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CHAPTER 6: CHAPTER 6: Anxiety DisordersAnxiety Disorders
Abnormal Psychology
Jan 20-27, 2009Classes # 3-5
Generalized Anxiety DisorderGeneralized Anxiety Disorder
Symptoms– Anxiety that is constantly present– Hypervigilance– Autonomic Reactivity
DiagnosisDiagnosis
This is when anxiety has become pathological in that it is excessive, chronic, and typically interferes with a person’s ability to function in normal daily activities
To be diagnosed, the worry must last six months and not be limited to a single life circumstance nor is triggered by a specific object
PrevalencePrevalence
Lifetime prevalence:• Approximately 5% of general population
will suffer from GAD
– Sex difference: • Women 6.6% Men 3.6%
OnsetOnset
Usual onset is late teens to early 20’s but can occur anytime
Risk FactorsRisk Factors
Environmental stressors Sleep deprivation and inconsistency Financial concerns Health Relationships School problems Work problems
More risk factors…More risk factors…Genetics
– Research has shown a 20% risk for GAD in blood relatives with this disorder
– There is also a 10% risk among relatives of people with depression
– Additional correlations between GAD and other psychiatric disorders such as phobia disorders and panic disorder
Also, GAD is a risk itself for insomnia – No surprise there
Case Study: John Madden
Explanations for GADExplanations for GAD
PsychodynamicBehavioralCognitivePhysiological
Psychodynamic ExplanationPsychodynamic Explanation
Sees anxiety as an alerting mechanism that arises when our unconscious motivations clash with the constraints of our conscious mind
We are often unaware of why we are anxious because these feelings are coming from repressed memories– Problems:
• No sound evidence and most feel it doesn’t apply to this one
Behavioral ExplanationBehavioral Explanation
This theory holds that anxiety results from not knowing how to behave in a given situation
The possibility of suffering negative consequences because of inappropriate behavior may result in hesitation and inaction
We have been classically conditioned to be anxious???
The Cognitive ExplanationThe Cognitive Explanation
Incorrect beliefs– Problems:
• Many individuals with GAD cannot explain exactly why they are anxious and their anxiety “comes out of the blue”…they can’t give specific reasons for it
• Vague worries about the future is about all they mention
• So, how do we get incorrect beliefs if we don’t know why we are worried about something?
Physiological Explanation: Physiological Explanation: Chemical imbalancesChemical imbalances
GAD is associated with irregular levels of neurotransmitters caused partly by an underactivity of inhibitory neurons…– GABA
• Too low levels– Serotonin
• Too low levels– Norepinephrine
• Too high levels
Behavioral TherapyBehavioral Therapy
The learning approach – Learning to relax…
–Applied relaxation training
–Biofeedback training
Cognitive TherapyCognitive Therapy
Changing beliefs and distraction– Meditation
• Mantra helps provide a distraction–Seems to be at least somewhat
effective in reducing anxiety but it may be a psychological rather than real effect
• But who cares? As long as it works…
Drug TreatmentsDrug Treatments Medications
– Antidepressants and anti-anxiety drugs• Valium and Xanax
– These fast-acting drugs increase GABA activity
• Effexor– This newer drug is now used to treat both depression and
GAD
• BuSpar – Alternative to benzodiazepines above
• Minor Tranquilizers – These increase the activity of the inhibitory neurons so
that the excitatory neurons will be less active
Concerns about drug treatmentConcerns about drug treatment
Side effects Not curesDrug dependence concerns
ComplicationsComplications
High risk for development of substance abuse or dependence
PrognosisPrognosis
Not good…can be long-standing and difficult to treat– Most probably will not be cured but all can
expect improvement with a drug/cognitive-behavioral combo
Obsessive-Compulsive Disorder (OCD)Obsessive-Compulsive Disorder (OCD)
To be diagnosed with OCD, a person must have recurrent obsessions and compulsions that are disabling– Significantly interfere with a person’s
routine, making it difficult to work, or to have a normal social life or relationships
Prevalence and OnsetPrevalence and Onset
Prevalence– Point prevalence:
• 1%-2% currently suffering
– Life-time prevalence: • Afflicts 2%-3% of population some time in their lives
– Group differences• No sex differences• Knows no geographic, ethnic, or economic boundaries
Onset• About two-thirds develop the disorder before they are 25
years old and only 15% after the age of 35• Onset after 40 is very rare
ObsessionsObsessions
Constant, intrusive, unwanted thoughts causing distressing emotions such as anxiety or disgust– Examples:
• Thoughts of violence (person feels he/she will hurt someone)
• Thoughts of contamination (germs)• Thoughts of uncertainty (did I lock the
door?)
They understand yet it doesn’t They understand yet it doesn’t matter…matter… They know thoughts
are irrational
CompulsionsCompulsions
Compulsions are urges to do something to lessen discomfort
Rituals are the behaviors in which these people engage in to accomplish this
Common OCD CompulsionsCommon OCD Compulsions
Cleaning – Fear of germs, etc.
Repeating – Feel harm will occur if they don't
Completing – Exact order until perfection
Being meticulous – Exact place for things (ex: appearance of
room, etc.)
OCD CompulsionsOCD Compulsions Avoiding
– Exaggerated avoidance of anxiety producing stimuli
Counting – Compelled to count things (like
how many steps it takes to get somewhere)
Hoarding – Constant collection of useless
items Slowness
– Tasks done extremely slowly Excessive and Ritualized praying
– May pray literally all day long in a ritualized manner
Explanations for OCDExplanations for OCD
PsychodynamicBehavioralCognitivePhysiological
Psychodynamic ExplanationPsychodynamic Explanation
Obsessions and compulsions are used to control anxiety coming from the unconscious– Problems
• Can't "prove" – pure speculation
BehavioralBehavioral Explanation Explanation
Operant conditioning explanation– Problems:
• Even after receiving drugs, etc. that reduce anxiety levels – they still continue obsessions and compulsions
Cognitive ExplanationsCognitive Explanations
OCD results from faulty thinking– "Something bad will happen if I don't do these
actions"• Problems:
– Although, it can explain the more realistic obsessions ("I must wash to stay germ-free") it doesn't explain more bizarre obsessions ("I must get up and down 8 times from my chair or something terrible will happen")
Physiological ExplanationsPhysiological Explanations
Scarcity of serotoninIn certain brain structures there are high
levels of brain activity (orbital frontal, etc.)
Brain damageGenetics
Treatments for OCDTreatments for OCD
No treatmentCognitive-Behavioral TherapyAntidepressant MedicationsPsychosurgeryOther Treatments
If you can wait 40 years…If you can wait 40 years…
Skoog and Skoog (1999)– No treatment
– 83% showed some improvement while 20% showed complete recovery
Cognitive-Behavioral TherapyCognitive-Behavioral Therapy
Systematic Desensitization – Gradual exposure
Response prevention – Preventing the person from doing the
compulsion or mental actRelaxation techniques
– Cognitive techniques such as self-talk are often combined with the above techniques
Cognitive-Behavioral TherapyCognitive-Behavioral Therapy
Effectiveness:
– 60-80% of those using the cognitive-behavioral treatments improve (show at least a partial reduction in symptoms)
Antidepressant MedicationsAntidepressant Medications
Drugs that influence (increase) serotonin levels have been used effectively – Prozac, Zoloft, Paxil, Anafranil, etc.
• Drawbacks:– High doses of these drugs may be required
in the treatment of OCD– It can take several weeks to feel their
beneficial effects – Additionally, there are potential side effects
to consider
Antidepressant MedicationsAntidepressant Medications
Effectiveness: – Depends on how you view the following
statistics… • About 70% of OCD sufferers respond
notably to antidepressant medication while others experience a partial reduction of symptoms
• However, only about 10% to 15% have a full remission of symptoms
PsychosurgeryPsychosurgery
Cingulotomy – Surgical treatment of the cingulum – here, a cut is
made between certain nerve fibers that trigger emotional arousal (cingulated gyrus) and the limbic system
– Has been used as a last resort for patients with severe persistent symptoms who have not responded to other treatments
• Effectiveness: – About 25-30% of these operations result in
improvement– The procedure is relatively uncomplicated
PrognosisPrognosis
The disease is chronic for most people even with drug treatment
Most take medication indefinitely, and about 85% of people relapse within one or two months after discontinuing usage
Panic DisorderPanic Disorder
Usually brief periods of intense anxietyUsually unexpected and do not appear
to be provoked by the situation the person is responding to
Prevalence and OnsetPrevalence and Onset
Lifetime prevalence:– Approximately 3% to 5% of the general
populationSex difference:
– Females 5 % – Males 2%
Onset – Usually before age 25
SymptomsSymptoms
Racing HRChest painChoking sensationExcessive sweatingDizziness and NauseaChills, shaking, etc.Feelings of unreality (detached from one’s
body)
Specific CharacteristicsSpecific Characteristics
Brevity of attacks (usually reach maximum intensity within a minute or so)– In very rare cases the attacks can last several hours or days
Marked intensity of stark terror – This terror lingers on long after the episode has ended –
they “fear the fear” People often have a fear of dying or going
crazy– Note: Some individuals will fear having a panic attack in
public so much that they will rarely leave home…if their avoidance of public places becomes this extreme the individual may be diagnosed as suffering from panic disorder with agoraphobia
DiagnosisDiagnosis
DSM-IV defines panic disorder as including recurrent, unexpected panic attacks with a minimum of one month of persistent concern over having them again
Physiological ExplanationsPhysiological Explanations
It appears that these people have an overly sensitive respiratory control center (RCC) in their brain:– RCC detects small increases in carbon
dioxide– Because of oversensitivity it sends false
alarms– Higher brain structures think we are
suffocating– We panic
PANIC DISODER’S UNUSUAL PANIC DISODER’S UNUSUAL FEATURESFEATURES
Sodium Lactate Inhaling air containing even small amounts of
carbon dioxide Hyperventilation process Stage 4 sleep (nocturnal panic attacks) Antidepressant drugs
Physiological Explanation: Physiological Explanation: GeneticsGenetics
Genetics play a role:
– Biological relatives: 25%
– Non-Biological relatives: 2%
– Identical twins 5 times more than non-identical
Other ExplanationsOther Explanations
It appears the physiological explanation is best but lets touch on some of the others:
– Psychodynamic
– Behavioral
– Cognitive
TreatmentsTreatments
Medication
– Anti-anxiety and antidepressants have been successful…• Xanax• Zoloft
TreatmentsTreatments
Cognitive–Behavioral Therapy– Psychotherapy combined with exposure
(usually systematic desensitization) Support Groups Family Therapy Other Recommendations
– Avoid stimulants (caffeine, cocaine, etc.)– Avoid alcohol
ComplicationsComplications
Substance abuse: 33%Clinical depression: 66%Attempted suicide: 20%OCD: 10%Also more at risk for:
– Hypertension (2 times the normal risk)– Heart Attack (4.5 times the normal risk)– Stroke (12 times the normal risk)– Disability (only about half can work full time)
PrognosisPrognosis Bad news:
– This illness can be chronic and difficult to treat• One study found 80% of patients were still
symptomatic at a 20 year follow-up evaluation
Good news: – Although, disorder may not be cured…nearly all can
expect improvement with a drug/behavioral combo Note:
– Don’t expect panic disorder to go away by itself – get help now!
Phobic DisordersPhobic Disorders
Fear has no justification in realityFear is greater than is justifiedIndividual is aware of irrationality of fear
Phobic DisordersPhobic Disorders
Social phobiaAgoraphobiaSpecific phobias
What is Social Phobia?What is Social Phobia?
Irrational fear that they will behave in an embarrassing way
Is limited to situations in which the scrutiny of others is likely
Extreme form of shyness that interferes significantly with an individual’s functioning
These individuals avoid all social situations
Prevalence/OnsetPrevalence/Onset
Recent study says over 13% of general population but other studies say its about 4%
Sex difference: Slightly more women than men
Average onset: early adolescence
SymptomsSymptoms
Avoidance of all social situationsHigh anxiety if ever placed in a social
situationRapid heart rateElevated blood pressureHistory of phobia
What causes social phobia?What causes social phobia?
Basically unknown but…
– Possible biological reasons: scarcity of serotonin
– Possible environmental factors…
Agoraphobia Agoraphobia “fear of the marketplace”“fear of the marketplace”
These people suffer from intense anxiety when in a place where escape would be difficult or embarrassing if they were to experience a panic attack
Fear being in a place where they can’t get help
In extreme cases, they may not leave their house
Prevalence and OnsetPrevalence and Onset
Prevalence– Estimated 5%-12% of general population will suffer
from agoraphobia Sex difference
– Women 7% – Men 3.5%
Onset– Usually occurs in their 20’s
TreatmentsTreatments
Usually a medication and psychotherapy combo
Commonly anti-depressants and anti-anxiety meds are used: – Prozac, Paxil, Zoloft, Elavil, etc.– Xanax, Klonipin, etc.
Cognitive-Behavioral TreatmentCognitive-Behavioral Treatment
Most common treatment is systematic desensitization…– Breathing and relaxation techniques are
sometimes used in conjunction with systematic desensitization
PsychotherapyPsychotherapy
Often psychodynamic in natureLooking to uncover unconscious
conflicts
PrognosisPrognosis
Very good – 90% improve
Specific PhobiasSpecific Phobias
DSM-IV classifies all other phobias (besides social phobia and agoraphobia) as “specific phobias”
We’re talking about specific objects or situations here Sex difference:
– Women 16% – Men 7%
Associated features: depressed mood and dependent personality
Exposure to the phobic stimulus may lead to a panic attack
As with other phobias, the person recognizes that the fear is excessive and unreasonable
TypesTypes
Situational Type
– Irrational fear of a specific situation Natural Environment Type
– Irrational fear of things in the environment Animal Type
– Irrational fear of animals or insects Other Type
– Irrational fear of any other stimuli
Explanations for PhobiasExplanations for Phobias
Psychodynamic: – Symbolically expressed conflicts and stress
Behavioral: – Classically conditioned fears
Cognitive: – Incorrect beliefs
Physiological: – Neurological arousal and genetics
Treatments for Anxiety DisordersTreatments for Anxiety Disorders Psychoanalysis Behavior Therapy
– Exposure– Systematic desensitization– Flooding– Virtual Reality Exposure– Modeling
Cognitive Therapy– Cognitive Restructuring– Thought Stopping– Cognitive Rehearsal
Physiological Approach– Drug treatment