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Anxiety and its Disorders - Coggle Diagram
Anxiety and its Disorders
Background
When we talk about anxiety disorders, we distinguish between anxiety, fear, and panic.
Anxiety is a negative affective state associated with somatic symptoms
Anxiety is future-oriented, based on the inability to control or predict upcoming events.
Fear is characterised by strong nervous system arousal leading to escapist tendencies in response to danger that is PRESENT.
Panic is centred around panic attacks.
Situationally bound
Unexpected
Situationally predisposed
Components of anxiety include
Emotional response
Physiological response (autonomic nerve system activation)
Cognitive responses
Attentional reorienting and narrowing, worry (form of repetitive negative thinking > about the situation and its consequences), avoidance
Behavioural responses > fight, flight, freeze > avoidance
Anxiety is adaptive; a bit of anxiety helps you avoid dangerous situations, but it becomes maladaptive when it becomes too long, too intense, inappropriate for the situation, and it causes interference and unmanageable distress.
Anxiety disorders are the most common mental disorders in the United States
In any given year, 18% of the US adult population experiences one of the six DSM-5 anxiety disorders.
About 29% develop one of the disorders at some point in their lives
About ⅓ of these individuals seek treatment
High comorbidity: 22% report 2 diagnoses, and 23% report 3 or more diagnoses.
Shared cognitive features of anxiety disorders
Fear generalisation
Like in classical conditioning
Those with higher fear generalisation are more likely to develop anxiety disorders.
Fear generalisation is significantly enhanced in anxiety-related disorders compared to healthy controls.
Preferential processing of threat-relative information (attentional bias)
There are issues with reliability of the paradigms assessing attentional bias
Interpreting ambiguous information as threatening (interpretation bias).
Neurobiology of Anxiety
Anxiety disorders arise from disruptions in the highly interconnected circuits normally serving to process the stream of stimuli detected by our brains from the outside world.
Information processing in distributed, interlinked nodes results in the assignment of emotional value to environmental stimuli, operationalised here as “interpretation”, as well as the weighing of potential threats against competing motivational needs, referred to as “evaluation”. Computations in corticolimbic circuits resulting in interpretation of the environmental threats subsequently drive an observable anxiety-like response.
Perturbations anywhere in these circuits disrupt the balance in the entire system, resulting in a fundamental misinterpretation of neural sensory information as threatening and leading to the inappropriate emotional- and thereby behavioural- responses seen in an anxiety disorder.
Calhoun and Tye 2015 > Nature Neuroscience
To study anxiety we use
disease models
(manipulations that create disease processes or symptoms in the lab) > see at what times, with what means, can we intervene.
Disease models need:
predictive validity:
all treatments that alleviate or worsen symptoms in the disease should have the same effect in the model, and vice versa.
face validity:
the symptom-eliciting procedure, the elicited symptoms, the treatment response, and the underlying physiology should all be similar to what is observed in the disease.
theoretical basis:
the rationale underlying the model should match the disease aetiology; this is almost impossible to assess in psychiatry, where disease aetiology is unknown for many conditions.
Cross-species anxiety tests > tests on animals.
Paradigms such as shock paradigms, aversive noise, spatial paradigms (separation > maternal, etc), behavioural paradigms (often taking advantage of an evolutionarily pre-disposed behaviour of the animal).
How are they validated?
Predictive: Do the same treatments that reduce anxiety in rodents reduce anxiety in humans? Are similar physiological mechanisms involved across species in controlling anxiety-like behaviour?
Face: regarding the behaviour-eliciting procedure, the human paradigm should be similar to the rodent paradigm, with the limitation that threats must usually be converted to mild primary reincforcers or to simulated threats.
Anxiety and anxiety disorders show alterations to functional brain networks, including a hypoconnectivity between the affective salience network and the cognitive control network > changes to inter-network connectivity.
There is increased activation in the salience network, but reduced connectivity in the cognitive control network, which is able to downregulate to assist with the regulation of heightened emotional reactions.
As well as hyperconnectivity within the affective salience network > changes to intra-network connectivity.
Anxiety Disorders
specific phobias
Marked fear about a specific object or situation
The phobic object or situation almost always provokes immediate fear or anxiety
The phobic object or situation is actively avoided or endured with intense fear or anxiety.
The fear is out of proportion to the actual danger posed by the specific object or situation
The fear is persistent, typically lasting 6 months or more
interference/impairment in life or marked distress
Phobias are acquired through classical conditioning
Phobias are maintained by operant conditioning > removing or avoiding the phobic object = negative reinforcement
Issues with the theory, because you might go through a traumatic experience and not end up developing a phobia, or you may have a phobia without a traumatic experience.
Main component of anxiety is appraisal
Appraisal specificity
More dangerous and harmful, more uncontrollable and more unpredictable
treatment
> exposure therapy, cognitive therapy (challenging faulty appraisals and biases
panic attacks
Recurrent unexpected panic attacks, which refer to an abrupt surge of intense fear/discomfort that reaches a peak within a minute, and during which time 4 or more of the following symptoms occur:
palpitations, sweating, trembling, shortness of breath, choking, chest pain, nausea, dizziness, de-realisation, fear of dying, numbing/tingling, chills/hot flashes
panic disorder
Panic attack is not the same as a panic disorder
At least one attack followed by 1+ month of one or both of the following:
Persistent concern/worry about additional panic attacks or their consequences
A significant maladaptive change in behaviour related to the attacks.
The disturbance is not attributable to substances or other medical conditions
The disturbance is not better explained by other mental disorders.
agoraphobia
Marked fear or anxiety about 2+ of the following:
Public transport, open spaces, enclosed spaces, in line or in a crowd, being outside the home
The individual fears and/or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other embarrassing symptoms
The agoraphobic situations almost always provoke fear or anxiety
The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety
The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context
The fear, anxiety, or avoidance is persistent, typically lasting for 6+ months
The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
If another medical condition is present, the fear, anxiety, or avoidance is clearly excessive.
It is not better explained by symptoms of another mental disorder.
cognitive approach
Bodily sensations are catastrophically interpreted > something is very wrong with health > therefore increases the perceived threat (including now a threat to life).
Hypervigilance of bodily sensations.
behavioural approach
Acute fear following initial PA depends on interoceptive conditioning or conditioned fear of internal cues.
Slight changes (sometimes unconscious) in bodily functions elicit conditioned fear/panic due to previous pairing of terror with panic.
May contribute to the unexpected quality of PAs because you may not be away of those small bodily changes, and that those bodily changes had preceded the previous panic attack.
Everyones sensitivity to their internal cues is different.
treatment
Education about anxiety
Challenge cognitions > correct misinterpretation of sensations
Difficult to do > need to make sure that other medical conditions have been isolated during treatment because it’s hard to say that someone who feels like they’re going to have a heart attack won’t actually have one eventually.
Exposure to internal feared cues > change conditioned reactions to cues
Exposure to external feared cues > reduces avoidance behaviour.
social phobia
Same as social anxiety
A persistent fear of one or more social situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way that will be embarrassing and humiliating.
Exposure to the feared situation almost invariably provokes anxiety, which may take the form of a situationally bound of a situationally pre-disposed panic attack.
The person recognises that this fear is unreasonable or excessive
The feared situations are avoided or else are endured with intense anxiety and distress.
The avoidance, anxious anticipation, or distress in the feared social or performance situations interferes significantly with the person’s functioning, or there is a marked distress about having the phobia.
The fear, anxiety, or avoidance is persistent (6+ months)
Not due to substance use, medical or mental conditions.
clinical features
The belief that others see you as inept, stupid, foolish
Often demonstrates a cycle of anxiety > social deficits > anxiety
Common safety behaviours: avoiding eye contact, only talking to safe people, covering face with hair or hands.
Ambiguous complements are more likely to be seen as negative by those with social anxiety.
cognitive model
Maintained by increased self-focused attention, use of misleading internal information, use of safety behaviours, and pre and post-event processing.
Distorted image of public self is central
Increase in self-focused attention/self-monitoring in social situations > see self from an observer perspective, but they believe the observer perspective is excessively negative (distorted > fear, not actual performance).
aetiology
Genetics that interact with environmental factors at the core
Interact with proximal factors (closely related to the onset of the disorder) > behavioural and cognitive
Excessive proximal factors lead to diagnosis
Genetics:
13-60% heritable.
Temperament: Behavioural inhibition > heightened sensitivity to novel perceptual stimuli and avoidance of novel situations
More likely to exhibit a social anxiety disorder with behavioural inhibition in childhood > less likely to have positive social interactions
environmental factors
overcontrolling parents increase the rate of social anxiety disorders due to behavioural inhibition.
Peer influences: fewer friends, and less well-liked and accepted > negative social experiences.
Culture: taijin kyofusho > japan > fear of causing offence to others.
treatment
In vivo exposure hierarchy
Name absolute worst fear
Determine the easiest related thing you can do that is still anxiety-provoking.
Do that, and then move up the hierarchy doing harder and harder activities gradually increasing the fear, until you can do the absolute worst fear
group therapy
Can be beneficial because of: vicarious learning, seeing others with the same problem, public commitment to change, multiple role-play partners, and multiple people to challenge thoughts.
cognitive approach
Individual formulation
Determine safety behaviours
Shift focus of attention to the conversational partner rather than yourself
Provide video feedback to show an objective view of the social situation
Behavioural experiments
Identify problematic anticipatory and post-event processing (rumination and worry)
Challenge the person's interpretation of the social event (cognitive challenging).
GAD
Excessive anxiety and worry (apprehensive expectation), occurring more day than not for at least 6 months, about a number of events or activities.
The person finds it difficult to control the worry.
3 or more of the following symptoms (1 for children)
Restlessness or feeling keyed up or on edge.
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance (difficulty falling asleep or staying asleep, restless satisfying sleep)
Not better explained through other disorders, physiological condition or substances
Very large overlap with the symptoms of depression
82% of individuals with GAD are comorbid (63% with any mood disorder, 52% with another anxiety disorder).
Not a lot of evidence that pharmacological treatments are helpful
CBT is effective compared to placebo
Also effective on depression.
Transdiagnostic (mechanism present across disorders) risk factors
sexual/physical abuse (multi final > can predict a large range of disorders)
Harsh parenting
Parental psychopathology
Transdiagnostic mechanisms
Intrusive thoughts > obsessions are intrusive, unwanted thoughts that evoke anxiety or distress > OCD, PTSD, eating disorders, etc.
recurrent/repetitive negative thinking > rumination > depression, PTSD, social anxiety
Emotion regulation difficulties
Executive control deficits