Anxiety Disorders CHAPTER

6 Anxiety Disorders CHAPTER CHAPTER OUTLINE OVERVIEW OF ANXIETY DISORDERS GENERALIZED ANXIETY DISORDER ETHNIC DIFFERENCES IN ANXIETY 171–172 198–200 DISORDERS 204–205 PANIC DISORDER 172–179 Theoretical Perspectives SUMMING UP 206–207 Treatment Approaches Theoretical Perspectives Treatment Approaches ACUTE STRESS DISORDER AND POSTTRAUMATIC STRESS DISORDER PHOBIC DISORDERS 179–193 200–204 Types of Phobic Disorders Features of Traumatic Stress Disorders Theoretical Perspectives Theoretical Perspectives Treatment Approaches Treatment Approaches OBSESSIVE–COMPULSIVE DISORDER 194–198 Theoretical Perspectives Treatment Approaches TRUTH or FICTION T❑ F❑ People who experience a panic “I Felt Like I Was Going to Die Right attack often think they are having a heart attack. (p. 173) Then and There” T❑ F❑ The same drugs used to treat schizo- I never experienced anything like this before. It happened while I was sitting in the phrenia are also used to control panic car at a traffic light. I felt my heart beating furiously fast, like it was just going to attacks. (p. 177) explode. It just happened, for no reason. I started breathing really fast but couldn’t T❑ F❑ Some people are so fearful of leaving get enough air. It was like I was suffocating and the car was closing in around me. their homes that they are unable to venture I felt like I was going to die right then and there. I was trembling and sweating outside even to mail a letter. (p. 183) heavily. I thought I was having a heart attack. I felt this incredible urge to escape, ❑ ❑ to just get out of the car and get away. T F We may be genetically predisposed I somehow managed to pull the car over to the side of the road but just sat there to acquire fears of objects that posed a waiting for the feelings to pass. I told myself if I was going to die, then I was going danger to ancestral humans. (p. 187) to die. I didn’t know whether I’d survive long enough to get help. Somehow—I can’t T❑ F❑ Therapists have used virtual reality say how—it just passed and I sat there a long time, wondering what had just hap- to help people overcome phobias. (p. 192) pened to me. Just as suddenly as the panic overcame me, it was gone. My breathing T❑ F❑ Obsessional thinking helps relieve slowed down and my heart stopped thumping in my chest. I was alive. I was not going anxiety. (p. 195) to die. Not until the next time, anyway. T❑ F❑ Exposure to combat is the most —“The Case of Michael,” from the Author’s Files common trauma linked to posttraumatic stress disorder (PTSD). (p. 203) WHAT IS IT LIKE TO HAVE A PANIC ATTACK? PEOPLE TEND TO USE THE WORD PANIC LOOSELY, AS when they say,“I panicked when I couldn’t find my keys.”Clients in therapy often speak of having panic attacks, although what they describe often falls in a milder spectrum of anxiety reactions. During a true panic attack, like the one Michael describes, the level of anxiety rises to the point of sheer terror. Unless you have suffered one, it is difficult to appreciate just how intense panic attacks can be. People who suffer them describe them as the most frightening experiences of their lives. Panic attacks are a feature of a severe form of anxiety disorder called panic disorder. There is much to be anxious about—our health, social relationships, examinations, careers, international relations, and the condition of the environment are but a few sources of possible concern. It is normal, even adaptive, to be somewhat anxious about these aspects of life. Anxiety is a generalized state of apprehension or foreboding. anxiety An emotional state characterized by Anxiety is useful because it prompts us to seek regular medical checkups or motivates physiological arousal, unpleasant feelings us to study for tests. Anxiety is therefore a normal response to threats, but anxiety of tension, and a sense of apprehension becomes abnormal when its level is out of proportion to a threat, or when it seems to or foreboding. come out of the blue—that is, when it is not in response to environmental changes. In Michael’s case, panic attacks began spontaneously, without any warning or trigger. This kind of maladaptive anxiety reaction, which can cause significant emotional dis- tress or impair the person’s ability to function, is labeled an anxiety disorder. Anxiety, anxiety disorder A class of psychological the common thread that connects the various types of anxiety disorders, can be expe- disorders characterized by excessive or rienced in different ways, from the intense fear associated with a panic attack to the maladaptive anxiety reactions. generalized sense of foreboding or worry we find in generalized anxiety disorder. OVERVIEW OF ANXIETY DISORDERS Anxiety is characterized by a wide range of symptoms that cut across physical, behavioral, and cognitive domains: a) Physical features may include jumpiness, jitteriness, trembling or shaking, tightness in the pit of the stomach or chest, heavy perspiration, sweaty palms, light-headedness or faintness, dryness in the mouth or throat, shortness of breath, heart pounding or racing, cold fingers or limbs, and upset stomach or nausea, among other physical symptoms. 171 172 Chapter 6 b) Behavioral features may include avoidance behavior, clinging or dependent behavior, and agitated behavior. c) Cognitive features may include worry, a nagging sense of dread or apprehension about the future, preoccupation or keen awareness of bodily sensations, fear of losing control, thinking the same disturbing thoughts over and over, jumbled or con- fused thoughts, difficulty concentrating or focusing one’s thoughts, and thinking that things are getting out of hand. Although people with anxiety disorders don’t necessarily experience all of these features, it is easy to see why anxiety is distressing. The DSM recognizes the following specific types of anxiety disorders we discuss in this chapter: panic disorder, phobic disorders, obsessive–compulsive disorder, generalized anxiety disorder, and acute stress disorder and posttraumatic stress disorder. Table 6.1 provides an overview of the anxiety disorders we discuss in this chapter. The anxiety disorders are not mutu- ally exclusive. People frequently meet diagnostic criteria for more than one of them. Moreover, many people with anxiety disorders also have other types of disorders, especially mood disorders. The anxiety disorders, along with dissociative disorders and somatoform disorders (see Chapter 7), were classified as neuroses throughout most of the 19th century. The term neurosis derives from roots meaning “an abnormal or diseased condition of the nervous system.” The Scottish physician William Cullen coined the term “neurosis” in the 18th century. As the derivation implies, it was assumed that neurosis had biologi- cal origins. It was seen as an affliction of the nervous system. At the beginning of the 20th century, Cullen’s organic assumptions were largely replaced by Sigmund Freud’s psychodynamic views. Freud maintained that neurotic behavior stems from the threatened emergence of unacceptable anxiety-evoking ideas into conscious awareness. According to Freud, disorders involving anxiety (as well as the dissociative and somatoform disorders discussed in Chapter 7) represent ways in which the ego attempts to defend itself against anxiety. Freud’s views on the origins of these problems united them under the general category of neuroses. Freud’s concepts panic disorder A type of anxiety disorder were so widely accepted in the early 1900s that they formed the basis for the classifica- characterized by repeated episodes of intense tion systems found in the first two editions of the Diagnostic and Statistical Manual of anxiety or panic. Mental Disorders (DSM). Since 1980, the DSM has not contained a category termed neuroses. The DSM today is based on similarities in observable behavior and distinctive features rather than on causal assumptions. Many clinicians continue to use the terms neurosis and neurotic in the manner in which Freud described them, however. Some clinicians use the term “neuroses” to group milder behavioral problems in which people maintain relatively good contact with reality. “Psychoses,” such as schizophrenia, are typified by loss of touch with reality and by the appearance of bizarre behavior, beliefs, and hallucinations. Anxiety is not limited to the diagnostic categories traditionally termed “neuroses,” moreover. People with adjustment problems, depression, and psychotic disorders may also encounter problems with anxiety. Let us now consider the major types of anxiety disorders in terms of their features or symptoms, causes, and ways of treating them. PANIC DISORDER Panic disorder is characterized by the occurrence of repeated, unexpected panic attacks. Panic attacks are intense anxiety reactions accompanied by physical symptoms such as a pounding heart; rapid respiration, shortness of breath, or difficulty breathing; heavy perspiration; and weakness or dizziness (Glass, 2000). There is a stronger bodily component to panic attacks than to other forms of anxiety. The attacks are accompanied by feelings of sheer terror and a sense of imminent danger or impending Panic. Panic attacks have stronger physical doom and by an urge to escape the situation. They are usually accompanied by components—especially cardiovascular thoughts of losing control, going crazy, or dying. symptoms—than other types of anxiety People who experience panic attacks tend to be keenly aware of changes in their reactions. heart rates and may think they are having a heart attack,

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