Chapter 5

1. Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University Chapter 5 Anxiety Disorders Comer, Fundamentals of Abnormal Psychology, 3e

2. 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. Comer, Fundamentals of Abnormal Psychology, 3e

3. Anxiety • Is the fear/anxiety response useful/adaptive? • Yes, when the “fight or flight” response is protective • However, 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 Comer, Fundamentals of Abnormal Psychology, 3e

4. Anxiety Disorders • Most common mental disorders in the U.S. • In any given year, 18% of the adult population in the U.S. experiences one of the six DSM-IV-TR anxiety disorders • Close to 29% develop one of the disorders at some point in their lives • Only ~20% of these individuals seek treatment • Most individuals with one anxiety disorder suffer from a second disorder, as well • Anxiety disorders cost $42 billion each year in health care, lost wages, and lost productivity Comer, Fundamentals of Abnormal Psychology, 3e

5. Anxiety Disorders • Six disorders: • Generalized anxiety disorder (GAD) • Phobias • Panic disorder • Obsessive-compulsive disorder (OCD) • Acute stress disorder • Posttraumatic stress disorder (PTSD) Comer, Fundamentals of Abnormal Psychology, 3e

6. 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 Comer, Fundamentals of Abnormal Psychology, 3e

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8. Generalized Anxiety Disorder (GAD) • The disorder is common in Western society • Affects ~3% of the population in any given year and ~6% at sometime during their lives • 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… Comer, Fundamentals of Abnormal Psychology, 3e

9. GAD: The Sociocultural Perspective • According to this theory, GAD is most likely to develop in people faced with social conditions that truly are 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, there are higher rates of GAD in lower SES groups Comer, Fundamentals of Abnormal Psychology, 3e

10. GAD: The Sociocultural Perspective • 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, ~6% of African Americans and 3.1% of Caucasians suffer from GAD • African American women have highest rates (6.6%) Comer, Fundamentals of Abnormal Psychology, 3e

11. 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 or when anxiety is too high…GAD develops Comer, Fundamentals of Abnormal Psychology, 3e

12. GAD: The Psychodynamic Perspective • Today’s psychodynamic theorists often disagree with specific aspects of Freud’s explanation • Researchers have found some support for the psychodynamic perspective: • People with GAD are particularly likely to use defense mechanisms (especially repression) • 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? Comer, Fundamentals of Abnormal Psychology, 3e

13. GAD: The Psychodynamic Perspective • Not necessarily; there are alternative explanations of the data: • Discomfort with painful memories or “forgetting” in therapy is not necessarily defensive • Also, some data actually contradict the model • Many (if not most) GAD clients report normal childhood upbringings Comer, Fundamentals of Abnormal Psychology, 3e

14. GAD: The Psychodynamic Perspective • 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 therapists: help patients identify and settle early relationship conflicts Comer, Fundamentals of Abnormal Psychology, 3e

15. 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 Comer, Fundamentals of Abnormal Psychology, 3e

16. 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 Comer, Fundamentals of Abnormal Psychology, 3e

17. 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… Comer, Fundamentals of Abnormal Psychology, 3e

18. GAD: The Cognitive Perspective • Theory: GAD is caused by maladaptive assumptions • Albert Ellis identified basic irrational assumptions: • It is necessary for humans to be loved by everyone • It is catastrophic when things are not as one wants them to be • 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 Comer, Fundamentals of Abnormal Psychology, 3e

19. GAD: The Cognitive Perspective • 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 • Research supports the presence of these types of assumptions in GAD, particularly about dangerousness Comer, Fundamentals of Abnormal Psychology, 3e

20. GAD: The Cognitive Perspective • Second-Generation Cognitive Explanations • In recent years, two promising explanations have emerged: • Metacognitive theory • Worry about worrying (metaworrying) • Avoidance theory • worrying serves a “positive” function by reducing unusually high levels of bodily arousal • Both theories have received considerable research support Comer, Fundamentals of Abnormal Psychology, 3e

21. GAD: The Cognitive Perspective • Two kinds of cognitive therapy: • Changing maladaptive assumptions • Based on the work of Ellis and Beck • Helping clients understand the special role that worrying plays, and changing their views about it Comer, Fundamentals of Abnormal Psychology, 3e

22. GAD: The Cognitive Perspective • Cognitive therapies • Focusing on worrying • Therapists begin with psychoeducation about worrying and GAD • Assign self-monitoring of somatic arousal and cognitive responses • As therapy progresses, clients become increasingly skilled at identifying their worrying and its counterproductivity Comer, Fundamentals of Abnormal Psychology, 3e

23. 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%) than general population (~6%) • The closer the relative, the greater the likelihood • Issue of shared environment Comer, Fundamentals of Abnormal Psychology, 3e

24. GAD: The Biological Perspective • 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 Comer, Fundamentals of Abnormal Psychology, 3e

25. GAD: The Biological Perspective • 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: buspirone (BuSpar) • Different receptors, same effectiveness, fewer problems Comer, Fundamentals of Abnormal Psychology, 3e

26. GAD: The Biological Perspective • 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 Comer, Fundamentals of Abnormal Psychology, 3e

27. GAD: The Biological Perspective • Biological treatments • Biofeedback • Therapist uses electrical signals from the body to train people to control physiological processes • Electromyograph (EMG) is the most widely used; provides feedback about muscle tension • Found to be most effective when used as an adjunct to other methods for the treatment of certain medical problems (headache, back pain, etc.) Comer, Fundamentals of Abnormal Psychology, 3e

28. Phobias • From the Greek word for “fear” • Formal names are also often from the Greek (see Box 5-2) • Persistent and unreasonable fears of particular objects, activities, or situations • Phobic people often avoid the object or thoughts about it Comer, Fundamentals of Abnormal Psychology, 3e

29. 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 that interferes with functioning Comer, Fundamentals of Abnormal Psychology, 3e

30. Specific Phobias • Persistent fear 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 Comer, Fundamentals of Abnormal Psychology, 3e

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32. Specific Phobias • ~9% of the U.S. population have symptoms in any given year • ~12% 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 • Vast majority do NOT seek treatment Comer, Fundamentals of Abnormal Psychology, 3e

33. 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 Comer, Fundamentals of Abnormal Psychology, 3e

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35. Social Phobias • Can greatly interfere with functioning • Often kept a secret • Affect ~7% of U.S. population in any given year • Women outnumber men 3:2 • Often begin in childhood and may persist for many years Comer, Fundamentals of Abnormal Psychology, 3e

36. What Causes Phobias? • Each model offers 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… Comer, Fundamentals of Abnormal Psychology, 3e

37. What Causes Phobias? • Other behavioral explanations • Phobias may 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 elicited by similar stimuli Comer, Fundamentals of Abnormal Psychology, 3e

38. 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 Comer, Fundamentals of Abnormal Psychology, 3e

39. What Causes Phobias? • A behavioral-evolutionary explanation • Some phobias are much more common than others… Comer, Fundamentals of Abnormal Psychology, 3e

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41. 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 Comer, Fundamentals of Abnormal Psychology, 3e

42. How Are Phobias Treated? • Surveys reveal that ~19% of those with specific phobia and 25% of those with social phobia currently are in treatment • Each model offers 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 Comer, Fundamentals of Abnormal Psychology, 3e

43. Treatments for Specific Phobias • Systematic desensitization • Technique developed by Joseph Wolpe • Teach relaxation skills • 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) Comer, Fundamentals of Abnormal Psychology, 3e

44. Treatments for Specific Phobias • Other behavioral treatments: • Flooding • Forced nongradual exposure • Modeling • Therapist confronts the feared object while the fearful person observes • Clinical research supports each of these treatments • The key to success is ACTUAL contact with the feared object or situation Comer, Fundamentals of Abnormal Psychology, 3e

45. 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 Comer, Fundamentals of Abnormal Psychology, 3e

46. 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 Comer, Fundamentals of Abnormal Psychology, 3e

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48. Panic Disorder • Anyone can experience a panic attack, but some people have panic attacksrepeatedly, 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 Comer, Fundamentals of Abnormal Psychology, 3e

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50. 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) Comer, Fundamentals of Abnormal Psychology, 3e