Week 6 - Anxiety and OCD Related Disorders

Question 1

Anxiety characteristics

Answer 1

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)

Question 2

Anxiety disorder

Answer 2

‘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

Question 3

Anxiety prevalence and comorbidity

Answer 3

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

Question 4

Common characteristics of Anxiety Disorders

Answer 4

Physiological symptoms of
panic

Cognitive biases

Dysfunctional beliefs

Specific early experiences (e.g. physical
abuse during childhood)

Question 5

Treating Anxiety Disorders

Answer 5

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

Question 6

DSM 5 diagnoses

Answer 6

– 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

Question 7

Specific Phobias

Answer 7

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

Question 8

Phobic Beliefs

Answer 8

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

Question 9

Examples of Phobic Beliefs and Spider Phobics

Answer 9

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

Question 10

Unpredictability and Speed Beliefs

Answer 10

When I encounter a spider:
– Its behaviour will be very unpredictable
– It will be very quick
– It will run in an illusive way

Question 11

Harm Beliefs

Answer 11

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

Question 12

Invasiveness Beliefs

Answer 12

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

Question 13

Response Beliefs

Answer 13

When I encounter a spider I will:
– Feel faint
– Lose control of myself
– Go hysterical
– Scream

Question 14

The Aetiology of Specific Phobias

Answer 14

Psychanalytic Accounts

Multiple Pathways to Phobias

Classical Conditioning Phobias

Evolutionary Accounts of Phobias

Question 15

Psychoanalytic Accounts

Answer 15

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

Question 16

Behavioural Accounts

Answer 16

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

Question 17

Evolutionary Accounts

Answer 17

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

Question 18

Multiple Pathways to Phobias

Answer 18

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

Question 19

DSM 5: Panic Disorder

Answer 19

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

Question 20

DSM 5: Panic Disorder Cont…

Answer 20

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)

Question 21

Aetiology of Panic Disorder: Psychological Theory

Answer 21

Classical Conditioning

Anxiety Sensitivity

Catastrophic Misinterpretation of Bodily Sensations

Question 22

Classical Conditioning

Answer 22

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

Question 23

Anxiety Sensitivity

Answer 23

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)

Question 24

Catastrophic Misinterpretation of Bodily Sensations

Answer 24

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)

Question 25

Misinterpretation of Bodily sensations model

Answer 25

Internal / External Trigger -> Perceived Threat -> Anxiety -> Physical Cognitive Symptoms -> Misinterpretation -> Anxiety

Question 26

Treatment of Panic Disorder

Answer 26

Benzodiazepines

Antidepressants

Cognitive Behaviour Therapy (CBT)
– Exposure-based treatment
– Cognitive restructuring of
dysfunctional beliefs about
bodily sensations

Question 27

A Typical Treatment Programme for Panic Disorder (CBT)

Answer 27

Education

Breathing training

Cognitive restructuring therapy

Interoceptive exposure

Prevention of ‘safety’ behaviours
– That may maintain attacks and avoid
disconfirmation of faulty beliefs

Question 28

Obsessive-Compulsive and Related Disorders

Answer 28

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

Question 29

Obsessions and Compulsions

Answer 29

Obsessions
- Intrusive and recurring thoughts

Compulsions
- Repetitive behaviours or mental actions repeated over and over to reduce anxiety

Question 30

Obsessive Compulsive Disorder (OCD)

Answer 30

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)

Question 31

DSM 5: Obsessive-Compulsive Disorder

Answer 31

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

Question 32

The Aetiology of OCD: Inflated Responsibility

Answer 32

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)

Question 33

Examples of Inflated Responsibility

Answer 33

1. I often feel responsible for things that go wrong
2. If I don’t act when I can foresee danger, then I am to blame for any
   consequences if it happens
3. If I think bad things, this is as bad as DOING bad things

Question 34

A cognitive model of OCD (Salkovskis, et al., 2000)

Answer 34

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

Question 35

Thought Suppression

Answer 35

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

Question 36

Treatment of OCD

Answer 36

Exposure and Response Prevention (ERP)

Pharmacological and Neurosurgical Treatments

Cognitive Behaviour Therapy (CBT)

Question 37

Exposure and Response Prevention (ERP)

Answer 37

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

Question 38

Example of ERP Exposure Hierarchy

Answer 38

1. Touch rim of own unwashed coffee cup (30)
2. Touch rim of partner’s unwashed coffee cup (40)
3. Eat snack from dish in cupboard after touching partner’s unwashed
   coffee cup (45)
4. Drink water from partner’s glass (55)
5. Eat snack straight from unwashed table top (65)
6. Have coffee at a café (70)
7. Have meal at a restaurant (80)
8. Touch toilet seat at home without washing hands for 15 mins (85)
9. Touch toilet seat at home without washing hands for 30 mins (90)
   10.Use public toilet (100)

Question 39

Example: Response Prevention Strategies

Answer 39

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

Question 40

CBT

Answer 40

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

Question 41

CBT cont.

Answer 41

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)

Question 42

Pharmacological Treatment

Answer 42

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)

Question 43

Case Study: Karen

Answer 43

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

Question 44

Karen cont.

Answer 44

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

Question 45

Karen after 3 months

Answer 45

– 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

Question 46

Addressing Karen’s Rituals

Answer 46

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

Question 47

Karen’s Outcome

Answer 47

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

Question 48

Theoretical Perspectives: Psychoanalytic

Answer 48

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

Question 49

Theoretical Perspectives: Psychoanalytic cont.

Answer 49

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

Question 50

Theoretical Perspectives: Behaviourists

Answer 50

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

Question 51

Theoretical Perspectives: Cognitive Theorists

Answer 51

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