1. PSY600: DIAGNOSIS AND TREATMENT OF MENTAL HEALTH DISORDERS
Class 5-6:
Anxiety Disorders
Obsessive-Compulsive Disorder
Stress-Related Disorders

2. Anxiety/OCD/Stress Disorders
You must often rule out substances and/or other medical conditions to Dx these disorders
Many substances and medical conditions can cause physiological or psychological Sx that look like anxiety Sx
There must be clinically significant distress or impairment in social, occupational, or other important areas of functioning to Dx these disorders
Avoidance of anxiety/fear-provoking objects or situations is often a key component of these disorders

3. Tx of Anxiety/OCD/Stress Disorders
Tx of these disorders will typically involve one or more of the following:
Cognitive therapy – change distorted/faulty thinking
Behavioral therapy –
Exposure, often with response prevention
Anxiety-reducing Bx training, such as relaxation training, meditation, distraction, biofeedback
Medication
Short-term Sx relief
Longer-term Tx of disorder

4. Panic Attacks
Panic Attack: An abrupt surge of intense fear or discomfort, in which the person experiences a variety of physiological and cognitive Sx.
Unexpected – no obvious cue or trigger at the time of occurrence. Seemingly “out of the blue.”
Expected - there is an obvious cue or trigger, e.g., phobic stimulus
Panic Attacks can be used as a specifier for all DSM disorders. Use the phrase “with panic attacks” after name of disorder

5. Panic Attacks Panic Sx include: Increased heart rate /palpitations
Sweating
Shaking
Shortness of breath
Chest pain
Nausea
Dizziness
Numbness/tingling
Derealization/depersonalization
Fear of “going crazy” or dying

6. Panic Disorder Panic Disorder Recurrent unexpected Panic Attacks
At least 1 of the attacks has been followed by a month or more of at least 1 of the following
Persistent worry about having more attacks or about the consequences of attacks
Significant change in Bx related to the attacks

7. Tx of Panic Disorder
Medical evaluation – physiological disorders, some serious, can cause panic-like Sx
Psychotherapy – can be sufficient as sole Tx method
CBT
Change catastrophic and distorted thinking surrounding physical symptoms
Relaxation training, meditation, distraction, interoceptive exposure
Medication – usually not sufficient as sole Tx method
Fast-acting anti-anxiety meds for Sx relief
Benzodiazepines – Xanax, Klonopin, Valium
Long-term anti-depressant therapy for Tx of underlying disorder
SSRIs
MAOIs
Tricyclics

8. Phobias
Marked fear or anxiety cued by the presence or anticipation of a specific object or situation
Exposure almost invariably provokes an immediate anxiety response, possibly in the form of expected Panic Attacks
Fear/anxiety is out of proportion to the actual danger posed and to the sociocultural context
Stimulus is avoided or endured with intense anxiety
Fear/anxiety/avoidance is persistent/lasts at least 6 months

9. Specific Phobia Code according to phobic stimulus Most Common Types
Animal Type
Natural Environment Type (e.g., heights, storm, water)
Blood-Injection-Injury Type
Situational Type (e.g., airplanes, elevators, enclosed places)
Other Type (e.g., fear of contracting an illness; in children: loud sounds, costumed characters)

10. Social Anxiety Disorder
Persistent fear of acting in a way that will be humiliating, embarrassing, or lead to rejection in 1 or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others
If another medical condition is present, fear is not related to it (e.g., fear is not of trembling in a patient with Parkinson’s Disease)
Specify if: Performance Only – fears are limited to public performance situations

11. Agoraphobia
Agoraphobia: Anxiety about being in situations from which escape might be difficult or in which help may not be available in the event of having panic or other embarrassing/incapacitating Sx.
Hx of Panic Attacks not required
Fear is experienced about two or more of these situations:
Public transportation
Open spaces
Enclosed places (where other people are present)
Standing in line/being in a crowd
Being outside the home alone

12. Behavioral Tx of Phobias
Exposure Therapy
Systematic Desensitization
Develop and implement anxiety hierarchy
In vivo or imaginal
Teach relaxation techniques and pair with exposure
Location and pacing determined by nature and severity of fear and client characteristics
Graduated Exposure
Gradually increasing duration of exposure
Flooding
Intense and prolonged exposure to feared object
Not all phobias or clients are appropriate for this approach
Virtual Reality

13. Other Tx of Phobias Cognitive restructuring
Encourage expression of feelings, self-confidence, responsibility
Attend to family/environmental issues that may impact phobia; possibly include a close associate in the Tx
Cognitive aspects of Tx play a larger role in treating Social Anxiety Disorder
Cognitive Behavioral Group Therapy helps skills development

14. Generalized Anxiety Disorder
Excessive anxiety and worry most of the time for at least 6 months about a number of events or activities
It is difficult to control the worry
Anxiety/worry associated with 3 or more of the following:
Restlessness or feeling on edge/keyed up
Being easily fatigued
Difficulty concentrating/mind going blank
Irritability
Muscle tension
Sleep disturbance

15. Treatment of GAD CBT Acceptance & Commitment Therapy Medication
Cognitive restructuring
Relaxation training
Exposure
Acceptance & Commitment Therapy
Acceptance & awareness of thoughts and feelings
Emotional detachment
Identification of values -- work toward acting based on those
Medication
Fast-acting for Sx relief
Long-term for Sx treatment
Relapse after stopping meds is high

16. Other Anxiety Disorders
Anxiety Disorder Due to Another Medical Condition
Sx are physiologically caused by medical condition, not by knowledge of having medical condition
Substance/Medication-Induced Anxiety Disorder
Code based on substance involved and presence/absence of other substance use disorder
Other Specified or Unspecified Anxiety Disorder
Clear anxiety disorder, but full criteria not met for any specific one,
For Specified, record reason with Dx
“Other Specified Anxiety Disorder, limited symptom attacks”

17. Obsessions & Compulsions
Recurrent, persistent and intrusive thoughts, impulses or images that cause marked anxiety or distress
Person attempts to ignore such thoughts or to neutralize them with some other thought or action
Compulsions
Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be rigidly applied
Behaviors are aimed at reducing distress or preventing some dreaded outcome, but are not realistically connected with what they are designed to prevent or are clearly excessive

18. Obsessive-Compulsive Disorder
Obsessions and/or compulsions
Sx cause marked distress, are time consuming, or significantly interfere with functioning
Sx not better explained by another mental disorder
Specify if:
With good or fair insight – person recognizes that beliefs are not or may not be true
With poor insight – person thinks beliefs probably true
With absent insight/delusional beliefs -- person is completely convinced beliefs are true
Tic-related – current or past tic disorder

19. Obsessive-Compulsive Disorder
Typical OCD themes include: contamination/washing; doubt/checking; fear of harming oneself or others; symmetry/counting and arranging
OCD is a chronic disorder that can be highly treatment resistant
High degree of heritability
Equally common in both genders: females onset more in adulthood, males more in childhood

20. Treatment of OCD
OCD presents at a wide range of severity and disability.
Exposure and response prevention
Graduated exposure to obsessional cues and strict prevention of rituals
Relaxation training may be used
Cognitive therapy
Challenge errors in thinking
Medication
SSRIs, tricyclics

21. Post-Traumatic Stress Disorder
Exposure to actual or threatened death, serious injury, or sexual violence in one of following ways:
For those older than 6 years:
Direct experience
Witnessing, in person, the event occurring to others
Learning that the event occurred to a close family member or friend
Experiencing related or extreme exposure to aversive details of the event(s)
There are somewhat different criteria for children 6 years or younger.

22. Post-Traumatic Stress Disorder
One or more intrusion Sx, beginning after event
One or more Sx indicating persistent avoidance of stimuli associated with event, beginning after event
Two or more negative alterations in cognitions and mood associated with event, beginning or worsening after event
Two or more marked alterations in arousal and reactivity associated with event, beginning or worsening after event

23. Post-Traumatic Stress Disorder
Duration of disturbance is more than one month
Rule out substances or other medical conditions
Specify whether:
With dissociative Sx
Depersonalization
Derealization
Specify if:
With delayed expression– if full criteria are not met for at least 6 months after the event

24. Treatment of PTSD
Begin Tx as soon as possible after trauma, even before Sx emerge as a preventative measure
Suicide evaluation
Substance use evaluation
Prolonged Exposure
Exposure to memory of trauma on a hierarchical, scheduled basis
Cognitive Processing Therapy
Structured model combining exposure, cognitive restructuring, and anxiety management training
Developed for sexual assault survivors
Anxiety Management Training
Pairing memory of trauma with relaxation, biofeedback, etc.

25. Treatment of PTSD Group/family therapy Medication
Support systems are vital to people with PTSD
Group with people with similar experiences can be very helpful
Family has likely been significantly impacted by PTSD
Work on trust, communication skills
Medication
SSRIs most commonly used
Help address anxiety, depression, sleep problems

26. Acute Stress Disorder Same exposure to traumatic event as with PTSD
Nine Sx related to intrusion, negative mood, dissociation, avoidance, and increased arousal
Disturbance lasts for at least 3 days and no more than1 month after trauma exposure
Rule out substances, another medical condition, and brief psychotic disorder.

27. Adjustment Disorder
Development of emotional or behavioral Sx in response to an identifiable stressor
Stressor can be of any severity, unlike PTSD
Sx start within 3 months of onset of stressor and don’t last more than 6 months past end of stressor
Distress in excess of what would be expected OR significant impairment in functioning
Criteria are not met for another mental disorder, and is not an exacerbation of a pre-existing mental disorder
Sx do not represent normal bereavement

28. Adjustment Disorder Specify whether: With Depressed Mood With Anxiety
With Mixed Anxiety and Depressed Mood
With Disturbance of Conduct
With Mixed Disturbance of Emotions and Conduct
Unspecified
Code according to nature of Sx

29. Differential Diagnosis
Panic Attacks can occur with all DSM-5 disorders – for Panic Disorder they must be present and unexpected
Nature of fear/worry helps determine Dx:
Panic Disorder – of having another attack or consequences of attack
Agoraphobia – of having panic Sx in a place that cannot be escaped or where help cannot be obtained
Specific Phobia – of a particular object or situation
Social Anxiety Disorder– of being humiliated/rejected in front of others

30. Differential Diagnosis
Avoidant Personality Disorder may just be a more pervasive form of Social Anxiety Disorder. They can be hard to distinguish. Look at Hx. Negative self evaluation is more prominent with P/D. Anxiety/avoidant Bx is present in most social situations with P/D.
Depressive ruminations are not obsessions because they are typically mood congruent, not experienced as intrusive or distressing, not linked to compulsions.
OCD with delusional beliefs is not diagnosed as Delusional Disorder if obsessions and compulsions are clearly present

31. Differential Diagnosis
Compulsive-like Bx (gambling, substance abuse) is not OCD because those activities bring pleasure, at least while they’re being executed
OCD and OCPD can be diagnosed in the same person, but they are not the same. No obsessions or compulsions with OCPD. OCD is often ego dystonic.
Stressor with Adjustment Disorder can be anything the person feels was stressful to them; PTSD requires extreme stressor as defined in criteria
PTSD can look like psychosis. Be aware of the whole profile.