2. Out lines
 Introduction
 Define the following terms
Anxiety, fear, & panic attack
Five major types of anxiety disorders are:
 Generalized anxiety disorder
 Panic disorder
 Phobias,
 Posttraumatic stress disorder (PTSD),
 Obsessive–compulsive disorder (OCD),
 Conclusion
 Reference

3. Introduction
 Everyone experiences feelings of anxiety during their
lifetime. For example, the person may feel worried
and anxious about sitting an examination, or having a
medical test, or a job interview. Feeling anxious
sometimes is perfectly normal. However, for people
with generalized anxiety disorder (GAD), feelings of
anxiety are much more constant, and tend to affect
their day-to-day life. However, anxiety is not always
pathological or maladaptive: it is a common emotion
along with fear, anger, sadness, and happiness, and it
has a very important function in relation to survival.

4. Anxiety
 Anxiety is a physiological state characterized by
cognitive, somatic, emotional, and behavioral
components. These components combine to create the
feelings that are typically recognize as fear,
apprehension, or worry.
Or
 Anxiety is a negative mood state characterized by
bodily symptoms of physical tension, & apprehension
about the future (American psychiatric association,
1994; Barlow, 2002)

5. Symptoms of anxiety
 Anxiety is often accompanied by physical sensations
such as:
Sympathetic nervous system (fight)
 heart palpitations
 chest pain
 shortness of breath
 headache.
 Papillary dilation

6.  nausea
 pale skin
 sweating
 trembling,
 stomach aches
 diarrhea, & chills.

7.  Emotionally, anxiety causes a sense of fear or panic
 The cognitive component entails expectation of a
diffuse and certain danger.
 Behaviorally, both voluntary and involuntary
behaviors may arise directed at escaping or avoiding
the source of anxiety and often maladaptive, being
most extreme in anxiety disorders.

8. Anxiety versus Fear
Anxiety is a future oriented mood state, characterized
by apprehension because one cannot predict or control
upcoming events(subjective feeling)
Fear is an immediate and current reaction to danger
characterized by a strong escapist action (objective
feeling)

9. Panic Attack
 An abrupt experience of intense fear or acute
discomfort accompanied by physical symptoms that
include:-
 Heart palpitations
 Chest pain
 Shortness of breath
 Dizziness
 Disorganized personality &
 Not able to make decision.

10. Three basic types of Panic Attacks are describe in DSM-IV
– Situationally bound (cued) panic attack.
are more common in specific phobias or social phobia
– Unexpected (uncued) panic attack
"SPONTANEOUS", Without apparent stimulus.
– Situationally predisposed panic In between
Increased in certain situations (e.g. driving; crowds)

11. The Phenomenology of Panic
Attacks
Figure 1.1 The relationships among anxiety, fear, and panic attack.

12. Anxiety Disorders
Anxiety disorders are the most common of emotional
disorders.
Many forms and symptoms may include:
 Overwhelming feelings of panic and fear
 Uncontrollable obsessive thoughts
 Painful, intrusive memories
 Recurring nightmares
 Physical symptoms such as feeling sick to the
stomach, “butterflies”, heart pounding, and muscle
tension

13.  Anxiety disorders differ from normal feelings of
nervousness.
 Untreated anxiety disorders can push people into
avoiding situations that trigger or worsen their
symptoms.
 People with anxiety disorders are likely to suffer
from depression, and they also may abuse alcohol and
other drugs in an effort to gain relief from their
symptoms.
Job performance, school work, and personal
relationships can also suffer.

14. Psychological Contributions to Anxiety and Fear
• Psychological Views
– Early experiences with uncontrollability / unpredictability
• Began with Freud
– Anxiety is a psychic reaction to danger
– Anxiety involves reactivation of an infantile fearful situation
• Behavioristic Views
– Anxiety and fear result from classical and operant
conditioning and modeling
• Social Contributions
– Stressful life events trigger vulnerabilities
– Many stressors are familial and interpersonal

15. An integrated Model
• Integrative View
– Biological vulnerability interacts with psychological,
experiential, and social variables to produce an anxiety
disorder
• Generalized biological vulnerability to anxiety is not
anxiety itself ,a given stressor could activate biological
tendencies to anxiety and psychological tendencies to
feel that not be able to deal with situation and control
the stress

16. Comorbidity of anxiety disorders
The co-occurrence of two or more disorders in a single
individuals is referred to as Comorbidity.
If each patient with an anxiety disorder also had every
other anxiety disorder, there would be little sense in
distinguishing among the specific disorders.
It would be enough to say, simply, that the patient had
an anxiety disorder.

17. Cont.
But this is not the case, & although rates of Comorbidity
are high, they vary somewhat from disorder to
disorder.
A large-scale study was recently completed at one of our
centers, examining the Comorbidity of DSM IV
anxiety & mood disorders substance abuse disorders,
other anxiety disorders (except Social Phobia)

18. Types of Anxiety Disorders
 Generalized Anxiety Disorder
 Panic Disorder with and without Agoraphobia
 Specific Phobias
 Social Phobia
 Posttraumatic Stress Disorder
 Obsessive-Compulsive Disorder

19. Generalized anxiety disorder
 Generalized anxiety disorder is a common chronic
disorder that affects twice as many women as men and
can lead to considerable impairment (Brawman-
Mintzer & Lydiard, 1996, 1997).

20. ICD10 classification
symptoms present most days for weeks
Motor tension
 Muscle tension, twitching and shaking, restlessness,
Apprehension
 Feeling on edge, unable to cope, poor concentration,
insomnia, irritability
 Autonomic over-activity
 Light headedness, sweating, tachycardia, dry mouth,
epigastric discomfort

21. Facts and Statistics
 4% of the general population meet criteria
 Females 2:1 over males
 Onset often insidious, beginning early adulthood
 Tendency to be anxious runs in families
 Associated Features
 Persons with GAD are “autonomic restrictors”
 Fail to process emotional component of thoughts &
Images.

22.  Generalized Anxiety Disorder: The “Basic”
Anxiety Disorder
 Excessive uncontrollable anxious apprehension
 Unproductively
 worry about life events
 Coupled with strong, persistent anxiety
 Somatic symptoms differ from panic (e.g., muscle
 tension, fatigue, irritability)
 Persists for 6 months or more

23. Generalized Anxiety Disorder:
Associated Features and Treatment
Figure 5.5 An integrative model of generalized anxiety disorder

24. 2. Panic disorder
The core symptom of panic disorder is the panic attack,
an overwhelming combination of physical and
psychological distress.

25. Panic Disorder with and without Agoraphobia
 Experience of recurrent unexpected panic attack
 Develop anxiety, worry, or fear about having another
attack or its implications
 Agoraphobia – Fear and avoidance of situations/events
escape is difficult associated with panic
 Symptoms and concern about another attack persists
for 1 month or more.

26. DSM IV diagnostic criteria for panic attack
 Palpitation
 Accelerated heart rate
 Sweating
 Trembling or shaking
 Sensations of shortness of breath
 Feeling of choking
 Chest pain

27. DSM IV diagnostic criteria for panic attack
cont.
 Nausea or abdominal distress
 Feeling dizzy, unsteady, lightheaded, or faint
 Derealization (feelings of unreality) or
depersonalization (being detached from oneself)
 Fear of losing control or going crazy
 Fear of dying
 Paresthesias (numbness or tingling sensations)
 Chills or hot flashes

28. Panic disorder - epidemiology
• Facts and Statistics
– Panic disorder affects about 3.5% of the population
– Two thirds with panic disorder are female
– Onset is often acute, beginning between ages 25 -29

29. Panic disorder - psychological treatments
 Behavioural therapy
 exposure and response prevention
 relaxation techniques
 Cognitive behaviour therapy
 Education
 Recognition and change of negative thoughts

30. Phobia
A phobia is excessive and persistent fear of a specific
object, situation, or activity.
These fears cause such distress that some people go to
extreme lengths to avoid what they fear.

31. There are three types of phobias:
1. Specific phobia
2. Social phobia
3. Agoraphobia

32. Specific Phobias:
• Overview and Defining Features
– Extreme and irrational fear of a specific object or
situation
– Markedly interferes with one's ability to function
– Recognize fears are unreasonable
– Still go to great lengths to avoid phobic objects

33. Causes of Phobias
 Genetic vulnerability
 Evolutionary influences
 Direct conditioning
 Observational learning
 Learning history
 Information transmission

34. Specific Phobias: Associated
Features and Treatment
• Associated Features and Subtypes of Specific Phobia
– Blood-injury-injection phobia – Vasovagal response
– Situational phobia – Public transportation or enclosed
places (e.g., planes)
– Natural environment phobia – Events occurring in
nature (e.g., heights, storms)
– Animal phobia – Animals and insects
– Other phobias – Do not fit into the other categories
(e.g., fear of choking, vomiting)
– Separation anxiety disorder – Children’s worry that
something will happen to parents

35. Facts and Statistics
 7-11% general population meet diagnostic criteria for
specific phobia
 Females are again over-represented
 Phobias run a chronic course, with onset beginning
between 15 and 20 years of age

36. DSM IV for specific phobia
 Marked & persistent fear that is excessive or
unreasonable, cued by the presence of a specific object
or situation (flying, heights, animals, receiving
injection, seeing blood)
 Exposure to be the phobic stimulus almost invariably
provokes an immediate anxiety response, which may
take the form of a situational bound or Situationally
predisposed panic attack
 The person recognized that the fear is excessive or
unreasonable.

37. Specific Phobias: Treatment
 Psychological Treatments of Specific Phobias
 Cognitive-behavior therapies are highly effective
 Structured and consistent graduated exposure

38. Social Phobia:
• Overview and Defining Features
– Extreme and irrational fear/shyness
– Focused on social and/or performance situations
– Markedly interferes with one's ability to function
– May avoid social situations or endure them with distress

39. Generalized subtype?
 Anxiety across many social situations Facts and
Statistics
 Affects about 13% of the general population at some
point
 Females are slightly more represented than males
 Onset is usually during adolescence
 Peak age of onset at about 15 years

40. Social Phobia: Treatment
Causes of Phobias
– Biological and evolutionary vulnerability
– Direct conditioning, observational learning, information
transmission

41. Social Phobia: Treatment (cont.)
 Psychological Treatment of Social Phobia
 Cognitive-behavioral treatment – Exposure, rehearsal,
role-play in a group setting
 Cognitive-behavior therapies are highly effective

42. Agoraphobia
 Fear of open spaces, crowds or public places.
 Fear of travelling by public transport
 Fear that it may be difficult to get to a place of safety
(home)
 Situations where an immediately available exit is
lacking are avoided.

43. Agoraphobia - epidemiology
(similar to panic disorder)
 Predominantly females – 75%
 Age of onset – 15 to 35
 Risk factors
 Stressful life events
 Family history – 20% relative with agoraphobia
 Domestic instability – family or marital difficulties
 History of childhood fears or enuresis
 Overprotective family members
 Differential diagnosis
 Depression, schizophrenia, dementia

44. Agoraphobia - symptoms
 Autonomic symptoms - faintness, palpitations, SOB,
sweating
 Panic attacks marker of severity
 Psychological symptoms - fear, dread
 Behavioural symptoms - avoidance to the extent that
the person becomes house bound
 Cognitive symptoms - “ I might have died”

45. Agoraphobia - Management
and Prognosis
 Behaviour therapy - graded exposure and systematic
desensitisation
 CBT
 Family therapy
 Self help books
 Pharmacotherapy - as for panic disorder

46. Situations Avoided by People with Agoraphobia
 Shopping malls
 Cars (driver or passenger)
 Buses
 Trains
 Subways
 Wide Streets
 Tunnels
 Restaurants
 Theaters
Source: Barlow & Durand, 2002, p. 124

47. Cont.
 Being far from home
 Staying at home alone
 Waiting in line
 Supermarkets
 Stores
 Crowds
 Planes
 Elevators
 Escalators

48. Social Phobia
 Fear of scrutiny by others in relatively small groups
 Fear of acting in a way that will be embarrassing or
humiliating or appear ridiculous
 Feared social situation associated with intense
anxiety and distress - blushing, tremor,butterflies
 Leads to avoidance of social situations that involve
e.g., eating, public speaking - isolation
 Differential diagnosis
 Body dysmorphic disorder, panic disorder, depression,
paranoid psychosis

49. Posttraumatic Stress Disorder
(PTSD): An Overview
• Overview and Defining Features
– Requires exposure to a traumatic event
– Person experiences extreme fear, helplessness, or horror
– Continue to re-experience the event (e.g., memories,
nightmares, flashbacks)
– Avoidance of reminders of trauma
– Emotional numbing
– Interpersonal problems are common
– Markedly interferes with one's ability to function
– PTSD diagnosis – Only 1 month or more post-trauma

50. Posttraumatic Stress Disorder
(PTSD): An Overview (cont.)
 Facts and Statistics
 Affects about 7.8% of the general population
 Most Common Traumas
 Sexual assault
 Accidents
 Combat

51. DSM diagnostic criteria for posttraumatic
stress disorder
a. The person has been exposed to a traumatic event in
which both of the following were present.
1. The person experience, witnessed, or was confronted
with an event
2. The person response involved intense fear,
helplessness,
b. The traumatic event is persistently reexperienced in
one (or more) of the following ways

52. Cont,
1. Recurrent & intrusive distressing recollections of the
event, including images, thought, pr perception
2. Recurrent distressing dreams of the event
3. Acting or feeling as if the traumatic event were
recurring
4. Intense psychological distress at exposure to internal
or external cues that symbolize
5. Physiologic reactivity on exposure to internal or
external cues that symbolize

53. Cont.
c. Persistent avoidance of stimuli associated with the
trauma & numbing of general responsiveness of the
following
1. Efforts to avoid thoughts, feelings or conversations
associated with the trauma
2. Efforts to avoid activities, places,
3. Inability to recall an important aspect of the trauma
4. Feeling of detachment
5. Restricted rang of affect
6. Sense of a foreshortened future (does not except to
have a career, marriage, children, or normal life span)

54. Cont.
d. Persistent symptoms of increased arousal
1. Difficulty falling or staying asleep
2. Irritability
3. Hpervigilance
4. Exaggerated startle response
e. Duration of the disturbance symptoms in b,c,d is
more than one month
f. The disturbance causes clinically significant distress in
social, occupational,
Acute: if duration of symptoms is less than 3 month
Chronic : if duration of symptoms is 3 months or more

55. Posttraumatic Stress Disorder
(PTSD):
Causes and Associated Features
• Subtypes and Associated Features of PTSD
– Acute PTSD – May be diagnosed 1-3 months post trauma
– Chronic PTSD – Diagnosed after 3 months post trauma
– Delayed onset PTSD – Symptoms begin after 6 months
or more post trauma
– Acute stress disorder – Diagnosis of PTSD immediately
post-trauma
• Causes of PTSD
– Intensity of the trauma and one’s reaction to it
– Uncontrollability and unpredictability
– Extent of social support, or lack thereof post-trauma
– Direct conditioning and observational learning

56. PTSD Comorbidity
 88% of men and 79% of women with PTSD meet
diagnostic criteria for another psychological disorder
 Drug/alcohol abuse/dependence
 Major Depressive Disorder
 Borderline Personality Disorder
 Phobias
 Panic Disorder
 Social Misconduct

57. PTSD - outcome
 Symptoms fluctuate over time
 Most intense at times of stress
 30% complete recovery
 10 % do badly
 Predictors of poor outcome - Hx of childhood trauma,
borderline or ontisocial personality traits, poor
support network, heavy alcohol intake

58. Posttraumatic Stress Disorder
(PTSD): Treatment
 Psychological Treatment of PTSD
 Cognitive-behavioral treatment involves graduated or
massed imaginal exposure
 Increase positive coping skills and social support
 Cognitive-behavior therapies are highly effective

59. Obsessive-Compulsive Disorder
(OCD): An Overview
• Overview and Defining Features
• Obsessions
– Intrusive and nonsensical thoughts, images, or urges
that one tries to resist or eliminate
• Compulsions
– Thoughts or actions to suppress thoughts
– Provide relief
• Most persons with OCD display multiple obsessions
• Many with cleaning, washing, and/or checking rituals

60. OCD
Most common obsessions
 Contamination
 Aggressive Impulses
 Somatic Concerns
 Need for Symmetry

61. OCD
Most common compulsions
 Checking
 Ordering
 Arranging
 Washing
 Cleaning
 Counting
 Hoarding

62. DSM diagnostic criteria for obsessive-
compulsive disorder
 Obsessive
1.Recurrent & persistent thoughts, impulses or images that
are experienced, at some time during the disturbance ,
as intrusive & inappropriate, & cause marked anxiety or
distress
2. The thoughts, impulses, or images are not simply
excessive worries about real-life problems
3. The person attempts to ignore or suppress such
thoughts, impulses, or images,
4. The person recognizes that the obsession thoughts,
impulses, or images are a product of his or her own
mind.

63. Cont.
Compulsions
1.Repetive behaviors (e.g., hand washing, ordering,
checking) or mental acts (e.g., praying, counting,
repeating words silently)that the person feels driven to
perform in response to an obsession,
2. The behaviors or mental acts are aimed at preventing
or reducing distress or preventing some dreaded event
or situation, however, these behaviors or mental acts
either are not connected in a realistic way with what
they are designed to neutralize or prevent,

64. OCD epidemiology
 Lifetime prevalence 1 -2%
 Equal sex incidence
 Age of onset 20 - usually abrupt
 Often delay of years in seeking tx
 Course chronic and fluctuating
 Often co-morbid anxiety disorders, (social phobia
25%), depression (67%), eating disorders

65. Causes of OCD
 Thought action fusion –
 Causes a person to not be able to throw the thought
away because it is almost as if they are doing it

66. OCD - Management
 Behaviour therapy
 Exposure and response prevention
 Paradoxical injunctions
 CBT - less useful
 Pharmacotherapy
 SSRIs, Clomipramine
 Augmentation with quetiapine or risperidone
 Clonazepam