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Flashcards in Anxiety Disorders Deck (45)
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1

Anxiety disorders are…

• Extremes of normal anxiety• Evidence of autonomic nervous system dysregulation - excessive, inappropriate or deficient• Common - Lifetime prevalence 15 -20%

2

Types of anxiety disorder

• Generalized Anxiety Disorder (GAD)• Panic Disorder• Agoraphobia• Social Anxiety Disorder (previously social phobia)• Specific Phobias• Obsessive Compulsive Disorder (OCD)• Body Dysmorphic Disorder (BDD)• Post Traumatic Stress Disorder (PTSD)• Selective Mutism• Separation Anxiety Disorder

3

What is the DSM-5 criteria for anxiety disorder

The DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder (which is included with the obsessive-compulsive and related disorders) or posttraumatic stress disorder and acute stress disorder (which is included with the trauma- and stressor-related disorders). However, the sequential order of these chapters in DSM-5 reflects the close relationships among them.

4

What are the shared features of anxiety disorders?

• Primarily stress linked• Reality testing remains intact• Symptoms are experienced as distressing• Disorders tend to be enduring or recurrent

5

What is aetiology of anxiety disorders

• Genetic– SLC6A4; short version transports serotonin less effectively (see Smoller et al., 2009)• Lowered neurotransmitter levels– 5HT, NA, GABA• Hypothalamic pituitary adrenal (HPA) axis dysregulation • Social factors– Early life adversity– Stressful events especially those involving threat– Lack of support network• Personality factors– Some personality traits predispose to certain anxiety disorders e.g. avoidant & perfectionistic

6

Parasympathetic Nervous SystemFeed and Breed

ANABOLIC PROCESSDecreased: cardiac rate and output, BP, respiration rate, glycogenolysis, peripheral diversion of blood, catecholamines and cortisol.Increased: gut function, kidney function, immune surveillance, fat stores, sex steroids

7

Sympathetic Nervous SystemFight or Flight

CATABOLIC PROCESSIncreased: cardiac rate and output, BP, respiration rate, glycogenolysis, peripheral diversion of blood, catecholamines and cortisol.Decreased: gut function, kidney function, immune surveillance, fat stores, sex steroids

8

“Fight or Flight”

• Physiological response to a stressor is mediated through the hypothalamus• Initial activation of the sympathetic nervous system• Subsequent activation of the pituitary adrenal axis• Terminated by negative feedback and the parasympathetic system NB ACTH is adrenocorticotropic hormone

9

Amygdala and Neurotransmitters

• Amygdala responds to emotional stimuli• Produce changes in the HPA axis and sympathetic ns.• GABA inhibits anxiety by modulating the amygdala and hypothalamus synapses e.g. benzodiazepines and alcohol act on same receptors.• Serotonin and beta-blockers also have an effect on anxiety

10

Post traumatic stress disorder (PTSD)

• Delayed or protracted response to trauma (often involving threat to life)• Onset usually within 6 months of event• Core symptom is “reliving the event”– Flashbacks, nightmares, waking dreams• Emotional numbness and detachment • Avoidance of activities, situations that remind person of trauma

11

Symptoms of PTSD

• Increased autonomic arousal (including exaggerated startle response, hypervigilance and sleep disturbance)• Avoidance & emotional numbing • Re-experiencing (flashbacks & nightmares)• Lifetime prevalence of 3-8%

12

DSM-IV-TR Diagnostic Criteria for PTSD

• The person has been exposed to a traumatic event• The traumatic event is persistently re-experienced• Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness• Persistent symptoms of increased arousal• Duration of the disturbance is more than 1 month• The disturbance causes clinically significant distress or impairment

13

Traumatic events that may precipitate PTSD

• Rape (90% develop PTSD symptoms)• Torture (70-90%)• Prisoners of war (>50%)• Earthquake & flood (20-25%)• Road traffic accidents (15%) (Davey, 2014)

14

It’s not all bad news though…

• > 50% of people will experience at least one trauma in their lifetime – not all will develop PTSD• Following trauma, women are more likely to develop PTSD than men (ratio of 2.4:1)• Some will experience post- traumatic growth (Joseph, 2012 )

15

The aetiology of PTSD

• Vulnerability factors• Theory of shattered assumptions• Conditioning theory• Emotional processing theory• Mental defeat• Dual representation theory

16

Vulnerability factors

• What makes people vulnerable to developing PTSD?– Tendency to take personal responsibility for the trauma– Environmental factors such as unstable family life– A family history of PTSD– Existing high levels of anxiety or a pre-existing psychopathology

17

Theory of shattered assumptions

• Argues that trauma will shatter a person’s belief in the world as a safe place• Individual is left in a state of shock and conflict• However, paradoxically it is those who already view the world as an unsafe place that are most likely to develop PTSD (Resick, 2001)

18

Conditioning theory

• Trauma (UCS) becomes associated with situational cues associated with the place and time of the trauma (CS) (Keane et al., 1985)• PTSD is therefore a conditioned fear reaction to cues associated with the trauma• However, does not explain why some people who experience trauma do not develop PTSD

19

Emotional processing theory

• Trauma creates a representation of the trauma in memory that is associated with situational cues (Foa et al., 1989)• Explains how fear memories are laid down and activated in fear networks in the brain• Has given rise to influential exposure treatments for PTSD

20

Dual representation theory

• Views PTSD as a hybrid disorder involving two separate memory systems (Brewin, 2001; Dalgleish, 2004)• The verbally accessible memory (VAM) system consciously processes memories of the event• The situationally accessible memory (SAM) system records information that is too brief to take in consciously• The SAM system is responsible for the vivid uncontrollable flashbacks experienced in PTSD

21

Mental defeat

• A frame of mind that makes individuals vulnerable to PTSD (Ehlers & Clark, 2000)• Individuals who develop PTSD tend to:– See themselves as a victim– Process information about the trauma negatively– View themselves as unable to act effectively– Do not believe they have the coping skills to overcome the traumatic experience– Believe the trauma has permanently changed their life

22

PTSD management includes

• SSRIs• Behavioural therapy• Stress innoculation training• Trauma focused CBT *• Eye movement desensitisation and reprocessing (EMDR) *• Debriefing after traumatic event *– no clear evidence base for thisNarrative exposure therapy

23

Trauma focused CBT

• See Ehlers & Clark (2000)• Psycho-education• Exposure; imaginal and/or In vivo• Reliving with cognitive restructuring• Behavioural experiments– Drop safety behaviours– Stimulus discrimination– Experience emotions• Imagery work

24

EMDR

• Developed by Francine Shapiro in the 1980s• Involves bilateral stimulation of the brain whilst recalling the traumatic event (dual attention)• Aims to desensitise the client to distress and reprocess ‘frozen’ traumatic memories so that the associated cognitions can become more adaptive - adaptive information processing Shapiro, 2007)• Works towards the installation of a positive cognition

25

Debriefing

• A structured way of trying to intervene immediately after trauma to prevent the development of PTSD• Also called Critical Incident Stress management (CISM) (Everly et al., 2000)• A form of post-event counselling for victims• Limited evidence that it is effective in preventing PTSD (McNally et al., 2003)

26

Narrative Exposure Therapy

• Development of testimony therapy (Cienfuegos & Monelli, 1983)• A short term approach• Developed for use with people who have experienced a series of traumatic events, resulting in PTSD (Schauer et al., 2005)• Aims to enable a coherent and meaningful narrative of events to be developed, influencing fear networks• Has been adapted for use with children – KIDNET (Onyut et al., 2005)

27

Anxiety Disorders in Children are...

 Anxiety disorders are one of the most prevalent emotional problems of childhood (e.g., Barrios & Hartmann, 1997) However, specific fears and anxieties are also one of the normal developmental challenges that face maturing individuals

28

The Features & Characteristics of Childhood Anxiety Problems

 Behavioural, cognitive and emotional aspects  Primarily manifested as withdrawn behaviour (internalizing) Children avoid activities and are clinging and demanding of parents and carers Anxious children report significantly more somatic complaints (Hofflich et al., 2006)

29

The Aetiology of Childhood Anxiety Problems

 Genetic Factors Trauma & Stress Experiences Modelling & Exposure to Information Parenting Style & Parent-Child Interaction

30

Genetic Factors of anxiety problems in children

 Twin studies suggest a significant but modest inherited component Both heritable and environmental factors appear to be important (Lichtenstein & Annas, 2000) May be different for specific anxiety disorders State vs. trait anxiety (Lau et al., 2006)