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Anxiety Disorders. Panic Attack. Brief episode where pt. feel intense dread accompanied by a variety of physical and other symptoms that begin suddenly and peak rapidly (usually 10 minutes) Physical/mental sensations

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Panic attack
Panic Attack

  • Brief episode where pt. feel intense dread accompanied by a variety of physical and other symptoms that begin suddenly and peak rapidly (usually 10 minutes)

  • Physical/mental sensations

    • Chest pain, chills or hot flashes, choking sensation, derealization/depersonalization, dizziness, fear of losing control, tachycardia, numbness, sweating, shortness of breath, trembling.

Panic disorder
Panic Disorder

  • Repeated Panic Attacks

  • Worry/dread at having additional attacks

  • With/without Agoraphobia

Posttraumatic StressDisorder

  • Symptoms following exposure to extreme trauma present for at least one month.

  • Experiencing or witnessing an event that involves actual or threatened death or serious injury to self or another

  • Elicits a reaction of intense fear, helplessness, or horror

  • After trauma there is persistent reexperiencing of the trauma, persistent avoidance of stimuli associated with trauma, and persistent symptoms of increased arousal

Acute Distress Disorder

  • Similar to PTSD, except Sx must have onset within 4 weeks of the trauma and must last for at least 2 days but no longer than 4 weeks

  • 3 or more dissociative Sxs (e.g.. sense of numbing or emotional detachment, derealization, dissociative amnesia)

  • Must exhibit persistent reexperiencing of the trauma.

  • Marked avoidance of stimuli that cause recollection the trauma

  • Sxs of marked anxiety or increased arousal.


  • Specific Phobia-patients fear specific objects or situation, such as animals, storms, heights, blood, airplanes, being closed in or any situation that may lead to vomiting, choking or developing an illness.

  • Social Phobia-These patient imagine themselves embarrassed when they speak, write, or eat in public, use a public urinal; during exposure-immediate panic attacks.

Generalized Anxiety Disorder

  • Excessive anxiety and worry about multiple events or activities.

  • The anxiety and worry are relatively constant for at least 6 months, and the person finds them difficult to control.

  • Must entail 3 of following: restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance

  • Disproportionate to feared events or their potential impact

  • Worrier or GAD? Measures-State Trait Inventory; How else?

Substance-InducedAnxiety Disorder

  • The development of anxiety, OC Sxs, or panic attacks are present within one month of Substance Intoxication or Withdrawal or are due to medication use.

  • Associated with caffeine, cannabis, cocaine, hallucinogen, inhalant, and PCP intoxication and withdrawal from alcohol, cocaine, or a sedative, hypnotic or anxiolytic

  • Medications and toxins (e.g. gasoline, paint, insecticides, and CO can produce anxiety symptoms.)

Obsessive-Compulsive Disorder

  • Characterized by recurrent obsessions or compulsions that are severe enough to cause significant distress, to be time-consuming (take more than one hour per day), or to markedly interfere with the person’s usual routine, occupational or academic functioning, social activities and relationships.

  • Person must be aware, at some time during the course of the disorder, that his/her obsessions and compulsions are excessive or unreasonable

Biology anxiety
Biology & Anxiety

  • Peripheral Nervous System

    • Somatic

      • Sensory Systems

      • Skeletal Motor System

    • Autonomic

      • Sympathetic-arousal & energy expenditure

      • Parasympathetic-conservation of energy

Ans anxiety disorders
ANS & Anxiety Disorders

  • Although primarily involuntary, it has been found to be brought under voluntary control

  • Pts. With Anxiety D/O’s demonstrate delayed response to repeated stimuli and excessive response to moderate stimuli

  • Predisposition or Learning?????

Anxiety d o epidemiology lifetime 12 month

Panic (M/F%) 2/5

Agoroph. W/O 3.5/7

Social Phobia 11/15

Simple Phobia 7/16

Gen. ADO 4/7

OCD 2/3

Any Phobia 10/18

Any ADO 19/31

1.3 vs. 3.2

1.7 vs. 3.8

6.6 vs. 9.1

4.4 vs. 13.2

2.0 vs. 4.3

1.4 vs. 1.9

6.2 vs. 12.8

11.8 vs. 22.6

Anxiety D/O EpidemiologyLifetime % 12-Month %


  • Norepinephrine, Serotonin & GABA

  • Act in brainstem (noradrenergic neurons); limbic system(anticipatory anxiety) and prefrontal cortex

  • PFC associated with the possible generation of phobic avoidance


  • Pts. have poorly regulated noradrenergic systems leading to occasional energy bursts

  • Stimulation leads to fear response

  • Beta-adrenergic agonists (Isuprel) or Alpha2-adrenergic antagonist (Yohimbine) lead to severe panic attacks

  • Alpha2-adrenergic agonist (Clonidine/Catapres) & B-ATN (Propanolol/Inderal) reduce anxiety


  • Many SE type receptors-more selective

  • Clomipramine (Anafranil)-OCD

  • Buspirone (Buspar) 5HT agonist with projections from brainstem, cortex, limbic system and hypothalamus

Gaba aminobutyric acid
GABA (Aminobutyric Acid)

  • Most common inhibitory NT in CNS

  • Benzodiazepines increase the activity of GABA at the receptor

  • Low potency most treatment for GAD

  • High potency GABA’s (e.g. Xanex) have been effective in treatment of PDO

Anxiolytic medications what to rx
Anxiolytic MedicationsWhat to Rx?

  • SSRIs: Paroxetine (Paxil)

    • other alternatives?

  • Benzodiazepines

    • Alprazolam (Xanex) Lorazepam (Ativan) & Clonzaepam (Klonopin)

    • Advantages and disadvantages?

  • Tricyclics: Clomipramine & Imipramine (Tofranil)

    • Alternatives, advantages & disadvantages

Psychotherapy and ados
Psychotherapy and ADOs

  • Controversies?

  • In vivo exposure with response prevention (flooding) –Agoraphobia

  • SDT or Participant modeling-Specific Phobias (observation/graded participation)

  • CBT, PMR, Social skills training & Assertiveness Training

  • Medication vs. Psychotherapy?