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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