Comer, Abnormal Psychology, 6e – Chapter 5 1 Chapter 5 Anxiety Disorders Slides & Handouts by...

Comer, Abnormal Psychology, 6e – Comer, Abnormal Psychology, 6e – Chapter 5Chapter 5

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Chapter 5Chapter 5

Anxiety DisordersAnxiety Disorders

Slides & Handouts by Karen Clay Slides & Handouts by Karen Clay Rhines, Ph.D.Rhines, Ph.D.

Seton Hall UniversitySeton Hall University

2Comer, Abnormal Psychology, 6e – Comer, Abnormal Psychology, 6e –

Chapter 5Chapter 5

AnxietyAnxiety

What distinguishes fear from anxiety?What distinguishes fear from anxiety? Fear is a state of immediate alarm in Fear is a state of immediate alarm in

response to a serious, known threat to response to a serious, known threat to one’s well-beingone’s well-being

Anxiety is a state of alarm in response to Anxiety is a state of alarm in response to a vague sense of threat or dangera vague sense of threat or danger

Both have the same physiological Both have the same physiological features: increase in respiration, features: increase in respiration, perspiration, muscle tension, etc.perspiration, muscle tension, etc.


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AnxietyAnxiety

Is the fear/anxiety response Is the fear/anxiety response useful/adaptive?useful/adaptive? Yes, when the “fight or flight” response is Yes, when the “fight or flight” response is

protectiveprotective

However, when it is triggered by However, when it is triggered by “inappropriate” situations, or when it is too “inappropriate” situations, or when it is too severe or long-lasting, this response can be severe or long-lasting, this response can be disablingdisabling Can lead to the development of anxiety Can lead to the development of anxiety

disordersdisorders


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Most common mental disorders in the U.S.Most common mental disorders in the U.S. In any given year, 18% of the adult population in the In any given year, 18% of the adult population in the

U.S. experiences one of the six DSM-IV-TR anxiety U.S. experiences one of the six DSM-IV-TR anxiety disordersdisorders

Close to 29% develop one of the disorders at some point in Close to 29% develop one of the disorders at some point in their livestheir lives

Only ~20% of these individuals seek treatmentOnly ~20% of these individuals seek treatment

Most individuals with one anxiety disorder suffer Most individuals with one anxiety disorder suffer from a second disorder, as wellfrom a second disorder, as well

Anxiety disorders cost $42 billion each year in Anxiety disorders cost $42 billion each year in health care, lost wages, and lost productivityhealth care, lost wages, and lost productivity


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Six disorders:Six disorders: Generalized anxiety disorder (GAD)Generalized anxiety disorder (GAD)

PhobiasPhobias

Panic disorderPanic disorder

Obsessive-compulsive disorder (OCD)Obsessive-compulsive disorder (OCD)

Acute stress disorderAcute stress disorder

Posttraumatic stress disorder (PTSD)Posttraumatic stress disorder (PTSD)


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Generalized Anxiety Generalized Anxiety Disorder (GAD)Disorder (GAD)

Characterized by excessive anxiety under Characterized by excessive anxiety under most circumstances and worry about most circumstances and worry about practically anythingpractically anything Vague, intense concerns and fearfulnessVague, intense concerns and fearfulness

Often called “free-floating” anxietyOften called “free-floating” anxiety

““Danger” not a factorDanger” not a factor

Symptoms include restlessness, easy fatigue, Symptoms include restlessness, easy fatigue, irritability, muscle tension, and/or sleep irritability, muscle tension, and/or sleep disturbancedisturbance Symptoms last at least six monthsSymptoms last at least six months


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Generalized Anxiety Generalized Anxiety Disorder (GAD)Disorder (GAD)

The disorder is common in Western societyThe disorder is common in Western society Affects ~3% of the population in any given year Affects ~3% of the population in any given year

and ~6% at sometime during their livesand ~6% at sometime during their lives

Usually first appears in childhood or Usually first appears in childhood or adolescenceadolescence

Women are diagnosed more often than men Women are diagnosed more often than men by 2:1 ratioby 2:1 ratio

Various theories have been offered to Various theories have been offered to explain the development of the disorder…explain the development of the disorder…


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GAD: The Sociocultural GAD: The Sociocultural PerspectivePerspective

According to this theory, GAD is most likely to According to this theory, GAD is most likely to develop in people faced with social conditions develop in people faced with social conditions that truly are dangerousthat truly are dangerous Research supports this theory (example: Three Mile Research supports this theory (example: Three Mile

Island in 1979)Island in 1979)

One of the most powerful forms of societal stress One of the most powerful forms of societal stress is povertyis poverty Why? Run-down communities, higher crime rates, fewer Why? Run-down communities, higher crime rates, fewer

educational and job opportunities, and greater risk for educational and job opportunities, and greater risk for health problemshealth problems

As would be predicted by the model, there are higher As would be predicted by the model, there are higher rates of GAD in lower SES groupsrates of GAD in lower SES groups


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Since race is closely tied to income Since race is closely tied to income and job opportunities in the U.S., it and job opportunities in the U.S., it is also tied to the prevalence of GADis also tied to the prevalence of GAD In any given year, ~6% of African In any given year, ~6% of African

Americans and 3.1% of Caucasians Americans and 3.1% of Caucasians suffer from GADsuffer from GAD African American women have highest rates African American women have highest rates

(6.6%)(6.6%)


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Although poverty and other social Although poverty and other social pressures may create a climate for pressures may create a climate for GAD, other factors are clearly at workGAD, other factors are clearly at work How do we know this?How do we know this?

Most people living in dangerous Most people living in dangerous environments environments do notdo not develop GAD develop GAD

Other models attempt to explain why Other models attempt to explain why some people develop the disorder and some people develop the disorder and others do not…others do not…


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GAD: The Psychodynamic GAD: The Psychodynamic PerspectivePerspective

Freud believed that all children experience Freud believed that all children experience anxietyanxiety Realistic anxiety when faced with actual dangerRealistic anxiety when faced with actual danger

Neurotic anxiety when prevented from expressing id Neurotic anxiety when prevented from expressing id impulsesimpulses

Moral anxiety when punished for expressing id Moral anxiety when punished for expressing id impulsesimpulses

One can use ego defense mechanisms to control One can use ego defense mechanisms to control these forms of anxiety, but when they don’t these forms of anxiety, but when they don’t work or when anxiety is too high…GAD developswork or when anxiety is too high…GAD develops


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Today’s psychodynamic theorists often Today’s psychodynamic theorists often disagree with specific aspects of Freud’s disagree with specific aspects of Freud’s explanationexplanation

Researchers have found some support for the Researchers have found some support for the psychodynamic perspective:psychodynamic perspective: People with GAD are particularly likely to use People with GAD are particularly likely to use

defense mechanisms (especially repression) defense mechanisms (especially repression) Children who were severely punished for expressing Children who were severely punished for expressing

id impulses have higher levels of anxiety later in lifeid impulses have higher levels of anxiety later in life

Are these results “proof” of the model’s Are these results “proof” of the model’s validity?validity?


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Not necessarily; there are alternative Not necessarily; there are alternative explanations of the data:explanations of the data: Discomfort with painful memories or Discomfort with painful memories or

“forgetting” in therapy is not necessarily “forgetting” in therapy is not necessarily defensive defensive

Also, some data actually contradict the Also, some data actually contradict the modelmodel Many (if not most) GAD clients report Many (if not most) GAD clients report

normal childhood upbringingsnormal childhood upbringings


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Psychodynamic therapies Psychodynamic therapies Use same general techniques for treating Use same general techniques for treating

all dysfunctionall dysfunction Free associationFree association Therapist interpretationTherapist interpretation

Specific treatments for GADSpecific treatments for GAD Freudians: focus less on fear and more on Freudians: focus less on fear and more on

control of idcontrol of id Object-relations therapists: help patients Object-relations therapists: help patients

identify and settle early relationship conflictsidentify and settle early relationship conflicts


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Psychodynamic therapies Psychodynamic therapies Overall, controlled research has not Overall, controlled research has not

consistently shown that psychodynamic consistently shown that psychodynamic approaches are helpful in treating cases approaches are helpful in treating cases of GADof GAD Short-term dynamic therapy may be Short-term dynamic therapy may be

beneficial in some casesbeneficial in some cases


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GAD: The Humanistic GAD: The Humanistic PerspectivePerspective

Theorists propose that GAD, like other Theorists propose that GAD, like other psychological disorders, arises when people psychological disorders, arises when people stop looking at themselves honestly and stop looking at themselves honestly and acceptinglyacceptingly

This view is best illustrated by Carl Rogers’s This view is best illustrated by Carl Rogers’s explanation:explanation: Lack of “unconditional positive regard” in childhood Lack of “unconditional positive regard” in childhood

leads to “conditions of worth” (harsh self-standards)leads to “conditions of worth” (harsh self-standards)

These threatening self-judgments break through These threatening self-judgments break through and cause anxiety, setting the stage for GAD to and cause anxiety, setting the stage for GAD to developdevelop


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GAD: The Humanistic GAD: The Humanistic PerspectivePerspective

Therapy based on this model is “client-Therapy based on this model is “client-centered” and focuses on creating an centered” and focuses on creating an accepting environment where clients can accepting environment where clients can “experience” themselves“experience” themselves Although case reports have been positive, Although case reports have been positive,

controlled studies have only sometimes found controlled studies have only sometimes found client-centered therapy to be more effective client-centered therapy to be more effective than placebo or no therapythan placebo or no therapy

Only limited support has been found for Only limited support has been found for Rogers’s explanation of causal factorsRogers’s explanation of causal factors


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GAD: The Cognitive GAD: The Cognitive PerspectivePerspective

Theorists believe that psychological Theorists believe that psychological problems are caused by maladaptive problems are caused by maladaptive and dysfunctional thinkingand dysfunctional thinking

Since GAD is characterized by Since GAD is characterized by excessive worry (cognition), this excessive worry (cognition), this model is a good start…model is a good start…


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Theory: GAD is caused by maladaptive Theory: GAD is caused by maladaptive assumptionsassumptions Albert Ellis identified basic irrational assumptions:Albert Ellis identified basic irrational assumptions:

It is necessary for humans to be loved by everyoneIt is necessary for humans to be loved by everyone

It is catastrophic when things are not as one wants them to It is catastrophic when things are not as one wants them to bebe

If something is dangerous, a person should be terribly If something is dangerous, a person should be terribly concerned and dwell on the possibility that it will occurconcerned and dwell on the possibility that it will occur

One should be competent in all domains to be a worthwhile One should be competent in all domains to be a worthwhile personperson

When these assumptions are applied to everyday When these assumptions are applied to everyday life, GAD may developlife, GAD may develop


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Aaron Beck is another cognitive theoristAaron Beck is another cognitive theorist Those with GAD hold unrealistic silent Those with GAD hold unrealistic silent

assumptions that imply imminent danger:assumptions that imply imminent danger: Any strange situation is dangerousAny strange situation is dangerous

A situation/person is unsafe until proven safeA situation/person is unsafe until proven safe

Research supports the presence of these Research supports the presence of these types of assumptions in GAD, particularly types of assumptions in GAD, particularly about dangerousness about dangerousness


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What kinds of people are likely to have What kinds of people are likely to have exaggerated expectations of danger?exaggerated expectations of danger? Those whose lives have been filled with Those whose lives have been filled with

unpredictable negative eventsunpredictable negative events To avoid being “blindsided,” they try to To avoid being “blindsided,” they try to

predict events; they look everywhere for predict events; they look everywhere for danger (and therefore see danger danger (and therefore see danger everywhere)everywhere)

Theory still under investigationTheory still under investigation


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Second-Generation Cognitive ExplanationsSecond-Generation Cognitive Explanations In recent years, two promising explanations have In recent years, two promising explanations have

emerged:emerged: Metacognitive theoryMetacognitive theory

Developed by Wells; holds that the most problematic Developed by Wells; holds that the most problematic assumptions in GAD are the individual’s beliefs about worrying assumptions in GAD are the individual’s beliefs about worrying itselfitself

Avoidance theoryAvoidance theory Developed by Borkovec; holds that worrying serves a “positive” Developed by Borkovec; holds that worrying serves a “positive”

function for those with GAD by reducing unusually high levels function for those with GAD by reducing unusually high levels of bodily arousalof bodily arousal

Both theories have received considerable research Both theories have received considerable research supportsupport


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Two kinds of cognitive therapy:Two kinds of cognitive therapy: Changing maladaptive assumptionsChanging maladaptive assumptions

Based on the work of Ellis and Beck Based on the work of Ellis and Beck

Helping clients understand the special Helping clients understand the special role that worrying plays, and changing role that worrying plays, and changing their views about ittheir views about it


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Cognitive therapies Cognitive therapies Changing maladaptive assumptionsChanging maladaptive assumptions

Ellis’s rational-emotive therapy (RET)Ellis’s rational-emotive therapy (RET) Point out irrational assumptionsPoint out irrational assumptions Suggest more appropriate assumptionsSuggest more appropriate assumptions Assign related homeworkAssign related homework Limited research, but findings are positiveLimited research, but findings are positive

Beck’s cognitive therapyBeck’s cognitive therapy Similar to his depression treatment (see Chapter 9)Similar to his depression treatment (see Chapter 9) Shown to be somewhat helpful in reducing anxiety Shown to be somewhat helpful in reducing anxiety

to tolerable levelsto tolerable levels


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GAD: The Cognitive GAD: The Cognitive Perspective Perspective

Cognitive therapies Cognitive therapies Focusing on worryingFocusing on worrying

Therapists begin with psychoeducation Therapists begin with psychoeducation about worrying and GADabout worrying and GAD

Assign self-monitoring of somatic arousal and Assign self-monitoring of somatic arousal and cognitive responsescognitive responses

As therapy progresses, clients become As therapy progresses, clients become increasingly skilled at identifying their increasingly skilled at identifying their worrying and its counterproductivityworrying and its counterproductivity


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GAD: The Cognitive GAD: The Cognitive Perspective Perspective

Cognitive therapies Cognitive therapies Focusing on worryingFocusing on worrying

With continued practice, clients are With continued practice, clients are expected to see the world as less expected to see the world as less threatening; to adopt more constructive threatening; to adopt more constructive ways of coping; and to worry lessways of coping; and to worry less

Research has begun to indicate that a Research has begun to indicate that a concentrated focus on worrying is a helpful concentrated focus on worrying is a helpful addition to traditional cognitive therapyaddition to traditional cognitive therapy


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GAD: The Biological GAD: The Biological PerspectivePerspective

Theory holds that GAD is caused by Theory holds that GAD is caused by biological factorsbiological factors Supported by family pedigree studiesSupported by family pedigree studies

Blood relatives more likely to have GAD Blood relatives more likely to have GAD (~15%) than general population (~6%)(~15%) than general population (~6%)

The closer the relative, the greater the The closer the relative, the greater the likelihoodlikelihood

Issue of shared environmentIssue of shared environment


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GAD: The GAD: The Biological Biological PerspectivePerspective

GABA inactivityGABA inactivity 1950s – Benzodiazepines (Valium, Xanax) 1950s – Benzodiazepines (Valium, Xanax)

found to reduce anxiety found to reduce anxiety

Why?Why? Neurons have specific receptors (lock and key)Neurons have specific receptors (lock and key)

Benzodiazepine receptors ordinarily receive Benzodiazepine receptors ordinarily receive gamma-aminobutyric acid (GABA, a common NT gamma-aminobutyric acid (GABA, a common NT in the brain)in the brain)

GABA is an inhibitory messenger; when received, it GABA is an inhibitory messenger; when received, it causes a neuron to stop firingcauses a neuron to stop firing


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In the normal fear reaction:In the normal fear reaction: Key neurons fire more rapidly, creating a Key neurons fire more rapidly, creating a

general state of excitability experienced as fear general state of excitability experienced as fear or anxietyor anxiety

A feedback system is triggered; brain and body A feedback system is triggered; brain and body activities work to reduce excitabilityactivities work to reduce excitability

Some neurons release GABA to inhibit neuron firing, Some neurons release GABA to inhibit neuron firing, thereby reducing experience of fear or anxietythereby reducing experience of fear or anxiety

Problems with the feedback system are believed Problems with the feedback system are believed to cause GADto cause GAD

Possible reasons: GABA too low, too few receptors, Possible reasons: GABA too low, too few receptors, ineffective receptorsineffective receptors


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Promising (but problematic) Promising (but problematic) explanation explanation Other NTs also bind to GABA receptorsOther NTs also bind to GABA receptors

Research conducted on lab animals Research conducted on lab animals raises question: is “fear” really fear?raises question: is “fear” really fear?

Issue of causal relationshipsIssue of causal relationships Do physiological events CAUSE anxiety? How Do physiological events CAUSE anxiety? How

can we know? What are alternative can we know? What are alternative explanations?explanations?


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GAD: The Biological GAD: The Biological PerspectivePerspective

Biological treatments Biological treatments Antianxiety drugsAntianxiety drugs

Pre-1950s: barbiturates (sedative-hypnotics)Pre-1950s: barbiturates (sedative-hypnotics) Post-1950s: benzodiazepinesPost-1950s: benzodiazepines

Provide temporary, modest reliefProvide temporary, modest relief Rebound anxiety with withdrawal and cessation of useRebound anxiety with withdrawal and cessation of use Physical dependence is possiblePhysical dependence is possible Undesirable effects (drowsiness, etc.)Undesirable effects (drowsiness, etc.) Multiply effects of other drugs (especially alcohol)Multiply effects of other drugs (especially alcohol)

1980s: buspirone (BuSpar)1980s: buspirone (BuSpar) Different receptors, same effectiveness, fewer Different receptors, same effectiveness, fewer

problemsproblems


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GAD: The Biological GAD: The Biological Perspective Perspective

Biological treatments Biological treatments Relaxation trainingRelaxation training

Theory: physical relaxation leads to Theory: physical relaxation leads to psychological relaxationpsychological relaxation

Research indicates that relaxation training Research indicates that relaxation training is more effective than placebo or no is more effective than placebo or no treatmenttreatment

Best when used in combination with Best when used in combination with cognitive therapy or biofeedbackcognitive therapy or biofeedback


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GAD: The Biological GAD: The Biological Perspective Perspective

Biological treatments Biological treatments BiofeedbackBiofeedback

Therapist uses electrical signals from the body to Therapist uses electrical signals from the body to train people to control physiological processestrain people to control physiological processes

Electromyograph (EMG) is the most widely used; Electromyograph (EMG) is the most widely used; provides feedback about muscle tensionprovides feedback about muscle tension

Found to be most effective when used as an Found to be most effective when used as an adjunct to other methods for the treatment adjunct to other methods for the treatment of certain medical problems (headache, of certain medical problems (headache, back pain, etc.)back pain, etc.)


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PhobiasPhobias

From the Greek word for “fear”From the Greek word for “fear” Formal names are also often from the Formal names are also often from the

Greek (see Box 5-2)Greek (see Box 5-2)

Persistent and unreasonable fears of Persistent and unreasonable fears of particular objects, activities, or particular objects, activities, or situationssituations

Phobic people often avoid the object Phobic people often avoid the object or thoughts about itor thoughts about it


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PhobiasPhobias

We all have some fears at some We all have some fears at some points in our lives; this is a normal points in our lives; this is a normal and common experienceand common experience How do phobias differ from these How do phobias differ from these

“normal” experiences?“normal” experiences? More intense fearMore intense fear

Greater desire to avoid the feared object or Greater desire to avoid the feared object or situationsituation

Distress that interferes with functioningDistress that interferes with functioning


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PhobiasPhobias

Most phobias are categorized as Most phobias are categorized as “specific”“specific” Also two broader kinds: Also two broader kinds:

Social phobia Social phobia

Agoraphobia Agoraphobia


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Specific PhobiasSpecific Phobias

Persistent fears of specific objects or Persistent fears of specific objects or situationssituations

When exposed to the object or When exposed to the object or situation, sufferers experience situation, sufferers experience immediate fearimmediate fear

Most common: phobias of specific Most common: phobias of specific animals or insects, heights, enclosed animals or insects, heights, enclosed spaces, thunderstorms, and bloodspaces, thunderstorms, and blood


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Specific PhobiasSpecific Phobias

~9% of the U.S. population have ~9% of the U.S. population have symptoms in any given yearsymptoms in any given year ~12% develop a specific phobia at some ~12% develop a specific phobia at some

point in their livespoint in their lives Many suffer from more than one phobia Many suffer from more than one phobia

at a timeat a time Women outnumber men 2:1Women outnumber men 2:1 Prevalence differs across racial and Prevalence differs across racial and

ethnic minority groups ethnic minority groups Vast majority do NOT seek treatmentVast majority do NOT seek treatment


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Social PhobiasSocial Phobias

Severe, persistent, and unreasonable Severe, persistent, and unreasonable fears of social or performance situations fears of social or performance situations in which embarrassment may occurin which embarrassment may occur May be May be narrownarrow – – talking, performing, talking, performing,

eating, or writing in publiceating, or writing in public May be May be broadbroad – – general fear of functioning general fear of functioning

inadequately in front of othersinadequately in front of others In both cases, people rate themselves as In both cases, people rate themselves as

performing less adequately than they performing less adequately than they actually didactually did


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Social PhobiasSocial Phobias

Can greatly interfere with Can greatly interfere with functioningfunctioning Often kept a secretOften kept a secret

Affect ~7% of U.S. population in any Affect ~7% of U.S. population in any given yeargiven year

Women outnumber men 3:2Women outnumber men 3:2 Often begin in childhood and may Often begin in childhood and may

persist for many yearspersist for many years


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What Causes Phobias?What Causes Phobias?

Each model offers explanations, but Each model offers explanations, but evidence tends to support the evidence tends to support the behavioral explanations:behavioral explanations:

Phobias develop through conditioningPhobias develop through conditioning Once fears are acquired, they are Once fears are acquired, they are

continued because feared objects are continued because feared objects are avoidedavoided

Behaviorists propose a classical Behaviorists propose a classical conditioning model…conditioning model…


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Classical Conditioning of Classical Conditioning of PhobiaPhobia

UCR

Fear

UCR

Fear

UCS

Entrapment

Running

water

CS

Running water

CR

Fear

+UCS

Entrapment


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Other behavioral explanations Other behavioral explanations Phobias develop through modelingPhobias develop through modeling

Observation and imitationObservation and imitation

Phobias are maintained through avoidancePhobias are maintained through avoidance

Phobias may develop into GAD when a Phobias may develop into GAD when a person acquires a large number of phobiasperson acquires a large number of phobias

Process of stimulus generalization: responses Process of stimulus generalization: responses to one stimulus are also elicited by similar to one stimulus are also elicited by similar stimulistimuli


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Behavioral explanations have received some Behavioral explanations have received some empirical support:empirical support: Classical conditioning study involving Little Classical conditioning study involving Little

AlbertAlbert

Modeling studiesModeling studies

Bandura, confederates, buzz, and shockBandura, confederates, buzz, and shock

Research conclusion is that phobias CAN be Research conclusion is that phobias CAN be acquired in these ways, but there is no acquired in these ways, but there is no evidence that this is how the disorder is evidence that this is how the disorder is ordinarily acquiredordinarily acquired


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A behavioral-evolutionary A behavioral-evolutionary explanationexplanation Some phobias are much more common Some phobias are much more common

than others…than others…


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A behavioral-evolutionary explanationA behavioral-evolutionary explanation Theorists argue that there is a species-specific Theorists argue that there is a species-specific

biological biological predispositionpredisposition to develop certain to develop certain fearsfears

Called “preparedness”: humans are more Called “preparedness”: humans are more “prepared” to develop phobias around certain “prepared” to develop phobias around certain objects or situationsobjects or situations

Model explains why some phobias (snakes, heights) Model explains why some phobias (snakes, heights) are more common than others (grass, meat)are more common than others (grass, meat)

Unknown if these predispositions are due to evolutionary Unknown if these predispositions are due to evolutionary or environmental factorsor environmental factors


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How Are Phobias How Are Phobias Treated?Treated?

Surveys reveal that ~19% of those with Surveys reveal that ~19% of those with specific phobia and 25% of those with social specific phobia and 25% of those with social phobia currently are in treatmentphobia currently are in treatment

Each model offers treatment approachesEach model offers treatment approaches Behavioral techniques (exposure treatments) are Behavioral techniques (exposure treatments) are

most widely used, especially for most widely used, especially for specific phobiasspecific phobias Shown to be highly effectiveShown to be highly effective

Fare better in head-to-head comparisons than other Fare better in head-to-head comparisons than other approachesapproaches

Include desensitization, flooding, and modelingInclude desensitization, flooding, and modeling


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Treatments for Specific Treatments for Specific PhobiasPhobias

Systematic desensitizationSystematic desensitization Technique developed by Joseph WolpeTechnique developed by Joseph Wolpe

Teach relaxation skillsTeach relaxation skills Create fear hierarchyCreate fear hierarchy Sufferers learn to relax while facing feared objectsSufferers learn to relax while facing feared objects

Since relaxation is incompatible with fear, the Since relaxation is incompatible with fear, the relaxation response is thought to substitute for the relaxation response is thought to substitute for the fear responsefear response

Several types:Several types: In vivoIn vivo desensitization (live) desensitization (live) Covert desensitization (imaginal)Covert desensitization (imaginal)


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Treatments for Specific Treatments for Specific PhobiasPhobias

Other behavioral treatments:Other behavioral treatments: FloodingFlooding

Forced nongradual exposure Forced nongradual exposure

ModelingModeling Therapist confronts the feared object while the fearful Therapist confronts the feared object while the fearful

person observesperson observes

Clinical research supports each of these Clinical research supports each of these treatmentstreatments The key to success is ACTUAL contact with the The key to success is ACTUAL contact with the

feared object or situationfeared object or situation


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Treatments for Social Treatments for Social PhobiasPhobias

Treatments only recently successfulTreatments only recently successful Two components must be addressed:Two components must be addressed:

Overwhelming social fearOverwhelming social fear Address fears behaviorally with exposureAddress fears behaviorally with exposure

Lack of social skillsLack of social skills Social skills and assertiveness trainings have Social skills and assertiveness trainings have

proved helpfulproved helpful


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Unlike specific phobias, social phobias Unlike specific phobias, social phobias respond well to medication (particularly respond well to medication (particularly antidepression drugs)antidepression drugs)

Several types of psychotherapy have proved Several types of psychotherapy have proved at least as effective as medicationat least as effective as medication People treated with psychotherapy are less likely People treated with psychotherapy are less likely

to relapse than people treated with drugs aloneto relapse than people treated with drugs alone

One psychological approach is exposure therapy, One psychological approach is exposure therapy, either in an individual or group settingeither in an individual or group setting

Cognitive therapies have also been widely usedCognitive therapies have also been widely used


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Another treatment option is social skills Another treatment option is social skills training, a combination of several training, a combination of several behavioral techniques to help people behavioral techniques to help people improve their social functioningimprove their social functioning Therapist provides feedback and reinforcementTherapist provides feedback and reinforcement

No single treatment approach is No single treatment approach is consistently helpful or superior to the consistently helpful or superior to the othersothers Results from using a combination of approaches Results from using a combination of approaches

seem to be most encouragingseem to be most encouraging


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Panic DisorderPanic Disorder

Panic, an extreme anxiety reaction, can Panic, an extreme anxiety reaction, can result when a real threat suddenly emergesresult when a real threat suddenly emerges

The experience of “panic attacks,” however, The experience of “panic attacks,” however, is differentis different Panic attacks are periodic, short bouts of panic Panic attacks are periodic, short bouts of panic

that occur suddenly, reach a peak, and passthat occur suddenly, reach a peak, and pass Sufferers often fear they will die, go crazy, or Sufferers often fear they will die, go crazy, or

lose controllose control Attacks happen in the absence of a real threatAttacks happen in the absence of a real threat


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Anyone can experience a panic attack, Anyone can experience a panic attack, but some people have panic attacks but some people have panic attacks repeatedlyrepeatedly, , unexpectedlyunexpectedly, and , and without without apparent reasonapparent reason Diagnosis: panic disorderDiagnosis: panic disorder

Sufferers also experience dysfunctional changes Sufferers also experience dysfunctional changes in thinking and behavior as a result of the attacksin thinking and behavior as a result of the attacks

Example: sufferer worries persistently about having an Example: sufferer worries persistently about having an attack; plans behavior around possibility of future attack; plans behavior around possibility of future attackattack


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Often (but not always) accompanied by Often (but not always) accompanied by agoraphobia agoraphobia From the Greek “fear of the marketplace”From the Greek “fear of the marketplace”

Afraid to leave home and travel to locations Afraid to leave home and travel to locations from which escape might be difficult or help from which escape might be difficult or help unavailableunavailable

Intensity may fluctuateIntensity may fluctuate

There has only recently been a recognition of There has only recently been a recognition of the link between agoraphobia and panic the link between agoraphobia and panic attacks (or panic-like symptoms)attacks (or panic-like symptoms)


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Two diagnoses: panic disorder with Two diagnoses: panic disorder with agoraphobia; panic disorder without agoraphobia; panic disorder without agoraphobiaagoraphobia ~3% of U.S. population affected in a given year~3% of U.S. population affected in a given year ~5% of U.S. population affected at some point in their ~5% of U.S. population affected at some point in their

liveslives

Likely to develop in late adolescence and early Likely to develop in late adolescence and early adulthoodadulthood

Women are twice as likely as men to be affectedWomen are twice as likely as men to be affected Approximately 35% of those with panic disorder Approximately 35% of those with panic disorder

are in treatmentare in treatment


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Panic Disorder: Panic Disorder: The Biological PerspectiveThe Biological Perspective

In the 1960s, it was recognized that In the 1960s, it was recognized that people with panic disorder were not people with panic disorder were not helped by benzodiazepines, but were helped by benzodiazepines, but were helped by antidepressantshelped by antidepressants Researchers worked backward from Researchers worked backward from

their understanding of antidepressant their understanding of antidepressant drugsdrugs


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What biological factors contribute to panic What biological factors contribute to panic disorder?disorder? NT at work is norepinephrineNT at work is norepinephrine

Irregular in people with panic attacksIrregular in people with panic attacks

Research suggests that panic reactions are related to Research suggests that panic reactions are related to changes in norepinephrine activity in the locus ceruleuschanges in norepinephrine activity in the locus ceruleus

Although norepinephrine is clearly linked to panic Although norepinephrine is clearly linked to panic disorder, what goes wrong isn’t exactly understooddisorder, what goes wrong isn’t exactly understood

May be excessive activity, deficient activity, or some other May be excessive activity, deficient activity, or some other defectdefect

Other NTs and brain circuits seem to be involvedOther NTs and brain circuits seem to be involved


Chapter 5Chapter 5


It is also unclear why some people have It is also unclear why some people have such abnormalities in norepinephrine such abnormalities in norepinephrine activityactivity Inherited biological predisposition is one Inherited biological predisposition is one

possible reasonpossible reason If so, prevalence should be (and is) greater If so, prevalence should be (and is) greater

among close relativesamong close relatives Among monozygotic (MZ, or identical) twins = 24%Among monozygotic (MZ, or identical) twins = 24%

Among dizygotic (DZ, or fraternal) twins = 11%Among dizygotic (DZ, or fraternal) twins = 11%

Issue is still open to debateIssue is still open to debate


Chapter 5Chapter 5

Panic Disorder:Panic Disorder:The Biological PerspectiveThe Biological Perspective

Drug therapiesDrug therapies Antidepressants are effective at preventing or Antidepressants are effective at preventing or

reducing panic attacksreducing panic attacks Function at norepinephrine receptors in the panic Function at norepinephrine receptors in the panic

brain circuitbrain circuit Bring at least some improvement to 80% of patients Bring at least some improvement to 80% of patients

with panic disorderwith panic disorder ~50% recover markedly or fully~50% recover markedly or fully

Require maintenance of drug therapy; otherwise Require maintenance of drug therapy; otherwise relapse rates are highrelapse rates are high

Some benzodiazepines (especially Xanax Some benzodiazepines (especially Xanax [alprazolam]) have also proved helpful[alprazolam]) have also proved helpful


Chapter 5Chapter 5


Drug therapiesDrug therapies Both antidepressants and benzodiazepines are Both antidepressants and benzodiazepines are

also helpful in treating panic disorder with also helpful in treating panic disorder with agoraphobia agoraphobia

Break the cycle of attack, anticipation, and fearBreak the cycle of attack, anticipation, and fear

It is important to note that when drug It is important to note that when drug therapy is stopped, symptoms may returntherapy is stopped, symptoms may return Combination treatment (medications + Combination treatment (medications +

behavioral exposure therapy) may be more behavioral exposure therapy) may be more effective than either treatment aloneeffective than either treatment alone


Chapter 5Chapter 5

Panic Disorder: Panic Disorder: The Cognitive PerspectiveThe Cognitive Perspective

Cognitive theorists and practitioners Cognitive theorists and practitioners recognize that biological factors are recognize that biological factors are only part of the cause of panic only part of the cause of panic attacksattacks In their view, full panic reactions are In their view, full panic reactions are

experienced only by people who experienced only by people who misinterpretmisinterpret bodily events bodily events

Cognitive treatment is aimed at Cognitive treatment is aimed at correcting such misinterpretationscorrecting such misinterpretations


Chapter 5Chapter 5


Misinterpreting bodily sensationsMisinterpreting bodily sensations Panic-prone people may be overly sensitive to Panic-prone people may be overly sensitive to

certain bodily sensations and may misinterpret them certain bodily sensations and may misinterpret them as signs of a medical catastrophe; this leads to panic as signs of a medical catastrophe; this leads to panic

Why might some people be prone to such Why might some people be prone to such misinterpretations?misinterpretations?

Experience more frequent or intense bodily Experience more frequent or intense bodily sensationssensations

Poor coping skillsPoor coping skills Lack of social supportLack of social support Unpredictable childhoodsUnpredictable childhoods Overly protective parentsOverly protective parents


Chapter 5Chapter 5


Misinterpreting bodily sensationsMisinterpreting bodily sensations Panic-prone people have a high degree of Panic-prone people have a high degree of

“anxiety sensitivity”“anxiety sensitivity” They focus on bodily sensations much of the time, They focus on bodily sensations much of the time,

are unable to assess the sensations logically, and are unable to assess the sensations logically, and interpret them as potentially harmfulinterpret them as potentially harmful

Examples include: overbreathing or Examples include: overbreathing or hyperventilation, excitement, fullness in the hyperventilation, excitement, fullness in the abdomen, acute anger, and heart “palpitations”abdomen, acute anger, and heart “palpitations”


Chapter 5Chapter 5


Cognitive therapyCognitive therapy Attempts to correct people’s misinterpretations Attempts to correct people’s misinterpretations

of their bodily sensationsof their bodily sensations Step 1: Educate clientsStep 1: Educate clients

About panic in generalAbout panic in general About the causes of bodily sensationsAbout the causes of bodily sensations About their tendency to misinterpret the sensationsAbout their tendency to misinterpret the sensations

Step 2: Teach clients to apply more accurate Step 2: Teach clients to apply more accurate interpretations (especially when stressed)interpretations (especially when stressed)

Step 3: Teach clients skills for coping with anxietyStep 3: Teach clients skills for coping with anxiety Examples: relaxation, breathingExamples: relaxation, breathing


Chapter 5Chapter 5


Cognitive therapyCognitive therapy May also use “biological challenge” May also use “biological challenge”

procedures to induce panic sensationsprocedures to induce panic sensations Induce physical sensations which cause Induce physical sensations which cause

feelings of panic:feelings of panic: Jump up and down Jump up and down

Run up a flight of stepsRun up a flight of steps

Practice coping strategies and making more Practice coping strategies and making more accurate interpretationsaccurate interpretations


Chapter 5Chapter 5


Cognitive therapy is often helpful in panic Cognitive therapy is often helpful in panic disorderdisorder 85% of treated patients are panic-free for two 85% of treated patients are panic-free for two

years compared with 13% of control subjectsyears compared with 13% of control subjects

Only sometimes helpful for panic disorder with Only sometimes helpful for panic disorder with agoraphobiaagoraphobia

At least as helpful as antidepressantsAt least as helpful as antidepressants

Combination therapy may be most effectiveCombination therapy may be most effective Still under investigationStill under investigation


Chapter 5Chapter 5

Obsessive-Compulsive Obsessive-Compulsive DisorderDisorder

Made up of two components:Made up of two components: ObsessionsObsessions

Persistent thoughts, ideas, impulses, or Persistent thoughts, ideas, impulses, or images that seem to invade a person’s images that seem to invade a person’s consciousnessconsciousness

CompulsionsCompulsions Repeated and rigid behaviors or mental acts Repeated and rigid behaviors or mental acts

that people feel they must perform to that people feel they must perform to prevent or reduce anxietyprevent or reduce anxiety


Chapter 5Chapter 5


Diagnosis may be called for when Diagnosis may be called for when symptoms:symptoms: Feel excessive or unreasonableFeel excessive or unreasonable

Cause great distressCause great distress

Consume considerable timeConsume considerable time

Interfere with daily functionsInterfere with daily functions


Chapter 5Chapter 5


Chapter 5Chapter 5


Classified as an anxiety disorder because Classified as an anxiety disorder because obsessions cause anxiety, while compulsions obsessions cause anxiety, while compulsions are aimed at preventing or reducing anxietyare aimed at preventing or reducing anxiety Anxiety rises if obsessions or compulsions are Anxiety rises if obsessions or compulsions are

avoidedavoided

~2% of U.S. population has OCD in a given ~2% of U.S. population has OCD in a given year; between 2% and 3% over a lifetimeyear; between 2% and 3% over a lifetime

Ratio of women to men is 1:1Ratio of women to men is 1:1 It is estimated that more than 40% of those It is estimated that more than 40% of those

with OCD seek treatmentwith OCD seek treatment


Chapter 5Chapter 5

What Are the Features of What Are the Features of Obsessions and Obsessions and Compulsions?Compulsions?

ObsessionsObsessions Thoughts that feel intrusive and foreignThoughts that feel intrusive and foreign

Attempts to ignore or avoid them Attempts to ignore or avoid them trigger anxietytrigger anxiety Take various Take various

forms:forms: WishesWishes

ImpulsesImpulses

ImagesImages

IdeasIdeas

DoubtsDoubts

Have common themes:Have common themes: Dirt/contaminationDirt/contamination

Violence and Violence and aggressionaggression

OrderlinessOrderliness

ReligionReligion

SexualitySexuality


Chapter 5Chapter 5


CompulsionsCompulsions ““Voluntary” behaviors or mental actsVoluntary” behaviors or mental acts

Feel mandatory/unstoppableFeel mandatory/unstoppable

Person may recognize that behaviors are Person may recognize that behaviors are irrationalirrational

Believe, though, that catastrophe will occur if Believe, though, that catastrophe will occur if they don’t perform the compulsive actsthey don’t perform the compulsive acts

Performing behaviors reduces anxiety Performing behaviors reduces anxiety ONLY FOR A SHORT TIME!ONLY FOR A SHORT TIME!

Behaviors often develop into Behaviors often develop into ritualsrituals


Chapter 5Chapter 5


CompulsionsCompulsions Common forms/themes:Common forms/themes:

CleaningCleaning

CheckingChecking

Order or balanceOrder or balance

Touching, verbal, and/or countingTouching, verbal, and/or counting


Chapter 5Chapter 5


Are obsessions and compulsions Are obsessions and compulsions related?related? Most (not all) people with OCD experience Most (not all) people with OCD experience

bothboth

Compulsive acts often occur in response to Compulsive acts often occur in response to obsessive thoughtsobsessive thoughts

Compulsions seem to represent a Compulsions seem to represent a yieldingyielding to to obsessionsobsessions

Compulsions also sometimes serve to help Compulsions also sometimes serve to help controlcontrol obsessions obsessions


Chapter 5Chapter 5


Are obsessions and compulsions Are obsessions and compulsions related?related? Many with OCD are concerned that they Many with OCD are concerned that they

will act on their obsessionswill act on their obsessions Most of these concerns are unfoundedMost of these concerns are unfounded

Compulsions usually do not lead to violence Compulsions usually do not lead to violence or “immoral acts”or “immoral acts”


Chapter 5Chapter 5


OCD was once among the least OCD was once among the least understood of the psychological understood of the psychological disordersdisorders

In recent years, however, researchers In recent years, however, researchers have begun to learn more about ithave begun to learn more about it

The most influential explanations are The most influential explanations are from the psychodynamic, behavioral, from the psychodynamic, behavioral, cognitive, and biological models…cognitive, and biological models…


Chapter 5Chapter 5

OCD: OCD: The Psychodynamic The Psychodynamic

PerspectivePerspective Anxiety disorders develop when children Anxiety disorders develop when children

come to fear their id impulses and use ego come to fear their id impulses and use ego defense mechanisms to lessen their anxietydefense mechanisms to lessen their anxiety

OCD differs from anxiety disorders in that the OCD differs from anxiety disorders in that the “battle” is not unconscious; it is played out in “battle” is not unconscious; it is played out in explicit thoughts and actionexplicit thoughts and action Id impulses = obsessive thoughtsId impulses = obsessive thoughts Ego defenses = counter-thoughts or compulsive Ego defenses = counter-thoughts or compulsive

actionsactions At its core, OCD is related to aggressive impulses At its core, OCD is related to aggressive impulses

and the competing need to control themand the competing need to control them


Chapter 5Chapter 5


PerspectivePerspective The battle between the id and the egoThe battle between the id and the ego

Three ego defenses mechanisms are common:Three ego defenses mechanisms are common: Isolation: disown disturbing thoughtsIsolation: disown disturbing thoughts

Undoing: perform acts to “cancel out” thoughtsUndoing: perform acts to “cancel out” thoughts

Reaction formation: take on lifestyle in contrast to Reaction formation: take on lifestyle in contrast to unacceptable impulsesunacceptable impulses

Freud believed that OCD was related to the Freud believed that OCD was related to the anal stage of developmentanal stage of development

Period of intense conflict between id and egoPeriod of intense conflict between id and ego

Not all psychodynamic theorists agreeNot all psychodynamic theorists agree


Chapter 5Chapter 5


PerspectivePerspective Psychodynamic therapiesPsychodynamic therapies

Goals are to uncover and overcome Goals are to uncover and overcome underlying conflicts and defensesunderlying conflicts and defenses

Main techniques are free association Main techniques are free association and interpretationand interpretation

Research evidence is poorResearch evidence is poor Some therapists now prefer to treat these Some therapists now prefer to treat these

patients with short-term psychodynamic patients with short-term psychodynamic therapiestherapies


Chapter 5Chapter 5

OCD: The Behavioral OCD: The Behavioral PerspectivePerspective

Behaviorists concentrate on Behaviorists concentrate on explaining and treating compulsions explaining and treating compulsions rather than obsessionsrather than obsessions

Although the behavioral explanation Although the behavioral explanation of OCD has received little support, of OCD has received little support, behavioral treatments for behavioral treatments for compulsive behaviors have been compulsive behaviors have been very successfulvery successful


Chapter 5Chapter 5


Learning by chanceLearning by chance People happen upon compulsions randomly:People happen upon compulsions randomly:

In a fearful situation, they happen to perform a In a fearful situation, they happen to perform a particular act (washing hands)particular act (washing hands)

When the threat lifts, they associate the When the threat lifts, they associate the improvement with the random actimprovement with the random act

After repeated associations, they believe the After repeated associations, they believe the compulsion is changing the situationcompulsion is changing the situation

Bringing luck, warding away evil, etc.Bringing luck, warding away evil, etc.

The act becomes a key method to avoiding or The act becomes a key method to avoiding or reducing anxietyreducing anxiety


Chapter 5Chapter 5


Key investigator: Stanley RachmanKey investigator: Stanley Rachman Compulsions do appear to be rewarded Compulsions do appear to be rewarded

by an eventual decrease in anxietyby an eventual decrease in anxiety Studies provide no evidence of the Studies provide no evidence of the learninglearning

of compulsionsof compulsions


Chapter 5Chapter 5


Behavioral therapyBehavioral therapy Exposure and response prevention (ERP)Exposure and response prevention (ERP)

Clients are repeatedly exposed to anxiety-provoking Clients are repeatedly exposed to anxiety-provoking stimuli and prevented from responding with compulsionsstimuli and prevented from responding with compulsions

Therapists often model the behavior while the client Therapists often model the behavior while the client watcheswatches

Homework is an important componentHomework is an important component Treatment is offered in individual and group settingsTreatment is offered in individual and group settings Treatment provides significant, long-lasting Treatment provides significant, long-lasting

improvements for most patientsimprovements for most patients However, as many as 25% fail to improve at all and the However, as many as 25% fail to improve at all and the

approach is of limited help to those with obsessions but no approach is of limited help to those with obsessions but no compulsionscompulsions


Chapter 5Chapter 5

OCD: The Cognitive OCD: The Cognitive PerspectivePerspective

Cognitive theory begins by pointing Cognitive theory begins by pointing out that everyone has repetitive, out that everyone has repetitive, unwanted, and intrusive thoughtsunwanted, and intrusive thoughts People with OCD blame themselves for People with OCD blame themselves for

normal (although repetitive and normal (although repetitive and intrusive) thoughts and expect that intrusive) thoughts and expect that terrible things will happen as a resultterrible things will happen as a result


Chapter 5Chapter 5


Overreacting to unwanted thoughtsOverreacting to unwanted thoughts To avoid such negative outcomes, they attempt To avoid such negative outcomes, they attempt

to neutralize their thoughts with actions (or to neutralize their thoughts with actions (or other thoughts)other thoughts)

Neutralizing thoughts/actions may include:Neutralizing thoughts/actions may include:

Seeking reassuranceSeeking reassurance

Thinking “good” thoughtsThinking “good” thoughts

WashingWashing

CheckingChecking


Chapter 5Chapter 5


When a neutralizing action reduces When a neutralizing action reduces anxiety, it is reinforcedanxiety, it is reinforced Client becomes more convinced that the Client becomes more convinced that the

thoughts are dangerousthoughts are dangerous

As fear of thoughts increases, the As fear of thoughts increases, the number of thoughts increasesnumber of thoughts increases


Chapter 5Chapter 5


If everyone has intrusive thoughts, why If everyone has intrusive thoughts, why do only some people develop OCD?do only some people develop OCD? People with OCD tend:People with OCD tend:

To be more depressed than othersTo be more depressed than others To have higher standards of morality and To have higher standards of morality and

conductconduct To believe thoughts are equal to actions and To believe thoughts are equal to actions and

are capable of bringing harmare capable of bringing harm To believe that they can and should have To believe that they can and should have

perfect control over their thoughts and perfect control over their thoughts and behaviorsbehaviors


Chapter 5Chapter 5


Cognitive therapiesCognitive therapies Focus on the cognitive processes that Focus on the cognitive processes that

help to produce and maintain obsessive help to produce and maintain obsessive thoughts and compulsive actsthoughts and compulsive acts

May include:May include: PsychoeducationPsychoeducation

Habituation trainingHabituation training


Chapter 5Chapter 5


Cognitive-Behavioral Therapy (CBT)Cognitive-Behavioral Therapy (CBT) Research suggests that a combination Research suggests that a combination

of the cognitive and behavioral models of the cognitive and behavioral models often is more effective than either often is more effective than either intervention aloneintervention alone

These treatments typically include These treatments typically include psychoeducation and exposure and psychoeducation and exposure and response prevention exercisesresponse prevention exercises


Chapter 5Chapter 5

OCD: The Biological OCD: The Biological PerspectivePerspective

Family pedigree studies provided Family pedigree studies provided the first clues that OCD may be the first clues that OCD may be linked in part to biological factorslinked in part to biological factors Studies of twins found a 53% Studies of twins found a 53%

concordance rate in identical twins concordance rate in identical twins versus 23% in fraternal twinsversus 23% in fraternal twins

Currently, more direct genetic studies Currently, more direct genetic studies are being conducted to try to pinpoint are being conducted to try to pinpoint the cause of the genetic predispositionthe cause of the genetic predisposition


Chapter 5Chapter 5


Two additional lines of research:Two additional lines of research: Role of NT serotoninRole of NT serotonin

Evidence that serotonin-based antidepressants reduce Evidence that serotonin-based antidepressants reduce OCD symptomsOCD symptoms

Brain abnormalitiesBrain abnormalities OCD linked to orbital region of frontal cortex and caudate OCD linked to orbital region of frontal cortex and caudate

nucleinuclei

Frontal cortex and caudate nuclei compose brain Frontal cortex and caudate nuclei compose brain circuit that converts sensory information into circuit that converts sensory information into thoughts and actionsthoughts and actions

Either area may be too active, letting through Either area may be too active, letting through troublesome thoughts and actionstroublesome thoughts and actions


Chapter 5Chapter 5


Some research provides evidence Some research provides evidence that these two lines may be that these two lines may be connectedconnected Serotonin plays a very active role in the Serotonin plays a very active role in the

operation of the orbital region and the operation of the orbital region and the caudate nucleicaudate nuclei Low serotonin activity might interfere with Low serotonin activity might interfere with

the proper functioning of these brain partsthe proper functioning of these brain parts


Chapter 5Chapter 5


Biological therapiesBiological therapies Serotonin-based antidepressantsSerotonin-based antidepressants

clomipramine (Anafranil), fluoxetine (Prozac), clomipramine (Anafranil), fluoxetine (Prozac), fluvoxaminefluvoxamine

Bring improvement to 50%Bring improvement to 50%––80% of those with OCD80% of those with OCD

Relapse occurs if medication is stoppedRelapse occurs if medication is stopped

Research suggests that combination therapy Research suggests that combination therapy (medication + cognitive behavioral therapy (medication + cognitive behavioral therapy approaches) may be most effectiveapproaches) may be most effective

May have same effect on the brainMay have same effect on the brain

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