ANCC Ch 8: Anxiety Disorders
ANCC + some of Barkley notes
Terms in this set (164)
Disproportionate to events, if it is sustained over a significant time frame, if it significantly impairs functioning, or if it is apparently unrelated to any identifiable event or situation in a person's life.
High pathological levels of anxiety interfere with perceptions, memory, judgement, and motor responses.
Level I, mild anxiety (Peplau)
Normative level of anxiety experienced by all
Functions to motivate the individual
Physiological s/s: VS WNL, pupils constricted, minimal increase in muscle tone
Psychological s/s: Heightened awareness of environment, perceptual field broadened
Barkley: motivation, senses, and learning increased; adaptive and necessary for survival
Level II, moderate anxiety (Peplau)
Normative level of anxiety
Experienced by most in response to significant stressors
Physiological s/s: VS WNL, mild increase in HR, moderate increase in muscle tone
Psychological s/s: Subjective feeling of tension or worry, narrowed perceptions
Barkley: selective attention, inability to concentrate, impaired learning, distorted perceptions; increase in muscular tension; restless; increased use of defense mechanisms
Somatic manifestations: pain, GI upset, immunological, CV/resp issues, GU
Level III, severe anxiety (Peplau)
Pathological level of anxiety
Physiological s/s: ANS triggered --> flight-or-fight response, dilated pupils, increased VS, diaphoresis, rigid muscles, decreased hearing, increased pain threshold, urinary frequency and diarrhea.
Psychological s/s: Narrowed perceptual field, difficulty with problem solving, distorted perception of time, selective inattention, dissociative sensations, automatic behavior
Barkley: diminished/scattered concentration, attention severely limited, inability to learn, physiological/somatic symptoms increase, response is not proportional to perceived threat, responses continue beyond the potential danger, neurosis, intellectual, cognitive, social, or occupational functioning are impaired
Level IV, panic anxiety (Peplau)
Pathological level of anxiety
Physiological s/s: Pallor, hypotension, poor eye=hand coordination, muscle pains, marked decrease in hearing, dizziness, SOB.
Psychological s/s: Scattered perceptions, unable to attend to environmental stim, illogical thinking, may have hallucinations/delusional thinking.
Barkley: MUST SLOW DOWN, pt is unable to perceive environment do not touch, sounds are distorted, just wait. Pt cannot understand simple directions, CV mortality potential, SI, severe inability to differentiate between internal environment and external reality (delusions/hallucinations), impaired IP functioning, impaired ability to communicate
Physiological/psychological findings in anxious patients
CC: may be more related to a somatic complaint. Must question the client regarding subjective sensations of being nervous, tense, worried, anxious, or stressed out
Psychological: far of dying, loosing one's mind, a sense of unreality, belief that they are ill (no findings to support this), narrowed perceptions, limited eye contact, thought content exhibing increased worry
Physiological: dilated pupils, tachycardia, increased muscle tone, HA, HTN, motor restlessness, diaphoresis, palpitations with tightness of chest, GI upset, dizziness or light-headedness.
Indicators of pathological anxiety levels
Perceived as pout pf control by the pt
Does not respond to, even momentarily, by conscious suppression
Overlaps into all spheres of functioning
Pronounced, distressing and of long duration
Unlinked to life events
Accompanied by somatic complaints
Interferes with social/occupational functioning and ADL
** Determine level using the 4-point scale above.
Dysfunctional coping in anxious patients
Increased caffeine use
Increased nicotine use
Most common group of psychiatric disorders
Anxiety Disorders; frequent comorbidity with MDD
With anxiety disorders, there is probably a multifocal etiological profile.
Anxiety disorders often present with
Mild physical complaints
Anxiety disorders may often be confused with...
Cardiac and respiratory disorders --> requires very careful differential diagnostic assessment
Psychodynamic Theory of anxiety
Freud. INTERNAL STRUGGLE OF DRIVES VS. IMPULSES!
Anxiety initially occurs in response to the stimulation of birth and need of the infant to adapt to the changed environment. Subsequent anxiety is the result of intrapsychic conflict between the id and the superego (conscience). We are unaware of this conflict but the anxiety is a signal telling the individual to deal with the conflict. Conflict is unconscious but the anxiety is perceived. Conflict entails far of punishment or of doing something wrong.
The process of unconscious repression of sexual drive is at the core of much of the conflict.
Defense mechanisms are unconsciously used by the individual to deal with conflict. The behavioral manifestations of anxiety steam from the pathological overuse of defense mechanisms.
Interpersonal Theory of Anxiety
Harry Stack Sullivan
Humans are goal directed toward attainment of satisfaction and security needs, and that these needs are usually met in interpersonal interactions. Anxiety arises when needs are not met. Anxiety is first experienced in an infants interactions with his/her mother. Subsequent anxiety arises as a result of interpersonal conflict.
Conflict occurs when an individual perceives his/her needs will not e met because of rejection, feelings of inferiority, or inability to engage with significant others.
Sense of self becomes based on the individuals perception of how others view him or her.
Pathological levels of anxiety result from neurobiological deficits in normal brain functioning.
Neurobiological Theory of Anxiety: Deficits are genetically mediated by and involve predominantly ____, ____, and _____.
The limbic system, midline brain stem area, and sections of the cortex.
Neurobiological Theory of Anxiety: These deficits predispose the individual to hyperactivity of autonomic nervous system, causing...
Increased heart rate, BP and respiratory rate, diaphoresis, papillary dilation, tremors.
Problems are found within which axis?
The hypothalamic pituitary adrenal (HPA) axis.
Treat --> amygdala --> sympathetic nervous system --> fight-or-flight response
Treat --> amygdala --> hypothalamus --> corticotropin-releasing hormone (CRH) secreted --> pituitary --> adrenocorticotropic hormone (ACTH) --> adrenal --> cortisol (which should shut off the alarm system and return body to homeostasis).
First step in Hypothalamic pituitary adrenal (HPA) axis problems:
Amygdala signals hypothalamus to secrete corticotropin-releasing hormone (CRH) in response to threat
Second step in HPA axis problems:
Amygdala activates the sympathetic nervous system to start the fight-or-flight response.
Third step in HPA axis problems:
Pituitary is stimulated to release adrenocorticotropic hormone (ACTH).
Fourth step in HPA axis problems
Adrenal glands are then stimulated to release cortisol.
What does cortisol due to in the final step of the HPA axis problem?
Shuts off the alarm system and restores the body to homeostatis.
What happens to the amygdala in those with anxiety disorders?
May not be able to shut off the response (overactive)
What happens to cortisol in those with anxiety disorders?
There may not be enough cortisol to stop the fight-or-flight response.
Low levels of what neurotransmitter are implicated in anxiety disorders?
GABA (gammaaminobutyric acid), which is the chemical responsible for inhibitory responses of neurons
High levels of what neurotransmitter are implicated with anxiety disorders?
Neurotransmitters involved in suppressing the HPA axis are
Serotonin and GABA
Collective neurobiological changes in anxiety disorders
Decreased GABA and 5HT (both function to suppress the HPA axis involved in stress responses)
Incidence of anxiety disorders in U.S.
Except for OCD and social phobia, anxiety disorders are more common in
Most anxiety disorders first manifest in what age group?
Adolescence & early childhood. Consider a general medical disorder if first episode panic attack symptoms occur after age 45!
A first-degree relative of an individual with panic disorder is up to _____ times more likely than the general population to develop panic disorder.
If a first-degree relative of an individual developed panic disorder before age 20, that individual is up to ____ times more likely than the general population to develop panic disorder.
Limited range of coping skills
Risk factor for anxiety disorder
Standardized rating scales for anxiety
Hamilton Rating Scale (HAM-A); Zung Self-rating Anxiety Scale (Zung); Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)
Cardiovascular conditions that may mimic anxiety disorders:
CHF, mitral valve prolapse, MI, arrhythmia, especially tachycardic arrhythmia (SVT), PE, and CAD
Respiratory conditions that may mimic anxiety disorders
Asthma, COPD, pneumonia
**May see compensated resp. alkalosis in anxiety pts:
Decreased bicarb and CO2 with a normal pH
Endocrine disorders that may mimic anxiety disorders
Hyperthyroidism, hyperparathyroidism, Cushing's disease
Neurological disorders that may mimic anxiety disorders:
Seizure disorder, TIA's, CVA's, encephalitis, CNS neoplasm
Metabolic Disorders that may mimic anxiety disorders:
Hypoglycemia, Vitamin B deficiency; porphyria
Substance abuse or dependency conditions that can mimic anxiety disorders
Intoxication with stimulants, withdrawal from CNS depressants (MJ & ETOH)
SSRIs & MOA
First line agents for chronic anxiety disorders
MOA: Action is on serotonin system and indirectly on GABA system
Takes 3-4 weeks to start to see symptom control
BEST when combined with psychotherapy
Benzodiazepines & MOA
Effective in treating anxiety but carry high risk for dependency; limit to lowest dose and short term use only. Long term use --> depression, tolerance, dependence, memory impairment
Use should be limited to period of excessive symptoms, period of high stress, or in unremitting symptoms
Contraindicated in pts w. hx of substance dependnece
MOA: Potentiate the effect of GABA, rapid onset of action
**Most meds known to help anxiety act on GABA
Klonopin and Valium
BNZs with longer half-lives require less frequent dosing, have less severe withdrawal and have less rebound anxiety.
Xanax and Ativan
BNZs with shorter half-lives require more frequent dosing, have more severe withdrawal and have more rebound anxiety. Increased risk of addiction!
Advantages: Less daytime sedation, less drug accumulation, quick onset of action, useful for treatment of insomnia.
TCAs for anxiety disorders
Effective but have dirty side effect profile, side effects often affect compliance.
Non-BNZ anxiolytic: Buspar (Buspirone)
SFX: insomnia, akathesia, dizziness, tremors,GI upset, dry mouth
Must be taken regularly, not PRN
Takes 6-8 weeks to see change
Usually adjunctive use with other pharmacological agent.
Non-BNZ anxiolytic: Gabitril (Tiagabine)
SFX: somnolence, dizziness, tremors, GI upset, dry mouth,
Usually adjunctive use with other pharmacological agent.
Non-BNZ anxiolytic: Neurontin (Gabapentin)
SFX: sedation, ataxia, decreased coordination, disequilibrium
Usually adjunctive use with other pharmacological agent.
Used for anxiety, neuropathic pain, fibromyalgia, and as an anti-craving medication
In children, alpha-agonists are often used for anxiety
Catapres (clonidine, dose .003-.01 mg/kg/day)
Tenex (guanfacine, dose 0.15 -0.5 mg/kg/day)
**MUST ensure not an organic CV issue FIRST!
Behavioral therapy (systematic desensitization, exposure therapy, relaxation therapies, biofeedback), CBT, IPT, community self-help groups
Comorbidities of anxiety disorders
Anemia, CV d/o (esp. arrhythmias), endocrine disorders (cushing's, hyperthyroidism, hypoglycemia), COPD, asthma, PE, pneumothorax, mood disorders, substance related disorders/withdrawal
**Many are also medical R/Os
Meds w/ anxiety as a side effect
Caffeine, nicotine, anticholinergics, antihistamines, antipsychotics, steroids, bronchodilators, anesthetics
Discrete episodes or attacks with sudden onset of intense apprehension, fearfulness, or terror, often associated with sense of impending doom. CAN LOOSE CONTACT WITH REALITY! Can make desperate attempts to escape stimulus (at risk for SI) but can also have extreme withdrawal (catatonia).
Attacks occur without real danger present; attacks build to a peak of intensity within a short, self-limiting time (usually within 10 minutes of onset). Panic attacks can occur with other anxiety disorders such as phobias or PTSD- must r/o prior to DX of Panic Disorder!
More common in women.
Begins in 2nd or 3rd decade
VERY comorbid with MDD. In 2/3 of patients, MDD occurs first. Panic disorder precedes major depression in 1/3 of cases.
In those with panic disorder, individuals are often sensitive to new somatic experiences or perceptions, and often intolerant of or concerned with common side effects of medication treatments.
Panic Disorder DX criteria
With or without agoraphobia
1) Panic Attack- A discrete period of intense fear or discomfort, 4+ s/s developed abruptly and reached a peak within 10 minutes:
palpitations, pounding heart, or accelerated heart rate, sweating, trembling or shaking, sensations of shortness of breath or smothering, feeling of choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady, lightheaded, or faint, derealization (feelings of unreality) or depersonalization (being detached from oneself), fear of losing control or going crazy, fear of dying, paresthesias (numbness or tingling sensations), chills or hot flushes
2) At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: (a) persistent concern about having additional attacks (b) worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy") (c) a significant change in behavior related to the attacks
Panic Disorder with Agoraphobia
A) anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd, or standing in a line; being on a bridge; and traveling in a bus, train, or automobile.
B) The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion.
C) The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as Social Phobia (e.g., avoidance limited to social situations because of fear of embarrassment), Specific Phobia (e.g., avoidance limited to a single situation like elevators), Obsessive-Compulsive Disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives).
3 types of Panic Disorder
1. Panic Disorder, Type I- Uncued - no internal or external trigger; experienced as "out of the blue"/spontaneous attack. May become situationally cused. NOTE: recurrent, unexpected, uncured attacks are required for inital DSM DX. If inital onset is NOT this type, consider another disorder (phobia, PTSD, GAD)
2. Panic Disorder, Type 2- Cued - occurs immediately and invariably on exposure to or in anticipation of an situational cue or trigger
3. Panic Disorder, Type 3- Situationally Cued: Similar to cued but is not immediate and not invariably cue to trigger.
Consider a general medical disorder if...
Attacks start after age 45
Atypical panic symptoms: vertigo, loss of consciousness, incontinence, HA, slurred speech, amnesic period after attacks
Panic disorder is differentiated from other disorders by:
Sudden onset of attack
Discrete, self-limiting nature of symptoms
Paroxysmal symptom profile (intense and sudden)
Level III-IV anxiety symptoms with somatic complaints that are experienced as distressing and severe by the pt
What should you assess to identify type of Panic Disorder?
Focus of anxiety, type and number of episodes; number of situations avoided by client, and level of anxiety experienced between attacks.
**Often have high levels of anticipatory anxiety between episodes
NOT an independent DSM DX- only coded in relation to panic disorder
Avoidance of places or situations from which escape may be difficult or embarrassing or in which help may not be available in the event of perceived need, such as a panic attack.
The anxiety usually leads to avoidant behaviors that impairs an individual's ability to travel, to work, or to carry out responsibilities of daily living.
One way to differentiate agoraphobia
The individual feels better and reports less significant concerns with anxiety when accompanied by a trusted companion (p162)
Agoraphobia most commonly occurs in conjunction with panic disorder and is labeled as
Panic Disorder with agoraphobia. Must meet criteria for panic disorder and must experience agoraphobic anxiety.
DX if agoraphobia is experienced without panic disorder?
"Agorphobia without history of panic disorder"
Specific (simple) Phobias
Clinically significant level of marked and persistent fear that is clearly observable and is, by client perception, clearly related to specific objects or situations. In adults, but not in children, there exists the conscious recognition that the fear is excessive or unreasonable.
In children, the degree of insight to the fear increases with age.
Level of anxiety in phobias is directly related to physical proximity and the degree to which escape is possible .
Individual engages in avoidant behavior and/or situation endured with extreme dread; distressful and has implications for social, recreational, or occupational functioning.
Risk factors for phobias:
Traumatic past exposure, seeing trauma occur to others, excessive informational transmission (repeated graphic parental warnings of dangers of certain events or situations); and genetic loading.
Most familial risk factor
Blood-injection-injury subtype. Subtype aggregation patterns are noted within families.
Kids & phobias
Children manifest anxiety by: crying, freezing, tantrums, excessive clinging.
DX should ONLY be made when there is significant functional impairment (such as the refusal to go to school for fear of seeing a dog).
There are 5- situational, natural environment, blood-injection-injury, animal, and other. Degree of anxiety may fit the criteria for a cued panic attack (d/t very similar symptom presentation)
Can have more than 1 type of phobia. Phobia within one type, predisposes the individual to another phobia within that same type (ex: phobia of rats and spiders)
Phobia: 1. Situational type
Cued by specific situations (ex: flying, bridges, ect).
Most common adult form. In elderly people, fear of closed-in situations is most common.
Bimodal peak of onset: first peak, childhood; second peak, mid 20s
Phobia: 2. Natural Environment Type
Second most common form of adult phobia
Fear cued by objects in the natural environment (ex: storms, heights, water, lightening)
Onset usually in childhood
Phobia: 3. Blood-Injection-Injury Type Phobia
Cued by seeing blood or an injury or by receiving an injection or other invasive medical procedure
Third most common phobia in adult form- high familial pattern!
There is a strong vasovagal component that can produce other somatic sensations; may exacerbate cardiac or respiratory disorders; fainting; paraoxysmal tachycardia and hypertension followed by deceleration of heart rate and drop in BP
Phobia: 4. Animal Type
Fear cued by animals or insects.
4th most common form; onset is usually in childhood
Phobia: 5. Other
Fear cued by range of other stimuli; such as fear of choking, vomiting and fear of specific illness.
In children often manifests as fear of load sounds or costumed characters.
With phobias, If avoidance behavior present, consider
PTSD, OCD, separation anxiety disorder or psychotic disorder
Social Anxiety (Phobia) Disorder (SAD)
Marked and persistent fear of social or performance situations in which embarrassment may occur
Anxiety levels are often so severe that they fit criteria for a situationally bound panic attack
Affects 3-13% among U.S. population and is = in M and W (as well as OCD, the rest have higher rates of females affected)
Onset is in the med-teens, often following humiliating experiences, and tends to remit with age
**These pts DO NOT feel better or experience decreased anxiety in social situations even when they have a trusted companion (as seen in agoraphobia)
SAD DSM DX
Some degree of social anxiety is normal in adolescents and social phobia should only be DX'd is symptoms persist for longer than 6 months
DSM: A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.
B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The fear or avoidance is not due to the direct physiological effects of asubstance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).
H. 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 Stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.
Specify if: Generalized: if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder)
Common Descriptive Features of SAD
Hypersensitivity to criticism; negative self-evaluations; sensitivity to rejection; low self-esteem; inferiority feelings; lack of assertiveness; protracted anticipatory anxiety may occur days or weeks before the feared social situation; subjective distress/impaired functioning is significant and associated with suicidal ideation
In addition to SSRIs and BNZs (short term use), SAD may be treated with
Beta blockers for discrete-episode relief (such as before having to attend a social function). MUST always try the med BEFORE the actual event to see how it is tolerated by the individual.
Presence of anxiety-provoking obsessions or compulsions that function to reduce the individual's subjective anxiety level.
M = W in prevalence rates (same w/ SAD)
Onset is most common during adolescence or early childhood.
Recurrent and persistent thought, impulse, or images that are experienced and that cause anxiety and distress; can be intrusive and inappropriate
Ego-dystonic- the individual feels the content of obsession is alien to his or her belief structure and not the kind of common thought, impulse, or image he/she usual experiences.
Repetitive behaviors or mental actions such that an individual feels driven to perform in response to an obsession. Functions as a means to bind anxiety!
Usual age of onset of OCD in and women
15 (men) and 20 (women)
Risk factors for OCD
Genetic loading. Risk higher for those with first-degree relative who has OCD. Rates are also higher in individuals with a first-degree relative who has Tourette's syndrome.
Diagnostic criteria for OCD
Presence of either obsessons or compulsions
The individual recognizes that this is excessive or unreasonable
The obsession or compulsion is accompanied by marked distress, is time consuming and interferes with normal life.
DSM OCD DX criteria
A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
(1) recurrent and persistent thoughts, impulses, or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
(2) the thoughts, impulses, or images are not simply excessive worries about real-life problems
(3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
(4) the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)
Compulsions as defined by (1) and (2):
(1) repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
(2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive
B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.
C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships.
D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).
Obsessions do not usually involve
Real world worries such as concerns over finances.
Common obsessions include: contamination, repeated doubts, need to have things in a specific order, aggressive or horrific impulses, sexual imagery
What level anxiety is present with compulsions?
Anxiety Level III
Function of compulsions (aka rituals)
With OCD, behaviors or mental acts (counting, praying) are not experienced as pleasurable and are intended to prevent or reduce distress and subjective anxiety. If the individual resists the compulsion, anxiety and subjective tension increase
Some individuals with OCD believe the compulsions
Can prevent some dreaded event or situation that is experienced as an obsession, such as sexual or horrific images.
Differential diagnosis for OCD
Body dysmorphic disorder; eating disorders; trichotillomania; hypochondriasis, Obsessive-compulsive personality disorder; tic or sterotypic movement disorder
Common comorbidities with OCD
Major depression; eating disorders, other anxiety disorders.
Hypochondriasis and a somatic fixation are often common
Pharmacological Management of OCD
SSRIs- Luvox, prozac, paxil, zoloft
TCAs- Anafranil (Clomipramine Hcl)
Lifespan considerations: OCD & childhood
In children, OCD is associated with group A beta-hemolytic streptococcal infections (scarlett fever, strep throat)
More common in childhood, usually with prepubertal onset
More common in boys than girls
Most common behavioral manifestations: washing, checking, and ordering
Children with OCD may also have learning disorders, disruptive behavioral disorder, and Tourette's syndrome
Lifespan considerations: OCD & older adults
More obsessions than compulsions usually present.
Obsessive content characteristically about dying.
Compulsions characteristically about washing and cleaning.
Re-experiencing an extremely traumatic event accompanied by symptoms of increased arousal and avoidance of stimuli associated with the trauma
With PTSD, the trauma may be a direct or
Indirect experience (witnessed)
There is a relationship between the individual's ___________ to the traumatic event and the likelihood of symptom onset.
Genetic loading, runs in families, h/o experienced trauma/witnessed trauma, h/o MDD in first-degree relative
Symptoms for less than 3 months
Symptoms last 3 months or longer
PTSD, Delayed onset
At least 6 months between traumatic event and the onset of symptoms
PTSD DSM Criteria
1+ s/s of re-experiencing/intrusive recollection, 3+ s/s of avoidance/numbing, and 2+ s/s of increased arousal/hypervigilance
S/s last for 1 month or longer
** Specify if acute, chronic, or with delayed onset!
Diagnostic criteria for PTSD: EXPOSURE
Experienced, witnessed, confronted - event involving actual/threatened death, serious injury AND response involved fear, helplessness or horror
Diagnostic criteria for PTSD: RE-EXPERIENCE
Intrusive distressing recollections that include images, thoughts and perceptions- Ex: flashbacks and rare cases involving dissociative states lasting hours to days
Feeling of event recurring
Intense psychological distress to cues that symbolize or resemble traumatic event
Physiological reactivity on exposure to cues.
Diagnostic criteria for PTSD: AVOIDANCE
Avoidance of stimuli & numbing of responsiveness
Efforts to avoid talking or thinking about event
Poor recall of important aspects r/t event
Decrease interest in activities
Feelings of detachment
Restricted range of affect
Sense of foreboding/shortened future, premature death, no expectations for success or happiness
Diagnostic criteria for PTSD: AROUSAL
Difficulty falling asleep
Exaggerated startle response.
Diagnostic criteria for PTSD: OTHER
Symptoms occur within 3 months of trauma (if its more than 6 months --> delayed onset)
Impairment in ADLs
High variation of duration of symptoms & waxing and waning of symptoms (50% of cases have s/s that remit within 3 months)
Differential Diagnosis for PTSD
Adjustment disorder, brief psychotic disorder, acute stress disorder, intrusive thoughts in OCD
Acute Stress Disorder DSM DX criteria
A. The person has been exposed to a traumatic event in which both of the following were present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
(2) the person's response involved intense fear, helplessness, or horror
B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:
(1) a subjective sense of numbing, detachment, or absence of emotional responsiveness
(2) a reduction in awareness of his or her surroundings (e.g., "being in a daze")
(5) dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
C. The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashbackepisodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.
D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping,irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
Common findings in pts w/ PTSD
Often have insomnia --> frequent chief complaint that brings them in for TX
Increase in autonomic functioning: tachycardia, diaphoresis, increased RR, dilated pupils, increased startle response
Pharmacological Treatment of PTSD
SSRIs, TCAs, BNZs, and antipsychotics during episodes of flashbacks
Common comorbidities with PTSD
Major depression, dysthymia, substance abuse or dependence
Childhood symptoms of PTSD
Expression of fear and horror occur in disorganized or agitated behaviors; repetitive play behaviors show themes or aspects of trauma; frightening dreams, but without recognized content are common
Generalized Anxiety Disorder (GAD)
Excessive worry, apprehension, or anxiety about events or activities occurs more days than not for a period of at least 6 months.
Hard to control anxiety, no clear link to life events or stressors, worry/anxiety interferes with daily living, nature and focus of anxiety shifts frequently, waxing and waning of symptoms present, symptoms worsen with life stresses.
Demographics of GAD
Onset of GAD, usually age 20
2/3 of patients are female
Risk factors for GAD
Anxiety and worry are out of proportion to the actual likelihood or impact of the feared event. Patients report subbjective distress caused by the constant worry but
Do not always describe the worry as excessive. Occurs on more days than not x 6 months. Individual finds it difficult to control the anxiety!
Differential diagnosis for GAD
PTSD, Adjustment disorder with anxiety, obsessions in OCD, and anxiety associated with another disorder such as hypochondriasis or social phobia
Associated health care problems for GAD
IBS, Migraines and other headache disorders
Often comorbid with mood disorders, other anxiety disorders and substance related disorders
Physical signs of anxiety include
Muscle tension, aches, soreness, tremors & twitching, subjective c/o shakiness, SOB, tachycardia, increased RR, dizziness, numbness, fatigue (activity intolerance), sleep disturbance, muscle tension and increased tone, autonomic hyperarousal, irritability, and difficulty concentrating
Pharmacological TX of GAD
Benzos as PRN agents
**Good candidates for therapy as a single TX modality
GAD in children
Anxiety is manifested in excessive worry over competence or quality of performance in school/sports
Common worry often manifests as anxiety over punctuality or natural catastrophes such as earthquake or war.
Overly conforming behavior, perfectionist self-expectations, excesive seeking of approval of others, need for frequent reassurance about performance.
Nonpharmacological TX of various anxiety d/o:
Panic disorder: CBT, individual or group therapy, exposure therapy, relaxation therapies
Agoraphobia: CBT, supportive group therapy, desensitization therapy
Specific phobia: CBT, biofeedback, desensitization therapy
SAD: CBT, exposure therapy, relaxation therapy
OCD: CBT and behavioral therapies
PTSD: CBT, group therapy, relaxation therapies, EMDR (eye movement desensitization and reprocessing)
GAD: CBT, relaxation therapies, stress management, supportive counseling
**GAD pts cn be good candidates for therapy as a single-treatment modality
The psychodynamic theory of anxiety states that the etiology of anxiety is
Conflict between the id and the ego
The interpersonal theory of anxiety states that the etiology of anxiety is
Perceived disapproval from significant others
Severe symptoms of anxiety can include
High use of defense mechanisms, physical discomfort, feelings of dread and horror; trembling, ritualistically washing his hand.
Which level of anxiety is considered normal and useful in motivating a person to action?
Stress Diathesis Model
Inherited vulnurability + acquired stress = disease/dysfunction
Attempts to explain behavior as a predispositional vulnerability together with stress from life experiences. The term diathesis derives from the Greek term for disposition, or vulnerability, and it can take the form of genetic, psychology, biological, or situational factors. A large range of individual differences exist between persons in their vulnerability to the development of disorder. The diathesis, or predisposition, interacts with the subsequent stress response of an individual. Stress refers to a life event or series of events that disrupt a person's psychological equilibrium and potentially serves as a catalyst to the development of a disorder. Thus, the diathesis-stress model serves to explore how non-biological or genetic traits (diatheses) interact with environmental influences (stressors) to produce disorders, such as depression, anxiety, or schizophrenia. The diathesis-stress model asserts that if the combination of the predisposition and the stress exceeds a threshold, the person will develop a disorder
General Adaptation Syndrome
1. ALARM STAGE - Your first reaction to stress recognizes there's a danger and prepares to deal with the threat, a.k.a. the fight or flight response. Activation of the HPA axis, the nervous system (SNS) and the adrenal glands take place. During this phase the main stress hormones cortisol, adrenaline, and noradrenaline, is released to provide instant energy. If this energy is repeatedly not used by physical activity, it can become harmful. Too much adrenaline results in a surge of blood pressure that can damage blood vessels of the heart and brain - a risk factor in heart attack and stroke. The excess production of the cortisol hormone can cause damage to cells and muscle tissues. Stress related disorders and disease from cortisol include cardiovascular conditions, stroke, gastric ulcers, and high blood sugar levels. At this stage everything is working as it should - you have a stressful event, your body alarms you with a sudden jolt of hormonal changes, and you are now immediately equipped with enough energy to handle it.
2. RESISTANCE STAGE -The body shifts into this second phase with the source of stress being possibly resolved. Homeostasis begins restoring balance and a period of recovery for repair and renewal takes place. Stress hormone levels may return to normal but you may have reduced defenses and adaptive energy left. If a stressful condition persists, your body adapts by a continued effort in resistance and remains in a state of arousal. Problems begin to manifest when you find yourself repeating this process too often with little or no recovery. Ultimately this moves you into the final stage.
3. EXHAUSTION STAGE - At this phase, the stress has continued for some time. Your body's ability to resist is lost because its adaptation energy supply is gone. Often referred to as overload, burnout, adrenal fatigue, maladaptation or dysfunction - Here is where stress levels go up and stay up! The adaptation process is over and not surprisingly; this stage of the general adaptation syndrome is the most hazardous to your health. Chronic stress can damage nerve cells in tissues and organs. Particularly vulnerable is the hippocampus section of the brain. Thinking and memory are likely to become impaired, with tendency toward anxiety and depression. There can also be adverse function of the autonomic nervous system that contributes to high blood pressure, heart disease, rheumatoid arthritis, and other stress related illness.
Stages of stress
Stress (event) --> Alarm (physiological response) --> resistance (defense mechanism) --> Adaptation (symptoms resolve = goal)
Stress continuation/increase/additional? --> Exhaustion (resources depleted) --> Disease (death)
**Adaptation is a healthy response to stress, with homeostasis being the goal!!
Initial response to stress
Hypothalamus --> sympathetic nervous system --> adrenal medulla --> releases epinephrine and norepinephrine into the blood stream
Biological response to stress
Dilated pupils, increased secretion from the lacrimal glands, bronchioles and pulmonary blood vessels dilate (so blood can flow out to limbs), increased CV output/contractility, HR, and BP, decreased motility and secretions from GI tract/sphincters, liver glycogenolysis and gluconeogenesis increased, decreased glycogen synthesis, fat cells undergo lipolysis, increased kidney ureter motility, smooth muscle of the bladder contracts/sphincter relaxes
Biological response to sustained stress (HPA axis)
Hypothalamus stimulates pituitary gland, releasing:
ACTH (which stimulates the adrenal cortex), mineralocorticoids, vasopressin (ADH), growth hormone, TSH (which stimulates the thyroid gland), and gonadotropins
Primary appraisal of a stressor
Individual makes a judgement of the stressor- deemed irrelevant, benign, or a threat.
Secondary appraisal of a stressor
Assessment of coping- resources, knowledge, ability to cope. Outcome results from the interaction between the primary and secondary appraisal and determines and individual's quality of adaption response.
Adaptive strategies vs. maladaptive strategies
Adaptive strategies- protect and restore homesotasis
Maladaptive strategies- used when stress is unresolved or intensifies
One of the most common and comorbid conditions
12-25% of US population experience pathological anxiety in their lifetime
W (30.5%) > M (19.2%)
The "four F's" are a mnemonic device for recall of the four behaviors associated with the hypothalamus - fighting, fleeing, feeding & fornicating. These are the basic drive related to survival.
Goal of TXing anxiety
Is not to eradicate the signal, but to increase one's tolerance and capacity to use anxiety as a tool for survival
6 factors in ruling out organic causes of anxiety
1.Onset after 35
2. Endocrine (hyperthyroidism)
4. Respiratory disease
6. SZ d/o
**Anxiety can mimic a lot of things- must do a nutritional assessment as well as substance abuse assessment
Medications that can mimic s/s of anxiety
Beta-adrenergic agents, theophylline (resp. med), corticosteroids, thyroid hormones, BC pills, stimulants, SSRIs, chemo
Substance abuse/withdrawal: alcohol, caffeine, amphetamines, cocaine
Enhance inhibition of GABA --> hyperpolarization of neurons --> makes the neuron less responsive to excitatory NT (glutamate)
1st line TX for anxiety d/o
Prozac- OCD 20-80 mg/day
Paxil- OCD, panic, social anxiety- 40-60 mg/day
Zoloft- panic, OCD (child & adult), PTSD- 50-200 mg/day
*Can give benzo until SSRI kicks in!
Other pharm TXs for anxiety d/o
Buspar- no CNS sedation, can go as high as 30 mg/day. Requires BID/TID dosing. Can take as log as 6-8 weeks to work! CAUTION WITH MAOIS AND HALDOL!
Betablockers- situational anxiety
Anafranil (TCA)- used for OCD 100-200 mg/day
Amitriptyline (Elavil) (TCA) & trazodone are used for agoraphobia and depression/paradoxical effect
Panic disorder demographics
25% = unemployed
1/3 = disability/public assistance
Significant morbidity/mortality, suicide
Freudian theory of phobias
Oedipal- child is frightened of aggression they feel --> fear is displaced and repressed (object relations), original anxiety displaced to a symbolic object (fear of phallus becomes fear of snakes)
Desensitization vs. flooding
Desensitization- systematic/well-paced and controlled way to introduce the pt to their fear/phobia; learnt o manage feelings through it and go forward
Flooding- intense approach; must have good ego strength
OCD etiological theories
Psychoanalytic: weak/under-developed ego --> regression to the preoedipal stage during times of anxiety --> obsessions/compulsions
Learning: conditioned response to a traumatic event
Biological: heritability + environmental stressor
Neuroanatomy: lesions in various regions of the brain have been implicated
Some OCD individuals exhibit non-specific EEG changes
Biochemical: decreased 5HT
Biological theory of PTSD
Symptoms maintained by endogenous opioid peptides
Removal of the stressor --> opioid withdrawal/symptoms similar to PTSD
Somatoform Disorders (4)
Physical symptoms characteristic of a medical disease. No organic cause. Psychological distress and chronic use of health services.
1. Pain disorder
2. Conversion disorder
4. Body dysmorphic disorder
Theories: anxiety is translated into physical illness.
Psychodynamic: poor mother-child relation
Family: focus shifted from family problems and onto "sick child"
Cultural: emotional problems not accepted within a culture
Interventions- learn to correlated physical symptoms with stress
Positive reinforcement fuels illness to continue via avoidance of undesired activities, support/assistance from others, and avoidance of emotional/psychological distress
Severe, chronic pain, with no organic cause found
Psychoanalytic: punishment/unconscious guilt/punishment as a child
Behavioral: +/- reinforcement
Family: pain garners support, + reinforced
Neurophysiological: inhibition of pain signals, decreased 5HT and endorphins
Interventions: learning more adaptive coping techniques [relaxation, distraction, and biofeedback (reinforcement given at times of no pain)]
Unrealistic preoccupation/fear of having a serious illness; when sick, s/s are disproportional to the illness
Psychodynamic: ego defense mechanism (physical disease more acceptable) --> sublimation of aggressive thoughts/feelings (guilt) towards others
Psychotherapy TX: identify feelings of self-worth
CBT: identification/resolution of internalized anger
Loss/change in physiological function without medical cause and accompanied by an inappropriate lack of concern with change ("La Belle Indifference" = hallmark of the disorder)
Psychoanalytic: emotions cannot be expressed --> converted to physical symptoms
Neurophysiological: decreased CNS arousal
Behavioral: + reinforcement
DO NOT reinforce the physical limitation but assist with ADLs until function is normalized
Body Dysmorphic Disorder
Exaggerated belief that the body is deformed
Associated with: depression, OCD behaviors, delusional thinking
TX: CBT with the goals of a realistic perception of one's self, identification/resolution of repressed fear/anxiety, and + reinforcement for accomplishments unrelated to physical appearance
Dissociative Disorders (4)
Disturbance/alteration of the integrative functions of identity, memory, or consciousness
1. Dissociative Amnesia
2. Psychogenic Fugue
3. Dissociative Identity Disorder (DID)
4. Depersonalization Disorder
Sudden inability to recall important personal information. 4 types:
1. Localized- no memory of details associated w/ traumatic event
2. Selective- recalls selective details for specific time after the event
3. Generalized- recall for events of past life, personal identity lost
4. Continuous- unable to recall events occurring after a specific time
Behavioral: reinforced by primary and secondary gains
Most cases resolve spontaneously, hypnosis, assist pt in learning adaptive coping skills/recall past
Amobarbital- to help retrieve lost memories
Sudden unexpected travel away from home or ones customary place of work, with inability to recall one's past. Confusion about personal identity or assumes new identity (partial or complete). Etiological theories are the same as dissociative amnesia
Intervention goals: assist pt in coping w/ severe anxiety and/or aggression. usually recovers rapidly, spontaneously, and completely.
Organic fugue states can be caused by a variety of meds-like phenothiazines, triozolam, hallucinogenic drugs, barbiturates, steroids, ect.
Borderline, histrionic, schizoid
Usually purposeful travel covering long distances
Unaware of memory loss
Display normal behavior during fugue
May be perplexed or disoriented
Dissociative Identity Disorder (DID)
The presence of 2 or more distinct identities or personality states (each with its own pattern of relating to the environment and self)
At least 2 states recurrently take control of the persons behavior. There are sudden, swift, and dramatic transitions between personalities, that are usually precipitated by stress. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. Not due to substances (alcohol) or GMC (complex partial seizures).
More common in 1st degree biological relatives
Psychological: traumatic experience overwhelms and individuals capacity to cope. Trauma usually happens in childhood and can be triggered later in life by stress.
Family dynamics: dysfunction with at least one caretaker with severe psychopathology
Interventions: protection from self-directed violence, assist pt in understanding the reasons for multiple personalities
TX: hypnosis, impressing the importance of merging personalities, abreaction in long-term psychotherapy
Psychoanalytical term for reliving an experience in order to purge it of its emotional excesses; a type of catharsis. Sometimes it is a method of becoming conscious of repressed traumatic events. Abreaction therapy is a form of psychotherapy in which abreaction is used to assist a patient suffering from post-traumatic stress disorder by re-living the experience in a controlled environment. Hypnosis is often used as a tool for recall in abreaction therapy.
(from online PPT)
Most severe and chronic dissociative d/o
Original personality is generally amnestic of & unaware of the other personalities
May be aware of certain aspects of other personalities
Each may have their own set of memories name & description, age, sex or race
May have different physiologic characteristics: e.g. diff eyeglass prescriptions
Psychometric testing: i.e. diff IQ scorings or
Psychiatric disorders: mood or personality disorders
Psychodynamics: Severe psychological & physical abuse (mostly sexual) in childhood leads to a profound need to distance ones self from horror and pain. This leads to an unconscious splitting off of different aspects of the original personality, with each personality expressing a necessary emotion or state (rage, sexuality, competence, playfulness) that the original personality dare not express. During abuse, the child attempts to protect him / herself from trauma by dissociating from the terrifying acts, becoming in essence another person who could not be subject to abuse or who is not experiencing abuse.
DID steps in therapy
Establish strong therapeutic alliance and a safe atmosphere
Have consistency ,clear communication, set boundaries with most readily reached personalities and agreements not to abandon therapy
Hx gathering from the diff alters and understanding their reasons for creation and persistence-their problems, concerns and how they function, responding to all alters in the same way
Pacing therapy to avoid re-traumatizing pt as buried trauma resurfaces
Facilitate integrating the personalities into one by pressing for collaboration and cooperation among the alters
Teaching new coping skills
Help pt understand that original reasons for dissociation (overwhelming rage, fear & confusion secondary to abuse) no longer exist & affect states can be expressed by one whole person without the self being destroyed
Temporary change in the quality of safe-awareness, often manifesting feelings of: unreality, changes in body image, feelings of detachment from the environment, and a sense of observing oneself from outside of the body
R/O: brain tumor
Psychodynamic: psychic conflict and disturbances of ego structure
Promote accurate perception of the self and environment and assist pt in responding more adaptively to stress
No particular theory has been proven widely successful- benzos for anxiety; amobarbital & ritalin with mixed results
Depersonalization Disorder (continued)
(from online PPT)
Depersonalization- is feeling that the body or personal self is strange
Derealization- perception of objects in the external world are strange and unreal
DX: A. Persistent or recurrent experiences of feeling detached from & as if one is an outside observer of, one's mental processes or body (e.g. like feeling like one is in a dream)
B. During the episode, reality testing remains intact
C. Causes significant distress or impairment in social, occupational functioning
Distortion in sense of time and space
Parts of the body (limbs) may seem unreal, detached or strange
Causes could be substance abuse, (benzos, THC, alcohol) epilepsy, endocrine d/os, emotional trauma.
Ego-dystonic: Pts are very aware of their disturbed sense of consciousness
TX: anxiolytics, supportive and insight oriented therapy
As anxiety is reduced, episodes of depersonalization decrease
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