chapter 5 anxiety disorders

The Limbic System: Hippocampus

Plays a role in recognizing the incoming information without emotion and sends them to the cortex. It also works to transfer short-term memories to long-term memories.

Prevention of Anxiety Disorders

Preventing an anxiety-related disorder involves: Building ability to control situations that might lead to anxiety. Education about dangerous and non-dangerous situations. Changing negative thoughts. Coping better with stress. Practicing skills in real-life situations.

What is worry?

- Worry is a largely cognitive (thinking) concept that refers to concerns about possible future threat. - Worry is not necessarily bad because it can call us to action and/or prepare us for the future. - Occurs in reaction to a potential threat.

What is a panic attack?

"A panic attack involves a period of time, usually several minutes, in which the person experiences intense feelings of fear, apprehension that something terrible will happen, and physical symptoms" (Kearny & Trull, 2018, p. 105).

Specific Phobia

"A specific phobia is an excessive, unreasonable fear of a particular object or situation. . . . People with specific phobias may have expected panic attacks when they encounter a dog, airplane, clown, or whatever they fear" (Kearny and Trull, p. 108).

Panic Disorder with Agoraphobia

"Agoraphobia refers to anxiety about being in places where panic symptoms might occur, especially places where escape might be difficult. . . . also refers to avoiding those places or enduring them with great anxiety or dread" (Kearny & Trull, p. 107).

generalized anxiety disorder

"Generalized anxiety disorder involves extreme levels of worry about various events or activities" (Kearny & Trull, p. 109). They usually have trouble concentrating, sleeping, or resting. Many people who have the disorder report worry as a life-long problem.

obsessive-compulsive disorder (OCD)

"Obsessive-compulsive disorder involves (1) obsessions, or troublesome thoughts, impulses, or images, and/or (2) compulsions, or ritualistic acts done repeatedly to reduce anxiety from the obsessions" (Kearny & Trull, p. 110).

What is fear?

- Fear is an intense emotional state that occurs as a threat is imminent or actually occurring. - It is a specific reaction that is often clear and immediate—fright, increased arousal, and/or need to get away.

Social Anxiety Disorder

- "Social phobia, also called social anxiety disorder, is marked by intense and ongoing fear of potentially embarrassing social or performance situations." (Kearny and Trull, p. 107). -Persons with the disorder may have "expected" panic attacks in these settings or endure them with great dread. -The DSM-5-TR refers to the disorder as Social Anxiety Disorder.

What is anxiety?

- Anxiety is an emotional state that occurs as a threatening event draws near. - Occurs in reaction to an approaching threat.

anxiety disorders

-An anxiety disorder develops when fear and anxiety significantly interfere with the individual's normal life. -Anxiety disorders are the most common mental disorders in the United States. -As many as 19% of the population (23 million people) suffer from one of the six anxiety disorders in any given year. -Children 9 -17 have a 1-year prevalence rate of 13% for all anxiety disorders.

What are the three components of anxiety?

-Physical feelings. -Thoughts. -Behavior

DSM-5-TR Panic Attack Specifier

1. Palpitations, pounding heart, or accelerated heart rate. 2. Sweating. 3. Trembling or shaking. 4. Sensations of shortness of breath or smothering. 5. Feelings 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 (numbness or tingling sensations). 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself). 12. Fear of losing control. 13. Fear of dying.

Acute Stress Disorder[Intrusive Symptoms]

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content. 3. Dissociative reactions (e.g., flashbacks) in which the person feels and acts as though the event(s) were recurring. (Such reactions may occur on a continuum with the most extreme expression being a complete loss of awareness of present surroundings). Note: In children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress or marked physiological reactions in response to external cues that symbolize or resemble an aspect of the traumatic event(s).

Acute Stress Disorder[Arousal Symptoms]

10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep). 11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects. 12. Hypervigilance. 13. Problems with concentration. 14. Exaggerated startle response.

Acute Stress Disorder[Negative Mood Symptoms]

5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

Acute Stress Disorder[Dissociative Symptoms]

6. An altered sense of the reality of one's surroundings or oneself (e.g., seeing one-self from another's perspective, being in a daze, time slowing). 7. Inability to remember an important aspect of the traumatic event(s) typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs.

Acute Stress Disorder[Avoidance Symptoms]

8. Efforts to avoid distressing memories, thoughts or feelings about or closely associated with the traumatic event(s). 9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

The Limbic System: Amygdala

A key player in developing anxiety and works like an early warning system. It registers all emotions, not just negative ones, but it prefers to notice the threatening, scary ones. It is involved in developing cues and triggers to cause anxiety and panic.

DSM-5-TR Diagnostic Criteria for Reactive Attachment Disorder

A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: 1. The child rarely or minimally seeks comfort when distressed. 2. The child rarely or minimally responds to comfort when distressed. B. The persistent social and emotional disturbance characterized by at least two of the following: 1. Minimal social and emotional responsiveness to others. 2. Limited positive affect. 3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during non-threatening interactions with adult caregivers. C. The child has experienced a pattern of extremes of insufficient care as evidence by at least one of the following: 1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. 2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). 3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios). D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (.e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C). E. The criteria are not met for autism spectrum disorder. F. The disturbance is evident before age 5 years. G. The child has a developmental age of at least 9 months. Specify if: Persistent: The disorder has been present for more than 12 months.

DSM-5-TR Diagnostic Criteria for Disinhibited Social Engagement Disorder

A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following: 1. Reduced or absent reticence in approaching and interacting with unfamiliar adults. 2. Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries). 3. Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings. 4. Willingness to go off with an unfamiliar adult with minimal or no hesitation. B. The behaviors in Criterion A are not limited to impulsivity (as in attention-deficit/hyperactivity disorder) but include socially disinhibited behavior. C. The child has experienced a pattern of extremes of insufficient care as evidence by at least one of the following: 1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. 2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). C. Continued: 3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios). D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C). E. The child has a development age of at least 9 months. Specify if: Persistent: The disorder has been present for more than 12 months.

DSM-5-TR Diagnostic Criteria for Selective Mutism

A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations. B. The disturbance interferes with educational or occupational achievement or with social communication. C. The duration of the disturbance is at least 1 month (not limited to the first month of school). D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.

DSM-5-TR Diagnostic Criteria for Separation Anxiety Disorder

A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following: 1. Recurrent excessive distress when anticipating or experiencing separation [Sic]from home or from major attachment figures. 2. Persistent and excessive worry about losing [sic] major attachment figures or about possible harm to them, such as illness, disasters, or death. A. Continued: 3. Persistent and excessive worry about experiencing an untoward event [Sic] (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure. 4. Persistent reluctance or refusal to go out, away from home, [Sic] to school, to work, or elsewhere because of fear of separation. 5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. A. Continued: 6. Persistent and reluctance or refusal to sleep [Sic] away from home or to go to sleep without being near a major attachment figure. 7. Repeated nightmares involving the theme of separation. 8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated. B. The fear, anxiety, or avoidance is persistent, lasting at lease 4 weeks in children and adolescents and typically 6 months or more in adults. C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.

DSM-5-Diagnostic Criteria for Generalized Anxiety Disorder

A. Excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least 6 months, about a number of events or activities (e.g., work, school performance, etc.). B. The individual finds it difficult to control the worry. C. The anxiety and worry are associated with 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. 1. Restlessness or feeling keyed up or on edge. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not attributable to the psychological effects of a substance or another medical condition. F. The disturbance is not better explained by another mental disorder.

DSM-5-TR Diagnostic Symptoms for Posttraumatic Stress Disorder [Adults, Adolescents and Children Older than 6 Years ]

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s) 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. A. Continued: 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [repetitive play in children] Note: In children older than 6 years, repetitive play may occur in which themes of aspects of the traumatic event(s) are expressed. B. Continued: 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content. 3. Dissociative reactions (e.g., flashbacks) in which the person feels and acts as though the event(s) were recurring. Note: In children, trauma-specific reenactment may occur in play. B. Continued: 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble the event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the event(s). C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Avoidance of or efforts to avoid external reminders (people, place,

DSM-5-TR Diagnostic Criteria for Acute Stress Disorder

A. Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. A. Continued: 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse). Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred. C. Duration of the disturbance (symptoms in criterion B) is 3 days to 1 month [Sic] after the traumatic exposure. Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria. D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

DSM-5-TR Diagnostic Symptoms for Posttraumatic Stress Disorder in Children 6 Years and Younger

A. In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers. 3. Learning that the traumatic event(s) occurred to a parent or caregiving figure. B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred. 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment. 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: It may not be possible to ascertain that the frightening content is related to the traumatic event. B. Continued: 3. Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Such trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to reminders of the traumatic event(s). C. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s), or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s): Persistent Avoidance of Stimuli 1. Avoidance of or efforts to avoid activities, places or physical reminders that arouse recollections of the traumatic event(s). 2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s) C. Continued: Negative Alterations in Cognitions 3. Substantially increased frequency of negative emotional

DSM-5-TR Diagnostic Criteria for Excoriation Disorder

A. Recurrent skin picking resulting in skin lesions. B. Repeated attempts to decrease or stop skin picking. C. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

DSM-5-TR Diagnostic Criteria for Specific Phobia

A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animal, receiving an injection, seeing blood). Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. B. The phobic object or situation almost always provokes immediate fear or anxiety. C. The phobic object or situation is actively avoided or endured with intense fear or anxiety. D. The fear of anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: Animal (e.g., spiders, insects, dogs). Natural environment (e.g., heights, storms, water). Blood-injection-injury (e.g., needles, invasive medical procedures).

DSM-5-TR Diagnostic Criteria for Social Anxiety Disorder

A. Marked fear or anxiety about one or more social situations in which the person is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). Note: In children, the anxiety must occur in peer settings and not just during interactions with adults. B. The individual fears he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others). C. The social situations almost always provoke fear/anxiety. Note: in children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. D. The social situations are voided or endured with intense fear/anxiety. E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

DSM-5-TR Diagnostic Criteria for Agoraphobia

A. Marked fear or anxiety about two (or more) of the following five situations: 1. Using public transportation (e.g., automobiles, buses, trains, ships, planes). 2. Being in open spaces (e.g., parking lots, marketplaces, bridges). 3. Being in enclosed places (e.g., shops, theaters cinemas). 4. Standing in line or being in a crowd. 5. Being outside of the home alone. B. The individual fears or avoids these situations because of 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). C. The agoraphobic situations almost always provoke fear or anxiety. D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context. F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. G. The fear, anxiety, or avoidance causes clinically significant distress or impairment. H. If another medical condition (e.g., inflammatory bowel disease, Parkinson's disease) is present, the fear, anxiety, or avoidance is clearly excessive.

DSM-5-TR Diagnostic Criteria for Hoarding Disorder

A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. B. This difficulty is due to a perceived need to save the items and to the distress associated with discarding them. C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the intervention of third parties (e.g., family members, cleaners, authorities). D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). Specify if: With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space.

DSM-5-TR Diagnostic Criteria for Body Dysmorphic Disorder

A. Preoccupation with one or more defects or flaws in physical appearance that are not observable or appear slight to others. B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns. C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case.

DSM-5-TR Diagnostic Criteria for Obsessive-Compulsive Disorder

A. Presence of obsessions, compulsions, or both: Obsessions [Sic] are defined by (1) and (2): 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance as intrusive, and unwanted, and that in most individuals cause marked anxiety or distress. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions [Sic] are defined by (1) and (2) 1. Repetitive behaviors (e.g., hand washing) or mental acts (e.g., repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or presenting some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or they are clearly excessive. B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

DSM-5-TR Diagnostic Criteria for Diagnostic Criteria for Trichotillomania

A. Recurrent pulling out of one's hair, resulting in hair loss. B. Repeated attempts to decrease or stop hair pulling. C. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

DSM 5 TR Diangostic Crtieria for Panic Disorder

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense ear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur (Next Slide). Note: The abrupt surge can occur from a calm state or an anxious state. B. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy."). C. 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). B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy."). 2. 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).

DSM-5-TR Diagnostic Criteria for Prolonged Grief Disorder

A. The death, at least 12 months ago, of a person who was close to the bereaved individual (for children and adolescents, at least 6 months ago). B. Since the death, the development of a persistent grief response characterized by one or both of the following symptoms, which have been present most days to a clinically significant degree. In addition, the symptom(s) has occurred nearly everyday for at least the last month: 1. Intense yearning/longing for the deceased person. 2. Preoccupation with thoughts or memories of the deceased person (in children and adolescents, preoccupation may focus on the circumstances of the death). C. Since the death, at least three of the following symptoms have been present most days to a clinically significant degree. In addition, the symptoms have occurred nearly every day for at least the last month: 1. Identity disruption (e.g., feeling as though part of oneself has died) since the death. 2. Marked sense of disbelief about the death. 3. Avoidance of reminders that the person is dead (in children and adolescents, may be characterized by efforts to avoid reminders). C. Continued: 4. Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death. 5. Difficulty reintegrating into one's relationships and activities after the death (e.g., problems engaging with friends, pursuing interests, or planning for the future). 6. Emotional numbness (absence or marked reduction of emotional experience) as a result of the death. 7. Feeling that life is meaningless as a result of the death. 8. Intense loneliness as a result of the death. D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The duration and severity of the bereavement reaction clearly exceed expected social, cultural, or religious norms for the individual's culture and context.

DSM-5-TR Diagnostic Criteria for Adjustment Disorders

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following: 1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external and the cultural factors that might influence symptom severity and presentation. 2. Significant impairment in social, occupational, or other important areas of functioning. C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder. D. The symptoms do not represent normal bereavement and are not better explained by prolonged grief disorder. E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months. Specify whether: 1. With depressed mood: low mood, tearfulness, or feelings of hopelessness are predominant. 2. With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant. 3. With mixed anxiety and depressed mood: A combination of depression and anxiety is predominant. 4. With disturbance of conduct. 5. With mixed disturbance of emotions and conduct. Specify whether: 1. Acute: This specifier can be used to indicate persistence of symptoms for less than 6 months. 2. Persistent (chronic): This specifier can be used to indicate persistence of symptoms for 6 months or longer. By definition, symptoms cannot persist for more than 6 months after the termination of the stressor or its consequences. The persistent specifier therefore applies when the duration of the disturbance is longer than 6 months in response to a chronic stressor or to a stressor that has enduring consequences.

Specific Phobia [Most Common Forms]

Animal Phobias: (dogs, rodents, etc.). Natural Environment phobias: (heights, water, weather, etc.). Blood-injection-injury phobias: (fears of needles, medical procedures, and harm to self). Situational phobias: (enclosed spaces in airplanes, elevators, etc.). Other phobias: (hundreds of specific phobias).

Biological Treatment of Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders

Antianxiety medication: benzodiazepines (sedating effects), antidepressants (moderate serotonin levels). Medication side effects, relapse rates are high if stop taking medication. Benzodiazepines produce a sedating effect enhancing the GABA system. Please check Table 5.14 (p. 131) of the textbook for a list of common medications for anxiety disorders. Antidepressants target serotonin, which is involved in anxiety disorders. Drug treatment is effective for 60 to 80 percent of people.

Behavioral Inhibition

Approximately 10 to 15 percent of people are born with behavioral inhibition, which comes in the form of irritability, shyness, fearfulness, overcautiousness, physical feelings of anxiety. People with behavioral inhibition withdrawal from unfamiliar or new stimuli. They are often at risk of developing anxiety-related disorders.

Anxiety Sensitivity

Belief that internal sensations are dangerous. Fear of the potential dangerousness of internal sensations.

Learning Experiences for anxiety, OCD, and trauma-related disorders

Classical conditioning: Walking in the park and being bit by a dog. Now fears all dogs. Operant conditioning: Parents may "reinforce" fearful behavior. "Stay away from all strangers; they will hurt you." Information transfer: Vicarious learning via hearing the story of someone else bitten by a dog.

cognitive risk factors for anxiety, OCD, and trauma-related disorders

Cognitive distortions - negative thought patterns. Catastrophizing - assuming terrible but incorrect. consequences will result from an event. Emotional reasoning - assuming one's physical feelings reflect how things truly are. Thought-action fusion - believing that thinking about something, such as hurting a baby, means he or she is a terrible person or that the terrible thing is more likely to happen. Emotional processing - person's ability to think about a past anxiety-provoking event without significant anxiety.

Common Compulsions (OCD)

Compulsions Are: Motor behaviors Mental acts Compulsions Include: Checking Hand washing Ordering Counting Repeating words Seeking reassurance

Genetics Risk factors for Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders

Family and twin studies indicate moderate genetic basis. Genetic contribution is less than other major mental disorders such as schizophrenia. BUT no single gene or set of genes lead to an anxiety-related disorder.

Causes of Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders

Diathesis-stress model: Biological vulnerabilities interact with environment. Psychological vulnerabilities. Direct traumatic experience (ex: dog bite fear of dogs).

The Limbic System: Hypothalamus

Is both a monitor and initiator. Scans inner environment for hormone levels, hunger and thirst, oxygen levels, etc. Sends corticotrophin releasing factor (CRF), a stress hormone, to the pituitary and activates the autonomic nervous system as it calls for norepinephrine.

The Peripheral Nervous System (PNS)

It comprises the somatic and autonomic nervous systems. The latter has three branches: Sympathetic Nervous System. Parasympathetic Nervous System Enteric System (digestion).

Common Obsession (OCD)

Obsessions Occur: - Spontaneously - Frequently - Intrusively Uncontrollably Common Obsessions: -Doubt -Need for order -Aggressive impulses -Sexual imagery

Family Factors for anxiety, OCD, and trauma-related disorders

Parents of anxious children may be overcontrolling, affectionless, overprotective, rejecting, demanding. Maltreatment. Modeling: Do you think the child below will "model" his behavior after the policeman?

Psychological Treatment of Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders

Psychological treatments address physical feelings, thoughts, and behaviors. Psychoeducation: educate the individual about the three components of anxiety, their symptoms, and how physical feelings, thoughts, and behaviors influence one another. Relaxation training: taught to tense and release different muscle groups to diffuse tension. Often known as progressive muscle relaxation. Cognitive Therapy: change negative thought patterns by examining the evidence, hypothesis testing, decatastrophizing. A,B,C,D,E Model: A = Activating Event. B = Belief (e.g., negative thinking). C = Consequence (emotional reaction). D = Dispute and change irrational thinking. E = New, more positive Emotions. Example of A,B,C,D,E: Activating Event = I need to fly home for my sister's wedding. Belief = The plane will crash, and I am going to die. Consequence = I'm anxious and about to have a panic attack. Dispute = According to statistics I have a 1 in 205,552 chance of arriving safely as compared to auto, which is 1 in 102. New Positive Emotion = much more relaxed. Breathing Retraining: teaches the individual to breath long, deep breaths during times of anxiety. Flooding involves exposing a person to fear with little preparation. It is usually fast-paced and intense. Flooding - exposure is fast-paced and intense. Exposure-Based Practices: - Systematic desensitization - Eye movement desensitization and reprocessing - Virtual reality therapy - Flooding - Interoceptive exposure - Response prevention - Worry exposure Mindfulness: increase awareness of symptoms so people can understand and accept them and still live a normal life.

Neurochemical Features For Anxiety Disorders

Serotonin: especially panic, obsessive-compulsive, and generalized anxiety disorders. - It is needed to regulate mood, so you are not too negative. Glutamate: the brain's "go" signal. - When it is excessive or not well controlled by GABA, you may experience mental agitation. Norepinephrine: panic, phobic, and posttraumatic stress disorders. -It is the "energizer bunny." - Too much = "uptight," "wired," or tense. GABA: Every "go" signal needs a "stop" signal. GABA is the stop signal. - If GABA is not slowing things down effectively or if GABA and glutamate are not in balance with one another and glutamate is too high, you may feel agitated, which is a setup for anxiety. Neuropeptide Y (NPY) and Galanin create a fat buildup as a reaction to chronic stress. - They are important buffers against stress hormones and norepinephrine. Both are involved in stimulating BDNF and appetite. Brain-derived Neurotophic Factor (BDNF) is produced in the brain and is necessary to stimulate the growth of new neurons, which is important in changing fear memories. Nitric Oxide (NO) is produced in the linings of blood vessels and functions as a vasodilator (widening of the vessels), allowing for lowered blood pressure and relaxation. It also helps to improve connectivity between neurons. Dopamine when released in the reward pathway it will send the message "mm-mmm good." - It helps you pay attention but may cause anxiety by forcing you to concentrate on what is negative or frightening in a specific situation and increase the probability you will remember those sources of fear.

Stigma: A Major Issue with Any Psychological Disorder

Stigma in mental health is a major problem. The following information from the National Alliance on Mental Illness (NAMI) might be helpful. They list nine ways to fight stigma in mental illness. https://www.nami.org/blogs/nami-blog/october-2017/9-ways-to-fight-mental-health-stigma

Prefrontal Cortex

The "CEO" where all information is ultimately received, analyzed, and responded to. The "buck stops here." When the PFC gets good data from the rest of the brain, it has what it needs to analyze whether a situation is actually threatening or not. It also decides whether data should be put into long-term memory. It creates new solutions to problems and plans how to carry them out.

Cultural Factors for anxiety, OCD, and trauma-related disorders

Where you live, what you experience. PTSD and anxiety-related disorders linked to mass trauma, exposure to terrorism, war zones, genocides. Different cultures, different symptoms.

Parts of the CNS Connected to Generating Anxiety

The Limbic System [the center of emotion and memory.] The Basal Ganglia [which together coordinate motivation and movement.] The Anterior Cingulate Cortex [Passes information between thinking and emotion.] The Insula [where bodily sensations are coordinated and interpreted.] The Cortex [which is responsible for language, thinking, and decision making—essentially all the conscious aspects of your brain.] NOTE: Much of the material in the remaining slides come from Margaret Wehrenberg's book (2018), The 10 Best-Ever Anxiety Management Techniques (Second Edition).

Parasympathetic Nervous System (PSNS)

The PSNS restores homeostasis after fight, flight, or freeze. It kicks in to calm down action in the body and takes over when you need to rest and relax. When you have an anxiety disorder, you overperceive threat or react too strongly. When that happens, you can stimulate the vagus nerve intentionally to initial PSNS via diaphragmatic breathing, and other calming techniques.

Sympathetic Nervous System (SNS)

The SNS turns on the "fight, flight, or freeze" system. It is this system that turns on when someone experiences a panic attack.

The Basal Ganglia

The basal ganglia are involved in the level of general arousal and energy you typically feel. One part, the nucleus accumbens, is specialized to interpret pleasure when it receives messages from dopamine. It is involved in forming habits to which you don't pay attention (e.g., tying your shoes).

Anterior Cingulate Cortex

The filter and amplifier of information. It works like a "gear shift," switching between emotion and thought. When the ACC does not have good balance, it can get stuck on negative feelings.

The Limbic System: Thalamus

The great relay station that takes in information from the world and passes it to other parts of the limbic system and the cortex.

Orbitofrontal Cortex

The place where working memory is held. Helps organize information from all the other parts of the brain and pass it along to the frontal cortex for analysis and decision-making. When the OFC is working properly you have good impulse control—you don't act on "half-baked" ideas.

The Stress Response System

The stress response system is known as the hypothalamus-pituitary-adrenal (HPA) axis. The hypothalamus activates the HPA system via norepinephrine, which in turn tells the pituitary to "contact" the adrenal glands to release adrenaline and cortisol in the blood stream boosting energy.

Evolutionary Influences

We may be biologically "prepared" to fear certain stimuli (e.g., snakes, heights, etc.). Social anxiety may help preserve social order lending itself to conformity. Fainting after a skin injury (needle injection) may be an adaptive response to an inescapable threat.

Insula

Where physical sensations are formed into a context so they can be interpreted by the prefrontal cortex. It gathers data on the way your body is feeling, noting all the sensations and forming an interpretation of this somatic experience.