Lecture 7: Anxiety and Stressor-Related Problems II

Generalised Anxiety Disorder: How it differs from normal worry

• worry about lots of different things and expect the worst

• uncontrollable worrying

• worries extremely upsetting and stressful

• worrying significantly disrupts job and social life

• worrying almost every day for at least 6 months

Why does worrying make the problem worse in GAD?

worry → physiological response → anxiety provoking → stressful → cannot stop worrying → distressing

What type of physical symptoms do people with GAD have?

• fatigue

• muscle tension

• aches/pains

• nausea

• headaches

Who is GAD most common in?

• females

• unemployed

• live alone

• low income

Cognitive features in GAD

• worrying thoughts about daily life

  • impending sense of doom

  • worry something bad is going to happen, won’t cope, can’t stand any uncertainty

• worry about worry

  • negative beliefs about worry

  • positive beliefs about worry

Define positive beliefs about worry

believe if they worry about something negative happening, makes them more prepared → confirm thoughts

Physiological features of GAD

• constant anxiety

• physical sensations of adrenaline response

  • restless, cannot relax, tension headaches, difficulty sleeping

Physical sensations of adrenaline response

• restless

• cannot relax

• tense

• headaches / aches

• difficulty sleeping, sleep disruptions

• hr increased

• breathing increased

Behavioural features of GAD

worry leads to:

• avoidance of situations/things

• check up on things/others

• seek reassurance

• try to stop thoughts

• distracting activity/ be distracted

‘Cycle’ mechanism of GAD

thoughts/ (cognitive) → feeling / (emotional) → behaviour → thoughts/ (cognitive) (repeat)

DSM-5 criteria GAD

• disproportionate fear or anxiety relating to different aspects of your life

• anxiety relating to at least two areas of activity

• feeling of anxiety accompanied by symptoms of restlessness, agitation, muscle tension

• feelings of anxiety and worry will be associated with behaviours such as avoidance, seeking reassurance, excessive preparing, etc

• symptoms cannot be explained by other mental health disorders

Is this in the DSM-5 criteria for GAD:

feelings of anxiety and worry will be associated with behaviours such as avoidance, seeking reassurance, excessive preparing, etc

yes

Is this in the DSM-5 criteria for GAD?

the individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some thought or action

no - it is OCD

Explanations for GAD

• heritability aspect

• biological theories

• environmental factors

Heritability of GAD

• aspect of heritability

• is low

• could be personality trait that predisposes development of GAD

• could be inherent vulnerability rather than GAD

Biological explanations of GAD

• increased amygdala activity

• larger amygdala in GAD vs controls

• greater activation of amygdala to negative images

  • more common in female sufferers

• suggests slight difference in brain structure and also sensitivity that predisposes individual to having GAD

Environmental risk factors for GAD

• negative life events

  • typically during childhood

  • leads to questioning stability/predictability about world; uncertainty → leads to overpreparation to compensate for lack of control

• attachment style

  • anxious or insecure → GAD

  • more likely to report felt parents rejected/ emotionally controlling/ emotionally detached or cold

• modelling

  • see parents react anxiously → influence

GAD: Cognitive bias- what are they in?

• attention

• information processing

• thinking, outcomes

GAD: Cognitive biases

• look for info that conforms worries

  • focus on negative stimuli and threatening information

  • biases in information processing

• attention focused on negative information

• always expect negative outcome

→ this all reinforces anxiety

→ give rise to interventions like attention bias modification

Pharmacological treatments for GAD

• SSRIs

• benzodiazepines

• B-blockers / beta-blockers

Benzodiazepines

• anxiolytic

• reduce anxiety, calm, sedative

• stimulate GABA activity in brain

• GABA is key inhibitory neurotransmitter

• so by stimulating GABA activity, actually dampens overactivity that ppl w GAD experience

• works with similar mechanism to alcohol

  → why some ppl self medicate w alcohol

  → complications like alc addiction

• benzos have addictive properties

• withdrawal effects

• should be considered

Beta-blockers

• dampening response of adrenaline

• reduce fight or flight response

• stress response increases w adrenaline and cause physiological effects

SSRIs

• depression and anxiety etc

• increase serotonin amount in synaptic cleft to increase serotonin activity

Therapeutic interventions for GAD

• stimulus- control treatment

• CBT for GAD

Stimulus-Control Treatment

• based on principles of conditioning

• conditioned to worrying about everything bc normality

• aim is to stop person worrying about/in all of these situations

• limit worrying to a specific place and time

• e.g. time slot for worrying like 30mins at 6pm

• might help reduce connection between worrying and external stimulus

• limit worrying time from a day to an hour

• use a location and specific time to make association with that and worrying and stop association with everything and worrying

• they can make list throughout the day

• and then address later

• might be really challenging, takes commitment and persistence, takes months

CBT

• help tackle core of problem- thinkng

• target maladaptive cognitions that result (assumed to) in the anxiety

• target distorted cognitions- biases in attention, processing, thinking

• asked to imagine worst possible outcome and work through it

key elements:

• self monitoring (response in situations, triggers, worrying)

• relaxation training

  • retraining and relaxing

  • breathing exercises, meditation, visual imagery training

• cognitive restructuring

  • challenge biases

  • generate thoughts more realistic

  • worst thing that cld happen, work back, challenge

  • alter beliefs

• behavioural rehearsal

  • imagine/rehearse situation, how wld cope if smth happened

  • develop better coping strategies

  • build confidence in ability to manage difficult situations

Panic Disorder

• characterised by repeated panic/anxiety attacks

• panic attacks unexpected and happen spontaneously

• must be spontaneous to be associated with panic disorder

• panic attacks that are situationally bound, due to anticipation or phobia, have a different condition

Panic attack

• brief period of intense fearfulness

• breathlessness, feeling of being choked, fear experiencing breakdown, nausea, shaking, chills, hot flashes, dizziness, heart palpitations, etc

What two disorders were treated as the same?

• panic disorder and social anxiety disorder

• lot of overlap in treatment, found social anxiety disorder w panic attacks responded to different treatment than panic disorder

DSM-5 Panic Disorder criteria

1. panic attacks are spontaneous/unpredictable

2. panic attacks should be recurrent

3. worry about further panic attacks

4. modify behaviours to avoid future attacks

5. rule out other diagnoses

Biological theories of panic disorder

(1)

failure to regulate/overactive fight or flight response, over triggered

stress response → arousal of sympathetic nervous system:

• dilated pupils

• decreased salvation

• perspiration

• increased respiration

• heart rate accelerates

• digestion inhibited

• adrenal glands secrete stress hormones

• immune system function reduced

(2)

hyperventilation

triggers autonomic response

Activation of sympathetic division: Eyes

pupils dilate

Activation of sympathetic division: Salvation

decreases

Activation of sympathetic division: Skin

perspires

Activation of sympathetic division: Respiration

increases

Activation of sympathetic division: Heart

accelerates

Activation of sympathetic division: Digestion

inhibits

Activation of sympathetic division: Adrenal Glands

secretes stress hormones

Activation of sympathetic division: Immune System Function

reduced

Activation of parasympathetic division: Eyes

pupils contract

Activation of parasympathetic division: Salvation

increases

Activation of parasympathetic division: Skin

dries

Activation of parasympathetic division: Respiration

decreases

Activation of parasympathetic division: Heart

slows

Activation of parasympathetic division: Digestion

activates

Activation of parasympathetic division: Adrenal Glands

decreases secretion of the stress hormone

Activation of parasympathetic division: Immune System Function

enhanced

Biological theory of panic disorder: Hyperventilation

stressor → hyperventilation → not taking in much oxygen, releasing lots of carbon dioxide → lowered pCo2, drop in Co2 level in bloodstream → changes blood pH level → oxygen not being delivered effectively between blood cells → symptoms of panic b/c cardiovascular change to compensate → apprehension → hyperventilation

• feeds into cycle

• only thing to do is change breathing, get them to breathe more calmy and deeply

Cognitive Model of Panic Disorder: Clarke’s panic cycle (1986)

trigger stimulus (in subconscious) → perceived threat → apprehension → body sensation → interpreted as catastrophic → perceived threat

Interventions for panic disorder

• pharmacological treatments

  • benzodiazepines

  • beta blockers

  • ssris

• therapeutic treatments

  • cbt

    • recognise trigger

    • restructure maladaptive beliefs

    • teach about fight or flight response

    • prevent safety behaviours