Supporting Students with Anxiety Disorders in Job Corps: A Mental Health Presentation

 
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Anxiety Disorders
 
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Helena Mackenzie, PhD, LP
Region 5 (Chicago) Mental
Health Specialist
 
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After this presentation, participants will be able to:
articulate applicable changes to titles and diagnostic criteria for anxiety
disorders based on DSM-5.
recognize how clinical presentations for anxiety disorders may vary for
adolescents and young adults.
identify at least one evidence-based intervention for anxiety disorders,
including panic attacks, social anxiety disorder, and generalized anxiety
disorder
 
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Mental health disorders account for 36% of medical separations
Anxiety disorders account for 4.1 % of all medical separations
Only Mood disorders accounts for more mental health related medical
separations (18% of all)
Increase from PY 12 which was 3.5 percent for anxiety disorders
Average Length of Stay (ALOS)
PY 2012, 206 days; PY 2013, 166 days; PY 2014, 151 days
Anxiety disorders account for 5.2 percent of all students with
disabilities (including all disability categories)
 
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Anxiety Disorders
 
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Separation Anxiety Disorder (previously under “Disorders Usually First Dx in Infancy, Childhood,
Adolescence”)
Selective Mutism (previously under “Disorders Usually First Dx in Infancy, Childhood, Adolescence”)
Specific Phobia
Social Anxiety Disorder
Panic Disorder
Agoraphobia
Generalized Anxiety Disorder
Substance/Medication-Induced Anxiety Disorder
Anxiety Disorder Due to Another Medical Condition
Other Specified Anxiety Disorder; Unspecified Anxiety Disorder
 
 
 
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Obsessive Compulsive Disorder (no longer included with anxiety
disorders, but with Obsessive-Compulsive and Related Disorders)
Posttraumatic Stress Disorder (no longer included with anxiety
disorders, but with Trauma- and Stressor-Related Disorders)
Sequential order of anxiety disorder chapter and these other two
chapters in DSM-5 reflects the close relationships between these
disorders
 
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All share features of excessive fear/anxiety that impact behavior:
Fear: emotional response to real or perceived imminent threat.
Example: Hear a loud sound while walking alone at night
Associated with autonomic nervous system arousal (fight/flight/freeze/faint); thoughts
of immediate danger; escape behaviors
Anxiety: anticipation of future threats
Example: Interviewing for job or giving a presentation in a week
Associated with muscle tension, vigilance in preparation for future danger, rumination,
and cautious and avoidant behaviors
 
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Differ from developmentally normative fear/anxiety:
Excessive or persist beyond developmentally appropriate periods
Clinician, taking culturally factors into account, determines if fear is excessive (out of
proportion to situation)
Differ from transient fear or anxiety (stress induced):
Persistent—last typically 6 months or more, although time criterion is general guide
Often develop in childhood and tend to continue if untreated
Most occur more frequently in females than males (approx 2:1)
 
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Differ from each other based on what the fear,
anxiety, or avoidance behavior is about and the
associated thoughts/beliefs
Separation Anxiety
: fearful/anxious about
separating from attachment figure
Selective Mutism: 
consistently 
not
 speaking in
social situations (like school) when able to speak
in other situations (home, with friends); highly co-
morbid with social anxiety disorder.
Specific Phobia: 
fearful, anxious or avoidant of a
specific object or situation (spiders, heights,
needles)
Social Anxiety
: fearful or anxious about social
interactions that involve possibility of being
scrutinized (fear of negative evaluation,
embarrassed, rejected)
Panic Disorder: 
recurrent panic attacks, concern
of having more panic attacks and/or avoiding
situations or changing behavior in maladaptive
ways to avoid panic attacks
Agoraphobia:  
fearful/anxious about specific
situations due to thoughts that escape is
difficult/help not available if have panic attack.
Leads to avoidance of situations.
Generalized Anxiety Disorder:
persistent/excessive worry and anxiety in
different areas (work/home/school), find it hard
to control worry, have specific physical symptoms.
 
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Referred by instructor because withdrawn and anxious; frequently leaves
classroom suddenly looking like “deer in headlights;” becomes agitated if
instructor tries to stop her
Frequently coming to wellness complaining of racing heart, chest pain,
feeling dizzy, and shaking.  Medical work up is normal.
Refusing to go to cafeteria because had symptoms before while eating
lunch and scared they’ll return.  Also refusing to go to recreation because
had ”episode” while exercising
Tells CMHC symptoms started a few months ago, come on quickly and
then pass, but terrified will return and wants to leave JC because feeling
overwhelmed
 
 
 
 
 
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Separation Anxiety Disorder
Generalized Anxiety Disorder
Panic Disorder
Specific Phobia
Selective Mutism
 
 
 
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1)
Recurrent, unexpected 
panic attacks—abrupt surge of intense fear, discomfort that reaches
peak within minutes.  4 or more symptoms:
pounding heart,
sweating,
trembling,
shortness of breath,
choking sensation,
chest pain,
nausea,
dizziness/lightheaded,
derealization (feeling of unreality) or depersonalization (detached from oneself),
fear of losing control/going crazy/dying.
2) At least one attack followed by month or more of either: persistent worry about another
attack; and/or significant change in behavior (avoiding exercise or unfamiliar situations, etc)
 
 
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Median age onset 20-24 years old; clinical presentation in adolescents same as
adults
Frequent school, work absences, and trips to ED, which can lead to dropping out
school, losing jobs.
Associated with agoraphobia, depression, social phobia, bipolar, alcohol use
disorder
Changes to DSM-5:
deleted different types of panic attacks (situationally bound/cued, situationally predisposed,
unexpected/uncued has been replaced with “unexpected” and “expected”)
Agoraphobia separated (see next slide)
Panic attacks (not disorder) can occur as part of other conditions (PTSD, depressive disorder,
alcohol use disorders).  Can use a Panic Attack specifier, meaning panic occurs but doesn’t
meet panic disorder criteria and is part of another disorder.
 
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Marked fear or anxiety about two (or more) situations—public transit; open
spaces; enclosed places; being in crowd; being outside home alone
Fear and avoidance due to thoughts that escape difficult/help unavailable if
panic or other embarrassing symptoms occur
Situations almost always cause fear/anxiety and are actively avoided or require
company of companion; cause clinically significant distress or impairment in
social, occupational, other functioning
Changes in DSM-5
Panic Disorder and Agoraphobia are unlinked—two separate diagnoses, with distinct criteria
Fear, anxiety, avoidance is persistent (six months or longer)
Fear, anxiety is out of proportion to actual danger posed (judged by clinician)
CAN diagnose agoraphobia in absence of panic disorder
 
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Hasn’t connected with peers, won’t make eye contact
Withdrawn and appears uncomfortable around adults and peers
Having difficulty in classroom because refuses to participate in class and
appears embarrassed and shuts down if called on
Told counselor thinks people are judging him and is anxious about doing
something embarrassing and not fitting in
Feels nauseous, hands shakes, blushes, and has butterflies when knows he
has to interact with people
Struggled with same symptoms in high school so dropped out
 
 
 
 
 
 
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Separation Anxiety Disorder
Generalized Anxiety Disorder
Specific Phobia
Selective Mutism
Social Anxiety Disorder
 
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Marked fear/anxiety in one or more social situations where exposed to possible
scrutiny of others:  social interactions (conversation, meeting new people); being
observed (eating, drinking), performing in front of others (speech)
For children/adolescents MUST occur in peer settings, not just with adults
Fear that will act in way or show anxiety and be negatively evaluated
(embarrassed; rejected by others)
Social situations almost always cause fear/anxiety
Changes to DSM-5
Deleted requirement that adults recognize fear/anxiety as excessive
For all ages, added duration of 6 months or more
Deleted “generalized” specifier and replaced with “performance only” specifier
 
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Median age onset in US is 13 (75% onset is between 8 and 15)
Onset may follow an embarrassing or stressful experience (bullying,
fainting during speech)
Adolescents often have broader pattern of fear and avoidance
(dating)
Associated with elevated rates of school dropout and employment
difficulties
 
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Referred to wellness by RA because of difficulty falling asleep
Reports feeling fatigued, muscle tension, and restless
Difficulty in classroom because can’t concentrate—worrying about
family, fearful won’t be successful getting GED, can’t stop thinking
that will fail at everything, worried won’t fit in, feels incompetent
“always” been a worrier, ”can’t stop” worrying
 
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Separation Anxiety Disorder
Generalized Anxiety Disorder
Specific Phobia
Social Anxiety Disorder
Panic Disorder
 
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Excessive anxiety and worry (“apprehensive expectation”), which occurs more
days than not for at least six months, about a number of events or activities
Difficulty controlling the worrying
Anxiety/worrying associated with 
at least three 
of following six symptoms (
only
one for children/adolescents
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Restlessness
Easily fatigued
Difficulty concentrating/mind going blank
Irritability
Muscle tension
Sleep problems
Causes clinically significant distress or impairment
 
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Median age of onset is 30, but most report “always been” anxious
(rare diagnosis prior to adolescence)
Approximately 2x as many females as males
In adolescents—anxiety often focuses on school performance or
sports, even when not being evaluated by others
 
 
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Referred to wellness because appears withdrawn and sad
Reports having headaches and stomachaches since arriving at Job Corps
five weeks before
Frequently calling home
Constant worry that his mother and brother have been in a car accident or
something bad has happened (but calls home and they’re fine)
Wants to leave Job Corps to make sure family stays safe (mother reports
family is safe, she has no worries about safety)
Reports prior to coming to JC, he refused to sleep or go away from home
due to fear something bad would happen if separated from family
 
 
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Agoraphobia
Panic Disorder
Generalized Anxiety Disorder
Separation Anxiety Disorder
Selective Mutism
 
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Developmentally inappropriate and excessive fear/anxiety about
separation from attachment figures, including at least 3 of following:
Recurrent, excessive distress when anticipating/experiencing separation from
attachment figure
Persistent/excessive worry about experiencing event (illness, accident, kidnapping)
causing separation from attachment figure
Persistent reluctance/refusal to go out, away from home due to fear of separation
Persistent, excessive fear of being alone without attachment figure
Repeated nightmares related to themes of separation
Repeated physical complaints (headache, stomachache, nausea) when separation
form attachment figures is anticipated or occurs
Lasts at least 4 weeks (kids/adolescents); 6 months or more in adults
 
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Previously only diagnosed in childhood with 12 month prevalence in
children 4% (in adolescents-1.6%; adults 0.9%-1.9%) in US
Equal ratio male/female in clinical sample
Most commonly starts in childhood, but can occur in adolescence or
adulthood
Adolescents may worry about separation from dating partners
May develop after life stress (loss, move, trauma)
 
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Develop Chronic Care Management Plan
Education around diagnosis (e.g. fact Sheet for Anxiety—see next slide)
Referral to groups on center (relaxation, mindfulness, peer support, etc)
Support plan with counselors, residential staff, others
Consider short term therapy sessions with CMHC
Consider referral for medication management
Would student benefit from longer term therapy at community clinic?
What else might you do?
 
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Does the student have a 
disability
? If yes,
have DC enter student into disability database
Hold Reasonable Accommodation Committee (RAC) meeting with DC, CMHC,
and student (and other staff as needed) to discuss and document
accommodations
Accommodations are adjustments to policies, practices or procedures.  They are
changes to how things are typically done, which allow an individual with a
disability to perform or participate (they “even the playing field”)—things like
adjusting a schedule to allow a student to attend off center appointments;
special transportation to attend appointment off-center
See JAN for sample accommodations for anxiety disorders (https://ask
jan
.org/)
 
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Brief
 Overview
 
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Cognitive Behavioral Therapy (CBT)
Acceptance and Commitment Therapy (ACT)
Medication
 
 
(This is NOT an exhaustive list of all of the evidence based treatments
for anxiety, but a sampling of a few)
 
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Well-establish, highly effective, time limited therapy
Psychoeducation 
(about anxiety and CBT approach)
Physical/somatic
 management skills training (how to self-monitor anxiety, muscle
relaxation, diaphragmatic breathing, imagery, etc)
Cognitive
 (identify negative thoughts, learn to challenge, identify positive self-talk,
identify realistic expectations)
Exposure
 (gradual imagined and in vivo exposure to feared situations to desensitize)
Social Skills Training/assertiveness
/nonverbal 
skills training (often part of CBT for anxiety
disorders)
CBT can be done individually or group format
 
 
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Evidence based intervention for anxiety (“third wave therapy”)
Goal is to increase ”psychological flexibility” (be able to live fully, in touch with present
moment, and modify behavior based on actual experience and long term values)
Mindfulness skills
Acceptance: willingly experiencing things as they are (e.g. painful feelings)
Cognitive defusion: untangling self from thoughts (step back and see thoughts as thoughts, not
“truth”)
Contact with present-moment: being present in here and now experience
Self-as context: the self that is more than all experiences added together (observing self across
time)
Values clarification and committed action
ACT can be done individually or in groups
 
 
 
 
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Mild anxiety: consider evidence based therapy alone
Moderate to severe anxiety: medications may help relieve acute
anxiety and allow more effective therapy
Severe anxiety: combination of evidence based treatment (such as
CBT, ACT) and medication may be most helpful
 
First line medications for anxiety are typically SSRIs
Anxiety tends to recur once medication stopped without therapy
 
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:
 
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, (5
th
 ed.). Washington,
DC. American Psychiatric Association.
American Psychiatric Association (2013). Highlights of changes from DSM-IV-TR to DSM-5. Arlington, VA: American Psychiatric
Publishing.  Retrieved from http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf from dsm-iv-tr
to dsm-5.pdf. Accessed July 18, 2016
Arch, J., Eifert, G., et al (2012).  Randomized Clinical Trial of Cognitive Behavioral Therapy Versus Acceptance and Commitment
Therapy (ACT) for Mixed Anxiety Disorders.  Journal of Counseling and Clinical Psychology, Voll. 80, No. 5, 750-765.
Hoffman, S., Asnaani, A., et al (2012).  The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-Analyses.  Cognitive
Therapy Research, 36 (5): 427-440.
Roye-Byrne, P., Craske, M., et al (2010).  Delivery of Evidence-Based Treatment for Multiple Anxiety Disorders in Primary Care.
Journal of the American Medical Association, 303 (19): 1921-1928.
Silove, D., Rees, S (2014).  Separation Anxiety Disorder Across the Lifespan: DSM-5 Lifts Age Restriction on Diagnosis.  Asian
Journal of Psychiatry, 11: 98-101.
Starcevic, V (2014). Classification of Anxiety Disorders: Changes, Conundrums and Consequences.  Australian & New Zealand
Journal of Psychiatry, 48 (12): 1164-1165.
 
 
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Helena Mackenzie, PhD, LP, a Mental Health Specialist, delivers a presentation on anxiety disorders in Job Corps, focusing on diagnostic changes, clinical presentations, and evidence-based interventions. The presentation highlights the prevalence of anxiety disorders in Job Corps students and emphasizes the importance of addressing mental health conditions in this population to enhance overall wellness and academic success.


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  1. Supporting Students with Supporting Students with Mental Health Conditions Mental Health Conditions in Job Corps in Job Corps Anxiety Disorders

  2. Presenter Information Presenter Information Helena Mackenzie, PhD, LP Region 5 (Chicago) Mental Health Specialist 2

  3. Learning Objectives Learning Objectives After this presentation, participants will be able to: articulate applicable changes to titles and diagnostic criteria for anxiety disorders based on DSM-5. recognize how clinical presentations for anxiety disorders may vary for adolescents and young adults. identify at least one evidence-based intervention for anxiety disorders, including panic attacks, social anxiety disorder, and generalized anxiety disorder 3

  4. IN 15 IN 15- -18 Job Corps Health and Wellness Report 18 Job Corps Health and Wellness Report Program Year (PY) 2014 Program Year (PY) 2014 Mental health disorders account for 36% of medical separations Anxiety disorders account for 4.1 % of all medical separations Only Mood disorders accounts for more mental health related medical separations (18% of all) Increase from PY 12 which was 3.5 percent for anxiety disorders Average Length of Stay (ALOS) PY 2012, 206 days; PY 2013, 166 days; PY 2014, 151 days Anxiety disorders account for 5.2 percent of all students with disabilities (including all disability categories) 4

  5. 5

  6. Diagnostic and Statistical Manual Diagnostic and Statistical Manual (DSM) 5 Overview (DSM) 5 Overview Anxiety Disorders 6

  7. Anxiety Disorders in DSM 5 Anxiety Disorders in DSM 5 Separation Anxiety Disorder (previously under Disorders Usually First Dx in Infancy, Childhood, Adolescence ) Selective Mutism (previously under Disorders Usually First Dx in Infancy, Childhood, Adolescence ) Specific Phobia Social Anxiety Disorder Panic Disorder Agoraphobia Generalized Anxiety Disorder Substance/Medication-Induced Anxiety Disorder Anxiety Disorder Due to Another Medical Condition Other Specified Anxiety Disorder; Unspecified Anxiety Disorder 7

  8. DSM DSM- -5 Changes in Classification 5 Changes in Classification Obsessive Compulsive Disorder (no longer included with anxiety disorders, but with Obsessive-Compulsive and Related Disorders) Posttraumatic Stress Disorder (no longer included with anxiety disorders, but with Trauma- and Stressor-Related Disorders) Sequential order of anxiety disorder chapter and these other two chapters in DSM-5 reflects the close relationships between these disorders 8

  9. Key Features of Anxiety Disorders Key Features of Anxiety Disorders All share features of excessive fear/anxiety that impact behavior: Fear: emotional response to real or perceived imminent threat. Example: Hear a loud sound while walking alone at night Associated with autonomic nervous system arousal (fight/flight/freeze/faint); thoughts of immediate danger; escape behaviors Anxiety: anticipation of future threats Example: Interviewing for job or giving a presentation in a week Associated with muscle tension, vigilance in preparation for future danger, rumination, and cautious and avoidant behaviors 9

  10. Features of Anxiety Disorders Features of Anxiety Disorders Differ from developmentally normative fear/anxiety: Excessive or persist beyond developmentally appropriate periods Clinician, taking culturally factors into account, determines if fear is excessive (out of proportion to situation) Differ from transient fear or anxiety (stress induced): Persistent last typically 6 months or more, although time criterion is general guide Often develop in childhood and tend to continue if untreated Most occur more frequently in females than males (approx 2:1) 10

  11. Differentiating Between Anxiety Disorders: Differentiating Between Anxiety Disorders: Highly co Highly co- -morbid (often meet criteria for more than one) morbid (often meet criteria for more than one) Differ from each other based on what the fear, anxiety, or avoidance behavior is about and the associated thoughts/beliefs interactions that involve possibility of being scrutinized (fear of negative evaluation, embarrassed, rejected) Separation Anxiety: fearful/anxious about separating from attachment figure Panic Disorder: recurrent panic attacks, concern of having more panic attacks and/or avoiding situations or changing behavior in maladaptive ways to avoid panic attacks Selective Mutism: consistently not speaking in social situations (like school) when able to speak in other situations (home, with friends); highly co- morbid with social anxiety disorder. Agoraphobia: fearful/anxious about specific situations due to thoughts that escape is difficult/help not available if have panic attack. Leads to avoidance of situations. Specific Phobia: fearful, anxious or avoidant of a specific object or situation (spiders, heights, needles) Generalized Anxiety Disorder: persistent/excessive worry and anxiety in different areas (work/home/school), find it hard to control worry, have specific physical symptoms. Social Anxiety: fearful or anxious about social 11

  12. Case Study: Jacky Case Study: Jacky Referred by instructor because withdrawn and anxious; frequently leaves classroom suddenly looking like deer in headlights; becomes agitated if instructor tries to stop her Frequently coming to wellness complaining of racing heart, chest pain, feeling dizzy, and shaking. Medical work up is normal. Refusing to go to cafeteria because had symptoms before while eating lunch and scared they ll return. Also refusing to go to recreation because had episode while exercising Tells CMHC symptoms started a few months ago, come on quickly and then pass, but terrified will return and wants to leave JC because feeling overwhelmed 12

  13. Poll: Most Likely Diagnosis? Poll: Most Likely Diagnosis? Separation Anxiety Disorder Generalized Anxiety Disorder Panic Disorder Specific Phobia Selective Mutism 13

  14. Panic Disorder Panic Disorder 1)Recurrent, unexpected panic attacks abrupt surge of intense fear, discomfort that reaches peak within minutes. 4 or more symptoms: pounding heart, sweating, trembling, shortness of breath, choking sensation, chest pain, nausea, dizziness/lightheaded, derealization (feeling of unreality) or depersonalization (detached from oneself), fear of losing control/going crazy/dying. 2) At least one attack followed by month or more of either: persistent worry about another attack; and/or significant change in behavior (avoiding exercise or unfamiliar situations, etc) 14

  15. Panic Disorder Panic Disorder Median age onset 20-24 years old; clinical presentation in adolescents same as adults Frequent school, work absences, and trips to ED, which can lead to dropping out school, losing jobs. Associated with agoraphobia, depression, social phobia, bipolar, alcohol use disorder Changes to DSM-5: deleted different types of panic attacks (situationally bound/cued, situationally predisposed, unexpected/uncued has been replaced with unexpected and expected ) Agoraphobia separated (see next slide) Panic attacks (not disorder) can occur as part of other conditions (PTSD, depressive disorder, alcohol use disorders). Can use a Panic Attack specifier, meaning panic occurs but doesn t meet panic disorder criteria and is part of another disorder. 15

  16. Agoraphobia Agoraphobia Marked fear or anxiety about two (or more) situations public transit; open spaces; enclosed places; being in crowd; being outside home alone Fear and avoidance due to thoughts that escape difficult/help unavailable if panic or other embarrassing symptoms occur Situations almost always cause fear/anxiety and are actively avoided or require company of companion; cause clinically significant distress or impairment in social, occupational, other functioning Changes in DSM-5 Panic Disorder and Agoraphobia are unlinked two separate diagnoses, with distinct criteria Fear, anxiety, avoidance is persistent (six months or longer) Fear, anxiety is out of proportion to actual danger posed (judged by clinician) CAN diagnose agoraphobia in absence of panic disorder 16

  17. Case Study: Juan Case Study: Juan Hasn t connected with peers, won t make eye contact Withdrawn and appears uncomfortable around adults and peers Having difficulty in classroom because refuses to participate in class and appears embarrassed and shuts down if called on Told counselor thinks people are judging him and is anxious about doing something embarrassing and not fitting in Feels nauseous, hands shakes, blushes, and has butterflies when knows he has to interact with people Struggled with same symptoms in high school so dropped out 17

  18. Poll: Most Likely Diagnosis? Poll: Most Likely Diagnosis? Separation Anxiety Disorder Generalized Anxiety Disorder Specific Phobia Selective Mutism Social Anxiety Disorder 18

  19. Social Anxiety Disorder Social Anxiety Disorder Marked fear/anxiety in one or more social situations where exposed to possible scrutiny of others: social interactions (conversation, meeting new people); being observed (eating, drinking), performing in front of others (speech) For children/adolescents MUST occur in peer settings, not just with adults Fear that will act in way or show anxiety and be negatively evaluated (embarrassed; rejected by others) Social situations almost always cause fear/anxiety Changes to DSM-5 Deleted requirement that adults recognize fear/anxiety as excessive For all ages, added duration of 6 months or more Deleted generalized specifier and replaced with performance only specifier 19

  20. Social Anxiety Disorder Social Anxiety Disorder Median age onset in US is 13 (75% onset is between 8 and 15) Onset may follow an embarrassing or stressful experience (bullying, fainting during speech) Adolescents often have broader pattern of fear and avoidance (dating) Associated with elevated rates of school dropout and employment difficulties 20

  21. Case Study: Nicole Case Study: Nicole Referred to wellness by RA because of difficulty falling asleep Reports feeling fatigued, muscle tension, and restless Difficulty in classroom because can t concentrate worrying about family, fearful won t be successful getting GED, can t stop thinking that will fail at everything, worried won t fit in, feels incompetent always been a worrier, can t stop worrying 21

  22. Poll: Most Likely Diagnosis? Poll: Most Likely Diagnosis? Separation Anxiety Disorder Generalized Anxiety Disorder Specific Phobia Social Anxiety Disorder Panic Disorder 22

  23. Generalized Anxiety Disorder (GAD) Generalized Anxiety Disorder (GAD) Excessive anxiety and worry ( apprehensive expectation ), which occurs more days than not for at least six months, about a number of events or activities Difficulty controlling the worrying Anxiety/worrying associated with at least three of following six symptoms (only one for children/adolescents): Restlessness Easily fatigued Difficulty concentrating/mind going blank Irritability Muscle tension Sleep problems Causes clinically significant distress or impairment 23

  24. Generalized Anxiety Disorder (GAD) Generalized Anxiety Disorder (GAD) Median age of onset is 30, but most report always been anxious (rare diagnosis prior to adolescence) Approximately 2x as many females as males In adolescents anxiety often focuses on school performance or sports, even when not being evaluated by others 24

  25. Case Study: Fernando Case Study: Fernando Referred to wellness because appears withdrawn and sad Reports having headaches and stomachaches since arriving at Job Corps five weeks before Frequently calling home Constant worry that his mother and brother have been in a car accident or something bad has happened (but calls home and they re fine) Wants to leave Job Corps to make sure family stays safe (mother reports family is safe, she has no worries about safety) Reports prior to coming to JC, he refused to sleep or go away from home due to fear something bad would happen if separated from family 25

  26. Poll: Most Likely Diagnosis? Poll: Most Likely Diagnosis? Agoraphobia Panic Disorder Generalized Anxiety Disorder Separation Anxiety Disorder Selective Mutism 26

  27. Separation Anxiety Disorder Separation Anxiety Disorder Developmentally inappropriate and excessive fear/anxiety about separation from attachment figures, including at least 3 of following: Recurrent, excessive distress when anticipating/experiencing separation from attachment figure Persistent/excessive worry about experiencing event (illness, accident, kidnapping) causing separation from attachment figure Persistent reluctance/refusal to go out, away from home due to fear of separation Persistent, excessive fear of being alone without attachment figure Repeated nightmares related to themes of separation Repeated physical complaints (headache, stomachache, nausea) when separation form attachment figures is anticipated or occurs Lasts at least 4 weeks (kids/adolescents); 6 months or more in adults 27

  28. Separation Anxiety Disorder Separation Anxiety Disorder Previously only diagnosed in childhood with 12 month prevalence in children 4% (in adolescents-1.6%; adults 0.9%-1.9%) in US Equal ratio male/female in clinical sample Most commonly starts in childhood, but can occur in adolescence or adulthood Adolescents may worry about separation from dating partners May develop after life stress (loss, move, trauma) 28

  29. Supporting Students With Anxiety Disorders in JC Supporting Students With Anxiety Disorders in JC Develop Chronic Care Management Plan Education around diagnosis (e.g. fact Sheet for Anxiety see next slide) Referral to groups on center (relaxation, mindfulness, peer support, etc) Support plan with counselors, residential staff, others Consider short term therapy sessions with CMHC Consider referral for medication management Would student benefit from longer term therapy at community clinic? What else might you do? 29

  30. 30

  31. Supporting Students with Anxiety Disorders in JC Supporting Students with Anxiety Disorders in JC Does the student have a disability? If yes, have DC enter student into disability database Hold Reasonable Accommodation Committee (RAC) meeting with DC, CMHC, and student (and other staff as needed) to discuss and document accommodations Accommodations are adjustments to policies, practices or procedures. They are changes to how things are typically done, which allow an individual with a disability to perform or participate (they even the playing field ) things like adjusting a schedule to allow a student to attend off center appointments; special transportation to attend appointment off-center See JAN for sample accommodations for anxiety disorders (https://askjan.org/) 31

  32. Evidence Based Interventions for Evidence Based Interventions for Anxiety Disorders Anxiety Disorders Brief Overview 32

  33. Evidence Evidence- -Based Options for Anxiety Based Options for Anxiety Cognitive Behavioral Therapy (CBT) Acceptance and Commitment Therapy (ACT) Medication (This is NOT an exhaustive list of all of the evidence based treatments for anxiety, but a sampling of a few) 33

  34. Cognitive Behavioral Therapy (CBT) Cognitive Behavioral Therapy (CBT) Well-establish, highly effective, time limited therapy Psychoeducation (about anxiety and CBT approach) Physical/somatic management skills training (how to self-monitor anxiety, muscle relaxation, diaphragmatic breathing, imagery, etc) Cognitive (identify negative thoughts, learn to challenge, identify positive self-talk, identify realistic expectations) Exposure (gradual imagined and in vivo exposure to feared situations to desensitize) Social Skills Training/assertiveness/nonverbal skills training (often part of CBT for anxiety disorders) CBT can be done individually or group format 34

  35. Acceptance and Commitment Therapy (ACT) Acceptance and Commitment Therapy (ACT) Evidence based intervention for anxiety ( third wave therapy ) Goal is to increase psychological flexibility (be able to live fully, in touch with present moment, and modify behavior based on actual experience and long term values) Mindfulness skills Acceptance: willingly experiencing things as they are (e.g. painful feelings) Cognitive defusion: untangling self from thoughts (step back and see thoughts as thoughts, not truth ) Contact with present-moment: being present in here and now experience Self-as context: the self that is more than all experiences added together (observing self across time) Values clarification and committed action ACT can be done individually or in groups 35

  36. Medication for Anxiety? Medication for Anxiety? Mild anxiety: consider evidence based therapy alone Moderate to severe anxiety: medications may help relieve acute anxiety and allow more effective therapy Severe anxiety: combination of evidence based treatment (such as CBT, ACT) and medication may be most helpful First line medications for anxiety are typically SSRIs Anxiety tends to recur once medication stopped without therapy 36

  37. Main References: Main References: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, (5th ed.). Washington, DC. American Psychiatric Association. American Psychiatric Association (2013). Highlights of changes from DSM-IV-TR to DSM-5. Arlington, VA: American Psychiatric Publishing. Retrieved from http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf from dsm-iv-tr to dsm-5.pdf. Accessed July 18, 2016 Arch, J., Eifert, G., et al (2012). Randomized Clinical Trial of Cognitive Behavioral Therapy Versus Acceptance and Commitment Therapy (ACT) for Mixed Anxiety Disorders. Journal of Counseling and Clinical Psychology, Voll. 80, No. 5, 750-765. Hoffman, S., Asnaani, A., et al (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-Analyses. Cognitive Therapy Research, 36 (5): 427-440. Roye-Byrne, P., Craske, M., et al (2010). Delivery of Evidence-Based Treatment for Multiple Anxiety Disorders in Primary Care. Journal of the American Medical Association, 303 (19): 1921-1928. Silove, D., Rees, S (2014). Separation Anxiety Disorder Across the Lifespan: DSM-5 Lifts Age Restriction on Diagnosis. Asian Journal of Psychiatry, 11: 98-101. Starcevic, V (2014). Classification of Anxiety Disorders: Changes, Conundrums and Consequences. Australian & New Zealand Journal of Psychiatry, 48 (12): 1164-1165. 37

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