Chapter 27: Anxiety, OCD, Dissociative DisordersStress Alarm stage: mobilization of bodys defensive forces; activation of potential for fight or flight +1 or +2 anxiety Increased level of alertness and anxiety Resistance stage: optimal adaptation to stress within the persons capabilities +2 to +3 anxiety Increased use of coping mechanisms Exhaustion stage: loss of ability to resist stress because of depletion of body resources; fight or flight or immobilization occurs +3 to +4 anxiety Disorganization of thinking and personality If exposure continues, stupor or violence may occurLazarus Interactional Model Anxiety is the response to threat. Primary appraisal: the judgment that individuals make about a particular event Secondary appraisal: the persons evaluation of the way to respond to an event Reappraisal: further appraisal that is made after new info is received Anxiety Subjective experience that can be detected only by objective behaviors; emotional pain; apprehension, fearfulness, or a sense of powerlessness from a perceived threat Most common mental disorderGeneralized Anxiety Disorder Excessive or unreasonable worry or apprehension Intensity of worry is out of proportion to actual likelihood of the event Chronic, excessive, or unreasonable worry that may concern everyday events Decreased concentration and memory problems Difficulty sleeping, fatigue, and muscle tension High genetic correlation between GAD and major depression Increased activity of the amygdala Usual onset 30 years More common in womenManagement Calm and quiet environment Ask patient to identify their feelings and identify possible causes Listen for helplessness or hopelessness Ask if they feel suicidal or have a plan to harm themselves Involve patients in activities

Psychopharmacology Antidepressants most effective; better than benzodiazepines due to possibility of dependency and tolerance with long-term useMilieu Management Cognitive therapy Recreational activities Relaxation exercisesPanic Disorder Recurrent panic attacks Worried about having more attacks Abrupt surge of intense fear or discomfort Peaks within 10 minutes Unexpected; occur out of the blue Situationally bound Women more prone

Management Stay with patient and acknowledge discomfort Maintain calm style and demeanor Speak in short simple sentences Give one direction at a time Treat hyperventilation Allow to cry and pace Tell patient you are in control and wont let anything happen to them Tell them they are safe Move or direct them to a quieter environment Encourage talking about fears

Psychopharmacology SSRIs and SNRIs used for long term treatment Benzodiazepines used for immediate effectAgoraphobia Fear or anxiety triggered by real or anticipated exposure to certain situations Public transportation Being in open spaces Being in enclosed spaces Being in a crowd Being outside of the home alone

Specific Phobias Phobias: marked fear or anxiety in the presence of a specific object or situation Provokes immediate fear, which is avoided or endured with intense anxiety Specific phobias typically develop after a traumatic eventSocial Anxiety Disorder (Social Phobia) Marked fear or anxiety of being scrutinized in social situations Fear of being humiliated or embarrassed by a negative evaluation Afraid they will be judges as weak, stupid, boring, crazy, unlikeable, or intimidating Trembling, sweating, or stumbling over their words Thinking about upcoming events cause anticipatory anxiety and dreadManagement Accept patients with a noncritical attitude Provide and involve patients in activities that dont increase anxiety Help patients with physical safety and comfort Help patients recognize their behavior is a method of avoiding anxiety Help enhance social interaction and decrease avoidancePsychopharmacology CBT: most successful treatment for phobias Systematic desensitization Exposure therapy Clonidine and propranolol: taken as needed before social engagements to ease symptoms of social phobia SSRIs: used to reduce anxiety and depression if presentObsessive-Compulsive and Related Disorders Includes OCD, body dysmorphic disorder, hoarding, trichotillomania, and excoriationObsessive-Compulsive Disorder Presence of obsessions or compulsions, or both Obsessions: recurrent and persistent thoughts, ideas, impulses, or images that are experienced as intrusive and unwanted Compulsions: the persons attempt to neutralize obsessions with another thought or action Repetitive behaviors or mental acts the person feels driven to perform to reduce anxiety triggered by the obsession Typically not connected realistically to the feared thoughts Origin: genetic transmission; might run in families Increased brain activity in the frontal lobe and basal ganglia Serotonin dysregulation may be involved Obsessions or compulsions can be so severe that they significantly interfere with the patients normal routine and so time-consuming they interfere with jobs or social functioning Interventions Ensure basic needs are met Provide time to perform rituals Explain expectations, routines, and changes Convey acceptance and understanding Assist patient to connect behavior and feelings Structure simple achievable activities Reinforce non-ritual behaviors to increase self-esteem and self-worth

Psychopharmacology SSRIs are effective in treating OCD Usually started with a higher treatment dosage of SSRIs than patients with depression Response usually occur at 10-12 weeksMilieu Management Relaxation Exercises Stress management Recreational skills CBT: thought stopping when an intrusive thought occurs, patient says stop and snaps a rubber band on the wrist or substitutes an adaptive behavior for the ritual

Body Dysmorphic Disorder Preoccupation with perceived flaws in ones physical appearance that arent noticeable by others Leads to the person feeling ugly, abnormal, or deformed Focuses on outward appearance Perform repeated behaviors in response (mirror checking; excessive surgery)Hoarding Disorder Persistent difficulties parting with possessions regardless of their actual value Distress associated with discarding, selling, recycling, or throwing them away Results in accumulation of possessions Main motivation: perceived value of the items or strong sentimental attachmentTrichotillomania Recurrent pulling out of ones hair, resulting in hair loss in various regions of the body Repeated attempts to quit are unsuccessful Feeling a loss of control, embarrassment, and shame May attempt to conceal the hair lossExcoriation Recurrent picking at ones own skin, resulting in lesions Commonly on face, arms, and hands Pick with fingernails, tweezers, or pins Preceded by feelings of anxiety or boredom and results in relief or pleasure

Trauma and Stressor-related Disorders Disorders that develop after exposure to a clearly identifiable traumatic eventPosttraumatic Stress Disorder and Acute Stress Disorder Intense emotional reactions after exposure to a traumatic event Denial, repression, suppression are common in both disorders Avoidance of situations, activities, or people who might evoke memories of the trauma Re-experiencing the traumatic event in some way Intrusive, unwanted memories Dreams or nightmares Illusions; flashbacks Increased arousal, anxiety, restlessness, irritability, sleep disturbance ASD: diagnosis is made when a person has dissociative symptoms during or immediately after the distressing event (3 days to 1 month) Amnesia Depersonalization Derealization Decreased awareness of surroundings Numbing Detachment Lack of emotional response Preexisting psychiatric disorders at increased risk PTSD: symptoms that occur 1 month or more after the trauma Same characteristic symptoms of ASD Occasional outbursts of anger or rage Survival guilt Increased risk to attempt suicide Preexisting psychiatric disorders at increased risk History of previous traumas at increased risk

Management Be nonjudgmental and honest Offer empathy and support Assure patient that feelings and behaviors are normal Help patient see connection between trauma and current feelings Help evaluate past behaviors in context of trauma to reduce guilt and self-judgment Provide safe verbalization of feelings Encourage adaptive coping strategies Facilitate progressive review of trauma to reduce re-experiencing it Encourage patient to establish or reestablish relationships Recreation and exercise programs can help reduce tension and promote relaxationPsychopharmacology SSRIs first line treatment for PTSD TCAs and MAOIs are second line Trazodone: helps with insomnia and reduces nightmares Benzodiazepines: reduce anxiety; risk for dependence Clonidine and propranolol: diminish response associated with fear, anxiety, and nightmares Atypical antipsychotics: used for severe PTSD or with comorbid diagnosis of psychosis or bipolar Adjustment Disorder Marked emotional distress resulting from an identifiable stressful life event Develops within 3 months Reaction not severe enough to be PTSD Symptoms out of proportion Acute reaction interferes with functioning but lasts no longer than 6 months after the stressor Major treatment goals: recognize relationship between stressful situation and current problems Review and integrate the feelings and memories of the original situationSomatic Symptom and Related Disorders Includes somatic symptom disorder, illness anxiety disorder, conversion disorder, and factitious disorder Patients have physical symptoms with no known organic cause Primary gain: the individuals desire to relieve anxiety to feel better and more secure Secondary gain: the attention or support the person derives from others because of illnessSomatic Symptom Disorder Multiple recurrent, significant somatic symptoms with no evidence of medical explanation Patients are not in control of their symptoms They dont deal with their anxiety but displace the anxiety into bodily symptoms Medical interventions rarely alleviate the individuals concernIllness Anxiety Disorder Excessively preoccupied with having or acquiring a serious undiagnosed illness Substantial anxiety over various types of bodily discomfort Preoccupation with undiagnosed illness results in the person researching the disease excessively and making it the prominent topic in social interactionsConversion Disorder A deficit or alteration in voluntary motor or sensory function that mimics a neurologic or medical condition Associated with psychological or physical stress or trauma Spontaneous attacks of severe physical disability despite lack of medical evidence Paralysis, tremors, gait abnormalities, abnormal limb posturing, altered or absent skin sensation, blindness, inability to hear, non-epileptic seizures Generalized limb shaking, dysphonia, dysarthria, globus, diplopiaFictitious Disorder Falsification of medical or psychological signs and symptoms in oneself or others Impose harm on themselves or others by representing, exaggerating, fabricating, inducing, simulating, or causes signs or symptoms of illness or injury Can lead to excessive medical intervention; adding blood to urine, injecting insulin, etc.Management Use a matter-of-fact approach Encourage description of feelings Assist patient to verbalize feelings Offer positive reinforcement when they focus on topics unrelated to illness or symptoms Be consistent Teach to distinguish between actual sensation and those with no source Encourage diversional activities Dont push insight into problems

Dissociative Disorders Disruption in consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior Depersonalization, derealization, amnesia, numbing, and flashbacks In the aftermath of trauma Dissociation: removal from conscious awareness of painful feelings, memories, thoughts, or aspects of identify An unconscious defense mechanism that protects a person from the emotion pain of experiences Helps them endure and survive intense emotional events Derealization: feelings of detachment or unfamiliarity with ones surroundings Blurriness, altered distant objects, heightened acuity, or muted soundsDissociative Amnesia Inability to recall important personal information, usually of traumatic nature Localized: when the person cant remember what occurred during a specific period of time Selective: ability to recall only a specific aspect of an event Generalized: complete loss of memory related to ones life history; very rareDepersonalization/Derealization Disorder Persistent or recurrent episodes of depersonalization or derealization or both in response to overwhelming stress Blurriness, altered distant objects, heightened acuity, or muted sounds Feel as if they are in a fog, dream, or bubbleDissociative Identity Disorder Existence of two or more distinct identities or personality states Recurrent episodes of amnesia Alternative personalities typically manifest as if another person is taking control Alters have distinct attitudes, emotions, and behaviors; each personality is different; has its own name, behavior traits, memories, emotional characteristics, social relations May be aware or unaware of the alters Can have memory problems, depersonalization, time loss, voices talking to each other, and somatic symptoms A defense against extreme anxiety that is aroused in highly painful and emotionally traumatic events; usually childhood sexual abuse Dissociative fugue: person reports suddenly found themselves in a location with no memory how they got there Often have comorbid disorders: depression, bipolar, PTSD, borderline personality disorder Some cultures may call it a possession Sexual abuse is a strong risk indicator Best predicted by disorganized attachment and absence of familial and social support in combo with abuseManagement Help patient gain control of overwhelming feelings and impulses through brief verbal interactions Help patient build on coping strategies that helped in the past Encourage patient to contact support people who will provide comfort Teach patient to avoid anxiety situation that provoke the behaviors Offer meds and other therapeutic strategies to alleviate symptoms