Anxiety and Dissociative Disorders

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Anxiety and Dissociative Disorders

• Susan D. Odom, Ph.D.

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Anxiety Disorders

• Panic Attacks
• Agoraphobia
• Panic Disorder without Agoraphobia
• Panic Disorder with Agoraphobia
• Agoraphobia without History of Panic Disorder
• Specific Phobia
• Social Phobia
• Obsessive-Compulsive Disorder
• Posttraumatic Stress Disorder
• Acute Stress Disorder
• Generalized Anxiety Disorder
• Anxiety Disorder due to a General Medical
  Condition
• Substance-Induced Anxiety Disorder
• Anxiety Disorder NOS

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Anxiety is Normal

• Anxiety can be a normal response to a situation
  that is perceived to be beyond our ability to
  cope
• Is a great motivator to study, work hard, move
  quickly
• So what makes Anxiety a Disorder?
• The degree and duration of the symptoms!
• Oh, and sometimes the trigger for the anxiety.

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What makes an event stressful?

• The nature of the event and how the person views
  it
• The persons resources
• The persons psychological defenses
• The persons coping mechanisms
• In other words, there is a mismatch between
  perceived demand and perceived ability. If this
  mismatch results in the persons ego being
  challenged, anxiety disorders sometimes result.
• The demands can be external (social demands, for
  instance) or internal (aggressive, sexual, and/or
  dependent impulses)

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Usual Anxiety Symptoms

• Dizziness, light-headedness
• Hypertension
• Palpitations
• Restlessness
• Diarrhea
• Tachycardia
• Tingling in extremities
• Tremors
• Upset Stomach
• Urinary frequency

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Epidemiology

• 1 in 4 have had an anxiety disorder (19 Million
  at one time)
• Lifetime prevalence is 30.5 for women and 19.2
  for men
• Prevalence is lower for higher socioeconomic
  classes
• Onset usually prior to age 35

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Etiology

• Psychological Causes
• Defense against a psychic conflict resolve the
  conflict and the anxiety is diminished
• Behavioral Theory of Anxiety
• Classical Conditioning a cause and effect
  relationship is perceived (which may or may not
  be true) and then generalized to other situations
• Social Learning parents
• Biology
• Autonomic nervous system dont habituate well,
  overreact to stimuli.
• Neurotransmitters norepinephrine, serotonin,
  GABA
• Genetics genes that affect serotonin
  transportation
• Neuroanatomical Considerations
• Higher pressure in the spinal column due to
  increased levels of spinal fluid result in
  anxiety symptoms

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Criteria for Panic Attack

• Four or more of the following symptoms that peak
  within 10 minutes
• Palpitations, pounding heart, or accelerated
  heart rate
• Sweating
• Trembling or shaking
• Shortness of breath or smothering
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Dizzy, unsteady, lightheaded or faint
• Derealization (feelings of unreality) or
  depersonalization (being detached from oneself)
• Fear of losing control or going crazy
• Fear of dying
• Paresthesias (numbness of tingling sensations)
• Chills or hot flashes

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Agoraphobia

• Agora Greek for the market, a place that is
  crowded, filled with people and unexpected
  events!
• Modern Day An anxiety about or avoidance of
  places or situations from which escape might be
  difficult or embarrassing help might not be
  available if a panic attack occurs
• Usually includes a characteristic cluster of
  situations (being outside, away from home,
  standing in a line being on a bridge or in an
  elevator traveling by bus, train, automobile,
  jet
• Situations are avoided or met with dread

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Panic Disorder

• Recurrent, unexpected panic attacks
• Panic attack followed by 1 month or more of
  persistent concern about having another attack,
  worry about the implications of the attack, or
  significant change in behavior in relation to the
  attack
• Can occur with or without agoraphobia

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Specific Phobia

• Most common mental disorder for women 2nd for
  men 5 - 10 of people have a specific phobia.
• Types
• Animal (dogs, bunnies, cats, bugs, reptiles)
• Natural environment (storms, heights, water)
• Blood, Injection, Injury (seeing blood, getting a
  shot, having blood drawn, illness or death)
• Situational (public transportation, tunnels,
  bridges, etc.)
• Other (clowns, loud sounds, toes, choking,
  vomiting, etc.)
• Immediate response is unreasonable fear and the
  person knows the fear is unreasonable
• Avoid or endure with intense anxiety

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Social Phobia

• Marked and persistent fear of social interactions
  or performance situations
• Exposure causes intense anxiety or maybe panic
  attack
• Hypersensitivity to criticism, evaluation by
  others
• May be accompanied by poor social skills,
  noticeable anxiety symptoms, fear of authority
  figures
• Social isolation, loneliness, lack of success in
  school, business, social relationships

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Obsessive Compulsive Disorder

• Recurrent, Persistent Obsessions (intrusive
  and/or inappropriate thoughts, images, impulses,
  ideas) and Compulsions (behaviors or thoughts to
  prevent or reduce anxiety or distress associated
  with obsession.)
• Person recognizes the obsessions are outside of
  the realm of control but also the product of his
  or her own mind
• Attempts to ignore or suppress usually fail
• Mounting anxiety of obsession can be relieved by
  enacting the compulsion

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Obsessive Compulsive Disorder

• Common types
• Fear of germs / compulsive hand washing
• Repeated thoughts of having hurt someone or
  leaving some important task undone / checking
  behaviors
• Need for order / placing things in symmetry or in
  a particular order, performing acts in a specific
  sequence, wearing the same clothes everyday
• Desire to say or do inappropriate things /
  counting, tapping, distracting behaviors or
  rigid, idiosyncratic behaviors or rules to follow

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Posttraumatic Stress Disorder

• It's been called shell shock, battle fatigue,
  accident neurosis and post rape syndrome.
• It is a set of symptoms that develop after a
  person sees, hears, or is involved in an extreme
  traumatic stressor.
• It affects people who have survived earthquakes
  accidental disasters such as airplane crashes or
  manmade disasters such as a terrorist bombing,
  inner-city violence, domestic abuse, rape, war,
  and the Holocaust.
• In some cases the symptoms of PTSD disappear with
  time, while in others they persist for many
  years. PTSD often occurs with-or leads to-other
  psychiatric illnesses, such as depression, social
  anxiety, GAD

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Symptoms of PTSD

• Usually appear within 3 months of the trauma, but
  can surface years later
• Symptoms fall into 3 categories
• Reexperiencing the trauma
• Avoidance of stimuli
• Persistent increased arousal

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Reexperiencing

• Recurrent and intrusive recollections of the
  events (images, thoughts, perceptions)
• Recurrent dreams or nightmares of the event
• Feeling as if it is happening again (flashbacks,
  illusions, hallucinations, physical sensations)
• Intense psychological distress upon exposure to
  internal or external triggers
• Physiological reactivity upon exposure to
  internal or external triggers

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Avoidance

• Efforts to avoid thoughts and feelings or
  conversations about the trauma
• Efforts to avoid the activities, places or people
  that activate memories
• Inability to recall important aspects of the
  trauma
• Markedly diminished interest or participation in
  significant activities
• Feelings of detachment or estrangement from
  others
• Restrict range of affect (unable to love)
• Sense of foreshortened future (doesnt expect to
  marry, have a career, children, normal life span)

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Increased Arousal

• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilence
• Exaggerated startle response

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Features Associated with PTSD

• Substance abuse
• Suicide

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Acute Stress Disorder

• Person is exposed to a traumatic event
  accompanied by 3 of the following
• Subjective sense of numbing, detachment, absence
  of emotions
• A reduction in awareness
• Derealization (doesnt seem quite real / out of
  sync)
• Depersonalization (as if it is happening to
  someone else)
• Dissociate amnesia (cannot remember what
  happened)
• Trauma is persistently reexperienced
• Avoidance of triggers
• Symptoms of anxiety
• Lasts for a minimum of 2 days and a maximum of 4
  week and occurs within 4 weeks of the trauma

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Generalized Anxiety Disorder

• Excessive worry and anxiety more days than not
  for at least 6 months across a number of
  situations (work, homelife, school performance)
• Cannot control the worry
• Feelings of
• Restlessness
• Easily fatigued
• Difficulty concentrating
• Irritability
• Muscle tension
• Disturbed sleep

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Anxiety Disorder Due to a General Medical
Condition

• Anxiety is caused by a medical condition such as
• Hyper/hypothyroidism
• Cardiovascular conditions (congestive heart
  failure)
• Respiratory conditions (COPD)
• Metabolic conditions (vitamin B12 deficiency)
• Neurological conditions (encephalitis)
• Anxiety can be expressed a number of ways
• GAD symptoms
• Panic Attacks
• OCD symptoms

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Anxiety Disorder Due to a General Medical
Condition

• Symptoms must occur after onset of physical
  condition and things like typical age of onset
  for the disorder, family psychological history,
  and remission when disease remits must be taken
  into consideration
• Can be caused by a wide variety of medical
  conditions and the anxiety looks just like a
  regular anxiety disorder
• The best treatment is to treat the underlying
  medical condition

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Substance Induced Anxiety Disorder

• Prominent anxiety, panic attacks, OCD symptoms,
  or phobia occurring during or within one month of
  substance intoxication or withdrawal or the
  medication use is etiologically related to the
  disturbance
• Symptoms are not better accounted for by symptoms
  of intoxication or withdrawal ((anxiety disorder
  sxs are more severe)
• Amphetamine or amphetamine like substance
• Caffeine, cannabis, cocaine
• Hallucinogen, inhalant, phencyclidine
• Sedative, hypnotic, anxiolytic
• Other/unkown

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Anxiety Disorders NOS

• Mixed Anxiety-Depressive Disorder but the
  criteria arent quite met for other disorders
• Clinically significant social phobic symptoms
  that are related to the social impact of a
  disease or mental disorder
• Situations where the clinician has concluded an
  anxiety order exists, but is unable to determine
  whether it is primary, due to a GMC, or substance
  induced

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Somatoform Disorder

• Presence of physical symptoms that suggests a
  general medical condition
• Not explained by a general medical condition
• Not the effects of a substance
• Arent explained by another mental disorder
• Symptoms are not intentional or under voluntary
  control

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Types of Somatoform Disorders

• Somatization Disorder (lt 30 y.o.,
  polysymptomatic, extends over years, combination
  of pain, gastrointestinal, sexual and
  pseudoneurological)
• Undifferentiated Somatization Disorder
• Conversion Disorder (including seizures)
• Pain Disorder
• Hypochondriasis (preoccupation with having a
  disease)
• Body Dysmorphic Disorder
• Somatoform NOS (false pregnancy, subjective
  sensation of fetal movement, unexplained physical
  complaints of less than 6 months.)

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Chronic Fatigue Syndrome

• Chronic fatigue not improved by rest
• Four of the following symptoms
• Substantial short-term memory impairment
• Sore throat
• Tender lymph nodes
• Muscle pain
• Multi-joint pain without swelling or redness
• Headaches of a new type, pattern or severity
• Unrefreshing sleep
• Post-exertional malaise lasting more than 24
  hours
• Worsened by physical or mental activity
• Levels of functioning are greatly reduced

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Fibromyalgia

• Chronic condition characterized by fatigue,
  widespread pain in the ligaments, muscles, and
  tendons, and multiple tender points where
  pressure causes pain.
• Is not progressive, crippling, or
  life-threatening
• Fatigue and sleep disturbances are common
• Co-occurs with irritable bowel, headaches and
  facial pain, heightened sensitivity to odors,
  noises, bright lights, and touch
• Diagnosis is very difficult no tests
• Treatment includes analgesics, antidepressants,
  muscle relaxants, CBT and psychological
  interventions such as biofeedback, chiropracty,
  massage therapy, osteopathy, and acupuncture.

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Factitious Disorder

• Deliberate production or feigning of physical or
  psychological symptoms
• Fake symptoms or making up complaints
• Self-inflicted wounds
• Exaggeration or exacerbation of preexisting GMC
• Motivation is to assume the sick role
• No external motivation (see malingering)
• Malingering ? has an external motivation such as
  economic gain, avoiding legal responsibility,
  improving physical well-being

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Dissociative Disorder

• The functions of consciousness, memory, identity,
  or perception of the environment become
  un-integrated or disrupted.
• Dissociative Amnesia cannot recall important,
  usually traumatic memories or information.
• Dissociative Fugue sudden travel away from
  home/work with an inability to recall the past
  and confusion about identity or assumption of a
  new identity
• Dissociate Identity Disorder (MPD) presence of
  two or more distinct identities or personalities
• Depersonalization Disorder persistent or
  recurrent feeling of being detached from ones
  mental processes or body accompanied by intact
  reality testing
• Dissociative Disorder NOS