Ch4 Concepts: ANXIETY, TRAUMA, STRESS, AND OBSESSIVE-COMPULSIVE DISORDERS

How are the concepts of fear and anxiety related to anxiety disorders? 

• These are normal emotional states, but the issue comes if overactive or excessive.  

  • Symptoms: fear and anxiety = pervasive and persistent  

  • Excessive avoidance and escape: feared object or situation 

  • Clinical distress and impairment: decreased daily functioning

• Fear: Present-oriented state

  • Danger/threat: current or immediate fear. Increased sympathetic nervous system (automatic)

• Anxiety: Future-oriented state

  • Danger/threat: future or anticipated anxiety 

  • Increased physical tension and stress as feared event draws closer 

What are the two main types of panic attacks?

1. Expected anxiety: directly triggered by the environmental stimulus 

2. Unexpected anxiety: unpredictable, out of the blue 

Describe the main biological and psychological contributions to anxiety disorders.

1. Biological Causes

   1. Genetic vulnerability: family history of anxiousness 

   2. Brain circuits and NTs: decreased GABA levels (main inhibitory NT) + imbalance: increased norepinephrine, decreased serotonin 

   3. Limbic and septal hippocampal systems

      1. Behavioral inhibition system (BIS): causes freezing when scared 

      2. Fight or flight systems: increased alarm or escape when afraid 

2. Psychological Causes

   1. Early childhood experience: environment is unpredictable and uncontrollable 

   2. Behavioral and cognitive views: conditioning and “learned response”. Rewards catastrophic thinking and negative appraisals. 

   3. Social contributions: biological and psychological vulnerabilities. Stressful environmental events triggers attacks.  

What is the triple vulnerability model?

• Biological, specific psychological, and generalized psychological vulnerabilities contribute to the development of anxiety disorders. If you possess all three, the odds are likely that you’ll develop an anxiety disorder after experiencing a stressful situation.

• General biological vulnerability: increased pessimism and nervousness 

• General psychological vulnerability: decreased self-esteem and poor coping skills 

• Specific psychological vulnerability: triggers, like traumatic events  

• Comorbidity with other anxiety disorders and mental illnesses is 50% 

• Major depression is number one! 

What are the major symptoms of generalized anxiety disorders (GAD)?

• Chronic state of general worry and anxiety that’s persistent, excessive, and uncontrollable about all aspects of their lives. Worry about meaningless things and always interpret things in negative ways. 

• Symptoms (6): must sit with symptoms for greater than or equal to 6 months  

  • Adults: greater than or equal to 3 symptoms 

  • Children: greater than or equal to 1 symptom 

  • Physical: muscle tension, restlessness 

  • Cognitive/emotional: poor concentration, irritability; always interpreting things in negative ways 

What are the statistics of generalized anxiety disorders (GAD)?

3. 3% report with GAD

   1. Runs in families 

   2. Women report with twice the rate as men, but we have to be cautious as women are more likely to communicate that they suffer from anxiety  

   3. Onset: insidious, begins in early adulthood. Starts off as a minor issue. 

   4. Very high level of GAD for the elderly, but not age-specific 

What are the causes of generalized anxiety disorders (GAD)?

• Biological vulnerability: autonomic restrictions. Natural responses that are designed to improve the bodily situation in times of stress.

• Very low physiological response to stress. Their bodies don’t respond to stress the way that others do. Usually, under stress, our heart rate and breathing increase. People with GAD experience the stress situation but their body doesn’t respond. If the stress overwhelms, that’s when the physical reaction kicks. Automatically, their body is restricted from responding normally to stress until it’s overwhelming, which is too late. That’s where the panic and fear come on, making them become hyper vigilant.

• Increased hyper-vigilance to threat since they can’t anticipate.

What are the specific treatments of generalized anxiety disorders (GAD)?

1. Benzodiazepines and antidepressants: short-term relief for comorbidity

   1. Side effects: Dependence and cognitive/motor impairment. Must increase dosage as your body needs more of it later on. Can impact your ability to focus and process information.  

2. CBT: similar short-term relief, but better long-term results 

3. Meditation and mindfulness therapy: promising results!

4. Combined treatments: NO added benefits 

What are the major symptoms of panic disorder (PD)?

• Greater than or equal to 1 panic attack suffered 

• Symptoms are greater than or equal to 1 month: fear of another panic attack 

• Increased anxiety and worry about having another PA 

• Avoids certain situations with maladaptive changes 

What are the major symptoms of agoraphobia?

• Heightened fear/anxiety about specific situations greater than or equal to 2; so, they AVOID THEM! 

• Ex: public transportation, open or enclosed spaces, standing in line or crowds, being outside home alone 

• Fear that you can’t escape from the PA 

• Fear that you won’t receive help if PA occurs 

What are the prevalence, major statistics, and risk factors for agoraphobia and panic disorder?

• 2.7%

• Onset: acute (Men = 20-24 years) 

• Agoraphobia: women (2/3)  

• Sleep paralysis (feeling paralyzed during sleep process): cultural influences; 40% of African and Asian Americans experience, compared to 8% of the general population 

• Risk factors: Higher emotional reactivity to stress = increased alarm reactions

  • Overreact to body sensations, interpreted as dangerous 

Specific treatments for PD and agoraphobia? 

• Medications: SSRIs & benzodiazepines

  • Decreased number of severity of symptoms: 60% panic-free. High relapse if stopped medications. SSRIs control serotonin re-uptake, make it higher

• CBT is highly effective. 70% improve from exposure and relaxation techniques.

  • Panic control treatment for panic disorders: treatment triggers panic to increase tolerance.

If you combine treatments, there’s little short-term benefit. The best long-term outcome is psychotherapy, especially CBT alone.

Associated Features of PD and agoraphobia?

• Nocturnal panic attacks (non-REM): 60% 

• Interoceptive avoidance: avoids physical sensations feeling like fear/anxiety (avoid caffeine, sex, exercise) 

What are the four main types of specific phobias?

1. Animal: snakes, insects, spiders 

2. Natural Environment: heights, storms 

3. Situational: flying, closed places 

4. Blood injection-injury: germs.

   1. Strong vasovagal response. Fainting = decreased blood pressure 

5. Other: clowns, loud noises 

What are the prevalence and statistics for specific phobias?

12.5%, one of the most common mental health disorders worldwide 

1. Snakes (1), heights (2), flying (3)  

2. Women report 4x more likelihood than men 

3. Ethnicity: Latinx 2x the rate than White Americans 

4. Chronic course unless treated 

What are the known causes for specific phobias?

• Direct experience to trauma: Now “false alarm” responses 

• Indirect experience from traumatic conditioning  

  • Vicarious learning from others’ trauma. Kids are observant and they watch their family go through things traumatic, see how it impacted them, and become fearful too. 

3. Biological vulnerability: runs in families  

4. Evolutional vulnerability (Prepared Learning): Survival mechanism (fear of heights, snakes). It’s in your DNA, and generations of your family survived. 

What are the major types of treatment for specific phobias?

1. CBT highly effective. Exposure through Structured/Gradual VS Massed Flooding 

2. Keep in mind of Cultural factors:

   1. Certain objects more feared in other cultures, like Voodoo and witch doctors 

   2. Gendered roles and masculinity: Men are supposed to be braver than women, so they think they shouldn’t get therapy.  

What are the main symptoms for separation anxiety disorder?  

• Children’s unrealistic and persistent worry that something will happen to their parents or other important people in their life

• Something will happen to them that’ll separate them from their parents (lost, killed, kidnapped)

What are the prevalence/statistics for separation anxiety disorder?  

• If untreated, can extend into adulthood (35%)

• Occurs in 6.6% of adult population over lifetime

• Onset is in adulthood rather than carrying over from childhood

What is the treatment for separation anxiety disorder?  

• With children, parents are included to help structure exercises, address parental reaction to childhood anxiety

• Real-time coaching of parents using a small mic

What are the major symptoms of social anxiety disorder (SAD)? 

• Social or performance situations: Fear/discomfort 

• Negative evaluation by others: Avoids or endures with extreme distress. Marked interference in social functioning. 

• Performance-only subtype: Situation-specific (public speaking)  

What are the prevalence and statistics for social anxiety disorder (SAD)?

12% rate

1. Gender: Women (1.4%) report slightly higher social anxiety disorder than men (1.0) 

2. Ethnicity: White Americans report higher than Blacks, Latinos, and Asians 

3. Onset: Adolescence (peak at 13 years) 

What are the causes for social anxiety disorder (SAD)?

1. Biological and evolutionary vulnerability 

   1. Adaptive response to fear of social rejection 

   2. Amygdala: overreaction to fear stimuli 

   3. Runs in families 

2. Similar in learning to specific phobias

   1. Ex: social evaluation is “dangerous”. You play tapes in your head, thinking people are out judging you so much.  

Preferred treatments for social anxiety disorder (SAD)?

1. Psychological treatment 

   1. CBT or CBGT (Group): Highly effective! Exposure, rehearsal, role playing in groups decreases distorted thoughts and avoidance behaviors 

   2. Opportunity to role play in social situations  

2. Medications, like SSRIs, are effective but not as good as CBT/CBGTs. High relapse if you stop medications. If we can avoid meds, it’s probably best. 

3. Combined treatment of CBT and medications show NO added benefits.  

What are the major characteristics for selective mutism, a rare childhood disorder?

• Lack of speech in 1 or more settings in which speaking’s socially accepted (home, school)

• Driven by social anxiety

• Lack of speech must occur for more than 1 month, can’t be limited to 1st month of school

Recommended treatment methods for selective mutism, a rare childhood disorder?

• cognitive behavioral principles w/ greater emphasis on speech

• behavioral reward system for participation in treatment

• engage in socializing games, trips, activities

ASD and PTSD symptoms?

1. For these conditions, one must have experienced major trauma, either direct or indirect, that caused alarm responses. There had to be greater than or equal to 1 symptom experienced

   1. Re-experiencing trauma (flashbacks, nightmares, fire) through triggers (sound) 

   2. Avoids trauma reminders (sights and sounds) 

   3. Negative alterations  

      1. Cognitions and moods (feels numb, dissociates; Go numb to not be overwhelmed by fear) 

      2. Increased arousal and reactivity (irritability, recklessness) 

   4. Sleep problems (can’t sleep or stay asleep) 

Difference between acute stress disorder and post-traumatic stress disorder (e.g., delayed onset)?

• How long you’ve had the symptom!

• ASD: symptom occurs within 30 days of the event

• PTSD: beyond 30 days; greater than or equal to 1 month

Major causes of PTSD?

1. Increased intensity of trauma and fear rejection increases risk 

2. Learned alarm responses: classical conditioning and operant learning 

3. Biological vulnerability, runs in families 

4. Uncontrolled and unpredictable environment: re-experiences childhood fear/distress 

5. Increased social support after trauma event decreases risk of stress disorders and helps in recovery 

Effective treatments for PTSD?

• Psychotherapy (CBT) is highly effective for the long term due to talk therapy 

  • Ex: “imaginal” exposure creates narrative of trauma event, try to get you to feel what you felt again  

  • Repeated, prolonged exposure therapy 

  • Decreased maladaptive beliefs (self-blaming and guilt)  

  • Help them realize that even though they’re exposed to these situations, they don’t have to have an automatic reaction like before. They have the ability to not be overwhelmed and manage it instead. Stop them from blaming themselves or having guilt from not being able to cope before.  

2. Medications: SSRIs decrease anxiety and panic symptoms. High relapse if meds stopped, however.  

Statistics of PTSD?

• 3.5% of adult population reports with some form of PTSD, ASD, or late onset PTSD

• It’s higher for military with combat at 7.6% 

Risk factors for PTSD?

• Most common traumas, risk factors: 

  • Kidnapped, held captive, or tortured 

  • Raped 

  • Badly beaten 

• Trauma survivors to PTSD: Actually, most don’t get PTSD.