Title: Anxiety Disorders
1Anxiety Disorders
2Obsessive 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).
3Obsessive 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).
4Obsessive 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
5Obsessive Compulsive Disorder Diagnostic Features
- Symptom patterns
- Contamination
- Pathological doubt
- Intrusive thoughts
- Symmetry
- Religious obsessions
- Hoarding
6Obsessive 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
7Obsessive 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
8Obsessive 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.
9Obsessive 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
10Obsessive 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
11Obsessive 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
12Obsessive 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
13Obsessive Compulsive DisorderTreatment
- Medication
- Psycho-dynamic
- Increases understanding of what precipitates
increase in symptoms - Can treats issues regarding resistance to
treatment - Cognitive-behavioral
- Exposure
- Flooding
14Posttraumatic 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
15Posttraumatic 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
16PTSD Acute Stress Disorder Diagnostic
Features
- Exposure to traumatic event
- Flashbacks
- Dreams
- Daily thoughts
- Patterns of avoidance and emotional numbing
- Hyperarousal
17PTSD 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
18PTSD 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.
19PTSD 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
20PTSD 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
21PTSD 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
22PTSD 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
23PTSD 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
24PTSD 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
25PTSD 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
26PTSD 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
27PTSD Acute Stress DisorderTreatment
- Medication
- Cognitive
- Retelling of the event reshaping its meaning
- Behavioral
- Exposure
- Stress management
- Hypnotic techniques
- EMDR
- Hypnosis
- Family group therapy
28Generalized 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
29Generalized 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
30Generalized Anxiety Disorder (GAD)Associated
Features
- Selective attention to negative details
- Distortions in information processing
- Negative perceptions of ones ability to cope
31Generalized 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
32Generalized 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
33Generalized 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
34Generalized 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
35Generalized 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
36Generalized 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
37Generalized Anxiety Disorder (GAD)Treatment
- Medication
- Cognitive
- Challenging cognitive distortions
- Behavioral
- Relaxation
- Biofeedback
- Supportive
- Talking through concerns usually leads to
decrease in symtpoms