Specific Phobias & GAD

1. Specific Phobias& GAD JONATHAN GASTON DIRECTOR – EMOTIONAL HEALTH CLINIC CENTRE FOR EMOTIONAL HEALTH

2. Defining Fear/Anxiety • ‘Fight-Flight Response’ • A necessary inbuilt protective response mechanism to protect us from danger and help us survive • Only a problem when: • Mechanism is switched on when we don’t want it to be OR • The intensity of the response seems ‘out of proportion’ to the actual danger

3. Physiological Anxiety Response • Rapid heart, heart palpitations, pounding heart • Sweating • Trembling or shaking • Shortness of breath or smothering sensations • Dry mouth or feeling of choking • Chest pain or discomfort • Nausea, stomach distress or gastrointestinal upset • Cold chills or hot flushes • Dizziness, unsteady feelings, lightheadedness, or faintness • Feelings of unreality or feeling detached from oneself • Numbing or tingling sensations • Visual changes (e.g., light seems too bright, spots, etc.) • Blushing or red blotchy skin (especially around face) • Muscle tension, twitching, weakness or heaviness

4. Neurobiology of Anxiety (Stein et al., 2007; Etkin & Wager, 2007) • Amygdala Hyperactivity – central to fear conditioning • Insula Hyperactivity– regulates autonomic nervous system and associated with interoceptive awareness

5. CBT MODELS & ANXIETY

6. ‘Traditional’ A-B-C Model of CBT • Linear • Unidirectional • ‘Thoughts cause feelings’ A B C D Situations Thoughts Feelings Behaviour • Focus is on challenging irrational thoughts (cognitive restructuring)

7. More Current CBT Model Thoughts Physiology Mood/Emotion Behaviour • Non-linear • Integrative • All components of equal importance

8. Final Cognitive Pathway Model Physiology (Physical Symptoms) Mood/Emotion COGNITION ‘More Conscious’ ‘More Automatic’ Behaviour Perception/Attention ‘Environment’

9. Cognitive Pathway Model • Cognitive, behavioural, emotional, physiological and attentional approaches are potentially ‘synergistic’ not ‘antagonistic’ • Humans always employing cognitive processes in solving any problem- whether these processes be more automatic or more conscious in nature • Different common pathways (eg., conditioning, observational learning, cognitive challenging, emotional processing, mindfulness) lead to same final common pathway: “Action on an underlying cognitive belief structure”

10. Final Cognitive Pathway Model for Anxiety Anxiety Symptoms ‘Fight or Flight’ Response Anxiety/Fear & Apprehension DANGER/THREAT APPRAISALS ‘Probability’ & ‘Cost’ Safety Behaviours Avoidance Escape Neutralising Hypervigilance for Danger ‘Scanning for threat’ Look for ‘confirming evidence’ ‘Environment’

11. Aim of Treatment for Anxiety “To modify danger/threat appraisals to become more realistic and adaptive”

12. In Designing Treatment for Anxiety • Key in Assessment: What are the specific danger/threat expectancies? • Key in Treatment: What factors are currently maintaining the specific danger/threat expectancies? • Order of Effectiveness in Learning: (Reiss, 1980) • Experience • Observation • Symbolic (e.g., language)

13. CBT for Anxiety - Cognition • Key: need to address both probability and cost with some fears • Also need to consider ‘Metacognition' - beliefs about the problem itself: • problem (causes, maintenance, costs, benefits) • utility of current coping strategies (general) • specific safety strategies • change • self-efficacy • coping with actual physiological sx. (are sx. harmful?)

14. CBT for Anxiety - Behaviour • Key: How is the client's behaviour maintaining their threat appraisals? • Safety Behaviours • avoidance & escape behaviours • proactive (‘neutralising’) behaviours • 'subtle' in-sitn. safety behaviours • cognitive safety behaviours

15. CBT for Anxiety – Physiology & Emotion • traditionally a ‘control-based’ approach • now less emphasis than previously • relaxation can useful as general stress/anxiety reduction tool • be careful intervention strategies do not become safety behaviours • often treatment (exposure) will involve increasing Sx. • ‘symptom surfing’ - increase coping • ‘symptom exposure’ – increase tolerance ‘short term gain vs. long-term change’

16. CBT for Anxiety - Attention • attentional focus can interfere with the processing of information from feared situations (‘selective filter’) • client needs to process 'range' of perceptual evidence • 'task-focussed attention' • 'mindfulness' (being in the moment) • how best to train???

17. Do Psychotherapies produce Neurobiological effects? (Kumari, 2008) • Emerging empirical evidence to demonstrate that psychological therapies produce changes at the neural level • Paquette et al., (2003) • Successful CBT modified neural activity in the dorsolateral prefrontal cortex and the para-hippocampal gyrus in a group of spider phobics • “CBT reduces phobic avoidance by de-conditioning contextual fear learned at the hippocampal/parahippocampal region, and by decreasing cognitive misattributions and catastrophic thinking at the level of the prefrontal cortex”

18. SPECIFIC PHOBIAS

19. Lohr, Oluntunji & Sawchuk (2007) • The more explicitly danger is signalled in terms of location, duration, intensity & onset, the more specifiable safety signals can be • Specific phobias provide the best example of a danger signal with clearly defined boundaries & properties • The safety behaviour of avoidance is often so effective that daily life is only minimally disrupted • This may account partially for the significant discrepancy between the high diagnostic prevalence vs. the low proportion seeking treatment (1%)

20. SPECIFIC PHOBIA - DSM IV A. MARKED AND PERSISTENT FEAR THAT IS EXCESSIVE OR UNREASONABLE AND CUED BY PRESENCE OR ANTICIPATION OF A SPECIFIC OBJECT OR SITUATION. B. EXPOSURE TO STIMULUS ALMOST INVARIABLE PROVOKES IMMEDIATE ANXIETY. C. PERSON RECOGNISES EXCESSIVENESS OF FEAR. D. STIMULUS AVOIDED OR ENDURED WITH DREAD. E. AVOIDANCE INTERFERES SIGNIFICANTLY WITH NORMAL ROUTINE OR FUNCTIONING

21. Specific Phobia - Subtypes ANIMAL – spiders, snakes, other insects, dogs, birds, sharks, etc NATURAL ENVIRONMENT – storms, heights, water BLOOD, INJECTION, INJURY – seeing blood or an injury, receiving an injection or invasive medical procedure (common fainting response) SITUATIONAL – tunnels, bridges, elevators, flying driving, enclosed spaces, driving OTHER – choking, vomiting, contracting an illness, loud noises, costumed characters

22. DANGER/THREAT APPRAISALS IN SPECIFIC PHOBIAS? • Pain • Physical/bodily harm • Illness/Disease • Death

23. Demographics of Specific Phobia • LIFETIME PREVALENCE 12.5% (Kessler et al., 2005) • AGE OF ONSET YOUNG (ÖST) • ANIMAL FEARS - <7 • BLOOD - <9 • DENTAL - <12 • SITUATIONAL (CLAUSTRO) - 20 • AGE OF PRESENTATION ?? • SEX DISTRIBUTIONFEMALE 2:1 ratio • COURSE OF DISORDERUNKNOWN • DEGREE OF INTERFERENCELOW • COMORBIDITY HIGH WITH OTHER ANXIETY DIS (Magee et al., 1996)

24. HERITABILITY OF SPECIFIC PHOBIAS – KENDLER ET AL (1999)

25. CONDITIONING THEORY OF PHOBIAS CS UCS AVOID (DOG) (BITE) CR UCR (FEAR) (PAIN/FEAR)

26. PROBLEMS WITH THE CONDITIONING THEORY OF PHOBIAS - RACHMAN (1970), SELIGMAN (1971) • MANY AVERSIVE EXPERIENCES DO NOT RESULT IN PHOBIAS (E.G. AIR-RAIDS) • PHOBICS DO NOT OFTEN RECALL “CONDITIONING” • PHOBIAS DO NOT EXTINGUISH EASILY • PHOBIAS OCCUR TO A LIMITED SET OF STIMULI (NO EQUIPOTENTIALITY)

27. PREPAREDNESS THEORY OF PHOBIAS - SELIGMAN (1971) A PREPARED STIMULUS IS ONE WHERE: • FEAR IS ACQUIRED IN A SINGLE LEARNING TRIAL • THE FEAR IS NON-COGNITIVE • THE FEAR IS RESISTANT TO EXTINCTION

28. SUPPORT FOR PREDICTIONS MADE BY THE PREPAREDNESS THEORY OF PHOBIAS (McNALLY, 1987)

29. Rachman (1976, 1977, 1991) Three (learning-based) Pathways to Fear: • Classical conditioning • Vicarious acquisition through direct or indirect observations • Informational acquisition

30. SPECIFIC THREAT EXPERIENCES IN HEIGHT PHOBIA (MENZIES & CLARK, 1993) A NON-ASSOCIATIVE ACCOUNT OF FEAR ACQUISITION ?

31. RELATIONSHIP BETWEEN FALLS AND FEAR OF HEIGHTS (POULTON ET AL, 1998)

32. RELATIONSHIP BETWEEN FALLS AND FEAR OF HEIGHTS (POULTON ET AL, 1998)

33. Cognitive Vulnerability Model of Phobias

34. Specific Phobia – Treatment Issues • The development of good, well-designed and specific exposure hierarchies • Being innovative in planning exposure (e.g., time vs. task) • Potential benefits of massed exposure/quick gains ??? • The client doing enough exposure (dose-response issue) • Dealing with the physical sx. of anxiety while doing exposure • ‘Subtle avoidance’ which may reduce exposure effect (the case for early ‘guided’ exposure) • The case for ‘overlearning’ ??? • Applied tension for fainting in blood-injury phobia • ‘Fear vs. disgust’

35. Optimising Exposure (Craske et al., 2008) 1. Variability throughout Exposure • Retention of learned material is enhanced by random and variable practice • While variation increases learning difficulty, it enhances long-term outcome • Variation increases the storage strength of information • Variation results in pairing the information to be learned with more retrieval cues, this enhancing retrievability • Variation leads to superior generalization

36. Optimising Exposure (Craske et al., 2008) 2. Spacing of Exposure Tasks • Temporally spaced learning trials may result in stronger learning acquisition than massed • Evidence suggests though that each trial must sufficiently violate fear expectancies • ? Massed X Spaced interaction • Some evidence for ‘tapering’ (progressively longer intervals between exposure occasions 3. Context Effects • Should conduct exposure therapy in multiple contexts, especially those in which the previously feared stimulus is likely to be encountered once treatment is over

37. Optimising Exposure (Craske et al., 2008) 4. Fear Toleration vs. Fear Reduction • Emotional regulation is potentially dysfunctional when applied rigidly to down regulate emotions through suppression, control, avoidance or escape • Persistent attempts to down regulate aversive states are often critical to the onset of phobias and other anxiety disorders • Some evidence that sustaining fear responding throughout extinction may actually enhance extinction learning

38. GENERALISED ANXIETY DISORDER

39. Lohr, Oluntunji & Sawchuk (2007) • The more explicitly danger is signalled in terms of location, duration, intensity & onset, the more specifiable safety signals can be • Danger signals that transcend time and place (unpredictability of onset) make for poorly defined safety signal development • Danger signals in the form of intrusive thoughts and worries that are future-oriented and involve catastrophic outcomes with objectively low probability do not allow for the establishment of safety relative to current time and place • The broad nature of threat will render safety seeking behaviour as ill defined and generalised • Is GAD largely a chronic but unsuccessful search for safety ? (Woody & Rachman, 1994)

40. GAD: DSM-IV Criteria • EXCESSIVE ANXIETY AND WORRY OCCURRING MORE DAYS THAN NOT FOR AT LEAST SIX MONTHS ABOUT A NUMBER OF EVENTS. • DIFFICULTY CONTROLLING THE WORRY C. AT LEAST THREE OF THE FOLLOWING: • 1) RESTLESSNESS OR FEELING KEYED UP • 2) EASILY FATIGUED • 3) DIFFICULTY CONCENTRATING • 4) IRRITABILITY • 5) MUSCLE TENSION • 6) SLEEP DISTURBANCE D. FOCUS OF WORRY NOT ANOTHER AXIS 1

41. DANGER/THREAT APPRAISALS IN GAD? Many and varied Two key underlying issues: • The world is an unpredictable and unsafe place • I am ill-equipped to deal and cope with this danger and general uncertainty (‘ a poor coper’) People with GAD like control and predictability

42. DEFINITION OF WORRYBORKOVEC ET AL. (1983) • AN ATTEMPT TO ENGAGE IN MENTAL PROBLEM-SOLVING ON AN UNCERTAIN ISSUE WITH A POTENTIAL THREAT OUTCOME

43. CONTENT OF WORRIES IN GAD- ROEMER ET AL (1997)

44. CONTENT OF MISCELLANEOUS WORRIES IN GAD - ROEMER ET AL (1997)

45. FEATURES OF WORRY IN GADCRASKE ET AL. (1989)

46. GAD - DEMOGRAPHICS • GAD has a lifetime prevalence of 5% • GAD affects approximately 400 000 adult Australians each year • Gender ratio: Females 60% • GAD makes the top 12 diseases for disability adjusted life years lost • GAD presents a substantial financial cost to the community, e.g., high health care costs and lost work productivity • GAD is associated with substantial co-morbidity - primarily other anxiety disorders & depression

47. DSM-IV DISORDERS AND AFFECTIVE STRUCTURE – BROWN ET AL (1998)

48. Life Interference • GAD interferes with: • Work and academic functioning/aspirations (over & under achievement) • Enjoyment and quality of life (chronic cognitive & physical arousal, avoidance) • Emotional experience (can be aloof or overly-emotional) • Engagement in interpersonal relationships (stress, intimacy, genuineness, avoidance, isolation) Pure GAD is equally as disabling as pure MDD

49. Course • GAD has an early onsetand a chronic course • Most people with GAD have always been worriers • Mean onset is between the teens and late twenties • BUT, onset may be earlier (children were previously diagnosed with “overanxious” disorder) • GAD symptoms are chronic and persist for 10 yrs or more • GAD is unlikely to remit spontaneously

50. PROBABILITY OF REMISSION OF GAD (YONKERS ET AL, 1996)