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Clinical and Neuropsychology - 1 > CP: Fear and Anxiety > Flashcards

CP: Fear and Anxiety Flashcards

1
Q

What are the components of emotions?

A
  • Expression
  • Behaviour
  • Appraisal
  • “Feeling”
  • Action tendencies
  • Physiology
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2
Q

What is fear? What are its components?

A
  • Immediate danger
  • Basic emotion
  • Very observable facial expression
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3
Q

What effects does fear have on the body/mind?

A
  • Physiology - Sympathetic division
    • Heart rate/Blood pressure
    • Muscle tone
    • Breathing
  • Behaviour
    • Freeze, flight, fight, fright
      • Mammals typically freeze and observe, then make a decision
  • Cognitive/subjective
    • If you are in a fearful state, it is much easier to have “hot” cognitions, meaning they are biased to danger-like interpretations
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4
Q

What is anxiety?

A
  • Apprehension over an anticipated problem
  • Threat in future: (Anticipatory) anxiety
  • Complex emotion
  • Avoidance
  • Preparation
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5
Q

What are common features of anxiety and fear?

A
  • Both anxiety and fear can involve arousal or sympathetic nervous system activity.
    • Anxiety often involves moderate arousal, fear involves higher arousal.
  • Both are adaptive, anxiety is an inverse u-shaped curve when plotted against performance
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6
Q

In an Anxiety disorder, what does fear have to be?

A
  • Irrational
    • Stimulus doesn’t justify the fear
    • Excessively intense fear
    • Excessively long duration of fear
  • Distress/impairment
    • Fear is very aversive
    • Avoidance, safety behaviours
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7
Q

Is fear common in all anxiety disorders?
Are fear and anxiety exclusive to anxiety disorders?

A

Fear is common in anxiety disorders other than GAD
There are specific anxiety disorders, but fear and anxiety are important in many other forms of psychopathology

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8
Q

What are the five major anxiety disorders?
What are they about?

A
  • Specific phobia
    • Fear of objects or situations that is out of proportion to any real danger
  • Social anxiety disorder
    • Fear of unfamiliar people or social scrutiny
  • Panic disorder
    • Anxiety about recurrent panic attacks
  • Agoraphobia
    • Anxiety about being in places where escaping or getting help would be difficult if anxiety symptoms occurred
  • Generalized anxiety disorder (GAD)
    • Uncontrollable worry
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9
Q

How many specific anxiety disorders are there in the DSM-5?
(You don’t need to know all of them by heart, just understand that theres a lot of them)

A
  • Separation anxiety disorder
  • Selective mutism
  • Specific phobia
  • Social anxiety disorder
  • Panic disorder
  • Panic attack as a specifier
  • Agoraphobia
  • Generalized Anxiety Disorder
  • Substance induced anxiety disorder
  • Anxiety disorder due to another medical condition
  • Other specified / unspecified anxiety disorder
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10
Q

How common/prevalent are anxiety disorders as a group?

A

Anxiety disorders as a group are the most common type of psychological disorder.
Global prevalence estimate is 26.9% for anxiety disorders

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11
Q

Are anxiety disorders costly/what effect on the world do they have?

A
  • Anxiety disorders are ninth leading cause of disability worldwide
  • People with Anxiety disorders have
    • Twice the rate of unemployment
    • Elevated risk of marital discord
    • Fourfold higher risk of suicide attempts
    • Higher risk of developing medical conditions
  • 3/4 of people with an Anxiety disorder meet the criteria for another Psychological disorder (comorbidity)
    • High comorbidity (60%) with depression
  • Relapse: often different anxiety disorder
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12
Q

What is the lifetime prevalence of anxiety disorders in the Netherlands?

You don’t need to know specifics, just the range/general number

A

Panic disorder: 3.8%
Agoraphobia without panic: 0.9%
Specific phobia: 7.9%
Social anxiety disorder: 9.3%
Generalized anxiety disorder: 4.5%
Anxiety disorder (overall): 19.6%

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13
Q

Is there a difference between male and female prevalence?

A

The numbers for male and female prevalence typically follow the pattern of female prevalence being 1.5-2x higher than male prevalence (e.g. Panic disorder: Lifetime=3.8, M=2.8, F=4.8)

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14
Q

What are some potential explanations for this?

Focus on concepts here, not specifically the info

A
  • Women may be more likely to report symptoms
  • Social influences, such as gender roles are involved
    • Men may experience more social pressure to face their fears (an excellent treatment method)
    • Women experience different life circumstances; much more likely to be sexually assaulted, which interferes with sense of control over environment
      • Less perceived control over one’s environment may set the stage for anxiety disorders
    • Men raised to believe in their personal control over situations
    • Women show higher neuroticism levels and more biological reactivity to stress.
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15
Q

Are anxiety disorders experienced in every culture?

A

People in every culture seem to experience problems with anxiety disorders, but culture and environment influence what people fear.
Cultural concepts of distress provide examples of how culture/environment shape the expression of an anxiety disorder

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16
Q

What is an example of a cultural-specific anxiety disorder?

A
  • In Japan, taijin kyofusho involves fear of displeasing or embarrassing others
    • Symptoms of this disorder overlap with social anxiety disorder, but the focus on others’ feelings is distinct.

.

  • There are other examples that I wont write out, but know usually the objects of anxiety and fear in these syndromes relate to environmental challenges as well as to attitudes that are prevalent in the culture.
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17
Q

Does the prevalence of anxiety disorders vary across culture?
If so, why?

A
  • Prevalence of anxiety disorders varies dramatically across cultures, ranging from 3% to 19%.

.

  • This is because of the usual cultural things, like relationship nature, countries with conflicts, attitudes towards disclosing psychological symptoms.
    • In some countries, cultural concepts of distress related to anxiety may be more common than Anxiety disorders, therefore showing lower prevalence’s.
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18
Q

What is a key factor that affects prevalence?

A
  • One important difference is level of income inequality (the gap between highest and lowest incomes in a country)
    • Countries with high levels (e.g. European countries and United states) have much higher rates of Anxiety disorders.
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19
Q

General anxiety disorders?

What are the influences that increase general risk for anxiety disorders?

It’s a long list, but they appear everywhere so try learn them

A
  • Cultural and cross-national influences: exposure to war, persecution, and income inequality
  • Behavioural conditioning (classical and operant conditioning)
  • Genetic vulnerability
  • Disturbances in the activity of the amygdala (increased), the medial prefrontal cortex (decreased), and other brain regions involved in processing fear and emotion
  • Decreased functioning of gamma-aminobutyric acid (GABA) and serotonin; increased norepinephrine activity
  • Increased cortisol awakening response (CAR)
  • Behavioural inhibition
  • Neuroticism
  • Cognitive influences, including sustained negative beliefs (assisted by safety behaviours), perceived lack of control, over-attention to cues of threat, and intolerance of uncertainty
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20
Q

General anxiety disorders

How do genes affect etiology?

A
  • Twin studies suggest heritability estimate of 0.5-0.6 for anxiety disorders
  • Neuroticism (~40% heritable)
    • Predicts both anxiety disorders and mood disorders
    • How is this heritable? Isn’t neuroticism a concept? Well polygenetic, etc. blah blah
  • Behavioural inhibition - Kagan
    • Related to genes and temperament, its the difference in baby’s reaction to the toy
    • High reactivity is related to shyness, and social anxiety
      • High reactivity = vulnerable temperament
  • Specific genes e.g. Panic disorder
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21
Q

General anxiety disorders

How does environment affect etiology?

A
  • Positive and negative experiences (Related to perceived lack of control)
  • Parent modelling
  • Parenting styles
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22
Q

General anxiety disorders

Neurobiological correlates: What brain regions play a role in etiology?

A

When responding to threatening stimuli, people with anxiety disorders tend to have

  • Heightened activity in the amygdala
  • Diminished activity of the medial prefrontal cortex
    • The pathways connecting them may be deficient
  • Other brain regions are involved
    • Bed nucleus of stria terminalis is engaged by cues of threats, particularly unpredictable or diffuse threats.
    • Anterior cingulate cortex involved in anticipation of threat
    • Insula related to awareness of and processing of bodily cues
    • Hippocampus encodes the context in which feared stimuli occur
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23
Q

General anxiety disorders

Neurobiological correlates: What neurotransmitters play a role in etiology?

A

Many neurotransmitters and neuropeptides are involved, and different techniques used to identify them

  • PET and SPECT imaging studies link Anxiety disorders to disruptions in serotonin levels; changes in function of GABA system.
  • Drug manipulation showed that Anxiety disorders are related to increased levels of norepinephrine and changes in sensitivity of receptors.
  • Other research focused on HPA axis and the size of early morning rise due to cortisol (known as cortisol awakening response, CAR).
    • The CAR predicted onset of Anxiety disorders over the next 6 years.
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24
Q

General anxiety disorders

What is the main model used for fear conditioning?

A

Mowrer’s two factor model of anxiety influences thinking in this area.
It suggests two steps in the development of an anxiety disorder

  1. Etiology: classical conditioning (little albert)
  • very important paradigm in studying fear
  1. Maintenance: operant conditioning
  • Reinforcement of avoidance
  • Neurotic paradox
    • Short term advantage: fear lessens temporarily
    • Long term disadvantage: pathology maintained/grows
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25
Q

General anxiety disorders

What is the first criticism of Mowrer’s model?
What is the rebuttal?

A

Criticism: Why more fears for certain stimuli?
Rebuttal:Evolutionary preparedness/prepared learning - Snakes, spiders, etc.

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26
Q

General anxiety disorders

What is the second criticism of Mowrer’s model?
What is the rebuttal?

A

Criticism: Why sometimes fear without traumatic experience?
Rebuttal: Vicarious learning, information transfer, inflation

  • Learning through someone else’s experience
  • Inflation: Of the association via new information
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27
Q

General anxiety disorders

What is the third criticism of Mowrer’s model?
What is the rebuttal?

A

Criticism: Why sometimes no fear after traumatic experience?
Rebuttal: Latent inhibition & differential learning

  • Previous positive experiences & different propensities to acquisition of fear
  • People with anxiety disorders are particularly sensitive to unpredictable, diffuse, or remote threats, rather than acute, immediate, well-defined threats.
28
Q

General anxiety disorders

What is the Neutral Predictable Unpredictable (NPU) threat task?

A
  • This is where participants perform behavioural tasks with N/P/U threats.
    • Anxiety disorders are specifically related to increased affective and psychophysiological response to the unpredictable threat condition compared to predictable.
29
Q

General anxiety disorders

Which factors distinguish individuals with anxiety disorders from those without?

A

People with Anxiety disorders seem

  • More easily conditioned to fear stimuli
  • To sustain conditioned fears longer
  • To respond more strongly to unpredictable threats
30
Q

General anxiety disorders

-Treatment section starts here-
What is a core component of cognitive behavioural therapy?

A
  • Exposure is a core component of CBT,
  • The typical approach is when the therapist and client make a list of triggers (situations and activities that might elicit anxiety or fear), and they create an “exposure hierarchy”.
  • Early sessions of exposure treatment CBT involve exposure to less challenging triggers, and gradually the more challenging triggers are faced.
31
Q

General anxiety disorders

How effective is CBT?

A
  • CBT works well for the anxiety disorders. Exposure treatment is effective for 70-90% of clients.
  • Effects of CBT endure for at least 6 months, and they begin to wear off
  • Exposure treatment is adapted to address the best duration and format of treatment for each specific anxiety disorder.
32
Q

General anxiety disorders

How did we use to think exposure worked?

A
  • Reciprocal inhibition?
    • Inhibition of fear response by relaxation response
    • Equivalent success rate without relaxation, so not this
  • Erase, or replace association?
    • Fear can return, can be quickly relearned
      • So not this
  • Habituation to stimulus (response fades out)
    • Fear doesn’t always go down in one session
    • Habituation doesn’t predict therapy success

You just need to understand the general ideas

33
Q

General anxiety disorders

What is the current behavioural view on exposure?

A

Extinction

  • Inhibition of CS-US association (amygdala)
  • By CS-noUS association (prefrontal cortex and hippocampus)
  • This works very well, and is backed by lots of research
  • Some explanations is that amygdala has reduced connection to prefrontal cortex
    • Exposure therapy might not work for everyone
34
Q

General anxiety disorders

What is the neurobiological view of extinction?

A

Extinction can reduce the fear felt, but doesn’t get rid of it entirely. The conditioned fear exists deep in the brain and can resurface.
Extinction involves learning new associations.
Therefore, exposure should

  • Include as many features of the fear object as possible
  • Be conducted in as many different contexts as possible
35
Q

General anxiety disorders

What is the cognitive view of exposure?

A

Exposure helps people correct their mistaken beliefs that they are unable to cope with the stimulus.
Cognitive approaches focus on challenging peoples beliefs about
1. The likelihood of negative outcomes if they face an anxiety-provoking object or situation
2. Their ability to cope with the anxiety.

However, when cognitive therapy is added to exposure therapy it doesn’t bolster results except for specific techniques

36
Q

General anxiety disorders

What are specific cognitive techniques/variations of exposure?

A
  • Virtual reality exposure therapy
    • Used to stimulate feared situations like flying, heights, etc.
      • Findings show that VR appears to be as effective as in vivo exposure
  • Internet-based CBT programs
    • Helps fill the gap created by sparse professional contact time.
37
Q

General anxiety disorders

What could be the future of behavioural therapy?

This is the lecturers field of study, so it was only in lecture

A
  • Cognitive enhancers with exposure?
    • D-cycloserine
  • Disrupting memory reconsolidation?
    • Beta-blockers
38
Q

General anxiety disorders

What is the name of drugs that reduce anxiety?
What are the two types of medications used?

A

Anxiolytics: Drugs that reduce anxiety
Two types of medications commonly used

  • Benzodiazepines
  • Antidepressants, such as SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs)
39
Q

General anxiety disorders

Are both medications effective?
Is there a preferred medication?

A

Both are more effective than placebos
Antidepressants are preferred over benzodiazepines

40
Q

General anxiety disorders

Why are antidepressants preferred over benzodiazepines?

A
  • People may experience severe withdrawal symptoms when they stop using benzodiazepines
  • Benzodiazepines can have significant cognitive and motor side effects, severe enough to increase risk of car accidents
41
Q

General anxiety disorders

Is medical or psychological treatment preferred?

A

Psychological treatment is preferred (for most anxiety disorders). This is because

  • Medication is only effective when taken
  • Most people relapse when they stop taking medication

Generalized anxiety disorder is the only possible exception, as both treatments are considered equivalent

42
Q

Specific Phobias

What are the criteria of a specific phobia?

A
  • Marked fear or anxiety
  • Always, immediate
  • Avoidance or endured
  • Out of proportion to actual danger (in socio-cultural context)
  • 6 months or more
  • Distress/impairment
  • Not better explained by something else

Types: Animal, natural environment, blood-injection-injury, situational, other
Specific phobias are highly comorbid

43
Q

Specific Phobias

Etiology: What is the dominant model? What is the most common example?

A

The dominant model of phobia is the two-factor model of behavioural conditioning.
Very common paradigm is Little Albert and his developed fear of the rat, because it showed that intense fears could be conditioned.

44
Q

Specific Phobias

Etiology: Behavioural conditioning theory suggests that phobias could be conditioned by direct trauma, modelling, or verbal instruction. Is this true?

A
  • Most people don’t remember their conditioning experience, so surveys can’t identify them
  • Some people with threatening experiences didn’t develop a phobia, por que?
    • The risk factors of fear conditioning (e.g. genetic vulnerability, neuroticism, negative cognitive styles, etc.) act as vulnerability factors that shape if a phobia develops.
  • Its also believed that only certain kinds of stimuli and experiences will contribute to a phobia. .
    • This is because of prepared learning: Evolution may have biologically “prepared” us to learn fear of certain stimuli very quickly and automatically.
      • Evidence for this is shown by monkeys being conditioned to fear snakes but not flowers.
45
Q

Specific phobias

Treatment: What is the most common psychological treatment used for phobias?

A

In vivo exposure CBT (Or virtual reality)
Most treatments focus on forcing the patient into contact with phobia so they can extinguish the fearful associations

46
Q

Social anxiety disorder (SAD)

Features/symptoms of SAD

A
  • Defining symptoms
    • Marked and disproportionate fear consistently triggered by exposure to potential social scrutiny
    • Exposure to the trigger leads to intense anxiety about being evaluated negatively
    • Trigger situations are avoided or else endured with intense anxiety
  • SAD ranges from a few specific fears to a generalized host of fears
    • Those with a broader array of fears are more likely to experience comorbid depression and alcohol abuse
  • People with SAD often work in worse jobs if they have limited social demand.
47
Q

Social anxiety disorder

Etiology: Behavioural conditioning of SAD

A
  • Behavioural perspectives are based on the two-factor conditioning model.
    • This involves classical and operant conditioning, ending up with avoidant behaviour
  • Safety behaviours are avoidance behaviours in smaller formats, since they reduce the anxiety perceived.
    • Examples in SAD are avoiding eye contact, disengaging in conversation, and standing apart from others.
    • Safety behaviours avoid negative feedback, but they create other problems
      • People dislike these behaviours which intensify the problem
48
Q

Social anxiety disorder

Etiology: Social cognitive influences

A

One sentence summary
People with SAD have too much focus on negative self-evaluations, internal cues, and social hierarchy

Expanded info
People with SAD…

  • Appear to have unrealistically harsh views of their social behaviours
  • Have overly negative beliefs about the consequences of their social behaviours
  • Attend more to how they are doing in social situations and their own internal sensations than other people do.
    • Meaning instead of attending to their conversation partner, they’ll think about their own performance.
    • However this distracts them from the conversation which reduces their performance making them more anxious.
      • This results in a big circle of suffering
  • They worry about failing to show expected submissiveness to social leader which can lead to conflict
    • Therefore, they display more submissive behaviour
49
Q

Social anxiety disorder

What psychological treatment is used?

A
  • CBT is effective, especially exposure
  • Social skills training also helps, especially to stop safety behaviours
  • Cognitive therapy aimed at helping people learn not to focus their attention internally.
50
Q

Panic disorder

What are the symptoms of a panic attack?

A

Surge of fear, 4/13 symptoms, peak relatively early

  • Pounding heart
  • Sweating
  • Trembling
  • Shortness of breath
  • Feeling of choking
  • Chest pain
  • Nausea
  • Dizzy, lightheaded, faint
  • Chills or heat sensations
  • Paresthesias (numbness or tingling)
  • Derealization/depersonalization
  • Fear of ‘going crazy’ or losing control
  • Fear of dying

You don’t need to know all symptoms, atleast 4 and then be familiar

51
Q

Panic disorder

What are the criteria for Panic disorder?

A

Recurrent unexpected panic attacks
At least 1 month of concern about the possibility that more attacks could occur or the possible consequences of an attack, or problematic behavioural changes to avoid attacks or their consequences.

In other disorders, panic attacks have predictable triggers. This is key difference

52
Q

Panic disorder

Etiology: Neurobiological correlates

A
  • The Locus coeruleus is the major source of norepinephrine. Surges of norepinephrine is the natural response to stress.
    • People with panic disorder show a more dramatic biological response to drugs that trigger releases of norepinephrine.
      • Drugs that increase activity in the locus coeruleus can trigger panic attacks
53
Q

Panic disorder

Etiology: Behavioural influences - Classical conditioning

A

Panic attacks are often triggered by internal bodily sensations of arousal
Classical conditioning of panic attacks in response to bodily sensations has been called interoceptive conditioning of fear
(Look at figure 6.1 that I sent in groupchat)
Conditioned responses to interoceptive stimuli are slower to extinguish than are those to nonbody stimuli.

54
Q

Panic disorder

Etiology: Can panic attacks be induced? What is the carbon dioxide manipulation?

A

Panic attacks can be experimentally induced in the laboratory, in many different ways, such as drugs, and carbon dioxide manipulation

  • Carbon dioxide manipulation is a common way to study panic attacks. Participants are split into two groups and one group gets a full explanation of the physical sensations they were likely to experience and the other group gets no experience.
    • Experimenters than manipulate the carbon dioxide levels in the room so they are higher.
      • Informed participants reported that they had fewer catastrophic interpretations of their bodily sensations and much less likely to have a panic attack than those who didn’t receive an explanation.
55
Q

Panic disorder

Etiology: What was our old explanation of panic attacks and what do we think now?

A

Old explanation: Hyperventilation causes dysregulation of blood acidity
Opposite disturbance, also panic
New explanation: catastrophic misinterpretation of bodily sensations
Look at figure 6.2 in the groupchat (DONT LOOK AT THE BOOKS MODEL, ITS SHIT)

56
Q

Panic disorder

Etiology: What is anxiety always accompanied by? How can we measure its effect on panic attacks

A

Anxiety is always accompanied by physiologic changes

  • Propensity toward catastrophic interpretations can be detected, most commonly using the Bodily Concerns subscale of the Anxiety Sensitivity Index (ASI).
    • High scores on the ASI might contribute to symptoms of panic disorder.
      • This was shown in a study using the carbon dioxide manipulation, but with two conditions, high scores on ASI; low scores on ASI.
        • Participants with high ASI and unexplained conditions, panic attacks were most common.
  • Unexplained physiological arousal in someone who is fearful of such sensations leads to panic attacks.
57
Q

Panic disorder

What psychological treatments are used?

A

CBT focuses on exposure, involving deliberately eliciting the bodily sensations associated with panic.
Clients begin to stop seeing physical sensations as signals of loss of control and see them instead as intrinsically harmless and controllable sensations.
Cognitive treatment identifies and challenges the thoughts that make physical sensations threatening.

58
Q

Agoraphobia

What are the symptoms?

A
  • Disproportionate and marked fear or anxiety about at least two situations where it would be difficult to escape or receive help in the event of incapacitation, embarrassing symptoms, or panic-like symptoms,
    • Such as being outside the home alone
    • Travelling on public transportation
    • Being in open spaces such as parking lots and marketplaces
    • Being in enclosed spaces such as shops, theatres, or cinemas
    • Standing in line or being in a crowd
  • These situations consistently provoke fear or anxiety
  • These situations are avoided, require the presence of a companion, or are endured with intense fear or anxiety

Many people with agoraphobia are virtually unable to leave their house, and even those who can leave do so only with great distress.

59
Q

Agoraphobia

Etiology: What is known?

A

Since agoraphobia was only recognized as a distinct disorder in the DSM-5, less is known about its etiology.
Risk of agoraphobia is related to genetic vulnerability and life events.

60
Q

Agoraphobia

Etiology: What is the major cognitive model?

A

The Fear-of-fear hypothesis

  • It suggests that agoraphobia is driven by negative thoughts about the consequences of experience anxiety in public. Research suggests people with agoraphobia think the consequences would be horrible.
  • They have catastrophic beliefs that their anxiety will lead to socially unacceptable consequences.
61
Q

Agoraphobia

What are the psychological treatments?

A

CBT focuses on systematic exposure to feared situations
Exposure treatment can be enhanced by involving the patients partner and teaching them that recovery rests upon exposure.

62
Q

Generalized anxiety disorder (GAD)

What are the criteria?

A

A: You need these

  • Excessive anxiety and worries
  • 6 month: more days than not
  • Multiple areas

B:You need these

  • Difficult to control the worry

C: 3/6

  • Restlessness
  • Easily fatigued
  • Difficulty concentrating
  • Irritability
  • Muscle tension
  • Sleep disturbance

D:You need these

  • Distress/impairment

E: Considerations

  • Substance, medical?

F: Considerations

  • Other disorder?
63
Q

Generalized anxiety disorder

Etiology: When does it begin?
What are some features of GAD?

A

GAD typically begins in adolescence, and once developed, is often chronic.
People with GAD are more likely to report marital distress and an absence of friendships than those with any other anxiety disorder
GAD tends to co-occur with other anxiety disorders, and with major depressive disorder (MDD)
Worry is a core feature of GAD

64
Q

Generalized anxiety disorder

What is the reason why people worry according to the cognitive model of Borkovec et al.?

A

Worrying decreases arousal, and is therefore a distraction from more powerful negative emotions and images, which increase arousal.

65
Q

Generalized anxiety disorder

Etiology: What is the current model for GAD?

A
  • Contrast avoidance model may explain why people worry more than others.
  • Core finding is that people with GAD find it highly aversive to experience rapid shifts in emotions.
    • Therefore people with GAD find it preferable to sustain a chronic state of worry and distress, because then when confronted with a stressor, there’s less room for a large shift in mood.
      • Seen in Newman & Llera experiment (Figure 6.3)
66
Q

Generalized anxiety disorder

What psychological treatments are there?

A

Most widely used behavioural technique involves relaxation training
Cognitive therapy has strategies to help tolerate uncertainty.

There is meta-cognitive therapy, he didn’t explain much but he showed one study that showed it did better than CBT
It used the Meta-cognitive model, with the beliefs:
* Type 1: worrying helps
* Type 2: worrying gets out of control (meta-worries)

Clinical and Neuropsychology - 1 (21 decks)

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