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Anxiety Disorder. Psychology case study.
Suddenly your heart is racing, palms are sweaty, stomach’schurning. Your muscles are tense and your senses alert. Yourmind is flooded with worries and fears that something bad willhappen. This is anxiety; and we have all had it. When faced witha threatening event such as a physical attack or a natural disaster,most people feel anxiety or fear. Our bodies give us a surge ofadrenaline and our instincts take over. This gives us the strengthwe need to get out of the situation and survive. Anxiety is ourbody’s response to stress and danger, but in today’s world mostof the ‘dangers’ we face day to day are not ones we can fight withour fists or run away from easily. These modern ‘dangers’ aremany and can be anything from a heavy work load at your jobto family conflicts, aggressive drivers or money troubles. Someanxiety from time to time is normal and healthy; it can helpmotivate us and help get us out of tough situations. But whenanxiety lasts for weeks or months, develops into a constant senseof dread or begins to affect your everyday life, you may have ananxiety disorder.Anxiety becomestroubling whenit lasts weeks ormonths, developsinto a constantsense of dread andbegins to affect youreveryday life.WHAT IS ANXIETY DISORDER ? Anxiety disorders are a group of mental disorders characterized by significant feelings of anxiety and fear. Anxiety is a worry about future events and fear is a reaction to current events. These feelings may cause physical symptoms, such as a fast heart rate and shakiness. There are a number of anxiety disorders: including generalized anxiety disorder, specific phobia, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and selective mutism. The disorder differs by what results in the symptoms. People often have more than one anxiety disorder.The cause of anxiety disorders is a combination of genetic and environmental factors. Risk factors include a history of child abuse, family history of mental disorders, and poverty. Anxiety disorders often occur with other mental disorders, particularly major depressive disorder, personality disorder, and substance use disorder. To be diagnosed symptoms typically need to be present for at least six months, be more than would be expected for the situation, and decrease functioning. Other problems that may result in similar symptoms including hyperthyroidism; heart disease; caffeine, alcohol, or cannabis use; and withdrawal from certain drugs, among others.Without treatment, anxiety disorders tend to remain. Treatment may include lifestyle changes, counselling, and medications. Counselling is typically with a type of cognitive behavioral therapy. Medications, such as antidepressants, benzodiazepines, or beta blockers, may improve symptoms.About 12% of people are affected by an anxiety disorder in a given year and between 5-30% are affected at some point in their life. They occur about twice as often in females as males, and generally begin before the age of 25. The most common are specific phobia which affects nearly 12% and social anxiety disorder which affects 10% at some point in their life. They affect those between the ages of 15 and 35 the most and become less common after the age of 55. Rates appear to be higher in the United States and Europe.Who does it affect?Anxiety is the most common type ofmental disorder affecting 12% of BC’spopulation, or one in eight people, inany given year. There are a number ofthings about who you are that can putyou at greater risk of developing ananxiety disorder:• Gender: Women are twice aslikely as men to be diagnosed withan anxiety disorder. There are anumber of reasons for this includingwomen’s hormonal changes,caregiving stress, and greatercomfort seeking help than men.• Age: Anxiety disorders most oftenappear in youth, with phobiasand OCD showing up in earlychildhood and panic disorders andsocial phobias in the teen years. Anestimated 6.5% of BC youth have ananxiety disorder.• Personality factors: Children whoare shy and worrisome are morelikely than other children to sufferfrom an anxiety disorder later in life.People who tend to be perfectionistsare also more prone to anxietydisorders.• Family history: Anxiety disordersrun in families. In addition topossible genetic influences, the role achild may play within their familiescan also be a factor in developing ananxiety disorder in the future.• Social factors: People with a lackof social support are more likely todevelop anxiety disorders.• Occupational risks: One kind ofanxiety disorder, post-traumaticstress, can be linked to people’sjobs. For example, emergencypersonnel and military personnelare at high risk.• Chronic illness: People who havechronic mental or physical illnessesoften worry about their illness, theirtreatments and the effect the illnesshas on their lives and the lives ofthose around them. This constantworry can sometimes lead to thedevelopment of an anxiety disorder. typesGeneralized anxiety disorder (GAD) is an anxiety disorder characterized by excessive, uncontrollable and often irrational worry, that is, apprehensive expectation about events or activities. This excessive worry often interferes with daily functioning, as individuals with GAD typically anticipate disaster, and are overly concerned about everyday matters such as health issues, money, death, family problems, friendship problems, interpersonal relationship problems, or work difficulties. Individuals may exhibit a variety of physical symptoms, including feeling tired, fidgeting, headaches, numbness in hands and feet, muscle tension, difficulty swallowing, upset stomach, vomiting, diarrhea, breathing difficulty, difficulty concentrating, trembling, irritability, sweating, restlessness, sleeping difficulties, hot flashes, rashes, and inability to fully control the anxiety. These symptoms must be consistent and ongoing, persisting at least six months, for a formal diagnosis of GAD.Standardized rating scales such as GAD-7 can be used to assess severity of GAD symptoms. GAD is the most common cause of disability in the workplace in the United States.In a given year, approximately two percent of American adults and European adults experience GAD. Globally about 4% are affected at some point in their life. GAD is seen in women twice as much as men. GAD is also common in individuals with a history of substance abuse and a family history of the disorder. Once GAD develops, it may become chronic, but can be managed or eliminated with proper treatment.CausesGeneticsSubstance-inducedDiagnosisDSM-5 criteria⦁ Too much anxiety or worry over more than six months. This is present most of the time in regards to many activities.⦁ Inability to manage these symptoms⦁ At least three of the following occur:Note: Only one item is required in children.RestlessnessTires easilyProblems concentratingIrritabilityMuscle tension.Problems with sleep⦁ Symptoms result in problems with functioning.⦁ Symptoms are not due to medications, drugs, other physical health problems⦁ Symptoms do not fit better with another psychiatric problem such as panic disorderSPECIFIC PHOBIAA specific phobia is any kind of anxiety disorder that amounts to an unreasonable or irrational fear related to exposure to specific objects or situations. As a result, the affected person tends to avoid contact with the objects or situations and, in severe cases, any mention or depiction of them. The fear can, in fact, be disabling to their daily lives.The fear or anxiety may be triggered both by the presence and the anticipation of the specific object or situation. A person who encounters that of which they are phobic will often show signs of fear or express discomfort. In some cases, it can result in a panic attack. In most adults, the person may logically know the fear is unreasonable but still find it difficult to control the anxiety. Thus, this condition may significantly impair the person's functioning and even physical health.Specific phobia affects up to 12% of people at some point in their life.Specific Phobia – DSM 5 CriteriaDiagnosisFear or anxiety about a specific object or situation (In children fear/anxiety can be expressed by crying, tantrums, freezing, or clinging)The phobic object or situation almost always provokes immediate fear or anxietyThe phobic object or situation is avoided or endured with intense fear or anxietyThe fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural contextThe fear, anxiety, or avoidance is persistent, typically lasting for 6 months or moreThe fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioningThe disturbance is not better explained by symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms; objects or situations related to obsessions; reminders of traumatic events; separation from home or attachment figures; or social situations.TreatmentCognitive behavioral therapy (CBT), a short term, skills-focused therapy that aims to help people diffuse unhelpful emotional responses by helping people consider them differently or change their behavior, is effective in treating specific phobias. Exposure therapy is a particularly effective form of CBT for specific phobias.PANIC DISORDERPanic disorder is an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something really bad is going to happen. The maximum degree of symptoms occurs within minutes. There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past.The cause of panic disorder is unknown. Panic disorder often runs in families. Risk factors include smoking, psychological stress, and a history of child abuse. Diagnosis involves ruling out other potential causes of anxiety including other mental disorders, medical conditions such as heart disease or hyperthyroidism, and drug use. Screening for the condition may be done using a questionnaire.Panic disorder is usually treated with counselling and medications. The type of counselling used is typically cognitive behavioral therapy (CBT) which is effective in more than half of people. Medications used include antidepressants and occasionally benzodiazepines or beta blockers. Following stopping treatment up to 30% of people have a recurrence.Panic disorder affects about 2.5% of people at some point in their life. It usually begins during adolescence or early adulthood but any age can be affected. It is less common in children and older people. Women are more often affected than men.Symptoms Sudden periods of intense fear, palpitations, sweating, shaking, shortness of breath, numbnessUsual onset Sudden and recurrentCauses UnknownRisk factors Family history, smoking, psychological stress, history of child abuseDiagnostic method Based on symptoms after ruling out other potential causesDifferential diagnosis Heart disease, hyperthyroidism, drug useTreatment Counselling, medicationsMedication Antidepressants, benzodiazepines beta blockersFrequency 2.5% of people at some pointSymptom inductions generally occur for one minute and may include:Intentional hyperventilation – creates lightheadedness, derealization, blurred vision, dizzinessSpinning in a chair – creates dizziness, disorientationStraw breathing – creates dyspnea, airway constrictionBreath holding – creates sensation of being out of breathRunning in place – creates increased heart rate, respiration, perspirationBody tensing – creates feelings of being tense and vigilantdignosisDSM-5 simplifies it into two very clear categories: expected and unexpected panic attacks.Expected panic attacks are those associated with a specific fear like that of flying. Unexpected panic attacks have no apparent trigger or cue, and may appear to occur out of the blue.According to DSM-5, a panic attack is characterized by four or more of the following symptoms:Palpitations, pounding heart, or accelerated heart rateSweatingTrembling or shakingSensations of shortness of breath or smotheringA feeling of chokingChest pain or discomfortNausea or abdominal distressFeeling dizzy, unsteady, lightheaded, or faintFeelings of unreality (derealization) or being detached from oneself (depersonalization)Fear of losing control or going crazyFear of dyingNumbness or tingling sensations (paresthesias)Chills or hot flushesThe presence of fewer than four of the above symptoms may be considered a limited-symptom panic attack.AGORAPHOBIAAgoraphobia is an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives the environment to be unsafe with no easy way to get away. These situations can include open spaces, public transit, shopping malls, or simply being outside their home. Being in these situations may result in a panic attack. The symptoms occur nearly every time the situation is encountered and last for more than six months. Those affected will go to great lengths to avoid these situations. In severe cases people may become completely unable to leave their homes due to the phobia.Agoraphobia is believed to be due to a combination of genetic and environmental factors. The condition often runs in families, and stressful or traumatic events such as the death of a parent or being attacked may be a trigger. In the DSM-5 agoraphobia is classified as a phobia along with specific phobias and social phobia. Other conditions that can produce similar symptoms include separation anxiety, posttraumatic stress disorder, and major depressive disorder. Those affected are at higher risk of depression and substance use disorder.Without treatment it is uncommon for agoraphobia to resolve. Treatment is typically with a type of counselling called cognitive behavioral therapy (CBT). CBT results in resolution for about half of people. Agoraphobia affects about 1.7% of adults. Women are affected about twice as often as men. The condition often begins in early adulthood and becomes less common in old age. It is rare in children. The term "agoraphobia" is from Greek ἀγορά, agorá, meaning a "public square" and -φοβία, -phobia, meaning "fear".Symptoms Anxiety in situations perceived to be unsafe, panic attacksComplications Depression, substance use disorderDuration > 6 monthsCauses Genetic and environmental factorsRisk factors Family history, stressful eventDifferential diagnosis Separation anxiety, posttraumatic stress disorder, major depressive disorderTreatment Cognitive behavioral therapyPrognosis Resolution in half with treatmentFrequency 1.7% of adultsSocial anxiety disorderSocial anxiety disorder (SAD; also known as social phobia) describes an intense fear and avoidance of negative public scrutiny, public embarrassment, humiliation, or social interaction. This fear can be specific to particular social situations (such as public speaking) or, more typically, is experienced in most (or all) social interactions. Social anxiety often manifests specific physical symptoms, including blushing, sweating, and difficulty speaking. As with all phobic disorders, those suffering from social anxiety often will attempt to avoid the source of their anxiety; in the case of social anxiety this is particularly problematic, and in severe cases can lead to complete social isolation.Social physique anxiety (SPA) is a subtype of social anxiety. It is concern over the evaluation of one's body by others. SPA is common among adolescents, especially females.Post-traumatic stress disorderPost-traumatic stress disorder (PTSD) was once an anxiety disorder (now moved to trauma- and stressor-related disorders in DSM-V) that results from a traumatic experience. Post-traumatic stress can result from an extreme situation, such as combat, natural disaster, rape, hostage situations, child abuse, bullying, or even a serious accident. It can also result from long-term (chronic) exposure to a severe stressor-- for example, soldiers who endure individual battles but cannot cope with continuous combat. Common symptoms include hypervigilance, flashbacks, avoidant behaviors, anxiety, anger and depression. In addition, individuals may experience sleep disturbances. There are a number of treatments that form the basis of the care plan for those suffering with PTSD. Such treatments include cognitive behavioral therapy (CBT), psychotherapy and support from family and friends.Posttraumatic stress disorder (PTSD) research began with Vietnam veterans, as well as natural and non natural disaster victims. Studies have found the degree of exposure to a disaster has been found to be the best predictor of PTSD.Separation anxiety disorderMain article: Separation anxiety disorderSeparation anxiety disorder (SepAD) is the feeling of excessive and inappropriate levels of anxiety over being separated from a person or place. Separation anxiety is a normal part of development in babies or children, and it is only when this feeling is excessive or inappropriate that it can be considered a disorder. Separation anxiety disorder affects roughly 7% of adults and 4% of children, but the childhood cases tend to be more severe; in some instances, even a brief separation can produce panic. Treating a child earlier may prevent problems. This may include training the parents and family on how to deal with it. Often, the parents will reinforce the anxiety because they do not know how to properly work through it with the child. In addition to parent training and family therapy, medication, such as SSRIs, can be used to treat separation anxiety.Situational anxietySituational anxiety is caused by new situations or changing events. It can also be caused by various events that make that particular individual uncomfortable. Its occurrence is very common. Often, an individual will experience panic attacks or extreme anxiety in specific situations. A situation that causes one individual to experience anxiety may not affect another individual at all. For example, some people become uneasy in crowds or tight spaces, so standing in a tightly packed line, say at the bank or a store register, may cause them to experience extreme anxiety, possibly a panic attack. Others, however, may experience anxiety when major changes in life occur, such as entering college, getting married, having children, etc.Obsessive–compulsive disorderObsessive–compulsive disorder (OCD) is not classified as an anxiety disorder by the DSM-5 but is by the ICD-10. It was previously classified as an anxiety disorder in the DSM-IV. It is a condition where the person has obsessions (distressing, persistent, and intrusive thoughts or images) and/or compulsions (urges to repeatedly perform specific acts or rituals), that are not caused by drugs or physical order, and which cause distress or social dysfunction. The compulsive rituals are personal rules followed to relieve the anxiety. OCD affects roughly 1-2% of adults (somewhat more women than men), and under 3% of children and adolescents.A person with OCD knows that the symptoms are unreasonable and struggles against both the thoughts and the behavior. Their symptoms could be related to external events they fear (such as their home burning down because they forget to turn off the stove) or worry that they will behave inappropriately.It is not certain why some people have OCD, but behavioral, cognitive, genetic, and neurobiological factors may be involved. Risk factors include family history, being single (although that may result from the disorder), and higher socioeconomic class or not being in paid employment. Of those with OCD about 20% of people will overcome it, and symptoms will at least reduce over time for most people (a further 50%).Symptoms Feel the need to check things repeatedly, perform certain routines repeatedly, have certain thoughts repeatedlyComplications Tics, anxiety disorder, suicideUsual onset Before 35 yearsCauses UnknownRisk factors Child abuse, stressDiagnostic method Based on the symptomsDifferential diagnosis Anxiety disorder, major depressive disorder, eating disorders, obsessive–compulsive personality disorderTreatment Counseling, selective serotonin reuptake inhibitors, tricyclic antidepressantsFrequency 2.3%Selective mutismMain article: Selective mutismSelective mutism (SM) is a disorder in which a person who is normally capable of speech does not speak in specific situations or to specific people. Selective mutism usually co-exists with shyness or social anxiety. People with selective mutism stay silent even when the consequences of their silence include shame, social ostracism or even punishment. Selective mutism affects about 0.8% of people at some point in their life.symptomsSelective mutism is by definition characterized by the following:Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations.The disturbance interferes with educational or occupational achievement or with social communication.The duration of the disturbance is at least 1 month (not limited to the first month of school).The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.The disturbance is not better accounted for by a communication disorder (e.g., childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.Shyness, social anxiety, fear of social embarrassment, and/or social isolation and withdrawalDifficulty maintaining eye contactBlank expression and reluctance to smileDifficulty expressing feelings, even to family membersTendency to worry more than most people of the same ageSensitivity to noise and crowdsOn the positive side, many people with this condition have:Above-average intelligence, perception, or inquisitivenessCreativity and a love for art or musicEmpathy and sensitivity to others' thoughts and feelingsA strong sense of right and wrong.Causes OF ANXIETY DISORDERDrugsAnxiety and depression can be caused by alcohol abuse, which in most cases improves with prolonged abstinence. Even moderate, sustained alcohol use may increase anxiety levels in some individuals. Caffeine, alcohol, and benzodiazepine dependence can worsen or cause anxiety and panic attacks. Anxiety commonly occurs during the acute withdrawal phase of alcohol and can persist for up to 2 years as part of a post-acute withdrawal syndrome, in about a quarter of people recovering from alcoholism. In one study in 1988–1990, illness in approximately half of patients attending mental health services at one British hospital psychiatric clinic, for conditions including anxiety disorders such as panic disorder or social phobia, was determined to be the result of alcohol or benzodiazepine dependence. In these patients, an initial increase in anxiety occurred during the withdrawal period followed by a cessation of their anxiety symptoms.There is evidence that chronic exposure to organic solvents in the work environment can be associated with anxiety disorders. Painting, varnishing and carpet-laying are some of the jobs in which significant exposure to organic solvents may occur.Taking caffeine may cause or worsen anxiety disorders, including panic disorder. Those with anxiety disorders can have high caffeine sensitivity. Caffeine-induced anxiety disorder is a subclass of the DSM-5 diagnosis of substance/medication-induced anxiety disorder. Substance/medication-induced anxiety disorder falls under the category of anxiety disorders, and not the category of substance-related and addictive disorders, even though the symptoms are due to the effects of a substance.Cannabis use is associated with anxiety disorders. However, the precise relationship between cannabis use and anxiety still needs to be established.Medical conditionsOccasionally, an anxiety disorder may be a side-effect of an underlying endocrine disease that causes nervous system hyperactivity, such as pheochromocytoma or hyperthyroidism.StressAnxiety disorders can arise in response to life stresses such as financial worries or chronic physical illness. Anxiety among adolescents and young adults is common due to the stresses of social interaction, evaluation, and body image. Anxiety is also common among older people who have dementia. On the other hand, anxiety disorder is sometimes misdiagnosed among older adults when doctors misinterpret symptoms of a physical ailment (for instance, racing heartbeat due to cardiac arrhythmia) as signs of anxiety.GeneticsGAD runs in families and is six times more common in the children of someone with the condition.While anxiety arose as an adaptation, in modern times it is almost always thought of negatively in the context of anxiety disorders. People with these disorders have highly sensitive systems; hence, their systems tend to overreact to seemingly harmless stimuli. Sometimes anxiety disorders occur in those who have had traumatic youths, demonstrating an increased prevalence of anxiety when it appears a child will have a difficult future. In these cases, the disorder arises as a way to predict that the individual’s environment will continue to pose threats.Persistence of anxietyAt a low level, anxiety is not a bad thing. In fact, the hormonal response to anxiety has evolved as a benefit, as it helps humans react to dangers. Researchers in evolutionary medicine believe this adaptation allows humans to realize there is a potential threat and to act accordingly in order to ensure greatest possibility of protection. It has actually been shown that those with low levels of anxiety have a greater risk of death than those with average levels. This is because the absence of fear can lead to injury or death. Additionally, patients with both anxiety and depression were found to have lower morbidity than those with depression alone. The functional significance of the symptoms associated with anxiety includes: greater alertness, quicker preparation for action, and reduced probability of missing threats. In the wild, vulnerable individuals, for example those who are hurt or pregnant, have a lower threshold for anxiety response, making them more alert. This demonstrates a lengthy evolutionary history of the anxiety response.Evolutionary mismatchIt has been theorized that high rates of anxiety are a reaction to how the social environment has changed from the Paleolithic era. For example, in the Stone Age there was greater skin-to-skin contact and more handling of babies by their mothers, both of which are strategies that reduce anxiety. Additionally, there is greater interaction with strangers in present times as opposed to interactions solely between close-knit tribes. Researchers posit that the lack of constant social interaction, especially in the formative years, is a driving cause of high rates of anxiety.Many current cases are likely to have resulted from an evolutionary mismatch, which has been specifically termed a "psychopathogical mismatch". In evolutionary terms, a mismatch occurs when an individual possesses traits that were adapted for an environment that differs from the individual’s current environment. For example, even though an anxiety reaction may have been evolved to help with life-threatening situations, for highly sensitized individuals in Westernized cultures simply hearing bad news can elicit a strong reaction.An evolutionary perspective may provide insight into alternatives to current clinical treatment methods for anxiety disorders. Simply knowing some anxiety is beneficial may alleviate some of the panic associated with mild conditions. Some researchers believe that, in theory, anxiety can be mediated by reducing a patient’s feeling of vulnerability and then changing their appraisal of the situation.MechanismsBiologicalLow levels of GABA, a neurotransmitter that reduces activity in the central nervous system, contribute to anxiety. A number of anxiolytics achieve their effect by modulating the GABA receptors.Selective serotonin reuptake inhibitors, the drugs most commonly used to treat depression, are frequently considered as a first line treatment for anxiety disorders.AmygdalaThe amygdala is central to the processing of fear and anxiety, and its function may be disrupted in anxiety disorders. Sensory information enters the amygdala through the nuclei of the basolateral complex (consisting of lateral, basal, and accessory basal nuclei). The basolateral complex processes sensory-related fear memories and communicates their threat importance to memory and sensory processing elsewhere in the brain, such as the medial prefrontal cortex and sensory cortices.Another important area is the adjacent central nucleus of the amygdala, which controls species-specific fear responses, via connections to the brainstem, hypothalamus, and cerebellum areas. In those with general anxiety disorder, these connections functionally seem to be less distinct, with greater gray matter in the central nucleus. Another difference is that the amygdala areas have decreased connectivity with the insula and cingulate areas that control general stimulus salience, while having greater connectivity with the parietal cortex and prefrontal cortex circuits that underlie executive functions.The latter suggests a compensation strategy for dysfunctional amygdala processing of anxiety. Researchers have noted "Amygdalofrontoparietal coupling in generalized anxiety disorder patients may ... reflect the habitual engagement of a cognitive control system to regulate excessive anxiety." This is consistent with cognitive theories that suggest the use in this disorder of attempts to reduce the involvement of emotions with compensatory cognitive strategies.Clinical and animal studies suggest a correlation between anxiety disorders and difficulty in maintaining balance. A possible mechanism is malfunction in the parabrachial area, a brain structure that, among other functions, coordinates signals from the amygdala with input concerning balance.Anxiety processing in the basolateral amygdala has been implicated with dendritic arborization of the amygdaloid neurons. SK2 potassium channels mediate inhibitory influence on action potentials and reduce arborization. By overexpressing SK2 in the basolateral amygdala, anxiety in experimental animals can be reduced together with general levels of stress-induced corticosterone secretion.DiagnosisAnxiety disorders are often severe chronic conditions, which can be present from an early age or begin suddenly after a triggering event. They are prone to flare up at times of high stress and are frequently accompanied by physiological symptoms such as headache, sweating, muscle spasms, tachycardia, palpitations, and hypertension, which in some cases lead to fatigue.In casual discourse the words "anxiety" and "fear" are often used interchangeably; in clinical usage, they have distinct meanings: "anxiety" is defined as an unpleasant emotional state for which the cause is either not readily identified or perceived to be uncontrollable or unavoidable, whereas "fear" is an emotional and physiological response to a recognized external threat. The term "anxiety disorder" includes fears (phobias) as well as anxieties.[medical citation needed]The diagnosis of anxiety disorders is difficult because there are no objective biomarkers, it is based on symptoms, which typically need to be present at least six months, be more than would be expected for the situation, and decrease functioning. Several generic anxiety questionnaires can be used to detect anxiety symptoms, such as the State-Trait Anxiety Inventory (STAI), the Generalized Anxiety Disorder 7 (GAD-7), the Beck Anxiety Inventory (BAI), the Zung Self-Rating Anxiety Scale, and the Taylor Manifest Anxiety Scale. Other questionnaires combine anxiety and depression measurement, such as the Hamilton Anxiety Rating Scale, the Hospital Anxiety and Depression Scale (HADS), the Patient Health Questionnaire (PHQ), and the Patient-Reported Outcomes Measurement Information System (PROMIS). Examples of specific anxiety questionnaires include the Liebowitz Social Anxiety Scale (LSAS), the Social Interaction Anxiety Scale (SIAS), the Social Phobia Inventory (SPIN), the Social Phobia Scale (SPS), and the Social Anxiety Questionnaire (SAQ-A30).Anxiety disorders often occur along with other mental disorders, in particular depression, which may occur in as many as 60% of people with anxiety disorders. The fact that there is considerable overlap between symptoms of anxiety and depression, and that the same environmental triggers can provoke symptoms in either condition, may help to explain this high rate of comorbidity.Studies have also indicated that anxiety disorders are more likely among those with family history of anxiety disorders, especially certain types.Sexual dysfunction often accompanies anxiety disorders, although it is difficult to determine whether anxiety causes the sexual dysfunction or whether they arise from a common cause. The most common manifestations in individuals with anxiety disorder are avoidance of intercourse, premature ejaculation or erectile dysfunction among men and pain during intercourse among women. Sexual dysfunction is particularly common among people affected by panic disorder (who may fear that a panic attack will occur during sexual arousal) and posttraumatic stress disorder.TREATMENTIn general, anxiety disorders are treated with medication, specific types of psychotherapy, or both.Treatment choices depend on the problem and the person’s preference.People with anxiety disorders who have already received treatment should tell their current doctorabout that treatment in detail. If they received medication, they should tell their doctor whatmedication was used, what the dosage was at the beginning of treatment, whether the dosagewas increased or decreased while they were under treatment, what side effects occurred, andwhether the treatment helped them become less anxious. If they received psychotherapy, theyshould describe the type of therapy, how often they attended sessions, and whether the therapywas useful.Often people believe that they have “failed” at treatment or that the treatment didn’t work for themwhen, in fact, it was not given for an adequate length of time or was administered incorrectly.Sometimes people must try several different treatments or combinations of treatment before theyfind the one that works for them.MedicationMedication will not cure anxiety disorders, but it can keep them under control while the personreceives psychotherapy. Medication must be prescribed by physicians, usually psychiatrists, whocan either offer psychotherapy themselves or work as a team with psychologists, social workers,or counselors who provide psychotherapy. The principal medications used for anxiety disordersare antidepressants, antianxiety drugs, and betablockers to control some of the physicalsymptoms. With proper treatment, many people with anxiety disorders can lead normal, fulfillinglives.AntidepressantsAntidepressants were developed to treat depression but are also effective for anxiety disorders.Although these medications begin to alter brain chemistry after the very first dose, their full effectrequires a series of changes to occur; it is usually about 4 to 6 weeks before symptoms start tofade. It is important to continue taking these medications long enough to let them work.SSRIsSome of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs.SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like otherneurotransmitters, helps brain cells communicate with one another.12/2/2014 NIMH · Anxiety Disordershttp://www.nimh.nih.gov/health/topics/anxietydisorders/index.shtml 4/17Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), andcitalopram (Celexa®) are some of the SSRIs commonly prescribed for panic disorder, OCD,PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs incombination with OCD, social phobia, or depression. Venlafaxine (Effexor®), a drug closelyrelated to the SSRIs, is used to treat GAD. These medications are started at low doses andgradually increased until they have a beneficial effect.SSRIs have fewer side effects than older antidepressants, but they sometimes produce slightnausea or jitters when people first start to take them. These symptoms fade with time. Somepeople also experience sexual dysfunction with SSRIs, which may be helped by adjusting thedosage or switching to another SSRI.TricyclicsTricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD.They are also started at low doses that are gradually increased. They sometimes cause dizziness,drowsiness, dry mouth, and weight gain, which can usually be corrected by changing the dosageor switching to another tricyclic medication.Tricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, andclomipramine (Anafranil®), which is the only tricyclic antidep12/2/2014 NIMH · Anxiety Disordershttp://www.nimh.nih.gov/health/topics/anxietydisorders/index.shtml 5/17inadequate doses.Buspirone (Buspar®), an azapirone, is a newer antianxiety medication used to treat GAD.Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines,buspirone must be taken consistently for at least 2 weeks to achieve an antianxiety effect.BetaBlockersBetablockers, such as propranolol (Inderal®), which is used to treat heart conditions, can preventthe physical symptoms that accompany certain anxiety disorders, particularly social phobia. Whena feared situation can be predicted (such as giving a speech), a doctor may prescribe a betablockerto keep physical symptoms of anxiety under control.Taking MedicationsBefore taking medication for an anxiety disorder:Ask your doctor to tell you about the effects and side effects of the drug.Tell your doctor about any alternative therapies or overthecounter medications you areusing.Ask your doctor when and how the medication should be stopped. Some drugs can’t bestopped abruptly but must be tapered off slowly under a doctor’s supervision.Work with your doctor to determine which medication is right for you and what dosage isbest.Be aware that some medications are effective only if they are taken regularly and thatsymptoms may recur if the medication is stopped.PsychotherapyPsychotherapy involves talking with a trained mental health professional, such as a psychiatrist,psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how todeal with its symptoms.CognitiveBehavioral TherapyCognitivebehavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive parthelps people change the thinking patterns that support their fears, and the behavioral part helpspeople change the way they react to anxietyprovoking situations.For example, CBT can help people with panic disorder learn that their panic attacks are not reallyheart attacks and help people with social phobia learn how to overcome the belief that others arealways watching and judging them. When people are ready to confront their fears, they are shownhow to use exposure techniques to desensitize themselves to situations that trigger their anxieties.People with OCD who fear dirt and germs are encouraged to get their hands dirty and waitincreasing amounts of time before washing them. The therapist helps the person cope with theanxiety that waiting produces; after the exercise has been repeated a number of times, the anxietydiminishes. People with social phobia may be encouraged to spend time in feared social situationswithout giving in to the temptation to flee and to make small social blunders and observe howpeople respond to them. Since the response is usually far less harsh than the person fears, theseanxieties are lessened. People with PTSD may be supported through recalling their traumaticevent in a safe situation, which helps reduce the fear it produces. CBT therapists also teach deep12/2/2014 NIMH · Anxiety Disordershttp://www.nimh.nih.gov/health/topics/anxietydisorders/index.shtml 6/17breathing and other types of exercises to relieve anxiety and encourage relaxation.Exposurebased behavioral therapy has been used for many years to treat specific phobias. Theperson gradually encounters the object or situation that is feared, perhaps at first only throughpictures or tapes, then later facetoface. Often the therapist will accompany the person to afeared situation to provide support and guidance.CBT is undertaken when people decide they are ready for it and with their permission andcooperation. To be effective, the therapy must be directed at the person’s specific anxieties andmust be tailored to his or her needs. There are no side effects other than the discomfort oftemporarily increased anxiety.CBT or behavioral therapy often lasts about 12 weeks. It may be conducted individually or with agroup of people who have similar problems. Group therapy is particularly effective for socialphobia. Often “homework” is assigned for participants to complete between sessions. There issome evidence that the benefits of CBT last longer than those of medication for people with panicdisorder, and the same may be true for OCD, PTSD, and social phobia. If a disorder recurs at alater date, the same therapy can be used to treat it successfully a second time.Medication can be combined with psychotherapy for specific anxiety disorders, and this is the besttreatment approach for many people.Ways to Make Treatment More EffectiveMany people with anxiety disorders benefit from joining a selfhelp or support group and sharingtheir problems and achievements with others. Internet chat rooms can also be useful in thisregard, but any advice received over the Internet should be used with caution, as Internetacquaintances have usually never seen each other and false identities are common. Talking witha trusted friend or member of the clergy can also provide support, but it is not a substitute for carefrom a mental health professional.Stress management techniques and meditation can help people with anxiety disorders calmthemselves and may enhance the effects of therapy. There is preliminary evidence that aerobicexercise may have a calming effect. Since caffeine, certain illicit drugs, and even some overthecountercold medications can aggravate the symptoms of anxiety disorders, they should beavoided. Check with your physician or pharmacist before taking any additional medications.The family is very important in the recovery of a person with an anxiety disorder. Ideally, the familyshould be supportive but not help perpetuate their loved one’s symptoms. Family members shouldnot trivialize the disorder or demand improvement without treatment.DIET Foods That Help AnxietyThere are many foods that can aid in controlling anxiety levels. By adding or increasing these “foods that calm” to your diet, you can help manage your generalized anxiety disorder symptoms:Complex carbs (brown rice, *whole grain breads and pastas)*Seaweed and kelp is a good alternative for those who are gluten sensitiveProvide balanced serotonin levels: keeps you happy and calmSupply magnesium: a magnesium deficiency can contribute to anxietyPeaches, blueberries, acai berriesRich in vitamins, phytonutrients, and antioxidants: provide calming nutrientsVegetables and legumesStrengthen your immune systemHealthy fats such as those found in nuts and seedsContain zinc and iron to ward off brain fatigue and increase energyWaterCirculates anxiety-reducing hormones through your bodyDehydration can result in mood changesChocolate: pure, dark chocolate without milks and sugarsReduces the stress hormone, cortisol, and improves your moodB vitamins, zinc, magnesium, antioxidantsCertain herbs such as passionflower and kavaFoods to Avoid or MinimizeCertain foods might provide you with a boost of energy or give you a temporary sense of calm, but the effects wear off quickly and often leave you feeling worse:Simple carbs, high-glycemic carbs (white bread, white flour, cookies, cakes, anything with a high sugar content)Give you an energy boost, followed by a “crash” that can produce anxietyFast food, fried food, processed food, foods with a high salt contentMakes your body more acidic, leading to more anxietyAlcoholInitial sense of relaxation, but disrupts sleep patterns, leading to anxietyCaffeine, especially if you are prone to panic attacksSmall amounts can be soothing, but caffeine increases your heart rate, leading to nervousness and raising your anxiety levels.PASTE THE QUESTIONNAIRETHE GAD-7 score is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of 'not at all', 'several days', 'more than half the days', and 'nearly every day', respectively, and adding together the scores for the seven questions.Scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate and severe anxiety, respectively. When used as a screening tool, further evaluation is recommended when the score is 10 or greater.Using the threshold score of 10, the GAD-7 has a sensitivity of 89% and a specificity of 82% for GAD. It is moderately good at screening three other common anxiety disorders - panic disorder (sensitivity 74%, specificity 81%), social anxiety disorder (sensitivity 72%, specificity 80%) and post-traumatic stress disorder (sensitivity 66%, specificity 81%)
Basic Clinical Science
Studying is nothing without practice. Practice makes a man perfect. So there are ample of questions to be practiced to improve and test your preparation level. These questions are taken from various books and approved by our teachers. Will help to fetch you good marks in exam.