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Chapter 5

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Psychology 2030A/B
David Vollick

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Abnormal  Psychology  Chapter  5:   Anxiety  Disorders     Anxiety,  Fear,  and  Panic   • Anxiety:  a  negative  mood  state  characterized  by  bodily  symptoms  of  physical   tension,  and  apprehension  about  the  future   • Anxiety  is  very  hard  to  study  and  can  be  a  subjective  sense  of  unease,  a  set  of   behaviours  or  a  physiological  response  originating  in  the  brain  and  reflected   in  elevated  heart  rate  and  muscle  tension   • Research  with  animals  provides  only  general  information  about  the  nature  of   anxiety  in  humans   • Anxiety  is  good  for  us,  at  least  in  moderate  amounts   • We  perform  better  when  we  are  a  little  anxious   • In  short,  physical  and  intellectual  performances  are  driven  and  enhanced  by   anxiety   • Severe  anxiety  usually  doesn’t  go  away   • Individuals  who  have  anxiety-­‐based  disorders  are  well  aware  that  they  have   little  to  fear  in  the  situations  they  find  so  stressful   • Fear:  immediate  alarm  reaction  to  danger   • Fear  can  be  good  for  us  by  protecting  us  by  activating  a  massive  response   from  the  autonomic  nervous  system,  which  along  with  our  subjective  sense   of  terror,  motivates  us  to  escape  or  possibly  to  attack  (fight-­‐or-­‐flight   response)   • Much  evidence  shows  that  fear  and  anxiety  reactions  differ  psychologically   and  physiologically   • Anxiety  is  a  future-­‐oriented  mood  state,  characterized  by  apprehension   because  we  cannot  predict  or  control  upcoming  events   • Fear  is  an  immediate  emotional  reaction  to  current  danger  characterized  by   strong  escapist  action  tendencies  and  often  a  surge  in  the  sympathetic   branch  of  the  ANS   • The  roots  of  the  panic  experience  are  deeply  embedded  in  out  cultural  myths   • Panic:  sudden  overwhelming  reaction   • Panic  Attack:  abrupt  experience  of  intense  fear  or  acute  discomfort,   accompanied  by  physical  symptoms  that  usually  include  heart  palpitations,   chest  pain,  shortness  of  breath,  and  possibly  dizziness   • Three  basic  types  of  panic  attacks   o Situationally  Bound  (cued)   o Unexpected  (uncued)   o Situationally  Predisposed  (in  between)   • You  are  more  likely  to  have  an  attack  where  you  have  had  one  before   • Unexpected  and  situationally  predisposed  attacks  are  important  in  panic   disorder   • Situationally  bound  attacks  are  more  common  in  specific  phobias  or  social   phobias       Causes   • Excessive  emotional  reactions  come  from  multiple  sources     Causes:  Biological  Contributions   • Evidence  shows  that  we  inherit  a  tendency  to  be  tense  or  uptight   • No  single  gene  seems  to  cause  anxiety   • Contributions  from  many  genes  in  several  different  areas  on  chromosomes   collectively  make  us  vulnerability  to  anxiety  when  the  right  psychological   and  social  factors  are  in  place   • The  tendency  to  panic  also  seems  to  run  in  families  and  may  have  a  genetic   component   • Anxiety  is  associated  with  specific  brain  circuits  and  neurotransmitter   systems:  GABA,  part  of  the  GABA-­‐benzodiasepine  system,  noradrenergic   system,  serotonergic  neurotransmitter  system   • The  corticotropin  releasing  factor  (CRF)  is  central  to  the  expression  of   anxiety   • CRF  activates  HPA  axis   • The  CRF  system  is  related  to  GABA-­‐benzodiasepine,  noradrenergic,   serotonergic  neurotransmitter  systems   • The  area  of  the  brain  most  often  associated  with  anxiety  is  the  limbic  system   which  acts  as  a  mediator  between  the  brain  stem  and  the  cortex   • Gray  determined  that  this  circuit  leads  from  the  septal  and  hippocampal  area   in  the  limbic  system  to  the  frontal  cortex   • BIS  is  activated  by  signals  of  unexpected  events  from  the  brain  stem   • The  BIS  also  receives  a  big  boost  from  the  amygdala   • Gray  identified  fight-­‐flight  system  (FFS)     • This  system  originates  in  the  brain  stem  and  travels  through  several   midbrain  structures,  including  the  amygdala,  hypothalamus,  and  the  central   grey  matters   • Gray  thinks  the  FFS  is  activated  in  part  by  deficiencies  in  serotonin   • Smoking  as  a  teenager  is  associated  with  greatly  increased  risk  for   developing  anxiety  disorders,  particularly  panic  disorder  and  generalized   anxiety  disorder   • One  possible  explanation  somehow  sensitizes  the  brain  circuits  associated   with  anxiety  and  increases  the  biological  vulnerability  to  develop  severe   anxiety  disorders     Causes:  Psychological  Contributions   • Behavioural  theorists  view  anxiety  as  a  product  of  early  classical   conditioning,  modeling,  or  other  forms  of  learning   • Evidence  is  accumulating  the  supports  an  integrated  model  of  anxiety   involving  a  variety  of  factors   • A  general  “sense  of  uncontrollability”  may  develop  early  as  a  function  of   upbringing  and  other  environmental  factors   • Actions  of  parents  foster  this  sense  of  control   • Parents  who  are  positive  and  predictable  teach  their  children  that  they  have   control  over  their  environment,  and  their  responses  have  an  effect  on  their   parents  and  their  environment   • Parents  who  are  overprotective  and  over  intrusive   • Children  don’t  learn  that  they  can  control  their  environment   • Most  psychological  accounts  of  panic  invoke  conditioning  and  cognitive   explanations  that  are  difficult  to  separate   • The  emotional  response  then  becomes  associated  with  a  variety  of  external   and  internal  cues  which  provoke  the  fear  response  and  an  assumption  of   danger   • External  cues  are  places  or  situations  and  internal  cues  are  increases  in  heart   rate  or  respiration     Causes:  Social  Contribution   • Stressful  life  events  trigger  our  biological  and  psychological  vulnerabilities  to   anxiety   • Stressors  can  trigger  physical  reactions   • Findings  suggest  a  possible  genetic  contribution,  at  least  to  initial  panic   attacks     Causes:  An  Integrated  Perspective   • Children  who  grow  up  believing  the  world  is  dangerous  might  not  be  able  to   cope  have  a  generalized  psychological  vulnerability  to  anxiety   • A  given  stressor  could  activate  your  biological  tendencies  to  anxiety  and  your   psychological  tendencies  to  feel  you  might  not  be  able  to  deal  with  the   situation  and  control  the  stress   • Anxiety  can  be  very  general,  evoked  by  many  aspects  of  your  life,  but  it  is   usually  focused  on  one  area   • Individual  associates  the  panic  attack  with  internal  or  external  cues,  the   attacks  are  called  learned  alarms   • Anxiety  increases  the  likelihood  of  panic     Comorbidity  of  Anxiety  Disorders   • Rates  of  Comorbidity  among  anxiety  disorders  are  emphasizes  these   disorders  share  the  common  features  of  anxiety  and  panic  described   • They  also  share  the  same  vulnerabilities,  biological  and  psychological,  for   developing  anxiety  and  panic   • They  differ  only  in  the  focus  of  anxiety  and  perhaps  the  patterning  of  panic   attacks   • Most  common  additional  diagnosis  for  all  anxiety  disorders  is  major   depression,  which  occurs  in  about  50  percent     Panic  Disorder  With  and  Without  Agoraphobia   • Panic  Disorder  with  Agoraphobia  (PDA):  individuals  experience  severe   unexpected  panic  attacks;  they  may  think  they’re  dying  or  otherwise  losing   control   • Because  they  never  know  when  an  attack  might  occur,  they  develop   agoraphobia   • Agoraphobia:  fear  and  avoidance  of  situations  in  which  they  would  feel   unsafe  in  the  event  of  a  panic  attack  or  symptoms     Clinical  Description   • In  PDA,  anxiety  and  panic  are  combined  with  phobic  avoidance   • Many  people  who  have  panic  attacks  do  not  necessarily  develop  panic   disorder   • Panic  Disorder  Without  Agoraphobia  (PD)   • To  meet  criteria  for  panic  disorder  a  person  must  experience  an  unexpected   panic  attack  and  develop  substantial  anxiety  over  the  possibility  of  having   another  attack  or  about  the  implications  of  the  attack  or  its  consequences   • They  may  avoid  going  to  certain  places  or  neglect  their  duties  around  the   house  for  fear  an  attack  might  occur  if  they  are  too  active     The  Development  of  Agoraphobia   • Agoraphobia  avoidance  behaviour  is  simple  one  complication  of  severe   unexpected  panic  attacks   • Anxiety  is  diminished  for  individuals  with  agoraphobia  if  they  think  a   location  or  person  is  “safe”   • People  with  agoraphobia  always  plan  for  rapid  escape   • Agoraphobic  behaviour  can  become  relatively  independent  of  panic  attacks   • Agoraphobic  avoidance  is  simply  one  way  of  coping  with  unexpected  panic   attacks   • Other  methods  of  coping  with  panic  attacks  include  using  alcohol  or  drugs   (high  comorbidity)   • Some  individuals  do  not  actually  avoid  agoraphobic  situations  but  endure   them  with  “intense  dread”   • Most  patients  with  severe  agoraphobic  avoidance  also  display  another   cluster  of  avoidant  behaviours  that  we  call  interceptive  avoidance  or   avoidance  of  internal  physical  sensations   • Removing  yourself  form  situations  that  might  produce  the  physiological   arousal  or  increased  cardiovascular  activity     Statistics   • 3.5%  of  the  population  meet  the  criteria  for  panic  disorder   • 2/3  of  them  are  women   • 5.3%  meet  the  criteria  for  agoraphobia   • Most  people  with  panic  disorder  do  have  agoraphobic  avoidance   • Onset  of  panic  disorder  usually  occurs  in  early  adult  life   • Panic  disorder  seems  less  pervasive  among  the  elderly   • Most  initial  unexpected  panic  attacks  begin  at  or  after  puberty,  this  seems  a   better  predictor  of  unexpected  panic  attacks  than  age   • Children  do  not  report  fear  of  dying  or  losing  control   • 75%  or  more  of  those  who  have  agoraphobia  are  women     • More  common  in  women,  this  could  be  due  to  the  culture   • More  accepted  for  women  to  report  fear  and  to  avoid  numerous  situations   • Another  possible  reason  is  gender  differences  in  fear  of  anxiety   • Gender  differences  are  even  observed  in  children   • Males  with  unexpected  panic  attacks  cope  by  consuming  large  amounts  of   alcohol   • Lower  agoraphobic  avoidance  of  men  with  panic  disorder  was  associated   with  their  alcohol  use     Cultural  Influences   • Panic  disorders  exist  worldwide   • Phobic  avoidance  was  more  common  in  panic  disorder  patients  in  North   America  relative  to  panic  patients  in  Latin  America   • Fear  of  dying  and  choking  or  smothering  sensations  were  common  in   southern  countries   • Somatic  symptoms  of  anxiety  may  be  emphasized  in  developing  cultures   • Subjective  feelings  may  not  be  part  of  the  cultural  idiom   • Hispanic  people  believe  in  ataques  de  nervios  which  has  symptoms  of   shouting  uncontrollably  and  bursting  out  into  tears   • Intuits  believe  in  kayak-­‐angst  which  has  symptoms  of  intense  fear,  worries  of   drowning,  physical  arousal,  and  intense  disorientation  that  occur  when  a  seal   hunter  or  fisher  is  alone  at  sea     Nocturnal  Panic   • 60%  of  the  people  with  panic  disorder  have  experienced  such  nocturnal   attacks   • Usually  occur  between  1:30-­‐3:30am   • In  some  cases,  people  are  afraid  to  go  to  sleep  at  night   • Nocturnal  panics  occur  during  delta  or  slow-­‐wave  sleep   • Reason  for  them  is  that  most  of  these  individuals  think  they  are  dying   • Change  in  stages  of  sleep  to  slow-­‐wave  sleep  produces  physical  sensation  of   “letting  go”  that  are  very  frightening  to  an  individual  with  panic  disorder   • People  are  not  dreaming  when  they  have  nocturnal  panics   • Isolated  sleep  paralysis  are  unable  to  move,  your  heart  pounds  as  you  stare   at  aspects  of  the  room   • Isolated  sleep  paralysis  occurs  during  the  transitional  state  between  sleep   and  waking   • During  this  period  the  individual  is  unable  to  move  and  experiences  a  surge   of  terror  that  resembles  a  panic  attack;  occasionally,  the  person  also  has  vivid   hallucinations   • One  possible  explanation  is  that  REM  sleep  is  spilling  over  into  the  waking   cycle     Suicide   • 20%  of  patients  with  panic  disorder  had  attempted  suicide   • Attempts  were  associated  with  panic  disorder  risk  comparable  to  that  for   individuals  with  major  depression   • Sareen  showed  that  panic  disorder  was  significantly  associated  with  suicide   attempts  and  suicidal  ideation,  even  after  controlling  for  other  comorbid   disorders   • Suicide  risk  is  much  greater  for  individuals  with  mood  disorders  as  well  as  an   anxiety  disorder  than  those  with  a  mood  disorder  alone     Causes   • Whether  agoraphobia  develops  and  how  severe  it  becomes  seem  to  be   socially  and  culturally  determined   • Panic  attacks  seem  to  be  related  most  strongly  to  biological  and   psychological  factors  and  their  interaction   • We  all  inherit  some  vulnerability  to  stress   • Thus,  some  people  are  more  likely  than  others  to  have  an  emergency  alarm   reaction  when  confronted  with  stress-­‐producing  events   • Particular  situations  quickly  become  associated  with  an  individuals  mind   with  external  and  internal  cues  that  were  present  during  the  attack   • Because  these  cues  become  associated  with  many  different  internal  and   external  stimuli  though  a  learning  process,  we  call  them  learned  alarms   • Individuals  must  be  susceptible  to  developing  anxiety  over  the  possibility  of   having  another  panic  attack   • This  is  what  creates  panic  disorder   • This  tendency  to  believe  that  unexpected  bodily  sensations  are  dangerous   reflects  a  specific  psychological  vulnerability  to  develop  panic  and  related   disorders   • 1/3  of  individuals  in  the  general  population  have  experienced  a  panic  attack   • 8-­‐12%  of  the  population  has  an  occasional  unexpected  panic  attack   • Only  3%  go  on  to  develop  anxiety  over  future  panic  attacks  and  thereby  meet   the  criteria  for  panic  disorder   • “Nonclinical  panickers”  have  similar  kinds  of  symptoms  hat  occur  during  a   panic  attack  with  panic  disorder  patients  experiencing  these  symptoms  to  a   greater  extent   • Phobic  avoidance  and  lifestyle  restriction  are  much  greater  in  panic  disorder   patients  relative  to  nonclinical  panickers   • Anxiety  sensitivity  refers  to  the  tendency  to  catastrophize  the  meaning  of   anxiety-­‐related  bodily  sensations   • Anxiety  sensitivity  levels  are  higher  in  panic  disorder  than  in  any  other   anxiety  disorder  except  PTSD   • Anxiety  sensitivity  is  partly  heritable  and  can  also  be  learned  within  the   family   • Clark  emphasizes  the  specific  psychological  vulnerability  of  people  with  this   disorder  to  interpret  normal  physical  sensation  in  a  catastrophic  way   • Clark  emphasizes  the  cognitive  process  as  most  important  in  panic  disorder   • Ehlers  and  Breuer  demonstrated  that  patients  with  panic  disorder  were   much  more  accurate  at  estimating  how  fast  their  hearts  were  beating,  also   more  vigilant  for  internal  sensations  or  more  interoceptively  aware   • This  awareness  helps  maintain  the  vicious  cycle  because  they  quickly  notice   any  somatic  response  and  interpret  it  as  dangerous     Treatment:  Medication   • High-­‐potency  benzodiazepines  are  effective  for  panic  disorder  as  are  tricyclic   antidepressants,  and  SSRI’s     • A  large  number  of  drugs  affect  either  noradrenergic,  serotonergic,  or  GABA-­‐   benzodiazepines  neurotransmitter  systems  or  some  combination  seem   effective  in  treating  panic  disorder   • Tricyclic  antidepressants,  produces  strong  side  effects  that  include  dizziness,   dry  mouth,  and  occasionally  sexual  dysfunction   • SSRI’s  are  just  as  effective  but  produce  fewer  immediate  side  effects.  They   are  currently  the  preferred  drug  for  panic  disorders,  sexually  dysfunction   does  occur   • High-­‐potency  benzodiazepines  work  very  fast  but  can  be  hard  to  stop  taking   because  of  psychological  and  physical  dependence  and  addiction.  They  also   adversely  affect  cognitive  and  motor  functions.   • 60%  of  patients  with  panic  disorder  are  free  of  panic  as  long  as  they  stay  on   an  effective  drug   • Relapse  rates  are  high  once  the  medication  is  stopped   • 20%  relapse  from  tricyclic  antidepressants   • 90%  relapse  from  benzodiazepines     Treatment:  Psychological  Intervention   • Originally  treatments  concentrated  on  reducing  agoraphobic  avoidance,   using  strategies  based  on  exposure  to  feared  situations   • Therapist  helps  the  patient  structure  his  or  her  own  exercises  and  provides   psychological  coping  mechanisms  to  help  the  patient  complete  the  exercises,   arranged  from  least  to  most  difficult   • 70%  substantially  improves  anxiety  and  panics  are  reduced  and  agoraphobic   avoidance  greatly  diminishes.     • Very  few  are  cured   • Panic  Control  Treatment  (PCT)  concentrates  on  exposing  patients  with  panic   disorder  to  the  cluster  of  interoceptive  sensations  that  remind  them  of  their   panic  attacks   • The  therapist  attempts  to  create  “mini”  panic  attacks   • Patients  also  receive  cognitive  therapy   • Basic  attitudes  and  perceptions  concerning  the  dangerousness  of  the  feared   but  objectively  harmless  situations  are  identified  and  modified   • They  are  taught  relaxation  or  breathing  retraining  to  help  them  cope  with   increases  in  anxiety  and  to  reduce  excess  arousal   • Patients  who  receive  PCT  indicate  that  most  of  them  remain  better  after  at   least  two  years   • Breathing  retraining  component  of  PCT  in  that  it  does  not  seem  to  add  to  the   effectiveness  of  PCT   • PCT  are  quite  effective,  they  are  relatively  new  and  not  yet  available  to  many   individuals  who  have  panic  disorder,  because  administering  them  requires   therapists  to  have  advanced  training     New  Evidence  on  Combined  Treatment   • Combined  effects  of  psychological  and  drug  treatments   • Data  were  based  on  the  judgment  of  an  independent  evaluator  using  the   panic  disorder  severity  scale  (PDSS)   • Combined  treatment  was  no  better  than  individual  treatments   • Treatments  containing  CBT  without  the  drug  tended  to  be  superior   • No  advantage  to  combining  drug  and  CBT  treatments  because  any   incremental  effect  of  combined  treatments  seems  to  be  a  placebo  effect  not  a   true  drug  effect   • Problem  for  people  with  panic  disorder  with  agoraphobia  may  be  access  to   effective  psychosocial  treatments  like  CBT   • Swinson  concluded  that  delivering  CBT  by  telephone  appears  to  be  a   promising  method  for  making  effective  treatment  available  to  patients  with   PDA  who  live  in  remote  regions  of  Canada  where  specialized  anxiety   disorder  services  are  not  readily  available   • Delivering  CNT  over  the  internet  also  appears  to  be  a  promising  method  for   making  effecting  treatments  for  panic  disorder  available  to  those  living  in   more  remote  areas     Generalized  Anxiety  Disorder   • GAD:     Clinical  Description   • GAD  is  the  basic  syndrome  that  characterizes  every  anxiety  disorder   • In  GAD,  the  focus  is  generalized  to  the  events  of  everyday  life   • DSM-­‐IV-­‐TR  criteria   o At  least  six  months  of  excessive  anxiety  and  worry  must  be  ongoing   more  days  than  not   o It  must  be  very  difficult  to  turn  off  or  control  the  worry  process   • GAD  is  characterized  by  muscle  tension,  mental  agitation,  susceptibility  to   fatigue,  come  irritability,  and  difficulty  sleeping   • Focusing  attention  is  difficult  as  the  mind  quickly  switches  from  crisis  to   crisis   • Adults  focus  on  possible  misfortune  to  their  children,  family  health,  job   responsibilities,  and  household  chores   • Children  focus  on  academic,  athletic,  or  social  performance  and  physical   injury     • The  elderly  focus  on  health,  and  have  difficulty  sleeping       Statistics   • 1.1%  of  the  Canadian  population  meet  criteria  for  GAD   • Although  GAD  is  one  of  the  most  common  anxiety  disorders,  relatively  few   people  with  GAD  come  for  treatment   • Most  patients  with  GAD  seek  help  from  their  primary  care  doctors   • 2/3  of  individuals  with  GAD  are  females   • This  sex  ratio  may  be  specific  to  developed  countries   • Some  people  with  GAD  report  onset  in  early  adulthood   • Stressful  life  events  may  play  some  role  in  the  development  of  GAD   • A  person  with  GAD  is  likely  to  have  experienced  an  excess  of  life  stressors   compared  with  someone  without  this  disorder   • Earlier  and  more  gradual  onset  than  most  other  anxiety  disorders   • GAD  most  often  is  chronic   • GAD  is  prevalent  among  the  elderly,  ages  45  and  older   • Prevalence  rates  of  GAD  in  older  adults  to  be  as  high  as  7%   • Minor  tranquilizers  in  the  elderly  is  very  high   • Prescirbed  drugs  may  be  primarily  for  sleeping  problems  or  other  secondary   effects  of  medical  illnesses   • Benzodiasepines  interfere  with  cognitive  function  and  put  the  elderly  at   greater  risks  for  falling  down  and  breaking  bones,  particularly  their  hips   • This  increasing  lack  of  control,  failing  health,  and  the  gradual  loss  of   meaningful  functions  may  be  a  particularly  unfortunate  byproduct  of  the  way   the  elderly  are  treated  in  Western  culture     Causes   • GAD  tends  to  run  in  families   • What  seems  to  be  inherited  is  the  tendency  to  become  anxious  rather  than   GAD  itself   • Individuals  with  GAD  do  not  respond  as  strongly  as  individuals  with  anxiety   disorders  in  which  panic  is  more  prominent   • Individuals  with  GAD  show  less  responsiveness  on  ore  physiological   measures  then  do  individuals  with  other  anxiety  disorders   • People  with  GAD  are  chronically  tense   • Four  distinct  cognitive  characteristics  of  people  with  GAD  are:   1. Intolerance  of  uncertainty   2. Erroneous  beliefs  about  worry  –  belief  worrying  is  effective  in   avoiding  negative  outcomes  and  promoting  positive  outcomes   3. Poor  problem  orientation  –  tend  to  view  problems  as  threats   4. Cognitive  avoidance  –  worry  may  serve  as  an  avoidance  function   • Worry  without  accompanying  images  may  be  exactly  what  causes  these   individuals  to  show  less  responsiveness  on  physiological  measures   • Don’t  have  the  attentional  capacity  left  for  the  all-­‐important  process  of   creating  images  of  the  potential  threat   • People  with  GAD  may  avoid  much  of  the  unpleasantness  and  pain  associated   with  the  negative  affect  and  imagery,  the  avoidance  means  that  they  are   never  able  to  work  through  their  problems  and  arrive  at  solutions   • They  become  chronic  worriers   • Dugas,  Marchand,  and  Ladoucher  showed  that  intolerance  of  uncertainty  was   related  to  GAD  but  not  to  panic  disorder  with  agoraphobia   • They  are  highly  sensitive  threat  and  they  allocate  their  attention  much  more   readily  to  sources  of  threat  than  people  who  are  not  anxious   • Acute  awareness  of  potential  threat  and  seems  to  be  entirely  automatic  or   unconscious   • This  model  is  very  current  as  it  combines
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