1. Manifestations of anxiety (p. 131) Anxiety is a fundamental human emotion that has an adaptive function. Anxiety disorders meet one of the following criteria: the anxiety is a major disturbance, the anxiety is manifested only in a particular situation, or anxiety results from attempts to master other symptoms. Anxiety is manifested cognitively, behaviorally, and somatically. Cognitive symptoms range from mild worry to panic; behaviors include avoidance of feared situations; somatic signs include shallow breathing, perspiring, and muscular tension. In the current diagnostic system, anxiety disorders consist of panic disorder, generalized anxiety disorder (GAD), phobias, obsessive-compulsive disorder, and acute and posttraumatic stress disorders. In each of these disorders, a person can experience panic attacksintense fear with symptoms such as a pounding heart and fear of losing control. There are three types of attacks: (1) situationally bound (occurring in response to a stimulus); (2) situationally predisposed (usually occurring in response to a stimulus); and (3) unexpected attacks. Most attacks are of the first two types.
2. Panic disorder and generalized anxiety disorder (p. 134) Free-floating anxiety characterizes both panic disorder and generalized anxiety disorder. Panic disorder is diagnosed when a person has recurrent panic attacks that alternate with periods of low anxiety. Such attacks are terrifying and may lead to agoraphobia. While attacks are fairly common, the disorder is not; the lifetime prevalence is about 3.5 percent. Generalized anxiety disorder is characterized by persistent anxiety, heart palpitations, tension, and restlessness, together lasting over six months. People with GAD worry over major and minor events and have more persistent but less severe physical symptoms than people with panic disorder. Estimated lifetime prevalence of GAD in the United States is 5 percent of the adult population, with females being twice as likely as males to receive this diagnosis.
   Psychoanalysts suggest that internal (sexual and aggressive) conflicts are expressed in outward anxiety. The effectiveness of defenses used determines whether the person develops panic disorder or generalized anxiety disorder. The cognitive-behavioral thinkers argue that catastrophic thoughts and overattention to internal signals maintain and inflate anxiety symptoms. Research in which subjects had marked increases in cardiovascular activity after focusing on negative thoughts supports this argument. The biological perspective focuses on neural structures and neurochemical responses to stressful stimuli and notes that such factors as oxygen-monitoring receptors and response to sodium lactate influence panic attacks. Dysfunction in the locus ceruleus, a part of the central anxiety system in the brain, may account for panic disorders. Genetics also seem to play a role, particularly in panic disorder.
3. Treatment of panic disorder and generalized anxiety disorder (p. 140) Medications, particularly the antidepressants, have proven useful in treating panic disorder, although relapse rates after ceasing the drugs is high. Benzodiazepines (Valium and Librium) have been used successfully to treat generalized anxiety disorder, but psychological treatment is also necessary. Behavior therapies, including relaxation training and cognitive restructuring, show promise. Treatment for panic disorder can include educating the client about the disorder, training in relaxation techniques, altering unrealistic thoughts, facing the, symptoms, and developing coping strategies. Cognitive-behavioral therapy seems particularly effective for generalized anxiety disorder.
4. Phobias: Agoraphobia, social phobias, and specific phobias (p. 142) A phobia is an intense, persistent, and unwarranted fear of an object or situation. Attempts to avoid the fear-inducing situation interfere with the persons life. Phobias are the most common mental disorder in the United States. Agoraphobia is a fear of being in public places without the availability of help. It is twice as common for females as for males. The disorder often has a precipitating event, and thoughts play a key role. People with agoraphobia tend to react more intensely to anxiety symptoms than people with other anxiety problems. Social phobia is an intense fear of being watched and humiliated. There are three types of social phobias: performance (involving such activities as public speaking), limited interactional (involving such interactions as going out on a date), and generalized (where extreme anxiety occurs in most social situations). The last category has been criticized for being too similar to avoidant personality disorder. Except for public speaking, social phobias are somewhat rare. Despite knowing that their fears are irrational, people with social phobias curtail many activities. Social phobias appear to be common in families who use shame as a method of control and who stress the importance of other peoples opinions. Specific phobias are fears of specific objects and include a long list of disorders. In DSM-IV-TR there are five types: animal, natural environmental (for example, thunder); blood/injections or injury; situational (for example, heights); and other (a range of situations that may lead to choking or illness). Common phobias involve fear of public speaking, speaking to strangers, animals, and heights. They are twice as prevalent in women as in men and are rarely incapacitating.
5. Etiology and treatemnt of phobias (p. 147) Psychoanalysts see phobias as symbolic of unconscious sexual or aggressive conflicts. The case of little Hans is used to explain a youths fear of horses. Classical conditioning explains the development of some phobias. Observational learning and operant conditioning principles may explain some phobias. Retrospective reports indicate that conditioning experiences play a major causative role. However, research suggests other cause factors as well. Catastrophic thoughts and distorted cognitions may cause strong fears to develop and phobic individuals are more likely than other people to overestimate the odds of unpleasant events occurring, supporting a cognitive-behavioral perspective. Genetic evidence indicates that phobias may stem from a predisposition to excessive autonomic reaction to stress, but genetic vulnerability has only a modest relationship to specific phobias. The notion of prepared learning is also related to the existence of certain phobias and the nonexistence of others.
   Biochemical treatment of the phobias usually involves antidepressants, although SSRIs have also been used to treat social phobias. Behavioral treatment includes exposure therapy (the gradual presentation of the feared situation), which has been helpful in reducing fears and panic attacks in agoraphobic individuals and those with specific phobias; cognitive strategies aimed at changing unrealistic thoughts; systematic desensitization; modeling; and a new technique, virtual reality therapy, which uses computer generated three-dimensional images that simulate a realistic, feared setting. A combined approach that includes cognitive, behavioral, and biological components is increasingly being used.
6. Obsessive-compulsive disorder (p. 153) Obsessive-compulsive disorder is an anxiety disorder characterized by intrusive thoughts (obsessions) and the need to perform ritualistic actions (compulsions). The symptoms are ego-dystonicthey are involuntary and are perceived as alien. Once thought to be rare., obsessive-compulsive disorder has an estimated lifetime prevalence of approximately 2.5 percent. Common obsessions among adults involve bodily wastes, dirt or germs, and environmental contamination. Many normal individuals have obsessions, but those with obsessive-compulsive disorder report thoughts that last longer, produce more discomfort, and cannot be easily controlled. Compulsions are behaviors that are designed to reduce anxiety but that cause distress if not performed correctly. To the compulsive, these actions have the magical ability to ward off danger.
7. Etiology and treatment of obsessive-compulsive disorder (p. 156) The causes of obsessive-compulsive disorder are unclear. One theory, favored by psychoanalysts, suggests that obsessions substitute for unconscious conflicts and that compulsions are based in defense mechanisms such as undoing and reaction formation. The behavioral perspective emphasizes the anxiety-reducing functions of compulsions. Biological models emphasize differences in brain function, genetic vulnerability, and effects of medication on individuals with obsessive-compulsive disorder. Recent research shows that people with obsessive-compulsive disorder have higher levels of glucose metabolism in the frontal lobes.
   Antidepressant medication is the chief biological treatment for obsessive-compulsive disorder, but only 60 to 80 percent of obsessive-compulsives respond to these drugs, relief is only partial, and relapse is a problem. The most effective behavioral treatment has been a combination of exposure therapy and response prevention. Cognitive approaches identify and modify the irrational thoughts of obsessive-compulsives.
8. Acute and posttraumatic stress disorders (p. 161) Acute stress disorder (ASD) produces dissociation, a reliving of a traumatic experience, and avoidance of reminders of the experience. It lasts for more than two weeks and less than thirty days and occurs within four weeks of the stressful event. Posttraumatic stress disorder (PTSD) is an anxiety disorder, lasting thirty or more days, characterized by delayed reactions to extraordinarily distressing events. Symptoms include re-experiencing the event, intrusive memories and dreams, emotional numbing, and heightened autonomic arousal. Recent research suggests that some extreme stressors may produce PTSD in almost everyone. Although men are more likely to be exposed to stressors, women seem to be twice as likely to suffer from PTSD. Roughly 75 percent of women in one sample developed ASD after being raped, and three months later 35 percent met the criteria for PTSD. Classical conditioning, coping styles, and social support all seem to play a mediating role in developing this disorder. Preexisting anxiety disorder or a family history of anxiety occurs in many with PTSD. A range of treatments for PTSD exists. Extinction through prolonged exposure has helped many sufferers. A new treatment is called eye movement desensitization and reprocessing (EMDR), in which the individual visualizes the disturbing situation and then visually tracks back and forth the clinicians finger while keeping the head immobile. It is not clear how this treatment has its therapeutic effects and some studies are questioning its effectiveness. Biological interventions generally consist of antidepressants and SSRIs, although the associated side effects often result in discontinuation of their use.