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.
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 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.
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 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 may not be stressful for them when they are at home or when they’re.
At school, 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 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 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 more anxiety.
You would expect that, but even the 31 percent that it was before 2020 seems to be higher than what is identified in the 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 appears in children first, so separation, anxiety, and disorder appear first, and generalized anxiety.
The disorder is down a little way, whereas you might expect 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 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 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 disturbance, I want you to think about it. Anxiety is part of the fight or flight response, so we would expect somebody to experience 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, so we would expect all of these symptoms or any of these symptoms. When the fight or flight system is engaged, the body is not focused on higher order, processing, memory, or concentration it’s focused on self-preservation protection the person 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 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 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 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 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 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 the diagnostic features of generalized anxiety disorder.
Well, 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 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 the coming 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 punctuality.
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, except for disaster, a lot of these worries revolve around the primary life areas or functions of the person.
You know: kids, are, n’t worried about paying bills or or maintaining or parenting, or some of the things that that adults worry about associated symptoms.
Well, let me talk about disaster. 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, the prevalence and likelihood of things.
So when there is a disaster such as you know, we’ve had several 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 chance of it happening again.
Do 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 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 you know how 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, and other somatic symptoms that are not 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 isn’t specifically indicated in diagnostic criteria, but we know it happens when that fight or flight response is kicked off the prevalence.
Remember I said if you start adding 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 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 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 has a much later onset than other disorders, which I did find to be somewhat interesting.
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 anxiety about separation from major attachment figures.
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 separation anxiety.
It actually can have an adult onset, so that is something to remember: symptoms, three or more distress due to or in anticipation of separation from home or from major attachment figures, anxiety about losing a major attachment figure, or possible harm to them.
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 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 to be cut 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, fear of or reluctance to be 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 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, whether that be their significant other, their parent, or 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 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 to rank a diagnosis.
Although the symptoms often develop in childhood, they can be expressed throughout adulthood.
It can be diagnosed in adults in the absence of a history of childhood separation, anxiety, or 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 and examples.
It’s a pretty straightforward diagnosis in terms of development and, 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 through the 20s, 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 an interesting associated feature.
Now these are not diagnostic criteria.
These are features that are associated 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, 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 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.
A lot of children who don’t have separation, anxiety, or disorder, experience homesickness 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 provoke anxiety, anger, and 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 there and by turning on the light.
So there are 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 they are in adults, and we want to make sure we don’t mislabel that as something related to a psychotic disorder, children with separation, Anxiety tends 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, and anxiety, 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 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 adolescents and adults, it ranges from one to two percent. In the culture section, the DSM talked about the importance of differentiating separation, and 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 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 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 the threat that persists for guess what six months or more and causes clinically significant distress – and I have this bold 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 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 cause me to have to alter my life to get around it? No, so it doesn’t rise to the level of a specific phobia. A lot of people have fears that may not have a um basis 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 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.
In the end, the diagnostic features again for specific phobias were pretty much a restatement of the diagnostic criteria-associated features.
Interestingly enough, 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 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 hers.
Wasn’t phobia-related, but when she would get startled 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 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 usually develops before age, 10 or after a trauma, and the presence of phobias is a risk factor for neurocognitive 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 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 and social anxiety disorder in social anxiety disorder.
There’s a marked fear of social situations when in which one might be judged.
So you’ve got generalized anxiety, which is anxiety about a lot of things over at least six months.
We have a specific phobia, which is 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 by children. The symptoms have 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 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 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, a level of social anxiety, because they fear not saying the right thing because they fear being canceled.
Social situations almost always trigger 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.
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.
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 persist again for six months or more causing clinically significant distress 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, or anything like that, 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 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 a social anxiety disorder who are highly controlling of situations, and they may try to control the conversation and control other people in the situation to avoid feeling out of control.
Use of substances, substance, use, misuse or abuse is often associated with people with social anxiety disorder, and I have parenthetically heard liquid courage is 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.
So using alcohol before a social situation may 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 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, a question mark that’s not identified in the DSM 5t. However, we know that hyperactivation of the hpa axis contributes to ultimately development of systemic inflammation and the 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 compared 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? What’s different in the United States? That is contributing to significantly higher rates of social anxiety fear of being judged and fear of offending people.
Just saying additionally, social anxiety disorder does tend to be highest in non-Hispanic whites.
So what is unique about nonhispanic? Whites in 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 peak within minutes and has a and accompanying 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 an expected panic attack 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 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, 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, in which things just don’t feel real.
You feel like you’re kind of a dream or depersonalization.
You don’t feel, like you, ‘re part of your own body, anymore, with fear of losing control or going crazy and fear of dying.
Now I’ll mention it, even though it’s pretty obvious.
Many of these symptoms are also symptoms of a heart attack.
It is important 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 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 of panic may include tinnitus or ringing in the ear and 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. Additionally, at least one of the attacks – unexpected attacks has been followed by one 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 attack avoidance of situations where You think they might happen again or ritualized, or superstitious behavior or extreme behavior, like changing your diet completely or doing something extreme to try to prevent the attack, so the unexpected attack happens and then for the next month or more.
Both of those persistent concerns about it happening again and significant 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 attacks, there were no specifiers, but in the diagnostic features, it did note that panic attacks can be full meaning four or more symptoms or limited symptoms, so it doesn’t meet all of them.
Doesn’t meet four symptoms or more, but the person’s having a panic response.
If the person has never had a full-blown panic attack, uh, four or more symptoms, 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, 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 had a panic disorder at some point, they probably will have another panic attack at another point.
Remember that expected 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 diagnostic issues, a 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’s associated features. People who have panic attacks.
Panic disorder may also cause 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 you once makes sense that you would be a little bit more hypersensitive to it happening again.
They may have increased anxiety about their ability to tolerate daily stress there.
A lot of times this may stem from the fear that if they experience too much stress it, ‘ll trigger another panic attack 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 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 us and 32 worldwide. So that is a little bit divergent.
You know the prevalence, and the number of people that experience it worldwide are pretty comparable, but the median age for panic disorder is much younger in us than in other countries.
Additionally, they speculate that older adults may attribute symptoms to medical conditions, so they may be underrepresented in the 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 in general.
Anxiety disorders often develop afterlife stress.
This could be a death, a severe illness, a disaster, a big move becoming a parent adverse childhood experiences, or aces that’s just to name a few that those aren’t all of the causes, 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 considered in the past as a risk factor for the development of anxiety disorders.
People who’ve been bullied have an increased risk of developing anxiety disorders.
The heritability of anxiety disorders ranges between 30 and 75 percent. I found that interesting, but they didn’t explain 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 experience the same psychosocial, and environmental stressors.
Both of them are so.
I don’t know what the actual data is on that person with negative affectivity.
They tend to be more brooding, more depressed, more irritable people who are more self-conscious.
People who ruminate more also all of these kinds 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 shows that people with 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 are, threats in the environment, and anxiety disorders by and large – tend to be much more frequent in women than in men. 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 shaping and behavioral training and more about a physiological response.
But additionally – and these last two were not in the DSM.
However, I did a PubMed search for risk factors for anxiety disorders and those who have a more external locus of control.
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 of anxiety and depressive disorders, and again not in the DSM, but in the 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.
Anxiety itself increases the 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 to increased risk, but people with specific 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 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 attempts and suicidal ideation, if you have somebody with a 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 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, 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 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 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.
As I mentioned earlier, people with anger, and anxiety disorders, have higher rates of autoimmune issues.
Continuous or excessive levels of stress hormones contribute to systemic inflammation, which will trigger depression 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 exhausted.
From being stressed out, all the time may not have a lot of energy to do.
Other stuff tends 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, a disorder 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 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.
I give the example of an MRI that 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, anxiety is about being judged negatively, and illness anxiety and this illness anxiety.
Falls under somatic disorders but illness anxiety. The worry is about the illness, not separation, judgment, or being away from your safe place, so that’s a differential diagnosis of your basic anxiety disorders in terms of other disorders because there’s that criteria not better explained by another mental health or medical disorder.
In psychotic disorders, people who have hallucinations and delusions may also have anxiety, but their worry or fear surrounds hallucinations or delusions 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 does. n’t help them feel more comfortable if they turn on the light to eliminate the shadows that don’t make them feel more comfortable, and the hallucinations are not due to psychotic disorders.
The hallucinations are not due to something present in eating disorders avoidance behavior is only related to food and food-related cues.
According to the DSM, however, one of the main criteria for your eating disorders is an 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 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 they start developing a fear of getting germs on their hands, so the fear becomes the object of their obsessions.
Their obsessions turn to cause what they’re.
Thinking about becoming a fear in the autism spectrum, the person lacks sufficient age, appropriate relationships, and social communication capacity in anxiety disorders. The person often has sufficient age-appropriate relationships and can communicate socially, and socially understand others, just fine.
What we’re, looking at in anxiety, is fear of being judged 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 are due to not wanting to be told what to do.
Thank you very much 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 attachment figure.
If somebody has a 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 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 occurs, 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, but you can’t.
Have somebody who develops 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 reluctance to leave home, but this is due to a lack of motivation and energy to engage and apathy.
It’s not due to fear of something out there.
They just don’t care or they don’t have an energy personality.
A person with a dependent personality relies too much on others.
It’s not that they fear 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, and related disorders, not in the DSM I’m. Bringing up for differential diagnosis.
Anxiety 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 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 sweating and agitation in people, so we want to differentially diagnose.
I believe I read a study that more than 25 of Americans are pre-diabetic and don’t know it.
Co-morbidity and 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, 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 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 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, 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 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 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.
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 of anxiety.
Symptoms include cardiovascular issues, pots, or diabetes.
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