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Anxiety v fear
- Defined as apprehension over an anticipated problem.
- Fear: a reaction to immediate danger.
- Anxiety often involves moderate arousal and fear involves higher arousal.
- Both adaptive. Anxiety is adaptive in helping us notice and plan for future threats — that is, to increase our preparedness
- Small anxiety helps with performance (inverse U curve performance).
- Anxiety disorders as a group are the most common type of psychological disorder.
- Associated with higher risk of cardiovascular disease and other medical conditions, twice the risk of suicidal ideation and attempts, high rates of unemployment and days off work, high rates of marital discord.
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Clinical descriptions of the anxiety disorders- general criteria for all
- Symptoms interfere with important areas of functioning or cause marked distress.
- Symptoms are not caused by a drug or a medical condition.
- Symptoms persist for at least six months or at least one month for panic disorder.
- The fears and anxieties are distinct from the symptoms of another anxiety disorder.
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Overview of the major DSM 5 anxiety disorders
- Specific phobia: Fear of objects or situations that is out of proportion to any real danger
- Social anxiety disorder: Fear of unfamiliar people or social scrutiny
- Panic disorder: Anxiety about recurrent panic attacks
- Agoraphobia: Anxiety about being in places where escaping or getting help would be difficult if anxiety symptoms occurred
- Generalised anxiety disorder: Uncontrollable worry
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Specific phobias
- a disproportionate fear caused by a specific object or situation, such as fear of flying, fear of snakes or fear of heights.
- The person recognises that the fear is excessive but still goes to great lengths to avoid the feared object or situation.
- In addition to fear, the object of a phobia may elicit intense disgust.
- Specific phobias are highly comorbid
- DSM-5 Criteria for Specific Phobia
- A phobia is a marked and disproportionate fear consistently triggered by specific objects or situations.
- The object or situation is avoided or else endured with intense anxiety.
Acrophobia: fear of heights
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Social anxiety disorder
- a persistent, unrealistically intense fear of social situations that might involve being scrutinised by, or even just exposed to, unfamiliar people.
- Feel as though ‘all eyes are watching them’, with others waiting to evaluate them and record any embarrassing acts.
- Often work in occupations far below their talents because of their extreme social fear
- Among people with social anxiety disorder, at least a third also meet the criteria for a diagnosis of avoidant personality disorder
- Generally begins during adolescence
- DSM-5
- People with social anxiety disorder have a marked and disproportionate fear consistently triggered by exposure to potential social scrutiny.
- Exposure to trigger situations leads to intense anxiety about being evaluated negatively — these situations are avoided or else endured with intense anxiety.
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Panic disorder
- Characterised by recurrent panic attacks that are unrelated to specific situations and by worry about having more panic attacks.
- Panic attack: a sudden attack of intense apprehension, terror and feelings of impending doom, accompanied by at least four other symptoms.
- Physical symptoms
- Depersonalisation: a feeling of being outside one's body
- Derealisation: a feeling of the world not being real
- DSM-5:
- People with panic disorder experience recurrent unexpected panic attacks.
- Panic disorder can be diagnosed if the person experiences at least one month of concern or worry about the possibility of more attacks occurring or the consequences of an attack, or maladaptive behavioural changes because of the attacks.
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Agoraphobia
- defined by anxiety about situations in which it would be embarrassing or difficult to escape if anxiety symptoms occurred, such as being in a crowded place like a shopping centre or church.
- Many people with agoraphobia are virtually unable to leave their house
- DSM 5:
- People who meet the criteria for agoraphobia experience a disproportionate and marked fear or anxiety about at least two situations where it would be difficult to escape or receive help in the event of incapacitation, embarrassing symptoms or panic-like symptoms, such as being outside of the home alone; travelling on public transportation; being in open spaces such as parking lots and marketplaces; being in enclosed spaces such as shops, theatres or cinemas; or standing in line or being in a crowd.
- These situations consistently provoke fear or anxiety.
- These situations are avoided, require the presence of a companion, or are endured with intense fear or anxiety.
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Generalised anxiety disorder
- Central feature is worry.
- People with GAD are persistently worried, often about minor things.
- Typically begins in adolescence.
- Often chronic
- DSM-5
- People who meet the criteria for generalised anxiety disorder experience excessive anxiety and worry at least 50 percent of days about a number of events or activities (e.g., family, health, finances, work and school).
- The person finds it hard to control the worry.
- The anxiety and worry are associated with at least three (or one in children) of the following:
- – restlessness or feeling keyed up or on edge
- – easily fatigued
- – difficulty concentrating or mind going blank
- – irritability
- – muscle tension
- – sleep disturbance
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Comorbidity in anxiety disorders
- More than half of people with one anxiety disorder meet the criteria for another anxiety disorder during their lifetime.
- Three-quarters of people with an anxiety disorder meet the diagnostic criteria for at least one other psychological disorder.
- 60% meet depression criteria
- Commonly comorbid with anxiety disorders include substance abuse and personality disorders.
- Comorbidity is associated with greater severity and poorer outcomes of the anxiety disorders
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Gender factors in anxiety disorders
- Women are more vulnerable to anxiety disorders than men, at 18 percent compared with 11 percent for male.
- Women may be more likely to report their symptoms.
- Men may experience more social pressure than women to face fears.
- Women may also experience different life circumstances than do men. eg. more likely to be sexually assaulted
- Men may be raised to believe more in their personal control over situations as well.
- Also appears that women show more biological reactivity to stress than do men
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Culture factors in anxiety
- People in every culture seem to experience problems with anxiety disorders, but culture and environment influence what people come to fear.
- The prevalence of anxiety disorders varies across cultures
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Common risk factors across the anxiety disorders
- Behavioural conditioning (classical and operant conditioning)
- Genetic vulnerability
- Disturbances in the activity in the fear circuit of the brain
- Decreased functioning of gamme-aminobutyric acid (GABA) and serotonin; increased norepinephrine activity
- Behavioural inhibition
- Neuroticism
- Cognitive factors, including sustained negative beliefs, perceived lack of control and attention to cues of threat.
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Fear conditioning
- Mowrer's two factor model of anxiety disorders:
- 1. Through classical conditioning, a person learns to fear a neutral stimulus (the conditioned stimulus or CS) that is paired with an intrinsically aversive stimulus (the unconditioned stimulus or UCS).
- 2. A person gains relief by avoiding the CS. Through operant conditioning, this avoidant response is maintained because it is reinforcing (it reduces fear).
Anxiety disorders are related to an elevated propensity to develop fears through classical conditioning and to a slow extinction of those fears once they are acquired
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Genetic factors
- Twin studies suggest a heritability of 20–40 percent for specific phobias, social anxiety disorder and GAD, and about 50 percent for panic disorder.
- Some genes may elevate risk for several different types of anxiety disorder.
- Neurobiological factors: the fear circuit and the activity of neurotransmitters.
- Amygdala: part of fear circuit. Involved in assigning emotional significance to stimuli. Elevated activity in the amygdala may help explain many different anxiety disorders.
- Medial prefrontal cortex: helps to regulate amygdala activity — it is involved in extinguishing fears and also appears to be engaged when people are regulating their emotions. Adults who meet diagnostic criteria for anxiety disorders display less activity in the medial prefrontal cortex when viewing and appraising threatening stimuli
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Personality: behavioural inhibition and neuroticism
- Behavioural inhibition: infants who show a tendency to become agitated and cry when faced with novel toys, people or other stimuli.
- Behavioural inhibition appears to be a particularly strong predictor of social anxiety disorder.
- Neuroticism: a personality trait defined by the tendency to experience frequent or intense negative affect.
- Neuroticism predicted the onset of both anxiety disorders and depression
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Cognitive factors
Sustained negative beliefs about the future: people think and act in ways that maintain these beliefs by engaging in protective behaviours. Eg. people who fear they will die from a fast heart rate stop all physical activity the minute they feel their heart race.
Perceived lack of control: People who report experiencing little sense of control over their surroundings are at risk for a broad range of anxiety disorders.
- Attention to threat: people with anxiety disorders pay more attention to negative cues in their environment than do people without anxiety disorders.
- Heightened attention to threatening stimuli
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Aetiology of specific phobias
- Two-factor model of behavioural conditioning
- Phobias could be conditioned by direct trauma, modelling or verbal instruction.
- Little Albert
- Vulnerability factors shape whether or not a phobia will develop in the context of a conditioning experience.
- Also believed that only certain kinds of stimuli and experiences will contribute to development of a phobia.
- Prepared learning: Suggested that during the evolution of our species, people learned to react strongly to stimuli that could be life-threatening
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Aetiology of social anxiety disorder
- Behavioural factors: conditioning
- Cognitive factors: too much focus on negative self evalutations
- Have unrealistically negative beliefs about the consequences of their social behaviours.
- They attend more to how they are doing in social situations and their own internal sensations than other people do.
- People with social anxiety disorder are overly negative in evaluating their social performance
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Aetiology of panic disorder
- Neurobiological factors: fear circuit
- Locus coeruleus: produces neurotransmitter norepinephrine. Natural response to stress and associated with inc activity in sympathetic nervous system.
- People with panic disorder show a more dramatic biological response to drugs that trigger releases of norepinephrine.
- Drugs that increase activity in the locus coeruleus can trigger panic attacks.
- (Increased sensitivty to norepinephrine triggers)
- Behavioural: classical conditioning
- Theory suggests that panic attacks are classically conditioned responses to either the situations that trigger anxiety or the internal bodily sensations of arousal.
- Interoceptive conditioning: a person experiences somatic signs of anxiety, which are followed by the person’s first panic attack; panic attacks then become a conditioned response to the somatic changes.
Cognitive factors: catastrophic misinterpretations of somatic changes.
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Aetiology of agoraphobia
- Risk of agoraphobia appears to be related to genetic vulnerability and life events
- Fear-of-fear hypothesis: cognitive model. Suggests that agoraphobia is driven by negative thoughts about the consequences of experiencing anxiety in public
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Aetiology of generalised anxiety disorder
- Tends to co-occur with other anxiety disorders.
- People who meet diagnostic criteria for GAD are much more likely to experience episodes of major depressive disorder than those with other anxiety disorders are.
- By worrying, people with GAD may be avoiding emotions that would be more unpleasant and more powerful than worry.
- Some research suggests that people who have a hard time accepting ambiguity are more likely to worry.
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Treatments: commonalities across all
- Exposure
- Exposure hierarchy
- Exposure should include as many features of the feared object as possible.
- Exposure should be conducted in as many different contexts as possible.
- Extinction involves learning new associations to stimuli. These newly learned associations inhibit activation of the fear.
- Cognitive treatments typically involve exposure in order to help people learn that they can cope with these situations.
- Mindfulness meditation, skills to promote acceptance of emotions.
- Medications: Drugs that reduce anxiety are referred to as anxiolytics.
- Benzodiazepines: eg. valium & xanax. More side effects
- Antidepressants: eg. SSRI. Preferred bc withdrawals from benzos
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Obsessive-compulsive and related disorders
- Obsessive-compulsive disorder: Repetitive, intrusive, uncontrollable thoughts or urges (obsessions)
- Repetitive behaviours or mental acts that the person feels compelled to perform (compulsions)
- Body dysmorphic disorder: Preoccupation with imagined flaw in one’s appearance
- Excessive repetitive behaviours or acts regarding appearance (e.g., checking appearance, seeking reassurance)
- Hoarding disorder: Acquisition of an excessive number of objects
- Inability to part with those objects
- These syndromes often co-occur.
- They often experience other anxiety disorders as well
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Obsessive-compulsive disorder: clinical description
- People with obsessive-compulsive disorder experience obsessions and/or compulsions.
- Obsessions are defined by:
- – recurrent, intrusive, persistent, unwanted thoughts, urges or images
- – the person tries to ignore, suppress or neutralise the thoughts, urges or images.
- Compulsions are defined by:
- – repetitive behaviours or thoughts that the person feels compelled to perform to prevent distress or a dreaded event
- – the person feels driven to perform the repetitive behaviours or thoughts in response to obsessions or according to rigid rules.
- The acts are excessive or unlikely to prevent the dreaded situation.
- The obsessions or compulsions are time consuming (e.g., at least one hour per day) or cause clinically significant distress or impairment.
- OCD tends to begin either before age 10 or else in late adolescence/early adulthood.
- The pattern of symptoms appears to be similar across cultures
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Body dysmorphic disorder description
DSM:
- People with body dysmorphic disorder experience preoccupation with one or more perceived defects in appearance.
- Others find the perceived defect(s) slight or unobservable.
- The person has performed repetitive behaviours or mental acts (e.g., mirror checking, seeking reassurance or excessive grooming) in response to the appearance concerns.
- Preoccupation is not restricted to concerns about weight or body fat.
Typically begins in adolescence.
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Hoarding disorder clinical description
DSM-5 criteria for hoarding disorder
- People who meet the criteria for hoarding disorder experience persistent difficulty discarding or parting with possessions, regardless of their actual value.
- People with hoarding disorder experience a perceived need to save items and distress associated with discarding.
- The symptoms result in the accumulation of a large number of possessions that clutter active living spaces to the extent that their intended use is compromised unless others intervene.
- Many people who hoard are unaware of the severity of their behaviour.
- About 1/3 also engage in animal hoarding.
- Hoarding behaviour usually begins in childhood or early adolescence.
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