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How Have Psychological Theories Elucidated the Nature of Anxiety: With Particular Reference to Panic Disorder

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How Have Psychological Theories Elucidated the Nature of Anxiety: With Particular Reference to Panic Disorder

Everybody has had experience with anxiety. Indeed anxiety responses have been found in all species right down to the sea slug (Rapee, et al 1998). The concept of anxiety was for a long time bound up with the work of Sigmund Freud where it was more commonly known as neurosis. Freud's concept of neuroses consisted of a number of conditions characterised by irrational and disproportionate fear. Through time it became apparent that the term was a) becoming to wide a term to be of any use in explanation and b) too intimately connected to psychoanalytic theory, of which many of its basic theoretical assumptions were being increasingly called into question. As successive versions of the Diagnostic and Statistical Manual (DSM) were created the term neurosis was eventually superseded by Anxiety disorder.The current version of the Manual (DSM-IV) recognises six specific categories of anxiety: phobias, panic disorder, generalised anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and acute stress disorder. Obviously in an essay such as this it would be impossible to give an adequate account of psychological theories regarding all of these distinct anxiety categories. Instead this essay will focus in on one important diagnostic category, that of Panic Disorder (PD). PD is chosen as it is has such extremely debilitating effects on the patient and has also been shown to incur a large proportion of health care costs relative to other anxiety disorders (Rees, Richards, & Smith, 1998) of which more is said below. This being the case there has been much recent research conducted into elucidating the nature of the condition and this offers a good opportunity to explore the way psychological research can help us to come to an understanding of such conditions in general.The Greek God Pan used to delight in terrifying lone travellers and it is his name that is used for the psychiatric condition known as Panic Disorder, though it has gone under many names including Dacosta's syndrome, soldiers heart, neurasthenia and anxiety hysteria (Baron-Cohen 1997). The condition is characterised by sudden and overwhelming dread. It is now widely recognised that the disorder is not merely an extreme form of ordinary fear but rather a condition with its own causes and treatments. The diagnostic criteria that defines PD in the DSM-IV include: a fear and discomfort that arises suddenly and mounts to high intensity in 10 minutes or less, along with several of the following symptoms: a palpitating or pounding heart, laboured breathing, sweating, trembling, chest pain, nausea, dizziness, numbness and tingling in the hands and feet, chills, hot flushes, choking sensations, a feeling of unreality, or a fear of collapsing, dying or going insane. The diagnostic criteria corresponds well with individual accounts of panic attacks, for example here is an account of a female sufferer:"--It started 10 years ago. I was sitting in a seminar in a hotel and this thing came out of the clear blue. I felt like I was dying. For me panic attack is almost a violent experience. I feel like I'm going insane. It makes me feel like I'm losing control in a very extreme way. My heart pounds really hard, things seem unreal, and there's this very strong feeling of impending doom." (Rapee, 1998) Typical onset of symptoms begin around late twenties and early thirties. There is a 6-month prevalence of panic disorder in major U.S. cities of around 6 in 1000 for men and 10 in 1000 for women (Weissman, 1985; cited in Baker, 1989). Onset is also associated with stressful life experiences (Pollard, Pollard & Corn, 1989; cited in Davison & Neale, 1998). PD is known to occur through a variety of cultures though it often carries with it strong cultural characteristics, for example among the Eskimo people of west Greenland it can take the form of kayak angst where symptoms include intense fear, disorientation and fear of drowning (Davison & Neale, 1998)PD has a high comorbidity with other disorders, which can make diagnosis difficult. It often occurs with or can lead to agoraphobic disorder, especially for women (Hallam, 1985). It often co-exists with major depression (Breier et al, 1986; cited in Davison & Neale, 1998) and/or alcoholism, which may function as a coping strategy, especially for males (Hallam, 1985).Research (Rees, Richards, & Smith, 1998) has shown that PD sufferers have more medical tests, use emergency services more and are more likely to be misdiagnosed than other anxiety groups i.e. social phobics. Sufferers have also been shown to incur health service costs 11 times higher than controls and 5 times higher than social phobics. This may be due to PD sufferers being misdiagnosed in the first place or simply unconvinced by a PD diagnosis in the face of intense feelings of bodily dysfunction, i.e. a perceived feeling of heart attack or choking etc (Rees, Richards, & Smith, 1998).The two prevalent psychological theories for PD are the cognitive model (Clark, 1986, cited in Baker, 1989) and the psychophysiological (PP) model (Ehlers, 1989, cited in Baker, 1989). Both models assume the PD arises as a result of a tendency to associate harmless bodily symptoms (Clark, 1986; cited in Windmann, 1998) or of "bodily and/or cognitive changes" (Ehlers, 1989; cited in Windmann, 1998) with threat of immanent attack. The models consider PD as quantitatively not qualitatively different from normal panic episodes (as opposed to the more medical models which view it as more of a qualitative difference, see Baker, 1989) on a number of different dimensions. Which include the nature of the triggering event (internal vs. external), the nature (somatic vs. psychic) and time factor (sudden vs. gradual) of the dominant symptoms and also the nature of the feared outcomes of the attacks (immediate bodily/mental catastrophes vs. long term negative events, (Margraf & Ehlers; cited in Baker 1989)).Both PP and cognitive models propose that the perception of threat based upon physical symptoms create a positive feedback loop which exacerbates the perceived feeling of panic which spirals up into a full-blown panic attack. The cognitive model refers to this process as 'cognitive misinterpretation' as sufferers erroneously take normal bodily sensations (such as increased heart rate) and catastrophically misinterpret them as signs of physical threats. The PP model extends this idea in that it also proposes that associated conditioning of fear responses can also provide panic provoking mechanisms (McNally, 1994; cited in Windmann, 1998). Any one of the features of the feedback loop could precipitate the panic attack, for instance physiological changes may occur due to activity, drug intake, situational



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