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Anxiety Disorders. Phobias Panic Disorders Generalized Anxiety Disorder Obsessive-Compulsive Disorder Post-trauma disorders Other anxiety disorders. Symptoms of anxiety. Gastrointestinal Genitourinary Cardiovascular Skin Ocular Musculoskeletal Mental/cognitive.

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Anxiety disorders l.jpg

Anxiety Disorders

Phobias

Panic Disorders

Generalized Anxiety Disorder

Obsessive-Compulsive Disorder

Post-trauma disorders

Other anxiety disorders


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Symptoms of anxiety

  • Gastrointestinal

  • Genitourinary

  • Cardiovascular

  • Skin

  • Ocular

  • Musculoskeletal

  • Mental/cognitive

Fear is a response to a perceived danger or threat. Anxiety is the anticipation of a possible threat.


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1. Phobias

  • General characteristics of phobias

    • Fear sensations

    • Avoidance behavior

    • Cognitive recognition that the fear is out of proportion to the stimulus


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1A. Specific Phobia: Objects or situations

  • Lifetime prevalence:

    • 7% men, 16% women

  • Types of specific phobias

    • Animal Type

    • Natural Environment Type

    • Blood-Injection-Injury Type

      • Predictive validity: Treat with muscle tension, not relaxation

    • Situational Type

    • Other Type


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Specific phobias in other cultures

  • Pa-feng and pa-leng

  • Jin-kyofu-sho or taijin-kyofu-sho


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1B. Social Phobia (Social Anxiety Disorder): People’s scrutiny

  • Lifetime prevalence: 11% M; 15% F

  • Fear of scrutiny

  • Fear of evaluation

  • Fear of doing or saying something humiliating or embarrassing

    • In USA, fear of personal embarrassment

    • In Japan, fear of embarrassing others

  • Adolescent onset


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2. Panic Disorder scrutiny

  • With Agoraphobia

  • Without Agoraphobia

  • Recurrent, unexpected (uncued) panic attacks followed by persistent worry

    • situationally cued phobias vs. situationally predisposed Panic Disorder

  • (DSM-IV also lists Agoraphobia without History of Panic Disorder)


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Panic attack: At least 4 symptoms within 10 minutes scrutiny

  • Heart: racing, palpitations, pounding

    • Dizzy, lightheaded, faint, unsteady

  • Skin: sweating

    • paresthesias

    • chills or hot flashes

  • Muscles: Trembling, shaking

  • Respiratory: shortness of breath, smothering

    • choking feeling

    • Chest pain or discomfort

  • Gastrointestinal: nausea or distress

  • Cognitive/mental:derealization/depersonalization

    • fear of losing control/going crazy

    • fear of dying


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3. Generalized Anxiety Disorder/ Overanxious Disorder of Childhood

  • Excessive anxiety and worry

    • More than half of the time

    • Lasting at least 6 months

    • Focussing on several topics

    • Hard to control

    • At least three symptoms (one in children) out of: restlessness, rapid fatigue, mind wandering or blanking, irritability, tense muscles, sleep problems


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4. Obsessive-Compulsive Disorder Childhood

  • Repeated, distressing obsessions (thoughts, impulses, images, doubts) or compulsions (rituals; yielding or controlling)

  • Take up at least 1 hour per day

  • Are done to relieve or prevent anxiety

  • Adults recognize the symptoms as extreme; children may not.

  • Resistance is futile.

  • Seen in religious people as scrupulosity.


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OCD Distribution Childhood

  • 80% of normal people report obsessions; 54% report compulsions

  • Lifetime prevalence 2 - 3%

  • No gender difference

  • Begins either before age 10 or 18-30

  • Less common among African Americans and Mexican Americans

  • More common in divorced, separated, or unemployed people


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OCD ramifications Childhood

  • Is there a connection to self-injury?

  • Are so-called sexual addictions examples of OCD?

  • Are obsessions ever the re-experiencing events of post-trauma disorders? (Freeman & Leonard, 2000)

  • Are eating disorders like OCD?

  • Is there a connection to tic disorders?


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5. Post-trauma disorders Childhood

  • Acute Stress Disorder: Within 1 month

  • Posttraumatic Stress Disorder: > 1 mo.

    • Acute, chronic, and delayed specifiers

  • Extreme trauma

    • Threat of death or serious injury

    • Witnessing trauma to others

    • Learning about violent death, harm, or threat to a loved one or close friend

    • Worse if caused by human design

  • Reexperiencing, arousal, and avoidance


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Post-trauma disorders… Childhood

  • Lifetime incidence between 1 and 14% in the general population, but between 3 and 58% in those exposed to trauma

  • PTSD is third only to Depression and Substance Abuse disorders among young adults (Breslau, Davis, Andreski, & Peterson, 1991), and is more common among young people than older folks (Norris, 1992)


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Post-trauma disorders… Childhood

  • Comorbid with Substance-Related Disorders, Panic Disorders, Obsessive-Compulsive Disorder, Phobias, Depression, and Somatization Disorder

  • Often experience survivor guilt, broken relationships

  • Especially common in war-torn areas and in migrants from such nations


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6. Other anxiety disorders Childhood

  • Anxiety Disorder Due to a General Medical Condition

    • Examples: Hyperthyroidism, hypoglycemia, congestive heart failure, pneumonia, B12 deficiency, encephalitis

  • Substance-Induced Anxiety Disorder

    • May be during intoxication or withdrawal

    • Examples: Alcohol, amphetamines, caffeine, cocaine, marijuana, many medications, heavy metals, CO, CO2

  • Anxiety Disorder NOS


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Etiologies of anxiety disorders Childhood

  • Psychoanalysis: Phobias

    • Freud: Defense against id-triggered anxiety

    • Arieti: Specific placement of general mistrust

    • Phobic object is symbolic

  • Behavioral theories: All anxiety disorders

    • Classical conditioning and operant avoidance

      • About half of people recall appropriate trauma experiences; half do not (Kendler, Myers, & Prescott, 2002)

      • But Loftus (1993) found that 25% of 1500 people who had been hospitalized in the last year had no recall memory of it.

      • Recall of painful childhood events is particularly poor.

    • Role of extinction, contingency, and preparedness

    • Focus on UCR, not UCS


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More etiologies Childhood

  • Gender and culture

    • All anxiety disorders but OCD are more often diagnosed in women, usually twice as often. Gender may be a marker variable.

  • Modeling and imitation: All anxiety disorders

    • Vicarious conditioning and consequences to the model

    • Mineka’s monkeys (1984, 1989)

    • Limited generality: Most people with phobias report no such modeling


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Cognition: All anxiety disorders Childhood

  • Rumination and self-awareness

  • Attendance to threat and perceived control

  • Negativity and pessimism in self-evaluation

  • Unconscious processes: Subliminal stimulation provokes fear in people with phobias (Ohman & Soares, 1994)

  • Social skills and social phobia



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Biological theories Childhood

  • ANS reactivity or lability

  • Genetic factors

    • Familiality:

      • 64% concordance vs 3% of population for blood and injection type of Specific Phobia

      • 20 – 40% heritability for phobias, GAD, and PTSD

      • 48% heritability for panic disorder

    • Temperament

    • Correlational data


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Neurological factors Childhood

  • Elevated responsiveness in the amygdala, part of the fear circuit of the limbic system

  • Poor functioning of serotonin (5-HT) and GABA, and elevated levels of norepinephrine (NE), perhaps caused by a surge in the fear circuit, which includes the locus ceruleus.


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Personality factors Childhood

  • Behavioral inhibition

    • Highly reactive infants (14 months old) were more likely (45%) to show anxiety symptoms at age 7.5 than those with low infant reactions (15%)

  • High neuroticism doubles the risk of anxiety disorders

  • About half of adults with anxiety disorders had evidence of psychiatric disorders in childhood, usually anxiety disorders (33%) or depression (Gregory et al., 2007)


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Treatment Childhood

  • Psychoanalysis

    • Uncover the repression

    • Confront the fear


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Behavioral approaches Childhood

  • Confront with relaxation: Systematic desensitization

  • Confront with tension: Blood and injection phobias

    • Counter parasympathetic overshoot

  • Flooding, in vivo, vicarious, and imaginal

  • Social skills training


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Cognitive approaches Childhood

  • Cognitive restructuring not effective with specific phobias

  • Some effectiveness for social phobia, if combined with social skills training


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Biological treatments Childhood

  • Anxiolytic drugs: Benzodiazepines

  • Antidepressants may be useful for social phobia.

    • Riddle (2001) found fluvoxamine (Luvox) effective in children with social phobia and OCD

  • Confronting the feared stimulus is essential for all of the treatment approaches, but anxiolytic drugs may lessen the effectiveness of exposure therapies.


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