Abnorm Psych Lecture Ch04


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Abnorm Psych Lecture Ch04

  1. 1. Chapter 4 Anxiety Disorders
  2. 2. Anxiety <ul><li>What distinguishes fear from anxiety? </li></ul><ul><ul><li>Fear is a state of immediate alarm in response to a serious, known threat to one’s well-being </li></ul></ul><ul><ul><li>Anxiety is a state of alarm in response to a vague sense of threat or danger </li></ul></ul><ul><ul><li>Both have the same physiological features: increase in respiration, perspiration, muscle tension, etc. </li></ul></ul>
  3. 3. Anxiety <ul><li>Is the fear/anxiety response useful/adaptive? </li></ul><ul><ul><li>Yes, when the “fight or flight” response is protective </li></ul></ul><ul><ul><li>However, when it is triggered by “inappropriate” situations, or when it is too severe or long-lasting, this response can be disabling </li></ul></ul><ul><ul><ul><li>Can lead to the development of anxiety disorders </li></ul></ul></ul>
  4. 4. Anxiety Disorders <ul><li>Most common mental disorders in the U.S. </li></ul><ul><ul><li>In any given year, 18% of the adult population in the U.S. experiences one of the six DSM-IV-TR anxiety disorders </li></ul></ul><ul><ul><ul><li>Only ~20% of these individuals seek treatment </li></ul></ul></ul><ul><li>Most individuals with one anxiety disorder suffer from a second disorder, as well </li></ul><ul><li>Anxiety disorders cost $42 billion each year in health care, lost wages, and lost productivity </li></ul>
  5. 5. Anxiety Disorders <ul><li>Six disorders: </li></ul><ul><ul><li>Generalized anxiety disorder (GAD) </li></ul></ul><ul><ul><li>Phobias </li></ul></ul><ul><ul><li>Panic disorder </li></ul></ul><ul><ul><li>Obsessive-compulsive disorder (OCD) </li></ul></ul><ul><ul><li>Acute stress disorder </li></ul></ul><ul><ul><li>Posttraumatic stress disorder (PTSD) </li></ul></ul>
  6. 6. Generalized Anxiety Disorder (GAD) <ul><li>Characterized by excessive anxiety under most circumstances and worry about practically anything </li></ul><ul><ul><li>Vague, intense concerns and fearfulness </li></ul></ul><ul><ul><ul><li>Often called “free-floating” anxiety </li></ul></ul></ul><ul><ul><ul><li>“ Danger” not a factor </li></ul></ul></ul><ul><li>Symptoms include restlessness, easy fatigue, irritability, muscle tension, and/or sleep disturbance </li></ul><ul><ul><li>Symptoms last at least six months </li></ul></ul>
  7. 8. Generalized Anxiety Disorder (GAD) <ul><li>The disorder is common in Western society </li></ul><ul><ul><li>Affects ~3% of the population in any given year and ~6% at sometime during their lives </li></ul></ul><ul><li>Usually first appears in childhood or adolescence </li></ul><ul><li>Women are diagnosed more often than men by 2:1 ratio </li></ul><ul><li>Various theories have been offered to explain the development of the disorder… </li></ul>
  8. 9. GAD: The Sociocultural Perspective <ul><li>According to this theory, GAD is most likely to develop in people faced with social conditions that truly are dangerous </li></ul><ul><ul><li>Research supports this theory (example: Three Mile Island in 1979) </li></ul></ul><ul><li>One of the most powerful forms of societal stress is poverty </li></ul><ul><ul><li>Why? Run-down communities, higher crime rates, fewer educational and job opportunities, and greater risk for health problems </li></ul></ul><ul><ul><li>As would be predicted by the model, there are higher rates of GAD in lower SES groups </li></ul></ul>
  9. 10. GAD: The Sociocultural Perspective <ul><li>Since race is closely tied to income and job opportunities in the U.S., it is also tied to the prevalence of GAD </li></ul><ul><ul><li>In any given year, ~6% of African Americans and 3% of Caucasians suffer from GAD </li></ul></ul><ul><ul><ul><li>African American women have highest rates (6.6%) </li></ul></ul></ul>
  10. 11. GAD: The Sociocultural Perspective <ul><li>Although poverty and other social pressures may create a climate for GAD, other factors are clearly at work </li></ul><ul><ul><li>How do we know this? </li></ul></ul><ul><ul><ul><li>Most people living in dangerous environments do not develop GAD </li></ul></ul></ul><ul><ul><li>Other models attempt to explain why some people develop the disorder and others do not… </li></ul></ul>
  11. 12. GAD: The Psychodynamic Perspective <ul><li>Freud believed that all children experience anxiety </li></ul><ul><ul><li>Realistic anxiety when faced with actual danger </li></ul></ul><ul><ul><li>Neurotic anxiety when prevented from expressing id impulses </li></ul></ul><ul><ul><li>Moral anxiety when punished for expressing id impulses </li></ul></ul><ul><li>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 </li></ul>
  12. 13. GAD: The Psychodynamic Perspective <ul><li>Today’s psychodynamic theorists often disagree with specific aspects of Freud’s explanation </li></ul><ul><li>Researchers have found some support for the psychodynamic perspective: </li></ul><ul><ul><li>People with GAD are particularly likely to use defense mechanisms (especially repression) </li></ul></ul><ul><ul><li>Children who were severely punished for expressing id impulses have higher levels of anxiety later in life </li></ul></ul>
  13. 14. GAD: The Psychodynamic Perspective <ul><li>Some scientists question the validity of these findings: </li></ul><ul><ul><li>There are alternative explanations of the data: </li></ul></ul><ul><ul><ul><li>Discomfort with painful memories or “forgetting” in therapy is not necessarily defensive </li></ul></ul></ul><ul><ul><li>Some data actually contradict the model </li></ul></ul><ul><ul><ul><li>Many (if not most) GAD clients report normal childhood upbringings </li></ul></ul></ul>
  14. 15. GAD: The Psychodynamic Perspective <ul><li>Psychodynamic therapies </li></ul><ul><ul><li>Use same general techniques for treating all dysfunction </li></ul></ul><ul><ul><ul><li>Free association </li></ul></ul></ul><ul><ul><ul><li>Therapist interpretation </li></ul></ul></ul><ul><ul><li>Specific treatments for GAD </li></ul></ul><ul><ul><ul><li>Freudians: focus less on fear and more on control of id </li></ul></ul></ul><ul><ul><ul><li>Object-relations therapists: help patients identify and settle early relationship conflicts </li></ul></ul></ul>
  15. 16. GAD: The Psychodynamic Perspective <ul><li>Psychodynamic therapies </li></ul><ul><ul><li>Overall, controlled research has found psychodynamic approaches to be of only modest help in treating cases of GAD </li></ul></ul><ul><ul><ul><li>Short-term dynamic therapy may be beneficial in some cases </li></ul></ul></ul>
  16. 17. GAD: The Humanistic Perspective <ul><li>Theorists propose that GAD, like other psychological disorders, arises when people stop looking at themselves honestly and acceptingly </li></ul><ul><li>This view is best illustrated by Carl Rogers’s explanation: </li></ul><ul><ul><li>Lack of “unconditional positive regard” in childhood leads to “conditions of worth” (harsh self-standards) </li></ul></ul><ul><ul><li>These threatening self-judgments break through and cause anxiety, setting the stage for GAD to develop </li></ul></ul>
  17. 18. GAD: The Humanistic Perspective <ul><li>Therapy based on this model is “client-centered” and focuses on creating an accepting environment where clients can “experience” themselves </li></ul><ul><ul><li>Although case reports have been positive, controlled studies have only sometimes found client-centered therapy to be more effective than placebo or no therapy </li></ul></ul><ul><ul><li>Only limited support has been found for Rogers’s explanation of causal factors </li></ul></ul>
  18. 19. GAD: The Cognitive Perspective <ul><li>Theorists believe that psychological problems are caused by maladaptive and dysfunctional thinking </li></ul><ul><li>Since GAD is characterized by excessive worry (cognition), this model is a good start… </li></ul>
  19. 20. GAD: The Cognitive Perspective <ul><li>Theory: GAD is caused by maladaptive assumptions </li></ul><ul><ul><li>Albert Ellis identified basic irrational assumptions: </li></ul></ul><ul><ul><ul><li>It is necessary for humans to be loved by everyone </li></ul></ul></ul><ul><ul><ul><li>It is catastrophic when things are not as one wants them to be </li></ul></ul></ul><ul><ul><ul><li>If something is dangerous, a person should be terribly concerned and dwell on the possibility that it will occur </li></ul></ul></ul><ul><ul><ul><li>One should be competent in all domains to be a worthwhile person </li></ul></ul></ul><ul><ul><li>When these assumptions are applied to everyday life, GAD may develop </li></ul></ul>
  20. 21. GAD: The Cognitive Perspective <ul><li>Aaron Beck is another cognitive theorist </li></ul><ul><ul><li>Those with GAD hold unrealistic silent assumptions that imply imminent danger: </li></ul></ul><ul><ul><ul><li>Any strange situation is dangerous </li></ul></ul></ul><ul><ul><ul><li>A situation/person is unsafe until proven safe </li></ul></ul></ul><ul><li>Research supports the presence of these types of assumptions in GAD, particularly about dangerousness </li></ul>
  21. 22. GAD: The Cognitive Perspective <ul><li>What kinds of people are likely to have exaggerated expectations of danger? </li></ul><ul><ul><li>Those whose lives have been filled with unpredictable negative events </li></ul></ul><ul><ul><ul><li>To avoid being “blindsided,” they try to predict events; they look everywhere for danger (and therefore see danger everywhere) </li></ul></ul></ul><ul><ul><ul><li>Theory still under investigation </li></ul></ul></ul>
  22. 23. GAD: The Cognitive Perspective <ul><li>Second-Generation Cognitive Explanations </li></ul><ul><ul><li>In recent years, two new promising explanations have emerged: </li></ul></ul><ul><ul><ul><li>Metacognitive theory </li></ul></ul></ul><ul><ul><ul><ul><li>Developed by Wells; holds that the most problematic assumptions in GAD are the individual’s beliefs about worrying itself </li></ul></ul></ul></ul><ul><ul><ul><li>Avoidance theory </li></ul></ul></ul><ul><ul><ul><ul><li>Developed by Borkovec; holds that worrying serves a “positive” function for those with GAD by reducing unusually high levels of bodily arousal </li></ul></ul></ul></ul><ul><ul><li>Both theories have received considerable research support </li></ul></ul>
  23. 24. GAD: The Cognitive Perspective <ul><li>Two kinds of cognitive therapy: </li></ul><ul><ul><li>Changing maladaptive assumptions </li></ul></ul><ul><ul><ul><li>Based on the work of Ellis and Beck </li></ul></ul></ul><ul><ul><li>Helping clients understand the special role that worrying plays, and changing their views about it </li></ul></ul>
  24. 25. GAD: The Cognitive Perspective <ul><li>Cognitive therapies </li></ul><ul><ul><li>Changing maladaptive assumptions </li></ul></ul><ul><ul><ul><li>Ellis’s rational-emotive therapy (RET) </li></ul></ul></ul><ul><ul><ul><ul><li>Point out irrational assumptions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Suggest more appropriate assumptions </li></ul></ul></ul></ul>
  25. 26. GAD: The Cognitive Perspective <ul><li>Cognitive therapies </li></ul><ul><ul><li>Focusing on worrying </li></ul></ul><ul><ul><ul><li>Therapists begin with psychoeducation about worrying and GAD </li></ul></ul></ul><ul><ul><ul><ul><li>Assign self-monitoring of somatic arousal and cognitive responses </li></ul></ul></ul></ul><ul><ul><ul><li>As therapy progresses, clients become increasingly skilled at identifying their worrying and its counterproductivity </li></ul></ul></ul>
  26. 27. GAD: The Cognitive Perspective <ul><li>Cognitive therapies </li></ul><ul><ul><li>Focusing on worrying </li></ul></ul><ul><ul><ul><li>With continued practice, clients are expected to see the world as less threatening; to adopt more constructive ways of coping; and to worry less </li></ul></ul></ul><ul><ul><ul><li>Research has begun to indicate that a concentrated focus on worrying is a helpful addition to traditional cognitive therapy </li></ul></ul></ul>
  27. 28. GAD: The Biological Perspective <ul><li>Theory holds that GAD is caused by biological factors </li></ul><ul><ul><li>Supported by family pedigree studies </li></ul></ul><ul><ul><ul><li>Blood relatives more likely to have GAD (~15%) than general population (~6%) </li></ul></ul></ul><ul><ul><ul><li>The closer the relative, the greater the likelihood </li></ul></ul></ul><ul><ul><ul><ul><li>Issue of shared environment </li></ul></ul></ul></ul>
  28. 29. GAD: The Biological Perspective <ul><li>GABA inactivity </li></ul><ul><ul><li>1950s – Benzodiazepines (Valium, Xanax) found to reduce anxiety </li></ul></ul><ul><ul><li>Why? </li></ul></ul><ul><ul><ul><li>Neurons have specific receptors (lock and key) </li></ul></ul></ul><ul><ul><ul><li>Benzodiazepine receptors ordinarily receive gamma-aminobutyric acid (GABA, a common NT in the brain) </li></ul></ul></ul><ul><ul><ul><ul><li>GABA is an inhibitory messenger; when received, it causes a neuron to stop firing </li></ul></ul></ul></ul>
  29. 30. GAD: The Biological Perspective <ul><li>In the normal fear reaction: </li></ul><ul><ul><li>Key neurons fire more rapidly, creating a general state of excitability experienced as fear or anxiety </li></ul></ul><ul><ul><li>A feedback system is triggered; brain and body activities work to reduce excitability </li></ul></ul><ul><ul><ul><li>Some neurons release GABA to inhibit neuron firing, thereby reducing experience of fear or anxiety </li></ul></ul></ul><ul><ul><li>Problems with the feedback system are believed to cause GAD </li></ul></ul><ul><ul><ul><li>Possible reasons: GABA too low, too few receptors, ineffective receptors </li></ul></ul></ul>
  30. 31. GAD: The Biological Perspective <ul><li>Promising (but problematic) explanation </li></ul><ul><ul><li>Other NTs also bind to GABA receptors </li></ul></ul><ul><ul><li>Research conducted on lab animals raises question: Is “fear” really fear? </li></ul></ul><ul><ul><li>Issue of causal relationships </li></ul></ul><ul><ul><ul><li>Do physiological events CAUSE anxiety? How can we know? What are alternative explanations? </li></ul></ul></ul>
  31. 32. GAD: The Biological Perspective <ul><li>Biological treatments </li></ul><ul><ul><li>Antianxiety drugs </li></ul></ul><ul><ul><ul><li>Pre-1950s: barbiturates (sedative-hypnotics) </li></ul></ul></ul><ul><ul><ul><li>Post-1950s: benzodiazepines </li></ul></ul></ul><ul><ul><ul><ul><li>Provide temporary, modest relief </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Rebound anxiety with withdrawal and cessation of use </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Physical dependence is possible </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Undesirable effects (drowsiness, etc.) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Multiply effects of other drugs (especially alcohol) </li></ul></ul></ul></ul><ul><ul><ul><li>1980s: buspirone (BuSpar) </li></ul></ul></ul><ul><ul><ul><ul><li>Different receptors, same effectiveness, fewer problems </li></ul></ul></ul></ul>
  32. 33. GAD: The Biological Perspective <ul><li>Biological treatments </li></ul><ul><ul><li>Relaxation training </li></ul></ul><ul><ul><ul><li>Theory: Physical relaxation leads to psychological relaxation </li></ul></ul></ul><ul><ul><ul><li>Research indicates that relaxation training is more effective than placebo or no treatment </li></ul></ul></ul><ul><ul><ul><li>Best when used in combination with cognitive therapy or biofeedback </li></ul></ul></ul>
  33. 34. GAD: The Biological Perspective <ul><li>Biological treatments </li></ul><ul><ul><li>Biofeedback </li></ul></ul><ul><ul><ul><li>Therapist uses electrical signals from the body to train people to control physiological processes </li></ul></ul></ul><ul><ul><ul><li>Electromyograph (EMG) is the most widely used; provides feedback about muscle tension </li></ul></ul></ul><ul><ul><ul><li>Found to be most effective when used as an adjunct to other methods for the treatment of certain medical problems (headache, back pain, etc.) </li></ul></ul></ul>
  34. 35. Phobias <ul><li>From the Greek word for “fear” </li></ul><ul><ul><li>Formal names are also often from the Greek (see “A Closer Look, p. 106) </li></ul></ul><ul><li>Persistent and unreasonable fears of particular objects, activities, or situations </li></ul><ul><li>Phobic people often avoid the object or thoughts about it </li></ul>
  35. 36. Phobias <ul><li>We all have some fears at some points in our lives; this is a normal and common experience </li></ul><ul><ul><li>How do phobias differ from these “normal” experiences? </li></ul></ul><ul><ul><ul><li>More intense fear </li></ul></ul></ul><ul><ul><ul><li>Greater desire to avoid the feared object or situation </li></ul></ul></ul><ul><ul><ul><li>Distress that interferes with functioning </li></ul></ul></ul>
  36. 37. Phobias <ul><li>Most phobias are categorized as “specific” </li></ul><ul><ul><li>Also two broader kinds: </li></ul></ul><ul><ul><ul><li>Social phobia </li></ul></ul></ul><ul><ul><ul><li>Agoraphobia </li></ul></ul></ul>
  37. 38. Specific Phobias <ul><li>Persistent fears of specific objects or situations </li></ul><ul><li>When exposed to the object or situation, sufferers experience immediate fear </li></ul><ul><li>Most common: phobias of specific animals or insects, heights, enclosed spaces, thunderstorms, and blood </li></ul>
  38. 40. Specific Phobias <ul><li>~9% of the U.S. population have symptoms in any given year </li></ul><ul><ul><li>~12% develop a specific phobia at some point in their lives </li></ul></ul><ul><li>Many suffer from more than one phobia at a time </li></ul><ul><li>Women outnumber men 2:1 </li></ul><ul><li>Prevalence differs across racial and ethnic minority groups </li></ul><ul><li>Vast majority do NOT seek treatment </li></ul>
  39. 41. Social Phobias <ul><li>Severe, persistent, and unreasonable fears of social or performance situations in which embarrassment may occur </li></ul><ul><ul><li>May be narrow – talking, performing, eating, or writing in public </li></ul></ul><ul><ul><li>May be broad – general fear of functioning inadequately in front of others </li></ul></ul><ul><ul><li>In both cases, people rate themselves as performing less adequately than is objectively true </li></ul></ul>
  40. 43. Social Phobias <ul><li>Can greatly interfere with functioning </li></ul><ul><ul><li>Often kept a secret </li></ul></ul><ul><li>Affect ~7% of U.S. population in any given year </li></ul><ul><ul><li>~12% develop a social phobia at some point in their lives </li></ul></ul><ul><li>Women outnumber men 3:2 </li></ul><ul><li>Often begin in childhood and may persist for many years </li></ul>
  41. 44. What Causes Phobias? <ul><li>Each model offers explanations, but evidence tends to support the behavioral explanations: </li></ul><ul><ul><li>Phobias develop through conditioning </li></ul></ul><ul><ul><ul><li>Once fears are acquired, they are continued because feared objects are avoided </li></ul></ul></ul><ul><ul><ul><li>Behaviorists propose a classical conditioning model… </li></ul></ul></ul>
  42. 45. Classical Conditioning of Phobia UCR Fear UCR Fear UCS Entrapment Running water CS Running water CR Fear + UCS Entrapment
  43. 46. What Causes Phobias? <ul><li>Other behavioral explanations </li></ul><ul><ul><li>Phobias develop through modeling </li></ul></ul><ul><ul><ul><li>Observation and imitation </li></ul></ul></ul><ul><ul><li>Phobias are maintained through avoidance </li></ul></ul><ul><ul><li>Phobias may develop into GAD when a person acquires a large number of phobias </li></ul></ul><ul><ul><ul><li>Process of stimulus generalization: responses to one stimulus are also elicited by similar stimuli </li></ul></ul></ul>
  44. 47. What Causes Phobias? <ul><li>Behavioral explanations have received some empirical support: </li></ul><ul><ul><li>Classical conditioning study involving Little Albert </li></ul></ul><ul><ul><li>Modeling studies </li></ul></ul><ul><ul><ul><li>Bandura, confederates, buzz, and shock </li></ul></ul></ul><ul><li>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 </li></ul>
  45. 48. What Causes Phobias? <ul><li>A behavioral-evolutionary explanation </li></ul><ul><ul><li>Some phobias are much more common than others; for example: animals, blood, and heights vs meat, grass, and houses </li></ul></ul>
  46. 49. What Causes Phobias? <ul><li>A behavioral-evolutionary explanation </li></ul><ul><ul><li>Theorists argue that there is a species-specific biological predisposition to develop certain fears </li></ul></ul><ul><ul><ul><li>Called “preparedness”: humans are more “prepared” to develop phobias around certain objects or situations </li></ul></ul></ul><ul><ul><ul><li>Unknown if these predispositions are due to evolutionary or environmental factors </li></ul></ul></ul>
  47. 50. How Are Phobias Treated? <ul><li>Surveys reveal that ~19% of those with specific phobia and 25% of those with social phobia currently are in treatment </li></ul><ul><li>Each model offers treatment approaches </li></ul><ul><ul><li>Behavioral techniques (exposure treatments) are most widely used, especially for specific phobias </li></ul></ul><ul><ul><ul><li>Shown to be highly effective </li></ul></ul></ul><ul><ul><ul><li>Fare better in head-to-head comparisons than other approaches </li></ul></ul></ul><ul><ul><ul><li>Include desensitization, flooding, and modeling </li></ul></ul></ul>
  48. 51. Treatments for Specific Phobias <ul><li>Systematic desensitization </li></ul><ul><ul><li>Technique developed by Joseph Wolpe </li></ul></ul><ul><ul><ul><li>Teach relaxation skills </li></ul></ul></ul><ul><ul><ul><li>Create fear hierarchy </li></ul></ul></ul><ul><ul><ul><li>Sufferers learn to relax while facing feared objects </li></ul></ul></ul><ul><ul><ul><ul><li>Since relaxation is incompatible with fear, the relaxation response is thought to substitute for the fear response </li></ul></ul></ul></ul><ul><ul><li>Several types: </li></ul></ul><ul><ul><ul><li>In vivo desensitization (live) </li></ul></ul></ul><ul><ul><ul><li>Covert desensitization (imaginal) </li></ul></ul></ul>
  49. 52. Treatments for Specific Phobias <ul><li>Other behavioral treatments: </li></ul><ul><ul><li>Flooding </li></ul></ul><ul><ul><ul><li>Forced nongradual exposure </li></ul></ul></ul><ul><ul><li>Modeling </li></ul></ul><ul><ul><ul><li>Therapist confronts the feared object while the fearful person observes </li></ul></ul></ul><ul><li>Clinical research supports each of these treatments </li></ul><ul><ul><li>The key to success is ACTUAL contact with the feared object or situation </li></ul></ul>
  50. 53. Treatments for Social Phobias <ul><li>Treatments only recently successful </li></ul><ul><ul><li>Two components must be addressed: </li></ul></ul><ul><ul><ul><li>Overwhelming social fear </li></ul></ul></ul><ul><ul><ul><ul><li>Address fears behaviorally with exposure </li></ul></ul></ul></ul><ul><ul><ul><li>Lack of social skills </li></ul></ul></ul><ul><ul><ul><ul><li>Social skills and assertiveness trainings have proved helpful </li></ul></ul></ul></ul>
  51. 54. Treatments for Social Phobias <ul><li>Unlike specific phobias, social phobias respond well to medication (particularly antidepression drugs) </li></ul><ul><li>Several types of psychotherapy have proved at least as effective as medication </li></ul><ul><ul><li>People treated with psychotherapy are less likely to relapse than people treated with drugs alone </li></ul></ul><ul><ul><li>One psychological approach is exposure therapy, either in an individual or group setting </li></ul></ul><ul><ul><li>Cognitive therapies also have been widely used </li></ul></ul>
  52. 55. Treatments for Social Phobias <ul><li>Another treatment option is social skills training, a combination of several behavioral techniques to help people improve their social functioning </li></ul><ul><ul><li>Therapist provides feedback and reinforcement </li></ul></ul>
  53. 56. Panic Disorder <ul><li>Panic, an extreme anxiety reaction, can result when a real threat suddenly emerges </li></ul><ul><li>The experience of “panic attacks,” however, is different </li></ul><ul><ul><li>Panic attacks are periodic, short bouts of panic that occur suddenly, reach a peak, and pass </li></ul></ul><ul><ul><li>Sufferers often fear they will die, go crazy, or lose control </li></ul></ul><ul><ul><li>Attacks happen in the absence of a real threat </li></ul></ul>
  54. 57. Panic Disorder <ul><li>Anyone can experience a panic attack, but some people have panic attacks repeatedly , unexpectedly , and without apparent reason </li></ul><ul><ul><li>Diagnosis: Panic disorder </li></ul></ul><ul><ul><ul><li>Sufferers also experience dysfunctional changes in thinking and behavior as a result of the attacks </li></ul></ul></ul><ul><ul><ul><ul><li>Example: sufferer worries persistently about having an attack; plans behavior around possibility of future attack </li></ul></ul></ul></ul>
  55. 59. Panic Disorder <ul><li>Often (but not always) accompanied by agoraphobia </li></ul><ul><ul><li>From the Greek “fear of the marketplace” </li></ul></ul><ul><ul><li>Afraid to leave home and travel to locations from which escape might be difficult or help unavailable </li></ul></ul><ul><ul><li>Intensity may fluctuate </li></ul></ul><ul><ul><li>There has only recently been a recognition of the link between agoraphobia and panic attacks (or panic-like symptoms) </li></ul></ul>
  56. 60. Panic Disorder <ul><li>Two diagnoses: panic disorder with agoraphobia; panic disorder without agoraphobia </li></ul><ul><ul><li>~3% of U.S. population affected in a given year </li></ul></ul><ul><ul><li>~5% of U.S. population affected at some point in their lives </li></ul></ul><ul><li>Likely to develop in late adolescence and early adulthood </li></ul><ul><li>Women are twice as likely as men to be affected </li></ul><ul><li>Approximately 35% of those with panic disorder are in treatment </li></ul>
  57. 61. Panic Disorder: The Biological Perspective <ul><li>In the 1960s, it was recognized that people with panic disorder were not helped by benzodiazepines, but were helped by antidepressants </li></ul><ul><ul><li>Researchers worked backward from their understanding of antidepressant drugs </li></ul></ul>
  58. 62. Panic Disorder: The Biological Perspective <ul><li>What biological factors contribute to panic disorder? </li></ul><ul><ul><li>NT at work is norepinephrine </li></ul></ul><ul><ul><ul><li>Irregular in people with panic attacks </li></ul></ul></ul><ul><ul><ul><ul><li>Research suggests that panic reactions are related to changes in norepinephrine activity in the locus ceruleus </li></ul></ul></ul></ul><ul><ul><li>Although norepinephrine is clearly linked to panic disorder, what goes wrong isn’t exactly understood </li></ul></ul><ul><ul><ul><li>May be excessive activity, deficient activity, or some other defect </li></ul></ul></ul><ul><ul><ul><li>Other NTs and brain circuits seem to be involved </li></ul></ul></ul>
  59. 63. Panic Disorder: The Biological Perspective <ul><li>It is also unclear why some people have such abnormalities in norepinephrine activity </li></ul><ul><ul><li>Inherited biological predisposition is one possible reason </li></ul></ul><ul><ul><ul><li>If so, prevalence should be (and is) greater among close relatives </li></ul></ul></ul><ul><ul><ul><ul><li>Among monozygotic (MZ, or identical) twins = 24% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Among dizygotic (DZ, or fraternal) twins = 11% </li></ul></ul></ul></ul><ul><ul><ul><li>Issue is still open to debate </li></ul></ul></ul>
  60. 64. Panic Disorder: The Biological Perspective <ul><li>Drug therapies </li></ul><ul><ul><li>Antidepressants are effective at preventing or reducing panic attacks </li></ul></ul><ul><ul><ul><li>Function at norepinephrine receptors in the panic brain circuit </li></ul></ul></ul><ul><ul><ul><li>Bring at least some improvement to 80% of patients with panic disorder </li></ul></ul></ul><ul><ul><ul><ul><li>~50% recover markedly or fully </li></ul></ul></ul></ul><ul><ul><ul><li>Require maintenance of drug therapy; otherwise relapse rates are high </li></ul></ul></ul><ul><ul><li>Some benzodiazepines (especially Xanax [alprazolam]) also have proved helpful </li></ul></ul>
  61. 65. Panic Disorder: The Biological Perspective <ul><li>Drug therapies </li></ul><ul><ul><li>Both antidepressants and benzodiazepines are also helpful in treating panic disorder with agoraphobia </li></ul></ul><ul><ul><ul><li>Break the cycle of attack, anticipation, and fear </li></ul></ul></ul><ul><li>Combination treatment (medications + behavioral exposure therapy) may be more effective than either treatment alone </li></ul>
  62. 66. Panic Disorder: The Cognitive Perspective <ul><li>Cognitive theorists and practitioners recognize that biological factors are only part of the cause of panic attacks </li></ul><ul><ul><li>In their view, full panic reactions are experienced only by people who misinterpret bodily events </li></ul></ul><ul><ul><li>Cognitive treatment is aimed at correcting such misinterpretations </li></ul></ul>
  63. 67. Panic Disorder: The Cognitive Perspective <ul><li>Misinterpreting bodily sensations </li></ul><ul><ul><li>Panic-prone people may be overly sensitive to certain bodily sensations and may misinterpret them as signs of a medical catastrophe; this leads to panic </li></ul></ul><ul><ul><li>Why might some people be prone to such misinterpretations? </li></ul></ul><ul><ul><ul><li>One possibility: Experience more frequent or intense bodily sensations </li></ul></ul></ul>
  64. 68. Panic Disorder: The Cognitive Perspective <ul><li>Misinterpreting bodily sensations </li></ul><ul><ul><li>Panic-prone people also have a high degree of “anxiety sensitivity” </li></ul></ul><ul><ul><ul><li>They focus on bodily sensations much of the time, are unable to assess the sensations logically, and interpret them as potentially harmful </li></ul></ul></ul>
  65. 69. Panic Disorder: The Cognitive Perspective <ul><li>Cognitive therapy </li></ul><ul><ul><li>Attempts to correct people’s misinterpretations of their bodily sensations </li></ul></ul><ul><ul><ul><li>Step 1: Educate clients </li></ul></ul></ul><ul><ul><ul><ul><li>About panic in general </li></ul></ul></ul></ul><ul><ul><ul><ul><li>About the causes of bodily sensations </li></ul></ul></ul></ul><ul><ul><ul><ul><li>About their tendency to misinterpret the sensations </li></ul></ul></ul></ul><ul><ul><ul><li>Step 2: Teach clients to apply more accurate interpretations (especially when stressed) </li></ul></ul></ul><ul><ul><ul><li>Step 3: Teach clients skills for coping with anxiety </li></ul></ul></ul><ul><ul><ul><ul><li>Examples: relaxation, breathing </li></ul></ul></ul></ul>
  66. 70. Panic Disorder: The Cognitive Perspective <ul><li>Cognitive therapy </li></ul><ul><ul><li>May also use “biological challenge” procedures to induce panic sensations </li></ul></ul><ul><ul><ul><li>Induce physical sensations which cause feelings of panic: </li></ul></ul></ul><ul><ul><ul><ul><li>Jump up and down </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Run up a flight of steps </li></ul></ul></ul></ul><ul><ul><ul><li>Practice coping strategies and making more accurate interpretations </li></ul></ul></ul>
  67. 71. Panic Disorder: The Cognitive Perspective <ul><li>Cognitive therapy is often helpful in panic disorder </li></ul><ul><ul><li>85% of treated patients are panic-free for two years compared with 13% of control subjects </li></ul></ul><ul><ul><li>Only sometimes helpful for panic disorder with agoraphobia </li></ul></ul><ul><ul><li>At least as helpful as antidepressants </li></ul></ul><ul><li>Combination therapy may be most effective </li></ul><ul><ul><li>Still under investigation </li></ul></ul>
  68. 72. Obsessive-Compulsive Disorder <ul><li>Made up of two components: </li></ul><ul><ul><li>Obsessions </li></ul></ul><ul><ul><ul><li>Persistent thoughts, ideas, impulses, or images that seem to invade a person’s consciousness </li></ul></ul></ul><ul><ul><li>Compulsions </li></ul></ul><ul><ul><ul><li>Repeated and rigid behaviors or mental acts that people feel they must perform to prevent or reduce anxiety </li></ul></ul></ul>
  69. 73. Obsessive-Compulsive Disorder <ul><li>Diagnosis may be called for when symptoms: </li></ul><ul><ul><li>Feel excessive or unreasonable </li></ul></ul><ul><ul><li>Cause great distress </li></ul></ul><ul><ul><li>Consume considerable time </li></ul></ul><ul><ul><li>Interfere with daily functions </li></ul></ul>
  70. 75. Obsessive-Compulsive Disorder <ul><li>Classified as an anxiety disorder because obsessions cause anxiety, while compulsions are aimed at preventing or reducing anxiety </li></ul><ul><ul><li>Anxiety rises if obsessions or compulsions are avoided </li></ul></ul><ul><li>Between 1% and 2% of U.S. population has OCD in a given year; around 3% over a lifetime </li></ul><ul><li>Ratio of women to men is 1:1 </li></ul><ul><li>It is estimated that more than 40% of those with OCD seek treatment </li></ul>
  71. 76. What Are the Features of Obsessions and Compulsions? <ul><li>Obsessions </li></ul><ul><ul><li>Thoughts that feel intrusive and foreign </li></ul></ul><ul><ul><li>Attempts to ignore or avoid them trigger anxiety </li></ul></ul><ul><ul><li>Take various forms: </li></ul></ul><ul><ul><ul><li>Wishes </li></ul></ul></ul><ul><ul><ul><li>Impulses </li></ul></ul></ul><ul><ul><ul><li>Images </li></ul></ul></ul><ul><ul><ul><li>Ideas </li></ul></ul></ul><ul><ul><ul><li>Doubts </li></ul></ul></ul><ul><ul><li>Have common themes: </li></ul></ul><ul><ul><ul><li>Dirt/contamination </li></ul></ul></ul><ul><ul><ul><li>Violence and aggression </li></ul></ul></ul><ul><ul><ul><li>Orderliness </li></ul></ul></ul><ul><ul><ul><li>Religion </li></ul></ul></ul><ul><ul><ul><li>Sexuality </li></ul></ul></ul>
  72. 77. What Are the Features of Obsessions and Compulsions? <ul><li>Compulsions </li></ul><ul><ul><li>“ Voluntary” behaviors or mental acts </li></ul></ul><ul><ul><ul><li>Feel mandatory/unstoppable </li></ul></ul></ul><ul><ul><li>Person may recognize that behaviors are irrational </li></ul></ul><ul><ul><ul><li>Believe, though, that catastrophe will occur if they don’t perform the compulsive acts </li></ul></ul></ul><ul><ul><li>Performing behaviors reduces anxiety </li></ul></ul><ul><ul><ul><li>ONLY FOR A SHORT TIME! </li></ul></ul></ul><ul><ul><li>Behaviors often develop into rituals </li></ul></ul>
  73. 78. What Are the Features of Obsessions and Compulsions? <ul><li>Compulsions </li></ul><ul><ul><li>Common forms/themes: </li></ul></ul><ul><ul><ul><li>Cleaning </li></ul></ul></ul><ul><ul><ul><li>Checking </li></ul></ul></ul><ul><ul><ul><li>Order or balance </li></ul></ul></ul><ul><ul><ul><li>Touching, verbal, and/or counting </li></ul></ul></ul>
  74. 79. What Are the Features of Obsessions and Compulsions? <ul><li>Are obsessions and compulsions related? </li></ul><ul><ul><li>Most (not all) people with OCD experience both </li></ul></ul><ul><ul><li>Compulsive acts often occur in response to obsessive thoughts </li></ul></ul><ul><ul><ul><li>Compulsions seem to represent a yielding to obsessions </li></ul></ul></ul><ul><ul><ul><li>Compulsions also sometimes serve to help control obsessions </li></ul></ul></ul>
  75. 80. What Are the Features of Obsessions and Compulsions? <ul><li>Are obsessions and compulsions related? </li></ul><ul><ul><li>Many with OCD are concerned that they will act on their obsessions </li></ul></ul><ul><ul><ul><li>Most of these concerns are unfounded </li></ul></ul></ul><ul><ul><ul><li>Compulsions usually do not lead to violence or “immoral acts” </li></ul></ul></ul>
  76. 81. Obsessive-Compulsive Disorder <ul><li>OCD was once among the least understood of the psychological disorders </li></ul><ul><li>In recent years, however, researchers have begun to learn more about it </li></ul><ul><li>The most influential explanations are from the psychodynamic, behavioral, cognitive, and biological models… </li></ul>
  77. 82. OCD: The Psychodynamic Perspective <ul><li>Anxiety disorders develop when children come to fear their id impulses and use ego defense mechanisms to lessen their anxiety </li></ul><ul><li>OCD differs from anxiety disorders in that the “battle” is not unconscious; it is played out in explicit thoughts and action </li></ul><ul><ul><li>Id impulses = obsessive thoughts </li></ul></ul><ul><ul><li>Ego defenses = counter-thoughts or compulsive actions </li></ul></ul><ul><li>At its core, OCD is related to aggressive impulses and the competing need to control them </li></ul>
  78. 83. OCD: The Psychodynamic Perspective <ul><li>The battle between the id and the ego </li></ul><ul><ul><li>Three ego defenses mechanisms are common: </li></ul></ul><ul><ul><ul><li>Isolation: disown disturbing thoughts </li></ul></ul></ul><ul><ul><ul><li>Undoing: perform acts to “cancel out” thoughts </li></ul></ul></ul><ul><ul><ul><li>Reaction formation: take on lifestyle in contrast to unacceptable impulses </li></ul></ul></ul><ul><ul><li>Freud believed that OCD was related to the anal stage of development </li></ul></ul><ul><ul><ul><li>Period of intense conflict between id and ego </li></ul></ul></ul><ul><ul><li>Research has not supported this explanation </li></ul></ul>
  79. 84. OCD: The Psychodynamic Perspective <ul><li>Psychodynamic therapies </li></ul><ul><ul><li>Goals are to uncover and overcome underlying conflicts and defenses </li></ul></ul><ul><ul><li>Main techniques are free association and interpretation </li></ul></ul><ul><ul><li>Research evidence is poor </li></ul></ul><ul><ul><ul><li>Some therapists now prefer to treat these patients with short-term psychodynamic therapies </li></ul></ul></ul>
  80. 85. OCD: The Behavioral Perspective <ul><li>Behaviorists concentrate on explaining and treating compulsions rather than obsessions </li></ul><ul><li>Although the behavioral explanation of OCD has received little support, behavioral treatments for compulsive behaviors have been very successful </li></ul>
  81. 86. OCD: The Behavioral Perspective <ul><li>Learning by chance </li></ul><ul><ul><li>People happen upon compulsions randomly: </li></ul></ul><ul><ul><ul><li>In a fearful situation, they happen to perform a particular act (washing hands) </li></ul></ul></ul><ul><ul><ul><li>When the threat lifts, they associate the improvement with the random act </li></ul></ul></ul><ul><ul><li>After repeated associations, they believe the compulsion is changing the situation </li></ul></ul><ul><ul><ul><li>Bringing luck, warding away evil, etc. </li></ul></ul></ul><ul><ul><li>The act becomes a key method to avoiding or reducing anxiety </li></ul></ul>
  82. 87. OCD: The Behavioral Perspective <ul><li>Key investigator: Stanley Rachman </li></ul><ul><ul><li>Compulsions do appear to be rewarded by an eventual decrease in anxiety </li></ul></ul><ul><ul><ul><li>Studies provide no evidence of the learning of compulsions </li></ul></ul></ul>
  83. 88. OCD: The Behavioral Perspective <ul><li>Behavioral therapy </li></ul><ul><ul><li>Exposure and response prevention (ERP) </li></ul></ul><ul><ul><ul><li>Clients are repeatedly exposed to anxiety-provoking stimuli and prevented from responding with compulsions </li></ul></ul></ul><ul><ul><ul><li>Therapists often model the behavior while the client watches </li></ul></ul></ul><ul><ul><ul><ul><li>Homework is an important component </li></ul></ul></ul></ul><ul><ul><ul><li>Treatment is offered in individual and group settings </li></ul></ul></ul><ul><ul><ul><li>Treatment provides significant, long-lasting improvements for most patients </li></ul></ul></ul><ul><ul><ul><ul><li>However, as many as 25% fail to improve at all and the approach is of limited help to those with obsessions but no compulsions </li></ul></ul></ul></ul>
  84. 89. OCD: The Cognitive Perspective <ul><li>Cognitive theory begins by pointing out that everyone has repetitive, unwanted, and intrusive thoughts </li></ul><ul><ul><li>People with OCD blame themselves for normal (although repetitive and intrusive) thoughts and expect that terrible things will happen as a result </li></ul></ul>
  85. 90. OCD: The Cognitive Perspective <ul><li>Overreacting to unwanted thoughts </li></ul><ul><ul><li>To avoid such negative outcomes, they attempt to neutralize their thoughts with actions (or other thoughts) </li></ul></ul><ul><ul><li>Neutralizing thoughts/actions may include: </li></ul></ul><ul><ul><ul><li>Seeking reassurance </li></ul></ul></ul><ul><ul><ul><li>Thinking “good” thoughts </li></ul></ul></ul><ul><ul><ul><li>Washing </li></ul></ul></ul><ul><ul><ul><li>Checking </li></ul></ul></ul>
  86. 91. OCD: The Cognitive Perspective <ul><li>When a neutralizing action reduces anxiety, it is reinforced </li></ul><ul><ul><li>Client becomes more convinced that the thoughts are dangerous </li></ul></ul><ul><ul><li>As fear of thoughts increases, the number of thoughts increases </li></ul></ul>
  87. 92. OCD: The Cognitive Perspective <ul><li>If everyone has intrusive thoughts, why do only some people develop OCD? </li></ul><ul><ul><li>People with OCD tend: </li></ul></ul><ul><ul><ul><li>To be more depressed than others </li></ul></ul></ul><ul><ul><ul><li>To have higher standards of morality and conduct </li></ul></ul></ul><ul><ul><ul><li>To believe thoughts are equal to actions and are capable of bringing harm </li></ul></ul></ul><ul><ul><ul><li>To believe that they can and should have perfect control over their thoughts and behaviors </li></ul></ul></ul>
  88. 93. OCD: The Cognitive Perspective <ul><li>Cognitive therapies </li></ul><ul><ul><li>Focus on the cognitive processes that help to produce and maintain obsessive thoughts and compulsive acts </li></ul></ul><ul><ul><li>May include: </li></ul></ul><ul><ul><ul><li>Psychoeducation </li></ul></ul></ul><ul><ul><ul><li>Habituation training </li></ul></ul></ul>
  89. 94. OCD: The Cognitive Perspective <ul><li>Cognitive-Behavioral Therapy (CBT) </li></ul><ul><ul><li>Research suggests that a combination of the cognitive and behavioral models often is more effective than either intervention alone </li></ul></ul><ul><ul><li>These treatments typically include psychoeducation and exposure and response prevention exercises </li></ul></ul>
  90. 95. OCD: The Biological Perspective <ul><li>Two recent lines of research indicate that biological factors play a key role in OCD: </li></ul><ul><ul><li>NT serotonin </li></ul></ul><ul><ul><ul><li>Evidence that serotonin-based antidepressants reduce OCD symptoms </li></ul></ul></ul><ul><ul><li>Brain abnormalities </li></ul></ul><ul><ul><ul><li>OCD linked to orbital region of frontal cortex and caudate nuclei </li></ul></ul></ul><ul><ul><ul><ul><li>Frontal cortex and caudate nuclei compose brain circuit that converts sensory information into thoughts and actions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Either area may be too active, letting through troublesome thoughts and actions </li></ul></ul></ul></ul>
  91. 96. OCD: The Biological Perspective <ul><li>Some research provides evidence that these two lines may be connected </li></ul><ul><ul><li>Serotonin plays a very active role in the operation of the orbital region and the caudate nuclei </li></ul></ul><ul><ul><ul><li>Low serotonin activity might interfere with the proper functioning of these brain parts </li></ul></ul></ul>
  92. 97. OCD: The Biological Perspective <ul><li>Biological therapies </li></ul><ul><ul><li>Serotonin-based antidepressants </li></ul></ul><ul><ul><ul><li>Examples: clomipramine (Anafranil), fluoxetine (Prozac), fluvoxamine (Luvox) </li></ul></ul></ul><ul><ul><ul><li>Bring improvement to 50% – 80% of those with OCD </li></ul></ul></ul><ul><ul><ul><li>Relapse occurs if medication is stopped </li></ul></ul></ul><ul><ul><li>Research suggests that combination therapy (medication + cognitive behavioral therapy approaches) may be most effective </li></ul></ul><ul><ul><ul><li>May have same effect on the brain </li></ul></ul></ul>