PSYCH 300 Midterm 2 - Anxiety Disorders

# Anxiety Disorders (Chap 5) ## Physiological Arousal: A Universal Human Experience - Innate fear system - Marked by HPA activation - Affects multiple brain regions - Affects every organ system in the body - Essential for survival ## Concepts Related to HPA Activation ### (1) Str...

# Anxiety Disorders (Chap 5) ## Physiological Arousal: A Universal Human Experience - Innate fear system - Marked by HPA activation - Affects multiple brain regions - Affects every organ system in the body - Essential for survival ## Concepts Related to HPA Activation ### (1) Stress - Response to perceived demands (problems) - Objectively demonstrable problem - Outweigh coping abilities ### (2) Fear - Present-oriented - Response to actual danger - Compared to stress there is something to actually fear - Surge in sympathetic nervous system (fight/flight response) - Strong urge to escape ### (3) Panic - Sudden rush of intense fear and physiological symptoms (fight or flight) - Short, intense HPA activation - No objective danger - False alarm ### (4) Anxiety - Also known as apprehension/apprehensive anxiety - Future-oriented - Possible future threat - Physical tension ## Anxiety vs Anxiety Disorders - When Does It Become a Disorder? When it's very: - Intense - Frequent - Excessive or unreasonable (reaction is exaggerated, exaggerated threat perception) - You have to experience distress and/or impairment ## Importance of Anxiety Disorders ### (1) Prevalence - They are the most prevalent condition - Single largest mental health problem in North America - General population (DSM-III) - 24.9% lifetime prevalence - 16.4% 12 month prevalence - 18% (Patients in primary care settings) - Even excluding specific phobias - Non-cardiac chest pain: 40% have panic disorder (PD) - Focal epilepsy: 19% develop comorbid anxiety disorder (e.g., anxious they will have another seizure, or social phobia of having a seizure in public) - Present in all cultures but prevalence varies: 12 month prevalence (DSM-IV) - Europe: 8.4% - USA: 22% - Australia: 5.6% - China: 13% - Canada: 5.8% (PD, Agoraphobia, SAD only) - Francophone: 3.85, Anglophone: 4.89 - More common in European, especially those with Anglophone backgrounds - Could be because these typically are wealthier countries where mental health care is more readily available - Tiwari & Wang (2006): Examined cultural groups within Canada - Canadian Community Health Survey - Residents > 13 years old - Self-reported heritage - 33,399 Euro (10% immigrants) - 733 Chinese (84.5% immigrants) - 1,113 other Asian (86%) - Found that people of European backgrounds seemed to be a higher risk of anxiety disorders than other groups in Canada - Consistent in anxiety disorders and depression - Issues with research - Definitions of culture, ethnic heritage - Any gold standard? - Ethnicity vs culture - A lot of Canadians consider themselves bi-culture - Controlling for generational status - By third generation, people resemble Canadian culture more than their ethnic culture - Grouping of heritage groups - "Asian" vs "European" - Lumping all Asian cultures together etc. disguises differences - Southern European cultures differ from Northern European cultures in anxiety disorders - Emotion terms don't translate well from one language to another - E.g. Social anxiety disorder (SAD) - Some cultures it means fear of other people, or paranoia - Interestingly, generalized anxiety disorder or worry, seems to be universal ### (2) Often Chronic ### (3) Cause Significant Personal Impairment ### (4) Risk Factors for Other Disorders (Depression, Suicide, Substance Use, Etc.) - 31% comorbid for another anxiety disorder - 50% also have depression - Increased risk of substance disorder - Possible links with suicide - Multiple health conditions ### (5) Economic Burden for Society - E.g. higher chance of martial discord because they seek reassurance or are more financially dependent etc., which places a burden on relationships ### (6) Often Under-Recognized and Under-Treated ## Etiology ### (1) Biological Contributions - **Genetics** - Non-specific, generalized predisposition - Negative affectivity (formerly "neuroticism") - Family studies done - Confounded with the environment, modeling etc. - Twin studies - Concordance rate for MZ vs DZ twins - MZ twins = identical, DZ twins = fraternal - If one twin has the disorder, what is the probability that the second twin does? - If concordance rate in MZ is not 100%, another contributor must be present - Across the anxiety disorders, overall concordance rates (heritability ratio) range from 12-26% for MZ twins and 4-15% for DZ twins - Low rates for genetic propensity for most anxiety disorders, but higher heritability for some phobias like blood-injury-injection phobia - Weak genetic propensity for anxiety disorders - **Biochemical - Neurotransmitter** - Depleted GABA or dysfunctional GABA system - Serotonin theories where the circuits may be dysfunctional and therefore not balancing other systems - Corticotropin-releasing factor (CRF) which is believed to activate the HPA axis - Both GABA and serotonin theories have quite a bit of support - **Brain Circuits** - Most studies looking at brain regions associated with anxiety focus on a fear network involving the: - Amygdala - Ventromedial prefrontal cortex (vmPFC) - Hippocampus - Brain-imaging studies show - Hyperresponsive amygdala - Deficient cortical control, less activity in PFC which especially deactivates the amygdala - Studies therefore suggest that fear centres increase arousal and executive system is not holding it in check - Hypothesized links with anxiety disorders - Amygdala responsivity -> abnormal threat assessment - Triggers excessive HPA activation - Insufficient vmPFC function - Inability to recal extinction information (i.e. absence of aversive stimulus) - Abnormal hippocampal function - Reduced capacity to distinguish safe and dangerous cues - can't tell when person is in danger vs safe - Increased contextual conditioning - Insensitivity to cortisol ### (2) Environmental Contributors - Those who are reactive to environmental cues and who are raised in supportive environments do better - But if you are reactive and raised in negative environments, you are more likely to develop anxiety disorders - Anxiety disorders in childhood: - Between 2.5% and 5% of children meet criteria for an anxiety disorder - Subclinical anxiety is more widespread and may lead to later anxiety disorder - 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: behavioral 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 a 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 victimization: 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 | Vulnerability | Description | |---|---| | 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 - **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. recognizing signs of panic attacks and acknowledging that it is nothing dangerous - 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 ### 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.81 and agoraphobia of .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) - 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 Behaviors** - 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 - Hypothesized Mechanisms (why does it work?)** - **Reconsolidation:** reactivate the fear memory & store with fewer emotion connections - **Extinction learning:** (aka inhibitory learning) develop new memory store associated with fear stimulus - **Cognitive change:** reduce selective attention to threat through safety learning, i.e., not focus on the fear ### 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** - Prevalence = 1.7% - Heritability = 61% - **Impairment** - Stay in safe zones, can become housebound - Interpersonally - Tend to be clingy and dependent on significant others because they believe they need them to feel safe ("safe person") - Tends to have a chronic course - in the absence of treatment, it persists, does not typically remiss - **Treatment** - CBT is the first-line treatment - Education - Relaxation & breathing instruction - In vivo exposure - Safety behaviour fading - SSRIs are an option - **Treatment Research** - North American vs European models - Treatment difficulties ### 4. Social Phobia/Social Anxiety Disorder (SAD) - Marked or persistent fear of one or more social or performance situations - **Performance** e.g., eating in public, public speaking, but since so many people are afraid of public speaking, many question if it should be considered a disorder - Fears doing something humiliating or embarrassing and being negatively evaluated - Subtype: performance only: e.g., singing in public - **Prevalence:** - 4th most prevalent disorder after depression, alcoholism and specific phobias - High prevalence in North America - 8.1% of Canadians - Lower elsewhere - Europe = 2.3% - Prevalence is the same in children (one of the most difficult childhood disorders to treat along with OCD), adolescents, and adults - **Time Course** - Onset at age 13 (pubescent age being the peak of bullying or heightening of self-awareness) but can begin earlier - **Gender** - More prevalent in women in community populations - Men are more likely to seek treatment - **Culture Influences** - **Taijin kyofusho:** fear of offending other people via behavior, 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) - **Biological Contributors:** - **Genetic**: - Nonspecific vulnerability - Behavioural inhibition: innate hypersensitivity to environmental change (stronger physical reaction to any change in the environment) - Higher physiological reaction to angry and disgusted faces - **Cognitive-behavioural (learning) contributors** - Mothers who are more attentive to the child they are more likely to get over their phobias or less likely to develop anxiety disorders - Negative life events - Negative self-beliefs - Negative predictions - Selective attention - Safety behaviours (e.g. not self-disclosing) - **Treatment** - **Selective serotonin reuptake inhibitors (SSRIs)** - **CBT** - Behavioural experiments to test negative beliefs - Try things in social situations - **Treatment outcomes** - Time course: medication response in ~6-8 weeks but CBT takes longer (months) - Relapse: 43% for medication and 17% for CBT - Usually there's improvement but hard to completely remove - Innate hypersensitivity -> Developmental experiences -> Negative self-beliefs -> Negative predictions -> Biased Judgment -> Safety behaviors -> Selective attention ### 5. Generalized Anxiety Disorder (GAD) - **Excessive worry** - **Number of events** - **Excessive and unreasonable** - **Difficulties controlling worry ("can't stop thinking")** - **Has to be accompanied by at least 1 of 5 physiological symptoms** - One distinguishing features is muscle tension - Other symptoms include restlessness, fatigue, difficulty concentrating, irritability, and sleep disturbance - **Worry Themes** - One clue is whether the person worries about minor things - Excessive in relation to the person's current life experiences - **Prevalence:** - 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 - **DSM-V said GAD is a form of depression** - **Speculation that GAD occurs in people with underactive GABA-benzodiazepine system** - **Cognitive-behavioural models** - **Maintaining factors: cognitive avoidance (Borkovec)** - People with GAD used cognition to avoid thinking about things that are very important - Found that people with GAD have less physiological reactivity/arousal except for muscle tension compared to people with panic disorder - Although they are worried, they have less arousal than other anxiety disorders - Worry about images - more verbal than pictorial - Focus on future not present events serves as distraction from fear - Talking to yourself (e.g. "What am I gonna wear? What if I'm early? What if I'm late?") and worrying verbally distracts yourself from serious events that may be happening in life (e.g., if a family member is sick) - Came up with the idea of using cognitions to avoid genuine emotions - **Intolerance of uncertainty (Durgas)** - People get anxious when there are uncertain situations - People with GAD often have erroneous beliefs about worry - more likely to believe that worry is useful - Poor problem orientation - people with GAD could generate solutions to problems but afraid to implement them - Also emphasize cognitive avoidance - people worry to avoid a deeper fear - Came up with the Why Worry questionnaire - Found that people with GAD believe that if they worry they will be less upset when something actually happens but it actually has no protective function at all (therefore a dysfunctional belief) - They also believe that worrying has a planning function but found that this actually keeps individuals from actually implementing problem solutions - In reality, if you worry about something you're more likely to procrastinate - **Safety behaviours of people with GAD: overpreparation** - **Treatment** - **Dugas & Robichaud: CBT for GAD** - Have people keep track of their worries and then ask them to divide those worries - **Worry discrimination:** Type 1 (controllable) and Type 2 (uncontrollable hypothetical situations) - **Type 1: exercise problem solving** - **Type 2: focus on increasing tolerance for uncertainty** - **Exercises to engage in actions without preparation** - Reduce reassurance-seeking - Exposure to most feared outcome - E.g. visualizing your fear/writing out a loved one getting into a car accident and reading it over and over till emotion drains out of the imagined scenario ## Disorders of Obsessions & Preoccupations (Chap 6) ### Somatic Symptom and Related Disorders - **Learning Objectives:** - Be able to distinguish Factitious Disorder, Malingering & Somatic Symptom Disorders - Be able to distinguish between various somatic symptoms disorders - Be aware of clinical picture in various disorders - Be familiar with models & treatments - **Critical conceptual distinction:** - **Malingering:** deliberate faking - Usually some financial/legal gain from faking - **Factitious disorder:** deliberate faking for no apparent gain other than attention - **Somatic symptom disorder:** genuine belief - **Somatic Symptom Disorders** - Typically present first in non-psychiatric settings - May occur in as many as 17-20% of individuals seeking hospital or outpatient medical treatment - Often comorbid with PTSD, depression - Further exacerbate pain and pain beliefs - Very difficult to diagnose - Pain and some physical symptoms inherently subjective phenomenon - DSM places emphasis on presentation, interpretation and impairment rather than pain - Somatic symptom disorder (per se) - Somatic symptoms are distressing or result in disruption of daily life - Excessive thoughts, feelings and behaviours related to symptoms - Disproportionate - High anxiety - Excessive time devoted to health - Focus on symptoms themselves - **Multiple vague symptoms** - Chronic complaints and person's life begins to revolve around symptoms - Predominant complaint: "I'm in pain" but vague, gets worse with events - **Clinical Picture** - Suffering is "authentic" - Often fuels avoidance - Catastrophizing thoughts - High level of medical care utilization - Usual medical care does not alleviate symptoms - Explanatory therapy (detailed explanation and reassurance) can be effective for mild cases - **Prevalence:** estimated 5-7% in general population - **Onset:** predictors are body checking, catastrophizing beliefs about pain, negative affect, activity avoidance (which causes weakening of muscles = more physical sensations) - **Culture:** affects how people express their somatic symptoms - idioms of distress can vary (e.g., "my body has too much heat", "burning in head") - **Impairment** - Work impairment - E.g. Fired because they cannot go to work - Substance abuse - Prescription opioids - Cannabis - Alcohol - Can become housebound - Take on role of an invalid ### Illness Anxiety Disorder - Used to be called hypochondrias - Preoccupation with having a serious disease that has gone undetected - Minimal somatic symptoms if any - High level of anxiety and low threshold for "sickness" - Excessive health-related behaviours - Duration - E.g., checking (cyberchondria), internet searches, reassurance-seeking all of which perpetuate their fear - Clinical picture - Prevalence uncertain: 1-5% in general population - Gender: similar in males and females - Course: chronic waxing and waning - Impairment: social, occupational ### Conversion Disorder (Functional Neurological Symptom Disorder) - One or more symptoms of altered voluntary motor or sensory function (neurological) - Incompatibility with recognized neurological or medical conditions - No muscle atrophy in someone who claims they are paralyzed - 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 recur if stress reappears - **Aetiology:** - Lower SES and less education or medical literacy - Major life stress - Not uncommonly found in people with religious beliefs (e.g. God can paralyse you) - Symptoms have to make sense in their context - Social acceptance of symptoms - **Aetiology of somatic symptom and related disorders** - **Physiological contributions** - Often involves presence of some biological symptoms - Caution: unrecognised medical conditions (e.g. Parkinson's, multiple sclerosis) - Pain sensitivity - Family aggregation - May be a small heritable components but shared with anxiety disorders - Negative affectivity - **Psychodynamic perspective** - Trauma or extreme stress - Defence mechanisms: repression, conversion, symbolism - Quasi-resolution - **Cognitive-behavioural perspective** - (Likely) Learned through experience of the illness they think they have - Develop illness concerns - Heightened vigilance - Contemporary anxiety - stressful event prior to onset of development - Attentional focus on symptoms of anxiety - Misinterpretation of symptoms that they're actually ill - Study asked: "your heart is beating firmly, why? - 4 options: - 1) You have been exercising - 2) You are having a heart attack - 3) You are excited -4) You are showing early signs of heart disease - Someone with panic disorder will likely choose 2) and those with somatic concerns would pick 4) - **Dysfunctional beliefs and interpretations** - Pain catastrophizing (e.g. I worry all the time whether the pain will end, I can't keep it out of my mind) - **Neural matrix mode** - Pain processing is genetically based - there are areas of the brain that detect pain - But this can be modified by experience - Engaging in cognitive activity that amplifies pain signals (like catastrophic interpretations, focusing on pain), sensitises neural mechanisms - Processes become increasingly automatic/under neural control - You'll automatically focus on such sensations - Anxiety prospectively predicted pain intensity - Listening to sad music increased pain intensity in back pain patients - Experimentally-induced negative emotions led to activity in brain regions associated with pain - I.e. You can teach yourself to be more sensitive to pain and some point this can become unconscious/automatic - **Dysfunctional safety behaviours that perpetuate concern** - Self-assessment activities (i.e. constantly checking for lumps or "abnormal" marks) - Excessive guarding and protection of injury (e.g. walking in a way that doesn't strain your back if you think it hurts = can result in muscle atrophy) - Reliance on analgesic medication (e.g. pain killers) - Seeking medical reassurance - Avoidance-constricted lifestyle (e.g. support/accommodation given at work will perpetuate behaviours) - **Reinforcement** - **Treatment** - Medication - SSRIs for comorbid anxiety & 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 -> Cognitive therapy: Challenge thoughts, reduce body vigilance and reduce focus on medications, alter core health beliefs, learn about normal sensations - Behavioral therapy: Replace the avoidance and reassurance-seeking with adaptive coping skills and problem-solving -> 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** - Prevalence: unknown - Course: intermittent episodes - Onset: under stress - **Factitious disorder by proxy:** when people create medical symptoms in someone else - Rare - **Signs** - Child has a history of many hospitalisations - Often with a strange set of symptoms - Worsening of the child's symptoms generally is reported by the mother and not witnessed by the hospital staff - Child's reported condition and symptoms don't agree with the result of diagnostic tests - Most people who do this are women (mothers etc.) - There might be more than 1 unusually illnesses or death of children in the family - Child's condition improves in the hospital but symptoms recur when the child returns home - Blood in lab samples might not match the blood of the child - There might of signs of chemicals in child's blood, stool or urine - Child can die by maltreatment by parent who just wants attention ### Obsessive-Compulsive Spectrum Disorders - **Learning Objectives:** - Why are the OCD-spectrum disorders separated from the anxiety disorders? - What are the primary types of OCD? - What are the biological contributions to OCD? - What are the biological treatments for OCD? - What are the psychological contributors to OCD and treatments for OCD? - What are the other OCD-spectrum conditions? - **OCD-Spectrum:** - Obsessive-Compulsive Disorder (OCD) - Body Dysmorphic Disorder - Hoarding Disorder - Trichotillomania (compulsive hair pulling) - Excoriation (compulsive skin-picking) - **Why do we distinguish OCD-spectrum disorders from anxiety disorders?** - **1. Different underlying neurocircuitry** - **Anxiety Disorders:** amygdala-cortical connectivity - fear system is overactive and prefrontal cortex that regulates fear is underactive - **OCD:** overactive fronto-striatal circuitry - **2. Distinct symptom patterns:** - **In OCD:** repetitive thoughts and compulsive behaviours, very difficult to control compulsive behaviours - To diagnose this condition, patient typically needs to engage in compulsive behaviour for at least 1h a day - **In anxiety:** safety behaviours but the person can usually control these behaviours - **3. Comorbidity among the OCD spectrum disorders** - Those with OCD are more likely to have body dysmorphic disorder and hoarding disorder - **OCD:** - **Marked by obsessions:** - Recurrent and persistent thoughts, impulses or urges - Experienced as intrusive and unwanted - Attempts to ignore or suppress or to neutralise with other thoughts or with actions - **Most common:** contamination, repugnant (unacceptable) thoughts (usually involve sex, violence or blasphemy) (moral OCD), harm, symmetry and everything has to be "just right". - **Compulsions** - 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 - Repetitive behaviours