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006 - Chapter 6 - Panic, Anxiety, And Their Disorders

006 - Chapter 6 - Panic, Anxiety, And Their Disorders

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Published by Joseph Eulo

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Published by: Joseph Eulo on Feb 08, 2009
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03/11/2014

 
Panic, Anxiety, andTheir Disorders
THE FEAR AND ANXIETY RESPONSE PATTERNSOVERVIEW OF THE ANXIETY DISORDERS ANDTHEIR COMMONALITIESSPECIFIC PHOBIAS
Blood-Injection-Injury Phobia Age of Onset and Gender Differences inSpecific PhobiasPsychosocial Causal FactorsGenetic andTemperamentalCausalFactors Treating SpeciicPhobias
SOCIAL PHOBIAS
Interactionof Psychosocialand Biological CausalFactors Treating SocialPhobias
PANIC DISORDER WITH AND WITHOUTAGORAPHOBIA
Panic DisorderAgoraphobiaPrevalence,Gender, andAge of Onset of Panic Disorder with and without Agoraphobia Comorbiditywith Other Disorders The Timing of a First Panic Attack  BiologicalCausal Factors Behavioral and Cognitive Causal FactorsTreating Panic Disorder and Agoraphobia
GENERALIZED ANXIETY DISORDER
GeneralCharacteristics Prevalence andAge of Onset Comorbidity with Other Disorders PsychosocialCausal Factors BiologicalCausalFactors Treating GeneralizedAnxiety Disorder
OBSESSIVE-COMPULSIVE DISORDER
Prevalence, Age of Onset, and Comorbidity Characteristics of OCD PsychosocialCausalFactors BiologicalCausalFactors Treating Obsessive-Compulsive Disorder
SOCIOCULTURAL CAUSAL FACTORS FOR ALLANXIETY DISORDERS
CulturalDif erences in Sources of Worry Taijin Kyof usho
 
s we noted in Chapter 5, even stable, well-adjusted people may break down ifforced to face extensive combat stress,torture, or devastating natural disaster. Butfor some people, simply performing everyday activities can be stressful.Faced withthe normal demands of life-socializing with friends, waiting in line for a bus, beingon an airplane, touching a doorknob-they become seriously fearful or anxious. Inthe most severe cases, people with anxiety problems may be unable even to leavetheir homes for fear of having a panic attack, or may spend much of their time inmaladaptive behavior such as constanthand washing.
 Anxiety-a
general feeling of apprehension about possible danger-was, inFreud's formulation, a sign of an inner battle or conflict between some primitivedesire (from the id) and prohibitions against its expression (from the ego and super-ego). Today the DSM has identified a group of disorders that share obvious symp-toms and features of fear and anxiety. These
anxiety disorders,
as they are known,affect approximately 25 to 29 percent of the U.s. population at some point in theirlives (over 23 million Americans) and are the most common category of disorders forwomen and the second most common for men (Kessler et aI., 1994; Kessler, Berglund, et aI., 2005b). In any 12-month period, about 23 percent of women and 12 percent ofmen suffer from at least one anxiety disorder (Kessler et aI., 1994). Anxiety disorderscreate enormous personal, economic,and health care problems for those affected. For example, in 1990 anxiety disorders cost the United States $42.3 billion in directand indirect costs, with 90 percent of these being direct costs (about 30 percent ofthe nation's total mental health bill of $148 billion in 1990; Greenberg et aI., 1999). Consider the following case of an anxious electrician:
A 27-year-old married electrician complains of dizziness, sweating palms, heart palpitations, and ringingofthe earsofmore than
18
months' duration.Hehas also experienced dry mouth and throat, periods of extreme muscle tension,and a constant "edgy" and watchful feeling that has ofteninterfered with his ability to concentrate. These feelingshave been presentmost ofthe time during the previous 2years ...Because ofthese symptoms the patient has seena familypractitioner, a neurologist, a neurosurgeon, a chi-ropractor,and an ear-nose-throat specialist....Healso has many worries.He constantly worries about the health of his parents ... Healso worries about whether he isa "goodfather," whether his wife will ever leave him (there is noindication that she is dissatisfied with the marriage), andwhether he is liked by co-workers on the job. Although herecognizes that his worries are often unfounded, he can'tstop worrying.Forthe past 2years the patient has had fewsocial contacts because of his nervous symptoms...he sometimes has to leaveworkwhen the symptoms becomeintolerable. (Adapted fromSpitzer et aI.,2002.)
Sourc e: 
Adaptedwith permission from the
DSM-/V TR Casebook 
(Copyright
2000.)
American Psychiatric Publishing,Inc.)
Thephysicians thismanconsulted couldnot determine the cause of hisphysicalsymptoms, andone of them finally ref erred him for treatmentatamental healthclinic, wherehewas diagnosed ashaving
generalized anxietyis- or er -one
of seven primary anxiety disorders. Historically, cases likethis andother cases of anxiety disorders were considered to beclassic examples o neurotic behavior.Although neuroticbehavior is mal- adaptive andself-deeating, aneurotic personis notoutof  touchwithreality,incoherent,or dangerous. To Freud, neuroseswerepsychological disordersthat resulted when intrapsychic conflict producedsignif icantanxiety.Some- times this anxiety was overtly expressed(as inthosedis- orders knowntoday asthe anxietydisorders). In certain other neurotic disorders, however, hebelieved that the anxietymight
not 
beobvious, either to theperson involved or to others,if psychological deense mechanisms were able todeflect or mask it.In1980 the DSM -III dropped the term
neurosis
andreclassif ied mostof these disorders that didnot involve obvious anxiety symptoms as eitherdisso- ciative or somatoform disorders(see Chapter 8).DSM-III made this change in order to group together smaller sets of  disordersthatsharemore obvious symptoms and features. Webegin bydiscussing thenature of fear and anxiety
as emotionalstates, both of whichhaveanextremely
importantadaptive value butto which humans attimes seem alltoo vulnerable. We willthen moveto a discussion othe anxietydisorders.
 
THE FEAR AND ANXIETY__RESPONSE PATTERNS
It isdifficult todefine
fear 
and
anxie y,
and therehas never beencomplete agreementabout howdistinct the two emotions are rom eachother.Historically,themost commonway of distinguishing between earandanxiety has beenwhether thereis aclearand obvioussourceo dangerthat would be regardedas real bymost people. When thesource of dangerisobvious, the experienced emotionhas been called
fear 
(e.g.,''I'mafraid osnaes"). With
anxiety,
however,wefrequentlycannotspecify clearlywhat the dangeris (e.g., ''I'm anxiousabout my parents'health"). Intuitively,anxiety seemsto be experi- enced as an unpleasantinner stateinwhich weare antic- ipating something dreadul happeningthatisnotentirely predictable fromour actualcircumstances (e.g.,Barlow, 2002a).
FEAR
Inrecentyears,manyprominent researchershave proposeda more undamental distinction betweenfearand anxiety(e.g., Barlow,1988, 2002a;Gray
&
McNaughton,1996).Accordingto thesetheorists,fearor panic is abasic emotion(shared by many animals)that involvesactivation of the"ight-or-light" responseof the sympatheticner- vous system. This is analmost instantaneousreaction to any imminent threatsuchasa dangerouspredatoror someone pointing aloadedgun.Its adaptive valueisthat it allowsus to escape rom imminent danger.When the fear/panic response occurs inthe absence of any obvious external danger, we saythe person hashad a spontaneous or uncued
panicattac.
The symptomsof apanic attack  are nearly identical tothose experienced duringa state of  fearexceptthat panic attacks are of tenaccompanied by a subjective sense of impendingdoom,including fears o dying,going crazy, orlosing control.Theselattercognitive symptomsdo notgenerally occurduringearstates. Thus ear and panichavethreecomponents: 1.cognitive / sub jectivecomponents ("Ifeel afraid /terrif ied";''I'm going to die"); 2.physiologicalcomponents (suchasincreased heart rate and heavybreathing); 3.behavioral components (a strongurge to escape or flee; Lang,1968, 1971). These components are only "loosely coupled" (Lang, 1985), which meansthatsomeone might show, f orexam- ple, physiological and behavioralindications of ear with- out muchof the sub jective component, or viceversa. As a primitive alarm response todanger, theearresponsemust be activatedwithgreatspeed toserveits adaptivepurpose: enabling us toescapeoravoid danger.Indeed, we of ten seem to go froma normalstate to a state of intenseear almost instantaneously.
ear or panic
is a
basicemotionhat 
is
shared bymany animals,includ ing humans, and may activate he " f ight-or- flight" res ponse o f hesympatheticnevous syst em.Thisallowsuso respond  apidly when facewith
a
danger aus situation , such
as
beinghreaened b y
a
preato.nhumans who ae having
a
panicattack  ,here
is
no external hreat; panic occurs because of somemisfiringof this response system.
ANXIETY
Incontrastto ear and panic,anxiety is a complexblend of unpleasantemotions and cognitions that isbothmore orientedtothe uture andmuch more dif use than fear(Barlow,1988, 2002a).But likeear, it hasnotonlycognitive /subjectivecomponentsbutalso physiologicaland behavioralcomponents. At the cognitive / sub jective level,anxiety involves negative mood, worry about possible uturethreat ordanger, self- preoccupation,anda sense of beingunable to predict the future threat orto controlit if itoccurs.At a physiological level,anxiety of tencreates a state of tensionand chronic overarousal, which may reflect readiness for dealing with dangershouldit occur("Something awulmay happen and I had betterbe ready forit iitdoes"). Although there is noactivationof the fight-or-flight response as inear, anxietydoesprepareorprime a personfor the fight-or- flight response should the anticipated danger occur. At a behavioral level, anxiety may create a strong tendencyto avoid situations where danger might be encountered, but thereis nottheimmediateurgeto fleewithanxiety as there is with ear (Barlow,1988, 2002a). Support orthe idea thatanxietyisdescriptivelyandunctionallydistinct

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