Presentation on theme: "PSY600: DIAGNOSIS AND TREATMENT OF MENTAL HEALTH DISORDERS"— Presentation transcript:
1PSY600: DIAGNOSIS AND TREATMENT OF MENTAL HEALTH DISORDERS Class 5-6:Anxiety DisordersObsessive-Compulsive DisorderStress-Related Disorders
2Anxiety/OCD/Stress Disorders You must often rule out substances and/or other medical conditions to Dx these disordersMany substances and medical conditions can cause physiological or psychological Sx that look like anxiety SxThere must be clinically significant distress or impairment in social, occupational, or other important areas of functioning to Dx these disordersAvoidance of anxiety/fear-provoking objects or situations is often a key component of these disorders
3Tx of Anxiety/OCD/Stress Disorders Tx of these disorders will typically involve one or more of the following:Cognitive therapy – change distorted/faulty thinkingBehavioral therapy –Exposure, often with response preventionAnxiety-reducing Bx training, such as relaxation training, meditation, distraction, biofeedbackMedicationShort-term Sx reliefLonger-term Tx of disorder
4Panic AttacksPanic 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 stimulusPanic Attacks can be used as a specifier for all DSM disorders. Use the phrase “with panic attacks” after name of disorder
5Panic Attacks Panic Sx include: Increased heart rate /palpitations SweatingShakingShortness of breathChest painNauseaDizzinessNumbness/tinglingDerealization/depersonalizationFear of “going crazy” or dying
6Panic 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 followingPersistent worry about having more attacks or about the consequences of attacksSignificant change in Bx related to the attacks
7Tx of Panic DisorderMedical evaluation – physiological disorders, some serious, can cause panic-like SxPsychotherapy – can be sufficient as sole Tx methodCBTChange catastrophic and distorted thinking surrounding physical symptomsRelaxation training, meditation, distraction, interoceptive exposureMedication – usually not sufficient as sole Tx methodFast-acting anti-anxiety meds for Sx reliefBenzodiazepines – Xanax, Klonopin, ValiumLong-term anti-depressant therapy for Tx of underlying disorderSSRIsMAOIsTricyclics
8PhobiasMarked fear or anxiety cued by the presence or anticipation of a specific object or situationExposure almost invariably provokes an immediate anxiety response, possibly in the form of expected Panic AttacksFear/anxiety is out of proportion to the actual danger posed and to the sociocultural contextStimulus is avoided or endured with intense anxietyFear/anxiety/avoidance is persistent/lasts at least 6 months
9Specific Phobia Code according to phobic stimulus Most Common Types Animal TypeNatural Environment Type (e.g., heights, storm, water)Blood-Injection-Injury TypeSituational Type (e.g., airplanes, elevators, enclosed places)Other Type (e.g., fear of contracting an illness; in children: loud sounds, costumed characters)
10Social 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 othersIf 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
11AgoraphobiaAgoraphobia: 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 requiredFear is experienced about two or more of these situations:Public transportationOpen spacesEnclosed places (where other people are present)Standing in line/being in a crowdBeing outside the home alone
12Behavioral Tx of Phobias Exposure TherapySystematic DesensitizationDevelop and implement anxiety hierarchyIn vivo or imaginalTeach relaxation techniques and pair with exposureLocation and pacing determined by nature and severity of fear and client characteristicsGraduated ExposureGradually increasing duration of exposureFloodingIntense and prolonged exposure to feared objectNot all phobias or clients are appropriate for this approachVirtual Reality
13Other Tx of Phobias Cognitive restructuring Encourage expression of feelings, self-confidence, responsibilityAttend to family/environmental issues that may impact phobia; possibly include a close associate in the TxCognitive aspects of Tx play a larger role in treating Social Anxiety DisorderCognitive Behavioral Group Therapy helps skills development
14Generalized Anxiety Disorder Excessive anxiety and worry most of the time for at least 6 months about a number of events or activitiesIt is difficult to control the worryAnxiety/worry associated with 3 or more of the following:Restlessness or feeling on edge/keyed upBeing easily fatiguedDifficulty concentrating/mind going blankIrritabilityMuscle tensionSleep disturbance
15Treatment of GAD CBT Acceptance & Commitment Therapy Medication Cognitive restructuringRelaxation trainingExposureAcceptance & Commitment TherapyAcceptance & awareness of thoughts and feelingsEmotional detachmentIdentification of values -- work toward acting based on thoseMedicationFast-acting for Sx reliefLong-term for Sx treatmentRelapse after stopping meds is high
16Other Anxiety Disorders Anxiety Disorder Due to Another Medical ConditionSx are physiologically caused by medical condition, not by knowledge of having medical conditionSubstance/Medication-Induced Anxiety DisorderCode based on substance involved and presence/absence of other substance use disorderOther Specified or Unspecified Anxiety DisorderClear anxiety disorder, but full criteria not met for any specific one,For Specified, record reason with Dx“Other Specified Anxiety Disorder, limited symptom attacks”
17Obsessions & Compulsions Recurrent, persistent and intrusive thoughts, impulses or images that cause marked anxiety or distressPerson attempts to ignore such thoughts or to neutralize them with some other thought or actionCompulsionsRepetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be rigidly appliedBehaviors 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
18Obsessive-Compulsive Disorder Obsessions and/or compulsionsSx cause marked distress, are time consuming, or significantly interfere with functioningSx not better explained by another mental disorderSpecify if:With good or fair insight – person recognizes that beliefs are not or may not be trueWith poor insight – person thinks beliefs probably trueWith absent insight/delusional beliefs -- person is completely convinced beliefs are trueTic-related – current or past tic disorder
19Obsessive-Compulsive Disorder Typical OCD themes include: contamination/washing; doubt/checking; fear of harming oneself or others; symmetry/counting and arrangingOCD is a chronic disorder that can be highly treatment resistantHigh degree of heritabilityEqually common in both genders: females onset more in adulthood, males more in childhood
20Treatment of OCDOCD presents at a wide range of severity and disability.Exposure and response preventionGraduated exposure to obsessional cues and strict prevention of ritualsRelaxation training may be usedCognitive therapyChallenge errors in thinkingMedicationSSRIs, tricyclics
21Post-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 experienceWitnessing, in person, the event occurring to othersLearning that the event occurred to a close family member or friendExperiencing related or extreme exposure to aversive details of the event(s)There are somewhat different criteria for children 6 years or younger.
22Post-Traumatic Stress Disorder One or more intrusion Sx, beginning after eventOne or more Sx indicating persistent avoidance of stimuli associated with event, beginning after eventTwo or more negative alterations in cognitions and mood associated with event, beginning or worsening after eventTwo or more marked alterations in arousal and reactivity associated with event, beginning or worsening after event
23Post-Traumatic Stress Disorder Duration of disturbance is more than one monthRule out substances or other medical conditionsSpecify whether:With dissociative SxDepersonalizationDerealizationSpecify if:With delayed expression– if full criteria are not met for at least 6 months after the event
24Treatment of PTSDBegin Tx as soon as possible after trauma, even before Sx emerge as a preventative measureSuicide evaluationSubstance use evaluationProlonged ExposureExposure to memory of trauma on a hierarchical, scheduled basisCognitive Processing TherapyStructured model combining exposure, cognitive restructuring, and anxiety management trainingDeveloped for sexual assault survivorsAnxiety Management TrainingPairing memory of trauma with relaxation, biofeedback, etc.
25Treatment of PTSD Group/family therapy Medication Support systems are vital to people with PTSDGroup with people with similar experiences can be very helpfulFamily has likely been significantly impacted by PTSDWork on trust, communication skillsMedicationSSRIs most commonly usedHelp address anxiety, depression, sleep problems
26Acute Stress Disorder Same exposure to traumatic event as with PTSD Nine Sx related to intrusion, negative mood, dissociation, avoidance, and increased arousalDisturbance lasts for at least 3 days and no more than1 month after trauma exposureRule out substances, another medical condition, and brief psychotic disorder.
27Adjustment DisorderDevelopment of emotional or behavioral Sx in response to an identifiable stressorStressor can be of any severity, unlike PTSDSx start within 3 months of onset of stressor and don’t last more than 6 months past end of stressorDistress in excess of what would be expected OR significant impairment in functioningCriteria are not met for another mental disorder, and is not an exacerbation of a pre-existing mental disorderSx do not represent normal bereavement
28Adjustment Disorder Specify whether: With Depressed Mood With Anxiety With Mixed Anxiety and Depressed MoodWith Disturbance of ConductWith Mixed Disturbance of Emotions and ConductUnspecifiedCode according to nature of Sx
29Differential Diagnosis Panic Attacks can occur with all DSM-5 disorders – for Panic Disorder they must be present and unexpectedNature of fear/worry helps determine Dx:Panic Disorder – of having another attack or consequences of attackAgoraphobia – of having panic Sx in a place that cannot be escaped or where help cannot be obtainedSpecific Phobia – of a particular object or situationSocial Anxiety Disorder– of being humiliated/rejected in front of others
30Differential 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
31Differential Diagnosis Compulsive-like Bx (gambling, substance abuse) is not OCD because those activities bring pleasure, at least while they’re being executedOCD 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 criteriaPTSD can look like psychosis. Be aware of the whole profile.