unreality or detachment from self). In panic disorder, the attacks ... will lead to humiliation, embarrassment, rejection, or will offend others. The individual avoids.
Chapter 7: Depression, Anxiety and Other Disorders Authors: Bryann B. DeBeer, Ph.D., Brian D. Konecky, Ph.D., & Eric C. Meyer, Ph.D.
This is a chapter in a book published by Oxford University Press. DeBeer, B., Konecky, B., & Meyer, E.C. (2015). Depression, anxiety, and other disorders. In N. Ainspan, C. Bryan, & W. Penk (Eds.). Handbook of psychosocial interventions for veterans: A guide for the non-military mental health clinician. New York: Oxford University Press.
Anxiety and depressive disorders are the most common types of mental health disorders in the U.S. general population. In the National Comorbidity Survey – Replication, twelve-month prevalence rates for any anxiety or major depressive disorder were 18.1% and 6.7%, respectively (NCS-R; Kessler et al., 2005). Depression and anxiety are also the most common mental health problems among veterans (Meyer, Kimbrel, Tull, & Morissette, 2011). Moreover, depression is the second most common mental health diagnosis among Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND) veterans enrolled for VA healthcare, after posttraumatic stress disorder (PTSD; VHA, 2013). Anxiety and depression are consistently linked to functional impairment and lower quality of life, even when full diagnostic criteria are not met (Meyer et al., 2011). There is significant co-occurrence among these disorders, and cooccurrence is linked to greater symptom severity, increased functional impairment, and poorer treatment response (Meyer et al., 2011). This chapter discusses diagnostic profiles, cooccurrence with other disorders, and treatment for depression and anxiety disorders. Depression
According to the recently released Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), major depressive disorder (MDD) occurs when an individual experiences at least five of the following symptoms during a two week period: depressed mood, loss of pleasure or interest, changes in weight or appetite, sleep problems (i.e., insomnia, hypersomnia), retardation or agitation of psychomotor functioning which is noticed by others, diminished energy or fatigue, feelings related to worthlessness or unwarranted guilt, cognitive difficulties (e.g., thinking, concentration problems), or ideation related to frequent thoughts of death or suicide. All symptoms, with the exception of weight change and suicidal ideation, must be present nearly every day. Additionally, symptom onset must signify a change in functioning. A major change in DSM-5 is the removal of the explicit exclusion criterion in DSM-IVTR that symptoms were not better accounted for by bereavement. This change to the diagnostic criteria for MDD was made recognizing that the duration of “normal” bereavement can vary considerably. Removal of this exclusion criterion also indicates that an interpersonal loss may precipitate a major depressive episode (MDE). Many military personnel experience the loss of fellow soldiers during the course of military service. DSM-5 offers guidelines for distinguishing normal grief from a MDE. These considerations include the following: differences in the nature (i.e., predominant feelings of loss in bereavement vs. continual dysphoric mood and/or inability to experience pleasant emotions in MDE) and course of the dysphoric mood (i.e., decreasing over time with recurrences related to reminders of the loss vs. persistent experience not tied to specific triggers in MDE), the presence of positive emotions during grieving but not during an MDE, feelings of worthlessness or self-critical rumination in MDE, and the function of suicidal thoughts (e.g., to reunite with the loved one who has died vs. to escape pain in MDE). Several other disorders have been added or modified under the “depressive disorders” category in DSM-
5 (i.e., disruptive mood dysregulation disorder, persistent depressive disorder, premenstrual dysphoric disorder). Anxiety In DSM-5, post-traumatic stress disorder (PTSD) has been moved from the Anxiety Disorders section to the Trauma- and Stressor-Related Disorders section and is covered in chapter 6 of this handbook.
Generalized Anxiety Disorder In the DSM-5, generalized anxiety disorder (GAD) is conceptualized as inordinate anxiety and worry across numerous events and/or activities that is present for the majority of time for at least 6 months. In order to meet criteria for the disorder, the worry must be difficult to control and cause functional impairment or clinically significant distress. The frequency, intensity, and duration of the anxiety and worry are disproportionate to the actual impact or likelihood of the anticipated event. The anxiety and worry must correspond to at least three of six symptoms (i.e., restlessness or keyed up or on edge, easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbances). The criteria for GAD are nearly identical to those published in DSM-IV-TR. The only change is that DSM-5 suggests a broader consideration of whether symptoms are better accounted for by other mental health disorders. Specifically, whereas DSM-IV-TR states, “The focus of the anxiety and worry is not confined to features of an Axis I disorder,” DSM-5 states “The disturbance is not better explained by another mental disorder.” Relatedly, the stipulation that the disturbance does not occur exclusively during a Psychotic Disorder, a Mood Disorder, or a Pervasive Developmental Disorder has been removed.
Panic Disorder In the DSM-5, panic disorder is described as unexpected, repetitious panic attacks that reach their peak within minutes, during which various somatic and cognitive symptoms are experienced (e.g., palpitations or pounding heart, sweating, trembling, nausea, feelings of unreality or detachment from self). In panic disorder, the attacks themselves become feared and result in avoidance behaviors aimed at preventing subsequent attacks. Often, cognitions regarding attacks are related to the potential for death, embarrassing oneself socially, or fear of “going crazy” or “losing it.” This process can be thought of as developing a fear of fear, which results in problematic behavioral responses. The only significant change to the DSM-5 criteria is that panic disorder and agoraphobia are no longer linked, with individuals who previously met criteria for panic disorder with agoraphobia now receiving both diagnoses. Agoraphobia As mentioned above, in DSM-5 the diagnosis of agoraphobia no longer necessitates the concurrent presence of panic disorder. Agoraphobia is described as a considerable fear or anxiety brought on by exposure (real or anticipated) to two or more situations. Common examples include open spaces, enclosed spaces, or using public transportation. In such situations, the person may believe that escape might be prevented or help unavailable if they experience panic like symptoms or other symptoms perceived to be embarrassing or incapacitating. These situations are frequently avoided or endured under great duress or with the assistance of others.
Specific Phobia
DSM-5 describes specific phobia as considerable fear or anxiety in the presence of a specific situation or object. Such feared situations often provoke intentional avoidance, or, if unavoidable, are endured with extreme distress. Several changes to the diagnostic criteria for specific phobia are included in DSM-5. First, it is no longer required that the individual recognizes that the fear is excessive. Instead, the fear or anxiety must be excessive in relation to the actual danger present. Second, a minimum duration (i.e., typically 6 months or more) has been added. As a specific phobia can be similar to agoraphobia, the number of feared situations should be considered for the purpose of differential diagnosis. Social Anxiety Disorder (Social Phobia) Social anxiety disorder (SAD) is described as intense fear or anxiety in social situations (e.g., being watched while eating, public speaking) in which the individual perceives that they may be scrutinized or judged negatively. The person experiences fear of acting in a manner that will lead to humiliation, embarrassment, rejection, or will offend others. The individual avoids such situations or endures them with severe distress. DSM-5 includes several changes to the classification of SAD. First, it no longer requires that the individual recognize the fear as excessive or unreasonable. Instead, the level of fear or anxiety must be disproportional to the actual threat (considering socio-cultural context). Second, a minimum duration (i.e., typically 6 months or more) has been added. Third, the generalized subtype was removed. Fourth, a performance-only specifier was added which is used if the individual only fears public speaking or other public performance. Other Obsessive Compulsive Disorder
In DSM-5, Obsessive Compulsive Disorder (OCD) has been removed from the Anxiety Disorders Section and placed in a new section entitled Obsessive-Compulsive and Related Disorders. OCD is described as the presence of unwanted, intrusive, and unpleasant obsessions, compulsions, or both; which are either time consuming, extremely distressing, or cause functional impairment. Typically, individuals with OCD attempt to manage these obsessions via ignoring, suppressing, or neutralizing with other thoughts or actions (e.g., engaging in a compulsion). Obsessions are described as recurrent and incessant thoughts, images, or urges, and compulsions are described as mental acts or repetitive behaviors that an individual feels compelled to perform according to rigid rules or in reaction to an obsession. Compulsions are aimed at reducing distress or preventing a frightening circumstance, and are either excessive or not realistically related to the feared outcome they are supposed to prevent. The compulsions in OCD functioning similarly to anxiety disorders in that they are often avoidance behaviors that temporarily reduce distress or are engaged in to prevent feared events from occurring. Several changes have occurred in the classification of OCD. First, it is no longer a requirement that the individual recognizes the images, obsessional thoughts, or impulses as products of their own mind. This is captured in the modified specifiers “with good or fair insight,” “with poor insight,” or “with absent insight/delusional beliefs.” Second, the criterion that obsessions could not merely be exaggerated worries concerning life problems has been removed. Third, specification regarding whether or not the individual has or previously had a history of a tic disorder was added. Co-occurrence with PTSD, Traumatic Brain Injury (TBI), and Physical Injuries Due to advances in battlefield-administered medical aid, more service members experiencing severe trauma and physical injuries are likely to survive and return home from
warzone service. Indeed, musculoskeletal injuries are the most common category of diagnoses among OEF/OIF/OND veterans enrolled for VA healthcare (VHA, 2013). Moreover, the complexity of psychological and physical injuries sustained by war veterans has increased, and it is not uncommon for veterans to experience multiple, co-occurring mental health problems, as well as TBI and physical injuries. Anxiety disorders and depression often co-occur with PTSD in veterans and civilians (Meyer et al., 2011). MDD has the highest rate of co-occurrence with PTSD within veteran populations (55%), and veterans diagnosed with both disorders report higher symptom severity than veterans diagnosed with either PTSD or MDD (Gros, Price, Magruder, & Frueh, 2012). veterans with PTSD are significantly more likely to be diagnosed with additional anxiety disorders compared to veterans without a diagnosis of PTSD. Within anxiety disorders, generalized anxiety disorder co-occurs the most frequently with PTSD, followed by panic disorder and OCD. Traumatic Brain Injury (TBI) is among the most common injuries experienced by service members during OEF/OIF/OND. In a study of OEF/OIF/OND veterans, 46% screened positive for one or more (primarily mild) TBI (Morrisette et al., 2011). TBI is associated with both PTSD and depression in OEF/OIF/OND veterans (Morrisette et al., 2011). In a survey of OEF/OIF/OND veterans with probable TBI, 37% also reported probable PTSD or MDD (Tanelian & Jaycox, 2008). Within that subgroup, most (78%) reported experiencing all three conditions (Tanelian & Jaycox, 2008). Within civilian populations, TBI is associated with increased risk of PTSD, panic disorder, social phobia, agoraphobia and MDD (Meyer et al., 2011). Treatment for Depression and Anxiety Disorders
In this section, we present an overview of empirically-supported treatments for depression and anxiety disorders. For further information on empirically supported treatments, please see the Society of Clinical Psychology (Division 12 of the American Psychological Association) at: http://www.apa.org/divisions/div12/cppi.html. Depression Cognitive therapy, behavioral therapy, and interpersonal therapy are all well-established, empirically supported interventions to treat depression (Barlow, 2008). Cognitive therapy addresses maladaptive thought patterns and information processing biases that are associated with depression. Specifically, cognitive therapy for depression is based on the assertion that individuals who are depressed frequently experience negative automatic thoughts about the self, the world and the future, as well as cognitive distortions (e.g., all-or-none thinking, magnification, emotional reasoning, jumping to conclusions, should statements) that maintain and strengthen depressive symptoms. The goal of cognitive therapy is to modify these maladaptive thought patterns (Barlow, 2008). The therapist works collaboratively with the client to identify and change these thoughts. Specific techniques in cognitive therapy include evaluating the evidence for and against thoughts, using Socratic questioning, and challenging the validity of negative automatic thoughts. As these thought patterns are modified, depressive symptoms decrease. Behavioral components are typically incorporated into cognitive therapy (e.g., behavioral experiments designed to collect and evaluate evidence regarding negative beliefs). Behavioral therapy is also a well-supported treatment for depression (Barlow, 2008; Jakupcak, Wagner, Paulson, Varra, & McFall, 2010). This approach is based on learning theory, which posits that depression results from a lack of positive reinforcement in the depressed
individual’s environment. Thus, the goal of behavioral therapy for depression is to increase the amount of pleasant activities that these individuals experience. This goal is accomplished through conducting a functional analysis to determine behaviors, or lack thereof, that maintain symptoms, discussing the behavioral model with the client, self-monitoring, activity scheduling, and problem solving. Behavioral therapy has been found to be effective when implemented with veterans in a primary care setting (Jakupcak et al., 2010). Further, behavioral therapy has been shown to reduce symptoms of both depression and co-occuring PTSD in veterans (Jakupcak et al., 2010). Both cognitive and behavioral therapy for depression can be administered in group or individual format. Interpersonal therapy (IPT) for depression was developed based on attachment theory and literature demonstrating the association between interpersonal deficits and depression (Barlow, 2008). Specifically, individuals with depression experience difficulties with interpersonal functioning, stress, role disputes, complicated bereavement and role transitions. In the interpersonal model, depressive episodes are thought to result from stressful life events, particularly those of an interpersonal nature. The goals of IPT are to address an interpersonal problem that appears key in the development of the depressive episode, and to increase social skills in order to improve interpersonal relations going forward. A primary interpersonal problem is identified as the focus of therapy, and the therapist and client work together to address the problem. Techniques in IPT include communication analysis, decision analysis, role plays, connecting the client’s mood to events, and exploration of the client’s options. Once the main problem is addressed, the therapeutic process is reviewed so that the client is better equipped to address subsequent interpersonal problems.
Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 2012) is a form of behavior therapy that is gaining empirical support in the treatment of depression (Walser, Karlin, Trocetl, Mazina, & Taylor, 2013). ACT is a trans-diagnostic approach that focuses on acceptance of unwanted emotions and detachment or defusion from unwanted thoughts as opposed to attempting to challenge or modify these thoughts. Clients work to clarify their values and commit to mindfully engaging in values-consistent behavior even when experiencing negative thoughts and depressive feelings. A large study of veterans indicates that individually administered ACT is associated with significant reductions in symptoms of depression (Walser et al., 2013). Specific Phobia Although specific phobia is one of the most common anxiety disorders, it is relatively rare for individuals with such to seek treatment (Barlow, 2008). Among empirically supported treatments for specific phobia, in vivo and imaginal exposure are the most well-supported. In vivo exposure involves exposing the individual to the feared stimulus. For example, if an individual had a phobia of dogs, treatment would involve exposing the client to a dog within the context of a therapeutic environment. Imaginal exposure involves a similar method except the client imagines the feared stimulus. In both in vivo and imaginal exposure, clients are instructed to rate their subjective units of distress (i.e., SUDS) on a scale from 0 (i.e., no distress) to 100 (i.e., the highest distress possible). During treatment, introduction of the feared stimulus will typically raise the client’s SUDS level, but over time the patient will acclimate to the feared stimulus and their SUDS level will reduce. Repeated exposures to the feared stimulus typically result in eventual reduction of symptoms. In vivo exposure reduces symptoms effectively and is considered to be superior to imaginal exposure. However, there may be cases in which exposure
to the feared stimulus may be difficult for practical reasons, in which case imaginal exposure may be preferred. Social Anxiety Disorder The most well-supported treatment for social anxiety disorder is cognitive behavioral therapy (CBT), which combines both cognitive and behavioral approaches (Barlow, 2008). At the beginning of therapy, the therapist and the client work together to construct a fear hierarchy in which the client identifies social situations that range from mildly to extremely distressing. During treatment, specific techniques include cognitive restructuring, exposure, psychoeducation, role plays, and homework assignments. During cognitive restructuring, the therapist guides the client in modifying maladaptive thought patterns regarding social situations so that they are viewed in a more realistic and less threatening way. Group therapy is an excellent format to administer CBT for social anxiety, as it provides a natural arena for exposure and social support. Nonetheless, if group treatment is not available, research indicates that individual treatment is also efficacious (Barlow, 2008). Generalized Anxiety Disorder CBT is also effective in treating Generalized Anxiety Disorder (GAD), as well as cooccuring depression (Barlow, 2008). Although CBT programs for GAD differ, typical treatment components include psychoeducation, early identification of situational triggers, worry monitoring, applied relaxation, cognitive restructuring, and practice of newly learned coping skills (e.g., behavioral experiments or self-control desensitization). While the evidence to support CBT for GAD is primarily based on individual therapy, there is also evidence that CBT for GAD is efficacious when administered in a group format. ACT and other mindfulness and acceptance-
based forms of behavior therapy are also gaining support as a treatment for GAD (Roemer, Orsillo, & Salters-Pedneault, 2008). Panic Disorder and Agoraphobia As outlined above, and in contrast to DSM-IV, DSM-5 Panic Disorder and Agoraphobia have been conceptualized as two separate disorders. As current empirically supported treatments are based on the DSM-IV diagnosis, this section will focus on treatment of both disorders. CBT is an efficacious treatment for panic disorder and agoraphobia (Barlow, 2008). The main treatment components are exposure and cognitive restructuring. Exposure includes two subcomponents, interoceptive and in vivo exposure. Interoceptive exposure involves the client engaging in in-session exercises to induce bodily sensations associated with panic (i.e., increased heart rate, light-headedness, shortness of breath). In vivo exposure consists of development of and gradual exposure to a hierarchy of feared situations. The individual is exposed to the feared situation until their SUDS level peaks and then gradually lessens. Cognitive restructuring focuses on helping clients identify and modify catastrophic or otherwise unrealistic beliefs about the likely consequences of panic. Psychoeducation, monitoring the frequency and severity of panic, homework assignments, breathing retraining, and applied relaxation are other techniques used in CBT for panic disorder and agoraphobia. It is important to have a medical professional determine that there are not medical risks (e.g., cardiopulmonary disorders, hyperthyroidism) which better explain panic disorder and pose a risk for conducting interventions such as interoceptive exposure. Obsessive-Compulsive Disorder Exposure with response prevention (EX/RP) is the intervention with the highest level of research support for the treatment of OCD (Barlow, 2008). Perhaps even more so than for
treatment of other anxiety disorders, it is essential for the clinician to spend time on rapport building and preparing the client to engage in the active treatment phase. The preparation phase includes psychoeducation, building rationale for treatment, teaching ritual monitoring skills, assessing the clients beliefs regarding abstaining from compulsive behaviors, and developing a specific treatment plan. The active treatment phase consists of graduated imaginal and in vivo exposures that create obsessional distress while abstaining from compulsive rituals and avoidance behaviors. Repeated exposure with response prevention typically leads to symptom reduction. In order to facilitate generalization of treatment gains, home visits are routinely included. This treatment is administered individually and there is some support that it is more effective when administered intensively (i.e., daily therapy sessions for 3-4 weeks; Barlow, 2008). Treatment of Co-occuring Disorders Co-occurrence of multiple mental and physical health problems can pose challenges in terms of setting priorities when planning treatment. For example, a clinician treating a veteran with PTSD and depression may be unsure whether to select an evidence-based treatment approach targeting PTSD or depression. A number of approaches (e.g., single-disorder, sequential, parallel, and integrated treatments) may be used in planning treatment for veterans with co-occurring disorders (Meyer et al., 2011). Some treatments designed to address a single disorder have been found to be efficacious in reducing symptoms of co-occurring conditions. For example, treatments for PTSD such as prolonged exposure (PE) or cognitive processing therapy (CPT) have been found to reduce depressive symptoms in addition to reducing PTSD symptoms in veterans (Liverant, Suvak, Pineles, & Resick, 2012). Behavioral treatment for depression may also reduce symptoms of PTSD in veterans (Jakupcak et al., 2010). Next, there is a growing
movement toward trans-diagnostic treatment approaches for anxiety and depression. Transdiagnostic approaches may be well-suited to addressing co-occurring conditions in an efficient, integrative manner. Moreover, they may facilitate training and dissemination by focusing on a single set of therapeutic principles rather than multiple disorder-specific treatment protocols. Barlow and colleagues (Farchione et al., 2012) developed a Unified Protocol (UP) for emotional disorders (i.e., anxiety and depression) based on therapeutic elements common to the CBT-based approaches described above (e.g., psychoeducation, cognitive restructuring, exposure, prevention of emotional avoidance). The core treatment components of the UP are well-supported, and preliminary data from a clinical trial with a heterogeneous sample of 37 civilians with primary anxiety disorders support its efficacy (Farchione et al., 2012). Finally, ACT is a trans-diagnostic approach that has demonstrated utility in treating a broad range of mental and physical health conditions, including depression, anxiety, and chronic pain (Hayes, Strosahl, & Wilson, 2012). More thorough empirical validation of these trans-diagnostic approaches is ongoing. Conclusion Anxiety and depression are among the most common mental health problems among veterans. These disorders are associated with significant distress, reduced quality of life, greater functional impairment, decreased productivity, greater absenteeism, early separation from military service, and high utilization of health care resources (e.g., Creamer et al., 2006). Moreover, these problems frequently co-occur, and co-occurrence is associated with greater symptom severity, functional impairment, and worse treatment response. Physical injuries sustained during military service, including TBI, often compound these challenges. When planning treatment, clinicians may draw upon the multiple evidence-based psychosocial treatments that exist for these problems. Finally, trans-diagnostic treatment approaches are
increasingly being applied as a way of efficiently addressing these inter-related mental and physical health challenges.
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