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anxiety disorders
the experience of anxiety
generalized anxiety disorder
panic disorder
phobias
obsessive-compulsive disorder
posttraumatic stress disorder
treating anxiety disorders
the experience of anxiety
anxiety involves worry, fear,
apprehension, intrusive thoughts,
physical symptoms, and feelings of
tension.
It often seems to have an automatic
quality that comes more from within the
individual than from situational factors.
It is normal for people to experience
anxiety when faced with stressful,
threatening situations, but it is
abnormal to feel strong, chronic anxiety
in the absence of an obvious cause.
(However “normal” may vary with level
of consciousness.)
common anxiety symptoms and selfdescriptions indicative of high anxiety
symptoms
• Nervousness,
jitteriness
• Tension
• Feeling tired
• Dizziness
• Frequency of
urination
• Heart palpitations
• Feeling faint
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•
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Breathlessness
Sweating
Trembling
Sleeplessness
Difficulty in
concentrating
• hypervigilance
pathological anxiety
epidemiology
• Anxiety disorders make
up one of the most
common groups of
psychiatric disorders.
• the national co morbidity
study reported that one
in four persons met the
diagnostic criteria for at
least one anxiety d/o
• Women (30.5 percent
lifetime prevalence) are
more likely to have an
anxiety d/o than are men
(19.2 percent lifetime
prevalence).
• Finally. The prevalence of
anxiety d/o decreases
with higher
socioeconomic status.
• Prevalence of anxiety
d/o
Disorder
percent(1yrprevalence)
Any anxiety d/o
13.3
Generalized anxiety
d/o
2.8
Panic d/o
1.7
Phobic d/o
8.0
Obsessive-compulsive
d/o
2.3
Posttraumatic stress
d/o
3.6
Source: National Institute
of Mental Health
self- descriptions
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“ I am often bothered by the thumping of my heart.”
“ little annoyances get on my nerves and irritate me.”
“ I often suddenly become scared for no good reason.”
“ I worry continuously, and that gets me down.”
“ I frequently get spells of complete exhaustion and
fatigue”
“ it is always hard for me to make up my mind.”
“ I always seem to be dreading something.”
“ I feel nervous and high-strung all the time.”
“ I often feel I can’t overcome my difficulties.”
“ I feel constantly under strain.”
Psychological sciences
psychological theories
each theory has both conceptual and practical usefulness in treating anxiety d/o
psychoanalytic theories
behavioral theories
existential theories
biological sciences
A range of biologically based sensitivities may exist among
persons with the symptoms of anxiety disorders.
•
Autonomic nervous system(functional division of the nervous
system concerned with visceral activities): stimulation of the ANS may
cause peripheral manifestations of anxietycardiovascular and/or gastrointestinal.
•
Neurotransmitters (chemical product of the NS that makes
possible the movement of the nerve impulse across the
synapse):norepinephrine, serotonin,and y-aminobutyric
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•
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acid (GABA) are the three major neurotransmitters
associated with anxiety.
Brain- imaging studies: CT, MRI, PET, SPECT, EEG.
Genetic studies
Neuroanatomical considerations: limbic system,
and cerebral cortex.
generalized anxiety disorder
300.02
A person with GAD experiences vague but intense
concerns and fearfulness that persist over a long periodat least 6-months.
The symptoms include motor tension, autonomic
reactivity, apprehension about the future, and
hypervgilance.
durations as long as 20 years.
prolonged use of drugs can have significant side effects.
The distinction between GAD and normal anxiety is
emphasized by the use of the words “excessive and
“difficult to control” in the criteria and by the
specification the symptoms cause significant impairment
or distress.
clinical features of GAD
1.
2.
3.
Excessive anxiety and worry occurring for at least 6
months and affecting many areas of a person’s life.
Inability to control worry
The presence of 3 or more of the following symptoms(
only one type of symptom is required for DSM-IV in
the diagnosis of children):
a. restlessness; feeling on edge
b. being easily fatigue
c. difficulty concentrating; mind goes blank
d. irritability
e. muscle tension
f. sleep disturbance( difficulty falling or staying asleep; unsatisfying sleep)
4.
Considerable distress or impairment in social,
occupational, or other important areas of life.
treatment for GAD
• Psychotherapy
Cognitive-behavioral:cognitive address
patient’s hypothesized cognitive distortions
directly, and behavioral approaches address
somatic symptoms directly. (relaxation and
biofeedback).
supportive: offers patient’s reassurance and
comfort, although its long-term efficacy is
doubtful.
Insight-oriented: focuses on uncovering
conflicts and identifying ego strengths.
substance-induced anxiety
disorder
293.84
• The disorder is the direct result of a toxic substance.
Including drugs of abuse, medication, poison, and
alcohol, among others.
• The DSM-IV diagnostic criteria for substance-induce
anxiety disorder require the presence of prominent
anxiety, panic attacks, obsessions, or compulsions. The
guidelines state that the symptoms should have develop
during the use of of the substance or within a month of
the cessation of substance use. The structure of the
diagnosis includes specification of the substance (e.g.
cocaine), specification of the appropriate state during
the onset (e.g., intoxication), and mention of the
specific symptom pattern (e.g., panic attacks).
Panic disorder
• Panic Disorder is an illness in which a person
experiences sudden, sometimes unexpected
rushes of intense fear or discomfort accompanied
by a number of distressing physical sensations.
• The panic attack, the core feature of panic
disorder, strikes suddenly, often in familiar places
where there is seemingly nothing to be afraid of.
• But when the attack comes, it comes as if there
were a real threat, and the body reacts
accordingly. Panic disorder is often accompanied
by agoraphobia, the fear of being alone in public
places (such as supermarkets), particularly places
from which a rapid exit would be difficult in the
course of a panic attack.
• In addition to agoraphobia, other phobias and
obsessive-compulsive disorder can coexist with
panic disorder.
.
Panic d/o:
Panic attacks
• The term panic attack
denotes an abrupt surge
of intense anxiety rising
to a peak that either is
cued by the presence, or
thoughts, of particular
stimuli or that occurs
without obvious cues and
is spontaneous and
unpredictable. During
these episodes, the
person experiences the
urge to flee, or the
feeling that they need to
escape. The symptoms may be
misdiagnose as a serious medical
condition (M.I.).
• It is known that the d/o
typically begins when its
victims are in their 20s.
Often a serious event,
will trigger the first
attack. Women are two
to three times more
likely to be affected than
men. 3 million Americans
will experience panic
disorders sometime in
their lives.
Criteria for panic attack
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2.
3.
4.
5.
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10.
11.
12.
13.
A discrete period of intense fear or discomfort, in
which four (or more) of the following symptoms
developed abruptly and reached a peak within 10
minutes: is not codable disorder.
Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath or smothering
Feeling of choking
Cheat pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded, or faint
Derealization (feelings or unreality) or
depersonalization (being detached from oneself)
Fear of losing control or going crazy
Fear of dying
Paresthesias
Chills or hot flashes
treatment for panic disorder
Can consist of taking a medication to adjust the chemicals
in your body-just as you might take medicine to correct
a thyroid imbalance or any other hormonal imbalance.
two major categories of medication that have been
shown to be safe and effective in the treatment of panic
disorder are antidepressants and benzodiazepines.
Another treatment is cognitive behavior therapy (CBT),
which focuses on reducing the person’s fears of panic
symptoms and assisting the person to resume avoided
activities. The combination of medication and
psychotherapy appears to be more effective than either
treatment alone.
agoraphobia
DSM-IV-TR includes diagnoses for panic disorder
with and without agoraphobia and also for
agoraphobia without history of panic disorder.
patients with agoraphobia avoid situations in
which it would be difficult to obtain help. They
prefer to be accompanied by someone in
crowded stores, closed-in spaces (tunnels,
bridges, and elevators) and closed-in vehicles
(subways, buses, and airplanes) severely
affected patients may refuse to leave the
house. Agoraphobic individuals are often
clinging and dependent.
Diagnostic criteria for:
•
A.
B.
Panic disorder with
agoraphobia 300.21
Both (1) and (2)
The presence of agoraphobia
•
A.
B.
C.
D.
Agoraphobia without
history of panic disorder
300.22
The presence of agoraphobia
related to fear of developing
panic-like symptoms
Criteria have never been met
for panic disorder
The disturbance is not due to
the direct physiological
effects of a substance or a
general medical condition
If an associated general
medical condition is present,
the fear described in criterion
A is clearly in excess of that
usually associated with the
condition.
phobias
• People who have phobias have fears related to
specific objects, people, or situations.
• Phobias often develop gradually or begin with
a generalized anxiety attack.
• Phobias are common disorders that affect
women about twice as frequently as men.
Phobias often begin before adulthood and are
likely to become chronic.
• Phobias can be grouped into three main types:
specific phobias, social phobias, and
agoraphobia.
examples for five categories of
phobias
Separation fear
Crowds
Traveling alone
Being alone at home
Animal fears
Mice
Rats
Insects
Nature fears
Mountains
The ocean
Cliffs, heights
social fears
eating with strangers
being watched while writing
being watched while working
mutilation fears
open wounds
surgical operations
blood
Specific phobias
300.29
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•
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Most commonly occurring type of phobia. This group includes
miscellaneous irrational fears such as intense fear of a certain type of
animal or of being in an enclosed place. Specific phobias may arise
from an earlier frightening or anxiety-producing situation that
involved the type of person or situation that later became associated
with the phobia. Procedures that use the classical conditioning
approach of pairing the phobic stimulus with nonanxiety response are
often used successfully to treat specify phobias.
Criteria A (excessive fear) and B (stimulus exposure)
In specific phobia the panic attack is situationally bound to the specific
phobic stimulus. Specify type.
Treatment: exposure therapy(therapist desensitize pt. by using a series of
gradual, self-paced exposures to the phobic stimuli, and they teach pt.’s various
techniques to deal with anxiety, including relaxation, breathing control, and
cognitive approaches. Pharmacotherapy may also benefit.
Social phobias
(social anxiety disorder)
300.23
• Intense and
incapacitating fear and
embarrassment when
dealing with others
characterize social
phobias. Fear of blushing
when in a social situation
and fear of eating when
others are present are
two social phobias that
are especially difficult to
treat successfully.
Treatment:
• Psychotherapy for the
generalized type of social
phobia usually involves a
combination of
behavioral and cognitive
methods, including
retraining,
desensitization, rehearsal
during sessions, and a
range of homework
assignments.
Obsessive-compulsive disorder
300.3
• People affected by an obsessive-compulsive d/o are
unable to control their preoccupation with specific ideas
or are unable to prevent themselves from repeatedly
carrying out a particular act or series of acts that affect
their ability to carry out normal activities.
• Obsessive behavior is the inability to stop thinking
about a particular idea or topic. The topic of these
thoughts is often felt by the person involved to be
unpleasant and shameful.
• Compulsive behavior is the need to perform certain
behaviors over and over. Many compulsions deal with
counting, ordering, checking, touching and washing.
OCD
DSM-IV-TR CRITERIA
• Criteria for obsessive-compulsive disorder include
having recurrent and persistent thoughts, impulses,
or images that are not simply general worries and
real-life problems.
• Patients recognize that the unwanted thoughts and
rituals are the products of their minds, but distress
persist and personal routines are seriously
disrupted.
OCD
symptoms patterns
• The presentation of obsessions and compulsions is
heterogeneous in adults and in children and adolescents. The
symptoms of an individual patient may overlap with time, but
OCD has four major symptoms patterns.
1. Contamination- the fear object is often hard to avoid (e.g.
feces, urine, dust, or germs)accompanied by compulsive
avoidance. patients usually believe that the contamination is
spread from object to object or person to person.
2. pathological doubt-often implies some danger of violence
(e.g. forgetting to turn off the stove or not locking the
door)followed by a compulsion of checking. The pt.’s always
feel guilty about having forgotten or committed something.
3. Intrusive thoughts- repetitious thoughts of a sexual or
aggressive act that is reprehensible to the pt. without
compulsions.
OCD-symptoms patterns
4. Symmetry- the fourth most common patterns is the need for
symmetry or precision, which can lead to a compulsion of
slowness.
5. Other symptom patterns- religious obsessions and
compulsive hoarding are common in patients with OCD.
Trichotilomania (compulsive hair pulling) and nail niting may
be compulsions related to OCD.
Cognitive therapist seek to help patients become aware of
their excessive sense of responsibility as a step toward
overcoming obsessions and compulsions.
Posttraumatic stress disorder
309.81 (PTSD)
• PTSD may occur after an extreme stress such as a
natural disaster, a serious accident, or participation in a
battle or other war-related situations.
• PTSD symptoms vary widely but may include recurrent
dreams, flashbacks, impaired concentration, and
emotional numbing. T
• hose experience PTSD after a stressful experience are
likely to have had previous histories of psychological
disorder.
• The emotional disorder that often arises after a trauma such
as war, assault, natural disaster, or death of a loved one is
posttraumatic stress disorder(PTSD). According to the
DSM-IV-TR, a person with
• PTSD must have been exposed to some event during
which he/she feels fear, helplessness, or horror.
• Then, the person continues to reexperience the event
through memories, reenactments, nightmares, or
flashbacks. Cues that remind the person of the event are
avoided and emotional responsiveness is numbed.
• Often such individuals are chronically overaroused, easily
startled, and quick to anger. With PTSD, the alarm
response is a true alarm, meaning that it occurs in response
to real threat or danger.
•