3.

PANIC
MODULE 7| ANXIETY DISORDERS
 Sudden overwhelming reaction named
I. THE COMPLEXITY OF ANXIETY DISORDERS
after Greek god Pan who terrified
A. ANXIETY, FEAR, AND PANIC: SOME travelers with bloodcurdling screams.
DEFINITIONS
➢ PANIC ATTACK
1. ANXIETY
 An abrupt experience of intense fear or
 A negative mood state is characterized acute discomfort, accompanied by
by bodily symptoms of physical tension physical symptoms that usually include
and by apprehension about the future. heart palpitations, chest pain, shortness
 A subjective sense of unease, a set of of breath, and possibly, dizziness.
behaviors (looking worried and anxious
or fidgeting), or a physiological  EXPECTED (CUED) PANIC ATTACK
response originating in the brain and o If you know you are afraid of high
reflected in elevated heart rate and places or of driving over long
muscle tension. bridges, you might have a panic
 The normal response to threats is attack in these situations but not
abnormal when it is out of proportion to anywhere else.
the reality of the threat or when it simply o More common in specific phobias or
comes out of the blue. social anxiety disorders.
 A future-oriented mood state is
characterized by apprehension  UNEXPECTED (UNCUED) PANIC ATTACK
because we cannot predict or control o If you do not know when or where
upcoming events. the next attack will occur.
 Social, physical, and intellectual o Important in panic disorder.
performances are driven and
enhanced by anxiety. B. COMORBIDITY OF ANXIETY AND RELATED
DISORDERS
2. FEAR
 COMORBIDITY
 An immediate reaction to danger. o The co-occurrence of two or more
 An immediate emotional reaction to disorders in a single individual.
current danger is characterized by
strong escapist action tendencies, and,  The high rates of comorbidity among
often, a surge in the sympathetic anxiety and related disorders (and
branch of the autonomic nervous depression) emphasize how all of these
system. disorders share the common features of
 Like anxiety, fear can be good for us, it anxiety and panic.
protects us by activating a massive  They share the same vulnerabilities –
response from the autonomic nervous biological and psychological – to
system (increased heart rate and blood develop anxiety and panic. The only
pressure, etc.), which along with our difference would be in what triggers the
subjective sense of terror, motivates us anxiety and the patterning of panic
to escape (flee), or possibly, to attack attacks.
(fight).  By far, the most common diagnosis for
all anxiety disorders is major depression,
which occurred in 50% of the cases
 over the course of a patient’s life,  May repeatedly seek reassurance from
probably due to the shared others that everything is okay.
vulnerabilities between depression and  Diagnosis:
anxiety disorders in addition to the o Marked emotional distress or
disorder-specific vulnerability. significant impairment in daily
functioning
C. COMORBIDITY WITH PHYSICAL
DISORDERS  Occurs together with other disorders:
o Depression or anxiety disorders,
 An important study indicated that the agoraphobia, and OCD
presence of anxiety disorder was
uniquely and significantly associated  Other related features:
with thyroid disease, respiratory disease, o Restlessness
gastrointestinal disease, arthritis, o Feeling tense, keyed up or on edge
migraine headaches, and allergic o Becoming easily fatigued
conditions. o Difficulty concentrating or finding
 The anxiety disorder most often begins one’s mind going blank
before the physical disorder, suggesting o Irritability
(but not proving) that something about o Muscle tension
having an anxiety disorder might cause, o Disturbances of sleep
or contribute to the cause of, the
physical disorder.  Tends to be a stable disorder that
 If someone has both an anxiety disorder initially arises in the mid-teens to mid-
and one of the physical disorders 20’s and then typically follows a lifelong
mentioned earlier, that person will suffer course.
from greater disability and poorer
quality of life from both the physical B. PANIC DISORDER AND AGORAPHOBIA
problem and the anxiety problem than
➢ PANIC DISORDER
if that individual had just the physical
disorder alone.
 Individuals experience severe,
unexpected panic attacks; they may
II. ANXIETY DISORDERS
think they are dying or otherwise losing
A. GENERALIZED ANXIETY DISORDER (GAD) control.
 Repeated, unexpected panic attacks
 Characterized by excessive anxiety and  One attack must be followed by a
worry that is not limited to any one period of at least one month by either
object, situation, or activity. or both of the following:
 Excessive anxiety becomes difficult to o Persistent fear of subsequent attacks
control and is accompanied by or of the feared consequences of
physical symptoms such as restlessness, an attack (i.e., fear of losing control,
jumpiness, and muscle tension. having a heart attack, or going
 Chronic worrying: worry about many crazy).
things, including their health, finances, o Significant maladaptive change in
the well-being of their children, and behavior (i.e., limiting activities or
their social relationships. refusing to leave the house or
 Avoid situations or events in which they venture into the public for fear of
expect that something “bad” might having another attack).
happen.
➢ AGORAPHOBIA ➢ NOCTURNAL PANIC

 Derived from the Greek words meaning  Panic attacks occur during delta wave
“fear of the marketplace” or slow-wave sleep, which typically
 Fear of being out in open, busy areas, occurs several hours after we fall asleep
shopping in crowded places, walking and is the deepest stage of sleep.
through crowded streets, crossing a  People with panic disorder often begin
bridge, commuting, eating in to panic when they start sinking into
restaurants, etc. delta sleep, and when they awaken
 Structure their lives by avoiding amid an attack.
exposure to fearful situations and in  Individuals experiencing nocturnal
some cases housebound for months or panic attacks do wake up and later
even years. remember the event clearly.
 Has the potential to become the most  CAUSE:
incapacitating type of phobia and o The change in stages of sleep to
become dependent on others for slow-wave sleep produces physical
support. sensations of “letting go” that are
 Develop a fear of places and situations frightening to an individual with
from which it may be difficult or panic disorder.
embarrassing to escape in the event of
panicky symptoms or a full-fledge panic SLEEP APNEA
attack
 Women are about as likely as men to  An interruption of breathing during
develop agoraphobia. sleep may feel like suffocation.
 Tends to follow a persistent or chronic
course. SLEEP TERRORS
 Begins in late adolescence or early
adulthood.  Often children awaken imagining that
 Occur either with or without something is chasing them around the
accompanying panic disorder. room; it is common for them to scream
 Those without a history of panic disorder and get out of bed as if something
may experience mild panicky were after them.
symptoms, i.e., dizziness, that lead them  Children do not wake up and have no
to avoid venturing away from places memory of the event in the morning.
where they feel safe and secure.  Tend to occur at a later stage of sleep,
 Fear and avoidance of situations in a stage associated with sleepwalking.
which a person feels unsafe or unable
to escape to get home or to a hospital ISOLATED SLEEP PARALYSIS
in the event of a developing panic,
panic-like symptoms, or other physical  Occurs during the transitional state
symptoms, such as loss of bladder between sleep and waking, when a
control. person is either falling asleep or waking
 People develop agoraphobia because up, but mostly when waking up.
they never know when these symptoms  During this period, the individual is
might occur. In severe cases, people unable to move and experiences a
with agoraphobia are unable to leave surge of terror that resembles a panic
the house, sometimes for years on end. attack; occasionally, there are also
vivid hallucinations.

 CAUSE: 2. SITUATIONAL PHOBIA
o REM sleep is spilling over into the
waking cycle.  Characterized by fear of public
o Vivid dreams could account for the transportation or enclosed spaces.
experience of hallucination.  CLAUSTROPHOBIA: Fear of small,
enclosed places.
C. SPECIFIC PHOBIA  People with situational phobia never
experience panic attacks outside the
 An irrational fear of a specific object or context of their phobic object or
situation that markedly interferes with situation. Therefore, they can relax
an individual’s ability to function. when they do not have to confront their
 Persistent or excessive fear of a specific phobic situation.
object or situation that is out of
proportion to the actual danger these 3. NATURAL ENVIRONMENT PHOBIA
objects or situations pose.
 The phobic person experiences high  Fears of situations or events occurring in
levels of fear and physiologic arousal nature.
when encountering the phobic object,  The major examples are heights, storms,
which prompts strong urge to avoid or and water; these fears seem to cluster
escape the situation or to avoid the together.
feared stimulus.  Many of these situations have some
 Phobic disorder: significantly affect the danger associated with them and,
person’s lifestyle or functioning or cause therefore, mild to moderate fear can
significant distress. be adaptive.
 Begin in childhood, (Claustrophobia  Onset: 7 years
develops later on)  They are not phobias is they are only
 People with specific phobic disorders passing fears; they have to be persistent
recognize that their fears are (lasting at least 6 months) and to
exaggerated or unfounded. interfere substantially with the person’s
functioning, leading to avoidance of
1. BLOOD-INJECTION-INJURY PHOBIA boat trips or summer vacations in the
mountains where there might be a
 Many people who suffer from phobias storm.
and experience panic attacks in their
feared situations report that they feel 4. ANIMAL PHOBIA
like they are going to faint, but they
never do because their heart rate and  Fears of animals and insects.
blood pressure are actually increasing.  These fears are common but become
 Runs in families more strongly than any phobic only if severe interference with
phobic disorder; people with this functioning occurs.
phobia inherit a strong vasovagal  People with snake or mice phobias are
response to blood, injury, or the unable to read magazines for fear of
possibility of an injection, all of which unexpectedly coming across a picture
cause a drop in blood pressure and a of one of these animals. There are many
tendency to faint. places that these people are unable to
 Onset: 9 years go, even if they want to very much,
such as to the country to visit someone.
 The fear experienced by people with developing social anxiety in the
animal phobias is different from an face of stressful experiences
ordinary mild revulsion.
 Onset: 7 years F. SELECTIVE MUTISM (SM)

D. SEPARATION ANXIETY DISORDER  A rare childhood disorder is

characterized by a lack of speech in
 Characterized by children’s unrealistic one or more settings in which speaking
and persistent worry that something will is socially expected.
happen to their parents or other  Driven by social anxiety, the failure to
important people in their life or that speak is not because of a lack of
something will happen to the children knowledge of speech or any physical
themselves that will separate them from difficulties, nor is it due to another
their parents. disorder in which speaking is rare or can
be impaired such as autism spectrum
E. SOCIAL ANXIETY DISORDER (SOCIAL disorder.
PHOBIA)  Speech in selective mutism commonly
occurs in some settings, such as home,
 More exaggerated shyness. but not others, such as home, but not
 Intense fear of social situations that they others, such as school, hence the term
avoid altogether or endure with great “selective”.
distress.  DIAGNOSIS:
 Excessive fear of negative evaluations o The lack of speech must occur for
from others, fear of being rejected, more than one month and cannot
humiliated, or embarrassed. be limited to the first month of
 Common forms: Stage Fright, speech school.
anxiety, dating fears o Children with SM also met the criteria
 Find excuses to decline social for SAD.
invitations.  Well-meaning parents enable this
 Relief from anxiety negatively reinforces behavior by being readily able to
escape behavior, escape prevents intervene and “do their talking for
learning how to cope with fear-evoking them”
situations.
 Severely impair a persons’ daily III. ETIOLOGY OF ANXIETY DISORDERS
functioning and quality of life.
 Often turn to tranquilizers or try to A. GENERALIZED ANXIETY DISORDERS
“medicate” with alcohol when 1. BIOLOGICAL PERSPECTIVE
preparing themselves for social
interactions.  Imbalance in GABA and
 Chronic, persistent disorder lasting Serotonin levels
about 16 years on average.  Increased activity of the amygdala
 First, receive help by the average age
of 27. 2. PSYCHODYNAMIC PERSPECTIVE
 DIATHESIS-STRESS MODEL:
o Strongly associated with the history  FREUD:
of childhood shyness o Free-floating anxiety because
o Shyness represents a predisposition people seem to carry it from
that makes a person vulnerable to situation to situation.
 o Represents the threatened leakage o Respiratory Alarm leads to physical
of unacceptable sexual or sensations associated with a panic
aggressive impulses or wishes into attack
conscious awareness.
 GAMMA-AMINOBUTYRIC ACID (GABA):
3. BEHAVIORAL PERSPECTIVE
o Inhibitory neurotransmitter
 Generalization of anxiety across o Tones down excessive activity in the
situations CNS, helps quell the body’s response to
 People concerned about broad life stress
themes are likely to experience o Inadequate actions:
apprehension or worry in a variety of o Neurons fire excessively and may
settings lead to seizures.
 Anxiety: connected with almost any o Heighten states of anxiety or nervous
environment or situation tension
o Low levels for people with Panic
4. COGNITIVE PERSPECTIVE Disorder

 Emphasizes the role of exaggerated or 2. COGNITIVE-BIOLOGICAL MODEL

distorted thoughts and beliefs
 Overly attentive to threatening cues in  Perception of bodily sensations as dire
the environment, perceiving danger threats triggers anxiety which is
and calamitous consequences at every accompanied by the activation of the
turn. sympathetic nervous system.
 Continually on the edge: nervous  The release of Epinephrine and
system responds to the perception of Norepinephrine intensify physical
threat or danger with the activation of sensations by inducing accelerated
the Sympathetic Nervous System. heart rate, rapid breathing and
sweating.
B. PANIC DISORDER  Catastrophic misattributions of bodily
sensations: reinforce perceptions of
1. BIOLOGICAL FACTORS
threats, intensify anxiety leading to
more anxiety-related bodily symptoms.
 Genetic predisposition
 Changes in bodily sensations may be
 LIMBIC SYSTEM AND FRONTAL LOBES:
the result of hyperventilation, exertion,
Sensitivity of internal alarm system
changes in temperature, or reactions to
associated with response to threats or
certain drugs or medications.
danger.
3. COGNITIVE FACTORS
 SUFFOCATION FALSE ALARM THEORY
o Donald Klein (1994)
 ANXIETY SENSITIVITY (AS): FEAR OF FEAR
o Defect in the brain’s respiratory
ITSELF
alarm system triggers a false alarm in
o Fear of one’s emotions and bodily
response to minor cues of
sensations getting out of control
suffocation
o High AS: experience bodily
o Reduced levels of CO2 in the blood
sensations of anxiety; avoid
leading to hyperventilation
situations in which they have
produces sensations of suffocation
experienced anxiety in the past.
 o Catastrophic thoughts intensify 3. BEHAVIORAL PERSPECTIVE: TWO-FACTOR
anxiety reactions MODEL (O. HOBART MOWRER)
o Influenced by genetic factors and
environmental factors.  Role of both classical conditioning and
operant conditioning in the
c. SPECIFIC PHOBIA, AGORAPHOBIA, & development of phobias
SOCIAL ANXIETY DISORDER (SOCIAL  CLASSICAL CONDITIONING: Fear
PHOBIA) component of phobias
o Neutral objects and situations gain
1. BIOLOGICAL PERSPECTIVE the capacity to evoke fear by being
paired to aversive or noxious stimuli
 Genetic predisposition
 NEGATIVE REINFORCEMENT: Avoidance
 OVERACTIVATION OF THE AMYGDALA
of fearful stimuli produces relief that
o Amygdala: brain’s emotional
strengthens the response
computer.
o Avoidance may persist for years,
o Induce fear in response to mildly
even a lifetime
threatening situations or
 FEAR CAN BE WEAKENED OR
environmental cues.
ELIMINATED:
o Observed in social phobia & PTSD.
o EXTINCTION: weakening of
conditioned response when the
 PREPARED CONDITIONING: Evolution
conditioned stimulus is repeatedly
favored the survival of human ancestors
presented in the absence of an
who were genetically predisposed to
unconditioned stimulus.
develop fears of potentially threatening
objects.
 OBSERVATIONAL LEARNING: Observing
parents or significant others model a
2. PSYCHODYNAMIC PERSPECTIVE
fearful reaction to a stimulus could lead
to the acquisition of a fearful response
 ANXIETY: Danger signals that
threatening impulses of a sexual or
4. COGNITIVE PERSPECTIVE
aggressive nature are nearing the level
of awareness. ➢ OVERSENSITIVITY TO THREATENING CUES:

 PROJECTION:  An acutely sensitive internal alarm that

led people with specific phobias to
o A phobic reaction is a projection of the become overly sensitive to threatening
person’s own threatening impulses onto cues.
the phobic object.  High alert for threatening objects or
o Fear of knives: projection of destructive stimuli.
impulses towards the phobic object.
o ACROPHOBIA: harbor unconscious ➢ OVERPREDICTION OF DANGER:
wishes to jump that are controlled by
avoiding heights.  Exaggeration of fear or anxiety that
they will experience in the fearful
situation.
 Expecting the worst encourages the
avoidance of feared situations.
 With repeated exposure, people with
anxiety disorders may come to
 anticipate their responses to fear- b. ANTIANXIETY DRUGS (ANXIOLYTICS)
inducing stimuli more accurately
leading to a reduction of fear  Benzodiazepine (Valium, Xanax)
expectancies.  Increase sensitivity of GABA receptors
 Enhance calming effect of GABA
➢ SELF-DEFEATING THOUGHTS AND
IRRATIONAL BELIEFS: 2. COGNITIVE-BEHAVIORAL THERAPY

 Self-defeating thoughts heighten and  Coping skills development for handling

perpetuate anxiety and phobic panic attacks
disorders.  Breathing retraining: resorting to normal
 Thoughts like “I’ve got to get out of levels of CO2 in the body through
here” or “My heart’s going to leap out diaphragmatic breathing
of my chest”.  Relaxation training to reduce states of
o Intensify autonomic arousal heightened bodily arousal
o Prompt avoidance behavior  Exposure to situations linked to panic
o Decrease self-efficacy tendencies attacks and bodily cues associated
 Self-defeating thoughts may inhibit with panicky symptoms
social participation.  Replace catastrophic thoughts
with SELF STATEMENTS:
IV. TREATMENT AND INTERVENTION o “I am having a heart attack.” →
“Calm down, these feelings will
A. GENERALIZED ANXIETY DISORDER pass.”
1. ANTIDEPRESSANTS  Longer lasting results as clients acquire
skills that they can use even after the
 Setraline & Paroxetine treatment program.
 Help relieve anxiety but may not be
helpful in curing the underlying C. SPECIFIC PHOBIA, AGORAPHOBIA, &
problem. SOCIAL ANXIETY DISORDER (SOCIAL
PHOBIA)
2. COGNITIVE-BEHAVIORAL THERAPY
1. BIOLOGICAL APPROACH
 Training in relaxation skills
 Antidepressants for Social Anxiety:
 Learning to substitute calming,
Setraline & Paroxetine
adaptive thoughts for intrusive and
worrisome thoughts. 2. COGNITIVE THERAPY
 Learning skills for de-catastrophizing.
 Seek to identify and correct
B. PANIC DISORDER dysfunctional or distorted beliefs
1. BIOLOGICAL APPROACH  Recognize the logical flaws in their
thinking and view situations rationally
a. ANTIDEPRESSANTS  Gather evidence to test their beliefs
which may lead them to alter beliefs
 Counter anxiety by normalizing they find are not grounded on reality
activities of Serotonin in the brain  Develop social skills to improve
 Tricyclics (Imipramine, Clomipramine) & interpersonal effectiveness and handle
SSRI (Paroxetine, Setraline) rejection
 COGNITIVE RESTRUCTURING: help clients c. FLOODING
pinpoint self-defeating thoughts and
generate rational alternatives they can  Form of exposure therapy in which the
use in coping with anxiety-provoking subjects are exposed to a high level of
situations fear-inducing stimuli either in
imagination or in real-life situations.
 RATIONAL EMOTIVE THERAPY (ALBERT  The person purposely engages in a
ELLIS): Eliminating exaggerated needs highly feared situation.
for social approval  Used in the treatment of various anxiety
disorders, including social anxiety and
3. BEHAVIORAL APPROACHES PTSD.
a. SYSTEMATIC DESENSITIZATION

 Joseph Wolpe (1958)

 A gradual process in which clients learn
to handle progressively disturbing stimuli
while they remain relaxed
 FEAR-STIMULUS HIERARCHY
o Arrangement of stimuli according to
their capacity to evoke anxiety
 Based on the assumption that phobias
are learned or conditioned responses
that can be unlearned by substituting
an incompatible response to anxiety in
situations that usually elicit anxiety.
 Creates a set of conditions that can
lead to the extinction of the fear
response by providing opportunities for
repeated exposure to phobic stimuli in
imagination without aversive
consequences
 Progressive muscle relaxation

b. GRADUAL EXPOSURE

 The stepwise approach in which phobic

individuals gradually confront the
object or situations they fear
 Lead to cognitive changes
 IMAGINAL EXPOSURE: Imagining oneself
in a fearful situation
 IN VIVO EXPOSURE: Actual encounters
with phobic stimuli in real life
 Goal: For the person to be able to
handle such a situation alone and
without discomfort or an urge to
escape.