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Evidence Based Practices for Mental Health Professionals

By Jim Messina, Ph.D., CCMHC, NCC, DCMHS


Chapter 7 Anxiety and Trauma and Stressor-Related Disorders

LEARNING OBJECTIVES FOR

ANXIETY and TRAUMA and STRESSOR-RELATED DISORDERS

After reading this section you will learn the answers to the following questions:

  1. What are the ICD-10-CM Codes for Anxiety and Trauma and Stressor-Related Disorders?
  2. What are the clinical descriptors for Anxiety and Trauma and Stressor-Related Disorders?
  3. What are the symptoms common for Anxiety and Trauma and Stressor-Related Disorders?
  4. What are the common populations which are treated for Anxiety and Trauma and Stressor-Related Disorders?
  5. What are the common treatment settings for Anxiety and Trauma and Stressor-Related Disorders?
  6. What are the Evidence Based Practices for treating Anxiety and Trauma and Stressor-Related Disorders?
  7. What are the common psychopharmacological treatments for Anxiety and Trauma and Stressor-Related Disorders?
  8. What are some common manuals, guideline books and client workbooks for treating Anxiety and Trauma and Stressor-Related Disorders?
  9. What are some good references you can use to learn more in-depth information about Anxiety and Trauma and Stressor-Related Disorders?

ICD-10-CM Codes for Anxiety Disorders in DSM-5

F93.0 Separation Anxiety Disorder

F94.0 Selective Mutism

F40.10 Social Anxiety Disorder (Social Phobia) Specify if Performance Only

F41.0 Panic Disorder

F40.00 Agoraphobia

F41.1 Generalized Anxiety Disorder


ICD-10-CM Codes for Trauma and Stressor-Related Disorders

F94.1 Reactive Attachment Disorder

F94.2 Disinhibited Social Engagement Disorder

F43.10 Acute Stress Disorder

F43.21 Adjustment Disorder with depressed mood

F43.22 Adjustment Disorder with anxiety

F43.23 Adjustment Disorder with mixed anxiety and depressed mood

F43.24 Adjustment Disorder with disturbance of conduct

F43.25 Adjustment Disorder with mixed disturbance of emotions and conduct

F43.20 Adjustment Disorder Unspecified

F43.8 Adjustment Disorder with Other Specified Trauma-and Stressor-Related Disorder

F43.9 Adjustment Disorder with Unspecified Trauma-and Stressor-Related Disorder

 

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.) (DSM-5). Washington, DC: Author.

Alexander: Panic Disorder due to Fear of Failure


Alexander was referred by his wife, because last week Alexander went to the emergency room looking like he had a heart attack. He himself was convince he was having a heart attack. Alexander says that the day it happened was like any average day at work. He had been given a new assignment which would be due in two weeks. The assignment was huge and it normally would take a month or two to complete but the company’s clients needed it done as soon as possible. Alexander took on the assignment with no problem. He finished the rest of his work day and then was on his way home when he thought he was having a heart attack. He called his wife on cell phone and asked her to get an ambulance to pick him up where he had pulled his car over. She did and met Alexander and the ambulance at the emergency room. The ER then proceeded to test and probe Alexander and even admitted him to the cardiac care unit for a minimum of a 24 hour stay to monitor his heart. The end result was that they could find no cause of the pain he experienced in the car on his way home and they said the good news was it was not a heart attack.


Once Alexander got his car off the highway where he left it and returned home, he knew something was wrong but he had no idea what it was. He called his uncle in Santa Fe, who mental health practitioner and told him about what had happened. His uncle strongly suggested he make an appointment with a Clinical Mental Health Counselor because it sounded like he might have had a panic attack.


On meeting with Alexander you explore his past family, school, work, social and community experiences and discover that when he was in college Alexander had a similar occurrence when he was to take his comps for his Master degree in Accounting. He got through that crisis and immediately stuck it away out of his memory never to reemerge he hoped. You probe deeper to find out that Alexander has always been bothered by the fear of failure. He says that ever since grade school he feared taking tests, but would “tough it out” to get through them and never complained to anyone about these fears. You point out that these fears have contributed to the two panic attacks he recalls, the recent one and one in college and you ask him if he is willing to work on lessening his anxiety so that the fear of failure is no more. He agrees and you give him a homework assignment to bring in for his next appointment.

Anxiety disorders occur in all age groups with the causations for the anxiety differing over the life span. For example, researchers have found that possible causes for anxiety in children stem from early sexual abuse and poor parenting or overlap with ADHD. For adults, researchers have shown that alcohol consumption, as well as the “aging” process are linked to anxiety symptoms (Balon, 2001).


Evidence based practices for anxiety disorders include:

1) Pharmacological Treatments only (Stein, 2006; Bandelow, Seidler-Brandler, Becker, Ruther and Wedekind, 2007; Katzman, 2009).

2) Psychotherapeutic interventions only

a) Cognitive Behavioral Therapy (Borkovec, Newman, Pincus and Lytle, 2002; Carmin and Albano, 2003: Dugas, Ladouceur, Leger, Freeston, Langlois, Provencher and Boisvert, 2003; Gaston, Abbott, Rapee. and Neary, 2006: Galassi, Quercioli, Charismas, Niccoli and Barculli, 2007; Hofmann and Smits, 2008; Newman, Castonguay, Borkovec, Fisher and Nordberg, 2008 Stewart, and Chambless, 2009). 

b) Behavioral Exposure Treatments (Deacon and Abramowitz, 2004; Hoffman and Mathew, 2008; Langhoff, Baer, Zubraegel and Linden, 2008; Hoyer, Beesdo, Gloster, Runge, Hofler and Becker, 2009; Bezerra de Menezes et al., 2011). 

3) Combination of CBT and medications (Balon, 2001: Beamish, Granello and Belcastro, 2002; Andrews, Oakley-Browne, Castle, Judd and Baillie, 2003; Hicks, Leitenberg, Barlow, Gorman, Shear and Woods, 2005; Mitte, 2005, Compton et al., 2010).  


Researchers have identified evidence based practice treatment for anxiety disorders with a variety of populations. These include:

1) Children and Adolescents (Rapee, Abbott and Lyneham, 2006; Verdeli, Mufson, Lee and Keith, 2006; Liber, Van Widenfelt, Utens, Ferdinand, Van der Leeden, Gastel and Treffers, 2008, Compton et al., 2010).

2) College age students (Baez, 2005).

3) Adults (Antony and Rowa, 2005; Hofmann and Smits, 2008; Stewart, and Chambless, 2009).

4) Older Adults (Ayers, Sorrell, Thorp and Wetherell, 2007).

5) Married Couples (Byrne, Carr and Clark, 2004).

Assignment given to Alexander after his first session


What new behavior patterns can help in overcoming your fear of failure?

I will work on the following new thinking, feelings and behaviors to overcome my fear of failure:

  1. I will verbally and emotionally reinforce myself for the hard work, effort, and sacrifices I've made to achieve success
  2. I will continually allow myself to honestly appraise my level of achievement, success, and accomplishment and reward myself for them
  3. I will work at accepting myself as being healthy, together, happy, successful, prosperous, and accomplished and let go of the fears of being otherwise
  4. I will stop letting the fear of not being successful on a task hinder me from facing the fear and confronting it rationally and honestly
  5. I will give others in my life permission to give me honest, open, candid feedback when they see I am becoming anxious or self-destructing or backsliding when pressured by new challenges and assignments
  6. I will continually be rational and realistic in maintaining my level of commitment and motivation to reach my personal and career goals
  7. I will work at visualizing me accomplishing the challenges in life which in the past have created pressure, tension and anxiety for me
  8. I will giving others and myself credit, recognition, and support for personal achievements, successes, and accomplishments
  9. I will work at giving myself honest, open, realistic self-talk that encourages me to work my hardest to achieve the goals I have set for myself and not allow the fears of mistakes or failures take my positive mood from me
  10. I will accept the compliments and recognition of others with an open heart and mind and no longer believe that only if I get such external reward will I feel successful since I am the only cheerleader I really need in my life.

I agree to begin to work on this plan of action:

Signed:                                                                 Dated:

Adapted from: Chapter 11: Fear of Success in: Messina, J.J. (2013). Tools for Personal Growth, retrieved at www.coping.us

CBT for Panic Disorder begins with psychoeducation to help clients gain an understanding of the condition and to learn how to manage the panic by learning the panic model. This model indicates that panic symptoms are not dangerous, but are caused by danger arousing the autonomic nervous system even if the danger does not exist, and that avoiding situations which bring up such fear just exacerbate the fear (Freedman and Adessky, 2009).

 

Medications used for Anxiety Disorders

Classificaton

Drug name (Generic Name)

New Benzodiazepines

Ativan (Lorazepam)   

Xanax (Alprazolam) 

Old Benzodiazepines

Valium (Diazepam) 

Librium (Chlordiazeproxide) 

Klonopine (Clonazepam)

Restoril (Temazepam) 

Halcion (Triazolam)

Buspirone

Buspar (Buspirone)

Non-Benzodiazepines

Ambien (Zolpidem) 

Sonata (Zaleplon)

Lunesta (Eszopiclone)

SNRI

Effexor XR (Venlafaxine)

SSRI

Lexapro (Escitalopram)    

 Paxil (Paroxetine)

Clinicians have found that the use of pharmacological treatments are most effective in the short term; whereas, CBT treatments have longer lasting positive effects (Acarturk, Cuijpers, van Straten and de Graaf, 2009).

Handouts for Alexander to better explain the elements involved in his treatment

  1. TEA System
  2. ALERT System
  3. ANGER System
  4. LET GO System
  5. CHILD System
  6. RELAPSE System

All available online at: www. coping.us at: http://coping.us/seastoolsforrecovery.html

Treatment Workbooks for Anxiety Disorders


Alberti, R.E. and Emmons, M.L. (2001). Your perfect right: Assertiveness and equality in your life and relationships, Eighth Edition. Atascandero, CA: Impact Publishers.

 

Antony, M.M. and McCabe, R.E. (2004). 10 simple solutions to panic: How to overcome panic attacks, calm physical symptoms, and reclaim your life. Oakland, CA: New Harbinger.

 

Antony, M.M. and Swinson, R.P. (2000). The shyness and social anxiety workbook: Proven step-by-step techniques for overcoming your fear. Oakland, CA: New Harbinger.

 

Barlow, D.H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic. Second edition. New York: Guilford Press.

 

Barlow, D.H. and Craske, M.G. (2007). Mastery of your anxiety and panic. Fourth edition. Client workbook. New York: Oxford University Press.

 

Beck, A.T., Emery, G. and Greenberg, R.L. (1990). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books. 

 

Benson, H. (1975, 2000). The relaxation response. New York: Avon.

 

Bernstein, D.A., Borkovec, R.G. and Hazlett-Stevens, H. (2000). New directions in progressive muscle relaxation: A guidebook for helping professionals. Westbury, CT: Praeger Publishers.

 

Bourne, E. (2005). The anxiety and phobia workbook. Oakland, CA: New Harbinger.

 

Butler, G. (1999). Overcoming social anxiety and shyness: A self-help guide using cognitive behavioral techniques. London, UK: Robinson. 

 

Carbonell, D. (2004). Panic attacks workbook: A guided program for beating the panic trick. Berkeley, CA: Ulysses Press.

 

Craske. M.G. and Barlow, D.H. (2007). Mastery of your anxiety and panic. Fourth edition, Therapist Guide.  New York: Oxford University Press.

 

Durand, V.M. (2008). When children don’t sleep well: Interventions for pediatric sleep disorders: Therapist guide. New York: Oxford University Press.

 

Edinger, J.D. and Carney, C.E. (2008). Overcoming insomnia. A cognitive-behavioral therapy approach: Therapist guide. New York: Oxford University Press.

 

Harris, R. (2007). The happiness trap: How to stop struggling and start living: A guide to ACT: The mindfulness-based program for reducing stress, overcoming fear and creating a rich and meaningful life. Oakland, CA: New Harbinger Press.

 

Hoffman, S.G. and Otto, M.W.(2008). Cognitive behavioral therapy for social anxiety disorder: Evidence-based and disorder specific treatment techniques. New York: Routledge.

 

Hope, D.A., Heimberg, R.G. and Turk, C.L. (2006). Therapist guide for managing social anxiety: A cognitive-behavioral therapy approach. New York: Oxford University Press.

 

Hope, D.A., Heimberg, R.G., Juster, H.R. and Turk, C.L. (2000). Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach, Client Workbook New York: Oxford University Press.

 

Jungsma, A.E. (2004). The complete anxiety treatment and homework planner. Hoboken, N.J.: John Wiley & Sons, Inc.

 

Kennedy, P. (2009). Coping effectively with spinal cord injuries, A group program: Therapist guide. New York: Oxford University Press.

 

Kennedy, P. (2009). Coping effectively with spinal cord injuries: A group program, workbook. New York: Oxford University Press.

 

Manne, S.L. and Ostroff, J.S. (2008). Coping with breast cancer: A couples focused group intervention: Therapist guide. New York: Oxford University Press.

 

Manne, S.L. and Ostroff, J.S. (2008). Coping with breast cancer: Workbook for couples. New York: Oxford University Press.

 

Marks, I. (2001). Living with fear. Second edition. London, UK: McGraw-Hill.

 

Messina, J.J. (2013). Tools for coping series: (1) Self-esteem seekers anonymous-The SEA’s program manual; (2) Laying the foundation: Personality traits of low self-esteem; (3) Tools for handling loss; (4) Tools for personal growth; (5) Tools for relationships; (6) Tools for communications; (7) Tools for anger work-out; (8) Tools for handling control issue; (9) Growing down:Tools for healing the inner child; (11) Tools for a balanced lifestyle, retrieved at www.coping.us

 

Otis, J.D. (2007). Managing chronic pain: A cognitive-behavioral therapy approach. Workbook. New York: Oxford University Press.

 

Penedo, F.J., Antoni, M.H. and Schneiderman, N. (2008). Cognitive-behavioral stress management for prostrate cancer recovery: Facilitator guide. New York: Oxford University Press.

 

Pincus, D.B., Ehrenreich, J.T. and Mattis, S.G. (2008). Mastery of anxiety and panic for adolescents: Riding the wave. Therapist guide. New York: Oxford University Press.

 

Satterfield, J.M. (2008). A cognitive-behavioral approach to the beginning of the end of life: Minding the body. Facilitator guide. New York: Oxford University Press.

 

Stein, M.B. and Walker, J.R. (2001). Triumph over shyness: Conquering shyness and social anxiety. New York: McGraw Hill.

 

Taylor, S. (2000). Understanding and treating panic disorder: Cognitive and behavioral approaches. Chichester, UK: Wiley.

 

Wells, A. (2009). Metacognitive therapy for anxiety and depression. New York: The Guilford Press.

 

Wilson, K.G. and Dufrene, T. (2010). Things might go terribly, horribly wrong: A guide to life liberated from anxiety. Oakland, CA: New Harbinger Publications, Inc.

 

Wilson, R. (2009). Don’t Panic: Taking control of anxiety attacks (3rd ed.). New York: HarperCollins.

 

Wincze, J.P. (2009). Enhancing Sexualitiy-A Problem Solving Approach to Treating Dysfunction, Second Edition, Therapist Guide. New York: Oxford University Press.

 

Wincze, J.P. (2009). Enhancing sexualitiy: A problem solving approach to treating dysfunction, Second Edition, Workbook. New York: Oxford University Press.

 

Zinbarg, R.E., Craske, M.G. and Barlow, D.H. (2006). Mastery of your anxiety and worry: Therapist guide. Second edition. New York: Oxford University Press.

References for Anxiety Disorders


Acarturk, C., Cuijpers, P., van Straten, A. and de Graaf, R. (2009). Psychological treatment of social anxiety disorder: a meta-analysis. Psychological Medicine, 39, 241-254. doi: 10.1017/S0033291708003590  

 

Andrews, G., Oakley-Browne, M., Castle, D., Judd, F., Baillie, A. (2003). Summary of guideline for the treatment of panic disorder and agoraphobia. Australasian Psychiatry, 11(1) 29-33. 

 

Antony, M and Rowa, K. (2005). Evidenced-based assessment of anxiety disorders in adults. Psychological Assessment, 17(3) 256-266. doi: 10.1037/1040-3590.17.3.256

 

Ayers, C., Sorrell, J., Thorp, S. and Wetherell, J. (2007). Evidence-based psychological

treatments for late-life anxiety. Psychology and Aging, 27, 8-17. doi: 10.1037/0882-7974.22.1.8  

 

Balon, R. (2001). Anxiety across the lifespan: Epidemiological evidence and treatment data. Depression and Anxiety, 13(4), 184-189. 

 

Baez, T. (2005). Evidenced-based practice for anxiety disorders in college mental health. Journal

of College Student Psychotherapy. 20(1), 33-548. doi:10.1300/J035v20n01_04  

 

Bandelow, B., Seidler-Brandler, U., Becker, A., Ruther, E. and Wedekind. (2007). Meta-analysis

of randomized controlled comparisons of psychopharmacological and psychological treatments for anxiety disorders. World Journal of Biological Psychiatry, 8(3), 175-187. 

 

Beamish, P.M., Granello, D.H. and Belcastro, A.L. (2002). Treatment of Panic Disorders: Practical Guidelines. Journal of Mental Health Counseling, 24(3), 224-246.

 

Borkovec, T. D., Newman, M.G., Pincus, A.L. and Lytle, R. (2002). A component analysis of cognitive-behavioral therapy for generalized anxiety disorder and the role of interpersonal problems. Journal of Consulting and Clinical Psychology70, (2) 288-298. doi: 0.1037//0022-006X.70.2.288 

 

Byrne, M., Carr, A., and Clark, M. (2004). The efficacy of couples-based interventions for panic

disorder with agoraphobia. Journal of Family Therapy, 26(2), 105-125.

 

Carmin, C. N. and Albano, A. M. (2003). Clinical management of anxiety disorders in psychiatric settings: Psychology's impact on evidence-based treatment of children and adults. Professional Psychology, 34(2) 170-176. doi: 10.1037/0735-7028.34.2.170 

 

Compton, S.N., Walkup, J.T., Albano, A.M., Piacentini, J.C., Birmaher, B., Sherrill, J.T.,

Ginsburg, G.S., Rynn, M.A., McCracken, J.T., Wasick, B.D., Lyengar, S., Kendall, P.C., and March, J.S. (2010). Child/Adolescent anxiety multimodal study (CAMS): Rationale, design, and methods. Child and Adolescent Psychiatry and Mental Health, 4, 1-15. doi:10.1186/1753-2000-4-1

 

Deacon, B.S. and Abramowitz, J.S. (2004). Cognitive and Behavioral Treatments for Anxiety

Disorders: A Review of Meta-analytic Findings. Journal of Clinical Psychology, 60(4), 429-441. DOI: 10.1002/jclp.10255 

 

Bezerra de Menezes, G., Coutinho, E.S.F., Fontenelle, L.F., Vigne, P., Figueira, I. and Versini,

M. (2011). Second-generation antidepressants in social anxiety disorder: meta-analysis of controlled clinical trail. Psychophacology, 215, 1-11. DOI 10.1007/s00213-010-2113-3

 

Dugas, M. J., Ladouceur, R., Leger, E., Freeston, M. H., Langlois, F., Provencher, M.D. and

Boisvert, J. M. (2003). Group cognitive-behavioral therapy for generalized anxiety disorder: Treatment outcome and long-term follow-up. Journal of Consulting and Clinical Psychology71(4), 821-825. doi: 10.1037/0022-006X.71.4.821 

 

Freedman, S. and Adessky, R. (2009). Cognitive behavior therapy for panic disorder. The Israel

Journal of Psychiatry and Related Sciences, 46(4), 251-256. 

 

Galassi, F., Quercioli, S., Charismas, D., Niccoli, V. and Barculli, E. (2007). Cognitive-

behavioral group treatment for panic disorder with agoraphobia. Journal of Clinical Psychology, 63(4), 409-416. doi: 10.1002/jclp.20358 

 

Gaston, J.E., Abbott, M.J., Rapee, R.M. and Neary, S.A. (2006). Do empirically supported

treatments generalize to private practice? A benchmark study of a cognitive-behavioral treatment programme for social phobia. Britich Journal of Clinical Psychology, 45, 33-48. DOI:10.1348/014466505X35146

 

Hicks, T.V., Leitenberg, H., Barlow, D. H., Gorman, J. M., Shear, M.K. and Woods S.W. (2005).

Physical, mental, and social catastrophic cognitions as prognostic factors in cognitive-behavioral and pharmacological treatments for panic disorder. Journal of Consulting and Clinical Psychology, 73(3), 506-514. doi: 10.1037/0022-006X.73.3.506 

 

Hofmann, S.G. and Smits, A.J. (2008). Cognitive-behavioral therapy adult anxiety disorders: A

meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69(4), 621-632.

 

Hoffman, E.J. and Mathew, S.J. (2008). Anxiety disorders: A comprehensive review of

pharmacotherapies. Journal of Medicine, 75, 248-262. DOI:10.1002/msj.20041

 

Hoyer, J., Beesdo, K., Gloster, A. T., Runge, J., Hofler, M. and Becker, E. S. (2009).Worry

exposure versus applied relaxation in the treatment of generalized anxiety disorder. Psychotherapy and Psychosomatics, 78, 106-115. doi: 10.1159/000201936 

 

Katzman, M.A. (2009). Current consideration in the treatment of generalized anxiety

disorder. CNS Drugs, 23(2), 103-120. doi: 1172-7047/09/0002-0103/$49.95/0  

 

Langhoff, C., Baer, T., Zubraegel, D. and Linden, M. (2008). Therapist-patient alliance, patient-

therapist alliance, mutual-therapeutic alliance, therapist-patient concordance, and out come of CBT in GAD. Journal of Cognitive Psychotherapy: An International Quarterly, 10(1), 68-79. doi: 10.1891/0889.8391.22.1.68 

 

Liber, J., Van Widenfelt, B., Utens, E., Ferdinand, R., Van der Leeden, A., Gastel, W., and

Treffers, P. (2008). No differences between group versus individual treatment of childhood anxiety disorders in a randomised clinical trial. Journal of Child Psychology and Psychiatry, 49(8), 886-893. doi:10.1111/j.1469-7610.2008.01877.x 

 

Mitte, K. (2005). Meta-analysis of cognitive-behavioral treatemnts for generalized anxiety

disorder: A comparison with pharmacotherapy. Psychological Bulletin, 131(5), 785-795. doi: 10.1037/0033-2909.131.5.785 

 

Newman, M., Castonguay, L., Borkovec, T., Fisher, A. and Nordberg, S. (2008). An open trial of

integrative therapy for generalized anxiety disorder. Psychotherapy: Theory, Research, Practice, Training, 45(2), 135-147. doi: 10.1037/0033-3204.45.2.135  

 

Rapee, R., Abbott, M. and Lyneham, H. (2006). Bibliotherapy for children with anxiety disorder

using written materials for parents: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74(3), 436-444. doi: 10.1037/0022-006X.74.3.436  

 

Stein, D. (2006). Evidence-based treatment of anxiety disorders. International Journal of

Psychiatry in Clinical Practice, 10(1), 16-21. doi: 10.1080/13651500600552487  

 

Stewart. R. E. and Chambless, D.I. (2009). Cognitive-behavioral therapy for adult anxiety

disorders in clinical practice: A meta-analysis of effectiveness studies. Journal of Consulting and Clinical Psychology, 77(4), 595-606. doi:10.1037/a0016032  

 

Verdeli, H., Mufson, L., Lee, L. and Keith, J.A. (2006). Review of evidenced based

psychotherapies for pediatric mood and anxiety disorders. Current Psychiatry Reviews (2), 395-421. doi: 1573-4005/06 $50.00+.00 

WHERE DO I GO FROM HERE?

CONCERNING ANXIETY DISORDERS

Now that you have read this section, in “My Mental Health Professional Practitioner Journal” record your answers and reactions to the following questions:

  1. How will this information help me as a Mental Health Professional?
  2. How interested am I in implementing Evidence Based Practices concerning Anxiety Disorders in my clinical practice?
  3. Why is it important that I learn more about Anxiety Disorders?
  4. What more do I need to know about Anxiety Disorders?
  5. Where can I go to obtain more information about Anxiety Disorders?
  6. Where can I go to obtain the journal articles, manuals, workbooks or guidebooks on Anxiety Disorders?