Anxiety Disorders

Unit 7
 Opening Song – Shallow, by Lady Gaga and Bradley Cooper

Lady Gaga is one of the many actors/

singers that have openly discussed
dealing with anxiety and depression.
Lady Gaga stated to Oprah in 2016, “I
openly admit to having depression and
anxiety and I think a lot of people do.”
Link: https://www.youtube.com/watch?
v=bo_efYhYU2A
 Anxiety Disorders
What’s normal anxiety – and what’s
an anxiety disorder?
Link:
https://www.youtube.com/watch?v=xsEJ6GeAGb0
Fear & Anxiety
Fear and anxiety are distinct but
related emotions that function to
signal danger, threat, or motivational
conflict and to trigger appropriate
adaptive responses
p. 512.
 What is Anxiety?
• Anxiety is an emotion
characterized by the
apprehension or dread of a
potentially threatening or
uncertain outcome.

• Future-oriented.

• It is the most basic of

What is Fear?
Fear is an
emotional response
to a specific and
proximal threat to
an organism’s life
or integrity.
 Family of Generalized Anxiety Disorder
Anxiety (GAD)

Disorders Social Anxiety Disorder

(Social Phobia)

• All of the anxiety

disorders share Panic Disorder (PD)
e xc e s s i v e f e a r o r
anxiety as their core
symptom. Specific Phobia
• D i ff e r f r o m o n e a n o t h e r
b a s e d o n t h e i r key
features.
Reflection
What are the signs
and symptoms of
Anxiety?
Signs and Symptoms of Anxiety
Reflection
What are the
differences
between anxiety
and fear?
Overview of Anxiety Disorders
• Anxiety disorders are the most common
mental illnesses.
• Lifetime prevalence of anxiety disorders
to be as high as 31%.
• Most treated disorder in childhood and
adolescence.
• Often begin in Adolescence.
• More common in females than in males.
• Females 5.6%.
• Males 4.2%.
• Anxiety can exist as a primary disorder,
however, it often co-occurs with other
conditions.
Generalized Anxiety Disorder (GAD)
• Worry excessively and uncontrollably about daily life
events and activities.

• Impacts the person’s functioning.

• Associated physical symptoms.

• Prevalence 2.6% in Canada.

• Onset of GAD early in life.

• Feel powerless to change, frustrated with life,

demoralized, and hopeless.

• Co morbidity – Depression.
 Generalized Anxiety Disorder
(GAD) – causes, symptoms &
treatment
Link:
h t t p s : / / w w w. y o u t u b e . c o m / w a t c h ? v = 9 m P w Q T i M S j 8
 DSM 5 - GAD
Diagnostic Criteria
A. Excessive anxiety and worry (apprehension expectation), occurring more days than not for at least 6 months, about a number of events
or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been
present for more days than not for the past 6 months):
Note only one item is required in children
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficultly concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas
of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical
condition (e.g., hypothyroidism).
F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder,
negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder,
separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining
weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder,
having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder.
GAD - 7
Hamilton Anxiety Scale – HAM A
Reflection
Your patient is Dx.
With GAD. What
symptoms will they
be experiencing?
Reflection
Yo u r p a t i e n t i s s a y i n g ,
“something is going to
happen, I just know it”.
What is this an example of?
Te s t a n x i e t y
White coat syndrome
Atypical anxiety
Generalized anxiety
 The Symptoms of
GAD and Panic
Disorder
Link:
https://youtu.be/n4gIMnU8E8U
 Panic Disorder (PD)
Panic disorder - recurrent
unexpected panic attacks and fear of another
attack.
• Sudden periods of intense fear or discomfort.
• Response to a serious threat or “out of the
blue”.
• Chronic condition.
• Temporarily impair normal ability to function
socially, occupationally, and interpersonally.
• Prevalence in Canada is 3.7%
• > in Women aged 30-59 years.
• Can occur with or without agoraphobia
• Symptoms resemble that of a Myocardial
Infarction.
 • Can be normal but
extreme, overwhelming
form of anxiety
• Often initiated when a
person is put in a real or
perceived life-
threatening situation

What is Panic? • Sudden sensation of fear

 DSM 5 – Panic Disorder
Diagnostic Criteria
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during with time four
(or more) of the following symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed, or faint
9. Chills or heat sensations
10. Paresthesias (numbness or tingling sensations)
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
12. Fear of losing control or “going crazy”
13. Fear of dying
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headaches, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four
required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
2. A significant maladaptive change in behaviour related to the attacks (e.g., behaviours designed to avoid having panic attacks, such as avoidance of exercise or
unfamiliar situations).
C. The disturbances is not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medication) or another medical conditions (e.g., hyperthyroidism,
cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder;
in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive–compulsive disorder; in response to reminders of
traumatic events, as in posttraumatic stress disorder; or in response to separate from attachment figures, as in separation anxiety disorder).
Reflection
What are the signs
and symptoms
associated with a
Panic Disorder?
 PD Risk Factors
• Gender – Female
• Age 30 – 59 years.
• Mean age of onset at 23 years.
• Previous triggered panic attack
• A family history of psychological
difficulties
• Childhood trauma
• History of mood disorders
• Adolescents higher risk for suicide
thoughts or attempts
 Airline Panic
Attack
Link:

h t t p s : / / w w w. y o u t u b e . c o m / w a t c h ? v = X x t y i s o N B a I
Phobias
• Panic attacks can precipitate a
phobia.

• Phobias are persistent, unrealistic

fear of situations, objects, or
activities.

• Unreasonable response to protect

personal safety.

• Intensity of anxiety related to

 Agoraphobia
• Agoraphobia is an
anxiety disorder
that covers diverse
categories of fears
that are based on
the need to escape
from a situation.
Specific Phobias (Simple Phobia)
• A disorder marked by an irrational
fear of a specific object or situation
that the person realizes is
unreasonable.
• Exposure to the stimulus object or
situation causes the anxiety.
• Anxiety is related to the proximity of
the object and the ability to escape.
Social Anxiety Disorder (Social Phobia)
• Marked or intense fear of social situations
• Highly sensitive to disapproval or criticism
• Tend to evaluate themselves negatively.
• Functional impairment.
• Onset – early adolescence.
• Prevalence in Canada 2.6% in men and 3.4% in
women.
• Two types of Social Anxiety Disorder:
• Generalized social phobia
• Specific social phobia
Reflection
What are the
most common
phobias?
Reflection
Do you have a
Phobia?
How to Get Rid of ANY Fear –
Systematic Desensitization
Explained
Link:

Link:
h t t p s : / / w w w. y o u t u b e . c o m / w a t c h ? v = B o Q Ly Z u A _ U s
Aetiologic Theories of Genetic Theories
• Focus on genetic vulnerabilities
Anxiety Disorders • Genetic component

Neurobiology of Anxiety
Neuroimaging
MRI – show the following: • Fear conditioning affects:
decrease in gray matter and white matter • Hippocampus and amygdala
Abnormal activation patters in response to provocation. • fMRI increased amygdalar activity
Neurotransmitter and
Psychodynamic Theories: Neruopeptides
Focus on the psychological influences • Serotonin
Early life experiences affect the brain and how we respond to • Norepinephrine
stressors. • Corticotropin-releasing hormone
• Cholescystokinin
 Biologic Domain - Assessment
Assessment

• First you need to determine

that the symptoms of Anxiety
have affected the individual's
ability to function.
• Assess for substance use.
• Assess sleep patterns
Biologic Domain - Treatment
Interventions for the Biologic Domain

These interventions can assist

individuals with either severe anxiety or
panic symptoms.

• Physical Activity

• Breathing Control

• Nutrition Planning

• Relaxation Techniques
 Pharmacotherapy for Anxiety and Anxiety Disorders
Pharmacology
• SSRIs & SNRIs
• 1st line of treatment for anxiety disorders
• TCAs
• Used when SSRI and SNRIs do not work
• Benzodiazepine
• Only used for short-term treatment
• Anxiolytic
Psychological Domain
Assessment
• Determine the patterns, symptoms
and emotional, cognitive, and
behavioral responses.
• Includes:
• Mental Status
• Suicidal tendencies and thoughts
• Cognitive thought patterns
• Avoidance patterns
• Comorbid depression symptoms.
• Self-Report Scales
Psychological Domain - Interventions & Therapies
Psychotherapy
• Distraction
• Once they can identify the early
symptoms of panic.
• Positive Self-Talk
• Cognitive-Behavioral Therapy CBT
• First-line, highly effective
• Exposure Therapy
Reflection
Which of the following are an
example of Systemic
Desensitization.

Th e t h r e e c ’s – c o g n i t i v e t h e r a p y
Utilizing distraction
Exposing the client to their fear
Incorporating breathing and
relaxation
 Social and Occupational Domains for AD
• Become socially isolated
• Assessment questions:
• How has the disorder affected your family’s social life?
• How has the disorder affected your work and work–life
balance?
• What limitations related to travel has the disorder placed on
you or your family?
• What coping strategies have you used to manage the
symptoms?
• How has the disorder affected your family members or others?

• Be mindful of cultural factors.

• May be considered a sign of weakness

View picture for interventions

Spiritual Domain for AD
Spiritual Domain
Anxiety is understood as a basic to the human
condition.
• Existentialist thinkers believe that we are aware of
our own mortality, the end causes us anxiety.
• Interventions:
• Help address feelings of alienation and
estrangement
• Help confront and reconcile fear of death
• Support hope
Family Response
The entire family will need
support in adjusting to the
disorder.

• Family involvement in the

therapy process.
• Families experience the
symptoms, treatments,
clinical set backs, and
recovery.
Reflection
 Obsessive-Compulsive
and Related Disorders:
This cluster of disorders
includes:
OCD
Body Dysmorphic
Disorder
Hoarding Disorder
Obsessive Compulsive Tr i c h o t i l l o m a n i a

Disorder & Related E x c o r i a t i o n D i s o r d e r.

Disorders We w i l l o n l y b e
discussing OCD and
Hoarding Disorder
 DSM 5 - OCD
Diagnostic Criteria
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as
intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other
thought or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
3. Repetitive behaviors (e.g., handwashing, ordering, checking) or mental acts (e.g., praying, counting, repeating words
silently) that the individual feels driven to perform in response to an obsession or according to rules that must be
applied rigidly.
4. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event
or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed
to neutralize or prevent, or are clearly excessive.
Note: Young children may not be able to articulate the aims of these behaviors or mental acts.
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically
significant distress or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug or abuse, a
medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder. See DSM 5 for list.
 Obsessive-Compulsive Disorder (OCD)
OCD is a psychiatric disorder characterized by severe obsessions,
compulsions, or both.
• Driven to do things with an irresistible urge in order to relieve stress
and feel better.
• They interfere with functioning.
• Common Patterns seen in OCD:
• Fear of contamination
• Pathologic doubt
• Need of symmetry
• Common Compulsion seen in OCD:
• Handwashing
• Checking and arranging things
• Counting things
• Persons with religious obsessions ruminate over the meaning of sins
and whether they have followed the letter of the law.
• Prevalence of OCD:
• 2.3% in an American sample.
• Men earlier onset than women.
• Mean age of onset is between 20 -30 years of age.
 What is an Obsession?
Obsession
• Unwanted, intrusive and persistent
thoughts, impulses, or images
• The thought patterns cause significant
anxiety and distress.
• The person tries to ignore, suppress or
neutralize the thoughts by some other
thought or action fails in doing so.
 What is a Compulsion?
What is a Compulsion?

• Behaviors performed
repeatedly, in a ritualistic
fashion.
• The goal is to prevent or
relieve anxiety and distress
caused by obsessions
This is a
photo of
what type of
compulsion
?
Reflection
Yo u r p a t i e n t i s l a t e f o r h e r
therapy session, you have
already reminded her 2 times.
Both times you’ve walked into
the patient's room they have
been washing their hands.

As the nurse, what do you do?

 Family Interventions for OCD
OCD often diminishes the quality
of family relationships

The most troublesome symptoms

of OCD for families include:
• Rituals
• Long standing unemployment
• Withdrawal from social and
family contact
• Noncompliance of medication
Treatment for OCD
Treatment for OCD
• Pharmacy
• Long-term SSRIs 1st line of treatment
• Psychosurgery
• Does not respond to pharmacologic treatment
• Radiotherapy
• Deep Brain Stimulation
• Those with Cleaning or Handwashing compulsions:
• Encourage to use tepid water when washing and hand
cream after.
• Overtime decrease the frequency of washing.
• Exposure with Response Prevention (ERP)
• Cognitive Behavioral Therapy (CBT)
 Howie Mandel
Talks About Living
With OCD- 20/20
Link:
h t t p s : / / w w w. y o u t u b e . c o m / w a t c h ?
v=dSZNnz9SM4g
Trauma & Stressor Related
Disorders
Acute Stress Disorder
• Symptoms develop after a traumatic event

• Person must have

experienced/witnessed/been confronted
with the event

• Event involved actual or threatened death

or serious injury or

• A physical threat to self or others

DSM
5
 Reflection
Yo u r p a t i e n t i s d i a g n o s e d
w i t h A c u t e S t r e s s D i s o r d e r.
They are sitting close to
the door and looking at the
wall.
What is the client
experiencing?
 Reflection
What type of behavior
will your client
experience with
dissociation?
 Trauma & Stressors Related Disorders
Post Traumatic Stress Disorder
(PTSD)
• Symptoms develop after a
traumatic event
• Involves a personal experience
of threatened death, injury, or
threat to physical integrity
 Post Traumatic Stress Disorder (PTSD)
A diagnosis of PTSD is made if an individual experiences or witnesses an
authentic, severe threat of death or injury (including sexual injury) to self or
others and this experience then affects the individual’s mental health in
specific ways.

• Relive the experience (thoughts or images)

• Avoid memories of the event, or reminders of the event.
• Daily functioning can be affected.
• Affect sleep and relationships.

• Symptoms overlap with: panic disorder, general anxiety disorder, and

depression.
• Factors that predict the development of PTSD:
 DSM 5 - PTSD
Diagnostic Criteria
Note: The following criteria apply to adults, adolescents, and children older than 6 years of age.
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened
death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders
collecting human remains; police officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this
exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after
the traumatic event(s) are occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note see DSM-5
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note
see DSM-5
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.
(Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of
present surroundings.) Note see DSM-5
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).
 DSM 5 - PTSD
Diagnostic Criteria Continue…
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s)
occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the
traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations)
that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the
traumatic event (s) occurred, as evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not
to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the work (e.g., I am bad, no
one can be trusted).
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual
to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feeling of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving
feelings).
 DSM 5 - PTSD
Diagnostic Criteria Continue…
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical
aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbances (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas
of functioning.
H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another
medical condition.
 American Sniper PTSD BBQ
Airline Panic Attack

Scene

Link:

h t t p s : / / w w w. y o u t u b e . c o m / w a t c h ? v = D 7 L - E r 1 b 2 C o
 PTSD Treatment
• Cognitive-behavioral therapy
• Psychotherapy
• Eye movement
desensitization
• Reprocessing (EMDR)
• Medication
 Reflection
Yo u r p a t i e n t i s a v e t e r a n a n d i s a t t e n d i n g
a B B Q w i t h h i s f a m i l y. T h e p a t i e n t
becomes frantic after hearing a car
backfire. What is he experiencing?

Social Phobia
Compulsive-obsessive
Bipolar
Post-traumatic stress
 Reflection
Yo u r p a t i e n t i s a v e t e r a n , h e i s s t a r i n g a t a c a r
behind him, and becoming increasingly
paranoid. He stated that he drove the tanks in
the war.

What is he experiencing?

Delusions of grandeur
Flashbacks
Auditory hallucinations
Free-floating anxiety
What is an
Obsession?
Reflection
A person arrives to the
ER Dept. saying they
are having a heart
attack, what dx has
similar S/S to that of a
heart attack?
What is a
Compulsion?
Reflection
What is agoraphobia?
Questions?
The End