{"id":290,"date":"2013-11-21T19:00:37","date_gmt":"2013-11-21T19:00:37","guid":{"rendered":"http:\/\/opentextbc.ca\/introductiontopsychology\/?post_type=chapter&p=290"},"modified":"2016-11-22T18:33:39","modified_gmt":"2016-11-22T18:33:39","slug":"12-2-anxiety-and-dissociative-disorders-fearing-the-world-around-us","status":"publish","type":"chapter","link":"https:\/\/opentextbc.ca\/introductiontopsychology\/chapter\/12-2-anxiety-and-dissociative-disorders-fearing-the-world-around-us\/","title":{"raw":"13.2 Anxiety and Dissociative Disorders: Fearing the World Around Us","rendered":"13.2 Anxiety and Dissociative Disorders: Fearing the World Around Us"},"content":{"raw":"
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Learning Objectives<\/h3>\r\n
    \r\n \t
  1. Outline and describe the different types of anxiety disorders.<\/li>\r\n \t
  2. Outline and describe the different types of dissociative disorders.<\/li>\r\n \t
  3. Explain the biological and environmental causes of anxiety and dissociative disorders.<\/li>\r\n<\/ol>\r\n<\/div>\r\nAnxiety<\/strong>, the nervousness or agitation that we sometimes experience, often about something that is going to happen<\/em>, is a natural part of life. We all feel anxious at times, maybe when we think about our upcoming visit to the dentist or the presentation we have to give to our class next week. Anxiety is an important and useful human emotion; it is associated with the activation of the sympathetic nervous system and the physiological and behavioural responses that help protect us from danger. But too much anxiety can be debilitating, and every year millions of people suffer from anxiety disorders<\/strong>, which are psychological disturbances marked by irrational fears, often of everyday objects and situations<\/em> (Kessler, Chiu, Demler, & Walters, 2005).\r\n

    Generalized Anxiety Disorder<\/h2>\r\nConsider the following, in which Chase describes her feelings of a persistent and exaggerated sense of anxiety, even when there is little or nothing in her life to provoke it:\r\n

    For a few months now I\u2019ve had a really bad feeling inside of me. The best way to describe it is like a really bad feeling of negative inevitability, like something really bad is impending, but I don\u2019t know what. It\u2019s like I\u2019m on trial for murder or I\u2019m just waiting to be sent down for something. I have it all of the time but it gets worse in waves that come from nowhere with no apparent triggers. I used to get it before going out for nights out with friends, and it kinda stopped me from doing it as I\u2019d rather not go out and stress about the feeling, but now I have it all the time so it doesn\u2019t really make a difference anymore (Chase, 2010).<\/p>\r\nChase is probably suffering from a generalized anxiety disorder (GAD)<\/strong>, a psychological disorder diagnosed in situations in which a person has been excessively worrying about money, health, work, family life, or relationships <\/em>for at least\u00a0six months, even though he or she knows that the concerns are exaggerated, and when the anxiety causes significant distress and dysfunction.\r\n\r\nIn addition to their feelings of anxiety, people who suffer from GAD may also experience a variety of physical symptoms, including irritability, sleep troubles, difficulty concentrating, muscle aches, trembling, perspiration, and hot flashes. The sufferer cannot deal with what is causing the anxiety, nor avoid it, because there is no clear cause for anxiety. In fact, the sufferer frequently knows, at least cognitively, that there is really nothing to worry about.\r\n\r\nAbout 3% of the general population suffer from GAD, and about two-thirds are women (Kessler, Chiu, Demler, & Walters, 2005; Robins & Regier, 1991).\u00a0Generalized anxiety disorder is most likely to develop between the ages of seven and 40 years, but its influence may in some cases lessen with age (Rubio & Lopez-Ibor, 2007).\r\n

    Panic Disorder<\/h2>\r\n

    When I was about 30 I had my first panic attack. I was driving home, my three little girls were in their car seats in the back, and all of a sudden I couldn\u2019t breathe, I broke out into a sweat, and my heart began racing and literally beating against my ribs! I thought I was going to die. I pulled off the road and put my head on the wheel. I remember songs playing on the CD for about 15 minutes and my kids\u2019 voices singing along. I was sure I\u2019d never see them again. And then, it passed. I slowly got back on the road and drove home. I had no idea what it was (Ceejay, 2006).<\/p>\r\nCeejay is experiencing panic disorder<\/strong>, a psychological disorder characterized by sudden attacks of anxiety and terror that have led to significant behavioural changes in the person\u2019s life<\/em>. Symptoms of a panic attack include shortness of breath, heart palpitations, trembling, dizziness, choking sensations, nausea, and an intense feeling of dread or impending doom. Panic attacks can often be mistaken for heart attacks or other serious physical illnesses, and they may lead the person experiencing them to go to a hospital emergency room. Panic attacks may last as little as one or as much as 20 minutes, but they often peak and subside within about 10 minutes.\r\n\r\nSufferers are often anxious because they fear that they will have another attack. They focus their attention on the thoughts and images of their fears, becoming excessively sensitive to cues that signal the possibility of threat (MacLeod, Rutherford, Campbell, Ebsworthy, & Holker, 2002).\u00a0They may also become unsure of the source of their arousal, misattributing it to situations that are not actually the cause. As a result, they may begin to avoid places where attacks have occurred in the past, such as driving, using an elevator, or being in public places. In Canada, 12-month and lifetime prevalence rates for panic attacks are 1.6% and 3.7%, respectively (Health Canada, 2006).\r\n

    Phobias<\/h2>\r\nA phobia<\/strong> (from the Greek word phobos<\/em>, which means fear) is a specific fear of a certain object, situation, or activity<\/em>. The fear experience can range from a sense of unease to a full-blown panic attack. Most people learn to live with their phobias, but for others the fear can be so debilitating that they go to extremes to avoid the fearful situation. A sufferer of arachnophobia (fear of spiders), for example, may refuse to enter a room until it has been checked thoroughly for spiders, or may refuse to vacation in the countryside because spiders may be there. Phobias are characterized by their specificity and their irrationality. A person with acrophobia (a fear of height) could fearlessly sail around the world on a sailboat with no concerns yet refuse to go out onto the balcony on the fifth floor of a building.\r\n\r\nA common phobia is social phobia<\/strong>, extreme shyness around people or discomfort in social situations<\/em>. Social phobia may be specific to a certain event, such as speaking in public or using a public restroom, or it can be a more generalized anxiety toward almost all people outside of close family and friends. People with social phobia will often experience physical symptoms in public, such as sweating profusely, blushing, stuttering, nausea, and dizziness. They are convinced that everybody around them notices these symptoms as they are occurring. Women are somewhat more likely than men to suffer from social phobia.\r\n\r\nThe most incapacitating phobia is agoraphobia<\/strong>, defined as anxiety about being in places or situations from which escape might be difficult or embarrassing, or in which help may not be available<\/em> (American Psychiatric Association, 2000).\u00a0Typical places that provoke the panic attacks are parking lots; crowded streets or shops; and bridges, tunnels, or expressways. People (mostly women) who suffer from agoraphobia may have great difficulty leaving their homes and interacting with other people.\r\n\r\nPhobias are one of the most common anxiety disorders, are among the most common psychiatric illnesses,\u00a0and are about twice as prevalent in women as\u00a0in men (Fredrikson, Annas, Fischer, & Wik, 1996; Kessler, Meron-Ruscio, Shear, & Wittchen, 2009).\u00a0In most cases phobias first appear in childhood and adolescence, and usually persist into adulthood. Table 13.3, \"The Most Common Phobias,\"\u00a0presents a list of the common phobias that are diagnosed by psychologists.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
    Table 13.3 The Most Common Phobias.<\/caption>\r\n
    Name<\/th>\r\nDescription<\/th>\r\n<\/tr>\r\n<\/thead>\r\n
    Acrophobia<\/td>\r\nFear of heights<\/td>\r\n<\/tr>\r\n
    Agoraphobia<\/td>\r\nFear of situations in which escape is difficult<\/td>\r\n<\/tr>\r\n
    Arachnophobia<\/td>\r\nFear of spiders<\/td>\r\n<\/tr>\r\n
    Astraphobia<\/td>\r\nFear of thunder and lightning<\/td>\r\n<\/tr>\r\n
    Claustrophobia<\/td>\r\nFear of closed-in spaces<\/td>\r\n<\/tr>\r\n
    Cynophobia<\/td>\r\nFear of dogs<\/td>\r\n<\/tr>\r\n
    Mysophobia<\/td>\r\nFear of germs or dirt<\/td>\r\n<\/tr>\r\n
    Ophidiophobia<\/td>\r\nFear of snakes<\/td>\r\n<\/tr>\r\n
    Pteromerhanophobia<\/td>\r\nFear of flying<\/td>\r\n<\/tr>\r\n
    Social phobia<\/td>\r\nFear of social situations<\/td>\r\n<\/tr>\r\n
    Trypanophobia<\/td>\r\nFear of injections<\/td>\r\n<\/tr>\r\n
    Zoophobia<\/td>\r\nFear of small animals<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n

    Obsessive-Compulsive Disorders<\/h2>\r\nAlthough he is best known his perfect shots on the field, the British soccer star David Beckham (Figure 13.6, \"David Beckham\") also suffers from obsessive-compulsive disorder (OCD). As he describes it, \"I have got this obsessive-compulsive disorder where I have to have everything in a straight line or everything has to be in pairs. I\u2019ll put my Pepsi cans in the fridge and if there\u2019s one too many then I\u2019ll put it in another cupboard somewhere. I\u2019ve got that problem. I\u2019ll 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\" (Dolan, 2006).\r\n\r\nDavid Beckham\u2019s experience with obsessive behaviour is not unusual. We all get a little obsessive at times. We may continuously replay a favorite song in our heads, worry about getting the right outfit for an upcoming party, or find ourselves analyzing a series of numbers that seem to have a certain pattern. And our everyday compulsions can be useful. Going back inside the house once more to be sure that we really did turn off the sink faucet or checking the mirror a couple of times to be sure that our hair is combed are not necessarily bad ideas.\r\n\r\n[caption id=\"attachment_288\" align=\"aligncenter\" width=\"300\"]\"""\"<\/a> Figure 13.6 David Beckham. Source:[\/caption]\r\n\r\nObsessive-compulsive disorder (OCD)<\/strong> is a psychological disorder that is diagnosed when an individual continuously experiences distressing or frightening thoughts, and engages in<\/em> obsessions<\/strong> (repetitive thoughts) or<\/em> compulsions<\/strong> (repetitive behaviours) in an attempt to calm these thoughts<\/em>. OCD is diagnosed when the obsessive thoughts are so disturbing and the compulsive behaviours are so time consuming that they cause distress and significant dysfunction in a person\u2019s everyday life. Washing your hands once or even twice to make sure that they are clean is normal; washing them 20 times is not. Keeping your fridge neat is a good idea; spending hours a day on it is not. The sufferers know that these rituals are senseless, but they cannot bring themselves to stop them, in part because the relief that they feel after they perform them acts as a reinforcer, making the behaviour more likely to occur again.\r\n\r\nSufferers of OCD may avoid certain places that trigger the obsessive thoughts, or use alcohol or drugs to try to calm themselves down. OCD has a low prevalence rate (about 1% of the population in a given year) in relation to other anxiety disorders, and usually develops in adolescence or early adulthood (Horwath & Weissman, 2000; Samuels & Nestadt, 1997).\u00a0The course of OCD varies from person to person. Symptoms can come and go, decrease, or worsen over time.\r\n

    Post-traumatic Stress Disorder (PTSD)<\/h2>\r\nPeople who have survived a terrible ordeal, such as combat, torture, sexual assault, imprisonment, abuse, natural disasters, or the death of someone close to them may develop post-traumatic stress disorder (PTSD)<\/em>. The anxiety may begin months or even years after the event. People with PTSD<\/strong> experience high levels of anxiety<\/em> along with reexperiencing<\/em> the trauma (flashbacks), and a strong desire to avoid any reminders of the event<\/em>. They may lose interest in things they used to enjoy; startle easily; have difficulty feeling affection; and may experience terror, rage, depression, or insomnia. The symptoms may be felt especially when approaching the area where the event took place or when the anniversary of that event is near.\r\n\r\nPTSD has affected approximately 8%\u00a0of the population (Kessler, Berglund, Jin, Demler, & Walters, 2005). \u00a0PTSD is a frequent outcome of childhood or adultsexual abuse<\/em>, a disorder that has its ownDiagnostic and Statistical Manual of Mental Disorders<\/em>DSM<\/em> diagnosis. Women are more likely to develop PTSD than men (Davidson, 2000).\r\n\r\nRomeo Dallaire, seen in Figure 13.7 \"Rom\u00e9o Dallaire,\" who\u00a0\u00a0served as Canadian Lieutenant General and Force Commander of UNAMIR, the ill-fated United Nations peacekeeping force for Rwanda in\u00a01993 and 1994, \u00a0attempted to stop the genocide that was being waged by Hutu extremists against Tutsis and Hutu moderates. Dallaire\u00a0has worked to bring understanding of post-traumatic stress disorder to the general public. He was a visiting lecturer at several Canadian and American universities and a\u00a0Fellow of the Carr Center for Human Rights Policy, Kennedy School of Government at Harvard University. He has also pursued research on conflict resolution and the use of child soldiers and\u00a0written several articles and chapters in publications on conflict resolution, humanitarian assistance, and human rights. Recently he wrote a book about the use of child soldiers, They Fight Like Soldiers,\u00a0They Die Like Children<\/em>.\r\n\r\n[caption id=\"attachment_4401\" align=\"aligncenter\" width=\"200\"]\"""\"<\/a> Figure 13.7 Rom\u00e9o Dallaire.[\/caption]\r\n\r\nRisk factors for PTSD include the degree of the trauma\u2019s severity, the lack of family and community support, and additional life stressors (Brewin, Andrews, & Valentine, 2000).\u00a0Many people with PTSD also suffer from another mental disorder, particularly depression, other anxiety disorders, and substance abuse (Brady, Back, & Coffey, 2004).\r\n

    Dissociative Disorders: Losing the Self to Avoid Anxiety<\/h2>\r\nIn 1985, Michelle Philpots of England suffered a head injury in a motorcycle accident. Five years later, she reinjured her head in a serious car accident. These injuries did enough cumulative damage to Philpots\u2019s brain that she eventually started having seizures and was diagnosed with epilepsy. By 1994, she was suffering from anterograde amnesia and had completely lost the ability to create new memories, as all\u00a0of her memories are wiped clean after she goes\u00a0to sleep.\u00a0Upon waking,\u00a0she believes that it is still 1994. Even though Philpots was in a relationship with her husband long before she suffered amnesia, they did not actually get married until 1997. As a result, Philpots\u2019s husband has to show her their wedding pictures every morning in order to remind her that they\u2019re married. A popular movie, 50 First Dates,<\/em> is loosely based on Philpots's story.\r\n\r\nPeople who experience anxiety are haunted by their memories and experiences, and although they desperately wish to get past them, they normally cannot. In some cases, however, such as with Michelle Philpots, people who become overwhelmed by stress experience an altered state of consciousness in which they become detached from the reality of what is happening to them. A dissociative disorder<\/strong> is a condition that involves disruptions or breakdowns of memory, awareness, and identity<\/em>. The dissociation is used as a defence against the trauma.\r\n

    Dissociative Amnesia and Fugue<\/h2>\r\nDissociative amnesia<\/strong> is a psychological disorder that involves extensive, but selective, memory loss, but in which there is no physiological explanation for the forgetting<\/em> (van der Hart & Nijenhuis, 2009).\u00a0The amnesia is normally brought on by a trauma \u2014 a situation that causes such painful anxiety that the individual \u201cforgets\u201d in order to escape. These kinds of trauma include disasters, accidents, physical abuse, rape, and other forms of severe stress (Cloninger & Dokucu, 2008).\u00a0Although the personality of people who experience dissociative amnesia remains fundamentally unchanged \u2014 and they recall how to carry out daily tasks such as reading, writing, and problem solving \u2014 they tend to forget things about their personal lives \u2014 for instance, their name, age, and occupation \u2014 and may fail to recognize family and friends (van der Hart & Nijenhuis, 2009).\r\n\r\nA related disorder, dissociative fugue<\/strong>, is a psychological disorder in which an individual loses complete memory of his or her identity and may even assume a new one, often far from home<\/em>. The individual with dissociative fugue experiences all the symptoms of dissociative amnesia but also leaves the situation entirely. The fugue state may last for just a matter of hours or may continue for months. Recovery from the fugue state tends to be rapid, but when people recover they commonly have no memory of the stressful event that triggered the fugue or of events that occurred during their fugue state (Carde\u00f1a & Gleaves, 2007).\r\n

    Dissociative Identity Disorder<\/h2>\r\nYou may remember the story of Sybil (a pseudonym for Shirley Ardell Mason, who was born in 1923), a person who, over a period of 40 years, claimed to possess 16 distinct personalities (Figure 13.8, \"Sybil\"). Mason was in therapy for many years trying to integrate these personalities into one complete self. A TV movie about Mason\u2019s life, starring Sally Field as Sybil, appeared in 1976.\r\n\r\n[caption id=\"attachment_289\" align=\"aligncenter\" width=\"200\"]\"""\"<\/a> Figure 13.8 Sybil. Shirley Ardell Mason.[\/caption]\r\n\r\nSybil suffered from the most severe of the dissociative disorders, dissociative identity disorder<\/em>. Dissociative identity disorder<\/strong> is a psychological disorder in which two or more distinct and individual personalities exist in the same person, and there is an extreme memory disruption regarding personal information about the other personalities<\/em> (van der Hart & Nijenhuis, 2009).\u00a0Dissociative identity disorder was once known as multiple personality disorder<\/em>, and this label is still sometimes used. This disorder is sometimes mistakenly referred to as schizophrenia.\r\n\r\nIn some cases of dissociative identity disorder, there can be more than 10 different personalities in one individual. Switches from one personality to another tend to occur suddenly, often triggered by a stressful situation (Gillig, 2009).\u00a0The host personality<\/strong> is the personality in control of the body most of the time<\/em>, and the alter personalities<\/em> tend to differ from each other in terms of age, race, gender, language, manners, and even sexual orientation (Kluft, 1996).\u00a0A shy, introverted individual may develop a boisterous, extroverted alter personality. Each personality has unique memories and social relationships (Dawson, 1990).\u00a0Women are more frequently diagnosed with dissociative identity disorder than are men, and when they are diagnosed also tend to have more \u201cpersonalities\u201d (American Psychiatric Association, 2000).\r\n\r\nThe dissociative disorders are relatively rare conditions and are most frequently observed in adolescents and young adults. In part because they are so unusual and difficult to diagnose, clinicians and researchers disagree about the legitimacy of the disorders, and particularly about dissociative identity disorder. Some clinicians argue that the descriptions in the DSM<\/em> accurately reflect the symptoms of these patients, whereas others believe that patients are faking, role-playing, or using the disorder as a way to justify behaviour (Barry-Walsh, 2005; Kihlstrom, 2004; Lilienfeld & Lynn, 2003; Lipsanen et al., 2004). Even the diagnosis of Shirley Ardell Mason (Sybil) is disputed. Some experts claim that Mason was highly hypnotizable and that her therapist unintentionally suggested the existence of her multiple personalities (Miller & Kantrowitz, 1999).\r\n

    Explaining Anxiety and Dissociation Disorders<\/h2>\r\nBoth nature and nurture contribute to the development of anxiety disorders. In terms of our evolutionary experiences, humans have evolved to fear dangerous situations. Those of us who had a healthy fear of the dark, of storms, of high places, of closed spaces, and of spiders and snakes were more likely to survive and have descendants. Our evolutionary experience can account for some modern fears as well. A fear of elevators may be a modern version of our fear of closed spaces, while a fear of flying may be related to a fear of heights.\r\n\r\nAlso supporting the role of biology, anxiety disorders, including PTSD, are heritable (Hettema, Neale, & Kendler, 2001),\u00a0and molecular genetics studies have found a variety of genes that are important in the expression of such disorders (Smoller et al., 2008; Thoeringer et al., 2009).\u00a0\u00a0Neuroimaging studies have found that anxiety disorders are linked to areas of the brain that are associated with emotion, blood pressure and heart rate, decision making, and action monitoring (Brown & McNiff, 2009; Damsa, Kosel, & Moussally, 2009).\u00a0\u00a0People who experience PTSD also have a somewhat smaller hippocampus in comparison with those who do not, and this difference leads them to have a very strong sensitivity to traumatic events (Gilbertson et al., 2002).\r\n\r\nWhether the genetic predisposition to anxiety becomes expressed as a disorder depends on environmental factors. People who were abused in childhood are more likely to be anxious than those who had normal childhoods, even with the same genetic disposition to anxiety sensitivity (Stein, Schork, & Gelernter, 2008).\u00a0And the most severe anxiety and dissociative disorders, such as PTSD, are usually triggered by the experience of a major stressful event. One problem is that modern life creates a lot of anxiety. Although our life expectancy and quality of life have improved over the past 50 years, the same period has also created a sharp increase in anxiety levels (Twenge, 2006).\u00a0These changes suggest that most anxiety disorders stem from perceived, rather than actual, threats to our well-being.\r\n\r\nAnxieties are also learned through classical and operant conditioning. Just as rats that are shocked in their cages develop a chronic anxiety toward their laboratory environment (which has become a conditioned stimulus for fear), rape victims may feel anxiety when passing by the scene of the crime, and victims of PTSD may react to memories or reminders of the stressful event. Classical conditioning may also be accompanied by stimulus generalization<\/em>. A single dog bite can lead to generalized fear of all dogs; a panic attack that follows an embarrassing moment in one place may be generalized to a fear of all public places. People\u2019s responses to their anxieties are often reinforced. Behaviours become compulsive because they provide relief from the torment of anxious thoughts. Similarly, leaving or avoiding fear-inducing stimuli leads to feelings of calmness or relief, which reinforces phobic behaviour.\r\n\r\nIn contrast to the anxiety disorders, the causes of the dissociative orders are less clear, which is part of the reason that there is disagreement about their existence. Unlike most psychological orders, there is little evidence of a genetic predisposition; they seem to be almost entirely environmentally determined. Severe emotional trauma during childhood, such as physical or sexual abuse, coupled with a strong stressor, is typically cited as the underlying cause (Alpher, 1992; Carde\u00f1a & Gleaves, 2007).\u00a0Kihlstrom, Glisky, and Angiulo (1994)\u00a0suggest that people with personalities that lead them to fantasize and become intensely absorbed in their own personal experiences are more susceptible to developing dissociative disorders under stress. Dissociative disorders can in many cases be successfully treated, usually by psychotherapy (Lilienfeld & Lynn, 2003).\r\n
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    Key Takeaways<\/h3>\r\n