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3 Anxiety and Obsessive-Compulsive Disorders Chapter Objectives After reading this chapter, you should be able to:
• Identify anxiety and obsessive-compulsive disorders.
• Describe how anxiety and obsessive-compulsive disorders develop.
• Identify and discuss how anxiety and obsessive-compulsive disorders are treated.
• Differentiate between fear, anxiety, and panic. John Holcroft/SuperStock get81325_03_c03.indd 59 12/5/13 3:59 PM Section 3.1 The Anxiety Spectrum 3.1 The Anxiety Spectrum When we encounter any kind of threat or stressor, we experience a number of physi- ological responses: our heart rate, blood pressure, and breathing increase; our muscles tense; our blood vessels constrict; our liver releases glucose to provide quick energy to muscles; our spleen releases red blood cells to help carry oxygen.
We feel fear or dread; we may also feel irritable or restless. We scan our environment for signs of danger. The intensity of our responses depends on the per- ceived magnitude of the stressor or threat. For people with anxi- ety disorders, these responses occur continuously or intermit - tently when no real threat or stressor is present or when they encounter a stimulus that is sim- ilar in some way to the original threat or stressor.
Let us consider the case of Dr.
Carole Ballodi. iStockphoto/Thinkstock Our bodies experience an array of physiological responses when faced with threats or stressors.
Case Study: Carole Ballodi, Part 1 1 On the night of February 24, three seriously injured infantry soldiers were transported by helicopter to Medivac Unit 4 CB, which was under the command of Captain Carole Ballodi. Captain Ballodi and her team of medics and nurses began to stabilize the wounded in preparation for surgery, when they found themselves under fire. They called for assistance, but before air strikes could be ordered, their Medivac unit was hit by a rocket. One of the wounded soldiers was struck in the head by shrapnel and killed instantly while Captain Ballodi was taking his pulse. A nurse was gravely injured. Although elec - trical supplies were cut off, and the shelling continued, Captain Ballodi and her team managed to tend to the wounded until the shelling stopped. She then assisted in an emergency surgery that required the amputation of one soldier’s leg. Captain Ballodi’s actions during that night saved the lives of the injured soldiers. She is worthy of the highest commendation.
Initial Interview between Dr. Carole Ballodi and Psychiatrist Dr. Sally Kahn UNIVERSITY HOSPITAL Psychiatry Service Consultation Transcript Reason for referral: Carole Ballodi is an internal medicine specialist at University Hospital. She was brought to the emergency room complaining of chest pain. A physical examination proved negative.
Because of her agitation, she was referred for a psychiatric consultation. (continued) 1. Post-traumatic stress disorder (PTSD) appeared in the Anxiety Disorders chapter of the DSM-IV-TR. In the DSM-5 it was moved to Trauma and Stressor-related disorders. Because Carole demonstrates signs and symptoms of Panic Disorder as well as PTSD we have decided to keep her case in this chapter. get81325_03_c03.indd 60 12/5/13 3:59 PM CHAPTER 3 Section 3.1 The Anxiety Spectrum DR. KAHN: Tell me, what do you consider your main problem?
DR. BALLODI: I have these pains in my chest and feel like I can’t catch my breath.
DR. KAHN: When does this occur?
DR. BALLODI: One time was in my car. I was just about to get on the bridge. I was at the toll booth when I heard a helicopter overhead. I panicked. I couldn’t catch my breath. I broke out in a sweat, and I could feel my heart pounding. I felt like there was a tight band across my chest. I got dizzy, hot, and nauseous. And I was very frightened. I thought I was dying.
DR. KAHN: Can you recall what thoughts were going through your head when this happened?
DR. BALLODI: Actually, I can. I thought that the helicopter sounded like the ones that delivered the wounded to the Medivac unit in Iraq. I think I just panicked.
DR. KAHN: You panicked?
DR. BALLODI: Yes. I was afraid that the helicopter would come down and crash into my car.
DR. KAHN: What would happen to you?
DR. BALLODI: I would be disabled for life and have to use a wheelchair.
DR. KAHN: So, you were thinking about these things and then began to feel the chest pain?
DR. BALLODI: I’m not sure—it all seemed to happen together. I was thinking about the helicopters and my car, and then I felt the pain in my chest and had trouble breathing.
DR. KAHN: What happened next?
DR. BALLODI: I pulled over to the side and just sat there. Traffic backed up behind me, but there was nothing I could do. It was like it was happening to someone else. Finally, someone called an ambulance.
DR. KAHN: What happened in the hospital?
DR. BALLODI: I felt better by the time I got to the hospital. They ran the usual tests but found nothing.
They suggested that I see you.
DR. KAHN: Have you “panicked” at any other time?
DR. BALLODI: Yes. Mostly at night. I wake up at two or three in the morning. I’m covered in sweat and my heart is racing. I can hardly catch my breath. I think I’m going to die.
DR. KAHN: Is there anything specific that set all this off?
DR. BALLODI: I had a patient die in my office. It brought back the war. I never used to, but now I spend hours each night going over things that have happened in the past. I relive what happened in Iraq. It’s like a videotape that I play over and over again in my mind while I ask myself whether I could have done things differently.
DR. KAHN: What do you do when you wake up during the night?
DR. BALLODI: I usually check all the windows and door locks and then I go back to sleep.
DR. KAHN: What about your work?
DR. BALLODI: I can’t concentrate on anything. I’ve taken practically all of my sick days.
DR. KAHN: What are you doing about your problems? (continued) Case Study (continued) get81325_03_c03.indd 61 12/5/13 3:59 PM CHAPTER 3 Section 3.1 The Anxiety Spectrum Fear Fear is an emotion that occurs in response to some real immediate threat or danger. Fear serves a positive purpose: it helps mobilize the body’s defenses quic\ kly in situations requiring fight or flight (defending oneself or running away) from a dangerous situation or an enemy. Figure 3.1 shows many of the physical responses of fear that comprise our reaction to a threat or an emergency. Lineage studies have found a tendency for fear to run in families (Clark, 2005; Wetherell, Lang, & Stein, 2006). Twin studies, for example, help us to determine whether behavior and mental illness, among other things, ar\ e caused by the environment or by biology. Because identical twins have the same genes and DNA, dif- ferences can be attributed to their environments. Identical twins raised apart are equally likely to develop fears and to be afraid of similar things (Kendler, Gardner, Annas, Neale, Eaves, Lichtenstein, et al., 2008).
DR. BALLODI: Mostly I stay home, hoping that rest will help. I have a few drinks to help me sleep.
DR. KAHN: Has this worked?
DR. BALLODI: Well, the drinks knock me out, but I’m missing lots of work.
DR. KAHN: Do you go out with friends?
DR. BALLODI: No. I’m afraid to leave home. I’m afraid to get in my car. I might have another incident.
I’m not interested in seeing anyone, and sex leaves me cold.
DR. KAHN: Do you ever see anyone you served with in Iraq?
DR. BALLODI: No. I was never really bothered by the war, but I don’t want to talk to anyone. Who knows what they might think? I don’t know what’s happening to me. I think I’m going mad.
On the basis of their discussion, Dr. Kahn felt certain that Carole Ballodi was suffering from an anxiety disorder or a trauma or stressor-related disorder, probably related to her war experiences. Before Dr.
Kahn could be more certain, however, she had to consider the possibility that Carole’s behavior was the result of a general medical condition. A variety of medical disorders can cause symptoms similar to Carole’s (an overactive thyroid gland, heart disease, vitamin deficiencies, respiratory disease, brain tumors). Because alcohol, caffeine, and many prescription and illicit drugs can also cause anxiety symptoms, Dr. Kahn had to be sure that Carole’s behavior was not substance-related (or related to withdrawal from a substance). Thus, Dr. Kahn began by ordering a medical history as well as physical and laboratory examinations. These found no evidence of a relevant medical condition or substance- induced anxiety.
Please see your e-book for Parts 2, 3, and 4 of this Case Study.
Case Study (continued) get81325_03_c03.indd 62 12/5/13 3:59 PM CHAPTER 3 Section 3.1 The Anxiety Spectrum Figure 3.1: Anxiety spectrum Fear can manifest itself as something as mild as worry or something as severe as a panic attack.
Adapted from Schwartz, S. 2000. Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, Fig 4.4, p. 143.
Anxiety Anxiety is an emotional state marked by an intense feeling of foreboding and somatic signs such as a racing heart, sweating, and difficulty breathing. The individual is afraid that the future will bring only bad results. Anxiety is a feature of everyday life. Anxiety is similar to fear but with a less specific focus. Whereas fear is usually a response to some immediate threat, anxiety is characterized by apprehension about imagined or real unpre- dictable dangers that may lie in the future. The limbic system, a complex set of brain structures that controls our emotions (see Figure 3.2), is involved in mediating anxiety levels. Low levels of anxiety are adaptive; they help us avoid danger (“I don’t think I like the look of that dark street”) and plan for the future (“I better study for the final exam or I will fail”). Anxiety becomes maladaptive when it interferes with a person’s relationships and daily functioning. Table 3.1 lists the DSM–5 anxiety disorders. get81325_03_c03.indd 63 12/5/13 3:59 PM CHAPTER 3 Section 3.1 The Anxiety Spectrum Figure 3.2: The limbic system Prefrontal cor tex Amygdala Hypothalamus Septum Cingulate gyrus Major Brain Structure Fornix Basal ganglia ThalamusThalamus Hypothalamus Spinal cord Brain stem Mindbrain Midbrain HippocampusAmygdala Fo rebrain Ce rebral cor tex Pituitary Raphe nuclei Hippocampus Locus coeruleus Ce rebellum Medulla oblongata Pons Except for the pituitary, all the highlighted areas in the forebrain are part of the limbic system and normally receive signals from neurons that secrete mood-altering neurotransmitters. Some neurotransmitter pathways are indicated by arrows.
Adapted from Schwartz, S. 2000. Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, Fig 4.3, p. 141. get81325_03_c03.indd 64 12/5/13 3:59 PM CHAPTER 3 Section 3.2 Specific Phobias Table 3.1: The DSM–5 anxiety disorders 1. Separation Anxiety Disorder 2. Selective Mutism 3. Specific phobia 4. Social Anxiety Disorder (Social phobia) 5. Panic disorder 6. Agoraphobia 7. Generalized anxiety disorder 8. Substance/medication induced anxiety disorder 9. Anxiety disorder due to another medical condition 10. Other Specified Anxiety Disorder Note: The DSM–5 includes an 11th diagnostic category for “Unspecified anxiety disorder.” Vague references to “unspecified” disorders appear throughout the DSM–5. Because they have no specific symptoms, etiology, or treatment, these disorders are not discussed in this book.
Co-Morbidity and the Anxiety Disorders Co-morbidity (co-occurrence or overlap with other disorders) is common with the anxiety disorders. Anxiety disorders are frequently accompanied by depression (Bruce et al., 2005; Clark, 2005; Garrett, 2010). This association is so common that Brown and Barlow (2002) theorized that anxiety and depression may share a common feature: They both involve emotional distress, but they vary in how the distress is expressed. People with other psy - chological disorders (i.e., schizophrenia) commonly report anxiety symptoms as well.
3.2 Specific Phobias At one time or another, everyone is afraid of something: snakes, storms, airplanes, and dentists. Fear is an important evolutionary adaptation (Boyer & Bergstrom, 2011). But fear can also be debilitating. It can torment us, destroy our sleep, and rob our lives of pleasure.
In extreme cases, it can cause disease or even death. Rational fears are not phobias. If you hurry home after hearing a storm warning on your car radio, you do not h\ ave a phobia— no matter how frightened you may feel. On the other hand, if your fear o\ f storms is so intense that you give up your job to move to a city with a different climate, uprooting your family and causing financial hardship, then you probably have a phobia. Fears become phobias when they disrupt daily life enough to justify clinical intervention (American Psychiatric Association [APA], 2013). get81325_03_c03.indd 65 12/5/13 3:59 PM CHAPTER 3 Section 3.2 Specific Phobias A specific phobia 2 consists of a persistent and irrational fear of an object or situation coupled with a strong desire to avoid the feared object or situation.
People with phobias display extreme fear reactions when exposed to the feared stimuli.
They recognize that their reac- tion is excessive and unreason - able, yet their fear disrupts their everyday lives (APA, 2013). Etiology of Phobias It has been estimated that about 12% of the population will meet the criteria for a specific phobia disorder at some time in their lives (Kessler, Chiu, Demler, & Walters, 2005). Once a phobia is established, it tends to last a lifetim\ e unless it is specifi- cally treated. The Encyclopedia of Phobias, Fears, and Anxieties (Doctor, Kahn, & Adamec, 2008) has more than 2,000 entries. Phobias are determined by the complex interaction of cultural and social norms (fears vary across cultures), our learning experiences (your best friend screams when she sees a spider and you become afraid of spiders), and cogn\ i - tive components (your thoughts and beliefs). Some of the more common phobias may be found in Table 3.2.
Table 3.2: Common fears and phobias Death FlyingSnakes Dentists HeightsStorms Enclosed places Illness/InjuryTraveling alone Cultural and Social Determinants To a large extent, our culture and society determine the objects and situations we fear (Andrews & Wilding, 2004; Tuan, 1980). The Aborigines of Central Australia, for example, have an intense fear of violating sacred tribal sites (Strehlow, 1985). Those who violate taboo areas are subject to “bone-pointing.” A tribal elder takes the leg bone of a kangaroo, dips it into an anthill, covers the end with human hairs, and points it \ at the transgres - sor while chanting a curse. Aborigines fear bone-pointing so much that some of those iStockphoto/Thinkstock For some, going to the dentist can be a frightening experience, leading to heightened anxiety about going for necessary checkups. 2. “Panic Attack” was not a diagnosis in the DSM-IV-TR and is not in the DSM-5. However the specifiers for different types of panic attacks have been changed from cued, situationally predisposed, and uncued to unexpected and expected panic attacks. Panic Attack is a specifier that can now apply to all DSM-5 diagnoses (APA, 2013). get81325_03_c03.indd 66 12/5/13 3:59 PM CHAPTER 3 Section 3.2 Specific Phobias subjected to the curse have reportedly died from fright (Basedow, 1925). When culture- bound fears become extreme enough to interfere with normal daily functioning, they cross over into becoming phobias.
Learning Experiences According to behavioral psychologists, a phobia is acquired initially through classical conditioning: A neutral stimulus that is repeatedly paired with a fear-inducing stimulus will, in time, elicit the fear response even in the absence of the primary fear-inducing stimulus. A bell doesn’t evoke a fear response, but if it is paired with a feared stimulus—a painful shock—it will eventually evoke a fear response even in the absence of the pain- ful shock. Over time, a person comes to avoid situations related to the one that originally caused a fear response. Once the phobia is generalized (occurs in situations similar b\ ut not identical to the original situation), the avoidance response continues because avoiding feared objects reduces anxiety, which in turn reinforces future avoidance.
Behaviorists note that phobias may be acquired indirectly by observing fear in others (Coelho & Purkis, 2009). Mineka (1985) found that rhesus monkeys raised in captivity were not afraid of snakes until they observed the fearful reactions of monkeys raised in the wild.
Although observational learning may account for many fears acquired in the absence of aversive experiences, exposure alone may not be sufficient for phobias to develop. Mineka’s monkeys did not develop fears of flowers or a toy rabbit, even when expo\ sed to apparently fearful models (Mineka 1985; see also Cook & Mineka, 1991). Perhaps observational learning produces phobias only for dangerous objects and situations that evolution has genetically “prepared” us to fear (Lundqvist & Ohman, 2005; Ohman & Soares, 1993). For example, humans are genetically “prepared” to acquire a fear of heights (we can fall from a high place and get injured or killed) and spiders (some spider bites can be lethal). Through evolution, we have developed phobias to make our survival more likely. Of course, even this “pre - paredness” hypothesis has difficulty determining whether our fears are due to evolution or to the environment (Ohman & Mineka, 2003). Cognitive Determinants Cognitive therapists believe that some people habitually make fearful attributions to objects or situations, overestimate the probability of risk, and underestimate their personal ability to cope (Ellis, 2005). Bandura (1986) suggested that, for some people, perceived inability to cope is responsible for anxiety and avoidance behaviors.
In other words, the real cause of fear is not the feared stimulus but the feelings of inadequacy in dealing with the challenge it presents. Fearful thoughts may become self-fulfilling prophecies:
For example, fearing failure on an examination may cause people to fail. Stockbyte/Thinkstock For those with test anxiety, it is often the fear of failure, and not the test itself, that causes feelings of anxiety. get81325_03_c03.indd 67 12/5/13 3:59 PM CHAPTER 3 Section 3.3 Social Phobia 3.3 Social Phobia The fear of examinations and speaking in front of other people (“stage fright”) are both forms of performance anxiety. Employment tests, driver ’s license tests, and medical exam- inations can produce feelings of apprehension and dread in many people (Sloboda, 1990).
Although low to moderate levels of anxiety may facilitate performance (\ Jones, 1995; Yer - kes & Dodson, 1908), high levels of anxiety lower performance (Koury &\ Rapaport, 2007).
In some instances, extreme anxiety may render people unable to perform at all. It can produce eating and sleeping disorders, and it can make sufferers physically ill (Koury & Rapaport, 2007). Performance anxiety occurs in both Western and Eastern cultures (Ruscio et al., 2007), but cultural sensitivity is necessary when interpreting performance anxiety.
Among Native American cultures, for instance, it is considered improper, impolite, and even disloyal to stand out from one’s peers (Dasen, Berry, & Sartorius, 1988; Kagitçibasi & Berry, 1989). Because people with performance anxiety can usually interact s\ uccessfully with others (provided they do not have to perform), few seek professional help. For some people, however, the fear of being evaluated by others extends to most aspects of socia\ l interaction. These people may curtail their social lives, even sacrifice their careers, to avoid threatening social situations.
Such persons are likely to be suf - fering from social anxiety disor - der (more commonly known as social phobia; APA, 2013).
Social phobia, which usually begins in adolescence, repre- sents an extreme form of per - formance anxiety in which the fear of social evaluation may severely restrict a person’s life (Koury & Rapaport, 2007). Like most anxiety disorders, social phobia affects more females than males (Ruscio et al., 2007).
Social phobias may sometimes be traced to a specific triggering event, s\ uch as an inability to find a date for the senior prom or being bullied during early adolescence (McCabe, Anthony, Summerfeldt, Liss, & Swinson, 2003). It is more often due to innately fearing angry, critical, or rejecting people or their faces (Mineka & Zinbarg, 2006).
Therapeutic Treatment for Specific and Social Phobias Many different treatments have been developed to deal with specific phobias and social phobia (Hoffman, 2004). Although each has its specific aspects, they all seek to motivate people to change, ensure that they prepare, and expose them to the feared stimulus. No matter what treatment is used, an important factor in helping someone to overcome any problem is to establish a trusting therapeutic relationship. © Frank Siteman - Doctor Stock/Science Faction/Corbis An extreme form of performance anxiety, also called social phobia, may include social withdrawal and fear of social interaction. get81325_03_c03.indd 68 12/5/13 3:59 PM CHAPTER 3 Section 3.3 Social Phobia Psychoanalytic Treatment of Specific and Social Phobias Psychoanalysts view phobias as surface manifestations of unconscious con\ flicts that are displaced onto an object or situation with some symbolic connection to t\ he conflict. Psy- choanalytic treatment consists of uncovering the repressed memories assumed to under - lie fear and avoidance. Dream interpretation, free association, and other psychoanalytic techniques are used to lift repression and make unconscious conflicts conscious. Psy- choanalysts may expose patients to the object they fear (Wolitzky, 1995). In such cases, exposure is not expected to extinguish the fear but to help retrieve repressed conflicts and desires.
Behavioral Treatment of Specific and Social Phobias Behavioral treatments focus on exposure. Perhaps the best-known exposure technique is systematic desensitization, developed by Joseph Wolpe (1997). The technique has three parts. The first is relax- ation training; the second is the construction of an anxiety hierarchy in which fear-related images are arranged according to the degree of anxiety they elicit. The third part involves the gradual presentation of the hierarchy images while the person attempts to maintain a relaxed state. The rationale is that one cannot be both fearful and relaxed at the same time.
Thus, a fearful person who can learn to relax while imagining anxiety-provoking scenes will eventually cease being afraid.
Another behavioral technique, flooding, requires fearful indi - viduals to become “flooded” with emotion through exposure to the feared stimulus. Because their fear is not “reinforced” (nothing bad actually hap - pens), repeated exposure should eventually cause them to no longer feel afraid. Implo- sive therapy is a type of flooding in which exposure is done through imagery rather than in real life (Hogan & Kirchner, 1968).
Cognitive-Behavioral Treatment of Specific and Social Phobias The goal of cognitive-behavioral treatment is to help clients learn to reappraise feared sit - uations so that they can replace maladaptive cognitions (thoughts and attributions) about dangerous objects or situations and fear of failure with positive cognitions (McEvoy, 2007). © Peter Dench/In Pictures/Corbis Part of the flooding technique involves exposing the fearful individual to the feared stimulus. Here, a woman confronts her fear of snakes. get81325_03_c03.indd 69 12/5/13 3:59 PM CHAPTER 3 Section 3.3 Social Phobia One cognitive-behavioral technique that has been applied to social phobi\ a is stress inocu- lation (Meichenbaum, 1985). Stress inoculation begins with an educational phase in which people are taught about the role that negative self-statements play in performance anxiety.
Next, clients are taught more accurate self-statements that they can then practice in stress - ful evaluative situations. In the final stage, clients are taught coping skills designed to help them deal with, rather than avoid, evaluative situations.
Drug Treatment of Specific and Social Phobias Many people with performance anxiety, specific phobia, social phobia, or any other anxiety disorder might be offered anxiolytic drugs ( lysis is Greek for “dissolve”; anxio- lytics dissolve anxiety). The most popular anxiolytic medications today are the benzo- diazepines. All benzodiazepines are descendants of chlordiazepoxide (Librium), whose anxiolytic effects were discovered accidentally by researchers observing how various chemical compounds affect animal behavior (Gelenberg, Bassuk, & Schoonover, 1991).
Diazepam (Valium) remains one of the most widely prescribed medications. Xanax (alprazolam), a high-potency benzodiazepine, is a reasonable alternative medication (Virani, Bezchlibnyk-Butler, & Jeffries, 2009). Table 3.3 contains the chemical (generic) names and the U.S. trade (brand) names of some of the most commonly pr\ escribed benzodiazepines.
Table 3.3: Some common benzodiazepines Generic Name Common U.S. Trade Name alprazolam Xanax chlordiazepoxide Librium clorazepate Tranxene diazepam Valium flurazepam Dalmane oxazepam Serax Note: Medication trade names always begin with a capital letter. Generic names always begin with a lowercase letter.
Even though benzodiazepines can temporarily relieve anxiety (Burijon, 2007), they are not without risk. Benzodiazepines are known to cause drowsiness (so they may adversely affect school or work performance), interfere with normal sleep, and harm cognitive func- tioning (Meyer & Quenzer, 2005). They are also associated with injury due to falling (hip fractures), especially with senior citizens (Wang, Bohn, Glynn, Mogun, & Avorn, 2001).
Even standard doses of benzodiazepines may cause tolerance, in which people require larger and larger doses to achieve the same therapeutic effect (Rickels, Schweizer, Case, & Greenblatt, 1990). get81325_03_c03.indd 70 12/5/13 3:59 PM CHAPTER 3 Section 3.4 Generalized Anxiety Disorder (GAD) 3.4 Generalized Anxiety Disorder (GAD) People with generalized anxiety disorder (GAD) feel apprehensive about vague or future events that may or may not occur. As soon as one cause for worry is eliminated, they become anxious about another or they worry about several things simultan\ eously. Their anxiety arises without any provocation; it is “free-floating.” Along with their many wor - ries, people with GAD are often restless and irritable. They describe themselves as being “on edge,” and their muscles are habitually tense.
Etiology of GAD Although probably the most common anxiety disorder after phobias, GAD is not fre- quently diagnosed in the psychology clinic. One researcher (Burijon, 2007) estimated that only about 25% of individuals who have GAD were in treatment. Many individuals never get to the clinic because they “treat” themselves with alcohol or other means. The indi - viduals who do get to the clinic frequently receive some other diagnosis because GAD is often co-morbid with other disorders (Garrett, 2010). (See Part 2 of the case of Dr. Carole Ballodi in your e-book.) Psychoanalytic Views of GAD Psychoanalysts attribute GAD to a subconscious conflict between the ego \ and the id. The ego attempts to prevent the id’s sexual impulses from breaking through to the surface because it fears the punishment that might ensue. But the ego’s repressive strategy is only partly successful. Sexual impulses remain unconscious but not the associated fear of punishment. The result is that the person is always fearful and apprehensive but does not know why. Like most psychoanalytic hypotheses, this explanation for GAD relies on clinical observations rather than controlled research for its support.
Behavioral Views of GAD Behaviorists view GAD as a form of classically conditioned (learned) fear that differs from a simple phobia or social phobia only by its greater generality (Kessler et al., 2002; New- man, Przeworski, Fisher, & Borkovec, 2010). People with GAD are always afraid because they are always encountering feared stimuli.
Cognitive-Behavioral Views of GAD Cognitive psychologists propose that people with GAD fear loss of control and helpless - ness. Experimental support for this theory comes from several classical experiments con - ducted in the 1940s by Mowrer and Viek (1948). These researchers administered electric shocks to rats while the animals ate (Figure 3.3). Rats who were unable to control the shock came to fear and avoid the area in which they were shocked, even though this was also the place in which they were fed. Rats who were taught how to terminate the shock— given a means of control—did not avoid the feeding area (Mineka, 1992). get81325_03_c03.indd 71 12/5/13 3:59 PM CHAPTER 3 Section 3.4 Generalized Anxiety Disorder (GAD) Figure 3.3: An experiment illustrating the consequence of controllability The “executive” rat can control the electric shock to its tail by turning a wheel. The “subordinate” rat has no control over the shock. The control rat receives no shock at all. Neither the control rat nor the executive rat avoids the feeding place. The subordinate, on the other hand, becomes vigilant and anxious.
From Maser, J. and Seligman, M.E.P. (Eds.). (1977). Psychopathology: Experimental Models. San Francisco: W.H. Freeman. Reprinted by permission. “Executive” rat To shock control To shock source No connection to shock source “Subordinate” ratControl rat Because most people have sexual and aggressive thoughts at one time or another and because everyone feels frightened or helpless sometimes, psychoanalysts, behaviorists, and cogni - tive psychologists all agree that GAD develops only when there is a pre-existing diathe - sis (vulnerability). Although there is evidence that the diathesis for GAD may be inherited (Wetherell et al., 2006), there is also evidence that it is acquired (Leppavuori, Pohjasvaara, Vataja, Kaste & Erikinjuntti, 2003; Donnellan, Hickey, Hevey, & O’Neill, 2010). We know that the social environment contributes to the disorder because GAD is more common in dan - gerous environments, such as war areas and inner-city ghettos (Kessler et al., 2005). get81325_03_c03.indd 72 12/5/13 3:59 PM CHAPTER 3 Section 3.5 Obsessive-Compulsive Disorder (OCD) Therapeutic Treatment of GAD Therapeutic treatment of GAD is determined largely by the theoretical orientation of the practitioner. Psychoanalysts use free association, dream interpretation, and other tech- niques to help people confront their repressed impulses and conflicts, whereas practical, traditional behavioral clinicians use desensitiza- tion and other forms of exposure therapies. Relax - ation training may help people reduce their level of anxiety in general, especially if it is used in conjunction with cognitive therapy (Lang, 2004).
Cognitive interventions are usually aimed at the chronic worry that is characteristic of people with GAD (Craske & Barlow, 2006). In a safe thera - peutic environment, clients can face the anxiety- producing images, thoughts, and ideas directly.
They learn to use coping techniques to control their worrying. Behavioral and cognitive treat- ments are reported to be about equally effective in the treatment of GAD, and both are better than no treatment at all (Barlow, Rapee, & Brown, 1992).
Drug Treatment for GAD Anxiolytics can be prescribed for GAD; how - ever, the Selective Serotinin Reuptake Inhibitors (SSRIs) Prozac (fluoxetine) and Paxil (paroxetine) are preferred because of their lack of physiologi - cal addiction potential (Virani, Bezchlibnyk- Butler, & Jeffries, 2009). Of course, even when medication temporarily relieves anxiety, it does nothing to overcome helplessness or to teach new coping skills.
3.5 Obsessive-Compulsive Disorder (OCD) Obsessions are unwelcome, intrusive, and recurring thoughts or images that appear irra - tional and uncontrollable to the individual experiencing them. Compulsions are repetitive ritualistic behaviors (counting, cleaning, checking) that a person fee\ ls driven to perform to ward off some calamity. Compulsive people feel obligated to dress, clean house, or fold clothes in just the “right” way. Their rituals often involve repetitions: counting cer- tain numbers, touching some religious icon, or going back several times to check that the © Corbis Part of the therapeutic treatment of GAD includes unlocking a person’s repressed impulses and conflicts. This can be achieved through several techniques, including dream interpretation, free association, desensitization, and even relaxation. get81325_03_c03.indd 73 12/5/13 3:59 PM CHAPTER 3 Section 3.5 Obsessive-Compulsive Disorder (OCD) doors are locked and the lights have been switched off. (See Figure 3.4.) Often, compulsions are linked to obsessive thoughts.
Thus, a person obsessed with infection and contamination may develop compulsive clean- liness rituals. All of us have obsessive thoughts at times as well as minor compulsions (Kanner, 2005), but people with obsessive-compulsive disorder (OCD) have them often.
Until the DSM-5, Obsessive- Compulsive Disorder was clas- sified as an anxiety disorder.
However, now it is considered its own separate category: “Obsessive-Compulsive and Related Disorders.” Despite the new classification, OCD still has many symptoms in common with anxiety d\ isorders. In particular, if those with OCD are prevented from performing compulsive rituals, the typical result is intense anxiety. Etiology of OCD OCD affects anywhere from 1.2% of the U.S. population (APA, 2013) to as many as 2–3% of the population (Wetherell et al., 2006). Women are slightly more likely to be affected by OCD than men (APA, 2013). Even though it does occur in childhood, OCD generally makes its first appearance in late adolescence or early adulthood, often\ in conjunction with some significant life event, such as pregnancy or the start of a new job. The specific nature of obsessions and compulsions varies across cultures. In some cultures, obses - sions and compulsions have religious themes. In most modern countries, obsessions center around dirt or contamination (Tolin & Meunier, 2008), and compulsions center around checking and cleaning (Radomsky, Ashbaugh, Gelfand, & Dugas, 2008).
The diagnosis of OCD is often complicated because clients show considera\ ble co-morbidity (Mahasuar, Reddy, & Math, 2011). Sometimes it is difficult to decide whether a person is depressed, phobic, obsessive-compulsive, suffering from a GAD, or all four (Hunt & Andrews, 1995). The diagnosis is often based on the presumed etiology. People with OCD get no pleasure from their compulsive behaviors, and typically know that their obsessions and compulsions are odd and irrational. Like the other anxiety disorders, OCD appears to run in families (Lambert & Kinsley, 2005). Some family studies have found OCD to be related to anxiety disorders and depression (Carter, Pollock, Suvak, & Pauls, 2004). Adam Gault/Digital Vision/Thinkstock An obsession with infection and contamination may result in compulsive cleanliness rituals. get81325_03_c03.indd 74 12/5/13 3:59 PM CHAPTER 3 Section 3.5 Obsessive-Compulsive Disorder (OCD) Figure 3.4: Normal routines Percentage of P opulation Who Follow Routine Routine Sleep on back Sleep on stomach Sleep on right side Sleep on left side 01020304 050607 08090100 Crack knuckles Brush teeth up and down Change towels daily or after ev ery shower Eat corn row by row Button shirts top to bottom 75% 60% 50% 50% 40% 34% 34% 25% 14% Most people find it comforting to follow set routines when they carry out everyday activities, and, in fact, 40% become irritated if they are forced to depart from their routines.
From Corner, R. J. 2007. Abnormal Psychology. 6e. NY: Worth Publishers, Fig. 5.6, p. 141. get81325_03_c03.indd 75 12/5/13 3:59 PM CHAPTER 3 Section 3.5 Obsessive-Compulsive Disorder (OCD) Psychoanalytic Views of OCD According to psychoanalytic theory, experiences that produce obsessive-compulsive behavior take place early in life, when children learn to suppress their id impulses because of the demands of society. In toilet training, for example, children must learn to replace their instinctual impulses to defecate anywhere with socially approved toileting behav- iors. The resolution of this conflict between a child’s biological impulses and \ society’s demands has important implications for later behavior. Children who are trained harshly may become obsessively orderly and conformist and remain this way throughout their lives. As is the case with other psychoanalytic explanations, there is little experimental evidence for the relationship between toilet training (or other early conflicts) and the later development of OCD.
Behavioral and Cognitive-Behavioral Views of OCD Once compulsive behaviors are established, it is not difficult to see how they may be reinforced by their anxiety-reducing consequences. Hand washing reduces worry about germs and illness; compulsive checking reduces concern about potential burglary or fire. But how do compulsive rituals get started in the first place? One pos\ sibility is that compulsions are learned “superstitiously” (Skinner, 1948). Pure coincidences (rubbing a lucky rabbit’s foot before winning a sporting event) may lead people into ritualistic behavior patterns (rubbing a rabbit’s foot before every contest). This explanation seems inadequate, however, because it fails to explain why we are not all obsessive-compulsive given the occurrence of such coincidences in everyone’s lives. Another problem with the superstitious-learning explanation is that it fails to explain obses\ sions. Obsessive thoughts do not reduce anxiety—usually they increase it.
In contrast to behavioral theorists, cognitive behaviorists emphasize the importance of obsessive thoughts. From the cognitive-behavioral viewpoint, we all have distressing thoughts at one time or another, but people with a tendency toward anxiety are unable to dismiss them from their minds (Sharfan, 2005). They dwell on the unwanted thoughts, which makes them feel even more anxious. Compulsive rituals arise to distract people from obsessive thoughts and reduce the anxiety that accompanies them (Salkovskis, Thorpe, Wahl, Wroe, & Forrester, 2003).
Biological Views of OCD Encephalitis, brain tumors, and closed-head injuries can all produce obsessive-compulsive behavior (Jenike, 1986). This suggests that the disorder is at least partly physiological.
The precise nature of the biological cause may lie in the metabolism of the neurotransmit - ter serotonin (Ma, Tan, Wang, Li, & Li, 2007). Antidepressant drugs that block serotonin reuptake, such as Prozac (fluoxetine), reduce the intensity and severity of obsessive- compulsive disorder (Stein & Fineberg, 2007). In the reuptake process, a neurotransmitter is quickly brought back to the same neuron from which it was released a short time earlier.
(See Figure 3.5.) Serotonin is involved with inhibition and restraint, and with regulating appetite and sexual and aggressive behaviors. This suggests that OCD may result from a defect in serotonin metabolism (Stein & Fineberg, 2007). get81325_03_c03.indd 76 12/5/13 3:59 PM CHAPTER 3 Section 3.5 Obsessive-Compulsive Disorder (OCD) Figure 3.5: Serotonin receptors and reuptake transporters Presynapticcell Serotonin Reuptake transporter Synapticcleft Serotonin receptors Regulatory signal Postsynaptic cell “Stop production” signal Serotonin in Action Autoreceptor Serotonin secreted by a synaptic cell binds to receptors on a postsynaptic cell and directs the postsynaptic cell to fire or stop firing. Serotonin levels in synapses are reduced by autoreceptors, which direct the cells to inhibit serotonin production, and reuptake transporters, which absorb the neurotransmitter.
Antidepressants, such as Prozac and Paxil, increase synaptic serotonin by inhibiting its reuptake.
Antidepressants can be similarly used to inhibit the reuptake of the neurotransmitter norepinephrine.
Adapted from Schwartz, S. 2000. Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, Fig 4.9, p. 169. get81325_03_c03.indd 77 12/5/13 3:59 PM CHAPTER 3 Section 3.5 Obsessive-Compulsive Disorder (OCD) Therapeutic Treatment for Obsessive-Compulsive Disorder As with other disorders, treatment modalities depend on the orientation of the treating clinician. Although a psychoanalytic approach is still used by some, the biological and cognitive-behavioral treatment approaches appear to be most helpful for individuals who have OCD.
Psychoanalytic Treatment for OCD Freud considered OCD to be among the most difficult disorders to treat. This was ironic, he thought, because people with obsessive-compulsive disorder knew they were “sick,” hated their symptoms, and were highly motivated to change. Freud’s initial impressions have proven accurate over time; OCD remains one of the most difficult anxiety disor- ders to treat. Psychoanalytic treatment attempts to make conscious the repressed conflicts presumed to be responsible for obsessive-compulsive behavior. Psychoanalysts do not attempt to inhibit the intrusive thoughts and ritualistic behaviors directly because they believe that these symptoms are keeping even more debilitating anxiety in check.
Behavioral and Cognitive-Behavioral Treatment of OCD The behavioral approach to treatment usually consists of exposure and response preven- tion (Greist, 1994; Riggs & Foa, 1993). Clients who fear germs may be asked to \ enter a hos- pital, touch the walls, and shake hands with patients while refraining from their normal ritualistic hand-washing response. Inhibiting hand washing causes the person to experi - ence the anxiety that hand washing helps them to avoid. Because nothing untoward actually happens, their anxiety is not reinforced. Repeated exposure should extinguish the anxiety associated with the obsession.
In a related manner, behav - ioral psychologists have treated obsessions using thought stop- ping, which requires clients to say “stop” to themselves each time they begin to dwell on an obsessive thought, and then attempt to distract themselves and think of something else that competes with the obsessive thoughts. Perhaps the major problem faced by behavior ther - apists treating OCD is getting clients to complete the treat- ment. Some people find behav - ioral treatment too threatening and drop out (Jenike, 1990).
Cognitive restructuring may help some clients persist with Siri Stafford/Lifesize/Thinkstock Thought stopping is one way in which behavioral psychologists have treated obsessions. Using this technique, an individual who begins worrying or thinking about an obsession consciously issues the command to “stop”—and then focuses on something else, usually something positive, reassuring, or healthy. get81325_03_c03.indd 78 12/5/13 3:59 PM CHAPTER 3 Section 3.6 Panic Disorder and Agoraphobia therapy because it provides them with a set of motivating self-statements that they can use to help deal with anxiety-producing situations, including the anxiety associated with the therapy itself (Rosa-Alcázar, Sánchez-Meca, Gómez-Conesa, & Marín-Martínez, 2008).
Drug Treatment for OCD People with OCD gain little relief from benzodiazepines or other anxiolytics. However, antidepressant medications—selective serotonin reuptake inhibitors, or SSRIs, like Prozac (fluoxetine) and the tricyclic antidepressant Anafranil (clomipramine)—have proven to be quite effective (Bareggi, Bianchi, Cavallaro, Gervasoni, Siliprandi, & Bellodi, 2004). These medications suppress symptoms; they do not teach people new behaviors. Clients treated solely with medication may require medication indefinitely (Abudy, Juven-Wetzler, & Zohar, 2011). They also run the risk of serious side effects and relapse when the drug is terminated (Abudy et al., 2011).
Although people with OCD may show no overt signs of anxiety, this is not the case for those suffering from panic disorder. As we shall see in the next section, in panic disorder the signs of anxiety are all too obvious.
3.6 Panic Disorder and Agoraphobia You suddenly feel very scared. Your heart beats so hard you think it will burst through your chest. You can barely catch your breath. Your mouth is totally dry; you are dizzy and shaking. You feel like you are going to faint, maybe even die. This is panic. Panic is not, by itself, abnormal. It is the intense fear produced by an especially frightening situation:
You lose control of your car on an icy road; you hear footsteps following you down a dark street. It is perfectly normal to feel panic in such situations.
Panic attacks are common occurrences; they may occur as part of everyday life. They are also associated with many psychological disorders (Kessler et al., 2006). When panic attacks become recurrent and when people become so anxious about them that they change their lives to avoid them, then panic attacks can become a full-blown panic disorder. In the United States and in several European countries, panic disorder affects between 2% and 3% of adults (Burijon, 2007; Kessler, Chiu, Jin, Ruscio, Shear, & Walters, 2006; APA, 2013), and women are twice as likely as men to receive the diagnosis (APA, 2013). Panic disorder and related anxiety conditions appear to be universal, occurring in all cultu\ res (Nazarian & Craske, 2008). (See Part 3 of the case of Dr. Carole Ballodi in your e-book.) Panic disorder usually begins in early adulthood, and most people report clear memories of their first panic attack. This initial attack, which may come on without warning, is often followed by further attacks. In such cases, the person comes to associate panic attacks with the situations in which they occur. Fearing further attacks, the person avoids these situa- tions. Over time, panic attacks occur in other situations, which must th\ en also be avoided.
As the number of situations that must be avoided increases, the person’s movements get81325_03_c03.indd 79 12/5/13 3:59 PM CHAPTER 3 Section 3.6 Panic Disorder and Agoraphobia become increasingly restricted.
In this way, panic disorder may give rise to agoraphobia. About one-third to one-half of people diagnosed with panic disorder develops agoraphobia (Kessler et al., 2005).
The term agoraphobia comes from the Greek for “fear of the marketplace.” The lifetime prev- alence for agoraphobia has been estimated at between 1% and 7% (Anthony & Stein, 2009; Grant, 2006; Magee, Eaton, Wittchen, et al., 1996). This makes it by far the most common phobia seen in the psychology clinic (Marks, 1987). Agoraphobia begins in late adolescence or early adult- hood and is twice as likely to appear in women (APA, 2013). People with agoraphobia worry about having panic-like symptoms or panic attacks in places or situations from which escape might be difficult (or embarrassing) or in which help might be unavailable. (See Figure 3.6.) They avoid feared situations in the hope that doing so will help them avoid panic attacks.\ Some people with agoraphobia cannot avoid fearful situations, and they enter feared situations full of dread.
Agoraphobic people, men particularly, may resort to alcohol or drugs just to get by. In extreme cases, they may escape by suicide (Henriksson, Isometsa, Kuoppasalmi, et al., 1996), although this is rare (Friedman, Jones, Chernen, & Barlow, 1992). In the DSM-IV- TR agoraphobia was diagnosed with panic disorder as a specifier: Panic Disorder with or without agoraphobia. In the DSM-5 agoraphobia is its own diagnosis and is diagnosed whether panic disorder is present or not. If both panic disorder and agoraphobia are pres - ent then both diagnoses are assigned. iStockphoto/Thinkstock The ruins of Ancient Agora was a gathering place in the center of ancient Athens. In Ancient Greece, an agora usually referenced a marketplace. Thus, agoraphobia, which literally means “fear of the marketplace,” refers to an unnatural fear of being in an embarrassing or inescapable situation in a public place. get81325_03_c03.indd 80 12/5/13 3:59 PM CHAPTER 3 Section 3.6 Panic Disorder and Agoraphobia Figure 3.6: Causes of panic disorder and agoraphobia From “Panic Disorder and Agoraphobia,” by K.S. White and D.H. Barl\ ow [2002], in Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic, by D.H. Barlow, 2nd ed. New York: Guilford Press. Copyright © 2002 by Guilford Press. Reprinted by\ Permission. get81325_03_c03.indd 81 12/5/13 3:59 PM CHAPTER 3 Section 3.6 Panic Disorder and Agoraphobia Etiology of Panic Disorder About 3% to 5% of people will develop panic disorder at some time (APA, 2013; Kessler et al., 2005); onset usually occurs between late adolescence and mid-30s a\ nd is more common in women. There is indirect evidence that some people are predisposed to develop panic disorder. It seems, for example, that panic disorder runs in families (Barlow, 2002) and that there is a greater concordance for such disorders among identical than fraternal twins (Maron, Hettema, & Shlik, 2010). There may even be a genetic component for panic and/ or panic disorders (Barlow, 2002). Because of the genetic evidence, considerable research has been devoted to understanding the physiological causes of panic disorder (Maron, Hettema, & Shlik, 2010). The bulk of this research focuses on the way certain physiological processes may interact with cognitions to produce panic disorder.
People prone to panic attacks may have a general tendency to appraise benign phys\ iologi- cal sensations as threatening (Casey, Oei, & Newcombe, 2004; Wilson & Hayward, 2005).
They may focus on their body’s sensations too often and may misinterp\ ret them as harm - ful. Panic-prone individuals are highly sensitive to their internal physiology. Whenever they detect any change, no matter how slight, they become fearful.
Therapeutic Treatment for Panic Disorder Psychological treatment approaches vary according to theoretical orientation. They are aimed at one or more of the variables that contribute to the vicious “fear of fear” cycle:
the preoccupation with internal bodily states, excessive physiological responsiveness to threat, faulty cognitive appraisals, or the quickly spiraling loss of contr\ ol. The goal of treatment for panic disorder is to break the vicious cycle that maintains it. Bourne (1990) and Craske and Barlow (1993) have suggested an integrated treatment program for panic disorder that treats the cognitive, physiological, and behavioral aspects of panic disor\ der rather than focusing on only one element.
Drug Treatment for Panic Disorder Medications are often prescribed in an attempt to prevent alarm reactions, or emergency reactions, that trigger panic attacks (see Figure 3.7). Early observations suggested that tricyclic antidepressant medications blocked panic attacks but had little effect on general anxiety, which responded to benzodiazepines (Klein, 1964). This observation was taken as support for the idea that the fear felt in a panic attack is physiologically different from the anxiety felt in GAD. However, we now know that SSRIs such as Prozac (fluoxetine) or Paxil (paroxetine) (Julien, 2008) or powerful benzodiazepines like Xanax (alpr\ azolam) are helpful to people who have panic attacks with agoraphobia (Clum & Feb\ braro, 2001).
Thus, fear and anxiety may not be as different as once thought. A combination of medica - tions and psychological treatment can be effective in treating panic disorder with agora - phobia (Wolfe, 2005). get81325_03_c03.indd 82 12/5/13 3:59 PM CHAPTER 3 Section 3.6 Panic Disorder and Agoraphobia Figure 3.7: Nervous system pathway StressorHypothalamus Au tonomic nervous sys tem Nervous sys tem pathway Pituitary gland Endocrine pathw ay (via bloodstream) Releases hormone (ACTH) Release hormones Increase heart rate Increase blood pressure Increase blood sugar (glucose) Decrease antibody production Increase fatty acids in blood Increase perspiration Ad renal glands Release hormones Increase heart rate Increase blood pressure Increase body temperature Increase oxygen consumption Ad renal glands Muscles tense Heart rate increases Blood pressure increases Breathing is deeper and faster Digestion of food stops Perspiration increases Secretion of saliva decreases Releases more red blood cells Increases blood clotting ability Pr oduces more white blood cells Spleen The alarm reaction starts a chain of physical responses through both hormonal and nerve pathways (ACTH = adrenocorticotropic hormone).
Adapted from Schwartz, S. 2000. Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, Fig 4.1, p. 140. get81325_03_c03.indd 83 12/5/13 3:59 PM CHAPTER 3 Chapter Summary 3.7 Anxiety Disorder Due to a Medical Condition and Substance/Medication-Induced Anxiety Disorder A variety of medical disorders can cause symptoms similar to anxiety disorders (e.g., an overactive thyroid gland, heart disease, vitamin deficiencies, respiratory disease, and brain tumors). Because alcohol, caffeine, and many prescription and illicit drugs can also cause anxiety symptoms, we need to be sure that an individual’s anxiety is not substance- related or related to withdrawal from a substance before we diagnose an anxiety disorder.
Chapter Summary • Panic is the intense fear produced by an especially frightening situation. • Fear is a negative emotion that occurs in response to some immediate threat or danger. • A panic attack consists of an abrupt and intense feeling of fear accompanied by somatic symptoms, usually in the absence of any objective danger. • Panic attacks that are invariably triggered by specific stimuli are called expected panic attacks. Unexpected panic attacks are those that occur anytime and anywhere. • A phobia consists of a persistent and irrational fear coupled with a desi\ re to avoid the feared object or situation. • Anxiety is a negative emotional state marked by foreboding and somatic signs of tension, such as a racing heart, sweating, and difficulty breathing. Co-Morbidity and the Anxiety Disorders • Co-morbidity means that several disorders seem to “go together” or appear at the same time in the same individual. • Anxiety disorders not only seem to go with one another, they are also frequently accompanied by depression. Performance Anxiety and Social Anxiety Disorder (Social Phobia) • Performance anxiety occurs in both Western and Eastern cultures. • Performance anxiety is rarely the result of a traumatic experience. It is more often related to shyness and lack of confidence. • Social Anxiety Disorder (Social phobia) begins in adolescence and represents an extreme form of performance anxiety in which fear of social evaluation can p\ ro - duce panic attacks and can severely restrict a person’s life. • Social phobias usually develop slowly in people who either inherit a ten\ dency toward shyness or become shy early in life. Overcoming Phobias • The first step in establishing a treatment program is assessment. • Behavioral observations are more practical than physiological measures because they are less intrusive. • Physiological measures of autonomic arousal can tell us how a person is reacting in threatening situations. Such measures are not contaminated by social desirabil- ity, but they are often impractical because they require sophisticated equipment, such as a polygraph, and trained operators. get81325_03_c03.indd 84 12/5/13 3:59 PM CHAPTER 3 Chapter Summary • No matter what treatment method is used, an important factor in helping some - one to overcome any problem is to establish a trusting relationship. • Motivation is important because people with phobias may resign themselves to their fear. • Preparation is crucial to successfully overcoming performance anxiety and social phobia. • People with phobias habitually avoid the feared object or situation. Successful treatment almost always requires overcoming this avoidance and getting the client to confront their fear. • Anxiolytic drugs (antianxiety medications) may also be used to treat anxiety disorders. Generalized Anxiety Disorder (GAD) • People with GAD are not fearful of specific objects or situations; they are appre - hensive about everything. • Many cases of GAD never get to the clinic because people “treat” themselves with alcohol. • Psychoanalysts, behaviorists, and cognitive psychologists agree that GAD devel - ops only when there is a pre-existing vulnerability. • Psychoanalysts attribute GAD to a conflict between the ego and the id. • Some behaviorists view GAD as a form of classically conditioned (learne\ d) fear that differs from a simple phobia only in its greater generalization. • Anxiolytics are frequently prescribed for GAD. Obsessive-Compulsive Disorder (OCD) • Obsessions are unwelcome, intrusive, and recurring thoughts or images that are recognized as irrational and are uncontrollable to the individual experiencing them. • Compulsions are repetitive ritualistic behaviors (counting, cleaning, checking) that a person feels driven to perform to ward off some calamity. • Although OCD is classified as an anxiety disorder, people with OCD do not always appear overtly anxious. • OCD generally makes its first appearance in late adolescence or early ad\ ulthood, often in conjunction with some significant life event. • According to psychoanalytic theory, the special experiences that produce obsessive- compulsive behavior take place early in life, when children learn to suppress their id impulses because of the demands of society. Psychoanalysts do not attempt to inhibit the intrusive thoughts and ritualistic behaviors directly because they believe that these symptoms are keeping even more debilitating anxiety in check. • Behaviorists note that compulsive behaviors are reinforced by their anxiety- reducing consequences and often treat OCD with exposure and response preven- tion therapy. • According to cognitive behaviorists, people with a vulnerability for anxiety \ are unable to dismiss distressing thoughts from their minds. Compulsive rituals arise to distract them from obsessive thoughts and reduce the anxiety that accompa- nies them. • Encephalitis, brain tumors, and closed-head injuries can all produce obsessive- compulsive behavior. People with obsessive-compulsive disorder gain little relief from antianxiety drugs, although some seem to respond to antidepressant medications. get81325_03_c03.indd 85 12/5/13 3:59 PM CHAPTER 3 Key Terms Panic Disorder and Agoraphobia • When panic attacks become recurrent and when people become so anxious about them that they change their lives to avoid them, panic attacks can becom\ e a full- blown panic disorder. • People prone to panic attacks may have a general tendency to appraise benign physiological sensations as threatening. • Panic disorder usually begins in early adulthood; it is rare in children. • There is strong evidence that panic disorder is hereditary. • People with agoraphobia worry about and avoid having panic-like symptoms\ in places or situations from which escape might be difficult (or embarrassing) or in which help might be unavailable. • Agoraphobia begins in early adulthood and is particularly common in olde\ r women. • Psychoanalysts assume that agoraphobia manifests in children who are fearful by nature. These children experience an unconscious conflict, wherein they wish to be independent, but they also fear being on their own. • Cognitive restructuring and relaxation training are two therapy modalities used to treat panic disorder and/or agoraphobia. • Long-acting benzodiazepines are helpful in treating people who have panic dis - order and/or agoraphobia. Critical Thinking Questions 1. Everyone has a superstition or two (or perhaps even more!). Discuss the differ - ence between superstitious behavior (yours, or perhaps a friend’s) and a phobia.
How do the two differ? 2. Discuss some of the more common venues where social anxiety disorder could present itself. How would you best handle this if a client came to see you\ with this concern? 3. Some people say that GAD should have been removed from the DSM–5 because it is too common a disorder and is difficult to accurately define. Discuss and give your views on this. 4. No doubt you have gone back inside your house/apartment to check the sto\ ve to make sure it’s off, to check the lights, and so on. What is the difference between this kind of behavior and OCD? Key Terms agoraphobia The fear of being in a place or in a situation where escape might be difficult, impossible, or embarrassing if a panic attack or panic symptoms occur. alarm reaction Another name for an emer - gency reaction; how we react in response to a very dangerous situation. anxiety A negative emotional state marked by a feeling of foreboding and bodily signs of tension such as a racing heart, sweating, and difficulty breathing. anxiety disorder Any of a number of disorders characterized by feelings of fear, dread, or panic plus physiological symp- toms such as racing heart, sweating, and difficulty breathing. get81325_03_c03.indd 86 12/5/13 3:59 PM CHAPTER 3 Key Terms benzodiazepines A class of antianxiety medications. classical conditioning According to learn- ing theory, a neutral stimulus, when paired repeatedly with a fear-inducing stimulus, will in time elicit the fear response even in the absence of the primary fear-inducing stimulus. co-morbidity When one or more disorders co-occur or overlap. compulsions Repetitive ritualistic behav- iors (counting, cleaning, checking) that a person feels driven to perform to ward off some imagined or unknown calamity. flooding A therapeutic technique that requires fearful individuals to become “flooded” with emotion through exposure to their most feared stimulus in order to realize the feared outcome does not occur. generalized anxiety disorder (GAD) An anxiety disorder characterized by “free-floating” anxiety not specific to real objects or situations but to real or imagined uncontrollable future events or situations. implosive therapy A type of flooding in which exposure is done through imagery rather than in vivo (real life). limbic system A complex set of brain structures that controls our emotions. obsessions Unwelcome, uncontrollable, intrusive, and recurring thoughts or images that are recognized as irrational to the individual experiencing them. obsessive-compulsive disorder (OCD) An anxiety disorder in which the individu- als suffer from obsessions and compul- sions that may take up the majority of their time and interfere with daily functioning. panic attack An abrupt and intense feeling of fear accompanied by bodily symptoms, usually in the absence of any objective danger. panic disorder An anxiety disorder char - acterized by recurrent, unexpected panic attacks. performance anxiety The fear of speaking or performing in front of other people. response prevention A form of therapy for OCD in which the individual encoun- ters or is exposed to the feared stimuli while refraining from the usual compul- sive behavior. social anxiety disorder (social phobia) An anxiety disorder in which individuals have an excessive concern about being in social situations where they may be evalu- ated by others. specific phobia An anxiety disorder in which a person experiences extreme anxiety or panic when confronted with a specific object or situation that triggers the response. stress inoculation A cognitive-behavioral treatment modality in which people are taught about the role that negative self- statements play in performance anxiety; more accurate self-statements that they can then practice in stressful evaluative situ- ations; and coping skills designed to help them deal with, rather than avoid, evalua- tive situations. systematic desensitization A behavioral treatment modality that attempts to reduce an individual’s anxiety through relaxation techniques paired with progressive expo- sure to a hierarchical presentation of feared stimuli. thought stopping A cognitive-behavioral treatment intervention that instructs clients to say “stop” to themselves each time they begin to dwell on an obsessive thought. get81325_03_c03.indd 87 12/5/13 3:59 PM CHAPTER 3 get81325_03_c03.indd 88 12/5/13 3:59 PM
