Week 6 - Anxiety and OCD Related Disorders Flashcards
Anxiety characteristics
Feeling of apprehension
A natural, adaptive response essential for
performance in challenging situations
Can become problematic
– Intense or attached to inappropriate events or situations (Lepine, 2002)
Anxiety disorder
‘An excessive or aroused state
characterised by feelings of
apprehension, uncertainty and fear’
(Davey, 2010, p. 118)
In Anxiety Disorders, anxiety is:
– Out of proportion to the threat posed
– A state that the individual constantly finds
themselves in
– A cause of distress that disrupts normal day-to-day
living
Anxiety prevalence and comorbidity
28% of people reported having experienced symptoms at some point (Kessler et al, 2012)
9th leading cause of disability worldwide in 2015 (Vos Allen et al., 2016)
Comorbidity
– Many symptoms of anxiety common across anxiety disorders
* More than half of people with one anxiety disorder meet criteria for another anxiety disorder during their lives (Wright, Krueger
et al., 2013)
– 60% of people in treatment for AN will meet criteria for DP
– Comorbidity – greater severity and poorer outcomes
Common characteristics of Anxiety Disorders
Physiological symptoms of
panic
Cognitive biases
Dysfunctional beliefs
Specific early experiences (e.g. physical
abuse during childhood)
Treating Anxiety Disorders
Exposure
– E.g., Systematic desensitisation (Wolpe, 1958)
* Combined with relaxation
Cognitive component
Medications
– Anxiolytics (sedatives/tranquilizers)
* E.g., benzodiazepines (valium, xanax)
– Antidepressants
* E.g., tricyclics, SSRIs
DSM 5 diagnoses
– Separation Anxiety Disorder
– Selective Mutism
– Specific Phobia
– Social Anxiety Disorder (Social Phobia)
– Panic Disorder
– Panic Attack Specifier
– Agoraphobia
– Generalised Anxiety Disorder
– Substance/Medication-Induced Anxiety Disorder
Specific Phobias
An excessive, unreasonable, persistent fear
triggered by a specific object or situation
Avoidance responses
Fear driven by a set of dysfunctional phobic
beliefs
Lifetime prevalence 13.8% (Kessler
et al., 2012)
Phobias occur cross-culturally
– May be influenced by cultural factors
Phobic Beliefs
Set of dysfunctional beliefs about a
phobic stimulus or event
Rarely challenged
– Avoidance of circumstances where such beliefs might be disconfirmed
These beliefs
– Maintain phobic fear
– Motivate responses designed to avoid contact
with the phobic stimulus
Examples of Phobic Beliefs and Spider Phobics
Chaser and Prey Beliefs
When I encounter a spider it will:
– Run towards me
– Stare at me
– Settle on my face
– Not be shaken off once
me
Unpredictability and Speed Beliefs
When I encounter a spider:
– Its behaviour will be very unpredictable
– It will be very quick
– It will run in an illusive way
Harm Beliefs
When a spider is in my vicinity I believe
that the spider will:
– Bite me
– Crawl towards my private parts
– Do things on purpose to tease me
– Get on to parts of me that I cannot reach
Invasiveness Beliefs
When I encounter a spider it will:
– Crawl onto my clothes
– Walk over me during the night
– Will hide in places I do not
want, such as my bed
Response Beliefs
When I encounter a spider I will:
– Feel faint
– Lose control of myself
– Go hysterical
– Scream
The Aetiology of Specific Phobias
Psychanalytic Accounts
Multiple Pathways to Phobias
Classical Conditioning Phobias
Evolutionary Accounts of Phobias
Psychoanalytic Accounts
Defence against anxiety produced by repressed id impulses
Fear becomes associated with external events or situations that had a symbolic relevance to that repressed id impulse
Function of phobias is to avoid confrontation
with the real, underlying issues
Little objective evidence to support such
accounts
Behavioural Accounts
Classical conditioning explanation
Problems
– Many individuals with phobias cannot recall a
traumatic event in the history of their phobia
– Not all people who have a traumatic
conditioning experience develop a phobia
– Phobias only appear to develop in relation to
certain stimuli and events
* E.g. heights, snakes
Evolutionary Accounts
Biological preparedness (Seligman, 1971)
– ‘a theory that argues that we have built-in
predisposition to learn to fear things such as
snakes, spiders, heights and water because they have been life-threatening to our ancestors’ (Davey, 2008, p.125)
Evolutionary accounts are easy to propose
– Very difficult to substantiate
Multiple Pathways to Phobias
Different types of phobias may be acquired in
quite different ways (Merckelback et al.,
1996)
Processes involved may include:
– Classical Conditioning
– The Disgust Emotion
– Misinterpretation of Bodily Sensations and Panic
DSM 5: Panic Disorder
Recurrent unexpected panic attacks. A panic attack is 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:
1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed, or faint
9. Chills or heat sensations
10.Paresthesias (numbness or tingling sensations)
11.Derealisation (feelings of unreality) or depersonalisation (being detached from
oneself)
12.Fear of losing control or ‘going crazy’
13.Fear of dying
DSM 5: Panic Disorder Cont…
B. At least one of the attacks has been followed by 1 month (or more) of one or
both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g.,
losing control, having a heart attack, ‘going crazy’)
2. A significant maladaptive change in behaviour related to the attacks (e.g., behaviours
designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar
situations)
C. The disturbance is not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication) or another medical condition (e.g.,
hyperthyroidism, cardiopulmonary disorders)
D. The disturbance is not better explained by another mental disorder (e.g., the
panic attacks to not occur only in in response to feared social situations, as in
social anxiety disorder; in response to circumscribed phobic objects or situations,
as in specific phobia; in response to obsessions, as in obsessive-compulsive
disorder; in response to reminders of traumatic events, as in posttraumatic stress
disorder; or in response to separation from attachment figures, as in separation
anxiety disorder)
Aetiology of Panic Disorder: Psychological Theory
Classical Conditioning
Anxiety Sensitivity
Catastrophic Misinterpretation of Bodily Sensations
Classical Conditioning
Bouton, Mineka and Barlow (2001)
Anxiety is anticipatory and prepares the system for a trauma
Panic deals with a trauma that is already in progress
– Anxiety is the learned reaction (CR)
– To the detection of cues (CS), that might predict a panic attack
Once conditioned anxiety develops it will exacerbate subsequent panic attacks and lead to the development of panic disorder
Anxiety Sensitivity
Fear of anxiety symptoms based on beliefs
that such symptoms have harmful
consequences
– Palpitations, pounding heart, or accelerated heart rate
– Sensations of shortness of breath or smothering
- Individuals with panic disorder score significantly higher on measures of anxiety sensitivity (Taylor & Cox, 1998)
Catastrophic Misinterpretation of Bodily Sensations
Panic attacks are precipitated by individuals
catastrophically misinterpreting bodily
sensations as threatening (Clark, 1986)
Individuals with panic disorder:
– Attend to their bodily sensations more than others
– Will interpret ambiguous signs as threatening
– Have panic attacks trigger merely by the expectancy of an attack (Sanderson et al., 1989)
Misinterpretation of Bodily sensations model
Internal / External Trigger -> Perceived Threat -> Anxiety -> Physical Cognitive Symptoms -> Misinterpretation -> Anxiety
Treatment of Panic Disorder
Benzodiazepines
Antidepressants
Cognitive Behaviour Therapy (CBT)
– Exposure-based treatment
– Cognitive restructuring of
dysfunctional beliefs about
bodily sensations
A Typical Treatment Programme for Panic Disorder (CBT)
Education
Breathing training
Cognitive restructuring therapy
Interoceptive exposure
Prevention of ‘safety’ behaviours
– That may maintain attacks and avoid
disconfirmation of faulty beliefs
Obsessive-Compulsive and Related Disorders
DSM 5 Diagnoses
– Obsessive-Compulsive Disorder
– Body Dysmorphic Disorder
– Hoarding Disorder
– Trichotillomania (Hair-Pulling Disorder)
– Excoriation (Skin Picking Disorder)
– Substance-Induced Obsessive-Compulsive and Related Disorder
Obsessions and Compulsions
Obsessions
- Intrusive and recurring thoughts
Compulsions
- Repetitive behaviours or mental actions repeated over and over to reduce anxiety
Obsessive Compulsive Disorder (OCD)
Consequences can be severe
– Relationships
– Isolation
Onset usually gradual (Kringlen, 1970)
Lifetime prevalence of OCD is 2% (Ruscio et
al., 2010)
OCD slightly more common among women than men (Buhlmann et al., 2010; Tores, Prince et al., 2006)
DSM 5: Obsessive-Compulsive Disorder
Specify if:
With good or fair insight: The individual recognises that the obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true
With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true
With absent insight/delusional beliefs: The
individual is completely convinced that obsessive-compulsive disorder beliefs are true
The Aetiology of OCD: Inflated Responsibility
Characteristic of individuals with OCD (Salkovskis et al., 1999)
– The belief that one has power to bring about or prevent subjectively crucial negative outcomes
– Essential to prevent
– Actual or moral
Experimental studies that have manipulated
inflated responsibility show that it causes
increases in compulsions (Lopatka & Rachman,
1995)
Examples of Inflated Responsibility
- I often feel responsible for things that go wrong
- If I don’t act when I can foresee danger, then I am to blame for any
consequences if it happens - If I think bad things, this is as bad as DOING bad things
A cognitive model of OCD (Salkovskis, et al., 2000)
Early experiences (making you vulnerable to OCD) -> Assumptions, General Beliefs (e.g. not preventing disaster is as bad as making it happen; better safe than sorry)
Critical incidents (what started the OCD off)
activates -> Assumptions
Assumptions -> Intrusive thoughts, images, urges, doubts -> Misinterpretations of significance of intrusions-responsible for action ->Counterproductive safety strategies (thought suppression, impossible criteria, avoidance) & Mood changes (distress, anxiety, depression)
Counterproductive & mood -> misinterpretation
-> intrusive thoughts
Thought Suppression
Obsessive thoughts – active thought suppression
– Rebound effect (Clark, Ball, Pape, 1991)
Deliberately suppressing thoughts can actually increase their frequency (Wenzlaff & Wegner, 2000)
Wenzlaff, Klein and Wegner (1991)
– Association between suppressed thoughts and negative mood state
– Whenever negative mood state occurs, more likely to elicit the unwanted and aversive thoughts
Treatment of OCD
Exposure and Response Prevention (ERP)
Pharmacological and Neurosurgical Treatments
Cognitive Behaviour Therapy (CBT)
Exposure and Response Prevention (ERP)
A means of treatment for obsessive
compulsive disorder (OCD)
Involves graded exposure to the thoughts
that trigger distress
Followed by the development of
behaviours designed to prevent the
individual’s compulsive ritual
Example of ERP Exposure Hierarchy
- Touch rim of own unwashed coffee cup (30)
- Touch rim of partner’s unwashed coffee cup (40)
- Eat snack from dish in cupboard after touching partner’s unwashed
coffee cup (45) - Drink water from partner’s glass (55)
- Eat snack straight from unwashed table top (65)
- Have coffee at a café (70)
- Have meal at a restaurant (80)
- Touch toilet seat at home without washing hands for 15 mins (85)
- Touch toilet seat at home without washing hands for 30 mins (90)
10.Use public toilet (100)
Example: Response Prevention Strategies
OCD Symptom -> Response Prevention Strategy
Hand washing or cleaning rituals-> Response delay (i.e., extending period between
‘contamination’ and cleaning or washing); use of ritual restrictions (e.g., decreasing cleaning or washing time); clenching fists; extension strategies to undermine avoidance (e.g., touch self, clothes)
Checking lights, switches, oven,
appliances etc. -> Response delay; use of ritual restrictions (e.g. restrict number of checks); turning and walking away; extension strategies (whistle a happy tune)
Counting (e.g., bricks, words) -> Refocusing techniques; signing a song; going ‘blank’’
meditation
CBT
Targeting and modifying dysfunctional beliefs
about fears, thoughts and significance of
rituals
Dysfunctional beliefs that are usually
challenged using CBT include:
– Responsibility Appraisals
– The Over-Importance of Thoughts
– Exaggerated Perception of Threat
CBT cont.
Educating clients
– Intrusive thoughts are quite normal
– Having a thought about an action is not the same as performing it (Salkovskis, 1999)
Focusing on changing clients’ abnormal risk
assessment
– Working through the probabilities associated with feared outcomes (van Oppen & Arntx,1994)
Providing clients with behavioural exercises that will disconfirm their dysfunctional beliefs
(Salkovskis, 1999)
Pharmacological Treatment
Short term effective and cheap way of treating OCD
– Relapse tends to be common on discontinuation of the drug treatment
(McDonough, 2003; Pato et al., 1988)
SSRIs
– Most regularly prescribed drug for OCD
– Comparative studies suggested that SSRIs are less effective than standard psychological therapies such as ERP (Greist, 1998)
ERP
– Equally effective as drug treatments in the short-term
– Free from physical and psychological side effects
– Associated with greater long-term gains (Greist, 1998; Marks, 1997)
Case Study: Karen
Counting compulsions
– Seemed to represent attempt to
reintroduce a sense of control over her life
Treatment initially focused on helping Karen to be more assertive
– Identified typical situations in which Karen was unassertive by
keeping a daily diary
* People involved
* Nature of interaction
* What believed would happen if she behaved
assertively
– Therapist and Karen role-played situations to introduce more
appropriate ways of responding
Karen cont.
Also discussed irrational fears
associated with being assertive
– ‘everyone should love me’, ‘if I stand up for
myself, people will reject me’
– Inhibiting expression of assertive behaviour
Proficiency in therapy – practice skills in real-life situations
Addressed child management issues using
skills based on operant conditioning
Karen after 3 months
– Improvement in Karen’s mood
– Increases sense of self-confidence
– Improvement in family life
– Decrease in anxiety – although continued to
observe her numerous rituals, less frequent
and less anxiety provoking when failed to
perform
At this point, Karen’s rituals addressed
using a behavioural treatment
Addressing Karen’s Rituals
Exposure and Response Prevention
(Meyer, 1966) (ERP)
– Exposure to anxiety provoking stimulus and prevention of anxiety-reducing rituals
Karen to smoke ONE cigarette at start of therapy session -> Anxiety re: oldest child -> Compulsion to smoke another cigarette
Procedure carried out during 4 consecutive 2 hour sessions and practice at home encouraged
Extended to other situations where Karen was concerned about numbers
Karen’s Outcome
Therapy terminated after 20 sessions
Karen
– Was no longer depressed
– Had not engaged in compulsive counting
rituals for 4 weeks
– Had become more assertive at home which
had improved relationships with children (who
were much better behaved) and husband
Theoretical Perspectives: Psychoanalytic
Compulsions
– Ego trying to fend off anxiety associated with
hostile impulses
Expression of anger is dangerous and
unacceptable to the ego and anticipation of
their expression is anxiety provoking
– Reaction formation to transform anger into its antithesis
Theoretical Perspectives: Psychoanalytic cont.
Karen
– Not unreasonable to assume felt angry towards her children
– perhaps to the point of physical harm
Anxiety provoking impulse to ego
Transformed to its opposite
– Protecting children from harm
Results
– Karen spending significant amounts of time performing her counting rituals in order to achieve this
Anxiety reduction mediated by an unconsciously activated defence mechanism
Theoretical Perspectives: Behaviourists
Karen’s rituals are an operant response being
maintained by negative reinforcement
1) Karen engages in activity that reminds her of numbers (and therefore her children) -> 2) Experiences anxiety -> 3) Engages in rituals to neutralise the anxiety - reinforcing the behaviour -> 1)
Similar to psychoanalytic approach whereby symptom produced as a means of reducing tension
Theoretical Perspectives: Cognitive Theorists
Intrusive thoughts are proof harm will come if left uncorrected
Anxiety level increases and individual engages in compulsive rituals to try to gain control over mental events and life experiences
Active attempts at thought suppression tend to increase severity of problem (Wegner, 1994)
ERP viewed as ‘behavioural experiment’ to disconfirm beliefs
Frequent intrusive thoughts about
children’s safety -> Karen believes if doesn’t act
on these, something bad will happen to them
‘if I don’t count cereal boxes, something bad will happen to my children’ -> Counting ritual
