Anxiety & OCD

What are some of the purposes/functions of anxiety?

Fight/flight/freeze response

Fight/Flight/Freeze Response

Can be too strong or not fit for the context/situation, making it maladaptive

Fear

Negative arousal during immediate danger

• Intensifies quickly and leads to escaping, fighting, or holding still

Anxiety

Negative arousal in anticipation of future problems

• Signal to prepare to upcoming event

Symptoms of Anxiety Disorders

• Fear — Negative arousal during immediate danger

  • Intensifies quickly and leads to escaping, fighting, or holding still

• Anxiety — Negative arousal in anticipation of future problems

  • Signal to prepare for upcoming event

• Worry — Repetitive anxious thought that a future event will turn out badly

  • “Apprehensive expectation”

    • Clinical worry is excessive, uncontrollable, and unrealistic

• Panic Attack — Sudden, overwhelming experience of terror

  • More intense and sudden than anxiety

  • Must reach peak level in 10 minutes

    • Rapid heartbeat, sweating, trembling, nausea, gagging, dizziness, heat or chills, chest discomfort, shortness of breath, unreality

  • Fear of dying, losing control, or “going crazy”

• Phobias — Persistent, irrational fears associatd with a specific object/situation

  • Always immediately experience fear around the objec tor situation

  • Almost always avoid contact with the object or situation

    • Heights, encolsed spaces, animals, injections, blood, injury, airplanes

• Avoidance Behaviors — Preventing or removing oneself from feared situation, rather than facing it

  • Attempting to reduce/eliminate anxiety

Worry

Repetitive anxious thought that a future event will turn out badly

• “Apprehensive expectation”

What are some differences between normal worry and clinical worry?

Clinical worry is excessive, uncontrollable, and unrealistic

Panic Attacks

Sudden, overwhelming experience of terror

• More intense and sudden than anxiety

• Must reach peak level in 10 minutes 

  • Rapid heartbeat, sweating, trembling nausea, gagging, dizziness, heat or chills, chest discomfort, shortness of breath, unreality 

• Fear of dying, losing control, or “going crazy”

Phobias (and common types)

Persistent, irrational fears associated with a specific object/situation

• Always immediately experience fear around the object or situation

• Almost always avoid contact with the object or situation

Avoidance

Preventing or removing onself from feared situation, rather than facing it

• Attempting to reduce/eliminate anxiety

Specific phobia

Intense fear of anxiety about specific object/situation. Object almost always provokes imemdiate fear 

• Object is actively avoided or endured with very intense fear

• Fear is out of proportion to actual danger

• Must last 6 months or more 

  • Distress/impairment 

Social anxiety disorder

Fear and avoid social situations

Primary concern

• Primarily concerned with possible negative evaluation

  • Fear of humiliation or embarrassment

Subtypes

1. Interpersonal interactions

   • Dating, parties, conversations

2. Performance-based

   • Speaking in front of others

Panic Disorder

Recurrent, frequent, unexpected panic attacks

• Must be followed by 1+ months of

  • Persistent concern about future attacks

  • Maladaptive change in behavior related to the attacks (avoidance)

• Panic attacks cannot be due to another disorder

  • Not only due to phobias, public speaking, socializing, crowds, etc

• Fear of fear. Body is conditioned to to fight fear with more fear

Agoraphobia

Fear of being in public, especially alone

• Persistent avoidance of many kinds of istuations

  • Being in crowds, enclosed/open spaces, public transportations

• May required another person to always accompany them

  • Safety object

• Primarily afraid that there will be no way to escape or get help

• Often unable to leave home

Why might panic disorder and agoraphobia be comorbid? Why would one lead to the other?

The fear of experiencing a panic attack can lead individuals with panic disorder to avoid situations where they feel escape is difficult or help is unavailable

• Core fear of agoraphobia 

• Avoidance develops as a response to the panic attacks, creating a cycle where individuals generalize their fear to a wide range of places and situations 

Generalized Anxiety Disorder

Safety object

Anxiety-reducing object or person that enables emotional avoidance. It prevents exposure and promotes disorder

What is the negative reinforcement cycle of anxiety? How does it work? What are its consequences/effects?

Anxiety → Avoidance → Stronger Anxiety → Stronger avoidance → Anxiety…

• Reinforced anxiety, does not help lessen it because you are not being exposed to the situation or stimuli

Causes of anxiety disorders

Conditioning

• Intense fear can become associated with specific situations/stimuli

Avoidance

• Behaviors that prevent or remove oneself from a feared situation

Social learning

• Modeling

• Parental relationships

Biases Threat attention

• Directing attention towards possible indicators of threat

Catastrophic Misinterpretation

• Misinterpreting bodily sensations as signaling serious problems

Genetics

• Anxiety disorders are moderately heritable (20-30% for GAD

Neurobiology

• Amygdala is the fear center and activates fight/flight/freeze response. Right next to the hippocampus, where the memory is stored 

Classical conditioning (Anxiety)

• Intense fear can become associated with specific situations/stimuli

  • Classical conditioning during fear events

• Humans develop phobias more readily to some things rather than others (ex, snakes, spiders, heights)

  • Preparedness model

Preparedness model

Humans have evolved to be more sensitive/prepared to developing extreme fear of stimuli that posed common survival risks in our evolutionary past (snakes, spiders, heights)

Social learning as anxiety cause

• People may begin to fear something solely from observing others fearing it or suffering from it (modeling)

• People also learn to avoid stimuli others fear, preventing them from ever learning if the fear is warranted

• Anxious, worrying parents model anxiety and teach their children to be anxious

  • “Helicopter” parenting can prevent natural exposure (”facing fears”) and healthy approach behavior

Helicopter parenting

Can prevent natural exposures/facing fears and healthy approach behaviors. Lets children stay in a bubble

Biased threat attention

• Those with anxiety disorders strongly direct their attention towards possible indicators of threat

• Hypervigilance

  • Extreme sensitivity to one’s surroundings, even when safe

• Increased stress/fear → Increased attention bias

Hypervigilance

State of increased awareness and scanning for danger 

Catastrophic misinterpretation

• Those with panic disorder misinterpret bodily sensations as signaling serious problems

• This CATASTROPHIC MISINTERPRETATION leads to more fear

  • Anxious interpretations increase anxious bodily responses and hypervigilance

Genetics in anxiety

• Anxiety disorders are moderately heritable (20-30% for GAD)

• Polygenic

Amygdala

Brain region for fear conditioning & responding

Neurobiological cause for anxiety

• The fear center

  • Links US and CS in memory and activates fight/flight/freeze response

• Right next to the hippocampus, where the memory is stored 

• Brain cares a lot about storing feared memories 

What are the emotional effects of worry

• Excessive & uncontrollable WORRY…

  • Functions to avoid future negative outcomes, uncertainty, and negative emotional shifts

  • Increased anxiety and sadness, irritability, a feeling of impending doom, a decrease in happiness and optimism

  • Tends to be unrealistic

Functional Models of worry in GAD

Contrast Avoidance Model

Intolerance of Uncertainty

Beliefs about Worry (Metacognitive model)

Contrast avoidance model

Worry creates distress to prevent sudden shifts in negative emotion 

• Those with GAD strongly dislike unexpected drops in mood, so they keep themselves distressed across time by worrying

Intolerance of uncertainty

Those with GAD find uncertainty adn ambiguity upsetting 

• Believe that worry will serve to either help them cope with feared events more effectively or to prevent those events from occuring 

Metacognitive model

People with GAD “worry about worry”

• Have positive believs about worry

  • Believes it motivates them, gives them a sense of control, prevents bad outcomes, makes them caring/conscientious, etc.

Treatments for anxiety

Exposure Therapy. Interoceptive exposure, Relaxation training, cognitive therapy, medication

Exposure therapy

Directly facing feared stimlus until habituation (ex, anxiety lessens) without relaxation

• Goal is to maximize anxiety and sustain it

• Recommended for all anxiety disorders but are not receommneded for GAD

What is viritual reality exposure therapy

Therapists use virtual reality goggles to put their clients in their most feared scenarios or events, which helps them become exposed to it without actually being exposed to it

Interoceptive exposure

Introducing internal body sensations as exposure for panis disorders

1. Help clients habituate to the physical cues that start panic attacks

2. Help clients fully realize their panic attacks are not dangerous

• Ex, Spinning in office char → dizziness → panic attack

• Ex, Breathing through a coffee straw → shortness of breath → panis

  • We are making clients have panic attacks on purpose

Diaphragmatic breathing (relaxation training)

Teaches clients to breath dteady from the stomach, not the chest

Applied relaxation (relaxation training)

Clients learn to recognize their anxiety cues

• Then engage in relaxation whenever they encounter cues 

Progressive muscle relaxation (relaxation training)

Tensing muscle groups prior to relaxing them in a systemic way

Decatastrophizing (Cognitive therapy)

Imagine worst case scenario, challenge its likelihood, imagaine coping

Worry outcome monitoring (Cognitive therapy)

Track worry predictions and mark whether they come true or not

Anti-anxiety medication

Benizodiazepines

• Tranquilizers that reduce bodily symptoms and possibly some worry/rumination

• Often taken “as needed” when a person starts feeling anxious

• Effective at the beginning, but problematic long-term

  • Maintain anxiety symptoms through avoidance/being a safety object

  • High potential for addiction 

• SSRIs

Benzodiazepines

Tranquilizers that reduce bodily symptoms and possibly some worry/rumination

• Often taken “as needed” when a person starts feeling anxious

• Effective at the beginning, but problematic long-term

Obsessions

Repeated, unwanted, intrusive cognitions

• Thoughts, images, or impulses

• Lead to an increase in anxiety

• Usually include socially unnaceptable themes 

  • Sex, violence, contamination, immoral or religious taboos

Compulsions

Repetitive behaviors or mental acts used to reduce anxiety

• Typically considered senseless or irrational by client 

  • Done nonetheless

• When resisting the urge to do compulsions, anxiety spikes 

Obsessive-compulsive disorder

People with OCD do not actually think the way they do

• Must have either obsessions or compulsions

  • Thought most who meet criteria have both

  • Compulsions must be aimed at preventing/reducing anxiety

• Must attempt to ignore, suppress, or neutralize obsessions

• Time Consuming — Must take more than one hour per day

  • Or cause significant distress or other impairment

• Specifier: Level of insight - good, poor, or absent

  • In how nonsensical their obsessions/compulsions are

Insight level as a specifier for OCD

good, poor, or absent

• In how nonsensical their obsessions/compulsions are

• Impacts the individual’s symptoms severity, comorbidity rates, and response to treatment 

Causes of OCD

Psychological

• Thought Action Fusion

Psychological Factors

• Thought suppression

• Mental rebound

Altin & Glençöz, 2011

• TAF Morality and Likelihood

Biopsychosocial

• In OCD, certain brain regions are overly active:

  • Basal ganglia

  • Orbital prefrontal cortex

  • Anterior cingluate cortex

Thought-Action Fusion

The belief that the consequences of having a thought are as influential as committing an actual action in the world 

• Ex, having an image of stabbing one’s spouse pop into one’s mind is as bad as actually stabbing the spouse 

Mediation results of Altin & Glencoz, 2011 study. How does TAF morality and likelihood increase OCD symptoms

TAF Fusion Morality — The belief that having a thought is as morally “bad” as intentionally acting on the thought 

TAF Fusion Likelihood — The belief that having a thought about an unwanted event increases the likelihood that the event will occur 

• Feels responsible for having the thought, so they try harder to stop thinking it

• If I have that thought, and I think it says something about me, then my OCD goes up

Overestimation of personal responsibility

People with OCD overestimate how much influence they have on bad outcomes

• Ex, individual believes that flicking a light switch 5 times prevents the death of their mother. They believe that singular action has control over said death, and if they didn’t, then it is their fault completely if their mother does die 

Thought suppression

Attempting to stop thinking about something by will

Mental Rebound

Attempts to stop a thought only increase the presence of the thought

• Greater Anxiety → greater mental rebound → greater anxiety

  • (Wegner, 1994)

• When thoughts are more upsetting, they are more strongly resisted

  • Which leads to greater mental rebound (ex, more obsessions)

• Compulsions then negatively reinforce obsessions

• Obsessions → Anxiety → Compulsions → Relief → Obsessions → Anxiety….

PANDAS (textbook pg. 169)

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection - Children with OCD who have a sudden onset and also test positive for strep infection

• Clinical scientists hypothesized that symptoms of OCD develop suddenly following a strep infection, and that antibodies are triggered by the infection attack nerve cells in the basal ganglia of the brain

• Existence of strep infection does not prove that it was casually related to OCD

  • Recommended that throat treatment be given to a child who shows sudden onset of OCD, but this may lead to parents ignoring more conventional treamtnets for the disorder

  • Combination of cognitive behavior therapy and SSRI medications has been shown to be ffective for children with PANDAS-related OCD

Treatments for OCD

Cognitive Behavioral Therapy

• Exposure and Response Prevention (ERP)

Exposure and response prevention

1. Clients are exposed to obsessions or cues

2. Then refrain from their compulsions (ideally until they habituate)

   • Ex, Put hands in the garbage, but don’t wash hands

• Gold Standard treatment for OCD

Cognitive techniques for OCD (How does helping people see thoughts as not-so-meaningful or so important help OCD? How does cognitive therapy for OCD work?)

Thoughts are just thoughts!

• Challenges the sense of significance and responsibility that people with OCD have for their thoughts, which decreases the power of obsessions and reduces the compulsion to neutralize them 

• Cognitive restructuring helps individuals with OCD reframe their irrational beliefs into a more balanced and realistic cognitive perspective 

Does everybody have weird thoughts?

Yes!!! But it doesn’t reflect who we are as people or the things we believe in