ANXIETY DISORDER

-All Mental Processes Have an Organic Basis

NOSOLOGY
DSM-IV-TR
ICD-10
1. Panic Disorder
Phobic Anxiety Disorders
Stress and Anxiety
2. Panic
Disorder
1. agoraphobia
- Much of anxiety is due to stressful stimuli
w/o agoraphobia
2. social phobia
- Some anxiety may be spontaneous (Generalized Anxiety
3. agoraphobia w/o
3. spcfc
(isolated)
Disorder)
Hx
of
panic
phobia
- Stress may threaten ego
disorder
4. other
phobic
4. spcfc phobia
anxiety disorders
ID
SUPEREGO
5. social phobia
5. phobic
anxiety
6. OCD
disorder,
7. PTSD
unspecified
EGO
Symptoms of Anxiety
- Affection of thinking, perception, and learning
DSM-IV-TR CRITERIA FOR PANIC ATTACK
- Confusion
- A discrete period of intense fear or discomfort, in w/c four
-Poor concentration
or more of the ff symptoms developed abruptly, and reached
- Poor memory
apeak w/in 10 mins:
-Selective attention
1. palpitations, pounding heart, or accelerated rate
2. sweating
Causes of Anxiety
3. trembling or shaking
1. Psychoanalytic
4. sensations of shortness of breath or smothering
* Sigmund Freud
5. feeling of choking
~ Damned-up Libido
6. chest pain or discomfort
~ Non-release of sexual tension
7. nausea or abdominal distress
~ Psychic conflict between unconscious sexual or 8. feeling dizzy, unsteady, lightheaded, or faint
aggressive wishes (id) and corresponding threats from 9. derealization (feelings of unreality) or depersonalization
superego or external reality
(being detached from oneself)
~ Weak defense mechanisms
10. feel of losing control or going crazy
11. fear of dying
SUPEREGO
12. paresthesias (numbness or tingling sensations)
13. chills or hot flushes

ID

Defense mechanisms
- at each phase of libidinal devt, specific drive components
2. Behavioral
evoke characteristic ego defenses
3. Existential
anal phase: reaction formation (devt of shame & disgust
4. Biological
in relation to anal impulses and pleasures)
* Neurotransmitters
- intrapsychic devices
~ NE
- ego defenses
+ poorly regulated noradrenergic system with - specific defensive operations existing outside of and
occasional bursts of activity
beyond conscious awareness
+ locus ceruleus in the rostral pons to the - adjustment techniques which serve as a constructive
cerebral cortex, limbic system, brain stem, and SC +
means for the maintenance of emotional equilibrium
beta-adrenergic agonists (isoproterenol)
- defenses can be grouped hierarchically accdg to relative
+ alpha2 antagonists (yohimbine)
degree of maturity associated with them
+ alpha2 agonists (clonidine)
1. Narcissistic defenses are the most primitive (children,
+ increased CSF MHPG
persons psychotically disturbed)
2. Immature defenses: adolescents and some nonpsychotic
~ 5-HT
patients
+ reduction in sertotonin
3. Neurotic defenses: OC and hysterical ppl; adults under
+ serotonergic antidepressants have therapeutic stress
effect in some anxiety disorders
4. Mature defenses
+ raphe nuclei in rostral brain stem to cerebral
cortex, limbic system (amygdala and hippocampus), and Primary Functions
hypothalamus
1. facilitate the resolution of emotional conflict
2. provide relief from stress
~ GABA
3. cushion emotional pain
+ efficiency of BZDs, which enhance GABA activity
4. avoid or alleviate anxiety
at the GABAA receptor
5. ways and means the ego wards off anxiety and
controls instinctive urges and unpleasant emotions
6. used by all people in day to day lives
7. Excessive reliance may lead to

EGO

Classification of Defense Mechanisms (George Vaillant)

Narcissistic defenses
Denial
- Avoiding the awareness of some painful aspect of reality by negating sensory data
- Although repression defends against affects and drive derivatives, denial abolishes external reality
- Denial may be used in both normal and pathological states
- mechanism by which the ego refuses to perceive or face emotional conflict
Distortion
- grossly reshaping external reality to suit inner needs (including unrealistic megalomania beliefs,
hallucinations, wish-fulfilling delusions)
- using sustained feelings of delusional superiority or entitlement
Projection
- perceiving & reacting to unacceptable inner impulses and their derivatives as though they were outside
the self
- on a psychotic level, this takes the form of frank delusions about external reality (usually persecutory)
and includes both perception of ones own feelings in another and subsequent acting on the perception
(psychotic paranoid delusions)
- impulse may derive from the id or the superego (hallucinated recriminations), but may undergo
transformation in the process
- accdg to Freuds analysis of homosexual libidinal impulses transform into hatred projected onto
the object of the unacceptable homosexual impulse
- mechanism through which the individual rejects aspects of self by imputing to others motives and
emotional feelings which are unacceptable to self
- attributing own wishes, thoughts or feeling onto someone else
Immature Defenses
Acting out

Blocking

Hypochondriasis

Introjection

Passive-Aggressive
behavior (pab)

Regression

Schizoid fantasy

- expressing an unconscious wish or impulse through action to avoid being conscious of an

accompanying affect
- unconscious fantasy is lived out impulsively in behavior- gratifying impulse (rather than
prohibition against it)
- involves giving in to an impulse to avoid the tension (from postponment of expression)
- behavioral or emotional outbursts
- temporarily or transiently inhibiting thinking
- affects and impulse may be involved
- resemble repression differ in the tension that arises when the impulse, affect or thought is
inhibited
- exaggerating/overemphasizing an illness purpose of evasion and regression
- reproach arising from bereavement, loneliness, or unacceptable aggressive impulses toward
others transformed to self-reproach & complaints of pain, somatic illness and neurasthenia
- responsibility can be avoided; guilt circumvented; instinctual impulses are warded off
- ego-alien hypochondriac: experience dysphoria and sense of affliction
- internalizing the qualities of an object
- when used as a defense can obliterate distinction bet. subject and object
- thru introjection
loved object, painful awareness of separateness or threat of loss may be avoided
feared object avoids anxiety when aggressive characteristics of object are internalized place
aggression under ones control
- example: indentification with aggressor; with victim(self-punitive qualities of the objects are taken
over and established within ones self as a symptom or char. trait
- a mechanism through which loved or hated attitudes, wishes, ideals, values objects or persons
are symbolically incorporated into selfe
- features of the external world are taken and made part of the self
- express aggression toward others indirectly through
a. Passivity
b. Masochism
c. Turning against
- manifestations of pab failure, procrastination, illness that affects others more than oneself
- attempting to return to an earlier libidinal phase of functioning to avoid the tension and
conflict evoked at the present level of devt
- reflects basic tendency to gain instinctual gratification at a less-developed period
- certain amt is essential for relaxation, sleep and orgasm in sex; also in creative process
- mechanism through which an individual retreats to an earlier and subjectively more comfortable
level of adjustment
- most immature of defenses
- indulge in autistic retreat to resolve conflict and to obtain gratification
- interpersonal intimacy avoided

Somatization

Neurotic defenses
Controlling
Displacement

Externalization
Inhibition
Intellectualization

Isolation
Rationalization

Dissociation

Reaction formation

Repression

Sexualization

- eccentricity serves to repel others

- person doesnt fully believe in fantasies and doesnt insist on acting them out
- converting psychic derivatives into bodily symptoms and tending to react with somatic
manifestations (rather than psychic manifestations)
- desomatization: infantile somatic responses are replaced by thought and affect
- resomatization: person regresses to earlier somatic forms in the face of unresolved conflicts
- attempt to manage or regulate events/objects in the envt to minimize anxiety and resolve
inner conflicts
- shift an emotion or drive cathexis from 1 idea/object to another that resembles the original
in some aspect/quality
- permits symbolic representation of original idea by one that is less highly cathected or
evokes less distress
- mechanism through which emotional feeling is transferred, deflected and redirected from one
idea, person or object to another
- tending to perceive in the external world & in external objects elements of ones own
personality, including instinctual impulses, conflicts, moods, attitudes, and styles of thinking
- more general term than projection
- consciously limiting or renouncing some ego functions (alone or in combination) evade
anxiety from conflict with instinctual impulses, superego, or environmental forces or figures
- excessively using intellectual processes to avoid affective expression/experience
- undue emphasis on inanimate to avoid intimacy with people
- attention paid to external reality
avoiding expression of inner feelings;
stress is excessively placed on irrelevant details to avoid perceiving
the whole
- closely allied to rationalization
- splitting or separating an idea from the affect that accompanies it but is repressed
- social isolation: absence of object relationships
- offering rational explanations in an attempt to justify attitudes, beliefs or behavior that may
otherwise be unacceptable
- underlying motives are usually instinctually determined
- ego justifies or attempts to modify otherwise unacceptable impulses, needs, feelings, behaviors,
and motives into ones which are consciously tolerable and acceptable
- temporarily but drastically modifying a persons character/ ones sense of personal identity
avoid emotional distress
- fugue states and hysterical conversion reactions are common manifestations of dissociation
- found in counterphobic behavior, dissociative identity disorder, use of pharmacological highs or
religious joys
- mechanism through which the effective emotional significance is separated and detached from
an idea, situation, object or relationship
- transforming an unacceptable impulse into the opposite
- this is charcteristic of obsessional neurosis
- if used at any early stage od ego devt can become a permanent charcter trait (as in an
obsessional charcter)
- mechanism through which an individual assumes attitudes, motives or needs which are
opposite to consciously disowned ones
- results in the formation of character traits
- expelling or withholding from consciousness an idea or feeling
- primary repression: curbing of ideas and feelings b4 they have attained consciousness
- secondary repression: exclude from awareness what was once experienced at a
conscious level
- repressed is not really forgotten in that symbolic behavior may be present
- differ from suppression by effecting conscious inhibition of impulses to the point of losing and
not just postponing cherished goals
- conscious perception of instincts and feelings is blocked in repression
- a mechanism in which there is automatic and involuntary submerging of unpleasant or painful
thoughts, feelings and impulses into the unconscious
- an idea or feeling is withheld from consciousness
- unconscious forgetting
- endow an object/ function with sexual significance (that it did not previously have or
possessed to a smaller degree) to ward off anxieties associated with prohibited impulses or
their derivatives

Mature defenses
Altruism
- using constructive and instinctually gratifying service to others to undergo a vicarious
experience
- include benign and constructive reaction formation
- altruism vs. altruistic surrender surrender of direct gratification or of instinctual needs takes
place in favor of fulfilling the needs of others to the detriment of the self; and satisfaction can only be
enjoyed vicariously through introjection
Anticipation
- realistically anticipating or planning for future inner discomfort
- goal directed mechanism and implies careful planning or worrying and premature but realistic affective
anticipation and potentially dreadful outcomes
Asceticism
- eliminating the pleasurable effects of experiences
- there is moral element in assigning values to specific pleasures
- gratification is derived from renunciation
- asceticism is directed against all base pleasures perceived consciously
Humor
- using comedy to overtly express feelings and thoughts w/o personal discomfort or immobilization and
w/o producing an unpleasant effect on others
- allows person to tolerate, yet focus on what is too terrible to be borne
- diff. frm wit form of displacement involving distraction from affective issue
- making fun of the situation
Sublimation
- achieving impulse gratification and the retention of goals but altering a socially objectionable
aim or object to a socially acceptable one
- allows instincts to be channeled, rather than blocked/diverted
- feelings are acknowledged, modified and directed toward a significant object or goal, and modest
instinctual satisfaction occurs
- most mature of the defenses
Suppression
- consciously or unconsciously postponing attention to a conscious impulse or conflict
- issues may be deliberately cut off, but not avoided
- discomfort is acknowledged but minimized
- a mechanism through which there is a deliberate, intentional exclusion of thoughts, feelings or
experiences from the conscious mind
- conscious forgetting
- the only conscious defense mechanism