Lecture 4
Anxiety Disorders
Lecture Outline
I. Distinction between Normal and Abnormal anxiety
A. Anxiety -definitions
B. Normal anxiety
C. Abnormal anxiety
II. Distinction between Anxiety and Other disorders
III.Background: The Neuroses
A. Introduction
B. William Cullen
C. Sigmund Freud
D. Criticisms
E. DSM-III
F. A final note
III.Conclusion
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I. Distinction between Normal and Abnormal anxiety:
1. Anxiety: DSM-III-R definition of "anxiety": "Apprehension,
tension, or uneasiness that stems from the anticipation of danger,
which may be internal or external...The manifestations of anxiety
and fear are the same and include motor tension, autonomic
hyperactivity, apprehensive expectation, and vigilance and
scanning" (APA, 1987, p. 392).
Anxiety is a complex, multidimensional experience, not a
simple unidimensional phenomenon. Anxiety can be understood as
having three separate dimensions (Lang, 1970):
i) Verbal reports of subjective experiences (eg: tension,
apprehension, sense of impending danger, expectations
of an inability to cope in the future).
ii) Behavioral responses (eg: avoidance, impaired speech
and motor coordination, performance deficits).
iii) Physiological responses (eg: muscle tension, increased
heart rate, elevated blood pressure, rapid respiration,
dryness of the mouth, nausea).
Note: These three dimensions often have low intercorrelations
(Bootzin & Max, 1980; Lang, 1970). For example, a person could say
that she is anxious (dimension 1) and not show clear behavioral
signs (dimension 2) of anxiety. This means that there is no single
measure that will tell us if a person is anxious. This also means
that anxiety is a construct - that it is an inferred state - you
can not actually observe the anxiety itself or measure it directly.
We infer its presence on the basis of the three dimensions in a
situational context.
B. Normal anxiety: Anxiety can be quite adaptive. It is not
necessarily pathological. Without anxiety, the human race would
have undoubtedly died off long ago. Anxiety acts as an important
signal that danger or threat is imminent. It cues us to attend to
important stimuli. Anxiety provides information to the individual.
Thus, we are able to activate protective responses, actions that
help us survive when confronted with danger and trouble. Anxiety
signals us to make adaptive responses.
eg: slow down on a slippery road
avoid dark alleys
go for medical checkups
return library books
As one researcher has said, "Without (anxiety), we would
probably all be asleep at our desks" (S.M. Paul, quoted in
Bootzin & Acocella, 1984).
C. Abnormal anxiety: Anxiety is abnormal when it is persistent and
coupled with no objective danger or threat, leading to ineffective
and self-defeating behavior. For example:
Example 1: I wish I could tell you what's the matter.
Sometimes I feel like something terrible has just happened
when actually nothing has happened at all. Other times, I'm
expecting the sky to fall down any minute. Most of the time I
can't point my finger at something specific. The fact is that
I am tense and jumpy almost all the time. Sometimes my heart
beats so fast, I'm sure it's a heart attack. Little things
can set it off. The other day I thought a supermarket clerk
had overcharged me a few cents on an item. She showed me that
I was wrong, but that didn't end it. I worried the rest of
the day. I kept going over the incident in my mind, feeling
terribly embarrassed at having raised the possibility that the
clerk had committed an error. The tension was so great, I
wasn't sure I'd be able to go to work in the afternoon.
Example 2: It happened without any warning, a sudden wave of
terror. My heart was pounding like mad, I couldn't catch my
breath, and the ground underfoot seemed unstable. I was sure
it was a heart attack. It was the worst experience of my
life.
Example 3: I can't tell you why I'm afraid of rats. They fill
me with terror. Even if I just see the word "rat" my heart
starts pounding. I worry about rats in restaurants I go to, in
my kitchen cupboard, and anywhere I hear a noise that sounds
like a small animal scratching or running.
Example 4: Before I come home from work I spend half my time
wondering whether a burglar has broken into the apartment. As
soon as I get home I check every room, under the bed, and in
the closets. Before going to sleep I probably check the lock
on the front door fifty times. I feel better after each check,
but then my concern wells up and I have to go check again
(Sarason & Sarason, 1984).
These four scenarios are examples of anxiety disorders. Example 1
is an example of "generalized anxiety disorder", where the anxiety
is chronic and is felt in a variety of situations. Example 2 =
panic disorder, where the anxiety is sudden and overwhelming.
Example 3 = phobic disorder; the anxiety is aroused by a specific
stimuli. And Example 4 = obsessive compulsive disorder where
thinking certain thoughts and not doing certain behaviors arouses
intense anxiety. (We will examine these specific disorders in more
detail next lecture).
Abnormal anxiety can have serious implications for an individual.
These include:
i) Emotional consequences: feelings of fear, unhappiness, guilt.
ii) Cognitive consequences: impaired concentration and problem-solving.
iii)Behavioral consequences: avoidance of every-day situations and
activities, breakdown of complex behaviors.
iv) Physiological consequences: long term anxiety has been shown to
produce actual physical damage. Eg: Anxiety/ stress has been shown
to interfere with the immune system. Anxiety has been linked to a
wide range of physical ailments such as ulcers, headaches, and even
cancer.
Anxiety is one of the most frequent complaints. According to
Barlow and Waddell (1985), anxiety dwarfs all other problems seen
by practitioners. Some numbers:
15 million cases currently (NIMH, 1985).
30% - 40% of the general population suffers from anxiety
(Barlow & Waddell, 1985).
(According to the DSM-III-R, females are much more frequently
diagnosed with an anxiety disorder).
These numbers are probably underestimates: Many people "self-
medicate" with alcohol and other drugs. Indeed, Valium is the most
frequently prescribed drug in the US (Sarason & Sarason, 1984).
II. Distinction between Anxiety and other disorders:
A. Schizophrenia: What distinguishes the anxiety disorders from
the more severe mental illnesses, such as schizophrenia, is that a
person with an anxiety disorder is typically
1) able to maintain reality contact - there are no gross
distortions of external reality.
2) "ambulatory" - he or she can still cope with day to day
life, however poorly and inefficiently; there is
usually no need to institutionalize the person.
A person with an anxiety disorder is "sane", there is no gross
disorganization of his/her personality or behavior.
B. Mood Disorders: In a few weeks, we will look at the Mood
Disorders. However, what distinguishes anxiety disorders from mood
disorders is: Mood disorders involve states of persistent positive
or negative emotion, or mood, typically elation and/or depression.
The anxiety disorders, however, refer to states of perceived
threat, tension, apprehension, impending danger and so on.
III. Background: The Neuroses
A. Introduction: The three following classes of disorders were
once all known as neurotic disorders: Anxiety (which we will look
at in the next few lectures), Somatoform (disorders that appear to
be physical in nature, eg: blindness, but for which there is no
physical cause - rather, there is some psychological cause), and
Dissociative (disorders such as certain amnesias, multiple
personality disorder - disorders where there is a "splitting apart"
of psychological functions which are normally integrated: identity,
memory, control over motor behavior). (We will look at anxiety
disorders in lecture, the other two disorders are discussed in your
text).
In recent years, the term "neurosis" has fallen into some
disfavor, and is only parenthetically mentioned in the DSM-III.
However, it is important that we examine the term "neurosis" - it
is part of our every day speech (most of you have undoubtedly heard
this term), and indeed it is still used by many professionals. So,
the questions are: How is neurosis related to the disorders we are
discussing, and why has the term been abandoned by the authors of
the DSM-III, and by many other professionals and theorists? We
begin our discussion with a historical look at the development of
the concept of Neurosis.
B. William Cullen (18th century): Cullen coined the term
"neurosis" to refer to a group of disorders which he believed were
organic in nature, or more specifically, were due to neurological
dysfunctions (hence "neurosis") (Bynum, 1983). These organic
disorders produced a range of "nervous" behaviors, such as
hypochondriasis (obsessions and fears about one's health),
melancholy, irritability, and oversensitivity. For most of the
19th century, such neurotic behaviors were thought to be due to
disorders of the nervous system (Carson, Butcher, & Coleman, 1988).
C. Sigmund Freud (early 20th century): The view that the neuroses
were biologically caused was gradually replaced with the Freudian
theory of neurosis (Bynum, 1983). For Freud, neurosis was not due
to organic causes, but was due to psychological causes,
specifically, to anxiety (Brenner, 1974; Guntrip, 1973):
Freud claimed that neurotic behavior is caused by the anxiety
that arises in an individual as he/she (unconsciously) struggles to
keep various thoughts, conflicts, desires and memories repressed in
the unconscious. When these thoughts, desires etc. threaten to
surface into our consciousness, anxiety will arise to the point
where neurotic behaviors will occur. These behaviors are either a
direct expression of that anxiety or an attempt to defend against
it (Brenner, 1974; Freud, 1917). In other words, Freud is saying
that we all have memories, desires, etc. that, if we were aware of
them, would upset us greatly - they would fill us with anxiety.
Eg: Unacceptable sexual desires, or memories of intense, murderous
rage for a parent or other loved one. If these unconscious
memories and desires start to rise to consciousness, or if they
have never been completely repressed in the first place, then a
person will experience increasing anxiety. This person will end up
either demonstrating obvious signs of anxiety, or he/she will
engage in certain, usually bizarre, behaviors in an attempt to
alleviate the anxiety. These include panic, amnesia, obsessions,
compulsive behaviors, and multiple personalities. The anxiety
symptoms and the bizarre behaviors form what Freud termed the
Neuroses. In any event (whether outright anxiety or defenses
against anxiety) the roots of the neurotic disorders are with
anxiety.
All neuroses, no matter how different they appear on the
surface, have the common factor of being caused by anxiety.
Anxiety is the common theme. Neurotic symptoms are simply signs of
the anxiety raging within (Carson, et al, 1988).
This theory was widely accepted for many years. For example,
in the 2nd edition of the DSM, a large category of disorders was
termed the Neuroses and were described in this manner: "Anxiety is
the chief characteristic of the neuroses. It may be felt and
expressed directly, or it may be controlled unconsciously and
automatically" (APA, 1968, p.39). This is essentially Freud's
conceptualization.
D. Criticisms: In the past few decades, there has been growing
opposition to the idea of neurosis as an overarching, theoretically
meaningful term. In particular, behaviorists have criticized the
Freudian conception of neurosis (Sweet, Giles & Young, 1987). One
criticism is that anxiety is often absent in certain so-called
neuroses (eg: a person suffering from a conversion disorder [a
physical symptom such as blindness, where in fact there is no
physical disorder] may experience no anxiety at all). Freudians
would respond that the anxiety is unconscious and the disorder is a
means of reducing (or defending against) the anxiety. However,
this explanation is based on an inference, not on observable fact.
Some psychologists (Ullman & Krasner, 1975) argue that a valid
classification scheme cannot be based on inference. To do so would
mean there is no way to verify the classification scheme's
validity. One person's inferred construct is another's fiction.
Another criticism of the Freudian perspective is that anxiety
is not limited to neurotics (actually, Freud would agree with this,
or claim that we are all neurotic to some degree). Psychotics,
depressed people, and others also experience anxiety (Nathan,
Robertson & Andberg, 1969). Indeed, normal people experience
anxiety. Such universality makes anxiety an unreliable diagnostic
criterion (Bootzin & Acocella, 1984).
Finally, there is the problem of measurement. Measurements of
the different dimensions of anxiety (self report, behavioral,
physiological) often fail to correlate with each other (Lang, 1970,
Rachman, 1978). This means we have no single reliable measure of
anxiety upon which to make diagnostic decisions. Therefore,
putting anxiety at the core of our diagnostic decisions will lead
to unreliable diagnoses.
E. DSM-III: The DSM-III did away with the conception of neurosis,
dividing those disorders into three different diagnostic categories
based on the observable behavior patterns they involve. This
approach is consistent with the DSM's goal of being descriptive and
atheoretical.
DSM-II DSM-III
---------> ANXIETY DISORDERS
|
THE NEUROSES -------------> SOMATOFORM DISORDERS
|
---------> DISSOCIATIVE DISORDERS
F. A final note: Although dropped from the DSM-III, the term
"neurosis" is still used. Psychodynamic (Freudian) theorists and
practitioners find it a central concept in the study of
psychopathology (eg: Murphy, 1983; Noy, 1982). Psychodynamic
theorists, however, are not the only ones to believe in the concept
of neurosis - there are many others who continue to us the term
(eg: Wolpe, 1952, 1982). In particular, however, the term is still
widely used by most mental health professionals as simply a generic
descriptive label - to make general distinctions between milder
disorders and the more seriously debilitating "psychotic"
disorders.
III. Conclusion
In this lecture we have looked at the distinction between normal
and abnormal anxiety, and the relation of anxiety to the more historical
term "neurosis". Next lecture we will examine the various types of
anxiety disorders, as described in the DSM-III-R.