Anxiety Disorders

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Anxiety Disorders

• All 12 of them

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Fear vs. Anxiety

• Fear
• A response to a known, external, definite, or
  non-conflictual threat
• Onset is sudden
• Is a protective factor against harm
• Anxiety
• A response to an unknown, internal, vague or
  conflictual threat
• Onset is insidious
• May also be a protective factor against harm, but
  can become a maladaptive coping mechanism.

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Factors which contribute to anxious responses

• Biological
• Numerous studies of various types of anxiety
  indicate an increased risk among first-degree
  relatives
• Rate varies with type of anxiety disorder
• Highest rate of concordance for Specific Phobia,
  blood, injection, injury type
• Some individuals with an Anxiety D/O may have a
  cerebral pathological condition, or other medical
  condition which contributes to development of
  these symptoms. See KS, page 605.
• Substance use, abuse and withdrawal may
  precipitate the symptoms of an Anxiety D/O.

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Factors which contribute to anxious responses

• Psychological
• Anxiety results from
• an imbalance between the pressures of the outside
  world (stress) and the individuals coping skills
  (ego strength)
• An imbalance between internal impulses
  (aggressive, sexual, dependent) and the
  individuals conscience (super-ego)
• The goal of treatment is to increase anxiety
  tolerance

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Factors which contribute to anxious responses

• Psycho-social
• Chronic stressors, such as loss of a parent while
  a child, lower socio-economic status, etc.
• Acute stressors, such as divorce, birth of a
  child, post-partum anxiety and/or depression, etc.

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First line of treatment

• Always refer clients with symptoms of Anxiety
  D/Os to their physician or to the Emergency Room
  for an evaluation before you begin any course of
  treatment.

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Panic Disorder AgoraphobiaCriteria for a Panic
Attack

• Four or more of the following over a 10 minute
  period of time
• Palpitations (tachycardia)
• Sweating
• Trembling or shaking
• Shortness of breath (hyperventilation or dyspnea)
• Feelings of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Dizzy, unsteady, light-headed, faint
• Derealization or depersonalization
• Fear of loss of control or going crazy
• Fear of dying
• Numbing or tingling sensation (parathesias)
• Chills or hot flashes
• Clients cannot usually name the source of their
  fear
• Last about 20-30 minutes, rarely more than an
  hour

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Panic DisorderCriteria for Agoraphobia

• Anxiety about being in places or situations from
  which escape might be difficult or embarrassing,
  or in which help might not be available in the
  event of a having an unexpected or situationally
  predisposed panic attack or panic-like symptoms.
• These situations are avoided or endured with
  significant distress or anxiety about having a
  panic attack or panic-like symptoms.
• The symptoms are not better accounted for by
  another mental disorder.

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Panic Disorder

• Coding
• 300.01 Panic Disorder without Agoraphobia
• 300.21 Panic Disorder with Agoraphobia
• 300.22 Agoraphobia without history of Panic
  Disorder

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Panic DisorderDiagnostic Features

• Presence of at least two Panic Attacks
  (unexpected, and not situationally bound)
• At least one Panic Attack is followed by one
  month of specific worry and concern about the
  panic attacks or the implication of having an
  additional attack
• Rule in or out associated Agorphobia
• The attacks cannot be due to a general medical
  condition or substance abuse
• The attacks cannot be better accounted for by
  another mental disorder

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Panic Disorder Associated Features

• Disruption of
• Important interpersonal relationships
• School/Occupational functioning
• Unfocussed constant or intermittent worry
• Anticipatory anxiety between attacks
• Catastophizing
• Demoralization
• High comorbidity
• Depression
• Other Anxiety D/O
• High rates of suicide

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Panic Disorder Culture, Age and Gender

• Usually develops in young adulthood, but can
  occur at any age
• Woman are 2-3 times more likely to be treated for
  the disorder than men (may be skewed due to women
  being more likely to seek treatment)
• Panic attacks are experienced in all cultures
• Be aware of some cultures and ethnic groups which
  restrict the public role of women (this would
  preclude Agoraphobia).

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Panic Disorder Course Prognosis

• Quite variable
• About 30 - 40 symptom free at long term
  follow-up
• 50 have mild symptoms
• 10-20 have persisting debilitating symptoms
• Depends on
• Severity of the Panic Attacks
• Presence of Agoraphobia
• Presence of comorbidity

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Agoraphobia without History of Panic Disorder

• Similar to symptoms of Panic Disorder with
  Agoraphobia, except
• The focus of fear is on the occurrence of
  incapacitating or embarrassing panic-like
  symptoms or limited symptom attacks rather than
  full Panic Attacks
• To qualify for this diagnosis, the client must
  never have experienced a Panic Attack, and the
  symptoms are not better accounted for by a
  general medical condition, substance abuse, etc.

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Panic Disorder AgoraphobiaDifferential
Diagnosis

• Use the decision tree on DSM page 754!
• Medical D/Os
• Refer to physician or ER as appropriate
• Substance Abuse D/Os
• Refer to physician or ER as appropriate

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Panic Disorder Agoraphobia Differential
Diagnosis

• Mental Disorders
• Malingering, Factitious D/O Hypochondriasis
• Depersonalization Disorder
• Lacks the full array of symptoms of a Panic
  Attack
• Depressive Disorders
• Look for shifts in mood
• Schizophrenia
• Look for other symptoms of psychosis

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Panic Disorder Agoraphobia Differential
Diagnosis

• Other Anxiety D/Os
• Agoraphobia without Panic Attack
• Lacks symptoms of Panic Attacks
• Separation Anxiety Disorder
• Symptoms directly related to separation from
  attachment figure
• Social Phobia
• Panic Attacks specific to fear of humiliation or
  embarrassment in social or performance situations
• Specific Phobia
• Fear is cued by object or situation

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Panic Disorder Agoraphobia Differential
Diagnosis

• Other Anxiety D/Os
• OCD
• Look for obsession and compulsions
• GAD
• 6 month period of excessive worry, plus anxiety
  symptoms
• PTSD
• Flashbacks, increased arousal, avoidance of
  stimuli associated with traumatic event
• Anxiety in response to a specific event with
  duration of one month

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Panic Disorder Agoraphobia Differential
Diagnosis

• Other Anxiety D/Os
• Acute Stress Disorder
• Flashbacks, increased arousal, avoidance of
  stimuli associated with traumatic event
• Anxiety in response to a specific event with
  duration of symptoms for less than one month
• Adjustment D/O with Anxiety
• Does not meet criteria for any other Anxiety D/O,
  and develops in response to a stressor
• Anxiety D/O NOS
• Clinically significant symptoms, but does not
  meet criteria for any other Anxiety D/O

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Panic Disorder AgoraphobiaTreatment Strategies

• Pharmocotherapy
• SSRIs
• Benzodiazepines
• Tricyclic and Tertacyclics
• MAOIs
• Medical (for non-responsive patients)
• ACT
• Surgery

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Panic Disorder AgoraphobiaTreatment Strategies

• Cognitive-Behavioral
• Cognitive
• Education about Panic Attacks
• Challenge clients cognitive distortions
• Applied Relaxation
• Respiratory Training
• Exposure Therapy

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Panic Disorder AgoraphobiaTreatment Strategies

• Family Therapy
• Helps family to understand and not enable the
  secondary gain of the disorder
• Insight-oriented
• Helps clients understand the unconscious meaning
  of the anxiety

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3 down, 9 to go

• Who do you think should have won American Idol?

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PhobiasSocial Specific

• Coding
• 300.29 Specific Phobia
• Specify
• Animal Type
• Natural Environment Type
• Blood-Injection-Injury Type
• Situational Type
• Other Type
• 300.23 Social Phobia
• Specify if Generalized

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Specific PhobiaDiagnostic Criteria

• Strong, specific fear of an object or situation,
  which produces conscious avoidance of the feared
  subject, activity or situation.
• Exposure to the phobia stimulus almost always
  provokes an immediate anxiety response
• The response may take the form of a situationally
  bound or predisposed Panic Attack
• Clients recognize the irrationality of their fear
  (ego-dystonic).

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Specific PhobiaAssociated Features

• Most common mental disorder in the U.S.
• May result in a restricted lifestyle or
  proscribed occupational circumstances
• High comorbidity with other mental disorders (50
  - 80)
• Blood-injection-injury Type may have symptoms of
  slowed heart rate (bradycardia) and low blood
  pressure (hypotension).

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Specific Phobia Culture, Age, Gender

• The content of phobias varies with culture and
  ethnicity
• Children may exhibit symptoms of crying,
  tantruming, clinging, and freezing
• The gender gap is 21 for females overall,
  although the sex ratio varies over types

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Specific PhobiaCourse Prognosis

• The severity of the condition is constant, and
  does not come and go, as seen in other Anxiety
  D/Os
• Many people simply avoid the stimulus throughout
  their lives, and never seek treatment

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Specific PhobiaDifferential Diagnosis

• Use the decision tree on DSM page 754!
• Rule out the usual General Medical Conditions and
  Substance Abuse

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Specific PhobiaDifferential Diagnosis

• Other Anxiety D/Os
• Panic Disorder with Agoraphobia
• The inter-episode rate of general anxiety is
  higher with this D/O. Those with a Specific
  Phobia do not usually experience a generalized
  anxiety unless anticipating exposure to the
  particular stimulus
• Panic Attacks with this D/O have a usually
  unexpected onset, and the subsequent avoidance of
  multiple stimuli. Panic Attacks with Specific
  Phobias usually take the form of avoidance of the
  stimulus in the absence of re-occurring Panic
  Attacks.
• Look at the focus of the fear, the type and
  number of Panic Attacks, the number of situations
  avoided and the level of inter episode anxiety

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Specific PhobiaDifferential Diagnosis

• Acute Stress Disorder
• Flashbacks, increased arousal, avoidance of
  stimuli associated with traumatic event
• Anxiety in response to a specific event with
  duration of symptoms for less than one month
• Adjustment D/O with Anxiety
• Does not meet criteria for any other Anxiety D/O,
  and develops in response to a stressor
• Anxiety D/O NOS
• Clinically significant symptoms, but does not
  meet criteria for any other Anxiety D/O

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Specific PhobiaDifferential Diagnosis

• OCD
• Look for obsession and compulsions
• GAD
• 6 month period of excessive worry, plus anxiety
  symptoms
• PTSD
• Flashbacks, increased arousal, avoidance of
  stimuli associated with traumatic event
• Anxiety in response to a specific event with
  duration of one month

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Specific PhobiaTreatment Strategies

• Behavioral
• Exposure Therapy
• Graded task assignments
• Patients must be committed to treatment