Anxiety Disorders

Anxiety Disorders

Anxiety DisordersDSM-IV-TRNecessary Information from Clinical Interview Current and past history of anxietyFeelings of:derealization, depersonalization, or emotional numbing Fears of:Losing control, orGoing crazySleep disturbance; e.g., bad dreamsNecessary Information from Clinical Interview Medical illnessPhysical symptomsPrevious and current psychiatric illnessesCurrent or past traumatic events or stressCompulsive behaviors or ritualsCurrent medications & abused substances

DiagnosingAnxiety Disorders Anxiety Building Blocks:

Panic Attacks and Agoraphobia

Not codable disorders

Several codable disorders are constructed from these building blocks.DiagnosingAnxiety Disorders What is a Panic Attack? A brief episode (peaks within 10 minutes)Sudden intense fear and/or discomfortClient feels intense dread feelings of impeding doomNumerous somatic symptoms, such as:Shortness of breathDizziness or unsteady feelingsPalpitations (tachycardia)Trembling or shaking,Sweating,Choking, Nausea or abdominal distressDepersonalization or derealization,Flushes or chills,Chest pain or discomfort,Fear of dying,Fear of losing control

DiagnosingAnxiety Disorders What is Agoraphobia?

Clients, with this condition have:

Intense fear and/or discomfortAvoid places or situations in which:Escape might be difficult or embarrassing.Help may not be available in the event of panic symptoms

This definition is different from the popular definition, in which a person with agoraphobia does not leave his/her home.

,

Twelve (12) Types of Anxiety Disorders1. Panic Disorder (without Agoraphobia)2. Panic Disorder with Agoraphobia3. Agoraphobia (without history of panic attacks)

4. Specific Phobia5. Social Phobia6. Obsessive Compulsive Disorder

7. Post Traumatic Stress Disorder8. Acute Stress Disorder

9. Generalized Anxiety Disorder

10. Anxiety Disorders due to a General Medical Condition (GMC)11. Substance-Induced Anxiety Disorder12. Anxiety Disorder NOS

Panic Disorder

These clients experience repeated panic attacks, together with worry about having additional attacks and other mental and behavioral changes related to them.

Panic disorder usually occurs with Agoraphobia (p. 441), but it is sometimes diagnosed without agoraphobia (p. 440).

300.21 Panic Disorder With Agoraphobia 300.01 Panic Disorder Without Agoraphobia

Panic DisorderAbout 30% of adult population occasionally has a panic attack.

Panic attacks are usually not too distressingPanic DisorderDifferences between clinical and non-clinical population :

Non-clinical population responds with less anxiety to the physical sensationClinical population gives themselves messages, such as:Im having a heart attackIm going mad And, they fear other peoples responses to the attack.

Panic DisorderRamifications for Treatment

Teach clients not to respond with anxiety-causing messages when having a panic attack.

Clients can say to self:It will be over in 10 minutes.Im not dying.Relax. Breathe slowly.

Most people when they are having panic attacks forget to breathe.

Panic DisorderMany clients tend to avoid situations or activities that trigger panic attacks.

This can lead to a very restricted life style.Panic DisorderExamples: Person who has panic attacks when driving on freeway, drives only on city streetsAxis I 300.21 Panic Disorder with Agoraphobia (p. 441)

Person does not have panic attacks, but is fearful that s/he might get dizzy when driving, so drives only on city streets. Axis I 300.22 Agoraphobia Without History of Panic Disorder (p. 441)Panic DisorderOver half of clients with Panic Disorder also qualify for another anxiety disorder or depression.

Alcohol abuse is common among clients with Panic Disorder

Panic DisorderPanic Disorder can be effectively treated with cognitive-behavior therapy and tricyclic antidepressants.

If medication is discontinued, relapse is the rule rather than the exception

Therefore, management of symptoms is often more the goal, rather than cure. Panic DisorderIn a recent study,therapists were able to reducethe number of panic attacks suffered by clients with high anxietybya Diagnostic Interviewin which they made the symptoms more tolerable, simply by naming and describing them.

Agoraphobia

This is a codable form of Agoraphobia related to fear of developing panic-like symptoms, in which the full criteria for Panic Disorder are not met (p. 441).

300.22 Agoraphobia Without History of Panic Disorder

Agoraphobiawith/without Panic Disorder 20% of clients with agoraphobia qualify for diagnosis of Avoidant Personality DisorderAgoraphobia is significantly more likely to diagnosed among women than men.Mean age of onset: 28 years usually between ages 17 and 19, with a few (16%) after age of 40. Agoraphobiawith/without Panic Disorder

If client has agoraphobia for a year, client is unlikely to get better without treatmentTreatment consists of in vivo exposure effective with 75% of clients

Agoraphobiawith/without Panic Disorder

A client with agoraphobia may seem to have Specific Phobias as well, but when questioned closely, the client was actually having a panic attack and the phobia was developed in the context of the panic attack. Agoraphobiawith/without Panic Disorder

Example: Client has panic attack when driving on freeway. Now client wont go near a car. Seems like a phobia, but is really a reaction to feelings of panic.

Usually if the panic and fear happen close in time the fear is a result of the panic.

Therefore, dont diagnose both Panic Disorder and Specific Phobia. Anxiety DisordersSometimes more than one Anxiety Disorder can be diagnosed.

Example: Phobias often start at a very young age. Fear of heights and fear of enclosed spaces may exist long before the onset of a first panic attack. In this case, a diagnosis of both Specific Phobia and Panic Disorder is justified. Specific Phobia

In this condition, clients fear specific objects or situations, such as animals, storms, heights, blood, airplanes, being closed in, or any situation that may lead to vomiting, choking, or developing an illness (p. 443).300.29 Specific Phobia,Specify type:Animal TypeNatural Environment TypeBlood-injection-injury TypeSituational TypeOther Type

Specific PhobiaA widespread anxiety disorder about 10% of population

Most common fears are:Fear of animals (zoophobia)Fear of heights (acrophobia)Fear of confinement (claustrophobia), andFear of injury and/or blood.

Specific PhobiaWhen a person is confronted withhis/her phobic item, there is:

Immediate, extreme distress and panic

Brain scans show rising blood flow and energy consumption in the amygdale (center for fear and anger), and sometimes in the insula (region that registers disgust and pain). Specific PhobiaTreatment

Cognitive behavior therapy and antidepressant medication lower the reaction to phobic item.

Behavioral exposure techniques lead people to confront the objects they fear. The exposure may be gradual and relaxed (desensitization), intense (flooding), or vicarious (modeling).

28Specific PhobiaTreatmentIn young children (2-6 years old), specific phobias often improve spontaneously.

If phobias continue to adulthood, they dont often improve spontaneously

Most people self-treat by staying away from the phobic item.

Usually people come for treatment only when faced with having to confront the fear item.

29Specific PhobiaFamily influence on phobias is very strong. A strong positive correlation exists between fears of children and their mother Correlation is especially strong if child is young and comes from a lower socioeconomic strata

Phobias about blood and/or injury seem most likely to run in families. Sixty percent (60%) of first-degree relatives also have this phobia. This 3 to 6 times more frequent than panic disorder, obsessive-compulsive, or phobias about dental, animals, or social situations. Specific PhobiaUsually anxiety disorders and depression overlap; however, Specific Phobia is the exception.Only 9% of clients with specific phobia report past depressive episodes.

A phobia can be part of another anxiety disorder.A client with obsessive-compulsive problems may have many cleaning rituals and obsessional concerns with germs and contamination. One of the clients concerns may pertain to the fear of developing AIDs. However, in this case, the diagnosis of Specific Phobia should not be made. Why?

Specific PhobiaMean age for onset of a phobia varies:For animal phobia and blood-injury, the mean age is 8 years old.For dental phobia, the mean age is 12 years oldFor claustrophobia, the mean age is 20 years oldThe overall mean age for all phobias is 19.6 years old.More women than men are diagnosed with a specific phobia Social Phobia

These clients imagine themselves embarrassed when they speak, write, or eat in public, use a public urinal or the like (p. 450) 300.23 Social Phobia, Specify if: Generalized

Social PhobiaSocial phobia is a persistent fear of one or more social or performance situations in which the person is exposed to possible scrutiny by others. The person fears to behave in a way that will be humiliating and embarrassingPeople with social phobia become very anxious when confronted with the feared situation they are trying to avoid.Often this avoidance interferes with occupational and social functioning.

Social PhobiaIf the person fears several social situations, it is classified as Social Phobia with the addition of generalized type.

Most people with this diagnosis have difficulty with at least two different situations, nearly half feel anxious in three or more situations. Social PhobiaA research study by Holt, Heimberg, Hope, and Liebowitz found four different situational domains of social phobia.

Formal speaking and interactionInformal speaking and interactionObservation by others, andAssertion.

75% of the participants in their study had problems in more than one domain.

Nearly all had problems in forma speaking Social PhobiaThis phobia is not due to inadequate social skills

Cognitive factors, such as negative self-statement and irrational beliefs, appear to be more important

They often evaluate their own social behavior in excessively negative ways and focus on negative experiences in social situationsSocial PhobiaRetrospective studies studying reasons forsocial phobia have found:

Problematic relationships with parents, such as relationships lacking in emotional warmth, and marred by rejection and overprotection Social PhobiaAlcohol abuse is often a problem; however, the prevalence is less than among individual with panic disorder.

Normally social phobia precedes the onset of the alcohol problem,Social PhobiaOnset is usually around 18 years old.

Sex ratio is equal

Social phobia is less prevalent than agoraphobiaSocial PhobiaFew studies have been conducted regarding genetic influence.

One study did find that 6.5% of first degree relatives have social phobia.

No twin studies.

Social PhobiaSocial phobia should be distinguished from shyness and social anxiety people with social phobia are abnormally avoidant and intensely fearful of social situations.There is considerable overlap among social phobia, panic disorder, and generalized anxiety.

Social PhobiaMany people with Social Phobia meet the criteria for Avoidant Personality Disorder.

However, people with Avoidant Personality seem to be less socially skilled and more socially anxious than people with Social Phobia. Social PhobiaSocial Phobia may also be related to Dysmorphia (Somatoform Disorder).

Dysmorphia - People preoccupied with a presumed physical anomaly of their body, with no objective basis.

People with Dysmorphia also avoid social situations.Obsessive-Compulsive Disorder(OCD) These clients are bothered by repeated thoughts or behaviors that appear senseless, even to them (p. 456).

300.3 Obsessive-Compulsive Disorder, Specify if: With Poor Insight

Obsessive Compulsive Disorder Obsessions are repetitive, recurring thoughts, ideas images, or impulses that are experienced as intrusive.

The person recognizes that the obsessions are the product of his/her own mind.

Obsession are experienced by the client as senseless or repugnant, which she or he attempts to ignore or suppress.

Obsessive Compulsive Disorder Compulsions, on the other hand, are behaviors that are:Repetitive,Apparent,Purposeful, and Performed according to certainrules, or in a stereotyped fashionObsessive Compulsive Disorder To receive the diagnosis, a persons complaints/symptoms have to:Cause marked distress, Are time-consuming (take more than an hour), orInterfere with social or work functioning.

The specifier, With Poor Insight, isgiven if the person does not recognize that the obsessions and compulsions are excessive or unreasonable.

Obsessive Compulsive Disorder The most common compulsions involve:Cleaning, e.g., washing handsChecking, e.g., checking the doors are locked

Less common compulsions are:Compulsive slownessOrderlinessHoardingBuyingCountingHoarding

Obsessive Compulsive Disorder Most clients have both obsessions and compulsions (80%).

A small minority have only obsessions most often about harming themselves or others.

A small minority of clients have only compulsions (e.g., rituals); this type of client is seen very rarely in therapy. Obsessive Compulsive Disorder The prevalence rate of OCD is growing: Ten years ago, studied indicated that about .05% of the population qualified for this diagnosis Now the mean lifetime prevalence of OCD is 2.4%

OCD is slightly more prevalent among females than males. Checking is more prevalent among males.Washing and cleaning are more common among females.

Obsessive Compulsive Disorder The mean age of onset is 20-25 years old. 10% start before age 10 9% start after age 40 Males start at an earlier age.

Twin studies indicate that OCD is influencedby genetic factors, although environmentalfactors also have an important role in development:About 4-15% of relatives of OCD clientshave compulsive traits or symptoms.

Obsessive Compulsive Disorder Sometimes OCD begins immediately, but usually onset is insidious over severalyears.

Normally a person does not see a therapist until about 10 years after the start of OCD - usually around age 30.

Obsessive Compulsive Disorder Without therapy, OCD has a chronic, fluctuating course.Current treatment of choice is in vivo exposure, plus response prevention.About 75% of clients improve and 25% remain unchanged, according to self-ratings of OCD symptoms, anxiety, and depression. Biological researchers have tied OCD to low serotonin activity and abnormal functioning in the orbitofrontal cortex and in the caudate nuclei.Antidepressant drugs that raise serotonin activity are useful in treatment.Obsessive Compulsive Disorder Some obsessive thoughts should not be diagnosed as OCD. For example:

Excessive anxiety and worry that would meet the criteria for Generalized Anxiety Disorder

Obsessive concern with ones own health, such as in hypochondriasis (Somatoform Disorder)

Obsessions that are part of a psychotic episode are not classified as OCD. People with OCD recognize that his/her thoughts are unreasonable; people with psychosis believe their obsessions are reasonable.

Obsessive Compulsive Disorder A strong connection exists between OCD and depression:About 75% of clients with OCD also meet the criteria for major depressionOCD symptoms worsen during depression and severe depression may hinder a client from getting better.A client is 3 times more likely to start with OCD and go to depression, rather than to start with depression and go to OCD.Obsessive Compulsive Disorder OCD overlaps with specific phobia, socialphobia, or panic disorder. One study found that 58% of 100 OCD clients also had, sometime in their lifetime, a simple phobia, social phobia, or panic disorder.

Women with Anorexia Nervosa often havea history of OCD

Obsessive Compulsive Disorder OCD also overlaps with Obsessive-Compulsive Personality Disorder. However, the clinical manifestations of these two disorders are quite different:O-C Personality Disorder involves a pervasive pattern of preoccupation with orderliness, perfectionism, and control and must begin by early adulthood. O-C Personality Disorder is not characterized by the presence of obsessions or compulsions. If a client meets the criteria for both disorders, both diagnoses can be given. Obsessive Compulsive Disorder It is sometimes hard to distinguish between agoraphobia and OCD especially is the OCD client avoid activities that some people with agoraphobia avoid, such as going outdoors. However, the reason is different: Persons with OCD may avoid outdoors, because of fear of contamination, while agoraphobic clients are often afraid of having a panic attack. Obsessive Compulsive Disorder Final note on OCD from the DSM-TR-IV:

Superstitions and repetitive checking behaviors are commonly encountered in everyday life. A diagnosis of OCD should be considered only if they are particularly time consuming or result in clinically significant impairment or distress.

Posttraumatic Stress Disorder(PTSD)

These clients develop characteristic symptoms following exposure to an extreme traumatic stressor (p. 463).

309.81 Posttraumatic Stress Disorder Disorder Specify if: Acute Duration of symptoms is less than 3 months Chronic Symptoms last 3 months or longerWith Delayed Onset At least 6 months have passed between the traumatic event and the onset of symptoms.

Diagnostic Criteria for Posttraumatic Stress Disorder (PTSD)A. Traumatic event in which: Person experienced, witnessed, or was confronted with an event(s) that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others Persons response involved intense fear, helplessness, or horror.PTSD ContinuedB. Traumatic event is persistently re- experiencedC. Persistent avoidance of stimuli associated with the trauma and numbing of general responsivenessD. Persistent symptoms of increased arousalE. Duration is more than one monthF. Disturbance causes clinically significant distress or impairment in social, occupational or other areas of functioning

Trauma and Brain Research

Rie Rogers Mitchell, Prof.

Effect of Traumaon the Brain Trauma impairs both mental and emotional functioning and affects brain functioning for a much longer time and far more significantly than previously realized (Harnell, 1999). Trauma feels like:

a Speechless TerrorWhy does trauma affect verbal expression?because - during trauma

the Left side of brain SHUTS DOWNThe Left side is the LANGUAGE side,called Brocas areathe Left side also governs REASONING and REFLETION

So, if the left side of the brain closes down, how is trauma assimilated?through the RIGHT side of the brain

and then

it is absorbed by the AMYGDALA

Whats so special about the Amygdale?Center of emotional response.Registers and manages fear. Responsible for generating negative feelings throughout life.Produces a physical memory.Stores unconscious emotional memories possibly before birth!

73Scientists believe that different parts of the brain interpret specific emotions.The left side of the brain the frontal cortex of the left hemisphere deals with positive emotions.The right frontal cortex is concerned with negative emotions.But when a traumatic event occursThe frontal lobe in the left side of the brain is deactivatedFurther, trauma seems to freeze the integrative process between the right and left sides of the brain.So, information about the trauma is not integrated in the same ways as ordinary memory through language and senses.What is remembered during trauma?Raw fragmentscoming from the senses.smellssoundsfragmented, brief imagescolorsFeelings ..emotional reactions felt in the body shortness of breathbeating of heartconfusionfear and angerWhat is the result of trauma?Sensations that are experienced normally in daily lifetrigger over-reactions to these sensations, creatingFlashbacks of memoriesHyper-vigilance Exaggerated startle responsesAnger outburstsInability to concentrate76 Jung (1928, CW 16 paragraph 267) speaks of this overreaction to neutral events as an explosion of affect that completely invades the individual.

Jung says, it pounces upon him like an enemy or a wild animal.

Dr. B.A. van der Kolk, prominent brain researcher, recommends for traumatized clients: The use of therapies that do not depend on language He specifically mentions:EMDR Eye Movement Desensitization and ReprocessingMovementSandplay Therapy

Van der Kolk believes:Since trauma is taken in on the right side of the brain into the unconscious amygdale, the traumatic event can only be reached by using non-verbal approaches.

Using a therapeutic approach that speaks the same language as the right brain provides a language through which these memories in the amygdale can be communicated.Van der Kolk states,Only after processing the trauma using a nonverbal therapy can the fragmented memory be transformed into a verbal narrative. Then, and only then can the person tell the story of what happened.It appears that

Talk therapy, by itself, has difficulty resolving traumatic experiences.

Non-verbal therapy is of primary importance when working with clients with PTSD.

Acute Stress Disorder

Acute Stress Disorder. This condition is much like Posttraumatic Stress Disorder, except that it begins during or immediately after the stressful event and lasts a month or less (p. 469).

Axis I 308.3 Acute Stress Disorder

Acute Stress DisorderCriterion A is the same for Acute Stress Disorder (ASD) and PTSD.ASD should only be used as a diagnosis if:The symptoms last at least 2 days and no more than 4 weeksCause significant distress and impair the functioning of the individual.

Generalized Anxiety Disorder(Includes Overanxious Disorder of Childhood)

Although they experience no episodes of acute panic, these clients feel tense or anxious much of the time and worry about practically anything, sometimes referred to as free-floating anxiety (p. 472).

Axis I 300.02 Generalized Anxiety Disorder

Generalized Anxiety Generalized Anxiety Disorder is common in Western societyAbout 3.1% of U.S. population have the symptoms of this disorder in any given year. A similar percentage is found in Canada, Britain, and other Western countries.Close to 6% of all people develop GAD sometime during their lives.

Generalized Anxiety GAD usually emerges in childhood or adolescence, although it can start at any age. Women with GAD outnumber men 2 to 1.About of individuals with GAD are currently in treatment. Biological relatives of persons with GAD are more likely than nonrelatives to have the disorder.

Anxiety Disorder Due to a GMC(General Medical Condition)

Some clients are anxious due to the direct physiological effects of a general medical condition.

293.84Anxiety Disorder Due to a (specify the General Medical Condition) Specify what symptom predominates:With Generalized AnxietyWith Panic AttacksWith Obsessive-Compulsive Symptoms

Anxiety Disorder Due to a GMC(General Medical Condition)

Panic attacks or generalized anxiety symptoms can be caused by numerous medical conditions (p. 476). In order to use this diagnosis, clinician must have evidence from

the clients history, physical examination, or laboratory findings

to show that the disturbance is the direct physiological consequence of a GMC. (See p. 478 for a list of associated GMC)

Substance-Induced Anxiety Disorder Various substances can lead to anxiety symptoms that don't necessarily fulfill criteria for any of the Anxiety Disorders (p. 479). The anxiety symptoms may be due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or toxin exposure).

Be sure to read Recording Procedures.

Code (Number and Name of specific substance, followed by induced Anxiety Disorder)

Axis I 291.89 Alcohol-Induced Anxiety Disorder (p.279) Specify if: With Generalized AnxietyWith Panic Attacks With Obsessive-Compulsive Symptoms With Phobic Symptoms Specify if: (see p. 193) With Onset During intoxication With Onset During Withdrawal

Anxiety Disorder NOS(Not Otherwise Specified) Use this category to code disorders with prominent anxiety symptoms that do not fit nearly into any of the group above.The category includes disorders with prominent anxiety or phobic avoidance that do not meet criteria for any specific Anxiety Disorder, Adjustment Disorder with Anxiety, or Adjustment Disorder with Mixed Anxiety and depressed Mood.

Axis I 300.00 Anxiety Disorder NOS See examples on p. 484.

Other Causes of Anxiety SymptomsAvoidance behavior that is associated with sexual aversion is classified with the sexual dysfunctions.

Anxiety symptoms can be found in clients with almost any Axis I disorder. They are especially prevalent in clients with Major Depressive Episode (p. 349) and Somatization Disorder (p. 486).