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PSYC*3390 Ch 6.doc

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University of Guelph
PSYC 3390
Mary Manson

Friday, October 12, 2012 Chapter 6: Panic, Anxiety, and Their Disorders - anxiety disorders affect approximately 25 to 30% of the population at some point in their lives - anxiety disorders are the most common category of psychological disorders in Canada - in a 12 month period, 16% of women and 9% of suffer from at least 1 anxiety disorder - anxiety disorders affect more than 4 million Canadians in any given year - historically, cases of anxiety disorders were considered to be classic examples of neu- rotic behaviour - although neurotic behaviour is maladaptive and self-defeating, a neurotic person is not out of touch with reality, incoherent, or dangers - to Freud, Neuroses were psychological disorders that resulted when intrapsychic con- flict produced significant anxiety - summits anxiety was overtly expressed and sometimes it is not obvious if psychologi- cal defence mechanisms were able to deflect or mask it - in 1980, the DSM-III dropped the term neurosis and reclassified most of these disor- ders that did not involved obvious anxiety symptoms as either dissociative or somato- form disorders The Fear and Anxiety Response Patterns - historically, the most common way of distinguishing between fear and anxiety has been whether there is a clear and obvious source of danger that would be regarded as real by most people - when the source of danger is obvious, the experienced emotion has been called fear - with anxiety, you cannot specify what the danger is, it is an unpleasant inner state Fear - fear or panic is a basic emotion (shared by many animals) that involves activation of the fight-or-flight response of the sympathetic nervous system - its adaptive value is that it allows us to escape from imminent danger - when fear/panic occurs in the absence of any obvious external danger, we say the per- son has had a spontaneous or uncured panic attack - the symptoms of a panic attack are nearly identical to those experienced in a state of fear except they are often accompanied by a subjective sense of impending doom, in- cluding fears of dying, going crazy, or losing control - fear and panic have 3 components: 1. Cognitive/subjective components (I feel afraid, I’m going to die) Friday, October 12, 2012 2. Physiological components (increased heart rate) 3. Behavioural components (a strong urge to escape or flee) - these components are only loosely coupled meaning they may not all appear Anxiety - a complex blend of unpleasant emotions and cognitions that is both more oriented to the future and much more diffuse than fear - has not only cognitive/subjective components but also physiological and behavioural - cognitive/subjective level = negative mood, worry about possible future threat or dan- ger, self-preoccupation, and a sense of being unable to predict the future threat or to control it if i occurs - physiological = state of tension and chronic over arousal, which may reflect readiness for dealing with danger should it occur - there is no activation of the fight-or-flight response as in fear, but does prepare or prime a person for the response should the anticipated danger occur - behavioural = strong tendency to avoid situations where danger might happen - the adaptive value of anxiety is that it helps us plan and prepare for possible threat - in mild to moderate degrees, anxiety actually enhances learning and performance - it is maladaptive when it becomes chronic and severe - many of our sources of fear and anxiety are learned - conditioned Overview of the Anxiety Disorders and Their Commonalities - the principal and most obvious manifestation of all anxiety disorders is unrealistic, irra- tional fears or anxieties of disabling intensity - DSM-IV-TR recognizes 7 primary types of anxiety disorders: phobic disorders, panic disorder with or without agoraphobia, generalized anxiety disorder, obsessive-compul- sive disorder, posttraumatic stress disorder - disorders vary from one another in terms of the relative preponderance of fear/panic versus anxiety symptoms that they experience and in the kinds of objects or situations that they are most concerned about - many people with one disorder will experience at least one more anxiety disorder and/or depression either concurrently or at a different point in their lives - there are some important similarities in the basic causes of the disorders, as well as differences - there are modest genetic contributions to each of these disorders, and at least part of the genetic vulnerability may be nonspecific Friday, October 12, 2012 - the common genetic vulnerability is manifested at a psychological level by the person- ality trait called neuroticism- a proneness to experience negative mood states - the brain structure most centrally involved are generally the limbic system (the emo- tional brain) and the neurotransmitter substances that are most centrally involved are GABA, norepinephrine, and serotonin - classical conditioning of fear/panic and/or anxiety to a range of stimuli plays a promi- nent role in most of these disorders - people who have perceptions of a lack of control over their environment and/or their own emotions seem more vulnerable to developing anxiety disorders - the development of this perception depends on the social environment of childhood - the sociocultural environment also affects the kinds of things people become afraid of or anxious about - parenting styles also significantly influence the likelihood that children will develop pho- bic fears and other anxiety disorders - there are many commonalities in the effective treatments for these disorders - for each disorder, graduated exposure to feared cues, objects and situations consti- tutes the single most powerful therapeutic ingredient - for certain disorders, the addition of cognitive-restructuring techniques can benefit - cognitive techniques help the individual understand his or her distorted patterns of thinking and how they can change - medication is useful except for specific phobias, and nearly all tend to fall into 2 prima- ry medications categories: benzodiazepines (anti-anxiety drugs) and antidepressants - the advantage of behavioural and cognitive-behavioural treatments over medications are that they produce much lower relapse rates and they don’t have side effects - now we will highlight each disorder Phobia - a persistent and disproportionate fear of some specific object or situation that presents little or no actual danger and yet leads to a great deal of avoidance - there are 3 main categories of phobias: specific phobia, social phobia and agoraphobia Specific Phobias - strong and persistent fear that is excessive or unreasonable and is triggered by the presence of a specific object or situation - when individuals encounter a phobic stimulus, they often show an immediate fear re- sponse that often resembles a panic attack Friday, October 12, 2012 - avoidance is a cardinal characteristic because the phobic response itself is so un- pleasant and because of the phobic person’s irrational appraisal of the likelihood of something terrible happening - there are 5 subtypes of specific phobias: animal, natural environment, blood-injection- injury, situational, and other - people with phobias usually known that their fears are irrational but they say they can- not help themselves - the benefits from being disabled, such as increased attention, sympathy, and some control over the behavior of others may reinforce a phobia Blood-Injection-Injury Phobia - 3-4% of the population - people usually experience as much, if not more, disgust as fear - show a unique physiological response when confronted with the sight of blood or in- jury, rather than showing an increase in heart rate and blood pressure, they experience an initial acceleration followed by a dramatic drop in both - this is usually accompanied by nausea, dizziness and/or fainting - they exhibit the more typical physiological response pattern to other feared objected - in an evolutionary standpoint, this may have evolved for a specific purpose: by fainting, the person being attacked might inhibit further attack, and the drop in blood pressure would minimize blood loss Age of Onset and Gender Differences in Specific Phobias - specific phobias are quite common, especially in women (12% of people) - among people with one specific phobia, over 75% have at least one other specific fear - 90-95% of people with animal phobias are women, and 2:1 for blood-injury phobia - animal, blood-injury and dental phobias usually begin in childhood - claustrophobia and driving phobia tend to being in adolescence and adulthood Psychosocial Causal Factors - according to the psychodynamic view, phobias represent a defence against anxiety that stems from repressed impulses from the id - the anxiety is displaced onto some external object or situation that has some symbolic relationship to the real object of anxiety Phobias as Learned Behaviour - classical conditioning accounts for the acquisition of irrational fears Friday, October 12, 2012 - the fear response can be readily conditioned to previously neutral stimuli when they are paired with traumatic or painful events - may be especially common in dental phobia, claustrophobia, and accident phobia Vicarious Conditioning of Phobic Fears - watching a phobic person behave fearfully can be distressing and can result in the fear being transmitted from one person to another through vicarious or observational classi- cal conditioning - monkeys who observed other monkeys behaving fearfully with snakes will acquire a fear of snakes Sources of Individual Differences in the Learning of Phobias - the differences in life experiences among individuals strongly affect whether or not conditioned fears or phobias actually develop - some experiences make people more experience and others are protective - events that occur during a conditioning experience as well as before it, are also impor- tant e.g. inescapable/uncontrollable event is more powerful - the experience that a person has after the experience may affect the strength and maintenance of the conditioned fear - the inflation effect suggests that a person who acquired a mild fear might develop a full-blown phobia if another traumatic event happens - our thoughts can help maintain our phobias once they have been acquired - people with phobias are constantly on the alert for their phobic objects or situations - nonphobic persons tend to direct their attention away from threatening stimuli - phobics markedly overestimate the probability that feared objects have been or will be followed by frightening events - this cognitive bias may help maintain or strengthen phobic fears with time Evolutionary Preparedness for the Development of Fears and Phobias - our evolutionary history has affected which stimuli we are most likely to come to fear - primates and humans seem to be evolutionarily prepared to rapidly associate certain objects-such as snakes, spiders, water, and enclosed spaces-with frightening or un- pleasant events - this preparedness occurs because, over the course of evolution, those primates and humans who rapidly acquired fears of certain objects or situations that posed real threats to our early ancestors may have enjoyed a selective advantage - prepared fears are not innate but are easily acquired or resistant to extinction - fear is conditioned more effectively to fear-relevant stimuli than to fear-irrelevant stimuli Friday, October 12, 2012 - once people acquire the conditioned responses to fear-relevant stimuli, these respons- es could be elicited even when the fear-relevant stimuli were presented subliminally - this subliminal activation of responses to phobic stimuli may help to account for certain aspects of the irrationality of phobias - the fear for people with phobias may airs from cognitive structures that are not under conscious control Genetic and Temperamental Causal Factors - affect the speed and strength of conditioning of fear - toddlers who were behaviorally inhibited at 21 months of age (timid, shy) were at a higher risk of developing multiple specific phobias at 7 and 8 years old - a large study of female twins found that monozygotic twins were more likely to share animal phobias, blood-injection-injury phobias, and situational phobias than dizygotic - the same study also found evidence that nonshared environmental factors also played a very substantial role in the origins of specific phobias, supporting the idea that phobias are learned behaviours Treating Specific Phobias - exposure therapy is the best treatment for specific phobias and involves controlled ex- posure to the stimuli or situations that elicit phobic fear - participants modeling is a variant of exposure therapy and is often more effective than exposure alone, here the therapist calmly models ways of interacting with the phobis stimulus or situation - the client learns that these situations are not as frightening as they thought and that their anxiety will gradually dissipate - for some phobias (claustrophobia, flying phobia, small-animal phobias), exposure ther- apy is often highly effective when administered in a single long session - recently therapists have started to use virtual reality environments to simulate certain kinds of phobic situations such as heights and airplanes - some researchers have also tried combining cognitive techniques or medications with exposure-base techniques - in general, studies using cognitive techniques along have not produced results as good a those using exposure-based techniques and the addition of cognitive techniques has generally not added much - medication treatments are ineffective by themselves, and there is evidence that anti- anxiety medications may interfere with the beneficial effects of exposure therapy Friday, October 12, 2012 Social Phobia - also called social anxiety disorder, is characterized by disabling fears of one or more specific social situations (public speaking, meeting new people) - a person fears that they may be exposed to the scrutiny and potential negative evalua- tion of others and/or they may act in an embarrassing or humiliating manner - people either avoid these situations or endure with great distress - intense fear of public speaking is the single most common type - generalized social phobia is people who have significant fears of most social situations and often have a diagnosis of avoidant personality disorder - the diagnosis is very common and even in famous performers such as Barbara Streisand and Carly SImon - 3-7.2% of people in Canada report symptoms meeting the DSM criteria per year - 12% of the population will qualify for a diagnosis of social phobia at some point - more common among women (60%) - social phobias begin during adolescence or adulthood - more than half of people with social phobias suffer form one or more additional anxiety disorders at some point in their lives, and about 50% also suffer from a depressive dis- order at the asme tim - 1/3 abuse alcohol to reduce anxiety and help them face the situations they fear - in more than 80% of cases where social phobia and alcohol abuse occur in the same person, social phobia begins first Interaction of Psychological and Biological Causal Factors - social phobias generally involve learned behaviours that have been shaped by evolu- tionary factors - such learning is most likely to occur in people who are genetically or temperamentally at risk Social Phobias As a Learned Behaviour - seem to originate from direct or vicarious classical conditioning - 56-58% of people with social phobia recalled and identified direct traumatic experi- ences as having been involved in the origin of their social phobias - 92% of adults with social phobias reported a history of severe teasing in childhood compared to only 35% of people with OCD - people with generalized social phobias may be especially likely to have grown up with parents who were socially isolated and avoidant and who devalued sociability, thus pro- viding ample opportunity for vicarious learning of social fears Friday, October 12, 2012 - not everyone who experiences direct or vicarious conditioning in social situations or who grows up with socially avoidant parents develops a social phobia Social Fears and Phobias in an Evolutionary Context - social fears and phobias involve fears of members of one’s own species - animal fears and phobias usually involve fear of potential predators - animal fears probably evolved to trigger activation of the fight-or-flight response to po- tential predators whereas social fears and phobias evolved as a by-product of domi- nance hierarchies that are a common social arrangement among animals - dominance hierarchies are established through aggressive encounters between mem- bers of a social group, and a defeated individual typically displays fear and submissive behaviour but only rarely attempts to escape the situation completely - that may be why people with social phobia endure being in their feared situations rather than running away and escaping - humans have an evolutionarily based predisposition to acquire fears of social stimuli that signal dominance and aggression from other humans - these social stimuli include facial expressions of anger which on average all humans seem to process more quickly and readily than happy or neutral facial expression - genetics and environment factors contribute equally to the development of social anxi- ety traits - a large proportion of variance in who develops social phobia is due to nonshared envi- ronmental factors, which is consistent with a strong role for learning - the most important temperamental variable is behavioural inhibition - children classified as behaviorally inhibited when they are toddlers had higher rates of social anxiety by age 13, another studied showed they are 4x more likely Perceptions of Uncontrollability and Unpredictability - perceptions of uncontrollability and unpredictability often lead to submissive and unassertive behaviour, which is characteristics of social anxious or phobic people - people with social phobia have a diminished sense of personal control over events in their lives, this may have developed from overprotective parents Cognitive Variables - people with social phobia tend to expect that other people will reject or negatively eval- uate them which leads to a sense of vulnerability when they are around people who might pose a threat - these danger schemas lead them to expect that they will behave in an awkward and unacceptable fashion, resulting in rejection and loss of status Friday, October 12, 2012 - these expectations make them preoccupied with bodily responses and negative self- images in social situations and overestimating how easily others will detect this anxiety - these preoccupations interferes with their ability to interact skillfully Treating Social Phobia - behaviour treatments developed first and generally involve prolonged and graduated exposure to social situations that evoke fear - cognitive techniques have been added to help the distorted cognitions, this generates a form of cognitive-behavioural therapy - social phobias can sometimes be treated with medications - the most effective and widely used medications are several categories of antidepres- sants (including the selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors) - the combination of medications and psychological treatments works about as well as either approach alone, at least in short term - cognitive-behavioural treatments generally produce more long-lasting improvement with very low relapse rates so they are better than medications Panic Disorder With and Without Agoraphobia Panic Disorder - the occurrence of unexpected panic attacks that often seem to come out of the blue - according to the DSM, the person must have experienced recurrent unexpected at- tacks and must have been persistently concerned about having another attack, worried about the consequences of having an attack, or must have changed their behaviour be- cause of the attacks, for at least a month - for an event to qualify as a full-blown panic attack, there must be abrupt onset of at least 4 of 15 symptoms: most of them are physical although 3 are cognitive: 1. Depersonalization (feeling of being detached from one’s body or Derealization (a feel- ing that the external world is strange or unreal) 2. Fear of Dying 3. Fear of “going crazy” or “losing control” - panic attacks are brief and intense, with symptoms developing abruptly and usually reaching peak intensity within 10 minutes, they usually finish in 20-30 minutes and rarely last more than an hour - panic attacks are often unexpected in a sense that they do not appear to be provoked by identifiable aspects of the immediate situation Friday, October 12, 2012 - because most of the symptoms are physical, 85% of people having a panic attack may show up repeatedly at emergency rooms or physicians offices for what they are con- vinced is a medical problem (cardiac, respiratory, neurological) - a correct diagnosis is usually not made for years - panic disorder causes about as much impairment in social and occupational function- ing as major depression and can contribute to the development or worsening of a variety of medical problems Agoraphobia - the most commonly feared and avoided situations include streets and crowded places such as shopping malls, movie theaters, and stores - today we think that agoraphobia usually develops as a complication of having panic at- tacks in one or more such situations - concerned that they may have a panic attack or get sick, people are anxious about be- ing in places or situations form which escape would be physically difficult or psychologi- cally embarrassing, or un which immediate help would be unavailable if something bad happened - they are also frightened by their own bodily sensations, so they also avoid activities that will create arousal, such as exercising, watching scary movies, drinking coffee and having sex - as agoraphobia first develops, people tend to avoid situations in which attacks have occurred but usually the avoidance spreads to other situations - sometimes people can’t even leave their home Agoraphobia Without Panic - can also occur without prior full-blown panic attacks - there is usually a gradually spreading fearfulness in which more and more aspects of the environment outside the home become threatening - these are rare in clinical settings, and over half of the time when they are seen, there is a history of what are called “limited symptom attacks” (with fewer than four symptoms), or of some other unpredictable physical ailment such as epilepsy Prevalence, Gender, and Age of Onset of Panic Disorder with and without Agora- phobia - in any given year, 1.6% of adults suffer from panic disorder and 0.7% suffer from ago- raphobia Friday, October 12, 2012 - the usual age of onset if between 15 and 24, especially for men, but can also begin when people, especially women, are in their 30s and 40s - the median age of onset has been 24 years - once panic disorder develops, it tends to have a chronic and disabling course - panic disorder is about twice as prevalent in women as in men - 80-90% of people with agoraphobia are women - the most common explanation of the gender differences is a sociocultural one - in our culture it is more acceptable for women who experience panic to avoid the situa- tions they fear and to need a trusted companion - men are more prone to “tough it out” Comorbidity with Other Disorders - more than 50% of people with panic disorder with or without agoraphobia have one or more additional diagnoses, these include generalized anxiety, social phobia, specific phobia, PTSD, depression, and substance-use disorders30-50% of people with panic disorder will experience a serious depression at some point in their lives - there is little evidence that panic disorder itself increases risk for suicide, but it may do so by increasing people’s risk for depression and substance use The Timing of a First Panic Attack - although panic attacks themselves appear to come out of the blue, the first one fre- quently occurs following feelings of distress or some highly distressful circumstance - 80-90% of clients report their first panic attack occurred after a negative event Biological Causal Factors Genetic Factors - panic disorder has a moderate heritable component - in study, 33-43% of variance was due to genetic factors Biochemical Abnormalities - decades ago, Klein argued that panic attacks are alarm reactions caused by biochemi- cal dysfunctions - studies have shown that people with panic disorder are much more likely to experience panic attacks when they are exposed to various biological challenge procedures e.g. in- fusions of sodium lactate, inhaling carbon dioxide, or caffeine - there is a broad range of so-called Panic Provocation Agents, and some of them are associated with quite different and even mutually exclusive neurobiological processes Friday, October 12, 2012 - no single neurobiological mechanism could possible be implicated - this observation led biologically oriented theorists to speculate that there are multiple different biological causes of panic - others believe that there are multiple different biological causes of panic - alternative explanations stem from the observation that what all these biological chal- lenge procedures have i
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