Week 7 Lecture 7 - Anxiety, obsessive-compulsive disorder & trauma/stressor-related disorders (DN) Flashcards
What are the three main DSM categories?
Anxiety Disorders
Obsessive Compulsive Disorders
Trauma- and Stressor-Related Disorders
Overview of DSM-5 categories
Anxiety disorders
- Separation anxiety disorder
- Selective mutism
- Specific phobia
- Social anxiety disorder
- Panic disorder
- Agoraphobia
- Generalised anxiety disorder
- Substance/medication induced anxiety
- Disorder due to another medical condition
- Other-specified/unspecified
Obsessive-compulsive and related disorders
- Obsessive-compulsive disorder
- Body dysmorphic disorder
- Hoarding disorder
- Trichotillomania (hair pulling disorder)
- Excoriation (skin picking) disorder
- Substance/medication induced disorder
- Disorder due to another medical condition
- Other-specified/unspecified
Trauma and stressor related disorders
- Reactive attachment disorder
- Disinhibited social engagement disorder
- Posttraumatic stress disorder
- Acute stress disorder
- Adjustment disorder
Other-specified/unspecifiedBold: focus for exam
Anxiety (definition)
Negative mood state, characterised by bodily symptoms of physical tension & apprehension about the future 4:15
- Set of characteristic behaviours
- fidgeting, pacing, looking worried
- Physiological response
- increased heart rates, sweating, brethlessness
- Subjective experiences
- thoughts, images, fear, guilt anger
- Good for us in moderate amounts
- Drives & enhances social, physical & intellectual performance
- Concern over & preparation for things that ‘might’ go wrong > ‘future oriented’
bold bits are key take home messages
Why are moderate amounts of anxiety good for us?
- Drives & enhances social, physical & intellectual performance
- e.g.,
- sitting exam (studying extra coz anxious
- meeting new people (trying to impress)
- job interview
- crossing road (pays to be a little bit anxious about being run over
5:30
What does Jo say is an important feature of anxiety for us to remember?
- its a future oriented mood state
- concern over things that might go wrong
What type of curve is associated with anxiety?
What does this tell us about the adaptiveness of anxiety?
- U-shaped curve
- No anxiety > unprepared
- Little anxiety > adaptive
- Too much anxiety > detrimental
Fear (definition)
- Emotion related to anxiety - also good for us!
- Protects us from threats by activating fight or flight response
- massive response from autonomic nervous system (inc. heart rate, breathlessness, sweaty)
7:40
What are the distinguishing features of anxiety and fear?
8:00
-
Anxiety:
- Thoughts of unpredictability or uncontrollability
- Apprehension about perceived potential threat
- Future – oriented
-
Fear:
- Strong escapist action tendencies
- Present-oriented
- What happens when you experience an alarm response of fear when there is actually nothing to be frightened of
- i.e., there is no fight or flight response as there is nothing to fight against or flee from?
8: 30
Panic attack
- “An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes”: DSM5
- (not transient moment)
- Occur in the context of many anxiety disorders, other mental disorders,
medical conditions - Diagnosis noted by clinician as a specifier
- Can be expected (cue), or unexpected (no cue)
Is Panic Attack a DSM-5 disorder?
- No, Panic disorder is a disorder, not panic attack.
- Panic attack typically occurs within context of another disorder
9:30
What is DSM5 criteria for panic attack?
In a calm or anxious state, 4 or more of the following physical and cognitive symptoms
- Palpitations, pounding heart, accelerated heart rate
- Sweating
- Trembling, shaking
- Sensations of shortness of breath or smothering
- Chest pain or discomfort
- Nausea or abdominal discomfort
- Feeling dizzy, unsteady, lightheaded, faint
- Chills, hot flushes
- Paraesthesia *(abnormal sensations in extremities - buzzing) *
- Derealisation, depersonalisation
- Fear of ‘going crazy’ or ‘losing control’
- Fear of dying
Physiology of anxiety, fear, panic
12:05
-
Autonomic nervous system
- provides rapid response to any threat
- violent muscular action - getting body ready for fight or flight
- sympathetic nervous system (SNS) engaged
- parasympathetic nervous system (PNS) withdrawn
- Adrenaline (norepinephrine) released
-
Acute anxiety/fear response
- cardiovascular, respiratory, gastro-intenstinal, renal and endocrine changes
- growth, reproduction & immune system goes on hold
- blood flow to skin decreases
- body eventually has enough of all of these reponses
- adrenaline eventually destroyed & PNS re-engaged & restores relaxed feeling
- cyclical
What does the Cohen, Barlow & Blanchard graph illustrate about panic attack?
14:00
- Occurs over about 15 minutes
- Enormous surge in heart rate & muscle tension
- Increase in body temperature
Dying down of response occurs over about 3 minutes
Which system (axis) is involved in the biological response in a panic attack?
14:28
- Hypothalamic-pituitary-adrenocortical (HPA) axis activated in panic attack
- major part of neuro-endocrine system
- secretion of Cortisol
- acute (whole body) response to stress
- also contributes to stopping response
- via inhibitory feedback
- longer term stress response
Describe the HPA axis.
15:00
**Hypothalamus / paraventricular nucleus **- contain neurons that synthesise and secrete:
- corticotropin releasing factor (CRF)
- vasopressin
which regulate
Pituitary gland (anterior lobe) *& stimulate secretion *of
- Adrenocorticotropic hormone (ACTH)
which acts on
Adrenal gland
-
cortisol (glucocorticoid hormone)
- survival responses
acts back on
- Pituitary & Hypothalamus to suppress CRF & ACTH
- production of cortisol mediates the alarm reaction to stress
- then faciliates adaptive response
- where alarm reactions are suppressed
- allows body to restore to rest
What is prolonged exposure to cortisol (stress hormone) thought to result in)
16:20
- atrophy of hippocampus
- (memory formation & retention of memory)
- thought to lead to brain forgetting appropriate stress responses & learning appropriate responses
What are the four areas associated with risk factors for Panic Attack?
- Neurobiological factors
- Personality factors
- Psychological factors
- Social factors
Neurobiological factors
*Genetic influence
*Neurotransmitter systems
- GABA
- Norepinephrine, Serotonin
*Corticotropin-releasing factor system
- Activates HPA axis
- Hypothalamus, pituitary gland, adrenal glands
*Wide ranging effects on brain regions implicated in anxiety
- limbic system, hippocampus & amygdala, locus ceruleus, PF ctx
Which system is most associated with panic & anxiety disorders (from a neurobiological perpective)?
19:10
Limbic system most associated
(‘mediator’ between brain stem & cortex)
Amygdala centrally involved by
- assigning emotional significance (non-aversive stimulus)
- overly responsive to stimulation
- *= abnormal bottom-up processing**
Medial prefrontal cortex also involved
- Fails to down-regulate hyper-excitable amygdala
- = abnormal top-down processing
Personality risk factors?
20:50
Behavioural inhibition:
- Strong predictor of social phobia
- (found in infants as young as 4 mnths - when exposed to novel situations)
- Neuroticism:
- Tendency to react with greater neg affect > High levels = strong predictor of anxiety disorder
What two research examples does Jo talk about when considering personality risk factors for developing an anxiety disorder?
22:00
Jo’s example
- 7000 adults
- those with high level of neuroticism were more than twice as likely to develop an anxiety disorder
Firefighters (text example)
- fire fighters: originally enlisted
- measured skin conductance to loud tone
- larger physiological response = greater risk of developing PTSD following major traumatic event
Psychological factors
22:55
Behaviourist theories:
- Anxiety as a learned response
- Classical & operant conditioning
- Modeling
Perceived lack of control:
- In childhood, total confidence > real uncertainty of control over environment (spectrum)
- Parents foster sense of control/not
- Anxiety following exposure to trauma as function of control over the incident
Attention to threat:
- Negative cues in the environment
What two factors are thought to contribute to psychological vulnerability to anxiety?
- Perceived control/or lack of control over environment
- Attention to threat: attention to negative cues
Social factors
- Stressful life events trigger biological & psychological vulnerabilities to anxiety
- Social & interpersonal
- Physical
- Familial
- 70% report severe stressor prior to onset
What integrated model of anxiety does Jo present?
27:00
Barlow’s (2002) - Triple Vulnerability Theory
-
Biological vulnerability
- heritable contribution to negative affect
- glass is half empty
- irritable
- driven
-
Specific psychological vulnerability
- hypochondriac
- non-clinical panic
- learn from early experience
-
Generalised psychological vulnerability
- sense that events are uncontrollable
- grow up believing world is dangerous place, out of your control
- cycle feeds on its self - viscious cycle - even after stressor has gone
Common features for diagnosis of Anxiety Disorders:
30:00
- Typically lasting more than 6 months
- Causes clinically significant distress or impairment (social, occupational, other)
- Not attributable to substance/medication use
- Not better explained by symptoms of another mental disorder
- Some have specifiers…..
Specific phobia
- Marked fear or anxiety about a specific object or situation:
- Almost always provokes immediate fear/anxiety
- Actively avoided or endured with intense fear/anxiety
- Disproportionate to actual danger
What are the four major sub-types of specific phobia?
-
Blood, injection, or injury
- inc heart rate, blood pressure, think going to faint
-
Situational
- specific situations: chlostrophobia, fear of flying
- never experience outside of situation itself
- 1st degree relatives also tend to have
-
Animals & insects
- common: debilitating
-
Natural environments
- commmon: many have element of danger anyway
- leads to avoidant behaviours
peak onset around 7yrs of age
What weakens the utility of sub-typing specific phobias?
tendency for multiple phobias
Aetiology of specific phobias?
39:44
Specific phobias come out in a variety of ways:
-
Direct experience
- e.g., choking
-
Experiencing a false alarm in specific situation
- many people have unexpected panic attack > develop phobia in that situation e.g., while driving
- Classical conditioning
-
Observing someone experiencing fear (modelling)
- Learn fears vicariously
-
Being told about a danger (verbal instruction)
- Information transmission e.g., being told about a snake (do not need to actually see one)
Specific Phobia: What is a true phobia?
42:30
not always experience causes phobia
- True phobia = anxiety over possibility of another traumatic event
can be
-
Traumatic conditioning experience
- Actual, false alarm, vicarious, informed
-
Inherited preparedness
- Fear of ‘real’ dangers e.g., stroms
-
Biological or psychological vulnerability
- susceptible / familial
- inheritable - fear of injections
- Social & cultural factors likely determinants
Treatment of specific phobia?
development is complex but treatment is:
- Fairly straightforward
- Structured & consistent exposure-based exercises
- Guided exposure most successful
- Tailoring important in cases like blood– injury–injection phobia
- Keep blood pressure sufficiently high
- ‘rewires’ the brain
- shown by imaging studies
What is Social Anxiety Disorder?
52:20
Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others.
- Exposure to the trigger leads to intense anxiety about being evaluated negatively
- Almost always provoke fear/anxiety
- Trigger situations are avoided or endured with intense fear/anxiety
- Disproportionate to actual threat
- In presence of another medical condition, fear/anxiety is unrelated or excessive
- Social Anxiety Disorder
- Prevalence?
- Comorbidities?
Prevalence: 3-13%
- ~50:50 gender ratio
- Generally begins in adolescence
- Most prevalent in young, undereducated, low SES singles
- Diagnosed as performance only or generalised
Comorbidities:
- Other anxiety disorders
- depression,
- alcohol abuse
Aetiology of Social Anxiety Disorder?
- Evolutionary advantage?
- Prepared to fear angry, critical, rejecting people
- Learn more quickly to fear angry expressions – diminishes more
- slowly (Dimberg & Ohman, 1983)
- Generalised social phobia greater activation of amygdala, less cortical control (Golin et al, 2009)
- Speculation!
- Generalised biological vulnerability
- Stress increases anxiety & self-focused attention
- Under stress > panic attack
- Social situation associated with panic
- Real social trauma > true alarm
- Anxiety in similar situations
- Belief that social evaluation can be dangerous
- Parental concern about opinion of others
Social Anxiety Disorder: Treatment?
- Exposure therapy:
- Role-play /practice in small groups public
- Cognitive therapy:
- Challenges beliefs re: appraisal & worthlessness Effective where added to exposure therapy
- Drug therapy:
- Tricyclic ADs, MAO inhibitors effective
- Combined treatments:
- Adding D-cycloserine to CBT sig
- enhances effect of treatment
Panic Disorder: DSM definition/criteria
Recurrent unexpected panic attacks…. 4 or more ‘panic’ symptoms
At least 1 of the attacks followed by ≥ 1 month of one or both:
- Persistent concern or worry about further attacks or their consequences
- Significant maladaptive behavioural changes because of the attacks.
What are some methods commonly used to deal with panic attacks?
-
Methods of avoiding panic attacks
- Drug & alcohol use /abuse
- ‘Endure’ fear with intense dread (rather than avoided)
-
Interoceptive avoidance:
- Remove self from situations that might produce physiological arousal
- Exercise
- Saunas
- Watching sport
- Remove self from situations that might produce physiological arousal
Panic Disorder:
- Prevalence
- Other manifestations
1:07
Prevalence
- ~5% of people at some time - 2/3 female (Kessler et al, 2005)
- 20% attempy suicide
- Onset early adulthood (mid-teens to ~40)
- 60% experience nocturnal attacks:
- Not while dreaming During delta wave (slow wave) sleep – deepest sleep
- may fear going to sleep
Sleep terrors:
- Occurs in children – don’t wake, no memory
- At later stage of sleep
- about an hour after sleep onset
Isolated sleep paralysis:
- Transition between sleep & wake (REM)
- Unable to move, vivid hallucinations
- History of trauma
Aetiology of Panic Disorders?
1:09:20
- Locus ceruleus (LC) particularly important
- Major source of norepinephrine - alters cognitive function through the prefrontal cortex
- activates the HPA axis
- triggers the sympathetic NS
LC: like a pacemaker of the brain
- increasing arousal, heightened awareness, alertness, hyper vigilance
- text: electrical stimulation to this region in monkeys - behave as if having a panic attack
What is the cycle of panic disorder (adapted from Kring)?
1:10:10
Most likely an overlap between Biological, psychological & social factors
- Biological & psychological vulnerability
results in
- Stress reaction
- (Due to negative life event)
- False alarm (first panic attack)
- Learned alarm
- (associated with interoceptive cues)
- Anxious apprehension about somatic symptoms
- believing they will result in a panic attack
- Panic disorder
viscious cycle
Panic Disorder: Treatment?
** Biological**:
- SSRIs & SNRIs
- Benzodiapepines (GABA)
- most widely used
- addictive, affect motor /cognitive function
- 60% free of panic, but relapse high (50-90%) once stopped
Cognitive behaviour treatment most successful
- Focus on exposure – combined with relaxation, breathing retraining
- Panic control therapy (recent technique)
- Exposure to interoceptive sensation e.g. by spinning in a chair
- Mimics panic attack
- Perceptions of danger identified & modified over time = symptoms less frightening
What is Agorophobia (according to DSM-5)
Marked fear or anxiety about ≥2 situations
- Public transport, open spaces, enclosed spaces, in line or in crowd, outside of home alone
- Fears: because escape might be difficult or help not available
- Almost always provokes fear or anxiety
- These situations are avoided, require the presence of a companion, or endured with intense fear or anxiety
- Out of proportion to actual danger
diagnosed irrespective of presence of panic disorder
Agorophobia:
Aetiology?
Treatment?
1:15:45
Aetiology:
- Genetic vulnerability (heritability 61%) & life events
- Fear-of-fear hypothesis:
- Driven by negative thoughts about the consequences of experiencing anxiety in public
Treatment:
- Systematic exposure to feared situations:
- More effective with a partner – stop enabling!
Generalised Anxiety Disorder: DSM-5 criteria?
1:16:45
Excessive anxiety and worry (apprehensive expectation) occurring more days than not, about a number of events/activities
- Difficult to control worry
- The anxiety & worry are associated with at least 3 of the following
- Restlessness / keyed up / on edge
- Easily fatigued
- Difficulty concentrating / mind going blank
- Irritability
- Muscle tension
- Sleep disturbances
- Without precipitants
- i.e., no particular trigger
Generalised Anxiety Disorder:
Prevalence?
Course?
1:18:15
- ~5.7% of the population meets criteria for GAD at some point in their lifetime
- one of the most common anxiety disorders
- 2/3 female
- may reflect a reporting bias
- Associated with an earlier & more gradual onset than most other disorders
- many report feeling anxious & tense all their lives
- Chronic course characterised by waxing & waning
- Prevalent among older adults
- may be particularly susceptible to anxiety about failing health or other life situations that begin to diminish whatever control they have over their lives
Why worry?
Function of worry
- Vigilant anticipation of potential danger
What happens in GAD?
- Overprediction of negative outcomes
- Failure to stop generating neg. outcomes
- Failure to move on to effective problem solving
Reinforcement
- Anticipate the worst
- Catastrophe usually doesn’t occur
- Reinforces beliefs about value of worrying
Generalised Anxiety Disorder: Aetiology?
121:00:05
Genetic vulnerability
- Tends to run in families
Autonomic restrictors
- Less responsive on physiological measures
- Instead > chronically tense
Highly sensitive to threat > unconscious
- Restricted autonomic arousal but intense frontal lobe activity
- Frantic, thought processes proposed to reflect avoidance of unpleasant emotions that would be more powerful than worry
Generalised Anxiety Disorder: Treatment?
123:00
Pharmacological
- Benzodiazepines most commonly prescribed (sedative action)
- short-term relief, temporary crisis
- decline in cognitive function
**Psychological treatments more effective long term Challenging negative thoughts **
relaxation training, then
- Confronting anxiety-provoking thoughts
- Acceptance rather than avoidance of distressing thought
- ‘Scheduling’ worry at particular times
What are the obsessive-compulsive & related disorders: DSM-5 Diagnosis & Key Features?
124:40
Obsessive-compulsive disorder
- Obsessions and compulsions
Body dysmorphic disorder
- Preoccupations with an imagined flaw in one’s appearance Excessive repetitive behaviours or acts regarding appearance (e.g. checking appearance, seeking reassurance, excessive grooming)
Hoarding disorder
- Acquiring an excessive number of objects Inability to part with those objects
Trichotillomania
- Recurrent pulling out of one’s hair, resulting in hair loss Repeated attempts to decrease or stop
Excoriation disorder
- Recurrent skin picking, resulting in skin lesions Repeated attempts to decrease or stop
Substance/medication induced Disorder due to another medical condition
Other-specified/unspecified
Obsessive-Compulsive Disorder: DSM-5 criteria?
126:00
Presence of obsessions, compulsions, or both
Obsessions:
- recurrent, intrusive, persistent, unwanted thoughts, urges, or images
- Cause marked distress and anxiety
- Individual tries to ignore, suppress or neutralise with other thought/actions
Compulsions:
- repetitive behaviours or mental acts that a person feels compelled to perform to in response to an obsession or according to rigid rules
- Aimed at preventing/reducing anxiety or distress
- Not always connected in realistic way
- can have some insight or none at all
Obsessions or compulsions are time consuming (e.g. require at least 1 hour per day) or cause clinically significant distress or impairment.
Obsessive-Compulsive Disorder:
Comorbidity?
Prevalence?
127:50
Commonly co-occurs with:
- anxiety disorder
- recurrent panic attacks
- debilitating avoidance
- major depression
Prevalence ~2%
- 13% of ‘normals’ - moderate symptoms
- Females 55-60%
How does the ‘impending danger’ differ in OCD compared to other anxiety disorders?
Other anxiety disorders
- the danger is the external object or situation
OCD
- the dangerous event is the thought, image, impulse
Obsessive-Compulsive Disorder
-
Symptom subtype
- Obsession
- Compulsion
-
Symmetry / exactness / “just right”
- O: Needing things to be symmetrical / aligned just so. / Urges to do things over and over until they feel “just right”
- C: Putting things in a certain order Repeating rituals
-
Forbidden thoughts or actions (aggressive / sexual / religious)
- O: Fears, urges to harm self or others / Fears of offending God
- C: Checking, Avoidance, Repeated requests for reassurance
-
Cleaning / contamination
- O: Germs / Fears of germs or contaminants
- C: Repetitive or excessive washing / Using gloves, masks to so daily tasks
Obsessive-Compulsive Disorder: Aetiology?
Hyperactive orbitofrontal cortex, caudate nucleus, anterior cingulate gyrus
- Compensation for loss of neuronal function in OFC?
- moderate heritability 30-50%
Thought-action fusion
- equating thoughts with specific actions
-
Hypotheses:
- Early experience that some thoughts are dangerous i.e. might make terrible things happen
- Attitudes of excessive responsibility & guilt i.e. thought is moral equivalent of dangerous act
Obsessive-Compulsive Disorder: Treatment?
1:33:45
SRIs most effective - ~60% benefit
- Relapse with discontinuation
Exposure & response prevention:
- Rituals actively prevented – e.g remove taps = unpleasant! (extreme end)
- Systematic & gradual exposure to feared thoughts/ situations
- Reality testing – learn there are no consequences
Cognitive approaches:
- Challenge beliefs about consequences > exposure to test
Psychosurgery:
- E.g. lesion to cingulate bundle – 30% benefit
- only for those extremely disabled by disorder
- Following failure to respond to drugs/therapy
Trauma- and stressor-related disorders:
- DSM-5 diagnosis
- Key features
135:30
Posttraumatic stress disorder
- Exposure to actual or threatened death, injury, sexual violence, duration more than 1 month
Acute stress disorder
- As for PTSD, duration 3 days to 1 month
- not examined on ones below*
Reactive attachment disorder
- Pattern of inhibited, emotionally withdrawn behaviour toward caregiver, experience of extremes or insufficient care
Disinhibited social engagement disorder
- Pattern of actively approaching/interacting with unfamiliar adults, experienced extremes of insufficient care
Adjustment disorders
- Emotional or behavioural symptoms in response to identifiable stressor within 3 months (no longer than further 6 months)
Other-specified/unspecified
Post-traumatic Stress Disorder: DSM-5 criteria?
135:55
extreme response to a severe stressor
- *Exposure to actual or threatened death, serious injury or sexual violence** *in one or more of the following
ways: * - experiencing the event personally
- witnessing the event
- learning that a violent or accidental death or threat of death occurred to a close other
- experiencing repeated or extreme exposure to aversive details of the event(s)
- e.g. first responders – human remains
Post-traumatic Stress Disorder: DSM-5 full criteria
136:55
1. At least 1 of the following intrusion symptoms:
- Recurrent, involuntary, and intrusive distressing memories of the trauma
- Recurrent, distressing dreams related to the event(s)
- Dissociative reactions (e.g. flashbacks) in which the individual feels or acts as of the trauma were recurrent
- Intense or prolonged distress or psychological reactivity in response to reminders of the trauma
- Marked physiological reaction to cues
- *2. At least 1 of the following avoidance
symptoms: ** - Avoids internal reminders of the trauma(s)
- Avoids external reminders of the trauma(s)
138:10
3. At least 2 negative alterations in cognitions & mood that began or worsened after the trauma(s);
- Inability to remember an important aspect of the trauma(s)
- Persistent & exaggerated negative expectations about oneself, others,
- world
- Persistently excessive blame of self or others about the trauma(s)
- Pervasive negative emotional state
- Markedly diminished interest or participation in sig. activities
- Feeling or detachment or estrangement form others
- Persistent inability to experience positive emotions
138:40
4. At least 2 of the following alterations in arousal & reactivity that began or worsened after the trauma(s):
- Irritability or aggressive behaviour
- Reckless or self-destructive behaviour
- Hypervigilance
- Exaggerated startle reflex
- Problems with concentration
- Sleep disturbances
beginning or worsening after trauma is key
5. The symptoms began or worsened after trauma(s) & continued for at least 1 month
Post-traumatic Stress Disorder:
- Prevalence?
- Comorbidity?
139:35
- Women twice as likely to develop PTSD 2/3 have history of another anxiety disorder
- Suicidal thoughts common
- Delayed onset – up to years
- Prevalence reflects proximity to the traumatic event
- Close exposure appears necessary for development
- WWar vs. Vietnam
- act by another human being inc. compared to act of nature
- Complex course of development - individual differences
Acute Stress Disorder (ASD):
DSM-criteria?
141:45
PTSD-like symptoms/criteria:
- Symptoms 3 days to 1 month following traumatic event
- 9 symptoms from 5 categories:
- Intrusions symptoms, negative mood, dissociative symptoms, avoidance
- symptoms, arousal symptoms
Prevalence of ASD varies depending on type of trauma
- More than 2/3 develop PTSD >2 years
Criticised as a diagnosis because:
- Pathologises common, short-term reaction to serious trauma
- Most people who go on to meet criteria for PTSD do not experience ASD in first month
Post-traumatic Stress Disorder: Aetiology?
143:30
Severity & type of trauma matter
- More prevalent if more severe or caused by another human
(severity is important) - text example: Vietnam war 30% compared to prisoners of war 50% PTSD
Neurobiological factors:
- Vulnerability
- family history of anxiety inc.
- twin studies
-
Elevated CRF
- Heightened HPA activity = inc. cortisol
- Sustained elevation = reactivity to changes in cortisol
- Chronic activation > hippocampal damage
- Fragmentation of memories
Smaller hippocampal volume precedes trauma? (seen in twin studies)
- Difficulty constructing a coherent narrative about event (which is important step in dealing with it)
- fragments of memory rather than narrative - hard to put it together
Psychological vulnerability
- Based on early experiences with unpredictable / uncontrollable events
- Although may be irrelevant at high levels of trauma
Conditioned response
- Where fear/anxiety is associated with traumatic event
- Conditioned stimulus = any similar sensation or image
Dissociation & memory suppression
- Play role in maintaining disorder
- Keeps the person from confronting memories of the trauma = no recovery
Social factors
- Strong support group reduces likelihood of developing PTSD
- Directly effects biological & psychological responses to stress
Post-traumatic Stress Disorder: Treatment?
147:45
- Face original trauma
- Process intense emotions
-
Develop effective coping strategies
- may involve returning to scene
- develop narrative of event
- re-living & reviewing in therapeutic setting
-
Cognitive therapy to correct negative assumptions
- common in case of rape victims (self-blame)
- SSRIs
- For ASD – series of cognitive-behavioural approaches
- including exposure
Anxiety Disorders: other comorbidities?
- Other comorbidities:
- substance abuse
- personality disorders
- Physical disorders:
- Anxiety disorder uniquely & significantly associated with:
- thyroid disorder
- respiratory disease
- gastrointestinal disease
- migraine & allergies
- Anxiety often precedes physical disorder – cause/contribute?
- poorer quality of life than physical disorder alone
- Same relationship with cardiovascular disease
- especially panic disorder
Comorbidity of anxiety disorders?
149:29
> 50% of people with one anxiety disorder diagnosed with a second AD
- Overlapping symptoms
- (subthreshold symptoms of other disorders)
- Shared vulnerabilities
- Different triggers & pattern of panic attacks
Around 75% of people diagnosed with an anxiety disorder also meet criteria for another disorder (IMPORTANT)
- 60% meet criteria for major depression
- Less likely to recover, more likely to relapse
Other comorbidities:
- substance abuse
- personality disorders
Physical disorders:
- Anxiety disorder uniquely & significantly associated with:
- thyroid disorder
- respiratory disease
- gastrointestinal disease
- migraine & allergies
- Anxiety often precedes physical disorder – cause/contribute?
- poorer quality of life than physical disorder alone
- Same relationship with cardiovascular disease
- especially panic disorder
Summary
Anxiety disorders most common type of mental illness
On the whole, seem more prevalent in women
Common risk factors:
- genetic factors
- elevated activity of limbic/fear circuit
- poor regulation of
- GABA,
- noradrinergic (norepinephrine),
- seratonergic &
- corticotropin-releasing hormone systems
- negative life events
- lack of perceived control
- tendency to attend to danger signs
Treatments: exposure, cognitive therapy, relaxation techniques, medication
