Anxiety Disorders

1
Anxiety Disorders

• Part II

2
Obsessive Compulsive Disorder

• Codes
• 300.3 Obsessive-Compulsive Disorder
• Specifier
• with poor insight
• Diagnostic Features
• Recurrent obsessions or compulsions which are
  severe enough to cause distress to the individual
  (ego dystonic).

3
Obsessive Compulsive Disorder Diagnostic Features

• Obsessions
• Persistent ideas, thoughts impulses or images
  that are experienced as intrusive and
  inappropriate, and which cause significant
  distress to the individual
• Compulsions
• Repetitive behaviors or mental acts the goal of
  which is to prevent or reduce anxiety or distress
  (and not to provide pleasure and gratification).

4
Obsessive Compulsive Disorder Diagnostic Features

• Obsessions and compulsions have certain features
  in common an idea or impulse intrudes itself
  insistently and persistently into a persons
  conscious awareness. A feeling of anxious dread
  accompanies the central manifestation and
  frequently leads the person to take
  countermeasures against the initial idea or
  impulse.
• KS p. 620

5
Obsessive Compulsive Disorder Diagnostic Features

• Symptom patterns
• Contamination
• Pathological doubt
• Intrusive thoughts
• Symmetry
• Religious obsessions
• Hoarding

6
Obsessive Compulsive Disorder Associated Features

• Avoidance of situations that involve the content
  of the obsession
• Hypochondriasis
• Guilt
• Sleep disturbance
• Abuse of alcohol and sedatives
• Marital discord

7
Obsessive Compulsive Disorder Culture, Age and
Gender

• Note that culture related rituals do not qualify
  for this diagnosis
• Child and adult presentations are similar,
  although more boys than girls present with the
  disorder
• In adults, gender rates are equal

8
Obsessive Compulsive DisorderCourse Prognosis

• Usually begins in adolescence or early adulthood
• Onset can be acute or gradual
• Onset comes after a significant stressor in 50
  to 70 on cases
• Course can be variable, with symptoms spiking
  during times of increased stress
• A good prognosis in indicated by good social
  supports and occupational adjustment, a specific
  precipitating event, and the episodic nature of
  symptoms.

9
Obsessive Compulsive Disorder Differential
Diagnosis

• Medical D/Os
• Refer to physician or ER as appropriate
• Substance Abuse D/Os
• Tourettes Disorder
• Vocal and physical tics
• 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

10
Obsessive Compulsive Disorder Differential
Diagnosis

• Other Anxiety D/Os
• Agoraphobia Panic Disorders
• Separation Anxiety Disorder
• Symptoms directly related to separation from
  attachment figure
• Social Phobia
• Specific Phobia
• Fear is cued by object or situation
• GAD
• 6 month period of excessive worry, plus anxiety
  symptoms

11
Obsessive Compulsive Disorder Differential
Diagnosis

• PTSD
• Flashbacks, increased arousal, avoidance of
  stimuli associated with traumatic event
• Anxiety in response to a specific event with
  duration of one month
• 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

12
Obsessive Compulsive Disorder Differential
Diagnosis

• 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
• Obsessive-Compulsive Personality Disorder
• More of a preoccupation with orderliness,
  perfectionism, control

13
Obsessive Compulsive DisorderTreatment

• Medication
• Psycho-dynamic
• Increases understanding of what precipitates
  increase in symptoms
• Can treats issues regarding resistance to
  treatment
• Cognitive-behavioral
• Exposure
• Flooding

14
Posttraumatic Stress Disorder Acute Stress
Disorder

• Both syndromes develop after a person sees, is
  involved in or hears of an extremely traumatic
  stressor
• The individual response to this experience
• With feelings of fear and helplessness
• By reliving the event (flashbacks)
• By attempts to avoid stimuli which trigger
  memories of the event

15
Posttraumatic Stress Disorder Acute Stress
Disorder Coding

• PTSD
• 309.81
• Specify if
• Acute
• Duration of symptoms is les than 3 months
• Chronic
• Duration of symptoms is 3 months or more
• Specify if
• With delayed onset
• Onset of symptoms if at least 6 months after the
  stressor
• Acute Stress Disorder
• 309.3
• No specifiers

16
PTSD Acute Stress Disorder Diagnostic
Features

• Exposure to traumatic event
• Flashbacks
• Dreams
• Daily thoughts
• Patterns of avoidance and emotional numbing
• Hyperarousal

17
PTSD Acute Stress Disorder Associated Features

• Feelings of guilt, rejection and humiliation
• Dissociative states
• Panic attack
• Illusions
• Hallucinations
• Aggression/violence
• Poor impulse control re-enactment
• Depression
• Substance abuse

18
PTSD Acute Stress Disorder Culture, Age and
Gender

• Be aware of immigrants/refugees from countries
  which have experienced prolonged civil war,
  ethnic cleansing, etc. People in this category
  may be especially reluctant to disclose
  experiences of torture and trauma.
• Women have a higher rate of PTSD than men,
  possibly because of higher rates of exposure to
  traumatic events.

19
PTSD Acute Stress Disorder Culture, Age and
Gender

• Children and adolescents have a higher rate of
  PTSD than adults who are exposed to the same
  stressors
• Parents responses to a traumatic event greatly
  affects how the child will respond to the same
  event
• Children and adolescents may cope with the event
  through re-enactment and traumatic play

20
PTSD Acute Stress DisorderCourse and prognosis

• Predisposing vulnerability factors
• Presence of childhood trauma
• Inadequate family or peer support
• Being female
• Recent life stressors
• Perception of external locus of control
• Recent excessive alcohol intake
• Co-morbid disorders, especially borderline,
  dependent, paranoid and anti-social PD

21
PTSD Acute Stress DisorderCourse and prognosis

• Good prognosis is predicted by
• Rapid onset of symptoms
• Short duration of symptoms (less than six months)
• Good pre-morbid functioning
• Strong social supports
• Absence of other psychiatric, medical or
  substance related disorders
• Absence of risk factors

22
PTSD Acute Stress DisorderDifferential
Diagnosis

• Acute Stress Disorder
• Onset is within 4 weeks of the traumatic event
• Duration of symptoms lasts for a minimum of 2
  days and a maximum of 4 weeks
• If symptoms persist for more than one month,
  change diagnosis to PTSD

• PTSD
• Onset occurs more than 4 weeks after the
  traumatic event
• Duration of symptoms last for a minimum of 1
  month

23
PTSD Acute Stress DisorderDifferential
Diagnosis

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

24
PTSD Acute Stress DisorderDifferential
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

25
PTSD Acute Stress DisorderDifferential
Diagnosis

• Other Anxiety D/Os
• Agoraphobia Panic D/Os
• 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

26
PTSD Acute Stress DisorderDifferential
Diagnosis

• Other Anxiety D/Os
• Specific Phobia
• Fear is cued by object or situation, and not
  traumatic event
• OCD
• Look for obsession and compulsions
• GAD
• 6 month period of excessive worry, plus anxiety
  symptoms

27
PTSD Acute Stress DisorderTreatment

• Medication
• Cognitive
• Retelling of the event reshaping its meaning
• Behavioral
• Exposure
• Stress management
• Hypnotic techniques
• EMDR
• Hypnosis
• Family group therapy

28
Generalized Anxiety Disorder (GAD)

• Coding
• 300.02
• No specifiers
• Diagnostic features
• Excessive worry that is difficult to control
• Somatic symptoms
• Muscle tension
• Irritability
• Trouble sleeping
• Restlessness
• Subjective distress due to constant worrying

29
Generalized Anxiety Disorder (GAD)Associated
Features

• Additional somatic symptoms
• Trembling shaking
• Nausea diarrhea
• Sweating
• Exaggerated startle response (but not
  hyperarousal)
• High comorbidity with mood disorders anxiety
  disorders

30
Generalized Anxiety Disorder (GAD)Associated
Features

• Selective attention to negative details
• Distortions in information processing
• Negative perceptions of ones ability to cope

31
Generalized Anxiety Disorder (GAD)Culture, Age
Gender

• Considerable variation in how different cultures
  express anxiety
• Slightly more women than men are diagnosed with
  this D/O
• Children may be over-diagnosed (consider
  Separation Anx. D/O, trauma, etc.)
• Children with this D/O may be pre-occupied with
  concern over academic performance, have
  perfectionistic tendencies, and approval seeking
  behaviors

32
Generalized Anxiety Disorder (GAD) Course and
prognosis

• Life long
• Only about 30 seek treatment more likely to see
  physician than therapist or psychiatrist
• Chronic fluctuating, with spikes in symptoms
  during times of stress
• Risk factors include the presence of multiple
  negative life events

33
Generalized Anxiety Disorder (GAD)Differential
Diagnosis

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

34
Generalized Anxiety Disorder (GAD)Differential
Diagnosis

• Mental Disorders
• Malingering, Factitious D/O Hypochondriasis
• Depersonalization Disorder
• Depressive Disorders
• Look for shifts in mood
• Schizophrenia
• Look for other symptoms of psychosis

35
Generalized Anxiety Disorder (GAD)Differential
Diagnosis

• Other Anxiety D/Os
• Agoraphobia without Panic Attack
• More rapid and acute onset than GAD
• 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
• OCD
• Look for obsession and compulsions

36
Generalized Anxiety Disorder (GAD)Differential
Diagnosis

• PTSD
• Flashbacks, increased arousal, avoidance of
  stimuli associated with traumatic event
• Anxiety in response to a specific event with
  duration of one month
• 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

37
Generalized Anxiety Disorder (GAD)Treatment

• Medication
• Cognitive
• Challenging cognitive distortions
• Behavioral
• Relaxation
• Biofeedback
• Supportive
• Talking through concerns usually leads to
  decrease in symtpoms