Midterm 2 First Half 5-6 Ch. Anxiety Disorders PDF

# Anxiety Disorders (chap 5) ## Physiological Arousal - A universal human experience - Innate fear system - Marked by HPA activation - Affects multiple brain regions - Affects every organ system in the body - Essential for survival ## Concepts Related to HPA Activation ### 1. Stress...

# Anxiety Disorders (chap 5) ## Physiological Arousal - A universal human experience - Innate fear system - Marked by HPA activation - Affects multiple brain regions - Affects every organ system in the body - Essential for survival ## Concepts Related to HPA Activation ### 1. Stress - Response to perceived demands (problems) - Objectively demonstrable problem - Outweigh coping abilities ### 2. Fear - Present-oriented - Response to actual danger - Compared to stress, there is something to actually fear - Surge in sympathetic nervous system (fight-or-flight response) - Strong urge to escape ### 3. Panic - Sudden rush of intense fear and physiological symptoms (fight-or-flight) - Short, intense HPA activation - No objective danger - False alarm ### 4. Anxiety - Also known as apprehension/apprehensive anxiety - Future-oriented - Possible future threat - Physical tension ## Anxiety vs Anxiety Disorders - When does it become a disorder? - When it's very intense, frequent, excessive or unreasonable (reaction is exaggerated; exaggerated threat perception) and you have to experience distress and/or impairment ## Importance of Anxiety Disorders ### 1. Prevalence - They're the most prevalent condition - Single largest mental health problem in North America - **General population (DSM-III)** - **24.9% lifetime prevalence** ## Affects Family System - Goes both ways - parenting styles can make a child more anxious but an anxious child can also affect parenting styles. ## Parenting Styles ### 1. Overprotective, Over-Controlling Parenting - Increase the risk of anxiety in children - **De Wilde and Rapee (2008)** - Does over-intrusive, controlling parenting cause anxiety? - **Speech task** - children were told they were going to give 2 public speeches - For the first one which the child was supposed to prepare for, the mother's reaction was manipulated - **Experimental manipulation:** moms randomly assigned to - Behave in over-intrusive and overprotective manner - Be minimally involved but supportive - **Dependent measure:** behavioural ratings of anxiety in second speech - **Found** that children whose mothers were overprotective and controlling displayed greater levels of anxiety in second speech - **Concluded** that over-involved, controlling parental behaviours produces lack of confidence and anxiety, shaped self-confidence and self-esteem ### 2. Critical-Hostile Parenting - Emotional abuse (berated, criticised) is especially bad ### 3. Neglectful Parenting - Physical or emotional ### 4. Modelling/Vicarious Learning (parental anxiety) - Good combination: one parent who is more anxious and another who is not = balances each other out. ## Peer Influences - Anxiety disorders are negatively associated with school popularity (the less popular they are the more likely they are to have an anxiety disorder). - Anxious kids tend to be overlooked which takes a toll on the child. - Anxiety is associated with peer victimisation: bullying (especially during puberty), exclusion - Girls tend to exclude or cyberbully - Boys tend to physically bully other boys - Bad treatment enhances anxiety - vicious cycle ## Barlow's Triple Vulnerability Model - **Genetic predisposition** - **General psychological vulnerability:** general sense that the world is an unsafe place (e.g. if you grew up in an environment where you did not feel safe) - **Specific psychological vulnerability:** specific set of events that shape the form of the anxiety disorder ## Types of Anxiety Disorders (DSM-5-TR) ### 1. Panic Disorder (PD) - “Pan”: Greek god who would leap out and yell at those who disturbed his nap - **Unexpected terror** - 30% of people will have a panic attack at some point in their lives but may not develop PD - **Diagnostic features** - **Recurrent, unexpected panic attacks** - **Panic attack:** sudden rush of symptoms, intense, peaks within minutes (goes away fairly quickly) - **Physiological** - Palpitations, pounding heart, or accelerated heart rate; chest pain - Shortness of breath, smothering; feeling of choking - Dizzy, unsteady, lightheaded, faint - Nausea or abdominal distress - Trembling or shaking - Sweating - Paresthesias (numbness or tingling) - Chills or hot flushes - **Psychological** - Derealization (feelings of unreality) - Depersonalization (being detached from oneself) - Fear of losing control, going crazy or dying ### 2. Specific Phobia - **Phobos** - Greek God of war - Came to mean "apprehension" - **Phobias**: anxious apprehension, i.e., something is going to happen and not that it's happening now. - **Diagnostic features** - Marked and persistent fear that is excessive and unreasonable - Cued by the presence or anticipation of a specific object or situation - **Types** - **Animal** - **Natural Environment** - **Blood-Injury-Injection** - **Situational** - **Miscellaneous** - **Small animal phobia**: arachnophobia (spiders), ophidiophobia (snakes) - E.g. phobia of wasps can be reasonable if you're allergic so it's important to judge the phobia in the context it occurs in - **Natural environment**: hydrophobia (water), acrophobia (heights) - **Blood-Injury-Injection (BII) phobia** - Can be learned - learning history of the phobia - **Situational**: e.g. of closets or in MRIs - **Miscellaneous**: coulrophobia (clowns), kinemortophobia (zombies), trypophobia (holes) - **Prevalence** - **General population:** specific fears are common - 6.7% of the population meet diagnostic criteria (excessive or impairing) - Fewer seek treatment - **Age**: need to consider developmental stage - some childhood fears are normal - **Culture** also shapes the things we may be afraid of - **Biological contributions** - **Family studies and twin studies suggest genetic vulnerabilities** - Phobias are typically ~40% heritable except for BII which has a heritability coefficient of 0.81 and agoraphobia of 0.61 - **Biological preparedness**: evolutionary influence of certain phobias (used to explain prepared learning) - Phobias are often what used to be actual dangers for palaeolithic humans (e.g. snakes, rats, enclosed spaces, water, heights) - Idea is that humans are vulnerable to certain fears - Early exposure to these events/objects may help (e.g. giving child swimming lessons so they aren't afraid of water) - **Learning contributions** - **2-factor learning theory** - **Step 1: classical conditioning** - **Step 2: operant conditioning** (conditioned fear can be strengthened through a process of negative reinforcement) - **Rachman 3 pathways** - **Direct conditioning** - **Vicarious conditioning** (e.g. becoming afraid of storms because parents were afraid of storms) - **Informational transmission** (able to pick up fears through media like Jaws the movie = fear of sharks) - **Interoceptive (internal sensation) exposure** - exposing the person to body sensations which stops them from engaging in catastrophic interpretations - **"In vivo" (in real life) exposure** - e.g. going out without carrying anti-anxiety medication ### 3. Agoraphobia - Anxiety about being in places/situations where escape might be difficult or embarrassing, or where help may not be available - Differs from simple phobias because it can occur in multiple situations - These situations are either avoided completely, entered only with a "safe person” (very dependent on that person) and/or endured with marked distress - **Commonly avoided situations** - Buses/subways - Bridges - Enclosed spaces - Crowds - Malls - Movie theaters - Standing in line-ups - **Controversy to agoraphobia** - Recall: people who have had panic attacks avoid situations that elicit bodily sensations that resemble panic attacks - According to Barlow, agoraphobia almost always follows panic/PD - European researchers disagree - So is it with or without panic disorder? - 46-80% don't report panic - **Clinically** - **Biological contributors** - **Genetic** - Nonspecific vulnerability - Behavioural inhibition: innate hypersensitivity to environmental change (stronger physical reaction to any change in the environment) - Higher physiological reaction to angry and disgusted faces - **Cognitive-behavioural (learning) contributors** - Mothers who are more attentive to the child they are more likely to get over their phobias or less likely to develop anxiety disorders - Negative life events - Negative self-beliefs - Negative predictions - Selective attention - Judgemental biases - Safety behaviours (e.g. not self-disclosing) - **Treatment** - Selective serotonin reuptake inhibitors (SSRIs) - CBT - Behavioural experiments to test negative beliefs - Try things in social situations - **Treatment outcomes** - Time course: medication response in ~6-8 weeks but CBT takes longer (months) - Relapse: 43% for medication and 17% for CBT - Usually there’s improvement but hard to completely remove ### 4. Social Phobia/Social Anxiety Disorder (SAD) - Marked or persistent fear of one or more social or performance situations - **Performance**: e.g. eating in public; public speaking but since so many people are afraid of public speaking, many question if it should be considered a disorder - Fears doing something humiliating or embarrassing and being negatively evaluated - **Subtype**: performance only - E.g. singing in public - **Prevalence** - 4th most prevalent disorder after depression, alcoholism and specific phobias - **High prevalence in North America** - 8.1% of Canadians - **Lower elsewhere** - Europe = 2.3% - **Prevalence is the same in children** (one of the most difficult childhood disorders to treat along with OCD), adolescents and adults - **Time course** - Onset at age 13 (pubescent age being the peak of bullying or heightening of self-awareness) but can begin earlier - **Gender** - More prevalent in women in community populations - Men are more likely to seek treatment - **Culture influences** - **Taijin kyofusho**: fear of offending other people via behaviour, body odour, intense gaze etc. - (Japan, Korea) - **Hikikomori**: severe social withdrawal (aka failure to launch) (Japan) - People from Asian cultures (especially China and Korea) report more social anxiety but have lower rates of social phobia - more accepting of being shy, quiet and reserved = less stigma so it doesn't impair them as much. - **Impairment** - Social: avoidant personality (people and other things like novel things), hikikomori (60% of men with social phobia don't marry), less social support, fewer friends, lonelier - Education: may choose professional career based on interaction with people - Occupational: underemployment (tend to go less far in their jobs than they should) - Comorbidity: risk factor for depression (usually precedes onset of depression), substance abuse (most strongly predicts marijuana abuse/dependence - 25% of those who use marijuana have SAD) - **DSM-V** said GAD is a form of depression - **Speculation that GAD occurs in people with underactive GABA-benzodiazepine system** - **Cognitive-behavioural models** - **Maintaining factors**: cognitive avoidance (Borkovec) - People with GAD used cognition to avoid thinking about things that are very important - Found that people with GAD have less physiological reactivity/ arousal except for muscle tension compared to people with panic disorder - Although they are worried, they have less arousal than other anxiety disorders - Worry about images - more verbal than pictorial - Focus on future not present events serves as distraction from fear - Talking to yourself (e.g. "What am I gonna wear? What if I’m early? What if I’m late?”) and worrying verbally distracts yourself from serious events that may be happening in life (e.g. if a family member is sick) - Came up with the idea of using cognitions to avoid genuine emotions - **Intolerance of uncertainty** (Durgas) - People get anxious when there are uncertain situations - People with GAD often have erroneous beliefs about worry - more likely to believe that worry is useful - Poor problem orientation - people with GAD could generate solutions to problems but afraid to implement them - Also emphasise cognitive avoidance - people worry to avoid a deeper fear - Came up with the Why Worry questionnaire - Found that people with GAD believe that if they worry they will be less upset when something actually happens but it actually has no protective function at all (therefore a dysfunctional belief) - They also believe that worrying has a planning function but found that this actually keeps individuals from actually implementing problem solutions - In reality, if you worry about something you’re more likely to procrastinate - **Safety behaviours of people with GAD:** overpreparation - Have people keep track of their worries and then ask them to divide those worries - **Worry discrimination**: Type 1 (controllable) and Type 2 (uncontrollable hypothetical situations) - **Type 1:** exercise problem solving - **Type 2:** focus on increasing tolerance for uncertainty - **Exercises to engage in actions without preparation** - **Reduce reassurance-seeking** - **Exposure to most feared outcome** - E.g. visualising your fear/ writing out a loved one getting into a car accident and reading it over and over till emotion drains out of the imagined scenario - **Treatment** - **Dugas & Robichaud: CBT for GAD** ### 5. Generalized Anxiety Disorder (GAD) - **Excessive worry** - **Number of events** - **Excessive and unreasonable** - **Difficulties controlling worry ("can't stop thinking")** - **Has to be accompanied by at least 1 of 5 physiological symptoms** - One distinguishing features is muscle tension - Other symptoms include restlessness, fatigue, difficulty concentrating, irritability and sleep disturbance - **Worry themes** - One clue is whether the person worries about minor things - Excessive in relation to the person's current life experiences. - **Prevalence** - **Culture** - 0.9% adolescents - 2.9% of adults - More common in people of European descent and in developed countries - Presence of mental health care = greater diagnosis - **Gender** - Slightly more common in women - **Time course** - Start earlier - Amount of worry waxes and wanes depending on underlying stress - **Genetic** - Small heritability coefficient of .33 - But genetic risk factors overlap almost completely with depression – runs in the same families as people who are depressed ## Illness Anxiety Disorder - Used to be called hypochondrias - Preoccupation with having a serious disease that has gone undetected - Minimal somatic symptoms if any - High level of anxiety and low threshold for "sickness" - Excessive health-related behaviours - **Duration** - E.g. checking (cyberchondria), internet searches, reassurance-seeking all of which perpetuate their fear - **Clinical picture** - Prevalence uncertain: 1-5% in general population - Gender: similar in males and females - Course: chronic waxing and waning - Impairment: social, occupational ## Conversion Disorder (functional neurological symptom disorder) - **One or more symptoms of altered voluntary motor or sensory function (neurological)** - **Incompatibility with recognised neurological or medical conditions** - No muscle atrophy in someone who claims they are paralysed - Holding eyes closed when you try to open them when they’re having a “seizure” - Normal EEG - **Clinical picture** - Prevalence: rare in general population, 30% of neurology referrals - Gender: 2:1 women to men - Onset: under stress - Prognosis: short duration better, can reoccur if stress reappears - **Aetiology** - Lower SES and less education or medical literacy - Major life stress - Not uncommonly found in people with religious beliefs (e.g. God can paralyse you) - Symptoms have to make sense in their context - Social acceptance of symptoms ## Aetiology of Somatic Symptom and Related Disorders - **Physiological contributions** - Often involves presence of some biological symptoms - Caution: unrecognised medical conditions (e.g. Parkinson’s, multiple sclerosis) - Pain sensitivity - Family aggregation - May be a small heritable components but shared with anxiety disorders - Negative affectivity - **Psychodynamic perspective** - Trauma or extreme stress - Defence mechanisms: repression, conversion, symbolism - Quasi-resolution - **Cognitive-behavioural perspective** - (Likely) Learned through experience of the illness they think they have - Develop illness concerns - Heightened vigilance - Contemporary anxiety - stressful event prior to onset of development - Attentional focus on symptoms of anxiety - Misinterpretation of symptoms that they’re actually ill - Study asked: "your heart is beating firmly, why?" - 4 options - 1) You have been exercising ## Factitious Disorder by Proxy - Rare - Signs - Child has history of many hospitalisations - Often with a strange set of symptoms - Worsening of the child's symptoms generally is reported by the mother and not witnessed by the hospital staff - Child's reported condition and symptoms don't agree with the result of diagnostic tests - Most people who do this are women (mothers etc.) - There might be more than 1 unusually illnesses or death of children in the family - Child's condition improves in the hospital but symptoms recur when the child returns home - Blood in lab samples might not match the blood of the child - There might be signs of chemicals in child's blood, stool or urine - Child can die by maltreatment by parent who just wants attention ## Obsessive-Compulsive Spectrum Disorders - **Learning Objectives** - Why are the OCD-spectrum disorders separated from the anxiety disorders? - What are the primary types of OCD? - What are the biological contributions to OCD? - What are the biological treatments for OCD? - What are the psychological contributors to OCD and treatments for OCD? - What are the other OCD-spectrum conditions? - **OCD-Spectrum** - Obsessive-Compulsive Disorder (OCD) - Body Dysmorphic Disorder - Hoarding Disorder - Trichotillomania (compulsive hair pulling) - Excoriation (compulsive skin-picking) - **Why do we distinguish OCD-spectrum disorders from anxiety disorders?** - 1. **Different underlying neurocircuitry** - Anxiety disorders: amygdala-cortical connectivity - fear system is overactive and prefrontal cortex that regulates fear is underactive - OCD: overactive fronto-striatal circuitry - 2. **Distinct symptom patterns** - **In OCD:** repetitive thoughts and compulsive behaviours, very difficult to control compulsive behaviours - To diagnose this condition, patient typically needs to engage in compulsive behaviour for at least 1h a day - **In anxiety:** safety behaviours but the person can usually control these behaviours - 3. **Comorbidity among the OCD spectrum disorders** - Those with OCD are more likely to have body dysmorphic disorder and hoarding disorder - **OCD** - Marked by obsessions - Recurrent and persistent thoughts, impulses or urges - Experienced as intrusive and unwanted - Attempts to ignore or suppress or to neutralise with other thoughts or with actions - **Prevalence: unknown** - Course: intermittent episodes - Onset: under stress - **Treatment** - Seldom sought - only the ones with at least some insight seek treatment - SSRIs aid - CBT - ERP ## Hoarding Disorder - Hoarding: persistent difficulty discarding possessions regardless of actual value - Perceived need to save items and distress associated with discarding them. - Accumulation of possessions that clutter living areas and compromise their intended use - E.g. can’t cook in the kitchen or sleep in the bed because it’s messy/full of belongings - **Clutter**: large group of usually unrelated objects piled together - Disorganised - In spaces designed for other purposes - Can spill beyond living spaces (e.g. to the yard) - **Frost** - developed a clutter assessment scale - **Squalor**: dirt and filth - Build up of food and food containers - Unsanitary - Vermin (e.g. mice) - **Saving is intentional** - Many reasons given - Perceived utility or aesthetic value - Strong sentimental attachment - Sense of responsibility for possessions - Fear of losing important information - **Most common items** - Newspapers, magazines - Old clothing - Bags - Books - Mail & paperwork - **Specific if they have: excessive acquisition** - 80-90% acquire items that are not needed or for which there is no available space - **Specify** - **Buying** - **Acquiring free items** - **Good to fair insight**: recognition that hoarding is problematic - **Poor insight**: convinced that hoarding is not problematic despite evidence - **Absent insight/delusional beliefs**: completely convinced that hoarding is not problematic despite evidence - **Clinical picture** - Prevalence: up to 5% in Vancouver - **Etiology** - Early onset - Some symptoms by age 11-15 - Significant impairment by mid 20s - **Culture** - Same as all cultures that have been studies - **Age** - It's quite a new diagnosis and has primarily been studied in Western cultures - prevalence is similar - **16.4% 12 month prevalence** - **Patients in primary care settings (who go to the doctor)** (DSM-III) - 18% (even excluding specific phobias) - **Non-cardiac chest pain**: 40% have panic disorder (PD) - **Focal epilepsy**: 19% develop comorbid anxiety disorder (e.g. anxious they will have another seizure, or social phobia of having a seizure in public) - **Present in all cultures, but prevalence varies:** 12 month prevalence (DSM-IV) - **Europe**: 8.4% - **USA**: 22% - **Australia**: 5.6% - **China**: 13% - **Canada**: 5.8% (PD, Agoraphobia, SAD only) - **Francophone**: 3.85, Anglophone: 4.89 - **More common in European especially those with anglophone backgrounds** - Could be because these typically are wealthier countries where mental health care is more readily available - **Tiwari & Wang (2006)** - Examined cultural groups within Canada - **Canadian Community Health Survey** - Residents > 13 years old - Self-reported heritage - **33,399 Euro** (10% immigrants) - **733 Chinese** (84.5% immigrants) - **1,113 other Asian** (86%) - **Found** that people of European backgrounds seemed to be at higher risk of anxiety disorders than other groups in Canada - **Consistent** in anxiety disorders and depression - **Issues with research** - **Definitions of culture, ethnic heritage** - **Any gold standard?** - **Ethnicity vs culture** - A lot of canadians consider themselves bi-culture - **Controlling for generational status** - By third generation, people resemble Canadian culture more than their ethnic culture - **Grouping of heritage groups** - "Asian" vs "European" - Lumping all Asian cultures together etc. disguises differences - **"Southern European cultures"** differ from "Northern European cultures" in anxiety disorders - **Emotion terms don’t translate well from one language to another** - E.g. social anxiety disorder (SAD) - Some cultures it means fear of other people, or paranoia - Interestingly, generalised anxiety disorder, or worry, seems to be universal - **Often chronic** - **Cause significant personal impairment** - **Risk factors for other disorders** (depression, suicide, substance use etc.) - 31% comorbid for another anxiety disorder - 50% also have depression - Increased risk of substance disorder - Possible links with suicide - Multiple health conditions - **Economic burden for society** ## Panic Disorder - **Panic itself subsides but feelings of anxiety may stay** - **A critical symptom**: sense of choking or unable to get enough air - **Diagnosis requires** - At least 5 symptoms listed above - Before: anticipatory anxiety - After: worry about the consequences of the attack - Significant behaviour change - **Situational** - avoid situations they associate with triggers for panic attacks. - **Internal sensations** - if someone feels a symptom associated with panic attacks they think another one will occur, e.g. avoid walking up the stairs to avoid a faster beating heart/getting out of breath - **Safety behaviours** - e.g. carrying anti-anxiety medication - **Subtypes of panic attacks** - **Cued** (situationally bound - confined to certain situations with certain triggers) - **Situationally predisposed** (e.g. someone with social anxiety may only have panic attacks in certain situations) - **Unexpected** - required for diagnosis of panic disorder - **Limited symptom attacks** - people may have some symptoms of a panic but not enough to be diagnosed - **Prevalence** - 1 in 3 people experience a panic attack - Only 3% meet the criteria for panic disorder - **Biological contributions** - **Biological challenge studies** - manipulations that increase CO2 - Infusions of lactic acid - Carbon dioxide inhalation - **Biological theorists** - **Neurochemical disturbance** - 30-40% genetically transmitted - E.g. suffocation false alarm theory: hypersensitivity to detecting carbon dioxide (chemoreceptors) - **Cognitive contributions** - **In biological challenge studies if told "sensations are not harmful" they are less likely to panic** - **Catastrophic misinterpretations of one's physical sensations (fear of fear)** - person associates bodily sensations with bad things = spiralling of anxiety which surmounts to a panic attack - E.g. interpreting heart beating as dangerous and something bad is going to happen = get more anxious = breathe less properly - **Cognitive model** - **Trigger (internal or external)** - **Treatment** - Medications may have side effects, i.e. bodily sensations which could trigger panic attacks - CBT is the first line of treatment - **Education** - e.g. recognising signs of panic attacks and acknowledging that it is nothing dangerous - **You can also condition yourself to be afraid of things or learn fears in different ways** - **Panic attacks** - have a panic attack in a situation can produce fear even if it's fairly benign - **Problems with 2-step learning theory** - Often conditioning event is absent - Individual differences in conditionability - Stimuli specificity - does not explain why we aren’t afraid of everything - Humans tend to develop fears of certain objects (e.g. people do not typically have a fear of a bottle of water) - **Cognitive interpretations influence fear** - **Integrative models - aetiology** - Interaction between innate vulnerability (biological predispositions whether genetics or evolutionary) and learning experiences - Results in exaggerated threat perceptions - people with phobias tend to have maladaptive thought processes regarding the object/situation they’re afraid of - Leads to avoidance and other safety behaviours - **Contemporary models - safety behaviours** - **Deliberate** - Adopted to prevent negative outcome - **Unnecessary** - Exercising of safety behaviours reinforces the belief - **First line treatment** - **Cognitive modification** - to change maladaptive thought processes - **"In vivo" (in real life) exposure** - Graduated (step-wise) - Virtual reality exposure - **Treatment - hypothesised mechanisms (why does it work?)** - **Reconsolidation**: reactivate the fear memory & store with fewer emotion connections - **Extinction learning**: (aka inhibitory learning) develop new memory store associated with fear stimulus - **Cognitive change**: reduce selective attention to threat through safety learning, i.e., not focus on the fear ## Disorders of Obsessions & Preoccupations (chap 6) - **Learning Objectives** - Be able to distinguish Factitious Disorder, Malingering & Somatic Symptom Disorders - Be able to distinguish between various somatic symptoms disorders - Be aware of clinical picture in various disorders - Be familiar with models & treatments - **Critical conceptual distinction** - **Malingering**: deliberate faking - Usually some financial/legal gain from faking - **Factitious disorder**: deliberate faking for no apparent gain other than attention - **Somatic symptom disorder**: genuine belief ## Somatic Symptom Disorders - Typically present first in non-psychiatric settings - May occur in as many as 17-20% of individuals seeking hospital or outpatient medical treatment - Often comorbid with PTSD, depression - Further exacerbate pain and pain beliefs - Very difficult to diagnose - Pain and some physical symptoms inherently subjective phenomenon - DSM places emphasis on presentation, interpretation and impairment rather than pain - Somatic symptom disorder (per se) - Somatic symptoms are distressing or result in disruption of daily life - Excessive thoughts, feelings and behaviours related to symptoms - Disproportionate - High anxiety - Excessive time devoted to health - Focus on symptoms themselves - Multiple vague symptoms - Chronic complaints and person's life begins to revolve around symptoms - Predominant complaint: "I'm in pain" but vague, gets worse with events - **Clinical picture** - Suffering is "authentic” - Often fuels avoidance - Catastrophizing thoughts - High level of medical care utilisation - Usual medical care does not alleviate symptoms - Explanatory therapy (detailed explanation and reassurance) can be effective for mild cases - **Prevalence**: estimated 5-7% in general population - **Onset**: predictors are body checking, catastrophizing beliefs about pain, negative affect, activity avoidance (which causes weakening of muscles = more physical sensations) - **Culture**: affects how people express their somatic symptoms - idioms of distress can vary (e.g. "my body has too much heat”, “burning in head”) - **Impairment** - Work impairment - E.g. fired because they cannot go to work - **Substance abuse** - Prescription opioids - Cannabis - Alcohol - Can become housebound - Take on role of an invalid - **Pain catastrophizing** (e.g. I worry all the time whether the pain will end, I can’t keep it out of my mind) - **Neural matrix mode** - Pain processing is genetically based - there are areas of the brain that detect pain - But this can be modified by experience - Engaging in cognitive activity that amplifies pain signals (like catastrophic interpretations, focusing on pain), sensitises neural mechanisms - Processes become increasingly automatic/ under neural control - You’ll automatically focus on such sensations - Anxiety prospectively predicted pain intensity - Listening to sad music increased pain intensity in back pain patients - Experimentally-induced negative emotions led to activity in brain regions associated with pain - I.e. you can teach yourself to be more sensitive to pain and some point this can become unconscious/automatic - **Dysfunctional safety behaviours that perpetuate concern** - Self-assessment activities (i.e. constantly checking for lumps or “abnormal” marks) - Excessive guarding and protection of injury (e.g. walking in a way that doesn’t strain your back if you think it hurts = can result in muscle atrophy) - Reliance on analgesic medication (e.g. pain killers) - Seeking medical reassurance - Avoidance-constricted lifestyle (e.g. support/accommodation given at work will perpetuate behaviours) ## Factitious disorder - Falsification of physical or psychological symptoms; induction of injury or disease - Social presentation as ill or injured - Absence of obvious external reward - **Clinical picture** - **Treatment** - **Medication** - SSRIs for comorbid anxiety & depression - **Cognitive-behavioural** - **Caution about dismissing concerns** - **Education** - Address triggering stress/trauma - Evaluate pain beliefs - Activity resumption - **Self-management** - Relaxation training - Reduce reassurance-seeing - Reduce social facilitation - E.g. ask family to encourage patient to be active and not to stay home - 62% return to work in people off work for > 6 months - **Most common**: contamination, repugnant (unacceptable) thoughts (usually involve sex, violence or blasphemy) (moral OCD), harm, symmetry and everything has to be “just right” - Those who get repugnant thoughts of sexual nature are typically highly religious (and in orthodox religions) → feel compelled to repeatedly touch the bible or Quran or go to church to confess sins they don’t have etc.; those with sexual impulses often avoid the people they have the impulses/thoughts towards - **Compulsions** - **Repetitive behaviours or mental acts** - That the person feels driven to perform - In response to an obsession or according to rigid rules - Aimed at preventing or reducing distress or some dreaded event or situation - Not realistic or are clearly excessive - **The more you check or engage in compulsions the less you think you’ve done something (e.g. check that you’ve locked the door)** - **Epidemiology** - **Specify** - 1.2% 12 month prevalence in general population - **Culture**: similarities across culture - **Most common** - **Obsession-Compulsion** - Contamination -> Cleaning - Repugnant thoughts -> Depends on specific thought - Harm (Doubting) -> Checking - Not just right -> - Symmetry, ordering, counting - **Gender**: somewhat more common in women than men, but in