Chapter_5 - Chapter 5 Trauma Anxiety Obsessive-Compulsive and Related Disorders CHAPTER OUTLINE Fear and Anxiety Along the Continuum Generalized Anxiety

Chapter_5 - Chapter 5 Trauma Anxiety Obsessive-Compulsive...

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Unformatted text preview: Chapter 5 Trauma, Anxiety, Obsessive-Compulsive, and Related Disorders CHAPTER OUTLINE Fear and Anxiety Along the Continuum Generalized Anxiety Disorder Extraordinary People: David Beckham, Perfection On and Off the Field Separation Anxiety Disorder Posttraumatic Stress Disorder and Acute Stress Disorder Specific Phobias and Agoraphobia 106 Obsessive-Compulsive Disorder Anxiety Disorders in Older Adults Chapter Integration Shades of Gray Discussion Shades of Gray Think Critically Social Anxiety Disorder Chapter Summary Panic Disorder Key Terms Chapter 5 Trauma, Anxiety, Obsessive-Compulsive, and Related Disorders CHAPTER OUTLINE Fear and Anxiety Along the Continuum Generalized Anxiety Disorder Extraordinary People: David Beckham, Perfection On and Off the Field Separation Anxiety Disorder Posttraumatic Stress Disorder and Acute Stress Disorder Specific Phobias and Agoraphobia 106 Obsessive-Compulsive Disorder Anxiety Disorders in Older Adults Chapter Integration Shades of Gray Discussion Shades of Gray Think Critically Social Anxiety Disorder Chapter Summary Panic Disorder Key Terms Fear and Anxiety Along the Continuum • Fear is in response to objectively threatening events (fearing you will fail a class after failing the midterm) • Fear is of appropriate severity given the threat (being concerned because you need this class to graduate) • Fear subsides when threat has passed (relaxing when you learn there was a grading error and you actually did well) • Fear leads to adaptive behaviors to confront or avoid threat (asking your instructor if you can improve your grade with extra work) Potentially meets diagnostic criteria for an anxiety disorder: • Fear is moderately unrealistic (fearing a car accident if you drive on Friday the 13th) • Fear is definitely more than is warranted given the severity of the threat (being very nervous when forced to drive on Friday the 13th) • Fear persists for quite a while after the threat has passed (worrying about the next Friday the 13th) • Fear leads to behaviors that are potentially dangerous or impairing (skipping class to avoid driving on Friday the 13th) Functional Dysfunctional • Fear may be somewhat unrealistic (fear of appearing foolish when giving a presentation in class) • Fear may be somewhat more than is warranted given the severity of the threat (being unable to sleep the night before a presentation) • Fear persists after the threat has passed (after you give the presentation, analyzing it and worrying about what people thought) • Fear leads to behaviors that may be somewhat inappropriate (taking a tranquilizer before the presentation to relax) Likely meets diagnostic criteria for an anxiety disorder: • Fears are completely unrealistic (fearing that every ache or pain is a sign of terminal illness) • Fears are excessive given the objective threat (thinking one is dying when one feels pain) • Fears persist long after the threat has passed, and chronic anticipatory anxiety exists (believing one has a terminal illness despite physician reassurance) • Fear leads to dangerous behavior or impairment (seeking out surgery to cure the terminal illness your physician says you do not have) Think of a time you felt fearful or anxious, perhaps on the first threat, and in how they behave in response to their fears. Fear day of college. Chances are you felt a bit tense or jittery, you can become maladaptive when it arises in situations that most worried about what you might encounter, and there were times people would not find threatening. For example, some people you wished you could just retreat back to familiar surroundings become incapacitated with fear if they have to leave their home. and people. This is a typical response to a new and potentially Fear is maladaptive if it is greatly out of proportion to the threat, threatening situation—here the threat is that you might not like for example, when people become panicked at the possibility of the people at your college, you might not feel you fit in, or you encountering a snake on a nature walk. Fear becomes anxiety might not do well in your classes. Fear is adaptive when it is when it persists long after the threat has subsided. For exam- realistic (i.e., when there is a real threat in the environment), ple, some people who have experienced traumatic events con- when it is in proportion to the threat, if it subsides when the tinue to be extremely fearful long after the trauma has ended. threat has passed, and if it leads to appropriate behaviors to And fear can become an anxiety disorder when a person en- overcome the threat (e.g., making an effort to meet new people gages in maladaptive behaviors in response to a threat; for ex- and become familiar with your new surroundings). ample, a person with agoraphobia may become housebound People vary greatly, however, in the situations they find due to fear of venturing out. threatening, in how fearful they become when they encounter a Fear and Anxiety Along the Continuum 107 108 Chapter 5 Trauma, Anxiety, Obsessive-Compulsive, and Related Disorders Extraordinary People David Beckham, Perfection On and Off the Field Soccer star David Beckham’s extraordinary ability to curve shots on corner kicks was immortalized in the movie Bend It Like Beckham. Beckham’s perfectionism on the field is paralleled by his perfectionism about order and symmetry: “I’ve got this obsessive compulsive disorder where I have to have everything in a straight line or everything has to be in pairs” (quoted in Dolan, 2006). Beckham spends hours ordering the furniture in his house in a particular way or lining up the clothes in his closet by color. His wife, Victoria (the former Posh Spice), says, “If you open our fridge, it’s all When we face any type of threat or stressor, our body mobilizes to handle it. Over evolutionary history, humans have developed a characteristic fight-or-flight response, a set of physical and psychological responses that help us fight a threat or flee from it. The physiological changes of the fight-or-flight response result from the activation of two systems controlled by the hypothalamus, as seen in Figure 5.1: the autonomic nervous system (in particular, the sympathetic division of this system) and the adrenal-cortical system (a hormone-releasing system; see Chapter 2). The hypothalamus first activates the sympathetic division of the autonomic nervous system. This system acts directly on the smooth muscles and internal organs to produce key bodily changes: The liver releases extra sugar (glucose) to fuel the muscles, and the body’s metabolism increases in preparation for expending energy on physical action. Heart rate, blood pressure, and breathing rate increase, and the muscles tense. Less essential activities, such as digestion, are curtailed. Saliva and mucus dry up, increasing the size of the air passages to the lungs. The body secretes endorphins, which are natural painkillers, and the surface blood vessels constrict to reduce bleeding in case of injury. The spleen releases more red blood cells to help carry oxygen. coordinated down either side. We’ve got three fridges—food in one, salad in another and drinks in the third. In the drinks one, everything is symmetrical. If there’s three cans he’ll throw away one because it has to be an even number” (quoted in Frith, 2006). Beckham has traveled around the world, playing for top teams including Real Madrid, Manchester United, Los Angeles Galaxy, and AC Milan. Each time he enters a new hotel room, he has to arrange everything in order: “I’ll go into a hotel room. Before I can relax I have to move all the leaflets and all the books and put them in a drawer. Everything has to be perfect” (quoted in Frith, 2006). His teammates on Manchester United knew of his obsessions and compulsions and would deliberately rearrange his clothes or move the furniture around in his hotel room to infuriate him. The hypothalamus activates the adrenal-cortical system by releasing corticotropin-release factor (CRF), which signals the pituitary gland to secrete adrenocorticotropic hormone (ACTH), the body’s major stress hormone. ACTH stimulates the outer layer of the adrenal glands (the adrenal cortex), releasing a group of hormones, the major one being cortisol. The amount of cortisol in blood or urine samples is often used as a measure of stress. ACTH also signals the adrenal glands to release about 30 other hormones, each of which plays a role in the body’s adjustment to emergency situations. Eventually, when the threatening stimulus has passed, the hippocampus, a part of the brain that helps regulate emotions, turns off this physiological cascade. The fight-or-flight system thus has its own feedback loop that normally regulates the level of physiological arousal we experience in response to a stressor. In many of the disorders we discuss in this chapter, the normal response becomes abnormal, and the fight-or-flight system becomes dysregulated. In addition to these physiological responses to a threat, characteristic emotional, cognitive, and behavioral responses occur (Table 5.1). Emotionally, we experience terror and dread, and we often are irritable or restless. Cognitively, we are on the lookout for danger. Behaviorally, we seek to confront the Extraordinary People The Fight-or-Flight Response. The body’s fight-or-flight response is initiated by the part of the brain known as the hypothalamus. The hypothalamus stimulates the sympathetic division of the autonomic nervous system, which acts on smooth muscles and internal organs to produce the bodily changes shown in the figure. The hypothalamus also releases corticotrophin-release factor (CRF), which triggers the pituitary gland to release adrenocorticotropic hormone (ACTH). In turn, ACTH stimulates the adrenal glands to release about 30 other hormones. The hormones act on organs and muscles to prepare the body to fight or flee. FIGURE 5.1 Stressor Amygdala Sympathetic nervous system Hypothalamus Adrenal-cortical system Releases CRF Dilates pupils Pituitary gland Weakly stimulates salivary glands Releases ACTH Relaxes bronchi in lungs Accelerates and strengthens heartbeat Adrenal glands Stimulates release of glucose by the liver Stimulates secretions by the adrenal glands Inhibits pancreatic activity Adrenal cortex Releases corticosteroids Adrenal medulla Releases epinephrine and norepinephrine Inhibits stomach activity Relaxes bladder threat or escape from it. In a realistic fear response, these emotional, cognitive, and behavioral responses subside when the threat subsides. In anxiety and related disorders, these responses may persist in the absence of any objective threat. Anxiety is a part of many psychological disorders. Most people with serious depression report Changes in internal organs and muscles bouts of anxiety (Watson, 2009). People with schizophrenia often feel anxious when they believe they are slipping into a new episode of psychosis. Many people who abuse alcohol and other drugs do so to dampen anxious symptoms. In addition, people with one anxiety disorder are likely to have another (Craske & Waters, 2005). 109 110 Chapter 5 Trauma, Anxiety, Obsessive-Compulsive, and Related Disorders TABLE 5.1 Responses to Threat These characteristic responses to threat can also be symptoms of an anxiety disorder. Somatic Emotional Cognitive Behavioral Tense muscles Sense of dread Anticipation of harm Escape Increased heart rate Terror Exaggeration of danger Avoidance Changes in respiration Restlessness Problems in concentrating Aggression Dilated pupils Irritability Hypervigilance Freezing Increased perspiration Worried, ruminative thinking Adrenaline secretion Fear of losing control Inhibited stomach acid Fear of dying Decreased salivation Sense of unreality Bladder relaxation PROFILES This chapter focuses on disorders in which anxiety is a key feature. We begin with two disorders in which an initial, potentially adaptive fear response develops into a maladaptive anxiety disorder. POSTTRAUMATIC STRESS DISORDER AND ACUTE STRESS DISORDER Two psychological disorders, posttraumatic stress disorder (PTSD) and acute stress disorder, are by definition the consequences of experiencing extreme stressors, referred to as traumas. In everyday conversations, people refer to a wide range of events as traumas, from a romantic breakup (“He was traumatized by her leaving him.”) to horrific tragedies (e.g., being the victim of a mass shooting, losing one’s family in a tornado). The DSM-5 constrains traumas to events in which individuals are exposed to actual or threatened death, serious injury, or sexual violation (Table 5.2). In addition, in the diagnostic criteria for PTSD and acute stress disorder, the DSM-5 requires that individuals either directly experience or witness the traumatic event, learn that the event happened to someone they are close to, or experience repeated or extreme exposure to the details of a traumatic event (as do first responders at a tragedy). Blair, a survivor of the terrorist attack on the World Trade Center on September 11, 2001, describes many core symptoms of both disorders. I just j t can’t ’t llett go of it. I was working at my desk on the 10th floor of the World Trade Center when the first plane hit. We heard it but couldn’t imagine what it was. Pretty soon someone started yelling, “Get out––it’s a bomb!” and we all ran for the stairs. The dust and smoke were pouring down the staircase as we made our way down. It seemed to take an eternity to get to the ground. When I got outside, I looked up and saw that the top of the tower was on fire. I just froze; I couldn’t move. Then the second plane hit. Someone grabbed my arm and we started running. Concrete and glass began to fly everywhere. People were falling down, stumbling. Everyone was covered in dust. When I got far enough away, I just stood and stared as the towers fell. I couldn’t believe what I was seeing. Other people were crying and screaming, but I just stared. I couldn’t believe it. Now, I don’t sleep very well. I try, but just as I’m falling asleep, the images come flooding into my mind. I see the towers falling. I see people with cuts on their faces. I see the ones who didn’t make it out, crushed and dead. I smell the dust and smoke. Sometimes, I cry to the point that my pillow is soaked. Sometimes, I just stare at the ceiling, as I stared at the towers as they fell. During the day, I go to work, but often it’s as if my head is in another place. Someone will say something to me, and I won’t hear them. I often feel as if I’m floating around, not touching or really seeing anything around me. But if I do hear a siren, which you do a lot in the city, I jump out of my skin. 111 Posttraumatic Stress Disorder and Acute Stress Disorder TABLE 5.2 DSM-5 Criteria for Posttraumatic Stress Disorder A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”). 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). (continued) 112 Chapter 5 TABLE 5.2 Trauma, Anxiety, Obsessive-Compulsive, and Related Disorders DSM-5 Criteria for Posttraumatic Stress Disorder (continued ) F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Specify whether: With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following: 1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). 2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note:...
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