ANXIETY DISORDERS AND OCD (ch 6)

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washu psychopathology and mental health

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47 Terms

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anxiety disorders

  • specific phobias

  • social phobia

  • panic disorder and agoraphobia

  • generalized anxiety disorder

  • OCD and OCD related disorders

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fear vs anxiety

fear = a normal, immediate reaction to an environmental stimulus

  • rxn to real, experienced danger

  • intensity builds quickly

  • helps behav responses to threats

anxiety = not as immediate, more of a period of that feeling. can be irrational or unprovoked

  • anticipation of future problems

  • general / diffuse emotional reactions

  • emotional experience is disproportionate to the threat

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commonality across all anxiety disorders?

  • failure to habituate: anxious feelings dont go away, person does not get used to situation. anxiety levels stay high even after much time has passed

<ul><li><p><strong>failure to habituate</strong>: anxious feelings dont go away, person does not get used to situation. anxiety levels stay high even after much time has passed</p><p></p></li></ul>
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lifetime prevalence of anxiety disorders

  • any anxiety disorder = 28.8% lifetime prevalence

  • most common disorders = social anxiety and specific phobia

<ul><li><p>any anxiety disorder = 28.8% lifetime prevalence</p></li><li><p>most common disorders = social anxiety and specific phobia</p></li></ul>
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social factors - anxiety disorders

  • stressful life events

    • involving danger, deprivation of resources, insecurity, family, discord

    • in contrast, depression stressful life events involve LOSS

  • childhood adversity

    • abuse, neglect

  • exposed to more anxiety in parents

    • caregivers who are more anxious more likely to have kids that are more anxious (not necessarily genetics — behavior modeling)

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biological factors — anxiety disorders

  • genetics: nonspecific for mood and anxiety disorders

    • cant find lots of specifics. lots of comorbid btwn mood and anxiety disorders

  • behavioral inhibition temperament

    • person has a more inhibited temperament

    • again, not v specific to anxiety

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the amygdala — anxiety disorders

amygdala = fear and emotions

  • increased amygdala activity associated w increased anxiety reaction, especially w specific phobia

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<p>the insula — anxiety disorders</p>

the insula — anxiety disorders

  • connected to autonomic nervous system

  • critical for interoception: how we interpret our bodily sensations (bodily perception) — some ppl more sensitive/intuitive of these than others

  • increased activity of this brain region in anxiety

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phobia

  • Persistent, irrational, narrowly defined fears that are associated with a specific object or situation

  • Characterized by avoidance and reactions that are irrational and unreasonable to the situation/object

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types of phobia disorders

  • specific phobia

  • social phobia

  • agoraphobia (**considered under panic disorder bc highly linked)

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specific phobia DSM-5 criteria:

  • marked and persistent fear that is excessive or unreasonable cued by the presence of anticipation of a specific object or situation

  • exposure tho the phobic stimulus = immediate anxiety response (possible panic attack)

  • phobic situation is avoided (or endured w intense anxiety and distress)

  • fear, anxiety, or avoidance is persistent, typically lasts 6 months or more

  • *avoidance or distress interferes significantly w the persons routine, occupational functioning, or social activities

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DSM-5 specific phobia subtypes

  • animal

  • natural environment

  • blood-injection-injury

  • situational

  • other

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specific phobia epidemiology

  • very common

  • lifetime prevalence = 12%

  • 3x more common in women than in men

  • blood-injection-injury phobia occurs in ab 3-4% of pop

  • age of onset varies widely typically bc there is some triggering event

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etiology of phobias (risk factors)

  • evolutionary adaptation: phobias may have been adaptive at some point in human history/development

  • classical conditioning: phobia may be a result of repeated pairing of stimulus

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preparedness theory of phobias:

  • we are biologically prepared for associations / anxious responses

  • prepared associations learned in one trial and are very difficult to extinguish.

  • easy to condition fear to fearful objects (snakes, spiders, etc), but more difficult to condition neutral objects.

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phobia treatments

  • exposure therapy

    • may be paired w SSRI or something for the anxiety

    • many different forms, but often in a fear hierarchy

    • imagination, observation, virtual reality, viewing, touching, experiencing, etc

<ul><li><p><mark data-color="yellow">exposure therapy</mark></p><ul><li><p>may be paired w SSRI or something for the anxiety</p></li><li><p>many different forms, but often in a fear hierarchy</p></li><li><p>imagination, observation, virtual reality, viewing, touching, experiencing, etc</p></li></ul></li></ul>
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Social anxiety disorder (SAD)

level of fear of social situations that leads to impairment

  • in education, employment, family relationships, marriage/romantic relationships, and friendships

DSM-5 criteria:

  • marked and persistent fear of one or more social or performance situations

  • fear of being scrutinized or embarrassing oneself

  • feared situations are avoided or endured with great distress

  • fears significantly interfere with funcitoning

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subtypes of social anxiety disorder

specific: 1-3 feared situations

  • most common form is fear of public speaking

  • ex: eating in public, performing in public, etc

generalized: 4+ feared situations

  • ex: eating in public, using bathroom, parties, maintaining conversations, meeting strangers, etc

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prevalence of Social anxiety disorder

  • lifetime: 12.1%

  • 12 month prevalence: 6.8%

  • rates higher in women (15.5%) than men (11%)

  • early age of onset: childhood to mid-adolescence

  • high comorbidity w other anxiety disorders, and depression

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etiology (risk factors) of Social anxiety disorder

genetic risk:

  • tendency toward high negative affect or low positive affect (—or—) low extraversion and high neuroticism levels

environmental risk factors:

  • bullying in childhood — directionality unknown

  • childhood neglect / abuse

  • parenting style: maternal overprotection

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Cognitive behavioral theory of Social Anxiety Disorder (Rapee and Heimberg)

thoughts = “i’m not good enough”

feelings = sadness and loneliness

behaviors = avoidance of social situations

  • beliefs: negative self-evaluation; being liked is fundamentally important

  • behaviors of hyper-vigilance

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hyper-vigilance in social anxiety disorder

  • heightened attention to signs of social threat / cues in the social environment

  • hyperaware

  • eye-tracking studies show that ppl w generalized social anxiety disorder are constantly scanning ppls faces a lot more than others

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treatment — social anxiety disorder

medication:

  • SSRI often prescribed need a constant treatment for the anxiety

  • sometimes benzodiazepines

psychotherapy:

  • group or individual CBT is most supported

  • attention bias retraining

cognitive behavioral therapy:

  • cognitive restructuring

  • social exposures

    • fear hierarchy

    • work up towards higher feared situations

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panic attack symptoms

**note: symptoms must peak in 10 minutes

  • palpitations

  • sweating

  • trembling or shaking

  • sensations of shortness of breath

  • feeling of choking

  • chest pain

  • nausea

  • dizziness

  • derealization

  • fear of losing control

  • numbness

  • fear of dying

  • chills / flushes

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relationship between panic attack and panic disorder

  • first attack frequently follows distress of highly stressful life circumstances

  • many adults who experience a single panic attack do not develop a panic disorder

    • 20% of college students have attack, but don’t develop disorder

  • how you respond to the initial attack dictates whether or not one develops the disorder

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DSM-5 criteria for panic disorder

  • recurrent, unexpected panic attacks

    • sudden, overwhelming experience of terror or fright

    • more focused than anxiety

    • “false alarm”

    • common in other anxiety disorders too

  • at least one panic attack followed by 1 month (or more) of 1 (or more) of the following

    • persistent concern about having another attack

    • worry about the implications of the attack

    • significant change in behavior related to the attacks

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DSM-5 criteria for agoraphobia — highly linked to panic disorder

  • anxiety about being in situations from which escape might be difficult or in which help might not be available if panic like symptoms develop

  • hallmark feature: these situations are avoided or else endured with distress

  • 80-90% of diagnoses are female

  • range of severity associated w disorder

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prevalence and course of panic disorders

  • lifetime prevalence = 3.5% of adult pop

  • twice as prevalent in females

  • chronic: 50% recover in 12 years

  • average age of onset = 23-24 years old

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catastrophic misinterpretation — cognitive factors in panic disorder

  • panic attacks are triggered by internal stimuli

  • anxious mood leads to physiological sensations

  • narrowed attention and increased awareness of bodily sensations

  • person misinterprets bodily sensations as catastrophic event

  • “fear of fear”

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the panic circle — cognitive factors in panic disorder

trigger stimulus → perceived threat → worry → bodily sensations → interpretation of sensations as catastrophic → go thru circle again

<p>trigger stimulus → perceived threat → worry → bodily sensations → interpretation of sensations as catastrophic → go thru circle again</p>
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panic disorder treatment

  • 85% of ppl w panic disorders show up repeatedly at emergency rooms

interoceptive exposure therapy: helps u revisit those feared internal stimuli that u experience in a panic attack —- (exposure to feared bodily sensations associated w panic)

cognitive therapy: target catastrophic automatic thoughts

psychoeducation

  • with treatment, 70-90% recover

  • ** benzodiazepines make relapse more frequent :(

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General anxiety disorder DSM-5 criteria

  • excessive anxiety and worry (apprehensive expectation) occurring more-days-than-not for at least 6 months, about a number of events or activities

  • person finds it difficult to control the worry

  • the anxiety and worry are associated with 3 or more of the following 6 symptoms (with at least some symptoms present for more-days-than-not for the past 6 months)

    • restlessness or feeling keyed up / on edge

    • being easily fatigued

    • difficulty concentrating or mind going blank

    • irritability

    • muscle tension

    • sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

  • causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

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GAD vs MDD — differential diagnosis

  • must have evidence that GAD exists outside of depressed episodes

  • differential must be made, bc these two disorders are highly comorbid

GAD-specific symptoms (vs MDD)

  • worry

  • cognitive biases

  • intolerance of uncertainty (difficulty w ambiguous and uncertain possiblilities)

  • GABA / benzodiazepine receptor dysfunction

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worry vs GAD

worry:

  • uncontrollable

  • negative emotional thoughts

  • concerned with possible future threats or dangers

  • usually verbal rather than visually expressed

when it becomes GAD:

  • frequency

  • control

  • range of topics

  • valence (how extreme it is)

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prevalence and comorbidity of GAD

  • lifetime prevalence = 5.7%

  • age of onset: 31-33

  • GAD and MDD correlate 0.59-0.70 ——> high correlation

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Tri-Partite model of mood and anxiety disorders

relates mood and anxiety disorders to broad underlying traits of positive and negative affect as well as autonomic arousal

  1. negative affect (mood and anxiety)

  2. positive affect (MDD only)

  3. physiological hyper-arousal (anxiety specific)

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GAD etiology:

cognitive = “intolerance of uncertainty”

  • difficulty with ambiguous and uncertain possibilities

biological:

  • GABA / benzodiazepine receptor dysfunction

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treatments for GAD

medications:

  • SSRIs

  • benzodiazepines — effective but rarely prescribed bc side effects and addictiveness

CBT: new treatments that target avoidance of emotion:

  • self-monitoring

  • interpersonal and emotional processing therapy

  • antecedent cognitive reappraisal

    • target cognitive biases (overestimate likelihood of negative events and underestimate ability to cope)

  • mindfulness-based CBT for GAD

  • emotion regulation therapy

  • emotional awareness training — prevention of emotional avoidance

    • staying in present moment, stop behavioral avoidance, engage w emotions as they come

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DSM-5 criteria for obsessions (OCD)

  • recurrent and persistent thoughts, impulses, and images

  • experienced as intrusive, inappropriate, unwanted

  • case marked anxiety or distress (& impairment)

  • thoughts r not simple excessive worries ab real life problems

  • person attempts to ignore / suppress thoughts

  • person recognizes that the thoughts are a product of his or her own mind (not imposed from the outside)

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DSM-5 criteria for compulsions (OCD)

  • repetitive behaviors or mental acts that the person feels driven to perform

  • in response to an obsession, or according to rules that must be applied rigidly

  • behavs aimed at preventing or reducing distress, or preventing some dreaded event or situation

  • behavs not connected in a realistic way w what they are designed to prevent, or are clearly excessive

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examples of obsessions and compulsions

obsessions:

  • contamination fears

  • fear of harming oneself or others

  • lack of symmetry

  • pathological doubt

compulsions:

  • cleaning

  • checking

  • repeating

  • ordering / arranging

  • counting

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DSM-5 definition of OCD

  • presence of obsessions, compulsions, or both

  • person recognizes that obsessions or compulsions are excessive or unreasonable

  • cause marked distress, are time consuming (More than 1 hour per day), or interfere w persons functioning

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OCD epidemiology

  • lifetime prevalence = 2.3%

  • affects both genders about equally

  • age of onset: adolescence or early adulthood

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OCD etiology (causes / risk factors)

psychological — learned behavior:

  • avoidance learning: neutral stimuli associated w frightening thoughts or experiences through classical conditioning

    • once association is made, person may find anxiety is reduced w compulsive behavior —> association btwn compulsive behav and reduced anxiety

    • difficult to extinguish these responses

cognitive — thought suppression:

  • thought suppression: if u tell someone to not think ab something, they will only think ab it more — for OCD, this happens w their intrusive thoughts. if try to suppress, think ab twice as frequently

genetics:

  • moderate heritability

  • nonspecific neurotic predisposition (general heritability of a neurotic temperament)

  • biologically based variant of OCD = PANDAS

  • some forms have chronic motor tics

    • related to Tourette’s Syndrome

    • 23% of individuals w Tourette’s have OCD

    • seems to be related to specific molecular genetic variants

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treatment of OCD

exposure and response prevention: expose individual to upsetting stimuli and prevent their typical response (expose to obsessions —> prevent compulsions or anxiety)

  • goal: to sever the link btwn obsessions and compulsions

  • anxiety will habituate — let the individual sit w anxiety until they get used to it

  • 50-70% show a positive response. 76% maintain these gains after treatment

SSRIs:

  • 40-60% show reduction of 25-35% of symptoms

  • high relapse rates

  • beneficial but not as effective as exposure and response prevention

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cross-cultural comparisons of anxiety disorders

  • Yoruba (Nigeria): GAD presentation is different; creating and maintaining a family, fertility, importance of dreams (bewitched)

  • Koro (China & Southeast Asia): intense, acute fear that the penis is retracting into the body and death will result

    • Also occurs in women with response to nipples

    • Attributed to contaminated food

    • Variant of shrinking in West Africa - fertility problems not death concerns

  • Taijin Kyofusho (Japan): fear of interpersonal relationships (similar to social phobia; but moreso a fear of offending others), but no fear of criticism

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Prevention of anxiety disorders

  • build ability to control situations that might lead to anxiety

  • education ab dangerous vs nondangerous situations

  • change negative thoughts

  • practicing skills in real life situations