Anxiety

Anxiety

Anxiety Disorders
1. seperation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, panic disorder, panic attack specifier, agoraphobia, generalized anxiety disorder, anxiety disorder due to another medical condition, other specified anxiety disorder, unspecified anxiety disorder
2. Obsessive-Compulsive and Related Disorders
  1. OCD, body dysmorphic disorder, hoarding, trichotillomania disorder , excoriation disorder, substance/medication-induced OCD, Other specified OC and related disorder/Unspecified OC and related disorder
3. Trauma and Stressor Related Disorders
  1. Reactive attachment disorder, disinhibited social engagement disorder, post traumatic stress disorder (includes PTSD for those <6), acute stress disorder, adjustment disorders, other specified trauma and stressor-related disorder, unspecified trauma and stressor-related disorder
Anxiety
1. negative mood state, moderate anxiety beneficial, apprehension
Fear
1. Intense neurobiological & cognitive features, can be protective (e.g., evokes flight or fight)
Panic
1. Fear in the absence of a tangible stimulus
Stress
1. main sources are frustration, pressure & conflict, defined as the point where ones’ demands exceeds ones’ resources
Causes of Anxiety Disorders
1. Generalised Biological Vulnerability
  1. Genetic component
2. Psychological Vulnerability
  1. Anxiety as a product of early classical conditioning, modelling, or other forms of learning
3. Social Contribution
  1. Stressful life events (most are interpersonal in nature e.g marriage, divorce)
What is the DSM - V?
1. DSM-5 is a manual for assessment and diagnosis of mental disorders and does not include information or guidelines for treatment of any disorder. That said, determining an accurate diagnosis is the first step toward being able to appropriately treat any medical condition, and mental disorders are no exception. DSM-5 is helpful in measuring the effectiveness of treatment, as dimensional assessments assist clinicians in assessing changes in severity levels as a response to treatment
Phobia
1. Irrational fear of specific object or situation
2. Out of proportion
3. Avoidance/escape
4. Recognition of extreme/excessive fear
5. Typically function well in other areas
6. Subtypes include: animals, natural environment, blood/injections/injury/, situational, other
7. Phobia specific techniques
  1. Aim: decrease fear driven avoidance; anxiety during exposure & anticipatory anxiety. Exposure - systematic desensitisation (graded) & flooding (ungraded) – In vivo or imaginal • Modelling • Importance of extinction • Coping self statements, adaptive thinking training
8. Psychoanalytic, behavioural and cognitive theories on aetiology
9. Psychoanalytic therapy, (id, ego , superego)
10. Behavioural therapy, (systematic desensitization, flooding)
11. Cognitive therapy (catastrophe scale)
12. Medical approach- anxiolytics, barbiturates, prozac, benzodiazepine
Aetiology
1. Psychodynamic- id, ego , superego
2. Realistic - genuine danger
3. Neurotic - prevented from expressing id impulses
4. Moral - punished or threatened for id impulses (anxiety at feeling this way)
Psychodynamic views
1. Anxiety & tension may result from:
  1. Id, ego, superego conflicts
  2. Fear caused as a result of past experiences (conscious and/or unconscious)
  3. Id impulses (e.g., sexual taboo)- superego derived guilt –inadequacies of ego to resolve conflict
2. Anxiety may be attached or ‘free floating’
3. Generalised anxiety- breakdown of defences under stress- overrun with neurotic or moral anxiety
4. Phobias-repression & displacement-Fears transferred to neutral objects (Little Hans)
Existensial & Humanistic views
1. Anxiety arises when people deny/distort true thoughts/emotions & behaviour by not honestly viewing or accepting themselves.
2. Existential anxiety-meaningless existence, mortality, responsibilities
Cognitive Behavioural views
1. Learned fear-Classical Conditioning
2. Prepared conditioning (evolutionary)
3. Social modeling
4. Expectation & interpretation of events
Biological explanations
1. Familial/genetic--twin studies
2. Neurotransmitter studies:
  1. abnormal serotonergic function. GABA (gamma-aminobutyric acid)--low in anxiety states--a feedback system normally reduces level of excitability in neurons--anxiety states--fear unchecked.
3. Cerebral imaging
  1. PET scans--increased cerebral glucose metabolic rate in caudate nuclei, orbital gyri, lateral prefrontal areas OCD, panic/agoraphobia--abnormalities in parahyppocampal area.
4. Panic--noradrenaline (norepinephrine) activity irregular; locus ceruleus
Medication Treatments
1. Benzodiazepines eg Valium; high potency eg Xanax—effect GABA neurotransmitters; suppress CNS
  1. Effective but problems with tolerance & dependency; interfere with cognitive & motor functioning, especially if combined with alcohol
2. Tricyclic Antidepressants-effect function of norepinephrine & serotonin & other neurotransmitters
Psychological Treatments
1. Make threats understandable & controllable
  1. De-arousal strategies (hyperventilation)
  2. Graded exposure
  3. Cognitive therapy
  4. Structured problem solving
2. Arousal Reduction—breath control, exercise, reducing stimulants,
3. • Relaxation, Monitoring , Distraction, Stimulus Control, Graded Exposure: Live or “in vivo” if possible; presented hierarchically, continue till 50% anxiety reduction.
4. Respiratory Control: breathe out slowly & pause between breaths
5. Rehearsal of Coping Techniques
6. Role Playing
7. Thought Stopping
8. Stress Management
9. Flooding
Panic
1. Abrupt experience of intense fear/acute discomfort plus physical symptoms.
  1. Out of control
  2. Urge to flee
  3. Cognitive appraisal of danger + physiological and behavioural activation
  4. Anxiety over future attacks
  5. Avoidance of situations with no escape
2. Panic Disorder and Agoraphobia
  1. Clinical Description
    1. › Avoidance can be persistent › Use and abuse of drugs and alcohol › Interoceptive avoidance
3. Situationally bound
4. Unexpected
5. Situationally predisposed
6. Peak within 10 minutes
7. Average HR increase of 49.2 BPM within 1-2 minutes
8. Children
  1. Hyperventilation
  2. Cognitive development
9. Elderly
  1. Health focus
  2. Changes in prevalence
10. Cultural Influences
  1. Social/Gender roles
    1. 75% of those with agoraphobia are female
11. Panic Therapy
  1. SSRIs less side effects-better compliance 60% success whilst on medication but relapse high.
  2. Cognitive – Behavioural:
    1. relaxation;breathing retraining; cognitive restructuring; progressive exposure, especially if agoraphobic
  3. Exposure to interoceptive sensations that remind them of panic attacks- HR, dizziness
  4. Modification of attitudes & perceptions of dangerousness
  5. Relaxation & breathing retraining
General Anxiety Disorder
1. Emotionally “on edge”
2. Cognitive- expects something awful
3. Physical- chronic overarousal
4. Behavioural- avoidance readiness
5. Clinically significant distress/impairment
6. Therapy
  1. Aims: reduce impairment from cognitive & somatic anxiety symptoms – Worry, tension & overarousal
    1. Education, & focus on beliefs, attitudes & expectations re fears
      1. Cognitions re: threats, challenge catastrophising thoughts, coping strategies
Obsessive-Compulsive Disorder
1. Obession
  1. repetitive unwelcome thoughts, ideas, impulses or images arise from within-- intrusive, difficult to control ie thoughts re: contamination, repeated doubts, need to have things in order, need for symmetry, aggressive impulses, sexual imagery.
2. Compulsion
  1. repetitive behavioural response, unwanted action/rituals; aim-- anxiety prevention or reduction, not pleasurable. May increase anxiety.
3. DSM-V
  1. – Either obsessions or compulsions –Adults recognise excessive or unreasonable –Attempts to ignore or neutralise –Cause marked distress, time consuming, interfere with normal routine
4. Etiology
  1. Psychoanalytic: (anal stage, inferiority complex)
  2. Behavioural: (Operant cond., suppression)
  3. Cognitive: “if anything can go wrong it will”
  4. Biological: Encephalitis, head injuries, brain tumors, serotonin levels.
5. Treatment
  1. Psychoanalytic: difficult to assess
  2. Behavioural: exposure and response prevention
  3. Cognitive: RET
  4. Biological: drugs used for depression-Prozac (60%) etc., psychosurgery-cingulum (30%)
Body Dysmorphic Disorder
1. Excessive concern with real or imagined defects in appearance, especially facial marks or features.
2. Frequent visits to plastic surgeons
3. Culturally-influenced, but not culture- bound
4. May be a symptom of more pervasive disorders: Obsessive-compulsive or delusional disorder, for example.
Post-Traumatic Stress Disorder (PTSD)
1. Anxiety precipitated by a traumatic event:
2. Experienced/witnessed/confronted with actual/threatened death/serious injury/threat to self or others,
3. Response involved intense fear/ helplessness/ horror .
4. DSM V
  1. AVOIDANCE of stimuli associated wit event & NEGATIVE ALTERATIONS in cognitions mood- worsened post-trauma- pervasive negative emotional state
  2. Symptoms
    1. hyperarousal--anxiety at reminders of the event; insomnia
    2. re-experiencing/intrusions: dreams, flashbacks
    3. avoidance of reminders
    4. numb emotionally
    5. loss of interest in everyday events
    6. survivor guilt (no longer core symptom)
    7. Clinically significant distress
  3. Duration > 1 month. Can be delayed onset.
    1. Short term:
      1. Acute Stress Disorder (2 days-4weeks) DSM- V; Acute StressReaction (few hours-3 days)  May be maladaptive coping: aggression, substance use, self harm.
5. Treatment
  1. Exposure to extinguish fear
    1. Reduces fear by extinction & emotional processing –Changes to traumatic memory network & meaning
  2. Challenging distorted cognitions
  3. Management of ongoing life stress
  4. Debriefing
  5. Anxiety management of arousal & fear– Controlled breathing, relaxation, exercise, reduced stimulants
  6. Cognitive – Thought stopping, distraction, coping self statements
  7. Behavioural–Activity scheduling, social reintegration

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