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Chapter 6

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McMaster University
Richard B Day

Psych 2AP3: Abnormal Psychology – Major Disorders Chapter 6: Panic, Anxiety, and Their Disorders The Fear and Anxiety Response Patterns - Fear:  Fear or panic is a basic emotion that involves activation of the fight- or-flight response of the sympathetic nervous system  When the fear/panic response occurs in the absence of any obvious external danger, we say the person has had a spontaneous or uncued panic attack: similar symptoms to state of fear accompanied by a subjective sense of impending doom, including fears of dying, going crazy, or losing control  Cognitive/subjective components, physiological components, and behavioural components - Anxiety:  Complex bend of unpleasant emotions and cognitions that is both more oriented to the future and much more diffuse than fear  Cognitive/subjective level: negative mood, worry about possible future threat or danger, self-preoccupation, and a sense of being unable to predict the future threat or to control it if it occurs  Physiological level: creates a state of tension and chronic overarousal, which may reflect readiness for dealing with danger should it occur  Behavioural level: create a strong tendency to avoid situations where danger might be encountered, but with anxiety there is not the immediate urge to flee as there is with fear  Adaptive value of anxiety may be that it helps us plan and prepare for possible threat. In moderate degrees, anxiety enhances learning and performance  Many of our sources of fear and anxiety are learned Overview of the Anxiety Disorders and their Commonalities - Unrealistic, irrational fears or anxieties of disabling intensity - Phobic disorders, panic disorder with or without agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder - People with these varied disorders differ from one another both 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 anxiety disorder will experience at least one more anxiety disorder and/or depression either concurrently or at a different point in their lives - Modest genetic contributions to each of these disorders, and at least part of the genetic vulnerability may be nonspecific or common across the disorders - Neuroticism: a proneness to experience negative mood states - Brain structure involved are in the limbic system, and the neurotransmitter substances involved are GABA, norepinephrine, and serotonin - Classical conditioning of fear/panic and anxiety to a range of stimuli plays a predominant role in most of these disorders - People who have a lack of control over their environment or emotions seem more vulnerable to developing anxiety disorders - Parenting styles influence the likelihood of developing anxiety disorders - Graduated exposure to feared cues constitutes the most powerful therapeutic ingredient - Cognitive –restructuring techniques and medication Specific Phobias - Phobia: 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 of these feared situations - Person is diagnosed as having a specific phobia if they show strong and persistent fear that is excessive or unreasonable and is triggered by the presence of a specific object or situation - Show immediate fear response resembling a panic attack - Avoidance occurs because the phobic response itself is unpleasant and because of the phobic person’s irrational appraisal of the likelihood that something terrible will happen - Blood-injection-injury phobia:  Experience as much disgust as fear  Unique physiological response when confronted with the sight of blood injury  Show initial acceleration, followed by a dramatic drop in both heart rate and blood pressure  Frequently accompanied by nausea, dizziness, and/or fainting  Show unique physiological response pattern only in the presence of blood and injury stimuli; exhibit the more typical physiological response pattern characteristic of the fight-or-flight response to other feared objects - Age of onset and gender differences in specific phobias:  Common, especially in women  Lifetime prevalence rate of about 12%  Over 75% have at least one other specific fear that is excessive  Gender ratio very according to the type of specific phobia  Age of onset for different types of specific phobias varies widely - Psychosocial causal factors:  According to the psychodynamic view, phobias represent a defence against anxiety that stems from repressed impulses from the id  Phobias as learned behaviour:  Principle classical conditioning appeared to account for the acquisition of irrational fears and phobias  Once acquired, phobic fears can generalize to other similar objects or situations  Vicarious conditioning of phobic fears:  Watching a phobic person behaving fearfully with his or her phobic object can be distressing to the observer and can result in fear being transmitted from one person to another through vicarious or observational classical conditioning  Sources of individual differences in the learning of phobias:  Differences in life experiences among individuals strongly affect whether or not conditioned fears or phobias actually develop  Importance of the individual’s prior familiarity with an object or situation in determining whether a phobia develops following a fear-conditioning experience  Events that occur during a conditioning experience, as well as before it, are also important in determining the level of fear that is conditioned  Experience that a person has after a conditioning experience may affect the strength and maintenance of the conditioned fear  Our cognitions can help maintain our phobias once they have been acquired  Evolutionary preparedness for the development of fears and phobias:  Evolutionary history has affected which stimuli we are most likely to come to fear  Prepared fears are not inborn or innate, but, rather, are easily acquired or especially resistant to extinction  People with phobias may not be able to control their fear because the fear may arise from cognitive structures that are not under conscious control - Genetic and temperamental causal factors:  Affect the speed and strength of conditioning fear  Modest genetic contribution to the development of specific phobias  Monozygotic twins were more likely to share animal, blood-injection- injury and situational phobias, however, nonshared environmental factors also played a role in the origin of specific phobias, a result that supports the idea that phobias are learned behaviours - Treating specific phobias:  Exposure therapy: controlled exposure to the stimuli or situations that elicit phobic fear  Participant modeling: therapist models ways of interacting with the phobic stimulus or situation  Virtual reality environments: stimulate certain kinds of phobic situations  Combining cognitive techniques or medications with exposure-based techniques Social Phobia - Disabling fears of one or more specific social situations - Person fears that they may be exposed to the scrutiny and potential negative evaluation of others and/or that they may act in an embarrassing or humiliating manner - Avoid these situations or endure them with great distress - Public speaking is the most common type of social phobia - Generalized social phobia: fears of most social situations and often also have a diagnosis of avoidant personality disorder - Diagnosis of social phobia is very common - In Canada 3-7.2% report symptoms meeting the criteria in a given year - 12% of the population will qualify for a diagnosis at some point in their lives - Somewhat more common in women than men - Typically begin during adolescence or early adulthood - More than half of people with social phobia suffer from one or more additional anxiety disorders at some point in their lives, and 50% suffer from a depressive disorder at the same time - One third abuse alcohol - Interaction of psychosocial and biological causal factors:  Social phobias as learned behaviour:  Seem to originate from instances of direct or vicarious classical conditioning  Likely to have grown up with parents who were socially isolated and avoidant and who devalued sociability  Individual differences in experiences play an important role in who develops social phobia  Social fears and phobias in an evolutionary context:  Involve fears of members of one’s own species  Social fears and phobias evolved as a by-product of dominance hierarchies that are common social arrangement among animals  Evolutionary based predisposition  Genetic and temperamental factors:  Genetics and environmental factors contribute equally to the development of social anxiety traits  Large proportion of variance in who develops social phobia is due to nonshared environmental factors  Behavioural inhibition  Perceptions of uncontrollability and unpredictability:  Exposure to uncontrollable and unpredictable stressful events may play an important role in the development of social phobia  Perceptions of uncontrollability and unpredictability often lead to submissive and unassertive behaviour  People with social phobia have a diminished sense of personal control over events in their life  Cognitive variables:  People with social phobia tend to expect that other people will reject or negatively evaluate them  Inward attention, and awkward behaviour - Treating social phobia:  Behaviour and cognitive-behavioural therapy  Therapist attempts to help clients identify their underlying negative automatic thoughts and change these inner thoughts and belief through logical reanalysis  Can also sometimes be treated with medications (antidepressants)  Advantage of behavioural and cognitive therapies over medications: produce more long-lasting improvement, with very low relapse rates Panic Disorder With and Without Agoraphobia - Panic Disorder:  Occurrence of unexpected panic attacks that often seem to come out of the blue  Person much have experienced recurrent unexpected attacks and must have been persistently concerned about having another attack, worried about the consequences of having an attack or must have changes their behaviour because of the attacks, for at least a month  Most of the symptoms are physical although three are cognitive: depersonalization or derealisation, fear of dying or fear of going crazy or losing control.  Panic attacks are brief and intense and often unexpected or uncued  Nocturnal panic  Situationally predisposed - Agoraphobia:  Most commonly feared and avoided situations include streets and crowded places  Develops as a complication of having panic attacks in one or more situations  Agoraphobia without panic:  Usually a gradually spreading fearfulness in which more and more aspects of the environment outside the home become threatening  Lifetime prevalence of agoraphobia without panic is 1.4% - Prevalence, gender, and age of onset of panic disorder with and without agoraphobia:  Statistics Canada: in any given year, 1.6% of adults suffer from panic disorder and 0.7% suffer from agoraphobia  4.7% of the adult population has had panic disorder with or without agoraphobia at some time in their lives  Prevalence of panic disorder seems to be increasing in younger generations  Usual age of onset for panic disorder with or without agoraphobia is between 15-24, especially for men; but it can also begin in 30-40s especially for women  Once panic disorder develops it tends to have a chronic and disabling course  Twice as prevalent in women than men  Men with panic disorder may be more likely to self-medicate with nicotine or alcohol as a way of coping with and enduring panic attacks, rather than developing agoraphobic avoidance - Comorbidity with other disorders:  More than 50% of people with panic disorder have one or more additional diagnoses  GAD, social phobia, specific phobia, PTSD, depression and substance- use disorders  30-50% will experience a serious depression at some point  dependent or avoidant personality disorder - The timing of a first panic attack:  First one frequently occurs following feelings of distress or some highly stressful life circumstance  Not all people who have a panic attack following a stressful event go on to develop full-blown panic disorder - Biological causal factors:  Genetic factors:  According to family and twin studies panic disorder has a moderate heritable component  33-43% of the variance in susceptibility to panic disorder was due to genetic factors  Biochemical abnormalities:  Panic attacks are alarm reactions caused by biochemical dysfunctions  Biological challenge procedures: sodium lactate, carbon dioxide, or caffeine  Injections of the peptide neurotransmitter cholecystokinin-4 can trigger panic attacks  Panic provocation agents  Noradrenergic and serotonergic systems  Panic and the brain:  Locus ceruleus in the brain stem and norepinephrine, involved in brain activity in this area  Increased activity in the amygdala, a collection of nuclei in front of the hippocampus in the limbic system involved in the emotion of fear  Stimulation of the central nucleus of the amygdala is known to stimulate the locus ceruleus, as well as the other autonomic, neuroendocrine, and behavioural responses that occur during panic attacks  Amygdala is involved in fear network, with connections to higher brain areas like the prefrontal cortex  Panic attacks occur when the fear network is activated  For people who have one or more panic attacks and who go on to develop significant conditioned anxiety about having another one in particular contexts, the hippocampus generates this conditioned anxiety and is probably also involved in the learned avoidance associated with agoraphobia  Cognitive symptoms that occur during panic attacks and overreactions to the danger posed by threatening bodily sensations are likely to be mediated by higher cortical centers - Behavioural and cognitive causal factors:  Comprehensive learning theory of panic disorder:  Origin of agoraphobia “fear of fear” hypothesis: through a process of interoceptive conditioning, initial internal bodily sensations of anxiety or arousal effectively become conditioned stimuli associated with higher levels of anxiety or arousal  Initial panic attacks become associated with initially neutral internal and external cues through a conditioning process  The more intense the panic attack, the more robust the conditioning that will occur  Panic attacks are like to be conditioned to certain internal cues  People with certain genetic, temperamental, or cognitive- behavioural vulnerabilities will show stronger conditioning of both anxiety and panic  The cognitive theory of panic:  Panic clients are hypersensitive to their bodily sensations and are very prone to giving them the direst possible interpretation  People with panic disorder are more likely to interpret their bodily sensations in a catastrophic manner  Evidence that cognitive therapy for panic works is consistent with this prediction  Psychological explanations of results from panic provocation studies:  Various agents that provoke panic produce arousal mimic the physiological c
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