Anxiety and Dissociative Disorders

Susan D. Odom, Ph.D.

Anxiety Disorders• Panic Attacks• Agoraphobia• Panic Disorder without Agoraphobia• Panic Disorder with Agoraphobia• Agoraphobia without History of Panic Disorder• Specific Phobia• Social Phobia• Obsessive-Compulsive Disorder• Posttraumatic Stress Disorder• Acute Stress Disorder• Generalized Anxiety Disorder• Anxiety Disorder due to a General Medical Condition• Substance-Induced Anxiety Disorder• Anxiety Disorder NOS

Anxiety is Normal

• Anxiety can be a normal response to a situation that is perceived to be beyond our ability to cope

• Is a great motivator – to study, work hard, move quickly

So what makes Anxiety a Disorder?

• The degree and duration of the symptoms!• Oh, and sometimes the trigger for the anxiety….

What makes an event stressful?

• The nature of the event and how the person views it

• The person’s resources• The person’s psychological defenses• The person’s coping mechanisms

In other words, there is a mismatch between perceived demand and perceived ability. If this mismatch results in the person’s ego being challenged, anxiety disorders sometimes result.

The demands can be external (social demands, for instance) or internal (aggressive, sexual, and/or dependent impulses)

Usual Anxiety Symptoms

• Dizziness, light-headedness• Hypertension• Palpitations• Restlessness• Diarrhea• Tachycardia• Tingling in extremities• Tremors• Upset Stomach• Urinary frequency

Epidemiology

1 in 4 have had an anxiety disorder (19 Million at one time)

Lifetime prevalence is 30.5% for women and 19.2% for men

Prevalence is lower for higher socioeconomic classes

Onset usually prior to age 35

Etiology• Psychological Causes

Defense against a psychic conflict – resolve the conflict and the anxiety is diminished

• Behavioral Theory of Anxiety Classical Conditioning – a cause and effect relationship is

perceived (which may or may not be true) and then generalized to other situations

Social Learning – parents

• Biology Autonomic nervous system – don’t habituate well, overreact to

stimuli. Neurotransmitters – norepinephrine, serotonin, GABA

• Genetics – genes that affect serotonin transportation• Neuroanatomical Considerations

Higher pressure in the spinal column due to increased levels of spinal fluid result in anxiety symptoms

Criteria for Panic Attack

Four or more of the following symptoms that peak within 10 minutes:

• Palpitations, pounding heart, or accelerated heart rate• Sweating• Trembling or shaking• Shortness of breath or smothering• Feeling of choking• Chest pain or discomfort• Nausea or abdominal distress• 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 of tingling sensations)• Chills or hot flashes

Agoraphobia

• Agora – Greek for the market, a place that is crowded, filled with people and unexpected events!

• Modern Day – An anxiety about or avoidance of places or situations from which escape might be difficult or embarrassing; help might not be available if a panic attack occurs

• Usually includes a characteristic cluster of situations (being outside, away from home, standing in a line; being on a bridge or in an elevator; traveling by bus, train, automobile, jet

• Situations are avoided or met with dread

Panic Disorder

• Recurrent, unexpected panic attacks • Panic attack followed by 1 month or more of

persistent concern about having another attack, worry about the implications of the attack, or significant change in behavior in relation to the attack

• Can occur with or without agoraphobia

Specific Phobia

• Most common mental disorder for women & 2nd for men – 5% - 10% of people have a specific phobia.

• Types– Animal (dogs, bunnies, cats, bugs, reptiles)– Natural environment (storms, heights, water)– Blood, Injection, Injury (seeing blood, getting a shot,

having blood drawn, illness or death)– Situational (public transportation, tunnels, bridges,

etc.)– Other (clowns, loud sounds, toes, choking, vomiting,

etc.)• Immediate response is unreasonable fear and the person

knows the fear is unreasonable• Avoid or endure with intense anxiety

Social Phobia

• Marked and persistent fear of social interactions or performance situations

• Exposure causes intense anxiety or maybe panic attack

• Hypersensitivity to criticism, evaluation by others

• May be accompanied by poor social skills, noticeable anxiety symptoms, fear of authority figures

• Social isolation, loneliness, lack of success in school, business, social relationships

Obsessive Compulsive Disorder

• Recurrent, Persistent Obsessions (intrusive and/or inappropriate thoughts, images, impulses, ideas) and Compulsions (behaviors or thoughts to prevent or reduce anxiety or distress associated with obsession.)

• Person recognizes the obsessions are outside of the realm of control but also the product of his or her own mind

• Attempts to ignore or suppress usually fail• Mounting anxiety of obsession can be

relieved by enacting the compulsion

Obsessive Compulsive Disorder

Common types:• Fear of germs / compulsive hand washing• Repeated thoughts of having hurt someone or

leaving some important task undone / checking behaviors

• Need for order / placing things in symmetry or in a particular order, performing acts in a specific sequence, wearing the same clothes everyday

• Desire to say or do inappropriate things / counting, tapping, distracting behaviors or rigid, idiosyncratic behaviors or rules to follow

Posttraumatic Stress Disorder

• It's been called shell shock, battle fatigue, accident neurosis and post rape syndrome.

• It is a set of symptoms that develop after a person sees, hears, or is involved in an extreme traumatic stressor.

• It affects people who have survived earthquakes; accidental disasters such as airplane crashes; or manmade disasters such as a terrorist bombing, inner-city violence, domestic abuse, rape, war, and the Holocaust.

• In some cases the symptoms of PTSD disappear with time, while in others they persist for many years. PTSD often occurs with-or leads to-other psychiatric illnesses, such as depression, social anxiety, GAD

Symptoms of PTSD

• Usually appear within 3 months of the trauma, but can surface years later

• Symptoms fall into 3 categories: – Reexperiencing the trauma – Avoidance of stimuli– Persistent increased arousal

Reexperiencing

• Recurrent and intrusive recollections of the events (images, thoughts, perceptions)

• Recurrent dreams or nightmares of the event• Feeling as if it is happening again (flashbacks,

illusions, hallucinations, physical sensations)• Intense psychological distress upon exposure to

internal or external triggers• Physiological reactivity upon exposure to internal

or external triggers

Avoidance• Efforts to avoid thoughts and feelings or

conversations about the trauma• Efforts to avoid the activities, places or people

that activate memories• Inability to recall important aspects of the

trauma• Markedly diminished interest or participation in

significant activities• Feelings of detachment or estrangement from

others• Restrict range of affect (unable to love)• Sense of foreshortened future (doesn’t expect to

marry, have a career, children, normal life span)

Increased Arousal

• Difficulty falling or staying asleep• Irritability or outbursts of anger• Difficulty concentrating• Hypervigilence• Exaggerated startle response

Features Associated with PTSD

• Substance abuse• Suicide

Acute Stress Disorder

• Person is exposed to a traumatic event accompanied by 3 of the following:– Subjective sense of numbing, detachment, absence of

emotions– A reduction in awareness– Derealization (doesn’t seem quite real / out of sync)– Depersonalization (as if it is happening to someone else)– Dissociate amnesia (cannot remember what happened)

• Trauma is persistently reexperienced• Avoidance of triggers• Symptoms of anxiety• Lasts for a minimum of 2 days and a maximum of 4

week and occurs within 4 weeks of the trauma

Generalized Anxiety Disorder

• Excessive worry and anxiety more days than not for at least 6 months across a number of situations (work, homelife, school performance)

• Cannot control the worry• Feelings of:

– Restlessness– Easily fatigued– Difficulty concentrating– Irritability– Muscle tension– Disturbed sleep

Anxiety Disorder Due to a General Medical Condition

Anxiety is caused by a medical condition such asHyper/hypothyroidismCardiovascular conditions (congestive heart failure)Respiratory conditions (COPD)Metabolic conditions (vitamin B12 deficiency)Neurological conditions (encephalitis)

Anxiety can be expressed a number of waysGAD symptomsPanic AttacksOCD symptoms

Anxiety Disorder Due to Anxiety Disorder Due to a General Medical Conditiona General Medical Condition

Symptoms must occur after onset of physical condition and things like typical age of onset for the disorder, family psychological history, and remission when disease remits must be taken into consideration

Can be caused by a wide variety of medical conditions and the anxiety looks just like a regular anxiety disorder

The best treatment is to treat the underlying medical condition

Substance Induced Anxiety Substance Induced Anxiety DisorderDisorder

Prominent anxiety, panic attacks, OCD symptoms, or phobia occurring during or within one month of substance intoxication or withdrawal or the medication use is etiologically related to the disturbance

Symptoms are not better accounted for by symptoms of intoxication or withdrawal ((anxiety disorder sxs are more severe)

Amphetamine or amphetamine like substance Caffeine, cannabis, cocaine Hallucinogen, inhalant, phencyclidine Sedative, hypnotic, anxiolytic Other/unkown

Anxiety Disorders NOS

Mixed Anxiety-Depressive Disorder but the criteria aren’t quite met for other disorders

Clinically significant social phobic symptoms that are related to the social impact of a disease or mental disorder

Situations where the clinician has concluded an anxiety order exists, but is unable to determine whether it is primary, due to a GMC, or substance induced

Somatoform Disorder

Presence of physical symptoms that suggests a general medical condition

– Not explained by a general medical condition

– Not the effects of a substance– Aren’t explained by another mental

disorder– Symptoms are not intentional or under

voluntary control

Types of Somatoform Disorders

• Somatization Disorder (< 30 y.o., polysymptomatic, extends over years, combination of pain, gastrointestinal, sexual and pseudoneurological)

• Undifferentiated Somatization Disorder• Conversion Disorder (including seizures)• Pain Disorder• Hypochondriasis (preoccupation with having a

disease)• Body Dysmorphic Disorder • Somatoform NOS (false pregnancy, subjective

sensation of fetal movement, unexplained physical complaints of less than 6 months.)

Chronic Fatigue Syndrome

• Chronic fatigue not improved by rest• Four of the following symptoms:

– Substantial short-term memory impairment– Sore throat– Tender lymph nodes– Muscle pain– Multi-joint pain without swelling or redness– Headaches of a new type, pattern or severity– Unrefreshing sleep– Post-exertional malaise lasting more than 24 hours

• Worsened by physical or mental activity• Levels of functioning are greatly reduced

Fibromyalgia

• Chronic condition characterized by fatigue, widespread pain in the ligaments, muscles, and tendons, and multiple tender points where pressure causes pain.

• Is not progressive, crippling, or life-threatening• Fatigue and sleep disturbances are common• Co-occurs with irritable bowel, headaches and

facial pain, heightened sensitivity to odors, noises, bright lights, and touch

• Diagnosis is very difficult – no tests• Treatment includes analgesics, antidepressants,

muscle relaxants, CBT and psychological interventions such as biofeedback, chiropracty, massage therapy, osteopathy, and acupuncture.

Factitious Disorder• Deliberate production or feigning of physical or

psychological symptoms– Fake symptoms or making up complaints– Self-inflicted wounds– Exaggeration or exacerbation of preexisting

GMC• Motivation is to assume the sick role• No external motivation (see malingering)

• Malingering has an external motivation such as economic gain, avoiding legal responsibility, improving physical well-being

Dissociative Disorder

The functions of consciousness, memory, identity, or perception of the environment become un-integrated or disrupted.

• Dissociative Amnesia – cannot recall important, usually traumatic – memories or information.

• Dissociative Fugue – sudden travel away from home/work with an inability to recall the past and confusion about identity or assumption of a new identity

• Dissociate Identity Disorder – (MPD) presence of two or more distinct identities or personalities

• Depersonalization Disorder – persistent or recurrent feeling of being detached from one’s mental processes or body accompanied by intact reality testing

• Dissociative Disorder NOS