Transcript Behavioral Therapy

CHAPTER 6:
Anxiety Disorders
Abnormal Psychology
Jan 20-27, 2009
Classes # 3-5
Generalized Anxiety Disorder
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Symptoms
– Anxiety that is constantly present
– Hypervigilance
– Autonomic Reactivity
Diagnosis

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This is when anxiety has become
pathological in that it is excessive, chronic,
and typically interferes with a person’s
ability to function in normal daily activities
To be diagnosed, the worry must last six
months and not be limited to a single life
circumstance nor is triggered by a specific
object
Prevalence

Lifetime prevalence:
• Approximately 5% of general population
will suffer from GAD
– Sex difference:
• Women 6.6% Men 3.6%
Onset

Usual onset is late teens to early 20’s
but can occur anytime
Risk Factors
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Environmental stressors
Sleep deprivation and inconsistency
Financial concerns
Health
Relationships
School problems
Work problems
More risk factors…
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Genetics
– Research has shown a 20% risk for GAD in
blood relatives with this disorder
– There is also a 10% risk among relatives of
people with depression
– Additional correlations between GAD and
other psychiatric disorders such as phobia
disorders and panic disorder
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Also, GAD is a risk itself for insomnia
– No surprise there
Case Study: John Madden
Explanations for GAD
Psychodynamic
 Behavioral
 Cognitive
 Physiological
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Psychodynamic Explanation

Sees anxiety as an alerting mechanism that
arises when our unconscious motivations
clash with the constraints of our conscious
mind
 We are often unaware of why we are anxious
because these feelings are coming from
repressed memories
– Problems:
• No sound evidence and most feel it
doesn’t apply to this one
Behavioral Explanation

This theory holds that anxiety results from not
knowing how to behave in a given situation
 The possibility of suffering negative
consequences because of inappropriate
behavior may result in hesitation and inaction
 We have been classically conditioned to be
anxious???
The Cognitive Explanation

Incorrect beliefs
– Problems:
• Many individuals with GAD cannot explain
exactly why they are anxious and their anxiety
“comes out of the blue”…they can’t give
specific reasons for it
• Vague worries about the future is about all they
mention
• So, how do we get incorrect beliefs if we
don’t know why we are worried about
something?
Physiological Explanation:
Chemical imbalances

GAD is associated with irregular
levels of neurotransmitters caused
partly by an underactivity of
inhibitory neurons…
– GABA
• Too low levels
– Serotonin
• Too low levels
– Norepinephrine
• Too high levels
Behavioral Therapy
learning approach – Learning
to relax…
–Applied relaxation training
–Biofeedback training
 The
Cognitive Therapy

Changing beliefs and distraction
– Meditation
• Mantra helps provide a distraction
–Seems to be at least somewhat
effective in reducing anxiety but it
may be a psychological rather than
real effect
• But who cares? As long as it
works…
Drug Treatments
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Medications
– Antidepressants and anti-anxiety drugs
• Valium and Xanax
– These fast-acting drugs increase GABA activity
• Effexor
– This newer drug is now used to treat both depression
and GAD
• BuSpar
– Alternative to benzodiazepines above
• Minor Tranquilizers
– These increase the activity of the inhibitory neurons
so that the excitatory neurons will be less active
Concerns about drug treatment
Side effects
 Not cures
 Drug dependence concerns
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Complications

High risk for development of substance
abuse or dependence
Prognosis

Not good…can be long-standing and
difficult to treat
– Most probably will not be cured but all can
expect improvement with a drug/cognitivebehavioral combo
Obsessive-Compulsive Disorder (OCD)
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To be diagnosed with OCD, a person
must have recurrent obsessions and
compulsions that are disabling
– Significantly interfere with a person’s
routine, making it difficult to work, or to
have a normal social life or relationships
Prevalence and Onset
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Prevalence
– Point prevalence:
• 1%-2% currently suffering
– Life-time prevalence:
• Afflicts 2%-3% of population some time in their lives
– Group differences
• No sex differences
• Knows no geographic, ethnic, or economic boundaries
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Onset
• About two-thirds develop the disorder before they are 25
years old and only 15% after the age of 35
• Onset after 40 is very rare
Obsessions

Constant, intrusive, unwanted thoughts
causing distressing emotions such as
anxiety or disgust
– Examples:
• Thoughts of violence (person feels
he/she will hurt someone)
• Thoughts of contamination (germs)
• Thoughts of uncertainty (did I lock the
door?)
They understand yet it doesn’t
matter…
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They know thoughts
are irrational
Compulsions
Compulsions are urges to do something
to lessen discomfort
 Rituals are the behaviors in which these
people engage in to accomplish this
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Common OCD Compulsions
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Cleaning
– Fear of germs, etc.
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Repeating
– Feel harm will occur if they don't
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Completing
– Exact order until perfection
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Being meticulous
– Exact place for things (ex: appearance of
room, etc.)
OCD Compulsions
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Avoiding
– Exaggerated avoidance of
anxiety producing stimuli
Counting
– Compelled to count things (like
how many steps it takes to get
somewhere)
Hoarding
– Constant collection of useless
items
Slowness
– Tasks done extremely slowly
Excessive and Ritualized praying
– May pray literally all day long in
a ritualized manner
Explanations for OCD
Psychodynamic
 Behavioral
 Cognitive
 Physiological
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Psychodynamic Explanation
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Obsessions and compulsions are used
to control anxiety coming from the
unconscious
– Problems
• Can't "prove" – pure speculation
Behavioral Explanation
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Operant conditioning explanation
– Problems:
• Even after receiving drugs, etc. that
reduce anxiety levels – they still
continue obsessions and compulsions
Cognitive Explanations

OCD results from faulty thinking
– "Something bad will happen if I don't do these
actions"
• Problems:
– Although, it can explain the more realistic
obsessions ("I must wash to stay germ-free") it
doesn't explain more bizarre obsessions ("I
must get up and down 8 times from my chair
or something terrible will happen")
Physiological Explanations
Scarcity of serotonin
 In certain brain structures there are high
levels of brain activity (orbital frontal,
etc.)
 Brain damage
 Genetics
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Treatments for OCD
No treatment
 Cognitive-Behavioral Therapy
 Antidepressant Medications
 Psychosurgery
 Other Treatments
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If you can wait 40 years…
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Skoog and Skoog (1999)
– No treatment
– 83% showed some improvement
while 20% showed complete recovery
Cognitive-Behavioral Therapy
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Systematic Desensitization
– Gradual exposure
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Response prevention
– Preventing the person from doing the
compulsion or mental act
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Relaxation techniques
– Cognitive techniques such as self-talk are
often combined with the above techniques
Cognitive-Behavioral Therapy
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Effectiveness:
– 60-80% of those using the cognitivebehavioral treatments improve (show
at least a partial reduction in
symptoms)
Antidepressant Medications
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Drugs that influence (increase) serotonin
levels have been used effectively
– Prozac, Zoloft, Paxil, Anafranil, etc.
• Drawbacks:
– High doses of these drugs may be required
in the treatment of OCD
– It can take several weeks to feel their
beneficial effects
– Additionally, there are potential side effects
to consider
Antidepressant Medications
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Effectiveness:
– Depends on how you view the following
statistics…
• About 70% of OCD sufferers respond
notably to antidepressant medication
while others experience a partial
reduction of symptoms
• However, only about 10% to 15% have a
full remission of symptoms
Psychosurgery
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Cingulotomy
– Surgical treatment of the cingulum – here, a cut is
made between certain nerve fibers that trigger
emotional arousal (cingulated gyrus) and the
limbic system
– Has been used as a last resort for patients with
severe persistent symptoms who have not
responded to other treatments
• Effectiveness:
– About 25-30% of these operations result in
improvement
– The procedure is relatively uncomplicated
Prognosis
The disease is chronic for most people
even with drug treatment
 Most take medication indefinitely, and
about 85% of people relapse within one
or two months after discontinuing usage
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Panic Disorder
Usually brief periods of intense anxiety
 Usually unexpected and do not appear
to be provoked by the situation the
person is responding to

Prevalence and Onset
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Lifetime prevalence:
– Approximately 3% to 5% of the general
population
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Sex difference:
– Females 5 %
– Males 2%
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Onset
– Usually before age 25
Symptoms
Racing HR
 Chest pain
 Choking sensation
 Excessive sweating
 Dizziness and Nausea
 Chills, shaking, etc.
 Feelings of unreality (detached from
one’s body)
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Specific Characteristics
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Brevity of attacks (usually reach maximum
intensity within a minute or so)
– In very rare cases the attacks can last several hours or days
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Marked intensity of stark terror
– This terror lingers on long after the episode has ended –
they “fear the fear”
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People often have a fear of dying or going
crazy
– Note: Some individuals will fear having a panic attack in
public so much that they will rarely leave home…if their
avoidance of public places becomes this extreme the
individual may be diagnosed as suffering from panic disorder
with agoraphobia
Diagnosis
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DSM-IV defines panic disorder as
including recurrent, unexpected panic
attacks with a minimum of one month of
persistent concern over having them
again
Physiological Explanations
 It
appears that these people have an
overly sensitive respiratory control
center (RCC) in their brain:
– RCC detects small increases in carbon
dioxide
– Because of oversensitivity it sends false
alarms
– Higher brain structures think we are
suffocating
– We panic
PANIC DISODER’S UNUSUAL
FEATURES
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Sodium Lactate
Inhaling air containing even small amounts of
carbon dioxide
Hyperventilation process
Stage 4 sleep (nocturnal panic attacks)
Antidepressant drugs
Physiological Explanation:
Genetics
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Genetics play a role:
– Biological relatives: 25%
– Non-Biological relatives: 2%
– Identical twins 5 times more than nonidentical
Other Explanations
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It appears the physiological explanation
is best but lets touch on some of the
others:
– Psychodynamic
– Behavioral
– Cognitive
Treatments
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Medication
– Anti-anxiety and antidepressants have
been successful…
• Xanax
• Zoloft
Treatments
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Cognitive–Behavioral Therapy
– Psychotherapy combined with exposure
(usually systematic desensitization)
 Support Groups
 Family Therapy
 Other Recommendations
– Avoid stimulants (caffeine, cocaine, etc.)
– Avoid alcohol
Complications
Substance abuse: 33%
 Clinical depression: 66%
 Attempted suicide: 20%
 OCD: 10%
 Also more at risk for:
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Hypertension (2 times the normal risk)
Heart Attack (4.5 times the normal risk)
Stroke (12 times the normal risk)
Disability (only about half can work full time)
Prognosis
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Bad news:
– This illness can be chronic and difficult to treat
• One study found 80% of patients were still
symptomatic at a 20 year follow-up evaluation
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Good news:
– Although, disorder may not be cured…nearly all
can expect improvement with a drug/behavioral
combo
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Note:
– Don’t expect panic disorder to go away by itself –
get help now!
Phobic Disorders
Fear has no justification in reality
 Fear is greater than is justified
 Individual is aware of irrationality of fear
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Phobic Disorders
 Social
phobia
 Agoraphobia
 Specific phobias
What is Social Phobia?

Irrational fear that they will behave in an
embarrassing way
 Is limited to situations in which the scrutiny of
others is likely
 Extreme form of shyness that interferes
significantly with an individual’s functioning
 These individuals avoid all social situations
Prevalence/Onset
Recent study says over 13% of general
population but other studies say its
about 4%
 Sex difference: Slightly more women
than men
 Average onset: early adolescence
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Symptoms
Avoidance of all social situations
 High anxiety if ever placed in a social
situation
 Rapid heart rate
 Elevated blood pressure
 History of phobia
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What causes social phobia?
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Basically unknown but…
– Possible biological reasons: scarcity
of serotonin
– Possible environmental factors…
Agoraphobia
“fear of the marketplace”
These people suffer from intense
anxiety when in a place where escape
would be difficult or embarrassing if they
were to experience a panic attack
 Fear being in a place where they can’t
get help
 In extreme cases, they may not leave
their house
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Prevalence and Onset
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Prevalence
– Estimated 5%-12% of general population will
suffer from agoraphobia
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Sex difference
– Women 7%
– Men 3.5%
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Onset
– Usually occurs in their 20’s
Treatments
Usually a medication and
psychotherapy combo
 Commonly anti-depressants and antianxiety meds are used:
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– Prozac, Paxil, Zoloft, Elavil, etc.
– Xanax, Klonipin, etc.
Cognitive-Behavioral Treatment
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Most common treatment is systematic
desensitization…
– Breathing and relaxation techniques are
sometimes used in conjunction with
systematic desensitization
Psychotherapy
Often psychodynamic in nature
 Looking to uncover unconscious
conflicts
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Prognosis
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Very good – 90% improve
Specific Phobias
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DSM-IV classifies all other phobias (besides social
phobia and agoraphobia) as “specific phobias”
We’re talking about specific objects or situations here
Sex difference:
– Women 16%
– Men 7%
Associated features: depressed mood and dependent
personality
Exposure to the phobic stimulus may lead to a panic
attack
As with other phobias, the person recognizes that the
fear is excessive and unreasonable
Types
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Situational Type
– Irrational fear of a specific situation
 Natural Environment Type
– Irrational fear of things in the environment
 Animal Type
– Irrational fear of animals or insects
 Other Type
– Irrational fear of any other stimuli
Explanations for Phobias
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Psychodynamic:
– Symbolically expressed conflicts and
stress
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Behavioral:
– Classically conditioned fears
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Cognitive:
– Incorrect beliefs
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Physiological:
– Neurological arousal and genetics
Treatments for Anxiety Disorders
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Psychoanalysis
Behavior Therapy
– Exposure
– Systematic desensitization
– Flooding
– Virtual Reality Exposure
– Modeling
Cognitive Therapy
– Cognitive Restructuring
– Thought Stopping
– Cognitive Rehearsal
Physiological Approach
– Drug treatment