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Panic & Anxiety Disorders - Coggle Diagram
Panic & Anxiety Disorders
Fear and Anxiety Response Patterns
Fear
: A basic emotion, an alarm reaction that involved the activation of the "fight-or-flight" response of the automatic nervous system in response to
immediate danger
Panic attack
: When the
fear response occurs in the absence of any obvious external danger
. This is often accompanied by a subjective sense of impending doom, including fears of dying, going crazy, or losing control
Three components
Cognitive/subjective components (e.g. "I'm going to die")
Physiological components (e.g. increased heart rate, heavy breathing)
Behavioural components (e.g. strong urge to escape or flee)
Anxiety
: General feeling of apprehension about
possible future danger
, meaning that at present, there is no danger, but the person fears a potential future danger that can happen in the next moment or further down the line.
Cognitive/subjective, psychological, and behavioural components
Many sources of fear and anxiety are learned
Basic fear and anxiety response patterns are highly conditionable
Overview of Anxiety Disorders and their Commonalities
Anxiety disorders
:
Unrealistic irrational fears or anxieties that cause significant distress and/or impairments
Specific Phobia: Strong and persistent fear that is triggered by the presence of a specific object or situation and leads to significant distress and/or impairment in a person's ability to function
Often show an immediate fear response that often resembles a panic attack
Go to great lengths to avoid encounters with phobic stimulus
Vary from mild anxiety to full activation of fight-of-flight response
Reinforced by avoiding stimulus
Blood-injection-injury phobia: Sight of blood or injury
Initial acceleration, followed by dramatic drop in both heart rate and blood pressure, followed by nausea, dizziness, or fainting
Highly heritable
Evolutionary purpose to inhibit further attack and to reduce blood loss
Prevalence: Common (12% of people at some point in lives), more common in women than men. Animal, dental, blood-injection-injury phobias begin in childhood, other phobias in early adolescence/early adulthood
Psychological causal factors
Psychoanalytic: Phobias is a defence against anxiety that stems from repressed impulses from the id. Because it is too dangerous to know the repressed impulse, the anxiety is displaced onto some external object or situation that has some symbolic relationship to the real object of the anxiety.
Behaviourism: Phobic behaviour is learned through classical conditioning. Fear response can be readily conditioned to previously neutral stimuli when these stimuli are paired with traumatic or painful events. Once acquired, these phobic fears would generalise to other similar objects and situations. This can also be due to vicarious conditioning, where observing a phobic person behave fearfully with their phobic object results in the transference of the phobia to another person. Use
behavioural therapy
to treat.
Individual differences in learning: Some experiences may serve as risk factors while others may serve as protective factors, resulting in whether conditioned fears or phobias develop
Prepared learning: Humans are evolutionary prepared to associate certain objects with frightening events. These prepared fears are ore easily acquired or especially resistant to extinction.
Biological causal factors
Genetics
Carriers of the s allele, a variant of the serotonin-transporter gene, show superior fear conditioning than those without the s allele
Carriers of the COMT met/met genotype did not show superior conditioning but showed enhanced resistance to extinction
Temperament
Neuroticism
Inhibition at higher risk of developing specific phobias by 7 to 8 years of age
Treatment
Exposure therapy
Participant modelling: Therapist models how to interact with phobic stimulus in a calm manner
Medications: Only to offset anxiety symptoms
Social Anxiety Disorder (Social phobia): Disabling fears of one or more specific social situations. There is an underlying fear of exposure to scrutiny and potential negative evaluation by others
Performance
: There is a real evaluation (e.g. public speaking)
Non-performance
: Just being in public (e.g. going to a public place)
Prevalence: 12% of population at some point in their lives. More common among women. Typically begins in adolescence or early adulthood. Often present with other anxiety disorders.
Psychological causal factors:
Behaviourism: Social anxiety as learned behaviour originating from direct or vicarious classical conditioning (being or witnessing someone else being a target of anger or criticism, or experiencing or witnessing a perceived social defeat or humiiliation)
Evolution: Evolutionarily-based predisposition to acquire fears of social stimuli that signal dominance/aggression from other humans, such as facial expressions of anger or contempt
Perceptions of uncontrollability and unpredictability: Exposure to stressful events that were uncontrollable and unpredictable could lead to submissive and unassertive behaviour.
Cognition: Tend to expect that others will reject or negatively evaluate them
Biological causal factors
Temperament: Behavioural inhibition (babies who are easily distressed by unfamiliar stimuli and who are shy and avoidant)
Treatment
Cognitive and behavioural therapies
Prolonged and graduated exposure to the feared situation
Cognitive restructuring: Therapist helps clients to identify their underlying negative thoughts and change them through logical reanalysis
Medications: Antidepressants. Cognitive-behavioural therapy is more long-lasting with lower relapse rates
Panic Disorder: The occurrence of panic attacks that often come out of the blue
DSM-5 criteria: Recurrent, unexpected attacks and persistently concerned about having another attack or worried about the consequences of having an attack for at least a month
Full-blown panic attack: Abrupt onset of at least 4-13 symptoms
Agoraphobia
: Fear of open gathering places
Anxious about being in places where it would be difficult to escape, or in which immediate help would be unavailable if something bad happened
Frightened by own bodily sensations
May not even be able to leave their own homes
Now a distinct disorder as many patients do not experience panic
Prevalence: 20s-40s, sometimes teen years. Twice as prevalent in women as compared to men.
Comorbidity with other disorders: Have at least one comorbid disorder (generalised anxiety disorder, social anxiety, specific phobia, PTSD, depression, and substance-abuse disorders, suicidal ideation)
First panic attack: Occurs following feelings of distress or some highly stressful life circumstance. Most adults who have experienced at least one panic attack in their lifetimes do not develop a full-blown panic disorder
Biological causal factors
Genetic: Moderate heritable component. 30-34% of the variance in liability to panic symptoms is due to genetic factors
Brain structure: amygdala (collection of nuclei in front of the hippocampus) is critically involved in the emotion of fear. The theory is that panic disorder is likely to develop in people who have abnormally sensitive fear networks that get activated too readily
Biochemical abnormalities: Individual who are more likely to experience panic attacks when exposed to various biologically challenging procedures (panic provocation procedures) compared to normal subjects
Noradrenergic and serotonergic systems most implilcated in panic attacks, GABA recently shown to be implicated in anticipatory anxiety
Psychological causal factors
Cognitive theory of panic: People with panic disorders are hypersensitive to their bodily sensations and tend to catastrophise the meaning of these bodily sensations. These frightening thoughts may cause more physical symptoms of anxiety, resulting in a vicious cycle culminating in a panic attack
Comprehensive learning theory of panic disorder: Panic attacks become associated with initially neutral internal (interoceptive) and external (exteroceptive) cues through an interoceptive /exteroceptive conditioning process. This leads anxiety to become conditioned to these conditioned stimuli. The more intense the panic attack, the more robust the conditioning that will occur.
Can develop Anticipatory anxiety and agoraphobic fears
May generalise the conditioned responding to other similar cues
Panic attacks themselves can be conditioned to certain internal cues. Panic attacks can thus come out of nowhere, as long as a person unconsciously experiences certain internal bodily sensations that have become conditioned stimuli
Anxiety sensitivity and perceived control: People with high levels of anxiety sensitivity (trait-like belief that certain bodily symptoms may have harmful consequences) are more prone to developing panic attacks and panic disorders. Simply having a sense of perceived control can reduce anxiety and even block panic attack
Safety behaviours and the persistence of panic: The engagement of safety behaviours before or during an attack would lead individuals to believe that the lack of catastrophe to having engaged in the safety behaviour, rather than to the idea that there is simply a lack of catastrophe. This perpetuates panic because there is no recognition that there is no catastrophe.
Cognitive biases and the. maintenance of panic: Tend to interpret ambiguous bodily sensations as threatening, and ambiguous situations as more threatening. Tend to automatically pay more attention to threatening information in their environment
Treatment
Behavioural and cognitive-behavioural treatments
Prolonged exposure to feared situations (effective in 60-75% of people with agoraphobia)
Interoceptive exposure: Deliberate exposure to feared internal sensations
Panic control treatment (PCT): Targets agoraphobic avoidance and panic attacks
Education about nature of anxiety and panic and how the capacity to experience both is adaptive
Teaching breathing control
Taught about logical errors and subject their own thoughts to logical reanalysis
Exposed to feared situations and bodily sensations to build up tolerance to discomfort
Medications
Antianxiety medications from the benzodiazepine category (e.g. alprazolam (Xanax), clonazepam (Klonopin)).
Work very quickly for acute situations of intense panic or anxiety.
Undesirable side effects, such as drowsiness or sedation, and developing dependency.
Antidepressants
No dependency, can alleviate any comorbid depressive symptoms or disorders.
3-4 weeks for effects. Side effects include dry mouth, constipation, blurred vision for tricyclics, interference with sexual arousal for SSRIs). Relapse rates are high when drugs are discontinued.
SSRIs more widely prescribed as they are better tolerated.
Generalised anxiety disorder (GAD): Living in a future-oriented mood state of anxious apprehension, chronic tension, worry, and diffuse uneasiness that they cannot control. They frequently engage in subtle avoidance activities like checking and procrastination
Prevalence: 3%, tends to be chronic. Twice as common in women as men. Most can still function despite their symptoms.
Comorbidity with other disorders: Co-occurs with other disorders, especially anxiety and mood disorders. Can also have panic disorder.
Psychological causal factors
Psychoanalytic: Generalised or free-floating anxiety results from an unconscious conflict between the ego and the id impulses. Theory abandoned
Perceptions of uncontrollability and unpredictability: History of experiencing important events in their lives as unpredictable or uncontrollable. Also may be more likely to have had history of trauma in childhood. Less tolerance for uncertainty.
Sense of mastery: Experiences with control and mastery over important events help to buffer
Reinforcing properties of worry: Think the benefits of worrying are a superstitious avoidance of catastrophe, avoidance of deeper emotional topics, coping and preparation
When people worry, emotional and physiological responses to aversive imagery are suppressed. It also insulates the person from fully experiencing or processing the topic that they are worrying about, so the anxiety continues.
Negative consequences of worry: Worrying can lead to greater sense of danger and anxiety and ore negative and intrusive thoughts.
Cognitive biases for threatening information: Biased processing with prominent danger schemas. More likely to think that bad things are likely to happen in the future and to interpret ambiguous stimuli as threats.
Biological causal factors
Genetics: Heritability about 30%, neuroticism
Neurotransmitter and neurohormonal abnormalities
GABA functionally deficient in the highly anxious
Corticotropin-releasing hormone (CRH)
Neurobiological differences between anxiety and panic
Generalised Anxiety: More diffused emotional state than acute fear or phobia. Smaller hippocampal region.
Treatment
Cognitive-behavioural treatment
Medication
Benzodiazepines for tension relief, reduction of other somatic symptoms, relaxation
Antidepressants
Causes
Psychological
Classical conditioning of fear, panic, or anxiety to a range of stimuli
Perceptions of lack of control over either their environments or their own emotions
Biological
Temperament: Neuroticism (Disposition to experience a negative mood state)
Neurotransmitters: GABA, norepinephrine, serotoninv
Brain structure: Limbic system
Sociocultural: Environment in which people are raised has prominent effects on the kinds of objects and experiences people become anxious about or come to fear
Treatment
Exposure therapy is the most powerful
Cognitive restructuring
Medications (except specific types of phobias): Antianxiety medications and antidepressant medications
OCD and Related Disorders
OCD: Occurrence of both obsessive thoughts and compulsive behaviours performed in an attempt to neutralise such thoughts
Obsessions: Persistent and recurrent intrusive thoughts, images, or impulses that are experienced as disturbing, inappropriate, and uncontrollable
Compulsions: Overt repetitive behaviours that are performed as lengthy rituals. May involve more covert mental rituals
Psychological causal factors
Behaviourism: OCD as learned behaviour.
Preparedness: Evolutionary
Suppress obsessive thoughts
Responsibility for intrusive thoughts
Cognitive biases: Attentional bias toward disturbing material relevant to obsessive concerns
Biological causal factors
Genetics: Moderately genetic heritability
Brain structure: Abnormalities in basal ganglia (controls emotional behaviour), abnormally high activity levels in orbital frontal cortex and cingulate cortex/gyrus
Neurotransmitter abnormalities: Increased serotonin activity and increased sensitivity of some brain structures to serotonin
Treatment
Behavioural and cognitive-behavioural treatments
Exposure and response prevention: Have clients repeatedly expose themselves to stimuli that provoke their obsessions and then refrain from engaging in the ritual that they would have to reduce their anxiety or distress
Medications: Those that affect the serotonin system
Clomipramine (Anafraniil) and fluoxetine (Prozac)
High relapse rates
Related
Body dysmorphic disorder (BDD): Obsessed with some perceived or imagined flaw or flaws in their appearance to the point they firmly believe they are disfigured or ugly
Symptoms: Compulsive checking behaviours, avoidance of usual activities due to fear of flaws being seen. Frequently seek reassurance from loved ones on appearance, but do not have effect.
Treatment: Similar to OCD
Hoarding disorder: Acquire and fail to discard many possessions that seem useless or of very limited value, in part due to the emotional attachment they develop to their possessions
Trichotillomania: Compulsive hair pulling