Chapter 5 Anxiety Disorders

Chapter 5 Anxiety Disorders
Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University

Anxiety What distinguishes fear from anxiety?
Fear is a state of immediate alarm in response to a serious, known threat to one’s well-being Anxiety is a state of alarm in response to a vague sense of threat or danger Both have the same physiological features: increase in respiration, perspiration, muscle tension, etc.

Anxiety Is the fear/anxiety response useful/adaptive?
Yes, when the fight or flight response is protective No, when it is triggered by “inappropriate” situations, or when it is too severe or long-lasting, this response can be disabling Can lead to the development of anxiety disorders

Anxiety Disorders Most common mental disorders in the U.S.
In any given year, 19% of the adult population in the U.S. experience one or another of the six DSM-IV anxiety disorders Most individuals with one anxiety disorder suffer from a second as well Anxiety disorders cost $42 billion each year in health care, lost wages, and lost productivity

Anxiety Disorders Six disorders: Generalized anxiety disorder (GAD)
Phobias Panic disorder Obsessive-compulsive disorder (OCD) Acute stress disorder Post-traumatic stress disorder (PTSD)

Generalized Anxiety Disorder (GAD)
Characterized by excessive anxiety under most circumstances and worry about practically anything Vague, intense concerns and fearfulness Often called “free-floating” anxiety “Danger” not a factor Symptoms include restlessness, easy fatigue, irritability, muscle tension, and/or sleep disturbance Symptoms last at least six months

Generalized Anxiety Disorder (GAD)
Symptoms are often misunderstood by others Sufferers are accused of “looking for” worries The disorder is common in Western society Affects ~4% of U.S. and ~3% of Britain’s population Usually first appears in childhood or adolescence Women are diagnosed more often than men by 2:1 ratio Various theories have been offered to explain the development of the disorder…

GAD: The Sociocultural Perspective
GAD is most likely to develop in people faced with social conditions that are truly dangerous Research supports this theory (example: Three Mile Island in 1979) One of the most powerful forms of societal stress is poverty Why? Run-down communities, higher crime rates, fewer educational and job opportunities, and greater risk for health problems As would be predicted by the model, rates of GAD are higher in lower SES groups

Since race is closely tied to income and job opportunities in the U.S., it is also tied to the prevalence of GAD In any given year, about 6% of African Americans vs. 3.5% of Caucasians suffer from GAD African American women have highest rates (6.6%)

Although poverty and other social pressures may create a climate for GAD, other factors are clearly at work How do we know this? Most people living in dangerous environments do not develop GAD Other models attempt to explain why some people develop the disorder and others do not…

GAD: The Psychodynamic Perspective
Freud believed that all children experience anxiety Realistic anxiety when faced with actual danger Neurotic anxiety when prevented from expressing id impulses Moral anxiety when punished for expressing id impulses One can use ego defense mechanisms to control these forms of anxiety, but when they don’t work…GAD develops!

Some research does support the psychodynamic perspective: People use defense mechanisms (especially repression) when faced with danger People with GAD are particularly likely to use defense mechanisms Children who were severely punished for expressing id impulses have higher levels of anxiety later in life Are these results “proof” of the model’s validity?

Not necessarily; there are alternative explanations of the data: Discomfort with painful memories or “forgetting” in therapy is not necessarily defensive Non-anxious people faced with threats may use repression Some data contradict the model Many (if not most) GAD clients report normal childhood upbringings

Psychodynamic therapies Use same general techniques for treating all dysfunction Free association Therapist interpretation Specific treatments for GAD Freudians: focus less on fear and more on control of id Object-relations: help patients identify and settle early relationship conflicts

Psychodynamic therapies Overall, controlled research has not consistently shown psychodynamic approaches to be helpful in treating cases of GAD Short-term dynamic therapy may be beneficial in some cases

GAD: The Humanistic Perspective
Theorists propose that GAD, like other psychological disorders, arises when people stop looking at themselves honestly and acceptingly This view is best illustrated by Carl Rogers’s explanation: Lack of “unconditional positive regard” in childhood leads to “conditions of worth” (harsh self-standards) These threatening self-judgments break through and cause anxiety, setting the stage for GAD to develop

GAD: The Humanistic Perspective
Therapy based on this model is “client-centered” and focuses on creating an accepting environment where clients can “experience” themselves Although case reports have been positive, controlled studies have only sometimes found client-centered therapy to be more effective than placebo or no therapy Only limited support has been found for Rogers’s explanation of causal factors

GAD: The Cognitive Perspective
Theorists believe that psychological problems are caused by maladaptive and dysfunctional thinking Since GAD is characterized by excessive worry (cognition), this model is a good start…

Theory: GAD is caused by maladaptive assumptions Albert Ellis identified basic irrational assumptions: It is a necessity for humans to be loved by everyone It is catastrophic when things are not as one wants them If something is dangerous, a person should be terribly concerned and dwell on the possibility that it will occur One should be competent in all domains to be a worthwhile person When these assumptions are applied to everyday life, GAD may develop

Aaron Beck is another cognitive theorist Those with GAD hold unrealistic silent assumptions that imply imminent danger: Any strange situation is dangerous A situation/person is unsafe until proven safe It is best to assume the worst My security depends on anticipating and preparing myself at all times for any possible danger

Research supports the presence of these types of assumptions in GAD Also shows that people with GAD pay unusually close attention to threatening cues

What kinds of people are likely to have exaggerated expectations of danger? Those whose lives have been filled with unpredictable negative events To avoid being “blindsided,” they try to predict events; they look everywhere for danger (and therefore see danger everywhere) Theory still under investigation

Two kinds of cognitive therapy: Changing maladaptive assumptions Based on the work of Ellis and Beck Teaching coping skills for use during stressful situations

Cognitive therapies Changing maladaptive assumptions Ellis’s rational-emotive therapy (RET) Point out irrational assumptions Suggest more appropriate assumptions Assign related homework Limited research, but findings are positive Beck’s cognitive therapy Similar to his depression treatment (see Chapter 8) Shown to be somewhat helpful in reducing anxiety to tolerable levels

Cognitive therapies Teaching clients to cope Meichenbaum’s self-instruction (stress inoculation) training Teach self-coping statements to apply during four stages of a stressful situation: Preparing for stressor Confronting and handling stressor Coping with feeling overwhelmed Reinforcing with self-statements

Cognitive therapies Teaching clients to cope Shown to be of modest help for GAD and moderate help with situational and more mild anxiety Best when used in combination with other treatments

GAD: The Biological Perspective
Theory holds that GAD is caused by biological factors Supported by family pedigree studies Blood relatives more likely to have GAD (~15%) compared to general population (~4%) The closer the relative, the greater the likelihood Issue of shared environment

GABA inactivity 1950s – Benzodiazepines (Valium, Xanax) found to reduce anxiety Why? Neurons have specific receptors (lock and key) Benzodiazepine receptors ordinarily receive gamma-aminobutyric acid (GABA, a common NT in the brain) GABA is an inhibitory messenger; when received, it causes a neuron to STOP firing

In the normal fear reaction: Key neurons fire more rapidly, creating a general state of excitability experienced as fear or anxiety A feedback system is triggered; brain and body activities work to reduce excitability Some neurons release GABA to inhibit neuron firing, thereby reducing experience of fear or anxiety Problems with the feedback system are believed to cause GAD Possible reasons: GABA too low, too few receptors, ineffective receptors

Promising (but problematic) explanation Other NTs also bind to GABA receptors Research conducted on lab animals raises question: is “fear” really fear? Issue of causal relationships Do physiological events CAUSE anxiety? How can we know? What are alternative explanations?

Biological treatments Antianxiety drugs Pre-1950s: barbiturates (sedative-hypnotics) Post-1950s: benzodiazepines Provide temporary, modest relief Rebound anxiety with withdrawal and cessation of use Physical dependence is possible Undesirable effects (drowsiness, etc.) Multiply effects of other drugs (especially alcohol) 1980s: azaspirones (BuSpar) Different receptors, same effectiveness, fewer problems

Biological treatments Relaxation training Theory: physical relaxation leads to psychological relaxation Research indicates that relaxation training is more effective than placebo or no treatment Best when used in combination with cognitive therapy or biofeedback

Biological treatments Biofeedback Uses electrical signals from the body to train people to control physiological processes EMG is the most widely used; provides feedback about muscle tension Once hailed as the approach that would change clinical treatment Found to be most effective when used as an adjunct to other methods for the treatment of certain medical problems (headache, back pain, etc.)

Phobias From the Greek word for “fear”
Formal names are also often from the Greek (see Box 5-3) Persistent and unreasonable fears of particular objects, activities, or situations Phobic people often avoid the object or thoughts about it

Phobias We all have some fears at some points in our lives; this is a normal and common experience How do phobias differ from these “normal” experiences? More intense fear Greater desire to avoid the feared object or situation Distress which interferes with functioning

Phobias Common in our society
~10% of adults affected in any given year ~14% develop a phobia at some point in lifetime Twice as common in women as men Most phobias are categorized as “specific” Two broader kinds: Social phobia Agoraphobia

Specific Phobias Persistent fears of specific objects or situations
When exposed to the object or situation, sufferers experience immediate fear Most common: phobias of specific animals or insects, heights, enclosed spaces, thunderstorms, and blood

Specific Phobias ~9% of the U.S. population have symptoms in any given year ~11% develop a specific phobia at some point in their lives Many suffer from more than one phobia at a time Women outnumber men 2:1 Prevalence differs across racial and ethnic minority groups

Social Phobias Severe, persistent, and unreasonable fears of social or performance situations in which embarrassment may occur May be narrow – talking, performing, eating, or writing in public May be broad – general fear of functioning inadequately in front of others In both cases, people rate themselves as performing less adequately than they actually did

Social Phobias Can greatly interfere with functioning
Often kept a secret Affect ~8% of U.S. population in any given year Women outnumber men 3:2 Often begin in childhood and may persist for many years Fewer than 20% of sufferers seek treatment

What Causes Phobias? All models offer explanations, but evidence tends to support the behavioral explanations: Phobias develop through conditioning Once fears are acquired, they are continued because feared objects are avoided Behaviorists propose a classical conditioning model…

Classical Conditioning of Phobia
UCS Entrapment UCR Fear UCS Entrapment UCR Fear Running water + CS Running water CR Fear

What Causes Phobias? Behavioral explanations
Phobias develop through modeling Observation and imitation Phobias are maintained through avoidance Phobias may develop into GAD when a person acquires a large number of phobias Process of stimulus generalization: responses to one stimulus are also produced by similar stimuli

What Causes Phobias? Behavioral explanations have received some empirical support: Classical conditioning study involving Little Albert Modeling studies Bandura, confederates, buzz, and shock Research conclusion is that phobias CAN be acquired in these ways, but there is no evidence that this is how the disorder is ordinarily acquired

What Causes Phobias? A behavioral-evolutionary explanation
Some phobias are much more common than others…

What Causes Phobias? A behavioral-evolutionary explanation
Theorists argue that there is a species-specific biological predisposition to develop certain fears Called “preparedness”: humans are more “prepared” to develop phobias around certain objects or situations Model explains why some phobias (snakes, heights) are more common than others (grass, meat) Unknown if these predispositions are due to evolutionary or environmental factors

How Are Phobias Treated?
All models offer treatment approaches Behavioral techniques (exposure treatments) are most widely used, especially for specific phobias Shown to be highly effective Fare better in head-to-head comparisons than other approaches Include desensitization, flooding, and modeling

Treatments for Specific Phobias
Systematic desensitization Technique developed by Joseph Wolpe Create fear hierarchy Sufferers learn to relax while facing feared objects Since relaxation is incompatible with fear, the relaxation response is thought to substitute for the fear response Several types: In vivo desensitization (live) Covert desensitization (imaginal)

Treatments for Specific Phobias
Systematic desensitization Flooding Forced non-gradual exposure Modeling Therapist confronts the feared object while the fearful person observes Clinical research supports these treatments The key to success is ACTUAL contact with the feared object or situation

Treatments for Social Phobias
Treatments only recently successful Two components must be addressed: Overwhelming social fear Address fears behaviorally with exposure Lack of social skills Social skills and assertiveness trainings have proved helpful

Unlike specific phobias, social phobias respond well to medication (particularly antianxiety drugs) Several types of psychotherapy have proved at least as effective as medication People treated with psychotherapy are less likely to relapse than people treated with drugs alone One psychological approach is exposure therapy, either in an individual or group setting Cognitive therapies have also been widely used

Another treatment option is social skills training, a combination of several behavioral techniques to help people improve their social functioning Therapist provides feedback and reinforcement No single treatment approach is consistently helpful or superior to the others Results from using a combination of approaches seem to be most encouraging

Panic Disorder Panic, an extreme anxiety reaction, can result when a real threat suddenly emerges The experience of “panic attacks,” however, is different Panic attacks are periodic, short bouts of panic that occur suddenly, reach a peak, and pass Sufferers often fear they will die, go crazy, or lose control Attacks happen in the absence of a real threat

Panic Disorder Anyone can experience a panic attack, but some people have panic attacks repeatedly, unexpectedly, and without apparent reason Diagnosis: panic disorder Sufferers also experience dysfunctional changes in thinking and behavior as a result of the attacks Example: sufferer worries persistently about having an attack; plans behavior around possibility of future attack

Panic Disorder Often (but not always) accompanied by agoraphobia
From the Greek “fear of the marketplace” Afraid to leave home and travel to locations from which escape might be difficult or help unavailable Intensity may fluctuate There has only recently been a recognition of the link between agoraphobia and panic attacks (or panic-like symptoms)

Panic Disorder Two diagnoses: panic disorder with agoraphobia; panic disorder without agoraphobia ~2.3% of U.S. population affected in a given year ~3.5% of U.S. population affected at some point in their lives Likely to develop in late adolescence and early adulthood Women are twice as likely as men to be affected

Panic Disorder: The Biological Perspective
In the 1960s, it was recognized that people with panic disorder were not helped by benzodiazepines, but were helped by antidepressants Researchers worked backward from their understanding of antidepressant drugs

What biological factors contribute to panic disorder? NT at work is norepinephrine Irregular in people with panic attacks Research suggests that panic reactions are related to changes in norepinephrine activity in the locus ceruleus While norepinephrine is clearly linked to panic disorder, what goes wrong isn’t exactly understood May be excessive activity, deficient activity, or some other defect Other NTs are likely involved

It is also unclear why some people have such biological abnormalities Inherited biological predisposition is one possible reason If so, prevalence should be (and is) greater among close relatives Among monozygotic (MZ or identical) twins = 24% Among dizygotic (DZ or fraternal) twins = 11% Issue is still open to debate

Drug therapies Antidepressants are effective at preventing or reducing panic attacks Function at norepinephrine receptors in the locus ceruleus Bring at least some improvement to 80% of patients with panic disorder ~40–60% recover markedly or fully Require maintenance of drug therapy; otherwise relapse rates are high Some benzodiazepines (especially Xanax (alprazolam)) have also proved helpful

Drug therapies Both antidepressants and benzodiazepines are also helpful in treating panic disorder with agoraphobia Break the cycle of attack, anticipation, and fear It is important to note that when drug therapy is stopped, symptoms return Combination treatment (medications + behavioral exposure therapy) may be more effective than either treatment alone

Panic Disorder: The Cognitive Perspective
Cognitive theorists and practitioners recognize that biological factors are only part of the cause of panic attacks In their view, full panic reactions are experienced only by people who misinterpret bodily events Cognitive treatment is aimed at changing such misinterpretations

Misinterpreting bodily sensations Panic-prone people may be overly sensitive to certain bodily sensations and may misinterpret them as signs of a medical catastrophe; this leads to panic Why might some people be prone to such misinterpretations? Poor coping skills Lack of social support Unpredictable childhoods Overly protective parents

Misinterpreting bodily sensations Panic-prone people have a high degree of “anxiety sensitivity” They focus on bodily sensations much of the time, are unable to assess the sensations logically, and interpret them as potentially harmful Examples include: overbreathing or hyperventilation, excitement, fullness in the abdomen, acute anger, and heart “palpitations”

Cognitive therapy Attempts to correct people’s misinterpretations of their bodily sensations Step 1: Educate clients About panic in general About the causes of bodily sensations About their tendency to misinterpret the sensations Step 2: Teach clients to apply more accurate interpretations (especially when stressed) Step 3: Teach clients skills for coping with anxiety Examples: relaxation, breathing

Cognitive therapy May also use “biological challenge” procedures to induce panic sensations Induce physical sensations which cause feelings of panic: Jump up and down Run up a flight of steps Practice coping strategies and making more accurate interpretations

The Cognitive Perspective
Cognitive therapy is often helpful in panic disorder 85% panic-free for two years vs. 13% of control subjects Only sometimes helpful for panic disorder with agoraphobia At least as helpful as antidepressants Combination therapy may be most effective Still under investigation

Obsessive-Compulsive Disorder
Comprised of two components: Obsessions Persistent thoughts, ideas, impulses, or images that seem to invade a person’s consciousness Compulsions Repeated and rigid behaviors or mental acts that people feel they must perform in order to prevent or reduce anxiety

Diagnosis may be called for when symptoms: Feel excessive or unreasonable Cause great distress Consume considerable time Or interfere with daily functions

Classified as an anxiety disorder because obsessions cause anxiety, while compulsions are aimed at preventing or reducing anxiety Anxiety rises if obsessions or compulsions are avoided ~2% of U.S. population has OCD in a given year Ratio of women to men is 1:1

What Are the Features of Obsessions and Compulsions?
Thoughts that feel intrusive and foreign Attempts to ignore or avoid them triggers anxiety Take various forms: Wishes Impulses Images Ideas Doubts Have common themes: Dirt/contamination Violence and aggression Orderliness Religion Sexuality

“Voluntary” behaviors or mental acts Feel mandatory/unstoppable Person may recognize that behaviors are irrational Believe, though, that catastrophe will occur if they don’t perform the compulsive acts Performing behaviors reduces anxiety ONLY FOR A SHORT TIME! Behaviors often develop into rituals

Common forms/themes: Cleaning Checking Order or balance Touching, verbal, and/or counting

Are obsessions and compulsions related? Most (not all) people with OCD experience both Compulsive acts often occur in response to obsessive thoughts Compulsions seem to represent a yielding to obsessions Compulsions also sometimes serve to help control obsessions

Are obsessions and compulsions related? Many with OCD are concerned that they will act on their obsessions Most of these concerns are unfounded Compulsions usually do not lead to violence or “immoral acts”

OCD was once among the least understood of the psychological disorders In recent years, however, researchers have begun to learn more about it The most influential explanations are from the psychodynamic, behavioral, cognitive, and biological models…

OCD: The Psychodynamic Perspective
Anxiety disorders develop when children come to fear their id impulses and use ego defense mechanisms to lessen their anxiety OCD differs from anxiety disorders in that the “battle” is not unconscious; it is played out in explicit thoughts and action Id impulses = obsessive thoughts Ego defenses = counter-thoughts or compulsive actions At its core, OCD is related to aggressive impulses and the competing need to control them

The battle between the id and the ego Three ego defenses mechanisms are common: Isolation: disown disturbing thoughts Undoing: perform acts to “cancel out” thoughts Reaction formation: take on lifestyle in contrast to unacceptable impulses Freud believed that OCD was related to the anal stage of development Period of intense conflict between id and ego Not all psychodynamic theorists agree

Psychodynamic therapies Goals are to uncover and overcome underlying conflicts and defenses Main techniques are free association and interpretation Research evidence is poor In fact, psychodynamic therapy may be detrimental for OCD by playing into the tendency to “think too much”

OCD: The Behavioral Perspective
Behaviorists concentrate on explaining and treating compulsions Although the behavioral explanation of OCD has received little support, behavioral treatments for compulsive behaviors have been very successful

Learning by chance People happen upon compulsions randomly: In a fearful situation, they happen to perform a particular act (washing hands) When the threat lifts, they associate the improvement with the random act After repeated associations, they believe the compulsion is changing the situation Bringing luck, warding away evil, etc. The act becomes a key method to avoiding or reducing anxiety

Key investigator: Stanley Rachman Compulsions are rewarded by an eventual decrease in anxiety Studies provide no evidence of the learning of compulsions

Behavioral therapy Exposure and response prevention (ERP) Clients are repeatedly exposed to anxiety-provoking stimuli and prevented from responding with compulsions Therapists often model the behavior while the client watches Homework is an important component Treatment is offered in individual and group settings Treatment provides significant, long-lasting improvements for most patients

OCD: The Cognitive Perspective
Cognitive theory and treatment for OCD is very promising Includes a number of behavioral principles, and thus has been called “cognitive-behavioral”

Overreacting to unwanted thoughts People with OCD blame themselves for normal (although repetitive and intrusive) thoughts and expect that terrible things will happen as a result To avoid such negative outcomes, they attempt to neutralize their thoughts with actions (or other thoughts) Neutralizing thoughts/actions may include: Seeking reassurance Thinking “good” thoughts Washing Checking

When a neutralizing action reduces anxiety, it is reinforced Client becomes more convinced that the thoughts are dangerous As fear of thoughts increases, the number of thoughts increases

If everyone has intrusive thoughts, why do only some people develop OCD? People with OCD: Are more depressed than others Have higher standards of morality and conduct Believe thoughts = actions and are capable of bringing harm Believe that they can and should have perfect control over their thoughts and behaviors Good research support for this model

Cognitive therapies Used in combination with behavioral techniques May include: Habituation training Covert-response prevention

OCD: The Biological Perspective
Significant attempts have been made to identify hidden biological factors that might contribute to the development of OCD Research has led to promising theories and treatments

Two lines of research: Role of NT serotonin Evidence that serotonin-based antidepressants reduce OCD symptoms Brain abnormalities OCD linked to orbital region of frontal cortex and caudate nuclei Compose brain circuit that converts sensory information into thoughts and actions Either area may be too active, letting through troublesome thoughts and actions

Some research support and evidence that these two lines may be connected Serotonin plays a very active role in the operation of the orbital region and the caudate nuclei Low serotonin activity might interfere with the proper functioning of these brain parts

Biological therapies Serotonin-based antidepressants Anafranil, Prozac, Luvox Bring improvement to 50–80% of those with OCD Relapse occurs if medication is stopped Research suggests that combination therapy (medication + cognitive behavioral therapy approaches) may be most effective May have same effect on the brain

Chapter 5 Anxiety Disorders

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