Anxiety Disorders
- Anxiety refers to an unpleasant feeling of fear and apprehension
Neuroses is a former term that refers to a group of disorders involving unrealistic anxiety, assumed to be due to unconscious conflicts
Anxiety disorders reflect the clear presence of symptoms of anxiety
Anxiety is not specific to anxiety disorders
Comorbidity: A person may be diagnosed with more than one disorder
among the most prevalent of psychological disorders affecting up to 25% of general population during lifetime
Phobias
a fear-mediated avoidance that is out of proportion to the object or situation
- Phobias involve intense anxiety
- Phobias are disruptive
- Person recognizes that the fear is groundless
- Many specific fears are not phobias because (a) they are in proportion to the feared stimulus (e.g., jellyfish 8 10 days after full moon)
or (b) they do not cause hardship (e.g.,fear of snakes in Hawaii where no snakes live in nature)
Examples of Phobias
Phobia Involves Fear of:
Agoraphobia Public Places
Acrophobia Heights
Pnigophobia Choking
Taphephobia Being Buried Alive
Hellenologophobia Pseudoscientific Terms
Claustrophobia Closed Places
-names derived from Greek
-Greek god Phobos frightened his enemies
Classes of Phobias
- Specific phobias are unwarranted fears elicited by the presence of a specific object or situation
- Blood, injuries, or injections
- Situations (planes, elevators)
- Animals
- Natural environment (water, heights)
- Cultural factors (fear of spirits more common in Thailand than in the U.S.)
*avoidance must impair functioning to be a phobia
* fear can generalize to impair functioning
- Social phobia involves a persistent fear linked to the presence of other people
- Lifetime prevalence rate of 10% for specific and
3% to 13% for social
Etiology of Phobias
- Psychoanalytic theory
: phobias result from anxiety produced by repressed id impulses; content is symbol of psychosexual stage of fixation (e.g., snake = phallic symbol and Oedipal stage)
- Behavioral theories
: focus on learning as the etiological basis of phobias
Phobias are learned avoidance responses (classical and operant conditioning)
Phobias may be acquired through modeling
We are biologically prepared to learn certain fears (e.g. taste with nausea)
Cognitive theory: Thought processes result in high levels of anxiety
Biological theory: genes and autonomic nervous system labilitiy
Humanistic/existential: self-actualization impeded
Treating Phobias
- Psychoanalytic therapy attempts to uncover repressed conflicts using free association & dream analysis
- Behavioral approaches use systematic desensitization, social skills training, & modeling to reduce anxiety responses to phobic stimuli and situations
- Flooding
: exposure to a phobic stimulus at full intensity
- Cognitive approaches focus on altering irrational beliefs via cognitive restructuring & exposure to phobic stimulus; changing cognitions alone is not sufficient
- also social skills training for social phobias
Treating Phobias
- Biological approach uses drugs to eliminate anxiety symptoms
- Anxiolytic drugs such as the benzodiazepines (Valium) can reduce anxiety but are also addictive and give rise to withdrawal symptoms upon termination
- MAO inhibitors such as phenelzine reduce the degradation of norepinephrine and serotonin
- MAO inhibitors can have adverse side effects
- Selective serotonin reuptake inhibitors (SSRIs) (fluoxetine) increase brain serotonin
- Humanistic/existential approaches use empathy, unconditional positive regard, and interpretation for all disorders
Panic Disorder
An attack of labored breathing, nausea, chest pain, dizziness, nausea, heart palpitations, sweating, trembling, sense of choking, numbness, chills or hot flashes, and intense apprehension (terror) of losing control or dying
Depersonalization: the feeling of being outside of ones body
Derealization: the feeling that the world is not real
Frequent occurrence of attack (e.g., once per week)
Attack may or may not be associated with a situation (cued versus uncued); cued only = phobia
Attack may or may not lead to agoraphobia
Attack lasts about five minutes
Common co-morbidity with other anxiety disorders, alcoholism, and personality disorders
Lifetime prevalence for panic disorder is 2% for men and 5% for women
Etiology of Panic Disorder
- The Fear-of-fear hypothesis of panic disorder suggests that some people have an overly aroused nervous system and a tendency to be upset by the sensations generated by their nervous system
- Eventually, worry about a panic attack makes a future attack more likely (vicious circle)
- Involves classical conditioning of words (worry of losing control) as conditioned stimuli that elicit fear responses = cognitive-behavioral paradigm
- Agoraphobia = fear of having a panic attack in public
Etiology of Panic Disorder
- Biological theories focus on the observations
- that panic disorder runs in families (genetic?)
- that panic disorder can be induced experimentally using
Hyperventilation may activate the autonomic nervous system
Infusions of lactate can induce panic attack
Panic attack may result from an exaggerated central response to arousal (noradrenergic system over-activity)
ETIOLOGY OF PANIC DISORDER
-- The panic attack is a defense mechanism used when the ego fears that the id may take control
--As with all disorders, self-actualization is impeded and there may be some decisions or choices to make
Panic Disorder Treatments
- Biological treatments include use of antidepressant and anxiolytic drugs
Require long-term use, symptoms return upon drug cessation
Side effects: jitteriness, weight gain, elevated heart rate & blood pressure, memory lapses, difficulty driving vehicle, addiction
50% do not comply with taking medication
Psychological treatments emphasize exposure to stimuli that accompany panic
Barlows therapy includes a combination of relaxation training, cognitive interventions and exposure to the internal cues that elicit panic; with agoraphobia, successive approximation
Treatment can involve spouse in successive approximation
Reduction or elimination of panic in long-term after treatment
Generalized Anxiety Disorder
- Generalized Anxiety Disorder (GAD) involves persistent anxiety and chronic (uncontrollable) worry more days than not for 6 months
- Anxiety and worry accompanied by: restlessness, fatigue, irritability, muscle tension, sleep disturbance, and impairment in functioning or severe distress
- Anxiety and worry not due to medication or substance use
- The lifetime prevalence of GAD is 5%
Women are twice as likely to develop GAD as are men
Etiology of GAD
- Psychoanalytic view: generalized anxiety results from unconscious
- conflicts between ego and id impulses
- sexual and aggressive impulses from any stage of psychosexual development in conflict with ego
-defenses fail to displace anxiety onto an object
- Cognitive-behavioral view: anxiety results from conditioning of anxiety to external stimuli that have generalized and irrational cognitions (fear of losing control, anticipation of danger and disaster
- Biological view: the transmitter GABA inhibits anxiety, anxiolytic drugs enhance the release of GABA in brain; may be an inherited condition
Therapies for GAD
- Psychoanalytic therapy for GAD is similar to that of phobia (reveal sources of conflict)
- Behavioral therapy involves a combination of relaxation training, desensitization, and cognitive intervention to change helplessness to competence (self-efficacy) and to reduce catastrophizing
- Biological therapy uses administration of anxiolytic and anti-depressant drugs to reduce anxiety
- Drug therapy is effective only while the drugs are taken
- Side effects severe
Obsessive-Compulsive
- Obsessions are intrusive and recurring thoughts (e.g., contamination, doubts about performance, need for orderliness, aggressive impulses, sexual imagery) that are not related to real-life problems
- Compulsions are repetitive behaviors or mental actions that are repeated over and over in order to reduce anxiety
- The lifetime prevalence of OCD is 1-2 %
- Women are more likely than men to develop OCD
Common Compulsions
- Pursuing cleanliness (e.g., chronic handwashing until hands are raw)
- Avoiding particular objects (e.g. cracks in a sidewalk)
- Performing repetitive, magical, protective practices (e.g., counting backwards)
- Checking (e.g. "is the gas off?")
Performing a particular act (e.g. chewing slowly)
Etiology of OCD
- The psychoanalytic view is that OCD reflects arrest of personality development at the anal stage due to severely harsh toilet training; obsessions and compulsions are defense mechanisms (often displacement or projection or reaction formation)
- Behavioral accounts of OCD point to learned behaviors reinforced by fear reduction
- The biological view of OCD has focused on activation of the frontal lobes and basal ganglia perhaps due to genetic disposition
- Cognitive view describes people with OCD as having general negative and intrusive schema = obsessions and reduce anxiety with compulsions
OCD Therapy
- Psychoanalytic procedures are not effective
- Behavioral: ERP (Exposure and Response Prevention) involves exposing the OCD client to situations that elicit a compulsion and then restraining the client from performing the compulsion for 90 minutes over 15 sessions; 25% drop out of treatment
- Cognitive restructuring of control beliefs
- Biological treatment involves drugs that increase brain serotonin activity (Prozac)
POSTTRAUMATIC STRESS DISORDER
- PTSD refers to an extreme response to an extreme stressor
- Stressor involved actual or threatened death or serious injury to self or others
- Response to stressor involved intense fear, helplessness, or horror
[In children, agitation]
POSTTRAUMATIC STRESS DISORDER
- PTSD symptoms include for more than 1 month at least one of the following:
- Increased anxiety and arousal
- Reexperiencing the traumatic event
- Recurring dreams or thoughts about the event
- Avoidance of stimuli associated with the trauma
POSTTRAUMATIC STRESS DISORDER
- PTSD symptoms also include at least 3 of the following for more than 1 month:
- Avoidance of reminders of the event
- Inability to recall an important aspect of the trauma
- Diminished interest in activities
POSTTRAUMATIC STRESS DISORDER
(3 of following continued)
- feeling detached from others
-restricted range of affect (e.g., unable to feel love)
-sense of foreshortened future (e.g., does not expect to have a career or normal life span)
POSTTRAUMATIC STRESS DISORDER
- PTSD symptoms also include at least 2 of the following for more than 1 month:
-difficulty falling or staying asleep
-irritability or outbursts of anger
-difficulty concentrating
POSTTRAUMATIC STRESS DISORDER
(2 of following continued)
-hypervigilance
-exaggerated startle response
- Lifetime prevalence estimates from 1% to 3% in general population and 9% in at-risk populations (e.g., combat veterans, victims of volcanic eruptions or criminal violence)
ETIOLOGY OF PTSD
- Compared to other anxiety disorders, causal variables are more empirically than theoretically derived
- Research has identified risk factors given exposure to a trauma:
-sex (females more at risk)
-early separation from parents
-family or personal history of a behavioral disorder
THEORIES OF PTSD
- Learning/behavioral view is that the trauma is a US and classical conditioning and avoidance conditioning occurs
- Psychoanalytic view is that the symptoms represent defense mechanisms in an attempt to repress traumatic memory from consiousness
- Biological view is inherited overactive noradrenergic system
TREATMENTS FOR PTSD
- Text indicates crisis intervention (recreating event and discussing it) but research has shown it may be iatrogenic
- Cognitive-behavioral therapy with exposure to thoughts and imagery of the trauma, relaxation, & cognitive restructuring (e.g., of survivor guilt)
- Psychoanalytic encourages catharsis
Biological: anxiety & depression meds
EMPIRICALLY VALIDATED TREATMENTS FOR ANXIETY DISORDERS
Chambless, D. L., et al. (1998). Update on empirically validated therapies, II.
The Clinical Psychologist, 51, 3 - 16.
CRITERIA FOR EMPIRICALL
Y-VALIDATED TREATMENTS
Well-Established Treatments
I. At least two good between group design experiments demonstrating efficacy in one or more of the following ways:
A. Superior (statistically significantly so) to pill or psychological placebo or to another treatment.
B. Equivalent to an already established treatment in experiments with adequate sample sizes.
OR
II. A large series of single case design experiments (n >9) demonstrating efficacy. These experiments must have:
A. Used good experimental designs and
B. Compared the intervention to another treatment as in IA.
FURTHER CRITERIA FOR BOTH I AND II:
III. Experiments must be conducted with treatment manuals.
IV. Characteristics of the client samples must be clearly specified.
V. Effects must have been demonstrated by at least two different investigators or investigating teams.
Probably Efficacious Treatments
I. Two experiments showing the treatment is superior (statistically significantly so) to a waiting-list control group.
OR
II. One or more experiments meeting the Well-Established Treatment Criteria IA or IB, III, and IV, but not V.
OR
III. A small series of single case design experiments (n >3) otherwise meeting Well-Established Treatment
Well-Established Treatments for Anxiety Disorders
Cognitive behavior therapy for panic disorder
with and without agoraphobia
Cognitive behavior therapy for generalized anxiety disorder
Exposure treatment for agoraphobia
*Exposure/guided mastery for specific phobia
Exposure and response prevention for obsessive-compulsive disorder
Stress Inoculation Training for Coping with Stressors
Probably Efficacious Treatments for Anxiety Disorders
Applied relaxation for panic disorder
Applied relaxation for generalized anxiety disorder
*Cognitive behavior therapy for social phobia
Cognitive therapy for OCD
Couples communication training adjunctive to exposure for agoraphobia
*EMDR for civilian PTSD
Exposure treatment for PTSD
*Exposure treatment for social phobia
Stress Inoculation Training for PTSD
Relapse prevention program for obsessive-compulsive disorder
Systematic desensitization for animal phobia
Systematic desensitization for publicspeaking anxiety
Systematic desensitization for social anxiety