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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

Anxiety Disorders

All 12 of them…

fear vs anxiety
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.
factors which contribute to anxious responses
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.
factors which contribute to anxious responses4
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
factors which contribute to anxious responses5
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.
first line of treatment
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.
panic disorder agoraphobia criteria for a panic attack
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
panic disorder criteria for agoraphobia
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.
panic disorder
Panic Disorder
  • Coding
    • 300.01 Panic Disorder without Agoraphobia
    • 300.21 Panic Disorder with Agoraphobia
    • 300.22 Agoraphobia without history of Panic Disorder
panic disorder diagnostic features
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
panic disorder associated features
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
panic disorder culture age and gender
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).
panic disorder course prognosis
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
agoraphobia without history of panic disorder
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.
panic disorder agoraphobia differential diagnosis
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
panic disorder agoraphobia differential diagnosis16
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
panic disorder agoraphobia differential diagnosis17
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
panic disorder agoraphobia differential diagnosis18
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
panic disorder agoraphobia differential diagnosis19
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
panic disorder agoraphobia treatment strategies
Panic Disorder & AgoraphobiaTreatment Strategies
  • Pharmocotherapy
    • SSRIs
    • Benzodiazepines
    • Tricyclic and Tertacyclics
    • MAOIs
  • Medical (for non-responsive patients)
    • ACT
    • Surgery
panic disorder agoraphobia treatment strategies21
Panic Disorder & AgoraphobiaTreatment Strategies
  • Cognitive-Behavioral
    • Cognitive
      • Education about Panic Attacks
      • Challenge clients’ cognitive distortions
    • Applied Relaxation
    • Respiratory Training
    • Exposure Therapy
panic disorder agoraphobia treatment strategies22
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
3 down 9 to go
3 down, 9 to go…
  • Who do you think should have won American Idol?
phobias social specific
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
specific phobia diagnostic criteria
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).
specific phobia associated features
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).
specific phobia culture age gender
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
specific phobia course prognosis
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
specific phobia differential diagnosis
Specific PhobiaDifferential Diagnosis

Use the decision tree on DSM page 754!

  • Rule out the usual General Medical Conditions and Substance Abuse
specific phobia differential diagnosis30
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
specific phobia differential diagnosis31
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
specific phobia differential diagnosis32
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
specific phobia treatment strategies
Specific PhobiaTreatment Strategies
  • Behavioral
    • Exposure Therapy
    • Graded task assignments
    • Patients must be committed to treatment
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