u 5
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Unit 5: Anxiety Disorders
Obsessive-Compulsive and Related Disorders
Trauma-and Stressor-Related Disorders
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Learning Objectives:
Describe the background of Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-related disorders
Identify the types of Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-related disorders
Discuss the causes of Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-related disorders
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Normal versus Pathologic Anxiety:
Normal anxiety is adaptive, inborn response to threat or absence of safety
Pathologic anxiety is excessive and impairs function
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General considerations for Anxiety Disorders:
Early onset, often in teens or early twenties
2:1 female predominance
Waxing and waning course over lifetime
Similar to major depression and chronic diseases in functional impairment and decreased quality of life
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Primary versus Secondary Anxiety:
Anxiety may be due to primary anxiety disorders or secondary to substance abuse, medical conditions, other psychiatric conditions, or psychosocial stressors
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Comorbid diagnoses:
It is common for other psychiatric diagnoses to be present alongside an anxiety disorder, which can impact treatment and prognosis
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9 Mental Disorders under Anxiety Category in DSM-5:
Separation Anxiety Disorder
Selective Mutism
Specific Phobia
Social Anxiety Disorder
Panic Disorder - Panic Attack
Agoraphobia
Generalized Anxiety Disorder
Substance/Medication-Induced Anxiety Disorder
Anxiety Disorder Due to Another Medical Condition
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Prevalence of Anxiety Disorders:
Specific Phobia: 8-12% of people
Social Anxiety Disorder (SAD): 7%
Panic Disorder: 2-3%
Agoraphobia: 1-2.9%
Generalized Anxiety Disorder (GAD): 2%
Separation Anxiety Disorder: 1-1.9%
Selective Mutism: 0.47-0.76%
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Signs & Symptoms of Anxiety:
Major Signs of Anxiety:
Cognitive: concentration problems, memory problems, recurrent, localized pain, attention problems, worry, cognitive dysfunctions
Behavioral: motor restlessness, "fidgety," erratic behavior, lack of participation, failing to complete tasks, seeking easy tasks
Physiological: rapid heart rate, sweating, shaking, freezing, flushing of the skin, perspiration, headaches, withdrawal, muscle tension, sleeping problems, nausea, vomiting, enuresis
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Anxiety Categories:
Generalized Anxiety Disorder (GAD): exaggerated feeling of uneasiness, impending doom
Specific Phobia: irrational fears of specific objects/situations
Agoraphobia: fear of being in open and crowded places
Social Anxiety Disorder (SAD): fear of overwhelming embarrassment or humiliation
Panic Disorder: sudden/intense feeling of fear or panic attack
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Prevalence of GAD in Malaysia:
National Health Morbidity Survey IV (NMHS IV) in 2011 reported a prevalence of GAD as 1.7%
Higher prevalence among females in the younger age group (16-24 years old) and the Indian ethnic group
Higher prevalence among singles, widows/widowers, divorcees, and those with tertiary education level
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Generalized Anxiety Disorder Epidemiology:
4-7% of the general population
Median onset at 30 years with a large range
Female-to-male ratio of 2:1
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Non-pathological Anxiety in GAD:
Mild anxiety allows normal functioning, severe anxiety impairs functioning
Endless, repetitive anxious thoughts in severe cases
Social, occupational, and other areas of functioning are affected
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DSM-5 Criteria for Generalized Anxiety Disorder:
Excessive anxiety and worry associated with difficulty controlling it
3 or more of the following symptoms occurring more days than not for at least 6 months:
Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
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Factors that keep GAD going:
Intolerance of uncertainty
Positive beliefs about worry
Certainty-seeking strategies
Planning in advance
Avoidance strategies
Cognitive avoidance orientation
Negative problem orientation
Seeking reassurance
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Causes of GAD:
Combination of factors involved
Biological factors: changes in brain functioning
Family history of mental health problems
Stressful life events
Psychological factors: perfectionistic tendencies, sensitivity
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Treatment for GAD:
Medication: anti-depressants, especially SSRIs like sertraline and fluoxetine
Benzodiazepines used in conjunction with anti-depressants for fast-acting relief
Medication affects serotonin activity in the brain's anxiety response
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Psychotherapy is a form of treatment for anxiety that involves talking to a mental health professional.
Cognitive-Behaviour Therapy is a common therapy used in psychotherapy.
The Generalized Anxiety Disorder (GAD) 7-item scale is a screening tool for anxiety disorders.
A score of ≥8 on the scale suggests an anxiety disorder.
A total score of ≥10 indicates a probable diagnosis of generalized anxiety disorder.
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Exposure therapy aims to reduce a person's fearful reaction to a stimulus.
Graded exposure involves targeting mildly feared stimuli first, followed by more strongly feared stimuli.
Flooding involves addressing the most difficult stimuli from the beginning of treatment.
In vivo exposure refers to real-world confrontation of feared stimuli.
Imaginal exposure can be used as an alternative when in vivo exposure is not feasible.
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Systematic desensitization is a type of behavioral therapy based on classical conditioning.
The therapy aims to remove the fear response of a phobia and replace it with a relaxation response.
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In PTSD, exposure therapy helps the patient face and gain control of the fear and distress from the trauma.
Trauma memories or reminders can be confronted all at once (flooding) or gradually (desensitization).
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Step 1 in exposure therapy is to build a hierarchy of anxiety-arousing stimuli.
Step 2 involves training the client in deep muscle relaxation.
Step 3 is when the client works through the hierarchy while using relaxation techniques.
Step 4, used in some cases, involves the client confronting their real fear.
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Relaxation techniques such as deep breathing exercises, meditation, and distraction can help calm anxiety.
A healthy lifestyle, including physical activity, healthy food, and enough sleep, is beneficial for reducing anxiety.
Limiting caffeine intake and avoiding smoking, alcohol, and drugs can also help reduce anxiety.
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The transcript on this page is a questionnaire for diagnosing anxiety disorders.
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This page only contains the header "SPECIFIC PHOBIA."
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Specific phobia is when an individual has a high level of fear or anxiety in the presence of a specific circumstance or object.
The fear or anxiety must be significantly disproportionate to the actual threat involved.
Specific phobias can result from experiencing or witnessing a traumatic experience.
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The primary feature of a specific phobia is a significant fear or anxiety of a specific object or situation.
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Categories of specific phobias include natural/environment type, injury type, animal type, situational type, and other types.
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Symptoms of specific phobia include muscle tension, shortness of breath, shaky, trouble breathing, feeling on edge, and more.
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Up to 15% of the general population may have specific phobias.
Specific phobias often onset early in life, with a female-to-male ratio of 2:1.
Learning and contextual conditioning are possible etiologies of specific phobias.
Systematic desensitization is a treatment for specific phobias.
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This page only contains the header "AGORAPHOBIA FEAR OF ENTERING OPEN OR CROWDED PLACES."
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Agoraphobia is a fear of places that can leave a person a prisoner in their own home.
It is associated with severe panic disorder and involves avoiding places where panic attacks have occurred.
Agoraphobia reflects an anxiety disorder.
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Agoraphobia is marked by fear or anxiety about specific situations, such as using public transportation or being outside of the home alone.
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Agoraphobia involves fearing or avoiding situations due to difficulty in escape or lack of available help.
The situations almost always provoke anxiety, and the anxiety is out of proportion to the actual threat.
The avoidance, fear, or anxiety significantly interferes with routine or function.
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Agoraphobia has a prevalence of 2% in the population, with a female-to-male ratio of 2:1.
The mean onset of agoraphobia is 17 years.
30% of individuals with agoraphobia also have panic attacks or panic disorder.
Agoraphobia confers a higher risk of other anxiety disorders, depressive disorders, and substance-use disorders.
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This page only contains the header "SOCIAL ANXIETY DISORDER."
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Social Anxiety Disorder (SAD) is marked by a fear of social or performance situations where the person fears humiliation.
Exposure to the feared situation provokes anxiety, which is out of proportion to the actual threat.
The anxiety lasts for more than 6 months and significantly interferes with routine or function.
Page 41: Strengthening Negative Beliefs about Social Anxiety
Negative beliefs about oneself in social situations
"I'm boring, I'm uninteresting"
Strengthening negative beliefs
Avoiding negative situations
Practicing self-beliefs
Page 42: Social Anxiety Disorder (SAD) Epidemiology
Prevalence of SAD in the general population
7%
Age of onset and gender differences
Onset in teens, more common in women
Impact of SAD
Causes significant disability
Increased risk of depressive disorders
Page 43: DSM-5 Criteria for Social Anxiety Disorder (SAD)
Fear and anxiety about social situations
Speaking in public, eating around others, initiating conversations
Fear of negative reactions from others
Fear and anxiety almost always provoked by social situations
Avoidance or enduring social situations with extreme anxiety or fear
Duration of symptoms: at least 6 months
Anxiety out of proportion to actual danger or threat
Page 44: Symptoms of Social Anxiety Disorder (SAD)
Physical symptoms
Sweating, dry throat, blushing, etc.
Automatic thoughts
"I didn't cope, I was boring, I looked stupid"
Negative thoughts
"I will not cope"
Safety behaviors
Avoiding eye contact, avoiding people, withdrawing
Increase in physical symptoms during social situations
Sweating, blushing, tense muscles, etc.
Page 45: Treatment for Social Anxiety Disorder (SAD)
Treatment options
Cognitive-behavioral therapy (CBT)
Exposure therapy
Anxiety management
Relaxation techniques
Medications
Psychotherapy
"Exposure" and "systematic desensitization" are effective treatments for specific phobias
Page 46: Panic Disorder
Panic disorder is different from panic attacks
Panic attack is a sudden episode of intense fear
Panic disorder is characterized by recurring panic attacks
Page 47: Panic Attacks
Symptoms of panic attacks
Chest pain, disturbed sleep, increased heart rate, shaking/trembling, muscle tension, shortness of breath, feeling disconnected from self or surroundings, irritability
"Anxiety attack" is not a recognized term in the DSM-5
Page 48: Symptoms of Panic Attacks
Palpitations or rapid heart rate
Sweating
Trembling or shaking
Shortness of breath
Feeling of choking
Chest pain or discomfort
Nausea
Chills or heat sensations
Paresthesia
Feeling dizzy or faint
Derealization or depersonalization
Fear of losing control or going crazy
Fear of dying
Page 49: Panic Disorder (PD)
Symptoms of panic disorder
Tachycardia, diaphoresis, trembling or shaking, shortness of breath, feelings of choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy or faint, chills or heat sensations, paresthesias
Recurrent unexpected panic attacks for at least one month
Persistent worry about having additional attacks
Significant change in behavior due to the attacks
Page 50: Panic Disorder Epidemiology
Prevalence of panic disorder in the general population and primary care patients
2-3% of general population, 5-10% of primary care patients
Onset in teens or early 20s
Female-to-male ratio of 2-3:1
Page 54: Panic Disorder Comorbidity
Comorbidity with major depression
50-60% have lifetime major depression, one-third have current depression
Comorbidity with substance dependence
20-25% have a history of substance dependence
Page 55: Panic Disorder Etiology
Factors contributing to panic disorder
Drug/alcohol use
Genetics
Social learning
Cognitive theories
Neurobiology/conditioned fear
Psychosocial stressors
Prior separation anxiety
Page 56: Treatment for Panic Disorder
Treatment response rate
70% or better
Treatment options
Education, reassurance, elimination of caffeine, alcohol, drugs, OTC stimulants
Cognitive-behavioral therapy
Medications (SSRIs, venlafaxine, tricyclics, MAOIs, benzodiazepines, valproate, gabapentin)
Page 57: Post-Traumatic Stress Disorder (PTSD)
Definition of PTSD
Psychiatric disorder involving extreme distress and disruption of daily living after exposure to a traumatic event
Page 58: Causes of PTSD
PTSD caused by exposure to trauma
Risk factors for developing PTSD
Genetics, gender (more common in women)
Lack of social support
Experience of past trauma
History of mental illness
History of substance use
Page 59: Symptoms of PTSD
Four categories of symptoms
Intrusion, avoidance, negative changes in thoughts and mood, changes in arousal and reactivity
Page 60: Intrusion Symptoms of PTSD
Symptoms related to intrusive thoughts and memories of the traumatic event
Reoccurring, involuntary, and intrusive upsetting memories
Repeated upsetting dreams
Dissociation and flashbacks
Strong distress to cues connected to the event
Strong bodily reactions when reminded of the event
Page 61: Avoidance Symptoms of PTSD
Avoidance of people, places, conversations, activities, objects, or situations related to the traumatic event
Avoidance of thoughts, feelings, or physical sensations that recall the event
Page 62: Negative Changes in Thoughts and Mood Symptoms of PTSD
Pervasive negative emotional state
Inability to remember important aspects of the event
Persistent negative evaluations about oneself, others, or the world
Elevated self-blame or blame of others
Loss of interest in previously enjoyable activities
Feeling detached from others
Inability to experience positive emotions
Page 63: Changes in Arousal and Reactivity Symptoms of PTSD
Constant hypervigilance or feeling "on guard"
Difficulty concentrating
Heightened startle response
Impulsive or self-destructive behavior
Irritability or aggressive behavior
Problems sleeping
Diagnosis of PTSD (Page 64)
Criteria for a diagnosis of PTSD:
Exposure to one or more traumatic event(s)
Traumatic event defined as death or threatened death, serious injury, or sexual violence
Exposure can be direct or indirect
Indirect exposure examples:
Witnessing the event happening to someone else
Learning about an event where a close friend or relative experienced violent or accidental death
Repeated exposure to distressing details of an event
Criteria for PTSD Diagnosis (Page 65)
Criteria for PTSD diagnosis:
Exposure to traumatic event
Intrusion symptoms
Symptoms of avoidance
Symptoms of negative changes in feelings and mood
Symptoms of changes in arousal or reactivity
Additional criteria:
Symptoms lasting longer than one month
Significant distress and interference with daily life
Not due to medical condition or substance use
Treatment for PTSD (Page 66)
Treatment options for PTSD:
Medication (antidepressants, specifically SSRIs)
Psychotherapy (CBT, cognitive processing therapy, exposure therapy, group therapy)
Cognitive Processing Therapy (Page 68)
Cognitive processing therapy (CPT):
Cognitive behavioral treatment for PTSD
Focuses on helping individuals "stuck" in thoughts about a trauma
Exposure Therapy (Page 69)
Exposure therapy:
Behavioral treatment for PTSD
Targets learned avoidance behaviors in response to frightening or anxiety-provoking situations or thoughts
Helps individuals confront and overcome their fears
Coping Strategies for PTSD (Page 70)
Coping strategies for PTSD:
Mindfulness practice
Support groups and relationships
Abstinence from drugs and alcohol
Exercise
Obsessive Compulsive Disorders (OCD) (Page 71)
OCD defined as frequent unwanted thoughts (obsessions) leading to repetitive behaviors (compulsions)
Compulsions can interfere with social interactions and daily tasks
OCD can be a chronic condition with symptoms coming and going over time
Difference between OCD and OCPD (Page 72)
OCD and OCPD are different conditions
OCPD is a personality disorder characterized by preoccupation with perfectionism, organization, and control
People with OCD recognize the need for professional help, while those with OCPD may not see anything wrong with their behavior
Who does OCD affect? (Page 73)
OCD can affect anyone, with an average age of onset at 19 years
About 50% of people with OCD develop symptoms in childhood or adolescence
Rare for OCD to develop after the age of 40
Symptoms and Causes of OCD (Page 74)
Main symptoms of OCD are obsessions and compulsions that interfere with normal activities
Symptoms can vary in severity and may come and go over time
Causes of OCD:
Genetics
Brain changes
PANDAS syndrome (associated with streptococcal infections)
Childhood trauma
Diagnosis of OCD (Page 77)
Criteria for OCD diagnosis:
Presence of obsessions, compulsions, or both
Time-consuming (more than an hour per day)
Causes distress or affects social activities, work, or other life events
Not caused by substances, alcohol, medications, or other mental health conditions
Treatment for OCD (Page 78)
Psychotherapy options for OCD:
Cognitive behavioral therapy (CBT)
Exposure and response prevention (ERP)
Acceptance and commitment therapy (ACT)
Mindfulness techniques can also help with symptoms
Medication options include serotonin reuptake inhibitors (SRIs) and tricyclic antidepressants
Prevention and Outlook for OCD (Page 80-81)
OCD cannot be prevented
Early diagnosis and treatment can help reduce symptoms and improve quality of life
Prognosis varies, but appropriate treatment can lead