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Abrupt and Aversive CNS Response
to Real Threat or Danger
Prepares Organisms for Immediate
Action
Action Tendency “Fight” or “Flight”
More Diffuse Response About
Impending Real or Imagined
“Future” Threat or Danger
Real Threat
True Alarm
Adaptive
Maladaptive
False Alarm
No Threat
Panic Disorder
PD With Agoraphobia
Agoraphobia
Specific Phobias
Social Phobia (social anxiety disorder)
Generalized Anxiety Disorder
Post-Traumatic Stress Disorder
Obsessive Compulsive Disorder
Clinical Description
An Unexpected Panic Attack
Develop Anxiety Over
the Next Attack
or
The Implications of the Attack
and Consequences
Symptoms of a Panic Attack
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The Panic Attack
Abrupt Autonomic Surge
Unexpected
Uncontrollable
Absence of Threat
“False Alarm”
10 Minutes
Clinical Description
Agoraphobic Avoidance is Common
Fear of the Marketplace
Is Consequence of Severe Unexpected
Panic Attacks
Can Have a Life of its Own
Facts and Statistics
Occurs in 2.7% of Population; 4.7 lifetime
Most with PD+Ag, 75%, are Women
Onset Between (25-29 yrs)
Attacks Often Begin at Puberty
20% Attempt ____________
Average 37 Medical Visits / Year
Cultural Influences
Occurs Worldwide
Prevalence in U.S. is Similar Across
Ethnic Groups
Nocturnal Panic Attacks
_____% Cases Panic While Asleep!
Usually Between 1:30 - 3:30am
Occur During Deep Sleep “Delta”
Do Not Occur During REM Sleep
Causes
Biological Vulnerability
STRESS
False Alarm
Bodily Cues
Learned Alarm
Involuntary Symptoms
Psychological Vulnerability
Biological Causes
Runs in Families
GABA-BZ Circuit
Limbic System
ANXIETY
Behavioral Inhibition System (BIS)
FEAR / PANIC
Fight / Flight System (FF)
Psychological Causes
Predictable
Uncontrollable
Controllable
Unpredictable
Pharmacologic Treatments
Block Panic
Antidepressants (e.g., Imipramine,
Paxil, Prozac)
20-50% Relapse
Benzodiazapines (e.g., Xanax)
90% Relapse
Psychological Interventions
Cognitive-Behavior Therapies
Brief and Time Limited (12 Sessions)
Graded Exposure + Coping Skills
Panic Control Treatment (PCT)
80-100% Panic Free After Treatment
Combined Treatment
THE RESULT
Multisite Study
Imipramine (TCA)
Alone
PCT Alone
Imipramine + PCT
Placebo Alone
Placebo + PCT
Combined Tx
is Better in
Short
Term
PCT Alone is
Better in
Long Term
Specific Phobias
“ ...aren’t just extreme fear; they are
irrational fear. You may be able to ski the
world’s tallest mountain with ease but feel
panic going above the 10th floor of an
office building.”
Clinical Description
Irrational Fear of Specific Objects
or Situations
Markedly Interferes With
Functioning
Four Major Subtypes
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Blood-Injection Injury Type
Unusual Reaction
Drop in Blood Pressure
Fainting
Runs in Families
Onset Early Childhood
Situational Type
Fears of Specific Situations
Planes, Transportation, Enclosed
Spaces (claustrophobia)
Response Similar to Panic
Onset Early 20’s
Animal Type
Fears of Animals and Insects
Common in Population, but
Different From Normal Revulsion
Early Onset (About 7 yrs of Age)
Natural Environment Type
Fears of Natural Events
Storms, Deep Water, High Places
Usually More Than One Fear
Peak Onset (About 7 yrs of Age)
Other Type(s)
Fear of Contracting Disease/ Illness
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Fear of Choking
e.g. ___________________
Separation Anxiety Disorder
Facts and Statistics
Occurs in 8.7% of Population
Top Fears: Heights and Snakes
Females > Males (4:1 Ratio)
Runs a Chronic Course
Many Do Not Seek Treatment:
WHY?
Exposure and More Exposure
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Blood-Injury /Injection Differs:
During Exposure, Muscle Tension
Exercises Needed to Offset Fainting
Response
“ People with social phobia aren’t
necessarily shy at all. They can be
completely at ease with people most of
the time, but in particular situations,
they feel intense anxiety.”
Clinical Description
Marked and Persistent Fear of One
or More...
Social or Performance Situations
Most Common Type of Social Fear?
Public Speaking
Interferes With Life Functioning
Causes
Similar to Panic and Specific Phobia
Interaction of
Biological Vulnerability
Psychological Vulnerability
Learning Experiences
Can be Quite Disabling
Psychological Interventions
Similar to Panic and Specific Phobia
Cognitive-Behavioral Approaches
Rehearsal and Skills Training
Cognitive Restructuring
Drug Treatments
Antidepressants SSRIs are now drug of choice
- “Do you suffer from social anxiety disorder?”
commercial that implies it is a medical disease which
should be treated by the gatekeepers of meds
Clinical Description
Worry About Everything
Worrying is Unproductive
Cannot Stop Worrying -Mental
Agitation
Interferes With Life Functioning
Must Last for at Least 6 Months
Facts and Statistics
Occurs in 3.1% of Population;
5.7% lifetime
50-65% are Female
Early Gradual (“insidious”) Onset
Runs a Chronic Course
Causes
Unclear and Puzzling?
Tend to show
Autonomic Restriction
Heightened Muscle Tension
High Sensitivity to Threat in General
Threat Sensitivity is Automatic
Avoid Negative Affect Related to Threat
Biological Vulnerability
STRESS
Psychological Vulnerability
(Anxious Apprehension)
Worry Process
Imagery Avoidance
Intense
Cognitive Processing
Restricted
Autonomic Response
Most Interventions are Still Weak
Benzodiazepines
Frequently Prescribed
Provide Some Relief
Cognitive-Behavioral Approaches
Process Avoided Emotional Material
& Relaxation Training Does as Well as Medication
Clinical Description
Culmination of All Anxiety Disorders
Obsessions: Intrusive Thoughts, Images,
or Urges That the Person Tries to
Suppress or Eliminate
Compulsions: Thoughts or Actions to
Suppress the Obsessions and Provide
Relief
Facts and Statistics
Occurs in 1% of Population; about 2%
lifetime
Most Common Obsessions
Contamination & Aggression
Most Common Compulsions
Checking & Washing
Almost Equal Sex Ratio (F > M)
Onset Early Adolescence to Mid-20s
Causes
•
Anxiety Focused on Unwanted and
Unacceptable Thoughts
Pink Elephants and Green Pigs
When Fighting to Control One’s
Thoughts it May Create More Distress
• Hay wire in the hard wired cortex?
Psychological Interventions
Cognitive-Behavioral Treatments:
Response Prevention
Rituals are Actively Prevented
Exposure
Systematic and Gradual Exposure to Feared
Thoughts or Situations
May Require Hospitalization
Drug Therapies
Medications Show Promise
Most Effective Medications
Inhibit Reuptake of Serotonin
(SSRIs -e.g., Prozac)
Meds May Benefit 60% of Patients