Anxiety- apprehension over an anticipated problem; adaptive as it helps us notice and plan for future threats—to

increase our preparedness, help ppl avoid potentially dangerous situations & to think through problems before they
happen; absence of anxiety is a problem, a little anxiety is adaptive, a lot is detrimental.

Fear – reaction to immediate danger; fundamental for fight or flight; triggers rapid changes in the sympathetic nervous
system that prepare the body for escape or fighting; fear save lives.

MAJOR ANIXIETY DISORDERS

 Specific phobia
 Social phobia
 Panic disorder
 Generalized anxiety disorder
 Obsessive-compulsive disorder
 Posttraumatic stress disorder
 Acute stress disorder

SPECIFIC PHOBIA

- Disproportionate fear caused by a specific object/situation

- Person recognize that the fear is excessive but still go to great lengths to avoid the feared object or situation
- Person w/ 1 type of specific phobia is very likely to have another type of specific phobia; there is high
comorbidity of specific phobias
- Interferes with an individual’s ability to function

DIAGNOSTIC CRITERIA

- Persistent & excessive fear triggered by specific objects/situations

- Exposure to the trigger almost always leads to intense anxiety
- The person recognizes the fear is unrealistic
- The object or situation is avoided or else endured with intense anxiety

MAJOR SUBTYPES OF SPECIFIC PHOBIA

4 major subtypes of specific phobia

1. Blood-injection-injury type: always differ in their physiological reaction from ppl w/other types of phobias; onset
is approx. 9 y/o
2. Situational type: fear of public transportation/enclosed places

Situational phobia: never experience panic attacks outside the context of their phobic object, they can relax
when they don’t have to confront their phobic situation

3. Natural environment type: fear of events occurring in nature (i.e. heights, storms, and water) onset approx. 7
y/o
Animal phobia: fear of animals/ insects. These fears are common but become phobic if severe interference with
functioning occurs.
4. Other: situational that may lead to choking, vomiting, or contracting an illness, avoidance of loud sounds or
costumed characters)
STATISTICS OF PHOBIA

1. fear of snakes & heights rank near the top

2. sex ratio among common fear is more on female
3. fear of heights ratio is approx. equal
4. As with common fears, the sex ratio for specific phobias is, at 4:1, overwhelmingly female; this is also consistent
around the world.
5. median age of onset for specific phobia is 7 years of age, the youngest of any anxiety disorder except separation
anxiety disorder.
6. Specific phobias seem to decline with old age.

CAUSES:

1. acquired by direct experience, where real danger or pain results in an alarm response (a true alarm).
2. experiencing a false alarm (panic attack) in a specific situation
3. observing someone else experience severe fear (vicarious experience), or, under the right conditions, being told
about danger.

TREATMENT

1. require structured and consistent exposure-based exercises.

2. Patients must expose themselves gradually to what they fear and must be under therapeutic supervision.
Individuals who attempt to carry out the exercises alone often attempt to do too much too soon and end up
escaping the situation, which may strengthen the phobia
3. For separation anxiety, parents are often included to help structure the exercises and also to address parental
reaction to childhood anxiety

SOCIAL ANXIETY DISORDER

- Ppl with this disorder try to avoid situations in which they might be evaluated, show signs of anxiety, or
behave in embarrassing ways
- The most common fears include public speaking, speaking up in meetings or classes, meeting new people,
and talking to people in authority.
- They often fear that they will blush or sweat excessively.
- . Speaking or performing in public, eating in public, using public restrooms, or engaging in virtually any
activity in the presence of others can cause extreme anxiety.
- Among people with social anxiety disorder, at least a third also meet the DSM IV-TR criteria for a diagnosis of
avoidant personality disorder. The symptoms of the two conditions overlap a great deal, and there is overlap
in the genetic vulnerability for the two conditions.
- Avoidant personality disorder, though, is a more severe disorder with an earlier onset and more pervasive
symptoms.
- Generally begin during adolescence
- For some, the symptoms first emerged during childhood. W/out treatment, social anxiety tends to be
chronic.
 INDIVIDUALS WITH PERFORMANCE ANXIETY

- Have no difficulty with social interaction, but when they must do something in front of ppl, anxiety takes
over and they focus on the possibility that they will embarrass themselves.
- Most common performance anxiety is public speaking.
- situations that commonly provoke performance anxiety are eating in a restaurant or signing a paper or
check in front of a person or people who are watching
- Anxiety-provoking physical reactions include blushing, sweating, trembling, or, for males, urinating in a public
restroom (“bashful bladder” or paruresis)

STATISTICS:

- prevalence is 6.8%, and 8.2% in adolescents. This makes SAD second only to specific phobia as the most
prevalent anxiety disorder
- sex ratio for SAD is nearly 50:50.
- usually begins during adolescence, onset around 13y/o
- more prevalent in people who are young (18–29 years), undereducated, single, and of low socioeconomic
class

CAUSES:

- socially anxious individuals more quickly recognized angry faces than “normals”, whereas “normals”
remembered the accepting expressions.
- Why should we inherit a tendency to fear angry faces? Our ancestors probably avoided hostile, angry,
domineering people who might attack or kill them
- Jerome Kagan and his colleagues have demonstrated that some infants are born with a temperamental
profile or trait of inhibition or shyness that is evident as early as 4 months of age
- Four-month-old infants with this trait become more agitated and cry more frequently when presented with
toys or other age-appropriate stimuli than infants without the trait

TREATMENT:

- Clark and colleagues evaluated a cognitive therapy program that emphasized real-life experiences during
therapy to disprove automatic perceptions of danger. This is a superior treatment.
- Subsequent studies indicated that this treatment was clearly superior to a second very credible treatment,
interpersonal psychotherapy (IPT) both immediately after treatment and at a 1-year follow-up, even when
delivered in a center specializing in treatment with IPT
- studies suggest that severely socially anxious adolescents can attain relatively normal functioning in school
and other social settings after receiving cognitive behavioral treatment. Since 1999, the SSRIs Paxil, Zoloft,
and Effexor have received approval from the Food and Drug Administration for treatment of SAD based on
studies showing effectiveness compared with placebo
- Using SSRI drug Prozac, along with instructions to the patients with SAD to attempt to engage in more social
situations (self-exposure).
- adding the drug D-cycloserine (DCS) to cognitive-behavioral treatments significantly enhances the effects of
treatment; works in the amygdala, a structure in the brain involved in the learning and unlearning of fear and
anxiety
- Unlike SSRIs, this drug is known to facilitate extinction of anxiety by modifying neurotransmitter flow in the
glutamate system
SELECTIVE MUTISM

- rare childhood disorder characterized by a lack of speech in one or more settings in which speaking is socially
expected.
- occurs in some settings, such as home, but not others, such as school, hence the term “selective”.
- In order to meet diagnostic criteria for SM, the lack of speech must occur for more than one month and
cannot be limited to the first month of school.
- Failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required
in the social situation
- Disturbance must not better be explained by a communication disorder and does not occur exclusively
during the course of autism spectrum disorder, schizo or another psychotic disorder

SEPARATION ANXIETY DISORDER

- characterized by children’s unrealistic and persistent worry that something will happen to their parents or
other important people in their life or that something will happen to the children themselves that will
separate them from their parents
- Children often refuse to go to school or even to leave home, not because they are afraid of school but
because they are afraid of separating from loved ones.

School phobia: Separation anxiety disorder

- fear of separation with loved ones
- fear is clearly focused on something specific
regardless of the settings
to the school situation; the child can leave
the parents or other attachment figures to
go somewhere other than school.

DIAGNOSTIC CRITERIA

A. inappropriate & excessive fear or anxiety concerning separation from those those to whom individual is
attached
1. excessive distress when experiencing separation from home/major attachment figures
2. persistent & excessive worry about losing major attachment figures or about possible harm to them
3. persistent & excessive worry about experiencing an untoward event that causes separation from major
attachment figure
4. persistent & excessive or reluctance about being alone or w/out major attachment figures at home
5. persistent reluctance or refusal to go out, away from home, school, work or elsewhere because of fear of
separation
6. persistent reluctance or refusal to sleep away from home or to sleep w/out being near to attachment
figures
7. repeated nightmares involving the theme of separation
8. repeated complaints of physical symptoms.
B. Fear, anxiety or avoidance is persistent, must last for at least 4 weeks in children and for adolescents,
typically 6 months or more in adults.
C. Disturbance causes clinically significant distress or impairment in social, academic, occupational, or other
important areas of functioning.
D. Disturbance must not better explained by another mental disorder
 TREATMENT

- , parents are often included to help structure the exercises and also to address parental reaction to
childhood anxiety

PANIC ATTACK

- abrupt experience of intense fear or acute discomfort, accompanied by physical symptoms such as heart
palpitations, chest pain, shortness of breath, and, possibly, dizziness.
- associated with autonomic arousal, presumably as a result of a sympathetic nervous system surge (for
instance, increased heart rate, palpitations, perspiration, and trembling)

2 BASIC TYPES:

1. unexpected (uncued) panic attacks - if you don’t have a clue when or where the next attack will occur
2. expected panic attacks - If you know you are afraid of high places or of driving over long bridges, you might
have a panic attack in these situations but not anywhere else; this is an expected (cued) panic attack.

BIOLOGICAL CONTRIBUTIONS:

- contributions from collections of genes in several areas on chromosomes make us vulnerable when the right
psychological and social factors are in place.
- Depleted levels of gammaaminobutyric acid (GABA): part of the GABA–benzodiazepine system, are
associated with increased anxiety
- noradrenergic system has also been implicated in anxiety, and evidence from basic animal studies, as well as
studies of normal anxiety in humans, suggests the serotonergic neurotransmitter system is also involved.
- corticotropin-releasing factor (CRF) system as central to the expression of anxiety (and depression) and the
groups of genes that increase the likelihood that this system will be turned on. CRF activates the
hypothalamic– pituitary– adrenocortical (HPA) axis, which is part of the CRF system, and this CRF system has
wide-ranging effects on areas of the brain implicated in anxiety, including the emotional brain (the limbic
system), particularly the hippocampus and the amygdala; the locus coeruleus in the brain stem; the
prefrontal cortex; and the dopaminergic neurotransmitter system
- The CRF system is also directly related to the GABA–benzodiazepine system and the serotonergic and
noradrenergic neurotransmitter systems. area of the brain most often associated with anxiety is the limbic
system which acts as a mediator between the brain stem and the cortex. The more primitive brain stem
monitors and senses changes in bodily functions and relays these potential danger signals to higher cortical
processes through the limbic system.
- Jeffrey Gray, identified a brain circuit in the limbic system of animals that seems heavily involved in anxiety.
The system that Gray calls the behavioral inhibition system (BIS). BIS is activated by signals from the brain
stem of unexpected events, such as major changes in body functioning that might signal danger.
- Danger signals in response to something we see that might be threatening descend from the cortex to the
septal– hippocampal system. The BIS also receives a big boost from the amygdala.
- When the BIS is activated by signals that arise from the brain stem or descend from the cortex, our tendency
is to freeze, experience anxiety, and apprehensively evaluate the situation to confirm that danger is present.
- The BIS circuit is distinct from the circuit involved in panic. Gray and Graeff identified what Gray calls the
fight/flight system (FFS)
 - This circuit originates in the brain stem and travels through several midbrain structures, including the
amygdala, the ventromedial nucleus of the hypothalamus, and the central gray matter.
- When stimulated in animals, this circuit produces an immediate alarm-and-escape response that looks very
much like panic in humans.
- The FFS is activated partly by deficiencies in serotonin, suggest Gray and McNaughton.
- One important study suggested that cigarette smoking as a teenager is associated with greatly increased risk
for developing anxiety disorders as an adult, particularly panic disorder and generalized anxiety disorder

PSYCHOLOGICAL CONTRIBUTIONS

- Freud thought anxiety was a psychic reaction to danger surrounding the reactivation of an infantile fearful
situation.
- Behavioral theorists thought anxiety was the product of early classical conditioning, modeling, or other
forms of learning.
- A general “sense of uncontrollability” may develop early as a function of upbringing and other disruptive or
traumatic environmental factors
- Parents who provide a “secure home base” but allow their children to explore their world and develop the
necessary skills to cope with unexpected occurrences enable their children to develop a healthy sense of
control

SOCIAL CONTRIBUTIONS

- Stressful life events trigger our vulnerabilities to anxiety

- Panic attacks often co-occur with a certain medical conditions such as cardio, respiratory, gastrointestinal &
vestibular disorders.
- 20% of patients with panic disorder had attempted suicide

GENERALIZED ANXIETY DISORDER

- characterized by muscle tension, mental agitation, susceptibility to, fatigue (probably the result of chronic
excessive muscle tension), some irritability, and difficulty sleeping
- Focusing one’s attention is difficult, as the mind quickly switches from crisis to crisis

DIAGNOSTIC CRITERIA

A. At least 6 months of excessive anxiety and worry occurring more days than not
B. Individual finds it difficult to control the worry
C. Anxiety and worry are associated with at least 3 or more if the following symptoms (must be present for
more days than not)
1. Restlessness/ feeling keyed up or on edge
2. Easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance
D. Anxiety, worry or physical symptoms cause clinically significant distress or impairment in different
important areas of functioning
E. Disturbance is not due to direct physiological effects of a substance or another general medical
condition
F. The disturbance is not better be explained by another mental disorder.
STATISTICS:

- two-thirds of individuals with GAD are female in both clinical samples. But this sex ratio may be specific to
developed countries. In the South African study mentioned here, GAD was more common in males.
- onset in early adulthood, usually in response to a life stressor. The median age of onset based on interviews
is 31
- GAD is prevalent among older adults. found to be most common in the group over 45 years of age and least
common in the youngest group, ages 15 to 24

TREATMENT:

1. Benzodiazepines: give some relief, at least in the short term

- benzodiazepines carry some risks as it impair both cognitive and motor functioning. people don’t seem to be
as alert, impair driving older adults tend to be associated with falls, resulting in hip fractures.
- seem to produce both psychological and physical dependence, making it difficult for people to stop taking
them.
2. Antidepressants (paroxetine) and (venlafaxine)
3. cognitive-behavioral treatment (CBT): evoke the worry process during therapy sessions and confront anxiety-
provoking images and thoughts head-on
4. CBT and the antidepressant drug sertraline (Zoloft) were equally effective immediately following treatment
compared with taking placebo pills for children with GAD and other related disorders

PANIC DISORDER WITH AGORAPHOBIA

- In DSM-IV, panic disorder and agoraphobia were integrated into one disorder called panic disorder with
agoraphobia, but investigators discovered that many people experienced panic disorder without developing
agoraphobia and some people develop agoraphobia in the absence of panic disorder.
- Many people who have panic attacks do not necessarily develop panic disorder.
-
PANIC DISORDER
- individuals experience severe, unexpected panic attacks; they may think they’re dying or otherwise losing
control
- person must experience an unexpected panic attack and develop substantial anxiety over the possibility of
having another attack or about the implications of the attack or its consequences
-
DIAGNOSTIC CRITERIA:
A. Recurrent unexpected panic attacks
B. At least 1 attack has been followed by 1 month or more of one of the ff:
- Persistent concern/ worry about addtl. Attacks or consequences
- Significant maladaptive change in behaviour related to the attacks.
C. Disturbance is not attributable to the physiological effects of substance
D. Must not be explained by another mental health disorder

AGORAPHOBIA
- Most agoraphobic avoidance behavior is simply a complication of severe, unexpected panic attack
- fear and avoidance of situations in which a person feels unsafe or unable to escape to get home or to a
hospital in the event of a developing panic symptoms or other physical symptoms, such as loss of bladder
control.
 DIAGNOSTIC CRITERIA:

A. Must be consistent for at least 6 months or more

B. Fear or anxiety abt. 2 or more of the ff:
- Public transpo
- Open spaces
- Enclosed spaces
- Standing in line/ being in a crowd
- Being outside at home alone
C. Fears or avoid this situations due to thoughts that escape might be difficult/help might not be available
in the event of developing panic-like symptoms
D. Agoraphobic situations always provoke fear or anxiety
E. Agoraphobic situations are actively avoided, require a companion, or are endured with intense fear or
anxiety
F. Fear or anxiety is out of proportion to the usual danger posed by the agoraphobic situations and to the
sociocultural context.
G. Fear/anxiety/avoidance causes clinically significant distress or impairment in other important areas of
functioning
H. If another medical condition is present, the fear/anxiety/avoidance must be clearly excessive
I. Fear/anxiety/avoidance is not better be explained by another mental disorder

METHODS OF COPING WITH PANIC ATTACKS

1. Agoraphobic avoidance: extent to which you think or expect you might have another attack rather than
by how many attacks you actually have or how severe they are. Thus, agoraphobic avoidance is simply
one way of coping with unexpected panic attacks.
2. drugs and/or alcohol by enduring them with “intense dread”
3. Using cluster of avoidant behaviors that we call interoceptive avoidance, or avoidance of internal
physical sensations (removing oneself from situations or activities that might produce the physiological
arousal that somehow resembles the beginnings of a panic attack)

STATISTICS OF PANIC DISORDER W/ AGORAPHOBIA

- Fairly common. 2.7% of the population meet criteria for PD during a given 1-year period and 4.7% met them
at some point during their lives, two-thirds of them women.
- Onset of panic disorder usually occurs in early adult life—from midteens through about 40 years of age.
- median age of onset is between 20 and 24
- health and vitality are the primary focus of anxiety in the elderly population
- (75% or more) of those who suffer from agoraphobia are women which logical explanation is cultural.
- It is more accepted for women to report fear and to avoid numerous situations. Men, however, are expected
to be stronger and braver, to “tough it out.”
- Men consume large amounts of alcohol. The problem is that they become dependent on alcohol, and many
begin the long downward spiral into serious addiction.
- 60% of the people with panic disorder have experienced such nocturnal attacks most happen between
1:30am and 3:30 am so some ppl are afraid to go to sleep at night

CAUSES
- Clark emphasizes the specific psychological vulnerability of people with this disorder to interpret normal
physical sensations in a catastrophic way.
- early object loss and/or separation anxiety might predispose someone to develop the condition as an adult.
- Dependent personality tendencies often characterize a person with agoraphobia. These characteristics were
hypothesized as a possible reaction to early separation.

Treatment of Panic Disorder and Agoraphobia

- drugs affecting the noradrenergic, serotonergic, or GABA–benzodiazepine neurotransmitter systems, or

some combination, seem effective in treating panic disorder
- high-potency benzodiazepines, the newer selective-serotonin reuptake inhibitors (SSRIs) such as Prozac and
Paxil
- serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine
- SSRIs are currently the indicated drug for panic disorder based on all available evidence, although sexual
dysfunction seems to occur in 75% or more of people taking these medications
- high-potency benzodiazepines such as alprazolam (Xanax), commonly used for panic disorder, work quickly
but are hard to stop taking because of psychological and physical dependence and addiction
- exposure-based treatments is to arrange conditions in which the patient can gradually face the feared
situations and learn there is nothing to fear.
- Gradual exposure exercises, sometimes combined with anxiety-reducing coping mechanisms such as
relaxation or breathing retraining, have proved effective in helping patients overcome agoraphobic behavior
whether associated with panic disorder or not
- Panic control treatment (PCT): exposing patients with panic disorder to the cluster of interoceptive (physical)
sensations that remind them of their panic attacks. The therapist attempts to create “mini” panic attacks in
the office by having the patients exercise to elevate their heart rates or perhaps by spinning them in a chair
to make them dizzy.
- General conclusions from these studies suggest no advantage to combining drugs and CBT initially for panic
disorder and agoraphobia.
- psychological treatments seemed to perform better in the long run (6 months after treatment had stopped)
therefore, psychological treatments should be offered initially, followed by drug treatment for those patients
who don’t respond to psychological treatment or when psychological treatment is not available.
Specific Phobia Social Anxiety Disorder Separation Anxiety Disorder Generalized Anxiety Panic Disorder/Agoraphobia
Disorder
-specific phobias require - evaluated a cognitive therapy - parents are often included - Benzodiazepines are - high-potency
structured and consistent program that emphasized to help structure the most often prescribed for benzodiazepines
exposure-based real-life experiences during exercises and also to generalized anxiety, and
exercises. therapy to disprove address parental reaction the evidence indicates - newer selective-
-patients who expose automatic perceptions of to childhood anxiety. that they give some serotonin reuptake
themselves gradually to danger. This is a superior relief, at least in the short inhibitors (SSRIs) such as
what they fear must be treatment term. (w/risk of impairing Prozac and Paxil
under therapeutic both cognitive and motor
supervision. - interpersonal psychotherapy functioning; impair - serotonin-
(IPT) both immediately driving, pp, don’t seem to norepinephrine reuptake
after treatment and at a 1- be as alert) inhibitors (SNRIs), such as
year follow-up, even when venlafaxine.
delivered in a center - Antidepressants such as
specializing in treatment PAXIL (paroxetine) and - high-potency
with IPT EFFEXOR (venlafaxine) benzodiazepines such as
alprazolam (Xanax),
- socially anxious adolescents - cognitive-behavioral commonly used for panic
can attain relatively normal treatment (CBT): evoke disorder, work quickly
functioning in school and the worry process during but are hard to stop
other social settings after therapy sessions and taking because of
receiving cognitive confront anxiety- psychological and
behavioral treatment. provoking images and physical dependence and
thoughts head-on addiction.
- SSRIs Paxil, Zoloft, and Effexor
- CBT and the - exposure-based
- psychological treatment was antidepressant drug treatments is to arrange
substantially better at all sertraline (Zoloft) were conditions in which the
times equally effective patient can gradually face
immediately following the feared situations and
- adding the drug D-cycloserine treatment compared learn there is nothing to
(DCS) to cognitive- with taking placebo pills fear.
behavioral treatments for children with GAD
significantly enhances the and other related - Gradual exposure
effects of treatment. disorders exercises, sometimes
combined with anxiety-
- DCS works in the amygdale reducing coping
(involved in learning and mechanisms such as
unlearning of fear and relaxation or breathing
 anxiety) retraining, have proved
effective in helping
- DCS is known to facilitate patients overcome
extinction of anxiety by agoraphobic behavior
modifying neurotransmitter whether associated with
flow in the glutamate panic disorder or not
system
- Panic control treatment
(PCT) developed at one
of our clinics
concentrates on exposing
patients with panic
disorder to the cluster of
interoceptive (physical)
sensations that remind
them of their panic
attacks.

- psychological treatments
seemed to perform
better in the long run (6
months after treatment
had stopped)

- psychological treatment
should be offered
initially, followed by drug
treatment for those
patients who do not
respond adequately or
for whom psychological
treatment is not available