Anxiety Disorders 2: Other diagnoses

PS6007
Dr Brooke Swash
Today we will cover:

• Specific phobia
• Social anxiety
• Panic disorder
• Obsessive-compulsive disorder
Reflection point

• What are your thoughts on the pros and cons of diagnosis?

Specific Phobia
Phobia (DSM 5)

• A disrupting, persistent fear of a specific object or situation.

• Fear must be excessive or unreasonable.

• Exposure to the stimulus provokes an immediate anxiety response e.g. panic attack.

• The object or situation is avoided which interferes with the person’s normal routine or
relationships.

• If the situation can’t be avoided, it is endured with intense anxiety.

Types of Phobia

• Animal type.

• Nature-forces type.

• Blood, injection and injury type.

• Situational type.

• Other type.
Phobia - Prevalence

• Common!

• 18% of adults (Jenkins et al., 1997).

• Less commonly diagnosed in children.

• Heights, snakes, and closed spaces are the most common specific phobias (Fredrikson et al.,
1997).
Phobia - Course

• Symptoms usually first appear in childhood or adolescence.

• The mean age at onset varies according to the type of specific phobia.

• Fear of the stimulus is usually present for some time before becoming sufficiently distressing
to warrant a diagnosis.

• If a phobia is still present in adulthood, then remission is only seen in around 20% of cases.
Phobia – Associated features

• Often impact upon a person’s lifestyle, restricting them from doing certain things.

• Rates of co-occurance with other mental health disorders between 50-80%.

• Fainting is commonly associated with certain types of specific phobias e.g. fear of needles.

• Can exacerbate existing conditions e.g. via a fear of accessing medical treatment.
Activity: Case study (source Mind.org)
Deciding to tell people about my phobia is always a tricky one. A laugh is always guaranteed and I realise that when I tell people that I have a phobia of
bananas. It isn’t exactly a common phobia – but for me, it is a daily challenge. According to my mother I was fine when I was a baby, eating mashed-up
banana like every other kid. But now, even writing the word makes my stomach churn. I don’t know where it came from or how it started but seeing a
banana in real life makes me extremely anxious, I hyperventilate and feel petrified. I know it seems daft – it’s only a piece of fruit – but for me it is more than
that.
I actively manage my phobia by explaining to work colleagues and friends that I cannot be around bananas, and I plead with them to respectfully eat them
away from me. I affectionately call any incidents I have a ‘Banana Drama’. I was at a conference a few years back, with some colleagues who were aware of
my phobia. I always ask colleagues or friends to test unknown cakes and desserts just in case there is banana inside. At the conference these lovely looking
cakes were set out for everyone to enjoy. My colleague bit into it to show me there was no banana inside, so I comfortably took a bite. As my teeth sank
down into the sponge, they then hit banana. I knew instantly what it was. In a split second I spat it out, ran into the toilets crying and threw up. The next
thing I remember is coming ‘round after fainting, my colleague having to unlock the toilet door to get me out. I can remember thinking it was ridiculous and
that I was just being stupid – but I didn’t know how to deal with it. I just had to try to calm myself down. It took two hours of walking around outside to bring
me back to a calm state.
Bananas scare me, I can’t explain it. The number of times I’ve had to get off a bus or a London Underground tube because someone has been eating a
banana near me is countless. I don’t want to impose my phobia on strangers, so I control it by taking myself out of the situation. It doesn’t inhibit my health
or my life and for that I am grateful. But it still impacts it to a point. My mother always brings up the discussion about me facing my phobia and maybe
getting treatment for it. But for me, right now, I don’t want to face it. I feel I am not ready and I don’t feel it is impacting my life enough that it needs to be
faced. I can handle it and work around it. I guess if it got to a point where it was significantly impacting my life I would face it. For example, if I ever had
children I wouldn’t want them to be impacted by my phobia – I would want them to have bananas so, who knows, maybe that would be the moment I
decided to face my phobia.
I do warn everyone I know, and those who have experienced a ‘Banana Drama’ can regale with tales of me having a panic attack, fainting, throwing up,
crying, screaming and in some cases nearly injuring those around me because of the quick jerk reaction I’ve when I am near one. I guess it can be a funny
tale, and it’s something I can usually laugh about – but when a banana does appear, the colour disappears from my friends’ faces because they know what is
about to happen! Phobias aren’t something to be ashamed of, but my biggest challenge is knowing when to tell people. Do I tell them before they plonk a
bunch of bananas on my desk? Or when I realise they are peeling one near me and have to excuse myself super sharpish so I don’t make a scene? I wish I had
a reason to explain to people where my phobia came from, but I don’t. I just handle it in the best way I can.
Heritability?

• High levels of variability have been found:

• Meta-analysis showed that for blood/injury/injection phobias, studies have found heritability rates to
range from 2% to 71% (Van Houtem et al., 2013).

• Overall heritability rates approx. 25-45% (Van Houtem et al., 2013).

• Gene-environment interactions:
• Hettema (2003) found that both ability to condition fear, and ability to extinguish were heritable. 35-45%
variance attributed to genetic factors.
• Heritability was higher for fear-relevant stimuli (e.g. snakes) than fear-irrelevant stimuli (e.g. geometric
shapes).
Preparedness Theory

• Preparedness is the idea that we are born to acquire fear of certain stimuli more easily than
others, because those stimuli were a threat to our ancestors (i.e. phobia of
snakes/heights/fire much more common than phobia of guns/knives/electrical sockets).
• Patterns in fears across populations can be viewed as evidence for a genetic underpinning to
fear.
• Seligman (1971) – we are born with a predisposition to learn to fear certain stimuli more
easily than others. This does NOT mean that we are born with a phobia.

• BUT… IS PREPAREDNESS A USEFUL THEORY??

The Learning Model of Fear

• Fear is thought to follow a distinctive developmental course e.g. loud noises in babies,
animals in slightly older children (e.g. Muris et al., 1997; Silverman & Nelles, 1989).

• This developmental pattern corresponds with reported onset of phobias:

• Those with height phobias may claim to have always had that phobia
• Those with blood/injection phobias is around the age of 9
• Social phobia onset around 15-18 (Ost, 1987).

• But… Experience is key!

Another ‘but’….

• Not all people who experience a traumatic event develop a phobia, and not all people who
have a phobia can remember experiencing a trauma.

• There is an uneven distribution of phobia prevalence, that does not correlate with prevalence
of stimuli.

Outcome
Expectancies
Rachmann’s Model of Fear

• Vicarious Learning
• Parent’s faked fear reactions to a toy snake influence the likelihood of their child developing a fear of
snakes (Gerull & Rappee, 2002).
• Similar effect seen in lab-reared monkeys (Mineka et al., 1984).

• Fear Information
• Fearful information (especially from adults) can induce fear in children (Field et al., 2001).
• E.g. an incident that was not perceived as traumatic at the time, can be re-evaluated in light of other
people’s reactions .
Phobias and Thoughts

• We know that there is evidence for cognitive factors in anxiety – think back to lecture on GAD

• Attentional biases
• Those with spider and snake phobias take longer to name the colour of the animal than those without
phobia (Ohman et al., 2001) – suggesting their attention is caught on the frightening image.
• People with anxiety take longer to process threatening words (Williams et al., 1996).

• Reasoning biases
• When faced with confronting the stimuli, those with a phobia report a greater perceived likelihood that
they will be adversely affected than those without e.g. that they will be bitten by a spider and injured.
Treating phobia

• ALL effective treatments for phobias contain a behavioural component

• CBT – exposure therapy has been traditionally used to treat phobias

• Use cognitive techniques to reduce beliefs
• Gradual exposure to the stimulus, in a hierarchical manner

• Has been found to be effective when compared to no treatment, with 84% of patients
showing an improvement (Choy et al., 2007).
Formulation: Spider Phobia
Trigger: Seeing a
spider

Cognitions:
Maintaining It will get into my
factors clothes; It will bite
me; I will die
Fight or flight
Avoidance
response

Cognitions about
physical reaction:
I might be sick
I might wet myself
I’ll embarrass myself
I might die
Formulation: Spider Phobia
Trigger: Seeing a Phobias generalise over time
spider

Cognitions:
Maintaining It will get into my
factors clothes; It will bite
me; I will die
Fight or flight
Avoidance
response

Cognitions about
physical reaction:
I might be sick
I might wet myself
I’ll embarrass myself
I might die
Fear Hierarchy

Belief Rating at start of session Rating at end of session

The spider will get onto my 95 80
arms and into my clothes
I won’t be able to get the spider 80 70
off me
I will be so scared that I will be 75 50
sick
If I see a spider I will be so 70 30
scared that I will wet myself
Spiders are my worst fear 100 80
…
Fear Hierarchy

Step Action
1 Look at cartoon images of spiders
2 Look at realistic drawings of spiders
3 Look at photographs of spiders
4 Look at a toy spider
5 Handle a toy spider
6 Look at a live spider
7 Gently touch a live spider with a pencil
8 Handle a live spider
 Going out of the house is a challenge because I
[have a] fear of panicking and feel that I’m
being watched or judged. It’s just horrible. I
want to get help but I’m afraid of being judged.

Panic and social phobia

Panic Disorder (DSM 5)

• Recurrent, unexpected panic attacks that are followed by a period of at least one month of
persistent anxiety about experiencing another panic attack.

• Symptoms of a panic attack: difficulty breathing, heart palpitations, nausea, chest pains,
sweating, dizziness, terror, trembling and feeling certain that something bad is going to
happen.

• Closely related to social anxiety disorder, we will come to this shortly…

Panic Disorder - Prevalence

• Lifetime prevalence rates: 1-2%

• One year prevalence rates: 0.5-1.5%

• In general medical samples, prevalence rates can be as high as 30%

• Around 1/3 to 1/2 of people with Panic Disorder in community samples also have
agoraphobia, this number increases in clinical samples
Social Anxiety Disorder

• Will often be characterised by panic attacks also, but here it is specifically social situations that
trigger the anxiety.

• Typically people with social anxiety disorder will be able to interact without difficulty with
some people, but will experience severe anxiety in other situations.

• Social phobia vs. social anxiety disorder

• Some evidence that there is a name effect on recommendation for treatment
• Renamed for DSM IV
Social anxiety disorder - prevalence

• The 3rd most common psychological disorder after major depression, and substance abuse.

• 12-month prevalence rate 6-7% of the population (Kessler et al., 2006).

Panic Disorder & Social Anxiety- Course

• Onset is most commonly in adolescence, although this varies considerably.

• Pattern of symptoms can be chronic or episodic outbreaks.

• Onset of agoraphobia is usually within one year of first experiencing recurrent panic attacks.

• After 10 years, approximately 30% of people will be symptom free.

Panic Disorder & Social Anxiety– Associated features

• People often also experience anxiety symptoms not related to a specific situation.

• Can impact upon interpersonal relationships.

• Can co-occur with Major Depressive Disorder.

• Co-morbidity with other anxiety disorders is common.

• Can be linked to irritable bowel syndrome, cardiac arrhythmias, asthma and chronic
obstructive pulmonary disease.
The Physiology of Fear

• Biological theories of panic are based on dysregulation of the fight or flight response

• Noradrenergic overactivity
• Overstimulated locus ceruleus
• Reduced GABA-receptor binding sites – GABA believed to play role in modulating anxiety, levels lowered
in panic disorder

• Chronic hyperventilation (‘suffocation false alarm theory’)

• Oversensitive CO2 receptors
• People with panic disorder more likely to have a panic attack if inhaling CO2 (Rapee et al., 1992).
• Klein (1993) suggests misinterpretation of increase in CO2 as meaning low O2 (i.e. suffocation), which
triggers fight or flight response.
Clark’s Panic Cycle (1986)
Safety Behaviours

• Behaviours that are believed to prevent the catastrophic outcome

• Seen as typically being counter-productive by preventing people from gathering accurate

evidence about their experiences

• Reinforce view of perceived threat

• E.g. Avoiding going to the supermarket for someone with social anxiety disorder
Model of Social Anxiety (Clark & Wells, 1995)
Activity: Case study (source – Mind.org)
I turned everything off, I locked the door, I remembered my bus pass, I look presentable - everything is
absolutely fine. But I still manage to attract the feeling that something's just not quite right. Then it hits me.
That awful feeling, something horrible is about to happen and I have absolutely no control over it.
'I don't feel right. Why is my heart racing? Should my heart be racing? I'm sat still. Am I going to have another
panic attack? I'm going to have another panic attack. Look for an exit. Get out, just get out quick or I'll pass
out... Its okay, I've taken my meds. I'm okay. Just focus on something else. It's a beautiful, bright sunny day
outside. Oh god, its that bad I'm having to focus on something else. Will they notice? When will my meds kick
in? I feel really really weird. It's way too bright. I'm trapped. Get off, just get off, quickly.'
That was my second attempt of leaving my family home in months. Agoraphobia is exhausting. It stops us
from doing the things we love. Because when you're scared of having a panic attack in public, you do the most
logical thing you can. You stay away from the perceived danger. It feels easier and safer to just stay in your
bed. On your own. Away from a dangerous world.
My anxiety disorder left me crippled, I felt like I was queuing for a roller-coaster the moment I locked the door
behind me. Everywhere I went, I looked for exits, over analysed conversations, wore a hat everyday so no one
would notice me if I had to leave. I went weeks thinking 'I haven't spoken a single word to anyone'. I was
scared to go out into public because I associated it with having panic attacks. And because I was so scared of
the attacks, I became even more terrified of the cause; going out.
I have sacrificed so much to satisfy my condition. I lost friends, I lost myself, a career, grades and passion for
the things I loved doing.
Treating Panic

SSRIs Benzodiazepine
Treating Panic

SSRIs Benzodiazepine

Not recommended for

social anxiety as a first
line treatment
Core Elements of CBT for Panic

• Psychoeducation/ Informational intervention

• Cognitive interventions
• Interoceptive (internal) exposure
• In vivo exposure
Interoceptive Exposure

• Exposure to internal sensations.

• Provide opportunities to examine negative predictions about internal sensations.

• Provide opportunities to increasing tolerance to and acceptance of internal sensations though

repeated exposure to sensations .

• Engage in systematic exercises that induce feared internal sensations (i.e., dizziness, increased
heart rate).

Otto et al., 2010

Meta-Analytic Results of
Panic Disorder Treatment Studies

CBT
(IE+CR)

Effect Size (Cohen’s d) CBT Benzo-

diazepines
SSRIs
Antide-
Non-SSRI
Antide- pressants
pressants

Gould et al, 1995; Otto et al., 2001

So CBT is great?

• Understanding HOW an intervention works is important!

• The effectiveness of challenging cognitions in therapy has been challenged (Longmore &
Worrell, 2007)
• Thought change relies on the client being able to suppress his or her initial, distressing
thought, which recent evidence suggests may be more problematic than simply leaving the
thought alone to begin with, and often results in that same thought, or thoughts related to it,
being more likely to occur in the future (Wenzlaff & Wenger, 2000)
Obsessive-Compulsive Disorder
Core symptoms

• Obsessions = intrusive thoughts about fear of harm to self or others unless action is taken
• Compulsions = the behaviour where protective action is taken

• The obsessions or compulsions are time consuming, > 1 hour per day
• Symptoms are not attributable to the physiological effects of another substance or disorder
Experiencing OCD

• Disruption to day-to-day life

• Impact on your relationships
• Feeling ashamed or lonely
• Feeling anxious
Biological explanations

• Orbito-frontal cortex
• Responsible for emotion regulation, evaluation, goal-directed behaviour
• Evidence to suggest this is heightened in people with OCD
• Serotonin systems
• Genetics
• Evidence for heritability suggests a genetic component
Psychosocial explanations

• Behavioural model of OCD

• Anxiety arises when we can’t easily escape
• Anxiety is reduced by engaging in behaviours believed to reduce the threat
• Avoidant behaviours reduce anxiety in the short-term, but maintain anxiety in the longer term

• Cognitive-behavioural model (Salkovskis & Kirk, 1997)

• Obsessions = intrusive beliefs
• Cognitive avoidance -> increased frequency
• Use of safety behaviours

• Meta-cognitive model (Wells, 2000)

• Thought-event fusion
• Thought-action fusion
• Thought-object fusion
Treatment

• Exposure is key!
• Thought experiments
• Thought challenging
• Behavioural exposure and response prevention

• Cognitive-behavioural interventions not more effective than behavioural interventions

(Olatunji et al., 2013)

• ACT has been shown to be effective (Twohig et al, 2010)

• Biological treatment = SSRIs

Activity: Case study

• https://www.youtube.com/watch?v=s1Kgv6kYU7w

• Holly’s mental health story for Mind

 End of session
Resources are available on the PS6007 Moodle page