli with anxiety.
?Many pathways to phobias: conditioning, vicarious transmission, verbal acquisition (Rachman, 1991)
Generalized Anxiety Disorder
Excessive anxiety, worry (apprehensive expectation)
- More days than not over six months
- Worry regarding number of events or activities
Subjective difficulty controlling worry
Physiological symptoms (3 or more)
- Restlessness or feeling keyed up or on edge.
- Being easily fatigued.
- Difficulty concentrating or mind going blank.
- Irritability.
- Muscle tension.
- Sleep disturbance
Marked distress or impairment
Generalized Anxiety Disorder models
Vulnerability Models
- Genetic vulnerability
- Psychosocial predispositions
- -Early experiences of uncontrollability
- Childhood history of psychosocial trauma
- -Insecure attachment to primary caregivers
Borkovec’s Model of Pathological Worry
CBT
see picture on slide 27
Basic CBT premise of GAD
Worry is an avoidance strategy (avoidance of aversive imagery or threat)
Obsessive Compulsive Disorder
What are obsessions:
Recurrent, persistent, intrusive thoughts, images or impulses.
Not simply worry about real life problems.
Ego-dystonic (thoughts/behaviours that are in conflict with the ego/ideal self image)
–Autogenous (repugnant uncued intrusions) vs Reactive (realistic, cued, related rationally to neutralising behaviour
OCD - What are compulsions?
Repetitive behaviours or mental acts related to an obsession or ritual.
Behaviours are aimed at reducing distress.
OCD continued
Obsessions and compulsions recognised as unreasonable.
Obsessions and/or
Compulsions cause marked distress or interference in everyday functioning
Obsessive Compulsive Disorder (changing conceptualisation in dsm)
Changing conceptualisation of obsessions and compulsions in DSM in recognition of the development of cognitive-behavioural models:
Obsessions recognized as stimulus eliciting anxiety
Compulsions recognized as anxiety reduction strategies
Requirement for insight reduced
Increasing recognition that most, if not all OCD patients have both obsessions and compulsions (either overt or covert).
Obsessive Compulsive Disorder
common obsessions/prevalance in sufferes
Contamination - 45 percent
Pathological Doubt - 42 percent
Somatic Obsessions - 36 percent
Need for Symmetry - 31 percent
Aggressive - 28 percent
Sexual - 26 percent
Other - 13 percent
Multiple Obsessions - 60 percent
Common Compulsions
in ocd sufferers
Checking - 63 percent
Washing - 50 percent
Counting - 36 percent
Need to Ask/Confess - 31 percent
Symmetry/Precision - 28 percent
Hoarding - 18 percent
Multiple Compulsions - 75 percent
Only 2 percent of OCD patients present with pure obsessions, when mental rituals are included as compulsions (Foa et al., 1995).
Obsessive Compulsive Disorder (models)
Fear acquisition and avoidant behaviour maintenance.
Some question of empirical support for acquisition by association, but more support for maintenance processes (see below).
Touch dirty surface > increase in anxiety >likelihood of touching reduced
Anxiety >cleaning behaviour >reduction in anxiety = cleaning behavior reinforced
Obsessive Compulsive Disorder
Dysfunctional Assumptions characterizing OCD
Having a thought about the action is like performing the action.
E.g., If I think, I hope she dies, I have partially killed her
Failing to prevent (or failing to try to prevent) harm to self or others is the same as having caused the harm in the first place.
E.g., They got sick because I did not wash my hands enough…it is my fault!
Dysfunctional Assumptions characterizing OCD part2
Responsibility is not attenuated by other factors (e.g. low probability of occurrence)
E.g., 0.001 percent chance is huge!
Not neutralizing when an intrusion has occurred is similar or equivalent to seeking or wanting the harm involved in that intrusion to actually happen.
E.g., If I do not check the stove then I must want her to be harmed
One should (and can) exercise control over one’s thoughts.
Psychodynamic & Cognitive Models of OCD
Contrast underlying assumption of psychodynamic vs cognitive models of OCD
=An urge from within the person results in distress because the person does and does not want to carry it out (psychodynamic)
=A thought from within the person results in distress because it is profoundly out of character and against the patient’s desired behaviour/ and thoughts (cognitive)
Post-Traumatic Stress Disorder
diagnostic criteria (a)
a. Exposure to actual or threatened death, serious injury, or sexual violence:
- Directly experiencing the traumatic event(s)
- Witnessing the event, in person, happening to others
- Learning that the traumatic event occurred to a close family member or close friend
- Repeated extreme exposure to aversive details of the event
PTSD diagnostic criteria (b)
Intrusion symptoms
- Recurrent, involuntary, and intrusive distressing memories
- Recurrent distressing dreams
- Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.
- Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble the event.
- Marked physiological reactions to internal or external cues that symbolize or resemble the event.
PTSD critera (C)
c. Persistent avoidance of stimuli associated with the event
Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about the event.
Avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about the event
PTSD criteria (d) - negative alterations in cognitions and mood
Negative alterations in cognitions and mood associated with the traumatic event
- Inability to remember an important aspect of the traumatic event(s)
- Exaggerated negative beliefs about oneself, others, or the world
- Distorted cognitions about the cause or consequences of the event that lead the individual to blame himself/herself or others.
- Persistent negative emotional state
- Markedly diminished interest or participation in significant activities.
- Feelings of detachment or estrangement from others.
- Persistent inability to experience positive emotions
PTSD (Continued) diagnostic criteria
e) & (f
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:
- Irritable behavior and angry outbursts
- Reckless or self-destructive behavior
- Hypervigilance
- Exaggerated startle response
- Problems with concentration
- Sleep disturbance
f. Duration of the disturbance is more than 1 month (if not consider acute stress disorder).
Post Traumatic Stress Disorder - risk factors
Severity of trauma
Past history of stress, abuse or trauma
History of behavioural or psychological problems
Comorbid psychopathology Cognitive factors (e.g. low IQ, low education opportunity)
Genetic factors (e.g. family history of psychopathology)
Subsequent exposure to reactivating environmental events
Lack of social support
Behavioural Formulation of PTSD
conditioned stimulus (eg, being at a bank)
traumatic event = UCS (eg, being held at gun point) which invokes the UCR (eg, fear, anxiety)
Conditioned stimulus = being at a bank > conditioned response (fear, anxiety)
ptsd behavioural formulation - positive punishment vs negative reinforcement of avoidance
positive punishment for approach =
Stimulus > approach bank > anxiety fear > reduced approach
Negative reinforcement of Avoidance = anxiety fear > avoidance of bank >avoiding bank reduced/elimiates anxiety > increased avoidance
Behavioural Formulation of ptsd in depth
Stimulus generalization occurs, meaning that an increasing number of stimuli elicit the fear response
Deficits in specific behavioural skills
- interpersonal skills (eg a study found that skills training was equivalent to exposure)
- help-seeking behaviour
Many more recent cognitive behavioural models of PTSD expand on the basic two-factor model
EXPOSURE therapy for Anxiety Disorders
Exposure Types
Direct contact with stimulus (rapid) = flooding
Direct contact with stimulus (graduated) = Graded In-Vivo exposure
Mental Image or other similar contact with stimulus
- -Rapid = Implosion
- -Graduated = Systematic Desensitization
Other types or extension on original techqniques:
Interoceptive exposure, worry exposure, exposure with response prevention, (OCD) Single-session phobia treatment and more.
Exposure Therapy and Return of Fear
Exposure Therapy is very efficient
-Basically, if you are motivated to do it, you are highly likely to benefit from it!
Unfortunately many experience return of fear!
Return of Fear occurs via
- Spontaneous Recovery – time makes the fear come back
- Reacquisition – having had the fear makes the fear come back more easily
- Renewal – encountering the phobic stimuli outside of the therapy room brings the fear back
- Reinstatement – having another aversive encounter brings the original fear back
Panic Disorder
Statistics
Statistics
Gender Features
-PD+Ag diagnosed three times as often in women
Prevalence
-Australian Point-Prevalence: 2.3% (Andrews et al., 2003)
-Clinical sample - 10% of individuals referred to mental health
-Agoraphobia present in 33% to 50% of community PD patients
Course
-Onset typically in adolescence or mid-30s (bimodal distribution)
72% have identifiable stressors at onset (Craske et al., 1990)
Familial Pattern
-8x higher risk in first-degree relatives
-Twin studies indicate genetic contribution
Agoraphobic Avoidance I (behavioural formulation - positive punishment)
positive punishment for approach behaviours =
behaviour > negative consequence > behaviour decreases
Approach > increase in anxiety > likelihood of approach reduced
Agoraphobic Avoidance II (negative reinforcement for avoidance )
Negative state > behaviour > negative state reduced (behaviour increases)
Anxiety > avoidance behaviour > reduction in anxiety > avoidance increases
Agoraphobic Avoidance
Cognitive Factors
Negative outcome expectancies.
E.g., I might get a panic attack in the shopping mall
Expectations of situational fears (rather than of the panic attack itself).
E.g., shopping malls are scary!
Expectation of negative social consequences.
E.g., people will laugh at me
Perception of link between situation and panic attacks.
E.g., buses give panic attacks!
Self-efficacy perceptions.
E.g., I will not be able to take the bus alone!
Origins of anxiety disorders can differ!
Anxiety disorders can be caused by
Primarily psychological and social factors
E.g., PTSD, Phobias, GAD
Primarily medical conditions – Anxiety disorder due to general medical condition
E.g., Neurological conditions (e.g., cerebral trauma)
Endocrine disturbance (e.g.,pituitary dysfunction)
Deficiency states (e.g. B12 deficiency)
Other conditions (e.g. hypoglycemia)
Primarily substance inducement – Substance induced Anxiety disorder
E.g., Alcohol, Benzodiazepines, Cannabis, d-LSD25, MDMA, Caffeine
Social Phobia
Stats etc
Statistics
Prevalence
Australian Point-Prevalence: 2.8% (Andrews et al., 2003)
Lifetime community prevalence: 3% - 13%
Course
-Typical onset in late adolesence, often out of a history of childhood shyness
-Onset may be insidious or abrupt.
-Course is often continuous, chronic and lifelong
-May be dependent of life situation (e.g. marriage)
Familial Pattern
Having a first-degree relative with Social Phobia increases risk.
Social Phobia
Etiology
Inherited Anxiety vulnerability / sensitivity
Cognitive theories
- Schemas including beliefs about catastrophic nature of negative evaluation
- Interpretive bias towards negative evaluation, even when not present
- Attentional bias towards threat cues
12m onth prevalence of any anxiety disorder
~ 15%
Panic Disorder
etiology
Vulnerability
-Anxiety proneness
Hyperventilation
-General current idea is that hyperventilation may be one of many routes to panic, but is neither necessary nor sufficient.
Biological Models
-GABA (inhibitory neurotransmitter)
Cognitive factors
- Perceived lack of control over bodily sensations
- Tendency to interpret ambiguous sensations as threatening
- Attentional and memory biases to threat related stimuli
Anxiety Sensitivity
-A tendency to interpret symptoms of anxiety as threatening
Agoraphobia Without Panic Disorder
stats
Statistics
Gender Features
Little specific information regarding gender differences exists.
Prevalence
- Australian Point-Prevalence: 1.7% (Andrews et al., 2003)
- Only 6% of a group of 562 agoraphobics denied a history of panic attacks (Goisman et al., 1994)
Course
Little is known about the natural course of the disorder
Generalized Anxiety Disorder
Stats
Gender
- 55-60% of cases presenting clinically are female
- In epidemiological studies the gender ratio is 2:1 Female:Male
Prevalence
- Australian Point-Prevalence: 4.1% (Andrews et al., 2003)
- Overdiagnosis may be present in children
- Community one-year prevalence: 3.0%
- Community lifetime prevalence: 5.0%
- Anxiety Disorder Clinic sample: Approx 25%
Familial Pattern
- Anxiety as inherited trait
- Relationship with genetic factors associated with mood disorder.
Course
- Typical report of chronic, life-long anxiety
- Onset in childhood or adolescence, with post-20 onset not uncommon
- Typical course is chronic, fluctuating depending on current stressors.
Obsessive Compulsive Disorder
Stats
Gender Features
- -Equally common in adult males and females
- -Childhood onset OCD more common in boys than girls
Prevalence
- -Australian Point-Prevalence: 0.8% (Andrews et al., 2003)
- -Community lifetime prevalence: 2.5% of adults
- -Community lifetime prevalence: 0.7% of children/adolescents
- -Community 1-year prevalence: 0.5% - 2.1% of adults
- -Community 1-year prevalence: 1.0% - 2.3% of children/adolesc.
- -Prevalence appears standard across different cultures.
Obsessive Compulsive Disorder
Stats continued (onset and course)
Onset typically in adolescence or adulthood
Childhood onset also recognised
Modal onset age for males: 6-15 years
Model onset age for females: 20-29 years
Onset is usually insidious, but acute onset noted in some cases.
Typical course is chronic, with waxing and waning severity
15% show progressive gradual deterioration in social and/or occupational functioning
5% show episodic course, with good inter-episode recovery
OCCWG (1997)
( (Obsessive Compulsive Cognitions
Working Group)
Broad domains of beliefs implicated in OCD
Inflated personal responsibility Over-importance of thought Beliefs about importance of controlling one’s thoughts Overestimation of threat Intolerance of uncertainty Perfectionism
All are highly associated with OCD symptoms
BUT…All are also highly correlated with each other
Other OC Spectrum Disorders
Hoarding Disorder
Persistent difficulty discarding or parting with possessions, regardless of their actual value.
This difficulty is due to a perceived need to save the items and to distress associated with discarding them.
The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use.
Other OC Spectrum Disorders
Body Dysmorphic Disorder
Preoccupation with one or more perceived defects or flaws in physical appearance. Perceived-self looks ugly, unattractive, abnormal, or deformed
—The perceived flaws are not observable or appear only slight to other individuals.
Specifier: with Muscle Dysmorphia
–The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular.
Post Traumatic Stress Disorder
stats etc
Prevalence
- Australian Point-Prevalence Rate: 1.7% (Andrews, et al., 2003)
- US Community lifetime prevalence: 8.0% of adults
- At risk individuals (e.g. rape survivors, combat veterans, ambulance officers, etc) prevalence rates up to 50%
Course
- Onset at any age, including in childhood years.
- Symptoms usually have onset within 3 months of traumatic event
- May emerge from Acute Stress Disorder as initial response to trauma
- Approximately 50% remit within 3 months of onset
- Others experience chronic fluctuating course.
- Approximately 33% do not recover, despite professional treatment
PTSD Stats continued
Prevalence
-Estimates vary due to changes in diagnostic criteria, demographics of sample group, etc.
-Large scale epidemioloigcal studies
North Carolina point-prevalence = 1.3%
Combat related (point-prevalence rates)
15.2% of US servicemen who served in Vietnam`
8.5% of US servicewomen who served in Vietnam
Conditional risk following exposure to any trauma as defined in DSM-IV = 9.2% (Breslau et al., 1998)
Cognitive Behavioural Models
of PTSD
For a thorough review of current psychological models of PTSD, see Brewin & Holmes (2002)
Information processing theory
Emotional processing theory
Dual Representation Theory
Ehlers and Clark’s Cognitive Model (see end of slides for an example)
Historical Overview of PTSD
Long recognition of trauma as aetiologically significant in psychological illness (e.g. psychoanalytic theory) Battlefield related symptoms Shell shock “Battle fatigue” Vietnam War Veterans
Historical Overview - Nomenclature
DSM-I
Gross Stress Reaction for acute symptoms
Chronic symptoms labelled anxiety or mood disorder
DSM-II
Transient Situational Disturbance for acute symptoms
Chronic symptoms labelled anxiety or mood disorder
DSM-III
Posttraumatic Stress Disorder conceived as diagnosis for asymptomatic individuals who develop psychiatric symptoms following exposure to trauma
DSM-IV
Change in definition of traumatic event (reduced severity)
Witnessing trauma to others included
Specification of reaction to event (‘fear, helplessness, horror)
Ehlers & Clark’s Cognitive Model of PTSD
Incorporating earlier emotional processing theory ideas
PTSD sufferers show a wide range of negative appraisals
“I am a victim”
“I deserve for bad things to happen to me.”
“I’ll never be able to relate to people again.”
“Others think I was a coward.”
“I’m a psychological wreck!”
Ehlers & Clark’s Cognitive Model of PTSD contd
Traumatic memories are poorly elaborated and contextualised
Trauma memories are poorly integrated with general autobiographical memory
Difficulty with intentional recall
Retrieval from memory is cue-driven and unintentional
Behavioural factors also contribute to maintenance
Use of safety behaviours
Maladaptive coping behaviours (e.g. alcohol)
Acute Stress Disorder
diagnostic criteria
Exposure to a traumatic event, involving actual or threatened death, serious injury, or sexual violation
Duration 3 days – 1 month
At least nine of the following symptoms:
Recurrent, distressing memories Recurrent distressing dreams Dissociative reactions Distress in response to internal or external cues Inability to experience positive emotions Altered sense of the reality Inability to remember an important aspect of the traumatic event(s) Efforts to avoid distressing memories Efforts to avoid external reminders Sleep disturbance Irritable behavior and angry outbursts Hypervigilance. Problems with concentration. Exaggerated startle response.
Breathing and Relaxation!
Breathing control
The training is a technique usually used with panic disorder patients as a method of reducing the impact of hyperventilation on their condition.
Relaxation
Patients are trained to recognise the difference between muscle tension and muscle relaxation, they can use increasing tension as a cue to commence arousal management skills.
Cognitive Restructuring
A broad array of techniques aimed at assisting a patient to identify and evaluate their existing beliefs that are associated with distressing emotions. After evaluation, the patient can be helped to create and integrate less distressing cognitions.
C: No one will find me attractive again
T: What is your evidence for this?
C: She did not reply to my texts
T: Can there be any other reasons for her not replying to your text?
C: Yes I suppose she could be busy
T: So is there room for a more helpful thought to be applied to this situation?
C: Yes, she may be interested in pursuing a relationship with me but may simply be busy at the time.
Prevalence of Anxiety disorders
PD - 1 year (~1%), lifetime (~1.5)
Agora - 1yr (1%), lifetime (3%)
social - 1yr (2%), lifetime (4%)
specific - 1yr (2.5%), lifetime (~4.2%)
Ocd - 1yr (0.5%), lifetime (1%)
PTSD - 1yr (1%), lifetime (2%)
GAD - 1yr (2%), lifetime (6%)
Any - 1yr (10%), lifetime (16%)
