Ch. 4 Anxiety, Obsessive-Compulsive, and Related Disorders

Question 1

Generalized Anxiety Disorder

Answer 1

GENERALIZED ANXIETY DISORDER (G.A.D.) – People with generalized anxiety disorder experience excessive anxiety under most circumstances and worry about practically anything.

• 6% of all people develop this at some point in their lives.
• Women diagnosed with it twice as much as men.
• SEPARATION ANXIETY DISORDER – a subcategory marked by severe anxiety due to separation – was once only diagnosed in children, but now extended to adults, but the adult form may actually be a form of PTSD.

SOCIOCULTURAL – generalized anxiety disorder is most likely to develop in people who are faced with ongoing societal conditions that are dangerous.

• One of the most powerful forms of societal stress is poverty – likely to live in rundown communities with high crime rates, etc. – have a higher rate of generalized anxiety disorder.
  
  • Impoverished are diagnosed twice as much as others.
• Even if sociocultural factors play a broad role, theorists still must explain why some people develop the disorder and others do not.

PSYCHODYNAMIC – believed that all children experience some degree of anxiety as part of growing up and that all use ego defense mechanisms to help control such anxiety, but some children have particularly high levels of anxiety, or their defense mechanisms are inadequate, and these individuals may develop generalized anxiety disorder.

• Overprotected children, shielded by their parents from all frustrations and threats, have little opportunity to develop effective defense mechanisms, which often leads to high levels of anxiety.
• The disorder can be traced to inadequacies in the early relationships between children and their parents (Typical of the psychodynamic explanation of most issues.)
• Researchers have tried to show that people with generalized anxiety disorder are particularly likely to use defense mechanisms – and they do use them.
• People who as children suffered extreme punishment for id impulses (natural urges suppressed by hyper-uptight parents) have higher levels of anxiety later in life.
• TREATMENT – Psychodynamic therapists use the same general techniques to treat all psychological problems: free association and the therapist’s interpretations of transference, resistance, and dreams. – to help clients become less afraid of their id impulses and more successful in controlling them.

HUMANISTIC – GAD arises when people stop looking at themselves honestly and acceptingly.

• Children who fail to receive UNCONDITIONAL POSITIVE REGARD from others may become overly critical of themselves and develop harsh self-standards, called CONDITIONS OF WORTH.
  
  • They try to meet these standards by repeatedly distorting and denying their true thoughts and experiences.
• CLIENT-CENTERED THERAPY – tries to show unconditional positive regard for their clients and to empathize with them. The therapists hope that an atmosphere of genuine acceptance and caring will help clients feel secure enough to recognize their true needs, thoughts, and emotions. When clients eventually are honest and comfortable with themselves, their anxiety or other symptoms will subside.
  
  • Little support for this approach.

COGNITIVE-BEHAVIORAL – psychological disorders are often caused by problematic behaviors and dysfunctional ways of thinking.

• With GAD, the focus is on the COGNITIVE dimension.
• GAD is primarily caused by MALADAPTIVE ASSUMPTIONS.
• ALBERT ELLIS – proposed that many people are guided by BASIC IRRATIONAL ASSUMPTIONS – irrational beliefs that lead them to act and react in inappropriate ways.
  
  • Research supports this perspective.
• METACOGNITIVE THEORY (Explanation of GAD) – suggests that people with generalized anxiety disorder implicitly hold both positive and negative beliefs about worrying.
  
  • On the positive side, they believe that worrying is a useful way of appraising and coping with threats in life. And so they look for and examine all possible signs of danger—that is, they worry constantly.
  • On the negative side are the negative attitudes about virtually everything, which results in this disorder. Society teaches them that worrying is a bad thing, they come to believe that their repeated worrying is in fact harmful and uncontrollable so they now further worry about the fact that they always seem to be worrying (so-called META-WORRIES).
  • Research supports this view. Studies show that people who hold both positive and negative beliefs about worrying are prone to developing GAD and that repeated meta-worrying is a powerful predictor of developing the disorder.
• INTOLERANCE OF UNCERTAINTY THEORY (Explanation of GAD) – certain individuals cannot tolerate the knowledge that negative events may occur, even if the possibility of occurrence is very small. Inasmuch as life is filled with uncertain events, these individuals worry constantly that such events are about to occur. Such intolerance and worrying leave them highly vulnerable to the development of generalized anxiety disorder. This is how people with generalized anxiety disorder feel all the time.
  
  • Develops in early childhood and can be passed from parent to child.
• AVOIDANCE THEORY (Explanation of GAD) – Thomas Borkovec, suggests that people with this disorder have greater bodily arousal (higher heart rate, perspiration, respiration) than other people and that worrying actually serves to AVOID (reduce) the uncomfortable state of bodily arousal.
• TREATMENT – Two kinds:
  
  1. Therapists help clients change the maladaptive assumptions that characterize their disorder
  2. Therapists help clients:
     
     • understand the special role that worrying may play in their disorder
     • modify their views about worrying
     • change their behavioral reactions to such unnerving concerns.
  • The technique of RATIONAL-EMOTIVE THERAPY:
    
    • points out the irrational assumptions held by clients,
    • suggests more appropriate assumptions
    • urges clients to challenge old assumptions and apply new ones
    • Modestly effective
  • ACCEPTANCE and COMMITMENT THERAPY – therapists help clients to become aware of their streams of thoughts, including their worries, as they are occurring and to accept such thoughts as mere events of the mind. By accepting their worries rather than trying to eliminate them, the clients are expected to be less upset by them and less influenced by them in their behaviors and life decisions.
  • MINDFULNESS-BASED THERAPY – which teaches people to pay attention to the thoughts and feelings that flow through their mind during meditation and to accept such thoughts in a nonjudgmental way.

BIOLOGICAL – GAD is caused chiefly by biological factors through genetics using FAMILY PEDIGREE STUDIES, where investigators determine how many and which relatives of a person with a disorder have the same disorder.

• BENZODIAZEPINES – a family of drugs that brings relief from anxiety (ex: Xanax, Valium) that affects receptors that receive the neurotransmitter, GAMMA-AMINOBUTYRIC ACID (GABA), whose low activity in the brain’s fear circuit has been linked to anxiety.
• BRAIN CIRCUITS – Networks of brain structures that work together.
  
  • The particular circuit that produces and manages fear reactions is called the “FEAR CIRCUIT, ” which includes such brain structures as the prefrontal cortex, anterior cingulate cortex, insula, and AMYGDALA (which is the center of emotion)
  • Studies reveal that the fear circuit is excessively active in people with generalized anxiety disorder.
• TREATMENT – SEDATIVE-HYPNOTIC DRUGS – drugs that calm people in low doses and help them fall asleep in higher doses. The benzodiazepines seemed less addictive than previous sedative-hypnotic medications, such as barbiturates.
  
  • Benzodiazepines reduce anxiety by traveling to receptor sites in the brain circuit—particularly in the amygdala—that ordinarily receive the neurotransmitter GABA.
  • Benzodiazepines have been replaced with a new preferred drug to treat GAD – ANTIDEPRESSANTS, which increase the activity of the neurotransmitters serotonin and norepinephrine, prominent in parts of the FEAR CIRCUIT.
  • Antipsychotic drugs are also used which may alter the activity of DOPAMINE, another fear circuit neurotransmitter.

Question 2

Phobias

Answer 2

PHOBIAS – a persistent and unreasonable fear of a particular object, activity, or situation. People with phobias often feel so much distress that their fears may interfere dramatically with their lives.

SPECIFIC PHOBIAS – persistent fear of a specific object or situation.

• 10% of Americans
• Women outnumber men 2 to 1
• Only 32% of phobics seek treatment while most simply try to avoid the object of their fear.

AGORAPHOBIA – afraid of being in public places or situations in which escape might be difficult or help unavailable, should they experience panic or become incapacitated.

• 1.7% of the population
• Twice as prevalent among women than men, and among the poor as the wealthy.
• PANIC ATTACKS – extreme and sudden explosions of fear.
  
  • Could result in a diagnosis of either Agoraphobia or Panic Disorder.

COGNITIVE-BEHAVIORAL – Focusing primarily on the behavioral dimension of this disorder, they believe that people with phobias first learn to fear certain objects, situations, or events through CLASSICAL CONDITIONING, a process of learning in which two events that repeatedly occur close together in time become tied together in a person’s mind and so produce the same response.

• MODELING – Another way of acquiring a fear reaction is through modeling, that is, through observation and imitation. A person may observe that others are afraid of certain objects or events and develop fears of the same things.
• Cognitive-behavioral theorists believe that after acquiring a fear response, people try to AVOID what they fear. They do not get close to the dreaded objects often enough to learn that the objects are really quite harmless. (Thus EXPOSURE TREATMENT is the primary treatment)
• LITTLE ALBERT (Watson & Rayner) – Made a baby (Albert) associate white rats with a painful banging noise, conditioning a fear response for the formerly innocuous white rats.
• Though this explanation has received the most research support, researchers have not established that the disorder is ordinarily acquired in this way.
• BEHAVIORAL-EVOLUTIONARY EXPLANATION – human beings, as a species, have a predisposition to develop certain fears. This idea is referred to as PREPAREDNESS because human beings, theoretically, are “prepared” to acquire some phobias and not others.
  
  • Ex: Fears of animals, darkness, and heights would aid survival.
• TREATMENT for SPECIFIC PHOBIAS – The Cognitive-Behavioral approach has the most effective treatments:
  
  • SYSTEMATIC DESENSITIZATION – An exposure treatment that uses relaxation training and a fear hierarchy to help clients with phobias react calmly to the objects or situations they dread.
  • EXPOSURE TREATMENT – persons are exposed to the objects or situations they dread.
    
    • IN VIVO DESENSITIZATION – Actual confrontation with the thing of dread.
    • COVERT DESENSITIZATION – Imagined confrontation with the thing of dread.
  • FLOODING – An exposure treatment for phobias in which clients are exposed repeatedly and intensively to a feared object and made to see that it is actually harmless.
  • MODELLING – An exposure technique, where the therapist confronts the feared object or situation while the fearful person observes.
    
    • PARTICIPANT MODELLING – the client is actively encouraged to join in with the therapist.
  • 70% of phobic clients show improvement.
  • Virtual Reality is an important tool in treatment.
• TREATMENT for AGORAPHOBIA – The Cognitive-Behavioral approach is again the most effective, though not as effective as for specific phobias.
  
  • The therapists typically help clients to venture farther and farther from their homes and to gradually enter outside places, one step at a time.
  • SUPPORT GROUP APPROACH – a small number of people with agoraphobia go out together for exposure sessions that last for several hours.
  • HOME-BASED SELF HELP – clinicians give clients and their families detailed instructions for carrying out exposure treatments themselves.
• Phone Apps have become useful tools for monitoring and logging progress, motivating clients to greater goals.
• 70% improve with therapy.

Question 3

Social Anxiety Disorder

Answer 3

SOCIAL ANXIETY DISORDER – severe, persistent, and irrational anxiety about social or performance situations in which they may face scrutiny by others and possibly feel embarrassment.

• In both NARROW and BROAD forms, people repeatedly judge themselves as performing less competently than they actually do.
• 8% of westerners suffer from this – the majority are women, poor, and white.

COGNITIVE-BEHAVIORAL – features an interplay of both cognitive and behavioral factors which include: Holding unrealistically high social standards, believing they are unattractive, socially unskilled, inadequate, and that these will inevitably lead to terrible consequences.

• As a result, they learn to perform “AVOIDANCE” and “SAFETY” behaviors.
  
  • SAFETY BEHAVIORS include wearing makeup to cover up blushing or gloves to hide shaking hands.

SOCIAL MEDIA ANXIETY – a third of users feel distinctly worse after visiting their social network—more anxious, more envious, and more dissatisfied with their lives.

• Also, studies show that excessive cell phone use often results in high levels of anxiety and tension due to the feeling of obligation to stay in touch.
• NOMOFOPHOBIA – the rush of fear that people have when they realize that they are disconnected from the world, friends, and family.
  
  • Two-thirds of cell phone users report feeling “panicked” when they misplace or lose their phones, even for a few minutes.
• TREATMENT – Successful treatment results in part to the growing recognition that the disorder has two distinct features:
  
  1. sufferers have overwhelming social fears
  2. they often lack skill at starting conversations, communicating their needs, or meeting the needs of others.
  • So reducing social fears and training in social skills are the keys to treatment.
  • Benzodiazepines or antidepressant drugs are often prescribed as well.
• On the behavioral side, they conduct exposure therapy, the intervention so effective with phobias.
• On the cognitive side, the clinicians and clients have systematic therapy discussions in which the clients are guided to reexamine and challenge their maladaptive beliefs and expectations, given the less-than-dire outcomes of their social exposures.
• SOCIAL SKILLS TRAINING – The therapist often models appropriate behaviors, but the inclusion and reinforcement from other people with similar social difficulties is often more powerful than the therapist alone.

Question 4

Panic Disorder

Answer 4

PANIC DISORDER – smothering nightmarish panic in which people lose control of their behavior and, in fact, are practically unaware of what they are doing. These occurrences of extreme panic are called:

• PANIC ATTACKS – periodic, short bouts of panic that occur suddenly, reach a peak within minutes, and gradually pass.
  
  • Symptoms can include all sorts of physical reactions as well as a sense of UNREALITY – a feeling of dissociation from reality.
  • 30% of all people experience a panic attack at some point in their lives, but repeated attacks may indicate a PANIC DISORDER.
    
    • 3% of Americans suffer from Panic Disorder in any given year. – twice as common among women and more likely with the poor and whites.
    • Panic Disorder often sets the stage of fear for Agoraphobia.

BIOLOGICAL – In the 1960s, when they discovered that the symptoms of this disorder were sometimes alleviated by antidepressant drugs that increase the activity of the neurotransmitter norepinephrine.

• Studies said that norepinephrine activity is irregular in people who suffer from panic attacks.
• The LOCUS COERULEUS is a brain area rich in neurons that use norepinephrine, and serves as a kind of “on-off” switch for many norepinephrine-using neurons throughout the brain, part of the “PANIC CIRCUIT” which tends to be hyperactive in people with PANIC DISORDER.
  
  • The PANIC CIRCUIT overlaps with the FEAR CIRCUIT.
• TREATMENT – Antidepressant drugs help 2/3 of those with PANIC DISORDER.

COGNITIVE-BEHAVIORAL – full panic reactions are experienced only by people who further MISINTERPRET the physiological events that are taking place within their bodies.

• Panic-prone people may be very sensitive to certain bodily sensations; when they unexpectedly experience such sensations, they misinterpret them as signs of a medical catastrophe rather than understanding the probable cause of their sensations as “something I ate” or “a fight with the boyfriend”. Those prone to panic grow increasingly upset about losing control, fear the worst, lose all perspective, and rapidly plunge into panic.
• BIOLOGICAL CHALLENGE TESTS – A procedure used to produce panic in participants or clients by having them exercise vigorously or perform some other potentially panic-inducing task in the presence of a researcher or therapist.
  
  • A sort of Exposure therapy to let them know that these physiological responses are noormal and not dangerous.
  • ANXIETY SENSITIVITY – a focus on bodily sensations much of the time, tthe inability to assess them logically, and thus incorrectly interpret them as potentially harmful.
    
    • Those with high anxiety sensitivity are 5 times more likely to have panic disorder.
• TREATMENT – First, they educate clients about:
  
  • the general nature of panic attacks
  • the actual causes of bodily sensations
  • the tendency of the clients to misinterpret their sensations.
  • Next, they teach the clients to apply more accurate interpretations during stressful situations, thus short-circuiting the panic sequence at an early point.
    
    • The therapists may also teach the clients ways to cope better with anxiety.

Question 5

Obsessive-Compulsive Disorder

Answer 5

OBSESSIVE-COMPULSIVE DISORDER – A disorder that exists when obsessions or compulsions feel excessive or unreasonable, cause great distress, take up much time, and interfere with daily functions.

• NOT considered an Anxiety disorder.
• Anxiety rises if a person tries to resist his or her obsessions or compulsions
• 1-2% have OCD
• EQUALLY COMMON in men and women.

OBSESSION – A persistent thought, idea, impulse, or image that is experienced repeatedly, feels intrusive, and causes anxiety.

• The most common theme appears to be dirt or contamination.
• Also violence and aggression, orderliness, religion, and sexuality.
• CULTURAL DIFFERENCES – Religious obsessions, for example, seem to be more common in cultures or countries with strict moral codes and religious values.

COMPULSION – A repetitive and rigid behavior or mental act that a person feels driven to perform in order to prevent or reduce anxiety.

• Compulsive behaviors are technically under voluntary control. However, the people who feel they must do them have little sense of choice in the matter.
• Most of these individuals recognize that their behavior is unreasonable, but they believe at the same time something terrible will happen if they don’t perform the compulsions.
• After performing a compulsive act, they usually feel less anxious for a short while.
• For some people, compulsive acts develop into detailed rituals. They must go through the ritual in exactly the same way every time, according to certain rules.
• CLEANING COMPULSIONS – are very common. People with these compulsions feel compelled to keep cleaning themselves, their clothing, or their homes. The cleaning may follow ritualistic rules and be repeated dozens or hundreds of times a day.
• People with CHECKING COMPULSIONS check the same items over and over.
• SEEK ORDER or BALANCE – People with this compulsion keep placing certain items (clothing, books, foods) in perfect order in accordance with strict rules.
• COMPULSIVE acts are often a response to OBSESSIVE thoughts where compulsive acts represent yielding to obsessive thoughts.
  
  • The OBSESSIVE thoughts create ANXIETY and the COMPULSIVE behavior seeks to reduce that ANXIETY.

PSYCHODYNAMIC – believes that an anxiety disorder develops when children come to fear their own id impulses and use ego defense mechanisms to lessen the resulting anxiety (Same as for General Anxiety Disorder GAD).

• The difference between OCD and GAD is that here the battle between anxiety-provoking id impulses and anxiety-reducing defense mechanisms is not buried in the unconscious but is played out in overt thoughts and actions.
• Research suggests this is not much help, instead using short-term psychodynamic therapies, which are more direct and action-oriented.

COGNITIVE-BEHAVIORAL – points out that everyone has obsessions or compulsions, but most are able to ignore them with ease. Those who develop this disorder, however, typically blame themselves for such thoughts and expect that somehow terrible things will happen.

• To avoid such negative outcomes, those with OCD try to neutralize the thoughts—thinking or behaving in ways meant to put matters right or to make amends.
• Those with OCD tend to:
  
  1. have exceptionally high standards of conduct and morality
  2. believe that intrusive negative thoughts are equivalent to actions and capable of causing harm, a point of view called THOUGHT-ACTION FUSION
  3. to believe that they should have perfect control over all of their thoughts and behaviors in life.
• TREATMENT – educating the clients:
  
  • point out how misinterpretations of unwanted thoughts, an excessive sense of responsibility, and neutralizing acts have helped to produce and maintain their symptoms.
  • guide the clients to identify and challenge their distorted cognitions.
  • Increasingly, the clients come to appreciate that their obsessive thoughts are inaccurate occurrences rather than valid and dangerous cognitions for which they are responsible.
  • Correspondingly, they recognize their compulsive acts as unnecessary.
• EXPOSURE AND RESPONSE PREVENTION – exposes a client to anxiety-arousing thoughts or situations and then prevents the client from performing his or her compulsive acts. (Also called exposure and ritual prevention).
• 50-70% find improvement with these treatments.

BIOLOGICAL – Biological factors play a role in OCD.

• The CORTICO-STRIATO-THALAMO-CORTICAL CIRCUIT – is hyperactive in people with OCD, making it difficult for them to turn off or dismiss their various impulses, needs, and related thoughts.
• TREATMENT – By far, the most widely used biological treatment for OCD is antidepressant drugs, particularly ones that specifically increase activity of the neurotransmitter serotonin.
  
  • These drugs bring relief to 50-60%.

OBSESSIVE-COMPULSIVE RELATED DISORDERS:

• HOARDING DISORDER – feel that they must save items, and they become very distressed if they try to discard them.
• TRICHOTILLOMANIA – repeatedly pull out hair from their scalp, eyebrows, eyelashes, or other parts of the body.
• EXCORIATION DISORDER – keep picking at their skin, resulting in significant sores or wounds.
• BODY DYSMORPHIC DISORDER – become preoccupied with the belief that they have a particular defect or flaw in their physical appearance. Actually, the perceived defect or flaw is imagined or greatly exaggerated in the person’s mind.
  
  • This has received the most study to date.
  • Treated the same as OCD – antidepressant drugs and Exposure and Response Prevention.

DEVELOPMENTAL PSYCHOPATHOLOGY – Integrating the Models:

• BIOLOGICAL – studies that link particular genetic variations to hyperactive fear circuits. From the earliest days of life, such children show a withdrawn, isolated, and cautious pattern known as BEHAVIORAL INHIBITION.
• Drawing from the cognitive-behavioral and psychodynamic – highlight the important role of parenting styles.
  
  • overprotective parenting denies them opportunities to learn how to manage distress by themselves
  • If children already have a biological vulnerability and an inhibited temperament, exposure to overprotective parenting can help promote repeated eruptions of anxiety, setting the stage for lifelong anxiety.
  • Finally, drawing from the sociocultural model, developmental psychopathologists have also been interested in research showing that life stress, poverty, school difficulties, family disharmony, peer pressure, and community danger can heighten the likelihood of developing anxiety-related disorders.