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Chapter 6

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Konstantine Zakzanis

Abnormal Psychology; Chapter 6 - Anxiety Disorders  anxiety - unpleasant feeling of fear and apprehension  anxiety disorders - diagnosed when subjectively experienced feelings of anxiety are clearly present  DSM-IV-TR proposes 6 categories: 1. phobias - fear and avoidance of objects or situations that do not present any real danger 2. panic disorder - recurrent panic attacks involving a sudden onset of physiological symptoms, such as dizziness, trembling, rapid heart rate; sometimes accompanied by agoraphobia- fear of being in public places 3. generalized anxiety disorder (GAD) - persistent, uncontrollable worry, often about minor things 4. obsessive-compulsive disorder (OCD) - the experience of uncontrollable thoughts, impulses or images(obsessions) and repetitive behaviours or mental acts (compulsions) 5. post-traumatic-stress disorder (PTSD) - aftermath of a traumatic experience in which the person experiences increased arousal, avoidance of stimuli associated with the event and anxiety in recalling the event 6. acute stress disorder - symptoms are the same as those of PTSD but last for 4 weeks or less  someone with anxiety disorder meets the diagnostic for another disorder  this comorbidity among anxiety disorders arises for 2 reasons: 1. symptoms of the various anxiety disorders are not disorder specific 2. the etiological factors that give rise to various anxiety disorders are probably applicable to more than one disorder  1 in 5 people have some form of anxiety disorder (common psychological disorders)  gender difference exists - anxiety disorders were more common in women than in men across all age groups  social anxiety disorder (SAD) was the most common anxiety disorder ; levels of PTSD may rival those of SAD  major of Canadians who met criteria for an anxiety disorder, reported that it interfered with their home, school, work and social life  those with anxiety disorder were less likely to seek help from any mental service  the anxiety of disorders are comorbid with many other conditions  social phobia is comorbid with other anxiety disorders, substance abuse, depressive disorder and bipolar disorder  there is a strong co-occurrence of the anxiety disorders and chronic pain, especially musculoskeletal pain  anxiety disorders are independent risk factors for suicide attempts  anxiety and depression show a strong relationship to each other at both genotypic and phenotypic levels and are two elements of a general negative affectivity factor  GAD and major depression appear to have overlapping heritable characteristics, they may be distinguishable by environmental factors and temporal presentations  functional MRI and PET studies of PTSD, SAD and specific phobia have examined responses across 3 conditions: negative emotion , positive emotion, neutral conditions  people with these disorders have greater activity in 2 areas associated with negative emotional responses: the amygdala and he insula 1 Abnormal Psychology; Chapter 6 - Anxiety Disorders  the right amygdala is implicated in PTSD PHOBIAS  phobia - disrupting, fear-mediated avoidance that is out of proportion to the danger actually posed and is recognized by the sufferer as groundless  extreme fear of heights, closed spaces, snakes - provided that there is no objective danger - accompanied by sufficient distress to disrupt one's life is likely to be diagnosed as a phobia  many specific fears do not cause enough hardship to seek treatment  term "phobia" implies that the person suffers intense distress and social or occupational impairment because of the anxiety  suffix phobia is preceded by a Greek word for the feared object - suffix derived from Greek god Phobo, who frightened his enemies  claustrophobia - fear or closed spaces  agoraphobia - fear of public places  acrophobia - fear of heights  ergasiophobia - fear of working  pnigophobia - fear of choking  taphephobia - fear of being buried alive  mysophobia - fear of contamination and dirt that plagues many people  psychoanalysts focus on the content of the phobia and see the phobic object as a symbol of an important unconscious fear  behaviourists tend to ignore the content of the phobia and focus on its function Specific Phobias  specific phobias - unwarranted fears caused by the presence or anticipation of a specific object or situation  DSM-IV-TR - subdivides these phobias according to the source of the fear:  blood  injuries and injections  situations  animals  natural environment  empirical research suggests that fears can be grouped into one of the 5 factors(types): 1. agoraphobia 2. fears and heights or water 3. threat fears (ex. blood/needles, storms/thunder) 4. fears of being observed 5. speaking fears  these fears reflect 2 higher-order categories: specific fears and social fears  specific phobias are high in prevalence 2 Abnormal Psychology; Chapter 6 - Anxiety Disorders  the most common specific phobia subtypes in order are: 1) animal phobias 2) heights 3) being in closed spaces 4) flying 5) being in or on water 6) going to the dentist 7) seeing blood or getting an injection 8) storms, thunder, lightning  the specific fear focus on in a phobia can vary cross-culturally  in China, a person with Pa-leng - a fear of the cold, worries that loss of body heat may be life threatening Social Phobias (Social Anxiety Disorder)  social phobias - are persistent, irrational fears linked generally to the presence of other people  people with social phobia try to avoid particular situations in which they might be evaluated, fearing that they will reveal signs of anxiousness or behave in an embarrassing way  SAD can be either generalized or specific, depending on the range of situations that are feared  generalized social phobias involve many different interpersonal situation  specific social phobias involve intense fear of one particular situation  people with generalized type have an earlier age of onset, more comorbidity with other disorders  social phobias have a high comorbidity rate with other disorders and often occur in conjunction with GAD, specific phobias, panic disorder, avoidant personality disorder and mood disorder  also has high comorbidity with heavy drinking, and alcohol dependence - also tend to be vulnerable to marijuana related problems  onset generally takes place during adolescence, when social awareness and interaction become more important in a person's life  prevalence of social phobias was higher among people who had never married or were divorced, not completed secondary education, had lower income, unemployed and had a physical condition  students with social phobia have lower-self-esteem and a distorted body image Etiology of Phobias Behavioural Theories:  behavioural theories focus on learning as the way in which phobias are acquired Avoidance Condition  the main behavioural account of phobias is that such reactions are learned avoidance responses  the avoidance-conditioning formulation, holds that phobias develop from 2 related sets of learning: 1) via classical conditioning, a person can learn to fear a neutral stimulus (the CS) if it is paired with an intrinsically painful or frightening event (the UCS) 2) the person can learn to reduce this conditional fear by escaping from or avoiding to be operant conditioning; the response is maintained by its reinforcing consequence of reducing fear 3 Abnormal Psychology; Chapter 6 - Anxiety Disorders  the evidence for this formulation demonstrates only the possibility that some fears may be acquired in this particular way  observing another person's fear response and not having explicit, conscious awareness of this conditioned stimulus can still contribute to the apparent learning of a fear response  fear is extinguished rather quickly when the CS is presented a few times without the reinforcement of moderate levels of shock  a phobia of a specific object or situation had sometimes been reported after a particularly painful experience with that object - other clinical reports suggest that phobias may develop without a prior frightening experience Modelling  a person can also learn fears through imitating the reactions of others  some phobias may be acquired by modelling, not through an unpleasant experience  vicarious learning - the learning of fear by observing others  vicarious learning may also be accomplished through verbal instructions - phobic reactions can be learned through another's description of what could happen  anxious-rearing model - based on the premise that anxiety disorders in children are due to constant parental warnings that increase anxiety in the child Prepared Learning  people tend to fear only certain objects and events such as spiders, snakes and heights but not others such as lambs  certain neutral stimuli, called prepared stimuli, are more likely than others to become classically conditioned stimuli  some fears may well reflect classical conditioning, but only to stimuli to which an organism is physiologically prepared to be sensitive  prepared learning is also relevant to learning fear by modelling A Diathesis is Needed  a cognitive diathesis (predisposition) - a tendency to believe that similar traumatic experiences will occur in the future - may be important in developing a phobia  many people with phobias do not report either direct exposure to a traumatic event or exposure to fearful models Social Skills Deficits in Social Phobias  a behavioural model of social phobia considers inappropriate behaviour or a lack of social skills as the cause of social anxiety  according to this view, 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 inept, and is often criticized by social companions 4 Abnormal Psychology; Chapter 6 - Anxiety Disorders  socially anxious people are rated as being low in social skills and that the timing and placement of their responses in a social interaction are impaired Cognitive Theories  cognitive views focus on how people's thought processes can serve as a diathesis and on how thoughts can maintain a phobia or anxiety  anxiety is related to being more likely to attend to negative stimuli, to interpret ambiguous information as threatening, and to believe that negative events are more likely than positive ones to occur in the future  socially anxious people tend to view themselves negatively even when they have actually performed well in a social interaction and they are less certain about their positive self-views and see their positive attributes as being less important  they seem to be hyper vigilant in looking for signs of negative social evaluation, this suggest that people with social phobia have a cognitive bias toward being more attentive visually to negative faces than to positives  cognitive-behavioural models of social phobia link social phobia with certain cognitive characteristics: 1) an attentional bias to focus on negative social information and interpret ambiguous situations as a negative 2) perfectionistic standard for accepted social performances 3) high degree of public self-consciousness  people with social phobia tend to falsely recall events they have interpreted as having emotionally negative features  the fundamental core fear in social phobia is that the self is deficient  social phobia is linked with excessive self-criticism  socially anxious students in both stressful and neutral situations have more negative thoughts  socially anxious students also engage in extensive post-event processing (PEP) of the negative social experiences Predisposing Biological Factors  people who are adversely affected by stress have a biological malfunction (a diathesis) that somehow predisposes them to develop a phobia following a particular stressful event Autonomic Nervous System (ANS)  one way people differ in their reaction to certain environmental situations is the ease with which their autonomic nervous systems become aroused  labile, or jumpy individuals are those whose autonomic systems are readily aroused by a wide range of stimuli  because of the extent to which the autonomic nervous system is involved in fear and hence in phobic behaviour, a dimension such as autonomic lability assumes considerable important  heredity may very well have a significant role in the development of phobias 5 Abnormal Psychology; Chapter 6 - Anxiety Disorders Genetic Factors  in social and specific phobias, prevalence is higher than average in first-degree relatives of clients  close relatives have considerable opportunity to observe and influence one another  linkage analyses seek to identify the specific genes implicated in these disorders - two problems are: 1) genetic complexity and 2) phenotypic complexity  genetic complexity poses a problem because disorders likely reflect the additive or interactive effects of multiple loci  phenotypic complexity is a problem because this complexity likely transcends the DSM categories that may be useful conventions but fail to take in account growing evidence that genetic factors are diffuse across various anxiety disorders Psychoanalytic Theories  according to Freud, 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  the phobia is the ego's way of warding off a confrontation with the real problem  Arieti proposed the repression stems from a particular interpersonal problem of childhood rather than from an id impulse Therapies for Phobias Behavioural Approaches  systematic desensitization was the first major behavioural treatment to be used  individual with a phobia imagines a serious of increasingly frightening scenes while in a state of deep relaxation  in vivo exposure - an exercise at home that requires the phobic person to be exposed to the highly feared stimulus or situation  virtual reality (VR) exposure treatments is just as effective as in vivo exposure  virtual reality involves exposure to stimuli that come in the form of computer-generated graphics  relaxation tends to make matters worse for people with blood-and-injection phobias  a person with the phobia experiences a sudden drop in blood pressure and heart rate and faints - by trying to relax, clients with these phobias may well contribute to the tendency to faint, increasing their already high levels of fear and avoidance, as well as their embarrassment  learning social skills can help people with social phobias who may not know what to do in social situations  some CBT therapists encourage clients to role-play interpersonal encounters  modelling is another technique that uses exposure to feared situations  in modelling therapy, fearful clients are exposed to filmed or live demonstrations of other people interacting fearlessly with the phobic object  flooding - is a therapeutic technique in which the client is exposed to the source of the phobia at full intensity 6 Abnormal Psychology; Chapter 6 - Anxiety Disorders  therapists who favour operant techniques ignore the feat assumed to underlie phobias and attend instead to the overt avoidance of phobic objects and to the approach behaviour that must replace it  CBT therapists attend both fear and to avoidance using exposure techniques to reduce fear and operant shaping to encourage approach  in the initial stages of treatment, when fear and avoidance are both very great, the therapist concentrates on reducing the fear through relaxation training  as therapy progresses, fear becomes less of an issue and avoidance more  Ost's one-session exposure treatment for phobias - the session is highly intensive and lasts for many hours Cognitive Approaches  the phobic fear is recognized by the individual as excessive or unreasonable  CBT interventions are generally more successful than drug treatments because they create lasting change, while the benefits of drug treatments are less permanent  all the behavioural and cognitive therapies for phobias have a recurrent theme - the need for the client to begin exposing himself to what has been afraid of  homework -between session learning that typically involves get practice in engaging in specific behaviours or thoughts ; considered to be an essential component of CBT A Cognitive-Behavioural Case Formulation Framework  the elements that are common to the anxiety disorders allow the framework to be used in case formulation development and treatment planning  the framework is useful in cases with novel presentation for which manualized treatments might not be available Biological Approaches  drugs that reduce anxiety are referred to as sedatives, tranquilizers or anxiolytics  barbiturates were the first major drugs used to treat anxiety disorders, but since they are highly addictive, they were supplanted by 2 other classes of drugs: propanediols and benzodiazepines  drugs originally developed to treat depression (antidepressants) have become popular in treating many anxiety disorders, phobias included  the monoamine oxidase (MAO) inhibitors, fared better in treating social phobias and was effective as CBT at a 12- week follow up  MAO inhibitors can lead to weight gain, insomnia, sexual dysfunction, and hypertension  selective serotonin reuptake inhibitors (SSRIs) such as Prozac, were also originally developed to treat depression and have shown reduced social phobia  key problem with treating phobias with drugs is that the client may find it difficult to discontinue their use, relapse being a common result 7 Abnormal Psychology; Chapter 6 - Anxiety Disorders Psychoanalytic Approaches  these treatments attempted to uncover the repressed conflicts believed to underlie the fear and avoidance characteristic of these disorders  direct attempts to reduce phobic avoidance were contraindicated because the phobia is assumed to protect the person from repressed conflicts that are too painful to confront  contemporary ego analysts focus more on encouraging the client to confront the phobia - they do view the phobia as an outgrowth of an earlier problem PANIC DISORDER  panic disorder - a person suffers a sudden and often inexplicable attack of a host of jarring symptoms: laboured breathing, heart palpitations, nausea and chest pain; feelings of choking and smothering; dizziness, sweating, and trembling and intense apprehension, terror and feelings of impending doom  depersonalization - a feeling of being outside one's body  derealization - a feeling of the world's not being real, as well as fears of losing control, of going crazy or even of dying  panic attacks occur frequently, they usually last for minutes and they are sometimes linked to specific situations  they are referred to as cued panic attacks when they are associated strongly with situational triggers  when their relationship with stimuli is present but not as strong, they are referred to as situationally predisposed attacks  panic attacks can also occur in benign states; such as relaxation or sleep - referred to as uncued attacks  recurrent uncued attacks and worry about having attacks in the future are required for the diagnosis of panic disorder  panic attacks were related to numerous psychological and physical function variables, including poor overall functioning, suicidal ideation, psychological distress, activity restriction, chronic physical conditions and self-rated physical and mental health  panic attacks may be a marker of severe psychopathology independent of a diagnosis of panic disorder  agoraphobia - a cluster of fears centring on public places and being unable to escape or find help should one become incapacitated - many people with agoraphobia are unable to leave the house  people who have panic disorder typically avoid the situations in which a panic attack could be dangerous or embarrassing  panic disorder has been linked with depression, GAD, alcohol and drug use and personality disorders  panic disorder is also linked with physical conditions such as asthma - the panic exacerbates the asthma and vice versa 8 Abnormal Psychology; Chapter 6 - Anxiety Disorders Etiology of Panic Disorders Biological Theories  physical sensations cause by an illness lead some people to develop panic disorder  panic disorder runs in families and has greater concordance in identical twin pairs than in fraternal twins  early onset of panic disorder is associated with increased risk for family members Noradrenergic Activity  another biological theory suggests that panic is caused by overeactivity in the noradrenergic system (neurons that use norepinephrine as a neurotransmitter)  research with humans has found that yohimbine, a drug that stimulates activity in the locus ceruleus (nucleus in the pons) can elicit panic attacks in people with panic disorder  study found that fewer GABA-receptor binding sites in clients with panic disorder Cholecystokinin  cholecystokinin (CCK), a peptide that occurs in the cerebral cortex, amygdala, hippocampus, and brain stem induces anxiety-like symptoms and the effect can be blocked with benzodiazepines - suggesting that changes in CCK produces changes in the development or expression of panic  panic disorder, at least in part, is due to hypersensitivity to CCK Psychological Theories  principal psychological theory of the agoraphobia that often accompanies panic disorder is the fear- of-fear hypothesis  which suggests that agoraphobia is not a fear of public places per se, but a fear of having a panic attack in public  as for panic attacks, the foundation for their development may be an autonomic nervous system (ANS) that is predisposed to be overly active, coupled with a psychological tendency to become very upset by these sensations  when high physiological arousal occurs, some people construe these unusual autonomic reactions (such as rapid heart rate) as a sign of great danger  after repeated occurrences, the person comes to fear having these
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