Obsessive compulsive disorder (OCD)
This condition is characterised by obsessional thoughts followed by compulsive rituals. Unpleasant thoughts which may feel beyond the persons control, create feelings of anxiety. To reduce the distress the person will engage in repetitive behaviour, known as rituals. OCD sufferers realise that their behaviour is unusual and senseless, but they can not stop. If the compulsive behaviour is interrupted the sufferer can experience extreme distress, which only reduces when the ritual is successfully carried out. OCD can therefore be very disruptive to everyday life. OCD typically begins in early adulthood. Once established it can persist for many years. The number of people seeking help for OCD has increased dramatically in the last ten years.
Post-traumatic stress disorder.
People often develop symptoms of anxiety after experiencing a very distressing event (a trauma). Usually the reaction lasts for a few weeks then fades away. In some people the symptoms continue or re-emerge after a substantial delay. This is known as post-traumic stress disorder. The symptoms are divided into 3 clusters, 1. persistent symptoms of anxiety, 2. Avoidance behaviour, 3. Involuntary re-experiencing of the event through intrusive, persistent memories or disturbed dreams.
Green reports that PTSD develops in about 25% of people who experience potentially traumatic events. The likelihood of PTSD developing increases with the severity of the event but obviously there are individual differences in how people respond to trauma.
Explanations and therapies for anxiety disorders.
Biological approach.
Biochemistry.
Anxiety disorders have been linked with disturbances in the brain's neurotransmitter systems. The brain produces chemicals to pass messages between neurons in the nervous systems. These substances are known as neurotransmitters. Scientists have considered the possible role of neurotransmitter gamma-amino butyric acid. (GABA).
When you are faced with a frightening event neurons throughout the brain fire and create the experience of anxiety. In normal anxiety, the neural firing sets off the production of GABA to slow down the neural activity. This ensures that the anxiety subsides. Someone with an anxiety disorder may have a defect in his or her GABA system, which means anxiety is not brought under control. Anxiety disorders may also result from too little GABA in the brain.
Evaluation.
May provide some explanations for some anxiety disorders such as GAD but others like specific type phobias are less convincingly explained by this approach.
Biological treatments.
Sedatives or tranquillisers have been developed to reduce anxiety. They are known as anxiolytic drugs and are among the most widely prescribed drugs. Barbiturates were the first major category of drugs used to treat anxiety. Because they were life threatening if someone took an overdose, they have largely been replaced by benzodiazepines. The group of anxiolytic drugs is known to affect GABA neurotransmitters in the brain. They reduce anxiety by enhancing the release of GABA. More recently , drugs that were originally developed to treat depression have become popular in treating anxiety disorders, in particular OCD and social phobia. Antidepressants such as Prozac are prescribed. This highlights that depression may be an important component of an anxiety disorder.
Evaluation.
A major problem with anxiolytic drugs is that they are addictive. Can develop dependency. Also the anxiety can return if the patient stops taking the drugs.
Genetics.
This study produces some evidence of a genetic vulnerability to developing anxiety disorders.
Aim - Slater and Shields investigated the role of heredity in anxiety disorders.
Method - They examined 17 pairs of identical (mz) twins and 28 non-identical (dz) twins, where one twin had been diagnosed with an anxiety disorder. Slater and Shields wanted to known if the other twin also had an anxiety disorder. As identical twins share 100% of their genes, it was expected that they would have very similar psychological functioning. This similarity is called a concordance rate. A lower conordance rate was expected for dz twins because they only share 50% of their genes.
Result - A total of 49% of the mz co-twins were also diagnosed as having an anxiety disorder. In the dz twins, as expected, the concordance rate was lower at 4%.
Conclusion - The study provides some evidence for the role of genetics in the development of anxiety disorders.
Evaluation.
If it were a wholly genetic disorder then the concordance rate for mz twins should be 100% for mz twins and 50% for dz twins. Approach does not provide a method of treatment.
Psychodynamic approach.
Freud believed that there are two types of anxiety. Objective anxiety (realistic anxiety) is caused by an external event. It can often be dealt with in a rational way. With this anxiety there is an environmental cause and is reasonable to feel anxious.
Neurotic anxiety is caused by internal psychological conflict. It is the result of the early power struggles between parent and child as a child's personality forms. Freud thought that personality developed in stages and consisted of three parts. The id (which you are born with) is an unconscious part of the personality and is composed of sexual and aggressive instincts. The ego develops in early childhood to keep these basic instincts in check. Freud thought that during this time, parents punish the young child whenever it fails to control sexual or aggressive desires. The child's wishes are often in conflict with the adult expectations, creating tension and distress. To reduce the conflict these painful encounters with adults are repressed. In adulthood, neurotic anxiety occurs when a person is faced with a situation that unconsciously reminds them of this repressed conflict. It represents the fear of the consequences of expressing the id-driven impulses.
Neurotic anxiety is dealt with though an unconscious distortion of reality by means of 'defence mechanisms'. These allow the ego to discharge some id energy .without facing up to its true nature. In effect, defence mechanisms are a disguised outlet for basic desires.
Examples of some defence mechanisms;
Repression - Pushing an unhappy memory into the unconscious.
Displacement - Transferring negative feelings on to an innocent target.
Denial - Refusing to acknowledge something because it is painful.
Reaction formation - Consciously feeling the exact opposite of what you unconsciously feel.
Psychodynamic treatment.
Freud was one of the first people to develop and use psychotherapy. It is a social interaction in which a trained professional tries to help another person feel differently. There are now many different types of psychotherapy. The psychodynamic approach assumes that the patient does not understand what motivates them. The therapy aims to help people gain insight into why they behave, feel and think the way they do. The therapist analyses what the patient says, to uncover the hidden, unconscious cause of neurotic anxiety.
Clients are encouraged to talk about whatever comes to mind without interruption. This is known as free association. During free association, the clients ego will try to protect itself from any threat of the id emerging using the defence mechanisms. The therapist analyses the hidden meaning of these defences to help the client gain insight.
Behaviourist approach.
The behaviourist approach focuses on the idea that anxiety is a learned response. Individuals associate fear with a neutral stimulus through a process of classical conditioning. Alternatively anxiety may develop because the response is reinforced in some way. This is known as operant conditioning.
Aim - Watson and Rayner wanted to show how a phobia can be learned.
Method - A 9 month old baby known as Albert was tested for fear reaction to a number of stimuli including a white rat, a rabbit, some cotton wool and a hammer hitting a steel bar just behind his head. Only the loud noise frightened him. Watson and Rayner then presented the rat to Albert and allowed him to stroke it. Whilst he was playing with the rat, Watson hit the hammer on the steel bar behind him and frightened him.
Results - After several parings of the two stimuli, Albert developed a phobic response to the rat. He was fearful even when it was presented without the loud noise.
Conclusion - Phobias are learned through a process of classical conditioning.
Two process theory.
Mowrer believed that there were two behavioural processes involved in anxiety disorders. First the acquisition of fear is brought about by classical conditioning. Second through a process of operant conditioning, the avoidance behaviour is maintained. By staying away from the feared object anxiety levels drop. Avoidance behaviour is therefore positively reinforcing.
Behaviourist treatments.
Behaviourist treatments are much less concerned about the underlying cause of the disorder than psychodynamic treatments, concentrating instead on helping the person learn new responses or behaviours to things that make them anxious.
Aim – Jones wanted to show how a phobia could be successfully treated using behaviourist techniques.
Method – He worked with Peter, a two year old boy, who was frightened of a number of things, including rabbits. Jones put a rabbit cage in front of peter whilst he was eating his lunch. Over 17 steps the rabbit was brought closer to peter, set free in the room and eventually sat on Peter’s lunch tray.
Result – Peter was no longer frightened of the rabbit.
Conclusion – Classical conditioning can be successfully used to treat phobias.
The process used by Jones in known as systematic desensitisation. Behaviour therapists work with clients suffering from a variety of anxiety disorders to help them slowly and systematically overcome their anxiety. First step is to teach the client relaxation techniques such as deep breathing. The therapist also educates the client about the body’s stress response. The client then works with the therapist to draw up a hierarchy of anxiety provoking events. This is a list of situations ranked from the most difficult to cope with, down to the least difficult. The client is then asked to imagine being in these situations, starting with the least stressful. If the experience any anxiety during this process they are asked to use their newly developed relaxation techniques or simply wait for the feeling to disappear. The approach works through classical conditioning. The client is learning to associate a new response with a previously distressing stimulus.
Evaluation.
Can be very useful but the client must be highly motivated to change and must be prepared to experience stressful situations. Behaviourist approach doesn’t look for underlying causes, and tends to focus on behaviour rather than thoughts and feelings.
The cognitive approach.
The cognitive theory of anxiety suggests that people become anxious because of their negative beliefs about themselves and the world. They have a tendency to perceive non-threatening situations as dangerous and anxiety provoking. Clark called this catastrophic misinterpretation. Beck believed that anxious people often had negative thoughts about issues of acceptance, competence, responsibility, control and the physical symptoms of anxiety.
Aim – Yun wanted to investigate the role of cognitive processes in anxiety disorders. In particular, they wanted to find out how anxious patients interpreted the physical symptoms of anxiety.
Method – They used questionnaire to measure and compare the interpretation of the physical symptoms of stress in three groups of participants. Group one consisted of participants suffering from anxiety disorders. Group two consisted of participants suffering from depression. Group three was a control group with no psychological difficulties.
Results – They found that those in the anxious groups were more likely to interpret the physical symptoms of anxiety as dangerous and life threatening than the other groups. Worries about the social consequences of the physical symptoms were found in both the anxious and depressed group.
Conclusion – Negative thoughts about the physical symptoms of stress play an important role in the onset and maintenance of anxiety disorders. Both depressed and anxious participants have greater concerns of what others think about them than a controlled group.
Cognitive treatments.
Cognitive therapy concentrates on the negative thought processes of an anxious individual and aims to directly challenge and change these catastrophic misinterpretations. First, the therapist will educate the client on the relationship between thought, feelings and behaviour. Client needs to start to understand that negative thoughts contribute to the anxiety disorder. The client may also be taught a variety of distraction techniques to help them manage negative thoughts. Towards the end of the therapy the emphasis will move away from reducing the symptoms of anxiety and towards maintaining the new ideas and thought processes.
Evaluation.
Clark found that cognitive therapy was highly effective in the treatment of anxiety. However, as with any talking cure the client must be quite articulate and be prepared to be challenged by the therapist.
Effectiveness of treatments for anxiety.
As we have seen there are different explanations and treatments for anxiety disorders. The behaviourist approach has been successful in treating patients with anxiety. Salkovis and Kirk claim a 75% improvement rate in the treatment of OCD by exposure techniques such as systematic desensitisation. However treatment refusal and drop-out rates are also high. This led Salkovis to recommend a combination of cognitive techniques with behavioural treatments. A collaborative relationship between the therapist and patient can be developed using a cognitive approach. This has been found to reduce treatment refusal. Whilst drug treatments have been effective reducing the symptoms of anxiety, Marks found a high incidence of trouble-some side effects. Also, when patients stop taking the medication, the symptoms may return. However, combining medication with behavioural techniques has been successful because it helps the patient to feel more confident during exposure to anxiety provoking situations. Garfield reported that psychodynamic therapies are effective with well –educated, strongly motivated and confident people, suffering from light to moderate difficulties with anxiety. Researchers call this YAVIS effect, since such people tend to be Young, Attractive, Verbal, Intelligent and Successful. Some psychologists, such as Beitman would argue that any effective therapy must be responsive to the individual client needs. An experienced mental health care practitioner would tailor treatment methods to suit an individual patient.
