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Chapter 5

Ch. 5 Anxiety Disorders.docx

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PSYC 3230
James Alcock

5. Anxiety Disorders Monday, February 4, 2013 9:00 AM Learning Objectives 1. Describe the characteristics of anxiety. 2. Discuss various etiological factors involved in anxiety disorders. 3. Identify and describe the methods involved in the assessment of anxiety disorders. 4. Differentiate the anxiety disorders from one another. 5. Summarize and discuss common treatments for anxiety disorders The characteristics of anxiety  Anxiety has two other related emotional states-- panic and fear  There are important theoretical distinctions between the three o Anxiety-- an affective state whereby an individual feels threatened by the potential occurrence of a future negative event ("future oriented") o Fear-- a more "primitive" emotion that occurs in response to a real or perceived current threat ("present oriented")  "Fight or flight" response-- fear prompts a person (or organism) to either flee from a dangerous situation or stand and fight o Panic-- an extreme fear reaction that is triggered even though there is nothing to be afraid of (it is essentially a "false alarm")  3 components of emotion: o Physiological  Involves changes in the autonomic nervous system that result in respiratory, cardiovascular, and muscular changes in the body (e.g., changes in breathing rate, heart rate, and muscle tone) o Cognitive  Includes alterations in consciousness (e.g., in attention levels) and specific thoughts a person may have while experiencing a particular emotion o Behavioral  Specific behavioral responses tent to be consequences of certain emotions  The 3 components of emotional states are highly interrelated, and each affects the other two Historical perspective  References to anxiety or fear have been made since the beginning of recorded history  Neurosis-- a 19th-century term for anxiety disorders, somatoform, and dissociative disorders  18th century-- people who were not psychotic but who still had emotional problems were labelled "neurotic" o This term implied that the cause was presumed to be to a disturbance in the central nervous system  Freud was one of the earliest to focus on anxiety o Theorized an important difference between objective fears and neurotic anxiety  The major models of anxiety today are behavioral and cognitive behavioral, although it is recognized that the causes of anxiety are complex and require an integrative understanding of biological, psychological, and interpersonal processes Etiology Biological factors  Genetics o Evidence of a genetic influence in the etiology of anxiety disorders comes from epidemiological studies of families and twins, which demonstrate that virtually all of the anxiety disorders show at least a moderate level of concordance within family members o The genetic risk associated with anxiety disorders appears to be fairly nonspecific  Neuroanatomy and neurotransmitters o The fear system principally involves a subcortical network that can be aroused without the influence of complex cortical input o Information transfer between the neuroanatomical structures involved in fear, anxiety, and panic is mediated by a complex and interacting number of neurotransmitter systems o There is no neurotransmitter system found to be solely dedicated to the expression of fear, anxiety or panic Psychological factors  Behavioral factors o The idea that anxiety and fear are acquired through learning has a long history o Mowrer's Two-factor theory-- the most influential theory of fear and phobias during the 1960s and 1970s. The model proposed that fears develop through classical conditioning and are maintained through operant conditioning o Vicarious learning (modelling)-- learning by observing the reactions of others  Cognitive factors o Aaron Beck proposed that people are afraid because of the biased perceptions that they have about the world, the future, and themselves o Anxious individuals often see the world as dangerous, the future as uncertain, and themselves as ill-equipped to cope with life's threats o Individuals who are susceptible to anxiety often have core beliefs that they are helpless and vulnerable o Anxious individuals tend to focus on information that is relevant to their fears o Schemas, information processing biases, and automatic thoughts are believed to be relevant to the development and maintenance of anxiety Interpersonal factors  Parenting styles from anxious parents may foster beliefs of helplessness and uncontrollability in children that contribute to a general psychological vulnerability to anxiety  The early attachment relationship may be important in the development of anxiety o Anxious-ambivalent attachment style in infancy predicted anxiety problems when the children were 17.5 years old Comment on etiology  No single factor causes anxiety  There is a complex and dynamic interplay among biological, psychological, and interpersonal factors The anxiety disorders  Anxiety disorders are the most common of all mental disorders (as high as 31%)  Without treatment, anxiety disorders tend to be chronic and recurrent, and are associated with significant distress and suffering  Anxiety disorders are costly in terms of treatment and lost productivity Panic disorder and agoraphobia  Description o Individuals with panic disorder experience recurrent and unexpected panic attacks-- a sudden rush of intense fear or discomfort during which an individual experiences a number of physiological and psychological symptoms o 1.5% of Canadians o At least one of the panic attacks must be followed by persistent concerns (lasting at least one month) about having additional attacks or by worry about the ramifications of the attack o Or, when the panic attack results in a significant alteration in behavior o Panic disorder with or without agoraphobia o Agoraphobia-- pertains to anxiety about being in places or situations where an individual might find it difficult to escape or in which he or she would not have help readily available should a panic attack occur  Diagnosis and assessment o Can be difficult to diagnose because panic attacks are not unique to panic disorder and occur in other anxiety disorders o The cardinal feature of panic disorder is that individuals initially experience uncued panic attacks and have marked apprehension and worry over the possibility of having additional panic attacks o In contrast, panic attacks associated with other anxiety disorders are usually cued by specific situations or feared objects o Anxiety Disorders Interview Schedule (ADIS-IV)-- a popular semi-structured interview which is used to establish differential diagnosis among the anxiety disorders o Behavioral avoidance test (BAT)-- patients are asked to enter situations that they would typically avoid and provide a rating of their degree of anticipatory anxiety and the actual level of anxiety that they experience  Etiology o Rooted in both biological and psychological factors o Tends to run in families o Between 44 and 77 percent of individuals with panic disorder report nocturnal panic-- attacks that occur while sleeping o Cognitive theories focus on the idea that individuals with panic disorder catastrophically misinterpret bodily sensations o A related theory contends that there is a trait-like tendency to be anxiety sensitive-- the belief that the somatic symptoms related to anxiety will have negative consequences that extend beyond the panic episode itself o Panic attacks are perceived as uncontrollable and unpredictable Specific phobia  Description o Phobia-- a fear that is so extreme as to cause marked distress and significantly disrupt a person's daily life o Fears are adaptive reactions to threats in the environment, but phobias are excessive and unreasonable fear reactions o Lifetime prevalence: 12.5%, higher among females  Diagnosis and assessment o 5 subtypes of specific phobia: animal, natural environment, blood injection- injury, situational, other o Having a phobia from one of these subtypes increases the probability of developing another phobia within the same category  Etiology o Equipotentiality premise-- the assumption that all neutral stimuli have an equal potential for becoming phobias, though this is not the case o Nonassociative model-- proposes that the process of evolution has endowed humans to respond fearfully to a select group of stimuli (e.g., water, heights, spiders) and thus no learning is necessary to develop these fears o Researchers have identified a genetic contribution to fears o People may be more likely to fear certain types of stimuli because of biological preparedness o Disgust sensitivity-- the degree to which people are susceptible to being disgusted by a variety of stimuli such as certain bugs, types of food, and small animals Social phobia/social anxiety disorder  Description o Social phobia-- a marked and persistent fear of social or performance-related situations o Anxiety often focuses on the fear of acting in a way that will be humiliating or embarrassing o Underlying fear of being evaluated negatively and frequently worry about what others may think of them o Non-generalized social phobia-- involves the fear of specific social situations or activities (e.g., public speaking) o Generalized social phobia-- involves the fear of most social settings and interactions o Exposing socially phobic individuals to their feared situation almost invariably provokes intense anxiety, which may take the form of situationally predisposed panic attacks o Aware of the fact that their fears are excessive and unreasonable o Patterns of overt and covert avoidance may result in socially phobic individuals becoming considerably lonely and isolated o Low self-esteem, increased risk for mood problems o One year prevalence in Canada: 3%; similar rates for males and females  Diagnosis and assessment o Assessment of social phobia usually involves a structured or semi-structured interview combined with completion of various self-report measures o Distinguishing between social phobia and agoraphobia is important  Both involve the experience of anxiety in in public places, but the reason for this fear is fundamentally different in the two disorders  Etiology o Includes genetic, biological, environmental, and cognitive factors o Behavioral inhibition (a temperamental characteristic of some children to respond to new situations with heightened arousal) is an early marker of risk for social phobia o Bullying or teasing as a child or parental criticism or overprotection may increase the risk of developing social phobia later in life o Cognitive factors associated with social phobia involve both negative beliefs and judgments about self and others, as well as abnormal processing of social information  Tend to judge themselves as inferior to others and to engage in negative self-referential thinking o Individuals with social phobia may also display elements of abnormal social information processing (i.e., avoiding eye contact, increased threat monitoring) o These individuals are high in public self-consciousness-- awareness of oneself as an object of attention, or the tendency to see one's actions from the perspective of an outside observer rather than through one's own eyes o Social phobia entails more than simply the presence of anxiety symptoms, it is an interpersonal disorder-- a condition that is commonly associated with marked disruption in the ability to relate with other people o It is not clear whether people with social phobia actually exhibit social skill deficits, though their excessive anxiety during interpersonal interactions may interfere with their ability to effectively communicate with others Obsessive-compulsive disorder (OCD)  Description o The primary features of OCD are recurrent obsessions and compulsions that cause marked distress for the individual o Lifetime prevalence: 1.6% o Typical age of onset: adolescence and early adulthood, though childhood OCD is not uncommon o Obsessions-- recurrent and uncontrollable thoughts, impulses, or ideas that the individual finds disturbing and anxiety-provoking  Common obsessions include thoughts related to uncertainty (e.g., doubting if one has turned off the stove), sexuality (e.g., homosexual imagery), violence (e.g., harming a child), and contamination (e.g., believing one is covered with germs)  Obsessions are often a source of personal shame and embarrassment o Compulsions-- repetitive behaviors or cognitive acts that are intended to reduce anxiety (e.g., handwashing, checking)  Compulsions involve observable behavior or mental acts (e.g., counting) that are used to reduce anxiety o Neutralizations-- behavioral or mental acts that are used by individuals to try to prevent, cancel, or "undo" the feared consequences and distress caused by an obsession  Neutralizing is a normal and common activity, and those who engage in it tend to be feel better afterwards o Thought-action fusing (TAF)-- refers to two types of irrational thinking:  Likelihood TAF-- the belief that having a particular thought increases the probability that the thought will come true  Likelihood-Others TAF-- thoughts about others (the only form of TAF considered to be a pathological OCD belief)  Likelihood-Self TAF-- thoughts about the self  Moral TAF-- the belief that having a particular thought is the moral equivalent of a particular action (highly related to religosity)  Diagnosis and assessment o Criteria:  Presence of either obsessions or compulsions (may be independent, but co-occur 96% of the time)  Individuals recognize that their obsessions or compulsions are excessive and irrational  Symptoms cause marked distress or significantly interfere with the person's life o Subtypes also exist: Contamination and Washing/Cleaning, Checking, Hoarding, Ordering/Symmetry  Etiology o Many theories exist, no fully accepted model o Two prominent models: neurobiological model and cognitive-behavioral model  Neurobiological model  There appears to be a mild genetic risk factor for the disorder  Implicates the basal ganglia and frontal cortex  Structural and/or functional abnormalities in this brain system may be responsible for compulsions and obsessions  Cognitive-behavioral model  Problematic obsessions are caused by the person's reaction to intrusive thoughts (t
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