PSY1204 Lecture 2 - Anxiety GC PDF

Anxiety Disorders Gina Collins [email protected]  1.1. Anxiety: Background Anxiety disorders Phobias and fears Post-traumatic Stress Disorder (PTSD) Bi...

Anxiety Disorders Gina Collins [email protected]  1.1. Anxiety: Background Anxiety disorders Phobias and fears Post-traumatic Stress Disorder (PTSD) Biological “readiness” factors Behavioural and social “learning” Treatment Mentimeter Have you ever felt anxious? If so, what made you feel anxious? Has anxiety ever stopped you doing something that you wanted to do? Describe what it was like to have anxiety Anxiety... An unpleasant emotional state characterized by fearfulness & unwanted and distressing physical symptoms and thoughts “When I’m out, I get this sinking feeling, I’m losing my mind, everything spins, heart feels like its exploding, everything slows down, I look at people, they’re [like they are] behind glass, I can’t reach out… I feel like I’m dying…” Anxiety Disorders (DSM V) Anxiety disorders share features of excessive fear and anxiety, and related behavioural disturbances. Fear: emotional response to real or perceived imminent threat; surges of autonomic arousals necessary for fight/flight, thoughts of immediate danger and escape behaviours. Anxiety: anticipation of future threat; more often associated with muscle tension and vigilance in preparation for future danger, and cautious/avoidant behaviours. Fear Anxiety Basic emotion Generalised mood state Non-cognitive or Cognitive and complex cognitions elementary/automatic cognitions Brief/discrete Long/chronic Dependent on the moment Dependent on learning experiences Distinct physiology Diffuse physiology Instantaneous response necessary Plan and prepare for challenge for survival and threat Response to imminent threat Response to future threat Intense autonomic arousal Less autonomic arousal Visual processing/imagery Verbal processing/worry Biological background Evolutionary preparedness Good evolutionary reasons to alter things quickly or avoid Fight/flight (or freeze) response system Evolutionary mechanism involving primitive brains areas and decision making (e.g., limbic system) transmits ‘adrenaline’ surge heart races (blood to arms, legs, e.g., away from stomach) muscles tense, pupils dilate etc. Helps cope with fighting or fleeing Over in short period; noradrenaline released; feel drained ‘Alarm system’ may be misfiring – we don’t need to do something physical Genetic risk Possible; may be disruption to those who have more/less ‘autonomic liability’ (readiness to arousal) E.g., those with close (1st degree) relative with agoraphobia have greater risk of agoraphobia and other phobias (but also role-modeling of fear is an important factor) “Does the amygdala mediate rapid unconscious processing of fearful stimuli ?”  Avoidance - Conditioning Theory some things are, with no exposure, frightening, but we can be made to fear pretty much anything e.g. learn to fear a neutral stimulus if it is paired with an intrinsically fearful stimuli Can happen in one-off events, Causes: e.g., adolescent avoiding public toilets as, Behavioural when 5yrs old, she was shouted at (FEAR response) by teacher for leaving classroom to go to toilet (FEAR Theory PAIRED WITH going to the TOILET) Reinforced for avoiding situations by drop off in arousal state This stops people from “unlearning” the “faulty learning” (stuck in an avoidance loop) Associative Learning: Classical Conditioning Classical conditioning “Pairing” a “stimulus” with a “response” for a new behaviour Pavlov’s Dog James Watson: Little Albert  Generalization: Reaction that is given to stimuli that are similar to the stimulus used during training Further Extinction: If the reaction that is given to the concepts trained stimulus is presented repeatedly that apply to without being followed by the reward, this conditioned response will diminish or cease Classical Spontaneous Recovery: Following Conditioning extinction, the conditioned can spontaneously re-appear after a delay Associative Learning: Operant Conditioning Operant conditioning Reinforcement influences behaviour Positive! Negative B.F. Skinner Context is crucial part of associative learning: Learning always takes place in a context and to the organism (context conditioned responses in drug use) Something is learned about a contingency, given a context  Associative learning leads to many associations between the environment and our behaviour, as well as our internal states. Associative It is thought to govern many aspects of our behaviour… perhaps more than you think! Learning in Always consider learning as a factor, as it plays an clinical essential role in our assumptions about ourselves and the world - affects how we feel every day. It is psychology thought to play an essential role in disorders like anxiety, depression, addiction and others. Associate learning plays a role in the cause of disorders, but can also be used in their treatment Main anxiety disorders in the DSM-V Specific Phobia Generalised Anxiety Disorder Social Anxiety Disorder Panic Disorder Agoraphobia (and some others)  Specific phobia is a disproportionate fear caused by a specific object, animal or situation Animals, e.g., snakes, spiders, birds Natural environment, e.g., open spaces Specific (Agoraphobia); closed spaces (Claustrophobia) Phobias Blood; injection; injury Situational, e.g., flying (Aerophobia) Others, e.g., germs, bacteria (Mysophobia); clowns (Coulrophobia) Fears and phobias Phobia diagnosed when: a fear that is out of proportion to the actual threat of the object/situation (e.g. of spiders in UK, but not Oz) recognized by person as a largely groundless disrupting to their life Prevalence rate and risk 6 in 100 people have phobic responses women twice as likely than men (4:2) 2 in 100 have phobia at a clinical level (I.e. a phobic disorder) Phobia DSM-V diagnostic criteria Marked fear or anxiety The fear or anxiety is out of The phobic object or about a specific object or proportion to the actual situation almost always situation (e.g., flying, danger posed by the specific provokes immediate fear or heights, animals, injections, object or situation and to anxiety seeing blood) the sociocultural context The phobic object or The fear, anxiety, or The disturbance is not better situation is actively avoided avoidance is persistent, explained by the symptoms or endured with intense fear typically lasting for 6 months of another mental disorder or anxiety or more  Causes of Phobias Vicarious conditioning Trans-generational and/or peer- generated Role modeled fear/anxiety by parent/friend e.g. “fear of flying” Reinforced by others Media influence (e.g., Jaws and shark phobias) Evolutionary advantages to pick up what’s a danger (n.b., animal research studies) Debiec, J., & Olsson, A. (2017). Social Fear Learning: From Animal Models to Human Function. Trends in Cognitive Science, 21(7), 546-555.  Systematic desensitization Unlearning the fear response (avoidance loop) Treatment Learn a coping response through: breathing/relax managing Negative Intrusive Thoughts (NITS) of Simple & developing coping thoughts over progressive stages, from least phobia worrisome to most Reinforcing coping responses by others Compare to “flooding” therapy Exposure therapy 1. Assessment and fear hierarchy 2. Start with the least fearful stimulus 3. Exposure session 4. Stay in the situation 5. Repeated exposure 6. Progressing through the hierarchy  Daddy long legs (crane fly) phobic Assess and treat: no problems in relationships sister/mother had insect phobias Crane fly phobia interferes with ability to be a medical student e.g. running off from ward round, and phobia: Case avoiding places when cranefly “in season” LM graded hierarchy relaxation exercises pictures/spiders/crane fly etc. Outcome catching & releasing crane fly Mother/sister started to use self-help  “CB is a very pleasant young man. He suffered a severe head injury on **/97. He also suffered orthopaedic injuries to his legs. His recovery has been remarkable. He is now fully mobile. His IQ is unaffected. However, his memory Referral for current events and past life appears limited. He has taken to staying at home, letter barely socialises, and seems to need to check locks, cookers etc. before leaving the house…I believe some psychological intervention of some form may be helpful…” Consultant Neurologist Dr Redwood  Pre-injury : Systems analyst Traumatic Brain Injury in a road accident (RTA) aged 23 Case Coma 4 weeks illustration: Cognitive function (thinking, reasoning etc.) fine Dense retrograde amnesia CB I.e. limited memory for People, even relatives Assessment Events from childhood through to the accident Own likes or dislikes Poor anterograde memory (everyday events since the accident)  did not “trust” himself to remember activities limited daily routine (“game boy thumb”) occasional visits to a local shop but will check and re-check the house before going CB: Self- Cooker “off”, back door & front door “locked” (up to 20 times) tolerated 20-minute visit to a pub once a week to socialise report of embarrassed “don’t know if I lent John something, might ask Steve for it back…” symptoms “checked himself” for personal possessions “constantly” Poor sleep, appetite down, pessimistic, suicidal thoughts Family very worried as CB getting ++ withdrawn & depressed CB: scores on mood measures at assessment 20 18 16 14 12 10 assess 8 6 4 2 0 anxiety depres M: OCD  Attention & Memory: checking to “keep order” that he did what he thought he had ? compensatory behaviour for cognitive deficits CB: ”underlying” Loss of self- control/ fear ? checking a means of re-asserting sense of control emotional Issues re: self-image issues said he “looked a mess” after his accident. Friends had said that he was good looking now, but he was “stuck” in a poor self image ? routines/checking “saves” from having to be with others  Individual and Group therapy (Neuro and CBT) Palm-top organiser for long term & prospective (future) memory E.g. to meet friends at pub Voice organiser for working memory CB: E.g. “Dave said to meet at gym tomorrow” Interventions Breathing/tense-relax exercises for general anxiety Attention training & CBT for managing worries Hierarchical goals for graded exposure to: Social activities Community mobility Physical activities CB: Working through a hierarchy 1. Making a call to a friend General Strategies: Friends only “putting up” with me  Check evidence (negative “voice”)  list chat items (check f-fax) Won’t remember what talked about  pad for notes  who-what-when-where  breathing exercises 2. Meeting friends in a pub Leaving house  listen to door “click”  visualise belongings at home Unable to keep track of belongings/conversation  find quiet area € check breathing 3 Going to a club with friends Too many people/pushing visualise belongings at home Losing friends and not getting home picture where things are make “leaving” arrangements CB: Anxiety ratings for getting around 10 9 8 7 6 week 1 5 discharge 4 follow up 3 2 1 0 buses town city CB: Anxiety ratings for socialising 10 9 8 7 6 week 1 5 discharge 4 follow up 3 2 1 0 calls pub clubbing CB: scores on mood measures, assessment and discharge 20 18 16 14 12 assess 10 discharge 8 6 4 2 0 anxiety depres M: OCD  “I’ve had my life back…I spent all the time since the accident at home watching TV..afraid that if I do something I’d look foolish… [now] every weekend, [I’m with] friends…using [memory and anxiety management] strategies... that was confusing for a while but CB Outcome over time you get used to the new habits, and what technique to use where and when, and you get to trust [yourself]..and get confident..[but] you’ve got to watch for that vicious cycle of withdrawal..”  A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance) Generalised B. The individual finds it difficult to control the worry. Anxiety C. The anxiety and worry are associated with three (or more) of the following six symptoms (With at least some symptoms Disorder having been presents for more days than not for the past 6 months). Note: Only one item is required in children – (GAD) 1. Restlessness or feeling keyed up or on edge. 2. Being easily fatigued. DSM V 3. Difficulty concentrating or mind going blank. Criteria 4. Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)  D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social occupational, or other important areas of functioning. Generalised E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) Anxiety F. or another medical condition (e.g., hyperthyroidism). The disturbance is not better explained by another mental Disorder disorder (e.g., anxiety or worry about having panic attacks in panic disorder, a negative evaluation in social anxiety (GAD) disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from DSM V Criteria attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic cont’d symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder.)  Excessive worrying impairs the individual's capacity to do things quickly and efficiently, whether at home or at work Functional The worrying takes time and energy; the associated symptoms of Consequences muscle tension and feeling keyed up or on edge, tiredness, difficulty concentrating, and disturbed sleep contribute to the impairment of Generalised Generalized anxiety disorder is associated with significant disability Anxiety and distress that is independent of comorbid disorders Disorder Generalised anxiety disorder accounts for 110 million disability days per annum in the US population  Some beliefs related to GAD 1. Catastrophising 2. Intolerance of uncertainty 3. Over-estimation of threat 4. Perfectionism 5. Need for control 6. Safety behaviors 7. Excessive responsibility 8. Negative beliefs about worry *co-morbidity with depression The cause is not well understood Evidence to suggest GAD may run in families. Studies of twins and families have found that individuals with a family history of anxiety disorders are at increased risk of developing GAD themselves This could be due to a neurological factors Stressful life events, trauma, and chronic stress can contribute to the onset or exacerbation of GAD. Adverse childhood experiences, such as abuse, neglect, or parental conflict, have been linked to an increased risk of developing anxiety disorders later in life Social learning from parents and other important people can play a role  Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a Social conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). Anxiety The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others). Disorder: Social situations almost always provoke fear or anxiety. Social situations are avoided or endured with intense fear or anxiety. DSM V The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. Diagnostic The fear, anxiety, or avoidance is persistent, typically lasting for six months or more. Causes clinically significant distress or impairment in social, occupational, or other Criteria important areas of functioning. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication), symptoms of another disorder or another medical condition  Social anxiety disorder is associated with elevated rates of school dropout, as well as decreased well-being, Functional employment, workplace productivity, socioeconomic status, and quality of life. Consequences Also associated with issues with relationships. of Social In older adults, there may be impairment in caregiving Anxiety duties and volunteer activities. Despite the extent of distress and social impairment Disorder associated with social anxiety disorder, only about half of individuals with the disorder in Western societies ever seek treatment, and they tend to do so only after 15-20 years of experiencing symptoms. Other anxiety disorders and their management Constant worry over health; frequent checking for signs of illness; Avoid anything to do with serious illness (e.g., TV) Health Anxiety Health anxiety can cause physiological symptoms BUT also risk of diagnostic overshadowing Very common co-morbidity with other specific anxiety Panic Disorder disorders/depression Understanding Fight/flight, graded exposure etc.. NB. medication, as with depression, SSRI’s shown to be useful in combination with CBT  Brain is an “approach OR avoid” system, Biological system for “fear” hard wired for avoidance of danger There is a degree of reactivity across people Anxieties and fears can be learnt in one-off or in a series of stress events SUMMARY (CONDITIONED) They can be reinforced by avoidance Can also be learnt vicariously Can be “unlearnt” through therapies (Behavioural/ Cognitive Behavioural) Core = reducing fear reaction, improving coping skills, understand the “function” of the response  PTSD is different in that there is a KNOWN “presumed aetiology”, i.e.: Person has directly experienced or witnessed an event in which there was actual or threatened death or serious injury or a threat to physical integrity to self or other The response involved fear, helplessness and horror Can be one-off event (e.g., assault, RTA) or continuous trauma (e.g., abuse, combat, persecution, domestic violence) NB. trauma events may lie behind other mood/mental health disorders also, but the links may be unclear Fight/flight: Flashbacks PTSD Nightmares Hyper arousal to reminders of trauma Hypervigilance for danger to self/others Freeze: Avoidance behaviour Numb and blunted affect Amnesia states Derealisation Disassociation More information in Professor Larysa Zasiekina’s lecture in Week 4