Chapter 6 Panic, Anxiety, Obsessions, and Their Disorders ABNORMAL PSYCHOLOGY, SIXTEENTH EDITION James N. Butcher/ Jill M. Hooley/ Susan Mineka Chapter 6 Panic, Anxiety, Obsessions, and Their Disorders © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Fear and Anxiety Response Patterns What is the difference between fear and anxiety? It is difficult to completely distinguish between fear and anxiety Anxiety: general fear about possible future danger Fear: alarm response that occurs due to immediate danger © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Fear and Anxiety Response Patterns Historically, distinction centered on whether source of danger is obvious Obvious danger leads to fear Less obvious danger leads to anxiety It is difficult to completely distinguish between fear and anxiety. © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

The Fear and Anxiety Response Patterns Fear or panic Activation of “fight-or-flight” response Fear or panic is basic emotion that involves activation of “fight-or-flight” response of the autonomic nervous system Fear with no external cause is known as panic attack and includes sense of impending doom © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

The Fear and Anxiety Response Patterns General feeling of apprehension about possible danger Future-oriented and diffuse Cognitive/subjective, physiological, and behavioral components Anxiety is more oriented to the future and more diffuse than fear © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Overview of the Anxiety Disorders and Their Commonalities Unrealistic, irrational fears or anxieties Disabling intensity © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Overview of the Anxiety Disorders and Their Commonalities The DSM-5 recognizes five primary types of anxiety disorders. How many of these can you identify? Specific phobia Social anxiety disorder (social phobia) Panic disorder Agoraphobia Generalized anxiety disorder © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Overview of the Anxiety Disorders and Their Commonalities Basic biological causes Basic psychological causes Effective treatments All have genetic component and this may be nonspecific to a disorder People with these disorders are all high in neuroticism Classical conditioning plays a role in all of these disorders. People who feel no control over their situation are at greater risk for anxiety disorders Graduated exposure to fears is a common treatment. All (except specific phobias) respond to antianxiety and antidepression drugs © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Strong and persistent fear recognized as excessive or unreasonable Specific Phobias Specific phobia Strong and persistent fear recognized as excessive or unreasonable Triggered by a specific object or situation © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Subtypes identified in DSM-5 Specific Phobias Subtypes identified in DSM-5 Animal Natural environment Blood-injection-injury Situational Other © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Prevalence, Age of Onset, and Gender Differences Age of onset for different phobias varies widely Blood-injection-injury phobia occurs in about 3-4% of population More common in women than men Lifetime prevalence rate of about 12% Common mental disorders © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Psychological Causal Factors Psychological Causes Psychoanalytic viewpoint Learned behavior/classical conditioning Vicarious conditioning Individual differences in learning Evolutionary preparedness Psychoanalytic viewpoint: defense against anxiety stemming from repressed id impulses © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Biological Causal Factors Genetics Temperament Genetics Monozygotic twins are more likely to share phobias than dizygotic twins Temperament Behaviorally inhibited temperament is linked to higher vulnerability to phobias © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Treatments Exposure therapy Participant modeling Virtual reality components Cognitive techniques combinations Exposure therapy is the treatment of choice for specific phobias Can involve participant modeling or virtual reality components Can also be combined with cognitive techniques © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Disabling fears of one or more specific social situations Social Phobias Social phobia Disabling fears of one or more specific social situations Fear of exposure to scrutiny and potential negative evaluation of others Social anxiety disorder Fear of exposure to scrutiny and potential negative evaluation of others and to humiliation or embarrassment © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Prevalence, Age of Onset, and Gender Differences Many have comorbid disorders such as other anxiety disorders or depression Typically begin during adolescence or early adulthood Somewhat more common in women than men Lifetime prevalence around 12% Common mental disorder Approximately 1/3 abuse alcohol to reduce anxiety and face fear Tend to have lower SES and lower employment rates Very persistent disorder. Only 37% recovered spontaneously in the 12-year period © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Psychological Causal Factors Learned behavior Evolutionary factors Perceptions of uncontrollability and unpredictability Cognitive biases toward “danger schemas” Learned behavior Classical conditioning that is direct or vicarious in nature Evolutionary factors Predisposition based on social hierarchies Perceptions of uncontrollability and unpredictability Cognitive biases toward “danger schemas” in social situations © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Biological Causal Factors Genetics Temperament Genetics Twin studies suggest about 30% of variance in liability to social phobia is due to genetic factors Temperament Behavioral inhibition correlates with social phobia © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Treatments for social phobias Cognitive therapy Behavior therapy Medications Treatments for social phobias include: Cognitive therapy Cognitive restructuring to change distorted automatic thoughts Behavior therapy Exposure to social situations that evoke fear Medications Antidepressants Relapse rate with medication is higher than with therapy © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Occurrence of panic attacks seems to come “out of the blue” Panic Disorder Panic Disorder Occurrence of panic attacks seems to come “out of the blue” Recurrent, unexpected attacks Worry about additional attacks Must be abrupt onset of 4 out of 13 symptoms Characterized by the occurrence of panic attacks that often seem to come “out of the blue” Recurrent, unexpected attacks and worry about additional attacks 13 possible symptoms of panic attacks, 10 of which are physical and 3 of which are cognitive Attacks are brief but intense © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Agoraphobia Can you define agoraphobia? Anxiety about being in places from which escape might be difficult or embarrassing: Crowds Theaters Malls Cars, buses, trains, planes Standing in line Elevators Other similar situations Frequent complaint of people with panic disorder but a distinct disorder in DSM-5 © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Prevalence, Age of Onset, and Gender Differences Average age of onset is 23–34 years Twice as prevalent in women as men 4.7% of adult population have had panic disorder at some time in their lives Panic disorder without agoraphobia more common than panic disorder with agoraphobia © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Comorbidity with Other Disorders 83% of people with panic disorder have at least one comorbid disorder 50–70% will experience serious depression at some point in their lives Panic disorder associated with suicidal ideation and suicide attempts independent of comorbidity © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Timing of a First Panic Attack First attack frequently follows feelings of distress or highly stressful life circumstance Many adults who experience single panic attack do not develop panic disorder © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Biological Causal Factors Genetics Biochemical agents Neural regions Panic disorder has a moderate heritable component: 33% to 43% due to genetic factors There is a broad range of biochemical panic provocation agents There are also several areas of the brain implicated in panic attacks © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Figure 6.1: A Biological Theory of Panic, Anxiety, and Agoraphobia © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Psychological Causal Factors Comprehensive learning theory of panic disorder Cognitive theory of panic Anxiety sensitivity and perceived control Safety behaviors and persistence of panic Cognitive biases and maintenance of panic Comprehensive learning theory of panic disorder Cognitive theory of panic Anxiety sensitivity and perceived control Safety behaviors and the persistence of panic Cognitive biases and the maintenance of panic © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Figure 6.2: The Panic Circle © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Treatments Medications Behavioral treatments Cognitive-behavioral treatments Medications Anxiolytics Antidepressants © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Generalized Anxiety Disorder Chronic or excessive worry about multiple events and activities Occurs more days than not for 6-month period © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Prevalence, Age of Onset, and Gender Differences 60–80% report having been anxious nearly all their lives Twice as common in women as in men Lifetime prevalence is 5.7% Each year 3% of population experiences GAD 60-80% report having been anxious nearly all their lives, so age of onset is difficult to determine © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Comorbidity with Other Disorders GAD Especially other anxiety disorders and mood disorders Experience occasional panic attacks © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Psychological Causal Factors Conflict between id and ego Perceptions of uncontrollability and unpredictability Worry positive or negative Automatic attentional bias toward threatening information in environment According to the psychoanalytic viewpoint, the disorder results from conflict between the id and the ego Sense of mastery can help © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Biological Causal Factors Genetics Neurotransmitters CRH It is modestly heritable The neurotransmitters GABA, serotonin, and perhaps norepinephrine all play a role in anxiety CRH also plays a role Neurobiological factors implicated in panic disorders and GAD are not the same © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Biological Causal Factors True or false? Neurobiological factors implicated in panic disorders and GAD are the same. False Neurobiological factors implicated in panic disorders and GAD are not the same © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Cognitive-behavioral therapy Treatments Anxiolytic drugs Buspirone Cognitive-behavioral therapy Anxiolytic drugs are commonly used and misused Buspirone seems effective and nonaddictive Cognitive-behavioral therapy has become increasingly effective © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Obsessive-Compulsive Disorder OCD Occurrence of unwanted and intrusive obsessive or distressing images Usually accompanied by compulsive behaviors New category of disorders in DSM-5: obsessive-compulsive and related disorders Usually accompanied by compulsive behaviors performed to neutralize obsessive thoughts or images and/or prevent some dreaded event or situation © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Obsessive-Compulsive Disorder Obsessions Contamination fears Fears of harming oneself or others Lack of symmetry Pathological doubt Compulsions Cleaning Checking Repeating Ordering/arranging Counting © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Prevalence, Age of Onset, and Gender Differences Typically begins in adolescence or early adulthood OCD affects both genders about equally Lifetime prevalence is 2.3% One-year prevalence is 1.2% Lifetime prevalence is some studies is as high as 3% Divorced (or separated) and unemployed individuals overrepresented Also not uncommon in children: more frequent in boys than girls and greater in severity © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Comorbidity with Other Disorders Frequently co-occurs with other anxiety disorders and mood disorders Also co-occurs with body dysmorphic disorder Depression very common comorbid disorder © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Psychological Causal Factors Mowrer developed the two-process theory of avoidance learning Neutral stimuli become associated with fearful thoughts via classical conditioning Examples Obsessions with contamination and dirt appear to have evolutionary roots Attempting to suppress unwanted thoughts may increase those thoughts Cognitive biases toward material relevant to one’s obsessive concerns © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Biological Causal Factors Genetics Brain function abnormalities Serotonin OCD appears moderately heritable Abnormalities in brain function may include: Slight structural abnormalities in the caudate nucleus high metabolic levels in other parts of the brain Serotonin is strongly implicated in OCD © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Treatments Exposure and response prevention Medications that affect neurotransmitter serotonin Exposure and response prevention may be most effective approach to obsessive-compulsive disorder Exposure to anxiety-producing obsession, prevention of compulsion typically used Gradually move through hierarchy of stimuli Medications that affect neurotransmitter serotonin have also been found helpful © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Body Dysmorphic Disorder BDD Obsessed with perceived or imagined flaw in appearance Causes clinically significant distress May focus on any body part Moved from somatoform disorders to OCD disorders because of its commonalities with OCD Most common locations of complaints are skin, hair, nose, eyes, breasts/chest/nipples, stomach, face size/shape Causes of BDD still being researched. There is some heritability and some issues with self-schema © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Prevalence, Age of Onset, and Gender Differences Typically begins in adolescence BDD affects both genders about equally People with depression prevalence is 8% General population prevalence is 1–2% Very common to also have diagnosis of depression Suicide attempts and ideations are also common © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Relationship to OCD and Other Disorders Similar behaviors and causes as OCD Shares body image distortions with eating disorders © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Cognitive-behavioral therapy Treatments Antidepressants Cognitive-behavioral therapy Therapy emphasizing exposure and response prevention appears to be effective © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Hoarding Hoarding Disorder Acquire and fail to discard limited value possessions Disorganization in living space interferes with daily life Poorer prognosis for treatment than OCD Occurs in approximately 10–40% of people with OCD Prevalence may be 3–5% of general population © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Trichotillomania Trichotillomania Urge to pull out hair from any body location Preceded by tension and followed by pleasure Must cause clinically significant distress Trichotillomania moved from impulse-control disorders to OCD-related disorders in DSM-5 Not much is known about the disorder © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Sociocultural Causal Factors For All Anxiety Disorders Anxiety is a universal emotion Expression and rates of anxiety expressed differently across cultures Examples Anxiety is a universal emotion, but anxiety disorders are expressed differently across cultures Ataque de nervios is common in the Caribbean Different countries have very different rates of anxiety disorders © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Cultural Differences in Sources of Worry How would you describe these sources of worry? Yoruba culture of Nigeria Koro in China Taijin kyofusho in Japan In the Yoruba culture of Nigeria, sources of anxiety are different than in the U.S. Creating and maintaining a large family Fertility Dreams that may indicate bewitchment Somatic complaints that are atypical in Western society In China, Koro is an anxiety that a body part is retracting into the body or shrinking Certain anxiety disorders may have evolved to fit certain cultural patterns The Japanese disorder taijin kyofusho is somewhat like social phobia in Western culture, but fear is about offending or embarrassing others, not self © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.

Unresolved Issue Which type of treatment is best for anxiety and obsessive-compulsive disorders? Many people do not know what treatment options are available to them Many therapists are not trained in specialized treatments for these classes of disorders © 2014, 2013, 2010 by Pearson Education, Inc. All rights reserved.