Week 7 Lecture 7 - Anxiety, obsessive-compulsive disorder & trauma/stressor-related disorders (DN) Flashcards

Question

What integrated model of anxiety does Jo present? 27:00

Answer 1

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

Answer 2

* 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.....

Answer 3

* 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

Answer 4

* **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

Answer 5

tendency for multiple phobias

Answer 6

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)

Answer 7

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**

Answer 8

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

Answer 9

**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

Answer 10

**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

Answer 11

* 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

Answer 12

*  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

Answer 13

Recurrent unexpected panic attacks.... 4 or more ‘panic’ symptoms At least 1 of the attacks followed by ≥ 1 month of one or both: 1. Persistent concern or worry about further attacks or their consequences 2. Significant maladaptive behavioural changes because of the attacks.

Answer 14

* **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

Answer 15

**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

Answer 16

* 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

Answer 17

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

Answer 18

** 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

Answer 19

**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

Answer 20

**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!

Answer 21

**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

Answer 22

* ~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

Answer 23

**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

Answer 24

**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

Answer 25

**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

Answer 26

**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

Answer 27

**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.

Answer 28

**Commonly co-occurs with**: * anxiety disorder * recurrent panic attacks * debilitating avoidance * major depression **Prevalence** ~2% * 13% of ‘normals’ - moderate symptoms * Females 55-60%

Answer 29

**Other anxiety disorders** * the danger is the external object or situation **OCD** * the dangerous event is the thought, image, impulse

Answer 30

* **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

Answer 31

**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

Answer 32

**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

Answer 33

**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**

Answer 34

***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

Answer 35

**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**

Answer 36

* 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

Answer 37

**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

Answer 38

**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

Answer 39

* 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

Answer 40

* 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

Answer 41

**\> 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

Answer 42

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