anxiety disorders

1. Anxiety Disorders

3. 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. (4) sensations of shortness of breath or smothering (5) feeling of choking (6) chest pain or discomfort (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

5. Panic Attack Unexpected: the onset is not associated with a situational trigger Required for Dx of Panic Disorder Situationally bound: the attack almost invariably results immediately on exposure to, or in anticipation of, a situational trigger Most often associated with specific and social phobias Situationally predisposed: the attack is more likely to occur on exposure to the situational trigger but does not invariably occur and may not occur immediately after the exposure Associated with panic disorder with agoraphobia

6. Panic Attack The nature of panic attacks can change over the course of the disorder beginning as unexpected and gradually becoming more situation specific The symptoms experienced as part of a panic attack are the result of decrease in in CO2 levels in the blood as a result of hyperventilation Hyperventilation can be caused by shallow rapid breathing or by a more subtle alterations in the pattern of breathing these alterations may be the result of increased activity in the HPA system as a result of environmental cues

7. HPA Axis

8. HPA Cascade

9. 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 include situations like being outside the home alone; being in a crowd or standing in line; being on a bridge; and traveling in a bus, train, or automobile. Consider a 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.

10. Agoraphobia B. the situations are avoided or endured with marked distress or with 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, Specific Phobia, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, or Separation Anxiety Disorder

11. Agoraphobia There is some dispute about whether panic attacks are primary or secondary symptoms in agoraphobia Fortunately, in clinical practice focusing on the panic attacks or panic like symptoms usually brings greater success than focusing only on desensitizing an individual to specific anxiety producing situations.

12. Panic Disorder w/wo Agoraphobia A. Both (1) and (2): (1) recurrent unexpected panic attacks (2) at least one of the attacks as been followed by at least a month of the following: (a) persistent concern about having additional attacks (b) worry about the implications of the attacks or its consequences (c.) a significant change in behavior related to the attacks

13. Panic Disorder w/wo Agoraphobia B. Can be with Agoraphobia or without Agoraphobia C. The panic attacks are not due to the direct physiological effects of a substance or a general medical condition D. The panic attacks are not better accounted for by another mental disorder such as Social Phobia, Specific Phobia, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, or Separation Anxiety Disorder.

14. Agoraphobia wo History of Panic Disorder Agoraphobia can also occur without any history of panic attacks This can often occur when individuals fear, or may have actually experienced embarrassing or debilitating symptoms in public It can also happen because someone knows someone who had such an experience Or because an individual has a disorder which may predispose them to an embarrassing or debilitating experience

17. Medical and Other Conditions of Concern Thyroid Dysfunctions: hyperthyroidism CNS Stimulant Intoxication CNS Depressant Withdrawal Parathyroid Dysfunction: hyperparathyroidism Cardiac Conditions: arrhythmias, supraventricular tachycardia, mitral valve prolapse Seizure Disorder: temporal lobe epilepsy Adrenal Dysfunction Vestibular Dysfunction

18. Panic Disorder w/wo Agoraphobia Is always a good idea to determine the context in which Panic Attacks occur In clinic samples Panic Disorder with Agoraphobia is far more common than Panic Disorder without Agoraphobia In community samples just the opposite is the case There is some possibility that many cases of Panic Disorder began without Agoraphobia and later develop to include Agoraphobia

19. Panic Disorder w/wo Agoraphobia Lifetime rates for Panic Disorder vary between 1.5% and 3.5% Lifetime rates for Agoraphobia vary more widely between 2.5% and 6.5% Family and to genetic studies would seem to indicate some genetic predisposition Individuals with first-degree relatives having Panic Disorder have fivefold to eightfold greater risk than individuals without genetic history of Panic Disorder A small number of twin studies indicate higher levels of concordance in monozygotic versus dizygotic twins

20. Panic Disorder w/wo Agoraphobia Initial panic attacks generally occur in late adolescence, there is another peak between ages 35 to 40 Initial panic attacks in any one 45 years old or older should be suspect Although Panic Disorder is generally chronic the long-term prognosis is good In one to eight year follow-ups 30% to 40% of patients were well, 30% to 50% were symptomatic but able to lead normal lives, and only 10% To 20% were still significantly ill and impaired There is strong evidence that Major Depressive Disorder is frequently comorbid with both Panic Disorder and Agoraphobia

21. Social Phobia There are two distinct varieties of this disorder The circumscribed variety focuses on fear of embarrassment that might arise when performing a particular activity in public The other is more generalized and involves individuals who are anxious in virtually any social situation There are also variants that contain elements of both It should be noted that some social anxiety is the rule rather than the exception, this diagnosis is reserved for those whose anxiety is so great it is debilitating.

22. Social Phobia 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 that will be humiliating or embarrassing 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. C. The person recognizes that the fear is excessive or unreasonable.

23. Social Phobia 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 interferes significantly with the person's normal routine, occupational functioning, or social activities or relationships, or there is marked distress about having the phobia.

24. Social Phobia F. and individuals under age 18, their duration is at least six months. G. the fear or avoidance is not due to the direct physiologic effects of a substance, or a general medical condition and is not better accounted for by another mental disorder. H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it.

25. Social Phobia Individuals with Generalized Social Phobia tend to have early onset and chronic stable course that is virtually indistinguishable from Avoid Personality Disorder. This points out both the weakness and artificiality of distinctions between Axis I and Axis II diagnoses. Criterion H. should be taken with a very large grain of salt. It seems best to use the diagnosis in those situations where avoidance is prominent and far out of proportion to the psychiatric or medical symptoms and warrants independent clinical attention

26. Social Phobia Prevalence for social phobia is between 1.9% to 3.2%. Age of onset is early, beginning before 20, most frequently between 11 and 15 years of age. Slightly more women than men experience social phobia. However, more men than women seek treatment. Family studies would seem to indicate some genetic contribution.

27. Social Phobia Epidemiologic studies showed that even uncomplicated social phobia increases financial dependence and utilization of medical treatment. Social phobia tends to be chronic, with early onset, and often results in academic and vocational impairment. Persons with social phobia often have no friends and commonly do not marry. Social phobia results in depression demoralization and substance abuse

29. Specific Phobias There are three general categories of specific phobias. The animal and natural environment types: usually have early-onset partially based on factors related to natural selection insects, snakes, dogs, cats, height, lightning, darkness, and drowning the situational type usually have later onset are most often related to traumatic experience the blood-injection-injury type May be related to personal or vicarious experience results in vasovagal reflex

30. Specific Phobias Phobias are a ubiquitous human experience In order to meet criteria the following are necessary: The fear, avoidance, and anticipation must be well in excess of what would be reasonable Exposure to the stimulus must provoke a severe and debilitating reaction (panic attack) The fear, anticipation, or reaction must interfere with the individuals conduct of his/her life

31. Specific Phobias The diagnosis is not meant to apply to transient fears which are common in childhood The most difficult differential diagnosis is between Specific Phobia Situational Type and Panic Disorder with Agoraphobia. The typical patient with Panic Disorder begins with an unexpected Panic Attack and then starts to avoid various situations that he/she believes are likely to trigger additional attacks. The typical individual with a Specific Phobia has panic attacks only in anticipation of, or when confronted with, a specific phobic stimulus. The individual who starts with an unexpected Panic Attack in a specific situation and then has anxiety or panic attacks only in that situation is the difficult one to diagnose.

32. Two Minute Paper Consider the following question and jot down a few ideas for yourself. Suppose a person develops an elevator phobia after having been trapped for several hours in an elevator. He sells his apartment in a high-rise building and buys a ranch style house, changes his job so that his office is on the first floor, shops only in malls that have escalators, and stays only in hotels that can give him a ground-floor room. Does he still have a Specific Phobia? Discuss your ideas with a colleague before sharing them with the class.

34. Obsessive-Compulsive Disorder An obsession is a repetitive and intrusive thought, impulse, or image that causes marked anxiety or distress. A compulsion is a repetitive and ritualistic behavior or mental act that aims to reduce anxiety. Obsessive-Compulsive Disorder is categorized under Anxiety Disorders because anxiety appears to be its driving force. There is some research to support the fact that it is different from other Anxiety Disorders in phenomenology, course, family history, treatment response, and perhaps etiology.

35. Obsessive-Compulsive Disorder A. either obsessions or compulsions: Obsession as defined by: (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 exceptional thoughts, impulses, or images are a product of his/her own mind (not imposed from without as in thought insertion)

36. Obsessive-Compulsive Disorder Compulsions as defined by: (1) repetitive behaviors or mental acts 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

37. 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. C. the obsessions or compulsions cause marked distress, are time-consuming, or significantly interfere with the person's normal routine, occupational functioning, or usual social activities or relationships. D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it. H. The disturbance is not due to the direct physiological effects of a substance or a general medical condition

38. Obsessive-Compulsive Disorder As a general rule this diagnosis should be used only in cases where both obsession and compulsion are present. Obsessions by themselves can be a feature of a number of disorders preoccupation with food and Eating Disorder , appearance in Body Dysmorphic Disorder, drugs or alcohol and Substance Use Disorder, illness in Hypochondriasis, guilt in Major Depressive Disorder Compulsions by themselves can also manifest in a number of disorders superstitious rituals in Generalized Anxiety Disorder, complex motor tics in Tourette�s Disorder impulsive behaviors, that give immediate gratification, can also be repeated frequently and confused with compulsive behaviors

39. Obsessive-Compulsive Disorder Although once considered very rare, lifetime prevalence is from 2% to 3%. Onset is generally in the early 20s, with onset after age 40 very rare. There are really no good theories, either biological or psychological, about the origin.

40. Obsessive-Compulsive Disorder Successful treatment most often involves a combination of medication (cyclic and atypical antidepressants) and behavioral therapy. The behavioral therapy is aimed at breaking the link between obsessive thinking and compulsive behavior. Interestingly, anxiolytic medication is ineffective. The course is chronic but 90% of individuals will experience some improvement with treatment.

41. Posttraumatic Stress Disorder This is one of the few disorders named for its cause. Prevalence rates vary depending on measures: about 9% lifetime, and about 14% with sub clinical pathology. The traumatic event occurring in a place where the victim feels safe, strong feeling of helplessness, shame, and guilt all seem to be risk factors; as is preexisting mental disorder.

42. PTSD The person has been exposed to a traumatic event in which both of the following were present: 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. The person�s response involved intense fear, helplessness, or horror.

43. PTSD The traumatic event is reexperienced in one (or more) of the following ways: Recurrent and intrusive distressing recollections of the event; Recurrent distressing dreams of the event; Acting or feeling as if the traumatic event were reoccurring; Intense psychological distress at exposure to external or internal cues; Psychological reactivity on exposure to external or internal cues.

44. PTSD Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, as indicated by three (or more) of the following: Efforts to avoid thoughts, feelings, or conversation associated with the trauma; Efforts to avoid activities, places, and people that arouse recollection of the trauma; Inability to recall important aspects of the trauma; Markedly diminished interest in participation in significant activities; Feelings of detachment or estrangement from others; Restricted range of affect; Sense of foreshortened future.

45. PTSD Persistent symptoms of increased arousal as indicated by two (or more) of the following: Difficulty falling asleep or staying asleep; Irritability or outbursts of anger; Difficulty concentrating; Hyper vigilance; Exaggerated startle response. Duration of more than 1 month. The disturbance causes clinically significant impairment or distress in social, occupational, or other areas of function.

46. An Aside John Briere (USC) raises some interesting points. The DSM-IV (TR) definition of trauma does not include the fact or threat of harm for psychological integrity. It does not allow for the numbing that frequently accompanies and follows traumatic experience. It allows for hearing about harm, an unlikely source of traumatic experience. The response described is easier to meet in women than in men and is unlikely in emergency responders of either gender.

47. An Aside Trauma might be better defined as a high intensity, adverse event that exceeds the individual�s existing resources for coping and response. This definition recognizes that it is not the event but the subjective reaction to the event and the subsequent ability to deal with it that is the defining feature.

48. Interesting Insights from John Briere Trauma can be impersonal or interpersonal Whether it is one or the other has a good deal to do with the victims perception. Interpersonal trauma is much more likely to result in symptoms. In adults, rape and torture and in children, sexual abuse are most likely to produce severe symptoms. The earlier in development that trauma occurs, the more likely long term symptoms.

49. Interesting Insights from John Briere Anxiety is the most probable residual symptom of trauma. Current experience my trigger fear related to earlier trauma. The current fear often makes no sense in the current situation. Childhood trauma may have more to do with neglect, abandonment, or rejection than with actual abuse.

50. Interesting Insights from John Briere Depression may be more typical than anxiety in childhood trauma and in adult trauma related to natural disaster. Helplessness, hopelessness, and low self-esteem in the face of trauma may be cognitive distortions. Often such distortions are pre-verbal and do not respond to �talk therapy�. Only repetitive positive experience seems to be effective in changing these distortions to some degree.

51. Interesting Insights from John Briere Childhood trauma: Predisposes to adult trauma Increases the effects of adult trauma Increases the likelihood of avoidant response Decreases positive prognosis There are adult trauma that can establish severe dysregulation without childhood trauma.

52. Acute Stress Disorder The person has been exposed to a traumatic event in which both of the following were present: 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. The person�s response involved intense fear, helplessness, or horror.

53. Acute Stress Disorder Either while or after experiencing the distressing event, the individual has 3 (or more) of the following dissociative symptoms: Sense of numbing, detachment, or absence of emotional responsiveness; Reduction of awareness of surroundings; Derealization; Depersonalization; Dissociative amnesia.

54. Acute Stress Disorder The traumatic event is reexperienced in at least one of the following ways: Recurrent and intrusive distressing recollections of the event; Recurrent distressing dreams of the event; Acting or feeling as if the traumatic event were reoccurring; Intense psychological distress at exposure to external or internal cues; Psychological reactivity on exposure to external or internal cues.

55. Acute Stress Disorder Marked avoidance of stimuli that arouse recollection of the trauma. Marked symptoms of anxiety or increased arousal. The disturbance causes clinically significant distress or impairment or impairs the individual's ability at some necessary task, such as obtaining help or mobilizing personal resources by telling family members about the traumatic experience.

56. Acute Stress Disorder The disturbance lasts for > 2 days and < 4 weeks and begins within 4 weeks of the traumatic event. The disturbance is not due to the direct effect of substance use or a general medical condition, is not better accounted for by a brief psychotic disorder, and is not merely a worsening of an already existing Axis I or II disorder.

57. Posttraumatic Stress Disorder Theories about cause are uncertain There is certainly sympathetic hyper arousal, as evidenced by a2 antagonists worsening symptoms. There is also neuroendocrine abnormalities, although these are not consistent. Perhaps Cognitive and Information Processing Theory is the most appropriate.

58. Posttraumatic Stress Disorder Differential diagnosis is necessary to distinguish PTSD from: Generalized Anxiety Disorder Depression Panic Disorder Obsessive-Compulsive Disorder Dissociative Disorder Borderline Personality Disorder Acquired Brain Injury

59. Posttraumatic Stress Disorder Treatment with medication favors the older tri-cyclic antidepressants. Both individual and group therapy are helpful. It would seem that the essential element is offering support and guidance as the individual integrates traumatic events into their life narrative. It should be remembered that full integration of traumatic events is not always, and perhaps not even often possible.

60. Posttraumatic Stress Disorder After experience of severe trauma, virtually all individuals will show symptoms of Acute Stress Disorder. After 1 month, 70% to 90% will show symptoms of PTSD. About 30% recover completely, 40% continue to have mild symptoms, 20% continue to have moderate symptoms, and 10% remain unchanged or worsen. Although rare, the onset of symptoms may be delayed years or even decades.

61. Generalized Anxiety Disorder This is one of the most common and most controversial of disorders The ECA Study indicates a 1 year prevalence of 2.5% to 8%. 4x more than Panic Disorder 3x more than Simple Phobia 2x more women than men Age of onset early There would seem to be a fairly strong genetic basis

62. Generalized Anxiety Disorder Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance). The person finds it difficult to control worry.

63. Generalized Anxiety Disorder 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 the past six months). Note: only one item is required for children (1) restlessness or feeling keyed up or on edge (2) being easily fatigued (3) difficulty concentrating or mind going blank (4) irritability (5) muscle tension (6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

64. Generalized Anxiety Disorder 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), 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 Post-Traumatic Stress Disorder

65. Generalized Anxiety Disorder The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not due to the direct physiological effects of a substance or a general medical condition and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or Pervasive Developmental Disorder

66. Generalized Anxiety Disorder Prominent symptoms fall into 3 categories: Motor tension Shakiness, inability to relax, restlessness, fatigue, back and neck pain, and headache. Autonomic hyperactivity Palpitations, shortness of breath, sweating, dizziness, hot and cold flashes, frequent urination, GI complaints. Hyperarousal Vigilance and scanning, irritability, exaggerated startle response.

67. Generalized Anxiety Disorder The disorder follows a chronic but fluctuating course and symptoms seem to lessen with age. Both psychotherapy (usually CBT) and medication are effective in reducing symptoms. The degree of social support seems to have some significant effect on outcome and response to treatment as does the level of environmental stress.

68. Other Anxiety Disorders Due to General Medical Condition Substance Induced Mixed Anxiety-Depressive Disorder (research criteria)

69. Mixed Anxiety-Depressive Disorder Persistent or recurrent dysphoric mood lasting at least one month. The dysphoric mood is accompanied by at least one month of four (or more) of the following symptoms: (1) difficulty concentrating or mind going blank (2) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) (3) fatigue or low energy (4) irritability (5) worry (6) being easily moved to tears (7) hypervigilance (8) anticipating the worst (9) hopelessness (pervasive pessimism about the future) (10) low self-esteem or feelings of worthlessness

70. Mixed Anxiety-Depressive Disorder The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. All of the following: (1) criteria had never been met for major depressive disorder, dysthymic disorder, panic disorder, or generalized anxiety disorder (2) criteria are not currently met for any other anxiety or mood disorder (including an anxiety or mood disorder, in partial remission) (3) the symptoms are not better accounted for by any other mental disorder