Anxiety Lecture_01.23.2024_Student.pdf

Anxiety, OCD, and PTSD Abnormal Psychology MacEwan University January 23, 2024 Kirstyn Krause, PhD, R. Psych. Agenda Overlap across anxiety disorders, OCD, and PTSD Behaviours Physical sensations Thoughts Emotion Distinguishing between anxiety disorders, OCD, and PTSD Cognitive-behavioural treatment...

Anxiety, OCD, and PTSD Abnormal Psychology MacEwan University January 23, 2024 Kirstyn Krause, PhD, R. Psych. Agenda Overlap across anxiety disorders, OCD, and PTSD Behaviours Physical sensations Thoughts Emotion Distinguishing between anxiety disorders, OCD, and PTSD Cognitive-behavioural treatment Thoughts (Examining the evidence) Behaviours (Exposure therapy) PTSD treatments DSM-5-TR Anxiety Disorders Specific Phobia Social Anxiety Disorder Panic Disorder Agoraphobia Generalized Anxiety Disorder Others covered today Obsessive-Compulsive Disorder Posttraumatic Stress Disorder Cognitive-Behavioural Model Situation/Trigger Emotion Thoughts Behaviours Physical sensations Overlap Across Anxiety Disorders: Behaviours Escape Leaving the situation Avoidance Obvious Staying away from the situation Subtle Staying in the situation, but only under certain conditions (i.e., “safety behaviours”) Reassurance seeking Situation/Trigger Emotion Thoughts Note: Often facilitated by family members and friends. Behaviours Physical sensations Overlap Across Anxiety Disorders: Physical sensations Situation/Trigger Emotion PARASYMPATHETIC NERVOUS SYSTEM Thoughts Behaviours Physical sensations Photo from 2-minute neuroscience: sympathetic nervous system https://www.youtube.com/watch?v=FNHRSXe5do8 Racing thoughts: helps us make quick decisions Fight-Flight Response Tunnel vision: helps us see more clearly Dry mouth: The sympathetic nervous system is a built-in stress response in the body that helps us to respond to danger and problem-solve. digestion shuts down and sends energy to important muscles Heart beats faster: helps us If we don’t use up the extra oxygen through “fight” or “flight” we can feel dizzy Breathing gets faster: sends oxygen to important muscles Adrenaline: helps us respond quickly run away or fight Sometimes this response occurs even when there is no danger or problem to solve. For example, when we are very anxious or under prolonged stress. In this case, we need strategies to help calm down. Nausea: Stress can make us need to use the washroom Hands get cold: Palms become sweaty: helps us digestion shuts down and sends energy elsewhere blood sent to more important muscles keep cool Muscles tense: helps us run away or fight Adapted from Psychology Tools Overlap Across Anxiety Disorders: Panic attacks Abrupt surge of intense fear 7. Nausea/abdominal distress or discomfort that reaches a 8. Feeling dizzy, unsteady, lightpeak within minutes and is headed, or faint accompanied by at least 4 of 9. Chills or heat sensations the following symptoms: 1. 2. 3. 4. 5. 6. Heart pounding, accelerated heart rate Sweating Trembling or shaking Shortness of breath, smothering Feelings of choking Chest pain/discomfort Note: The abrupt surge can occur from a calm state or an anxious state 10. Numbness or tingling sensations 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself) 12. Fear of losing control or “going crazy” 13. Fear of dying Situation/Trigger Emotion Thoughts Expected Obvious cue or trigger DSM-5-TR Behaviours Unexpected No obvious cue or trigger Physical sensations Overlap Across Anxiety Disorders: Thoughts Probability Overestimation: thinking that a negative event is far more likely to occur than it actually is. Catastrophizing: jumping to the worst possible outcome Intolerance of Uncertainty: needing to be 100% sure of something before being able to “let it go” (Very common in GAD and OCD) Emotional reasoning: Assuming that negative emotions actually reflect reality “I feel it, therefore it must be true” All-or-nothing: Seeing things in black or white categories, rather than on a continuum Mind reading: Concluding that someone is reacting negatively to you without evidence Overgeneralization: Seeing a single event as a never-ending pattern Mental filter: Picking out a single negative detail and dwelling on it exclusively Disqualifying the positive: Rejecting positive experiences, insisting that they “don’t count” Situation/Trigger Emotion Thoughts Behaviours Physical sensations Adapted from D. Burns, Feeling Good Handbook, 1999 Overlap Across Anxiety Disorders: Emotion Fear vs. Anxiety Similarities Both can be experienced across anxiety disorders Differences Fear: Emotional response to real or perceived imminent threat Anxiety: Anticipation of future threat Surge of physical sensations associated with fight or flight response Thoughts of immediate danger Escape behaviours Muscle tension Vigilance Preparation for future danger Cautious or avoidant behaviours Situation/Trigger Note: We will return to the idea of “worry” when we speak about Generalized Anxiety Disorder DSM-5-TR Emotion Thoughts Behaviours Physical sensations How do we distinguish between anxiety disorders? The reason for the fear (e.g., What are you worried would happen if you went into that situation? What does your anxiety tell you will go wrong?) How do we distinguish between anxiety disorders? The reason for the “marked” fear or anxiety Specific Phobia Specific object or situation (e.g., flying, heights, animals, needles) Social Anxiety Disorder Social or performance situations (perceived or actual evaluation from others Panic Disorder Fear of having panic attacks, fear of their consequences Agoraphobia Fear of specific situations because belief that escape is impossible or difficult in the event of developing a panic-like or embarrassing symptoms Generalized Anxiety Disorder Worry about a number of events or activities (e.g., work, school, finances, future, health) DSM-5-TR Shared Diagnostic Criteria Specific Phobia Social Anxiety Disorder Agoraphobia DSM-5-TR 1. Intense or severe (i.e., “marked”) fear or anxiety 2. The feared situation almost always provokes immediate fear or anxiety 3. The feared situation is actively avoided or endured with intense fear of anxiety 4. The fear or anxiety is out of proportion to the actual danger posed 5. The fear or anxiety is persistent (i.e., > 6 months) 6. Clinical significant distress or impairment in social, occupational, or other important areas of functioning. 7. Not attributable to a substance or medical condition 8. Not better explained by another mental disorder Note: Less overlap for Panic Disorder and Generalized Anxiety Disorder Specific Phobia Feared Object or Situation Animal (e.g., spiders, insects, dogs) Natural environment (e.g., heights, storms, water) Blood-injection-injury (e.g., needles, invasive medical procedures) Often experience vasovagal fainting response (initial increase in heart rate followed by drop in blood pressure) Situational (e.g., airplanes, elevators, enclosed spaces) Others (e.g., choking, vomiting) Amount of fear may change depending on proximity to the object or situation Common to change life circumstances so that encountering the situation no longer occurs, leading to a lack of day-to-day fear or anxiety Potential reasons for development: Traumatic event, Unexpected panic attack in feared situation, Informational transmission DSM-5-TR Social Anxiety Disorder Fear of social situations due to negative evaluation Examples of avoidance, can be both obvious (e.g., avoiding the party) and subtle (e.g., avoiding eye contact) Associated features may include difficulty being assertive, inadequate eye contact, speaking softly, rigid body posture, little disclosure, blushing May affect life decisions Potential reasons for development Social inhibition or shyness History of social humiliation (e.g., bullying, vomiting during public speech) DSM-5-TR Panic Disorder Recurrent unexpected panic attacks Unexpected = no obvious cue or trigger Expected panic attacks can also be present Frequency and severity of panic attacks can vary widely At least 1 attack is followed by 1 month of 1. Persistent concern of worry about additional panic attacks or their consequences 2. Significant unhelpful change in behaviour related to attacks (e.g., avoidance) Anxiety sensitivity DSM-5-TR PsychologyTools Agoraphobia Fear of specific situations due to the belief that escape is impossible or difficult in the event of developing a panic-like or embarrassing symptoms 1. 2. 3. 4. 5. Using public transportation (e.g., car, bus, train, plane) Being in open spaces (e.g., parking lots, marketplaces, bridges) Being in enclosed spaces (e.g., shops, theaters) Standing in line or being in a crowd Being outside of the home alone Diagnosis requires fear of two of these situations Examples of avoidance Connection with panic disorder 30% of community samples have onset of panic attacks/panic disorder first 50% of clinical samples have onset of panic attacks/panic disorder first DSM-5-TR Generalized Anxiety Disorder (GAD) Excessive anxiety and worry occurring more days than not for at least 6 months about a number of events or activities Individual finds it difficult to control the worry Anxiety and worry are associated with 3+ symptoms (present more days than not) 1. 2. 3. 4. 5. 6. DSM-5-TR Restlessness or feeling keyed up or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance (e.g., difficulty falling or staying asleep, unsatisfying sleep, restlessness) Generalized Anxiety Disorder (GAD) What is worry? It occurs in the mind Mentally anticipating and preparing for/trying to prevent potential negative outcomes in future Typically start as “what-if” questions Focused on the future Always negative Robichaud and Dugas (2014) Generalized Anxiety Disorder (GAD) Beliefs about worry Belief Example Worry is a positive personality trait Worrying about the family finances shows that I’m a conscientious and organized person. Worry helps me problem solve Worrying about my tasks at work allows me to anticipate problems and solve them more efficiently Worry helps motivate me Worrying about my exams motivates me to study and do well in school Worry protects me from negative emotions Worrying about the health of my loved ones prepares me to deal with sadness and pain if anything bad should happen to them. Worry can prevent negative outcomes Every time I worry about my husband when he’s traveling for work, he comes home safe and sound. Robichaud and Dugas (2014) Generalized Anxiety Disorder (GAD) Problems with the diagnosis The name of the diagnosis Overlap of physical symptoms with other disorders (e.g., depression) Practice of assessing GAD last Obsessive-Compulsive Disorder (OCD) OCD is defined by two main symptom clusters: DSM-5-TR For a diagnosis of OCD, the obsessions and compulsions must be either time-consuming (e.g., they take up at least 1 hour of your time each day) or cause significant levels of distress and/or problems for you in your daily life (e.g., interfere with work, school, social life, daily responsibilities). Note: Research shows that everyone has intrusive thoughts. What’s the difference between obsessions in the general population and those experienced in OCD? How one reacts to or interprets the obsession. Those with OCD interpret the obsession as important or significant. Posttraumatic Stress Disorder (PTSD) CRITERION A: What is trauma according to PTSD? Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways 1. Directly experiencing the traumatic event(s) 2. Witnessing, in person, the event(s) as it occurred to others 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers exposed to child abuse) DSM-5-TR Other Definitions of Trauma: 1. Complex PTSD 1. Laypersons use of the word “trauma” Posttraumatic Stress Disorder (PTSD) Intrusive Symptoms Avoidance Recurrent, involuntary Memories Dreams Dissociation (e.g., flashbacks) Intense or prolonged emotional or physical reactions when reminded about the event Persistent avoidance of INTERNAL: Memories, thoughts, or feelings about the event EXTERNAL: People, places, conversations, activities, objects, situations about the event Negative changes to mood and thinking Changes to arousal and reactivity Can’t remember elements of the trauma Negative beliefs about self, others, world Blaming self or others for trauma Persistent negative emotions Inability to feel positive emotions Loss of interest Feeling detached from others Irritability/angry outbursts Reckless or self-destructive behaviour Hypervigilance Exaggerated startle response Problems with concentration Sleep disturbance Treatment Cognitive-Behavioural Treatment of Anxiety Situation/Trigger Emotion Cognitive Intervention: Examining the evidence Behavioural Intervention: Exposure therapy Thoughts Behaviours Physical sensations Overlap Across Anxiety Disorders: Thoughts Probability Overestimation: thinking that a negative event is far more likely to occur than it actually is. Catastrophizing: jumping to the worst possible outcome Intolerance of Uncertainty: needing to be 100% sure of something in order before being able to “let it go” (Very common in GAD and OCD) Emotional reasoning: Assuming that negative emotions actually reflect reality “I feel it, therefore it must be true” All-or-nothing: Seeing things in black or white categories, rather than on a continuum Mind reading: Concluding that someone is reacting negatively to you without evidence Overgeneralization: Seeing a single event as a never-ending pattern Mental filter: Picking out a single negative detail and dwelling on it exclusively Disqualifying the positive: Rejecting positive experiences, insisting that they “don’t count” Situation/Trigger Emotion Thoughts Behaviours Physical sensations Adapted from D. Burns, Feeling Good Handbook, 1999 Examining the Evidence What does my past experience tell me about the likelihood that my fear will come true? What do other people’s experiences tell me about my fears? Am I focusing too much on a few very memorable (but unlikely) events? Am I forgetting about relevant facts that would seem to disconfirm my fear? Have there been times when my predicted feared outcome did not come true? How might someone else look at this situation or intrusive thought? What have I learned about intrusive thoughts? Are my fears based on how I feel or based on actual circumstances? Am I confusing a high-probability event with a low-probability event? Adapted from Getting Over OCD: A 10-Step Workbook for Taking Back your Life, 2nd Edition by Jonathan Abramowitz © 2018 The Guilford Press What do you know about exposure therapy? Expectancy Violation What do I believe is going to happen? Exposure What actually happened? Exposure: Learning something new about the feared situation by confronting it in a planned, gradual way. Craske et al. (2014) Adapted from Getting Over OCD: A 10-Step Workbook for Taking Back your Life, 2nd Edition by Jonathan Abramowitz © 2018 The Guilford Press Guidelines for Exposure Exposure practices should be planned, structured, and predictable Exposure pace can be gradual (but it doesn’t have to be) Expect to feel uncomfortable Don’t fight your fear Continue each exposure until you’ve learned something Rate your fear and urge to escape on a scale from 0 to 100 Do not use subtle avoidance strategies during exposure Vary the setting of your exposure Adapted from Jonathan Abramowitz “Guidelines for Exposure” www.jabramowitz.com/resources-and-free-stuff.html Think of a possible exposure exercise for the following fears. Specific Phobia Fear and avoidance of dogs Social Anxiety Disorder Avoiding eye contact or self-disclosure at a party Panic Disorder Never exercising or drinking coffee Agoraphobia Walking everywhere instead of taking the LRT or bus Generalized Anxiety Disorder Requiring partner to always text when they’ve arrived at work ObsessiveCompulsive Disorder Avoidance of public washrooms due to contamination fear Evidence-Based Treatment of PTSD 1. Prolonged Exposure (PE) 2. Cognitive Processing Therapy (CPT) 3. Eye movement desensitization and reprocessing (EMDR) Simple explanation of each treatment: https://www.ptsd.va.gov/appvid/video/index.asp Bonus Info: Panic Disorder Remember this list of shared diagnostic criteria for specific phobia, social anxiety disorder, and agoraphobia? Specific Phobia Social Anxiety Disorder Agoraphobia DSM-5-TR 1. Intense or severe (i.e., “marked”) fear or anxiety 2. The feared situation almost always provokes immediate fear or anxiety 3. The feared situation is actively avoided or endured with intense fear of anxiety 4. The fear or anxiety is out of proportion to the actual danger posed 5. The fear or anxiety is persistent (i.e., > 6 months) 6. Clinical significant distress or impairment in social, occupational, or other important areas of functioning. 7. Not attributable to a substance or medical condition 8. Not better explained by another mental disorder Similarities to Panic Disorder Differences to Panic Disorder Criteria 1, 2, 3, 4, 6 are not explicitly outlined in the diagnostic criteria for panic disorder, however all of these criteria are still inherently part of the panic disorder presentation. Can you see how? Criterion 5 is 1 month instead of 6 months. Bonus Info: Generalized Anxiety Disorder (GAD) Remember this list of shared diagnostic criteria for specific phobia, social anxiety disorder, and agoraphobia? Specific Phobia Social Anxiety Disorder Agoraphobia DSM-5-TR 1. Intense or severe (i.e., “marked”) fear or anxiety 2. The feared situation almost always provokes immediate fear or anxiety 3. The feared situation is actively avoided or endured with intense fear of anxiety 4. The fear or anxiety is out of proportion to the actual danger posed 5. The fear or anxiety is persistent (i.e., > 6 months) 6. Clinical significant distress or impairment in social, occupational, or other important areas of functioning. 7. Not attributable to a substance or medical condition 8. Not better explained by another mental disorder Similarities to GAD Differences to GAD 1. Worry instead of fear 2. Anxiety and worry is present more days than not 3. GAD does not mention avoidance (although avoidance and safety behaviours are still prevalent in GAD) 4. Not mentioned in the criteria, but mentioned in the text.