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Chapter 6

Abnormal Psych Chapter 6.doc

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Konstantine Zakzanis

Chapter 6: Anxiety Disorders • Anxiety is an unpleasant feeling of fear and apprehension • It can occur in many psychopathologies • An anxiety disorder is diagnosed when feelings of anxiety are clearly present • DSM proposes 6 categories o Phobias  Fear & avoidance of objects or situations that do not present any real danger o Panic disorder  Recurrent panic attacks involving a sudden onset of physiological symptoms (dizziness, rapid heart rate etc) accompanied by terror and feeling of impending doom; sometimes accompanied with agoraphobia, a fear of being in public places o Generalized anxiety disorder  Persistent, uncontrollable worry, often about minor things o Obsessive-compulsive disorder  Experience of uncontrollable thoughts, impulses, or images (obsessions) and repetitive behaviours or mental acts (compulsions) o Posttraumatic stress disorder  Aftermath of traumatic experience in which the person experiences increased arousal, avoidance of stimuli associated with the event, and anxiety in recalling the event o Acute stress disorder  Symptoms are the same as those of posttraumatic stress disorder, but last for 4 weeks or less • Often someone with one anxiety disorder meets the diagnostic criteria for another disorder as well (co-morbidity) because... o Symptoms of the various anxiety disorders are not entirely disorder specific o The etiological factors that give rise to various anxiety disorders may be applicable to more than one disorder • 16% and 9% of men suffer from anxiety disorders (mostly women 15- 24 years) Phobias • Phobia: a disrupting, fear mediated avoidance that is out of proportion to the danger actually posed and is recognized by the sufferer as groundless C h a p t e r 6 : A n x i e t y D i s o r d e r s Page 1 • Examples: fear of heights, closed spaces, snakes or spiders • The person suffers intense distress and social or occupational impairment because of the anxiety • For other phobia disorders, the suffix phobia is preceded by a Greek word for the feared object or situation o Claustrophobia: fear of closed spaces o Agoraphobia: fear of public places o Acrophobia: fear of heights o Ergasiophobia: fear of writing o Pnigophobia: fear of choking o Taphenphobia: fear of being buried alive o Anglophobia: fear of England • Psychoanalysts believe that the content of the phobias has important symbolic value • Behaviourist ignore the content of the phobia and focus on its function instead • There are 2 types of phobias: Specific & Social Phobias Specific Phobias • Social Phobia: unwarranted fears caused by the presence or anticipation of a specific object or situation • DSM-IV subdivides these phobias according to the source of the fear o Blood o Injuries & Injections o Situations o Animals o Natural Environment • Recent empirical research involving a national representative sample suggests that fear can be grouped into 1 of 5 factors o Agoraphobia o Fears of heights of water o Threat fear (blood/needle, storms/thunder) o Fear or being observed o Speaking fears o But then these were classified under the higher-order categories – specific & social fears • Specific fear focused on in a phobia can vary cross culturally o Pa-leng: fear of the cold  They worry that loss of body heat may be life threatening o Taijinkyofu-sho: fear of other people  Fear of embarrassing others Social Phobias • Social Phobia: persistent, irrational fears linked generally to the presence of other people C h a p t e r 6 : A n x i e t y D i s o r d e r s Page 1 • They try to avoid particular situations where they might be evaluated, fearing they will reveal signs of anxiousness or behave in an embarrassing way • People with generalized type have an earlier age of onset, more co- morbidity with other disorders (depression, alcohol abuse, and more severe impairments) • Social phobias are fairly common • 11% in men and 15% in women • Often occur in conjunction with generalized anxiety disorder, specific phobias, panic disorder, avoidant personality disorder, and mood disorders • Onset is usually during adolescent when social awareness and interaction with others is important • There was a link between social phobia and dropping out of school Etiology of Phobias Psychoanalytic Theories • Freud o Phobias are against the anxiety produced by repressed id impulses o Anxiety is deplaced from the feared id impulse and moved to an object or situation that has some symbolic connection to it • Arieti o Repression stems from a particular interpersonal problem of childhood rather than from an id impulse Behavioural Theories • Learning is the way in which phobias are acquired • Types of learning (3) • Avoidance Conditioning o Phobias reactions are learned avoidance responses o (Watson & Rayner) Phobias develop from 2 related sets of learning:  Via classical conditioning (a person learns to fear a neutral stimulus when it’s paired with a painful or frightening event). The person learns to reduce the conditioned fear by avoiding/escaping it  Via operant conditioning (response is maintained by its reinforcing consequence of reducing the fear) o The evidence is very little in the laboratory (because you can’t apply aversive stimuli to people) and mixed outside (some people do produce a phobia through bad experiences) • Modelling o A person can learn a fear through imitating the reaction of others o Viscarious learning: learning of fear by observing others C h a p t e r 6 : A n x i e t y D i s o r d e r s Page 1 o Viscarious learning can also be accomplished through verbal instructions o Anxious-rearing model: anxiety disorders in children are due to constant parental warnings that increase anxiety in the child • Prepared Learning o Prepared stimuli: certain neutral stimuli o Certain prepared stimuli are more likely that others to become classically conditioned stimuli o People tend to fear only certain objects and events; spiders, snakes and heights o It is also relevant to learning fear by modelling • So why do some people have this fear and others don’t? o Cognitive diathesis (a tendency to believe that a similar situation will happen in the future) is important in developing a phobia • In sum, some phobias are developed through avoidance conditioning other are not Social Skills Deficits in Social Phobias • This view says that a person develops social phobias because the individual has not learned how to behave so that he/she feels comfortable with others OR the person repeatedly commits faux pas, is awkward and socially unskilled and is often criticized by social companions • (Behaviourists say its caused by inappropriate behaviour or lack of social skills) Cognitive Theories • How people’s thought processes can serve as a diathesis and how thoughts can maintain a phobia • People are more likely to attend to negative stimuli, and believe that negative events are more likely than positive ones to occur in the future • Socially anxious people are more considered of what others think of them and are preoccupied with hiding imperfections • (Clark & Wells, Rappee & Heimberg) link social phobia with certain cognitive characteristics o Attention on negative social information o Perfectionistic standards for accepted social performances o High degree of public self-consciousness • Research has shown social phobia is linked with high self criticism Predisposing Biological Factors • Maybe there is a biological malfunction (diathesis) that predisposes someone to develop a phobia to a stressful event • Autonomic nervous system o People differ in how easily their ANS become aroused C h a p t e r 6 : A n x i e t y D i s o r d e r s Page 1 o Autonomic liability: extent to which the ANS is involved in fear and phobic behaviour o Autonomic liability may be genetically determined • Genetic Factors o Blood-injection phobia is strongly related in first-degree relatives o Social and specific phobias are also higher in relatives o Twin studies have shown a heritable component as well o In a study inhibited children are shown to be more than 5x more likely o develop a phobia later on Therapies for Phobias Psychoanalytic Approaches • Attempt to uncover the repressed conflicts believed to underlie the extreme fear and avoidance characteristic of these disorders • Free association – the analyst listens carefully to what the patients mentions in connection to the phobia; also to discover the clues to the repressed origins of the phobia in the manifest content of dreams • Orthodox analyst – will look for conflicts related to sex or aggression • Arieti’s theorists – will encourage patients to examine their generalized fear or other people • Contemporary ego analyst – focus less on gaining historical insights and more on encouraging the patient to confront the phobia (but they do view the phobia as resulting from some earlier problem) Behavioural Approaches • Systematic desensitization was most widely used • The individual images a series of increasingly frightening scenes while in a deep relaxation • In vivo exposure - using real life situations instead of just imaging them • Virtual reality: using exposure through a realistic computer program • Blood-and-injection phobias are distinguished from others by the DSM- IV because of the distinctive reactions that people have (instead of using relaxation techniques, they are asked to tense because their blood pressure drops and faint instead of increasing) • For social phobia, social skills can help people with social phobias • Role-play - interpersonal encounters in the consulting room or in small therapy groups • Modelling – uses exposure to feared situations; they are exposed to a film or live demonstration of other people fearlessly interacting with the phobic object • Flooding – client is exposed at full intensity • Behaviour therapists who favour operant conditioning techniques ignore the fear assumed to underlie phobias and attend instead to the overt avoidance of phobia objects. C h a p t e r 6 : A n x i e t y D i s o r d e r s Page 1 • Many behaviour therapists attend to both fear and to avoidance, using techniques such as desensitization to reduce fear and operant shaping to encourage approach • Secondary gain: when other people cater to the persons incapacities, in a way reinforcing the persons phobia • Overt behaviour can be positively reinforced, and avoidance discouraged by family and friends Cognitive Approaches • There is no evidence that the elimination of irrational beliefs alone, without exposure to the fearsome situation, reduces phobic avoidance • For social phobia, cognitive method with social skill training can help • Behavioural and cognitive approach both have them face their fears Biological Approaches • Sedatives, tranquilizers or anxiolytics help reduce anxiety • Barbiturates were used before but were banned because of its addictiveness • Valium & Xanax are still used today • Antidepressants have become popular in treating many anxiety drugs o Monoamine oxidase (MAO) inhibitors treat social phobias better than benzodiazepine. But it can lead to weight gain, insomnia, sexual dysfunction and hypertension o Prozac (serotonin reuptake inhibitors) help reduce social phobias too • A problem with drugs is that a patient would have difficulty after discontinued use Panic Disorder • The person suffers a sudden and often inexplicable attack of symptoms (laboured breathing, heart palpitations, nausea, chest pain, feelings of choking and smothering, dizziness, sweating, trembling, intense apprehension, terror, and feelings of doom • Depersonalization: feeling of being outside one’s body • Derealization: feeling of the world’s not being real, as well as fears of losing control, going crazy and even dying • May occur frequently  once a week and lasts for minutes • Cued panic attacks: when they are associated with situational triggers (driving) • Situationally predisposed attacks: when their relationship with stimuli is present but not as strong • Uncued attacks: occur in benign states like relaxation or sleep, and in unexpected situations • Exclusive presence of cued attacks most likely reflects the presence of a phobia C h a p t e r 6 : A n x i e t y D i s o r d e r s Page 1 • Panic attacks are common among university/college students • Prevalence is about 2% for men and 5% for women • The onset is associated with a stressful life experience and typically begins in adolescence • Prevalence varies cross culturally • Hayak-angst: occurs in seal hunters who are alone at sea; intense fear, disorientation, and concerns about drowning • DSM-IV panic disorder is diagnosed as with or without agoraphobia • Agoraphobia: is a cluster of fears centring on public places and being unable to escape or find help should one become incapacitated (fear of shopping, crowds, and travelling); they have fear of just leaving the house • Patients who have panic attacks avoidance sometimes become widespread  that’s when panic disorder with agoraphobia results • 80% of patients diagnosed as having 1 of the other anxiety disorders also experience panic attacks • Coexistence with major depressive disorder is also common as well as a comorbidity with generalized anxiety disorder Etiology of Panic Disorder Biological Theories • Minority of the cases; physical sensations caused by an illness lead some people to develop phobias • Mitral valve prolapsed syndrome: causes heart palpitations and inner ear dizziness  which would lead to a panic attack • Panic disorders run in families • Genetic diathesis may be involved and specific chromosomes are being investigated • Noradrenergic Activity o Panic attack is caused by overactivity in the noradrenergic system (neurons that use norepinephrine as a NT) o Stimulation of the locus ceruleus causes monkeys to have attacks o So natural attacks may be caused by over activation of the locus ceruleus o In humans, yohimbine stimulates locus ceruleus  panic attack o BUT, drugs that block firing of the locus ceruleus have not been effective o Another idea is that noradrenergic overactivity results from  a problem in GABA neurons (that generally inhibit noradrenergic activity)  Remains an area of active research • Cholecystokinin o CCK (a peptide in brain regions) induces anxiety like symptoms in rats which can be blocked by benzodiazepines C h a p t e r 6 : A n x i e t y D i s o r d e r s Page 1 • Creating Panic Attacks Experimentally o Panic attacks are linked to hyperventilation or over breathing  which activates somatic aspects of a panic episode o Lactate may also produce it o Oversensitive CO2 receptors o But research found hyperventilation only occurs in 1/24 attacks o Thus, it’s not supported Psychological Theories • Fear of fear hypothesis: says that agoraphobia is a fear of having a panic attack in public (rather than fear of public places) • Foundation for their development may be an autonomic nervous system that is predisposed to be overly active + a psychological tendency to become very upset by these sensations • Thus, the psychology of the person takes over from where the biology began • So there is a vicious circle- fearing another panic attack  increased autonomic activity  symptoms are interpreted in catastrophic ways  raise the anxiety level  full blown panic attack • A study showed that frequency of panic attacks were higher in participants who were high in fear of their own bodily sensations • The frequency of panic attacks were strikingly high in participants who feared their bodily sensations, breathed air containing high concentration of carbon dioxide, and did not expect it to be arousing • Thus, showing that unexplained physiological arousal in someone who is highly fearful of such sensations lead to panic attacks • Heightened tendency to be afraid of fear sensations appear to play an important role • There is also the concept of control; that patients with the disorder have an extreme fear of losing control • A study showed that 80% of people that had no control had a panic attack Therapies for Panic disorder & Agoraphobia Biological Treatments • Antidepressants show some control for panic disorders • Ex. Prozac, selective serotonin reuptake inhibitors, tricyclic antidepressants, and anxiolytics • Drug treatments must be continued or they may return • About ½ drop out of using tricyclics because it causes bad side effects • Benzodiazepines are addicting and produce cognitive and motor side effects • Many patients use anxiolytics or alcohol to get the stress off on their own • Use and abuse of drugs are common Psychological Treatments C h a p t e r 6 : A n x i e t y D i s o r d e r s Page 1 • Exposure based treatments are often used in reducing panic disorder with agoraphobia (which is maintained for many years) • Families may benefit from family oriented therapies • In vivo exposure treatment • Therapy by Barlow  3 components o Relaxation training o Combination of Ellis-and Back-type cognitive behaviour intervention, including cognitive restructuring o Exposure to internal cues that trigger panic • There are therapeutic gains from cognitive and exposure therapy • Overall, cognitive-behavioural treatments show better results in long- term follow-ups than tricyclics Generalized Anxiety Disorder • They are persistently anxious, often worry about minor items. It’s a chronic, uncontrollable worry about all manner of things • Difficulty concentrating, tiring easily, restlessness, irritability, and high level of muscle tension • Prevalence is fairly high – 5% • Onset is mid-teens – but has been reported to be there all their lives (stressful life events play a role in the onset) • 2x common in women as in men • High level of comorb
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