Anxiety Disorders in Childhood and Adolescence

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Anxiety Disorders in Childhood and Adolescence

• Psy 610A
• Gary S. Katz, Ph.D.

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Anxiety Disorders

• Generalized Anxiety Disorder
• Panic Disorder With Agoraphobia
• Panic Disorder Without Agoraphobia
• Agoraphobia Without History of Panic Disorder
• Obsessive-Compulsive Disorder
• Acute Stress Disorder
• Posttraumatic Stress Disorder
• Social Phobia
• Specific Phobia
• Substance-Induced Anxiety Disorder
• Anxiety Disorder Due to General Medical Condition
• Anxiety Disorder NOS

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Presenting Complaints of Anxiety Disorders in
Childhood

• Anxiety
• Tachycardia
• Shortness of breath
• Fear
• Sense of going crazy
• Separation problems
• Scared
• Repetitive play
• Sleep difficulties
• Shyness

• Palpitation
• Dizziness
• School refusal
• Sense of impending death
• Nervousness and worry
• Tremulousness
• Avoidant behavior
• Hypervigilance
• Social withdrawal

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Definitions and Symptoms

• Anxiety is a normal response to sudden,
  threatening changes facing an individual which
  may include real danger or perceived loss of
  self-esteem or control.
• Manifestations may very for different children,
  generally see signs of
• Motor tension, autonomic hyperactivity, worry
  about future events, and wariness.
• When symptoms of anxiety are persistent, there is
  a need for treatment.
• Can also see chronic anxiety accompanied by
  suicidal feelings, substance abuse, or other
  self-destructive behaviors. This implies serious
  risk requiring immediate attention.
• Often see anxiety symptoms comorbid with
  depression.

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Definitions

• Dissociation The capability or process of
  separating thoughts, emotions, affects, or
  experiences from one another either purposely or
  involuntarily.
• Derealization The dissociative experience of
  unreality or of loss of reality.
• Depersonalization The dissociative experience of
  loss of identity as a person.
• Paresthesia a sensation of numbness or tingling
  on the skin, sometimes described as pins and
  needles.

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Generalized Anxiety Disorder (300.02)

• Includes Overanxious Disorder of Childhood
• Essential feature excessive anxiety and worry
  (apprehensive expectation), occurring more days
  than not for a period of at least 6 months.
• Intensity, duration, or frequency of the anxiety
  and worry is far out of proportion to the actual
  likelihood or impact of the fear event.
• Children tend to worry excessively about their
  competence or the quality of their performance.
• During the course of the disorder, the focus of
  worry may shift from one concern to another.

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Generalized Anxiety Disorder (300.02)

• 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.
• (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)

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Generalized Anxiety Disorder (300.02)

• 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.

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Associated Features and Disorders

• Associated with muscle tension, may see
• trembling, twitching, feeling shaky, muscle
  aches, soreness.
• Somatic symptoms
• sweating, nausea, or diarrhea
• Exaggerated startle response
• Autonomic hyperarousal symptoms are less
  prominent in GAD than in other anxiety disorders
• e.g., tachycardia, shortness of breath, dizziness
• Depressive symptoms also common.

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Associated Features and Disorders

• GAD frequently co-occurs with
• Mood Disorders (e.g., Major Depressive Disorder,
  Dysthymic Disorder).
• Other Anxiety Disorders (e.g., Panic Disorder,
  Social Phobia)
• Substance-Related Disorders (e.g., Alcohol or
  Sedative, Hypnotic, or Anxiolytic Dependence or
  Abuse).
• Other conditions associated with stress (e.g.,
  irritable bowel syndrome, headaches) frequently
  accompany GAD.

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Culture, Age, Gender Features

• Considerable cultural variation in the expression
  of anxiety (e.g., some cultures focus on
  somaticization, others are more cognitive).
• Important to consider the cultural context in
  evaluating anxious symptoms.
• In children, worries often concern the quality of
  their performance, competence at school, or in
  sporting events, even when their performance is
  not being evaluated by others.
• May be excessive concerns about punctuality,
  catastrophic events (e.g., nuclear war,
  earthquakes).
• Children with GAD may be overconforming,
  perfectionistic, unsure of themselves, and may
  redo tasks because of excessive dissatisfaction
  with less-than-perfect performance.
• Children with GAD may be overzealous in seeking
  approval or require excessive reassurance about
  their performance.

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Culture, Age, Gender Features

• GAD may be overdiagnosed in children.
• Need to conduct a thorough diagnostic evaluation
  to determine if the anxiety-related concerns are
  truly GAD or better accounted for by one of the
  other Anxiety Disorders.
• In adults, GAD appears more prevalent in females.
• In clinical settings, about 55-60 of those
  presenting with GAD are female.
• In community epidemiological studies, about 66
  of the GAD cases are female.
• Epidemiology of child GAD is currently being
  studied.
• Links with behavioral inhibition and shyness
• Role of the amygdala (hypersensitivity)

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Common Developmental Presentations

• Infancy
• Rarely diagnosed
• During second year of life, fears and distress
  occurring in situations not ordinarily associated
  with expected anxiety that is not amenable to
  traditional soothing and has an irrational
  quality about it may suggest GAD.

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Common Developmental Presentations

• Early Childhood
• Rarely diagnosed
• May be expressed by crying, tantrums, freezing,
  or clinging, or staying close to a familiar
  person.
• Young children may appear excessively timid in
  unfamiliar social settings, shrink from contact
  with others, refuse to participate in group play,
  remain on the periphery of social activities, and
  attempt to remain close to familiar adults to the
  extent that family life is disrupted.

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Common Developmental Presentations

• Middle Childhood to Adolescence
• Symptoms generally include physiologic symptoms
  associated with anxiety (e.g., restlessness,
  sweating, tension) and avoidance behaviors such
  as refusing to attend school, lack of
  participation in school, decline in classroom
  performance or social functions.
• Can also see increase in worries and sleep
  disturbance.
• These developmental presentations are common to
  many Anxiety Disorders

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Prevalence Course

• In adults
• 1yr prevalence rate approx 3
• Lifetime prevalence 5
• In children?
• Up to 25 of individuals presenting at anxiety
  clinics present with GAD.
• Many individuals with GAD report that they have
  been anxious all their lives.
• Half of those presenting for treatment report
  onset in childhood or adolescence.
• Onset after 20yrs of age is not uncommon.
• Course is generally chronic but fluctuating,
  worsening during periods of stress.

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Familial Pattern

• Early studies show inconsistent findings
  regarding familial patterns for GAD.
• More recent twin studies suggest a genetic
  contribution to the development of GAD.
• Genetic factors influencing GAD may also
  influence Major Depressive Disorder.
• Hettema, et. al., (2005) find that there may be
  common genetic factors for a range of anxiety
  disorders in a comprehensive twin study of nearly
  5000 twin pairs.

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Differential Diagnosis

• Anxiety Disorder Due to a General Medical
  Condition
• Substance-Induced Anxiety Disorder
• Need to be sure that the anxiety in GAD is
  unrelated to other Axis I disorders (e.g., eating
  disorders and fear of gaining weight).
• OCD
• PTSD
• Nonpathological anxiety

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Panic Disorder

• Essential feature the presence of recurrent,
  unexpected Panic Attacks followed by at least 1
  month of persistent concern about having another
  Panic Attack.
• Unexpected Panic Attack
• Not immediately associated with a situational
  trigger
• out of the blue
• Situationally-bound attacks are rare
• Frequency and severity of Panic Attacks vary
  widely.
• Once weekly, monthly
• Limited-symptom attacks are typically reported in
  individuals with Panic Disorder

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Panic Disorder

• Fears are real in Panic Disorder
• Individual believes that they are dying, having a
  heart attack, or have some undiagnosed,
  life-threatening illness.
• Despite repeated medical testing showing no
  concerns, often the fear persists.
• Adults with Panic Disorder will quit their jobs,
  avoid physical exertion all to prevent another
  Panic Attack. Can see school avoidance in kids
  with Panic Disorder.
• This avoidant behavior may meet criteria for
  Agoraphobia, in which case Panic Disorder with
  Agoraphobia is diagnosed.

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Panic Attack

• Note A Panic Attack is not a codable disorder.
  Code the specific diagnosis in which the Panic
  Attack occurs (e.g., 300.21 Panic Disorder With
  Agoraphobia.
• 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
• (7) nausea or abdominal distress
• (8) feeling dizzy, unsteady, lightheaded, or
  faint
• (9) derealization or depersonalization
• (10) fear of losing control or going crazy
• (11) fear of dying
• (12) paresthesias (numbness or tingling
  sensations)
• (13) chills or hot flushes

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Agoraphobia

• Note Agoraphobia is not a codable disorder.
  Code the specific disorder in which the
  Agoraphobia occurs (e.g., 300.21 Panic Disorder
  With Agoraphobia or 300.22 Agoraphobia Without
  History of Panic Disorder).
• 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.

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Agoraphobia

• B. The situations are avoided (e.g., travel is
  restricted) or else are 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, 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).

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Associated Features and Disorders

• Frequently experience constant or intermittent
  feelings of anxiety not focused on any specific
  situation or event. May not be able to get this
  information from children.
• Can see individuals anticipate a catastrophic
  outcome from a mild physical symptom or
  medication side effect.
• Loss or disruption of important interpersonal
  relationships is associated with the onset or
  exacerbation of Panic Disorder in adults.
• Demoralization also common among adults and
  adolescents leading to school work drop-outs.

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Associated Features and Disorders

• Comorbid MDD ranges between 10 and 65 in
  individuals with Panic Disorder.
• Other Anxiety Disorders 15 to 30 in
  individuals with Panic Disorder
• Induced Panic Attacks with sodium lactate
  infusion or carbon dioxide inhalation are more
  common in individuals with Panic Disorders than
  controls or individuals with GAD.

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Associated Physical Findings

• During Panic Attacks
• Transient tachycardia
• Moderately elevated systolic BP
• Numerous general medical conditions have been
  found to be comorbid
• Dizziness, cardiac arrhythmias, hyperthyroidism,
  asthma, CPOD, irritable bowel
• however, cause-and-effect relationship remains
  unclear.

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Culture and Gender Features

• In some cultures, may see Panic Attack associated
  with an intense fear of witchcraft or magic.
• Panic Disorder has been found in epidemiological
  studies throughout the world.
• Need to account for cultural restrictions in
  making the agoraphobia distinction
• e.g., cultural restriction of women in public
  life is not agoraphobia
• More common in adult women than in adult men
• Without Agoraphobia 21 sex ratio
• With Agoraphobia 31 sex ratio
• In children?

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Prevalence Course

• Rare in childhood
• Onset typically in late adolescence and mid-30s.
• Bimodal distribution.
• Usual course is chronic, but with some waxing and
  waning.

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Familial Pattern

• First degree biological relatives of positive
  probands have an 8x increased risk of Panic
  Disorder
• If the age of onset is before 20, risk jumps to
  20x
• In clinical settings, 50 to 75 of individuals
  with Panic Disorder do not have an affected
  first-degree biological relative with Panic
  Disorder.
• Twin studies suggest a biological contribution to
  the development of Panic Disorder.

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Common Developmental Presentations

• Infancy not relevant
• Early Childhood
• Crying, tantrums, freezing, clinging, or staying
  close to a familiar person during a panic attack.
• Middle Childhood
• Panic attacks may be manifested by symptoms such
  as tachycardia, shortness of breath, spreading
  chest pain, and extreme tension
• Adolescence
• Symptoms similar to adults.
• Sense of impending doom, fear of going crazy,
  feelings of unreality and somatic symptoms such
  as shortness of breath, palpitations, sweating,
  choking, and chest pain.

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Differential Diagnosis

• Anxiety Disorder Due to a General Medical
  Condition
• Substance-Induced Anxiety Disorder
• Other Axis I disorders
• Other Anxiety Disorders
• Social Phobia and Panic Disorder with Agoraphobia
  differential may be difficult
• Focus on the nature of the fear and the
  subsequent panic attack
• If the fears and panic attacks generalize, may
  warrant a Panic Disorder diagnosis. Otherwise,
  Social Phobia may be more appropriate.
• Can Dx multiple Anxiety/Mood Disorders
• Self-medication leading to Substance-Related
  Disorders is common.

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Panic Disorder With Agoraphobia (300.21)

• 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.

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Panic Disorder With Agoraphobia (300.21)

• 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),
  Obsessive-Compulsive 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).

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Panic Disorder Without Agoraphobia (300.01)

• 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 Agoraphobia.

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Panic Disorder Without Agoraphobia (300.01)

• 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),
  Obsessive-Compulsive 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).

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Agoraphobia Without History of Panic Disorder
(300.22)

• Essential feature focus of ones fear is on the
  occurrence of incapacitating or extremely
  embarrassing panic-like symptoms or
  limited-symptom attacks rather than full Panic
  Attacks.

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Culture Gender Features

• Need to consider cultural restrictions on
  participation of women in public life not
  agoraphobia.
• Agoraphobia diagnosed far more frequently in
  females than in males.
• Children?

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Prevalence Course

• Vast majority of individuals with Agoraphobia
  also present with current (or history of) Panic
  Disorder.
• Unknown in childhood.
• Little known about course assumed to be
  persistent and associated with considerable
  impairment.

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Differential Diagnosis

• Panic Disorder with Agoraphobia
• Social Phobia
• Specific Phobia
• Major Depressive Disorder
• Persecutory fears in OCD or Delusional Disorder
• Separation Anxiety Disorder

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Agoraphobia Without History of Panic Disorder
(300.22)

• A. The presence of Agoraphobia related to fear of
  developing panic-like symptoms (e.g., dizziness
  or diarrhea).
• B. Criteria have never been met for Panic
  Disorder.
• C. 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.
• D. If an associated general medical condition is
  present, the fear described in Criterion A is
  clearly in excess of that usually associated with
  the condition.

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Obsessive-Compulsive Disorder (300.3)

• Essential feature recurrent obsessions or
  compulsions.
• Obsessions persistent ideas, thoughts,
  impulses, or images that are experienced as
  intrusive and inappropriate, causing anxiety or
  distress
• Compulsions repetitive behaviors (e.g., hand
  washing, ordering, checking) or mental acts
  (e.g., praying, counting, repeating words
  silently) the goal of which is to prevent or
  reduce anxiety or distress, not to provide
  pleasure or gratification.
• While adults may recognize that the obsessions or
  compulsions are excessive or unreasonable,
  children may not.

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Associated Features and Disorders

• Avoidance of situations involving the content of
  the obsessions (e.g., dirt, germs leading to
  avoding public restrooms or shaking hands with
  strangers).
• Can see dermatologic problems caused by excessive
  washing with water or caustic clearning agents.

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Cultural Features

• Culturally-prescribed ritual behavior is not OCD
  unless it exceed cultural norms, occurs at times
  and places judged inappropriate by others of the
  same culture, and interferes with social role
  functioning.
• Life transitions and mourning may lead to an
  intensification of ritualized behavior.

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Age and Gender Features

• Washing, checking, and ordering rituals are
  common in children.
• Children generally experience OCD as
  ego-syntonic.
• More often, the problem is identified by parents.
• Gradual declines in schoolwork, secondary to
  impaired concentration has been reported.
• A small subset of children with Group A
  beta-hemolytic strep (e.g., scarlet fever and
  strep throat) may develop OCD.
• This form of OCD also associated with other
  movement and neurological abnormalities.
• Childhood onset OCD more common in boys than in
  girls.

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Common Developmental Presentations

• Infancy rarely present at this age
• Early Childhood
• Child evidences a higher degree of compulsive and
  ritualistic behavior, from holding onto certain
  objects, watching certain videos, or lining up
  toys in certain sequences. These rigidities are
  less responsive to soothing and interaction than
  at the problem level.

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Common Developmental Presentations

• Middle Childhood and Adolescence
• Child presents with obsessions and compulsions
  such as repetitive hand washing, ordering,
  checking, counting, repeating words silently,
  repetitive praying.
• The obsessions or compulsions interfere with
  listening or attending in class and frequently
  grades worsen because the child cannot sit still
  during tests or lectures.
• Child may fear harming himself or herself or
  others if compulsion is not performed and has
  problems with task completion.

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Prevalence and Course

• Community studies of children and adolescents
  estimated lifetime prevalence of 1 to 2.3 and a
  1-year prevalence of 0.7.
• Research suggests that prevalence is consistent
  in many different cultures.
• Usually, OCD begins in adolescence or adulthood.
• May begin in early childhood.
• Modal age at onset is earlier in males (6y-16y)
  than for females (20-29).
• Onset is usually gradual, acute onset has been
  noted.
• Majority of individuals have a chronic waxing and
  waning, exacerbated by stress.
• 15 show progressive deterioration in
  occupational and social functioning.
• 5 of episodic course with minimal or no symptoms
  between episodes.

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Familial Pattern

• Concordance rates for OCD higher in monozygotic
  twins than in dizygotic twins.
• Rate of OCD in first-degree biological relatives
  of OCD positive probands is higher.
• Also see familial clustering of OCD in
  individuals with first-degree biological
  relatives with Tourettes Disorder.

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Differential Diagnosis

• Anxiety Disorder Due to a General Medical
  Condition
• Substance-Induced Anxiety Disorder
• Recurrent or intrusive thoughts with other Axis I
  disorders
• Body Dysmorphic Disorder
• Specific or Social Phobia
• Trichotillomania
• Major Depressive Disorder
• GAD
• Hypochondriasis

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Differential Diagnosis

• With loose reality testing re obsessions and
  compulsions, consider Delusional Disorder or
  Psychotic Disorder NOS
• Schizophrenia
• Tic Disorder
• Eating Disorders
• Paraphilias
• OCPD
• Pervasive pattern of preoccupation with
  orderliness. NOT OCD
• Superstitions or repetitive checking behaviors.

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Obsessive-Compulsive Disorder (300.3)

• 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)

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Obsessive-Compulsive Disorder (300.3)

• A. Either obsessions or compulsions
• Compulsions as defined by (1) and (2)
• (1) repetitive behaviors (e.g., hand washing,
  ordering, checking) or mental acts (e.g.,
  praying, 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

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Obsessive-Compulsive Disorder (300.3)

• 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.

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Obsessive-Compulsive Disorder (300.3)

• 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 Disorders 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 Use 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

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Acute Stress Disorder (308.3)

• Essential feature the development of
  characteristic anxiety, dissociative, and other
  symptoms that occurs within 1 month after
  exposure to an extreme traumatic stressor.
• As a response to the traumatic event, the
  individual develops dissociative symptoms.
• Individuals with Acute Stress Disorder may
• have a decrease in emotional responsiveness
• feel guilty about pursuing usual life tasks
• experience difficulty concentrating
• experience the world as unreal or dreamlike
• have difficulty recalling details from the
  traumatic event
• yet re-experience the traumatic event
• avoid reminders of the trauma
• experience hyperarousal hypervigilance

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Associated Features and Disorders

• Symptoms of despair and hopelessness may present
  sufficiently to warrant a diagnosis of Major
  Depressive Disorder (can be comorbid)
• Survivors guilt
• Problems may result from a lack of attention to
  the individuals basic health and safety needs
  following the trauma
• Increased risk for PTSD
• 80 of victims of auto crash survivors, victims
  of violent crime who meet criteria for Acute
  Stress Disorder go on to meet criteria for PTSD
• Impulsive and risk-taking behavior also common
  after the trauma.

61
Specific Culture Features

• Need to consider culturally-bound events
  regarding loss as being processed differently by
  different cultures.
• Different cultures may have different prescribed
  coping behaviors.
• Dissociative behaviors that are
  culturally-sanctioned are not Acute Stress
  Disorder

62
Prevalence Course

• Prevalence in the general population (adults)
  ranges from 14 to 33 in individuals exposed to
  severe trauma (i.e., being in a motor vehicle
  accident, being a bystander at a mass shooting)
• Prevalence in children?
• Symptoms, by definition, start during or
  immediately after the trauma, last for 2 days,
  and either resolves within 4 weeks or the
  diagnosis changes (PTSD).
• Severity, duration, and proximity of exposure to
  the traumatic event predict the likelihood of
  developing Acute Stress Disorder
• Other factors include social supports, family
  history, childhood experiences, personality
  variables, and preexisting mental disorders may
  have a role in developing Acute Stress Disorder.

63
Differential Diagnosis

• Mental Disorder Due to a General Medical
  Condition
• Substance-Induced Disorder
• If psychotic symptoms are present, consider Brief
  Psychotic Disorder
• Major Depressive Disorder can develop afterwards
  as well
• If symptoms persist beyond 4 weeks, PTSD
• Adjustment Disorder
• Malingering (if financial remuneration, benefit
  eligibility, or forensic determinations play a
  role).

64
Acute Stress Disorder (308.3)

• A. The person has been exposed to a traumatic
  event 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
• B. Either while experiencing or after
  experiencing the distressing event, the
  individual has three (or more) of the following
  dissociative symptoms
• (1) a subjective sense of numbing, detachment, or
  absence of emotional responsiveness
• (2) a reduction in awareness of his or her
  surroundings (e.g., "being in a daze")
• (3) derealization
• (4) depersonalization
• (5) dissociative amnesia (i.e., inability to
  recall an important aspect of the trauma)

65
Acute Stress Disorder (308.3)

• C. The traumatic event is persistently
  reexperienced in at least one of the following
  ways recurrent images, thoughts, dreams,
  illusions, flashback episodes, or a sense of
  reliving the experience or distress on exposure
  to reminders of the traumatic event.
• D. Marked avoidance of stimuli that arouse
  recollections of the trauma (e.g., thoughts,
  feelings, conversations, activities, places,
  people).
• E. Marked symptoms of anxiety or increased
  arousal (e.g., difficulty sleeping, irritability,
  poor concentration, hypervigilance, exaggerated
  startle response, motor restlessness).

66
Acute Stress Disorder (308.3)

• F. The disturbance causes clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning or
  impairs the individual's ability to pursue some
  necessary task, such as obtaining necessary
  assistance or mobilizing personal resources by
  telling family members about the traumatic
  experience.
• G. The disturbance lasts for a minimum of 2 days
  and a maximum of 4 weeks and occurs within 4
  weeks of the traumatic event.
• H. 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, is not better accounted for by Brief
  Psychotic Disorder, and is not merely an
  exacerbation of a preexisting Axis I or Axis II
  disorder.

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68
Posttraumatic Stress Disorder (309.81)

• Essential feature the development of
  characteristic symptoms following exposure to an
  extreme traumatic stressor involving direct
  personal experience of an event that involves
  actual or threatened death or serious injury, or
  a threat to the physical integrity of another
  person or learning about similar threats
  experienced by a family member or a close
  associate.
• Examples of traumatic events
• Military combat, violent personal assault, being
  kidnapped, taken hostage, terrorist attack,
  torture, incarceration as a POW, natural or
  manmade disasters
• For children
• sexually traumatic events (e.g., developmentally
  inappropriate sexual experiences without
  threatened or actual violence or injury).
• Witnessing events involving serious injury or
  unnatural death of another person

69
Associated Features and Disorders

• Survivor guilt
• Avoidance patterns
• Can see auditory hallucinations and/or paranoid
  ideation
• In child survivors of sexual or physical abuse
• Impaired affect modulation
• Self-destructive and impulsive behavior
• Dissociative symptoms
• Somatic complaints
• Feelings of ineffectiveness
• Shame, despair, or hopelessness
• Feeling permanently damaged
• A loss of previously sustained beliefs
• Hostility
• Social withdrawal
• Feeling constantly threatened
• Impaired relationships with others
• Change from the individuals original personality
  characteristics

70
Associated Features and Disorders

• PTSD is associated with increased rates of
• Major Depressive Disorder
• Substance-Related Disorders
• Panic Disorder
• Agoraphobia
• OCD
• GAD
• Social Phobia
• Specific Phobia
• Bipolar Disorder
• These conditions can either precede, follow, or
  emerge concurrently with the onset of PTSD

71
Culture Features

• Recent immigrants from areas of social unrest and
  civil conflict may have elevated rates of PTSD.
• These individuals may be reluctant to divulge
  these experiences of torture and trauma due to
  their vulnerable political immigrant status.
• Specific assessments for these individuals are
  warranted.

72
Age Features

• In younger children, can see distressing dreams
  of the event may within weeks change into
  generalized nightmares of monsters, rescuing
  others, or of threats to self or others.
• Young children usually do not have the sense that
  they are reliving the trauma rather, this may
  occur through repetitive play.
• Diminished interest in significant activities,
  affect constriction not usually reported by
  children need to interview collateral sources
  (parents, teachers) for this information.
• Foreshortened future may include a prediction
  that they will never be an adult.
• Omen formation belief in an ability to
  foresee future untoward events
• Also see physical symptoms such as stomachaches
  and headaches.

73
Prevalence

• Community-based samples lifetime prevalence of
  8 in adults
• Children?
• Higher rates of PTSD prevalence (between 33 and
  50) seen in survivors of rape, military combat
  and captivity, and ethnically or politically
  motivated internment and genocide.

74
Course

• PTSD can begin at any age, including childhood.
• Rarely diagnosed in infancy
• May take the form of extra fears or aggressive
  behaviors in response to stress
• Symptoms usually begin with 3 months after the
  trauma, although may be a delay of months or even
  years.
• Frequently individuals progress from Acute Stress
  Disorder to PTSD
• Duration of symptoms vary
• Complete recovery within 3 months for 50 of the
  cases
• Many others having symptoms persist for longer
  than 12 months
• Course can be waxing and waning
• Symptom reactivation response to reminders of
  the original trauma
• Severity, duration, and proximity of an
  individuals exposure to the traumatic event are
  the most important factors affecting the
  likelihood of developing PTSD.
• Some evidence that social supports, family
  history, childhood experiences, personality
  variables, and preexisting mental disorders may
  influence the development of PTSD.

75
Familial Pattern

• Evidence of a heritable component to the
  transmission of PTSD
• History of depression in first-degree relatives
  linked to increased vulnerability to developing
  PTSD
• Twin study published in 2003 showed an increase
  concordance rate of PTSD in a study of twins who
  were Vietnam veterans.

76
Differential Diagnosis

• Adjustment Disorder (low intensity stressor)
• Acute Stress Disorder (duration criterion)
• OCD
• Illusions, hallucinations, perceptual
  disturbances also seen in
• Schizophrenia, other Psychotic Disorders
• Mood Disorder with Psychotic Features
• Delirium
• Substance-Induced Disorders
• Malingering (if financial remuneration, benefit
  eligibility, or forensic determinations are in
  play).

77
Posttraumatic Stress Disorder (309.81)

• A. The person has been exposed to a traumatic
  event 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

78
Posttraumatic Stress Disorder (309.81)

• B. The traumatic event is persistently
  reexperienced in one (or more) of the following
  ways
• (1) 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.
• (2) recurrent distressing dreams of the event.
  Note In children, there may be frightening
  dreams without recognizable content.
• (3) 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.
• (4) intense psychological distress at exposure to
  internal or external cues that symbolize or
  resemble an aspect of the traumatic event
• (5) physiological reactivity on exposure to
  internal or external cues that symbolize or
  resemble an aspect of the traumatic event

79
Posttraumatic Stress Disorder (309.81)

• 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)

80
Posttraumatic Stress Disorder (309.81)

• D. Persistent symptoms of increased arousal (not
  present before the trauma), as indicated by two
  (or more) of the following
• (1) difficulty falling or staying asleep
• (2) irritability or outbursts of anger
• (3) difficulty concentrating
• (4) hypervigilance
• (5) exaggerated startle response
• E. Duration of the disturbance (symptoms in
  Criteria B, C, and D) is more than 1 month.

81
Posttraumatic Stress Disorder (309.81)

• 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

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83
Social Phobia (300.23)

• Also known as Social Anxiety Disorder
• Essential feature marked and persistent fear of
  social or performance situations in which
  embarrassment may occur.
• Individuals often afraid of being judged to be
  anxious, weak, crazy, or stupid.
• Almost always experience symptoms of anxiety
• Adults may realize that the fear is unusual or
  excessive, children may not.
• Symptom duration of 6mos for those under the age
  of 18.

84
Associated Features and Disorders

• Hypersensitivity to criticism, negative
  evaluation, or rejection
• Difficulty being assertive
• Low self-esteem or feelings of inferiority
• Can see poor social skills (e.g., poor eye
  contact) or observable signs of anxiety (e.g.,
  cold clammy hands)
• Often see underachievement in school due to test
  anxiety or avoidance of classroom participation
• In severe cases, these individuals may drop out
  of school, have no friends or cling to
  unfulfilling relationships, completely refrain
  from dating, or remain with their family of
  origin
• Can see suicidal ideation when other comorbid
  disorders are present.

85
Cultural Features

• Clinical presentation may vary across cultures,
  depending upon social demands.
• In certain cultures, fear of offending others may
  pervade (e.g., Japan and Korea)

86
Age Features

• In children crying, tantrums, freezing, clinging,
  or staying close to a familiar person and
  inhibited interactions to the point of mutism may
  be present.
• Young children may appear excessively timid in
  unfamiliar social settings, shrink from others,
  refuse to participate in group play, stay on the
  periphery of social activities, and attempt to
  remain close to familiar adults.
• Unlike adults, children usually do not have the
  option of avoiding feared situations altogether
  and may be unable to identify the nature of their
  anxiety.
• Decline in school performance, school refusal,
  avoidance of age-appropriate social activities
  and dating.
• Need to see capacity to have social relationships
  with familiar people to make diagnosis in
  children.

87
Age Features

• Early onset and chronic course leads to failure
  to achieve at expected level of functioning,
  rather than a decline from optimal functioning.
• With onset in adolescence, can see decrements in
  social and academic performance.

88
Gender Features and Prevalence

• Epidemiological studies suggest Social Phobia is
  more common in women than in men.
• In most clinical samples, equal sex
  representation or majority males.
• Children?
• UK sample .4 to 1.8 prevalence

89
Course

• Typical onset in mid-teens, sometimes emerging
  out of a childhood history of social inhibition
  or shyness.
• Some individuals report onset in early childhood.
• Onset may follow an abruptly humiliating
  experience.
• Course is usually continuous, lifelong, although
  severity may attenuate or remit in adulthood.
• May diminish after marriage and reemerge after
  death of a spouse.

90
Familial Pattern

• Occurs more frequently among first-degree
  biological relatives of those with Social Phobia
  than in the general population.
• Evidence strongest for the generalized subtype.

91
Differential Diagnosis

• Panic Disorder with Agoraphobia
• Separation Anxiety Disorder
• SAD Children usually comfortable at home, SP
  children may not be.
• Generalized Anxiety Disorder
• Pervasive Developmental Disorder
• Performance anxiety, stage fright, shyness

92
Social Phobia (300.23)

• 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.
• 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.

93
Social Phobia (300.23)

• 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.

94
Social Phobia (300.23)

• 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.
• F. In individuals under age 18 years, the
  duration is at least 6 months

95
Social Phobia (300.23)

• 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 for by
  another 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 dsease, 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)

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97
Specific Phobia (300.29)

• 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.

98
Specific Phobia (300.29)

• 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.

99
Specific Phobia (300.29)

• F. In individuals under age 18 years, the
  duration is at least 6 months.
• 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.
• Specify type
• Animal Type
• Natural Environment Type (e.g., heights, storms,
  water)
• Blood-Injection-Injury Type
• Situational Type (e.g., airplanes, elevators,
  enclosed places)
• Other Type (e.g., phobic avoidance of situations
  that may lead to choking, vomiting, or
  contracting an illness in children, avoidance of
  loud sounds or costumed characters)

100
Specific Phobia Comments relevant to Children
and Adolescents

• Children may not be aware that the fear is
  excessive or unreasonable.
• Animal Type, Natural Environment Type generally
  has a childhood onset.
• Childrens anxiety may be expressed by
• Crying, tantrums, freezing, or clinging.
• Diagnosis is not warranted unless fears lead to
  clinically significant impairment (e.g., fears
  going to school) as transient fears are common in
  childhood.

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102
Substance-Induced Anxiety Disorder

• A. Prominent anxiety, Panic Attacks, or
  obsessions or compulsions predominate in the
  clinical picture.
• B. There is evidence from the history, physical
  examination, or laboratory findings of either (1)
  or (2)
• (1) the symptoms in Criterion A developed during,
  or within 1 month of, Substance Intoxication or
  Withdrawal
• (2) medication use is etiologically related to
  the disturbance

103
Substance-Induced Anxiety Disorder

• C. The disturbance is not better accounted for by
  an Anxiety Disorder that is not substance
  induced. Evidence that the symptoms are better
  accounted for by an Anxiety Disorder that is not
  substance induced might include the following
  the symptoms precede the onset of the substance
  use (or medication use) the symptoms persist for
  a substantial period of time (e.g., about a
  month) after the cessation of acute withdrawal or
  severe intoxication or are substantially in
  excess of what would be expected given the type
  or amount of the substance used or the duration
  of use or there is other evidence suggesting the
  existence of an independent non-substance-induced
  Anxiety Disorder (e.g., a history of recurrent
  non-substance-related episodes).
• D. The disturbance does not occur exclusively
  during the course of a Delirium.

104
Substance-Induced Anxiety Disorder

• E. The disturbance causes clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.
• Note This diagnosis should be made instead of a
  diagnosis of Substance Intoxication or Substance
  Withdrawal only when the anxiety symptoms are in
  excess of those usually associated with the
  intoxication or withdrawal syndrome and when the
  anxiety symptoms are sufficiently severe to
  warrant independent clinical attention.
• Code Specific Substance-Induced Anxiety
  Disorder
• (291.89 Alcohol 292.89 Amphetamine (or
  Amphetamine-Like Substance) 292.89 Caffeine
  292.89 Cannabis 292.89 Cocaine 292.89
  Hallucinogen 292.89 Inhalant 292.89
  Phencyclidine (or Phencyclidine-Like Substance)
  292.89 Sedative, Hypnotic, or Anxiolytic 292.89
  Other or Unknown Substance)

105
Substance-Induced Anxiety Disorder

• Specify if
• With Generalized Anxiety if excessive anxiety
  or worry about a number of events or activities
  predominates in the clinical presentation
• With Panic Attacks if Panic Attacks predominate
  in the clinical presentation
• With Obsessive-Compulsive Symptoms if
  obsessions or compulsions predominate in the
  clinical presentation
• With Phobic Symptoms if phobic symptoms
  predominate in the clinical presentation
• Specify if
• With Onset During Intoxication if the criteria
  are met for Intoxication with the substance and
  the symptoms develop during the intoxication
  syndrome
• With Onset During Withdrawal if criteria are
  met for Withdrawal from the substance and the
  symptoms develop during, or shortly after, a
  withdrawal syndrome

106
Anxiety Disorder Due to a General Medical
Condition (293.84)

• A. Prominent anxiety, Panic Attacks, or
  obsessions or compulsions predominate in the
  clinical picture.
• B. There is evidence from the history, physical
  examination, or laboratory findings that the
  disturbance is the direct physiological
  consequence of a general medical condition.
• C. The disturbance is not better accounted for by
  another mental disorder (e.g., Adjustment
  Disorder With Anxiety in which the stressor is a
  serious general medical condition).

107
Anxiety Disorder Due to a General Medical
Condition (293.84)

• D. The disturbance does not occur exclusively
  during the course of a Delirium.
• E. The disturbance causes clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.
• Specify if
• With Generalized Anxiety if excessive anxiety
  or worry about a number of events or activities
  predominates in the clinical presentation
• With Panic Attacks if Panic Attacks predominate
  in the clinical presentation