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
