Anxiety Disorders

1. Anxiety Disorders

2. Biological Findings • GAD and Panic D/o • GABA Theory • problem binding to the BZD receptors • Altered receptor sensitivity • Abnormal NE and 5-HT neurotransmission • Studies have shown CO2 inhalation precipitates panic attacks • OCD • if obsessions are r/t a defect in neural inhibition of dominant frontal systems • 5-HT neurotransmission is dysregulated

3. Biological Findings (cont) • PTSD • Extreme stress is assoc with damaging effects to the brain • Abuse causes reduction in the hippocampus (Bremner, et al 1997)

4. Psychological Factors • Psychodynamic • Anxiety results from breakthrough of repressed ideas and emotions • Ego defense mechanisms are used to help manage anxiety • Interpersonal • Anxiety is linked to the emotional distress caused when early needs go unmet

5. Psychological Factors (cont) • Learning Theories • Anxiety is a learned response that can be unlearned • Learn to be anxious through modeling • Cognitive Theories • Anxiety is caused by distortions in thinking and perceiving

6. Anxiety Disorders 1. Panic Disorder 2. Generalized Anxiety Disorder (GAD) 3. Phobias

7. Panic Anxiety Disorder • Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: 1. Palpitations, pounding heart, or accelerated heart rate. 2. Sweating. 3. Trembling or shaking. 4. Sensations of shortness of breath or smothering. 5. Feelings of choking. 6. Chest pain or discomfort. 7. Nausea or abdominal distress.

8. Panic Anxiety Disorder 8. Feeling dizzy, unsteady, light-headed, or faint. 9. Chills or heat sensations. 10. Paresthesias (numbness or tingling sensations). 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself). 12. Fear of losing control or “going crazy.” 13. Fear of dying. • Note:Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

9. Panic Anxiety Disorder B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1. Persistent concern or worry about additional panic attacks or their consequences. 2. A significant maladaptive change in behavior related to the attacks.

10. Panic Anxiety Disorder C. The disturbance is not attributable to the physiological effects of a substance or another medical condition. D. The disturbance is not better explained by another mental disorder.

11. Panic Anxiety Disorder with Agoraphobia • If the condition is accompanied with excessive fear from the attack to occur that is the person develops phobic avoidance to situations in which a sense being alone in public places from which escape might be difficult or in which help is not available.

12. Panic Anxiety Disorder • Prevalence • In the general population, the 12-month prevalence estimate for panic disorder across the United States and several European countries is about 2%-3% in adults and adolescents. • Females are more frequently affected than males, at a rate of approximately 2:1 • Suicide Risk • Panic attacks and a diagnosis of panic disorder in the past 12 months are related to a higher rate of suicide attempts and suicidal ideation • Functional Consequences of Panic Disorder • Panic disorder is associated with high levels of social, occupational, and physical disability.

13. “I always thought I was just a worrier. I’d feel keyed up and unable to relax. At times it would come and go, and at times it would be constant. It could go on for days. I’d worry about what I was going to fix for a dinner party, or what would be a great present for somebody. I just couldn’t let something go.” • When my problems were at their worst, I’d miss work and feel just terrible about it. Then I worried that I’d lose my job. My life was miserable until I got treatment.

14. Generalized Anxiety Disorder A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B. The individual finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months);

15. Generalized Anxiety Disorder Note: Only one item is required in children. 1. Restlessness or feeling keyed up or on edge. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

16. Generalized Anxiety Disorder E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The disturbance is not better explained by another mental disorder

17. Generalized Anxiety Disorder • Prevalence • The 12-month prevalence for the disorder in other countries ranges from 0.4% to 3.6%. • Females are twice as likely as males to experience generalized anxiety disorder. • Functional Consequences of Generalized Anxiety Disorder • Excessive worrying impairs the individual's capacity to do things quickly and efficiently, whether at home or at work. The worrying takes time and energy; the associated symptoms of muscle tension and feeling keyed up or on edge, tiredness, difficulty concentrating, and disturbed sleep contribute to the impairment.

18. Phobias

19. Phobias • Irrational fear of an object, situation that is recognized by the person as being unreasonable • Types: 1. Agoraphobia 2. Specific Phobia 3. Social Phobia

20. Agoraphobia A. Marked fear or anxiety about two (or more) of the following five situations: 1. Using public transportation 2. Being in open spaces 3. Being in enclosed places 4. Standing in line or being in a crowd. 5. Being outside of the home alone. B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms

21. Agoraphobia C. The agoraphobic situations almost always provoke fear or anxiety. D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context. F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

22. Agoraphobia G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. If another medical condition is present, the fear, anxiety, or avoidance is clearly excessive. I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder. Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder.

23. Agoraphobia • Functional Consequences of Agoraphobia • Agoraphobia is associated with considerable impairment and disability in terms of role functioning, work productivity, and disability days.

24. Specific Phobia D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

25. Specific Phobia A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. B. The phobic object or situation almost always provokes immediate fear or anxiety. C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.

26. About Specific Phobia • The average individual with specific phobia fears three objects or situations, and approximately 75% of individuals with specific phobia fear more than one situation or object • Prevalence: • In the United States, the 12-month community prevalence estimate for specific phobia is approximately 7%-9%. but rates are generally lower in Asian, African, and Latin America • Females are more frequently affected than males, at a rate of approximately 2:1, although rates vary across different phobic stimuli.

27. Specific Phobia • Specific phobia sometimes develops following: 1. a traumatic event 2. observation of others going through a traumatic event 3. an unexpected panic attack in the to be feared situation 4. or informational transmission • However, many individuals with specific phobia are unable to recall the specific reason for the onset of their phobias.

28. Phobia Top 10 • Arachnophobia • Social Phobia • Aerophobia • Agoraphobia • Claustrophobia • Acrophobia • Emetophobia • Carcinophobia • Brontophobia • Necrophobia

30. Social Anxiety Disorder (Social Phobia) A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. • Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). • Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.

31. Social Phobia B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing: will lead to rejection or offend others). C. The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. D. The social situations are avoided or endured with intense fear or anxiety.

32. Social Phobia E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance or another medical condition.

33. Social Phobia I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder J. If another medical condition the condition is worsened

34. Social Phobia • Prevalence • The 12-month prevalence estimate of social anxiety disorder for the United States is approximately 7%. • Lower 12-month prevalence estimates are seen in much of the world around 0.5%-2.0. • Functional Consequences of Social Anxiety Disorder • Social anxiety disorder is associated with elevated rates of school dropout and with decreased well-being, employment, workplace productivity, socioeconomic status, and quality of life.

35. Social Phobia • Comorbidity • Social anxiety disorder is often comorbid with other anxiety disorders, major depressive disorder, and substance use disorders.

36. “I couldn’t do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn’t. It took me longer to read because I’d count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn’t add up to a ’bad’ number.” • “I knew the rituals didn’t make sense, and I was deeply ashamed of them, but I couldn’t seem to overcome them until I had therapy.”

37. “Getting dressed in the morning was tough, because I had a routine, and if I didn’t follow the routine, I’d get anxious and would have to get dressed again. I always worried that if I didn’t do something, my parents were going to die. I’d have these terrible thoughts of harming my parents. That was completely irrational, but the thoughts triggered more anxiety and more senseless behavior. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me.”

38. Obsessive-Compulsive andRelated Disorders.

39. Obsessive-Compulsive Disorder A. Presence of obsessions, compulsions, or both: • Obsessions are defined by (1) and (2): 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action.

40. Obsessive-Compulsive Disorder • Compulsions are defined by (1) and (2): • 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. • 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

41. Obsessive-Compulsive Disorder Note: Young children may not be able to articulate the aims of these behaviors or mental acts. B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. D. The disturbance is not better explained by the symptoms of another mental disorder

42. Obsessive-Compulsive Disorder • Prevalence • The 12-month prevalence of OCD in the United States is 1.2%, with a similar prevalence internationally (1.1%-1.8%). • Females are affected at a slightly higher rate than males in adulthood, although males are more commonly affected in childhood. • Suicide Risk • Suicidal thoughts occur at some point in as many as about half of individuals with OCD. Suicide attempts are also reported in up to one-quarter of individuals with OCD; the presence of comorbid major depressive disorder increases the risk.

43. Checking …………………………..63% • Washing ………………….….……50% • Contamination…………….…….45% • Doubting……………………….…..42% • Body fears………................... 36% • Counting……………………..…….36% • Insisting on symmetry……….. 31% • aggressive behaviors ………..28%

44. Obsessive-Compulsive Disorder • Functional Consequences of Generalized Anxiety Disorder • Excessive worrying impairs the individual's capacity to do things quickly and efficiently, whether at home or at work. The worrying takes time and energy; the associated symptoms of muscle tension and feeling keyed up or on edge, tiredness, difficulty concentrating, and disturbed sleep contribute to the impairment.

45. Body Dysmorphic Disorder

46. Body Dysmorphic Disorder • A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. • B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns. • C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

47. Body Dysmorphic Disorder • D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder. • Prevalence • The point prevalence among U.S. adults is 2.4% (2.5% in females and 2.2% in males). • Suicide Risk • Individuals with body dysmorphic disorder have many risk factors for completed suicide, such as high rates of suicidal ideation and suicide attempts, demographic characteristics associated with suicide, and high rates • of comorbid major depressive disorder.

48. Body Dysmorphic Disorder • Functional Consequences of Body Dysmorphic Disorder • Nearly all individuals with body dysmorphic disorder experience impaired psychosocial functioning because of their appearance concerns. Impairment can range from moderate (e.g., avoidance of some social situations) to extreme and incapacitating (e.g., being completely housebound).

49. Trauma and Stressor-Related Disorders

50. Posttraumatic Stress Disorder Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see corresponding criteria below. A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.