Anxiety Disorder

ANXIETY Maria Luisa B. Archivido

Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by mental health providers in the United States. It contains a listing of diagnostic criteria for every psychiatric disorder recognized by the U.S. health care system.

• Revisions Published in 2013

Anxiety Disorders• Separation Anxiety Disorder• Selective Mutism• Specific Phobia• Social Anxiety Disorder (Social Phobia)• Panic Disorder• Panic Attack (Specifier)• Agoraphobia• Generalized Anxiety Disorder• Substance/Medication-Induced Anxiety Disorder• Anxiety Disorder Due to Another Medical Condition• Other Specified Anxiety Disorder• Unspecified Anxiety Disorder

Obsessive-Compulsive and Related Disorders• Obsessive-Compulsive Disorder• Body Dysmorphic Disorder• Hoarding Disorder• Trichotillomania (Hair-Pulling Disorder)• Excoriation (Skin-Picking) Disorder• Substance/Medication-Induced Obsessive-Compulsive

and Related Disorder• Obsessive-Compulsive and Related Disorder Due to

Another Medical Condition• Other Specified Obsessive-Compulsive and Related

DisorderUnspecified Obsessive-Compulsive and Related Disorder

Trauma- and Stressor-Related Disorders• Reactive Attachment Disorder• Disinhibited Social Engagement Disorder• Posttraumatic Stress Disorder• Acute Stress Disorder• Adjustment Disorders• Other Specified Trauma- and Stressor-Related

Disorder• Unspecified Trauma- and Stressor-Related

Disorder

Overview• What is Anxiety?• What are the different types of anxiety

disorders?• What are the causes?• What are the symptoms?• What are the treatments?

Definition of Anxiety• Anxiety is a feeling of apprehension or fear. • The source of this uneasiness is not always known or

recognized, which can add to the distress you feel.• Anxiety disorders are a group of psychiatric conditions

that involve excessive anxiety.• A feeling state consisting of physical, emotional and

behavioural responses to perceived threats1

• Diffuse, unpleasant sense of apprehension accompanied by physical symptoms such as headache, sweating, palpitations, chest tightness, stomach upset, restlessness

• Normal and necessary part of everyday life

Anxiety Facts• Most common mental illness in the U.S. with 19 million of the adult

(ages 18-54) U.S. population affected.

• Anxiety disorders cost more than $42 billion a year.• More than $22 billion are associated with the repeated use of

healthcare services, as those with anxiety disorders seek relief for symptoms that mimic physical illnesses.

• Anxiety is highly treatable (up to 90% of cases), but only one-third of those who suffer from it receive treatment

• People with an anxiety disorder are three-to-five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than non-sufferers.

• Depression often accompanies anxiety disorders

Anxiety vs. Fear

Anxiety Fear

Threat

Response to a threat that is unknown, internal, vague or

conflictual

Response to a known, external, definite threat

Anxiety as a DisorderWhen does anxiety become a disorder? 1) Greater intensity and/or duration than

expected given the circumstances 2) Leads to impairment or disability 3) Daily activities are disrupted by avoidance of

certain situations or objects to decrease anxiety

4) Includes clinically significant unexplained physical symptoms, obsessions, compulsions, or intrusive recollections of traumaCan J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006

Anxiety

Anxiety =Likelihood x Harm

Ability to cope

Overestimated

Underestimated

Beck et al. 1985

Anxiety Disorders in DSM-IV TRPanic Disorder with and without agoraphobiaAgoraphobia without history of Panic DisorderSocial PhobiaSpecific PhobiaObsessive Compulsive DisorderGeneralized Anxiety DisorderPost Traumatic Stress DisorderAcute Stress DisorderAnxiety Disorder due to a General Medical ConditionSubstance-Induced Anxiety DisorderAnxiety Disorder NOS

Pathophysiology of Anxiety• Caudate nucleus has been implicated in

OCD• fMRI studies have found increased activity

in the amygdala in PTSD• Abnormalities in parahippocampal gyrus in

Panic Disorder• 3 major neurotransmitters involved are

norepinephrine, serotonin, and GABAKaplan and Sadock’s Synopsis of Psychiatry 10th edition

Neurobiology of anxietyLimbic cortex

Periaqueductal Gray matter

Brain Stem

Ventral Tegmental Area

Hippocampus

Amygdala

Nucleus accumbens

Orbitofrontal cortex

* Slide courtesy of Dr. Elliott Lee

Locus coeruleus

Epidemiology• Lifetime prevalence for any anxiety

disorder ranges from 10% to 29%• 12 month prevalence 18%• Common presentation in primary care • 1:5 to 1:12 patients presenting to primary

care will have an anxiety disorder• Suicide rate 10 x higher than general

populationCan J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006

Initial Assessment of Patients with Anxiety• Four scenarios: 1) Anxiety disorder is primary and there is no

physical disorder present (any physical symptoms present are due to the anxiety)

2) The anxiety is secondary to a physical illness (e.g. hyperthyroidism)

3) The anxiety is secondary to a medication or substance

4) Both an anxiety and physical disorder are present by not causally related

Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006

Medical conditions that mimic or worsen anxiety symptomsEndocrine conditions

HyperthyroidismHypothyroidism

PheochromocytomaCushing’s diseaseAddison’s disease

MenopauseCardiovascular Acute Coronary Syndrome

ArrhythmiaCHF

HypertensionHypertension

Mitral Valve Prolapse

Medical conditions that mimic or worsen anxiety symptoms (con’t)Neurological Epilepsy

Cerebrovascular diseaseMeniere’s diseaseMultiple Sclerosis

MigraineEncephalitis

Early dementiaMetabolic Porphyria

DiabetesPulmonary Asthma

COPDPulmonary Embolism

Pneumonia

Medical conditions that mimic or worsen anxiety symptoms (con’t)Other Anemia

UTI (in elderly)Irritable Bowel Syndrome

Heavy metal poisoningB12 deficiency

Electrolyte disturbancesMedications Anti-cholinergics

SteroidsStimulants (methylphenidate

and amphetamine based)Theophylline

VentolinNasal decongestants

Substance Abuse and Anxiety• Substance abuse is often co-morbid with anxiety

disorders as patients often try to self-medicate to cope with anxiety

• 37% of patients with GAD and 20-40% of patients with Panic Disorder have alcohol abuse/dependence

• Drug intoxication can mimic anxiety: - Amphetamines - Marijuana - Caffeine - Hallucinogens - Nicotine - Ecstasy - Cocaine - Excessive alcohol consumption - Phencyclidine

Substance Abuse and Anxiety (con’t)• Drug withdrawal also associated with

anxiety

–Alcohol–Benzodiazepines–Opiate–Barbiturate–Anti-hypertensives

Key features Panic

Disorder• Fear of losing control, dying or going crazy• Avoid situations in which attacks may occur

Agoraphobia

• Fear of situations from which escape may be difficult or help unavailable (crowds, bus, bridge etc.)

OCD • Intrusive, unwanted thoughts or urges (obsessions) and/or repetitive behaviours or mental acts (compulsions)• Fear of harm, uncertainty, uncontrollable actions

Key features Generali

zedAnxiety

• Anxiety regarding a number of everyday events• Future and uncertainty difficult to accept

Social Anxiety

• Fear of humiliation, embarrassment or scrutiny by others

PTSD • Re-experiencing of trauma through flashbacks, dreams, recollections

Specific phobia

• Fear of a specific object, animal or situation

PANIC DISORDER

Panic Disorder• The abrupt onset of an episode of intense fear or discomfort,

which peaks in approximately 10 minutes, and includes at least four of the following symptoms:

• A feeling of imminent danger or doom• The need to escape• Palpitations• Sweating• Trembling• Shortness of breath or a smothering • feeling • A feeling of choking • Chest pain or discomfort

• Nausea or abdominal discomfort• Dizziness or lightheadedness• A sense of things being unreal, • depersonalization• A fear of losing control or "going

crazy" • A fear of dying • Tingling sensations • Chills or hot flushes

Panic DisorderThere are three types of Panic Attacks:

1. Unexpected - the attack "comes out of the blue" without warning and for no discernable reason.

2. Situational - situations in which an individual always has an attack, for example, upon entering a tunnel.

3. Situationally Predisposed - situations in which an individual is likely to have a Panic Attack, but does not always have one. An example of this would be an individual who sometimes has attacks while driving.

Panic Disorder with or without agoraphobia – DSM-IV criteria• The person has experienced both :

• Recurrent, unexpected panic attacks• One or more of the attacks has been followed by either 1) Persistent concern about having another attack 2) Worry about the implications of the attack 3) Significant change in behaviour

• The presence (or absence of agoraphobia)• Not due to a substance, medication or medical

condition• Not better accounted for by another mental

disorder

Panic Disorder• Lifetime prevalence of Panic Disorder is

4.7%• Lifetime prevalence of having a panic

attack is 15%• 1/3 to 1/2 of patients also have

agoraphobia• More common in women than in men• Generally begins in late adolescence or

early adulthoodCan J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006

Panic Disorder• 20 X the risk of suicidal ideation and suicide

attempts as the general population

• Felt to be related to dysregulation of brain noradrenergic systems

• Abnormalities have been found in the autonomic nervous system of some patients (increased sympathetic tone, less adaptive to repeated stimuli)

Kaplan and Sadock’s Synopsis of Psychiatry 10th edition

Panic Disorder - Treatment• Pharmacotherapy:

• 1st line SSRI or SNRI• 2nd line Benzodiazepines

** Often clinically, a small dose of long acting benzodiazepine is started along with SSRI/SNRI to provide more immediate relief from distressing symptoms

i.e. 0.5 mg clonazepam BID for 2-3 weeks, then tapered until it is stopped

Panic Disorder - Treatment• Psychological treatment:

– CBT most consistently efficacious psychotherapy for Panic Disorder, according to the literature

– Individual or group therapy, bibliotherapy– CBT for Panic Disorder includes same CBT concepts of

psychoeducation, cognitive approaches, relaxation, problem solving

– Also incorporates interoceptive exposure (exposure to feared symptoms therapist may ask patient to hyperventilate or spin to make themselves dizzy)

– Exposure to avoided situations is important

Social Phobia

Social Phobia/Social Anxiety Disorder• Social anxiety disorder, also known as social phobia, is an

intense fear of social situations. This fear arises when the individual believes that they may be judged, scrutinized or humiliated by others.

• Individuals with the disorder are acutely aware of the physical signs of their anxiety and fear that others will notice, judge them, and think poorly of them.

• In extreme cases this intense uneasiness can progress into a full blown panic attack.

• The person recognizes that the fear is excessive or unreasonable

Social Phobia• Most people in the general population

experience a degree of discomfort with certain social situations

• Generalized type vs. non-generalized (a restricted number of situations i.e. public speaking)

• Differentiate from panic disorder (panic attacks in social phobia always occur in feared situations)

• Differentiate from normal shyness (shyness should not cause functional impairment or marked distress)

Social Phobia/Anxiety• Common anxiety provoking social situations

include: • public speaking • talking with people in authority • dating and developing close relationships • making a phone call or answering the phone • interviewing • attending and participating in class • speaking with strangers • meeting new people • eating, drinking, or writing in public • using public bathrooms • driving • shopping

Social Anxiety Disorder (Social phobia)• The feared situations are avoided or endured with

intense anxiety and distress• The avoidance, anxious anticipation or distress

interferes with functioning or causes marked distress

• In individuals under 18, duration is at least 6 months

• Not due to substance, medical condition or other mental disorder

Social Phobia• Has significant impact on quality of life

• Lifetime prevalence of 8-12% 1 (one of the most common anxiety disorders)

• Early onset, usually in childhood

• Chronic course, usually 20 years or longer

Social Phobia• Interferes with career, relationship, goals • “illness of missed opportunities”• Comorbid conditions include substance

abuse, depression, or another anxiety disorder

• Key symptoms include blushing, sweating, palpitations, tremor and lightheadedness, panic attacks

• Situations are often avoided as an effort to alleviate distress

Social Phobia - treatment• Pharmacotherapy:

• 1st line SSRI or SNRI• 2nd line Benzodiazepine

» Only recommended for short term use due to side effects (cognitive impairment, ataxia, sedation) and dependence and withdrawal

» Avoid in people with substance abuse and the elderly

• 3rd line Adjunctive Abilify or Risperidone Mirtazapine, wellbutrin

• ** Although not in guidelines, in practice, beta blockers have been used with effect for non-generalized type performance anxiety

Social Phobia - treatment• Psychological treatment

– CBT (group or individual)– CBT for social phobia includes exposure to

feared situations and social skills training– Similar efficacy to pharmacotherapy– In practice, CBT and medications are often

combined – After discontinuation of CBT or medications,

gains with CBT last longer

What are you afraid of?

Specific Phobia

Specific Phobia • Excessive or unreasonable fear cued by the presence or

anticipation of a specific object or situation (insects, flying, heights, blood)

• Exposure provokes an immediate anxiety response• Fear is recognized as excessive or unreasonable• Situation is avoided or endured with intense distress• Marked distress or interferes with functioning• Not due to a substance, medical condition or other mental

disorder

Common symptoms:• You feel uncontrollable anxiety when exposed to the source of your fear• You feel the need to do everything possible to avoid your fear• You are unable to even function normally because of your anxiety• You know your fears are unreasonable/exaggerated but you’re not able to

control it• You get anxiety just thinking about your fear• Physical & psychological reactions:

SweatingRapid heartbeatDifficulty breathingFeeling of panic/intense anxiety

Specific Phobia• Lifetime prevalence of 12%• Most common mental disorder • Begins at young age, 5-12 years old• Treatment is exposure based therapy• Graded exposure helpful• Virtual reality or computer programs sometimes

used for fear of heights, flying, dentist

SPECTROPHOBIA

List of some Phobias:

Ablutophobia: Fear of washing or bathingAnemophobia: Fear of windAnthrophobia: Fear of flowersBatophobia: Fear of being close to high buildingsBibliophobia: Fear of booksChaetophobia: Fear of hairChionophobia: Fear of snowChronophobia: Fear of timeDendrophobia: Fear of treesDidaskaleinophobia: Fear of schoolEisoptrophobia: Fear of mirrorsEosophobia: Fear of daylightErgophobia: Fear of workGeliophobia: Fear of laughterGraphophobia: Fear of writingHeliophobia: Fear of the sunHemophobia: Fear of bloodHomichlophobia: Fear of fogKainophobia: Fear of anything newLachanophobia: Fear of vegetablesLogophobia: Fear of written wordsMelophobia: Fear of music

Sciophobia: Fear of shadowsScolionophobia: Fear of schoolSociophobia: Fear of society or people in generalSomniphobia: Fear of sleepSpectrophobia: Fear of ghostsSpheksophobia: Fear of waspsStenophobia: Fear of narrow things or placesSuriphobia: Fear of miceTachophobia: Fear of speedTaurophobia: Fear of bullsTechnophobia: Fear of technologyTelephonophobia: Fear of telephonesThalassophobia: Fear of the seaThanatophobia or Thantophobia: Fear of death or dyingTocophobia: Fear of pregnancy or childbirthTomophobia: Fear of surgical operationsTraumatophobia: Fear of injury

Trypanophobia: Fear of injectionsUrophobia: Fear of urine or urinatingVerbophobia: Fear of verbal wordsVenustraphobia: Fear of beautiful womenVerminophobia: Fear of germsVirginitiphobia: Fear of rapeWiccaphobia: Fear of witches and witchcraftXenoglossophobia: Fear of foreign languagesXenophobia: Fear of strangers or foreignersXyrophobia: Fear of razorsZeusophobia: Fear of God or godsZoophobia Zoophobia : Fear of animals

Metrophobia: Fear of poetryNeophobia: Fear of anything new, again...Oneirophobia: Fear of dreamsPhengophobia: Fear of daylight, again...Photophobia: Fear of lightPogonophobia: Fear of beards

Selective Mutism

Common CharacteristicsFearful of being seen or heard speaking in

certain situations (at school)• Visibly anxious when expected to speak • May communicate nonverbally • Social phobia symptoms

A. Pencer October 2012 83

Prevalence and Course • ~1% of young children• Seems more common in girls• Onset in preschool years• Little known about the course• Without effective intervention, may

persist for many years

Possible Contributing Factors• Shy or anxious temperament

• Family history of shyness or anxiety

• Speech - language difficulties

• New culture

• Limited socializing with school peers

APA Diagnostic Criteria• Consistent failure to speak in specific

situations• Speaking in other situations• Interferes with: educational achievement

or social communication• At least one month duration• Not due to: communication disorder or

unfamiliarity with the language

Intervention Approaches• Most approaches have not been

systematically evaluated

• Approaches useful in treating anxiety have been applied to selective mutism:

behavioural therapy cognitive-behavioural therapy (CBT) medication

Behavioural Approach● Most evidence based approach

(Cohan, Chavira, & Stein, 2006)● Emphasis on modifying the

environment● Stimulus fading/ graduated exposure

is key

Intervention: First Steps

● Establish “management team”● Provide psychoeducation ● Reduce pressure to speak ● Encourage nonverbal participation ● Begin regular monitoring

The Use of Positive Reinforcement (Praise, Rewards)

● Positive reinforcement creates positive memories of approaching, not avoiding.

● Praise the child’s bravery (emphasis on effort, not outcome). Low key praise is best.

● Incentives (rewards) can be helpful in some circumstances.

General Strategies: Building Social Skills

● Practice social skills at home (role playing with puppets; conversations with older children)

● Help the child develop strategies to solve problems

● Gently provide direct instruction and feedback as needed

● Arrange real-life opportunities for practice (find activities that play to the child’s strengths)

General Strategies: Anxiety Management

• Psychoeducation re: anxiety • Help the child learn relaxation

strategies (so they can tolerate discomfort)

• Use other anxiety management strategies as appropriate

Generalized Anxiety Disorder• Excessive uncontrollable worry about

everyday things. This constant worry affects daily functioning and can cause physical symptoms.

• GAD can occur with other anxiety disorders, depressive disorders, or substance abuse.

Generalized Anxiety Disorder• The focus of GAD worry can shift, usually

focusing on issues like job, finances, health of both self and family; but it can also include more mundane issues such as, chores, car repairs and being late for appointments.

• The intensity, duration and frequency of the worry are disproportionate to the issue

Post-Traumatic Stress Disorder• Exposure to traumas such as a serious

accident, a natural disaster, or criminal assault can result in PTSD.

• When the aftermath of a traumatic experience interferes with normal

functioning, the person may be suffering from PTSD.

Posttraumatic Stress Disorder - Treatment• Other meds sometimes used include:

– Clonidine (antiadrenergic agent)– Prazosin for nightmares (alpha-1 adrenergic

antagonist)

• Psychological treatment:– CBT recommended

When It Never Gets Easier to Say Goodbye

Separation Anxiety Disorder

Separation anxiety disorder is a psychological condition in which an individual has excessive anxiety regarding separation from home or from people to whom the individual has a strong emotional attachment (like a mother).

Present in all age groups, adult separation anxiety is now

believed to be even more common than childhood separation anxiety.

[Thoughts, Feelings, & Behaviors] An unrealistic and lasting worry that something bad will

happen to the parent or caregiver if the child leaves. Refusal to go to school in order to stay with the caregiver. Refusal to go to sleep without the caregiver being nearby

or to sleep away from home. Fear of being alone. Bed Wetting. Complaints of physical symptoms, such as headaches

and stomachaches, on school days. Repeated nightmares involving separation. Worry that harm may befall important attachment figures

or that they will lose these people.

Associated Features…

Separation anxiety symptom of a co-morbid condition. Studies show that children suffering from separation anxiety are much more likely to have ADHD, bipolar disorder, panic disorder, and others later in life.

Associated Features..

[Potential Causes] Separation anxiety often develops after a significant

stress or trauma in the child’s life, such as:• stay in the hospital• the death of a loved one • change in the environment

It usually ends when the child is around 2 years old. At this age, toddlers begin to understand that parents may be out of sight now, but will return later. There is also a normal desire to test their independence.

To get over separation anxiety, children must:• Feel save in their home environment • Trust people other than their parents• Trust that their parents will return

Etiology

Separation anxiety affects approximately 4%-5% of children in the U.S. ages 7-11 years. It is less common in teen agers, affecting about 1.3% of American teens and affects boys and girls equally.

Anxiety disorders are often debilitating chronic conditions, which can be present from an early age or begin suddenly after a triggering event. They are prone to flare up at times of high stress.

Prevalence

Cognitive behavioral psychotherapy is the primary type of treatment used for separation anxiety disorder.

There are a number of commonly used treatments for separation anxiety disorder, most of which focus on one or more types of psychotherapy.

As with most childhood issues, the more likely the treatment will be successful.

That’s why it’s important to seek professional care for your child if you suspect they might suffer from this disorder.

Treatment…

For older children who have not outgrown separation anxiety within the normal developmental timetable or who have regressed to it under stress.

Effective treatments may include:• Anti-anxiety medications• Changes in parenting techniques• Counseling for the parents and child

Treatments for severe cases may include:• Family education• Family therapy • Individual psychotherapy

Treatment…

Over 60% of children participating with their parents in cognitive behavioral treatment are successful in managing their symptoms with out medication.

Separation anxiety disorder has a poorer prognosis in environment where threat of physical harm or separation actually exist.

Existence of other conditions, such as autism, decrease the like hood of a positive prognosis.

Prognosis

Anxiety Disorders• Separation Anxiety Disorder• Selective Mutism• Specific Phobia• Social Anxiety Disorder (Social Phobia)• Panic Disorder• Panic Attack (Specifier)• Agoraphobia• Generalized Anxiety Disorder• Substance/Medication-Induced Anxiety Disorder• Anxiety Disorder Due to Another Medical Condition• Other Specified Anxiety Disorder• Unspecified Anxiety Disorder

Obsessive-Compulsive Disorder• Characterized by uncontrollable

obsessions and compulsions which the sufferer usually recognizes as being excessive or unreasonable.

• Obsessions are recurring thoughts or impulses that are intrusive or inappropriate and cause the sufferer anxiety:

Obsessive Compulsive Disorder – DSM IV criteria

• Either obsessions or compulsions• Obsessions are defined as:• Recurrent and persistent thoughts, images or

impulses that are experienced as intrusive and inappropriate and cause marked anxiety/distress

• Not simply excessive worries about real-life problems

• Person attempts to ignore or suppress the obsessions, or neutralize them with other thoughts or actions

• Recognized as a product of the patient’s own mind

• Compulsions are defined as:• Repetitive behaviours or mental acts that the

person feels driven to perform in response to an obsession, or according to rigid rules

• Compulsions are aimed at reducing distress or preventing some dreaded event,

• however they are not connected in a realistic way to what they are meant to neutralize, or are clearly excessive

Obsessive Compulsive Disorder – DSM IV criteria (con’t)• At some point during the course of the disorder,

the person recognizes that the obsessions and/or compulsions are excessive or unreasonable

• The obsessions and/or compulsions cause marked distress, are time consuming (> 1 h/day), or significantly interfere with functioning

• Not due to substance, or another medical or mental disorder

Obsessive-Compulsive Disorder• Estimated lifetime prevalence of 1.6%• Median age of onset 19 years (range 14 – 30

years)• 60% are female• High psychiatric co-morbidity rate (56% -83%)• Common co-morbidities include substance abuse,

depression, social phobia, generalized anxiety disorder, panic disorder

Obsessive-Compulsive Disorder• In 50-70% of patients, onset of symptoms is

following a stressful event (i.e. pregnancy, death)• Course is usually long, can be constant or

fluctuating• 20-30 % have significant improvement• 40-50% have moderate improvement• 20-30% have no improvement or worsening

Obsessive-Compulsive Disorder• 20-30% have tics, 6-7% Tourette’s

• Possible link between a subset of OCD and tics

• PET studies have shown increased activity in the frontal lobes, basal ganglia (caudate), and cingulum in patients with OCD

• PANDAS – Pediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal infections

• Streptococcus infection may trigger an autoimmune response which causes acute onset OCD symptoms and tics in children

Obsessive-Compulsive Disorder• Most common obsessions include:

– Contamination (#1)– Doubt/safety (idea that stove was left on, door unlocked etc.) (#2)– Sexual and aggressive impulses (#3)– Symmetry and exactness (#4)– Somatic and religious preoccupations

• Most common compulsions include:– Checking– Washing– Repeating– Ordering– Counting– Hoarding

Thoughts about contamination, for example, when an individual fears coming into contact with dirt, germs or "unclean" objects;

Persistent doubts, for example, whether or not one has turned off the iron or stove, locked the door or turned on the answering machine;

Extreme need for orderliness;

Aggressive impulses or thoughts

hoarding

slowness

OCD - treatment• Pharmacotherapy:

• 1st line SSRI (serotonergic response needed)• 2nd line : Clomipramine (2nd line due to side effects –

cardiotoxicity, anticholinergic, drug interactions and lethality in overdose)

Effexor XR, Mirtazapine Adjunctive Risperidone

• Dosages of meds e.g. SSRIs may need to be higher than in mood disorders

• Response may take 6 wks or longer (Guidelines state adequate trial 6-8 weeks)

OCD - treatment• Psychological

1) Exposure with Response Prevention (ERP) – form of behavioural therapy

2) CBT which combines Exposure and Response Prevention with cognitive interventions

• BDD sufferers experience extreme anxiety over a real or imagined physical flaw.

• stands apart from typical insecurities about appearance in that the person who suffers is obsessed and chronically anxious about the perceived defect to the extent that quality of life is impaired.

• Men and women suffer equally from body dysmorphic disorder. They obsess over individual physical features, combinations of features, or even the entire body and appearance.

• this illness can lead to compulsive symptoms such as hair plucking, skin picking, excessive grooming, eating disorders, repeated cosmetic surgeries, and varying degrees of clinical depression.

Trauma- and Stressor-Related Disorders• Reactive Attachment Disorder• Disinhibited Social Engagement Disorder• Posttraumatic Stress Disorder• Acute Stress Disorder• Adjustment Disorders• Other Specified Trauma- and Stressor-Related

Disorder• Unspecified Trauma- and Stressor-Related

Disorder

Reactive Attachment Disorder

Disinhibited Social Engagement Disorder

The primary defining feature of DSED is a person’s pattern of behavior that involves culturally inappropriate, overly familiar behavior with strangers.

This behavior violates the ordinary social customs and boundaries of the culture.

• They may be over-zealousness in their efforts to form attachment to others.

• They may willingly, and without question, wander off with strangers.

• They may behave in an overly familiar manner with unfamiliar adults, such as lavishing them with hugs and other forms of physical or verbal affection.

• Clearly this places them at greater risk for victimization.

• In addition to the overly needy or clingy behaviors that are not better explained by culturally appropriate norms.

• a short-term condition that occurs when a person has great difficulty coping with, or adjusting to, a particular source of stress, such as a major life change, loss, or event. In 2013, themental health diagnostic system technically changed the name of "adjustment disorder" to "stress response syndrome."

• People with an adjustment disorder/stress response syndrome often have some of the symptoms of clinical depression, such as tearfulness, feelings of hopelessness, and loss of interest in work or activities, adjustment disorder is sometimes informally called "situational depression."

Triggers:• Ending of a relationship or marriage• Losing or changing job• Death of a loved one• Developing a serious illness (yourself or a loved one)• Being a victim of a crime• Having an accident• Undergoing a major life change (such as getting married,

having a baby, or retiring from a job)• Living through a disaster, such as a fire, flood, or

hurricane

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