Lecture: Panic, Anxiety and their Disorders Class Participation

READING: CHAPTER 6 Fernandez’s “Rotten Teeth” and “House of Horrors “ pgs 168-172.

Additional Readings:

Sims’s Chapter 19 (Links to an external site.) (Links to an external site.)


Keeping you on track:

1. Take Test 1 if you have not done so yet.

2. Read Chapter 6 from Textbook.

3. Read Sims’s Chapter 19 and Fernandez’s “Rotten Teeth” (included below) and “House of Horrors “ pgs 168-172 ( a very interesting case of OCD).

4. Write your reaction (Class Participation)


I have been very impressed by your postings and I want to thank you all for excellent class participation. I appreciate your kind words and I am glad this class has been especially useful for so many of you.

I hope I could continue to inspire you and encourage you to engage and love this field, or any field you should choose for your life’s work. A few months ago, a former student sent me a link to an interview she had had in a TV news show. She had a remarkable post-college career and they had interviewed her. In it, she described how a college professor had inspired her to overcome her own fears (she had been very anxious and phobic) and motivated her to become the person she had become. In her e-mail to me, she said I had been that professor. I was grateful she did not mention my name; I do not like the spotlight at all, BUT I was deeply thankful she remembered me. If whatever you learn in this class is helpful to you, not only as information learned, but as life experience, share it, pass it on, and help others along the way. That would be my greatest joy 😊

I am always impressed by the optimism and enthusiasm expressed on those postings, and I am hoping this spirit can be maintained through the end of the semester as well your careers in college. You will get out of your scholarly experience what you put in, as you will in life as well. Hang in here do your work and you will be very successful.

OK, back to our class! I do not want to continue without briefly note the “pearls of wisdom” from the previous section of the course:

1. In terms of assessment I think is clear we need to focus in understanding our patient, and not just placing a “label”, a diagnosis, and then thinking we are done; we are not!

2. We need to be competent and well-versed in Psychopathology, and the typical pathological manifestations a patient may exhibit. As I mentioned before, patients come to you with complicated pictures and will take a while to clear through all that confusion. Patience, knowledge, clinical experience, listening with your “intuitive ear” and other tools such as Psychological Testing will help you in that process.

3. Stress-related disorders are serious, do not play them down, either in your life or that of your patients. As a clinician you have a responsibility to take care of yourself ; in other words, you need to learn to effectively manage your life and your stress. Ultimately, the patients will hear your “actions” louder than any nice words you may speak. Develop good habits, as they will become your character and character is destiny!

This week’s topic is very interesting. Anxiety as a human emotion is ubiquitous. It is a normal reaction to stress and existentialist writers have pointed out that is a feature essential to our experience as humans.

Anxiety has been described in terms of state anxiety (I am fearful or anxious now) or its opposite Trait anxiety (I am always anxious) . Anxiety has also been seen as Physiological anxiety which symptoms include palpitations, difficulties breathing, dry mouth, etc; and Psychological or Psychic anxiety with typical symptoms such as feelings of dread, anxious anticipation, worries, etc. Finally, some have argued, that there is a “normal” everyday anxiety, which Existentialists have termed “Existential Angst”. We are not going to discuss it in any great detail, bit I want you to be aware of it. The DSM5 as well as the ICD 10 classify different clinical presentations or disorders in which anxiety is the primary Mood state” of the individual. I hope you find this chapter interesting and illuminating.

As I read your reactions to my case stories, I see many of you have interest in children and I want to comment a little on anxiety in children.

Children have “normally” diverse fears and anxieties; at the point when those fears begin to affect the child’s life (or the parent’s) we begin to see those as abnormal and then we want to treat them.

The causes of anxiety in children are multiple, and in some ways, different from adults. From the perspective of a practicing clinician, I see the child’s world (and his sense of self/Ego) as still fragile and much more vulnerable to events in the world that he/she cannot control. As adults, we manage anxiety by “containing it” incorporating it into our schemas of the world and ourselves. Nevertheless, that ability presupposes an integrated Ego and a firm grip of reality. For example, if I am sleeping in a dark room and I hear a noise, I may attribute it to the wind (natural causes) and I may get up or not to check it out, but generally, I will not fear it. On the other hand, a child may attribute the noises to imaginary, uncontrollable and perhaps malicious sources (monsters, etc) and greatly fear it. If the child’s life is unstable (ie; parents breaking up, abuse, etc), he or she may project many of the “inner fears” into the world out there. In other words, their fears may reflect the inner instability they feel “inside”.

Recently I had a little kiddo who was referred to me by his Pediatrician for nighttime fears and seeing monsters in his room. Parents were having some marital issues, which was not helping the situation at all. I told the parents they needed to increase their child’s sense of security and it would take various actions to do so. They moved the child from an upstairs room to a room (which was Dad’s office) closer to their bedroom. Then they started a nighttime routine consisting in reading pleasant stories (if parents are religious I would ask them to pray with the child), then do a short relaxation with suggestions such as “you will sleep comfortably and without fears”, “dad and Mom love you” etc. Finally, I suggested a night-light as it is also helpful in most cases. Above all, I told them they can’t fight in front of the children as they have their own interpretation of what that means and the child’s may feel that the whole world may be collapsing on them. Eventually,  he responded well, with full night sleep and significantly less reporting of fears. There is more to this story, but I am compressing it in order to illustrate a point; children are not miniature adults and to understand their anxiety we must grasp their understanding of reality.

OK, I hope you enjoy this chapter. In the new version of the DSM5, there are a new reordering of the disorders which were grouped under anxiety disorders. In the DSM5 the anxiety disorders are as follow:

Separation Anxiety Disorder

Selective Mutism

Specific Phobia

Social Anxiety Disorder

Panic Disorder


Generalized Anxiety Disorder

Substance-Medication induced Anxiety Disorder

Other Specified anxiety Disorder

Other unspecified Anxiety Disorder



You may notice that Obsessive Compulsive Disorder (OCD) is not listed. In the DSM5 OCD is under Obsessive Disorders and Related Disorders, a new category, and PTSD is under Trauma and Stressor Related Disorders. In your book OCD is listed under that category because it makes sense to do so. I must note however, that both of those disorders exhibit significant anxiety, and up until the DSM5 were included in the Anxiety Disorders category.


I am including on this posting another brief case history of a young woman that I treated a few years back for a severe case of dental phobia. From Tales from the Couch, read the other story I included (House of Horrors): it is a very interesting OCD story.


I hope you find it useful, and yes, I EXPECT your reactions.

Thank you!


Rotten Teeth


My good friend at the Family Practice clinic talked to me over lunch regarding a patient he had seen in the clinic. She was a young German woman, married to an American Servicemen with a very severe phobia of the dentist, so much so that she would not even call to make an appointment for her children or take them to see the Dentist. The problem was her teeth were so bad, my friend referred to them as “rotten teeth”. He was wondering if I could help her to overcome her fear so she could save her teeth. He had spoken to her and she had agreed to see the shrink, but believed her case was beyond help.

When we finally met, she was very pleasant and engaging. She described her fears of the dentist and the reason why. She had grown up in East Germany, and through early childhood she had had dental work done, often without anesthetic. This is unbelievable, unless you were raised in a Communist Country, as I did. I told her I too had dental work done and in a couple of occasions they drilled my teeth without anesthetic (because it was not available). I shared with her I still felt uncomfortable going to the dentist and the sound of the drill was upsetting, but I had learned to overcome my anxiety and focus on the blessing of knowing we do now have anesthetic, and with that I have pushed forward.

In every other respect, she was a very capable woman, and very intelligent. Typical of many Europeans, she spoke several languages and had started to get a degree at an American University. I explained to her the typical process of acquiring the fear response and the method of facing it, using a very simple method of relaxation, systematic desensitization, and exposure. Ultimately, I said, we only overcome our fears by facing them.

We started our treatment program and she progressed exceedingly well. We joked about life in the “workers’ paradise” and were happy to share childhood stories.

She was now ready for the exposure portion, but this was going to be a “role-play” exposure using the Dentist office, wearing the Dentist scrubs, starting the drill, etc. The Chief of the Dental Clinic was also a friend and he provided me with the resources to do this. I was going to dress with scrubs and a mask, my Psych Tech was going to be my assistant, and we were going to use one of the available rooms with a Dentist chair. My friend showed me how to run the drill, the water spout, etc. The set-up of this particular clinic was such that the rooms had three walls with one remaining side opening towards a hallway, only separated from the hallway by a curtain.

The day in question, our patient came in and we set her up in the chair while we made arrangements for the “procedure”. The curtain was not pulled, so as to make the patient a little more comfortable. As we initiated our session, and I began to talk to the patient telling her what I was going to do, and started the drill, another dentist, who had no knowledge of our exposure treatment, walked by our room and stopped for a second looking in our direction. He had found the procedure of not having the curtain drawn uncomfortable and he was about to speak when his face turned pale by surprise as he recognized me behind my mask. I burst out laughing and pulled the mask down, stopped the drill and told him we were just treating a case of dental phobia. My patient actually found the whole confusion very funny and her laughter relaxed her even more. The very same day, they had arranged for the first real procedure, which was successful.

We had just one more session in my office and she brought two “Certificates of Appreciation” one for me and one for the Tech, thanking us for the “magic” of her cure. To this date I have it in my memory papers, and the German girl of rotten teeth, finally got a beautiful smile.

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