Chapter 6 Flashcards
Anxiety: definition
Involves a general feeling of apprehension about possible future danger
Fear: definition
An alarm reaction that occurs in response to immediate danger
How many people are affected by anxiety disorders in the USA
Approximately 29% of the US population at some point in their lives experience anxiety disorders. Anxiety disorders are the most common category of disorders for women and the second most common for men
What medical conditions are associated with anxiety disorders
Asthma, chronic pain, hypertension, arthritis, cardiovascular disease, and irritable bowel syndrome
Neurotic disorder’s
Individuals With neurotic disorders show maladaptive and self-defeating behaviors, they are not incoherent, dangerous, or out of touch with reality
How would Freud describe neurotic disorder’s
To Freud, these neurotic disorders developed when intrapsychic conflict produced significant anxiety. To Freud anxiety was a sign of an inner battle or conflict between some primitive desire and prohibitions against its expression. Sometimes this anxiety was overtly expressed. In certain other neurotic disorders, he believed that the anxiety might not be obvious if psychological defence mechanisms were able to deflect or mask it
Obsessive compulsive disorder
OCD is no longer classified as an anxiety disorder. It is now listed in its own category of obsessive compulsive and related disorders.
What has historically been the most common way of distinguishing between fear and anxiety response patterns
The most common way of distinguishing has been to determine whether a clear and obvious source of danger is present that would be regarded as real by most people. When the source of danger is obvious, the experienced emotion has been called fear. With anxiety, we frequently cannot specify clearly what the danger is
What is fear
Fear is a basic emotion that involves activation of the fight or flight response of the autonomic nervous system. This is an almost instantaneous reaction to any imminent threat such as a dangerous predator or someone pointing a loaded gun. It’s adaptive value allows us to escape.
What is a panic attack
When a fear response occurs in the absence of any obvious external danger
What are the symptoms of a panic attack
The symptoms are nearly identical to those experienced during a state of fear except that panic attacks are often accompanied by a subjective sense of impending doom. These latter cognitive symptoms do not generally occur during fear states
Three components that fear and panic share
- Cognitive or subjective components, “I’m going to die”
- Physiological components, example increased heart rate and heavy breathing
- Behavioural components, example a strong urge to escape or flee
These components are loosely coupled, which means that someone might show Physiological and behavioural indications without the subjective component or vice versa
Cognitive/subjective components of anxiety
Involves negative mood, worry about possible future threats or danger, self preoccupation, and a sense of being unable to predict the future threat or to control it if it occurs. “ I am worried about what might happen”
Physiological components of anxiety
Anxiety often creates a state of tension and chronic over arousal, which may reflect risk assessment and readiness for dealing with danger should it occur. There is no activation of the fight or flight response as there is with fear, but anxiety does prepare or prime a person for the fight or flight response should the anticipated danger occur.
Tension, chronic over arousal
Behavioural component of anxiety
Anxiety may create a strong tendency to avoid situations where danger might be encountered, but the immediate behavioural urge to flee is not present with anxiety as it is with fear.
General avoidance
Adaptive value of anxiety
Anxiety may help us plan and prepare for a possible threat. In mild to moderate degrees anxiety actually enhances learning and performance. But although anxiety is often adaptive in mild or moderate degrees, it is maladaptive when it becomes chronic and severe, as we see in people diagnosed with anxiety disorders
Conditioning and fear and anxiety
Although many threatening situations occur that provoke fear and anxiety unconditionally, many of our sources of fear and anxiety are learned. The basic fear and anxiety response patterns are highly condition of all. Previously neutral and novel stimuli that are repeatedly paired with, and reliably predict, frightening or unpleasant events such as various kinds of physical or psychological trauma can acquire the capacity to elicit fear or anxiety themselves. Such conditioning is a completely normal and adaptive process that allows all of us to learn to anticipate upcoming frightening events
What are anxiety disorders characterized by
Unrealistic, irrational fears or anxieties that cause significant distress and/or impairments in functioning
Anxiety disorders recognized in the DSM – five
- Specific phobia
- Social anxiety disorder, social phobia
- Panic disorder
- Agoraphobia
- Generalized anxiety disorder
People with these very disorders differ from one another both in terms of the amount of fear or panic versus anxiety symptoms that they experience and in the kinds of objects or situation that most concern them
Anxiety disorders and other disorders
Many people with one anxiety disorder will experience at least one more anxiety disorder and/or depression either concurrently or at a different point in their lives
Similarities in the basic causes of anxiety disorders: common biological causes
Genetics contributes to each of these anxiety disorders and at least part of the genetic vulnerability may be nonspecific or common across the disorders. In adults the common genetic vulnerability is manifested at a psychological level at least in part by the personality trait called neuroticism. The brain structures most centrally involved in most disorders are generally in the limbic system and certain parts of the cortex, and the neurotransmitter substances that are most centrally involved are gamma amino butyric acid (GABA), norepinephrine, and serotonin
Neuroticism
An important personality trait. A proneness or disposition to experience negative mood states that is a common risk factor for both anxiety and mood disorders
Similarities in the basic causes of anxiety disorders: psychological causal factors
Classical conditioning of fear, panic, or anxiety to a range of stimuli plays an important role in many anxiety disorders. People who have perceptions of a lack of control over their environments or their own emotions seem more vulnerable to developing anxiety disorders. The development of these perceptions of uncontrollability depends on the social environment people are raised in. faulty or distorted patterns of cognition also may play an important role. The sociocultural environment in which people are raised also has effects on the objects and experiences people become anxious about
Commonalties across effective treatments for various anxiety disorders
Graduated exposure to feared cues, objects, and situations constitutes the single most powerful therapeutic ingredient. For certain disorders the addition of cognitive restructuring techniques can provide added benefit by helping the individual to understand their distorted patterns of thinking about anxiety related situation and how these patterns can be changed. Medication also can be useful in treating all disorders except specific phobias, and tend to fall into two primary medication categories: anti-anxiety medication‘s and antidepressant medication‘s
Phobic disorders, or phobias
The most common anxiety disorder. A phobia is a persistent and disproportionate fear of some specific object or situation that presents little or no actual danger and yet leads to a great deal of avoidance of these weird situation’s
Three main categories of phobias
- Specific phobia
- Social phobia
- Agoraphobia
What is a specific phobia
Said to be present if a person shows a strong and persistent fear that is triggered by the presence of a specific object or situation and leads to significant distress and or impairment in a persons ability to function
What happens when people with specific phobias encounter a phobic stimulus
They often show an immediate fear response that often resembles a panic attack except for the existence of a clear external trigger. These individuals also experience anxiety if they anticipate they may encounter a phobic object or situation and so go to great lengths to avoid encounters with their phobic stimulus. They often even avoid seemingly harmless representations of it such as photographs or images.
What do people with specific phobias think about their fear
People with specific phobias recognize that their fear is somewhat excessive or unreasonable although occasionally they may not have this insight
Phobias and avoidance
Avoidance is characteristic of phobias. It occurs both because the phobic response itself is so unpleasant and because of the phobic person‘s irrational appraisal of the likelihood that something terrible will happen
What happens when people who suffer from phobias attempt to approach the object of the phobia
They are overcome with fear or anxiety, which may vary from mild feelings of apprehension and distress, usually well still at some distance, to full fledged activation of the fight or flight response.
Phobic behaviour and reinforcement
Phobic behaviour tends to be reinforced because every time the person with a phobia avoids a feared situation, their anxiety decreases. Also the secondary benefits derived from being disabled, such as increased tension, sympathy, and some control over the behaviour of others, can also sometimes reinforce a phobia
Blood injection injury phobia
Occurs in approximately 3 to 4% of the population. People with this phobia typically experience at least as much discussed as fear. They also show a unique physiological response when confronted with the site of blood or injury. Rather than showing the simple increase in heart rate and blood pressure scene when most people with phobias encounter their phobic object, these people show an initial acceleration, followed by a dramatic drop in both heart rate and blood pressure. This is very frequently accompanied by nausea, dizziness, or fainting, which does not occur with other specific phobias. People with this phobia demonstrate this unique physiological response pattern only in the presence of blood and injury stimuli. They exhibit the more typical physiological response pattern characteristics of the fight or flight response to their other feared objects
Evolutionary and functional benefits of blood injection injury phobia
The unique physiological response pattern may have evolved for a specific purpose: by fainting, the person being attacked might inhibit further attack, and if an attack did occur, the drop in blood pressure it would minimize blood loss. This type of phobia appears to be highly heritable
Prevalence, of specific phobias
Specific phobias are common, occurring in about 12% of people at some point in their lifetime,. Phobias are much more common in women than men, although the gender ratio varies by type of phobia. 90 to 95% of people with animal phobias are women, but the gender ratio is less than 2 to 1 for blood injection injury phobias
Age of onset of specific phobias
Animal phobias usually begin in childhood, as do blood injection injury phobias and dental phobias. Other phobias such as claustrophobia and driving phobia tend to begin in adolescence or early adulthood
Psychological causal factors of specific phobias
These range from deep-seated psychodynamic conflicts, has seen from a psychoanalytic viewpoint, or straightforward traumatic conditioning of fear
Psychological causal factors of specific phobias and the psychoanalytic viewpoint
According to the psychoanalytic view, phobias represent a defence against anxiety that stems from repressed impulses from the id. Because it is too dangerous to know the repressed impulse, the anxiety is displaced onto some external object or situation that has some symbolic relationship to the real object of the anxiety. Criticisms: this account may be too speculative, so a simpler account from learning theory was proposed
Psychological causal factors of specific phobias: phobias as learned behaviour
Six to explain the development of phobic behaviour through classical conditioning. The fear response can be conditioned to previously neutral stimuli when these stimuli are paired with traumatic or painful events. Once acquired, phobic fears could generalize to other similar objects or situations
Specific phobias: vicarious conditioning
Simply watching a phobic person behaving fearfully with their phobic object can be distressing to the observer and can result in fear being transmitted from one person to another through vicarious or observational classical conditioning. Also watching a non-fearful person undergoing a frightening experience can also lead to vicarious conditioning.
Specific phobias: individual differences in learning
Individual differences in life experiences strongly affect whether conditioned fears or phobias actually develop. Some life experiences may serve as risk factors and make certain people more vulnerable to phobias than others, whereas other experiences may serve as protective factors for the development of phobias. this is also true for vicarious learning. Certain aspects of the conditioning experience and our response to it are also important in determining the level of fear that is conditioned. Also our cognitions or thoughts can help maintain our phobias once they have been acquired. People with phobias are constantly on the alert for their phobic objects or situations and other stimuli but non-phobic persons tend to direct their attention away from threatening stimuli. Phobics also over estimate the probability that feared objects have been or will be followed by frightening events. This cognitive bias may help maintain or strengthen phobic fears with the passage of time
Revolutionary preparedness for learning certain fears and phobias
Revolutionary history has affected which stimuli we are most likely to come to fear. Primates and humans seem to be evolutionarily prepared to rapidly associate certain objects, such as snakes spiders water and enclosed spaces, with frightening or unpleasant events. This prepared learning occurs because, over the course of evolution, these primates and humans who rapidly acquired fears of certain objects or situations that posed real threats to our early ancestors may have enjoyed a selective advantage.
Prepared learning and prepared fears
Over the course of evolution, primates and humans who rapidly acquired fears of certain objects or situations that pose real threats to our early ancestors may have enjoyed a selective advantage. Thus, prepared fears are not inborn or innate but rather are easily acquired or especially resistant to extinction.
Experimental evidence to support the preparedness theory of phobias (subliminal activation)
It was found that fear is conditioned more effectively to fear relevant stimuli then to fear irrelevant stimuli. Also once the individuals acquired the conditioned responses to fear relevant stimuli, these responses could be elicited even when the fear relevant stimuli were presented subliminally. This subliminal activation of responses to phobic stimuli may help to account for certain aspects of the irrationality of phobias. I.e. people with phobias may not be able to control their fear because the fear may arise from cognitive structures that are not under conscious control
Experimental evidence to support the preparedness theory of phobias (monkeys)
Lab reared monkeys in a vicarious conditioning paradigm can easily acquire fears of fear relevant stimuli but not of fear irrelevant stimuli. Thus, both monkeys and humans seem selectively to associate certain fear relevant stimuli with threat or danger. These monkeys had no prior exposure to any of the stimuli involved, supporting the evolutionary-based preparedness hypothesis even more strongly than the human experiments
Biological causal factors of specific phobias
Genetic and temperamental variables also affect the speed and strength of conditioning of fear. 
Specific phobias and the serotonin transporter gene
It was found that individuals who are carriers of one of the two variants of the serotonin transporter gene, the S allele which has been linked to heightened neuroticism, show superior fear conditioning than those without the S allele. However those with one of the two variants of a different gene, the COMT met/met genotype, did not show superior conditioning but did show enhance resistance to extinction.
Behaviourally inhibited toddlers and specific phobias
It was found that behaviourally inhibited toddlers, who are excessively timid, shy, easily distressed etc., at 21 months of age were at higher risk of developing multiple specific phobias by 7 to 8 years of age then were uninhibited children
Twin studies and specific phobias
Large twin studies show that monozygotic, identical twins are more likely to share animal phobias and situational phobias, such as heights or water, then were dizygotic, non-identical twins. However the same studies also found that non-shared environmental factors such as individual specific experiences not shared by twins play a substantial role in the origins of specific phobias, a result that supports the idea that phobias are learned behaviours. Another study found that the heritability of animal phobias was separate from the heritability of complex phobias such as social phobia and agoraphobia
Treatments for specific phobias
Exposure therapy is the most effective treatment for specific phobias. It is a form of behaviour therapy that involves controlled exposure to the stimuli or situations that elicit phobic fear. In Exposure therapy, clients are encouraged to gradually expose themselves, either alone or with the aid of a clinician or friend, to their feared situation for long enough periods of time so that their fear begins to subside.
Participant modelling
A variant of exposure therapy. It is often more effective than exposure alone. Hear the therapist calmly models ways of interacting with the phobic stimulus or situation. These techniques enable clients to learn that these situations are not as frightening as they had thought and that their anxiety, well unpleasant, is not harmful and will gradually dissipate. The new learning is believed to be mediated by changes in brain activation in the amygdala, which is essentially involved in the emotion of fear
Exposure therapy with animal phobias, flying phobia, claustrophobia, and blood injury phobia
For these phobias, exposure therapy is often highly effective when administered in a single long session of up to three hours. This can be an advantage because some people are more likely to seek treatment if they have to go only once. This treatment has also been shown to be highly effective in youths with specific phobias
Virtual reality and exposure therapy
Psychologists have begun to use virtual reality to simulate different kinds of phobic situations. Controlled studies have yielded very promising results and show results comparable to those seen with live exposure
How have researchers tried to increase the effectiveness of exposure therapy
Do use of cognitive restructuring techniques alone has not produced results as good as those using exposure-based techniques, and the addition of cognitive techniques to exposure therapy has generally not added much. Medication treatments are in effective by themselves, and there is even some evidence that anti-anxiety medication‘s may interfere with the beneficial effects of exposure therapy. Recently however studies have shown that a drug called D-cycloserine, Which is known to facilitate extinction of conditioned fear in animals, can enhance the effectiveness of exposure therapy for fear of heights in a virtual reality environment; this drug by itself however it has no effect
Social phobia
A.k.a. social anxiety disorder. Characterized by disablebling fears of one or more specific social situations such as public speaking, urinating in a public bathroom, or eating or writing in public. In these situations, a person fears that she or he may be exposed to the scrutiny and potential negative evaluation of others or that they may act in an embarrassing or humiliating manner. Because of their fears, people with social phobia avoid the situation or endure them with great distress. There are two subtypes of social phobia
To subtypes of social phobia
The DSM – five identifies to subtypes of social phobia. One centres on performance situation such as public speaking and one is more general and includes non-performance situation such as eating in public. People with the more general subtype of social phobia often have a significant fears of most social situation rather than simply a few and often also have a diagnosis of avoidant personality disorder
Fear of public speaking
Intense fear of public speaking is the single most common type of social phobia
Prevalence of social phobia
Approximately 12% of the population meets the diagnostic criteria for social phobia at some point in their lives. It is more common among women and typically begins during adolescence or early adulthood. 2/3 of people with social phobia suffer from one or more additional anxiety disorders at some point in their lives and 50% also suffer from a depressive disorder at the same time. 1/3 abuse alcohol to reduce anxiety. People with social phobia on average have lower employment rates and lower socioeconomic status, and about 1/3 have severe impairment in one or more domains of their life. The disorder is persistent, with one study finding that only about a third recover spontaneously over a 12 year period
Psychological causal factors of social phobia
Like specific phobias social phobia generally involves learned behaviours that have been shaped by revolutionary factors. Such learning is most likely to occur in people who are genetically or temperamentally at risk
Psychological causal factors of social phobia: learned behaviour
Social phobia often seems to originate from simple instances of direct or vicarious classical conditioning such as experiencing or witnessing a perceived social defeat or humiliation, or being or witnessing the target of anger or criticism. Studies show people with social phobia recall and identify direct traumatic experiences is having been involved in the origin of their social phobias. Another study reports a large percent of people with social phobia reported a history of severe teasing in childhood. People with social phobia show especially robust conditioning of fear when the unconditioned stimulus was socially relevant as opposed to more non-specifically negative stimuli. Another study showed 96% of people with social phobia remembered some socially traumatic experience that was linked to their own current image of themselves in socially phobic situations. Keep in mind that not everyone who experiences direct or vicarious conditioning in social situations develops social phobia. Individual differences play a part
Psychological causal factors of social phobia: evolutionary context
Social fears and phobia involve fears of members of one’s own species. It has been proposed that social fears and phobia evolved as a byproduct of dominance hierarchy‘s that are a common social arrangement among animals such as primates. Dominance hierarchy‘s are established through aggressive encounters between members of a social group and a defeated individual typically displays fear and submissive behaviour but only rarely attempts to escape the situation completely, similarly to people with social phobia who endure being in their feared situation rather than running away. Humans have an Evolutionarily faced predisposition to acquire fears of social stimuli that signal dominance and aggression from other humans, which may include facial expressions of anger or contempt.
Evolutionary context of social phobia: studies
A study demonstrated that subjects develop stronger conditioned responses when slides of angry faces are paired with mild electric shocks then when happy or neutral faces are paired with the same shocks. Even very brief subliminal presentations of the angry face that had been paired with shock were sufficient to activate the conditioned responses, probably because even these subliminal angry faces activate the amygdala. People who have social phobia showed greater activation of the amygdala in response to negative facial expressions than normal controls. This may help explain the seemingly irrational quality of social phobia, in the angry faces are processed very quickly and an emotional reaction can be activated without a persons awareness of any threat
Social phobia and perceptions of uncontrollability and unpredictability
Being exposed to uncontrollable and unpredictable stressful events may play an important role in the development of social phobia. Perceptions of uncontrollability and unpredictability often lead to submissive and on assertive behavior, which is characteristic of people who are socially anxious or phobic. This kind of behaviour is especially likely if the perceptions of uncontrollability stemmed from an actual social defeat. People with social phobia have a diminished sense of personal control over events in their lives. This may develop at least in part as a function of having been raised in families with somewhat overprotective parents
Social phobia and cognitive biases
Cognitive factors also play a role in the onset and maintenance of a social phobia. It has been suggested that people with social phobia tend to expect that other people will reject or negatively evaluate them. This leads to a sense of vulnerability when they are around people who might pose a threat. It has been proposed that these danger schemas of socially anxious people lead them to expect that they will behave in an awkward and unacceptable fashion, resulting in rejection and loss of status. This leads to their being preoccupied with bodily responses and stereotypical negative self images in social situations, to over estimating how easily others will detect their anxiety, and to miss understanding how well they come across to others. This interferes with their ability to interact skillfully. They vicious cycle may evolve, confirming the cognitive bias.
Another cognitive bias is a tendency to interpret ambiguous social information in a negative rather than a benign manner. It is also been suggested that these biased cognitive processes combine to maintain social phobia and possibly even contribute to the development
Biological causal factors of social phobia
Most important temperamental variable is behavioural inhibition, which shares characteristics with both neuroticism and introversion. Behaviourally inhibited infants who are easily distressed by unfamiliar stimuli and who are shy and avoidant are more likely to become fearful during childhood and adolescence to show increased risk of developing social phobia
Behavioural causal factors of social phobia: studies
One classic study was connected on behavioural innovation as a risk factor in a large group of children, most of him were already known to be at risk for anxiety because their parents had an emotional disorder. Those who had been assessed as being high on behavioural inhibition between two and six years of age were nearly 3 times more likely to be diagnosed with social phobia even in middle childhood then we’re children who are low on behavioural inhibition at 2 to 6 years. Results from twin studies have shown that there is a modest genetic contribution to social phobia. Estimates are that about 30% of the variance in liability to social phobia is due to genetic factors. However these studies suggest that an even larger proportion of variance and who develops social phobia is due to non-shared environmental factors which is consistent with a strong role for learning
Treatments for social phobia
Treatment centre around both cognitive and behavioural therapy’s and sometimes involve medication
Cognitive and behavioural therapy’s for social phobia
Prolonged and graduated exposure to the feared situation has proven to be a very effective treatment. Cognitive restructuring techniques have been added to the behavioural techniques, generating a form of cognitive behavioural therapy. Many studies over the years have shown that exposure therapy and cognitive behavioural therapy produce comparable results. However one study suggests that this new very effective variant and cognitive treatment may be more effective than exposure therapy. At least one study has now shown that simply training individuals with social phobia to disengage from negative social cues during a 15 minute lab task that is repeated eight times over 4 to 6 weeks produced such remarkable reductions in social anxiety symptoms that nearly 3 out of four of the participants no longer met the criteria for social phobia
Cognitive restructuring in social phobia
In cognitive restructuring the therapist attempts to help clients with social phobia identify their underlying negative, automatic thoughts. After helping clients understand that such automatic thoughts often involve cognitive distortions, the therapist helps the clients change these inner thoughts and beliefs through logical reanalysis. A process of logical reanalysis might involve asking oneself questions to challenge the automatic thoughts
Medication for social phobia
Social phobia can sometimes be effectively treated with medications. The most effective and widely used medications are several categories of antidepressants. In some studies the effects of these antidepressant medications have been comparable to those seen with cognitive behavioural treatments. However in several studies the newer version of cognitive behaviour therapy produced much more substantial improvement than the medication. Also the medication‘s must be taken over a long period of time to help ensure relapse does not occur. Several studies have also suggested that when D- cycloserine is added to exposure therapy the treatment gains occur more quickly and are more substantial
Advantage of behavioural and cognitive behavioural therapy’s over medication For social phobia
They generally produce more long lasting improvement with very low relapse rates. Clients often continue to improve after treatment is over
Panic disorder definition
Panic disorder is defined and characterized by the occurrence of panic attacks that often seem to come out of the blue. Panic attacks are fairly brief but intense, with symptoms developing abruptly and usually reaching peak intensity within 10 minutes. The attacks often subside in 20 to 30 minutes and rarely last more than an hour. Periods of anxiety, by contrast, do not typically have such an abrupt onset and are more long lasting
Criteria for panic disorder
According to the DSM five criteria for panic disorder, the person must have experienced recurrent, unexpected attacks and must’ve been persistently concerned about having another attack or worried about the consequences of having an attack for at least a month. For such an event to qualify as a full-blown panic attack, there must be abrupt onset of at least four of 13 symptoms. Most of these symptoms are physical although three are cognitive
When do panic attacks occur
Panic attacks are often unexpected or UnCute in the sense that they do not appear to be provoked by identifiable aspects of the immediate situation. They sometimes occur in situations in which they might be least expected, such as during relaxation or sleep. In other cases they are said to be situationally predisposed, occurring only sometimes while the person is in a particular situation such as well driving a car or being in a crowd
misdiagnosing a panic attack
Because most symptoms of a panic attack or physical, as many as 85% of people having a panic attack may show up repeatedly at ERs or doctors offices for what they are convinced is a medical problem, usually cardiac respiratory or neurological. The correct diagnosis is often not made for years due to the normal results on numerous medical tests. Further complications may arise because patients with cardiac problems are at a nearly twofold elevated risk for developing panic disorder. Prompt diagnosis and treatment are also important because panic disorders cause approximately as much impairment in social and occupational functioning is that caused by major depressive disorder, and panic disorder can contribute to the development or worsening of a variety of medical problems
Criteria for social anxiety disorder, social phobia
- Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. 
- The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated
- The social situations almost always provoke fear or anxiety
- Social situations are avoided or injured with intense fear or anxiety
- The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the social cultural context
- The fear, anxiety or avoidance is persistent, typically lasting for six months or more
- The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
- If you’re, anxiety or avoidance is not attributable to the physiological effects of a substance or another medical condition
- I fear, anxiety or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder
- If another medical condition is present, fear, anxiety or avoidance is clearly unrelated or is excessive
Criteria for panic disorder
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of the following symptoms occur:
1. Palpitations, pounding heart or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, Unsteady, light headed or faint
9. Chills or heat sensations
10. paresthesias (numbness or tingling sensations)
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
12. Fear of losing control or going crazy
13. Fear of dying
B. At least one of the attacks has been followed by one month or more of one of the following:
1. Persistent concern or worry about additional panic attacks were the consequences
2. A significant maladaptive change in behaviour related to the attacks
C. The disturbance is not attributable to the physiological effects of a substance or another medical condition
D. The disturbance is not better explained by another mental disorder
Paresthesias
Numbness or tingling sensations
Derealization
Feelings of unreality
Depersonalization
Being detached from oneself
Agoraphobia
Most commonly feared and avoided situations include streets and crowded places such as shopping malls, movie theatres and stores. Standing in line can be particularly difficult. Sometimes agoraphobia develops as a complication of having panic attacks in one or more such situation. Concerned that they may have a panic attack, people with agoraphobia or anxious about being in places or situations from which escape would be difficult or embarrassing or immediate help would be unavailable if something bad happened. Typically people with agoraphobia are also frightened by their own bodily sensations so they avoid activities that will create sensations of arousal
When agoraphobia first develops
As agoraphobia first develops, people tend to avoid situations in which attacks have occurred, but usually the avoidance gradually spreads to other situations where attacks might occur. In moderately severe cases people with agoraphobia may be anxious even when venturing outside their homes alone. In very severe cases, agoraphobia is an utterly disabling disorder in which a person cannot go beyond the narrow confines of home, or even particular parts of the home
Agoraphobia and panic disorder
Agoraphobia is a frequent complication of panic disorder. However many patients with agoraphobia do not experience panic, so in DSM-V agoraphobia is now listed as a distinct disorder. Is agoraphobia develops there is often a gradually spreading fearfulness in which more and more aspects of the environment outside of the home become threatening. Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individuals presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned
Lifetime prevalence of agoraphobia without panic
1.4%
Prevalence of Panic disorder
Approximately at 4.7% of the adult population has had panic disorder with or without agoraphobia at sometime in their lives, with panic disorder without agoraphobia being more common
Age of onset of panic disorder
Panic disorder with or without agoraphobia typically begins in the 20s to the 40s, but sometimes begins in the late teen years. Once panic disorder develops, it tends to have a chronic and disabling course, although the intensity of symptoms often waxes and Wayne’s overtime. Indeed one 12 year longitudinal study found that less than 50% of patients with panic disorder with agoraphobia had recovered in 12 years, and 58% of those who had recovered at some point had had a reoccurrence
Gender differences in panic disorder
Panic disorder is about twice as prevalent in women as in men. Agoraphobia also occurs much more frequently in women than men and the percentage of women increases as the extent of agoraphobic avoidance increases. Among people with severe agoraphobia, approximately 80 to 90% or female.
Explanation for the gender differences in agoraphobia
The explanation is a sociocultural one. In our culture, it is more acceptable for women who experience panic to avoid the situations they fear and to need a trusted companion to accompany them when they enter fear situations. Men who experience panic are more prone to tough it out because of societal expectations and they’re more assertive, instrumental approach to life. Some evidence indicates that men with panic disorder may be more likely to self medicate with nicotine or alcohol as a way of coping with and enduring panic attacks rather than developing agoraphobic avoidance
Criteria for agoraphobia
A. Marked fear or anxiety about two or more of the following five situations:
1. Using public transportation
2. Being in open spaces
3. Being in enclosed spaces
4. Standing in line or being in a crowd
5. Being outside of the home alone
B. The individual fears or avoids these situations because of thoughts escape might be difficult or help might not be available in the event of developing panic like symptoms or other incapacitating or embarrassing symptoms
C. The agoraphobic situation’s almost always provoke fear or anxiety
D. The agoraphobic situation’s are actively if we did, require the presence of a companion, where are injured with intense fear or anxiety
E. I fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situation and to the socio-cultural context
F. The fear, anxiety or avoidance is persistent, typically lasting for six months or more
G. The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
H. If another medical condition is present, fear, anxiety or avoidance is clearly excessive
I. The fear, anxiety or avoidance is not better explained by the symptoms of another mental disorder. For example the symptoms are not confined to a specific phobia, situational type; do not involve only social situations; and are not related exclusively to obsessions, perceived defects or flaws in physical appearance, reminders of traumatic events, or fear of separation
Panic disorder and Comorbidity with other disorders
The vast majority of people with panic disorder have at least one comorbid disorder, most often generalized anxiety disorder, social phobia, specific phobia, PTSD, depression, and substance use disorders. Depression is especially common among those with panic disorder, approximately 50 to 70% of people with panic disorder experience serious depression at some point. They may also meet criteria for dependent or avoidant personality disorder. Panic disorder is a strong predictor of suicidal behavior.
Panic disorder and suicidal behaviour
The link between panic and suicidal behaviour is largely explained by the presence of comorbid disorders such as depression and substance abuse, leading researchers to conclude that panic itself doesn’t increase the risk of suicidal behavior. However other recent studies have found that panic disorder is indeed associated with increased risk for suicidal ideation and attempts independent of its relationship with comorbid disorders
Timing of first panic attack
The first one frequently occurs following feelings of distress or some highly stressful life circumstance such as loss of a loved one, loss of an important relationship, loss of a job, or criminal victimization. Some studies have estimated that approximately 80 to 90% of people report that their first panic attack occurred after one or more negative life events. Not all people who have a panic attack following a stressful event go on to develop full-blown panic disorder. About 23% of adults have experienced at least one panic attack in their lifetimes but most do not develop panic disorder.
Biological causal factors of panic disorder
Biological causal factors include genetics, brain activity, and bio chemical abnormalities
Genetic factors leading to panic disorder
Panic disorder has a moderate heritable component. In a twin study, it was estimated that 30 to 34% of the variance in liability to panic symptoms is due to genetic factors. This genetic vulnerability is manifested at a psychological level by the important personality trait called neuroticism. Several studies have begun to identify which specific genetic polymorphisms are responsible for this moderate irritability, either alone or in interaction with certain types of stressful life events. Twin studies suggest there is overlap in the genetic vulnerability factors for panic disorder, phobias and separation anxiety. But another study suggests overlap in the genetic vulnerability for a panic disorder, generalized anxiety disorder, and agoraphobia. Further research is needed
