Anxiety, Obsessive - Compulsive, and Related Disorders

Anxiety Disorders - Fear

Central nervous system’s physiological and emotional response to a serious threat to one’s well-being

Anxiety Disorders - Anxiety

Central nervous system’s physiological and emotional response to a vague sense of threat or danger

Anxiety Disorders - Generalized anxiety disorder

Disorder marked by persistent and excessive feelings of anxiety and worry about numerous events and activities

Most common mental disorders in the United States

• In any given year, 18 percent of the U.S. adult population experiences one of the six DSM-5 anxiety disorders.

• About 29 percent develop one of the disorders at some point in their lives.

• About one-third of these individuals seek treatment

Generalized anxiety disorder

Higher in females, low-income groups, and the elderly

Specific phobias

Higher in females and low-income groups;

Lower in elderly

Agoraphobia

• Higher in females, low-income groups, and the elderly

Social anxiety disorder

Higher in females and low-income groups;

Lower in elderly

Panic disorder

Higher in females and low-income groups;

Lower in elderly

Obsessive-compulsive disorder

Same in females; Higher in low-income groups;

Lower in elderly

Separation anxiety disorder

• Most common disorder among young children.

• DSM-5 determined separation anxiety can develop in adults.

• New categorization as an anxiety disorder is controversial

GAD checklist

• For 6 months or more, the person experiences

  • disproportionate

  • uncontrollable

  • ongoing anxiety

  • worry about multiple matters.

• Significant distress or impairment

• GAD symptoms include at least three

• Edginess

• Fatigue

• Poor concentration

• Irritability

• muscle tension

• sleep problems

Sociocultural perspective on GAD

• GAD is most likely to develop in people faced with dangerous ongoing social conditions.

  • Supported by research findings.

• Forms of societal stress:

  • Poverty

  • Race and ethnicity

Psychodynamic perspective on GAD (1)

• Freud posited that all children experience anxiety.

  • Realistic anxiety when they face actual danger.

  • Neurotic anxiety when they are prevented from expressing id impulses.

  • Moral anxiety when they are punished for expressing id impulses.

• Some children experience particularly high levels of anxiety or their defense mechanisms are particularly inadequate

Psychodynamic therapies

• Free association.

• Therapist interpretations of

  • transference

  • resistance

  • dreams.

Specific treatments for GAD

• Freudians focus less on fear and more on control of id.

• Short-term psychodynamic therapy is more effective

Humanistic perspective on GAD

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

Carl Rogers' explanation of Humanistic perspective

• Lack of unconditional positive regard in childhood leads to conditions of worth

• Threatening self-judgments break through and cause anxiety, setting the stage for GAD to develop

Humanistic perspective on GAD -pt2.

• Client-centered approach, used to show unconditional positive regard for clients and to empathize with them.

• Despite optimistic case reports, controlled studies have failed to offer strong support.

• Only limited support for Rogers' explanation of GAD and other forms of abnormal behaviour

Cognitive-behavioral perspective on GAD (1)

• Problematic behaviors and dysfunctional thinking often cause psychological disorders.

• Treatment focus involves the nature of behavior and thoughts.

Early approach of cognitive-behavioural perspective

• Maladaptive or basic irrational assumptions (Ellis).

• Silent assumptions (Beck)

Cognitive-behavioural perspective on GAD

• Newer explanations:

  • Metacognitive theory (Wells) and meta-worries.

  • Intolerance of uncertainty theory (Koerner and colleagues).

  • Avoidance theory (Borkovec)

Cognitive-behavioral therapies for GAD

• Changing maladaptive assumptions:

  • Ellis's rational-emotive therapy (RET).

• Breaking down worrying.

  • Mindfulness-based cognitive-behavioural therapy.

  • Acceptance and commitment therapy

Biological perspective on GAD (1)

• GAD is caused chiefly by biological factors.

  • Supported by family pedigree studies and brain researchers.

  • Challenged by competing explanation of shared environment.

• Fear reactions are tied to brain circuits

GAD results from a hyperactive fear circuit

• GAD results from a hyperactive fear circuit involving neurotransmitters like GABA, which plays a crucial role in regulating anxiety responses.

Fear network involves several brain structures

• Prefrontal cortex

• Anterior cingulate cortex

• Insula

• Amygdala

Drug therapy in Biological perspective of GAD

• Early 1950s: Barbiturates (sedative-hypnotics).

• Late 1950s: Benzodiazepines.

• More recently: Antidepressant and antipsychotic medications

Differences between Fear and Phobias

Fear: a normal and common experience

Phobias:

• More intense and persistent fear

• Greater desire to avoid the feared object or situation

• Create distress that interferes with functioning

Biggest Existential fears

Categories of phobias

• specific phobias

• Agoraphobia

Specific Phobia

• Yearly symptoms exist in 10 percent of all U.S. people

• 14% of people experience symptoms durin lifetime

• Women outnumber men 2:1

• 32 % seek treaatment

Checklist for specific phobias

• Marked, persistent, and disproportionate fear of a particular object or situation; usually lasting at least 6 month

• Exposure to the object produces immediate fear

• Avoidance of the feared situation

• Significant distress or impariment

Agoraphobia

• Yearly symptoms exist in 1.7 percent of U.S. population

• 2.6 percent of people experience symptoms during lifetime; gender differences

• 46% seek treatment

Checklist of Agoraphobia

• Pronounced disproportionate, or repeated fear about being in at least twp delineated situations

• Avoidance of the agoraphobic situations

• Symptoms usually continue for at least 6 months

• Significant distress or impairment; often fluctuates

What causes specific phobias?

• Evidence supports the behavioural explanations

  • Cognitive-behavioural theory

  • Behavioural-evolutionary explanations

Cognitive-behavioral perspective

• Classical conditioning

• Modelling

  • Observation

  • Imitation

Why does cognitive-behavioural research indicate?

• Early laboratory studies of classical conditioning of fear : Watson and Rayner

• Modelling: Bandura and Rosenthal

Behavioural-evolutionary perspective

• Some specific phobias are much more common than others

• Species-specific biological predisposition to develop certain fears: preparedness

• Explains why some phobias (snakes, spiders) are more common than others (cars, guns, bicycles

• Treatments for specific phobias in BE perspective

• Actual contact with the feared object or situation is key to greater success in all forms of exposure treatment

  • Systematic desensitization

    • Covert and in vivo desensitization; virtual reality

  • Flooding

  • Modeling

Treatments for agoraphobia

• Variety of exposure therapy approaches

  • Support groups

  • home-based self-help programs

• Are successful for about 70 percent of agoraphobic clients

• Relapses may occur, especially when panic disorder also exists

Social Anxiety Disorder

• Yearly symptoms exist in 8 percent of U.S. population

• 13 percent of people experience symptoms during lifetime

• Often begin in late childhood or adolescence and into adulthood

• 40 percent seek treatment

Check list for SAD

• Pronounced, disproportionate, and repeated anxiety about social situation(s) in which the individual could be exposed to scrutiny by others; typically lasting 6 months or more

• Fear of being negatively evaluated by or offensive to others

• Exposure to the social situation almost always produces anxiety

• Avoidance of feared situations

• Significant distress or impairment

Cognitive-behavioral perspective on SAD

• Leading explanation for this disorder features cognitive and behavioural factors'

• Group of social realm dysfunctional beliefs and expectations held

• Anticipation of social disasters and dread of social situations

• Avoidance and safety behaviours performed to reduce or prevent these disasters

Treatments for social anxiety disorder

• Overwhelming social fears: Addressed behaviourally with exposure

  • Cognitive-behavioural therapy: Exposure therapy and systematic therapy discussions

  • Medications: Benzodiazepine or antidepressant drugs

• Lack of social skills

  • Social skills and assertiveness training

MindTech: Social Media Jitters

• Computer and mobile device use can produce more common forms of anxiety, including social and generalized anxiety

  • Facebook, Instagram, or Snapchat

Panic attacks - PD

Periodic, short bouts of panic that occur suddenly, reach a peak within minutes, and gradually pass

Feature at least four of the following symptoms of panic:

• Heart palpitations

• Tingling in the hands or feet

• Shortness of breath

• Sweating

• Hot and cold flashes

• Trembling

• Chest pains

• Choking sensations

• Faintness

• Dizziness

• Feeling of unreality

Panic Disorder

• 3.1 percent of U.S. population experience this disorder yearly

• More than 5 percent of people experience symptoms during lifetime

• Often begins in late adolescence or early adulthood

• 59 percent seek treatment

• Maybe accompanied by agoraphobia

Checklist for PD

• Unforeseen panic attacks occurs repeatedly

• One or more of the attacks precede either of the following symptoms

  • At least a month of continual concern about having additional attacks

  • At least a month of dysfunctional behaviour changes associated with the attacks

Biological perspective

• Initial theory

  • Panic attacks caused by abnormal norepinephrine activity in locus coeruleus

• More recent theory

  • Brain circuits and amygdala are the more complex root of the problem

  • May be an inherited predisposition to abnormalities in these areas

Caused by a hyperactive panic circuit

• Amygdala

• Hippocampus

• Ventromedial nucleus of hypothalamus

• Central gray matter

• Locus coeruleus

Drug therapies for PD

• Various antidepressants bring some improvement to more than tow-thirds of patients

• Function in norepinephrine receptors in the panic brain circuit

• Improvements require maintenance of drug therapy

• Some Benzodiazepines have probed helpful (Xanax especially)

Cognitive-behavioral perspective in PD

• Biological factors are only part of the cause of panic attacks

• Bodily sensations are misinterpreted as signs of medical catastrophe and controlled by avoidance and safety behaviours

• Anxiety sensitivity may exist

  • The tendency to focus on biological sensations and interpret them as harmful

Biological challenge test for PD

procedure used to produce panic and asses panic disorder

Cognitive therapy for PD

Seeks to correct people’s misinterpretations of their bodily sensations

• Educate about the nature of panic attacks

• Teach applications of more accurate interpretations

• Teach skills for coping with anxiety, including biological challenge procedures

Obsessions

Persistent thoughts, ideas, impulses, or images that seem to invade a person’s consciousness

Compulsions

Repetitive and rigid behaviours or mental acts that people feel they must perform to prevent or reduce anxiety

Obsessive Compulsive Disorder

• Related to other disorders in features, causes and treatment reponsiveness

• Affects 1 to 2 percent of world population

• Begins in childhood or young adulhood; Fluctuating severity

• Equally common among men and women

• 40 percent seek treatment

OCD Checklist

• Occurrence of repeated obsessions, compulsions, or both

• The obsessions or compulsions take up considerable time

• Significant distress or impairment

Obsessions features

• Thoughts that feel both intrusive and foreign

• Attempts to ignore or resist them trigger anxiety

Common Obsession Themes

• Dirt / contamination

• Violence and aggression

• Orderliness

• Religion

• Sexuality

Compulsions features

• Various forms of voluntary behaviours or mental acts

• Feel mandatory/ unstoppable

• Most people recognize that their behaviour is unreasonable

• Performing behaviours reduces anxiety for a short time

• Behaviours often develop into rituals

Common Compulsion Themes

• Cleaning

• Checking

• Order or Balance

• Touching / counting / verbalizing.

Theory of Psychodynamic View on OCD

• Battle between the ID and the EGO defence mechanisms lessens anxiety in overt thoughts and actions

• Freud: OCD related to the anal stage of development.

• Not all psychodynamic theorists agree

Treatment of Psychodynamic View on OCD

• Classical techniques of free association and therapist interpretation; have little research support

• Short-term psychodynamic therapies are direct and action-oriented

CBT View on OCD

• Disorder grow from human tendencies to have unwanted and unpleasant thought

• To avoid negative outcomes, individuals attempt to neutralize their thoughts with actions (or other thoughts)

• Irrational though contribute to the disorder

To avoid negative outcomes, individuals attempt to neutralize their thoughts with actions (or other thoughts)

• Seeking reassurance

• Thinking ‘Good’ thoughts

• Washing or checking

Irrational though contribute to the disorder

• Having very high moral standards

• Though-action fusion: idea that thoughts are equivalent to do behaviour and can do damage

• Need for perfect control over thoughts

CBT Treatment for OCD+

• Focus on the cognitive processes that help to produce and maintain obsessive thoughts and compulsive acts

• Use exposure and response prevention exercises (ERP) (Meyer)

  • Set example

  • Use videoconferencing in recent years (exposure in naturalistic environment)

  • Between 50 and 70 percent improvement with therapy

Biological View on OCD

Early research

• Family pedigree and twin studies

Recent research

• Abnormal serotonin activity

• Abnormal brain structure and functioning

• Cortico - striato - thalamo - cortical circuit

Biological Treatment for OCD

Serotonin-based antidepressants

• Clomipramine (Anafanil) and similar drugs

• Improvement in 50 to 80 percent of those with OCD

• Relapse occurs if medication is stopped

Research suggests that combination therapy (Medication +CBT) may be most effective

Related Disorders to OCD (DSM-5)

• Hoarding

• Trichotillomania (Hair pulling disorder)

• Excoriation (Skin-picking disorder)

• Body dysmorphic disorder.

Developmental Psychopathology View

Examination of how key factors emerge and intersect at a point throughout the lifespan

General foci in Developmental psychopathology perspective

• Genetic factors

• Hyperactive fear circuit in brain

• Inhibited temperament

• Parenting style

• Maladaptive thinking

• Avoidance behaviours

• Life stress

• Negative social factors

Francis gets very anxious whenever she gets on a plane. Whenever she needs to fly, she needs to take a sleeping pill because otherwise she becomes very tense and starts to worry that she cannot escape the plane if needed. For the same reason, she does not enjoy going to malls or the theatre. What is the best fitting diagnosis for Francis?

Agoraphobia