Module Four ANXIETY AND SOMATOFORM DISORDERS Lesson 1: Anxiety and its manifestations (2 training hours) Lesson 2: Disorders caused by anxiety (2 training hours) Lesson 3: The causes and the treatment of Anxiety Disorders (2 training hours) Lesson 4: Somatoform Disorders (2 training hours) TOTAL TIME 8 TRAINING HOURS OF 45 MINUTES

Lesson 1 ANXIETY AND ITS MANIFESTATIONS TIME : 90 minutes (2 training hours of 45 minutes)

Step 1: Introduction (10΄) Anxiety, like sadness, is a normal emotion. Usually anxiety is a reaction to a stressful situation. Normal anxiety is the one we feel when we are exposed to external stressful situations and remains until the solution of the problem. We are aware of anxiety both by psychological and somatic expression. Anxiety’s somatic symptoms derive from the hyperactivity of Autonomous Nervous System.

Step 2: Discussion (10΄) Can anxiety be useful in some cases but not in other?

Step 3: Brainstorming (10΄) How is anxiety manifested?

Step 4: Slide projection (10΄) Slide 4.1.1: Anxiety’s manifestations Emotion of stress, uneasiness, fear, nervousness Irritability Impossible to relax Difficulties in concentration Muscles aches (headaches, abdominal pain) Poor appetite Restless sleep – difficulties to fall asleep Somatic symptoms from Autonomous Nervous System

Step 4 (continued) Somatic symptoms from the Autonomous Nervous System Dry mouth Fast breathing irregular heart beating Dizziness – feel faint Excitement Perspiration Fear Hyperactivity of cysts and intestines

Step 5: Theory presentation (5΄) Normal anxiety becomes alarming when the symptoms are so intense or they last for so long that the person cannot accomplish its everyday tasks, because they are extremely painful and stressful. Then it is considered that the person shows an Anxiety Disorder. The Anxiety Disorders are many times described as “neurosis”. The term “neurosis” is used to distinguish “psychosis” from disorders where the person does not lose contact with reality (there are no delusions or aberrant ideas). Neurosis’ symptoms are similar to experiences that all people have but more severe.

Step 6: Exercise and discussion (35΄) Pen and paper Describe briefly a personal experience that filled you with anxiety.

Step 7: Questions and comments (5΄)

Step 8: Lesson’s evaluation (5΄)

Lesson 2 DISORDERS CAUSED DROM ANXIETY TIME : 90 minutes (2 training hours of 45 minutes)

Step 1: Slide projection (10΄) Slide 4.2.1: Anxiety Disorders Panic Attack Agoraphobia Specific Phobia Social Phobia Generalized Anxiety Disorder (GAD) Posttraumatic Stress Disorder Obsessive Compulsive Disorder

Step 2: Discussion (10΄) Have you ever met persons with one of the disorders mentioned above?

Step 3: Exercise (25΄) Leaflet 4.2.1: Clinical Cases Which Anxiety Disorder has each of the persons mentioned?

Step 4: Theory presentation (35΄) Panic attack Recurrent panic attacks, usually under great stress. The person needs to abandon the situation it is into. Because of the intensity of physical symptoms, the person believes that is going to die. Between the attacks the person might show milder anxiety symptoms.

Step 4 (continued) Agoraphobia Intense anxiety when found in specific locations or situations or even thinking of these. Anxiety might be so intense that manifests Panic Attack. The person feels like loosing control of the situation. Usually avoids these locations or situations or needs to be accompanied by another person. In Agoraphobia, fear is not related to a specific situation but to seveeral.

Step 4 (continued) Specific Phobia The person fears of a specific object or situation and has the tendency to avoid it. The thing might be: a dog, a cockroach, other animal or blood, injections, etc. The specific situations include: enclosed spaces, height, airplanes, etc. The person fears that something bad is going to happen when he/ she meets the object or is found in a specific situation. May be the person fears that he/she is going lose control (of the situation), have a panic attack or faint.

Step 4 (continued) Social Phobia Anxiety (or distress?) is apparent to social or performance situations (to all or specific). The person is worried that might be the centre of interest. Tends to avoid the situation that is afraid of.

Step 4 (continued) Generalized Anxiety Disorder (GAD) At this disorder the person experiences distress and anxiety for long periods of time, usually longer than 6 months. Along with anxiety emotion the person shows many other stress symptoms.

Step 4 (continued) Posttraumatic Stress Disorder (PTSD) Disorder developed after the person has experienced a severe traumatic event. The person might develop various symptoms in which there are included : Symptoms of anxiety and depression. Recurrent memory of the event in dreams or re-experiencing it (…? ). Tendency to avoid thoughts, conversations or activities that remind him/ her the event.

Step 4 (continued) Obsessive Compulsive Disorder Obsessions are uncontrollable intrusive thoughts or ideas, compulsions or images that come to the person’s mind. Distract his/her attention and prevent him/her from accomplishing their tasks. Compulsions are repeated actions that the person feels obligated to do even though these are opposite to his sense. In most of the cases the person feels obligated to execute them in order to eliminate the anxiety (distress) caused by a compulsive idea and prevent a horrible event.

Step 5: Questions and comments (5΄)

Step 6: Lesson’s evaluation (5΄)

Lesson 3 THE CAUSES AND THE TREATMENT OF ANXIETY DISORDERS TIME : 90 minutes (2 training hours of 45 minutes)

Step 1: Slide projection (10΄) Slide 4.3.1: rate of incidence of Anxiety Disorders Disorder % of General Population Anxiety Disorders in total 20 Panic Attacks 2 Agoraphobia 3 Specific Phobia 9 Social Phobia 8 Generalized Anxiety Disorder 3 Posttraumatic Stress Disorder (PTSD) ? Obsessive Compulsive Disorder 2

Step 2: Brainstorming (5΄) Which factors you think contribute to anxiety disorders?

Step 3: Slide projection (10΄) Slide 4.3.2: the causes of Anxiety Disorders Genetic Factors Hereditary predisposition Experiences in early age Parting High emphasis to achievements Pressure for compromises Recent experiences Stressful situations Incertitude Conflict Biological factors Dysfunction of Autonomous Nervous System

Step 4: Group discussion (20΄) Which are in your opinion the appropriate therapeutical interventions for treating the needs of the persons that suffer from each one of the Anxiety Disorders?

Step 5: Slide projection (20΄) Slide 4.3.3: therapeutical interventions in Anxiety Disorders Psychotherapies Expression and discussion of the problem Psychoanalytic psychotherapy Person – behaviour therapy? Cognitive –diagnostic Therapy Therapy with medication Antidepressants’ medication Tranquilizers

Step 6: Exercise (15΄) Leaflet 4.3.1: Clinical Cases Which are the appropriate therapeutical interventions for each of the persons mentioned ?

Step 7: Questions and comments (5΄)

Step 8: Lesson’s evaluation (5΄)

Lesson 4 SOMATOFORM DISORDERS TIME: 90 minutes (2 training hours of 45 minutes)

Step 1: Introduction (10΄) The experience of manifestation of physical symptoms with absence of somatic disease is known to everybody. Many times these appear when the person is stressed or tired. People differ to the tendency to express the symptoms and to how much attention they give to them In any place of the world, it is proved that 10 % to 30% of the persons that ask for help from the first aid services suffer from psychiatric problems and most of them arrive for somatic disturbances.

Step 2: Slide projection (10΄) Slide 4.4.1: relationship between physical and mental disorders Psychological factors as causing factors of the physical disease Psychiatric disorders can appear as physical illness Psychiatric consequences of physical illness Coexistence of physical and mental disorders Physical disturbances due to psychiatric disorder

Step 3: Brainstorming (20΄) Pen and paper Do you know any psychic disorders? Which are their symptoms ?

Step 4: Slide projection (5΄) Slide 4.4.2: The most common Somatoform and related to them Disorders Somatoform Disorders Somatization Disorder Hypochondriasis Conversion Disorder Disorders related to Somatoform Incomprehensible Pretentious Disorder Pretention

Step 5: Theory presentation (25΄) Somatoform Disorder It is the disorder during which the person shows various physical disturbances during many years. These symptoms cannot be justified/ explained from a physical illness.

Step 5 (continued) Hypochondriasis Is the obsessive occupation of the person with the fear or the idea that suffers from a serious disease. This is based on his personal explanation of physical symptoms or emotions which consider as proof to the physical disease.

Step 5 (continued) Conversion Disorder It was called Hysteria in the past. This term is replaced by Conversion Disorder. A conversion (traversing) symptom can indicate physical disease, but it is manifested with out the presence of a disease coming from unconscientiously With the person being unaware of it or without doing it on purpose. These disorders can be manifested in various forms: As movement dysfunction, for ex. Paralysis, fear, inability to speak. As senses dysfunction for example, pain, blindness, deafness. As psychiatric symptoms, for example, memory loss, running away (wandering with loss of memory and lack of recognition of its personality).

Step 5 (continued) Incomprehensible Pretentious Disorder In incomprehensible pretentious disorder the person tries with the production of the symptoms to gain the medical attention and care with no external motives. They might pretend that they have depression, delusions, traverse symptoms or pains, nausea, skin rashes, bleedings etc There is a special case in incomprehensible pretentious disorder known as Munchausen's syndrome. People who have this syndrome usually are admitted to hospital for a disease they pretend to have and undertake tests and treatments, even surgical procedures.

Step 5 (continued) Pretention similar symptoms appear again in Pretension, but there is always an external Motive, as for example avoiding the military service, early retirement, etc. Pretention is no mental disorder.

Step 6: Brainstorming (10΄) Express your ideas for therapeutical intervention you consider necessary to the treatment of Somatoform and Related to these Disorders?

Step 7: Questions and comments (5΄)

Step 8: Lesson’s evaluation (5΄)