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Anxiety, Obsessive-Compulsive and Trauma Related Disorders

The Nature of Fear and Anxiety Disorders


Cannon(1929) described the Flight or Fight Response as an alarm response to which
the body prepares itself to deal with danger
o Adrenaline (ephinephrine released into the bloodstream) to release bodily
changes
o Blood pressure increases
o Blood diverted from organs to muscles (which tense up)
o Breathing increases to provide brain and muscles with more oxygen for the
response action
The flight or fight response allocates the bodys reserves so that it may,
1. Freeze whilst fear stimuli is being appraised.
2. Flight when danger is approaching
3. Fight when danger is unavoidable.
Barlow (2002) describes the fight or flight response as a, True Alarm. That is, Fear
occurs in response to a direct danger, such as an impending attack. True alarms are in
contrast with, False Alarms.
A false alarm is when the fight or flight response is to some situation or stimuli which
do not represent true danger.
False alarms are a hallmark feature of anxiety disorders.

People differ in the ease with which an alarm (true or false) is triggered.
The Triple Vulnerability Model
The Triple Vulnerability Model emphasises three specific vulnerabilities which
increase the sensitivity of a persons alarm trigger.
1. Biological Factors
2. Generalised Psychological Factors
3. Specific Psychological Factors
Biological Factors
o An example of a biological factor is an inherited predisposition (diathesis)
towards depression and anxiety disorders. These share similar genotypes.
o Another example of a biological factor is comorbidity. There is a clustering of
emotional disorders around a common genetic vulnerability. This is known as
the general neurotic syndrome.
Generalised Psychological Factors
o Generalised psychological vulnerability includes beliefs that the world is a
generally dangerous place, combined with broad expectations that events are
beyond ones control.
Specific Psychological Factors
o Specific psychological factors refer to specific objects or situations and
include factors which might influence the expectation of a negative outcome
when confronted with a specific object or event.
o Conditioning is one way to acquire such an expectation.

o You can think of Specific Psychological Factors as a specific psychological


reason for a phobia. This can be thought of as an initial phobic event which
inspires the expectation.
o For example. If a child is bitten by a dog and then goes on to fear all dogs, this
can be seen as the initial phobic event. The dog bite is the unconditioned
stimulus which induces the unconditioned fear response to the dog. This is
natural, however it is in the generalising of this so that Dogs are a conditioned
stimulus to the conditioned response, fear of all dogs, that the event is now a
specific psychological factor.

o Furthermore, the relief from anxiety caused by avoiding an unpleasant, fear


inducing, stimuli, amounts to a negative reinforcer. A negative reinforcer
encourages behaviour by removal of an unpleasant stimuli. This removal of
anxiety therefore encourages the phobic behaviour of stimuli
escape/avoidance.
Conditioning is a direct way to learn about potential dangers, but indirect pathways
include Information and vicarious acquisition. For example, one may come to fear
wolves and bears despite limited opportunities for exposure to either.
In Vicarious acquisition, fear is acquired through the process of modelling, whereby
an individual observes another responding with fear to a threatening object or
situation.
A clear example of this can be seen by the way children react to the emotions of their
mother. Among other mechanisms, social cuing is used by infants to learn about the
world. This is when the mothers emotional reaction to stimuli is used as an emotional
compass for an infants own reaction. Should a mother display fear, her infant will
pick up on this and react accordingly. Conversly, the case of the SS officers wife who
entered the gas chamber with her children was said to show no fear for the sake of her
children. Had she expressed fear, her children would have seen this and responded in
turn. In these ways, vicarious acquisition can play an important role in phobia
development.
The Common Thread
The common thread underlying the conditioning, informational and vicarious
acquisition pathways to fear is that, despite their differences, they all contribute to an
individual developing an expectation that, given a particular set of circumstances, an
aversive outcome is probable. This expectation of a negative outcome is, in turn,
associated with the fear and avoidance of feared situations characterising anxiety
disorders.

While the triple vulnerability model emphasises similarities between the various
anxiety disorders, others seek to identify areas of both similarity and differences
across these conditions.
One such approach is to focus on three dimensions of emotions;
1. Negative affectivity
2. Positive affectivity and,
3. Autonomic arousal.
This approach sees anxiety disorders as the result of some combination of these
factors. People with the disorders are high on trait anxiety and hence are more likely
to experience false alarms.
This approach allows disorders to be distinguished between in terms of the emotional
dimensions of negative and positive affectivity.
For Example, social phobia and depression are distinguished from other disorders as
they present with a lack of positive affectivity. That is, there is autonomic arousal
(they are alert) they feel negative affect to do with this (alert in a distressed way) and
have a notable lack of positive affect.
Specific Phobias

The Diagnosis of Specific Phobias


According to the DSM 5, major factors of specific phobias are that fear responses
must be;
o Intense
o Persist over at least a 6 month period
o in response to the stimulus or anticipation thereof.
o Disproportionate to the actual danger and contextually inappropriate.
The DSM-5 distinguishes 4 types of phobias by their content
1. Environment
2. Blood/Injection and injury
3. Situation specific
The DSM subtyping is useful for treatment. As phobias differ on treatment patterns.
The Epidemiology of Specific Phobias
Most phobias begin in childhood but remit naturally with age.
Age of onset is not fixed.
The Aetiology of Specific Phobias
Phobias have a heritable component.
Even if the conditioning event is a necessary cause (dog bite), this is insufficient alone
to produce a phobia.
Learning pathways are also likely to be involved in the development of specific
phobias.
Seligman (1971) suggested a biological evolutionary basis for phobic fears.
Prepared Classical Conditioning states that evolution prepares people to be easily
conditioned to fear objects or situations that were dangerous in prehistoric times. For
example, we would learn to fear snakes or lions far more readily than fear of a
computer or toaster.
In Summary

Specific Phobias are False Alarms


A false alarm is an instance where the fight or flight response is triggered
inappropriately or excessively.
The fear may have its origins in an accurate appraisal of past events (dog bite) which
is then inaccurately generalised to current, innocuous events.
The direct (conditioning) and indirect (information or vicarious transmission)
pathways involve cognitions that certain stimuli will probably end badly.
This learning occurs against a backdrop of biological vulnerability in the form of a
genetic diathesis stress.
Phobias of certain stimuli may have an evolutionary basis, making certain phobias
easier to acquire than others.
Specific Phobia Treatment
Specific phobias represent false alarms of the fight or flight response due to
inaccurate fear expectations. As such, effective treatments involve procedures to
modify these expectations which inspire the false alarms.
Exposure-based treatments serve this function
In Exposure therapy, the phobic person gradually faces their phobic stimulus in real
life. This is in vivo exposure.
Flooding is a behavioural technique in which the client is intensively exposed to a
feared object until anxiety diminishes. This can be coupled with relaxation training.
Repeated exposure yields reductions in anxiety.
In Vivo Exposure is the most effective treatment for specific phobias.
The success of exposure therapy can be explained by the extinction mechanism from
conditioning. Through confronting conditioned fear stimuli, the absence of any
unconditioned stimuli (a bite), the conditioned fear response decreases.
Cognitive processes may also account for the success of exposure therapy. By
challenging expectations that danger will occur in the presence of the phobic stimulus,
self-efficacy (confidence the client can cope with the fear) increases as the clients
perception of control over their anxiety grow.
Panic Disorder and Agoraphobia

Panic Disorders and Agoraphobia


Agoraphobia is anxiety about being in places where escape might be difficult or
embarrassing, or in which help may not be available in the event of having a panic
attack symptoms. As a result of this anxiety, such places are often avoided, endured
with extreme distress, or require the presence of a companion.
The focus of agoraphobic fear is not the external environment, but the fear of panic
and its consequences in the environment.
A Panic Attack is defined as an episode of intense fear involving,
o Racing heart
o Choking/smothering sensations
o Sweating
o Shortness of breath
o Trembling
o Chills/heat sensations
o Dizziness or fainting
o Fears of death/losing control

A Panic Disorder is diagnosed when panic attacks are recurrent and unexpected.
Symptoms include,
1. Persistent (one month) concern or worry about additional panic attacks or
their consequences. AND/OR
2. Significant changes in behaviour related to the attack.
Agoraphobia is diagnosed when the sufferer experiences marked fear or anxiety in at
least two of the five following situations;
o Public transport
o Crowded places or queues.
o Open spaces
o Outside of the home alone
o Enclosed spaces

o
Agoraphobic situations almost always trigger fear and anxiety. They are actively
avoided or are endured with intense fear or anxiety for at least a six month period.
Furthermore fear and anxiety must be out of proportion for the context and culture.
For example, the same set of behaviours and fears whilst living in a warzone would
negate a diagnosis, as such behaviour is understandable in the context.
o
o The Epidemiology of Panic Disorder and Agoraphobia
As with most other anxiety disorders, panic disorder occurs more in females.
Panic disorders tend to be chronic, however their severity waxes and wanes with time.
o
o The Aetiology of Panic Disorders and Agoraphobia
The origins of panic disorder involve all three aspects of Barlows (2002) triple
vulnerability. Recall this involves biological, generalised psychological and specific
psychological factors.
The experience of a false alarm panic is not the cause of a panic disorder.
A Generalised Biological Vulnerability comes in the form of an inherited genetic
risk for anxiety sensitivity.
The psychological vulnerabilities account for the progression from having a panic
attack to developing panic disorder.
A Generalised Psychological Vulnerability exacerbates the experience of a false
alarm, and one such vulnerability is Anxiety Sensitivity. People with high anxiety
sensitivity fear arousal-related sensations in their body, steaming from the belief
that such sensations are dangerous.
A Specific Psychological Vulnerability is that the individual specifically fears the
sensations of pain.
o According to Clarks (1986) Cognitive Model of Panic Disorder, people
misinterpret the physical sensations of panic in a catastrophic manor. I am
having a heart attack and, I am going to lose it are common examples.
o Such catastrophic misinterpretations elicit the fight or flight response (a
false alarm), which elicits additional physical sensations that are also
misinterpreted catastrophically. Therefore the cycle snowballs.
o In short: the panic escalates in a spiral of arousal >> misinterpretation >>
further arousal.
o Finally, the psychological vulnerabilities increase further as the person
worries about the possible recurrence of a panic attack. Such beliefs
increase the likelihood of further arousal, which is misinterpreted as a sign
of impending catastrophe.
o Hence the individual moves beyond a single isolated panic attack, to
frequent panic attacks.
o
Agoraphobia can develop as a complication of panic disorder, as people with panic
attacks come to fear situations in which a panic attack may occur
o The Treatment of Panic Disorders and Agoraphobia
All medications have their advantages and disadvantages which must be weighed up
before prescription.

o Tricyclic antidepressants
o Selective Serotonin Reuptake Inhibitors (SSRIs)
o Benzodiazepines
Cognitive Behaviour Therapy (CBT) is an effective psychological treatment for both
panic disorder and agoraphobia.
A major aim of CBT is to address phobic avoidances, which can be external or
internal.
External phobic avoidances are treated with graded in vivo exposure.
Internal phobic avoidances are not so simply dealt with.
o Internal phobic avoidances are bodily sensations a person ignores which may
be signalling pain.
o Interoceptive exposure is an example CBT technique used to treat internal
phobic avoidances.
o Interoceptive exposure entails exposing the client to the physical sensations of
a panic attack.
o For instance, a person may fear the sensations of hyperventilation. To confront
the sensation, the person is asked to deliberately and repetedly generate the
feelings of hyperventilation by overbreathing until the fear of the sensation
decreases.
The fear of panic can also be addressed with cognitive techniques that aim to change
the false beliefs a person has about panic and its sensations.
o Common beliefs associated with panic are that the symptoms signal that the
person is about to die or lose control. In cognitive restructuring, the person
learns to challenge false beliefs through psychoeducation.
o
CBT techniques are highly effective treatments for panic disorder and agoraphobia.
Effective treatment of panic disorder has been found to involve a combination of
exposure, relaxation training, slow breathing and homework assignments.

o
Gradual and regular exposure to panic-like sensations is a powerful technique to
reduce vulnerability to panic attacks and anxiety symptoms. Thus, regularly
experiencing the uncomfortable physical sensations during interoceptive exposure, in
the absence a catastrophic consequence, may be a powerful strategy for disconfirming
the individuals catastrophic misinterpretations of their benign physical sensations that
lead them to a panic attack.
o

o Social Anxiety Disorder

According to the DSM-5, the key features of Social Anxiety Disorder (aka social
phobia) involve marked fear or anxiety in social situations in which the person faces
potential scrutiny by others.
The key is FEAR OF NEGATIVE EVALUATION and rejection
As a result, social situations are avoided entirely. The anxiety or avoidance interferes
with the individuals functioning and/or causes considerable distress.
The DSM-5 specifies Performance only social anxiety disorder, where the fear is
restricted to performance in public.
The main difference between social anxiety and other anxiety disorders is that fear is
reserved for the visible components of fight or flight. E.g.
o Sweating
o Blushing
o
o The Epidemiology of Social Anxiety Disorder
Social anxiety disorder is one of the most common and earliest onset anxiety
disorders, with half of sufferers below 12 years of age.
Without treatment, the disorder can take 25 years to remit.
There is a reluctance to seek treatment. Which is partially due to the disorder itself.
Sufferers fear being judged for their disorder.
This common treatment delay is a concern, as social anxiety disorder is heavily
comorbid with depression.
People with social anxiety disorder are often poor achievers in education and
occupation. Furthermore, they are less likely to marry.
o
o The Aetiology of Social Anxiety Disorder
Biological, psychological and social factors influence the onset of Social Anxiety
Disorder.
Biologically, there is an inherited risk factor.
Psychological factors include,
o Excessive parental criticism
Reduces childrens confidence
Teaches the child to be overly concerned with the opinions of others
o The social withdrawal associated with social anxiety disorder may itself elicit
dislike and rejection form others during adolescence.
o Cognitive dysfunctions also increase the likelihood of experiencing anxiety in
social situations.
E.g. not smiling
o
The core psychological vulnerabilities for social phobia involve the distorted way in
which people perceive how they are evaluated.
People with social phobia assume others are inherently critical and likely to form
negative evaluations
o Require fewer facial cues to identify threating features
o Make less optimistic assessments of their ability to communicate

These cognitive factors increase the probability that perfoamance in social situations
will trigger a false alarm, which is percieved by the individual as evidence of his or
her own social ineptness and contributes to the intensification of anxiety in social
situations. Thus maintaining the phobia.

o
Adults with social phobia are not always assessed as being less socially skilled than
non-clinical controls, suggesting that they do not necessarily have social skills deficit,
but rather that their social skills are inhibited by the anxiety.
Therefore if the social anxiety is effectively treated, people with the disorder can
usually interact skilfully.
That is, a large part of the problem is not that they are socially incompetent. Rather,
they are because they believe themselves to be.
o
o Treatment of Social Anxiety Disorder
CBT is the best treatment for social anxiety disorder. Either in groups or individually.
Group treatment has the advantage of providing a social context within which clients
can practice their skills.
Treatment involves,
o Psychoeducation of social phobia
o Skills for challenging negative thoughts/images
o Behavioural experiments designed to directly challenge negative cognitions.
o Reduction of safety behaviour reliance
Gaze avoidance
Alcohol use
o Challenging entrenched views of oneself.
I am adequet
o
o Generalised Anxiety Disorder
o
o The Diagnosis of Generalised Anxiety Disorder
According to the DSM-5, the main feature of Generalised Anxiety Disorder is
excessive anxiety and worry about a number of events or activities.
The anxiety and worry must have been present on most days for at least six months.
These worries must be difficult to control, meaning the sufferer finds stopping
difficult and cannot easily dismiss thoughts from the mind.
o
The worries that characterise GAD include a more diverse range of FUTURE
FOCUSED FEARS
Core worries in GAD are broadly catagorised as those which relate to,
o Social threats
Work performance.
o Physical threat
Health, wellbeing.
o World threat
War, terrorist attack.
People with GAD have a catastrophic style of thinking which typically ends in worst
case conclusions, causing considerable anxiety.

o
Those with GAD also believe that if their fears were to eventuate, they would lack the
necessary resources and capacity to cope with negative events, should they occur.
o
In addition, the DSM-5 criteria specify that the individual experience a range of
associated symptoms in relation to worries such as,
o Irritability
o Fatigue
o Difficulties concentrating
o Sleep problems
o Restlessness/agitation
o Muscle tension
Some GAD sufferers become rigidly focused on over-achievement to the exclusion of
all other pursuits to avoid fears of inadequacy being fulfilled by themselves or others.
In contrast, others with GAD tend to avoid perceived challenges for fear of failure.
Chronic worrying and autonomic arousal experienced by people with GAD impacts
strongly on their quality of life and functioning.
o
o The Epidemiology of Generalised Anxiety Disorder
GAD affects women more than men
Most GAD sufferers do not seek help. Of those that do, there is a substantial delay
between diagnosis and treatment seeking. This is a problem, as GAD has an early
onset age and a chronic course which is unlikely to improve without intervention.
GAD is substantially comorbid with other anxiety disorders, depressive disorders and
personality disorders.
o
o The Aetiology of Generalised Anxiety Disorder
Beyond the biological inherited risk factors, there are three models of GAD. These
include,
o The Information Processing Model
o The Metacognitive Model
o The Intolerance of Uncertainty Model
o
o THE INFORMATION PROCESSING MODEL OF GAD
The information processing model of GAD begins with the premise that people with
GAD actively seek out potential threats in their environment.
Triggers then occur in the environment that create an expectation of threat, which in
turn activates symptoms of anxiety, including behavioural responses such as
avoidance.
Anxiety only reduces when perception of control over the threat has been achieved.
o
o THE META-COGNITIVE MODEL OF GAD
The meta-cognitive model of GAD highlights the importance of a number of
interacting systems that maintain and promote worry, such as the use of worry as a
coping strategy, negative appraisals or beliefs about worry, and control strategies
aimed at stopping the worry process.

The Meta-Cognitive model describes two types of worry,


o Type One: normal worry about regular events
o Type Two: involves beliefs about worry itself named meta-beliefs. These
entail negative appraisals or interpretations of the worry process that focus on
the idea that ones worry is dangerous.
For example, Ill go insane
The meta-cognitive model proposes that the process of worry activates a range of
other unhelpful coping strategies aimed at controlling worry and preventing threat,
such as avoidance, and seeking reassurance from others.
While these strategies help to reduce anxiety in the short term (and are thereby
reinforced), they prevent the individual from learning that nothing bad was ever going
to happen even if they had not used that strategy.
o
o THE INTOLERANCE OF UNCERTAINTY MODEL
The Intolerance of Uncertainty Model argues that situations and events that involve
uncertain outcomes trigger negative emotional (anxious feelings), cognitive (threat
beliefs) and behavioural (avoidance) responses in people with GAD.
Uncertainty is something which cannot be controlled or avoided and hence people
with GAD find this distressing as it signals the possibility of threat.
This model argues that people with GAD are intolerant of even mild amounts of
uncertainty and will attempt to control situations that are associated with uncertain
outcomes.
Intolerance of uncertainty is argued to interact with three other key processes to
maintain GAD symptoms
o Individuals with GAD have positive beliefs about the use of worry as a coping
strategy.
o People with GAD possess a poor problem orientation such that they
selectively focus on the uncertain aspects of problems and have low levels of
confidence regarding their capacity to solve problems
o Worry is a process that functions as a means of inhibiting distressing mental
images and accompanying physiological arousal. Thus the process of worry is
negatively reinforced in the short term, since it reduces fear, but prevents the
processing of the feared scenarios and habituation processes over the long
term.
o
o The Treatment of Generalised Anxiety Disorder
Pharmacological treatments for GAD include,
o Benzodiazepines
o Azapirones
o Tricyclic Antidepressants
o SSRIs
Most commonly used
Current treatment recommendations suggest that medication be used only when
necessary and alongside psychological interventions
o
CBT is the psychological intervention of choice for GAD.

CBT programs aim to treat the primary factors thought to maintain the clients
symptoms
Most CBT programs include psychoeducational about worry and teach realistic
thinking skills to help clients re-appraise negative predictions about threat, beliefs
about worry and negative self-beliefs.
o

o Obsessive-Compulsive Disorder

o
Historically, obsessive-compulsive disorders and post-traumatic stress disorders were
both classed as anxiety disorders. The DSM-5 however separates them into their own
individual, but adjacent, chapters.
The DSM-5 describes OCD according to four diagnostic criteria.
o Obsessions and/or compulsions
o The disorder must be time consuming ( >1 hour per day) or significantly
interferes with the sufferers life.
o Symptoms cannot be attributed to substance use or other medical condition.
o The content of obsessions or compulsions cannot relate to some other disorder.
For instance, body obsession in anorexia.
o
Obsessions are defined as recurrent and persistent thoughts, impulses or images which
are experienced as intrusive, innapropriate and/or distressing.
o The thoughts are not simply excessive worries about real-life problems.
o To be defined as an obsession, the person must attempt to ignore the thoughts,
impulses or images or to neutralise them by engaging in some other mental
routine or behaviour (ritual).
o In order to distinguish obsessions from some aspects of psychotic illness, the
person must realise that the obsessional thoughts are the product of his/her
own mind.
Compulsions are defined as repetitive behaviours or rituals (including mental
routines) that the person feels compelled to perform in response to an obsession or
according to strict rules.
o To be termed a compulsion, the behaviours must be aimed at reducing anxiety
(usually triggered by an obsession) or preventing a threatening outcome.
o
Additionally, the DSM-5 requires that the extent to which a person understands that
their obsessions are in their own head is repoted.
o Good or fair --------------- realises OCD beliefs are probably untrue
o Poor ------------------------ argues OCD beliefs are true
o Absent---------------------- completely convinced OCD beliefs are true
o
The DSM-5 does little to indicate the breadth of possible presentations of the disorder.
This is because OCD varies considerably from case to case. A seemingly endless list
of possible topics can become the source of an obsession. Common topics include,
o Fears of contamination and germs
o Fire
o Robbery
o Rape and assault.
Almost any behaviour can become a compulsion. Even when there is no obvious or
logical link between the behaviour and the prevention of harm. For example, in order
to prevent fire, a sufferer may check power points and blink a set amount of times.
A less common manifestation of OCD are occurrences of aggressive obsessions.
Compulsive washing is the most common presentation of OCD.
o

o
o
o
Compulsive checking is the most common and prominent feature of OCD.
o Checking behaviours can include a seemingly endless range of objects and
activities.
Another form of OCD is Primary Obsessional Slowness.
o Refers to OCD in which the sufferer carries out everyday activities in an
exceedingly precise, slow and unvarying sequence. (think American psycho
getting ready?)
o The word Primary is used to indicate that the slowness is not because of a
need to check and recheck.
o Rare form of the disorder
Hoarding disorder is closely related to OCD.
o The DSM-5 defines the condition as a persistent difficulty in discarding
possessions in spite of limited value or meaning.
o Hoarding disorder is associated with substantial health and safety risks.
Namely fire.
o
Body dysmorphic disorder is also included in the DSM-5s OCD chapter.
o Body dysmorphic disorder entails a preoccupation with an imagined defect of
appearance. The individual believes some part of their body to be deformed, or
the wrong size.
o The individual presents with a clinically significant level of concern for the
body part. This accompanies clinically significant distress or impairment (e.g.
avoiding public situations) and importantly, cannot be accounted for by some
other disorder (e.g. anorexia nervosa).
o Cosmetic surgery can be of some assistance, however psychological therapies
can also be of benefit.
o
o The Epidemiology of OCD
OCD is associated with a lifetime of impairment.
Onset age is about 10 years old.
The condition waxes and wanes in intensity over time.
o
o The Aetiology of OCD
Aetiology ~ cause
Two models;
o The Neuropsychological Model
o The Cognitive Model
(favoured)
o
o THE NEUROPSYCHOLOGICAL MODEL OF OCD
The neuropsychological model of OCD is grounded in neuroimaging which suggests
the disorder results from a failure of inhibitory pathways in the basal ganglia. These
inhibitory pathways fail to stop behavioural macros being triggered in response to
internal or external stimuli.

Behavioural macros are defined as complex sets of behaviours choreographed for


specific situations such as grooming and checking.
This model is seen as simplistic at best. This current understanding of OCD
neurobiology may be the consequence, rather than the cause of the disorder.
Furthermore the enormous variety of OCD presentations does not seem to be covered
by the notion of behavioural macros. This is because OCD sufferers do more than just
check and groom. They engage in compulsions as diverse as tapping, blinking and so
on.
o
o THE COGNITIVE MODEL OF OCD
The obsessions experienced in OCD are not qualitatively different from the intrusive
thoughts experienced by the general population. What appears to be different, is the
way in which OCD sufferers appraise or interpret their intrusive thoughts.
The Cognitive Model of OCD emphasises that OCD results from the
misinterpretation of intrusive thoughts.
o The OCD sufferer gives the intrusive thoughts significance, rather than
simply ignoring them as do the rest of the general population.
o The OCD sufferer interprets an intrusive throughs to indicate that danger may
occur to themselves and others, and that they could be personally responsible
for bringing this about or preventing it.
o Behavioural responses (such as compulsions) are driven by the desire to
reduce these threat appraisals and seek safety.
The cognitive model of OCD remains the only theoretical position that is consistent
with the full range of phenomenology of OCD. It is also supported by the
effectiveness of CBT therapy approaches, which are based on the cognitive model.
o
o The Treatment of OCD
CBT remains the best treatment choice for OCD.
CBT procedures include exposure-based tasks, behavioural experiments and other
tasks designed to challenge the irrational threat-related beliefs of OCD sufferers.
The exposure and response prevention procedure is the most effective CBT
treatment.
o The individual is asked to confront the feared stimuli and their typical
compulsive response is prevented or reduced.
Various forms of cognitive restructuring have also been effectively used to treat
OCD.
o This involves challenging the appraisals individuals give to their intrusive
thoughts. This often involves altering their inflated risk estimates.
In some cases, cognitive techniques alone, without the need for exposure, can be
successfully applied to treat OCD
Danger Ideation Reduction Therapy (DIRT) for compulsive washers.
Medical treatments include clomipramine. However only 50% of people benefit from
medication.
o
o Post-Traumatic Stress Disorder
Posttraumatic stress disorder (PTSD) is classified among Trauma- and stressor
related disorders in the DSM-5 and is defined as a disorder that entails extreme
stress reactions after exposure to a traumatic event.

The event must include threatened or actual harm to the self or others.
Although PTSD can develop in response to a wide range of traumatic events, there is
strong evidence of a relationship between the greater likelihood of PTSD
development as the severity of trauma increases.
Common examples are war and terrorism.
o
o
o Symptoms
PTSD comprises four major symptom clusters
o Re-experiencing symptoms
o Avoidance symptoms
o Negative changes in cognition and mood
o Marked alterations in arousal.
Re-experiencing symptoms include
o Intrusive memories
o Flashbacks
o Nightmares related to the trauma event
o Distress when exposed to trauma event reminders
Avoidance symptoms include
o Active avoidance of thoughts and reminders of the trauma event
Negative changes in cognition and mood includes
o Emotional numbing
o Being unable to recall important aspects of the trauma event
o Exaggerated negative expectations about oneself or the world
o Excessive blaming of the self or others and pervasive negative affective states
Fear
Anger
Guilt
Shame
o Hyper vigilance
o Sleeping and concentration difficulties
o Reckless or self-destructive behaviour
o Anger outbursts
Symptoms must be present for at least one month
There is overwhelming evidence that PTSD can be characterised by catastrophic
cognitive interpretations of the event and by a range of emotional responses beyond
fear and anxiety
o
o The Epidemiology of Posttraumatic Stress Disorder
Despite the frequency of exposure to potentially traumatising events, relatively few
people actually develop PTSD.
PTSD is strongly comorbid with other psychiatric disorders.
o
o PTSD Prevalence in Children
The prevalence of PTSD in children is generally similar to adults.

PTSD manifests itself differently in children with fewer cognitive and avoidance
symptoms than in older children.
o
o Risk Factors
It is common for individuals to experience a broad array of PTSD-type symptoms in
the initial weeks after the trauma. However the majority of these will be transient.
That is, the onset of the disorder following the trauma event is slow to start up.
There is evidence that PTSD development is associated with a history of
psychological disturbance predating the trauma, prior traumatic experiences, lower
intelligence levels, female gender, more severe trauma exposure, low social support
and ongoing stressors in the aftermath of the trauma.
o The Aetiology of Posttraumatic Stress Disorder
Cognitive, learning and biological factors also influence the causation of PTSD
o
o Cognitive Models
Maladaptive appraisals or interpretations of the traumatic event (e.g. I was weak)
The individuals response to it (e.g. I am worthless because I am not coping).
The environment after the trauma (e.g. I can never feel safe again).
Are all pivotal in terms of perpetuating the individuals sense of threat.
There is much evidence that maladaptive thoughts about the trauma predict the
development of the disorder.
o
o Learning Accounts
Application of classical conditioning principles to trauma
I.e.
o Unconditioned
o
o
o
o Unconditioned
Stimulus
Response
o
o
o
o
o
o
o
o
o The Traumatic
o Intense,
o
o
o
Event
overwhelming
fear
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o Unconditioned Response
o
o
o
o
o
o
o
o
o
o
o
o Conditioned
o
o
o
o
o
o
o
Stimulus
o
o
o
o
o
o
o
o Any detail,
o
o
o
o
o
o
o
however small,
o
o
o
o
o
o
o
that reminds the
person of the
trauma
As reminders of the trauma occur, people then respond with the same fear reactions as
they did the first time.

o
o Biological Accounts
Extreme sympathetic arousal at the time of a traumatic event may result in the release
of stress neurochemicals (noradrenaline and adrenaline) into the cortex, resulting in
strong conditioning of fear responses with the associated memories.
o
o Avoidance
Avoidance of trauma reminders maintains the PTSD.
According to cognitive models, this is because avoidance prevents people from
having the opportunity to access corrective information that the percieved threats are
no longer realistically dangerous.
According to the learning processes with their biological bases, avoidance serves to
imped the extinction of classically conditioned fear. The combination of predisposing,
cognitive learning and biological factors that are theorised to result in the
development of PTSD are shown below.
o
o
o
o
Fig. 2.6
o
o Predis
o
posing
Factor
s
o
o
o o
o
o
o
o
o o
o
o
o
o
o o
o
o
o
o Maladapti o o
o Fear
o
ve
Conditioni
Appraisals
ng
o
o
o o
o
o
o
o
o o
o
o
o
o
o o
o
o
o
o Avoid
o
ance
Strate
gies
o
o
o o
o
o
o
o
o o
o
o
o
o Impair
o
ed
extinct
ion
learnin
g and
no

opport
unity
to
challe
nge
beliefs
regard
ing
ongoin
g
threat
o
o

o
o
o

o o
o o
o PTSD

o
o

o
o
o

o
o Treatment of Posttraumatic Stress Disorder
CBT is the treatment of choice for PTSD
PTSD CBT typically comprises
o Psychodeucation
o Anxiety management
o Cognitive restructuring
o Imaginal and in vivo exposure
o Relapse prevention
Prolonged imaginal exposure requires the individual to vividly imagine the trauma or
extended periods. Typically at least 50 minutes and is usually supplemented with daily
homework.
o
o Prevention
The efficacy of CBT treatment of PTSD has lead to the use of CBT as a preventative
measure for at risk trauma survivors shortly after trauma exposure.
Note that CBT is different from psychological debriefing, because whereas the latter
requires the person to express their responses to the trauma on a single occasion
within days of the event, CBT requires repeated systematic exposure for prolonged
periods and this intervention does not commence until at least two weeks after trauma
exposure.
o

o
o
D

o
Tri

o
Co

o
Be

o
E

o Animals
S Natural
environment
Blood, injection,
injury
situational
o Bodily sensations
P
e.g. changes in
heart rate,
breathlessness,
dizziness

I will be bitten
I will fall
I will faint

Avoidance
Safety behaviours
e.g. holding an
object they
think keeps
them safe

Fear
Anxiety

Increased heart rate


Sweating
Trembling
Increased Respiration

I will have a heart


attack
I am going crazy

Fear
Anxiety

Increased heart rate


Sweating
Trembling
Increased respiration
rate

o Natural
A
environment

I cant cope if I
cant escape or
someone isnt
there to help
me

Fear
Anxiety

Increased heart rate


Sweating
Trembling
Increased respiration
rate

o Blood, injection,
S
injury

Fear of negative
evaluation (e.g.
Others will see
how anxious I
am and I will be
rejected).

Avoidance of
activities that
trigger panic,
such as bodily
sensations.
o
E.g. walking
up stairs
Safety behaviours
o
E.g. carrying
medication
Avoidance
o
E.g. avoiding
trains, crowded
busses, and
shopping
centres.
Safety behaviours
o
E.g. only
leaving house
with a family
member
Avoidance
o
E.g. not giving
presentations at
work, avoiding
eye contact
with others.
Safety behaviours
o
E.g. alcohol
use.
Avoidance and
safety
behaviours such
as,
o
Avoiding
feared
situations
o
Negative
thoughts and
feelings
o
Worry triggers.
Reassurance
seeking
Being overly
pleasing
Perfectionism
Busyness
Controlling
behaviour.
Avoidance of
triggers or
engaging in
neutralising
behaviours

Fear
Anxiety
Shame

Increased heart rate


Sweating
Trembling
Increased respiration
rate

Fear
Anxiety
Worry

Increased heart rate


Increased respiration
rate
Sweating
Trembling
Hypervigilance
Agitation
Restlessness
Irritability
Muscle tension
Sleep problems

Fear
Anxiety
Shame
Guilt

Increased heart rate


Sweating
Trembling
Increased respiration
rate

o
G

o Animals
O

o
sit

Bad things will


happen, they
will be
catastrophic and
I wont be able
to cope
Uncertainty is
threatening;
worry will make
me crazy
My feelings are
dangerous
Worry makes me a
good person It
shows I care for
others

Direct threat from


trigger (e.g. Ill
get sick)
o
OR
Symbolic meaning

P
h
y
s
i
o
l
o
g
y

attached to the
trigger (e.g. Ill
lose my mind,
Im a bad
person).

o Natural
P
environment

when contact
with triggers is
unavoidable.
E.g.
o
Washing
o
Tapping
o
Touching
o
Repeated
checking
o
Mental
routines or
mantras.
Thoughts of future Avoidance of all
harm(e.g.I can
reminders of the
never be safe)
trauma.
o
OR
o
E.g. avoiding
driving after
Of ones role in the
being in a
trauma (e.g.I
serious car
am to blame for
crash.
being raped).
Safety behaviours
o
E.g. carrying a
knife at all
times after
being
assaulted.

Fear
Anxiety

Shame
Anger
Guilt

Increased heart rate


Sweating
o Trembling
An Increased respiration
rate
Increase startle
reaction.