Anxiety Disorders

1. Anxiety Disorders • Panic Disorder • Specific Phobias • Social Phobia • Obsessive-Compulsive Disorder (OCD) • Posttraumatic Stress Disorder (PTSD) • Generalized Anxiety Disorder (GAD)

2. Panic Attack • A period of intense fear or discomfort involving at least 4 of the following symptoms that develop abruptly and peak within 10 min. • Racing heart, pounding heart (palpitations) • Sweating • Trembling or shaking • Feeling short of breath or smothering sensations • Feeling of choking • Chest pain or discomfort • Nausea or abdominal distress • Feeling dizzy, unsteady, lightheaded, & faint • Derealization or depersonalization • Fear of losing control or going crazy • Fear of dying • Numbness or tingling • Chills or hot flushes • May be expected or unexpected (“out of the blue”)

3. Main Diagnostic Criteria for Panic Disorder • Recurrent unexpected panic attacks • Persistent worry about having more attacks • Worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy") • Significant change in behavior related to the attacks • Presence or Absence of agoraphobia • The attacks are not due to a substance or a medical condition (thyroid problems)

4. Main Diagnostic Criteria for Specific Phobia • Excessive or unreasonable fear triggered by a specific object or situation (e.g., flying, animals). • Exposure to the phobic stimulus invariably provokes anxiety. • The person recognizes the fear is irrational. • The phobic situation(s) is avoided or endured with intense anxiety. • Significant personal distress or interference with routine.

5. Categories of Specific Phobias • Animal • Dogs, spiders, snakes • Natural environment • Water, storms, heights • Situational • Bridges/tunnels, flying, driving, elevators, tight spaces • Blood-injection-injury • Involves drop in blood pressure and can involve fainting • Other • Choking, vomiting, balloons, clowns

6. Main Diagnostic Criteria for Social Phobia • Excessive fear of one or more social and performance situations where the person is exposed to unfamiliar people or to possible scrutiny by others. • Fear of acting in a way (or show anxiety symptoms) that will be humiliating or embarrassing. • Exposure to the feared social situation invariably provokes anxiety • May take the form of a panic attack • The person recognizes the fear is excessive or unreasonable. • The feared social or performance situations are avoided or endured with intense anxiety • Excessive personal distress/interference in functioning

7. Main Diagnostic Criteria for OCD • Obsessions as defined by:  • Recurrent and persistent thoughts, impulses, or images that are experienced as intrusive, senseless, and inappropriate • Cause marked anxiety or distress  • the thoughts, impulses, or images are not simply excessive worries about real-life problems  • the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action  • the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind

8. Main Diagnostic Criteria for OCD (2) • Compulsions as defined by:  • Rituals: Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) • The person feels driven to perform the rituals in response to an obsession, or according to certain rules   • the rituals are aimed at preventing or reducing distress or preventing some dreaded event or situation • The rituals either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive 

9. Main Diagnostic Criteria for OCD (3) • At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.  • The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's routine. • With Poor insight: if, for most of the time the person does not recognize the obsessions and compulsions are excessive or unreasonable

10. Some Common Obsessions • contamination - dirt, germs, bodily waste, chemicals • mistakes - locks, appliances, paperwork, decisions • impulses - violent, sexual, religious, embarrassing • order - neatness, symmetry, numbers

11. Uncommon Obsessions • Contamination from people with disabilities • Thoughts of becoming pregnant (male) • Crumbs of the communion wafer fell in my underwear • Put the baby in the oven by mistake

12. Some Common Compulsive Rituals • Washing/Cleaning – hand washing, showering, toilet, inanimate objects, hand gel • Checking – locks, appliances, for assurance, • Mental rituals – praying, neutralizing, mental reviewing • Repeating – steps, touching • Ordering/arranging – left-right balance

13. Causes of anxiety disorders • Biological/genetic • General vulnerability • Negative affect • Intensity of fight/flight response • Psychological/environmental/learning • Personal experiences (traumatic?) • Vicarious learning • Informational transmission

14. Persistence of anxiety disorders • Physiological • Fight/flight response • Cognitive • Dysfunctional beliefs and interpretations • Overestimates of probability and severity • Behavioral • Avoidance • Safety behaviors, rituals, & safety signals

15. Types of Exposure Therapy • In vivo: confrontation with fear-evoking situations • example: party, closet, floor, driving • Imaginal: confrontation with anxiety-evoking thoughts/doubts • Fires, responsibility for harming a loved one • Interoceptive: confrontation with fear-evoking bodily sensations • example: dizziness, breathlessness, headache

16. Criteria for Fear Reduction During Exposure Therapy • Elicit fear • Allow habituation to occur • Provide corrective information

17. Effects of Repeated and Prolonged Exposure on Irrational fear

18. Sarah: Contamination OCD • Married female in her late 20s, has baby • Fears of contamination from animals (pets, bugs) • Will get germs and then perhaps get sick • Compulsive washing, cleaning, & changing clothes rituals to minimize contact with contaminants and to keep anxiety manageable • Avoidance: neighbor’s home, own baby, certain clothes, handling food • Asks others to touch many things

19. Exposure Therapy Hierarchy: Fear of contamination from animals • Situation (SUDS) • Office floor (40) • Floor near entry to home (45) • Neighbor’s house/couch (65) • Neighbor’s pet • Dresser where bug was found (70) • Clothes from “buggy” dresser (75) • Bugs (85)

20. Response Prevention: Washer • No contact with water except for 1 daily ten-minute shower • No changing clothes during the day • No cleaning objects in the house • No use of gloves/towels to touch surfaces • No asking others to open doors, hold baby, prepare food, etc.