PSYCHONEUROSIS

1. PSYCHONEUROSIS OR ANXIETY BASED DISORDERS PRESENTED BY- Mrs.Shalini Chhabra Department Of Psychology DAV College For Girls, Yamunanagar

2. ANXIETY: a general feeling of apprehension about possible danger. Acc to Sigmund Freud: it is a sign of inner conflict between some primitive desire (from the id) and prohibitions against its expression (from the ego and superego)

3. DEFINITION OF ANXIETY BASED DISORDERS Acc to DSM: The group of disorders that share the obvious symptoms and features of anxiety are known as anxiety disorders.

4. Historically,anxiety disorders were considered to be the example of neurotic behaviour, which involved following symptoms • Exaggerated use of avoidance behaviour. • Exaggerated use of defense mechanisms. • Maladaptive and self defeating behaviour.

5. But neurotic person is • Not out of touch with reality • Not incoherent • Not dangerous Nevertheless, such persons social relations and work performance are likely to be impaired to an extent by their effort to cope with their anxiety and fear

6. The idea of neurosis has a long history and the term is still used in psychodynamic circles and in casual conversation by the general public. Since 1980, with each edition of DSM, the attempt has been made to separate what used to be officially called neurosis into different categories based on their symptoms, which can be observed and measured.

7. Acc to DSM-IV the group of mental disorders commonly characterized by irrational anxiousness, worries, tensions and negative expectations are Anxiety based disorders and roughly categorized into 4 types • Generalized anxiety disorder and panic disorder. • Phobic disorders. • Obsessive-Compulsive disorders. • Post traumatic stress disorder

8. GENERALIZED ANXIETY DISORDER (GAD)

9. DEFINITION Acc to DSM IV “GAD may be characterized by the excessive, chronic, distressing and free floating anxiety and worry whose source the sufferer can not specify, which causes clinically significant distress or impairment in the key areas of functioning, and which is difficult to control.

10. DIAGNOSTIC CRITERIA FOR GENERALIZED ANXIETY DISORDER (GAD)

11. 1. Unrealistic or excessive anxiety and worry for at least 6 months. 2. Its content may not be related with AXIS 1 disorder such as the possibility of having panic attack

12. 3. The subjective experience of excessive worry may be accompanied by at least three of the following six symptoms: • Restlessness or feeling of being keyed up or on edge • A sense of being easily fatigued • Difficulty in concentrating or mind going blank • Irritability • Muscle tension • Sleep disturbance

13. In previous DSMs, symptoms of autonomic hyperactivity were also included (such as shortness of breath, rapid pulse rate, sweating, dizziness and nausea) but these were dropped from DSM IV because many of clients reported the less frequency of these symptoms.

16. GENERAL CHARACTERISTICS • Constant state of tension, worry and diffuse uneasiness. • Anxious apprehension-future oriented mood state in which a person attempts to deal with upcoming negative events. • The mood is characterized by negativeaffect, chronic overarousal and a sense of uncontrollability.

17. 4. Although anxious apprehension is a part of other disorders such as the agrophobic is anxious about future panic attacks and about dying the social phobic is anxious about negative social evaluation but it is the essenceof GAD. 5. Have difficulty in concentrating making decisions and dreading to make a mistake

18. 6. Marked vigilance for possible signs ofthreat in the environment. 7. Commonly, they complain of muscletension, especially in the neck and upper shoulder region, sleep disturbances, insomnia and nightmares

19. 8. No matter how well things seems to be going people with GAD are apprehensive and anxious. The constant worry leave them continually upset, uneasy anddiscouraged. 9. The common spheres of worry were found to be family, work, finances andpersonal illness (Roemer, Molina and Borkovec, 1997 )

20. 10. Not only do they have difficulty inmaking decisions, but even afterwards they are constantly worried over the possible errors that may lead to disaster. 11. They do not find any relief from their worries, they review each mistake, real or imagined recent or remotely past. They may anticipate all the difficulties that may arise in future.

21. 12. They have no appreciation of the logic most of us use in concluding that it is pointless to torment ourselves aboutpossible outcomes over which we have no control. 13. It seems at times that persons suffering from GAD are actually looking for things to worry about. They do not have any control over their tendency to worry.

22. PREVALENCE AND AGE OF ONSET • GAD occurs twice as common in womenthan men. • Age of onset is often difficult to determine because 60 to 80% of clients reporting that they remember having been anxious nearly all their lives,many others report a slow and insidious onset (Rapel and Barlow 1993; Wells and Butler, 1997)

23. 3. In recent years, this has led many to suggest that GAD might be reconceptualized as a personality disorder because clients themselves feel that their anxiety and worry as their personality characteristics (Wells and Butler 1997 ) 4. It occurs across all cultures and in all ages.

24. GENDER DIFFERENCES IN THE ANXIETY DISORDERS: LIFETIME PREVALENCE ESTIMATES Sources: (Barlow,1988;Eaton et al.,1994; Karno et al.,1988;Kessler et al., 1994; Magee et al.,1996)

25. COMORBIDITY WITH OTHER • DISORDERS • GAD often co occurs with • OtherAxis 1 disorders, especially other anxiety and mood disorders. • With GAD many experience panic attacks ( Barlow 1988 )

26. With panic disorder, social phobia and specific phobia ( Wittchen et al., 1994 ) • May show mild to moderate depression (Brown et al., 1993 ; Schweizer and Rickels, 1996 ; Wells and Butler 1997 )

27. CASUAL FACTORS IN • GAD • The Psychoanalytic viewpoint • Generalized or free floating anxiety results from an unconscious conflict b/w ego and id impulses, that is not adequately dealt with

28. ii. Freud believed that it was primarily sexual and aggressive impulses that have been either blocked from expression or punished upon expression that led to free floating anxiety. iii. In some cases adequate defense mechanism may never have developed.

29. 2. The Behaviouristic viewpoint i. Classical Conditioning to many stimuli : The pure behaviouristic viewpoint says that GAD stems from conditioning of anxiety to many environmental cues in the same wayas phobias are conditioned.

30. ii. The role of unpredictable and uncontrollable events : Unpredictable and uncontrollable aversive events are much more stressful than are controllable and predictable aversive events and that’s why they create more fear and anxiety (Barlow, 1998 ; Barlow et al., 1996 ; Mineka, 1985 ; Mineka and Zinbarg 1996)

31. 3. The Cognitive viewpoint • The content of anxious thoughts : • Beck and Emery (1985) summerized the evidence showing that clients with GAD tend to have images and automatic thoughts revolving around • Physical inqury 2. Illness 3. Loss of control • 4. Failure 5. Inability to cope • 6. Death 7. Rejection 8. Mental illness

32. COMMON AUTOMATIC • THOUGHTS INCLUDED • “ I will make fool of myself.” • “People will laugh at me.” • “ What if I fail.” • “ I’ll never be as capable as I should be.”

33. ii. These negative thoughts are based on maladaptive assumptions or schemas about the world such as • Any strange situation should be regarded as dangerous. • It is always best to assume the worst. • My security and safety depends on anticipating and preparing myself for any possible danger.

34. iii. Cognitive Biases for Threatening information: People with GAD process the threatening information in a biased way. Many studies have shown their attention is drawn to the threatening cues in the environment more easily. Anxious people do have the tendency to interpret ambiguous information in threatening way.

35. 4. The Biological viewpoint • Genetic Factors: Evidence regarding the role of genetic factors in GAD is mixed and it seems that there is a modest heritability for this disorder. Some studies support the idea that GAD and panic disorder have separate genetic diathesis and other studies suggest that they may have common diathesis (Mackinnon and Foley 1996) There is a strong evidence that anxiety and major depressive disorder share a common underlying genetic diathesis.

36. Recently scientists identified specific gene related to anxiety and neuroticism. This gene effect the brain’s ability to use the neurotransmitter serotonin. This is for the first time that a specific gene has been identified that affects an important human personality trait- specially who is prone to anxiety and negative moods and who is prone to stable, laid-back attitude. The gene affect is known as Serotonin transporter- molecules that are separate from serotonin itself but allow surrounding nerve cells to respond to serotonin ( Lesch et al., 1996 )

37. ii. Deficiency of GABA: In 1950, certain drugs were found to reduce anxiety. The benzodiazepines include some of today’s most prescribed psychoactive drugs. This drugs have their effect on GAD, they exert their effect through stimulating the action of (GABA) Gamma aminobutyric acid a neurotransmitter, strongly implicated in generalized anxiety.It appears that anxious people have a kind of functional deficiency in GABA, which plays an imp role in the way our brain inhibits anxiety in stressful situations.At present, it seems that GABA serotonin and perhaps norepinephrine all play a role in anxiety but the way in which they interact remain unknown.

39. TREATMENT • Many clients with generalized anxiety disorders are seen by family physicians rather than by mental health professional. • Most often used drug is benzodiazepine and also most misused for tension relief and for relaxation but their effectiveness may wears off after few weeks of continuous medication and it habit forming and difficult to taper.

40. 3. Another drug busipirone (from the azaspirone category) seems effective. It is not addictive but it take several weeks to show desired effect. 4. Several categories of antidepressent are also useful in the treatment of GAD (Gitlin 1996)

41. 5. Cognitive behavioural therapy for generalized anxiety disorders has become increasingly effective. It usually involves combination of behavioural techniques such as training in deep muscle relaxation and cognitive restructuring techniques aimed at reducing worry and its negative content.