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Abrupt and Aversive CNS Response
to Real Threat or Danger
Prepares Organisms for Immediate
Action
Action Tendency “Fight” or “Flight”
 More Diffuse Response About
Impending Real or Imagined
“Future” Threat or Danger
Real Threat
True Alarm
Adaptive
Maladaptive
False Alarm
No Threat
 Panic Disorder
 PD With Agoraphobia
 Agoraphobia
 Specific Phobias
 Social Phobia (social anxiety disorder)
 Generalized Anxiety Disorder
 Post-Traumatic Stress Disorder
 Obsessive Compulsive Disorder
 Clinical Description
 An Unexpected Panic Attack
 Develop Anxiety Over
 the Next Attack
or
 The Implications of the Attack
and Consequences
 Symptoms of a Panic Attack
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 The Panic Attack
 Abrupt Autonomic Surge
 Unexpected
 Uncontrollable
 Absence of Threat
 “False Alarm”
10 Minutes
 Clinical Description
 Agoraphobic Avoidance is Common
 Fear of the Marketplace
 Is Consequence of Severe Unexpected
Panic Attacks
 Can Have a Life of its Own
 Facts and Statistics
 Occurs in 2.7% of Population; 4.7 lifetime
 Most with PD+Ag, 75%, are Women
 Onset Between (25-29 yrs)
 Attacks Often Begin at Puberty
 20% Attempt ____________
 Average 37 Medical Visits / Year
 Cultural Influences
 Occurs Worldwide
 Prevalence in U.S. is Similar Across
Ethnic Groups
 Nocturnal Panic Attacks
 _____% Cases Panic While Asleep!
 Usually Between 1:30 - 3:30am
 Occur During Deep Sleep “Delta”
 Do Not Occur During REM Sleep
 Causes
Biological Vulnerability
STRESS
False Alarm
Bodily Cues
Learned Alarm
Involuntary Symptoms
Psychological Vulnerability
 Biological Causes
 Runs in Families
 GABA-BZ Circuit
 Limbic System
 ANXIETY
Behavioral Inhibition System (BIS)
 FEAR / PANIC
Fight / Flight System (FF)
 Psychological Causes
Predictable
Uncontrollable
Controllable
Unpredictable
 Pharmacologic Treatments
 Block Panic
 Antidepressants (e.g., Imipramine,
Paxil, Prozac)
 20-50% Relapse
 Benzodiazapines (e.g., Xanax)
 90% Relapse
 Psychological Interventions
 Cognitive-Behavior Therapies
 Brief and Time Limited (12 Sessions)
 Graded Exposure + Coping Skills
 Panic Control Treatment (PCT)
 80-100% Panic Free After Treatment
 Combined Treatment
THE RESULT
 Multisite Study
 Imipramine (TCA)




Alone
PCT Alone
Imipramine + PCT
Placebo Alone
Placebo + PCT
Combined Tx
is Better in
Short
Term
PCT Alone is
Better in
Long Term
 Specific Phobias
“ ...aren’t just extreme fear; they are
irrational fear. You may be able to ski the
world’s tallest mountain with ease but feel
panic going above the 10th floor of an
office building.”
 Clinical Description
 Irrational Fear of Specific Objects
or Situations
 Markedly Interferes With
Functioning
 Four Major Subtypes
 ______________________________
______________________________
______________________________
______________________________
______________________________
_____________________________
 Blood-Injection Injury Type
 Unusual Reaction
 Drop in Blood Pressure
 Fainting
 Runs in Families
 Onset Early Childhood
 Situational Type
 Fears of Specific Situations
Planes, Transportation, Enclosed
Spaces (claustrophobia)
 Response Similar to Panic
 Onset Early 20’s
 Animal Type
 Fears of Animals and Insects
 Common in Population, but
Different From Normal Revulsion
 Early Onset (About 7 yrs of Age)
 Natural Environment Type
 Fears of Natural Events
Storms, Deep Water, High Places
 Usually More Than One Fear
 Peak Onset (About 7 yrs of Age)
 Other Type(s)
 Fear of Contracting Disease/ Illness
_________________
 Fear of Choking
e.g. ___________________
 Separation Anxiety Disorder
 Facts and Statistics
 Occurs in 8.7% of Population
 Top Fears: Heights and Snakes
 Females > Males (4:1 Ratio)
 Runs a Chronic Course
 Many Do Not Seek Treatment:
WHY?
 Exposure and More Exposure
 ______________________________
 ______________________________
 ______________________________
 ______________________________
 Blood-Injury /Injection Differs:
During Exposure, Muscle Tension
Exercises Needed to Offset Fainting
Response
“ People with social phobia aren’t
necessarily shy at all. They can be
completely at ease with people most of
the time, but in particular situations,
they feel intense anxiety.”
 Clinical Description
 Marked and Persistent Fear of One
or More...
Social or Performance Situations
 Most Common Type of Social Fear?
Public Speaking
 Interferes With Life Functioning
 Causes
 Similar to Panic and Specific Phobia
 Interaction of
Biological Vulnerability
Psychological Vulnerability
Learning Experiences
 Can be Quite Disabling
Psychological Interventions
 Similar to Panic and Specific Phobia
 Cognitive-Behavioral Approaches
Rehearsal and Skills Training
Cognitive Restructuring
Drug Treatments
Antidepressants SSRIs are now drug of choice
- “Do you suffer from social anxiety disorder?”
commercial that implies it is a medical disease which
should be treated by the gatekeepers of meds
Clinical Description
 Worry About Everything
 Worrying is Unproductive
 Cannot Stop Worrying -Mental
Agitation
 Interferes With Life Functioning
 Must Last for at Least 6 Months
Facts and Statistics
 Occurs in 3.1% of Population;
5.7% lifetime
 50-65% are Female
 Early Gradual (“insidious”) Onset
 Runs a Chronic Course
Causes
Unclear and Puzzling?
Tend to show
Autonomic Restriction
Heightened Muscle Tension
High Sensitivity to Threat in General
Threat Sensitivity is Automatic
Avoid Negative Affect Related to Threat
Biological Vulnerability
STRESS
Psychological Vulnerability
(Anxious Apprehension)
Worry Process
Imagery Avoidance
Intense
Cognitive Processing
Restricted
Autonomic Response
Most Interventions are Still Weak
Benzodiazepines
Frequently Prescribed
Provide Some Relief
Cognitive-Behavioral Approaches
Process Avoided Emotional Material
& Relaxation Training Does as Well as Medication
Clinical Description
Culmination of All Anxiety Disorders
Obsessions: Intrusive Thoughts, Images,
or Urges That the Person Tries to
Suppress or Eliminate
Compulsions: Thoughts or Actions to
Suppress the Obsessions and Provide
Relief
Facts and Statistics
Occurs in 1% of Population; about 2%
lifetime
Most Common Obsessions
Contamination & Aggression
Most Common Compulsions
Checking & Washing
Almost Equal Sex Ratio (F > M)
Onset Early Adolescence to Mid-20s
Causes
•
Anxiety Focused on Unwanted and
Unacceptable Thoughts
Pink Elephants and Green Pigs
When Fighting to Control One’s
Thoughts it May Create More Distress
• Hay wire in the hard wired cortex?
Psychological Interventions
Cognitive-Behavioral Treatments:
Response Prevention
Rituals are Actively Prevented
Exposure
Systematic and Gradual Exposure to Feared
Thoughts or Situations
May Require Hospitalization
Drug Therapies
Medications Show Promise
Most Effective Medications
Inhibit Reuptake of Serotonin
(SSRIs -e.g., Prozac)
Meds May Benefit 60% of Patients