A Presentation on Anxiety Disorders (DSM5)

8/12/2019 A Presentation on Anxiety Disorders (DSM5)

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Anxiety DisordersSy and Morga


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Presentation Flow

I. GADAngelita

II. SADHenry

III. Snippet: Social Anxiety DisorderIV. Journals


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Angelita

A case of Generalized

Anxiety Disorder


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Identifying Information

Name of Client: Angelita

Sex: Female

Age (as of Sep 7, 2011): 45 years, 1 month, 11 days

Present home address: Cavite

Educational Attainment: College graduate, BSCommerce

Working Impressions:Osteoarthritis of the Right Knee;R/O Generalized Anxiety Disorder;R/O Hypochondriasis


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Personal background

Married to Susano, former OFW from Qatar andunemployed since 2008.

Currently experiencing distress because of the

present financial difficulty of their family (in-lawsare supporting them)

Three children: Shekainah (14), Stephen John (12)and Samuel James (10).

Relationship with husband somewhatharmonious


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Significant health history

June 2011: has been to a psychiatrist aftercomplaining that she was laging kinakabog, lagingtense.

In times of emotional unpreparedness and stressfulsituations, she would experience palpitations,dyspnea, trembling and incessant crying.

There have also been times during class discussionsand oral presentations that she would not be ableto think clearly (mental block) or to speakcoherently and audibly (garalgal ang boses).


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Prescribed Alprazolam (Xanax; benzodiazepine) andVenlafaxine (anti-depressant; SNRI)doesntusually take them

Appetite is relatively elevated (she has to restrainherself from eating)

She currently experiences some sleep disturbancebecause of intrusive thoughts relating to theirfinancial difficulties (worry).

Worries about the school performance of herchildren.


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Describes herself as maligalig (tense or agitated),workaholic, impulsive, socially reserved andmelancholic.

After her mother and father died when she was inGrade 6 and 2ndyear High School, respectively, shefelt neglected and uncared for by her siblings.

She sought for a boyfriend on the hope that this

could satisfy her need for love from her family. However, when her boyfriend left her for another

woman, Angelita sank in a state of depression tothe point that she had thoughts of suicide anddeath.


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She also seems to express some apprehension in herinability to restrain herself from sharing her personallife to other people she just met.

She also seems to be frustrated at herself for not beingable to overcome her weaknesses and insecuritieswhich include her inability to speak in English fluentlybecause of her regional dialect

The client also shared that her decision to marry her

present partner seems somewhat impulsive. She claimsthat nakapag-asawa siya ng di niya mahal and thisresulted to her present regrets of not being able towork (and wasting her education) because of child-rearing responsibilities.


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Angelita seems to express some fears aboutthe safety of her children, and the kind ofdeath that she would have if ever she willpass away.


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Behavioral Observations

Speech behavior: Angelita spoke in an audible volume and at a relatively

fast speaking rate

Appropriate affect, no perceptual and thoughtdistortions

Client emotionally appeared agitated and tenseespecially when she is not able to answer questionsasked of her.

Appeared agitated and apprehensive in her actions.

Angelita shared that it was only recently that thepeople around her noticed her relative agitationand nervousness (premorbid personality).


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Test Results

Average intelligence (Slosson Intelligence TestRevised and Test of Non-Verbal Intelligence2)

MMPI2:

Valid profile with minor inconsistencies

Presently experiencing a great amount of psychologicalturmoil (fear, anxiety, tension, depression).

Various clinical scales indicate that she is highly anxious,

apprehensive, unhappy and cynical Intrusive thoughts present

Tends to internalize and be conventional and cautious


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Test results (Draw-a-Persontest) Suggestive of feelings of weakness, inadequacy, futility

and depression.

Indicative of the clients need for emotional supportwhen under stress and her tendency to head for flight

from a frustrating environment Client has a tendency to avoid unpleasant situations,

and some free flow of basic drives and impulses withinadequate controls.

Over-all, the strokes of her drawing impliesdetermination and fearfulness although the location ofher drawn figure is indicative of the need to maintaincareful control in freely expressing feelings oremotions.


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Qualifies for a diagnosis ofGAD Excessive anxiety and worry at least 50% of days

about at least two life domains (finances, school,work, family)

Sustained for at least three months (June to Sep2011 and even before)

Anxiety and worry associated with difficultyconcentrating or mind going blank, restlessness,sleep disturbance

Avoids situations in which negative outcomes couldoccur (confrontations)


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Therapy Plan (8 to 10 sessions)

Initially, therapy had two goals:

1. To reduce the clients anxiety and apprehension tomanageable levels that will enable her to expressherself better.

2. To enable the client to face unfinished businessesin her past and integrate her experiences into onecoherent whole.

Limitation:

Financial concerns of client

Time constraints for therapist

Priority: Management of anxiety symptoms (Goal 1)


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Goal of Therapy: Teach client skillsto cope with agitation and anxiety

Once a week for 1 to 1 hours, for 8 weeks

Relaxation techniques (deep breathing exercisesand progressive muscle relaxation, guided mental

imagery) Behavior rehearsal (how to talk/assert ones needs

to a person in authority or to other people)

Some cognitive behavior therapy/RET (countering

some of the clients automatic thoughts such as if Ido not assist my children in school they will fail)

Tried to invite family members (refused to go)


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Henry

A case on Social Anxiety Disorder


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Personal Background

Henry

Caucasian descent; 26 yrs old

Took a test so he can leave high school earlier than

usual (GED) Enrolled in a community college but could not afford to

continue school

Was in the military for 6 years, was deployed to Asia

and Middle East Now a part-time cashier in a retail company

And a full-time student (University); completed 2semesters; major in Engineering


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Personal Background

Born in Europe, moved to America at the age of 2or 3

Moved again to Asia and finally to a southern state

Has 2 older brothers

Never been married

Lives alone

Has few close friends

Doesnt interact much with peers


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Significant History

Had many academic problems as a child

Would get into fights; interrupts others; loiters inclassroom

Described himself as a shy and timid child/introvert

Family environment:

Father was critical and remorseless in upholding

his standards of behavior Father was judgmental and did not allow voicing

of complaints or expression of emotions


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Significant History

Started experiencing loss of sleep, low appetite andfeelings of sadness while in the military

Had difficulty adjusting after returning from his

final assignment in the military (could not sleep)

But these symptoms did not last long

Feelings of anxiety has been increasing in the past 2

years


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Significant History

Denies smoking tobacco

Denies taking illegal substances

Rarely consumed alcohol


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Reason for Referral

Does not like to speak in classes

Becomes anxious when a teacher asks him in class

Gets anxious when her has to speak in public

Anxious around women

Anxious when he knew people would see and readhis handwriting (problems with hand written

tests/exams)


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Assessments


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Diagnostic Interview Anxiety Disorders Interview

Schedule for DSM-IV (ADIS-IV)

It was determined he

met criteria for SAD


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Treatment used in actualcase Cognitive Behavioral Approach

from Therapist guide for managing social anxiety: Acognitive-behavioral therapy approach by Hope andcolleagues (2006;2010)

Approximately 16 weekly 1-hour sessions that are tooccur within a 16 to 20 week period.

Comprised of five segments (psychoeduation,cognitive restructuring, exposure, advanced cognitive

restructuring, and termination) Use of a Workbook for SAD with outline and home

works
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383032/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383032/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383032/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383032/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383032/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383032/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383032/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383032/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383032/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383032/


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Treatment used in actualcase

Psychoeduation4 sessions

Self-report on physiological, cognitive, andbehavioral components of his social anxiety

Self-monitoring Cognitive restructuring2 sessions

Learning automatic thoughts, thinking errors andrational responses

Exposure6 sessions Engaging in situations he identified on his fear and

avoidance hierarchy


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Treatment used in actualcase Advanced cognitive restructuring2 sessions

Move the client from situation-specific automaticthoughts to being able to recognize more general themes

in automatic thoughts and core beliefs Use the techniques they have learned to challenge and

modify their automatic thoughts and core beliefs.

Termination

Discussed assessment of progress and relapse prevention

Processed the emotions he felt about the course oftreatment and termination.

Agreement to come back if necessary


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Snippet:

Afraid of People:A Social Anxiety Documentary


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Journals


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Mindfulness-Based Cognitive BehaviorTherapy in Patients with AnxietyDisorders


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Mindfulness-based CBT

Meditative technique from ancient India (Vipassanameditation)

It is a state in which one is required to remain

psychologically present and with whatever happens inand around one, without reacting in any way.

The practice enables the person to respondconsciously and reflectively (vs auto react)


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Used to address stress related medical conditions,emotional disorders and anxiety and depression

Effective in reducing both physiological / somatic

symptoms, as well as cognitive symptoms ofanxiety in patients with anxiety disorders


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MBCT Program: 23 sessions, over four to six weeks

Education about anxiety

Self-monitoring of symptoms,

Relaxation training - mindfulness meditation,

Cognitive restructuring for dysfunctional beliefs

Worry postponement and distraction

Verbal challenging and reattribution

Although relaxation is not the primary aim ofmindfulness meditation, it does produce the benefits

of relaxation through its focus on breathing.


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Mindfulness works on anxiety through detachmentbetween external contingencies and internalexperience enhanced by worry

Awareness of the present-moment experience andreflective focus replaces usual patterns ofresponses

Relaxation techniques CBT monitoring techniques complements this


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Mindful focus on the present provided analternative response that may have facilitatedadaptive responding

Training in mindfulness meditation is cost-effectivein terms of time and is applicable to a wide range ofpatients


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Parental and Peer Predictors of SocialAnxiety in Youth


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Predictors of Social Anxietyin YouthAre there parental and peer factors?

Parental Predictors:

Parental Anxiety, Parental Overcontrol, ParentalRejection

Peer Predictors

Social acceptance, social support and friendship quality

Importance of parental and peer variables inpredicting social anxiety in children


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Predictors of Social Anxietyin Youth Parental anxiety predicts child social anxiety based

on independent evaluator

Validation from a friend reduces child social anxiety

based on independent evaluator

Parental over protection (or over control) predictschild social anxiety based on child reported

symptoms Social acceptance based on child reported

symptoms


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Predictors of Social Anxietyin Youth Children whose parents had higher levels of anxiety

were rated as having higher levels of social anxiety.

genetic and environmental factors likely contribute.

Parental rejection may negatively affect childrensself-perceptions

May lead them to believe that their peers will also reject

them


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Predictors of Social Anxietyin Youth Children who perceived themselves as more

socially accepted (e.g., have classmates who likethem and spend time with them) reported lower

levels of social anxiety

Children who have friends and classmates who talkwith them about problems, understand theirproblems, enjoy spending time with them, and care

about their feelings worry less about criticism andhumiliation in social interactions.


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Predictors of Social Anxietyin Youth Children who have friends that make them feel

good about their ideas, tell them they are good atthings, and make them feel important and special

are less likely to experience social anxietysymptoms.


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Predictors of Social Anxietyin Youth Peer factors may be more robust predictors than

parental factors

Peer experiences are direct influences

Parental factors are indirect

Positive peer experiences (or perception of it) maybuffer the impact of parental factors


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Association between social phobia, socialanxiety cognitions and paranoidsymptoms


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Aims and methods

Cross-sectional and longitudinal associationsbetween social phobia and paranoid symptomswere examined.

2,584 respondents


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Significant findings

Paranoid ideations are thought to build uponcommon interpersonal anxieties and worries suchas fears of rejection

Social anxiety has been found to be correlated withfeeling hostile towards others, and with hostileperceptions of others.


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Thank you.

Documents

A Presentation on Anxiety Disorders (DSM5)