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Chapter Seven.doc

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University of Toronto St. George

Chapter Seven • Anxiety: state of apprehension, tension and worry; prominent feature in many psychological disorders; four types of symptoms o Somatic: muscle tensions; heart palpitations; stomach pain; need to urinate; accelerated respiration; inhibited stomach acid o Emotional: sense of dread; terror; restlessness; irritability o Cognitive: anticipation of harm; exaggeration of danger; problems in concentrating; hyper vigilance; fear of dying; sense of unreality o Behavioural: escape; avoidance; aggression; freezing; decrease appetitive responding; increased aversive responding • Adaptive fear: people’s concerns are realistic given the circumstances; amount of fear experienced is proportional to reality of threat; people’s fear response subsides when the threat ends • Maladaptive anxiety: concerns are unrealistic; amount of fear out of proportion to harm threat could cause; concern is persistent when threat passes; anticipatory anxiety about the future • Neurosis: term used by Freud and other early theorists to refer to disorder in which anxiety aroused by unconscious conflicts could not be quelled or channelled by defence mechanisms; could be experienced directly as conscious symptoms or in maladaptive forms (depression, etc) • Neuroticism: also called negative affectivity or behavioural inhibition; general tendency towards anxiety from a very early age; may not develop anxiety disorder until later in life or until experience parenting (over-involved, controlling) that exacerbates behaviour Panic disorder • Panic attacks: short but intense periods in which one experienced many symptoms of anxiety, including heart palpitations, trembling, a feeling of choking, dizziness, intense dread; characterized by core themes of dizziness related symptoms, cardio-respiratory distress and cognitive factors; don’t follow set pattern; about 40% of all young adults have occasional panic attacks • Triggers: might or might not have trigger; most commonly are related to specific situations (ex: speaking in public); facing a traumatic event can induce a panic attack • Panic disorder: diagnosable when panic attacks are common occurrence, are not usually provoked by any particular situation, are causing a person distress and causing them to change their behaviour; need to frequently experience four or more and have them interfere with daily living; believe they’re about to die • Theories of panic disorder: biological and psychological • Role of genetics: appears to run in families; biological vulnerability to panic disorder or to a chronic diffuse anxiety that predisposes one to a disorder • Neurotransmitters and brain: discovery by Donald Klein in 1960s that antidepressant medications reduce panic attacks; meds affect levels of norepinephrine, which may be poorly regulated in people with panic disorders, especially in an area of the brain stem called the locus ceruleus, which is involved in fear response o Serotonin: drugs that alter the functioning of serotonin systems are helpful in reducing panic attacks; animal studies suggest that increases of serotonin in certain part of brain stem (specifically the periaqueductal gray) reduce panic like responses while increases in serotonin in amygdala increase anxiety o Progesterone: play role in vulnerability to panic attacks; indicated by women with panic disorders reporting increases in anxiety symptoms during pre-menstrual periods and postpartum period; can affect activity of GABA and serotonin; can induce mild chronic hyperventilation o Kindling model: Gorman and colleagues; anticipatory anxiety that many people with the disorder have chronically sets the stage for the experience of panic attacks; link has to do with locus ceruleus and limbic system; LC involved in production of panic attacks and LS involved in diffuse, anticipatory anxiety; poor regulation in LC causes panic attacks, which then stimulate and kindle LS, lowering threshold for activation of diffuse/chronic anxiety, which increases likelihood of dysregulation of locus ceruleus and thereby of a new attack o Hyperventilation: ingesting small about of carbon dioxide, calcium, sodium lactate or breathing into a paper bag can induce panic attacks; initiate physiological changes of fight or flight response (poorly regulated in those with panic disorder) • Cognitive model: people prone to panic attacks pay very close attention to their bodily sensations, misinterpret bodily sensations in a negative way and engage in snowballing catastrophic thinking, exaggerating symptoms and consequences o Anxiety awareness: belief that symptoms of anxiety have harmful consequences; females score higher on Anxiety Sensitivity Index o Interoceptive awareness: heightened awareness of bodily cues that a panic attack may soon happen; slight sensations of arousal or changes in bodily functions become conditioned stimuli for more severe symptoms of panic; study where individuals with “safe person” present were less likely to experience symptoms of anxiety • Integrated model: combine biological and cognitive theories to create a vulnerability stress model; biological vulnerability to hypersensitive fight/flight response AND a tendency to engage in catastrophizing cognitions about somatic symptoms create panic attacks and hyper vigilance for signs of panic; can be generalized and result in agoraphobia • Biological treatments: most effective drugs classified as antidepressants and anti-anxiety; quell immediate symptoms and disorder but relapse high if drugs discontinued (diminished if also use CBT) o Tricyclic antidepressants: increase levels of norepinephrine and several other neurotransmitters (including serotonin); ex: imipramine; side effects include blurred vision, sexual dysfunction, weight gain and dry mouth; relapse rate once drugs discontinued o SSRIs: increase functional levels of serotonin in the brain; commonly used ones are Paxil, Prozac, Zoloft and Celexa; side effects include GI upset and irritability, insomnia, tremor and sexual dysfunction; as effective as tricyclics o Benzodiazepines: suppress CNS and influence functioning in GABA, norepinephrine and serotonin neurotransmitter systems; approved drugs are alprazolam and clonazepam; disadvantages are that they are physically and psychologically destructive, they can interfere with cognitive/motor functioning and relapse is extremely high after discontinuation • CBT: involves getting clients to confront situations/thoughts that arouse anxiety; helpful because irrational thoughts can be challenged and changed and anxious behaviours can be extinguished; at least as effective as drug therapies and more effective in preventing relapse; questions over whether combining meds and CBT is additive or deleterious; potential preventative role for CBT in panic disorder o First: teach relaxation and breathing exercises; give people control over symptoms o Second: clients guided in identifying catastrophizing cognitions they have about changes in bodily sensations; can keep panic thoughts diary; may need to experience panic symptoms in front of therapist and can induce that via interoceptive exposure (engaging in exercises/tasks that bring on feelings of anxiety) o Third: clients practice using relaxation/breathing exercises while experiencing panic in therapy o Fourth: therapist challenges catastrophizing thoughts about bodily sensations and teaches them to challenge thoughts for themselves o Fifth: uses systematic desensitization therapy to expose client gradually to situations they most fear while helping them maintain control over panic symptoms Phobias • Agoraphobia: fear of crowded, bustling places (malls), enclosed spaces (elevators, buses) and wide open spaces (fields); wide variety of situations; worry they might not be able to escape or help might not be available in case of emergency; can occur in people who don’t have panic attacks but most people who seek treatment do experience panic attacks or severe social phobia (panic like symptoms in social situations); typically begins within one year after a person begins experiencing frequent anxiety symptoms; strikes during youth • Specific phobias: fear of specific objects, places or situations; anxiety is immediate and intense when encounter feared object and may even have panic attacks; go to great lengths to avoid object; most develop during childhood; adults realize anxieties are illogical and unreasonable; 90% don’t seek treatment o Animal type phobias: focused on specific animals or insects, like spiders; most common is snakes in North America o Natural environment type phobias: focused on events or situations in the natural environment, such as storms, heights or water; mild to moderate fears of these can be common and adaptive o Situational type phobias: usually involves fear of public transport, tunnels, bridges, elevators, flying and driving; claustrophobia is a common situational type phobia; fear or have experienced panic attacks; different from agoraphobia as only have attacks in specific feared situations o Blood-injection-injury type phobias: fear seeing blood or injury; experience drops in heart rate and blood pressure; likely to faint; runs more strongly in families; first recognized in DSM-IV-TR • Social phobia: not categorized as a specific phobia because instead of fearing a specific object/situation, people fear be judged or embarrassing themselves in front of others; more likely to severely disrupt a person’s daily life as is difficult to avoid social situations; more than 1/3 of population experience anxiety when public speaking; social phobics experience trembling, palpitations, dizziness, confusion; relatively common; develops in early preschool years and adolescent years; often co-occurs with mood disorders, anxiety disorders and antisocial personality disorder o Three groups: fearing only public speaking, moderate anxiety about variety of social situations and severe fear of many social situations, from public speaking to having conversations (generalized type) • Psychodynamic theories: phobias result when unconscious anxiety is displaced onto a neutral or symbolic object; ex: Little Hans developed a horse phobia, which represented his Oedipal fears of his father • Behavioural theories: classical conditioning leads to fear of phobic object when paired when naturally frightening event and avoidance of the object reduces anxiety, reinforcing it through operant conditioning o Little Albert experiment: John Watson; pairing of a banged bar (US), which naturally led to startle response (UR), and the white rat (CS) leads to white rat producing same startle response (CR) o Negative conditioning: run away or avoid object causing phobia (counter productive as exposure would extinguish phobia) which is reinforced by subsequent reduction of anxiety o Safety signals: safe people/places associated with low risk for panic attacks o Safety signal hypothesis: people vividly remember locations of panic attacks, associate places with symptoms of panic and may feel them again if they go to those places; by avoiding them, they reduce symptoms; can explain why agoraphobia develops often in people with panic disorders o Observational learning: some theorists argue that phobias can develop phobias by watching someone else experience extreme fear in response to a situation o Prepared classical conditioning: evolution may have selected for the rapid conditioning of fear of certain objects or situations, even if they don’t cause us harm today; carry vestiges of evolutionary history; quicker to develop and harder to extinguish anxiety reactions to snakes/spiders than to
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