Agoraphobia, GAD, OCD

What is the DSM criteria for Agoraphobia?

A. Marked fear or anxiety about >= 2:

1. Using public transport

2. Being in open spaces

3. Being in enclosed spaces

4. Standing in line or being in a crowd

5. Being outside of home alone

The agoraphobic situations…

B. Are feared because of thoughts that escape might be difficult or help might not be available in event of panic-like or other incapacitating symptoms

C. Almost always provoke fear or anxiety

D. Are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety

Fear or anxiety (or avoidance):

E. Is out of proportion to actual danger

F. Persistent, >6 mths

G. Causes significant distress or impairment

What ihe prevalence of agoraphobia?

1.7% of adults and adolescents

2:1 females:males

Consistent across cultural/racial groups

May occur in childhood, peaks in late adolescence/early adulthood

Onset before 35y in 2/3 of cases

Persistent, chronic course

Comorbidity is norm

What are risk factors for agoraphobia?

Genetic

• Heritability 61%

Temperamental

• Behavioural inhibition

• Anxiety sensitivity

• Negative affectivity

Environmental

• Negative events in childhood

• Stressful events

• Family climate of lower warmth + overprotectiveness

What is the DSM-5 criteria for GAD?

A. Excessive anxiety and worry (apprehensive expectation

Occurring more days than not

Duration >6 mths

About a number of events or activities

B. The individual finds it difficult to control the worry

C. Anxiety and worry are associated with 3+ of:

1. Restlessness or feeling keyed up, on edge

2. Being easily fatigued

3. Difficulty concentrating or mind going blank

4. Irritability

5. Muscle tension

6. Sleep disturbance

D, E, F - clinical distress or impairment, excluding substances and other disorders

What is the epidemiology of GAD?

12 month prevalence 2.9% among adults, .9% adolescents

Lifetime risk is 9%

2:1 f:m

Prevalence peaks in middle age then declines

More common in European descent + developed countries

What are genetic risk factors of GAD?

1/3 of risk is genetic

Genetic factors overlap with neuroticism risk and are shared with other anxiety and mood disorders, particularly MDD

What are temperamental risk factors of GAD?

Negative affectivity (i.e., neuroticism)

Behavioural inhibition

Harm avoidance

What are environmental risk factors of GAD?

Childhood adversities

Parental overprotectiveness

What is Borkovec’s model of cognitive avoidance?

Based on two-factor model

Worry is an avoidant response and an ineffective cognitive strategy used to reduce the threat of somatic fear

It is…

• Reinforcing in the short-term

• Maladaptive in the long-term - verbal focus inhibits mental imagery, and somatic and emotional activation is necessary for habituation and extinction

What is Wells’ Metacognitive view of worry?

Two types of worry in GAD:

Type 1: Worry about non-cognitive events, in response to a trigger, following activation of positive beliefs regarding worry

Type 2: ‘Worry about worry’ / meta-worry, following activation of negative beliefs re: worry (uncontrollable, dangerous)

What is obsessive compulsive disorder?

Unwanted, recurrent obsessional thoughts and compulsive actions which cause anxiety or distress

Characterised by attempts to resist these thoughts

Actions to try to reduce distress related to thoughts, or to prevent feared event or situation, but are not realistically connected

Time consuming or impair functioning

What is DSM-5 criteria for OCD?

A. Presence of obsessions, compulsions, or both

B. Obsessions/compulsions are time-consuming and/or cause distress or impairment

C & D - Exclusionary due to substance abuse/mental health disorders

What are obsessions defined by?

1. Recurrent and persistent thoughts, urges, or images, that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress

2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralise them with some other thought or action (i.e., performing a compulsion)

What are compulsions defined by?

1. Repetitive behaviours (hand washing, ordering, checking, etc) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly

2. The behaviours or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviours or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

What is the course of OCD?

Severe

Can lead to hospitalisation, psychosurgery in extreme cases

High comorbidity, especially with anxiety disorders, extreme avoidance, and depression

Excessive responsibility and guilt: thoughts are equated with the actions or activities represented by the thoughts (thought-action fusion)

While _____ are not unique to OCD, _____ to _____ is different.

intrusive thoughts; response to intrusive thoughts

How are responses to intrusive thoughts different to those without OCD?

Overestimation of threat

Underestimation of coping

Inflated responsibility/guilt

Intolerance of uncertainty

Intolerance of anxiety

Perfectionism

Thought-action fusion (both moral and likelihood)

What are categories of obsessions?

Sexual

Somatic

Violent/aggressive

Post-partum (women and men)

Physical contamination

Mental contamination

Religious (scrupulosity)

“Just not right” experiences

Order and symmetry

Miscellaneous

What are the four major categories of compulsions? What are some other categories?

Checking

Ordering

Arranging

Washing/cleaning

And:

• Touchingtapping

• Re-doing/repeating actions

• Ruminating or mentally rehearsing

How might an obsessional theme be tied to a compulsion?

Fear of contamination → washing, cleaning

Need for symmetry → Ordering, arranging, balancing, straightening until just right

Unwanted sexual or aggressive thoughts or images → Checking, praying, undoing

Doubts (doors locked, iron/oven/gas turned off, hitting pedestrian) → Repeated checking behaviour

Concerns about throwing something away valuable → hoarding

What is mental ritualising, and what presentation of OCD is it associated with?

Repetitive thoughts to counteract or reduce anxiety from obsessions

“pure” O (EXTREMELY rare)

Praying, repeating words or phrases, counting, recalling events in detail or repeating a mental list

What is the burden of OCD?

Significant negative impact, severe personal distress, interference with employment, relationships, daily activities

80-100% with severe OCD report substantial impairment

Interpersonal difficulties

Top 10 causes of disability worldwide

What is the prevalence of OCD?

1.6-2.3% (life), 1% (year)

Female = male

Chronic

Onset = childhood to 30s

Poor response (WITHOUT TREATMENT)

What are risk factors/ causes for OCD?

Genetics

Psychological vulnerability

Temperament

Trauma

Distraction temporarily reduces anxiety but increases frequency of thought

How does genetics relate to OCD?

Highly heritable although variable across studies (27-65%)

Similar generalised biological vulnerability to having anxiety in general

What are specific psychological vulnerabilities to OCD?

Early life experiences and learning

• Thoughts are dangerous/unacceptable

• Thought-action fusion (simply thinking about an action = carrying out that action… thinking about hitting my partner is the same as hitting him)

What are temperamental risk factors for OCD?

Internalising

Conscientious

Perfectionistic

What is a basic OCD cycle?

Trigger →

Intrusion (+interpretation) → Anxiety/distress (urge to neutralise) → Behavioural/mental ritual → temporary relief (reinforcement) → repeat