Anxiety
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Adjustment disorder: DSM-IV criteria
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: 

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

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

D. The symptoms do not represent Bereavement

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

309.0 With Depressed Mood 
309.24 With Anxiety 
309.28 With Mixed Anxiety and Depressed Mood 
309.3 With Disturbance of Conduct 
309.4 With Mixed Disturbance of Emotions and Conduct 
309.9 Unspecified

�@

Adjustment disorder: ��Diagnosis

��made by excluding an anxiety or depressive disorder

��Aetiology

��stressful environment+ individual vulnerability

��Treatment

1.help a resolution of the stressful problem
2.aid the natural process

��by reducing denial and avoidance
��by encouraging problem solving
��discouraging maladaptive coping responses
��reducing anxiety by talking about the stress and expressing feelings

�@

Adjustment to illness:

Sick role

Parsons(1951)

1.Exemption from certain social responsibilities
2.Right to expect help and care from others
3.Obligation to seek and cooperate with treatment
4.Expectation that the sick person will have a desire to recover

�@

Adjustment to Bereavement:

Normal Grief

1st Stage:

denial, numbness, feeling of unreality, restlessness

2nd Stage:

extreme sadness, anxiety, yearning of the dead, guilty, anger, projection, vivid experience or hallucination of the dead, intrusive images, social withdrawal, physical symptoms

3rd Stage:

 resumed, recall the good times

�@

Adjustment to Bereavement:

Treatment

1.talk about the loss, to express feelings of sadness, guilt, or anger, and to understand the normal course of grieving

2.forewarn the unusual experiences

3.to accept that the loss is real; to work through the stages of grief; to adjust to life without the deceased

4.maintaining and caring for the young

5.resume social contacts, talk to other people about the loss, remember happy and fulfilling experiences

6. consider positive activities that the deceased would have wanted survivors to undertake

�@

Adjustment to death ��Symptoms:
1.Anxiety: pain, disfigurement, incontinence, fear of death, concerns about the future of the family
2.Depression:  separation from family, loss of valued activities
3.Guilt: excessive demands, punishment for wrongdoing
4.Anger: unjustness

��Kubler-Ross(1969): DABDA

��Defense mechanisms: (3D)
Denial, Dependency, Displacement�]�E��^

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1.reduce symptoms as much as possible:  adequate control of pain and breathlessness and the reduction of confusion

2.establish a good relationship with the patient: explanation, expressing feelings

3.talk with relatives(anxiety, depression����guilt, anger, denial)

4.dealing with psychiatric symptoms or behavioral disturbance

5.depressive disorder: esp. early morning wakening, extreme hopelessness and self-blame

�@

Generalized Anxiety Disorder
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. 

(1) restlessness or feeling keyed up or on edge 
(2) being easily fatigued 
(3) difficulty concentrating or mind going blank 
(4) irritability 
(5) muscle tension 
(6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) 

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.

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Panic Attack �@

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Obsessive-Compulsive Disorder
A. Either obsessions or compulsions

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

(1) recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress 
(2) the thoughts, impulses, or images are not simply excessive worries about real-life problems 
(3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action 
(4) 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): 

(1) 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 
(2) 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 

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 Disorders; 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. 

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OCD: psychotherapy �{���欰�v��������h�O�J

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Acute stress disorder:

Treatment

�@

1.Reducing the emotional response: talk and express emotion to understanding person, anxiolytics
2.Encouraging recall: to prevent "avoidance" or "denial", phobias or PTSD
3.Learning effective coping skills

�@

Posttraumatic Stress Disorder
A. The person has been exposed to a traumatic event in which both of the following were present: 

(1) 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 
(2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior 

B. The traumatic event is persistently reexperienced in one (or more) of the following ways: 

(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. 
(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. 
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur. 
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event 
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event 

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: 

(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma 
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma 
(3) inability to recall an important aspect of the trauma 
(4) markedly diminished interest or participation in significant activities 
(5) feeling of detachment or estrangement from others 
(6) restricted range of affect (e.g., unable to have loving feelings) 
(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) 

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: 

(1) difficulty falling or staying asleep 
(2) irritability or outbursts of anger 
(3) difficulty concentrating 
(4) hypervigilance
(5) exaggerated startle response 

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

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

�@

Post-traumatic stress disorder:

Symptoms

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1.Hyperarousal
persistent anxiety
irritability
insomnia
poor concentration

2.Intrusions
difficulty in recalling
flashbacks
recurring dreams

3.Avoidance
avoid reminders
detachment
numbness
avolition

�@

Post-traumatic stress disorder:

Treatment

�@

Immediate measures:

1.encouragment to recall the stressful experiences
2.express associated emotions to an understanding person

Later treatment:

��Councelling

1.provide emotional support
2.encourage recall of the traumatic events
3.facilitate "working through" the associated emotions
4.dealing with guilty feeling
5.existential concerns about the meaning and purpose of life and death

��Behavioural techniques

desensitize pts to intrusive memories by relaxing/flooding

��Psychodynamic psychotherapy

��Drug: Anxiolytics, MAOI, TCA, SSRI

�@

�@ �@
PTSD: rape 1.Acute reactions:
(1)Anxiety and depressive disorders
(2)Psychosexual dysfunction
(3)PTSD(94%)

2. Feelings:
vulnerability, self-blame, loss of self-esteem
why chosen as victim

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