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Anxiety Disorders . All 12 of them…. Fear vs. Anxiety. Fear A response to a known, external, definite, or non-conflictual threat Onset is sudden Is a protective factor against harm Anxiety A response to an unknown, internal, vague or conflictual threat Onset is insidious

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Anxiety Disorders

All 12 of them…


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Fear vs. Anxiety

  • Fear

    • A response to a known, external, definite, or non-conflictual threat

    • Onset is sudden

    • Is a protective factor against harm

  • Anxiety

    • A response to an unknown, internal, vague or conflictual threat

    • Onset is insidious

    • May also be a protective factor against harm, but can become a maladaptive coping mechanism.


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Factors which contribute to anxious responses

  • Biological

    • Numerous studies of various types of anxiety indicate an increased risk among first-degree relatives

    • Rate varies with type of anxiety disorder

    • Highest rate of concordance for Specific Phobia, blood, injection, injury type

    • Some individuals with an Anxiety D/O may have a cerebral pathological condition, or other medical condition which contributes to development of these symptoms. See K&S, page 605.

    • Substance use, abuse and withdrawal may precipitate the symptoms of an Anxiety D/O.


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Factors which contribute to anxious responses

  • Psychological

    • Anxiety results from

      • an imbalance between the pressures of the outside world (stress) and the individual’s coping skills (ego strength)

      • An imbalance between internal impulses (aggressive, sexual, dependent) and the individual’s conscience (super-ego)

    • The goal of treatment is to increase anxiety tolerance


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Factors which contribute to anxious responses

  • Psycho-social

    • Chronic stressors, such as loss of a parent while a child, lower socio-economic status, etc.

    • Acute stressors, such as divorce, birth of a child, post-partum anxiety and/or depression, etc.


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First line of treatment…

  • Always refer clients with symptoms of Anxiety D/Os to their physician or to the Emergency Room for an evaluation before you begin any course of treatment.


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Panic Disorder & AgoraphobiaCriteria for a Panic Attack

  • Four or more of the following over a 10 minute period of time:

    • Palpitations (tachycardia)

    • Sweating

    • Trembling or shaking

    • Shortness of breath (hyperventilation or dyspnea)

    • Feelings of choking

    • Chest pain or discomfort

    • Nausea or abdominal distress

    • Dizzy, unsteady, light-headed, faint

    • Derealization or depersonalization

    • Fear of loss of control or going crazy

    • Fear of dying

    • Numbing or tingling sensation (parathesias)

    • Chills or hot flashes

  • Clients cannot usually name the source of their fear

  • Last about 20-30 minutes, rarely more than an hour


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Panic Disorder:Criteria for Agoraphobia

  • Anxiety about being in places or situations from which escape might be difficult or embarrassing, or in which help might not be available in the event of a having an unexpected or situationally predisposed panic attack or panic-like symptoms.

  • These situations are avoided or endured with significant distress or anxiety about having a panic attack or panic-like symptoms.

  • The symptoms are not better accounted for by another mental disorder.


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Panic Disorder

  • Coding

    • 300.01 Panic Disorder without Agoraphobia

    • 300.21 Panic Disorder with Agoraphobia

    • 300.22 Agoraphobia without history of Panic Disorder


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Panic DisorderDiagnostic Features

Presence of at least two Panic Attacks (unexpected, and not situationally bound)

  • At least one Panic Attack is followed by one month of specific worry and concern about the panic attacks or the implication of having an additional attack

  • Rule in or out associated Agorphobia

  • The attacks cannot be due to a general medical condition or substance abuse

  • The attacks cannot be better accounted for by another mental disorder


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Panic Disorder Associated Features

Disruption of

  • Important interpersonal relationships

  • School/Occupational functioning

  • Unfocussed constant or intermittent worry

  • Anticipatory anxiety between attacks

  • Catastophizing

  • Demoralization

  • High comorbidity

    • Depression

    • Other Anxiety D/O

  • High rates of suicide


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    Panic Disorder Culture, Age and Gender

    • Usually develops in young adulthood, but can occur at any age

    • Woman are 2-3 times more likely to be treated for the disorder than men (may be skewed due to women being more likely to seek treatment)

    • Panic attacks are experienced in all cultures

    • Be aware of some cultures and ethnic groups which restrict the public role of women (this would preclude Agoraphobia).


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    Panic Disorder Course & Prognosis

    Quite variable

    • About 30% - 40% symptom free at long term follow-up

    • 50% have mild symptoms

    • 10%-20% have persisting debilitating symptoms

  • Depends on

    • Severity of the Panic Attacks

    • Presence of Agoraphobia

    • Presence of comorbidity


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    Agoraphobia without History of Panic Disorder

    • Similar to symptoms of Panic Disorder with Agoraphobia, except

      • The focus of fear is on the occurrence of incapacitating or embarrassing panic-like symptoms or limited symptom attacks rather than full Panic Attacks

      • To qualify for this diagnosis, the client must never have experienced a Panic Attack, and the symptoms are not better accounted for by a general medical condition, substance abuse, etc.


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    Panic Disorder & AgoraphobiaDifferential Diagnosis

    Use the decision tree on DSM page 754!

    • Medical D/Os

      • Refer to physician or ER as appropriate

    • Substance Abuse D/Os

      • Refer to physician or ER as appropriate


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    Panic Disorder & Agoraphobia Differential Diagnosis

    • Mental Disorders

      • Malingering, Factitious D/O & Hypochondriasis

      • Depersonalization Disorder

        • Lacks the full array of symptoms of a Panic Attack

      • Depressive Disorders

        • Look for shifts in mood

      • Schizophrenia

        • Look for other symptoms of psychosis


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    Panic Disorder & Agoraphobia Differential Diagnosis

    • Other Anxiety D/Os

      • Agoraphobia without Panic Attack

        • Lacks symptoms of Panic Attacks

      • Separation Anxiety Disorder

        • Symptoms directly related to separation from attachment figure

      • Social Phobia

        • Panic Attacks specific to fear of humiliation or embarrassment in social or performance situations

      • Specific Phobia

        • Fear is cued by object or situation


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    Panic Disorder & Agoraphobia Differential Diagnosis

    • Other Anxiety D/Os

      • OCD

        • Look for obsession and compulsions

      • GAD

        • 6 month period of excessive worry, plus anxiety symptoms

      • PTSD

        • Flashbacks, increased arousal, avoidance of stimuli associated with traumatic event

        • Anxiety in response to a specific event with duration of one month


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    Panic Disorder & Agoraphobia Differential Diagnosis

    • Other Anxiety D/Os

      • Acute Stress Disorder

        • Flashbacks, increased arousal, avoidance of stimuli associated with traumatic event

        • Anxiety in response to a specific event with duration of symptoms for less than one month

      • Adjustment D/O with Anxiety

        • Does not meet criteria for any other Anxiety D/O, and develops in response to a stressor

      • Anxiety D/O NOS

        • Clinically significant symptoms, but does not meet criteria for any other Anxiety D/O


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    Panic Disorder & AgoraphobiaTreatment Strategies

    • Pharmocotherapy

      • SSRIs

      • Benzodiazepines

      • Tricyclic and Tertacyclics

      • MAOIs

    • Medical (for non-responsive patients)

      • ACT

      • Surgery


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    Panic Disorder & AgoraphobiaTreatment Strategies

    • Cognitive-Behavioral

      • Cognitive

        • Education about Panic Attacks

        • Challenge clients’ cognitive distortions

      • Applied Relaxation

      • Respiratory Training

      • Exposure Therapy


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    Panic Disorder & AgoraphobiaTreatment Strategies

    • Family Therapy

      • Helps family to understand and not enable the secondary gain of the disorder

    • Insight-oriented

      • Helps clients understand the unconscious meaning of the anxiety


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    3 down, 9 to go…

    • Who do you think should have won American Idol?


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    PhobiasSocial & Specific

    • Coding

      • 300.29 Specific Phobia

        • Specify:

          • Animal Type

          • Natural Environment Type

          • Blood-Injection-Injury Type

          • Situational Type

          • Other Type

      • 300.23 Social Phobia

        • Specify if: Generalized


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    Specific PhobiaDiagnostic Criteria

    • Strong, specific fear of an object or situation, which produces conscious avoidance of the feared subject, activity or situation.

    • Exposure to the phobia stimulus almost always provokes an immediate anxiety response

    • The response may take the form of a situationally bound or predisposed Panic Attack

    • Clients recognize the irrationality of their fear (ego-dystonic).


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    Specific PhobiaAssociated Features

    • Most common mental disorder in the U.S.

    • May result in a restricted lifestyle or proscribed occupational circumstances

    • High comorbidity with other mental disorders (50% - 80%)

    • Blood-injection-injury Type may have symptoms of slowed heart rate (bradycardia) and low blood pressure (hypotension).


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    Specific Phobia Culture, Age, Gender

    • The content of phobias varies with culture and ethnicity

    • Children may exhibit symptoms of crying, tantruming, clinging, and freezing

    • The gender gap is 2:1 for females overall, although the sex ratio varies over types


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    Specific PhobiaCourse & Prognosis

    • The severity of the condition is constant, and does not come and go, as seen in other Anxiety D/Os

    • Many people simply avoid the stimulus throughout their lives, and never seek treatment


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    Specific PhobiaDifferential Diagnosis

    Use the decision tree on DSM page 754!

    • Rule out the usual General Medical Conditions and Substance Abuse


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    Specific PhobiaDifferential Diagnosis

    • Other Anxiety D/Os

      • Panic Disorder with Agoraphobia

        • The inter-episode rate of general anxiety is higher with this D/O. Those with a Specific Phobia do not usually experience a generalized anxiety unless anticipating exposure to the particular stimulus

        • Panic Attacks with this D/O have a usually unexpected onset, and the subsequent avoidance of multiple stimuli. Panic Attacks with Specific Phobias usually take the form of avoidance of the stimulus in the absence of re-occurring Panic Attacks.

        • Look at the focus of the fear, the type and number of Panic Attacks, the number of situations avoided and the level of inter episode anxiety


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    Specific PhobiaDifferential Diagnosis

    • Acute Stress Disorder

      • Flashbacks, increased arousal, avoidance of stimuli associated with traumatic event

      • Anxiety in response to a specific event with duration of symptoms for less than one month

    • Adjustment D/O with Anxiety

      • Does not meet criteria for any other Anxiety D/O, and develops in response to a stressor

    • Anxiety D/O NOS

      • Clinically significant symptoms, but does not meet criteria for any other Anxiety D/O


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    Specific PhobiaDifferential Diagnosis

    • OCD

      • Look for obsession and compulsions

    • GAD

      • 6 month period of excessive worry, plus anxiety symptoms

    • PTSD

      • Flashbacks, increased arousal, avoidance of stimuli associated with traumatic event

      • Anxiety in response to a specific event with duration of one month


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    Specific PhobiaTreatment Strategies

    • Behavioral

      • Exposure Therapy

      • Graded task assignments

      • Patients must be committed to treatment


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