ANXIETY DISORDERS:Social Phobias, Agoraphobia, Treating Phobias

<< ANXIETY DISORDERS:THEORIES ABOUT ANXIETY DISORDERS

MOOD DISORDERS:Emotional Symptoms, Cognitive Symptoms, Bipolar Disorders >>

Abnormal Psychology PSY404

LESSON 25

ANXIETY DISORDERS

(Symptoms of anxiety)

(Type of anxiety disorders)

Recap Lecture No. 24

· Panic and anxiety combine to form different anxiety disorders

· 1- Generalized Anxiety Disorder (GAD)

· 2- panic with agoraphobia

· 3-Specific phobia

· 4- Social phobia

· 5-Post Traumatic Stress Disorder (PTSD)

· 6-Obessive Compulsive Disorder (OCD)

· Generalized Anxiety Disorder is unfocused, prolonged anxiety and worry.

· Anxiety is about minor every day events

· Genetics and psychological factors responsible for GAD.

Before GAD can be diagnosed, several criteria must be met. According to DSM-IV, the excessive

and unrealistic anxiety and worry must be present for a minimum of six months; impulses must be

experienced as difficult to control; and they must be associated with at least three of the following

symptoms:

Restlessness, feeling on the edge

Easily fatigued

Difficulty in concentrating or mind going blank

Irritability

Muscle tension

Sleep disturbance (difficulty falling or staying asleep, or restless and unsatisfying sleep)

Although 98.6 percent of GAD patients meet the criterion of three out of six symptoms, a large

percentage of patients with other anxiety disorders also fulfill this criterion. Raising the criterion to

four or more symptoms increases diagnostic accuracy.

Treating GAD Borkovec and his colleagues (1983) have provided some interesting information

about the ability of clients to learn how to manage their worrying.

In one study clients reported that worry consumed approximately 50 percent of each day and

caused those major problems. During an intervention, the clients participated in a program that

included (1) establishing a specified half-hour period (same place, same time) for daily worrying, (2)

identifying negative thoughts and task- relevant thoughts, (3) postponing worrying until the allotted

time, and (4), at the time assigned for worrying, engaging in intense worry and problem solving.

After four weeks, the treated subjects showed a reduction in the percentage of time they spent

worrying.

Apparently, providing a time and place for worrying (stimulus control) reduces its detrimental

effects.

Phobic disorders are tied to specific objects or situations. Phobias are intense, recurrent, and

irrational fears that are disproportionate to the actual situation. Claustrophobia, the fear of closed

spaces, is a common example of a phobia. Small room or lift etc.

Most of us have some discomfort or fear associated with fire, disease, snakes, and being in small

and enclosed places. Youngsters have been known to avoid walking near an abandoned "haunted

house," and college students may avoid biology courses because they are uneasy about the blood

that is rumored to be a part of the lab work. To a degree, these fears are rational but Phobic

reactions are irrational.

Phobias involve specifiable fear reactions --

114

Abnormal Psychology PSY404

Clients with phobias recognize that their fears are excessive and unreasonable, and they work to

avoid the phobic stimulus.

Symptoms such as headaches, dizziness, stomach pains, and other general physical complaints are

often reported in association with phobias. Lack of self-confidence and mild depression may also

accompany phobic conditions. Fainting has been reported in phobic exposed to the feared situation

or object (such as the sight of blood), but these reports are not as prevalent as once thought.

Some phobias, such as those provoked by small animals, are present in early childhood, but phobic

disorders typically begin in adolescence or early adulthood.

Who Is Affected with Phobias? Phobic disorders are the most common of the anxiety disorders,

with a lifetime prevalence of 14.2 percent of the population (Eaton, Dryman & Weissman, 1991).

Using current diagnostic criteria, and sampling from more than eight thousand people from non-

institutional households, Magee and associates (1996) reported lifetime prevalence of 13.3 percent

for social phobia, 11.3 percent for specific phobia, and 6.7 percent for agoraphobia.

Specific (Simple) Phobias

Specific phobias are pathological (excessive and unrealistic) fears of specific animals, objects, or

situations.

Common examples include phobias of the needles, elevators, dogs, snakes, storms, blood, dentists,

and tightly enclosed spaces although the phobic individual may be reasonably well adjusted when

not directly faced by the phobic stimulus, he or she experiences anticipatory anxiety when aware of

an impending situation that could force a confrontation with the object of fear. When the phobic

individual is actually exposed to the phobic stimulus, there is almost invariably an intense and

immediate anxiety response.

For example, the person with needle phobia who comes in contact with a needle will report

sweating, difficulty breathing, and a racing heart. The phobic stimulus is viewed as powerful indeed,

as this example illustrates. In an experiment conducted in the Netherlands. Women with phobias

were shown various, slides of phobic stimuli and given very mild shock. The researchers concluded

that because phobic stimuli cause such discomfort, they are routinely avoided rather than faced

directly and endured.

Social Phobias

It refers to being asked to perform before an audience will produce some anxiety in almost all of us.

The thought of having nothing to say or of saying something inappropriate causes us to become

self-conscious and nervous. These are normal, rational fears. Social phobias, however, involve a

persistent fear of being in a social situation in which one is exposed to scrutiny by others and a

related fear of acting in a way that will be humiliating or embarrassing. As self-focus increases, so

does the anticipation of anxiety (Woody, 1996).

Phobic and non-phobic individuals have comparable concerns, but the intensity, extremeness, and

irrationality of the reactions of social phobic set them apart from their non-phobic counterparts.

Examples of social phobias include irrational reactions to eating in public places, using public

restrooms, or speaking in front of large groups of people. Like the specific phobic, the social

phobic experiences marked anxiety when anticipating the phobic situation and therefore usually

avoids it. This avoidance interferes with the person's daily routine and can potentially ruin his or

her career.

Agoraphobia

The term agoraphobia, which is derived from the Greek word agora, meaning marketplace, was

originally used to refer to a pathological fear of open or public places.

At present, agoraphobia is considered a fear of being alone or of being in public places where

escape is difficult or where help is not readily available in case of a panic attack that the person

fears would be overwhelming. The agoraphobic might experience intense fear in shopping malls

115

Abnormal Psychology PSY404

during the holidays, in crowds at concerts or sports events, and in tunnels, bridges, or in public

transport.

Agoraphobia also occurs within an interrelated and overlapping cluster of phobias, such as a

phobia of cars, buses, planes, and trains. As a result of agoraphobia, the sufferer restricts travel or

requires a companion when away from home.

Label

Fear

Agoraphobia

Open places

Aichmophobia

Pointed objects

Algophobia

Pain

Arachnophobia

Spiders

Astraphobia

Storms; thunder and lightning

Claustrophobia

Closed spaces; confinement

Hydrophobia

Water

Nyctophobia

Darkness

Ophidiophobia

Snakes

Pyrophobia

Fire

Thanatophobia

Death

Xenophobia

Strangers

Causes of Phobias

· Phobic disorders have been explained in several ways, according to the various models of

psychopathology.

· For example, the psychodynamic explanation of phobia is that the anxiety expressed toward the

phobic object or situation is actually displacement of an internal anxiety.

· From this perspective, then, a snake phobia is more than a fear of snakes -- it represents some

other underlying anxiety. The phobia is seen as having arisen because the patient lacks

understanding about this underlying anxiety and uses displacement as a defense mechanism.

Some evidence of a genetic predisposition for phobic disorder exists (Torgersen, 1983). First,

regarding incidence of behaviors that are relevant to the study of social phobia (such as eating in

public, being observed at work), monozygotic twins are more alike than dizygotic twins. Second,

parents of children who are diagnosed with a childhood phobic disorder are themselves more likely

to meet the criteria for this disorder. Although these findings suggest that the pattern can be genetic

or learned.

**One model of the development of agoraphobia specifically includes cognitive and behavioral

processes

· 1- A case of agoraphobia.

116

Abnormal Psychology PSY404

2- Persons with agoraphobia hold biased emotional expectations; they expect

unwanted emotional arousal, are overly alert to cues that signal anxiety, and are

highly motivated to avoid anxiety- provoking stimuli.

3- In persons with agoraphobia, have an unwillingness to approach or to try to

master stressful situations is accompanied by a sense of loss of control.

Treating Phobias

· Specific phobias have been successfully treated with systematic desensitization, where anxiety is

paired with relaxation with imagined (or real) scenes involving the client in anxiety-producing

situations.

· Systematic desensitization is a behavior therapy procedure developed by Joseph Wolpe (1995,

1982).where old maladaptive associations are replaced by newer, more adaptive ones.

· Behavioral exposure treatments, both flooding and desensitization, do provide evidence of clients'

newly acquired knowledge and ability to manage anxiety. As the clients come to experience and

accept the ability to cope with once-feared situations, self-efficacy increases and remains with the

clients as part of their newly acquired sense of mastery over prior phobia.

· To paraphrase a familiar maxim: Nothing succeeds like a belief in success.

Panic Disorder

· The term panic originated with Pan, the Greek god who was said to be a happy but an ugly man: He

had the horns, ears, and legs of a goat. When in a bad mood, he enjoyed scaring away travelers --

hence the word panic (Ley, 1987). Experiences that may well be called panic have been around for a

long but it was not until recently that consistency in research findings and clinical practice led to the

identification of panic disorder as a separate type of anxiety disorder.

· A person suffering from panic disorder is vulnerable to frequent panic attacks -- discrete

instances of fear or discomfort. Panic attacks are unexpected in the sense that they do not occur in

a predictable context or immediately before a situation that almost always causes anxiety reactions;

they are not the result of evaluation of the person or of scrutiny by others. In these ways, panic

disorder is differentiated from specific phobia and social phobia, which do involve situational

determinants.

· Who Is Affected with Panic Disorder? Panic attacks occur in panic disorder, but they are also

sometimes reported in patients with phobias, substance-abuse disorder, and mild depression. In

one study, researchers interviewed 1,306 residents of San Antonio, Texas, and found that 5.6

percent reported panic attacks, but only 3.8 percent met criteria for panic disorder.

· Panic disorder in women typically occurs at more than twice the frequency of panic disorder in

men. However, research conducted in Australia determined that, in terms of symptoms, age of

onset, cognition, and duration, there are no significant differences between male and female

patients with panic attacks (Oei, Wanstall & Evans, 1990).

1. Palpitations pounding heart, or accelerated heart rate

2. Sweating

3. Trembling or shaking

4. Sensations of shortness of breath

5. Feeling of choking

6. Chest pain or discomfort,

7. Nausea or abdominal distress

8. Feeling dizzy, unsteady, lightheaded,

117

Abnormal Psychology PSY404

9. Derealization (feelings of unreality) or depersonalization (feeling detached from

oneself)

10. Fear of losing control or going crazy

11. Fear of dying

12. Numbness or tingling sensations

13. Chills or hot flashes

Source: Adapted from DSM-1V Reprinted with permission from The Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition, Copyright @ 1994 American

Psychiatric Association.

Are Panic Attacks Biological?

**Are panic attacks specifically associated with biological factors?

Proponents of a biological model cite studies showing that panic patients responded distinctively

to a variety of "challenges" they faced in the laboratory. Other proponents of a biological model

have suggested that patients with panic disorder have a dysfunctional heart.

**panic is a fear response to unexpected and unexplained somatic events (Clark, 1989). It is as if

changes in bodily functions that can't be easily explained (such as a sudden change in breathing)

prompt the panic sufferer to anticipate the worst and to experience fear and panic (see also

McNally & Eke, 1996).

According to Clark (1986), misinterpretation of the arousal cues is causally linked to panic. Thus,

although persons with panic attack with a history of it and those without such a history both

experience similar arousal (as a result of, say, hyperventilation), only the subjects with panic

disorder view these physiological cues as indications that a catastrophe is forthcoming. Somatic

complaints precede the fear, and the somatic changes are frightening to the panic sufferer.

In general, research has supported the idea that panic attacks result from the client's fear response

to certain bodily sensations.

Obsessive-Compulsive Disorder (OCD)

· Have you ever found yourself humming a commercial jingle -- a tune that stays in your mind

longer than you want it to? In a small way, this experience is like an obsession. Obsessions are

persistent and unwanted thoughts, ideas, or images that a person does not intentionally produce.

Rather, the unwanted thoughts are perceived as invading the person's thinking. The recurring

thoughts are troublesome, unnecessary, and distracting, and the person tries to be rid of them.

Features of OCD

The content and form of normal and abnormal obsessions are similar. Abnormal obsessions,

however, are more frequent, more intense, and of longer duration; they produce more

discomfort; and they are more associated with compulsions than are normal obsessions.

· Is heightened emotional intensity possibly an important aspect of the intrusive quality of

obsessions? (Clark & de Silva, 1985). The studies to date, using nonclinical cases, support this

hypothesis and suggest that reducing the frequency of any negative cognition will increase the

client's ability to dismiss such thoughts.

· Although compulsions appear to be purposeful behaviors, they are essentially nonfunctional and

ritualistic. The compulsion reported most often is checking, which results from pathologic doubt

linked to repeated attempts to "make sure".

An obsessive- compulsive person might fear that the front door was left unlocked and so

repeatedly return to the door to check that it is locked. Other common examples of compulsive

checking include repetitions intended to determine that gas and water taps are shut and lights and

118

Abnormal Psychology PSY404

appliances are off. Still other cases highlight a need for organization -- checking that kitchen

utensils are properly aligned, cupboard contents are correctly arranged, and closets are organized in

the "right" order. Some common rituals include repeatedly putting clothes on and taking them off;

hoarding items such as newspapers, mail, or boxes; and repeating certain actions such as going

through a doorway.

Compulsive hand washing is linked to a preoccupation with dirt and contamination and may be

tinged with reports of disgust regarding urine and feces. Compulsive hand washers avoid public

restrooms, doorknobs, shaking hands, and money, all of which are viewed as contaminated.

Patients may wash as many as eighty times a day, often causing damage to their skin.

Causes of OCD

· **Researchers have speculated that the obsessions and compulsions reflect fixed-action patterns

that are "wired" into the brain. When stressful conditions stimulate the person's perception of

danger, these fixed action patterns may be inappropriately activated. Normal individuals cease

performing an action when their senses tell them that the action has been completed, whereas,

according to the theory just described, persons with OCD become helpless victims of their

repeating patterns. Example hand washing.

Treating OCD

· The impatient friend of an obsessive person advises, "Just don't think about it." But the person's

unwanted thoughts persist nonetheless.

The spouse of a compulsive checker shouts, "We're going to be late. Stop that damn checking."

But the checking continues. The experience of nonprofessionals is that obsessive- compulsive

disorder is very resistant to direct instructions. Indeed, obsessive patients have thought and thought

about matters that they feel are major, and they frequently do not respond to the suggestions of

others. Compulsive persons, too, are said to be resistant to advice.

Treatment of OCD especially of chronic cases is difficult earlier the treatment begins the better it is and

when it is becomes chronic or it goes without any treatment for some time then patient takes time to

respond to any therapy.

Posttraumatic Stress Disorder (PTSD)

· Psychologically speaking, what is similar about the experiences of rape, torture, military combat,

airplane crash, earthquake, a disastrous fire, and the collapse of a large building? Each can cause

severe trauma. Posttraumatic stress disorder (PTSD) is a cluster of psychological symptoms that

can follow a psychologically distressing event. Stressors that produce PTSD would produce marked

distress in almost anyone, and they are outside the range of normal, common stressors such as

chronic illness, marital separation, or business failure. Although not all disasters result in

psychopathology (Rubonis & Bickman, 1991) -- indeed, some people seem invulnerable to the

distress -- certain individuals do develop severe disorders related to trauma.

· The typical symptoms of PTSD occur following a recognizable stressor (traumatic event) that has

involved intense fear and horror. They include re-experiencing of the traumatic event, persistent

avoidance of any reminders of the event, numbing of general responsiveness, and increased arousal.

To warrant a diagnosis of PTSD, a client must experience these symptoms for at least one month.

Acute stress disorder, a recent addition to DSM, refers to PTSD-like reactions that persist for at

least two days but less than four weeks.

**Who Is Affected with PTSD?

According to recent epidemiological data (Kessler et al., 1995),

the estimated lifetime prevalence of PTSD is 7.8 percent. The trauma most commonly associated with

posttraumatic stress disorder among men is combat exposure, which is rated the most upsetting trauma for

28.8 percent of men with PTSD. Among women, rape is most commonly associated with PTSD; it is rated

most upsetting by 29.9 percent of women with PTSD. Fifty-eight percent of battered women also report

high rates of PTSD (Astin, Ogland-Hand, Coleman & Foy, 1995).

119

Abnormal Psychology PSY404

**Military-combat-produced PTSD is not new; writers described its occurrence after the Civil War,

World Wars I and II, and the Korean War. Early reference was made to "shell shock" or "battle

fatigue" to refer to an array of symptoms seen in men whose military experience included exposure

to artillery fire, attack, and bombings. In the United States, the Centers for Disease Control

conducted a four-year epidemiological study of approximately 15,000 Vietnam veterans and

reported that 15 percent suffered from combat-related PTSD since their discharge (Roberts, 1988).

Catastrophes such as aircraft disasters, tornadoes, and fires can also produce widespread and serious

emotional problems. An aircraft crash at a major airport can cause emotional stress reactions in any of the

surviving passengers or flight crew as well as in witnesses to the crash, in members of the families or work

associates waiting for passengers to arrive, and in the airport employees who are asked to assist in the

emergency services and crash cleanup. Only some of those involved actually suffer diagnosed PTSD or

acute stress disorder, but case reports nevertheless indicate widespread distress. After mobilizing energies

and working cooperatively during the immediate time of the emergency, people soon tire. When the event

has passed and is no longer the topic of conversation, people report loss of sleep, a reliving of the

experience, and fearful dreams.

**Treating PTSD

The psychological treatment of clients with posttraumatic stress disorder has generated interest and

enthusiasm. The research literature is young, however, because PTSD did not appear as an

identifiable form of disorder until 1980. An early and practical first step was Operation Outreach, a

program designed specifically for Vietnam combat veterans. At Operation Outreach, any veteran

can find a needed outlet for his or her emotional distress.

**An approach has proved effective in the management of PTSD among rape victims. Edna Foa

and her colleagues (1991) reported that a cognitive-behavioral treatment and a prolonged exposure

treatment (at follow-up) were more effective in reducing PTSD symptoms.

Many of the rape victims who were offered treatment declined to participate. This may be related

to rape victims' tendency to avoid confrontation of the rape memory, a tendency that is

symptomatic of PTSD. In addition, some rape victims may not show symptoms of any disorder or

may not see themselves as patients in need of treatment. Nevertheless, cognitive-behavioral and

exposure treatments seem to be helpful to PTSD sufferers, whether veterans or rape victims.

CLASSIFYING AND TREATING ANXIETY DISORDERS

"Neuroses Are No Longer a Psychological Problem!" If such a headline had appeared in the

newspaper, it would have been technically accurate, because, the DSM IV TR system abandoned the

use of terms and categories related with neurosis. For example, phobic neurosis is now called specific

phobia or social phobia, and obsessive-compulsive neurosis became obsessive- compulsive disorder.

Panic and anxiety combine to form different anxiety disorders

1- Generalized Anxiety Disorder (GAD)

2- Panic with agoraphobia

3- Specific phobia

4- Social phobia

5- Post Traumatic Stress Disorder (PTSD)

6- Obsessive Compulsive Disorder (OCD)

Anxiety is very hard to study. In humans a sense of uneasiness, looking worried and anxious.

The physiological response of anxiety is reflected in increased heart beat and muscle tension.

Anxiety is not pleasant; it is some unpleasant thing most commonly observed.

120

Table of Contents: