Anxiety D I S O R D E R

+Social Impact Is hazardous…+ When an Individual is socially and situation ally bound by thought, Impaired cognitive process and emotion s that causes worry, the ability to socialize to others is hindered.

+ Overall, personal Health is Compromised

+ Anxiety can lead to withdrawal and absense from work and result in physical deficiencies and social problems• Many have a media onset as early as 13 years of

age

+ Anxiety Disorder is a maladaptive anxiety reaction, which can cause significant emotional distress or impair the persons ability to function.

+ Responses to stress and anxiety especially when severe can include physiological reactions that stimulate Sympathetic and Parasympathetic Nervous System resulting inIncreased heart rate, trembling, sweating, nausea, shortness of breath, dizziness, headaches and diarrhea.

+ Anxiety Disorders begins with the experience of two clinical features :

• Panic Attacks• Phobia

+Panic Attacks+ Panic Attacks are intense anxiety reactions accompanied by physical symptoms such as pounding heart ; rapid respiration, shortness of breath, or difficulty breathing; heavy perspirations and weakness or dizziness.

+ The attacks are accompanied by feelings of sheer terror and a sense of imminent danger or impending doom and by an urge to escape the situation. Accompanied by thoughts of losing control, going crazy or dying

+ There are three kinds of Panic attacksIt can be…

• Unexpected

• Situational

• Predisposed Situation

• An internal Process, such as in Generalized Anxiety Disorder

• (CUED)• Predominately

external process with immediate reaction such as phobias or OCD

• An episodic and specific reaction to situations as those found in PTSD

“ I ”

I Felt like I was going to die right then and there

I never experienced anything like this before. It happened while I was sitting in the car at a traffic light. I felt my heart beating furiously fast, like it was just going to explode. It just happened, for no reason, I started breathing really fast but couldn’t get enough air. It was like I was suffocating then and there. I was trembling and seating heavily. I thought I was having a heart attack. I felt this incredible urge to escape, to just get out of the car and get away.

I somehow managed to pull the car over to the side of the road but just sat there waiting for the feeling to past. I told myself if I was going to die, then I was going to die. I didn’t know whether I’d survive long enough to get help. Somehow I cant say how – It just passed and I sat there a long time, wondering what had just happened to me. Just as suddenly as the panic overcame me, it was gone. My breathing slowed down and my heart stopped thumbing in my chest. I was alive. I was not going to die. Not until the next time anyway -- “The Case of Miguel

+ During panic attacks, people tend to be keenly aware of changes in their heart rates and may think they are having a heart attack, even though there is really nothing wrong with their hearts.

+ As in case of Miguel, Panic attacks began suddenly and spontaneously, without any warning or clear triggering event.

+ The attacks builds to a peak of intensity within 10 or 15 minutes. Attacks usually last for minutes, but it can last for hours.

+ People describe panic attacks as the worst experiences of their lives. Their coping abilities are overwhelmed. They may feel they must flee. If Flight seem useless, they may freeze.

+ Recurring Panic attacks may become so difficult to cope with that panic sufferers become suicidal.

+ For a diagnosis of panic disorder to be made, the person must have experienced repeated, unexpected panic attacks, and at least one of the attacks may be followed by one of these features

a.) At least a month of persistent fear of subsequent attacks

b.) Worry about the implications or the consequences of the attack

c.) Significant change of behavior

+ Theoretical Perspective + BIOLOGICAL FACTORS :

• Suffocation False AlarmFrom the psychiatrist : David Klein

He postulated that a defect in the brain`s respiratory alarm system triggers a false alarm in responses to minor cues of suffocation.In Klein`s Model, small changes in the level of carbon dioxide in blood perhaps resulting into hyperventilation, produce a sensation of suffocationThese respiratory sensation, leading to a cascade of physical symptoms trigger the respiratory alarm.

+ COGNITIVE FACTORS

• President Franklin Roosevelt said in his 1932 inaugural address “We have nothing to fear but the fear itself”. These words echo today in research on the role of Anxiety Sensitivity (AS).

• In the 1970s and 1980s the fear of fear was considered as an important consequences of panic attack, people learn to fear recurrence, and thus developed agoraphobia.

+Treatment Approach• The most widely used form of treatment for panic disorder

are drug therapy and cognitive-behavioral therapy.

• Drugs commonly used to treat depression, called anti-depressant drugs, also have antianxiety and antipanic effects.

• Antidepressants help counter anxiety by normalizing activity of neurotransmitters in the brain.

• A potential problem with drug therapy is that patients may attribute clinical improvement to the drugs and not to their own resources.

+ Cognitive-behavioral therapy

• Coping Skills development for handling panic attacks, breathing retraining and relaxation training to reduce stress of heightened body arousal and exposure to situations linked to panic attacks.

• The therapist may help clients think differently about changes in bodily cues, such as sensations of dizziness or heart palpitations.

• Breathing retraining is a technique that aims at restoring a normal level of carbon dioxide in the blood by having clients breathe slowly and deeply from the abdomen avoiding the shallow, rapid breathing that leads to breathing off too much carbon dioxide.

+ Phobic Disorders• The word Phobia derives from the Greek word phobos meaning

“fear”. The concept of fear and anxiety is closely related.• Fear is anxiety experienced in response to a particular threat.• A phobia is a fear of an object or situation that is disproportionate to

the threat it poses.

“To experience a sense of gripping fear when your car is about to go out of control is not a phobia, because you truly are in danger”.

People with driving phobia for example : might become fearful even when they are driving well below the speed limit on a sunny day on un uncrowned highway. Or might be so afraid that they will not drive or even ride in a car.

• Phobias can become disabling they interfere with daily task such as taking buses, planes, or trains .

+ Types Of Phobic DisordersThe DSM recognizes three distinct phobic

disorders :• Specific Phobia• Social Phobia• Agoraphobia

• A curious thing about phobias is that they usually involve fears of the ordinary events in life, such as taking an elevator or driving on a highway, not the extraordinary.

+ SPECIFIC PHOBIAS• A Specific Phobia is a persistent, excessive fear of a specific object or situation, such as fear of heights (acrophobia), fear of enclosed spaces (Claustrophobia), or fear of small animals such as mice or snakes and various other “creepy-crawlies”

• The person experiences high levels of fear and physiological arousal when encountaring the phobic objects, which prompts strong urges to avoid or escape the situation or to avoid the feared stimulus, as in following case

Carla Passes the Bar But Not the Courthouse Staircase : A Case of Specific Phobia

Passing the bard exam was a significant milestone in Carla’s life, but it left her terrified at the thought of entering the county courthouse. She wasn’t afraid of encountering a hostile judge or losing a case, but of climbing the stairs leading to a second floor promenade where the courtrooms were located. Carla, 27, suffered from acrophobia, or fear or heights. “ It’s funny, you know,” Carla told her therapist “ I have no problem flying or looking out the window of a plane at 30,000 feet. But the escalator at the mall throws me into tailspin. It’s just any situation where I could possibly fall, like over the side of balcony or banister. People with anxiety disorder try to avoid situations or objects they fear. Carla scouted out the courthouse before she was scheduled to appear. She was relieved to find a service elevator in the rear of the building she could use instead of stairs. She told her felloe attorneys with whom she was presenting the case that she suffered from a heart condition and couldn’t climb stairs. Not suspecting the real problem, one of the attorneys said, “ This is great. I never knew this elevator existed. Thanks for finding it. -- The case of Carla

+ To rise to the level of diagnosable disorder, the phobia must significantly affect the person’s lifestyle or functioning or cause significant distress. You may have a fear of snakes, but unless your fear interferes with your daily life or cause you significant emotional distress, it would not warrant a diagnosis of phobic disorder.

+ People with specific phobias will often recognize that their fears are exaggerated or unfounded. But they are still afraid.

+ Social Phobia• It is not abnormal to experience some degree of fear in social

situations such as dating, attending parties or social gatherings, or giving a talk or presentation to a class or group.

• Yet People with social phobia ( also called social anxiety disorder ) have such an intense dear of social situations that they may avoid them altogether or endure them only with great distress.

• Imagine what's it like to have social phobia. You are always fearful of doing something or saying something humiliating or embarrassing. You may feel as if a thousand eyes is scrutinizing your every move. You are probably your highest critic and are likely to become fixated on whether your performance measures up when interacting with others.

• Negative thoughts run through your mind. “Did I say something right?” do they think I’m stupid?” you may even experience a full-fledged panic attack.

+ Agoraphobia• The word agoraphobia id derived from the Greek words meaning

“Fear of the marketplace,” which suggest a fear of being out in the open, busy areas.

• People with agoraphobia develop a fear of places and situations from which it might be difficult or embarrassing to escape in.

• People with agoraphobia may fear shopping in crowded stores; walking through crowded streets, crossing the street travelling by bus or train.

• People may structure their lives around avoiding exposure to fearful situation and in some cases Become housebound for months or even years, even to the extent of being unable to venture outside to mail a letter.

• Agoraphobia has the potential to become the most incapacitating type of phobia

+ Theoretical Perspective Psychodynamic Perspective

• From the psychodynamic perspective, anxiety is a danger signal that threatening impulses of a sexual or aggressive (murderous or suicidal) nature are nearing the level of awareness. To fend of these threatening impulse, the ego mobilizes its defense mechanisms.

• In phobias, the Freudian defense mechanism, of projection comes into play.

• A phobic reaction is a projection of the person’s own threatening impulses onto the phobic object. For instance, a fear of knives or other sharp instruments may represent the projection of one’s own destructive impulses.

Biological Perspective

• According to the concept of prepared conditioning, we are generally predisposed to more readily acquire fears of the types of stimuli that would have threatened the survival of ancestral humans – stimuli such as large animals, snakes, and other creepy crawlies.Cognitive Perspective

a.) Oversensitive to threatening cues -- Sensitive to cues of threat

b.) Overproduction of danger -- Over predict how much fear or anxiety They will experience in the fearful situation.

c.) Self Defeating thoughts and Irrational Beliefs – heighten and perpetuateAnxiety and phobic disorder

+ Treatment approachesa. ) Learning –Based Approaches

• Systematic desensitization – a fear reduction procedure originated by psychiatrist Joseph wolpe. It is a gradual process in which clients learn to handle progressively more disturbing stimuli while they remain relaxed.

• Gradual Exposure – is a stepwise approach in which phobic individuals gradually confront the objects or situations they fear. Repeated exposure to a phobic stimulus in the absence of any aversive event can lead to extinction, or gradual weakening of the phobic response.

• Exposure therapy can take several forms, including Imaginal exposure – imagining oneself in a fearful situation.

• Flooding – is a form of exposure therapy in which subjects are exposed to high levels of fear inducing stimuli either in imagination or real life situations.

• Virtual Reality Therapy (VRT) – is a behavior therapy technique that uses computer generated stimulated environments as therapeutic tools. By donning a specialized helmet and gloves that are connected to a computer, a person with a fear of heights, for example, can encounter frightening stimuli in this virtual world, such as riding a glass-enclosed elevator to the top floor.

+ Obsessive Compulsive BehaviorAre troubled by recurrent obsessions, compulsions, or both obsessions and compulsions to the extent that they cause marked distress, occupy more than an hour a day, or significantly with normal routines or occupational or social functioning.

An Obsession is an intrusive and recurrent thought, idea or urge that seems beyond the persons ability and can engender significant distress.

Ex one can wonder endlessly whether or not one has locked the doors and shut the windows.

A Compulsion is a repetitive behavior or mental act that the person feels compelled or driven to perform.

Ex. Praying, Repeating certain words or counting

“I”

Tormenting Thoughts and Secret Rituals My compulsions are caused by fears of hurting someone

through my negligence. It’s always the same mental rigmarole. Making sure the doors are latched and the gas jets are off. Making sure I switch off the light with just the right amount of pressure, so I don’t cause electrical problem. Making sire I shift the car’s gears cleanly, so I don’t damage the machinery I fantasize about finding an island in the south pacific and living alone. That would take the pressure off; if I would harm anyone it would just be me. Yet even if I were alone, I’d still have my worries, because even insects can be a problem. Sometimes when I take the garbage out, I’m afraid that I’ve stepped on an ant. I stare down to see if there’s an ant kicking and writhing in agony. I took a walk last week by the pond, but I couldn’t enjoy it because I remembered it was spawning season, and I worried that I might be stepping on the eggs of bass or bluegill. I realize that other people don’t do these things. Mainly, its that I don’t want to go through the guilt of having hurt anything. It’s selfish in that sense. I don’t care about them as much as I do about not feeling guilt

+ Obsessive thought Pattern• Thinking that one’s hand remain dirty despite repeated washing• Difficulty shaking the thought that a loved one has been hurt or killed• Repeatedly thinking that one has left the door to the house unlocked• Worrying constantly that the gas jets in the house were not turned off• Repeatedly thinking that one has done terrible things to loved ones

+ Compulsive Behavior Pattern• Rechecking one’s work time and time again• Rechecking the doors or gas jets before leaving them home• Constantly washing ones hand to keep them clean and germ

free

Most Compulsions fall into two categories : • Cleaning Rituals• Checking Rituals

+ Theoretical Perspective• Within the psychodynamic tradition, obsession represent

leakage of unconscious impulses into consciousness and compulsion are acts that help keep these impulses repressed.

Ex. Obsessive thoughts about contamination by dirt or germs may represent the Threatened emergence of unconscious infantile wishes to soil oneself and play with feces. The compulsion (cleaning rituals) help keep such wishes at bay.

+ Generalized Anxiety Disorder• Generalized anxiety disorder (GAD) is characterizedby unfounded worrying where there are no precipitantsand the individual has difficulty trying to control it.

• The feelings of worry and apprehension are significant enough to impair the engagement of activities

• For a minimum of 6 months, the anxiety and worry is pronounced and excessive, and the intensity, duration, andfrequency of the worrying are out of proportion to the Event (real or imagined).

• GAD accounts for a prevalencerate of 6.8 million people with the disorderages 18 and above with a median onset at age 31

+Symptoms of restlessness, fatigue, disturbed sleep, difficulty concentrating, irritability, muscle tension, aches, trembling, twitching, shakes, accelerated heart rate, nausea, diarrhea, shortness of breath, and dizziness are but a few of the presenting clinical features of GAD.

• It is twice as common in women as in men.

+ Treatment Approach

• The major forms of treatment of GAD are psychiatric drugs and cognitive-behavioral therapy.

• Anti depressant drugs such as sertraline (Zoloft) can help relieve anxiety symptoms

+ Acute Stress and Posttraumatic Disorder• Acute Stress Disorder (ASD) involeves a maladaptive

reaction in the initial month following a traumatic event.

• Posttraumatic Stress disorder is a prolonged maladaptive reaction to a traumatic event. PTSD may last for months, years, even decades, and may not developed until many months or even years after the traumatic event.

• PTSD accounts for a prevalence of 7.7 million people in the United States age 18 and above and can be found in any age group, with a median onset at age 23

• Prevalence is highest among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide

+ In both ASD or PTSD, the traumatic event involves either actual or threatened death or serious physical injury, or threats to one’s own or another’s physical safety.

+ The major difference in the features of ASD and PTSD is the emphasis in ASD on dissociation– feelings of detachment from oneself or one’s environment.. People with actual ASD may feel they are “in a daze” or that the world seems dreamlike or unreal place.

+ Common Features of Traumatic Stress Disorders+Avoidance Behavior

+Re-experiencing the Trauma

+Emotional Distress and Impaired Functioning

The person may avoid cues or situation associated with the trauma .A rape survivor may avoid travelling to the part of town where she was attacked. A combat veteran may avoid reunions with soldiers or watching movies or feature stories about war or combat.

The person may experience the trauma in the form of intrusive memories, recurrent disturbing dreams, or momentary flashbacks of the battlefield or being pursued by an attacker.

The person may experience a significant emotional distress or have difficulty functioning effectively in meeting daily responsibility

+ Common Features of Traumatic Stress Disorders

+Heightened Arousal

+Emotional Numbing

The person may show signs of increased arousal, such as becoming hyper vigilant. Have difficulty sleeping and concentrating become irritable or have outburst of anger, or show an exaggerated startle response, such as jumping at sudden noise

In PTSD, the person may feel numb inside and kise the ability to have loving feelings.

+ Treatment Approach• The basic treatment component is repeated exposure to

cues and emotions associated with the trauma The PTSD patient may be encouraged to repeatedly talk about the traumatic experience, re-experience the emotional aspects of the trauma in imagination, view related slides or film or visit the scene of the traumatic event.

• Exposure therapy is also of benefit in treating people with ASD.

• For rape survivors, exposure may take the form of recounting the horrifying ordeal within the supportive therapeutic setting.

Anxiety Disorder Not Otherwise SpecifiedThe last condition in this section cited in the DSM-IV-TR is anxiety disorder not otherwise specified (NOS). This condition is assessed when the criteria for all other anxiety disorders cannot be met, including the adjustment disorders (APA, 2000).

+ DSM IV300.02 + Generalized anxiety disorder + Panic disorder

300.21 With agoraphobia 300.01 Without agoraphobia

300.22  + Agoraphobia without history of panic disorder300.29  + Specific phobia300.23  + Social phobia300.3  + Obsessive-compulsive disorder309.81  + Posttraumatic stress disorder308.3  + Acute stress disorder 293.84 Anxiety disorder due to a general medical condition 293.89 Anxiety disorder due to... [indicate the general medical condition] 300.00 Anxiety disorder NOS

+ DSM V

+ Separation Anxiety Disorder+ Diagnostic Features

• The essential feature of separation anxiety disorder is excessive fear or anxiety concerning separation from home or attachment figures. The anxiety exceeds what may be expected given the person's developmental level

Individuals with separation anxietydisorder have symptoms that meet at least three of the following criteria:

1.) They experience recurrent excessive distress when separation from home or major attachment figures is anticipated or occurs

2.) They worry about the well-being or death of attachment figures, particularly when separated from them, and they need to know the whereabouts of their attachment figures and want to stay in touch with them

3.) They also worry about untoward events to themselves, such as getting lost, being kidnapped, or having an accident, that would keep them from ever being reunited with their major attachment figure

4.) Individuals with separation anxiety disorder are reluctant or refuse to go out by themselves because of separation fears

5.) They have persistent and excessive fear or reluctance about being alone or without major attachment figures at home or in other settings. Children with separation anxiety disorder may be unable to stay or go in a room by themselves and may display "clinging" behavior, staying close to or "shadowing" the parent around the house, or requiring someone to be with them when going to another room in the house.

6.) They have persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home

7.) Children with this disorder often have difficulty at bedtime and may insist that someone stay with them until they fall asleep. During the night, they may make their way to their parents' bed (or that of a significant other, such as a sibling). Children may be reluctant or refuse to attend camp, to sleep at friends' homes, or to go on errands. Adults may be uncomfortable when traveling independently (e.g., sleeping in a hotel room). There may be repeated nightmares in which the

8.) Physical symptoms (e.g., headaches, abdominal complaints, nausea, vomiting) are common in children when separation from major attachment figures occurs or is anticipated

content expresses the individual's separation anxiety (e.g., destruction of the family through fire, murder, or other catastrophe)

• Onset of separation anxiety disorder may be as early as preschool age and may occur at any time during childhood and more rarely in adolescence.

+Risk and Prognostic FactorsEnvironmental. Separation anxiety disorder often develops after life stress, especially a loss (e.g., the death of a relative or pet; an illness of the individual or a relative; a change of schools; parental divorce; a move to a new neighborhood; immigration; a disaster that involved periods of separation from attachment figures)

+ Selective MutismDiagnostic Criteria :

A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations.

B. The disturbance interferes with educational or occupational achievement or with social communication.

C. The duration of the disturbance is at least 1 month (not limited to the first month of school).

D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.

E. The disturbance is not better explained by a communication disorder (e.g., childhood onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.

+Specific PhobiaSpecify if:Code based on the phobic stimulus:+ Animal (e.g., spiders, insects, dogs).

+ Natural environment (e.g., heights, storms, water).

+ Blood-injection-injury (e.g., needles, invasive medical procedures).

+ Situational (e.g., airplanes, elevators, enclosed places).

+ Other (e.g., situations that may lead to choking or vomiting: in children, e.g., loud sounds or costumed characters).

+ Diagnostic Criteria for Panic DisoderA. Recurrent unexpected panic attacks.

1. Palpitations, pounding heart, or accelerated heart rate.2. Sweating.3. Trembling or shaking.4. Sensations of shortness of breath or smothering.5. Feelings of choking.6. Chest pain or discomfort.7. Nausea or abdominal distress.8. Feeling dizzy, unsteady, light-headed, or faint.9. Chills or heat sensations.10. Paresthesias (numbness or tingling sensations).11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).12. Fear of losing control or “going crazy.”13. Fear of dying.

B. At least one of the attacks has been followed by 1 month (or more) of Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”). And a significant maladaptive change in behaviour related to the attacks (avoidance behaviours)

C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication)

D. The disturbance is not better explained by another mental disorder.

+ Panic Attack SpecifierThere are two characteristic types of panic attacks: • Expected • Unexpected.

+ Expected panic attacks are attacks for which there is an obvious cue or trigger, such as situations in which panic attacks have typically occurred.

+ Unexpected panic attacks are those for which there is no obvious cue or trigger at the time of occurrence (e.g., when relaxing or out o sleep [nocturnal panic attack])

+ One type of unexpected panic attack is a nocturnal panic attack (i.e., waking from sleep in a state of panic), which differs from panicking after fully waking from sleep.

+ Substance/Medication-Induced Anxiety Disorder

A. Panic attacks or anxiety is predominant in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory findings of• substance intoxication• or withdrawal or after exposure to a medication.

DSM-5 DisordersAnxiety Disorders• Separation Anxiety Disorder

• Selective Mutism

• Specific Phobia

• Social Anxiety Disorder (Social Phobia)

• Panic Disorder

• Panic Attack (Specifier)

• Agoraphobia

• Generalized Anxiety Disorder

• Substance/Medication-Induced Anxiety Disorder

• Anxiety Disorder Due to Another Medical Condition

• Other Specified Anxiety DisorderUnspecified Anxiety Disorder

END