13.2 Anxiety and Dissociative Disorders: Fearing the World Around Us

Anxiety, the nervousness or agitation that we sometimes experience, often about something that is going to happen, 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, which are psychological disturbances marked by irrational fears, often of everyday objects and situations (Kessler, Chiu, Demler, & Walters, 2005).

Generalized Anxiety Disorder

Consider 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:

For a few months now I’ve 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’t know what. It’s like I’m on trial for murder or I’m 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’d rather not go out and stress about the feeling, but now I have it all the time so it doesn’t really make a difference anymore (Chase, 2010).

Chase is probably suffering from a generalized anxiety disorder (GAD), a psychological disorder diagnosed in situations in which a person has been excessively worrying about money, health, work, family life, or relationships for at least six months, even though he or she knows that the concerns are exaggerated, and when the anxiety causes significant distress and dysfunction.

In 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.

About 3% of the general population suffer from GAD, and about two-thirds are women (Kessler, Chiu, Demler, & Walters, 2005; Robins & Regier, 1991). Generalized 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).

Panic Disorder

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’t 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’ voices singing along. I was sure I’d 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).

Ceejay is experiencing panic disorder, a psychological disorder characterized by sudden attacks of anxiety and terror that have led to significant behavioural changes in the person’s life. 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.

Sufferers 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). They 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).

Phobias

A phobia (from the Greek word phobos, which means fear) is a specific fear of a certain object, situation, or activity. 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.

A common phobia is social phobia, extreme shyness around people or discomfort in social situations. 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.

The most incapacitating phobia is agoraphobia, 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 (American Psychiatric Association, 2000). Typical 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.

Phobias are one of the most common anxiety disorders, are among the most common psychiatric illnesses, and are about twice as prevalent in women as in men (Fredrikson, Annas, Fischer, & Wik, 1996; Kessler, Meron-Ruscio, Shear, & Wittchen, 2009). In most cases phobias first appear in childhood and adolescence, and usually persist into adulthood. Table 13.3, “The Most Common Phobias,” presents a list of the common phobias that are diagnosed by psychologists.

Obsessive-Compulsive Disorders

Although 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’ll put my Pepsi cans in the fridge and if there’s one too many then I’ll put it in another cupboard somewhere. I’ve got that problem. I’ll 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).

David Beckham’s 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.

Obsessive-compulsive disorder (OCD) is a psychological disorder that is diagnosed when an individual continuously experiences distressing or frightening thoughts, and engages in obsessions (repetitive thoughts) or compulsions (repetitive behaviours) in an attempt to calm these thoughts. 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’s 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.

Sufferers 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). The course of OCD varies from person to person. Symptoms can come and go, decrease, or worsen over time.

Post-traumatic Stress Disorder (PTSD)

People 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). The anxiety may begin months or even years after the event. People with PTSD experience high levels of anxiety along with reexperiencing the trauma (flashbacks), and a strong desire to avoid any reminders of the event. 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.

PTSD has affected approximately 8% of the population (Kessler, Berglund, Jin, Demler, & Walters, 2005).  PTSD is a frequent outcome of childhood or adultsexual abuse, a disorder that has its ownDiagnostic and Statistical Manual of Mental DisordersDSM diagnosis. Women are more likely to develop PTSD than men (Davidson, 2000).

Romeo Dallaire, seen in Figure 13.7 “Roméo Dallaire,” who  served as Canadian Lieutenant General and Force Commander of UNAMIR, the ill-fated United Nations peacekeeping force for Rwanda in 1993 and 1994,  attempted to stop the genocide that was being waged by Hutu extremists against Tutsis and Hutu moderates. Dallaire has 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 Fellow 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 written 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, They Die Like Children.

Risk factors for PTSD include the degree of the trauma’s severity, the lack of family and community support, and additional life stressors (Brewin, Andrews, & Valentine, 2000). Many people with PTSD also suffer from another mental disorder, particularly depression, other anxiety disorders, and substance abuse (Brady, Back, & Coffey, 2004).

Dissociative Disorders: Losing the Self to Avoid Anxiety

In 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’s 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 of her memories are wiped clean after she goes to sleep. Upon waking, she 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’s husband has to show her their wedding pictures every morning in order to remind her that they’re married. A popular movie, 50 First Dates, is loosely based on Philpots’s story.

People 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 is a condition that involves disruptions or breakdowns of memory, awareness, and identity. The dissociation is used as a defence against the trauma.

Dissociative Amnesia and Fugue

Dissociative amnesia is a psychological disorder that involves extensive, but selective, memory loss, but in which there is no physiological explanation for the forgetting (van der Hart & Nijenhuis, 2009). The amnesia is normally brought on by a trauma — a situation that causes such painful anxiety that the individual “forgets” in order to escape. These kinds of trauma include disasters, accidents, physical abuse, rape, and other forms of severe stress (Cloninger & Dokucu, 2008). Although the personality of people who experience dissociative amnesia remains fundamentally unchanged — and they recall how to carry out daily tasks such as reading, writing, and problem solving — they tend to forget things about their personal lives — for instance, their name, age, and occupation — and may fail to recognize family and friends (van der Hart & Nijenhuis, 2009).

A related disorder, dissociative fugue, 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. 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 (Cardeña & Gleaves, 2007).

Dissociative Identity Disorder

You 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’s life, starring Sally Field as Sybil, appeared in 1976.

Sybil suffered from the most severe of the dissociative disorders, dissociative identity disorder. Dissociative identity disorder 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 (van der Hart & Nijenhuis, 2009). Dissociative identity disorder was once known as multiple personality disorder, and this label is still sometimes used. This disorder is sometimes mistakenly referred to as schizophrenia.

In 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). The host personality is the personality in control of the body most of the time, and the alter personalities tend to differ from each other in terms of age, race, gender, language, manners, and even sexual orientation (Kluft, 1996). A shy, introverted individual may develop a boisterous, extroverted alter personality. Each personality has unique memories and social relationships (Dawson, 1990). Women are more frequently diagnosed with dissociative identity disorder than are men, and when they are diagnosed also tend to have more “personalities” (American Psychiatric Association, 2000).

The 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 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).

Explaining Anxiety and Dissociation Disorders

Both 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.

Also supporting the role of biology, anxiety disorders, including PTSD, are heritable (Hettema, Neale, & Kendler, 2001), and 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).  Neuroimaging 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).  People 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).

Whether 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). And 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). These changes suggest that most anxiety disorders stem from perceived, rather than actual, threats to our well-being.

Anxieties 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. 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’s 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.

In 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; Cardeña & Gleaves, 2007). Kihlstrom, Glisky, and Angiulo (1994) suggest 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).

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Image Attributions

Figure 13.6: Photo courtesy of Raj Patel, http://commons.wikimedia.org/wiki/File:Beckham_LA_Galaxy_cropped.jpg

Figure 13.7: Roméo Dallaire by gdcgraphics (http://commons.wikimedia.org/wiki/File:Rom%C3%A9oDallaire07TIFF.jpg) used under CC BY 2.0 (http://creativecommons.org/licenses/by/2.0/deed.en).

Figure 13.8: http://en.wikipedia.org/wiki/File:Shirley_Ardell_Mason.jpg.