Professional Documents
Culture Documents
People differ in the ease with which an alarm (true or false) is triggered.
The Triple Vulnerability Model
The Triple Vulnerability Model emphasises three specific vulnerabilities which
increase the sensitivity of a persons alarm trigger.
1. Biological Factors
2. Generalised Psychological Factors
3. Specific Psychological Factors
Biological Factors
o An example of a biological factor is an inherited predisposition (diathesis)
towards depression and anxiety disorders. These share similar genotypes.
o Another example of a biological factor is comorbidity. There is a clustering of
emotional disorders around a common genetic vulnerability. This is known as
the general neurotic syndrome.
Generalised Psychological Factors
o Generalised psychological vulnerability includes beliefs that the world is a
generally dangerous place, combined with broad expectations that events are
beyond ones control.
Specific Psychological Factors
o Specific psychological factors refer to specific objects or situations and
include factors which might influence the expectation of a negative outcome
when confronted with a specific object or event.
o Conditioning is one way to acquire such an expectation.
While the triple vulnerability model emphasises similarities between the various
anxiety disorders, others seek to identify areas of both similarity and differences
across these conditions.
One such approach is to focus on three dimensions of emotions;
1. Negative affectivity
2. Positive affectivity and,
3. Autonomic arousal.
This approach sees anxiety disorders as the result of some combination of these
factors. People with the disorders are high on trait anxiety and hence are more likely
to experience false alarms.
This approach allows disorders to be distinguished between in terms of the emotional
dimensions of negative and positive affectivity.
For Example, social phobia and depression are distinguished from other disorders as
they present with a lack of positive affectivity. That is, there is autonomic arousal
(they are alert) they feel negative affect to do with this (alert in a distressed way) and
have a notable lack of positive affect.
Specific Phobias
A Panic Disorder is diagnosed when panic attacks are recurrent and unexpected.
Symptoms include,
1. Persistent (one month) concern or worry about additional panic attacks or
their consequences. AND/OR
2. Significant changes in behaviour related to the attack.
Agoraphobia is diagnosed when the sufferer experiences marked fear or anxiety in at
least two of the five following situations;
o Public transport
o Crowded places or queues.
o Open spaces
o Outside of the home alone
o Enclosed spaces
o
Agoraphobic situations almost always trigger fear and anxiety. They are actively
avoided or are endured with intense fear or anxiety for at least a six month period.
Furthermore fear and anxiety must be out of proportion for the context and culture.
For example, the same set of behaviours and fears whilst living in a warzone would
negate a diagnosis, as such behaviour is understandable in the context.
o
o The Epidemiology of Panic Disorder and Agoraphobia
As with most other anxiety disorders, panic disorder occurs more in females.
Panic disorders tend to be chronic, however their severity waxes and wanes with time.
o
o The Aetiology of Panic Disorders and Agoraphobia
The origins of panic disorder involve all three aspects of Barlows (2002) triple
vulnerability. Recall this involves biological, generalised psychological and specific
psychological factors.
The experience of a false alarm panic is not the cause of a panic disorder.
A Generalised Biological Vulnerability comes in the form of an inherited genetic
risk for anxiety sensitivity.
The psychological vulnerabilities account for the progression from having a panic
attack to developing panic disorder.
A Generalised Psychological Vulnerability exacerbates the experience of a false
alarm, and one such vulnerability is Anxiety Sensitivity. People with high anxiety
sensitivity fear arousal-related sensations in their body, steaming from the belief
that such sensations are dangerous.
A Specific Psychological Vulnerability is that the individual specifically fears the
sensations of pain.
o According to Clarks (1986) Cognitive Model of Panic Disorder, people
misinterpret the physical sensations of panic in a catastrophic manor. I am
having a heart attack and, I am going to lose it are common examples.
o Such catastrophic misinterpretations elicit the fight or flight response (a
false alarm), which elicits additional physical sensations that are also
misinterpreted catastrophically. Therefore the cycle snowballs.
o In short: the panic escalates in a spiral of arousal >> misinterpretation >>
further arousal.
o Finally, the psychological vulnerabilities increase further as the person
worries about the possible recurrence of a panic attack. Such beliefs
increase the likelihood of further arousal, which is misinterpreted as a sign
of impending catastrophe.
o Hence the individual moves beyond a single isolated panic attack, to
frequent panic attacks.
o
Agoraphobia can develop as a complication of panic disorder, as people with panic
attacks come to fear situations in which a panic attack may occur
o The Treatment of Panic Disorders and Agoraphobia
All medications have their advantages and disadvantages which must be weighed up
before prescription.
o Tricyclic antidepressants
o Selective Serotonin Reuptake Inhibitors (SSRIs)
o Benzodiazepines
Cognitive Behaviour Therapy (CBT) is an effective psychological treatment for both
panic disorder and agoraphobia.
A major aim of CBT is to address phobic avoidances, which can be external or
internal.
External phobic avoidances are treated with graded in vivo exposure.
Internal phobic avoidances are not so simply dealt with.
o Internal phobic avoidances are bodily sensations a person ignores which may
be signalling pain.
o Interoceptive exposure is an example CBT technique used to treat internal
phobic avoidances.
o Interoceptive exposure entails exposing the client to the physical sensations of
a panic attack.
o For instance, a person may fear the sensations of hyperventilation. To confront
the sensation, the person is asked to deliberately and repetedly generate the
feelings of hyperventilation by overbreathing until the fear of the sensation
decreases.
The fear of panic can also be addressed with cognitive techniques that aim to change
the false beliefs a person has about panic and its sensations.
o Common beliefs associated with panic are that the symptoms signal that the
person is about to die or lose control. In cognitive restructuring, the person
learns to challenge false beliefs through psychoeducation.
o
CBT techniques are highly effective treatments for panic disorder and agoraphobia.
Effective treatment of panic disorder has been found to involve a combination of
exposure, relaxation training, slow breathing and homework assignments.
o
Gradual and regular exposure to panic-like sensations is a powerful technique to
reduce vulnerability to panic attacks and anxiety symptoms. Thus, regularly
experiencing the uncomfortable physical sensations during interoceptive exposure, in
the absence a catastrophic consequence, may be a powerful strategy for disconfirming
the individuals catastrophic misinterpretations of their benign physical sensations that
lead them to a panic attack.
o
According to the DSM-5, the key features of Social Anxiety Disorder (aka social
phobia) involve marked fear or anxiety in social situations in which the person faces
potential scrutiny by others.
The key is FEAR OF NEGATIVE EVALUATION and rejection
As a result, social situations are avoided entirely. The anxiety or avoidance interferes
with the individuals functioning and/or causes considerable distress.
The DSM-5 specifies Performance only social anxiety disorder, where the fear is
restricted to performance in public.
The main difference between social anxiety and other anxiety disorders is that fear is
reserved for the visible components of fight or flight. E.g.
o Sweating
o Blushing
o
o The Epidemiology of Social Anxiety Disorder
Social anxiety disorder is one of the most common and earliest onset anxiety
disorders, with half of sufferers below 12 years of age.
Without treatment, the disorder can take 25 years to remit.
There is a reluctance to seek treatment. Which is partially due to the disorder itself.
Sufferers fear being judged for their disorder.
This common treatment delay is a concern, as social anxiety disorder is heavily
comorbid with depression.
People with social anxiety disorder are often poor achievers in education and
occupation. Furthermore, they are less likely to marry.
o
o The Aetiology of Social Anxiety Disorder
Biological, psychological and social factors influence the onset of Social Anxiety
Disorder.
Biologically, there is an inherited risk factor.
Psychological factors include,
o Excessive parental criticism
Reduces childrens confidence
Teaches the child to be overly concerned with the opinions of others
o The social withdrawal associated with social anxiety disorder may itself elicit
dislike and rejection form others during adolescence.
o Cognitive dysfunctions also increase the likelihood of experiencing anxiety in
social situations.
E.g. not smiling
o
The core psychological vulnerabilities for social phobia involve the distorted way in
which people perceive how they are evaluated.
People with social phobia assume others are inherently critical and likely to form
negative evaluations
o Require fewer facial cues to identify threating features
o Make less optimistic assessments of their ability to communicate
These cognitive factors increase the probability that perfoamance in social situations
will trigger a false alarm, which is percieved by the individual as evidence of his or
her own social ineptness and contributes to the intensification of anxiety in social
situations. Thus maintaining the phobia.
o
Adults with social phobia are not always assessed as being less socially skilled than
non-clinical controls, suggesting that they do not necessarily have social skills deficit,
but rather that their social skills are inhibited by the anxiety.
Therefore if the social anxiety is effectively treated, people with the disorder can
usually interact skilfully.
That is, a large part of the problem is not that they are socially incompetent. Rather,
they are because they believe themselves to be.
o
o Treatment of Social Anxiety Disorder
CBT is the best treatment for social anxiety disorder. Either in groups or individually.
Group treatment has the advantage of providing a social context within which clients
can practice their skills.
Treatment involves,
o Psychoeducation of social phobia
o Skills for challenging negative thoughts/images
o Behavioural experiments designed to directly challenge negative cognitions.
o Reduction of safety behaviour reliance
Gaze avoidance
Alcohol use
o Challenging entrenched views of oneself.
I am adequet
o
o Generalised Anxiety Disorder
o
o The Diagnosis of Generalised Anxiety Disorder
According to the DSM-5, the main feature of Generalised Anxiety Disorder is
excessive anxiety and worry about a number of events or activities.
The anxiety and worry must have been present on most days for at least six months.
These worries must be difficult to control, meaning the sufferer finds stopping
difficult and cannot easily dismiss thoughts from the mind.
o
The worries that characterise GAD include a more diverse range of FUTURE
FOCUSED FEARS
Core worries in GAD are broadly catagorised as those which relate to,
o Social threats
Work performance.
o Physical threat
Health, wellbeing.
o World threat
War, terrorist attack.
People with GAD have a catastrophic style of thinking which typically ends in worst
case conclusions, causing considerable anxiety.
o
Those with GAD also believe that if their fears were to eventuate, they would lack the
necessary resources and capacity to cope with negative events, should they occur.
o
In addition, the DSM-5 criteria specify that the individual experience a range of
associated symptoms in relation to worries such as,
o Irritability
o Fatigue
o Difficulties concentrating
o Sleep problems
o Restlessness/agitation
o Muscle tension
Some GAD sufferers become rigidly focused on over-achievement to the exclusion of
all other pursuits to avoid fears of inadequacy being fulfilled by themselves or others.
In contrast, others with GAD tend to avoid perceived challenges for fear of failure.
Chronic worrying and autonomic arousal experienced by people with GAD impacts
strongly on their quality of life and functioning.
o
o The Epidemiology of Generalised Anxiety Disorder
GAD affects women more than men
Most GAD sufferers do not seek help. Of those that do, there is a substantial delay
between diagnosis and treatment seeking. This is a problem, as GAD has an early
onset age and a chronic course which is unlikely to improve without intervention.
GAD is substantially comorbid with other anxiety disorders, depressive disorders and
personality disorders.
o
o The Aetiology of Generalised Anxiety Disorder
Beyond the biological inherited risk factors, there are three models of GAD. These
include,
o The Information Processing Model
o The Metacognitive Model
o The Intolerance of Uncertainty Model
o
o THE INFORMATION PROCESSING MODEL OF GAD
The information processing model of GAD begins with the premise that people with
GAD actively seek out potential threats in their environment.
Triggers then occur in the environment that create an expectation of threat, which in
turn activates symptoms of anxiety, including behavioural responses such as
avoidance.
Anxiety only reduces when perception of control over the threat has been achieved.
o
o THE META-COGNITIVE MODEL OF GAD
The meta-cognitive model of GAD highlights the importance of a number of
interacting systems that maintain and promote worry, such as the use of worry as a
coping strategy, negative appraisals or beliefs about worry, and control strategies
aimed at stopping the worry process.
CBT programs aim to treat the primary factors thought to maintain the clients
symptoms
Most CBT programs include psychoeducational about worry and teach realistic
thinking skills to help clients re-appraise negative predictions about threat, beliefs
about worry and negative self-beliefs.
o
o Obsessive-Compulsive Disorder
o
Historically, obsessive-compulsive disorders and post-traumatic stress disorders were
both classed as anxiety disorders. The DSM-5 however separates them into their own
individual, but adjacent, chapters.
The DSM-5 describes OCD according to four diagnostic criteria.
o Obsessions and/or compulsions
o The disorder must be time consuming ( >1 hour per day) or significantly
interferes with the sufferers life.
o Symptoms cannot be attributed to substance use or other medical condition.
o The content of obsessions or compulsions cannot relate to some other disorder.
For instance, body obsession in anorexia.
o
Obsessions are defined as recurrent and persistent thoughts, impulses or images which
are experienced as intrusive, innapropriate and/or distressing.
o The thoughts are not simply excessive worries about real-life problems.
o To be defined as an obsession, the person must attempt to ignore the thoughts,
impulses or images or to neutralise them by engaging in some other mental
routine or behaviour (ritual).
o In order to distinguish obsessions from some aspects of psychotic illness, the
person must realise that the obsessional thoughts are the product of his/her
own mind.
Compulsions are defined as repetitive behaviours or rituals (including mental
routines) that the person feels compelled to perform in response to an obsession or
according to strict rules.
o To be termed a compulsion, the behaviours must be aimed at reducing anxiety
(usually triggered by an obsession) or preventing a threatening outcome.
o
Additionally, the DSM-5 requires that the extent to which a person understands that
their obsessions are in their own head is repoted.
o Good or fair --------------- realises OCD beliefs are probably untrue
o Poor ------------------------ argues OCD beliefs are true
o Absent---------------------- completely convinced OCD beliefs are true
o
The DSM-5 does little to indicate the breadth of possible presentations of the disorder.
This is because OCD varies considerably from case to case. A seemingly endless list
of possible topics can become the source of an obsession. Common topics include,
o Fears of contamination and germs
o Fire
o Robbery
o Rape and assault.
Almost any behaviour can become a compulsion. Even when there is no obvious or
logical link between the behaviour and the prevention of harm. For example, in order
to prevent fire, a sufferer may check power points and blink a set amount of times.
A less common manifestation of OCD are occurrences of aggressive obsessions.
Compulsive washing is the most common presentation of OCD.
o
o
o
o
Compulsive checking is the most common and prominent feature of OCD.
o Checking behaviours can include a seemingly endless range of objects and
activities.
Another form of OCD is Primary Obsessional Slowness.
o Refers to OCD in which the sufferer carries out everyday activities in an
exceedingly precise, slow and unvarying sequence. (think American psycho
getting ready?)
o The word Primary is used to indicate that the slowness is not because of a
need to check and recheck.
o Rare form of the disorder
Hoarding disorder is closely related to OCD.
o The DSM-5 defines the condition as a persistent difficulty in discarding
possessions in spite of limited value or meaning.
o Hoarding disorder is associated with substantial health and safety risks.
Namely fire.
o
Body dysmorphic disorder is also included in the DSM-5s OCD chapter.
o Body dysmorphic disorder entails a preoccupation with an imagined defect of
appearance. The individual believes some part of their body to be deformed, or
the wrong size.
o The individual presents with a clinically significant level of concern for the
body part. This accompanies clinically significant distress or impairment (e.g.
avoiding public situations) and importantly, cannot be accounted for by some
other disorder (e.g. anorexia nervosa).
o Cosmetic surgery can be of some assistance, however psychological therapies
can also be of benefit.
o
o The Epidemiology of OCD
OCD is associated with a lifetime of impairment.
Onset age is about 10 years old.
The condition waxes and wanes in intensity over time.
o
o The Aetiology of OCD
Aetiology ~ cause
Two models;
o The Neuropsychological Model
o The Cognitive Model
(favoured)
o
o THE NEUROPSYCHOLOGICAL MODEL OF OCD
The neuropsychological model of OCD is grounded in neuroimaging which suggests
the disorder results from a failure of inhibitory pathways in the basal ganglia. These
inhibitory pathways fail to stop behavioural macros being triggered in response to
internal or external stimuli.
The event must include threatened or actual harm to the self or others.
Although PTSD can develop in response to a wide range of traumatic events, there is
strong evidence of a relationship between the greater likelihood of PTSD
development as the severity of trauma increases.
Common examples are war and terrorism.
o
o
o Symptoms
PTSD comprises four major symptom clusters
o Re-experiencing symptoms
o Avoidance symptoms
o Negative changes in cognition and mood
o Marked alterations in arousal.
Re-experiencing symptoms include
o Intrusive memories
o Flashbacks
o Nightmares related to the trauma event
o Distress when exposed to trauma event reminders
Avoidance symptoms include
o Active avoidance of thoughts and reminders of the trauma event
Negative changes in cognition and mood includes
o Emotional numbing
o Being unable to recall important aspects of the trauma event
o Exaggerated negative expectations about oneself or the world
o Excessive blaming of the self or others and pervasive negative affective states
Fear
Anger
Guilt
Shame
o Hyper vigilance
o Sleeping and concentration difficulties
o Reckless or self-destructive behaviour
o Anger outbursts
Symptoms must be present for at least one month
There is overwhelming evidence that PTSD can be characterised by catastrophic
cognitive interpretations of the event and by a range of emotional responses beyond
fear and anxiety
o
o The Epidemiology of Posttraumatic Stress Disorder
Despite the frequency of exposure to potentially traumatising events, relatively few
people actually develop PTSD.
PTSD is strongly comorbid with other psychiatric disorders.
o
o PTSD Prevalence in Children
The prevalence of PTSD in children is generally similar to adults.
PTSD manifests itself differently in children with fewer cognitive and avoidance
symptoms than in older children.
o
o Risk Factors
It is common for individuals to experience a broad array of PTSD-type symptoms in
the initial weeks after the trauma. However the majority of these will be transient.
That is, the onset of the disorder following the trauma event is slow to start up.
There is evidence that PTSD development is associated with a history of
psychological disturbance predating the trauma, prior traumatic experiences, lower
intelligence levels, female gender, more severe trauma exposure, low social support
and ongoing stressors in the aftermath of the trauma.
o The Aetiology of Posttraumatic Stress Disorder
Cognitive, learning and biological factors also influence the causation of PTSD
o
o Cognitive Models
Maladaptive appraisals or interpretations of the traumatic event (e.g. I was weak)
The individuals response to it (e.g. I am worthless because I am not coping).
The environment after the trauma (e.g. I can never feel safe again).
Are all pivotal in terms of perpetuating the individuals sense of threat.
There is much evidence that maladaptive thoughts about the trauma predict the
development of the disorder.
o
o Learning Accounts
Application of classical conditioning principles to trauma
I.e.
o Unconditioned
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o Unconditioned
Stimulus
Response
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o The Traumatic
o Intense,
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Event
overwhelming
fear
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o Unconditioned Response
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o Conditioned
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Stimulus
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o Any detail,
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o
however small,
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o
o
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o
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that reminds the
person of the
trauma
As reminders of the trauma occur, people then respond with the same fear reactions as
they did the first time.
o
o Biological Accounts
Extreme sympathetic arousal at the time of a traumatic event may result in the release
of stress neurochemicals (noradrenaline and adrenaline) into the cortex, resulting in
strong conditioning of fear responses with the associated memories.
o
o Avoidance
Avoidance of trauma reminders maintains the PTSD.
According to cognitive models, this is because avoidance prevents people from
having the opportunity to access corrective information that the percieved threats are
no longer realistically dangerous.
According to the learning processes with their biological bases, avoidance serves to
imped the extinction of classically conditioned fear. The combination of predisposing,
cognitive learning and biological factors that are theorised to result in the
development of PTSD are shown below.
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Fig. 2.6
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o Predis
o
posing
Factor
s
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o o
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o o
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o o
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o Maladapti o o
o Fear
o
ve
Conditioni
Appraisals
ng
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o Avoid
o
ance
Strate
gies
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o Impair
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ed
extinct
ion
learnin
g and
no
opport
unity
to
challe
nge
beliefs
regard
ing
ongoin
g
threat
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o PTSD
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o Treatment of Posttraumatic Stress Disorder
CBT is the treatment of choice for PTSD
PTSD CBT typically comprises
o Psychodeucation
o Anxiety management
o Cognitive restructuring
o Imaginal and in vivo exposure
o Relapse prevention
Prolonged imaginal exposure requires the individual to vividly imagine the trauma or
extended periods. Typically at least 50 minutes and is usually supplemented with daily
homework.
o
o Prevention
The efficacy of CBT treatment of PTSD has lead to the use of CBT as a preventative
measure for at risk trauma survivors shortly after trauma exposure.
Note that CBT is different from psychological debriefing, because whereas the latter
requires the person to express their responses to the trauma on a single occasion
within days of the event, CBT requires repeated systematic exposure for prolonged
periods and this intervention does not commence until at least two weeks after trauma
exposure.
o
o
o
D
o
Tri
o
Co
o
Be
o
E
o Animals
S Natural
environment
Blood, injection,
injury
situational
o Bodily sensations
P
e.g. changes in
heart rate,
breathlessness,
dizziness
I will be bitten
I will fall
I will faint
Avoidance
Safety behaviours
e.g. holding an
object they
think keeps
them safe
Fear
Anxiety
Fear
Anxiety
o Natural
A
environment
I cant cope if I
cant escape or
someone isnt
there to help
me
Fear
Anxiety
o Blood, injection,
S
injury
Fear of negative
evaluation (e.g.
Others will see
how anxious I
am and I will be
rejected).
Avoidance of
activities that
trigger panic,
such as bodily
sensations.
o
E.g. walking
up stairs
Safety behaviours
o
E.g. carrying
medication
Avoidance
o
E.g. avoiding
trains, crowded
busses, and
shopping
centres.
Safety behaviours
o
E.g. only
leaving house
with a family
member
Avoidance
o
E.g. not giving
presentations at
work, avoiding
eye contact
with others.
Safety behaviours
o
E.g. alcohol
use.
Avoidance and
safety
behaviours such
as,
o
Avoiding
feared
situations
o
Negative
thoughts and
feelings
o
Worry triggers.
Reassurance
seeking
Being overly
pleasing
Perfectionism
Busyness
Controlling
behaviour.
Avoidance of
triggers or
engaging in
neutralising
behaviours
Fear
Anxiety
Shame
Fear
Anxiety
Worry
Fear
Anxiety
Shame
Guilt
o
G
o Animals
O
o
sit
P
h
y
s
i
o
l
o
g
y
attached to the
trigger (e.g. Ill
lose my mind,
Im a bad
person).
o Natural
P
environment
when contact
with triggers is
unavoidable.
E.g.
o
Washing
o
Tapping
o
Touching
o
Repeated
checking
o
Mental
routines or
mantras.
Thoughts of future Avoidance of all
harm(e.g.I can
reminders of the
never be safe)
trauma.
o
OR
o
E.g. avoiding
driving after
Of ones role in the
being in a
trauma (e.g.I
serious car
am to blame for
crash.
being raped).
Safety behaviours
o
E.g. carrying a
knife at all
times after
being
assaulted.
Fear
Anxiety
Shame
Anger
Guilt