LECTURE NOTES 4: Anxiety and the Anxiety Disorders

I ANXIETY AND THE ANXIETY DISORDERS

Anxiety is very complex and mysterious and as time goes on it becomes more intriguing to the mental health experts. It is an emotion and state that is rooted in Freudian theory.

1. PSYCHODYNAMIC EXPLANATIONS OF ANXIETY

1 It is an emotion

according to Freud emotions automatically develop with an influx of stimulation too much for the psychic apparatus ( id,ego, & superego) to handle.- Freud believed it results in suppression of the sexual instinct???

2 ANXIETY PSYCHOANALYTICALLY IS EXPERIENCED IN THE EGO STRUCTURE:

1. conscious feeling of fear
2. patterns of physical arousal
3. disturbance of our problem solving abilities

 

3 IS A HUMAN CONDITION THAT MAY BE NORMAL OR PATHOLOGICAL

but runs

Through most areas of pathology which may or may not become an anxiety disorder.. especially depression and schizophrenia. i.e. It can mobilize our defenses to help deal with stress or undermine the defenses with a loss of control.

 

4 ANXIETY IS DIFFERENT THAN FEAR

fear may be a useful rational type of fright that may occur as a result of an extra-psychic danger but anxiety is intra-psychic and usually inaccessible or not clearly understood by the person

5. SOURCES OF ANXIETY

1. Danger from unacceptable feelings, isolation, loneliness, anticipate separations
2. Fears of change
3. Feeling of helplessness to change patterns- this type is amenable to treatment

6- ANXIETY PROVIDES THE FORCE THAT LEADS TO REPRESSION

Anxiety may cause symptom formation

II. ANXIETY, FEAR AND PANIC

1. GENERAL DEFINITIONS AND RELATED COMPONENTS.

A.P.A. definition: anxiety is a mood-state characterized by marked negative affect, body symptoms of tension, apprehension about the future, and the feeling that one cannot predict or control the upcoming events: a test, an interview, a trip, a date, even thinking about it

2 AS NOTED ABOVE EXPERTS HAVE DIFFERENTIATED FEAR AND ANXIETY: Fear is an immediate alarm reaction to danger and like anxiety can be good or bad- fear as a negative affect

1. leads to a strong sympathetic nervous system arousal
2. characterized by strong escapist tendencies in response to present danger or life threatening emergencies. This can lead to panic

3 ANXIETY

1. is a negative affect
2. which has somatic symptoms of tension
3. Is future oriented
4. Contains the feelings that one cannot control upcoming events .

   According to our text(Hoeksema pp. 108-109):

   1. 4 different types of symptoms with anxiety
      1. somatic symptoms- physical i.e. sweating, dizziness. etc.
      2. emotional symptoms- affects
      3. cognitive- unrealistic worry.
      4. behavioral- situational avoidance.

4 PANIC OR PANIC ATTACK

Defined as an abrupt experience of intense fear or acute distress, accompanied by physical symptoms that usually include heart palpitations, chest pain shortness of breath , and sometimes dizziness.

1. Fear occurring at an inappropriate time
2. There are three types of panic;
   1. situationally bound (cued).
   2. Unexpected (uncued).
   3. Situationally predisposed i.e. If you fear it will happen today, and it does- like in the shopping mall-however the panic attack does not always occur in these situations.
3. The above three will help determine the type of anxiety disorder it is.
   1. Unexpected or situational will be PANIC DISORDER whereas
   2. Situationally predisposed would be SPECIFIC or SOCIAL PHOBIAS.

5. CAUSES OF ANXIETY AND PANIC

I- BIOLOGICAL

1. Some evidence suggests that genetic components may exist but no specific genes have been identified. However- they suggest the right combination of psychological and social factors to show a link with biological components that could run in families is necessary.
2. Some further evidence suggests we could inherit a tendency to be uptight, overemotional, or anxious. E.g., A brain system defect ( the limbic system ) was isolated by a neuropsychologist which deals with danger signals that lead to anxiety, but it is not the brain system involved that causes panic.

   Panic may result in ( The Fright-or-Flight principle) in the gray matter of the brain.

II - PSYCHOLOGICAL FACTORS

1. Behavioral- Classical conditioning, modeling, or learned.
2. Psychoanalytic- anxiety results from the activation of early infantile fearful situations.
3. An Integrative Approach seems most likely combining all approaches.

   i.e., most likely is the feeling of loss of control early in life or our perception from a set of danger-laden beliefs (these beliefs are from our upbringing and environmental factors) leading to a "sense of uncontrollability"

   Causes of PANIC - Conditioning and Cognitive explanations difficult for the individuals experiencing the panic to separate.

   The process of Panic :

   1. Strong fear responses( a true alarming situation ) from a dangerous situation.
   2. These make us associate with external and internal cues.
   3. Then CONDITIONING occurs- External cues- places or situations where the initial panic occurred.
      1. Internal cues- Heart rate, respiration associated with the initial panic attack even it under normal circumstances without physical exercise. I.e., if your heart is beating fast you might feel an attack is coming.
   4. Person may experience derealization or depersonalization

   Most likely stressful events that could trigger anxiety- these are known as stressors.

   • Marriage, divorce, work difficulties, school( perhaps to excel) - these can also lead to physiological reactions such as headaches, hypertension, and panic.

6. THE ANXIETY DISORDERS - A LIST

1. Panic disorder without agoraphobia
2. Panic disorder with agoraphobia
3. Agoraphobia without history of panic disorder
4. Specific phobias
5. Social phobias
6. Obsessive - compulsive disorder
7. Acute stress disorder
8. Generalized anxiety disorder
9. Post traumatic stress disorder

7. SUMMATION OF ANXIETY DISORDERS, PANIC DISORDERS AND AGORAPHOBIA

Agoraphobia: Greek- fear of open places

1. Panic attacks may cause agoraphobia
2. Basic fear- having a panic attack away from "safe" place.- in the event of a panic attack or its symptoms and may die or need a hospital. They will also fear of the loss of control .
3. Follows a series of unpredictable, uncontrollable panic attacks
4. Attacks in certain places leads to avoidance of those places- typical avoidance places are; shopping malls, cars, trains,planes,buses,subways,wide streets, theaters, being far from home, staying at home alone,crowds,elevators, restaurants,etc. 6- attacks must occur "out of the blue".
5. Too many places the person becomes housebound
6. May result in Suicide- one study found 20% of patients with panic disorders attempted suicide and these patients are at risk even if not accompanied by depression- other studies suggest that more suicide ideation and attempts are prevalent with borderline personality disorders .
7. Panic can become a Panic Disorder without Agoraphobia

In this case they must meet the following criteria; experience an unexpected panic attack and develop substantial anxiety over the possibility of having another attack or about the implications of the attack or its consequences.

For the panic attacks to be a panic disorder it must be accompanied by at least one month of worry or concern regarding another attack.

Prevalence and At Risk-

1. of Agoraphobiacs are women and
2. Most likely to occur in late adolescence or early adulthood

CAUSES OF Panic Disorders and Agoraphobia

Psychodynamic

Freud- unconscious need to act out sexual impulses- unresolved oedipal complex ??

Object Relations: more likely

1. Agoraphobia is unresolved separation anxiety
2. Parents did not answer infant's need for security
3. Fears are reactivated later in life

BIOLOGICAL CAUSES OF PANIC DISORDER AND AGORAPHOBIA

1. Panic disorders and agoraphobia run in families
2. 17% of families have some disorder, 46% female relatives
3. As noted earlier some neurophysiological and biochemical mechanisms identified.

COGNITIVE EXPLANATIONS

• As noted above cognition is involved- some people are psychophysiologically vulnerable to interpret normal physical sensations as catastrophic.- interpreting to the point of raising the level of anxiety producing more physical symptoms and thus perceiving the symptoms as even more dangerous.

Generalized Anxiety Disorder ( GAD )

1. Is a chromic state of diffuse anxiety
2. Characterized by a excessive worry over a period of six months about several life situations
3. Three most popular areas of worry are family, work, health
4. People with this disorder are continuously waiting for something dreadful to happen
5. Anxiety occurs in the form of restlessness and irritability with associate physical symptoms of increased heart rate . problems concentrating., chronic muscle tension , and Insomnia
6. Many develop secondary anxiety about their anxiety
7. Is a resting state of a panic disorder but has marked differences specifically that GAD is chronic and has insomnia and is more gradual in arousal
8. GAD does not necessarily run in families

Prevalence and At Risk for GAD

1. All ages
2. Lower socioeconomic
3. Develops early in life
4. 5% of pop have it
5. Twice as high in women
6. highest among Afro-American men

THE PHOBIAS - in addition to Agoraphobia are the Specific Phobias and Social Phobia.

Two main factors

1. A Phobia is an intense( severe ) and persistent fear of an object or situation, that the person actually realizes , poses no real threat- but may in fact have a suggestion of danger.- dogs, insects, snakes, high places, mice etc.
2. The person will avoid the phobic situation which will interfere with one's education, occupation, or social life

Specific Phobias

There are four categories:

1. Animal
2. Situational: elevators, tunnels, planes, small rooms, enclosed places.
3. Blood and Body Injury and injections
4. Natural Environment: storms, deep water, heights

"Other" Phobias: new category - loud sounds , vomiting, choking

1. Most frequent are Acrophobia- heights Claustrophobia- enclosed places and Animal Phobias
2. Animal Phobias easiest to avoid except dogs and least interference with life plans.

Social Phobias

Is an excessive fear of being evaluated or possibly embarrassed and humiliated.

1. Most common is public speaking or public performance, meeting strangers, eating in public, and using public bathrooms.
2. These people are likely to underachieve and not marry.
3. This phobia erodes self-confidence and avoid the situations in daily living that seriously affects careers and restricts choices- one study showed 90% affected the career or work
4. Often accompanied by high use of alcohol and or tranquilizers.

   Prevalence and At Risk with Social Phobias

   1. Begins in early childhood

   Affect 11% of pop - extremely common

   1. Women twice as high than men

   Lower socio-eco and lower education level.

TREATMENT OF THE PHOBIAS - treatment has been shown to be fairly straight forward.

1. Systematic Desensitization -
   1. teach muscle relaxation ( leads to calmness).
   2. Construct an anxiety hierarchy- imagine least frightening then - moving up the list to most frightening . When person is calm with most frightening then treatment is successful.
2. Exposure procedures: used for specific phobias- should be gradual and under supervision.
   1. principle of extinction
   2. gradual hierarchy to live fears, not imaginary exposures.
   3. Virtual reality is now being used
   4. caution with blood-injection injury phobia due to fainting - here it is recommended that patient tense up muscles to avoid blood pressure from dropping to avoid fainting.
3. Flooding- very successful with social phobias.
   1. expose patient to most intense stimuli
   2. leads to an initial increase in anxiety followed by a rapid reduction.
   3. 20 sessions have been indicated for social phobias.
4. Modeling
   1. Albert Bandura- client observes model
   2. Model interacts with feared stimuli without fear
   3. Then participant Modeling- here therapist demonstrates feared behavior, then assists client and confidence reduces fear behavior.

OBSESSIVE - COMPULSIVE DISORDER

Characterized by obsessions= which are unwanted, disturbing, often irrational thoughts, feelings, or images that people cannot get out of their head.

1. Is different than a preoccupation or a daydream
2. Involves frightening images or aggressive urges.
3. Most common;
   1. fear of dirt, germs, disease, touching infected people or objects
   2. disgust over body waste or secretions
   3. Undue concern job has not been done adequately
   4. Fear of shouting obscenities or insults.
   5. fear of thinking sexual thoughts.
4. 80% of people are compelled to take action to suppress or ease the anxiety, or guilt.

Compulsions: repetitive, nearly irresistible acts that temporarily neutralize obsessions or relieve the anxiety.

1. Most common compulsive rituals
   1. repetitively washing one's hands or other contaminated objects.
   2. Checking doors, windows, water, or gas taps.
   3. Counting objects a precise number of times, repeating actions.
   4. Hoarding items: old newspapers, mail, used and useless items
   5. putting dishes and silver in precisely aligned patters
2. Patient tries to resist performing rituals( because they understand it is excessive).
3. But the impulse to act wins out

Prevalence and At Risk

1. Affects 2-3% of the population
2. Most at risk are divorced, widowed, separated, or unemployed.
3. Men and women equal- with men young and single have more checking rituals, whereas married women to have cleaning rituals
4. Usually appears in late adolescent or early adulthood- median age is 23.
5. 30% in family members but inheritance not genetic but more environment.

Causes and Treatment of OCD-

Causes

1. some biological causes: may have low levels of serotonim, overactive brain, nad high with severe head injuries.
2. Cognitive- behavioral factors- greatest under stress rituals neutralize anxiety and use compulsive behavior to undue thoughts.

Treatment

1. Most difficult to treat.
2. Desperate patients submit to psychosurgery.
3. Two most successful approaches.
   1. Drug therapy- Clominpramine ( blocks serotonin uptake )
      1. 50-70% improve, but removal of drug behavior returns.
   2. Cognitive Behavior therapy- can be combined with drug treatment based on extinction model- others use combined exposure and response prevention.