Anxiety Disorders
v
Prevalence rates for
anxiety disorders range from about 1% - 17% with specific phobias having the
highest prevalence rates in the general population (estimated to be about 1 in
10 persons undiagnosed)
v
Slightly higher
female:male ratio although reasons not well described, ? role of gonadal
steroids
v
Panic Attacks and
Agoraphobia are not DSM-IV Axis I disorders but are coded with the disorders in
which the panic attack or agoraphobia occurs.
v
Specific Phobia was
formerly known as Simple Phobia and is now classified according to subtypes:
o
Animal
o
Natural Environment
o
Blood-injection-injury
o Situational (flying, closed places, etc.)
o
Other Type (e.g., phobic
avoidance of situations that may lead to choking, vomiting, or contracting an
illness; in children, avoidance of loud sounds or costumed characters)
o
Phobic avoidance that is
limited to genital contact with a sexual partner is classified as a Sexual
Aversion Disorder and included in the Sexual Disorders section of the DSM-IV
v
Separation Anxiety
Disorder, characterized by anxiety related to separation from parental figures,
usually occurs in childhood and is included in the Childhood Disorders section
of the DSM-IV
Brief Overview of Anxiety Disorders
Anxiety disorders are the most common psychiatric illnesses affecting both children and adults.
- Anxiety disorders may develop from a complex set of risk factors, including genetics, brain chemistry, personality, and life events.
- An estimated 19 million adult Americans suffer from anxiety disorders.
- Anxiety disorders are highly treatable, yet only about one-third of those suffering from an anxiety disorder receive treatment.
Anxiety disorders are categorized as:
- Generalized Anxiety Disorder (GAD). GAD is characterized by
excessive, unrealistic worry that lasts six months or more; in adults, the
anxiety may focus on issues such as health, money, or career. In addition
to chronic worry, GAD symptoms include trembling, muscular aches,
insomnia, abdominal upsets, dizziness, and irritability.
- Obsessive-Compulsive Disorder (OCD). In OCD, individuals are
plagued by persistent, recurring thoughts (obsessions) that reflect
exaggerated anxiety or fears; typical obsessions include worry about being
contaminated or fears of behaving improperly or acting violently. The
obsessions may lead an individual to perform a ritual or routine
(compulsions)-such as washing hands, repeating phrases or hoarding-to
relieve the anxiety caused by the obsession.
- Panic Disorder. People with panic disorder suffer severe
attacks of panic-which may make them feel like they are having a heart
attack or are going crazy-for no apparent reason. Symptoms include heart
palpitations, chest pain or discomfort, sweating, trembling, tingling
sensations, feeling of choking, fear of dying, fear of losing control, and
feelings of unreality. Panic disorder often occurs with agoraphobia, in
which people are afraid of having a panic attack in a place from which
escape would be difficult, so they avoid these places.
- Post-Traumatic Stress Disorder (PTSD). PTSD can follow an
exposure to a traumatic event such as a sexual or physical assault,
witnessing a death, the unexpected death of a loved one, or natural
disaster. There are three main symptoms associated with PTSD:
"reliving" of the traumatic event (such as flashbacks and
nightmares); avoidance behaviors (such as avoiding places related to the
trauma) and emotional numbing (detachment from others); and physiological
arousal such difficulty sleeping, irritability or poor concentration.
- Social Anxiety Disorder (Social Phobia). Social Anxiety
Disorder (SAD) is characterized by extreme anxiety about being judged by
others or behaving in a way that might cause embarrassment or ridicule.
This intense anxiety may lead to avoidance behavior. Physical symptoms
associated with this disorder include heart palpitations, faintness,
blushing and profuse sweating.
- Specific phobias. People with specific phobias suffer from an intense fear reaction to a specific object or situation (such as spiders, dogs, or heights); the level of fear is usually inappropriate to the situation, and is recognized by the sufferer as being irrational. This inordinate fear can lead to the avoidance of common, everyday situations.
Anxiety disorders are highly treatable with psychosocial therapies, medication, or both.
Panic Attack
A Panic Attack is defined as the abrupt onset of an episode of intense fear or discomfort, which peaks in approximately 10 minutes, and includes at least four of the following symptoms:
- a feeling of imminent danger or doom;
- the need to escape;
- palpitations;
- sweating;
- trembling;
- shortness of breath or a smothering feeling;
- a feeling of choking;
- chest pain or discomfort;
- nausea or abdominal discomfort;
- dizziness or lightheadedness;
- a sense of things being unreal, depersonalization;
- a fear of losing control or "going crazy";
- a fear of dying;
- tingling sensations;
- chills or hot flushes.
There
are three types of Panic Attacks:
1. Unexpected - the attack "comes out of the blue" without warning
and for no discernable reason.
2. Situational - situations in which an individual always has an attack, for
example, upon entering a tunnel.
3. Situationally Predisoposed - situations in which an individual is likely to
have a Panic Attack, but does not always have one. An example of this would be
an individual who sometimes has attacks while driving.
Panic Disorder
Panic
Disorder is diagnosed when an individual suffers at least two unexpected Panic
Attacks, followed by at least 1 month of concern over having another attack.
Sufferers are also prone to situationally predisposed attacks. The frequency
and severity of the attacks varies from person to person, an individual might
suffer from repeated attacks for weeks, while another will have short bursts of
very severe attacks. The sufferer often worries about the physical and
emotional consequences of the Panic Attacks. Many become convinced that the
attacks indicate an undiagnosed illness and will submit to frequent medical
tests. Even after tests come back negative, a person with Panic Disorder will
remain worried that they have a physical illness. Some individuals will change
their behavioral patterns, avoiding the scene of a previous attack for example,
in the hopes of preventing having another attack.
Agoraphobia
Agoraphobia often, but not always, coincides with Panic Disorder. Agoraphobia is characterized by a fear of having a panic attack in a place from which escape is difficult. Many sufferers refuse to leave their homes, often for years at a time. Others develop a fixed route, or territory, from which they cannot deviate, for example the route between home and work. It becomes impossible for these people to travel beyond what they consider to be their safety zones without suffering severe anxiety.
The age of onset of Panic Disorder varies from late adolescence to mid-thirties. Relatively few suffer from the disorder in childhood.
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Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance). The person finds it difficult to control the worry. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past six months). NOTE: Only one item is required in children. Restlessness
or feeling keyed up or on edge 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 having a panic attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Post-traumatic Stress Disorder. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder. |
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Reprinted with permission from the American Psychiatric
Association. Diagnostic and statistical manual of mental disorders. 4th ed.
Washington, D.C.: American Psychiatric Association, 1994:435-6. |
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Distinguishing Characteristics of Generalized Anxiety Disorder, Panic Disorder and Major Depression |
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Information from American
Psychiatric Association. Diagnostic and statistical manual of mental
disorders. 4th ed. Washington, D.C.: American Psychiatric Association,
1994:436, and Noyes R, Woodman C, Garvey MJ, Cook BL, Suelzer M, Clancy J, et
al. Generalized anxiety disorder vs. panic disorder. Distinguishing
characteristics and patterns of comorbidity. J Nerv Ment Dis 1992;180:369-79. |
Diagnostic Criteria for
Separation Anxiety Disorder
A. Developmentally inappropriate and excessive anxiety concerning
separation from home or from those to whom the individual is attached, as
evidenced by three (or more) of the following:
(1) recurrent excessive distress when separation from home
or major attachment figures occurs or is anticipated
(2) persistent and excessive worry about losing, or about possible harm
befalling, major attachment figures
(3) persistent and excessive worry that an untoward event will lead to
separation from a major attachment figure (e.g., getting lost or being
kidnapped)
(4) persistent reluctance or refusal to go to school or elsewhere because of
fear of separation
(5) persistently and excessively fearful or reluctant to be alone or without
major attachment figures at home or without significant adults in other
settings
(6) persistent reluctance or refusal to go to sleep without being near a major
attachment figure or to sleep away from home
(7) repeated nightmares involving the theme of separation
(8) repeated complaints of physical symptoms (such as headaches, stomachaches,
nausea, or vomiting) when
separation from major attachment figures occurs or is anticipated
B.
The duration of the disturbance is at least 4 weeks.
C.
The onset is before age 18 years.
D.
The disturbance causes clinically significant distress or impairment in social,
academic (occupational), or other important areas of functioning.
E.
The disturbance does not occur exclusively during the course of a Pervasive
Developmental Disorder, Schizophrenia, or other Psychotic Disorder and, in
adolescents and adults, is not better accounted for by Panic Disorder With
Agoraphobia.
Specify if:
Early Onset: if onset
occurs before age 6 years
Social
Anxiety/Social Phobia
v Social Anxiety Disorder (social phobia) is
the third largest
mental health care problem in the world.
v Social phobia affects over 7% of the
population at any given time.
v Lifetime prevalence rate above 13%.
Definition: Social anxiety is the fear of social
situations that involve interaction with other people. Social anxiety is the
fear and anxiety of being judged
and evaluated by
other people. If a person usually becomes anxious in social situations, but
seems fine when they are alone, then "social anxiety" may be the
problem.
Perceptions: People with social anxiety are many
times seen by others
as being shy, quiet, backward, withdrawn, inhibited, unfriendly, nervous,
aloof, and disinterested. People with social anxiety want to be "normal" socially, they want to make friends and they want to be involved and engaged in social
interactions.
Triggering Symptoms: People with social anxiety usually
experience significant distress in the following situations:
Being introduced to other people
Being teased or criticized
Being the center of attention
Social situations where the
person exhibits excessive self-consciousness
Being watched or observed while
doing something
Having to say something in a
formal, public situation
Meeting people in authority
("important people/authority figures")
Feeling insecure and out of
place in social situations ("I don’t know what to say.")
Embarrassing easily (e.g.,
blushing)
Making eye contact
Swallowing, writing, talking,
making phone calls if in public
Diagnostic Criteria for Specific Phobia
A. Marked and persistent fear that is excessive or unreasonable, cued
by the presence or anticipation of a specific object or situation (e.g.,
flying, heights, animals, receiving an injection, seeing blood).
B.
Exposure to the phobic stimulus almost invariably provokes an immediate anxiety
response, 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 clinging.
C.
The person recognizes that the fear is excessive or unreasonable. Note: In
children, this feature may be absent.
D.
The phobic situation(s) is avoided or else is endured with intense anxiety or
distress.
E.
The avoidance, anxious anticipation, or distress in the feared situation(s)
interferes significantly with the person's normal routine, occupational (or
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 anxiety, Panic Attacks, or phobic avoidance associated with the specific
object or situation are not better accounted for by another mental disorder,
such as Obsessive-Compulsive Disorder (e.g., fear of dirt in someone with an
obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance
of stimuli associated with a severe stressor), Separation Anxiety Disorder
(e.g., avoidance of school), Social Phobia (e.g., avoidance of social
situations because of fear of embarrassment), Panic Disorder with Agoraphobia,
or Agoraphobia Without History of Panic Disorder.
Specify
type:
Animal
Type
Natural
Environment Type (e.g., heights, storms, water)
Blood-Injection-Injury
Type
Situational
Type (e.g., airplanes, elevators, enclosed places)
Other
Type (e.g., phobic avoidance of situations that may lead to choking,
vomiting,
or contracting an illness; in children, avoidance of loud sounds or costumed characters)
ANXIETY DECISION TREE
