Anxiety Disorders and OCD (1)

1 ANXIETY DISORDERS  GENTLE WARNING 2 ❖ If by any Chance the content of this class has emotional repercussions for you, please reach out to me so I can help you process it and/or direct you to the right resources on campus. ❖ You can als...

1 ANXIETY DISORDERS  GENTLE WARNING 2 ❖ If by any Chance the content of this class has emotional repercussions for you, please reach out to me so I can help you process it and/or direct you to the right resources on campus. ❖ You can also find direct psychological support at our Counseling Center, located on the 1st floor of Padre Rubio Hall, or bu asking for an appointment with them here ❖ There is also a Counseling Emergency Number: (+34) 609 269 323. You can also find it on the back of your ID card. ANXIETY RELATED 3 DISORDERS  Specific Phobias  Social Anxiety Disorder  Panic Disorder & Agoraphobia  Generalized Anxiety Disorder (GAD)  Obsessive- Compulsive Disorder (OCD)  Trauma & Stress- related disorders  What are Anxiety Disorders? 4  An anxiety disorder is an excessive or aroused state characterized by feelings of apprehension, uncertainty and fear  In anxiety disorders, anxiety is: Out of proportion to the threat posed A state that the individual constantly finds themselves in A cause of distress that disrupts normal day-to-day living  As such, Anxiety Disorders need to be distinguished from anxiety in general which is a normal part of human experience based on the physiological fight or flight response What's normal anxiety -- and what's an anxiety disorder? | Body Stuff with Dr. Jen Gunter | TED (youtube.com)  5 FIGHT OR FLIGHT RESPONSE  6 PSY3460-D.MANOS ANXIETY 7  What we call anxiety is the psychological experience elicited around the fight or flight reponse.  Besides those physiological symptoms, it also includes:  cognitive  emotional  behavioral components  FIGHT OR FLIGHT 8 PSY3460-D.MANOS  9  Physiological symptoms of panic Common  Biases towards selectively Characteristics attending to threatening or negative information Of  Associated with ANXIETY dysfunctional beliefs DISORDERS  Often related to specific early experiences (e.g., physical abuse during childhood)  Comorbid among them  10 SPECIFIC PHOBIA SPECIFIC PHOBIA 11 An excessive, Phobic individuals will unreasonable, usually develop a set persistent fear of avoidance triggered by a specific responses object or situation Fear is driven by a set of dysfunctional phobic beliefs that the sufferer has developed DSM-5 diagnostic criteria for 12 SPECIFIC PHOBIA LIFETIME PREVALENCE rates for 13 common Specific Phobias Etiology of Specific Phobias 14  Psychoanalytic accounts  Classical conditioning & phobias  Biological accounts - evolution  Multiple pathways to phobias 1. Psychoanalytic Accounts 15 Little Hans: The psychoanalytic interpretation of a specific phobia One of the most famous cases in the history of psychoanalysis is that of ‘Little Hans’. Hans began to have a fear of horses, which eventually grew to the point that he refused to leave the house. The immediate event that precipitated this phobia was seeing a big, heavy horse fall down. Freud interpreted this to mean that Hans at that moment perceived his own wish that his father would fall down. Then Hans, a little Oedipus, could take his father’s place with his beautiful mother. Another part of the fear derived from the large size of horses, which Hans unconsciously identified with the great power of his father. 2. Classical Conditioning The ‘Little Albert’ Experiment 16 The Little Albert Experiment (youtube.com) Problems with conditioning 17 accounts of phobias  Many people with phobias cannot recall a traumatic event in the history of their phobia  Not all people who have a traumatic conditioning experience develop a phobia  Phobias only appear to develop in relation to certain stimuli and events (e.g. heights, snakes, etc.)  A conditioning model cannot account for the phenomenon of incubation 3. Evolutionary Accounts Of Phobias 18  Biological preparedness (Seligman, 1971)  Non-associative fear acquisition (Poulton & Menzies, 2002) Biological Preparedness 19  Evolutionary selection pressures have developed biological predispositions in us  These predispositions enable us to learn to quickly fear certain stimuli that were hazardous to our ancestors (e.g., heights, snakes, water, etc.)  Supported by human classical conditioning studies using ‘fear-relevant’  Supported by studies of conditioned snake fear in laboratory-bred rhesus monkeys Non-associative fear acquisition 20  Argues that fear of a set of biologically relevant stimuli develops naturally after early encounters in childhood  Following repeated exposure to these stimuli, fear would normally habituate  Explains why most children go through developmental stages where they fear a range of stimuli  Adult phobias are instances where these childhood phobias have failed to habituate Problems with evolutionary accounts 21  Very difficult to verify whether a phobic stimulus was ever an important selection pressure in the evolutionary past  Evolutionary accounts can be constructed in a post hoc manner and may be just adaptive stories (McNally, 1995)  Evolutionary accounts are tantalizingly easy to propose but very difficult to substantiate 4. Multiple Pathways to Phobias 22  Different types of phobias may be acquired in quite different ways  Processes involved may include: Classical conditioning The disgust emotion Misinterpretation of bodily sensations & panic Classical conditioning 23  There is evidence that the following phobias are caused by traumatic classical conditioning: Dog phobia Dental phobia Choking phobia Accident phobia  However, many other phobias are NOT characterized by a traumatic onset: Most animal phobias Height and water phobias Treatment of phobias 24 Treatments include:  EXPOSURE THERAPIES, including:  Systematic Desensitization (can be done also with Virtual Reality)  Flooding  Counterconditioning (seen in Part 2.2. Therapeutic techniques)  COGNITIVE THERAPY TECHNIQUES  ONE-SESSION RAPID TREATMENTS  Virtual Reality for fear of Heights https://www.youtube.com/watch?v=66JreCaEr20&t=50s  COGNITIVE- BEHAVIOR THERAPY FOR PHOBIAS 25  In the Behavioral Paradigm, maladjustment is the result of erroneous conditioning of stimuli  Systematic Desensitization (COUNTER CONDITIONING)  therapy for specific anxieties in which anxiety-producing stimuli are presented in a progressive fashion along with an incompatible response (usually deep muscle relaxation)  EMDR  Flooding or implosive therapy (EXTINCTION)  therapy for responses where SD does not work Systematic Desensitization in Fear of Flying 26 Systematic Desensitization using Virtual Reality 27  https://www.youtube.com/watch?v=Yw0_1ZjxWCM Flooding 28 Flooding is a technique in which the individual is exposed directly to a maximum-intensity anxiety- producing situation or stimulus, either described or real, without any attempt made to lessen or avoid anxiety or fear during the exposure. Flooding techniques aim to diminish or extinguish the undesired response to a feared situation or stimulus and are used primarily in the treatment of individuals with phobias and similar disorders.  29 SOCIAL ANXIETY DISORDER SOCIAL ANXIETY DISORDER 30  Social Anxiety Disorder is distinguished by a severe and persistent fear of social or performance situations.  People with social phobia try to avoid any kind of social situation in which they believe they may behave in an embarrassing way or in which they believe they may be negatively evaluated.  DSM-5 Diagnostic criteria for 31 SOCIAL ANXIETY DISORDER Prevalence of Social Anxiety Disorder 32  Lifetime prevalence rate of 4%  Afflicts females more than males  Age of onset is typically mid-teens  Persistent disorder  Lowest overall remission rate of main anxiety disorders  Important cross-cultural factors Social Anxiety Disorder explained for beginners - how I wish I was taught - YouTube Etiology of Social Anxiety Disorder 33  Genetic factors  Familial & developmental factors  Cognitive factors 1. Genetic factors 34  Evidence from twin studies for a genetic component  Submissiveness, anxiousness, social avoidance and behavioural inhibition have genetic component  Estimates of genetic component vary drastically between 13-76% because of methodological differences (Moreno et al., 2016) 2. Familial & developmental factors 35  Related to behaviourally inhibited style in childhood (Neal et al., 2002) but not a sufficient condition for social phobia  Influence of parent-child interactive style Exert greater control Show less warmth Are less sociable Use shame as a method of discipline 3. Cognitive factors 36  Information & interpretation bias  Interpret performance significantly more critically  Show self-focused attention  Indulge in excessive post-event processing of social events Social phobia & self-criticism 37 Treatment of Social Anxiety Disorder 38  Cognitive Behavioral Therapy Exposure therapy Social skills training Cognitive restructuring  Drug treatments Monoamine oxidise inhibitors (MAOIs) Selective serotonin reuptake inhibitors (SSRIs) Differential for social anxiety as a SYMPTOM 39 PSY3460-D.MANOS  40 PANIC DISORDER AND AGORAPHOBIA PANIC DISORDER 41  Panic Disorder is characterized by:  repeated panic attacks  followed by at least 1 month of worrying about further attacks  significant modification of behaviour designed to avoid further attacks  42 DSM5 Criteria for PANIC DISORDER PSY3460-D.MANOS 43 DSM-5 diagnostic criteria for a 44 diagnosis of AGORAPHOBIA PANIC DISORDER AND 45 AGORAPHOBIA  Although the two diagnoses often go together, they are two distint syndromes  Panic Disorder may occur without agoraphobia  i.e. person has equal fear of having another panic attack no matter what the context  Agoraphobia can exist without Panic Disorder  i.e. when person fears and avoids places for fear of a different event (not panic attack) such as urinating or fainting  Note that in order to diagnose Agoraphobia the person must fear/avoid at least TWO different situation types Prevalence of Panic Disorder and 46 Agoraphobia  1.5% - 3% Panic Disorder 0.4% - 3% for Agoraphobia  Onset common in adolescence or early adulthood  Onset often associated with a period of stress  Culturally determined variance (e.g., Ataque de Nervios) Etiology of Panic Disorder & 47 Agoraphobia  There are a number of psychological theories of panic disorder Classical conditioning The role of safety behaviours Anxiety sensitivity Catastrophic misinterpretation of bodily sensations We will focus on the last two theories.  ANXIETY SENSITIVITY 48  Anxiety sensitivity is fear of anxiety symptoms based on beliefs that such symptoms have harmful consequences  For example, that a rapid heartbeat predicts a heart attack  Individuals with panic disorder score significantly higher on measures of anxiety sensitivity Example items from the Anxiety Sensitivity Index (ASI-R) (Taylor & Cox, 1998). 49  When I feel like I’m not getting enough air I get scared that I might suffocate  When my chest feels tight, I get scared I won’t be able to breathe properly  It scares me when I feel faint  When my throat feels tight, I worry that I could choke to death  It scares me when my heart beats rapidly  It scares me when my body feels strange or different in some way  I think it would be horrible for me to faint in public CATASTROPHIC MISINTERPRETATION 50 OF BODILY SENSATIONS  Panic attacks are precipitated by individuals catastrophically misinterpreting bodily sensations as threatening  Individuals with panic disorder: Attend to their bodily sensations more than others Will interpret ambiguous signs as threatening Have panic attacks triggered merely by the expectancy of an attack Clark’s (1986) Model of Panic Disorder 51 52 Treatment of Panic Disorder 53  Cognitive Behaviour Therapy (CBT) Exposure treatment Cognitive restructuring of dysfunctional beliefs about bodily sensations  Medication  Antidepressants and benzodiazepines A typical 54 Treatment Program for Panic Disorder  Education about the nature and physiology of panic attacks  Breathing training designed to control hyperventilation  Cognitive restructuring therapy to identify and challenge dysfunctional beliefs  Interoceptive exposure to reduce faulty threat perceptions of harmless bodily sensations  Prevention of ‘safety’ behaviors that may maintain attacks and avoid disconfirmation of faulty beliefs VIDEOS 55  Alternative way of Dealing with Panic Disorder https://www.youtube.com/watch?v=of6xObz3aK4  56 GENERALIZED ANXIETY DISORDER GENERALIZED ANXIETY DISORDER 57 (GAD)  Characterised by physical symptoms of anxiety  Pathological worrying is a cardinal diagnostic feature  Worrying is perceived as uncontrollable by the sufferer  Worrying is closely associated with catastrophizing Assessment GAD7 DSM-5 diagnostic criteria for GAD 58 Prevalence of Generalized Anxiety Disorder 59  Lifetime prevalence rate of 3.7%  Twice as common in women as in men  Frequently comorbid with major depression  Associated with significant impairment in psychosocial functioning role functioning work productivity health-related quality of life Etiology of Generalized Anxiety Disorder 60  Biological theories  Information processing biases  Beliefs, meta beliefs & the function of worrying  Dispositional characteristics of worriers 1. Biological theories 61  Evidence that both anxiety generally and GAD specifically have an inherited component  Growing neuroimaging evidence suggests prefrontal brain regions may be involved  Focus on possible abnormalities in emotional regulation in GAD sufferers 2. Cognitive theories 62 Information processing biases in GAD  Individuals with GAD preferentially allocate attention to threatening stimuli  Preferential allocation occurs to both verbal and visual stimuli  This attentional bias occurs at both the conscious and unconscious level  This attentional bias may actually cause anxiety 3. Beliefs, metabeliefs & the function of 63 worrying  Individuals with GAD hold strong beliefs that worry is a necessary thing to do  These beliefs motivate worriers to persist with their worrying  Worry may be reinforced because it prevents the sufferer from experiencing other negative emotions 4. Dispositional characteristics of 64 worriers  Individuals with GAD exhibit the following characteristics that may maintain their worry: Intolerance of uncertainty High perfectionism Treatment of Generalized Anxiety Disorder 65  Pharmacological treatment  Stimulus control treatment  Cognitive behaviour therapy (CBT)  Pharmacological 66 treatment  50% of GAD sufferers receive initial treatment with antidepressants such as SSRIs or SNRIs  Only around 35% are treated with anxiolytics such as the benzodiazepines  GAD is regularly comorbid with depression and SSRIs tend to be better tolerated than benzodiazepines  Lack of longitudinal outcome studies PSY3460-D.MANOS  Stimulus control treatment 67  Learn to identify worrisome thoughts.  Distinguish these from necessary or pleasant thoughts related to the present moment.  Establish a half-hour worry period to take place at the same time and in the same location each day.  When you catch yourself worrying, postpone the worry to the worry period and replace it with attending to present moment experience.  Make use of the half-hour worry period to worry about your concerns and to engage in problem solving to eliminate those concerns. PSY3460-D.MANOS Cognitive Behaviour 68 Therapy (CBT)  CBT for GAD normally consists of a number of elements: Self-monitoring Relaxation training Cognitive restructuring Behavioural rehearsal Mindfulness training  69 OBSESSIVE COMPULSIVE DISORDER (OCD) OBSESSIVE-COMPULSIVE DISORDER (OCD) 70  Obsessions Intrusive, recurring thoughts that the individual finds disturbing and uncontrollable (e.g., causing harm to someone you love)  Compulsions Repetitive or ritualized behaviour patterns that the individual feels driven to perform in order to prevent a negative outcome from happening DSM-5 diagnostic criteria for OCD 71 (now separate from Anxiety DOs) TYPES OF COMPULSIONS 72  Compulsive checking (e.g., of doors and windows)  Compulsive washing (to prevent contamination and infection)  Superstitious ritualized movements or thoughts (e.g., Counting backwards till a thought has gone)  Systematic arranging of objects  Compulsive hoarding Prevalence of Obsessive Compulsive 73 Disorder  Lifetime prevalence rate is around 2.5%  Onset is usually gradual  Frequently manifests in early adolescence following a stressful event or life period  Females more frequently affected than men OCD-RELATED DISORDERS 74  DSM-5 divides OCD-type problems into a number of separate diagnostic categories: Body dysmorphic disorder Hoarding disorder Hair-pulling disorder (trichotillomania) Skin picking disorder What it´s like to live with OCD https://www.youtube.com/watch?v=p5EItATGNGA&list=PLi7iNjjRRCAEP8oqm g1T9pHuB9xWwtdJ8&index=42&t=236s Etiology of Obsessive Compulsive 75 Disorder  Biological factors  Psychological factors Thought-action fusion Mental contamination Thought suppression Family Accommodation & Excessive Reassurance Seeking Perseveration and the role of mood Biological factors 76  High concordance for OCD in monozygotic twins (80-87%) compared with dizygotic twins (47-50%)  Family relatives of individuals with OCD are also more likely to have a diagnosis of OCD than non- family controls  Around 37% of children with autism spectrum disorder (ASD) also suffer diagnosable OCD symptoms  OCD symptoms are often associated with abnormalities in the basal ganglia area of the brain Psychological Factors 77 Thought-Action Fusion  The belief that simply having unpleasant, unacceptable thoughts can influence events in the world  This leads to thought suppression and generates distress & anxiety  TAF related to degree to which an individual assigns importance to thoughts, which has been shown to be related to religiosity and superstition Psychological Factors Mental Contamination 78  The experience of extreme feelings of dirtiness provoked without any physical contact with a contaminant  Can be caused by images, thoughts, and memories  Tends to be caused by a violation of some kind by another person, e.g., degradation, betrayal, emotional abuse, physical abuse or humiliation  Individuals also experience anxiety, disgust, shame, anger, guilt, and sadness Psychological Factors Family Accommodation & Excessive 79 Reassurance Seeking  Family Accommodation refers to family members directly participating in a sufferer’s OCD compulsions and rituals  Excessive Reassurance Seeking is the repeated solicitation of safety-related information from carers or family members – a form of checking by proxy Psychological Factors 80 Perseveration & the Role of Mood  Individuals with OCD are often in negative moods  They use their moods to determine whether they have met the goals of their task (e.g., checking)  Their negative mood suggests they have not met the goal – so they continue to persevere  This is known as the mood-as-input hypothesis (MacDonald & Davey, 2005) Treatment of Obsessive Compulsive 81 Disorder  Exposure & Ritual Prevention (EPR)  Cognitive Behaviour Therapy (CBT)  Pharmacological & neurosurgical treatments Exposure & Ritual Prevention (ERP) 82  The most common and most successful treatment for OCD  Involves graded exposure to the thoughts that trigger distress, followed by the development of behaviours designed to prevent the individual’s compulsive ritual. Example of ERP Exposure Hierarchy Example: FEAR OF CONTAMINATION (distress level/100) 83 1 Touch rim of own unwashed coffee cup. (30) 2 Touch rim of partner’s unwashed coffee cup. (40) 3 Eat snack from dish in cupboard after touching partner’s unwashed coffee cup. (45) 4 Drink water from partner’s glass. (55) 5 Eat snack straight from unwashed table top. (65) 6 Have coffee at a café. (70) 7 Have meal at a restaurant. (80) 8 Touch toilet seat at home without washing hands for 15 mins. (85) 9 Touch toilet seat at home without washing hands for 30 mins. (90) 10 Use public toilet. (100) Example of ERP Response 84 Prevention Strategies OCD Symptom Checking lights, switches, oven, etc. Response Prevention Strategies Response delay Use of ritual restrictions (e.g., restrict number of checks) Turning and walking away Extension strategies (whistle a happy tune) Cognitive Behaviour Therapy (CBT) 85  Dysfunctional beliefs are challenged using CBT Responsibility appraisals The over-importance of thoughts Exaggerated perception of threat  Integrated therapy for OCD would consist of: Educating clients that intrusive thoughts are quite normal Focusing on changing the client’s abnormal risk assessment Providing the client with behavioural exercises that will disconfirm their dysfunctional beliefs Pharmacological & Neurological 86 treatments  Short-term effective and cheap way of treating OCD  Relapse is common on discontinuation of the drug treatment  SSRIs are the most commonly prescribed drug VIDEOS 87  What´s normal anxiety and what are anxiety disorders https://www.youtube.com/watch?v=xsEJ6GeAGb0&list=PLi7iNjjRRCAE P8oqmg1T9pHuB9xWwtdJ8&index=34&t=10s  The Little Albert Experiment https://www.youtube.com/watch?v=9hBfnXACsOI  Virtual Reality for fear of Heights https://www.youtube.com/watch?v=66JreCaEr20&t=50s  What it´s like to live with OCD https://www.youtube.com/watch?v=p5EItATGNGA&list=PLi7iNjjRRCAE P8oqmg1T9pHuB9xWwtdJ8&index=42&t=236s  What is Hoarding Disorder? https://www.youtube.com/watch?v=Mgc_sql_dQE  Hoarders: Carol, before and after https://www.youtube.com/watch?v=M6EU33oK6hg  READ: Epidemiology of Specific Phobia GAD in general practiotioners during the COVID 19 pandemic 88 PSY 3460- D. Manos