2Anxiety Spectrum Updates 2012 Ricardo J. Fermo, MDMedical DirectorEast Cooper Psychiatric Solutions, LLC1073 B. Johnnie Dodds Blvd.Mount Pleasant, South Carolina 29464Diplomate of the American Board of Psychiatry and Neurology Diplomate of American Board of Child and Adolescent PsychiatryDATE: Friday, May 4th 8:30 AM - 10:30 AMLocation: Palmetto Lowcountry Behavioral Health, 2777 Speissegger Drive, North Charleston, SC 29405Presentation: Anxiety Spectrum Updates Presenter: Ricardo Fermo, MDDr. Fermo is a dual board certified psychiatrist with a Diplomate of the American Board of Psychiatry and Neurology and Diplomate of the American Board of Child and Adolescent Psychiatry. Dr. Fermo has been practicing psychiatry for 21 years and has a strong background in evaluating, diagnosing and treating child to adult psychiatric disorders. He specializes in early childhood and adult conditions such as attention deficit hyperactivity disorder, affective disorders such as clinical depression and bipolar, psychotic, and anxiety disorders, substance use related disorders, autism spectrum and behavioral disorders. Dr. Fermo completed an internship at Robert Wood Johnson University Hospital in South Jersey, residency in General Psychiatry at the University of Cincinnati, and Clinical Fellowship in Child and Adolescent Psychiatry at the University of Cincinatti. Dr. Fermo practices Adult/Child and Adolescent Psychiatry at East Cooper Psychiatric Solutions, LLC in Mt. Pleasant. Program Description: This session will provide updates on the Anxiety Spectrum in regards to :EpidemiologyEvidence Based MedicineDiagnostic Criteria If you have questions, please contact Stacey Lindbergh at or
4Learning Objectives Review updates on the epidemiology of Anxiety Provide a summary of the disease state (s)Discuss diagnostic criteria for various anxiety disordersTreatment/GoalsDiscuss evidence-based approaches for treatment-AnxietyEpidemiologyEvidence Based MedicineDiagnostic Criteria ECPSLLC.COM
5References NIMH SAMHCA APA CDC CLINICALTRIALS.GOV CLINICAL PRACTICE EVIDENCE BASED MEDICINE WEBSITESGOOGLE SCHOLARCOCHRANEPUBMEDDYNAMEDEVIDENCE BASED (BMJ)
8Stress and anxiety are the same thing. True False Stress is your response to a change in your environment, be it positive or negative. Your body reacts to change -- falling in love, starting a new job, or suffering an unexpected loss -- with physical, mental, and emotional responses. Anxiety is an emotion that’s characterized by a feeling of apprehension, nervousness, or fear.
9The causes of stress are essentially the same for everyone. True False YOUR ANSWER: FalseSomething that causes stress for you may not for someone else. Something that's a source of negative stress for one person -- such as a deadline -- might actually be helpful for someone else.
10Anxiety is the most common mental illness in the US: TrueFalseAbout 40 million American adults (18 and older) are affected by anxiety disorders each year. That's about 18% of the adult population.
11Men are twice as likely to have Generalized Anxiety then Woman? TrueFalseWomen are twice as likely as men to be affected by generalized anxiety disorder, which is characterized by at least six months of excessive, unrealistic worry over everyday problems.
12What percentage of people with mental illnesses improve if they receive treatment? 25% to 45%50% to 70%70% to 90%Between 70% and 90% of people with mental illnesses have an improved quality of life if they receive appropriate treatment and support. However, only about a third of people who are ill receive treatment.
13Anxiety as a Normal and an Abnormal Response Some amount of anxiety is “normal” and is associated with optimal levels of functioning.Only when anxiety begins to interfere with social or occupational functioning is it considered “abnormal.”
14ANXIETY DISORDERSAnxiety is a normal reaction to stress and can actually be beneficial in some situations.Fear and anxiety are part of lifeanxiety can become excessive, and while the person suffering may realize it is excessive they may also have difficulty controlling it and it may negatively affect their day-to-day living.Most common of emotional disordersAffects more than 40 million AmericansThe most prevalent psychiatric disordersAnxiety disorders are the most common of emotional disorders and affect more than 25 million Americans. Many forms and symptoms may include:• Overwhelming feelings of panic and fear• Uncontrollable obsessive thoughts• Painful, intrusive memories• Recurring nightmares• Physical symptoms such as feeling sick to your stomach, “butterflies” in your stomach, heart pounding, startling easily, and muscle tension
15The Fear and Anxiety Response Patterns PanicAnxietyAnxiety Disorder
16Definition of AnxietyAnxiety is a feeling of apprehension or fear. The source of this uneasiness is not always known or recognized, which can add to the distress you feel.Anxiety disorders are a group of psychiatric conditions that involve excessive anxiety.
172003 Anxiety Disorders Association of America Anxiety FactsMost common mental illness in the U.S. with 18 million of the adult (ages 18-54) U.S. population affected.Anxiety disorders cost more than $42 billion a year.More than $22 billion are associated with the repeated use of healthcare services, as those with anxiety disorders seek relief for symptoms that mimic physical illnesses.Anxiety is highly treatable (up to 90% of cases), but only one-third of those who suffer from it receive treatmentPeople with an anxiety disorder are three-to-five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than non-sufferers.Depression often accompanies anxiety disorders2003 Anxiety Disorders Association of America
18Anxiety FactsAnxiety disorders are the most common mental illness in the U.S., affecting 40 million adults in the United States age 18 and older (18% of U.S. population).Anxiety disorders are highly treatable, yet only about one-third of those suffering receive treatment.Anxiety disorders cost the U.S. more than $42 billion a year, almost one-third of the country's $148 billion total mental health bill, according to "The Economic Burden of Anxiety Disorders," a study commissioned by ADAA (The Journal of Clinical Psychiatry, 60(7), July 1999). More than $22.84 billion of those costs are associated with the repeated use of health care services; people with anxiety disorders seek relief for symptoms that mimic physical illnesses.
19Anxiety disorders in the U.S. cost more than $42 billion each year. 1/3 of the total amount spent on mental health care
20Anxiety DisordersOne-quarter of the U.S. population experiences pathologic anxiety in their lifetimePeople with an anxiety disorder are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than those who do not suffer from anxiety disorders.Anxiety disorders develop from a complex set of risk factors, including genetics, brain chemistry, personality, and life events.Anxiety and DepressionIt's not uncommon for someone with an anxiety disorder to also suffer from depression or vice versa. Nearly 70 % of those diagnosed with depression are also diagnosed with an anxiety disorder.Presenting problem for 11% of patients visiting primary care physicians90% of patients with anxiety present with somatic complaints
21Anxiety Nervousness and fear are common human emotions. Adaptive at lower levels; disabling at high levels.Physicians must recognize the difference between pathological anxiety and anxiety as a normal or adaptive response.
22Definition of Anxiety Diffuse, unpleasant, vague sense of apprehension Often accompanied by autonomic symptoms such as headache, perspiration, heart palpitations, chest tightness, stomach discomfort and restlessnessPresentation depends on perception of stress, personal resources, psychological defenses, and coping mechanisms
23Pathological AnxietyAnxiety that is excessive, persistent, easily triggered.Degree of the person’s fear is out-of-proportion to actual danger.Disrupts the person’s life and functioning.Creates intense discomfort.Doesn’t respond to rational reassurance.in pathological anxiety, attention is focused also on the person's response to the threat.
24Features of Pathologic Anxiety Autonomy: no or minimal environmental triggerIntensity: exceeds patient’s capacity to bear the discomfortDuration: symptoms are persistentBehavior: anxiety impairs coping and results in disabling behaviors
25Etiology Neurophysiology Cognitive-Behavioral Formulations Central noradrenergic systems– in particular, the locus coeruleus is the major source of adrenergic innervationGABA neurons from the limbic systemSerotoninergic systems and neuropeptidesCognitive-Behavioral FormulationsDevelopmental (Psychodynamic) Formulations
30Lifetime Prevalence of Common Psychiatric Disorders Major depressive disorder117.1%Alcohol dependence114.1%Social anxiety disorder113.3%Posttraumatic stressdisorder (PTSD)27.8%Generalized anxietydisorder (GAD)15.1%Panic disorder13.5%Obsessive-compulsivedisorder (OCD)32.5%24681012141618Prevalence (%)*In menstruating women.Kessler RC, et al. Arch Gen Psychiatry. 1994;51(1): Kessler RC, et al. Arch Gen Psychiatry. 1995;52(12): DSM-IV-TR29 of 45
3140 million American adults age 18 years and older (about 18%) Anxiety Disorders affect about 40 million American adults age 18 years and older (about 18%) in a given year,1 causing them to be filled with fearfulness and uncertainty. Unlike the relatively mild, brief anxiety caused by a stressful event (such as speaking in public or a first date), anxiety disorders last at least 6 months and can get worse if they are not treated. Anxiety disorders commonly occur along with other mental or physical illnesses, including alcohol or substance abuse, which may mask anxiety symptoms or make them worse. In some cases, these other illnesses need to be treated before a person will respond to treatment for the anxiety disorder
32Generalized Anxiety Disorder Obsessive-Compulsive Disorder (OCD) Panic DisorderPost-Traumatic Stress Disorder (PTSD)Social Phobia (or Social Anxiety Disorder)Specific PhobiaEach anxiety disorder has different symptoms, but all the symptoms cluster around excessive, irrational fear and dread.Each anxiety disorder has different symptoms, but all the symptoms cluster around excessive, irrational fear and dread.Fear and anxiety are part of life. You may feel anxious before you take a test or walk down a dark street. This kind of anxiety is useful - it can make you more alert or careful. It usually ends soon after you are out of the situation that caused it. But for millions of people in the United States, the anxiety does not go away, and gets worse over time. They may have chest pains or nightmares. They may even be afraid to leave home. These people have anxiety disorders.
34Learning perspective Fear conditioning Stimulus generalization One bad event can lead to classical conditioning of fearStimulus generalizationFear may broaden: fear of heights fear of airplanesGuy who got bit by spider and became arachnophobic
35Learning perspective Reinforcement can help maintain fears. Avoiding or escaping the feared situation reduces anxiety, so the avoiding or escaping behavior is reinforcedCan anyone give an example?
36Learning perspective Observational learning We learn our fears by watching and listening to othersExample of parent-instilled fear?Roommate banging tooth on beer bottle
37Biological perspective We are biologically prepared to fear threats faced by ancestorsSpidersSnakesDarkness
38Biological perspective GenesSome people seem genetically predisposed to particular fears and high anxiety35 year old identical twins
39Biological perspective 35 year old identical twins who independently developed claustrophobia and fear of water
40Biological perspective PhysiologyBrain scans of people with OCD unusually high activity in certain parts of the frontal lobes
41PhysiologyGeneralized anxiety, panic attacks, and OCD are linked with overarousal in brain areas linked with impulse control and habitual behaviorsPeople cannot “turn off” these thoughts.
42Physical Reaction to Anxiety Auditory and Visual Stimuli:sights and sounds are processedfirst by the thalamus, which filtersthe incoming cues and shuntsthem either directly to theamygdala or to the other parts ofthe cortex.Olfactory and tactile stimuli:Smells and touch sensationsBypass the thalamus altogether,Taking a shortcut directly to theAmygdala. Smells, therefore,Often evoke stronger memoriesOr feelings than do sights orSounds.
43Physical Reaction to Anxiety Thalamus:The hub for sights and sounds,The thalamus breaks downIncoming visual ques by size,Shape and color, and auditoryCues, by volume andDissonance, and then signalsThe appropriate part of theCortex.Cortex:It gives raw sights and soundsmeanings, enabling the brainto become conscious of what itIs seeing or hearing. Oneregion, the prefrontal cortex,may be vital to turning off theanxiety response once a threathas passed.
44Physical Reaction to Anxiety Amygdala:emotional core of the brain, theamygdala has the primary roleof triggering the fear response.information that passes throughthe amygdala is tagged withemotional significance.Bed Nucleus of Stria Terminalis:unlike the Amygdala, which sets off an immediate burst of fear, the BNST perpetuates the fear response, causing the longer term unease typical ofanxiety.
45Physical Reaction to Anxiety Locus Ceruleus:It receives signals from theamygdala and is responsiblefor initiating many of theclassic anxiety responses:rapid heartbeat, increasedblood pressure, sweating andpupil dilation.Hippocampus:This is the memory center,vital to storing the rawinformation coming in fromthe senses along with theemotional baggage attachedto the data during their tripthrough the amygdala.
46Generalized Anxiety Disorder: Biological Causal Factors Genetic factorsA functional deficiency of GABANeurobiological differences between anxiety and panic
47Relationship Between Arousal (anxiety) and Performance Yerkes-Dodson Law47
48Three Components of Anxiety PhysicalPsychological (Cognition and emotion)Behaviours
51The Psychological Component Anxious ThoughtsAnxious PredictionsAnxious Beliefs and InterpretationsDifficulty in Attention and MemoryMental ImagesUnreality/DetachmentHypervigilanceInsomniaDecreased libidoLump in the throat
52The Behavioural Component Avoidance of Situations and ActivitiesSubtle Avoidance Strategies, Safety Signals, and Overprotective BehavioursAlcohol, Drug, and Medication Use
53Anxiety Disorders - DSM-IV 1. Generalized AnxietyDisorder (GAD)2. Panic Disorder (PD)with Agoraphobia (AG)3. PD without Agoraphobia4. Specific Phobia (SP)5. Social Phobia (SoP)6. Obsessive CompulsiveDisorder (OCD)7. Post traumatic StressDisorder (PTSD)8. Acute Stress Disorder(ASD)9. Substance-InducedAnxiety disorder (SIAD)10. Anxiety disorder duesome medical illnessDual Diagnosis Disorders
54Panic disorder with agoraphobia Phobic anxiety disorder Anxiety disordersContinuous anxietyEpisodic anxietyGeneralized anxiety disorderMixed patternIn any situationIn defined situationPanic disorder with agoraphobiaPanic disorderPhobic anxiety disorderSimple phobiaSocial phobiaAgoraphobia
55EpidemiologyOverall, anxiety disorders are among the most prevalent of psychiatric disorders.Age; Earlier onset than depressionSex factor; More in femalesFrequency (Prevalence):18 %of general population28% (life time prevalence)Strong genetic component55
56Shared features of anxiety disorders Substantial proportion of aetiology is stress related.Difference with Psychosis- free of delusions and hallucinations, good insight- Reality testing is intact.Symptoms are ego dystonic (distressing)Disorders are enduring or recurrent.Demonstrable organic factors are absentNote: Hierarchy of Diagnosis Precedence:Psychosis >Depression >Anxiety
57Risk Factors/Etiology Psychodynamic theory posits that anxiety occurs when instinctual drives arc thwarted (dissatisfied).Behavioral theory states that anxiety is a conditioned response to environmental stimuli originally paired with a feared situation.Cognitive approach: Selective attention and catastrophic thinkingBiologic theories implicate various neurotransmitters (especially:gamma-aminobutyric acid [GABA], norepinephrine, and serotonin)and various CNS structures (especially reticular activating system and limbic system).Other theories: Social and personality factors.
58The Psychodynamic Approach to Anxiety Anxiety is a signal that the ego is having a hard time mediating between reality, id and superego.Different anxiety disorders are the result of different defense mechanisms used to cope.Phobia - displacementOCD - reaction formation, undoingPTSD - denial, repressionAttachment Theories : Bowlbydisturbances in parent-child bond leads to “anxious attachment” and a vulnerability to anxiety disorders later in life.
59The Behavioural Approach to Anxiety (learning theory) Behavioral theories:- anxiety is a conditional response to specific environmental stimuli followed by its generalization, displacement, or transference.It may be learned through identification and imitation of anxiety pattern in parents (social learning theory).Mowrer (1948) Avoidance learning (learned behaviour)1) classical (respondent) conditioning2) negative reinforcement
60The Cognitive Approach to Anxiety Individuals misperceive and misinterpret internal and external stimuli.Selective attention and catastrophic thinkingCognitive Appraisal (perceive threat)Stimulus--->Appraisal---> Responseevaluation of stimulus based on memories, beliefs, and expectations.. Albert Ellis identified basic irrational assumptions:It is necessary for humans to be loved by everyoneIt is catastrophic when things are not as one wants them to beIf something is dangerous, a person should be terribly concerned and dwell on the possibility that it will occurOne should be competent in all domains to be a worthwhile personThe idea is, when these assumptions are applied to everyday life, GAD may develop.Aaron Beck :Those with GAD hold unrealistic silent assumptions that imply imminent danger:Any strange situation is dangerousA situation/person is unsafe until proven safeIndividuals misperceive and misinterpret internal and external stimuli.Selective attention and catastrophic thinkingCognitive Appraisal (perceive threat)Stimulus--->Appraisal---> Responseevaluation of stimulus based on memories, beliefs, and expectations.. Albert Ellis identified basic irrational assumptions:It is necessary for humans to be loved by everyoneIt is catastrophic when things are not as one wants them to beIf something is dangerous, a person should be terribly concerned and dwell on the possibility that it will occurOne should be competent in all domains to be a worthwhile personThe idea is, when these assumptions are applied to everyday life, GAD may develop.Aaron Beck :Those with GAD hold unrealistic silent assumptions that imply imminent danger:Any strange situation is dangerousA situation/person is unsafe until proven safe
61The Biological Approach to Anxiety Genetic Componentfamily and twin studies suggest a genetic component in most anxiety disorderspanic disorder shows the strongest genetic component and generalized anxiety disorder the least.Neurotransmitter abnormalities- the release of catecholamine (NA, DA) is increased.- decrease level of GABA (GABA inhibit CNS irritability).- serotonin decrease causes anxiety; increased dopaminergic activity is associated with anxiety.Activity in the temporal cerebral cortex is increased.The locus ceruleus, a brain center of noradrengic neurons, is hyperactive in anxiety disorders, especially panic attacks.Elevated responsiveness in the amygdala, part of the fear circuit of the limbic system.HPA axis dysregulationSerotonin and basal ganglia abnormalities in OCDHormonal theory of PTSD
62Other theories: Social factors Personality factors Early life adversityStressful events especially those involving threatLack of support networkPersonality factorsSome personality traits predispose to certain anxiety disorders – avoidant, perfectionist
63Depression-Anxiety Comorbidity The lifetime prevalence of depression is 60% in patients with social anxiety disorderMajorDepressiveDisorder 16.2% (lifetime prevalence)Anxiety Disorders 24.9% (lifetime prevalence)Up to 60%OverlapThe lifetime prevalence of depression is 57% in patients with panic disorderBrown TA, et al. J Abnorm Psychol 2001;36:Kessler RC, et al. JAMA 2003;289:Kessler RC, et al. Arch Gen Psychiatry 1994;51:8-19.
64Depression and Anxiety Disorders Commonly Occur Together SAD37%*(SAD + MDD2)Fear/avoidanceof social situationsBlushingTrembling/shakingPalpitationsSweatingLow self- esteemGADMDDDifficulty concentratingGI complaints Interpersonal sensitivity62%*(GAD + MDD1)AnhedoniaDepressed moodSuicidal ideationFeelings of worthlessnessAppetite disturbanceWorryAnxietyMuscle tensionDry mouthAgitationIrritabilitySleep disturbanceFatiguePain*Lifetime prevalence of MDD among individuals with lifetime diagnoses of each anxiety disorder.1. Wittchen HU, et al. Arch Gen Psychiatry. 1994;51:2. Magee WJ, et al. Arch Gen Psychiatry. 1996;53:3. DSM-IV-TR™. Washington, DC: American Psychiatric Association; 2000.
65Screening and Diagnosis Measurement-Based Care GAD-7, LSAS, PTSD, YBOCDetect depression (PHQ-9, QIDS, CUDOS, Zung)Rule out bipolarity (MDQ, WHO CIDI 3.0)DiagnosisDSM-IV overviewComorbiditySuicide AssessmentSymptom TrackingHAM-A (physician)CGI-A
66Generalized Anxiety Disorder (GAD) GAD affects 6 Generalized Anxiety Disorder (GAD) GAD affects 6.8 million adults, or 3.1% of the U.S. population. Women are twice as likely to be affected as men. Obsessive-Compulsive Disorder (OCD) 2.2 million, 1.0% Equally common among men and women. The median age of onset is 19, with 25 percent of cases occurring by age 14. One-third of affected adults first experienced symptoms in childhood.Hoarding is the compulsive purchasing, acquiring, searching, and saving of items that have little or no value.Panic Disorder 6 million, 2.7% Women are twice as likely to be affected as men. Very high comorbidity rate with major depression. Posttraumatic Stress Disorder (PTSD) 7.7 million, 3.5% Women are more likely to be affected than men. Rape is the most likely trigger of PTSD: 65% of men and 45.9% of women who are raped will develop the disorder. Childhood sexual abuse is a strong predictor of lifetime likelihood for developing PTSD. Social Anxiety Disorder 15 million, 6.8% Equally common among men and women, typically beginning around age 13. According to a 2007 ADAA survey, 36% of people with social anxiety disorder report experiencing symptoms for 10 or more years before seeking help. Specific Phobias 19 million, 8.7% Women are twice as likely to be affected as men.Related Illnesses Many people with an anxiety disorder also have a co-occurring disorder or physical illness, which can make their symptoms worse and recovery more difficult. It’s essential to be treated for both disorders.Generalized Anxiety Disorder (GAD) GAD affects 6.8 million adults, or 3.1% of the U.S. population. Women are twice as likely to be affected as men. Obsessive-Compulsive Disorder (OCD) 2.2 million, 1.0% Equally common among men and women. The median age of onset is 19, with 25 percent of cases occurring by age 14. One-third of affected adults first experienced symptoms in childhood.Hoarding is the compulsive purchasing, acquiring, searching, and saving of items that have little or no value. Posttraumatic Stress Disorder (PTSD) 7.7 million, 3.5% Women are more likely to be affected than men. Rape is the most likely trigger of PTSD: 65% of men and 45.9% of women who are raped will develop the disorder. Childhood sexual abuse is a strong predictor of lifetime likelihood for developing PTSD. Social Anxiety Disorder 15 million, 6.8% Equally common among men and women, typically beginning around age 13. According to a 2007 ADAA survey, 36% of people with social anxiety disorder report experiencing symptoms for 10 or more years before seeking help. Specific Phobias 19 million, 8.7% Women are twice as likely to be affected as men.Related Illnesses Many people with an anxiety disorder also have a co-occurring disorder or physical illness, which can make their symptoms worse and recovery more difficult. It’s essential to be treated for both disorders.
68Generalized Anxiety Disorder Excessive uncontrollable worry about everyday things. This constant worry affects daily functioning and can cause physical symptoms.GAD can occur with other anxiety disorders, depressive disorders, or substance abuse.People with generalized anxiety disorder (GAD) go through the day filled with exaggerated worry and tension, even though there is little or nothing to provoke it. They anticipate disaster and are overly concerned about health issues, money, family problems, or difficulties at work. Sometimes just the thought of getting through the day produces anxiety.GAD is diagnosed when a person worries excessively about a variety of everyday problems for at least 6 months.13 People with GAD can’t seem to get rid of their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. They can’t relax, startle easily, and have difficulty concentrating. Often they have trouble falling asleep or staying asleep. Physical symptoms that often accompany the anxiety include fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, nausea, lightheadedness, having to go to the bathroom frequently, feeling out of breath, and hot flashes.When their anxiety level is mild, people with GAD can function socially and hold down a job. Although they don’t avoid certain situations as a result of their disorder, people with GAD can have difficulty carrying out the simplest daily activities if their anxiety is severe.GAD affects about 6.8 million American adults,1 including twice as many women as men.2 The disorder develops gradually and can begin at any point in the life cycle, although the years of highest risk are between childhood and middle age.2 There is evidence that genes play a modest role in GAD.13Other anxiety disorders, depression, or substance abuse2,4 often accompany GAD, which rarely occurs alone. GAD is commonly treated with medication or cognitive-behavioral therapy, but co-occurring conditions must also be treated using the appropriate therapies.
69Generalized Anxiety Disorder The focus of GAD worry can shift, usually focusing on issues like job, finances, health of both self and family; but it can also include more mundane issues such as, chores, car repairs and being late for appointments.The intensity, duration and frequency of the worry are disproportionate to the issue
70Generalized Anxiety Disorder Characterized by at least 6 months of persistent and excessive anxiety and worry
71Generalized Anxiety Disorder (GAD) GAD affects 6 Generalized Anxiety Disorder (GAD) GAD affects 6.8 million adults, or 3.1% of the U.S. population. Women are twice as likely to be affected as men.
72GAD Epidemiology 5% prevalence in community samples 2:1 female/male ratioAge of onset is frequently in childhood or adolescenceChronic but fluctuating course of illness (worsened during stressful periods)
73Generalized Anxiety Disorder (GAD) Patients with GAD suffer from severe worry or anxiety that is out of proportion to situational factors.Must last most days for at least 6 monthsDescribed as “worriers” or “nervous”
75GAD Diagnostic Criteria Excessive anxiety and worry that occurs more days than not for 6 monthsDifficult to control the worry3 out of 6 symptomsAnxiety caused significant distress or impairment in functionNot attributed to another organic cause
76GAD Treatment Cognitive Behavioral Therapy Other Psychotherapies PharmacotherapyAntidepressantsBenzodiazepinesBuspirone
77Common CausesThere is no one cause for anxiety disorders. Several factors can play a roleGeneticsBrain biochemistryOveractive "fight or flight" responseCan be caused by too much stressLife circumstancesPersonalityPeople who have low self-esteem and poor coping skills may be more proneCertain drugs, both recreational and medicinal, can lead to symptoms of anxiety due to either side effects or withdrawal from the drug.In very rare cases, a tumor of the adrenal gland (pheochromocytoma) may be the cause of anxiety.
78Symptoms of Anxiety Anxiety is an emotion often accompanied by various physical symptoms, including:Twitching or tremblingMuscle tensionHeadachesSweatingDry mouthDifficulty swallowingAbdominal pain (may be the only symptom of stress especially in a child)
79Additional Symptoms of Anxiety Sometimes other symptoms accompanyanxiety:DizzinessRapid or irregular heart rateRapid breathingDiarrhea or frequent need to urinateFatigueIrritability, including loss of your temperSleeping difficulties and nightmaresDecreased concentrationSexual problems
80Generalized anxiety disorder Person is continually tense, apprehensive, and in a state of CNS arousal.
81Generalized anxiety disorder Tense and jitteryWorried bad things will happenMuscular tensionAgitationSleeplessness
82Generalized anxiety disorder Person cannot identify the cause of the anxiety, and therefore can’t avoid or deal“Free floating anxiety”
83Generalized anxiety disorder Worry about things that are not too likely to happenWorry more intensely
84Generalized Anxiety Disorder Generalized anxiety disorder (GAD) is characterized by unrealistic or excessive worry (generalized free-floating persistent anxiety) about every day events/problems with symptoms of muscle and psychic tension, causing significant distress/functional impairment.
85What is Gen. Anxiety Disorder ? Anxiety Disorders are characterized by persistent fear and anxiety that occurs too often, is too severe, is triggered too easily or lasts too long.Compared with others with anxiety disorders, persons with GAD have a better ability to maintain normal work and social relationships in spite of their distress.The “What if?” disorder
86DSM-IV Diagnostic Criteria for Generalized Anxiety Disorder A. Excessive anxiety or worry is present most days during at least a six-month period and involves a number of life events.B. The anxiety is difficult to control.C. At least three of the following:1. Restlessness or feeling on edge.2. Easy fatigability.3. Difficulty concentrating.4. Irritability.5. Muscle tension.6. Sleep disturbance.D. The focus of anxiety is not anticipatory anxiety about having a panic attack, as in panic disorder.E. The anxiety or physical symptoms cause significant distress or impairment in functioning.F. Symptoms are not caused by substance use or a medical condition, and symptoms are not related to a mood or psychotic disorder.
87Diagnostic criteria of GAD- SUMMARY Excessive Worry AboutWorkFamily and ChildrenHealthFinancesMinor MattersWorry occurs most days (for at least 6 months)Difficult to control worryAssociated with disturbed sleep, irritability, restlessness, poor concentration, fatigue, muscle tension
88Clinical Features of Generalized Anxiety Disorder A. Other features often include insomnia, irritability, trembling, muscle aches and soreness, muscle twitches, sweaty hands, dry mouth, and a heightened startle reflex. Patients may also report palpitations, dizziness, difficulty breathing, urinary frequency, dysphagia, light-headedness, abdominal pain, and diarrhea.B. Patients often complain that they “can't stop worrying,” which may revolve around valid concerns about money, jobs, marriage, health, and the safety of children.C. Chronic worry is a prominent feature of generalized anxiety disorder, unlike the intermittent terror that characterizes panic disorder.
89D. Mood disorders, substance- and stress-related disorders (headaches, dyspepsia) commonly coexist with GAD.Up to one-fourth of GAD patients develop panic disorder.Excessive worry and somatic symptoms, including autonomic hyperactivity and hypervigilance, occur most days.E. About 30-50% of patients with anxiety disorderswill also meet criteria for major depressive disorder. Drugs and alcohol may cause anxiety or may be an attempt at self-treatment.Substance abuse may be a complication of GAD.
90Differential Diagnosis of Generalized Anxiety Disorder Substance-Induced Anxiety Disorder:Substances such as caffeine, amphetamines, or cocaine can cause anxiety symptoms.Alcohol or benzodiazepine withdrawal can mimic symptoms of GAD.These disorders should be excluded by history and toxicology screen.B. Panic Disorder, Obsessive-Compulsive Disorder, Social Phobia, Hypochondriasis and Anorexia Nervosa1. Many psychiatric disorders present with marked anxiety, and the diagnosis of GAD should be made only if the anxiety is unrelated to the other disorders.2. For example, GAD should not be diagnosed in panic disorder if the patient has excessive anxiety about having a panic attack, or if an anorexic patient has anxiety about weight gain.
91C. Anxiety Disorder Due to a General Medical Condition C. Anxiety Disorder Due to a General Medical Condition. Hyperthyroidism, cardiac arrhythmias, pulmonary embolism, congestive heart failure, and hypoglycemia, may produce significant anxiety and should be ruled out as clinically indicated. D. Mood and Psychotic Disorders 1. Excessive worry and anxiety occurs in many mood and psychotic disorders. 2. If anxiety occurs only during the course of the mood or psychotic disorder, then GAD cannot be diagnosed.
92Course and prognosisCourse is chronic; symptoms may diminish as the patient get older.With time, secondary depression may develop. This is not uncommon if the condition is left untreated.
93Treatment of Generalized Anxiety Disorder The combination ofpharmacologic therapy and psychotherapyis the most successful form of treatment.
94I. Pharmacotherapy of Generalized Anxiety Disorder: ,Fluoxetine
95Antidepressants 1. SSRIs and Venlafaxine a. The onset of action of antidepressants is much slower than the benzodiazepines, but they have no addictive potential and may be more effective.An antidepressant is the agent of choice when depression coexists with anxiety.b. The side-effect profile for GAD patients is similar to that seen with depressive disorders.2. Tricyclic antidepressantsare also effective in treating GAD, but adverse effects limit their use.
97Alternative Treatments AcupunctureAromatherapyBreathing ExercisesExerciseMeditationNutrition and Diet TherapyVitaminsSelf Love
98Factors to Consider in Choosing an Medications for Anxiety Patient preferenceNature of prior response to medicationRelative efficacy and effectivenessSafety, tolerability, and anticipated side effectsCo-occurring psychiatric or general medicalconditionsPotential drug interactionsHalf-lifeCost
99B. Buspironea. Buspirone is an effective treatment for GAD. It lacks sedative effects. Tolerance to the beneficial effects of buspirone does not seem to develop. There is no physiologic dependence or withdrawal syndrome.
100C. Benzodiazepines1. Benzodiazepines can almost always relieve anxiety if given in adequate doses, and they have no delayed onset of action.2. Benzodiazepines have few side effects other than sedation. Tolerance to their sedative effects develops but not to their antianxiety properties.3. Drug dependency becomes a clinical issue if the benzodiazepine is used regularly for more than 2-3 weeks. A withdrawal syndrome occurs in 70% of patients, characterized by intense anxiety, tremulousness, dysphoria, sleep and perceptual disturbances and appetite suppression.4. Slow tapering of benzodiazepines is crucial (especially those with short half-lives).
102II. Non-Drug Approaches to Anxiety 1. Patients should stop drinking coffee and other caffeinated beverages, and avoid excessive alcohol consumption.2. Patients should get adequate sleep, with the use of medication if necessary. Moderate exercise each day may help reduce the intensity of anxiety symptoms.3. Psychotherapya. Cognitive behavioral therapy, with emphasison relaxation techniques and instruction on misinterpretation of physiologic symptoms, may improve functioning in mild cases.b. Supportive or insight oriented psychotherapy can be helpful in mild cases of anxiety.
103GOOD SLEEP HYGENE ECPSLLC.COM No sleeping during the day (If you have to no longer than 30 mins)Don’t lay in bed if not sleepy Get out of bed if unable to sleepNo milk during the eveningNo caffeineNo NicotineNo AlcoholWarm baths, no showersNo exercising before going to bed but exercise in the morningSleep at the same time every nightWake up at the same time every morningMake sure bed and pillow is comfortable, primarily for sleep with appropriate room temp (Cool about 60 degrees), noise free (some sleep better with white noise). Remember Cool, dark and quiet)Jot down all of your concerns and worriesAvoid “Over the counter” sleep aidesDon’t over sleepSet your body clock (wake up to light)Develop a bedtime routineNo TV in bedECPSLLC.COM
104Other Psychological managements: Education about nature of disorderProgressive muscle relaxationStructured problem solvingGraded exposure to difficult situationsSupport (guidance, advice, development of coping strategies)CounsellingStress management (relaxation, meditation, exercise regimens that improve stress recovery)
105Combination Maximize benefit by affecting multiple neurotransmitters Could increase adherence and lower drop-out ratesCould target side effects of first agent (eg, insomnia, fatigue, sexual dysfunction)Papakostas G. J Clin Psychiatry. 2009;70(S6):16-25.
108Social Anxiety Disorder 15 million, 6 Social Anxiety Disorder 15 million, 6.8% Equally common among men and women, typically beginning around age 13. (According to a 2007 ADAA survey, 36% of people with social anxiety disorder report experiencing symptoms for 10 or more years before seeking help.Comorbity exisitsSocial phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. People with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends.While many people with social phobia realize that their fears about being with people are excessive or unreasonable, they are unable to overcome them. Even if they manage to confront their fears and be around others, they are usually very anxious beforehand, are intensely uncomfortable throughout the encounter, and worry about how they were judged for hours afterward.Social phobia can be limited to one situation (such as talking to people, eating or drinking, or writing on a blackboard in front of others) or may be so broad (such as in generalized social phobia) that the person experiences anxiety around almost anyone other than the family.Physical symptoms that often accompany social phobia include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with social phobia feel as though all eyes are focused on them.Social phobia affects about 15 million American adults.1 Women and men are equally likely to develop the disorder,10 which usually begins in childhood or early adolescence.2 There is some evidence that genetic factors are involved.11 Social phobia is often accompanied by other anxiety disorders or depression,2,4and substance abuse may develop if people try to self-medicate their anxiety.4,5Social phobia can be successfully treated with certain kinds of psychotherapy or medications.
109Facts AFFECTS ABOUT 15 MILLION AMERICANS BEGINS IN CHILDHOOD AND EARLY ADOLESCENCEEVIDENCE THAT GENETICS ARE INVOLVEDCOMORBIDITY OFTEN EXSISTSSocial phobia affects about 15 million American adults.Women and men are equally likely to develop the disorderUsually begins in childhood or early adolescence.There is some evidence that genetic factors are involved.Social phobia is often accompanied by other anxiety disorders or depression, and substance abuse may develop if people try to self-medicate their anxiety.
110Social Phobia General characteristics Fear of being in social situations in which one will be embarrassed or humiliatedSocial phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. People with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends.While many people with social phobia realize that their fears about being with people are excessive or unreasonable, they are unable to overcome them. Even if they manage to confront their fears and be around others, they are usually very anxious beforehand, are intensely uncomfortable throughout the encounter, and worry about how they were judged for hours afterward.Social phobia can be limited to one situation (such as talking to people, eating or drinking, or writing on a blackboard in front of others) or may be so broad (such as in generalized social phobia) that the person experiences anxiety around almost anyone other than the family.Physical symptoms that often accompany social phobia include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with social phobia feel as though all eyes are focused on them.Social phobia affects about 15 million American adults.1 Women and men are equally likely to develop the disorder,10 which usually begins in childhood or early adolescence.2 There is some evidence that genetic factors are involved.11 Social phobia is often accompanied by other anxiety disorders or depression,2,4and substance abuse may develop if people try to self-medicate their anxiety.4,5Social phobia can be successfully treated with certain kinds of psychotherapy or medications.
111Social PhobiaInteraction of psychosocial and biological causal factorsSocial phobias as learned behaviorSocial fears and phobias in an evolutionary contextPreparedness and social phobia
112Social PhobiaInteraction of psychosocial and biological causal factorsGenetic and temperamental factorsPerceptions of uncontrollabilityCognitive variables
113Social phobias Shyness to the extreme Persistent, irrational fear linked to presence of othersFear of being scrutinized or negatively evaluated by others
114Social phobias Person with social phobia may avoid Speaking Eating out Going to partiesAnything in the presence of others
115CONCERN Very Under diagnosed and Therefore undertreated. Can cause severe impairment in social, occupational and academic functioningCan Lead to Avoidant Behavior
116DIAGNOSIS Fear or avoidance of social or performance situations Situations avoided, or endured with anxiety or distressPatients recognize symptoms as excessive or unreasonableVery distressing or disablingKey PointThe core feature of SAD is fear/anxiety associated with social or performance situationsBackgroundDSM-IV diagnostic criteria for SAD includeFear and/or avoidance of social situationsFeared situations are avoided, or endured with intense anxiety or distressThe fear is recognized as excessive or unreasonableThe fear or avoidance interferes with work, social, and daily activitiesReferenceDSM-IV-TR™. Washington, DC: American Psychiatric Association; 2000..
117Feared/Avoided Situations Public speaking/performingEating, drinking, writing, working while being observed by othersSocial eventsDatingMeeting new peopleBeing center of attentionUsing public bathroom
119Spectrum of Social Discomfort TransientLow interferenceLow avoidanceChronicHigh interferenceHigh avoidanceShynessKey PointThe symptoms of social phobia lie on a continuumBackgroundSome researchers feel that SAD represents the severe end of a continuum of shyness, as shown on the slide. Although the relationship between shyness and SAD has not been extensively researched, there are a number of similarities between the 2 constructsBoth are characterized by the manifestation of symptoms of physiologic arousal and fears of negative evaluation in response to various social situationsDifferentiation may be a matter of severityShyness tends to be transitory and associated with little impairment or avoidance, while SAD is chronic and is often associated with substantial impairment and avoidanceAt the far end of the continuum is avoidant personality disorder, which may be conceptualized as chronic, severe generalized SADReferenceLang AJ, Stein MB. J Clin Psychiatry. 2001;62(suppl 1):5-10.Nongeneralized SADGeneralized SADAvoidantpersonality disorder
120Treatment Goals Eliminate anxiety/phobic avoidance Eliminate functional disabilityTreat associated comorbiditiesChoose therapy that is tolerable for the long term
121Social Phobia: Treatment Antidepressants, SSRI’s and MAOI’sHigh potency benzodiazepinesLow doses of beta blockers are helpful for public speaking (if only an occasional event); this alleviates the autonomic symptomsPsychotherapy-cognitive restructuring
122Treatment Medication Management Psychotherapy Combined Medication Management and PsychotherapyPractice Practice Practice!
123Social Effects of Anxiety DepressionNot as involved with family and friends the way you used to beLowered quality of relationshipsLow energyLack of motivation to do the things you once looked forward to doingUnable to convey the person that you areFear and avoidance of situations where previous attacks occurred
125Social Phobia/Anxiety Social anxiety disorder, also known as social phobia, is an intense fear of social situations. This fear arises when the individual believes that they may be judged, scrutinized or humiliated by others.Individuals with the disorder are acutely aware of the physical signs of their anxiety and fear that others will notice, judge them, and think poorly of them.In extreme cases this intense uneasiness can progress into a full blown panic attack.
126Social Phobia/Anxiety Common anxiety provoking social situations include:public speakingtalking with people in authoritydating and developing close relationshipsmaking a phone call or answering the phoneinterviewingattending and participating in classspeaking with strangersmeeting new peopleeating, drinking, or writing in publicusing public bathroomsdrivingshopping
127Specific Disorder Facts Generalized Anxiety DisorderWomen are twice as likely to be afflicted than men.Very likely to exist along with other disorders.Obsessive Compulsive DisorderIt is equally common among men and women.One third of afflicted adults had their first symptoms in childhood.Panic DisorderOccurs with major depression in very high rates.2003 Anxiety Disorders Association of America
128Obsessive-Compulsive Disorder People with obsessive-compulsive disorder (OCD) have persistent, upsetting thoughts (obsessions) and use rituals (compulsions) to control the anxiety these thoughts produce. Most of the time, the rituals end up controlling them.For example, if people are obsessed with germs or dirt, they may develop a compulsion to wash their hands over and over again. If they develop an obsession with intruders, they may lock and relock their doors many times before going to bed. Being afraid of social embarrassment may prompt people with OCD to comb their hair compulsively in front of a mirror-sometimes they get “caught” in the mirror and can’t move away from it. Performing such rituals is not pleasurable. At best, it produces temporary relief from the anxiety created by obsessive thoughts.Other common rituals are a need to repeatedly check things, touch things (especially in a particular sequence), or count things. Some common obsessions include having frequent thoughts of violence and harming loved ones, persistently thinking about performing sexual acts the person dislikes, or having thoughts that are prohibited by religious beliefs. People with OCD may also be preoccupied with order and symmetry, have difficulty throwing things out (so they accumulate), or hoard unneeded items.Healthy people also have rituals, such as checking to see if the stove is off several times before leaving the house. The difference is that people with OCD perform their rituals even though doing so interferes with daily life and they find the repetition distressing. Although most adults with OCD recognize that what they are doing is senseless, some adults and most children may not realize that their behavior is out of the ordinary.OCD affects about 2.2 million American adults,1 and the problem can be accompanied by eating disorders,6 other anxiety disorders, or depression.2,4 It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood.2 One-third of adults with OCD develop symptoms as children, and research indicates that OCD might run in families.3The course of the disease is quite varied. Symptoms may come and go, ease over time, or get worse. If OCD becomes severe, it can keep a person from working or carrying out normal responsibilities at home. People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs to calm themselves.4,5OCD usually responds well to treatment with certain medications and/or exposure-based psychotherapy, in which people face situations that cause fear or anxiety and become less sensitive (desensitized) to them. NIMH is supporting research into new treatment approaches for people whose OCD does not respond well to the usual therapies. These approaches include combination and augmentation (add-on) treatments, as well as modern techniques such as deep brain stimulation.
129Obsessive-Compulsive Disorder (OCD) 2. 2 million, 1 Obsessive-Compulsive Disorder (OCD) 2.2 million, 1.0% Equally common among men and women. The median age of onset is 19, with 25 percent of cases occurring by age 14. One-third of affected adults first experienced symptoms in childhood.Hoarding is the compulsive purchasing, acquiring, searching, and saving of items that have little or no value.
130Obsessive-Compulsive Disorder Characterized by uncontrollable obsessions and compulsions which the sufferer usually recognizes as being excessive or unreasonable.Obsessions are recurring thoughts or impulses that are intrusive or inappropriate and cause the sufferer anxiety:Thoughts about contamination, for example, when an individual fears coming into contact with dirt, germs or "unclean" objects;Persistent doubts, for example, whether or not one has turned off the iron or stove, locked the door or turned on the answering machine;Extreme need for orderliness;Aggressive impulses or thoughts, for example, being overcome with the urge to yell 'fire' in a crowded theater
131Obsessive-Compulsive Disorder Compulsions are repetitive behaviors or rituals performed by the OCD sufferer, performance of these rituals neutralize the anxiety caused by obsessive thoughts, relief is only temporary.Cleaning. Repeatedly washing their hands, showering, or constantly cleaning their home;Checking. Individuals may check several or even hundreds of times to make sure that stoves are turned off and doors are locked;Repeating. Some repeat a name, phrase or action over and over;Slowness. Some individuals may take an excessively slow and methodical approach to daily activities, they may spend hours organizing and arranging objects;Hoarding. Hoarders are unable to throw away useless items, such as old newspapers, junk mail, even broken appliancesIn order for OCD to be diagnosed, the obsessions and/or compulsions must take up a considerable amount of the sufferers time, at least one hour every day, and interfere with normal routines .
132Obsessive-Compulsive Disorder Obsessions- repetitive unwanted ideas that the person recognizes are irrationalCompulsions- repetitive, often ritualized behavior whose behavior serves to diminish anxiety caused by obsessions
133Obsessive-Compulsive Disorder Prevalence and age of onsetCharacteristics of OCDTypes of compulsionsComorbidity with other disorders
134Common Examples of OCD Common Obsessions: Common Compulsions: Contamination fears of germs, dirt, etc.WashingImagining having harmed self or othersRepeatingImagining losing control of aggressive urgesCheckingIntrusive sexual thoughts or urgesTouchingExcessive religious or moral doubtCountingForbidden thoughtsOrdering/arrangingA need to have things "just so"Hoarding or savingA need to tell, ask, confessPraying
135OCD is not OCPDObsessive-Compulsive Disorder is different from obsessive compulsive personality disorder (OCPD)OCPD: a pervasive pattern of preoccupation with orderliness, perfectionism and control that begins by early adulthood
136Obsessive-Compulsive Disorder: Psychosocial Causal Factors Psychoanalytic viewpointBehavioral viewpointThe role of memoryAttempting to suppress obsessive thoughts
137Obsessive-Compulsive Disorder: Biological Causal Factors Genetic influencesAbnormalities in brain functionThe role of serotonin
138OCD Treatment Serotonin reuptake inhibitors Clomipramine, a serotonergic tricyclic antidepressantPsychotherapy: exposure and response prevention
139Panic DisorderPanic disorder is a real illness that can be successfully treated. It is characterized by sudden attacks of terror, usually accompanied by a pounding heart, sweatiness, weakness, faintness, or dizziness. During these attacks, people with panic disorder may flush or feel chilled; their hands may tingle or feel numb; and they may experience nausea, chest pain, or smothering sensations. Panic attacks usually produce a sense of unreality, a fear of impending doom, or a fear of losing control.A fear of one’s own unexplained physical symptoms is also a symptom of panic disorder. People having panic attacks sometimes believe they are having heart attacks, losing their minds, or on the verge of death. They can’t predict when or where an attack will occur, and between episodes many worry intensely and dread the next attack.Panic attacks can occur at any time, even during sleep. An attack usually peaks within 10 minutes, but some symptoms may last much longer.Panic disorder affects about 6 million American adults1 and is twice as common in women as men.2 Panic attacks often begin in late adolescence or early adulthood,2 but not everyone who experiences panic attacks will develop panic disorder. Many people have just one attack and never have another. The tendency to develop panic attacks appears to be inherited.3People who have full-blown, repeated panic attacks can become very disabled by their condition and should seek treatment before they start to avoid places or situations where panic attacks have occurred. For example, if a panic attack happened in an elevator, someone with panic disorder may develop a fear of elevators that could affect the choice of a job or an apartment, and restrict where that person can seek medical attention or enjoy entertainment.Some people’s lives become so restricted that they avoid normal activities, such as grocery shopping or driving. About one-third become housebound or are able to confront a feared situation only when accompanied by a spouse or other trusted person. 2 When the condition progresses this far, it is called agoraphobia, or fear of open spaces.Early treatment can often prevent agoraphobia, but people with panic disorder may sometimes go from doctor to doctor for years and visit the emergency room repeatedly before someone correctly diagnoses their condition. This is unfortunate, because panic disorder is one of the most treatable of all the anxiety disorders, responding in most cases to certain kinds of medication or certain kinds of cognitive psychotherapy, which help change thinking patterns that lead to fear and anxiety.Panic disorder is often accompanied by other serious problems, such as depression, drug abuse, or alcoholism.4,5 These conditions need to be treated separately. Symptoms of depression include feelings of sadness or hopelessness, changes in appetite or sleep patterns, low energy, and difficulty concentrating. Most people with depression can be effectively treated with antidepressant medications, certain types of psychotherapy, or a combination of the two.
140Panic Disorder 6 million, 2 Panic Disorder 6 million, 2.7% Women are twice as likely to be affected as men. Very high comorbidity rate with major depression. Panic Disorder 6 million, 2.7% Women are twice as likely to be affected as men. Very high comorbidity rate with major depression.
141Epidemiology of Panic Disorder Panic disorder has a lifetime prevalence of %2:1 female/male ratio? Of true gender difference versus men tend to self-medicate with alcohol and are less likely to seek treatment.Onset is late teens through third decade of life.
142Panic Disorder With and Without Agoraphobia Panic versus anxietyAgoraphobiaAgoraphobia without panic
143Panic Disorder Prevalence and age of onset Comorbidity with other disordersBiological causal factorsThe role of Norepinephrine and Serotonin
144Panic Attack Discrete episodes of intense anxiety Sudden onset Peak within 10 minutesAssociated with at least 4 of the 13 other somatic or cognitive symptoms of autonomic arousal
145Panic Attack SymptomsCardiac: palpitations, tachycardia, chest pain or discomfortPulmonary: shortness of breath, a feeling of chokingGI: nausea or abdominal distressNeurological: trembling and shaking, dizziness, lightheadedness or faintness, paresthesias
146Panic Attack SymptomsAutonomic Arousal: sweating, chills or hot flashesPsychological:Derealization (feeling of unreality)Depersonalization (feeling detached from oneself)Fear of losing control or going crazyFear of dying
147Panic DisorderA syndrome characterized by recurrent unexpected panic attacks (at least 4 in one month)Attacks are followed for at least one month with:Concern about having another attackWorry about implications of the attackBehavior changes because of the attacks
148Agoraphobia Complication of panic disorder Means “ fear of the market” Anxiety or avoidance of places or situations from which escape might be difficult, embarrassing, or help may be unavailable.Restricts daily activities
149Agoraphobia Agoraphobia The patient may avoid crowds, restaurants, highways, bridges, movie theaters etc.In its most severe form, the patient may become dependent on companions to face situations outside the home.Some individuals become homebound.
150Differential Diagnosis of Panic Disorder Not due to another anxiety disorderNot due to effects of a general medical conditionCardiovascular diseasePulmonary diseaseNeurological diseaseEndocrine diseaseDrug intoxication or withdrawalOther (lupus, infections, heavy metal poisoning, uremia, temporal arteritis)
151Panic Disorder: Costs200,000 normal coronary angiograms/yr in the U.S. at a cost of 600 million dollars: 1/3 of these patients have panic disorder½ of patients referred for non-invasive testing for atypical chest pain and who have normal tests have panic disorder1/3 patients undergoing work-up for vestibular disorder with c/o dizziness have panic disorder
152Panic Disorder: Comorbidity Panic disorder patients have an increased personal and family history of other anxiety, mood and substance abuse disorders.Major depression is a co-morbid diagnosis in 1/3 of cases presenting for treatmentUntreated patients have high risk of suicide
153Panic Disorder: Treatment About 80% of patients will respond to treatmentAntidepressant medications are effectiveSerotonin reuptake inhibitors (SSRI) are first line therapyTricyclic antidepressants (TCA) and monoamine oxidase inhibitors (MAOI’s) are also used.
154Panic Disorder: Treatment Sedative-Hypnotics: benzodiazepines are ideally used in the short term before an antidepressant has had time to workCognitive Behavioral Therapy (CBT): helps patients overcome a learned pattern of catastrophically misinterpreting the physical symptoms associated with panic attacks.
155Panic DisorderThe abrupt onset of an episode of intense fear or discomfort, which peaks in approximately 10 minutes, and includes at least four of the following symptoms:A feeling of imminent danger or doomThe need to escapePalpitationsSweatingTremblingShortness of breath or a smotheringfeelingA feeling of chokingChest pain or discomfortNausea or abdominal discomfortDizziness or lightheadednessA sense of things being unreal,depersonalizationA fear of losing control or "going crazy"A fear of dyingTingling sensationsChills or hot flushes
156Panic Disorder There are three types of Panic Attacks: 1. Unexpected - the attack "comes out of the blue" without warning and for no discernable reason.2. Situational - situations in which an individual always has an attack, for example, upon entering a tunnel.3. Situationally Predisposed - situations in which an individual is likely to have a Panic Attack, but does not always have one. An example of this would be an individual who sometimes has attacks while driving.
160Panic Disorder: The Cognitive Theory of Panic Perceived control and safetyAnxiety sensitivity as a vulnerability factor for panicSafety behaviors and the persistence of panicCognitive biases and the maintenance of panic
161Treating Panic Disorder and Agoraphobia MedicationsBehavioral and cognitive-behavioral treatments
162Post-traumatic stress disorder (PTSD) Post-traumatic stress disorder (PTSD) develops after a terrifying ordeal that involved physical harm or the threat of physical harm. The person who develops PTSD may have been the one who was harmed, the harm may have happened to a loved one, or the person may have witnessed a harmful event that happened to loved ones or strangers.PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes.People with PTSD may startle easily, become emotionally numb (especially in relation to people with whom they used to be close), lose interest in things they used to enjoy, have trouble feeling affectionate, be irritable, become more aggressive, or even become violent. They avoid situations that remind them of the original incident, and anniversaries of the incident are often very difficult. PTSD symptoms seem to be worse if the event that triggered them was deliberately initiated by another person, as in a mugging or a kidnapping.Most people with PTSD repeatedly relive the trauma in their thoughts during the day and in nightmares when they sleep. These are called flashbacks. Flashbacks may consist of images, sounds, smells, or feelings, and are often triggered by ordinary occurrences, such as a door slamming or a car backfiring on the street. A person having a flashback may lose touch with reality and believe that the traumatic incident is happening all over again.Not every traumatized person develops full-blown or even minor PTSD. Symptoms usually begin within 3 months of the incident but occasionally emerge years afterward. They must last more than a month to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic.PTSD affects about 7.7 million American adults,1but it can occur at any age, including childhood.7 Women are more likely to develop PTSD than men,8 and there is some evidence that susceptibility to the disorder may run in families.9 PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders.4Certain kinds of medication and certain kinds of psychotherapy usually treat the symptoms of PTSD very effectively.
163Women are more likely to be afflicted than men. Posttraumatic Stress Disorder (PTSD) 7.7 million, 3.5% Women are more likely to be affected than men. Rape is the most likely trigger of PTSD: 65% of men and 45.9% of women who are raped will develop the disorder. Childhood sexual abuse is a strong predictor of lifetime likelihood for developing PTSD. Women are more likely to be afflicted than men.Rape is the most likely trigger of PTSD, 65% of men and 45.9% of women who are raped will develop the disorder.Childhood sexual abuse is a strong predictor of lifetime likelihood for developing PTSD.
164Post Traumatic Stress Disorder (PTSD) Patients with PTSD have experienced a trauma and develop disabling symptoms in response to the event.Symptoms usually begin within 3 months of the traumaSyndrome can occur at any age
165Definition of TraumaThe person experienced, witnessed or learned of an event that involved actual or threatened death, serious injury, or threat of harm to self or othersThe person’s response involved intense fear, helplessness or horror
166Diagnosis of PTSDSymptoms must be > one month duration and include:Re-experiencing symptomsAvoidance symptomsEmotional numbingHyperarousal symptoms
167Re-experiencing Symptoms There are recurrent, intrusive thoughts of the event (can’t not think about it)Dreams (nightmares) about the eventActing or feeling the event is recurring, or sense of living the event (flashbacks)Psychological or Physiological Distress upon exposure to reminders or cues of the event.
168Avoidance/Numbing Symptoms Avoid thoughts, feelings, places or people that arouse memories of the eventBeing unable to recall important parts of the eventDecrease interest in activitiesFeeling detached or estranged from othersDecreased range of affectSense of foreshortened future
169Hyperarousal Symptoms Patient experiences at least two of the following:Insomnia (falling or staying asleep)Irritability or outbursts of angerDecreased concentrationHypervigilanceIncreased/exaggerated startle response
170Post-Traumatic Stress Disorder Critical ComponentSymptoms occurs AFTER a traumatic stressor
171Types of Traumas Natural Human induces earthquakes floods fires war crimes of violence
172Types of Trauma Being diagnosed with a life threatening illness Sudden unexpected death of family/friendWitnessing violence (including domestic violence)Learning one’s child has life threatening illnessSexual abuseRapePhysical abuseSevere motor vehicle accidentsRobbery/muggingTerrorist attackCombat veteranNatural disasters
173Co-Morbid Diagnoses Alcoholism Depression Generalized Anxiety 75% for Vietnam Veterans with PTSDDepression77% of firefighters with PTSD also have depressionGeneralized AnxietyPanic Attacks
177Diagnoses Acute Stress Disorder PTSD new to DSM-IV (1994) symptoms 2 days to 4 weeks following traumatic eventPTSDnew to DSM-III (1980)symptoms beyond 4 weeksdelayed onset
178Post-Traumatic Stress Disorder Exposure to traumas such as a serious accident, a natural disaster, or criminal assault can result in PTSD. When the aftermath of a traumatic experience interferes with normal functioning, the person may be suffering from PTSD.Symptoms of PTSD are:Reexperiencing the event, which can take the form of intrusive thoughts and recollections, or recurrent dreams;Avoidance behavior in which the sufferer avoids activities, situations, people,and/or conversations which he/she associates with the trauma;A general numbness and loss of interest in surroundings;Hypersensitivity, including: inability to sleep, anxious feelings, overactive startle response, hypervigilance, irritability and outbursts of anger.
180Who Is Vulnerable? All ages Both genders Across Cultures and ethnic groups
181PTSD Treatment Psychotherapies Exposure-based cognitive behavioral therapyPsychotherapy aimed at survivor anger, guilt and helplessness (victimization)Pharmacological treatment targets the reduction of prominent symptomsSSRI’s are first line therapyAtypical antipsychotics are being increasingly used
182Specific PhobiaA specific phobia is an intense, irrational fear of something that poses little or no actual danger. Some of the more common specific phobias are centered around closed-in places, heights, escalators, tunnels, highway driving, water, flying, dogs, and injuries involving blood. Such phobias aren’t just extreme fear; they are irrational fear of a particular thing. You may be able to ski the world’s tallest mountains with ease but be unable to go above the 5th floor of an office building. While adults with phobias realize that these fears are irrational, they often find that facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety.Specific phobias affect an estimated 19.2 million adult Americans1 and are twice as common in women as men.10 They usually appear in childhood or adolescence and tend to persist into adulthood.12 The causes of specific phobias are not well understood, but there is some evidence that the tendency to develop them may run in families.11If the feared situation or feared object is easy to avoid, people with specific phobias may not seek help; but if avoidance interferes with their careers or their personal lives, it can become disabling and treatment is usually pursued.Specific phobias respond very well to carefully targeted psychotherapy.
183Specific Phobias 19 million, 8 Specific Phobias 19 million, 8.7% Women are twice as likely to be affected as men.Related Illnesses Many people with an anxiety disorder also have a co-occurring disorder or physical illness, which can make their symptoms worse and recovery more difficult. It’s essential to be treated for both disorders.
184Epidemiology of Specific Phobias Lifetime prevalence is 10% of the populationAge of onset varies with subtypeChildhood onset for phobias of animals, natural environments blood and injectionsBimodal distribution (childhood and mid-twenties for situational phobias
187Specific Phobias Psychosocial causal factors Genetic and temperamental causal factorsPreparedness and the nonrandom distribution of fears and phobiasTreating specific phobias
188Specific PhobiaMarked and persistent fear that is excessive and unreasonable of a specific object or situationExposure to the phobic stimulus will provoke an anxiety response
189Phobia Subtypes Animals or insects Natural environment– storms, water, heightsBlood, injury, injection, medical procedureSituational flying, driving, enclosed placesHaving a phobia of a specific subtype increased the chances of having another phobia within that subtype
190Specific Phobia Treatments Flooding-exposing the person to the feared stimulusExposure therapy works to desensitize the patient using a series of gradual, self-paced exposures to the phobic stimulus; uses relaxation, hypnosis, breathing control and other cognitive approachesBenzodiazepines or Beta blockers are useful acutely
191Specific Phobia: Treatment Example: Fear of FlyingVisualize a plane. Look at a plane in the sky. Drive by an airport. Go to a museum that has planes. Same museum—visualize going inside. Go inside. Go to airport and watch planes take off and land. Visualize yourself on a plane flying. Omnimax theater experience. The real thing.
192Generalized anxiety disorder (GAD) is a pattern of frequent, constant worry and anxiety over many different activities and events.CausesAnyone can develop this disorder, even kids. Most people with the disorder report that they have been anxious for as long as they can remember. GAD occurs somewhat more often in women than in men.Generalized anxiety disorder (GAD) is a common condition. Genes may play a role. Stress may also contribute to the development of GAD.SymptomsThe main symptom is the almost constant presence of worry or tension, even when there is little or no cause. Worries seem to float from one problem to another, such as family or relationship problems, work issues, money, health, and other problems.Other symptoms include:Even when aware that their worries or fears are stronger than needed, a person with GAD still has difficulty controlling them.Difficulty concentratingFatigueIrritabilityRestlessness, and often becoming startled very easilyProblems falling or staying asleep, and sleep that is often restless and unsatisfyingAlong with the worries and anxieties, a number of physical symptoms may also be present, including muscle tension (shakiness, headaches) and stomach problems, such as nausea or diarrhea.Exams and TestsThe health care provider will perform a physical and mental health exam. Tests will be done to rule out other conditions and behaviors that cause similar symptoms.The goal of treatment is to help you function well during day-to-day life. A combination of medicine and cognitive-behavioral therapy (CBT) works best.TreatmentMedications are an important part of treatment. Once you start them, do not suddenly stop without talking with your health care provider. Medications that may be used include:Selective serotonin reuptake inhibitors (SSRIs) are usually the first choice in medications. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are another choice.Other antidepressants and some antiseizure drugs may be used for severe cases.Benzodiazepines such as alprazolam (Xanax), clonazepam (Klonopin), and lorazepam (Ativan) may be used if antidepressants don't help enough with symptoms. Long-term dependence on these drugs is a concern.A medication called buspirone may also be used.Cognitive-behavioral therapy helps you understand your behaviors and how to gain control of them. You will have 10 to 20 visits over a number of weeks. During therapy you will learn how to:Understand and gain control of your distorted views of life stressors, such as other people's behavior or life events.Manage stress and relax when symptoms occur.Recognize and replace panic-causing thoughts, decreasing the sense of helplessness.Avoid thinking that minor worries will develop into very bad problems.Avoiding caffeine, illicit drugs, and even some cold medicines may also help reduce symptoms.A healthy lifestyle that includes exercise, enough rest, and good nutrition can help reduce the impact of anxiety.A support group allows you to talk to people who share common experiences and problems. This may help ease the stress related to a medical condition.Support GroupsSupport groups are not a substitute for effective treatment, but can be a helpful addition to it.Outlook (Prognosis)How well a person does depends on the severity of the condition. GAD may continue and be difficult to treat. However, most patients get better with a combination of medication and behavioral therapy.Depression and substance abuse may occur with an anxiety disorder.Possible ComplicationsWhen to Contact a Medical ProfessionalCall your health care provider if you constantly worry and feel anxious and it interferes with your daily activities.Alternative NamesGAD; Anxiety disorder
193Treatment of Anxiety Disorders MedicationsSpecific types of psychotherapyComorbiditiesHistoryIn general, anxiety disorders are treated with medication, specific types of psychotherapy, or both.14 Treatment choices depend on the problem and the person’s preference. Before treatment begins, a doctor must conduct a careful diagnostic evaluation to determine whether a person’s symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the type of disorder or the combination of disorders that are present must be identified, as well as any coexisting conditions, such as depression or substance abuse. Sometimes alcoholism, depression, or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control.Treatment of Anxiety DisordersPeople with anxiety disorders who have already received treatment should tell their current doctor about that treatment in detail. If they received medication, they should tell their doctor what medication was used, what the dosage was at the beginning of treatment, whether the dosage was increased or decreased while they were under treatment, what side effects occurred, and whether the treatment helped them become less anxious. If they received psychotherapy, they should describe the type of therapy, how often they attended sessions, and whether the therapy was useful.Often people believe that they have “failed” at treatment or that the treatment didn’t work for them when, in fact, it was not given for an adequate length of time or was administered incorrectly. Sometimes people must try several different treatments or combinations of treatment before they find the one that works for them.Medication will not cure anxiety disorders, but it can keep them under control while the person receives psychotherapy. Medication must be prescribed by physicians, usually psychiatrists, who can either offer psychotherapy themselves or work as a team with psychologists, social workers, or counselors who provide psychotherapy. The principal medications used for anxiety disorders are antidepressants, anti-anxiety drugs, and beta-blockers to control some of the physical symptoms. With proper treatment, many people with anxiety disorders can lead normal, fulfilling lives.MedicationAntidepressantsAntidepressants were developed to treat depression but are also effective for anxiety disorders. Although these medications begin to alter brain chemistry after the very first dose, their full effect requires a series of changes to occur; it is usually about 4 to 6 weeks before symptoms start to fade. It is important to continue taking these medications long enough to let them work.Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®) are some of the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. Venlafaxine (Effexor®), a drug closely related to the SSRIs, is used to treat GAD. These medications are started at low doses and gradually increased until they have a beneficial effect.Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.SSRIsSSRIs have fewer side effects than older antidepressants, but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time. Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another SSRI.Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD. They are also started at low doses that are gradually increased. They sometimes cause dizziness, drowsiness, dry mouth, and weight gain, which can usually be corrected by changing the dosage or switching to another tricyclic medication.TricyclicsMAOIsTricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil®), which is the only tricyclic antidepressant useful for treating OCD.Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. The MAOIs most commonly prescribed for anxiety disorders are phenelzine (Nardil®), followed by tranylcypromine (Parnate®), and isocarboxazid (Marplan®), which are useful in treating panic disorder and social phobia. People who take MAOIs cannot eat a variety of foods and beverages (including cheese and red wine) that contain tyramine or take certain medications, including some types of birth control pills, pain relievers (such as Advil®, Motrin®, or Tylenol®), cold and allergy medications, and herbal supplements; these substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help lessen these risks. MAOIs can also react with SSRIs to produce a serious condition called “serotonin syndrome,” which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions.High-potency benzodiazepines combat anxiety and have few side effects other than drowsiness. Because people can get used to them and may need higher and higher doses to get the same effect, benzodiazepines are generally prescribed for short periods of time, especially for people who have abused drugs or alcohol and who become dependent on medication easily. One exception to this rule is people with panic disorder, who can take benzodiazepines for up to a year without harm.Anti-Anxiety DrugsSome people experience withdrawal symptoms if they stop taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is stopped. These potential problems have led some physicians to shy away from using these drugs or to use them in inadequate doses.Clonazepam (Klonopin®) is used for social phobia and GAD, lorazepam (Ativan®) is helpful for panic disorder, and alprazolam (Xanax®) is useful for both panic disorder and GAD.Buspirone (Buspar®), an azapirone, is a newer anti-anxiety medication used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an anti-anxiety effect.Beta-blockers, such as propranolol (Inderal®), which is used to treat heart conditions, can prevent the physical symptoms that accompany certain anxiety disorders, particularly social phobia. When a feared situation can be predicted (such as giving a speech), a doctor may prescribe a beta-blocker to keep physical symptoms of anxiety under control.Beta-BlockersBefore taking medication for an anxiety disorder:Taking MedicationsAsk your doctor when and how the medication should be stopped. Some drugs can’t be stopped abruptly but must be tapered off slowly under a doctor’s supervision.Tell your doctor about any alternative therapies or over-the-counter medications you are using.Ask your doctor to tell you about the effects and side effects of the drug.PsychotherapyBe aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.Work with your doctor to determine which medication is right for you and what dosage is best.Cognitive-Behavioral TherapyPsychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how to deal with its symptoms.Cognitive-behavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive part helps people change the thinking patterns that support their fears, and the behavioral part helps people change the way they react to anxiety-provoking situations.For example, CBT can help people with panic disorder learn that their panic attacks are not really heart attacks and help people with social phobia learn how to overcome the belief that others are always watching and judging them. When people are ready to confront their fears, they are shown how to use exposure techniques to desensitize themselves to situations that trigger their anxieties.People with OCD who fear dirt and germs are encouraged to get their hands dirty and wait increasing amounts of time before washing them. The therapist helps the person cope with the anxiety that waiting produces; after the exercise has been repeated a number of times, the anxiety diminishes. People with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee and to make small social blunders and observe how people respond to them. Since the response is usually far less harsh than the person fears, these anxieties are lessened. People with PTSD may be supported through recalling their traumatic event in a safe situation, which helps reduce the fear it produces. CBT therapists also teach deep breathing and other types of exercises to relieve anxiety and encourage relaxation.Exposure-based behavioral therapy has been used for many years to treat specific phobias. The person gradually encounters the object or situation that is feared, perhaps at first only through pictures or tapes, then later face-to-face. Often the therapist will accompany the person to a feared situation to provide support and guidance.CBT is undertaken when people decide they are ready for it and with their permission and cooperation. To be effective, the therapy must be directed at the person’s specific anxieties and must be tailored to his or her needs. There are no side effects other than the discomfort of temporarily increased anxiety.CBT or behavioral therapy often lasts about 12 weeks. It may be conducted individually or with a group of people who have similar problems. Group therapy is particularly effective for social phobia. Often “homework” is assigned for participants to complete between sessions. There is some evidence that the benefits of CBT last longer than those of medication for people with panic disorder, and the same may be true for OCD, PTSD, and social phobia. If a disorder recurs at a later date, the same therapy can be used to treat it successfully a second time.Medication can be combined with psychotherapy for specific anxiety disorders, and this is the best treatment approach for many people.
194How to Get Help for Anxiety Disorders See our MDSee A ClincianSupport GroupsCBTCut Caffiene, Alcohol, Drugs, Cold MedicaationsInternetFamily Support SystemsHow to Get Help for Anxiety DisordersIf you think you have an anxiety disorder, the first person you should see is your family doctor. A physician can determine whether the symptoms that alarm you are due to an anxiety disorder, another medical condition, or both.If an anxiety disorder is diagnosed, the next step is usually seeing a mental health professional. The practitioners who are most helpful with anxiety disorders are those who have training in cognitive-behavioral therapy and/or behavioral therapy, and who are open to using medication if it is needed.You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere. Once you find a mental health professional with whom you are comfortable, the two of you should work as a team and make a plan to treat your anxiety disorder together.Remember that once you start on medication, it is important not to stop taking it abruptly. Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you stop taking it. If you are having trouble with side effects, it’s possible that they can be eliminated by adjusting how much medication you take and when you take it.Most insurance plans, including health maintenance organizations (HMOs), will cover treatment for anxiety disorders. Check with your insurance company and find out. If you don’t have insurance, the Health and Human Services division of your county government may offer mental health care at a public mental health center that charges people according to how much they are able to pay. If you are on public assistance, you may be able to get care through your state Medicaid plan.Ways to Make Treatment More EffectiveMany people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common. Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental health professional.Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided. Check with your physician or pharmacist before taking any additional medications.The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one’s symptoms. Family members should not trivialize the disorder or demand improvement without treatment. If your family is doing either of these things, you may want to show them this booklet so they can become educated allies and help you succeed in therapy.
195Physical and psychological stress Diet Brain imaging technology Role of Research in Improving the Understanding and Treatment of Anxiety DisordersRole of GenesEnviormental factorsPhysical and psychological stressDietBrain imaging technologyNeurochemical techniques – Amygdala and HippocampusDeveloping Medications and behavioral therapiesNIMH supports research into the causes, diagnosis, prevention, and treatment of anxiety disorders and other mental illnesses. Scientists are looking at what role genes play in the development of these disorders and are also investigating the effects of environmental factors such as pollution, physical and psychological stress, and diet. In addition, studies are being conducted on the “natural history” (what course the illness takes without treatment) of a variety of individual anxiety disorders, combinations of anxiety disorders, and anxiety disorders that are accompanied by other mental illnesses such as depression.Scientists currently think that, like heart disease and type 1 diabetes, mental illnesses are complex and probably result from a combination of genetic, environmental, psychological, and developmental factors. For instance, although NIMH-sponsored studies of twins and families suggest that genetics play a role in the development of some anxiety disorders, problems such as PTSD are triggered by trauma. Genetic studies may help explain why some people exposed to trauma develop PTSD and others do not.Several parts of the brain are key actors in the production of fear and anxiety. 15 Using brain imaging technology and neurochemical techniques, scientists have discovered that the amygdala and the hippocampus play significant roles in most anxiety disorders.The amygdala is an almond-shaped structure deep in the brain that is believed to be a communications hub between the parts of the brain that process incoming sensory signals and the parts that interpret these signals. It can alert the rest of the brain that a threat is present and trigger a fear or anxiety response. It appears that emotional memories are stored in the central part of the amygdala and may play a role in anxiety disorders involving very distinct fears, such as fears of dogs, spiders, or flying.The hippocampus is the part of the brain that encodes threatening events into memories. Studies have shown that the hippocampus appears to be smaller in some people who were victims of child abuse or who served in military combat.16, 17 Research will determine what causes this reduction in size and what role it plays in the flashbacks, deficits in explicit memory, and fragmented memories of the traumatic event that are common in PTSD.By learning more about how the brain creates fear and anxiety, scientists may be able to devise better treatments for anxiety disorders. For example, if specific neurotransmitters are found to play an important role in fear, drugs may be developed that will block them and decrease fear responses; if enough is learned about how the brain generates new cells throughout the lifecycle, it may be possible to stimulate the growth of new neurons in the hippocampus in people with PTSD.18Current research at NIMH on anxiety disorders includes studies that address how well medication and behavioral therapies work in the treatment of OCD, and the safety and effectiveness of medications for children and adolescents who have a combination of anxiety disorders and attention deficit hyperactivity disorder.
196PSYCHIATRIC MANAGEMENT Establish and maintain a therapeutic allianceComplete the psychiatric assessmentEvaluate the safety of the patientEstablish the appropriate setting for treatmentEvaluate the functional impairment and quality of lifeCoordinate the patient’s care with the other cliniciansMonitor the patient’s psychiatric statusIntegrate measurements into psychiatric managementEnhance treatment adherenceProvide education to the patient and the familyECPSLLC.COM
197Monitor psychiatric status and safety. Monitor the patient for changes in destructive impulses to self andothers.Be vigilant in monitoring changes in psychiatric status, includingmajor depressive symptoms and symptoms of potential comorbidconditions.Consider diagnostic reevaluation if symptoms change significantly orif new symptoms emerge.
198PE • History of the present illness and current symptoms • Psychiatric history, including symptoms of mania• Treatment history with current treatments and responses to previoustreatments• General medical history• History of substance use disorders• Personal history (e.g., psychological development, response tolife transitions, major life events)• Social, occupational, and family histories• Review of the patient’s medications• Review of systems• Mental status examination• Physical examination• Diagnostic tests as indicated
199Items to Monitor Throughout Treatment Symptomatic status, including functional status, and quality of lifeDegree of danger to self and othersSigns of “switch” to maniaOther mental disorders, including alcohol and other substance use disordersGeneral medical conditionsResponse to treatmentSide effects of treatmentAdherence to treatment plan
200Selection of Treatment: Make Your First Choice Count! Aim for remission of symptomsChoose agents with proven efficacyUse optimal doseMinimize dropoutConsider efficacy/tolerability/safety profileMaximize adherencePrevent relapse/recurrenceAchieve remission of symptoms!Adequate durationKey PointAs clinicians, it is imperative that we do everything in our power to ensure remission of symptoms is achievedBackgroundTreatment should be selected to quickly and appropriately aggressively treat patients to remission with the first choice of therapyMany patients treated with antidepressant medications are not given adequate doses for a long enough period. Physicians should ensure that adequate doses of medication are administered and that patients are treated for an adequate durationPoor patient adherence is a common problem contributing to nonresponse, partial response, and relapse/recurrence. Education and information should be provided to the patient and family to combat this problem. Obstacles to adherence should be prospectively identified and eliminated to the extent possible. Patients should be educated that remission, and not just an improvement in symptoms, is the goal of treatmentAchievement of remission has been shown to be a modifiable factor that can influence long-term prognosis; thus, the ideal approach to chronic, recurrent disease is prevention via earlier and effective treatmentReferenceAmerican Psychiatric Association. Practice Guideline for the Treatment of Patients With Major Depression. 2nd ed. Washington, DC; 2000.American Psychiatric Association. Am J Psychiatry. 2000;157(4 suppl):1-45.
201Summary and Take-Home Messages Patients can have a high rate of nonadherence with SSRIs due to adverse eventsFirst few weeks of therapy are criticalMonitor medication compliance during this time periodChoose a medication that is effective and generally well tolerated across indicationsWe hope that this presentation will support you in being even more successful in your important efforts to help persons who suffer from depression and associated anxiety symptoms.
202Onset of Adverse Events and Efficacy Therapeutic EffectAdverse EventsAntidepressantTherapyTimeAdapted from American Psychiatric Association. Am J Psychiatry. 2000;157(Suppl 4):1-45.Bull SA, et al. Ann Pharmacother. 2002;36:
203Side effects of antidepressant medications 1. Selective serotonin reuptake inhibitorsa. Gastrointestinalb. Activation/insomniac. Sexual side effectsd. Neurologicale. Fallsf. Effects on weightg. Serotonin syndromeh. Drug interactionsi. Discontinuation syndrome
208Psychotherapy . Specific psychotherapies Implementation Cognitive and behavioral therapiesInterpersonal psychotherapyPsychodynamic psychotherapyProblem-solving therapyMarital therapy and family therapyGroup therapyImplementationCombining psychotherapy and medication
209Complementary and alternative treatments a. St. John’s wortb. S-adenosyl methioninec. Omega-3 fatty acidsd. Folatee. N-Acetyl Cysteinef. AcupunctureG. Yoga
211Potential Reasons for Treatment Nonresponse Inaccurate diagnosisUnaddressed co-occurring medical or psychiatricdisorders, including substance use disordersInappropriate selection of therapeutic modalitiesInadequate dose of medication or frequency ofpsychotherapyPharmacokinetic/pharmacodynamic factors affectingmedication actionInadequate duration of treatmentNonadherence to treatmentPersistent or poorly tolerated side effectsComplicating psychosocial and psychological factorsInadequately trained therapist or poor “fit” betweenpatient and therapist
212Treatment Should Be Discontinued Gradually Most antidepressants need to be taperedGradually taper dose (1 dosage level per week)1Longer-term treatment may require slower taper1,2Discontinuation symptoms are possible soon after stopping drugs with short half-lives1,2Counsel patients on possible discontinuation symptoms, including:Agitation, anorexia, diarrhea, dizziness, dry mouth, insomnia, nausea, nervousness, sensory disturbances, somnolence, and sweating1Key PointIt is important to discontinue treatment by tapering the dose to minimize the potential for adverse eventsBackgroundMost antidepressants need to be tapered when discontinued. The drug should be tapered over a several-week period, which will allow any symptoms or recurrence to emerge and treatment to be resumed, if needed, while the patient is still partially treated1,2As a rule of thumb, the dose should be tapered by approximately 1 dosage level per week.1 If treatment has been long term, or if the drug has a short half-life, a slower taper may be required.1,2 Tapering the drug may also minimize discontinuation symptoms, which can occur soon after stopping drugs with short half-lives1,2Patients should be counseled on possible discontinuation symptoms1References1. EFFEXOR XR® (venlafaxine HCl) Prescribing Information.2. American Psychiatric Association. Am J Psychiatry. 2000;157(suppl 4):1-45.1. EFFEXOR XR® (venlafaxine HCl) Prescribing Information.2. American Psychiatric Association. Am J Psychiatry. 2000;157(4 suppl):1-45.
213Considerations in the Decision to Use Maintenance Treatment Risk of recurrenceSeverity of episodesSide effects experiencedwith continuous treatmentPatient preferencesNumber of prior episodes; presenceof comorbid conditions; residualsymptoms between episodesSuicidality; psychotic features;severe functional impairments
214SPECIFIC CLINICAL FEATURES INFLUENCING THE TREATMENT PLAN Psychiatric FactorsDemographic and Psychosocial VariablesCo-occurring psychiatric disordersTreatment Implications of Co-occurring General Medical Conditions
215Co-occurring psychiatric disorders Dysthymic disorderAffective disordersDementiaSubstance use disordersPersonality disordersEating disorders
216Treatment Implications of Co-occurring General Medical Conditions 1. Hypertension2. Cardiac disease3. Stroke4. Parkinson’s disease5. Epilepsy6. Obesity7. Diabetes8. Sleep apnea9. Human immunodeficiency virus and hepatitis C infections10. Pain syndromes11. Obstructive uropathy12. Glaucoma
217Unmet Needs in Anxiety Underdiagnosed therefore untreated Faster improvementFewer side effects and better tolerabilityGreater efficacyLong term efficacyDespite all the advances made in the treatment of depression, there remains important unmet needs.We need therapeutic agents that help address these unmet needs.Source: Datamonitor, Stakeholder Insight: MDD, Q1.2; Adult population figures from and MDD prevalence rates applied.217
218National Survey Dispels Notion that Social Phobia is the Same as Shyness social phobia is not simply shyness that has been inappropriately medicalizedsocial phobia affects a minority of youth and only a fraction of those who consider themselves to be shythe greater disability that youth with social phobia experience and the greater likelihood that they will have another disorderthey are not more likely to be getting treatment compared to their peers, questioning the notion that these youth are being unnecessarily medicated.Critics of the diagnosis have suggested that psychiatrists and pharmaceutical companies publicize social phobia, also known as social anxiety disorder, in order to increase sales of psychotropic medications, especially among youth. In addition, some have debated whether social phobia is just a “medicalization” of a normal variation in human temperament.The authors found that while about half of youth identified themselves as shy, only 12 percent of shy youth also met criteria for social phobia in their lifetime. Moreover, among youth who did not identify themselves as shy, about 5 percent met criteria for social phobia, suggesting that social phobia and shyness are not necessarily directly related. Rather, the presence of social phobia may be independent of shyness in some instances.Science Update • October 17, 2011National Survey Dispels Notion that Social Phobia is the Same as ShynessSource: iStockNormal human shyness is not being confused with the psychiatric anxiety disorder known as social phobia, according to an NIMH survey comparing the prevalence rates of the two among U.S. youth. The study was published online ahead of print October 17, 2011, in the journal Pediatrics.BackgroundSocial phobia is a disabling anxiety disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social or performance situations. Critics of the diagnosis have suggested that psychiatrists and pharmaceutical companies publicize social phobia, also known as social anxiety disorder, in order to increase sales of psychotropic medications, especially among youth. In addition, some have debated whether social phobia is just a “medicalization” of a normal variation in human temperament.In response, Marcy Burstein, Ph.D., and colleagues at NIMH examined the rate of normal shyness among youth and its overlap with social phobia using data from the National Comorbidity Survey-Adolescent Supplement (NCS-A), a nationally representative, face-to-face survey of more than 10,000 teens aged sponsored by NIMH. Social phobia was assessed using standard diagnostic criteria set by the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV). To assess shyness, teens were asked to rate how shy they felt around peers that they did not know well.Results of the StudyIn addition, those with social phobia were consistently more likely to also have another psychiatric disorder in their lifetime, like depression or a behavior or drug use disorder, compared to those who identified themselves as shy. Those with social phobia also showed higher levels of impairment in work or school, or among family or peers, though they were no more likely to be receiving professional treatment than those who were shy.Finally, rates of prescribed medication use were low for all groups. Only about 2.3 percent of those with social phobia were taking the antidepressant paroxetine (commonly used to treat anxiety disorders), while 0.9 percent who described themselves as shy were taking it. In addition, those with social phobia were no more likely to be taking any prescribed psychiatric medication compared to the other groups.SignificanceThe results suggest that social phobia is not simply shyness that has been inappropriately medicalized. Rather, social phobia affects a minority of youth and only a fraction of those who consider themselves to be shy. In addition, despite the greater disability that youth with social phobia experience and the greater likelihood that they will have another disorder, they are not more likely to be getting treatment compared to their peers, questioning the notion that these youth are being unnecessarily medicated.
219About half of adults with an anxiety disorder had symptoms of some type of psychiatric illness by age 15, a NIMH-funded study shows.Results from a small clinical trial suggest that it might be possible, using computer-based training, to help children with anxiety shift their attention away from threat.Normal human shyness is not being confused with the psychiatric anxiety disorder known as social phobia, according to an NIMH survey comparing the prevalence rates of the two among U.S. youth.
220Anxiety as a personality trait appears to be linked to the functioning of two key brain regions involved in fear and its suppression, according to an NIMH-funded study. Differences in how these two regions function and interact may help explain the wide range of symptoms seen in people who have anxiety disorders. The study was published February 10, 2011 in the journal, Neuron.
221Youth with obsessive compulsive disorder (OCD) who are already taking antidepressant medication benefit by adding a type of psychotherapy called cognitive behavior therapy (CBT), according to an NIMH-funded study published September 21, 2011, in the Journal of the American Medical Association.
222Anxiety Linked to Smarts in Brain Study Tendency to worry may have evolved along with intelligence in humans, researchers say
223Health Tip: When Your Child is Stressed Stress is a fact of life, and children are no less immune than their parents.How can you recognize if your child is "stressed out?" The American Academy of Pediatrics mentions these possible warning signs:Having physical problems, such as stomach ache or headache.Appearing agitated, tired or restless.Seeming depressed and unwilling to talk about his or her feelings.Losing interest in activities and wanting to stay at home.Acting irritable or negative.Participating less at school, possibly including slipping grades.Exhibiting antisocial behavior (stealing or lying), avoiding chores or becoming increasingly dependent on his or her parents.
224Mental Stress May Be Harder on Women's Hearts Researchers Find Blood Flow to Women's Hearts Doesn't Increase in Face of Stress
225Psychoeducation: Perhaps one of the most difficult aspects of coping with Social Phobia is simply understanding what it is, where it came from, why it's so hard to change, and how it keeps coming back with a vengeance. Psychoeducation involves you and your therapist working together to develop a better way to understand your Social Phobia, and subsequently, how to work with it.Cognitive Restructuring: As discussed earlier, individuals with Social Phobia frequently hold negative beliefs about themselves and others, which often show up as unhelpful thoughts in social situations. Cognitive restructuring is an important component of CBT, and it involves working with your therapist to identify these thoughts and look for patterns within them. As you become skilled at noticing these thoughts, you then develop strategies for gaining flexibility in your thinking and considering more helpful ways of looking at your experiences.In Vivo Exposure: In vivo (real life) exposure is another core element of CBT for Social Phobia. You and the therapist identify situations that you avoid because of Social Phobia, and then gradually enter these situations while accepting your anxiety and allowing it to naturally dissipate. While this step probably sounds quite intimidating, it is important to know that exposure is done at a very gradual, planned pace, and that your therapist will support you throughout the process. Many clients report exposure practices as being among the most useful elements in their treatment.Interoceptive Exposure: Some individuals with Social Phobia are fearful not only of social situations, but also of the anxious physical sensations (such as blushing, shaking, sweating, etc.) that can accompany them. Interoceptive exposure practices deliberately bring about these sensations through such activities as wearing a warm sweater to induce sweating in social situations. Just as exposure to feared situations leads to reductions in situational fear, exposure to feared sensations will lead to a reduction in anxiety over experiencing these feelings in social situations.Social Skills Training: In the midst of a tense social situation, many people with Social Phobia fear that they do not have the necessary social skills to successfully navigate the exchange. While this may be due to negative self-talk and self-consciousness (rather than an actual lack of skill), many people find it helpful to discuss such topics as carrying on conversations, being assertive, and effective listening. Social skills training provides a chance to work on these areas in therapy.
226Anxiety Disorder Association of American (ADAA) The ADAA brings together professionals from many disciplines including psychiatrists, psychologists, social workers, physicians, nurses, etc. Through networks, the ADAA increases awareness about anxiety disorders, provides education resources, offers access to care, and supports research.
230Concluding Thoughts —There is a clear and pressing need for faster, robust and well tolerated therapy/therapies.Thinking is rapidly changing and evolving – combination strategies from treatment initiation may be the new frontier for patients who need greater efficacy than antidepressant monotherapy.Personalized medicine may be needed to address genetic differences in depressed individuals to achieve and maintain remission.230
232EDUCATIONAL RESOURCES FOR PATIENTS AND FAMILIES Healthy Minds, Healthy LivesNational Alliance on Mental IllnessNational Institute of Mental HealthNational Center for Complementary andAlternative MedicinePostpartum Support InternationalMentalHelp.net
233rx http://www.ocfoundation.org/CBT.aspx#ERP OCD cannot be prevented. However, early diagnosis and treatment can help reduce the time a person spends suffering from the condition
237Another Bell Curve- Courtesy of Our Good Buddies Yerkes-Dodsen
238Generalized Anxiety Disorder General characteristicsPrevalence and age of onsetComorbidity with other disorders
239Generalized Anxiety Disorder: Psychosocial Causal Factors The psychoanalytic viewpointClassical conditioning to many stimuliThe role of unpredictable and uncontrollable eventsA sense of mastery: immunizing against anxiety
244Overview What is Anxiety? What are the different types of anxiety disorders?What are the causes?What are the symptoms?What are the treatments?Professional Resources available.
245Anxiety Disorders One-Year Prevalence (Adults) Anxiety StatisticsAnxiety Disorders One-Year Prevalence (Adults)PercentPopulation Estimate* (Millions)Any Anxiety Disorder13.319.1Panic Disorder1.72.4Obsessive-Compulsive Disorder2.33.3Post-Traumatic Stress Disorder3.65.2Any Phobia8.011.5Generalized Anxiety Disorder2.84.0* Based on 7/1/98 U.S. Census resident population estimate of million, age 18-54
247MedicationsBuspirone: shown to be effective but usually takes 3-4 weeks, particularly useful in elderly patientsBenzodiazepines: include Xanax and Valium, act rapidly and successfully but can be addictive and loses effectiveness over timeSide Effects: dizziness, headaches, nausea, impaired memory
248Behavioral and Cognitive Therapy Teaches patient to react differently to situations and bodily sensations that trigger anxietyTeaches patient to understand how thinking patterns that contribute to symptomsPatients learn that by changing how they perceive feelings of anxiety, the less likely they are to have themExamples: Hyperventilating, writing down list of top fears and doing one of them once a week, spinning in a chair until dizzy; after awhile patients learned to cope with the negative feelings associated with them and replace them with positive ones
249Psychodynamic Psychotherapy Psychodynamic therapy is a general name for therapeutic approaches which try to get the patient to bring to the surface their true feelings, so that they can experience them and understand them. Psychodynamic Psychotherapy uses the basic assumption that everyone has feelings held in the subconscious which are too painful to be faced. We then come up with defenses (such as denial) to protect us knowing about these painful feelings.Psychodynamic psychotherapy assumes that these defenses have gone wrong and are causing more harm than good, making you seek help. It tries to subdue them, with the intention that once you are aware of what is really going on in your mind the feelings will not be as painful.Takes an extremely long time and is labor intensive
250AcupunctureCaused by the imbalance of chi coming about by keeping emotions in for too longEmotion effects the chi to move in an abnormal way: when fearful it goes to the floor, when angry the neck and shoulders tightenRedirects the chi into a balanced flow, releases tension in the muscles, increases flow of blood, lymph, and nerve impulses to affected areasTakes weekly sessions
251AromatherapyCalming Effect: vanilla, orange blossom, rose, chamomile, and lavenderReducing Stress: Lavender, sandalwood, and nutmegUplifting Oils: Bergamot, geranium, juniper, and lavenderEssential Oil Combination: 3 parts lavender, 2 parts bergamot, and 1 part sandalwood
252ExerciseBenefits: symbolic meaning of the activity, the distraction from worries, mastery of a sport, effects on self image, biochemical and physiological changes associated with exercise, symbolic meaning of the sportHelps by expelling negative emotions and adrenaline out of your body in order to enter a more relaxed, calm state to deal with issues and conflicts
253Meditation Cultivates calmness to create a sense of control over life Practice: Sit quietly in a position comfortable to you and take a few deep breaths to relax your muscles, next choose a calming phrase (such as “om” or that with great significance to you), silently repeat the word or phrase for 20 minutes
254Nutrition and Diet Therapy Foods to Eat: whole grains, bananas, asparagus, garlic, brown rice, green and leafy veggies, soy products, yogurtFoods to Avoid: coffee, alcohol, sugar, strong spices, highly acidic foods, foods with white flourKeep a diary of the foods you eat and your anxiety attacks; after awhile you may be able to see a correlationEast small, frequent meals
255VitaminsB-Vitamins stabilize the body’s lactate levels which cause anxiety attacks (B-6, B-1, B-3)Calcium (a natural tranquilizer) and magnesium relax the nervous system; taken in combination before bed improves sleepVitamin C taken in large doses also has a tranquilizing effectPotassium helps with proper functioning of adrenal glandsZinc has a calming effect on the nervous system
256Self Love The most important holistic treatment of all Laugh: be able to laugh at yourself and with others; increases endorphin levels and decreases stress hormonesLet go of frustrationsDo not judge self harshly: don’t expect more from yourself than you do othersAccept your faults
257Additional Links Anxiety Screening Tools Anxiety Disorders Association of America (ADAA)Freedom From Fear (www.freedomfromfear.org)National Institute of Mental Health (www.nimh.nih.gov)U.S. Dept. of Health & Human Services (http://www.mentalhealth.samhsa.gov/topics/explore/stress/)
258What is Anxiety? According to Kaplan and Sadock Anxiety is “a diffuse, unpleasant, vague sense of apprehension, often accompanied by autonomic symptoms such as headache, perspiration, palpitations, tightness in the chest, mild stomach discomfort, and restlessness, as indicated by an inability to sit or stand still for long.”
259Fear, Anxiety and Worry Normal emotional responses Clear adaptive purposeIn anxiety disorders,these normal responses become excessive, persistent, easily triggered, and disruptive to the person’s life.
261Epidemiology of PTSDPrevalence is 1% in the general population, and can be as high as 25% in those who have experienced traumaIn combat veterans, prevalence is 20%Very high prevalence in women who are victims of sexual trauma
262PTSD CostsPatients with PTSD are frequent users of the health care systemPatients usually present to primary care physicians with somatic complaintsAfter panic disorder, PTSD is the most costly anxiety disorder
263Social Phobia Fear of being exposed to public scrutiny Fear of behaving in a way which will be humiliating or embarrassingSymptomatic resemblance to panic disorder with anticipatory anxiety (person may be anxious/worrying far in advance of the event)Extensive phobic avoidance
264Social PhobiaDistinction: anxiety only occurs when the patient is subject to the scrutiny of others (public speaking, oral exam, eating in the cafeteria)Phobic stimulus is avoided or endured with intense anxietyFear and avoidant behaviors interfere with person’s normal routine or cause marked distress
265Epidemiology: Social Phobia Prevalence rates vary depending on study; overall range is 3 –13% of the populationOnset in adolescencePrevalence greater in females, but greater for males in clinical samplesFrequent comorbidity with depression and substance abuse
266Obsessive Compulsive Disorder (OCD) Obsessions: recurrent, intrusive, unwanted thoughts (i.e. fear of contamination)Compulsions: behaviors or rituals aimed at reducing distress or preventing a dreaded event (i.e. compulsive handwashing)
267OCD SymptomsRecurrent obsessions and/or compulsions are severe enough to consume more than one hour/dayPerson recognizes the obsession as a “product of his/her own mind”, rather than imposed from the outside, and that they are unreasonable or excessive
268OCD SymptomsThe obsessions are “ego-dystonic” (not enjoyable for the ego), as opposed to “ego-syntonic” (the ego likes it)
269Common Obsessions Contamination Repeated doubts Order Aggressive or horrific imagesSexual/pornographic imageryScrupulosity
270Obsessions and Common Compulsive Responses Contamination: cleaning, hand washing, showeringRepeated doubts: checking, requesting or demanding reassurances from others, countingOrder: checking, rituals, countingAggressive or horrific images, checking, prayers, ritualsSexual/Pornographic imagery: prayer/rituals
271Epidemiology of OCDLifetime prevalence is 2-3% in the general populationMean age of onset is mid-twenties, although men may develop symptoms earlierLess than 5% of patients develop disease after age of 35 yearsChronic course, stress can exacerbate symptoms
272Substance Induced Anxiety Disorder Prominent symptoms of anxiety that are judged to be the direct physiological consequence of a drug or abuse, a medication or toxin exposure
273Panic Attacks and Panic Disorder Agoraphobia without a history of panic disorderPanic Disorder without agoraphobiaPanic Disorder with agoraphobia
274Post Traumatic Stress Disorder Characterized by the re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the traumaSymptoms present for at least one monthIf event just occurred and/or symptoms present for less than one month, a diagnosis of Acute Stress Disorder is given
275Specific PhobiaClinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidance behavior
276Obsessive Compulsive Disorder Characterized by obsessions that cause marked anxiety or distress and/or compulsions that serve to neutralize anxiety
277Substance Induced Anxiety Disorder Anxiety Disorder not otherwise specified
278E 00 Separation Anxiety DisorderE 01 Panic DisorderE 02 AgoraphobiaE 03 Specific PhobiaE 04 Social Anxiety Disorder (Social Phobia)E 05 Generalized Anxiety DisorderE Substance-Induced Anxiety DisorderE 12 Anxiety Disorder Attributable to Another Medical ConditionE 13 Anxiety Disorder Not Elsewhere ClassifiedPanic Attack