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Chapter 6

Chapter 6.docx

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Department
Psychology
Course Code
PSYB32H3
Professor
Konstantine Zakzanis

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Chapter 6: Anxiety Disorders  Anxiety: unpleasant feeling of fear and apprehension  Anxiety disorders are diagnosed when one subjectively experienced feelings of anxiety are clearly presented. The DSM proposes six categories: phobias, panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and acute stress disorder.  Comorbidity among anxiety disorders arises for two reasons (except OCD): 1. Symptoms of the various anxiety disorders are not entirely disorder specific 2. The etiological factors that give rise to various anxiety disorders are probably applicable to more than one disorder.  All comorbidity could reflect the operation of common mechanisms.  The theories of anxiety disorders and to focus exclusively on a single disorder.  Anxiety disorders are the most common psychological disorders.  Women have higher prevalence rates of anxiety disorders than men.  Anxiety disorders are quite common among university students.  Social anxiety disorder was the most common anxiety disorder.  Those with an anxiety disorder were less likely to seek help from any mental health services, relative to those with a mood disorder.  Social phobia was a powerful predictor of the subsequence first onset of major depression.  The tripartite model posits that anxiety and depression share a common component of negative affect; however, they can be differentiated by higher physiological hyperarousal associated with anxiety and viable positive effect associated with depression.  Some experts have recommended paradigm shift toward a mixed categorical – dimensional classification system for the DSM five. These experts wants to categorize a number of disorders under one umbrella because: o they may be treated with SSRIs and using common principles of cognitive behavior therapy o many symptoms for each separate disorder overlap o each separate disorder has comorbidities in common with the other  The right amygdala is related to PTSD. Phobias  Phobia is a disrupting, fear mediated avoidance that is out of proportion to the danger actually posed and is recognized by the sufferer as groundless.  The term phobia usually implies that the person suffers intense distress and social or occupational impairment because of the anxiety.  Psychologists tend to focus on different aspects of phobias according to the paradigm they have adopted. Specific Phobias  Specific phobias are unwarranted fears caused by the presence or anticipation of a specific object or situation.  The DSM-IV – TR subdivides these phobias according to the source of the fear: blood, injuries, and injections; situations; animals; the natural environment.  Empirical research suggests that fears can be grouped into one of the five factors: 1. Agoraphobia 2. Fear of heights or water 3. Threat fears (blood, needles, storms, thunder) 4. Fears of being observed 5. Speaking fears  These fears reflect to higher – order categories: specific fears and social fears  Specific phobias are high in prevalence. The mean onset was around 10 years old. The mean duration was 20 years and only 8% with a specific phobia receive treatment for their specific phobia or phobias.  The most common specific phobia subtypes in order were: 1. Animal phobias 2. Height 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, or lightning  Social phobias are persistent, irrational fears linked generally to the presence of other people. Individuals with a social phobia try to avoid particular situations in which they might be evaluated, fearing that they will reveal signs of anxiousness or behave embarrassingly.  Social anxiety disorder can be either generalized or specific, depending on the range of situations that are feared and avoided. Generalized social phobias involve many different interpersonal situations; specific social phobias involve intense fear of one particular situation.  People with the generalized type have an earlier age of onset, or comorbidity with other disorders, such as depression and alcohol abuse, and more severe impairment.  The three factor model reveals the structure of feared situation on most people with a lifetime diagnosis of social anxiety disorder: 1. Social interaction fears 2. Observation fears 3. Public speaking fears  Individuals with generalized SAD are most likely to report social interaction and observation fears.  Social phobias have high comorbidity rate with other disorders and often occur in conjunction with generalized anxiety disorder, specific phobias, panic disorder, avoidant personality disorder and mood disorders.  Social phobia also has high levels of comorbidity with heavy drinking and alcohol dependence, perhaps due to self-medication with alcohol.  People diagnosed with SAD also tend to be especially vulnerable to marijuana related problems.  Onset generally takes place during adolescence, when social awareness and interaction with others become much more important in a person's life. The average age of onset was 13 years and average duration of symptoms was 20 years.  The prevalence of social phobia was higher among people who never married or divorced, not completed secondary education, had lower income or were unemployed, reported lacking adequate social support, reported low quality of life and had a chronic physical condition.  Students with social phobias have lower self-esteem and a distorted body image relative to students who were not phobic.  Prevalence increased and the gender ratio shifted to primarily females as age increased. Social phobia was associated with educational, impairment, depression and anxiety and parents and peer victimization.  Predictors of recovery included being employed, no lifetime depression, fewer than three lifetime psychiatric disorders, and fewer daily hassles. Etiology of Phobias: Behavioral Theories  Behavioral theories focus on learning the way in which phobias are acquired.  Avoidance conditioning: the main behavioral accounts of phobias are that such reactions are learned avoidance responses. The avoidance – conditioning formulation, which is based on the two factor theory holds that phobias develop from two related sets of learning: o Via classical conditioning, a person can learn to fear the neutral stimulus if it is paired with an intrinsically painful or frightening event o The person can learn to reduce this conditioned fear by escaping from for avoiding neutral stimulus. The second kind of learning is assumed to be operant conditioning; the responses maintained by its reinforcing consequence of reducing fear  Observing another person's fear response and not having an 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 neutral stimulus is presented a few times without the reinforcement of moderate levels of shock.  Modeling: a person can also learn fears through imitating the reactions of others. The learning of fear by observing others is generally referred to as vicarious line.  Vicarious learning may be accomplished through verbal instructions.  The anxious–rearing model is based on the premise that anxiety disorders in children are due to constant parental warnings that increase anxiety in a child.  Prepared Learning: people tend to fear only certain objects and events. The fact that certain neutral stimuli, called prepared stimuli for, are more likely than others to become classically conditioned stimuli may account for this tendency.  A Diathesis is Needed: a predisposition (cognitive diathesis)-tendency to believe that similar dramatic experiences will occur in the future-may be important in developing a phobia. Another possible psychological diathesis is a history of not being able to control the environment. Social Skills Deficits in Social Phobias  A behavioral model of social phobia considers inappropriate behavior or lack of social skills is the cause of social anxiety.  The 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. Etiology of Phobias: 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 are more concerned about the evaluation than are people who are not socially anxious, are more aware of the image they present to others, and are preoccupied with hiding imperfections and not making mistakes in front of other people. They are less certain about their positive self-views. Socially anxious people tend to have a cognitive bias toward being more attentive visually to negative faces than to positive faces.  Cognitive behavioral models of social phobia of his social phobia link social phobia with certain cognitive characteristics: 1. an attentional bias to focus on negative social information and interpret ambiguous situations as negative 2. perfectionistic standards for accepted social performances 3. a high degree of public self-consciousness  Excessive self-consciousness and self-focus tend to increase social anxiety.  People with social phobia have a memory bias owing to a negative interpretation bias. People with social phobia tend to falsely recall events that interpreted as having emotionally negative features.  The fundamental core fear in social phobia is that the self is deficient. The key situational triggers are those situations and circumstances that will publicly reveal the self as inadequate.  Social phobia is linked with excessive self-criticism.  Researchers have begun to focus and interventions designed to boost self- efficacy, especially in the terms of self-efficacy for changing social anxiety.  Socially anxious students also engage in extensive post-event processing (PEP) of the negative social experiences, sometimes experiencing intrusive thoughts and images associated typically with OCD. Predisposing Biological Factors Autonomic Nervous System  One way people differ in their reaction to certain environmental situations is the ease with which their autonomic nervous systems become aroused.  Individuals who are jumpy or labile are those whose autonomic systems are readily aroused by a wide range of stimuli. Genetic Factors  Blood-and-injection phobia is strongly familial.  Two significant problems have been identified: o Genetic complexity: disorders likely reflect the additive or interactive effect of multiple loci o Phenotypic complexity: this complexity likely transcends the DSM categories that may be useful conventions for clinicians but failed to take into account growing evidence that genetic factors are diffuse across various inside the disorders and they transcend these diagnostic categories Psychoanalytic Theories  According to Freud, phobias are a defense 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.  By avoiding the objects or situations that person fears, the person is able to avoid dealing with repressed conflicts.  The phobia is the ego's way of warding off a confrontation with the real problem, a repressed childhood conflict. Therapies for Phobia Behavioral Approaches  Systematic desensitization was the first major behavioral treatment to be used widely in treating phobias.  Many behavior therapists, however, came to recognize the critical importance of exposure to real life phobic situations, sometimes during the period in which a client is being desensitized in imagination and sometimes instead of imagery-based procedure.  Historically, clinical researchers have regarded in vivo exposure superior to techniques using imagination, not surprising finding given that imaginary stimuli are by definition not the real thing.  In a meta-analytic review of 33 randomized controlled trials of the treatment of specific phobias, concluded that exposure-based treatment produced large effect sizes relative to no treatment and outperformed both placebo conditions and other psychotherapeutic approaches.  While most phobias do respond well two in vivo exposures, it is associated with a high dropout rate and low treatment acceptance.  Some research comparing in vivo exposure with virtual reality (VR) exposure treatments is found VR exposure to be just as effective as in vivo exposure and just as effective as group CBT.  Virtual reality involves exposure to stimuli that come into form of computer- generated graphics.  Clients with blood and injection phobias are encouraged to tense rather than relax their muscles when confronting fearsome situations.  Modeling is a technique that is also used in exposure-feared situations. In modeling therapy, fearful clients are exposed to film or live demonstrations of other people interacting fearlessly with phobic object.  Flooding is a therapeutic technique in which the clients are exposed to the source of the phobia at full intensity.  Flooding is used for OCD and PTSD.  Real life exposures to the phobic object are gradually achieve and the client is rewarded for even minimal successes in moving closer to it. Exposure is in inevitable aspect of any operant shaping of approach behaviors.  In the initial stages of treatment, when fear and avoidance is are both very great, the therapist concentrates on reducing the fear through relaxation training and graded exposures to the phobic situation. As therapy progresses, fear becomes less of an issue and avoidance more. Cognitive Approaches  Cognitive treatments for specific phobias have been viewed with skepticism because of the central defining characteristic of phobias: the phobic fears recognized by the individual as excessive or unreasonable.  Social phobias, and the other hand, such cognitive methods – sometimes combined with social skills training – are more promising.  In a cognitive approach, patients may be persuaded by the therapist tovmore accurately appraise people's reactions to them, but also to rely less and approval of others for a sense of self-worth.  CBT interventions also been used to treat other anxiety disorders and meta- analysis support their usefulness.  CBT interventions are generally more successful than drug treatments because they create lasting change, while the benefits of drug treatments are less permanent and appeared to be largely palliative in nature.  All the behavioral and cognitive therapies for phobias have a recurring theme – the need for the client to begin exposing him or herself to what has been deemed to terrifying to face. Homework or between session learning is considered to be an essential component of CBT. A Cognitive-Behavioral Case Formulation  Approach behaviors. Contact with anxiety eliciting stimuli often occurs as a consequence of the person's behavior.  Stimulus. Feared stimuli can be drawn from external objects or situations, interoreceptive stimuli, and cognitions. Stimulis are not directly targeted by any particular CBT intervention.  Hypervigilance to stimulus. People attend to threatening stimuli. Interventions address hypervigilance to threat cues.  Perception of danger. The perception of threat or danger elicits anxiety. Cognitive restructuring is the primary vehicle by which perceptions of danger are addressed.  Neuroticism. Neuroticism is a stable, pervasive personality they mentioned that predisposes people to experience negative affective states that influence both cognition and anxiety symptoms.  Information or experience. Stimuli can come to be appraised as threatening through direct experience, observation, and verbal acquisition. CBT treatments usually begin with psychoeducation – corrective information provided to the client about anxiety and client specific disorder. Verbal information acquired during therapy sessions is consolidated through homework tasks.  Increased anxiety. Excessive, unreasonable anxiety is experienced through a constellation of emotional, physiological, cognitive, and behavioral symptoms. Methods of managing anxiety include relaxation training and breathing control training.  Reduced self-efficacy. Perceptions of ability to cope with anxiety provoking stimuli and consequent symptoms have been implicated in the anxiety disorders.  Anxiety reducing behavior. The choice of anxiety reducing behavior use is influenced by the nature of the anxiety provoking stimuli. As part of the treatment, the person needs to refrain from the behaviors usually used to relieve anxiety, circumventing negative reinforcement and strengthening perception of coping ability.  Safety signals. Many anxiety reducing behaviors are aimed at obtaining a sense of safety through degeneration of safety signals – stimuli that indicate an aversive event outcome is less likely. During exposure the person surrenders previously used safety signals, thereby enhancing self-efficacy  reduced anxiety and reinforcement of inciting reducing behaviors. Anxiety reducing behavior and use of safety signals produce a decrease in anxiety symptoms, which reinforces their use. During treatment the client inhibits usual anxiety reducing behavior and overtime it extinguishes.  Punishment of approach behaviors. Arousal symptoms that accompany danger perception are an aversive, punishing experience. During exposure habituation occurs and the punishing effects of anxiety are diminished. Biological Approaches  Drugs that reduce anxiety are referred to as sedatives, tranquilizers or anxiolytics.  Barbiturates were the first major category of drugs to treat anxiety disorders, but because they are highly addictive and present great risk of legal overdose, they were supplanted in the 1950s by two other classes of drugs: propanediols (Miltown) and benzodiazepines (Valium and Xanax).  Valium and Xanax are still used today, although they have been largely supplanted by newer benzodiazepines, such as Ativan and Clonapam.  These drugs are of demonstrated benefit with some anxiety disorders; however they are not used extensively with the specific phobias.  Although the risk of lethal dose is not as great as barbiturates, benzodiazepines and can produce a severe withdrawal syndrome.  Drugs originally developed to treat depression have become popular in treating many anxiety disorders, phobias included.  One class of these drugs, the monoamine oxidase (MAO) inhibitors, fared better in treating social phobias than benzodiazepine and in another study was as effective as CBT at a 12-week follow-up.  MOA inhibitors such as phenelzine (Nardil), can lead to weight gain, insomnia, sexual dysfunction, and hypertension. The selective serotonin reuptake inhibitors, such as fluoxetine (Prozac), for also originally developed to treat depression. They show some promise in reducing social phobia in double blind Canadian studies, and the meta-analysis of past studies confirm their effectiveness. Psychoanalytic Approach  Classical psychoanalytic treatments of phobias attempted to uncover the repressed conflicts believed to underlie the extreme fear and avoidance characteristics of these disorders. Panic Disorder  Panic disorder, a person suffers a sudden and often inexplicable attack of a host of jarring and symptoms: labored 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 and derealization, a feeling of the world's not being a real, as well as fears of losing control, of going crazy, or even the dying may beset and overwhelm the person.  Panic attacks may occur frequently, perhaps once a week or more often; they usually last for minutes, fairly for hours; and are sometimes linked to specific situations, such as driving car.  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 seemingly benign states, such as relaxation, sleep and in unexpected situations; in these cases there referred to as uncued attacks.  Panic attacks are 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.  Agoraphobia is a cluster of fears centering on public places and being unable to escape or find help should one become incapacitated.  People with panic disorder typically avoid the situations in which a panic attack could be dangerous or embarrassing.  Panic disorder has been linked with a wide range of conditions, including depression, GAD, alcohol and drug use, and personality disorders. Panic disorders also include physical conditions such as asthma, and in people suffering from both, it is believed that the panic exacerbates the asthma and
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