PSYC 304 Psychopathology Anxiety Disorders

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PSYC 304 Psychopathology Anxiety Disorders

• Graham Lindegger
• Room 36A
• School of Psychology
• [phone]
• Lindegger_at_ukzn.ac.za

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1. Introduction and Definition

• central phenomenon
• typical ego-dystonic condition
• aims in looking at anxiety
• Demonstrate problem of separating normality from
  pathology
• Problems in valid and reliable definition
• Problem of classification
• Demonstrate theoretical controversies

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1. Introduction and definition contd
Hypothetical scenario

• Imagine a hypothetical scenario
• A person presents with anxiety
• May mean very different phenomena
• Undermines validity reliability
• Different definitions focus on different aspects
  (cognitive, physiological, behavioural)

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1. Introduction and definition contd multiple
meanings of anxiety

• "Anxiety can be regarded as an
  intrapsychic phenomenon, as a behavioural
  response, as an intervening variable
  modifying behavioural styles, as a
  central concomitant to specific physiological
  patterns etc, depending on one's viewpoint"
  (Spielberger).

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1. Introduction and definition sample of
definitions

• apprehension cued off by any threat to some
  value which an individual holds as essential to
  their existence (Rollo May, 1960).
• "a hypersensitive alarm system....sensitive to
  any stimuli that might be taken as indicating
  imminent disaster or harm" (Beck, 1975)

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Introduction definition contdA working
definition

• My definition
• state of apprehension, reflected in cognitive
  preoccupations with threat, and frequently
  accompanied by physiological arousal and
  disorganized behaviour or the personality-based
  predisposition to this state of apprehension

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1. Introduction definition contdCommon
denominators

• Triad of anxiety
• Cognitive state of preoccupation with impending
  threat
• Physiological ANS arousal
• Behavioural avoidance or disorganization
• Different elements more important in different
  types of anxiety

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2. Problems in Classification 2.1. Introduction

• Lack of reliable criteria to define
• Desjairlais complicated by cultural
  considerations
• Great inconsistency in use
• experience or emotion
• personality trait
• clinical symptom or syndrome
• compare hypothetical groups

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2.2. Anxiety as emotion

• Fundamental and universal emotion
• Psycho-physiological response mediating
  adjustment to environment
• Adaptative or survival oriented
• Triggered by apparent threat to survival
• Complex threats to human existence
• So when is this a disorder?

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2.3. Anxiety as personality trait

• An enduring disposition to respond to situations
  of threat.
• Anxiousness.
• Lay notion of worrier
• Spielberger distinction
• State anxiety
• Trait anxiety

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2.3. Anxiety as personality trait contd

• STATE ANXIETY refers to the "subjective feelings
  of tension and apprehension, and the heightened
  activity of the ANS that are experienced in
  situations perceived as threatening". (Anxiety
  as emotion)
• Primarily cognitive and physiological.

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2.3. Anxiety as personality trait contd

• TRAIT ANXIETY the personality trait of anxiety,
  refers to "the relatively stable individual
  differences in anxiety proneness that are
  manifested in behaviour, and in the frequency
  with which an individual experiences anxiety
  (state elevations) over time".
• Primarily cognitive and behavioural.

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2.4. Normal vs. pathological anxiety.

• Normality debate How do we separate normal from
  clinical anxiety requiring treatment?
• How does the normality debate get applied to
  anxiety and its disorders?
• Link with original hypothetical example

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2.4. Normal vs. pathological anxiety.(Malcolm
Laders classification)
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2.4. Normal vs. pathological anxiety.

• How do we make the distinction?
• Wakefield dysfunction harm
• But anxiety as state (or trait) is adaptive and
  functional.
• Anxiety is clinical when
• fails to perform as adaptive function
  dysfunctional
• causes harm (DSM impairment or distress)

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2.4. Normal vs. pathological anxietyDSMs
approach

• DSM quantitative and qualitative criteria
• Quantitative so extreme that disrupts
  functioning (dysfunctional), causing harm
• Specifies regarding symptoms number, length of
  time experienced, frequency
• Example panic attacks and panic disorder -
  disturbed emotion of anxiety

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2.4. Normal vs. pathological anxietyDSMs
approach

• Qualitative criteria
• Not only about severity
• Also about forms of anxiety not triggered by
  apparently threatening stimuli
• Therefore not adaptive or functional
• Example Obsessive-compulsive disorder
• What if culturally normative?

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3. CLINICAL ANXIETY3.1. Anxiety as a symptom

• Anxiety as symptom vs syndrome
• Signs (objective) and symptoms (subjective)
• Symptom is a manifestation of underlying disorder
  
• Ego-dystonic disorders
• Examples depression, organic disorders

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3.2. Anxiety as clinical syndrome

• Meaning of syndrome
• Pattern of symptoms in which a dysfunctional and
  harmful form of the emotion of anxiety is
  dominant feature
• Combination of symptoms cognitive, physiological
  and/or behavioural

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3.2. Anxiety as clinical syndrome contdDSM-IV
classification

• predominant, manifest, ego-dystonic disturbance
• - panic disorder
• - generalized anxiety disorder
• - social phobia
• - post-traumatic stress disorder
• (Desjarlais sees as problematic)
• underlying mechanism
• - obsessive compulsive disorder

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3.3. Anxiety as clinical syndrome contdSocial
Phobia

• a) Description of social phobia.
• the most prevalent psychological disorder
• exact presentation varies by culture
• but is a socially and culturally common
  phenomenon

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3.3. Anxiety as clinical syndrome contdSocial
Phobia

• DSM criteria
• Marked fear of social or performance situations
• Exposed to unfamiliar people or scrutiny
• Fear will act in embarrassing or humiliating way
• Exposure to these situations evokes emotion of
  anxiety or panic attacks
• Person realizes fear is excessive
• Feared situations are avoided

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3.3. Anxiety as clinical syndrome contdSocial
Phobia contd

• b) Human emotion vs. disorder
• can be seen as an adaptive reaction to fear of
  social cues of threat - especially seen in angry
  or threatening faces or voices - humans are
  hardwired
• so when is it a disorder rather than common
  emotion?

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3.3. Anxiety as clinical syndrome contdSocial
Phobia contd

• applying Wakefields argument for abnormality
• when occurs without any obvious threat e.g. being
  watched eating - dysfunctional and maladaptive
  doesnt enhance survival (person knows that)
• and creates harm e.g. inability to eat, urinate
  or ride on trains

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3.3. Anxiety as clinical syndrome contdSocial
Phobia contd

• c) What are the pathways to social phobia?
• biological vulnerability
• - to arousal
• - or to be socially inhibited
• learned as a result of particular experience e.g.
  public humiliation (conditioning)

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3.3. Anxiety as clinical syndrome contdSocial
Phobia contd

• B D distinguish true alarm and false alarm
• true alarm there is a threat to the person
  trigger
• - but how generalized into disorder?
  (dysfunction)
• - hyperarousal (biological vulnerability)
• - classical conditioning to other stimuli
• - excess cognitive sensitivity to social threat
  cognitive vulnerability

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3.3. Anxiety as clinical syndrome contdSocial
Phobia contd

• false alarm
• misinterpretation of social cues as threatening
• primarily as a function of overdeveloped
  cognitive schemas around criticism or
  disapproval cognitive vulnerability
• lack of demonstrable external threat

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4. Dimensions and Aetiology of Anxiety

• what makes people vulnerable to anxiety?
• what is the causation of each anxiety disorder?
• why does one develop specific disorders?
• dimensions cognitive, physiological, behavioural
  in answer to each
• Barlow integrative perspective vs
  controversies

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4. Panic Disorder Causation

• What causes panic disorder? Controversy
• Biological theories
• - neurotransmitter dysfunction accounts for
  spontaneous panic attacks
• - especially in locus cereleus
• - respiratory dysfunction hyperventilation
• - are these cause or effect?

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4. Panic Disorder Causation

• Cognitive theories
• - Clark and Salkovskis cognitive
  misinterpretation of physiological cues as
  catastrophic and life threatening
• - Again, cause or effect?
• Cyclical interaction and feedback
• Behavioural avoidance short-term relief,
  long-term exacerbation

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• 4.1. Cognitive dimension.
• Beck "hypersensitive alarm systems...sensitive
  to any stimuli that might be taken as indicating
  imminent disaster or harm"
• Vulnerability mode
• Dysfunction
• hypersensitive to danger cues
• hyposensitive to safety cues
• Questions arising
• are these necessary/sufficient?
• Are these primary/secondary?

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• 4.2. Physiological dimension.
• Apparent in anxiety disorders
• - manifest form
• - blocking avoidance
• - secondary symptoms
• Mechanisms
• - diagram of NS, especially ANS (Bootzin OHT
  6 12)
• Link with SxS panic disorder
• - mediated through CNS - OHP (Bootzin OHT)

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• range of specific theories
• - mainly neurotransmitters (see Bootzin)
• - example panic disorder
• gt facilitated by adrenalin
• gt hyperdynamic beta adrenergic model
• gt dysfunction of locus ceruleus (OHT)
• gt benzodiazepines
• - genetic transmission of
• questions
• - primary or secondary
• - mechanisms, causes, vulnerabilities

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• 4.3. Behavioural dimension.
• manifested in two considerations
• - distinct behavioural features most commonly
  in form of avoidance
• gt OCD panic-disorder c agoraphobia
• realization of importance of B'al/learning
  principles
• - classical conditioning of ANS responses
• - recognized as esp NB in maintenance
• e.g. avoidance in PD

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• 4.4. Integration of dimensions and theories.
• OHT vicious cycle of panic disorder (Barlow T
  28 OHT)
• OHT integrated model of panic disorder (Barlow T
  22 OHT)

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Lader's Classification of Types of Anxiety