"We have
nothing to fear but fear itself"
President
Franklin Roosevelt,
Chapter 4
Anxiety Disorders
Dale L. Johnson
It makes sense to begin our survey
of psychiatric disorders with anxiety. Anxiety is part of nearly all of the other disorders as well as existing by
itself as a disorder. The girl with anorexia who feels she is putting on weight
will be anxious. The person with schizophrenia in a psychotic episode
experiences a particularly severe form of anxiety. Depression and anxiety go
together so often that some think the two comprise a single disorder. It is a
key part of disorders of sexual dysfunction.
When I began working as a clinical
psychologist in the Houston VA Hospital in the late 1950s, patients tended to
be given one of three diagnoses: anxiety, depression or schizophrenia. We used
the DSM-I at that time and diagnosis was difficult because the categories were
so vaguely defined. Now, with improved research on classification we have
several types of anxiety disorders, not just one.
In those early days neurosis was a
major category of mental disorder in the DSM-I and II, but the DSM-III deleted
it: "..neurosis is an undesirable diagnostic category because no data
support the assumption that all such patients show some common set of problems...symptoms."
Freud: "We are all neurotic." If so, how does using the label
"neurotic" help the clinician. Of course, Freud thought everyone
could use psychoanalysis, too. Just bring your money: $150 per day, four days a
week, for six or so years.
Neurosis covered a wide-range of
behaviors/symptoms as long as they fell in the non-psychotic realm. Neurosis
and psychosis were believed to be on a continuum. That does not seem to be the
case. A severe case of anxiety phobia does not show psychotic signs. In addition,
research was reoriented with the DSM-III: Instead of beginning with presumed
causes, the researchers began with the development of criteria for syndromes.
One consequence is that more than one kind of anxiety was included in the
classification system.
Anxiety: Sometimes defined
as "Uneasiness, apprehension, or fearfulness stemming from anticipated
danger, the source of which is undefinable." The existential view of anxiety is that there is a threat of
non-being of the self. That is, that the self will disappear. When you feel
anxious, ask what is happening? What is the source of the anxiety? Why does it
exist? A common situation for anxiety to occur is the school examination. One
is to take a test and becomes so anxious that it may be difficult to recall
information needed to pass the test. How can this be a "threat to
non-being?" The threat is that if one fails the test, one will not be the
person one wants to be.
Note that while anxiety is
unpleasant, it also has positive or adaptive features. It helps plan for the
future by defining what is out-of-bounds, what we should not get into. The Danish philosopher, Soren
Kierkegaard, once said, "Anxiety
is the best teacher."
Fear: Fear is the
immediate reaction to a perceived threat with fight or flight as typical
responses. It is an emergency reaction with a very rapid physiological
response.
Panic: This is the abrupt
experience of intense fear or discomfort accompanied by physical symptoms such
as heart palpitations.
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Website
Information about anxiety is
available from the National Institute of Mental Health at
www.nimh.nih,gov/anxiety.
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Theories of Anxiety
Psychoanalytic
The key idea is that phobias develop
as a defense against anxiety which is produced by repressed id impulses.
Anxiety is displaced from the id impulses to a fear object that is linked
symbolically. By avoiding the phobic object, one avoids dealing with repressed
conflicts; repressed childhood conflict.
One of Freud's famous case studies
is that of a boy known as "Little Hans." The child developed a fear
of horses. This was in Vienna around 1908. Freud reasoned that the problem was
that the boy had the following sequence of experiences (unknown to him, of
course, because they were repressed and unconscious).
1.
Sexual impulses toward his mother which had to be repressed.
2.
He developed a fear of castration by his father for having such wicked
desires toward his mother, and this was converted into neurotic anxiety.
3.
He developed a horse phobia which was really a fear of his father
transposed to the horse {horse + van = phobia}.
What had happened was that Hans went
for a walk with his mother. Right in front of him a horse fell over, as did the
van the horse was pulling. It made quite a noise with the horse neighing,
drivers shouting, and the van crashing to the street. All this happened in
front of Little Hans. After this Hans cried when he saw a horse nearby and
would not approach one.
Behaviorist Hobart Mowrer analyzed
the same situation in learning terms. The boy developed a fear reaction through
classical associative learning. Then, he found staying away from the horse
rewarding (operant conditioning). It was a clear case of a learning-based
phobia. Apparently, the boy grew up without too much impairment. He later, the
story goes, became director of the Metropolitan Opera and held that post for
many years.
It may be relevant that Freud never
saw Hans. He developed his theory on the basis of letters written to him by
Hans' father, who was working to become a psychoanalyst.
Behavioral
In another classic case, John
Watson, a leading early behaviorist, demonstrated that phobias could develop
through associative learning. Another boy, Little Albert, was encouraged to
play with a white rat. He enjoyed this. While playing with the animal there was
a very loud noise which frightened Albert. This sequence was repeated several
times. Albert became afraid of the rat owing to the paired learning experience.
The noise was the unconditioned stimulus and the fear response was associated
with the conditioned stimulus (the sight of the rat). The fear generalized to
all small animals, his mother's fur coat, and a Santa Claus mask. This
experiment shows how Little Hans' phobia might have developed. We do not know
how Albert turned out.
Modeling is a form of learning that
should be included in the development of specific fears. This is vicarious
conditioning, learning by watching others. A common example is the child who is
afraid of dogs even though the child has never had a bad experience with a dog.
The child has seen the reaction of a parent showing fear of the dog. As a
source of specific phobia it doesn't work well. Vicarious fear extinguishes
quickly when the child has positive experiences with dogs.
Operant conditioning is particularly
important in some forms of fear. If a situation is disliked or the source of
unpleasant association, the person may avoid it. Avoidant responses are
rewarding. Staying away is a positive reward. This is a common source of school
phobias. The child has an unpleasant experience in school, it may even seem to
very mild to the parent or teacher, and wants to stay away. Psychodynamic
therapies sought the hidden conflicts that gave rise to this symptom, but the
treatments were uniformly unsuccessful. Kennedy developed a rapid treatment
that is very successful. After the school phobia has appeared and conferences
with teacher and parents have been held to explore the problem a plan is agreed
upon with teachers and parents. Then the parents are told to inform the child
that he or she will go to school the next morning. That morning preparations
are usual and the child is taken to school and left at the school in care of
the teacher. The child makes a big fuss, and the teacher may find this
difficult, but the child is in school. This is repeated for about three days
and the fuss, and the phobia, disappear. There is some evidence that children
who have had separation anxiety in the past predisposes them to school
phobia. Some 50% in Kennedy's sample
had prior separation anxiety.
Integrative
Today it is believed by most
researchers and clinicians that the most productive theories about the
development of anxiety disorders are of the integrative type. They arise from a
combination of genetic or other biological predisposition and personal
experiences. Psychoanalytic theory fails because it cannot be scientifically
tested. Behavioral theories have been found to be limited. They explain some
cases well, but not all. It is clear that they lack what the person thinks
about experiences. Biology helps to explain individual differences. Two people
can have identical experiences, but one develops anxiety and another does not.
The difference may be in biological predispositions. The textbook well
describes the integrative theory.
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DSM-IV Diagnostic Criteria for Anxiety
Disorders
In
older Abnormal Psychology textbooks the DSM criteria were always given in
detail. Now, the briefer books have eliminated these lists (They are back again
in Edition Three). I think it was a mistake to eliminate them. It seems to me
that one of the things students find interesting is a detailed description of
just what a psychiatric disorder is. Therefore, I have listed the criteria as they
appear in the DSM-IV. American Psychiatric Association (1994). DSM-IV:
Diagnostic and Statistical Manual for Mental Disorders, 4th ed. Washington,
DC: American Psychiatric Press.
I have adapted some of the criteria
for brevity. In most instances I have omitted special criteria for children.
Diagnostic Criteria for Panic Attack
The predominant complaint is a
discrete period of intense fear or discomfort, in which at least four of the
following symptoms developed abruptly and reached a peak within 10 minutes.
1. Palpitations, pounding heart or
accelerated heart rate.
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath
or of smothering.
5. Fear of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady,
light-headed or faint.
9. Derealization (feelings of
unreality) or depersonalization (being detached from oneself).
10. Fear of losing control or going
crazy.
11. Fear of dying.
12. Paresthesias--numbness, or
tingling sensations.
13. Chills or hot flushes.
Diagnostic Criteria for Generalized
Anxiety Disorder
A. Excessive
anxiety and worry (apprehensive expectation) occurring more days than not for
at least 6 months, about a number of events or activities (such as work or
school performance).
B. The person
finds it difficult to control the worry.
C. The anxiety
and worry are associated with at least three of the following six symptoms
(with at least some symptoms present for more days than not (or for the past 6
months)(note: only one item required in children),
1. Restlessness or feeling keyed up
or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind
going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty
falling or staying asleep or restless, unsatisfying sleep).
D. The focus of
the anxiety is not confined to features of an Axis I disorder; that is, anxiety
or worry is not about having a panic attack (as in panic disorder), being
embarrassed in public (as in school phobia), being contaminated (as in
obsessive-compulsive disorder), being away from home or close relatives (as in
separation anxiety), gaining weight (as in anorexia nervosa), or having a
serious illness (as in hypochondriasis), and is not part of post-traumatic
stress disorder.
E. The anxiety,
worry or physical symptoms cause clinically significant stress or impairment in
social, occupational, or other important areas of functioning.
F. Not due to
the direct effects of a substance (e.g., drugs of abuse, medication) or a general
medical condition (e.g., hyperthyroidism), and does not occur exclusively
during a mood disorder, psychotic disorder, or pervasive developmental
disorder.
Diagnostic Criteria for Panic Disorder
with Agoraphobia
A. Both one and
two
1. Recurrent, unexpected panic
attacks are present.
2. At least one of the attacks has
been followed by 1 month (or more) of the following: a) persistent concern
about having additional attacks, b) worry about the implications of the attack
or its consequences (e.g., losing control, having a heart attack, going crazy)
or c) significant change in behavior related to the attacks.
B. The presence
of agoraphobia in which the predominant complaint is anxiety about being in
places or situations from which escape might be difficult or embarrassing, or
in which help might not be available in the event of an unexpected or
situationally predisposed panic attack or panic-like symptoms. Agoraphobic
fears typically involve characteristic clusters of situations that include
being outside the home alone, being in a crowd or standing in line, being on a
bridge, or traveling on a bus, train, or automobile.
C. The panic
attacks are not due to the direct physiological of a substance (e.g., drug of
abuse, medication),or a general medical condition (e.g., hyperthyroidism).
D. The panic
attacks are not better accounted for by another mental disorder such as social
phobia (e.g., occurring on exposure to social situations), specific phobia
(e.g., exposure to a specific social situation), obsessive-compulsive disorder
(e.g., exposure to dirt in someone with an obsession about contamination),
post-traumatic stress disorder(e.g., in response to stimuli associated with a
severe stressor), or separation anxiety (e.g., in response to being away from
home or close relatives).
Diagnostic Criteria for Specific Phobia
A. Excessive fear cued by presence of specific
object or situation.
B. Exposure to feared object or event provokes
immediate anxiety.
C. Person recognizes the fear is excessive or
unreasonable.
D. Feared situation is avoided.
E. Avoidance interferes with routines.
F. If under age 18, lasts at least 6 months.
G. No other disorder accounts for behavior.
Diagnostic Criteria for Social Phobia
A. Marked and
persistent fear of one or more social performance situations in which the
person is exposed to unfamiliar people or to possible scrutiny by others. The
individual feels that he or she will act in a way (or show anxiety symptoms)
that will that will be humiliating or embarrassing.
B. Exposure to
the feared social situation almost invariably provokes anxiety which may take
the form of a situational bound or situationally predisposed panic attack.
C. The person
recognizes that the fear is excessive or unreasonable.
D. The feared
social or performance situations are avoided or endured with intense anxiety or
distress.
E. The
avoidance, anxious anticipation, or distress in the feared social performance
situations interfere significantly with the person's normal routine,
occupational (academic) functioning, or social activities or relationships, or
there is marked distress about having the phobia.
F. Not due to
substance abuse, medical condition, or other psychiatric disorder.
Diagnostic Criteria for Post-Traumatic
Stress Disorder
A. The person
has been exposed to a traumatic event in which both of the following were
present:
1. The person experienced,
witnessed, or was confronted with an event or events that involve actual or
threatened death or serious injury, or threat to the physical integrity of
himself or herself or others.
2. The person's response involved
intense fear, helplessness or horror.
B. The traumatic
event is persistently reexperienced in one or more of the following ways:
1. Recurrent and intrusive
distressing recollections of the event including images, thoughts or
perceptions.
2. Recurrent distressing dreams of
the event.
3. Acting or feeling as if the
traumatic event were recurring.
4. Intense psychological distress at
exposure to internal or external cues that symbolize or resemble an aspect of
the traumatic event.
5. Physiological activity on
exposure to internal or external cues that symbolize or resemble an aspect of
the traumatic event.
C. Persistent
avoidance of stimuli associated with the trauma and numbing of general
responsiveness as indicated by three of the following:
1. Efforts to avoid thoughts,
feelings or conversations associated with the trauma.
2. Efforts to avoid activities,
places or people that arouse recollections of the trauma.
3. Inability to recall an important
aspect of the trauma.
4. Markedly diminished interest or
participation in significant activities.
5. Feeling of detachment or
estrangement from others.
6. Restricted range of affect (e.g.,
unable to have love feelings.)
7. Sense of foreshortened future
(e.g., does not expect to have a career, marriage, children or a normal life
span).
D. Persistent
symptoms of increased arousal (not present before the trauma) as indicated by
two or more of the following:
1. Difficulty falling or staying asleep.
2. Instability or outbursts of
anger.
3. Difficulty concentrating.
4. Hypervigilance.
5. Exaggerated startle response.
E. Duration of
the symptoms is more than one month.
F. The
disturbance causes clinical distress or impairment in social, occupational, or
other important areas of functioning.
Car accidents are most frequent
cause of PTSD for American men and sexual assault is most common for women.
Blanchard and Hickling have found that about half of people who have automobile
accidents suffer later from PTSD. They have described their work in a book, After
the crash: assessment and treatment of motor vehicle accident survivors,
APA Press, 1997. At least 15% of the victims developed a driviing phobia
leading them to stop driving or to severely limit it. 93% avoided the scene of
the accident. Treatment includes cognitive behavior therapy, exposure, and
relaxation training.
Diagnostic Criteria for
Obsessive-Compulsive Disorder
A. Either obsessions or compulsions.
Obsession
1.
Recurrent, persistent thoughts, impulses, images that are experienced as
intrusive and inappropriate and cause anxiety and distress.
2.
Thoughts, etc., that are not about real-life issues.
3.
Person attempts to ignore or suppress the thoughts or to neutralize them
with other thoughts or actions.
4.
Person recognizes that the thoughts are a product of own mind.
Compulsion
1.
Repetitive behaviors that the person feels driven to perform in response
to an obsession or according to rigidly applied rules.
2.
Behaviors are aimed at preventing or reducing distress of some dreaded
event or situation.
B. Person knows that the obsessions and
compulsions are unreasonable.
C. Obsessions or compulsions cause marked
distress, are time-consuming or interfere with routines.
D. Not part of other disorder.
Note: There are
a number of other disorders that seem to part of a spectrum of
obsessive-compulsive disorders. These include Tourette's Syndrome (involuntary
shouting of obscenities and jerking movements), Trichotillomania (pulling hair
of one's body; head, eyebrows, chest, pubic region), and hypochondriasis
(obsession with having a serious illness).
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Epidemiology
Twelve-month prevalence rates in
cases per 100 (Kessler, 1994).
Male Female
Total
Obsessive-Compulsive
Panic
1.3 3.2 2.3
Agoraphobia 1.7 3.8 2.8
Social
Phobia
6.6 9.1 7.9
Simple
Phobia
4.4 13.2 8.8
Generalized
Anxiety
2.0 4.3 3.1
Obsessive-Compulsive
2.1
Any Anxiety
Disorder 11.8 22.6
17.2
As may be seen the prevalence rates
are high. Note that women have higher rates than men in every case.
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Culture
The textbook mentions several
cultural variations on how anxiety appears. I did a study of anxiety in 6th
grade children, testing the hypothesis that children who live in authoritarian
cultures will show higher rates of anxiety. I selected three nations for the
study: Mexico, high authoritarian (Monterrey), Norway, low authoritarian
(Bergen) and USA (Houston) for a middle group. We tested girls and boys of
white collar and blue collar socioeconomic status. Other researchers had
decided that a nation was high or low authoritarian on the basis of general
observations of the society. We did that as well as reviewing the relevant
literature, but we also asked the children to describe the child rearing they
experienced in terms of authoritarian relationships. This had not been done
before by other researchers. About 500
children took part.
We found that Mexican
children were more anxious than the Norwegian children, but not more than
children in the USA, and according to the children's reports of authoritarian
child rearing, the USA children were reared in least authoritarian households.
What we found that was most interesting was that the most anxious children were
those in Mexico reared in non-authoritarian households and children in Norway
and the USA who were reared in most authoritarian households. In other words,
children were most anxious if they were reared in households that were not
typical of the culture. [Johnson, D.L., Teigen, K., & Davila, R. (1983).
Anxiety and social restriction as experienced as experienced by children
in Mexico, Norway and the United
States. Journal of Cross-cultural Psychology, 14, 439-454.]
Trends Over Time
Research reported by Twenge (2000, Journal
of Personality and Social Psychology, 79, 1007-1021) indicates that
Americans are more anxious today than they were 50 years ago. Using results of
tests that were administered throughout the time period she found that there
has been a steady increase in anxiety. This was true for college students and
children. She explains the results in terms of decreases in social
connectedness and increases in perceived environmental dangers. Economic
factors were not involved. It may be relevant that Putnam (2000, Bowling
alone) found a similar pattern for voluntary participation. He found
declines in voting, church involvement, club membership, etc.).
Several studies have found that
although many people have experience severe anxiety, few actually seek
treatment (Olfson, American Journal of Psychiatry, April, 2000). See
more information on this at www.freedomfromfear.org.
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Medical Treatment of Anxiety
The most common treatments for
anxiety are medications even though most of these medications carry with them a
high risk for addiction.
Benzodiazapines.
These are all used for the general
treatment of anxiety and all are addictive and may interfere with alertness and
coordination. If used it should be for a short period of time only.
Trade
Name Generic Name
XANAX ALPRAZOLAM (Most commonly used.)
VALIUM DIAZEPAM
TRANXENE CLORAZEPATE
ATIVAN LORAZEPAM
SERAX OXAZEPAM
CENTRAX PRAZEPAM
LIBRIUM CHLORDIAZEPOXIDE
PAXIPAM HALAZEPAM
Listed in order
of usage.
Other
Anti-Anxiety Drugs
Buspar Buspirone
Chemically different from the
benzodiazapines, it appears that it is not addictive, but is as effective as
benzodiazapines. It is also less sedating, but there is increased risk for
lowering white blood cells thus increasing the danger of infections.
Anti-depressants
These are drugs that were first
developed for depression and then found to be effective in the treatment of
some anxiety disorders.
Trofranil Imipramine
Anafranil Clomipramine Especially for OCD.
Prozac Fluoxetine For OCD. Few side effects
Psychological Treatment of Anxiety
Disorders
It should be clear from reading the text
that cognitive-behavioral (cognitive behavioral therapy or CBT) methods are
most effective and most often used. There are a number of variations on these
methods. One is that while most anxiety disorders require many sessions a
single session of CBT was found to be as effective as benzodiazepine in
treating dental phobia (Thom & Johren, 2000, Journal of Consulting and
Clinical Psychology, 68, 378-387). Both were better than the no-treatment
control, but CBT also prevented relapse and the drug did not.
Exposure therapy is effective, but
how do you expose a person to some hazardous situation? You use virtual therapy
on a computer program. The hazardous situation is recreated on a computer
screen and the person becomes involved with it. Rothbaum (American Journal of Psychiatry) found this an
effective treatment of fear of heights. There are some important sub-features.
One is exposure to the traumatic situation. This is described many times, but I
have an example that I think is important.
Throughout high school, college and
graduate school I avoided any situation that called for speaking in public. I
was in a band and orchestra, played basketball and had an active social life.
It was only public speaking that was a problem. While still at the Houston VA
Hospital I began teaching at UH in evenings. I was intensely anxious and hoped
no one would notice. However, on student, wishing to be helpful, said he liked
the course, but wished the instructor was not so anxious. I nearly gave up
teaching. As it happened, however, I was moved to a new job at the VA Hospital
where I directed the Patients Training Laboratory, a research and treatment center.
This job required that I make a speech on some training topic to 30 men every
morning. I found my speaker anxiety dwindled to nothing. Today I have no
speaker anxiety. I have addressed US Senate committees, I led a rally of 3000
NAMI members before the US Capitol with a strong lets-go-get-'em speech, and I
have been master of ceremonies for many conferences and banquets. I cannot
imagine a public situation in which I could not make a speech with little or no
anxiety. What is the point? Exposure. If one fears a specific situation or
place expose yourself to it and do so repeatedly. If you are anxious about
elevator-riding, start with a two-story elevator, ride up and down a number of
times and go on to taller elevators. Save the glass-sided elevator at the Hyatt
for last.
In the treatment of
obsessive-compulsive disorder (OCD) involving fear of dirt or germs, Marx, in
London, trained nurses to carry out the treatment. After a careful physical
examination to rule out heart problems, the patient is taken into a bare,
unfurnished room, with a garbage can. The patient is then told to sort the
garbage (no gloves allowed) into appropriate categories (paper here, cans here,
messy stuff here). The garbage has been allowed to ripen in the sun so it is
quite aromatic. Patients nearly faint with anxiety when confronted with task,
but the nurses are unyielding. "Do it." And they do. When they
finish, they sort another garbage can and another. They come back the next day
and do it again. In a very short while the OCD symptoms of hand washing and
fear of dirt have disappeared, and do not return. This is another kind of
exposure.
The newer
therapies such as CBT are highly effective and are in great contrast to
psychodynamic or humanistic therapies that show no effectiveness whatsoever.
This is worth noting because there are so many kinds of psychotherapies.
Somewhere on my bookshelves I have a book titled "210 Psychotherapies."
They are all described and presumably practiced by someone, somewhere. Two of
them were developed by former UH students. A recent catalog of the publisher,
Guilford, includes the following books about psychotherapy:
Shapiro--Eye movement
desensitization and reprocessing.
Young--Schema therapy
Hayes--Acceptance and
commitment therapy
Mahoney--Constructive
therapy
Lipchik--Solution-focused
therapy
Gendlin--Focusing-oriented
therapy
Rutan--Psychodynamic
group psychotherapy
Greenberg--Experiential
psychotherapy
Ritter--Affirmative
psychotherapy
Budman--Brief therapy
There is no end of imagination by psychotherapists, and some of these
forms of therapy might actually be effective. We do not know until they are
subjected to multiple clinical trials, and that will not happen because too
often therapists are not researchers or even interested in research. The wise
person asks what therapy is being offered by a therapist and continues if the
therapy has been tested and effectiveness shown. In most cases that means
picking cognitive behavior therapy (CBT). It has been tested many times and nearly always wins. The Guilford catalog has
twelve books on this therapy.
A case in point about
comparisons is the popularity of eye movement desensitization and Reprocessing
(EMDR). This form of therapy is for a wide range of disorders. After
establishing a food relationship with the patient the therapist explains that
traumatic events harm the brain and that eye movements help to restore brain
functioning. Then the therapist moves her fingers in front of the patient's
eyes and is told to follow them. This is repeated many times. There is more to
the process, but that is the core of the therapy. Whether it is effective is
controversial and there have been many studies, but, unfortunately, most have
not been carried out well. Devilly (2002, Eye movement desensitization and
reprocessing: a chronology of its development and scientific standing.
Scientific Review of Mental Health Practice, 1, 113-138) has reviewed the set
of studies and has concluded that the procedure is not very effective, and if
effective, it is only for a short time.
According to research by
Olfson et al. (2002, National trends in the use of outpatient psychotherapy,
American Journal of Psychiatry, 159, 1914-1920) more people are in therapy, or have been, than fifteen years ago,
but the rate of increase was low. The use of medications increased at a higher
rate. When people do see a psychotherapist, they see a non-medical
professional, typically a clinical or counseling psychologist, social worker or
licensed professional counselor.
There is another new
development: psychotherapy on-line. See www.ultrasis.com for more information
about this kind of treatment. It is not really new, but more programs are now
available and they have been evaluated. Proudfoot et al. (2003, Computerized,
interactive, multimedia cognitive-behavioural program for anxiety and
depression in general practice. Psychological Medicine, 33, 217-227.)
found the new method was better than treatment as usual.
It was expected that
after the horrendous events of September 11, 2001 there would be a huge demand
for psychotherapy in New York. Counselors rushed in to provide services. They
say waiting. There was no rush to the city mental health clinics and the VA
facilities were not over-whelmed. Just after 9-11 7% of New Yorkers had symptoms
of post-traumatic stress disorder, but in 6 months this rate had declined by
half. People are resilient and get better on their own.
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Genetic Studies of Anxiety Disorders
Twin Concordance Rates for Anxiety
Disorders
Type of Twin
DISORDER MZ DZ
PANIC .31 .00
GAD-1 .00 .05
GAD-2 .28 .17
AGORAPHOBIA .23
.15
SOCIAL
PHOBIA .24 .15
ANIMAL
PHOBIA .26 .11
PHOBIAS--ALL .88
.31
OCD . 87
.47
Note: MZ =
monozygotic or identical twins; DZ = dizygotic or fraternal twins.
Notice that the
difference between MZ and DZ for Panic Disorder is fairly high, indicating a
fairly high degree of heritability. But
also notice that GAD-1 is low, suggesting virtually no involvement of genetics.
It is hard to know what to make of Obsessive Compulsive Disorder (OCD) since
both MZ and DZ are high. Certainly genetics is involved, but in a way that is
different from Panic disorder. The genetic predisposition for phobias and OCD
is high.
It appears genetics
works though transporter facilitated uptake of serotonin. Little is known about
the genes involved except that it is expected than there will be more than one
gene. Researchers at the National Institute for Mental Health have
recently discovered how genes are
associated with emotionality and temperament.
A gene encodes a transmitter protein that sends serotonin back to
neurons after being released. Weinberger and associates (2002, Science,
297, 400-403) found genetic activity in patterns of brain activity as shown
with fMRI. Subjects who had the gene were compared with subjects without the
gene on amygdala response to presentations of angry or frightened faces. Those
with the gene showed more activity when shown the emotional faces. This is a
first study of the link between frightening emotion and genetic structure.
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Final Notes
The program, Monk,
on various channels and at unpredictable timesis a fairly realistic depiction
of a man with obsessive-compulsive disorder. He could be helped with CBT or
medication, but there goes the program.
Not only did Willard
Scott, the TV weatherman mentioned in the textbook, have panic disorder, so did
Earl Campbell, star running back for UT and the Houston Oilers.