1. Anxiety Disorders in the DSM
An unpleasant feeling of fear and apprehension.
Clinical anxiety is often grossly disproportionate to its recognizable stimulus or free floating if the stimulus is unknown to the patient.
Two common features:
Excessive Worry: about things that are either unlikely to happen or, if they did happen, would be much more manageable than the individual predicts.
Physical tension - feeling “uptight” or “high strung”

2. Phobias
A fear and/or avoidance of an object, activity, or situation that the individual knows is out of proportion to the actual danger posed.
DSM-IV Phobias:
Specific Phobia
Social Phobia
Agoraphobia

3. DSM-IV Criteria For Specific Phobia
Marked or persistent fear that is excessive or unreasonable, cued by a specific object or situation
Exposure to the phobic stimulus invariably provokes an immediate anxiety response
The person realizes the fear is excessive or unreasonable (except in children)
The phobic situation is avoided or endured with intense distress
Phobia interferes with the person’s functioning
If under 18 years - duration > 6 months

4. Etiology of Phobias
Psychoanalytic - defense against anxiety produced by repressed id impulses
Avoidance-Conditioning Model - involves both classical and operant conditioning
Preparedness Theory
Modeling - vicarious learning
Cognitive Theories - increased attention to negative stimuli and alarming predictions
Social Skills Deficits in Social Phobia
Autonomic Liability
Avoidance-Conditioning Model (Mower) - phobias develop from two related sets of learning: (1) via classical conditioning a person can learn to fear a neutral stimulus (the CS) if it is paired with an intrinsically painful or frightening event (the UCS); (2) then the person can learn to reduce this conditioned fear by escaping from or avoiding the CS.
Problems: (1) evidence exists that phobias can exist without a prior frightening experience, (2) many people experiencing traumatic episodes do not develop phobias, (3) little evidence exists that a classically conditioned fear can develop for neutral stimuli, (4) even when a classically conditioned fear is established (e.g., in animals), it is rapidly extinguished.
Prepared Stimuli - prepared stimuli are more likely to become classically conditioned than neutral stimuli. May result from evolutionary history - e.g., spiders, dogs, etc., not electrical outlets.
Modeling - phobic responses may be learned through imitating the reactions of others. The learning of phobic reactions by observing other is generally referred to as vicarious learning. Vicarious learning may also be accomplished through verbal instructions; that is, phobic reactions can be learned through another’s description of what may happen as well as observing another’s fear. (e.g., mother repeatedly warns child of dire consequences of some activity)
Cognitive Theories - phobic individuals focus attention on possibility of feared stimuli. Socially anxious people are significantly more concerned about evaluation than are people who are not socially anxious. However, for many phobias the individual realizes that the fear is irrational.
Social Skills Deficits - social phobics are rated by others as less socially skilled, verbal interchanges impaired (e.g., saying thank you at the appropriate moment).
Autonomic Lability - phobic individuals may become more easily autonomically aroused than others.

5. Treatment of Phobias
Systematic Desensitization - in vivo exposure an important addition
Cognitive Approaches - there is no evidence that eliminating irrational beliefs alone, without exposure, reduces phobias
Biological Approaches - anxiolytics - benzodiazepines are addicting and produce severe withdrawal syndrome - relapse common
Systematic Desensitization - the phobic individual imagines a series of increasingly frightening scenes while in a state of deep relaxation.
For blood and injection phobias - relaxation tends to make the problem worse. Patients with blood or injection phobias often faint because there is a sudden drop in blood pressure and heart rate after the initial acceleration of sympathetic nervous system activity. These patients are asked to tense their muscles when confronted with fearful situations.
Social Skills Training for Social Phobia - pass around our syllabus for social skills training
Cognitive Therapy - not effective for specific phobia without exposure. For social phobia, when added to as part of social skills training - can be effective.
Common Theme to Psychological Therapies - Exposure to Feared Stimulus
Medications (benzodiazepines such as Valium and Xanax) are difficult to discontinue and relapse is common if patient stops taking them.

6. Childhood Fears and Social Withdrawal
Anxiety disorders are the most common disorders of childhood
School Phobia - two types:
separation anxiety
true fear of school
Social Phobia - elective mutism
Treatment - exposure with encouragement
10 to 15 percent of children and adolescents in U.S. meet the definition of an anxiety disorder
School Phobia - can cause serious academic and social consequences.
Separation Anxiety - children worry constantly that some harm will befall their parents or themselves when they are away from their parents. One study found that 75% of children who have refused school have mothers who also refused school in childhood. Hypothesized etiology - difficulty with the mother-child relationship. Perhaps the mother communicates her own separation anxieties and unwittingly reinforces the child’s dependent and avoidant behavior
True Phobia of School - generally begin refusing to go to school later in life and have more severe and pervasive avoidance of school. Their fear is more likely to be related to specific aspects of the school environment, such as worries about academic failure or discomfort with peers.
Social Phobia - Although some children who are shy may simply be slow to warm up, withdrawn children never do, even after prolonged exposure to new people.
Extremely shy children may refuse to speak at all in unfamiliar social circumstances; called elective mutism. At home these children ask their parents endless questions about situations that worry them. Withdrawn children usually have warm and satisfying relationships with family members and family friends, and they do show an eagerness for affection and acceptance. Theories propose that, because of anxiety, these children avoid social situations and do not obtain practice to develop social skills. Alternatively, isolated children may have spent most of their time with adults, such children do interact more with adults than children.
Theories of the etiology of childhood social phobia not well worked out.

7. Characteristics of Panic Disorder
Sudden and often inexplicable attack of a host of jarring symptoms
Strong urge to escape and reach safety
Depersonalization and derealization
Fear of losing control, going crazy, or dying
The beginning of the attack is “out of the blue” with no obvious outside cause
Agoraphobia - a cluster of fears centering on public places and being unable to escape or find help should the individual become incapacitated
A panic attack is basically an alarm reaction. In panic disorder, the panic attacks are “false” alarms, because the feelings of the alarm occurs even though there is no danger.
Common symptoms: shortness of breath or smothering feelings, dizziness, feeling faint or unsteady, racing or pounding heart, trembling or shaking, sweating, choking sensations, nausea or abdominal distress, numbness or tingling sensations, hot flashes or cold chills, chest pain or discomfort.
Recurrent uncued panic attacks are required for the diagnosis of panic disorder; the exclusive presence of cued attacks most likely reflects the presence of a phobia.
Approximately 2%of men and 5% of women have panic disorder in their lifetime
Panic disorder with Agoraphobia more common in women. Agoraphobia is linked to a fear of having a panic attack.

8. Etiology of Panic Disorder
Biological Theory - overactivity in the noradrenergic system - hyperventilation
Psychological Theory of Panic Disorder - patients misinterpret physiological symptoms in a catastrophic way
Psychological Theory of Agoraphobia - due to fear-of-fear
Extreme Fear of Losing Control
One biological theory suggests that panic is caused by overactivity in the noradrenergic system (neurons that use norepinephrine as a neurotransmitter), particularly in a nucleus in the pons called the locus ceruleus. Stimulation of the locus ceruleus causes monkeys to have what appears to be panic attacks. However, drugs that blockfiring in the locus ceruleus have not been found to be very effective in treating panic disorder
Hyperventilation may activate the autonomic nervous system, thus leading to the familiar somatic aspects of the panic attack. Based on the findings that breathing air containing higher than usual amounts of carbon dioxide (CO2) can generate a panic attack in a laboratory setting, oversensitive CO2 receptors have also been proposed as a mechanism that could stimulate hyperventilation.
Subsequent research has found that hyperventilation occurs in only on of twenty-four attacks - thus this line of biological research has not panned out.
Psychological theory: For agoraphobia - not fear of public places per se but a fear of having a panic attack in a public place. For panic - patients misinterpret physiological symptoms in a catastrophic way
Go over Telch and Harrington study - unexplained physiological arousal in someone who is fearful of such sensations leads to panic attacks
Associated Psychological Theory - patients with the disorder have an extreme fear of losing control, which would happen if they had an attack in public. Sanderson et al (1989) study - patients with panic breathed CO2 - were told that when a light came on they could control CO2. For 1/2 of subjects, the light was on continuously, while for the other 1/2 it never came on. Turning the dial actually had no effect on CO2 levels, so the study was of the effect of perceived control. 80% of he group with no control had a panic attack, compared to 20% of those who thought they had control.

9. Components of Panic Disorder Treatment
1. Re-education about the physical symptoms of anxiety and fear, to correct misinterpretations of them as being harmful
2. Training in methods for reducing physical tension, by breathing retraining or relaxation
3. Repeated exposure to feared and avoided physical situations
4. Repeated exposure to feared and avoided sensations
Exposure to physical sensations is the most recently developed procedure. Specific exercises are used to produce the various symptoms that characterize panic attacks. For example, aerobic exercise might be used to produce shortness breath and a pounding heart, and overbreathing might be used to produce lightheadedness and dizziness. Systematic exposure to these sensations reduces the person’s fear of them,and teaches the person that the sensations are not dangerous. Activities which were avoided are practiced to establish that they are not dangerous. These activities might include climbing flights of stairs for aerobic effects, eating certain foods, drinking coffee,and so on.
When fear of the body sensations is lessened so is the fear of the return of a panic attack. These new behavioral treatments eliminate panic attacks in most clients. Research has shown that two years following behavioral treatment, most patients remain panic free. In contrast, patients treated with medications often experience a return of panic when medications are discontinued.

10. Generalized Anxiety Disorder
Chronic, uncontrollable worry about several life circumstances. Must clearly interfere with day-to-day functioning.
Motor Tension Autonomic Hyperactivity Vigilance
trembling, twitching shortness of breath keyed up
muscle tension, aches tachycardia easily startled
restlessness shortness of breath insomnia
easy fatigability sweating irritability
dizziness/lightheaded
nausea and diarrhea
flushes (hot flashes) or chills
The key feature of GAD is defined as excessive and pervasive (or wide-ranging) worry about several life circumstances. The life circumstances refer to such things as relationships with family and friends, health, and well-being of oneself or one’s family, home management and work responsibilities, finances, self-worth, and various other worries about neatness, being on time, and so on. Typically, the emphasis in upon striving for perfection, with a strong sense for and preventing bad things from happening. Must not be caused directly by having encountered real-life trauma.

11. Etiology of GAD
Cognitive theory emphasizes the perception of not being in control as a central characteristic of all views of anxiety
GAD clients are more inclined to interpret ambiguous stimuli as threatening and to rate ominous events as likely to occur to them.
Worry as negatively reinforcing - it distracts patients from even more negative emotions
Defect in GABA system
Research has shown that in certain circumstances it is the perception of control (rather than actual control) that is important. GAD patients perceive threatening events as out of their control.
These patient often perceive benign events, such as crossing the street, as involving threats, and their cognitions focus on anticipated future disasters.
The attention of GAD patients is easily drawn to stimuli that suggest possible physical harm or social misfortune, such as criticism, embarrassment, or rejection. For example, if a person a GAD patient is talking to looks around the room a couple of times, it is interpreted as disdain and rejection.
Borkovec and colleagues have focused their research on the worry component of GAD. From a punishment perspective one might wonder why anyone would worry a lot, since worry is thought to be a negative state that should discourage its repetition. However, worry may distract from even more negative emotions.

12. Three Pervasive Themes in Worry
Perfectionism - worry about making mistakes or things not proceeding in just the right way
Responsibility - worry that if you do not worry then a negative event may actually happen, making you responsible
A Sense of Uncontrollability - worry as a means of gaining control
While people who are not chronic worriers tend to worry about the same kinds of things as people who are not chronic worriers, chronic worry is characterized by an added dimension of excessiveness because of the difficulty stopping the worry process. The chronic worrier may lie in bed at night worrying about upcoming events during the week or the years to come, despite the desire to stop worring. Similarly, the worrier may tend to bring work-related worries home instead of being able to “turn them off.”
Magical Thinking - Worry Prevents Actual Negative Events
Worry exposure

13. Obsessive-Compulsive Disorder
Persistent and uncontrollable thoughts or compulsion to repeat certain acts again and again, causing significant distress and interference with everyday functioning
Obsessions - intrusive and recurring thoughts, impulses, and images that come unbidden to the mind and appear irrational and uncontrollable to the client
Compulsion - repetitive behavior or mental act that the person is driven to perform to reduce the distress caused by obsessional thoughts or to prevent some calamity
Frequent obsessions include fears of contamination, expressing some sexual or aggressive impulse, or hypochondrical fears of bodily dysfunction. Obsessions may also take the form of extreme doubting, procrastination, and indecision.
Common compulsions include elaborate ceremonies to achieve cleanliness and orderliness, avoiding particular objects, such as staying away from anything brown; with repetitive, magical, protective practices, such as counting, saying certain numbers, touching a talisman or a particular part of the body; and with checking, going back seven or eight times to verify that already performed actions were actually carried out. Some compulsions take the form of performing an act, such as eating extremely slowly.
A frequent consequence of OCD is a negative effect on the individual’s relations with other people, especially family members.

14. Etiology of OCD
Psychoanalytic - Due to harsh toilet training,person is fixated at anal stage.
Behavioral - operant escape-responses, memory, active attempts to suppress thoughts
Biological Factors - OCD is caused by a neurotransmitter coupled to serotonin
In psychoanalytic theory obsessions and compulsions are viewed as similar, resulting from instinctual forces, sexual or aggressive, that are not under control because of overly harsh toilet training. The person is thus fixated at the anal stage. The symptoms observed represent the outcome of the struggle between the id and the defense mechanisms.
Behavioral accounts of obsessions and compulsions consider the disorder to be learned behaviors reinforced by their consequences. One set of consequences is the reduction of fear. For example, compulsive hand washing is viewed as an operant escape-response that reduces an obsessional preoccupation with and fear of contamination by dirt or germs. Similarly, compulsive checking may reduce anxiety about whatever disaster the patient anticipates if the checking ritual is not completed.
Studies have demonstrated that some compulsivity is a problem with memory (i.e., poor recall of prior actions)
Persons with OCD may try to actively suppress troubling thoughts. Studies have shown that actively trying to inhibit thoughts has the paradoxical effect of inducing preoccupation with it. Further, attempts to suppress unpleasant thoughts are typically associated with intense emotional states, resulting in a strong link between the suppressed thought and the emotion.
Research on neurochemical factors has focused on serotonin. Antidepressants that inhibit the reuptake of serotonin have proved useful in OCD. The usual interpretation of this finding would be that because the drugs facilitate synaptic transmission in serotonin neurons, OCD is related to low levels of serotonin or reduced number of receptors. However, research has not supported this theory. Serotonin changes may cause changes in another system, which is the real location of the therapeutic effect. Both dopamine and acetylcholine have been proposed as transmitters that are coupled to serotonin and play the more important role in OCD.

15. Treatments for OCD Victor Meyer - Exposure plus response prevention
Research has shown some improvement in OCD with serotonin reuptake inhibitors and tricyclics
REBT - OCD results from an irrational belief that one must never make a mistake
Regardless of the treatment modality, OCD patients are rarely cured
OCD is one of the most difficult psychological disorders to treat.
The most widely used and generally accepted behavioral approach to compulsive rituals, pioneered in England by Victor Meyer, combines exposure with response prevention. In this method the person exposes himself or herself to situations that elicit the compulsive act - such as touching a dirty dish - and then refrains from performing the accustomed ritual - hand washing. The assumption is that the ritual is negatively reinforcing because it reduces anxiety that is aroused by some environmental stimulus or event, such as dust on a chair, and that preventing the person from performing the ritual will expose him or her to the anxiety-provoking stimuli, thereby allowing the the anxiety to extinguish.
Exposure + Response prevention effective for about 1/2 of OCD suffers, including children and adolescents
Problems - sometimes control over rituals only possible in a hospital (must prepare family members to take over program - hard to do). In the short term, curtailment is arduous and unpleasant for the clients; up to 25% of cases refuse treatment.
With medications, treatment gains are modest and symptoms return if the drug is discontinued.
A study comparing Prozac with behavior therapy found that both treatments was associated with the same changes in brain function, namely, reduced metabolic activity in the right caudate nucleus, overactivity of which has been linked to OCD.

16. Posttraumatic Stress Disorder (PTSD)
An extreme response to a severe stressor, including increased anxiety, avoidance of stimuli associated with the trauma, and a numbing of emotional responses.
The etiology in partially assumed in the definition - traumatic event(s)
Distinguished from Acute Stress Disorder in DSM-IV
Made popular due to combat experiences, especially after the Vietnam war. Now includes traumas such as rapes, accidents, natural disasters, experiences of emergency and rescue personnel, etc.
The traumatic event must have created intense fear, horror, or a sense of helplessness. The cause of PTSD is primarily the event, not the person. However, this has raised some controversy since only a minority of individuals experiencing a traumatic event will develop PTSD.
Acute Stress Disorder - diagnosed if symptoms are within 1 month of the traumatic event.

17. Major Symptoms of PTSD
Reexperiencing the traumatic event - nightmares, difficulty during “anniversaries,” upset by stimuli associated with the event (e.g., thunder)
Avoidance of stimuli associated with the event or numbing of responsiveness - decreased interest in others, estrangement
Symptoms of increased arousal - insomnia, low concentration, exaggerated startle response
Talk about the VA and the Tet Offensive
My A-10 pilot story - search and rescue, saw a bus of Iraqi soldiers on road, they shoot at him - he blows away - guilt and nightmares
Avoidance - person tries to avoid thinking about the trauma or event. Avoids encountering stimuli that will bring the trauma to mind. In PTSD, the person frequently goes back and forth between reexperiencing and numbing.
Children can experience PTSD different from adults - Sleep disorders and nightmares about monsters are common, as are behavioral changes, for example, a previously outgoing child becoming quiet and withdrawn or previously quiet child becoming aggressive and loud. Children have much more difficulty talking about their upset than adults.

18. Treatment of PTSD Emotional and Behavioral Stabilization
Trauma Education
Stress Management
Trauma Focus
Relapse Prevention
Follow-up and Maintenance
Emotional and Behavioral Stabilization - Initial efforts are directed at crisis resolution, stabilization, and modification of substance abuse.
Trauma Education - teach the patient about PTSD. Emphasis is on understanding the ramifications for people who are exposed to life-threatening traumatic events and who develop PTSD
Stress Management - Relaxation training, interpersonal skills training, anger management, problem solving training
Trauma Focus - Exposure to trauma - systematic desensitization, flooding, implosive therapy, etc.
Relapse Prevention - how to manage the inevitable return of symptoms
Follow-up and maintenance - develop the expectation that the treatment team is available to consult, self-help groups, etc.
Patients may become temporarily worse in the initial stages of therapy and the therapists themselves may become upset when they hear about the horrifying events that their patients experienced.