Transcript abnormal PSYCHOLOGY Third Canadian Edition

Chapter 6
Anxiety, Obsessive-compulsive, and
Post-traumatic Stress Disorders
Anxiety Disorders
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Anxiety: the unpleasant feeling of fear and
apprehension
Anxiety has two major components:
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the physiological
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the heightened level of arousal and physiological
activation
the cognitive
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the subjective perception of the anxious arousal and
the associated cognitive processes: worry and
rumination.
Anxiety Disorders
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Anxiety tends to be future-focused
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The emphasis is on things that could happen.
The negative reinforcement problem
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Anxiety and worry can be reinforced by the
avoidance of feared outcomes and possible
experiences that never happen.
Anxiety disorders tend to be comorbid
The most common psychological
disorders in Canada (2006)
When does anxiety become a problem?
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The anxiety must be chronic, relatively
intense, associated with role impairment, and
causing significant distress for self or others.
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there is a subjective element to the diagnosis
What tends to distinguish chronically anxious
people is their propensity to perceive threat
and to be concerned/worried when there is no
objective threat or the situation is ambiguous
Prevalence of anxiety disorders
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Anxiety disorders are the most common psychological disorders
A majority of Canadians who met criteria for an anxiety disorder report
that it interfered with their home, school, work, and social life
(Government of Canada, 2006).
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According to the Ontario Mental Health Supplement study (Ontario Ministry of
Health, 1994), a clear gender difference exists, with 16% of women and 9% of
men having suffered from anxiety disorders in the preceding year.
The highest one-year prevalence rates (i.e., almost 1 in 5) were found in
women 15 to 24 years of age.
Anxiety disorders were more common in women than in men across all
age groups.
Similar results were found in 15 countries around the world (see Seedat
et al., 2009).
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International Prevalence
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Somers, Goldner, Waraich, and Hsu (2006) pooled
the results of 41 international epidemiological
studies:
one-year prevalence: 10.6%
lifetime prevalence: 16.6%
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These disorders have an early age of onset,
typically during childhood.
U.S. Prevalence
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Kessler et al. (2012) surveyed existing U.S. data
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lifetime morbid risk (LMR)
major depressive episode (29.9%)
specific phobia (18.4%)
social phobia (13.0%)
post- traumatic stress disorder (10.1%)
generalized anxiety disorder (9.0%)
separation anxiety disorder (8.7%)
panic disorder (6.8%)
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one-year prevalence
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specific phobia (12.1%),
Major depressive episode (8.6%)
social phobia (7.4%).
The two disorders with the earliest median age of onset (15–17
years old) were phobias and separation anxiety.
Summary of Major Anxiety Disorders
Disorder
Description
Phobia
Fear and avoidance of objects or situations that do
not present any real danger.
Panic Disorder
Recurrent panic attacks involving a sudden onset of
physiological symptoms, such as dizziness, rapid
heart rate, and trembling, accompanied by terror and
feelings of impending doom; sometimes
accompanied with agoraphobia, a fear of being in
public places.
Generalized Anxiety
Disorder
Persistent, uncontrollable worry, often about minor
things.
Separation anxiety
The anxious arousal and worry about losing contact
with and proximity to other people, typically
significant others.
Changes in DSM-5
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Post-Traumatic Stress Disorder (PTSD) is now
recognized in DSM-5 as a stress disorder
Obsessive-Compulsive Disorder (OCD) is now
classified under “Obsessive-Compulsive and
Related Disorders”
Separation Anxiety
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Separation anxiety is the anxiety that results from
not having contact or the possibility of losing contact
with attachment figures.
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It is seen generally as a type of anxiety that is
prevalent among children of various ages but
not relevant among older people.
Adult Separation Anxiety
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There is a growing focus on separation anxiety disorder in
adults.
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adults who cannot stand to be alone and are cognitively preoccupied with losing
contact with loved ones
It is intriguing that in a recent study conducted with 520 patients from an anxiety
disorders clinic in Australia, the separation anxiety disorder diagnosis was the most
prevalent when all anxiety disorder diagnoses were considered; in fact, almost 1 in 4
adult patients were diagnosed with an adult form of separation anxiety disorder
(Silove et al., 2010).
These data suggest that the separation anxiety disorder
diagnosis in adults deserves much more consideration
than it currently receives.
Phobias
•Phobia—disrupting, fear-mediated avoidance
that is out of proportion to the danger actually
posed and is recognized by the sufferer as
groundless
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Many specific fears do not cause enough hardship to
compel an individual to seek treatment.
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an urban dweller with an intense fear of snakes will
probably have little direct contact with the feared
object and may therefore not believe that anything is
seriously wrong.
The term “phobia” usually implies that the person
suffers intense distress and social or occupational
impairment because of the anxiety.
Naming Phobias
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For phobias the suffix phobia is preceded by a Greek
word for the feared object or situation.
The suffix is derived from the name of the Greek
god Phobos, who frightened his enemies.
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Claustrophobia , fear of closed spaces
agoraphobia , fear of public places
acrophobia , fear of heights
ergasiophobia , fear of working
Pnigophobia, fear of choking
taphephobia , fear of being buried alive
mysophobia , the fear of contamination and dirt
Is there precision in treating phobias?
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These authoritative terms convey the impression
that we understand how a particular problem
originated and how it can be treated.
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As with so much in the field of abnormal
psychology, there are more theories and jargon
pertaining to phobias than there are firm
findings.
Changing Phobias
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New phobias tend to emerge in keeping with societal
changes.
nomophobia
a pathological fear of remaining out of touch
with technology that is experienced by people
who have become overly dependent on using
their mobile phones (nomophobia meaning
no mobile phone phobia) or personal
computers.
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Phobias Considered From Different
Paradigms
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Psychoanalysts focus on the content of the phobia
and see the phobic object as a symbol of an
important unconscious fear.
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the content of phobias has important symbolic
value.
Behaviourists focus on the function of phobias.
Specific Phobias
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Specific phobias— unwarranted fears caused by the
presence or anticipation of a specific object or situation
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Evidence to support the grouping of fears into five factors:
1. Agoraphobia
2. Fears of heights or water
3. Threat fears (e.g., blood/needles, storms/thunder)
4. Fears of being observed
5. Speaking fears
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These fears reflect two higher-order categories:
specific fears and social fears.
Specific Phobias
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Specific phobias tend to be long-lasting
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mean duration of 20 years
only 8% of people with a specific phobia received treatment.
The most common specific phobia subtypes in order were:
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(1) animal phobias (including insects, snakes, and birds);
(2) heights;
(3) being in closed spaces;
(4) flying;
(5) being in or on water;
(6) going to the dentist;
(7) seeing blood or getting an injection;
(8) storms, thunder, or lightning.
Specific Phobias: Culture
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The specific fear focused on in a phobia can vary cross
culturally.
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China: Pa-leng (a fear of the cold) worries that loss of body
heat may be life-threatening.
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This fear appears to be related to the Chinese philosophy of yin
and yang: yin refers to the cold, windy, energy-sapping, and
passive aspects of life, while yang refers to hot, powerful, and
active aspects.
Japan: taijin kyofusho (TKS), fear of other people.
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it is an extreme fear of embarrassing others—for example, by
blushing in their presence, glancing at their genital areas, or
making odd faces. It is believed that this phobia arises from
elements of traditional Japanese culture, which encourages
extreme concern for the feelings of others yet discourages direct
communication of feelings (McNally, 1997).
Social Phobia or Social Anxiety Disorder
•Social phobias— persistent, irrational fears
linked generally to the presence of other people.
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People with a social phobias try to avoid situations in
which they might be evaluated because they fear that
they will reveal signs of anxiousness or behave in an
embarrassing way
•Examples:
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Speaking or performing in public
Eating in public
Using public lavatories
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Social Phobia or Social Anxiety
Disorder (cont.)
Social phobias can be either generalized or specific
Generalized Social Phobia
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involve many different interpersonal situations
an earlier age of onset
often comorbid with other disorders such as depression and alcohol use
more severe impairment than specific phobia
Specific SP involve intense fear of one particular situation (e.g.,
public speaking).
Lifetime prevalence in Canada
7.5% in men
8.7% in women
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DSM-5 SAD criteria were modified to allow for a performance
only specifier.
Social Phobia or Social Anxiety
Disorder: Onset and Duration
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Onset generally takes place during adolescence
The lifetime prevalence of social phobia in the CCHS 1.2 was
7.5% in men and 8.7% in women.
The average age of onset was 13 years and average duration
of symptoms was 20 years (see Stansfeld et al., 2008).
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The prevalence of social phobia was higher among people who
had never married or were divorced, had not completed
secondary education, had lower income or were unemployed,
reported lacking adequate social support, reported low quality of
life, or had a chronic physical condition (see Stansfeld et al.,
2008).
Aetiology of Phobias
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Behavioural Theories
• Focus on learning
• Avoidance Conditioning — reactions are
learned avoidance responses
• Phobias develop from two related sets of
learning:
•1. Via classical conditioning
•2. Person learns to reduce conditioned fear
by escaping from or avoiding the CS (operant
conditioning)
Behavioural Theories (cont.)
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Modelling
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person can learn fear through imitating the reactions of others
(vicarious learning).
Prepared Learning
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Some fears may reflect classical conditioning, but only to
stimuli to which an organism is physiologically prepared to
be sensitive
People fear spiders, snakes, and heights but not lambs
Is a diathesis needed?
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Cognitive diathesis such as the tendency to believe that
similar traumatic experiences will occur in the future or not
being able to control the environment may be important in
developing a phobia.
Behavioural Theories (cont.)
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Social Skills Deficits in Social Phobias
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Inappropriate behaviour or a lack of social skills the
cause of social anxiety
The individual has not learned how to behave so that he
or she feels comfortable with others or the person
repeatedly commits faux pas, is awkward and socially
inept, and is often criticized by social companions.
Socially anxious people are indeed rated as being low
in social skills (Twentyman & McFall, 1975)
The timing and placement of socially anxious responses
in a social interaction, such as saying thank you at the
right time and place, are impaired (Fischetti, Curran, &
Wessberg, 1977).
Aetiology of Phobia (cont.)
•Cognitive Theories
• Focus on how people’s thought processes can serve as a
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diathesis and on how thoughts can maintain a phobia
Anxiety is related to being more likely to:
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Attend to negative stimuli
Interpret ambiguous information as threatening
Believe that negative events are more likely than positive
ones to re-occur
Social Anxiety
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Socially anxious people are:
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more concerned about evaluation than are people who are not socially
anxious (Goldfried, Padawer, & Robins, 1984)
are highly aware of the image they present to others (Bates, 1990)
high in public self-consciousness
preoccupied with a need to seem perfect and not make mistakes in
front of other people (Flett, Coulter, & Hewitt, 2012; Hewitt et al., 2003).
tend to view themselves negatively even when they have actually
performed well in a social interaction (Wallace & Alden, 1997)
are less certain about their positive self-views
relative to people without social phobia, they see their positive
attributes as being less important (Moscovitch et al., 2009).
Aetiology of Phobia (cont.)
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Cognitive-behavioural models of social phobia link social phobia
to certain cognitive characteristics:
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Attentional bias to focus on negative social information
Perfectionistic standards for accepted social performances
High degree of public self-consciousness
People with social phobia have a tendency to interpret
ambiguous social situations as negative and a reflection of
their personal shortcomings, they also have a memory
bias linked to this interpretation bias (Hertel, Brozovich,
Joormann, & Gotlib, 2008).
Cognitive-behavioural models of social phobia
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David Moscovitch (2009) concluded that the
fundamental core thematic fear in social phobia is
“the self is deficient.”
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Moscovitch maintains that the key situational
triggers are those situations and circumstances
that will publicly reveal the self as inadequate.
Related research has shown that social phobia
is linked with excessive self-criticism (Cox,
Walker, Enns, & Karpinski, 2002).
Post-event Processing (PEP) of negative
social experiences
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Post-event processing
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a form of rumination about previous experiences
and responses to these situations, especially
experiences involving other people that did not
turn out well.
There is a link between social anxiety and PEP.
Aetiology of Phobia (cont.)
•Predisposing Biological Factors
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People with specific phobia, PTSD, and SAD, relative to comparison
subjects, have greater activity in two areas associated with negative
emotional responses: the amygdala and the insula (Etkin & Wager, 2007).
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1. Autonomic Nervous System
Lacey (1967): stability-lability.
Labile, or jumpy, individuals are those whose autonomic systems
are readily aroused by a wide range of stimuli. Because of the
extent to which the autonomic nervous system is involved in fear
and hence in phobic behaviour, a dimension such as autonomic
lability assumes considerable importance.
Since there is reason to believe that autonomic lability is to some
degree genetically determined (Gabbay, 1992), heredity may very
well have a significant role in the development of phobias.
Predisposing Biological Factors
•Genetic factors
•Jerome Kagan has focused on the trait of behavioural
inhibition or shyness (Kagan, 1997). Some infants as
young as four months become agitated and cry when they
are shown toys or other stimuli. This behaviour pattern,
which may be inherited, may set the stage for the later
development of phobias.
•no specific susceptibility genes have been found thus far.
Aetiology of Phobias (cont.)
•Psychoanalytic Theory
• Phobias are a defence against the anxiety
produced by repressed id impulses
anxiety is displaced from the feared id impulse
and moved to an object or situation that has
some symbolic connection to it.
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These objects or situations then become the
phobic stimuli.
By avoiding them the person is able to avoid
dealing with repressed conflicts.
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Panic Disorder
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Panic Attack—person suffers a sudden and often
inexplicable attack of alarming symptoms:
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Laboured breathing, heart palpitations,
Nausea and chest pain;
Feelings of
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Choking and smothering;
Dizziness, sweating, and trembling;
Intense apprehension, terror, and feelings of impending
doom.
May also experience depersonalization (a feeling of
being outside one ’s body) and derealization (a feeling
of the world ’s not being real, as well as fears of losing
control, of going crazy, or even of dying).
Panic Disorder (cont.)
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Other features of panic attacks:
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may occur frequently
May be situationally predisposed
May be uncued
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Panic attacks can also occur in seemingly benign states, such
as relaxation or sleep, and in unexpected situations
Recurrent uncued attacks and worry about having
attacks in the future are required for the diagnosis of
panic disorder.
The exclusive presence of cued attacks most likely
reflects the presence of a phobia.
Prevalence: Panic Disorder
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Among Canadians.
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The 12-month prevalence of panic attacks was 6.4%.
Panic attacks were related to numerous psychological and
physical function variables, including poor overall functioning,
suicidal ideation, psychological distress, activity restriction,
chronic physical conditions, and self-rated physical and mental
health (Kinley et al., 2009).
The authors concluded that panic attacks may be a marker of severe
psychopathology independent of a diagnosis of panic disorder.
Among the Inuit of Northern Canada and west
Greenland, kayak-angst occurs among seal hunters
who are alone at sea.
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Attacks involve intense fear, disorientation, and concerns
about drowning.
Agoraphobia
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Panic disorder is diagnosed as with or without agoraphobia
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Agoraphobia (from the Greek agora, meaning
“marketplace”) is a cluster of fears centring on public
places and being unable to escape or find help should
one become incapacitated.
Fears of shopping, crowds, and travelling are often present.
Many people with agoraphobia are unable to leave the
house or do so only with great distress
Panic Disorder
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People who have panic disorder typically avoid the
situations in which a panic attack could be
dangerous or embarrassing.
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If the avoidance becomes widespread, panic
with agoraphobia is the result.
Panic disorder with agoraphobia and agoraphobia
without a history of panic disorder are both much
more common among women than among men.
Aetiology of Panic Disorder
•Biological Theories
•Mitral valve prolapse syndrome
•Inner ear disease causes dizziness
•Panic disorder runs in families and has greater concordance in
identical-twin pairs than in fraternal twins (Smoller et al., 2008).
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An increased risk of 5–16% among relatives of those with panic
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disorder.
Early onset of panic disorder is associated with increased risk for
family members.
•May be linked to “Val158Met COMT polymorphism” or other loci
within or near the COMT gene (on chromosome 22)
Aetiology of Panic Disorder (cont.)
•Noradrenergic activity theory
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Panic is caused by overactivity in the noradrenergic system
Stimulation of the locus ceruleus causes monkeys to have “panic
attack”
in humans yohimbine (drug that stimulates activity in the locus
ceruleus) can elicit panic attacks
Drugs that block firing in the locus ceruleus have not been found
to be very effective in treating panic attacks (McNally, 1994).
•Problem in gamma-aminobutyric acid (GABA)
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GABA generally inhibit noradrenergic activity
Positron emission tomography study found fewer GABAreceptor binding sites in people with PD
therapeutic improvement involves changes in GABA receptors,
but this applies to both anxiety and depression (Mohler, 2012).
Aetiology of Panic Disorder (cont.)
•Cholecystokinin (CCK)
• Peptide that occurs in the cerebral cortex, amygdala,
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hippocampus, and brain stem, induces anxiety-like
symptoms in rats and effect can be blocked with
benzodiazepines
Bradwejn hypothesized that panic disorder is, at least in
part, due to hypersensitivity to CCK
Exposure to CCK-4 induces panic attacks and patients
with panic disorder have a clear sensitivity to CCK-4.
There is genetic basis to CCK-4 and its role in panic
disorder (Zwanzger et al., 2012).
Aetiology of Panic Disorder (cont.)
•Psychological Theories
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The fear-of-fear hypothesis
• Suggests that agoraphobia is not a fear of public
places per se, but a fear of having a panic attack in
public.
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Misinterpretation of physiological arousal symptoms
• an ANS that is predisposed to be overly active
(Barlow, 1988) coupled with a psychological tendency
to become very upset by these sensations.
A Vicious Circle: Panic Attacks
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When high physiological arousal occurs, some people construe these
unusual autonomic reactions (such as rapid heart rate) as a sign of great
danger or even as a sign that they are dying.
After repeated occurrences, the person comes to fear having these
internal sensations and, by worrying excessively, makes them worse and
panic attacks more likely.
Thus, the psychology of the person takes over from where the biology
began. The person becomes more vigilant about even subtle signs of an
impending panic attack, and this, too, makes an attack more probable.
The result is a vicious circle: fearing another panic attack leads to
increased autonomic activity; symptoms of this activity are interpreted in
catastrophic ways; and these interpretations in turn raise the anxiety
level, which eventually blossoms into a full-blown panic attack (Craske &
Barlow, 1993).
Anxiety Sensitivity
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There is converging evidence that anxiety sensitivity
acts as a risk factor for anxiety psychopathology (see
Schmidt, Zvolensky, & Maner, 2006, for review).
Anxiety sensitivity predicts the development of
spontaneous panic attacks.
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More importantly, independent of a history of anxiety
problems and baseline trait anxiety, anxiety sensitivity
predicted the development of anxiety diagnoses and
overall Axis I clinical diagnoses, including anxiety,
mood, and alcohol-use disorders.
Generalized Anxiety Disorder (GAD)
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People with GAD are persistently
anxious and often about minor items.
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Chronic, uncontrollable worry about everything
Most frequent worries concern their
health and the hassles of daily life
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Generalized Anxiety Disorder (GAD)
Other features include:
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Difficulty concentrating,
Tiring easily, restlessness,
Irritability,
A high level of muscle tension
People with GAD do not typically seek psychological treatment
GAD typically begins in mid-teens
Stressful life events play role in onset
There is a high level of comorbidity with other anxiety disorders and
with mood disorders (Brown, Barlow, & Liebowitz, 1994).
It is difficult to treat GAD successfully.
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In one five-year follow-up study, only 18% of clients had achieved a
full remission of symptoms (Woodman et al., 1999).
Aetiology of GAD
•Cognitive-Behavioural Perspectives
•Learning view
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•Cognitive
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Anxiety regarded as having been classically
conditioned to external stimuli, but with a broader
range of conditioned stimuli.
This model focuses on control and helplessness.
Cognitive theory emphasizes the perception of
not being in control as a central characteristic of
all forms of anxiety (Mandler, 1966).
Intolerance Of Uncertainty & GAD
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Related to this idea of control is the fact that
predictable events produce less anxiety than do
unpredictable events (see Mineka, 1992).
Extensive research has shown the role of an
intolerance of uncertainty in the experience of chronic
worry and GAD (e.g., Ladouceur, Gosselin, & Dugas,
2000).
Uncertainty intolerance is particularly relevant when
assessing ambiguous situations, and appraisals of
ambiguous situations mediate the association
between uncertainty intolerance and worry (Koerner &
Dugas, 2008).
Two-Factor Model Linking GAD With
Approach-Avoidance Conflict
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two factors are:
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intolerance of uncertainty and a fear of anxiety.
GAD-prone people with an intolerance of
uncertainty have a desire to engage in
approach behaviours to reduce their feelings of
uncertainty.
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However, they are also characterized simultaneously by
a fear of anxiety that promotes the use of avoidance
strategies designed to limit the experience of anxious
arousal.
Worry Is Potentially Negatively Reinforcing
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Worry distracts people from negative emotions.
worry does not produce much emotional arousal.
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It does not produce the physiological changes that
usually accompany emotion, and it actually blocks the
processing of emotional stimuli.
Therefore, by worrying, people with GAD are avoiding
certain unpleasant images and so their anxiety about
these images does not extinguish.
Aetiology of GAD (cont.)
• Biological Perspectives
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GAD may have a genetic component.
Neurobiological model for GAD based on fact that
benzodiazepines are often effective in treating anxiety
• Receptor in the brain for benzodiazepines has been
linked to the inhibitory neurotransmitter GABA
• Benzodiazepines may  anxiety by  release of
GABA
• Drugs that block or inhibit the GABA system 
anxiety
Aetiology of GAD (cont.)
•Psychoanalytic Perspective
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Unconscious conflict between the ego and id impulses
The impulses, usually sexual or aggressive in nature, are
struggling for expression, but the ego cannot allow their
expression because it unconsciously fears that
punishment will follow.
Since the source of the anxiety is unconscious, the
person experiences apprehension and distress without
knowing why.
The true source of anxiety—namely, desires associated
with previously punished id impulses seeking
expression—is ever-present.
Obsessive-Compulsive Disorder
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No longer an anxiety disorder in DSM5
Obsessive-Compulsive Disorder
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Obsessive-compulsive disorder (OCD)—a disorder
in which the mind is flooded with persistent and
uncontrollable thoughts (obsessions) and the
individual is compelled to repeat certain acts again
and again (compulsions)
Obsessions vs. Compulsions
•Obsession— intrusive and recurring thoughts,
impulses, and images
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Most frequent obsessions: fears of contamination, fears
of expressing some sexual or aggressive impulse, and
hypochondriacal fears of bodily dysfunction
can take the form of extreme doubting, procrastination,
and indecision.
Most people with OCD keep the content and frequency
of their obsessions secret for many years (Newth &
Rachman, 2001).
Obsessions vs. Compulsions
•Compulsion — a repetitive behaviour or mental act that the
person feels driven to perform to reduce the distress caused by
obsessive thoughts or to prevent some calamity from occurring
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The activity is not realistically connected with its apparent
purpose and is clearly excessive.
Often an individual who continually repeats some action fears
dire consequences if the act is not performed.
Examples: checking, cleanliness and orderliness, avoiding
particular objects, performing protective practices or a
particular act
primary obsessional slowness.
when the slowness is the central problem and is not secondary
to other OCD symptoms (eg checking)
What Makes Compulsions Worse?
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According to Rachman (2002), three “multipliers”
that increase the intensity and frequency of
compulsive checking are:
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A sense of personal responsibility,
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the predicted seriousness of harm.
the probability of harm if checking does not take
place
Aetiology of OCD
• Behavioural and Cognitive Theories
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Learned behaviours reinforced by fear reduction
Compulsive checking may result from a memory deficit.
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An inability to remember some action accurately (such as
turning off the stove) or to distinguish between an actual
behaviour and an imagined behaviour (“Maybe I just thought I
turned off the stove”) could cause someone to check
repeatedly.
General research on OCD suggests inconsistent
evidence of memory deficits for verbal information, but
there is stronger evidence for impairments in memory
for non-verbal information (Muller & Roberts, 2005).
Rachman’s Theory of Obsessions in OCD
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Obsessions often involve catastrophic misinterpretations
of negative intrusive thoughts
Rachman and Shafran (1998) identified a range of
cognitive factors involved in OCD in addition to the
obsessions themselves, including an inflated sense of
personal responsibility for outcomes and a cognitive bias
involving thought-action fusion.
Thought-action-fusion involves two beliefs:
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(1) the mere act of thinking about unpleasant events
increases the perceived likelihood that they will actually
happen;
(2) at a moral level, thinking something unpleasant (e.g.,
imagining the self hurting others) is the same as actually
having carried it out.
Meta-Cognition In OCD
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There are meta-cognitive differences in OCD:
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people with OCD have such highly developed
cognitive self-consciousness that they reflect
excessively on their cognitive processes
(Janeck, Calamari, Riemann, & Heffelfinger,
2003).
Aetiology of OCD (cont.)
• Biological Factors
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Genetic evidence
• High rates of anxiety disorders occur among the first-
degree relatives (10.3%) than control relatives (1.9%)
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Brain structure
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Encephalitis, head injuries, and brain tumours associated
with the development of OCD
PET scan studies shown  activation in the frontal lobes
The is a link to the basal ganglia
a system linked to the control of motor behaviour
Tourette ’s syndrome is marked by both motor and vocal tics and has
been linked to basal ganglia dysfunction.
People with Tourette ’s often have OCD as well (Sheppard et al., 1999).
Aetiology of OCD (cont.)
• Biological Factors con’t.
• Hypothesized to be related to serotonin
•
However, 40-60% of OCD clients treated with
SSRIs do not show improvement
Aetiology of OCD (cont.)
• Psychoanalytic Theory
•
•
Classical psychoanalysis:
•
•
Obsessions and compulsions are viewed as similar
Result from instinctual forces, sexual or aggressive, that
are not under control because of overly harsh toilet
training (fixation at the anal stage)
Alfred Adler viewed OCD as a result of feelings of
incompetence due to an inferiority complex
•
when children are kept from developing a sense of
competence by doting or excessively dominating parents,
they develop an inferiority complex and may
unconsciously adopt compulsive rituals in order to carve
out a domain in which they exert control and can feel
proficient.
Therapies For Anxiety
Disorders
•
Those with an anxiety disorder are much
less likely than people with other
disorders (including depression) to seek
treatment (Johnson & Coles, in press).
•
many people who could be diagnosed by a
clinician as having a phobia do not feel they
have a problem that merits attention and this
applies especially to those with social phobia.
Behavioural Approaches To Anxiety
Treatment
•
Systematic desensitization was the first major
behavioural treatment to be used widely in treating
phobias (Wolpe, 1958).
•
•
The individual with a phobia imagines a series of
increasingly frightening scenes while in a state
of deep relaxation.
Clinical and experimental evidence indicates
that this technique is effective in eliminating, or
at least reducing, phobias.
In Vivo Exposure: Anxiety
•
In vivo exposure is often seen as superior using
imagination
In a meta-analytic review of 33 RCTs of the treatment
of specific phobias, Wolitzky-Taylor, Horowitz,
Powers, and Telch (2008) concluded that exposurebased treatment produced large effect sizes relative
to no treatment and outperformed both placebo
conditions and other psychotherapeutic approaches.
•
•
•
In vivo exposure outperformed other modes of
exposure (e.g., imaginal exposure and virtual reality)
at post-treatment (but not at follow-up).
in vivo exposure is associated with a high dropout
rate and low treatment acceptance.
Virtual Reality (VR) Exposure
•
A meta-analysis of 23 studies comparing in vivo
exposure with virtual reality (VR) exposure treatments
has found VR exposure to be just as effective as in
vivo exposure (Opris et al., 2012).
•
•
•
VR exposure therapy has a powerful real-life impact
and yields stable outcomes comparable to other
treatment interventions.
VR exposure treatment has comparatively better
efficacy for the fear of flying.
VR exposure has been dubbed in virtuo exposure (see
Côté & Bouchard, 2008).
Tailoring Treatment For Specific Phobias
•
•
Blood-and-injection phobias are distinguished from other phobias
due to the distinctive reactions that people with these phobias have
to the usual behavioural approach of relaxation paired with
exposure (Page, 1994).
Relaxation tends to make matters worse for people with blood-andinjection phobias.
•
•
•
After the initial fright, accompanied by dramatic increases in heart rate
and blood pressure, a person with a blood-and-injection phobia often
experiences a sudden drop in blood pressure and heart rate and
faints (McGrady & Bernal, 1986).
By trying to relax, clients with these phobias may well contribute to the
tendency to faint, increasing their already high levels of fear and
avoidance, as well as their embarrassment (Ost, 1992).
Clients with blood-and- injection phobias are now encouraged to
tense rather than relax their muscles when confronting the fearsome
situation (e.g., Hellstrom, Fellenius, & Ost, 1996).
Exposure With Response Prevention (ERP)
for OCD
•
•
In this method the person exposes himself or herself to
situations that elicit the compulsive act—such as touching
a dirty dish—and then refrains from performing the
accustomed ritual—hand washing.
The assumption is that the ritual is negatively reinforcing
because it reduces the anxiety that is aroused by some
environmental stimulus or event, such as dust on a chair.
•
Preventing the person from performing the ritual (response
prevention) will expose him or her to the anxiety provoking
stimulus, thereby allowing the anxiety to be extinguished.
Exposure With Response Prevention (ERP)
for OCD
•
the ERP treatment is arduous and unpleasant for clients.
•
•
It typically involves exposures lasting upwards of 90
minutes for 15 to 20 sessions within a three-week
period, with instructions to practise between
sessions, as well.
17 to 19% of clients refuse treatment (for a review,
see Clark, 2005), and refusal to enter treatment and
dropping out are generally recognized problems for
many interventions for OCD.
Social Skills Training With Social Phobia
•
•
Learning social skills can help people with social
phobias who may not know what to do or say in
social situations
Some CBT therapists encourage clients to role-play
interpersonal encounters in the consulting room or
in therapy groups and several studies attest to the
long-term effectiveness of this approach (e.g.,
Garcia- Lopez et al., 2006).
Therapies With Phobias
•Modelling therapy:
• fearful clients are exposed to filmed or live
demonstrations of other people interacting
fearlessly with the phobic object (e.g., handling
snakes).
•Flooding
• a client is exposed to the source of the phobia at
•
full intensity.
Often a last resort
Behavioural Treatment of GAD
•
•
•
It is difficult to find specific causes of the anxiety
suffered by clients with GAD
tend to prescribe more generalized treatment (intensive
relaxation training), in the hope that if clients learn to relax
when beginning to feel tense, their anxiety will be kept from
spiralling out of control (Borkovec & Mathews, 1988).
Clients are taught to relax away low-level tensions, to
respond to incipient anxiety with relaxation rather than
alarm. This strategy is quite effective in alleviating GAD
(see Borkovec & Whisman, 1996).
Cognitive Approaches to Phobias
•
Cognitive treatments for specific phobias have
been viewed with scepticism because of a
central defining characteristic of phobias:
•
•
•
the phobic fear is recognized by the individual as
excessive or unreasonable.
If the person already acknowledges that the fear is of
something harmless, what use can it be to alter the person
’s thoughts about it?
There is no evidence that the elimination of irrational
beliefs alone, without exposure to the fearsome situations,
reduces phobic avoidance (e.g., Turner et al., 1992).
Exposure-based Treatments Panic Disorders
•
One well-validated therapy developed by Barlow
and his associates (e.g., Barlow & Craske, 1994)
has three principal components:
•
•
•
(1) relaxation training
(2) a combination of Ellis- and Beck-type CBT
interventions, including cognitive restructuring
(3) exposure to the internal cues that trigger
panic.
How Effective Is CBT For Treating OCD?
•
•
•
OCD is difficult to treat
CBT conducted in clinical settings with well-trained
clinicians has proven effective (see Hunsley & Lee,
2007; van Ingen et al., 2009).
Jonsson and Hougaard (2008) conducted a metaanalysis of 13 trials of group CBT/ERP for OCD and
concluded that the group treatments are effective;
however, additional studies are required to compare the
effectiveness of group and individual formats.
•
In two studies, better results were achieved by group CBT
relative to pharmacological treatment.
Dropout Rates In The Treatment of OCD?
•
While CBT is effective in treating OCD, Foa (2010)
observed that it is still the case that about 20% of
patients drop out and another 20% are not treated
successfully.
•
we know very little about what might work best
for someone who has OCD but is a checker vs.
an orderer or a compulsive washer.
What Are The Key Processes Involved In
Change in OCD?
•
Research is increasingly supporting the role of
threat reappraisal in symptom improvement
•
but the definitive study is still needed to
establish threat reappraisal as the main factor
vs. other mechanisms (see Smits, Julian,
Rosenfi eld, & Powers, 2012).
Behavioural Therapy Generally:
The Need For Homework
•
All the behavioural and cognitive therapies for
phobias have a recurrent theme—namely, the need
for the client to begin exposing himself or herself to
what has been deemed too terrifying to face.
•
It should be noted that homework or betweensession learning is considered to be an essential
component of CBT.
Biological Approaches To Treatment Of
Anxiety
•
•
Drugs that reduce anxiety are referred to as
sedatives, tranquilizers, or anxiolytics (the suffix lytic comes from the Greek word meaning to loosen
or dissolve).
Barbiturates
•
the first major category of drugs used to treat
anxiety disorders
highly addictive
great risk of a lethal overdose
•
•
Biological Approaches To Treatment Of
Anxiety
•
Barbiturates they were supplanted in the 1950s by
two other classes of drugs:
•
•
propanediols (e.g., Miltown)
benzodiazepines (e.g., Valium and Xanax).
Biological Approaches To Treatment Of
Anxiety
•
•
Valium and Xanax are still used today, although
they have been largely supplanted by newer
benzodiazepines, such as Ativan and Clonapam.
These drugs are of demonstrated benefit with some
anxiety disorders; however, they are not used
extensively with the specific phobias.
Biological Approaches To Treatment Of
Anxiety
•
•
•
•
•
Drugs originally developed to treat depression
(antidepressants) have become popular in treating many
anxiety disorders, phobias included.
monoamine oxidase (MAO) inhibitors
Better in treating social phobias than benzodiazepine (Gelernter et al.,
1991)
as effective as CBT at a 12-week follow-up (Heimberg et al., 1998).
The selective serotonin reuptake inhibitors (SSRIs), such as
fluoxetine (Prozac), were also originally developed to treat
depression.
• shown some promise in reducing social phobia in double-blind
Canadian studies (Stein et al., 1999), and a meta-analysis
of past studies initially confirmed their effectiveness
(Federoff & Taylor, 2001).
Biological Approaches To Treatment Of
Anxiety
•
Koen and Stein (2011) noted that up to 50%
of people with OCD or social anxiety disorder
do not respond to SRI treatment.
•
•
there is little information about what to do for the
patient with GAD who fails to respond to drug
treatment.
many drugs have undesirable side effects,
ranging from nausea, dizziness, drowsiness,
memory loss, and depression to physical
addiction and damage to body organs (see
Ryan et al., 2008).
Psychosurgery For OCD
•
•
Used occasionally
Cingulotomy - involves destroying two to three
centimetres of white matter in the cingulum, an area
near the corpus callosum.
this intervention is viewed as a treatment of
last resort, given its permanence, the risks of
psychosurgery, and the poor understanding
of how it works.
•
•
Deep brain stimulation is also possible
Psychoanalytic Approaches
•
Attempt to uncover the repressed conflicts
believed to underlie the extreme fear and
avoidance characteristic of these disorders.
•
•
Because the phobia itself was regarded as
symptomatic of underlying conflicts, it was usually not
dealt with directly.
Indeed, direct attempts to reduce phobic avoidance
were contraindicated because the phobia is assumed
to protect the person from repressed conflicts that are
too painful to confront.
Psychoanalytic Approaches
•
Many analytically oriented clinicians recognize the
importance of exposure to what is feared, although
they often regard any subsequent improvement as
merely symptomatic and not as a resolution of the
underlying conflict that was assumed to have
produced the phobia (Wolitzky & Eagle, 1990).
Post-Traumatic Stress Disorder
•
Extreme response to a severe stressor, including
increased anxiety, avoidance of stimuli associated with
the trauma, and a numbing of emotional responses.
•
Note. Unlike the definitions of other psychological
disorders, the definition of PTSD includes part of its
presumed aetiology:
a traumatic event or events that the person has
directly experienced or witnessed involving the deaths
of others, threatened death to oneself, serious injury,
or a threat to the physical integrity of self or others.
The event must have created intense fear, horror, or
helplessness.
PTSD is often experienced by first responder
emergency workers, including police officers and
firefighters.
•
•
•
PTSD
•
In previous editions of the DSM, the traumatic event
was defined as “outside the range of human
experience.”
•
This definition of being outside the range of
human experience was considered too
restrictive, as it would have ruled out the
diagnosis of PTSD following such events as
automobile accidents or the death of a loved
one, or even prolonged exposure to abuse.
Acute Stress Disorder
•
•
There is a difference between PTSD and acute
stress disorder (a diagnosis introduced in DSM-IV)
Nearly everyone who encounters a trauma
experiences stress, sometimes to a considerable
degree. This is normal.
•
If the stressor causes significant impairment in
social or occupational functioning that lasts for
less than one month, an acute stress disorder is
diagnosed.
Acute Stress Disorder
•
The proportion of people who develop an acute
stress disorder varies with the type of trauma they
have experienced.
•
•
•
Rape: over 90%
motor vehicle accident 13%
Some people get over an acute stress disorder,
many go on to develop PTSD (Harvey & Bryant,
2002).
PTSD
•
•
The inclusion in the DSM of severe stress as a
significant causal factor of PTSD was meant to reflect a
formal recognition that the cause of PTSD is primarily
the event, not some aspect of the person.
However:
•
•
most people who encounter traumatic life events do not
develop PTSD.
One study - only 25% of people who experienced a
traumatic event leading to physical injury subsequently
developed PTSD (Shalev et al., 1996); thus, the event
itself cannot be the sole cause of PTSD.
Three Major Clusters Of Symptoms In PTSD
•
•
Re-experiencing the traumatic event
•
Symptoms of increased arousal
Avoidance of stimuli associated with the event or
numbing of responsiveness
Prevalence
•
•
•
lifetime prevalence of PTSD in Canada is almost 1
in 10
one-month prevalence is about 1 in 25 Canadians
(Van Ameringen et al., 2008).
Prevalence varies depending on the severity of the
trauma experienced
Risk Factors of PTSD
•
•
•
•
•
•
•
•
•
•
•
•
•
Risk Factors
Exposure to trauma and severity of trauma
Gender (more females)
Perceived threat to life
Family history of psychiatric disorders
Presence of pre-existing psychiatric disorders
Early separation from parents
Previous exposure to traumas
Dissociative symptoms (including amnesia and out-of-body
experiences) at the time of the trauma
trying to push memories of the trauma out of one ’s mind (Ehlers et al.,
1998).
Tendency to take personal responsibility for failures
Coping with stress by focusing on emotions (“I wish I could change how
I feel”)
Attachment style (insecure attachment style)
Protective Factors
•
•
being exposed to less severe events
having high intelligence (an IQ of 115 or greater)
(see Breslau, Lucia, & Alvarado, 2006).
Aetiology of PTSD
•Psychological Theories
•
•
PTSD arises from a classical conditioning of fear avoidances are
built up, and they are negatively reinforced by the reduction of
fear that comes from not being in the presence of the CS.
Anxiety sensitivity
•Cognitive theorists characterize PTSD as a disorder of memory
•
•
•
the hallmark feature being the constant involuntary recollection of
the traumatic event (McNally, 2006).
it has been shown across several studies that PTSD is associated
with impaired memory of emotionally neutral stimuli.
there is a robust association between PTSD and memory
impairment and this tendency is stronger for verbal memory than
visual memory (Brewin, Kleiner, Vasterling, & Field, 2007).
•
Psychodynamic theory proposed by Horowitz
(1990)
•
memories of the traumatic event occur
constantly in the person ’s mind and are so
painful that they are either consciously
suppressed (by distraction, for example) or
repressed.
Aetiology of PTSD
•Biological theories
•
•
Genetics
Specific domains of noradrenergic system
•
•
Trauma may raise levels of norepinephrine
Evidence for increased sensitivity of noradrenergic
receptors in patients with PTSD
When to intervene?
•
Many experts on trauma agree that it is best to
intervene in some fashion as soon as possible after
a traumatic event, well before PTSD has a chance
to develop.
•
The Psychological First Aid Field Operations
Guide was developed to provide guidance to
frontline practitioners who must respond
immediately to mental health needs following a
disaster or terrorist event (see Vernberg et al.,
2008).
Crisis intervention
•
A promising approach for people who have been
sexually assaulted is a CBT strategy that involves,
in combination, exposing clients to trauma-related
cues in imagination, teaching them relaxation, and
helping them think differently about what happened
(e.g., to not blame themselves) (Foa et al., 1995).
Prolonged Exposure Therapy
•
•
•
•
•
developed specifically to treat PTSD.
It is a combined CBT approach that involves a step-by-step
process of being exposed to imagery reflecting traumatic
memories as well as actual life situations reflecting trauma.
Exposure is accompanied by changing thoughts and cognitive
appraisals as well as being taught specific skills such as
regulating and controlling breathing (see Foa, Hembree, &
Rothbaum, 2007).
Research indicates that prolonged exposure therapy is
effective.
How does exposure work?
•
•
possibility that it leads to the extinction of the fear response.
it may also change the meaning that stimuli have for people.
Virtual reality exposure treatment
•
Virtual Iraq
•
Virtual Iraq is a three-dimensional program that
allows the therapist to gradually introduce a
variety of sensations including audio cues,
visual cues, vibrations, and even smells.
Eye Movement Desensitization and
Reprocessing (EMDR).
•
•
purported to be extremely rapid—often requiring only one or
two sessions— and more effective than the standard
exposure procedures
the client imagines a situation related to his or her problem,
such as the sight of a horrible automobile accident. Keeping
the image in mind, the client follows with his or her eyes the
therapist ’s fingers as the therapist moves them back and
forth about a foot in front of the client. This process
continues for a minute or so or until the client reports that the
horror of the image has been reduced.
•
•
Eye Movement Desensitization and
Reprocessing (EMDR).
Then the therapist has the client verbalize whatever
negative thoughts are going through his or her mind, again
while following the moving target with his or her eyes.
Finally, the therapist encourages the client to think a more
positive thought, such as “I can deal with this,” and this
thought, too, is held in mind as the client follows the
therapist ’s moving fingers
•
eye movements do not add anything to what may be
happening as a result of exposure itself (e.g., Cahill,
Carrigan, & Frueh, 1999), as well as a study showing that
exposure therapy appears to be more effective than EMDR
(Taylor et al., 2003).
MMDA and PTSD
•
One controversial development is the recent
use of ecstasy (MMDA) in the treatment of
PTSD.
•
•
Mithoefer et al. (2011) conducted an RCT with 12
PTSD patients receiving ecstasy and 8 PTSD
patients in the control condition receiving a placebo.
Ten of the 12 patients (83%) in the treatment
condition had clinically significant improvement vs.
only two people in the control group.
•
Whatever the specific mode of intervention, experts in
PTSD agree that social support is critical.
•
•
Sometimes finding ways to lend support to others can
help the giver as well as the receiver (Hobfoll et al.,
1991).
Belonging to a religious group, having family, friends, or
fellow traumatized individuals listen non-judgementally
to one ’s fears and recollections of the trauma, and
having other ways to feel that one belongs and that
others wish to help ease the pain may spell the
difference between post-traumatic stress and PTSD.
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