Chapter 5

1. Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University Chapter 5 Anxiety Disorders Comer, Abnormal Psychology, 6e – Chapter 5

2. Anxiety • What distinguishes fear from anxiety? • Fear is a state of immediate alarm in response to a serious, known threat to one’s well-being • Anxiety is a state of alarm in response to a vague sense of threat or danger • Both have the same physiological features: increase in respiration, perspiration, muscle tension, etc. Comer, Abnormal Psychology, 6e – Chapter 5

3. Anxiety • Is the fear/anxiety response useful/adaptive? • Yes, when the “fight or flight” response is protective • However, when it is triggered by “inappropriate” situations, or when it is too severe or long-lasting, this response can be disabling • Can lead to the development of anxiety disorders Comer, Abnormal Psychology, 6e – Chapter 5

4. Anxiety Disorders • Most common mental disorders in the U.S. • In any given year, 18% of the adult population in the U.S. experiences one of the six DSM-IV-TR anxiety disorders • Close to 29% develop one of the disorders at some point in their lives • Only ~20% of these individuals seek treatment • Most individuals with one anxiety disorder suffer from a second disorder, as well • Anxiety disorders cost $42 billion each year in health care, lost wages, and lost productivity Comer, Abnormal Psychology, 6e – Chapter 5

5. Anxiety Disorders • Six disorders: • Generalized anxiety disorder (GAD) • Phobias • Panic disorder • Obsessive-compulsive disorder (OCD) • Acute stress disorder • Posttraumatic stress disorder (PTSD) Comer, Abnormal Psychology, 6e – Chapter 5

6. Generalized Anxiety Disorder (GAD) • Characterized by excessive anxiety under most circumstances and worry about practically anything • Vague, intense concerns and fearfulness • Often called “free-floating” anxiety • “Danger” not a factor • Symptoms include restlessness, easy fatigue, irritability, muscle tension, and/or sleep disturbance • Symptoms last at least six months Comer, Abnormal Psychology, 6e – Chapter 5

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8. Generalized Anxiety Disorder (GAD) • The disorder is common in Western society • Affects ~3% of the population in any given year and ~6% at sometime during their lives • Usually first appears in childhood or adolescence • Women are diagnosed more often than men by 2:1 ratio • Various theories have been offered to explain the development of the disorder… Comer, Abnormal Psychology, 6e – Chapter 5

9. GAD: The Sociocultural Perspective • According to this theory, GAD is most likely to develop in people faced with social conditions that truly are dangerous • Research supports this theory (example: Three Mile Island in 1979) • One of the most powerful forms of societal stress is poverty • Why? Run-down communities, higher crime rates, fewer educational and job opportunities, and greater risk for health problems • As would be predicted by the model, there are higher rates of GAD in lower SES groups Comer, Abnormal Psychology, 6e – Chapter 5

10. GAD: The Sociocultural Perspective • Since race is closely tied to income and job opportunities in the U.S., it is also tied to the prevalence of GAD • In any given year, ~6% of African Americans and 3.1% of Caucasians suffer from GAD • African American women have highest rates (6.6%) Comer, Abnormal Psychology, 6e – Chapter 5

11. GAD: The Sociocultural Perspective • Although poverty and other social pressures may create a climate for GAD, other factors are clearly at work • How do we know this? • Most people living in dangerous environments do not develop GAD • Other models attempt to explain why some people develop the disorder and others do not… Comer, Abnormal Psychology, 6e – Chapter 5

12. GAD: The Psychodynamic Perspective • Freud believed that all children experience anxiety • Realistic anxiety when faced with actual danger • Neurotic anxiety when prevented from expressing id impulses • Moral anxiety when punished for expressing id impulses • One can use ego defense mechanisms to control these forms of anxiety, but when they don’t work or when anxiety is too high…GAD develops Comer, Abnormal Psychology, 6e – Chapter 5

13. GAD: The Psychodynamic Perspective • Today’s psychodynamic theorists often disagree with specific aspects of Freud’s explanation • Researchers have found some support for the psychodynamic perspective: • People with GAD are particularly likely to use defense mechanisms (especially repression) • Children who were severely punished for expressing id impulses have higher levels of anxiety later in life • Are these results “proof” of the model’s validity? Comer, Abnormal Psychology, 6e – Chapter 5

14. GAD: The Psychodynamic Perspective • Not necessarily; there are alternative explanations of the data: • Discomfort with painful memories or “forgetting” in therapy is not necessarily defensive • Also, some data actually contradict the model • Many (if not most) GAD clients report normal childhood upbringings Comer, Abnormal Psychology, 6e – Chapter 5

15. GAD: The Psychodynamic Perspective • Psychodynamic therapies • Use same general techniques for treating all dysfunction • Free association • Therapist interpretation • Specific treatments for GAD • Freudians: focus less on fear and more on control of id • Object-relations therapists: help patients identify and settle early relationship conflicts Comer, Abnormal Psychology, 6e – Chapter 5

16. GAD: The Psychodynamic Perspective • Psychodynamic therapies • Overall, controlled research has not consistently shown that psychodynamic approaches are helpful in treating cases of GAD • Short-term dynamic therapy may be beneficial in some cases Comer, Abnormal Psychology, 6e – Chapter 5

17. GAD: The Humanistic Perspective • Theorists propose that GAD, like other psychological disorders, arises when people stop looking at themselves honestly and acceptingly • This view is best illustrated by Carl Rogers’s explanation: • Lack of “unconditional positive regard” in childhood leads to “conditions of worth” (harsh self-standards) • These threatening self-judgments break through and cause anxiety, setting the stage for GAD to develop Comer, Abnormal Psychology, 6e – Chapter 5

18. GAD: The Humanistic Perspective • Therapy based on this model is “client-centered” and focuses on creating an accepting environment where clients can “experience” themselves • Although case reports have been positive, controlled studies have only sometimes found client-centered therapy to be more effective than placebo or no therapy • Only limited support has been found for Rogers’s explanation of causal factors Comer, Abnormal Psychology, 6e – Chapter 5

19. GAD: The Cognitive Perspective • Theorists believe that psychological problems are caused by maladaptive and dysfunctional thinking • Since GAD is characterized by excessive worry (cognition), this model is a good start… Comer, Abnormal Psychology, 6e – Chapter 5

20. GAD: The Cognitive Perspective • Theory: GAD is caused by maladaptive assumptions • Albert Ellis identified basic irrational assumptions: • It is necessary for humans to be loved by everyone • It is catastrophic when things are not as one wants them to be • If something is dangerous, a person should be terribly concerned and dwell on the possibility that it will occur • One should be competent in all domains to be a worthwhile person • When these assumptions are applied to everyday life, GAD may develop Comer, Abnormal Psychology, 6e – Chapter 5

21. GAD: The Cognitive Perspective • Aaron Beck is another cognitive theorist • Those with GAD hold unrealistic silent assumptions that imply imminent danger: • Any strange situation is dangerous • A situation/person is unsafe until proven safe • Research supports the presence of these types of assumptions in GAD, particularly about dangerousness Comer, Abnormal Psychology, 6e – Chapter 5

22. GAD: The Cognitive Perspective • What kinds of people are likely to have exaggerated expectations of danger? • Those whose lives have been filled with unpredictable negative events • To avoid being “blindsided,” they try to predict events; they look everywhere for danger (and therefore see danger everywhere) • Theory still under investigation Comer, Abnormal Psychology, 6e – Chapter 5

23. GAD: The Cognitive Perspective • Second-Generation Cognitive Explanations • In recent years, two promising explanations have emerged: • Metacognitive theory • Developed by Wells; holds that the most problematic assumptions in GAD are the individual’s beliefs about worrying itself • Avoidance theory • Developed by Borkovec; holds that worrying serves a “positive” function for those with GAD by reducing unusually high levels of bodily arousal • Both theories have received considerable research support Comer, Abnormal Psychology, 6e – Chapter 5

24. GAD: The Cognitive Perspective • Two kinds of cognitive therapy: • Changing maladaptive assumptions • Based on the work of Ellis and Beck • Helping clients understand the special role that worrying plays, and changing their views about it Comer, Abnormal Psychology, 6e – Chapter 5

25. GAD: The Cognitive Perspective • Cognitive therapies • Changing maladaptive assumptions • Ellis’s rational-emotive therapy (RET) • Point out irrational assumptions • Suggest more appropriate assumptions • Assign related homework • Limited research, but findings are positive • Beck’s cognitive therapy • Similar to his depression treatment (see Chapter 9) • Shown to be somewhat helpful in reducing anxiety to tolerable levels Comer, Abnormal Psychology, 6e – Chapter 5

26. GAD: The Cognitive Perspective • Cognitive therapies • Focusing on worrying • Therapists begin with psychoeducation about worrying and GAD • Assign self-monitoring of somatic arousal and cognitive responses • As therapy progresses, clients become increasingly skilled at identifying their worrying and its counterproductivity Comer, Abnormal Psychology, 6e – Chapter 5

27. GAD: The Cognitive Perspective • Cognitive therapies • Focusing on worrying • With continued practice, clients are expected to see the world as less threatening; to adopt more constructive ways of coping; and to worry less • Research has begun to indicate that a concentrated focus on worrying is a helpful addition to traditional cognitive therapy Comer, Abnormal Psychology, 6e – Chapter 5

28. GAD: The Biological Perspective • Theory holds that GAD is caused by biological factors • Supported by family pedigree studies • Blood relatives more likely to have GAD (~15%) than general population (~6%) • The closer the relative, the greater the likelihood • Issue of shared environment Comer, Abnormal Psychology, 6e – Chapter 5

29. GAD: The Biological Perspective • GABA inactivity • 1950s – Benzodiazepines (Valium, Xanax) found to reduce anxiety • Why? • Neurons have specific receptors (lock and key) • Benzodiazepine receptors ordinarily receive gamma-aminobutyric acid (GABA, a common NT in the brain) • GABA is an inhibitory messenger; when received, it causes a neuron to stop firing Comer, Abnormal Psychology, 6e – Chapter 5

30. GAD: The Biological Perspective • In the normal fear reaction: • Key neurons fire more rapidly, creating a general state of excitability experienced as fear or anxiety • A feedback system is triggered; brain and body activities work to reduce excitability • Some neurons release GABA to inhibit neuron firing, thereby reducing experience of fear or anxiety • Problems with the feedback system are believed to cause GAD • Possible reasons: GABA too low, too few receptors, ineffective receptors Comer, Abnormal Psychology, 6e – Chapter 5

31. GAD: The Biological Perspective • Promising (but problematic) explanation • Other NTs also bind to GABA receptors • Research conducted on lab animals raises question: is “fear” really fear? • Issue of causal relationships • Do physiological events CAUSE anxiety? How can we know? What are alternative explanations? Comer, Abnormal Psychology, 6e – Chapter 5

32. GAD: The Biological Perspective • Biological treatments • Antianxiety drugs • Pre-1950s: barbiturates (sedative-hypnotics) • Post-1950s: benzodiazepines • Provide temporary, modest relief • Rebound anxiety with withdrawal and cessation of use • Physical dependence is possible • Undesirable effects (drowsiness, etc.) • Multiply effects of other drugs (especially alcohol) • 1980s: buspirone (BuSpar) • Different receptors, same effectiveness, fewer problems Comer, Abnormal Psychology, 6e – Chapter 5

33. GAD: The Biological Perspective • Biological treatments • Relaxation training • Theory: physical relaxation leads to psychological relaxation • Research indicates that relaxation training is more effective than placebo or no treatment • Best when used in combination with cognitive therapy or biofeedback Comer, Abnormal Psychology, 6e – Chapter 5

34. GAD: The Biological Perspective • Biological treatments • Biofeedback • Therapist uses electrical signals from the body to train people to control physiological processes • Electromyograph (EMG) is the most widely used; provides feedback about muscle tension • Found to be most effective when used as an adjunct to other methods for the treatment of certain medical problems (headache, back pain, etc.) Comer, Abnormal Psychology, 6e – Chapter 5

35. Phobias • From the Greek word for “fear” • Formal names are also often from the Greek (see Box 5-2) • Persistent and unreasonable fears of particular objects, activities, or situations • Phobic people often avoid the object or thoughts about it Comer, Abnormal Psychology, 6e – Chapter 5

36. Phobias • We all have some fears at some points in our lives; this is a normal and common experience • How do phobias differ from these “normal” experiences? • More intense fear • Greater desire to avoid the feared object or situation • Distress that interferes with functioning Comer, Abnormal Psychology, 6e – Chapter 5

37. Phobias • Most phobias are categorized as “specific” • Also two broader kinds: • Social phobia • Agoraphobia Comer, Abnormal Psychology, 6e – Chapter 5

38. Specific Phobias • Persistent fears of specific objects or situations • When exposed to the object or situation, sufferers experience immediate fear • Most common: phobias of specific animals or insects, heights, enclosed spaces, thunderstorms, and blood Comer, Abnormal Psychology, 6e – Chapter 5

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40. Specific Phobias • ~9% of the U.S. population have symptoms in any given year • ~12% develop a specific phobia at some point in their lives • Many suffer from more than one phobia at a time • Women outnumber men 2:1 • Prevalence differs across racial and ethnic minority groups • Vast majority do NOT seek treatment Comer, Abnormal Psychology, 6e – Chapter 5

41. Social Phobias • Severe, persistent, and unreasonable fears of social or performance situations in which embarrassment may occur • May be narrow–talking, performing, eating, or writing in public • May be broad–general fear of functioning inadequately in front of others • In both cases, people rate themselves as performing less adequately than they actually did Comer, Abnormal Psychology, 6e – Chapter 5

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43. Social Phobias • Can greatly interfere with functioning • Often kept a secret • Affect ~7% of U.S. population in any given year • Women outnumber men 3:2 • Often begin in childhood and may persist for many years Comer, Abnormal Psychology, 6e – Chapter 5

44. What Causes Phobias? • Each model offers explanations, but evidence tends to support the behavioral explanations: • Phobias develop through conditioning • Once fears are acquired, they are continued because feared objects are avoided • Behaviorists propose a classical conditioning model… Comer, Abnormal Psychology, 6e – Chapter 5

45. Classical Conditioning of Phobia UCS Entrapment UCR Fear UCS Entrapment UCR Fear Running water + CR Fear CS Running water Comer, Abnormal Psychology, 6e – Chapter 5

46. What Causes Phobias? • Other behavioral explanations • Phobias develop through modeling • Observation and imitation • Phobias are maintained through avoidance • Phobias may develop into GAD when a person acquires a large number of phobias • Process of stimulus generalization: responses to one stimulus are also elicited by similar stimuli Comer, Abnormal Psychology, 6e – Chapter 5

47. What Causes Phobias? • Behavioral explanations have received some empirical support: • Classical conditioning study involving Little Albert • Modeling studies • Bandura, confederates, buzz, and shock • Research conclusion is that phobias CAN be acquired in these ways, but there is no evidence that this is how the disorder is ordinarily acquired Comer, Abnormal Psychology, 6e – Chapter 5

48. What Causes Phobias? • A behavioral-evolutionary explanation • Some phobias are much more common than others… Comer, Abnormal Psychology, 6e – Chapter 5

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50. What Causes Phobias? • A behavioral-evolutionary explanation • Theorists argue that there is a species-specific biological predisposition to develop certain fears • Called “preparedness”: humans are more “prepared” to develop phobias around certain objects or situations • Model explains why some phobias (snakes, heights) are more common than others (grass, meat) • Unknown if these predispositions are due to evolutionary or environmental factors Comer, Abnormal Psychology, 6e – Chapter 5