ANXIETY ANXIETY DISORDERSDISORDERS

women affected nearly twice as frequently as men women affected nearly twice as frequently as men

Normal Anxiety - Normal Anxiety - diffuse, unpleasant, vague sense of apprehension, often accompanied by autonomic symptoms diffuse, unpleasant, vague sense of apprehension, often accompanied by autonomic symptoms

alerting signal; it warns of impending danger and enables a person to take measures to deal with a threatalerting signal; it warns of impending danger and enables a person to take measures to deal with a threat

anxiety prevents damage by alerting the person to carry out certain acts that forestall the danger anxiety prevents damage by alerting the person to carry out certain acts that forestall the danger

Fear versus Anxiety Fear versus Anxiety

Peripheral Manifestations of AnxietyPeripheral Manifestations of Anxiety

DiarrheaDiarrhea Dizziness, light-Dizziness, light-

headednessheadedness HyperhidrosisHyperhidrosis HyperreflexiaHyperreflexia HypertensionHypertension PalpitationsPalpitations Pupillary mydriasisPupillary mydriasis

Restlessness (e.g., Restlessness (e.g., pacing)pacing)

SyncopeSyncope TachycardiaTachycardia Tingling in the Tingling in the

extremitiesextremities TremorsTremors Upset stomach Upset stomach

(butterflies)(butterflies) Urinary frequency, Urinary frequency,

hesitancy, urgency hesitancy, urgency

Pathological AnxietyPathological Anxiety

P s y c h o a n a ly tic T h e o rie s :P s y c h o a n a ly tic T h e o rie s :

A n x ie ty w a s v ie w e d a s th e re s u lt o f p s y c h ic c o n fl ic t b e tw e e n u n c o n s c io u s s e x u a l o r a g g re s s iv e w is h e s a n d c o rre s p o n d in g th re a ts fro m th e s u p e re g o o r e x te rn a l re a lity . A n x ie ty w a s v ie w e d a s th e re s u lt o f p s y c h ic c o n fl ic t b e tw e e n u n c o n s c io u s s e x u a l o r a g g re s s iv e w is h e s a n d c o rre s p o n d in g th re a ts fro m th e s u p e re g o o r e x te rn a l re a lity .

- th e g o a l o f th e ra p y is to in c re a s e a n x ie ty to le ra n c e , - th e g o a l o f th e ra p y is to in c re a s e a n x ie ty to le ra n c e ,

Behavioral TheoriesBehavioral Theories : :

- anxiety is a conditioned response to a anxiety is a conditioned response to a specific environmental stimulus. specific environmental stimulus.

- In the social learning model, a child may In the social learning model, a child may develop an anxiety response by develop an anxiety response by imitating the anxiety in the imitating the anxiety in the environment, such as in anxious parents environment, such as in anxious parents

Contributions of Biological SciencesContributions of Biological Sciences

The autonomic nervous systems - exhibit The autonomic nervous systems - exhibit increased sympathetic tone, adapt slowly increased sympathetic tone, adapt slowly to repeated stimuli, and respond to repeated stimuli, and respond excessively to moderate stimuli.excessively to moderate stimuli.

three major neurotransmitters - three major neurotransmitters - norepinephrine (NE), serotonin, and GABA norepinephrine (NE), serotonin, and GABA

Alterations in hypothalamic-pituitary-Alterations in hypothalamic-pituitary-adrenal (HPA) axis function adrenal (HPA) axis function

Hypothalamic levels of CRH are increased by Hypothalamic levels of CRH are increased by stress, resulting in activation of the HPA axis stress, resulting in activation of the HPA axis

poorly regulated noradrenergic system with poorly regulated noradrenergic system with occasional bursts of activity. occasional bursts of activity.

increased 5-hydroxytryptamine (5-HT) increased 5-hydroxytryptamine (5-HT) turnover in the prefrontal cortex, nucleus turnover in the prefrontal cortex, nucleus accumbens, amygdala, and lateral accumbens, amygdala, and lateral hypothalamus hypothalamus

abnormal functioning of their GABA -A abnormal functioning of their GABA -A receptors, receptors,

•panic disorder with or without panic disorder with or without agoraphobia;agoraphobia;

•specific phobia; specific phobia;

•social phobia;social phobia; •obsessive-compulsive disorder obsessive-compulsive disorder (OCD);(OCD);

•generalized anxiety disordergeneralized anxiety disorder

panic disorder - panic disorder - acute intense attack of anxiety acute intense attack of anxiety accompanied by feelings of impending doom accompanied by feelings of impending doom

Agoraphobia -Agoraphobia - refers to a fear of or anxiety refers to a fear of or anxiety regarding places from which escape might be regarding places from which escape might be difficult. difficult. fear of having a panic attack in a public place from which fear of having a panic attack in a public place from which

escape would be formidableescape would be formidable

Panic Disorder and AgoraphobiaPanic Disorder and Agoraphobia

lifetime prevalence of panic disorder is in the 1 to 4 lifetime prevalence of panic disorder is in the 1 to 4 percent rangepercent range; ; 3 to 5.6 percent for panic attacks 3 to 5.6 percent for panic attacks

Women are two to three times more likely to be Women are two to three times more likely to be affected than men affected than men

The only social factor identified as contributing to the The only social factor identified as contributing to the development of panic disorder is a recent history of development of panic disorder is a recent history of divorce or separation divorce or separation

the mean age of presentation is about 25 years old the mean age of presentation is about 25 years old

lifetime prevalence of agoraphobia varies between 2 lifetime prevalence of agoraphobia varies between 2 to 6 percent across studies;to 6 percent across studies;

Of patients with panic disorder, 91 percent have at Of patients with panic disorder, 91 percent have at least one other psychiatric disorder as do 84 percent least one other psychiatric disorder as do 84 percent of those with agoraphobia;of those with agoraphobia;

..

Of persons with panic disorderOf persons with panic disorder::

15 to 30 %- social phobia 15 to 30 %- social phobia 2 to 20 % - specific phobia2 to 20 % - specific phobia 15 to 30 % - generalized anxiety disorder15 to 30 % - generalized anxiety disorder 2 to 10 % - posttraumatic stress disorder (PTSD)2 to 10 % - posttraumatic stress disorder (PTSD) 30 % - obsessive-compulsive disorder (OCD). 30 % - obsessive-compulsive disorder (OCD). 10 to 15 % - major depressive disorder10 to 15 % - major depressive disorder

Serotonergic dysfunction is quite evident in panic Serotonergic dysfunction is quite evident in panic disorder ;disorder ;

brainstem (particularly the noradrenergic neurons of brainstem (particularly the noradrenergic neurons of the locus ceruleus and the serotonergic neurons of the the locus ceruleus and the serotonergic neurons of the median raphe nucleus)median raphe nucleus)

the limbic system (possibly responsible for the the limbic system (possibly responsible for the generation of anticipatory anxiety)generation of anticipatory anxiety)

the prefrontal cortex (possibly responsible for the the prefrontal cortex (possibly responsible for the generation of phobic avoidance). generation of phobic avoidance).

panicogens panicogens respiratory - carbon dioxide (5 to 35 percent mixtures), respiratory - carbon dioxide (5 to 35 percent mixtures),

sodium lactate, and bicarbonatesodium lactate, and bicarbonate

Neurochemical- yohimbine, m-chlorophenylpiperazine Neurochemical- yohimbine, m-chlorophenylpiperazine (mCPP), m-Caroline drugs; flumazenil (Romazicon), (mCPP), m-Caroline drugs; flumazenil (Romazicon), cholecystokinin; and caffeine. cholecystokinin; and caffeine.

Isoproterenol - mechanism of action in inducing panic Isoproterenol - mechanism of action in inducing panic attacks is poorly understood attacks is poorly understood

first-degree relatives of patients with panic disorder first-degree relatives of patients with panic disorder have a fourfold to eightfold higher risk for panic have a fourfold to eightfold higher risk for panic disorder than first-degree relatives of other disorder than first-degree relatives of other psychiatric patients psychiatric patients

monozygotic twins are more likely to be concordant monozygotic twins are more likely to be concordant for panic disorder than are dizygotic twins for panic disorder than are dizygotic twins

Behavioral theories posit that anxiety is a response Behavioral theories posit that anxiety is a response learned either from parental behavior or through the learned either from parental behavior or through the process of classic conditioning.process of classic conditioning.

Psychoanalytic theories conceptualize panic attacks Psychoanalytic theories conceptualize panic attacks as arising from an unsuccessful defense against as arising from an unsuccessful defense against anxiety-provoking impulses. anxiety-provoking impulses.

Psychodynamic Themes in Panic DisorderPsychodynamic Themes in Panic Disorder

Difficulty tolerating anger Difficulty tolerating anger Physical or emotional separation from significant person both in Physical or emotional separation from significant person both in

childhood and in adult life childhood and in adult life May be triggered by situations of increased work responsibilities May be triggered by situations of increased work responsibilities Perception of parents as controlling, frightening, critical, and demanding Perception of parents as controlling, frightening, critical, and demanding Internal representations of relationships involving sexual or physical Internal representations of relationships involving sexual or physical

abuse abuse A chronic sense of feeling trapped A chronic sense of feeling trapped Vicious cycle of anger at parental rejecting behavior followed by Vicious cycle of anger at parental rejecting behavior followed by

anxiety that the fantasy will destroy the tie to parents anxiety that the fantasy will destroy the tie to parents Failure of signal anxiety function in ego related to self-fragmentation Failure of signal anxiety function in ego related to self-fragmentation

and self-other boundary confusion and self-other boundary confusion Typical defense mechanisms: reaction formation, undoing, somatization, Typical defense mechanisms: reaction formation, undoing, somatization,

and externalization. and externalization.

Panic AttackPanic Attack ((4 or more developed abruptly reaching a 4 or more developed abruptly reaching a peak within 10 minutes)peak within 10 minutes)

palpitations, pounding palpitations, pounding heart, or accelerated heart, or accelerated heart rate heart rate

sweating sweating trembling or shaking trembling or shaking sensations of shortness sensations of shortness

of breath or of breath or smothering smothering

feeling of choking feeling of choking chest pain or chest pain or

discomfort discomfort nausea or abdominal nausea or abdominal

distress distress

feeling dizzy, unsteady, feeling dizzy, unsteady, lightheaded, or faint lightheaded, or faint

derealization (feelings of derealization (feelings of unreality) or unreality) or depersonalization (being depersonalization (being detached from oneself) detached from oneself)

fear of losing control or fear of losing control or going crazy going crazy

fear of dying fear of dying paresthesias (numbness paresthesias (numbness

or tingling sensations) or tingling sensations) chills or hot flushes chills or hot flushes

DSM-IV-TR Diagnostic Criteria forDSM-IV-TR Diagnostic Criteria for

Panic Disorder with Agoraphobia Panic Disorder with Agoraphobia A.A. Both (1) and (2): Both (1) and (2):

1.1. recurrent unexpected panic attacks recurrent unexpected panic attacks

2.2. at least one of the attacks has been followed by 1 month (or at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: more) of one (or more) of the following:

persistent concern about having additional attacks persistent concern about having additional attacks worry about the implications of the attack or its worry about the implications of the attack or its

consequences (e.g., losing control, having a heart attack, consequences (e.g., losing control, having a heart attack, going crazy) going crazy)

a significant change in behavior related to the attacksa significant change in behavior related to the attacks

B.B. The presence of agoraphobia The presence of agoraphobia

C.C. The panic attacks are not due to the direct physiological The panic attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).a general medical condition (e.g., hyperthyroidism).

D.D. The panic attacks are not better accounted for by another The panic attacks are not better accounted for by another mental disorder.mental disorder.

Specific Phobia and Social PhobiaSpecific Phobia and Social Phobia

phobia refers to an excessive fear of a specific object, phobia refers to an excessive fear of a specific object, circumstance, or situation. circumstance, or situation.

specific phobia is a strong, persisting fear of an object specific phobia is a strong, persisting fear of an object or situation or situation

social phobia is a strong, persisting fear of situations social phobia is a strong, persisting fear of situations in which embarrassment can occur in which embarrassment can occur

Specific phobia is more common than social phobiaSpecific phobia is more common than social phobia

Specific phobia is the most common mental disorder Specific phobia is the most common mental disorder among women and the second most common among among women and the second most common among men men

Persons with social phobia may have a history of Persons with social phobia may have a history of other anxiety disorders, mood disorders, substance-other anxiety disorders, mood disorders, substance-related disorders, and bulimia nervosa related disorders, and bulimia nervosa

comorbidity in specific phobia range from 50 – 80% comorbidity in specific phobia range from 50 – 80%

Common: anxiety, mood, and substance-related Common: anxiety, mood, and substance-related disordersdisorders. .

Watson's hypothesisWatson's hypothesis : : Anxiety is aroused by a naturally Anxiety is aroused by a naturally frightening stimulus that occurs in contiguity with a second frightening stimulus that occurs in contiguity with a second inherently neutral stimulus. As a result of the contiguity, inherently neutral stimulus. As a result of the contiguity, especially when the two stimuli are paired on several especially when the two stimuli are paired on several successive occasions, the originally neutral stimulus becomes successive occasions, the originally neutral stimulus becomes capable of arousing anxiety by itself. The neutral stimulus, capable of arousing anxiety by itself. The neutral stimulus, therefore, becomes a conditioned stimulus for anxiety therefore, becomes a conditioned stimulus for anxiety production. production.

Psychodynamic Themes in PhobiasPsychodynamic Themes in Phobias Principal defense mechanisms include displacement, Principal defense mechanisms include displacement,

projection, and avoidance. projection, and avoidance. Environmental stressors, including humiliation and criticism Environmental stressors, including humiliation and criticism

from an older sibling, parental fights, or loss and separation from an older sibling, parental fights, or loss and separation from parents, interact with a genetic-constitutional diathesis. from parents, interact with a genetic-constitutional diathesis.

A characteristic pattern of internal object relations is A characteristic pattern of internal object relations is externalized in social situations in the case of social phobia. externalized in social situations in the case of social phobia.

Anticipation of humiliation, criticism, and ridicule is projected Anticipation of humiliation, criticism, and ridicule is projected onto individuals in the environment. onto individuals in the environment.

Shame and embarrassment are the principal affect states. Shame and embarrassment are the principal affect states. Family members may encourage phobic behavior and serve as Family members may encourage phobic behavior and serve as

obstacles to any treatment plan. obstacles to any treatment plan. Self-exposure to the feared situation is a basic principle of all Self-exposure to the feared situation is a basic principle of all

treatmenttreatment..

Acrophobia - fear of heightsAcrophobia - fear of heights Agoraphobia - fear of open placesAgoraphobia - fear of open places Ailurophobia - fear of catsAilurophobia - fear of cats Hydrophobia - fear of waterHydrophobia - fear of water Claustrophobia - fear of closed spacesClaustrophobia - fear of closed spaces Cynophobia - fear of dogsCynophobia - fear of dogs Mysophobia - fear of dirt and germsMysophobia - fear of dirt and germs Pyrophobia - fear of firePyrophobia - fear of fire Xenophobia - fear of strangersXenophobia - fear of strangers Zoophobia - fear of animalsZoophobia - fear of animals

DSM-IV-TR Diagnostic Criteria for DSM-IV-TR Diagnostic Criteria for

Specific PhobiaSpecific Phobia

A.A. Marked and persistent fear that is excessive or unreasonable, Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, situation (e.g., flying, heights, animals, receiving an injection, seeing blood). seeing blood).

B.B. Exposure to the phobic stimulus almost invariably provokes Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack.situationally bound or situationally predisposed panic attack.NoteNote: In children, the anxiety may be expressed by crying, : In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. tantrums, freezing, or clinging.

C.C. The person recognizes that the fear is excessive or The person recognizes that the fear is excessive or unreasonable.unreasonable.NoteNote: In children, this feature may be absent. : In children, this feature may be absent.

D.D. The phobic situation(s) is avoided or else is endured with The phobic situation(s) is avoided or else is endured with intense anxiety or distress.intense anxiety or distress.

E.E. The avoidance, anxious anticipation, or distress in the feared The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about activities or relationships, or there is marked distress about having the phobia. having the phobia.

F.F. In individuals under age 18 years, the duration is at least 6 In individuals under age 18 years, the duration is at least 6 months. months.

G.G. The anxiety, panic attacks, or phobic avoidance associated The anxiety, panic attacks, or phobic avoidance associated with the specific object or situation are not better accounted with the specific object or situation are not better accounted for by another mental disorder, such as obsessive-compulsive for by another mental disorder, such as obsessive-compulsive disorder (e.g., fear of dirt in someone with an obsession about disorder (e.g., fear of dirt in someone with an obsession about contamination), posttraumatic stress disorder (e.g., avoidance contamination), posttraumatic stress disorder (e.g., avoidance of stimuli associated with a severe stressor), separation of stimuli associated with a severe stressor), separation anxiety disorder (e.g., avoidance of school), social phobia anxiety disorder (e.g., avoidance of school), social phobia (e.g., avoidance of social situations because of fear of (e.g., avoidance of social situations because of fear of embarrassment), panic disorder with agoraphobia, or embarrassment), panic disorder with agoraphobia, or agoraphobia without history of panic disorder.agoraphobia without history of panic disorder.

DSM-IV-TR Diagnostic Criteria for DSM-IV-TR Diagnostic Criteria for

Social PhobiaSocial Phobia A.A. A marked and persistent fear of one or more social or A marked and persistent fear of one or more social or

performance situations in which the person is exposed to performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.anxiety symptoms) that will be humiliating or embarrassing.Note: In children, there must be evidence of the capacity for age-Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.occur in peer settings, not just in interactions with adults.

B.B. Exposure to the feared social situation almost invariably Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack.bound or situationally predisposed panic attack.Note: In children, the anxiety may be expressed by crying, Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with tantrums, freezing, or shrinking from social situations with unfamiliar people. unfamiliar people.

C.C. The person recognizes that the fear is excessive or The person recognizes that the fear is excessive or unreasonable.unreasonable.Note: In children, this feature may be absent. Note: In children, this feature may be absent.

D.D. The feared social or performance situations are avoided or The feared social or performance situations are avoided or else are endured with intense anxiety or distress else are endured with intense anxiety or distress

E.E. The avoidance, anxious anticipation, or distress in the feared The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is functioning, or social activities or relationships, or there is marked distress about having the phobia. marked distress about having the phobia.

F.F. In individuals under age 18 years, the duration is at least 6 months.In individuals under age 18 years, the duration is at least 6 months.

G.G. The fear or avoidance is not due to the direct physiological effects The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental medical condition and is not better accounted for by another mental disorder (e.g., panic disorder with or without agoraphobia, disorder (e.g., panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, or schizoid personality disorder). developmental disorder, or schizoid personality disorder).

H.H. If a general medical condition or another mental disorder is present, If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it (e.g., the fear is not of the fear in Criterion A is unrelated to it (e.g., the fear is not of stuttering, trembling in Parkinson's disease, or exhibiting abnormal stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa). eating behavior in anorexia nervosa or bulimia nervosa).

Obsessive-Compulsive DisorderObsessive-Compulsive Disorder Obsession - is a recurrent and intrusive thought, Obsession - is a recurrent and intrusive thought,

feeling, idea, or sensation feeling, idea, or sensation

Compulsion - is a conscious, standardized, recurrent Compulsion - is a conscious, standardized, recurrent behavior, such as counting, checking, or avoiding behavior, such as counting, checking, or avoiding

ego-dystonic ego-dystonic

Lifetime prevalence in the general population Lifetime prevalence in the general population estimated at 2 to 3 percent estimated at 2 to 3 percent

fourth most common psychiatric diagnosis after fourth most common psychiatric diagnosis after phobias, substance-related disorders, and major phobias, substance-related disorders, and major depressive disorder. depressive disorder.

men and women are equally likely to be affected men and women are equally likely to be affected

among adolescents, boys are more commonly among adolescents, boys are more commonly affected than girls affected than girls

mean age of onset is about 20 years mean age of onset is about 20 years

Comorbidity Comorbidity major depressive disorder – 67%major depressive disorder – 67%social phobia – 25%social phobia – 25%Tourette’s disorder – 5 to 7 %Tourette’s disorder – 5 to 7 %History of tics – 20 – 30%History of tics – 20 – 30%

DSM-IV-TR Diagnostic Criteria for DSM-IV-TR Diagnostic Criteria for

Obsessive-Compulsive DisorderObsessive-Compulsive Disorder A.A. Either obsessions or compulsions:Either obsessions or compulsions:

Obsessions as defined by (1), (2), (3), and (4): Obsessions as defined by (1), (2), (3), and (4): 1.1. recurrent and persistent thoughts, impulses, or images that are recurrent and persistent thoughts, impulses, or images that are

experienced, at some time during the disturbance, as intrusive experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress and inappropriate and that cause marked anxiety or distress

2.2. the thoughts, impulses, or images are not simply excessive the thoughts, impulses, or images are not simply excessive worries about real-life problemsworries about real-life problems

3.3. the person attempts to ignore or suppress such thoughts, the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other impulses, or images, or to neutralize them with some other thought or actionthought or action

4.4. the person recognizes that the obsessional thoughts, the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion) imposed from without as in thought insertion)

Compulsions as defined by (1) and (2): Compulsions as defined by (1) and (2): 1.1. repetitive behaviors (e.g., hand washing, ordering, checking) repetitive behaviors (e.g., hand washing, ordering, checking)

or mental acts (e.g., praying, counting, repeating words or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied an obsession, or according to rules that must be applied rigidlyrigidly

2.2. the behaviors or mental acts are aimed at preventing or the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive to neutralize or prevent or are clearly excessive

B.B. At some point during the course of the disorder, the person At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are has recognized that the obsessions or compulsions are excessive or unreasonable.excessive or unreasonable.NoteNote: This does not apply to children. : This does not apply to children.

C.C. The obsessions or compulsions cause marked distress, are The obsessions or compulsions cause marked distress, are time-consuming (take more than 1 hour a day), or time-consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social occupational (or academic) functioning, or usual social activities or relationships. activities or relationships.

D.D. If another Axis I disorder is present, the content of the If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an eating disorder; preoccupation with food in the presence of an eating disorder; hair pulling in the presence of trichotillomania; concern with hair pulling in the presence of trichotillomania; concern with appearance in the presence of body dysmorphic disorder; appearance in the presence of body dysmorphic disorder; preoccupation with drugs in the presence of a substance use preoccupation with drugs in the presence of a substance use disorder; preoccupation with having a serious illness in the disorder; preoccupation with having a serious illness in the presence of hypochondriasis; preoccupation with sexual urges presence of hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a paraphilia; or guilty or fantasies in the presence of a paraphilia; or guilty ruminations in the presence of major depressive disorder). ruminations in the presence of major depressive disorder).

E.E. The disturbance is not due to the direct physiological effects The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a of a substance (e.g., a drug of abuse, a medication) or a general medical condition. general medical condition.

most common pattern is an obsession of most common pattern is an obsession of contamination, followed by washing or accompanied contamination, followed by washing or accompanied by compulsive avoidance of the presumably by compulsive avoidance of the presumably contaminated object.contaminated object.

second most common pattern is an obsession of second most common pattern is an obsession of doubt, followed by a compulsion of checking. doubt, followed by a compulsion of checking.

third most common pattern, there are intrusive third most common pattern, there are intrusive obsessional thoughts without a compulsion obsessional thoughts without a compulsion

fourth most common pattern is the need for symmetry fourth most common pattern is the need for symmetry or precision, which can lead to a compulsion of or precision, which can lead to a compulsion of slowness. slowness.

Generalized Anxiety DisorderGeneralized Anxiety Disorder

1-year prevalence range from 3 to 8 percent.1-year prevalence range from 3 to 8 percent.

The ratio of women to men with the disorder is about The ratio of women to men with the disorder is about 2 to 1 2 to 1

50 to 90 percent of patients with generalized anxiety 50 to 90 percent of patients with generalized anxiety disorder have another mental disorder disorder have another mental disorder

DSM-IV-TR Diagnostic Criteria for DSM-IV-TR Diagnostic Criteria for

Generalized Anxiety DisorderGeneralized Anxiety Disorder A.A. Excessive anxiety and worry (apprehensive expectation), Excessive anxiety and worry (apprehensive expectation),

occurring more days than not for at least 6 months, about a occurring more days than not for at least 6 months, about a number of events or activities (such as work or school number of events or activities (such as work or school performance).performance).

B.B. The person finds it difficult to control the worry. The person finds it difficult to control the worry. C.C. The anxiety and worry are associated with three (or more) of the The anxiety and worry are associated with three (or more) of the

following six symptoms (with at least some symptoms present following six symptoms (with at least some symptoms present for more days than not for the past 6 months).for more days than not for the past 6 months).NoteNote: Only one item is required in children. : Only one item is required in children. 1. restlessness or feeling keyed up or on edge1. restlessness or feeling keyed up or on edge2. being easily fatigued 2. being easily fatigued 3. difficulty concentrating or mind going blank 3. difficulty concentrating or mind going blank 4. irritability 4. irritability 5. muscle tension 5. muscle tension 6. sleep disturbance (difficulty falling or staying asleep, or restless 6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) unsatisfying sleep)

D.D. The focus of the anxiety and worry is not confined to features The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about of an Axis I disorder, e.g., the anxiety or worry is not about having a panic attack (as in panic disorder), being having a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), being embarrassed in public (as in social phobia), being contaminated (as in obsessive-compulsive disorder), being contaminated (as in obsessive-compulsive disorder), being away from home or close relatives (as in separation anxiety away from home or close relatives (as in separation anxiety disorder), gaining weight (as in anorexia nervosa), having disorder), gaining weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), or multiple physical complaints (as in somatization disorder), or having a serious illness (as in hypochondriasis), and the having a serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively during anxiety and worry do not occur exclusively during posttraumatic stress disorder. posttraumatic stress disorder.

E.E. The anxiety, worry, or physical symptoms cause clinically The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or significant distress or impairment in social, occupational, or other important areas of functioning. other important areas of functioning.

F.F. The disturbance is not due to the direct physiological effects The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a mood disorder, a psychotic not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder. disorder, or a pervasive developmental disorder.

TREATMENTTREATMENT Alprazolam (Xanax) and paroxetine (Paxil) - Alprazolam (Xanax) and paroxetine (Paxil) -

approved by the US Food and Drug Administration approved by the US Food and Drug Administration (FDA) for the treatment of panic disorder (FDA) for the treatment of panic disorder

All SSRIs are effective for panic disorder All SSRIs are effective for panic disorder among tricyclic drugs, clomipramine and imipramine among tricyclic drugs, clomipramine and imipramine

(Tofranil) are the most effective in the treatment of (Tofranil) are the most effective in the treatment of panic disorder. panic disorder.

MAOIs appear less likely to cause overstimulation MAOIs appear less likely to cause overstimulation than either SSRIs or tricyclic drugs, but they may than either SSRIs or tricyclic drugs, but they may require full dosages for at least 8 to 12 weeks to be require full dosages for at least 8 to 12 weeks to be effective effective

Once it becomes effective, pharmacological treatment Once it becomes effective, pharmacological treatment should generally continue for 8 to 12 months. should generally continue for 8 to 12 months.

The most studied and most effective treatment for The most studied and most effective treatment for phobias is probably behavior therapy. phobias is probably behavior therapy.

common treatment for specific phobia is exposure common treatment for specific phobia is exposure therapy therapy

Effective drugs for the treatment of social phobia:Effective drugs for the treatment of social phobia: selective serotonin reuptake inhibitors (SSRIs) selective serotonin reuptake inhibitors (SSRIs) the benzodiazepinesthe benzodiazepines venlafaxine (Effexor)venlafaxine (Effexor) buspirone (BuSpar). buspirone (BuSpar).

Venlafaxine is approved by the FDA for treatment of Venlafaxine is approved by the FDA for treatment of generalized anxiety disordergeneralized anxiety disorder

In OCD, the standard approach is to start treatment In OCD, the standard approach is to start treatment with an SSRI or clomipramine and then move to with an SSRI or clomipramine and then move to other pharmacological strategies if the serotonin-other pharmacological strategies if the serotonin-specific drugs are not effective. specific drugs are not effective.

Benzodiazepines have been the drugs of choice for Benzodiazepines have been the drugs of choice for generalized anxiety disorder generalized anxiety disorder

Buspirone,a 5-HT1A receptor partial agonist, is most Buspirone,a 5-HT1A receptor partial agonist, is most likely effective in 60 to 80 percent of patients with likely effective in 60 to 80 percent of patients with generalized anxiety disorder generalized anxiety disorder

a2a2-adrenergic receptor antagonists may reduce the -adrenergic receptor antagonists may reduce the somatic manifestations of anxiety, but not the somatic manifestations of anxiety, but not the underlying condition underlying condition

BAP GuidelinesBAP Guidelines