Anxiety Disorders: Types, Features, Diagnostic Criteria, and Treatment, Exams of History

Download Anxiety Disorders: Types, Features, Diagnostic Criteria, and Treatment and more Exams History in PDF only on Docsity! Manual of Basic Psychiatry 2012-2013 Draft-2 M. Al-Sughayir Anxiety Disorders 601 • Definitions & Types • 1-Panic Disorder. • 2-Agoraphobia. • 3-Social Phobia. • 4-Specific Phobia. • 5-Generalized Anxiety Disorder (GAD). • 6-Obsessive Compulsive Disorder (OCD). • 7-Acute & Post- Traumatic Stress Disorder. Anxiety Disorders + Adjustment Disorders Grief & Dying Patient Psychological Treatment Dependent Personality D. Avoidant Personality D. Obsessive Compulsive Personality D. Anti-anxiety Medications Manual of Basic Psychiatry 2012-2013 Draft-2 M. Al-Sughayir Anxiety Disorders 601 Definitions of Relevant Symptoms: 1. Anxiety: subjective feeling of worry, fear, and apprehension accompanied by autonomic symptoms (such as palpitation, sweating, and muscles), caused by anticipation of threat/danger. Free-floating anxiety: diffuse, unfocused anxiety, not attached to a specific danger. 2. Fear: anxiety caused by realistic consciously recognized danger. 3. Panic: acute, self-limiting, episodic intense attack of anxiety associated with overwhelming dread and autonomic symptoms. 4. Phobia: irrational exaggerated fear and avoidance of a specific object, situation or activity. State vs. Trait Anxiety: Features of Anxiety: Psychological Physical Excessive worries & fearful anticipation. Feeling of restlessness/irritability. Hypervigilance. Difficulty concentrating. Subjective report of memory deficit. Sensitivity to noise. Sleep: insomnia / bad dreams. Chest: chest discomfort & difficulty in inhalation. Cardiovascular: palpitation &cold extremities. Neurological : tremor, headache, dizziness, tinnitus, numbness & blurred vision. Gastrointestinal: disturbed appetite, dysphagia, nausea, vomiting, epigastric discomfort & disturbed bowel habits. Genitourinary: increased urine frequency and urgency, low libido, erectile dysfunction, impotence & dysmenorrhea. Musculoskeletal: muscle tension, joint pain, easily fatigued. Skin: sweating, itching, hot & cold skin. Trait anxiety (longitudinal view):part of personality character in which a person has a habitual tendency to be anxious in a wide range of different circumstances. State anxiety (cross – sectional view): anxiety is experienced as a response to external stimuli. Manual of Basic Psychiatry 2012-2013 Draft-2 M. Al-Sughayir Anxiety Disorders 660 However, the term may be misleading. Fear in agoraphobic patients is about being alone in crowded places from which escape seems difficult or help may not be available in case of sudden incapacitation (places cannot be left suddenly without attracting attention e.g. a place in the middle of a row in a mosque). Fear is usually revolving around self-safety issues (fainting/losing control of behavior e.g. screaming, vomiting, or defecating ) rather than personal performance in the presence of others (which is the case in social phobia). Diagnostic Criteria: - Anxiety about being in places or situations from which escape might be difficult, or in which help would not be readily available in the event of a panic attack (shopping malls, social gathering, tunnels, and public transport). -The situations are either avoided, endured with severe distress, or faced only with the presence of a companion. - Symptoms cannot be better explained by another mental disorder. - Functional impairment. Associated conditions:  Panic disorder (in > 60 % of cases.  Social phobia (in around 55% of cases)  Depressive symptoms (> 30 % of cases).  As the condition progresses, patients with agoraphobia may become increasingly dependent on some of their relatives or spouse for help with activities that provoke anxiety such as shopping.  Housebound housewife syndrome may develop. It is a severe stage of agoraphobia when the patient cannot leave the house at all. Etiology: Epidemiology: Women: men = 2:1. Onset: most cases begin in the early or middle twenties, though there is a further period of high onset in the middle thirties. Both of these ages are later than the average onset of specific phobia (childhood) and social phobias (late teenagers or early twenties). One-year prevalence: men; about 2 %, women: about 4 %. Lifetime prevalence: 6 – 10 %. Mrs. Amal is a 36-year-old woman seen at outpatient clinic because of several weeks' history of excessive fear of fainting when patient is in crowds or in situations that she cannot leave easily. Agoraphobia Literally, it means fear and avoidance of market places and open spaces. "Agora"= the open market for farmers in Tadmur (old Syria). Predisposing Factors: -Separation anxiety in childhood. -Parental overprotection. -Dependent personality traits. -Defective normal inhibitory mechanisms. Precipitating Factors: - A Panic attack in a public place where escape was difficult. - Conditioning (public places trigger fear of having subsequent attacks). -Often precipitated by major life events. Maintaining Factors: -Avoidance reduces fear & ensures self-safety. Manual of Basic Psychiatry 2012-2013 Draft-2 M. Al-Sughayir Anxiety Disorders 666 Treatment:  Cognitive-Behavior Therapy (CBT):  Detailed inquiry about the situations that provoke anxiety, associated thoughts, and how much these situations are avoided.        Medications: as for panic disorder (SSRIs +/- anxiolytics as per need). Prognosis: ##### ###### ############### ##### ##### Good prognostic factors: 1- Younger age. 2- Presence of panic attacks. 3- Early treatment. Bad prognostic factors: 1- Age > 30 years. 2- Absence of panic attacks. 3- Late treatment. It can be chronic disabling disorder complicated by depressive symptoms. Dependent Personality Disorder Diagnostic criteria: a pervasive dependence, clinging behavior, and fears of separation indicated by ≥ 5 of: 1. Difficulty making personal decisions without excessive amount of advice and reassurance from others 2. Needs others to assume responsibilities for most areas of his/ her life. 3. Difficulty expressing disagreement because of fear of loss of support and approval (unassertive). 4. Difficulty doing things on his/her own or initiating projects because of lack of self-confidence. 5. Goes to excessive lengths to obtain support from others (doing unpleasant things). 6. Feels uncomfortable or helpless when alone. 7. Urgently seeks another relationship as a source of support when one ends. 8. Preoccupied with fears of being left to take care of self. Defense mechanisms Epidemiology: Prevalence=1%. Women > men. Persons with chronic physical illness in childhood may be most susceptible to the disorder. DDx: 1.Avoidant Personality D. 2.Agoraphobia (may coexist). Treatment: 1.Insight-oriented therapies & behavior therapy enable patients to become more independent, assertive, and self-reliant. 2.Medications; to deal with specific symptoms, such as anxiety and depression, which are common associated features. Behavioral Component:  Detailed inquiry about the situations that provoke anxiety, associated thoughts, and how much these situations are avoided.  Hierarchy is drawn up (from the least – to the most anxiety provoking).  The patient is then taught to relax (relaxation training).  Exposure: the patient is persuaded to enter the feared situation (to confront situations that he generally avoids).  The patient should cope with anxiety experienced during exposure and try to stay in the situation until anxiety has declined.  When one stage is accomplished the patient moves to the next stage.  The patient is trained to overcome avoidance (as escape during exposure will reinforce the phobic behavior). Cognitive Component: Detection and correction of wrong thoughts & illogical ways of reasoning (cognitive distortions) about the origin, meaning, a d consequence of symptoms. E.g. of cognitive distortions: magnification of events out of proportion to their actual significance. Defense Mechanisms: 1-Idealization of others (protective…). 2-Regression. 3-Projective Identification. Manual of Basic Psychiatry 2012-2013 Draft-2 M. Al-Sughayir Anxiety Disorders 661 Social Phobia (also called social anxiety disorder) Mr. Jamal is a 28-year-old man presented with 3-year history of disabling distress when talking to important people. He would feel anxious, and his voice would become so disturbed that he had difficulty speaking. Marked irrational performance anxiety when a person is exposed to a possible scrutiny by others particularly unfamiliar people or authority figures leading to a desire for escape or avoidance associated with a negative belief of being socially inadequate. The problem leads to significant interference with functioning (social, occupational, academic…). The person has anticipatory anxiety. The response may take a form of panic attack (situationally bound or situationally predisposed). Common complaints: palpitation, trembling, sweating, and blushing. Examples: speaking in public (meetings, parties, lectures) - serving coffee or tea to guests- leading prayers. Social phobia can be either: a-specific to certain situations (e.g. speaking to authority) or b-generalized social anxiety. Epidemiology: Age: late teenage or early twenties. It may occur in children. Lifetime prevalence: 3 – 13 %. In the general population, most individuals fear public speaking and less than half fear speaking to strangers or meeting new people. Only 8 – 10 % is seen by psychiatrists. Local studies in Saudi Arabia suggested that social phobia is a notably common disorder among Saudis, (composes 80 % of phobic disorders). Social and cultural differences have some effect on social phobia in terms of age at treatment, duration of illness and some social situations. Associated Features: Hypersensitivity to criticism and negative evaluation or rejection (avoidant personality traits). Other phobias. Complications: Secondary depression. Alcohol or stimulant abuse to relieve anxiety and enhance performance. Deterioration in functioning (underachievement in school, at work, and in social life e.g. delayed marriage). Etiology: Genetic factors: some twins' studies found genetic basis for social phobia. Social factors: excessive demands for social conformity and concerns about impression a person is making on others, (high cultural superego increases shame feeling), some Arab cultures are judgmental and impressionistic. Behavioral factors: sudden episode of anxiety in a social situation followed by avoidance, reinforces phobic behavior. Cognitive factors: exaggerated fear of negative evaluation based on thinking that other people will be critical, and one should be ideal person. A. Psychological: 1. Cognitive-Behavior Therapy -CBT-(the treatment of choice for social phobia). Exposure to feared situations is combined with anxiety management (relaxation training with cognitive techniques designed to reduce the effects of anxiety-provoking thoughts). 2. Social Skill Training: e.g. how to initiate, maintain and end conversation. 3. Assertiveness Training: how to express feelings and thoughts directly and appropriately. B. Medications: 1. Antidepressants (one of the following):SSRIs (e.g. fluoxetine 20mg) or SNRIs( e.g. Venlafaxine 150mg). 2. Beta-blockers (e.g.propranolol 20- 40 mg),as they are non-sedative, they are useful in specific social phobia e.g. test anxiety to reduce palpitation and tremor. Beware of bronchial asthma. 3. Benzodiazepines (e.g. alprazolam 1mg): small divided doses for short time (to avoid the risk of dependence). Treatment Prognosis: If not treated, social phobia often lasts for several years and the episodes gradually become more severe with increasing avoidance. When treated properly the prognosis is usually good. Presence of avoidant personality disorder may delay the improvement. Differential Diagnosis: Other phobias. However, multiple phobias can occur together. Generalized anxiety disorder. Panic disorder. Depressive disorder primary or secondary to social phobia. Patients with persecutory delusions avoid certain social situations. Avoidant personality disorder may coexist with social phobia. Features: Manual of Basic Psychiatry 2012-2013 Draft-2 M. Al-Sughayir Anxiety Disorders 661 DDx: OCD should be differentiated from other mental disorders in which some obsessional symptoms may occur, like: Depressive disorders. Anxiety, panic and phobia disorders. Hypochondriasis. Schizophrenia: some schizophrenic patients have obsessional thoughts, these are usually odd with peculiar content (e.g. sexual or blasphemous). The degree of resistance is doubtful. Organic disorders: some organic mental disorders are associated with obsessions e.g. encephalitis, head injury, epilepsy, dementia. Obsessive Compulsive Personality Disorder (OCPD). Associated features / complications: Anxiety is an important component of OCD. Compulsions are done to reduce anxiety. Thus, reinforces obsessive compulsive behavior. Severe guilt due to a pathological sense of self- blaming and total responsibility to such absurd thoughts especially in blasphemous, aggressive and sexual obsessions. Avoidance of situations that involve the content of the obsessions, such as dirt or contamination. Depressive features either as precipitating factor (ie primary), secondary to, or simultaneously arising with OCD. . Obsessive Compulsive Disorder (OCD). Epidemiology: M=F. Mean age at onset = 20 – 25 years. Mean age of seeking psychiatric help = 27 years. Lifetime prevalence in the general population is 2 -3 % across cultural boundaries. About 10 % of outpatients in psychiatric clinics Search for a depressive disorder and treat it, as effective treatment of a depressive disorder often leads to improvement in the obsessional symptoms. Reduce the guilt through explaining the nature of the illness and the exaggerated sense of responsibility. Medications; 1. Antidepressants with an antiobsessional effect ;enhancing 5HT activity. a. Clomipramine: required doses may reach 200 mg / day. b. SSRIs (e.g. paroxetine 40-60mg). Treatment of OCD often requires high doses of SSRIs. 2. Anxiolytics (e.g. lorazepam 1mg) to relief anxiety. Behavior therapy; for prominent compulsions but less effective for obsessional thoughts. Exposure and response prevention. Thought distraction / thought stopping. Behavior therapy may be done at outpatient clinics, day centers or as in – patient. It is important to interview relatives and encourage them to adopt an empathetic and firm attitude to the patient. A family co-therapist plays an important role. In-patient behavior therapy can appreciably be helpful for resistant cases and can reduce patient’s disability, family burden and major demands on health care resources that are incurred by severe chronic OCD patients. Ms. Maha is a 20-year-old college student seen at outpatient clinic complaining of recurrent intrusive thoughts about incomplete ablution, bathing, and prayers. She spends 3- 4 hours/day repeating prayers to feel fully satisfied and relaxed. She realizes that her thoughts are silly but she cannot resist them. Still you are not pure. Etiology: 1. Genetic Factors. 2. Neurobiological hypothesis: serotonin dysregulation. 3. Psychodynamic Theories: unconscious urges of aggressive or sexual nature reduced by the action of the defense mechanisms of repression, isolation, undoing, and reaction formation. 4.Behavioral Theory: Excessive obsessions when followed by compulsions or avoidance are reinforced ,maintained and perpetuated. Recurrent obsessions or compulsions that are severe enough to be time consuming (> 1 hour a day) or causes marked distress or significant impairment. The person recognizes that the obsessions or compulsions are excessive and unreasonable. The disturbance is not due to the direct effect of a medical condition, substance or another mental disorder. Diagnostic Criteria Obsessional forms Obsessional Contents (themes) Thoughts. Images. Urges. Feelings. Dirt/Contamination. Religious acts/beliefs. Doubts/Checking. As if committing offences. Course and Prognosis: In most cases onset is gradual but acute cases have been noted. The majority has a chronic waxing and waning course with exacerbations related to stressful events. Severe cases may become persistent and drug resistant. Depression is a recognized complication. Prognosis of OCD is worse when the patient has OCPD. Good prognosis: presence of mood component (depression/anxiety), compliance with treatment, and family support. Management Manual of Basic Psychiatry 2012-2013 Draft-2 M. Al-Sughayir Anxiety Disorders 661 DDx: 1-Obsessive-compulsive disorder (OCD): although OCPD and OCD have similar names, the clinical manifestations of these disorders are quite different; OCPD is not characterized by the presence of obsessions or compulsions and instead involves pervasive pattern of preoccupation with orderliness, perfectionism, and control and must begin by early adulthood. The most difficult distinction is between some obsessive- compulsive traits and OCPD. The diagnosis of personality disorder is reserved for those with significant functioning impairments. Comorbidity is common. If an individual manifests symptoms of both OCPD and OCD, both can be given. Axis I; OCD. AxisII; OCPD. 2-Narcissistic personality disorder patient seeks perfectionism motivated by status and more likely to believe that he has achieved it, whereas OCPD patient is motivated by the work itself and more likely to believe that he has not achieved perfectionism. Treatment: Psychological: supportive and directive individual or group therapy. Pharmacological: clomipramine or any SSRI have been found useful. Mr. Kamal is a 33-year-old married employee sought treatment at his wife's insistence. She could no longer tolerate his rigidity, scrupulousness about matters of health, excessive perfectionism, and excessive devotion to productivity to the exclusion of leisure activities. Defense Mechanisms: 1. Isolation of affect. 2. Displacement. 3. Reaction Formation. 4. Undoing. Obsessive Compulsive Personality Disorder (OCPD) A pervasive pattern of preoccupation with orderliness, perfectionism, and interpersonal control, at the expense of flexibility, openness, and efficiency, as indicated by ≥ 4 of 8: 1. excessive preoccupation with details, organization, or rules to the extent that the major point of the activity is lost. 2. excessive perfectionism that interferes with task completion. 3. excessive devotion to work and productivity to the exclusion of leisure activities and friendships. 4. inflexibility and scrupulousness about matters of morality, health, ethics, or values. 5. inability to discard worthless or worn-out objects even when they have no sentimental value 6. reluctance to delegate tasks or to work with others unless they submit to exactly his/her way of doing things. 7. adoption of a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. 8. rigidity and stubbornness. Epidemiology: the prevalence in the general population is 1 %. Men > women (2:1). OCPD is found more frequently within professions requiring strict dedication to duty and meticulous attention to details. Course & Prognosis: OCPD patients may flourish in professions demanding devotion to work, meticulous attention to details, and productivity, but they are vulnerable to depressive disorders & OCD. Manual of Basic Psychiatry 2012-2013 Draft-2 M. Al-Sughayir Anxiety Disorders 661 Etiology: Etiology: Recent research work places great emphasis on a person’s subjective response to trauma than the severity of the stressor itself, which was considered the prime causative factor. The traumatic event provokes a massive amount of information and emotions, which is not processed easily by the brain (There are alternating periods of acknowledging the event and blocking it, creating distress). Treatment: Psychological (the major approach): Support – reassurance – explanation – education. Encourage discussing stressful events and overcome patient’s denial. In vivo (imaginary) exposure with relaxation and cognitive techniques. Eye movement desensitization and reprocessing (EMDR): while maintaining a mental image of the trauma the patient focuses on, and follow the rapid lateral movement of the therapist's finger so that the traumatic mental experience is distorted and the associated intense emotions are eliminated. Group therapy (for group of people who were involved in a disaster e.g. flooding, fire). Pharmacological: Symptomatic treatment; anxiolytics (e.g. alprazolam) and serotonin-selective reuptake inhibitors (e.g. sertraline) or tricyclics (e.g. imipramine). Post-traumatic Stress Disorder (PTSD) & Acute Stress Disorder (ASD) Diagnostic Criteria: A-Exposure to a traumatic threatening event (experienced, or witnessed) & response with horror or intense fear. B-Persistent re-experience of the event (e.g. flashback, recollections, or distressing dreams. C-Persistent avoidance of reminder (activities, places, or people). D- Increased arousal (e.g. hypervigilance, irritability). E- ≥ 1 month duration of the disturbance. F- Significant distress or functional impairment. Mr. Fahad is a 25-year-old man was injured in a serious road traffic accident 3 months ago in which he witnessed his friend dying. Two weeks later he developed recurrent distressing feelings of horror, bad dreams, and irritability. DDx. 1. Acute stress disorder: similar features to PTSD but a-onset is within 1 month after exposure to a stressor (If symptoms appeared after one month consider post-traumatic stress disorder(PTSD). b- duration: a minimum of 2 days and a maximum of 4 weeks(If symptoms continued more than one month consider PTSD). Treatment: same as for PTSD. 2. Other anxiety disorders( GAD, Panic d., & phobias). 3. Adjustment disorders (stressor is not life-threatening, no dissociative features, mental flash backs or horror). 4. Head injury sequence (if the traumatic event has included injury to the head, e.g. road accident). Neurological examination should be carried out to exclude a subdural hematoma or other forms of cerebral injury. 5. Substance abuse (intoxication or withdrawal). Life-threatening traumas: major road accidents, fire, physical attack, sexual assault, mugging, robbery, war, flooding, earthquake. Prognosis is good if:1-the person is cooperative with treatment and has healthy premorbid function, 2- the trauma was not severe or prolonged, & 3- early intervention and social support exist Epidemiology: the lifetime incidence is 10-15% & the lifetime prevalence is about 8 % of the general population. PTSD can appear at any age but young > old & females > males. Manual of Basic Psychiatry 2012-2013 Draft-2 M. Al-Sughayir Anxiety Disorders 610 They act on specific receptor sites (benzodiazepine receptors) linked with gamma aminobutyric acid (GABA) receptors in the C.N.S. They enhance GABA action which has an inhibitory effect.  They have several actions:  Sedative & hypnotic action.  Anxiolytic action.  Anticonvulsant action.  Muscle relaxant action.  They differ in potency and half-life: - Relatively short acting e.g. alprazolam (xanax), lorazepam (ativan) & Long acting (more than 24 hours) e.g. diazepam (valium) and clonazepam (rivotril). - .  Side effects:  Dizziness and drowsiness (patient should be warned about these side effects which may impair functions e.g. operation of dangerous machinery, driving).  Release of aggression due to reducing inhibition.  Dependence and withdrawal: - If given for several weeks. - Short acting drugs have more risk of dependence.  Withdrawal Syndrome: - It generally begins 2 – 3 days after cessation of short acting, and 7 days after cessation of long acting benzodiazepines and then diminishes in another 3 – 10 days. - Features:  Anxiety, irritability, apprehension  Nausea  Tremor and muscle twitching  Heightened sensitivity to stimuli  Headache  Sweating  palpitation  Muscle pain  Withdrawal fit may occur when the dose of benzodiazepine taken has been high.  Withdrawal is treated with a long acting benzodiazepine (e.g. diazepam) in equivalent doses before withdrawal then the dose is reduced gradually by about 10 – 20 % every 10 days. Benzodiazepines It has anxiolytic activity comparable to that of benzodiazepines. However, it is pharmacologically unrelated to benzodiazepines. It stimulates 5HT – 1A receptors and reduces 5 HT (serotonin) transmission. It’s onset of action is gradual (several days – weeks) therefore, it is not effective on PRN basis. It does not cause functional impairment, sedation nor interaction with CNS depressants. It does not appear to lead to dependence. Adverse effects:  Headache.  Irritability.  Nervousness.  Light-headedness.  Nausea. Buspirone (Buspar) Beta Blockers (e.g. propranolol; inderal) are frequently used to control tremor and palpitation in performance anxiety (social phobia) 10 to 40 mg of propranolol 30-60 minutes before the anxiety-provoking situation). Other uses in psychiatry: 1- other anxiety disorders (e.g. GAD). 2- neuroleptic-induced akathisia 3- lithium-induced postural tremor. 4- control of aggressive behavior. Caution in patients with asthma, insulin- dependent diabetes, & cardiac diseases(CCF, IHD ). Adrenergic Receptor Antagonists Anti-anxiety Medications (Anxiolytics) Manual of Basic Psychiatry 2012-2013 Draft-2 M. Al-Sughayir Anxiety Disorders 616 Cognitive Error Assumption Intervention Overgeneralizing If it's true in one case, it applies to any case that is even slightly similar. Exposure of faulty logic. Establish criteria of which cases are similar to what degree. Selective abstraction The only events that matter are failures, deprivation, etc. Should measure self by errors, weaknesses, etc. Use log to identify successes patient forgot. Excessive responsibility (assuming personal causality) I am responsible for all bad things, failures, etc. Disattribution technique. Assuming temporal causality (predicting without sufficient evidence) If it has been true in the past, it's always going to be true. Expose faulty logic. Specify factors that could influence outcome other than past events. Self-references I am the center of everyone's attention especially my bad performances. I am the cause of misfortunes. Establish criteria to determine when patient is the focus of attention and also the probable facts that cause bad experiences. Catastrophizing Always think of the worst. It's almost likely to happen to you. Calculate real probabilities. Focus on evidence that the worst did not happen. Dichotomous thinking Everything is either one extreme or another (black or white, good or bad). Demonstrate that events may be evaluated on a continuum. Adapted from Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive Therapy of Depression. New York: Guilford Press. Definition: a group of non-pharmacological psychotherapeutic techniques employed by a therapist to ameliorate distress, abnormal patterns of relations or symptoms (phobias, obsessions, depressive thinking…) Concept:  Maladaptive cognitive processes (ways of thinking, expectations, attitudes and beliefs) are associated with behavioral and emotional problems.  Correcting maladaptive cognitive processes reduces patient’s problems. Process: maladaptive thinking is identified; the common cognitive errors include: Magnification and minimization of events out of proportion to their actual significance, e.g. depressed patient magnifies his faults and minimizes his achievements. Overgeneralization: forming a general rule from few instances and applying this rule to all situations no matter how inappropriate. Arbitrary inferences: making an inference without backing it up with evidence, or alternatively ignoring conflicting evidences. Selective abstraction: taking a fact out of context while ignoring other significant features and then proceeding to base entire experience on that isolated fact. Dichotomous thinking: thinking about events or persons in terms of opposite extremes (all or none). Personalization: relating events and incidents to self where such incidents have no personal bearing or significance. The maladaptive thinking is then challenged by correcting misunderstandings with accurate information and pointing out illogical ways of reasoning. Then alternative ways of thinking are sought out and tested. Psychological Treatments Cognitive Therapy Manual of Basic Psychiatry 2012-2013 Draft-2 M. Al-Sughayir Anxiety Disorders 611 A. Psychological Treatments: Concept: The aim for the client (patient) is to increase desirable behaviors and decrease undesirable ones. Behavioral assessment seeks to observe and measure maladaptive behaviors focusing on how the behavior varies in particular settings and under specific conditions. Problems will be decreased through client’s learning more adaptive behaviors. Behavioral techniques: 1. Exposure (flooding or gradual exposure & response prevention; for phobias & OCD). 2. Thought stopping(for OCD). 3. Relaxation training ( for anxiety & phobias). 4. Assertiveness training( for dependent and avoidant personality disorders) 5. Token economy (for children, chronic schizophrenic, and intellectually disabled people). Behavior Therapy Person’s behavior is determined by unconscious process. Current problems arise from unresolved unconscious conflicts originating in early childhood. Problems will be reduced or resolved through the client attaining insight (greater understanding of aspects of the disorder) as a mean to gaining more control over abnormal behavior). It helps some chronically depressed or anxious patients and those with personality problems. Psychodynamic Psychotherapy Cognitive behavioral therapy (CBT): combines cognitive and behavioral techniques. It is indicated in: depressive disorders (mild – moderate, but not severe) & anxiety disorders (GAD, phobias, panic disorders). Marital Therapy: Indications: marital discord & when marital problems act as a maintaining factor of a psychiatric disorder in one or both partners.  The couple and the therapist identify marital problems, such as:  Failure to listen to the other partner.  Failure to express wishes, emotions and thought directly.  Mind reading.  The couple then are helped to understand each other.  The therapist should remain neutral.  Techniques used include:  Behavioral: reinforcement of positive behavior  Dynamic: eliciting and correcting unconscious aspects of interaction.  Problem solving.