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Chapter 5

Abnormal Psychology CHAPTER 5 NOTES - I got a 4.0 in the course

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Chapter 5:Anxiety Disorders (Review Summary pg. 167) The Complexity of Anxiety Disorders: • Difference between anxiety, fear, and panic: o Anxiety- a negative mood state characterized by bodily symptoms of physical tension and by apprehension about the future o Fear- an immediate alarm reaction to danger o Panic attack- an abrupt experience of intense fear or acute discomfort, accompanied by physical symptoms that usually include heart palpitations, chest pain, shortness of breath, and dizziness • Three basic types of panic attacks: o Situationally bound- if you know you are afraid of heights, you might have a panic attack only in these situations (more common in specific phobias) o Unexpected- no idea when or where the next attack will occur (more common in panic disorder) o Situationally predisposed- you are more likely to, but will not inevitably, have an attack where you have had one before (more common in panic disorder) • Causes of Anxiety Disorders: o Biological Contributions:  We inherit a tendency to be tense, uptight, and anxious  Agenetic vulnerability does not cause anxiety or panic directly. Stress or other factors in the environment can “turn on” these genes  Neurotransmitters related to anxiety: • Depleted levels of GABA • Serotonin • Noradrenergic • Corticotropin releasing factor (CRF)  The area of the brain most often associated with anxiety is the limbicsystem  Behavioral inhibition system- is activated by signals from the brain stem of unexpected events, such as major changes in body functioning that might signal danger. Danger signals in response to something we see that might be threatening descent from the cortex to the septal-hippocampal system  When the BIS is activated by signals that arise from the brain stem or descend from the cortex, our tendency is to freeze, experience anxiety, and apprehensively evaluate the situation to confirm that danger is present  Flight/fight system (FFS)- produces an immediate alarm and escape response that looks very much like panic.Activated partly by deficiencies in serotonin. o Psychological Contributions:  Ageneral sense of uncontrollability may develop early as a function of upbringing and other disruptive or traumatic environmental factors  Parents who interact in a positive and predictable way with their children by responding to their needs, teach their children that they have control over their environment and their responses have an effect on their parents and their environment  Parents who provide a “secure home base” but allow their children to explore their world and develop the necessary skills to cope with unexpected occurrences enable their children to develop a healthy sense of control  Most psychological accounts of panic (as opposed to anxiety) invoke conditioning and cognitive explanations that are difficult to separate: cues, or conditioned stimuli, provoke the fear response and an assumption of danger, even if the danger is not actually present so it is really a learned or false alarm  External cues are places or situations similar to the one where the initial panic attack occurred  Internal cues are increases in heart rate or respiration that were associate with the initial panic attack, even if they are now the result of normal circumstances  These cues or triggers travel from the eyes directly to the amygdala in the emotional brain without going throw the cortex (the source of awareness), making them unconscious o Social Contributions  Stressful life events trigger our biological and psychological vulnerabilities to anxiety  Most are social and interpersonal (divorce, work, death) but some may be physical (injury or illness) o An Integrated Model  Triple vulnerability theory: 1. general biological vulnerability 2. general psychological vulnerability 3. specific psychosocial vulnerability • Comorbidity ofAnxiety Disorders: o Comorbidity- the co-occurrence of two or more disorders in a single individual o The various anxiety disorders differ only in what triggers the anxiety and the patterning of panic attacks o Results indicate that 76% of patients who receive a principal diagnosis of anxiety or depressive disorder had at least one additional anxiety or depressive disorder in his or her life o Most common additional diagnosis for all anxiety disorders was major depression o Drug or alcohol abuse makes it less likely that you will recover from an anxiety disorder and more likely that you will relapse if you do • Comorbidity with Physical Disorders: o Studies show that the presence of any anxiety disorder is uniquely associated with thyroid disease, respiratory disease, gastrointestinal disease, arthritis, migraines, and allergic conditions o People with these physical conditions are likely to have an anxiety disorder o Anxiety disorders most often begin before the physical disorder, suggesting that something about having an anxiety disorder might cause the physical disorder • Suicide: o 20% of patients with panic disorder had attempted suicide o The risk of someone with panic disorder attempting suicide is comparable to that for individuals with major depression GeneralizedAnxiety Disorder: • Clinical Description: o Definition- no matter how much you worry, you cant seem to decide what to do about an upcoming problem or situation. o At least 6 months of excessive anxiety and worry must be ongoing more days than not o Physical symptoms are generally muscle tension, mental agitation, susceptibility to fatigue, irritability, and difficulty sleeping • Statistics: o GAD is one of the most common anxiety disorders o 2/3 women, except in southAfrica, GAD more common in males o Onset in early adulthood, usually in response to a life stressor. However, GAD is associated with an earlier and more gradual onset than most other anxiety disorders o Is chronic after 12 years after the beginning of an episode of GAD there was only a 58% chance of recovering o GAD is most common in groups over 45 years of age and least common in the youngest group ages 15-24 • Causes: o Biological? Tends to run in families. The tendency to be anxious runs more in families than GAD itself o Individuals with GAD show less physiological responses (heart rate, blood pressure, respiration rate, etc.) than do individuals with other anxiety disorders, and therefore have been called autonomic restrictors o Muscle tension is the principle physical symptom in diagnosis GAD o Are highly sensitive to threats in general. May have arisen in early stressful experiences where they earned that the world is dangerous and out of control, and may not be able to cope o Intense cognitive processing in the frontal lobes, particularly in the left hemisphere. This suggests frantic, intense thought processes or worry without accompanying images, which would be reflected in the right hemisphere o Are thinking so hard about upcoming problems that they don’t have the attentional capacity left for the process of creating images of the threat. They avoid images of the threat. o Because people with GAD do not seem to engage in this process, they may avoid much of the unpleasantness and pain associated with the negative affect and imagery, but they are never able to work through their problems and arrive at solutions.Adaptation never occurs. • Treatment: o Benzodiazepines  Are most often prescribed for generalized anxiety, and they usually give short term relief  Impair both cognitive and motor functioning. People are less alert and may impair driving. Older people tend to fall more, resulting in hip fractures. Also addictive  For these reasons, generally used for short term anxiety relief associated with a temporary crisis or stressful event o Antidepressants o Psychological treatments  Seem to be more effective in the long term  Clinicians have designed treatments to help patients with GAD process the threatening information on an emotional level, using images so that they will feel (rather than avoid feeling) anxious  Teaching patients how to relax deeply to combat tension o Meditation o Cognitive Behavioral Treatment (CBT)  Patients evoke the worry process during therapy sessions and confront anxiety provoking images and thought head on  Learn to counteract and control the worry process  Successfully decreased anxiety and improved the quality of life Panic Disorder with and withoutAgoraphobia: • Panic disorder with agoraphobia (PDA)- individuals experience severe, unexpected panic attacks • Because they never know when an attack might occur, they develop agoraphobia-the fear and avoidance of situations in which they would feel unsafe in the event of a panic attack or symptoms • Clinical Description: o Anxiety and panic are combined with phobic avoidance o Panic disorder without agoraphobia (PD)-anxiety and panic without developing agoraphobia o Aperson 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 • The Development of Agoraphobia: o Almost all agoraphobic avoidance behavior is simply a complication of severe, unexpected panic attacks o Anxiety is diminished for individuals with agoraphobia if they think a location or person is “safe”, even if there is nothing effective the person could do if something bad did happen o An individual who has not had a panic attack for years may still have strong agoraphobic avoidance o Some individuals do not avoid agoraphobic situations but endure them with “intense dread” o Interoceptive avoidance-removing yourself from situations or activities that might produce the physiological arousal that somehow resembles the beginnings of a panic attack o Many individuals with agoraphobia avoid daily activities that may remind them of having a panic attack “Sweating, getting involved in debates, exercising, saunas, etc.) • Statistics: o 2.7% of the population meet criteria for PD or PFAduring a given 1 year period and 4.7% met them at some point during their lives o 1.4% develop agoraphobia without ever having a full blown panic attack. This is called agoraphobia without a history of panic disorder, but it looks much the same as PDAand is treated with the same treatments o Onset usually occurs in early adult life (midteens through about 40) o Many prepubertal children who are seen buy general medical practitioners haves symptoms of hyperventilation that may well be panic attacks. However, these children do not report fear of dying or losing control—perhaps because they are not at a stage of their cognitive development where they can make these attributions o For the elderly, the primary phobia is agoraphobia, which had a late onset and was often related to a stressful life even. o In general, the prevalence of PD or PDAdecreases among the elderly from 5.7% at ages 30-44 to 2.0% or less after age 60 o 75% of those who suffer from agoraphobia are women. It is more accepted for women to report fear and to avoid numerous situations. Men, however are expected to be stronger and braver o Alarge proportion of males with unexpected panic attacks cope in a culturally acceptable way: they drink. • Cultural Influences: o In Lesotho,Africa, the prevalence of panic disorder was found to be equal to or greater than in all of NorthAmerica o Rates are similar among different ethnic groups in the US o However, panic disorder often co-occurs with hypertension inAfricanAmerican patients • Nocturnal Panic: o Panic attacks occur more often between 1:30AM and 3:30AM thanany other time. For this reason, some people are afraid to go to sleep at night o Nocturnal panics occur during delta wave or slow wave sleep, which typically occurs several hours after we fall asleep and is the deepest stage of sleep. People with panic disorder often begin to panic when they start sinking into delta sleep, then they awaken amid an attack o The change in stages of sleep to slow wave sleep produces physical sensations of “letting go” that are frightening to an individual with PD • Causes: o Strong evidence indicates that agoraphobia develops after a person has unexpected panic attacks, but whether agoraphobia develops and how severe it becomes seem to be socially and culturally determined o We all inherit a vulnerability to stress which is a tendency to be generally neurobiologically overreactive to the events of daily life. But some people are also more likely than others to have an emergency alarm reaction when confronted with stress producing events o An individual must be susceptible to developing anxiety over the possibility of having another panic attack. That is, he or she thinks the physical sensations associated with the panic attack mean something terrible is about to happen. This is what creates PD. o Anxiety sensitivity index- an instrument used to measure one aspect of psychological vulnerability o Although we all typically experience rapid heartbeat after exercise, if you have a psychological or cognitive vulnerability, you might interpret the response as dangerous and feel a surge of anxiety. This anxiety, in turn, produces more physical sensations because of the action of the sympathetic nervous system, you perceive these addition sensations as even more dangerous, and a vicious cycle begins that result in a panic attack. Because of this David Clark believes that the cognitive process is most important in panic disorder o Women who had a history of having various physical disorders and were anxious about their health tended to develop PD rather than another anxiety disorder o Another hypothesis that PD and agoraphobia evolve from psychodynamic causes suggested that early object loss and/or separation anxiety might predispose someone to develop the condition as an adult • Treatment: o Alarge number of drugs affecting the noradrenergic, serotonergic, or GABA neurotransmitter systems seem effective in treating PD o SSRIs are currently the indicated drug for panic disorder although sexual dysfunction seems to occur in 75% or more of people taking these medications o On the other hand, high potency benzodiazepines such as Xanax, work quickly but are hard to stop taking because of psychological and physical dependence and affect cognitive and motor functions to some degree o Relapse rates are very high if an individual stops the drug before treatment is done • Psychological Intervention: o Originally treatments concentrated on reducing agoraphobic avoidance, using strategies based on exposure to feared situations o Gradual exposure exercises, sometimes combined with anxiety reducing coping mechanisms (relaxation or breathing retraining) have proved effective in helping as many as 70% of patients overcome agoraphobic behavior. However, few are actually cured, because many still experience some anxiety and panic attacks, although at a less severe level o Panic control treatment (PCT) concentrates on exposing patients with PD to the cluster of physical sensations that remind them of their panic attacks. The therapist attempts to create “mini” panic attacks in the office. Patients also receive cognitive therapy where basic attitudes and perceptions concerning the dangerousness of the feared but harmless situations are identified and modified (b/c many of these are unconscious to the patient) • Combined Psychological and Drug Treatments: o Combined treatment proved to be no better than individual treatments o Many studies show that drugs, particularly benzodiazepines
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