Chapter Five: Anxiety, Obsessive-Compulsive, and Related Disorders

• Fear: State of immediate alarm
• Anxiety: Vague sense of being in danger
• Anxiety Disorders: When people have discomfort from fear and anxiety is too severe, too frequent, lasts too long, or is triggered too easily
    * Most common mental disorders in the us
    * Most people with one anxiety disorder suffer from a second
    * Generalized Anxiety Disorder: Experience general and persistent feelings of worry and anxiety
    * Specific Phobias: Persistent and irrational fear of a particular object, activity, or situation
    * Agoraphobia: Fear traveling to public places
    * Social Anxiety Disorder: Intense fear of social or performance situations in which they may become embarrassed
    * Panic Disorder: Recurrent attacks of terror

Generalized Anxiety Disorder

• People experience excessive anxiety under most circumstances and worry about anything
• Symptoms: restlessness, on edge, tire easily, have difficulty concentrating, suffer from muscle tension, have sleep problems
    * Last at least 6 months
    * Lead to a reduced quality of life
• Common in Western society
• May emerge at any age
• Twice as common in women

The Sociocultural Perspective: Societal and Multicultural Factors

• GAD is most likely to develop in people who are faced with ongoing societal conditions that are dangerous
• ex - poverty: as wages decrease, the rate of GAD steadily increases
• Race and ethnicity can also affect GAD

The Psychodynamic Perspective

• Freud: Early developmental experiences may produce an unusually high level of anxiety in certain children
• Today: GAD can be traced to inadequacies in the early relationships between children and their parents
• Therapies
    * Psychodynamic Methods: free association and therapist’s interpretations of transference, resistance, and dreams
    * Freudian Psychodynamic Therapists: help clients with gad become less afraid of their id impulses and more successful in controlling them
    * object relations therapists: help anxious patients identify and settle the childhood relationship problems that continue to produce anxiety in adulthood
    * short-term psychodynamic therapy has significantly reduced the levels of anxiety, worry, and social difficulty of patients

The Humanistic Perspective

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

• Client-centered therapy is basically placebo therapy

The Cognitive-Behavioral Perspective

• GAD is primarily caused by maladaptive assumptions
• Albert Ellis: Many people are guided by irrational beliefs that lead them to act and react in inappropriate ways (basic irrational assumptions)
• Aaron Beck: Ppl with GAD constantly hold silent assumptions that imply they’re in imminent danger
• Adrian Wells’ Metacognitive Theory: Ppl with GAD implicitly hold positive and negative beliefs about worrying
    * Positive: Believe worrying is a useful way of appraising and coping with threats in life, so they worry constantly
    * Negative: Believe their repeated worrying is harmful and uncontrollable, so they meta-worry
• Intolerance of Uncertainty Theory: Certain individuals can’t tolerate the knowledge that negative events can occur, even if the possibility is small
• Avoidance Theory: Thomas Borkovec
    * People with GAD have greater bodily arousal and worrying serves to reduce that arousal
    * People with GAD worry repeatedly in order to reduce or avoid uncomfortable states of bodily arousal
• Therapies:
    * Ellis’ Rational-Emotive Therapy: Therapists point out the irrational assumptions held by clients, and suggest more appropriate assumptions
    * Breaking Down Worrying: Therapists guide clients to recognize and change their dysfunctional worrying
      * Educate clients about the role of worrying
      * Have clients observe their bodily arousal and cognitive responses
      * Clients are expected to see the world as less threatening and try out more constructive ways of dealing with arousal
    * Mindfulness-based Cognitive-Behavioral Therapy
      * Therapists help clients become aware of their stream of thoughts as they’re happening and to accept such thoughts are mere events of the mind
      * Borrows heavily from mindfulness meditation

The Biological Perspective

• GABA plays a key role in the reduction of normal, everyday fear reactions
    * Low GABA activity can help produce circuit hyperactivity
• Fear reactions are tied to brain circuits
    * The fear circuit is excessively active in people with GAD
• Drug Therapies
    * Sedative-hypnotic Drugs: Drugs that calm people at lower doses and help them to fall asleep at higher doses
    * Benzodiazepines, while helpful, pose significant problems
      * Effects are short-lived and anxiety comes back full-force
      * Ppl who take them in large doses for an extended time can become physically dependent
      * Can produce undesirable effects: drowsiness, lack of coordination, memory loss, depression, aggressive behavior
      * Drugs mix badly with certain other drugs / substances
• Antidepressants and antipsychotics are both used for GAD

Phobias

• Phobias: Persistent and unreasonable fears

Specific Phobia

• Specific Phobia: Persistent fear of a specific object or situation (ex: animals/insects, heights, flying, etc)

Agoraphobia

• Agoraphobia: Fear of being in public places or situations where escape might be difficult or help unavailable

• Twice as common among women, twice as common among poor ppl

• Intensity fluctuates

• May also have panic disorder

• Support-Group Approach: A small number of ppl with agoraphobia go out together for exposure sessions

• Home-based Self-help Programs: Clinicians give clients and their families detailed instructions for carrying out exposure treatments themselves

What Causes Phobias?

• Cognitive-Behavioral: Ppl learn their fears
    * Classical Conditioning (two events repeatedly occur close together)
    * Modeling (through observation and imitation)
• Behavioral-Evolutionary: Some phobias are much more common than others
    * Humans have a predisposition to develop certain fears
    * Preparedness: Human beings are prepared to acquire some phobias and not others

How Are Phobias Treated?

• Exposure Treatments: People are exposed to the objects / situations they dread
    * Systematic Desensitization: An exposure treatment that uses relaxation training and a fear hierarchy to help clients with phobias react calmly to their fear
      * Relaxation Training: Teaching clients how to bring on a state of deep muscle relaxation at will
      * Fear Hierarchy: A list of feared objects / situations
      * In Vivo Desensitization: Actual confrontation
      * Covert Desensitization: Confrontation may be imagined
    * Flooding: Clients are exposed repeatedly and intensively to a feared object and made to see that it is actually harmless
    * Modeling: The therapist confronts the feared object / situation while the fearful person observes

Social Anxiety Disorder

• Social Anxiety Disorder: A severe and persistent fear of social or performance situations in which embarrassment may occur

• Can interfere greatly with one’s life

What Causes Social Anxiety Disorder?

• Ppl have dysfunctional beliefs that make them anticipate social disasters and dread social situations
    * Those beliefs are reinforced by reducing feelings of anxiety
    * Ppl with social anxiety disorder manifest the dysfunctional beliefs

Treatments for Social Anxiety Disorder

• Medications
• Cognitive-Behavioral Therapy
• Exposure Therapy: Expose themselves to their dreaded social situations, re-examine and challenge maladaptive beliefs
• Social Skills Training: Modeling, role-playing, rehearsing, feedback, reinforcement
• Assertiveness Training Groups: Members try out and rehearse new social behaviors with other group members

Panic Disorder

• Panic Disorder: An anxiety disorder marked by recurrent and unpredictable panic attacks

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

• ⅓ of ppl have one or more panic attacks at some point in their lives

• Often accompanied by agoraphobia

The Biological Perspective

• Panic disorder might be caused by abnormal norepinephrine activity

• Locus Coeruleus: A small area of the brain that seems to be active in the regulation of emotions

• Panic reactions are produced by a brain circuit

• The panic circuit tends to be hyperactive in people who suffer from panic disorder

• Panic circuit seems to be more extensive than the fear circuit - panic responses are more complex reactions than fear responses

• A predisposition to hyperactive panic circuits may be inherited

• Antidepressants are used

The Cognitive-Behavioral Perspective

• Panic prone people may be very sensitive to certain bodily sensations and misinterpret them as signs of a medical catastrophe
• Biological Challenge Tests: Researchers produce hyperventilation / other biological sensations by administering drugs / instructing clinical research participants to breathe, exercise, or think in certain ways
• High degree of anxiety sensitivity: A tendency to focus on one’s bodily sensations, assess them illogically, and interpret them as harmful
• Therapy
    * Educate clients about the general nature of panic attacks, causes of bodily sensations, and the tendency for clients to misinterpret their sensations
    * Teach clients to apply more accurate interpretations during stressful situations
    * Teach the clients better ways to cope with anxiety
    * Use biological challenge procedures to induce panic sensations so clients can apply their new interpretations and skills
    * Cognitive-Behavioral Therapy

Obsessive-Compulsive Disorder

• Obsessive Compulsive Disorder: A disorder in which a person has recurrent obsessions, compulsions, or both

What Are the Features of Obsessions and Compulsions?

• Obsessions: Persistent thoughts, ideas, impulses, or images that seem to invade a person’s consciousness
    * Feel intrusive and foreign to the ppl who experience them
    * Ppl w obsessions are aware that their thoughts are excessive
    * Common themes: contamination, violence, orderliness, religion, sexuality
• Compulsions: Repetitive and rigid behaviors / mental acts that people feel they must perform in order to prevent or reduce anxiety
    * Technically under voluntary control, but the person doesn’t feel like they have a choice
    * For some people the compulsive acts develop into detailed rituals
    * Common themes: cleaning, checking, order, counting
• Anxiety plays a major role in this disorder
    * Obsessions cause intense anxiety
    * Compulsions prevent / reduce anxiety

The Psychodynamic Perspective

• The Id impulses take the form of obsessive thoughts
• The Ego defenses appear as counter-thoughts or compulsive actions
• Freud traced OCD to the anal stage of development
    * Children repeatedly feel the need to express their strong aggressive Id impulses while also feeling they should try to restrain and control the impulses
    * If the conflict between the Id and the Ego continues, it may eventually turn into OCD

The Cognitive-Behavioral Perspective

• Everyone has repetitive, unwanted, and intrusive thoughts
    * Those with OCD blame themselves for those thoughts and expect that something bad will happen, so they try to neutralize the thoughts
    * Neutralizing: A person’s attempt to eliminate unwanted thoughts by thinking or behaving in ways that put matters right internally, making up for the unacceptable thoughts
      * Eventually the neutralizing thought or act is used so often that it becomes an obsession or compulsion
    * Those with OCD find their thoughts to be so disturbing because they
      * Tend to have exceptionally high standards of conduct and morality
      * Tend to believe that intrusive negative thoughts  are equivalent to actions and capable of causing harm (thought-action fusion)
      * Tend to believe that they should have perfect control over all their thoughts and behaviors in life
    * Exposure and Response Prevention: Clients are repeatedly exposed to objects or situations that produce anxiety and obsessive fears but they are told to resist performing their compulsive behaviors

The Biological Perspective

• Some genetic studies have identified clusters of gene abnormalities
• Researchers have identified a brain circuit that helps regulate our primitive impulses. hyperactive in ppl with OCD
• Antidepressants are used

Obsessive-Compulsive-Related Disorders

• Hoarding Disorder: People feel compelled to save items and become very distressed if they try to discard them
• Trichotillomania: Hair pulling disorder. ppl repeatedly pull out hair from their scalp, eyebrows, eyelashes, or other parts of the body. They often try to reduce / stop the behavior
• Excoriation Disorder: Skin picking disorder. Ppl keep picking at their skin, resulting in significant sores or wounds. They often try to reduce / stop the behavior
• Body Dysmorphic Disorder: People become preoccupied with the belief that they have a particular defect / flaw in their physical appearance
    * The perceived defect / flaw is imagined or greatly exaggerated in the person’s mind