PSYCH 300 Midterm 2 PDF

# 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...

# 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) and you have to experience distress and/or impairment ## Importance of Anxiety Disorders 1. **Prevalence** * They're 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** * Patients in primary care settings (who go to the doctor) (DSM-III): * 18% (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 at 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, generalised 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 marital discord because they seek reassurance or are more financially dependent etc., which places a burden on relationships 6. **Often under-recognized and undertreated** ## Etiology 1. **Biological contributions** * **Genetics** * Non-specific, generalised 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 recall 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:** behavioural ratings of anxiety in second speech * **Found** that children whose mothers were overprotective and controlling displayed greater levels of anxiety in second speech * **Concluded** that over-involved, controlling parental behaviours produces lack of confidence and anxiety, shaped self-confidence and self-esteem * **Critical-hostile parenting** * Emotional abuse (berated, criticised) is especially bad * **Neglectful parenting** (physical or emotional) * **Modeling / Vicarious learning (parental anxiety)** * Good combination: one parent who is more anxious and another who is not = balances each other out * **Peer influences** * Anxiety disorders are negatively associated with school popularity (the less popular they are, the more likely they are to have an anxiety disorder) * Anxious kids tend to be overlooked which takes a toll on the child * Anxiety is associated with peer victimisation: bullying (especially during puberty), exclusion * Girls tend to exclude or cyberbully * The boys tend to physically bully other boys * Bad treatment enhances anxiety — vicious cycle ## Barlow's Triple Vulnerability Model * **Genetic predisposition** * **General psychological vulnerability:** general sense that the world is an unsafe place (e.g. if you grew up in an environment where you did not feel safe) * **Specific psychological vulnerability:** specific set of events that shape the form of the anxiety disorder ## Types of Anxiety Disorders (DSM-5-TR) 1. **Panic disorder (PD)** * **Pan:** Greek god who would leap out and yell at those who disturbed his nap * **Unexpected terror** * 30% of people will have a panic attack at some point in their lives but may not develop PD * **Diagnostic features** * **Recurrent, unexpected panic attacks** * **Panic attack:** sudden rush of symptoms, intense, peaks within minutes (goes away fairly quickly) * **Physiological** * Palpitations, pounding heart, or accelerated heart rate; chest pain * Shortness of breath, smothering; feeling of choking * Dizzy, unsteady, lightheaded, faint * Nausea or abdominal distress * Trembling or shaking * Sweating * Paresthesias (numbness or tingling) * Chills or hot flushes * **Psychological** * Derealization (feelings of unreality) * Depersonalization (being detached from oneself) * Fear of losing control, going crazy or dying * **Panic itself subsides but feelings of anxiety may stay** * **A critical symptom:** sense of choking or unable to get enough air * **Diagnosis requires** * At least 5 symptoms listed above * Before: anticipatory anxiety * After: worry about the consequences of the attack * **Significant behaviour change** * **Situational**—avoid situations they associate with triggers for panic attacks * **Internal sensations**—If someone feels a symptom associated with panic attacks they think another one will occur, e.g., avoid walking up the stairs to avoid a faster beating heart/getting out of breath * **Safety behaviours** - e.g. carrying anti-anxiety medication * **Subtypes of panic attacks** * **Cued** (situationally bound—confined to certain situations with certain triggers) * **Situationally predisposed** (e.g. someone with social anxiety may only have panic attacks in certain situations) * **Unexpected**—required for diagnosis of panic disorder * **Limited symptom attacks**—people may have some symptoms of a panic but not enough to be diagnosed * **Prevalence** * 1 in 3 people experience a panic attack * Only 3% meet the criteria for panic disorder * **Biological contributions** * **Biological challenge studies** — manipulations that increase CO2 * Infusions of lactic acid * Carbon dioxide inhalation * **Biological theorists** * Neurochemical disturbance * 30-40% genetically transmitted * E.g. suffocation false alarm theory: hypersensitivity to detecting carbon dioxide (chemoreceptors) * **Cognitive contributions** * In biological challenge studies, if told "sensations are not harmful", they are less likely to panic * **Catastrophic misinterpretations of one's physical sensations (fear of fear)** — person associates bodily sensations with bad things = spiralling of anxiety which surmounts to a panic attack * E.g. interpreting heart beating as dangerous and something bad is going to happen = get more anxious = breathe less properly * **/Cognitive model/** * **Trigger (internal or external)** * Catastrophic Misinterpretations * Perceived Threat * Apprehension * Bodily Sensations (Anxiety) * **Treatment** * Medications may have side effects, i.e. bodily sensations which could trigger panic attacks * CBT is the first line of treatment * **Education** —e.g. recognising signs of panic attacks and acknowledging that it is nothing dangerous * **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 0.81 and agoraphobia of 0.61 * **Biological preparedness: evolutionary influence of certain phobias (used to explain prepared learning)** * Phobias are often what used to be actual dangers for palaeolithic humans (e.g. snakes, rats, enclosed spaces, water, heights) * Idea is that humans are vulnerable to certain fears * Early exposure to these events/objects may help (e.g. giving child swimming lessons so they aren't afraid of water) * **Learning contributions** * **2-factor learning theory** * **Step 1: classical conditioning.** * **Step 2: operant conditioning (conditioned fear can be strengthened through a process of negative reinforcement)** * **Rachman 3 pathways** * Direct conditioning * Vicarious conditioning (e.g. becoming afraid of storms because parents were afraid of storms) * Informational transmission (able to pick up fears through media like Jaws the movie = fear of sharks) * 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 inmate vulnerability (biological predispositions whether genetics or evolutionary) and learning experiences * Results in exaggerated threat perceptions — people with phobias tend to have maladaptive thought processes regarding the object/situation they're afraid of * Leads to avoidance and other safety behaviours * **Contemporary models - safety behaviours** * Deliberate * Adopted to prevent negative outcome * Unnecessary * Exercising of safety behaviours reinforces the belief * **First line treatment** * **Cognitive modification** —to change maladaptive thought processes * In vivo (in real life) exposure * Graduated (step-wise) * Virtual reality exposure * **Treatment - hypothesised mechanisms (why does 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 behaviour, body odour, intense gaze etc. (Japan, Korea) * **Hikikomori:** severe social withdrawal (aka failure to launch) (Japan) * People from Asian cultures (especially China and Korea) report more social anxiety but have lower rates of social phobia —more accepting of being shy, quiet and reserved = less stigma, so it doesn't impair them as much * **Impairment** * **Social:** avoidant personality (people and other things like novel things), hikikomori (60% of men with social phobia don't marry), less social support, fewer friends, lonelier * **Education:** may choose professional career based on interaction with people * **Occupational:** underemployment (tend to go less far in their jobs than they should) * **Comorbidity:** risk factor for depression (usually precedes onset of depression), substance abuse (most strongly predicts marijuana abuse/dependence—25% of those who use marijuana have SAD) * **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 * Judgemental biases * 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 5. **Generalised anxiety disorder (GAD)** * **Excessive worry** * Number of events * Excessive and unreasonable * Difficulties controlling worry ("can't stop thinking") * **Has to be accompanied by at least 1 of 5 physiological symptoms** * One distinguishing feature is muscle tension * Other symptoms include restlessness, fatigue, difficulty concentrating, irritability and sleep disturbance * **Worry themes** * One clue is whether the person worries about minor things * Excessive in relation to the person's current life experiences * **Prevalence** * Culture * 0.9% adolescents * 2.9% of adults * More common in people of European descent and in developed countries * Presence of mental health care = greater diagnosis * Gender * Slightly more common in women * Time course * Start earlier * Amount of worry waxes and wanes depending on underlying stress * Genetic * Small heritability coefficient of .33 * But genetic risk factors overlap almost completely with depression—runs in the same families as people who are depressed * 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 emphasise 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. visualising 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 * **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 * **Exposure therapy:** * Experience anxiety in a controlled environment to practice distress tolerance and reduce anxiety sensitivity ## Disorders of Obsessions & Preoccupations (Chap 6) ### Somatic Symptom and Related Disorders **Learning Outcomes** * 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 utilisation * 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 recognised neurological or medical conditions * E.g. No muscle atrophy in someone who claims they are paralysed * Holding eyes closed when you try to open them when they're having a "seizure" * Normal EEG * **Clinical picture** * Prevalence: rare in general population, 30% of neurology referrals * Gender: 2:1 women to men * Onset: under stress * Prognosis: short duration, better, can reoccur if stress reappears * **Aetiology** * Lower SES and less education or medical literacy * Major life stress * Not uncommonly found in people with religious beliefs (e.g. God can paralyse you) * Symptoms have to make sense in their context * Social acceptance of symptoms * **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 * Engaing 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 region 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 doesnt strain your back if you think it hurts = can result in muscle atrophy) * Reliance on analgesic medication (e.g. pain killers) * Seeking medical reassurance * Avoidance-constricted lifestyle (e.g. support/accommodation given at work will perpetuate behaviours) * **Reinforcement** * **Medication - SSRIs for comorbid anxiety & depression** * **Cognitive-behavioural** * Caution about dismissing concerns * Education * Address triggering stress/trauma event * Evaluate pain beliefs * Activity resumption * **Self-management** * Relaxation training * Reduce reassurance-seeking * 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 * 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 * **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 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 be 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 Outcomes** * 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