Chapter 5 (Adult) Flashcards
State 9 anxiety disorders
- Separation anxiety
- Selective mutism
- Specific phobias
- Social phobia
- Agoraphobia
- Panic
- Generalized anxiety
- Medical condition induced anxiety
- Substance induced anxiety disorder
State 5 trauma, stress related disorders
- Adjustment disorder
- PTSD
- Disinhibited social engagement
- Acute stress disorder
- Reactive detachment
State 7 Obsessive-compulsive and related disorders
- OCD
- Hoarding
- Trichotillomania
- Excoriation
- Body dysmorphic
- Obsessive compulsive and related disorder due to medical condition
- Substance induced obsessive/related
What common symptomatology do ocd spectrum and trauma related disorders share?
Anxiety
Differentiate between fear and anxiety
Fear is a normal, natural response to threat by humans and animals. From an evolutionary respect
Anxiety is a mood characterized by negative affect and bodily symptoms like tension, in which a person anticipates future danger/ misfortune. Anxiety involves feelings, behaviors and physiological responses.
Why is anxiety a future-oriented feeling state
Because human ability to conceive and plan for the future is connected to the g n a w i n g feeling that things might go wrong and that we have better prepared for them
State five bodily symptoms of anxiety
Muscular tension increased pulse dry mouth altered breathing and fidgeting
If fear can be likened to an alarm what can pathological fear like panic be likened too
False alarm. Or a state of excessive vigilance because this fearful state is experienced in an overexaggerated manner often or good reason at all
What is an archetypal threat
It is a Primal Fear or danger that is deeply rooted in the human site amongst all human. Examples include the Field of death abandonment and the unknown which can trigger and intense emotional response and Influence behavior often manifesting in various forms like anxiety aggression or avoidance
What is the fear-anxiety rule of thumb
It is a simplified way to understand the relationship between fear and anxiety
What is the relationship between an archetypal threat and a pathological response
An archetypal threat is a a Primal Fear the tips into universal human experiences and often relates to Survival Instincts I think examples include fear death fear of abandonment smothering. A pathological response refers to reactive behavior that deviate from normal functioning and cause distress or impairment and life. Please responses can run first a psychological disorders or dysfunctional coping mechanisms
Give five archetypal threats and the corresponding pathological responses
- Smothering- panic attack or panic disorder.
- Animals and environment- specific phobia.
- Social rejection- social anxiety.
- Dirt, disorganization- OCD.
- Future- generalized anxiety disorder
What is the most intense expression of Fear
Panic. It is encountered across a range of normal situations and physical conditions and many mental disorders which one not limited to the panic disorder
What is an immediate emotional reaction to a current threat geared towards averting danger
Fear
What is a future-oriented mood state which is characterized and should because we cannot predict or control upcoming event
Anxiety
What is a panic attack
It is a true expression of Fear immediate and overwhelming
What is a panic attack in psychopathology
an abrupt experience of intense fear or acute discomfort accompanied by physical symptoms like breathing changes, palpitations, chills and flushing
Cued and uncued panic attacks (DSM-5)
Expected and unexpected
Provide examples for acute and uncued panic attack
For example if one knows that there are afraid for high places they might have a panic attack in a situation with it or in a high place but not anywhere else this is a cubed or unexpected panic Clinch. One might experience unexpected panic attacks if attacked by a stranger for no good reason. Unexpected funny attacks are important in panic disorder
In which phobias are expected attacks more common in
Specific phobias or social phobias
Since uh panic attack is not to considered a disorder by the dsm5 what is it recognized as
Recognized as occurring across arrange of conditions including panic disorder which is characterized by recurrent panic attacks
What is the diagnostic criteria for the panic attack in the dsm-5
A panic attack according to the dsm-5 is an abrupt surge of intense fear that reaches a peak within minutes and during which time for or more of the symptoms occur; palpitations ford/pounding heart/accelerated heart rate sweating trembling/shaking sensations of shortness of breath or smothering feeling of choking chest pains/discomfort nausea/abdominal distress feeling dizzy for slash and steady/l/ faint paresthesius( numbness or tinglings sensations) chills or heat do you realization (feelings of unreality) or the personalization (being detached from oneself closed) fear of losing control or going crazy and fear of dying
The difference between panic and a panic attack
Panic is a sudden overwhelming fright or fear
a panic attack is the abrupt experience of intense fear or discomfort accompanied by a number physical symptoms such as dizziness or heart palpitations
Biological contributions to panic and anxiety
Tendencies to feel tension, uptight and anxious may be inherited.
Anxiety and panic tendencies can run in families and have a genetic component.
No single gene causes anxiety or panic- it is influenced by collections of genes on chromosomes. Genetic vulnerability doesn’t directly cause anxiety or panic but it makes individuals more subsceptible to them. Environmental stressors can activate genes associated with anxiety or panic. Anxiety is associated with specific neurosystems in the brain. Various neurotransmitter systems ( gaba noradrenaline dopamine and serotonin) are implicated in the anxiety development
The Corticotropin-releasing factor system (CPF)
CPF activates the hypothalamic pictureary adrenocortinol( HPA) axis, which affects areas of the brain associated with anxiety including the hippocampus, amygdala, brain stem, locus coeruleus and the prefrontal cortex. The CRF system interacts with neurotransmitter systems like gabaergic serotonergic and noradrinergic Systems.
Which system is heavily implicated in anxiety and act as a mediator between the brain stem and cortex
The limbic system articularly the amygdala and hippocampus
Which other systems in the brain that control mood does the CRF also interact with
G a b a e r g i c so serotonergic and Nora denergic systems
Which two parts of the limbic system are important for anxiety and what is their roll
The amygdala and hippocampus which act as Middleman between the brain stem and the cortex
What is the purpose of the brain stem
It is like a Watchdog that notices changes in the body and since dangerous signals through the limbic system to the Cortex which is the thinking part of the brain
What is the behavioral inhibition system(b i s)
a pathway in the limbic system that goes from the septal and the hippocampul areas to the frontal cortex which gets activated by signals from the brain stem when something unexpected happens
BIS-behavioral inhibition system
Brain circuit in the limbic system that responds to threat signals by inhibiting activity and causing anxiety. P i s circuit is distinct from the circuit involved in panic
What is the fight/ flight system( FFS)
It is a brain circuit in animals that when stimulated causes an immediate alarm and escape responds resembling human panic. The circuit originate in the brainstem and travels through several midbrain structures including the amygdala the ventromedial nucleus off the hypothalamus and the central Gray matter
What activates FFS
Partly by abnormalities in serotonin e r g i c transmission
Explain how environmental factors affect anxiety
Environmental factors can influence the sensitivity of neural systems affecting the risk of anxiety disorders
A study followed nearly 700 adolescence into Adulthood finding that teenagers who smoked heavily where it significantly higher risk of developing panic disorder and generized anxiety disorder later on in life confirming the complex relationship between smoking and panic disorder
How are brainstem chemo receptors implicated in panic disorder
Brainstem kimo receptors are implicated in panic disorder because panic attacks can be induced by lactic acid infusion which mimics the biochemical effects of smothering
What triggers panic like responses in the brain
Kimo receptors in the brain stem detect increases in carbon dioxide triggering panic-like responses
What is associated with brainstem abnormalities in terms of anxiety disorders
Agoraphobia often accompanied by mild disequilibrium symptoms
What cardio respiratory conditions can provoke panic attacks
Conditions such as myocardial infarction pulmonary embolism pneumothorax and pneumonia
Infection in patients with AIDS main present with hyperventilation and panic symptoms
Pneumocystis Carini is a fungus that may present with Mark type of ventilation and panic symptoms in patients with AIDS.
What endocrine disorders can precipitate panic attacks
Endocranopathies such as hypothyroidism and pharochromocytoma ( a tumor producing excessive noradrenaline and adrenaline) may precipitate panic attacks
What chronic conditions are associated with anxiety symptoms
Chronic gastrointestinal disease and various arthritides
What movement disorder is often characterized by anxiety
Parkinson’s Disease
What type of seizures may produce symptoms similar to panic attacks
Focal seizures particularly those originating in the medial temporal lobe as well as migraines
What type of medications may cause anxiety symptoms and panic
Beta-agonists used to treat asthma may cause anxiety symptoms and panic
What substances of abuse are implicated in causing anxiety symptoms
Substances of abuse with the during intoxication or with four our implicated in anxio Genesis. Alcohol and sedative-hypnotic withdrawals are noted for the prominence of anxiety
Why is it important to exclude potentially life threatening physical conditions in the management of panic
Because a panic attack is often mistaken for a heart attack until proven otherwise
What are some theories on the psychological causes of anxiety/ psychological contributions to anxiety
Freud foot anxiety was a psychic reaction to danger surrounding the reactivation of an infantile fearful situation the. Behavioral theorists believed that anxiety was the product of early classical conditioning modeling and other forms of learning
What evidence support and integrated model of anxiety
New and accumulating evidence supports an integrated model of anxiety involving a variety of psychological factors
How might upbringing and environmental factors contribute to a sense of uncontrollability
Upbringing and disruptive or traumatic environmental factors can contribute to a sense of uncontrollability ranging from total confidence in control to Deep uncertainty about the dealing with upcoming events
How did the apartheid political system contributes to anxiety?
It created adverse social conditions including extreme poverty HIV infection intimate partner violence and child abuse which contributed to a sense of uncontrollability and anxiety
What parenting Styles Foster a healthy sense of control and children
Parents who interact positively and predictably with their children responding to their needs and allowing exploration while providing secure home base Fosters a healthy sense of control
How do overprotective parenting Styles impact children’s sense of control?
Overprotective parenting styles that shield children from adversity may prevent them from learning to cope leading to a diminished sense of control and an increased vulnerability to anxiety
What psychological factor influences vulnerability to anxiety in later life?
The sense of control (or lack there off) that develops from early experiences influences vulnerability to anxiety in later life
What is the conditioning process in psychological accounts of panic?
The conditioning process involves associating an emotional response with external and internal Cues which leads to a learned or false alarm response to those cues
How do external and internal Cues contribute to panic attacks?
External Cues such as places or situation similar to where panic attacks occurred and internal Cues like the increase is in heart rate can provoke panic attacks even when no actual danger is present
Why might individuals be unaware of Cues or triggers of severe fear?
Individuals may be unaware of Cues or triggers of severe fear because they are unconscious and made bypass the Cortex traveling directly to the amygdala in the emotional brain
How does socioeconomic status relate to anxiety
Decreased socioeconomic status in social capital are associated with non-specific psychological distress in South Africa suggesting that anxiety is more common in groups with low socioeconomic status
How do cultural factors influence the experience and interpretation of anxiety?
Cultural factors strongly influence how anxiety is experienced interpreted and responded to
What is the triple vulnerability theory of anxiety development?
It’s suggests three vulnerabilities that contribute to anxiety development; general biological vulnerability general psychological vulnerability and specific psychological vulnerability
How do the three vulnerabilities interact to predispose individuals to anxiety disorders?
If individuals possess all three vulnerabilities ( biological general psychological and specific psychological) they are more likely to develop and anxiety disorder after experiencing a stressful situation
How does panic relate to stress and genetic factors?
Panic is a characteristic response to stress influenced by genetic components separate from anxiety. Anxiety increase as the likelihood of panic suggesting and evolutionary preparation for reacting to imminent danger
What are the characteristics of each vulnerability in the triple vulnerability Theory?
Biological vulnerability- heritable contribution to negative affect irritability and driven behavior.
Specific psychological vulnerability- anxiety about death and non-clinical panic.
psychological vulnerability-tendency towards select off self-confidence low self-esteem and inability to cope
How does stress perpetuate anxiety in the triple vulnerability model?
Stressors can activate biological and psychological vulnerabilities to anxiety. Once the cycle starts it tends to feed on itself persisting even after the stressor has passed
How does the experience of anxiety prepare individuals for potential threats?
Anxiety as a response to possible future threats prepares individuals to react instantaneously with an alarm response if the danger becomes imminent
Why is it important to note the comorbidity of anxiety and related disorder?
Comorbidity emphasizes how these disorders share common features in vulnerabilities both biological and psychological contributing to their development
Is the most common additional diagnosis for anxiety disorders?
Major depression
How do additional diagnosis of depression or substance abuse affect recovery from anxiety disorders?
Make recovery less likely and increase the likelihood of a relapse
What physical conditions are commonly c o morbid with anxiety disorders
- thyroid disease
- respiratory disease
- Gastrointestinal disease
- Arthritis
- Migraine
- Allergic conditions
How does comorbidity with physical diseases affect quality of life
They cause greater morbidity and a poorer quality of life
What relationship exists between panic disorder and cardiovascular disease
Panic attacks often co-occur with certain medical conditions particularly cardio respiratory gastrointestinal and vestibular disorders
How long does comorbidity with anxiety disorders affect suicide risk?
Having an anxiety or related disorder increases the risk of suicidal thoughts or attempts with a panic disorder and PTSD showing the strongest Association
What disorders are traditionally grouped together as anxiety disorders?
- Generalized anxiety disorder (g a d)
- panic disorder (PD)
- agoraphobia
- specific phobia
- social anxiety disorder
- separation anxiety disorder 7. selective mutism
What distinguishes specific anxiety disorders from other conditions
The other disorders are complicated by panic attacks or other features but are the focus of the anxiety
What is generalized anxiety disorder (g a d)
intense, chronic, uncontrollable and continuous worry about everyday life events accompanied by physical symptoms like tenseness irritability and restlessness
What distinguishes pathological worrying in general anxiety disorder from normal worrying
Pathological worrying in general anxiety disorder is present more days than not for at least six months and it’s difficult to control unlike normal worrying that stops once the challenge is over
What physical symptoms are associated with gad
Muscle tension headaches susceptibility to fatigue and difficulty sleeping
What distinguishes the focus of worry in g A D from other anxiety disorders
People with g a d mostly worry about minor everyday life events although major events can also become the focus of anxiety
What are common worries for children with gad
Health related concerns and difficulty sleeping often exacerbated by insomnia and anxiety
What are the general guidelines for anxiety disorders
Common conditions common comorbidity with other psychological disorders more than one anxiety disorder coexistence with major depression common commonity with physical conditions panic attacks are non-specific and can occur across various conditions panic may be the first presentation of serious physical illness suicide is a serious and common risk
What is the duration requirement for excessive anxiety and worry in g a d according to the dsm-5 criteria
Excessive worry and anxiety must occur on more days than not for at least 6 months
What is the Criterion related to the individuals control over the worry in g a d(dsm5 criteria)
The individual must find it difficult to control the worry
How many of the six listed symptoms must be present in gad for diagnosis and how many are required for children according to the dsm-5
At least three of these six symptoms listed are required for diagnosis in adults with only one symptom required for children.
Restlessness or feeling on edge being easily fatigued difficulty concentrating or mind going blind irritability muscle tension sleep disturbance
What is the diagnostic criteria for gad according to the dsm-5
A. Excessive anxiety and worry about a number of events like school or work performance occurring on more days than not for at least 6 months
B. The individual finds it difficult to control the worry.
C. The anxiety and why we are associated with at least three or more of six symptoms. Only one of the following is required in children:
1. Restlessness
2. Easily fatigued
3. Irritability
4. Muscle tension
5. Sleep disturbance
6. Difficulty concentrating
D. The anxiety worry or physical symptoms cause clinically significant distress or impairment in social occupation and other important areas of functioning.
E. The disturbance is not due to the direct psychological effects of a substance (drug abuse, medication ) or general medical condition such as hyperthyroidism.
F. The disturbance is not better explained by another mental disorder (anxiety/ worry about panicking attacks in PD)
What are the six symptoms associated with g a d according to the dsm-5
- Restlessness or feeling on edge
- being easily fatigued
3.difficulty concentrating or mind going blank - irritability
- muscle tension
- sleep disturbance
What level of distress or impairment is required in gad
Anxiety worry or physical symptoms must cause clinically significant distress or impairment in social occupational and other important areas of functioning
What exclusions are specified in the dsm-5 criteria for gad
The disturbance cannot be due to the direct physiological effects of substances or general medical conditions and it cannot be better explained by another mental disorder
What is the general biological vulnerability associated with g a d
If there is a generalized biological vulnerability reflected in genetics studies showing attendancy to become anxious rather than g8d itself being inherited
How do individuals with g a d differ in physiological responsiveness compared to those with other anxiety disorders
Individuals with g a d showed less physiological responsiveness to stresses often termed” automatic restrictors closed with chronic muscle tension being a key distinguishing Factor
What cognitive processes contribute to the development of gad
Individuals with g a d show high-end sensitivity to threat particularly threat to with personal relevance which leads to intense cognitive processing such as worry without accompanying images
How does intense cognitive processing contributes to autonomic restriction in the g80
Intense cognitive processing particularly worry may consume attentional resources leaving the capacity for creating mental images of potential threats thus leading to autonomic restriction
Why do individuals with g a d show chronic worry and muscle tension
They may avoid processing negative affect and imagery associated with anxiety leading to chronic worry and muscle tension as a result of continuous autonomic arousal
What are the key factors contributing to the development of gad
Generized biological vulnerability (inheritance of a tendency to be tense) and the general psychological vulnerability (early experiences of uncontrollable adverse events) play significant Rose exacerbated by significant stress triggering intense worry and physiological changes
What is the model of development proposed for gad
The development of g a d involves a combination of biological and psychological vulnerabilities leading to intense worry and physiological changes rather than an immediate response to threat
What is the most prudent approach to managing GAD?
It involves excluding physical causes or contributors to anxiety symptoms
What are the 2 separate approaches to pharmacological treatment for GAD?
First approach involves acute symptomatic relief with anxiolytic agents like benzodiazepines.
The second approach concerns long-term management with antidepressants
What are the proffered characteristics of benzodiazepines for acute symptomatic relief in GAD?
Longer-acting, lower-potency agents like diazepam are preferred over short-acting high potency agents to reduce the risk of dependence
What are some limitations of benzodiazepines in GAD treatment?
They have a modest therapeutic effect, they impact cognitive and motor functioning, increase the risk of falls in old people and are recommended only for short term relief during crises
Besides benzodiazepines, what other pharmacological agent is useful for acute symptomatic relief in GAD?
Beta blockers, particularly propranolol which is used for acute symptomatic relief
What type of antidepressants are effective for the long-term management of CAD
Both newer agents like ssri’s and s n r i’s as well as the older agents like tricyclic antidepressants have been shown to be effective
What is the current clinical consensus on the use of benzodiazepines in gad treatment
Benzodiazepines are recommended for short-term relief of anxiety associated with temporary crisis or stressful events such as family problems
What are some recent Innovations in psychological treatment for g80
Recent Innovations include treatments that help patients process threatening information emotionally using images and teaching relaxation techniques to combat tension
What psychological treatment has proven efficacy in the management of gad
Cognitive Behavioral Therapy (CBT)
What did b o r k o v e c and his colleagues find regarding the effectiveness of a particular psychological treatment for gad compared to a placebo
The found that the treatment was significantly better than the placebo not only at post treatment but also at a one-year follow-up
What is a recent psychological treatment for gad that Focuses on acceptance rather than avoidance of distressing thoughts and feelings
A new psychological treatment for gad that incorporates acceptance-based procedures in addition to cognitive therapy
What is the effectiveness of psychological treatments for children with g a d
Psychological treatment particularly CBT have shown effectiveness in children with gad with significant improvements maintain for at least one year
What progress has been made in adapting psychological treatments for older adults with g a d
Adaptations of psychological treatments have shown efficiency for older adults with gat compared to usual care
What does s n r i and SSRI stand for
Selective serotonin reuptake inhibitors and serotonin n o r a d r e n e r g i c reuptake inhibitors s n r i
What characterizes panic disorder
It involves recurrent unexpected panic attacks accompanied by concern about future attacks and/or lifestyle changes to avoid future attacks
Define agoraphobia
It is characterized by anxiety about being in places or situations from which escape might be difficult in the event of panic symptoms or other unpleasant physical symptoms
What is anticipatory anxiety in the context of panic disorder
Refers to the anxiety experienced by individuals with panic disorder about the possibility of experiencing a panic attack leading them to avoid situations that may provoke an attack
What is the relationship between panic disorder and agoraphobia
Many individuals with PD also experience symptoms of agoraphobia particularly fearing experiencing a panic attack in certain situations. Although not all individuals with PD develop agoraphobia
How does agoraphobia relate to panic attacks
It’s often develops as a response to severe unexpected panic attacks leading individuals to avoid situations or places where they fear experiencing a panic attack
What are some common avoidance behaviors associated with agoraphobia
Avoidance behaviors include sitting near exit for rapid escape avoiding certain locations or people perceived as unsafe and enduring situations with intense dread despite anxiety
What is interceptive avoidance and why is it important in panic disorder and agoraphobia
It involves avoiding internal physical sensations that resemble the beginning’s of a panic attack such as avoiding exercise to due to increased cardiovascular activity or faster respiration. It is as important as classical goraphobia avoidance
What is the dsm-5 diagnostic criteria for a panic disorder
A. Recurrent unexpected panic attacks should be present.
B. At least one of the attacks has been followed by one month or more of one or both of the following- persistent concern or worry about additional panic attacks and their consequences like going crazy or have in the heart attack. They significant maladaptive change in behavior related to the attacks for example avoidance of exercise are familiar situations
C. The disturbance is not attributable to the physiological effects of a substance for example drug abuse on medication or another medical condition like hypothyroidism
D. The disturbance is not better explained by another mental disorder( like the panic attacks do not occur only in response to feared situations as in social anxiety disorder)
Are there significant differences in panic disorder rates among different ethnic groups in the USA
Rates are similar among different ethnic groups in the USA including african-americans. Black and white patients with panic disorder shown no significant differences in symptoms
How do some cultures perceive subjective feelings of dread?
Subjective feelings of dread may be foreign to some cultures leading to individuals to focus more on body licensations rather than emotional experiences
How did traditional healers in South Africa respond to a case of panic disorder and agoraphobia?
Traditional healers in South Africa often do not recognize mental illness
What is brain f a g syndrome and where is it commonly described?
It is a reactive form of anxiety including symptoms such as depersonalization, sensory disturbances( itchiness of the scalp) and cognitive limitations( restriction of memory and concentration)
What symptoms are commonly associated with brain f a g syndrome
It is often attributed to an overemphasis on academic achievement and its typically found among individuals involved in scholarly Pursuits
Are nocturnal panic attacks similar to Nightmares?
No research indicates that nocturnal panic attacks occur during delta or slow wave sleep typically several hours into sleep as frustrated by p o l y s o m n o g r a p h y
What is a related phenomenon in children to nocturnal panic attacks?
Sleep terrors
How do individuals experiencing nocturnal panic attacks differ from those experiencing sleep terrors?
Individuals experiencing nocturnal panic attacks do wake up and later remember the event clearly
At which stage of sleep do sleep terrors tend to occur
Latest stage of sleep known as stage 4 which is associated with sleepwalking
What factors contribute to understanding panic disorder?
Biological psychological and social contributing factors
How does agoraphobia typically develop?
It often develops after a person has unexpected panic attacks or panic likes sensations but the severity and development of agoraphobia seem to be socially and culturally determined
What are panic attacks and panic disorder strongly related to?
Biological encyclological factors and their interaction
What is the triple vulnerability model in panic disorder
It explains how biological psychological and social factors may contribute to the development and Maintenance of anxiety and to an initial unexpected panic attack
How do individuals develop specific associations during panic attacks?
Particular situations quickly become associated in an individual’s mind with external and internal causes that were present during the panic attack
How can being in a movie theater during a panic attack lead to future panics?
Being in a movie theater when a panic attack occurs can become an external queue that might lead to future panic attacks as a condition stimulus
What are Cues associated with panic attacks through a learning process
Earned alarm which are Cues that become associated with a number of different internal and external stimuli through a learning process
What is the significance of these learned Cues in relation to panic attacks?
They play a role in the development and maintenance of panic disorder
What factors differentiate individuals who develop anticipatory anxiety from those who do not?
Those with a history of physical disorders and health anxiety were more likely to develop panic disorder than either anxiety disorders suggesting a learned belief that an unexpected bodily sensations are dangerous
What does the tendency to believe unexpected body sensations are dangerous indicate
It reflects a specific psychological vulnerability to develop panic and related disorders
How do individuals who do not develop anticipatory anxiety typically respond to panic attacks?
The attribute the attack to events of the moment such as an argument something they ate or a bad day and go on with their lives perhaps experiencing occasional panic attacks when they are under stress again
What cognitive processes does David Clark’s Theory emphasize in panic disorder?
The specific psychological vulnerability of interpreting normal physical sensations in a catastrophic way
How does the interpretation of normal physical sensations lead to a vicious cycle in panic disorder?
Individuals may interpret normal physical sensations as dangerous leading to anxiety. This anxiety produces more physical sensations perceived as even more dangerous resulting in a panic attack
What hypothesis suggests the development of panic disorder and agoraphobia from psychodynamic causes?
One hypothesis suggests that early object loss/ separation anxiety might predispose someone to develop panic disorder and agoraphobia as an adult