Transcript Anxiety Disorders - Santa Barbara Therapist

Anxiety Disorders
Anxiety Disorders
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Panic Attack
Agoraphobia
Panic Disorder
w/out
agoraphobia
Agoraphobia
w/out hx of
panic disorder
Specific Phobia
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Social Phobia
OCD
PTSD
Acute Stress
Disorder
GAD
Anxiety due to
Medical condition
Substance induced
Anxiety NOS
Anxiety due to a Medical
Condition
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Cardiopulmonary disorders
Hyperthyroidism-may include heat
intolerance and tremor
Hypoglycemia- reduced by eating
candy
Alcohol ingestion
Caffeine overdose
Must cause distress or impaiment
Specify: with generalized anxiety,
with panic attacks, or with oc
symptoms
Panic Attack- not a diagnosis, but
specified with anxiety diagnosis
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Four or more that develop abruptly and peak with in
10 minutes
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Pounding, racing, palpitating heart
Sweating
Trembling, shaking
Short of breath or smothering
Feeling of choking
Chest pain, discomfort
Nausea/abdominal stress
Dizzy, lightheaded, faint
Derealization (detached from reality) or
depersonalization (detached from oneself)
Fear of losing control or going crazy
Fear of dying
Paresthesias (numbness/tingling)
Chills/hot flashes
Panic Attacks
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After the first one, people tend to
become afraid of further attacks,
making symptoms worse and
causing anxiety between attacks
(anticipatory anxiety)
If cued, people begin avoiding
triggers- leading to agoraphobia at
times
Teach to breath (they are
hyperventilating) or use paper bag.
Educate about attacks and cycles.
Ensure they are not going crazy.
Agoraphobia- also not codable,
but occurs with other disorders
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Anxiety about being in places from
which escape might be difficult:
Being outside the home alone, being
in a crowd, on a bridge, on a bus,
train or car, etc.
Situations are avoided, endured with
much distress, or require a
companion
Not a social or specific phobia
Panic Disorder
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Usually begins prior to 35 yrs
Separation anxiety or childhood loss
may predispose
Runs in families
Has fluctuating course and tx has not
failed if some symptoms persist or
reoccur
Catastrophobic thinking needs to be
addressed
Imipramine, SSRIs, MAOIs,
Benzodiazepines
Presentation of Panic Disorder
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In some cultures: Intense fear of
witchcraft or magic
More often in women than men
Onset is typically between
adolescents and mid-30’s
Chronic, but waxes and wanes
Familiar pattern
Panic Disorder
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Presence of recurrent,
unexpected panic attacks with at
least 1 month of persistent
concern about having another,
consequenses, or sig behavior
change related to attack
Not substance or medical
Not social, specific, OCD,
PTSD, or Separation Anxiety
Panic Disorder
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With agoraphobia or without
agoraphobia
Agoraphobia w/out history of
Panic Disorder
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Focus of fear is on having panic like
symptoms or embarrassing/incapacitating
symptoms (no full panic attacks)
Does not meet criteria for Panic Disorder
Not Substance or Medical
Not better accounted for by another
disorder or Axis II avoidant
More often diagnosed in females
May persist for years and has much
impairment
Specific Phobia (formerly
Simple Phobia)
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Marked and persistent fear of an object or
situation
Exposure provokes anxiety response
Avoided or endured with dread
Realization in adolescents and adults that
the fear is excessive (as opposed to
delusions)
Marked distress or interference with
functioning
Not better accounted by another mental
disorder
If under 18, at least 6 months
Specific phobia subtypes
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Animal Type, Natural Environment Type,
Blood-Injection-injury type (may have
genetic link), Situational Type, Other Type
Often results in restrictive lifestyle
Children may express with crying,
tantrums, freezing, or clinging and do not
have the cognitive abilities to recognize the
fears are excessive
Predisposing factors: traumatic events,
pairing w/ unexpected panic attacks, or
informational transmission
Familial link
Specific Phobia researched
Treatment
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Desensitization: exposure,
relaxation, mental rehearsal,
supportive therapy
Flooding, graduated exposure,
systematic desensitization
MAOIs and SSRIs
Social Phobia 300.23
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Marked and persistent fear of social or
performance situations in which
embarrassment may occur.
May also be hypersensitive to criticism,
negative evaluation, or rejection, trouble
with assertiveness, low self-esteem and
feelings of inferiority, poorer social skills
Typical onset in mid-teens, but can begin in
childhood and may be continuous
depending on environmental demands
Familial link
Social Phobia & Culture
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Japan and Korea: fears of giving
offense to others in social
situations (blushing, eye
contact, or one’s body odor will
offend others)
Social Phobia Criteria
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Fear of social or performance situations,
and provoke anxiety. Situations are either
avoided or endured with extreme distress.
Person recognizes the fear is excessive
The avoidance or distress impairs
functioning
Under 18, must last at least 6 months
Not substance or medical
Specify Generalized if fears include most
social situations ( and consider avoidant
personality disorder)
Tx of Social Phobia
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SSRIs
Beta Blockers for performance
Social Skill training and
Assertiveness training
Exposure
CBT
Obsessive Compulsive
Disorder
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Obsessions- persistent, disturbing, intrusive,
thoughts or impulses which the patient finds illogical
but irresistible
These obsessions are considered absurd and
client’s actively resist them
Compulsions- obsessions expressed in action.
Rituals used to prevent or reduce anxiety (repetitive
behaviors)
Both are used to reduce anxiety
Symptoms take up time, interfere with routine or
functioning, and marked distress
Not specific to another mental disorder
Specify with poor insight if excessiveness is not
recognized
OCD Presentation
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People keep symptoms a
secret, due to embarrassment
Thoughts or images can be
violent or disgusting. “I want to
stab my cat” which disturb the
client.
Compulsions must be
completed or the client believes
something bad will happen.
Forms of OCD
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Washers
Checkers
Doubters and Sinners
Counters and Arrangers
Hoarders
OCD
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2/3rds had symptoms prior to 15,
and most had some symptoms in
childhood.
Chronic, lifelong, waxing and waning
illness
Attempts to resist obsessions and
compulsions increases anxiety
Familial link
Obsessions are overvalued ideas,
not delusions
OCD vs OCPD
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OCPD- ego syntonic
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No true obsessions/compulsions
OCD- ego dystonic
OCD Presentation
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May avoid situations related to
obsessions, such as dirt/germs
Guilt and sleep disturbances may be
present
Excessive use of substances or
sedatives may occur
Equal in males and females
Onset: males 6 to 15, females 20-29.
Chronic, waxing and waning course
Familial link
OCD Treatment
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SSRIs
Need Continued medication due
to chronic nature of disorder
Behavior therapy with graded
exposure and response
prevention
Address catastrophic thoughts
PTSD
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Exposure to trauma that involved actual or threatened
death or serious injury, or threat to physical integrity of
self or others
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A stressor is followed by either 1) reexperiencing
(intrusion)
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Hypervigilant, on edge, flooded by intrusive images
(hallucinations, nightmares, mental images), poor sleep and
concentration, ruminate about stressor, cry “without reason”,
emotionally labile, easily startled, somatic anxiety, fear going
crazy and are unable to think about anything except the
stressor
And
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2) avoidance of the event
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May deal with denial w/ psychic numbing, minimizing the
significance of the stressor, forgetting it, feeling detached
from others, losing interest in life, constricted affect,
daydream and abuse drugs
PTSD
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Increased arousal: difficulty
falling or staying asleep, irritable
or anger outbursts, poor
concentration, hypervigilance,
exaggerated startle response
Lasts more than 1 month
Significant distress or
impairment
PTSD
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Acute: less than 3 months
Chronic: 3 months or more
With delayed onset: 6 months
after stressor (worst prognosis)
Triggers worsen symptoms
Natural events cause less
distress than People distress
(torture)
PTSD
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Auditory hallucinations and
paranoid ideations can occur in
severe cases
PTSD Diversity
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In Men, more common
military/war
In women, more common rape,
sexual and physical abuse
Immigrants from war areas may
be hesitant to talk about
experiences
PTSD Treatment
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Debriefing immediately after event
can prevent PTSD
Support groups
Confronting feared memories/topics
Examining misinterpretations of
events
Development of coping
EMDR, TFT
Trazodone for sleep
Acute Stress Disorder
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Briefer form of PTSD lasting 2 days to 4 weeks
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Plus 3 symptoms immediately after stressor (with in 4
weeks): subjective numbing, reduced awareness of
surroundings “being in a daze”, derealization,
depersonalization, dissociative amnesia (inability to
remember important aspects of the trauma)
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Persistent reexperience of trauma
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Avoidance of triggers
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High Anxiety
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Impairment
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Not substance or medical
Generalized Anxiety Disorder
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Excessive anxiety and worry occurring
more days than not for at least 6 months,
about a number of things. Person has
trouble controlling the worry.
3 or more: Restless/keyed up/on edge,
easily fatigued, difficulty concentrating,
irritability, muscle tension, sleep
disturbance
Anxiety or worry not confined to other Axis I
disorder
Cause distress or impairment in functioning
Not substance or medical
GAD Presentation
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Chronic worry
warts
Tense
Highly
distractible
Irritable
Restless
On edge
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Fatigued and
mildly
depressed
Physical
complaints
Depression and Anxiety
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50% comorbid
Treat depression with
antidepressants and this will
help with anxiety
GAD Treatment
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ID stressors that exacerbate
anxiety
Eliminate dietary and physical
sources of anxiety
Increase exercise with
physician’s approval
Deep Muscle relaxation,
meditation, biofeedback
Buspar, SSRIs, Benzos
Generalized Anxiety Disorder
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Culture: In many cultures, anxiety is
expressed somatically or cognitively
Children: performance in school,
sports, punctuality, catastrophying
about war/earthquakes/etc, seek
excessive approval and
reassurance, things need to be
perfect
Somewhat more frequent in women
Chronic but fluctuating course
Familial association
Others
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Anxiety due to a general
medical disorder
Substance-induced anxiety
disorder
Anxiety Disorder NOS