Very urgent
For a small part of a business plan, I need to think of two novel services that can meet a client’s needs, I have to write at least 2 pages, and I also put the rest of the team up, and need to maintain a uniform level
All requirements are in the attachment and I high light the part for me.All information is based on our entrepreneurial project and the parts completed by other team members
Two novel service ideas or products that can be used in our program
Assignment 1: Identifying Unmet Needs
DO NOT COPY PASTE BUT PARAPHRASE!!!!!!
1: Nature of the area + the potential (one paragraph each)
Accessibility Consulting Company
Nature: description of the business (use info from last term: what is it, components of the business)
We have selected the tourism industry but more particularly the accessible tourism area as our area of interest. Accessible tourism is tourism dedicated to people having special needs and is not yet developed enough. We believe disabled people should be able to enjoy the tourism industry, no matter if they are able to walk or not, to see or not or to hear or not.
We would like to create an online platform in the form of a website in California, USA, that gives users access to places with accessibility features. Due to California’s population of more than 6 million disabled adults, we believe it is the best location for us to develop this project (CDC, 2022).
Our headquarters would be in California due to its high rate of mobility and we would like to concentrate on a particular city with significant demand before expanding. We aim to serve as the link between disabled customers and businesses given the fact there is a huge gap that needs to be filled.
Due to our conviction that persons with any physical limitations should have greater access to information, we made the decision to design this whole new concept.
What exactly is it about? Our main objective is to give consumers who are concerned about impairment access to clear information so they can verify any infrastructures imposed by the destinations. It does not only apply to hotel facilities, but also to catering, transportation, and excursions disabled people would like to participate in.
We provide a website platform where customers can directly access information that has been updated by businesses and locations regarding the degree of accessibility accommodations they have. The business owner only needs to pay a fee to register on our website, and after that, we would have an automated system that would authenticate their registration and only require them to supply the required paperwork. It is done in order to verify the veracity of the information they share on our site.
Customers simply need to tap once on their phone to gain immediate access to the provided information. It would be convenient for them since they do not have to browse for places that might be capable of accommodating them (or not). Additionally, this would lessen information communication errors brought on by conflicting contact information.
People now have the ability to communicate nationally and globally, which was previously impossible, via the internet. The advancement of the internet and the development of technology have provided countless opportunities for communication among persons with impairments. Utilizing the advantages provided by the internet such as placing online orders for goods and services to have everything delivered right to their door or participating in excursions that are mobility-friendly is a smart way to make things move. The services can be given with just a tap on their devices. Even if a person lacks the physical capacity to locate the information, they can still do so through our website.
We would develop a powerful marketing strategy to convince the companies interest in working with us to better attract the publics attention. Releasing explicit information to spread awareness and keeping up with social media activity is a good way to attract customers. Moreover, we also want to work with other platforms that are attempting to strengthen the arguments for this community. There are certain platforms that are introducing vacation packages for those with physical disabilities but this is an opportunity for us to provide a wider variety of choices from which to select.
The potential:
In todays world, disabled people are either confirming through contact with the establishments or simply trying their luck to see if they can be accommodated; there are no dedicated platforms that are focusing on boosting information collection to give ease to this population.
“More than 1 billion individuals live with a disability worldwide” (Who, 2021). It makes up 15% of the world’s population, 3.8% of which have functional difficulties, necessitating the provision of supplementary care services (Who, 2021).
In fact, people with disabilities have made the decision to travel less, primarily because of the poor services they received but also because they had to double-check every place they go to make sure the facilities are fully functional. At some point, it is too much effort for, most of the time, negative outcomes. In fact, a study shows that seven out of ten respondents with impairments said they travel less frequently every day because of their constraints (Bts, 2022).
Regarding Californias population, 6.7 million Californians, or 1 in 4 of the state’s adult population, are disabled, making up 23% of the adult population (CDC, 2022). It is therefore a market where solutions may be more than needed and useful for disabled people.
The market’s depreciation has, however, decreased the flow of reliable information, prompting customers to take extra precautions to make sure that offers are consistent with the facilities they require. This element affects a visitor’s perception of their entire trip. Explaining the facilities and the number of guests they can hold in detail is the simplest way to allay client anxieties. The destinations face difficulties due to the demand for more professional help in this area. We specifically intervene in this situation to satisfy the needs of the client. Disability discrimination disturbs people since it subjects them to unfair treatment as a result of our society’s ignorance.
2:
Disabled people face challenging situations on a daily basis because of their physical condition. The number of problems they are facing is infinite but can be regrouped into different categories. First of all, transportation is not easy for them given the fact that it is not always adapted for people with special needs. Lets take a pretty simple example. In Paris, a historical city and capital of France, metro stations are decades old and were built with stairs given the fact elevators did not exist. Today, it is impossible to place elevators in those kinds of stations because of the way the metro station has been built at first. Walls cannot be demolished or the whole metro station will be destroyed.
Moreover, they can face accessibility issues in many places such as hotels, restaurants or any touristic places.
Concerning the hotel industry, disabled people have special requirements that are often ignored by persons that have never faced this kind of challenge. By this fact, when it comes for example to hotels, they receive poor service because of this lack of knowledge from the employees. It is therefore easy to conclude that hotel employees are not trained adequately which fosters severe prejudice against people with disabilities (Who,2021).
To go further, a study from the Bureau of Transportation Statistics shows that 7 out of 10 participants with disabilities travel less frequently every day because of their condition (Bts, 2022). It is confirmed by a study from NHTS that emphasises the fact that 34.1% of people with disabilities between the ages of 18 and 64 do not travel daily (Gov, 2018). It is reliable given the fact that some hotels are not accessible enough. In other words, some hotels in California do not respect the ADA standards, standing for The Americans with Disabilities Act. It has been established in order to make sure every type of customer can access the property, whatever their physical conditions to avoid any kind of discrimination.
Accessible rooms are also impacted by the usual demand and supply relationship in economics. In fact, accessible rooms in hotels are really limited and therefore are proposed at a higher price which is completely unfair for disabled customers that only want to travel as everyone does. At the cost of their disability, they need to spend more money than a regular customer for a service quality that is most of the time inferior than the one received by normal guests.
To better illustrate the previous discussion, we would like to share a lawcase regarding the breach of the ADA standards from a hotel. A disabled person wanted to go on a trip and therefore booked a room that was mentioned as accessible on the hotels website. The customer called the hotel to confirm that the room is indeed accessible but also that the room is available for her stay dates. The hotel clearly confirmed all those information but once the customer reached the hotel, the property was not able to offer them an available room. If it was with a regular customer, the employees could have found another room but, in this case, the guest was not even able to stay at the hotel because of her physical condition. This is a perfect example of unmet needs within the hotel industry towards disabled persons (EIN News, 2019).
Finally, disabled people also like to travel around the world as they are not different in this aspect and would like to live some experiences as everyone does like going up the mountains or visiting a winery just to illustrate it. Let’s use the example of a customer who wants to take a boat trip to demonstrate earlier assertions. A person without any disabilities will have no trouble accessing the boat, but what about someone with a disability? Consider that if the disabled person requires a wheelchair, it would be impossible for them to enter the boat without assistance. As a result, a disabled individual won’t consider getting into a boat because he already knows it will be problematic.
From a more general perspective, disabled people must conduct thorough research to ensure that the establishment is accessible. This set of people will not visit if the website does not provide enough information or the amenities are not up to par. This is applicable to any tourism industry nowadays and this lack of information is clearly discrimination towards disabled people that never asked for anything else than visiting places that actually meet their physical needs.
Moreover, disabled people are facing emotional stress and social isolation because of their limited capacity to go outside and enjoy life as a person without a disability can. This is due to the lack of accessibility in California in an infinite number of places. Melina Karp, Vice President of Consumer Centered Quality at Commonwealth Care Alliance says: When a persons disability includes a mobility impairment, one issue that can arise is increased physical and social isolation. As opportunities for social engagement get smaller and smaller based on an individuals ability to navigate their physical surroundings, depression and anxiety can also develop (Seervai, S., Shah, A., & Shah, T. ,2019). Therefore, there is a real need to move things in order for disabled people to reduce stress related to their physical condition and increase their mental well-being.
A physical need is an important preoccupation today in California that needs to be changed as quickly as possible. Disabled people have the right to live a normal life and to be able to enjoy travel experiences without being worried whether their physical condition allows them to access this place or not.
JUSTIFICATION + EXAMPLES
Disability and health. (2021). Retrieved 11 October 2022, from
https://www.who.int/news-room/fact-sheets/detail/disability-and-health
Bts. (2022). Travel Patterns of American Adults with Disabilities | Bureau of Transportation Statistics. Retrieved 11 October 2022, from
https://www.bts.gov/travel-patterns-with-disabilities
Gov. (2018). Travel Patterns of American Adults with Disabilities | Bureau of Transportation Statistics. Retrieved 11 October 2022, from
https://www.bts.gov/travel-patterns-with-disabilities
EIN News. (2019). Retrieved 11 October 2022, from
https://www.einnews.com/pr_news/495508829/dannlaw-files-lawsuit-alleging-homewood-suites-by-hilton-mahwah-and-hilton-worldwide-repeatedly-violated-the-ada
Seervai, S., Shah, A., & Shah, T. (2019). The Challenges of Living with a Disability in America, and How Serious Illness Can Add to Them. Retrieved 12 October 2022, from
https://www.commonwealthfund.org/publications/fund-reports/2019/apr/challenges-living-disability-america-and-how-serious-illness-can
A. Okoro, C. (2018). Prevalence of Disabilities and Health Care Access by Disability Status and Type Among Adults United States, 2016. Retrieved 11 August 2022, from
https://www.cdc.gov/ncbddd/disabilityandhealth/infographic-disability-impacts-all.html
Disabled People in the World: Facts and Figures. (2021). Retrieved 11 August 2022, from
Bts. (2022). Travel Patterns of American Adults with Disabilities | Bureau of Transportation Statistics. Retrieved 11 August 2022, from
https://www.bts.gov/travel-patterns-with-disabilities
Assignment 2: Generating Products to Meet the Unmet Need
In Assignment 1 you identified unmet needs that you could target with a new product. In this assignment, do the following:
Organize the customer needs and come up with a set of product specifications that could meet those needs better than current products.
Generate Concept(s). This is a brainstorm-type exercise. Come up with at least five ideas that could meet these unmet needs. These could be physical products, a set of services, or some combination. Use your imagination.
Refine the concept using ideas in Chapter 5 of your textbook. You do not have to go through ALL the steps described in the textbook, as that would be too extensive.
Describe the final product form. Describe the market for that product by defining who would buy it and what kinds of products it would pull sales away from. Make sure you have searched for similar products in similar markets on the internet (so you have to describe the market as well).
In each step, but especially Steps 1 and 4, provide your reasoning for your choices.
Written reports should show professional quality. They should be well-written and well-organized. Use paragraphs and topical paragraph headings. Where appropriate, organize your report by the questions asked in the assignment. It is a good idea to state the question as a paragraph heading, then give your answer to the question. Then reread the question and answer together to be sure your answer addresses the specific question. Leave a space between paragraphs. Bullet points are allowed.
Reports must include a cover sheet, like what you would use if submitting a printed report. Your cover sheet should include the Course Name, Assignment Title, Date of Submission, and the full names and nicknames of each member of the group. Only ONE group member should submit the report on Canvas.
Prepare your report in a word processor with a spelling and grammar checker. If your English is not strong, you are likely to need stronger grammar checking than what is available in MS Word.
When your report is fully proofed and is formatted the way you want it, save your final version on your computer, then also save it as a PDF file. Submit your PDF before the deadline at the link in Canvas for the assignment’s submission. All written work must be submitted online as a PDF file. Only ONE group member should submit the report on Canvas.
Summarize how our product match all the customers needs (speak about all the aspects of our business that help disabled people)
!!!!Come up with 2 different concepts (2 ideas, products or services,..) that could also answer to customers needs 2page!!!!
10 brainstorming ideas:
1.define your purpose 2.choose participants 3.choose a facilitator 4.brainstorm spontaneously; copiously 5.no criticisms, no negatives 6.Record ideas in full view 7.Invent to the void 8.Resist becoming committed to one idea 9.Identify the most promising ideas 10.refine and prioritize
(page: 117)
Market research = potential customers, rivals products(similar services)
Talk about the profitability, numbers = justification, reasons: more fo the step 4
Do not talk about financial aspect in details, it will be for later
But say why this business will be profitable (if its not, there are no reasons for opening it)
1.Summarize how our product match all the customers needs (speak about all the aspects of our business that help disabled people)
Due to their limited ability to go outside and enjoy life as a person without a condition can, people with disabilities often experience emotional stress and social isolation. This is a result of California’s general lack of accessibility in countless locations. Melina Karp, Vice President of Consumer Centered Quality at Commonwealth Care Alliance says: When a persons disability includes a mobility impairment, one issue that can arise is increased physical and social isolation. As opportunities for social engagement get smaller and smaller based on an individuals ability to navigate their physical surroundings, depression and anxiety can also develop (Seervai, S., Shah, A., & Shah, T. ,2019). In order for people with disabilities to lessen the stress associated with their physical state and improve their emotional well-being, there is a real need to make changes.
With our new concept, we give the opportunity to disabled people to share experiences with people that face the same daily challenges. We want to create a community through this website by reuniting them together to do not feel lonely anymore. For example, on our platform, customers will have the possibility to go on group tours even if they are travelling alone. In this situation, they will only be with people they do not know and might create strong relationships thanks to that.
In the tourism industry, there is in general an important lack of information about accessibility in different places that includes hotel facilities, transportation, tours, parks or restaurants.
We want to give access to people, with impairment problems, to clear information regarding the infrastructures imposed by the destinations.
At the same time, on our platform, the different information provided on the website is updated frequently by businesses regarding the degree of accessible features they have. It is useful given the fact that sometimes the business might be doing some construction work and therefore it might not be accessible for a certain period of time. It will be accordingly updated on our website.
There are still too many situations where disabled people have to double-check the places accessibility by sending a mail or by making a phone call to make sure they can be welcome there. This is mainly due to the poor reliability of the information provided on businesses websites. Information communication errors happen as we have seen in a law case opposing a disabled customer to a big chain hotel. To sum up, a disabled person booked a room mentioned as accessible on the hotels website. The customer called the hotel to confirm that the room is indeed accessible but also that the room is available for her stay dates. The hotel clearly confirmed all those information but once the customer reached the hotel, the property was not able to offer them an available room (EIN News, 2019)
From our side, we require the different businesses to provide us with the needed paperwork regarding their accessibility information as proof. To check, we want to develop a software able to recognize the reliability of those papers to avoid any falsification and the accuracy of the data. By doing that, we are sure about the reliability of the information provided and avoid any problems welcoming disabled persons.
Moreover, when planning a trip, it is complicated for a disabled person to have to go through different websites, each useful for a part of the trip. It, in fact, takes time for them to go through all those websites looking for accessible places. Imagine that it takes at least twice more time than any other regular customer.
By this fact, we want to develop a platform that combines in one website places that are fully accessible. Customers only have to choose where they want to go, and what they want to visit among the different places proposed. They only need to tap their phone once to obtain the available information right away. They would find it convenient because they would not have to look for suitable places (or not) through different websites.
Most of the time, disabled people receive poor service from employees because they are not trained enough and therefore do not have the required knowledge to take care of a customer with a disability.
To solve that, we have a website that directly links disabled customers with businesses which will then be able to answer any customers concerns. Moreover, businesses that are on the platform are aware of disabled peoples differences and employees are trained accordingly.
EIN News. (2019). Retrieved 22 October 2022, from
https://www.einnews.com/pr_news/495508829/dannlaw-files-lawsuit-alleging-homewood- suites-by-hilton-mahwah-and-hilton-worldwide-repeatedly-violated-the-ada
Seervai, S., Shah, A., & Shah, T. (2019). The Challenges of Living with a Disability in America, and How Serious Illness Can Add to Them. Retrieved 22 October 2022, from https://www.commonwealthfund.org/publications/fund-reports/2019/apr/challenges-living- disability-america-and-how-serious-illness-can
3. Refine the concept using ideas in Chapter 5 of your textbook. You do not have to go through ALL the steps described in the textbook, as that would be too extensive.
No criticisms, no negatives
Every proposal should be considered, regardless of how absurd it may seem. Then we determine which choice could be applied to our work. Throughout this process, we promote various forms of imaginative thinking without passing judgment on what any one person has expressed.
As we are getting more exposure, we want to gain a better insight towards this community. We reach a point where we want to come up with a solution for the obstacles and concerns they are facing as it touches physical needs.
Due to the nature of our project, we would like to appease the critics by introducing fresh offerings to a segment that has received little attention. The main goal is to improve the entire visitor experience for clients with disabilities. The idea behind our business concept would be to create a more convincing environment while having an optimistic result.
Resist becoming committed to one idea
– Every idea should go through a process in order to get the desired result; in this case, our first step is to provide an internet platform. We believe that our adherence to our basic values will define who we are in this industry. We are dedicated to paying close attention to disabled customers and to combining and balancing the needs of our clients regardless of their physical limitations. To turn our concepts into a reality, we are consistently aligning for incremental innovation. We would constantly develop new products and services linked to mobility as long as customers benefit from the platform we built.
Identify the most promising ideas
Before choosing a prospective business, background market research is crucial. For the accessibility market, we decided to launch in California due to the significant market gap area. The community’s unmet demands for particular services and the dissemination of knowledge have greatly distorted supply and demand. We have seen that there is not yet a particular platform with transparency regarding the infrastructure and the level of customer impairment they can support.
The unmet demands and the statistics have shown that the accessibility platform may be a promising sector for investment. Due to the first-runner advantage, we might be able to capture a sizable portion of the market.
Refine and prioritize
As we focused down from the brainstorming, we would be concentrating on the platform to partner with new businesses, catering venues, hotels, and locations that could be able to offer services for people with impairments.
This will be our first action once the social platform is introduced. To establish a standard for the accuracy of the data, we shall develop our own system of verification.
Considering we will provide an intangible product, we would always prioritize the needs of our customers, therefore we put user experiences a high priority.
We would introduce a sub-product focused on accommodating people with disabilities as the platform matures. We will contemplate expanding into another city once the client capacities reach a certain point.
4. Describe the final product form. Describe the market for that product by defining who would buy it and what kinds of products it would pull sales away from. Make sure you have searched for similar products in similar markets on the internet (so you have to describe the market as well). JEANNE
There are currently no specific online platforms focusing on tourism but for disabled people and this is how we came up with the idea of developing a website that connects customers to locations with accessible features. We think the USA is the perfect place for us to launch this business given the fact there are more than 6 million disabled persons living there. (Bts, 2022).
On this website, we will be able to connect disabled people to businesses such as hotels, restaurants, tour guides or excursions accessible for people with physical impairments. Customers can enter the dates of their desired stay, what kind of activity they would like to be part of, and the platform will give a panel of different options to choose from. The time when disabled people had to go through deep research to find an accessible place is now over: welcome to the new area where disabled people have their own platform with places that suit them and their needs.
We decided to start small by targeting firstly California, but the main goal is to become national and even international one day. In fact, according to Who (2021), More than 1 billion individuals live with a disability worldwide. The market potential is huge, making it 15% of the worlds population. Concerning California, 6.7 million inhabitants or 1 of 4 adults are disabled, equivalent to 23% of the population (Bts, 2022).
People with disabilities have actually decided to travel less, mostly due to the subpar services they received but also because of the reliability of the information provided on businesses websites. In fact, disabled people always have to check to make sure the facilities are fully accessible for them. It eventually becomes too much work for, often, unfavourable results. According to a research by Bts (2022), seven out of ten participants with impairments indicated their limitations prevent them from travelling daily.
In fact, the market’s decline has slowed the supply of trustworthy information, causing customers to exercise more vigilance to ensure that offerings are compatible with the facilities they need. This factor influences how a visitor feels about their entire vacation. The simplest way to ease customer concerns is to thoroughly explain the facilities and the number of individuals they can accommodate. The need for more specialized assistance in this area puts the destinations in a difficult situation. In this instance, we expressly step in to meet the client’s needs. People are disturbed by disability discrimination because it subjects disabled people to unfair treatment as a consequence of our society’s misunderstanding.
As our idea is to take what actual online travel agencies are doing but specialized in accessible places, we believe that disabled people will not use those platforms anymore but will directly use our website instead. In fact, they will gain time, energy but, most importantly, confidence and self-esteem. According to FlyOfinder, the five most used online travel agencies in the USA are Expedia, Orbitz, Travelocity, FlyOfinder and Skyscanner. Therefore, we believe we will pull sales away from those five platforms mentioned. However, our impact is still small given the fact we are starting with California to expand furthermore in the future.
Our product being unique, we do not have any direct competitors. Similar services can be assigned to traditional travel agencies that will make the work and the research for the customers. As explained previously, disabled people are not well taken care of and rapid growth in this market is more than conceivable. Furthermore, we will make money by asking for a monthly fee from the different businesses that want to be present on our website. We will also take a commission of 15% on each transaction made through our platform. At the same time, we do not have a lot of costs if it is to taking care of the website and promoting our concept. The profitability of our business will therefore be consequent, our target market being no less than 6.8 million people. It is at the same time interesting for the businesses that would like to work with us given the fact that we will bring them more visibility towards disabled people and consequently more revenue.
Bts. (2022). Travel Patterns of American Adults with Disabilities | Bureau of Transportation Statistics. Retrieved 22 October 2022, from https://www.bts.gov/travel-patterns-with- disabilities
FlyOfinder. (2022). Top 5 online travel agencies (OTA) in USA: Flyofinder. Retrieved October 22, 2022, from
https://www.flyofinder.com/blog/top-flight-deals/top-5-online-travel-agencies-in-usa
SHOW MORE…
discussion
In addition, to prepare for this discussion read
Chapter 3
and
Chapter 6
in your required textbook and view the videos
Depression and Its Treatments
Links to an external site.
and
OCD: One Patients Story
Links to an external site.
.
Read the following case studies and refer to your textbook, and the
DSM-5, as needed to support your understanding.
Option 1:
Generalized Anxiety Disorder
Joe is a 44-year-old, married Latino male. He presents with racing thoughts and constant worry. He states that he cannot control the anxious thoughts and they are constant. In the session, Joe has a hard time sitting still and his leg bounces up and down the entire time. Speaking more about his anxiety, he states he doesnt sleep much because the worry keeps him from falling and staying asleep. He has had to quit his job because he cannot focus on work, as his racing worried thoughts keep him from concentrating. At home, he paces the floor because he struggles to sit still. Over the past year, he has lost several friends because he loses his patience with them easily. He has stated he has always been a worrier, but it really started to get out of control after he had a car accident last year.
Option 2: Panic disorder Week 2
Deanna is a 52-year-old African American married female. She was driving home from work one day when she all of a sudden high tightness in her chest and had a hard time breathing. She thought that she was going to die. Fearing she might be having a heart attack, she pulled into the next parking lot and called an ambulance that took her to the ER. She explained to the doctors that she started feeling dizzy, then had tightness in her chest and hard a hard time breathing, and her heart was pounding fast in her chest. The doctors checked her out and stated she was fine and sent her home. After that, Deanna started to have more attacks like this, even when she was not driving. She started to worry about when the next one would come. She started to avoid driving, fearing that she might cause an accident when one of the attacks comes back and would have her husband drive her where she needed to go.
In your initial post,
First, choose one of the options and describe the patients symptoms and the available demographic and historical data.
Based on the scenario you chose, evaluate how the intensity, duration, and focus support the identified diagnosis. (Support your discussion with citations outlined in the University of Arizona Global Campus Writing Centers
APA: Citing Within Your Paper
Links to an external site.
resource.)
List all references used at the end of your discussion according to
APA 7 guidelines.
Links to an external site.
Discuss the available treatments for this patient.
Discuss the implications of a therapist who actively encourages a patient to take medication that has been shown to be effective when the patient has strong objections to the use of a pharmacological approach to treatment.
Develop at least three recommendations for the patient/family for ongoing functioning (social, occupational, and academic, if applicable), associated with the scenario you chose.
Finally, analyze the differences between both scenarios: Generalized Anxiety Disorder and Panic Disorder? Do the recommendations differ?
Access the American Psychiatric Association’s (2013)
Diagnostic and Statistical Manual of Mental Disorders
(5th ed.)
Links to an external site.
and search it to support your suggestions. (Be sure to cite.)
For additional support citing this resource, review the video
The DSM-5.
Links to an external site.
Post your initial response of 300 words or more by
Day 3 (Thursday). Respond to at least two of your peers by
Day 7 (Monday). Peer postings should be a minimum of 200 words each.
Guided Peer Responses:Peer responses should be carefully crafted and insightful. The goal of the discussion forum is to foster continual dialogue, similar to what might occur in a verbal face-to-face exchange. Consider discussing areas of interest as well as the following questions in your responses:
What strikes you as interesting or something you did not know that your peer shared?
What additional recommendations would you offer the patient/family that your peer chose to investigate?
Share diagnoses that could potentially be considered for your peers case study. (Support with citations.)
Discuss differing implications that you shared for the therapist who actively encourages a patient to take medication that has been shown to be effective, when the patient has strong objections to the use of a pharmacological approach to treatment.
Instructor Responses:Review any instructor feedback on your postings. Often feedback is shared to help you to elevate your level of critical thought or make corrections. Reply based on this feedback to advance your understanding of the content addressed.
Observe the following guidelines for all responses:
Remember that discussion forums should be conversations; dialogue is encouraged throughout the course.
Provide a courteous and interactive learning environment.
Continue to monitor this discussion through 5:00 p.m. on Day 7 of the week and reply to anyone (instructor or classmate) who has chosen to respond to your original post.
Your grade will reflect the quality of your initial post, the depth of your peer replies, and your active support of forum dialogue.
Your responses should demonstrate that you have read the existing replies on the board. (In your response mention information and viewpoints already expressed by existing responses to the same post.) Whenweencounteranykindofthreatorstressor,weexperienceanumberofphysiologicalresponses:Heartrate,bloodpressure,andbreathingincrease;musclestense;bloodvesselsconstrict;theliverreleasesglucosetoprovidequickenergytomuscles;andthespleenreleasesredbloodcellstohelpcarryoxygen.Wefeelfearordread;wemayalsofeelirritableorrestless.Wescanourenvironmentforsignsofdanger.Theintensityofourresponsesdependsontheperceivedmagnitudeofthestressororthreat.
TheAnxietySpectrum
Forpeoplewith
anxietydisorders,theseresponsesoccurcontinuouslyorintermittentlywhennorealthreatorstressorispresentorwhentheyencounterastimulusthatissimilarinsomewaytotheoriginalthreatorstressor.Typically,theirreactionisoutofproportiontothedegreeofdanger.Anxietymanifestsitselfinaspectrumfrommildtosevere(seeFigure3.1).
Figure3.1:Anxietyspectrum
Anxietycanmanifestitselfassomethingasmildasworryorsomethingassevereasapanicattack.
Source:
AdaptedfromS.Schwartz,AbnormalPsychology:ADiscoveryApproach.
MountainView,CA:MayfieldPublishingCompany,2000,Figure4.4,p.143.
AnxietyDisordersRelatedtoMedicalConditionsandSubstanceorMedicationUse
Avarietyofmedicalconditionscancausesymptomssimilartothoseassociatedwithanxietydisorders.Anoveractivethyroidgland,heartdisease,vitamindeficiencies,respiratorydisease,andbraintumorsareamongtheconditionsthatsharesymptomswiththeanxietydisorders.Alcohol,caffeine,andmanyprescriptionandillicitdrugscanalsocauseanxietysymptoms.Beforediagnosingananxietydisorder,weneedtobesurethatanindividualsanxietyisnotrelatedtoamedicalconditionortosubstanceuseorwithdrawalfromasubstance.Aprudentmethodistomakesuretheindividualhashadacompletephysicalbeforestartingpsychotherapy.
LetsconsiderthecaseofCaroleBallodi.
TheCaseofCaroleBallodi:Part1
OnthenightofFebruary24,threeseriouslyinjuredinfantrysoldiersweretransportedbyhelicoptertoMedivacUnit4CB,whichwasunderthecommandofCaptainCaroleBallodi.CaptainBallodiandherteamofmedicsandnursesbegantostabilizethewoundedinpreparationforsurgery,whentheyfoundthemselvesunderfire.Theycalledforassistance,butbeforeairstrikescouldbeordered,theirMedivacunitwashitbyarocket.OneofthewoundedsoldierswasstruckintheheadbyshrapnelandkilledinstantlywhileCaptainBallodiwastakinghispulse.Anursewasgravelyinjured.Althoughelectricalsupplieswerecutoff,andtheshellingcontinued,CaptainBallodiandherteammanagedtotendtothewoundeduntiltheshellingstopped.Shethenassistedinanemergencysurgerythatrequiredtheamputationofonesoldiersleg.CaptainBallodisactionsduringthatnightsavedthelivesoftheinjuredsoldiers.Sheisworthyofthehighestcommendation.
InitialInterviewBetweenCaroleBallodiandPsychiatristDr.SallyKahn
UNIVERSITYHOSPITAL
PsychiatryService
ConsultationTranscript
ReferringPhysician:Dr.Berg
ReasonforReferral:CaroleBallodiisaninternalmedicinespecialistatUniversityHospital.Shewasbroughttotheemergencyroomcomplainingofchestpain.Aphysicalexaminationprovednegative.Becauseofheragitation,shewasreferredforapsychiatricconsultation.
Posttraumaticstressdisorder(PTSD)appearedintheAnxietyDisorderschapterofthe
DSMIVTR.Inthe
DSM5itwasmovedtotheTraumaandStressor-RelatedDisorderschapter.BecauseCaroledemonstratessignsandsymptomsofpanicdisorderaswellasPTSDwehavedecidedtokeephercaseinthischapter.
DR.KAHN:Tellme,whatdoyouconsideryourmainproblem?
CAROLE:IhavethesepainsinmychestandfeellikeIcantcatchmybreath.
DR.KAHN:Whendoesthisoccur?
CAROLE:Onetimewasinmycar.Iwasjustabouttogetonthebridge.IwasatthetollboothwhenIheardahelicopteroverhead.Ipanicked.Icouldntcatchmybreath.Ibrokeoutinasweat,andIcouldfeelmyheartpounding.Ifeltliketherewasatightbandacrossmychest.Igotdizzy,hot,andnauseous.AndIwasveryfrightened.IthoughtIwasdying.
DR.KAHN:Canyourecallwhatthoughtsweregoingthroughyourheadwhenthishappened?
CAROLE:Actually,Ican.IthoughtthatthehelicoptersoundedliketheonesthatdeliveredthewoundedtotheMedivacunitinIraq.IthinkIjustpanicked.
DR.KAHN:Youpanicked?
CAROLE:Yes.Iwasafraidthatthehelicopterwouldcomedownandcrashintomycar.
DR.KAHN:Whatwouldhappentoyou?
CAROLE:Iwouldbedisabledforlifeandhavetouseawheelchair.
DR.KAHN:So,youwerethinkingaboutthesethingsandthenbegantofeelthechestpain?
CAROLE:Imnotsureitallseemedtohappentogether.Iwasthinkingaboutthehelicoptersandmycar,andthenIfeltthepaininmychestandhadtroublebreathing.
DR.KAHN:Whathappenednext?
CAROLE:Ipulledovertothesideandjustsatthere.Trafficbackedupbehindme,buttherewasnothingIcoulddo.Itwaslikeitwashappeningtosomeoneelse.Finally,someonecalledanambulance.
DR.KAHN:Whathappenedinthehospital?
CAROLE:IfeltbetterbythetimeIgottothehospital.Theyrantheusualtestsbutfoundnothing.TheysuggestedthatIseeyou.
DR.KAHN:Haveyoupanickedatanyothertime?
CAROLE:Yes.Mostlyatnight.Iwakeupattwoorthreeinthemorning.Imcoveredinsweatandmyheartisracing.Icanhardlycatchmybreath.IthinkImgoingtodie.
DR.KAHN:Isthereanythingspecificthatsetallthisoff?
CAROLE:Ihadapatientdieinmyoffice.Itbroughtbackthewar.Ineverusedto,butnowIspendhourseachnightgoingoverthingsthathavehappenedinthepast.IrelivewhathappenedinIraq.ItslikeavideotapethatIplayoverandoveragaininmymindwhileIaskmyselfwhetherIcouldhavedonethingsdifferently.
DR.KAHN:Whatdoyoudowhenyouwakeupduringthenight?
CAROLE:IusuallycheckallthewindowsanddoorlocksandthenIgobacktosleep.
DR.KAHN:Whataboutyourwork?
CAROLE:Icantconcentrateonanything.Ivetakenpracticallyallofmysickdays.
DR.KAHN:Whatareyoudoingaboutyourproblems?
CAROLE:MostlyIstayhome,hopingthatrestwillhelp.Ihaveafewdrinkstohelpmesleep.
DR.KAHN:Hasthisworked?
CAROLE:Well,thedrinksknockmeout,butImmissinglotsofwork.
DR.KAHN:Doyougooutwithfriends?
CAROLE:No.Imafraidtoleavehome.Imafraidtogetinmycar.Imighthaveanotherincident.Imnotinterestedinseeinganyone,andsexleavesmecold.
DR.KAHN:DoyoueverseeanyoneyouservedwithinIraq?
CAROLE:No.Iwasneverreallybotheredbythewar,butIdontwanttotalktoanyone.Whoknowswhattheymightthink?Idontknowwhatshappeningtome.IthinkImgoingmad.
Onthebasisoftheirdiscussion,Dr.KahnfeltcertainthatCaroleBallodiwassufferingfromananxietydisorderoratraumaorstressor-relateddisorder,probablyrelatedtoherwarexperiences.BeforeDr.Kahncouldbemorecertain,however,shehadtoconsiderthepossibilitythatCarolesbehaviorwastheresultofageneralmedicalcondition.AvarietyofmedicaldisorderscancausesymptomssimilartoCaroles.Becausealcohol,caffeine,andmanyprescriptionandillicitdrugscanalsocauseanxietysymptoms,Dr.KahnhadtobesurethatCarolesbehaviorwasnotsubstancerelated(orrelatedtowithdrawalfromasubstance).Thus,Dr.Kahnbeganbyorderingamedicalhistoryaswellasphysicalandlaboratoryexaminations.Thesefoundnoevidenceofarelevantmedicalconditionorsubstance-inducedanxiety.
Click
here
forfullcasestudy.
Beforewecontinue,weneedtodefineanxiety,fear,andpanic.Theseconceptsmayseemsimilarifnotidentical,butyouwillsoonseethattheyarenot.
Anxiety
Anxietyisanemotionalstatemarkedbyanintensefeelingofforebodingandsomaticsignssuchasaracingheart,sweating,anddifficultybreathing.Theindividualisafraidthatthefuturewillbringonlybadresults.Anxietyisafeatureofeverydaylife.Anxietyissimilartofearbutwithalessspecificfocus.Whereasfearisusuallyaresponsetosomeimmediatethreat,anxietyischaracterizedbyapprehensionaboutimaginedorrealunpredictabledangersthatmaylieinthefuture.The
limbicsystem,acomplexsetofbrainstructuresthatcontrolsouremotions(seeFigure3.2),isinvolvedinmediatinganxietylevels.Lowlevelsofanxietyareadaptive;theyhelpusavoiddanger(Idontlikethelookofthatdarkstreet)andplanforthefuture(IbetterstudyforthefinalexamorIwillfail).Anxietybecomesmaladaptivewhenitinterfereswithapersonsrelationshipsanddailyfunctioning.Table3.1liststhe
DSM5anxietydisorders.
Figure3.2:Thelimbicsystem
Exceptforthepituitary,allthehighlightedareasintheforebrainarepartofthelimbicsystemandnormallyreceivesignalsfromneuronsthatsecretemood-alteringneurotransmitters.Someneurotransmitterpathwaysareindicatedbyarrows.
Source:
AdaptedfromS.Schwartz,AbnormalPsychology:ADiscoveryApproach.
MountainView,CA:MayfieldPublishingCompany,2000,Figure4.3,p.141.
Table3.1:The
DSM5anxietydisorders
Separationanxietydisorder
Agoraphobia
Selectivemutism
Generalizedanxietydisorder
Specificphobia
Substance/medication-inducedanxietydisorder
Socialanxietydisorder(socialphobia)
Anxietydisorderduetoanothermedicalcondition
Panicdisorder
Otherspecifiedanxietydisorder
Note:The
DSM5includesanadditionaldiagnosticcategoryforUnspecifiedanxietydisorder.Vaguereferencestounspecifieddisordersappearthroughoutthe
DSM5.Becausetheyhavenospecificsymptoms,etiology,ortreatment,thesedisordersarenotdiscussedinthisbook.
Fear
Fearisanemotionthatoccursinresponsetosomerealimmediatethreatordanger.Fearservesapositivepurpose:Ithelpsmobilizethebodysdefensesquicklyinsituationsrequiringfightorflight(defendingoneselforrunningaway)fromadangeroussituationoranenemy.Lineagestudieshavefoundatendencyforfeartoruninfamilies(VanHoutemetal.,2013).Twinstudies,forexample,helpustodeterminewhetherbehaviorandmentalillness,amongotherthings,arecausedbytheenvironmentorbybiology.BecauseidenticaltwinshavethesamegenesandDNA,differencescanbeattributedtotheirenvironments.Identicaltwinsraisedapartareequallylikelytodevelopfearsandtobeafraidofsimilarthings(Kendleretal.,2008).
PanicandPanicAttacks
Panicisanextremeanxietyreactionthatcanresultwhenarealthreatsuddenlyemerges.Somedefinitionsmightaddthatthethreatcanbeperceivedinsteadofanactualthreat.Theexperienceofpanicattacks,however,isdifferent.Panicattacksareperiodic,shortboutsofpanicthatoccursuddenly,reachapeak,andpass.Sufferersoftenfeartheywilldie,gocrazy,orlosecontrol.Attackshappenintheabsenceofarealthreat.Wewilldiscusspanic,panicattacks,andpanicdisorderindepthlaterinthischapter.
Panicattackwasnotadiagnosisinthe
DSMIVTRandisnotinthe
DSM5.However,thespecifiersfordifferenttypesofpanicattackshavebeenchangedfromcued,situationallypredisposed,anduncuedtounexpectedandexpectedpanicattacks.Panicattackisaspecifierthatcannowapplytoall
DSM5diagnoses(AmericanPsychiatricAssociation[APA],2013).
ComorbidityandtheAnxietyDisorders
Recalltheterm
comorbidityfromChapter1.Comorbidity(whenadisorderhasahighlevelofco-occurrencewithotherdisorders)iscommonwiththeanxietydisorders.Anxietydisordersarefrequentlyaccompaniedbydepression(Kessler,Sampson,etal.,2015).ThisassociationissocommonthatBrownandBarlow(2002)theorizedthatanxietyanddepressionmayshareacommonfeature:Theybothinvolveemotionaldistress,buttheyvaryinhowthedistressisexpressed.Peoplewithotherpsychologicaldisorders(forexample,schizophrenia)commonlyreportanxietysymptomsaswell.
3.2SpecificPhobias
william87/iStock/Thinkstock
Forsomepeople,goingtothedentistcanbeafrighteningexperience,leadingtoheightenedanxietyaboutgoingfornecessarycheckups.
Atonetimeoranother,everyoneisafraidofsomething:snakes,storms,airplanes,ordentists.Fearisanimportantevolutionaryadaptation(LeDoux&Pine,2016).Butfearcanalsobedebilitating.Itcantormentus,destroyoursleep,androbourlivesofpleasure.Inextremecases,itcancausediseaseorevendeath.Rationalfearsarenotphobias.Ifyouhurryhomeafterhearingastormwarningonyourcarradio,youdonothaveaphobianomatterhowfrightenedyoumayfeel.However,ifyourfearofstormsissointensethatyouboardupallyourwindowsandattheslightestthreatofarainshoweryourunhomeandbarricadeallofthedoorsandwindows,andheadtothebasement,thenyouprobablyhaveaphobia.Fearsbecomephobiaswhentheydisruptdailylifeenoughtojustifyclinicalintervention(APA,2013).
A
specificphobiaconsistsofapersistent,excessive,andirrationalfearofanobjectorsituationcoupledwithastrongdesiretoavoidthefearedobjectorsituation.Peoplewithphobiasdisplayextremefearreactionswhenexposedtothefearedstimuli.Theyrecognizethattheirreactionisexcessiveandunreasonable,yettheirfeardisruptstheireverydaylives(APA,2013).
EtiologyofPhobias
Ithasbeenestimatedthatanywherefrom7.7%to12.5%oftheworldspopulationwillmeetthecriteriaforaspecificphobiadisorderatsometimeintheirlives(Wardenaaretal.,2017).Theoverallaveragelifetimeprevalenceisestimatedtobeapproximately7.4%(Wardenaaretal.,2017).Onceaphobiaisestablished,ittendstolastalifetimeunlessitisspecificallytreated.The
EncyclopediaofPhobias,Fears,andAnxieties(Doctor,Kahn,&Adamec,2008)hasmorethan2,000entries.Phobiasaredeterminedbythecomplexinteractionofculturalandsocialnorms(fearsvaryacrosscultures),learningexperiences(yourbestfriendscreamswhensheseesaspiderandyoubecomeafraidofspiders),andcognitivecomponents(yourthoughtsandbeliefs).Table3.2listssomeofthemorecommonphobias.
Table3.2:Commonfearsandphobias
Death
Storms
Flying
Enclosedplaces
Snakes
Illness/injury
Dentists
Travelingalone
Heights
CulturalandSocialDeterminants
Toalargeextent,ourcultureandsocietydeterminetheobjectsandsituationswefear(Sato,Yuki,&Norasakkunkit,2014;Yeh,Nguyen,&Lizarraga,2014).TheAboriginesofCentralAustralia,forexample,haveanintensefearofviolatingsacredtribalsites(Strehlow,1985).Thosewhoviolatetabooareasaresubjecttobone-pointing,inwhichatribaleldertakesthelegboneofakangaroo,dipsitintoananthill,coverstheendwithhumanhairs,andpointsitatthetransgressorwhilechantingacurse.Aboriginesfearbone-pointingsomuchthatsomeofthosesubjectedtothecursehavereportedlydiedfromfright(Basedow,1925).Whenculture-boundfearsbecomeextremeenoughtointerferewithnormaldailyfunctioning,theycrossoverintobecomingphobias.
LearningExperiences
Accordingtobehavioralpsychologists,aphobiaisacquiredinitiallythrough
classicalconditioning:Aneutralstimulusthatisrepeatedlypairedwithafear-inducingstimuluswill,intime,elicitthefearresponseevenintheabsenceoftheprimaryfear-inducingstimulus.Abelldoesntevokeafearresponse,butifitispairedwithafearedstimulusapainfulshockitwilleventuallyevokeafearresponseevenintheabsenceofthepainfulshock.Overtime,apersoncomestoavoidsituationsrelatedtotheonethatoriginallycausedafearresponse.Oncethephobiaisgeneralized(occuringinsituationssimilarbutnotidenticaltotheoriginalsituation),theavoidanceresponsecontinuesbecauseavoidingfearedobjectsreducesanxiety,whichinturnreinforcesfutureavoidance.
Behavioristsnotethatphobiasmaybeacquiredindirectlybyobservingfearinothers(Bunaciu,Fleschin,&Aboul-Enein,2014).Mineka(1985)foundthatrhesusmonkeysraisedincaptivitywerenotafraidofsnakesuntiltheyobservedthefearfulreactionsofmonkeysraisedinthewild.Althoughobservationallearningmayaccountformanyfearsacquiredintheabsenceofaversiveexperiences,exposurealonemaynotbesufficientforphobiastodevelop.Minekasmonkeysdidnotdevelopfearsofflowersoratoyrabbit,evenwhenexposedtoapparentlyfearfulmodels(Mineka1985;seealsoCook&Mineka,1991).Perhapsobservationallearningproducesphobiasonlyfordangerousobjectsandsituationsthatevolutionhasgeneticallypreparedustofear(McNally,2016).Forexample,humansaregeneticallypreparedtoacquireafearofheights(wecanfallfromahighplaceandbeinjuredorkilled)andspiders(somespiderbitescanbelethal).Throughevolution,wehavedevelopedphobiastomakeoursurvivalmorelikely.Ofcourse,eventhispreparednesshypothesishasdifficultydeterminingwhetherourfearsareduetoevolutionortotheenvironment(McNally,2016).
CognitiveDeterminants
Cognitivetherapistsbelievethatsomepeoplehabituallymakefearfulattributionstoobjectsorsituations,overestimatetheprobabilityofrisk,andunderestimatetheirpersonalabilitytocope(Beck&Haigh,2014).Bandura(1986)suggestedthat,forsomepeople,perceivedinabilitytocopeisresponsibleforanxietyandavoidancebehaviors.Inotherwords,therealcauseoffearisnotthefearedstimulusbutratherthefeelingsofinadequacyindealingwiththechallengeitpresents.Fearfulthoughtsmaybecomeself-fulfillingprophecies:Forexample,fearingfailureonanexaminationmaycausepeopletofail.
TreatmentforSpecificPhobias
Therapeuticanddrugtreatmentsforspecificphobiasaredescribedinthetreatmentsectionsrelatedtosocialanxietydisorder,sincethetreatmentapproachesaresimilar.
3.3SocialAnxietyDisorder(SocialPhobia)
Thefearofexaminationsandspeakinginfrontofotherpeople(stagefright)arebothformsof
performanceanxiety.Forexample,employmenttests,driverslicensetests,andmedicalexaminationscanproducefeelingsofapprehensionanddreadinmanypeople,andcansignificantlyimpactoneslife(Cooper,Hildebrandt,&Gerlach,2014;Morrison&Heimberg,2013;Sloboda,1990).Althoughlowtomoderatelevelsofanxietymayfacilitateperformance,highlevelsofanxietylowerperformance(Sodhi,Luthra,&Mehta,2016).Insomeinstances,extremeanxietymayrenderpeopleunabletoperformatall.Itcanproduceeatingandsleepingdisorders,anditcanmakesufferersphysicallyill(Culbert,Racine,&Klump,2015;Shanahan,Copeland,Angold,Bondy,&Costello,2014;Vogelzangs,Beekman,DeJonge,&Penninx,2013).PerformanceanxietyoccursinbothWesternandEasterncultures(Ruscioetal.,2007),butculturalsensitivityisnecessarywheninterpretingperformanceanxiety.AmongNativeAmericancultures,forinstance,itisconsideredimproper,impolite,andevendisloyaltostandoutfromonespeers(Dasen,Berry,&Sartorius,1988;Kagitibasi&Berry,1989).Becausepeoplewithperformanceanxietycanusuallyinteractsuccessfullywithothers(providedtheydonothavetoperform),fewseekprofessionalhelp.Forsomepeople,however,thefearofbeingevaluatedbyothersextendstomostaspectsofsocialinteraction.Thesepeoplemaycurtailtheirsociallives,evensacrificetheircareers,toavoidthreateningsocialsituations.Suchpersonsarelikelytobesufferingfrom
socialanxietydisorder(alsoknownas
socialphobia;APA,2013).
EvanAgostini/Invision/APPhotos
BarbraStreisand,thefamoussinger,actress,director,andproducerisawell-knownindividualwithsocialphobia.
Socialphobia,whichusuallybeginsinadolescence,representsanextremeformofperformanceanxietyinwhichthefearofsocialevaluationmayseverelyrestrictapersonslife(Iverach&Rapee,2014).Likemostanxietydisorders,socialphobiaaffectsmorefemalesthanmales(Pesceetal.,2016).Socialphobiasmaysometimesbetracedtoaspecifictriggeringevent,suchasaninabilitytofindadatefortheseniorpromorbeingbulliedduringearlyadolescence(McEvoy&Saulsman,2014).Itismoreoftenduetoinnatelyfearingangry,critical,orrejectingpeopleortheirfaces(McEvoy&Saulsman,2014;Prater,Hosanagar,Klumpp,Angstadt,&Phan,2013).
TherapeuticTreatmentforSpecificandSocialPhobias
Manydifferenttreatmentshavebeendevelopedtodealwithspecificphobiasandsocialphobia(Arroll,Wallace,Mount,Humm,&Kingsford,2017;Mayo-Wilsonetal.,2014).Althougheachhasitsspecificaspects,theyallseektomotivatepeopletochange,ensurethattheyprepare,andexposethemtothefearedstimulus.Nomatterwhattreatmentisused,animportantfactorinhelpingsomeonetoovercomeanyproblemistoestablishatrustingtherapeuticrelationship.
PsychoanalyticTreatmentofSpecificandSocialPhobias
Psychoanalystsviewphobiasassurfacemanifestationsofunconsciousconflictsthataredisplacedontoanobjectorsituationwithsomesymbolicconnectiontotheconflict.Psychoanalytictreatmentconsistsofuncoveringtherepressedmemoriesassumedtounderliefearandavoidance.Dreaminterpretation,freeassociation,andotherpsychoanalytictechniquesareusedtoliftrepressionandmakeunconsciousconflictsconscious.Psychoanalystsmayexposepatientstotheobjecttheyfear(Karon&Widener,2013).Insuchcases,exposureisnotexpectedtoextinguishthefearbuttohelpretrieverepressedconflictsanddesires.Psychoanalytictreatmentsarerarelyusedtodayinthetreatmentofspecificphobiasandsocialanxietydisorder.
BehavioralTreatmentofSpecificandSocialPhobias
Behavioraltreatmentsfocusonexposure.Perhapsthebest-knownexposuretechniqueis
systematicdesensitization,developedbyJosephWolpe(1997).Thetechniquehasthreeparts.Thefirstisrelaxationtraining;thesecondistheconstructionofananxietyhierarchyinwhichfear-relatedimagesarearrangedaccordingtothedegreeofanxietytheyelicit.Thethirdpartinvolvesthegradualpresentationofthehierarchyimageswhilethepersonattemptstomaintainarelaxedstate.Therationaleisthatonecannotbebothfearfulandrelaxedatthesametime.Thus,afearfulpersonwhocanlearntorelaxwhileimagininganxiety-provokingsceneswilleventuallyceasebeingafraid.
lemhartley/iStock/Thinkstock
Partofthefloodingtechniqueinvolvesexposingthefearfulindividualtothefearedstimulus.
Anotherbehavioraltechnique,
flooding,requiresfearfulindividualstobecomefloodedwithemotionthroughexposuretothefearedstimulus.Becausetheirfearisnotreinforced(nothingbadactuallyhappens),repeatedexposureshouldeventuallycausethemtonolongerfeelafraid.
Implosivetherapyisatypeoffloodinginwhichexposureisdonethroughimageryratherthaninreallife(Schare&Wyatt,2013).
Cognitive-BehavioralTreatmentofSpecificandSocialPhobias
Thegoalofcognitive-behavioraltreatmentistohelpclientslearntoreappraisefearedsituationssothattheycanreplacemaladaptivecognitions(thoughtsandattributions)aboutdangerousobjectsorsituationsandfearoffailurewithpositivecognitions(McAleavey,Castonguay,&Goldfried,2014).
Onecognitive-behavioraltechniquethathasbeenappliedtosocialphobiais
stressinoculation(Jackson,Compton,Thorton,&Dimmock,2017).Stressinoculationbeginswithaneducationalphaseinwhichpeoplearetaughtabouttherolethatnegativeself-statementsplayinperformanceanxiety.Next,clientsaretaughtmoreaccurateself-statementsthattheycanthenpracticeinstressfulevaluativesituations.Inthefinalstage,clientsaretaughtcopingskillsdesignedtohelpthemdealwith,ratherthanavoid,evaluativesituations.
DrugTreatmentforSpecificandSocialPhobias
Manypeoplewithperformanceanxiety,specificphobia,socialphobia,oranyotheranxietydisordermightbeofferedanxiolyticdrugs(
lysisisGreekfordissolve;anxiolyticsdissolveanxiety).Themostpopularanxiolyticmedicationstodayarethe
benzodiazepines.Allbenzodiazepinesaredescendantsofchlordiazepoxide(Librium),whoseanxiolyticeffectswerediscoveredaccidentallybyresearchersobservinghowvariouschemicalcompoundsaffectanimalbehavior(Calcaterra&Barrow,2014;Dellosso&Lader,2013).Diazepam(Valium)remainsoneofthemostwidelyprescribedmedications.Xanax(alprazolam),ahigh-potencybenzodiazepine,isareasonablealternativemedication(Calcaterra&Barrow,2014;Griffin,Kaye,Bueno,&Kaye,2013).Table3.3containsthechemical(generic)namesandtheU.S.trade(brand)namesofsomeofthemostcommonlyprescribedbenzodiazepines.
Table3.3:Commonbenzodiazepines
CommonU.S.TradeName
GenericName
Xanax
alprazolam
Librium
chlordiazepoxide
Tranxene
clorazepate
Valium
diazepam
Dalmane
flurazepam
Serax
oxazepam
Note:Medicationtradenamesalwaysbeginwithacapitalletter.Genericnamesalwaysbeginwithalowercaseletter.
Eventhoughbenzodiazepinescantemporarilyrelieveanxiety(Starcevic,2014),theyarenotwithoutrisk.Benzodiazepinesareknowntocausedrowsiness(sotheymayadverselyaffectschoolorworkperformance),andtheymayharmcognitivefunctioning(Chenetal.,2016;Starcevic,2014).Starcevicetal.(2014)notethatfindingsaboutbenzodiazepinescausingcognitivechangesareconflicting,whichmaybetheresultofconfoundingvariables.Benzodiazepinesmaycausesleepissues,butagaintheevidenceisconflicting.Chenetal.(2016)foundthatsubjectswhousedlong-actingbenzodiazepines(thatis,thosewithalongerhalf-life)hadhigherqualitynighttimesleepthandidthosewhousedshort-actingonesorwhohadlongerdaytimenaps.Theyconcludedthatthesubjectsimprovementsweremodestatbest,andtheevidenceremainsinconclusive.Benzodiazepinesarealsoassociatedwithinjuryduetofalling(hipfractures),especiallyinseniorcitizens(Hametal.,2017;Starcevic,2014).Starcevicetal.(2014)notethatantidepressantsandantipsychoticsalsoincreasefallrisksinseniorcitizens,whichindicatesotherfactorsmaybeinvolvedintheincreasedrisk.Finally,evenstandarddosesofbenzodiazepinesmaycausetolerance,inwhichpeoplerequirelargerandlargerdosestoachievethesametherapeuticeffect(Calcaterra&Barrow,2014).Forexample,a2013SAMHSAstudyfoundthat,onatypicalday,31outof174emergencydepartmentvisitsfordrugmisuseorabusebychildrenaged12to17(about18%)wereforbenzodiazepineabuse.Ifamedicationnotonlycalmsyoudownbutalsorelaxesyourmuscles,ithaspotentialtobecomephysiologicallyaddicting.Benzodiazepineabuseisarealproblem,andcliniciansneedtobeespeciallyawareofit.
3.4GeneralizedAnxietyDisorder(GAD)
Peoplewith
generalizedanxietydisorder(GAD)feelapprehensiveaboutvagueorfutureeventsthatmayormaynotoccur.Assoonasonecauseforworryiseliminated,theybecomeanxiousaboutanotherortheyworryaboutseveralthingssimultaneously.Theiranxietyariseswithoutanyprovocation;itisfree-floating.Alongwiththeirmanyworries,peoplewithGADareoftenrestlessandirritable.Theydescribethemselvesasbeingonedge,andtheirmusclesarehabituallytense.
EtiologyofGAD
Althoughprobablythemostcommonanxietydisorderafterphobias,GADisnotfrequentlydiagnosedinthepsychologyclinic.Oneresearcher(Allgulander,2012;Mackenzie,Reynolds,Chou,Pagura,&Sareen,2011)estimatedthatonlyabout28.3%ofindividualswhohaveGADsoughttreatmentovera12-monthtimeframe.Forolderindividualswhodidnothaveaconcurrentdiagnosis,thepercentagefellto18%.Allgulander(2012)foundthatinGreatBritainonly8%ofthosediagnosedwithGADsoughttreatment.Manyindividualsnevergettotheclinicbecausetheytreatthemselveswithalcoholorothermeans.TheindividualswhodogettotheclinicfrequentlyreceivesomeotherdiagnosisbecauseGADisoftenco-morbidwithotherdisorders(Allgulander,2012;Moreno-Peraletal.,2014).(Click
here
andseePart2ofCaroleBallodiscase.)
PsychoanalyticViewsofGAD
PsychoanalystsattributeGADtoasubconsciousconflictbetweentheegoandtheid.Theegoattemptstopreventtheidssexualimpulsesfrombreakingthroughtothesurfacebecauseitfearsthepunishmentthatmightensue.Buttheegosrepressivestrategyisonlypartlysuccessful.Sexualimpulsesremainunconsciousbutnottheassociatedfearofpunishment.Theresultisthatthepersonisalwaysfearfulandapprehensivebutdoesnotknowwhy.Likemostpsychoanalytichypotheses,thisexplanationforGADreliesonclinicalobservationsratherthancontrolledresearchforitssupport.
BehavioralViewsofGAD
BehavioristsviewGADasaformofclassicallyconditioned(learned)fearthatdiffersfromaspecificphobiaorsocialphobiaonlybyitsgreatergenerality(Lisseketal.,2014).PeoplewithGADarealwaysafraidbecausetheyarealwaysencounteringfearedstimuli.
Cognitive-BehavioralViewsofGAD
CognitivepsychologistsproposethatpeoplewithGADfearlossofcontrolandhelplessness.Experimentalsupportforthistheorycomesfromseveralclassicalexperimentsconductedinthe1940sbyMowrerandViek(1948).Theseresearchersadministeredelectricshockstoratswhiletheanimalsate(seeFigure3.3).Ratsthatwereunabletocontroltheshockcametofearandavoidtheareainwhichtheywereshocked,eventhoughthiswasalsotheplaceinwhichtheywerefed.Ratsthatweretaughthowtoterminatetheshockgivenameansofcontroldidnotavoidthefeedingarea(Mineka,1992).
Figure3.3:Anexperimentillustratingtheconsequenceofcontrollability
Theexecutiveratcancontroltheelectricshocktoitstailbyturningawheel.Thesubordinaterathasnocontrolovertheshock.Thecontrolratreceivesnoshockatall.Neitherthecontrolratnortheexecutiveratavoidsthefeedingplace.Thesubordinate,bycontrast,becomesvigilantandanxious.
Source:
J.MaserandM.E.P.Seligman(Eds.),Psychopathology:ExperimentalModels.
SanFrancisco:W.H.Fre