Anxiety and Obsessive Compulsive Disorders

What is fear?

An emotional response to a real or perceived current threat

What is panic?

Extreme fear when there is nothing to be afraid of

What is anxiety?

An affective state whereby an individual feels threatened by the potential occurrence of a future negative event

• Future oriented

• Characterized by tension, apprehension and worry

What are symptoms of the fight-or-flight response?

• Increased heart rate

• Increased breathing rate

• Increase sweating on palms

• Dilation of pupils

What is a stress response?

Another name for the fight-or-flight response

Underlies the fear and anxiety involved in almost all anxiety disorders

What is the connection between anxiety and depression?

50% of people with an anxiety disorder are also depressed

What is the three-part model of anxiety and depression?

1. High level of negative emotions (overlap)

2. Low level of positive emotions (depression)

3. Psychological hyperarousal (anxiety)

What is the connection between anxiety disorders and alcohol abuse?

~10-25% of people with anxiety disorders abuse/depend on alcohol

• phobias: abuse develops after the anxiety symptoms

• other anxiety disorders: may occur before or after onset of symptoms

What are the characteristics of Generalized Anxiety Disorder?

• Persistent, excessive anxiety — often about minor items

• Chronic, uncontrollable worry about everything

  • Primarily focused on family, finances, work and illness

• Difficulty concentrating

• Tiring easily, restlessness

• Irritability

• High level of muscle tension

What can influence the onset of GAD?

Stressful life events

What is the diagnostic criteria for GAD?

• Excessive anxiety and worry over a number of events/activities occurring more days than not for at least 6 months

• Difficulty controlling the worry

• Anxiety and worry associated with 3 or more of the following:

  • *only one is required for kids

  • Restlessness or feeling on edge

  • Easily fatigued

  • Difficulty concentrating or mind going blank

  • Irritability

  • Muscle tension

  • Sleep disturbance i.e. difficulty falling/staying asleep or restless, unsatisfying sleep

• Anxiety, worry or physical symptoms cause distress or impairment in daily functioning

• Cannot be attributed to substance use/abuse or other medical condition

• Cannot be better explained by other disorder

Why do people with GAD have decreased arousal?

Caused by highly responsive parasympathetic nervous system

What is the impact of worry on the body, even temporarily?

• Arousal reduced

• Negative emotions suppressed

• Muscle tension produced

What happens to neurotransmitters when you have GAD?

Dopamine in frontal lobes doesn’t function normally

Possible dysfunction in:

• GABA

• serotonin

• norepinephrine

What is the heritability of GAD?

Between 15-45%

What is the category of medications used to treat anxiety disorders?

Anxiolytics

What type of anxiolytics are commonly used to treat anxiety disorders like GAD and phobias?

Benzodiazepines

How do benzodiazepines influence anxiety? What is the role of GABA?

Receptor in the brain for benzos is linked to inhibitory neurotransmitter GABA

Benzodiazepines may decrease anxiety because they increase the release of GABA

• Drugs that block/inhibit GABA increase anxiety

What are the three characteristic modes of thinking and behaving? (GAD)

1. Alert for possible threats (hypervigilance)

2. Feeling that worrying is out of control

3. Sensing that the worrying prevents panic — gives the illusion of coping

What is hypervigilance?

Heightened search for threats

What is a panic attack?

When someone suffers a sudden and often inexplainable attack of alarming symptoms

What are the symptoms of a panic attack?

• Labored breathing

• Heart palpitations

• Nausea and chest pain

• Feelings of choking and smothering

• Dizziness, sweating, and trembling

• Intense apprehension, terror and feelings of impending doom

What form of dissociation may someone with a panic disorder experience?

Depersonalization and derealization

What is a cued panic attack?

Associated with particular objects, situations or sensations

What is an uncued panic attack?

Spontaneous and not associated with a particular object or situation

When can panic attacks occur?

At anytime, even when sleeping or falling asleep

• nocturnal panic attacks

When do panic disorders typically begin?

In adolescence

What is associated with the onset of a panic disorder?

A stressful life experience

How often do patients with anxiety disorder also have panic attacks?

>80% of patients diagnosed with anxiety disorder also have panic attacks

What is the diagnostic criteria for a panic disorder?

• Recurrent unexpected panic attacks

• At least one attack being followed by a month (or more) of

  • Persistent concern/worry about additional panic attacks or their consequences (e.g. losing control, having a heart attack, etc)

  • A significant maladaptive change in behaviour related to the attacks (behaviours designed to avoid having panic attacks)

• Cannot be attributed to substance use/abuse or other medical condition

• Cannot be better explained by other disorder

What are the genetic components of panic disorder?

Runs in families

5 times more likely to have panic disorder if parent has it

What are the two origins of panic disorder documented by researchers?

1. Panic disorder based on a lower threshold for detecting suffocation

2. Panic disorder based on learning

How does the brain of someone with panic attacks influence their breathing?

• Unable to hold breath as long, relative to those without panic attacks

• Brain has low threshold for detecting oxygen in the blood

• Neural mechanism doesn’t just produce panic, but leads to hyperventilation and need to escape

How does learning theory relate to panic disorder?

• First panic attack is response to stressful or dangerous life event (true alarm)

• Initial bodily sensations of panic become false alarms associated with panic attacks

  • Normal sensations become associated with subsequent attacks

• Causes fear of introspective cues or of external environment where panic attack happened

• Sensations of arousal elicit panic attacks (learned alarms)

• Develop a fear of fear

• Avoid behaviours or situations where those sensations might occur

What do cognitive theories about panic disorder focus on?

How alarm signals are processed and responded to

What happens when normal bodily sensations are interpreted as indicating catastrophic effects?

1. Catastrophic thinking

2. Turning a panic attack into panic disorder

3. Anxiety sensitivity & catastrophic thinking about it

What is anxiety sensitivity?

Fear of bodily sensations related to anxiety

What percentage of people with panic disorder had it develop after a stressful life event?

80%

What do people with panic disorder tend to have experienced?

Higher than average number of stressful life events during childhood and adolescence

What types of medication has been used to successfully treat panic disorder?

Antidepressants — SSRIs and tricyclic

What is agoraphobia?

1. Persistent avoidance of situations that might trigger panic

2. Persistent avoidance of places where it would be embarrassing or hard to find help with panic attacks

   • i.e. tunnels, crowded theaters, highways

When does agoraphobia usually develop?

Within the first year of recurrent panic attacks

How does agoraphobia impact a panic disorder diagnosis?

Panic disorders are diagnosed as with or without agoraphobia

What is the fear-of-fear hypothesis?

Agoraphobia is not a fear of public places, but rather a fear of having a panic attack in public

What is a “safe person”?

Close relative or friend of someone with agoraphobia

What are the pros of a “safe person”?

Presence helps decrease catastrophic thinking and panicking

What are the cons of a “safe person”?

Can perpetuate disorder by making person feel more lonely/isolated when alone

What indicates extreme cases of agoraphobia?

Being housebound

What type of treatments are useful for reducing panic disorder with agoraphobia?

Exposure-based treatments

What is social phobia?

Persistent, irrational fears linked generally to the presence of other people

*Can be extreme debilitating

What other situations may people with social phobia avoid?

Situations where they might be evaluated out of fear they’ll reveal signs of anxiousness or act embarrassingly

• For example,

  • Speaking or performing in public

  • Eating in public

  • Using public bathrooms

What is generalized social phobia?

1. Generalized = many different interpersonal situations

   1. earlier age of onset

   2. comorbid with more disorders

2. Specific = intense fear of one particular situations e.g. public speaking

What gender is more likely to have social phobia?

Women

How does someone with social phobia respond to rejection or criticism?

• Very sensitive to criticism and rejection

• Worried about meeting others’ expectations

How does social phobia impact school or job performance?

• Might not complete school or advance at work due to avoiding social interactions

• Dread being evaluated and may not perform to their potential

  • ex. when taking tests

How does diminished performance impact someone with social phobia?

Challenges self-esteem which increases anxiety

How does amygdala response contribute to social phobia?

Amygdala controls fear response

Activates when shown faces

What parts of the brain (aside from the amygdala) are impacted by social phobia?

1. Hippocampus

2. Cortical areas

3. Right hemisphere

What neurotransmitters function abnormally for those with social phobia?

1. Dopamine

2. Serotonin

3. Norepinephrine

What is the heritability (%) of social phobia?

37%

How does social phobia manifest in children?

1. Shy temperament

2. Behavioural inhibition

What is behavioural inhibition?

Temperament trait in children linked to development of social phobia

The tendency to experience distress or fear and withdraw from new/unfamiliar situations, environments, and people.

What is shy temperament?

Temperament trait in children linked to development of social phobia

Hesitant, uneasy or cautious with new situations and people

How does classical conditioning impact social phobia?

Social situation + negative social experience

= a conditioned emotional response

How does operant conditioning impact social phobia?

Avoid social situations to decrease probability of an uncomfortable experience

Avoidance acts as negative reinforcement because avoidance decreases anxiety

How can parents influence the development of social phobia?

Extremely overprotective parents can cause children to cope with anxiety through avoidance

How can culture influence the development of social phobias?

Different cultures have their own concerns about social interactions — concerns influence specific social phobias

• Examples:

  • Fear of offending others (Asian cultures like Japan)

  • Fear of humiliation (Western cultures)

What are phobias?

Disruptive, fear-mediated avoidance disproportionate to actual danger posed

Recognized by the sufferer as groundless

*Different than legitimate fear

What are the 3 subtypes of phobia?

1. Agoraphobia

2. Social phobia

3. Specific phobia

What are specific phobias?

Unwarranted fears caused by the presence or anticipation of a specific object or situation

What are the 5 sources of fear?

1. Blood, injuries and injections (aka trypanophobia)

2. Situations (e.g., planes, elevators, enclosed spaces)

3. Animals

4. Natural environment (e.g., heights, water)

5. Other

What is the diagnostic criteria for phobias?

1. Fear or anxiety about a specific object or situation

2. Phobic object or situation almost always provokes immediate fear or anxiety

3. Phobic object or situation is actively avoided OR endured with intense fear or anxiety

4. Fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context

5. Fear, anxiety or avoidance is persistent — lasting 6+ months

6. Causes significant distress or impairment in daily functioning

7. Not better explained by other mental disorder

How is fear or anxiety related to phobias expressed by children?

1. Crying

2. Tantrums

3. Freezing

4. Clinging

What areas of the brain are activated just by viewing photos of the phobic object?

1. Limbic system

   1. Amygdala is very sensitive in those with phobias

2. Somatosensory cortex

   1. Images may trigger feeling of phobic object touching body

3. Left anterior insular cortex

What neurotransmitter is linked to anxiety from specific phobias?

Anxiety (brought on by specific phobia) is linked to too little GABA

What medications are beneficial for specific phobias? Why?

Benzodiazepines

Creates calming effect by increasing GABA activation

Are all specific phobias influenced by genetics and environment to the same degrees?

No — different phobias are influenced to different degrees by genetics and environment

What is classical conditioning?

Two stimuli are repeatedly paired

Response initially elicited by second stimulus is eventually elicited by the first stimulus alone

What is an unconditioned stimulus?

Stimulus that produces an unconditioned response

• ex. getting to go outside (UCS) makes the dog excited (UCR)

What is a neutral stimulus?

Stimulus that produces no response

• ex. leash (NS) used to walk the dog

What is a conditioned stimulus?

Stimulus that produces conditioned response

• ex. dog gets excited (CR) when it sees the leash (CS)

What are the process for classical conditioning?

1. Neutral stimulus is paired with unconditioned stimulus — unconditioned response occurs

   • When the dog goes outside, the owner puts it on a leash

   • **Step 1 is repeated multiple times

2. Neutral stimulus becomes associated with unconditioned response over time — makes it a conditioned stimulus

   • The dog learns that wearing the leash means going outside

3. The conditioned stimulus alone can evoke the unconditioned response — makes it a conditioned response

   • When seeing the leash, the dog gets excited and anticipates going outside

How does classical conditioning explain phobias?

1. An UCS produces fear (UCR)

2. UCS paired with NS produces fear

3. NS becomes CS

4. CS produces fear (becomes phobia)

What is the behaviourism belief behind how phobias form?

Believed that people with phobias had bad experience with target of phobia at some point

**Watson’s experiment is used as evidence for this

What is flawed about the behaviourism belief on phobias?

Not everyone with a phobia has:

1. had a negative experience with phobic object or situation

2. ever interacted with phobic object or situation

What was the famous experiment done by John B. Watson? What was it called?

The Little Albert experiment

Classical conditioning was used to trigger a fear response to furry objects by pairing them with a sudden loud noise.

What was the resulting belief from the Little Albert experiment?

Fear responses can be conditioned

What happens to the conditioned stimulus when it is no longer paired unconditioned stimulus? What is this process called?

If the CS is repeated not paired with the UCS, it weakens or eliminates the CR over time

• ex. bell is rang without giving food. over time, the bell stops triggering the dog to salivate

This is called (classical) extinction

What is avoidance conditioning?

Reactions are learned avoidance responses (negative reinforcement)

*Operant conditioning

How does operant conditioning explain the formation of phobias?

Person learns that they can reduce fear by escaping from or avoiding the CS

What is modeling?

learning fears through imitating the reactions of others

What is vicarious learning?

learning of fear by observing others

What is prepared learning?

People tend to fear only certain objects/events

• Fear spiders, snakes, heights, not a lamb

• Phobias that “make sense”— inherent danger

How does prepared learning differ from classical conditioning?

Fears are based only on instinctual/natural sensitivities

What is cognitive diathesis?

how a person's predisposition (diathesis) interacts with environmental stressors (stress) to produce disorders

What are two examples that show how cognitive diathesis may be important in developing a phobia?

• expecting similar traumatic experiences to occur in the future

• being unable to control the environment

What do cognitive theories for phobias focus on?

How thought processes can serve as a diathesis and how thoughts maintain a phobia

What does anxiety make one more likely to do?

• attend to negative stimuli

• interpret ambiguous information as threatening

• believe negative events are more likely to re-occur than positive ones

What is the psychoanalytical approach to treating phobias?

Attempt to uncover the repressed conflicts believed to underlie extreme fear and avoidance characteristics of disorder

What are two types of systematic desensitization used for treating phobias?

1. in vivo exposure — gradually confronting feared object/situation

2. virtual reality exposure