Category Archives: Mental Health Diagnosis

Bipolar Disorder Medication: Treatments of Choice?




Bipolar Disorder Medication Treatments: Overview

Bipolar disorder medication has been the treatment of choice for several decades now to control the severe and sometimes disabling symptoms of bipolar disorder. Doctors have been prescribing lithium and other mood stabilizers as well as anticonvulsant medications and atypical antipsychotics as the primary treatment for bipolar disorder along with the use of antidepressants and antianxiety medications, to help manage acute episodes as well as for the longer term management and to assist in managing future episodes.

Bipolar disorder medication treatments still rely upon the use of mood stabilizers such as lithium for the acute treatment of both manic and depressive episodes. Lithium has been used now for many decades to manage these moods and to prevent cycling into the other mood state. Doctors also have been known to use the anticonvulsants, antipsychotic medications, antidepressants, antianxiety and even sleep medications to manage the intense manic and depressive episodes as well as some of the associated problems, such as when the bipolar patient has a high level of anxiety or difficulty sleeping.

Mood stabilizers such as Lithium are used to prevent and treat the manic highs and the depressive lows. These medications are used to manage the symptoms so they do not interfere with school, work and with personal relationships. The main mood stabilizing medications are:

Divalproex sodium (Depakote)
Carbamazepine (Tegretol)
Lithium
Lamotrigine (Lamictal)
Valproic acid (Depakene)




Some of these medications are also chategorized as anticonvulsants such as valproic acid, lamotrigine and carbamazepine.

Other medications used to treat bipolar disorder include the atypical antipsychotic medications. These include
Aripiprazole (Abilify)
Risperidone (Risperdal)
Quetiapine fumarate (Seroquel)
Olanzapine (Zyprexa)
Ziprasidone (Geodon)
Loxapine (Loxitand or loxapine inhaler (Adasuve)
Asenapine (Saphris)
Cariprazine (Vraylar)
Lurasidone (Latuda)

If an individual is experiencing insomnia or sleep difficulties in relation to their bipolar symptoms, they may receive prescriptions for antianxiety medications such as benzodiazepines. Some of the more common benzodiazepines include:

Alprazolam (Xanax)
Lorazepam (Ativan)
Diazepam (Valium)
Clonazepam (Klonopin)

Or frequently some of the newer sleep medication such as zaleplon (Sonata) and eszopiclone (Lunesta} will be prescribed as they are believed to cause fewer problems with thinking and memory then the antianxiety medicines, benzodiazepines.

Frequently, the doctor will prescribe the mood stabilizing medication lithium initially, but may also start a medication to also assist with the bipolar depression such as:

Fluoxetine (Prozac) which is combined with olanzapine (Zyprexa) to form a medication referred to as Symbyax
Quetiapine fumarate (Seroquel)
Lurasidone (Latuda) which may be taken either alone or with valproic acid or lithium.

Bipolar disorder medication treatments and depression:

Due to the predominance of depressive symptoms in bipolar disorder, antidepressants are often combined with mood stabilizers. However, there are significant concerns that the use of antidepressants can trigger manic episodes. These concerns have usually been related to the older antidepressants referred to as tricyclics rather than some of the newer serotonin reuptake inhibitors such as Paxil, Prozac and Zoloft. This risk was identified in a study by Gijsman, Geddes, Rendell, Nolen and Goodwin in 2004 in which it was found that there was a significant risk of the emergence of a manic conversion from depression among patients with a mood or anxiety disorder treated with tricyclic antidepressants, rather than when patients were treated with the SSRI’s. Also, even higher conversion rates from depression to manic episodes were found among younger antidepressant users.

Benzodiazepines and bipolar disorder:

Benzodiazepines have been used at times to reduce agitation and comorbid anxiety as an adjunctive medication treatment for bipolar disorder. However, the actual efficacy of these medicines has not been adequately studied at the present time when used in addition to the mood stabilizing medications.

Normal course of medication treatment for bipolar disorder:

Although mood stabilizers, antidepressants and other adjunctive medications have been used for the treatment of bipolar disorder for many years, the normal course of bipolar disorder continues to be one of relapse of episodes of mania/ hypomania and depression. Studies (Gitlin, Swenson, Heller, and Hammond, 1995) have found one-year relapse rates as high as 40% even while being treated with mood stabilizers. Medication compliance continues to be a major issue with patients with bipolar disorder, with one study (Keck et al., 1998) finding inadequate medication use among approximately one half to two thirds of the patients within one year of initial treatment. Discontinuing the use of medications and the related relapse of bipolar symptoms with these patients is very problematic, especially when these medications have been stopped abruptly. Psychological treatments have been successfully utilized to promote medication compliance and to improve the symptom course of bipolar disorder patients. Overall, psychosocial interventions and psychotherapy have been found to improve the management of long-term bipolar symptoms and assist in relapse prevention.

References:

Gijsman, H.M., Geddes, J.R., Rendell, J.M., Nolen W.A. and Goodwin, G.M. (2004). Antidepressants for bipolar depression: a systematic review of randomized, controlled trials. American Journal of Psychiatry, 161, 1537-1547.

Gitlin, M.J., Swenson, J., Heller, T.L. and Hammen, C. (1995). Relapse and impairment in bipolar disorder. American Journal of Psychiatry, 152, 1635-1640.

Keck, P.E., McElroy, S.L., Strakowski, S.M., West, S.A., Sax, K.W., Hawkins et al (1998). Twelve-month outcome of patients with bipolar disorder following hospitalization for a manic or mixed episode. American Journal of Psychiatry, 155, 646-652.

By Paul Susic Ph.D. Licensed Psychologist


Bipolar Disorder: What is it exactly?




Bipolar Disorder an Overview:

Dipolar disorder, formerly called manic depression is a chronic and very disabling condition. Bipolar disorder is a disorder of instability in mood, behaviors and lifestyle. The main feature of bipolar disorder is a manic episode followed by either another episode of mania at a later point in time, depression or hypomania. In most cases, one or more of these patterns occur repeatedly and chronically over an individual’s lifetime. The overall diagnosis of bipolar disorder is usually bipolar I or bipolar II disorder, with a reference to the most recent episode of “manic, hypomanic or depressed”. Specific symptoms and diagnosis can be found on this website by referring to the bipolar disorder diagnostic pages.

Individuals diagnosed with bipolar disorder may have very different symptom patterns. Some episodic symptom patterns seem to have some balance between episodes of mania, depression and hypomania, while others seem to have predominately one symptom pattern. Some researchers have found that among individuals with bipolar I disorder depressive episodes seem to predominate, with over 3.5 times as many weeks of depression relative to weeks experiencing manic episodes or hypomania. Most bipolar individuals will receive a diagnosis of bipolar disorder I most- recent episode depressed at some point in their mental health history. Individuals with bipolar II disorder, have 38 times more depressive symptoms than hypomanic symptoms.




People diagnosed with bipolar disorder experience tremendous levels of functional impairment in their lives even while maintained on medication. These deficits in functioning are very comprehensive including work-related, academic and interpersonal functioning. Some studies have found that even while maintained on medicine that deficits in functioning continue for as much is five years after the depressive or manic episodes have remitted. Some researchers (Dion, Tohen, and Anthony, 1998) have concluded that 30% of these individuals were unable to work at all and only 21% were able to work at their previous level of functioning following a manic, depressive or hypomanic episode. Similar findings were also found for individuals already on medication for bipolar disorder. Only a small percentage of manic patients seem able to work consistently following hospitalization. Bipolar disorder is also found to be associated with very high levels of marital and family distress, dysfunction and divorce.

Bipolar Disorder: Some Basic Information

Bipolar disorder has been estimated to affect about 1% to 2% of the general population. These estimates may be even higher levels when considering the entire bipolar spectrum including cyclothymia.
The initial onset of bipolar disorder seems to be in the late teens to early twenties. People with early onset disorder seem to have a higher level of additional comorbid symptoms, including conditions such as substance abuse and anxiety disorders. Also, early onset patients seem to have a more chronic course, with more episodes of depression and to have a higher likelihood of suicidal behaviors.

Men and women both seem to have about the same likelihood of developing bipolar disorder. However, more women than men seem to have the rapid cycling pattern, which is defined as four or more cycles in a year, as well as being diagnosed with bipolar II disorder more often.

People with bipolar disorder seem to experience comorbidity with several other mental health conditions and disorders. The most common comorbid conditions experienced by individuals with bipolar disorder include panic disorder, social anxiety disorder, posttraumatic stress disorder, obsessive-compulsive disorder and generalized anxiety disorder. High rates of substance use disorders have been identified in clinical populations as well, with some clinicians believing that the rates may be as high as six times the general population.

The General Course of Bipolar Disorder:

The general course of bipolar disorder is to have repeated manic, depressive and hypomanic episodes that significantly impair an individual’s work and school experiences as well as their personal relationships. Also, these disruptions in functioning may increase the intensity and frequency of the symptoms and episodes. Over the long-term, about three fourths of the individuals who have met the diagnostic criteria for bipolar disorder will have a relapse within a period of 4 to 5 years, with about half having a relapse the following year. As previously mentioned, the residual impairment in functioning seems to continue even in between symptom episodes.

A number of factors seem to be associated with the increased frequency or likelihood of a mood episode. Stressful life and family experiences seem to delay recovery and increase the rate of relapse. It is believed that stressful family experiences and negative interaction patterns are associated with greater relapse rates.

The high level of comorbidity is also associated with a more difficult course. There appears to be significant evidence to support the fact that anxiety and substance use disorders are particularly significant to the appearance, maintenance and relapse of bipolar symptoms and episodes. Clinical experience also seems to confirm that the comorbid existence of anxiety in addition to bipolar disorder is linked to a reduced likelihood of recovery from a mood episode, reduced ability to function in everyday life, greater likelihood of suicide attempts and a reduced ability to respond to some medications. Comorbid substance abuse disorders often cause an individual to experience poor recovery, increase the level of noncompliance with an individual’s medication routine, and increase the frequency of hospitalization. Some individuals may also experience psychotic episodes during depressive episodes resulting in significantly impaired functioning and relapse.

Suicide is also a great concern among individuals with bipolar disorder. Researchers (Brown, Beck, Steer, and Grisham, 2000) have evaluated the course of over 7000 psychiatric outpatients in Pennsylvania diagnosed according to the DSM-IV criteria and found that among the various mental health diagnosis, bipolar disorder patients have the highest level of completed suicides, followed by major depressive disorder and personality disorders. When compared to what are determined to be relatively average psychiatric patients, patients with bipolar disorder seem to have about a 400% higher risk of suicide followed by major depressive disorder which seems to have about 300% higher risk for suicide.

Bipolar Disorder Treatments:

Optimum treatment for bipolar related disorders includes psychotherapy and mood stabilizing medications. Some the primary psychological treatments include psychoeducation, cognitive behavior therapy, family-focused therapy, and interpersonal social rhythm therapy. Lithium and other mood stabilizing medications have had a high rate of success in stabilizing bipolar symptoms and episodes. Individuals who are noncompliant with their medications continue to have very high rates of relapse however.

References:

Brown, G.K., Beck, A.T., Steer, R.A. & Grisham, J.R. (2000) Risk factors for suicide in psychiatric outpatients: A 20-year prospective study. Journal of Consulting and Clinical Psychology, 68, 371-377.
Dion, G.L.,Tohen, M., and Anthony, W.A., (1998). Symptoms and functioning of patients with bipolar disorder six months after hospitalization. Hospital Community Psychiatry, 39, 652-657.

By Paul Susic Ph.D. Licensed Psychologist



See Related Posts:

Social Anxiety Disorder (Social Phobia) Symptoms, Diagnosis and Treatment




Social Anxiety Disorder Symptoms:

Social Anxiety Disorder, previously referred to as social phobia is one of the more common anxiety disorders. It is usually experienced when you must perform in front of others or feel like you are being scrutinized by other people. The overall feeling is one of fear of possible embarrassment or humiliation. While many people find some way to endure the high level of anxiety they experience, others may avoid these feared experiences altogether. Usually you fear that you are going to be judged by others as being nervous, weak or stupid when you say or do something. In most cases people believe that their anxiety is excessive, and their fear is way out of proportion to the situation. Children however, do not recognize that their fear is excessive.

Studies have found that the most common social anxiety disorder or phobia is the fear of public speaking. It is believed to affect 3 out of 4 people or 75% of the population. It also accounts for approximately 19% and is easily the largest majority of those suffering from some form of phobia. This anxiety speech disorder is known to commonly affect speakers, people whose jobs require them to make public presentations, and even students speaking before the class. This form of social anxiety disorder is just as prevalent among men as among women. Overall, the most common social anxiety disorders include the following:

• fear of signing documents and writing in public
• fear of crowds
• fear of using restrooms in public
• fear of eating, spilling food or choking in public
• fear of being watched by others at work
• fear of taking examinations

Social Anxiety Disorder Diagnosis:

Social Anxiety Disorder is often distinguished by whether it is generalized or specific. The DSM-V has a performance only specifier which is given if you only experience this severe level of anxiety performing such as when public speaking. In these cases you may not feel otherwise impaired in your occupational, social or academic situations where public speaking is a requirement. You may not be afraid or avoid other social experiences. Also, if you experience panic attacks in conjunction with Social Anxiety Disorder, the specifier with panic attacks should be added to the diagnosis. If you experience anxiety in a more generalized sense in any social group situation where you fear being watched or evaluated, you may be experiencing a more generalized form of Social Anxiety Disorder. In most cases, the actual Social Anxiety Disorder diagnosis will not be given unless it interferes with your work, social activities or important personal relationships in very significant ways, usually causing a high level of personal distress. Like agoraphobia, Social Anxiety Disorder may be accompanied by panic that is related to the feelings of being embarrassed or humiliated, when trapped in a circumstance that provokes a high level of anxiety and distress. In these situations, the anxiety would rise only in circumstances related to the specific type of social situation feared.




Social Anxiety Disorder treatment:

There are several treatments that have been used to cope with Social Anxiety Disorder. One of the common sense recommendations by lay persons and some clinicians is to “take a deep breath”. Deep breathing from the abdomen and relaxation techniques can be practiced on a regular basis to relieve the physical symptoms of anxiety.

Social Anxiety Disorder Psychological Treatments:

Cognitive Behavior Therapy:

Cognitive Behavior Therapy has been effectively used for Social Anxiety Disorder. With this type of therapy, fearful thoughts are identified, challenged and often replaced by more realistic and adaptive thoughts. For example, a thought such as “I am going to be so nervous that I make a fool of myself” may be replaced by a thought such as “I will be nervous at first, but most people will not be bothered by that”.

Exposure Techniques for Social Anxiety Disorder:

One of the more effective long-term treatments for Social Anxiety Disorder is the use of exposure. Exposure can be imaginal or real-life exposure to the actual circumstances that are feared. The exposure is usually gradual or incremental in facing circumstances you are phobic or fearful of. If you experience an extremely high level of social anxiety about public speaking, you may give a very short talk to one or several friends, and then gradually increase it to a longer period of time with more observers. You would incrementally build up both the length of time and individuals observing to reduce the level of anxiety over a period of time.

While treatment for Social Anxiety Disorder is often done on a one-on-one basis, many mental health clinicians recommend group therapy as the ideal treatment format. This seems to more directly reflect the stimuli that would provoke the actual phobic reaction or Social Anxiety Disorder.

Social Skills and Assertiveness Training:

Sometimes learning basic social skills and learning to assert oneself can be very helpful in overcoming social phobias and Social Anxiety Disorder. Learning to smile, make eye contact, and maintaining conversations can be very helpful to developing a sense of mastery and coping with social situations, reducing the underlying level of anxiety. Also, learning to assert oneself can also be very helpful in learning how to tell others what you want or don’t want, without feeling like you must just go along with others demands.

Medications for Social Anxiety Disorder:

Medications are often given for Social Anxiety Disorder. The most common medications are the antidepressants, SSRI medications such as Paxil, Zoloft, Luvox and Serzone, and anxiety medications such as the benzodiazepines, which include Xanax or Klonopin. These medications are usually used as an adjunct to the cognitive behavior and exposure-based therapies mentioned above. Occasionally, MAO inhibitors such as Nardil and Parnate have been recommended to treat social phobias or social anxiety disorders.

Summary of Social Anxiety Disorder:

Many people suffer from Social Anxiety Disorder sometimes referred to as social phobia. The actual diagnosed disorder was changed in the new DSM-V which is used to diagnose mental health disorders by clinicians. You don’t have to suffer from Social Anxiety Disorder forever as both medications and psychological treatments are now available to relieve suffering.

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from The Anxiety and Phobia Workbook by Edmund J. Bourne Ph.D.



Bipolar and Related Disorders and DSM-5 Diagnostic Codes




Bipolar and Related disorders:

The bipolar in bipolar disorder refers to the fluctuation between depression and mania sometimes in a very dramatic, severe way. Earlier in the 19th century, mental health professionals used the terms manic depression and affective psychosis to describe bipolar disorder. In the first edition of the DSM (Diagnostic And Statistical Manual of Mental Disorders), bipolar disorder was referred to as manic depressive illness and was later renamed bipolar disorder in the DSM-III because of the stigma attached to mania and an attempt to describe and focus on the polarity between the two different symptom patterns of depression and mania.

The diagnosis of bipolar disorder has increased significantly especially among adolescents since the DSM-III. A report by CNN concluded that as many as 4.4% of individuals in the United States may receive some type of diagnosis along the bipolar spectrum in their lifetime. Unfortunately, individuals with bipolar disorder have the highest suicide rate among all of the mental health disorder diagnoses, with the rate of anywhere from 10 to 20 times higher than the general population in the United States.


”.,.”


Specific Bipolar and Related Disorders and DSM-5 Diagnostic Codes:

The following specifiers apply to bipolar related disorders were indicated: specify: with anxious distress (specify current severity: mild, moderate, moderate-severe, severe); with mixed features; with rapid cycling; with melancholic features; with atypical features; with mood-incongruent psychotic features; with mood-incongruent psychotic features; with catatonia (use additional code 293.89 [F06. 1]); with peripartum onset; with seasonal pattern

Bipolar I Disorder:

Current or Most Recent Episode Manic:
296.41 (F31.11) Mild
296.42 (F31.12) Moderate
296.43 (F31.13) Severe
296.44 (F31.2) With psychotic features
296.45 (31.73) In partial remission
296.46 (F31.74) In full remission
296.40 (F31.9) Unspecified
296.40 (F31.0) Current or most recent episode hypomanic
296.45 (F31.73) In partial remission
296.46 (F31.74) In full remission
296.40 (F31.9) Unspecified

Current or Most Recent Episode Depressed:
296.51 (F31.31) Mild
296.52 (F31.32) Moderate
296.53 (F31.4) Severe
296.54 (F31.5) With psychotic features
296.55 (F31.75) In partial remission
296.56 (F31.76) In full remission
296.50 (F31.9) Unspecified

296.7 (F31.9) Current or most recent episode unspecified

296.89 (F31.81) Bipolar II Disorder

Specify current or most recent episode: Hypomanic, Depressed

Specify courses if full criteria for a mood episode are not currently met: In partial remission, In full remission
Specify severity if full criteria for a mood episode are not currently met: Mild, Moderate, Severe

301.13 (F34.0) Cyclothymic Disorder

Specify if: With anxious distress
Substance/Medication – Induced Bipolar and Related Disorder
Note: See the criteria set a corresponding recording procedures for substance-specific codes and ICD-nine-CM and ICD-10-CM coding.

293. 83 Bipolar Related Disorder Due to Another Medical Condition
specify if:
(F06.33) With manic features
(F06. 33) With manic-or hypomanic-like episode
(F06. 34) With mixed features

296.89 (F31.89) Other Specified Bipolar Related Disorder

296.80 (F31.9) Unspecified Bipolar and Related Disorder



Agoraphobia Symptoms and Treatments: Must know Information




Agoraphobia Symptoms and Treatment Overview:

The symptoms of agoraphobia may be the most prevalent of all of the anxiety disorders with as many as 5% of the general population or one in 20 people experiencing varying degrees of agoraphobic symptoms. In the United States, the only mental health disorder that experiences a higher level of prevalence may be alcoholism. Therefore, an understanding of agoraphobia symptoms, diagnosis and treatment is imperative to a well rounded understanding of panic and mental health disorders.

Agoraphobia symptoms:

From a practical perspective, agoraphobia is experienced as a fear of having panic attacks although the term actually refers to a fear of open spaces. An individual experiencing agoraphobia usually has an intense fear of having a panic attack and being in a circumstance in which escape is impossible. An individual may avoid such things as driving on highways for fear of having a panic attack, and being unable to escape the circumstances. Most people experiencing agoraphobia symptoms fear not only the panic attack , but being observed by others while having panic symptoms. Some of the more common circumstances avoided by agoraphobics are:

• Being trapped home alone.
• Being in areas where they feel enclosed such as while getting an MRI, tunnels etc.
• Being on public transportation and unable to leave if necessary such as on a bus or train.
• Being in places such as grocery stores or restaurants and other crowded places.

Agoraphobics frequently feel comforted when a “safe person” is present, which seems to help alleviate the agoraphobia symptoms. One of the more common features of this panic related disorder is a fear of being away from home and/or away from this “safe person”. A “safe person” may be a spouse, parent or anyone whom you have a significant relationship with who provides some comfort in these anxiety provoking situations. You may have an intense fear of driving or walking alone or experiencing any other circumstance without this “safe person”.




Most people who are agoraphobic have a relatively high level of anxiety most of the time. Much of this anxiety seems to be anticipatory, fearing future circumstances and situations which may provoke a panic attack, such as a fear of being left alone at home in the future. The severe restrictions on your life related to future panic attacks may also result in depression. Some people experience depression when they are in adverse circumstances that they have no control over which seem unescapable.

Agoraphobia Symptoms and Panic Disorder:

Agoraphobia develops as a result of having panic attacks or panic disorder. At the very beginning you may have panic attacks that occur for no reason, eventually resulting in a panic disorder. Later you begin to recognize that these panic attacks are occurring in specific situations and you begin to avoid those circumstances for fear of having continued panic attacks. These panic symptoms may be mild at the beginning resulting in uncomfortable feelings but not necessarily avoiding these specific circumstances. When experienced at a more moderate level the panic symptoms begin to result in avoidance of these panic inducing circumstances such as avoiding public transportation or shopping on your own. In these moderate anxiety circumstances, you may avoid some panic inducing situations but still continue on without serious restrictions on other aspects of your life. The restriction is usually only partial. When experiencing severe agoraphobic symptoms, you may experience restrictions which seem to affect every aspect of your life, resulting in being unable to leave home unaccompanied.

It is not really known why some people develop agoraphobia from their panic attacks and why others do not, or why agoraphobia is more severe for some rather than others. Some clinicians and researchers believe that the development of agoraphobia may have some environmental and hereditary components. It has been observed to run in families and twin studies have found that identical twins have a higher risk for both to develop agoraphobia. When looking at environmental factors, there may be some childhood experiences that predispose a child to agoraphobia. Some of these experiences may include growing up with parents who (1) are overprotective and/or (2) are overly anxious and communicate that the world is a “dangerous place” and/or (3) overly critical and perfectionistic.

People experience agoraphobia symptoms from all walks of life and all socioeconomic levels, At the present time, approximately 80% of agoraphobics are women. It is unclear what environmental issues factor into the gender difference, although it has been noticed recently that the level of agoraphobic women relative to men with the disorder seems to be leveling off somewhat. That would probably indicate more of a environmental than a genetic influence.

Agoraphobia Symptoms and Treatment:

There are various treatments available to help alleviate the symptoms of agoraphobia. Since agoraphobia is basically a disorder developed in relation to panic disorder and panic attacks, the same treatments are utilized for both including psychosocial treatments and the management of panic attack symptoms utilizing anxiety medications and antidepressant medications. An overall analysis of the medication management of panic disorder and panic attacks as well as an overview of the psychosocial treatments of panic disorder follow on separate pages.

Some of the main psychosocial treatments include relaxation training, panic control therapy and interoceptive desensitization. Once again, the same treatments that are utilized for panic disorder and panic attacks are also used for patients with agoraphobia. Also, additional assistance or treatment for agoraphobia symptoms may also include assertiveness training since agoraphobics frequently have difficulty standing up for themselves. Finally, as mentioned previously, some of the main treatments for agoraphobia include medication, graded exposure, cognitive therapy and group therapy.

Agoraphobia Treatments with Medication:

Some of the main treatments for agoraphobia as well as panic attacks and panic disorder include treatment with medication such as selective serotonin reuptake inhibitors (SSRI’s) such as, Zoloft and Paxil and tranquilizers such as Xanax, Ativan or Klonopin. The SSRI’s are more likely to be used in very severe cases where a person is homebound and otherwise very restricted in their activities of daily living. Low doses of tranquilizers such as Xanax may also be used to assist people who are going through the early stages of exposure treatment as well as being used by many doctors as a mainline treatment for anxiety and panic.

Graded exposure treatment for Agoraphobia:

When the treatment or intervention is referred to as “exposure” therapy it usually means that the person is exposed to the stimuli that seems to provoke the anxiety or panic reaction. Situations or circumstances that have been feared and/or avoided are exposed to the individual in incremental steps to gradually increase the amount of time and exposure without having a full-blown panic attack. A good example of graded exposure may be if a person has a severe fear of driving long distances or on the highway. They may initially drive short distances or at slower speeds and build up to greater distances or greater speeds. Sometimes a support person is used to accompany the agoraphobic. Finally, they may then eventually be able to drive alone. If a person is fearful of staying home alone, they may be at home by themselves for short periods of time building up to longer times alone.

Cognitive Treatment to Alleviate Agoraphobia Symptoms:

The goal of cognitive therapy is to help the individual recognize and eliminate exaggerated, fearful thinking which result in phobias and panic attacks in a more realistic way. You will then learn to identify, challenge and ultimately replace counterproductive thoughts with ones that are more helpful and realistic to the stimuli or environment.

Group therapy:

Agoraphobia symptoms can be effectively treated in a group setting with other individuals experiencing similar symptoms and disorders. Group therapy provides an opportunity for an individual to share their experiences with others and recognize that they are not alone and that there are many others who experience agoraphobic related panic attacks.

Agoraphobia Symptoms and Treatment: Some Final Words

Agoraphobia symptoms are successfully treated through the use of several psychosocial interventions and medications to alleviate the symptoms. Additional information is also available on this website related to panic disorder, psychosocial interventions and medication management. Do not allow yourself to continue to suffer agoraphobia symptoms when treatment is so readily available.

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from The Anxiety and Phobia Workbook by Edmund J. Bourne Ph.D.

See Related Posts:




Panic Disorder Treatment: The Best Long-term Solution




Panic Disorder Treatment: An Overview

The treatment of panic disorder is usually approached very differently from the way it probably should be in that the first line of treatment is almost always to “throw a medication at it”. When given the fact that the medications usually used for panic disorder treatment have serious side effects, a more reasonable approach would probably be to consider possible psychological interventions prior to using medications that have serious side effects. These medications may be necessary in place of psychological interventions or in addition to, but they should not always be the first line of defense in the treatment of panic disorder. In fact, efficacy studies related to the treatment of panic disorder with cognitive behavioral therapy, have found that it performs as well as pharmacological interventions in the short-term and may possibly be more durable in the long-term.

Panic Disorder Treatment: The Psychological Approach

The core feature in the treatment of panic disorder from a psychological treatment perspective, is that panic disorder is frequently caused by and maintained by heightened fears associated with anxiety symptoms. The main psychological treatment modality in current practice by psychologists and other mental health practitioners is cognitive behavioral therapy (CBT) which seeks to reduce those fears. The belief which has also been confirmed by research is that it is this “fear of fear” that is the main culprit and the focus of intervention. This fear can be reduced, resulting in the clinical improvement of panic disorder. Cognitive behavioral therapists utilize various cognitive techniques including psychoeducation about panic along with cognitive restructuring, as well as behavioral methods such as interoceptive exposure to assist in the reduction of the symptoms of panic disorder.




Psychoeducation for Panic Disorder:

Psychotherapists using the cognitive behavioral method, usually first begin by providing patients with information about panic disorder. Information and education about panic and how it is maintained is seen as the most basic aspect of this program, allowing the patient and therapist to collaborate on future treatment and intervention. It has been found that there is an enormous amount of misinformation about panic symptoms as well as how they will affect the individual patient. Many patients present to emergency rooms mistaking intercoastal muscle tension in the chest as an indication that they are having a heart attack. Cardiac arrest is much more than pain in the chest. It most often involves a crushing pain in the chest usually accompanied by pain shooting downward through the arm. Also, many patients mistake hyperventilation-related dizzy feelings for fainting, without realizing that ultimately dizziness may be the result of blood pressure and the heart rate suddenly dropping. In actuality, an elevated heart rate during panic will actually protect against fainting in spite of dizziness.

There are certain physiological reactions that protect us from various threats including what has been referred to as the “fight or flight” reaction to stress or danger. The “fight or flight” syndrome is actually believed to help protect us against danger but is not in itself threatening or dangerous. It is a heightened level of physiological arousal that allows us to respond to threatening or dangerous circumstances, but does not specifically pose a threat to our well-being.

Some patients also fear that the physiological symptoms of panic disorder will lead them to more serious mental health concerns. These additional mental health worries also exacerbate the underlying mistaken beliefs that bodily sensations and a fearful response to dizziness and heart palpitations for example, will lead to a full-blown panic attack or result in some other type of mental illness.

Panic Disorder Treatment and Basic Beliefs:

Cognitive behavioral therapy focuses on catastrophic beliefs and misconceptions about our bodily sensations and the prevention of testing these misconceptions and refuting these beliefs. In order to assist with alleviating these catastrophizing beliefs, the therapist may ask the patient what has kept them from experiencing the actual catastrophe that they had envisioned. In most circumstances, patients will indicate that they have taken various safety measures to short-circuit the catastrophe from actually occurring. For example, a patient may state that they are afraid that the panic disorder related dizziness will result in them becoming weak and falling down. The therapist may then ask what has kept them from falling down in the past? The patient will usually state that they were able to sit down prior to falling down. They were able to rely upon these safety measures to keep the catastrophe from actually occurring. So, in effect, specific catastrophic thinking can be addressed along with safety measures that maintain the related fears that seem to drive the panic process.

Panic Disorder Treatment: Using Cognitive Restructuring

Another important aspect of panic disorder treatment using the cognitive behavioral approach involves using the cognitive restructuring of catastrophic beliefs. An important part of cognitive restructuring of these beliefs is that behavioral experiments are also used along with psychoeducation to alleviate the panic symptoms. The behavioral experiments are used to provide direct, experimental evidence that catastrophic consequences are not the inevitable result of catastrophic thoughts and the experience of heightened physiological sensations. A behavioral experiment may involve something as simple as when an individual believes that they will faint when dizzy and immediately sits down to avoid falling down. The behavioral experiment might involve having the patient hyperventilate while sitting down and experiencing the related sensations of dizziness and lightheadedness. The patient’s catastrophic thinking might involve the thought that they will faint if they stand up. The therapist may then encourage the alternative prediction that only a slight sense of unsteadiness will actually occur. Having the patient experience the physical sensations without having them engage in the customary safety behavior is one of the most powerful ways to help an individual change the catastrophic thinking that maintains the panic disorder. The goal of the therapist is to have the patient experience behavioral experiments that allow them to refute the beliefs associated with the usual bodily symptoms. Cognitive restructuring is actually a combination of psychoeducation and the creation of behavioral experiments that allow the individual to refute the catastrophic beliefs.

Panic Disorder Treatment: Exposure

Panic disorder is experienced pretty much in the same way that individuals experience phobias. After an individual experiences a high level of anxiety in relation to a certain stimuli they may then attempt to avoid similar experiences. Prolonged exposure to stimuli that is feared causing an extinction of the fear is an important feature of the behavioral treatments associated with anxiety and panic disorders. In individuals with panic disorder, the principle of exposure requires people to expose themselves to the stimuli that they fear and feel the related bodily sensations until they no longer hold the same capacity to provoke fear and discomfort.

Deep Breathing and Additional Treatments for panic disorder:

Some additional panic disorder treatments include applied muscle relaxation and breathing retraining, which is oriented toward counteracting hyperventilation. However, some therapists now wonder if these techniques are such a good idea. These methods were originally designed to help reduce the intensity of the bodily sensations which by implication were bad, which is contrary to the psychoeducational component in which these sensations are essentially taught to be considered harmless. However, teaching the concept that anxiety management techniques are a means of helping an individual to feel some sense of control over their bodies may indeed have some value.

Panic Disorder Treatment and Agoraphobia:

An intense fear of certain circumstances and objects can cause patients to avoid those experiences. This residual agoraphobia can continue even after panic has been successfully treated using cognitive behavioral techniques. Psychologists and mental health clinicians will frequently develop in vivo (real-life) exposure situations where individuals will purposefully enter into feared experiences and circumstances without avoiding the stimuli until the intense discomfort is reduced or goes away.

Some final words on panic disorder treatment:

There have been many studies over time that have identified the efficacy of psychological approaches to the management of panic disorder. Cognitive behavioral therapy delivered on an individual basis or in a group setting has been found to significantly reduce symptoms of panic. Some studies have found as many as 74 4% of cognitive behavioral therapy treated patients are panic free posttreatment. Similar outcomes have also occurred in community mental health settings. Also, cognitive behavioral therapy has significantly outperformed other interventions including the use of some medications such as imipramine, applied relaxation and emotion focused therapy. Finally, panic disorder treatment using psychological methods including cognitive behavioral therapy with or without medication have frequently been found to be the best long-term solution to the treatment of panic disorder.

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from Practitioner’s Guide to Evidenced-Based Psychotherapy by Jane E. Fisher and William T. O’Donohue




See Related Posts:

Unspecified Depressive Disorder Symptoms and Related DSM–5 Diagnosis





Unspecified Depressive Disorder 311 (F32.9)

Information related to Unspecified Depressive Disorder as well as the specific symptoms follow below. While some of these Unspecified Depressive Disorder symptoms may be recognized by family, teachers, legal and medical professionals, and others, only properly trained mental health professionals (psychologists, psychiatrists, professional counselors etc.) can or should even attempt to make a mental health diagnosis. A multitude of factors are considered in addition to the psychological symptoms in making a proper diagnosis, including medical and psychological testing considerations. This information is for information purposes only and should never replace the judgment and comprehensive assessment of a trained mental health clinician.

Unspecified Depressive Disorder 311 (F32.9) Diagnostic criteria:

This category applies to presentations in which symptoms characteristic of a depressive disorder that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive disorders diagnostic class. The Unspecified Depressive Disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific depressive disorder, and includes presentations for which there is insufficient information to make a more specific diagnosis such as in an emergency room setting.

Adapted by Paul Susic Ph.D. Licensed Psychologist from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition DSM-5: American Psychiatric Association




See Related Posts:

Having a Panic Disorder? Symptoms, Diagnosis and Treatment




Panic Disorder Overview:

Panic disorders are usually identified by extreme feelings of apprehension or intense fear that may appear suddenly or “out of the blue”. They may or may not have an apparent cause. In most cases, intense panic usually lasts no more than a few minutes but in rarer circumstances it can continue for up to about two hours. If you’re having a panic attack and ultimately have developed a panic disorder you should notice some of the following symptoms:

A fear of dying
Fears of going crazy or losing control
Shortness of breath or a feeling of being smothered
Heart palpitations, pounding heart or accelerated heart rate
Chest discomfort or pain
Dizziness, faintness or unsteadiness
Hot and cold flashes
Shaking and trembling
Numbness or tingling in feet and/or hands
Sweating
Feeling of choking
Abdominal distress or nausea
Feeling of unreality is if you’re not all there

In a full-blown panic attack, at least four of the symptoms will be present. In a limited-symptom attack you may experience possibly two or three of the symptoms.

Panic Attack or Panic Disorder:

If you experience (1) two or more panic attacks and had of at least (2) one of these attacks followed by a month of concern about continuing panic attacks or their consequences, you may be experiencing a panic disorder. In most cases, panic disorder by itself does not usually involve the development of a phobia. The panic itself is usually spontaneous rather than when you’re approaching, thinking about or entering a phobic situation. In many cases, its spontaneity and unexpected nature makes it difficult to recognize any apparent cause. Also, panic attacks are not the result of physiological precipitating factors such as a drug use or withdrawal or a medical condition.




You can possibly have several panic attacks within a month or two and never have another one for years, or may never have a recurrent attack. Or you could have several attacks, followed by a period of time with no attacks, only to have the panic return several months later. Panic attacks can have many different symptom patterns. You could have several within a week or many within the same month. In all of these cases, there is a tendency to develop anticipatory anxiety which is a deep feeling of apprehension and fear about having further attacks. It is usually after several attacks that individuals seek treatment.

Diagnosing Panic Disorder:

People having panic attacks frequently go to the emergency room or otherwise seek a medical or physiological answer to why they are feeling heart palpitations and excessive anxiety. They are often very frightened by the symptoms which often lead to an EKG or other cardiac tests which in most cases turn out to be normal. Occasionally, they may find a mitral valve prolapse (a benign arrhythmia of the heart) which may coexist with the panic attack. However, doctors have become much better at distinguishing between purely physical complaints, anxiety attacks and panic disorders.

A diagnosis of a panic disorder is only made after ruling out all possible medical considerations including hyperthyroidism, reactions to excess caffeine, hypoglycemia or withdrawal from alcohol, tranquilizers or sedatives. The root cause of panic disorder is most often some combination of heredity, personal stress and chemical changes within the body and brain.

The specific criteria for panic disorder can be found on another page of this website but in summary it requires recurrent and unexpected panic attacks of the previously mentioned symptoms. At least one of the attacks must be followed by a month or more of persistent concern, maladaptive change in behavior, and the disturbance cannot be attributable to the physiological effects of a substance or any other medical condition. Also, the disturbance cannot be better explained by any other mental disorder.

Development of panic disorder:

People most often first develop panic disorder in their late teens and early twenties. In some cases, the panic disorder can become complicated by developing into agoraphobia. It is estimated that between 1% and 2% of the population have a pure form of panic disorder while approximately 5% experience panic disorder with agoraphobia.

Panic Disorder Treatment:

Effective treatment for panic disorder usually requires both physiological and/or psychological intervention. Physiological treatments usually involve medications specifically for anxiety referred to as anxiolytics or anti-anxiety drugs, and/or antidepressants to reduce the symptoms of panic attacks. Psychological interventions frequently include lifestyle and personality changes, psychotherapy, and relaxation training.

Some of medications used to treat panic disorder include the benzodiazepine medication such as Xanax, Ativan, Valium or Klonopin. Also, antidepressants may be used such as Paxil, Serzone, Zoloft, or Celexa. These medications are most effectively used in conjunction with psychological interventions however.

A common sense understanding of the psychological dynamics associated with an individual’s experience of anxiety and panic disorders is imperative. Frequently, there are precipitating events or experiences that seem to maintain or exacerbate underlying symptoms of anxiety. Only by recognizing, problem solving and focusing on these precipitating and exacerbating experiences, may you truly have a reduction in your anxiety symptoms. There are various lifestyle and personality changes that can be used to focus on and reduce the symptoms of panic disorder including stress management, eliminating stimulants and sugar from your diet, regular exercise, slowing down your life and creating some “downtime” and even focusing on personality characteristics such as expecting too much of yourself, having excessive need to please others or even an excessive need for control of your life or others.

Relaxation training can be helpful also. Practicing breathing from your abdomen and some type of progressive muscle relaxation on a daily basis has been found to be helpful by many people. This may be helpful in reducing the physical symptoms of panic as well as helping to bring an element of control into your life, and possibly reducing the feeling of anticipatory anxiety that you may have before having a panic attack. Physical exercise is also recommended to assist in reducing underlying symptoms of anxiety.

Psychological interventions also include a form of panic control therapy which focuses on eliminating catastrophic thoughts such as “I’m going to have a heart attack”. Cognitive behavioral therapy is frequently used effectively in assisting people to understand the connections between their thinking and moods as well as physiological reactions. Many times, these catastrophic thoughts are believed to trigger panic attacks.

Another psychological intervention is referred to as interoceptive desensitization. This type of desensitization involves voluntarily habituating to the bodily symptoms of panic such as sweaty hands, shortness of breath, dizziness and rapid heartbeat. Often the symptoms are created deliberately in a therapist’s office through such activities as spinning in a chair to create dizziness, or rapid heartbeat by running up and down stairs. Repeatedly being exposed to unpleasant bodily symptoms promotes desensitization which means adjusting to and learning to cope better with the actual symptoms associated with panic attacks and panic disorder.

Summary of Panic Disorder:

Panic attacks and panic disorder can become very uncomfortable and even disabling. If not treated they can become even worse resulting in such comorbid conditions as panic disorder with agoraphobia. Thankfully, psychological and physiological treatments are available to effectively assist with panic disorder.

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from The Anxiety and Phobia Workbook Third Edition by Edmund J. Bourne Ph.D.

See Related Posts:




Other Specified Depressive Disorder Symptoms and Related DSM-5 Diagnosis





Other Specified Depressive Disorder 311 (F32.8):

Information related to Other Specified Depressive Disorder as well as the specific symptoms follow below. While some of these Other Specified Depressive Disorder symptoms may be recognized by family, teachers, legal and medical professionals, and others, only properly trained mental health professionals (psychologists, psychiatrists, professional counselors etc.) can or should even attempt to make a mental health diagnosis. A multitude of factors are considered in addition to the psychological symptoms in making a proper diagnosis, including medical and psychological testing considerations. This information is for information purposes only and should never replace the judgment and comprehensive assessment of a trained mental health clinician.




Other Specified Depressive Disorder 311 (F32.8) diagnostic criteria:

This category applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive disorders diagnostic class. The Other Specified Depressive Disorder category is used in situations of when the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific depressive disorder. This is done by recording “other specified depressive disorder” followed by the specific reason such as “short-duration depressive disorder”.

Examples of presentations that can be specified using the “other specified” designation include the following:

1. Recurrent brief depression: Concurrent presence of depressed mood and at least four other symptoms of depression for 2-13 days at least once per month (not associated with the menstrual cycle) for at least 12 consecutive months in an individual whose presentation has never met criteria for any other depressive or bipolar disorder and does not currently meet active or residual criteria for any psychotic disorder.

2. Short-duration depressive disorder (4-13 days): Depressed affect and at least four of the other eight symptoms of a major depressive episode associated with clinically significant distress or impairment that persists for more than 4 days, but less than 14 days, in an individual whose presentation has never met criteria for any other depressive or bipolar disorder, does not currently meet active or residual criteria for any psychotic disorder, and does not meet criteria for recurrent brief depression.

3. Depressive episode with insufficient symptoms: Depressed affect and at least one of the other eight symptoms of a major depressive episode associated with clinically significant distress or impairment that persists for at least two weeks in an individual whose presentation has never met criteria for any other depressive or bipolar disorder, does not currently meet active or residual criteria for any psychotic disorder, and does not meet criteria for mixed anxiety and depressive disorders.

Adapted by Paul Susic Ph.D. Licensed Psychologist from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) American Psychiatric Association


Depressive Disorder Due to Another Medical Condition Symptoms and Related DSM–5 Diagnosis





Depressive Disorder Due to Another Medical Condition:

Information related to Depressive Disorder Due to Another Medical Condition as well as the specific symptoms follow below. While some of these Depressive Disorder Due to Another Medical Condition symptoms may be recognized by family, teachers, legal and medical professionals, and others, only properly trained mental health professionals (psychologists, psychiatrists, professional counselors etc.) can or should even attempt to make a mental health diagnosis. A multitude of factors are considered in addition to the psychological symptoms in making a proper diagnosis, including medical and psychological testing considerations. This information is for information purposes only and should never replace the judgment and comprehensive assessment of a trained mental health clinician.





Depressive Disorder Due to Another Medical Condition diagnostic criteria:

A. A prominent and persistent period of depressed mood or markedly diminished interest or pleasure in all, or almost all, activities that predominates in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder such as adjustment disorder, with depressed mood, in which the stressor is a serious medical condition.
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Coding Note: The ICD-9-CM code for Depressive Disorder Due to Another Medical Condition is 293.83, which is assigned regardless of the specifier. The ICD-10-CM code depends on the specifier (see below).

Specify if:

(F06. 31) With depressive features: Full criteria are not met for major depressive episode.
(F06. 32) With major depressive-like episode: Full criteria are met (except criterion C) for major depressive episode.
(F06. 34 With mixed features: Symptoms of mania or hypomania are also present but do not predominate in the clinical picture.

Coding Note: Include the name of the other medical condition in the name of the mental disorder such as 293. 83 [F06.31] depressive disorder due to hypothyroidism, with depressive features. The other medical condition should also be coded and listed separately immediately before the Depressive Disorder Due to the Medical Condition such as 244.9 [E03.9] hypothyroidism; 293. 83 [F06.31] depressive disorder due to hypothyroidism, with depressive features.

Adapted by Paul Susic Ph.D. Licensed Psychologist from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) American Psychiatric Association