anxiety disorders

1. Anxiety Disorders 6.21.2006 6.23.2006

3. Fear Present-oriented mood state characterized by strong negative affect Immediate, temporary activation of stress response system Strong avoidance/escape tendencies Panic Disorder, Agoraphobia, Social Phobia, Specific Phobia

4. Anxiety Disorders Most common mental disorders in the U.S. At least 19% of the adult population suffer from at least one anxiety disorder in any given year Anxiety Disorders cost $42 billion each year in health care, lost wages, and lost productivity

5. Panic Attack (not a diagnosis) A. Discrete period of intense fear or discomfort, in which 4 or more of the following Sx develop abruptly and reach a peak within 10 minutes Palpitations Sweating Trembling/aching Sensations of shortness of breath or smothering Feeling of choking Chest pain/discomfort Nausea/abdominal distress Feeling dizzy/unsteady/lightheaded/faint Derealization/depersonalization Fear of losing control/going crazy Fear of dying Paresthesias (numbness or tingling sensation) Chills/hot flushes

6. Agoraphobia (not a diagnosis) A. Anxiety about being in places or situations from which escape might be difficult or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. B. The situations are avoided or are endured with marked distress C. Not better accounted for by another mental disorder

7. Some help�

8. Panic Disorder without Agoraphobia A. Both 1 and 2 1. Recurrent, unexpected panic attacks 2. At least one of the attacks has been followed by 1 or more months of 1 or more of the following a. Persistent concern about having additional attacks b. Worry about the implications of the attack or its consequences c. Significant change in behavior related to the attacks B. Absence of agoraphobia C. Panic attacks are not due to a GMC or substance D. Panic Attacks are not better accounted for by another mental disorder

9. Panic Disorder with Agoraphobia A. Both 1 and 2 1. Recurrent, unexpected panic attacks 2. At least one of the attacks has been followed by 1 or more months of 1 or more of the following a. Persistent concern about having additional attacks b. Worry about the implications of the attack or its consequences c. Significant change in behavior related to the attacks B. Presence of agoraphobia C. Panic attacks are not due to a GMC or substance D. Panic Attacks are not better accounted for by another mental disorder

10. Facts about Panic Disorder Prevalence: 1-2% in community samples 10-30% in clinical samples Approx. 1/3 - 1/2 have agoraphobia Gender: 2-3 times more common in women Age of onset: Late adolescence to mid-30�s Course: Chronic Often waxes and wanes Treatment: One of the most treatable mental illnesses, can be treated in 3-4 sessions with a specialist

11. Agoraphobia without History of Panic Disorder A. Presence of Agoraphobia related to fear of developing panic-like symptoms B. Criteria have never been met for Panic Disorder C. Disturbance is not due to a GMC or substance D. If an associated GMC is present, the agoraphobia is in excess of that usually associated with the condition

12. Facts about Agoraphobia Prevalence: Relatively unknown�seems to be rare Gender: More common in females Age of Onset: Unknown Course: Relatively unknown�may persist for years

13. Panic Attacks, Panic Disorder, and Agoraphobia

14. Specific Phobia A. Marked, persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation B. Exposure to the phobic stimulus almost always provokes an immediate anxiety response C. The person recognizes that the fear is excessive or unreasonable D. The phobic stimulus is avoided or endured with intense anxiety or distress E. There is significant distress or an impairment in functioning due to the phobia F. The phobia is not better accounted for by another mental disorder

15. Subtypes of Specific Phobia Animal type Natural environment type Blood-Injection-Injury type Situational type Other type

16. Facts about Specific Phobia Prevalence: 4-9% (current) 7-11% (lifetime) Gender: Ratio of women to men = 2:1 Age of Onset: Varies based on type of phobia Animal, Natural environment, Blood- Injection-Injury types � childhood to early adolescence Situational � childhood or mid-20s Course: Often remit in adulthood, old-age Culture: Content of phobias vary across cultures and cultural context needs to be considered

17. Social Phobia A. Marked, 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 an anxiety response C. The person recognizes that the fear is excessive or unreasonable D. The phobic stimulus is avoided or endured with intense anxiety or distress E. There is significant distress or an impairment in functioning due to the phobia F. The phobia is not better accounted for by another mental disorder and is not due to a GMC or substance G. If another mental disorder or GMC is present, the feared social situation is unrelated

18. Facts about Social Phobia Prevalence: 3-13% (lifetime) Gender: Community studies � women > men Clinical studies � women = men women < men Age of Onset: Childhood through mid-adolescence Course: Often lifelong, waxing and waning in response to life stressors Associated w/: Hypersensitivity to criticism, difficulty being assertive, low self-esteem, feelings of inferiority, poor social skills

19. Phobias � what to look for Almost invariable immediate fear response to being in fear situation Active avoidance of the fear situation or the fear situation is endured with intense anxiety Client recognizes that the fear is excessive or unreasonable (this may not be present in children) Impairment in functioning or marked distress Duration of 6 months or longer

20. Obsessive-Compulsive Disorder A. Either obsessions or compulsions: Obsessions as defined by 1, 2, 3, and 4 Recurrent, 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 The thoughts, impulses, or images are not simply excessive worries about real-life problems The person attempts to ignore or suppress such thoughts, impulses, or images or tries to neutralize them with some other thought or action The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind

21. Obsessive-Compulsive Disorder Compulsions as defined by 1 and 2 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 The compulsions are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

22. Obsessive-Compulsive Disorder B. The person has recognized that the obsessions or compulsions are excessive or unreasonable C. There is significant distress or an impairment in functioning due to the obsessions or compulsions D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to the other Axis I disorder E. The disturbance is not due to a GMC or substance

23. Typical Obsessions Doubts (eg. Did I turn off the stove? Did I lock the door? Did I hurt someone?) Fears that someone else has been hurt or killed Fears that one has done something criminal Fears that one may accidentally injure someone Worry that one has become dirty or contaminated Blasphemous or obscene thoughts NOT just excessive worries about real-life problems

24. Typical Compulsions Checking Cleaning/washing Doing things a certain number of times in a row Doing and then undoing things Doing things in a certain order Mental acts such as praying, counting, etc.

25. Relationship between obsessions and compulsions Compulsions are aimed at preventing or reducing distress, or at preventing some dreaded event/situation Typical distress being avoided: intense anxiety Typical dreaded situation: someone you love will come to harm, others will abandon you The connection between the obsessions and the dreaded situation is not realistic � �magical thinking� However, insight diminishes over time � person comes to accept it as quite reasonable that you have to count to 1,000 or your husband will die

26. Facts about OCD Prevalence: 2.5% (lifetime) Gender: Equal rates, different ages of onset Age of Onset: Ages 6-15 (males) Ages 20-29 (females) Course: Gradual onset Chronic, waxing and waning Associated w/: Avoidance, hypochondriasis, guilt, pathological sense of responsibility, sleep disturbances, self-medicating

27. Posttraumatic 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. (NOTE: in children, this may be expressed instead by disorganized or agitated behavior)

28. Posttraumatic Stress Disorder B. The traumatic event is persistently reexperienced in one (or more ) or the following ways: 1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions

29. Facts about PTSD Prevalence: 8% (lifetime) Gender: No gender differences Age of Onset: Any age Course: Symptoms usually manifest themselves within approx. 3 months � - Recover within 3 months � - Chronic, waxing and waning

30. Rates vary among trauma victims 25% Female crime victims (non-rape) 48% Female adult rape victims 20% Vietnam combat veterans 46% Holocaust survivors (not all in concentration camps) 53% of WWII � Korean War prisoners of war 26% Witnesses at mass shooting 31% Child sexual abuse victims 3% Breast cancer survivors 18% Bus accident victims

31. Acute Stress Disorder A. 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(s) that involved actual or threatened death, serious injury, or a threat the physical integrity of self or others The person�s response involved fear, helplessness, or horror B. Either while experiencing or after experiencing the event, the individual has 3 or more of the following dissociative symptoms Sense of numbing, detachment, or absence of emotional responsiveness Reduction in awareness of his/her surroundings Derealization Depersonalization Dissociative amnesia

32. Acute Stress Disorder C. The traumatic event s persistently reexperienced in at least one of the following ways: thoughts, dreams, illusions, flashbacks, etc. D. Marked avoidance of stimuli that arouse recollections of the trauma E. Marked symptoms of anxiety or increased arousal F. There is clinically significant distress or impairment in functioning G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the event H. Not due to a GMC or substance

33. Facts about Acute Stress Disorder Prevalence: 14-33% of people who have experienced a traumatic experience Gender: No gender differences cited Age of Onset: Any age Course: By definition, no longer than 4 weeks If longer than 4 weeks, PTSD may be considered Associated w/: Despair, hopelessness, guilt, pathological feelings of responsibility, impulsive/risky behavior

34. Generalized Anxiety Disorder (GAD) Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events The person finds it difficult to control the worry The anxiety and worry are associated with 3 or more of the following symptoms Restlessness or feeling keyed up or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep Disturbance

35. Generalized Anxiety Disorder (GAD) D. The focus of the anxiety and worry is not confined to features of another disorder and do not occur exclusively during PTSD E. There is clinically significant distress or impairment in functioning F. Not due to a GMC or substance

36. Facts about GAD Prevalence: 5% (lifetime) Gender: Slightly more common in females Age of Onset: Mostly childhood-adolescence Course: Chronic, waxing and waning Associated w/: Somatic complaints, mood disorders, substance use disorders, headaches, irritable bowel syndrome, etc.

37. Nervios (Latin America) General state of vulnerability to life stressors and/or a syndrome brought on by difficult life circumstances Chronic, but severity varies among sufferers Wide range of symptoms including: Emotional distress, headaches (�brain aches�), irritability, stomach disturbances, sleep difficulties, nervousness, easy tearfulness, inability to concentrate, trembling, tingling sensations, and dizziness Similar to Adjustment, Anxiety, Depressive, Dissociative, Somatoform, and Psychotic disorders

38. Ataque de nervios Direct result of a stressful event relating to the family Sense of being out of control Common symptoms: Uncontrollable shouting, attacks of crying, trembling, heat in the chest rising into the head, verbal or physical aggression Infrequent symptoms: Dissociative experiences, seizure-like or fainting episodes, and suicidal gestures Brief episode, return to normal functioning rapidly Similar to Panic Disorder, but is not associated with fear or apprehension of additional attacks and is related to a specific event

39. Dhat (India), Jiryan (India), Sukra Prameha (Sri Lanka), & Shen-k�uei (China) Severe anxiety, panic symptoms, somatic complaints, hypochondriachal symptoms associated with the discharge of semen Excessive semen loss is feared because of the belief that it represents the loss of one�s vital essence and can thereby be life threatening

40. Koro (South and Southeast Asia) Sudden and intense anxiety that one�s genitalia will recede into the body and possibly cause death Can occur in epidemics

41. Taijin Kyofusho (Japan) An intense fear that one�s body, its parts, or its functions (sweating, body odor, facial expressions, etc.) displease, embarrass, or are offensive to other people Similar to the DSM�s Social Phobia