1. Anxiety Disorders All 12 of them…

2. 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.

3. 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.

4. 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

5. 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.

6. 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.

7. 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

8. 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.

9. Panic Disorder • Coding • 300.01 Panic Disorder without Agoraphobia • 300.21 Panic Disorder with Agoraphobia • 300.22 Agoraphobia without history of Panic Disorder

10. 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

11. 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

12. 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).

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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

20. Panic Disorder & AgoraphobiaTreatment Strategies • Pharmocotherapy • SSRIs • Benzodiazepines • Tricyclic and Tertacyclics • MAOIs • Medical (for non-responsive patients) • ACT • Surgery

21. Panic Disorder & AgoraphobiaTreatment Strategies • Cognitive-Behavioral • Cognitive • Education about Panic Attacks • Challenge clients’ cognitive distortions • Applied Relaxation • Respiratory Training • Exposure Therapy

22. 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

23. 3 down, 9 to go… • Who do you think should have won American Idol?

24. 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

25. 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).

26. 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).

27. 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

28. 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

29. Specific PhobiaDifferential Diagnosis Use the decision tree on DSM page 754! • Rule out the usual General Medical Conditions and Substance Abuse

30. 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

31. 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

32. 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

33. Specific PhobiaTreatment Strategies • Behavioral • Exposure Therapy • Graded task assignments • Patients must be committed to treatment