Anxiety Disorders

1. Anxiety Disorders Panic Disorder Agoraphobia Social Phobia Specific Phobia Obsessive Compulsive Disorder Generalized Anxiety Disorder (PTSD & Acute Stress Disorder)

2. Panic Attack (not a diagnosis) A. Discrete period of intense fear or discomfort, in which 4 or more of the following Six develop abruptly and reach a peak within 10 minutes • Palpitations • Sweating • Trembling/aching • Sensations of shortness of breath or smothering • Feeling of choking • Chest pain/discomfort • Nausea/abdominal distress • Feeling dizzy/unsteady/lightheaded/faint • Derealization/depersonalization • Fear of losing control/going crazy • Fear of dying • Paresthesias (numbness or tingling sensation) • Chills/hot flushes

3. Agoraphobia (not a diagnosis) A. Anxiety about being in places or situations from which escape might be difficult or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. B. The situations are avoided or are endured with marked distress C. Not better accounted for by another mental disorder

4. Some help… Panic Attacks NO YES NO Agoraphobia YES

5. Panic Disorder without Agoraphobia A. Both 1 and 2 1. Recurrent, unexpected panic attacks 2. At least one of the attacks has been followed by 1 or more months of 1 or more of the following a. Persistent concern about having additional attacks b. Worry about the implications of the attack or its consequences c. Significant change in behavior related to the attacks B. Absence of agoraphobia C. Panic attacks are not due to a GMC or substance D. Panic Attacks are not better accounted for by another mental disorder

6. Panic Disorder with Agoraphobia A. Both 1 and 2 1. Recurrent, unexpected panic attacks 2. At least one of the attacks has been followed by 1 or more months of 1 or more of the following a. Persistent concern about having additional attacks b. Worry about the implications of the attack or its consequences c. Significant change in behavior related to the attacks B. Presence of agoraphobia C. Panic attacks are not due to a GMC or substance D. Panic Attacks are not better accounted for by another mental disorder

7. Agoraphobia without History of Panic Disorder A. Presence of Agoraphobia related to fear of developing panic-like symptoms B. Criteria have never been met for Panic Disorder C. Disturbance is not due to a GMC or substance D. If an associated GMC is present, the agoraphobia is in excess of that usually associated with the condition

8. Social Phobia A. Marked, persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way that will be humiliating or embarrassing. B. Exposure to the feared social situation almost invariably provokes an anxiety response C. The person recognizes that the fear is excessive or unreasonable D. The phobic stimulus is avoided or endured with intense anxiety or distress E. There is significant distress or an impairment in functioning

9. Specific Phobia A. Marked, persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation B. Exposure to the phobic stimulus almost always provokes an immediate anxiety response C. The person recognizes that the fear is excessive or unreasonable D. The phobic stimulus is avoided or endured with intense anxiety or distress E. There is significant distress or an impairment in functioning due to the phobia F. The phobia is not better accounted for by another mental disorder

10. Subtypes of Specific Phobia • Animal type • Natural environment type • Blood-Injection-Injury type • Situational type • Other type

11. Phobia Marked by a persistent and irrational fear of an object or situation that disrupts behavior.

12. Kinds of Phobias Agoraphobia Phobia of open places. Acrophobia Phobia of heights. Claustrophobia Phobia of closed spaces. Hemophobia Phobia of blood.

13. Don’t concept map this • Acrophobia: Heights Aquaphobia: Water • Gephyrophobia: Bridges Ophidiophobia: Snakes • Aerophobia: Flying Arachnophobia: Spiders • Herpetophobia: Reptiles Ornithophobia: Birds • Agoraphobia: Open spaces Astraphobia: Lightning • Mikrophobia: Germs Phonophobia: Speaking aloud • Ailurophobia: Cats Brontophobia: Thunder • Murophobia: Mice Pyrophobia: Fire • Amaxophobia: Vehicles, driving Claustrophobia: Closed spaces • Numerophobia: Numbers Thanatophobia: Death • Anthophobia: Flowers Cynophobia: Dogs

14. Good Question… If phobias are learned behaviors, why don’t they extinguish on their own???

15. Answer to the Good Question… • Avoidance works! • Fear is never tested

16. Obsessive-Compulsive Disorder Persistence of unwanted thoughts (obsessions) and urges to engage in senseless rituals (compulsions) that cause distress.

17. Obsessive-Compulsive Disorder A. Either obsessions or compulsions: Obsessions as defined by 1, 2, 3, and 4 • Recurrent, persistent thoughts, impulses, or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress • The thoughts, impulses, or images are not simply excessive worries about real-life problems • The person attempts to ignore or suppress such thoughts, impulses, or images or tries to neutralize them with some other thought or action • The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind

18. Typical Obsessions • Doubts (e.g. Did I turn off the stove? Did I lock the door? Did I hurt someone?) • Fears that someone else has been hurt or killed • Fears that one has done something criminal • Fears that one may accidentally injure someone • Worry that one has become dirty or contaminated • Blasphemous or obscene thoughts • NOT just excessive worries about real-life problems

19. Obsessive-Compulsive Disorder Compulsions as defined by 1 and 2 • Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly • The compulsions are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

20. Typical Compulsions • Checking • Cleaning/washing • Doing things a certain number of times in a row • Doing and then undoing things • Doing things in a certain order, with symmetry • Mental acts such as praying, counting, etc.

21. Obsessive-Compulsive Disorder B. The person has recognized that the obsessions or compulsions are excessive or unreasonable C. There is significant distress or an impairment in functioning due to the obsessions or compulsions D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to the other Axis I disorder E. The disturbance is not due to a GMC or substance

22. OCD in Children • Children have an average of 4 obsessions and 4 compulsions at any given time • Often comorbid with Tourette’s syndrome and/or ADHD

23. Generalized Anxiety Disorder (GAD) • Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events • The person finds it difficult to control the worry • The anxiety and worry are associated with 3 or more of the following symptoms • Restlessness or feeling keyed up or on edge • Being easily fatigued • Difficulty concentrating or mind going blank • Irritability • Muscle tension • Sleep Disturbance

24. Generalized Anxiety Disorder (GAD) D. The focus of the anxiety and worry is not confined to features of another disorder and do not occur exclusively during PTSD E. There is clinically significant distress or impairment in functioning F. Not due to a GMC or substance

25. Post-Traumatic Stress Disorder A. The person has been exposed to a traumatic event and have experienced four or more weeks of one or more of the following symptoms: • Haunting memories 2. Nightmares 3. Social withdrawal 4. Jumpy anxiety 5. Sleep problems Bettmann/ Corbis

26. Resilience to PTSD Only about 10% of women and 20% of men react to traumatic situations and develop PTSD. Holocaust survivors show remarkable resilience against traumatic situations. All major religions of the world suggest that surviving a trauma leads to the growth of an individual.

27. Resilience to PTSD Only about 10% of women and 20% of men react to traumatic situations and develop PTSD. Holocaust survivors show remarkable resilience against traumatic situations. All major religions of the world suggest that surviving a trauma leads to the growth of an individual.

28. Anxiety Disorders - Overview • Most common mental disorders in the U.S. • At least 19% of the adult population suffer from at least one anxiety disorder in any given year • All are more common in women, except for OCD • Except for Panic Disorder, ages of onset are most likely going to be in childhood or adolescence (but do not have to be) • Anxiety Disorders cost $42 billion each year in health care, lost wages, and lost productivity

29. Anxiety DisordersCultural Variations • Fear, Anxiety, and Anxiety Disorders exist in all cultures • Prevalence rates vary, but are generally the most common mental illness in all countries • Low rates: China (2.4%), Japan, Nigeria, and Spain • High rates: U.S. (19%), France, Colombia, and Lebanon • Fear stimulus and content of anxiety differ greatly between cultures

30. Dhat (India), Jiryan (India), Sukra Prameha (Sri Lanka), & Shen-k’uei (China) • Severe anxiety, panic symptoms, somatic complaints, hypochondriachal symptoms associated with the discharge of semen • Excessive semen loss is feared because of the belief that it represents the loss of one’s vital essence and can thereby be life threatening

31. Koro (South and Southeast Asia) • Sudden and intense anxiety that one’s genitalia will recede into the body and possibly cause death • Can occur in epidemics

32. Taijin Kyofusho (Japan) • An intense fear that one’s body, its parts, or its functions (sweating, body odor, facial expressions, etc.) displease, embarrass, or are offensive to other people • Similar to the DSM’s Social Phobia

33. Explaining Anxiety Disorders Freud suggested that we repress our painful and intolerable ideas, feelings, and thoughts, resulting in anxiety.

34. The Learning Perspective Learning theorists suggest that fear conditioning leads to anxiety. This anxiety then becomes associated with other objects or events (stimulus generalization) and is reinforced. John Coletti/ Stock, Boston

35. The Learning Perspective Investigators believe that fear responses are inculcated through observational learning. Young monkeys develop fear when they watch other monkeys who are afraid of snakes.

36. The Biological Perspective Natural Selection has led our ancestors to learn to fear snakes, spiders, and other animals. Therefore, fear preserves the species. Twin studies suggest that our genes may be partly responsible for developing fears and anxiety. Twins are more likely to share phobias.

37. The Biological Perspective Generalized anxiety, panic attacks, and even OCD are linked with brain circuits like the anterior cingulate cortex. S. Ursu, V.A. Stenger, M.K. Shear, M.R. Jones, & C.S. Carter (2003). Overactive action monitoring in obsessive-compulsive disorder. Psychological Science, 14, 347-353. Anterior Cingulate Cortex of an OCD patient.

38. Panic Disorder • What Causes Panic Disorder? • We don’t really know; many factors. • But: Strong evidence that norepinephrine is involved. • Norepinephrine: neurotransmitter especially active in Locus ceruleus part of the brain.

39. Models of Abnormality Biological model: Anatomy (structures) Neo-Cortex Corpus callosum Amygdala Locus ceruleus (Pons)

40. Panic Disorder • Anti-depressant drugs that regulate norepinephrine successful in treating panic • When Locus ceruleus stimulated in monkeys  panic like behavior • Locus ceruleus rich in norepinephrine carrying neurons • Hypothesis: Norepinephrine dysregulation may well be implicated in Panic Disorder

41. Obsessive-Compulsive Disorder Psychodynamic Perspective • Anxiety rooted in repressed ID impulses • Impulses = obsessive thoughts • Compulsions = ego defenses against them • E.g.: Lady Macbeth: Anxiety/guilt over her part in a murder  compulsive hand washing to get rid of the imagined blood. • How would you treat Lady Macbeth?

42. Obsessive-Compulsive Disorder Behavioral Perspective • Focus on compulsions, not obsessions • Theory: association forms randomly between fear/anxiety reduction and the compulsive behavior • Compulsive behavior becomes reinforcing because it reduces anxiety • Therefore compulsion increases in frequency

43. Obsessive-Compulsive Disorder Biological Perspective • Drugs that increase Serotonin activity are somewhat effective in treating OCD • Serotonin is also active in 2 brain areas that have been associated with OCD: the orbital region of the frontal cortex and caudate nucleus

44. Caudate nucleus Orbital frontal cortex