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Page 1 of 17 PSYCHIATRY 2 Anxiety Disorders Dr. Los Banos 2.1 Aug 07, 2014 Bautista, Cruz, Gillera, Janolo, Merilles OUTLINE I. Introduction II. Separation Anxiety Disorder III. Selective Mutism IV. Specific Phobia V. Social Anxiety Disorder VI. Panic Disorder VII. Panic Attack Specifier VIII. Agoraphobia IX. Generalized Anxiety Disorder X. Substance/ Medication Induced Anxiety Disorder XI. Anxiety Disorder due to Another Medical Condition XII. Other Specified Anxiety Disorder XIII. Unspecified Anxiety Disorder INTRODUCTION  Anxiety disorders o Share features of excessive fear and anxiety FEAR ANXIETY  Emotional response to real or perceived imminent threat  Associated with surges of autonomic arousal necessary for fight or flight  Thoughts of immediate danger  Escape behaviors  Anticipation of future threat  Excessive or persisting, lasting 6 months or more, beyond developmentally appropriate periods  Px overestimate the danger in situations they fear or avoid  Associated with muscle tension and vigilance in preparation for future danger  Cautious or avoidance behaviors  Female > Male, 2:1 OVERVIEW OF DISORDERS Disorder Selective Mutism Consistent failure to speak in social situations in which there is an expectation to speak (e.g., school) even though the individual speaks in other situations Phobia The fear, anxiety, or avoidance is almost always immediately induced by a phobic situation, to a degree that is persistent and out of proportion to the actual risk posed Social anxiety disorder (social phobia) Being fearful or anxious about or avoidant of social interactions and situations that involve the possibility of being scrutinized Panic Attack/ Disorder Abrupt surges of intense fear or intense discomfort that reach a peak within minutes, accompanied by physical and/or cognitive symptoms; Limited-symptom panic attacks include fewer than four symptoms; can be expected or unexpected attack Agoraphobia Being fearful and anxious about two or more of the following situations: - using public transportation - being in open spaces - being in enclosed places - standing in line or being in a crowd - being outside of the home alone Fear because of thoughts that escape might be difficult or help might not be available in that specific situation Generalized anxiety disorder persistent and excessive anxiety and worry about various domains, including work and school performance, that the individual finds difficult to control Note: The disorders, as in the order they are presented here, are sequenced according to the typical age of their onset. SEPARATION ANXIETY DISORDER DIAGNOSTIC CRITERIA A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following: 1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures. 2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death. 3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure. 4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation. 5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. 6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. 7. Repeated nightmares involving the theme of separation. 8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated. B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults. C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder. DIAGNOSTIC FEATURES  The following are example manifestations or observations on patients that may qualify them for each of the given criteria above. o Criterion A  The anxiety exceeds what may be expected given the person's developmental level o Criterion A1  They experience recurrent excessive distress when separation from home is anticipated or occurs o Criterion A2  They worry about the well-being or death of attachment figures, particularly when separated from them, and they need to know the whereabouts of their attachment figures and want to stay in touch with them o Criterion A3  They worry about untoward events to themselves, such as getting lost, being kidnapped, or having an accident, that would keep them from ever being reunited with their major attachment figure o Criterion A4  They are reluctant or they refuse to go out by themselves because of separation fears o Criterion A5  They have persistent and excessive fear or reluctance about being alone at home.  Children unable to stay or go in a room by themselves and may display "clinging" behavior, staying close to or "shadowing" the parent around the house
Page 2 of 17 PSYCHIATRY 2 Anxiety Disorders 2.1 Aug 07, 2014 Bautista, Cruz, Gillera, Janolo, Merilles  They require someone to be with them when going to another room in the house o Criterion A6  They have persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home o Criterion A7  They have difficulty at bedtime and may insist that someone stay with them until they fall asleep.  During the night, they may make their way to their parents' bed (or that of a significant other, such as a sibling).  Children may be reluctant or refuse to attend camp, to sleep at friends' homes, or go on errands.  Adults may be uncomfortable when traveling independently  There may be repeated nightmares in which the content expresses one’s separation anxiety such as destruction of the family through fire, murder, or other catastrophe o Criterion A8  Physical symptoms (e.g., headaches, abdominal complaints, nausea, vomiting) are common in children when separation occurs or is anticipated. ASSOCIATED FEATURES SUPPORTING DIAGNOSIS  When separated from major attachment figures, children with separation anxiety disorder may exhibit social withdrawal, apathy, sadness, or difficulty concentrating on work or play.  Some individuals become homesick and uncomfortable to the point of misery when away from home. o Some kids refuse to go to school.  Children may show anger or occasionally aggression toward someone who is forcing separation.  When alone, especially in the evening or the dark, young children may report unusual perceptual experiences such as: o Seeing people peering into their room o Frightening creatures reaching for them o Feeling eyes staring at them  Children with this disorder may be described as demanding, intrusive, and in need of constant attention, and, as adults, may appear dependent and overprotective. PREVALENCE  In children, 6- to 12-month prevalence is estimated to be approximately 4%.  In adolescents, the 12-month prevalence is 1.6%.  In adults, prevalence is 0.9%-1.9%.  In clinical studies, the disorder is equally common in males and females. However, in the community, the disorder is more frequent in females. DEVELOPMENT AND COURSE  Periods of heightened separation anxiety from attachment figures are part of normal early development and may indicate the development of secure attachment relationships o That is, if you are around 1 year of age only  Majority of children with separation anxiety disorder are free of impairing anxiety disorders over their lifetimes.  Manifestations: o Younger children are more reluctant to go to school or may avoid school altogether.  They may not express worries or specific fears of definite threats to parents, home, or themselves  Anxiety is manifested only when separation is experienced.  As children age, worries emerge; these are often worries about specific dangers (e.g., accidents, kidnapping, mugging, death) or vague concerns about not being reunited with attachment figures. o In adults, separation anxiety disorder may limit their ability to cope with changes in circumstances (e.g., moving, getting married).  They are typically overconcemed about their offspring and spouses and experience marked discomfort when separated from them  They have a need to continuously check on the whereabouts of a significant other. RISK AND PROGNOSTIC FACTORS  Environmental o Separation anxiety disorder often develops after life stress, especially a loss:  the death of a relative or pet  an illness of the individual or a relative  a change of schools  parental divorce  a move to a new neighborhood  immigration  a disaster that involved periods of separation from attachment figures  Genetic and Physiological o Separation anxiety disorder in children may be heritable.  Heritability was estimated at 73% in a community sample of 6-year-old twins, with higher rates in girls. o Children with separation anxiety disorder display particularly enhanced sensitivity to respiratory stimulation using C02-enriched air. CULTURE-RELATED DIAGNOSTIC ISSUES  There are cultural variations in the degree to which it is considered desirable to tolerate separation, so that demands and opportunities for separation between parents and children are avoided in some cultures. For example, there is wide variation across countries and cultures with respect to the age at which it is expected that offspring should leave the parental home. It is important to differentiate separation anxiety disorder from the high value some cultures place on strong interdependence among family members. GENDER-RELATED DIAGNOSTIC ISSUES  Girls manifest greater reluctance to attend or avoidance of school than boys. o Indirect expression of fear of separation may be more common in males than in females, for example, by limited independent activity, reluctance to be away from home alone, or distress when spouse or offspring do things independently or when contact with spouse or offspring is not possible. SUICIDE RISK  Separation anxiety disorder in children may be associated with an increased risk for suicide. FUNCTIONAL CONSEQUENCES OF SEPARATION ANXIETY DISORDER  Individuals with separation anxiety disorder often limit independent activities away from home or attachment figures (e.g., in children, avoiding school, not going to camp, having difficulty sleeping alone; in adolescents, not going away to college; in adults, not leaving the parental home, not traveling, not working outside the home). DIFFERENTIAL DIAGNOSIS  Generalized anxiety disorder o Separation anxiety disorder is distinguished from generalized anxiety disorder in that the anxiety predominantly concerns separation from attachment figures, and if other worries occur, they do not predominate the clinical picture.  Panic Disorder o Threats of separation may lead to extreme anxiety and even a panic attack. In separation anxiety disorder, in contrast to panic disorder, the anxiety concerns the possibility of being away from attachment figures and worry about untoward events befalling them, rather than being incapacitated by an unexpected panic attack.  Agoraphobia o Unlike individuals with agoraphobia, those with separation anxiety disorder are not anxious about being trapped or incapacitated in situations from which escape is perceived as difficult in the event of panic-like symptoms or other incapacitating symptoms.  Conduct Disorder
Page 3 of 17 PSYCHIATRY 2 Anxiety Disorders 2.1 Aug 07, 2014 Bautista, Cruz, Gillera, Janolo, Merilles o School avoidance (truancy) is common in conduct disorder, but anxiety about separation is not responsible for school absences, and the child or adolescent usually stays away from, rather than returns to, the home.  Social Anxiety Disorder o School refusal may be due to social anxiety disorder (social phobia).In such instances, the school avoidance is due to fear of being judged negatively by others rather than to worries about being separated from the attachment figures.  Post Traumatic Stress Disorder o Fear of separation from loved ones is common after traumatic events such as disasters, particularly when periods of separation from loved ones were experienced during the traumatic event. In posttraumatic stress disorder (PTSD), the central symptoms concern intrusions about, and avoidance of, memories associated with the traumatic event itself, whereas in separation anxiety disorder, the worries and avoidance concern the well-being of attachment figures and separation from them.  Illness Anxiety Disorder o Individuals with illness anxiety disorder worry about specific illnesses they may have, but the main concern is about the medical diagnosis itself, not about being separated from attachment figures.  Bereavement o Intense yearning or longing for the deceased, intense sorrow and emotional pain, and preoccupation with the deceased or the circumstances of the death are expected responses occurring in bereavement, whereas fear of separation from other attachment figures is central in separation anxiety disorder.  Depressive and Bipolar Disorders o These disorders may be associated with reluctance to leave home, but the main concern is not worry or fear of untoward events befalling attachment figures, but rather low motivation for engaging with the outside world. However, individuals with separation anxiety disorder may become depressed while being separated or in anticipation of separation.  Oppositional Defiant Disorder o Children and adolescents with separation anxiety disorder may be oppositional in the context of being forced to separate from attachment figures. Oppositional defiant disorder should be considered only when there is persistent oppositional behavior unrelated to the anticipation or occurrence of separation from attachment figures.  Psychotic Disorders o Unlike the hallucinations in psychotic disorders, the unusual perceptual experiences that may occur in separation anxiety disorder are usually based on a misperception of an actual stimulus, occur only in certain situations (e.g., nighttime), and are reversed by the presence of an attachment figure.  Personality Disorders o Dependent personality disorder is characterized by an indiscriminate tendency to rely on others, whereas separation anxiety disorder involves concern about the proximity and safety of main attachment figures. o Borderline personality disorder is characterized by fear of abandonment by loved ones, but problems in identity, self-direction, interpersonal functioning, and impulsivity are additionally central to that disorder, whereas they are not central to separation anxiety disorder. COMORBIDITY  In children, separation anxiety disorder is highly comorbid with generahzed anxiety disorder and specific phobia.  In adults, common comorbidities include specific phobia, PTSD, panic disorder, generalized anxiety disorder, social anxiety disorder, agoraphobia, obsessive-compulsive disorder, and personality disorders.  Depressive and bipolar disorders are also comorbid with separation anxiety disorder in adults. SELECTIVE MUTISM DIAGNOSTIC CRITERIA A.Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations. B.The disturbance interferes with educational or occupational achievement or with social communication. C.The duration of the disturbance is at least 1 month (not limited to the first month of school). D.The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation. E.The disturbance is not better explained by a communication disorder (e.g., childhoodonset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder. DIAGNOSTIC FEATURES  Children with selective mutismdo not initiate speech or reciprocally respond when spoken to by others  Children with selective mutismwill speak in their home in the presence of immediate family members but often noteven in front of close friends or second-degree relatives, such as grandparents or cousins  High social anxiety  Refuse to speak at school, leading to academic or educational impairment  Use nonspoken ornonverbal means (e.g., grunting, pointing, writing) to communicate and may be willing or eager to perform or engage in social encounters when speech is not required ASSOCIATED FEATURES SUPPORTING DIAGNOSIS  Include: o excessive shyness o fear of social embarrassment o social isolation and withdrawal o clinging o compulsive traits o negativism o temper tantrums o mild oppositional behavior PREVALENCE  Relatively rare disorder  The disorderis more likely to manifest in young children than in adolescents and adults. DEVELOPMENT AND COURSE  Onset of selective mutism is usually before age 5 years  Disturbance may notcome to clinical attention until entry into school, where there is an increase in social interactionand performance tasks, such as reading aloud. CULTURE RELATED DIAGNOSTIC FEATURES  Children in families who have immigrated to a country where a different language is spokenmay refuse to speak the new language because of lack of knowledge of the language FUNCTIONAL CONSEQUENCES OF SELECTIVE MUTISM  May result in social impairment, as children may be too anxious to engagein reciprocal social interaction with other children  In school settings, these children maysuffer academic impairment  Severe impairment in school and social functioning, includingthat resulting from teasing by peers, is common DIFFERENTIAL DIAGNOSIS  Communication disorders  Neurodevelopmental disorders and schizophrenia and other psychotic disorders  Social anxiety disorder (social phobia)
Page 4 of 17 PSYCHIATRY 2 Anxiety Disorders 2.1 Aug 07, 2014 Bautista, Cruz, Gillera, Janolo, Merilles COMORBIDITY  Anxiety disorders  Social anxiety disorder  Separation anxiety disorder  Specific phobia SPECIFIC PHOBIA DIAGNOSTIC CRITERIA A.Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. B.The phobic object or situation almost always provokes immediate fear or anxiety. C.The phobic object or situation is actively avoided or endured with intense fear or anxiety. D.The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. E.The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. F.The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia): objects or situations related to obsessions (as in obsessive- compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder). Specifiers:  It is common for individuals to have multiple specific phobias  In such cases, multiple specific phobiadiagnoses, each with its own diagnostic code reflecting the phobic stimulus, would need to be given  For example, if an individual fears thunderstorms and flying, then two diagnoseswould be given: specific phobia, natural environment, and specific phobia, situational. LIST OF PHOBIAS AS SHOWN IN THE POWERPOINT: Acrophobia fear of heights Agoraphobia fear of open places Ailurophobia fear of cats Claustrophobia fear of closed spaces Cynophobia fear of dogs Mysophobia fear of dirt and germs Pyrophobia fear of fire Xenophobia fear of strangers Zoophobia fear of animals DIAGNOSTIC FEATURES  A key feature of this disorder is that the fear or anxiety is circumscribed to the presence of a particular situation or object (Criterion A), which may be termed the phobic stimulus.  For the diagnosis of specific phobia, the response must differ from normal, transient fears that commonly occur in the population.  The fear or anxiety may take the form of a full or limited symptom panic attack  Fear or anxiety is evoked nearly every time the individual comes into contact with the phobic stimulus  Thus, an individual who becomes anxious only occasionally(ex.1/5 times lang) upon being confronted with the situation or object would not be diagnosed with specific phobia  The individual actively avoids the situation, or if he or she either is unable or decides not to avoid it, the situation or object evokes intense fear or anxiety  Active avoidance means the individual intentionally behaves in ways that are designed to prevent or minimize contact with phobic objects or situations  The fear or anxiety is out of proportion to the actual danger that the object or situation poses, or more intense than is deemed necessarythey tend to overestimatethe danger in their feared situations, and thus the judgment of being out of proportion is made by the clinician  The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more which helps distinguish the disorder from transient fears that are common in the population  The specific phobia must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning ASSOCIATED FEATURES SUPPORTING DIAGNOSIS  Increase in physiological arousalin anticipation of or during exposure to a phobic object or situation  Individuals with situational,natural environment, and animal specific phobias are likely to show sympatheticnervous system arousal  Individuals with blood-injection-injury specific phobia oftendemonstrate a vasovagal fainting or near-fainting response PREVALENCE  Prevalence rates are lower in older individuals  Females are more frequently affected than males DEVELOPMENT AND COURSE  Specific phobia sometimes develops following a traumatic event (e.g., being attacked byan animal or stuck in an elevator), observation of others going through a traumatic event (e.g.,watching someone drown), an unexpected panic attack in the to be feared situation (e.g.,an unexpected panic attack while on the subway), or informational transmission  The median age at onset is between 7 and 11 years, with the mean at about 10 years.  When specific phobia is being diagnosed in children, two issues should be considered. o First, young children may express their fear and anxiety by crying, tantrums, freezing,or clinging. o Second, young children typically are not able to understand the concept ofavoidance. SUICIDE RISK  Individuals with specific phobia are up to 60% more likely to make a suicide attempt thanare individuals without FUNCTIONAL CONSEQUENCES OF SELECTIVE MUTISM  The distress and impairment caused by specific phobias tend to increasewith the number of feared objects and situations  Fear of vomiting and chokingmay substantially reduce dietary intake.  Fear of falling in older adults can lead to reduced mobility andreduced physical and social functioning DIFFERENTIAL DIAGNOSIS  Agoraphobia  Social anxiety disorder  Panic disorder  Obsessive-compulsive disorder  Trauma- and stressor-related disorders  Eating disorders  Schizophrenia spectrum and other psychotic disorders COMORBIDITY  Individuals with specific phobia are at increased risk for the development of other disorders,including other anxiety disorders, depressive and bipolar disorders, substancerelateddisorders, somatic symptom and related disorders, and personality disorders (particularlydependent personality disorder).