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Chapter 6

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Konstantine Zakzanis

Chapter 6: Anxiety Disorders Anxiety: unpleasant feeling of fear and apprehension Anxiety Disorders: Phobia- fear and avoidance of objects or situations that don’t present any real danger Panic disorder- recurrent panic attacks (dizziness, rapid heart rate, trembling, terror and feelings of impending doom; sometimes accompanied by agoraphobia (fear of being in public places) Generalized anxiety disorder- persistent uncontrollable worry, often about minor things Obsessive-compulsive disorder- uncontrollable thoughts/impulses/obsessions & repetitive bhvrs Post-traumatic stress disorder (PTSD)- aftermath of a traumatic experience (experiences arousal, avoidance of stimuli associated with the event, and anxiety recalling the event) Acute stress disorder- same symptoms as PTSD but only lasts for 4 weeks or less Comorbidity among anxiety disorders arises for 2 reasons:  Symptoms of the various anxiety disorders are not entirely disorder specific (perspiration, fast heart rate are among the diagnostic criteria for panic disorder, phobias, and PTSD)  Etiological factors that give rise to various anxiety disorders are probably applicable to more than 1 disorder As a group, anxiety disorders are the most common psychological disorders more common in women than men across all age groups more common in women of 15-24 years of age common among university students social anxiety disorder is the most common type of anxiety with a lifetime prevalence of 8.1%, PTSD could be a rival with a lifetime prevalence of 9.2% Anxiety disorders are comorbid with many other conditions (social phobia is comorbid with other anxiety disorders, substance abuse, depressive disorder, and bipolar disorder. Comorbidity is strongest with the depressive disorders Anxiety and depression show a strong relationship to each other at both genotypic and phenotypic levels and are 3 elements of a general negative affectivity factor Social phobia plays a role in promoting depression Clark and Watson proposed a tripartite model to account for the symptom overlap and diagnostic comorbidity between anxiety and depression. Model points that anxiety and depression share a common component of negative affect but the can be differentiated by high physiological hyper arousal associated with anxiety and by low positive effect associated with depression Distressed Disorders: o Major depression o Dysthymic disorder o GAD o PTSD Fear Disorders:  Panic disorder  Agoraphobia  Social phobia  Specific phobia Bipolar Disorders:  Bipolar 1  Bipolar 2  Cyclothymia Maser’s rationale for including some disorders under a single, broad category: All these disorders may be treated with SSRI’s and/or using common principles of cognitive- behaviour theory Many symptoms for each separate disorder overlap Each separate disorder has comorbidities in common with the other Functional MRI & PET studies of PTSD, SAD, & specific phobia examined responses across 3 conditions:  Negative emotion  Positive emotion  Neutral conditions PHOBIAS - Suffix is derived from the Greek god Phobos, who frightened his enemies Common phobias:  Claustrophobia- fear of closed spaces  Agoraphobia- fear of public places  Acrophobia-fear of heights Exotic phobias:  Ergasiophobia- fear of working  Pnigophobia- fear of choking  Taphephobia- fear of being buried alive 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 sources of the fear:  Blood  Injuries  Injections  Situations (planes, elevators, enclosed spaces)  Animals  Natural environment (heights, water)  Empirical research suggests that fears can be grouped into 1 of 5 factors:  Agoraphobia  Fears of heights or water  Threat fears (blood/needles, storms/thunder)  Fears of being observed  Speaking fears  Lifetime prevalence is almost 1 in 10  The mean age of onset was around 10 years old  Mean duration was 20 years  Only 8% received treatment for their specific phobia or phobias  Most common specific phobia subtypes in order are: 1. Animal phobias (insects, snakes, and birds) 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, or lightening  Specific fear 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. Relates to the philosophy of yin (cold, windy and energy-sapping and passive aspects of life) and yang (hot, powerful, and active aspects)  In Japan, tajin kyofu-sho, is a fear of other people (not a social phobia but an extreme fear of embarrassing others- blushing in their presence, glancing at their genital areas, or making odd faces) Social phobias:  Persistent, irrational fears linked generally to the presence of other people  Try to avoid situations in which they might be evaluated, fearing they will reveal signs of anxiousness or behave in an embarrassing way  Speaking/performing in public, eating in public… can elicit extreme anxiety  Prevalence was higher among people who had never married or were divorced, not completed secondary education, had lower income or were unemployed (inadequate social support, low quality of life, and chronic physical conditions)  Students with social phobia have lower self-esteem and distorted body image  Role playing interpersonal encounters and modelling can help Behavioural theories: way in which phobias are acquired The avoidance-condition formulation holds that phobias develop from 2 related sets of learning:  Via classical conditioning, a person can learn to fear a neutral stimulus (conditioned) if it is paired with an intrinsically painful or frightening event (the unconditioned stimulus)  The person can learn to reduce this conditioned fear by escaping from or avoiding the CS. Operant conditioning; response is maintained by its reinforcing consequence of reducing fear Modelling: imitating the reactions of others Vicarious learning: learning of fear by observing others can also be learned through verbal instructions (child may fear an activity a parent has repeatedly warned him/her about) The anxious-rearing model is based on the premise that anxiety disorders in children are die to constant parental warnings that increases anxiety in the child Prepared learning: people tend to fear only certain objects and events (snakes but not lambs) Cognitive diathesis: tendency to believe that similar traumatic experiences will occur in the future (severe teasing and bullying has been proposed to play a role in the development of social phobia) Cognitive theories: how people’s thought processes can serve as a diathesis and on how thoughts can maintain a phobia or anxiety anxiety is more likely to attend to negative stimuli Cognitive-behavioural models of social phobia link social phobia with certain cognitive characteristics: Attentional bias to focus on negative social information (perceived criticism and hostile reactions from others and interpret ambiguous situations as negative Perfectionistic standards for accepted social performances High degree of public self-consciousness Excessive self-consciousness and self-focus tend to increase social anxiety Fundamental core fear in social phobia is that the self is deficient Predisposing biological factors: Autonomic nervous system Genetic factors- blood & injection phobia (relaxation tends to make it worse, are encouraged to tense) is strongly familial (64% have at least 1 first degree relative with this phobia) Linkage analysis has 2 major problems: Genetic complexity- disorders likely reflect the additive or interactive effects of multiple loci Phenotypic complexity- this 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 diagnostic categories Psychoanalytic theories: 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 childhood conflict Systematic desensitization was the first major behavioural treatment used widely in treating phobias individual with phobia imagines a series of increasingly scenes while in a state of deep relaxation effective in eliminating/reducing phobias in vivo exposure: treatment using imaginary stimuli in virtuo exposure: involves exposure stimuli that come in the form of computer-generated graphics Virtual reality exposure: tailored to involve graded exposure to threatening stimuli in a hierarchy similar to the increasingly frightening scenes used in a systematic desensitization (for social phobia
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