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Chapter 6

PSYB32-Chapter 6 Notes.docx

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Department
Psychology
Course Code
PSYB32H3
Professor
Konstantine Zakzanis

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Chapter 6: Anxiety Disorder  Anxiety: An unpleasant feeling of fear and apprehension accompanied by increased physiological arousal. In learning theory, it is considered a drive that mediates between a threatening situation and avoidance behaviour. Anxiety can be assessed by self-report, by measuring physiological arousal, and by observing overt behaviour.  Anxiety disorders are diagnosed when subjectively experienced feelings of anxiety are clearly present. DSM-IV-TR proposed six categories: phobias, panic disorders, generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and acute stress disorder.  Often someone with one anxiety disorder meets the diagnostic criteria for another disorder, as well, with the possible exception of OCD. This comorbidity among anxiety disorders arises for two reasons: 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.  As a group, the anxiety disorders are the most common psychological disorders. These disorders have early age of onset, typically during childhood.  Anxiety disorders were more common in women than in men across all age groups.  Social anxiety disorder (SAD) was the most common anxiety disorder with a lifetime prevalence of 8.1%  Social phobia (but not agoraphobia and specific phobia) was a powerful predictor of the subsequent first onset of major depression.  The distress disorders would include major depression dysthymic disorders, GAD, and PTSD; the fear disorders would include panic disorder, agoraphobia, social phobia, and specific phobia; and the bipolar disorders would include bipolar I, bipolar II, and cyclothymia.  Master et al. recommended a “paradigm shift” toward a mixed categorical- dimensional classification system for DSM-5 and provided an example for an umbrella category, 300. 23Social Anxiety Disorder, that would include social anxiety disorder avoidant personality disorder, selective mutism, separation anxiety disorder, and school phobia. Maser et al.’s rationale for including all of these disorder under a single, broad category is as follows: a. All of these disorders may be treated with SSRIs and/or using common principles of cognitive-behaviour therapy. b. Many symptoms for each separate disorder overlap. c. Each separate disorder has comorbidities in common with the other.  The right amygdala is implicated in PTSD PHOBIAS  Phobias 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 suffix phobia is preceded by a Greek word for the feared object or situation.  Some of the more familiar terms are claustrophobia, fear of closed spaces  Fear of public spaces: agoraphobia  Fear of heights: acrophobia  Fear of working: ergasiophobia  Fear of chocking: pnigophobia  Fear of being buried alive: taphephobia  Fear of contamination and dirt that plagues many people: mysophobia  Psychoanalysts focus on the content of the phobia and see the phobic object as a symbol of an important unconscious fear. Thus, psychoanalysts believe that the content of phobias has important symbolic value. SPECIFIC PHOBIAS  Specific phobias are 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; and the natural environment. Empirical research suggests that fear can be grouped into one of five factors: (1) agoraphobia; (2) fears of heights or water; (3) threat fears; (4) fears of being observed, and (5) speaking fears. These fears reflect two higher-order categories: specific fears and social fears.  Specific phobias are high in prevalence.  The most common specific phobia subtypes in order were: (1) animal phobia; (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; and (8) storms, thunder, or lightening.  In China, for example a person with Pa-leng (a fear of the cold) worries that loss of body heat may be life threatening.  Another example is a Japanese syndrome called taijin kyofu-sho (TKS), fear of other people. This is not a social phobia; rather, it is an extreme fear of embarrassing others – for example, by blushing in their presence, glancing at their genital areas, or making odd faces.  Social phobias are persistent, irrational fears linked generally to the presence of other people.  SAD can be either generalized or specific, depending on the range of situations that are feared and avoided. While generalized social phobia involve many different interpersonal situations, specific social phobias involve intense fear of one particular situation (e.g. public speaking). People with the generalized type have an earlier age of onset, more comorbidity with other disorders, such as depression and alcohol abuse, and more severe impairment.  People with a lifetime diagnosis of SAD in the National Comorbidity Survey – Replication (NCS-R) and the CCHS and found strong support for a three- factor model composed of (1) social interaction fears, (2) observation fears, and (3) public speaking fears.  Social phobias have a high comorbidity rate with other disorders and often occur in conjunction with GAD, specific phobias, panic disorders, 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 seem also to be especially vulnerable to marijuana related problems. Behavioural Theories: Behavioural theories focus on learning as the way in which phobias are acquired. Avoidance Conditioning: The main behavioural account of phobias is that such reactions are learned avoidance responses. The avoidance-conditioning formulation, which is based on the two-factor theory originally proposed by Mowrer, holds that phobias develop from two 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 conditioned fear by escaping from or avoiding the CS. This second kind of learning is assumed to be operant conditioning; the response is maintained by its reinforcing consequences of reducing fear. Modelling: 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 learning. - The anxious- rearing model is based on the premise that anxiety disorders in children are due to constant parental warning. Prepared Learning: Another issue that the original avoidance-learning model fails to address is that people tend to fear only certain objects and event, such as spiders, snakes, and heights, but no others, such as lambs. The fact that certain neutral stimuli, called prepared stimuli, are more likely than others to become classically conditioned stimuli may account for this tendency. Diathesis in 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. Social Skills Deficits in Social Phobias: A behavioural model of social phobia considers inappropriate behaviour or a lack of social skill as the cause of social anxiety. 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 evens are more likely than positive ones to occur in the future. - Socially anxious people are more concerned about 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. - Cognitive-behavioural models of social phobia link social phobia with certain cognitive characteristics: (1) an attentional bias to focus on negative social information, (2) perfectionistic standards for accepted social performances; (3) a high degree of public self-consciousness. - Rechman, Gruter-Andrew, and Shafran reported that socially anxious student not only anticipate negative social experience, they also engage in extensive post-event processing (PEP) of the negative social experience. 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. Lacey identified a dimension of autonomic activity that he called stability-lability. Labile, or jumpy, individuals are those whose autonomic systems are readily aroused by a wide range of stimuli. - Autonomic lability: Tendency for the autonomic nervous system to be easily aroused. Genetic Factors: Smoller et al. also identified two significant problems: (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 for clinicians but fail to take into account growing evidence that genetic factors are diffuse across various anxiety disorders and they transcend these diagnosis categories. Psychoanalytic Theories: According to Freud, phobias are a defence against the anxiety produced by repressed id impulses. The phobia is the ego’s way of warding off a confrontation with the real problem, a repressed childhood conflict. Therapies For Phobias Behavioural Approaches  Systematic desensitization was the first major behavioural treatment to be used widely in treating phobias. The individual with a phobia imagines a series 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: A treatment for phobias using computer- generated graphics and sound to construct an experience similar to one that a client fears.  This type of exposure has been dubbed in virtuo exposure.  Blood-and-injection phobias have, in DSM-IV, been distinguished from other kinds of serve fears and avoidances because of the distinctive reactions that people with these phobias have to the usual behavioural approach of relaxation paired with exposure.  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.  Clients with blood-and-injection phobias are now encouraged to tense rater than relax their muscles when confronting fearsome situation.  Some CBT therapists encourage clients to role-play interpersonal encounters in the consulting room or in therapy groups and several studies attest to the long-term effectiveness of this approach.  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. The extreme discomfort that is inevitable discourages therapists from using this technique, except perhaps as a last resort when graduated exposure has not worked.  Therapists who favour operant techniques ignore the fear assumed to underlie phobias and attend instead to the overt avoidance of phobic objects and to the approach behaviour that must replace it. They treat approach to the feared situation as any other operant and shape it via the principles of successive approximations.  Many CBT therapists attend both to fear ad to avoidance, using exposure technique to reduce fear and operant shaping to encourage approach.  A person with a phobia has often settled into an existence in which other people cater to his or her incapacities, in a way reinforcing the person’s phobia (psychoanalysts call this phenomenon secondary gain) Cognitive Approaches  Homework or between session learning is considered to be an essential component of CBT. Cognitive-Behavioural Case Formulation Framework  Boschen and Oei presented a cognitive behavioural case formulation framework (CBCFF) for anxiety disorders. In this framework, casual and maintaining factors are outlined in a single but simple visual framework. They argue that the elements that are common to the anxiety disorders allow the framework to be used in a case formulation development and treatment planning.  The following is a brief description of the flow chart components excerpted and adapted from Boschen and Oei: - The left-to-right chain describes a situation where an anxious person comes into contact with a perceived danger situation and then acts in such a way to reduce the ensuing anxiety. - Other cognitive variables also impact on this basic chain. - Thought bubbles and six-sided shapes represent cognition and behaviour, respectively. Rectangular symbols represent other components. - Approach Behaviours. Exposure-based interventions require an increase in the frequency of approach behaviour. - Stimulus. Feared stimuli can be drawn from external objects or situations, interceptive stimuli, and cognitions. - Hypervigilance to stimulus. People attend to threatening stimuli. - 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 dimension that predisposes people to experience negative affective states and 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
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