5.6 PUTTING IT...together

Diathesis-Stress in Action

Clinicians and researchers have developed many ideas about generalized anxiety disorder, phobias, panic disorder, and obsessive-compulsive disorder. At times, however, the sheer quantity of concepts and findings makes it difficult to grasp what is really known about the disorders.

Overall, it is fair to say that clinicians currently know more about the causes of phobias, panic disorder, and obsessive-compulsive disorder than about generalized anxiety disorder and social anxiety disorder. It is worth noting that the insights about panic disorder and obsessive-compulsive disorder—once among the field’s most puzzling patterns—did not emerge until clinical theorists took a look at the disorders from more than one perspective and integrated those views. Today’s cognitive explanation of panic disorder, for example, builds squarely on the biological theorists’ idea that the disorder begins with abnormal brain activity and unusual physical sensations. Similarly, the cognitive explanation of obsessive-compulsive disorder takes its lead from the biological position that some people are predisposed to having more unwanted and intrusive thoughts than others do.

It may be that a fuller understanding of generalized anxiety disorder and social anxiety disorder awaits a similar integration of the various models. In fact, such integrations have already begun. Recall, for example, that one of the new-wave cognitive explanations for generalized anxiety disorder links the cognitive process of worrying to heightened bodily arousal in people with the disorder.

CLINICAL CHOICES

Now that you’ve read about anxiety, obsessive-compulsive and related disorders, try the interactive case study for this chapter. See if you are able to identify Priya’s symptoms and suggest a diagnosis based on her symptoms. What kind of treatment would be most effective for Priya? Go to LaunchPad to access Clinical Choices.

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PsychWatch

Beauty Is in the Eye of the Beholder

People almost everywhere want to be attractive, and they tend to worry about how they appear in the eyes of others. At the same time, these concerns take different forms in different cultures. Whereas people in Western society worry in particular about their body size and facial features, women of the Padaung tribe in Myanmar focus on the length of their neck and wear heavy stacks of brass rings to try to extend it. Many of them seek desperately to achieve what their culture has taught them is the perfect neck size. Said one, “It is most beautiful when the neck is really long…. I will never take off my rings…. I’ll be buried in them” (Mydans, 1996).

Similarly, for centuries women of China, in response to the preferences of men in that country, worried greatly about the size and appearance of their feet and practiced foot binding to stop the growth of these extremities (Wang Ping, 2000). In this procedure, which began in the year 900 and was widely practiced until it was outlawed in 1911, young girls were instructed to wrap a long bandage tightly around their feet each day, forcing the four toes under the sole of the foot. The procedure, which was carried out for about 2 years, caused the feet to become narrower and smaller. Typically the practice led to serious medical problems and poor mobility, but it did produce the small feet that were considered attractive.

Western society also falls victim to such cultural influences. Recent decades have witnessed staggering increases in such procedures as rhinoplasty (reshaping of the nose), breast augmentation, and body piercing—all reminders that cultural values greatly influence each person’s ideas and concerns about beauty, and in some cases may set the stage for body dysmorphic disorder.

Similarly, a growing number of theorists are adopting a diathesis-stress view of generalized anxiety disorder. They believe that certain individuals have a biological vulnerability toward developing the disorder—a vulnerability that is eventually brought to the surface by psychological and sociocultural factors. Indeed, genetic investigators have discovered that certain genes may determine whether a person reacts to life’s stressors calmly or in a tense manner, and developmental researchers have found that even during the earliest stages of life some infants become particularly aroused when stimulated (Burijon, 2007; Kalin, 1993). Perhaps these easily aroused infants have inherited defects in GABA functioning or other biological limitations that predispose them to generalized anxiety disorder. If, over the course of their lives, they also face intense societal pressures, learn to interpret the world as a dangerous place, or come to regard worrying as a useful tool, they may be candidates for developing generalized anxiety disorder.

In the treatment realm, integration of the models is already on display for each of the anxiety disorders and for obsessive-compulsive disorder. Therapists have discovered, for example, that treatment is at least sometimes more effective when medications are combined with cognitive techniques to treat panic disorder and when medications are combined with cognitive-behavioral techniques to treat obsessive-compulsive disorder. Similarly, cognitive techniques are often combined with relaxation training or biofeedback in the treatment of generalized anxiety disorder—a treatment package known as a stress-management program. For the millions of people who suffer from these various anxiety disorders, such treatment combinations are a welcome development.

stress-management program An approach to treating generalized and other anxiety disorders that teaches clients techniques for reducing and controlling stress.

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BETWEEN THE LINES

Playlist Anxiety

Many people in today’s digital music world share music playlists, so it may not be surprising that researchers have observed that a growing number of people are experiencing “playlist anxiety”—intense concern about the image they are projecting through the music they make available to others. The problem is particularly common among college students and office workers. A respondent in one study disclosed, “I just went through my playlist and said, ‘I wonder what kind of image this is giving of me.’ I went through it to see if there was stuff that I would not like people to know I had.”

(Voida et al., 2005; ZDNet, 2005)

BETWEEN THE LINES

In Their Words

“When all by myself, I can think of all kinds of clever remarks, quick comebacks to what no one said, and flashes of witty sociability with nobody. But all of this vanishes when I face someone in the flesh….”

Fernando Pessoa

BETWEEN THE LINES

Top-Grossing Fear Movies of the Twenty-First Century

Twilight series

Paranormal Activity series

Scream series

The Grudge series

Van Helsing

The Mummy series

Jurassic Park series

Signs

King Kong

The Ring

SUMMING UP

  • GENERALIZED ANXIETY DISORDER People with generalized anxiety disorder experience excessive anxiety and worry about a wide range of events and activities. The various explanations and treatments for this anxiety disorder have received only limited research support, although recent cognitive and biological approaches seem to be promising.

    According to the sociocultural view, societal dangers, economic stress, or related racial and cultural pressures may create a climate in which cases of generalized anxiety disorder are more likely to develop.

    In the original psychodynamic explanation, Freud said that generalized anxiety disorder may develop when anxiety is excessive and defense mechanisms break down and function poorly. Psychodynamic therapists use free association, interpretation, and related psychodynamic techniques to help people overcome this problem.

    Carl Rogers, the leading humanistic theorist, believed that people with generalized anxiety disorder fail to receive unconditional positive regard from significant others during their childhood and so become overly critical of themselves. He treated such individuals with client-centered therapy.

    Cognitive theorists believe that generalized anxiety disorder is caused by maladaptive assumptions and beliefs that lead people to view most life situations as dangerous. Many cognitive theorists further believe that implicit beliefs about the power and value of worrying are particularly important in the development and maintenance of this disorder. Cognitive therapists help their clients to change such thinking and to find more effective ways of coping during stressful situations.

    Biological theorists hold that generalized anxiety disorder results from low activity of the neurotransmitter GABA. Common biological treatments are antianxiety drugs, particularly benzodiazepines, and serotonin-enhancing antidepressant drugs. Relaxation training and biofeedback are also applied in many cases. pp. 130–143

  • PHOBIAS A phobia is a severe, persistent, and unreasonable fear of a particular object, activity, or situation. There are two main categories of phobias: specific phobias (persistent fears of specific objects or situations) and agoraphobia (fear of being in public places or situations in which escape might be difficult if one should experience panic or become incapacitated). Behaviorists believe that phobias are often learned from the environment through classical conditioning or through modeling, and then are maintained by avoidance behaviors.

    Specific phobias have been treated most successfully with behavioral exposure techniques by which people are led to confront the objects they fear. The exposure may be gradual and relaxed (desensitization), intense (flooding), or vicarious (modeling). Agoraphobia is also treated effectively by exposure therapy. However, for people with both agoraphobia and panic disorder, exposure therapy alone is not as effective. pp. 143–152

  • SOCIAL ANXIETY DISORDER People with social anxiety disorder experience severe and persistent anxiety about social or performance situations in which they may be scrutinized by others or be embarrassed. Cognitive theorists believe that the disorder is particularly likely to develop among people who hold and act on certain dysfunctional social beliefs and expectations.

    Therapists who treat social anxiety disorder typically distinguish two components of this disorder: social fears and poor social skills. They try to reduce social fears by drug therapy, exposure techniques, group therapy, various cognitive approaches, or a combination of these interventions. They may try to improve social skills by social skills training. pp. 152–157

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  • PANIC DISORDER Panic attacks are periodic, discrete bouts of panic that occur suddenly. Sufferers of panic disorder experience panic attacks repeatedly and unexpectedly and without apparent reason. Panic disorder may be accompanied by agoraphobia in some cases, leading to two diagnoses.

    Some biological theorists believe that abnormal norepinephrine activity in the brain’s locus coeruleus may be central to panic disorder. Others believe that related neurotransmitters or a panic brain circuit may also play key roles. Biological therapists use certain antidepressant drugs or powerful benzodiazepines to treat people with this disorder.

    Cognitive theorists suggest that panic-prone people become preoccupied with some of their bodily sensations, misinterpret them as signs of medical catastrophe, panic, and in some cases develop panic disorder. Such persons have a high degree of anxiety sensitivity and also experience greater anxiety during biological challenge tests. Cognitive therapists teach patients to interpret their physical sensations more accurately and to cope better with anxiety. pp. 157–161

  • OBSESSIVE-COMPULSIVE DISORDER People with obsessive-compulsive disorder are beset by obsessions, perform compulsions, or both. Compulsions are often a response to a person’s obsessive thoughts.

    According to the psychodynamic view, obsessive-compulsive disorder arises out of a battle between id impulses, which appear as obsessive thoughts, and ego defense mechanisms, which take the form of counter-thoughts or compulsive actions. Behaviorists believe that compulsive behaviors develop through chance associations. The leading behavioral treatment combines prolonged exposure with response prevention. Cognitive theorists believe that obsessive-compulsive disorder grows from a normal human tendency to have unwanted and unpleasant thoughts. The efforts of some people to understand, eliminate, or avoid such thoughts actually lead to obsessions and compulsions. Cognitive therapy for this disorder includes psychoeducation and, at times, habituation training. While the behavioral and cognitive therapies are each helpful to clients with obsessive-compulsive disorder, research suggests that a combined cognitive-behavioral approach may be more effective than either therapy alone.

    Biological researchers have tied obsessive-compulsive disorder to low serotonin activity and abnormal functioning in the orbitofrontal cortex and in the caudate nuclei. Antidepressant drugs that raise serotonin activity are a useful form of treatment.

    In addition to obsessive-compulsive disorder, DSM-5 lists a group of obsessive-compulsive-related disorders, disorders in which obsessive-like concerns drive individuals to repeatedly and excessively perform specific patterns of behavior that greatly disrupt their lives. This group consists of hoarding disorder, trichotillomania, excoriation (skin-picking) disorder, and body dysmorphic disorder. pp. 161–172

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