Lecture 2

Anxiety

 Definitions and characteristics

o Fear/anxiety:
 Short term – can be useful
 Moderate levels: optimal performance
 Protective – adrenalin (fight or flight)
o Anxiety disorder
 Maladaptive response to a threat
 Negative impact on everyday thinking and behaviour
 Unpleasant emotions dominate
 Fear (innate) vs. anxiety (learned)
 Duration, disproportionate, avoidance, distress, loss of control, panic
attacks, significantly influences day-to-day life
o Features
 Fear and worry dominate
 Tension, apprehension, uneasiness
 Elevated arousal
 Negative affect
 Fear, dread, anger, sadness, also shame, guilt
 Anticipation of danger or discomfort
 Avoidance of stimuli - events/objects
 Bodily sensations (trembling, shaking, tight chest)

o Prevalence (Remes, 2016)

 Pooled one-year prevalence 10.6 %
 Pooled life time prevalence 16.6%
 Higher in:
 Younger age groups (<35)
 Women (2:1)
 North America/North Africa/Middle East (7.7%)
 Lifetime Swiss/US (23-28.7%)
 Low in Asia (2.8%)
 GAD (6.2%)/Specific phobia (4.9%) > panic attacks (1.2%)

 Theoretical background
 o Biological: ‘fight or flight’ physiological response
 (Sudden rise in heartbeat = I’m afraid of something)
o Behavioural: classical/operant conditioning
 (Being scared of dogs bcs were bitten before= Seeing dogs  Gets
anxious)
o Cognitive Theory: perceived threat
o Psychodynamic: unconscious internal conflict
 Types of Anxiety Disorder
o Separation anxiety disorder
 excessive anxiety regarding separation from home or from people to
whom the individual has a strong emotional attachment (e.g., a parent,
caregiver, significant other or siblings).
o Selective mutism
 complex childhood anxiety disorder characterized by a child's inability to
speak and communicate effectively in select social settings, such as
school. These children can speak and communicate in settings where they
are comfortable, secure, and relaxed
o Specific Phobia
 Animal,
 Natural environment (height),
 Blood-injection-injury,
 Situational (airplanes),
 Other
o Social anxiety disorder
 intense anxiety or fear of being judged, negatively evaluated, or rejected
in a social or performance situation.
o Panic disorder
 anxiety disorder characterized
by reoccurring unexpected panic
attacks. Panic
o Agoraphobia
 anxiety disorder in which you
fear and avoid places or
situations that might cause you
to panic and make you feel
trapped, helpless or
embarrassed.
o Substance/Medication-Induced Anxiety
disorder
o Other Specified Anxiety Disorder
o Unspecified Anxiety Disorder
o Generalized Anxiety disorder
 characterized by excessive, exaggerated anxiety and worry about
everyday life events with no obvious reasons for worry.
 Ongoing, exaggerated tension – severely interferes with daily
 functioning
 Very common
 8% primary care patients, (Wittchen and Hoyer, 2001)
 2-5% general population
 30% psychiatric consults (Hale, 1997)
 Excessive anxiety
 constant worrying (even when no apparent reason)
  out of proportion to probability of unfortunate event
 More days than not - lasting at least 6 months
 Physical symptoms
 Comorbidity
 Assessment tools for GAD
o Multiple Item Scales
 Beck Anxiety Inventory (Beck 1990)
 Penny Worry Questionnaire (PSWQ) (Meyer et al 1990)
 “I am always worrying about something”
 “My worries overwhelm me”
 “I find it easy to dismiss worrisome thoughts”
o Interview
 Excessive anxiety and worry (Key symptom: Gale, 2003)
 The person finds it difficult to control the worry.
 The anxiety and worry are associated with three (or more) of the following
six symptoms (with at least some symptoms present for more days than
not for the past 6 months).
 (1) restlessness or feeling keyed up or on edge
 (2) being easily fatigued
 (3) difficulty concentrating or mind going blank
 (4) irritability
 (5) muscle tension
 (6) sleep disturbance (difficulty falling or staying asleep, or restless
unsatisfying sleep)
 Specific Phobias
o Intense, persistent fear of specific objects or situations
o Exhibits Avoidance response
o Start mainly in childhood
o Predisposing factors
 Biological
 Traumatic event
 Repeated warnings
 Fears acquired through conditioning
 Evidence
 Traumatic experience at onset (Di Nardo et al,
 1988): 66% dog phobics
o However
 Fears may not be conditioned
 Uneven distribution of fears
 Specific Phobia Assessment
o Self-report
o Physiological recording
o Scales
 Single item
 Multi-item questionnaires e.g. state anxiety (STAI)
o Behavioural testing: avoidance testing, hierarchies of situations, time can
tolerate
o Video assessment
o Diagnostic challenges
 Comorbidity (Co-Exist) – especially depression
 Has Implications for
 Assessment
  Treatment
 Reliability and validity of assessments (not all test are reliable)
 Self-report vs. clinician interview/observation
 Psychological treatments
o Systematic desensitisation for phobias (Wolpe 1958)
 Graded exposure in imagination with relaxation
 Rank situations in order
 Exposure in vivo: repeated, graduated and prolonged (Butler,1985)
o Cognitive approaches
 Attention
 Memory recall bias
 Misinterpretation
 Rumination
 Problem: where do the maladaptive thoughts come from?
o Blend of cognitive and behavioural techniques the best treatment.
o CBT
 Specific phobias
 Functional analysis
 Goal setting (set a specific goal)
 Use Measures: scales, behaviour tests
 Systematic desensitisation (Get them more familiar with the thing)
 Homework
o GAD
 Educate them
 Formulate
 Awareness of thoughts
 Encourage new thinking
 and test it
 Effectiveness of psychological treatments for Phobia
o Review Choy et al 2007 1960-2005
 In vivo exposure therapy most ‘robust’ treatment for specific phobias
(>placebo, WLC)
 But drop out = high
 For claustrophobia CBT = In vivo exposure
 Treatment gains up till one year
 Long term follow-up needs more research
o Some studies report high relapse rates
o Virtual reality for heights
o Applied tension for blood/needles
 Effectiveness of psychological treatments for GAD
o Cuijpers, 2016; meta-analysis
 42 studies
 Effects on panic > GAD/SAD
o Cuijpers, 2014; meta-analysis
 41 studies
 Pooled effect 38 comparisons
 (28 studies) psychotherapy vs control large
 Effects self-report < clinician-rated )bias?)
 Effects on depression large
 Lack of proper control groups (mainly WLC) and FU data
o Issues when evaluating therapies for anxiety disorders
 Evidence base
  Therapist effects
 Control group problems: ethics
 Quality of randomisation
 Statistical power
 Blind assessment of outcomes
 Comorbidity – especially depression
 Shortage of trained therapists
 Seeking help (especially with phobias)
 Drop-outs (patient quitting)
 Relapse
 Long-term outcome

Eating Disorder

 Definitions and characteristics

 DSM5: Feeding and Eating Disorder
o Pica
 In children
 In adults
 Eating nonnutritive, nonfood substances
 >1 month (but > 2 years to properly diagnose)
 Inappropriate
 Example: Eating rocks/sands
 Not part of culturally supported or socially normative practice
 Do also eat other foods
 Higher with intellectual disability
o Rumination Disorder
 Regurgitate food (> 1 month) (re-chew, re-swallow, spit out)
 Happens daily basis
 Higher with intellectual disability
o Avoidant/Restrictive Food Intake Disorder
 Eating/feeding disturbance (e.g., apparent lack of interest in eating or
food; avoidance based on the sensory characteristics of food; concern
about aversive consequences of eating) as manifested by persistent
failure to meet appropriate nutritional and/or energy needs associated
with one (or more) of the following:
 Significant weight loss (or failure to achieve weight gain in children).
 Not due to wanting to lose weight
 Significant nutritional deficiency.
 Dependence on enteral feeding or oral
nutritional supplements.
 Marked interference with psychosocial
functioning.
o Anorexia Nervosa
 Restricted energy intake leading to a
sign. low body weight (<minimally
normal)
 Fear of gaining weight or of becoming fat.
 Persistent behavior that interferes with
weight gain (while
 underweight)
 Disturbance in experienced of body
shape, lack of recognition of seriousness
of low body weight
  They perceive themselves as being fat (Even when they’re underweight)
 Not eating gives the perception of control over your own body.
 Huge influence on social interaction (Family/friends)
 Higher in females than males.
 Types:
 Restricting type (dieting, fasting, exercise)
 Binge-eating/purging type (binge eating and purging)

o Bulimia Nervosa
 Recurrent episodes of binge eating.
 Eating a lot in a brief time
 Lack of control over eating during the episode
 Compensatory behaviors to prevent weight gain
 Occurs more than once a week for three months.
 Self-evaluation highly influenced by body shape and weight
 Does not occur exclusively with anorexia nervosa

o Binge-Eating Disorder
 Binge eating without any compensatory behaviour
 They could be overweight
o Other Specified Feeding or Eating Disorder
 Looks similar to other disorder but less frequent
o Unspecified Feeding or Eating Disorder
 Not similar to other diagnosis specified
 Theoretical background
o Genetic predisposition
 But: twin studies and family studies cannot rule out ‘contagiousness (it
could just be rivalry- wanting to be skinnier than your twin etc)
o Control/anxiety
o Environment
 Culture
 Media
 Assessment tools
 Psychological treatments
o Cognitive behavioural therapy
o Psychodynamic psychotherapy
o Family therapy (most effective)
o Antidepressant medication sometimes work à for bulimia
o Challenge:
 Low weight influences cognition  Weight too low, CBT not Possible
(Malnourished disturbs proper cognition)
 Refusal to collaborate
 Force feeding
  Anorexia can be considered a ‘dieting addiction’. However, one will always
need to eat, making it difficult to treat
o Anorexia difficult to treat, high recurrence rate
 Long term risks
o Long lasting starvation can have irreversible effects on the body
o Psychological effects
 Depression
 Exclusion

Addiction (DSM 5 Substance related and addictive disorders)

Types of Addiction

 Alcohol
 Caffeine
 Cannabis
 Hallucinogens
 Inhalants
 Opioids
 Sedatives
 Hypnotics
 Anxiolytics
 Stimulants
 Tobacco
 Other (or unknown) substances.

Criteria for Addiction

1. Impaired control
2. Social impairment
3. Risky use
4. pharmacological criteria
5. Craving

2 Different Types of Addiction

 Substance use disorder

 Substance induced disorder – Intoxication and Withdrawal

Alcohol

 Alcohol Use Disorder

o Taken more and longer than planned.
o Persistent desire or unsuccessful effort to cut down or control.
o Much time spent on obtaining, using, recovering from alcohol,
o Craving,
o Causes failure to fulfil obligations at work, school, or home.
o Continued despite social problems caused by alcohol.
o Many activities given up / reduced
o Alcohol use when physically hazardous
o Continued despite physical/psychological problems caused by alcohol
o Tolerance:
 Needing increased amounts for intoxication/desired effect
 Diminished effect with same amount
o Withdrawal:
 Withdrawal syndrome for alcohol
  Alcohol taken to relieve withdrawal
 Alcohol Intoxication
o Recent ingestion of alcohol.
o Problematic behavioral/psychological changes related to alcohol
 (e.g., inappropriate sexual or aggressive behaviour, mood lability,
impaired judgment)
o Signs/symptoms
 Slurred speech.
 Incoordination.
 Unsteady gait.
 Nystagmus
 eyes make repetitive, uncontrolled movements. These movements
often result in reduced vision and depth perception and can affect
balance and coordination.
 Impairment in attention or memory.
 Stupor or coma.
 state of near-unconsciousness or insensibility

 Alcohol Withdrawal
o Cessation/reduction alcohol use (after long and much)
o 2 or more symptoms present:
 Autonomic hyperactivity (sweating, high heart rate)
 Hand tremor
 Insomnia
 Nausea or vomiting
 Transient visual, tactile, or auditory hallucinations or illusions
 Psychomotor agitation
 Anxiety
 Generalized tonic-clonic seizures
o Clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
 Other Alcohol-induced Disorders
o Korsakoff syndrome
 chronic memory disorder caused by severe deficiency of thiamine (vitamin
B-1).
 Korsakoff syndrome is most commonly caused by alcohol misuse, but
certain other conditions also can cause the syndrome.
 Anterograde and retrograde amnesia
 Can’t make new memories or remember old memories
 Fixation amnesia
 Confabulation
 Gaps in memory is filled with some other information
 Minimal conversational content
 Lack of insight
 Don’t realize that they don’t have their memory anymore
 Apathy
 Unspecified Alcohol-Related Disorder

Substance Addiction

 Substance use disorder

 Substance induced disorder
o Intoxication:
  Disturbances of perception, wakefulness, attention, thinking,
judgment, psychomotor behavior, and interpersonal behavior.
 Short-term/acute
 Sustained/chronic
o Withdrawal
 Substance induced mental disorder

Heroin Addiction

 Biological mechanism
o Reward system in the brain
o Dopamine from VTA to limbic system and frontal cortex
o All those substances activates the VTA to release dopamine.
 DSM includes gambling disorder: evidence that gambling activates reward systems
similar to drugs, and behavioral symptoms comparable.
