Anxiety Disorders

Anxiety Disorders

Anxiety Disorders • Panic Attack • Agoraphobia • Panic Disorder w/out agoraphobia • Agoraphobia w/out hx of panic disorder • Specific Phobia Social Phobia OCD PTSD Acute Stress Disorder GAD Anxiety due to Medical condition Substance induced Anxiety NOS

Anxiety due to a Medical Condition • Cardiopulmonary disorders • Hyperthyroidism-may include heat intolerance and tremor • Hypoglycemia- reduced by eating candy • Alcohol ingestion • Caffeine overdose • Must cause distress or impaiment • Specify: with generalized anxiety, with panic attacks, or with oc symptoms

Panic Attack- not a diagnosis, but specified with anxiety diagnosis • Four or more that develop abruptly and peak with in 10 minutes • Pounding, racing, palpitating heart • Sweating • Trembling, shaking • Short of breath or smothering • Feeling of choking • Chest pain, discomfort • Nausea/abdominal stress • Dizzy, lightheaded, faint • Derealization (detached from reality) or depersonalization (detached from oneself) • Fear of losing control or going crazy • Fear of dying • Paresthesias (numbness/tingling) • Chills/hot flashes

Panic Attacks • After the first one, people tend to become afraid of further attacks, making symptoms worse and causing anxiety between attacks (anticipatory anxiety) • If cued, people begin avoiding triggers- leading to agoraphobia at times • Teach to breath (they are hyperventilating) or use paper bag. Educate about attacks and cycles. Ensure they are not going crazy.

Agoraphobia- also not codable, but occurs with other disorders • Anxiety about being in places from which escape might be difficult: Being outside the home alone, being in a crowd, on a bridge, on a bus, train or car, etc. • Situations are avoided, endured with much distress, or require a companion • Not a social or specific phobia

Panic Disorder • Usually begins prior to 35 yrs • Separation anxiety or childhood loss may predispose • Runs in families • Has fluctuating course and tx has not failed if some symptoms persist or reoccur • Catastrophobic thinking needs to be addressed • Imipramine, SSRIs, MAOIs, Benzodiazepines

Presentation of Panic Disorder • In some cultures: Intense fear of witchcraft or magic • More often in women than men • Onset is typically between adolescents and mid-30’s • Chronic, but waxes and wanes • Familiar pattern

Panic Disorder • Presence of recurrent, unexpected panic attacks with at least 1 month of persistent concern about having another, consequenses, or sig behavior change related to attack • Not substance or medical • Not social, specific, OCD, PTSD, or Separation Anxiety

Panic Disorder • With agoraphobia or without agoraphobia

Agoraphobia w/out history of Panic Disorder • Focus of fear is on having panic like symptoms or embarrassing/incapacitating symptoms (no full panic attacks) • Does not meet criteria for Panic Disorder • Not Substance or Medical • Not better accounted for by another disorder or Axis II avoidant • More often diagnosed in females • May persist for years and has much impairment

Specific Phobia (formerly Simple Phobia) • Marked and persistent fear of an object or situation • Exposure provokes anxiety response • Avoided or endured with dread • Realization in adolescents and adults that the fear is excessive (as opposed to delusions) • Marked distress or interference with functioning • Not better accounted by another mental disorder • If under 18, at least 6 months

Specific phobia subtypes • Animal Type, Natural Environment Type, Blood-Injection-injury type (may have genetic link), Situational Type, Other Type • Often results in restrictive lifestyle • Children may express with crying, tantrums, freezing, or clinging and do not have the cognitive abilities to recognize the fears are excessive • Predisposing factors: traumatic events, pairing w/ unexpected panic attacks, or informational transmission • Familial link

Specific Phobia researched Treatment • Desensitization: exposure, relaxation, mental rehearsal, supportive therapy • Flooding, graduated exposure, systematic desensitization • MAOIs and SSRIs

Social Phobia 300.23 • Marked and persistent fear of social or performance situations in which embarrassment may occur. • May also be hypersensitive to criticism, negative evaluation, or rejection, trouble with assertiveness, low self-esteem and feelings of inferiority, poorer social skills • Typical onset in mid-teens, but can begin in childhood and may be continuous depending on environmental demands • Familial link

Social Phobia & Culture • Japan and Korea: fears of giving offense to others in social situations (blushing, eye contact, or one’s body odor will offend others)

Social Phobia Criteria • Fear of social or performance situations, and provoke anxiety. Situations are either avoided or endured with extreme distress. • Person recognizes the fear is excessive • The avoidance or distress impairs functioning • Under 18, must last at least 6 months • Not substance or medical • Specify Generalized if fears include most social situations ( and consider avoidant personality disorder)

Tx of Social Phobia • SSRIs • Beta Blockers for performance • Social Skill training and Assertiveness training • Exposure • CBT

Obsessive Compulsive Disorder • Obsessions- persistent, disturbing, intrusive, thoughts or impulses which the patient finds illogical but irresistible • These obsessions are considered absurd and client’s actively resist them • Compulsions- obsessions expressed in action. Rituals used to prevent or reduce anxiety (repetitive behaviors) • Both are used to reduce anxiety • Symptoms take up time, interfere with routine or functioning, and marked distress • Not specific to another mental disorder • Specify with poor insight if excessiveness is not recognized

OCD Presentation • People keep symptoms a secret, due to embarrassment • Thoughts or images can be violent or disgusting. “I want to stab my cat” which disturb the client. • Compulsions must be completed or the client believes something bad will happen.

Forms of OCD • Washers • Checkers • Doubters and Sinners • Counters and Arrangers • Hoarders

OCD • 2/3rds had symptoms prior to 15, and most had some symptoms in childhood. • Chronic, lifelong, waxing and waning illness • Attempts to resist obsessions and compulsions increases anxiety • Familial link • Obsessions are overvalued ideas, not delusions

OCD vs OCPD • OCPD- ego syntonic • No true obsessions/compulsions • OCD- ego dystonic

OCD Presentation • May avoid situations related to obsessions, such as dirt/germs • Guilt and sleep disturbances may be present • Excessive use of substances or sedatives may occur • Equal in males and females • Onset: males 6 to 15, females 20-29. Chronic, waxing and waning course • Familial link

OCD Treatment • SSRIs • Need Continued medication due to chronic nature of disorder • Behavior therapy with graded exposure and response prevention • Address catastrophic thoughts

PTSD • Exposure to trauma that involved actual or threatened death or serious injury, or threat to physical integrity of self or others • A stressor is followed by either 1) reexperiencing (intrusion) • Hypervigilant, on edge, flooded by intrusive images (hallucinations, nightmares, mental images), poor sleep and concentration, ruminate about stressor, cry “without reason”, emotionally labile, easily startled, somatic anxiety, fear going crazy and are unable to think about anything except the stressor And • 2) avoidance of the event • May deal with denial w/ psychic numbing, minimizing the significance of the stressor, forgetting it, feeling detached from others, losing interest in life, constricted affect, daydream and abuse drugs

PTSD • Increased arousal: difficulty falling or staying asleep, irritable or anger outbursts, poor concentration, hypervigilance, exaggerated startle response • Lasts more than 1 month • Significant distress or impairment

PTSD • Acute: less than 3 months • Chronic: 3 months or more • With delayed onset: 6 months after stressor (worst prognosis) • Triggers worsen symptoms • Natural events cause less distress than People distress (torture)

PTSD • Auditory hallucinations and paranoid ideations can occur in severe cases

PTSD Diversity • In Men, more common military/war • In women, more common rape, sexual and physical abuse • Immigrants from war areas may be hesitant to talk about experiences

PTSD Treatment • Debriefing immediately after event can prevent PTSD • Support groups • Confronting feared memories/topics • Examining misinterpretations of events • Development of coping • EMDR, TFT • Trazodone for sleep

Acute Stress Disorder • Briefer form of PTSD lasting 2 days to 4 weeks • Plus 3 symptoms immediately after stressor (with in 4 weeks): subjective numbing, reduced awareness of surroundings “being in a daze”, derealization, depersonalization, dissociative amnesia (inability to remember important aspects of the trauma) • Persistent reexperience of trauma • Avoidance of triggers • High Anxiety • Impairment • Not substance or medical

Generalized Anxiety Disorder • Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of things. Person has trouble controlling the worry. • 3 or more: Restless/keyed up/on edge, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance • Anxiety or worry not confined to other Axis I disorder • Cause distress or impairment in functioning • Not substance or medical

GAD Presentation • Chronic worry warts • Tense • Highly distractible • Irritable • Restless • On edge • Fatigued and mildly depressed • Physical complaints

Depression and Anxiety • 50% comorbid • Treat depression with antidepressants and this will help with anxiety

GAD Treatment • ID stressors that exacerbate anxiety • Eliminate dietary and physical sources of anxiety • Increase exercise with physician’s approval • Deep Muscle relaxation, meditation, biofeedback • Buspar, SSRIs, Benzos

Generalized Anxiety Disorder • Culture: In many cultures, anxiety is expressed somatically or cognitively • Children: performance in school, sports, punctuality, catastrophying about war/earthquakes/etc, seek excessive approval and reassurance, things need to be perfect • Somewhat more frequent in women • Chronic but fluctuating course • Familial association

Others • Anxiety due to a general medical disorder • Substance-induced anxiety disorder • Anxiety Disorder NOS

Anxiety Disorders