Anxiety Disorder

Anxiety Disorder Symptoms Worry, fear, and anxiety are a normal part of our life. Have you experienced feeling anxious before taking an exam and later find out that you got a higher result more than what you’ve expected? Or, feeling anxious for a job interview and ended up getting hired, or feeling frightened walking down an alley where bad things often happened? Normal anxiety helps us cope in any stressful situation, it also keeps us watchful. Mental health professional are not concerned with normal anxiety. But, if your anxiety suddenly occur without apparent reason and lasts for weeks to months and happens in most days than not, that is another issue. If anxiety persists in most days than not, and takes longer than six months, it has become an immobilizing disorder. An anxiety disorder is a recurring and excessive anxiety and worry about events or activities without logical reasons at all lasting for more than six months and it is interfering with everyday activities, such as going to work, and socializing. A person experiencing anxiety condition finds it difficult to control the feelings of worry and fear. The thing about people with anxiety disorder is that they actually know that what they think of feel is not real and that they are just made-up. The common anxiety disorders are Panic Disorder, Social Phobia, Agoraphobia, Specific Phobia, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder, Separation Anxiety, Post-traumatic Stress Disorder, and Selective Mutism. A person with anxiety condition may suffer different anxiety disorder symptoms. And because no two individuals are the same, the anxiety disorder symptoms may vary from one person to the other. The physical symptoms of anxiety disorder are cause by brain sending messages to parts of the body to prepare for the flight-to-fight response. The lungs, heart, and other parts of the body work faster and the brain releases stress hormones, including adrenaline, and that explains that physical symptoms. Anxiety disorder symptoms may experience physically can include but not limited to: ,[object Object]

Rapid heartbeat or palpitations

Anxiety disorder symptoms may experience psychologically can include:

Feeling unreal and not in control of your behaviorThere are several types of anxiety disorders and sometimes they are associated with physical problem such alcohol and drug abuse. Anxiety is the main symptoms of other mental illness called anxiety disorders. Anxiety disorder symptoms may differ from the symptoms of other anxiety disorders, but all the symptoms cluster around excessive, irrational fear and dread. For people with anxiety condition, cheer up! Your world does not stop there because there is cure for anxiety disorder. Anxiety disorders are curable and there are two types of treatments available for anxiety disorder- medication and psychotherapy. But, it is said that the proven most effective way to treat anxiety sufferers is psychotherapy. Signs and symptoms of anxiety disorders Because the anxiety disorders are a group of related conditions rather than a single disorder, they can look very different from person to person. One individual may suffer from intense anxiety attacks that strike without warning, while another gets panicky at the thought of mingling at a party. Someone else may struggle with a disabling fear of driving or uncontrollable, intrusive thoughts. Still another may live in a constant state of tension, worrying about anything and everything. But despite their different forms, all anxiety disorders share one major symptom: persistent or severe fear or worry in situations where most people wouldn’t feel threatened. Emotional symptoms of anxiety In addition to the primary symptoms of irrational and excessive fear and worry, other common emotional symptoms of anxiety include: Feelings of apprehension or dreadTrouble concentratingFeeling tense and jumpyAnticipating the worstIrritability RestlessnessWatching for signs of dangerFeeling like your mind’s gone blank Physical symptoms of anxiety Anxiety is more than just a feeling. As a product of the body’s fight-or-flight response, anxiety involves a wide range of physical symptoms. Because of the numerous physical symptoms, anxiety sufferers often mistake their disorder for a medical illness. They may visit many doctors and make numerous trips to the hospital before their anxiety disorder is discovered. Common physical symptoms of anxiety include: Pounding heartSweatingStomach upset or dizzinessFrequent urination or diarrheaShortness of breathTremors and twitchesMuscle tension HeadachesFatigueInsomnia What are the Anxiety Disorders? The DSM specifies anxiety disorders and describes anxiety symptoms under the following main headings: Panic Disorder (both Without Agoraphobia and With Agoraphobia) Agoraphobia Without a History of Panic Disorder Specific Phobia (sometimes called Simple Phobia) Social Phobia (sometimes called Social Anxiety Disorder) Obsessive-Compulsive Disorder PTSD (Posttraumatic Stress Disorder) Acute Stress Disorder Generalized Anxiety Disorder It also includes classifications for anxiety disorders which result directly from a general medical condition or from exposure to chemicals or medications, and a catch-all category for anxiety disorders which do not fit the other categories. Clinical diagnoses of some anxiety disorders refer to the presence or absence of two particular underlying types of anxiety symptoms with their own criteria: Panic Attack Agoraphobia These are not diagnosed separately, but rather serve as the components for diagnosis of other disorders. ,[object Object],Also known as Agoraphobia, panic disorders are characterized by recurring panic attacks which are often unexpected. Symptoms are usually shaking, chest pains, dizziness, fear of losing control, and reluctance of being alone. People with panic disorder are aware that their panic is usually unfounded and illogical. This is why they avoid public situations and being alone. A panic attack can be so severe that people may lose control and hurt themselves. Symptoms of Panic Disorder According to the DSM,
The essential feature of Panic Disorder is the presence of recurrent, unexpected Panic Attacks...followed by at least 1 month of persistent concern about having another Panic Attack, or worry about the possible implications or consequences of the Panic Attacks, or a significant behavioral change related to the attacks
(p. 433). (Note that panic attacks are often called 'anxiety attacks' in popular parlance.) The following specific diagnostic criteria are reproduced verbatim (except for codings and page references) from the DSM-IV TR (where 'IV TR' indicates fourth edition, text revision), page 440 for Panic Disorder Without Agoraphobia and page 441 for Panic Disorder With Agoraphobia. Diagnostic Criteria for Panic Disorder Without Agoraphobia A. Both (1) and (2): recurrent unexpected Panic Attacks at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: persistent concern about having additional attacks worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack,
going crazy
) a significant change in behavior related to the attacks B. Absence of Agoraphobia C. The Panic Attacks are 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). D. The Panic Attacks not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives). Symptoms of Panic Attacks and Agoraphobia Because the lists of symptoms for panic attacks (sometimes called 'anxiety attacks' in popular parlance) and for agoraphopbia play roles in the diagnosis of panic disorder and other anxiety disorders, both are included here separately. The DSM-IV TR (where 'IV TR' indicates fourth edition, text revision) summarizes that
The essential feature of a Panic Attack is a discrete period of intense fear or discomfort in the absence of real danger that is accompanied by at least 4 of 13 somatic or cognitive symptoms
(p. 430). Note that when the other criteria for a panic attack are met, but fewer than 4 symptoms are experienced, the attack is called a limited-symptom attack. The following full diagnostic criteria for panic attacks are reproduced verbatim from page 432 of the DSM-IV TR. Criteria for Panic Attack A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms 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 Diagnostic Criteria for Panic Disorder With Agoraphobia A. Both (1) and (2): recurrent unexpected Panic Attacks at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: persistent concern about having additional attacks worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack,
going crazy
) a significant change in behavior related to the attacks B. The presence of Agoraphobia C. The Panic Attacks are 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). D. The Panic Attacks not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives). B. Specific phobia Unlike someone with generalized anxiety disorder, a person who has a specific phobia experiences extreme and often irrational fear of a certain situation or object. When exposed to the object or situation they fear, people with specific phobias exhibit signs of intense fear like shaking, shortness of breath, heart palpitations, and nausea. Common specific phobias include fear of heights, enclosed spaces, blood, and animals. The fear a person with phobia feels can be so extreme that he or she may disregard safety just to escape the situation. Diagnostic Criteria for Specific Phobia 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). 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 The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent. The phobic situation(s) is avoided or else is endured with intense anxiety or distress. 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. In individuals under age 18 years, the duration is at least 6 months. 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) Treatment Systematic desensitization and exposure (for specific phobias) and cognitive behavioral therapy (for social phobias). Beta-blockers may be effective in treating performance-anxiety symptoms. Drugs used in generalized social phobias include SSRIs (doses higher than those used in depression) or an MAOI (such as phenelzine). See also Panic Disorder for detailed description of medication issues. Associated Features Depressed Mood Anxious or Fearful or Dependent Personality Differential Diagnosis Some disorders have similar or even the same symptom. The clinician, therefore, in his/her diagnostic attempt has to differentiate against the following disorders which he needs to rule out to establish a precise diagnosis. Panic Disorder With Agoraphobia; Social Phobia; Posttraumatic Stress Disorder; Obsessive-Compulsive Disorder; Separation Anxiety Disorder; Hypochondriasis; Anorexia Nervosa; Bulimia Nervosa; Schizophrenia or another Psychotic Disorder ,[object Object],Alternatively called social anxiety, a person with social phobia may exhibit similar symptoms like those of panic disorder especially in social situations. Shaking, dizziness, shortness of breath, and heart palpitations may ensue when a person with social phobia finds his or herself at the center of attention or in the company of many people, regardless whether they are strangers or not. Diagnostic Criteria for Social Anxiety Disorder 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. 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. The person recognizes that the fear is excessive or unreasonable.Note: In children, this feature may be absent. The feared social or performance situations are avoided or else are endured with intense anxiety or distress. 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. In individuals under age 18 years, the duration is at least 6 months. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general 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). 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) Treatment Systematic desensitization and exposure (for specific phobias) and cognitive behavioral therapy (for social phobias). Beta-blockers may be effective in treating performance-anxiety symptoms. Drugs used in generalized social phobias include SSRIs (doses higher than those used in depression) or an MAOI (such as phenelzine). See also Panic Disorder for detailed description of medication issues. Associated Features Depressed Mood Somatic or Sexual Dysfunction Addiction Anxious or Fearful or Dependent Personality Differential Diagnosis Some disorders have similar or even the same symptom. The clinician, therefore, in his/her diagnostic attempt has to differentiate against the following disorders which he needs to rule out to establish a precise diagnosis. Panic Disorder With Agoraphobia; Agoraphobia Without History of Panic Disorder; Separation Anxiety Disorder; Generalized Anxiety Disorder; Specific Phobia; Pervasive Developmental Disorder; Schizoid Personality Disorder; Avoidant Personality Disorder; Associated features of many other mental disorders; Anxiety Disorder Not Otherwise Specified; Performance anxiety, stage fright, and shyness. D. Obsessive-compulsive disorder People with obsessive-compulsive disorder experience anxiety caused by a persistent obsession or idea. They tend to avoid experiencing anxiety by resorting to repetitive actions or behaviors that prevent anxiety. For example, a person who is obsessed about cleanliness may experience anxiety at the mere sight of a vase placed slightly off-center. To prevent anxiety, he or she will clean and organize everything compulsively or without reason. Diagnostic Criteria For OCD Either obsessions or compulsions:Obsessions as defined by (1), (2), (3), and (4): 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 the thoughts, impulses, or images are not simply excessive worries about real-life problems the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action 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): 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 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 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. 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. 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). 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. Treatment The Expert Consensus Guideline Series on OCD (very extensive desription of treatment options) A Guide for Patients and Families(short version for laypersons of the above) OCD and SSRIs The introduction of the SSRIs (selective serotonin reuptake inhibitors) over the past decade has provided exciting new opportunities for the treatment of obsessive-compulsive disorder (OCD). The serotonin hypothesis, based on the preferential response of OCD to the serotonin reuptake inhibitor, clomipramine, paved the way for research into the efficacy of the SSRIs in the treatment of this disorder. Large, controlled, multicenter studies have found clomipramine and the SSRIs, fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), and paroxetine (Paxil), to be effective and safe in the treatment of OCD. Meta-analytic studies have reported that clomipramine is superior to the SSRIs; however, direct head-to-head comparisons suggest equal efficacy. As SSRIs have a more favorable side-effect profile they may be preferable as first-line treatment of OCD. Improvement following adequate OCD drug treatment is frequently partial whereupon augmentation strategies may become necessary. High rates of relapse have been reported on discontinuation of SRI treatment. Long-term maintenance treatment has been found to be effective in sustaining initial therapeutic gains and bringing about further improvement. Read the full Research Report ---> SSRIs in the Treatment ofOCD Associated Features Depressed Mood Somatic or Sexual Dysfunction Guilt or Obsession Addiction Anxious or Fearful or Dependent Personality Differential Diagnosis Some disorders display similar or sometimes even the same symptom. The clinician, therefore, in his diagnostic attempt has to differentiate against the following disorders which one needs to be ruled out to establish a precise diagnosis. Anxiety Disorder Due to a General Medical Condition; Substance-Induced Anxiety Disorder; Body Dysmorphic Disorder; Specific Phobia; Social Phobia; Trichotillomania; Major Depressive Episode; Generalized Anxiety Disorder; Hypochondriasis; Delusional Disorder; Psychotic Disorder Not Otherwise Specified; Schizophrenia; Tic Disorder; Stereotypic Movement Disorder; Eating Disorders; Paraphilias; Pathological Gambling; Alcohol Dependence; Alcohol Abuse; Obsessive-Compulsive Personality Disorder; Superstitions; Repetitive checking behaviors. E. Post- Traumatic Stress Disorder (PTSD) Post-traumatic stress disorder may occur after a person experienced a severely traumatic event. He or she may relive the experience in his or her mind which causes stress and anxiety. If a person with PTSD comes into contact with stimuli (any object, person, or situation) that he or she associates with the traumatic event, he or she may literally re-experience the event by crying uncontrollably, panicking, or losing control. Subtler symptoms include insomnia and avoidant behavior. PTSD may manifest itself immediately after the traumatic event or even years after. Determining the type of anxiety disorder a person has is crucial to seeking treatment and recovery. Techniques and methods that are used to help a person cope with a certain anxiety usually target not only the management of symptoms but coping mechanisms when exposed to triggers. Only after thorough diagnosis can treatment and recovery for anxiety disorders really commence. Diagnostic Criteria for PTSD The person has been exposed to a traumatic event in which both of the following were present: 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 the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior The traumatic event is persistently reexperienced in one (or more) of the following ways: recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur. intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic eventphysiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: efforts to avoid thoughts, feelings, or conversations associated with the trauma efforts to avoid activities, places, or people that arouse recollections of the trauma inability to recall an important aspect of the trauma markedly diminished interest or participation in significant activities feeling of detachment or estrangement from others restricted range of affect (e.g., unable to have loving feelings) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: difficulty falling or staying asleep irritability or outbursts of anger difficulty concentrating hypervigilance exaggerated startle response Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more Specify if: With Delayed Onset: if onset of symptoms is at least 6 months after the stressor Treatment The Expert Consensus Guideline Series on PTSD (very extensive desription of treatment options) A Guide for Patients and Families(short version for laypersons of the above) Medication: According to researchers at the Dallas Veterans Affairs Medical Center (VAMC), two drugs already on the market seem to relieve the major symptoms of combat-induced post-traumatic stress disorder (PTSD) in veterans. The antidepressant Nefazodone (Serzone) was found to reduce PTSD symptoms by almost 30 percent in 24 veterans who took the drug during a year-long study's eight-week treatment period. The VAMC study found that Serzone not only alleviated depression, but also the core symptoms of PTSD-flashbacks and nightmares. There are also strong indications that the atypical antipsychotic Olanzapine (Zyprexa) aids in stabilizing the mood and reducing flashbacks in combat veterans suffering from PTSD. The VAMC has received a research grant to confirm these initial findings. No drugs are currently designated for the treatment of PTSD. Although psychotherapy is commonly used to treat the disorder, its effectiveness is unproven. Psychotherapy: Although psychodynamic psychotherapy is commonly used to treat the disorder, its effectiveness is controversial. Recently Exposure Therapy as part of a Cognitive Behavioral approach and/or EMDR Therapy (Eye Movement Desensitization and Reprocessing Therapy; Francine Shapiro) have in many cases been the treatment of choice with reports of very successful interventions. Associated Features Depressed Mood Somatic or Sexual Dysfunction Guilt or Obsession Addiction Differential Diagnosis Some disorders display similar or sometimes even the same symptom. The clinician, therefore, in his/her diagnostic attempt has to differentiate against the following disorders which he/she needs to rule out to establish a precise diagnosis. Adjustment Disorder; Symptoms of avoidance, numbing, and increased arousal that are present before exposure to the stressor; Another mental disorder (e.g., Brief Psychotic Disorder, Conversion Disorder, Major Depressive Disorder); Acute Stress Disorder; Obsessive-Compulsive Disorder; Schizophrenia; Other Psychotic Disorders; Mood Disorder With Psychotic Features; A delirium; Substance-Induced Disorders; Psychotic Disorders Due to a General Medical Condition; Malingering. E. Acute Stress Disorder Acute Stress Disorder is characterized by the development of severe anxiety, dissociative, and other symptoms that occurs within one month after exposure to an extreme traumatic stressor (e.g., witnessing a death or serious accident). As a response to the traumatic event, the individual develops dissociative symptoms. Individuals with Acute Stress Disorder have a decrease in emotional responsiveness, often finding it difficult or impossible to experience pleasure in previously enjoyable activities, and frequently feel guilty about pursuing usual life tasks. A person with Acute Stress Disorder may experience difficulty concentrating, feel detached from their bodies, experience the world as unreal or dreamlike, or have increasing difficulty recalling specific details of the traumatic event (dissociative amnesia). In addition, at least one symptom from each of the symptom clusters required for Posttraumatic Stress Disorder is present. First, the traumatic event is persistently reexperienced (e.g., recurrent recollections, images, thoughts, dreams, illusions, flashback episodes, a sense of reliving the event, or distress on exposure to reminders of the event). Second, reminders of the trauma (e.g., places, people, activities) are avoided. Finally, hyperarousal in response to stimuli reminiscent of the trauma is present (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, an exaggerated startle response, and motor restlessness). Specific Symptoms of Acute Stress Disorder: Acute stress disorder is most often diagnosed when an individual has been exposed to a traumatic event in which both of the following were present: 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 The person's response involved intense fear, helplessness, or horror Either while experiencing or after experiencing the distressing event, the individual has 3 or more of the following dissociative symptoms: A subjective sense of numbing, detachment, or absence of emotional responsiveness A reduction in awareness of his or her surroundings (e.g.,
being in a daze
) Derealization Depersonalization Dissociative amnesia (i.e., inability to recall an important aspect of the trauma) The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event. Acute stress disorder is also characterized by significant avoidance of stimuli that arouse recollections of the trauma (e.g., avoiding thoughts, feelings, conversations, activities, places, people). The person experiencing acute stress disorder also has significant symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness). For acute stress disorder to be diagnosed, the problems noted above must cause 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. The disturbance in an acute stress disorder must last for a minimum of 2 days and a maximum of 4 weeks, and must occur within 4 weeks of the traumatic event. Symptoms also can not be the result of substance use or abuse (e.g., alcohol, drugs, medications), caused by or an exacerbation of a general or preexisting medical condition, and can not be better explained by a a Brief Psychotic Disorder. Diagnostic Criteria for Acute Stress Disorder The person has been exposed to a traumatic event in which both of the following were present: 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 the person's response involved intense fear, helplessness, or horror Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms: a subjective sense of numbing, detachment, or absence of emotional responsiveness a reduction in awareness of his or her surroundings (e.g.,
being in a daze
) derealization depersonalization dissociative amnesia (i.e., inability to recall an important aspect of the trauma) The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people). Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness). 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. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event. 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, is not better accounted for by Brief Psychotic Disorder , and is not merely an exacerbation of a preexisting Axis I or Axis II disorder. Differential Diagnosis Some disorders display similar or sometimes even the same symptom. The clinician, therefore, in his diagnostic attempt has to differentiate against the following disorders which one needs to be ruled out to establish a precise diagnosis. Mental Disorder Due to a General Medical Condition; Substance-Induced Disorder; Brief Psychotic Disorder; Major Depressive Episode; Exacerbation of a Preexisting Mental Disorder; Posttraumatic Stress Disorder; Adjustment Disorder; Malingering. F. Generalized Anxiety Disorder Generalized anxiety disorder (GAD) is more than the normal anxiety people experience day to day. It's chronic and exaggerated worry and tension, even though nothing seems to provoke it. Having this disorder means always anticipating disaster, often worrying excessively about health, money, family, or work. Sometimes, though, the source of the worry is hard to pinpoint. Simply the thought of getting through the day provokes anxiety. People with GAD can't seem to shake their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. People with GAD also seem unable to relax. They often have trouble falling or staying asleep. Their worries are accompanied by physical symptoms, especially trembling, twitching, muscle tension, headaches, irritability, sweating, or hot flashes. They may feel lightheaded or out of breath. They may feel nauseated or have to go to the bathroom frequently. Or they might feel as though they have a lump in the throat. Many individuals with GAD startle more easily than other people. They tend to feel tired, have trouble concentrating, and sometimes suffer depression, too. Usually the impairment associated with GAD is mild and people with the disorder don't feel too restricted in social settings or on the job. Unlike many other anxiety disorders, people with GAD don't characteristically avoid certain situations as a result of their disorder. However, if severe, GAD can be very debilitating, making it difficult to carry out even the most ordinary daily activities. GAD comes on gradually and most often hits people in childhood or adolescence, but can begin in adulthood, too. It's more common in women than in men and often occurs in relatives of affected persons. It's diagnosed when someone spends at least 6 months worried excessively about a number of everyday problems. Specific Symptoms of Generalized Anxiety Disorder: Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 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 6 months; children don't need to meet as many criteria). Restlessness or feeling keyed up or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) Additionally, the anxiety or worry is not about having a Panic Attack, 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 Posttraumatic Stress Disorder (PTSD). 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. Diagnostic Criteria for Generalized Anxiety Disorder Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 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 6 months).Note: Only one item is required in children. restlessness or feeling keyed up or on edge being easily fatigued difficulty concentrating or mind going blank irritability muscle tension sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) 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 Posttraumatic 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. Treatment Options Therapy Psychotherapy: Most patients with mild symptoms can be treated with supportive counseling and education without need for medication. Other therapies: Relaxation training and cognitive therapy. General measures: Regular exercise and avoidance of caffeine and alcohol. Medications: Tricyclic Antidepressants (TCAs). Imipramine 25 to 150 mg/day. Does not become effective for 2 to 3 weeks. Most beneficial in patients with comorbid depression or sleep disturbance. Antihistamines. Hydroxyzine (Atarax, Vistaril) 50 to 100 mg QID may be used PRN, as an adjunct to other medications, or as an alternative therapy for patients with addiction potential. Benzodiazepines. Usually of short-term use with no long-term efficacy proved. Use lowest dose that alleviates anxiety. Longer half-life drugs may be easier to taper. May cause rebound anxiety with taper or withdrawal. Examples: Alprazolam (Xanax) 0.25 to 0.5 mg PO TID initial dose; rarely need to exceed 4 mg/day. Diazepam (Valium) 2 to 10 mg PO BID to QID. Lorazepam (Ativan) 1 mg PO BID or TID initially; rarely need to exceed 10 mg/day. Use lower doses than above in the elderly. Buspirone. May be less effective than other agents. Start 5 mg PO TID and increase to typical dose of 20 to 30 mg/day. Takes 2 weeks to be effective. Nonsedating. Little abuse potential. Selective Serotonin Reuptake Inhibitors (SSRIs). Clinically appear helpful but not well studied yet. Use in doses similar to those for Panic Disorder. In select patients may add a benzodiazepine for first several weeks of treatment, since it has a quicker onset of action and avoids potential initial side effect of increased anxiety with SSRIs (Prozac, Paxil, Luvox, Zoloft). Beta-blockers. Propranolol (Inderal) may help physical symptoms (not FDA approved) but has no effect on psychic component of anxiety. Associated Features Depressed Mood Somatic or Sexual Dysfunction Anxious or Fearful or Dependent Personality Differential Diagnosis Some disorders have similar or even the same symptoms. The clinician, therefore, in his diagnostic attempt has to differentiate against the following disorders which he needs to rule out to establish a precise diagnosis. Anxiety Disorder Due to a General Medical Condition; Substance-Induced Anxiety Disorder; Panic Disorder; Social Phobia; Obsessive-Compulsive Disorder; Anorexia Nervosa; Hypochondriasis; Somatization Disorder; Separation Anxiety Disorder; Obsessional thoughts; Posttraumatic Stress Disorder; Adjustment Disorder; Mood Disorders; Psychotic Disorders; Nonpathological anxiety

Anxiety Disorder

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Anxiety Disorder