Topic 4 - Anxiety, OCD, trauma, and stressor-related disorders

Anxiety

future orientated tension, dread/apprehension

fear

immediate emotional response to threat

• autonomic and adrenal cortical system

threat perception

hypothalamus activates sympathetic division of autonomic nervous system

• releases corticotropin-release factor (CRF)

• CRF signals pituitary to release adrenalcorticotropic hormone (ACTH)

• ACTH stimulates adrenal cortex to realse group of hormones to stimulate changes

• physical changes that increase adrenaline and increase change of survival

panic attacks

short intense periods of panic symptoms

• some have triggers and other dont

• ~20% of adults expereince panic attacks with most being isolated events

• diagnosis comes when attacks are persistent

  • many feel shame and fear

  • ~3-5% suffer from diagnosable panic attack

  • chronic and common in women

biological pactors of panic disorders

• runs in families

  • 43-48% heritability on no specific gene

• fight or flight poorly regulated

  • may be due to poor reg. of NT

• easily triggered by:

  • hyperventilation

  • carbon dioxide inhalation

  • caffine

  • breathe into paper bag

  • infusions of sodium lactate

  • those with no diagnosis may just feel uncomfortable → rarely have attack

• differences in the limbic system

  • containing amygdala, hypothalamus, hippocampus

• abnormalities in thalamus and somatosensory cortex (determines sensations in body)

• dysregulation of norepinephrine systems in locus ceruleus

  • pathways in limbic system that can lower threshold is stimulated more (more attacks)

cognitive factors for panic attacks

• pays close attention to body sensations and misinterpret in negative way

• catastrophic thinking

• increased interoceptive awareness (awareness of bodily cues → conditioned to signal attacks even if theres no stimulus)

• feelings of control

  • ex. in study, 2 groups tested. 1 had perceived control, the other had perceived no control

  • grp wiht no perceived control had higher risk of panic attack

integrated model of panic disorders

biological and psychological factors both ocntribute

• hyper-vigilance → constant attack heightened risk

biological treatments for panic disorder

• medications that affect serotonin an norepinephrine systems

• relapse if medication stops without CBT as well

cognitive behavioural therapy for panic disorder

client confronts thoughts and situations that cause anxiety with therapist

• challenge and extinguish behaviours

separation anxiety disorder

only diagnosed if symptoms have lastend for at least 4 weeks and impair child’s functioning

• occurs in 4-10% of children

• equally common in girls and boys

• can continue through adolescence

• can occur and begin at any point in life

• prevalence: 7.7% adolescence, 6.6% in adults

• highly comorbid with internalizing and externalizing disorders

biological factors of separation anxiety disorder

• familt history of depressive and anxiety disorders

• heritability: 70%

• behavioural inhibition (withdraw, clingy, excessive arousal in new situation)

psychosociocultural factors for separation anxiety disorder

• caregivers tend to be more controlling and more critical and negative

  • emotionally and behaviourally

treatments for separation anxiety disorder

CBT:

• create changes in thinking anf behavioural patterns

• reduce anxiety

variations of CBT

• mindfullness-based and acceptance and commitment therapy effective

drugs:

• antidepressants

• antianxiety drugs

• usually combined with psychological treatments

selective mutism (SM)

• failure to speak in certain social situations

  • capable but unwilling

• strong association with anxiety and social phobia

• anxiety disorder in DSM-5

• emerges in early childhood and can last into adulthood

• onset: 2 ½ - 4 ½ yr

• prevalence: 0.3-0.8%

generalized anxiety disorder (GAD)

• excessive anxiety in everyday situations

• anxiety is intrusive, cause distress, and encompass many domains

• less understood compared to other anxiety disorders

  • research suggests GAD involves comorbidity and functional impairment

emotional and cognitive factors of GAD

emotional:

• intense negative emotions

• high reactivity

• lack of control and manageability

cognitive:

• negative assumptions that lead to negative responses

  • trigger anxiety and lead to overreactions

biologicla thoeries of GAD

• heightened activity in sympathetic NS

• greateer reactivity to emotional stimuli in amygdala

• abnormalities in GABA NT system underlying factor

CBT for GAD

• challenge thoughts

• develop coping strat.

• equally effective as benzodiazepine treatment

biological treatments for GAD

benzodiazepine

• short term relief

• many side effects and adictive

antidepressant

• can be effective

• symptom relapse if use is stopped

• need CBT and drug treatments

social anxiety disorder

anxious in social situations

• fear of rejection, judgement, humiliation

• contributes to other mental health concerns

• women are more likely to develop

• onset: preschool years or adolescence

theories of social anxiety disorder

genetic basis:

• runs in families

• genetic basis from twin studies

• tendancy to develop anxiety disorders

cognitive perspectives:

• those vulnerable have high standards and focus on neg. elements of social interactions

• harsh behavioural evaluations

those with critical/controlling caregiers may impact risk

treatments for social anxiety disorder

drug:

• SSRI and SNRI

• stop → symptom relapse

CBT:

• equally effective as antidepressants in reducing symptoms

• mindfulness-based interventions and acceptance and commitment therapy

• internet-based cognitive behavioural treatments (ICBT) show promise

specific phobias

5 categories:

1. animal type

2. natural environment type

3. situational type

4. blood-injection-injuiry type

5. other

• symptoms:

  • fear/anxiety ab particular stimulus not proportional to the actual danger presented

  • can become panic attack

  • at least 6 months to be diagnosable

• most develop in childhood and persist through adulthood if untreated

• prevalence worldwide ~7.2%

animal type

phobia of animals

• adaptive for survival

natural environment type

situations that occur in natural environments

situational type

fear of public transport, elevators, driving, flying, and what might happe in those situations

blood injection injury type

decrease in heart rate and blood pressure

• usually runs in families

agoraphobia

strong fear of places where they have a hard time escaping

• comes from a fear of judgment

~50% of those with agoraphobia have had panic attacks

• the other half experience: other anxiety disorders, depression, somatic symptom disorder

behavioural theories for phobias

mowrer’s 2 factor theory:

• classical conditioning leads to a fear of a stimulus

• operant conditioning maintains that fear

researchers argue phobias come from observational learning

• theory of prepared classical conditioning

  • martin seligman

  • evolution sleected for quick conditioning of fear to specific stimuli for survival

biological theories for phobias

• first degree relatives are 3-4x lilely to have phobia

• twin studies support genetic component

behavioural treatments for phobias

• exposure of phobia to extinguish fear

• 3 fundamental components of behavioural therapy for phobias

  1. systematic desensitization (fear hierarchy)

  2. modeling (used with systematic desensitization)

  3. flooding (intense exposure)

biological treatments for phobias

benzodiazepines sometimes used

• temporary relief but phobia remains

• addiction risk

• important to confront fears

obsessive-compulsive and related disorders (OCRDs)

• obsessive-compulsive component

• ex:

  • OCD

  • hoarding

  • body dysmorphia

  • trichotillomania (hairpulling)

  • excoriation (skin picking)

OCD

overwhelming obsessions, compulsions or both

• most common obsessions:

  • germs

  • responsibility of cuasing/preventing harm

  • forbidden thoughts

  • symmetry

• irrational beliefs

• varying degrees of insight into their own obsessions and compulsions

  • individuals usually acknowledge thoughts are irrational but have difficulty controlling them

• prevalence: 2.3%

• male onset: 6-15

• female onset: 20-29

• high comorbidity: anxiety disorders, mood disorders, impulse control, substance use

compulsions

• repetitive behaviours or mental acts

• feeling of a need to complete behaviour

• can be cover or overt

hoarding

• urge to keep items of no value or utility

  • often times trash

• sentimental attachment to items or give items human characteristics

• may have different biological underpinnings than OCD

behaviour may increase with age

• occurs in around 5% of US pop.

• high rates of psychiatric comobidity

trichotillomania

hair pulling

• noticable hair loss and functional impairment

  • can be hair from anywhere

• automatic and focused (targeted and aware) pulling

• prevalence: 0.5-2% esp women

• onset: 10-13 yr

excoriation

skin picking disorder

• picking in recurring manner

• any part of the body on healthy and non-healthy skin

• results in scars, skin lesions and sometimes infections

• prevalence: 2.5%

• onset: adolescence

obsessive-compulsive and related disorders (OCD, hoarding, trichotillomania, excoriation) all share:

• repetitiveness

• inability to stop behaviour

• similar comorbidity

• experience tension before behaviour and after release

body dysmorphic disorder (BDD)

excessive concern for physical appearance

• significant distress

• impairment in interpersonal relationships

• obsession can be ab one part of the body or many parts all at once

• gender differences in areas of concer

• compulsive behaviours: mirror gazing, grooming, seking reassurance, etc

onset: 16 years

• can be chronic if not treated

affect men and women equally

comorbid with: anxiety, depression, personality dis., substance use, OCD, etc

muscle dysmorphia: subtype. usually commin in men where they want to increase muscle

associated with: suicidal ideation, suicide attempts, and completed suicide

biological theories of OCRD

• strong genetic predispositions

  • too many impulses get to hypothalamus and create obsession

• OCRD associates with neural circuit involved in motor, cognition, and emotion

• influences basal ganglia esp. → caudate nucleus

  • filters impulses in orbital frontal and only lets in most powerful stimuli to reach hypothalamus

• hypothalamic-pituitary-adrenal (HPA) axis associated with ORCD

  • drug relief from serotonin

cognitive theories of OCRD

• those with OCD may experience anxiety or depression → triggers negative thoughts

• compulsions developed thorugh operant conditioning

biological treatments for OCRD

• antidepressants relieve symptoms of OCD

• those with OCD may not respond to SSRIs

cognitive-behavioural treatments for OCRD

• drugs in conjunction with CBT to successfully treat OCD

• sometimes clients are given homework

• challenge clients moralistic way of thinking

• effective in treating:

  • hoarding

  • BDD

  • trichotillomania

  • excoriation

posttraumatic stress disorder and acute stress disorder

• post traumatic stress disorder (PTSD)

• acute stress disorder (ASD)

• disorders manifest in psychological and physiological symptoms

PTSD

prevalence: ~7% of adults in their lifetime

• women at higher risk

4 types of symptoms must be present:

1. reexperiencing traumatic event

2. avoidance

3. neg. changes in mood

4. chronic arousal or hyper-vigilance

more likely to experience insomnia and disassociation

ASD

• caused by traumatic events

• symptoms occur within 1 month of experience and last no longer than 4 weeks

• characterised by symptoms found in PTSD

• dissociative symptoms common

adjustment disorder

cluster of symtoms that occur within 3 months following stressor

• depressive symptoms

• anxiety symptoms

• antisocial behaviours

reactive attachment disorder (RAD)

• severe neglect, abuse, maltreatment in early childhood

• onset: ~9m to 5yr

• children:

  • interpersonal disfunction

  • emotionally withdrawn

  • minimal positive effect

disinhibited social engagement disorder

• opposite of RAD

• too attached and has no discomfort with adult strangers

environmental and social factors of PTSD

factors: severity, duration, proximity and social support to the stressor/trauma

psychological factors of PTSD

factors: comorbidity is risk factor, coping mech. has role in PTSD, sense of lifes purpose is resilience factor

cultural assets of PTSD

• ethnic identity can serve as protective factor of distress

biological theories of PTSD

neuroimaging research

• amygdala respond to emotional stimuli

• medial prefrontal cortex less active in those with more severe PTSD

• shrinkage in hippocampus
  

biochemical theories of PTSD

• resting lvl of cortisol lower in those with PTSD

• elevated heart rate

• increased epinephrine and norepinephrine
  

genetic theories of PTSD

vulnerability heritable

• increased risk in identical twins

• cortisol production may be heritable

treatments for PTSD

3 goals:

1. expose to fearful stimuli

2. challenge distorted cognitions

3. assist clients in stress reduction

CBT and stress management

• systematic desensitization

• 2 specific types of cbt

  • prolonged exposure therapy

  • cognitive processing therapy

stress-inoculation therapy

• learning skills to overcome challenges

internet-based treatments can be effective

drugs:

• SSRI

• benzodiazepines