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