psychopathology ch 5 - anxiety, OCD, and related disorders

Fear

Central nervous

system’s physiological

and emotional response

to a serious threat to

one’s well-being.

Anxiety

Central nervous

system’s physiological

and emotional response

to a vague sense of threat or danger

Anxiety disorders

The most common mental disorders in the US.

Generalized anxiety disorder symptoms

1. For 6 months or more, person experiences

disproportionate, uncontrollable, and ongoing

anxiety and worry about multiple matters.

2. The symptoms include at least three of the

following: edginess, fatigue, poor concentration,

irritability, muscle tension, sleep problems.

3. Significant distress or impairment.

• Generalized anxiety disorder

● Excessive anxiety experienced

under most circumstances

● Worry about practically anything

● Reduced quality of life

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● 3% of U.S. population

● Most likely to develop in people faced with dangerous ongoing social conditions or highly threatened environment. (Poverty or widespread contagious diseases)

Generalized Anxiety Disorder:

Psychodynamic Perspective

● GAD occurs with high

anxiety levels or

inadequate defense

mechanisms.

● GAD can be traced to

early parent-child

relationships such as

harsh punishment

Generalized Anxiety Disorder:

Humanistic Perspective

● GAD arises when people stop looking at

themselves honestly and acceptingly.

● Carl Rogers' explanation

● Lack of unconditional positive regard in

childhood leads to conditions of worth (i.e., harsh

self-standards).

● Threatening self-judgments break through and

cause anxiety, setting the stage for GAD to

develop.

Generalized Anxiety Disorder:

Cognitive-Behavioral Perspective

● Problematic behaviors and dysfunctional

thinking often cause psychological disorders.

● Many proponents of this model

concentrate largely on the cognitive

dimension of GAD.

● Maladaptive assumptions

● metacognitive theory

● Intolerance of uncertainty theory

Maladaptive assumptions

●People are guided by basic irrational

assumptions (Ellis)

● Researchers have repeatedly found that

people with GAD do hold maladaptive

assumptions, particularly about

dangerousness.

Metacognitive theory

People hold positive and

negative beliefs about

worrying. Worrying is key

feature of GAD.

Lo

Intolerance of

uncertainty theory

People cannot tolerate

knowledge that negative

events may occur

Generalized Anxiety Disorder: Biological

Perspective

GAD is caused chiefly by biological factors.

● Supported by family pedigree studies

● Brain research

● Approximately 15% of relatives of people with

GAD display it themselves; much higher

prevalence rate than that found in general

population.

● Brain circuits

● Circuits are networks of brain structures that

work together, triggering each other into

action.

● Fear circuit starts emotional chain of events;

hyperactive in people with GAD.

Biological therapies

● Benzodiazepines (alprazolam,

lorazepam, diazepam).

-Benzodiazepine receptors receive GABA.

-GABA carries inhibitory message that ends

firing of neuron receptor.

-But these meds are addictive.

-Low GABA could help produce excessive

brain circuit communication and contribute to

GAD development.

● Gabapentinoids (gabapentin,

pregabalin) - Have significant anxiety-reducing effect;

act to increase GABA levels throughout

brain.

● Antidepressants - BEST TREATMENT, Increase serotonin and norepinephrine

neurotransmitter activity

GAD Cognitive-Behavioral Therapies

● Changing maladaptive assumptions

-Ellis's rational-emotive therapy (RET)

● Breaking down worrying

-Mindfulness-based cognitive-behavioral therapy

-Acceptance and commitment therapy

Phobias

● More intense and persistent fear of object,

activity, or situation

● Avoidance of the feared object or situation

● Create distress that interferes with functioning

Specific Phobia symptoms

1. Marked, persistent, and disproportionate fear of a particular object or situation; lasting at least 6 months

2. Exposure to the object produces immediate fear

3. Avoidance of the feared situation

4. Significant distress or impairment

Agoraphobia Symptoms

1. Pronounced, disproportionate, or repeated

fear about being in at least two delineated

situations, e.g. shops, crowds, away from home

2. Fear of such agoraphobic situations

derives from concern that it would be hard to

escape or get help if panic, embarrassment, or

disabling symptoms were to occur

3. Avoidance of the feared situation

4. Significant distress or impairment

Cause of phobias

Cognitive-behavioral theories receive

most research support.

● Focus primarily on behavioral dimension

● First fear of certain objects, situations, or

events is learned through classical

conditioning or modeling.

● Once fears are acquired, individuals avoid

dreaded object or situation and permit fears to

become entrenched due to operant

conditioning.

Behavioral-biological explanation

• species-specific biological predisposition to develop certain fears: biological preparedness, leading to some phobias more common

Behavioral treatment for phobia

Exposure treatment for specific phobias

● Systematic desensitization

-Relaxation training

-Fear hierarchy

-In vivo desensitization

● Flooding

● Modeling

● Actual contact with the feared object or

situation is key to greater success.

Agoraphobia treatments

Include variety of exposure therapy

(cognitive-behavioral) approaches

● Support groups

● Support groups

● Home-based self-help programs

Relapses more likely when panic disorder exists

Social anxiety disorder symptoms

1. Pronounced, disproportionate, or repeated

anxiety about social situation(s) in which the individual could be exposed to scrutiny by others; typically lasting 6 months or more.

2. Fear of being negatively evaluated by or

offensive to others

3. Exposure to the social situation almost always

produces anxiety.

4. Avoidance of feared situations

5. Significant distress or impairment

Causes of social anxiety disorder

Cognitive-behavioral perspective

● Social dysfunctional beliefs and expectations

● Anticipation of social disasters and dread of

social situations.

● Avoidance and safety behaviors performed to

reduce or prevent these disasters.

Genetic predispositions

● Trait tendencies

● Biological inheritance

Treatments for social anxiety disorder

Medications:

● Benzodiazepine

● Antidepressant drugs*

Cognitive-behavioral therapy:

● Exposure therapy* (systemic desensitization)

● Social skills and assertiveness training

Panic attacks

Periodic, short bouts of panic that occur

suddenly, reach a peak within minutes, and

gradually pass. They 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 symptoms

1. Unforeseen panic attacks occur repeatedly

2. One or more of the attacks are followed by:

● At least a month of continual concern

about having additional attacks

● At least a month of dysfunctional

behavior changes associated with the

attacks (e.g., avoiding new experiences)

biological factors in panic disorder

Hyperactive panic circuit

● Amygdala

● Hippocampus

● Ventromedial nucleus of hypothalamus

● Central gray matter

● Locus coeruleus

● Most today’s researchers believe that brain circuit

(panic circuit) tends to be hyperactive in people

who display panic disorder

● Predisposition to develop such irregularities is

inherited.

Panic disorder Drug therapies

The best treatment for panic.

• Various antidepressants bring some

improvement to more than two-thirds of

patients.

● Drugs function in norepinephrine receptors in

the panic brain circuit.

● Improvements require maintenance of drug

therapy.

● Some benzodiazepines and antihistamines

(e.g. Xanax and hydroxyzine) have proved

helpful.

Cognitive-behavioral perspective of panic

● Bodily sensations are misinterpreted as

signs of medical catastrophe and controlled by

avoidance and safety behaviors.

● Anxiety sensitivity may exist.

Cognitive-behavioral therapy for panic

Best treatment.

Seeks to correct people's misinterpretations

of their bodily sensations

● Educate about nature of panic attacks

● Teach applications of more accurate

interpretations

● Teach skills for coping with anxiety, including

biological challenge procedures

● Use biological challenge procedures to induce

panic sensations so clients can apply new

interpretations and skills under watchful

supervision

Obsessions

Persistent thoughts, ideas, impulses, or

images that seem to invade a person's

consciousness

Compulsions

Repetitive and rigid behaviors or mental acts

that people feel they must perform to prevent

or reduce anxiety

OCD symptoms

1. Occurrence of repeated obsessions,

compulsions, or both

2. The obsessions or compulsions take

up considerable time

3. Significant distress or impairment

Features of obsessions

Features

● Thoughts that feel both intrusive and foreign

● Attempts to ignore or resist them trigger

anxiety

● Awareness that thoughts are excessive

Basic themes

● Dirt/contamination

● Violence and aggression

● Orderliness

● Religious values

● Sexuality

Features of compulsions

Features

● Feel mandatory/unstoppable

● Recognition that behaviors are unreasonable

● Performing behaviors briefly reduces anxiety

Themes

● Cleaning compulsions

● Checking compulsions

● Order or balance seeking

● Touching

● Counting

Cognitive-behavioral perspective of OCD

● People have uncomfortable thoughts.

● People with OCD attempt to neutralize

their thoughts with actions.

● Experience a brief reduction in anxiety

after “neutralizing” behavior = negative

reward.

● So, they continue to engaging in

neutralizing behaviors which become

compulsions.

Cognitive-behavioral therapy for OCD

Exposure and response prevention**

● Exposure client to anxiety provoking situation

● Prevent (or greatly delay) performing

compulsion.

● Prevents negative reward.

● 2/3 of people improve with ERP therapy

Cognitive habituation

● Repeatedly think about obsessional thoughts

until they lose their power.

● Not as effect of ERP, but useful if person only

has obsessions.

Biological perspective of OCD

● Genetic studies identified gene anomalies.

● Brain scan procedures reveal hyperactive

cortico-striato-thalamo-cortical brain

circuit.

● Difficulty in turning off or dismissing various

impulses

● Symptoms often arise or subside after

structures in the brain circuit are damaged.

Biological treatment of OCD

Serotonin-enhancing antidepressants

● Improvement in 50 to 60% of those with OCD

Most affective treatment for OCD

combination of medication + cognitive-behavioral therapy approaches

OCD related disorders

• Hoarding disorder

• trichotillomania

• Excoriation

• Body dysmorphic disorder

Trichotillomania

Hair-pulling disorder

Excoriation

Skin-picking disorder

Body dysmorphic disorder

preoccupied with the belief that they have certain defects in their physical appearance