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Flashcards in 7. Specific Disorders - Anxiety Disorders Deck (29)
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What are the diagnostic criteria for Generalized Anxiety Disorder (GAD)?

A. Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)

B. Individual finds it difficult to control the worry

C. The anxiety/worry are associated with 3 or more of the following (only 1 required in children)
(Indiana Jones Fights Monsters, Rattlesnakes, Communists, and Swastikas)
1. Irritability
2. Fatigue
3. Muscle Tension
4. Restlessness
5. Concentration/mind going blank
6. Sleep disturbance (difficulty falling or staying asleep,
or restless unsatisfying sleep)

D. Clinically significant distress in social, occupational, or other areas of functioning.

E. Not due to a substance or medical condition.

F. Not better explained by another mental disorder (for example anxiety or worry about panic attacks in panic disorder, negative evaluation in social anxiety disorder (social phobia), contamination or other obsessions OCD, separation from attachment figures in separation anxiety disorder, PTSD reminders, gaining weight in anorexia, physical complaints in somatic symptom disorder, body flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or delusional beliefs from schizophrenia or delusional disorder).


Lifetime prevalence of GAD is _______.

.9% among adolescents and 2.9% among adults in the US.

Other countries - .4% to 3.6%


Are there gender differences in the prevalence of GAD?

Yes, females are twice as likely to have it than males.


At what age does GAD tend to be the highest?

It peaks in middle age, then declines in later years of life.


Are there racial or cultural differences in prevalence of GAD?

Yes, individuals of European descent tend to be diagnosed more regularly.

Culture influences whether somatic or cognitive symptoms dominate.

Although there is no evidence that the propensity for excessive worrying is related to culture, the topic of being worried about can be culture specific.


Define a panic attack, and include the diagnostic criteria.

An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of a list of 13 physical and cognitive symptoms occur:

1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness or breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feelings 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, headache, uncontrollable screaming or crying) might be seen, but shouldn't be considered one of the four required.


List diagnostic criteria for Panic Disorder.

A. An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of a list of 13 physical and cognitive symptoms occur:

1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness or breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feelings 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

B. At least one of the attacks has been followed by 1 month or more of one or both of the following: 1) persistent worry about additional attacks or their consequences, 2) A significant maladaptive change in behavior related to the attacks, like avoiding exercise or unfamiliar situations

C. Not due to a substance or other medical condition

D. Not better explained by another medical disorder (e.g., they aren't just in response to feared social situations like in social anxiety disorder, in responses to circumscribed phobic objects or situations like in specific phobia, in responses to obsessions like in OCD, in response to reminders of traumatic events like in PTSD, or in response to separation from attachment figures like in separation anxiety disorder)


What is the 12-month prevalence of panic disorder?

2-3% in adults and adolescents

American Indians have significantly higher rates

Female to male ratio is about 2:1

Dx peaks during adulthood, and declines in adults over age 64


What is known about the comorbidity of panic disorder and other disorders?

It infrequently occurs in the absence of other psychopathology. It is elevated in individuals with other disorders, especially anxiety disorders (especially agoraphobia), major depression, bipolar disorder, and possibly mild alcohol use disorder.


What is known about the comorbidity of GAD and other disorders?

They are likely to have met, or currently meet, criteria for other anxiety and unipolar depressive disorders. The neuroticism or emotional lability that underpins this pattern of comorbidity is associated with temperamental antecedents and genetic and environmental risk factors shared between these disorders.

LESS common - Comorbidity with substance use, conduct, psychotic, neurodevelopmental, and neurocognitive disorders.


List all DSM-5 Anxiety Disorders (189)

1. Separation Anxiety Disorder (190)
2. Selective Mutism (195)
3. Specific Phobia (197)
4. Social Anxiety Disorder (Social Phobia; 202)
5. Panic Disorder (208)
6. Panic Attack Specifier (214)
7. Agoraphobia (217)
8. Generalized Anxiety Disorder (222)
9. Substance/Medication-Induced Anxiety Disorder (226)
10. Anxiety Disorder Due to Another Medical Condition (230)
11. Other Specified Anxiety Disorder (233)
12. Unspecified Anxiety Disorder (233)


What are the risk and prognostic factors for GAD?

Temperamental - behavioral inhibition, neuroticism, and harm avoidance

Environmental - childhood adversities and parental overprotection

Genetic/Physiological - 1/3 is genetic, and these genetic factors overlap with risk of neuroticism and are shared with other anxiety and mood disorders, in particular major depression


What should you consider in the differential diagnosis of generalized anxiety disorder (225)?

1. Anxiety disorder due to another medical condition
2. Substance/medication-induced anxiety disorder
3. Social anxiety disorder - anxiety is focused on upcoming social situations
4. Obsessive-compulsive disorder - in GAD the focus of the worry is about upcoming problems, and it is the excessiveness of the worry about future events that is abnormal
5. PTSD and adjustment disorders
6. Depressive, bipolar, and psychotic disorders


What is the median age of onset for panic disorder in the United States?

20 - 24 years old

A small number of cases begin in childhood, and onset after age 45 is unusual but can occur


What are risk and prognostic factors for panic disorder?

Temperamental - Neuroticism and anxiety sensitivity, Hx of fearful spells, separation anxiety in childhood esp. when severe could also be one, though not consistently

Environmental - Childhood sexual and physical abuse, smoking, and identifiable stressors (such as interpersonal stressors, threats to well being like bad experiences with drugs, disease, or death in the family)

Genetic/Physiological - Multiple genes confer vulnerability to panic attack though exact ones are unknown. Amygdala and related structures are implicated. Increased risk among offspring of parents with anxiety, depressive, and bipolar disorders. Asthma is also associated with panic disorder.


What are some culture-related diagnostic issues for panic disorder?

Cultural expectations may influence the classification of panic attacks as either expected or unexpected.

Other cultural symptoms, such as ataque de nervios ("attack of nerves") among Latin Americans and khyâl attacks and "soul loss" among Cambodians.

Ataque de nervios ("attack of nerves") among Latin Americans may involve trembling, uncontrollable screaming and crying, aggressive/suicidal behavior, and depersonalization or derealization, which may be experienced longer than the typical few minutes panic attacks are.

Non-latino whites tends to have less functional impairment than African-Americans from panic attacks.

non-Latino Caribbean blacks report higher rates of objective severity of panic attacks, but overall have lower rates among all individuals of African descent. This suggests that the criteria for PD may only be met when there is substantial severity and impairment.


Describe gender differences in panic disorder.

Clinical features don't appear to differ between males and females.

Some evidence for sexual dimorphism, with an association between panic disorder and COMT gene in females only.


What is important to know for differential diagnosis of panic disorder?

Differentiate it from:
1. Other specified anxiety disorder or unspecified anxiety disorder
2. Anxiety disorder due to another medical condition
3. Substance/medication-induced anxiety disorder
4. Other mental disorders with panic attacks as an associated feature (e.g., other anxiety disorders and psychotic disorders)


What is special about noting the presence of panic attacks?

A panic attack is not a mental diagnosis and cannot be coded. Instead, it is used as specifier with another disorder.

For panic disorder, the presence of a panic attack is contained in the disorder, so you don't use panic attack as a specifier.


What is the essential feature of separation anxiety disorder (191)?

A. Excessive fear or anxiety concerning separation from home or attachment figures (3+/8 listed)


How long does fear, anxiety, or avoidance characteristic of separation anxiety disorder have to last in children and adults to be diagnosed?

B. 4 weeks in children and adolescents, typically 6 months or more in adults


To be diagnosed with separation anxiety disorder, the disturbance can't be better explained by another mental disorder. Give some common examples.

D. Refusing to leave home because of excessive resistance to change in autism spectrum disorder, delusions or hallucinations concerning separation in psychotic disorders, refusal to go outside without a trusted companion in agoraphobia, worries about ill health or other harm befalling significant others in GAD, or concerns about having an illness in illness anxiety disorder.


List the diagnostic criteria for selective mutism (195).

A. Consistent failure to speak in specific social situations in which it's expected (e.g., school) despite speaking in other situations.

B. The disturbance interferes with educational or occupational achievement or with social communication.

C. The disturbance lasts at least 1 month (and not limited to the first month of school)

D. Failure to speak not due to a lack of knowledge or comfort with the spoken language required in the social situation.

E. Not better explained by a communication disorder (e.g., childhood onset fluency disorder) and doesn't occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.


What differentiates specific phobia from panic disorder, social phobia disorder, and agoraphobia?

With specific phobia, there is marked fear about a specific object or situation.

In panic disorder, panic attacks occur unexpectedly not just when in contact with the feared object/situation.

With social phobia disorder and agoraphobia, it is in response to fear of negative evaluation or agoraphobic situation, specifically.


What are the diagnostic criteria for social anxiety disorder (social phobia)?

A. Marked or persistent fear of one or more social or performance situations in which the person is exposed to possible scrutiny by others. Could include social interactions, being observed, or performing in front of others

B. Individual fears he/she will show anxiety symptoms that will be negatively evaluating

C. The social situations almost always provoke fear/anxiety

D. The social situations are avoided or endured with intense fear/anxiety

E. Fear/anxiety is out of proportion to actual threat posed

F. Persistent, typically lasting for 6-months or more

G. Clinically significant distress

H. Not due to a substance/other medical condition

I. Not due to another disorder (like panic disorder, body dysmorphic disorder, or autism spectrum disorder)

J. If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive

*Specify if performance only


To be diagnosed with agoraphobia, certain criterion need to be met. An individual needs to have marked fear or anxiety about which situations?

A. Marked fear/anxiety about two (or more) of the following five situations:
1. Using public transportation
2. Being in open spaces
3. Being in enclosed places
4. Standing in line or being in a crowd
5. Being outside of the home alone


What should you remember about the diagnosis of agoraphobia?

It can be diagnosed irrespective of the presence of panic disorder.

If an individual's presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.


In agoraphobia, how long should the fear, anxiety, or avoidance persist?

F. 6 months or more


What disorders should you r/o before diagnosing with agoraphobia?

Symptoms shouldn't be confined to specific phobia, situational type (221). You should diagnose specific phobia, situational type if the fear/anxiety/avoidance is limited to one of the agoraphobic situations. Also, keep in mind cognitive ideation. If the person is afraid of the situation for reasons OTHER than panic-like symptoms (like the plane crashing) then social phobia, situational type may be more appropriate.

They also should not involve only social situations (like social anxiety disorder), not related to obsessions (obsessive-compulsive disorder), perceived defects or flaws in physical appearance (body dysmorphic disorder), reminders of traumatic events (PTSD), or fear of separation (separation anxiety disorder).

May also want to consider avoidant personality disorder.