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

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Flashcards in Week 7 Lecture 7 - Anxiety, obsessive-compulsive disorder & trauma/stressor-related disorders (DN) Deck (66):
1

What are the three main DSM categories?

Anxiety Disorders

Obsessive Compulsive Disorders

Trauma- and Stressor-Related Disorders

2

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

3

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

4

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

5:30

5

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

6

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

7

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)

7:40

8

What are the distinguishing features of anxiety and fear?

8:00

  • Anxiety:
    • Thoughts of unpredictability or uncontrollability
    • Apprehension about perceived potential threat
    • Future – oriented
  • Fear:
    • Strong escapist action tendencies
    • Present-oriented

9

  • 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?

8:30

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)

10

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

9:30

11

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

12

Physiology of anxiety, fear, panic

 

12:05

  • 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

13

What does the Cohen, Barlow & Blanchard graph illustrate about panic attack?

14:00

  • 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 

14

Which system (axis) is involved in the biological response in a panic attack?

14:28

  • 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

15

Describe the HPA axis.

15:00

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

 

16

What is prolonged exposure to cortisol (stress hormone) thought to result in)

16:20

  • atrophy of hippocampus
  • (memory formation & retention of memory)
  • thought to lead to brain forgetting appropriate stress responses & learning appropriate responses

17

What are the four areas associated with risk factors for Panic Attack?

  • Neurobiological factors
  • Personality factors
  • Psychological factors
  • Social factors

18

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

 

 

19

Which system is most associated with panic & anxiety disorders (from a neurobiological perpective)?

19:10

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

20

Personality risk factors?

20:50

 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

21

What two research examples does Jo talk about when considering personality risk factors for developing an anxiety disorder?

22:00

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 

22

Psychological factors

22:55

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

23

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

24

Social factors

  • Stressful life events trigger biological & psychological vulnerabilities to anxiety
  • Social & interpersonal
  • Physical
  • Familial
  • 70% report severe stressor prior to onset 

25

What integrated model of anxiety does Jo present?

27:00

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

26

Common features for diagnosis of Anxiety Disorders:

30:00

  • 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.....

27

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

28

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

29

What weakens the utility of sub-typing specific phobias?

tendency for multiple phobias

30

Aetiology of specific phobias?

39:44

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)

31

Specific Phobia: What is a true phobia?

42:30

 

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

32

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

33

What is Social Anxiety Disorder?

52:20

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

34

  • 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

Comorbidities:

  • Other anxiety disorders
  • depression,
  • alcohol abuse

35

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

36

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

37

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.

38

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

39

Panic Disorder:

  • Prevalence
  • Other manifestations

1:07

 

Prevalence
  • ~5% of people at some time - 2/3 female (Kessler et al, 2005)
    • 20% attempy suicide
  • Onset early adulthood (mid-teens to ~40)
  • 60% experience nocturnal attacks:
    • Not while dreaming During delta wave (slow wave) sleep – deepest sleep
    • may fear going to sleep

Sleep terrors:

  • Occurs in children – don’t wake, no memory
  • At later stage of sleep
    • about an hour after sleep onset

Isolated sleep paralysis:

  • Transition between sleep & wake (REM)
  • Unable to move, vivid hallucinations
  • History of trauma

40

Aetiology of Panic Disorders?

1:09:20

  • 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

41

What is the cycle of panic disorder (adapted from Kring)?

1:10:10

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

42

Panic Disorder: Treatment?

 Biological:

  • SSRIs & SNRIs
  • Benzodiapepines (GABA)
    • most widely used
    • addictive, affect motor /cognitive function
    • 60% free of panic, but relapse high (50-90%) once stopped

Cognitive behaviour treatment most successful

  • Focus on exposure – combined with relaxation, breathing retraining
  • Panic control therapy (recent technique)
    • Exposure to interoceptive sensation e.g. by spinning in a chair
    • Mimics panic attack
    • Perceptions of danger identified & modified over time = symptoms less frightening

43

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

44

Agorophobia:

Aetiology?

Treatment?

1:15:45

Aetiology:

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

Treatment:

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

45

Generalised Anxiety Disorder: DSM-5 criteria?

1:16:45

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

46

Generalised Anxiety Disorder:

Prevalence?

Course?

1:18:15

  • ~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

47

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

Reinforcement

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

48

Generalised Anxiety Disorder: Aetiology?

121:00:05

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

49

Generalised Anxiety Disorder: Treatment?

123:00

Pharmacological

  • Benzodiazepines most commonly prescribed (sedative action)
    • short-term relief, temporary crisis
    • decline in cognitive function

Psychological treatments more effective long term Challenging negative thoughts 

relaxation training, then

  • Confronting anxiety-provoking thoughts
  • Acceptance rather than avoidance of distressing thought
  • ‘Scheduling’ worry at particular times

50

What are the obsessive-compulsive &  related disorders: DSM-5 Diagnosis & Key Features?

124:40

Obsessive-compulsive disorder

  • Obsessions and compulsions

Body dysmorphic disorder

  • Preoccupations with an imagined flaw in one’s appearance Excessive repetitive behaviours or acts regarding appearance (e.g. checking appearance, seeking reassurance, excessive grooming)

Hoarding disorder

  • Acquiring an excessive number of objects Inability to part with those objects

Trichotillomania

  • Recurrent pulling out of one’s hair, resulting in hair loss Repeated attempts to decrease or stop

Excoriation disorder

  • Recurrent skin picking, resulting in skin lesions Repeated attempts to decrease or stop

Substance/medication induced Disorder due to another medical condition

Other-specified/unspecified

51

Obsessive-Compulsive Disorder: DSM-5 criteria?

126:00

Presence of obsessions, compulsions, or both

Obsessions:

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

Compulsions:

  • repetitive behaviours or mental acts that a person feels compelled to perform to in response to an obsession or according to rigid rules
  • Aimed at preventing/reducing anxiety or distress
  • Not always connected in realistic way
    • can have some insight or none at all

Obsessions or compulsions are time consuming (e.g. require at least 1 hour per day) or cause clinically significant distress or impairment.

52

Obsessive-Compulsive Disorder:

Comorbidity?

Prevalence?

127:50

Commonly co-occurs with:

  • anxiety disorder
  • recurrent panic attacks
  • debilitating avoidance
  • major depression

Prevalence ~2%

  • 13% of ‘normals’ - moderate symptoms
  • Females 55-60%

53

How does the 'impending danger' differ in OCD compared to other anxiety disorders?

Other anxiety disorders

  • the danger is the external object or situation

OCD

  • the dangerous event is the thought, image, impulse

54

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

55

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

56

Obsessive-Compulsive Disorder: Treatment?

1:33:45

SRIs most effective - ~60% benefit

  • Relapse with discontinuation

Exposure & response prevention:

  • Rituals actively prevented – e.g remove taps = unpleasant! (extreme end)
  • Systematic & gradual exposure to feared thoughts/ situations
  • Reality testing – learn there are no consequences

Cognitive approaches:

  • Challenge beliefs about consequences > exposure to test

Psychosurgery:

  • E.g. lesion to cingulate bundle – 30% benefit
    • only for those extremely disabled by disorder
  • Following failure to respond to drugs/therapy

57

Trauma- and stressor-related disorders:

  • DSM-5 diagnosis
  • Key features

135:30

Posttraumatic stress disorder

  • Exposure to actual or threatened death, injury, sexual violence, duration more than 1 month

Acute stress disorder

  • As for PTSD, duration 3 days to 1 month

 

not examined on ones below

Reactive attachment disorder

  • Pattern of inhibited, emotionally withdrawn behaviour toward caregiver, experience of extremes or insufficient care

Disinhibited social engagement disorder

  • Pattern of actively approaching/interacting with unfamiliar adults, experienced extremes of insufficient care

Adjustment disorders

  • Emotional or behavioural symptoms in response to identifiable stressor within 3 months (no longer than further 6 months)

Other-specified/unspecified

58

Post-traumatic Stress Disorder: DSM-5 criteria?

135:55

extreme response to a severe stressor

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

  • experiencing the event personally
  • witnessing the event
  • learning that a violent or accidental death or threat of death occurred to a close other
  • experiencing repeated or extreme exposure to aversive details of the event(s)
    • e.g. first responders – human remains

59

Post-traumatic Stress Disorder: DSM-5 full criteria

136:55

1. At least 1 of the following intrusion symptoms:

  • Recurrent, involuntary, and intrusive distressing memories of the trauma
  • Recurrent, distressing dreams related to the event(s)
  • Dissociative reactions (e.g. flashbacks) in which the individual feels or acts as of the trauma were recurrent
  • Intense or prolonged distress or psychological reactivity in response to reminders of the trauma
  • Marked physiological reaction to cues

2. At least 1 of the following avoidance
symptoms:

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

138:10

3. At least 2 negative alterations in cognitions & mood that began or worsened after the trauma(s);

  • Inability to remember an important aspect of the trauma(s)
  • Persistent & exaggerated negative expectations about oneself, others,
  • world
  • Persistently excessive blame of self or others about the trauma(s)
  • Pervasive negative emotional state
  • Markedly diminished interest or participation in sig. activities
  • Feeling or detachment or estrangement form others
  • Persistent inability to experience positive emotions

138:40

4. At least 2 of the following alterations in arousal & reactivity that began or worsened after the trauma(s):

  • Irritability or aggressive behaviour
  • Reckless or self-destructive behaviour
  • Hypervigilance
  • Exaggerated startle reflex
  • Problems with concentration
  • Sleep disturbances

beginning or worsening after trauma is key

5. The symptoms began or worsened after trauma(s) & continued for at least 1 month

60

Post-traumatic Stress Disorder:

  • Prevalence?
  • Comorbidity?

139:35

  • 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

61

Acute Stress Disorder (ASD):

DSM-criteria?

141:45

 

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

62

Post-traumatic Stress Disorder: Aetiology?

143:30

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

63

Post-traumatic Stress Disorder: Treatment?

147:45

  • 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

64

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

65

Comorbidity of anxiety disorders?

149:29

> 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

66

Summary

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

Decks in zz Abnormal Psychology week by week Class (39):