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PS280-Chapter 6 Lecture Notes.doc

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Wilfrid Laurier University
John Stephens

PS280: Abnormal Psychology Lecture Notes Chapter 6: Anxiety Types of Anxiety Disorders 1. Phobias 2. Panic Disorder (PD) 3. Generalized Anxiety Disorder (GAD) 4. Obsessive-Compulsive Disorder (OCD) 5. Post-Traumatic Stress Disorder (PTSD) 6. Acute Stress Disorder o Complexity of anxiety responses are unique from person to person o People also have various anxiety buffers, they differ from person to person as well Anxiety Disorders • Anxiety: the unpleasant feeling of fear and apprehension; a occur in many psychopathologies o Before anxiety can be classified as a disorder, it must pass a certain threshold • Anxiety disorders tend to be co-morbid (paired with another disorder, commonly mood disorders) • The most common psychological disorder in Canada • A high rate of childhood maltreatment has been linked to greater symptom severity an poorer quality of life and function in people seeking treatment for generalized social anxiety disorder (SAD) Prevalence • In Ontario (1 year) o 16% of women and 9% of men suffered from anxiety disorders o Highest one-year prevalence rates found in women 15 to 24 years of age • In U.S (1 year) o 12% in university students for 12-month prevalence o 80% of them do not seek treatment • In Canada (Life time prevalence) o PTSD at 9.2% o Social anxiety disorder at 8.1% • Anxiety disorders are more common in women than men across all age groups and decrease with age • A majority of Canadians who met the criteria for an anxiety disorder reported that it interfered with their home, school, social and work life 1. Phobias • Phobia: disrupting, fear-mediated avoidance that is out of proportion to the danger actually posed and is recognized by the sufferer as groundless • Phobia’ usually implies that the person suffers intense distress and social/occupational impairment • Examples of Common Phobias o Claustrophobia: fear of o Ergosiaphobia: fear of closed spaces working o Agoraphobia: fear of public o Mysophobia: fear of spaces contamination and dirt o Acrophobia: fear of heights Specific Phobias • Specific Phobias: unwarranted fears caused by the presence or anticipation of a specific object or situation • Phobias sub—divided according to source of fear: o 1. Blood, injuries, and injections o 2. Situations (planes, elevators, enclosed spaces) o 3. Animals o 4. Natural Environment (heights, water) • Evidence to support the grouping of fears into 5 factors: o 1. Agoraphobia (fear of public spaces) o 2. Fears of Heights or Water o 3. Threat fears (e.g. blood/needles, storms/thunder) o 4. Fears of being observed o 5. Speaking fears Social Phobias • Social Phobias: persistent, irrational fears linked generally to the presence of other people o Can be extremely devastating o People with a social phobia try to avoid situations in which they might be evaluated because they fear that they will reveal signs of anxiousness or behave in an embarrassing way • Examples: o Speaking or performing in public o Eating in public o Using public lavatories • Social phobias can be either generalized or specific o Generalized social phobias involve many different interpersonal situations o Specific social phobia involve intense fear of one particular situation (e.g. public speaking) o Generalized social phobias have an earlier age of onset and is more often comorbid with other disorders than specific social phobias • Lifetime prevalence in Canada o 7.5% for men 8.7% for women o Predictors of recovery include: employment, no lifetime deppresoin, no more than 2 psychiatric disorders, and fewer daily hassles Etiology of Phobias Behavioural Theories • Focus on learning as the way in which phobias are acquired; several types of learning may be involved • Avoidance Conditioning: reactions are learned avoidance responses o Avoidance-conditioning formulation o Phobias develop from 2 related sets of learning:  1. Classical Conditioning (Stimulus  Response)  2. Operant Conditioning (person learns to reduce conditioning by escaping from or avoiding the CS) • Modelling: a person can also learn fears through imitating the reactions of others o Learning of fear by observing others is referred to as vicarious learning o Bandura did a study on modeling o Modeling may also happen through verbal responses; what someone says could happen • Prepared Learning: people tend to fear only certain objects and events o Fear spiders, snakes, and heights but not lambs o The fact that certain neutral stimuli (called prepared stimuli) are more likely than others to become classically conditioned stimuli may account for this tendency o Some fears may reflect classical condition, but only to stimuli to which an organism is physiologically prepared to be sensitive • Is a diathesis needed? o Cognitive diathesis such as the tendency to believe that similar traumatic experiences will occur in the future or not being able to control the environment may be important in developing phobia o While some phobias are learned through avoidance condition, avoidance conditioning should not be regarded as a totally validated theory; many people with phobias do not report direct exposure, a traumatic event, or exposure to fearful models • Social Skills Deficits in Social Phobias o Is inappropriate behaviour or a lack of social skills the cause of social anxiety? o Individual has not learned how to behave so that he or she feels comfortable with others, or the person repeatedly commits faux pas, is awkward and socially inept, and is often criticized by social companions o Little etiological evidence, however critical for planning a therapeutic plan to help the client Cognitive Theories • Focus on how peoples thought processes can serve as a diathesis and on how thoughts can maintain a phobia • Anxiety is related to individuals who are more likely to: o 1. Attend to negative stimuli o 2. Interpret ambiguous information as threatening o 3. Believe that negative events are more likely than positive ones to re-occur • Cognitive-Behavioural Models of Social Phobia o Link social phobia to certain cognitive characteristics:  1. Attentional bias to focus on negative social information  2. Perfectionist standards for accepted social performances  3. High degree of public self-consciousness • Socially anxious individuals not only anticipate negative social experiences, but also engage in extensive post event processing (PEP) of negative social experiences, sometimes experiences intrusive thoughts and images associated with OCD Predisposing Biological Factors • Generally the various anxiety disorders may reflect a complex array of biological factors and processes • Research in 2 specific areas was conducted: • 1. Automatic Nervous System o One way people differ in their reactions to anxiety; bodily arousal o Autonomic Lability: assumes considerable importance; to some degree is genetic o Labile (or jumpy) individuals are those whose autonomic systems are readily aroused by a wide range of stimuli • 2. Genetic Factors o Blood-and-injection phobia has a very strong familial association  64% have at least one first-degree relative with the same disorder  3-4% prevalence in general population o Prevalence of social and specific phobias higher than average in first degree relatives of patients o Twin studies provide support for this theory Psychoanalytic Theory • Freud was the first to attempt to account systematically for the development of phobic behaviour • Phobias are a defence against the anxiety produced by repressed ID impulses • This anxiety is displaced from the feared ID impulse and moved to an object or situation that has some symbolic connection to it • Phobia is the EGO’s way of warding off a confrontation with the real problem; repressed conflicts • Repression stems from an interpersonal problem of childhood rather than from ID impulses Therapies for Phobias Behavioural Approaches · Systematic Desensitization o Individual with phobia imagines a series of increasingly frightening scenes while in a state of deep relaxation; one cannot be tense and relaxed at the same time o In vivo exposure: exposure to real-life phobic situations, during period of which client is being desensitised through their imagination o Virtual reality exposure: virtual reality; involves exposure to stimuli that come in the form of computer-generated graphics · Flooding o Fearful person is exposed to what is frightening, in reality or in imagination, for extended periods of time and without opportunity for escape Cognitive Approaches · Viewed with skepticism because of central defining characteristics of phobias · Phobic fear is recognized by the individual as excessive or unreasonable · People with social phobias benefit from treatment strategies derived from Beck and Ellis; they may be persuaded by the therapist to more accurately appraise people’s reactions to them · Homework: between session learning, is considered to be an essential component of CBT · Recurrent theme, the need for the client to begin exposing themselves to what has been deemed to terrifying to face · Cognitive-Behavioural Case Formulation Framework o Contains causal and maintaining factors outlined in a simple framework o Permits the development of case formation (framework) and treatment planning Biological Approaches · Anxiolytics: drugs that reduce anxiety (sedatives and tranquilizers) o Barbiturates—first major category of drugs used to treat anxiety disorders and we supplanted in the 1950s by two other classes of drugs: o Propanediols (e.g., Miltown) o Benzodiazepines (e.g., Valium and Xanax).  Today newer benzodiazepines such as Ativan and Clonapam are prescribed o Monoamine Oxidase (MAO) inhibitors and SSRIs also used to treat social phobias · Drugs originally developed to treat depression, but have become popular in treating many anxiety disorder, phobias included Psychoanalytic Approach · Attempt to uncover the repressed conflicts believed to underlie the extreme fear and avoidance characteristics of a disorder · Because the phobias itself was symptomatic of underlying conflict, thus usually not dealt with directly · Focus less on historical insight and more on encouraging the client to confront the phobia 2. Panic Disorder • Panic Attack: person suffers a sudden and often inexplicable attack of alarming symptoms o Laboured breathing, heart palpitations o Nausea and Chest pain o Feelings of choking/smothering, dizziness, sweating, and trembling • Intense apprehension, terror, and feelings of impending doom • May also experience depersonalization and derealization o Depersonalization: feeling of being outsides one’s body o Derealization: feeling of the world not being real; fear of losing control, going crazy, even dying • Panic attacks may occur frequently; some describe it to be relatively short (10-20 mins) • May be linked to specific situations if so referred to as cued panic attacks o Doesn’t have to be cued though, can be fooled to believe it is cued o If it IS cued, it is better; easier to diagnose a treatment plan to help stop the attacks when you know what exactly is causing the onset of them • Panic disorder is diagnosed as with or without agoraphobia(fear of public) • Lifetime Prevalence o 2-3% for men 5-6% for women o Typically begins in adolescence (many have an attack in adolescence, but doesn’t occur again until way later in life, even 10,20, even 30 years later) o Onset associated with stressful life experience o > 80% of patients diagnosed as having an anxiety disorder also experience panic attacks  GAD in particular, attack leads to anxiety and fear of future attacks • Panic Disorder in Canadian University Students o 34% of first-year and 22.1% of university students reported having experienced at least one panic attack during the previous year o Those meeting criteria for panic attack had 4 attacks on average over the previous year Etiology of Panic Disorder Biological Theories • Mitral valve prolapse syndrome o Kind of clicking valve syndrome, not dangerous and can be managed readily, but experience is not fun to go through • Inner ear disease causes dizziness o For some it is more chronic inner ear pain that leads to panic disorders • May be linked to “Val158Met COMT polymorphism” or other loci within or near the COMT gene (on chromosome 22) • There are many discrete genes being studied that represented many aspects of fear circuit biology (receptors for neuropeptides, monoamines, and GABA) • COMT appears to be one of the few consistent findings in anxiety disorder genetics; not just anxiety disorders, linked to many other disorders as well • Noradrenergic Activity Theory o Panic is caused by over-activity in the noradrenergic system o Specifically locus ceruleus (a nucleus in the pons) has been implicated o Stimulation of the locus ceruleus causes monkeys to have “panic attack” o In humans yohimbine (drug that stimulates activity in the locus ceruleus) can elicit panic attacks • Problem in gamma-aminobutyric acid (GABA) o GABA generally inhibit noradrenergic activity o Positron emission tomography (PET) study found fewer GABA-receptor binding sites in people with Panic Disorder • Cholecystokinin (CCK) o Peptide that occurs in the cerebral cortex, amygdala, hippocampus, and brain stem, induces anxiety-like symptoms in rats and effect can be blocked with benzodiazepines o Suggests that changes in the CCK produce changes in the development or expression of panic o Thus, panic disorder is (in part) due to hypersensitivity to CCK o May affect action of neurotransmitters or neurons in the noradrenergic system OR people are reacting psychologically to the strong sensations caused by CCK Psychological Theories • The fear-of-fear hypothesis o Suggests that agoraphobia is not a fear of public places per se but a fear of having a panic attack in public o There is a very strong association between panic disorder and agoraphobia • Misinterpretation of physiological arousal symptoms o People who have panic disorder, typically have difficulty with accurate identification of affect; misinterpret at times what might be a fear response, agitation response, anger response o Therefore misinterpret normal bodily functions to anxious arousal; when they experience any sort of arousal they believe they are on the path towards an panic attack Therapies for Panic Disorder · Biological Treatments o Antidepressants; both SSRI’s and tricyclic antidepressants have been used successfully • Psychoanalytic Treatments o Exposure-based treatments are often useful in reducing panic disorder with agoraphobia o Frequently use an imagined aspect, imagine a situation where an attack may occur and help the client relax during times of panic o If there is an agoraphobic aspect to the panic attacks, role playing can help manage their anxiety o Cognitive-Behavioural Therapy: CBT o A lot of panic attack patients have over stimulated thought processes, irrational fears, thus CBT is very helpful to make patients change their thought processes Generalized Anxiety Disorder • People with generalized anxiety disorder are persistently anxious and often worry about minor things o Chronic, uncontrollable worry about everything (everything is key) o A small aspect of an experience can be taken to a MUCH higher level (unnecessarily) • Most frequent worries concern their health and the hassles of daily life • Compared to the normal population, most people with GAD show less responsiveness on most Psychophysiological measures (heart rate, GSR-measure of sweat glad activity, respiratory rate, BP) but are consistently elevated in muscle tension (EMG) o To look at anxiety, sample these results; bodily reactions to the experience of anxiety o These reactions are great, because they are very immediate; all of these reactions are less responsive with patients with GAD, EXCEPT muscle tension (EMG levels) • Other Features of GAD: o Difficulty concentrating, tiring easily, restlessness o Irritability, a high level of muscle tension o At times symptoms look like ADHD symptoms, but are not • Lifetime Prevalence is 5% for the general public • Generalized anxiety disorder typically begins in the mid-teens • Stressful life events play a role in the onset of this disorder o Many people talk about, and have vivid memories of when their anxiety was
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