Anxiety Disorders

Question 1

What is Anxiety?

Answer 1

Fear/Panic

Response to threat

Question 2

Three systems of Anxiety

Answer 2

Physical: Fight/Flight, SNS activation –> mobilising response
Cog
Behavioural

Question 3

Eliciting conditions for Anxiety

Answer 3

Realistic/objective threat to self
Specific “prepared” stimuli
Novel Stimuli

Threat appraisal –> Expectancy of harm –> Anxiety

Question 4

Threat appraisal

Answer 4

Generates expectancy of harm (e.g. public transport)
Product of perceived probability and perceived cost
Often based on past experience (cond, rft), obs learning, and instruction

Question 5

Separation Anxiety

Answer 5

Anxious about being away from primary caregiver

Question 6

Specific phobias

Answer 6

Excessive and Inappropriate fear about specific targets

Question 7

Social phobia

Answer 7

Fear of negative social evaluation

Question 8

General Anxiety Disorder (GAD)

Answer 8

Excessive & Uncontrollable worry about a range of outcomes

Question 9

Panic disorder

Answer 9

Unexpected/spontaneous panic attacks
Anxiety about having more panic attacks
Agoraphobia (fear of public/open places) - can result from excessive avoidance of places where panic attacks have previously occurred. Complication of Panic Disorder

Question 10

OCD

Answer 10

Obsession: Intrusive Thoughts/impulses
- Hard to avoid thought
- Belief: Think thought –> bad event will happen
Compulsion: Ritualistic behaviour that relieves anxiety caused by obsession

Question 11

PTSD

Answer 11

Intrusive thoughts/memories about past traumatic event

Question 12

Anxiety: Comorbid conditions

Answer 12

Anxieties comorbid with each other, depression & substance abuse
General bio vulnerabilities: Genetics, Neuroticism
General psych vulnerabilities: Trait anxiety, low perceived control
Specific psych vulnerabilities: Focus of threat-related beliefs

Question 13

Biological treatment for Anxiety Disorders?

Answer 13

Barbituates - quick, common relapse, but addictive & interacts with alcohol
Benzodiazepines - quick, common relapse, interacts with alcohol
SSRIs/antidepressants - slower, common relapse, less side effects

Question 14

Psychological treatment for Anxiety Disorders/CBT? (Cog + behavioural techniques)

Answer 14

CBT:
Aim: To reduce (biased) threat appraisal by reducing perceived probability and cost of event while increasing (biased) coping appraisal.

Cognitive techniques:

• Thought diaries –> increased awareness of anxious thoughts
• Thought challenging - leading questions –> self-realisation of irrationality of thoughts

Behavioural techniques: EXPOSURE
- Exposure: in vivo or imaginary exposure
- Either flooding (highest fear level) or systematic desensitisation
-

Question 15

Anxiety Disorders: Changes from DSM-IV to DSM-V

Answer 15

Selective mutism added

PTSD, OCD and Acute Stress Disorder have their own chapters now

Question 16

DSM-V: Which disorders are in the chapter of Obsessive Compulsive and Related Disorders?

Answer 16

OCD
Hoarding Disorder
Trichotillomania 
Excoriation Disorder
Body Dysmorphic Disorder

Question 17

Hoarding Disorder

Answer 17

Excessive hoarding - unwilling to discard items, regardless of value

Question 18

Trichotillomania

Answer 18

Excessive hair-pulling, to relieve anxiety caused by intrusive thoughts/images

Question 19

Excoriation Disorder

Answer 19

Excessive skin-picking, to relieve anxiety caused by intrusive thoughts/images

Question 20

Body Dysmorphic disorder

Answer 20

Preoccupation with perceived defects/flaws in physical appearance. Extreme manifestation of vanity

Question 21

Panic Attack (mention >4 symptoms)

Answer 21

Influx of fear/discomfort within minutes, reflective of >4 symptoms:

• increased HR/palpitations
• sweating
• Trembling
• Choking sensation
• shortness of breath
• dizziness
• nausea
• Chill/heat sensation
• Fear of losing control
• Fear of dying

Question 22

Panic Attack: two types of attack

Answer 22

Expected (cued) attack: 
 - Trigger: specific or social phobias
 - Context: most anxiety disorders
Unexpected (uncued) attack:
 - Unidentifiable trigger
 - Context: Panic Disorder
 - >2 unexpected attacks --> Panic Disorder

Question 23

Panic Disorder

Answer 23

> 2 unexpected attacks
Persistent concern/worry about having another attack
Significant maladaptive change in behaviour related to attacks
Symptoms for >1 mth

Question 24

Panic Disorder: Other information (e.g. comorbidity, etc.)

Answer 24

One-year incidence: 2-3%
Median age onset: 20-29
Course: Chronic, but waxing/waning
Comorbid: Other anxieties, Depression, alcohol use (10-65%)

Question 25

Cognitive Theory of Panic (Clark, 1988)

Answer 25

Panic comes from fear of bodily sensations --> misinterpret their consequences (e.g. heart palpitations --> impending heart attack) - positive feedback between increased anxiety and increased symptoms Misinterpretations are maintained by safety behaviours: protective actions to prevent harmful events - prevents learning that bodily sensations are safe Risk factors: neuroticism, anxiety sensitivity

Question 26

Agoraphobia - DSM edition changes, Symptoms

Answer 26

DSM edition changes: - DSM-IV: Always accompanied Panic Disorder - DSM-V: Separate entity, as often occurs without panic Symptoms: - Avoidance of public transport, open/enclosed public places, being part of a crowd/line, and being outside alone - Anxiety that they would not be able to escape when panic-like symptoms will occur - Not like normal phobias: added fear of embarrassment/incontinence, etc, on top of panic symptoms

Question 27

Why does Agoraphobia develop?

Answer 27

(Social fears) - heightened childhood dependence - lowered perception of self-coping ability - History of separation anxiety & social phobia - physical concerns that weakness --> Panic --> embarrassment/incontinence - has increased social evaluative concerns

Question 28

Treatment of Panic/Agoraphobia

Answer 28

Biological: Anxiolytics (Barbiturates, Benzos) and Antidepressants Psych/Cog-behav: - Cog restructuring - Exposure to: Interoceptive stim (Panic) or Avoided situations (Agoraphobia) - decrease safety behaviours - CBT: Effective in 80-85% of Panic Disorder Patients

Question 29

GAD Diagnostic criteria

Answer 29

Excessive, uncontrollable worry about a variety of events/outcomes occurs more days than not, for >6mths >3-6 somatic symptoms: Restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance - NO SNS AROUSAL

Question 30

What is normal worry?

Answer 30

Response to perceived threat Focus: Adults: Social threat, Older adults: Physical threat Contains verbal thought (vs imagery) Perceived positive aspects: e.g. motivates actions, etc. Worry control: Problem solving, distraction, social support Normal Worry --> problem solving attempts Pathological worry --> No solution, due to thwarted problem solving - biased threat perception

Question 31

What are some Problem Solving Theories? Social Problem Solving

Answer 31

1. Define problem 2. Generate alternative solutions 3. Solution evaluation (pos/negative) 4. Solution selection - Pathological worriers: Steps 3-4 do not occur - Step 3: only generate negative solutions --> don't want to select a solution --> No chosen solution

Question 32

What are some Problem Solving Theories? Metacognitive Worry

Answer 32

Type 1 Worry: Perception of threat + Positive beliefs about worry --> Worry to cope with threat - Possible exit: Problem solving or reassurance Type 2 Metaworry: Worry + negative beliefs about worrying --> Metaworry --> Ineffective thought-control strategies --> Increased anxiety and worry - Excessive and uncontrollable worry

Question 33

What are some Problem Solving Theories? Avoidance Theory

Answer 33

Worry: More verbal thought than imagery, because - Images of possible negative event are highly aversive, and cause anxiety symptoms (= sympathetic arousal) - Anxiety symptoms are highly aversive - Reduced imagery --> Reduced arousal/anxiety - -- GAD associated with tension symptoms - Worry = cognitive avoidance: Interferes with emotional processing - Fear structures are maintained --> Keep worrying

Question 34

What are some Problem Solving Theories? Experiential Avoidance

Answer 34

``` Worry is associated with: - Fear of anxiety/anxiety sensitivity - Distress intolerance - Experiential avoidance: Worriers avoid internal experiences Difficulties in emotional regulation: Worriers have difficulties with - Clearly identifying emotion - Tolerating emotion - Modulating emotion ```

Question 35

What are some Problem Solving Theories? Intolerance of Uncertainty Theory

Answer 35

Uncertainty reflects badly on a person --> frustration and stress, and prevents action - Worry to reduce uncertainty - Leads to preoccupation with details - Interferes with problem solving - Worries aim to reduce uncertainty to 0 - not possible

Question 36

Treatment of GAD: 4 approaches

Answer 36

1. Biased threat perception: Prob/cost judgements 2. Problem solving: Structured problem solving training 3. Metacog: Challenge beliefs about worry (pos/neg) 4. Avoidance: Exposure to: - Vivid images of feared event - Emotional experience/distress - Uncertainty Treatment effects have been modest: 50-60% improvement at follow-up (not very good)

Question 37

PTSD: Diagnostic Criteria

Answer 37

A. Exposure to actual/threatened death, serious injury, or sexual violence in >1 of the following ways - Direct experience - Witnessing event as it occurs - Learning about traumatic event to close family/friend - Experience repeated/extreme exposure to aversive details of traumatic event B. Intrusion symptoms (1+: memories, dreams, flashback) C. Persistent Avoidance of stimuli (1+) D. Negative changes in cog/mood (2+): Fear, negative beliefs about self, others, world E. Changes in arousal, reactivity (2+): Anger, recklessness, self-destructive acts, sleep-disturbance Duration of symptoms >1 month

Question 38

What normally happens in immediate post-trauma phase?

Answer 38

50-60% of people experience traumatic event 25% develop post-traumatic problems: PTSD, depression, anxiety, substance abuse. - PTSD prevalence: 5-11% Western countries Normative response to trauma: Get over it. - Distress immediately after traumatic event is normal - Distress drops substantially within 3 months in about 75% of people

Question 39

Risk factors Pre-trauma:

Answer 39

Childhood trauma, Prior psychiatric history, family instability, substance abuse, social-economic disadvantage (limited resources to deal with trauma)

Question 40

Risk factors During trauma:

Answer 40

Degree of life threat/loss, Severity of exposure to traumatic elements, Location of trauma (safe place/elsewhere), Individual role in trauma (victim, helper), Meaning

Question 41

Risk factors post-trauma:

Answer 41

Social support, coping style, ongoing stressors

Question 42

Treatments For PTSD

Answer 42

Biological: Benzo's, antidepressants CBT: Core treatment components include - Assess suitability for treatment - Psychoeducation - Anxiety management techniques (prep for exposure) - Cog restructuring of biased thoughts - Prolonged exposure - great detail of reporting of event, being willing to be exposed to associated objects/symbols CBT more effective than medication or supportive psychotherapy EMDR (Eye-Movement Desensitisation and Reprocessing) - Eye movements as critical components of procedure and essential for its effectiveness - EMDR as exposure technique - Eye mvt not necessary for effectiveness