This is a persistent and unreasonable fear of a particular object, activity, or situation.

Lecture 5 Anxiety Disorders 2 Lecture Outline I. Introduction II. Generalized Anxiety III. Panic Disorder A. Panic Attacks B. Agoraphobia IV. Phobias A. Definition B. Agoraphobia C. Social Phobia D. Simple Phobia V. Obsessive Compulsive Disorder A. Obsessions B. Compulsions VI. Post-traumatic stress disorder (not covered) VII.Conclusions ------------------------------------------- I. Introduction "The characteristic features of this group of disorders are symptoms of anxiety and avoidance behavior" (APA, 1987, p.235). As we discussed in the previous lecture, such symptoms are not limited to people suffering anxiety disorders. To one degree or another, we have all experienced these symptoms. It is when these symptoms become disabling that the person suffering from them comes to the attention of mental health professionals. The feelings of anxiety characterizing these disorders are persistent and are involved with everyday life circumstances. In the next three lectures we will look at these disorders, and examine some of the possible explanations and theories about them. Special attention will be paid to Panic disorder and Agoraphobia. Today's lecture will present a descriptive overview of the different types of Anxiety Disorders. II. Generalized Anxiety As the name implies, a person suffering from Generalized Anxiety is someone who experiences anxiety and excessive worry most of the time. The anxiety is not about any single life circumstance or situation, and it is unrealistic and excessive given the reality of the person's life. The DSM requires that the anxiety be present six months or more, for more days than not, before a diagnosis is made. In other words, people with this disorder live in a relatively constant state of diffuse and unfocused anxiety, apprehension and dread, what Freud called "free floating" anxiety. Thus, this disorder is something much more severe than the common brief periods of mild anxiety that most of us experience. Various symptoms are associated with this disorder, in addition to the experience of anxiety: 1. Motor Tension: twitching, trembling, muscle aches, restlessness. 2. Autonomic hyperactivity: shortness of breath, accelerated heart rate, sweating, dry mouth, dizziness, nausea, chills. 3. Vigilance and Scanning: feeling keyed-up or on edge, easily startled, difficulty concentrating, insomnia, irritability. Apparently, this is not a very commonly diagnosed disorder (APA, 1987; Barlow, 1988). There is confusion among clinicians and researchers over the precise nature of Generalized Anxiety Disorder (Barlow, 1987). For example, there is some evidence that people diagnosed with GAD may actually be suffering from milder forms of other anxiety disorders, such as panic disorder. It may be more accurate, then, to classify these people in these other categories and indicate the degree of severity. Others argue that GAD and Panic disorder represent different points on a single dimension of anxiety. Add to this the concern of some clinicians that the diagnostic criteria are too vague. Diagnosis thus tends to be quite unreliable (Barlow, 1988). The DSM-III-R category is substantially revised over the DSM-III, which may help clarify some of this confusion. For example, the symptom list has been expanded in the DSM-III-R to provide a richer description of the disorder. III. Panic Disorder A. Panic Attacks: This is similar to Generalized Anxiety Disorder in that there is an anxiety response while there may be no clear life circumstance that would trigger such a response (there is evidence, however, that the initial panic attack is typically preceded by an identifiable stressful life event, such as divorce [Foa, Steketee & Young, 1984]). The distinction between Panic Disorder and Generalized Anxiety Disorder is that Panic Disorder is characterized by the occurrence of one or more unexpected "panic attacks" - discrete periods of intense fear or discomfort, rather than the chronic, free-floating fear found in Generalized Anxiety Disorder. These attacks usually last a few minutes, although in rare cases they may last for a couple of hours. The attacks often occur unexpectedly, leading to even more anxiety as the person wonders if he or she is going crazy or dying The panic attacks typically occur several times a week, or even daily, and may continue to recur for years. According to the DSM-III-R, Panic Disorder is the most common anxiety disorder among people seeking treatment. Case Study: A 35-year-old mathematician gave a history of episodic palpitations and faintness over the previous 15 years. There had been periods of remission of up to 5 years, but in the past year the symptoms had increased and in the last few days the patient had stopped working because of the distress. His chief complaints were that at any time and without warning, he might suddenly feel he was about to faint and fall down, or tremble and experience palpitations, and if standing would cringe and clutch at the nearest wall or chair. If he was driving a car at the time he would pull up at the curbside and wait for the feelings to pass off before he resumed his journey. He was becoming afraid of walking alone in the street or of driving his car for fear that the episodes would be triggered by it and was loath to travel by public transport. Although he felt safer when accompanied, this did not abolish his symptoms. The attacks could come on at any time of day or night. (Marks & Lader, 1973, p. 11). B. Agoraphobia: A frequent complication of panic disorder is Agoraphobia: "the fear of being in places or situations from which escape might be difficult or in which help might not be available in the event of a panic attack" (APA, 1987, p.236). Agoraphobia is thus not the fear of open spaces so much as the fear of fear (Barlow & Waddell, 1985). One popular view held by psychologists is that agoraphobics are afraid of their own internal sensations of anxiety and panic. The agoraphobia may develop as a secondary reaction to the distressing experience of the recurring panic attacks (Noyes, Crowe, Harris, Hamra & McChesney, 1986). Because of their fear of these attacks, and the distress caused by the unexpectedness of the attack, the individual will end up restricting travel away from home, or else enduring intense anxiety if travel becomes necessary. We saw this illustrated in the case study, where the man was increasingly fearful about walking alone, driving his car, and using public transportation. Interestingly, some investigators have found a possible genetic link between panic and agoraphobia (Noyes, et al., 1986). The DSM-III-R acknowledges the connection between Panic and Agoraphobia by providing two separate diagnostic categories for Panic Disorder: 1. Panic Disorder with Agoraphobia 2. Panic Disorder without Agoraphobia Panic with Agoraphobia is much more common than panic without agoraphobia (APA, 1987; Barlow, 1988). Between 2.8% and 5.7% of the general population suffer from panic with agoraphobia (Barlow, 1988). And finally, Panic with Agoraphobia is about twice as common in females than males. IV. Phobias A. Definition: The DSM-III-R refines a phobia as "a persistent, irrational fear of a specific object, activity, or situation that results in a compelling desire to avoid the dreaded object, activity or situation" (APA, 1987, p.403), although the person is aware that his or her fear is unreasonable and excessive. [This definition is a bit confusing, however. It requires the fear to be of something specific - but agoraphobia and some of the other phobias such as social phobias are not really about anything specific; they are about a general situation, activity, etc.] The basic impairment: limits a person's choices, forcing him or her into restricted and rigid behaviors. Traditionally, phobias were named by means of Greek prefixes that stood for the object that was feared. eg:xenophobia = fear of foreigners claustrophobia = fear of closed places acrophobia = fear of heights Such a practice is not widely used today - it is "jargony" and our knowledge of Greek isn't what it once was. To give each fear its own term could add up to an unwieldy list indeed (see Handout 5-1)! The DSM-III-R groups the phobias into 3 general types: 1. Agoraphobia 2. Social Phobia 3. Simple Phobia B. Agoraphobia (without history of panic disorder): The DSM-III-R provides this category as distinct from the Panic Disorder category, although it is not clear whether agoraphobia with no or limited panic symptoms is actually a separate disorder (APA, 1987): agoraphobia is rarely diagnosed without there also being, at some level, symptoms of panic. For example, "out of 41 agoraphobics seen (at a clinic) during a period of 1 year, only 1 fit the diagnosis of agoraphobia without panic attacks, and even this particular classification was questionable...Do not expect to see too many agoraphobics without panic" (Barlow & Waddell, 1985, p.15). Agoraphobia is the most common phobia: 50%-80% of phobias diagnosed are agoraphobia (Chambless, 1982). The majority are women: eg: 88% (Seidenberg & DeCrow, 1983). C. Social Phobia: Characterized by a persistent fear of one or more social situations where one might be exposed to the scrutiny and attention of others,as well as the fear that one may do something in those situations that will be humiliating or embarrassing. eg: stage fright, fear of public speaking, generalized fear of most social situations. Case Study: "I sometimes don't go to class because I think the professor might call on me. My fear doesn't have anything to do with being unprepared if he asks me a question because I'm almost always well prepared. My grades on exams are always near the top of the class. What I keep thinking about is that the professor and all the students will see how red my face gets whenever I have to say something in a group" (Sarason & Sarason, 1984, p. 140). Even prior to engaging in a social situation, a person with a social phobia will experience anxiety from merely anticipating the social encounter. Thus, it is not surprising that he or she will often end up avoiding such situations all together. As a result, some people will go through life feeling inadequate and lonely, yet afraid of becoming involved in interpersonal relationships. Four common interpersonal fears: 1. fear of asserting oneself 2. fear of criticism 3. fear of making a mistake 4. fear of public speaking (Sarason & Sarason, 1984). In clinical sample (ie: people who have been diagnosed and/or are in treatment), social phobia is more common in males (APA, 1987). In the general population, however, this sex difference seems to disappear (Barlow, 1988). Overall, approximately 1 - 2% of the population suffer from social phobia (Barlow, 1988). D. Simple Phobia: A miscellaneous category made up of irrational fears of specific objects or situations not covered by Agoraphobia or Social Phobia. eg: fear of animals (dogs, cats, snakes, etc.), blood, closed spaces, heights, airplanes. (fear of animals is the most common Simple Phobia) (Barlow, 1988). Exposure to the feared object will typically result in an immediate anxiety response. The feared object is therefore avoided. (You should notice a common pattern with the anxiety disorders: that which is feared is avoided - Why might this be important?) Case Study: "I know it's crazy, but I really freak out when I see a german shepherd dog. Even a picture will make me kind of nervous. But if I see one for real, I start shaking, I can't think straight, all I want to do is get away. If I'm talking to someone at the time I have trouble staying in the conversation - I'm just feeling like I really want to get away. I know the dog won't really attack me, but I can't help being afraid anyways". Simple phobias are common in the general population, but because they rarely result in severe impairment, people suffering from Simple Phobias seldom end up in treatment (APA, 1987). Simple phobias seem to be most common in women (Agras et al., 1969, APA, 1987). Handout 5-2 lists prevalence and sex distribution for seven phobias (Barlow, 1988) V. Obsessive Compulsive Disorder People with this disorder experience recurring and persistent thoughts and acts which cause them significant distress. A. Obsessions: persistent thoughts, impulses, or images that are experienced as intrusive and distressing. Most common: Aggressive impulses (eg: killing one's child), contamination (eg: becoming infected by touching people), doubt (eg: wondering if you turned off the gas stove or not), sex (eg: images of culturally unacceptable sexual practices), concern over health (eg: worrying about the preservatives in your food), need for symmetry (eg: worrying that one's desk is not rigidly organized) (Akhtar, Wig, Verma, Pershad & Verma, 1975; Jenike, Baer & Minichiello, 1986). Obsessions are internal, intrusive and anxiety provoking, and will occur daily if not many times a day. Case Study: A newly married young computer programmer...spent many long hours ruminating over whether she had or had not murdered a solitary old lady whom she had visited regularly. This troublesome thought intruded repeatedly, seriously impaired her concentration, and provoked considerable discomfort and guilt. Repeated enquiries, including several visits to the local police station, failed to satisfy her that the woman had in fact died of natural causes some days after the (woman) had last seen her. (This) single tormenting obsessional rumination...had plagued her for years (Rachman & Hodgson, 1980, pg.257). B. Compulsions: repetitive and intentional behaviors or cognitions performed in response to an obsession. The compulsion is designed to neutralize the anxiety caused by the obsession. Whatever else the person has attempted to reduce the anxiety, it has not worked. Where his/her control over the anxiety producing obsessions seems hopeless, he/she resorts to magic and ritual in a vain attempt to re-establish safety (Barlow, 1988). As the person with a dog phobia will learn to avoid the dog, the person with an obsession will avoid the thought. Case study: A 38-year-old mother of one child was obsessed by a fear of contamination for over 20 years. Her concern with the possibility of being infected by germs resulted in washing and cleaning rituals that invaded all aspects of her life. Her child was restrained in one room, which was kept entirely germ free. She opened and closed all doors with her feet in order to avoid contaminating her hands (Rachman & Hodgson, 1980, p. 111). Some typical compulsions (Rachman & Hodgson, 1980): 1. Checking Rituals: The obsessive fear is of some future imagined disaster. Being ever vigilant and constantly checking the status of things relieves anxiety to a certain extent because it reassures the person that everything is in order. eg: Someone will rob my house or attack me if I leave the house unlocked ----> repeatedly checking all the doors and windows ----> normal activities are constantly interrupted, can't sleep. 2. Cleaning Rituals: The fear is of contact with objects, people or situations that may be contaminating. To restore safety, compulsive washing or other types of cleaning are engaged in. eg: Scrubbing hands and arms many times an hour for fear of having picked up some disease, even to the point where sores develop on the skin. Depression is a common complication: "up to 80% of people diagnosed with obsessive compulsive disorder also suffer from depression" (Barlow, 1988). This shouldn't be surprising, given the distressing, time consuming, and interfering nature of obsessions and compulsions. The prevalence is not clear, although it may be more common than once thought: 1.3 - 2% of the general population (Barlow, 1988). Note: By "obsessive compulsive disorder", scientists mean something quite different from what people mean when they use it in their everday speech. We might describe the guy with the clean desk as "obsessive" or "compulsive" but this does not mean he suffers from the symptoms just outlined. We all have recurring thoughts, etc at times; this doesn't mean we have this disorder. [Later in the course, we will also learn about a disorder called Obsessive Compulsive Personality Disorder - this is to be distinguished from the current anxiety disorder: the personality disorder refers to a pervasive pattern of perfectionism and inflexibility, rather than to fairly well defined, recurring, and distressing thoughts and behaviors]. VI. Post-traumatic stress disorder: [not covered. See text] VII. Conclusions We have reviewed some of the disorders classified by the DSM-3-R as Anxiety Disorders. Undoubtedly, you have experienced some of these symptoms to one degree or another at some time in your life. Such experiences are not abnormal. Anxiety becomes abnormal when it becomes excessive, irrational, and chronic. The anxiety experienced by people suffering from these disorders is intrusive and disruptive to their everyday lives. But why do some people suffer from Anxiety Disorders, while others do not? What are the causes of these disorders? We will turn to these questions in the next lecture.  Handout 5-2 Prevalence and Sex Distribution of Phobias Phobia Prevalence per 1000 Sex distribution Illness/ 31 m: 22 injury f: 39 Storms 13 m: 0 f: 24 Animals 11 m: 6 f: 18 Death 5 m: 4 f: 6 Crowds 4 m: 2 f: 6 Heights 4 m: 7 f: 0 (from Barlow, 1988)

Is a persistent and unreasonable fear of a particular object situation or activity?

What are situational phobias?

What is specific phobia?

What are the 3 types of phobias?