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
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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)