Chapter 5

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

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.

3. 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

4. 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

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

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

7. 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…

8. 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

9. 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, about 6% of African Americans vs. 3.5% of Caucasians suffer from GAD • African American women have highest rates (6.6%)

10. GAD: The Sociocultural Perspective • 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…

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…GAD develops!

12. GAD: The Psychodynamic Perspective • 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?

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 • Non-anxious people faced with threats may use repression • Some data contradict the model • Many (if not most) GAD clients report normal childhood upbringings

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: help patients identify and settle early relationship conflicts

15. GAD: The Psychodynamic Perspective • 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

16. 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

17. 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

18. 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…

19. GAD: The Cognitive Perspective • 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

20. 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 • It is best to assume the worst • My security depends on anticipating and preparing myself at all times for any possible danger

21. GAD: The Cognitive Perspective • Research supports the presence of these types of assumptions in GAD • Also shows that people with GAD pay unusually close attention to threatening cues

22. GAD: The Cognitive Perspective • 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

23. GAD: The Cognitive Perspective • Two kinds of cognitive therapy: • Changing maladaptive assumptions • Based on the work of Ellis and Beck • Teaching coping skills for use during stressful situations

24. GAD: The Cognitive Perspective • 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

25. GAD: The Cognitive Perspective • 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

26. GAD: The Cognitive Perspective • 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

27. 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

28. 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

29. GAD: The Biological Perspective • 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

30. GAD: The Biological Perspective • 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?

31. 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: azaspirones (BuSpar) • Different receptors, same effectiveness, fewer problems

32. 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

33. GAD: The Biological Perspective • 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.)

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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…

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

43. 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

44. 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

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

47. 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

48. 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

49. 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)

50. 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