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Anxiety Disorders Understanding Anxiety Disorders in Disability Services Agenda • Define Anxiety Disorders • How Anxiety impacts individuals with disabilities • Recommendations on supporting individuals with disabilities who may have a anxiety disorder Diagnostic Manual-Intellectual Disability “Consequently, the extent to which the criteria can be validly and reliably applied in this population is problematic and should be decided on the basis of robust empirical data with relation to phenomenology of the disorders” (DM-ID, pg. 317) Prevalence of Anxiety in ID Population Adults with Autism are 3x more likely to have anxiety than ID population 55.5 % of children with Autism met the criteria for Anxiety Disorders Studies show 14% to 26% of adult ID population have anxiety disorder Disabilities and Anxiety • Cognitive deficits make it more difficult for individuals with IDD to express themselves • Dependence on others to assist them with personal care and daily living activities • Communication or physical impairments may over shadow anxiety disorders • Lack of awareness and education • Lack of self advocacy training and a system which encourages compliance • People with disabilities often rely on others to recognize mental health issues What Causes Anxiety • • • • • • Risk Factors for Anxiety with ID Population Trauma/Bullying Multiple Homes Many transitions Loss/separation Stressful environments Illness Disabilities and Trauma • Some studies estimate that close to 80% of women with developmental disabilities have been sexually assaulted at some point in their lives. • Other studies show that people with disabilities are more likely to experience more severe abuse, experience abuse for a longer duration, be victims of multiple episodes, and be victims of a larger number of perpetrators. • Prevalence of abuse and neglect in the IDD population is conservatively estimated to be at least four times more likely than those people without disabilities. Types of Anxiety Disorders • Panic Disorder without Agoraphobia, Panic Disorder with Agoraphobia, Agoraphobia without History of Panic Disorder, Specific Phobia, Social Phobia • Obsessive-Compulsive Disorder • Post Traumatic Stress Disorder, Acute Stress Disorder, Generalized Anxiety Disorder • Substance-Induced Anxiety Disorder • Anxiety Disorder Not Otherwise Specified Panic Attack A Panic Attack is a discrete period in which there is the sudden onset of intense apprehension, fearfulness, or terror, often associated with feelings of impending doom. Symptoms include shortness of breath, palpitations, chest pain or discomfort, choking or smothering sensations, and fear of “going crazy” or losing control are present (DM-ID) Panic Attack No adaptations for Mild to Moderate ID for Panic Attack Panic Attack might be observed rather than self-reported in severe to profound ID population. The person may appear to be intensely frightened/agitated/distressed. Pounding racing heartbeats and skipped beats might be identified by taking the pulse or listening through a stethoscope in the Severe to Profound ID population Chest pains may be observed if the person is clutching or rubbing their chest in Severe to Profound ID. (DM-ID) Agoraphobia Agoraphobia is anxiety about, or avoidance of places or situations from which escape is difficult or embarrassing. Panic Disorder Without Agoraphobia is characterized by recurrent unexpected Panic Attacks, about which there is persistent concern. Panic Disorder With Agoraphobia is characterized by recurrent unexpected Panic Attacks and Agoraphobia. Agoraphobia No adaptations for Mild to Moderate ID Inapplicable in persons with profound disability. Difficult to apply in Severe IDD unless there is clear and reliable evidence from the person with IDD or the caregiver attributable to the cause and effect that satisfies criteria Avoidance of situations is limited/impractical on account of disabilities or through lack of choice in severe and profound ID Panic Disorder Without Agoraphobia No adaptations for Mild to Moderate ID (note: The person may have difficulty with temporal sequencing following a panic attack. Try to use important anchors in time such as birthdays, holidays, important trips or events) This condition cannot be detected in Severe to Profound ID population, however consider if the person has the appearance of being worried or distressed, increased search for reassurance, clinging or crying. Specific Phobia In ID Population • Characterized by clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidance. • Marked and persistent fear of a situation or object (e.g., flying, heights, animals, receiving an injection, giving lab work, loud sounds or noises, or crowded places/enclosed places) Specific Phobia in ID Population No adaptations for Mild to Moderate ID Populations A note for Severe to Profound ID is the anxiety may be expressed by crying, tantrums, freezing, or clinging. It may not be possible to avoid the phobic situation in persons with Severe ID through lack of choice. In individuals with ID the duration for this disorder is at least 6 months Specific Phobia in ID Population Sensory processing issues happen from the brain having trouble receiving and responding to information that comes through the senses. Common sounds may be painful. Sensory problems in individuals with Autism can lead to phobias. For example, exposure to clothes, which can chafe the skin, or loud noises in crowded places. Social Phobia in ID Population Fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. No adaptations for Mild to Moderate ID Population In persons with Severe ID the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people. Acute Stress Disorder in ID Population Exposed to a traumatic event in which both of the following are present: • The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death, serious injury, or threat to physical integrity. • The person’s response involved intense fear, helplessness, or horror • Other criteria include possible numbing, detachment, reduction in awareness of surroundings, absence of response, dissociation Acute Stress Disorder in ID Population • No adaptations for Mild to Moderate ID population • Dissociative symptoms are difficult to apply and may only be observed in persons with Severe/Profound ID- for example, absence of response may look like “being in a daze” Generalized Anxiety Disorder in ID Population • Excessive anxiety and worry, occurring more days than not for at least 6 months • Focus of anxiety and worry is not confined to features of an Axis I disorder such as Social Phobia or Panic Attack. • Need three of the following six symptoms • • • • • • Person finds it difficult to control worry Restlessness or feeling keyed up or on edge Being easily fatigued Irritability Muscle tension Sleep disturbance Generalized Anxiety Disorder in ID Population • No adaptations for Mild to Moderate ID population • For Severe/Profound ID only one item is needed from the previous slides list of symptoms • Difficult to apply in persons with Severe ID and inapplicable to persons with Profound ID. Anxiety Disorder Due to General Medical Condition • Prominent anxiety, panic attack or obsessions or compulsions predominate clinical picture and seem to be directly related physiologically to a medical condition. • No adaptations for Mild to Moderate ID populations • Severe/Profound ID individuals will usually not be able to self-report but may be observed to be agitated for frightened Obsessive-Compulsive Disorder in ID Population • Obsessions for defined; • Recurrent intrusive thoughts , impulses , or images that cause anxiety • Not associated with real-life worries • Person attempts to ignore or suppress such thoughts, impulses or images with another thought or action • Obsessions may be difficult to elicit in ID population due to communication deficits. • ID population may be unable to report wanting to ignore Obsessive-Compulsive Disorder in ID Population • Compulsions are defined; • Repetitive behaviors (hand washing, ordering, checking, asking questions, hoarding or rubbing) or mental acts (praying, counting repeating words silently) that the person feels driven to perform according to rules that must be applied rigidly • Behaviors are aimed at preventing or reducing distress or preventing some dreaded event or situation • May be difficult or impossible to elicit due to cognitive impairment or communication difficulties in ID population • For compulsions in Severe/Profound ID look for excessive ordering, arrangements • Challenging behaviors such as aggression or self-injury may occur if the person is prevented from compulsion. Obsessive-Compulsive Disorder in ID Population • Compulsions are defined; • There are many possible underlying reasons for self-injurious behaviors/movements in people with ID therefore, self-injury should not be used for making a diagnosis of OCD • Stereotypic actions such as rocking, banging objects, flipping, swinging objects, and pointing at body parts does not by itself mean a diagnosis of OCD in ID population • Some repetitive behaviors with physiologically rewarding properties should not be used to make the OCD diagnosis (examples include; masturbating, stealing, overeating, overdrinking, humming, pacing) Post Traumatic Stress Disorder Diagnostic criteria for PTSD include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: Intrusion Avoidance Negative alterations in cognitions and mood, and Alterations in arousal and reactivity. The sixth criterion concerns duration of symptoms; the seventh assesses functioning; and, the eighth criterion clarifies symptoms as not attributable to a substance or co-occurring medical condition. Genetic Syndromes • Individuals with ID and specific chromosomal syndromes such as Autism, Prader-Willi, Down Syndrome, Fragile X, and Williams Syndromes have a heightened probability of demonstrated ritualized or compulsive-like behavior. (DM-ID pg. 357) Anxiety Screening Tools for ID Population • • • • • • Mood and Anxiety Semi-Structured Interview The Fear Survey (children and adults) Anxiety and Depression Mood Scale Glasgow Anxiety Scale Yale Brown OCD Scale Aberrant Behavior Checklist (ABC) Social/Environmental Biopsychosocial Approach to Treatment • Biological Biopsychosocial Approach to Treatment • Biological Biopsychosocial Approach to Treatment • Biological Biopsychosocial Approach to Treatment • Biological • • • • • • • • SSRI often used for repetitive behaviors, hair pulling, self-injury Naltrexone used for self-injury Propranolol-generalized anxiety Rare to see Benzodiazepines Overall wellness management through medical providers Nutrition Exercise Sleep Social/Environmental • Reduce stimuli such as clutter, noise, lighting, temperature, earphones, eye glasses • Reduction in transitions • Wellness and Lifestyle Supports (Intellectual, Spiritual, Occupational, Environmental, Social, Emotional, and Physical Wellness) • Social connections (Special Olympics, community support groups and events) • Peer programs • Sensory Diets What is Mental Health First Aid Mental Health First Aid is the help offered to a person developing a mental health problem or experiencing a mental health crisis. The first aid is given until appropriate treatment and support are received or until the crisis resolves. Mental Health First Aid: ALGEE • Assess for risk of suicide or harm • Listen nonjudgmentally • Give support and reassurance • Encourage appropriate professional help • Encourage self-help and other support strategies References • ACE Study • Diagnostic Manual of Intellectual Disabilities • University of New Mexico, Dr Molly Faulkner, March 2015 • Goodnewswellnessliving • Bruce Perry, Boy Raised as a Dog, Child Trauma Academy Resources • http://goodnewswellnesslifestyle.com/ • http://thenadd.org/ • http://vkc.mc.vanderbilt.edu/etoolkit/