phobia, panic, and the anxiety disorders - anderson university, a
TRANSCRIPT
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Phobia, Panic, and the
Anxiety Disorders
Chapter 5
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The Nature Of Anxiety
Disorders• False alarms in response to harmless stimuli
• Inordinately apprehensive, tense, uneasy
• Interferes with functioning
• May be disabling
• Physical and psychological
reactions
• Cognitive and affective
components
• Twelve percent of Americans
affected3
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The Nature of Anxiety Disorders
• Fear is an innate alarm response
to a dangerous or life-threatening
situation.
• Anxiety is the state in which an
individual is inordinately
apprehensive, tense, and uneasy
about the prospect of something
terrible happening.
• People with anxiety disorders are
incapacitated with chronic and
intense feelings of anxiety. 4
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Discriminate between the Disorders
• Phobia is a fear of a specific object
• PTSD numbing fear after experiencing a
specific trauma
• Panic anxiety that occurs suddenly
• Agoraphobia fear of a panic attack in a public
place
• GAD pervasive anxiety that is nonspecific,
experiential an chronic
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Specific vs. General
Object vs. Experience
Phobia PTSD
Sudden vs. Chronic
Panic
Disorder
Generalized
Anxiety
Disorder
Agora
phobia
Fear Anxiety
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Four Elements of Fear
• Cognitive - thoughts of impending harm, exaggerating the actual amount of danger;
• Somatic - paleness of skin, goose bumps, muscle tension, face of fear, heart rate increase, accelerated respiration;
• Emotional/subjective - feelings of dread, fear, or panic, queasiness or "butterflies"; and
• Behavioral - decreasing appetite, escape, avoidance, freezing, aggression.
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1. In which of the four areas do
you most intensely feel anxiety?
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Fear vs. Anxiety
• Anxiety has the same four components as
fear,
• The cognitive component differs
– fear is the expectation of a clear and specific
danger,
– anxiety is the expectation of something of a much
more diffuse danger; Ex. "Something terrible might
happen,"
• Treatments will be the same except in
cognitive area
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Panic Disorder
http://www.healpastlives.com/future/cure/crpanic.htm
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Panic Disorder
Frequent and Recurrent Panic Attacks
Constant Worry and Apprehension
About Possible Panic Attacks
or
Unexpected (Uncued) Attacks
Situationally Bound (Cued) Attack
Situationally Predisposed Attack
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Panic Disorder
• Intense fear and physical discomfort
• Fear of loss of control
• Sudden onset, peak within 10 minutes
• Bodily sensations- Shortness of breath, fear of being smothered, hyperventilation, dizziness, choking, heart palpitations, sweating, stomach distress, chest discomfort, flashes or chills, numbness, sense of unreality or disorientation, fear of dying
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Panic Disorder
• 15% of Americans experience at some
time• World lifetime prevalence from 1.4 to 2.9 %
• Most develop around age of 20
• Rare to develop in children and later adulthood
• Women twice as likely as men to be diagnosed
• Course variable - Some experience only once, most
continues, off and on, for years
• Attempts to avoid panic-filled situations can lead to
agoraphobia- intense anxiety of being trapped,
stranded, or embarrassed in event of a panic attack
(fear of the fear)
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Panic Disorder
Panic disorder is often associated with
agoraphobia.
Agoraphobia:
Intense anxiety about being trapped
or stranded in a situation without help
if a panic attack occurs.
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Panic Disorder
• Neurotransmitters
• Anxiety Sensitivity
• Conditioned Fear Reactions
Suggested explanations include:
Biological relatives of people with
panic disorder are 8 times more
likely to develop this condition.
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Cognitive View of Panic
Disorder • Results from catastrophic misinterpretation of bodily sensations
• Certain bodily sensations are inherent
• These can be misinterpreted
• The drug induces these sensations that are misinterpreted.
• The failure of the body to dampen symptoms is a consequence and
not a cause of the misinterpretation of the impending doom, and the
drugs dampen the bodily sensations.
• Both theories explain possible causes of panic disorder and have
therapies, but the cognitive approach has a 80-90% reduction of
panic attacks in patients who have learned to correctly interpret their
bodily sensations.
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Panic Disorder-Theories• Cognitive-Behavioral
– The “vicious cycle”
– Individual experiences the unpleasant
physical sensations, which leads to feeling
loss of control
– Faulty cognitions and misperceptions of these
bodily sensations accounts for constant fear
of the symptoms reoccurring.
http://www.flakmag.com/film/panicroom.html
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Biomedical View of Panic
Disorder • Chemical induction of panic,
• Neuro-chemical abnormalities in panic
patients
• Drug relief of panic.
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Biological Theories
• Physiological disturbances underlie the
psychological
– Increase in blood lactate levels
– Excess of norepinephrine
– Defect in GABA
– Hypersensitive brainstem may account for
sense of suffocation that leads to
hyperventilation, leading to lower levels of
carbon dioxide in blood
– Hypersensitive to body’s anxiety “cues”
that arise with increased heart activity (they
overreact) 19
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Treatment
• Medication
– Benzodiazepines to increase GABA
activity - Librium, Valium, Xanax
– Antidepressants to increase serotonin
activity Prozac, Luvox
• Relaxation training
– Alternate tensing and relaxing muscles
• Counterconditioning
– Learn how to control the physical
symptoms (For instance, hyperventilate
intentionally, then breathe normally)
http://www.uah.edu/ASEF/hyperventilate.gif
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Treatment• Panic Control Therapy (PCT)
– Comprehensive cognitive-behavioral model
– Cognitive restructuring
– Awareness of bodily cues associated with panic
attacks
– Breathing retraining
– Greater percentage of clients treated with PCT
improve comparably with those on medication
– PCT-treated clients more likely to remain symptom
free
– PCT appears to be highly efficacious treatment
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In what situation if any do you
think you might panic?
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Phobiashttp://www.evesindia.com/body-talk/img/phobia.jpg
http://www.utexas.edu/features/archive/2002/phobia.html
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Specific Phobias
Specific Phobia:
An irrational and unabating fear of a particular
object, activity, or situation that provokes an
immediate anxiety response, disrupts functioning,
and results in avoidance behavior.
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Common Specific Phobias
Hematophobia Blood
Ephidophobia Snakes
Aerophobia Flying
Death-related
phobia
Funerals, corpses,
and cemeteries
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Common Phobias
• Acrophobia Heights
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Common Phobias
• Acrophobia Heights
• Agoraphobia Open Places
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Common Phobias
• Acrophobia Heights
• Agoraphobia Open Places
• Claustrophobia Closed Places
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Common Phobias
• Acrophobia Heights
• Agoraphobia Open Places
• Claustrophobia Closed Places
• Nyctophobia Darkness
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Common Phobias
• Acrophobia Heights
• Agoraphobia Open Places
• Claustrophobia Closed Places
• Nyctophobia Darkness
• Pathophobia Disease
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Common Phobias
• Acrophobia Heights
• Agoraphobia Open Places
• Claustrophobia Closed Places
• Nyctophobia Darkness
• Pathophobia Disease
• Zoophobia Animals
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Less Common Specific Phobias
Ailurophobia Cats
Chionophobia Snow
Erythrophobia The color red
Metallophobia Metals
Ponophobia Work
Triskaidekaphobia The number 13
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2. Which phobia do you relate to
most closely?
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Uncommon Phobias
Angoraphobia
Fear of Furry Sweaters
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Uncommon Phobias
• Friend-or-phobia
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Uncommon Phobias
• Fear of forgetting the password
Friend-or-phobia
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Uncommon Phobias
• Claustrophobia
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Uncommon Phobias
Claustrophobia
• Fear of Christmas
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Uncommon Phobias
Super Phobia
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Uncommon Phobias
Super Phobia
• Fear of missing while leaping over tall
buildings in a single bound.
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Uncommon Phobias
Charmin Phobia
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Uncommon Phobias
Charmin Phobia
• Fear of being squeezed.
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Authoritative Sounding Names
for Phobias• Convey the impression that we understand
how a particular problem originated or
even how to treat it merely because we
have an authoritative-sounding name for it.
• There are more theories and jargon
pertaining to phobias than there are firm
findings.
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Necessary and Sufficient
Elements of Fear• All need not be present
• Some elements must be present
but not always in the same
combination.
• No one element of fear is
necessary
• Any element of fear is sufficient
• The more elements and the more
intense the more confidence in
the diagnosis
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Difference between fear and
phobia• Normal fear is in proportion to
the degree of danger in the
situation,
• Phobia is when the fear response
is out of proportion to the amount
of danger
• They are both on the same
continuum--they differ in degree,
not in kind.
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Low Moderate High Extreme
A
B
X
D
Reality of Danger
Deg
ree
of
Fea
r R
esponse
Phobia vs. Normal Fear
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Research on Phobia
• Unusually well-defined,
• Little trouble in
diagnosing it,
• Much known about its
cause and cure,
• The best-understood
disorder.
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Phobias
• Simple vs.
Agoraphobia
• Nosophobia vs.
hypochondriasis
• Blood phobia vs.
simple phobias
• Fear vs. panic
• One vs. many attack
• Tense vs. relax
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Common subtypes of phobia.
• Agoraphobia
• Social phobia
• Specific phobias
• Blood phobia
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Specific Phobias
• Intense irrational fear about a dreaded
object
• There is no real danger
• Anxiety builds as they approach the
stimulus - may experience panic attack
• May be traced to childhood experiences
• Two-thirds of people who have panic
disorder with agoraphobia have specific
phobias
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Agoraphobia
• Fear of having a panic attack
• In an open place
• No one coming to aid
• Most common phobia
• Unlike other phobias these
patients are often highly
anxious and generally
depressed.
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Types of treatment for
agoraphobia.
• Flooding
• Antidepressant drugs
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Social Phobia
A social phobia is a fear of being observed
by others acting in a way that will be
humiliating or embarrassing. They show
the following characteristics:
• recognizing their own fears as unreasonable
• low self-esteem
• underestimating their own abilities
•ruminate about how they could have
acted differently in a social event
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Social Phobia
• Intense, irrational fear that behavior will be
mocked or criticized by others
• May be general (all social, public situations) or
specific (such as speaking in public)
• May arise in childhood (especially in shy
children) and continue to adulthood
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Agoraphobia vs. Social Phobia
• Both are afraid of crowds
• Agoraphobics for fear they cannot get away if they have a panic attack
• Social phobics that someone will see them and observe them doing something embarrassing.
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Social Phobia - Theories
• Serotonin functioning
• Low levels of growth hormones in childhood
• Maladaptive thought processes –
– Can’t stop thinking about anticipated criticism and
focus on performance.
– Bad experience is self-fulfilling prophecy.
– Even if a good experience, the anxiety was so
unpleasant they don’t want to repeat it.
• Sociocultural - Similarities
across cultures, especially Japan
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Social Phobia - Treatment
• Cognitive restructuring
• In vivo exposure
• Social skills training
• Training to deal with interpersonal stress
• Antidepressants may help, but must be
combined with cognitive-behavioral
treatment
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Phobia Theories
• Evolutionary/Biological --we are programmed to
fear dangerous situations but we acquire
irrational fears
• Freud - Phobias defend the ego against anxiety
• Behavioral - Acquired through conditioning
• Cognitive- Faulty thinking maintains phobias
acquired in childhood
• Cognitive-behavioral - You think something is to
be feared because you feel bodily sensations
associated with fear (overactive “alarm
system”)
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Psychoanalytic View of
Phobias.
• The account is based
almost entirely on case
material
• There are large inferential
leaps from this material
• Therapy does not work
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Behavioral Account of Phobia.
• It is consistent with case history
material,
• It has generated three effective
therapies based on classical fear
extinction,
• It is supported by a good
deal of laboratory evidence.
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Classical Conditioning of Fear.
• The conditioned stimulus,
• The unconditioned stimulus,
• The unconditioned response,
• The conditioned response in an
example of a classically
conditioned phobia
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Problems with the Behavioral
Account Of Phobias.
• Selectivity: only certain objects
• Irrationality: only persists for certain
stimuli
• Lack of traumatic conditioning: can be
learned by observation
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Prepared Classical Conditioning
• People seem biologically prepared to
condition fears
• To certain objects such as snakes and
spiders,
• While they are less likely to develop fears to
pillows and pajamas.
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3. What is something of which
you have a fear that you have
no reason to be afraid of?
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Phobia
Common underlying
process that seems
operative in all three
effective therapies
• Extinction
Behavioral Explanation
for maintenance
• Phobic never confront
fear to test for reality
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Treatment For Phobias
• Systematic Desensitization
• Flooding (Imagined Or In Vivo)
• Positive Reinforcement
• Cognitive Restructuring
• Graduated Exposure
• Thought Stopping
• Stress Inoculation
• Bolstering Sense Of Self-efficacy
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Treatments for Phobias
• Cognitive treatment: discriminating
between real and imagined harm
• Somatic treatments (drugs, relaxation)
calm the physiological reactions
• Emotional/subjective treatments: allow
the person to experience emotions
under control
• Behavioral treatments extinction trials
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Virtual reality software is sometimes used
to treat people with phobias such as
fear of heights or flying.
Copyright © The McGraw-Hill
Companies, Inc. Permission
required for reproduction or
Specific Phobias
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Fear of Death & Phobia
• Culture says do not fear
death
• Is that wise?
• If result of death is hell
then fear is appropriate
• Worldview can determine
what constitutes
appropriate and
inappropriate fear
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4. On a 1 to 10 scale (with 10
intense) how much fear do you
have of death?
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Terms
• Classical conditioning– Learning by pairing US with CS to produce UR
• Instrumental conditioning– Being reinforced for behaviors usually negatively
by the withdrawal of fear
• Escape responding – Lowering fear by leaving the situation
• Avoidance responding– Lowering fear by avoiding the situation
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Terms• Systematic desensitization
– Counter-conditioning hierarchy of feared situationrelaxation
• Flooding – Massive exposure to the stimulus until anxiety
subsides
• Modeling vs. Systematic desensitization
• Applied Tension– Blood phobia tensing muscles
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Obsessive-Compulsive Disorder
OCD
© 2007 G. Lee Griffith, Ph. D.
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Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder:
An anxiety disorder characterized by
recurrent obsessions or compulsions that are
inordinately time-consuming or that cause
significant distress or impairment.
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Obsessive-Compulsive Disorder
• Obsession:A persistent and intrusive idea, thought, impulse or image.
• Compulsion:A repetitive and seemingly purposeful behavior performed in response to uncontrollable urges or according to a ritualistic or stereotyped set of rules .
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Four major dimensions:
• Checking compulsions
• Need for symmetry and order
• Cleanliness and washing compulsions
• Hoarding-related behaviors
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Obsessive-Compulsive Disorder
So far, treatment with clomipramine or other serotonin reuptake inhibiting medications, such a fluoxetine (Prozac) is the most effective biological treatment available for OCD.
OCD is increasinglybeing understoodas a genetic disorder.
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OCD AND OCPD Distinguished
• Obsessive-Compulsive Personality
Disorder - Rigid and inflexible. May need
to have all books in neat order
• Obsessive Compulsive Disorder -
Extremely disturbed thinking and behavior.
May check several times a
day to see that books did
not get moved somehow
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Prevalence
• Lifetime prevalence - 1-2 percent
• Commonly first appears in childhood &
adolescence
• Mostly male, family history of OCD, lack of
insight into symptoms, comorbid with
other disorders,
especially ADHD
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Perspectives- Biological
• Heightened activity in
brain regions that control
motor centers of basal
ganglia and frontal lobes
• Indicates that brain
working overtime to
control thoughts and
actions, but without effect
• Deficits in serotonergic
functioning
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Behavioral Perspective of OCD
• Symptoms
established through
conditioning
• Compulsions
become associated
with relief of anxiety
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Obsessions vs.
Normal Recurring Thoughts• Obsessions are distressing and
unwelcome
• They arise from within not an external
situation
• Difficulty to control
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Cognitive-behavioral view of the
maintenance of OCD’s• All have unwanted, repetitive thoughts.
• More stressed more frequent and intense these
thoughts.
• A person without OCD can easily dismiss or distract
himself from a thought,
• Person with OCD will be made anxious by the thought
and anxiety and depression reduce his/her ability to
dismiss it.
• The inability to turn off the thought then increases
anxiety, helplessness, and depression.
• The compulsion results from an attempt to act to reduce
the bad thoughts, and compulsive rituals become
reinforcing because of the termination of anxiety. 83
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Treatment of OCD
• Integrate biological and psychological
• Biological
– Improve serotonergic functioning
– Clomipramine, Zoloft, Luvox
• Psychological
– Exposure - Reduces obsessive
anxiety
– Response prevention - Helps
control compulsions84
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Response prevention and
modeling• They provide extinction
• Showing the patient that the
dreaded event does not occur
in the feared situation
• When the compulsive action
is not performed.
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5. How often do you have an
unwanted thought recur?
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Generalized Anxiety Disorder
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Generalized Anxiety Disorder
Generalized Anxiety Disorder:
An anxiety disorder characterized by anxiety
that is not associated with a particular object,
situation, or event but seems to be a
constant feature of a person's day-to-day
existence.
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Generalized Anxiety Disorder
• Uncontrollable anxiety most of the time
• Physical and psychological symptoms interfere
with functioning
• Restless, poor sleep patterns
• Tired, irritable, tense
• More common in women, and in
women over age of 24
• Often comorbid with other disorders,
particularly dysthymic disorder
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Theories
• Cognitive
– Distorted thinking and
inability to control
negative thoughts
• Sociocultural factors
– Causes lie in negative
life events and stress
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Treatment
• Medications- benzodiazepines
or Buspar
• Cognitive-behavioral therapy
– Break the cycle of negative
thinking and worrying
– Develop control over
behavior
– Manage and reduce
anxious thoughts
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AnxietyReduced
Effectiveness
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Copyright © The
McGraw-Hill
Companies, Inc.
TRAUMA
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Trauma-Induced Disorders
Acute Stress Disorder:
An anxiety disorder that develops
during the month after a traumatic
event. Lasts 2-4 weeks.
Symptoms may include depersonalization,
numbing, dissociative amnesia, intense
anxiety, and impairment of everyday
functioning.
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ACUTE STRESS DISORDER
• Post-trauma - disastrous personal tragedy or
those involving others (school shootings,
bombings, war)
• Feelings of helplessness, fear, horror
• Flashbacks
• Difficulties in sleep, concentration
• May be hypervigilant, easily startled
• May lead to Post-Traumatic Stress Disorder
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Post-Traumatic Stress
Disorder: PSTD
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Trauma-Induced Disorders
• Post-Traumatic Stress Disorder:
More than a month after a traumatic event,
stress interferes with the individual’s ability
to function
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PTSD Symptoms Clusters
• Intrusions and avoidance
– Intrusive thoughts, recurrent dreams,
flashbacks, avoidance of reminders
• Hyper-arousal and numbing
– Detachment, loss of interest in daily activities,
sleep disturbance, irritability, sense of
foreshortened future
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Post-traumatic Stress Disorder
• The person relives the trauma recurrently in dreams, in flashback, and in reverie
• The person becomes numb to the work and avoids stimuli that remind him of the trauma
• The experience symptoms of anxiety and arousal that were not present before the trauma
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PTSD Phases
• Outcry Phase
• Denial/Intrusion Phase
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Perspectives on Trauma-
Induced Disorders
• Brain Changes
• Conditioned Fear
• Economic Disadvantage
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Biological Perspectives Of PTSD
• Subcortical pathways in CNS and structures
in sympathetic nervous system altered and
become more “alert” to signs of impending
harm
• Trauma may alter neurotransmitter
functioning-Norepinephrine, serotonin,
dopamine
• Trauma may alter brain structure-
Hippocampus, temporal lobe
• May be genetic predisposition for
reexperiencing, avoidance, and arousal101
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Psychodynamic Perspectives -
PTSD
• Ego flooded with
uncontrollable anxiety.
• Trauma may stimulate
repressed memories or
aggressive impulsive,
• which themselves cause
anxiety
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Behavioral –Perspectives -
PTSD • Acquired a conditioned fear to trauma-
• related stimuli that produces anxiety that
leads to avoidance.
• Avoidance is reinforcing.
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Cognitive-behavioral –
Perspectives - PTSD
• Self-blame, guilt,
cynicism and pessimism
about life
• can lead to
– self-isolation
– drug and alcohol abuse.
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Sociocultural Perspective -
PTSD
• Lack of social support (Vietnam)
• Education
• Income level
• Social status
• Ethnicity
• Environment (Economically disadvantaged,
high-crime neighborhoods)
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PSTD & Compensation
• Future epidemiologists would do well
to compare symptoms under
reimbursable and non-reimbursable
conditions to arrive at accurate severity
and prevalence figures.
• Pre-DSM III data make it look as if post-
traumatic stress disorder is both real
and lasting.
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Treatment of Trauma-Induced
Disorders
• Medication
• “Covering”
• “Uncovering”
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PTSD - Treatment
• Medications - Benzodiazepines, antidepressants, anticonvulsants but in combination with psychotherapy
• Psychotherapy techniques– Covering - Supportive therapy and stress
management
– Uncovering - Reliving the trauma using systematic desensitization, imaginal flooding
– Meichenbaum Six Step Program
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PTSD - Treatment
• Meichenbaum’s six-step cognitive-behavioral
plan
– Good relationship with client
– Look at symptoms from positive standpoint
– Look at trauma specifically, not globally
– Confront the feared situation in real settings
– Confront fears, guilt, depression and distorted beliefs
– Anticipate recurrence of symptoms
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Scripture on Anxiety
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Proverbs. 12:25 (NASV)
• Anxiety in the heart of a man
weighs it down, but a good
word makes it glad.
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Matthew 6:25,34
• For this reason I say to
you, do not be anxious
for your life, as to what
you shall eat, or what
you shall drink nor for
your body as to what
you shall put on. Is not
life more than food and
the body more than
clothing?112
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Matthew 6:25
"Therefore I tell you, do not worry about your life, what you will eat or drink; or about your body, what you will wear. Is not life more important than food, and the body more important than clothes?
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Matthew 6:26
Look at the birds of the air; they do not
sow or reap or store away in barns, and
yet your heavenly Father feeds them.
Are you not much more valuable than
they?
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Matthew 6:27-29
27 Who of you by worrying can add a single hour to his life?
28 "And why do you worry about clothes? See how the lilies of the field grow. They
do not labor or spin.
29 Yet I tell you that not even Solomon in all his splendor was dressed like one of these.
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Matthew 6:30 -32
30 If that is how God clothes the grass of the field,
which is here today and tomorrow is thrown into
the fire, will he not much more clothe you, O you
of little faith?
31 So do not worry, saying, 'What shall we eat?' or
'What shall we drink?' or 'What shall we wear?'
32 For the pagans run after all these things, and
your heavenly Father knows that you need them.
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Matthew 6:33 -34
33 But seek first his kingdom and his
righteousness, and all these things will be
given to you as well.
34 Therefore do not worry about tomorrow, for
tomorrow will worry about itself. Each day
has enough trouble of its own.
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Philippians 4:6-8
6 Do not be anxious about anything, but in everything, by prayer and petition, with thanksgiving, present your requests to God.
7 And the peace of God, which transcends all understanding, will guard your hearts and your minds in Christ Jesus.
8 Finally, brothers, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable - if anything is excellent or praiseworthy -think about such things.
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Philippians 4:9
• Whatever you have
learned or received or
heard from me, or seen in
me - put it into practice.
And the God of peace will
be with you.
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How would step one be
described in secular terms. • Thinking on good things,
• praying,
• modifying self-talk.
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