Lecture 2: Anxiety disorders

What topics are discussed?

Phobias
A lot of phobias make sense from an evolutionary perspective. Being afraid of snakes meanwhile you have never had an encounter with a snake could be due to ancestors having to deal with dangerous snakes. Many people with phobias choose to live with their symptoms rather than seeking treatment. This is because they don’t realise they are having irrational thoughts, or because they are embarrassed. Phobias are very treatable if done properly. Exposure treatment is an effective treatment. however, people fear those because they don’t want to be exposed.

Conclusions to start with
- Understanding the nature of anxiety disorders is vital to evidence-based and effective treatment. It starts with a thorough understanding of the conditioning theory. If you don’t understand the conditioning theory you might not be able to perform an effective treatment.
- The search for new treatments continues because of incomplete response to existing treatment, relapses, and problems with acceptability of treatment.
- In general, new treatments are being implemented fast, with little attention to potential adverse effects.

Mowrer’s theory of fear and avoidance
According to Mowrer’s theory of fear and avoidance, acquisition of fear is done via classical conditioning. There must have been an incident in which the person has experienced fear. Avoidance would be reinforced by operant conditioning, which reduces anxiety. People avoid situations that they associate with their phobia. Avoiding these situations immediately reduces anxiety/fear. This theory describes that fear generates search for safety. Fear is considered a balance between signals of threat and signals of safety. If someone is fearful for birds, that person may be so generalised that he or she might not be able to drive or go outside, unless there is someone’s with him or her who can scare away birds. This is a signal of safety.

Video 1
A video is shown in which a woman has a phobia of birds. She is shown a feather. Her heart beat goes up, she shows avoidance behaviour. As a clinician, there is no such thing as an irrational fear. You have to change the irrational fear into a rational one.

Early versions of behaviour therapy for anxiety disorders
Behaviour therapy for anxiety disorders is based on the habitation model. For example, you can induce fear by unexpectedly playing a noise sound. Then the person will startle, but if you play them the sound multiple times after that, their response will be less. When you confront someone you basically wait for the fear to die out.
As a clinician, you have to teach people that the physiological response is antagonistic to anxiety. You help people control their fears and responses. This is done by e.g. meditation and breathing techniques. These will help someone get through the exposure.
Another way to treat anxiety disorders is to work your way through an ‘anxiety hierarchy’. You rank order situations in hierarchy and you work through those. You start with the easy situations, and if the person has mastered relaxation on that level you work your way up.

Video 2
The same woman gets therapy. However, the clinician doesn’t solve the irrational thought for her. Hypnosis is done. By doing this the clinician tries to adapt her conditioning responses and teaches her to be relaxed and then to very carefully mention feathers. He is mentally preparing her for difficult situations. Apparently the woman had completely forgotten the situation in which she first encountered a bird/fear. It is important to note that avoiding fear is not the way to get treated. When exposed to a bird the woman still feels fear. The clinician helps her avoid it, which he shouldn’t do.

Panic disorder
symptoms of a panic disorder are emotions of panic and anxiety, increased heart rate, sweating, dizziness, nausea, the idea or feeling that you’re going to die. Bodily sensations can cause catastrophic misinterpretation (‘my heart is beating so fast, there is something wrong with my body’), which can lead to anxiety (‘I am going to die’) and so on. You search for these three dimensions with someone who might be having a panic attack. To this model adds attentional bias: when you focus on scanning your body you’re more likely to feel things which you first didn’t feel. Feared catastrophes can be dying, fainting, going insane or losing control.

Video 3
In this video a man is shown who has a panic disorder. He only feels comfortable close to his home. during his first panic attack he had no idea what was going on. Symptoms he showed were a rush of adrenaline, heart racing, sweaty palms, and feeling very uncomfortable. With panic disorders or panic attacks come cognitions and thoughts, for example What if I don’t feel good?, what if I want to go home?, What is I get stuck in traffick?. These questions are also asked in therapy. A clinician could ask, in response to e.g. What if I get stuck in traffic?, ‘so what?’ or ‘then what?’. Then the patient is likely to say that he or she is afraid of dying. ‘So, your fear is dying, not e.g. driving a car / being in a crowded place etc.’.

Video 4
This video is about the woman who is afraid of birds. She gets therapy from another clinician. He motivates her and tells her it’s not going to be worse and that the therapy will be done with a purpose. He is giving her the control by asking her if she really wants to do this. He won’t do anything without her consent. The woman’s worst fear is dying. That is a rational thought/fear. Now the clinician can frame the exposure session in a different way. She needs an alternative explanation of why her heart starts racing etc. She is shown a small feather and the clinician shows her she is not dying. The idea is to activate the anxiety rather than trying to keep it down like the previous clinician did.

What are safety behaviours?
Social phobia: gripping object tightly to avoid shaking, monitoring their speech
OCD: compulsions
PTSD: discussing traumatic event in an unemotional way
Pain: avoiding daily activities to not re-injure
Panic disorder: holding onto objects, lying down, escaping the situation
 

EMDR and PTSD
In the 80s they would also call a panic disorder a hyperventilation disorder. When someone would hyperventilate they would calm that person down by using breathing techniques, e.g. breathing into a bag to restore the balance of breathing out too much CO2.
EMDR started to come off in the 80s. In EMDR, the patient has to follow an object or finger with their eyes while thinking about the traumatic event. Eye movements reduce the vividness of imaginations. People immediately feel better after the exposure/EMDR. You can also do different tasks, as long as they are concurrent. If you are using working memory tasks, doing the task will take up space in the working memory so you have less space to think about the traumatic event, then that will become less vivid and less emotional.
EMDR lasts for one to three sessions for straight forward incidents of traumatic events. For PTSD it can last 12-16 sessions.

What topics are discussed which aren’t discussed in the literature?
All topics discussed in the lecture are discussed in the literature as well. Pay attention to the literature, as that discusses topics which aren’t discussed in the lectures.

How has this topic developed over the past few years?
E.g., a panic disorder was looked at differently years ago while the DSM IV was still used. Just like in many other disorders, the DSM has developed, and with the transition from DSM IV to DSM V, disorders and their criteria were adjust, or removed or added.

What comments are made with regard to the exam?
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What questions are being asked which could be asked on the exam? What is the answer?

What are symptoms of a panic disorder?
Emotions of panic and anxiety, sweating, an increased heart rate, dizziness, nausea, feeling of dying.

What is the attentional bias?
When focusing on scanning your body, you are more likely to feel sensations which you didn’t feel at first.