Anxiety Disorders Discussion Assignment

6 panic, anxiety, obsessions, and their disorders

learning objectives 6

·  6.1 What are the essential features of anxiety disorders?

·  6.2 Describe the clinical features of specific and social phobias.

·  6.3 Why do anxiety disorders develop?

·  6.4 What are the clinical features of panic disorder?

·  6.5 What factors are implicated in the development of panic disorder?

·  6.6 Describe the clinical aspects of generalized anxiety disorder.

·  6.7 How are anxiety disorders treated?

·  6.8 What are the clinical features of obsessive-compulsive disorder and how is this disorder treated?

·  6.9 Describe three obsessive-compulsive related disorders.

Leni: Worried About Worrying So Much Leni is a 24-year-old graduate student. Although she is doing exceptionally well in her program, for the past year she has worried constantly that she will fail and be thrown out. When her fellow students and professors try to reassure her, Leni worries that they are just pretending to be nice to her because she is such a weak student. Leni also worries about her mother becoming ill and about whether she is really liked by her friends. Although Leni is able to acknowledge that her fears are excessive (she has supportive friends, her mother is in good health, and, based on her grades, Leni is one of the top students in her program), she still struggles to control her worrying. Leni has difficulty sleeping, often feels nervous and on edge, and experiences a great deal of muscle tension. When her friends suggested she take a yoga class to try and relax, Leni even began to worry about that, fearing that she would be the worse student in the class. “I know it makes no sense,” she says, “But that’s how I am. I’ve always been a worrier. I even worry about worrying so much!” Anxiety Disorders Discussion Assignment

Anxiety  involves a general feeling of apprehension about possible future danger, and  fear  is an alarm reaction that occurs in response to immediate danger. Today the DSM has identified a group of disorders—known as the anxiety disorders—that share obvious symptoms of clinically significant fear or anxiety. Anxiety disorders affect approximately 25 to 29 percent of the U.S. population at some point in their lives and are the most common category of disorders for women and the second most common for men (Kessler et al.,  1994 ; Kessler, Berglund, Delmar, et al.,  2005 ). In any 12-month period, about 18 percent of the adult population suffers from at least one anxiety disorder (Kessler, Chiu, et al.,  2005c ). Anxiety disorders create enormous personal, economic, and health care problems for those affected. Some years ago several studies estimated that the anxiety disorders cost the United States somewhere between $42.3 billion and $47 billion in direct and indirect costs (about 30 percent of the nation’s total mental health bill of $148 billion in 1990; Greenberg et al.,  1999 ; Kessler & Greenberg,  2002 ). The figure is no doubt even higher now. Anxiety disorders are also associated with an increased prevalence of a number of medical conditions including asthma, chronic pain, hypertension, arthritis, cardiovascular disease, and irritable bowel syndrome (Roy-Byrne et al.,  2008 ) and people with anxiety disorders are very high users of medical services (e.g., Chavira et al.,  2009 ).

In this chapter, we describe a number of different anxiety disorders. We also focus on  obsessive-compulsive disorder (OCD) .  Obsessions  are persistent and highly recurrent intrusive thoughts or images that are experienced as disturbing and inappropriate. People affected by such obsessions try to resist or suppress them, or to neutralize them with some other thought or action. Compulsions are repetitive behaviors (such as hand-washing or checking) that the person feels must be performed in response to the obsession. Compulsions are sometimes performed as lengthy rituals. These behaviors have the goal of preventing or reducing distress or preventing some dreaded outcome from occurring.

Historically, anxiety and obsessive-compulsive disorders were considered to be classic neurotic disorders. Although individuals with  neurotic disorders  show maladaptive and self-defeating behaviors, they are not incoherent, dangerous, or out of touch with reality. To Freud, these neurotic disorders developed when intrapsychic conflict produced significant anxiety. Anxiety was, in Freud’s formulation, a sign of an inner battle or conflict between some primitive desire (from the id) and prohibitions against its expression (from the ego and superego). Sometimes this anxiety was overtly expressed (as in those disorders known today as the anxiety disorders). In certain other neurotic disorders, however, he believed that the anxiety might not be obvious, either to the person involved or to others, if psychological defense mechanisms were able to deflect or mask it. The term neurosis was dropped from the DSM in 1980. In addition, in DSM-III, some disorders that did not involve obvious anxiety symptoms were reclassified as either dissociative or somatoform disorders (some neurotic disorders were absorbed into the mood disorders category as well—see  Chapters 7  and  8 ). This change was made to group together smaller sets of disorders that shared more obvious symptoms and features. In DSM-5 this trend has gone a step further. Obsessive-compulsive disorder is no longer classified as an anxiety disorder. Instead, it is now listed in a new DSM-5category called  obsessive-compulsive and related disorders  (see Thinking Critically about DSM-5). Anxiety Disorders Discussion Assignment

We begin by discussing the nature of fear and anxiety as emotional and cognitive states and patterns of responding, each of which has an extremely important adaptive value but to which humans at times seem all too vulnerable. We will then move to a discussion of the anxiety disorders. Finally, we consider OCD and other disorders from the new obsessive-compulsive and related disorders category. Anxiety Disorders Discussion Assignment

The Fear and Anxiety Response Patterns

There has never been complete agreement about how distinct the two emotions of fear and anxiety are from each other. Historically, the most common way of distinguishing between the fear and anxiety response patterns has been whether there is a clear and obvious source of danger that would be regarded as real by most people. When the source of danger is obvious, the experienced emotion has been called fear (e.g., “I’m afraid of snakes”). With anxiety, however, we frequently cannot specify clearly what the danger is (e.g., “I’m anxious about my parents’ health”).

Fear

In recent years, however, many prominent researchers have proposed a more fundamental distinction between the fear and anxiety response patterns (e.g., Barlow,  1988 ,  2002 ; Bouton,  2005 ; Grillon,  2008 ; McNaughton,  2008 ). According to these theorists, fear is a basic emotion (shared by many animals) that involves activation of the “fight-or-flight” response of the autonomic nervous system. This is an almost instantaneous reaction to any imminent threat such as a dangerous predator or someone pointing a loaded gun. Anxiety Disorders Discussion Assignment

Its adaptive value as a primitive alarm response to imminent danger is that it allows us to escape. When the fear response occurs in the absence of any obvious external danger, we say the person has had a spontaneous or uncued  panic attack . The symptoms of a panic attack are nearly identical to those experienced during a state of fear except that panic attacks are often accompanied by a subjective sense of impending doom, including fears of dying, going crazy, or losing control. These latter cognitive symptoms do not generally occur during fear states. Thus fear and panic have three components:

·  1. cognitive/subjective components (“I feel afraid/terriffied”; “I’m going to die”)

·  2. physiological components (such as increased heart rate and heavy breathing)

·  3. behavioral components (a strong urge to escape or Thee; Lang,  1968 ,  1971 )

DSM-5 THINKING CRITICALLY about DSM-5: Why Is OCD No Longer Considered to Be an Anxiety Disorder?

In DSM-5, obsessive-compulsive disorder was removed from the anxiety disorders category and placed into a new category called “obsessive-compulsive and related disorders.” (As you already know from  Chapter 5 , PTSD was also removed and put into a new category called “trauma and stressor-related disorders.”)

One reason for moving OCD into the new category was that anxiety is not generally used as an indicator of OCD severity. Indeed, for people with certain forms of OCD such as symmetry-related obsessions and compulsions, anxiety is not even a prominent symptom. It was also noted that anxiety occurs in a wide range of disorders, so the presence of some anxiety is not a valid reason to regard OCD an anxiety disorder. Indeed Stein et al. ( 2010 ) wrote that “the highly stereotyped, driven, repetitive, and nonfunctional quality of compulsive behaviors differentiate OCD from normal acts and from the types of avoidance that occur in other anxiety disorders” ( p. 497 ).

Yet another reason is that the neurobiological underpinnings of OCD appear to be rather different from those of other anxiety disorders, focusing on frontal-striatal neural circuitry including the orbitofrontal cortex, anterior cingulate cortex, and striatum (especially the caudate nucleus). Studies examining the “OCD-related disorders” such as body dysmorphic disorder (obsessing about perceived or imagined flaws in physical appearance) and trichotillomania (chronic hair pulling) also suggest shared involvement of frontal-striatal neural circuitry. Finally, other anxiety disorders respond to a wider range of medication treatments than does OCD, which seems to respond selectively to selective serotonin reuptake inhibitors.

How compelling do these reasons sound to you? What kinds of research findings might further support the grouping of OCD with related disorders such as hoarding or trichotillomania? On the contrary, what research findings might incline you to think that it was wrong to remove OCD from the anxiety disorders category?

Fear or panic is a basic emotion that is shared by many animals, including humans, and may activate the fight-or-flight response of the sympathetic nervous system. This allows us to respond rapidly when faced with a dangerous situation, such as being threatened by a predator. In humans who are having a panic attack, there is no external threat; panic occurs because of some misfiring of this response system.

These components are only “loosely coupled” (Lang,  1985 ), which means that someone might show, for example, physiological and behavioral indications of fear or panic without much of the subjective component, or vice versa. Anxiety Disorders Discussion Assignment

Anxiety

In contrast to fear and panic, the anxiety response pattern is a complex blend of unpleasant emotions and cognitions that is both more oriented to the future and much more diffuse than fear (Barlow,  1988 ,  2002 ). But like fear, it has not only cognitive/subjective components but also physiological and behavioral components. At the cognitive/subjective level, anxiety involves negative mood, worry about possible future threats or danger, self-preoccupation, and a sense of being unable to predict the future threat or to control it if it occurs. At a physiological level, anxiety often creates a state of tension and chronic overarousal, which may reflect risk assessment and readiness for dealing with danger should it occur (“Something awful may happen, and I had better be ready for it if it does”). Although there is no activation of the fight-or-flight response as there is with fear, anxiety does prepare or prime a person for the fight-or-flight response should the anticipated danger occur. At a behavioral level, anxiety may create a strong tendency to avoid situations where danger might be encountered, but there is not the immediate behavioral urge to flee with anxiety as there is with fear (Barlow,  1988 ,  2002 ). Support for the idea that anxiety is descriptively and functionally distinct from fear or panic comes both from complex statistical analyses of subjective reports of panic and anxiety and from a great deal of neurobiological evidence (e.g., Bouton,  2005 ; Bouton et al.,  2001 ; Davis,  2006 ; Grillon,  2008 ).

The adaptive value of anxiety may be that it helps us plan and prepare for possible threat. In mild to moderate degrees, anxiety actually enhances learning and performance. For example, a mild amount of anxiety about how you are going to do on your next exam, or in your next tennis match, can actually be helpful. But although anxiety is often adaptive in mild or moderate degrees, it is maladaptive when it becomes chronic and severe, as we see in people diagnosed with anxiety disorders.

Although there are many threatening situations that provoke fear or anxiety unconditionally, many of our sources of fear and anxiety are learned. Years of human and nonhuman animal experimentation have established that the basic fear and anxiety response patterns are highly conditionable (e.g., Fanselow & Ponnusamy,  2008 ; Lipp,  2006 ). That is, previously neutral and novel stimuli (conditioned stimuli) that are repeatedly paired with, and reliably predict, frightening or unpleasant events such as various kinds of physical or psychological trauma (unconditioned stimulus) can acquire the capacity to elicit fear or anxiety themselves (conditioned response). Such conditioning is a completely normal and adaptive process that allows all of us to learn to anticipate upcoming frightening events if they are reliably preceded by a signal. Yet this normal and adaptive process can also lead in some cases to the development of clinically significant fears and anxieties, as we will see.

For example, a girl named Angela sometimes saw and heard her father physically abuse her mother in the evening. After this happened four or five times, Angela started to become anxious as soon as she heard her father’s car arrive in the driveway at the end of the day. In such situations a wide variety of initially neutral stimuli may accidentally come to serve as cues that something threatening and unpleasant is about to happen—and thereby come to elicit fear or anxiety themselves. Our thoughts and images can also serve as conditioned stimuli capable of eliciting the fear or anxiety response pattern. For example, Angela came to feel anxious even when thinking about her father.

in review

·  ● Compare and contrast fear or panic with anxiety, making sure to note that both emotions involve three response systems.

·  ● Explain the significance of the fact that both fear and anxiety can be classically conditioned.

Overview of the Anxiety Disorders and their Commonalities

Anxiety disorders  all have unrealistic, irrational fears or anxieties of disabling intensity as their principal and most obvious manifestation. Among the disorders recognized in DSM-5 are:

·  1. specific phobia

·  2. social anxiety disorder (social phobia)

·  3. panic disorder

·  4. agoraphobia

·  5. generalized anxiety disorder

As seen in the following brief overview, people with these varied disorders differ from one another both in terms of the relative preponderance of fear or panic versus anxiety symptoms that they experience and in the kinds of objects or situations that most concern them. For example, people with specific or social phobias exhibit many anxiety symptoms about the possibility of encountering their phobic situation, but they may also experience a fear or panic response when they actually encounter the situation. People with panic disorder experience both frequent panic attacks and intense anxiety focused on the possibility of having another one. People with agoraphobia go to great lengths to avoid a variety of feared situations, ranging from open streets, bridges, and crowded public places. By contrast, people with generalized anxiety disorder (like Leni in the case study that opened this chapter) mostly experience a general sense of diffuse anxiety and worry about many potentially bad things that may happen; some may also experience an occasional panic attack, but it is not a focus of their anxiety. It is also important to note that many people with one anxiety disorder will experience at least one more anxiety disorder and/or depression either concurrently or at a different point in their lives (e.g., Brown & Barlow,  2002 ,  2009 ; Kessler, Berglund, Demler, et al.,  2005 ). Anxiety Disorders Discussion Assignment

Given these commonalities across the anxiety disorders, it should come as no surprise that there are some important similarities in the basic causes of these disorders (as well as many differences). Among biological causal factors, we will see that there are genetic contributions to each of these disorders and that at least part of the genetic vulnerability may be nonspecific, or common across the disorders (e.g., Barlow,  2002 ; Craske & Waters,  2005 ). In adults, the common genetic vulnerability is manifested at a psychological level at least in part by the important personality trait called neuroticism—a proneness or disposition to experience negative mood states that is a common risk factor for both anxiety and mood disorders (e.g., Klein et al.,  2009 ). The brain structures most centrally involved in most disorders are generally in the limbic system (often known as the “emotional brain”) and certain parts of the cortex, and the neurotransmitter substances that are most centrally involved are gamma aminobutyric acid (GABA), norepinephrine, and serotonin (see  Chapter 3 ).

Among common psychological causal factors, we will see that classical conditioning of fear, panic, or anxiety to a range of stimuli plays an important role in many of these disorders (Forsyth et al.,  2006 ; Mineka & Oehlberg,  2008 ; Mineka & Zinbarg,  1996 ,  2006 ). In addition, people who have perceptions of a lack of control over either their environments or their own emotions (or both) seem more vulnerable to developing anxiety disorders. The development of such perceptions of uncontrollability depends heavily on the social environment people are raised in, including parenting styles (Chorpita & Barlow,  1998 ; Craske & Waters,  2005 ; Mineka & Zinbarg,  2006 ; Hudson & Rapee,  2009 ). For certain disorders, faulty or distorted patterns of cognition also may play an important role. Finally, the sociocultural environment in which people are raised also has prominent effects on the kinds of objects and experiences people become anxious about or come to fear. Ultimately what we must strive for is a good biopsychosocial understanding of how all these types of causal factors interact with one another in the development of anxiety disorders.

Finally, as we will see, there are many commonalities across the effective treatments for the various anxiety disorders (e.g., Barlow,  2004 ; Campbell-Sills & Barlow,  2007 ). For each disorder, graduated exposure to feared cues, objects, and situations—until fear or anxiety begins to habituate—constitutes the single most powerful therapeutic ingredient. Further, for certain disorders the addition of cognitive restructuring techniques can provide added benefit. What these cognitive restructuring techniques for different disorders have in common is that they help the individual understand his or her distorted patterns of thinking about anxiety-related situations and how these patterns can be changed. Medications can also be useful in treating all disorders except specific phobias, and nearly all tend to fall into two primary medication categories: antianxiety medications (anxiolytics) and antidepressant medications.

We now turn to a more detailed discussion of each disorder, highlighting their common and their distinct features as well as what is known about their causes. We start with phobic disorders—the most common anxiety disorders. A  phobia  is a persistent and disproportionate fear of some specific object or situation that presents little or no actual danger and yet leads to a great deal of avoidance of these feared situations. As we will see in our discussion of DSM-5, there are three main categories of pho-bias: (1) specific phobia, (2) social phobia, and (3) agoraphobia.

in review

·  ● What is the central feature of all anxiety disorders? That is, what do they have in common?

·  ● What differentiates the anxiety disorders from one another?

·  ● What are some common kinds of biological and psychosocial causes of the different anxiety disorders?

·  ● What is the most important ingredient across effective psychosocial treatments for the anxiety disorders?

Specific Phobias

A person is diagnosed as having a  specific phobia  if she or he shows strong and persistent fear that is triggered by the presence of a specific object or situation (see DSM-5 box for diagnostic criteria). When individuals with specific phobias encounter a phobic stimulus, they often show an immediate fear response that often resembles a panic attack except for the existence of a clear external trigger (APA,  2013 ). Not surprisingly, such individuals also experience anxiety if they anticipate they may encounter a phobic object or situation and so go to great lengths to avoid encounters with their phobic stimulus. Indeed, they often even avoid seemingly innocent representations of it such as photographs or television images. For example, claustrophobic persons may go to great lengths to avoid entering a closet or an elevator, even if this means climbing many flights of stairs or turning down jobs that might require them to take an elevator. Generally, people with specific phobias recognize that their fear is somewhat excessive or unreasonable although occasionally they may not have this insight. Anxiety Disorders Discussion Assignment

DSM-5 criteria for: Specific Phobia

·  A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.

·  B. The phobic object or situation almost always provokes immediate fear or anxiety.

·  C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.

·  D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.

·  E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

·  F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

·  G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

This avoidance is a cardinal characteristic of phobias; it occurs both because the phobic response itself is so unpleasant and because of the phobic person’s irrational appraisal of the likelihood that something terrible will happen.  Table 6.1  on page 168 lists the five subtypes of specific phobias recognized in DSM-5, along with some examples. Anxiety Disorders Discussion Assignment