Anxiety Disorders Lesson 18 PDF

**[Lesson 18]** **[Anxiety Disorders II]** **[Topic 89-95]** **[Topic 89: Panic Disorder]** **Panic disorder is characterized by frequent panic attacks that are unrelated to specific situations and by worry about having more panic attacks. A panic attack is a sudden attack of intense apprehensio...

**[Lesson 18]** **[Anxiety Disorders II]** **[Topic 89-95]** **[Topic 89: Panic Disorder]** **Panic disorder is characterized by frequent panic attacks that are unrelated to specific situations and by worry about having more panic attacks. A panic attack is a sudden attack of intense apprehension, terror, and feelings of impending doom, accompanied by at least four other symptoms. Physical symptoms can include labored breathing, heart palpitations, nausea, upset stomach, chest pain, feelings of choking and smothering, dizziness, lightheadedness, sweating, chills, heat sensations, and trembling. Other symptoms that may occur during a panic attack include depersonalization, a feeling of being outside one's body; de-realization, a feeling of the world's not being real; and fears of losing control, of going crazy, or even of dying. Not surprisingly, people often report that they have an intense urge to flee whatever situation they are in when a panic attack occurs. The symptoms tend to come on very rapidly and reach a peak of intensity within 10 minutes.** **Panic attacks that occur unexpectedly are called uncued attacks. Panic attacks that are clearly triggered by specific situations, such as seeing a snake, are referred to as cued panic attacks.** **Diagnostic Criteria:** **A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur;** **Note: The abrupt surge can occur from a calm state or an anxious state.** 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 or "going crazy."** 13. **Fear of dying.** **Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.** **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).** **C. 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).** **D. 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: in response to circumscribed phobic objects or situations, as in specific phobia: in response to obsessions, as in obsessive-compulsive disorder: in response to reminders of traumatic events, as in posttraumatic stress disorder: or in response to separation from attachment figures, as in separation anxiety disorder).** **[Topic 90: Generalized Anxiety Disorder]** **The central feature of generalized anxiety disorder (GAD) is worry. People with GAD are persistently worried, often about minor things. The term worry refers to the cognitive tendency to chew on a problem and to be unable to let go of it. Often, worry continues because a person cannot settle on a solution to the problem. Most of us worry from time to time, but the worries of people with GAD are excessive, uncontrollable, and long-lasting.** **GAD is not diagnosed if a person worries only about concerns driven by another psychological disorder; for example, a person with claustrophobia who only worries about being in closed spaces would not meet the criteria for GAD. The worries of people with GAD are similar in focus to those of most people: they worry about relationships, health, finances, and daily hassles, but they worry more about these issues, and these persistent worries interfere with daily life. Other symptoms of GAD include difficulty concentrating, tiring easily, restlessness, irritability, and muscle tension.** **Diagnostic Criteria:** **A. 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).** **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 having been 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 physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).** **F. 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 \[social phobia\], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).** **[Topic 91: Substance/Medication-Induced Anxiety Disorder]** **Substance or medication-induced anxiety disorder is the diagnostic name for severe anxiety or panic which is caused by taking or stopping any drug.** **Diagnostic Criteria:** **A. Panic attacks or anxiety is predominant in the clinical picture.** **B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):** 1. **The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication.** 2. **The involved substance/medication is capable of producing the symptoms in Criterion A.** **C. The disturbance is not better explained by an anxiety disorder that is not substance/ medication-induced. Such evidence of an independent anxiety disorder could include the following:** - **The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication: or there is other evidence suggesting the existence of an independent non-substance/medication-induced anxiety disorder (e.g., a history of recurrent non substance/medication-related episodes).** **D. The disturbance does not occur exclusively during the course of a delirium.** **E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.** **[Topic 92: Anxiety Disorder Due to another Medical Condition]** **Anxiety disorder due to a medical condition includes symptoms of intense anxiety or panic that are directly caused by a physical health problem. When a person suffers from anxiety disorder due to another medical condition, the presence of that medical condition leads directly to the anxiety experienced.** **Diagnostic Criteria:** **A. Panic attacks or anxiety is predominant in the clinical picture.** **B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.** **C. The disturbance is not better explained by another mental disorder.** **D. The disturbance does not occur exclusively during the course of a delirium.** **E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.** **[Topic 93: Etiology of Anxiety Disorders]** **Separation Anxiety Disorder:** **Genetics plays a role in anxiety among children, however, genes do their work via the environment, with genetics playing a stronger role in separation anxiety in the context of more negative life events experienced by a child for example loss of a significant other or a primary care giver.** **Parenting practices play a role in childhood anxiety. Specifically, parental control and overprotectiveness, more than parental rejection, is associated with childhood anxiety. Other psychological factors that predict anxiety symptoms among children and adolescents include emotion-regulation problems and insecure attachment in infancy.** **Etiology of Selective Mutism:** **If an individual has traits of Negative affectivity (neuroticism) or behavioral inhibition, it may lead to selective mutism. Parental history of shyness, social isolation, and social anxiety also leads to this problem. Parental overprotection, as discussed earlier, also plays a role in developing this problem.** **Etiology of Specific Phobia:** **In the behavioral model, phobias are seen as a conditioned response that develops after a threatening experience (classical conditioning) and is sustained by avoidant behavior (Operant conditioning). Behavioral theory suggests that phobias could be conditioned by direct trauma, modeling, or verbal instruction.** **[Topic 94: Etiology of Social Anxiety Disorder]** **Behavioral Factors: Conditioning of Social Anxiety Disorder Behavioral perspectives on the causes of social anxiety disorder are similar to those on specific phobias, insofar as they are based on a two-factor conditioning model. That is, a person could have a negative social experience (directly, through modeling, or through verbal instruction) and become classically conditioned to fear similar situations, which the person then avoids. Through operant conditioning, this avoidance behavior is maintained because it reduces the fear the person experiences.** **Cognitive Perspective:** **The theory focuses on several different ways in which cognitive processes might intensify social anxiety. First, people with social anxiety disorders appear to have unrealistically negative beliefs about the consequences of their social behaviors, for example, they may believe that others will reject them if they blush or pause while speaking. Second, they attend more to how they are doing in social situations and their own internal sensations than other people do. Instead of attending to their conversation partner, they are often thinking about how others might perceive them (e.g., "He must think I'm an idiot"). They often form powerful negative visual images of how others will react to them. The resultant anxiety interferes with their ability to perform well socially, creating a vicious circle, for example, the socially anxious person doesn't pay enough** **attention to others, who then perceive the person as not interested in them. Such people set unrealistically high social standards and view themselves as unattractive and socially unskilled.** **Such people anticipate that social disasters will occur so they perform "avoidance" and "safety" behaviors. After a social event, they review the details and overestimate how poorly things went or what negative results will occur.** **[Topic 95: Etiology of Panic Disorder]** **Biological Perspective:** **A panic attack seems to reflect a misfire of the fear circuit, with a concomitant surge in activity in the sympathetic nervous system. The fear circuit appears to play an important role in many of the anxiety disorders. The locus ceruleus is the major source of the neurotransmitter norepinephrine in the brain, and norepinephrine plays a major role in triggering sympathetic nervous system activity. Changes in level of norepinephrine are associated with panic attacks. Amygdala is associated with panic attacks also.** **Researches prove that genetic and chromosomal factors also play a role in panic attacks. It has been seen that close relatives have higher rates of panic disorder than more distant.** **Cognitive Factor:** **Cognitive perspectives focus on catastrophic misinterpretations of somatic changes. According to cording to this model, panic attacks develop when a person interprets bodily sensations as signs of impending doom. For example, the person may interpret the sensation of an increase in heart rate as a sign of an impending heart attack. Obviously, such thoughts will increase the person's anxiety, which produces more physical sensations, creating a vicious circle. This proneness is due to reason that they experienced more traumatic events over the course of their lives.** **Etiology of Generalized Anxiety Disorder:** **Psychodynamic Perspective:** **According to Freud, early developmental experiences may produce an unusually high level of anxiety in certain children. Say that a boy is spanked every time he cries for milk as an infant,** **messes his pants as a 2-year-old, and explores his genitals as a toddler. He may eventually come to believe that his various id impulses are very dangerous, and he may feel overwhelming anxiety whenever he has such impulses, setting the stage for generalized anxiety disorder.** **Alternatively, a child's ego defense mechanisms may be too weak to cope with even normal levels of anxiety. Overprotected children, shielded by their parents from all frustrations and threats, have little opportunity to develop effective defense mechanisms. When they face the pressures of adult life, their defense mechanisms may be too weak to cope with the resulting anxieties. Adults, who as children suffered extreme punishment for expressing id impulses, have higher levels of anxiety later in life.** **Cognitive Perspective:** **According to cognitive perspective, psychological disorders are often caused by dysfunctional ways of thinking. When people who make these assumptions are faced with a stressful event, such as an exam or a first date, they are likely to interpret it as dangerous, to overreact, and to feel fear. As they apply the assumptions to more and more events, they may begin to develop generalized anxiety disorder.**