2.  Abrupt and Aversive CNS Response to Real Threat or Danger  Prepares Organisms for Immediate Action  Action Tendency “Fight” or “Flight”  Abrupt and Aversive CNS Response to Real Threat or Danger  Prepares Organisms for Immediate Action  Action Tendency “Fight” or “Flight”

3.  More Diffuse Response About Impending Real or Imagined “Future” Threat or Danger

4. No Threat Adaptive True Alarm False Alarm Maladaptive Real Threat

5. Etiology “Disordered” or “Maladaptive” Experience of Anxiety or Fear “Disordered” or “Maladaptive” Experience of Anxiety or Fear “Normal” or “Adaptive” Experience of Anxiety or Fear “Normal” or “Adaptive” Experience of Anxiety or Fear

6. Process Psychobiological & Experiential Processes Psychobiological & Experiential Processes Onset, Maintenance, and Course Onset, Maintenance, and Course Successful Treatment Response and Outcome Successful Treatment Response and Outcome

7. Outcome What Treatments, by Whom, are Most Effective, and WHY? What Treatments, by Whom, are Most Effective, and WHY? Panic Disorder Agoraphobia Specific Phobias Social Phobias PTSD Acute Stress GAD OCD Anxiety NOS

8.  Panic Disorder  PD With Agoraphobia  Agoraphobia  Specific Phobias  Social Phobias  Generalized Anxiety Disorder  Post-Traumatic Stress Disorder  Obsessive Compulsive Disorder  Panic Disorder  PD With Agoraphobia  Agoraphobia  Specific Phobias  Social Phobias  Generalized Anxiety Disorder  Post-Traumatic Stress Disorder  Obsessive Compulsive Disorder

9.  Panic Disorder “ You may genuinely believe you’re having a heart attack, losing your mind, or on the verge of death. Attacks can occur any time, even during nondream sleep ” “ You may genuinely believe you’re having a heart attack, losing your mind, or on the verge of death. Attacks can occur any time, even during nondream sleep ” “ For me, a panic attack is a most violent experience …I feel as though I’m losing control and going insane. ” “ For me, a panic attack is a most violent experience …I feel as though I’m losing control and going insane. ”

10.  An Unexpected Panic Attack  Develop Anxiety Over  the Next Attack or  The Implications of the Attack and Consequences  An Unexpected Panic Attack  Develop Anxiety Over  the Next Attack or  The Implications of the Attack and Consequences  Clinical Description

11.  Agoraphobia is Common  Fear of the Marketplace  Consequence of Severe Unexpected Panic Attacks  Can Have a Life of its Own  Agoraphobia is Common  Fear of the Marketplace  Consequence of Severe Unexpected Panic Attacks  Can Have a Life of its Own

12.  Facts and Statistics  Occurs in 3.5% of Population  75% are Women  Onset Between (25-29 yrs)  Attacks Often Begin at Puberty  20% Attempt Suicide  Average 37 Medical Visits / Year  Occurs in 3.5% of Population  75% are Women  Onset Between (25-29 yrs)  Attacks Often Begin at Puberty  20% Attempt Suicide  Average 37 Medical Visits / Year

13.  Cultural Influences  Occurs Worldwide  Prevalence in U.S. is Similar Across Ethnic Groups  Occurs Worldwide  Prevalence in U.S. is Similar Across Ethnic Groups

14.  Nocturnal Panic  60% Cases Panic While Asleep!  Usually Between 1:30 - 3:30am  Occur During Deep Sleep “Delta”  Do Not Occur During REM Sleep  60% Cases Panic While Asleep!  Usually Between 1:30 - 3:30am  Occur During Deep Sleep “Delta”  Do Not Occur During REM Sleep

15.  Symptoms of a Panic Attack  Palpitations / Sweating  Trembling / Shaking  Shortness of Breath  Feeling of Choking, Loss of Control  Derealization, Feeling of Dying  Palpitations / Sweating  Trembling / Shaking  Shortness of Breath  Feeling of Choking, Loss of Control  Derealization, Feeling of Dying

16.  The Panic Attack  Abrupt Autonomic Surge  Unexpected  Uncontrollable  Absence of Threat  “False Alarm”  Abrupt Autonomic Surge  Unexpected  Uncontrollable  Absence of Threat  “False Alarm” 10 Minutes

17.  Laboratory Panic Provocation  Lactate Infusion  Hyperventilation  CO2 Inhalation  Caffeine  Lactate Infusion  Hyperventilation  CO2 Inhalation  Caffeine 10 Minutes

18.  Causes Biological Vulnerability False Alarm Involuntary Symptoms STRESS Bodily Cues Psychological Vulnerability Learned Alarm

19.  Biological Causes  Runs in Families  GABA-BZ Circuit  Limbic System  Runs in Families  GABA-BZ Circuit  Limbic System  ANXIETY Behavioral Inhibition System (BIS)  FEAR / PANIC Fight / Flight System (FF)  ANXIETY Behavioral Inhibition System (BIS)  FEAR / PANIC Fight / Flight System (FF)

20. Uncontrollable Unpredictable  Psychological Causes Controllable Predictable

21.  Pharmacologic Treatments  Block Panic  Antidepressants (e.g., Imipramine, Paxil, Prozac)  20-50% Relapse  Benzodiazapines (e.g., Xanax)  90% Relapse  Block Panic  Antidepressants (e.g., Imipramine, Paxil, Prozac)  20-50% Relapse  Benzodiazapines (e.g., Xanax)  90% Relapse

22.  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  Cognitive-Behavior Therapies  Brief and Time Limited (12 Sessions)  Graded Exposure + Coping Skills  Panic Control Treatment (PCT)  80-100% Panic Free After Treatment

23.  Combined Treatment  Multisite Study  Imipramine Alone  PCT Alone  Imipramine + PCT  Placebo Alone  Placebo + PCT  Multisite Study  Imipramine Alone  PCT Alone  Imipramine + PCT  Placebo Alone  Placebo + PCT THE RESULT Combined Tx is Better in Short Term PCT Alone is Better in Long Term

24.  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.”

25.  Irrational Fear of Specific Objects or Situations  Markedly Interferes With Functioning  Irrational Fear of Specific Objects or Situations  Markedly Interferes With Functioning  Clinical Description

26.  Animal Type  Natural Environment Type  Blood-Injection Injury Type  Situational Type  Other  Animal Type  Natural Environment Type  Blood-Injection Injury Type  Situational Type  Other  Four Major Subtypes

27.  Unusual Reaction  Vasovagal Response to Blood  Drop in Blood Pressure  Fainting  Runs in Families  Onset Early Childhood  Unusual Reaction  Vasovagal Response to Blood  Drop in Blood Pressure  Fainting  Runs in Families  Onset Early Childhood  Blood-Injection Injury Type

28.  Fears of Specific Situations Planes, Transportation, Heights  Response Similar to Panic  Onset Early 20’s  Fears of Specific Situations Planes, Transportation, Heights  Response Similar to Panic  Onset Early 20’s  Situational Type

29.  Fears of Animals and Insects  Common in Population, but Different From Normal Revulsion  Early Onset (About 7 yrs of Age)  Fears of Animals and Insects  Common in Population, but Different From Normal Revulsion  Early Onset (About 7 yrs of Age)  Animal Type

30.  Fears of Natural Events Heights, Storms, Water  Usually More Than One Fear  Peak Onset (About 7 yrs of Age)  Fears of Natural Events Heights, Storms, Water  Usually More Than One Fear  Peak Onset (About 7 yrs of Age)  Natural Environment Type

31.  Fears Contracting Disease / Illness Illness Phobia  Fear of Choking Avoid Swallowing Pills or Foods  Fears Contracting Disease / Illness Illness Phobia  Fear of Choking Avoid Swallowing Pills or Foods  Other Type

32.  Facts and Statistics  Occurs in 11% of Population  Top Fears: Heights and Snakes  Females > Males (4:1 Ratio)  Runs a Chronic Course  Hispanics > Caucasian Americans  Many Do Not Seek Treatment: WHY?  Occurs in 11% of Population  Top Fears: Heights and Snakes  Females > Males (4:1 Ratio)  Runs a Chronic Course  Hispanics > Caucasian Americans  Many Do Not Seek Treatment: WHY?

33.  Causes  Direct Traumatic Conditioning  Observational Learning  Information and Language  Having a Panic Attack  Probably Some Evolutionary Basis  Direct Traumatic Conditioning  Observational Learning  Information and Language  Having a Panic Attack  Probably Some Evolutionary Basis

34.  Exposure and More Exposure  Structured and Consistent  Confront Objects of Fear  Extinguish Anxious Responding  Disrupt Avoidance / Escape  Blood-Injury /Injection Differs Exercises to Offset Fainting  Structured and Consistent  Confront Objects of Fear  Extinguish Anxious Responding  Disrupt Avoidance / Escape  Blood-Injury /Injection Differs Exercises to Offset Fainting

35. “ 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.” “ 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.”

36.  Marked and Persistent Fear of One or More... Social or Performance Situations  Most Common Type of Social Fear? Public Speaking  Interferes With Life Functioning  Marked and Persistent Fear of One or More... Social or Performance Situations  Most Common Type of Social Fear? Public Speaking  Interferes With Life Functioning  Clinical Description

37.  Facts and Statistics  Occurs in 13.3% of Population  Most Prevalent Disorder  Males > Females  Begins in Adolescence  Presents Differently in Some Cultures (e.g., Japan)  Occurs in 13.3% of Population  Most Prevalent Disorder  Males > Females  Begins in Adolescence  Presents Differently in Some Cultures (e.g., Japan)

38.  Causes  Similar to Panic and Specific Phobia  Interaction of Biological Vulnerability Psychological Vulnerability Learning Experiences  Can be Quite Disabling  Similar to Panic and Specific Phobia  Interaction of Biological Vulnerability Psychological Vulnerability Learning Experiences  Can be Quite Disabling

39.  Psychological Interventions  Similar to Panic and Specific Phobia  Cognitive-Behavioral Approaches Rehearsal and Skills Training Cognitive Restructuring  Similar to Panic and Specific Phobia  Cognitive-Behavioral Approaches Rehearsal and Skills Training Cognitive Restructuring

40.  Drug Treatments  Antidepressants for Severe Anxiety MAO Inhibitors Relapse is Common  Antidepressants for Severe Anxiety MAO Inhibitors Relapse is Common

41.  Worrywart?  Perfectionist?  Tense and keyed up most of the time?  Cross bridges before you get to them?  Worry unproductive?  Trouble Controlling Worry?  Worrywart?  Perfectionist?  Tense and keyed up most of the time?  Cross bridges before you get to them?  Worry unproductive?  Trouble Controlling Worry?

42.  Worry About Everything  Worrying is Unproductive  Cannot Stop Worrying  Mental Agitation and Muscle Tension  Interferes With Life Functioning  Must Last for at Least 6 Months  Worry About Everything  Worrying is Unproductive  Cannot Stop Worrying  Mental Agitation and Muscle Tension  Interferes With Life Functioning  Must Last for at Least 6 Months  Clinical Description

43.  Facts and Statistics  Occurs in 4% of Population  50-65% are Female  Early Gradual (“insidious”) Onset  Runs a Chronic Course  Few Seek Treatment: WHY?  Occurs in 4% of Population  50-65% are Female  Early Gradual (“insidious”) Onset  Runs a Chronic Course  Few Seek Treatment: WHY?

44.  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  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

45. Intense Cognitive Processing Intense Cognitive Processing Biological Vulnerability Worry Process Psychological Vulnerability (Anxious Apprehension) Psychological Vulnerability (Anxious Apprehension) STRESS Imagery Avoidance Restricted Autonomic Response Restricted Autonomic Response

46.  Most Interventions are Weak  Benzodiazepines Frequently Prescribed Provide Some Relief  Cognitive-Behavioral Approaches Process Avoided Emotional Material Relaxation Training Does as Well as Medication  Benzodiazepines Frequently Prescribed Provide Some Relief  Cognitive-Behavioral Approaches Process Avoided Emotional Material Relaxation Training Does as Well as Medication

47.  Exposure to Traumatic Events War and Combat Rape and Assault Car Accidents Natural Disasters  Reexperiencing, Flashbacks, Numbing  Sleep Disturbance, Chronic Arousal  Exposure to Traumatic Events War and Combat Rape and Assault Car Accidents Natural Disasters  Reexperiencing, Flashbacks, Numbing  Sleep Disturbance, Chronic Arousal  Clinical Description

48.  Acute 1-3 Months After the Trauma  Chronic Symptoms Last > 3 Months  Acute 1-3 Months After the Trauma  Chronic Symptoms Last > 3 Months  Subtypes

49.  Facts and Statistics  Occurs in 7.8% of Population  Most Common Traumas? Combat and Assault  Trauma is Necessary, not Sufficient  Severity of Response Seems Important  Runs a Chronic Course  Occurs in 7.8% of Population  Most Common Traumas? Combat and Assault  Trauma is Necessary, not Sufficient  Severity of Response Seems Important  Runs a Chronic Course

50.  Causes  Only Disorder With Clear Etiology  Biological Vulnerability  Experience With Events That are... Uncontrollable and Unpredictable  Severity of Trauma and One’s Reaction True Alarm!  Social Support Helps  Only Disorder With Clear Etiology  Biological Vulnerability  Experience With Events That are... Uncontrollable and Unpredictable  Severity of Trauma and One’s Reaction True Alarm!  Social Support Helps

51.  Psychological Interventions  Face the Original Trauma Imaginal Reexposure Flooding  Arrange for Corrective Emotional Learning  Problem of Secondary Gain Disability and Compensation  Face the Original Trauma Imaginal Reexposure Flooding  Arrange for Corrective Emotional Learning  Problem of Secondary Gain Disability and Compensation

52.  Culmination of All Anxiety Disorders  Obsessions: Intrusive Thoughts, Images, or Urges That the Person Trys to Suppress or Eliminate  Compulsions: Thoughts or Actions to Suppress the Obsessions and Provide Relief  Culmination of All Anxiety Disorders  Obsessions: Intrusive Thoughts, Images, or Urges That the Person Trys to Suppress or Eliminate  Compulsions: Thoughts or Actions to Suppress the Obsessions and Provide Relief  Clinical Description

53.  Facts and Statistics  Occurs in 2.6% of Population  Most Common Obsessions Contamination & Aggression  Most Common Compulsions Checking & Washing  Almost Equal Sex Ratio (F > M)  Onset Early Adolescence to Mid-20s  Occurs in 2.6% of Population  Most Common Obsessions Contamination & Aggression  Most Common Compulsions Checking & Washing  Almost Equal Sex Ratio (F > M)  Onset Early Adolescence to Mid-20s

54.  Causes  Anxiety Focused on Unwanted Thoughts  Thoughts are Unacceptable When Fighting to Control One’s Psychology Creates More Psychopathology  Anxiety Focused on Unwanted Thoughts  Thoughts are Unacceptable When Fighting to Control One’s Psychology Creates More Psychopathology

55.  Psychological Interventions  Cognitive-Behavioral Treatments  Response Prevention Rituals are Actively Prevented  Exposure Systematic and Gradual Exposure to Feared Thoughts or Situations  May Require Hospitalization  Cognitive-Behavioral Treatments  Response Prevention Rituals are Actively Prevented  Exposure Systematic and Gradual Exposure to Feared Thoughts or Situations  May Require Hospitalization

56.  Drug Therapies  Medications Show Promise  Most Effective Medications Inhibit Reuptake of Serotonin  May Benefit 60% of Patients  Medications Show Promise  Most Effective Medications Inhibit Reuptake of Serotonin  May Benefit 60% of Patients