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