Module 3

Question 1

What is Anxiety?

Answer 1

• Anxiety is a general state of apprehension or foreboding.
  
  • Adaptive when it prompts us to seek medical attention, to study for an upcoming test or avoid a dangerous situation.
  • Maladaptive when the level of anxiety is out of proportion to the level of threat or when it occurs out of the blue, not in response to environmental changes.
• Common: Most people experience it in varying degrees.

Question 2

What are the major types of anxiety disorders?

Answer 2

• Panic Disorder
  
  • With Agoraphobia
    
    • fear of leaving the home
  • Without Agoraphobia
• Agoraphobia without history of panic disorder
• Specific Phobia
• Social Phobia
• Generalized Anxiety Disorder
  
  • has become epidemic
• Obsessive-Compulsive Disorder (OCD)
• Posttraumatic Stress Disorder (PTSD)
  
  • person encounters a fairly significant threatening experience → usually a period of calm → then out of the blue is a period of anxiety
• Acute Stress Disorder
• → Most are more common in females than males.

Question 3

What are the two other anxiety disorders listed in the DSM-5/TR?

Answer 3

• Anxiety Disorder due to a General Medical Condition
• Substance-Induced Anxiety Disorder
• (There is also an Anxiety Disorder NOS category)
  
  • dustbin kind of category

Question 4

What is the DSM-5/TR Criteria for Panic Attack?

Answer 4

• The building block of Panic Disorder (defined next)
  
  • panic attack is not the same as panic disorder
• DSM-5/TR: A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:
  
  1. Palpitations, pounding heart, or accelerated heart rate
  2. Sweating
  3. Trembling or shaking
  4. Sensations of shortness of breath or smothering
  5. Feeling of choking
  6. Chest pain or discomfort
  7. Nauseas or abdominal distress
  8. Feeling dizzy, unsteady, lightheaded, or faint
  9. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
  10. Fear of losing control or going crazy
  11. Fear of dying
  12. Paresthesias (numbness or tingling sensations)
      
      • the sense that you do not have full control of your limbs or loss in sensation
  13. Chills or hot flushes
• Situationally Bound vs. Situationally Predisposed
  
  • situationally bound → it only happens when I’m at work, it only happen when I’m driving
    
    • high variability
    • if you can’t go to one specific place, this is a situationally bound phobia, not agoraphobia
  • situationally predisposed → more likely to occur in a situation like that

Question 5

What is the DSM-5/TR Criteria for Panic Disorder?

Answer 5

1. Recurrent unexpected Panic Attacks and
2. at least one of the attacks has been followed by one month (or more) of one (or more) of the following:
   
   1. persistent concern about having additional attacks
      
      • can throw themselves into another panic attack bc the recollection of how bad the event was can cause anxiety sensitivity
   2. worry about the implications of the attack or its consequences (eg. losing control, having a heart attack, “going crazy”)
   3. a significant change in behaviour related to the attacks.
      
      • not willing to go out, staying home
      • avoidance is the key consequence in terms of changes → negative reinforcement → as a result of relenting, or staying at home and avoiding the place where a panic attack occurred, the behaviour of staying home is reinforced.
      • even as they approach the door to leave, the debilitating feelings may start again
      • if they engage in a different type of behaviour and it gets reinforced → can lead to OCD

B) The Panic Attacks are not due to the direct physiological effects of a substance (eg. a drug of abuse, a medication) or a general medical condition (eg. hyperthyroidism → which tends to produce anxiety-like symptoms in sb).

C) The Panic Attacks are not better accounted for by another mental illness.

• 1 - 5% prevalence (lifetime)
• Anxiety sensitivity

Question 6

What is Agoraphobia?

Answer 6

• Agoraphobia (fear of the market place) accompanies panic attacks in a large minority of cases (30 - 50%; other writers report up to 75%).
  
  • When it does, it is usually fear of having another panic attack that is most impairing.
  • Makes treatment less likely unless patient gets strong support to attend, or psychologist makes house calls.
    
    • bc that is the setting they’re trying to avoid
• Even without agoraphobia, panic disordered patients are often reluctant to discuss their episodes for fear of triggering another attack.
  
  • (Almost like victims of violence who refuse to report to police.)
  • bc it causes them more anxiety

Question 7

What is Generalized Anxiety Disorder?

Answer 7

• An anxiety disorder characterized by general feelings of dread, foreboding, and heightened states of sympathetic arousal.
  
  • Not linking to any one particular fear or trigger
  • Formerly referred to as free-floating anxiety
    
    • Freudian term

Question 8

What is the DSM-5-TR Criteria for GAD?

Answer 8

• A. At least 6 months of “excessive anxiety and worry” about a variety of events and situations. Generally, “excessive” can be interpreted as more than would be expected for a particular situation or event.
  
  • Most people become anxious over certain things, but the intensity of the anxiety typically corresponds to the situation.
• B. There is significant difficulty in controlling the anxiety and worry. If someone has a very difficult struggle to regain control, relax, or cope with the anxiety and worry, then this requirement is met.
  
  • Telling them not to worry is unlikely to be enough.
• C. The presence for most days over the previous 6 months of 3 or more (only 1 for children) of the following symptoms:
  
  1. feeling wound-up, tense, or restlessness
  2. Easily becoming fatigued or worn-out
  3. Concentration problems
  4. Irritability
  5. Significant tension in muscles
  6. Difficulty with sleep
• Note: The usual criteria regarding level of impairment and the disorder not being better accounted for by another medical or psychological condition are also in DSM-5/TR, but will be omitted from this point on for brevity.

Question 9

What are the different types of phobic disorders?

Answer 9

• Specific phobia
  
  • something in particular that freaks out or stokes anxiety, that in other circumstances, you would be completely calm
  • Claustrophobia
    
    • fear of enclosed spaces
• Social Phobia
  
  • fear about the interaction with other people and the opportunities it presents to embarass oneself, make a fool of oneself
• Agoraphobia

Question 10

What are the 5 diagnostic subtypes of specific phobias?

Answer 10

• 5 diagnostic subtypes of specific phobias
• Most phobias fall into 5 subtypes, including
  
  1. animal type
     
     • kittens, dogs (not snakes like evolutionary scary animals)
  2. natural environment type
     
     • hurricanes
  3. blood-injection-injury type
     
     • medical things
  4. situational type, and
  5. other types (eg. phobias of choking or contracting an illness)

Question 11

Is there a relationship between age and the type of phobia one develops?

Answer 11

• There is a strong relationship between age (developmental stage) and the type of phobia one is most likely to develop.
  
  • Young children: animals
  • Teenagers: social
    
    • the problem is much bigger in this group and in your young adulthood (university age)
  • Adults: agora- or claustrophobia
    
    • when its an adult who reports claustrophobic types of symptoms in their 20s, 30s or 40s can not really figure out the logic of it

Question 12

What are the Physical, Behavioural and Cognitive Features of Anxiety Disorders?

Answer 12

• Physical Features include jumpiness, jitters, increased perspiration and heart rate, shortness of breath, dizziness, nausea
  
  • ON EXAM
• Behavioural Features include the need to escape or avoid a situation, agitation, clinginess, need for reassurance.
• Cognitive Features include excessive and prolonged worrying, overly aware of bodily sensations, jumbled thoughts, nagging thoughts

Question 13

What is the DSM-5/TR Criteria for Specific Phobia?

Answer 13

1. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (eg. flying, heights, animals, receiving and injection, seeing blood)
2. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally pre-disposed panic attack. Note: in children, the anxiety may be expressed by crying, tantrums, freezing or clinging.
   
   • fight, flight, freeze or fawn
3. The person recognizes that the fear is excessive and unreasonable. Note: in children this feature may be absent.
4. The phobic situation is avoided or is endured with intense anxiety or distress
5. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with a person’s routine, occupational (or academic) functioning, or social activities or relationships or there is a marked distress about having the phobia.
   
   • it is seldom a case that we are dealing with a mental disorder if there is not a significant interference with functioining in some way → socially, physically, etc.
6. In individuals under the age of 18 years the duration is at least 6 months.

Question 14

What is Obsessive-Compulsive Disorder?

Answer 14

• Obsession: An intrusive, unwanted, and recurrent thought, image, or urge that seems beyond a person’s ability to control.
  
  • about a thought
• Compulsion: A repetitive behaviour or mental act that a person feels compelled or driven to perform.
  
  • About behaviours

Question 15

What do Anxiety Disorders have to be distinguished from?

Answer 15

• All of these must be distinguished from Adjustment Disorders
  
  • Maladaptive reactions to an identified stressor or stressors that occur shortly following exposure to the stressor(s) and result in impaired functioning or signs of emotional distress that exceed what would normally be expected in the situation.
  • The reaction may be resolved if the stressor is removed or the individual learns to adapt to it successfully.
    
    • in the case of an adjustment disorder, ppl can usually answer exactly what the issue is
    • so removing it can stop the reaction

Question 16

What is acute stress disorder?

Answer 16

• Acute Stress Disorder (ASD): A traumatic stress reaction occurring in the days and week following exposure to a traumatic event.
  
  • there is not a significant delay
  • usually potentially life threatening event to yourself or other
  • it is more likely to occur if that exposure is repeated
  • does not have to be fatal: serious injury or adverse outcome can trigger it
• A prolonged reaction to a traumatic event that threatened death or serious injury to one’s own or another’s physical safety.

Question 17

What are the Features of Traumatic Stress Reactions?

Answer 17

• Features of Traumatic Stress Reactions
  
  • Extreme anxiety or dissociation (feelings of detachment from one’s self or one’s environment)
  • Intrusive memories and flashbacks (chronic re-experiencing, extremely vivid, may feel like they’re back in the situation)
  • Heightened arousal or vigilance
    
    • constantly on-guard
    • eg. when sb rings the doorbell
    • can never let their guard down
  • Difficulty concentrating

Question 18

What are the Features of Traumatic Stress Reactions?

Answer 18

• Features of Traumatic Stress Reactions
  
  • Extreme anxiety or dissociation (feelings of detachment from one’s self or one’s environment)
  • Intrusive memories and flashbacks (chronic re-experiencing, extremely vivid, may feel like they’re back in the situation)
  • Heightened arousal or vigilance
    
    • constantly on-guard
    • eg. when sb rings the doorbell
    • can never let their guard down
  • Difficulty concentrating

Question 19

What was the case of Romeo Dallaire?

Answer 19

• Romeo Dallaire
  
  • Dollaire, the former head of the doomed United Nations peacekeeping mission in Rwanda, was discharged from the military for PTSD a few years after the 1994 mission, in which his force tried in vain to stop the slaughter of 800 000 to 1 million Tutsis and moderate Hutus. He attempted suicide several times before learning to cope thanks to medication and therapy.
• Up to 3 months delay is PTSD between event and disorder
  
  • acute has no delay

Question 20

What is the Psychodynamic Perspective of Anxiety Disorders?

Answer 20

Psychodynamic Perspective

• Anxiety is warning sign that some unconscious conflict is approaching consciousness
  
  • superego → highly socialized, tells you what you cannot do
  • ego → sense of self trying to keep peace between id and superego
  • Projection: anxiety is brought about by the perception that some external threat is posed by someone or something else.
    
    • eg. you’re chronically angry but see sb else frowning on you → project that it is them being angry at you
    • Anxiety likely to be more specific in focus in this case bc it is focused on specific people
    • everybody in your environment is then a threat to you
  • Displacement: anxiety more likely to be generalized.
    
    • from one person on to another
    • from one place on to another
    • so non-specific it can flow on to anything → free flowing anxiety

Question 21

What is the Learning Perspective of Anxiety Disorders?

Answer 21

• Two-factor model: O. Hobart Mowrer eg.
  
  • Phase 1: Man is on street (CS) barely escapes being run down (US) → Fear reaction (UR)
    
    • Subsequently experiences fear upon walking roadside (CR)
  • Road *Sd): Walks away (R) → Fear reduction (Rf)
    
    • Subsequently finds he can minimize fear/anxiety symptoms by avoiding roadways (negative reinforcement → removing unpleasant state → Pavlovian)
• Prepared Conditioning
  
  • The reason we seem to develop phobias to some things more readily than others - a diathesis (a predisposition)
  • eg. spiders → evolutionary
• Superstition: OCD
  
  • an irrational belief that doing sth will produce a certain outcome
    
    • to be OCD you need to have some kind of actual distress associated with not doing it
  • eg. bet on a horse → horse comes in first → wins money → the sweater you wore resulted in the outcome (Skinnerian)
  • if and only if you count back from 100 in groups of 7, you know the elevator you are going to get on will not crash
    
    • worked once
    • but the time before that, you didn’t do it and it got stuck → so you start to count backwards in 7 from 100 every time

Question 22

What is the Cognitive Perspective of Anxiety Disorders?

Answer 22

• In what way does an individual’s perceptions and beliefs they have about those perceptions influence their behaviour and disorders?
• Self-defeating or irrational beliefs
  
  • they understand in principal, that air travel is in general safe but the narrow passageway or awkwardness of being in close proximity with sb
  • eg. if sb beside you on a plane falls asleep, it will cause the plane to crash → when you do pose this on a 1-10 scale of a likelihood, it can help ppl think more clearly about it
• Self-defeating thoughts can heighten and perpetuate anxiety disorders.
  
  • When faced with fear-evoking stimuli, a person may think “I’ve got to get out of here” or “My heart is going to burst out of my chest”.
  • Thoughts like these intensify autonomic arousal, disrupt planning, magnify the aversiveness of stimuli, prompt avoidance behaviour, and decrease one’s confidence about controlling a situation.
• Irrational beliefs may involve exaggerated needs to be approved of by everyone one meets and to avoid any situation in which negative appraisal from others might arise.
  
  • Eg. “What if I have an anxiety attack in front of other people? They might think I’m crazy!”
• Oversensitivity to threat
  
  • believing that sth that is anxiety inducing has much more ability to confer negative consequences on your life
  • your level of confidence that you can cope with sth effectively
  • eg. overriding concern when driving that a kid is going to jump in front of you → can drive slow, be alert
• People with phobias perceive danger in situations that most people consider safe, such as riding in elevators or driving over bridges.
• Children with separation anxiety may envision harm coming to themselves or their parents when anticipating a separation from their parents.
• People today who have anxiety disorders may have inherited an acutely sensitive internal alarm that leads them to be overly responsive to cues of threat.
  
  • It may lead to inappropriate anxiety reactions in response to a wide range of cues that actually pose no danger to them.
• Anxiety sensitivity
• • A “fear of fear,” or fear that one’s emotions or states of bodily arousal will get out of control and lead to harmful consequences.
• People with a high degree of anxiety sensitivity may be prone to panic when they experience bodily signs of anxiety, such as a racing heart or shortness of breath, bc they take these symptoms to be signs of an impending catastrophe, such as a heart attack.
• Is an important risk factor for panic attacks.
• Panic-prone individuals also tend to misattribute changes in their bodily sensations to dire consequences.
  
  • much of this is about not going down that path in therapy
  • but also back it up with practical strategies
  • if you find yourself concerned about experiencing high amounts of anxiety → can have an emotional-support animals
  • a fear of fear, or fear that one’s emotions or states of bodily arousal will get out of control and lead to harmful consequences.
• Misattributions for panic attacks
  
  • ppl will not recognize their panic attack is a combo (usually) of 2 things:
    
    • minor heart palpitations
    • think that it is sign of sth worse → start to lose control fall into bad thought pattern

Question 23

What is the biological perspective on anxiety disorders?

Answer 23

• Genetic Factors
  
  • Higher concordance (sameness) rates MZ (identical) twins
    
    • if your fav colour is blue and your twin’s fav colour is blue → you are concordant for colour preference
    • genetically identical twins
    • more genetically similar ppl are the more likely they are to tentatively have
    • ppl who are similar in their behaviour, appereance who are born and reared in the same home also have similarities
    • so is confounded whether there is a genetic effect or other variable
    • dizygotic twins are no more similar than other siblings
  • Neuroticism
    
    • 3-factor model to describe the fundamental dimensions of personality (Isaac)
      
      • introversion vs extroversion
      • stability vs instability
        
        • emotionally stable vs not
      • psychoticism
        
        • whether ppl find themselves well integrated with the environment or see themselves as separate
      • the likelihood sb would become emotionally excited for him was genetically determined
• Neurotransmitters
  
  • Gamma-aminobutyric acid (GABA)
    
    • Inhibitory
  • Benzodiazepines
    
    • activate sites for GABA
    • take episodically

Question 24

What are the biological aspects of panic disorders?

Answer 24

• Hyperventilation - Can bring about panic-like symptoms
• equated to running away from a tiger in the jungle
• exacerbates hyper arousal → brain interprets it as sth is wrong → panic symptoms

Question 25

What is a perceived threat in the cognitive view of an anxiety disorder?

Answer 25

- perceived threat - that sth unpleasant will occur AND you won’t be able to cope with it

Question 26

So can we just tie anxiety to genetics?

Answer 26

No! - Not all people who experience traumatic events develop related phobias or anxiety reactions. - majority do not - Some people may inherit a genetic predisposition (diathesis_ that makes them respond with greater negative arousal or makes them more likely to panic in response to changes in bodily sensations. - there is a physical feedback loop → eg. if you have distressing thoughts but feel calm, you will probably have less of a reaction - Whether anxiety gets out of control may depend on another vulnerability factor, anxiety sensitivity. - Social support isn’t always directive → sometimes it’s just a matter of knowing they are not going it alone - lack of extinction opportunities - take that person that is being negatively reinforced by not going out and avoiding that area does not help them → if they introduced into that area gradually, the fear will decrease over time → if you do not provide yourself with the opportunities to get rid of the phobia → extinction - eg. if you believe a boogey man is there in your closet → keep opening the closet, realize it’s not there → over time it will be extinct - Emotional and Cognitive Factors - Low self-efficacy - not having the confidence in your ability to cope with sth

Question 27

How does the Psychodynamic Approaches Treat Anxiety?

Answer 27

**Psychodynamic Approaches** - Free association and psychoanalysis to resolve the deeper conflict. - free association → we know there is that unconscious conflict you can’t access - present them with a word and get them to say what first comes to mind - intended to give you clues about subjects held in the unconscious that are not available to access in other ways - Freud would choose words he thought were relevant to whatever issue they had - eg. sausage and knife → oedipal complex → phobia that your dad is going to castrate you and kill you - principal method of healing in this approach is insight → when the person understands what that problem is and is an adult they can now understand what the strategies needed to get rid of it are - Phobic objects are symbolic of those conflicts. - problem is by definition a symbol is not an exact representation of what it stands for therefore requires interpretation that may or may not be correct

Question 28

What is the Humanistic Approach to Anxiety Treatment?

Answer 28

- Unconditional positive regard allows integration of inauthentic social presentation with authentic self. - all you have to do to treat ppl - you accept them as a person and they will naturally regain the developmental path they were intended upon. - ON EXAM: Rogers → ppl acquire psychopathology of having their true behaviour suppressed - conditions of worth → forced to behave in a way that is not authentic to ourselves to gain social approval → obstacles to self-actualization leads to psychopathology

Question 29

What are the Biological Approaches to Anxiety Disorder Treatment?

Answer 29

- Antidepressants - SSRIs/SNRIs - Less likely to have enduring benefits than CBT - equally useful in treatment of anxiety symptoms too - problem is if you take them away the symptoms can remerge - so psychotherapy and meds is the most effective method - teaches them a set of skills and abilities they can implement after medication - trying to reinstate a normal balance of neurotransmitter functioning

Question 30

What are the Cognitive Approaches to Anxiety Disorder Treatment?

Answer 30

- Irrational beliefs, bolstering self-efficacy, individual meaning, regular “worry period” (Borkevic, 1985) - Sometimes you just have to give ppl a period of time to worry - Give yourself the space to acknowledge the worried feelings you’re experiencing - some ppl report it is useful

Question 31

What are the Learning Based Approaches to Anxiety Disorder Treatment?

Answer 31

- Best approaches combine exposure with response prevention - Systematic Desensitization - Fear-Stimulus Hierarchy - an orderly list where the first thing the person will be asked to do is low-risk, but not trivial to their fear - eg. person with plane anxiety → get them to go to the aviation museum (if it is sth they are afraid of) → have them go and sit in a plane while doing their relaxation techniques - eg. think of sth that could be a phobia and a potential list of these steps for that phobia - Gradual Exposure - more about psychological or physical distance from the phobia - Behavioural Treatment of Social Phobia - eg. if those ppl are having those thoughts, how does that actually effect you? - Behavioural Treatment of Agoraphobia - Behavioural Treatment of Obsessive-Compulsive Disorder - eg. challenge them to sit in a place, relax and not get up and run away and obsessively wash their hands - flooding → unethical → directly present them with the phobia after you’ve taught them the relaxation techniques → usually effective - have to prevent them from running way - if they do run away and feel better when they run away → negative reinforcement → reinforcer the escaping behaviour - Cognitive-Behavioural Treatment of Generalized Anxiety - Cognitive-Behavioural Treatment of Panic Disorder

Question 32

What has Virtual Reality been used for in the treatment of anxiety disorders?

Answer 32

**Virtual Reality Research** - For Combat vets with PTSD - The system contains eye-tracking software to study a person’s response when exposed to a virtual combat environment - tells them where exactly the patient is focusing their gaze - It is important to realize that treatment for anxiety disorders often improves the condition significantly, but doesn’t necessarily eliminate it completely.