anxiety disorders

1. Anxiety Disorders GAD, Specific Phobias, Social Phobias, OCD, Panic Disorder, Agoraphobia, PTSD, Acute Stress Disorder

2. Physical symptoms include things like: increased heart rate, fatigue, increased respiration, nausea, stomach upset, dry mouth, muscle tension blushing, urination, dizziness These physical symptoms are the result of the messages that the brain sends to the sympathetic nervous system �the part that mobilizes the body for action, the flight or fight response. Cognitive: thourghts of being scared, self-deprecatory of self-crtical thoughts, thoughts of incompetence or inadquacy, blanking out forgetfulness, thoughts of going crazy Behavioral: behavioral responses that result from the anxiety or in some way help to cope with it like: avoidance, crying, nail biting, eyes shut, stutering, trembling lip, twitching, avoidance of eye contact, pfidgeting, trembiling voice, clenched jaw�..gratitutious arem, hand and leg movements.Physical symptoms include things like: increased heart rate, fatigue, increased respiration, nausea, stomach upset, dry mouth, muscle tension blushing, urination, dizziness These physical symptoms are the result of the messages that the brain sends to the sympathetic nervous system �the part that mobilizes the body for action, the flight or fight response. Cognitive: thourghts of being scared, self-deprecatory of self-crtical thoughts, thoughts of incompetence or inadquacy, blanking out forgetfulness, thoughts of going crazy Behavioral: behavioral responses that result from the anxiety or in some way help to cope with it like: avoidance, crying, nail biting, eyes shut, stutering, trembling lip, twitching, avoidance of eye contact, pfidgeting, trembiling voice, clenched jaw�..gratitutious arem, hand and leg movements.

3. Physiology of Anxiety: Physical System Perceived danger Brain sends message to autonomic nervous system Sympathetic nervous system is activated (all or none phenomena) Sympathetic nervous system is the fight/flight system Sympathetic nervous system releases adrenaline and noradrenalin (from adrenal glands on the kidneys). These chemicals are messengers to continue activity

4. Parasympathetic Nervous System Built in counter-acting mechanism for the sympathetic nervous system Restores a realized feeling Adrenalin and noradrenalin take time to destroy

5. Cardiovascular Effects Increase in heart rate and strength of heartbeat to speed up blood flow Blood is redirected from places it is not needed (skin, fingers and toes) to places where it is more needed (large muscle groups like thighs and biceps) Respiratory Effects-increase in speed and dept of breathing Sweat Gland Effects-increased sweating

6. Behavioral System Fight/flight response prepares the body for action-to attack or run When not possible behaviors such as foot tapping, pacing, or snapping at people

7. Cognitive System Shift in attention to search surroundings for potential threat Can�t concentrate on daily tasks Anxious people complain that they are easily distracted from daily chores, cannot concentrate, and have trouble with memory

8. �U� Shaped Function of Anxiety Useful part of life Expressed differently at various age levels Since everyone is familiar with this concept then we know that anxiety is a part of everyday normal life. In fact without any anxiety we probably would not accomplish a heck of a lot. In contrast too much anxiety prevents us from thinking effectively and getting anything valuable done. This too little or too much phenomena is described as a U shaped function where on one part of the U too little anxiety and on the other part-too much and middle ground is optimal. The expression of anxieties seem to change across the lifespan. In Infancy when sensory experience predominate, they are also the amjor source of fear, for example loud sounds or sudden loss of physcial support. Development proceeds, infant acquires object permanence: At this point fear of strangers and distress upon caretakers departure emerge and separation anxiety appears. Early childhood: new fears appears animals, the dark and imaginary beasts and creats Late childhood: concerns about perfomance begin Early adolescene; interpersonal social anceitySince everyone is familiar with this concept then we know that anxiety is a part of everyday normal life. In fact without any anxiety we probably would not accomplish a heck of a lot. In contrast too much anxiety prevents us from thinking effectively and getting anything valuable done. This too little or too much phenomena is described as a U shaped function where on one part of the U too little anxiety and on the other part-too much and middle ground is optimal. The expression of anxieties seem to change across the lifespan. In Infancy when sensory experience predominate, they are also the amjor source of fear, for example loud sounds or sudden loss of physcial support. Development proceeds, infant acquires object permanence: At this point fear of strangers and distress upon caretakers departure emerge and separation anxiety appears. Early childhood: new fears appears animals, the dark and imaginary beasts and creats Late childhood: concerns about perfomance begin Early adolescene; interpersonal social anceity

9. Anxiety Disorders Generalized Anxiety Disorder GAD

10. Generalized Anxiety Disorder Unfocused worry

11. Generalized Anxiety Disorder: Diagnostic Criteria Excessive anxiety or worry occurring more days than not for at least 6 months about a number of events or activities Difficulty controlling worry 3 of 6 symptoms are present for more days than not:restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance

12. Generalized Anxiety Disorder (GAD): Prevalence ~ 4% of the population (range from 1.9% to 5.6%) 2/3 of those with GAD are female in developed countries Prevalent in the elderly (about 7%)

13. Generalized Anxiety Disorder: Genetics Familial studies support a genetic model (15% of the relatives of those with GAD display it themselves-base rate is 4% in general population) Risk of GAD was greater for monozygotic female twin pairs than for dizygotic twins. The tendency to be anxious tends to be inherited rather than GAD specifically Heritability estimate of about 30%

14. Generalized Anxiety Disorder: Neurotransmitters Finding that benzodiazepines provide relief from anxiety (e.g. valium) Benzodiazepine receptors ordinarily receive GABA (gamma-aminobutyric acid) GABA causes neuron to stop firing (calms things down)

15. Generalized Anxiety Disorder: Neurotransmitters Getting Anxious Hypothesized Mechanism: Normal fear reactions Key neurons fire more rapidly Create a state of excitability throughout the brain and body �perspiration, muscle tension etc. Excited state is experienced as anxiety Calming Down Feedback system is triggered Neurons release GABA Binds to GABA receptors on certain neurons and �orders� neurons to stop firing State of calm returns GAD: problem in this feedback system

16. GABA Problems? Low supplies of GABA Too few GABA receptors GABA receptors are faulty and do not capture the neurotransmitter

17. Generalized Anxiety Disorder: Cognitions Intense EEG activity in GAD patients reflecting intense cognitive processing Worrying as a form of avoidance restrict their thinking to thoughts but do not process the negative affect Worry hinders complete processing of more disturbing thoughts or images Content of worry often jumps from one topic to another without resolving any particular concern

18. Generalized Anxiety Disorder: Treatment Short term-benzodiazepine (valium) Cognitive Therapy (focus on problem) Valium gives some short term relief but few studies have examined the effects of this medication fr a period longer than 8 weeks. Those that have examined longer term effects suggest modest effects only up to 6 months. However these medications carry some risks: impair cognitive and motor functioning and produce psychologicl and physical dependence. Should be only used for several days or a week or two at the most. Helping people with this disorder to focus on what is actually trheatening is useful.Treatments are designed to help these people process the information on an emotional level, using images, so they will feel anxious. And teach them to work through the problem.Valium gives some short term relief but few studies have examined the effects of this medication fr a period longer than 8 weeks. Those that have examined longer term effects suggest modest effects only up to 6 months. However these medications carry some risks: impair cognitive and motor functioning and produce psychologicl and physical dependence. Should be only used for several days or a week or two at the most. Helping people with this disorder to focus on what is actually trheatening is useful.Treatments are designed to help these people process the information on an emotional level, using images, so they will feel anxious. And teach them to work through the problem.

19. Anxiety Disorders Phobias: Specific & Social

20. Phobia: Diagnostic Criteria Marked & persistent unreasonable fear of object or situation Anxiety response Unreasonable Object or situation avoided or endured with distress

21. Differential Diagnosis of Specific Phobia Vs. SAD: not related to fear of separation Vs. Social Phobia: not related to fear of a social situation or fear of humiliation Vs. Agoraphobia: fear not related to closed places Vs. PTSD: fear not related to a specific past traumatic event

22. Phobias: Types Specific phobias Blood-Injection Injury phobias Situational phobia Natural environment phobia Animal phobia Pa-leng (Chinese) colpa d�aria (Italian) Germs Choking phobia�.. A specific phobia is an irrational fear of a specific object or situation that markedly interferes with an individual�s functioning. Blood injection: how many people pass out when they get blood drawn? Situational: fear of public transportation or enclosed spaces like claustrophobia, or planes. Natural enviroment: heights, storms, water�peak at about age 7 A specific phobia is an irrational fear of a specific object or situation that markedly interferes with an individual�s functioning. Blood injection: how many people pass out when they get blood drawn? Situational: fear of public transportation or enclosed spaces like claustrophobia, or planes. Natural enviroment: heights, storms, water�peak at about age 7

23. Developmentally Normal Fears

24. Phobias: Prevalence Fears are very prevalent Phobias occur in about 11% of the population More common among women Tends to be chronic High percentage makes phobias one of the most common psychologyical disorders in the United statesHigh percentage makes phobias one of the most common psychologyical disorders in the United states

25. Etiology of Phobias: Genetics 31% of first degree relatives of phobics also had a phobia (compared to 11% in the general population) Relatives tended to have the same type of phobia Not clear if transmission is environmental or genetic

26. Specific Phobia: Behavioral Perspective Case of Little Albert Two-factor model: Acquisition-classical conditioning Maintenance-operant conditioning

27. Specific Phobia: Behavioral Perspective Classical conditioning Modeling Stimulus generalization Stimulus generalization: responses to one stiumulus are also produced by similar sitimuli. Fear of one bug is likely to generalize to other bugs.Stimulus generalization: responses to one stiumulus are also produced by similar sitimuli. Fear of one bug is likely to generalize to other bugs.

28. Evolutionary Preparedness Predilection (or preparedness inherited from ancient ancestors) to be afraid of hazards Good evolutionary reasons to be afraid of some things (snakebites, falls from large heights, and being trapped in small places)

29. Biological Preparedness: Exercise Write down an object or situation of which you are particularly afraid Write down the events that led to the fear As a group, tally the feared objects and the percentage of times the person could recall the beginning of the fear As a group, indicate which group of fears are associated with dangerous consequences, e.g. fear of snakes

30. Hypothesis According to biological preparedness theory, objects of phobic fear are nonrandomly distributed to objects or situations that were threatening to the survival of the species. Hypothesis: More threatening objects or situations (that are threatening) will be listed than those that are not threatening

31. Specific Phobia: Cognitive Perspective

32. Specific Phobia: Social and Cultural Factors Predominantly female Unacceptable in cultures around the world for men to express fears

33. Specific Phobia: Treatment Systematic Desensitization

34. Social Phobia Fearful apprehension Social situations

35. Social Phobia: Diagnostic Criteria Marked or persistent fear in one or more social or performance situations Exposure to fear situation is associated with extreme anxiety Person recognizes that fear is excessive or unreasonable Feared social and performance situations are avoided or endured with intense anxiety

36. Social Phobia: Prevalence 13% of the general population About equally distributed in males and females, however, males more often seek treatment Usually begins around age 15 Equally distributed among ethnic groups One of the most prevalent disorders.One of the most prevalent disorders.

37. Etiology of Social Phobia Biological vulnerability to develop anxiety or be socially inhibited. May increase under stress or when the situation is uncontrollable Unexpected panic attack during a social situation or experience a social trauma resulting in conditioning (i.e. a learned alarm). Modeling of socially anxious parents Preparedness Biological preparedness We are prepared to fear rejecting people Social phobics more likely to focus on critical facial expressions Biological preparedness We are prepared to fear rejecting people Social phobics more likely to focus on critical facial expressions

38. Kagan�s theory: inhibited temperament Inhibited temperament: risk factor in social phobia Behaviorally inhibited children at age 2 remained inhibited at age 7 and 12 Inhibition tends to be related to social phobia. Kagan found that some infants are born with this temperament.Inhibition tends to be related to social phobia. Kagan found that some infants are born with this temperament.

39. Biological Basis of Temperament Kagan proposed temperamental differences related to inborn differences in brain structure and chemistry: He found inhibited children have: Higher resting heart rates Greater increase in pupil size in response to unfamiliar Higher levels of cortisol (released with stress)

40. Kagan�sTemperamental/Biological Theory and Prevention Early identification of at risk children Parental training Avoid overprotecting Encourage children to enter new situations Help kids to develop coping skills Avoid forcing the child

41. Social Phobia: Treatment Cognitive-Behavioral Therapy Assess which social situations are problematic Assess their behavior in these situations Assess their thoughts in these situations Teaches more effective strategies Rehearse or role play feared social situations in a group setting Medication Tricyclic antidepressants Monoamine oxidase inhibitors SSRI (Paxil) approved for treatment Relapse is common with medications are discontinued Noted medications seem to reduce social anxietyNoted medications seem to reduce social anxiety

42. Phobias: content vs. function Psychoanalysts: believe content is important Phobic stimulus has symbolic value Little Hans & the horse Behaviorists: believe function is important All phobias acquired in same manner & can be treated in same manner All means of avoidance, treat with exposure Little Hans: Freud�s client, afraid of horses specifically mentioned the black things around mouth and eyes, Freud stated really a fear of the father b/c he wore glasses & had a mustacheLittle Hans: Freud�s client, afraid of horses specifically mentioned the black things around mouth and eyes, Freud stated really a fear of the father b/c he wore glasses & had a mustache

43. Psychoanalytic Etiology Phobias as defenses against anxiety from id impulses Anxiety taken from id impulse and placed onto symbolic representation of the impulse Ex: Little Hans fear of his father (i.e. Oedipal conflict) displaced onto horses Horses symbolized his father

44. Behavioral Etiology: Phobias are learned. But how? Avoidance-conditioning model: classical conditioning results in fear Ex: fear of heights following a bad fall Problem #1: phobias can develop without prior exposure to the feared stimulus Ex: snake phobics Problem #2: many have frightening experiences without developing a phobia Ex: car accidents Person learsn to fear a neutral stimulus if paired with a frigtening/painful stimulus Reduce fear by avoiding the conditioned stimulusPerson learsn to fear a neutral stimulus if paired with a frigtening/painful stimulus Reduce fear by avoiding the conditioned stimulus

45. Avoidance-conditioning cont. Fewer problems if preparedness of stimuli considered Preparedness: phobias may result from stimuli to which an organism is prepared to have a fear reaction Evolutionary prepared fear response Snakes, spiders, heights Vs. electrical outlets, lambs Ohman�s studies Provides method of addressing findings that feared stimuli are not random Mc Nally: against the A-C model Ohman: electric shock paired with slides of neutral and prepared stimuli (snakes). After shock, the CR to the neutral slides diminished quicker than the CR to the prepared slides McNally: not clear that mild shocks used in Ohman�s study create fear, specific phobias easily treated and therefore not evolutionarily determinedOhman: electric shock paired with slides of neutral and prepared stimuli (snakes). After shock, the CR to the neutral slides diminished quicker than the CR to the prepared slides McNally: not clear that mild shocks used in Ohman�s study create fear, specific phobias easily treated and therefore not evolutionarily determined

46. Behavioral cont: Modeling Phobias learned by watching reactions of others �vicarious learning� Can also be learned by listening to warnings Mineka & the rhesus monkeys Teen monkeys placed with snake phobic adults developed fear of snakes Monkeys shown videos of a monkey reacting fearfully to neutral vs. prepared stimuli Only monkeys exposed to prepared stimulus developed phobia Neutral: rabbit, flowers Prepared: toy snake, crocodileNeutral: rabbit, flowers Prepared: toy snake, crocodile

47. Cognitive Theories Anxiety due to attending to negative stimuli & to believing negative events likely to occur Social phobics thoughts focused on image they present and negative evaluation �I think I am boring when I talk to others� Fears seem irrational to phobics Maybe b/c the fear is unconscious Ohman & Soares study Increased response to pictures matching their phobia O & S: people phobic of either sankes or spiders shown pictures of either snakes, spiders, or neutral stimuli for only 30 miliseconds so content of the picture was masked. Spider phobic showed increased SCR to spider slides vs. All others as did snake phobics for snkae slides vs. all others.O & S: people phobic of either sankes or spiders shown pictures of either snakes, spiders, or neutral stimuli for only 30 miliseconds so content of the picture was masked. Spider phobic showed increased SCR to spider slides vs. All others as did snake phobics for snkae slides vs. all others.

48. Anxiety Disorders Obsessive Compulsive Disorder (OCD)

49. Obsession and Compulsions Obsession: Unwanted repetitive intrusive thoughts, images or urges Exs: contamination, sexual impulses, &/or hypochondriacal fears Compulsion: Repeated thoughts or actions designed to provide relief Ex: cleanliness, checking, avoiding certain objects Perceived of as irrational or silly Compulsions are thoughts or actions designed to suppres the thoughts and provide relief. Compulsion may be behavioral (eg. hand washing, checking) or mental ( e.g. counting, pryaing).Compulsions are thoughts or actions designed to suppres the thoughts and provide relief. Compulsion may be behavioral (eg. hand washing, checking) or mental ( e.g. counting, pryaing).

50. Relationship between Compulsion and Obsession The most common obsession- germs and dirt is related to the most common compulsion handwashing Obsessions create considerable anxiety Compulsions are an attempt to cope with the anxiety. Repeating rituals (second most common compulsion) is often a way-in their mind-to avoid harm (eg. �step on the crack� game) Children recognize that compulsions are unreasonable and will attempt to hide the behavior with nonfamily members Some controversey on this point: in one text they said there is usually no relationship. In this study there seems to be one.Some controversey on this point: in one text they said there is usually no relationship. In this study there seems to be one.

51. OCD: Diagnostic Criteria A. Either obsession or compulsions B. Recognition that obsessions or compulsions are excessive or unreasonable (does not apply to children)\ C. The obsession or compulsions cause marked distress, and are time consuming (take over one hour a day) or significantly interfere with the person�s normal functioning D. If another Axis I disorder is present, the content of the obsession or compulsion is not restricted to it (preoccupation in food in eating disorder, concern with drugs in Substance Abuse disorder) E. The disturbance is not due to the direct effects of drugs, medication or a physical condition Specifier: With poor insight ; if, most of the time, the person does not recognize the obsessions and compulsions are unreasonable

52. OCD: Prevalence 2.6% (may be a bit of an overestimate) 10 to 15% of normal college students engage in clinically significant checking behavior More common in females (reversed in childhood) Age of onset is in teens to young adulthood Chronic course

53. OCD Etiology: Psychoanalytic Obsessions and compulsions as a reaction to instinctual, Id, impulses Due to harsh toilet training Fixation in anal stage Id vs. defense mechanisms (ego) Id: obsessions Ego: compulsions Adler: feel incompetent as a child, create control over environment through compulsions

54. OCD Etiology: Cognitive & Behavioral Compulsions learned behaviors based on consequences Reduced fear after completing compulsions But not obsessions Poor memories? Compulsive checkers have poor recall for whether they had completed the compulsion (e.g. turning off lights) previously Obsessions Thought suppression: paradoxical effect Increased prreoccupation and negative mood Don�t think about chocolate brownies, warm gooey triple chocolate brownies�Don�t think about chocolate brownies, warm gooey triple chocolate brownies�

55. Etiology OCD: Biological Explanations Neurotransmitter (low serotonin) Brain structures/areas One biological explanation points to abnormally low activity of serotonin. The first clue to its role in ocd was the surprising finding by clinical resarchers that two antidepressant drugs Anafranil and Prozac) reduce symptoms. Since these particular drugs increase serotonin activity, some researchers concluded that the disorder is caused by low serotonin activity. In fact only medications that increase serotonin activity help in cases of ocd and not antidpressant medications that affect other nerutotransmitters. The other line of research points to abnormal functioning in key brain structures/areasOne biological explanation points to abnormally low activity of serotonin. The first clue to its role in ocd was the surprising finding by clinical resarchers that two antidepressant drugs Anafranil and Prozac) reduce symptoms. Since these particular drugs increase serotonin activity, some researchers concluded that the disorder is caused by low serotonin activity. In fact only medications that increase serotonin activity help in cases of ocd and not antidpressant medications that affect other nerutotransmitters. The other line of research points to abnormal functioning in key brain structures/areas

56. Research has linked obsessive-compulsive disorder to abnormal brain functioning. The circuit begins in the orbital region of the frontal cortex (just above each eye). This is the region where sexual, violent, and other primitive impulses normally arise. Point out where frontal cortex is: The impulses then next move on to the caudate nuclei (point out the path). And move to a bigger version of the caudate nucleiResearch has linked obsessive-compulsive disorder to abnormal brain functioning. The circuit begins in the orbital region of the frontal cortex (just above each eye). This is the region where sexual, violent, and other primitive impulses normally arise. Point out where frontal cortex is: The impulses then next move on to the caudate nuclei (point out the path). And move to a bigger version of the caudate nuclei

57. Point out caudate nuclei The caudate nuclei act as filters that send only the most powerful impulses on to the thalamus. (point out the path) If impulses reach the thalamus, the person is drive to think further about them and perhaps to act. Point out caudate nuclei The caudate nuclei act as filters that send only the most powerful impulses on to the thalamus. (point out the path) If impulses reach the thalamus, the person is drive to think further about them and perhaps to act.

58. Cause of OCD: Many theorists now believe that either the orbital region or the caudate nuclei of some people are too active leading to a constant eruption of troublesome thoughts and actions which get sent to the thalamus. In support of this theory, meidcal scietist have observed for years that obsessive compulsive symptoms do somethtimes arise or subside after the orbital region of the frontal corbext, caudate nuclei or related brain areas are damaged by accident or illness. Similarly, PET scans, which offer pictures of brain activity, have shown that the caudate nuclei and the orbital region of patients with obsessive compulsive disorder are generally more active than those of control subject.Cause of OCD: Many theorists now believe that either the orbital region or the caudate nuclei of some people are too active leading to a constant eruption of troublesome thoughts and actions which get sent to the thalamus. In support of this theory, meidcal scietist have observed for years that obsessive compulsive symptoms do somethtimes arise or subside after the orbital region of the frontal corbext, caudate nuclei or related brain areas are damaged by accident or illness. Similarly, PET scans, which offer pictures of brain activity, have shown that the caudate nuclei and the orbital region of patients with obsessive compulsive disorder are generally more active than those of control subject.

59. OCD: Treatment Medication SSRI�s (serotonin reuptake inhibitors) Average treatment gain with medication is moderate and relapse occurs when medication is discontinued Exposure and ritual prevention (ERP) Psychosurgery Medications with prevent the re-uptake of serotonin (which is low in OCD) ERP: Patieent is systematically and gradually exposed to the feared thoughts or situation and the rituals are prevented. In this way the client soon learns that no harm will result if he or she does not carry ou t the ritual. Studies are now available (good source for paper review) that examine the combined effects of medication and psychological treatment. Psychosurgery�lesions to particular area of the brain�used in only very severe cases that have failed to respond to all other treatments. In a study of 33 patients psychosurgery reulted in improvement in 30% of the subjects. The improvement was substantial. Medication: These medications procude about a 30% reduction oin OCD symptoms Psychosurgery: When other treatments fail Up to 80% of treated adulst with infractory cases receive significant beneitfit Also true in one published study with kids.Medications with prevent the re-uptake of serotonin (which is low in OCD) ERP: Patieent is systematically and gradually exposed to the feared thoughts or situation and the rituals are prevented. In this way the client soon learns that no harm will result if he or she does not carry ou t the ritual. Studies are now available (good source for paper review) that examine the combined effects of medication and psychological treatment. Psychosurgery�lesions to particular area of the brain�used in only very severe cases that have failed to respond to all other treatments. In a study of 33 patients psychosurgery reulted in improvement in 30% of the subjects. The improvement was substantial. Medication: These medications procude about a 30% reduction oin OCD symptoms Psychosurgery: When other treatments fail Up to 80% of treated adulst with infractory cases receive significant beneitfit Also true in one published study with kids.

60. Anxiety Disorders Panic Disorder with and without agoraphobia

61. Panic Disorder Attack occurs suddenly, unexpectedly, peaking within a few minutes and lasting around ten minutes Heart palpitations, nausea, chest pain, choking, dizziness, apprehension Depersonalization: feeling outside your body Derealization: feeling world is unreal Fear losing control, dying, going insane Interoceptive avoidance Can develop agoraphobia Panic disorder is characterized by the occurrence of unexpected, recurrent panic attacks. Panic attacks are discrete, intense periods of fear and disconfort with psychologica and somatic symptoms that escalate Some symptoms include: palpatations, punding heart, seating, trembling or shaking, sensations of shortness of breath, feeling of chosing, fear of dying, numbing or tingling sensations Agoraphobia. Persons with panic disorder with agoraphobia experience severe unexpeted panic attacks during which time they feel a loss of control or endangered. Persons� may also experience panic disorder without agoraphobia. The agoraphoic behavior can become independent of panic attacks. According to DSM-IV agoraphobia may be characterized either by avoiding situations or enduring them with marked distress. Interoceptive avoidance: Some forms of agoraphobia invoed interoceptive avoidance, particularly of actives that my increase physical symptoms of arousal. You will see later on that this fous on physical arouosal is a key part of their cognitions. Panic disorder is characterized by the occurrence of unexpected, recurrent panic attacks. Panic attacks are discrete, intense periods of fear and disconfort with psychologica and somatic symptoms that escalate Some symptoms include: palpatations, punding heart, seating, trembling or shaking, sensations of shortness of breath, feeling of chosing, fear of dying, numbing or tingling sensations Agoraphobia. Persons with panic disorder with agoraphobia experience severe unexpeted panic attacks during which time they feel a loss of control or endangered. Persons� may also experience panic disorder without agoraphobia. The agoraphoic behavior can become independent of panic attacks. According to DSM-IV agoraphobia may be characterized either by avoiding situations or enduring them with marked distress. Interoceptive avoidance: Some forms of agoraphobia invoed interoceptive avoidance, particularly of actives that my increase physical symptoms of arousal. You will see later on that this fous on physical arouosal is a key part of their cognitions.

62. Panic Disorder: Diagnostic Criteria Recurrent unexpected panic attacks( A discrete period of intense fear of discomfort in which four or more somatic/anxiety symptoms developed abruptly and reached a peak within 10 minutes) At least one of the attacks has been followed by conern for additional attacks and significant change in behavior Not due to physiological effects of medications, drugs, or medical conditions Not accounted for by another disorder Panic attack: A discrete period of intense fear of discomfort in which four or more somatic/anxiety symptoms developed abruptly and reached a peak within 10 minutes Panic attack: A discrete period of intense fear of discomfort in which four or more somatic/anxiety symptoms developed abruptly and reached a peak within 10 minutes

63. Three Types of Panic Attacks Unexpected: out of the blue Situationally bound: almost always occur in certain contexts Situationally predisposed or �cued�: occur in certain contexts but not all the time If only cued or situational, could be phobia

64. Panic Disorder Prevalence: 2% men, 5% women Average age of onset is between 25 and 29 Commonly paired with a traumatic experience With or without agoraphobia Fears of public places and inability to escape from them (shopping malls, crowds) Fear having a panic attack in public Often don�t leave the house if avoidance widespread, agoraphobia results

65. Etiology Panic Disorder: Biological Explanations Neurotransmitters Biological vulnerability: neurotransmitters norepinephrine Not clear whether the problem is excessive or deficient activity or some other form of dysfunction related to norepinephrine Genetics One study found 24 % concordance among identical twins and 11% concordance in fraternal twins. (baserate is 3.5%) In the 1960� s clinicians made the surprising discovery that persons with panic disorder were helped less by the usual medications used in treating anxiety disorders (benzodiazapines) and more by antidepressant medications. Therefore to understand the biological basis for panic disorder, researchers have worked backwards from this accidental clinical finding. They knew that these medications change the activity of norepiephrine. Several additional lines of evidence pointing to the key role of norepi: eg. when an area of the brain rich in norepi neurons is stimulated in mondeys, monkeys have responded with panic like reactions.In the 1960� s clinicians made the surprising discovery that persons with panic disorder were helped less by the usual medications used in treating anxiety disorders (benzodiazapines) and more by antidepressant medications. Therefore to understand the biological basis for panic disorder, researchers have worked backwards from this accidental clinical finding. They knew that these medications change the activity of norepiephrine. Several additional lines of evidence pointing to the key role of norepi: eg. when an area of the brain rich in norepi neurons is stimulated in mondeys, monkeys have responded with panic like reactions.

66. Fear of fear hypothesis Goldstein & Chambless Agoraphobia as a fear of having a panic attack in public Panic disorder: patients misinterpret bodily signs/symptoms catastrophically Anxiety sensitivity: focus on their bodily sensations and inability to assess these sensations logically Cognitive theorists believe that panic prone people may be very sensitive to their bodily sensations. When they unexpected experience certain sensations, they misinterpret them as signs of a medical catastrophe. Cognitive theorists believe that panic prone people may be very sensitive to their bodily sensations. When they unexpected experience certain sensations, they misinterpret them as signs of a medical catastrophe.

68. Comorbidities Panic attacks found in 80% of those diagnosed with an anxiety disorder other than PD Not frequent enough to meet PD criteria MDD, GAD, phobias, substance abuse

69. Panic Disorder: Treatment Medication: Antidepressant medications associated with some improvement in 80% of patients with 40% to 60% recovering markedly or fully Improvements contingent on medications Benzodiazepines (such as Xanax) have also been empirically effective Cognitive Emphasis on correcting misinterpretations of body sensations Educating about panic attacks Teach more accurate interpretations Exposure 70% of patients improve but few are cured

70. Panic: Combined Treatment Short Term Combined treatment no more effective than individuals treatments in the short term Long Term Those receiving CBT alone maintained most of their treatment gains Those taking medication (alone or in combination) deteriorated somewhat

71. Anxiety Disorders Post Traumatic Stress Disorder PTSD

72. PTSD Extreme response to a stressor Anxiety, avoidance of similar stimuli, emotional flattening Significant impairment Person must have experienced or witnessed: event involving actual/threatened death or serious injury to self or others 25% experiencing a trauma develop PTSD

73. PTSD VS. Acute Stress Disorder Acute Stress Disorder Reaction to trauma, significant impairment Lasts up to one month �Normal� reaction to trauma 60% recover without experiencing PTSD PTSD Acute stress disorder lasting greater than one month

74. PTSD Symptoms Symptoms in each category > 1 month Reexperiencing: recalling the event, nightmares, emotional distress w/ similar stimuli or on anniversaries Avoidance/numbing: attempt to avoid thinking about the event, amnesia, decreased ability to feel positive emotions, decreased contact/interest in others Go back and forth between 1 & 2

75. PTSD Symptom Cont. Increased arousal: sleep difficulties, low concentration, hypervigilance, exaggerated startle response Comorbidities: MDD, anxiety disorders, marital problems, substance abuse, suicidality, somatic complaints Prevalence: 1 � 3% general population 20% in Vietnam veterans 94% rape victims

76. PTSD in kids Different manifestation of symptoms Nightmares (monsters) Behavioral changes Quiet to aggressive, outgoing to withdrawn Regression Loss of acquired skills (toilet training, speech) Difficulty discussing traumatic event

77. Risk Factors for PTSD Given exposure to a trauma, Female gender Early separation from parents Family history Preexisting mental illness Increased severity of trauma Initial reaction to trauma Depressed, anxious, dissociative symptoms

78. PTSD Etiology: Behavioral Classical conditioning to fear Ex: woman fears parking lots (CS) b/c she was shot in one (UCS) Avoidance builds due to negative reinforcement (i.e. reduction in fear by avoiding parking lots)

79. Other PTSD Etiologies Psychodynamic: memories so painful they are repressed Person tries to reintegrate memories into consciousness Biology: twin studies support a genetic diathesis Heightened norepinephrine Increased startle Evidence still mixed No good evidence for why some develop PTSD & others do not

80. General Etiology of Anxiety Disorders Biological Contributions Evidence that suggests individuals inherit the tendency to be anxious or highly emotional What could be inherited? Specific brain circuits and neurotransmitter systems (GABA; noradrenergic; serotonergic systems) Over production of corticotropin releasing factor (CRF) which is associated with activation of the HPA axis Functional systems gone awry

81. Role of the Behavioral Inhibition System (BIS) Functional system proposed by Jeffrey Gray BIS is activated by brain stem signals of unexpected events or danger signals from the cortex Leads to anxiety Corresponds to the Limbic system Specifically, the septo-hippocampal system innervated by both serotonergic circuits and noradrenergic circuits

82. Fight/Flight Systems Also proposed by Jeffrey Gray Originates in the brain stem, activates the amygdala, and results in an immediate alarm-and-escape response in animals that looks a lot like panic Most likely associated with Panic Disorder

83. Etiology of Anxiety Disorders (cont�d) Psychological Contributions Freud � anxiety as a psychic reaction to danger surrounding the reactivation of an infantile fear situations Behaviorists � anxiety as a by product of conditioning experience More recent view � children initially obtain a perception that events are not under their control and this is dangerous Sense of control develops via interactions with parents Important psychological contribution

84. Etiology of Anxiety Disorders (cont�d) Stressful life events Many stressors activate biological and psychological vulnerabilities to anxiety Integrated model Interaction between biological, psychological, experiential, and social variables

85. Etiology for Specific Anxiety Disorders? Why would it be hard to derive etiologies for specific types of anxiety disorders?

86. Comorbidity in Anxiety Within anxiety disorders due to: Overlapping symptoms Ex � fast heart rate is a symptom of PTSD, Panic disorder, and GAD Overlapping etiologies Ex � helplessness as a theory for both phobias and GAD Across other DSM-IV disorders Spectrum idea Depression on a continuum with anxiety Common symptoms: lack of sleep, lack of concentration, worry