Anxiety Disorders DSM-IV-TR
Necessary Information from Clinical Interview • Current and past history of anxiety • Feelings of: • derealization, • depersonalization, or • emotional numbing • Fears of: • Losing control, or • Going crazy • Sleep disturbance; e.g., bad dreams
Necessary Information from Clinical Interview Medical illness Physical symptoms Previous and current psychiatric illnesses Current or past traumatic events or stress Compulsive behaviors or rituals Current medications & abused substances
DiagnosingAnxiety Disorders Anxiety “Building Blocks:” • Panic Attacks and Agoraphobia • Not codable disorders • Several codable disorders are constructed from these “building blocks.”
DiagnosingAnxiety Disorders What is a Panic Attack? • A brief episode (peaks within 10 minutes) • Sudden intense fear and/or discomfort • Client feels intense dread – feelings of impeding doom • Numerous somatic symptoms, such as: • Shortness of breath • Dizziness or unsteady feelings • Palpitations (tachycardia) • Trembling or shaking, • Sweating, • Choking, • Nausea or abdominal distress • Depersonalization or derealization, • Flushes or chills, • Chest pain or discomfort, • Fear of dying, • Fear of losing control
DiagnosingAnxiety Disorders What is Agoraphobia? • Clients, with this condition have: • Intense fear and/or discomfort • Avoid places or situations in which: • Escape might be difficult or embarrassing. • Help may not be available in the event of panic symptoms • This definition is different from the popular definition, in which a person with agoraphobia does not leave his/her home. ,
Twelve (12) Types of Anxiety Disorders 1. Panic Disorder (without Agoraphobia) 2. Panic Disorder with Agoraphobia 3. Agoraphobia (without history of panic attacks) 4. Specific Phobia 5. Social Phobia 6. Obsessive Compulsive Disorder 7. Post Traumatic Stress Disorder 8. Acute Stress Disorder 9. Generalized Anxiety Disorder 10. Anxiety Disorders due to a General Medical Condition (GMC) 11. Substance-Induced Anxiety Disorder 12. Anxiety Disorder NOS
Panic Disorder These clients experience repeated panic attacks, together with worry about having additional attacks and other mental and behavioral changes related to them. Panic disorder usually occurs with Agoraphobia (p. 441), but it is sometimes diagnosed without agoraphobia (p. 440). 300.21 Panic Disorder With Agoraphobia 300.01 Panic Disorder Without Agoraphobia
Panic Disorder About 30% of adult population occasionally has a panic attack. Panic attacks are usually not too distressing
Panic Disorder Differences between clinical and non-clinical population : • Non-clinical population responds with less anxiety to the physical sensation • Clinical population gives themselves messages, such as: • “I’m having a heart attack” • “I’m going mad” And, they fear other peoples responses to the attack.
Panic Disorder Ramifications for Treatment Teach clients not to respond with anxiety-causing messages when having a panic attack. Clients can say to self: “It will be over in 10 minutes.” “I’m not dying.” “Relax. Breathe slowly.” Most people when they are having panic attacks forget to breathe.”
Panic Disorder • Many clients tend to avoid situations or activities that trigger panic attacks. • This can lead to a very restricted life style.
Panic Disorder Examples: Person who has panic attacks when driving on freeway, drives only on city streets Axis I 300.21 Panic Disorder with Agoraphobia (p. 441) Person does not have panic attacks, but is fearful that s/he might get dizzy when driving, so drives only on city streets. Axis I 300.22 Agoraphobia Without History of Panic Disorder (p. 441)
Panic Disorder Over half of clients with Panic Disorder also qualify for another anxiety disorder or depression. Alcohol abuse is common among clients with Panic Disorder
Panic Disorder Panic Disorder can be effectively treated with cognitive-behavior therapy and tricyclic antidepressants. If medication is discontinued, relapse is the rule rather than the exception Therefore, management of symptoms is often more the goal, rather than cure.
Panic Disorder In a recent study, therapists were able to reduce the number of panic attacks suffered by clients with high anxiety by a Diagnostic Interview in which they made the symptoms more tolerable, simply by naming and describing them.
Agoraphobia This is a codable form of Agoraphobia related to fear of developing panic-like symptoms, in which the full criteria for Panic Disorder are not met (p. 441). 300.22 Agoraphobia Without History of Panic Disorder
Agoraphobiawith/without Panic Disorder 20% of clients with agoraphobia qualify for diagnosis of Avoidant Personality Disorder Agoraphobia is significantly more likely to diagnosed among women than men. Mean age of onset: 28 years – usually between ages 17 and 19, with a few (16%) after age of 40.
Agoraphobiawith/without Panic Disorder If client has agoraphobia for a year, client is unlikely to get better without treatment Treatment consists of in vivo exposure – effective with 75% of clients
Agoraphobiawith/without Panic Disorder A client with agoraphobia may seem to have Specific Phobias as well, but when questioned closely, the client was actually having a panic attack and the phobia was developed in the context of the panic attack.
Agoraphobiawith/without Panic Disorder Example: Client has panic attack when driving on freeway. Now client won’t go near a car. Seems like a phobia, but is really a reaction to feelings of panic. Usually if the panic and fear happen close in time – the fear is a result of the panic. Therefore, don’t diagnose both Panic Disorder and Specific Phobia.
Anxiety Disorders Sometimes more than one Anxiety Disorder can be diagnosed. Example: Phobias often start at a very young age. Fear of heights and fear of enclosed spaces may exist long before the onset of a first panic attack. In this case, a diagnosis of both Specific Phobia and Panic Disorder is justified.
Specific Phobia In this condition, clients fear specific objects or situations, such as animals, storms, heights, blood, airplanes, being closed in, or any situation that may lead to vomiting, choking, or developing an illness (p. 443). 300.29 Specific Phobia, • Specify type: Animal Type Natural Environment Type Blood-injection-injury Type Situational Type Other Type
Specific Phobia • A widespread anxiety disorder – about 10% of population • Most common fears are: • Fear of animals (zoophobia) • Fear of heights (acrophobia) • Fear of confinement (claustrophobia), and • Fear of injury and/or blood.
Specific Phobia When a person is confronted with his/her phobic item, there is: Immediate, extreme distress and panic Brain scans show rising blood flow and energy consumption in the amygdale (center for fear and anger), and sometimes in the insula (region that registers disgust and pain).
Specific Phobia Treatment Cognitive behavior therapy and antidepressant medication lower the reaction to phobic item. Behavioral exposure techniques lead people to confront the objects they fear. The exposure may be gradual and relaxed (desensitization), intense (flooding), or vicarious (modeling).
Specific Phobia Treatment In young children (2-6 years old), specific phobias often improve spontaneously. If phobias continue to adulthood, they don’t often improve spontaneously Most people “self-treat” by staying away from the phobic item. Usually people come for treatment only when faced with having to confront the fear item.
Specific Phobia • Family influence on phobias is very strong. • A strong positive correlation exists between fears of children and their mother • Correlation is especially strong if child is young and comes from a lower socioeconomic strata • Phobias about blood and/or injury seem most likely to run in families. • Sixty percent (60%) of first-degree relatives also have this phobia. • This 3 to 6 times more frequent than panic disorder, obsessive-compulsive, or phobias about dental, animals, or social situations.
Specific Phobia • Usually anxiety disorders and depression overlap; however, Specific Phobia is the exception. • Only 9% of clients with specific phobia report past depressive episodes. • A phobia can be part of another anxiety disorder. • A client with obsessive-compulsive problems may have many cleaning rituals and obsessional concerns with germs and contamination. One of the client’s concerns may pertain to the fear of developing AIDs. However, in this case, the diagnosis of Specific Phobia should not be made. Why?
Specific Phobia • Mean age for onset of a phobia varies: • For animal phobia and blood-injury, the mean age is 8 years old. • For dental phobia, the mean age is 12 years old • For claustrophobia, the mean age is 20 years old • The overall mean age for all phobias is 19.6 years old. • More women than men are diagnosed with a specific phobia
Social Phobia These clients imagine themselves embarrassed when they speak, write, or eat in public, use a public urinal or the like (p. 450) 300.23 Social Phobia, Specify if:Generalized
Social Phobia Social phobia is a persistent fear of one or more social or performance situations in which the person is exposed to possible scrutiny by others. The person fears to behave in a way that will be humiliating and embarrassing People with social phobia become very anxious when confronted with the feared situation they are trying to avoid. Often this avoidance interferes with occupational and social functioning.
Social Phobia If the person fears several social situations, it is classified as “Social Phobia” with the addition of “generalized type.” Most people with this diagnosis have difficulty with at least two different situations, nearly half feel anxious in three or more situations.
Social Phobia A research study by Holt, Heimberg, Hope, and Liebowitz found four different situational domains of social phobia. • Formal speaking and interaction • Informal speaking and interaction • Observation by others, and • Assertion. • 75% of the participants in their study had problems in more than one domain. • Nearly all had problems in forma speaking
Social Phobia This phobia is not due to inadequate social skills Cognitive factors, such as negative self-statement and irrational beliefs, appear to be more important They often evaluate their own social behavior in excessively negative ways and focus on negative experiences in social situations
Social Phobia Retrospective studies studying reasons for social phobia have found: Problematic relationships with parents, such as relationships lacking in emotional warmth, and marred by rejection and overprotection
Social Phobia Alcohol abuse is often a problem; however, the prevalence is less than among individual with panic disorder. Normally social phobia precedes the onset of the alcohol problem,
Social Phobia Onset is usually around 18 years old. Sex ratio is equal Social phobia is less prevalent than agoraphobia
Social Phobia Few studies have been conducted regarding genetic influence. One study did find that 6.5% of first degree relatives have social phobia. No twin studies.
Social Phobia Social phobia should be distinguished from shyness and social anxiety – people with social phobia are abnormally avoidant and intensely fearful of social situations. There is considerable overlap among social phobia, panic disorder, and generalized anxiety.
Social Phobia Many people with Social Phobia meet the criteria for Avoidant Personality Disorder. However, people with Avoidant Personality seem to be less socially skilled and more socially anxious than people with Social Phobia.
Social Phobia • Social Phobia may also be related to Dysmorphia (Somatoform Disorder). Dysmorphia - People preoccupied with a presumed physical anomaly of their body, with no objective basis. • People with Dysmorphia also avoid social situations.
Obsessive-Compulsive Disorder (OCD) These clients are bothered by repeated thoughts or behaviors that appear senseless, even to them (p. 456). 300.3 Obsessive-Compulsive Disorder, Specify if: With Poor Insight
Obsessive Compulsive Disorder • Obsessions are repetitive, recurring thoughts, ideas images, or impulses that are experienced as intrusive. • The person recognizes that the obsessions are the product of his/her own mind. • Obsession are experienced by the client as senseless or repugnant, which she or he attempts to ignore or suppress.
Obsessive Compulsive Disorder • Compulsions, on the other hand, are behaviors that are: • Repetitive, • Apparent, • Purposeful, and • Performed according to certain rules, or in a stereotyped fashion
Obsessive Compulsive Disorder To receive the diagnosis, a person’s complaints/symptoms have to: • Cause marked distress, • Are time-consuming (take more than an hour), or • Interfere with social or work functioning. The specifier, “With Poor Insight,” is given if the person does not recognize that the obsessions and compulsions are excessive or unreasonable.
Obsessive Compulsive Disorder The most common compulsions involve: • Cleaning, e.g., washing hands • Checking, e.g., checking the doors are locked Less common compulsions are: • Compulsive slowness • Orderliness • Hoarding • Buying • Counting