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Anxiety - Coggle Diagram
Anxiety
PTSD
Posttraumatic Stress Disorder
- Exposure to trauma (actual/threatened death, injury, sexual violence)
- Via experiencing / witnessing / learning / repeated exposure
- Re-experience event (intrusion) 1+: memories, dreams, flashbacks; psych distress to cues, physiological reactions to cues
- Avoidance 1+ of memories/thoughts/feelings or reminders
- -ve cognition & mood changes 2+: can't remember, -ve beliefs, blame, -ve emotional state, less interest in activities, can't experience +ve emotions
- Arousal & reactivity changes 2+: irritable/angry, reckless/self-destructive, hypervigilant, exag. startle response, can't concentrate, sleep disturbed
- >1m
- With dissociative symptoms: depersonalisation or derealisation
- With delayed expression: 6m+ after event
Acute Stress Disorder
- Similar but in first month after trauma
- Doesn't predict PTSD
Stats
- 2nd highest in Aus
- Higher if assaultive violence, directly/personally affected
- 10-15% who experience trauma (not all)
- Predicts suicidal attempts
- Course: chronic
Causes
- G bio (anxiety & stress) + G psych (uncontrollable) + trauma
- -> true alarm -> learned alarm
- Anxious apprehension (about re-experiencing emotions)
- -> Avoid / numb emotional response
- Social support + +ve coping strategies -> less cortisol/HPA -> less PTSD
- Stress-diathesis & reciprocal gene-env
Adjustment Disorder
- Anxiety/depression in response to stressful (not traumatic) life event
Treatment
Psych
- Imaginal exposure: work through content/emotions, prolonged expsoure
- CT: to correct -ve assumptions
Drugs
- SSRIs for anxiety & panic attacks
- DCS to augment CBT via fear memory reconsolidation (if good exposure)
Causes
Psych
-
-
Conditioning: stress/danger -> fear response -> assoc. with cues -> panic
- External cues:(places, situations) vs internal cues (heart rate, breathing)
- Cues may be unconcsious
-
Biological
Genetic: tendency to be anxious; to panic - diff genes!
- Collection of genes -> vulnerability -> env. turns genes on/off
Brain / NT
- Anxiety <-> less GABA, noradrenergic, serotonergic
- CRF -> activates HPA axis
- BIS in limbic -> receives messages down from cortex, up from brain stem -> freeze & evaluate => anxiety
- FFS in brain stem / midbrain -> alarm & escape => panic
- Limbic (amygdala) overly responsive + cortex deficiently down-regulating
- Env -> changes sensitivity in brain circuits (PFC & amygdala) -> more susceptible to anxiety disorders
Triple vulnerability theory of anxiety
- Generalised bio: inherit tendency for -ve affect (uptight/irritable/-ve)
- Generalised psych: believe uncontrollable / unpredictable / dangerous -> can't cope / low confidence & self-esteem -> poor mental health in general
- Specific psych: learn specific situations/objects/sensations dangerous
General model of anxiety
- True/false alarm -> learned alarm -> anxious apprehension -> disorder
Panic & Agoraphobia
Panic disorder
- Recurring, unexpected panic attack
- AND anxiety over another attack (worry or behaviour change)
- 1m+
- May be suicidal, have nocturnal panic, have agoraphobia
Agoraphobia
- Fear of 'unsafe' situations (PT, open spaces, enclosed spaces, lines/crowds, outside home alone)
- B/c escape hard or no help
- Avoided / require companion / endured with fear or anxiety
- Out of proportion
- Typically 6m+
- Notes
- 50% with panic attacks
- Interoceptive avoidance: avoid internal sensations resembling start of panic attack
Stats
- Gender / age: most female
- Onset / course: most early adult
- Culture: ataques de nervois (Hispanic), wind overload (Khmer & Vietnamese refugees)
Causes
- G bio (alarm tendency) + G psych + stress
- Learned alarm: assoc. with somatic sensations
- -> S psych: unexplained physical sensations dangerous
- Anxious apprehension: focused on somatic sensations
- Agoraphobia: socio/cultural/pragmatic factors + safety signals
Treatments
Psych = exposure
- Panic control treatment: exposure to sensations + CT + relaxation/breathing
- Exposure-based treatments: for agora
- Effective, but not available to most
Drug
- SSRIs: but sexual dysfunction
- Benzos: most used; work quickly but dependence
- Effective for 60% but half relapse when stopped
Combined
- No advantage
- Psych more effective long term
Social Anxiety
Features
- Fear of social or performance situations
- Social: conversation, new people, authorities, eye contact
- Performance (only): eating, drinking, giving speech, signing paper, blushing, urinating
- Fear that actions or anxiety symptoms will be -vely evaluated
- Avoided / endured with fear or anxiety
- Out of proportion
- Typically 6m+
Selective mutism
- Childhood disorder: lack of speech in 1+ settings (not all)
- 1+m (but not 1st month at school)
- Strongly related to SAD
- Treatment: speech-focused CBT
Stats
- Highest prevalence in Aus
- Gender / age: equal, less in older adults
- Onset / course: adolescence
- Culture: more single/white, Japan/Asia - fear personal reprehensible -> cause others to be embarrassed
Cause
- G bio: anxiety/social inhibition/both + G psych: uncontrollable + stress
- -> No alarm; false alarm or true alarm -> learned alarm
- -> Anxious apprehension
- -> S psych: social evaluation dangerous
Treatment
- Psych: cognitive therapy (experience disproves danger, confront actual consequences)
- Drug: SSRIs
- Combined: CT > SSRI, no benefit combining, DCS can make treatment effect quicker
Definitions
Fear: present, known/actual danger -> immediate action (fight/flight/freeze)
Panic: no danger -> fear response
- Panic attack: intense fear/discomfort + physical symptoms
- Neurobiological overreaction to stress
- Unexpected / uncued -> panic disorder
- Expected / cued -> specific phobias, SAD
- Nocturnal attack: 'let go' sensation
- Genetic response to stress, increased by anxiety
Anxiety: future, unknown/imagined danger -> physical symptoms + apprehension
- Enhances social/physical/intellectual performance
- If severe, doesn't go away with awareness
-
GAD
Causes
- G bio (anxious tendency) & G psych (sensitive to threat) + stress
- -> anxious apprehension & worry
- -> intense cognitive processing / can't problem solve
- and avoid images / restricted autonomic response
Treatments
Psych
- Brief treatments: 'processs' images & -ve affect -> feel -> stop worry
- CBT
- Meditation/mindfulness/relaxation
- Increase uncertainty tolerance, change maladaptive beliefs about worry
- Effective short term, more effective long term
Drugs
- Benzodiazepine
- Effective short, but not long term
- Impairs cognitive & motor function, psych/physical dependence
- Antidepressants - Paroxetine, Velafaxine (Effexor)
Features
- Minor everyday events
- Irritable, tense, restless, tired, can't concentrate
- 6m+
Stats
- Gender / age: more females/older adults
- Onset / course: early, gradual; chronic
Specific Phobia
Features
- Irrational fear of object / situation: animal, natural env, blood-injection-injury, situational, other
- Avoided / endured with fear or anxiety
- Out of proportion
- Typically 6m+
- Notes: most people have several phobias
Stats
- One of most common
- Gender / age: most female (males endure), less older adults
- Onset / course: most childhood, chronic
- Culture: more Hispanics, Chinese pa-leng (fear of yin/cold)
Cause
- G bio ('prepared' to fear objects/situations + low threshold for defensive reactions) -> runs in families
- Learned alarm: from direct or vicarious experience or taught/told (true alarm), or life stress / panic attack (false alarm)
- and S psych (specific object/situation is dangerous)
- -> G psych: anxious apprehension about future contact with object/situation
Treatment
Psych = exposure
- Structured, consistent - rewires brain
- Effective
Prolonged Grief
Features
- Death 12+m ago (6m+ for children/adolescents)
- Persistent grief response 1+: yearning/longing, preoccupation with thoughts
- Plus 3+: ID disruption, disbelief, avoidance or reminders, emotional pain, can't reintegrate relationships/activities, numbness, life meaningless, loneliness
- 1m+
- Not socioculturally normal
Stats
- 10% adults who experience grief - more with COVID
Cause
- Similar to other disorders
-
OCD
Features
- Obsessions: Intrusive/unwanted/persistent thoughts/urges/images (not object/situation), attempt to ignore/suppress/neutralise via C
- Compulsions: repetitive behaviour, behaviour/mental acts to prevent distress/event/situation - but not connected or excessive
- O, C, or both
- Time-consuming (1h+) or distress/impairment
- Types: symmetry/exactness, forbidden thoughts, cleaning/contamination, hoarding, + doubts/checking
- With good/poor/absent insight
- Tic-related: involuntary mvt - current/past history
Stats
- 1-2%, O & C along continuum
- Gender / age: equal
- Onset / course: from childhood to 30s, chronic
- Culture: similar across cultures
Cause
- G bio & G psych + stress
- -> Obsessions: intrusive thoughts/images/impulses
- -> S psych: excessive responsibility/guilt -> thought-action fusion (equate them)
- -> Anxious apprehension/alarms
- -> Compulsions to neutralise/suppress
Treatment
Psych
- Exposure & ritual prevention (ERP)
- CT
- Effective, but not ready available
Drugs
- SSRIs, modestly successful
Combined: ERP > drugsPsychosurgery: lesion to cingulate bundle (serious side effects) OR DBS (reversible)
Comorbidity
Physical disorders
- With thyroid, respiratory, gastrointestinal, arthritis, migraines, allergic
- Anxiety usually begins before physical disorder
Suicide
- Panic & PTSD have stronger relationship than mood & substance use
- GAD & SAD: more likely self-harm
Anxiety disorders
- Share bio/psych vulnerabilities & features of anxiety/panic
- High comorbidity with: anxiety, depressive, substance use
Treatment
Drug
- Benzodiazepine: short term, sedate, tolerance
- Antidepressant: less long-term effect (compared to CBT)
Psych
- Highly effective, 10-20 sessions
- Psychoeducation
- Relaxation
- CT: thought monitoring, thought challenging, mindfulness
- Exposure therapy
- +ve coping skills
Combined
- No advantage
- Maybe CBT & DCS -> helps learning/unlearning