Anxiety Disorders in the DSM

An unpleasant feeling of fear and apprehension. Clinical anxiety is often grossly disproportionate to

its recognizable stimulus or free floating if the stimulus is unknown to the patient.

Two common features:– Excessive Worry: about things that are either unlikely to

happen or, if they did happen, would be much more manageable than the individual predicts.

– Physical tension - feeling “uptight” or “high strung”

Phobias

A fear and/or avoidance of an object, activity, or situation that the individual knows is out of proportion to the actual danger posed.

DSM-IV Phobias:– Specific Phobia– Social Phobia– Agoraphobia

DSM-IV Criteria For Specific Phobia Marked or persistent fear that is excessive or unreasonable,

cued by a specific object or situation Exposure to the phobic stimulus invariably provokes an

immediate anxiety response The person realizes the fear is excessive or unreasonable

(except in children) The phobic situation is avoided or endured with intense

distress Phobia interferes with the person’s functioning If under 18 years - duration > 6 months

Etiology of Phobias Psychoanalytic - defense against anxiety produced by repressed

id impulses Avoidance-Conditioning Model - involves both classical and

operant conditioning Preparedness Theory Modeling - vicarious learning Cognitive Theories - increased attention to negative stimuli and

alarming predictions Social Skills Deficits in Social Phobia Autonomic Liability

Treatment of Phobias

Systematic Desensitization - in vivo exposure an important addition

Cognitive Approaches - there is no evidence that eliminating irrational beliefs alone, without exposure, reduces phobias

Biological Approaches - anxiolytics - benzodiazepines are addicting and produce severe withdrawal syndrome - relapse common

Childhood Fears and Social Withdrawal

Anxiety disorders are the most common disorders of childhood

School Phobia - two types:– separation anxiety– true fear of school

Social Phobia - elective mutism Treatment - exposure with encouragement

Characteristics of Panic Disorder Sudden and often inexplicable attack of a host of jarring

symptoms Strong urge to escape and reach safety Depersonalization and derealization Fear of losing control, going crazy, or dying The beginning of the attack is “out of the blue” with no

obvious outside cause Agoraphobia - a cluster of fears centering on public places

and being unable to escape or find help should the individual become incapacitated

Etiology of Panic Disorder

Biological Theory - overactivity in the noradrenergic system - hyperventilation

Psychological Theory of Panic Disorder - patients misinterpret physiological symptoms in a catastrophic way

Psychological Theory of Agoraphobia - due to fear-of-fear

Extreme Fear of Losing Control

Components of Panic Disorder Treatment

1. Re-education about the physical symptoms of anxiety and fear, to correct misinterpretations of them as being harmful

2. Training in methods for reducing physical tension, by breathing retraining or relaxation

3. Repeated exposure to feared and avoided physical situations

4. Repeated exposure to feared and avoided sensations

Generalized Anxiety Disorder Chronic, uncontrollable worry about several life

circumstances. Must clearly interfere with day-to-day functioning.

Motor Tension Autonomic Hyperactivity Vigilance

trembling, twitching shortness of breath keyed up

muscle tension, aches tachycardia easily startled

restlessness shortness of breath insomnia

easy fatigability sweating irritability

dizziness/lightheaded

nausea and diarrhea

flushes (hot flashes) or chills

Etiology of GAD Cognitive theory emphasizes the perception of not

being in control as a central characteristic of all views of anxiety

GAD clients are more inclined to interpret ambiguous stimuli as threatening and to rate ominous events as likely to occur to them.

Worry as negatively reinforcing - it distracts patients from even more negative emotions

Defect in GABA system

Three Pervasive Themes in Worry

Perfectionism - worry about making mistakes or things not proceeding in just the right way

Responsibility - worry that if you do not worry then a negative event may actually happen, making you responsible

A Sense of Uncontrollability - worry as a means of gaining control

Obsessive-Compulsive Disorder Persistent and uncontrollable thoughts or compulsion to

repeat certain acts again and again, causing significant distress and interference with everyday functioning

Obsessions - intrusive and recurring thoughts, impulses, and images that come unbidden to the mind and appear irrational and uncontrollable to the client

Compulsion - repetitive behavior or mental act that the person is driven to perform to reduce the distress caused by obsessional thoughts or to prevent some calamity

Etiology of OCD

Psychoanalytic - Due to harsh toilet training,person is fixated at anal stage.

Behavioral - operant escape-responses, memory, active attempts to suppress thoughts

Biological Factors - OCD is caused by a neurotransmitter coupled to serotonin

Treatments for OCD

Victor Meyer - Exposure plus response prevention

Research has shown some improvement in OCD with serotonin reuptake inhibitors and tricyclics

REBT - OCD results from an irrational belief that one must never make a mistake

Regardless of the treatment modality, OCD patients are rarely cured

Posttraumatic Stress Disorder (PTSD)

An extreme response to a severe stressor, including increased anxiety, avoidance of stimuli associated with the trauma, and a numbing of emotional responses.

The etiology in partially assumed in the definition - traumatic event(s)

Distinguished from Acute Stress Disorder in DSM-IV

Major Symptoms of PTSD Reexperiencing the traumatic event -

nightmares, difficulty during “anniversaries,” upset by stimuli associated with the event (e.g., thunder)

Avoidance of stimuli associated with the event or numbing of responsiveness - decreased interest in others, estrangement

Symptoms of increased arousal - insomnia, low concentration, exaggerated startle response

Treatment of PTSD

Emotional and Behavioral Stabilization Trauma Education Stress Management Trauma Focus Relapse Prevention Follow-up and Maintenance