Anxiety Disorders - PowerPoint PPT Presentation

Anxiety Disorders

All 12 of them…

• 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.

• 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.

• 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

• 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.

• 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.

• 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

• 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.

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

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

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

• 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).

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

• 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.

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

• 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

• 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

• 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

• 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

• Pharmocotherapy
• SSRIs
• Benzodiazepines
• Tricyclic and Tertacyclics
• MAOIs
• Medical (for non-responsive patients)
• ACT
• Surgery

• Cognitive-Behavioral
• Cognitive
• Education about Panic Attacks
• Challenge clients’ cognitive distortions
• Applied Relaxation
• Respiratory Training
• Exposure Therapy

• 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

• Who do you think should have won American Idol?

• 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

• 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).

• 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).

• 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

• 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

Use the decision tree on DSM page 754!

• Rule out the usual General Medical Conditions and Substance Abuse

• 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

• 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

• 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

• Behavioral
• Exposure Therapy
• Graded task assignments
• Patients must be committed to treatment