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Anxiety is a specific type of disorder; It is an emotion implicated so heavily across the full range of psychopathology

that our discussion explores its general nature, both biological and psychological.

-is a negative mood state characterized by bodily symptoms of physical tension and by apprehension about the
future. (American Psychiatric Association, 2013; Barlow, 2002)

- is also closely related to depression (Barlow, 2000, 2002; Brown & Barlow, 2005, 2009; Clark, 2005; Craske et
al, 2009)

*Psychologists have known for over a century that we perform better when we are a little anxious (Yerkes &
Dodson, 1908)

*Social, physical, and intellectual performances are driven and enhanced by anxiety. Without it, few of us would
get much done.

*Howard Liddell (1949) , called anxiety the shadow of intelligence human ability to plan in some detail for
the future was connected to that connected to that gnawing (=to cause someone to feel continual anxiety or pain)
feeling that things could go wrong and had better be prepared for them. ---- anxiety as future oriented mood stated (
characterized by apprehension because we cannot predict or control upcoming events.


Fear - is an immediate alarm reaction to danger; it protects us by activating a massive response from the autonomic
nervous system. (increased heart rate and blood pressure) motivates us to escape (flee) or to attack (fight).


Panic -sudden overwhelming reaction

Panic attack an abrupt experience of intense fear or acute discomfort.

*basic types : expected (cued) panic attack panic attack in certain situations but not anywhere
Unexpected (uncued) panic attack if you dont know have a clue when or when
the next attack will occur

Diagnostic criteria for panic attack table---------------

Causes of Anxiety and Related Disorders:

Biological Contributions
- We inherit a tendency to be tense, uptight, and anxious (Barlow et al.,2013; Clark, 2005;
Eysenck, 1967; Gray & McNaughton,1996)
- The tendency to panic seems to run in families and has a genetic component that differs from
genetic contributions to anxiety (Barlow,2002;Craske& Barlow,2013; Kendler et al., 1995)

- Stress or other factors in the environment can turn on these genes (Gelernter & Stein, 2009;
Smoller, Block, & Young, 2009)

- Anxiety is associated with specific brain circuits and neurotransmitter systems

- The area of the brain most often associated with anxiety is the limbic system which acts as a
mediator between the brain stem and the cortex (Britton & Rauch, 2009; Gray & McNaughton,
1996; Hermans et al., 2011; LeDoux, 2002)

- Behavioral inhibition system (BIS) is activated by changes in body functioning that might signal
danger. Signals that arise from brain stem/ decend from cortex, our tendency is to freeze,
experience anxiety.

- Fight/flight systems is activated partly by deficiencies in serotonin (Gray and McNaughton, 1996;
Graeff, 1993)

Psychological Contributions
- Behavioral theories thought anxiety was the product of early classical conditioning, modelling
or other forms of learning (Bandura, 1986)

- Parents teach their children that they have control over their environment and their responses
have an effect on their parents and their environment.

- Parents who provide a secure home base but allow children to explore their world and
develop necessary skills to cope with unexpected occurrences enable their children to develop a
healthy sense of control (Chorpita & Barlow, 1998)

Social Contributions
- Stressful life events trigger our biological and psychology vulnerabilities to anxiety.
- Same stressors can trigger physical reactions, such as headaches or hypertension, and emotional
reactions, such as panic attacks (Barlow, 2002)

Integrated Model

Triple vulnerability theory theory of development of anxiety

Generalized biological vulnerability might be inherited

Generalized psychological vulnerability growing up believing the world is dangerous and out of
Specific psychological vulnerability - learn from early experience; being taught.

Comorbidity co-occurrence or two or more disorders in a single individual

- Share common features and vulnerabilities of anxiety and panic. What differs only in what triggers the
anxiety and patterning of panic attacks

- Presence of any anxiety disorder was uniquely and significantly associated with thyroid disease,
gastrointestinal disease, arthritis, migraine headaches, and allergic conditions (Sareen et al., 2006)

- Same relationship between anxiety disorders, particularly panic disorders, and cardiovascular(heart)

Generalized Anxiety Disorder - a psychological disorder characterized by excessive or disproportionate anxiety

about several aspects of life, such as work, social relationships, or financial matters

- DSM 5 criteria specify that at least 6 months of excessive anxiety and worry must be ongoing more days than
- Characterized as muscle tension, mental agitation and susceptible to fatigue
- Mostly worry about minor, everyday life events
- Children with GAD most often worry about competence in academic, athletic, or social performance, as well as
family issues
- Older adults tend to focus, understandably, on health; have difficulty in sleeping
- GAD is prevalent among older adults. Most common in the group over 45 years old and least common in the
youngest group, ages 15- 24.


- Individuals with GAD do not respond as strongly to stressors as individuals with anxiety disorders in which panic
is more prominent. Therefore people with GAD show less responsiveness on most physiological measures (such
as heart rate, blood pressure, skin conductance, and respiration rate) than do individuals with other anxiety

- Using stroop effect, individuals with GAD were slower to name the colors of the words than were nonanxious

- Words were more relevant to people with GAD. SEARCH MO BAKET


- Benzodiazepines are most often prescribed for generalized anxiety, that they give some relief at least in the
short term.
- Benzodiazepines seem to impair both cognitive and motor functioning
- They also seem to produce both psychological and physical dependence
- Treatments have other components, such as teaching patients how to relax deeply to combat tension
- Cognitive- behavioural treatment patients learn to use cognitive therapy and other coping techniques to
counteract and control worry process
- Focusing on acceptance rather than avoidance of distressing thoughts
- Meditational approaches help teach the patient to be more tolerant of these feelings

Panic disorder and Agoraphobia

Agoraphobia fear and avoidance of situations in which a person feels unsafe or unable to escape

*People experienced panic disorder without developing agoraphobia and some people develop agoraphobia in the
absence of panic disorder

* Term agoraphobia was coined by Karl Westphal, a German physician (1871). In Greek agora is marketplace, so
therefore agoraphobia refers to fear of the marketplace.

TABLE 5.1---------------------------

*Introceptive avoidance avoidance of internal physical sensations; removing oneself from situations or activities that
mightproduce the physiological arousal that somehow resembles beginnings of panic attack.


Onset of panic disorder usually occurs in early adult life from midteens -40 years old. Median onset is between 20-24
years old. (Kessler, Berglund, et al., 2005)

75% or more those who suffer from agoraphobia are women (Barlow, 2002; Myers et al., 1984; Thorpe & Burns, 1983)
most logical explanation is cultural. Men are expected to be stronger and braver, to tough it out

Cultural Influences

*Prevalence rates for panic disorder were remarkably similar in the United States, Canada, Puerto Rico, New Zealand,
Italy, Korean, Taiwan. (Horwath & Weissman, 1997)

Nocturnal Panic

60% of people with panic disorder have experienced nocturnal attacks. (Craske & Rowe, 1997; Uhde, 1994)

Panic attacks often occur between 1:30am and 3:30am

What causes nocturnal panic is that the change in stages of sleep to slow wave produces physical sensations of letting

Therapists assume that patients are repressing their dream material, perhaps because it might relate to an early
trauma too painful to be admitted to consciousness,
Patients with NP might have a breathing disorder called sleep apnea


Three contributing factors: biological, psychological and social.

One hypothesis that panic disorder and agoraphobia evolve from psychodynamic causes suggested that early object loss
and/or separation anxiety might predispose someone to develop the condition as an adult.



A large number of drugs affecting the noradrenergic, serotonergic, or GABA- benzodiazepine neurotransmitter systems,
high potency benzodiazepines, the newer selective serotonin reuptake inhibitors (SSRIs) such as Prozac and Paxil and
closely related serotonin- norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine (Barlow, 2002;Barlow &
Craske, 2013)

Psychological Intervention

Psychological treatments have proved quite effective for panic disorder. Such treatments concentrated on reducing
agoraphobic avoidance, using strategies based in exposure to feared situations.

Gradual exposure exercises, sometimes combined with anxiety reducing coping mechanisms such as relaxation or
breathing retraining, have proved effective in helping patients overcome agoraphobic behavior.

Panic Control Treatment (PCT) developed one of our clinics concentrates on exposing patients with panic disorder to tha
cluster of introceptive (physical) sensations that remind them of their panic attacks. patients are taught relaxation and
breathing retraining to help reduce anxiety.

Panic disorder and generalized anxiety disorder GAD are both considered mental health conditions that can
greatly impact a person's quality of life. Both conditions are identified as anxiety-related illnesses in the
Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM 5) - the handbook used by mental
health providers to determine a diagnosis. Although they share some common symptoms, including
excessive worry, they are two separate and distinct illnesses.

Panic Disorder

Recurring panic attacks are the hallmark features of panic disorder. Panic attacks are sudden and intense feelings of
terror, fear or apprehension, without the presence of actual danger. These feelings are often accompanied by numerous
uncomfortable physical sensations. Some of the common somatic symptoms of panic attacks include chest pain,
trembling and shaking, accelerate heart rate, hyperventilation orshortness of breath, and excessive sweating.

These physical symptoms are typically met with disturbing thoughts and fears. For example, the person may become
confused, fearful of going insane, or even feel attached from reality. The symptoms of a panic attack usually happen
suddenly, peak within 10 minutes and then subside. However, some attacks may last longer or may occur in succession,
making it difficult to determine when one attack ends and another begins.

Generalized Anxiety Disorder (GAD)

The main feature of GAD is excessive and pervasive worry about many everyday life events. This worry is difficult to
control and the person finds her worrisome thoughts to be unmanageable. In order to be considered GAD, worry and
anxiety must persists for more than 6 months and interferes with daily functioning.

For example, people with GAD find it difficult to concentrate and to simply feel "okay." The worry and anxiety can take
over, making it difficult for the person to complete job tasks, maintain healthy relationships, and take care of oneself.

The Focus of Worry

Panic disorder often causes excessive worry about having another panic attack. It is not unusual for one to become so
consumed with worry and fear that he or she develops behavioral changes in the hopes of avoiding another attack. This
may lead to the development of agoraphobia, which complicates recovery and limits ones ability to function in usual
daily activities.

The focus of worry in GAD generally surrounds many usual life circumstances. For example, excessive worry about
finances, job issues, children, and other everyday life events is associated with GAD. This is in contrast to the worry of
having a panic attack that is associated with panic disorder.

It should be noted that it is possible to have both panic disorder and GAD.

In fact, it is not uncommon for GAD to co-occur with mood disorders or other anxiety disorders. But, in order for a
distinct diagnosis of GAD to be made, excessive and pervasive worry about many everyday life events that persists for
more than 6 months must be present.

The Importance of Getting Help

The symptoms of panic disorder and GAD can be potentially disabling. But, the vast majority of sufferers will find
significant relief with treatment. The sooner treatment begins after the onset of symptoms, the more quickly symptom
reduction or elimination will be realized. If you have symptoms of panic disorder, GAD or both, talk to your doctor or
other healthcare provider.


American Psychiatric Association. "Diagnostic and Statistical Manual of Mental Disorders, 5th ed.," 2013 Washington, DC: Author.

The frequency of symptoms during panic attacks and anticipation of the panic consequences were compared
in patients with the subtypes of panic disorder (PD). Patients with moderate and severe agoraphobic
avoidance reported that they had experienced more symptoms than patients with an uncomplicated PD
(without agoraphobia [AG]); they also experienced almost all of the symptoms more frequently, with the
difference being significant for a quarter of the examined panic symptoms. Panic patients with moderate and
severe AG were also significantly more concerned about the loss of control and social and physical
consequences of panic attacks. Taken together, these findings suggest that the severity of panic attacks,
defined as the number of panic symptoms, along with a variety of anticipatory fears about the consequences
of the attacks may contribute to the development of AG in panic patients.