Post on 22-Dec-2015
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Anxiety DisordersAnxiety Disorders
Anxiety DisordersAnxiety Disorders
Panic AttackPanic Attack AgoraphobiaAgoraphobia Panic Disorder Panic Disorder
w/out w/out agoraphobiaagoraphobia
Agoraphobia Agoraphobia w/out hx of w/out hx of panic disorderpanic disorder
Specific PhobiaSpecific Phobia
Social PhobiaSocial Phobia OCDOCD PTSDPTSD Acute Stress DisorderAcute Stress Disorder GADGAD Anxiety due to Medical conditionAnxiety due to Medical condition Substance induced Substance induced Anxiety NOSAnxiety NOS
Anxiety due to a Medical Anxiety due to a Medical ConditionCondition Cardiopulmonary disordersCardiopulmonary disorders Hyperthyroidism-may include heat Hyperthyroidism-may include heat
intolerance and tremorintolerance and tremor Hypoglycemia- reduced by eating Hypoglycemia- reduced by eating
candycandy Alcohol ingestionAlcohol ingestion Caffeine overdoseCaffeine overdose Must cause distress or impaimentMust cause distress or impaiment Specify: with generalized anxiety, Specify: with generalized anxiety,
with panic attacks, or with oc with panic attacks, or with oc symptomssymptoms
Panic Attack- not a diagnosis, but Panic Attack- not a diagnosis, but specified with anxiety diagnosisspecified with anxiety diagnosis Four or more that develop abruptly and peak with in Four or more that develop abruptly and peak with in
10 minutes10 minutes Pounding, racing, palpitating heartPounding, racing, palpitating heart SweatingSweating Trembling, shakingTrembling, shaking Short of breath or smotheringShort of breath or smothering Feeling of chokingFeeling of choking Chest pain, discomfortChest pain, discomfort Nausea/abdominal stressNausea/abdominal stress Dizzy, lightheaded, faintDizzy, lightheaded, faint Derealization (detached from reality) or Derealization (detached from reality) or
depersonalization (detached from oneself)depersonalization (detached from oneself) Fear of losing control or going crazyFear of losing control or going crazy Fear of dyingFear of dying Paresthesias (numbness/tingling)Paresthesias (numbness/tingling) Chills/hot flashesChills/hot flashes
Panic AttacksPanic Attacks
After the first one, people tend to After the first one, people tend to become afraid of further attacks, become afraid of further attacks, making symptoms worse and making symptoms worse and causing anxiety between attacks causing anxiety between attacks (anticipatory anxiety)(anticipatory anxiety)
If cued, people begin avoiding If cued, people begin avoiding triggers- leading to agoraphobia at triggers- leading to agoraphobia at timestimes
Teach to breath (they are Teach to breath (they are hyperventilating) or use paper bag. hyperventilating) or use paper bag. Educate about attacks and cycles. Educate about attacks and cycles. Ensure they are not going crazy. Ensure they are not going crazy.
Agoraphobia- also not codable, Agoraphobia- also not codable, but occurs with other disordersbut occurs with other disorders
Anxiety about being in places from Anxiety about being in places from which escape might be difficult: which escape might be difficult: Being outside the home alone, being Being outside the home alone, being in a crowd, on a bridge, on a bus, in a crowd, on a bridge, on a bus, train or car, etc.train or car, etc.
Situations are avoided, endured with Situations are avoided, endured with much distress, or require a much distress, or require a companioncompanion
Not a social or specific phobiaNot a social or specific phobia
Panic DisorderPanic Disorder
Usually begins prior to 35 yrsUsually begins prior to 35 yrs Separation anxiety or childhood loss Separation anxiety or childhood loss
may predispose may predispose Runs in familiesRuns in families Has fluctuating course and tx has not Has fluctuating course and tx has not
failed if some symptoms persist or failed if some symptoms persist or reoccurreoccur
Catastrophobic thinking needs to be Catastrophobic thinking needs to be addressedaddressed
Imipramine, SSRIs, MAOIs, Imipramine, SSRIs, MAOIs, BenzodiazepinesBenzodiazepines
Presentation of Panic DisorderPresentation of Panic Disorder
In some cultures: Intense fear of In some cultures: Intense fear of witchcraft or magicwitchcraft or magic
More often in women than menMore often in women than men Onset is typically between Onset is typically between
adolescents and mid-30’sadolescents and mid-30’s Chronic, but waxes and wanesChronic, but waxes and wanes Familiar patternFamiliar pattern
Panic DisorderPanic Disorder
Presence of recurrent, Presence of recurrent, unexpected panic attacks with at unexpected panic attacks with at least 1 month of persistent least 1 month of persistent concern about having another, concern about having another, consequenses, or sig behavior consequenses, or sig behavior change related to attackchange related to attack
Not substance or medicalNot substance or medical Not social, specific, OCD, Not social, specific, OCD,
PTSD, or Separation AnxietyPTSD, or Separation Anxiety
Panic DisorderPanic Disorder
With agoraphobia or without With agoraphobia or without agoraphobiaagoraphobia
Agoraphobia w/out history of Agoraphobia w/out history of Panic DisorderPanic Disorder Focus of fear is on having panic like Focus of fear is on having panic like
symptoms or embarrassing/incapacitating symptoms or embarrassing/incapacitating symptoms (no full panic attacks)symptoms (no full panic attacks)
Does not meet criteria for Panic DisorderDoes not meet criteria for Panic Disorder Not Substance or MedicalNot Substance or Medical Not better accounted for by another Not better accounted for by another
disorder or Axis II avoidantdisorder or Axis II avoidant More often diagnosed in femalesMore often diagnosed in females May persist for years and has much May persist for years and has much
impairmentimpairment
Specific Phobia (formerly Specific Phobia (formerly Simple Phobia)Simple Phobia) Marked and persistent fear of an object or Marked and persistent fear of an object or
situationsituation Exposure provokes anxiety responseExposure provokes anxiety response Avoided or endured with dreadAvoided or endured with dread Realization in adolescents and adults that Realization in adolescents and adults that
the fear is excessive (as opposed to the fear is excessive (as opposed to delusions)delusions)
Marked distress or interference with Marked distress or interference with functioningfunctioning
Not better accounted by another mental Not better accounted by another mental disorderdisorder
If under 18, at least 6 monthsIf under 18, at least 6 months
Specific phobia subtypesSpecific phobia subtypes
Animal Type, Natural Environment Type, Animal Type, Natural Environment Type, Blood-Injection-injury type (may have Blood-Injection-injury type (may have genetic link), Situational Type, Other Typegenetic link), Situational Type, Other Type
Often results in restrictive lifestyleOften results in restrictive lifestyle Children may express with crying, Children may express with crying,
tantrums, freezing, or clinging and do not tantrums, freezing, or clinging and do not have the cognitive abilities to recognize the have the cognitive abilities to recognize the fears are excessivefears are excessive
Predisposing factors: traumatic events, Predisposing factors: traumatic events, pairing w/ unexpected panic attacks, or pairing w/ unexpected panic attacks, or informational transmissioninformational transmission
Familial linkFamilial link
Specific Phobia researched Specific Phobia researched TreatmentTreatment
Desensitization: exposure, Desensitization: exposure, relaxation, mental rehearsal, relaxation, mental rehearsal, supportive therapysupportive therapy
Flooding, graduated exposure, Flooding, graduated exposure, systematic desensitizationsystematic desensitization
MAOIs and SSRIsMAOIs and SSRIs
Social Phobia 300.23Social Phobia 300.23
Marked and persistent fear of social or Marked and persistent fear of social or performance situations in which performance situations in which embarrassment may occur.embarrassment may occur.
May also be hypersensitive to criticism, May also be hypersensitive to criticism, negative evaluation, or rejection, trouble negative evaluation, or rejection, trouble with assertiveness, low self-esteem and with assertiveness, low self-esteem and feelings of inferiority, poorer social skillsfeelings of inferiority, poorer social skills
Typical onset in mid-teens, but can begin in Typical onset in mid-teens, but can begin in childhood and may be continuous childhood and may be continuous depending on environmental demandsdepending on environmental demands
Familial linkFamilial link
Social Phobia & CultureSocial Phobia & Culture
Japan and Korea: fears of giving Japan and Korea: fears of giving offense to others in social offense to others in social situations (blushing, eye situations (blushing, eye contact, or one’s body odor will contact, or one’s body odor will offend others)offend others)
Social Phobia CriteriaSocial Phobia Criteria
Fear of social or performance situations, Fear of social or performance situations, and provoke anxiety. Situations are either and provoke anxiety. Situations are either avoided or endured with extreme distress.avoided or endured with extreme distress.
Person recognizes the fear is excessivePerson recognizes the fear is excessive The avoidance or distress impairs The avoidance or distress impairs
functioningfunctioning Under 18, must last at least 6 monthsUnder 18, must last at least 6 months Not substance or medicalNot substance or medical Specify Generalized if fears include most Specify Generalized if fears include most
social situations ( and consider avoidant social situations ( and consider avoidant personality disorder)personality disorder)
Tx of Social PhobiaTx of Social Phobia
SSRIsSSRIs Beta Blockers for performanceBeta Blockers for performance Social Skill training and Social Skill training and
Assertiveness trainingAssertiveness training ExposureExposure CBT CBT
Obsessive Compulsive Obsessive Compulsive DisorderDisorder Obsessions- persistent, disturbing, intrusive, Obsessions- persistent, disturbing, intrusive,
thoughts or impulses which the patient finds illogical thoughts or impulses which the patient finds illogical but irresistiblebut irresistible
These obsessions are considered absurd and These obsessions are considered absurd and client’s actively resist themclient’s actively resist them
Compulsions- obsessions expressed in action. Compulsions- obsessions expressed in action. Rituals used to prevent or reduce anxiety (repetitive Rituals used to prevent or reduce anxiety (repetitive behaviors)behaviors)
Both are used to reduce anxietyBoth are used to reduce anxiety Symptoms take up time, interfere with routine or Symptoms take up time, interfere with routine or
functioning, and marked distressfunctioning, and marked distress Not specific to another mental disorderNot specific to another mental disorder Specify with poor insight if excessiveness is not Specify with poor insight if excessiveness is not
recognizedrecognized
OCD PresentationOCD Presentation
People keep symptoms a People keep symptoms a secret, due to embarrassmentsecret, due to embarrassment
Thoughts or images can be Thoughts or images can be violent or disgusting. “I want to violent or disgusting. “I want to stab my cat” which disturb the stab my cat” which disturb the client.client.
Compulsions must be Compulsions must be completed or the client believes completed or the client believes something bad will happen.something bad will happen.
Forms of OCDForms of OCD
WashersWashers CheckersCheckers Doubters and SinnersDoubters and Sinners Counters and ArrangersCounters and Arrangers HoardersHoarders
OCDOCD
2/3rds had symptoms prior to 15, 2/3rds had symptoms prior to 15, and most had some symptoms in and most had some symptoms in childhood.childhood.
Chronic, lifelong, waxing and waning Chronic, lifelong, waxing and waning illnessillness
Attempts to resist obsessions and Attempts to resist obsessions and compulsions increases anxietycompulsions increases anxiety
Familial linkFamilial link Obsessions are overvalued ideas, Obsessions are overvalued ideas,
not delusionsnot delusions
OCD vs OCPDOCD vs OCPD
OCPD- ego syntonicOCPD- ego syntonic No true obsessions/compulsionsNo true obsessions/compulsions
OCD- ego dystonicOCD- ego dystonic
OCD PresentationOCD Presentation
May avoid situations related to May avoid situations related to obsessions, such as dirt/germsobsessions, such as dirt/germs
Guilt and sleep disturbances may be Guilt and sleep disturbances may be presentpresent
Excessive use of substances or Excessive use of substances or sedatives may occursedatives may occur
Equal in males and femalesEqual in males and females Onset: males 6 to 15, females 20-29. Onset: males 6 to 15, females 20-29.
Chronic, waxing and waning course Chronic, waxing and waning course Familial linkFamilial link
OCD TreatmentOCD Treatment
SSRIsSSRIs Need Continued medication due Need Continued medication due
to chronic nature of disorderto chronic nature of disorder Behavior therapy with graded Behavior therapy with graded
exposure and response exposure and response prevention prevention
Address catastrophic thoughtsAddress catastrophic thoughts
PTSDPTSD
Exposure to trauma that involved actual or threatened Exposure to trauma that involved actual or threatened death or serious injury, or threat to physical integrity of death or serious injury, or threat to physical integrity of self or othersself or others
A stressor is followed by either 1) reexperiencing A stressor is followed by either 1) reexperiencing (intrusion) (intrusion)
Hypervigilant, on edge, flooded by intrusive images Hypervigilant, on edge, flooded by intrusive images (hallucinations, nightmares, mental images), poor sleep and (hallucinations, nightmares, mental images), poor sleep and concentration, ruminate about stressor, cry “without reason”, concentration, ruminate about stressor, cry “without reason”, emotionally labile, easily startled, somatic anxiety, fear going emotionally labile, easily startled, somatic anxiety, fear going crazy and are unable to think about anything except the crazy and are unable to think about anything except the stressor stressor
AndAnd
2) avoidance of the event2) avoidance of the event May deal with denial w/ psychic numbing, minimizing the May deal with denial w/ psychic numbing, minimizing the
significance of the stressor, forgetting it, feeling detached significance of the stressor, forgetting it, feeling detached from others, losing interest in life, constricted affect, from others, losing interest in life, constricted affect, daydream and abuse drugsdaydream and abuse drugs
PTSDPTSD
Increased arousal: difficulty Increased arousal: difficulty falling or staying asleep, irritable falling or staying asleep, irritable or anger outbursts, poor or anger outbursts, poor concentration, hypervigilance, concentration, hypervigilance, exaggerated startle responseexaggerated startle response
Lasts more than 1 monthLasts more than 1 month Significant distress or Significant distress or
impairmentimpairment
PTSDPTSD
Acute: less than 3 monthsAcute: less than 3 months Chronic: 3 months or moreChronic: 3 months or more With delayed onset: 6 months With delayed onset: 6 months
after stressor (worst prognosis)after stressor (worst prognosis) Triggers worsen symptomsTriggers worsen symptoms Natural events cause less Natural events cause less
distress than People distress distress than People distress (torture)(torture)
PTSDPTSD
Auditory hallucinations and Auditory hallucinations and paranoid ideations can occur in paranoid ideations can occur in severe casessevere cases
PTSD DiversityPTSD Diversity
In Men, more common In Men, more common military/warmilitary/war
In women, more common rape, In women, more common rape, sexual and physical abusesexual and physical abuse
Immigrants from war areas may Immigrants from war areas may be hesitant to talk about be hesitant to talk about experiencesexperiences
PTSD TreatmentPTSD Treatment
Debriefing immediately after event Debriefing immediately after event can prevent PTSDcan prevent PTSD
Support groupsSupport groups Confronting feared memories/topicsConfronting feared memories/topics Examining misinterpretations of Examining misinterpretations of
eventsevents Development of copingDevelopment of coping EMDR, TFTEMDR, TFT Trazodone for sleepTrazodone for sleep
Acute Stress DisorderAcute Stress Disorder
Briefer form of PTSD lasting 2 days to 4 weeks Briefer form of PTSD lasting 2 days to 4 weeks
Plus 3 symptoms immediately after stressor (with in 4 Plus 3 symptoms immediately after stressor (with in 4 weeks): subjective numbing, reduced awareness of weeks): subjective numbing, reduced awareness of surroundings “being in a daze”, derealization, surroundings “being in a daze”, derealization, depersonalization, dissociative amnesia (inability to depersonalization, dissociative amnesia (inability to remember important aspects of the trauma)remember important aspects of the trauma)
Persistent reexperience of traumaPersistent reexperience of trauma
Avoidance of triggersAvoidance of triggers
High AnxietyHigh Anxiety
ImpairmentImpairment
Not substance or medicalNot substance or medical
Generalized Anxiety DisorderGeneralized Anxiety Disorder
Excessive anxiety and worry occurring Excessive anxiety and worry occurring more days than not for at least 6 months, more days than not for at least 6 months, about a number of things. Person has about a number of things. Person has trouble controlling the worry.trouble controlling the worry.
3 or more: Restless/keyed up/on edge, 3 or more: Restless/keyed up/on edge, easily fatigued, difficulty concentrating, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep irritability, muscle tension, sleep disturbancedisturbance
Anxiety or worry not confined to other Axis Anxiety or worry not confined to other Axis I disorderI disorder
Cause distress or impairment in functioningCause distress or impairment in functioning Not substance or medicalNot substance or medical
GAD PresentationGAD Presentation
Chronic worry Chronic worry wartswarts
TenseTense Highly Highly
distractibledistractible IrritableIrritable RestlessRestless On edgeOn edge
Fatigued and Fatigued and mildly mildly depresseddepressed
Physical Physical complaintscomplaints
Depression and Anxiety Depression and Anxiety
50% comorbid50% comorbid Treat depression with Treat depression with
antidepressants and this will antidepressants and this will help with anxietyhelp with anxiety
GAD TreatmentGAD Treatment
ID stressors that exacerbate ID stressors that exacerbate anxietyanxiety
Eliminate dietary and physical Eliminate dietary and physical sources of anxietysources of anxiety
Increase exercise with Increase exercise with physician’s approvalphysician’s approval
Deep Muscle relaxation, Deep Muscle relaxation, meditation, biofeedbackmeditation, biofeedback
Buspar, SSRIs, BenzosBuspar, SSRIs, Benzos
Generalized Anxiety DisorderGeneralized Anxiety Disorder
Culture: In many cultures, anxiety is Culture: In many cultures, anxiety is expressed somatically or cognitivelyexpressed somatically or cognitively
Children: performance in school, Children: performance in school, sports, punctuality, catastrophying sports, punctuality, catastrophying about war/earthquakes/etc, seek about war/earthquakes/etc, seek excessive approval and excessive approval and reassurance, things need to be reassurance, things need to be perfectperfect
Somewhat more frequent in womenSomewhat more frequent in women Chronic but fluctuating courseChronic but fluctuating course Familial associationFamilial association
OthersOthers
Anxiety due to a general Anxiety due to a general medical disordermedical disorder
Substance-induced anxiety Substance-induced anxiety disorderdisorder
Anxiety Disorder NOSAnxiety Disorder NOS