Anxiety Disorders

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Anxiety Disorders

• RCS 6931
• Steven R. Pruett, Ph.D.
• May 31, 2007

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Anxiety Disorders

• Panic Disorders
• (with without Agoraphobia)
• Specific Phobias
• Social Phobia
• Obsessive-Compulsive Disorder
• Posttraumatic Stress Disorder (PTSD)
• Acute Stress Disorder

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Anxiety Disorders

• Generalized Anxiety Disorder (GAD)
• Anxiety Disorder Due to a General Medical
  Condition
• Substance-Induced Anxiety Disorder
• Anxiety Disorder Not Otherwise Specified (NOS)

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Anxiety Disorders

• Agoraphobia Panic Attacks
• Not codable disorders by themselves
• Building Blocks of other codable anxiety
  disorders.

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Agoraphobia Panic Attacks

• Agoraphobia
• A fear of situations or places such as a store
  when the individual might have trouble obtaining
  help if they became anxious (Morrison p. 247)
• Panic Attacks
• Brief episode in which a patient feels intense
  dread accompanied by a variety of physical and
  other symptoms begins suddenly then peaks
  rapidly (Morrison p. 251)

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Agoraphobia

• Fear of the marketplace?
• Actually fear of situations where escape is
  difficult or help is unavailable if anxiety
  symptoms arise.
• Frequently it involves situations that are away
  from home or being with many people or being home
  alone, traveling, etc.
• Criteria for Agoraphobia is on Morrison 248 and
  on p. 433 of DSM-IV-TR.

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Agoraphobia without History of Panic Disorder
(300.22)

• Criteria
• on Morrison p. 250, DSM-IV-TR p. 443
• Fairly uncommon diagnosis
• panic-like symptoms
• But never met the criteria for a Panic Disorder.

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Panic Attacks

• Panic Attacks can occur in many contexts
• Sense of impending doom, disaster
• Frequently associated with cardiac symptoms and
  trouble breathing
• Frequently starts quickly and peaks usually
  within 10 minutes then subsides in less than 30
  minutes.

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Development of a Panic Attack
Initiating Circumstance (internal or external)
Slight increase in unusual or unpleasant body
symptoms (e.g. heart palpitations, dizziness,
shortness of breath)
Internalization (increased focus on symptoms
makes them more noticeable)
Catastrophic Interpretation (e.g, Im going to
have a heart attack and die!)
Panic
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Panic Attacks

• Common
• Easily Treated
• Assurance or breathing into a paper bag
• Can be debilitating if left untreated
• Can mask/co-occur with other illnesses
• See coding note on Morrison p. 255.
• Cued attacks
• Criteria
• Morrison p. 252, DSM-IV-TR p. 432.

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Panic DISORDERS

• Most common of anxiety disorders
• (3 of population vs. 10 for Panic Attacks).
• Recurrent Panic Attacks
• Usually uncued
• Sometimes co-occur with Agoraphobia
• Very uncomfortable for patient
• Usually begin when patient is young

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Panic Disorders

• Panic Disorder without Agoraphobia (300.01)
• Unexpected recurrent panic attacks
• More commonly found in Women (21)
• Diagnostic Criteria
• Morrison p. 258, DSM-IV-TR p. 440.
• Panic Disorder with Agoraphobia (300.21)
• Has unexpected recurrent panic attacks AND has
  Agoraphobia
• Most individuals with Agoraphobia have also have
  a Panic Disorder (95).
• However, more people have a Panic Disorder than
  Agoraphobia.
• Diagnostic criteria
• Morrison p. 255, DSM-IV-TR p. 441

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Panic Disorders

• Treatment
• Elimination of stimulants (caffeine, sugar,
  nicotine)
• Regular exercise
• Cognitive-Behavioral Therapy (CBT)
• About 10-15 weekly sessions
• Assessment/Education (e.g., identification of
  triggers, understanding of beliefs/assumptions).
• Cognitive Therapy Strategies
• Regular practice of deep relaxation
• Acknowledgement expression of feelings of anger
  sadness
• Adopting self-talk core beliefs to promote a
  calmer and more accepting outlook toward life
• Exposure techniques
• Termination and strategies for maintenance

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Treatment of Panic Disorders

• Pharmacotherapy (usually in conjunction with CBT)
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Benzodiazepines

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Phobias

• According to Beck Emery (1985) there are three
  types of Phobias
• Fixation
• (early intense fears that people usually grow out
  of)
• Traumatic Phobias
• Specific Phobias

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Specific Phobia (300.29)

• Unwarranted fear of specific objects or
  situations
• E.g., animals, blood, closed in, airplanes
• Does my dog have a phobia about vacuum cleaners?
• About 10 of the US population has some degree of
  a Specific Phobia (not all diagnosable)
• Onset is usually in late teens early adulthood
  and is found more often in women than men.

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Specific Phobia (300.29)

• Can lead to a restricted lifestyle and
  interference with jobs etc.
• Common for Specific Phobia to co-occur with other
  anxiety disorders, mood disorders, and
  substance-related disorders.
• Increase in heart rate (HR) blood pressure (BP)
• Fainting (vasovagal)
• Increased HR BP followed by a decrease in HR
  and drop of BP.
• Childhood fears generally do not warrant a
  diagnosis of Specific Phobia.

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Specific Phobia (300.29)

• Diagnostic Criteria
• Morrison p. 260, DSM-IV-TR p. 449.
• Subtypes
• Animal
• Natural Environment
• Blood-Injection
• Situational
• Other

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Specific Phobia

• Treatment
• Relaxation
• CBT
• Incremental Exposure
• Education and Recognition of the Phobia DOES NOT
  WORK!!!
• Patients know they have a phobia and know it is
  irrational but they are still afraid.

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Social Phobia (300.23)

• AKA Social Anxiety Disorder
• Fear of appearing clumsy, silly or shameful and
  having this behavior observed by others.
• On set is usually in middle teens
• Equal gender representation
• Physical Symptoms
• Blushing
• Hoarseness
• Tremor
• Perspiration

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Social Phobia

• Rarely a cause for inpatient hospitalization
• Can be accompanied by Panic Attacks
• Life-time prevalence of 3-13
• Outpatient clinics rates for social phobia range
  from 10 to 10.
• Familial Pattern
• Frequently comorbid with Mood Disorders, Anxiety
  Disorders, Eating Disorders, or Substance Abuse.

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Social Phobia (300.23)

• Diagnostic Criteria
• Morrison p. 262-263, DSM-IV-TR p. 456
• Watch out for possible Axis II diagnosis
  Avoidant Personality Disorder.
• Valerie Tubbs vignette

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Social Phobia (300.23)

• Treatment
• CBT
• Individual and/or group
• Education that dysfunction is maintained by
  avoidant behaviors
• Exposure to social situations
• Psychopharmacology
• SSRIs such as Effexor, Paxil, Zoloft.
• MAOIs may be used if SSRIs are ineffective

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Obsessive-Compulsive Disorder (300.3)

• Obsessions
• Persistent ideas, thought, impulses that are
  considered to be intrusive and inappropriate
  (ego-dystonic)
• Compulsions
• Repetitive behaviors (e.g. handwashing, checking)
  or mental acts (counting, praying, repeating
  words silently) which has the goal of reducing
  anxiety or distress (not to provide pleasure or
  gratification).

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OCD

• Recurrent thoughts, beliefs, ideas, or behaviors
  that dominate a persons thought process and
  cause distress.
• These persist despite the patients recognition
  that they are unreasonable.
• Usually begin during adolescence or young
  adulthood
• Relatively uncommon as an anxiety disorder, but
  significant due to the amount of distress it
  causes.

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OCD Course of Disease

• Often debilitating and chronic in nature.
• Onset is usually in adolescence
• Earlier for males (6-15) than females (20-29).
• Usually onset is gradual, but acute onset is
  possible.
• Chronic waxing and waning symptoms increase
  with stress.
• 15 show progressive deterioration
• 5 have episodic course with little to no
  symptoms between episodes.

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OCD

• Four major symptom patterns
• Fear of contamination
• Doubts
• Obsessions without compulsions
• Obsessions with compulsions.
• Equally distributed between men and women
• However with childhood onset disorder is more
  common with boys than girls.
• Prevalence as high as 2 of general population.

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OCD

• Associated features disorders
• Hypochondriasis
• Guilt
• Substance abuse
• Mood disorders
• Eating disorders
• OCPD
• Avoidant PD
• Tourettes disorder

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OCD

• Diagnostic criteria
• Morrison p. 266, DSM-IV-TR p. 462-463.
• Treatment
• Behavior therapy
• Usually for uncomplicated highly motivated
  individuals
• Intense exposure to trigger stimulus associated
  with response prevention
• frequently very uncomfortable for the patient
• Psychopharmacology
• SSRIs
• Usually works faster and helps many symptoms at
  once.
• Surgery (only for refractory OCD)
• bilateral anterior capsulotomy
• Thermally disables the cingulate gyrus, a small
  section of brain that connects the limbic region
  of the brain with the frontal lobes.

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Posttraumatic Stress Disorder (PTSD) 309.81

• Individuals who survive traumatic events often
  develop PTSD.
• Combat
• Floods (Katrina)
• Airplane Crashes
• Rape
• Abductions
• Threats
• Indirect PTSD (spouses, children)

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PTSD

• Re-experiencing a traumatic event
• Recurrent and intrusive recollections
• Recurrent distressing dreams
• Rare dissociative states (flashbacks)
• Physiological reactivity or intense psychological
  distress can occur when a trigger occurs (e.g.,
  anniversary of traumatic event).

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PTSD

• Associated with Major Depression, Substance
  Related Disorders, Panic Disorders, Agoraphobia,
  OCD, GAD, Social Phobia, Specific Phobia,
  Bipolar Disorder
• Physical injuries may occur as a direct result of
  traumatic event.
• May also have increased somatic complaints and
  general medical complaints.

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PTSD

• Prevalence
• 8 of US population.
• Can occur at any age
• Symptoms usually begin within 3 mos of traumatic
  event
• Recovery occurs within 3 mos in 50 of cases.
• Some cases symptoms become chronic and wax and
  wane.
• Symptom reactivation can occur with reminders of
  original trauma.
• Social supports, family history, childhood
  experiences, personality variables and
  pre-existing mental disorders may influence the
  development to PTSD.

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PTSD

• Diagnostic Criteria
• Morrison p. 269-270, DSM-IV-TR p. 467-468.
• Treatment
• Cognitive Therapy
• Group therapy?
• Exposure Therapy
• Eye movement desensitization reprocessing
  (EMDR)
• Psychopharmacology
• SSRIs SNRIs

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Acute Stress Disorder 308.3

• Shell Shock
• New disorder to DSM-IV-TR
• Symptoms include all those for PTSD
• Severe stress that provokes fear, horror or
  helplessness
• Re-experiencing event in some way
• Numbing of responsiveness
• Hyperarousal (or symptoms of severe anxiety)
• If symptoms last more than 1 month then diagnosis
  of PTSD is indicated.

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Acute Stress Disorder

• Diagnostic Criteria
• Morrison, p. 274, DSM-IV-TR p. 471-472
• Treatment
• Cognitive Therapy (immediately following
  traumatic event)
• Supportive interventions
• Psychoeducation
• Encourage individual to rely in inherent
  strengths, social networks own judgments.
• Psychological debriefings and single session
  techniques are not recommended and may increase
  symptoms.

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Generalized Anxiety Disorder (GAD) 300.02

• Difficult to diagnosis
• Lack of focus in symptoms
• Excessive anxiety and worry occurring more days
  than not for a period of at least 6 mos about any
  number of events or activities.
• Cant control the worry
• Have at least 3 other symptoms

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GAD

• Occurs in 3-5 of the population
• Degree of functional impairment is usually not
  severe.
• Frequently occurs with Mood disorders (Major
  depressive, dythymic) and with other anxiety
  disorders and with substance abuse disorders.

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GAD

• Can be overdiagnosed in children
• Somewhat more common in women (23)
• 1 year prevalence 3
• Life-time prevalence 5
• Up to 25 have a comorbid disorder.

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GAD

• Diagnostic criteria
• Morrison p. 277, DSM-IV-TR p. 476.
• Treatment
• Relaxation/Biofeedback
• Individual therapy
• Possible group therapy
• Breathing

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GAD

• Psychopharmacology
• Buspirone/Buspar
• Benzodiazepines
• SSRIs

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Anxiety Disorder due to a General Medical
Condition 293.84

• Clinician judges that the significant anxiety is
  the direct physiological effect of a general
  medical condition
• e.g. thyroid disorder as in the vignette on
  Millicent Worthy.
• Diagnostic criteria
• Morrison p. 293.84, DSM-IV-TR p. 479
• Treatment
• Attend to medical condition

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Substance-Induced Anxiety Disorder

• Two different codes
• 291.89 - Alcohol
• 292.89 All other substances
• Many substance can induce anxiety. If the
  clinician perceives that the anxiety disorder is
  a direct result of the substance (intoxication or
  withdrawal) this diagnosis may be appropriate.

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Substance-Induced Anxiety Disorder

• Diagnostic Criteria
• Morrison p. 282-283, DSM-IV-TR p. 483
• Treatment
• Detox
• Medical care for withdrawal
• e.g., Benzodiazepines for ETOH to reduce risk of
  seizures.

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Anxiety Disorder NOS 300.00

• Other anxiety disorders that are not covered in
  DSM.
• Watch out for Adjustment disorders!!