anxiety disorders

the experience of anxietygeneralized anxiety disorder

panic disorderphobias

obsessive-compulsive disorderposttraumatic stress disorder

treating anxiety disorders

the experience of anxietyanxiety involves worry, fear,

apprehension, intrusive thoughts, physical symptoms, and feelings of tension.

It often seems to have an automatic quality that comes more from within the individual than from situational factors.

It is normal for people to experience anxiety when faced with stressful, threatening situations, but it is abnormal to feel strong, chronic anxiety in the absence of an obvious cause. (However “normal” may vary with level of consciousness.)

common anxiety symptoms and self-descriptions indicative of high anxiety

symptoms

• Nervousness, jitteriness

• Tension• Feeling tired• Dizziness• Frequency of urination• Heart palpitations• Feeling faint

• Breathlessness• Sweating• Trembling• Sleeplessness• Difficulty in

concentrating• hypervigilance

pathological anxietyepidemiology

• Anxiety disorders make up one of the most common groups of psychiatric disorders.

• the national co morbidity study reported that one in four persons met the diagnostic criteria for at least one anxiety d/o

• Women (30.5 percent lifetime prevalence) are more likely to have an anxiety d/o than are men (19.2 percent lifetime prevalence).

• Finally. The prevalence of anxiety d/o decreases with higher socioeconomic status.

• Prevalence of anxiety d/oDisorder percent(1yr-

prevalence)Any anxiety d/o 13.3Generalized anxiety d/o 2.8Panic d/o 1.7Phobic d/o 8.0Obsessive-compulsived/o 2.3Posttraumatic stress d/o 3.6

Source: National Institute of Mental Health

self- descriptions

• “ I am often bothered by the thumping of my heart.”• “ little annoyances get on my nerves and irritate me.”• “ I often suddenly become scared for no good reason.”• “ I worry continuously, and that gets me down.”• “ I frequently get spells of complete exhaustion and

fatigue”• “ it is always hard for me to make up my mind.”• “ I always seem to be dreading something.”• “ I feel nervous and high-strung all the time.”• “ I often feel I can’t overcome my difficulties.”• “ I feel constantly under strain.”

Psychological sciences

psychoanalytic theories behavioral theories ex istential theories

psychological theorieseach theory has bo th conceptua l and practica l u sefu lness in trea ting anx iety d/ o

biological sciencesA range of biologically based sensitivities may exist among

persons with the symptoms of anxiety disorders.• Autonomic nervous system(functional division of the nervous

system concerned with visceral activities): stimulation of the ANS may cause peripheral manifestations of anxiety- cardiovascular and/or gastrointestinal.

• Neurotransmitters (chemical product of the NS that makes possible the movement of the nerve impulse across the synapse):norepinephrine, serotonin,and y-aminobutyric acid (GABA) are the three major neurotransmitters associated with anxiety.

• Brain- imaging studies: CT, MRI, PET, SPECT, EEG.• Genetic studies• Neuroanatomical considerations: limbic system,

and cerebral cortex.

generalized anxiety disorder300.02

A person with GAD experiences vague but intense concerns and fearfulness that persist over a long period- at least 6-months.

The symptoms include motor tension, autonomic reactivity, apprehension about the future, and hypervgilance.

durations as long as 20 years.prolonged use of drugs can have significant side effects.

The distinction between GAD and normal anxiety is emphasized by the use of the words “excessive and “difficult to control” in the criteria and by the specification the symptoms cause significant impairment or distress.

clinical features of GAD1. Excessive anxiety and worry occurring for at least 6

months and affecting many areas of a person’s life.2. Inability to control worry3. The presence of 3 or more of the following symptoms(

only one type of symptom is required for DSM-IV in the diagnosis of children):a. restlessness; feeling on edgeb. being easily fatiguec. difficulty concentrating; mind goes blankd. irritabilitye. muscle tensionf. sleep disturbance( difficulty falling or staying asleep; unsatisfying sleep)

4. Considerable distress or impairment in social, occupational, or other important areas of life.

treatment for GAD

• PsychotherapyCognitive-behavioral:cognitive address patient’s hypothesized cognitive distortions directly, and behavioral approaches address somatic symptoms directly. (relaxation and biofeedback).supportive: offers patient’s reassurance and comfort, although its long-term efficacy is doubtful.Insight-oriented: focuses on uncovering conflicts and identifying ego strengths.

substance-induced anxiety disorder293.84

• The disorder is the direct result of a toxic substance. Including drugs of abuse, medication, poison, and alcohol, among others.

• The DSM-IV diagnostic criteria for substance-induce anxiety disorder require the presence of prominent anxiety, panic attacks, obsessions, or compulsions. The guidelines state that the symptoms should have develop during the use of of the substance or within a month of the cessation of substance use. The structure of the diagnosis includes specification of the substance (e.g. cocaine), specification of the appropriate state during the onset (e.g., intoxication), and mention of the specific symptom pattern (e.g., panic attacks).

Panic disorder• Panic Disorder is an illness in which a person

experiences sudden, sometimes unexpected rushes of intense fear or discomfort accompanied by a number of distressing physical sensations.

• The panic attack, the core feature of panic disorder, strikes suddenly, often in familiar places where there is seemingly nothing to be afraid of.

• But when the attack comes, it comes as if there were a real threat, and the body reacts accordingly.  Panic disorder is often accompanied by agoraphobia, the fear of being alone in public places (such as supermarkets), particularly places from which a rapid exit would be difficult in the course of a panic attack.

• In addition to agoraphobia, other phobias and obsessive-compulsive disorder can coexist with panic disorder.

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Panic d/o:Panic attacks

• The term panic attack denotes an abrupt surge of intense anxiety rising to a peak that either is cued by the presence, or thoughts, of particular stimuli or that occurs without obvious cues and is spontaneous and unpredictable. During these episodes, the person experiences the urge to flee, or the feeling that they need to escape. The symptoms may be misdiagnose as a serious medical condition (M.I.).

• It is known that the d/o typically begins when its victims are in their 20s. Often a serious event, will trigger the first attack. Women are two to three times more likely to be affected than men. 3 million Americans will experience panic disorders sometime in their lives.

Criteria for 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: is not codable disorder.

1. Palpitations, pounding heart, or accelerated heart rate2. Sweating3. Trembling or shaking4. Sensations of shortness of breath or smothering5. Feeling of choking6. Cheat pain or discomfort7. Nausea or abdominal distress8. Feeling dizzy, unsteady, lightheaded, or faint9. Derealization (feelings or unreality) or depersonalization

(being detached from oneself)10. Fear of losing control or going crazy11. Fear of dying12. Paresthesias13. Chills or hot flashes

treatment for panic disorderCan consist of taking a medication to adjust the chemicals

in your body-just as you might take medicine to correct a thyroid imbalance or any other hormonal imbalance. two major categories of medication that have been shown to be safe and effective in the treatment of panic disorder are antidepressants and benzodiazepines. Another treatment is cognitive behavior therapy (CBT), which focuses on reducing the person’s fears of panic symptoms and assisting the person to resume avoided activities. The combination of medication and psychotherapy appears to be more effective than either treatment alone.

agoraphobia

DSM-IV-TR includes diagnoses for panic disorder with and without agoraphobia and also for agoraphobia without history of panic disorder.

patients with agoraphobia avoid situations in which it would be difficult to obtain help. They prefer to be accompanied by someone in crowded stores, closed-in spaces (tunnels, bridges, and elevators) and closed-in vehicles (subways, buses, and airplanes) severely affected patients may refuse to leave the house. Agoraphobic individuals are often clinging and dependent.

Diagnostic criteria for:

• Panic disorder with agoraphobia 300.21

A. Both (1) and (2)B. The presence of agoraphobia

• Agoraphobia without history of panic disorder 300.22

A. The presence of agoraphobia related to fear of developing panic-like symptoms

B. Criteria have never been met for panic disorder

C. The disturbance is not due to the direct physiological effects of a substance 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.

phobias

• People who have phobias have fears related to specific objects, people, or situations.

• Phobias often develop gradually or begin with a generalized anxiety attack.

• Phobias are common disorders that affect women about twice as frequently as men. Phobias often begin before adulthood and are likely to become chronic.

• Phobias can be grouped into three main types: specific phobias, social phobias, and agoraphobia.

examples for five categories of phobias

Separation fear social fearsCrowds eating with strangersTraveling alone being watched while writingBeing alone at home being watched while workingAnimal fearsMiceRats mutilation fearsInsects open woundsNature fears surgical operationsMountains bloodThe oceanCliffs, heights

Specific phobias300.29

• Most commonly occurring type of phobia. This group includes miscellaneous irrational fears such as intense fear of a certain type of animal or of being in an enclosed place. Specific phobias may arise from an earlier frightening or anxiety-producing situation that involved the type of person or situation that later became associated with the phobia. Procedures that use the classical conditioning approach of pairing the phobic stimulus with nonanxiety response are often used successfully to treat specify phobias.

• Criteria A (excessive fear) and B (stimulus exposure)• In specific phobia the panic attack is situationally bound to the specific

phobic stimulus. Specify type.• Treatment: exposure therapy(therapist desensitize pt. by using a series of

gradual, self-paced exposures to the phobic stimuli, and they teach pt.’s various techniques to deal with anxiety, including relaxation, breathing control, and cognitive approaches. Pharmacotherapy may also benefit.

Social phobias(social anxiety disorder)

300.23• Intense and

incapacitating fear and embarrassment when dealing with others characterize social phobias. Fear of blushing when in a social situation and fear of eating when others are present are two social phobias that are especially difficult to treat successfully.

Treatment:• Psychotherapy for the

generalized type of social phobia usually involves a combination of behavioral and cognitive methods, including retraining, desensitization, rehearsal during sessions, and a range of homework assignments.

Obsessive-compulsive disorder300.3

• People affected by an obsessive-compulsive d/o are unable to control their preoccupation with specific ideas or are unable to prevent themselves from repeatedly carrying out a particular act or series of acts that affect their ability to carry out normal activities.

• Obsessive behavior is the inability to stop thinking about a particular idea or topic. The topic of these thoughts is often felt by the person involved to be unpleasant and shameful.

• Compulsive behavior is the need to perform certain behaviors over and over. Many compulsions deal with counting, ordering, checking, touching and washing.

OCDDSM-IV-TR CRITERIA

• Criteria for obsessive-compulsive disorder include having recurrent and persistent thoughts, impulses, or images that are not simply general worries and real-life problems.

• Patients recognize that the unwanted thoughts and rituals are the products of their minds, but distress persist and personal routines are seriously disrupted.

OCDsymptoms patterns

• The presentation of obsessions and compulsions is heterogeneous in adults and in children and adolescents. The symptoms of an individual patient may overlap with time, but OCD has four major symptoms patterns.

1. Contamination- the fear object is often hard to avoid (e.g. feces, urine, dust, or germs)accompanied by compulsive avoidance. patients usually believe that the contamination is spread from object to object or person to person.

2. pathological doubt-often implies some danger of violence (e.g. forgetting to turn off the stove or not locking the door)followed by a compulsion of checking. The pt.’s always feel guilty about having forgotten or committed something.

3. Intrusive thoughts- repetitious thoughts of a sexual or aggressive act that is reprehensible to the pt. without compulsions.

OCD-symptoms patterns

4. Symmetry- the fourth most common patterns is the need for symmetry or precision, which can lead to a compulsion of slowness.

5. Other symptom patterns- religious obsessions and compulsive hoarding are common in patients with OCD. Trichotilomania (compulsive hair pulling) and nail niting may be compulsions related to OCD.

Cognitive therapist seek to help patients become aware of their excessive sense of responsibility as a step toward overcoming obsessions and compulsions.

Posttraumatic stress disorder309.81 (PTSD)

• PTSD may occur after an extreme stress such as a natural disaster, a serious accident, or participation in a battle or other war-related situations.

• PTSD symptoms vary widely but may include recurrent dreams, flashbacks, impaired concentration, and emotional numbing. T

• hose experience PTSD after a stressful experience are likely to have had previous histories of psychological disorder.

• The emotional disorder that often arises after a trauma such as war, assault, natural disaster, or death of a loved one is posttraumatic stress disorder(PTSD). According to the DSM-IV-TR, a person with

• PTSD must have been exposed to some event during which he/she feels fear, helplessness, or horror.

• Then, the person continues to reexperience the event through memories, reenactments, nightmares, or flashbacks. Cues that remind the person of the event are avoided and emotional responsiveness is numbed.

• Often such individuals are chronically overaroused, easily startled, and quick to anger. With PTSD, the alarm response is a true alarm, meaning that it occurs in response to real threat or danger.

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