Anxiety Disorders in the DSM 5 TR | Symptoms and Diagnosis

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Hey there everybody and welcome to this  presentation on diagnosing anxiety and panic   in the dsm-5tr i’m your host dr donnelly snipes  in this presentation very briefly we’re going   to review the diagnostic criteria for anxiety  disorders or at least most of them in the dsm 5 tr
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so let’s talk a little bit about anxiety  disorders in general when we’re talking about   anxiety disorders we need to remember that fear  and anxiety may be expressed as fighting agitation   tantrums fleeing freezing fawning clinging or  withdrawal or what i call the final f which is um  
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politely forget about it because people just don’t  have any more energy left so they kind of withdraw   anxiety disorders differ from each other  regarding the types of objects or situations   that cause fear anxiety or avoidance  behaviors and the associated beliefs  
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anxiety disorders represent a response that is  not developmentally culturally or i also add   contextually normative in terms of intensity or  duration so when we’re looking at what somebody is   anxious about we want to examine obviously culture  and development something that a five-year-old is  
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afraid of is not necessarily going to be the  same thing that a 25 year old is afraid of   we also want to look at context though  something that uh you’re afraid of in one   context you may not be afraid of in another  like for children being around strangers  
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may not be stressful for them when they are at  home or when they’re at school and somebody comes   in to do a presentation versus when they are  alone and they don’t have a caregiver around interestingly from august 2020 through december  2020 the percentage of adults reporting symptoms  
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of an anxiety disorder rose from 31.4 to  36.9 now when you go through the dsm and   you start adding up the prevalence of these  anxiety disorders it is really hard to get to   a number anywhere close to 36.9 so the  numbers in the dsm and the numbers in the  
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uh national health survey don’t seem to jive very  well we also have to remember that during 2020 we   were at the beginning of the pandemic so there  was obviously more anxiety you would expect that   but even the 31 percent that it was prior to 2020  seems to be higher than what is identified in the  
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dsm so i think that’s interesting the anxiety  chapter in the dsm-5tr just like in the dsm-5   is arranged in order of diagnosis which appear  in children first so separation anxiety disorder   appears first and generalized anxiety disorder  is down a little ways whereas you might expect  
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some of the quote more common disorders to be  first but that’s not how the dsm is arranged however in this presentation i did put  generalized anxiety first when we talk about   generalized anxiety we’re talking about excessive  anxiety most days for six or more months and the  
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anxiety is about a variety of things it’s not  just about one particular thing like health or   an individual or a phobia it is about a variety  of things the worry in addition to being excessive   for the person’s developmental age culture  and context the worry is difficult to control  
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the anxiety or the feeling of anxiety is  associated with three or more symptoms in adults   or one or more symptoms in children feeling  restless or feeling keyed up or on edge   easily fatigued difficulty concentrating or mind  going blank irritability muscle tension or sleep  
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disturbance i want you to think about it anxiety  is part of the fight or flight response so we   would expect somebody experiencing anxiety would  it be experiencing symptoms of hpa axis activation   or activation of the threat threat response or  stress response whatever you want to call it  
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so we would expect all of these symptoms  or any of these symptoms because when the   fight or flight system is engaged the body  is not focused on higher order processing or   memory or the concentration it’s focused on  self-preservation and protection the person  
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becomes more vigilant because they are trying to  protect themselves from threats they’re not able   to relax enough to get good quality sleep because  guess what they are keyed up they’re scanning for   those threats muscle tension and i’ve mentioned  in other videos when i used to play tennis my  
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coach always used to say don’t stand flat-footed  on the baseline because it takes more time and   it’s harder for you to run and spring into  action to where that ball is going to be   now that is not a threat per se but the same thing  is true for people with anxiety disorders when  
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you are when you’ve got that muscle tension it’s  kind of like standing on your toes on the baseline   in tennis you are primed and ready to go and it  makes it easier to theoretically fight or flee   these symptoms have to cause clinically  significant distress people can have subclinical  
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anxiety disorder where they have a lot of worry  about a variety of things but it is either not   excessive for what they’re worried about or it  doesn’t cause them clinically significant distress   overall they report a decent quality of life it  doesn’t interfere with functioning in major areas  
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of their life and generalized anxiety disorder  as well as all of the disorders are not better   explained by a medical mental or substance use  disorder and we’re going to talk in the end about   differential diagnosis of the anxiety disorders  in general because there’s a lot of overlap  
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between the symptoms as well as the  differential diagnosis and comorbidities for   anxiety disorders remember the difference is often  what the person experiences anxiety about and   the cognitions associated with that diagnostic  features of generalized anxiety disorder well  
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this section as with most of the sections in the  anxiety chapter pretty much just recapitulated   the diagnostic criteria and it elaborated a  little bit one interesting feature is that   for generalized anxiety disorder they noted that  adults tend to worry about general life things  
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like paying bills and getting a promotion or  what’s going to happen with this or that or what’s   going on in the world kids tend to worry about  their competence like performing at school or   their ability to be competent in relationships  sometimes they worry about disaster now with  
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coming off of the pandemic  we can probably add that too   but other disasters like hurricanes and  fires and floods and those sorts of things   can prompt a lot of worry in  children and and punctuality  
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interestingly enough some children become very  concerned about being punctual and so it’s   interesting to note that there is a difference  in what they worry about which makes sense   because adults have different responsibilities  than kids do and you notice that with the  
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exception of disaster a lot of these worries  revolve around the primary life areas or functions   of the person you know kids aren’t worried  about paying bills or or maintaining   or parenting or some of the things that that  adults worry about associated symptoms well let  
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me talk about disaster really quick i’m trying not  to go too far off the rails today because we’ve   got a lot to cover but it’s important to recognize  that children have a difficult time understanding   prevalence and likelihood of things so when there  is a disaster such as you know we’ve had several  
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in middle tennessee over the past two years and a  child watching the news or hearing about the news   may not understand how close or far away that  disaster was or the likelihood of it recurring   adults are better able to understand you know  it’s a 100 year flood or there’s the chances  
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of it happening again are you know whatever  the probability is depending on what you’re   talking about children don’t understand that  they see it on the news it feels like since   it’s on the news it’s kind of in their house  so it feels like it’s right in their space  
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and it’s hard to know when it’s going to end  or when it’s going to happen again which can   prompt them to have a lot more worries about  disasters parents can help by explaining some   of the things to them and explaining to children  the probability of another disaster occurring and  
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you know how that they’re safe right now and the  steps that they can take it won’t do everything   but it is important again to recognize children’s  different cognitive abilities compared to adults   associated symptoms with generalized anxiety  disorder other somatic symptoms that are not  
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as intense as those seen in panic disorder so we  will also see potentially heart racing clammy skin   rapid breathing other things and an upset  stomach that aren’t specifically indicated   in diagnostic criteria but we know happen when  that fight or flight response is kicked off  
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the prevalence remember i said if you start add  up the prevalence of all these anxiety disorders   you’re going to be hard-pressed to get anywhere  close to 31 percent and according to the dsm-5 tr   between one percent of adolescents and three  percent of adults in the u.s experience  
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generalized anxiety disorder according to  the national center on health statistics   in 2019 now that was before the pandemic  15.6 of adults experienced symptoms of   generalized anxiety disorder in the prior  two weeks the development and course  
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the mean onset is rarely before adolescence  and is i’m sorry the mean onset is 35   and rarely before adolescence so this is one  of the disorders that actually has a much   later onset than other disorders which i  did find that to be somewhat interesting
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now we’ll move on to separation anxiety separation  anxiety is the first disorder in the chapter   because it tends to be the one that presents  earliest and it can be diagnosed as early as   preschool separation anxiety is characterized by  developmentally inappropriate excessive recurrent  
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anxiety about separation from major attachment  figures in order to be diagnosed the person has to   have three or more symptoms it can be diagnosed  in childhood it can be diagnosed in adulthood   if it’s diagnosed in adulthood you do  not have to have a childhood onset of  
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separation anxiety it actually can have an  adult onset so that is something to remember symptoms three or more distress due to or in in  anticipation of separation from home or from major   attachment figures anxiety about losing a major  attachment figure or about possible harm to them  
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anxiety about something bad happening to the  person the patient which would cause them to be   separated from an anxiety from an attachment  figure so they have fears about something   happening to the attachment figure causing  separation and fears about them something  
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bad happening to themselves causing separation a  reluctance a refusal to go out or away from home   because of fear of separation now generally  this is leaving home and separating from that   attachment figure but in some cases it can include  even being reluctant to leave the house be cut  
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with the attachment figure because they’re afraid  that when they’re out there they may get separated   now think how this might occur if there was a  child who happened to be at a carnival and got   separated from their caregiver that might prompt  future fears of separation when in public places  
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fear of or reluctance to being alone  or without major attachment figures   refusal to go to sleep without being near a major  attachment figure nightmares about separation   or physical complaints in reaction to or  in anticipation of separation so they have  
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those physiological symptoms of anxiety  now note here they keep talking about   major attachment figures because remember this can  be diagnosed in adulthood we’re not talking about   the primary attachment from infancy we’re talking  about the person’s current major attachment figure  
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whether that be their a significant other  their parent whomever that happens to be the fear anxiety or avoidance is persistent  lasting at least four weeks in children and   adolescents and typically six months or more  in adults and you’ll find that’s a common theme  
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where a lot of these situations or conditions  have to last six months or more and be causing   clinically significant distress for six  months or more in order to rank a diagnosis   although the symptoms often develop in childhood  they can be expressed throughout adulthood it can  
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be diagnosed in adults in the absence of a history  of childhood separation anxiety disorder and as   i said it causes clinically significant distress  or impairment in one or more areas of functioning the diagnostic features section repeats the  diagnostic criteria with some elaboration  
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and examples it’s a pretty straightforward  diagnosis in terms of development and course   the onset of separation anxiety can be any time  from preschool through adulthood but generally   before the age of 30. so you can have diagnoses  of separation anxiety up in through the 20s  
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there may be periods of exacerbation and remission  although most child onset cases do not experience   ongoing clinically significant impairment  i thought that was kind of interesting associated features now these are not diagnostic  criteria these are features that are associated  
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with separation anxiety but didn’t rank in the  diagnostic criteria sadness or apathy well if   somebody is perpetually anxious that hpa axis is  going to down regulate some which may contribute   to apathy if they are perpetually anxious they  may also start feeling hopeless and hopeless  
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which is associated with feelings of sadness and  depression they may have difficulty concentrating   well the mind is not focused on concentration  if it’s in a perpetual state of fight or flee   there may be social withdrawal just stepping  away from everything because they don’t have  
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the energy to engage with others because the  anxiety is so pervasive in older children you   may see homesickness or pining when they are away  at camp or or something like that now obviously a   lot of children who don’t have separation  anxiety disorder experience homesickness  
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when they’re away at camp for the first  time however this is also associated with   separation anxiety the child migs or the person  may exhibit anger or aggression towards separators   so anybody who’s causing a separation between the  patient and their major attachment figures may
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provoke anxiety provoke anger perceptual  disturbances now these are not hallucinations   these are when a person is alone for example at  night and they feel like somebody’s watching them   or they think they see something moving in the  shadows it’s not really there and by turning  
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on the light so there’s no more shadows you  know that goes away it’s not a persistent   uh hallucination that the person is experiencing  but perceptual disturbances are more common   in children than than they are in adults and  we want to make sure we don’t mislabel that as  
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something related to a psychotic disorder children  with separation anxiety tend to be described as   demanding intrusive and in need of constant  attention according to the dsm now i would   argue when we get down a little further that this  may be true of all people with separation anxiety  
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adults may appear dependent and are likely  to contact their major attachment figures   throughout the day and track their whereabouts  they are also often overprotective as parents   and pet owners interestingly enough the  dsm did mention pets where the person with  
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separation anxiety may be excessively concerned  about knowing where their pet is at all times the prevalence of separation anxiety in  children is approximately four percent   and in adolescence and adults it ranges  from one to two percent in the culture  
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section the dsm talked about the importance of  differentiating separation anxiety disorder from   the high value some cultural communities place  on strong interdependence among family members specific phobias is the next in the line of  disorders we’re going to talk about and a specific  
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phobia is pretty straightforward there’s a marked  fear or anxiety about an object or a situation   about 75 percent of people that have one phobia  have more than one phobia and i think if you think   about it even if it doesn’t rise to the level  of being a diagnosable phobia you can think  
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about if you have one what we’ll call irrational  fear you probably have a couple of others when i   started to think about it i’m like yeah i have  i have a couple in there the stimulus almost   always produces an immediate fear response and is  actively avoided the fear is disproportionate to  
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the threat persist for guess what six months or  more and causes clinically significant distress   and i have this bold and and italicized because  it’s important to remember that having a fear   and i’ve talked in other videos about my fear of  bridges i also have a fear of enclosed spaces i  
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hate you know those little water tubes and tunnels  and things that make me feel closed in does it   cause me clinically significant distress or caused  me to have to alter my life to get around it no so   it doesn’t rise to the level of specific phobia  a lot of people have fears that may not have a um  
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basis or or the fear may be disproportionate  to the threat in reality we recognize it but   it doesn’t cause us clinically significant  distress so it would not be diagnosable as   a specific phobia and the specific phobia is  not better explained by another mental disorder  
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and i’m thinking here more obsessive compulsive  disorder but in the differential diagnosis list   on the anxiety disorders there were a lot so we’re  just going to go through all of those at the end the diagnostic features again in for specific  phobias was pretty much a restatement of the  
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diagnostic criteria associated features  interestingly enough for some people   are arousal well that makes sense when the hpa  axis kicks off a lot of people have a um increased   heart rate sort of a panic sort of feeling  about them not to the level of a panic attack  
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necessarily but they have that aroused state in  preparation for fight or flee other people may   have what they call a vasovagal response in which  their heart rate decelerates their blood pressure   drops and they may faint my grandmother used  to do this oh my gosh and it wasn’t necessarily  
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hers wasn’t phobia related but when she would get  startled or surprised she would fall out and for   the longest time the doctors couldn’t figure  out exactly what was going on but ultimately   my guess would be it re had something to do with  with anxiety or generalized anxiety the prevalence  
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of phobias is between eight and twelve percent it  peaks in adolescence at sixteen percent so sixty   percent of adolescents have specific phobias the  development in course it usually develops prior   to age 10 or after a trauma and the presence  of phobias is a risk factor for neurocognitive  
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disorders in older adults why is this we’ve  again we’ve talked in other videos about how hyperactivation of that stress response system  keeps levels of glutamate and norepinephrine and   stuff high in the brain which causes  neurodegeneration which can lead to  
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neurocognitive disorders additionally because of  social withdrawal and avoidance and restructuring   of their daily lives to avoid the phobic stimulus  there tends to be less stimulation for the person   with specific phobias which may also lead to  a decline in what they call cognitive reserve
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and social anxiety disorder in social  anxiety disorder there’s a marked fear   of social situations in when in which one might be  judged so you’ve got generalized anxiety which is   anxiety about a lot of things over the course of  at least six months we have specific phobia which  
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is obviously something specific like enclosed  spaces or spiders or snakes um separation anxiety   which is anxiety or fear of being separated from  an attachment figure and then social anxiety which   is fear from being in situations in which one  might be judged with children the symptoms have  
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to be present not only in relationships with  adults but in relationships with their peers   it’s natural for children to be somewhat  anxious if they’re interacting with adults   if they’re having the same anxiety when they’re  interacting with their peers then that’s really  
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what we’re going to look for for a trigger the  person has an excessive fear of being embarrassed   rejected or offensive and the offensive  seems to be increasing in popularity   or not popularity in commonality um very  quickly with twitter and facebook and tick  
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tock and all these other things and trying to be  politically correct a lot of people have developed   a level of social anxiety maybe not to the level  of being a disorder but definitely a level of   social anxiety because they fear not saying the  right thing because they fear being cancelled  
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social situations almost always trigger  the anxiety and social anxiety disorder   social situations are actively  avoided or endured with intense fear   and the level of fear is disproportionate  to the potential consequences  
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people may have a high level of fear and  anxiety uh before going out and giving a   performance in front of 10 000  people the level of anxiety for that   would probably be different than giving  a speech in front of six classmates  
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you know you see the difference here but a person  with social anxiety disorder they would have that   same level of fear in front of six people they  knew as opposed to ten thousand that they didn’t   persistence again for six months or more  causes clinically significant distress  
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and is not due to another medical mental  health or substance related condition   there is a note that social anxiety disorder can  be performance only and you do want to specify   that if it only has to do with giving speeches  performing sports music anything like that
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the diagnostic criteria   features section gave further examples of the  symptoms that were identified in the diagnostic   criteria associated features with social anxiety  the person may be passive or shy they may want  
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to kind of blend into the wall they may be  somewhat withdrawn because they don’t want to be   out there in the limelight they don’t want to  be in this position where they fear being judged   on the other end of the spectrum though there’s a  proportion of people with social anxiety disorder  
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who are highly controlling of situations and  they may try to control the conversation and   control other people in the situation  in order to avoid feeling out of control use of substances substance use misuse or abuse is  often associated with people with social anxiety  
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disorder and i have parenthetically hear liquid  courage that’s what we used to call it back in   the day i don’t know if it’s what they still call  it but using substances to help temporarily allay   anxiety interestingly as alcohol leaves the body  people tend to have an enhanced anxiety response  
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so using alcohol prior to a social situation  may actually end up causing more problems   for some people but that’s that’s up to them  additionally you may see a worsening of physical   illness symptoms such as tachycardia or increased  tremor in people with social anxiety disorder so  
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if they already have something that causes a  tremor or a tick that may get worse if they   already have something that causes tachycardia  that may get worse in situations in which   they fear being judged now i have here increased  pain question mark that’s not identified in the  
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dsm-5t however we know that hyperactivation of the  hpa axis contributes to ultimately development of   systemic inflammation and worsening of autoimmune  disorders so i would be interested to see   what the actual numbers are for that and no i  could not find any research that actually compared  
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the rates of increased pain with social anxiety  specifically prevalence seven percent of people   in the united states experience social anxiety  disorder now brace yourself this is not a typo 2.3   percent of people in europe can be diagnosed with  social anxiety disorder so what is that a third  
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what’s different in the united states that is  contributing to significantly higher rates of   social anxiety and fear of being judged  and fear of offending people just saying   additionally social anxiety disorder does  tend to be highest in non-hispanic whites  
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so what is unique about non-hispanic whites  in the us i’ll leave you to talk about that and panic disorder people with panic  disorder experience recurrent unexpected   surges of intense fear or discomfort that peaks  within minutes and has a and the accompanying  
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four plus symptoms now i have bolded  and italicized unexpected here   there are expected panic attacks when you’re  in a situation in which you’ve had a panic   attack before when there is a known trigger for  the panic attack that’s a expected panic attack  
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that doesn’t count towards our diagnosis here  which i don’t know seems a little strange but   okay the panic attacks have to be unexpected  that is they come from out of the clear blue and the panic attacks need to be characterized  by four or more of the following symptoms  
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palpitations which is when it feels  like your heart is like fluttering   pounding heart or tachycardia which is  racing heart sweating trembling or shaking   a feeling of shortness of breath or smothering  you just can’t don’t feel like you can breathe  
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feeling like you’re choking chest pain or  discomfort nausea or abdominal distress   feeling dizzy unsteady lightheaded or  faint chills or heat sensations numbness   or tingling derealization which things just don’t  feel real you feel like you’re kind of in a in a  
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dream or depersonalization you don’t feel  like you’re part of your own body anymore   fear of losing control or going crazy and fear  of dying now i’ll mention even though it’s   pretty obvious these many of these symptoms are  also symptoms of a heart attack it is important  
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if you are a clinician not to assume that  somebody who is experiencing a panic attack   it’s it’s just a panic attack and to dismiss  it it’s important to take every panic attack   seriously when somebody’s experiencing it and  work with their medical provider to help them  
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differentiate between what’s a panic attack how  do i know when i’m having another panic attack   versus how do i know when i need to go to the  er and their doctor will work with them on that culture specific symptoms for panic may  include tinnitus or ringing in the ear  
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neck soreness headache uncontrollable screaming  or crying interestingly even though these are   culture specific symptoms the dsm said those don’t  count toward the required four plus symptoms so additionally at least one of the attacks  unexpected attacks has been followed by one  
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month or more of both of the following persistent  concern or worry about additional panic attacks or   their consequences and a significant maladaptive  change in behavior related to the attacks   avoidance of situations where you think  they might happen again or ritualized or  
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superstitious behavior or extreme behavior like  changing your diet completely or doing something   extreme in order to try to prevent the attack  so the unexpected attack happens and then for   the next month or more both of those persistent  concern about it happening again and significant  
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maladaptive changes in behavior are occurring  it has to cause clinically significant distress   and it’s not due to another mental  medical or substance use disorder interestingly for panic attack there were no  specifiers but in the diagnostic features it  
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did note that panic attacks can be full means  four or more symptoms or limited symptom   so it doesn’t meet all of it doesn’t meet four  symptoms or more but the person’s clearly having   a panic response if the person has never had a  full-blown panic attack uh four or more symptoms  
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then you would not diagnose panic disorder  frequency can be relatively regular like one   per week or it can come in bursts where they where  they have multiple really close together then they   go weeks months or even years without having them  and then they have another burst of panic attacks  
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and there could also be instances where they just  have a panic attack and then they may go for a   couple of years or more before they have another  one it still qualifies as panic disorder there is   no code for remission of panic disorder and the  expectation is unfortunately that if somebody has  
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had a panic disorder at some point they probably  will have another panic attack at another point   remember that expected to panic attacks occur with  known triggers and there are many culture related   diagnostic issues due to expected triggers  so if you read through the culture related  
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diagnostic issues section of the dsm-5tr  you will find they talk about a lot of   culture bound triggers that can  cause a panic attack in people associated features people who  have panic attacks panic disorder  
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may also have intermittent anxiety  about health or mental health   they tend to be more somatically sensitive that  means they’re more aware of what’s going on in   their body well that makes sense if you’ve  already had your body kind of go haywire on  
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you once makes sense that you would be a little  bit more hypersensitive to it happening again   they may have increased anxiety about ability  to tolerate daily stress there a lot of times   this may stem from the fear of if they experience  too much stress it’ll trigger another panic attack  
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and they may have more extreme  behaviors to control panic   the prevalence of panic disorder is about  the same two and two percent to three percent   in both the u.s in europe and europe the  only disorder that had a marked difference  
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between the u.s and other countries  interestingly enough was social anxiety disorder   the development of panic disorder  the median age is 20 to 24 in the us   and 32 worldwide so that is a little bit  divergent you know the prevalence the the  
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number of people that experience it worldwide  is pretty comparable but the median age for   panic disorder is much younger in the us than  other countries additionally they speculate that   older adults may attribute symptoms to medical  conditions so they may be under represented in the
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prevalence rates because when they’re having  these panic symptoms they’re attributing   them to medication side effects or other  health conditions that they already have so let’s talk about some of the risk and  prognostic factors for anxiety disorders  
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in general anxiety disorders often develop  after a life stress this could be a death a   severe illness a disaster a big move becoming a  parent or adverse childhood experiences or aces   that’s just to name a few obviously  that those aren’t all of the causes  
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but i think it’s interesting that  becoming a parent was in there as a life stress that often triggers the development of  anxiety disorders i mean i’m a parent myself i can   see how that could happen but it’s not something  that i had really considered in the past as a
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risk factor for the development  of anxiety disorders   people who’ve been bullied have an increased risk  of developing anxiety disorders heritability of   anxiety disorders ranges between 30 and 75 percent  i found that interesting but they didn’t explain  
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in any of the diagnoses whether they were looking  at twins that were raised in the same household   or twins that were raised in different households  if they’re raised in different households   it gives more credence to a genetic component if  they’re raised in the same household then they’re  
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experienced to the same psychosocial environmental  stressors both of them are so i i don’t know what   the actual data is on that people with negative  affectivity they tend to be more brooding more   depressed more irritable people who are more  self-conscious people who ruminate more also  
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all of these kind of are combined often referred  to as neuroticism they are at higher risk for   the development of anxiety disorders attentional  bias to threat was noted in generalized anxiety   disorder as being an associated feature but  research actually shows that people with  
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any anxiety disorder tend to have a stronger  attentional bias to threat which means they tend   to be more hyper vigilant they tend to be more  aware when there’s threats in the environment   anxiety disorders by and large tend to be  much more frequent in women than in men  
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interesting not sure why again my assumption  is this is people who are biologically female   and it seems to be consistent across cultures  therefore i am wondering what the genetic   predisposition might be that may cause this  it seems like it’s less about environment and  
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shaping and behavioral training and  more about a physiological response but   additionally and these last two were not in  the dsm but i did a pubmed search for risk   factors for anxiety disorders and those  who have a more external locus of control  
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that means they believe that things happen in  the world by fate by chance there’s not a they   don’t have a whole lot of control or ability to  change what’s going on destiny is preordained etc   people with that outlook who have a more external  locus of control tend to have much higher rates  
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of anxiety and depressive disorders and again not  in the dsm but in the in pubmed in the literature   people who have a lack of emotional  support also tend to be at greater risk   for developing anxiety disorders seems pretty  self-explanatory in terms of suicidal thoughts  
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anxiety itself increases risk of suicidal  thoughts all of your anxiety disorders carry   with them an increased risk of suicidal  thoughts people with separation anxiety have that generalized anxiety-related  increased risk but people with specific  
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phobias interestingly enough have an  increased transition from ideation to attempt   in a study that was cited in the ds well mentioned  in the dsm but they didn’t say what the study was   they looked at adults and they found  that up to 30 percent of people
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who had their first suicide attempt it was  related they also had a specific phobia or it   was related to that specific phobia so that’s 30  percent is a big number uh when we’re especially   when we’re talking about suicide suicide attempts  and suicidal ideation if you have somebody with a  
00:45:58
specific phobia we often downplay that because we  think it’s just a fear of this or a fear of that   but that fear can feel very limiting and  oppressive to a lot of people and again   30 percent of them uh 30 percent of people who  have attempted suicide also had specific phobia
00:46:23
functional consequences now i could go on a  diatribe about the functional consequences   of anxiety disorders the dsm didn’t have much to  say about it so let’s talk about some of these   limited independent activities this is especially  true in agoraphobia and separation anxiety  
00:46:47
people who are afraid of leaving the house  for fear of being separated from their   significant other or for fear of being separated  from their safe place and people who have social   anxiety who fear being in social situations  may have a lot of restrictions on their life  
00:47:08
activities and limited activities that they  feel safe or comfortable doing by themselves   not in the dsm 5 tr but in the literature also the  functional consequences of impaired relationships   people with anxiety disorders may be because of  their restrictions on life activities and their  
00:47:34
um potential need to know where people  are and their separation anxiety etc   a lot of times people with anxiety disorders   struggle in their relationships because  it can feel overwhelming to the partners  
00:47:53
as i mentioned earlier people with anger anxiety  disorders have higher rates of autoimmune issues   continuous or excessive levels of stress hormones   contributes to systemic inflammation  which will trigger depression  
00:48:12
or is associated with triggering depression and  associated with worsening of autoimmune conditions   and obesity i thought this one was interesting  but it makes sense when you look at it people   with anxiety disorders who often are restricted  in their life activities may feel worn down and  
00:48:35
exhausted from being stressed out all the time  may not have a lot of energy to do other stuff   tend to be more prone to develop obesity so  that’s an interesting functional consequence now differential diagnosis i told you there was a  laundry list of them generalized anxiety disorder  
00:49:01
in gad excessive anxiety is about a variety of  things for at least six months separation anxiety   the worry or the anxiety is about  separation from the attachment figure   okay that’s pretty clear agoraphobia the  fear is about being trapped or helpless  
00:49:20
in situations in which escape is difficult the  fear surrounds being away from their safe place   not being away from a person they want  to be in a place where they feel safe   and it needs to be not specific to one setting  so being trapped or helpless in a situation
00:49:46
i give the example of an mri those  closed mris oh my gosh i can’t stand them   i’m terrified of them but that is specific to one  setting and i’m not afraid to leave the house for   fear of being trapped or helpless in a situation  social anxiety the anxiety is about being judged  
00:50:10
negatively and illness anxiety and this illness  anxiety actually falls under the somatic disorders   but illness anxiety the worry is about the  illness not separation judgment or being away   from your safe place so that’s differential  diagnosis of your basic anxiety disorders  
00:50:34
in terms of other disorders because there’s  that criteria not better explained by another   mental health or medical disorder psychotic  disorders people who have hallucinations and   delusions may also have anxiety but their worry  or fear surrounds hallucinations or delusions  
00:50:53
and is not reversed by context or the presence of  an attachment figure so a person with psychotic   disorders if their major attachment figure shows  up that doesn’t help them feel more comfortable   if they turn on the light to eliminate the shadows  that doesn’t make them feel more comfortable  
00:51:15
and the hallucinations are not due to the with  psychotic disorders the hallucinations are not   due to something that are actually present  eating disorders avoidance behavior is only   related to food and food-related cues according  to the dsm however one of the main criteria  
00:51:41
for your eating disorders is a excessive fear  about weight shape and size and it’s important   to recognize that because people with eating  disorders may avoid mirrors and scales and   food obviously certain foods and that could all be  related to their eating disorder body dysmorphic  
00:52:11
disorder the fears are only related to people  being offended by a particular perceived flaw   in obsessive-compulsive disorder the fear is an  object or situation as a result of obsessions so   if they start thinking about germs on their  hands and they keep thinking about it then  
00:52:33
they start developing a fear of getting germs  on their hands so the fear becomes the object   of their obsessions or their their obsessions turn  cause what they’re thinking about to become a fear   in autism spectrum the person lacks  sufficient age-appropriate relationships  
00:52:57
and social communication capacity in  anxiety disorders the person often has   sufficient age-appropriate relationships  and can communicate socially socially   understand others just fine what we’re  looking at in anxiety is fear of being judged
00:53:25
conduct disorder school avoidance is a  very common symptom of conduct disorder   but school avoidance is not due to worry or  fear in conduct disorder school avoidance   and conduct disorder is due to not wanting  to be told what to do thank you very much  
00:53:44
in oppositional defiant disorder the oppositional  behaviors occur in response to multiple situations   not just separation or situational anxiety  not just in response to an anxiety provoking   threat so if somebody has separation anxiety they  may become oppositional about leaving their major  
00:54:06
attachment figure if somebody has social phobia  they may become oppositional about engaging in   situations that would prompt that anxiety or if  they have a specific phobia maybe they’re afraid   of snakes they may become oppositional  about doing something like going hiking  
00:54:25
because they are actively  avoiding that phobic stimulus if they are actively avoiding a phobic  stimulus or an anxiety provoking stimulus   it’s probably not oppositional defiant now  you can have both you can have them co-occur  
00:54:45
but you do want to differentiate what is the cause  of the behavior prolonged grief is characterized   by intense longing and yearning for the deceased  not fear of separation from them now you can have   prolonged grief and separation anxiety  co-occur you can’t have somebody who develops  
00:55:11
a fear of separation from others after a  particularly particularly traumatic loss   that can happen but you do want to  differentiate and diagnose appropriately   and in depression and bipolar a lot of people  who are in a major depressive episode may have  
00:55:32
reluctance to leave home but this is due to lack  of motivation and energy to engage and apathy   it’s not due to fear of something out there they  just they don’t care or they don’t have the energy personality the person with dependent personality  relies too much on others it’s not that they fear  
00:55:55
uh their safety or loss of attachment figures and  avoidant personality disorder broader avoidance   patterns and a pervasive negative self-concept  differentiate avoidant personality disorder from   anxiety related disorders not in the dsm i’m  bringing up for differential diagnosis anxiety  
00:56:22
is related to apprehension and vigilance  of physiological sensations and may have   an onset after a concussion pots is a postural  orthostatic tachycardia and when people have it   when they stand up their heart rate will jump  30 or more beats just from when they move from  
00:56:46
sitting to standing and that can feel very scary  they can also get light-headed they can faint   hypoglycemia can also produce symptoms  of anxiety and sweating and agitation   in people so we want to differentially diagnose  i believe i read a study that more than 25  
00:57:07
of americans are pre-diabetic and don’t know it co-morbidity anxiety disorders are comorbid  with each other so if you have one you probably   have some of its buddies it’s also comorbid  with depression bipolar ptsd prolonged grief  
00:57:27
obsessive-compulsive disorder  obsessive-compulsive personality disorder   somatic symptom related disorders so  any of your physical symptom disorders   anti-social personality specifically social  anxiety common commonly may co-occur with  
00:57:49
anti-social oppositional defiant  disorder and substance use disorders physically autoimmune diseases may increase the  risk of psychiatric disorders partially due to   thyroid dysfunction when that hpa axis goes  offline it also affects the functioning of  
00:58:10
the thyroid cardiovascular issues  like supraventricular tachycardia   can also be misdiagnosed and is  often misdiagnosed for panic disorder   hormone level fluctuations especially extreme  hormone fluctuations can contribute to anxiety  
00:58:32
related symptoms high levels of estrogen or  testosterone nutrient deficiencies or toxicities   so too much or too little of certain vitamins  and minerals can also cause anxiety like symptoms   environmentally poverty is a high risk factor for  the development of anxiety disorders for obvious  
00:58:57
reasons and socially adverse childhood experiences  that include abuse neglect abandonment or mental   illness in the household are all risk factors for  the development of anxiety disorders later in life anxiety disorders represent an anxiety  response that is developmentally  
00:59:21
culturally and contextually excessive  it’s persistent or recurrent and causes   clinically significant distress so  that differentiates it from people’s   run-of-the-mill anxiety if you will  multiple anxiety disorders are common  
00:59:41
this presentation covered some of the more  common anxiety disorders but did not cover   selective mutism substance induced anxiety or  other specified and unspecified anxiety disorders   finally it is important to rule out or  diagnose comorbidly any physiological causes