Anxiety - Clinical Psych

}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

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 

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. 

• 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

• 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 

• 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)

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 

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 

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

}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 

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 

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 

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 

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

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 

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 

• 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 

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. 

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. 

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  

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

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 

•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