Anxiety DisordersAnxiety Disorders

Dr. Kayj Nash OkineDr. Kayj Nash Okine

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