Chapter 5

Statistics of social anxiety disorder

12.1% (life); 6.8% (year) Female : Male = 1:1 Onset = usually adolescence Peak age of onset = 13 More common in people who are young (18 to 29 years), undereducated, single, and of low socioeconomic class, 13.6% prevalence in ages 18 to 29 6.6% prevalence in ages 60+ Japan—taijin kyofusho Fear of offending others or making them uncomfortable Concern about aspects of personal appearance (e.g., stuttering, blushing, body odor) More common in males As many as 12.1% of the general population suffer from SAD at some point in their lives (Kessler, Berglund, Demler, et al., 2005). In a given 1-year period, the prevalence is 6.8% (Kessler, Chiu, et al., 2005), and 8.2% in adolescents (Kessler et al., 2012). This makes SAD second only to specific phobia as the most prevalent anxiety disorder, afflicting more than 35 million people in the United States alone, based on current population estimates. Many more people are shy, but not severely enough to meet criteria for social anxiety disorder. Unlike other anxiety disorders for which females predominate (Hofmann, Alpers, & Pauli, 2009; Magee et al., 1996), the sex ratio for SAD is nearly 50:50 SAD usually begins during adolescence, with a peak age of onset around 13 years (Kessler, Berglund, Demler, et al., 2005). SAD also tends to be more prevalent in people who are young (18-29 years), undereducated, single, and of low socioeconomic class. Considering their difficulty meeting people, it is not surprising that a greater percentage of individuals with SAD are single than in the population at large. In the United States, white Americans are typically more likely to be diagnosed with social anxiety disorder (as well as generalized anxiety disorder and panic disorder) than African Americans, Hispanic Americans, and Asian Americans

Statistics of Panic Disorder

2.7% (year) 4.7% (life) Female: male = 2:1 Acute onset, most common in young adulthood (e.g. ages 20-24) Special populations Children Hyperventilation is a common symptom Earlier cognitive development > fewer cognitive symptoms (e.g. less fear of dying) Elderly Health focus is more common Changes in prevalence - decreases with age PD is fairly common. Approximately 2.7% of the population meet criteria for PD during a given 1-year period (Kessler, Chiu, et al.,2005; Kessler, Chiu, Jin, et al., 2006) 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. The median age of onset is between 20 and 24 (Kessler, Berglund, Demler, Jin, & Walters, 2005). Most initial unexpected panic attacks begin at or after puberty. Furthermore, many prepubertal children who are seen by general medical practitioners have symptoms of hyperventilation that may well be panic attacks. As we have said, most (75% or more) of those who suffer from agoraphobia are women (Barlow, 2002; Myers et al., 1984; Thorpe & Burns, 1983). For a long time, we didn't know why, but now it seems the most logical explanation is cultural (Arrindell et al., 2003a; Wolitzky-Taylor et al., 2010). 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." The higher the severity of agoraphobic avoidance, the greater the proportion of women. Prevalence rates for panic disorder show some degree of cross-cultural variability with Asian and African countries usually showing the lowest rates. These findings mirror cross-ethnic comparisons within the United States, with Asian Americans showing the lowest, and White Americans showing the highest prevalence rates (Asnaani, Gutner, Hinton, & Hofmann, 2009; Lewis-Fernandez et al., 2010; Hofmann & Hinton, 2014). Furthermore, rates of recovery from panic disorder is lower among African Americans as compared to non-Latino White individuals (Sibrava et al., 2013). . In Chapter 2, we described a fright disorder in Latin America that is called susto, a disorder that is characterized by sweating, increased heart rate, and insomnia but not by reports of anxiety or fear, even though a severe fright is the cause. An anxiety-related, culturally defined syndrome prominent among Hispanic Americans, particularly those from the Caribbean, is called ataques de nervios (Hinton, Chong, Pollack, Barlow, & McNally, 2008; Hinton, Lewis-Fernández, & Pollack, 2009). The symptoms of an ataque seem quite similar to those of a panic attack, although such manifestations as shouting uncontrollably or bursting into tears may be associated more often with ataque than with panic.

Statistics

3.1% (year) 5.7% (lifetime) Similar rates worldwide Insidious onset Early adulthood Chronic course Relatively few people with GAD come for treatment, however, compared with patients with panic disorder. Anxiety clinics like ours report that only approximately 10% of their patients meet criteria for GAD compared with 30% to 50% for panic disorder. Approximately 3.1% of the population meets criteria for GAD during a given 1-year period (Kessler, Chiu, Demler, & Walters, 2005) and 5.7% at some point during their lifetime (Kessler, Berglund, Demler, Jin, & Walters, 2005). For adolescents only (ages 13-17), the one-year prevalence is somewhat lower at 1.1% (Kessler et al., 2012). This is still quite a large number, making GAD one of the most common anxiety disorders. GAD in the elderly Worry about failing health, loss Up to 10% prevalence Use of minor tranquilizers: 17 to 50% Sometimes prescribed for medical problems or sleep problems Increase risk for falls and cognitive impairments

Statistics PTSD

6.8% (life); 3.5% (year) Prevalence varies Most people who undergo traumatic events do not develop PTSD Type of trauma E.g., experiencing repeated sexual assault makes an individual 2 to 3 times as likely to develop PTSD Proximity - more likely to develop PTSD if closer to the trauma Results are presented in Table 5.8. As one can see, the highest rates are associated with experiences of rape; being held captive, tortured, or kidnapped; or being badly assaulted. Close exposure to the trauma seems to be necessary to developing this disorder (Friedman, M. J.,2009; Keane & Barlow, 2002). But this is also evident among Vietnam veterans, among whom 18.7% developed PTSD, with prevalence rates directly related to amount of combat exposure We also know that once it appears, PTSD tends to last (i.e., it runs a chronic course) (Breslau, 2012; Perkonigg et al., 2005). Since a diagnosis of PTSD predicts suicidal attempts independently of any other problem, such as alcohol abuse, every case should be taken very seriously (Wilcox, Storr, & Breslau, 2009).

Obsessions

60% have multiple obsessions Need for symmetry Forbidden thoughts or actions Cleaning and contamination

Nocturnal Panic

60% with panic disorder experience nocturnal attacks Occur in non-REM sleep Occur during delta/slow wave sleep Caused by deep relaxation, Sensations of "letting go" are anxiety provoking to people with panic attacks Sleep terrors Isolated sleep paralysis Sleep terrors = childhood condition of intense fear in the middle of the night. Often involves screaming and getting out of bed, but the children don't wake up and don't remember it the next day. Isolated sleep paralysis = temporarily unable to move when transitioning from sleep to wake, accompanied by surge of terror and occasional hallucination Generalized biological vulnerability Alarm reaction to stress Cues get associated with situations Conditioning occurs Generalized psychological vulnerability Anxiety about future attacks Hypervigilance Increase interoceptive awareness We have learned that nocturnal panic attacks occur during delta wave or slow wave sleep, which typically occurs several hours after we fall asleep and is the deepest stage of sleep. People with panic disorder often begin to panic when they start sinking into delta sleep, and then they awaken amid an attack. Because there is no obvious reason for them to be anxious or panicky when they are sound asleep, most of these individuals think they are dying (Craske & Barlow, 1988; Craske & Barlow, 2014).

Disinhibited Social Engagement Disorder

A pattern of abnormally low inhibition in children E.g., approaching unfamiliar adults without fear

Body Dysmorphic Disorder (BDD)

A preoccupation with some imagined defect in appearance Actual defect, if present, appears slight to others Comorbid with OCD 10% Course lifelong Onset - early adolescence through 20s Two treatments SSRIs Exposure and response prevention Examples of concerns in BDD: Ears too big, muscles too small, skin uneven/blotchy, nose too big

Reactive Attachment Disorder

Abnormally withdrawn and inhibited behavior Less receptive to support from caregivers The child will very seldom seek out a caregiver for protection, support, and nurturance and will seldom respond to offers from caregivers to provide this kind of care

Animal Phobia

Animal phobia Dogs, snakes, mice, insects May be associated with real dangers Onset = usually in childhood

Summary

Anxiety and related disorders occur when natural and adaptive processes (anxiety, fear and panic) become disproportionate to the environment These disorders occur as a result of generalized biological vulnerabilities, generalized psychological vulnerabilities, and specific psychological vulnerabilities Anxiety disorders include: Panic disorder Agoraphobia Generalized anxiety disorder Social anxiety disorder Specific phobia Selective mutism Separation anxiety disorder Trauma- and stressor-related disorders share a common etiology: stressful experiences. Trauma- and stressor-related disorders include: PTSD Acute stress disorder Adjustment disorders Reactive attachment disorder Disinhibited social engagement disorder

Adjustment Disorders

Anxious or depressive reactions to life stress Milder than PTSD/acute stress disorder Occur in reaction to life stressors like moving, new job, divorce, etc Clinically significant distress or impairment

Anxiety

Apprehensive, future-oriented Somatic symptoms: muscle tension, restlessness, elevated heart rate

Trauma and Stressor-Related Disorders

Attachment disorders Posttraumatic stress disorder and acute stress disorder Also, a wider range of emotions—such as rage, horror, guilt, and shame, in addition to fear and anxiety—may be implicated in the onset, particularly for posttraumatic stress disorder

Social Contributions to Anxiety

Biological vulnerabilities triggered by stressful life events Family Interpersonal Occupational Educational The same stressors can trigger physical reactions, such as headaches or hypertension, and emotional reactions, such as panic attacks (Barlow, 2002). The particular way we react to stress seems to run in families. If you get headaches when under stress, chances are other people in your family also get headaches. If you have panic attacks, other members of your family probably do also. This finding suggests a possible genetic contribution, at least to initial panic attacks.

Blood-Injection-Injury Phobia

Blood-injection-injury phobia Decreased heart rate and blood pressure when seeing blood, injections, or injury Fainting Inherited vasovagal response Onset = usually in childhood Rather than the usual surge of activity in the sympathetic nervous system and increased heart rate and blood pressure, Judy experienced a marked drop in heart rate and blood pressure and fainted as a consequence. Many people who suffer from phobias and experience panic attacks in their feared situations report that they feel like they are going to faint, but they never do because their heart rate and blood pressure are actually increasing. Therefore, those with blood-injection-injury phobias almost always differ in their physiological reaction from people with other types of phobia This is probably because people with this phobia inherit a strong vasovagal response to blood, injury, or the possibility of an injection, all of which cause a drop in blood pressure and a tendency to faint.

Generalized Anxiety Disorder (GAD)

Clinical description Shift from possible crisis to crisis Worry about minor, everyday concerns Job, family, chores, appointments Accompanied by symptoms such as sleep disturbance and irritability Leads to behaviors like procrastination, overpreparation GAD in children Need only one physical symptom Worry = academic, social, athletic performance

Separation Anxiety Disorder

Clinical Description Characterized by unrealistic and persistent worry that something will happen to self or loved ones when apart (e.g., kidnapping, accident) as well as anxiety about leaving loved ones 4.1% of children meet criteria, 6.6% for adults Used to be diagnosed in children only, but now may be diagnosed in adults Loved one from whom separation is feared usually has some caretaking responsibility for affected individual (e.g. spouse, parent). It is not common to see parents fearing separation from their children, for example. If a parent has pathological worry about harm coming to their child, it would more likely be diagnosed as part of GAD. Several years ago it was discovered that separation anxiety, if untreated, can extend into adulthood in approximately 35% of cases (Shear et al., 2006). Furthermore, evidence suggests that we have overlooked this disorder in adults and that it occurs in approximately 6.6% of the adult population over the course of a lifetime (Shear et al., 2006). In treating separation anxiety in children, parents are often included to help structure the exercises and also to address parental reaction to childhood anxiety

Obsessive-Compulsive Disorder (OCD)

Clinical description Obsessions Intrusive and nonsensical Thoughts, images, or urges Attempts to resist or eliminate Compulsions Thoughts or actions Provide relief from obsessive thoughts Examples of obsessions: Doubting (whether you've locked the door, done something correctly), thoughts about contamination, unwanted sexual/aggressive/religious urges, horrific images popping into your head, need for symmetry/exactness/doing something until it feels "just right," thoughts about accidentally hurting other people

Specific Phobias

Clinical description Extreme and irrational fear of a specific object or situation Feared situation almost always provokes anxiety Significant impairment or distress A specific phobia is an irrational fear of a specific object or situation that markedly interferes with an individual's ability to function. Four major subtypes of specific phobia have been identified: blood-injection-injury type, situational type (such as planes, elevators, or enclosed places), natural environment type (for example, heights, storms, and water), and animal type. A fifth category, "other," includes phobias that do not fit any of the four major subtypes (for example, situations that may lead to choking, vomiting, or contracting an illness or, in children, avoidance of loud sounds or costumed characters).

Social Anxiety Disorder (Social Phobia)

Clinical description Extreme/irrational concern about being negatively evaluated by other people Sometimes (not always) manifests as shyness Leads to significant impairment and/or distress Avoidance of feared situations, or endurance with extreme distress Subtype Performance only: Anxiety only in performance situations (e.g. public speaking) Performance-only subtype tends to be less interfering because individuals are able to function in most social situations without a problem. Both subtypes are often associated with professional/educational impairment (e.g., not speaking up at meetings, avoiding classes that require presentations) he most common type of performance anxiety, to which most people can relate, is public speaking. Other 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).

Selective Mutism (SM)

Clinical description Rare childhood disorder characterized by a lack of speech Must occur for more than one month and cannot be limited to the first month of school High comorbidity with SAD Treatment CBT most efficacious, similar to treatment for SAD 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. Further evidence that this disorder is strongly related to social anxiety is found in the high rates of comorbidity of SM and anxiety disorders, particularly SAD (Bögels et al. 2010). In fact, in one study, nearly 100% of a series of 50 children with selective mutism also met criteria for SAD (Dummit et al., 1997). Why does lack of speech in certain situations emerge as the specific symptom in selective mutism instead of other socially anxious behaviors? It is not entirely clear yet, but there is some evidence that well-meaning parents enable this behavior by being more readily able to intervene and "do their talking for them" (Buzzella et al., 2011). Treatment employs many of the same cognitive behavioral principles used successfully to treat social anxiety in children but with a greater emphasis on speech (Carpenter, Puliafico, Kurtz, Pincus, & Comer, 2014). For example, in one of our clinics, we run a specialized program called "The Boston University Brave Buddies Camp."

Posttraumatic Stress Disorder (PTSD)

Clinical description Trauma exposure Continued re-experiencing (e.g., memories, nightmares, flashbacks) Avoidance Emotional numbing Reckless or self-destructive behavior Interpersonal problems Refers to problems that persist for more than one month after the trauma Acute stress disorder assigned for post-traumatic symptoms lasting less than a month In the DSM, "Traumatic exposure" means experiencing or witnessing an event in which death, serious injury, or sexual violation occurred or was threatened to the self or someone else, OR learning about violent or accidental death or serious injury occurring to a close loved one, OR extreme aversive exposure to details of a traumatic event (such as a first responder collecting body parts at the scene of an explosion). When memories occur suddenly, accompanied by strong emotion, and the victims find themselves reliving the event, they are having a flashback. Victims most often avoid anything that reminds them of the trauma. They often display a characteristic restriction or numbing of emotional responsiveness, which may be disruptive to interpersonal relationships. They are sometimes unable to remember certain aspects of the event. It is possible that victims unconsciously attempt to avoid the experience of emotion itself, like people with panic disorder, because intense emotions could bring back memories of the trauma. Finally, victims typically are chronically overaroused, easily startled, and quick to anger. New to DSM-5 is the addition of "reckless or self-destructive behavior" under the PTSD E criteria as one sign of increased arousal and reactivity. Also new to DSM-5 is the addition of a "dissociative" subtype describing victims who do not necessarily react with the reexperiencing or hyperarousal, characteristic of PTSD. Rather, individuals with PTSD who experience dissociation have less arousal than normal along with (dissociative) feelings of unreality Since many individuals experience strong reactions to stressful events that typically disappear within a month, the diagnosis of PTSD cannot be made until at least one month after the occurrence of the traumatic event. In PTSD with delayed onset, individuals show few or no symptoms immediately or for months after a trauma, but at least 6 months later, and perhaps years afterward, develop full-blown PTSD (O'Donnell et al., 2013). Acute stress disorder was included in DSM-IV because many people with severe early reactions to trauma could not otherwise be diagnosed and, therefore, could not receive insurance coverage for immediate treatment. The surveys described above confirm that people with early severe reactions to traumatic stress are severely impacted and can benefit from treatment. But these early reactions are not particularly good predictors of who will go on to develop PTSD.

Panic Disorder and Agoraphobia

Clinical description Unexpected panic attacks Anxiety, worry, or fear of another attack Persists for 1 month or more Agoraphobia Fear or avoidance of situations/events Concern about being unable to escape or get help in the event of panic symptoms or other unpleasant physical symptoms (e.g., incontinence, vomiting, falling) Clinical description Avoidance can be persistent Use and abuse of drugs and alcohol Interoceptive avoidance Interoceptive avoidance = avoiding activities that might bring on physical sensations reminiscent of panic (e.g. exercise, sex, caffeine, anger, exhilarating movies, amusement park rides) Your aunt may not have been just odd or eccentric. She may have suffered from debilitating anxiety disorder called panic disorder (PD), in which individuals experience severe, unexpected panic attacks; they may think they're dying or otherwise losing control. In many cases, but not all, PD is accompanied by a closely related disorder called agoraphobia, which is 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, panic-like symptoms, or other physical symptoms, such as loss of bladder control. To meet criteria for panic disorder, a 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. Simply put, if you have had unexpected panic attacks and are afraid you may have another one, you want to be in a safe place or at least with a safe person who knows what you are experiencing if another attack occurs so that you can quickly get to a hospital or at least go into your bedroom and lie down (the home is usually a safe place). Even if agoraphobic behavior is closely tied to the occasions of panic initially, it can become relatively independent of panic attacks (Craske & Barlow, 1988; White & Barlow, 2002). In other words, an individual who has not had a panic attack for years may still have strong agoraphobic avoidance, like Mrs. M. Agoraphobic avoidance seems to be determined for the most part by the 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. Other methods of coping with panic attacks include using (and sometimes abusing) drugs and/or alcohol. Some individuals do not avoid agoraphobic situations but endure them with "intense dread." Thus, DSM-5 notes that agoraphobia may be characterized either by avoiding the situations or by enduring them with intense fear and anxiety. As noted above, epidemiological surveys have identified a group of people who seem to have agoraphobia without ever having a panic attack or any fearful spells whatsoever. In fact, approximately 50% of individuals with agoraphobia identified in population surveys fit this description, although it is relatively rare to see these cases in the clinic (Wittchen et al., 2010). These individuals may have other distressing unpredictable experiences such as dizzy spells, possible loss of bladder or bowel control such that they can never be far from a bathroom, or fear of falling (particularly in the elderly) any of which might be embarrassing or dangerous if away from a safe place or without the presence of a safe person.

Treatment of Phobias

Cognitive-behavior therapies Exposure Graduated Structured Relaxation - used to be practiced more, now often not a part of empirically supported treatment Graduated and structured = systematically progress through hierarchy of feared situations related to phobia. Example: Someone who fears spiders would first look at pictures of spiders, then watch videos of spiders, then be in a room with a spider in a cage, then approach the cage, then touch the spider, etc. Each level of the hierarchy may be repeated until the person's anxiety decreases. Although the development of phobias is relatively complex, the treatment is fairly straightforward. Almost everyone agrees that specific phobias require structured and consistent exposure-based exercises New developments make it possible to treat many specific phobias, including blood phobia, in a single, session taking anywhere from approximately 2 to 6 hours (see, for example, Antony et al., 2006; Craske et al., 2006; Hauner, Mineka, Voss, & Paller, 2012; Oar, Farrell, Waters, Conlon, & Ollendick, 2015; Öst, Svensson, Hellström, & Lindwall, 2001). It is interesting that in these cases, not only does the phobia disappear, but in blood phobia the tendency to experience the vasovagal response at the sight of blood also lessens considerably. It is also now clear based on brain-imaging work that these treatments change brain functioning in an enduring way by modifying neural circuitry in such areas as the amygdala, insula, and cingulate cortex

Treatment of PTSD

Cognitive-behavioral treatment Imaginal exposure to memories of traumatic event Graduated or massed Increase positive coping skills Increase social support Highly effective Psychoanalytic therapy: catharsis = reliving emotional trauma to relieve suffering Medications SSRIs can be helpful Relieve heightened anxiety and panic attacks common to PTSD

Causes of Phobias

Direct experience Vicarious experience - seeing someone else encounter a feared object Information transmission - learning about a situation/object being dangerous "Preparedness" "Preparedness" = it is easier for us to acquire phobias of things that would have been useful for our ancestors to fear (e.g., more likely to fear spiders and snakes than buses although the latter are more dangerous). In other words, through natural selection, we have been "prepared" to fear certain things more than others These are examples of phobias acquired by direct experience, where real danger or pain results in an alarm response (a true alarm). This is one way of developing a phobia, and there are at least three others: experiencing a false alarm (panic attack) in a specific situation, observing someone else experiencing severe fear (vicarious experience), or, under the right conditions, being told about danger. Remember our earlier discussion of unexpected panic attacks? Studies show that many people with specific phobias do not necessarily experience a true alarm resulting from real danger at the onset of their phobia. Many initially have an unexpected panic attack in a specific situation, perhaps related to current life stress. In summary, several things have to occur for a person to develop a phobia. First, a traumatic conditioning experience often plays a role (even hearing about a frightening event is sufficient for some individuals). Second, fear is more likely to develop if we are "prepared"; that is, we seem to carry an inherited tendency to fear situations that have always been dangerous to the human race, such as being threatened by wild animals or trapped in small places (see Chapter 2). Third, we also have to be susceptible to developing anxiety about the possibility that the event will happen again. In a collaborative study between Fyer's clinic and our center, we replicated these results, finding a 28% prevalence in the first-degree relatives of patients with phobia compared with 10% in relatives of controls. More interestingly, it seems that each subtype of phobia "bred true," in that relatives were likely to have identical types of phobia. Finally, social and cultural factors are strong determinants of who develops and reports a specific phobia. In most societies, it is almost unacceptable for males to express fears and phobias. Thus, the overwhelming majority of reported specific phobias occur in women

Attachment Disorders

Disturbed and developmentally inappropriate behaviors in children Child is unable or unwilling to form normal attachment relationships with caregiving adults Occurs as a result of inadequate or neglectful care in early childhood

Hoarding Disorder

Excessively collecting and keeping items with minimal value, leading to cluttering and disruption of living space Prevalence: between 2% and 5% of the population, (twice as high as the prevalence of OCD) Men = women OCD tends to wax and wane, whereas hoarding behavior can begin early in life and get worse with each passing decade

Diagnostic Criteria for PTSD

Exposure to actual or threatened event Presence of one or more intrusional symptoms Persistent avoidance of stimuli associated with traumatic event Negative alterations in cognitions and mood associated with traumatic event Marked alterations in arousal and activity associated with the traumatic event Sleep disturbance Significant distress Not attributable to substance use

Compulsions

Four major categories Checking Ordering Arranging Washing/cleaning Association with obsessions These four categories are NOT exhaustive, but they capture many common compulsions. The function of compulsions is to reduce discomfort associated with obsessions.

Psychological Contributions

Freud Anxiety = psychic reaction to danger Reactivation of infantile fear situation Behaviorists Classical and operant conditioning - symptoms are a result of learned associations Modeling - anxious behavior Beliefs about control over environment Early life experiences give us a sense of greater or lesser control over the environment - leading to less or more anxiety But, new and accumulating evidence supports an integrated model of anxiety involving a variety of psychological factors (see, for example, Barlow, 2002; Barlow, Ellard et al, 2014). In childhood, we may acquire an awareness that events are not always in our control (Chorpita & Barlow, 1998; Gallagher, Bentley, & Barlow, 2014). The continuum of this perception may range from total confidence in our control of all aspects of our lives to deep uncertainty about ourselves and our ability to deal with upcoming events. Generally, it seems that parents who interact in a positive and predictable way with their children by responding to their needs, particularly when the child communicates needs for attention, food, relief from pain, and so on, perform an important function. These parents teach their children that they have control over their environment and their responses have an effect on their parents and their environment. In addition, 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 (Chorpita & Barlow, 1998). Another feature among patients with panic is the general tendency to respond fearfully to anxiety symptoms. This is known as anxiety sensitivity, which appears to be an important personality trait that determines who will and who will not experience problems with anxiety under certain stressful conditions (Reiss, 1991). Most psychological accounts of panic (as opposed to anxiety) invoke conditioning and cognitive explanations that are difficult to separate (Bouton, Mineka, & Barlow, 2001). Thus, a strong fear response initially occurs during extreme stress or perhaps as a result of a dangerous situation in the environment (a true alarm). This emotional response then becomes associated with a variety of external and internal cues. In other words, these cues, or conditioned stimuli, provoke the fear response and an assumption of danger, even if the danger is not actually present (Bouton, 2005; Bouton et al., 2001; Mineka & Zinbarg, 2006; Razran, 1961), so it is really a learned or false alarm.

Diagnostic Criteria for Generalized Anxiety Disorder

From the DSM-5: Excessive anxiety and worry occurring more days than not for at least 6 months Difficulty controlling the worry Anxiety and worry associated with other physical symptoms Anxiety causes clinically significant distress or impairment Not due to substance use or medical condition Not better explained by another mental disorder Whereas panic is associated with autonomic arousal, presumably as a result of a sympathetic nervous system surge (for instance, increased heart rate, palpitations, perspiration, and trembling), GAD is characterized by muscle tension, mental agitation (Brown, Marten, & Barlow, 1995), susceptibility to fatigue (probably the result of chronic excessive muscle tension), some irritability, and difficulty sleeping (Campbell-Sills & Brown, 2010). Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months about a number of events or activities (such as work or school performance). The individual finds it difficult to control the worry. The anxiety and worry are associated with at least three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months) [Note: Only one item is required in children]: Restlessness or feeling keyed up or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance (difficulty falling or staying asleep or restless, unsatisfying sleep) The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism). The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder).

Plastic Surgery

Fully 76.4% had sought this type of treatment and 66% were receiving it 8% to 25% of all patients who request plastic surgery may have BDD Plastic surgery does not make BDD go away - it often intensifies it.

Biological Contributions

Increased physiological vulnerability Polygenetic influences Corticotropin releasing factor (CRF) Affects the HPA axis Brain circuits and neurotransmitters GABA Noradrenergic Serotonergic systems CRF is important because it activates the hypothalamic-pituitary-adrenocortical (HPA) axis which impacts anxiety (see chapter 2) Lower levels of GABA are associated with more anxiety "Noradrenergic" and "serotonergic" systems refer to the release of the neurotransmitters norepinephrine (also called noradrenaline) and serotonin. Deficits in norepinephrine and serotonin are linked to greater anxiety Limbic system Behavioral inhibition system (BIS) Received danger signals from: Brain stem Septal-hippocampal system Fight/flight (FFS) system Panic circuit Alarm and escape response Limbic system mediates between the brainstem (lower order structure which senses changes in bodily function and communicates danger signals) to the higher-order more cognitive cortex. BIS is part of the limbic system. It is activated by signals from the brainstem of unexpected events and also signals from the cortex about perceived danger, which travel to the septal-hippocampal system Increasing evidence shows that we inherit a tendency to be tense, uptight, and anxious (Barlow et al., 2014; Clark, 2005; Eysenck, 1967; Gray & McNaughton, 2003). The tendency to panic also seems to run in families and probably has a genetic component that differs somewhat from genetic contributions to anxiety Anxiety is also associated with specific brain circuits (Domschke, & Dannlowski, 2010; Hermans, Henckens, Joels, & Fernandez, 2014; Tovote et al., 2015) and neurotransmitter systems (Durant, Christmas, & Nutt, 2010). For example, depleted levels of gamma-aminobutyric acid (GABA), part of the GABA-benzodiazepine system, are associated with increased anxiety, although the relationship is not quite so direct. The noradrenergicsystem has also been implicated in anxiety (Hermans et al., 2011), and evidence from basic animal studies, as well as studies of normal anxiety in humans, suggests the serotonergic neurotransmitter system is also involved (Canli & Lesch, 2007). But increasing attention in the past several years is focusing on the role of the 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 This is because CRF activates the hypothalamic-pituitary-adrenocortical (HPA) axis, described in Chapter 2, 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. The system that Gray calls the behavioral inhibition system (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 (LeDoux, 1996, 2002, 2015). 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 As is true for other anxiety disorders (such as social anxiety disorder, which we will discuss later), activation of a network that involves the prefrontal cortex and the amygdala while performing certain tasks, can predict response to CBT (Hahn et al., 2015). It is likely that factors in your environment can change the sensitivity of these brain circuits, making you more or less susceptible to developing anxiety and its disorders, a finding that has been demonstrated in several laboratories (Francis, Diorio, Plotsky, & Meaney, 2002; Stein, Schork, & Gelernter, 2007). For example, 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 (Johnson et al., 2000). The current thinking about the link between smoking and anxiety is that anxiety sensitivity (the general tendency to fear bodily sensations, which we will briefly discuss later), distress tolerance (how much distress a person can tolerate), and anhedonia (the inability to feel pleasure) all contribute to smoking, which could be one reason why so many people with anxiety find it very difficult to quit smoking. Brain-imaging procedures are yielding more information about the neurobiology of anxiety and panic (Britton et al, 2013; Shin & Liberzon, 2010).

Causes of SAD

Generalized psychological vulnerability E.g., belief that threatening events are uncontrollable Generalized biological vulnerability E.g., propensity toward anxiety Just like we are "prepared" to fear dangerous animals, we are also "prepared" to fear angry or rejecting people. It's evolutionarily useful to worry about social rejection, because we are more likely to survive if we are socially accepted. Similarly, it seems we are also prepared to fear angry, critical, or rejecting people (Blair et al., 2008; Mineka & Zinbarg, 2006; Mogg, Philippot, & Bradley, 2004). In a series of studies, Öhman and colleagues (see, for example, Dimberg & Öhman, 1983; Öhman & Dimberg, 1978) noted that we learn more quickly to fear angry expressions than other facial expressions, and this fear diminishes more slowly than other types of learning.

Comorbidity of Anxiety and Related Disorders to Anxiety

High rates of comorbidity 55% to 76% Commonalities Features Vulnerabilities Links with physical disorders The high rates of comorbidity among anxiety and related disorders (and depression) emphasize how all of these disorders share the common features of anxiety and panic described here. They also share the same vulnerabilities—biological and psychological—to develop anxiety and panic. f we examine just rates of comorbidity at the time of assessment, the results indicate that 55% of the patients who received a principal diagnosis of an anxiety or depressive disorder had at least one additional anxiety or depressive disorder at the time of the assessment. If we consider whether the patient met criteria for an additional diagnosis at any time in his or her life, rather than just at the time of the assessment, the rate increases to 76%. By far the most common additional diagnosis for all anxiety disorders was major depression, which occurred in 50% of the cases over the course of the patient's life, probably due to the shared vulnerabilities between depression and anxiety disorders in addition to the disorder-specific vulnerability. Also important is the finding that additional diagnoses of depression or alcohol or drug abuse makes it less likely that you will recover from an anxiety disorder and more likely that you will relapse if you do recover (Bruce et al., 2005; Ciraulo et al., 2013 Huppert, 2009). An important study indicated that the presence of any anxiety disorder was uniquely and significantly associated with thyroid disease, respiratory disease, gastrointestinal disease, arthritis, migraine headaches, and allergic conditions (Sareen et al., 2006). Furthermore, the anxiety disorder most often begins before the physical disorder, suggesting (but not proving) that something about having an anxiety disorder might cause, or contribute to the cause of, the physical disorder. Finally, if someone has both an anxiety disorder and one of the physical disorders mentioned earlier, that person will suffer from greater disability and a poorer quality of life from both the physical problem and the anxiety problem than if that individual had just the physical disorder alone Also, DSM-5 now makes it explicit that panic attacks often co-occur with certain medical conditions, particularly cardio, respiratory, gastrointestinal, and vestibular (inner ear) disorders, even though the majority of these patients would not meet criteria for panic disorder (Kessler et al., 2006).

Fear

Immediate, present-oriented Sympathetic nervous system activation Fear, on the other hand, is an immediate emotional reaction to current danger characterized by strong escapist action tendencies and, often, a surge in the sympathetic branch of the autonomic nervous system

Causes

Inherited tendency to become anxious Neuroticism Less responsiveness "Autonomic restrictors" Threat sensitivity Frontal lobe activation Left vs. right Neuroticism = tendency to experience more frequent and more intense negative affect and to react to this affect with avoidant coping Cognitive activity in the left frontal lobe serves to avoid distressing worry images that would otherwise be activated in the right frontal lobe This is reflected in studies examining a genetic contribution to GAD, although Kendler and colleagues (1995; Hettema, Neale, & Kendler, 2001; Hettema, Prescott, Myers, Neale, & Kendler, 2005) confirmed that what seems to be inherited is the tendency to become anxious rather than GAD itself. In support of this finding, heritability has been found for a particular trait, called anxiety sensitivity, which is the tendency to become distressed in response to arousal related sensations, arising from beliefs that these anxiety-related sensations have harmful consequences The first hints of difference were found in the physiological responsivity of individuals with GAD. It is interesting that individuals with GAD do not respond as strongly to stressors as individuals with anxiety disorders in which panic is more prominent. Several studies have found that individuals with GAD show less responsiveness on most physiological measures, such as heart rate, blood pressure, skin conductance, and respiration rate When individuals with GAD are compared with nonanxious "normal" participants, the one physiological measure that consistently distinguishes the anxious group is muscle tension—people with GAD are chronically tense The evidence indicates that individuals with GAD are highly sensitive to threat in general, particularly to a threat that has personal relevance. That is, they allocate their attention more readily to sources of threat than do people who are not anxious ? Tom Borkovec and his colleagues noticed that although the peripheral autonomic arousal of individuals with GAD is restricted, they showed intense cognitive processing in the frontal lobes as indicated by EEG activity, particularly in the left hemisphere. This finding would suggest frantic, intense thought processes or worry without accompanying images (which would be reflected by activity in the right hemisphere of the brain rather than the left) (Borkovec, Alcaine, & Behar, 2004). Borkovec suggests that this kind of worry may be what causes these individuals to be autonomic restrictors (Borkovec, Shadick, & Hopkins, 1991; Roemer & Orsillo, 2013). That is, they are thinking so hard about upcoming problems that they don't have the attentional capacity left for the all-important process of creating images of the potential threat, images that would elicit more substantial negative affect and autonomic activity. In other words, they avoid images associated with the threat Because people with GAD do not seem to engage in this process, they may avoid much of the unpleasantness and pain associated with the negative affect and imagery, but they are never able to work through their problems and arrive at solutions. Therefore, they become chronic worriers, with accompanying autonomic inflexibility and quite severe muscle tension. Thus, intense worrying for an individual with GAD may act as avoidance does for people with phobias.

Tic disorder

Involuntary movements (e.g. sudden jerking of limbs, movement of jaw, etc) Often co-occurs in patients with OCD Sometimes tics are used as compulsive behaviors - performed to relieve anxiety associated with obsessions

Diagnostic Criteria for Specific Phobias

Marked Fear or anxiety about a specific object or situation Phobic object or situation almost always provokes immediate fear or anxiety Phobic object/situation is actively avoided Phobic object/situation out of proportion to actual danger Lasts more than 6 months Clinically significant distress Not better explained by symptoms of another mental disorder Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). The phobic object or situation almost always provokes immediate fear or anxiety. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. The phobic object or situation is actively avoided or endured with intense fear or anxiety. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation, and to the sociocultural context. The fear, anxiety or avoidance is persistent, typically lasting for 6 months or more. The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational or other important areas of functioning. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety and avoidance of: situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder). Specify type: Animal Natural environment (e.g., heights, storms, and water) Blood-injection-injury Situational (e.g., planes, elevators, or enclosed places) Other (e.g., phobic avoidance of situations that may lead to choking, vomiting, or contracting an illness; or in children, avoidance of loud sounds or costumed characters)

Diagnostic Criteria for Agoraphobia

Marked fear/anxiety for two or more: public transportation, open spaces, enclosed spaces, standing in line, being outside the home alone Avoids these situations Situations always provoke fear Anxiety not proportional to real danger Significant distress Anxiety is excessive Not better explained by another mental disorder Marked fear or anxiety about two or more of the following five situations: Public transportation, open spaces, enclosed places, standing in line or being in a crowd, being outside the home alone. The individual fears or avoids these situations due to thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly, fear of incontinence). The agoraphobic situations almost always provoke fear or anxiety. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations, and to the sociocultural context. The fear, anxiety or avoidance is persistent, typically lasting for 6 months or more. The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational or other important areas of functioning. If another medical condition (e.g., inflammatory bowel disease, Parkinson's disease) is present, the fear, anxiety or avoidance is clearly excessive. The fear, anxiety or avoidance is not better explained by the symptoms of another mental disorder, e.g., the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder) and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived deficits or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder).

Panic Treatment

Medications Multiple systems affected by medication serotonergic noradrenergic GABA Benzodiazepines (e.g. Ativan) SSRIs (e.g., Prozac and Paxil) High relapse rates after discontinuation of medication Psychological intervention Exposure-based Reality testing Relaxation and breathing skills Example: Panic control treatment (PCT) Exposure to interoceptive cues Cognitive therapy Relaxation/breathing High degree of efficacy Reality testing = testing patient's hypothesis that they can't handle an anxiety-provoking situation by entering the situation and discovering that it is survivable Combined psychological and drug treatments No better than CBT or drugs alone CBT = better long term A large number of drugs affecting the noradrenergic, serotonergic, or GABA-benzodiazepine neurotransmitter systems, or some combination, seem effective in treating panic disorder, including high-potency benzodiazepines, the newer selective-serotonin reuptake inhibitors (SSRIs) such as Prozac and Paxil, and the closely related serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine (Barlow, 2002; Barlow & Craske, 2013; Pollack, 2005; Pollack & Simon, 2009). There are advantages and disadvantages to each class of drugs. 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 On the other hand, 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. Therefore, they are not recommended as strongly as the SSRIs. Approximately 60% of patients with panic disorder are free of panic as long as they stay on an effective drug (Lecrubier, Bakker,et al., 1997; Pollack & Simon, 2009), but 20% or more stop taking the drug before treatment is done (Otto, Behar, Smits, & Hofmann, 2009), and relapse rates are high (approximately 50%) once the medication is stopped (Hollon et al., 2005). The relapse rate is closer to 90% for those who stop taking benzodiazepines (see, for example, Fyer et al., 1987). The strategy of exposure-based treatments is to arrange conditions in which the patient can gradually face the feared situations and learn there is nothing to fear. Most patients with phobias are well aware of this rationally, but they must be convinced on an emotional level as well by "reality testing" the situation and confirming that nothing dangerous happens. 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. 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. Booster sessions produced significantly lower relapse rates (5.2%) and reduced work and social impairment compared with the assessment-only condition without booster sessions (18.4%) at a 21-month follow-up (see Figure 5.6). Although these treatments are quite effective, they are relatively new and not yet available to many individuals who suffer from panic disorder, because administering them requires therapists to have advanced training (Barlow, Levitt, & Bufka, 1999; McHugh & Barlow, 2010). Because of this, investigators are evaluating new and creative ways to get these programs out to the people who need them. The data indicate that all treatment groups responded significantly better than the placebo group, but approximately the same number of patients responded to both drug and psychological treatments. Combined treatment was no better than individual treatments. After 6 additional months of maintenance treatment (9 months after treatment was initiated), during which patients were seen once per month, the results looked much as they did after initial treatment, except there was a slight advantage for combined treatment at this point and the number of people responding to placebo had diminished. Figure 5.7 shows the last set of results, 6 months after treatment was discontinued (15 months after it was initiated). At this point, patients on medication, whether combined with CBT or not, had deteriorated somewhat, and those receiving CBT without the drug had retained most of their gains. Most studies show that drugs, particularly benzodiazepines, may interfere with the effects of psychological treatments (Craske & Barlow, 2014). Furthermore, benzodiazepines taken over a long period are associated with cognitive impairment Both of the above studies indicate that a "stepped care" approach in which the clinician begins with one treatment and then adds another if needed may be superior to combining treatments from the beginning. General conclusions from these studies suggest no advantage to combining drugs and CBT initially for panic disorder and agoraphobia. Furthermore, the psychological treatments seemed to perform better in the long run (6 months after treatment had stopped).

Treatment of SAD

Medications Beta blockers Benzodiazepines SSRI (Paxil, Zoloft, and Effexor) D-cycloserine Beta blockers are often used by performers (e.g. musicians) to combat stage fright. Benzodiazepines are more commonly prescribed for performance-only social anxiety/ SSRIs are more commonly prescribed for generalized social anxiety. D-cycloserine is an antibiotic originally used to treat tuberculosis. It is a "cognitive enhancer" that improves extinction learning (the learning that occurs when someone is engaged in exposure therapy, learning about their ability to cope with feared situations. Some studies have shown that DCS improves outcomes when given to social anxiety patients doing exposures. Psychological Cognitive-behavioral treatment Challenging of anxious thoughts about the consequences of social judgment Exposure to anxiety-provoking situations Rehearsal Role-play Highly effective Clark and colleagues (2006) evaluated a cognitive therapy program that emphasized real-life experiences during therapy to disprove automatic perceptions of danger. This program substantially benefited 84% of individuals receiving treatment, and these results were maintained at a 1-year follow-up. One important reason why SAD is maintained in the presence of repeated exposure to social cues is because individuals with SAD engage in a variety of avoidance and safety behaviors to reduce the risk of rejection and, more generally, prevent patients from critically evaluating their catastrophic beliefs about how embarrassed and foolish they will look if they attempt to interact with somebody. Social mishap exposures directly target the patients' beliefs by confronting them with the actual consequences of such mishaps, such as what would happen if you spilled something all over yourself while you were talking to somebody for the first time We have adapted these protocols for use with adolescents, directly involving parents in the group treatment process. Results of numerous studies suggest that severely socially anxious adolescents can attain relatively normal functioning in school and other social settings after receiving cognitive behavioral treatment A more recent long-term follow up study indicates that youth who receive a parent component as part of anxiety treatment are significantly more likely to be diagnosis-free three years following treatment (Cobham, Dadds, Spence & McDermott, 2010), and a family-based intervention can even prevent the onset of anxiety disorders in the children of anxious parents (Ginsburg, Drake, Tein, Teetsel, & Riddle, 2015). Once the child develops an anxiety disorder, early treatment with CBT can be successful to treat the symptoms or prevent future problems with anxiety he evidence is mixed on the usefulness of combining SSRIs or related drugs with psychological treatments. Davidson, Foa, and Huppert (2004) found that a cognitive-behavioral treatment and an SSRI were comparable in efficacy but that the combination was no better than the two individual treatments. Several exciting studies suggest that adding the drug D-cycloserine (DCS) to cognitive-behavioral treatments can enhance exposure therapy (Chasson et al., 2010; Wilhelm et al.,2008). Neuroscientists working with rats in the laboratory, such as Michael Davis at Emory University, learned that DCS made extinction work faster and last longer (Walker, Ressler, Lu, & Davis, 2002). Further research indicated that this drug 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 as described in Chapter 2 (Hofmann, 2007a). SSRIs and other antidepressants might even interact with DCS to block its facilitating effect on exposure therapy (Andersson et al., 2015). When used with individuals suffering from SAD (or other anxiety disorders), DCS is given approximately an hour before the extinction or exposure trial, and the individual does not take the drug on an ongoing basis. The people who got the drug improved significantly more during treatment than those who didn't get the drug. This is particularly noteworthy because the feared cues for people with panic disorder are physical sensations, and the drug DCS helped extinguish anxiety triggered by sensations such as increased heart rate or respiration. We (Hofmann and colleagues (2006; 2013) found a similar result with social anxiety disorder. A recent extension of this earlier trial showed that DCS was associated with a 24% to 33% faster rate of improvement in symptom severity and remission rates relative to placebo during a full course, 12-week CBT intervention. At post-treatment, DCS did not improve the response and remission rates of the CBT intervention as compared with placebo, however (Hofmann et al., 2013).

Treatment of OCD

Medications SSRIs 60% benefit High relapse when discontinued Psychosurgery (cingulotomy) 30% benefit Cognitive-behavioral therapy Exposure and ritual prevention (ERP) Highly effective One study found that 86% of patients benefit No added benefit from combined treatment with drugs ERP = exposure to cues that would trigger obsessions, with prevention of compensatory compulsions. Example: Patient with fears about contamination who washes her hands compulsively has to touch every doorknob in her house and then make dinner without washing her hands.

Natural Enviroment Phobia

Natural environment phobia Heights, storms, water May cluster together Associated with real dangers Onset = usually in childhood Sometimes very young people develop fears of situations or events occurring in nature. These fears are called natural environment phobias. The major examples are heights, storms, and water. These fears also seem to cluster together

Neurobiological Model of PTSD

Neurobiological model Threatening cues activate CRF system CRF system activates fear and anxiety areas Amygdala (central nucleus) Increased HPA axis activation Cortisol

Panic attack

Panic attack - abrupt experience of intense fear Physical symptoms: heart palpitations, chest pain, dizziness, sweating, chills or heat sensations, etc. Cognitive symptoms: Fear of losing control, dying, or going crazy Two types Expected Unexpected Panic attacks come on suddenly, they typically reach a peak within 10 minutes, and they are accompanied by uncomfortable physical sensations and catastrophic thoughts. People may also experience "limited symptom episodes," or panic attacks that have only a few symptoms (less than 4 total). Panic attacks are very common. Most people have at least one panic attack in their lives. People with severe anxiety may have multiple panic attacks every day. Unexpected attacks occur out of the blue - they could come up when you're just watching TV at home. Expected attacks may be cued by certain situations (e.g., public speaking), especially in places where a person has had an attack in the past (e.g., while driving in the location of a previous panic attack)

Treatments of GAD

Pharmacological Benzodiazepines Risks versus benefits Antidepressants Benzodiazepines provide fast-acting relief, but there is limited support for long-term use and they lead to minor cognitive and motor impairment. Psychological Similar benefits to drugs and better long-term results Cognitive-behavioral treatments Exposure to worry process Confronting anxiety-provoking images Coping strategies Acceptance Meditation GAD is quite common, and available treatments, both drug and psychological, are reasonably effective. Benzodiazepines are most often prescribed for generalized anxiety, and the evidence indicates that they give some relief, at least in the short term. Few studies have looked at the effects of these drugs for a period longer than 8 weeks (Mathew & Hoffman, 2009). But the therapeutic effect is relatively modest. Furthermore, benzodiazepines carry some risks. First, they seem to impair both cognitive and motor functioning More important, benzodiazepines seem to produce both psychological and physical dependence, making it difficult for people to stop taking them Under these circumstances, a physician may prescribe a benzodiazepine until the crisis is resolved but for no more than a week or two. There is stronger evidence for the usefulness of antidepressants in the treatment of GAD, such as paroxetine (also called Paxil) (Rickels, Rynn, Ivengar, & Duff, 2006) and venlafaxine (also called Effexor) (Schatzberg, 2000). These drugs may prove to be a better choice (Brawman-Mintzer, 2001; Mathew & Hoffman, 2009). Under these circumstances, a physician may prescribe a benzodiazepine until the crisis is resolved but for no more than a week or two. There is stronger evidence for the usefulness of antidepressants in the treatment of GAD, such as paroxetine (also called Paxil) (Rickels, Rynn, Ivengar, & Duff, 2006) and venlafaxine (also called Effexor) (Schatzberg, 2000). These drugs may prove to be a better choice (Brawman-Mintzer, 2001; Mathew & Hoffman, 2009). In the early 1990s, we developed a cognitive-behavioral treatment (CBT) for GAD in which patients evoke the worry process during therapy sessions and confront threatening images and thoughts head-on. The patient learns to use cognitive therapy and other coping techniques to counteract and control the worry process incorporates procedures focusing on acceptance rather than avoidance of distressing thoughts and feelings in addition to cognitive therapy. Meditational and mindfulness-based approaches help teach the patient to be more tolerant of these feelings (Hofmann, Sawyer, Witt, & Oh, 2010; Khoury et al., 2013; Orsillo & Roemer, 2011; Roemer & Orsillo, 2009; Roemer et al., 2002). Results from a clinical trial reported some of the highest success rates yet to appear in the literature (Hayes-Skelton, Roemer, & Orsillo, 2013). Other promising new strategies are to train patients in increasing their tolerance to uncertainty about the future (Dugas, Schwartz, & Francis, 2012) and changing their beliefs about worrying (Wells, Welford, King, Papageorgiou, Wisely, & Mendel, 2010), because oftentimes patients feel a strong need to control the future and hold maladaptive beliefs about worrying, which has been referred to as meta-cognitions (cognitions [beliefs] about cognitions [worrying]).

Diagnostic Criteria of Body Dysmorphic Disorder

Preoccupation with one or more defects or flaws in physical appearance that are small or not observable to others Repetitive behaviors Significant distress Preoccupation with body not better explained

DSM Criteria for OCD

Presence of obsessions, compulsions, or both Obsessions/compulsions are time-consuming Disturbance is not due to substance abuse Disturbance not better explained by another mental health disorder

Diagnostic Criteria for Panic Disorder

Recurrent unexpected panic attaches At least one attach has been followed by significant worry or maladaptive change in behavior Not attributable to substance use Not better explained by another mental disorder Recurrent unexpected panic attacks are present. At least one of the attacks has been followed by 1 month or more of one or both of the following: Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy"), or A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations). The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders). The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder).

Excoriation (Skin Picking Disorder)

Repetitive and compulsive picking of the skin, leading to tissue damage Face is common target for picking

Causes of OCD

Similar generalized biological vulnerability to having anxiety in general Specific psychological vulnerability Early life experiences and learning Thoughts are dangerous/unacceptable Thought-action fusion Distraction temporarily reduces anxiety Increases frequency of thought Thought-action fusion = equating having a thought with the specific outcome/action associated with that thought (e.g., if I imagine my spouse dying, it means he's going to die.)

Situational Phobia

Situational phobia Fear of specific situations E.g., Flying, driving No uncued panic attacks Fear centers around risks of the situation (e.g. Plane crashing), not having a panic attack Onset = early to mid 20s Phobias characterized by fear of public transportation or enclosed places are called situational phobias. Claustrophobia, a fear of small enclosed places, is situational, as is a phobia of flying. The main difference between situational phobia and panic disorder is that people with situational phobia never experience panic attacks outside the context of their phobic object or situation. Therefore, they can relax when they don't have to confront their phobic situation. People with panic disorder, in contrast, might experience unexpected, uncued panic attacks at any time.

Gender, Culture, Panic Disorder and Agoraphobia

Social/gender roles ~75% of those with agoraphobia are female Cultural factors Similar prevalence rates across cultures Variable symptom expression Somatic symptoms more emphasized than emotional symptoms in developing countries Culture-bound syndromes Susto Ataque de nervios Kyol goeu

Statistics OCD

Statistics 1.6% to 2.3%(life); 1% (year) Female = Male Chronic Onset = childhood to 30s

Statistics for Phobias

Statistics 12.5% (life); 8.7% (year) Female : Male = 4:1 Chronic course Onset = Most often childhood Notice also that the sex ratio among common fears is overwhelmingly female with a couple of exceptions. Among these exceptions is fear of heights, for which the sex ratio is approximately equal. Few people who report specific fears qualify as having a phobia, but for approximately 12.5% of the population, their fears become severe enough to earn the label "phobia." During a given 1-year period the prevalence is 8.7% overall (Kessler, Berglund, Demler, et al., 2005), but 15.8% in adolescents (Kessler, Petukhova, et al., 2012). The median age of onset for specific phobia is 7 years of age, the youngest of any anxiety disorder except separation anxiety disorder (Kessler, Berglund, Demler, et al., 2005). Once a phobia develops, it tends to last a lifetime (run a chronic course) ispanics are two times more likely to report specific phobias than white non-Hispanic Americans (Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996), for reasons not entirely clear. A variant of phobia in Chinese cultures is called Pa-leng, sometimes frigo phobia or "fear of the cold." Pa-leng can be understood only in the context of traditional ideas—in this case, the Chinese concepts of yin and yang (Tan, 1980). Chinese medicine holds that there must be a balance of yin and yang forces in the body for health to be maintained. Yin represents the cold, dark, windy, energy-sapping aspects of life; yang refers to the warm, bright, energy-producing aspects of life. Individuals with Pa-leng have a morbid fear of the cold.

Suicide

Suicide attempt rates Similar to major depression 20% of panic patients attempt suicide Increases for all anxiety disorders Comorbidity with depression? Based on epidemiological data, Weissman and colleagues found that 20% of patients with panic disorder had attempted suicide. They concluded that such attempts were associated with panic disorder. They also concluded that the risk of someone with panic disorder attempting suicide is comparable to that for individuals with major depression (Johnson, The Weissman study suggests that having any anxiety or related disorder, not just panic disorder, uniquely increases the chances of having thoughts about suicide (suicidal ideation) or making suicidal attempts (Sareen et al., 2006), Whereas earlier studies have suggested that panic disorder is not associated with suicidal behavior in the absence of other risk factors (e.g., Warshaw, Dolan, & Keller, 2000), a later epidemiological study reported that all anxiety disorders are associated with an increased risk for suicide attempts and suicidal ideations, even after accounting for mood disorders, such as dysthymia, major depressive disorder, and bipolar disorder, as well as substance use disorders

Causes of PTSD

Trauma intensity - PTSD more likely with severe trauma Generalized biological vulnerability Twin studies Reciprocal gene-environment interactions Generalized psychological vulnerability Beliefs about uncontrollability and unpredictability of threatening situations Poor social support = greater risk Twin studies: When both twins are exposed to trauma (like in combat), identical twins have higher concordance rates for PTSD compared to fraternal twins Certain genes are associated with greater likelihood of developing PTSD

Diagnostic Criteria for Panic Attack

The DSM - 5 diagnostic criteria for panic attack — 4 (or more) of the following symptoms occur: 1. Palpitations, pounding heart, or accelerated heart rate 2. Sweating 3. Trembling or shaking 5. Feeling of choking 6. Chest pain or discomfort 7. Nausea or abdominal distress 8. Feeling dizzy, unsteady, light-headed or faint 9. Chills or heat sensations 10. Paresthesias 11. Derealization 12. Fear of losing control or going crazy 13. Fear of dying

Trichotillomania (Hair Pulling Disorder)

The urge to pull out one's own hair from anywhere on the body Leads to noticeable hair loss on scalp, eyebrows, arms, pubic region, etc. Excoriation (skin picking disorder) is characterized by repetitive and compulsive picking of the skin, leading to tissue damage 1 to 5% prevalence rate Behavioral habit reversal treatment is most effective treatment

An Integrated Model of Anxiety

Triple vulnerability Generalized biological vulnerability Diathesis Generalized psychological vulnerability Beliefs/perceptions Specific psychological vulnerability Learning/modeling Putting the factors together in an integrated way, we have described a theory of the development of anxiety called the triple vulnerability theory (Barlow, 2000, 2002; Barlow, Ellard et al., 2014; Brown & Naragon-Gainey, 2013). The first vulnerability (or diathesis) is a generalized biological vulnerability. We can see that a tendency to be uptight or high-strung might be inherited. But a generalized biological vulnerability to develop anxiety is not sufficient to produce anxiety itself. The second vulnerability is a generalized psychological vulnerability. That is, you might also grow up believing the world is dangerous and out of control and you might not be able to cope when things go wrong based on your early experiences. If this perception is strong, you have a generalized psychological vulnerability to anxiety. The third vulnerability is a specific psychological vulnerability in which you learn from early experience, such as being taught by your parents, that some situations or objects are fraught with danger (even if they really aren't).

The Anxiety Disorders

Types of anxiety disorders Generalized Anxiety Disorder Panic Disorder and Agoraphobia Specific Phobias Social Anxiety Disorder Separation Anxiety Disorder Selective Mutism