ANXIETY DISORDERS

Any time you face what seems to be a serious threat to your well-being, you may react with the state of
immediate alarm known as fear. Sometimes you cannot pinpoint a specific cause for your alarm, but still
you feel tense and edgy, as if you expect something unpleasant to happen. The vague sense of being in
danger is usually called anxiety, and it has the same features—the same increases in breathing,
muscular tension, perspiration, and so forth—as fear.
Although everyday experiences of fear and anxiety are not pleasant, they often are useful. They prepare
us for action—for “fight or flight”—when danger threatens.
Anxiety disorders are the most common mental disorders in the United States (Hollander & Simeon,
2011). In any given year around 18 percent of the adult population suffer from one or another of the
anxiety disorders identified by DSM-5, while close to 29 percent of all people develop one of the
disorders at some point in their lives (Kessler et al., 2012,
ICD-10 has divided the anxiety disorders mainly into two categories, i.e. phobic disorders and other anxiety
disorders, and each is further subdivided into three groups. The three phobic disorders are agoraphobia, social
phobia and specific phobia. The three subgroups of other anxiety disorders are panic disorder, generalized
anxiety disorder (GAD), and mixed anxiety and depressive disorder. ICD-10 does not include obsessive-
compulsive disorder (OCD) under the group of anxiety disorders.
Anxiety is commonly experienced by virtually all humans. Anxiety is an alerting signal; it warns of threat,
external or internal, and it is probably life saving, more than once in a life time. 11 Anxiety initiates person to
take necessary steps to prevent the threat, or at least lessen its consequences, e.g. getting down to hard word to
prepare for examination. Since it is beneficial for a person to respond with anxiety in certain threatening
situations, one can speak of normal anxiety in contrast to abnormal or pathological anxiety.
Pathological anxiety, on the other hand, is an inappropriate response to a given stimulus, by virtue of either its
intensity or duration. The complete absence of anxiety is just as pathological as excessive anxiety. Anxiety has
an inverted ‘U-shaped relationship’ with performance, as demonstrated by well known Yerkes-Dodson law. In
Yerkes-Dodson law, it is seen that at very low level of anxiety, the performance is poor. Each increment of
anxiety produces equivalent increment in performance. This can be regarded as normal or healthy anxiety.
Then, there is a phase where performance has reached its maximum and any increase in anxiety does not
improve the performance any further. At this stage, the subject may in fact begin having the symptoms of
anxiety, although symptoms produced at this stage do not affect performance. The anxiety, at this point, acts as
a secondary reinforcer, often leading to behaviors that reduce the anxiety level. Later on, any minor increase in
anxiety causes deterioration in performance, which may in turn produce more anxiety. However, there are a
number of other factors which influence the anxiety response to a given stimulus, indicating individual
vulnerability in such responses.
HISTORY : Anxiety and abnormal fears did not play a prominent role in the psychiatric classification systems
that began to emerge in Europe during the second half of the nineteenth century. The focus them was patients
in asylums who were mainly psychotic and people with anxiety seldom came to the forefront. Freud and his
followers were responsible for some of the first extensive clinical descriptions of pathological anxiety states. He
studied and treated GAD, phobias and OCD
 During the first half of the twentieth century, psychiatrists tended to adopt a generalized position with
regard to anxiety disorders (see Jablensky, 1985). In other words, they lumped together the various
anxiety disorders.
 The DSM-IV-TR system splits them into many separate disorders. That approach—dividing the anxiety
disorders into smaller, distinct subcategories—has been quite popular for the past 40 years.
 The organizing scheme: organizes specific forms of psychopathology using two broad dimensions or
spectra: internalizing and externalizing disorders. Anxiety and mood disorders fall into the former
domain because both are characterized by symptoms that involve high levels of negative emotion and
internal distress. Externalizing disorders (such as antisocial personality disorder and substance use
disorders) are more concerned with symptoms with failure to inhibit problematic behaviors.
EITOLOGY
Psychological Theories
1. Psychoanalytic Theories
Freud, in his book ‘Inhibitions, Symptoms and Anxiety’ (1926), proposed that anxiety is a signal to the ego to
take defensive action against the ‘pressure’ from within. If anxiety rises above the low level of intensity
characteristic of its function as a signal, it may emerge with all the fury of a panic attack.
 Ideally, the use of repression alone results in a restoration of psychological equilibrium without
symptom formation, because effective repression completely contains the drives and their associated
affects and fantasies, rendering them unconscious. If repression is unsuccessful as a defense, other
defense mechanisms (such as conversion, displacement and regression) may result in symptom
formation, thus producing picture of classic neurotic disorders such as hysteria, phobia and OCD.
Within psycho analytic theory, anxiety is seen as falling into four major categories.
 Id or impulse anxiety is related to the primitive, diffuse discomforts of infants when they feel
overwhelmed with needs and stimuli over which their helpless state provides no control.
 Separation anxiety occurs in somewhat older but still preoedipal children, who fear the loss of love or
even abandonment by their parents, if they fail to control and direct their impulses in conformity with
their parents’ standards and demands.
 Castration anxiety of adult reflects the castration fantasies of oedipal child, in relation to child’s
developing sexual impulses.
 Superego anxiety is the direct result of the final development of superego that marks the passing of the
oedipus complex and the prepubertal period of latency.
The various personality theories differ regarding establishing the sources and the nature of anxiety.
 Otto Rank, e.g. traced the genesis of all anxiety back to the ‘trauma of birth’.
 Harry Stack Sullivan emphasized the early relationship between the mother and child, and the
transmission of mother’s anxiety to her infant.
 Regardless of the school of psychoanalysis, however, the treatment of anxiety disorders by
psychoanalytical methods usually involves long-term, insight-oriented psychotherapy or
psychoanalysis directed toward the formation of a transference, which allows the re-working of the
development problem and the resolution of the neurotic symptoms.

2. Behavioral Theories
 Behavioral theories propose that anxiety is a conditioned response to specific environmental
stimuli. In a model example of classic conditioning, a person who does not have any food allergies
may become sick after eating contaminated seafood in a restaurant.
 Subsequent exposures to seafood may cause that person to feel sick. Through generalization, such a
person may come to distrust all food prepared by others. As an alternative causal possibility, the
person may learn to have an internal response of anxiety, imitating the anxiety responses of his
parents (social learning theory).
 In either case, treatment is usually with some form of desensitization by repeated exposure to the
anxiogenic stimulus, coupled with cognitive psychotherapeutic approaches.
Recently, the proponents of behavioral theories have shown increasing interest in cognitive approaches to
conceptualizing and treating anxiety disorders.
 The cognitive concept of non-phobic anxiety states that faulty, distorted or counterproductive
thinking patterns accompany or precede maladaptive behaviors and emotional disorders.
 According to one model, patients suffering from anxiety disorders tend to overestimate the degree
of danger and the probability of harm in a given situation, and tend to underestimate their abilities
to cope with perceived threats to their physical or psychological well-being.
 The patients with panic disorder, according to this model, often have thoughts of loss of control and
fears of dying, that follow inexplicable physiological sensations (such as palpitations, tachycardia
and light-headedness).
3. Existential Theories
 There is no specific identifiable stimulus for a chronic anxious feeling. The central concept of
existential theories is the persons’ awareness of a profound nothingness in their lives, which may be
more profoundly discomforting than an acceptance of their inevitable death. Anxiety is the person’s
response to that void of existence and meaning.

4. Biological Theories
 ANS- Stimulation of the autonomic nervous system causes cardiovascular, respiratory and
gastrointestinal symptoms. These peripheral manifestations of anxiety are neither peculiar to anxiety
disorders nor necessarily correlated with the subjective experience of anxiety.. The autonomic nervous
systems that exhibit increase sympathetic tone, adapt slowly to repeated stimuli, and respond
excessively to moderate stimuli.
 Norepinephrine- Anxiety disorder patients have a poorly regulated noradrenergic system, that has
occasional bursts of locus ceruleus. Experiments in primates have demonstrated that stimulation of the
locus ceruleus produces a fear response in animals and that ablation of the same area inhibits or
completely blocks the ability of the animals to form a fear response
 Serotonin-
 GABA-
5. Evolutionary : Generalized forms of anxiety probably evolved to help the person prepare for threats
that could not be identified clearly. More specific forms of anxiety and fear probably evolved to provide
more effective responses to certain types of danger. For example, fear of heights is associated with a
freezing of muscles rather than running away, which could lead to a fall. Social threats are more likely to
provoke responses such as shyness and embarrassment that may increase acceptance by other people
by making the individual seem less threatening. Each type of anxiety disorder can be viewed as the
dysregulation of a mechanism that evolved to deal with a particular kind of danger. This model leads us
to expect that the etiological pathways leading to various forms of anxiety disorders may be partially
distinct but not completely independent
 Current views on the process by which fears are learned suggest that the process is guided by a
module, or specialized circuit in the brain, that has been shaped by evolutionary pressures
(Öhman & Mineka, 2001). Some psychologists have argued that the mind includes a very large
number of prepared modules (specialized neural circuits) that serve particular adaptive
functions, such as the recognition of faces and the perception of language (Pinker, 1997). These
modules are designed to operate at maximal speed, are activated automatically, and perform
without conscious awareness. They are also highly selective, in the sense that the module is
particularly responsive to a narrow range of stimuli. Human beings seem to be prepared to
develop intense, persistent fears only to a select set of objects or situations. Fear of these stimuli
may have conferred a selective advantage upon those people—hundreds of thousands of years
agowho were able to develop fears and consequently avoid certain kinds of dangerous stimuli,
such as heights, snakes, and storms. This is not to say that the fears are innate or present at
birth, but rather that they can be learned and maintained very easily.
 Many investigations have been conducted to test various facets of this preparedness model
(Mineka & Oehlberg, 2008). The results of these studies support many features of the theory.

F40-F48 Neurotic, stress-related and somatoform disorders

 F40 Phobic anxiety disorders
 F40.0 Agoraphobia .00 Without panic disorder .01 With panic disorder
 F40.1 Social phobias
o F40.2 Specific (isolated) phobias F40.8 Other phobic anxiety disorders F40.9 Phobic anxiety
disorder, unspecified
 F41 Other anxiety disorders
 F41.0 Panic disorder [episodic paroxysmal anxiety]
 F41.1 Generalized anxiety disorder
 F41.2 Mixed anxiety and depressive disorder
 F41.3 Other mixed anxiety disorders
  F41.8 Other specified anxiety disorders
 F41.9 Anxiety disorder, unspecified
 F42 Obsessive-compulsive disorder
o F42.0 Predominantly obsessional thoughts or ruminations
o F42.1 Predominantly compulsive acts [obsessional rituals] F42.2 Mixed obsessional thoughts
and acts
o F42.8 Other obsessive-compulsive disorders F42.9 Obsessive-compulsive disorder, unspecified

Neurotic, stress-related, and somatoform disorders have been brought together in one large overall group
because of their historical association with the concept of neurosis and the association of a substantial
(though uncertain)proportion of these disorders with psychological causation. As noted in the general
introduction to this classification, the concept of neurosis has not been retained as a major organizing
principle, but care has been taken to allow the easy identification of disorders that some users still might
wish to regard as neurotic in their own usage of the term (see note on neurosis in the general introduction
(page 3).
Mixtures of symptoms are common (coexistent depression and anxiety being by far the most frequent),
particularly in the less severe varieties of these disorders often seen in primary care. Although efforts
should be made to decide which is the predominant syndrome, a category is provided for those cases of
mixed depression and anxiety in which it would be artificial to force a decision (F41.2).
OBSESSIVE COPULSIVE DISORDERS
 Obsessions are repetitive, unwanted, intrusive cognitive events that may take the form of thoughts or
images or urges. They intrude suddenly into consciousness and lead to an increase in subjective anxiety.
Unwelcome anxiety provoking thoughts. They are aware that it doesn’t make sense but are unable to
ignore and dismiss them. Most normal people , 80% experience similar to obsessions in one form that
they have thoughts that are intrusive, unacceptable, but not so frequent, long lasting or distressing.
Obsessive thinking can be distinguished from worry in two primary ways
o (1) Obsessions are usually experienced by the person as being nonsensical, whereas worries are
often triggered by problems in everyday living; and
o (2) the content of obsessions most often involves themes that are perceived as being socially
unacceptable or horrific, such as sex, violence, and disease/contamination, whereas the content
of worries tends to center around more acceptable, commonplace concerns, such as money and
work (de Silva & Rachman, 2004)
 Compulsions are repetitive behaviors or mental acts that are used to reduce anxietyThese actions are
typically considered by the person who performs them to be senseless or irrational. The person
attempts to resist performing the compulsion but cannot.
 Although obsessive-compulsive disorder is not classified as an anxiety disorder in DSM-5, anxiety does
play a major role in this pattern. The obsessions cause intense anxiety, while the compulsions are aimed
at preventing or reducing anxiety. In addition, anxiety rises if a person tries to resist his or her
obsessions or compulsions. Icd 10 classifies it as an anxiety disorder
CLINICAL PICTURE
 Intrusive and foreign
 Attempts to ignore or resist produces more anxiety
 Obsessions can be – wises, impulses, images, ideas, doubts
 Themes are followed by most obsessive thinking- most common is dirt and contamination
 Religious obsessions are more common in countries with strict moral codes (Hart 2008)
 Although compulsive behaviors are technically under voluntary control, the people who feel they must
do them have little sense of choice in the matter.
 For some people the compulsive acts develop into detailed rituals. They must go through the ritual in
exactly the same way every time, according to certain rule- Checking, order and balance, touching,
counting, cleaning
 In fact, compulsive acts are often a response to obsessive thoughts. One study found that in most cases,
compulsions seemed to represent a yielding to obsessive doubts, ideas, or urges (Akhtar et al., 1975).
  The study also found that compulsions sometimes serve to help control obsessions. A teenager
describes how she tried to control her obsessive fears of contamination by performing counting and
verbal rituals
COURSE AND OUTCOME
Anxiety disorders are often chronic conditions. Long-term follow-up studies focused on clinical populations
indicate that many people continue to experience symptoms of anxiety and associated social and occupational
impairment many years after their problems are initially recognized. On the other hand, some people do
recover completely. The most general conclusion, therefore, is that the long-term outcome for anxiety disorders
is mixed and somewhat unpredictable (Tyrer et al 2004)
 The long-term course of obsessive–compulsive disorder also follows a pattern of improvement mixed
with some persistent symptoms. One remarkable study has reported outcome information for a sample
of 144 patients with severe OCD who were assessed at two follow-up intervals: first about five years
after they were initially treated at a psychiatric hospital and then again more than 40 years later (Skoog
& Skoog, 1999). The data are interesting both because of the very long follup, and were treated between
1947 and 1953, well before the introduction of modern pharmacological and psychological treatments
for the disorder.
 Slightly less than 30 percent of the patients were rated as being recovered at the first follow-up interval.
 By the time of the 40-year followup, almost 50 percent of the patients were considered to show either
full recovery or recovery with subclinical symptoms.
 More than 80 percent of the patients showed improved levels of functioning if we also count people who
continued to exhibit some clinical symptoms.
 Nevertheless, half of the patients in this sample exhibited symptoms of OCD for more than 30 years.
This study shows that although many patients do improve, OCD is a chronic disorder for many people
 The disorder usually begins by young adulthood and typically persists for many years, although its
symptoms and their severity may fluctuate over time (Angst et al., 2004)
EPIDEMIOLOGY: As many as 3 percent develop the disorder at some point during their lives. It is equally
common in men and women and among people of different races and ethnic groups (Matsunaga & Seedat,
2011).

EITIOLOGY
1. PSYCHODYNAMIC
 Anxiety Develops when children learn to fear their own id impulses and use ego defense
mechanisms
 What distinguishes obsessive-compulsive disorder from other anxiety disorders, is that here the
battle between anxiety-provoking id impulses and anxiety-reducing defense mechanisms is not
buried in the unconscious but is played out in overt thoughts and actions
 .The id impulses usually take the form of obsessive thoughts, and the ego defenses appear as
counterthoughts or compulsive actions. Three ego defenses are common- isolation, undoing and
reaction formation
 Isolation – simply disown their unwanted thoughts and experience them as foreign intrusions
 Undoing- perform acts that are meant to cancel out their undesirable impulses
 Reaction formation- take on a lifestyle that directly opposes their unacceptable id impulses
 Freud traces OCD to the Anal stage- in this some children experience intense rage and shame as
result of negative toilet training
 Others have argued instead that such early rage reactions are rooted in feelings of insecurity
(Erikson, 1963; Sullivan, 1953; Horney, 1937).
Children repeatedly feel the need to express their strong aggressive id impulses while at the same
time knowing they should try to restrain and control the impulses. If this conflict between the id and
ego continues, it may eventually blossom into obsessive-compulsive disorder. Research has support
this
2. BEHAVIOURAL
 They focus on explaining and treating compulsions
 They propose that people happen upon their compulsions quite randomly. In a fearful situation,
they happen just coincidentally to wash their hands, say, or dress a certain way. When the threat
lifts, they link the improvement to that particular action.
 After repeated accidental associations, they believe that the action is bringing them good luck or
actually changing the situation, and so they perform the same actions again and again in similar
situations. The act becomes a key method of avoiding or reducing anxiety (Grayson, 2014)
 The famous clinical scientist Stanley Rachman and his associates have shown that compulsions
do appear to be rewarded by a reduction in anxiety. In this study 12 ocd patients were placed in
contact with objects that they considered contaminated. As behaviorists would predict, the
hand-washing rituals of these participants seemed to lower their anxiety. (Rachman 1972)
 They work on the principle that if they learn to perform compulsive behaviours in order to
prevent bad outcomes and ensure +ve outcomes, they can be taught that such behaviours are
not really serving this purpose

3. COGNITIVE
 begin their explanation of obsessive-compulsive disorder by pointing out that everyone has
repetitive, unwanted, and intrusive thoughts. Those who develop this disorder, however,
typically blame themselves for such thoughts and expect that somehow terrible things will
happen (Grayson, 2014; ). To avoid such negative outcomes, they try to neutralize the
thoughts—thinking or behaving in ways meant to put matters right or to make amends.
Neutralizing act include special reassurance from others, deliberately thinking good
thoughts and washing ones hands
 When a neutralizing effort brings about a temporary reduction in discomfort, it is reinforced
and will likely be repeated. Eventually the neutralizing thought or act is used so often that it
becomes, by definition, an obsession or compulsion. At the same time, the individual
becomes more and more convinced that his or her unpleasant intrusive thoughts are
dangerous. As the person’s fear of such thoughts increases, the thoughts begin to occur more
frequently and they, too, become obsessions
 studies have found that people with obsessive compulsive disorder have intrusive thoughts
more often than other people, resort to more elaborate neutralizing strategies, and
experience reductions in anxiety after using neutralizing techniques ( Jacob et al, 2014;)
 predisposition to develop ocd –
o Researchers have found that this population tends (1) to be more depressed than
other people (Klenfeldt et al., 2014;)
o to have exceptionally high standards of conduct and morality
o to have an inflated sense of responsibility in life and believe that their intrusive
negative thoughts are equivalent to actions and capable of causing harm (Lawrence
& Williams, 2011)
o generally to believe that they should have perfect control over all of their thoughts
and behaviors (Gelfand & Radomsky, 2013)
4. BIOLOGICAL
 Studies of twins found that if one identical twin has this disorder, the other twin also develops it
in 53 percent of cases. In contrast, among fraternal twins (twins who share half rather than all of
their genes), both twins display the disorder in only 23 percent of the cases. In short, the more
similar the gene composition of two individuals, the more likely both are to experience
obsessive-compulsive disorder, if indeed one of them displays the disorder
 Abnormal Serotonin Activity: Research found 2 antidepressant drugs to help reduce oc
symtpoms – clomipramine and fluoxetine (Anderson 2014). . Since these particular drugs
increase serotonin activity, some researchers concluded that the disorder might be caused by
low serotonin activity.
  recent studies have suggested that other neurotransmitters, particularly glutamate, GABA, and
dopamine, may also play important roles in the development of the disorder (Bokor & Anderson,
2014). Some researchers even argue that, with regard to obsessive-compulsive disorder,
serotonin may act largely as a neuromodulator, a chemical whose primary function is to increase
or decrease the activity of other key neurotransmitters.
 Abnormal Brain Structure and Functioning: Another line of research has linked obsessive-
compulsive disorder to the abnormal functioning of specific regions of the brain, particularly the
orbitofrontal cortex ( just above each eye) and the caudate nuclei (structures located within the
brain region known as the basal ganglia). These regions are part of a brain circuit that usually
converts sensory information into thoughts and actions (Craig & Chamberlain, 2010)\
 The circuit begins in the orbitofrontal cortex, where sexual, violent, and other primitive
impulses normally arise. These impulses next move on to the caudate nuclei, which act as filters
that send only the most powerful impulses on to the thalamus, from there the person is driven
to think about it further and act on it
 OBFC and caudate nuclei are too active leading to constant eruption of troublesome thoughts , as
seen in brain scans of patients w ocd (Marsh 2014)
 Cingulate cortex and amygdala also have been found to play a role (Via eta l 2014)

MANAGEMENT
PSYCHODYNAMIC
 Psychodynamic therapists try to help the individuals uncover and overcome their underlying conflicts
and defenses, using the customary techniques of free association and therapist interpretation. Research
has offered little evidence, however, that a traditional psychodynamic approach is of much help (Bram &
Björgvinsson, 2004).
BEHAVIOURAL
 In a behavioral treatment called exposure and response prevention (or exposure and ritual prevention),
first developed by psychiatrist Victor Meyer (1966). Clients are repeatedly exposed to objects and
siutations that produce anxiety
 Patients are repeatedly exposed to objects or situations that produce anxiety, obsessive fears, and
compulsive behaviors, but they are told to resist performing the behaviors they feel so bound to
perform. Many behavioral therapists now use exposure and response prevention in both individual and
group therapy formats. Some of them also have people carry out selfhelp procedures at home (Franklin
& Foa, 2014)
 Some homework assignment examples may be – do not mop the floor for a week, after this clean for 3
minutes, use this mop for other chores without cleaning it
 55-85 % patients with OCD have found to improve considerably with exposure and response prevention
which continue indefinitely (Abrahamowitz 2011)
 Research has revealed key limitations in exposure and response prevention. Few clients who receive the
treatment overcome all their symptoms, and as many as one-quarter fail to improve at all (Franklin &
Foa, 2014; Frost & Steketee, 2001). Also, the approach is of limited help to those who have obsessions
but no compulsions (Hohagen et al., 1998)
COGNITIVE
 Cognitive therapists help clients focus on the cognitive processes involved in their obsessive-compulsive
disorder. Initially, they educate the clients, pointing out how misinterpretations of unwanted thoughts,
an excessive sense of responsibility, and neutralizing acts help produce and maintain their symptoms.
 The therapists then guide the clients to identify, challenge, and change their distorted cognitions. It
appears that cognitive techniques of this kind often help reduce the number and impact of obsessions
and compulsions (Franklin & Foa, 2014)
  Research suggests that a combination of cognitive and behavioural is more helpful : In such cognitive-
behavioral treatments, clients are first taught to view their obsessive thoughts as inaccurate
occurrences rather than as valid and dangerous cognitions for which they are responsible and upon
which they must act. As they become better able to identify and recognize the thoughts for what they
are, they also become less inclined to act on them, more willing to subject themselves to the rigors of
exposure and response prevention, and more likely to make gains using that behavioral technique.
BIOLOGICAL
 We now know that the drugs not only increase brain serotonin activity but also help produce more
normal activity in the orbitofrontal cortex and caudate nuclei (McCabe & Mishor, 2011)
 They’ve shown improvement in 50 and 80 percent of those with ocd (bareggi 2004) they cut oc
symptoms in half within 8 weeks of treatment
 They do tend to relapse if their mediciation is stopped
 A combination of behavioural biological and cbt therapies are most efficient in treatment nd yield
higher levels of symptom reduction and bring some relief to more clients than do each approach alone
(Simpson 2013)

PANIC DISORDER
A panic attack is a sudden, overwhelming experience of terror or
fright. Whereas anxiety involves a blend of several negative emotions,
panic is more focused. Some clinicians think of panic as a normal fear
response that is triggered at an inappropriate time (Barlow, Brown, &
Craske, 1994). In that sense, panic is a “false alarm.” Descriptively,
panic can be distinguished from anxiety in two other respects: It is
more intense, and it has a sudden onset.
Panic attacks—periodic, short bouts of panic that occur suddenly,
reach a peak within minutes, and gradually pass (APA, 2013). The
attacks feature at least four of the following symptoms of panic:
palpitations of the heart, tingling in the hands or feet, shortness of
breath, sweating, hot and cold flashes, trembling, chest pains,
choking sensations, faintness, dizziness, and a feeling of unreality
 (APA, 2013). Small wonder that during a panic attack many
people fear they will die, go crazy, or lose control.
Panic attacks are defined largely in terms of a list of somatic or
physical sensations, ranging from heart palpitations, sweating,
and trembling to nausea, dizziness, and chills.
People undergoing a panic attack also report a number of
cognitive symptoms. They may feel as though they are about to
die, lose control, or go crazy. Some clinicians believe that the
misinterpretation of bodily sensations lies at the core of panic
disorder. Patients may interpret heart palpitations as evidence of
an impending heart attack or racing thoughts as evidence that
they are about to lose their minds.
Panic attacks are further described in terms of the situations in
which they occur, as well as the person’s expectations about their
occurrence. An attack is said to be expected, or cued, if it occurs
only in the presence of a particular stimulus. For example, someone who is afraid of public speaking might
have a cued panic attack if forced to give a speech in front of a large group of people. Unexpected panic
attacks, like Johanna’s experience in the grocery checkout line, appear without warning or expectation, as if
“out of the blue.”
To meet the diagnostic criteria for panic disorder, a person must experience recurrent, unexpected panic
attacks. At least one of the attacks must have been followed by a period of one month or more in which the
person has either persistent concern about having additional attacks, worry about the implications of the
attack or its consequences, or a significant change in behavior related to the attacks.
ONSET – Late adolescence or early adulthood
EPIDEMIOLOGY-Twice as common in women as among men , twice as common in poor people than in
wealthy (Sareen 2011) More than 5 percent develop it at some point in their lives (Kessler 2012)

EITIOLOGY
BIOLOGICAL - Researchers began to suspect that panic disorder might be caused in the first place by
abnormal norepinephrine activity.
 For example, the locus coeruleus is a brain area rich in neurons that use norepinephrine, and serves
as a kind of “on-off” switch for most norephrine-using neurons throughout the brain (Hedaya,
2011). When this area is electrically stimulated in monkeys, the monkeys have a panic-like reaction,
suggesting that panic reactions may be related to increases in norepinephrine activity in the locus
coeruleus (Redmond, 1981).
 Similarly, in another line of research, scientists were able to produce panic attacks in human beings
by injecting them with chemicals known to increase the activity of norepinephrine (Bourin et al.,
1995; Charney et al., 1990)
 It turns out that panic reactions are produced in part by a brain circuit consisting of areas such as
the amygdala, hippocampus, ventromedial nucleus of the hypothalamus, central gray matter, and
locus coeruleus (Henn, 2013)
 When a person confronts a frightening object or situation, the amygdala is stimulated. In turn, the
amygdala stimulates the other brain areas in the circuit, temporarily setting into motion an “alarm
and escape” response (increased heart rate, respiration, blood pressure, and the like) that is very
similar to a panic reaction (Gray & McNaughton, 1996). Most of today’s researchers believe that this
brain circuit—including the neurotransmitters at work throughout the circuit—probably functions
improperly in people who experience panic disorder (Henn, 2013; Bremner & Charney, 2010;
Burijon, 2007).
COGNITIVE - Cognitive theorists have come to recognize that biological factors are only part of the cause of
panic attacks. In their view, full panic reactions are experienced only by people who further misinterpret the
physiological events that are taking place within their bodies.
 Cognitive theorists believe that panic-prone people may be very sensitive to certain bodily
sensations; when they unexpectedly experience such sensations, they misinterpret them as signs of
a medical catastrophe (Gloster et al., 2014; Clark & Beck, 2012).Rather than understanding the
probable cause of their sensations as “something I ate” or “a fight with the boss,” those prone to
panic grow increasingly upset about losing control, fear the worst, lose all perspective, and rapidly
plunge into panic
 In biological challenge tests, researchers produce hyperventilation or other biological sensations by
administering drugs or by instructing clinical research participants to breathe, exercise, or simply
think in certain ways. People with panic disorder experience greater upset during these tests than
participants without the disorder, particularly when they believe that their bodily sensations are
dangerous or out of control (Bunaciu et al., 2012)
 One possibility is that panic-prone individuals generally experience, through no fault of their own,
more frequent or more intense bodily sensations than other people do (Nillni et al., 2012)
 Another possibility, supported by some research, is that people prone to bodily misinterpretations
have had more traumafilled events over the course of their lives than other persons (Hawks et al.,
2011)
 Panic-prone individuals generally have a high degree of what is called anxiety sensitivity; that is,
they focus on their bodily sensations much of the time, are unable to assess them logically, and
interpret them as potentially harmful. people who scored high on anxiety-sensitivity surveys are up
to five times more likely than other people to develop panic disorder (Hawks et al., 2011)

Attention to Threat and Biased Information Processing Earlier in this chapter we mentioned that
anxiety involves negative thoughts and images anticipating some possible future danger. In recent years,
several lines of research have converged to clarify the basic cognitive mechanisms involved in generalized
anxiety disorder as well as panic disorder. Experts now believe that attention plays a crucial role in the
onset of this process. People who are prone to excessive worrying and panic are unusually sensitive to cues
that signal the existence of future threats (MacLeod et al., 2002; Teachman, Smith-Janik, & Saporito, 2007).
They attend vigilantly to even fleeting signs of danger, especially when they are under stress. At such times,
the recognition of danger cues triggers a maladaptive, self-perpetuating cycle of cognitive processes that
can quickly spin out of control.
The threatening information that is generated in this process is presumably encoded in memory in the form
of elaborate schemas, which are easily reactivated. The threat schemas of anxious people contain a high
proportion of “what-if” questions, such as “What am I going to do if I don’t do well in school this semester?”
Once attention has been drawn to threatening cues, the performance of adaptive, problem-solving
behaviors is disrupted, and the worrying cycle launches into a repetitive sequence in which the person
rehearses anticipated events and searches for ways to avoid them. This process activates an additional
series of “what if” questions that quickly leads to a dramatic increase in negative affect (McLaughlin,
Borovec, & Sibrava, 2007).
MANAGEMENT
1. DRUG THERAPY - It appears that all antidepressant drugs that restore proper activity of
norepinephrine in the locus coeruleus and other parts of the panic brain circuit are able to help
prevent or reduce panic symptoms (Pollack, 2005).In recent years alprazolam (Xanax) and other
powerful benzodiazepine drugs have also proved effective in the treatment of panic disorder (NIMH,
2013)

2. COGNITIVE THERAPY- Cognitive therapists try to correct people’s misinterpretations of their

bodily sensations (Barlow, 2014; Beck, 2012). Psychoeducation of panic attacks and bodily
sensation, apply more accurate interpretations, cope better with anxiety. In addition, cognitive
therapists may use biological challenge procedures to induce panic sensations, so that clients can apply
 their new skills under watchful supervision. Individuals whose attacks typically are triggered by a rapid
heart rate, for example, may be told to jump up and down for several minutes or to run up a flight of
stairs. They can then practice interpreting the resulting sensations appropriately, without dwelling on
them

a. Cognitive restructuring involves

i. Role of thoughts in emotions
ii. Seeing and recognizing thoughts as hypothese instead of facts
iii. Questioning and challenging the thought
iv. Self monitoring of emotions and associated cognitions, thought record
v. Identifying beliefs, assumptions, and appraisals
vi. Identifying cognitive errors such as overestimation of risk of negative events ,
catastrophizinig
vii. Use an empirical approach to check validity of thoughts by considering all
evidence
viii. Socratic quesionin g
ix. Core beliefs and schemas are questioned
b. Exposure – invivo and interoceptive exposure
c. Acceptance and commitment therapy for reducing avoidance and increasing acceptance
and willingness to experience distress
__________________________________________________________________________________________________________________
_

________________________________________________________________________________________________________________________________