CLASS 5-6: ANXIETY DISORDERS

OBSESSIVE-COMPULSIVE DISORDER

STRESS-RELATED DISORDERS

PSY600: DIAGNOSIS AND TREATMENT OF MENTAL HEALTH DISORDERS

Anxiety/OCD/Stress Disorders

You must often rule out substances and/or other medical conditions to Dx these disorders Many substances and medical conditions can

cause physiological or psychological Sx that look like anxiety Sx

There must be clinically significant distress or impairment in social, occupational, or other important areas of functioning to Dx these disorders

Avoidance of anxiety/fear-provoking objects or situations is often a key component of these disorders

Tx of Anxiety/OCD/Stress Disorders

Tx of these disorders will typically involve one or more of the following: Cognitive therapy – change distorted/faulty thinking Behavioral therapy –

Exposure, often with response prevention Anxiety-reducing Bx training, such as relaxation

training, meditation, distraction, biofeedback Medication

Short-term Sx relief Longer-term Tx of disorder

Panic Attacks

Panic Attack: An abrupt surge of intense fear or discomfort, in which the person experiences a variety of physiological and cognitive Sx. Unexpected – no obvious cue or trigger at the time of

occurrence. Seemingly “out of the blue.” Expected - there is an obvious cue or trigger, e.g.,

phobic stimulus

Panic Attacks can be used as a specifier for all DSM disorders. Use the phrase “with panic attacks” after name of disorder

Panic Attacks

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

Panic Disorder

Panic DisorderRecurrent unexpected Panic AttacksAt least 1 of the attacks has been

followed by a month or more of at least 1 of the followingPersistent worry about having more

attacks or about the consequences of attacks

Significant change in Bx related to the attacks

Tx of Panic Disorder

Medical evaluation – physiological disorders, some serious, can cause panic-like Sx

Psychotherapy – can be sufficient as sole Tx method CBT

Change catastrophic and distorted thinking surrounding physical symptoms

Relaxation training, meditation, distraction, interoceptive exposure

Medication – usually not sufficient as sole Tx method Fast-acting anti-anxiety meds for Sx relief

Benzodiazepines – Xanax, Klonopin, Valium Long-term anti-depressant therapy for Tx of underlying disorder

SSRIs MAOIs Tricyclics

Phobias

Marked fear or anxiety cued by the presence or anticipation of a specific object or situation

Exposure almost invariably provokes an immediate anxiety response, possibly in the form of expected Panic Attacks

Fear/anxiety is out of proportion to the actual danger posed and to the sociocultural context

Stimulus is avoided or endured with intense anxiety

Fear/anxiety/avoidance is persistent/lasts at least 6 months

Specific Phobia

Code according to phobic stimulusMost Common Types

Animal Type Natural Environment Type (e.g., heights, storm, water) Blood-Injection-Injury Type Situational Type (e.g., airplanes, elevators, enclosed

places) Other Type (e.g., fear of contracting an illness; in

children: loud sounds, costumed characters)

Social Anxiety Disorder

Persistent fear of acting in a way that will be humiliating, embarrassing, or lead to rejection in 1 or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others

If another medical condition is present, fear is not related to it (e.g., fear is not of trembling in a patient with Parkinson’s Disease)

Specify if: Performance Only – fears are limited to public performance situations

Agoraphobia

Agoraphobia: Anxiety about being in situations from which escape might be difficult or in which help may not be available in the event of having panic or other embarrassing/incapacitating Sx. Hx of Panic Attacks not required Fear is experienced about two or more of these situations:

Public transportation Open spaces Enclosed places (where other people are present) Standing in line/being in a crowd Being outside the home alone

Behavioral Tx of Phobias

Exposure Therapy Systematic Desensitization

Develop and implement anxiety hierarchy In vivo or imaginal Teach relaxation techniques and pair with exposure Location and pacing determined by nature and severity of

fear and client characteristics Graduated Exposure

Gradually increasing duration of exposure Flooding

Intense and prolonged exposure to feared object Not all phobias or clients are appropriate for this approach

Virtual Reality

Other Tx of Phobias

Cognitive restructuringEncourage expression of feelings, self-confidence,

responsibilityAttend to family/environmental issues that may

impact phobia; possibly include a close associate in the Tx

Cognitive aspects of Tx play a larger role in treating Social Anxiety Disorder Cognitive Behavioral Group Therapy helps skills

development

Generalized Anxiety Disorder

Excessive anxiety and worry most of the time for at least 6 months about a number of events or activities

It is difficult to control the worryAnxiety/worry associated with 3 or more of the

following: Restlessness or feeling on edge/keyed up Being easily fatigued Difficulty concentrating/mind going blank Irritability Muscle tension Sleep disturbance

Treatment of GAD

CBT Cognitive restructuring Relaxation training Exposure

Acceptance & Commitment Therapy Acceptance & awareness of thoughts and feelings Emotional detachment Identification of values -- work toward acting based on

thoseMedication

Fast-acting for Sx relief Long-term for Sx treatment

Relapse after stopping meds is high

Other Anxiety Disorders

Anxiety Disorder Due to Another Medical Condition Sx are physiologically caused by medical condition, not by

knowledge of having medical conditionSubstance/Medication-Induced Anxiety Disorder

Code based on substance involved and presence/absence of other substance use disorder

Other Specified or Unspecified Anxiety Disorder Clear anxiety disorder, but full criteria not met for any

specific one, For Specified, record reason with Dx

“Other Specified Anxiety Disorder, limited symptom attacks”

Obsessions & Compulsions

Obsessions Recurrent, persistent and intrusive thoughts, impulses or

images that cause marked anxiety or distress Person attempts to ignore such thoughts or to neutralize

them with some other thought or actionCompulsions

Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be rigidly applied

Behaviors are aimed at reducing distress or preventing some dreaded outcome, but are not realistically connected with what they are designed to prevent or are clearly excessive

Obsessive-Compulsive Disorder

Obsessions and/or compulsionsSx cause marked distress, are time consuming,

or significantly interfere with functioningSx not better explained by another mental

disorderSpecify if:

With good or fair insight – person recognizes that beliefs are not or may not be true

With poor insight – person thinks beliefs probably true With absent insight/delusional beliefs -- person is

completely convinced beliefs are true Tic-related – current or past tic disorder

Obsessive-Compulsive Disorder

Typical OCD themes include: contamination/washing; doubt/checking; fear of harming oneself or others; symmetry/counting and arranging

OCD is a chronic disorder that can be highly treatment resistant

High degree of heritabilityEqually common in both genders: females

onset more in adulthood, males more in childhood

Treatment of OCD

OCD presents at a wide range of severity and disability.

Exposure and response prevention Graduated exposure to obsessional cues and strict

prevention of rituals Relaxation training may be used

Cognitive therapy Challenge errors in thinking

Medication SSRIs, tricyclics

Post-Traumatic Stress Disorder

Exposure to actual or threatened death, serious injury, or sexual violence in one of following ways:

For those older than 6 years: Direct experience Witnessing, in person, the event occurring to others Learning that the event occurred to a close family

member or friend Experiencing related or extreme exposure to aversive

details of the event(s)

There are somewhat different criteria for children 6 years or younger.

Post-Traumatic Stress Disorder

One or more intrusion Sx, beginning after event

One or more Sx indicating persistent avoidance of stimuli associated with event, beginning after event

Two or more negative alterations in cognitions and mood associated with event, beginning or worsening after event

Two or more marked alterations in arousal and reactivity associated with event, beginning or worsening after event

Post-Traumatic Stress Disorder

• Duration of disturbance is more than one month

• Rule out substances or other medical conditions

• Specify whether:• With dissociative Sx• Depersonalization• Derealization

• Specify if:• With delayed expression– if full criteria are not met for

at least 6 months after the event

Treatment of PTSD

Begin Tx as soon as possible after trauma, even before Sx emerge as a preventative measure

Suicide evaluationSubstance use evaluationProlonged Exposure

Exposure to memory of trauma on a hierarchical, scheduled basis

Cognitive Processing Therapy Structured model combining exposure, cognitive

restructuring, and anxiety management training Developed for sexual assault survivors

Anxiety Management Training Pairing memory of trauma with relaxation, biofeedback,

etc.

Treatment of PTSD

Group/family therapy Support systems are vital to people with PTSD Group with people with similar experiences can be

very helpful Family has likely been significantly impacted by

PTSD Work on trust, communication skills

Medication SSRIs most commonly used Help address anxiety, depression, sleep problems

Acute Stress Disorder

• Same exposure to traumatic event as with PTSD

• Nine Sx related to intrusion, negative mood, dissociation, avoidance, and increased arousal

• Disturbance lasts for at least 3 days and no more than1 month after trauma exposure

• Rule out substances, another medical condition, and brief psychotic disorder.

Adjustment Disorder

Development of emotional or behavioral Sx in response to an identifiable stressor Stressor can be of any severity, unlike PTSD

Sx start within 3 months of onset of stressor and don’t last more than 6 months past end of stressor

Distress in excess of what would be expected OR significant impairment in functioning

Criteria are not met for another mental disorder, and is not an exacerbation of a pre-existing mental disorder

Sx do not represent normal bereavement

Adjustment Disorder

Specify whether: With Depressed Mood With Anxiety With Mixed Anxiety and Depressed Mood With Disturbance of Conduct With Mixed Disturbance of Emotions and Conduct Unspecified

Code according to nature of Sx

Differential Diagnosis

Panic Attacks can occur with all DSM-5 disorders – for Panic Disorder they must be present and unexpected

Nature of fear/worry helps determine Dx: Panic Disorder – of having another attack or

consequences of attack Agoraphobia – of having panic Sx in a place that

cannot be escaped or where help cannot be obtained Specific Phobia – of a particular object or situation Social Anxiety Disorder– of being

humiliated/rejected in front of others

Differential Diagnosis

Avoidant Personality Disorder may just be a more pervasive form of Social Anxiety Disorder. They can be hard to distinguish. Look at Hx. Negative self evaluation is more prominent with P/D. Anxiety/avoidant Bx is present in most social situations with P/D.

Depressive ruminations are not obsessions because they are typically mood congruent, not experienced as intrusive or distressing, not linked to compulsions.

OCD with delusional beliefs is not diagnosed as Delusional Disorder if obsessions and compulsions are clearly present

Differential Diagnosis

Compulsive-like Bx (gambling, substance abuse) is not OCD because those activities bring pleasure, at least while they’re being executed

OCD and OCPD can be diagnosed in the same person, but they are not the same. No obsessions or compulsions with OCPD. OCD is often ego dystonic.

Stressor with Adjustment Disorder can be anything the person feels was stressful to them; PTSD requires extreme stressor as defined in criteria

PTSD can look like psychosis. Be aware of the whole profile.