Practice teaching

on:
Anxiety disorders

Submitted to: Submitted by:

Mr.D.E.Bhasakara Raj Ms.Jyoti Chetty

HoD, Psychiatry Depatt. M.Sc Nursing IInd yr.
PION PION
 CONTENT:

I. INTRODUCDTION
II.TERMINOLOGIES
III.
IV.
V.
VI.
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Anxiety symptoms and disorders are the number one health problem in America, ranging from a
simple Adjustment Disorder to more difficult and debilitating disorders such as Panic Disorder
and Posttraumatic Stress Disorder. According to the most recent data, the lifetime prevalence for
anxiety disorders as a whole in adults is about 25%; the frequency in children is unknown, but
felt to be significantly underreported and under-diagnosed. More specifically Social Anxiety
Disorder has a lifetime risk of 17%, while Panic Disorder occurs in approximately 1-3% of the
adult population.

Although quite common, Anxiety Disorders in children often are overlooked or misjudged, despite
them being very treatable conditions with good, persistent medical care. What does seem to be
developing in the medical literature is the consensus that many “adult” psychiatric disorders
likely have their first (although perhaps subtle or ignored) manifestations in childhood, and that if
left untreated these anxiety disorders in children likely progress to adult versions.

Symptoms of Anxiety Disorders

Anxiety is a subjective sense of worry, apprehension, fear and distress. Often it is normal to have
these sensations on occasion, and so it is important to distinguish between normal levels of
anxiety and unhealthy or pathologic levels of anxiety. The subjective experience of anxiety
typically has two components: physical sensations (e.g., headache, nausea, sweating) and the
emotions of nervousness and fear. Anxiety disorders, when severe, can affect a child's thinking,
decision-making ability, perceptions of the environment, learning and concentration. It raises
blood pressure and heart rate, and can cause a multitude of bodily complaints, such as nausea,
vomiting, stomach pain, ulcers, diarrhea, tingling, weakness, and shortness of breath, among
other things.

Types of Anxiety Disorders

Diagnosis of normal versus abnormal anxiety depends largely upon the degree of distress and its
effect on a child's functioning in life. The degree of abnormality must be gauged within the
context of the child's age and developmental level. The specific anxiety disorder is diagnosed by
the pattern and quality of symptoms as follows:

 Generalized Anxiety Disorder. Defined as excessive worry, apprehension, and anxiety

occurring most days for a period of 6 months or more that involves concern over a number of
activities or events. The person has difficulty controlling the anxiety, which is associated with
the following: restlessness, feeling “keyed up” or on edge; being easily fatigued; difficulty
concentrating or having the mind go blank; irritability; muscle tension; difficulty falling
asleep or staying asleep, or restless sleep. The anxiety causes significant distress and
problems functioning.
 Panic Disorder. Panic Disorder is different from Panic Attacks; panic attacks are defined as
sudden, discrete episodes of intense fear and/or discomfort accompanied by 4 out of 13
bodily or cognitive symptoms, often manifesting with an intense desire to escape, feeling of
doom or dread, and impending danger. These symptoms peak within 10 minutes, and often
subside within 20-30 minutes. The 13 symptoms are: heart palpitations or fast heart rate;
sweating; trembling or shaking; shortness of breath or smothering; choking sensation; chest
discomfort or pain; nausea or abdominal distress; feeling dizzy, lightheaded, faint or
unsteady; feelings of unreality or being detached from oneself; fear of losing control or
going crazy; fear of dying; numbness or tingling sensations; chills or hot flashes. Panic
Disorder consists of recurrent unexpected panic attacks with inter-episode worry about
having others; the panic attacks lead to marked changes in behavior related to the attacks.
Panic attacks are frequently associated with Agoraphobia (anxiety and avoidance of
situations from which escape might be difficult or help might not be available).
 Obsessive-Compulsive Disorder. Defined by persistent Obsessions (intrusive, unwanted
thoughts, images, ideas or urges) and/or Compulsions (intense uncontrollable repetitive
behaviors or mental acts related to the obsessions) that are noted to be unreasonable and
excessive. These obsessions and compulsions cause notable distress and impairment and are
time consuming (more than one hour a day). The most common obsessions concern dirt and
contamination, repeated doubts, need to have things arranged in a specific way, fearful
aggressive or murderous impulses, and disturbing sexual imagery. The most frequent
compulsions involve repetitive washing of hands or using handkerchief/tissue to touch

 things; checking drawers, locks, windows, and doors; counting rituals; repeating actions;
and requesting reassurance.
 Posttraumatic Stress Disorder. A person is exposed to a traumatic event in which he or she
experiences, witnesses, or is confronted by an event or events that involved actual or
perceived threat of death or serious bodily injury, and the person’s response involves intense
fear, helplessness, or horror. The traumatic event is continually re-experienced in the
following ways: recurrent and intrusive distressing remembrances of the event involving
images, thoughts, or perceptions; distressing dreams of the event; acting or believing that the
traumatic event is recurring; intense anxiety and distress to exposure to situations that
resemble the traumatic event; bodily reactivity on exposure situations that resemble the
traumatic event. The person avoids situations associated with and remind him of the
traumatic event, leading to avoidance of thoughts, feelings or conversations associated
 with the trauma; activities, places, or people that remind him of the traumatic event;
inability to remember details of the event; markedly diminished participation and interest
in usual activities; feeling detached and estranged from others; restricted range of
emotional expression; sense of a foreshortened future or lifespan; persistent signs of
physiologic arousal, such as difficulty falling asleep or staying asleep, irritability or anger
outbursts, difficulty concentrating, excessive vigilance, and exaggerated startle response.
The above symptoms persist for more than one month and cause significant distress and
impairment of functioning.
 Acute Stress Disorder. A person is exposed to a traumatic event in which he or she
experiences, witnesses, or is confronted by an event or events that involved actual or
perceived threat of death or serious bodily injury, and the person’s response involves intense
fear, helplessness, or horror. The traumatic event is continually re-experienced in the
following ways: recurrent and intrusive distressing remembrances of the event involving
images, thoughts, or perceptions; distressing dreams of the event; acting or believing that the
traumatic event is recurring; intense anxiety and distress to exposure to situations that
resemble the traumatic event; bodily reactivity on exposure situations that resemble the
traumatic event. The person avoids situations associated with and remind him of the
traumatic event, leading to avoidance of thoughts, feelings or conversations associated with
the trauma; activities, places, or people that remind him of the traumatic event; inability to
remember details of the event; markedly diminished participation and interest in usual
activities; feeling detached and estranged from others; restricted range of emotional
expression; sense of a foreshortened future or lifespan; persistent signs of physiologic
arousal, such as difficulty falling asleep or staying asleep, irritability or anger outbursts,
difficulty concentrating, excessive vigilance, and exaggerated startle response. The above
symptoms persist for less than one month and cause significant distress and impairment of
functioning.
 Social Phobia. Persistent and significant fear of one of more social situations in which a
person is exposed to unfamiliar persons or scrutiny by others and feels he or she will behave
in a way that will be embarrassing or humiliating. Exposure to the feared social situations
almost always causes significant anxiety, even a panic attack despite the fact that the anxiety
is seen as excessive and unreasonable. This belief may lead to avoidance of such situations
or endurance under extreme distress, leading to marked interference in the person’s
functioning and routine.
 Specific Phobia. Persistent and significant fear that is recognized as unreasonable and
excessive that is triggered by the presence or perception of a specific feared situation or
object; exposure to this situation or object immediately provokes an anxiety reaction. The
distress, avoidance, and anxious anticipation of the feared situation or object significantly
interfere with a person’s normal functioning or routine. Animal Type: animals or insects;
Natural Environmental Type: storms, heights, water, etc.; Blood-Injection-Injury Type:
getting injections, seeing blood, seeing injuries, watching or having invasive medical
procedures; Situational Type: elevators, flying, driving, bridges, escalators, trains, tunnels,
closets, etc.
 Adjustment Disorder with Anxiety (with or without depressed mood). When the
development of emotional and/or behavioral symptoms occur within 3 months in response to
an identifiable stressor. These symptoms and behaviors cause marked distress in excess of
that which could be expected and results in significant occupational, social, or academic
 performance. Once the initiating stressor has ceased, the disturbance does not last longer
than 6 months.
 Anxiety Disorder Due to a General Medical Condition. When the physiologic consequences
of a distinct medical condition is judged to be the cause of prominent anxiety symptoms.
 Drug-Induced Anxiety Disorder. When the physiologic consequences of the use of a drug or
medication is judged to be the cause of prominent anxiety symptoms.
 Anxiety Disorder Not Otherwise Specified. When the prominent symptoms of anxiety and
avoidance exist but do not fully meet the above diagnostic criteria.

Etiology/Causes of Anxiety

 Psychological. Anxiety can result when a combination of increased internal and external
stresses overwhelm ones normal coping abilities or when ones ability to cope normally is
lessened for some reason.
o Psychodynamic: When internal competing mental processes, instincts and impulses
conflict, causing distress.
o Behavioral: Anxiety is a maladaptive learned response to specific past experiences
and situations that becomes generalized to future similar situations.
o Spiritual. When people experience a profound, unquenchable emptiness and
nothingness to their lives, often leading to distress concerning their mortality and
eventual death.
 Genetic. Studies show 50% of patients with Panic Disorder have at least one relative
affected with an anxiety disorder. There is a higher chance of an anxiety disorder in the
parents, children, and siblings of a person with an anxiety disorder than in the relatives of
someone without an anxiety disorder. Twin studies demonstrate varying but important
degrees of genetic contribution to the development of anxiety disorders.
 Biologic. Evidence exists that supports the involvement of norepinephrine, serotonin, and
GABA. In some cases there appears to be a dysregulation of the noradrenergic and
serotonergic neural systems, two systems that are complexly interrelated in the brain.
Theories and some experimental evidence suggest abnormal functioning in the brain's
GABA receptors. Brain imaging and functional studies have shown some evidence of
abnormal function is several regions of the brain.
 Medical. Illnesses such as cardiovascular disease (mitral valve prolapse, arrhythmias),
lung disease, certain tumors (pheochromocytoma), endocrine disorders (hyperthyroidism),
infections, and neurologic disease can all cause anxiety disorders. Therefore it is
important to see your doctor in order to exclude medical diseases as potential causes or
contributors to anxiety disorders.

Anxiety Treatments

 Psychological Treatments
o Cognitive-Behavioral Therapy: addresses underlying “automatic” thoughts and
feelings that result from thoughts, as well as specific techniques to reduce or
replace maladaptive behavior patterns
o Psychotherapy: Centers on resolution of conflicts and stresses, as well as the
developmental aspects of an anxiety disorders solely through talk therapy
 o Behavioral Therapies: focus on using techniques such as guided imagery,
relaxation training, progressive desensitization, flooding as means to reduce
anxiety responses or eliminate specific phobias
 Psychopharmacological Treatments
o Benzodiazepines: Long-acting are best (Klonopin, Ativan, Valium, Librium, Serax)
to quickly reduce the symptoms of an anxiety disorder. However, if used long term
the result may be that tolerance develops.
o Serotonergic Agents: newer antidepressants act as antianxiety agents as well, with
excellent tolerability and effectiveness. Takes 4 to 6 weeks for full response (Luvox,
Prozac, Zoloft, Paxil).
o Tricyclic Antidepressants (TCAs): older antidepressants with more side effects
typically than the serotonergic agents, but also effective. Takes 4 to 6 weeks for full
response (Tofranil, Elavil, Pamelor, Sinequan)
o Combination Serotonin/Norepinephrine Agents: new medications such as Effexor,
Serzone, and Remeron, also with excellent tolerability and effectiveness. Takes 4 to
6 weeks for full response.
o Antihistamines: older medications used for mild to moderate anxiety for many
years. These, like the benzodiazepines, work fairly quickly (Atarax, Vistaril).
o Buspirone (BuSpar): a new serotonergic combination agonist/antagonist. Is
nonaddicting, but may take 2 to 4 weeks for full effect.
o Major Tranquilizers (also called neuroleptics): medications that act on a variety of
neurotransmitter systems (acetylcholine, dopamine, histamine, adrenergic). Most
are somewhat sedating, and have been used in situations where anxiety is severe
enough to cause disorganization of thoughts and abnormal physical and mental
sensations, such as the sense that things around you aren't real (derealization) or
that you are disconnected with your body (derealization). Commonly used
neuroleptics include: Zyprexa, Risperdal, Seroquel, Mellaril, Thorazine, Stelazine,
Moban, Navane, Prolixin, and Haldol.
 Environmental Treatments
o Avoidance or minimization of stimulants. No caffeine, minimize use of asthma
medications if possible (bronchodilators, theophylline), avoid use of nasal
decongestants, some cough medications, and diet pills.
o Good sleep habits. Getting adequate, restful sleep improves response to
interventions to treat anxiety disorders.
o Reduction of stressors. Identify and remove or reduce stressful tasks or situations at
home, school and work.

What are anxiety disorders?

Children and adolescents with anxiety disorders typically experience intense fear, worry, or
uneasiness that can last for long periods of time and significantly affect their lives. If not treated
early, anxiety disorders can lead to:

 Repeated school absences or an inability to finish school;

 Impaired relations with peers;
 Low self-esteem;
  Alcohol or other drug use;
 Problems adjusting to work situations; and
 Anxiety disorder in adulthood.

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What are the types and signs of anxiety disorders?

Many different anxiety disorders affect children and adolescents. Several disorders and their signs
are described below:

Generalized Anxiety Disorder: Children and adolescents with generalized anxiety disorder engage
in extreme, unrealistic worry about everyday life activities. They worry unduly about their
academic performance, sporting activities, or even about being on time. Typically, these young
people are very self-conscious, feel tense, and have a strong need for reassurance. They may
complain about stomachaches or other discomforts that do not appear to have any physical cause.

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Separation Anxiety Disorder: Children with separation anxiety disorder often have difficulty
leaving their parents to attend school or camp, stay at a friend's house, or be alone. Often, they
"cling" to parents and have trouble falling asleep. Separation anxiety disorder may be
accompanied by depression, sadness, withdrawal, or fear that a family member might die. About
one in every 25 children experiences separation anxiety disorder.1

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Phobias: Children and adolescents with phobias have unrealistic and excessive fears of certain
situations or objects. Many phobias have specific names, and the disorder usually centers on
animals, storms, water, heights, or situations, such as being in an enclosed space. Children and
adolescents with social phobias are terrified of being criticized or judged harshly by others. Young
people with phobias will try to avoid the objects and situations they fear, so the disorder can
greatly restrict their lives.

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Panic Disorder: Repeated "panic attacks" in children and adolescents without an apparent cause
are signs of a panic disorder. Panic attacks are periods of intense fear accompanied by a
pounding heartbeat, sweating, dizziness, nausea, or a feeling of imminent death. The experience is
so scary that young people live in dread of another attack. Children and adolescents with the
disorder may go to great lengths to avoid situations that may bring on a panic attack. They also
may not want to go to school or to be separated from their parents.

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Obsessive-Compulsive Disorder: Children and adolescents with obsessive-compulsive disorder,

sometimes called OCD, become trapped in a pattern of repetitive thoughts and behaviors. Even
though they may recognize that the thoughts or behaviors appear senseless and distressing, the
pattern is very hard to stop. Compulsive behaviors may include repeated hand washing, counting,
or arranging and rearranging objects. About two in every 100 adolescents experience obsessive-
compulsive disorder (U.S. Department of Health and Human Services, 1999).

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Post-traumatic Stress Disorder: Children and adolescents can develop post-traumatic stress
disorder after they experience a very stressful event. Such events may include experiencing
physical or sexual abuse; being a victim of or witnessing violence; or living through a disaster,
such as a bombing or hurricane. Young people with post-traumatic stress disorder experience the
event over and over through strong memories, flashbacks, or other kinds of troublesome thoughts.
As a result, they may try to avoid anything associated with the trauma. They also may overreact
when startled or have difficulty sleeping.

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How common are anxiety disorders?

Anxiety disorders are among the most common mental, emotional, and behavioral problems to
occur during childhood and adolescence. About 13 of every 100 children and adolescents ages 9
to 17 experience some kind of anxiety disorder; girls are affected more than boys.1 About half of
children and adolescents with anxiety disorders have a second anxiety disorder or other mental or
behavioral disorder, such as depression. In addition, anxiety disorders may coexist with physical
health conditions requiring treatment.

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Who is at risk?

Researchers have found that the basic temperament of young people may play a role in some
childhood and adolescent anxiety disorders. For example, some children tend to be very shy and
restrained in unfamiliar situations, a possible sign that they are at risk for developing an anxiety
disorder. Research in this area is very complex, because children's fears often change as they age.

Researchers also suggest watching for signs of anxiety disorders when children are between the
ages of 6 and 8. During this time, children generally grow less afraid of the dark and imaginary
creatures and become more anxious about school performance and social relationships. An
excessive amount of anxiety in children this age may be a warning sign for the development of
anxiety disorders later in life.

Studies suggest that children or adolescents are more likely to have an anxiety disorder if they
have a parent with anxiety disorders. However, the studies do not prove whether the disorders are
caused by biology, environment, or both. More data are needed to clarify whether anxiety
disorders can be inherited.
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What help is available for young people with anxiety disorders?

Children and adolescents with anxiety disorders can benefit from a variety of treatments and
services. Following an accurate diagnosis, possible treatments include:

 Cognitive-behavioral treatment, in which young people learn to deal with fears by

modifying the ways they think and behave;
 Relaxation techniques;
 Biofeedback (to control stress and muscle tension);
 Family therapy;
 Parent training; and
 Medication.

While cognitive-behavioral approaches are effective in treating some anxiety disorders,

medications work well with others. Some people with anxiety disorders benefit from a combination
of these treatments. More research is needed to determine what treatments work best for the
various types of anxiety disorders.

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What can parents do?

If parents or other caregivers notice repeated symptoms of an anxiety disorder in their child or
adolescent, they should:

 Talk with the child's health care provider. He or she can help to determine whether the
symptoms are caused by an anxiety disorder or by some other condition and can also
provide a referral to a mental health professional.
 Look for a mental health professional trained in working with children and adolescents,
who has used cognitive-behavioral or behavior therapy and has prescribed medications for
this disorder, or has cooperated with a physician who does.
 Get accurate information from libraries, hotlines, or other sources.
 Ask questions about treatments and services.
 Talk with other families in their communities.
 Find family network organizations.

People who are not satisfied with the mental health care they receive should discuss their
concerns with the provider, ask for information, and/or seek help from other sources.

This is one of many fact sheets in a series on children's mental health disorders. All the fact
sheets listed below are written in an easy-to-read style. Families, caretakers, and media
professionals may find them helpful when researching particular mental health disorders. To
obtain free copies, call 1-800-789-2647 or visit http://mentalhealth.samhsa.gov/child.
Journal abstract :mental health services:
http://www.informaworld.com/smpp/content~db=all~content=a739161946

Mental health services for people with intellectual disability:

Current developments
Author: Helen Molony a
Affiliation: a Prince of Wales Hospital,
DOI: 10.1080/07263869300034931
Publication Frequency: 4 issues per year
Published in: Journal of Intellectual & Developmental Disability, Volume 18, Issue 3 1993 ,
pages 169 - 176
Subjects: Disability; Inclusion and Special Educational Needs; Rehabilitation Medicine;
Formats available: PDF (English)
Previously published as: Australia and New Zealand Journal of Developmental Disabilities until
1996
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Abstract

Mental health services for people with intellectual disability have remained relatively
underdeveloped in Australia and New Zealand. The reasons for this include the lack of a
subspeciality of the psychiatry of disability, limited undergraduate and post graduate medical
education on the topic, lack of practical experience with people with intellectual disability for
psychiatric trainees, the use of institutional care and psychotropic medication to deal with disturbed
behaviours, progressive demedicalisation of services as a result of transfer of responsibility from
health to welfare agencies and a dearth of resources. Nevertheless, the problems with this group of
people have remained a matter of increasing concern on a number of levels and have been
highlighted by the continuing trend towards deinstitutionalisation. Considerable progress has been
made in finding interdisciplinary solutions in the last decade. This report gives an update on the
current status of planning and delivery of mental health services for people with intellectual
disability who have psychiatric disorders, and outlines some of the initiatives adopted in the
Australian States and New Zealand to fill the gap. A number of innovative approaches in the areas of
policy and planning, legislative support, education, consultation and co-ordination between services
and some new programmes have been developed.