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

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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



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)



What are the distinguishing features of anxiety and fear?


  • 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?


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



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



  • 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?


  • 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?


  • 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.


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)


  • 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)?


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?


 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?


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


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?


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:


  • 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?


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?



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?


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


  • 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:

  1. Persistent concern or worry about further attacks or their consequences
  2. 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


Panic Disorder:

  • Prevalence
  • Other manifestations



  • ~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?


  • 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)?


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?


  • 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







  • Genetic vulnerability (heritability 61%) & life events
  • Fear-of-fear hypothesis:
  • Driven by negative thoughts about the consequences of experiencing anxiety in public


  • Systematic exposure to feared situations:
    • More effective with a partner – stop enabling!


Generalised Anxiety Disorder: DSM-5 criteria?


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:




  • ~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


  • Anticipate the worst
  • Catastrophe usually doesn’t occur
  • Reinforces beliefs about value of worrying


Generalised Anxiety Disorder: Aetiology?


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?



  • 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?


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


  • 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



Obsessive-Compulsive Disorder: DSM-5 criteria?


Presence of obsessions, compulsions, or both


  • recurrent, intrusive, persistent, unwanted thoughts, urges, or images
  • Cause marked distress and anxiety
  • Individual tries to ignore, suppress or neutralise with other thought/actions


  • 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:




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


  • 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?


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


  • 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


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)



Post-traumatic Stress Disorder: DSM-5 criteria?


extreme response to a severe stressor

Exposure to actual or threatened death, serious injury or sexual violence in one or more of the following

  • 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


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

  • Avoids internal reminders of the trauma(s)
  • Avoids external reminders of the trauma(s)


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


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?


  • 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):




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?


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?


  • 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?


> 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



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