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A Brief Lecture on Anxiety, Obsessive-Compulsive, Trauma and Stress Related Disorders

by DSM-5, NIMH, NIH and SAMHSA

 

Introduction to Abnormal Psychology and Life

Perspectives on Abnormal Psycholog

Risk and Prevention of Psychological Disorders

Diagnosis and Assessment of Psychological Disorders

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders

Somatic Symptom and Dissociative Disorders

Depressive and Bipolar Disorders

Eating Disorders

Substance-Related Disorders

Personality Disorders

Sexual Dysfunctions

Schizophrenia and Other Psychotic Disorders

Developmental and Disruptive Behavior Disorders

 

The newly published Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5) has divided previously designated anxiety disorders into anxiety disorders, obsessive-compulsive and Trauma and Stress Related Disorders.

 
 
 

 

Description of Anxiety Disorders

Types of Anxiety Disorders

Causes of Anxiety Disorders

Treatment for Anxiety Disorders

US Resources for Anxiety Disorders

Wis Resources for Anxiety Disorders

 

Description of Obsessive-Compulsive Disorders and Related Disorders

Causes of Obsessive-Compulsive and Related Disorders

Treatments for Obsessive-Compulsive and Related Disorders

US Resources for Obsessive-Compulsive and Related Disorders

Wis Resources for Obsessive-Compulsive and Related Disorders

 

Description of Trauma and Stress Related Disorders

Causes for Trauma and Stress Related Disorders

Treatments for Trauma and Stress Related Disorders

US Resources for Trauma and Stress Related Disorders

Wis Resources for Trauma and Stress Related Disorders

 
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Anxiety Disorders

The newly published Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5) has divided previously designated anxiety disorders into anxiety disorders, obsessive-compulsive and stress related disorders.

Anxiety is a general sense of fear, dread and apprehension that produces bodily responses such as increased heart rate, sweating, shaking, breathing, muscular tension, and respiration. Anxiety prepares us for “fight or flight.” The main symptom of anxiety disorders is anxiety.

According to the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5), anxiety disorders include generalized anxiety disorder, panic disorder, agoraphobia, specific phobia disorder, social anxiety disorder, separation anxiety disorder, selective mutism, and substance/medication-induced anxiety disorder (2013).

Information from National Institute of Mental Health

  • In a given year, approximately 40 million American adults age 18 and older, or about 18.1 percent of people in this age group, have an anxiety disorder.
  • Anxiety disorders frequently co-occur with depressive disorders or substance abuse. Most people with one anxiety disorder also have another anxiety disorder.
  • Nearly three-quarters of those with an anxiety disorder will have their first episode by age 21.5.

 

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GAD
 

Generalized Anxiety Disorder

Generalized anxiety disorder is characterized by persistent high levels of anxiety and excessive worry over many of life’s circumstances, events, and activities. According to DSM-5 (2013), the diagnostic criteria for generalized anxiety disorder are:

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

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):

Note: Only one item is required in children.

  • Restlessness or feeling keyed up or on edge.
  • Being easily fatigued.
  • Difficulty concentrating or mind going blank.
  • Irritability.
  • Muscle tension.
  • Sleep disturbance (difficulty falling or staying asleep, or restless sleep).

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

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PANIC DISORDER

Panic Disorder

Panic disorder is an anxiety disorder characterized by recurrent and unpredictable panic attacks. A panic attack is a periodic, sudden, and intense episode of fear that reaches a peak within minutes and gradually passes. The individual diagnosed with panic disorder demonstrates a persistent concern or worry about having additional attacks. These symptoms cause significant maladaptive change in behavior related to the attack. According to DSM-5 (2013), the diagnostic criteria of panic disorder are:

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

Note: The abrupt surge can occur from a calm state or an anxious state.

  • Palpitations, pounding heart, or accelerated heart rate.
  • Sweating.
  • Trembling or shaking.
  • Sensations of shortness of breath or smothering.
  • Feelings of choking.
  • Chest pain or discomfort.
  • Nausea or abdominal distress.
  • Feeling dizzy, unsteady, light-headed, or faint.
  • Chills or heat sensations.
  • Paresthesias (numbness or tingling sensations).
  • Derealization (feelings of unreality) or depersonalization (being detached from oneself).
  • Fear of losing control or “going crazy.”
  • Fear of dying.

Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

B. At least one of the attacks has been followed by one month (or more) of one or both of the following:

  • Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
  • A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).

C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).

D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder: in response to circumscribed phobic objects or situations, as in specific phobia: in response to obsessions, as in obsessive-compulsive disorder: in response to reminders of traumatic events, as in posttraumatic stress disorder: or in response to separation from attachment figures, as in separation anxiety disorder).

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Agoraphobia

Agoraphobia involves fear of being in public places or situations where escape might be difficult, embarrassing, or help might be unavailable in case of a panic attack or incapacitation. Symptoms often lead to avoidance of situations such as being alone outside of the home, traveling in a car, bus, or airplane, or being in a crowded area. According to DSM-5 (2013), the diagnostic criteria of agoraphobia include:

A. Marked fear or anxiety about two (or more) of the following five situations:

  • Using public transportation (e.g., automobiles, buses, trains, ships, planes).
  • Being in open spaces (e.g., parking lots, marketplaces, bridges).
  • Being in enclosed places (e.g., shops, theaters, cinemas).
  • Standing in line or being in a crowd.
  • Being outside of the home alone.

B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence).

C. The agoraphobic situations almost always provoke fear or anxiety.

D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly excessive.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder): and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder).

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Specific Phobia

Specific phobia involves a strong, persistent, and disproportionate fear of some specific object or situation often leading to avoidance. According to DSM-5 (2013), the diagnostic criteria of specific phobia are:

A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.

B. The phobic object or situation almost always provokes immediate fear or anxiety.

C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.

D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.

E. The fear, anxiety, or avoidance is persistent, typically lasting for six months or more.

F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia): objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).

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Social Anxiety Disorders
 

Social Anxiety Disorder

Social anxiety disorder (formerly, social phobia) involves excessive and persistent fear of social or performance situations in which embarrassment may occur. According to DSM-5 (2013), the diagnostic criteria of social anxiety disorder are:

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech).

Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.

B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing: will lead to rejection or offend others).

C. The social situations almost always provoke fear or anxiety.

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

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Separation Anxiety Disorder

Separation anxiety disorder involves excessive anxiety, even panic, whenever the child is separated from home or parents. According to DSM-5 (2013), the diagnostic criteria of separation anxiety disorder are:

A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:

  • Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
  • Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
  • Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
  • Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.
  • Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
  • Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
  • Repeated nightmares involving the theme of separation.
  • Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.

B. The fear, anxiety, or avoidance is persistent, lasting at least four weeks in children and adolescents and typically six months or more in adults.

C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.

D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.

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Selective Mutism

Selective mutism (formerly known as elective mutism) includes persistent failure to speak in specific social situations (such as in school with teachers and playmates) where speaking is expected, despite speaking in other situations. According to DSM-5 (2013), the diagnostic criteria of selective mutism are:

A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations.

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

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

D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.

E. The disturbance is not better explained by a communication disorder (e.g., childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.

For more information on Selective mutism please visit Selective Mutism Foundation at http://www.selectivemutismfoundation.org/.

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Substance/Medication-Induced Anxiety Disorder

According to Diagnostic and Statistical Manual of Mental Disorders — Fifth Edition (DSM-5, 2013), “Substance/medication-induced anxiety disorder involves anxiety due to substance intoxication or withdrawal or to a medication treatment. In anxiety disorder due to another medical condition, anxiety symptoms are the physiological consequence of another medical condition.” According to DSM-5 (2013), the diagnostic criteria for substance/medication-induced anxiety disorder are:

A.  Panic attacks or anxiety is predominant in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):

  • The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
  • The involved substance/medication is capable of producing the symptoms in Criterion A.

C. The disturbance is not better explained by an anxiety disorder that is not substance/ medication-induced. Such evidence of an independent anxiety disorder could include the following: The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication: or there is other evidence suggesting the existence of an independent non-substance/medication-induced anxiety disorder (e.g., a history of recurrent non-substance/medication-related episodes).

D. The disturbance does not occur exclusively during the course of a delirium.

E.  The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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Explanations for the Causes and Risk Factors of Anxiety and Anxiety Disorders

 
 
 
 
 
 
 
 
 
 
 
 
 

Mental health professionals believe that mental illnesses are complex and probably result from a combination of genetic, environmental, psychological, and developmental factors.

Biological Explanations

According to the biological theory, biochemical imbalance, a person’s heredity (genetic predisposition), and brain structures may play a role in the development of an anxiety disorder.

Biochemical Factors

Biochemical factors involve neurotransmitters and hormones. Neurotransmitters are chemicals in the nervous system that process and transmit information. Hormones are messengers produced by glands in the endocrine system.

NIMH (2013) studies suggest that an imbalance of neurotransmitters, such as gamma-aminobutyric acid (GABA), serotonin, dopamine, and epinephrine, may lead to anxiety disorders. Serotonin appears to be specifically important in feelings of well-being and deficiencies are highly related to anxiety and depression. Stress hormones, such as cortisol, also play a role.

Brain Structure and Functions

Magnetic resonance imaging (MRI), a brain imaging technique, has linked the hyperactivity of the amygdala (a structure in the brain) to anxiety disorders. The amygdala is associated with fear, memory, emotion, and physiological responses to stress, such as increased heart rate or respiration.

Research shows that the high sensitivity of the amygdala to unknown stimuli results in high stress responses in people diagnosed with anxiety disorders (University of Maryland Medical Center Website, 2013).

Genetic Factors

Scientific research shows that anxiety disorders involve 17 different gene combinations. Some genes cause anxiety by monitoring serotonin and others affect glutamate; the result is that close relatives of people with anxiety disorders are at a higher risk for developing these disorders compared to family members without the disorder (Canli, 2008; Lafleur et al., 2006; Welch et al., 2007).

Research by Hettema et al. (2001) and Kendler et al. (2002) concluded that in monozygotic twins (identical twins), if one is diagnosed with an anxiety disorder, the other will be likely to develop the disorder. The same finding exists in monozygotic twins raised separately due to adoption. Specifically, National Institute of Mental Health (NIMH, 2013) research has found the following links:

About 50% of people with panic disorder and 40% of patients with generalized anxiety disorder (GAD) have close relatives with the disorder.

About half of generalized anxiety disorder (GAD) patients have family members with panic disorder and about 30% have relatives with simple phobias.

Psychological Explanations

Psychodynamic/Psychoanalytic Explanation

According to Freud’s psychodynamic perspective, there is an unconscious intrapsychic conflict between the ego and id impulses. The id’s sexual or aggressive impulses struggle for expression that the ego cannot allow because it fears punishment. If the ego is weak, the individual will experience overwhelming anxiety.

Cognitive Explanation

According to cognitive theory, a person’s distorted cognitive processes can develop and maintain anxiety disorders. That is, people diagnosed with these disorders hold expectation, interpretation, thoughts, beliefs, ideas, and assumptions that are inaccurate, irrational, and catastrophic. For instance, a cognitive therapist may view someone diagnosed with a panic disorder as someone who misinterprets unpleasant bodily sensations as indicators of an impending doom and disaster.

Behavioral Explanation

According to the behavioral model, the symptoms of anxiety disorders are learned through classical conditioning, operant conditioning and modeling or observational learning.

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Treatment for Anxiety and Anxiety Disorders

 
 
 
 
 
 
 
 
 
 

A combination of psychotherapy and medication has shown to be effective in treating most anxiety disorders. However, a clear diagnosis of a specific anxiety disorder is critical because treatments vary based on type.

Psychotherapy

Psychotherapy or “talk therapy” can help people with anxiety disorders. To be effective, psychotherapy must be directed at the person’s specific anxieties and tailored to his or her needs. A typical “side effect” of psychotherapy is temporary discomfort involved with thinking about confronting feared situations.

Cognitive Behavioral Therapy (CBT)

CBT is a type of psychotherapy that can help people with anxiety disorders. It teaches a person to assess, identify, and to develop different ways of thinking, behaving, and reacting to anxiety-producing and fearful situations. Specifically, the client learns to:

  • Evaluate their own thoughts, beliefs, ideas, assumptions, expectations, and interpretations.
  • Identify the inaccurate, irrational, and catastrophic cognitive processes.
  • Modify and restructure their fear provoking and distorted cognitive processes into adaptive and realistic ones.

In addition, cognitive therapy helps clients acquire skills that promote a sense of competence through:

  • Assertiveness training
  • Social skills modeling
  • Teaching stress-management and relaxation techniques

Two specific stand-alone components of CBT used to treat social anxiety disorder are cognitive therapy and exposure therapy. Cognitive therapy focuses on identifying, challenging, and then neutralizing unhelpful thoughts underlying anxiety disorders.

Exposure therapy focuses on confronting the fears underlying an anxiety disorder in order to help people engage in activities they have been avoiding. Exposure therapy is used along with relaxation exercises and/or imagery. One study, called a meta-analysis because it pulls together all of the previous studies and calculates the statistical magnitude of the combined effects, found that cognitive therapy was superior to exposure therapy for treating social anxiety disorder.

CBT may be conducted individually or with a group of people who have similar problems. Group therapy is particularly effective for social anxiety disorder. Often “homework” is assigned for participants to complete between sessions.

Self-Help or Support Groups

Some people with anxiety disorders might benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms might also be useful, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common. Talking with a trusted friend or member of the clergy can also provide support, but it is not necessarily a sufficient alternative to care from an expert clinician.

Stress-Management Techniques

Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. While there is evidence that aerobic exercise has a calming effect, the quality of the studies is not strong enough to support its use as treatment. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, avoiding them should be considered. Check with your physician or pharmacist before taking any additional medications.

The family can be important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one’s symptoms.

Medication

Medication does not cure anxiety disorders but often relieves symptoms. Medication can only be prescribed by a medical doctor (such as a psychiatrist or a primary care provider), but a few states allow psychologists to prescribe psychiatric medications.

Medications are sometimes used as the initial treatment of an anxiety disorder, or are used only if there is insufficient response to a course of psychotherapy. In research studies, it is common for patients treated with a combination of psychotherapy and medication to have better outcomes than those treated with only one or the other.

The most common classes of medications used to combat anxiety disorders are antidepressants, anti-anxiety drugs, and beta-blockers (visit Mental Health Medications). Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.

Antidepressants

Antidepressants are used to treat depression, but they also are helpful for treating anxiety disorders.

Antidepressants were developed to treat depression, but they also help people with anxiety disorders. Selective serotonin reuptake inhibitors, or SSRI's, such as fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa) are commonly prescribed for panic disorder, OCD, PTSD, and social phobia. The serotonin-norepinephrine reuptake inhibitors, or SNRI, venlafaxine (Effexor) is commonly used to treat GAD. The antidepressant bupropion (Wellbutrin) is also sometimes used. When treating anxiety disorders, antidepressants generally are started at low doses and increased over time.

Monoamine oxidase inhibitors, or MAOI's, are also used for anxiety disorders. Doctors sometimes prescribe phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan). People who take MAOI's must avoid certain food and medicines that can interact with their medicine and cause dangerous increases in blood pressure.

They take several weeks to start working and may cause side effects such as headache, nausea, or difficulty sleeping. The side effects are usually not a problem for most people, especially if the dose starts off low and is increased slowly over time.

Please Note: Although antidepressants are safe and effective for many people, they may be risky for children, teens, and young adults. A “black box” warning—the most serious type of warning that a prescription can carry—has been added to the labels of antidepressants. The labels now warn that antidepressants may cause some people to have suicidal thoughts or make suicide attempts. For this reason, anyone taking an antidepressant should be monitored closely, especially when they first start taking the medication.

Anti-Anxiety Medications

Anti-anxiety medications help reduce the symptoms of anxiety, panic attacks, or extreme fear and worry. The most common anti-anxiety medications are called benzodiazepines. Benzodiazepines are first-line treatments for generalized anxiety disorder. With panic disorder or social phobia (social anxiety disorder), benzodiazepines are usually second-line treatments, behind antidepressants.

Benzodiazepines

The anti-anxiety medications called benzodiazepines can start working more quickly than antidepressants. The ones used to treat anxiety disorders include:

  • Clonazepam (Klonopin), which is used for social phobia and GAD.
  • Lorazepam (Ativan), which is used for panic disorder.
  • Alprazolam (Xanax), which is used for panic disorder and GAD.

The most common side effects for benzodiazepines are drowsiness and dizziness. Other possible side effects include:

  • Upset stomach
  • Blurred vision
  • Headache
  • Confusion
  • Grogginess
  • Nightmares

Buspirone (Buspar)

Buspirone (Buspar) is an anti-anxiety medication used to treat GAD. Unlike Benzodiazepines, however, it takes at least two weeks for buspirone to begin working. Beta-blockers control some of the physical symptoms of anxiety, such as trembling and sweating.

Possible side effects from buspirone (Buspar) include:

  • Dizziness and/orNausea
  • Headaches
  • Nervousness
  • Lightheadedness
  • Excitement
  • Trouble sleeping

Beta-Blockers

Beta-blockers, such as propranolol and atenolol, are also helpful in the treatment of the physical symptoms of anxiety, especially social anxiety. Physicians prescribe them to control rapid heartbeat, shaking, trembling, and blushing in anxious situations.

Propranolol (Inderal)

Propranolol (Inderal) is a beta-blocker usually used to treat heart conditions and high blood pressure. This medication also helps people who have physical problems related to anxiety. For example, when a person with social phobia must face a stressful situation, such as giving a speech or attending an important meeting, a doctor may prescribe a beta-blocker. Taking this medication for a short period of time can help the person keep physical symptoms under control.

Common side effects from beta-blockers include:

  • Fatigue
  • Cold hands
  • Dizziness
  • Weakness

In addition, beta-blockers generally are not recommended for people with asthma or diabetes because they may worsen symptoms. People can build a tolerance to benzodiazepines if they are taken over a long period of time and may need higher and higher doses to get the same effect. Some people may become dependent on them. To avoid these problems, doctors usually prescribe this medication for short periods, a practice that is especially helpful for people who have substance abuse problems or who become easily dependent on medication. If people suddenly stop taking benzodiazepines, they may get withdrawal symptoms, or their anxiety may return, therefore, they should be tapered off slowly.

Buspirone and beta-blockers are similar. They are usually taken on a short-term basis for anxiety. Both should be tapered off slowly. Talk to your doctor before stopping any anti-anxiety medication.

Choosing the right medication, medication dose, and treatment plan should be based on a person’s needs and medical situation, and done under an expert’s care. Only an expert clinician can help you decide whether the medication’s ability to help is worth the risk of a side effect. Your doctor may try several medicines before finding the right one.

You and your doctor should discuss:

  • How well medications are working or might work to improve your symptoms
  • Benefits and side effects of each medication
  • Risk for serious side effects based on your medical history
  • The likelihood of the medications requiring lifestyle changes
  • Costs of each medication
  • Other alternative therapies, medications, vitamins, and supplements you are taking and how these may affect your treatment
  • How the medication should be stopped. Some drugs can’t be stopped abruptly but must be tapered off slowly under a doctor’s supervision.

For more information, please visit Medications Health Topic webpage developed by the National Institute of Mental Health (NIMH). Please note that any information on this website regarding medications is provided for educational purposes only and may be outdated. Information about medications changes frequently. Please visit the U.S. Food and Drug Administration (FDA) website  for the latest information on warnings, patient medication guides, or newly approved medications.

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Obsessive-Compulsive and Related Disorders

One of the major changes in the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5) (2013) is the removal of obsessive-compulsive disorder from anxiety disorders into a new category designated as obsessive-compulsive and related disorders. In addition to obsessive-compulsive disorder (OCD), this category includes four other disorders: excoriation (skin-picking) disorder, hair-pulling disorder (trichotillomania), hoarding disorder, and body dysmorphic disorder. The rational for classifying these disorders in one category is that they share many common characteristics (American Psychiatric Association, 2013).

Information from National Institute of Mental Health (NIMH)

  • Approximately 2.2 million American adults over the age of 18 are diagnosed with OCD.
  • The first symptoms of OCD often begin during childhood or adolescence, however, the median age of onset is 19.
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Obsessive-Compulsive Disorder

A disorder in which the mind is flooded with recurrent and unwanted thoughts and the individual is compelled to repeat certain acts again and again, causing significant distress and interference in everyday functioning.

Obsessions are defined as “recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted” (DSM-5, 2013).

Compulsions are defined as “repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly” (DSM-5, 2013). According to DSM-5 (2013), the diagnostic criteria of obsessive-compulsive disorder are:

A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

    1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
    2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

  1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to per­ form in response to an obsession or according to rules that must be applied rigidly.
  2. The behaviors or mental acts are aimed at preventing or reducing anxiety or dis­tress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neu­tralize or prevent, or are clearly excessive.

Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with ap­pearance, as in body dysmorphic disorder; difficulty discarding or parting with posses­sions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoc­cupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct dis­ orders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

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Excoriation Disorder (Formerly Referred to as Skin-Picking Disorder)

People diagnosed with excoriation disorder engage in irrational and recurring picking of their skin that may result in major soars or wounds.
According to DSM-5 (2013), the diagnostic criteria  of excoriation (skin-picking) disorder are:

A. Recurrent skin picking resulting in skin lesions.

B. Repeated attempts to decrease or stop skin picking.

C. The skin picking causes clinically significant distress or impairment in social, occupa­tional, or other important areas of functioning.

D. The skin picking is not attributable to the physiological effects of a substance (e.g., co­caine) or another medical condition (e.g., scabies).

E. The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in ste­reotypic movement disorder, or intention to harm oneself in non-suicidal self-injury).

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Hair-Pulling Disorder (Trichotillomania)

People diagnosed with hair pulling disorder engage in recurrently pulling hair from their scalp, eyebrows, and eyelashes.
According to DSM-5 (2013), the diagnostic criteria for hair-pulling disorder (trichotillomania) are:

A. Recurrent pulling out of one’s hair, resulting in hair loss.

B. Repeated attempts to decrease or stop hair pulling.

C. The hair pulling causes clinically significant distress or impairment in social, occupa­tional, or other important areas of functioning.

D. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).

E. The hair pulling is not better explained by the symptoms of another mental disorder
(e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).

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Hoarding Disorder

Individuals diagnosed with hoarding disorder experience significant difficulty disposing possessions regardless of the age, shape, or value of the item. The accumulation of the items can result in significant stress and unsafe and insanitary living conditions. According to DSM-5 (2013), the diagnostic criteria of hoarding disorder are:

A. Persistent difficulty discarding or parting with possessions, regardless of their actual value.

B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them.

C. The difficulty discarding possessions results in the accumulation of possessions that
congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).

D. The hoarding causes clinically significant distress or impairment in social, occupa­tional, or other important areas of functioning (including maintaining a safe environ­ment for self and others).

E. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).

F. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder).

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Body Dysmorphic Disorder

Individuals diagnosed with body dysmorphic disorder are overly concerned with their appearance, imagined flaws, and may have an exaggerated view of their minor imperfections. According to DSM-5 (2013), the diagnostic criteria of body dysmorphic disorder are:

A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.

B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seek­ing) or mental acts (e.g., comparing his or her appearance with that of others) in re­sponse to the appearance concerns.

C. The preoccupation causes clinically significant distress or impairment in social, occu­pational, or other important areas of functioning.

D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

Explanations for the Causes of Obsessive-Compulsive and Related Disorders
Mental health professionals believe that mental illnesses are complex and probably result from a combination of genetic, environmental, psychological, and developmental factors.

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Explanations for the Causes of Obsessive-Compulsive and Related Disorders

Biological Explanations

According to the biological perspective, biochemical imbalance, a person's heredity (genetic predisposition), and brain structures may play a role in the development of a disorder.

Biochemical Factors

Biochemical research has mainly focused on the low levels or hypo-activity (diminished activity) of the neurotransmitter serotonin as the cause of obsessive-compulsive disorder.
Other neurotransmitters associated with the development of obsessive-compulsive disorder are gamma-aminobutyric acid (GABA), glutamate, and dopamine.

Genetic Factors

Scientific research shows that first-degree relatives of people with obsessive-compulsive disorder are at a higher risk for certain cognitive deficits, such as problems in decision-making, planning, and mental flexibility.

Brain Structure and Functions

Brain imaging techniques have linked increased metabolic activity of the frontal lobe in the left hemisphere to the diagnosis of obsessive-compulsive disorder.

Psychological Explanations

Psychodynamic/Psychoanalytic Explanation

According to the psychodynamic perspective, there is an intrapsychic conflict between the ego and id impulses. The id’s sexual or aggressive impulses struggle for expression. However, the ego cannot allow it because it fears punishment. The conflict (between the id and the superego) is conscious and expressed through thoughts and actions, in contrast to the explanation of anxiety disorders where the intrapsychic conflict is assumed to be unconscious. Obsessions represent the id and compulsions signify the ego’s efforts to block or neutralize them.

Cognitive Explanation

According to cognitive theory, individuals diagnosed with OCD exhibit the following characteristics:

  • Hold extremely high morals and standards (Rachman, 1993).
  • Assume that their disturbing thoughts can result in damage or increase the probability of an awful event (Lawrence and Williams, 2011).
  • Need to have total control over their thoughts and behaviors (Coles et al., 2005).

Behavioral Explanation

Behavioral theories of OCD mainly focus on the development of compulsions. They state that when in a frightening situation (such as driving on an icy road) an individual randomly does something (such as the driver tapping his fingers twice on the dashboard). Once the frightening situation passes, the individual associates his/her action or behavior (tapping his fingers twice on the dashboard) with the desired conclusion of the situation (safely getting home on the icy road). The individual may repeat the same action or behavior in the future, to avoid or reduce the anxiety associated with frightening situations.

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Treatment for Obsessive-Compulsive and Related Disorders
 
 
 


Individuals treated with a combination of antidepressant medications and cognitive-behavioral approaches show significant reduction in the symptoms of obsessive-compulsive disorder.

Biologically-Based Treatment

Medications that increase serotonin levels, such as the selective serotonin inhibitory reuptake, or SSRI’s, and some tricyclics, are used to treat obsessive-compulsive disorder.

Cognitively-Based Treatments

Rational-emotive therapy is a form of cognitive treatment that focuses on encouraging clients to test their fear, if something awful will happen when they do not perform their compulsive rituals.

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Trauma and Stress Related Disorders

The Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5) (2013) classifies acute stress disorder and post-traumatic stress disorder in the trauma and stress related disorders category (formerly, under anxiety disorders).

This category also includes reactive attachment disorder, disinhibited social engagement disorder, and adjustment disorders.

 

Information from National Institute of Mental Health

  • Approximately 7.7 million American adults age 18 and older, or about 3.5 percent of people in this age group in a given year, have PTSD.
  • PTSD can develop at any age, including childhood, but research shows that the median age of onset is 23 years.
  • About 19 percent of Vietnam veterans experienced PTSD at some point after the war.
  • The disorder also frequently occurs after violent personal assaults such as rape, mugging, or domestic violence; terrorism; natural or human-caused disasters; and accidents.
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Reactive Attachment Disorder

Reactive attachment disorder of infancy or early childhood is characterized by a pattern of markedly disturbed and developmentally inappropriate attachment behaviors, in which a child rarely or minimally turns preferentially to an attachment figure for comfort, support, protection, and nurturance. The essential feature is absent or grossly underdeveloped attachment between the child and putative caregiving adults (DSM-5, 2013). According to DSM-5 (2013), the diagnostic criteria for reactive attachment disorder are:

A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers,
manifested by both of the following:

  • The child rarely or minimally seeks comfort when distressed.
  • The child rarely or minimally responds to comfort when distressed.

B. A persistent social and emotional disturbance characterized by at least two of the following:

  • Minimal social and emotional responsiveness to others.
  • Limited positive affect.
  • Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.

C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:

  • Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
  • Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
  • Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).

D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C).

E. The criteria are not met for autism spectrum disorder.

F. The disturbance is evident before age 5 years.

G. The child has a developmental age of at least 9 months.

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Post-Traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder is characterized by anxiety related symptoms, which may develop following exposure to an extreme stressor lasting months or years. According to DSM-5 (2013), the diagnostic criteria of post-traumatic stress disorder, in adults, adolescents, and children older than six years, are:

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

  • Directly experiencing the traumatic event(s).
  • Witnessing, in person, the event(s) as it occurred to others.
  • Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
  •  Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains: police officers repeatedly exposed to details of child abuse).

Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

  • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

  • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

Note: In children, there may be frightening dreams without recognizable content.

  • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)

Note: In children, trauma-specific reenactment may occur in play.

  • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
  • Marked physiological reactions to internal or external cues that symbolize or re­semble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

  • Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
  • Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feel­ings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

  •  Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
  • Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” ‘The world is completely dangerous,” “My whole nervous system is permanently ruined”).
  • Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
  • Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
  • Markedly diminished interest or participation in significant activities.
  • Feelings of detachment or estrangement from others.
  • Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), be­ginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

    • Irritable behavior and angry outbursts (with little or no provocation) typically ex­ pressed as verbal or physical aggression toward people or objects.
    • Reckless or self-destructive behavior.
    • Hypervigilance.
    • Exaggerated startle response.
    • Problems with concentration.
    • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social, occupa­tional, or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

According to DSM-5 (2013), the diagnostic criteria of post-traumatic stress disorder for children six years and younger are:

A. In children 6 years and younger, exposure to actual or threatened death, serious injury,
or sexual violence in one (or more) of the following ways:

  • Directly experiencing the traumatic event(s).
  • Witnessing, in person, the event(s) as it occurred to others, especially primary care­givers.

Note: Witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures.

  • Learning that the traumatic event(s) occurred to a parent or caregiving figure.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

  • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: Spontaneous and intrusive memories may not necessarily appear distress­ing and may be expressed as play reenactment.

  • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

Note: It may not be possible to ascertain that the frightening content is related to the traumatic event.

  • Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present sur­roundings.) Such trauma-specific reenactment may occur in play.
  • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
  • Marked physiological reactions to reminders of the traumatic event(s).

C. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s):

Persistent Avoidance of Stimuli

  • Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s).
  • Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s).

Negative Alterations in Cognitions

  •  Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion).
  • Markedly diminished interest or participation in significant activities, including con­striction of play.
  • Socially withdrawn behavior.
  • Persistent reduction in expression of positive emotions.

D. Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

  • Irritable behavior and angry outbursts (with little or no provocation) typically ex­ pressed as verbal or physical aggression toward people or objects (including ex­treme temper tantrums).
  • Hypervigilance.
  • Exaggerated startle response.
  • Problems with concentration.
  • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

E. The duration of the disturbance is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior.

G. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition.

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Acute Stress Disorder

Acute stress disorder is characterized by anxiety related symptoms, which develop shortly after exposure to an extreme stressor and last less than a month. According to DSM-5 (2013), the diagnostic criteria for acute stress disorder are:

A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:

  • Directly experiencing the traumatic event(s).
  • Witnessing, in person, the event(s) as it occurred to others.
  • Learning that the event(s) occurred to a close family member or close friend. Note:
    • In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
  • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse).
    • Note: This does not apply to exposure through electronic media, television, mov­ies, or pictures, unless this exposure is work related.

B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or wors­ening after the traumatic event(s) occurred:

Intrusion Symptoms

  •  Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
  • Recurrent distressing dreams in which the content and/or effect of the dream are related to the event(s). Note: In children, there may be frightening dreams without recognizable content.
  • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.
  • Intense or prolonged psychological distress or marked physiological reactions in re­sponse to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Negative Mood

  •  Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

Dissociative Symptoms

  • An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing).
  • Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

Avoidance Symptoms

  • Efforts to avoid distressing memories, thoughts, or feelings about or closely asso­ciated with the traumatic event(s).
  • Efforts to avoid external reminders (people, places, conversations, activities, ob­jects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

Arousal Symptoms

  • Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).
  • Irritable behavior and angry outbursts (with little or no provocation), typically ex­pressed as verbal or physical aggression toward people or objects.
  • Hypervigilance.
  • Problems with concentration.
  • Exaggerated startle response.

C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.

Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria.

D. The disturbance causes clinically significant distress or impairment in social, occupa­tional, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.

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Adjustment Disorders

The presence of emotional or behavioral symptoms in response to an identifiable stressor is the essential feature of adjustment disorders. The stressor may be a single event (e.g., a termination of a romantic relationship), or there may be multiple stressors (e.g., marked business difficulties and marital problems) (DSM-5, 2013). According to DSM-5 (2013), the diagnostic criteria for adjustment disorders are:

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).

B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:

    • Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation.
    • Significant impairment in social, occupational, or other important areas of functioning.

C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.

D. The symptoms do not represent normal bereavement.

E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.

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Disinhibited Social Engagement Disorder

The essential feature of disinhibited social engagement disorder is a pattern of behavior that involves culturally inappropriate, overly familiar behavior with relative strangers. This overly familiar behavior violates the social boundaries of the culture (DSM-5, 2013). According to DSM-5 (2013), the diagnostic criteria for disinhibited social engagement disorder are:

A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:

  • Reduced or absent reticence in approaching and interacting with unfamiliar adults.
  • Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
  • Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
  • Willingness to go off with an unfamiliar adult with minimal or no hesitation.

B. The behaviors in Criterion A are not limited to impulsivity (as in attention-deficit/hyperactivity disorder) but include socially disinhibited behavior.

C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:

  • Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
  • Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
  • Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).

D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).

E. The child has a developmental age of at least 9 months.

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Explanations for the Causes and Treatment Trauma and Stress Related Disorders

 
 
 
 

Although most people who develop acute stress disorder and post-traumatic stress disorder have been exposed to a severe traumatic event, not everyone experiences these disorders. Some events that may attribute to stress-related disorders include, but are not limited to, exposure to war as a combatant or civilian, threatened or actual violent personal assault (e.g., sexual violence, physical attack, active combat, mugging, childhood physical and/or sexual violence, being kidnapped, being taken hostage, terrorist attack, torture), natural or human­ made disasters (e.g., earthquake, hurricane, airplane crash), and severe accident (e.g., severe motor vehicle, industrial accident) (DSM-5, 2013). Scientists have been studying biological factors, personality factors, childhood experiences, social support, multicultural factors, and severity of the trauma as potential differences.

Some of the ways someone can receive support for acute stress disorder and post-traumatic stress disorder include: psychotherapy, medication, support groups, and self-care, which may include support from loved ones and an increased awareness of one’s well-being.

In addition to cognitive-behavioral approaches, medications that increase serotonin levels, such as selective serotonin reuptake inhibitors (SSRI's), and antidepressants, such as Zoloft, Paxil, and Prozac, are used as treatment for these disorders.

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Behavioral Health Treatment Services Locator

Behavioral Health Treatment Services Locator By entering your zip code at findtreatment.samhsa.gov, you can quickly find alcohol and drug abuse treatment or mental health treatment facilities in your area. This service is courtesy of the Substance Abuse and Mental Health Services Administration (SAMHSA) which works to "to improve the quality and availability of substance abuse prevention, alcohol and drug addiction treatment, and mental health services." (SAMHSA)

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