Psych2
Evidence for Genetic Origins for panic disorder
"First degree" relatives of someone with panic disorder are 8 times more likely to develop it Concordance among MZ twins has been found to range from 20-40%.
Social Anxiety Disorder: Types
"Generalized" Social Anxiety: most social situations are feared In other cases, social anxiety will be specific to certain social situations; public speaking and speaking up in a meeting/class are the most commonly feared situations Other commonly feared situations include meeting new people, going to parties, talking to people in authority positions, and dating
Panic Disorder: DSM-5 Definition
"Recurrent" unexpected (uncued) panic attacks Actual frequency and severity of attacks varies and is not specified At least 1 of the attacks has been followed by 1 month of 1 or more of following: concern about additional attacks or their consequences Maladaptive change in behavior related to the attacks
What Causes Panic Disorder?
(genetic vulnerability triggered by environmental stressors) There is evidence for both genetic and environmental factors in causing panic disorder
How Common is Social Anxiety Disorder?
12% of the US population experience social anxiety disorder at some point in their lives Social anxiety disorder is the 3rd most common DSM disorder in the US population (after Major Depression and Specific Phobia) In recent research, generalized social anxiety (>8 feared situations) was found to exist among 71% of those meeting criteria for the disorder
How Common is Panic Disorder?
22% of the US population reported experiencing at least one panic attack in their lifetime (most had cued panic attacks) Roughly 5% of the population meet criteria for panic disorder (most without agoraphobia) Thus, many individuals experience panic attacks, but most do not develop panic disorder
hypomanic symptoms
3 or more of following symptoms have persisted during the period (4 if mood only irritable): Inflated self-esteem or grandiosity Decreased need for sleep (feels rested after 3 hours) More talkative than usual Flight of ideas or racing thoughts Distractibility Increase in "goal-directed" behavior or psychomotor agitation Excessive involvement in risky pleasurable activities (e.g., buying sprees, casual sex, gambling, etc.)
manic symptoms of bipolar disorder
3 or more of following symptoms have persisted during the period (4 if mood only irritable): Inflated self-esteem or grandiosity Decreased need for sleep (feels rested after 3 hours) More talkative than usual Flight of ideas or racing thoughts Distractibility Increase in "goal-directed" behavior or psychomotor agitation Excessive involvement in risky pleasurable activities (e.g., buying sprees, casual sex, gambling, etc.)
Bipolar I: DSM-5 "Features"
A majority (roughly 60%) of manic episodes have "psychotic features" Psychotic Features Delusions or hallucinations (usually "mood congruent" in theme) may co-occur with manic, and/or major depressive episodes Delusions or hallucinations that co-occur with manic episodes are likely to reflect "grandiose" and "expansive" themes
Panic Attack (DSM-5 Definition)
Abrupt surge of intense fear or intense discomfort that develops abruptly and peaks within minutes of onset 4 or more of following symptoms need to occur: Palpitations, pounding or accelerated heart Sweating Trembling or shaking Sensations of shortness of breath Feelings of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded or faint Chills or hot flushes Numbness or tingling sensations (paresthesias) Derealization (feelings of unreality) or depersonalization (being detached from oneself) Fear of losing control or "going crazy" Fear of dying
Rule-Outs for PTSD
Adjustment Disorder (stressful event does not meet criteria for a traumatic event) Acute Stress Disorder (similar symptoms but duration less than 1 month) Flashbacks should be distinguished from psychotic or dissociative experiences caused by other disorders
Social anxiety most typically begins during _____
Adolescence
All of the following are evidence-based treatments of PTSD except:
Antipsychotics
Social Anxiety: Treatment
As in panic disorder, evidence supports the effectiveness of both medication and psychosocial treatment However, evidence supports that psychosocial treatment (cognitive-behavioral treatment) is associated with a lower likelihood of later relapse
OCD: Treatment
As in the anxiety disorders, evidence supports the effectiveness of both medication and psychosocial treatment Antidepressants (specifically SSRI's) show evidence for reducing OCD symptoms - One psychosocial treatment has strong support: individual CBT
Bipolar I Disorder: Importance
Associated with a high degree of impairment and hospitalization Increased suicide risk (up to 50% will attempt suicide, up to 15% will succeed) Suicide risk is particularly associated with "mixed" features- situation in which there is depression accompanied by manic energy Manic episodes are associated with increased risk of violence at rates similar to people with schizophrenia (roughly 8% will engage in violence) Violence is most associated with situations in which one challenges (tries to arrest, etc.) someone when they are manic
Bipolar II Disorder: DSM-5 Definition
At least one major depressive episode and at least one hypomanic episode (no manic or mixed episodes) Significant "distress" or disability Rule-outs of other causes (drugs, medical conditions, schizoaffective disorder)
Bipolar I Disorder: DSM-5 Definition
At least one manic episode Major depressive and hypomanic episodes may also occur (but not necessarily) Significant "distress" or disability Rule-outs of other causes (drugs, medical conditions, schizoaffective disorder) "Classic" Bipolar I pattern has Major Depressive Episodes that follow Manic Episodes
A risk in the use of benzodiazepines is that they can _____
Be addictive
How Does Bipolar Disorder Develop?
Bipolar Disorder develops across a wide-range of ages, but most typically appears at two periods The first typical period is between ages 21-25 The second, slightly less common, time is between ages 35-45 Early onset cases tend to have stronger family history and have a more severe presentation As with schizophrenia, there are also later onset cases after 45 (more common for women)
Social Anxiety: Psychosocial Treatment
Both individual and group-based CBT treatment have been found to be very effective Cognitive-behavioral treatment of social anxiety consists of two basic elements: Gradual (hierarchical) exposure to avoided situations Cognitive restructuring to counter-act cognitive distortions related to social anxiety Breathing retraining may also be used as a strategy to deal with associated panic attacks
What Causes PTSD?
By definition, the causes of PTSD are linked to environmental factors It has also been proposed that genetic factors may increase risk for exposure to certain types of trauma (assaultive trauma)
An area of the brain believed to be involved in OCD is called
Caudate Nucleus A lack of serotonin is also thought to be involved
Environmental Factors associated with Bipolar Disorder
Child abuse/neglect and other adverse childhood events Urban birth Cannabis use
Traumatic Events
Criminal Victimization Being suddenly violently attacked Disasters Tornadoes, floods, earthquakes, fires, terrorist attacks Common Traumatic Events Car accidents, work accidents, sudden deaths of loved ones Combat and War-Related Trauma Witnessing death or experiencing a life-threatening event Abuse Childhood physical, emotional, and sexual abuse Adult physical, emotional and sexual abuse (including rape and domestic violence)
Hoarding Disorder
Criteria include: Persistent difficulty discarding or parting with possessions, regardless of their actual value. This difficulty is due to a perceived need to save the items and distress associated with discarding them. The difficulty results in the accumulation of possessions that clutter or congest active living areas and substantially compromise their intended use Causes clinically significant distress or impairment in functioning
EMDR
Developed by Francine Shapiro in 1987 Two main elements: focus on a disturbing image or memory related to the trauma (exposure?) movement of the eyes back and forth (following therapist's fingers)
History of Concept of PTSD
Early descriptions of trauma 1666 Great fire of London U.S. Civil War Traumatic neurosis Hysterical neurosis War neurasthenia and shell shock War neurasthenia: weak nervous system deemed unable to handle the challenges of combat
CBT for PTSD
Education about the causes of PTSD symptoms Breathing retraining to counter-act physical over-arousal Cognitive restructuring to address the way that people interpret life situations as a result of the trauma Exposure to avoided situations related to PTSD Edna Foa's treatment of PTSD subsequent to sexual assault includes imaginal exposure to the traumatic event Virtual reality presents a promising new mechanism for exposure
"Traumatic Event": DSM-5 Definition
Exposure to actual or threatened death, serious injury or sexual violence in one or more ways: Directly experiencing the traumatic event Witnessing, in person, the event Learning that the traumatic event occurred to a close family member or friend (the event must have been violent or accidental) Experiencing repeated or extreme exposure to aversive details of the event(s) (e.g., first responders collecting human remains) Note: Does not include exposure through electronic media unless work-related
Men are more likely to experience bipolar disorder than women.
False
General Symptoms of Anxiety
Fear (emotional component) Worry/Rumination (cognitive component) Tenseness, jitteriness, accelerated heart rate (physiological component) Avoidance of feared situations (behavioral component)
Panic Disorder: History
First discussion of the experience akin to what we now call "panic attacks" appeared in the mid-1800's, under the term "irritable heart" (heart problem with no physical cause) Freud discussed "anxiety neurosis," but did not distinguish between generalized anxiety and panic disorder The category of panic disorder was officially born in the DSM-III published in 1980
Obsessive-Compulsive Disorder (OCD)
Freud discussed a case of treatment of "obsessional neurosis" (the Rat Man) OCD was categorized as an anxiety disorder in the DSM-IV, but was moved into its own category in the DSM-5, (along with Hoarding, Body Dysmorphic Disorder and Trichotillomania)
Twin study data suggest that the genetic contribution to Bipolar 1 disorder is ___ MDD.
Greater than
According to the DSM, in agoraphobia, people fear _____, whereas in social anxiety they fear____.
Having a panic attack, embarassment
The "response prevention" component of the psychological treatment for OCD involves:
Having clients refrain from engaging in rituals when exposed to anxiety-provoking stimuli
"Mass" Trauma Effects
In cases where large numbers of persons have been exposed to severe trauma (e.g., war, terrorism exposure), rates of PTSD go way up Among Vietnam veterans, rates of 20-30% were observed 25% of Sept. 11th survivors met criteria for "probable" PTSD
Bipolar Disorder: History
In the early 1900's Emil Kraepelin distinguished "Manic-depressive psychosis" from "dementia praecox" (which became schizophrenia); this distinction has persisted as bipolar disorder has continued to be seen as a mood, rather than psychotic, disorder
The distinction between mania and schizophrenia was originally made by:
Kraepelin
How Common is OCD?
Lifetime prevalence of 1% in the US Lifetime estimates from studies in other countries tend to hover between 1-3% Although previous research suggested that OCD is equally common among men and women, recent research found that it was 2x more common among women than men
How Common is PTSD?
Lifetime prevalence of roughly 7% in the USA Lifetime rates vary by gender: 5-6% among men, and 10-14% among women Thus, not everyone who experiences a traumatic event develops PTSD (much lower than 40-60% who experience trauma), and women are 2X more likely to develop it than men
Panic Disorder: Gender Difference
Like Major Depressive Disorder, panic disorder (both with and without agoraphobia) is more common among women than men (roughly 2x more common)
Agoraphobia
Marked fear or anxiety about two (or more) of the following five situations: -Using public transportation -Being in open spaces -Being in enclosed places -Standing in line or being in a crowd -Being outside of the home alone The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling; fear of incontinence) -Duration of at least 6 months
Social Anxiety Disorder
Marked or persistent fear of one or more social situations in which the individual is exposed to possible scrutiny by others The individual fears that he or she will act in a way that will be negatively evaluated The social situations almost always provoke fear or anxiety Situations either avoided or "endured with intense fear or anxiety" The fear is out of proportion to the actual threat posed by the situation and to the sociocultural context The fear lasts 6 months or longer Interferes with social, occupational or academic functioning
Bipolar Disorder: Treatment
Medications are considered to be essential in the treatment of this disorder Both "mood stabilizers" and antipsychotic medications are effective in preventing manic and major depressive episodes
Rule-Outs for Bipolar disorder
Not due to drugs (e.g., stimulant intoxication) or general medical condition Distinguish from Attention-Deficit Hyperactivity Disorder (lack of "expansive mood" in ADHD)
Rule-Outs for s.a.d
Not due to drugs or general medical condition Differentiate from other disorders, especially agoraphobia Note: Panic attacks may occur in social anxiety disorder Key distinction with Agoraphobia: panic attacks in social anxiety disorder will be "cued"; avoidance in Agoraphobia will be due to fear of having a panic attack or panic-like symptoms, rather than social scrutiny or negative evaluation
OCD: DSM-5 Definition
Obsessions and/or compulsions (not necessarily both, although roughly 80% have both) The obsessions or compulsions: cause marked distress, are time consuming (take more than 1 hour a day), significantly interfere with the person's normal routine, occupational (or academic) functioning, Interfere with usual social activities or relationships.
Avoidance
One (or more) of the following: efforts to avoid thoughts, feelings, or conversations associated with the trauma efforts to avoid activities, places, or people that arouse recollections of the trauma
Re-experiencing (Now "Intrusions")
One or more of the following: recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. recurrent distressing dreams of the event. acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
Emergence of PTSD as a diagnosis in DSM-III (1980)
PTSD Rape trauma syndrome Now includes many kinds of trauma Shell shock (World Wars I and II): attributed to repeated exposure to exploding artillery shells
Disorders that Commonly Include Panic Attacks
Panic Disorder Social Anxiety Disorder Generalized Anxiety Disorder PTSD
Environmental Risk Factors for PTSD
People who have experienced childhood trauma are at increased risk for developing PTSD when they are traumatized as adults This suggest that when one has experienced trauma as a child it increases both risk of re-traumatization and susceptibility to developing PTSD
Manic Episode
Period of "elevated [euphoric or high], expansive, or irritable mood and abnormally increased goal directed activity or energy" lasting at least 1 week Causes some impairment in functioning, hospitalization, and/or there are psychotic features
Hypomanic Episode
Period of "elevated [euphoric or high], expansive, or irritable mood and abnormally increased goal directed activity or energy" lasting at least 4 days. No impairment in functioning, hospitalization, or psychotic features.
DSM-5 Obsessions are Not...
Persistent worries about real-life problems -Intense preoccupations about real-life goals or plans
Post-traumatic Stress Disorder (PTSD): DSM-5 Definition
Person has experienced at least one traumatic event Person has evidence of all four classes of symptoms: "intrusion symptoms," avoidance, negative alterations in cognitions and mood, and overarousal Duration of at least 1 month Causes clinically significant distress or impairment
Which of the following is not a commonly-prescribed mood stabilizer?
Prozac (an SSRI)
Which of the following is not an evidence-based psychosocial intervention for bipolar disorder?
Psychoanalysis
Which of the following is not an evidence-based treatment of social anxiety and panic?
Psychoanalysis
How Common Is Bipolar Disorder?
Recent research indicates a lifetime prevalence of 1% for Bipolar I Disorder and a lifetime prevalence of 1% for Bipolar II Disorder These estimates are comparable to estimates from other countries, which tend to be between .5 and 1.5%.
Women are ____to experience panic disorder, compared to men.
Roughly 2 times more likely
Social Anxiety: Importance
Serious impairment most associated with generalized social anxiety disorder While the majority of impairment might not experience "serious" impairment (such as hospitalization, incarceration or job loss) substantial "role impairment" is experienced that impairs quality of life. "Role impairment" includes impaired romantic relationships, educational attainment and work productivity Much social anxiety goes untreated
Social Anxiety: Development
Social anxiety is associated with childhood "shyness" (also called behavioral inhibition) DSM-5 social anxiety usually develops in early adolescence and may be associated with life events associated with the transition from childhood to adulthood (e.g., dating)
DSM-5 Anxiety Disorders
Specific Phobia, Social Anxiety Disorder, Panic Disorder, Agoraphobia, Generalized Anxiety Disorder, and Separation Anxiety Disorder The DSM-IV had included PTSD and Obsessive-Compulsive Disorder as anxiety disorders, but they are presently in separate categories, reflecting the view that they are distinct from anxiety disorders
How Common Is Exposure to Trauma?
Studies have found high rates of lifetime exposure to trauma in the US general population: rates ranging from 40-60% The world-wide rate of exposure has been found to be 68%, with greater exposure in higher income countries (attributable primarily to automobile accidents)A consistent finding is that men have a slightly elevated risk of exposure to trauma relative to women Nevertheless, women are more likely to experience specific types of traumatic events than men: adult sexual assault and childhood sexual abuse Men are more likely to experience nonsexual assault, accidents, and combat/war/terrorism related trauma
Which of the following would not be considered a traumatic event by the DSM-5?
Sudden loss of a job
OCD: Chances of Improvement
The course of OCD is typically considered to be "persistent" or "chronic" However, treatment appears to significantly impact the likelihood of good outcome
Most Common Obsessions and Compulsion Patterns
The most common compulsions are washing and cleaning rituals which are connected with obsessions about germs and contamination Checking compulsions, associated with doubting obsessions, are also common
Outcome for PTSD
There appear to be two patterns of course for PTSD: an acute course and a "chronic" course Roughly 50% of cases appear to remit within 1 year; however the other cases persist beyond 1 year. Long-term follow-ups of 9/11 and Oklahoma City bombing survivors confirm that roughly 50% of PTSD cases did not remit Having a history of childhood abuse increases the likelihood that course will be chronic; having a co-occurring substance abuse problem also negatively impacts course Another study found that evidence-based treatment significantly improved likelihood of recovery over 5 years
What Causes Social Anxiety?
There is evidence for both genetic and environmental influences in the development of social anxiety There is more evidence for a genetic contribution to the generalized subtype of social anxiety There is also better evidence for a genetic association with "shyness" or behavioral inhibition more broadly. Specifically a study found concordances of 57% for "shyness" among identical twins
What Causes OCD?
There is good evidence for a genetic contribution to OCD from family studies, but limited evidence from twin studies In family studies, the risk of having OCD if a first-degree relative has it is roughly 10x greater than the risk in the general population Twin studies have been fraught with small sample sizes, but concordance rates among identical twins have been found to be between 60-80%
Evidence for Genetic Origins
Twin studies support a similar pattern to that of schizophrenia: 40-60% concordance for identical twins and only 4-10% concordance for fraternal twins. Family linkage studies looking at the likelihood of developing Bipolar Disorder if one has a "first-degree" relative with the disorder indicate a 6 times greater risk Some research suggests that the genetic contribution to bipolar disorder is even stronger than for schizophrenia
Over-arousal
Two (or more) of the following: irritability or outbursts of anger Reckless or self-destructive behavior difficulty concentrating Hypervigilance (General mistrustfulness or greater sensitivity to perceived danger) exaggerated startle response Difficulty falling or staying asleep
Bipolar Disorder: Mood Stabilizers
Two kinds of "mood stabilizers" are used to treat Bipolar Disorder: Lithium and Anticonvulsants The essence of a mood stabilizer is that it prevents both manic and depressive episodes
Negative Alterations in Cognitions and Mood
Two or more of the following (new areas italicized): inability to recall an important aspect of the trauma Persistent and exaggerated negative expectations about one's self, others, or the world (e.g., "I am bad," "no one can be trusted," "the world is completely dangerous"). Persistent distorted blame of self or others about the cause or consequences of the traumatic event(s) Pervasive negative emotional state -- for example: fear, horror, anger, guilt, or shame markedly diminished interest or participation in significant activities feeling of detachment or estrangement from others Persistent inability to experience positive emotions ("emotional numbing")
Treatment for PTSD
Two types of treatment have the strongest evidence in the treatment of PTSD: cognitive-behavioral therapy (CBT) and eye-movement desensitization and reprocessing (EMDR) Pharmacologic treatments are also recommended (generally SSRI antidepressants), but the psychosocial treatments have a stronger evidence-base
When Does Panic Disorder Develop?
Typically develops in early adulthood (range from 20 to 32) Average age of onset has been reported to be 26.5, but a later age of onset has been reported in other studies
If panic attacks occur in panic disorder they will be ___, but if they occur in social anxiety they will probably be ____.
Uncued, cued
Panic Attacks: Subtypes
Unexpected (Uncued) Occur "out of the blue" Situationally Bound (Cued) Associated with a specific context Situationally Predisposed Greater risk in certain contexts
Bipolar Disorder: Gender Difference
Unlike Major Depressive Disorder (but like Schizophrenia), prevalences are roughly equivalent for men and women There is some evidence, though, that men tend to have manic episodes first
Panic Disorder: Importance
When there is agoraphobia, panic disorder can be quite disabling A large number of persons with panic disorder plus agoraphobia apply for disability and leave the work force Much panic disorder goes untreated
Does Social Anxiety Get Better?
Without treatment, social anxiety may have a persistent course (lifelong?) It is considered to be "more" persistent than panic disorder However, complete remission is possible with treatment and positive life-events Studies suggest that, after 8 years, less than 50% attain partial remission, and roughly 33% achieve full remission
Is Mania Associated with Creativity?
Yes
According to the DSM-5, in obsessive-compulsive disorder, compulsions are typically driven by:
a desire to reduce distress
A person experiences an accelerated heart rate and has a desire to get away only when she is in the presence of snakes, but not in other situations. It is most likely that this person has:
a specific phobia
All of the following are core symptoms of PTSD in the DSM-5 except:
depressed mood
OCD
environmental factors Some research suggests that stressful life events, including traumatic events, are associated with increased risk for developing OCD and the exacerbation of OCD symptoms among people who already have OCD
Generalized Anxiety Disorder
excessive and persistent worry for at least 6 months that interferes with functioning or causes significant distress
The essence of mania is that the person experiencing it feels_____.
excited or elated
"Exposure:" in OCD
exposing clients to anxiety-provoking stimuli specific to their obsessions or compulsions (e.g., a messy desk)
Women are more likely to experience traumatic events than men:
false
Which of the following is not a potential overarousal symptom?
feelings of detachment
an anxiety disorder characterized by excessive worry about many or most situations is
generalized anxiety disorder
Bipolar Disorder: Course/Outcome
it is "persistent" and episodes tend to recur several times over the lifespan. Episodes come and go, and there may be extended periods where individuals are have no symptoms, even without treatment (experiencing neither a manic or depressive episode)
Specific Phobia
marked fear and avoidance of specific animals, objects or situations (e.g., spiders, snakes, planes)
Obsessions: DSM-5 Criteria
recurrent and persistent thoughts, impulses, or images that are experienced, as intrusive and unwanted and that cause marked anxiety or distress the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
Compulsions: DSM-5 Definition
repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly