Anxiety Disorders

Submitted to:
Ms. Hina Maqsood
Group Members:
Abeera Mansoori
Fareeha Farrukh
Madnia Zahid
Rumaisa Jalil
Date:
22/6/2015

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Anxiety Disorders

Table of Contents
Introduction......................................................................................................................................5
Generalized Anxiety Disorder.........................................................................................................8
Case study....................................................................................................................................9
DSM IV Criteria- TR.................................................................................................................10
Symptoms...................................................................................................................................12
Etiology......................................................................................................................................13
The Psychoanalytical Viewpoint............................................................................................13
Cognitive theories...................................................................................................................13
Biological Theories................................................................................................................14
Treatments..................................................................................................................................15
Medications............................................................................................................................15
Cognitive-behavioral therapy (CBT)......................................................................................15
Obsessive Compulsive Disorder....................................................................................................16
Case study..................................................................................................................................17
DSM IV Criteria.........................................................................................................................18
Symptoms...................................................................................................................................20
Etiology......................................................................................................................................21
Neurobiological Factors.........................................................................................................21
Behavioral Factors in Compulsions.......................................................................................21
Cognitive-behavioral interventions........................................................................................22
Treatments..................................................................................................................................23
Medications............................................................................................................................23
Behavioral and cognitive-behavioral treatments....................................................................23
Phobias...........................................................................................................................................26
Case Study..................................................................................................................................27
DSM IV Criteria:........................................................................................................................28
Symptoms...................................................................................................................................30
Etiology......................................................................................................................................31

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Cognitive theory.....................................................................................................................31
Psychoanalytic viewpoint.......................................................................................................32
Neurobiological viewpoint.....................................................................................................32
Treatments..................................................................................................................................33
Cognitive Behavior Treatment:..............................................................................................33
Exposure Treatment................................................................................................................33
Psychotherapy........................................................................................................................34
Medicinal Treatments.............................................................................................................34
Panic Disorder...............................................................................................................................36
Case Studies...............................................................................................................................38
DSM IV Criteria- TR.................................................................................................................39
Symptoms...................................................................................................................................40
Etiology......................................................................................................................................41
Psychoanalytic approach........................................................................................................41
Cognitive Behavior Approach................................................................................................42
Treatments..................................................................................................................................44
Cognitive Behavioral Therapy...............................................................................................44
Exposure therapy....................................................................................................................44
Medication treatment..............................................................................................................45
Post Traumatic Stress Disorder......................................................................................................46
Case Study..................................................................................................................................47
DSM IV Criteria- TR (PTSD)....................................................................................................48
DSM IV Criteria- TR (ASD)......................................................................................................50
Symptoms...................................................................................................................................52
Etiology......................................................................................................................................54
Neurobiological viewpoint.....................................................................................................54
Psychoanalytic viewpoint.......................................................................................................54
Treatments..................................................................................................................................56
Cognitive Behavior Therapy for PTSD..................................................................................56

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EMDR....................................................................................................................................56
Treatment of ASD......................................................................................................................57
Antidepressant Medication.....................................................................................................57
Psychological Debriefing.......................................................................................................57
References......................................................................................................................................59

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Anxiety Disorders

Introduction

Anxiety Disorders are Psychological disorders that involve excessive levels of negative emotions
such as nervousness, tension, worry, fright and anxiety. Most anxiety disorders begin in
childhood, adolescence, and early adulthood. They occur slightly more often in women than in
men. However, Anxiety is dened as apprehension over an anticipated problem. In contrast, fear
is dened as a reaction to immediate danger. Psychologists focus on the immediate aspect of
fear versus the anticipated aspect of anxietyfear tends to be about a threat thats happening
now, whereas anxiety tends to be about a future threat. Thus, a person facing a bear experiences
fear, whereas a college student concerned about the possibility of unemployment after graduation
experiences anxiety.

Both anxiety and fear can involve arousal, or sympathetic nervous system activity. Anxiety often
involves moderate arousal, and fear involves higher arousal. At the low end, a person
experiencing anxiety may feel no more than restless energy and physiological tension; at the high
end, a person experiencing fear may sweat profusely, breathe rapidly, and feel an overpowering
urge to run.

Anxiety and fear are not necessarily badin fact, both are adaptive. Fear is fundamental for
ight-or-ght reactionsthat is, fear triggers rapid changes in the sympathetic nervous system
that prepare the body for escape or ghting. In the right circumstance, fear saves lives. (Imagine
a person who faces a bear and experiences no impulse to ee, no surge in energy, and no
marshaling of that energy to run quickly!) In some anxiety disorders, though, the fear system
seems to misrea person experiences fear at a time when there is no danger in the environment

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The symptoms of Anxiety disorder depends upon the type of Anxiety disorder but the general
symptoms include feelings of panic, fear, and uneasiness, problems in sleep patterns, cold or
sweaty hands and/or feet, shortness of breath, heart palpitations, an inability to be still and calm,
dry mouth, numbness or tingling in the hands or feet, nausea, muscle tension and dizziness.

Anxiety disorders may be caused by problems in the functioning of brain circuits that regulate
fear and other emotions. Studies have shown that severe or long-lasting stress can change the
way nerve cells within these circuits transmit information from one region of the brain to
another. Other studies have shown that people with certain anxiety disorders have changes in
certain brain structures that control memories linked with strong emotions. In addition, studies
have shown that anxiety disorders run in families, which means that they can at least partly be
inherited from one or both parents, like the risk for heart disease or cancer. Moreover, certain
environmental factors -- such as a trauma or significant event -- may trigger an anxiety disorder
in people who have an inherited susceptibility to developing the disorder. Anxiety disorder can
also be caused due to emotional, cognitive and behavioral characteristics. Emotionally, we
experience terror and dread, and we often are irritable or restless. Cognitively, we are on the
lookout for danger. Behaviorally, we seek to confront the threat or escape from it. In a realistic
fear response, these emotional, cognitive, and behavioral responses subside when the threat
subsides. In anxiety disorders, these responses may persist in the absence of any objective threat.
Anxiety is a large part of many psychological disorders. Most people with serious depression
report bouts of anxiety. People with schizophrenia often feel anxious when they believe they are
slipping into a new episode of psychosis.

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Generally, Anxiety disorders are treated through medication which includes drugs that reduce the
symptoms of anxiety disorders including anti-depressants and anxiety-reducing drugs. Moreover,
Psychotherapy (a type of counseling) addresses the emotional response to mental illness- a
process in which trained mental health professionals help people by talking through strategies for
understanding and dealing with their disorder is another way to treat Anxiety disorders. Other
than this, cognitive-behavioral therapy is also a treatment which is a particular type of
psychotherapy in which the person learns to recognize and change thought patterns and
behaviors that lead to troublesome feelings. Furthermore, Dietary and lifestyle changes and
Relaxation therapies are also some general treatments for Anxiety disorders.

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Generalized Anxiety Disorder

GAD includes people who are anxious all the time, however, in almost all situations. People with
GAD worry about many things in their lives likes their job performance, relationships, health,
getting late from work etc. The focus of their worries may shift frequently, and they tend to
worry about many things instead of focusing on only the issue of concern. Their worry is
accompanied by physiological symptoms, including muscle tension, sleep disturbances, and
chronic restlessness. People with GAD feel tired much of the time, probably due to chronic
muscle tension and sleep loss AD is relatively common, with cross-national studies showing a
lifetime prevalence of about 5 percent of women and 3 percent of men. It tends to be chronic).
Many people with this disorder report that they have been anxious all their lives; the disorder
most commonly begins in childhood or adolescence. Over 50 percent of people with GAD also
develop another anxiety disorder. Over 70 percent experience a mood disorder, and 33 percent
have a substance use disorder.

According to DSM IV criteria TR, GAD is the excessive anxiety and worry (apprehensive
expectation), occurring more days than not for at least 6 months, about a number of events or
activities (such as work or school performance). The person nds it difcult to control their
worry.

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Case study
Joe, a 24-year-old mechanic, had been referred for psychotherapy by his physician, whom he had
consulted because of difficulty in falling asleep. He was quite visibly distressed during the entire
initial interview, gulping before he spoke and continually fidgeting in his chair. He repeatedly
requested water to slake a seemingly unquenchable thirst. Although he described his physical
concerns first, a picture of pervasive anxiety soon emerged. He reported that he nearly always
felt tense. He seemed to worry about everything. He was apprehensive of disasters that could
befall him as he interacted with other people and worked and he described worrying much of the
time about his ability to form a relationship, his finances, and other issues. He reported a long
history of difficulties relating to others, which had led to his being fired from several jobs. As he
put it, I really like people and try to get along with them, but it seems like I fly off the handle
too easily. Little things upset me too much. I just cant cope unless everything is going exactly
right. Joe reported that he had always felt more nervous than other people but that his anxiety
had become much worse after a romantic breakup one year ago.

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DSM IV Criteria- TR
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for
at least 6 months, about a number of events or activities (such as work or school
performance).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following
six symptoms (with at least some symptoms present for more days than not for the past 6
months). Note: Only one item is required in children.
(1) restlessness or feeling keyed up or on edge
(2) being easily fatigued
(3) difficulty concentrating or mind going blank
(4) irritability
(5) muscle tension
(6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g.,
the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being
embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive
Disorder), being away from home or close relatives (as in Separation Anxiety Disorder),
gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as
in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety
and worry do not occur exclusively during Posttraumatic Stress Disorder.

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E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur
exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental
Disorder.

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Symptoms
According to the DSM IV criteria TR, the anxiety and worry are associated with at least three of
the following:

Restlessness or feeling keyed up or on edge

Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance

The focus of the anxiety and worry is not attributable to another disorder. The anxiety, worry, or
physical symptoms cause clinically signicant distress or impairment in social, occupational, or
other important areas of functioning. The disturbance is not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g.
Hyperthyroidism).

Etiology
The Psychoanalytical Viewpoint

According to this viewpoint, generalized anxiety results from an unconscious conflict between
ego and id impulses that is not adequately dealt with because the persons defense mechanisms

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have either broken down or have never developed. Freud believed that 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 may become overwhelmed
when a person experiences frequent and extreme levels of anxiety, as might happen if id
impulses are frequently blocked from expression (e.g., under periods of prolonged sexual
deprivation). According to this view, the primary difference between specific phobias and freefloating anxiety is that in phobias, the defense mechanisms of repression and displacement of an
external object or situation actually work, whereas in free-floating anxiety these defense
mechanisms do not work, leaving the person anxious nearly all the time.

Cognitive theories

They suggest that the cognitions of people with GAD are focused on threat, at both the conscious
and unconscious levels. At the conscious level, people with GAD make a number of maladaptive
assumptions, such as Its always best to expect the worst and I must anticipate and prepare
myself at all times for any possible danger. Many of these assumptions reflect concerns about
losing control. People with GAD believe that worrying can help them avoid bad events by
motivating them to engage in problem solving. Yet they seldom get to the problem solving.
Although they are always anticipating a negative event, they tend not to think it through. Indeed,
they actively avoid visual images of what they worry about, perhaps as a way of avoiding the
associated negative emotion. This avoidance prevents them from habituating to the negative
emotions associated with the event or considering ways they might cope. Their maladaptive
assumptions lead people with GAD to respond to situations with automatic thoughts that stir up
anxiety, cause them to be hyper vigilant, and lead them to overreact. When facing an exam, a

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person with GAD might reactively think, I dont think I can do this, Ill fall apart if I fail this
test, and My parents will be furious if I dont get good grades. The unconscious cognitions
of people with GAD also appear to focus on detecting possible threats in the environment.

Biological Theories

The discovery in the 1950s that the benzodiazepines provide relief from generalized anxiety has
led to theories about the neurotransmitters active in generalized anxiety. The benzodiazepines
increase the activity of GABA, a neurotransmitter that carries inhibitory messages from one
neuron to another. When GABA binds to a neuronal receptor, it prevents the neuron from fi ring.
One theory is that people with generalized anxiety disorder have a deficiency of GABA or
GABA receptors, which results in excessive firing of neurons through many areas of the brain,
particularly the limbic system, which is involved in emotional, physiological, and behavioral
responses to threat. As a result of excessive and chronic neuronal activity, the person experiences
chronic, diffuse symptoms of anxiety.

Treatments
Medications

Many clients with generalized anxiety disorder consult family physicians, seeking relief from
their nerves or anxieties or their various functional (psychogenic) physical problems. Most
often in such cases, medications from the benzodiazepine (anxiolytic) category such as Xanax or
Klonopin are usedand misusedfor tension relief, reduction of other somatic symptoms, and

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relaxation. Their effects on worry and other psychological symptoms are not as great. Moreover,
they can create physiological and psychological dependence and withdrawal and are therefore
difficult to taper. A newer medication called buspirone (from a different medication category) is
also effective, and it neither is sedating nor leads to physiological dependence. It also has greater
effects on psychic anxiety than do the benzodiazepines. However, it may take 2 to 4 weeks to
show results.

Cognitive-behavioral therapy (CBT)

CBT has become increasingly effective as clinical researchers have refined the techniques used.
It usually involves a combination of behavioral techniques, such as training in applied muscle
relaxation, and cognitive restructuring techniques aimed at reducing distorted cognitions and
information-processing biases associated with GAD as well as reducing catastrophizing about
minor events. GAD initially appeared to be among the most difficult of the anxiety disorders to
treat, and to some extent this is still true. However, advances have been made, and a quantitative
review of many controlled studies showed that CBT approaches resulted in large changes on
most symptoms measured. Finally, CBT has also been found to be useful in helping people who
have used benzodiazepines for over a year to successfully taper their medications.

Obsessive Compulsive Disorder

OCD is the prototypical disorder of anxiety disorders, is defined by repetitive thoughts and urges
(obsessions), as well as an irresistible need to engage in repetitive behaviors or mental acts
(compulsions). The repetitive thoughts and behaviors are distressing, feel uncontrollable, and

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require a considerable amount of time. For the person with these conditions, the thoughts and
behaviors feel unstoppable.
Obsessions are intrusive and recurring thoughts, images, or impulses that are persistent and
uncontrollable (i.e., the person cannot stop the thoughts) and that usually appear irrational to the
person experiencing them. For Bernice (described in the clinical case on the next page) and
others with OCD, obsessions have such force and frequency that they interfere with normal
activities. The most frequent obsessions concern fears of contamination, sexual or aggressive
impulses, and body problems. People with obsessions may also be prone to extreme doubts,
procrastination, and indecision.
Compulsions are repetitive, clearly excessive behaviors or mental acts that the person feels
driven to perform to reduce the anxiety caused by obsessive thoughts or to prevent some
calamity from occurring. Bernices rituals while washing and eating, described in the case
example below, fit this definition. Even though the person rationally understands that there is no
need for this behavior, he or she feels as though something dire will happen if the act is not
performed. The sheer frequency with which compulsions are repeated may be staggering (for
example, Bernice chewed each mouthful of food 300 times).

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Case study
Bernice was a 46-year-old woman. This was her fourth time seeking outpatient therapy, and she
had been hospitalized twice previously. Her obsessive-compulsive disorder had begun 12 years
earlier, shortly after the death of her father. Since then, it had waxed and waned but currently was
as severe as ever.
Bernice was obsessed with a fear of contamination, a fear she developed after her fathers death
from pneumonia (which she related to germs). Although she reported that she was afraid of
nearly everything because germs could be anywhere, she was particularly afraid of touching
wood, scratchy objects, mail, canned goods, silver embossing on a greeting card, eyeglass
frames, shiny appliances, and silverware. She was unable to state why these particular objects
were sources of possible contamination.
To try to reduce her discomfort, Bernice engaged in a variety of compulsive rituals that took up
almost all her waking hours. In the morning, she spent 3 to 4 hours in the bathroom, washing and
rewashing herself. Before each washing, she scraped away the outside layer of her bar of soap so
that it would be free of germs. Mealtimes lasted for hours because of rituals designed to
decontaminate her food, such as eating three bites of food at a time and chewing each mouthful
300 times. Her rituals had taken over her lifeshe did almost nothing else. Because of her fear
of contamination, she would not leave the house, do housework, or even talk on the telephone.

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DSM IV Criteria
A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
1. Recurrent and persistent thoughts, impulses, or images that are experienced, at some time
during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
2. The thoughts, impulses, or images are not simply excessive worries about real-life problems
3. The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize
them with some other thought or action
4. The person recognizes that the obsessional thoughts, impulses, or images are a product of his
or her own mind (not imposed from without as in thought insertion)
Compulsions as defined by (1) and (2):
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying,
counting, repeating words silently) that the person feels driven to perform in response to an
obsession, or according to rules that must be applied rigidly
2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some
dreaded event or
situation; however, these behaviors or mental acts either are not connected in a realistic way with
what they are designed to neutralize or prevent or are clearly excessive
B. At some point during the course of the disorder, the person has recognized that the obsessions
or compulsions are excessive or unreasonable. Note: This does not apply to children.

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C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1
hour a day), or significantly interfere with the persons normal routine, occupational (or
academic) functioning, or usual social activities or relationships.
D. If another Axis I disorder is present, the content of the obsessions or compulsions is not
restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling
in the presence of Trichotillomania; concern with appearance in the presence of Body
Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder;
preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation
with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the
presence of Major Depressive Disorder).
E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition.

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Symptoms
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 how the compulsive
behavior should be performed. The compulsive behaviors are performed with the goal of
preventing or reducing distress or preventing some dreaded event or situation. OCD is 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
In addition, the person must recognize that the obsession is the product of his or her own mind
rather than being imposed from without (as might occur in schizophrenia). However, there is a
continuum of insight among persons with obsessive-compulsive disorder about exactly how
senseless and excessive their obsessions and compulsions are (Mathews, 2008; Ruscio et al.,
2010). In a minority of cases, this insight is absent most of the time. Most of us have experienced
minor obsessive thoughts, such as whether we remembered to lock the door or turn the stove off.
In addition, most of us occasionally engage in repetitive or stereotyped behavior, such as
checking the stove or the lock on the door or stepping over cracks on a sidewalk.

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Etiology
Neurobiological Factors

It has been noted for decades that OCD symptoms are relatively common among people with
certain neurological disorders, such as Huntingtons chorea. Brain-imaging studies indicate that
three closely related areas of the brain are unusually active in people with OCD the
orbitofrontal cortex (an area of the frontal lobe located just above the eyes),

the

caudate

nucleus (part of the basal ganglia), and the anterior cingulated (cingulate gyrus). When people
with OCD are shown objects that tend to cause symptoms (such as a soiled glove for a person
who fears contamination), activity in these three areas increases. Overall, evidence is fairly
strong that the symptoms of OCD are tied to over activity in these three brain areas. One recent
brain imaging study which allowed researchers to examine the biochemical function of neurons
suggested that there may be some loss of neuronal function in the anterior cingulate and that the
hyperactivity of neurons in this area reflects an attempt to compensate for the underlying
abnormality. Studies indicate that when symptoms of OCD decrease with either medication or
psychological treatment, neurobiological deficits normalize.

Behavioral Factors in Compulsions

Behavioral models consider compulsions to be operantly conditioned responses. That is,

compulsions are reinforced because they reduce anxiety. For example, compulsive hand washing
would provide immediate relief from the anxiety associated with obsessions about germs.
Similarly, checking the stove may provide immediate relief from the anxiety associated with the

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thought that the house will catch fire. Consistent with this view, after compulsive behavior, selfreported anxiety and even psycho physiological arousal drop.

Cognitive-behavioral interventions

According to cognitive-behavioral theories of OCD, what differentiates people with OCD from
people without the disorder is the inability to turn off these negative, intrusive thoughts. Most
people can ignore or dismiss the thoughts, attributing them to their distress. With the passage of
time, the thoughts subside. First, they may be depressed or generally anxious much of the time so
that even minor negative events are likely to invoke intrusive, negative thoughts.
Second, people with OCD may have a tendency toward rigid, moralistic thinking. They judge
their negative, intrusive thoughts as more unacceptable than most people would and become
more anxious and guilty about having them. This anxiety then makes it harder for them to
dismiss the thoughts. People who feel more responsible for events that happen in their lives and
the lives of others will also have more trouble dismissing thoughts such as Did I hit someone on
the road? and thus might be more likely to develop OCD.

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Treatments
Medications

Serotonin reuptake inhibitors (SRIs) are the most commonly used medications for the
obsessive-compulsive and related disorders. SRIs were initially developed as antidepressants, but
it is well established that they are effective in the treatment of OCD. The most commonly
prescribed SRI for OCD is clomipramine. In one multisite study, clomipramine led to an
approximately 50 percent reduction in OCD symptoms and it is helpful for youth as well as
adults.
Selective serotonin reuptake inhibitors (SSRIs) are a newer class of SRIs that have fewer side
effects. Although more studies are available for SRIs like clomipramine, SSRIs also appear to be
effective in the treatment of OCD.
A major disadvantage of medication treatment for OCD, as for other anxiety disorders, is that
when the medication is discontinued relapse rates are generally very high.

Behavioral and cognitive-behavioral treatments

A behavioral treatment that combines exposure and response prevention seems be the most
effective approach to treating obsessive-compulsive disorders. This 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. Then the clients are asked to
expose themselves repeatedly (either in guided fantasy or directly) to stimuli that will provoke
their obsession (such as, for someone with compulsive washing rituals, touching the bottom of

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their shoe or a toilet seat in a public bathroom). Following each exposure, 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, even if this takes several hours.
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. For example, on one occasion well into
treatment, a therapist drove a patient who was terrified of being contaminated by dog dirt,
bathroom germs, garbage, and dead animals in the road to a place where she had observed a dead
cat on the roadside. The therapist insisted that the patient approach the smelly corpse, touch it
with the sole of her shoe, and then touch her shoe. A pebble lying close by and a stick with which
she had touched the cat were presented to the patient with the instruction that she keep them in
her pocket and touch them frequently throughout the day. Although some people refuse such
treatment or drop out early, it does help a majority of clients who stick with the treatment, most
of whom show a 50 to 70 percent reduction in symptoms, as well as improvement in quality of
life.

Additionally, a variant of ERP, sometimes called "imaginal exposure," is frequently used in the
treatment of OCD, OC Spectrum Disorders, and related anxiety disorders. Imaginal exposure

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involves using short stories based on the client's obsessions. These stories are audiotaped and
then used as ERP tools, allowing the client to experience exposure to their fearful thoughts. This
form of exposure therapy is particularly beneficial for obsessions that cannot be experienced
through traditional ERP (e.g., killing one's spouse or molesting a child). When combined with
standard ERP, and other cognitive-behavioral techniques, this type of imaginal exposure
treatment can help to greatly reduce the frequency and magnitude of these intrusive obsessions,
as well as the individual's sensitivity to unwanted thoughts and mental images.

Phobias

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Phobias are a mind-boggling and irrational apprehension of an article or circumstance that poses
minimal genuine danger however incites nervousness and avoidance. Not at all like the brief
anxiety the vast majorities feels when they give a discourse or take a test, a fear is enduring,
reasons extraordinary physical and mental responses, and can influence your ability to function
regularly at work or in social settings. Fears can grow around any article or circumstance. They
can be generally classified into two gatherings:

Specific (simple) phobia: a specific phobia is an excessive or unreasonable fear of an object or

situation, exposure to which provokes anxiety (American Psychiatric Association, 2000). The
DSM-IV-TR categorizes specific phobias into five subtypes: animal (e.g., fear of snakes), natural
environment (e.g., fear of heights), blood/injection/injury (e.g., fear of needles), situational (e.g.,
fear of car, heights), and other (e.g., fear of vomiting). Social Anxiety Disorder: Social anxiety
disorder (SAD), otherwise called social phobia, is a anxiety issue portrayed by an exceptional
fear in one or more social circumstances bringing on impressive pain and hindered capacity to
capacity in any event a few sections of everyday life.

Case Study
The patient was a 27-year-old man suffering from social phobia, youngest in his family,
unmarried, graduate, having average socioeconomic status and hailing from Jharkhand state,

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India. The patient came to RINPAS OPD with complaints of fearfulness in crowd, sweating, low
confidence, negative thoughts, decreased interaction and inferiority complex. The duration of
illness was 5 to 6 years. The patient had difficultly in carrying out his daily routine;
consequently, he came for treatment. It was revealed from his history that he was fearful as
compared to other persons of his age; from childhood, his mother was overprotective about him.
His father was dominating and did not listen to anyone in the family; the patient was very scared
of his father. Due to fearfulness, he remained dependent on others for the completion of his
simple tasks. Gradually he started avoiding gatherings and crowd and did not go out of home. He
felt difficulty in interacting with unknown people and even in opening up with people with
whom he was familiar. He was unable to talk with them in a crowd. He thought that he did not
have a good pattern of behavior and could not behave like other people. Although he put in
efforts to behave normally, yet he sweated a lot during public interaction. Whenever he went out
in social gatherings, he thought people were avoiding him, and he felt inferior or disapproved.
His self-esteem decreased gradually as he could not take initiative in any activity. Negative ideas
also developed in his mind that he would never flourish; he would not be successful; he
would not be able to behave like other people in society. Behavioral analysis was done with
regard to antecedent frequency, duration, intensity and motivation of the patient in order to target
behavior. Assessment regarding family interaction system, available support system and
perceived support system, as well as behavior of other significant persons towards the patient,
was done systematically.

DSM IV Criteria:
A. A marked and persistent fear of one or more social or performance situations in which the

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person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that
he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.
Note: In children, there must be evidence of the capacity for age-appropriate social relationships
with familiar people and the anxiety must occur in peer settings, not just in interactions with
adults.
B. Exposure to the feared social situation almost invariably provokes anxiety, which may take
the form of a situationally bound or situationally predisposedPanic Attack. Note: In children, the
anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with
unfamiliar people.
C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this
feature may be absent.
D. The feared social or performance situations are avoided or else are endured with intense
anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared social or performance
situation(s) interferes significantly with the person's normal routine, occupational (academic)
functioning, or social activities or relationships, or there is marked distress about having the
phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The fear or avoidance is not due to the direct physiological effects of asubstance (e.g., a drug
of abuse, a medication) or a general medical condition and is not better accounted for by another
mental disorder (e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety
Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid
Personality Disorder).

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H. If a general medical condition or another mental disorder is present, the fear in Criterion A is
unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson's dsease, or exhibiting
abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.

Symptoms
Symptoms of having a specific phobia often include uncomfortable and terrifying feelings of
anxiety: Symptoms of having a particular fear regularly incorporate uncomfortable and
frightening emotions of nervousness: an inclination of inescapable risk or fate, the need to get

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away, heart palpitations, sweating, trembling shortness of breath or a covering feeling, an

inclination of gagging, midsection torment or uneasiness queasiness or stomach discomfort,
feeling black out, unsteady or dizzy, a feeling of things being lighthearted, depersonalization, an
apprehension of losing control or "going insane", fear of dying, shivering sensation, chills or
warmth flush. Symptoms of social phobia are excessive blushing, overabundance sweating,
trembling, palpitations and queasiness. Stammering may be available, alongside fast discourse.
Fits of anxiety can likewise happen under serious apprehension and inconvenience. A few
sufferers may utilize liquor or different medications to decrease apprehensions and hindrances at
get-togethers. It is regular for sufferers of social fear to self-cure in this design, particularly on
the off chance that they are undiscovered, untreated, or both; this can prompt liquor addiction,
dietary problems or different sorts of substance misuse.

Etiology
Specific episodes or injuries, Case in point, somebody who encounters a great deal of turbulence
on a plane at a youthful age may later build up a fear about flying. Responses to panic or fear, On
the off chance that you have an in number response, or fit of anxiety, in light of a specific
circumstance or article, and you locate this humiliating or individuals around you respond
unequivocally, this can make you add to a more exceptional uneasiness about being in that

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circumstance once more. Learned reactions, got in ahead of schedule life. You may add to the
same particular fear as a guardian or more older sibling. Figures the family environment, for
example, folks who are exceptionally stressed or restless, can have an impact in transit you adapt
to uneasiness in later life. Genetics, some people appear to be born with a tendency to be more
anxious than others. Long term anxiety can bring about sentiments of uneasiness and dejection,
and decrease your capacity to adapt specifically circumstances. This can make you feel more
frightful or restless about being in those circumstances once more, and more than a long stretch,
could prompt you building up a fear. Phobias usually start when a person is a child or a teenager.
Children have more animal phobias, natural environment phobias, and blood-injection-injury
phobias than teenagers or adults. Situational phobias usually start when a person is an adult.
Women often have phobias at a younger age than men do. If a person has one phobia, he or she is
likely to have another phobia as well.

Cognitive theory

Social cognitive theory may explain why some people develop phobias. Many phobias stem from
early childhood, when our parents were our greatest influences and role models. It is not
uncommon for a parents distaste for spiders or rats to become a full-blown phobia in her child.
Watching someone else, whether a parent, friend, or even stranger, go through a negative
experience such as falling down the stairs can also lead to a phobia.

Psychoanalytic viewpoint

The psychoanalytic theory of phobias is based largely on the theories of repression and
displacement. It is believed that phobias are the product of unresolved conflicts between the id

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and the superego. Psychoanalysts generally believe that the conflict originated in childhood, and
was either repressed or displaced onto the feared object. The object of the phobia is not the
original source of the anxiety.

Neurobiological viewpoint

A few zones of the mind - the prefrontal cortex, average prefrontal cortex, ventromedial
prefrontal cortex, and the amygdala - store and review perilous or possibly dangerous occasions.
An in future event, if a very much alike occasion is faced, those territories recover that same
memory and the body responds is if there were a repeat. With a few individuals, the occasion
may feel as though it is rehashing itself commonly. Some successful medications figure out how
to get the cerebrum to supplant the memory and responses with something more objective. Fears
are unreasonable phenomena - the cerebrum goes overboard to a boost. Shockingly, the cerebrum
regions that arrangement with apprehension and anxiety continue recovering the alarming
occasion improperly. Neuroscience specialists have found that fears are frequently connected to
the amygdala, which lies behind the pituitary organ. The amygdala can trigger the arrival of
"battle or-flight" hormones, which put the body and brain in an exceedingly ready and focused
on state.

Treatments
Unlike many of the other anxiety disorders, however, the source of the anxiety is difficult to
physically avoid; for example, on account of particular fears, the article or circumstance of pain
can be evaded. There is some evidence suggesting that paroxetine might have beneficial effects
in the acute treatment of specific phobias.

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Cognitive Behavior Treatment:

CBT plans to distinguish associations between contemplations, emotions and conduct, and to
encourage create pragmatic aptitudes to deal with any examples that may be bringing on you
issues. At the point when CBT is utilized to treat fears, it ought to incorporate a scope of diverse
procedures, including a strategy called exposure treatment (or desensitization).

Exposure Treatment

This includes continuously uncovering you, in a protected and controlled path, to the item or
circumstance that you fear. Case in point, on the off chance that you have a fear of heading off to
the dental practitioner, you may read about the dental practitioner, and then take a gander at a
photo of a dental practitioner's seat, sit in the holding up room and converse with the dental
specialist, before at long last sitting in the dental specialist's seat. The amount of adaptive
learning between exposure treatment sessions nearly connected with the general impact of dcycloserine in social uneasiness issue. In particular, for patients accepting d-cycloserine, a
positive relationship was found between enhancements (from sessions 2 to 5) on examinations
about members' speech performance and reported enhancements in social fear and avoidance
side effects. Disgrace, obviously, is a focal part of social anxiety disorder, since the individual
endeavors to conceal the uneasiness anxiety from other individuals. The patient can be asked
precisely what is anticipated if somebody realize that he or she is on edge and afterward to test
these forecasts by revealing the uneasiness to a few companions. Further, the disgrace can be
lessened by having the patient canvas other individuals about their mental issues. We have found
that this frequently lessens the disgrace and builds the agreement and acceptance on the grounds
that numerous companions or relatives will recognize particular fears, fixations, or different

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issues. Specific phobias usually are treated with exposure therapy. Social phobias may be treated
with exposure therapy or with antidepressants or beta blockers.

Psychotherapy

Psychotherapy is another form of treatment i.e. talking with a trained mental health professional
can help you deal with your phobias. Several types of psychotherapy, also called talk therapy,
may be effective. Lastly with the help of medications, can help control the nervousness and panic
attacks from considering or being presented to the item or circumstance you fear.

Medicinal Treatments

Beta blockers: These solutions work by obstructing the animating impacts of adrenaline on your
body, for example, expanded heart rate, hoisted circulatory strain, beating heart, and shaking
voice and appendages that are brought about by tension. Transient utilization of beta blockers
can be powerful in diminishing indications when taken before an expected occasion, for instance,
before an execution for individuals who have serious stage dismay.

Antidepressants: Antidepressants called specific serotonin reuptake inhibitors (SSRIs) are

normally utilized as a part of the treatment of fears. These prescriptions follow up on the
synthetic serotonin, a neurotransmitter in your cerebrum that is accepted to impact temperament.
As an option, your specialist may endorse another kind of energizer, contingent upon your
circumstance.

Sedatives: Medicines called benzodiazepines help you unwind by diminishing the measure of
uneasiness you feel.

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Tranquillizers: These need to be utilized with alert in light of the fact that they can be addictive
and ought to be maintained a strategic distance from on the off chance that you have a
background marked by liquor or medication reliance.

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Panic Disorder

Panic disorder is an anxiety disorder characterized by recurring panic attacks, causing a series of
intense episodes of extreme anxiety during panic attacks. It may also include significant
behavioral changes lasting at least a month and of ongoing worry about the implications or
concern about having other attacks. Panic attacks are characterized by a fear of disaster or of
losing control even when there is no real danger. A person may also have a strong physical
reaction during a panic attack. It may feel like having a heart attack. Panic disorder is twice as
common in women as men. Panic attacks often begin in late adolescence or early adulthood, but
not everyone who experiences panic attacks will develop panic disorder. Many people have just
one attack and never have another. The tendency to develop panic attacks appears to be inherited.
Panic attacks can occur at any time, even during sleep. An attack usually peaks within 10
minutes, but some symptoms may last much longer.
People who have full-blown, repeated panic attacks can become very disabled by their condition
and should seek treatment before they start to avoid places or situations where panic attacks have
occurred. For example, if a panic attack happened in an elevator, someone with panic disorder
may develop a fear of elevators that could affect the choice of a job or an apartment, and restrict
where that person can seek medical attention or enjoy entertainment.
Some peoples lives become so restricted that they avoid normal activities, such as grocery
shopping or driving. About one-third become housebound or are able to confront a feared
situation only when accompanied by a spouse or other trusted person. When the condition
progresses this far, it is called agoraphobia, or fear of open spaces.

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Early treatment can often prevent agoraphobia, but people with panic disorder may sometimes go
from doctor to doctor for years and visit the emergency room repeatedly before someone
correctly diagnoses their condition. This is unfortunate, because panic disorder is one of the most
treatable of all the anxiety disorders, responding in most cases to certain kinds of medication or
certain kinds of cognitive psychotherapy, which help change thinking patterns that lead to fear
and anxiety.

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Case Studies
Paula had her first panic attack six months ago. She was in her office preparing for an important
work presentation when, suddenly, she felt an intense wave of fear. Then the room started
spinning and she felt like she was going to throw up. Her whole body was shaking, she couldnt
catch her breath, and her heart was pounding out of her chest. She gripped her desk until the
episode passed, but it left her deeply shaken.

Paula had her next panic attack three weeks later, and since then, theyve been occurring with
increasing frequency. She never knows when or where shell suffer an attack, but shes afraid of
having one in public. Consequently, shes been staying home after work, rather than going out
with friends. She also refuses to ride the elevator up to her 12th floor office out of fear of being
trapped if she has another panic attack.

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DSM IV Criteria- TR
A. Both (1) and (2):
(1) recurrent unexpected Panic Attacks
(2) at least one of the attacks has been followed by 1 month (or more) of one (or more) of the
following:
(a) persistent concern about having additional attacks
(b) worry about the implications of the attack or its consequences (e.g., losing control, having a
heart attack, "going crazy")
(c) a significant change in behavior related to the attacks
B. Absence of Agoraphobia.
C. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition (e.g., hyperthyroidism).
D. The Panic Attacks are not better accounted for by another mental disorder, such as Social
Phobia (e.g., occurring on exposure to feared social situations),Specific Phobia (e.g., on exposure
to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in
someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in
response to stimuli associated with a severe stressor), or Separation Anxiety Disorder(e.g., in
response to being away from home or close relatives).

Symptoms
People with panic disorder may have:

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Sudden and repeated attacks of fear

A feeling of being out of control during a panic attack
An intense worry about when the next attack will happen
A fear or avoidance of places where panic attacks have occurred in the past

Physical symptoms during an attack, such as a pounding or racing heart, sweating, breathing
problems, weakness or dizziness, feeling hot or a cold chill, tingly or numb hands, chest pain, or
stomach pain.

Panic disorder is often accompanied by other serious problems, such as depression, drug abuse,
or alcoholism. These conditions need to be treated separately. Symptoms of depression include
feelings of sadness or hopelessness, changes in appetite or sleep patterns, low energy, and
difficulty concentrating. Most people with depression can be effectively treated with
antidepressant medications, certain types of psychotherapy, or a combination of the two.

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Etiology
Although the exact causes of panic attacks and panic disorder are unclear, the tendency to have
panic attacks runs in families. There also appears to be a connection with major life transitions
such as graduating from college and entering the workplace, getting married, and having a baby.
Severe stress, such as the death of a loved one, divorce, or job loss can also trigger a panic
attack.

Panic attacks can also be caused by medical conditions and other physical causes. If youre
suffering from symptoms of panic, its important to see a doctor to rule out the following
possibilities:

Mitral valve prolapse, a minor cardiac problem that occurs when one of the hearts valves

doesn't close correctly

Hyperthyroidism (overactive thyroid gland)
Hypoglycemia (low blood sugar)
Stimulant use (amphetamines, cocaine, caffeine)
Medication withdrawal

Psychoanalytic approach

A psychoanalyst would likely submit the generation of panic attacks goes back to infancy and
childhood. They would, however, acknowledge that panic attacks may also occur as a result of
assorted cues in the present, such as the fear of having a panic attack in a situation where one
recently occurred. For the record, an attack occurring within this context could either be
situationally-bound or situationally-predisposed. The psychoanalysts consider both conscious
and unconscious panic triggers as representations of intense early life wishes and fears. So, panic

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attacks, in large part, occur in response to cues associated with long past psychological and
biological threats to ones existence. By the way, these cues are based in retained themes of
intensely feared eventualities such as castration, separation, and parental disapproval.

Cognitive Behavior Approach

A cognitivist would likely submit that a panic attack is a manifestation of an intense feeling of
helplessness in the face of intense danger. The vicious cycle of panic, which we know all too
well, is generated and sustained by combining the very real terror of vulnerability with ones
traditional distorted thought and feeling responses. Within the context of human genetic
predisposition, which from a phylogenetic perspective leans toward the anxious for purposes of
survival, it naturally flows that these thought and feeling responses appear to be designed to
produce the belief that out-of-control internal distress can lead to grave danger, even disaster.
Doesnt it make sense that its this dynamic that so often generates the intense need to seek a
caregiver for immediate assistance? I mean, at this point all bets on reason and logic are
absolutely off as our primal instincts take over. And then all sorts of physical symptoms arrive on
the scene because our mind really believes were in imminent danger, and its getting us ready to
fight the good fight. And the snowball just rolls on down the hill from there. Finally, the
cognitivists would likely submit that though panic attacks are often thought of as spontaneous,
some sort of event had to have tripped the trigger. Who knows, the culprit may have been a
sudden physiological change; say, feeling faint upon standing, sensing a rapid or palpitating heart
beat, or detecting a shortened breath. The thought is that events such as these, in the absence of
reason, are interpreted as indicators of immediate physiological danger. And, boom, off to the
races we go.

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Treatments
Panic attacks and panic disorder are treatable conditions. They can usually be treated
successfully with self-help strategies or a series of therapy sessions.

Cognitive Behavioral Therapy

Cognitive behavioral therapy is generally viewed as the most effective form of treatment for
panic attacks, panic disorder, and agoraphobia. Cognitive behavioral therapy focuses on the
thinking patterns and behaviors that are sustaining or triggering the panic attacks. It helps you
look at your fears in a more realistic light.

For example, if you had a panic attack while driving, what is the worst thing that would really
happen? While you might have to pull over to the side of the road, you are not likely to crash
your car or have a heart attack. Once you learn that nothing truly disastrous is going to happen,
the experience of panic becomes less terrifying.

Exposure therapy

In exposure therapy for panic disorder, you are exposed to the physical sensations of panic in a
safe and controlled environment, giving you the opportunity to learn healthier ways of coping.
You may be asked to hyperventilate, shake your head from side to side, or hold your breath.
These different exercises cause sensations similar to the symptoms of panic. With each exposure,
you become less afraid of these internal bodily sensations and feel a greater sense of control over
your panic.

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If you have agoraphobia, exposure to the situations you fear and avoid is also included in
treatment. As in exposure therapy for specific phobias, you face the feared situation until the
panic begins to go away. Through this experience, you learn that the situation isnt harmful and
that you have control over your emotions.

Medication treatment

Medication can be used to temporarily control or reduce some of the symptoms of panic disorder.
However, it doesn't treat or resolve the problem. Medication can be useful in severe cases, but it
should not be the only treatment pursued. Medication is most effective when combined with
other treatments, such as therapy and lifestyle changes, that address the underlying causes of
panic disorder.

The medications used for panic attacks and panic disorder include:

Antidepressants: It takes several weeks before they begin to work, so you have to take them
continuously, not just during a panic attack.

Benzodiazepines: These are anti-anxiety drugs that act very quickly (usually within 30 minutes
to an hour). Taking them during a panic attack provides rapid relief of symptoms. However,
benzodiazepines are highly addictive and have serious withdrawal symptoms, so they should be
used with caution.

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Post-Traumatic Stress Disorder

Stress is an inevitable, and in many ways a desirable, fact of everyday life. Some stressors,
however, are so catastrophic and horrifying that they can cause serious psychological harm. Such
traumatic stress is defined in DSM-IV-TR as an event that involves actual or threatened death
or serious injury to self or others and creates intense feelings of fear, helplessness, or horror.
Anyone who has gone through a life-threatening event can develop PTSD including military
troops who served in wars; rescue workers for catastrophes like the 2001 terrorist attacks on New
York City and Washington, D.C; survivors of accidents, rape, physical or sexual abuse, and other
crimes; immigrants fleeing violence in their countries; survivors of earthquakes, floods, and
hurricanes; and those who witness traumatic events. It is normal for both survivors and witnesses
to be greatly distressed by trauma. For some, however, the disturbance continues long after the
trauma has ended. Acute stress disorder (ASD) occurs within four weeks after exposure to
traumatic stress and is characterized by dissociative symptoms, re-experiencing of the event,
avoidance of reminders of the trauma, and marked anxiety or arousal. Posttraumatic stress
disorder (PTSD) also is defined by symptoms of reexperiencing, avoidance, and arousal, but the
symptoms either are longer lasting or have a delayed onset.

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Case Study
Maria was only 15 when she was attacked by a group of men on the way home from school.
They took turns screaming abuse at her and then they each raped her. Finally, they tried to stab
her to death and would almost certainly have succeeded had the police not arrived on the scene.
For months after this horrifying event, Maria was not herself. She was unable to keep the
memories of the attack out of her mind. At night she would have terrible dreams of rape, and
would wake up screaming. She had difficulty walking back from school because the route took
her past the site of the attack, so she would have to go the long way home. She felt as though her
emotions were numbed, and as though she had no real future. At home she was anxious, tense,
and easily startled. She felt dirty and somehow shamed by the event, and she resolved not to
tell close friends about the event, in case they too rejected her.

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DSM IV Criteria- TR (PTSD)

A. The person has been exposed to a traumatic event in which both of the following were
present:
1. The person experienced, witnessed, or was confronted with an event or events that involved
actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
2. The persons response involved intense fear, helplessness, or horror.
B. The traumatic event is persistently reexperienced in one (or more) of the following ways:
1. Recurrent and intrusive distressing recollections of the event including images, thoughts, or
perceptions
2. Recurrent distressing dreams of the event
3. Acting or feeling as if the traumatic event were recurring
4. Intense psychological distress at exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event
5. Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble
an aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma and numbing of general
responsiveness (not
present before the trauma), as indicated by three (or more) of the following:
1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. Efforts to avoid activities, places, or people that arouse recollections of the trauma

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3. Inability to recall an important aspect of the trauma

4. Markedly diminished interest or participation in significant activities
5. Feeling of detachment or estrangement from others
6. Restricted range of affect
7. Sense of a foreshortened future
D. Persistent symptoms of increased arousal, as indicated by two (or more) of the following:
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated startle response
E. Duration of the disturbance is more than 1 month
Specify if: Acute: If duration of symptoms is less than 3 months
Chronic: If duration of symptoms is 3 months or more
Specify if: With delayed onset: If onset of symptoms is at least 6 months after the stressor

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DSM IV Criteria- TR (ASD)

A. The person has been exposed to a traumatic event in which both of the following were
present:
1. The person experienced, witnessed, or was confronted with an event or events that involved
actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
2. The persons response involved intense fear, helplessness, or horror.
B. Either while experiencing or after experiencing the distressing event, the individual has three
(or more) of the following dissociative symptoms:
1. A subjective sense of numbing, detachment, or absence of emotional responsiveness
2. A reduction in awareness of his or her surroundings (e.g., being in a daze)
3. Derealization
4. Depersonalization
5. Dissociative amnesia (i.e., the inability to recall an important aspect of the trauma)
C. The traumatic event is persistently reexperienced in at least one of the following ways:
recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the
experience; or distress on exposure to reminders of the traumatic event.
D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings,
conversations, activities, places, and people).
E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor
concentration, hypervigilance, exaggerated startle response, motor restlessness).

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F. The disturbance causes clinically significant distress or impairment in social, occupational, or

other important areas of functioning or impairs the individuals ability to pursue some necessary
task, such as obtaining necessary assistance or mobilizing personal resources by telling family
members about the traumatic experience.
G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within
4 weeks of the traumatic event.

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Symptoms
The defining symptoms of both acute and posttraumatic stress disorder include (1)
reexperiencing, (2) avoidance, and (3) persistent arousal or anxiety. Dissociative symptoms also
are common in the immediate aftermath of a trauma and must be present to make a diagnosis of
ASD, but not PTSD.

Reexperiencing:

Flashbacksreliving the trauma over and over, including physical symptoms like a

racing heart or sweating

Bad dreams
Frightening thoughts.

Re-experiencing symptoms may cause problems in a persons everyday routine. They can start
from the persons own thoughts and feelings. Words, objects, or situations that are reminders of
the event can also trigger re-experiencing.

Avoidance:

Staying away from places, events, or objects that are reminders of the experience
Feeling emotionally numb
Feeling strong guilt, depression, or worry
Losing interest in activities that were enjoyable in the past
Having trouble remembering the dangerous event.

Things that remind a person of the traumatic event can trigger avoidance symptoms. These
symptoms may cause a person to change his or her personal routine.

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Persistent arousal:

Being easily startled

Feeling tense or on edge
Having difficulty sleeping, and/or having angry outbursts

People suffering from ASD and PTSD also experience increased arousal and anxiety following
the trauma, a symptom that, when it is more severe, predicts a worse prognosis. Examples of
arousal and anxiety include restlessness, agitation, and irritability. A number of people with
PTSD or ASD also have an exaggerated startle response, excessive fear reactions to unexpected
stimuli, such as loud noises. These symptoms are why traumatic stress disorders are grouped
with the anxiety disorders in DSM-IV-TR.

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Etiology
The cause of PTSD is unknown, but psychological, genetic, physical, and social factors are
involved. PTSD changes the body's response to stress. It affects the stress hormones and
chemicals that carry information between the nerves (neurotransmitters). Having been exposed to
trauma in the past may increase the risk of PTSD. People who have suffered childhood abuse or
other previous traumatic experiences are more likely to develop the disorder. And people who
experience emotional distancing may be more prone to PTSD.

Neurobiological viewpoint

People with PTSD show alterations in the functioning, and perhaps the structure, of the
amygdala and hippocampus, findings consistent, respectively, with the experience of heightened
fear reactivity and intrusive memories. In people with PTSD, the hippocampus appears smaller
in size. It is thought that changes in this part of the brain may be related to fear and anxiety,
memory problems and flashbacks.

Psychoanalytic viewpoint

The repressed trauma re-emerge later in life, it also reactivates previously repressed but
unresolved conflicts from childhood. The combined anxiety (neurotic anxiety) resulting from the
reawakening of this earlier conflict and from the more recent trauma results in other defense
mechanisms such as regression, denial, reaction formation and undoing, which are all
responsible for some of the symptoms of PTSD. From a psychoanalytic perspective, therefore,
the dreams and flashbacks which PTSD patients often experience are a result of repetition

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compulsion. An important point to remember is that the reliving of the trauma in PTSD patients
is usually experienced as a real and contemporary event. Patients do not simply recall the ordeal,
they usually feel as if they are reliving it in the present. Some individuals are pulled back so far
into these experiences that they even lose awareness of their present surroundings and realities

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Treatments
Cognitive Behavior Therapy for PTSD

While great sensitivity is required, the most effective treatment for PTSD is reexposure to
trauma. One of the first studies of prolonged exposure asked rape victims to relive the trauma
repeatedly over nine therapy sessions. While surely painful, exposure reduced PTSD symptoms
more, over the long term, than three randomized alternatives, including relaxation/stress
management, supportive counseling, and a wait list control group. Prolonged exposure has now
been successfully used for PTSD following combat , childhood sex abuse and assault. Depending
on the client, the therapist, and the circumstances of the trauma, prolonged exposure might
involve confronting feared situations in real life, in ones imagination, or by recounting events in
therapy. One treatment, imagery rehearsal therapy, successfully reduces recurrent nightmares, a
troubling problem frequently associated with PTSD. The exposure involves reliving nightmares
while awake, but rewriting the nightmare script in any way the client wishes.

EMDR

One treatment for PTSD, eye movement desensitization and reprocessing (EMDR), is a technique
that has been greeted with considerable enthusiasmand skepticism. Psychologist Francine
Shapiro (1995) discovered that rapid back-and-forth eye movements reduced her own anxiety,
so she tried the technique on her clients, who appeared to benefit from it. Shapiro and other
proponents use EMDR as a relaxation technique, while clients with PTSD simultaneously relive
vivid images of trauma. A recent meta-analysis concluded that EMDR may be effective;
however, prolonged exposure, not eye movements, again appears to be the active ingredient.

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Treatment of ASD
Several studies of ASD treatment have now been completed. Research indicates that structured
interventions with ASD can lead to the prevention of future PTSD. Unlike CISD, these
treatments last longer and target the select group of trauma victims who meet ASD diagnostic
criteria. The empirically backed ASD treatments are based on the principles of cognitive
behavior therapy, although they are briefer, typically involving five 90-minute sessions.

Antidepressant Medication

In addition to cognitive behavior therapy, numerous practice guidelines recommend

antidepressants (SSRIs) as a treatment for PTSD. The effectiveness of SSRIs is likely at least
partially due to the high comorbidity between PTSD and depression. While antidepressants are
helpful, only about 30 percent of treated patients recover fully from PTSD symptoms. However,
traditional antianxiety medications are not effective for PTSD.

Psychological Debriefing

People who are traumatized by disasters, victimization, or accidents profit from many of the
same treatments that are used to help survivors of combat. In addition, because their traumas
occur in their own community, where mental health resources are close at hand, these individuals
may, according to many clinicians, further benefit from immediate community interventions.
One of the leading such approaches is called psychological debriefing, or critical incident
stress debriefing, an intervention applied widely over the past 25 years. The use of this
intervention has, however, come under careful scrutiny in recent years, reminding the clinical
field of the ongoing need for systematic research into its assumptions and applications.

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Psychological debriefing is a form of crisis intervention that has victims of trauma talk
extensively about their feelings and reactions within days of the critical incident. Based on the
assumption that such sessions prevent or reduce stress reactions, they are often applied to trauma
victims who have not yet displayed any symptoms at all, as well as those who have. During the
sessions, often conducted in a group format, counselors guide the individuals to describe the
details of the recent trauma, to vent and relive the emotions provoked at the time of the event,
and to express their current feelings. The clinicians then clarify to the victims that their reactions
are perfectly normal responses to a terrible event, offer stress management tips, and, in some
cases, refer the victims to professionals for long-term counseling.

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References

Butcher, J. N., Mineka, S., Hooley, J. M., (2013). Abnormal Psychology. New Jersey: Pearson
Education, Inc.

Diagnostic criteria for 300.01 Panic Disorder without Agoraphobia. Retrieved From the website:
http://behavenet.com/node/21594

Hoeksema, S. N. (2011). Abnormal Psychology. New York: McGraw-Hill.

Kring, A. M., Johnson, S. L., Davison, G. C., Neale, J. M. (2010). Abnormal Psychology.
Jefferson City: R. R. Donnelley.

Thomas F. Oltmanns , Robert E. Emery, Abnormal Psychology

Ronald J Comer, Abnormal Psychology

National Institute of Mental Health. Panic Disorders. Retrieved From the website:
http://www.nimh.nih.gov/health/topics/panic-disorder/index.shtml#part_145354

NHS, PTSD-Causes, Retrieved from the website:

http://www.nhs.uk/conditions/post-traumatic-stress-disorder/pages/causes.aspx

Panic Attacks and Panic Disorders. Retrieved From the website:

http://www.helpguide.org/articles/anxiety/panic-attacks-and-panic-disorders.htm

Post-Traumatic Stress Disorder, Retrieved from the website:

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http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorderptsd/index.shtml#part_145373

Post Traumatic Stress Disorder, Retrieved from the website

:https://www.psychologytoday.com/conditions/post-traumatic-stress-disorder

http://www.whatispsychology.biz/posttraumatic-stress-disorder-psychodynamic-explanations

Two Stories of PTSD, Retrieved from the website:

http://psychcentral.com/lib/two-stories-of-ptsd/

Web MD, Anxiety & Panic Disorders Health Center. Retrieved From the website:
http://www.webmd.com/anxiety-panic/guide/mental-health-anxiety-disorders?page=2