chapter 6: panic, anxiety, obsessions, and their disorders

  PANIC ATTACK #AbsenceOfExternalDanger

CASE STUDY OF GENERALIZED ANXIETY - the person has this if fear response occurs in
DISORDER: the absence of any obvious external danger
- symptoms of a panic attack are nearly identical
to those experienced during a state of fear
except that panic attacks are often accompanied
by a subjective
sense of impending doom including fears of
dying, going crazy, or losing control
- panic occurs because of some misfiring of this
response system

FEAR AND PANIC HAVE THREE (3)

COMPONENTS:
- these components are only loosely coupled
FEAR #PrimitiveAlarmReaction - ex. physiological and behavioral indications of

#ImminentThreat fear or panic without much of the subjective

#ActivationOfAdrenaline #Escape component, or vice versa

- an alarm reaction that occurs in response to

immediate danger/ any imminent threat such as 1.) COGNITIVE/SUBJECTIVE COMPONENTS

a dangerous predator or someone pointing a - including “I feel afraid/terrified” or “I’m going

loaded gun to die”

- is a basic emotion (shared by many animals)

that involves activation of the fight-or-flight 2.) PHYSIOLOGICAL COMPONENTS #SNS

(adrenaline) response of the autonomic nervous - increased heart rate and heavy breathing

system (sympathetic nervous system)

- its adaptive value as a primitive alarm

response to imminent danger is that it allows us 3.) BEHAVIORAL COMPONENTS #Adrenaline

to escape - a strong urge to escape or flee (fight or flight

- when the source of danger is obvious, the or adrenaline neurotransmitter)

experienced emotion such as “I’m afraid of

dogs”

- cognitive/subjective symptoms do not

generally occur during fear states such as “I feel ANXIETY #Plan #Prepare
afraid” since it allows us to escape #PossibleFutureThreat

- involves a general feeling of apprehension
about possible future danger
- we frequently cannot specify clearly what the
danger is “I’m anxious about the future”
- To Freud, it is a sign of an inner battle or
conflict between some primitive desire (from
the id) and prohibitions against its expression
(from the ego and superego); but he believed
that anxiety may not be obvious if a person uses
a defense mechanism to mask or deflect it
- adaptive value of anxiety may be that it helps
us plan and prepare for possible threat
- anxiety response pattern is a complex blend of
unpleasant emotions and cognitions that is both
more oriented to the future and much more
diffuse than fear
- like fear, it does not only have
cognitive/subjective components but also
physiological and behavioral components
ADAPTIVE VALUE OF ANXIETY MAY BE THAT IT
HELPS US PLAN AND PREPARE FOR POSSIBLE
THREAT
- mild to moderate degrees of anxiety, anxiety
actually enhances learning and performance
similar with eustress effect
- it is maladaptive (it lessens our productivity)
when it becomes chronic and severe, as we see
in people diagnosed with anxiety disorders
ANXIETY AND THE 3 COMPONENTS:
1.) COGNITIVE/SUBJECTIVE LEVEL
#NegativeMood
- anxiety involves negative mood, worry about
possible future threats or danger, self-
preoccupation, and a sense of being unable to
predict the future threat or to control it if it
occurs
2.) PHYSIOLOGICAL LEVEL #Tension
#OverArousal
- anxiety often creates a state of tension and
chronic over arousal (sense of being awake or
increase autonomic nervous system), which may
reflect risk assessment and readiness for dealing
with danger should it occur
- ex. something awful may happen, and I had
better be ready for it if it does
3.) BEHAVIORAL LEVEL #Avoid
- anxiety may create a strong tendency to avoid
situations where danger might be encountered,
but there is not the immediate behavioral urge
to flee with anxiety as there is with fear
- there is no activation of the fight-or-flight
response as there is with fear, anxiety does
prepare or prime a person for the fight-or-flight
response should the anticipated danger occur
BASIC FEAR AND ANXIETY RESPONSE PATTERNS
ARE HIGHLY CONDITIONABLE
- previously neutral and novel stimuli
(conditioned stimuli) that are repeatedly paired
with, and reliably predict, frightening or
unpleasant events such as various kinds of
physical or psychological trauma (unconditioned
stimulus) can acquire the capacity to elicit fear
or anxiety themselves (conditioned response)
- ex. Angela sometimes saw and heard her
father physically abuse her mother in the
evening. After this happened four or five times,
Angela started to become anxious as soon as
she heard her father’s car arrive in the driveway
at the end of the day.
- initially neutral stimuli may accidentally come
to serve as cues that something threatening and
unpleasant is about to happen and thereby
come to elicit fear or anxiety themselves
• OUR THOUGHTS AND IMAGES CAN ALSO
SERVE AS CONDITIONED STIMULI CAPABLE OF
ELICITING THE FEAR OR ANXIETY RESPONSE
PATTERN
- ex. angela came to feel anxious even when
thinking about her father
ANXIETY DISORDERS
#Fear&AnxietySymptoms #Unrealistic
#IrrationalFears
- share obvious symptoms of clinically significant
fear or anxiety
- all have unrealistic, irrational fears or anxieties
of disabling intensity as their principal and most
obvious manifestation
- DSM-5 recognized 5 anxiety disorders
including specific phobia, social anxiety
disorder, panic disorder, agoraphobia, and
generalized anxiety disorder
- create enormous personal, economic, and
health care problems for those affected
- most common category of disorders for
women and the second most common for men
- are also associated with an increased
prevalence of a number of medical conditions
including asthma, chronic pain, hypertension,
arthritis, cardiovascular disease, and irritable
bowel syndrome
- many people with one anxiety disorder will
experience at least one more anxiety disorder
and/or depression either concurrently or at a
different point in their lives
5 ANXIETY DISORDERS’ SIMILARITIES AND
DIFFERENCE:
- there are some important similarities in the
basic causes of these disorder but they also
differ from one another both in terms of the
relative preponderance of fear or panic versus
anxiety symptoms and in the kinds of objects
or situations that most concern them
- among biological causal factors, there are
genetic contributions to each of these disorders
and that at least part of the genetic vulnerability
may be nonspecific, or common across the
disorders
>> BIOLOGICAL CAUSAL FACTORS
#BrainStructure #Neurotransmitters
#Neuroticism
- brain structures most centrally involved in
most disorders are generally in the limbic
system (responsible for regulating emotions and
anxiety) or the emotional brain since anxiety
disorders often show heightened amygdala
response to anxiety cues
- certain parts of the cortex such as the frontal-
striatal neural circuitry, orbitofrontal cortex,
anterior cingulate cortex, striatum particularly
caudate nucleus
- 3 neurotransmitter substances that are most
centrally involved gamma aminobutyric
acid/GABA (calm response), norepinephrine
(concentration response), and
serotonin (mood response)
- In adults, the common genetic
vulnerability is manifested at a
psychological level at least in part by
the important personality trait called
neuroticism
NEUROTICISM #NegativeMoodStates
- proneness or disposition to experience
negative mood states that is a common risk
factor for both anxiety and mood disorders
>> PSYCHOLOGICAL CAUSAL FACTORS
#LackOfControl #DistortedPatternsOfCognition
- classical conditioning of fear, panic, or anxiety
to a range of stimuli plays an important role in
many of these disorders
- people who have perceptions of a lack of
control/uncontrollability over either their
environments or their own emotions (or both)
seem more vulnerable to developing anxiety - are a category of drugs used to prevent anxiety
disorders and treat anxiety related to several anxiety
- development of such perceptions of disorders
uncontrollability depends heavily on the social
environment people are raised such as < ANTIDEPRESSANT MEDICATIONS #Serotonin
parenting styles #Norepinephrine #Dopamine
- for certain disorders, faulty or distorted - increase the activity of chemicals called
patterns of cognition also may play an neurotransmitters in the brain
important role - increasing the activity of the
neurotransmitter’s serotonin (mood response),
>> SOCIOCULTURAL ENVIRONMENT #Raise norepinephrine (concentration response) and
- which people are raised also has prominent dopamine (pleasure response) seems to help
effects on the kinds of objects and experiences lessen the symptoms of depression and anxiety
people become anxious about or come to fear
PHOBIC DISORDERS
>> COMMONALITIES ON EFFECTIVE TREATMENT - most common anxiety disorders
#GraduatedExposure #CognitiveRestructuring
#Medications
- graduated exposure to feared cues, objects,
and situations until fear or anxiety begins to
habituate constitutes the single most powerful
therapeutic ingredient
- cognitive restructuring techniques can provide
added benefit since they help the individual
PHOBIA #LittleOrNoActualDanger #Avoidance
understand his or her distorted patterns of
- persistent and disproportionate fear of some
thinking about anxiety-related situations and
specific object or situation that presents little or
how these patterns can be changed
no actual danger and yet leads to a great deal of
- medication can also be useful in treating all
avoidance of these feared situations
disorders except specific phobias

3 MAIN CATEGORIES OF PHOBIAS:

TWO PRIMARY MEDICATION CATEGORIES:
1.SPECIFIC PHOBIA #PersistentFear
< ANTIANXIETY MEDICATIONS/ANXIOLYTICS
#ImmediateFear #Avoidance
#Fear #Dread #Uneasiness #MuscleTightness
- she or he shows strong and persistent fear that
- drug used to treat symptoms of anxiety, such
is triggered by the presence of a specific object
as feelings of fear, dread, uneasiness, and
or situation
muscle tightness, that may occur as a reaction
arise from cognitive structures that are not
to stress
under conscious control such as amygdala
- when an individual encounters phobic
stimulus, they often show an immediate fear
response that often resembles a panic attack
except for the existence of a clear external
trigger
- such individuals also experience anxiety if they
anticipate they may encounter a phobic object
or situation and so go to great lengths to avoid
encounters with their phobic stimulus
- they often even avoid seemingly innocent
representations of it such as photographs or
television images
- people with specific phobias recognize that
their fear is somewhat excessive or
unreasonable although occasionally they may
not have this insight
- this avoidance is a cardinal characteristic of
phobias; it occurs both because the phobic
response itself is so unpleasant and because of
the phobic person’s irrational appraisal of the
likelihood that something terrible will happen
- phobic behavior tends to be reinforced
because every time the person with a phobia
avoids a feared situation his or her anxiety
decreases. In addition, the secondary benefits
derived from being disabled, such as increased
attention, sympathy, and some control over the
behavior of others, may also sometimes
reinforce a phobia

EXAMPLES OF SPECIFIC PHOBIA:
*CLAUSTROPHOBIA #EnclosedSpaces
- intensely afraid of enclosed spaces such as
closets, elevators, etc.
- they feel very frightened and have thoughts
about the elevator falling, the
doors never opening, or not having enough air
to breathe
- they make an effort to avoid it by taking stairs
or turning down jobs that might require them to
take an elevator
*ACROPHOBIA
- intense fear of height
*SPACE PHOBIA #FallingDown
- fear of falling down if away from walls or other
support
*BLOOD-INJECTION-INJURY
PHOBIA/BIIP
-people afflicted with this phobia typically
experience at least as much (if not more) disgust
as fear
- rather than showing the simple increase in
heart rate and blood pressure seen when most
people with phobias encounter their phobic
object, these people show an initial
acceleration, followed by a dramatic drop in
both heart rate and blood pressure frequently
accompanied by nausea, dizziness, or fainting
- they exhibit the more typical physiological
response pattern characteristic of the fight-or-
flight response to their other feared objects
- by fainting, the person being attacked might
inhibit further attack, and if an attack did occur,
the drop in blood pressure would minimize
blood loss
- this type of phobia appears to be highly
heritable
PREVALENCE, AGE OF ONSET, AND GENDER
DIFFERENCES OF SPECIFIC PHOBIAS
- among people with one specific phobia, over
75 percent have at least one other specific fear
that is excessive
- phobias are always considerably more
common in women than in men especially with
animal phobias
- phobias varied in terms of onset and age since
animal phobias, usually begin in childhood, as
do blood-injection-injury phobias and dental
phobias
while claustrophobia and driving phobia tend to
begin in adolescence or early adulthood
CAUSAL FACTORS OF SPECIFIC PHOBIA
- there are variety of causal factors have been
implicated in the origins of specific phobias,
ranging to psychodynamic conflicts to relatively
straightforward traumatic conditioning of fear
and a multitude of individual differences in who
is at risk for such conditioning
<< PSYCHOANALYTIC VIEWPOINT  conditioning
- according to the psychoanalytic view, phobias
represent a defense against anxiety that stems
from repressed impulses from the id
- since it is too dangerous to know the repressed
id impulse, anxiety displaced onto some
external object or situation that has some
symbolic relationship to the real object of the
anxiety
- but later on, it was criticized as being far too
speculative
<< PHOBIA AS LEARNED BEHAVIOR
#ConditionedStimuli+TraumaticEvents
- an alternative to psychoanalytic viewpoint
- this explained that the fear response can
readily be conditioned to previously neutral
stimuli when these stimuli are paired with
traumatic or painful events
- ex. Mary’s claustrophobia had probably been
caused by multiple incidents as a child when her
siblings locked her in closets and confined her
under blankets to scare her
- some of these traumatic conditioning events
were simply uncued panic attacks, which are
now known to effectively condition
<< VICARIOUS CONDITIONING #Witness
#FacialExpression #Transmitted
#WatchingAFearfulPersonTowardsHisPhobicSti
muli
- watching a phobic person behaving fearfully
with his or her phobic object can be distressing
to the observer and can result in fear being
transmitted from one person to another
through vicarious or observational classical
- seeing the facial expression of a fearful person
facing its phobic stimuli can cause phobia
- ex. children who saw pictures of an unfamiliar
animal (an Australian marsupial) paired 10 times
with fearful facial expressions showed increased
fear beliefs and behavioral avoidance of this
conditioned stimulus (CS) relative to children
who saw the unfamiliar animal paired with
happy facial expressions
- watching non-fearful person undergoing a
frightening experience can also lead to vicarious
conditioning
- ex. one man, as a boy, had witnessed his
grandfather vomit while dying; later on, he had
a vomiting phobia
- significant fear was acquired after only 4 to 8
minutes of exposure after watching a fearful
expression facing the phobic stimuli
- mass media also play a role in the vicarious
conditioning; ex. watching video tapes
<< INDIVIDUAL DIFFERENCES IN
LEARNING #RiskFactors #ProtectiveFactors
- some life experiences may serve as risk factors
and make certain people more vulnerable to
phobias than others while other experiences
may serve as protective factors for the
development of phobias such as first
nontraumatic and positive experiences with the
stimuli or seeing a person having a positive
reaction towards the stimuli
- ex. if a child has extensive exposure to a
nonfearful parent behaving nonfearfully with
the phobic object (spiders) or situation (heights)
of the other, they will less likely to react or
having a phobia to a traumatic event later on
- another way in which fear of a CS can be
inflated following conditioning is if the organism
later is exposed to uncontrollable stress
- the experiences that a person has after a
conditioning experience may affect the strength
and maintenance of the conditioned fear;
inflation effect may involve here
INFLATION EFFECT #SimilarWithDiathesis
- a person who acquired, a mild fear of driving
following a minor crash might be expected to
develop a full-blown phobia if he or she later
were physically assaulted, even though no
automobile was present during the assault
COGNITION OR THOUGHTS
#MakePhobiaStable
- can help maintain our phobias once they have
been acquired
- ex. people with phobias are constantly on the
alert for their phobic objects or situations and
for other stimuli relevant to their phobia
<< EVOLUTIONARY PREPAREDNESS FOR
LEARNING CERTAIN FEARS AND PHOBIAS 
- our evolutionary history has affected which
stimuli we are most likely to come to fear
PREPARED LEARNING #AncestorsKnowledge
#FearRelevantStimuli
- refers to our early ancestors’ knowledge about
feared stimuli or fear-relevant stimuli that
causes us to be prepared and feared with those
including snakes, lions, waters, heights, etc.
- prepared fears are not inborn or innate but
rather are easily acquired or especially resistant
to extinction
• FEAR IS CONDITIONED MORE EFFECTIVELY TO
FEAR-RELEVANT STIMULI (SLIDES OF SNAKES
AND SPIDERS) THAN TO FEAR-IRRELEVANT
STIMULI (SLIDES OF FLOWERS AND
MUSHROOMS)
<< BIOLOGICAL CAUSAL FACTORS #Genetic
#Temperament/Personality
- genetic and temperamental variables affect
the speed and strength of conditioning of fear,
depending on their genetic makeup or their
temperament and personality
- individuals who are carriers of one of the two
variants on the serotonin-transporter
gene/5HTT (having 2 short “s” alleles) show
superior fear conditioning relative to individuals - one variant procedure of exposure therapy
who do not carry the s allele that is often more effective than exposure alone
- therapist calmly models ways of interacting
BEHAVIORALLY INHIBITED TODDLERS #Shy with the phobic stimulus or situation
#Timid #EasilyDistressed - this enable clients to learn that these
- refers to toddlers that are excessively timid, situations are not as frightening as they had
shy, easily distressed, etc. thought and that their anxiety, while
- at 21 months of age were at higher risk of unpleasant, is not harmful and will gradually
developing multiple specific phobias by 7 to 8 dissipate
years of age
• NEW LEARNING IS PROBABLY MEDIATED BY
• SEVERAL BEHAVIOR GENETIC STUDIES ALSO CHANGES IN BRAIN ACTIVATION IN THE
SUGGEST A MODEST GENETIC CONTRIBUTION AMYGDALA, WHICH IS CENTRALLY INVOLVED IN
TO THE DEVELOPMENT OF SPECIFIC PHOBIAS THE EMOTION OF FEAR
- ex. monozygotic or identical twins were more
likely to share animal phobias and situational
phobias such as of heights or water than were
dizygotic or nonidentical twins
• HERITABILITY OF ANIMAL PHOBIAS WAS
SEPARATE FROM THE HERITABILITY OF
COMPLEX PHOBIAS SUCH AS SOCIAL PHOBIA
AND AGORAPHOBIA

TREATMENTS FOR SPECIFIC PHOBIAS

> EXPOSURE THERAPY #BestTreatment
> SINGLE LONG SESSION #3Hours
#RealLifeConditions #ControlledExposure
#EffectiveTo4Phobia
- is the best treatment for specific phobias since
- exposure to long sessions up to 3 hours
it involves controlled exposure to the stimuli or
- is highly effective when administered to a
situations that elicit phobic fear
person with small-animal phobias, flying phobia,
- clients are gradually placed symbolically or
claustrophobia, and blood-injury phobia
increasingly under real-life conditions in those
situations they find most frightening; clients are
• USING COGNITIVE TECHNIQUES ALONE HAVE
encouraged to expose themselves (either alone
NOT PRODUCED RESULTS AS GOOD AS THOSE
or with the aid of a therapist or friend) to their
USING EXPOSURE-BASED TECHNIQUES
feared situations for long enough periods of
time so that their fear begins to subside
• MEDICATION TREATMENTS ARE INEFFECTIVE
BY THEMSELVES, AND THERE IS EVEN SOME
> PARTICIPANT MODELING
EVIDENCE THAT ANTIANXIETY MEDICATIONS
#ModelsWaysOfInteracting
MAY INTERFERE WITH THE BENEFICIAL EFFECTS
OF EXPOSURE THERAPY
- except with d-cycloserine
> D-CYCLOSERINE
#EnhanceEffectivenessOfExposureTherapy
- known to facilitate extinction of conditioned
fear in animals
- may enhance the effectiveness of small
amounts of exposure therapy for fear of heights
in a virtual reality environment
- by itself, like other medications, it has no
effect
- results are very promising, but much more
work is necessary before it will be known how
useful this drug will be in enhancing the effects
of exposure therapy for many different kinds of
phobias
2.SOCIAL ANXIETY DISORDER/SOCIAL
PHOBIA #DisablingFearsOfSocialSituation
#AnxietyFearPanicResponse #AvoidOrEndure
#ScrutinyOrNegativeEvaluation
- exhibit many anxiety symptoms about the
possibility of encountering their phobic
situation, but they may also experience fear or
panic response when they actually encounter
the situation
- is characterized by disabling fears of one or
more specific social situations such as public
speaking, urinating in a public bathroom, or
eating or writing in public
- a person fears that she or he may be exposed
to the scrutiny and potential negative
evaluation of others or that she or he may act in
an embarrassing or humiliating manner
- people with social phobias either avoid these
situations or endure them with great distress
PREVALENCE, AGE OF ONSET, AND GENDER
DIFFERENCES
- more common in women than in men
- this disorder is somewhat more common
among and begin with during early or middle
adolescence or certainly by early adulthood
- people with social phobia suffer from one or
more additional anxiety disorders at some point
in their lives, and 50 percent also suffer from a
depressive disorder at the same time
- often also have a diagnosis of avoidant
personality disorder
- one-third abuse alcohol to reduce their
anxiety and help them face the situation, and
have lower employment rates and lower
socioeconomic status

2 SUBTYPES OF SOCIAL PHOBIA:

1.) PERFORMANCE SITUATIONS
- such as public speaking

NON-PERFORMANCE SITUATIONS
- eating at public places

INTENSE FEAR OF PUBLIC SPEAKING

- is the single most common type of social
phobia

CAUSAL FACTORS OF SOCIAL PHOBIA symptom, self-conscious and uncomfortable in

>> SOCIAL PHOBIAS AS LEARNED
BEHAVIOR  previously been bullied and called a “nothing”
#WitnessingDefeatHumiliationAnger
#SevereTeasingInChildhood #OCD
#DirectTraumaticExperience #ColdParents
#Bullied #NotFittingIn
- originate from simple instances of direct or
vicarious classical conditioning such as
experiencing or witnessing a perceived social
defeat or humiliation, or being or witnessing the
target of anger or criticism
- it could also be direct traumatic experiences,
history of severe teasing in childhood, people
with obsessive-compulsive disorder
- some socially traumatic experience that was
linked to their own current image of themselves
in socially phobic situations that has themes
including criticized for having an anxiety
public as a consequence of past criticism, having
- grown up with parents who were emotionally
cold, socially isolated, and avoidant, devalued
sociability and did not encourage their children
to go to social events
- they were having problems with their peers
such as not fitting in
>> SOCIAL FEARS AND PHOBIAS IN AN
EVOLUTIONARY CONTEXT 
#EvolutionaryBasedPredisposition
#AgressionDominance
#NegativeFacialExpression
#DominanceHierarchies
- humans have an evolutionarily based
predisposition to acquire fears of social stimuli
that signal dominance and aggression from
other humans
- negative facial expression like having angry
faces are processed very quickly and an
emotional reaction can be activated without a
person’s awareness of any threat since
amygdala and other part of the brain that are
responsible for emotional response are just
being activated
- social fears and phobias by definition involve
fears of members of one’s own species
- usually involve fear of potential predators such
as dominance hierarchies
DOMINANCE HIERARCHIES
#AgressiveEncounters #MemberSpecies
#EndureThanEscape
- are established through aggressive encounters
between members of a social group, and a
defeated individual typically displays fear and
submissive behavior but only rarely attempts to
escape the situation completely since people
with social phobia endure being in their feared
situations rather than running away and
escaping them
>> PERCEPTIONS OF UNCONTROLLABILITY
AND UNPREDICTABILITY #StressFulEvents
#SubmissiveOrUnAssertiveBehaviors
#DiminishedControl&Expectation
- being exposed to uncontrollable and
unpredictable stressful events such as parental
separation and divorce, family conflict, sexual
abuse, or stressful/traumatic experiences
- uncontrollability and unpredictability often
lead to submissive (passive means shying away
from saying what you really wanted to say to
not hurt the feeling of others or by fearing with
others) and unassertive behavior (not having or
showing a confident), which is characteristic of
socially anxious or phobic people
- people with social phobia have a diminished
sense of personal control over events in their
lives, and diminished expectations that are
caused by being raised on family that is
somewhat overprotective or sometimes
rejecting
> COGNITIVE BIASES 
#ContributeOrMaintenance
#NegativeExpectations
#NegativeInterpretations
#RejectOrNegativeEvaluate
- cognitive factors also play a role in the onset
and maintenance of social phobia
- people with social phobia tend to expect that
other people will reject or negatively evaluate
them and this leads to a sense of vulnerability
- lead them to expect that they will behave in an
awkward and unacceptable fashion, resulting in
rejection and loss of status
- such negative expectations lead to their being
preoccupied with bodily responses and with
stereotyped, negative self-images in social
situations; to their overestimating how easily
others will detect their anxiety; and to their
misunderstanding how well they come across to
others
- social phobic inward attention and somewhat
awkward behavior may lead others to react to
them in a less friendly fashion, confirming their
expectations
- they have a tendency to interpret ambiguous
social information in a negative rather than a
benign manner such as interpreting smiling of
others as a seeing them being foolish
BIASED COGNITIVE PROCESSES
- combine to maintain social phobia and
possibly even contribute to its development
>> BIOLOGICAL CAUSAL FACTORS #Genetics
#Temperaments #Twins
#NonSharedEnvironmentalFactors
- genetic and temperaments factors also play an
important role on causal factors of social phobia
- twins also shown that there is a modest
genetic contribution to social phobia
- social phobia is also due to nonshared
environmental factors, which is consistent with
a strong role for learning
BEHAVIORAL INHIBITION #Temperamental
#Neuroticism&Introversion
#ShyDistressAvoidant
- is one of the important temperamental
variables in social phobia
- it shares characteristics with both neuroticism
and introversion
- behaviorally inhibited infants/children easily
distressed by unfamiliar stimuli and who are shy
and avoidant/timid are more likely to become
fearful during childhood
- during adolescence, they show increased risk
of developing social phobia
- between 2 and 6 years of age were nearly
three times more likely to be diagnosed with
social phobia
TREATMENTS FOR SOCIAL PHOBIA
- behavioral and cognitive behavioral therapy
helps an individual with social anxiety disorder
- cognitive restructuring techniques are the best
treatment for social phobia
>> COGNITIVE RESTRUCTURING
TECHNIQUES
#IdentifyUnderstandChangeAskOneself
- generating a form of cognitive behavioral
therapy
- the therapist attempts to help clients with
social phobia identify their underlying negative,
automatic thoughts
- after helping clients understand that such
automatic thoughts which usually occur just
below the surface of awareness, often involve
cognitive distortions, the therapist helps the
clients change these inner thoughts and beliefs
through logical reanalysis
- process of logical reanalysis might involve
asking oneself questions to challenge the
automatic thoughts
- another version of this technique which
involves clients that have assigned exercises in
which they manipulate their focus of attention
(internally versus externally) to demonstrate to
themselves the adverse effects of internal self-
focus
- also, videotaped feedback helps them modify
their distorted self-images
• SIMPLY TRAINING INDIVIDUALS WITH SOCIAL
PHOBIA TO DISENGAGE FROM NEGATIVE
SOCIAL CUES DURING A 15-MINUTE LAB TASK
REPEATED 8 TIMES OVER 4 TO 6 WEEKS
- may result to reductions in social anxiety
symptoms that nearly 3 out of 4 of the
participants no longer met criteria for social
anxiety disorder
MEDICATIONS
- social phobias can also sometimes be treated
with medications than specific phobias
- the most effective and widely used
medications are several categories of
antidepressants particularly monoamine oxidase
inhibitors/MAOIs and the selective serotonin
reuptake inhibitors/SSRIs
- the medications must be taken over a long
period of time to help ensure that relapse does
not occur
- d-cycloserine is added to exposure therapy,
the treatment gains occur more quickly and are
more substantial
MONOAMINE OXIDASE INHIBITORS
- the first antidepressant that was developed
- it is less use than SSRIs since it has a lot of side
effects such as dizziness, skin reaction, and
there are a lot of foods that should be avoided
• A DISTINCT ADVANTAGE OF BEHAVIORAL AND
COGNITIVE-BEHAVIORAL THERAPIES OVER
MEDICATIONS
- they generally produce more long-lasting
improvement with very low relapse rates which
leads to continuation of improvement after
treatment or when treatment is over
3.PANIC DISORDER #FrequentPanic&Anxiety
#UncuedUnexpected #Recurrent
- defined and characterized by the occurrence of
panic attacks that often seem to come out of
the blue/uncued/unexpected
- the person must have experienced recurrent,
unexpected attacks and must have been
persistently concerned about having another
attack or worried about the consequences of
having an attack for at least a month
ANTICIPATORY ANXIETY
- worried about the consequences of having a
heart attack for at least a month
- it is more acceptable for women who
experience panic to avoid the situations they
fear and to need a trusted companion to
accompany them when they enter feared
situations
- men who experience panic are more prone to 3 COGNITIVE IN PANIC ATTACKS:
“tough it out” because of societal expectations 1.) DEPERSONALIZATION &
and their more assertive, instrumental approach DEREALIZATION
to life - depersonalization is a feeling of being
- most symptoms of a panic attack are physical detached from one’s body
that leads to medical problem usually cardiac, - derealization is a feeling that the external
respiratory, and neurological world is strange or unreal
- medical causes have to be ruled out first but if 2.) FEAR OF DYING
the person is also experiencing the symptoms of
panic attacks and worries about the possible 3.) FEAR OF GOING CRAZY OR LOSING
consequnces and the additional attack later on, CONTROL
they will be diagnosed with panic disorder NOCTURNAL PANIC

- panic attack can also be a specifier for other - when the panic attack occurs in situations in

diagnoses such as PTSD with Panic Attacks which they might least expected such as during

- panic attacks are fairly brief but intense, with sleep or relaxation

symptoms developing abruptly and usually

reaching peak intensity within 10 minutes • PANIC ATTACKS ARE SAID TO BE

- the attacks usually subside in 20 to 30 minutes SITUATIONALLY PREDISPOSED, OCCURRING

and rarely last more than an hour; do not ONLY SOMETIMES WHILE THE PERSON IS IN A

usually have such an abrupt onset and are more PARTICULAR SITUATION SUCH AS WHILE

long lasting DRIVING A CAR OR BEING IN A CROWD

- there must be abrupt onset of at least 4 of 13

symptoms, most of which are physical, although
three are cognitive

can accelerate your body's metabolism, causing

HYPERTHYROIDISM #UnintentionalWeightLoss
#IrregularHeartbeat
unintentional weight loss and a rapid or
irregular heartbeat
CARDIOPULMONARY DISORDERS
#UnhealthyLifeStyle #Heart&Lungs
- describe a range of serious disorders that
affect the heart “cardio-” and lungs “-
pulmonary”
- caused by unhealthy lifestyles that can cause
atherosclerosis that leads to this
PREVALENCE, AGE OF ONSET, AND GENDER
DIFFERENCES
- panic disorder with or without agoraphobia
often starts in the late teenage years; but the
average age is 23 to 34 years
- in women, it begins at the age of 30s or 40s
- occurs much more frequently in
women than in men
of distress or some highly stressful life
circumstance such as loss of a loved one, loss of
an important relationship, loss of a job, or
criminal victimization to sum it up, after a
negative life event
- not all people who have a panic attack
following a stressful event go on to develop full-
blown panic disorder since some people
experience one panic attack in their lifetimes
- people who have other anxiety disorders or
major depression often experience occasional
panic attacks as well
CAUSAL FACTORS OF PANIC DISORDER:
>> BIOLOGICAL CAUSAL FACTORS
- including genetic factors, panic and the brain
- genetic vulnerability is manifested at a

COMORBIDITY WITH OTHER

DISORDERS
- people with panic disorder have at
least one comorbid disorder including
generalized anxiety disorder, social
psychological level at least in part by the
phobia, specific phobia, PTSD, depression, and
important personality trait called neuroticism
substance-use disorders particularly smoking
and alcohol dependence
- they also experience serious depression or
dependent or avoidant personality disorder
NEUROTICISM
- panic disorder is associated with increased risk
- related to the temperamental construct of
for suicidal ideation and attempts independent
behavioral inhibition
of its relationship with comorbid disorders
- hippocampus also play an important role since
it is also part of the limbic system, where
THE TIMING OF A FIRST PANIC ATTACK
amygdala is also involved
#AfterNegativeLifeEvent
- neurotransmitters such as norepinephrine
- although panic attacks appear out of the blue,
which is centrally involved in brain activity in
the first one frequently occurs following feelings
this area but it is increased activity in the
amygdala that plays a more central role in panic
attacks than does activity in the locus coeruleus
AMYGDALA #EmotionOfFear
#FearNetworkWithConnections
- is a collection of nuclei in front of the
hippocampus in the limbic system of the brain
that is critically involved in the emotion of fear
- stimulation of the central nucleus of the
amygdala is known to stimulate the locus
coeruleus as well as the other autonomic,
neuroendocrine, and behavioral responses that
occur during panic attacks
- is the central area involved in what has been
called a fear network with connections not only
to lower areas in the brain like the locus
coeruleus but also to higher brain areas like the
prefrontal cortex
- panic attacks occur when the fear network is
activated, either by cortical inputs or by inputs
from lower brain areas
- panic disorder is likely to develop in people
who have abnormally sensitive fear networks
which amygdala is involve, that get activated
too readily to be adaptive
HIPPOCAMPUS #LearningEmotionalResponses
#GenerateAnticipatoryAnxiety
#InvolveInAvoidance
- a part of the limbic system, below the cortex,
which is very involved in the learning of
emotional responses
- for people who have one or more panic attacks
and who go on to develop significant
conditioned anxiety about having another
one in particular contexts, hippocampus is
thought to generate this conditioned
anxiety, and is probably involved in the
learned avoidance associated with
agoraphobia
• PANIC ATTACKS ARE ONLY ONE
COMPONENT OF PANIC DISORDER
• PEOPLE WITH PANIC DISORDER ALSO BECOME
ANXIOUS ABOUT THE POSSIBILITY OF ANOTHER
ATTACK, AND THOSE WITH AGORAPHOBIA ALSO
ENGAGE IN PHOBIC AVOIDANCE BEHAVIOR
>> NEUROBIOLOGICAL FACTORS #FearCircuit
#SNS
- panic attack seems to reflect a misfire of the
fear circuit, with a concomitant surge in activity
in the sympathetic nervous system
- particular part of the fear circuit is especially
important in panic disorder which is the locus
coeruleus
LOCUS COERULEUS #Norepinephrine
- is the major source of the neurotransmitter
norepinephrine in the brain, and
norepinephrine plays a major role in triggering
sympathetic nervous system activity
• DRUGS THAT INCREASE ACTIVITY IN THE
LOCUS COERULEUS CAN TRIGGER PANIC
ATTACKS
>> BIOCHEMICAL ABNORMALITIES  - panic attacks are often triggered by internal
- panic attacks are alarm reactions caused by
biochemical dysfunctions
- people with panic disorder are much more
likely to experience panic attacks when they are
exposed to various biological challenge
- GABA has also been implicated/involve in the
anticipatory anxiety that many people with
panic disorder have about experiencing another
attack
GABA #InhibitAnxiety
- known to inhibit/prevent anxiety and has been
shown to be abnormally low in certain parts of
the cortex in people with panic disorder
2 PRIMARY NEUROTRANSMITTER
SYSTEMS ARE MOST IMPLICATED IN
PANIC ATTACK:
1. NORADRENERGIC ACTIVITY
#RaiseCardioSymptoms #BadActivity
- in certain brain areas can stimulate/raise level
of cardiovascular symptoms associated with
panic
2. INCREASED SEROTONERGIC ACTIVITY
#DecreaseNoradrenergicActivity #GoodActivity
- also decreases noradrenergic activity
- SSRIs seem to increase serotonergic activity in
the brain but also to decrease noradrenergic
activity
- by decreasing noradrenergic activity, these
medications (SSRIs) decrease many of the
cardiovascular symptoms associated with panic
that are ordinarily stimulated by noradrenergic
activity
>> LEARNING THOERY
bodily sensations of arousal
- according to this theory, initial panic attacks
become associated with initially neutral internal
(interoceptive) and external (exteroceptive)
cues through an interoceptive conditioning (or
exteroceptive conditioning) process
- anxiety becomes conditioned to these CSs, and
the more intense the panic attack, the more
robust the conditioning that will occur
- conditioning of anxiety to the internal or
external cues associated with panic thus sets
the stage for the development of two of the
three components of panic disorder which are
anticipatory anxiety sometimes agoraphobic
fears, and panic attacks themselves
INTEROCEPTIVE CONDITIONING
#BodilySensations #SomaticChanges
#ConditionedResponse=Panic
- this theory builds on the earlier theory that
initial internal bodily sensations of anxiety or
arousal
- a person experiences somatic signs of anxiety
(insomnia, restlessness, muscle aches) which
are followed by the person’s first panic attack
- panic attacks then become a conditioned
response to the somatic changes

>> COGNITIVE FACTORS #ImpendingDoom
#MisinterpretationOfSomaticChanges
- focus on catastrophic misinterpretations of
somatic changes
- person interprets bodily sensations as signs of
impending doom
- ex. the person may interpret the sensation of
an increase in heart rate as a sign of an
impending heart attack
- exercise alone, simple relaxation, or the
physical sensations caused by an illness such as
inner-ear disease also can induce/increase panic
attacks
- exposing people to air with high levels of
carbon dioxide; in response to the diminished
oxygen, breathing rate increases, and for some
people this induces panic
AUTOMATIC THOUGHTS #TriggersPanic
#Catastrophize
- sense the triggers of panic
- cognitive model proposes that only people
with this tendency to catastrophize go on to
develop panic disorder
>> ANXIETY SENSITIVITY #TraitLikeBelief
#Predict #Prone
- is a trait-like belief that certain bodily
symptoms may have harmful consequences
- high levels of anxiety sensitivity is more prone
to developing panic attacks and perhaps panic
disorder
- high anxiety sensitivity also serves to predict
the onset of other anxiety disorders as well as
panic attacks
ANXIETY SENSITIVITY INDEX/ASI
#BeforePanicDevelops #Test
#MeasurePeopleAnxietySensitivity
- test that propensity toward catastrophic
interpretations can be detected before panic
disorder develops
- which measures the extent to which people
respond fearfully to their bodily sensations
- sample items from scales include unusual body
sensations scare me, when I notice that my
heart is beating rapidly, I worry that I might
have a heart attack
>> PERCEIVED CONTROL
#ReducesAnxiety #BlocksPanic
- simply having a sense of this, for instance, over
the amount of carbon-dioxide-altered air that is
inhaled reduces anxiety and even blocks panic
- anxiety sensitivity has a greater effect on panic
symptoms in people with low perceived control
- panic disorder may also be protected against
the development of agoraphobic avoidance if
they have relatively high levels of perceived
control over their emotions and threatening
situation
TREATMENTS OF PANIC DISORDER:
>> PANIC PROVOCATION PROCEDURE
- laboratory test that provokes internal bodily
sensations to produce panic attack on people
with panic disorder
>> PSYCHODYNAMIC TREATMENT #24Sessions
#IdentifyingEmotions&Meanings
#ClientGainInsight #ASA #SymptomRelief
- treatment involves 24 sessions focused on
identifying the emotions and meanings
surrounding panic attacks
- help clients gain insight into areas believed to
relate to the panic attacks such as issues
involving anger, separation, and autonomy/ ASA
- clients who receive treatments like this,
achieved more symptom relief than those who
were assigned to a control condition of
relaxation training
• PSYCHODYNAMIC TREATMENT ADDED WITH
ANTIDEPRESSANT MEDICATIONS WAS RELATED
TO DIMINISHED RATES OF RELAPSE
>> PANIC CONTROL THERAPY/PCT
#ExposureTechniques #UnderSafeConditions
#PracticeCopingTactics
#DiminishCognitiveFactors
- is based on the tendency of people with panic
disorder to overreact to the bodily sensations
- therapist uses exposure techniques; he or she
persuades the client to deliberately elicit the
bodily sensations associated with panic, after
that, therapist experience them under safe
conditions
- in addition, the person practices coping tactics
for dealing with somatic symptoms (breathing
from the diaphragm to avoid hyperventilation)
- with practice and encouragement from
therapist, the person learns to stop seeing
internal sensations as signals of loss of control
and to see them instead as intrinsically harmless
sensations that can be controlled
> COGNITIVE TREATMENT
#Identify&ChallengeThoughts
#ExamineEvidence
#DevelopDifferentImageOfConsequences
- in another version of cognitive treatment,
therapist helps the person identify and
challenge the thoughts that make the physical
sensations threatening
- ex. if a person with panic disorder imagine
herself that he or she will collapse, the therapist
might help the person examine the evidence for
this belief and develop a different image of the
consequences of a panic attack
MEDICATIONS OF PANIC DISORDER:
>> CLONIDINE
- is an antihypertensive drug
- it decreases the risk of panic attacks
>> ANTIDEPRESSANT
- decrease the risk of panic attacks
- including tricyclics, SSRIs, and serotonin-
norepinephrine reuptake inhibitors
- major advantage is that they do not create
physiological dependence in the way
benzodiazepines can; they also can alleviate
(lessen the severity) any comorbid depressive
symptoms or disorders
- disadvantages can be taking about 4 weeks
before they have any beneficial effects, so they
are not useful in an acute situation where a
person is having a panic attack
- relapse rates when the drugs are discontinued
are quite high but not as high as with the
benzodiazepines
TRICYCLICS
- troublesome side effects such as dry mouth,
constipation, and blurred vision
-   a group of antidepressants with molecular
structures characterized by three fused rings;
interfere with the reuptake of norepinephrine
and serotonin.
SELECTIVE SEROTONIN REUPTAKE
INHIBITORS
- troublesome side effects such as interference
with sexual arousal
• TODAY THE SSRIs ARE MORE WIDELY
PRESCRIBED THAN THE TRICYCLICS BECAUSE
THE SSRIS ARE GENERALLY BETTER TOLERATED
BY MOST PATIENTS
>> ANXIOLYTICS/ ANTIANXIETY
MEDICATIONS
- from benzodiazepine category including
alprazolam or Xanax and clonazepam or
klonopin
- people frequently show some symptom
relief from these medications, and many can
function more effectively
- they act very quickly, 30–60 minutes and
so can be useful in acute situations of
intense panic or anxiety
- the major disadvantage is it can also have
quite undesirable side effects such as
drowsiness and sedation can lead to impaired
cognitive and motor performance
- also, with prolonged use, most people using
moderate to high doses develop physiological
dependence on the drug, which results in
withdrawal symptoms when the drug is
discontinued including nervousness, sleep
disturbance, dizziness, and further panic attacks
- withdrawal from these drugs can be very slow
and difficult, and it precipitates relapse in a high
percentage of cases, the reason why
benzodiazepines are no longer considered as a
first-choice treatment
• SOME EVIDENCE INDICATES THAT MEN WITH
PANIC DISORDER MAY BE MORE LIKELY TO SELF-
MEDICATE WITH NICOTINE OR ALCOHOL AS A
WAY OF COPING WITH AND ENDURING PANIC
ATTACKS RATHER THAN DEVELOPING
AGORAPHOBIC AVOIDANCE
- because of stereotypes and they are prone to
“tough it out”
>> D-CYLOSERINE
- has shown promise for enhancing
responsiveness to CBT of panic disorder
>>
AGORAPHOBIA
#SpreadingFearfulness
#AvoidedCrowded&Streets #EscapeIsDifficult
#HelpIsUnavailable #SimilarWithPanicDisorder
#FearOfBodilySensations
 - many patients with agoraphobia do not
experience panic
- as agoraphobia develops, there is often a
gradually spreading fearfulness in which more
and more aspects of the environment outside
the home become threatening

- agoraphobia was thought to involve a fear of

the agora, the greek word for public places of
assembly
- the most commonly feared and avoided
situations include streets and crowded places
- sometimes, it develops as a complication of
having panic attacks in one or more such
situations
- similar with panic disorder, it is concerned that
an
individual may have a panic attack or get sick,
people with agoraphobia are anxious about
being in places or situations from which escape
would be physically difficult or psychologically
embarrassing, or which immediate help would
be unavailable if something bad happened
- are also frightened by their own bodily
sensations, so they also avoid activities that will
create arousal
such as exercising, watching scary movies,
drinking caffeine, and even engaging in sexual
activity
- people tend to avoid situations in which
attacks have occurred, but usually the
avoidance gradually spreads to other situations
where attacks might occur; may be anxious even
when venturing outside their homes alone
- severe cases, a person may be disabling to the
point that they cannot go outside of their
homes or parts of their home
- it is also a frequent complication of panic
disorder

CASE EXAMPLE OF AGORAPHOBIA:
PREVALENCE, AGE OF ONSET, AND GENDER
DIFFERENCES
- occurs much more frequently in women than
in men, and the percentage of women increases
as the extent of agoraphobic avoidance
increases
CAUSAL FACTORS OF AGORAPHOBIA:
>> COGNITIVE FACTORS
- including fear-of-fear hypothesis
FEAR-OF-FEAR HYPOTHESIS
#CatastrophicThoughtsAboutPublicAnxietyCons
equences
- which suggest that agoraphobia is driven by
negative thoughts about the consequences of
experiencing anxiety in public
- people with agoraphobia think the
consequences of public anxiety would be
horrible
- they seem to have catastrophic beliefs that
their anxiety will lead to socially unacceptable
consequences
>> GENETIC VULNERABILITY
6 TREATMENTS FOR AGORAPHOBIA:
>> PROLONGED EXPOSURE TO FEARED
SITUATIONS #OrginalBehavioralTreatment
#GraduallyFaceFear #2-4YearFollowUp
#DidNotTargetPanicAttacks
- original behavioral treatment for agoraphobia
from the early 1970s with the help of a therapist
or family member
- the idea was to make people gradually face the
situations they feared and learn that there was
nothing to fear
- exposure-based treatments were quite
effective and helped about 60 to 75 percent of
people with agoraphobia show clinically
significant improvement
- effects were generally well maintained at 2- to
4-year follow-up
- one limitation of these original treatments was
that they did not specifically target panic
attacks, only external feared situations
>> INTEROCEPTIVE EXPOSURE
- involves the variant on exposure, meaning
deliberate exposure to feared internal
sensations
- fear of these internal sensations should be
treated in the same way that fear of external
agoraphobic situations is treated
- ex. people are asked to engage in various
exercises that bring on various internal
sensations, and to stick with those sensations
until they subside, thereby allowing habituation
of their fears of these sensations
>> COGNITIVE RESTRUCTURING
TECHNIQUES
- in recognition that catastrophic automatic
thoughts may help maintain panic attacks
>> PANIC CONTROL TREATMENT
#BothAgoraphobicPanicAttacks #Educate
#TeachControlBreathing #TaughtLogicalErrors
#ExposeToInternal&ExternalFearSituations
#NocturnalPanic #8-14Weeks
- targets both agoraphobic avoidance and panic
attacks
- it has 4 steps
- first, clients are educated about the nature of
anxiety and panic and how the capacity to
experience both is adaptive
- second, involves teaching people with panic
disorder to control their breathing
- third, clients are taught about the logical
errors that people who have panic disorders are
prone to making and learn to subject their own
automatic thoughts to a logical reanalysis
- fourth or lastly, they are exposed to feared
situations and feared bodily sensations to build
up a tolerance to the discomfort
THESE TREATMENT PRODUCES BETTER RESULTS
THAN THE ORIGINAL EXPOSURE-BASED
TECHNIQUES THAT FOCUSED EXCLUSIVELY ON
EXPOSURE TO EXTERNAL SITUATIONS
- 70 to 90 percent of people with panic disorder
were panic free at the end of 8 to 14 weeks of
treatment, and gains were well maintained at 1-
to 2-year follow-up
- these treatments have been extended and
shown to be very useful in treating people who
also have nocturnal panic
>> SELF-GUIDED TREATMENT
#OwnStepByStepExposureTreatment
- those with agoraphobia use a manual to
conduct their own step-by-step exposure
treatment
>> COGNITIVE BEHAVIORAL TREATMENTS
#InvolvePartners
- including systematic exposure to feared
situations
- partner without agoraphobia is encouraged to
stop catering to the partner’s avoidance of
leaving home
- treatment to agoraphobia like this is more
effective when partner is involved
MEDICATIONS OF AGORAPHOBIA:
>> ANTIDEPRESSANT
- decrease the risk of panic attacks
- including tricyclics, SSRIs, and serotonin-
norepinephrine reuptake inhibitors
- major advantage is that they do not create
physiological dependence in the way
benzodiazepines can; they also can alleviate
(lessen the severity) any comorbid depressive
symptoms or disorders
- disadvantages can be taking about 4 weeks
before they have any beneficial effects, so they
are not useful in an acute situation where a
person is having a panic attack
- relapse rates when the drugs are discontinued
are quite high but not as high as with the
benzodiazepines
TRICYCLICS
- troublesome side effects such as dry mouth,
constipation, and blurred vision
SELECTIVE SEROTONIN REUPTAKE
INHIBITORS
- troublesome side effects such as interference
with sexual arousal
• TODAY THE SSRIs ARE MORE WIDELY
PRESCRIBED THAN THE TRICYCLICS BECAUSE
THE SSRIS ARE GENERALLY BETTER TOLERATED
BY MOST PATIENTS
ANXIOLYTICS/ ANTIANXIETY
MEDICATIONS
- from benzodiazepine category including
alprazolam or Xanax and clonazepam or
klonopin
- people frequently show some symptom relief
from these medications, and many can function
more effectively
- they act very quickly, 30–60 minutes and so
can be useful in acute situations of intense panic
or anxiety
- the major disadvantage is it can also have
quite undesirable side effects such as
drowsiness and sedation can lead to impaired
cognitive and motor performance
- also, with prolonged use, most people using
moderate to high doses develop physiological
dependence on the drug, which results in
withdrawal symptoms when the drug is
discontinued including nervousness, sleep
disturbance, dizziness, and further panic attacks
- withdrawal from these drugs can be very slow
and difficult, and it precipitates relapse in a high
percentage of cases, the reason why
benzodiazepines are no longer considered as a
first-choice treatment
COMBINATION OF ANTIANXIETY MEDICATION
AND COGNITIVE-BEHAVIORAL THERAPY
- such combined treatment sometimes produces
a slightly superior result compared to either
type of treatment alone
- those individuals who had received combined
treatment showed fewer medication side
effects and fewer dropouts than those who had
used medication alone
- in the long term, after medication has been
tapered (especially benzodiazepine
medications), clients who have been on
medication with or without cognitive or
behavioral treatment seem to show a greater
likelihood of relapse because they have
attributed their gains to the medication rather
than to their personal efforts
ANXIETY
#Plan&Prepare
- is an adaptive emotion that helps us plan and
prepare for possible threat
>> GENERALIZED ANXIETY DISORDER/GAD generalized worry disorder or pathological
#ExcessiveChronicUnreasonableWorryEndlessly worry disorder, but that did not happen
#DiffuseAnxiety #BasicAnxietyDisorder
#CantControl #Vigilant #Avoid • GENERAL PICTURE OF PEOPLE SUFFERING
#RarelyLivingInPresent #SSD FROM GENERALIZED ANXIETY DISORDER
- they live in a relatively constant future-
oriented mood state of anxious apprehension,
chronic tension, worry, and diffuse uneasiness
that they cannot control
- show marked vigilance for possible signs of
threat in the environment and frequently
engage in subtle avoidance activities such as
- free-floating anxiety
procrastination, checking, or calling a loved one
- anxiety and worry about many different
frequently to see if he or she is safe
aspects of life including minor events becomes
chronic, excessive, and unreasonable
GAD AS THE “BASIC” ANXIETY DISORDER
- experience a general sense of diffuse anxiety
- nearly constant worries of people with
and worry about many potentially bad things
generalized anxiety disorder leave them
that may happen
continually upset and discouraged
- some may also experience an occasional panic
- the most common spheres with worry were
attack, but it is not a focus of their anxiety
found to be family, work, finances, and personal
- worry must occur on more days than not for at
illness
least 6 months and that it must be experienced
- not only do they have difficulty making
as difficult to control; worry must be about a
decisions, but after they have managed to make
number of different events or activities
a decision they worry endlessly even after going
- worries’ content cannot be exclusively related
to bed
to the worry associated with another
PEOPLE WITH GAD HAVE NO APPRECIATION OF
concurrent disorder, such as the possibility of
THE LOGIC BY WHICH MOST OF US CONCLUDE
having a panic attack
THAT IT IS POINTLESS TO TORMENT OURSELVES
- worry must also be accompanied by at least
ABOUT POSSIBLE OUTCOMES OVER WHICH WE
three of six other symptoms, such as muscle
HAVE NO CONTROL
tension, restlessness, easily fatigue, difficult
- they fail to escape the illusory world created in
concentrating, etc.
their thoughts and images and rarely experience
the present moment that possesses the
THERE MUST BE CHANGE OF NAME FROM DSM-
potential to bring them joy
IV TO DSM-5
- those with GAD experienced a similar amount
- instead of naming or calling it generalized
of role impairment and lessened quality of life
anxiety disorder, it was planned to name it
to those with major depressive

PREVALENCE, AGE OF ONSET, AND GENDER
DIFFERENCES
- it tends to be chronic
- GAD is approximately twice as common in
women
- often develops in older adults but some people
remember that they have been anxious nearly
all their lives
- after age 50 the disorder seems to disappear
for many people and tends to be replace by a
somatic symptom disorder and characterized by
physical symptoms and health concerns
- most people with this disorder manage to
function in spite of their high levels of worry and
low perceived well-being
- less likely to go to clinics for psychological
treatment than are people with panic disorder
or major depressive disorder but people with
GAD do frequently show up in physicians’ offices
with medical complaints such as muscle tension
or gastrointestinal and/or cardiac symptoms
COMORBIDITY WITH OTHER
DISORDERS
- often co-occurs with other disorders,
especially other anxiety and mood disorders
- panic disorder, social phobia, specific phobia,
PTSD, and major depressive disorder
- experience occasional panic attacks without
qualifying for a diagnosis of panic disorder
CAUSAL FACTORS OF GAD:
>> PSYCHOANALYTIC VIEWPOINT
#Broken/NeverDevelopedDefenseMechanism
- results from an unconscious conflict between
ego and id impulses that is not adequately dealt
with because the person’s defense mechanisms
have either broken down or have never
developed
- it was primarily sexual and aggressive impulses
that had been either blocked from expression or
punished upon expression that led to free-
floating anxiety
- defense mechanisms do not work, leaving the
person anxious nearly all the time, unlike with
specific phobia that defense mechanisms are
helping people
- been largely abandoned among clinical
researchers since it was not testable
>> PERCEPTIONS OF UNCONTROLLABILITY
AND UNPREDICTABILITY  protection and have little control themselves
#TraumaticEvents #TraumaInChildhood
#LessToleranceForUncertainty
#Tension&Hypervigilance #LackingSafetySignals
- people with GAD may have a history of
experiencing many important events in their
lives as unpredictable or uncontrollable
- unpredictable and uncontrollable events
involved in GAD are generally not as severe and
traumatic as those involved in the origins of
PTSD but people with GAD may be more likely
to have had a history of trauma in childhood
than individuals with several other anxiety
disorders
- people with GAD clearly have far less tolerance
for uncertainty especially disturbed by not being
able to predict the future
- their tension and hypervigilance or the sense
of always looking for signs of threat, stems from
their lacking safety signals in their environment
but can also feel safe when that signal is missing
- but if another person has experienced many
unpredictable or unsignaled stressors, this
uncertainty may lead to chronic anxiety
- relative lack of safety signals may help explain
why people with GAD feel constantly tense and
vigilant for possible threats
>> A SENSE OF MASTERY: THE
POSSIBILITY OF IMMUNIZING AGAINST
ANXIETY 
- person’s history of control over important
aspects of his or her environment
- parents of anxious children often have an
intrusive, overcontrolling parenting style, which
may serve only to promote their children’s
anxious behaviors by making them think of the
world as an unsafe place in which they require
>> THE CENTRAL ROLE OF WORRY AND
ITS POSITIVE FUNCTIONS
- positive beliefs about worry play a key role in
maintaining high levels of anxiety and worry
such as superstitious avoidance of catastrophe
like “Worrying makes it less likely that the
feared event will occur”; avoidance of deeper
emotional topics like “Worrying about most of
the things I worry about is a way to distract
myself from worrying about even more
emotional things, things that I don’t want to
think about”; and coping and preparation
- when people with GAD worry, their emotional
and physiological responses to aversive imagery
are actually suppressed and this suppression of
aversive emotional physiological responding
may serve to reinforce the process of worry
- because worry suppresses physiological
responding, it also insulates the person from
fully experiencing or processing the topic that
she or he is worrying about, and it is known that
such full processing is necessary if extinction of
that anxiety is to occur

• WORRY PROCESS IS NOW CONSIDERED THE
CENTRAL FEATURE OF GAD  are likely to happen in the future, they have a
- worry is a self-sustaining process in some
people and perceived to be uncontrollable
>> THE NEGATIVE CONSEQUENCES OF
WORRY #IntrusiveThoughts
- people who worry about something tend
subsequently to have more negative intrusive
thoughts than people who do not worry
- lead to increased experience of intrusive
thoughts and enhanced perception of being
unable to control them
>> COGNITIVE BIASES FOR THREATENING
INFORMATION  deficiency in GABA, which ordinarily plays an
#ThreateningCues #ThreateningInterpretations
- process threatening information in a biased
way, perhaps because they have prominent
danger schemas
- generally anxious people tend to preferentially
allocate their attention toward threatening cues
when both threat and nonthreat cues are
present in the environment
- if a person is already anxious, having his or her
attention automatically focused on threat cues
in the environment would seem only to
maintain the anxiety or even make it worse
- generally anxious people are also more likely
than nonanxious people to think that bad things
much stronger tendency to interpret ambiguous
information in a threatening way
- tendency to interpret ambiguous information
negatively has actually been shown to increase
anxiety in several situations, including watching
a stressful video
>> GENETIC FACTORS #TwinStudies
#Neuroticism
- several large twin studies reveal exactly how
heritability estimates vary as a function of one’s
definition of GAD 
- GAD and major depressive disorder have a
common underlying genetic predisposition
- basic personality trait commonly known as
neuroticism also play an important role
>> NEUROTRANSMITTER AND
NEUROHORMONAL ABNORMALITIES 
#GABA #Serotonin #Norepinephrine
- GABA a neurotransmitter now strongly
implicated in generalized anxiety since highly
anxious people have a kind of functional
important role in the way our brain inhibits
anxiety in stressful situations
- GABA does appear that this functional
deficiency promotes the maintenance of anxiety
- serotonin and norepinephrine also play a role
in anxiety
THE CORTICOTROPIN-RELEASING HORMONE
SYSTEM AND ANXIETY 
- anxiety-producing hormone corticotropin
releasing hormone/CRH has also been strongly
implicated as playing an important role in
generalized anxiety and also depression
- when activated by stress or perceived threat,
CRH stimulates the release of
ACTH/adrenocorticotropic hormone from the
pituitary gland which in turn causes release of
the stress hormone cortisol from the adrenal
gland
- The CRH hormone may play an important role
in generalized anxiety through its effects on the
bed nucleus of the stria terminalis which is an
extension of the amygdala, and which is now
believed to be an important brain area
mediating generalized anxiety
#ReducingDistortedCognition&InformationBiase
s
- aimed at reducing distorted cognitions and
information-processing biases associated with
GAD
• GAD INITIALLY APPEARED TO BE AMONG THE
MOST DIFFICULT OF THE ANXIETY DISORDERS
TO TREAT, AND TO SOME EXTENT THIS IS STILL
TRUE

>> NEUROBIOLOGICAL DIFFERENCES

BETWEEN ANXIETY AND PANIC 
- smaller left hippocampal region similar to what
is seen with major depression
MEDICATIONS FOR GAD:
- seem most strongly implicated in these
>> ANXIOLYTICS
emotional responses are the amygdala and
#Benzodiazepine #Buspirone
locus coeruleus
- including benzodiazepine category specifically
Xanax and klonopin, similar with panic disorder
TREATMENTS OF GAD:
and agoraphobia’s medications
>> COGNITIVE-BEHAVIORAL TREATMENT 
- this benzodiazepine can help for tension relief,
- has become increasingly effective as clinical
reduction of other somatic symptoms, and
researchers have refined the techniques used
relaxation; they can create physiological and
- usually involves a combination of behavioral
psychological dependence and withdrawal and
techniques, such as training in applied muscle
are therefore difficult to taper
relaxation
- another is the buspirone category that is also
effective, and it neither is sedating nor leads to
• CBT has also been found to be useful in
physiological dependence; has greater effects
helping people who have used benzodiazepines
on psychic anxiety than do the benzodiazepines
for over a year to successfully taper their
but it takes 2-4 weeks to show results than
medications
benzodiazepine that shows result for just 30-60
minutes
>> COGNITIVE RESTRUCTURING
TECHNIQUES
>> ANTIDEPRESSANT MEDICATIONS
- similar with panic disorder medications
including tricyclics, SSRIs, and SNRIs
OBSESSIVE-COMPULSIVE AND RELATED
DISORDERS
- a category where OCD belongs
- this includes not only OCD but also new
related disorders including hoarding disorder,
trichotillomania, body dysmorphic disorder, and
excoriation
WHY IS OCD NO LONGER CONSIDERED TO
BE AN ANXIETY DISORDER?
OBSESSIVE-COMPULSIVE DISORDER/OCD
- are no longer classified as anxiety disorder
- is defined by the occurrence of unwanted and
intrusive obsessive thoughts or distressing
images
- are usually accompanied by compulsive
behaviors performed to undo or neutralize the
obsessive thoughts or images or as a way of
preventing some dreaded event or situation
- often one of the most disabling mental
disorders in that it leads to a lower quality of life
and a great deal of functional impairment
- for it to be OCD, the person must recognize
that the obsession is the product of his or her
own mind rather than being imposed from
without
- there is a continuum of insight among persons
with obsessive-compulsive disorder about
exactly how senseless and excessive their
obsessions and compulsions are
- the diagnosis requires that obsessions and
compulsions must take at least 1 hour in a day,
in severe cases they may take most of the
person’s waking hours
OBSESSIONS
#RecurrentIntrusiveThoughts
#DisturbingInappropriate #Uncontrollable
- persistent and highly recurrent intrusive
thoughts or images that are experienced as
disturbing, inappropriate, and uncontrollable
- people affected by such obsessions try to resist
or suppress them, or to neutralize them with
some other thought or action

OBSESSIVE THOUGHTS
#ContaminationFears #Doubt #Symmetry
#SexuaAgressionReligionObsessions
- contamination fears, fears of harming oneself
or others, and pathological doubt
- other fairly common themes are concerns
about or need for symmetry, sexual obsessions,
and obsessions concerning religion or
aggression
- ex. of themes of violence or aggression might
include a wife being obsessed with the idea
that she might poison her husband or child, or
a daughter constantly imagining pushing her
mother down a flight of stairs
• COMPULSIVE BEHAVIORS PERFORMED WITH
THE GOAL OF PREVENTING OR REDUCING
DISTRESS OR PREVENTING SOME DREADED
EVENT OR SITUATION
• PEOPLE WITH OCD FEEL COMPELLED TO
PERFORM ACTS REPEATEDLY THAT OFTEN SEEM
POINTLESS AND ABSURD EVEN TO THEM AND
THAT THEY IN SOME SENSE DO NOT WANT TO
PERFORM

COMPULSIONS
- can involve either overt repetitive behaviors
that are performed as lengthy rituals such as
hand washing or checking rituals; may also
involve more covert mental rituals such as
counting, praying, or saying certain words
silently over and over again
- that the person feels must be performed in
response to the obsession
- are sometimes performed as lengthy rituals
- behaviors have the goal of preventing or
reducing distress or preventing some dreaded
outcome from occurring

• A PERSON WITH OCD USUALLY FEELS

DRIVEN TO PERFORM THIS COMPULSIVE,
RITUALISTIC BEHAVIOR IN RESPONSE TO AN
OBSESSION, AND THERE ARE OFTEN VERY
RIGID RULES REGARDING EXACTLY HOW THE
COMPULSIVE BEHAVIOR SHOULD BE
PERFORMED
CASE STUDY OF OCD:
FOR A SMALLER NUMBER OF PEOPLE, THE
COMPULSIONS ARE TO PERFORM VARIOUS
EVERYDAY ACTS
- such as eating or dressing
- it could also be compulsive behavior such as
extremely slowly known as primary obsessional
slowness
- some compulsion can be symmetrical or
evened up
5 PRIMARY TYPES OF COMPULSIVE
RITUALS:
#CRROC #StoryOfRock
>> CLEANING
>> REPEATED CHECKING
>> REPEATING
>> ORDERING OR ARRANGING
>> COUNTING
WASHING OR CLEANING RITUALS
- vary from mild to more extreme rituals
- vary from relatively mild ritual like behavior
such as spending 15 to 20 minutes washing
one’s hands after going to the bathroom
- more extreme behavior such as washing one’s
hands with disinfectants for hours every day to
the point where the hands bleed
CHECKING RITUALS
#2-3timesLock
#HoursCheckingOnImagineAccident
- mild checking rituals such as checking all the
lights, appliances, and locks two or three times
before leaving the house
- very extreme checking rituals such as going
back to an intersection where one thinks one
may have run over a pedestrian and spending
hours checking for any sign of the imagined
accident
• BOTH CLEANING AND CHECKING RITUALS ARE
OFTEN PERFORMED A SPECIFIC NUMBER OF
TIMES AND THUS ALSO INVOLVE REPETITIVE
COUNTING
- usually brings a feeling of reduced tension and
satisfaction
- a sense of control, although this anxiety relief
is typically fleeting
YEDASENTIENCE
#IntuitiveSignal #SubjectiveFeelingOfKnowing
#Enough
- defined as this subjective feeling of knowing
- an intuitive signal that you have thought
enough, cleaned enough, or in other ways done
what you should to prevent chaos and danger
- people with OCD suffer from a deficit in
yedasentience because they fail to gain the
internal sense of completion, they have a hard
time stopping their thoughts and behaviors
PREVALENCE, AGE OF ONSET, AND GENDER
DIFFERENCES
- divorced or separated and unemployed people
are somewhat overrepresented among people
with OCD since it has a great difficulty this
disorder creates for interpersonal and
occupational functioning
- OCD showed little or no gender difference in
adults but in childhood or early adolescent
onset, it is more common in boys than in girls
and is often associated with greater severity
- it begins usually/generally in late adolescence
or early adulthood
COMORBIDITY WITH OTHER DISORDERS
- co-occurs with other mood disorders such as
depression and major depression
- anxiety disorders including social phobia. panic
disorder, GAD, and PTSD
- personality disorders including dependent and
avoidant personality disorder
- also, disorder from the category OCRD
particularly BDD
CAUSAL FACTORS OF OCD:
>> OCD AS LEARNED BEHAVIOR 
- derived from mowrer’s two-process theory of
avoidance learning
MOWRER’S TWO-PROCESS THEORY OF
AVOIDANCE LEARNING
#Avoid #CompulsiveRituals
- neutral stimuli become associated with
frightening thoughts or experiences through
classical conditioning and come to elicit anxiety
- ex. in shaking hands, the person may discover
that the anxiety produced by shaking hands or
touching a doorknob can be reduced by hand
washing; washing response is reinforced, which
makes it more likely to occur again in the future
when other situations evoke anxiety about
contamination
- any stressors that raise anxiety levels can lead
to a heightened frequency of avoidance
responses in animals or compulsive rituals in
humans
• EXPOSURE TO FEARED OBJECTS OR
SITUATIONS SHOULD BE USEFUL IN TREATING
OCD IF THE EXPOSURE IS FOLLOWED BY
PREVENTION OF THE RITUAL, ENABLING THE
PERSON TO SEE THAT THE ANXIETY WILL
SUBSIDE NATURALLY IN TIME WITHOUT THE
RITUAL
>> OCD AND PREPAREDNESS 
#EvolutionaryContext #DisplacementActivties
- explained by evolutionary context similar with
specific phobia’s causal factors (prepared
learning)
- displacement activities that many species of
animals engage in under situations of conflict or
high arousal resemble the compulsive rituals
seen in obsessive-compulsive disorder
DISPLACEMENT ACTIVITIES
#AnimalsGrooming
- often involve grooming such as a bird preening
its feathers or nesting under conditions of high
conflict or frustration
>> THE EFFECTS OF ATTEMPTING TO
SUPPRESS OBSESSIVE THOUGHTS  - inflated sense of responsibility for the harm
#ThoughtSuppresion
#IncreaseIntrusiveThoughts
- normal people attempt to suppress unwanted
thoughts, they may sometimes experience a
paradoxical increase in those thoughts later
- one factor contributing to the frequency of
obsessive thoughts, and the negative moods
with which they are often associated, may be
these attempts to suppress them
- thought suppression leads to a more general
increase in obsessive-compulsive symptoms
beyond just the frequency of obsessions
- ex. when people with OCD were asked to
record intrusive thoughts in a diary, both on
days when they were told to try to suppress
those thoughts and on days without instructions
to suppress, they reported approximately twice
as many intrusive thoughts on the days when
they were attempting to suppress them
THOUGHT-ACTION FUSION
- people who have inflated sense of
responsibility can be associated with beliefs that
simply having a thought about doing something
and is morally equivalent to actually having
done it, or that thinking about committing a sin
increases the chances of actually doing so
- is when you believe that simply thinking about
an action is equivalent to actually carrying out
that action
they may cause adds to the perceived awfulness
of any harmful consequences and also may
motivate compulsive behaviors such as washing
and checking to try to reduce the likelihood of
anything harmful happening
• PEOPLE WITH OCD HAS THIS SENSE OF
RESPONSIBILITY THAT MAKES THE THOUGHT SO
AWFUL.
>> COGNITIVE BIASES AND DISTORTIONS 

>> APPRAISALS OF RESPONSIBILITY FOR

INTRUSIVE THOUGHTS 
#DifficultyBlockingOutNegativeInput #Suppress
- people with OCD often seem to have an
#IncreaseCompulsions #LowConfidence
inflated sense of responsibility, in some
#DeficitInMotorResponseAbility
vulnerable people, this inflated sense of
- people with OCD has shown that their
responsibility which pertains to thought-action
attention is drawn to disturbing material
fusion
relevant to their obsessive concerns, much as
occurs in the other anxiety disorder
- people with OCD also seem to have difficulty
blocking out negative, irrelevant input or
distracting information, so they may attempt to
suppress negative thoughts stimulated by this
information that leads to increase frequency of
compulsions
- low confidence in their memory ability
especially for situations they feel responsible for
which may contribute to their repeating their
ritualistic behaviors over and over again
BIOLOGICAL CAUSAL FACTORS
#Genetic #Brain&NeurotransmitterAbnormal
- ranging from studies about its genetic basis to
studies of abnormalities in brain function and
neurotransmitter abnormalities
>> GENETIC FACTORS #Twin
#EarlyOnsetOCD #GeneticPolymorphisms
- including twin and family heritability
- in twin studies, moderately high concordance
rate for monozygotic twins or identical twins
and a lower rate for dizygotic twins
- early-onset OCD has a higher genetic loading
than later-onset OCD
- OCD that often starts in childhood and is
characterized by chronic motor tics shows a
linkage between OCD and tourette’s syndrome
- an additional factor contributing to their
repetitive behavior is that people with OCD
have deficits in their ability to inhibit both
motor responses
- genetic polymorphisms are implicated in OCD
with Tourette’s syndrome and in OCD without
Tourette’s syndrome, suggesting that these two
forms of OCD are at least partially
distinguishable at a genetic level
TOURETTE’S SYNDROME
#SevereMotor&VocalTic
#RepetitiveMovements&Tic
- a disorder characterized by severe chronic
motor and vocal tics that is known to have a
substantial genetic basis
- it involves repetitive movements or unwanted
sounds/tics that can't be easily controlled
- ex. you might repeatedly blink your eyes, shrug
your shoulders or blurt out unusual sounds or
offensive words
GENETIC POLYMORPHISMS
#MultipleAlleles #LeastPartialDistinguishable
- are implicated in OCD with Tourette’s
syndrome and in OCD without Tourette’s
syndrome, suggesting that these two forms of
OCD are at least partially distinguishable at a
genetic level
- are defined as the occurrence of multiple
alleles at a locus, where at least two alleles
occur with a frequency greater than 1%
>> OCD AND THE BRAIN #Cortical
#Subcortical
- abnormalities occur primarily in certain cortical
structures as well as in certain subcortical
structures known as the basal ganglia
BASAL GANGLIA #ControlEmotionalBehaviors
- linked at the amygdala to the limbic system,
which controls emotional behaviors
PEOPLE WITH OCD HAVE ABNORMALLY HIGH
LEVELS OF ACTIVITY IN TWO PARTS OF THE
FRONTAL CORTEX THAT ARE BOTH LINKED TO
THE LIMBIC AREA:
1. ORBITAL FRONTAL CORTEX
2. CINGULATE CORTEX/GYRUS
• PEOPLE WITH OCD ALSO HAVE ABNORMALLY
HIGH LEVELS OF ACTIVITY IN THE SUBCORTICAL
CAUDATE NUCLEUS
- which is part of the basal ganglia
- these primitive brain circuits are involved in
executing primitive patterns of behavior such as
those involved in sex, hygiene, and aggression
or also known as stuff of obsessions
- activity in some of these areas is further
increased when symptoms are provoked by
relevant/disturbing stimuli that activate
obsessive thoughts

• THE CORTICO-BASAL GANGLIA-THALAMO-
CORTICAL LOOP (CBGTC LOOP) IS A SYSTEM OF
NEURAL CIRCUITS IN THE BRAIN. THE LOOP
INVOLVES CONNECTIONS BETWEEN THE
CORTEX,
THE BASAL GANGLIA, THE THALAMUS, AND
BACK TO THE CORTEX
ORBITAL FRONTAL CORTEX
#ReleaseHAS
- seems to be where primitive urges regarding
sex, aggression, hygiene, and danger come from
- these urges are ordinarily filtered by the
caudate nucleus as they travel through the
cortico-basal-ganglionic-thalamic circuit,
allowing only the strongest to pass on to the
thalamus
CAUDATE NUCLEUS/CORPUS STRIATUM
#LinkOrbitalFrontalToThalamus
- part of the set of structures called the basal
ganglia, which are involved in the execution of
voluntary, goal-directed movement
- is part of an important neural circuit linking the
orbital frontal cortex to the thalamus
2 OTHER STRUCTURES OF BASAL
GANGLIA:
- are also involved in this cortico-basal-
ganglionic-thalamic circuit
1.) GLOBUS PALLIDUS
- output nucleus, primarily, sends information to
the thalamus
2.) SUBSTANTIA NIGRA
- ranging from movement control, cognitive
executive functions, and emotional limbic
activity
THALAMUS #RelayStation
- an important relay station that receives nearly
all sensory input and passes it back to the
cerebral cortex
CORTICO-BASAL-GANGLIONIC-THALAMIC
CIRCUIT #BehavioralResponses
#SocialConcernRitual #HygienceConcernRitual
- normally involved in the preparation of
complex sets of interrelated behavioral
responses used in specific situations such as
those involved in territorial or social concern
- when this circuit is not functioning properly,
inappropriate behavioral responses may occur,
including repeated sets of behaviors stemming
from territorial and social concerns such as
checking behavior, and from hygiene concerns
such as cleaning
• OVERACTIVATION OF THE ORBITAL FRONTAL
CORTEX, WHICH STIMULATES STUFF OF
OBSESSIONS, COMBINED WITH A
DYSFUNCTIONAL INTERACTION AMONG THE
ORBITAL FRONTAL CORTEX which is the corpus
striatum or caudate nucleus and thalamus may
be the central component of the brain
dysfunction in OCD
- dysfunctions in this circuit in turn prevent
people with OCD from showing the normal
inhibition of sensations, thoughts, and
behaviors that would occur if the circuit were
functioning properly (responsible of cerebral
cortex)
WHITE MATTER
- involved in connectivity between various brain
structures
- least part of the reason that this circuit
specifically the cortico-basal-ganglionic-thalamic
circuit does not function properly may be due to
abnormalities in white matter in some of these
brain areas
>> NEUROTRANSMITTER ABNORMALITIES
#Serotonin #Dopamine #Gaba #Glutamate
- increased serotonin activity and increased
sensitivity of some brain structures to serotonin
are involved in OCD symptoms
- drugs that stimulate serotonergic systems lead
to a worsening of symptoms
- immediate short-term effects of clomipramine
or fluoxetine may be to increase serotonin
levels and exacerbate/make worse OCD
symptoms too but long-term effects are quite
different
- drugs must be taken for at least 6 to 12 weeks
before significant improvement in OCD
symptoms occurs
- other neurotransmitter systems such as
dopaminergic, GABA (blocks, or inhibits, certain
brain signals and decreases activity in your
nervous system; helps with feelings of anxiety,
stress, and fear), and glutamate systems
(responsible for sending signals between nerve
cells) are also included
TREATMENT FOR OCD:
>> EXPOSURE AND RESPONSE PREVENTION
- a combination of behavioral treatment that
seems to be the most effective approach to
treating obsessive-compulsive disorders
- treatment involves having the OCD clients
develop a hierarchy of upsetting stimuli and rate
them on a 0 to 100 scale according to their
capacity to evoke anxiety, distress, or disgust
- clients are asked to expose themselves
repeatedly either in guided fantasy or directly to
stimuli that will provoke their obsession
- they are asked to not engage in the rituals that
they ordinarily would engage in to reduce the
anxiety or distress provoked by their obsession
• PREVENTING THE RITUALS IS ESSENTIAL SO
THAT THEY CAN SEE THAT IF THEY ALLOW
ENOUGH TIME TO PASS, THE ANXIETY CREATED
BY THE OBSESSION WILL DISSIPATE NATURALLY
DOWN TO AT LEAST 40 TO 50 ON THE 100-
POINT SCALE
- in intensive versions of this treatment,
clients who, for example, are used to spending
2 to 3 hours a day showering and hand washing
may be asked to not shower at all for 3 days at a
time and then only for 10 minutes
- later in treatment they are encouraged to
shower for only 10 minutes a day, with no more
than five 30-second hand washings at
mealtimes, after bathroom use, and after
touching clearly soiled objects. In addition to
the exposures conducted during therapy
sessions, homework is liberally assigned
>> COGNITIVE-BEHAVIORAL THERAPY
- this form of treatment can also be quite
effective, but unfortunately it has not been
shown to be superior to exposure and response
prevention therapy in any of the predicted ways
>> NEUROSURGICAL TECHNIQUES
- the person must have had severe OCD for at
least 5 years and must not have responded to
any of the known treatments can have this
- neurosurgery designed to destroy brain tissue
in one of the areas implicated in this condition
MEDICATIONS FOR OCD:
- medications that affect the neurotransmitter
serotonin seem to be the primary class of
medication that has mild to moderate effects in
treating persons with OCD
>> ANTIDEPRESSANT MEDICATIONS
#Anafranil #Fluoxetine
- these are also a serotonergic medication
which alter functioning of the serotonin
system, appear to reduce the intensity of
the symptoms of this disorder
- these medications include the fluoxetine
(prozac) and tricyclic medication such as
anafranil (clomipramine)
>> ANTI ANXIETY MEDICATIONS
#DCycloserine
- including d-cycloserine which is a drug known
to facilitate extinction of fear
- can decrease the number of sessions of
exposure and response prevention that are
needed
>> ANTIPSYCHOTIC MEDICATIONS
- people who fail to respond to these
serotonergic medications, small doses of certain
antipsychotic may produce significantly greater
improvement
A MAJOR DISADVANTAGE OF
MEDICATION /TREATMENT FOR OCD
- when the medication is discontinued relapse
rates are generally very high
• MANY PEOPLE WHO DO NOT SEEK
ALTERNATIVE FORMS OF BEHAVIOR THERAPY
THAT HAVE MORE LONG-LASTING BENEFITS
MAY HAVE TO STAY ON THESE MEDICATIONS
INDEFINITELY
• COMBINING MEDICATION WITH EXPOSURE
AND RESPONSE PREVENTION IS MUCH MORE
EFFECTIVE THAN BEHAVIOR THERAPY ALONE-
combination treatment was superior in the
treatment of children and adolescents with OCD

CLASSIC NEUROTIC DISORDER

- anxiety and obsessive-compulsive disorders
were considered to be this
- classified as a somatoform disorder in DSM-IV-
TR because it involves preoccupation with
NEUROSIS
certain aspects of the body
- is a disorder involving obsessive thoughts or
- but because of its very strong similarities with
anxiety
OCD, it was moved out of the somatoform
category and into the OCRD category in DSM-5
NEUROTIC DISORDERS
- sometimes called imaginary defect disorder
#Maladaptive&SelfDefeatingBehavior
- people with BDD are obsessed with some
#NotDangerous #IntraPsychicConflict
perceived or imagined flaw or flaws in their
- show maladaptive and self-defeating behaviors
appearance to the point they firmly believe they
- they are not incoherent, dangerous, or out of
are disfigured or ugly
touch with reality
- spend hours a day thinking about their
- to Freud, these neurotic disorders developed
appearance
when intrapsychic conflict (conflicting drives,
- preoccupation is so intense that it causes
wishes, or agencies) produced significant
clinically significant distress and impairment in
anxiety
social or occupational functioning
- not considered necessary for the diagnosis but
• SOME DISORDERS THAT DID NOT INVOLVE
most people with BDD have compulsive
OBVIOUS ANXIETY SYMPTOMS WERE
checking behaviors such as checking their
RECLASSIFIED AS EITHER DISSOCIATIVE OR
appearance in the mirror excessively or hiding
SOMATOFORM DISORDERS
or repairing a perceived flaw
- another very common symptom is avoidance
BODY DYSMORPHIC DISORDER
of usual activities because of fear that other
/BDD/IMAGINARY DEFECT DISORDER
people will see the imaginary defect and be
https://youtu.be/lr6bsE-G978
repulsed
- severe cases, they may become so isolated
that they lock themselves up in their houses and
never go out, even to work, with the average
employment rate estimated at only about 50
percent
- their average quality of life is quite poor
- people with BDD have concerns about their
appearance that are of delusional intensity and
spend an inordinate amount of time obsessively
checking their appearance in the mirror
- others do not even see the defects that the
person with BDD believes she or he has, or if
they do, they see only a very minor defect
within the normal range
PEOPLE WITH BDD MAY FOCUS ON
ALMOST 7 ANY BODY PART:
- sufferers have perceived defects in more than
one body part
- that these are not the ordinary concerns that
most of us have about our appearance; they are
far more extreme, leading in many cases to
complete preoccupation and significant
emotional pain
ᴥ SKIN
ᴥ HAIR
ᴥ NOSE
ᴥ STOMACH
ᴥ CHEST/BREAST/NIPPLES
ᴥ EYES
ᴥ FACE SHAPE AND SIZE
PEOPLE WITH BDD DO NOT APPEAR TO HAVE
DISTORTED VISUAL PERCEPTIONS OF THEIR
BODY
- rather, they have a detail-oriented analytic
style which has the tendencies to overvalue the
meaning of appearance for self-worth, and
excessive attention to cues related to
appearance
PEOPLE WITH BDD FREQUENTLY DO
SOMETHING SUCH AS:
> SEEK REASSURANCE FROM FRIENDS AND
FAMILY ABOUT THEIR DEFECTS
- but the reassurances almost never provide
more than very temporary relief
> FREQUENTLY SEEK REASSURANCE FOR
THEMSELVES BY DOING REPETITIVE
BEHAVIOR
- checking their appearance in the mirror
countless times in a day although some avoid
mirrors completely
>> USUALLY DRIVEN BY THE HOPE THAT THEY
WILL LOOK DIFFERENT
- sometimes they may think their perceived
defect does not look as bad as it has at other
times, much more commonly they feel worse
after mirror gazing
>> FREQUENTLY ENGAGE IN EXCESSIVE
GROOMING BEHAVIOR
- often trying to camouflage their perceived
defect through their hairstyle, clothing, or
makeup
PREVALENCE, AGE OF ONSET, AND GENDER
DIFFERENCES
- prevalence of BDD are difficult to obtain
because of the great secrecy that usually
surrounds this disorder
- equal in men and women but has primary
body parts that are focused on tend to differ in
men and women
- men are more likely to obsess about their
genitals, body build, and balding; women tend
to obsess more about their skin, stomach,
breasts, buttocks, hips, and legs
- age of onset is usually in adolescence when
many people start to become preoccupied with
their appearance
- people with BDD very commonly also have a
depressive diagnosis and it often leads to
suicide ideation, suicide attempts, or completed
suicide
• BDD, LIKE OCD, IS OFTEN ASSOCIATED WITH A
POOR QUALITY OF LIFE
• ONE STUDY FOUND THAT 8-20 PERCENT OF
THOSE SEEKING COSMETIC MEDICAL
TREATMENTS MET CRITERIA FOR BDD
- however, an astute doctor will not do the
requested procedures and may instead make a
referral to a psychologist or psychiatrist
• PATIENT DOES GET WHAT HE OR SHE
REQUESTS AND UNFORTUNATELY IS ALMOST
NEVER SATISFIED WITH THE OUTCOME
- even if they are satisfied with the outcome,
such patients still tend to retain their diagnosis
of BDD
RELATIONSHIP TO OCD AND BDD
- the similarities to OCD should be fairly obvious
since people with OCD, those with BDD have
prominent obsessions, and they engage in a
variety of ritualistic behaviors such as
reassurance seeking, mirror checking,
comparing themselves to others, and
camouflage
- people with BDD are more convinced that their
obsessive beliefs are accurate than are people
with OCD
- the same neurotransmitter (serotonin) and the
same sets of brain structures are implicated in
the two disorders; and the same kinds of
treatments that work for OCD are also the
treatments of choice for BDD
• SIGNIFICANT OVERLAPPING FEATURES
BETWEEN BDD AND EATING DISORDERS
- particularly anorexia nervosa
- the most striking similarity being the body
image distortion in both kinds of conditions
specifically excessive concerns and
preoccupation about physical appearance,
dissatisfaction with one’s body, and a distorted
image of certain features of one’s body are
central to the diagnostic criteria for each
• PEOPLE WITH BDD LOOK NORMAL AND YET
ARE TERRIBLY OBSESSED AND DISTRESSED
ABOUT SOME ASPECT OF THEIR APPEARANCE
• PEOPLE WITH ANOREXIA ARE
EMACIATED/THIN AND GENERALLY SATISFIED
WITH THIS ASPECT OF THEIR APPEARANCE
• BDD SEEMS TO BE A UNIVERSAL DISORDER,
OCCURRING IN ALL EUROPEAN COUNTRIES, THE
MIDDLE EAST, CHINA, JAPAN, AND AFRICA
ALTHOUGH IT SEEMS TO BE UNIVERSAL, WHY,
THEN, DID ITS EXAMINATION IN THE
LITERATURE BEGIN ONLY RECENTLY?
- first, its prevalence may actually have
increased in recent years as contemporary
Western culture has become increasingly
focused on looks as everything, with billions of
dollars spent each year on enhancing
appearance through makeup, clothes, plastic
surgery, and other means
- second, most people with this condition never
seek psychological or psychiatric treatment,
rather, they suffer silently or go to
dermatologists or plastic surgeons
- reasons for this secrecy and shame include
worries that others will think they are
superficial, silly, or vain and that if they mention
their perceived defect, others will notice it and
focus more on it
• AS INCREASING ATTENTION IS FOCUSED ON
THIS DISORDER, THE SECRECY AND SHAME
OFTEN SURROUNDING IT SHOULD DECREASE,
AND MORE PEOPLE WILL SEEK TREATMENT
CAUSAL FACTORS OF BDD
- biopsychosocial approach offers some
reasonable hypotheses
>> TWIN STUDY #HeritableTrait
- found that over-concern with a perceived or
slight defect in physical appearance is a
moderately heritable trait
>> SOCIOCULTURAL CONTEXT
#SelfSechemas
#Attractiveness&Beauty
- places great value on attractiveness and
beauty, and people who develop BDD often
hold attractiveness as their primary value
- self-schemas are heavily focused around such
ideas as “If my appearance is defective, then I
am worthless”
>> PSYCHOLOGICAL FACTORS
#Childhood #Appearance>Behavior
#HistoryOfEmotionalNeglect
- these people were reinforced as children for
their overall appearance more than for their
behavior; they were teased or criticized for their
appearance, which caused conditioning of
disgust, shame, or anxiety to their own image of
some part of their body
- history of emotional neglect or emotional
abuse, physical or sexual abuse or physical
neglect
>> BIASED ATTENTION AND
INTERPRETATION
- relating to attractiveness
- selectively attend to positive or negative words
such as ugly or beautiful more than to other
emotional words not related to appearance
- they tend to interpret ambiguous facial
expressions as contemptuous or angry more
than do controls
- ex. when they are shown pictures of their own
face that have been manipulated to be more or
less symmetrical than in reality, they show a
greater discrepancy/inconsistency than controls
between judgments of their actual face and
their ideal face
>> NEGATIVE EVALUATIONS OR - the treatments that are effective for BDD are
EXPERIENCES ABOUT YOUR BODY OR closely related to those used in the effective
SELF-IMAGE treatment of obsessive-compulsive disorder

>> BDD AND BRAIN > EXPOSURE AND RESPONSE PREVENTION

#CBT #Identify&ChangeDistortedPerceptions
#HiglightThanDisguise
- a form of cognitive-behavioral treatment
- a treatment similar with OCD
- it focuses on getting the patient to identify and
change distorted perceptions of his or her body
during exposure to anxiety-provoking situations
such as when wearing something that highlights

- differences in visually processing since they rather than disguises the defect; and on

showed a bias for extracting local, detailed prevention of checking responses such as mirror

features rather than the more global or holistic checking, reassurance seeking, and repeated

processing of faces seen in controls examining of the imaginary defect

- when patients with BDD are shown a picture of

their own face, they demonstrate greater MEDICATIONS FOR BDD:

activation than do healthy controls in brain > ANTIDEPRESSANT MEDICATIONS

regions associated with inhibitory processes and #SSRICategory #HigherDoses

the rigidity of behavior and thinking in - medications from the SSRI category often

orbitofrontal cortex and caudate produce moderate improvement in patients

- performance deficits on tasks that measure with BDD, but many are not helped or show

executive functioning such as manipulating only a modest improvement

information, planning, and organization which is - it seems that higher doses of these

thought to be guided by prefrontal brain regions medications are needed to effectively treat BDD
relative to OCD

• BDD EXHIBITED GREATER ACTIVITY IN THE

AREAS OF THE BRAIN THAT PROCESS DETAILED
INFORMATION; THE MORE ACTIVITY THEY HAD
IN THESE DETAIL-PROCESSING REGIONS, THE
LESS ATTRACTIVE THEY PERCEIVED THE FACES
TO BE
HOARDING DISORDER
TREATMENTS FOR BDD: #Possession #EmotionalAttachment
#Disorganize&ClutteredHouse
#OverPowerOdors
#EffortToHaveNewUselessThings #RiskOfFire
they were no longer able to use their
refrigerator, kitchen sink, or bathtub, and about
10 percent were unable to use their toilet
- respiratory conditions, poor hygiene, and
difficulties with cooking can all contribute to
poor physical health

• PEOPLE WITH HOARDING DISORDER ENGAGE

IN EXCESSIVE BUYING AND MANY ARE UNABLE
TO WORK
- thought of as one particular symptom of OCD,
but this categorization began to be seriously COMPULSIVE HOARDING

questioned, but has now been added as a new - as a symptom occurs in approximately 10 to 40

disorder in DSM-5 percent of people diagnosed with OCD,

- such individuals both acquire and fail to however, as many as 4 out of 5 people show

discard many possessions that seem useless or only compulsive hoarding

of very limited value, in part because of the

emotional attachment they develop to their • COMPULSIVE HOARDERS ARE SIGNIFICANTLY

possessions MORE DISABLED BOTH OCCUPATIONALLY AND

- their living spaces are extremely cluttered and SOCIALLY THAN PEOPLE WITH OCD BUT

disorganized to the point of interfering with WITHOUT COMPULSIVE HOARDING SYMPTOMS

normal activities that would otherwise occur in - high risk for fire, falling, poor sanitation, and

those spaces, such as cleaning, cooking, and serious health problems

walking through the house

- spend a good deal of their time repetitively
thinking about their current and potential future
possessions and engage in intensive efforts to
acquire new objects, and these efforts can
resemble the compulsions observed in OCD
- the repetitive thoughts and behaviors are
distressing, feel uncontrollable, and require a
considerable amount of time, also, thoughts and
behaviors feel unstoppable
- severe cases people have literally been buried
alive in their own home by their hoarded
possessions; characterized by overpowering
odors, from rotten food or feces, more than 40
percent had accumulated so many items that

PREVALENCE, AGE OF ONSET, AND GENDER
DIFFERENCES  clothes when the weather got cold, it would be
- more common among men than among
women but very few seek treatment
- hoarding behavior usually begins in childhood
or early adolescence
- these early symptoms may be kept under
control by parents and by limited income, so
severe impairment from the hoarding often
does not surface until later in life
- animal hoarding often does not emerge until
middle age or older
ANIMAL HOARDING
- people with hoarding disorder also engage in
animal hoarding
- sometimes view themselves as animal rescuers
- the accumulating number of animals often
outstrips the person’s ability to provide
adequate care, shelter, and food
- animal hoarders often describe their animals
as their closest confidants
HOARDING DISORDER COMORBIDITY
- including OCD, depression, generalized anxiety
disorder, and social phobia
• WHEN SYMPTOMS ARE BETTER EXPLAINED BY
ANOTHER DISORDER, HOARDING DISORDER
SHOULD NOT BE DIAGNOSED
CAUSAL FACTORS OF HOARDING
DISORDER
>> EVOLUTIONARY PERSPECTIVE
- basic instincts become so uncontrollable for
some people
- ex. imagine you were a caveman with no
access to grocery stores to replenish food
reserves and no clothing stores to find warm
adaptive to store any vital resources you could
find
>> COGNITIVE BEHAVIORAL MODEL
- hoarding is related to poor organizational
abilities, unusual beliefs about possessions, and
avoidance behaviors
POOR ORGANIZATIONAL ABILITIES
#PoorAttentionAndOrganization
- people with hoarding disorder demonstrate
difficulties with attention, and find it difficult to
categorize objects
- hoarders tend to be slow, to generate many
more categories than others do, and to find the
process much more anxiety-provoking
- it is difficult for them to make decisions,
attending to the task at hand, organizing
objects, and making decisions influence almost
every aspect of acquiring objects, organizing the
home, and removing excessive acquisitions
- many patients find it excruciatingly hard to
sort through their objects and figure out what
to discard
UNUSUAL BELIEFS ABOUT POSESSION
- hoarders demonstrate an extreme emotional
attachment to their possessions
- report feeling comforted by their objects,
being frightened by the idea of losing an object,
and seeing the objects as core to their sense of
self and identity
- perceive a sense of responsibility for taking
care of those objects and are likely to resent it if
others touch, borrow, or remove them
- attachments may be even stronger when
animals are involved
- these beliefs about the importance of each
and every object interfere with any attempts to
tackle the clutter
AVOIDANCE
- in the face of the anxiety of all these decisions,
this is the common
- many people with this disorder feel that it is
better to pause than to make the wrong
decision or to lose a valued object
- it is considered one of the key factors that
maintains the clutter
>> PATTERNS OF ACTIVATION IN CERTAIN BRAIN
- symptoms also show in certain areas when
their symptoms are provoked
- brain activation patterns are different from
those of people diagnosed with OCD who do not
have hoarding symptoms
- may be neurologically distinct from people
with OCD
>> ABNORMALITIES IN THE BRAIN
- It is suggested that abnormal brain
development and brain lesions could lead to
compulsive behaviors of hoarding
>> BRAIN DAMAGE
- sometimes hoarding may begin after brain
damage due to surgery, stroke, brain injury or
infections
TREATMENTS FOR HOARDING
DISORDER
- these individuals have a poorer prognosis for
treatment than do people without hoarding
symptoms
- typically used to treat OCD were generally not
effective in treating people with compulsive
hoarding symptoms
>> EXPOSURE AND RESPONSE PREVENTION
THERAPY
- exposure element of treatment focuses on the
most feared situation for people with hoarding
disorder, getting rid of their objects
- response prevention focuses on halting the
rituals that they engage in to reduce their
anxiety, such as counting or sorting their
possessions
- need motivational strategies; once people
decide to change, therapists help them make
decisions about their objects, provide tools to
help them get their clutter organized, and
schedule sessions to work on de-cluttering
- therapists supplement their office sessions
with in-home visits which is more effective than
the traditional ERP therapy
• PATIENTS WHO RECEIVED CBT
DEMONSTRATED SIGNIFICANTLY MORE
IMPROVEMENT THAN DID THOSE ASSIGNED TO
A WAITING LIST
>> MOTIVATIONAL STRATEGIES
- therapy cannot begin to address the hoarding
symptoms until the person develops insight
- are used to help the person consider reasons
to change
>> FAMILY APPROACHES
- by building rapport around these difficult
issues
- rather than aiming for a total absence of
clutter, family members are urged to identify
the aspects of hoarding and clutter that are
most dangerous for safety
>> FAMILY RELATIONSHIPS
- are often profoundly damaged for those with
hoarding disorder
- relatives usually try various approaches to
helping people rid their life of clutter, only to
become more and more frustrated and angry as
those attempts fail since their strategies
typically create mistrust and animosity
MEDICATIONS FOR HOARDING
DISORDER
>> ANTIDEPRESSANT
- can be somewhat effective
TRICHOTILLOMANIA
- also known as compulsive hair pulling or hair
pulling disorder
- its primary symptom is the urge to pull out
one’s hair from anywhere on the body such as
scalp, eyebrows, or arms, resulting in noticeable
hair loss
- in earlier DSM, it was categorized as an
impulse-control disorder but placed to OCRD
later on
- hair pulling is usually preceded by an
increasing sense of tension, followed by
pleasure, gratification or relief when the hair is
pulled out
- symptoms must cause clinically significant
distress or impairment in some important areas
of functioning
- it usually occurs when the person is alone or
with immediate family member, and the person
often examines the hair root, twirls it off and
sometimes pulls the strand between their teeth
and/or eats it also known as trichophagia
- dolls, pets, carpet, and sweaters are often
pulled on like hair, and nail biting, scratching,
gnawing, and excoriation are often associated
with this disorder.
• THE TERM “MANIA” SEEMS INAPPROPRIATE
FOR TRICHOTILLOMANIA
- however, changing too rapidly to a more
descriptive term such as hair-pulling disorder
may be confusing for clinicians, hence we
propose to retain trichotillomania in
parentheses
A: Hair loss may not always be noticeable in
those suffering from this disorder
B and C: Patients with chronic hair-pulling may
or may not meet criteria B or C. Those who do
and do not meet these criteria do not appear
distinguishable on a range of clinical validators.
D: The exclusion criterion may be more clinically
useful if it lists disorders that may be
misdiagnosed as trichotillomania. For purposes
of clarity and consistency, we have used the
phrase not restricted to in the hierarchy
criterion of other disorders in our section.

2 TYPES OF TRICHOTILLOMANIA:
1.) FOCUSED PULLING
- used to control negative emotions such as
anger
2.) NON-FOCUSED PULLING
- is a nonintentional type of pulling that occurs
without the patient’s complete awareness
PREVALENCE, AGE OF ONSET, AND
GENDER DIFFERENCES  >> NEGATIVE EMOTIONS
- onset can be in childhood or later, with onset
post-puberty or period following puberty being
associated with a more severe course
- mean age of onset is 9 to 14 years old. It is
more common during the first 20 years of
someone’s life
- in children, the rates between genders tend to
be relatively equal, however, when
trichotillomania is present in an adult, it is more
common in females
- women tend to pull from limited locations
while men pull from many locations on the body
CAUSAL FACTORS OF TRICHOTILLOMANIA
>> GENETIC PREDISPOSITION
- mutations found in a gene known as SLITRK1
have been linked to trichotillomania as well as
to Tourette syndrome, a neurological disorder
that causes a person to make unusual
movements and sounds
SLITRK1
- is a protein coding gene
- gene helps form connections between brain
cells so that brain cells can communicate with
one another
- one of these mutations, written as del1264C,
deletes a single DNA building block (base pair)
from the gene
- mutations in SLITRK1 cause neurons to develop
faulty connections, and that this faulty wiring
produces the urge to pull one's hair
>> NEUROCHEMICAL PROBLEMS
- abnormalities in the natural brain chemicals
serotonin and dopamine
- negative or uncomfortable feelings including
stress, anxiety, tension, boredom, loneliness,
fatigue, or frustration
TREATMENTS FOR TRICHOTILLOMANIA
>> BEHAVIOR THERAPY
- aimed at habit reversal
- sufferers learn to identify when they have
urges to pull out their hair and how to relax in
order to reduce the tension caused by the urge
- therapy also helps them develop a competing
response when their urge arises
- ex. they may make a fist with their hands to
stop from pulling out hair
>> COGNITIVE THERAPY
- used to address distorted thinking
MEDICATIONS FOR TRICHOTILLOMANIA
>> ANTIDEPRESSANT
- particularly selective serotonin reuptake
inhibitors or SSRIs
EXCORIATION
- also known as skin picking disorder
- disorder defined by skin picking
- associated features supporting the diagnosis
include a range of behaviors or rituals involving
the skin that has been picked
- ex. examining, playing with or even swallowing
the skin after it has been pulled off
SCABIES
- is a skin infestation caused by a mite known as
the sarcoptes scabiei
- untreated, these microscopic mites can live on
your skin for months and they reproduce on the
surface of your skin and then burrow into it and
lay eggs
- this causes an itchy, red rash to form on the
skin
PREVALENCE, AGE OF ONSET, AND GENDER
DIFFERENCES  SOMEWHAT SURPRISING WAYS ACROSS
- more common in women than men
CAUSAL FACTORS OF EXCORIATION
>> BAD HABIT
>> STRESS
>> ABNORMAL BRAIN ACTIVATION
>> INJURY
TREATMENTS FOR EXCORATION
>> HABIT REVERSAL TRAINING
- find other things to do
>> STIMULUS CONTROL
- change environment
MEDICATIONS FOR EXCORATION
>> PSYCHOTROPIC DRUG THERAPY
>> ANTIDEPRESSANT MEDICATIONS
- including SSRIs
>> LOW-DOSE ATYPICAL ANTIPSYCHOTIC AGENT
>> ANTIANXIETY AGENT
CULTURAL PERSPECTIVES 
- anxiety is a universal emotion and anxiety
disorders probably exist in all human societies,
there are some differences in prevalence and in
the form in which the different disorders are
expressed in different cultures
• SEVERAL ANXIETY DISORDERS VARY IN
DIFFERENT RACIAL AND ETHNIC GROUPS,
INCLUDING NON-HISPANIC WHITES, AFRICAN
AMERICANS, AND HISPANIC AMERICANS
7 CULTURAL DISORDERS
1.) ATAQUE DE NERVOIS
- most of the symptoms of ataque de nervios
are the same as in a panic attack, but they may
also include bursting into tears, anger, and
uncontrollable shouting
- other symptoms include shakiness, verbal or
physical aggression, dissociative experiences,
and seizure-like or fainting episodes
- such attacks are often associated with a
stressful event relating to the family such as
news of a death and the person may have
amnesia for the episode; and childhood trauma
- quite common in children and adolescents
• INDIVIDUALS WHO EXPERIENCE ATAQUE DE
NERVIOS ALSO SEEM TO BE VULNERABLE TO A
WIDER RANGE OF OTHER ANXIETY AND MOOD
DISORDERS
2..) KORO
- a sudden fear that one’s genitals will recede
into the body into the body and believe that
when this process is complete, the sufferer will
die
- it has gender differences in terms of symptoms
- men focuses on intense, acute fear that the
penis is retracting into the body; while women
involves fear that their nipples are retracting
and breast are shrinking
- it occurs in places like china and other
southeast asian countries
- it is often attributed to either malicious spirits
or contaminated food, and it is also linked to
their survival especially when is threatened;
amphetamine abuse also plays a role with this
culture-related syndrome
- in west african nations, where afflicted
individuals report shrinking of the penis or
breasts but not retraction, which they fear will
lead to loss of sexual functioning and
reproductive capacity but not death
3.) KAYAK-ANGST
- a disorder that is similar to panic disorder,
occurs among the Inuit people of western
Greenland
- seal hunters who are alone at sea may
experience intense fear, disorientation, and
concerns about drowning
- people who are alone in harsh and unforgiving
environment
- it is a culture syndrome in western greenland
and it is sometimes caused by hereditary defect
4.) SHENKUI
- intense anxiety and somatic symptoms
attributed to the loss of semen, as through
masturbation or excessive sexual activity
- it reported in china and similar to other
syndromes reported in india and sri lanka
5.) SUSTO
- fright-illness
- the belief that a severe fright has caused the
soul to leave the body
- symptoms include increase heart rate,
sweating, and insomnia but not by fear or
anxiety
- Latin America and among Latinos in the United
States
6.) TAIJIN KYOFUSHO
- it is a japanese disorder that is related to the
western diagnosis of social phobia
- like social phobia, it is a fear of interpersonal
relations or of social situations, but most people
with taijin kyofusho are concerned about doing
something that will embarrass or offend others
- the objects of anxiety and fear in these
syndromes relate to environmental challenges
as well as to attitudes that are prevalent in the
cultures where the syndromes occur
- culture influences what people come to fear
- they may fear offending others by blushing,
emitting an offensive odor, staring
inappropriately into the eyes of another person,
or through their perceived physical defects or
imagined deformities
- fear of bringing shame on others or offending
them is what leads to social avoidance
- BDD commonly occurs in sufferers of taijin
kyofusho
• PATTERN OF SYMPTOMS THAT OCCURS IN
TAIJIN KYOFUSHO HAS CLEARLY BEEN SHAPED
BY CULTURAL FACTORS
- japanese children are raised to be highly
dependent on their mothers and to have a fear
of the outside world, especially strangers
- as babies and young children, they are praised
for being obedient and docile
• THERE IS ALSO A GREAT DEAL OF EMPHASIS
ON TAIJIN KYOFUSHO IMPLICIT
COMMUNICATION BEING ABLE TO GUESS
ANOTHER’S THOUGHTS AND FEELINGS AND
BEING SENSITIVE TO THEM
- people who make too much eye contact are
likely to be considered aggressive and
insensitive, and children are taught to look at
the throat of people with whom they are
conversing rather than into their eyes
7.) KYOL GOEU
- also known as wind overload or wind mutes
- extreme stress experienced by cambodians
particularly cambodian refugees over the past
several decades
- symptoms includes dizziness, trembling,
fatigue
- person lies supine, eyes open and aware of
surrounding, unable to move or speak
- tightening of jaw often serves as a prodrome
- fear that the wind cannot circulate effectively
throughout the body
CULTURAL PERSPECTIVES 
3 PRIMARY CLUSTERS OF SYMPTOMS
ASSOCIATED WITH GAD:
1.) WORRY
- are very different than those in western
society; they focus on creating and maintaining
a large family and on fertility
2.) DREAMS
- are major source of anxiety because they are
thought to indicate that one may be bewitched
3.) BODILY COMPLAINTS
- common somatic complaints are also unusual
from a western standpoint including “I have the
feeling of something like water in my brain”,
“things like ants keep on creeping in various
parts of my brain”, and “I am convinced some
types of worms are in my head”
NIGERIANS WITH GAD SYNDROME OFTEN HAVE
PARANOID FEARS OF MALEVOLENT ATTACK BY
WITCHCRAFT
• INDIA ALSO THERE ARE MANY MORE WORRIES
ABOUT BEING POSSESSED BY SPIRITS AND
ABOUT SEXUAL INADEQUACY THAN ARE SEEN
IN GENERALIZED ANXIETY IN WESTERN
CULTURES