Anxiety Disorders Midterm First Part PDF

# Anxiety Disorders ## 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 - **Overprotective, over-controlling parenting** - Increase the risk of anxiety in children - De Wilde an...

# Anxiety Disorders ## 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 - **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 - **Critical-hostile parenting** - Emotional abuse (berated, criticized) is especially bad - **Neglectful parenting** (physical or emotional) ## 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 theatres - 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** 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 Candians - 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) 5. **Generalised 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 6. **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 7. **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** 8. **Factitious disorder by proxy:** when people create medical symptoms in someone else - Rare - **Signs** - Child has a strange set of symptoms - Often with a history of many hospitalisations - 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 ## Obesessive-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 disorder from anxiety disorders?** - 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 - 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 - 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 - **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 - **Epidemiology** - 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 children: 2x as many boys as girls - **OCD onsets earlier for youth boys (around ages 15-18) than for females (ages 20-24)** - **Good or fair insight** - "I hate it; I want to get rid of it" - **Poor insight** - "Yea, I know I do it too much but people get sick and many things are contaminated" - **Absent insight/delusional beliefs** - completely believe that the contamination is real = ~1/3 - **Clinical course** - Onset: earlier in men with 25% <10 years; average age = 19.5 - Chronic waxing and waning - it comes and goes (worse with stress), very hard to get rid of - Those with OCD often have shame about it so they delay seeking treatment (average of a 7 year delay) - Significant impairment - Occupational and interpersonal aspects - Parents may inadvertently reinforce the OCD (e.g. allowing time for child to go through the rituals before they go out) - **Comorbidity** - 49% have anxiety disorder - 27% have major depressive disorder (MDD) - E.g. OCD hinders relationship development which can make you depressed - **Biological models of OCD** - Genetics: nonspecific heritable component shared with anxiety disorders - Dysregulation of a brain circuit - Between orbital frontal cortex, anterior cingulate cortex, caudate nucleus and the thalamus - There is an area of the brain that is overactive - More activity in this area even at rest - Magnitude of activation is correlated with severity of the OCD symptoms - Speculated that this area is responsible for turning of activity – brain is less able to say that you've done something and you can stop obsessing about it - Some speculation of serotonin deficiencies - **Biological treatments** - Pharmacotherapy - SSRIs - Improvement is usually partial - Average response is 35% reduction in OCD symptoms - improved but still impaired - **Cognitive-behavioural therapy** - Includes exercises to address cognitive elements - Goal of treatment is to normalise intrusive thoughts - **How effective** - Lower dropout rate - 10% - Same reduction in symptom severity as ERP - Fewer studies ### OCD-related disorders 1. **Body dysmorphic disorder (BDD)** - 56% of university women are unhappy with their appearance and 43% of men - not unusual for people to wish they looked different - **But BDD involves contortions** - Preoccupation with a perceived defect in physical appearance that is not observable or appears slight to others - Most common site: face, i.e., facial dysmorphia (eyes, jaw) but is not confined to the face - Can be extremely impairing - At some point in the condition, one has performed repetitive behaviours - **Specific example:** muscle dysmorphia - **Men** - body too small or not sufficiently muscular - Excessive workout regimes, steroid abuse - **Safety behaviours:** comparison to other men, excessive care with diet, clothes management, mirror checking - **Clinical picture** - Prevalence: 2.4% - 8% of patients seeking cosmetic surgery - 15% among dermatology patients - 10% oral surgery patients - **Cosmetic treatments** - 76% sought treatments - 15% among dermatology patients - 10% among oral surgery patients - No benefit - 81% were dissatisfied - Repeated surgeries - Ideas of reference - **Clinical course** - Onset: mean age 16-17 years old - 66% onset before age 18 - Chronic without treatment - **Consequences** - Significant distress/impairment - Suicide risk (suicide ideation/attempts): 44% of youth and 24% of adults - Housebound: 20% school drop out - Ideas of reference: everything related to their appearance (thinking that people are staring because of parts of appearance they don't like) - **Insight** 2. **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 - **More common in older people** - Average age: 50 - **Chronic course** - **Substantial impairment** - Inability to use living spaces - Danger to self (e.g falling objects, eviction → in Vancouver, it's legal to evict someone because they're a hoarder) - Danger to others (e.g. fire) (1% of fires in Australia involved a hoarder but caused 24% of fire-related deaths) - Interpersonal (e.g. children moving out because they can't live with parents anymore) and social conflict (e.g. unhappy neighbours) - **Is hoarding a type of OCD?** - Ego syntonic vs dystonic - Something that is "ego-syntonic" truly aligns with one's values, identity, core beliefs, and desires - Something that is "ego-dystonic" does not it is separate or opposite of what someone truly agrees with, desires, believes in, and values - No rituals - Acquisition associated with positive emotions - Distress emerges ONLY when faced with discarding possession - Only 18% of hoarders display OCD symptoms - Hoarders equate possessions with their sense of self & well-being - merging between self and things they own and feel better when they have things around them - So researchers say that differences indicate that hoarding needs its own category but other researchers disagree - **Treatment** - SSRIs and ERP are ineffective - Forced removal of possessions is ineffective - Specialised CBT is more effective - Education re hoarding - Cognitive therapy for dysfunctional beliefs - Skills training for organising, decision-making - Problems with categorisation - Sorting: keep, discard, don't know - **Reducing acquisition** - Question: do I need this item? Have room for this item? - Sorting and discarding practice: treat carefully (therapist does not decide whether something gets thrown out) - Home visits - **Animal hoarding** - More common in older women than men, and older people than younger people - Distinct - Have at least 15 animals - Median number of animals = 39 - Animals often suffer - View animals as source of love - Extremely debilitating - Very poor insight - delusional disorder? 3. **Trichotillomania (hair-pulling)** 4. **Skin-picking** - (don't need to know about trichotillomania or skin-picking) ## Disorders of obsessions and preoccupations (chap 6) - **Somatic Symptom and Related Disorders** - **Learning Objectives** - Be able to distinguish Factitious Disorder, Malingering and Somatic Symptom Disorders - Be able to distinguish between various somatic symptoms disorders - Be aware of clinical picture in various disorders - Be familiar with models and 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 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 - **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) - **Reinforcement** - Medication - SSRIs for comorbid anxiety and depression - **Cognitive-behavioural** - Caution about dismissing concerns - Education - Address triggering stress/trauma event - 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 - **Treatment Alliance:** Cognitive therapy: Replace short-term relief from the safety behavior with empathy, patience, and understanding from providers, family, friends | Temporary relief | Thoughts about being sick | Behavioral therapy: Replace the avoidance and reassurance-seeking with adaptive coping skills and problem-solving | The cycle of illness anxiety | Avoidance OR Seeking Reassurance | Exposure therapy: Experience anxiety in a controlled environment to practice distress tolerance and reduce anxiety sensitivity - **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** ## How Effective is the Treatment of Anxiety Disorders? - **40-60% do not respond significantly** - **Relapse often occurs after medication is terminated = ~90%** - There are different approaches to treating anxiety, including: - **Surgical techniques** - Reserved for severe, incapacitating symptoms who are treatment refractory (failed other treatments) - **Ablation techniques** - Ablate sections of OCD-circuit - Radiosurgery guided by MRI - Gamma knife - Sites selected "empirically" - Empirical evidence - Some improvement: 40-70% of cases; reduction of 35% in symptoms - Research design very weak - **Deep brain stimulation** - Craniotomy followed by implantation of electrodes - Adjustable and reversible - Empirical evidence - Few studies - **Behavioral models** - No controlled comparisons - **Two-factor learning models** - 1. Obsessions: conditioned fear to neutral stimulus - 2. Compulsions: temporary reduction in anxiety - negative reinforcement - **Behavioral treatments - Exposure and Ritual Prevention (ERP)** - Gradual exposure to obsession triggers - Prevent compulsive behaviours - **Effectiveness** - Significant reductions in OCD symptoms - Large effect sizes - Corrects overactive neurocircuit - ERP is the first line treatment for OCD with the strongest research support - 60-68% respond to ERP and 57% achieve clinical remission if person remains in treatment - Research issues: willing to accept random assignment - 19-25% may drop out - **Comparing ERP to medication** - 149 patients with OCD randomly assigned to 1) ERP, 2) Clomipramine, 3) combined ERP + Clomipramine, 4) placebo - All treatment groups better than placebo - Both ERP groups > SSRI alone - Medication was not found to add anything to patient recovery on top of ERP - **Cognitive models** - 90% of people experience intrusive thoughts - **Obsessions in nonclinical samples examples** - Appraisal of the intrusive thought is what differentiates people who do and do not develop OCD - **Faulty appraisals** - (1) Over-importance of thoughts - Thoughts are accurate and meaningful - If I have a thought, it must mean something - (2) Inflated responsibility - My fault if I feared event happens - (3) Thought-action fusion (TAF) - E.g. I want (loved one) to die - Likelihood TAF: thinking increases the likelihood of feared outcome - Moral TAF: thinking it is as bad as doing it - **Good / fair:** the individual recognizes that OCD beliefs are definitely or probably not true or that they may or may not be true - **Poor:** the individual thinks the OCD beliefs are probably true - **Absent/delusion:** 33% - **Treatment** - Seldom sought - only the ones with at least some insight seek treatment - SSRIs aid - CBT - ERP ## 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) - Catastrophic Misinterpretations | Perceived Threat | Apprehension | Bodily Sensations (Anxiety) - **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 ## Anxiety Treatment - **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 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