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1 Anxiety Disorders Anxiety Disorders: Assessment and Treatment 2 CE Hours Learning objectives 1. Identify the DSM-5 diagnostic criteria for each type of anxiety disorder. 2. Describe the assessment tools used to identify the subcategories of anxiety disorders. 3. List the symptoms of the subcategories of anxiety disorders. 4. Discuss strategies that parents can use to assist children with anxiety disorders. 5. Explain the different classes of medications used to treat each type of anxiety disorder. 6. Discuss therapeutic treatment models used for specific anxiety disorders. Introduction Mandy is a 52-year-old woman who has a responsible job as an accountant. To her friends and family, she appears to to “have it all together.” However, in the last three months, Mandy has been more reluctant to go to places she describes as “open”— in particular, to the mall. Two months ago when she was at the mall, Mandy felt her legs go numb and tingle. She felt different and scared for no real reason; however, it went away after a few minutes. The next week when at the mall again, Mandy felt as if she were having a heart attack: her heart began to pound uncontrollably and she began shaking and gasping for breath. Her friend called 911; Mandy was examined by the emergency medical personnel who later determined that nothing was wrong with her heart. Mandy felt foolish and embarrassed. As a result, she has become very reluctant to go out with friends and now frequently stays at home. She has made an appointment to go see her primary care doctor because she is sure that something is wrong with her heart. James, 29, has always described himself as a “neurotic.” He is a perfectionist who worries over every detail of his life, including his job as a nurse. He has recently begun to 1 wake up in the middle of the night two or three times a week, worrying that he has forgotten to do something important at work. He calls the hospital to check on his patients, as well as any tasks that he was assigned. His coworkers found this amusing at first— a sign of how conscientious he was as a nurse. In the last week, however, his coworkers started to laugh at him and to appease him: they tell him that they have checked on things when they really had not done so. James also constantly worries that something will happen to his young son. He is unable to stop worrying that his son will get cancer or have an accident. When these thoughts occur, James cannot concentrate on anything else. He also forbids his son to participate in activities – such as skateboarding or playing basketball with other kids— because he is afraid the boy will get hurt. He has also begun to worry about his wife leaving him. He asks her for daily reassurance that she will not divorce him and she is becoming increasingly annoyed by the questioning. Jordan is a 7-year-old boy who recently witnessed his father die in a car accident. Jordan was a passenger in the car, but was unharmed. He has been having nightmares and has also started sucking his thumb and wetting the bed. His mother noted that while playing, Jordan acts out a car accident with his toys. Jordan is well behaved, but his mother is worried about his other behaviors. All of the individuals in these vignettes are displaying symptoms consistent with some form of an anxiety disorder. Anxiety is a broad term that encompasses a broad spectrum of disorders, each with their own distinct features and courses of treatment. According to the Anxiety and Depression Association of America, (2016a): • Anxiety disorders are the most common mental illness in the U.S. and affect about 18.1 percent of the U.S. adult population, or about 42 million people. Numbers may be even higher due to untreated and unreported cases. 2 • Anxiety disorders are highly treatable, yet only 36.9% of those suffering receive treatment. • People with an anxiety disorder are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than those who do not suffer from anxiety disorders. • Anxiety disorders develop from a complex set of risk factors, including genetics, brain chemistry, personality, and life events. • It is not uncommon for someone with an anxiety disorder to also suffer from depression, or vice versa. Nearly one-half of those diagnosed with depression are also diagnosed with an anxiety disorder. • Many of these persons have dual diagnoses; for example, some have both PTSD and GAD, or co-occurring social phobia and OCD. • There are a large number of individuals with anxiety disorders who also experience co-occurring substance abuse issues (National Institute of Mental Health, 2016a). The impact on society is enormous. In particular, those with anxiety disorders tend to have physical issues resulting from their anxiety which mimic a variety of physical ailments. Therefore, persons with anxiety disorders spend $42 billion dollars a year due to anxiety disorder; $22.84 billion of that is spent seeking treatment for physical problems that have mimicked anxiety symptoms, instead of seeking treatment for the real cause – underlying anxiety (Folk and Folk, 2017). It is important, however, to differentiate between ordinary life stressors and true anxiety. For example, stress experienced as “butterflies in the stomach” before giving a speech or a presentation is normal; however, being so afraid to speak before a group that one resigns from a job rather than give a speech is a more serious form of anxiety. Furthermore, worrying about doing a good job on a paper for school and stressing over the outcome is normal; however, being so concerned about failing that a student is unable 3 to start the project and then fails the class is more in line with one who is experiencing a generalized anxiety disorder. Most people are hesitant to go into a new social setting and may occasionally turn down an invitation because they “won’t know anyone there.” Someone who avoids social contact altogether, however, has more serious social phobia issues. Statistics on prevalence The following statistics are from the National Institute of Mental Health, (2016a): • Generalized anxiety disorder (GAD) GAD affects 6.8 million adults, or 3.1% of the U.S. population, yet only 43.2% are receiving treatment. Women are twice as likely to be affected as men. GAD often co-occurs with major depression. • Panic disorder (PD) PD affects six million adults, or 2.7% of the U.S. population. Women are twice as likely to be affected as men. Social anxiety disorder affects 15 million adults, or 6.8% of the U.S. population. It is equally common among men and women and typically begins around age 13. According to an ADAA (2016a) survey, 36% of people with social anxiety disorder report experiencing symptoms for 10 years or more before seeking help. • Specific phobias Specific phobias affect 19 million adults, or 8.7% of the U.S. population. Women are twice as likely to be affected as men. Symptoms typically begin in childhood; the average age-of-onset is seven years old. • Obsessive-compulsive disorder (OCD) OCD affects 2.2 million adults, or 1.0% of the U.S. population. OCD is equally common among men and women. The average age of onset is 19; 25 percent of cases occur by age 14. One-third of affected adults first experienced symptoms in childhood. 4 • Post-traumatic stress disorder (PTSD) PTSD affects 7.7 million adults, or 3.5% of the U.S. population. Women are more likely to be affected than men. Rape is the most likely trigger of PTSD: 65% of men and 45.9% of women who are raped will develop the disorder. Childhood sexual abuse is also a strong predictor of lifetime likelihood for developing PTSD. Children Anxiety disorders affect 25.1% of children between 13 and 18 years old. Research shows that untreated children with anxiety disorders are at a higher risk to perform poorly in school, miss out on important social experiences, and engage in substance abuse. Anxiety disorders also often co-occur with other disorders such as depression, eating disorders, and attention-deficit/hyperactivity disorder (ADHD). Note: All children experience a certain amount of anxiety. However, worry that interferes with daily functioning may become problem. Not all children may meet the criteria for an anxiety disorder. There are many helpful tips for parents when managing an anxious child, regardless of the child’s diagnosis. The Anxiety and Depression Association of America (2016c) provides the following tips to help parents dealing with an anxious child: • Pay attention to the child’s feelings. • Stay calm when the child becomes anxious about a situation or an event. • Recognize and praise small accomplishments. Build on the child’s strengths. • Do not punish mistakes or lack of progress. • Be flexible and try to maintain a normal routine. • Support the child but help him/her learn to do things on his/her own. • Help children handle feelings; they need to know it is OK to feel anxious, express how they feel, and that they can cope with these feelings. 5 • Do not pass fears to children. Model positive responses and strategies to handle anxiety. • Modify expectations during stressful periods. • Plan for transitions. (For example, allow extra time in the morning if getting to school is difficult.) Parents must keep in mind that a child’s anxiety disorder diagnosis is not a sign of poor parenting. It may add stress to family life so it is helpful to build a support network of relatives and friends.
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