Chapter 4: Anxiety and Obsessive-Compulsive Disorders

• PSYC 168 covers Anxiety Disorders and Obsessive-Compulsive Disorder.

Fear vs. Anxiety

• Fear involves the central nervous system's response to a serious threat.
• Anxiety involves the central nervous system's response to a vague sense of threat or danger.

Anxiety Disorders

• Anxiety Disorders are a defined set within the DSM, characterized by anxiety.
• Anxiety Disorders are the most common mental disorders in the United States.
• 19% of adults experience an anxiety disorder in any given year.
• 31% of the population will develop an anxiety disorder at some point in their lives.
• Disorders covered include: Generalized Anxiety Disorder, Specific Phobia, Social Anxiety Disorder, and Panic Disorder.
• Obsessive-Compulsive Disorder is also discussed, being formerly part of Anxiety Disorders in DSM-IV.

Generalized Anxiety Disorder (GAD)

• GAD is marked by persistent, excessive anxiety and worry about various events and activities.
• The anxiety experienced is excessive in most circumstances.
• GAD results in a reduced quality of life.
• GAD affects approximately 3% of the U.S. population, with a 2:1 ratio of women to men.
• It is more prevalent in the LGBTQ+ population and has higher rates in White Americans compared to other racial and ethnic groups.

GAD Diagnosis Checklist

• For at least 6 months, the individual experiences disproportionate, uncontrollable, ongoing anxiety and worry about multiple matters.
• Symptoms include at least three of the following: edginess, fatigue, poor concentration, irritability, muscle tension, and sleep problems.
• Causes significant distress or impairment.
• Psychiatrists can prescribe anti-anxiety medications without a formal diagnosis.

Sociocultural Factors in GAD

• GAD is more likely to develop in people facing dangerous social conditions.
• Factors include threatened environments, crime, and violence.
• Societal stress, poverty, and widespread contagious diseases (e.g., COVID-19) contribute to GAD.
• GAD rates increase as wage rates decrease.

Psychodynamic Perspective on GAD

• Freud theorized that all children experience anxiety due to id impulses, using ego mechanisms to control it.
• High anxiety occurs due to inadequate defense mechanisms.
• Modern psychodynamic theorists link GAD to early parent-child relationships like harsh punishment or overprotectiveness.

Humanistic Perspective on GAD

• GAD arises when people stop looking at themselves honestly and acceptingly.
• Carl Rogers stated that a lack of unconditional positive regard in childhood leads to conditions of worth and harsh self-standards.
• Threatening self-judgments can also cause anxiety, setting the stage for GAD to develop.

Cognitive-Behavioral Perspective on GAD

• GAD results from dysfunctional thoughts, especially maladaptive assumptions.
• Basic irrational assumptions (Ellis): dire need for love/approval, catastrophe when things aren't as desired, being terribly concerned about dangers, or high self-competence.
• Beck argued that silent assumptions of assuming the worst can also cause GAD.
• People with GAD hold maladaptive assumptions, are particularly overattentive to threatening stimuli.

Metacognitive Theory

• Individuals hold both positive and negative beliefs about worrying.
• Their ability to recognize worry is useful, however, they tend to worry about worrying (meta-worry).
• Meta-worry eventually leads to GAD.

Intolerance of Uncertainty Theory

• People with GAD cannot tolerate the chance of negative events occurring, even if the possibility is very small.
• Resulting intolerance and worrying leave them vulnerable to GAD development.

Avoidance Theory

• People with GAD have higher bodily arousal (increased heart rate, sweating).
• Worrying reduces the physical feelings of discomfort, and distracts individuals from their feelings.

Cognitive-Behavioral Approaches to Treatment

• Ellis's rational-emotive therapy (RET): challenges old assumptions and generates new ones.
• Breaking down the cycle of worrying with education and acceptance.
• Mindfulness-based cognitive-behavioral therapy: acceptance and commitment therapy.

Mindfulness Techniques

• Mindfulness means being present in the moment intentionally, without judgment.
• Mindfulness meditation is a main approach.
• Common techniques involves becoming aware of body sensations, breathing, wandering thoughts, and busy thoughts.
• Yoga and journaling

Biological Perspective on GAD

• It is supported by family pedigree studies, and family history.
• GABA role in carrying an inhibitory message that ends firing of neuron receptors.
• Brain circuits: Networks of brain structures working together, triggering each other into action.

Drug Therapies for Anxiety (1950s)

• Barbiturates were used as sedative-hypnotic drugs
• Benzodiazepines later appeared to increase GABA's ability to bind to neuro receptors.
• Effect is short-lived.
• There is potential for dependence.
• Mixing benzodiazepines with alcohol can cause dangerous side effects.
• Benzodiazepine cannot be used long term due to risk of dependency.
• GAD typically requires antidepressants to increase serotonin and norepinephrine neurotransmitter activity.
• Antipsychotics are sometimes used for severe GAD cases.

Phobias

• Phobias differ, characterized by intense fear toward an object, activity, or situation (DSM-5-TR).
• Great desire to avoid the feared object or situation.
• Causes distress that interferes with functioning.
• Most phobias fall categorization of "Specific Phobia", while exception is "Agoraphobia".
• Social Anxiety Disorder is a known separate diagnosis (used to call Social phobia).

Specific Phobia

• It is a persistent fear of specific objects of situations.
• Common examples include animals, insects, heights, blood, or thunderstorms.
• The annual prevalence in the U.S. is 9%, and the lifetime prevalence is 13%.
• There is a 2:1 ratio of women to men in the U.S. population.
• About 32% seek treatment, others typically avoid.

Specific Phobia Dx Checklist

• Marked, persistent, disproportionate fear of a particular object or situation, lasting at least 6 months.
• Exposure to the object produces immediate fear.
• There is avoidance of the feared situation.
• Significant distress or impairment exists due to the phobia.

Agoraphobia

• Involves fear of being in public spaces, with worry of no place for escape or help if panic occurs.
• Avoiding going outside, or very limited places possible.
• It involves panic attacks, with 1% annual prevalence and 1.3% lifetime prevalence.
• 46% seek treatment.

Agoraphobia Dx Checklist

• Pronounced, disproportionate, or repeated fear about being in at least two of these following: using public transportation, parking lots, shops, lines, or being unaccompanied.
• Concern that it would be hard to escape or get help if panic or embarrassment occurred.
• Involves avoidance of agoraphobic situations.
• Symptoms usually continue for at least 6 months.
• Significant distress or impairment.

What Causes Phobias?

• Cognitive-behavioral theories receive most research support.
• Focus primarily on behavioral dimensions.
• Fear of certain objects, situations, or events are learned through classical conditioning or modeling.
• Once fears exist, individuals avoid to permit fears to become entrenched.

Behavioral-Evolutionary Explanation for Phobias

• Some specific phobias are more common, through species-specific biological predisposition to develop fears (preparedness).
• Explains why some phobias (animals, heights, darkness, etc.) are more common than others.

Treatments for Specific Phobias

• Actual contact with the feared object or situation is key for exposure treatment.
• Systematic desensitization: relaxation training, fear hierarchy, in vivo desensitization, covert desensitization, virtual reality.
• Includes flooding and Modeling.

Treatments for Agoraphobia

• Older approaches less successful than newer treatments.
• Exposure therapy (cognitive-behavioral), support groups (go out together, coax move away), and home-based self-help programs.
• Successful for about 70% of clients, but relapse occurs as many as half when panic disorder coexists.

Panic Disorder: Panic Attacks

• Involves periodic, short bouts of panic that occur suddenly, reach a peak within minutes, and gradually pass.
• Characterized by at least four of the following symptoms: heart palpitations, tingling, breath shortness, sweating, hot/cold flashes, trembling, chest pains, choking sensations, faintness/dizziness, and feeling of unreality.
• Many people often call ambulance or rush to emergency room.
• ⅓ of the population may have had, one-time panic attack, will not constitute, or equal to, a panic disorder diagnosis.
• Repeated panic Attacks = Panic Disorder.

Panic Disorder Dx Checklist

• Panic attacks occur repeatedly and unforeseen.
• One or more attacks either leads to: continual concern, or dysfunctional behavior changes (avoiding new experiences).

Biology of Panic

• Panic circuit involves: amygdala, hippocampus, ventromedial nucleus of hypothalamus, central gray matter, and locus coeruleus.
• Hyperactivity of the panic circuit can cause panic disorder.
• Predisposition to developing these irregularities is inherited.

Drug Therapies- Panic Disorder

• Antidepressants work on the serotonin and norepinephrine receptors of panic brain circuit especially at the locus coeruleus.
• Benzodiazepines reduce immediate panic (high dependency), hydroxyzine (antihistamine) also commonly applied.

Cognitive-Behavioral Perspective

• Experience more frequent intense feelings, and bodily interpreted sensations are signs of medical catastrophe.
• Common bodily responses due to breathing: hyperventilate which causes physical symptoms.
• Increased anxiety to physical signs, they are unable to assess the sensations logically = harmful.
• Display avoidance and safety behaviors.

Cognitive-Behavioral Therapy (CBT)- Panic Disorder

• Corrects misinterpretations of physical sensations.
• Educate about panic attacks.
• Teach applications of more accurate interpretations.
• Teach skills for coping through anxiety.
• Biological challenge exercise by doing panic-inducing tasks- induces sensory feelings, clients apply the newfound skills to.
• ⅔ patients improve, helpful with medication.

Social Anxiety Disorder

• Severe, persistent irrational anxietys, that interfere daily in social or performance situations, and narrow/broad anxietys.
• Annual prevalence: 7%
• Lifetime Prevalence: 12%
• 3:2 women to men ratio.
• More prevalent in white Americans, and low incomes.
• 40 Percent seek treatment

Social Anxiety Dx Checklist

• Anxiety about performance or social anxiety
• Fear of being negatively evaluated by or oftersive to others
• Exposure to social situation produces anxiety
• Avoidance of feared situations
• Significant distress or impairment

Social Anxiety Disorder: Causes

• interplay of cognitive and behavioral factors
• anticipation of social disasters/ dread of situations
• Avoindance, and safety behaviors

Social Anxiety Disorder: Treatments

-Overwhelming social fears: -Benzodiazepine or antidepressant drugs -Exposure therapy, change maladaptive beliefs

• Lack of Social Skills: -Model appropriate social behavior (Role Playing)
• Social and assertiveness training

Obsessive-Compulsive Disorder (OCD)

• Most have rituals/routines
• Daily routines (check stove, lock door, etc)
• Superstitious behaviors.
• Personal ritual (lucky socks, etc)
• Believed as fine, not pathological.

OCD: Obsessions

• Persistent thoughts/images, that seen to invade a persons consciousness

OCD: Compulsions

• Repetitive, rigid behaviors/acts that must be performed to reduce anxiety in response to obsessions

OCD Dx Checklist

• Obsession, compulsions, or both occurs

• Take up considerable time

• Results in impairment or distress

• OCD was considered a part of Anxiety Disorder in DSM-IV.

Themes of Obsessions

• Dirt/contamination
• Violence/Aggression
• Orderliness
• Religion
• Sexuality

Features of Compulsions:

• Voluntary Behaviors

• Mandatory/unstoppable, causes anxiety in short term

• Cleaning, verbalizing, and/or counting compulsions

• Most OCD patients have both obsessions and compulsions.

• Compulsions serve as a yielding to obsessions help control obsessions.

Cognitive-Behavioral Theory- OCD

• Unwanted, intrusive, unpleasant thoughts ignored/dismissed.
• People with OCD have such expectations that causes terrible outcomes.
• Neutralizing actions reduce anxiety to obsessions/compusions:
  • Reduce anxiety in the short term, and becomes a full cycle.

Cognitive-Behavioral Therapy- OCD

• Education on misinterpretations, excessive responsibility, and how it maintains symptoms.
• Guides clients to dentify, challenge their cognitions.
• Exposure, response prevention (or ERP)
• Between 50-70 percent improvement with therapy

Biological Perspective-OCD

• GENETIC, studies have identified anomalies genetic make up
• CSTC circuit (Cortico-Striato-Thalamo-Cortical brain circuit.)
• Circuits is associated with: impulse, reward, habit, movements
• High hyperactivity for OC patients, turn of impulses

Biological Treatment OCD

• Serotonin: main hormone related to OCD
• Anti-Depressants: are used to treat OCD
• Doses used by therapists are higher
• In 50-60 percent patients, 50 percent cut in half
• Research suggest that combo of medication works, and more effective

Obsessive-Compulsive Disorders

• Concerns drive people repeatedly/excessively in behavior patterns
• Hoarding Disorder
• Trichotillomania (hair pulling)
• Excoration (skin picking)
• Body dysmorphic disorder

Equifinality

• Multiple Negative Variables

Multifinality

• Power of Protective Factors

Overview of Anxiety Disorders and Obsessive-Compulsive Disorder (formerly part of Anxiety Disorders in DSM-IV). Covers Generalized Anxiety Disorder, Specific Phobia, Social Anxiety Disorder, and Panic Disorder. Includes U.S. prevalence data.