Agoraphobia - Literally means “fear of the market”- Complication of panic disorder – person begins to fear and avoid places associated with the occurrence of panic attacks (open spaces, stores, malls, cars, elevators, etc.)- In severe cases, the person may become completely homebound- Panic with agoraphobia considerably more difficult to treat- Effective treatment for agoraphobia: graded exposure hierarchyExample graded exposure hierarchy (case study):Driving on interstate, rush hour, aloneDriving on interstate, 7pm, alone . .Driving on 23rd Street, aloneDriving on 23rd Street, with friend . .Driving around block, aloneDriving around block, with friend . .Backing down drivewaySitting in driver’s seat with engine runningSitting in driver’s seat with key in ignition, engine offSpecific Phobia: e.g., snakes, spiders, other animal, heights, water, blood, needles . . . 1) Marked and persistent fear (excessive) cued by presence or anticipation of specific object or situation2) Exposure consistently produces anxiety (possibly panic)3) Person recognizes fear excessive (otherwise psychosis)4) The feared situation is avoided5) The anxiety and/or avoidance causes impairment in functionSpecific Phobia Lifetime Prevalence = 12.5% (Natl Comorbidity Survey)Hypothesized causes of specific phobia:- Biological model: preparedness hypothesis, also genetic vulnerability- Psychodynamic model: phobic object is symbol of inner conflict- Behavioral model: classical conditioning- Cognitive: observational learning Treatments:- Exposure ~ 90% cure rate- No drug treatments even come close, not widely used- d-cycloserine: promotes formation of new memories, faster therapySocial Phobia- Two sub-types: performance-linked (e.g., public speaking) “social anxiety disorder” (pervasive social anx)- Estimated prevalence: 12% lifetime- Treatment: 1. cognitive-behavior therapy (CBT): 50-60% response (can get higher)2. Nardil (MAO inhibitor): 80% responseRisk of hypertensive crisis (aged foods like cheese, sausage, wine)Emsam (new MAO inhibitor patch)3. SSRI: 40-55% response4. beta-blocker: very effective for performance-linked sub-typeGeneralized Anxiety Disorder (GAD)- Diagnostic criterion: excessive worry for > 6 months- Other symptoms: restlessness, fatigue, insomnia, irritability, concentration difficulties, muscle tension . . .- 90% GAD patients have another Axis I diagnosis- Treatment:1. SSRI’s: average 30% reduction of symptoms2. Benzodiazepines: 30-50% reduction3. CBT: 40-50% reductionObsessive-Compulsive Disorder (OCD)- Obsession: recurrent intrusive thought, impulse, or image that causes anxiety and cannot be dismissed or put out of one’s mindCommon themes: aggression, contamination, religious/blasphemy, pathological doubt/loss, sexuality, symmetry- Compulsion: repetitive action (ritual) person feels compelled to do- For diagnosis: either obsessions or compulsions (both not required)- Lifetime Prevalence: ~2%- Moderate genetic loading for OCD (40-50% heritability)- Neurobiology: anterior cingulate (“error detection”) orbitofrontal cortex/basal ganglia (“attention fixation”)- Strep infection link (autoimmune response)- OCD Treatment: 1. Exposure & Ritual Prevention (Foa) – 86% success (largest study)2. Anafranil – 48% success3. SSRI ~ 40%