Chapter Four

1. Chapter Four Anxiety and Obsessive-Compulsive and Related Disorders

2. Understanding Anxiety Disorders • Anxiety: • Fundamental human emotion • A feeling of uneasiness or apprehension • Anxiety is anticipatory: waiting for a dreaded event to occur • Has an adaptive function • Fear: • Intense emotion experienced in response to threatening situation

3. Understanding Anxiety Disorders (cont’d.) • Anxiety disorder: • Fear or anxiety symptoms that interfere with an individual’s day-to-day functioning • Three anxiety disorder covered in chapter • Phobias • Panic disorder • Generalized anxiety disorder • Obsessive-compulsive and related disorders also discussed due to similarities with anxiety disorders

4. Understanding Anxiety Disorders (cont’d.) Figure 4-1 Prevalence of Anxiety Disorders in the United States Anxiety disorders are the most common mental condition in the United States. Source: R.C. Kessler, Berglund, Demler, Jin, Merikangas, et al. (2005); R.C. Kessler, Chiu, Demler & Walters (2005).

5. Understanding Disorders from a Multipath Perspective • Etiological models: • Developed to explain the cause of a disorder • Insufficiently explain individual variations in response to fearful situations • Various factors play a role • Biological • Psychological • Social and Sociocultural

6. Understanding Disorders from a Multipath Perspective (cont’d.) Figure 4-2 Multipath Model of Anxiety Disorders The dimensions interact with one another and combine in different ways to result in a specific anxiety disorder. The importance and influence of each dimension varies from individual to individual.

7. Biological Dimension • Two main biological factors: • Brain function • Amygdala • Hippocampus • Prefrontal cortex • Genetic influences • Modest contribution to anxiety disorders • Interact with other multipath factors

8. Biological Dimension (cont’d.) Figure 4-3 Neuroanatomical Basis for Panic and Other Anxiety Disorders The fear network in the brain is centered in the amygdala, which interacts with the hippocampus and areas of the prefrontal cortex. Antianxiety medications appear to desensitize the fear network. Some psychotherapies also affect brain functioning related to anxiety.

9. Biological Dimension (cont’d.) • Genetic influences • Neurotransmitters: chemicals that help transmit messages between neurons • Serotonin: regulates mood, sleep, and appetite • Alleles: gene pair responsible for a specific trait • Polymorphic variation • Predisposition: a susceptibility to certain symptoms or disorders

10. Interactions Among Factors • Biological, psychological, social, and sociocultural factors interact with one another • Interplay between genetic and environmental influences • Environmental variables affect gene expression • Reducing risk of lifelong anxiety: • Environmental factors can both contribute to and protect against behavioral inhibition

11. Psychological Dimension • Psychological characteristics can interact with biological predispositions • Anxiety sensitivity (a personality variable) may be a risk factor • Psychological variables such as one’s sense of control may also be involved

12. Social and Sociocultural Dimensions • Daily environmental stress • Poverty • Traumatic events • Social support network • Gender • Acculturation factors among minority groups • Discrimination and prejudice

13. Phobias • Phobia: • Strong, persistent, unwarranted fear of a specific object or situation • Extreme anxiety or panic is expressed when phobic stimulus is encountered • Most common mental disorder in United States • Comes from Greek word for fear

14. Social Anxiety Disorder • Social anxiety disorder (SAD): • Intense fear of being scrutinized in one or more social or performance situations • Generalized type versus performance type • Comorbid: existing simultaneously with another condition • “Threat cues” and “safety behaviors” • Can be chronic and disabling

15. Specific Phobias • Specific phobia: • Extreme fear of a specific object or situation; exposure to stimulus nearly always produces intense anxiety or panic • Primary types: • Animal • Natural environmental • Blood/injection or injury • Situational

16. Specific Phobias (cont’d.) Figure 4-4 Phobia Onset This graph illustrates the average ages at which 370 people said their phobias began. Animal phobias began during childhood, whereas the onset of agoraphobia did not occur until the individuals were in their late 20s. What accounts for the difference reported in the age of onset for the types of phobias? Source: Based on Öst (1987, 1992)

17. Agoraphobia • Intense fear of at least two of the following: • Being outside of the home alone • Traveling in public transportation • Being in open spaces • Being in stores or theatres • Standing in line or being in a crowd • These situations are feared because escape or help may not be readily available • Anxiety over having a panic attack

18. Etiology of Phobias Figure 4-5 Multipath Model of Phobias The dimensions interact with one another and combine in different ways to result in a phobia.

19. Etiology of Phobias (cont’d.) • Biological dimension: • Genetics or biological preparedness • Psychological dimension: • Classical conditioning perspective • Observational learning or modeling perspective • Negative information perspective • Cognitive-behavioral perspective

20. Etiology of Phobias (cont’d.) • Social dimension: • Family interaction patterns • Peer victimization • Sociocultural dimension: • Gender • Child-rearing practices • Culturally distinctive phobias

21. Treatment of Phobias • Biochemical: • Benzodiazepines and antidepressant SSRIs are effective in treating social anxiety disorder • Benzodiazepines also used for specific phobias • Side effects of medications • Dependence • Withdrawal symptoms • Paradoxical reactions • Symptoms recur when medication is discontinued

22. Treatment of Phobias (cont’d.) • Behavioral: • Exposure therapy: • Gradually introduce increasingly difficult encounters with feared situation • Systematic desensitization: • Uses muscle relaxation to reduce anxiety • Cognitive restructuring: • Unrealistic thoughts are altered • Modeling: • Patient observes a model coping with, or responding appropriately to, the feared situation

23. Treatment of Phobias (cont’d.) Rapid Behavioral Treatment of a Phobia (Snake Phobia, Fear Conditioning) Watch a demonstration of exposure therapy that helps a snake phobic overcome her severe phobic reaction- in just 3 hours. Learn what researchers have to say about this very brief form treatment and how well the results are maintained over time.

24. Panic Disorder • Recurrent unexpected panic attacks in combination with: • Apprehension over having another attack or worry about consequences of an attack • Changes in behavior or activities designed to avoid another panic attack • Reactions must be present for at least one month

25. Panic Disorder (cont’d.) Panic Disorder Learn about the symptoms and diagnosis of panic disorder.

26. Etiology of Panic Disorder Figure 4-6 Multipath Model of Panic Disorder The dimensions interact with one another and combine in different ways to result in a panic disorder.

27. Etiology of Panic Disorder (cont’d.) • Biological dimension: • Higher concordance rates found in monozygotic twins • Modest heritability rate of 32% • Brain structures (e.g., amygdala) and neurotransmitters (e.g., serotonin) involved • Reduction in GABA receptors in hippocampus and amygdala

28. Etiology of Panic Disorder (cont’d.) • Psychological dimension: • Characteristics associated with panic disorder • Cognitive behavioral perspective: • Stresses individual’s misinterpretation of unpleasant bodily sensations as indicators of impending disaster • Interoceptive conditioning

29. Etiology of Panic Disorder (cont’d.) Figure 4-7 Role of Cognitions in Panic Attacks A positive feedback loop between cognitions and somatic symptoms leads to panic attacks. Source: Roy-Byrne, Craske, & Stein (2006), p. 1027

30. Etiology of Panic Disorder (cont’d.) • Social and sociocultural dimensions: • Stressful childhood involving • Separation anxiety • Family conflicts • School problems • Loss of loved one • Major life changes occurring prior to attacks • Culture plays a role

31. Treatment of Panic Disorder • Both medication and cognitive-behavioral therapies have been effective • Biochemical: • Benzodiazepines, antidepressants, and SSRIs • Cognitive-behavioral: • Extinction of fear associated with internal bodily sensations and fear-producing environmental situations

32. Generalized Anxiety Disorder (GAD) • Persistent high levels of anxiety and excessive worry over many life circumstances • Symptoms must be present for at least three months • Develops gradually, beginning in childhood or adolescence • Somatic symptoms: • Muscle tension, restlessness, sleep difficulties, poor concentration, and avoidance of situations associated with worry

33. Generalized Anxiety Disorder (cont’d.) • 3.1% of adult U.S. population has GAD in any given year • Twice as common in women as in men • Most frequently diagnosed anxiety disorder worldwide

34. Etiology of GAD Figure 4-8 Multipath Model of GAD The dimensions interact with one another and combine in different ways to result in generalized anxiety disorder (GAD).

35. Etiology of GAD (cont’d.) • Biological dimension: • Small but significant heritability factor • May disrupt prefrontal cortex modulation of amygdala • Psychological dimension: • Cognitive theories: role of dysfunctional thinking and beliefs • Negative schemas: set of beliefs or ideas

36. Etiology of GAD (cont’d.) • Social and sociocultural dimensions: • Children of mothers with GAD may develop anxiety disorder • Poverty • Poor housing • Prejudice • Discrimination • More common in separated, divorced, widowed, or unemployed individuals

37. Treatment of GAD • Biochemical treatment: • Benzodiazepines, but problems of dependence • Tricyclic and SSRI antidepressants are medications of choice due to less risk or dependence • Newer antianxiety medication: buspirone • Cognitive-behavioral therapy: • Only consistently validated psychological treatment

38. Obsessive-Compulsive and Related Disorders • Have much in common with anxiety disorders • Include: • Obsessive-compulsive and related disorders • Body dysmorphic disorder • Hair-pulling disorder • Skin-picking disorder

39. Obsessive-Compulsive Disorder • Characterized by: • Obsessions: • Intrusive, repetitive thoughts or images that produce anxiety (e.g., contamination, orderliness, uncertainty) • Compulsions: • The need to perform acts or dwell on thoughts to reduce anxiety (e.g., repetitive behaviors, mental acts)

40. Obsessive-Compulsive Disorder (cont’d.) • Associated thoughts and actions that are out of character and not under voluntary control • Recognition that thoughts and impulses are senseless, but no control • In a given year, about 1% of U.S. adult population suffers from OCD • Onset occurs in childhood or adolescence • May be underdiagnosed

41. Body Dysmorphic Disorder (BDD) • Involves preoccupation with a perceived physical defect in a normal-appearing person or excessive concern over a slight physical defect • Comes from Greek word for abnormal shape • Produces marked clinical distress • Chronic and difficult to treat • Underdiagnosed

42. Body Dysmorphic Disorder (cont’d.) • Compulsive behaviors: • Frequent mirror checking • Excessive grooming • Seeking constant reassurance • Common concerns: • Bodily features (e.g., lack of hair, size of nose) • Muscle dysphoria: believing that one’s body is too small or insufficiently muscular

43. Hair-Pulling Disorder • Hair-pulling disorder (trichotillomania): • Recurrent and compulsive hair pulling that causes significant distress and results in hair loss • Symptoms usually begin before age 17 • 4% of population may be affected • Four times higher prevalence in women

44. Skin-Picking Disorder • Skin-picking disorder: • Distressing and recurrent compulsive picking of the skin resulting in skin lesions • Three-quarters are females • Often comorbid with body dysmorphic disorder or trichotillomania

45. Etiology of Obsessive-Compulsive and Related Disorders Figure 4-11 Multipath Model for OCD The dimensions interact with one another and combine in different ways to result in obsessive-compulsive disorder.

46. Etiology of Obsessive-Compulsive and Related Disorders (cont’d.) • Biological dimension: • Decision making, planning, and mental flexibility may be endophenotypes for OCD • Brain structure: • Orbitofrontal cortex • Caudate nuclei • Genetic studies • Biochemical abnormalities: • Serotonin deficiency

47. Etiology of Obsessive-Compulsive and Related Disorders (cont’d.) Figure 4-12 OrbitoFrontal Cortex Individuals with untreated obsessive-compulsive disorder show a high metabolism rate in this area of the brain. Certain medications reduce metabolic rates to “normal” levels and also reduce obsessive-compulsive symptoms.

48. Etiology of Obsessive-Compulsive and Related Disorders (cont’d.) • Psychological dimension: • Behavioral perspective: • Obsessive-compulsive behaviors develop because they reduce anxiety • Cognitive characteristics: • Threat estimation • Control • Intolerance of uncertainty • Distrust of own memories and judgment • Disconfirmatory bias

49. Etiology of Obsessive-Compulsive and Related Disorders (cont’d.) • Social and sociocultural dimensions: • Family variables • Controlling, overly critical parenting styles • Low parental warmth • Discouragement of autonomy • Being raised in adverse environments • Ethnic minorities underrepresented in clinical studies • Culture may affect how symptoms are expressed

50. Treatment of Obsessive-Compulsive and Related Disorders • Biological treatments: • SSRI’s have fewer side effects but only 60% of individuals respond to them • Rapid return of symptoms • Behavioral treatments: • Combination of exposure and response prevention • Flooding versus gradual exposure • Cognitive-behavioral therapy