ANXIETYANXIETY
DISORDERSDISORDERS
 women affected nearly twice as frequently aswomen affected nearly twice as frequently as
menmen
 Normal Anxiety -Normal...
Fear versus AnxietyFear versus Anxiety
 Fear is a response to a known, external,Fear is a response to a known, external,
...
Peripheral Manifestations of AnxietyPeripheral Manifestations of Anxiety
 DiarrheaDiarrhea
 Dizziness, light-Dizziness, ...
Pathological AnxietyPathological Anxiety
 Women - 30.5 percent lifetime prevalenceWomen - 30.5 percent lifetime prevalenc...
Psychoanalytic Theories :Psychoanalytic Theories :
Anxiety was viewed as the result of psychicAnxiety was viewed as the re...
Behavioral TheoriesBehavioral Theories ::
- anxiety is a conditioned response to aanxiety is a conditioned response to a
s...
Existential Theories :Existential Theories :
-- persons experience feelings of living in apersons experience feelings of l...
Contributions of Biological SciencesContributions of Biological Sciences
 The autonomic nervous systems - exhibitThe auto...
 Hypothalamic levels of CRH are increased byHypothalamic levels of CRH are increased by
stress, resulting in activation o...
 Heredity has been recognized as aHeredity has been recognized as a
predisposing factor in the development ofpredisposing...
•panic disorder with or withoutpanic disorder with or without
agoraphobia;agoraphobia;
•specific phobia;specific phobia;
•...
 panic disorder -panic disorder - acute intense attack of anxietyacute intense attack of anxiety
accompanied by feelings ...
 lifetime prevalence of panic disorder is in the 1 to 4lifetime prevalence of panic disorder is in the 1 to 4
percent ran...
 the mean age of presentation is about 25 years oldthe mean age of presentation is about 25 years old
 lifetime prevalen...
 Of persons with panic disorderOf persons with panic disorder::
 15 to 30 %- social phobia15 to 30 %- social phobia
 2 ...
 Serotonergic dysfunction is quite evident in panicSerotonergic dysfunction is quite evident in panic
disorder ;disorder ...
 panicogenspanicogens
 respiratory - carbon dioxide (5 to 35 percent mixtures),respiratory - carbon dioxide (5 to 35 per...
 first-degree relatives of patients with panic disorderfirst-degree relatives of patients with panic disorder
have a four...
 Behavioral theories posit that anxiety is a responseBehavioral theories posit that anxiety is a response
learned either ...
Psychodynamic Themes in Panic DisorderPsychodynamic Themes in Panic Disorder
 Difficulty tolerating angerDifficulty toler...
Panic AttackPanic Attack ((4 or more developed abruptly reaching a peak4 or more developed abruptly reaching a peak
within...
DSM-IV-TR Diagnostic Criteria forDSM-IV-TR Diagnostic Criteria for
Panic Disorder with AgoraphobiaPanic Disorder with Agor...
B.B. The presence of agoraphobiaThe presence of agoraphobia
C.C. The panic attacks are not due to the direct physiological...
Specific Phobia and Social PhobiaSpecific Phobia and Social Phobia
 phobia refers to an excessive fear of a specific obje...
 Specific phobia is more common than social phobiaSpecific phobia is more common than social phobia
 Specific phobia is ...
 comorbidity in specific phobia range from 50 – 80%comorbidity in specific phobia range from 50 – 80%
 Common: anxiety, ...
Psychodynamic Themes in PhobiasPsychodynamic Themes in Phobias
 Principal defense mechanisms include displacement,Princip...
 Acrophobia - fear of heightsAcrophobia - fear of heights
 Agoraphobia - fear of open placesAgoraphobia - fear of open p...
DSM-IV-TR Diagnostic Criteria forDSM-IV-TR Diagnostic Criteria for
Specific PhobiaSpecific Phobia
A.A. Marked and persiste...
D.D. The phobic situation(s) is avoided or else is endured withThe phobic situation(s) is avoided or else is endured with
...
G.G. The anxiety, panic attacks, or phobic avoidance associatedThe anxiety, panic attacks, or phobic avoidance associated
...
DSM-IV-TR Diagnostic Criteria forDSM-IV-TR Diagnostic Criteria for
Social PhobiaSocial Phobia
A.A. A marked and persistent...
C.C. The person recognizes that the fear is excessive orThe person recognizes that the fear is excessive or
unreasonable.u...
F.F. In individuals under age 18 years, the duration is at least 6In individuals under age 18 years, the duration is at le...
Obsessive-Compulsive DisorderObsessive-Compulsive Disorder
 Obsession - is a recurrent and intrusive thought,Obsession - ...
 Lifetime prevalence in the general populationLifetime prevalence in the general population
estimated at 2 to 3 percentes...
 mean age of onset is about 20 yearsmean age of onset is about 20 years
 ComorbidityComorbidity
major depressive disord...
DSM-IV-TR Diagnostic Criteria forDSM-IV-TR Diagnostic Criteria for
Obsessive-Compulsive DisorderObsessive-Compulsive Disor...
Compulsions as defined by (1) and (2):Compulsions as defined by (1) and (2):
1.1. repetitive behaviors (e.g., hand washing...
C.C. The obsessions or compulsions cause marked distress, areThe obsessions or compulsions cause marked distress, are
time...
 most common pattern is an obsession ofmost common pattern is an obsession of
contamination, followed by washing or accom...
Generalized Anxiety DisorderGeneralized Anxiety Disorder
 1-year prevalence range from 3 to 8 percent.1-year prevalence r...
DSM-IV-TR Diagnostic Criteria forDSM-IV-TR Diagnostic Criteria for
Generalized Anxiety DisorderGeneralized Anxiety Disorde...
D.D. The focus of the anxiety and worry is not confined to featuresThe focus of the anxiety and worry is not confined to f...
TREATMENTTREATMENT
 Alprazolam (Xanax) and paroxetine (Paxil) -Alprazolam (Xanax) and paroxetine (Paxil) -
approved by th...
 Once it becomes effective, pharmacological treatmentOnce it becomes effective, pharmacological treatment
should generall...
 Venlafaxine is approved by the FDA for treatment ofVenlafaxine is approved by the FDA for treatment of
generalized anxie...
 Buspirone,a 5-HT1A receptor partial agonist, is mostBuspirone,a 5-HT1A receptor partial agonist, is most
likely effectiv...
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Anxiety disorders, Psych II

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Anxiety disorders, Psych II

  1. 1. ANXIETYANXIETY DISORDERSDISORDERS
  2. 2.  women affected nearly twice as frequently aswomen affected nearly twice as frequently as menmen  Normal Anxiety -Normal Anxiety - diffuse, unpleasant, vague sensediffuse, unpleasant, vague sense of apprehension, often accompanied by autonomicof apprehension, often accompanied by autonomic symptomssymptoms  alerting signal; it warns of impending dangeralerting signal; it warns of impending danger and enables a person to take measures toand enables a person to take measures to deal with a threatdeal with a threat  anxiety prevents damage by alerting theanxiety prevents damage by alerting the person to carry out certain acts that forestallperson to carry out certain acts that forestall the dangerthe danger
  3. 3. Fear versus AnxietyFear versus Anxiety  Fear is a response to a known, external,Fear is a response to a known, external, definite, or nonconflictual threat; anxiety is adefinite, or nonconflictual threat; anxiety is a response to a threat that is unknown,response to a threat that is unknown, internal, vague, or conflictual.internal, vague, or conflictual.  Fear is sudden; anxiety is insidious;Fear is sudden; anxiety is insidious;
  4. 4. Peripheral Manifestations of AnxietyPeripheral Manifestations of Anxiety  DiarrheaDiarrhea  Dizziness, light-Dizziness, light- headednessheadedness  HyperhidrosisHyperhidrosis  HyperreflexiaHyperreflexia  HypertensionHypertension  PalpitationsPalpitations  Pupillary mydriasisPupillary mydriasis  Restlessness (e.g.,Restlessness (e.g., pacing)pacing)  SyncopeSyncope  TachycardiaTachycardia  Tingling in the extremitiesTingling in the extremities  TremorsTremors  Upset stomachUpset stomach (butterflies)(butterflies)  Urinary frequency,Urinary frequency, hesitancy, urgencyhesitancy, urgency
  5. 5. Pathological AnxietyPathological Anxiety  Women - 30.5 percent lifetime prevalenceWomen - 30.5 percent lifetime prevalence  men - 19.2 percent lifetime prevalencemen - 19.2 percent lifetime prevalence  Three major schools of psychological theory:Three major schools of psychological theory: psychoanalytic, behavioral, and existentialpsychoanalytic, behavioral, and existential
  6. 6. Psychoanalytic Theories :Psychoanalytic Theories : Anxiety was viewed as the result of psychicAnxiety was viewed as the result of psychic conflict between unconscious sexual orconflict between unconscious sexual or aggressive wishes and corresponding threatsaggressive wishes and corresponding threats from the superego or external reality.from the superego or external reality. - the goal of therapy is to increase anxiety- the goal of therapy is to increase anxiety tolerance,tolerance,
  7. 7. Behavioral TheoriesBehavioral Theories :: - anxiety is a conditioned response to aanxiety is a conditioned response to a specific environmental stimulus.specific environmental stimulus. - In the social learning model, a child mayIn the social learning model, a child may develop an anxiety response by imitating thedevelop an anxiety response by imitating the anxiety in the environment, such as inanxiety in the environment, such as in anxious parentsanxious parents
  8. 8. Existential Theories :Existential Theories : -- persons experience feelings of living in apersons experience feelings of living in a purposeless universe. Anxiety is their responsepurposeless universe. Anxiety is their response to the perceived void in existence and meaning.to the perceived void in existence and meaning.
  9. 9. Contributions of Biological SciencesContributions of Biological Sciences  The autonomic nervous systems - exhibitThe autonomic nervous systems - exhibit increased sympathetic tone, adapt slowly toincreased sympathetic tone, adapt slowly to repeated stimuli, and respond excessively torepeated stimuli, and respond excessively to moderate stimuli.moderate stimuli.  three major neurotransmitters - norepinephrinethree major neurotransmitters - norepinephrine (NE), serotonin, and GABA(NE), serotonin, and GABA  Alterations in hypothalamic-pituitary-adrenalAlterations in hypothalamic-pituitary-adrenal (HPA) axis function(HPA) axis function
  10. 10.  Hypothalamic levels of CRH are increased byHypothalamic levels of CRH are increased by stress, resulting in activation of the HPA axisstress, resulting in activation of the HPA axis  poorly regulated noradrenergic system withpoorly regulated noradrenergic system with occasional bursts of activity.occasional bursts of activity.  increased 5-hydroxytryptamine (5-HT) turnoverincreased 5-hydroxytryptamine (5-HT) turnover in the prefrontal cortex, nucleus accumbens,in the prefrontal cortex, nucleus accumbens, amygdala, and lateral hypothalamusamygdala, and lateral hypothalamus  abnormal functioning of their GABA -Aabnormal functioning of their GABA -A receptors,receptors,
  11. 11.  Heredity has been recognized as aHeredity has been recognized as a predisposing factor in the development ofpredisposing factor in the development of anxiety disorders.anxiety disorders.  increased activity in the septohippocampalincreased activity in the septohippocampal pathway (anxiety), and the cingulate gyrus,pathway (anxiety), and the cingulate gyrus, which has been implicated particularly in thewhich has been implicated particularly in the pathophysiology of OCD.pathophysiology of OCD.
  12. 12. •panic disorder with or withoutpanic disorder with or without agoraphobia;agoraphobia; •specific phobia;specific phobia; •social phobia;social phobia; •obsessive-compulsive disorder (OCD);obsessive-compulsive disorder (OCD); •generalized anxiety disordergeneralized anxiety disorder
  13. 13.  panic disorder -panic disorder - acute intense attack of anxietyacute intense attack of anxiety accompanied by feelings of impending doomaccompanied by feelings of impending doom  Agoraphobia -Agoraphobia - refers to a fear of or anxietyrefers to a fear of or anxiety regarding places from which escape might beregarding places from which escape might be difficult.difficult.  fear of having a panic attack in a public place from whichfear of having a panic attack in a public place from which escape would be formidableescape would be formidable Panic Disorder and AgoraphobiaPanic Disorder and Agoraphobia
  14. 14.  lifetime prevalence of panic disorder is in the 1 to 4lifetime prevalence of panic disorder is in the 1 to 4 percent rangepercent range;; 3 to 5.6 percent for panic attacks3 to 5.6 percent for panic attacks  Women are two to three times more likely to beWomen are two to three times more likely to be affected than menaffected than men  The only social factor identified as contributing to theThe only social factor identified as contributing to the development of panic disorder is a recent history ofdevelopment of panic disorder is a recent history of divorce or separationdivorce or separation
  15. 15.  the mean age of presentation is about 25 years oldthe mean age of presentation is about 25 years old  lifetime prevalence of agoraphobia varies between 2lifetime prevalence of agoraphobia varies between 2 to 6 percent across studies;to 6 percent across studies;  Of patients with panic disorder, 91 percent have atOf patients with panic disorder, 91 percent have at least one other psychiatric disorder as do 84 percentleast one other psychiatric disorder as do 84 percent of those with agoraphobia;of those with agoraphobia; ..
  16. 16.  Of persons with panic disorderOf persons with panic disorder::  15 to 30 %- social phobia15 to 30 %- social phobia  2 to 20 % - specific phobia2 to 20 % - specific phobia  15 to 30 % - generalized anxiety disorder15 to 30 % - generalized anxiety disorder  2 to 10 % - posttraumatic stress disorder (PTSD)2 to 10 % - posttraumatic stress disorder (PTSD)  30 % - obsessive-compulsive disorder (OCD).30 % - obsessive-compulsive disorder (OCD).  10 to 15 % - major depressive disorder10 to 15 % - major depressive disorder
  17. 17.  Serotonergic dysfunction is quite evident in panicSerotonergic dysfunction is quite evident in panic disorder ;disorder ;  brainstem (particularly the noradrenergic neurons ofbrainstem (particularly the noradrenergic neurons of the locus ceruleus and the serotonergic neurons of thethe locus ceruleus and the serotonergic neurons of the median raphe nucleus)median raphe nucleus)  the limbic system (possibly responsible for thethe limbic system (possibly responsible for the generation of anticipatory anxiety)generation of anticipatory anxiety)  the prefrontal cortex (possibly responsible for thethe prefrontal cortex (possibly responsible for the generation of phobic avoidance).generation of phobic avoidance).
  18. 18.  panicogenspanicogens  respiratory - carbon dioxide (5 to 35 percent mixtures),respiratory - carbon dioxide (5 to 35 percent mixtures), sodium lactate, and bicarbonatesodium lactate, and bicarbonate  Neurochemical- yohimbine, m-chlorophenylpiperazineNeurochemical- yohimbine, m-chlorophenylpiperazine (mCPP), m-Caroline drugs; flumazenil (Romazicon),(mCPP), m-Caroline drugs; flumazenil (Romazicon), cholecystokinin; and caffeine.cholecystokinin; and caffeine.  Isoproterenol - mechanism of action in inducing panicIsoproterenol - mechanism of action in inducing panic attacks is poorly understoodattacks is poorly understood
  19. 19.  first-degree relatives of patients with panic disorderfirst-degree relatives of patients with panic disorder have a fourfold to eightfold higher risk for panichave a fourfold to eightfold higher risk for panic disorder than first-degree relatives of otherdisorder than first-degree relatives of other psychiatric patientspsychiatric patients  monozygotic twins are more likely to be concordantmonozygotic twins are more likely to be concordant for panic disorder than are dizygotic twinsfor panic disorder than are dizygotic twins
  20. 20.  Behavioral theories posit that anxiety is a responseBehavioral theories posit that anxiety is a response learned either from parental behavior or through thelearned either from parental behavior or through the process of classic conditioning.process of classic conditioning.  Psychoanalytic theories conceptualize panic attacksPsychoanalytic theories conceptualize panic attacks as arising from an unsuccessful defense againstas arising from an unsuccessful defense against anxiety-provoking impulses.anxiety-provoking impulses.
  21. 21. Psychodynamic Themes in Panic DisorderPsychodynamic Themes in Panic Disorder  Difficulty tolerating angerDifficulty tolerating anger  Physical or emotional separation from significant person both inPhysical or emotional separation from significant person both in childhood and in adult lifechildhood and in adult life  May be triggered by situations of increased work responsibilitiesMay be triggered by situations of increased work responsibilities  Perception of parents as controlling, frightening, critical, and demandingPerception of parents as controlling, frightening, critical, and demanding  Internal representations of relationships involving sexual or physicalInternal representations of relationships involving sexual or physical abuseabuse  A chronic sense of feeling trappedA chronic sense of feeling trapped  Vicious cycle of anger at parental rejecting behavior followed byVicious cycle of anger at parental rejecting behavior followed by anxiety that the fantasy will destroy the tie to parentsanxiety that the fantasy will destroy the tie to parents  Failure of signal anxiety function in ego related to self-fragmentationFailure of signal anxiety function in ego related to self-fragmentation and self-other boundary confusionand self-other boundary confusion  Typical defense mechanisms: reaction formation, undoing, somatization,Typical defense mechanisms: reaction formation, undoing, somatization, and externalization.and externalization.
  22. 22. Panic AttackPanic Attack ((4 or more developed abruptly reaching a peak4 or more developed abruptly reaching a peak within 10 minutes)within 10 minutes)  palpitations, poundingpalpitations, pounding heart, or acceleratedheart, or accelerated heart rateheart rate  sweatingsweating  trembling or shakingtrembling or shaking  sensations of shortnesssensations of shortness of breath or smotheringof breath or smothering  feeling of chokingfeeling of choking  chest pain or discomfortchest pain or discomfort  nausea or abdominalnausea or abdominal distressdistress  feeling dizzy, unsteady,feeling dizzy, unsteady, lightheaded, or faintlightheaded, or faint  derealization (feelings ofderealization (feelings of unreality) orunreality) or depersonalization (beingdepersonalization (being detached from oneself)detached from oneself)  fear of losing control orfear of losing control or going crazygoing crazy  fear of dyingfear of dying  paresthesias (numbnessparesthesias (numbness or tingling sensations)or tingling sensations)  chills or hot flusheschills or hot flushes
  23. 23. DSM-IV-TR Diagnostic Criteria forDSM-IV-TR Diagnostic Criteria for Panic Disorder with AgoraphobiaPanic Disorder with Agoraphobia A.A. Both (1) and (2):Both (1) and (2): 1.1. recurrent unexpected panic attacksrecurrent unexpected panic attacks 2.2. at least one of the attacks has been followed by 1 month (orat least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:more) of one (or more) of the following:  persistent concern about having additional attackspersistent concern about having additional attacks  worry about the implications of the attack or itsworry about the implications of the attack or its consequences (e.g., losing control, having a heart attack,consequences (e.g., losing control, having a heart attack, going crazy)going crazy)  a significant change in behavior related to the attacksa significant change in behavior related to the attacks
  24. 24. B.B. The presence of agoraphobiaThe presence of agoraphobia C.C. The panic attacks are not due to the direct physiologicalThe panic attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) oreffects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).a general medical condition (e.g., hyperthyroidism). D.D. The panic attacks are not better accounted for by anotherThe panic attacks are not better accounted for by another mental disorder.mental disorder.
  25. 25. Specific Phobia and Social PhobiaSpecific Phobia and Social Phobia  phobia refers to an excessive fear of a specific object,phobia refers to an excessive fear of a specific object, circumstance, or situation.circumstance, or situation.  specific phobia is a strong, persisting fear of an objectspecific phobia is a strong, persisting fear of an object or situationor situation  social phobia is a strong, persisting fear of situationssocial phobia is a strong, persisting fear of situations in which embarrassment can occurin which embarrassment can occur
  26. 26.  Specific phobia is more common than social phobiaSpecific phobia is more common than social phobia  Specific phobia is the most common mental disorderSpecific phobia is the most common mental disorder among women and the second most common amongamong women and the second most common among menmen  Persons with social phobia may have a history ofPersons with social phobia may have a history of other anxiety disorders, mood disorders, substance-other anxiety disorders, mood disorders, substance- related disorders, and bulimia nervosarelated disorders, and bulimia nervosa
  27. 27.  comorbidity in specific phobia range from 50 – 80%comorbidity in specific phobia range from 50 – 80%  Common: anxiety, mood, and substance-relatedCommon: anxiety, mood, and substance-related disordersdisorders..  Watson's hypothesisWatson's hypothesis :: Anxiety is aroused by a naturallyAnxiety is aroused by a naturally frightening stimulus that occurs in contiguity with a secondfrightening stimulus that occurs in contiguity with a second inherently neutral stimulus. As a result of the contiguity,inherently neutral stimulus. As a result of the contiguity, especially when the two stimuli are paired on severalespecially when the two stimuli are paired on several successive occasions, the originally neutral stimulus becomessuccessive occasions, the originally neutral stimulus becomes capable of arousing anxiety by itself. The neutral stimulus,capable of arousing anxiety by itself. The neutral stimulus, therefore, becomes a conditioned stimulus for anxietytherefore, becomes a conditioned stimulus for anxiety production.production.
  28. 28. Psychodynamic Themes in PhobiasPsychodynamic Themes in Phobias  Principal defense mechanisms include displacement,Principal defense mechanisms include displacement, projection, and avoidance.projection, and avoidance.  Environmental stressors, including humiliation and criticismEnvironmental stressors, including humiliation and criticism from an older sibling, parental fights, or loss and separationfrom an older sibling, parental fights, or loss and separation from parents, interact with a genetic-constitutional diathesis.from parents, interact with a genetic-constitutional diathesis.  A characteristic pattern of internal object relations isA characteristic pattern of internal object relations is externalized in social situations in the case of social phobia.externalized in social situations in the case of social phobia.  Anticipation of humiliation, criticism, and ridicule is projectedAnticipation of humiliation, criticism, and ridicule is projected onto individuals in the environment.onto individuals in the environment.  Shame and embarrassment are the principal affect states.Shame and embarrassment are the principal affect states.  Family members may encourage phobic behavior and serve asFamily members may encourage phobic behavior and serve as obstacles to any treatment plan.obstacles to any treatment plan.  Self-exposure to the feared situation is a basic principle of allSelf-exposure to the feared situation is a basic principle of all treatmenttreatment..
  29. 29.  Acrophobia - fear of heightsAcrophobia - fear of heights  Agoraphobia - fear of open placesAgoraphobia - fear of open places  Ailurophobia - fear of catsAilurophobia - fear of cats  Hydrophobia - fear of waterHydrophobia - fear of water  Claustrophobia - fear of closed spacesClaustrophobia - fear of closed spaces  Cynophobia - fear of dogsCynophobia - fear of dogs  Mysophobia - fear of dirt and germsMysophobia - fear of dirt and germs  Pyrophobia - fear of firePyrophobia - fear of fire  Xenophobia - fear of strangersXenophobia - fear of strangers  Zoophobia - fear of animalsZoophobia - fear of animals
  30. 30. DSM-IV-TR Diagnostic Criteria forDSM-IV-TR Diagnostic Criteria for Specific PhobiaSpecific Phobia A.A. Marked and persistent fear that is excessive or unreasonable,Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object orcued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection,situation (e.g., flying, heights, animals, receiving an injection, seeing blood).seeing blood). B.B. Exposure to the phobic stimulus almost invariably provokesExposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of aan immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack.situationally bound or situationally predisposed panic attack. NoteNote: In children, the anxiety may be expressed by crying,: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.tantrums, freezing, or clinging. C.C. The person recognizes that the fear is excessive orThe person recognizes that the fear is excessive or unreasonable.unreasonable. NoteNote: In children, this feature may be absent.: In children, this feature may be absent.
  31. 31. D.D. The phobic situation(s) is avoided or else is endured withThe phobic situation(s) is avoided or else is endured with intense anxiety or distress.intense anxiety or distress. E.E. The avoidance, anxious anticipation, or distress in the fearedThe avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normalsituation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or socialroutine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress aboutactivities or relationships, or there is marked distress about having the phobia.having the phobia. F.F. In individuals under age 18 years, the duration is at least 6In individuals under age 18 years, the duration is at least 6 months.months.
  32. 32. G.G. The anxiety, panic attacks, or phobic avoidance associatedThe anxiety, panic attacks, or phobic avoidance associated with the specific object or situation are not better accountedwith the specific object or situation are not better accounted for by another mental disorder, such as obsessive-compulsivefor by another mental disorder, such as obsessive-compulsive disorder (e.g., fear of dirt in someone with an obsession aboutdisorder (e.g., fear of dirt in someone with an obsession about contamination), posttraumatic stress disorder (e.g., avoidancecontamination), posttraumatic stress disorder (e.g., avoidance of stimuli associated with a severe stressor), separationof stimuli associated with a severe stressor), separation anxiety disorder (e.g., avoidance of school), social phobiaanxiety disorder (e.g., avoidance of school), social phobia (e.g., avoidance of social situations because of fear of(e.g., avoidance of social situations because of fear of embarrassment), panic disorder with agoraphobia, orembarrassment), panic disorder with agoraphobia, or agoraphobia without history of panic disorder.agoraphobia without history of panic disorder.
  33. 33. DSM-IV-TR Diagnostic Criteria forDSM-IV-TR Diagnostic Criteria for Social PhobiaSocial Phobia A.A. A marked and persistent fear of one or more social orA marked and persistent fear of one or more social or performance situations in which the person is exposed toperformance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. Theunfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or showindividual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-Note: In children, there must be evidence of the capacity for age- appropriate social relationships with familiar people and the anxiety mustappropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.occur in peer settings, not just in interactions with adults. B.B. Exposure to the feared social situation almost invariablyExposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationallyprovokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack.bound or situationally predisposed panic attack. Note: In children, the anxiety may be expressed by crying,Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations withtantrums, freezing, or shrinking from social situations with unfamiliar people.unfamiliar people.
  34. 34. C.C. The person recognizes that the fear is excessive orThe person recognizes that the fear is excessive or unreasonable.unreasonable. Note: In children, this feature may be absent.Note: In children, this feature may be absent. D.D. The feared social or performance situations are avoided orThe feared social or performance situations are avoided or else are endured with intense anxiety or distresselse are endured with intense anxiety or distress E.E. The avoidance, anxious anticipation, or distress in the fearedThe avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantlysocial or performance situation(s) interferes significantly with the person's normal routine, occupational (academic)with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there isfunctioning, or social activities or relationships, or there is marked distress about having the phobia.marked distress about having the phobia.
  35. 35. F.F. In individuals under age 18 years, the duration is at least 6In individuals under age 18 years, the duration is at least 6 months.months. G.G. The fear or avoidance is not due to the direct physiologicalThe fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or aeffects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for bygeneral medical condition and is not better accounted for by another mental disorder (e.g., panic disorder with or withoutanother mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphicagoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, or schizoiddisorder, a pervasive developmental disorder, or schizoid personality disorder).personality disorder). H.H. If a general medical condition or another mental disorder isIf a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it (e.g., the fearpresent, the fear in Criterion A is unrelated to it (e.g., the fear is not of stuttering, trembling in Parkinson's disease, oris not of stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behavior in anorexia nervosa orexhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa).bulimia nervosa).
  36. 36. Obsessive-Compulsive DisorderObsessive-Compulsive Disorder  Obsession - is a recurrent and intrusive thought,Obsession - is a recurrent and intrusive thought, feeling, idea, or sensationfeeling, idea, or sensation  Compulsion - is a conscious, standardized, recurrentCompulsion - is a conscious, standardized, recurrent behavior, such as counting, checking, or avoidingbehavior, such as counting, checking, or avoiding  ego-dystonicego-dystonic
  37. 37.  Lifetime prevalence in the general populationLifetime prevalence in the general population estimated at 2 to 3 percentestimated at 2 to 3 percent  fourth most common psychiatric diagnosis afterfourth most common psychiatric diagnosis after phobias, substance-related disorders, and majorphobias, substance-related disorders, and major depressive disorder.depressive disorder.  men and women are equally likely to be affectedmen and women are equally likely to be affected  among adolescents, boys are more commonlyamong adolescents, boys are more commonly affected than girlsaffected than girls
  38. 38.  mean age of onset is about 20 yearsmean age of onset is about 20 years  ComorbidityComorbidity major depressive disorder – 67%major depressive disorder – 67% social phobia – 25%social phobia – 25% Tourette’s disorder – 5 to 7 %Tourette’s disorder – 5 to 7 % History of tics – 20 – 30%History of tics – 20 – 30%
  39. 39. DSM-IV-TR Diagnostic Criteria forDSM-IV-TR Diagnostic Criteria for Obsessive-Compulsive DisorderObsessive-Compulsive Disorder A.A. Either obsessions or compulsions:Either obsessions or compulsions: Obsessions as defined by (1), (2), (3), and (4):Obsessions as defined by (1), (2), (3), and (4): 1.1. recurrent and persistent thoughts, impulses, or images that arerecurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusiveexperienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distressand inappropriate and that cause marked anxiety or distress 2.2. the thoughts, impulses, or images are not simply excessivethe thoughts, impulses, or images are not simply excessive worries about real-life problemsworries about real-life problems 3.3. the person attempts to ignore or suppress such thoughts,the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some otherimpulses, or images, or to neutralize them with some other thought or actionthought or action 4.4. the person recognizes that the obsessional thoughts,the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (notimpulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)imposed from without as in thought insertion)
  40. 40. Compulsions as defined by (1) and (2):Compulsions as defined by (1) and (2): 1.1. repetitive behaviors (e.g., hand washing, ordering, checking)repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating wordsor mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response tosilently) that the person feels driven to perform in response to an obsession, or according to rules that must be appliedan obsession, or according to rules that must be applied rigidlyrigidly 2.2. the behaviors or mental acts are aimed at preventing orthe behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event orreducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either aresituation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designednot connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessiveto neutralize or prevent or are clearly excessive B.B. At some point during the course of the disorder, the personAt some point during the course of the disorder, the person has recognized that the obsessions or compulsions arehas recognized that the obsessions or compulsions are excessive or unreasonable.excessive or unreasonable. NoteNote: This does not apply to children.: This does not apply to children.
  41. 41. C.C. The obsessions or compulsions cause marked distress, areThe obsessions or compulsions cause marked distress, are time-consuming (take more than 1 hour a day), ortime-consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine,significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual socialoccupational (or academic) functioning, or usual social activities or relationships.activities or relationships. D.D. If another Axis I disorder is present, the content of theIf another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g.,obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an eating disorder;preoccupation with food in the presence of an eating disorder; hair pulling in the presence of trichotillomania; concern withhair pulling in the presence of trichotillomania; concern with appearance in the presence of body dysmorphic disorder;appearance in the presence of body dysmorphic disorder; preoccupation with drugs in the presence of a substance usepreoccupation with drugs in the presence of a substance use disorder; preoccupation with having a serious illness in thedisorder; preoccupation with having a serious illness in the presence of hypochondriasis; preoccupation with sexual urgespresence of hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a paraphilia; or guiltyor fantasies in the presence of a paraphilia; or guilty ruminations in the presence of major depressive disorder).ruminations in the presence of major depressive disorder). E.E. The disturbance is not due to the direct physiological effectsThe disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or aof a substance (e.g., a drug of abuse, a medication) or a general medical condition.general medical condition.
  42. 42.  most common pattern is an obsession ofmost common pattern is an obsession of contamination, followed by washing or accompaniedcontamination, followed by washing or accompanied by compulsive avoidance of the presumablyby compulsive avoidance of the presumably contaminated object.contaminated object.  second most common pattern is an obsession ofsecond most common pattern is an obsession of doubt, followed by a compulsion of checking.doubt, followed by a compulsion of checking.  third most common pattern, there are intrusivethird most common pattern, there are intrusive obsessional thoughts without a compulsionobsessional thoughts without a compulsion  fourth most common pattern is the need for symmetryfourth most common pattern is the need for symmetry or precision, which can lead to a compulsion ofor precision, which can lead to a compulsion of slowness.slowness.
  43. 43. Generalized Anxiety DisorderGeneralized Anxiety Disorder  1-year prevalence range from 3 to 8 percent.1-year prevalence range from 3 to 8 percent.  The ratio of women to men with the disorder is aboutThe ratio of women to men with the disorder is about 2 to 12 to 1  50 to 90 percent of patients with generalized anxiety50 to 90 percent of patients with generalized anxiety disorder have another mental disorderdisorder have another mental disorder
  44. 44. DSM-IV-TR Diagnostic Criteria forDSM-IV-TR Diagnostic Criteria for Generalized Anxiety DisorderGeneralized Anxiety Disorder A.A. Excessive anxiety and worry (apprehensive expectation),Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about aoccurring more days than not for at least 6 months, about a number of events or activities (such as work or schoolnumber of events or activities (such as work or school performance).performance). B.B. The person finds it difficult to control the worry.The person finds it difficult to control the worry. C.C. The anxiety and worry are associated with three (or more) ofThe anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptomsthe following six symptoms (with at least some symptoms present for more days than not for the past 6 months).present for more days than not for the past 6 months). NoteNote: Only one item is required in children.: Only one item is required in children. 1. restlessness or feeling keyed up or on edge1. restlessness or feeling keyed up or on edge 2. being easily fatigued2. being easily fatigued 3. difficulty concentrating or mind going blank3. difficulty concentrating or mind going blank 4. irritability4. irritability 5. muscle tension5. muscle tension 6. sleep disturbance (difficulty falling or staying asleep, or restless6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)unsatisfying sleep)
  45. 45. D.D. The focus of the anxiety and worry is not confined to featuresThe focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not aboutof an Axis I disorder, e.g., the anxiety or worry is not about having a panic attack (as in panic disorder), beinghaving a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), beingembarrassed in public (as in social phobia), being contaminated (as in obsessive-compulsive disorder), beingcontaminated (as in obsessive-compulsive disorder), being away from home or close relatives (as in separation anxietyaway from home or close relatives (as in separation anxiety disorder), gaining weight (as in anorexia nervosa), havingdisorder), gaining weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), ormultiple physical complaints (as in somatization disorder), or having a serious illness (as in hypochondriasis), and thehaving a serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively duringanxiety and worry do not occur exclusively during posttraumatic stress disorder.posttraumatic stress disorder. E.E. The anxiety, worry, or physical symptoms cause clinicallyThe anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, orsignificant distress or impairment in social, occupational, or other important areas of functioning.other important areas of functioning. F.F. The disturbance is not due to the direct physiological effectsThe disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or aof a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and doesgeneral medical condition (e.g., hyperthyroidism) and does not occur exclusively during a mood disorder, a psychoticnot occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder.disorder, or a pervasive developmental disorder.
  46. 46. TREATMENTTREATMENT  Alprazolam (Xanax) and paroxetine (Paxil) -Alprazolam (Xanax) and paroxetine (Paxil) - approved by the US Food and Drug Administrationapproved by the US Food and Drug Administration (FDA) for the treatment of panic disorder(FDA) for the treatment of panic disorder  All SSRIs are effective for panic disorderAll SSRIs are effective for panic disorder  among tricyclic drugs, clomipramine and imipramineamong tricyclic drugs, clomipramine and imipramine (Tofranil) are the most effective in the treatment of(Tofranil) are the most effective in the treatment of panic disorder.panic disorder.  MAOIs appear less likely to cause overstimulationMAOIs appear less likely to cause overstimulation than either SSRIs or tricyclic drugs, but they maythan either SSRIs or tricyclic drugs, but they may require full dosages for at least 8 to 12 weeks to berequire full dosages for at least 8 to 12 weeks to be effectiveeffective
  47. 47.  Once it becomes effective, pharmacological treatmentOnce it becomes effective, pharmacological treatment should generally continue for 8 to 12 months.should generally continue for 8 to 12 months.  The most studied and most effective treatment forThe most studied and most effective treatment for phobias is probably behavior therapy.phobias is probably behavior therapy.  common treatment for specific phobia is exposurecommon treatment for specific phobia is exposure therapytherapy  Effective drugs for the treatment of social phobia:Effective drugs for the treatment of social phobia:  selective serotonin reuptake inhibitors (SSRIs)selective serotonin reuptake inhibitors (SSRIs)  the benzodiazepinesthe benzodiazepines  venlafaxine (Effexor)venlafaxine (Effexor)  buspirone (BuSpar).buspirone (BuSpar).
  48. 48.  Venlafaxine is approved by the FDA for treatment ofVenlafaxine is approved by the FDA for treatment of generalized anxiety disordergeneralized anxiety disorder  In OCD, the standard approach is to start treatmentIn OCD, the standard approach is to start treatment with an SSRI or clomipramine and then move towith an SSRI or clomipramine and then move to other pharmacological strategies if the serotonin-other pharmacological strategies if the serotonin- specific drugs are not effective.specific drugs are not effective.  Benzodiazepines have been the drugs of choice forBenzodiazepines have been the drugs of choice for generalized anxiety disordergeneralized anxiety disorder
  49. 49.  Buspirone,a 5-HT1A receptor partial agonist, is mostBuspirone,a 5-HT1A receptor partial agonist, is most likely effective in 60 to 80 percent of patients withlikely effective in 60 to 80 percent of patients with generalized anxiety disordergeneralized anxiety disorder  a2a2-adrenergic receptor antagonists may reduce the-adrenergic receptor antagonists may reduce the somatic manifestations of anxiety, but not thesomatic manifestations of anxiety, but not the underlying conditionunderlying condition
  50. 50. BAP GuidelinesBAP Guidelines
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