Anxiety - Clinical Psych
- Created by: imanilara
- Created on: 30-01-19 09:12
Objectives
}To understand core concepts relating to anxiety }To become familiar with the main anxiety disorders }To learn about models of anxiety disorders }To learn about clinical approaches to anxiety disorders
What is anxiety?
Fear - adaptive response to a definite known threat - can manifest behaviourally/physiologically/cognitively
Anxiety - Generalised fear state without actual threat being present
Anxiety Disorder - Marked, persistent, distressing
Worry - Cognitive component of anxiety - streams of negative thoughts
How is anxiety measured
Continuous vs. categorical approaches
Continuous = a questionnaire - a scoring above 'x' indicates an anxiety disorder, e.g. GAD-7 "In the last two weeks how often have you experienced these symptoms?"
Categorical approach = an interview with someone, use DSM-V or ICD-1- align individual with specific criteria.
When does anxiety becomes an anxiety disorder + ho
- You have a range of symptoms over 6 months, e.g. three or more of the following: trouble sleeping, agitation, frustration, muscle tension
- Persists over a long time, i.e. 6 months
- Causes clinically significant distress - i.e. anxiety interferes with normal functioning and life.
Women more likely to get anxiety disorder over men
There are many different anxiety disorders, and often present comorbidly, i.e. anxiety and depression
Different anxiety disorders
- Agoraphobia - without a history of panic attacks
- Generalised anxiety disorder
- OCD
- Panic disorder - feeling like you are about to die, and a strong fear of these panic attacks
- PTSD
- Social anxiety disorder - worried about being embarrassed or humiliated in social situations
- Specific phobias - e.g.
- Arachnophobia - spiders
- Ophidiophobia - fear of snakes
- Acrophobia - fear of heights
- Claustrophobia - fear of small spaces
Fear learning as a model of developing fear (condi
- Pavlov 1927
- Watson and Rayner 1927
Before fear conditioning:
Neutral stimulus - CS
Aversive stimulus - UCS causes UCR (unconditioned response)
During fear conditioning:
CS repeatedly paired with UCS
CS starts to elicit fear response - CR
During fear extinction:
CS no longer repeatedly paired with UCS
CS no longer elicits conditioned response (CS)
Fear conditioning generalisation difficulties
Lissek et al - 2005 - the introduction of a safety cue
During fear extinction
CS no longer repeatedly paired with UCS
CS no longer elicits a conditioned fear response
- Anxious patients generalise fear to the safety cue and fail to inhibit fear, when the threat cue and the safety cue are two differently coloured squares on a screen
Anxious individuals show greater fear to the conditioned threat cue during conditioning
Anxious individuals show greater fear generalisation to conditioned safety cues
Anxious individuals do not extinguish fear quickly
Operant conditioning
Reinforcement:
- Any event that increases the likelihood of behaviour happening
- Positive reinforcers - +ve outcomes after behaviour
- Negative reinforcers - removal of an unpleasant outcome after behaviour
- In both of these cases behaviour will increase
Punishment:
- Adverse event or outcome that decreases likelihood of behaviour
- +ve punishment - present an unfavourable event
- -ve punishment - removal of favourable event
- Beh will decrease
Why do we need treatments
Cause distress and suffering – impairs the ability to function in daily life }Some have a chronic time course e.g., GAD remission rate after 5 years only 38% } The Relapse rate is high e.g., GAD relapse common at 3 years (27%) } }Often accompanied by mood disorders, heightened risk to self
Behavioural treatments of anxiety disorders
}Systematic desensitization – imaginal + relaxation (Wolpe, 1985) } The Repeated pairing of incompatible response (usually muscular relaxation) with thinking about the anxious situation (reciprocal inhibition) } }Led onto In vivo exposure – approach stimulus, in the hierarchy of fear (Mathews, 1978) i.e. rather than doing it in imagination - you apply in real life
Exposure therapy
1. Generate fear hierarchy - e.h. think about spider - look at a photo of spider - look at a real spider in a closed box etc.
2. Imagine or enter the feared situation
3. Stay imagining or in the feared situation until the anxiety reduces
4. Move onto next item on the hierarchy
Or flooding - start with the hardest part on hierarchy
Limitations of purely behavioural approach - 1977
Some people have traumatic experiences but do not develop a phobia
It is difficult to produce phobias experimentally - biological preparedness is important in experimentally developing a phobia - i.e. we are naturally afraid of spiders but not of a pencil - adaptive
Some situations more easily frightening than others
Some people develop phobias without having a traumatic experience
Phobias can be acquired vicariously, i.e. parents - no direct traumatic experience yourself
Cognitive behavioural therapy
Based on the cognitive theory of anxiety (Beck, 1967.1976)
* = threat appraisal
- People are upset not by events or situations which occur but by the personal meaning that these have for them - it depends on your interpretation - one might interpret a smile as a good sign, someone else might think that they are being laughed at
- When the meaning is negative, negative emotions result
Threat appraisals across disorders
Panic: imminent catastrophic danger indicated by bodily sensations Health anxiety: less imminent catastrophic danger indicated by medically relevant bodily sensations - check themselves very often and not reassured even after a doctor visit - negative interpretations and dismiss info that lets them know that they are healthy - focus also constantly changes - shifts from disease to disease Social anxiety disorder: imminent negative social judgement Obsessive-compulsive disorder: responsibility for harm, focused on intrusive cognitions - they check things repeatedly and driven by a strong sense of responsibility -they experience rituals and have clear images in their head of adverse consequences if they do not carry out these rituals
Generalised anxiety disorder: overestimation of threat, intolerance of uncertainty, negative interpretations - they worry about everything with lots of different topics - there must be at least two domains in life that are adversely affected and it is uncontrollable
PTSD: a current threat of harm, another trauma - nightmares + flashbacks - outside threat Phobias: imminent danger from an identifiable situation
Threat appraisals - neg interpretations
Clark et al 1997
Normal vs. those with anxiety disorder have a racing heart
Anxiety = something wrong with my heart vs. I'm excited
NEGATIVE INTERPRETATION
Cognitive-emotional processing biases - Mathews and Mcleod 1994
Interpretation bias
Attentional bias - selective attention to threatening stimuli
Interpretation bias
A tendency to interpret ambiguous stimuli as threatening rather than non-threatening
Recognition test - ambiguous sentences, e.g. the doctor examined Emily's "growth", an anxious person will assume a tumour but a non-anxious person will assume general growth
Lexical decision task - if you have anxiety, you will have a quicker response to a negative sentence ending than a non-negative sentence ending, because it has been primed in your mind
Panic disorder
- Lifetime prevalence - 3%, but 60% will experience a one-off panic attack
- Highest treatment seeking rates because the individual will often end up in A&E
- Higher in females than males
- Onset in early adulthood
Panic attacks - come on quickly, four or more of the following - tight chest, loss of control, shaking, choking, breathless
Panic disorder - Recurrent panic attacks and must have at least one PA followed by persistent worry of a future attack and causes significant adaptations in behaviour
Panic disorders
VICIOUS CYCLE: Sensation (heart racing, those is PD notice changes in heart rate quicker than those who don't have PD) - Interpretation ( I am having a heart attack, neg. interpretation) - Emotion (Anxiety - heart will race more - cycle).
The types of thoughts that drive panic are: "I will die", "I will stop breathing", "I will faint", "I will collapse", "I will have a heart attack" - as you attend to parts of your body, it makes you notice things that you didn't before and could lead to negative interpretation and worry.
Paired associates
Clarke -
Asked different Ps to read out a sheet with different words on it:
Breathlessness - Suffocate
Palpitations - Heart attack
Dizziness - Fainting
Numbness - Stroke
Panic patients: 80% experience a panic attack Anxious controls: 17% experience a panic attack
Healthy controls: 0% experience a panic attack
Thoughts can cause PA.
Maintenance of Panic Disorder
Negative interpretation (to bodily sensations, e.g. heart rate)
Then additional maintaining factors
Selective attention (to bodily sensations, e.g. heart rate) Avoidance(e.g. of activities, places, feelings and emotions) Safety behaviours (e.g. sitting down, taking deep breaths) - focus on breath makes it harder to breathe Behaviours or strategies to minimise the feared catastrophe, (Clark, 2001) Several unhelpful effects prevent disconfirmation of fear can increase the stimuli which are misinterpreted increase preoccupation and rumination
Behavioural experiments
Test out negative thoughts & beliefs Reproduce sensation to show cause }Paired associates }Hyperventilation }Focus of attention } Test consequences of feared sensations }Drop safety behaviours - i.e. of you usually sit-down, try standing up
Exposure to avoided situations / activities
Social anxiety disorder
Persistent fear and avoidance of social and performance situations
Prevalence is 12% - very common, 2:1 gender ratio F:M and often starts in adolescence
Afraid of looking anxious or embarrassing yourself, i.e. fear of blushing, fear of going blank, conversation, performing
It makes you fear the worst social situation which has negative indications of how people will value them
It leads to avoidance of social situations, e.g. going to parties, public speaking, dating etc.
Safety behaviours can cause more anxiety as it has a paradoxical effect - if you are nervous about blushing, hiding your face might draw more attention to you and adversely affect your social performance
Summary
•Anxiety: generalised fear state •Anxiety disorders: anxiety impairs functioning and causes significant distress and disability •Fear conditioning and operant conditioning – explain some anxiety disorders •Behavioural approaches e.g., graded exposure to feared stimuli •Complex anxiety disorders maintained by cognitive processes such as negative interpretations •CBT targets both cognitive and behavioural processes: e.g. panic disorder and social anxiety disorder
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