Agoraphobia

    A disorder characterized by chronic (at least 6 months), unrealistic, and excessive anxiety and worry

 Panic disorder

   Purposeless activities that an individual performs repeatedly in an effort to decrease anxiety (hand washing); common in OCD

   Formerly called simple phobia; A marked, persistent, and excessive or un-reasonable fear when in the presence of, or when anticipating an encounter with, a specific object or situation

   A treatment for phobias in which the individual is taught to relax and then asked to imagine carious components of the phobic stimulus on a graded hierarchy, moving from that which produces the least fear to that which produces the most

     a sudden overwhelming feeling of terror or impending doom. This most severe form of emotional anxiety is usually accompanied by behavioral, cognitive, and physiological signs and symptoms considered to be outside the expected range of normalcy

    unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause marked anxiety or distress. The most common ones include repeated thoughts about contamination, repeated doubts, a need to have things in a particular order, aggressive or horrific impulses, and sexual imagery

    unwanted repetitive behavior patterns or mental acts (praying, counting, repeating words silently) that are intended to reduce anxiety, not to provide pleasure or gratification. They may be performed in response to an obsession or in a stereotyped fashion.

A disorder characterized by recurrent panic attacks, the onset of which is unpredictable, and manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom, and accompanied by intense physical discomfort

Characterized by the symptoms described for panic disorder; in addition; experiences of fear of being in places or situations from which escape might be difficult (or embarrassing) or in which help might not be available in the event that a panic attack should occur

A disorder characterized by chronic (at least 6 months), unrealistic, and excessive anxiety and worry

Etiology of Phobias:

Psychoanalytic theory

Freud believed that phobias develop when a child experiences normal incestuous feelings toward the opposite-sex parent and fears aggression from the same-sex parent. To protect themselves, these children repress this fear of hostility from the same-sex parent, and displace it onto something safer and more neutral, which becomes the phobic stimulus. The phobic stimulus becomes the symbol for the parent, but the child does not realize it.

Etiology of Phobias:

Learning Theory

“Unconditioned” response to fear; when the stressful stimulus is repeatedly paired with a harmless object, eventually the harmless object alone produces a “conditioned” response: fear. This becomes a phobia when the individual consciously avoids the harmful object to escape fear.

Etiology of Phobias

Cognitive theory

Anxiety is the product of faulty cognitions or anxiety-inducing self-instructions. Two types of faulty thinking have been investigated: negative self-statements and irrational beliefs. Cognitive theorists believe that some individuals engage in negative and irrational thinking that produces anxiety reactions. The individual begins to seek out avoidance behaviors to prevent the anxiety reactions, and phobias result.

Etiology of Phobias

Biological aspects

   Temperament:  Children experience fears as a part of normal,development,  Common fears:   Infants- loud noises,

                                              Toddlers & Preschoolers- strangers, animals, darkness, and separation from parents or attachment figures,

                                              School age years- death and anxiety about school achievement,

                                                    Adolescents- social rejection and sexual anxieties,

      Innate fears represent a part of overall characteristics or tendencies one’s born with that influences how they respond though out life to specific situations,

   Innate fears can reach phobic intensity if reinforced by events in later life (ex:4 yr. old fears dogs, by 5 overcomes fear, at 19 being bit by a stray dog causes development of a dog phobia)

Etiology of Phobias

Life experiences

Certain early experiences may set stage for phobic reactions later in life

Specific phobias are symbolic of original anxiety-producing objects or situations that have been repressed (ex: kid locked in closet for punishment develops phobia for elevators or closed places)

Unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause marked anxiety or distress. The most common ones include repeated thoughts about contamination, repeated doubts, a need to have things in a particular order, aggressive or horrific impulses, and sexual imagery

     Unwanted repetitive behavior patterns or mental acts (praying, counting, repeating words silently) that are intended to reduce anxiety, not to provide pleasure or gratification. They may be performed in response to an obsession or in a stereotyped fashion.

Etiology of OCD

Pyschoanalytical Theory

Weak, underdeveloped egos; for any of a variety of reasons; unsatisfactory parent-child relationship, conditional love, or provisional gratification

views clients as having regressed to earlier developmental stages of infantile superego- the harsh, exacting, punitive characteristics that now reappear as part of the psychopathology

Regression to the pre-Oedipal analsadistic phase, combined with use of specific ego defense mechanism produces the clinical symptoms of obsessions and compulsions.

Etiology of OCD

   Learning Theory

Passive Avoidance: A condition response to a traumatic event that produces anxiety and discomfort and individual learns to prevent the anxiety and discomfort by avoiding the situation with which they associated.

Active Avoidance: Individual learns to engage in behaviors that provide relief from the anxiety and discomfort associated with the traumatic situation.

A traumatic event should mark the beginning of the OC behaviors; however; a significant number of cases the onset if gradual and clients relate it to problems to stress in general rather than one or more traumatic experience

Etiology of OCD

 Biological Aspect

Neurological disturbances may play role in pathogenesis and maintenance of OCD

Neutoanatomy

Various regions of brain abnormalities

Abnormal metabolic rates in basal ganglia and orbitalfrontal cortex

clomipramine

selective serotonin reuptake inhibitors (SSRI’s)

by blocking neuronal reuptake of serotonin thereby potentiating serotoninergic activity in the CNS

Post-Traumatic Stress Disorder (PTSD)

A syndrome of symptoms that develop following a psychologically distressing vent that is outside the range of usual human experiences (rape, war). The individual is unable to put the experience out of his or her mind, and has nightmares, flashbacks, and panic attacks.

 Post-Traumatic Stress Disorder

  Psychosocial Theory

  Seeks to explain why certain people exposed to massive trauma develop PTSD and others do not.

  Variables include characteristics that relate to 1-the traumatic experience, 2- the individual, and 3 the recovery treatment

 Post-Traumatic Stress Disorder

 Learning Theory

Views negative reinforcement as behavior that leads to reduction in aversive experience, thereby reinforcing and resulting in repetition of the behavior

Avoidance behaviors and psychic numbering in response to a trauma are mediated by negative reinforcement

Anger and aggression and drug and alcohol abuse are behavior patterns reinforced by capacity to reduce objectionable feelings

 Post-Traumatic Stress Disorder

Cognitive Theory

Takes into consideration the cognitive appraisal of event and focus on assumptions that an individual makes about the world

Epstein’s 3 fundamental beliefs that most people construct within a personal theory of reality

World is benevolent and a source of joy

Work is meaningful and controllable

The self is worthy (lovable, good, competent)

Individual is vulnerable to PTSD when functional beliefs are invalidated by trauma

 Post-Traumatic Stress Disorder

  Biological Aspect

Individuals who experienced previous trauma is more likely to develop symptoms after a stressful event

More likely to become exposed to future trauma bc they are inclined to reactivate old behaviors associated with the original trauma

Read Addiction to Trauma on Page 400 last paragraph starting at bio. Aspects

Psychopharmacology for  Post-Traumatic Stress Disorder

Antidepressant

SSRI- 1st line treatment bc of efficancy, tolerability, & safety ratings

-Paroxetine & Sertraline-

Tricyclic antidepressants- amitriptyline & imipramine

MAO inhibitors- phenelzine

Trazodone

Psychopharmacology for  Post-Traumatic Stress Disorder

Anxiolytics

Alprazolam- perscribed for its antidepressant & antipanic effects

Benzodiazepines- lack of studies

Buspirone- reduces symptoms; further trials needed

Psychopharmacology for  Post-Traumatic Stress Disorder

Antihypertensives

 Beta-Blocker propranolol 

&

 alpha-receptor agonist clonidine

alleviates some symptoms, reduces nightmares, intrusive recollections, hypervigilance, insomnia, startle responses, anygry outburst

Psychopharmacology for  Post-Traumatic Stress Disorder

Other Drugs

Cambamazepine, Valproic Acid, & Lithium Carbonate

alleviate symptoms of intrusive recollections, flashbacks, nightmares, impulsivity, irritability, and violent behaviors

-little + evidence concerning use of antipsychotics; should be reserved for short-term control of severe aggression and agitation

Antidepressants- SSRIs, Tricyclic antidepressants, MAO inhibitors, Trazodone

Anxiolytics- Alprazolam, benzodiazepines, buspirone

Antihypertensives- Beta-blocker propranolol, alpha 2-receptor agonist clonidine,

Others- Carbamazepine, Valporic Acid, Lithium Carbonate, Anytipsychotics (for short-term control of severe aggression and agitation)

Psychopharmacology for  OCD

Only Antidepressants

SSRIs Fluoxtine, Paroxetine, Sertraline, & Fluvoxamine

-doses in excess for depression required for OCD

-Side effects: sleep disturbances, headache, & restlessness

-Effects transient & less than triyclics

Tricyclic Antidepressant Clomipramine

-more selective  for serotonin reuptake

-efficacy well established

-adverse effects make it less desirable than SSRI's

Psychopharmacology for generalized anxiety disorders

Antiolytics

 Benzodiazepines:

Major Risks- physical dependence & tolerance which encourage abuse, should be tappered off due to life-threatening withdrawal symptoms

Buspirone (Buspar)

Disadvantage- 10-14 day delay in alleciating symptoms

Benifits- lack of dependence and tolerance  making it the drug of choice

SSRI's , Noradrenergic Agents (Propranolol & Clonidine) , & Barbiturates

Psychopharmacology for generalized anxiety disorders

Antidepressants

Tricyclics Imipramine & SSRI's

Paroxetine

Escitalopram

Venlafaxineextened release

Amygdala: fear; paricularly important in panic and phobic disorders

Hippocampus: associated with memory related to fear responses

Locus Ceruleus: arousal

Brain Stem: respitatory activation; heart rate

Hypothalamus: activation of stress response

Frontal Cortex: cognitice interpretations

Thalamus: intergration of sensory stimuli

Basal Ganglis: tremor

Antiolytic Agents

Benzodiazepines

 Actions & Side Effects

Action- Increase affinity of GABA-A receptor for GABA

Side Effects- Sedation, dizziness, weakness, ataxia, decreased motor performance, dependence, withdrawal

Antiolytic Agents

SSRIs

 Actions & Side Effects

Action- Block reuptake of serotonic into the presynaptic nerve terminal, increasing synaptic concentration of serotonin

Side Effects- Nausea, diarrhea, headache, insomnia, somnolence, sexual disfunction

Antiolytic Agents

Noradrenergic Agents

 Actions & Side Effects

(Propranolol & Clonidine)

Action-

Propranolol: blocks beta-adrenergic receptor activity

Clonidine: stimulates alpha-adrenergic receptors

Side Effects-

Propranolol: bradycardia, hypotencion, weakness, fatigue, importence, GI upset, bronchospasm

Clonidine: dry mouth, sedation, fatigue, hypotension

Antiolytic Agents

Barbiturates Agents

 Actions & Side Effects

Action- CNA depression; also produces effects in the hepatic and cardiovascular systems

Side Effects- Somnolence, agitation, confusion, ataxia, diaainess, bradycardia, hypotension, constipation

Antiolytic Agents

Buspirone Agents

 Actions & Side Effects

Action- Partial agonist of 5-HT1A receptor

Side Effect- Dizziness, drowsiness, dry mouth, headache, nercousness, nausea, insomnia

Psychonpharmacology for Panic Disorders

Anxiolytics

Alprazolam

Lorazepam

Clonazepam

Major Risks- dependency & tolerance which encourage abuse; withdrawal symptoms which can be life-threatening; should tapper off medication

Psychonpharmacology for Panic Disorders

Antidepressants

Tricyclics Clomipramine & imipramine

-Tricyclis used less bc of severe side effects & high doses required

SSRI's

-Paroxetine, Fluoxetine, & Sertraline

-Doses must be titrated slowly bc of sensitivity to overstimulation

Psychonpharmacology for Panic Disorders

Antihypertensive

Clonidine has limited usefulness in long-term treatment of paninc disorders bc of development of tolerance to its antianxiety affects

Antiolytics

Antidepressants

Antihypertensives (limited usefulness)

Anxiolytics

Antidepressants

ANtihypertensives

Agoraphobia w/o Hx of panic disorders

Social Phobia

Specific Phobia (animal, natural environment, blood-injection-injury, situational, and other types)

Psychopharmacology for Social Phobic Disorder

Anxiolytics

Benzodiazepines-

Alprazolam & Clonazepam  reduce symptoms

-Well tolerated & have rapid onset of action

-Potential for abuse & dependence (not 1st line of choice)

Psychopharmacology for Social Phobic Disorder

Antidepressants

Tricycline imipramine & monoamine oxidase (MAO) inhibitor Phenelzine

SSRI's-1st line treatment

- Paroxetine & Sertraline

Psychopharmacology for Social Phobic Disorder

Antihypertensives