D. "Let's set some guidelines and goals for your visit here."

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Reaction Formation

• unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion.



• reverting to an earlier, more primitive and childlike pattern of behavior that may or may not have been previously exhibited.



• first-line psychological defense against anxiety
• temporary or long-term exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness. 
• happens at an unconscious level.



• the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. 

• Aspects of the self and of others tend to alternate between opposite poles; for example, either good, loving, worthy, and nurturing, or bad, hateful, destructive, rejecting, and worthless.



• unconscious process of substituting mature, constructive, and socially acceptable activity for immature, destructive, and unacceptable impulses. 

• Often these impulses are sexual or aggressive.



• the conscious denial of a disturbing situation or feeling.



• when a person makes up for an act or communication
• most commonly seen in children


Anxiety Disorders

• Individuals with anxiety disorders use rigid, repetitive, and ineffective behaviors to try to control their anxiety. 

• Common element of such disorders → those affected experience a degree of anxiety so high that it interferes with personal, occupational, or social functioning.


Panic Disorder (PD) and Panic Attacks

• Panic attacks are the key feature of panic disorder (PD). 

• Panic attack → the sudden onset of extreme apprehension or fear, usually associated with feelings of impending doom. 
• The feelings of terror present during a panic attack are so severe that normal function is suspended, the perceptual field is severely limited, and misinterpretation of reality may occur.
• Severe personality disorganization is evident. 
• People experiencing panic attacks may believe they are losing their minds or having a heart attack.
• attacks are often accompanied by highly uncomfortable physical symptoms such as palpitations, chest pain, breathing difficulties, nausea, and feelings of choking, chills, and hot flashes. 
• Typically panic attacks come "out of the blue" (i.e., suddenly and not necessarily in response to stress), are extremely intense, last a matter of minutes, and then subside.


Panic Disorder with Agoraphobia

• combination of panic-attack symptoms and agoraphobia. 

• Agoraphobia → is intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available if a panic attack occurred 
• The feared places are avoided in an effort to control anxiety. 
• Avoidance behaviors can be debilitating and life constricting.



• persistent, irrational fear of a specific object, activity, or situation that leads to a desire for avoidance, or actual avoidance, of the object, activity, or situation 

• Specific phobias are characterized by the experience of high levels of anxiety or fear in response to specific objects or situations
• Characteristically, phobic individuals experience overwhelming and crippling anxiety when faced with the object or situation provoking the phobia. 
• Phobic people go to great lengths to avoid the feared object or situation. 
• A phobic person may not be able to think about or visualize the object or situation without becoming severely anxious. 
• The life of a phobic person becomes more restricted as activities are given up so the phobic object can be avoided. All too frequently, complications ensue when people try to decrease anxiety through self-medication with alcohol or drugs.

• Clinical names for common phobias:

Acrophobia → Heights
Agoraphobia → Open spaces
Astraphobia → Electrical storms
Claustrophobia → Closed spaces
Glossophobia → Talking
Hematophobia → Blood
Hydrophobia → Water
Monophobia → Being alone
Mysophobia → Germs or dirt
Nyctophobia → Darkness
Pyrophobia → Fire
Xenophobia → Strangers
Zoophobia → Animals


Social Phobia or Social Anxiety Disorder (SAD)

• characterized by severe anxiety or fear provoked by exposure to a social or a performance situation (e.g., fear of saying something that sounds foolish in public, not being able to answer questions in a classroom, eating in public, performing on stage). 

• Fear of public speaking is the most common social phobia.


Obsessive-Compulsive Disorder

• Obsessions: thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the mind. Obsessions often seem senseless to the individual who experiences them (ego-dystonic), and their presence causes severe anxiety.

• Compulsions: ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety. Performing the compulsive act temporarily reduces high levels of anxiety. Primary gain is achieved by compulsive rituals, but because the relief is only temporary, the compulsive act must be repeated again and again.
• Although obsessions and compulsions can exist independently of each other, they most often occur together. 
• Obsessive-compulsive behavior exists along a continuum. "Normal" individuals may experience mildly obsessive-compulsive behavior. Minor compulsions, such as touching a lucky charm, knocking on wood, and making the sign of the cross upon hearing disturbing news, are not harmful to the individual. Mild compulsions about timeliness, orderliness, and reliability are valued traits in U.S. society.
• At the pathological end of the continuum are obsessive-compulsive symptoms that typically involve issues of sexuality, violence, contamination, illness, or death. 
• Pathological obsessions or compulsions cause marked distress to individuals, who often feel humiliation and shame regarding these behaviors. The rituals are time consuming and interfere with normal routines, social activities, and relationships with others.
• Severe OCD consumes so much of the individual's mental processes that the performance of cognitive tasks may be impaired.


Generalized Anxiety Disorder (GAD)

• characterized by excessive anxiety or worry about numerous things, lasting for 6 months or longer 

• The individual with GAD also displays many of the following symptoms:
- Restlessness
- Fatigue
- Poor concentration
- Irritability
- Tension
- Sleep disturbance

• The individual's anxiety is out of proportion to the true impact of the event or situation about which the person is worried. 

• Sleep disturbance is common because the individual worries about the day's events and real or imagined mistakes, reviews past problems, and anticipates future difficulties. 
• Decision making is difficult, owing to poor concentration and dread of making a mistake.


Posttraumatic Stress Disorder (PTSD)

• characterized by persistent reexperiencing of a highly traumatic event that involved actual or threatened death or serious injury to self or others, to which the individual responded with intense fear, helplessness, or horror 

• PTSD may occur after any traumatic event that is outside the range of usual experience. 
• symptoms often begin within 3 months after the trauma, but a delay of months or years is not uncommon. 

The major features of PTSD are:

- Persistent reexperiencing of the trauma through recurrent intrusive recollections of the event, dreams about the event, and flashbacks— dissociative experiences during which the event is relived, and the person behaves as though he or she is experiencing the event at that time
- Persistent avoidance of stimuli associated with the trauma, causing the individual to avoid talking about the event or avoid activities, people, or places that arouse memories of the trauma
- Persistent numbing of general responsiveness, as evidenced by the individual's feeling detached or estranged from others, feeling empty inside, or feeling turned off to others
- Persistent symptoms of increased arousal, as evidenced by irritability, difficulty sleeping, difficulty concentrating, hypervigilance, or exaggerated startle response

Difficulty with interpersonal, social, or occupational relationships nearly always accompanies PTSD, and trust is a common issue of concern. 

• Child and spousal abuse may be associated with hypervigilance and irritability, and chemical abuse may begin as an attempt to self-medicate to relieve anxiety


Acute Stress Disorder

• occurs within 1 month after exposure to a highly traumatic event, such as those listed in the section on PTSD. 

• To be diagnosed with acute stress disorder, the individual must display at least three dissociative symptoms either during or after the traumatic event, including a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization (a sense of unreality related to the environment); depersonalization (experience of a sense of unreality or self-estrangement); or dissociative amnesia (loss of memory) 
• By definition, acute stress disorder resolves within 4 weeks.


Substance-Induced Anxiety Disorder

• characterized by symptoms of anxiety, panic attacks, obsessions, and compulsions that develop with the use of a substance or within a month of stopping use of the substance 

• For a diagnosis of substance-induced anxiety disorder, evidence of the use of a psychoactive substance (e.g., alcohol, cocaine, heroin, hallucinogens) must be obtained through the history, physical examination, or laboratory findings.


Anxiety Due to Medical Conditions

• In anxiety due to a medical condition, the individual's symptoms of anxiety are a direct physiological result of a medical condition, such as hyperthyroidism, pulmonary embolism, or cardiac dysrhythmias

• To determine whether the anxiety symptoms are due to a medical condition, a careful and comprehensive assessment of multiple factors is necessary. 
• Evidence must be present in the history, physical examination, or laboratory findings for a diagnosis of anxiety due to a medical condition.


Anxiety Disorder Not Otherwise Specified

• diagnosis used for disorders in which anxiety or phobic avoidance predominates but the symptoms do not meet full diagnostic criteria for a specific anxiety disorder.


Anxiety Disorders, Neurobiological Causes & Theories

• Certain anatomic pathways (the limbic system) provide the transmission structure for the electrical impulses that occur when anxiety-related responses are sent or received. Neurons release chemicals (neurotransmitters) that convey these messages. 
• The neurochemicals that regulate anxiety include epinephrine, norepinephrine, dopamine, serotonin, and gamma-aminobutyric acid (GABA).
• GABA benzodiazepine theory: Benzodiazepine receptors are linked to a receptor that inhibits the activity of the neurotransmitter GABA. The release of GABA slows neural transmission, which has a calming effect. Binding of benzodiazepine medications to benzodiazepine receptors facilitates the action of GABA. This theory proposes that abnormalities of the benzodiazepine receptors may lead to unregulated anxiety levels.
• Studies suggest that the stress response of the hypothalamus-pituitary-adrenal system is abnormal in patients with PTSD. Repeated trauma or stress not only alters the release of neurotransmitters but also changes the anatomy of the brain. Neuroimaging has demonstrated that the size of the right hippocampus is significantly reduced in combat veterans who suffer from PTSD.


Anxiety Disorders, Psychological Theories

• Psychodynamic theories about the development of anxiety disorders center on the idea that unconscious childhood conflicts are the basis for symptom development. 

• Sigmund Freud suggested that anxiety results from the threatened breakthrough of repressed ideas or emotions from the unconscious into consciousness. 
• Freud also suggested that ego defense mechanisms are used by the individual to keep anxiety at manageable levels. The use of defense mechanisms results in behavior that is not wholly adaptive because of its rigidity and repetitive nature.
• Harry Stack Sullivan (1953) believed that anxiety is linked to the emotional distress caused when early needs go unmet or disapproval is experienced (interpersonal theory). 
• Also suggested that anxiety is "contagious," being transmitted to the infant from the mother or caregiver. Thus the anxiety experienced early in life becomes the prototype for anxiety experienced when unpleasant events occur later in life.


Anxiety Disorders, Behavioral Theories

• suggest that anxiety is a learned response to specific environmental stimuli (classical conditioning). 

• The social learning model suggests that anxiety is learned through the modeling of parents or peers.
• Such individuals can unlearn this behavior by observing others who react normally to a storm by lighting candles and telling stories.


Anxiety Disorders, Cognitive Theories

• anxiety disorders are caused by distortions in an individual's thoughts and perceptions. 

• Because individuals with such distortions may believe that any mistake will have catastrophic results, they experience acute anxiety.


Anxiety Disorders, Cultural Considerations

• sociocultural variation in symptoms of anxiety disorders has been noted. 

• n some cultures, individuals express anxiety through somatic symptoms, whereas in other cultures, cognitive symptoms predominate. 
• Panic attacks in Latin Americans and Northern Europeans often involve sensations of choking, smothering, numbness, or tingling, as well as fear of dying.
In other cultural groups, panic attacks involve fear of magic or witchcraft. 
• Social phobias in Japanese and Korean cultures may relate to beliefs that the individual's blushing, eye contact, or body odor is offensive to others.


Anxiety Disorders, Cultural Considerations (Ataque de Nervios)

• primarily experienced by people from Hispanic cultures. 

• culture-bound syndrome
• in English, "attack of the nerves." 
• This a disorder found primarily among Hispanic populations in response to stressful events, such as a death, acute family discord, or witnessing an accident.
• Symptoms are dramatic, and people afflicted by ataque de nervios exhibit sudden trembling, faintness, palpitations, out-of-control shouting, heat that moves from the chest to head, and seizure-like activities. 
• After the episode, the affected individual often has little memory of it. 
• This disorder is more common in socially disadvantaged females with less than a high school education.
• unlike people who have panic attacks, people with this disorder are responding to a precipitating event, and they do not typically experience fear or apprehension prior to the attack.


Hamilton Rating Scale for Anxiety

• popular tool in measuring anxiety 

• High scores may indicate GAD or PD, although it is important to note that high anxiety scores may also be a symptom of major depressive disorder.
• intended for use by experienced clinicians as a guide for planning care and not as a method of self-diagnosis.
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