Samenvatting
Summary ALL literature summaries Anxiety and related disorders
- Instelling
- Universiteit Utrecht (UU)
In this document, summaries of all of the literature for each week of the course Anxiety and related disorders is gathered.
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WEEK 1: Emotion theory and anxiety disorders1. Mental disorders as networks of problems: a review (Fried et al., 2017)
Approach that treats mental disorders as networks of interacting symptoms using network
psychometrics a causal interplay between symptoms constitutes mental disorders (we can draw
causal links between symptoms of a disorder, realize what came first and hence what should be
treated first).
1. Time-series allow to look at these causal relationships (are directional).
2. Whereas cross-sectional data is an undirected network.
1) Comorbidity
o People with more disorders have a poorer prognosis, worse treatment outcomes, and higher
suicide rates.
o The approach hypothesizes disorders co-occur due to mutual interactions among symptoms
(and hence, aren’t totally unrelated as has been traditionally believed). Comorbidity arises
when symptoms bridge two disorders bridge symptoms can spread activation from one
disorder to another.
o For example, one such symptom, common to most disorders, is emotional pain = a promising
target for psychotherapeutic interventions.
o There are no sharp boundaries between many disorders due to a substantial symptom overlap.
diagnoses may co-occur as a function of their number of shared symptoms. Disorders that
share more symptoms are more likely to co-occur (a ni to po definiciji sicer?), but only if they
share common underlying causes (if the causes are independent, this isn’t a predictor of
comorbidity, such as in physical illnesses, even if symptoms are the same, but the cause
different,
o Empirical comorbidity rates were related to distances between disorders in an analysis of
symptom overlap in the DSM.
o However, the way comorbidity arises may very well be different for different people with the
same comorbid diagnoses and different for different types of comorbid diagnoses.
2) Prediction
o While many people experience single symptoms, only part of them develop a mental disorder.
o Prediction of psychopathology onset is thus crucial for intervention, it allows us to know when
a transition happens between healthy and disordered states, when a tipping point is reached.
o Such knowledge (of early warning signs and of centrality degree of each symptom) also helps
predict such tipping points.
o For weakly connected symptom networks, negative external conditions (i.e., stressful events)
lead to a gradual increase in symptoms, whereas for strongly connected networks, external
stress leads to a sudden shift from a healthy to depressed state. Knowledge of such
networks sheds new light on a long-standing discussion whether psychopathology is
dimensional or categorical: for those with a strong connectivity of symptoms, it’s categorical,
for those with a weaker symptom connectivity, it’s dimensional.
3) Clinical intervention of the concept of centrality
, o Network analysis may provide promising leads towards improving clinical prevention and
intervention strategies by investigating which symptoms are more strongly connected or more
central than others.
o If a symptom (e.g., depressed mood) has many connections to other symptoms in a
psychopathological system, it may cause the development of these symptom, hence, it should
be the first to treat.
o However, the problems are that different studies use:
1) different questionnaires
2) different time frames
3) different samples
4) different network estimation methods
Network models of psychopathology help:
1) predict onset / tipping points / transition from healthy to disordered time interventions
2) determine the most central symptoms to a disorder target interventions to people with those
symptoms
2. Anxiety disorders: why they persist and how to treat them (Clark, 1999)
But isn’t the idea of exposure therapy precisely that enough disconfirming evidence helps tackle
anxiety disorders? But the article says exactly the opposite: DESPITE a ton of disconfirming
experience, people with anxiety disorders still engage in their negative maladaptive thinking
patterns, so exposure didn’t work? exactly, this works is a direct critique of the behavioral
conditioning theories of anxiety!
1. Safety-seeking behavior
o Safety behaviors = behavior which is performed in order to prevent or minimize a feared
catastrophe.
o This explains why the non-occurrence of a feared event fails to change patients' negative
beliefs: if the person uses safety behaviors, their beliefs aren’t really disconfirmed, since they
can attribute the absence of the US to their safety behaviors.
o In an experiment that manipulated safety seeking behaviors, dropping-safety behaviors
condition led to a significantly larger decrease in negative beliefs and produced a significantly
greater improvement in anxiety in a subsequent behavior test.
o Several additional interesting features of safety behaviors:
1) many safety “behaviors” are internal mental processes (worrying, memorizing, rehearsing,
reassuring, checking) making their basic fear to persist
2) patients often engage in a large number of different safety behaviors in a feared situation
3) safety behaviors can create some of the symptoms that those with anxiety disorders fear
4) some safety behaviours can draw other people's attention to the patient
5) some safety behaviours influence other people in a way which partially confirms the
patient’s fears
2. Attentional deployment
o Selective attention towards threat cues may play a role in the maintenance of anxiety disorders
by enhancing the perception of threat.
, o Attention towards threat cues
In an experiment, patients with spider phobia showed an attentional bias towards the spider
pictures more than non-patient controls.
Panic disorder patients were more accurate at counting their heart beats than infrequent
panickers, simple phobics and non-patient controls.
Yeah, but still, this is a defining characteristic of anxiety disorders, it doesn’t explain
WHY people develop an anxiety disorder. These traits are merely symptoms one
developed after already having a disorder.
o Attention away from threat cues
Socially anxious individuals tend to avoid looking at other people when in a feared social
situation, but it’s precisely the eye contact that gives information about how others react
towards us. The high socially anxious students showed an attentional bias away from faces
and towards objects. In this way, attentional avoidance would maintain their fears.
There’s a difference though: patients with spider phobia, panic disorder and
hypochondriasis show an attentional bias towards threat cues, whereas patients with social
phobia show some evidence of an attentional bias away from others' facial expressions.
If a spider phobic is presented with a spider, looking away does not remove the threat
hence, it doesn’t help to look away.
On the other hand, looking away from others' faces and avoiding eye contact is likely
to reduce some aspects of threat for a social phobic (less likely to engage them in
conversation) provides a psychological escape.
3. Spontaneously occurring images
o Spontaneously occurring mental images in which patients `see' their fears realized are common
in anxiety disorders and enhance the perception of threat.
o One particularly potent source of information is self-imagery, which serves as “evidence” even
in the absence of any real empirical evidence.
o In these images, patients see they see their fears visualized, which to them, confirms these
fears.
o In an experiment, the majority (77%) of patients with social phobia reported spontaneously
occurring, negative, observer-perspective images, and only 10% of non-patient controls
reported such images and their images were in general less negative.
o Also, these images lack updating in social phobia, there are recurrent images which appear
in similar form in various social situations, are often outdated, from times when the person was
humiliated etc. from a time when a mental model of the patient’s social self was laid down
after a traumatic experience., and then this model is reactivated in subsequent social
encounters. Reduced attention to social situations prevents the model from being updated.
4. Emotional reasoning
o Patients with social phobia use self-images and other anxiety-related interoceptive
information, to make erroneous inferences about how they appear to others.
o In an experiment, within the high social anxiety group, perceived body sensations were
significantly correlated with self-ratings, but not observer-ratings, of anxious appearance.
o Social anxiety may be partly maintained by patients using perceived body sensations to make
erroneous inferences about how anxious they appear and how poorly they come across an
instance of emotional reasoning.
, 5. Memory processes
1) selective retrieval of negative memories and impressions of the observable self
Anxious individuals selectively retrieve information which appears to confirm their worst
fears. They recall fewer positive words and recall more negative ones, but only when
anticipating a speech, and only for those terms referring to how they would appear to others.
2) dissociation between explicit and implicit memory (recall and priming)
Those with PTSD have difficulty in intentionally retrieving a complete memory of the
traumatic event.
However, they also often they involuntarily re-experience aspects of the trauma vividly and
emotionally.
3) affect without recollection
Triggering of intense affect by the presence of stimuli that were associated with the trauma,
without
simultaneous recollection of the traumatic event. An aspect of PTSD is the out of the blue'
intense affect which may be maintained because the threat cue that triggers the problem is out
of awareness.
6. Nature of the perceived threat
o A neglected aspect of PTSD is patients' interpretation of the symptoms they experience in the
first days and weeks after the traumatic event (before the disorder develops).
o Why are the symptoms of PTSD persistent in some people and not in others? One factor may
be the way you interpret your initial normal intrusive recollections and other symptoms. If you
interpret them
o negatively thinking they indicate you are going mad, losing control or becoming a neurotic
person, you may engage in thought suppression and other dysfunctional strategies that could
prolong the intrusions and other symptoms. There is a positive correlation between initial
interpretations of PTSD symptoms and the subsequent severity and persistence of PTSD.
7. Empirically derived treatment
o It is hoped that precisely targeting maintenance processes will make therapy more efficient and
effective.
o Developing an idiosyncratic model
Treatment starts by developing with patients an idiosyncratic version of the cognitive model
(how specific triggers produce negative automatic thoughts and how they are maintained) at
the end of the first session of therapy.
o Examining and modifying negative beliefs and linked maintenance processes
1) identify patients' evidence for their negative beliefs (help the client see the significance of
the counter evidence)
2) education about the symptoms of anxiety
3) image modification: finish out' the image by asking patients to recreate their negative
image, hold it in mind until they start to feel anxious and then run it on until they see the
positive resolution; you need to elicit the affect normally associated with the image.
o Anxiety results from overestimating the cost of feared events as well as their probability.
Interventions aimed at modifying perceived cost are often helpful.
o Exposure to feared situations and sensations is a key component of cognitive therapy for
anxiety disorders, but cognitive therapists do not generally consider simple repetition of an
exposure assignment to be helpful. The cognitive change model posits that exposure is
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