CHAPTER 5
CHAPTER OUTLINE
I.
II.
Understanding anxiety disorders from a multi-path perspective. Anxiety is a
fundamental human emotion that has an adaptive function. Anxiety disorders meet one
of the following criteria: the anxiety is a major disturbance, the anxiety is manifested
only in a particular situation, or anxiety results from attempts to master other symptoms.
In the current diagnostic system, anxiety disorders consist of panic disorder,
generalized anxiety disorder (GAD), phobias, obsessive-compulsive disorder.. In each
of these disorders, a person can experience panic attacks—intense fear with symptoms
such as a pounding heart and fear of losing control. There are three types of attacks: (1)
situationally bound (occurring in response to a stimulus); (2) situationally predisposed
(usually occurring in response to a stimulus); and (3) unexpected attacks. Most attacks
are of the first two types. In the biological dimension there are two main biological
factors affecting anxiety disorders: brain structure and genetic influences. In brain
structure the amygdala (a part of the brain involved in the formation and memory of
emotional events) plays a central role in anxiety disorders. It alerts other brain
structures, such as the hippocampus and prefrontal cortex, when a threat is present,
triggering a fear or anxiety response. In genetic influences there appears to be a modest
contribution of genes to anxiety disorders. In the psychological, and social interactions
dimensions many etiological theories of mental disorders are psychological in nature
and tend to deemphasize either biological or social influences.
Phobias. A phobia is an intense, persistent, and unwarranted fear of an object or
situation. Attempts to avoid the fear-inducing situation interfere with the person’s life.
Phobias are the most common mental disorder in the United States. Social phobia is an
intense fear of being watched and humiliated. There are three types of social phobias:
performance (involving such activities as public speaking), limited interactional
(involving such interactions as going out on a date), and generalized (where extreme
anxiety occurs in most social situations). The last category has been criticized for being
too similar to avoidant personality disorder. Except for public speaking, social phobias
are somewhat rare. Despite knowing that their fears are irrational, people with social
phobias curtail many activities. Social phobias appear to be common in families who
use shame as a method of control and who stress the importance of other people’s
opinions. Specific phobias are fears of specific objects and include a long list of
disorders. In DSM-IV-TR there are five types: animal, natural environmental (for
example, thunder); blood/injections or injury; situational (for example, heights); and
other (a range of situations that may lead to choking or illness). Common phobias
involve fear of public speaking, speaking to strangers, animals, and heights. They are
twice as prevalent in women as in men and are rarely incapacitating. Etiology of
phobias include genetic evidence that indicates phobias may stem from a predisposition
to excessive autonomic reaction to stress, but genetic vulnerability has only a modest
relationship to specific phobias. Psychoanalysts see phobias as symbolic of unconscious
sexual or aggressive conflicts. The case of little Hans is used to explain a youth’s fear of
horses. Classical conditioning explains the development of some phobias. Observational
learning and operant conditioning principles may explain some phobias. Retrospective
reports indicate that conditioning experiences play a major causative role. However,
research suggests other cause factors as well. Catastrophic thoughts and distorted
cognitions may cause strong fears to develop and phobic individuals are more likely
than other people to overestimate the odds of unpleasant events occurring, supporting a
cognitive-behavioral perspective. Biochemical treatment of the phobias usually involves
antidepressants, although SSRIs have also been used to treat social phobias. Behavioral
treatment includes exposure therapy (the gradual presentation of the feared situation),
which has been helpful in reducing fears and panic attacks in agoraphobic individuals
and those with specific phobias; cognitive strategies aimed at changing unrealistic
thoughts; systematic desensitization; modeling. A combined approach that includes
cognitive, behavioral, and biological components is increasingly being used.
III. Panic disorder and agoraphobia Free-floating anxiety characterizes both panic
disorder and generalized anxiety disorder. Panic disorder is diagnosed when a person
has recurrent panic attacks that alternate with periods of low anxiety. Such attacks are
terrifying and may lead to agoraphobia. While attacks are fairly common, the disorder is
not; the lifetime prevalence is about 3.5 percent. Agoraphobia is a fear of being in
public places without the availability of help. It is twice as common for females as for
males. The disorder often has a precipitating event, and thoughts play a key role.
People with agoraphobia tend to react more intensely to anxiety symptoms than people
with other anxiety problems. The biological perspective focuses on neural structures and
neurochemical responses to stressful stimuli and notes that such factors as oxygen monitoring receptors and response to sodium lactate influence panic attacks.
Dysfunction in the locus ceruleus, a part of the central anxiety system in the brain, may
account for panic disorders. Genetics also seem to play a role, particularly in panic
disorder. Psychoanalysts suggest that internal (sexual and aggressive) conflicts are
expressed in outward anxiety. The effectiveness of defenses used determines whether
the person develops panic disorder or generalized anxiety disorder. The cognitive behavioral thinkers argue that catastrophic thoughts and overattention to internal signals
maintain and inflate anxiety symptoms. Research in which subjects had marked
increases in cardiovascular activity after focusing on negative thoughts supports this
argument.. In the social and sociocultural dimensions many patients with panic disorder
report a disturbed childhood environment that involved separation anxiety, family
conflicts, school problems, leaving home, or the loss of a loved one.) Medications,
particularly the antidepressants, have proven useful in treating panic disorder, although
relapse rates after ceasing the drugs is high. Benzodiazepines (Valium and Librium)
have been used successfully to treat generalized anxiety disorder, but psychological
treatment is also necessary. Behavior therapies, including relaxation training and
cognitive restructuring, show promise. Treatment for panic disorder can include
educating the client about the disorder, training in relaxation techniques, altering
unrealistic thoughts, facing the, symptoms, and developing coping strategie s. Cognitivebehavioral therapy seems particularly effective for generalized anxiety disorder.
IV. Generalized anxiety disorder. Generalized anxiety disorder is characterized by
persistent anxiety, heart palpitations, tension, and restlessness, together lasting over six
months. People with GAD worry over major and minor events and have more persistent
but less severe physical symptoms than people with panic disorder. Estimated lifetime
prevalence of GAD in the United States is 5 percent of the adult population, with
females being twice as likely as males to receive this diagnosis. In the biological
dimension there appears to be less support for the role of genetic factors in GAD than in
panic disorder. In the psychological dimension psychoanalytic and cognitive behavioral
theories have been developed regarding the etiology of GAD, and recent research has
focused on the relationship between types of worry and GAD. In the social and
sociocultural dimensions stressful conditions such as poverty, poor housing, prejudice,
and discrimination can also contribute to GAD. Treatments include Benzodiazepines
which have been successful in treating GAD, but because it is a chronic condition,
medication dependence issues are a concern, particularly if there is a history of
substance abuse.
V. Obsessive-compulsive disorder Obsessive-compulsive disorder is an anxiety disorder
characterized by intrusive thoughts (obsessions) and the need to perform ritualistic
actions (compulsions). Once thought to be rare, obsessive-compulsive disorder has an
estimated lifetime prevalence of approximately 1 percent. Common obsessions among
adults involve bodily wastes, dirt or germs, and environmental contamination. Many
“normal” individuals have obsessions, but those with obsessive-compulsive disorder
report thoughts that last longer, produce more discomfort, and cannot be easily
controlled. Compulsions are behaviors that are designed to reduce anxiety but that cause
distress if not performed correctly. To the compulsive, these actions have the magical
ability to ward off danger. The causes of obsessive-compulsive disorder are unclear.
Biological models emphasize differences in brain function, genetic vulnerability, and
effects of medication on individuals with obsessive-compulsive disorder. One theory,
favored by psychoanalysts, suggests that obsessions substitute for unconscious conflicts
and that compulsions are based in defense mechanisms such as undoing and reaction
formation. The behavioral perspective emphasizes the anxiety-reducing functions of
compulsions. In the social and sociocultural dimensions OCD is more common among
the young and among individuals who are divorced, separated, or unemployed.
Treatments include antidepressant medication, but only 60 to 80 percent of obsessive compulsives respond to these drugs, relief is only partial, and relapse is a problem. The
most effective behavioral treatment has been a combination of exposure therapy and
response prevention.
VI. Implications. It is becoming clear that single model approaches are unable to explain
why anxiety disorders develop in some individuals and not others.