Download Anxiety Disorders

Survey of Modern Psychology
Anxiety Disorders
The Anxiety Disorders
Panic Attack
Agoraphobia
Panic Disorder Without Agoraphobia
Panic Disorder With Agoraphobia
Specific Phobia
Obsessive Compulsive Disorder
Post Traumatic Stress Disorder
Generalized Anxiety Disorder
Panic Attack
• A discrete period of intense fear or discomfort, in
which four (or more) of the following symptoms
developed abruptly and reached a peak within 10
minutes
1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feeling of choking
6. Chest pain or discomfort
Panic Attack (4 or more)
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheaded, or faint
9. Derealization (feelings of unreality) or
depersonalization (being detached from oneself)
10.Fear of losing control or going crazy
11.Fear of dying
12.Paresthesias (numbness or tingling sensations)
13.Chills or hot flushes
Panic Attack
Not a disorder by itself
Can occur in Anxiety Disorders or other
disorders
i.e., Mood Disorders, Substance Related, general
medical conditions
Different from generalized anxiety because it
happens within a discrete period of time
There is no real danger present
Panic Attacks
 Uncued/Unexpected
The individual does not associate onset with a particular
internal or external situational trigger
Seems to occur spontaneously
 Cued/Situationally Bound
Almost invariably occur immediately upon exposure to,
or in anticipation of, the situational cue or trigger
 Situationally Predisposed
Similar to situationally bound but there are times that
the person is exposed to the stimulus and does not have
a Panic Attack
Agoraphobia
The essential feature is a fear of being in places or
situations from which escape might be difficult
(or embarrassing) or impossible, or in which help
would not be available in the event of a Panic
Attack
The individual avoids feared situations and may
not be able to work or carry out responsibilities
Agoraphobia by itself is not a codable disorder
However, a diagnosis of Agoraphobia Without History
of Panic Disorder is possible
Agoraphobia
A. Anxiety about being in places or situations from which
escape might be difficult (or embarrassing) or in which help
may not be available in the event of having an unexpected or
situationally predisposed Panic Attack or panic-like
symptoms. Agoraphobic fears typically involve characteristic
clusters of situations that include being outside the home
alone; being in a crowd or standing in a line; being on a
bridge; and traveling in a bus, train, or automobile
Note: Consider the diagnosis of Specific Phobia if the avoidance
is limited to one or only a few specific situations, or Social
Phobia if the avoidance is limited to social situations
Agoraphobia
B. The situations are avoided (e.g., travel is restricted) or else are
endured with marked distress or anxiety about having a Panic Attack
or panic-like symptoms, or require the presence of a companion
C. The anxiety or phobic avoidance is not better accounted for by
another mental disorder, such as Social Phobia (e.g., avoidance
limited to social situations because of fear of embarrassment),
Specific Phobia (e.g., avoidance limited to a single situation like
elevators), Obsessive-Compulsive Disorder (e.g., avoidance of dirt in
someone with an obsession about contamination), Posttraumatic
Stress Disorder (e.g., avoidance of stimuli associated with a severe
stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving
home or relatives)
Panic Disorder Without Agoraphobia
A. Both (1) and (2):
1. Recurrent unexpected Panic Attacks
2. At least one of the attacks has been followed by 1
month (or more) of one (or more) of the following:
a. Persistent concern about having additional attacks
b. Worry about the implications of the attack or its
consequences (e.g., losing control, having a heart attack,
“going crazy”)
c. A significant change in behavior related to the attacks
B. Absence of of Agoraphobia
Panic Disorder Without Agoraphobia
C. The Panic Attacks are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication) or
a general medical condition (e.g., hyperthyroidism)
D. The Panic Attacks are not better accounted for by another
mental disorder, such as Social Phobia (e.g., occurring on
exposure to feared social situations), Specific Phobia (e.g., on
exposure to a specific phobic situation), ObsessiveCompulsive Disorder (e.g., on exposure to dirt in someone
with an obsession about contamination), Posttraumatic
Stress Disorder (e.g., in response to stimuli associated with a
severe stressor), or Separation Anxiety Disorder (e.g., in
response to being away from home or close relatives)
Panic Disorder With Agoraphobia
A. Both (1) and (2):
1. Recurrent unexpected Panic Attacks
2. At least one of the attacks has been followed by 1
month (or more) of one (or more) of the following:
a. Persistent concern about having additional attacks
b. Worry about the implications of the attack or its
consequences (e.g., losing control, having a heart attack,
“going crazy”)
c. A significant change in behavior related to the attacks
B. The presence of Agoraphobia
Panic Disorder With Agoraphobia
C. The Panic Attacks are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication) or
a general medical condition (e.g., hyperthyroidism)
D. The Panic Attacks are not better accounted for by another
mental disorder, such as Social Phobia (e.g., occurring on
exposure to feared social situations), Specific Phobia (e.g., on
exposure to a specific phobic situation), ObsessiveCompulsive Disorder (e.g., on exposure to dirt in someone
with an obsession about contamination), Posttraumatic
Stress Disorder (e.g., in response to stimuli associated with a
severe stressor), or Separation Anxiety Disorder (e.g., in
response to being away from home or close relatives)
Panic Disorder: Notes
Tend to have more anxiety overall
Often are less tolerant of medication side effects
and need continued reassurance when taking a
medication
If the Panic Disorder was initially misdiagnosed or
not treated, the person may believe that they have
an undetected life-threatening condition
May be exacerbated by disruptions in interpersonal
relationships
Panic Disorder: Notes
 Mixed reports on high comorbidity with Major Depressive
Disorder
Rates are reported as anywhere from 10% to 65%
In 1/3 of these cases, the Depression precedes the Panic Disorder
In the other 2/3, they occur together
 Some may develop a substance abuse problem by trying
to treat the anxiety with alcohol or other drugs
 Separation Anxiety Disorder in childhood is strongly
associated with a later diagnosis of Panic Disorder
 Often comorbid with Hypochondriasis
Panic Disorder: Notes
 Panic Disorder is more common in women
 Lifetime prevalence is 1% - 2%
 Point prevalence is .5% - 1.5%
 Age of onset is bimodal:
 Late adolescence
 Mid 30’s
 Some cases begin in childhood, and can occur later in life
 First degree relatives are more likely to have Panic Disorder
 The risk is higher if it began before age 20
 Twin studies indicate a genetic component
Specific Phobia
Rarely severe enough to require treatment
A. Marked and persistent fear that is excessive or
unreasonable, cued by the presence or anticipation of a
specific object or situation (e.g., flying, heights, animals,
receiving an injection, seeing blood)
B. Exposure to the phobic stimulus almost invariably
provokes an immediate anxiety response, which may
take the form of a situationally bound or situationally
predisposed Panic Attack. Note: In children, the anxiety
may be expressed by crying, tantrums, freezing, or
clinging
Specific Phobia
C. The person recognizes that the fear is excessive or
unreasonable. Note: In children, this feature may be absent
D. The phobic situation(s) is avoided or else is endured with
intense anxiety or distress
E. The avoidance, anxious anticipation, or distress in the feared
situation's) interferes significantly with the person’s normal
routine, occupational (or academic) functioning, or social
activities or relationships, or there is marked distress about
having the phobia
F. In individuals under age 18 years, the duration is at least 6
months
Specific Phobia
G. The anxiety, Panic Attacks, or phobic avoidance
associated with the specific object or situation are not
better accounted for by another mental disorder, such as
Obsessive-Compulsive Disorder (e.g., fear of dirt in
someone with an obsession about contamination),
Posttraumatic Stress Disorder (e.g., avoidance of stimuli
associated with a severe stressor), Separation Anxiety
Disorder (e.g., avoidance of school), Social Phobia (e.g.,
avoidance of social situations because of fear of
embarrassment), Panic Disorder With Agoraphobia, or
Agoraphobia Without History of Panic Disorder
Specific Phobia
Specify type:
Animal Type
Natural Environment Type (e.g., heights, storms,
water)
Blood-Injection-Injury Type
Situational Type (e.g., airplanes, elevators,
enclosed spaces)
Other Type (e.g., fear of choking, vomiting, or
contracting an illness; in children, fear of loud
sounds or costumes characters)
Social Phobia
(Social Anxiety Disorder)
A. A marked and persistent fear of one or more social
or performance situations in which the person is
exposed to unfamiliar people or to possible
scrutiny by others. The individual fears that he or
she will act in a way (or show anxiety symptoms)
that will be humiliating or embarrassing. Note: In
children, there must be evidence of the capacity
for age-appropriate social relationships with
familiar people and the anxiety must occur in peer
settings, not just in interactions with adults
Social Phobia
(Social Anxiety Disorder)
B. Exposure to the feared social situation almost invariably provokes anxiety,
which may take the form of a situationally bound or situationally
predisposed Panic Attack. Note: In children, the anxiety may be expressed by
crying, tantrums, freezing, or shrinking from social situations with unfamiliar
people
C. The person recognizes that the fear is excessive or unreasonable Note: In
children, this feature may be absent
D. The feared social or performance situations are avoided or else are endured
with intense anxiety or distress
E. The avoidance, anxious anticipation, or distress in the feared social or
performance situation(s) interferes significantly with the person’s normal
routine, occupational (academic) functioning, or social activities or
relationships, or there is marked distress about having the phobia
Social Phobia
(Social Anxiety Disorder)
F. In individuals under age 18 years, the duration is at least 6 months
G. The fear or avoidance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition and is not better accounted fro by other mental disorder
(e.g., Panic Disorder With or Without Agoraphobia, Separation
Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive
Developmental Disorder, or Schizoid Personality Disorder)
H. If a general medical condition or another mental disorder is present,
the fear in Criterion A is unrelated to it, e.g., the fear is not of
Stuttering, trembling in Parkinson’s disease, or exhibiting abnormal
eating behavior in Anorexia Nervosa or Bulimia Nervosa.
Specify if:
Generalized: if the fears include most social situations (also consider
the additional diagnosis of Avoidant Personality Disorder)
Social Phobia: Specifiers
Generalized
The fears are related to most social situations
Fear of public performance and social interaction
This is as opposed to a more specific fear of
certain types of social situations
Social Phobia: Notes
 Social Phobia should only be diagnosed if the fear or
avoidance interferes with the person’s normal routine or
causes distress
For example, a person who is afraid of public speaking would
not be diagnosed if he or she does not routinely encounter
public speaking at work/school and is not distressed about it
 In general, a fear of being embarrassed in social situations
is common, but it usually does not cause impairment
 Transient social anxiety or avoidance is common in
childhood and adolescence
Social Phobia: Notes
Associated features:
Hypersensitivity to criticism, negative evaluation, or
rejection
Difficulty being assertive
Low self esteem
Feelings of inferiority
May manifest poor social skills
May underachieve in school due to test anxiety or
avoiding participation
Smaller social support network
Less likely to marry
Social Phobia: Notes
High comorbidity:
Other Anxiety Disorders
Mood Disorders
Substance Related Disorders
Bulimia
Most of these disorders are preceded by Social
Phobia
Social Phobia: Notes
Presentation may differ across groups and social
demands
i.e., might fear offending others rather than
embarrassing oneself
Young children might be selectively mute
In children:
Must be evidence of a capacity for relationships with
familiar people
Impairment tends to show in failure to make expected
achievements rather than a decline in functioning
Social Phobia: Notes
 Lifetime prevalence reports range from 3% to 13%
 Depends on the threshold used to determine distress or
impairment and the number of situations specifically asked about
In one study, 20% of people reported an “excessive” fear of public
speaking, but only 2% reported enough impairment to warrant a
diagnosis
 Rarely a primary cause for seeking treatment
 Community based studies suggest that it’s more common
among females; in clinical samples, it’s equally common
among males and females or more common among males
 There is strong genetic evidence for Generalized Social Phobia
Obsessive Compulsive Disorder
A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
1. Recurrent and persistent thoughts, impulses, or images that are
experienced, at some time during the disturbance, as intrusive
and inappropriate and that cause marked anxiety or distress
2. The thoughts, impulses, or images are not simply excessive
worries about real-life problems
3. The person attempts to ignore or suppress such thoughts,
impulses, or images, or to neutralize them with some other
thought or action
4. The person recognizes that the obsessional thoughts, impulses, or
images are a product of his or her own mind (not imposed from
without as in thought insertion)
Obsessive Compulsive Disorder
Compulsions as defined by (1) and (2):
1. Repetitive behaviors (e.g., hand washing, ordering,
checking) or mental acts (e.g., prying, counting,
repeating words silently) that the person 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 distress or preventing some dreaded event
or situation; however, these behaviors or mental acts
either are not connected in a realistic way with what
they are designed to neutralize or prevent or are
clearly excessive
Obsessive Compulsive Disorder
B. At some point during the course of the disorder,
the person has recognized that the obsessions
or compulsions are excessive or unreasonable.
Note: this does not apply to children.
C. The obsessions or compulsions cause marked
distress, are time consuming (take more than 1
hour a day), or significantly interfere with the
person’s normal routine, occupational (or
academic) functioning, or usual social activities
or relationships
Obsessive Compulsive Disorder
D. If another Axis I disorder is present, the content of the obsessions or
compulsions is not restricted to it (e.g., preoccupation with food in the
presence of an Eating Disorder; hair pulling in the presence of
Trichotillomania; concern with appearance in the presence of Body
Dysmorphic Disorder; preoccupation with drugs in the presence of a
Substance Abuse Disorder; preoccupation with having a serious illness in the
presence of Hypochondriasis; preoccupation with sexual urges or fantasies
in the presence of a Paraphilia; or guilty ruminations in the presence of
Major Depressive Disorder)
E. The disturbance is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition
Specify if:
With Poor Insight: if, for most of the time during the current episode, the
person does not recognize that the obsessions and compulsions are
excessive or unreasonable
Obsessive-Compulsive Disorder: Notes
Example: http://www.youtube.com/watch?v=-sM3h6nnus
From the movie “As Good As It Gets”
Obsessive-Compulsive Disorder: Notes
Situations that trigger obsessions or compulsions are
frequently avoided
In laboratory settings, people with OCD show increased
autonomic activity when faced with triggering stimuli;
the physiological reactivity decreases after the
compulsion is performed
Cultural or religious beliefs may influence the themes
of obsessions and compulsions
In general, people are more likely to engage in ritual
behavior at home rather than in front of strangers
Obsessive-Compulsive Disorder: Notes
High comorbidity with:
Major Depressive Disorder
Other Anxiety Disorders
Eating Disorders
Some Personality Disorders
Learning Disabilities
Disruptive Behavior Disorders
High incidence in children and adults with Tourette’s
Disorder
35% - 50% of people with Tourette’s have OCD
Obsessive-Compulsive Disorder: Notes
In some cases, OCD may be associated with
Group A beta hemolytic streptococcal infection
This is characterized by:
 Onset prior to puberty
 Neurological abnormalities (Choreiform movements –
involuntary, rapid, jerky movements and Motoric
hyperactivity)
Abrupt onset
Exacerbated during times of streptococcal infection
Obsessive-Compulsive Disorder: Notes
Common behaviors in children:
Washing
Checking
Ordering
Common behaviors in adults:
Obsessions with morality
Washing
Obsessive-Compulsive Disorder: Notes
In adults, OCD is equally common in males and females
In children, OCD is more common in males than
females
Lifetime prevalence: 1% - 2.3%
Point prevalence: .7%
Prevalence is similar across cultures internationally
Usually begins in adolescence or early adulthood
Males: between age 6 – 15 years
Females: between 20 – 29 years
Obsessive-Compulsive Disorder: Notes
Symptoms are usually exacerbated by stress
Symptoms tend to be chronic wax and wane
over the lifetime
About 15% of people with OCD show a
progressive deterioration in functioning
5% have an episodic course, with little to no
symptoms between episodes
Strong genetic component
Obsessive-Compulsive Disorder:
Hoarding
A common symptom of
OCD is hoarding
Acquisition of, and inability
to discard, meaningless
objects
Cluttered living spaces that
limit their use
Significant distress and/or
interference in functioning
Obsessive-Compulsive Disorder:
Hoarding
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 person 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 present for more
days than not for the past 6 months.) Note:
Only one item is required in children.
Generalized Anxiety Disorder
(3 or more)
1.
2.
3.
4.
5.
6.
Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance (difficulty falling or staying
asleep, or restless unsatisfying sleep)
Generalized Anxiety Disorder
D. The focus of the anxiety and worry is not confined to features of an Axis I
disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in
Panic Disorder), being embarrassed in public (as in Social Phobia), being
contaminated (as in Obsessive-Compulsive Disorder), being away from home
or close relatives (as in Separation Anxiety Disorder), gaining weight (as in
Anorexia Nervosa), having multiple physical complaints (as in Somatization
Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety
and worry do not occur exclusively during Posttraumatic Stress Disorder
E. The anxiety, worry, or physical symptoms cause clinically significant distress
or impairment in social, occupational, or other important areas of
functioning
F. The disturbance is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition (e.g.,
hyperthyroidism) and does not occur exclusively during a Mood Disorder, a
Psychotic Disorder, or a Pervasive Developmental Disorder
Generalized Anxiety Disorder:
Notes
 The intensity, duration, and frequency of the anxiety and worry are out
of proportion to the actual likelihood or impact of the feared event
 During the course of GAD, the focus of worry may shift from one
concern to another
 There may be trembling, twitching, feeling shaky, muscle aches or
soreness associated with muscle tension from the anxiety
 May also have sweating, gastrointestinal problems, and an
exaggerated startle response
 Symptoms that are prominent in other Anxiety Disorders, such as
accelerated heart rate, shortness of breath, and dizziness are less
common in GAD
Generalized Anxiety Disorder:
Notes
High comorbidity with:
Mood Disorders
Other Anxiety Disorders
Substance abuse
Medical conditions that are associated with stress
Generalized Anxiety Disorder:
Notes
 Expressions of anxiety tend to vary across cultures
 Somatic vs. cognitive symptoms
 Common focuses of worry for children tend to be:
 Quality of performance or competence (even when they are not
being evaluated)
 Excessive concerns about punctuality
 Catastrophes that are unlikely to happen
 Overly conforming
 Perfectionistism
 Tendency to redo tasks because of excessive dissatisfaction with an
“imperfect” performance
 Overzealous in seeking approval
 Require excessive reassurance
Generalized Anxiety Disorder:
Notes
More common in women
In clinical settings, 55% - 60% of GAD cases are female
In anxiety disorder clinics, up to 25% of clients
have GAD as a presenting or comorbid diagnosis
Usually begins in childhood or adolescence
Strong genetic component which may be related
to the same genetic factors as those for Major
Depressive Disorder
Anxiety Disorders: Treatment
Cognitive Behavioral Therapy is extremely
effective
Particularly exposure techniques
Medication
Medication is most effective when combined with
therapy
Medications used often act on serotonin, other
times tranquilizers are used
Occasionally, antipsychotic medications are used
Blood pressure medication may also be used to treat the
physiological signs of anxiety
Anxiety Disorders: Treatment
Beta – Blockers:
Inderal
Selective Serotonin Reuptake Inhibitors
(antidepressants)
Celexa
Luvox
Paxil
Prozac
Zoloft
Anxiety Disorders: Treatment
Benzodiazepines (act on GABA)
•Ativan
•Klonopin
•Librium
•Serax
•Tranxene
•Valium
•Xanax
Side effects include
Short term:
•Sedation
•Impaired physical
coordination
•Memory loss
Over an extended period:
•Cognitive impairment
•Depression
•Brain shrinkage
Daily use for a month or more:
•Withdrawal symptoms upon
cessation
•addiction
Posttraumatic Stress Disorder
(PTSD)
A. The person has been exposed to a traumatic
even in which both of the following were
present:
1.The person experienced, witnessed, or was
confronted with an event or events that involved
actual or threatened death or serious injury, or a
threat to the physical integrity of self or others
2.The person's response involved intense fear,
helplessness, or horror. Note: In children, this may
be expressed instead by disorganized or agitated
behavior
Posttraumatic Stress Disorder
(PTSD)
B. The traumatic even is persistently reexperienced in
one (or more) of the following ways:
1.
2.
3.
4.
5.
Recurrent and intrusive distressing recollections of the event, including images,
thoughts, or perceptions. Note: in young children, repetitive play may occur in
which themes or aspects of the trauma are expressed
Recurrent distressing dreams of the event. Note: in children, there may be
frightening dreams without recognizable content
Acting or feeling as if the traumatic event were recurring (includes a sense of
reliving the experience, illusions, hallucinations, and dissociative flashback
episodes, including those that occur on awakening or when intoxicated.) Note: in
young children, trauma-specific reenactment may occur
Intense psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event
Physiological reactivity on exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event
Posttraumatic Stress Disorder
(PTSD)
C. Persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness (not present before the trauma),
as indicated by three (or more) of the following:
1. Efforts to avoid thoughts, feelings, or conversations associated with
the trauma
2. Efforts to avoid activities, places, or people that arouse recollections
of the trauma
3. Inability to recall an important aspect of the trauma
4. Markedly diminished interest or participation in significant activities
5. Feeling of detachment or estrangement from others
6. Restricted range of affect (e.g., unable to have loving feelings(
7. Sense of a foreshortened future (e.g., does not expect to have a
career, marriage, children, or a normal life span)
Posttraumatic Stress Disorder
(PTSD)
D. Persistent symptoms of increased arousal (not
present before the trauma), as indicated by two
(or more) of the following:
1.
2.
3.
4.
5.
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
Posttraumatic Stress Disorder
(PTSD)
E. Duration of the disturbance (symptoms in Criteria B, C, and
D) is more than 1 month
F. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
With Delayed Onset: if onset of symptoms is at least 6
months after the stressor
PTSD: Notes
 PTSD is more common among people who have recently
emigrated from areas of social unrest and conflict
They may be less likely to discuss the problem or seek
therapy because of immigration status
 Young children are less likely to experience flashbacks and
more likely to show symptoms through their play
 Reports from parents and/or teachers are important to
monitor changes in functioning
 Children are more likely to report physical symptoms
PTSD: Notes
 Can begin at any age
 Usually starts within three months of the trauma
 Severity, duration, and proximity of an individual’s
exposure to the trauma are the most important factors
that affect the likelihood of the person developing PTSD
 More likely to develop in people with preexisting mental
illnesses, but it can develop in anyone if the trauma is
extreme
 More common among people who are first degree
relatives to someone with a history of Depression
PTSD: Treatment
 Talk therapy and medication (depending on symptoms)
 Eye Movement Desensitization Reprocessing
 The client focuses on the memory of the traumatic event while
looking at a moving visual target
 The theory is that the eye movement replicates the movement in
the REM phase of sleep and helps the brain process the memory
 There is question as to whether or not it actually works, or may be
harmful
 Debriefing
 The client repeats the memory until it loses its full emotion effect