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Psychology: Anxiety, General Anxiety Disorder, Phobias, Autism

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Victoria Wooldridge

on 30 August 2010

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Transcript of Psychology: Anxiety, General Anxiety Disorder, Phobias, Autism

ANXIETY Anxiety disorders are a group of disorders which affect behaviour, thoughts, emotions and physical health(1) DSM IV - criteria: Acute Stress Disorder Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms: a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of his or her surroundings (e.g., "being in a daze"); derealization; depersonalization; dissociative amnesia (i.e., inability to recall an important aspect of the trauma). Adjustment Disorder 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). Agoraphobia The presence of Agoraphobia related to fear of developing panic-like symptoms (e.g., dizziness or diarrhea). Generalized Anxiety Disorder (GAD) Excessive anxiety and worry (apprehensive expectation),
occurring more days than not for
at least 6 months, about a number
of events or activities (such as
work or school performance). Obsessive-Compulsive Disorder At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Panic Disorder A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes. Social Phobia A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Specific Phobia Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood) Autism Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play. A. The person has been exposed to a traumatic event in which both of the following were present:

the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
the person's response involved intense fear, helplessness, or horror

B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:

a subjective sense of numbing, detachment, or absence of emotional responsiveness
a reduction in awareness of his or her surroundings (e.g., "being in a daze")
derealization
depersonalization
dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
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 either of the following:

marked distress that is in excess of what would be expected from exposure to the stressor
significant impairment in social or occupational (academic) functioning

C. The stress-related disturbance does not meet the criteria for another specific Axis I disorder (clinical disorder) and is not merely an exacerbation of a preexisting Axis I or Axis II disorder (Personality Disorder or Mental Retardation).

D. The symptoms do not represent Bereavement.
A. The presence of Agoraphobia related to fear of developing panic-like symptoms (e.g., dizziness or diarrhea).

Criteria for Agoraphobia

a. Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or automobile.

Note: Consider the diagnosis of Specific Phobia if the avoidance is limited to one or only a few specific situations, or Social Phobia if the avoidance is limited to social situations.

b. The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety
about having a Panic Attack or panic-like symptoms, or require the presence of a companion. A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The person 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 present for more days than not for the past 6 months).

Note: Only one item is required in children.
a. restlessness or feeling keyed up or on edge
b. being easily fatigued
c. difficulty concentrating or mind going blank
d. irritability
e. muscle tension
f. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
A. Either obsessions or compulsions:

Obsessions as defined by (1), (2), (3), and (4):

a. recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and
b. inappropriate and that cause marked anxiety or distress
the thoughts, impulses, or images are not simply excessive worries about real-life problems
c. the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
d. the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

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

a. repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
b. the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive A. Recurrent unexpected Panic Attacks

Criteria for Panic Attack:
A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

a. palpitations, pounding heart, or accelerated heart rate
b. sweating
c. trembling or shaking
d. sensations of shortness of breath or smothering
e. feeling of choking
f. chest pain or discomfort
g. nausea or abdominal distress
h. feeling dizzy, unsteady, lightheaded, or faint
i. derealization (feelings of unreality) or depersonalization (being detached from oneself)
j. fear of losing control or going crazy
k. fear of dying
l. paresthesias (numbness or tingling sensations)
m. chills or hot flushes


Panic Disorder with Agoraphobia

A. Meets the criteria for Panic Disorder

B. The presence of Agoraphobia:

a. Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or
automobile.
Note: Consider the diagnosis of Specific Phobia if the avoidance is limited to one or only a few specific
situations, or Social Phobia if the avoidance is limited to social situations.
A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.

B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack.
Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social
situations with unfamiliar people.

C. The person recognizes that the fear is excessive or unreasonable.
Note: In children, this feature may be absent.

D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.

E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. A. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack.
Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or
clinging

C. The person recognizes that the fear is excessive or unreasonable.
Note: In children, this feature may be absent.

D. The phobic situation(s) is avoided or else is endured with intense anxiety or distress.

E. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

A. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):

a. qualitative impairment in social interaction, as manifested by at least two of the following:

i. marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
ii. failure to develop peer relationships appropriate to developmental level
iii. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
iv. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)

b. qualitative impairments in communication as manifested by at least one of the following:

i. delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
ii. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
iii. stereotyped and repetitive use of language or idiosyncratic language
iv. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level Statistics: Up to 12% of Canadians have social anxiety disorder. (14) 480,000 Canadians (1.5%) have panic disorder. 227,000 Canadians (0.7%) have agoraphobia. (2) 42% of young adults in America regularly use recreational drugs to cope with anxiety. (National Institute on Drug Abuse) Alcohol is commonly used to cope with anxiety. 72% of Canadians consume alcohol each year. (12) Autism is currently reaching epidemic levels (1 in 200 children now being diagnosed – ten years ago 1 in 10,000 were identified); 75% of afflicted are male. 90% of autistic individuals may be placed in institutions and residential facilities, if they do not receive treatment. (13) Anxiety Disorders were only recognized in 1980 by the American Psychiatric Association. Before this recognition people experiencing one of these Disorders usually received a generic diagnosis of 'stress' or 'nerves'. As there was no understanding of the Disorders by the health professionals, very few people received effective treatment. Since 1980, international research has shown the severe disabilities associated with these Disorders. Most of these disabilities can be prevented with early diagnosis and effective treatment. It was often thought that Anxiety Disorders and panic attacks were a "women's problem." This is certainly untrue. Although men are more hesitant to present for treatment, both women and men are affected by these Disorders.(4) About 13 of every 100 children and adolescents between 9 to 17 years experience some kind of anxiety disorder and girls are more affected than boys. (6) HISTORY In 1911, autism was suggested as a condition that applied to adult schizophrenia; it was described for the first time as a separate problem in 1943. Until the 1960s, the medical community still believed that schizophrenia was the cause of autism, which led many parents to believe they were at fault. During the 1960's people began to understand autism and more precisely identify autism symptoms and treatments. (9) CAUSES It is common for people to suffer from more than one anxiety disorder; and for an anxiety disorder to be accompanied by depression, eating disorders or substance abuse. Anxiety disorders can also coexist with physical disorders, in which case the physical condition should also be treated.(1) According to research, childhood anxiety disorders are caused by biological and psychological factors. Also, it is suggested that when children have a parent with anxiety disorders, they are more likely to have an anxiety disorder, too. Stress also can trigger anxiety disorders, but also, children and adolescents with anxiety disorders seem to have an increased physical and psychological reaction to stress. Their reaction to danger, even if it is a small one, is more quickly and more strongly. (6) Like most mental health problems, anxiety disorders appear to be caused by a combination of biological factors, psychological factors and challenging life experiences, including: stressful or traumatic life events (e.g. -stress due to financial worries, prolonged or chronic physical illness, or dementia a family history of anxiety disorders
childhood development issues alcohol, caffeine, medications (e.g. benzodiazepines, methylphenidate), or illicit substances (e.g. cocaine) either while the person is intoxicated or in withdrawal in some cases, significant chronic exposure to organic solvents in the work environment: painting, varnishing and carpet laying
other medical or psychiatric problems (e.g. low levels of GABA (Gamma-aminobutyric acid), serotonin, norepinephrine, or disruption in the amygdale (wikipedia and (7) MANAGEMENT Panic Disorder:

A. Non-Pharmaceutical
Behavioural and Cognitive-Behaviour Therapy; Psychotherapy

B. Pharmaceutical:

Selective Serotonin Reuptake Inhibitors (SSRIs) are the drugs of choice (currently only Paxil is FDA approved for this indication). Recommended dosage ranges: Paxil (paroxetine) 10 to 50 mg/day,
Luvox (fluvoxamine) 25 to 300 mg/day, and
Prozac (fluoxetine) 5 to 60 mg/day.
Monitor for initial paradoxical anxiety secondary to drug side effect, which
usually resolves with time.

Tricyclic Antidepressants (TCAs). For example, start Imipramine at 10 to 25 mg QHS and increase by 10 to 25 mg every 3 or 4 days until effective, side effects predominate, or initial target dose of 150 to 200 mg QHS is reached. If no response after 4 to 6 weeks at target dose, may increase to maximum dose of 300 to 400 mg QHS as tolerated. Clinical experience has shown that serotonergic TCAs are more effective than noradrenergic TCAs.

Benzodiazepines have a quicker onset of action than other drugs; may use as a short-term adjunct to SSRIs if initial paradoxical anxiety arises. They may be used long term if patients fail treatment or are unable to tolerate SSRIs or TCAs.

Monamine Oxidase Inhibitors (MAOIs) are reserved for patients who do not respond to SSRIs or TCAs because of serious adverse drug reactions.

Propanolol (Inderal) is not a first-line agent for panic disorder but is very effective for physical symptoms of panic attacks associated with performance anxiety.

Buspirone (Buspar) has demonstrated little efficacy in patients with panic disorders.
What causes obsessive-compulsive disorder?

There is no single, proven cause of OCD. Research suggests that OCD involves problems in communication between the front part of the brain (the orbital cortex) and deeper structures (the basal ganglia). These brain structures use the chemical messenger serotonin. It is believed that insufficient levels of serotonin are prominently involved in OCD. Drugs that increase the brain concentration of serotonin often help improve OCD symptoms. Pictures of the brain at work also show that the brain circuits involved in OCD return toward normal in those who improve after taking a serotonin medication or receiving cognitive-behavioral psychotherapy. Although it seems clear that reduced levels of serotonin play a role in OCD, there is no laboratory test for OCD. Rather, the diagnosis is made based on an assessment of the person's symptoms. When OCD starts suddenly in childhood in association with strep throat, an autoimmune mechanism may be involved, and treatment with an antibiotic may prove helpful. Obsessive-Compulsive Disorder:

Non-Pharmaceutical:
Education (re: management and prevention of episodes), and Psychotherapy

Pharmaceutical:

The introduction of the SSRIs (selective serotonin reuptake inhibitors) over the past decade has provided exciting new opportunities for the treatment of obsessive-compulsive disorder (OCD):

Large, controlled, multicenter studies have found the following to be effective and safe in the treatment of OCD:

fluoxetine (Prozac),
fluvoxamine (Luvox),
sertraline (Zoloft), and
paroxetine (Paxil)

Improvement following adequate OCD drug treatment is frequently partial whereupon augmentation strategies may become necessary. High rates of relapse have been reported on discontinuation of SRI treatment. Long-term maintenance treatment has been found to be effective in sustaining initial therapeutic gains and bringing about further improvement.

Generalized Anxiety Disorder (GAD):

Non-Pharmaceutical:

1. Therapy
Psychotherapy: Most patients with mild symptoms can be treated with supportive counseling and education without need for medication.

Other therapies: Relaxation training and cognitive therapy.

2. General measures: Regular exercise and avoidance of caffeine and alcohol.

Pharmaceutical:

1. Tricyclic Antidepressants (TCAs). Imipramine 25 to 150 mg/day. Does not become effective for 2 to 3 weeks. Most beneficial in patients with comorbid depression or sleep disturbance.

2. Antihistamines. Hydroxyzine (Atarax, Vistaril) 50 to 100 mg QID may be used PRN, as an adjunct to other medications, or as an alternative therapy for patients with addiction potential.

3. Benzodiazepines. Usually of short-term use with no long-term efficacy proved. Use lowest dose that alleviates anxiety. Longer half-life drugs may be easier to taper. May cause rebound anxiety with taper or withdrawal. Examples: Alprazolam (Xanax) 0.25 to 0.5 mg PO TID initial dose; rarely need to exceed 4 mg/day. Diazepam (Valium) 2 to 10 mg PO BID to QID. Lorazepam (Ativan) 1 mg PO BID or TID initially; rarely need to exceed 10 mg/day. Use lower doses than above in the elderly.

4. Buspirone. May be less effective than other agents. Start 5 mg PO TID and increase to typical dose of 20 to 30 mg/day. Takes 2 weeks to be effective. Nonsedating. Little abuse potential.

5. Selective Serotonin Reuptake Inhibitors (SSRIs). Clinically appear helpful but not well studied yet. Use in doses similar to those for Panic Disorder. In select patients may add a benzodiazepine for first several weeks of treatment, since it has a quicker onset of action and avoids potential initial side effect of increased anxiety with SSRIs (Prozac, Paxil, Luvox, Zoloft).

6. Beta-blockers. Propranolol (Inderal) may help physical symptoms (not FDA approved) but has no effect on psychic component of anxiety. Social Phobia:

Non-Pharmaceutical:

Systematic desensitization and exposure (for specific phobias) and cognitive behavioral therapy (for social phobias).

Pharmaceutical:

1. Beta-blockers may be effective in treating performance-anxiety symptoms.
2. Drugs used in generalized social phobias include SSRIs (doses higher than those used in depression) or an MAOI (such as phenelzine). See also Panic Disorder for detailed description of medication issues. Specific Phobia:

Non-Pharmaceutical:

Systematic desensitization and exposure (for specific phobias) and cognitive behavioral therapy (for social phobias).

Pharmaceutical:

1. Beta-blockers may be effective in treating performance-anxiety symptoms.
2. Drugs used in generalized social phobias include SSRIs (doses higher than those used in depression) or an MAOI (such as phenelzine). See also Panic Disorder for detailed description of medication issues. Autism:

Non-Pharmaceutical:

changes to diet, and/or supplementing deficient vitamins and minerals etc.,
building the individual’s immune system
detoxifying, and
improving nutrition. (3)

Pharmaceutical:

a. Antipsychotics: b. Stimulants
-Thorazine -Amphetamines (Dexedrine, Adderall)
-Haldol -Methylphenidates (Ritalin, Concerta,
-Clozaril Biphentin)
-Risperdal (most common)

c. Antidepressants d. Antianxiety Medications (Anxiolytics)
-Zoloft (Sertraline) -Valium (diazepam)
-Prozac (Fluoxetine) -Ativan (lorazepam)
-Celexa (Citalopram)
-Luvox (Fluvoxamine)
-Paxil (Paroxetine)
-tricyclic antiobsessional
antidepressant (Anafranil)

e. Sedative-hypnotics f. Anti-epileptic
-Aquachloral -Depakote (Valproate)
-Ataraxnistarii -Tegretol (Carbamazapine)
-barbiturates (secobarbital,
phenobarbital, and
pentobarbital)
-Benadryl (diphenhydramine)
-Phenerg (promethazine)

g. Anti-Hypertensive
-Inderol (Propranolol)
-Visken (Pindolol) (3) SIGNS & SYMPTOMS Panic Disorder (Panic Attacks):
Adults Children / Youth
- accompanied by sudden feelings of terror, - shortness of breath
- chest pain and/or heart palpitations - racing heart
- shortness of breath - choking sensation
- dizziness - dizziness
- abdominal discomfort - fear of dying or losing control (2)
- feelings of unreality *-diagnosed when a child experiences
- fear of dying at least two panic attacks which occur
*When a person avoids situations that he/she suddenly or ‘out of the blue’ followed
fears may cause a panic attack, his or her condition by a month of feeling fearful and
is described as panic disorder with agoraphobia. (1) apprehensive of having another episode. (2)
Obsessive-Compulsive Disorder
Adults: Children / Youth
- persistent unwanted thoughts - obsessions: involuntary thoughts or
(obsessions, often concerning images that arise repeatedly in the child’s
contamination, doubting [such as mind which can be unpleasant or
worrying that the iron hasn’t been frightening to the child, e.g. thoughts about
turned off], and disturbing sexual or getting sick or that something bad will
religious thoughts) happen to their parents
- persistent unwanted rituals - to try to protect him/herself, a child will
(compulsions, e.g. washing, checking, feel compelled to engage in specific rituals
organizing, and counting)(1) (compulsions, e.g. dressing in a certain
way, counting, hand washing, checking
things like doors and locks, repeating
certain words or numbers over and over
again) (2)   Generalized Anxiety Disorder
Adults Children / Youth
- feeling restless or keyed up - muscle tension
- difficulty concentrating - headaches
- being easily fatigued - stomach aches
- feeling irritable - restlessness
- experiencing muscle tension - sleep difficulties
- having sleep difficulties - difficulty concentrating (2)  
- gastrointestinal discomfort including
nausea and diarrhea
- sweating (2) Social Phobia / Specific Phobia
Adults Children / Youth
(Social) - excessive/unrealistic fear
- paralysing, irrational self- - intense clinginess
consciousness about social situations - crying
- intense fear of being observed or of - tantruming
doing something horribly wrong in - freezing
front of other people - stomach aches
- avoidance of objects or situations - headaches
that might stimulate that fear, which - racing heart
dramatically reduces the ability to - avoid situations where they might have lead a normal life. (1) to engage in activities that make them
(Specific) feel anxious
- overwhelmed by unreasonable fears, - avoid initiating conversations with
which they are unable to control peers or teachers
- exposure to feared situations can - speaking in front of the class
cause extreme anxiety and panic, even - inviting others to social activities
if they recognize that their fears are - participating in peer oriented
illogical. (1) activities (2)  Autism
early signs @ 12 to 24 months Children to Adult
- often begins to develop language then - behaves as though other people do not exist
loses it, or doesn't acquire language at all - social skills are characteristically rote and awkward in nature
- may appear deaf, respond unevenly or - inability to take in another’s perspective, feelings and emotions,
not at all to sounds provide or seek comfort in conventional ways
- difficulty consoling during transitions - tend to crave predictability and structured situations
(tantrums) - learns behaviour patterns of social interaction through imitation
- difficulty sleeping / wakes at night - may engage in repetitive, stereotyped body movements (e.g. hand
- does not "point and look" flicking, spinning, rocking)
- failure to bond (e.g. child is indifferent to - may insist on carrying certain objects around with them for security
parents' presence) - may persevere in discussing one or two topics, exhausting the
- reaction to vaccines listener with his/her knowledge
- self restricted/selected diet - reacts with extreme stress when routine disrupted: screaming,
- limited imaginative play tantrums, self-injury
- not interested in playing with other - hypersensitivity to stimuli (e.g. can hear lights buzzing, cannot
children tolerate touch, fascinated with spinning objects, must smell
- chronic gastrointestinal problems everything, etc.)
- repeated infections (3) - hyposensitivity (e.g. demonstrates high pain tolerance, acts as if deaf, etc.)
- engages in property destruction, self-injury, tantrums, acts of engagement
- many have problems with toileting, often related to sensory issues or
actual gastrointestinal problems. A great many have diarrhea or
constipation, abdominal pain, gaseousness and bloating and in many cases
foul smelling light coloured stools. This discomfort could be the cause of
poor sleep habits as many individuals suffer from reflux esophagitis. (3) There are five diagnoses under the spectrum of Autism disorders.

1. Autistic Disorder occurs four times more frequently in boys than girls and is characterized in some children by withdrawn behaviour or other unusual social behaviours, problems using language to communicate, repetitive patterns of behaviour and the inability to engage in imaginative play. Usually the child begins with normal development and shows regression between 12 and 24 months of age.

2. Asperger's Disorder - Many experts view Asperger's Disorder as high-functioning autism. Children with Asperger's Disorder have no significant delays in language skills or in cognitive development, self-help skills or adaptive behaviour. There is, however, significant impairment in social functioning as well as stereotyped behaviours and repetitive mannerisms.

3. Pervasive Development Disorder - Not otherwise Specified (PDD-NOS) occurs when a child may not fall within the realm of other ASD's, but nonetheless shows signs of severe and pervasive impairment in the development of reciprocal social interaction, verbal and non-verbal communication skills.

4. Rett's Disorder has only appeared in girls to date. These children seem to develop normally until between 5-18 months, then experience a deceleration of head growth and lose previously acquired language. Hand skills are replaced by stereotypical behaviour (hand-flapping, wringing). There is also a loss of social interaction, physical coordination and receptive and expressive language is impaired. Recently, a genetic marker for Rett's syndrome has been identified.

5. Childhood Disintegrative Disorder (CDD), also known as Heller's Disease, refers to the normal development of children until 2 years of age, who then lose acquired skills. This usually occurs between 36 and 48 months of age but may occur up to 10 years of age. (3)
References

1) “Anxiety Disorders.”Canadian Mental Health Association (CMHA).
http://www.cmha.ca/bins/content_page.asp?cid=3-94. 2010. Web. 08/28/10.

2) “Generalized Anxiety Disorders,” “Treatment,” and “Childhood Anxiety.” Anxiety
Disorders Association of Canada / Association Canadienne des Troubles
Anxieux (ACAC/ACTA). http://www.anxietycanada.ca/english/GAD.php. 2007.
Web. 08/28/10.

3) “Characteristics,” “Early Signs,” and “Diagnoses.” Autism Canada Foundation.
http://www.autismcanada.org/characteristics.htm. 2010. Web. 08/28/10.

4) Staff Writer. “History of Anxiety Disorders.” HealthyPlace.Com.
http://www.healthyplace.com/anxiety-panic/insights-into-anxiety/history-of-
anxiety-disorders/menu-id-1236/. 02/10/08. Web. 08/28/10.

5) Catherine L. Woodman, MD. “The Natural History of Generalized Anxiety
Disorder: A Review.” Medscape Today from WebMD; Medscape Psychiatry &
Mental Healthy eJournal. http://www.medscape.com/viewarticle/431268.
04/05/2002. Web. 08/28/10.

6) Wikipedia contributors. "Anxiety disorder." Wikipedia, The Free Encyclopedia.
Wikipedia, The Free Encyclopedia, 27/08/10. Web. 29/08/2010.

7) “What causes anxiety disorders?” Centre for Addiction and Mental Health/Centre
de toxicomanie et de sante mentale.
http://www.camh.net/About_Addiction_Mental_Health/Mental_Health
_Information/Anxiety_Disorders/causes_anxiety.html. 2009. Web. 08/28/10.

8) Wikipedia contributors. "Phobia." Wikipedia, The Free Encyclopedia.
Wikipedia, The Free Encyclopedia, 29/08/10. Web. 29/08/10.

9) “History of Autism.” Autism PDD.net http://www.autism-pdd.net/autism-
history.html 2003-2005. Web. 29/08/10

10) “A History of Autism.” WebMd. http://www.webmd.com/brain/autism/history-of-
autism 2005-2010. Web. 29/08/10

11) “DSM-IV Diagnostic Criteria of Mental Disorders – Childhood Disorders.”
PsychologyNet. http://www.psychologynet.org/dsm/autism.html. Web. 29/08/10.

12) “Anxiety, Anxiety Disorder Statistics.” AnxietyCentre.com.
http://www.anxietycentre.com/anxiety-statistics-information.shtml 1987-2010.
Web. 08/29/10

13) Brenda Deskin. Autism in Canada. http://featbc.org/downloads/AutismInCanada
flyer.pdf June 2005. Web. 08/29/10.

14) “Obssessive-Compulsive Disorder: A Guide for Patients and Families.” EKS -
Expert Consensus Guidelines. http://www.psychguides.com/ochex 1996-2008.
Web. 08/28/10.
C. The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event

D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).

E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.

H. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.

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

Specify if:

Acute: if the disturbance lasts less than 6 months
Chronic: if the disturbance lasts for 6 months or longer

Adjustment Disorder subtypes are selected according to the predominant symptoms:

With Depressed Mood
With Anxiety
With Mixed Anxiety and Depressed Mood
With Disturbance of Conduct
With Mixed Disturbance of Emotions and Conduct
Unspecified

Associated Features:

Depressed Mood
Somatic/Sexual Dysfunction
Guilt/Obsession
c. The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as Social Phobia (e.g., avoidance limited to social situations because of fear of embarrassment), Specific Phobia (e.g., avoidance limited to a single situation like elevators), Obsessive-Compulsive Disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives).

B. Criteria have never been met for Panic Disorder

C. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

D. The symptoms do not represent Bereavement.

E. If an associated general medical condition is present, the fear described in Criterion A is clearly in excess of that usually associated with the condition.

Associayed Features

Depressed Mood
Somatic/Sexual Dysfunction
Addiction
Anxious or Fearful or Dependent Personality D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.

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

F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

Associated Features

Depressed Mood
Somatic or Sexual Dysfunction
Anxious or Fearful or Dependent Personality B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.

C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships.

D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).

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

Associated Features

Depressed Mood
Somatic or Sexual Dysfunction
Guilt or Obsession
Addiction
Anxious or Fearful or Dependent Personality
B. At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

a. persistent concern about having additional attacks
b. worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
c. a significant change in behavior related to the attacks

C. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

D. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).
b. The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion.
c. The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as Social Phobia (e.g., avoidance limited to social situations because of fear of embarrassment), Specific Phobia (e.g., avoidance limited to a single situation like elevators), Obsessive-Compulsive Disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives).

Panic Disorder without Agoraphobia

A. Meets the criteria for Panic Disorder
B. Absence of Agoraphobia: F. In individuals under age 18 years, the duration is at least 6 months.

G. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).

H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.

Specify if:
Generalized: if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder)

Associated Features

Depressed Mood
Somatic or Sexual Dysfunction
Addiction
Anxious or Fearful or Dependent Personality F. In individuals under age 18 years, the duration is at least 6 months.

G. The anxiety, Panic Attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder, such as Obsessive-Compulsive Disorder (e.g., fear of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), Separation Anxiety Disorder (e.g., avoidance of school), Social Phobia (e.g., avoidance of social situations because of fear of embarrassment), Panic Disorder With Agoraphobia, or Agoraphobia Without History of Panic Disorder.

Specify Type:

Animal Type
Natural Environment Type (e.g., heights, storms, water)
Blood-Injection-Injury Type
Situational Type (e.g., airplanes, elevators, enclosed places)
Other Type (e.g., phobic avoidance of situations that may lead to choking, vomiting, or contracting an illness; in children, avoidance of loud sounds or costumed characters)

Associated Features

Depressed MoodA.
Anxious or Fearful or Dependent Personality c. restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

i encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
ii. apparently inflexible adherence to specific, nonfunctional routines or rituals
iii. stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
iv. persistent preoccupation with parts of objects

B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.

C. The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder.

Associated Features

Learning Problem
Dysarthria or Involuntary Movement
Hypoactivity
Psychosis
Odd or Eccentric or Suspicious Personality
Anxious or Fearful or Dependent Personality
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