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What is Anxiety?What is Anxiety?
Physiological – bodily rxns, such as Physiological – bodily rxns, such as rapid heartbeat, muscle tension, rapid heartbeat, muscle tension, queasiness, dry mouth, or sweatingqueasiness, dry mouth, or sweating
Behavioral – may sabotage your Behavioral – may sabotage your ability to act, express yourself, or ability to act, express yourself, or deal with situations effectivelydeal with situations effectively
Psychological – subjective state of Psychological – subjective state of apprehension, uneasiness, apprehension, uneasiness, fearfulnessfearfulness
Normal “Everyday” Normal “Everyday” Anxiety vs. Clinical Anxiety vs. Clinical AnxietyAnxietyClinical Anxiety:Clinical Anxiety: Is more intense Is more intense Lasts longerLasts longer Interferes with your lifeInterferes with your life Is out of proportion to the situationIs out of proportion to the situation May not be directed to any May not be directed to any
concrete situation or eventconcrete situation or event
The Anxiety DisordersThe Anxiety Disorders
Panic DisorderPanic Disorder AgoraphobiaAgoraphobia Specific PhobiaSpecific Phobia Social PhobiaSocial Phobia Generalized Anxiety DisorderGeneralized Anxiety Disorder Obsessive Compulsive DisorderObsessive Compulsive Disorder Posttraumatic Stress Disorder/Acute Stress Posttraumatic Stress Disorder/Acute Stress
DisorderDisorder Anxiety Disorder Due to a General Medical Anxiety Disorder Due to a General Medical
ConditionCondition Substance-Induced Anxiety DisorderSubstance-Induced Anxiety Disorder Anxiety Disorder Not Otherwise SpecifiedAnxiety Disorder Not Otherwise Specified
Panic AttacksPanic Attacks
Sudden episodes of Sudden episodes of acute apprehension or acute apprehension or intense fear that occur intense fear that occur out of the blue and are out of the blue and are accompanied by at least accompanied by at least 4 of the following:4 of the following:– Heart palpitationsHeart palpitations– Numbness, tingling Numbness, tingling
sensationsensation– Trembling, shakingTrembling, shaking– Chills, hot flashesChills, hot flashes– SweatingSweating– Shortness of breath, Shortness of breath,
smothering sensationsmothering sensation
– Choking sensationChoking sensation– Chest pain or Chest pain or
discomfortdiscomfort– Nausea, upset stomachNausea, upset stomach– Feeling dizzy, faint, Feeling dizzy, faint,
lightheaded, unsteadylightheaded, unsteady– Feeling detached, out of Feeling detached, out of
touch with selftouch with self– Fear of losing control, Fear of losing control,
going crazy, going crazy, – Fear of having a heart Fear of having a heart
attack or dyingattack or dyingSx typically develop Sx typically develop
abruptly & reach a peak abruptly & reach a peak rapidly within 10 minsrapidly within 10 mins
3 Types of Panic 3 Types of Panic AttacksAttacks Unexpected panic attacks (uncued): Unexpected panic attacks (uncued):
absence of situational triggers; most absence of situational triggers; most associated with panic disorder associated with panic disorder
Situationally-bound panic attacks Situationally-bound panic attacks (cued): presence of “invariable” (cued): presence of “invariable” triggers; most associated with social triggers; most associated with social phobia & specific phobiasphobia & specific phobias
Situationally-predisposed panic Situationally-predisposed panic attacks: presence of triggers; most attacks: presence of triggers; most associated with GAD & PTSDassociated with GAD & PTSD
Panic Disorder: Panic Disorder: Diagnostic CriteriaDiagnostic Criteria Presence of recurrent, unexpected panic Presence of recurrent, unexpected panic
attacks (at least 2)attacks (at least 2) At least 1 panic attack is followed by a month At least 1 panic attack is followed by a month
or more of:or more of:– Apprehension about having another panic Apprehension about having another panic
attackattack– Worry about the possible implications of an Worry about the possible implications of an
attack, such as losing control, “going crazy,” attack, such as losing control, “going crazy,” having a heart attack, or dyinghaving a heart attack, or dying
– A significant behavioral change related to A significant behavioral change related to the attacksthe attacks
Possible medical causes or the effects of Possible medical causes or the effects of substances have been ruled outsubstances have been ruled out
Specify absence or presence of agoraphobiaSpecify absence or presence of agoraphobia
Agoraphobia: Agoraphobia: Diagnostic CriteriaDiagnostic Criteria Anxiety about being in places or Anxiety about being in places or
situations where:situations where:– Escape may be difficult or embarrassingEscape may be difficult or embarrassing– Help may not be availableHelp may not be available
These situations:These situations:– Are avoidedAre avoided– Are endured with marked distress or Are endured with marked distress or
anxietyanxiety– Require the presence of a companion (a Require the presence of a companion (a
“safe person”“safe person” The anxiety and phobic avoidance is The anxiety and phobic avoidance is
not better accounted for by another not better accounted for by another psychological disorderpsychological disorder
Agoraphobia: Agoraphobia: Common Feared Common Feared SituationsSituations Being outside the homeBeing outside the home Being home aloneBeing home alone Crowded public places – restaurants, Crowded public places – restaurants,
theaters, malls, stores, supermarketstheaters, malls, stores, supermarkets Enclosed or confined spaces – Enclosed or confined spaces –
escalators, tunnels, elevatorsescalators, tunnels, elevators Public transportation – buses, trains, Public transportation – buses, trains,
subways, planessubways, planes Open spacesOpen spaces Driving or riding in carsDriving or riding in cars
Agoraphobia & Panic Agoraphobia & Panic DisorderDisorder Panic Disorder with Agoraphobia: Panic Disorder with Agoraphobia:
agoraphobia is due to the fear of agoraphobia is due to the fear of experiencing a full panic attackexperiencing a full panic attack
Agoraphobia without a history of Agoraphobia without a history of Panic Disorder: fear of being Panic Disorder: fear of being incapacitated or humiliated due incapacitated or humiliated due to unpredictable, sudden panic to unpredictable, sudden panic sx, such as dizziness or diarrheasx, such as dizziness or diarrhea
Panic Disorder & Panic Disorder & Agoraphobia: CausesAgoraphobia: Causes
HeredityHeredity Overly-sensitized & reactive “fear system”Overly-sensitized & reactive “fear system”
– includes the amygdala, hippocampus, locus includes the amygdala, hippocampus, locus ceruleus, hypothalamus, periacqueductal gray ceruleus, hypothalamus, periacqueductal gray region, & parabrachial nucleusregion, & parabrachial nucleus
– results from the fear system’s being activated results from the fear system’s being activated too frequently &/or intensely due to acute too frequently &/or intensely due to acute stress or the long-term result of multiple stress or the long-term result of multiple stressors over time stressors over time
Chemical imbalances in the brain: Chemical imbalances in the brain: deficiencies in serotonin & norepinephrinedeficiencies in serotonin & norepinephrine
Classical/associative conditioningClassical/associative conditioning
Panic Disorder & Panic Disorder & Agoraphobia: CausesAgoraphobia: Causes Growing up with parents who: are overly Growing up with parents who: are overly
critical & perfectionistic; are critical & perfectionistic; are overprotective; are overly anxious; overprotective; are overly anxious; communicate that the world is a communicate that the world is a dangerous placedangerous place
Tendency to interpret normal physical Tendency to interpret normal physical sensations in a catastrophic waysensations in a catastrophic way
Personal stress levelPersonal stress level Sudden losses Sudden losses Major life changesMajor life changes Exposure to stimulants or withdrawal from Exposure to stimulants or withdrawal from
narcotics, barbiturates, & tranquilizersnarcotics, barbiturates, & tranquilizers
Panic Disorder & Panic Disorder & Agoraphobia: Facts & Agoraphobia: Facts & FiguresFigures Onset: late adolescence or 20’sOnset: late adolescence or 20’s Prevalence: 1-3.5% of the Prevalence: 1-3.5% of the
population; 5% of the population population; 5% of the population has panic attacks with agoraphobiahas panic attacks with agoraphobia
Gender Differences: 2-3x as Gender Differences: 2-3x as common in women as men; common in women as men; approximately 75-80% of approximately 75-80% of agoraphobics are womenagoraphobics are women
Panic Disorder & Panic Disorder & Agoraphobia: Agoraphobia: Current TreatmentsCurrent Treatments Relaxation Training – deep breathing, Relaxation Training – deep breathing,
muscle relaxationmuscle relaxation Panic Control Therapy (interoceptive Panic Control Therapy (interoceptive
desensitization) – repeatedly exposing desensitization) – repeatedly exposing oneself to the unpleasant physical sx of oneself to the unpleasant physical sx of panic via induction techniques until the panic via induction techniques until the sx are no longer frighteningsx are no longer frightening
Graded Exposure – avoided situations Graded Exposure – avoided situations are gradually confronted through a are gradually confronted through a process of small, incremental stepsprocess of small, incremental steps
Medication – SSRI’s, tricyclics Medication – SSRI’s, tricyclics antidepressants, benzodiazepinesantidepressants, benzodiazepines
Panic Disorder & Panic Disorder & Agoraphobia: Agoraphobia: Current TreatmentsCurrent Treatments Cognitive Therapy: identifying & Cognitive Therapy: identifying &
modifying catastrophic thoughts that modifying catastrophic thoughts that tend to trigger panic attackstend to trigger panic attacks
Assertiveness TrainingAssertiveness Training Group Therapy Group Therapy Lifestyle & Personality Changes – stress Lifestyle & Personality Changes – stress
mgt, regular exercise, eliminating mgt, regular exercise, eliminating stimulants & sugar, creating downtime, stimulants & sugar, creating downtime, slowing down, altering attitudes about slowing down, altering attitudes about perfectionism, needing to please, and perfectionism, needing to please, and needing to controlneeding to control
Specific Phobia: Specific Phobia: Diagnostic CriteriaDiagnostic CriteriaA.A. Strong, persistent fear of specific objects or Strong, persistent fear of specific objects or
situationssituationsB.B. Exposure to feared object or situation Exposure to feared object or situation
provokes an immediate anxiety responseprovokes an immediate anxiety responseC.C. Recognition that fear is excessive or Recognition that fear is excessive or
unreasonable (except for children)unreasonable (except for children)D.D. The person avoids the feared object or The person avoids the feared object or
situation or endures it with dreadsituation or endures it with dreadE.E. The avoidance, fear, or anxious anticipation The avoidance, fear, or anxious anticipation
interferes significantly with the person’s interferes significantly with the person’s functioning or causes significant distressfunctioning or causes significant distress
F.F. Duration of at least 6 monthsDuration of at least 6 months
Specific Phobia: SpecifiersSpecific Phobia: Specifiers
Animal Type – snakes, insects, ratsAnimal Type – snakes, insects, rats Natural Environment Type – storms, Natural Environment Type – storms,
heights, waterheights, water Blood-Injection-Injury Type – blood, Blood-Injection-Injury Type – blood,
injury, injection, medical proceduresinjury, injection, medical procedures Situational Type – public Situational Type – public
transportation, tunnels, bridges, transportation, tunnels, bridges, elevators, flying, driving, enclosed elevators, flying, driving, enclosed spacesspaces
Other Type – choking, vomiting, Other Type – choking, vomiting, contracting an illness, loud soundscontracting an illness, loud sounds
Specific Phobia: Specific Phobia: Facts & FiguresFacts & Figures Prevalence: Affects 10-11% of Prevalence: Affects 10-11% of
populationpopulation Gender Differences: 4x more Gender Differences: 4x more
common for womencommon for women Only a minority seek treatmentOnly a minority seek treatment Course: decline with old ageCourse: decline with old age
Specific Phobia: Specific Phobia: CausesCauses Childhood fears that were never Childhood fears that were never
outgrownoutgrown Vicarious learning – modeling, being Vicarious learning – modeling, being
warned about a potential danger warned about a potential danger Experiencing a traumatic eventExperiencing a traumatic event Experiencing a false alarm in a specific Experiencing a false alarm in a specific
situationsituation Classical conditioning – conditioning by Classical conditioning – conditioning by
associationassociation Conditioning by avoidanceConditioning by avoidance
Specific Phobia: Specific Phobia: Current TreatmentsCurrent Treatments Relaxation trainingRelaxation training Cognitive therapyCognitive therapy Systematic desensitization via Systematic desensitization via
imagery &/or real life exposureimagery &/or real life exposure
Social Phobia: Social Phobia: Diagnostic CriteriaDiagnostic Criteria
Intense, persistent fear of being embarrassed, Intense, persistent fear of being embarrassed, humiliated, or negatively evaluated in social or humiliated, or negatively evaluated in social or performance situationsperformance situations
Exposure to the feared social or performance situation Exposure to the feared social or performance situation typically provokes an immediate anxiety responsetypically provokes an immediate anxiety response
Recognition that the fear is excessive or unreasonable Recognition that the fear is excessive or unreasonable (except for children)(except for children)
The social or performance situation is avoided or The social or performance situation is avoided or endured with considerable anxiety or distressendured with considerable anxiety or distress
The avoidance, fear, or anxious anticipation interferes The avoidance, fear, or anxious anticipation interferes significantly with the person’s functioning or causes significantly with the person’s functioning or causes the person considerable distressthe person considerable distress
Symptoms must have persisted for at least 6 monthsSymptoms must have persisted for at least 6 months Specifier: Generalized – fear in a wide range of social Specifier: Generalized – fear in a wide range of social
situationssituations
Social Phobia: Social Phobia: Common FearsCommon Fears Public speakingPublic speaking BlushingBlushing Choking on or spilling food while Choking on or spilling food while
eating in publiceating in public Being watchedBeing watched Using public restroomsUsing public restrooms Writing or signing documents in the Writing or signing documents in the
presence of otherspresence of others CrowdsCrowds Taking examsTaking exams PerformingPerforming
Social Phobia:Social Phobia:Facts & FiguresFacts & Figures Prevalence: affects 2-13% of the Prevalence: affects 2-13% of the
US populationUS population Gender Differences: roughly Gender Differences: roughly
equivalent rates for men and equivalent rates for men and womenwomen
Onset: late childhood or Onset: late childhood or adolescenceadolescence
Social Phobia:Social Phobia:Causal & Associated Causal & Associated FeaturesFeatures Hypersensitivity to criticism, negative Hypersensitivity to criticism, negative
evaluation, or rejectionevaluation, or rejection Difficulty being assertiveDifficulty being assertive Low self esteem, feelings of inferiorityLow self esteem, feelings of inferiority Poor social skillsPoor social skills Lack of social supportLack of social support Childhood history of social inhibition, Childhood history of social inhibition,
shyness, or stressful or humiliating shyness, or stressful or humiliating social experiencessocial experiences
Parents are more socially fearful and Parents are more socially fearful and concerned with the opinions of othersconcerned with the opinions of others
Social Phobia:Social Phobia:Current TreatmentsCurrent Treatments Relaxation trainingRelaxation training Cognitive therapyCognitive therapy Imaginal & real life exposureImaginal & real life exposure Group therapy – ideal treatment formatGroup therapy – ideal treatment format Medication – beta-blockers, tricyclic Medication – beta-blockers, tricyclic
antidepressants, MAO inhibitors, SSRI’santidepressants, MAO inhibitors, SSRI’s Social skills trainingSocial skills training Assertiveness trainingAssertiveness training
Generalized Anxiety Generalized Anxiety Disorder: Diagnostic Disorder: Diagnostic CriteriaCriteria
A.A. Chronic anxiety & worry persist for at least 6 Chronic anxiety & worry persist for at least 6 months & focuses on 2+ stressful life months & focuses on 2+ stressful life circumstancescircumstances
B.B. The anxiety and worry are difficult to control and The anxiety and worry are difficult to control and are out of proportion to the actual likelihood of are out of proportion to the actual likelihood of feared events happeningfeared events happening
C.C. The anxiety and worry are associated with 3+ of The anxiety and worry are associated with 3+ of the following sx, which occur a majority of days the following sx, which occur a majority of days during a 6-month period (only 1 item is required in during a 6-month period (only 1 item is required in children):children):
1.1. Restlessness, feeling keyed up or on edgeRestlessness, feeling keyed up or on edge2.2. Easily fatiguedEasily fatigued3.3. Difficulty concentratingDifficulty concentrating4.4. IrritabilityIrritability5.5. Muscle tensionMuscle tension6.6. Difficulties with sleepDifficulties with sleep
GAD: Diagnostic GAD: Diagnostic CriteriaCriteria
D.D. The focus of the anxiety & worry The focus of the anxiety & worry is not confined to the features of is not confined to the features of another Axis I disorder, e.g. such another Axis I disorder, e.g. such as anxiety about gaining weight as anxiety about gaining weight in anorexia nervosain anorexia nervosa
E.E. The anxiety, worry, or physical The anxiety, worry, or physical sx cause significant distress or sx cause significant distress or impairment in functioningimpairment in functioning
GAD: Facts & FiguresGAD: Facts & Figures
Affects approximately 4% of the Affects approximately 4% of the American PopulationAmerican Population
More common in females than More common in females than males (55-67%) males (55-67%)
Onset: earlier and more gradual Onset: earlier and more gradual onset than most other anxiety onset than most other anxiety disordersdisorders
Course: chronicCourse: chronic
GAD: CausesGAD: Causes
HeredityHeredity A disturbance in the functioning of the A disturbance in the functioning of the
benzodiazepine/GABA system of the brain, benzodiazepine/GABA system of the brain, which is associated with the body’s natural which is associated with the body’s natural calming response calming response
Predisposing childhood experiences – e.g. Predisposing childhood experiences – e.g. excessive parental expectations, parental excessive parental expectations, parental abandonment or rejectionabandonment or rejection
Maladaptive attitudes – perfectionism, Maladaptive attitudes – perfectionism, excessive need to please others, excessive excessive need to please others, excessive need to control, over-sensitivity to threatneed to control, over-sensitivity to threat
““Basic fears” that Sustain GAD: fear of losing Basic fears” that Sustain GAD: fear of losing control, fear of not being able to cope, fear of control, fear of not being able to cope, fear of rejection or abandonment, fear of death or rejection or abandonment, fear of death or diseasedisease
GAD: Current GAD: Current TreatmentsTreatments
Relaxation TrainingRelaxation Training Cognitive Therapy – fearful self talk underlying Cognitive Therapy – fearful self talk underlying
worry themes are identified, challenged, & worry themes are identified, challenged, & replaced with more realistic, optimistic thinkingreplaced with more realistic, optimistic thinking
Problem Solving – focus on solutions rather than Problem Solving – focus on solutions rather than worrying, learn to accept what you can’t changeworrying, learn to accept what you can’t change
Distraction Techniques Distraction Techniques Medication – benzodiazepines, tricyclics, SSRI’s, Medication – benzodiazepines, tricyclics, SSRI’s,
SNRI’sSNRI’s Lifestyle & Personality Changes – stress Lifestyle & Personality Changes – stress
management, increased downtime, regular management, increased downtime, regular exercise, eliminating sweets & stimulants from exercise, eliminating sweets & stimulants from diet, resolving interpersonal conflictsdiet, resolving interpersonal conflicts
Obsessive Compulsive Obsessive Compulsive Disorder: Diagnostic Disorder: Diagnostic CriteriaCriteriaObsessions:Obsessions: Recurring, intrusive, senseless ideas, thoughts Recurring, intrusive, senseless ideas, thoughts
or images that can’t seem to be suppressedor images that can’t seem to be suppressed Not merely excessive worries about real-life Not merely excessive worries about real-life
problems; in fact, are usually unrelated to real-problems; in fact, are usually unrelated to real-life problemslife problems
Person recognizes that these thoughts, fears, Person recognizes that these thoughts, fears, images are irrationalimages are irrational
Most common: aggressive impulses, fear of Most common: aggressive impulses, fear of contamination, sexual thoughts, somatic contamination, sexual thoughts, somatic concerns, the need for symmetry and concerns, the need for symmetry and exactness exactness
25% of people only have obsessions 25% of people only have obsessions
OCD: Diagnostic OCD: Diagnostic CriteriaCriteriaCompulsions:Compulsions: Behaviors or rituals the person feels Behaviors or rituals the person feels
compelled to perform in order to dispel the compelled to perform in order to dispel the anxiety brought up by obsessionsanxiety brought up by obsessions
E.g. washing hands numerous times to dispel E.g. washing hands numerous times to dispel fear of being contaminated, checking fear of being contaminated, checking windows and doors over and over again to windows and doors over and over again to make sure they’re lockedmake sure they’re locked
Most common: washing, checking, counting, Most common: washing, checking, counting, ordering and arrangingordering and arranging
Person recognizes that the rituals are Person recognizes that the rituals are unreasonableunreasonable
Conflict between desire to be free of the Conflict between desire to be free of the compulsive ritual and the irresistible desire to compulsive ritual and the irresistible desire to perform it perform it anxiety, shame, despair anxiety, shame, despair
OCD: Facts & FiguresOCD: Facts & Figures
Prevalence: 2-3% of general populationPrevalence: 2-3% of general population Gender Differences:Gender Differences:
– Affect men & women in equal numbersAffect men & women in equal numbers– Men outnumber women as checkersMen outnumber women as checkers– Women outnumber men as washers and Women outnumber men as washers and
cleanerscleaners– Age of onset is earlier in men than womenAge of onset is earlier in men than women
Onset: half of cases begin in childhood; Onset: half of cases begin in childhood; half begin in adolescence or young half begin in adolescence or young adulthoodadulthood
Often accompanied by, and may wax & Often accompanied by, and may wax & wane with, depressionwane with, depression
OCD: CausesOCD: Causes
Deficiency in serotonin Deficiency in serotonin Associated with excessive activity in certain Associated with excessive activity in certain
parts of the brain (orbitofrontal cortex, the parts of the brain (orbitofrontal cortex, the cingulated gyrus, & the caudate nuclei)cingulated gyrus, & the caudate nuclei)
The tendency to develop anxiety over having The tendency to develop anxiety over having additional obsessive thoughtsadditional obsessive thoughts
Being taught that certain thoughts are Being taught that certain thoughts are dangerous and unacceptable and must be dangerous and unacceptable and must be suppressedsuppressed
Thought-action fusion: equating thoughts with Thought-action fusion: equating thoughts with their corresponding actionstheir corresponding actions
Attitudes of excessive responsibility and Attitudes of excessive responsibility and perfectionismperfectionism
Compulsions develop to suppress or neutralize Compulsions develop to suppress or neutralize obsessionsobsessions
OCD: Current OCD: Current TreatmentsTreatments Relaxation TrainingRelaxation Training Cognitive Therapy – fearful, Cognitive Therapy – fearful,
superstitious, or guilty thoughts superstitious, or guilty thoughts associated with the obsessions are associated with the obsessions are identified, challenged, and replacedidentified, challenged, and replaced
Exposure & Response PreventionExposure & Response Prevention Medication – SSRI’s, clomipramineMedication – SSRI’s, clomipramine Life Style & Personality ChangesLife Style & Personality Changes Psychosurgery – surgical lesion to the Psychosurgery – surgical lesion to the
cingulate bundle (cingulotomy)cingulate bundle (cingulotomy)
Posttraumatic Stress Posttraumatic Stress Disorder: Diagnostic Disorder: Diagnostic CriteriaCriteriaEXPOSURE TO A TRAUMATIC EVENTEXPOSURE TO A TRAUMATIC EVENT The person has been exposed to a The person has been exposed to a
traumatic event whichtraumatic event which– involved threats to personal integrity, serious involved threats to personal integrity, serious
injury, or death.injury, or death.– produced intense fear, helplessness, or horror produced intense fear, helplessness, or horror – for children: produced disorganized or agitated for children: produced disorganized or agitated
behaviorbehavior e.g. earthquakes, tornadoes, auto e.g. earthquakes, tornadoes, auto
accidents, combat, rape, physical assault, accidents, combat, rape, physical assault, violent crimeviolent crime
PTSD: Diagnostic PTSD: Diagnostic CriteriaCriteriaRE-EXPERIENCINGRE-EXPERIENCING The traumatic event is persistently re-The traumatic event is persistently re-
experienced in 1+ of the following ways:experienced in 1+ of the following ways:– Repetitive, distressing thoughts or images Repetitive, distressing thoughts or images
about the eventabout the event– Nightmares related to the eventNightmares related to the event– Intense flashbacks Intense flashbacks – Intense psychological distress &/or Intense psychological distress &/or
physiological reactivity to stimuli associated physiological reactivity to stimuli associated with the traumawith the trauma
– For children: frightening dreams without For children: frightening dreams without recognizable content, repetitive play relating recognizable content, repetitive play relating to the trauma, trauma reenactmentto the trauma, trauma reenactment
PTSD: Diagnostic PTSD: Diagnostic CriteriaCriteria
AVOIDANCEAVOIDANCE Persistent avoidance of stimuli Persistent avoidance of stimuli
associated with the trauma:associated with the trauma:– efforts to avoid thoughts, feelings, or efforts to avoid thoughts, feelings, or
conversations associated with the conversations associated with the traumatrauma
– efforts to avoid activities, places, or efforts to avoid activities, places, or people that arouse recollections of people that arouse recollections of the traumathe trauma
PTSD: Diagnostic PTSD: Diagnostic CriteriaCriteriaNUMBINGNUMBING Numbing of general responsiveness Numbing of general responsiveness
(not present before the trauma)(not present before the trauma)– inability to recall an important aspect of inability to recall an important aspect of
the traumathe trauma– losing interest in activities that used to losing interest in activities that used to
give pleasuregive pleasure– feeling detached or estranged from othersfeeling detached or estranged from others– emotional numbness – being out of touch emotional numbness – being out of touch
with feelingswith feelings– sense of foreshortened future, e.g. not sense of foreshortened future, e.g. not
expecting to have a career, marriage, expecting to have a career, marriage, children, or normal life spanchildren, or normal life span
PTSD: Diagnostic PTSD: Diagnostic CriteriaCriteria
INCREASED AROUSALINCREASED AROUSAL Persistent symptoms of increased Persistent symptoms of increased
arousal (not present before the arousal (not present before the trauma), as indicated by 2+ of the trauma), as indicated by 2+ of the following:following:– difficulty falling or staying asleepdifficulty falling or staying asleep– irritability or outbursts of angerirritability or outbursts of anger– difficulty concentratingdifficulty concentrating– hypervigilancehypervigilance– startling easilystartling easily
PTSD: Diagnostic PTSD: Diagnostic CriteriaCriteria Duration of the disturbance is more than Duration of the disturbance is more than
one monthone month The disturbance causes significant The disturbance causes significant
distress or impairment in important areas distress or impairment in important areas of functioningof functioning
Specify if:Specify if:– Acute – if duration of symptoms is < 3 monthsAcute – if duration of symptoms is < 3 months– Chronic – if duration of symptoms is 3+ Chronic – if duration of symptoms is 3+
monthsmonths– Delayed onset – if onset of symptoms is at Delayed onset – if onset of symptoms is at
least 6 months after the stressor least 6 months after the stressor
PTSD: Facts & FiguresPTSD: Facts & Figures
Can occur at any ageCan occur at any age Prevalence:Prevalence:
– 3-8% of the general population3-8% of the general population– 18% of women experiencing trauma18% of women experiencing trauma– 32% of rape victims 32% of rape victims – 15-20% of those experiencing serious auto 15-20% of those experiencing serious auto
accidents accidents Often accompanied by anxiety & Often accompanied by anxiety &
depressiondepression
PTSD: CausesPTSD: Causes
Person personally experiences a trauma and Person personally experiences a trauma and develops an array of symptoms that develops an array of symptoms that “recreate” the original trauma“recreate” the original trauma
Distressing recollections & dreams about the Distressing recollections & dreams about the trauma are the mind’s attempt to gain trauma are the mind’s attempt to gain control of the original event & to neutralize control of the original event & to neutralize the emotional charge it carries the emotional charge it carries
Family history of anxietyFamily history of anxiety Family instabilityFamily instability Lack of social supportLack of social support Elevated corticotropin-releasing factor (CRF) Elevated corticotropin-releasing factor (CRF)
and heightened activity in the HPA axis and heightened activity in the HPA axis resulting from the traumaresulting from the trauma
PTSD: Current PTSD: Current TreatmentsTreatments Relaxation Training Relaxation Training Cognitive TherapyCognitive Therapy Exposure Therapy – imaginal exposureExposure Therapy – imaginal exposure Medication – SSRI’sMedication – SSRI’s Support GroupsSupport Groups EMDR – Eye Movement Desensitization EMDR – Eye Movement Desensitization
& Reprocessing& Reprocessing HypnotherapyHypnotherapy
Acute Stress Disorder: Acute Stress Disorder: Diagnostic CriteriaDiagnostic Criteria The person has been exposed to a traumatic The person has been exposed to a traumatic
event which:event which:– involved threat to personal integrity, serious injury, involved threat to personal integrity, serious injury,
or deathor death– produced intense fear, helplessness, or horrorproduced intense fear, helplessness, or horror
Either during or after the traumatic incident, Either during or after the traumatic incident, the person has 3+ of the following dissociative the person has 3+ of the following dissociative symptoms:symptoms:– numbing, detachment, or absence of emotional numbing, detachment, or absence of emotional
responsivenessresponsiveness– reduced awareness of one’s surroundings (e.g. being reduced awareness of one’s surroundings (e.g. being
in a daze)in a daze)– feelings of unreality or depersonalizationfeelings of unreality or depersonalization– dissociative amnesia (i.e. inability to recall an dissociative amnesia (i.e. inability to recall an
important aspect of the trauma) important aspect of the trauma)
Acute Stress Disorder: Acute Stress Disorder: Diagnostic CriteriaDiagnostic Criteria
The traumatic event is persistently re-experienced The traumatic event is persistently re-experienced in at least one of the following ways: in at least one of the following ways: – recurrent images, thoughts, dreams, flashbacksrecurrent images, thoughts, dreams, flashbacks– a sense of reliving the experiencea sense of reliving the experience– distress on exposure to stimuli associated with traumatic distress on exposure to stimuli associated with traumatic
eventevent Marked avoidance of anything that reminds the Marked avoidance of anything that reminds the
person of the trauma (e.g. thoughts, feelings, person of the trauma (e.g. thoughts, feelings, conversations, activities, places, people)conversations, activities, places, people)
The disturbance causes the person significant The disturbance causes the person significant distress or impairment in important areas of distress or impairment in important areas of functioningfunctioning
The disturbance occurs within 4 weeks of The disturbance occurs within 4 weeks of traumatic event & lasts for a minimum of 2 days traumatic event & lasts for a minimum of 2 days and a maximum of 4 weeksand a maximum of 4 weeks
Anxiety Due to a General Anxiety Due to a General Medical Condition: Diagnostic Medical Condition: Diagnostic
CriteriaCriteria Significant anxiety, panic attacks, or Significant anxiety, panic attacks, or
generalized anxiety are a direct generalized anxiety are a direct physiological effect of a specific physiological effect of a specific medical condition:medical condition:– Endocrine conditions – hyperthyroidism, Endocrine conditions – hyperthyroidism,
hypothyroidism, pheochromocytoma, hypothyroidism, pheochromocytoma, hypoglycemiahypoglycemia
– Cardiovascular conditions – congestive Cardiovascular conditions – congestive heart failure, pulmonary embolismheart failure, pulmonary embolism
– Metabolic conditions – vitamin B12 Metabolic conditions – vitamin B12 deficiency, porphyriadeficiency, porphyria
– Neurological conditions – vestibular Neurological conditions – vestibular problems, encephalitisproblems, encephalitis
Substance-Induced Substance-Induced Anxiety DisorderAnxiety Disorder Significant anxiety, panic attacks, or Significant anxiety, panic attacks, or
generalized anxiety are a direct generalized anxiety are a direct physiological effect of a substance: physiological effect of a substance: – a medicationa medication– drug of abusedrug of abuse– toxin exposuretoxin exposure
Anxiety may be due to exposure to Anxiety may be due to exposure to the substance or withdrawal from itthe substance or withdrawal from it
Long-Term, Predisposing Long-Term, Predisposing Causes of Anxiety DisordersCauses of Anxiety Disorders
Heredity Heredity – Having the same genetic makeup as someone with Having the same genetic makeup as someone with
phobias or anxiety makes it more than 2x as likely phobias or anxiety makes it more than 2x as likely that you will have a similar problemthat you will have a similar problem
– Inherit a reactive, excitable nervous system and Inherit a reactive, excitable nervous system and personality that predisposes you to anxietypersonality that predisposes you to anxiety
Childhood CircumstancesChildhood Circumstances– Parents communicate an overly cautious view of Parents communicate an overly cautious view of
the world.the world.– Parents are overly critical & perfectionistic and set Parents are overly critical & perfectionistic and set
excessively high standardsexcessively high standards– Experiencing neglect, rejection, abandonment (e.g. Experiencing neglect, rejection, abandonment (e.g.
via divorce or death), physical abuse, sexual via divorce or death), physical abuse, sexual abuse, alcoholic parent(s) abuse, alcoholic parent(s) emotional insecurity & emotional insecurity & excessive dependencyexcessive dependency
– Parents suppress your ability to express your Parents suppress your ability to express your feelings & assert yourselffeelings & assert yourself
Long-Term, Predisposing Long-Term, Predisposing Causes of Anxiety DisordersCauses of Anxiety Disorders
Cumulative and/or Enduring Stress Cumulative and/or Enduring Stress – Over time, stress can affect the Over time, stress can affect the
neuroendocrine regulatory systems of neuroendocrine regulatory systems of the brain, which play an important the brain, which play an important role in depression and anxietyrole in depression and anxiety
– Stress is nonspecific in its action – it Stress is nonspecific in its action – it has the greatest impact on the has the greatest impact on the weakest point(s) in one’s systemweakest point(s) in one’s system
Biological Causes Biological Causes
Long-Term, Predisposing Long-Term, Predisposing Causes of Anxiety DisordersCauses of Anxiety Disorders
Medical Conditions:Medical Conditions:– Hyperventilation syndrome – rapid, shallow breathing Hyperventilation syndrome – rapid, shallow breathing
can produce light-headedness, dizziness, feelings of can produce light-headedness, dizziness, feelings of unreality, trembling, tingling, shortness of breathunreality, trembling, tingling, shortness of breath
– Hypoglycemia – anxiety, shakiness, dizziness, Hypoglycemia – anxiety, shakiness, dizziness, weakness, disorientationweakness, disorientation
– Hyperthyroidism – heart palpitations, sweating, Hyperthyroidism – heart palpitations, sweating, generalized anxietygeneralized anxiety
– Mitral valve prolapse – causes heart palpitations Mitral valve prolapse – causes heart palpitations – Premenstrual syndrome Premenstrual syndrome – Inner ear disturbances – dizziness, light-headedness, Inner ear disturbances – dizziness, light-headedness,
unsteadinessunsteadiness– Acute reactions to cocaine, amphetamines, caffeine, Acute reactions to cocaine, amphetamines, caffeine,
or other stimulantsor other stimulants– Withdrawal from alcohol, sedatives, or tranquilizersWithdrawal from alcohol, sedatives, or tranquilizers
Short-Term Triggering Short-Term Triggering
CausesCauses of Anxiety Disordersof Anxiety Disorders
Stressful events/circumstances that Stressful events/circumstances that precipitate panic attacks:precipitate panic attacks:– Significant personal loss – death, divorce, Significant personal loss – death, divorce,
separation, loss of employment, illness, separation, loss of employment, illness, financial reversal, etcfinancial reversal, etc
– Significant life change – getting married, Significant life change – getting married, having a baby, going off to college, having a baby, going off to college, moving, changing jobs, etcmoving, changing jobs, etc
Exposure to stimulants and withdrawal Exposure to stimulants and withdrawal from narcotics, barbiturates, from narcotics, barbiturates, tranquilizerstranquilizers
Maintaining Causes of Maintaining Causes of Anxiety DisordersAnxiety Disorders
Avoidance of feared situationsAvoidance of feared situations Anxiety-provoking self-talkAnxiety-provoking self-talk Mistaken beliefs about yourself, others, and Mistaken beliefs about yourself, others, and
the worldthe world Withheld feelings – denying feelings of anger, Withheld feelings – denying feelings of anger,
sadness, frustration, excitementsadness, frustration, excitement Lack of assertivenessLack of assertiveness Lack of self-nurturing skillsLack of self-nurturing skills Muscle tension Muscle tension feel “uptight” feel “uptight” StimulantsStimulants Dietary factors – sugar, food additivesDietary factors – sugar, food additives High stress lifestyleHigh stress lifestyle Lack of meaning or sense of purpose in lifeLack of meaning or sense of purpose in life