PSYCHOLOGY Etiology of Mental Dysfunction Psychosocial Theories of Anxiety Disorders

1. PSYCHOLOGYEtiology of Mental DysfunctionPsychosocial Theories of Anxiety Disorders Sources: Mental Health Nursing, Fontaine & Fletcher, 4th ed., Addison Wesley Longman, Inc., 1999 Psychiatric Mental Health Nursing, Fortinash & Holoday-Worret, Mosby-Year Book, Inc. 1996 Contemporary Psychiatric-Mental Health Nursing; Kneisl, Wilson & Trogoboff, Pearson Education Inc., New Jersey, 2004 Instructor: Doris O. Aghazarian, M.A., B.Sc.N., R.N.

2. Etiology of Anxiety Disorders(Source 1)Intrapersonal Theory • Intrapersonal theorists view anxiety disorders as a reaction to anticipated future danger based on past experiences such as separation, loss of love and guilt. • The resulting anxiety is pushed out of conscious awareness by the use of repression, projection, displacement or symbolization. • As stress increases, the defenses become increasingly inefficient, symptoms develop and the person engages in repeated self-defeating behaviour.

3. Etiology of Anxiety Disorders(Source 1)Intrapersonal Theory (cont´d) • People suffering from anxiety disorders often have an external locus of control. • In dissociative disorders, stressful life events are disowned and kept out of conscious awareness by amnesia. For example, dissociating abuse and denying the events obliterates the pain. • Anxiety is viewed as a major component of the somatoform disorders, where the original source of the anxiety remains unrecognized and the discomfort is experienced as physical symptoms or disorders. • Somatoform disorders may be unconscious expressions of anger in those unable to communicate such feelings directly. • Physical distress then provides an acceptable excuse for the suffering.

4. Etiology of Anxiety Disorders(Source 2)Intrapersonal Theory (cont´d) • The Intrapersonal Theory is termed the Psychodynamic Model in this source. • It views the disorder in psychoanalytic terms. • Anxiety warns the ego that it is in danger from an internal or external threat. • Anxiety is viewed as a neurosis (Freud´s anxiety neurosis). • It develops in conjunction with maladjustments of the personality and how it functions.

5. Etiology of Anxiety Disorders(Source 2)Intrapersonal Theory (cont´d) • There are three types of anxiety identified in psychoanalytic theory: • Reality anxiety: a painful emotional experience resulting from perception of danger in the external world. The response is fear leading to anxiety. • Moral anxiety: the ego´s experience of guilt and/or shame. • Neurotic anxiety: the perception of a threat from one´s instincts.

6. Etiology of Anxiety Disorders(Source 2)Intrapersonal Theory (cont´d) • In his theory of signal anxiety, Freud postulated that anxiety was a signal of impending emergence of threatening unconscious mental content. • Neurotic symptoms developed in an attempt to defend against anxiety – including hysterical symptoms, obsessions, compulsions and phobias.

7. Etiology of Anxiety Disorders(Source 3)Intrapersonal Theory (cont´d) • In other words, the psychoanalytic theory views anxiety as a sign of psychologic conflict resulting from the threatened emergence into consciousness of forbidden or repressed ideas and/or emotions.

8. Etiology of Anxiety Disorders(Source 3)Intrapersonal Theory (cont´d) • The individual fears expression of the forbidden impulses, which occur in four forms, according to the nature of their consequences: • Superego anxiety: in which people suffer from anxious expectation of guilt if they break their inner code of ethics and standards. • Castration anxiety: or fear of fantasized danger or injuries to the body or genitals. • Separation anxiety: feal of losing the love, esteem and caring of significant people. • Id or impulsive anxiety: fear of the complete annihilation of self.

9. Etiology of Anxiety Disorders(Source 3)Intrapersonal Theory (cont´d) • Other analytic vies, sometimes referred to as neo-Freudian, evolved from the work of Freud and differ about the nature of anxiety. • Rank (1952) believed that anxiety can be traced back to birth trauma. • Sullivan (1953) stressed the importance of the early relationship between the mother and the child and the transmission of the mother´s anxiety to the child.

10. Etiology of Anxiety Disorders(Source 3)Intrapersonal Theory (cont´d) • According to the psychoanalytic model, the unconscious conflict must be brought into conscious awareness so that the real source of anxiety can be discovered and resolved. • Treatment takes the form of analysis or the less time-consuming psychodynamic psychotherapy.

11. Etiology of Anxiety Disorders(Source 1)Interpersonal Theory • Interpersonal theorists believe people with anxiety disorders become anxious when they sense or fear disapproval from significant others. • They may feel trapped in unpleasant circumstances, believing they are unable to leave the situation. • Fearing abandonment, they are unable to behave assertively during conflict, so they develop anxiety as a means of coping.

12. Etiology of Anxiety Disorders(Source 1)Interpersonal Theory (cont´d) • Interpersonal theories focus on the secondary gains for people suffering from somatoform disorders. • Physical symptoms of those with a high degree of dependency may receive a great deal of attention and support. • The sympathy and nurturing these people receive may be a major factor in maintaining the disorder. • The attention from others provides reassurance of care and love, since sick or weak people are in a position of power, and unconsciously attempt to gain and maintain control through their illness.

13. Etiology of Anxiety Disorders(Source 2)Interpersonal Theory • In Source 2 it is said that the interpersonal model views anxiety as a response to the individual´s external environment, rather then the relatively simple psychoanalytic view of a response to instinctual drives. • Particularly Sullivan regarded symptom formation as a result of expectations, insecurities, frustrations, and conflicts between individuals and primary groups. • Primary groups include families, work colleagues and social associates.

14. Etiology of Anxiety Disorders(Source 2)Interpersonal Theory (cont´d) • Like psychoanalystic theorists, interpersonal theorists place a great deal of emphasis on the impact of early development and experiences on later mental health. • Sullivan marks the individual´s experiences of anxiety as the infant´s perception of the anxiety of the mothering person. • The self system develops in the context of approval or disapproval from significant others. Disapproval results in fear leading to anxiety.

15. Etiology of Anxiety Disorders(Source 2)Interpersonal Theory • Interpersonal theorists define anxiety broadly. • Sullivan believed that anxiety is the first great educative experience in living (!) • Sullivan believed that one of the tasks of psychology is to discover the basic vunerabilities to anxiety in inter-personal relations rather than to try to deal with the symptoms of anxiety.

16. Etiology of Anxiety Disorders(Source 3)Interpersonal Theory • Source 3 does not mention the interpersonal model.

17. Etiology of Anxiety Disorders(Source 1)Cognitive Theory • (N.B. Source 1 is the only one that mentions the Cognitive Theory.) • Cognitive theorists believe symptoms develop from ideas and thoughts. • On the basis of limited events, people with anxiety disorders magnify the significance of the past and overgeneralize to the future. • They become preoccupied with impending disaster and self-defeating statements.

18. Etiology of Anxiety Disorders(Source 1)Cognitive Theory (cont´d) • Their cognitive expectations then determine reactions to and behaviour in various situations (Wakefield & Pallister, 1997). • Cognitive theory explains phobic disorders in a three-part sequence:

19. Etiology of Anxiety Disorders(Source 1)Cognitive Theory (cont´d) • Phobic people have negative thoughts that increase anxiety and actually precede the feeling of fear in the phobic situation. Phobic people also have irrational thinking and unrealistic expectations about what might occur if the phobic situation is encountered.

20. Etiology of Anxiety Disorders(Source 1)Cognitive Theory (cont´d) 2. These anticipatory thoughts and feelings enhance the physiological arousal leven even before the phobic situation is encountered. 3. The physiological arousal level is misinterpreted. Although thought to be caused by an external object or situation, the arousal is caused by the negative thoughts and irrational expectations. This mislabeling of feelings causes phobic people to displace the feelings onto objects or situations that can be avoided. (Cantor, 1996)

21. Etiology of Anxiety Disorders(Source 1)Learning Theory • (N.B. Source 1 is also the only one to give the Learning Theory as separate from the behavioural theory) • Phobias may be learned from significant others. If a child observes a parent experienceing anxiety in certain situations, the child may learn that anxiety is the appropriate response. • People may also be explicitly taught by others through warning of impending dangers that e.g. it is dangerous to go out at night and develop night agoraphobia. • Or people may teach themselves anxious behaviour through repeatedly escaping rather than confronting their fears, or through choosing amnesia to avoid pain.

22. Etiology of Anxiety Disorders(Source 1)Behavioural Theory • Closely related to learning theory is the behavioural theory of how phobic disorders develop. • Behavioural theorists believe phobias are conditioned, learned responses. • Classical conditioning occurs when a stimulus results in anxiety or pain. The person then develops a fear of that particular stimulus, e.g. a fear of all dogs after being bitten by a dog. The person responds to this by avoiding any place that the object of the phobia could be present in.

23. Etiology of Anxiety Disorders(Source 1)Behavioural Theory (cont´d) • Since the person experiences less anxiety when avoiding the object or situation, avoidance becomes a habitual response. • B. theorists view OCD as learned responses – maladaptive attempts to reduce anxiety, which have become a habit. • B. theorists believe that somatoform disorders are also learned through conditioning and habitual response to stress through somatization rather than direct dealing with the source of their anxiety.

24. Etiology of Anxiety Disorders(Source 2)Behavioural Theory • Source 2 adds that the etiology of anxiety symptoms detects a progressive generalization from an earlier traumatic experience to a benign setting or object. E.g. A child who is ridiculed while bowling experiences feelings of embarrassment and shame that are carried on to a fear of any sport event till even reading the sports page provokes anxiety or even panic attacks. Any mention, connection with or reference to sports becomes a trigger.

25. Etiology of Anxiety Disorders(Source 2)Behavioural Theory (cont´d) • Early B. Therapists directed their efforts at the anxiety disorder. • Wolpe, a South African physician working with soldiers experiencing what we now call PTSD, reported success using systematic desensitization applied to simple phobia (1973).

26. Etiology of Anxiety Disorders(Source 2)Behavioural Theory (cont´d) • Systemic desensitization is a method derived from learning theory in which the deeply relaxed client is exposed to a graded hierarchy of phobic stimuli. • This method was refined further into a method termed in vivo desensitization where the individual is exposed to progressively more anxiety-provoking situations, accompanied by a therapist. • These live exposure treatments can take a variety of forms, including graded practice, participant modeling and prolonged or brief duration.

27. Etiology of Anxiety Disorders(Source 3)Behavioural Theory • In Source 3 it is said that behaviourists (learning theorists) view anxiety as a learned response that can be unlearned. • The person repeats actions to achieve relief until eventually the act becomes a learned pattern of behaviour.

28. Etiology of Anxiety Disorders(Source 3)Behavioural Theory (cont´d) • Behaviour modification is a treatment approach that teaches clients new ways to behave. • ”Conditioning” techniques – using positive and negative reinforcements – are examples of modification techniques. • Another method of treatment is systematic desensitization, in which a client builds up tolerance to anxiety through gradual exposure to a series of anxiety-provoking stimuli.

29. Etiology of Anxiety Disorders(Source 3)Behavioural Theory (cont´d) • Behavioural approaches are often effective in the treatment of anxiety and are widely used for modifying symptoms in phobic disorder and obsessive-compulsive disorder. • Behavioural therapists believe it is unnecessary to use insight-oriented psychotherapy to induce clients to struggle with anxiety. Instead, clients need only face the anxiety repeatedly until it becomes manageable.

30. Etiology of Anxiety Disorders(Source 3)Behavioural Theory (cont´d) • Behavioural treatment approaches are often used in treating phobic individuals because the method are more efficient, less costly and less time-consuming than insight-oriented psychotherapy treatment. • Like some psychodynamically and psychoanalytically oriented therapists, behavioural therapists tend to avoid the use of medication because they believe it may interfere with the client´s ability to learn more appropriate behaviour.

31. Etiology of Anxiety Disorders(Source 1)Feminist Theory • (N.B. Source 1 is the only one that mentions the Feminist Theory.) • Feminist theory has been used to explain the disproportionate number of women who experience agoraphobia. • These theorists believe women have been reinforced to behave dependently, passively and submissively, which results in adult women who are unable to assume responsibility for themselves and who view themselves as incompetent and helpless. • Often, the symptoms are reinforced by family members who also have been socialized to expect women to be helpless and dependent. Thus, that pattern of withdrawal can continue until the woman is completely homebound (Yonkers and Gurguis, 1995).

32. Etiology of Anxiety Disorders(Source 2)Continuum Model • Source 2 mentions the Continuum Model. • Until the 1980 publication of the DSM-III and the subsequent epidemiologival data obtained in the Epidemiological Catchment Area (ECA) study, the most prevalent view of anxiety disorders was a continuum of neurotic states, increasing in severity. • Disorders characterized by delusions, hallucinations and dementia clearly were outside ordinary experiences. But the experiences of anxiety and depression were common to most people, and the line between normal variance and pathology was blurred.

33. Etiology of Anxiety Disorders(Source 2)Continuum Model (cont´d) • This continuum model was consistent with social agendas aimed at destigmatizing mental illness and eliciting compassion and concern for persons with mental illness. • As more and more research conflicting with the continuum model was conducted and disseminated, it was abandoned in favour of several distinct paradigms, contained it the theories that have been described.

34. Etiology of Anxiety Disorders(Source 2)Continuum Model (cont´d) • Other formulations are better suited to some of the anxiety disorders. • It must be kept in mind that no single model is comprehensive enough to explain etiology of all anxiety, somatization and dissosiative disorders. • The biological and behavioural paradigms or models are the most recent and have the most convincing evidence to explain pathogenesis and treatment strategies.

35. Etiology of Anxiety Disorders(Source 2)SHORT REVISION Etiology models of anxiety and related disorders are: • BIOLOGICAL: Involves dysregulation of neurotransmitter system. Provides framework for symptom development and pharmacotherapeutic intervention. • PSYCHODYNAMIC: Involves unconscious conflict. Provides framework for continuum of anxiety responses as individual attempts to defend against anxiety. • INTERPERSONAL: Involves interaction. Provides framework to explain anxiety responses experienced in relation to other individuals. • BEHAVIOURAL: Involves cognition. Provides framework to explain anxiety as physiological and cognitive responses to external stimuli.

36. Etiology of Anxiety Disorders(Source 3)HUMANISTIC MODEL • Source 3 ends the etiology of anxiety disorders by presenting the Humanistic Model, which encompasses all other models. • The humanistic perspective is particularly important in understanding anxiety disorders.

37. Etiology of Anxiety Disorders(Source 3)HUMANISTIC MODEL (cont´d) • Environmental stressors, biologic factors and intrapsychic fears or conflicts cannot be adequately dealt with separately, but only as they INTERACT WITH ONE ANOTHER! • This perspective has given rise to a multifaceted approach to the care of clients with anxiety isorders. • Humanistic treatment approaches are INTEGRATIVE and may include a range of psychotherapeutic interventions, including psychotherapy (cognitive, behavioural and/or dynamic), measures to develop effective social support systems, measures to reduce environmental stress and psychopharmacologic treatment. • Each ”case” must be individually evaluated and treated.

38. Etiology of Anxiety Disorders(Source 1)MULTIDISCIPLINARY INTERVENTIONS • Source one stresses the following points as a conclusion to this chapter: • Medications play an important role in medical interventions, but intrapersonal and interpersonal aspects must also be treated. • Clients and their families need to cope with various aspects of anxiety, learn to take control of their lives and manage family stress. • Therefore, the best treatment is accomplished through a blending of techniques and the use of individual, family and group psychotherapy.

39. Etiology of Anxiety Disorders(Source 3)EMPHASIS ON BEHAVRIOURAL THERAPY • The most effective behavioural interventions technique is exposure and response prevention. Clients are exposed, in reality or in their mind, to feared situations or objects and try to refrain from or delay their usual phobic or ritualistic response. Gradually, the unwanted response disappear. • Stress inoculation training involves rehearsing other coping skills and testing these skills under stressful situations. • Hypnosis is also effective, especially in DID. • Nonverbal therapies such as play therapy, art therapy, occupational therapy and especially journal writing are extensively used and produce very good results.

40. Etiology of Anxiety Disorders(Source 3)CONCLUSION Where there is a way, there is a will... (D.O.A.)