PY 358 Test 2

-Sleep definition -CDC data from the Behavioral Risk Survey "Sleep is a = (happens over and over again), = (can go in and out of) neurobehavioral state (it involves both behavior and the brain) of r= p= d= from and = to the = (someone is going in and out of consciousness). Sleep is typically accompanied (in humans) by = = (lying down), = = (not moving), and = =.

"Sleep is a recurring (happens over and over again), reversible (can go in and out of) neurobehavioral state (it involves both behavior and the brain) of relative perceptual disengagement from and unresponsiveness to the environment (someone is going in and out of consciousness). Sleep is typically accompanied (in humans) by postural recumbence (lying down), behavioral quiescence (not moving), and closed eyes. - Carskadon and Dement (Father of Sleep Medicine and a long-time Stanford University professor who taught course on sleep and dreaming) - 2005 -"During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?" -Concentrated areas along the Southern U.S. and particularly the Southeast where individuals reported somewhere between 11-19 days out of 30 for insufficient sleep. Relatively better scores in states like CO, UT, and CA and other trends that mirror the Southern states but not quite as severe in the Northeast and Midwest. -People in our country are not getting enough sleep! Next time on a plane: See how many people fall asleep before the flight attendant finished his or her announcements prior to takeoff you would be astonished.

-Psychological Contributions to Major Depression -Stressful life events: Especially important? Different from grief. -Learned helplessness a. The Learned Helplessness Theory of Depression b. Three different depressive-attributional styles that flow from this theory -Negative Cognitive Style a. Depressive Cognitive Triad

-Very important precipitants for Major Depression. -Studying the roles that big changes in life such as losing a job, starting a new job, getting married, having a child, etc. have in contributing to Major Depression. -One important thing to note is Depression must be different from grief, they are actually classified as different disorders in the DSM-5. Even though the loss of a loved one is very stressful and would normally be categorized as a stressful event, the stressful events we are talking about as contributing to Major Depression are often separated from Grief in these studies. -Context is important. Measuring the context of events and their impacts. Even though severe or major life events precede Major Depression episodes, we should consider context. EX: Early life stress, childhood abuse or neglect could be particularly damaging, whereas a romantic breakup during adolescence may be more troublesome than in our later emerging adulthood. Context may be particularly important for understanding the impact of stressful life events to the onset and progression of Major Depression. -Stress is important particularly for the first or initial episodes of Major Depression. ________________________________________________________________________ -Martin Seligman, study of dogs led to a very important model he called the Learned Helplessness Theory of Depression a. Often overlooked in this model is Seligman's idea that anxiety is usually the first response to a stressful situation and that Depression may follow as marked hopelessness by trying to cope with difficult events. b. 1. Internal : individual attributes negative events to personal shortcomings and failings "This is my fault." 2. Stable : Even after a particular negative event such as losing a job passes, the thought/attribution is that additional bad things will happen to them and it will be their fault 3. Global : Attributions extended across a variety of issues and often times individuals begin to think that particular stressful events were out of their control and they are unable to cope with the slings and arrows of modern life. -This leads to a relative downward spiral into a Major Depressive episode that is often unremitting and leads to further episodes. ___________________________________________________________________________ -Aaron Beck, famous psychiatrist and founder of Cognitive-Behavioral Therapy, suggested that Major Depression may result from a negative cognitive style - a tendency to interpret everyday events in a negative way. -People with Depression make the worst out of everything with their lives. The smallest setbacks are often viewed as major catastrophes. -Through his extensive years of clinical work, Beck observed that all patients with Major Depression thought this way and began to characterize this way of thinking as cognitive errors. He would then come up with the... a. Depressive Cognitive Triad - three cognitive errors that people make in their thinking about (negative thought about...) 1: Themselves 2: The world around them 3: Their future -According to Beck's NCS, which he called the Depressive Cognitive Triad, individuals with Depression are negativistic about themselves, the world, and their future.

-Social Isolation, Stress, and Atherosclerosis (the process that underlies CHD and other cardiovascular diseases) in Rabbits: -University of Miami, Watanabe rabbits (Rabbits genetically engineered to be at greater risk for Atherosclerosis processes and thus hard disease end points like heart attacks).

-3 Groups of Rabbits: (a) Stable housing group: Housing was not shuffled around at all, they stayed with their cagemates, which bunnies really like. (b) Unstable housing group: Bunnies were constantly having their cagemates switched in and out, very stressful for rabbits. (c) Isolation housing group: One bedroom apartment. Bunny by himself. -Total aortic atherosclerosis measured (in the aorta of bunnies). -Stable group looked pretty good, unstable group not so much, and the worst group was in fact the socially isolated bunnies.

-Eating Disorder Statistics -Age of onset -Course -Key symptom -Which is more difficult to treat? -Anorexia and Bulimia Statistics

-All eating-related disorder age of onset (where early or late): Adolescence -Anorexia: Average age of onset: 15 years old -But, anorexia can occur as early as 11 years old -Chronic life course (Lasts well throughout the life span and is particularly difficult to treat) -Bulimia: Age of onset is as early as 10 years old -Chronic course too (can too be difficult to treat but likely not as difficult as anorexia) _______________________________________________________________________ -Key symptom: Drive to be thin. -Main takeaway: Not just a fear of gaining weight, but a fear of losing control over eating. -Control is a very important aspect both to Anorexia and Bulimia. -Lifetime prevalence is small, but these conditions are very impactful and have severe health consequences: -Prevalence in lifetime: Anorexia: 0.9%, Bulimia: 1.5% -Between 10 and 20% die as a result of Anorexia. Between 20 and 30% of these deaths are due to suicide. Anorexia has the highest mortality rate among all DSM disorders. -Anorexia has a 50x higher mortality rate than suicide mortality rates. -Bulimia: 90-95% are women. Prevalence rates increasing for males, but adolescent girls are most at risk.

-(THE RIGHT) Treatment for Insomnia Disorder -Biological 1. Ambien - benzodiazepine 2. Trazodone - tricyclic 3. Lunesta - sedative/hypnotic

-Ambien - benzodiazepine -Trazodone - tricyclic antidepressant (both A and T are commonly prescribed medications) -Lunesta, another medication, actually a sedative (known as a hypnotic) - It impacts chemicals in your brain that may be imbalanced, when there is an insomnia complaint, however just like A and T, these medications tend to work in the short-term and less effective for the long-term. -These medications are commonly prescribed in the primary-care setting and certainly may be very effective in the short-term, but perhaps not as effective in the long-term.

-(THE RIGHT) Treatment for Insomnia Disorder -Cognitive Behavioral Therapy for Insomnia (CBT-I) 4) Cognitive Therapy -Lacks and Mori, 1992 -Morin and Azrin, 1988 -Morin, 1993

-Another component less commonly used within the treatment of insomnia broadly. -This involves adjusting negative, maladaptive or dysfunctional thoughts about sleep and usually these thoughts have to do with the daytime consequences of poor sleep, so things like a) I won't be able to perform my job. b) I'll be a total wreck at work. c) I'll be irritable with my coworkers and loved ones. -While this is effective, that is certainly true, and I would say certain groups of Cana and CA advocate for cognitive responses for the treatment of insomnia, BUT the behavioral approach just for the treatment of insomnia just mentioned/described that is STIMULUS CONTROL and SLEEP RESTRICTION are certainly the most active and effective components of CBT-I. a) Focus on negative thoughts and/or maladaptive/faulty beliefs about sleep and its consequences. b) GOAL or the idea here is we want to help patients to challenge the veracity/truthiness or usefulness of unhelpful thoughts about sleep then to modify those thoughts. -In his experience with treating insomnia, which is quite extensive, is if you engage with those behavioral practices first (Sleep Restriction and Stimulus Control) that actually modifies some of these negative thoughts because the behavior treatment is working. c) The main idea on the cognitive side of things: Adjusting maladaptive thoughts decreases anxiety and hyperarousal (Targets the underlying anxiety and hyperarousal we believe is present or central to ID, so really its aim is to decrease both anxiety and physiological hyperarousal).

-(THE RIGHT) Treatment for Insomnia Disorder -Cognitive Behavioral Therapy for Insomnia (CBT-I) 5) Relaxation Techniques -Lichstein, 1988 -Garland et al., 2015 -Ong et al., 2014

-Another component of CBT-I. 1) Progressive muscle relaxation: Often used, where you tense up certain muscles in your body. Example: Start with your feet and tense those up for a period of a few seconds and release them, then legs, thighs, all the way up through your arms, into your shoulders, etc. -The idea is through this period of time while you're tensing and relaxing muscles, that will actually induce overall relaxation and perhaps promote sleep. 2) Mindfulness meditation: Become very very popular for the treatment of insomnia in the last 10 years or so, actually does work quite well. This involves some kind of meditative practice in addition to a nonjudgmental focus on what's going on around you. -However, both require constant practice. -Should be emphasized to the patient that the goal of relaxation is not to induce sleep, but to reduce the overall basal arousal rate (hyperarousal) well within the body.

-Anxiety: -Can anxiety be adaptive? -If so, when? -When is anxiety maladaptive?

-At first glance you might say no, it cannot be adaptive at all. Anxiety seems bad to me. -Under what circumstances is it adaptive? -According to the Yerkes-Dodson Law: Basic research from social psychology, you plot arousal (anxiety) along the horizontal axis and performance along the vertical axis. We see that performance tends to be poor under low levels of arousal (anxiety), and performance actually peaks under medium levels of arousal, and then declines at high levels of arousal. -Can be a performance on anything (exam, athletic event, etc.) -Inverted U-graph shows us that actually under medium levels of arousal or anxiety, we perform at peak levels. We can say there are some instances when anxiety can be adaptive. -Then, at what point is anxiety maladaptive? -Edvard Munch's The Scream - painting used to show depiction of anxiety, the painting is actually however about the imposing and impending modernization coming at the turn of the last century in Europe. People were very frightened about technological advances of the oncoming IR and the associated changes that may be present in life. -Can anxiety be adaptive? Yes, it can be. -If so when? Basic Social Psychology: Yerke's Dodson Law: Under levels of medium arousal or anxiety, performance on multiple outcome measures tends to peak. This is why getting a little keyed up before taking an exam, for example, or the night before a concert performance or athletic event is probably helpful. -At very low levels of anxiety and very high levels of anxiety, performance tends to suffer. -This begs the question... At what point does anxiety become maladaptive? (At what point does the scale begin to tip?) -This is a very important feature that underlies all the clinical disorders we will talk about, that when a particular psychological disorder interferes with your daily living, that is your ability to perform occupational, social, and academic roles.

-Bipolar Disorder review -"Rapid cycling" specifier (a specifier listed in the DSM) -Prevalence of rapid cycling specifier, Last for 5 years?

-BPD is actually a family of disorders and is different from Unipolar disorders (whereas in the case of Major Depression only one extreme of mood is experienced) -However with Bipolar Mood Disorders, episodes of both severe depression and elevated moods that are consistent with severe mania are seen in patients. -3 Types of Bipolar Disorders: 1) BP1: Alternations between Major Depressive episodes and manic episodes (pressured speech, irritability, risky behaviors to name a few) 2) BP2: Alternations between Major Depressive episodes and hypomanic episodes (milder form of severe mania) 3) Cyclothymic Disorder: Alternations between mild to moderate episodes of Depression and Hypomanic episodes ________________________________________________________________________ -People may move quickly in and out of mania and depression -Can occur as often as 4 times per year (either manic or depressive) -High prevalence rates (20-50% of bipolar patients) -Tends to increase in the frequency over time (episodes) -Treatment Resistant: Especially when there is no time between mania and depression -Not sustainable long-term (When we see rapid cycling this places the individual at increased risk for things like suicide and again treatment resistance) -3-5% continue with rapid cycling across a 5-year period

-Integrative model of GAD GBV + GPV STRESS A.A. W.P.: A failed attempt to cope and problem-solve ICP -> IPS | AOI -> RAR GAD

-Barlow expands on the tri-part type model and tries to bring things together. 1. GPV and GBV interact with stress due to life events (we talked about the importance of life events as a potential contributing factor to anxiety) -> 2. These things together contribute to muscle tension and an increased sort of vigilance (or monitoring of one's environment) -> 3. That leads to worry (cannot get around or cope with the worry, cannot problem solve) -> 4a. Here we have an intense cognitive effort to try to process the worry -> And an inability to do so due to poor problem-solving skills on side following the worry and on another side ... 4b. Avoidance of things that make you anxious in your mind -> And blunted autonomic response such as blood pressure and heart rate.

-Contributions to Panic Disorder: -Biological -General vulnerability to stress

-Biological: -A general vulnerability to stress. We discussed Barlow's Tripartite or Triple Vulnerability model about the development and maintenance of anxiety and it holds here too for an initial unexpected panic attack. -The tendency to sort of be neurobiologically overreactive to the events of daily life, which Barlow called the Generalized Biological Vulnerability is what we are talking about here with respect to Panic Disorder, and I think he described it as an Emergency Alarm Reaction when confronted by stress producing events. -Anything that is inherently stressful such as: -Stress at your workplace -Passing of a loved one -Exams -Anything to do with deadlines at school or work -Prospect of starting a new career -Getting married -Changing jobs -These all might be quickly associated with sort of external and internal cues that are aligned with the symptoms we described in terms of a panic attack. -If someone is vulnerable to experiencing these things and is placed in one of these situations, that is very very stressful, we can see how easily Panic Disorder might develop.

-Treatments for Eating Disorders -Biological: Anorexia is egocentric., Bulimia... -Psychological -CBT-E: Fairburn and Colleagues -1st stage: Physical consequences -2nd stage: Psychoeducation adverse effects of dieting, patients scheduled to eat small and manageable amounts of food (5 or 6 times a day, for no more than 3 hour intervals between) -3rd stage: Shaping or altering dysfunctional thoughts about body image -Family studies (on next slide)

-Biological: -Anorexia: Drugs not particularly effective (very treatment resistant because it's linked so heavily with someone's sense of self and identity -> when something is so tightly interconnected with a sense of who you are as a person we often call it egocentric, your condition is so closely tied to who you are, so it is very difficult to treat: also see this in personality disorders) -Bulimia: Prozac (SSRI) for reduction in binging and purging -Psychological: Can gain traction in treatment! -Cognitive Behavioral Therapy-Enhanced (CBT-E): Developed by Fairburn and Colleagues: -1st stage of treatment: Teach patient that there are physical consequences of binging and purging as well as help patient understand ineffectiveness of vomiting and laxative abuse for weight controtl itself -2nd stage: Psychoeducation component continuing when the adverse effects of dieting are described and patients are scheduled to eat small, manageable amounts of food for 5 or 6 times a day, for no more than 3 hour intervals between any planned meal or snacks which in effect, as a behavioral intervention, eliminates alternating periods of overeating and restrictions that are the hallmarks of things like Bulimia. -3rd stage: As the treatment progresses in later stages of treatment, CBT focuses on shaping or altering dysfunctional thoughts and attitudes about body shape, weight, body image, and eating itself. Coping or compensatory strategies for resisting the impulse to do something like binge and/or purge are also developed which include arranging activities the individual can do with other people (not spending time alone after eating or during the earlier stages of treatment) -These particular cognitive-behavioral treatments for A and B in particular have proven to be fairly effective and results of these interventions seem to last results gained tend to maintain over time (CBT-E).

-Panic Disorder review on treatments

-Biological: -Selective Serotonin Reuptake Inhibitors (SSRIs) -Paxil and Prozac, comes with undesired side effects such as decreased libido -Benzodiazepines: Certainly effective in the short term. -Xanax, but we know they can impact things like learning and driving and have a high addictive potential -Psychological: -Exposure therapy: Very very effective in treating panic -When the person is in the session with the therapist, ET will be about creating a list of things that are sort of potential symptoms of panic such as shallow breathing or rapid heart rate and trying to induce those actual symptoms in session if possible and help the client understand that she or he can tolerate those symptoms of panic disorder. This is done behaviorally and through cognitive restructuring (changing the way people sort of evaluate appraise and think about the symptoms of panic disorder and its subsequent consequences.) -Long-term study: These techniques are very effective over the long haul for the treatment of panic disorder -Booster sessions work! Assess the status and reinforce the progress made from preliminary sessions. -When individuals return after a period of time to psychotherapy that booster sessions actually work and are helpful for treatment of panic.

-Treatment for Panic Disorder -Biological -SSRIs not particularly ... but ... -Benzodiazepines: more ... but ... -Psychological -Exposure therapy

-Biological: -Selective Serotonin Reuptake Inhibitors (SSRIs): -Paxil and Prozac - very helpful for the treatment of Panic Disorder, not particularly fast-acting, but do come with some negative side effects such as decreased libido. -Benzodiazepines: -On the more fast-acting side of things -Xanax - very helpful, can be taken in the moment, but have a high addictive potential ____________________________________________________________________________ -Psychological: -Exposure therapy: Incredibly helpful for folks just like those with GAD. -We want to induce panic in the therapy session and work with the client to restructure his or her thoughts about again these cognitive aspects of "I'm going to lose control." "I'm going to die." "Something terrible is going to happen." that come along with these symptoms of racing heart, shallow breathing, dizziness, in older adults fear of falling, and sometimes loss of bladder or bowel function -Cognitive restructuring (Exposure therapy) -Idea is to work with the thoughts that people are having and dial it back from the worst case scenarios that "I'm not going to be able to handle this." "I can't make it." "I'm not going to be able to escape." "I'm going to be embarrassed." -What we know from a long-term therapy study is that the psychological treatments for Panic Disorder are actually quite effective and they tend to maintain over time.

-Generalized anxiety disorder (GAD) -Hallmark symptom -Prevalence rates -Average age of onset, What kind of onset is it? -Course -Additional statistics: What is its onset? When does it often begin? Who is it more common in?

-Hallmark symptom: Worry. We all have probably experienced worry in our day-to-day lives, we might get concerned about things around you (exams, grades, What will I do after college?, What will I do tonight?), but -This is a different level of worry. This is really dialed up worry, it is so intense that is interferes with daily functioning. This is key to remember. -Prevalence rates of GAD: 1 year period: 3.1% of US adult population ; severe: 32.3% of these GAD cases or roughly 1% of the US adult population are classified as severe. Particularly dehabilitating for academic, occupational, or social functioning. -Average age of onset: 31 years old. Can occur in childhood, adolescence, and emerging adulthood (earlier ages of onset). -Data from National Institute of Mental Health -Additional statistics: -More common among women (may simply be because women are more likely to seek help for their anxiety disorders and report them to their primary care doctors or actual psychotherapists). -Common among older adults (may have to do with aging in the brain or other sort of changes that go along with our brains and bodies as we age). -Insidious onset (onset trajectory: that could be classified as insidious). -Often begins in early adulthood. -Once it occurs, it has a chronic course (lasts for a long time).

-Contributions to Bipolar Disorder -REM Latency, bi-directional relationship of sleep and mood -Type of stressful event -Treatments for Bipolar Disorder -Lithium -IPT -Family therapy INVOLVING - - IN THE TREATMENT OF BPD CAN BE A VERY VERY USEFUL THING.

-Biological: A. Shorter REM latency - to some extent we have a physiological marker of BPD - just like in those with MDD, found among bipolar patients B. Bi-directional relationship between negative mood and poor sleep (U. Pittsburgh Department of Psychiatry) -Psychological: A. Negative stressful events trigger depressive episodes (holds true for MDD and BPD) B. More positive stressful events trigger mania (respect to sleep - if someone has a diagnosis of BPD and experiences erratic or even short sleep can trigger mania too) __________________________________________________________________________ -Biological: -Lithium (Lithium Carbonate): Has been and will probably continue to be a drug of choice. Naturally occurring salt known by Ancient Greeks. For mood stabilizing properties - synthesize the properties of those salts and use it in pill form and is quite effective. Mood stabilizing drug. Effective in preventing and treating manic episodes. -Psychological: A. Interpersonal Psychotherapy (IPT): Particularly important. Ellen Frank, colleague of Cribbet's at the U. of Pittsburgh, would say IPT is very effective in the treatment of BPD, whereas a large group at UCLA suggests that (not that IPT is not a valid treatment) but tend to favor family therapy approaches.) B. Family Therapy: Particularly important. -Want to gain collaboration of family members to help patients with BPD. A) Not only manage the ups and downs that come along with alternating cycles of depression and mania (or even changes that occur with Cyclothymia), but also B) Help people recognize when those changes are about to come or are coming. EX: Another patient at Rochester, outpatient setting. -Involved her boyfriend (like a family therapy treatment technique), very very heavily in her treatment. -She found it incredibly important to have him assist with identification of changes in mood or what might be a precursor to those changes in her mood and again help her regulate the negative side effects of those mood swings. -This patient also reported that online sites and her ability to connect with individuals or other patients with BPD through a website called PATIENTS LIKE ME was also very very effective. So... INVOLVING SOCIAL RELATIONSHIPS IN THE TREATMENT OF BPD CAN BE A VERY VERY USEFUL THING.

-Hele M. Farrell: What is Bipolar Disorder?

-Bipolar is two extremes - life is split between 2 different realities (elation and depression). Although there are many variations of BPD, we have two types. -Type 1: Extreme highs alongside extreme lows -Type 2: Briefer, less extreme periods of elation interspersed with long periods of depression -Manic episodes can make a person range from feeling irritable to invincible. Euphoric episodes exceed ordinary feelings of joy -> troubling symptoms like racing thoughts, sleeplessness, rapid speech, impulsive actions, and risky behaviors. -Without the treatment, manic episodes can become more frequent, intense and take longer to subside. -Depressed phase manifests in may ways - low mood, dwindling interest in hobbies, changes in appetite, feeling worthless or excessively guilty, sleeping either too little or too much, restlessness or slowness, or persistent thoughts of suicide. -1-3% of adults worldwide experience broad range of symptoms that indicate BPD. Most are functional, contributing members of society, their lives choices and relationships are not defined by the disorder, but still for many the consequences are serious. -Illness can undermine educational and professional performance, relationships, financial security, and personal safety. -What Causes BPD? -Key player is the brain's intricate wiring - healthy brains maintain strong connections between neurons thanks to the brain's continuous efforts to prune itself and remove unused or faulty neural connections. Process is important because our neural pathway serves as a map for everything we do. -Using functional magnetic resonance imaging (fMRI), scientists have discovered that the brain's pruning ability is disrupted in people with BPD. Their neurons go haywire and create a network that's impossible to navigate. With only confusing signals as a guide, people with BPD develop abnormal thoughts and behaviors. -Psychotic symptoms like disorganized speech and behavior, delusional thoughts, paranoia, and hallucinations can emerge during extreme phases of BPD. This is attributed to the overabundance of a NT called Dopamine. -Despite these insights, we cannot pin BPD down to a single cause. It's a complex problem. -For example, the brain's amygdala is involved in thinking, long-term memory, and emotional processing. In this brain region, factors as varied as genetics and social trauma may create abnormalities and trigger symptoms of BPD. -The condition tends to run in families, so we do know that genetics have a lot to do with it. But, there isn't a single bipolar gene. In fact, the likelihood of developing BPD is driven by the interactions between many genes. -Causes are complex and consequently, diagnosing and living with BPD is a challenge. Despite this, the disorder is controllable. -Medications like lithium can help manage risky thoughts and behaviors by stabilizing moods. These mood-stabilizing medications work by decreasing abnormal activity in the brain, thereby strengthening the viable neural connections. -Other frequently used medications include antipsychotics - alter the effects of dopamine and Electroconvulsive Therapy (ECT) - a carefully controlled seizure in the brain used as an emergency treatment. -Some BP patients reject treatment because they are afraid it will dim their emotions and destroy their creativity, but modern psychiatry is actively trying to avoid this. -Today, doctors work with patients on a case-by-case basis to administer a combination of treatments and therapies that allows them to live to their fullest possible potential. -Beyond treatment, people with BPD can benefit from even simpler changes: 1) regular exercise, 2) good sleep behaviors, 3) sobriety from drugs and alcohol, 4) acceptance and empathy of family and friends (social networks) -BPD is a medical condition, not a person's fault or their whole identity, it is something that can be controlled through a combination of medical treatments doing their work internally, friends and family fostering acceptance and understanding on the outside, and people with BPD empowering themselves to find balance in their lives.

-Coronary Heart Disease -Statistics: Among 40 year old or older men and women, 30-50% (or 1/3-1/2) will develop CHD. -Psychosocial Risk factors: Because people are living longer with these chronic conditions and that they unfold much more slowly than do the acute causes of death in the early part of the last century, we can begin to study psychosocial risk factors that contribute to CHD. -5 Risk Factors (Psychosocial)

-Blockage of the arteries supplying blood to the heart (what was previously described as the underlying process behind both CHD and Coronary Artery Disease as Atherosclerosis). -Imagine in the previous diagram that we have the coronary arteries completely or almost completely blocked as seen in the last frame of the diagram (of Endothelial Dysfunction). -500,000 deaths each year in the US, probably higher now due to an older statistic. -1,200,000 new or recurrent events yearly (CHD associated with). -Among 40 year old or older men and women, 30-50% (or 1/3-1/2) will develop CHD. -The direct cost of CHD can be upwards of $100 billion each year in the US or more. Direct medical costs, disability, lost productivity, etc. CHD is not just any typical disease. 1. Low Socioeconomic Status -This category exerts its risks in a multitude of ways. a) Limiting access to healthy foods - Often living in food deserts - do not have the option for fresh things like fruits and vegetables to eat. b) Financial strain and stress of being in a low SES group - Dr. Kunda, how low SES and race (associated racial disparities) lead to poor cardiovascular health. 2. Type A Behavior (Particularly hostility and dominance) -Individual differences and personality side of things. Born out of trying to understand what is it about individuals that contributes to risk for cardiovascular disease or in this case CHD. -Conducted in middle part of last century. -People who are 'Type A' are time-pressured, competitive, achievement-striving, hostile, dominant individuals. -A distillation of the Type A Behavior pattern really found that hostility and cynical hostility in particular along with dominance were the most potent risk factors of that broad category. -Most physicians recognize Type A as being a potent psychosocial risk factor for the development and progression of CHD as do they consider... (Number 3 to be too). 3. Depression and Anxiety -2-3x fold increase in risk factor for cardiovascular events once an individual has had an episode of Major Depression. 4. Social Isolation and Conflict -The role of social isolation on health. -Feeling lonely and not necessarily being alone is also very important for cardiovascular health and social isolation is an extremely potent risk factor for both the development and progression of CHD and other cardiovascular diseases. -This lets us know then that the flip side is also probably true - social support may perhaps have buffering qualities when it comes to staving off disease risk and... -So its not merely the presence or absence of social relationships or the perceived absence of those relationships that is important, we know that conflict in close relationships such as marriage also tends to portend risk to CHD. 5. Job Stress and Strain -Another important risk factor to consider. -Tons of large-scale epineurological studies point to the fact that stress and position or role at work is very potent in terms of risk for CHD.

-(THE RIGHT) Treatment for Insomnia Disorder -Cognitive Behavioral Therapy for Insomnia (CBT-I)

-CBT-I is a multi-component therapy that includes all of these different aspects. 1) Sleep Hygiene 2) Stimulus Control 3) Sleep Restriction Therapy 4) Cognitive Therapy 5) Relaxation Techniques

-The Interaction of Risk Factors for CHD (The Reserve Capacity Model, Linda Gallo and Karen Matthews, 2003 with updates in 2005/2013)

-CHD is also linked to chronic negative affect, low SES, and stressful life experiences. [An interaction of risk factors, largely noted in theoretical and some empirical data.] -The Reserve Capacity Model provides a model for contributions of psychosocial factors to CHD. -1st box: Low socioeconomic status and relatively few resources/low prestige or position in social hierarchy... -2nd box: Stressful life events (like the threat or actual loss or harm to you as an individual In combination with the low likelihood of potential/actual benefits or gain so that if you're of low SES, not only do you have limited access to resources and lower social hierarchy position, you may be more threatened by the actual loss or harm of the accompanying stressful life events and may be less able to benefit/gain/learn from those stressful experiences. -3rd box: However, Matthews and Gallo said people often come to the table with something they call RESERVE CAPACITY, some sort of psychosocial resources including tangible, inter and intrapersonal aspects of support, specifically or means by which one could improve oneself and that low SES is linked to CHD as said through stressful life events, and through ... (4th box) -4th box: Low SES is linked through to CHD through negative emotional states - an increase in negative thoughts and feelings and a decrease in positive feelings. These may feed back to and in fact inform someone's Reserve Capacity (building up strength and resistance against the negative onslaughts that come with being from a lower socioeconomic position.) -As all of these unfold over time, as does the risk for CHD and its underlying condition Atherosclerosis. Arrow A: Direct influence of SES on the exposure to stressful experiences. Arrow B: Direct impact of stress experiences on emotion and cognition. Arrow C: SES conditions and shapes the bank of resources that people have at their disposal with respect to managing stress - that is RESERVE CAPACITY and often times this comes in the form of social support. Arrow D: RESERVE CAPACITY represents a potential modifier/moderator of the association between stress and negative thoughts and feelings. Arrow E: The direct effects of emotional and cognitive factors in the influence risk for Atherosclerosis and CHD. Arrows bouncing from the Reserve Capacity and Negative Emotional State Boxes: This process is transactional and repeated over time. Dashed Arrows: From negative emotions back to threat (stressful events), from negative emotions back to low SES. Possible reverse influences (were added later in 2005). -While this is a very important theoretical model, we ultimately see very limited empirical support for it in the literature. However, we should continue to test and refine this particular model as it has important information that might help us understand why individuals from low socioeconomic status might be at increased risk for the development and progression of cardiovascular disease specifically Atherosclerosis and CHD compared to their high SES counterparts.

-Psychological contributions to anxiety disorders -Childhood perceptions of controllability -Insel et al., monkeys -Perceptions of controllability in environment: 1. Increased threat sensitivity: Homework and test example 2. Uncontrollability -Principles of behavior

-Childhood perceptions of controllability (Perceptions about how controllable your environment is when you're a child) -Monkey studies (Insel et al.: Clear association between lack of control, control, anxiety, and anger) -And early studies on fear learning by Albert Bandura (children hit Bobo doll), but perceptions of controllability in the environment actually seem to be very very important to some factors that underly the development of anxiety including... -Contribute to increased threat sensitivity -The idea that you maybe have some general sense of controllability, that you may be very sensitive to the environment around you and view things as particularly threatening when that is not actually the case. EX: Might be anxious about schoolwork, or that you'll do poorly on your next test even though up until that point you've earned all As and some Bs. -Childhood perceptions of how controllable their environments are lead to a sort of general sense potentially of uncontrollability. -Uncontrollability: May develop as a function of upbringing and other environmental factors -Principles of behaviorism: Children in general through the principles of classical conditioning or modeling and other forms of social learning may actually develop anxiety simply by behavior done, however what we'll find out by going over all these aspects is... -Anxiety is likely manifest through not only psychological but social, biological, and other contributions as well, supporting an Integrative Model towards the development of anxiety.

-Stanford 3-Community Study, California -Goal: Reduce risk factors of CHD. Broad effort to help people get healthier!

-Conducted in 3 entire, similar communities. -Each group got either: (a) No intervention (control group). (Tracy control). (b) Media blitz (lots of information about something on TV, radio, magazines all at once). (Gilroy media only, Watsonville media only). (c) Media blitz plus face-to-face intervention. (Watsonville intensive intervention). (Got information for how to stave off risk or to reduce the factors of CHD like physical activity, diet, smoking, etc., then followed up with face-to-face intervention. This proved to be worthwhile.) -The highest benefit from this study was the media blitz plus live intervention group. (Watsonville intensive intervention). -Very novel intervention -> Looked across these communities and people either received no intervention, media blitz, or a face-to-face intervention plus a media blitz.

-Social and Cultural Contributions to Major Depression -Marriage and Depression: Participants overall were 3x likelier to develop Depression if separated/divorced -Bruce and Kim, 1990s

-Depression and Bipolar Disorder are strongly influenced by interpersonal stress especially in marital dissatisfaction. -Large study by Bruce and Kim, early 1990s: -Data from about 700 women, 530 men. -Participants who were separated from or divorced from their spouses were at 3x higher rates to experience severe Depression. -Nearly 17% of men reported martial split developed severe Depression (rate 9x higher than that of men who remained married) versus 21% of women (rate 3x higher) -The importance of social support: Conflict within a marriage seems to have differential effects for both men and women. -For men, Depression seems to cause withdrawal or disruptions in the rate of the relationship, whereas for women problems in the relationship most often cause Depression. Thus for men and women, Depression and problems in martial relations are associated, but the causal direction may be different. -Depression Among Women. -Women get Depression from problems of staying in the relationship, whereas men get Depression get it from a marriage/relationship separation or divorce.

-Andrew Solomon: Depression, the secret we share -Not just true with Major Depression, is true for other Psychological Disorders, people rarely if ever walk into a therapist or mental health care provider's office and just lay out the symptoms like the DSM-V does. -More commonly than not they put these symptoms in tangible everyday language. -Solomon does a beautiful job at describing Depression and talks about some of the contributions and potential treatments.

-Emily Dickinson: I felt a funeral in my brain. And mourners, to and fro. Kept treading, treading, till it seemed. That sense was breaking through And when they all were seated. A service like a drumKept beating, beating, till I thought. My mind was going numb And then I heard them lift a box. And creak across my soul. With those same boots of lead, again. Then space began to toll As all the heavens were a bell. And Being but an ear. And I and silence some strange race. Wrecked, solitary, here And then a plank in Reason broke. And I fell down and down. And hit a world with every plunge. And finished knowing, then. -We know Depression through metaphors, Dickinson conveyed it in language. Goya in an image. Half the purpose of art is to describe such iconic states. -Solomon had always thought himself to be tough, to survive a concentration camp. Several losses three years prior to 1994: mom died, relationship ended, moved back to States from studying abroad. He made it through these situations in tact, but in 1994 he found himself losing interest in almost everything and he did not know why. The opposite of Depression is not happiness, but vitality. Everything there was to do seemed like too much work. Had light on answering machine, should be excited to call back friends, but instead he thought what a lot of people that is to call back. Decided he wanted to have lunch, but he'd have to get the food out and put it on a plate and cut it and chew it up and swallow it. -What often gets lost in discussions in Depression is you know its ridiculous while you are experiencing it. You know most people answer the answering machine, eat their lunch, organize themselves to take a shower and go out the door and that this is not a big deal, and yet you are nonetheless unable to figure out any way around it. -He did less and thought less and felt less. He was nulling and then the anxiety set. The feeling you have when you walk and slip/trip and the ground is rushing up at you, but instead of lasting for half a second it lasts 6 months. It's the sensation of being afraid all the time, but not knowing what you're afraid of. He thought it was too painful to be alive, the only reason to not kill oneself was to not hurt other people. One day he woke up and thought he had a stroke. He lied completely frozen looking at the phone and thinking something is wrong and he should call for help, but he could not reach his arm out to pick up the phone and dial. Four hours after lying on the bed, his father rang and he managed to pick it up. He said "I'm in serious trouble. We need to do something." and he began with medication and therapy. -"If I'm not the tough person who can make it through a concentration camp, then who am I? If I have to take medication, is that medication making me more fully myself or is it making me someone else? How do I feel about it if its making me someone else?" 2 advantages to get him through his fight: 1: He had a nice life, if he could only get well there was something at the other end that was worth living for. 2: He had access to good treatment. -He continued to emerge and relapse and realized he would have to be on medication and therapy forever and he thought "But is it a chemical problem or a psychological problem? Does it need a chemical care or a philosophical cure?" -Could not figure out which it was and then he understood that actually, we are not advanced enough in either area to explain it fully. Chemical and psychological cure both had a role to play and he also figured out Depression was braided so deep into us that there was no separating it from our character and personality.

-Brain circuits and environment study (Johnson et al., 2000 JAMA) -Anxiety sensitivity -Distress tolerance -Anhedonia -Limbic system (Nicotine, new information)

-Environmental factors may change the sensitivity of brain circuits (How the brain circuits and environment might overlap and help us understand contributions to anxiety disorders more broadly.) -Nearly 700 adolescents were followed into adulthood, studied at age 16 and studied again at age 22. -Heavy cigarette smoking (more than 20 a day) was associated with higher risk of: -Generalized Anxiety Disorder (5x more likely) -And Panic Disorder (15x more likely) -Teens who smoked 20 or more cigarettes daily were more likely to develop a psychological disorder, 5x more likely to develop GAD than teens who smoked less or did not smoke at all. -Complex interactions between smoking and anxiety disorders that has been confirmed in a large scale study published in the journal JAMA. -In terms of current thinking about how smoking might relate to anxiety, is that... -Anxiety Sensitivity: The general tendency to fear bodily sensations in the psychological nurture along with -Distress Tolerance: How much stress or distress can someone manage or tolerate and -Anhedonia: The inability to feel pleasure All contribute to smoking, which can be one reason why individuals with anxiety find it very difficult to quit smoking. -Brain imaging studies are yielding even more information about the neurobiology of anxiety more generally and panic more specifically. -Key brain regions in the limbic system including the amygdala tend to be very overactive in response to stimulation (i.e. that might come along with nicotine) or new information -Individuals who are 'priming the pump' repeatedly with cigarette smoking are more likely to have higher rates for things such as panic disorder and GAD when followed up after an initial time point during adolescence.

-Biological contributions to anxiety disorders: -Genetic contributions -GABA -Corticotropin-Releasing Factor -HPA Axis

-Evidence is stronger for panic -Large scale study of teens in emerging adulthood is the evidence for genetic contributions are perhaps the stronger for panic disorders and less for other anxiety disorders like GAD. -Multiple genes involved (in the expression of behavior that underlies anxiety), but -But, what is thought to be true is that there is Decreased GABA (neurotransmitter Gamma Aminobutyric Acid) (Associated with increased anxiety likely, has an important role in the expression of anxiety, an inhibitory neurotransmitter) -Corticotropin-Releasing Factor -Limbic system (Direct implications for particular brain regions we think are involved with anxiety in particular) -Known as "the emotional brain" (Limbic system) - particularly the hippocampus and amygdala in addition to the locus coeruleus and brain stem in the prefrontal cortex may be implicated in anxiety disorders and have to do with negative feedback loops, loops that involve CRF. -Hippocampus and amygdala -The HPA Axis -The hypothalamus (a brain region) releases CRH (Corticotropin Releasing Hormone) to the anterior pituitary which releases ACTH (Adrenocorticotropic hormone) all the way down to your adrenal glands particularly the adrenal cortex where the primary stress hormone cortisol is released. -When cortisol is released, this release triggers a negative feedback loop to shut off the AP's production of ACTH and the production of CRH in the hypothalamus. -Normally when this system is working as it should, these feedback loops shut off in this cascade, however we might hypothesize that in anxiety disorders this cascade goes unchecked and there is an excessive amount of cortisol released by the adrenal cortex.

-GAD Review: Key symptoms and biological treatments -Sample exam question: Tim has struggled for a significant amount of time with worrying about his future. He worries so much that he is unable to concentrate at work and in his classes. Moreover, Tim has noticed he feels fatigued most days, has trouble sleeping, and his girlfriend told him he is more irritable than normal. Based on these symptoms it is likely Tim has... A. GAD: Hallmark symptom of worry. Then the impact of that worry in his academic and occupational function. Other symptoms including and associated with GAD: Fatigue, difficulty sleeping, muscle tension. B. Major Depression: NO. No information listed about sadness. C. Panic Disorder: NO. No symptoms of panic present. D. Agoraphobia: NO. Tim is obviously going to work still, going to classes, and spending time with his girlfriend. He does not have any inherent issues with being in public places with a fear of escape, which is the hallmark symptom of agoraphobia.

-Excessive worry defined as apprehensive expectation that occurs more days than not (5-6 days out of the week) for at least 6 months. -Individual finds it hard to control the worry (cannot get it out of your head), cannot stop worrying about any sort of slight or small happening in your day, sometimes big happenings too. -Anxiety and worry are associated with 3 or more of the following symptoms: a. Restlessness, feeling keyed up or on edge (not able to calm down) b. Easily fatigued (like you ran a marathon, played a full-court basketball game, entire field hockey game: just wiped out.) c. Difficulty concentrating d. Irritability e. Muscle tension (in neck and shoulder for example: more pervasive and lasts for multiple days) f. Sleep disturbances (not able to go to sleep because you're continually worried about things as you approach bedtime). -The anxiety, worry or physical symptoms cause clinically significant distress (how they interfere with your work, social, or other important areas of functioning) or impairment in occupational, social, or other important areas of functioning. -Disturbance is not due to direct physiological effect of a substance or general medical condition (taking a drug, misusing alcohol, or other medical condition as a sort of root cause). Has to occur on its own and not be tied to other psychiatric or medical conditions. -The disturbance is not better explained by another mental disorder. Depression is the one that Is mot likely to overlap with GAD and can often times be a very difficult differential diagnosis. Depression and GAD share a lot of the same symptoms (irritability, poor sleep, difficulty concentrating), and have key differences too (sad mood), so this particular complaint must not be explained solely by that of another mental disorder predominantly often times Major Depression is the key differential diagnosis here. -Treatment: -Biological: Benzodiazepines (medications like Xanax) -Effective in short-term

-Biological Contributions to Major Depression -Genetic Influences a. Twin studies -General biological influences: 37 a. Permissive hypothesis b. HPA axis -> Dexamethasone Suppression Test, Overproduction impacts the hippocampus c. Sleep and circadian rhythms

-First degree relatives have 2-3x increased risk than of the general population -Greater risk if proband has: 1) More severe Depression 2) Recurrent (more than one episode) Major Depression 3) Earlier onset of Depression -Twin studies: -Suggest Depression is heritable -Identical twins 2-3x more likely to present with Depression compared to Fraternal twins. -37% estimated heritability of Depression. -Also suggest Environment may be a larger factor for men than they are for women. _______________________________________________________________________ 1. Low levels of Serotonin found in Depression (Likely low levels of Serotonin are implicated in individuals with Major Depression. Means when Serotonin levels are low, other neurotransmitters are permitted to range more widely, become disregulated and contribute to mood irregularities including Major Depression.) -The balance of various NTs and their interrelation to systems of self-regulation in the brain are more important than any absolute level of 1 NT alone. -(PH specifically in Major Depression): Low levels of Serotonin determine the range of both dopamine and norepinephrine. As these 2 NTs are allowed to vary widely, then this behaviorally looks like dysregulated mood. -Dopamine and norepinephrine range widely = Dysregulated mood 2. In Endocrine system. May also provide some contributions to Major Depression. a) Cortisol levels are elevated in Major Depression. Cortisol is the end point of the HPA axis and is the primary stress hormone released by the adrenal glands out into the body. b) DST: Dexamethasone Suppression Test: Experimental paradigm that help us understand the role of the HPA axis in Major Depression. Negative feedback loop not as efficient. -When things are not working well, we see a present negative feedback loop; when cortisol is released by the adrenal glands it should feedback and shut off those higher-order brain systems (the pituitary and the hypothalamus control of hormones that ultimately lead to the secretion of cortisol). -Dexamethasone is a glucocorticoid that suppresses cortisol. Secretion in normal participants. When Dexamethasone is given to depressed patients, much less suppression is noticed than in normal patients and what did occur did not last as long. This suggests that the negative feedback loop is not working as efficiently as it does. -Studies suggest approximately 50% of depressed patients show reduced suppression particularly if their Depression is severe. Thinking behind this: In depressed patients the adrenal cortex secretes enough cortisol to overwhelm the suppressive effects of Dexamethasone. However, more recent literature studies suggest this may not be specific to Depression and we see these similar effects in Anxiety Disorders too. c) Overproduction impacts the hippocampus. 3: Another important contribution to Major Depression. -REM latency : shorter in depressed patients -David Kupfer, researcher and former chair at department of psychiatry at the University of Pittsburgh. -When we fall asleep we go through several stages of sleep. We go progressively into non-REM sleep (NREM) and after about 90 minutes we experience REM (Rapid Eye Movement sleep) our eyes move back and forth rapidly under our eyelids and as the night goes on we have increasing amounts of REM sleep. -In addition to entering REM more quickly, individuals with Depression experience REM activity that is more intense and the stages of sleep that occur during non-REM periods (slow wave sleep) do not occur at all and if they do occur later among depressed participants. -Reductions in deep sleep -Interrupted sleep continuity (interruptions to other aspects of sleep. You wake up in the night, your sleep is not continuous.) -Insomnia as a risk factor for Major Depression. Not only is it a symptom, but it may be a risk factor too. a. Particularly for older adults who are not only more at risk for developing Depression from a host of psychosocial factors such as loneliness, but also have higher rates of disordered sleep, thus placing them at risk for Major Depression.

-Contributions to Insomnia Disorder: The 3-P Model! 1. Predisposing factors (Biological, psychological, social) -Hyperarousal/hyperactivity, family history, sleep reactivity -Prone to worry, driven -Bed partner with incompatible sleep schedule, work or school 2. Precipitating factors (Biological, psychological, social) -Medical illness or injury -Acute stress, major life events -Changes in social environment 3. Perpetuating factors -Excessive time in bed -Non-sleep behaviors occurring in bed

-General Diathesis-Stress Model known as the 3-P Model, is the primary theoretical backdrop for contributions to ID. -All 3 types of factors contribute to Insomnia Disorder. -Prior to a precipitating event, all we have are predisposing factors. -When predisposing factors are coupled with precipitating factors, we have an acute insomnia episode. -Over time, we see Early Insomnia includes all three of these factors and as time goes on and the insomnia complaint is characterized as more chronic, we see a predominance of perpetuating factors and less influence of precipitating factors with a stable dose of predisposing factors across all aspects or phases of Insomnia Disorder. 1) Predisposing Factors: Individual variants. a) Certain Biological Factors: Hyperarousal/hyperactivity (See this through a host of physiological biomarkers present in the body like... -Certain electrical signals measured through EEG in the brain -Higher levels of stress hormones measured in the blood -Heightened BP and heart-rate and the underlying determinants of those things), family history of sleep disorders, and sleep reactivity (tendency to have poor sleep in reaction to stress). b) Psychological factors: Tendency to worry, ruminate, be driven (hard-driving) c) Social factors: Bed partner with an incompatible sleep schedule, sleeping on a non-preferred sleep schedule (if you are a night owl and like to go bed late/wake up late, if there's an external factor like work or school that pushes you to go to bed and wake up early that may tip the scales and lead to insomnia.) Predisposing factors must occur in combination with... 2) Precipitating Factors: Acute occurrences that interact with predispositions. a) Biological factors: Medical illness and injury b) Most predominant -> PSYCHOLOGICAL FACTORS: Acute stress -> Something stressful happens in your day or multiple things build up throughout the day that may disrupt your sleep (getting caught in traffic, having a small deadline at work, negative interaction with a coworker, lousy conversation with a friend), but could also be... -Major life events: Moving, changing jobs, getting married, having or losing a child, getting fired, etc. c) Social factors: Changes in the social environment (like providing care for an infant) And then these complaints persist due to... 3) Perpetuating Factors: Maladaptive behaviors and thoughts. -Maladaptive strategies (these maladaptive behaviors and thoughts usually in the service of trying to get more sleep) adopted in an attempt to get more sleep. a) Excessive time in bed (going to bed earlier, getting up later, taking naps) On the behavioral side of things. "Well if I just get in my bed on the earlier side of things, I'll be in there and be resting. (Going to bed early). Logic is off and is a counter-intuitive behavioral response to insomnia. What we WANT TO DO is pair the bed very very closely with the onset of sleep! -Wakefulness and the associated negative emotions that often times go along with Insomnia such as anxiety, sadness, frustration, or anger, create an association on some sort of subconscious level that your bed is not a place for rest! Your bed is merely a place to be frustrated or sad or anxious or even just awake. -Getting up late and taking naps are also very counterintuitive to sleep. b) Non-sleep related behaviors occurring in bed. -Aside from intimacy and sexual intercourse, people should NOT BE working on laptops, eating food, studying. Bed should be aside for sleeping and intimacy alone! -Relating your bed to things other than sleep (bed is now the place for eating or studying or watching YouTube/TikTok on a laptop and not for sleeping.) -Pairing your bed with something other than sleep and creating a strong association especially if done overtime. c) Repeated pairing of sleep-related cues with wakefulness and/or arousal (What a and b do), when they are done in your bed they are particularly potent d) Sleep-related cues elicit arousal ... conditioned arousal (as a result of c) Sleep-related cues now associated with wakefulness/negative emotional states or non-sleep behaviors are conditioning you to be awake. -Opposite of sleep is actually arousal/wakefulness (not behavioral quiescence or recumbent posture or closed eyes or relative disengagement with the environment, it's arousal! The opposite of sleep.)

-Social Anxiety Disorder (Social Phobia) -Hallmark Symptom -Statistics : Prevalence remains steady throughout the lifespan, Older Adult Prevalence Rate -Gerald Moyer: the Imaginary Audience -Book refers to it as SAD, but Cribbet says SAD is Seasonal Affective Disorder. Just call the disorder by its full name or by social phobia, what it is commonly called.

-Hallmark symptom: Difficulty speaking, eating, or writing in public. -Any opportunity for a sort of evaluation by others, by doing things in front of other people. -Statistics: -12.1% lifetime prevalence, lifetime prevalence is fairly high. -6.8% prevalence for one year. -Older adults - 6.6% prevalence - prevalence remains steady throughout the lifespan. -Translates into about 35 million people. -Onset: Adolescence - peak at 13 years old. -Gerald Moyer, developmental psychologist at Ohio State, thesis project on social psychological phenomenon known as the IMAGINARY AUDIENCE, put forth by Gillilage and his colleagues related that a conceptual way to Social Anxiety Disorder and tested some of those hypotheses by using a factor analysis. -IDEA: The imaginary stage and under the scrutiny of others almost like in a live performance. -Similar to the developmental concept called Adelus and the egocentrism: you think you are the sort of concept of other people's thoughts and how is that different from a clinical concept of social phobia so we gave people questionnaires and had them play a video game while they were being evaluated by other people and examined all of these by factor analysis.

-Psychological Treatments for Cancer -What can help with... 1. Health habits 2. Treatment adherence 3. Endocrine function 4. Stress response/coping

-How can we help someone as psychologists with someone who has been diagnosed with cancer already? -Psychological interventions can improve... 1) Health habits (Getting better sleep, better nutrition, getting some physical activity if possible, reducing alcohol intake, and certainly stopping the use of cigarette and tobacco products. 2) Treatment adherence 3) Endocrine function 4) Stress response/coping -May lead to better remission and decreased mortality! -One of the things that is particularly difficult is that cancer is a very stressful disease. The diagnosis is stressful and coping with it can be very stressful too - it often involves waxing and waning in things like energy, fatigue, it has poor sleep, and heightened anxiety and depression. -Psychological treatments delivered agains for individuals that already have cancer can help with adherence to treatment regimens (continually showing up for radiation or chemotherapy which are very distressing in their own rights). -Can help people manage with their stressful responses to not only the diagnosis but treatment for cancer. -In fact, psychological intervention may actually help with remission rates and may influence mortality rates among cancer patients.

-Barbara Andersen, Ohio State University. Psycho-oncology, Psychological interventions actually probably do work! -Effect on Psychological Intervention for Breat Cancer, Anderson et al., 2008

-In fact, psychological intervention may actually help with remission rates and may influence mortality rates among cancer patients. -Randomized 227 patients who had been surgically treated for breast cancer to a psychological intervention plus assessment or to an assessment only condition. -2 conditions (intervention + assessment, assessment-only). -2 outcomes, proportion of surviving on y-axis, months on x-axis. Recurrence-free survival and breast cancer specific survival. -The intervention included strategies to reduce stress such as decreasing or reducing smoking and increasing exercise. In addition to that, there was an emphasis of adhering to cancer treatment and general care. -The treatment was successful in reducing stress and increasing positive mood and healthy behaviors, but perhaps more importantly and remarkably, after 11 years of follow-up, patients receiving the psychological intervention reduced their risk of dying by breast cancer by 56% and reduced their risk of recurrence for breast cancer by 45%. -SUPPORTS the survival-enhancing potential of psychological treatments. -Takeaway: Psychological interventions may be helpful for staving off a diagnosis of cancer, but can certainly be very helpful for helping people live longer and potentially healthier lives once they've been diagnosed and treated for cancer, breast cancer specifically.

-Bipolar Disorder Statistics -Key symptom -Onset -Course, progression -How many cases occur in adolescence?

-Key Symptom: Alternating high and low mood states (like riding a roller coaster; lots of ups and downs) -Avg. Age of Onset: BPI: 15-18 years old BPII: 19-22 years old -BP disorders develop suddenly and begin acutely. -Prevalence rates are low: 1% lifetime prevalence and 0.8% prevalence during any given year. HOWEVER, despite these low prevalence rates, a lot of attention is paid to this particular psychological disorder because of the severe nature of their highs and lows and the troubling consequences that come along with it: -For manic episodes: Reckless driving, misuse of substances like drugs and alcohol, risky sexual behavior, irritability, broken homes and families -For depressive episodes: Social isolation, increased suicide risk, disconnection from family members and friends -Chronic course: -1/3 of cases begin in adolescence -Rarely begins after 40, but once it does someone has it for life -Persistent mood states alternate or shift (over the life course) between mania and depression -Depending on the type of BPD that's present (BPI, BP2, Cyclothymia) gives us a clue about the extent or extreme nature of these mood swings and perhaps the duration of them as well

-Insomnia Statistics -Key symptom, 35% of... -Insomnia Disorder: Clinical Description

-Key Symptom: Difficulty falling or staying asleep. -About 33% of US reports insufficient sleep, corresponding to the CDC data. -8-10% report Insomnia Disorder. -Sleep complaints around 35% for older adults. -African Americans report higher rates of sleep complaints. -Sleep complaints in general are higher for certain populations like older adults, African Americans, [and interestingly women diagnosed with breast cancer show rates of ID specifically 2-2.5x that of the population]. ___________________________________________________________________________ -Includes all 3 (A-C): A. Difficulty falling sleep. B. Difficulty maintaining or staying asleep. C. Early morning awakenings with difficulties returning to sleep (Not simply waking up a few minutes prior to the start of your alarm going off. This is waking up an hour or more before your desired wake time that is accompanied by an inability to return to sleep.) D. The sleep disturbance causes clinically significant distress in social, occupational, educational, or other areas of functioning. (Impairment to at least one area of functioning). E. The sleep difficulty occurs at least 3 nights per week. F. The sleep difficulty is present for at least 3 months. G. Importantly - The sleep difficulty occurs despite adequate opportunity for sleep. -> Someone must be be giving him or herself an opportunity to sleep well. A. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder. Example: We often see Insomnia in the context of Shift-to-Work Disorder. If someone works all night and has to try and sleep during the day, then our bodies are certainly not prepared for this and our brains aren't hardwired for this so we have episodes of Insomnia. The ID would not be diagnosed in the case where Shiftwork predominates. B. The insomnia is not attributable to the physiological effects of a substance. Example: While drinking copious amounts of alcohol may help us fall asleep, we know it actually DISRUPTS sleep. People have trouble with sleep maintenance! If the alcohol is the reason behind the ID, we do not give an ID diagnosis. C. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia. Example: Often comorbid with Insomnia is Depression - Remember, Insomnia is in fact a symptom for Major Depressive Disorder.

-Emergence of Health Psychology Review -Psychosocial risk factors of CHD Review

-Late early to middle part of the last century. Driven in large party by a change in the leading cause of death in the US from infectious diseases to chronic diseases. -People were living longer, but not necessarily healthier lives and because of this, Health Psychology grew as a discipline and we found that through intervention on psychological, social, and behavioral factors we could actually influence physical health outcomes that matter to people. -CHD and the Associated Psychosocial Risk Factors include... 1) Low SES (socioeconomic background) 2) Type A Behavior Pattern (including hostility, dominance, and cynicism as key components) 3) Negative Affective States like Depression and Anxiety 4) Social Isolation and Conflict in close relationships 5) Job stress 6) CHD is also linked to chronic negative affect, low SES, and stressful life experiences. [An interaction of risk factors, largely noted in theoretical and some empirical data.]

Evidence-Based Assessment of Insomnia Disorder c) Sleep diaries -These parameters are used to calculate - - - for that night, - - - - (how long it took you to return to sleep after awakening in the middle of the night), - - - (how long it takes you to fall asleep once you get into bed), - - (percentage - total # of hours you actually slept divided by your total amount of time in bed x 100 -> If that number is less than 80% you might have insomnia disorder.

-Measures like the Epworth Sleepiness Scale are often used in conjunction with a sleep diary - like a journal kept every day of the week to be completed in the morning after a person wakes up. -Person must answer the following questions... 1) What time did you get into bed? (In our example that time is very different from the time they actually went to sleep. They got to bed at 10:15 p.m., but did not fall asleep or try to fall asleep until 11:30 p.m.) 2) What time did you try to go to sleep? 3) How long did it take you to fall asleep? 4) How many times did you wake up, not counting your final awakening? 5) In total, how long did these awakenings last? 6) What time was your final awakening? 7) What time did you get out of bed for the day? 8) How would you rate the quality of your sleep (very poor, poor, fair, good, very good)? 9) Comments (if applicable). What are some things that may have intervened with your sleep that we might need to know about. Example: "I have a cold." -These parameters are used to calculate total sleep time for that night, secondary sleep onset latency (how long it took you to return to sleep after awakening in the middle of the night), sleep onset latency (how long it takes you to fall asleep once you get into bed), sleep efficiency (percentage - total # of hours you actually slept divided by your total amount of time in bed x 100 -> If that number is well south of 80%, this is a value consistent with ID). -Finally, sleep diaries also include subjective questions (see Question 8). Sleep quality can include how refreshed or how restful your sleep was from the prior night.

-Contributions to Eating Disorders -Social: From a young age, how tightly you couple your value with your body image -Familial: Enmeshment (Minuchin) -Biological -Psychological: Perfectionism towards body image Keys et al.

-Most dramatic influences are social and cultural unlike disorders we have covered thus far. Biological contributions are minimized relative to those that are social and cultural in nature. 1) Social: Body image is equated with self-worth and happiness -From an early age (Your opinions of yourself, how you value yourself is very tightly coupled with your body image) -Do these actually correlate with happiness and success? Probably not, but the individual with the eating disorder is very difficult to uncouple self-worth, happiness, and body image. 2) Familial: As seen in latter half of 20th century. Emphasis on driven, hard driving, successful, concerned about external experiences. Ignore conflict. Could be a contributing factor to eating disorders. A lot of families are like this, but it's taken to the extreme. PSYCHOPATHOLOGY IS MULTIPLY DETERMINED. Familial input, though very important, is not sufficient enough to cause an ED on its own. -Key factor may be enmeshment: 1970s, Minuchin: Within a familial sphere or contribution to EDs, Anorexia in particular. Enmeshment is a key and important factor. Your parents are all up in your sh/t all the time. Constantly on top of you and controlling your every move. CONTROL very important aspect for individuals who have diagnoses of Anorexia and Bulimia. -We think that enmeshment is why so much over control on the part of the parents that the individual has to take control over something it just turns out that food intake and compensatory behaviors when there's binge-eating episodes is something the individual can actually control with some consistency and regularity. 3) Biological: Relatives of patients with EDs are 4-5x more likely to have the eating disorder. -Higher rates among identical twins -Fighting better nutrition: Nutritional factors: Extent to which your body is able to extract key nutrients from the food you are intaking 4) Psychological: Perfectionism directed toward body perception KEYS ET AL., 1950: Cowboy days of psychology, would not be an ethical experiment today -Semi-starvation experiment of 36 conscientious objectors -Volunteered as an alternative to military service -9 month time period; first 6 months given 50% of food intake; last 3 months food was gradually increased to normal levels. -During the diet phase participants lost 25% of their body weight (Initial 6 months) -Psychological manifestations of anorexia and bulimia came to light in individuals who did not have an eating disorder already: -Individuals not only became preoccupied with food, but they actually hoarded recipes and food-related items (things we often see in those with anorexia and bulimia)

-Integrated model of anxiety disorders -Barlow's Triple Vulnerability Theory As you sort of combine these things, a GPV and a GBV, you develop some sort of SPV that you learn from early experience such as being taught from your parents, that some situations or objects are fraught with danger.

-Not one bin or category only that contributes to the development of anxiety disorders, it may be that the integration of things cross, and all three categories are particularly important 1) There is some sort of general biological vulnerability represented that is some sort of heritable contribution to negative affect. This biological vulnerability in and of itself is not sufficient for the development of anxiety disorders, there must be some sort of generalized psychological vulnerability and specific psychological vulnerability as well. -You might grow up with these sort of tendencies maybe among them things like uptightness, being high-strung, things that are likely inherited. 2) A generalized psychological vulnerability maybe that you sense the world around you is not only unpredictable, but uncontrollable which is manifested in tendencies toward lower self-esteem, inability to cope with stress, and a lack of self-confidence. 3) These GPVs get translated into a specific psychological vulnerability that is relevant to you such as anxiety about your health, actual panic disorder that comes along with particular notions such as 'physical sensations are dangerous!' EX: Panic disorder: you may think the anxiety you're experiencing as rapid or shallow breathing, racing heart, might mean something dangerous and immediately threatening about your health when in fact it is actually panic. -The idea here is that no one of these factors alone is sufficient for the development of an anxiety disorder! As you sort of combine these things, a GPV and a GBV, you develop some sort of SPV that you learn from early experience such as being taught from your parents, that some situations or objects are fraught with danger. EX: If one of your parents is afraid of dogs or expresses anxiety about being negatively evaluated by others, you may also adopt these as well. You may be worried about social evaluative threat or you may develop a fear of dogs.

-Social contributions to anxiety disorders -How people react to stressful life events

-One of the things I think is probably a very potent contribution on the social side of things to the development of anxiety is how people react to stressful life events -Reactions to Stressful Life Events (one way we can assess this is by simply asking people in an interview to name off the most stressful things that have happened in the past year.) -People will often list illness/disease, death of loved one, difficulties at work, life transitions (new job, moving, even something very positive such as marriage: can be stressful simply because it involves change), problems with personal relationships (dating relationships, marriage, siblings) and larger family events or issues can all be contributed to anxiety disorder on the social side of things.

-Unipolar Mood Disorder -Bipolar Mood Disorders -3 Types of Bipolar Mood Disorder

-Only one extreme of mood is expressed. Such as Major Depressive Disorder: We only experience the severe feelings of Depression. -Both depressed and elevated moods are experienced (in kind of a vicarious cycle). Bipolar means alternating or cycling between episodes of severe depression and severe mania (mania includes increased energy, activation, sometimes irritability and anger and what is seemingly almost the opposite of severe depression). 1) Bipolar I Disorder (BPI): Alternations between major or severe depressive episodes and manic episodes. 2) Bipolar II Disorder (BP2): Alternations between major or severe depressive episodes and hypomanic episodes (less severe, mild-moderate symptoms of mania). 3) Cyclothymic Disorder (Cyclothymia): Alternations between less severe depressive and hypomanic episodes. Both are mild-moderate.

-What constitutes a panic attack? -7

-Panic attacks include things like... -Shallow breathing -Racing heart rate -Feelings that one might die to these symptoms -Dizziness -Tightness in chest -Loss of bladder or bowel control -In older adults: a fear of falling -What brings people into seek treatment often is people think they are having a heart attack and sometimes it is just panic disorder. -Panic disorder includes panic attacks and there's a lot of unpredictable experiences that constitute a panic attack such as: -Fast respiration or shallow breathing -Increased cardiovascular activity -Dizzy spells -Loss of bowel or bladder control -Fear of falling for older adults. -These are the common symptoms that constitute a panic attack. To have panic disorder you must have the occurrence of those panic attacks and sometimes you have panic disorder with or without agoraphobia.

-Contributions to Panic Disorder: -Psychodynamic perspective to panic -Object loss (Separation Anxiety leads to...)

-Psychodynamic: -Object loss: An early separation from a caregiver or a loved one, what's called an early object loss, as usually our attachment figures, our parents, get internalized, we carry them around with us and the loss of a caregiver or being separated from them might predispose someone to develop Panic Disorder as an adult. -Separation Anxiety is what a child might feel at the threat of separation or an actual separation from the parent and if played forward into adulthood we could have the manifestation of Panic Disorder. -Think of Clark's model like fire alarms, the tendency to over-interpret in a sort of very loud signal, that physical sensations are catastrophic and -Think of these Object Losses as very sort of existential and deeply rooted, such as Edvard Munch's "The Scream".

-Psychological treatments for GAD -CBT -Mindfulness and acceptance-based treatment -Walkup et al. 2008 study in JAMA

-Psychological treatments, such as 1. cognitive-behavioral therapy (CBT) for GAD is very effective for the long-term. -The idea is to actually get somebody to worry actively in the therapy session, in the room with the practitioner and then that worry is slowly sort of unpackaged through Cognitive interventions that counteract the worry -We want to change the way that someone is thinking about all of the things they're worrying about, trying to get them to sort of play this game of 'Well, what if is this happened?' and 'What if this happens' and 'What if this happens' and so on. -What we end up finding out at the end of the day is the actual worry isn't about the exam grade per se if you carry the train on down. EX: "Well maybe I don't get into the honor society that I want to." "Maybe I don't get into the graduate school I want to." "Maybe I don't get a job." "Maybe I'm worthless." -Taking the anxiety all the way out to that end step of feeling worthless or no good is the thing we actually really need to dig down deep for and make some lasting change on, but also those other steps along the way too. -So really, the hallmark of GAD is this sort of series of 'What If's?' -> 'What if I don't do this well' or do that well or what if this or that happens and it's that sort of unchecked series of 'What If's?' that I think is a nice way to characterize GAD. -2. Mindfulness and acceptance based treatment for GAD -More recent, third wave approach to CBT and this includes aspects of meditation and mindful practices really from the Eastern tradition and some more acceptance based treatments about being sort of observational and nonjudgemental toward your anxiety. -These therapies are building in their efficacy. _____________________________________________________________________________ -Psychological treatments for GAD, Walkup et al. 2008 -Studied children with GAD, comparing different treatment groups -Randomized controlled clinical trial of 488 children aged 7-17. -Either randomized into a placebo group - blue -CBT alone group - yellow -Sertraline/Zoloft alone group - purple -Or a combination of CBT and Zoloft - red -Both CBT and Zoloft alone worked, but the steepest and best decline was the combination of the two. Though CBT and Zoloft alone did provide lower outcome scores than the placebo alone. -The combination worked better! (psychological intervention paired by pharmacology) -Very standard in the literature that therapy alone is very good, not across all conditions and disorders but generally, and medication can be helpful, but the combination of those two really pack a good punch. -The horizontal axis measured number of weeks since initial session. -The vertical axis measured the scores on a GAD outcome measure. -Everyone starts at the similar level or baseline, which is very important for statistical reasons especially in a randomized-control trial. -Ensures your randomization worked, and among other things you're not violating some other statistical assumptions that are commonly used.

-Contributions to Panic Disorder: -Psychological: -David Clark: Over-interpretation of normal physical symptoms in catastrophic ways. (Vicious cycle between normal physical sensations, anxiety, and SNS leading to more physical sensations)

-Psychological: -David Clark: vulnerability to over-interpretation of normal physical symptoms in catastrophic ways. -Prominent researcher in this field, cognitively oriented and he would often emphasize this object that people would tend to interpret normal physical sensations like rapid heart rate after exercise as often sort of dangerous, catastrophic, so much so that it would be associated with a surge of anxiety that this anxiety then in turn would produce more physical sensations because of the activation of the Sympathetic Nervous System and thus a vicious cycle begins that results in a panic attack. -What Clark did to push the field forward is he emphasized the cognitive process as being the most important in Panic Disorders. -Clark's model is Cognitive. That is an over-interpretation of normal physical sensation in a very dangerous or catastrophic way.

-Comparing the CDC data on Insufficient Sleep to the prevalence of Heart Disease

-Same states that had insufficient sleep also had higher rates of Heart Disease. Similar pattern. -This data is CORRELATIONAL not CAUSATION! We are not saying that poor sleep causes Heart Disease, it could be the other way around. Why we do sleep research and research that includes the intersection of both sleep and health. -However data like this is intriguing because it suggests to us there may indeed be a RELATIONSHIP between poor sleep and risk for the development and progression of chronic diseases like Heart Disease. -The CDC data is not about full-blown Insomnia Disorder but rather just about insufficient sleep. -Important because that particular characteristic is related to this key symptom of Insomnia Disorder (see next slide.)

-Social Stress and Coronary Artery Disease in Monkeys -Cynomolgus macaques: University of Pittsburgh, late 1980s, early 1990s

-Similar pattern of results holds true in monkeys as seen with rabbits. -If we put monkeys in a stable living environment (cagemates are not shuffled around - perhaps more pronounced in monkeys than rabbits because that constant shuffle of the dominance hierarchy is very stressful for monkeys). If you put or introduce a new monkey into a cage full of male monkeys, the monkeys will fight, they will try to establish America's Next Top Monkey essentially and that is incredibly stressful. (a) Stable condition: The submissive monkeys (easily dominated by the top monkeys) and the dominant monkeys (those that like to constantly challenge for the hierarchy) BOTH looked kind of similar in CAD severity. (b) Unstable housing condition: We switch cagemates and introduce a new male monkey into these cages, those in the dominant condition look worse off in terms of CAD severity than do the submissive or subordinate monkeys. So, this is a classic paradigm used often in animal research where we have some sort of condition, we manipulate something (adding/switching cagemates), and then use some kind of medical intervention or blockade and see if we can get results that mirror the initial/baseline condition and that is what we see here with the study of Social Stress and CAD in monkeys. (c) Medical intervention condition: When we block the Sympathetic Nervous System (nerves that innervate the heart), we see that conditions return to normal even in the unstable condition - look more like the stable condition. We see monkeys, both dominant and submissive, return back to their baseline condition. The takeaway: Having an unstable housing environment for monkeys is very stressful, but if you block the SNS input that returns it to levels of stable housing for them.

Evidence-Based Assessment of Insomnia Disorder d) Actigraphy (Optional)

-Small wristwatch devices - not necessary to diagnosis, but can be used. -Clinic and research grade devices that look like Fitbits or Apple watches. -Included an accelerometer that measured rest-activity patterns. -> -Black lines (physical activity) -Blue squares (where we think sleep has occurred, because sleep involves limited physical activity) -Black lines within the blue squares that increase typically account for middle-of-the-night awakenings. -Sometimes actographs have the ability to collect light as an additional informational marker (as seen in yellow). Can be beneficial in providing what other inputs might be impacting sleep aside from movement.

-(THE RIGHT) Treatment for Insomnia Disorder -Cognitive Behavioral Therapy for Insomnia (CBT-I) 1) Sleep Hygiene -Peter Hauri, 1982 This is the kind of information you are likely to get from a nurse practitioner, primary care provider, however it is not the most potent component of CBT-I.

-Some of Peter Hauri's early work was seminal in developing sleep hygiene as a valuable component for the treatment of sleep disorders specifically insomnia. This is the kind of information you are likely to get from a nurse practitioner, primary care provider, however it is not the most potent component of CBT-I. a) Wake up the same time each day. b) Discontinue caffeine 4-6 hours before bedtime. c) Avoid nicotine. d) Avoid alcohol late in the evening because while alcohol might help with falling asleep it actually disrupts sleep maintenance or sleep continuity. e) Avoid rigorous exercise 3-4 hours before bedtime. f) Minimize noise, light, and excessive temperatures (really hot or really cold) during the sleep period. g) Move alarm clock or cellphone away from the bed.

Evidence-Based Assessment of Insomnia Disorder -Sleep diaries continued

-Sometimes sleep diaries are presented in a graphical format. -Dark shading = sleep, Down arrow = getting into bed, Up arrow = getting out of bed. -Example: Graduate school patient - Esther, elderly outpatient at the sleep/wake center. Esther came in for a long-standing insomnia complaint and she filled out a chart similar to the one shown. She had pink little hearts next to some of the wake-up arrows. "Those are cases when Walter was feeling particularly amorous." -Esther is OK because your bed is a place for such amorous pursuits along with sleep. Esther particularly detailed her sleep and bedtime activities. She would actually use her bed for sleep and intimacy ALONE.

Evidence-Based Assessment of Insomnia Disorder b) Self-report scales (Epworth Sleepiness Scale)

-This particular sleep history (previously mentioned) often is utilized with self-report scales such as the Epworth Sleepiness Scale. -Helps screen for Sleep Apnea - a comorbid complaint with chronic insomnia. -Give each question a particular score of 0-3 -0: Would never -1: Slight chance -2: Moderate chance -3: High chance -If total score for this particular scale is north of 10 you may be at risk for sleep apnea. This is just a screening measure - other measures must be obtained before the diagnosis of sleep apnea appropriately including an overnight sleep study, but it does give clinicians a direction they might want to follow up with.

-Panic Disorder -Hallmark symptom -Statistics (Onset, prevalence, gender differences) -Does it increase/decrease with age in prevalence? -Likely age to experience first panic attack.

-Spinning around in chair, spinning around in circles while standing, breathing rapidly through a straw to simulate what panic does to the body, do with company of someone else (wouldn't want anyone to faint). Can relate to symptoms of panic like shortness of breath, shallow breathing, rapid heart rate. -Hallmark symptom: Panic attacks and fear of dying and/or of losing control. (A fear of losing control or dying that accompanies a panic attack.) -Statistics: -Fairly common psychological disorder - 2.7% (close to 3% of US general population) meet criteria during a 1-year period. -More common among women. -Onset: mid-teens to 40 years old (wide-range age of onset can occur In terms of first episode of panic), however most people experience a panic attack or full-blown panic disorder for the first time between ages of 20 and 24. -Prevalence decreases with age. -Men typically present with alcohol misuse disorder -> Common and probably true of other psychological disorders as well that men who have panic disorder and other things such as Major Depression often present with an alcohol misuse disorder and we come to find out once they cross the threshold of the clinic that they actually have other complaints and panic is a common one to coincide with alcohol misuse in men.

Evidence-Based Assessment of Insomnia Disorder a) Clinical interviews + forms used by clinicians 1. Sleep History 2. Medical History 3. Psychiatric History 4. Substance Use History

-Standard of practice. Journal of Clinical Sleep Medicine, 2008 (Clinical Guidelines for the Evaluation or Management of Chronic Insomnia in Adults) is the gold standard paper for treating ID that a lot of clinicians who treat sleep disorders are very familiar with. -You should be obtaining a... 1) Sleep History: Asking people about what their sleep was like across the lifespan (as far back as they can remember, usually as far back as adolescence). a) Specific Insomnia Complaints: Has the person ever experienced Insomnia complaints? b) Sleep-Wake Patterns: What time do you typically like to go to bed and wake up? c) Daytime Consequences: What are the daytime consequences for your ID: Is it irritability, fatigue, trouble with attention/concentration/memory? Do you find yourself getting in more arguments? Lacking motivation to do your job? d) Pre-Sleep Conditions: -What is it like in and around your bedroom prior to you initiating sleep? Is your bedroom environment too hot or cold? Is there any light getting in? Sheets and pillows comfortable? -What are you doing right before bed? Are you watching shows on your laptop or television? Engaging in arguments with your significant other? -All things that are antithetical and thus do not promote sleep are things you want to watch out for when taking someone's sleep history. 2) Medical History 3) Psychiatric History: Have there ever been things like Depression, PTSD, anxiety disorders, or chronic pain complaints? Things that are highly comorbid with Insomnia. 4) Substance Use History: Is there a history of alcohol misuse? Does the person smoke? Do they use elicit drugs? -Methamphetamine is NOT GOOD for sleep if you could guess. -Often times these sleep histories are created in forms by clinicians and sort of individualized for specific practice.

-Diagnostic criteria for Agoraphobia The agoraphobic situations are actively avoided, often require the presence of a companion/another person, or are endured with intense fear and anxiety

-Stems from the Greek word for marketplace (agora) and fear (phobia). Being afraid of being out in public. -The complaint that kind of comes along with panic disorder. -Does not necessarily have to be public transportation or open spaces, can be closed spaces or standing in line. Simply being outside the home. A. Marked fear about two or more of the following five situations: -Public transportation -Open spaces -Closed spaces -Standing in line or being alone in a crowd -Being outside the home alone EX: University of Rochester medical center: Woman with agoraphobia: absolutely terrified of riding the city bus (public transportation) because she couldn't escape. She was afraid of not being able to stop the bus and get on if she had a panic attack and that scared her, she would start to hyperventilate with a racing heart rate, was afraid she would die and lose control. This is very real and very terrifying for people. B. The individual fears or avoids these situations due to thoughts that escape might be difficult or help might not be available due in the event of developing panic-like symptoms or other incapacitation or embarrassing symptoms. EX: Woman: she was afraid she would not be able to get off the bus when she wanted to, this idea of not going to be able to escape the situation or it may be difficult for them to get help when they develop panic-like symptoms. C. The agoraphobic situations almost always provoke fear or anxiety -Could be straightforward as just stepping foot outside the house, walking to the mailbox could induce panic, could be classified as an agoraphobic situation, does not have to be riding public transportation or being in a crowd. -You may talk to someone who hasn't sought out psychological interventions for Panic Disorder with Agoraphobia and they might say they have not been to the grocery store for ten years or the only thing they are able to do is make it to their mailbox. _____________________________________________________________________________ A. The agoraphobic situations are actively avoided, often require the presence of a companion/another person, or are endured with intense fear and anxiety B. The fear or anxiety is out of proportion to the actual danger posed by agoraphobic situations, and to the sociocultural context. EX: It's not dangerous generally to go to your mailbox or to go to the grocery store. C. The fear, anxiety or avoidance has lasted for 6 months or more. D. The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupation, or other important areas of functioning. -Must impact social, occupational, or other important areas of functioning. _______________________________________________________________________________ A. If another medical condition is present, the fear, anxiety or avoidance is clearly excessive. (Cannot be due to another medical condition if the medical condition is present.) EX: Sometimes medical complaints have fear and anxiety that go along with them such as a cancer diagnosis, having a heart attack, but the avoidance that is associated with the condition must be excessive. B. The fear, anxiety or avoidance is not better explained by another mental disorder.

-Pathways to Illness -If we think about pathways to illness and in particular health behaviors, we can talk about not only the sort of development, but the course or progression of illness in and of itself.

-The idea is that stress and associated negative emotional states (anxiety, depression, anger) that go along with stress can get in the way of how health behaviors may directly be linked up with illness and they can either sort of impact the health behavior very directly (as seen in the upward arrow) or they can impact the impact and course of the illness itself (as seen in the diagonal arrow).

-(THE RIGHT) Treatment for Insomnia Disorder -Cognitive Behavioral Therapy for Insomnia (CBT-I) 3) Sleep Restriction -Spielman, Caruso, Glovinsky, 1987

-The other sort of active and powerful component of this multi-component therapy known as CBT-I like Stimulus Control includes Sleep Restriction. -This is a tailored intervention that is developed from the sleep diary - where after a period of 1-2 weeks out from the initial appointment to establish a diagnosis of insomnia, a patient will return to a clinic with information over the course of 2 weeks about things like, a) Common bed times b) Time it takes to fall asleep c) Total sleep time d) Common wake times -This information to establish not only a fixed wait time, but to set a sleep window. a) Determine average total sleep time from 1-2 weeks of sleep diaries. b) Establish fixed wait time c) Set a 'sleep window' equal to total sleep time + 30 minutes. Example: Let's say someone gets into bed at 10 p.m. and does not actually fall asleep until 12 a.m., tosses and turns maybe wake up a couple of times, wake up the final time around 5:30-6 a.m. and does not actually get up out of bed until 8 a.m. -Recommend as a clinician treating the insomnia for this patient to not probably get into bed until 12:30 or 1 a.m. and set a sleep window of 6 hours after that around 7:30 a.m. and at that point is taken out of bed and begins her or his day. d) Keep weekly diaries and adjust the sleep window and adjust the window based on weekly sleep efficiency -Over time as sleep becomes more consolidated and less interrupted, the sleep window is adjusted usually based on sleep efficiency, a parameter that we have talked about (includes total number of hours divided by total amount of time in bed x 100) and if we see improvements in sleep efficiency we can extend this sleep window in 15-minute increments (that's allowing the opportunity for more sleep for the insomnia patient). e) Continue weekly adjustments until daytime functioning reaches adequate or desired levels and/or sleep efficiency is greater than or equal to 90%.

-Major Depression -Hallmark Symptom -Other statistics -Diagnostic Criteria for a Major Depressive Episode -Psychomotor...

-The prevalence of diagnosed clinical depression is seen all across the world. -Hot spots in parts of Africa, Middle East, and Asia, with America and parts of Europe not trailing too far behind. The map is a couple years old and probably still lagging to some extent with respect to prevalence of diagnosed clinical depression. -Hallmark symptom: Depressed mood (not talking about sadness that leaves one in a transit fashion, it doesn't just come and go. This is a profound level of sadness. This sadness more importantly is accompanied by a host of other symptoms. -Other statistics: -In terms of a Major Depressive episode, one isolated episode is relatively rare. -Once people have an initial episode of Major Depression, they are somewhere between 35-85% more likely to have a second episode. -First year following episode risk is 20%, second year is 40%. -Median number of lifetime episodes is 4-7. Depression is not only an outcome in its own right with serious and severe consequences, we know that Major Depression including repeated episodes place individuals at greater risk for cardiovascular disease, onset of sleep disorders, diabetes, and perhaps certain types of cancer. There are health implications beyond mental health implications associated with Major Depression in fact it appears Depression can impact physical health and functioning too. _________________________________________________________________________ A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning (must be different from previous functioning); at least one of the symptoms is either 1: depressed mood or 2: loss of interest or pleasure (in the things you normally enjoy doing) 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report ("Yes, I feel depressed mood.") or observation made by others (Family member, close friend, spouse/significant other) Profound depressed mood: Feeling down or blue most of the day, nearly everyday, for more days than not. 2. Markedly diminished interest or pleasure in all, or almost all, activities nearly everyday. -If you enjoy having cereal for breakfast, taking walks during the day, shooting hoops, riding you bike... You will not want to do any of those things. 3. Significant weight loss or weight gain (a change of 5% increase or decreased of body weight) or decrease or/sometimes accompanied by increase in appetite (Could not feel like eating, so it's not only gaining weight, it could be losing it too.) 4: Insomnia (Sleeping too little) or Hypersomnia (Sleeping too much) nearly every day. 5: Psychomotor agitation (amped up, fast, agitated movements) or retardation (slowed down, very slow, deliberated movements) nearly every day. -Walking slowly, eating slowly... 6: Fatigue or loss of energy nearly everyday. 7: Feelings of worthlessness or excessive or inappropriate guilt. -"Everything is my fault." -"I don't matter." -"I don't mean anything." 8: Diminished ability to think or concentrate, or indecisiveness, nearly everyday. 9: Recurrent thoughts of death (suicidal ideation: with or without a specific plan), recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide. -A very severe symptom. As with other psychological disorder... B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The symptoms are not due to the direct physiological effects of a substance (drugs, alcohol) or a general medical condition.

-(THE RIGHT) Treatment for Insomnia Disorder -Cognitive Behavioral Therapy for Insomnia (CBT-I) 4) Cognitive Therapy: Automatic thought records (Charts clinicians use)

-The questions asked are across the top, you might encounter a use for this with a patient and you would say something like this... 1) Situation: What (if any) distressing physical sensations did you have (over the past week)? -I was awake in bed in the middle of the night and that was very upsetting for me. 2) Automatic thought(s): When that was happening, what thought(s) and/or image(s) went through your mind? -My main thought was I won't be able to function well tomorrow. -Well how well do you believe that? How much did you believe each one at a time (0-100%)? -Well gosh, I believe that 90%. 3) Emotion(s): Well, you said you had this distressing thought, What emotion(s) (sad, angry, anxious, etc.) did you feel at the time? -I felt very anxious. -OK, How anxious did you feel from 0-100%? (How intense (0-100%) was the emotion?) -Probably 80%. 4) Alternative Thoughts: Then you would try to do something to help the person come up with alternative ways of thinking about for example lying awake in bed in the middle of the night and not being able to function. -You know there's really no point in worrying about this now, in fact sometimes I find I can still function after a poor night of sleep, do you think that's true for you as well? -You know, I don't really know, I'm just so worried I'll be a total wreck/total mess tomorrow. -Have you had nights in the past where you actually didn't sleep very much and were still able to get everything you needed to get done at work? -Well yeah, I always get my job done. -Oh, so you've had some times in the past, sounds like several in fact, where you didn't get very good sleep and you could still perform your job. -That's true. -Use questions at bottom to compose a response to the automatic thought(s). -How much do you believe each response? 5) Outcome: So how much do you actually believe that thought right now? -Instead of how highly I rated it, maybe it's around 50%. -That's really good you also said you've felt very anxious when you were lying in bed and having that particular thought about your ability to do well at work tomorrow, How anxious do you feel now? -Maybe 25%. -How much do you believe each automatic thought (now)? -What emotion(s) do you feel now? How intense (0-100%) is the emotion? -What is happening here is you're using the adjustment in thinking and hopefully that then, as we see here, also adjusts the extent to which the person is experiencing negative mood states such as anxiety.

-Psychological Effects on Physical Disorders - Cancer -Psycho-oncology -Psychological and behavioral contributions to the etiology and maintenance of cancer 1. Perceived lack of control 2. Poor coping responses 3. Stressful life events 4. Lifestyle risk behaviors -Mechanism: Psychological factors impact cancer risk by impacting functions such as... (impact the development and progression of cancer by acting on such biological factors as seen in...) 1. Immune function 2. Viral activity 3. DNA repair processes 4. Gene expression

-The study of psychological factors in cancer (how psychological factors influence the development and progression of cancer, not just cardiovascular disease). A relatively new field of study. 1) Perceived lack of control 2) Poor coping responses (e.g. denial) 3) Stressful life events 4) Life-style risk behaviors -Tons of research over decades now has concluded that perceived lack of control, inadequate coping such as using denial, the accumulation of stressful life events, and risk behaviors such as not adequate sun protection, obesity, cigarette smoking or tobacco use more broadly, alcohol use -> All are likely components that portend risk for cancer diagnosis. ______________________________________________________________________ -What we know from fields like psychoneuroimmunology is that psychological factors impact cancer risk by impacting functions such as... 1) Immune function 2) Viral activity Example: Predominantly the HPV virus that is often contracted by young women in their teens that places them at risk for gynecological cancers, why we recommend that young girls get vaccinated against HPV beginning in early adolescence 3) DNA repair processes 4) Gene expression Example: The experience of a stressful life event, which we talked about as being a potent risk factor for the development and progression of cancer, in the past year particularly among individuals with troubled early parent-child relationships predicts greatly decreased immune system reactivity to basal cell carcinoma tumors and anything that promotes closer, more supportive relationships in cancer patients is important because it buffers against stress, slows disease progression, and may act on immune functioning and DNA repair as well. -Things like perceived lack of control and inadequate coping responses, or the use of inappropriate coping responses all contribute to the development of cancer. That is before someone has a diagnosis, probably through changes in immune functioning, but also through the regulation of cancer-causing viruses like HPV and DNA repair processes. Example: Chronic psychological stress is associated with cellular aging, recall the earlier talk on telomeres, stress is particularly responsible for cellular aging itself, it has implications for cancer.

-The Current View of Stress -Divides these ideas by Cannon, Selye, Lazarus/Folkmen in a sort of different way. 1. Events (Stressors) 2. Appraisal 3. Behavior (Coping) + Physiological Response or 4. Behavior -> Physiological Response 5. Illness

-There are discrete events or stressors and those are followed by appraisal processes (perhaps a little bit different from what we just saw from Lazarus) and that appraisal processes lead to some kind of coping (behavior) whether it be cognitive or behavioral, but we will go with the behavioral idea. There's also some sort of physiological response and that the way in which we cope can also influence the physiological response as we see from the downward arrow. And then following all of this up, and for a sort of long period of time, we have actual illness.

-(THE RIGHT) Treatment for Insomnia Disorder -Cognitive Behavioral Therapy for Insomnia (CBT-I) 2) Stimulus Control -Bootzin and Nicassio, 1978

-What IS proven to be very very effective for the treatment of insomnia in terms of the active ingredients of CBT-I is Stimulus Control and Sleep Maintenance. a) Use an alarm everyday to keep a fixed wake time (Having a fixed wake time is very very important because it ensures consistent meal times, usually but more importantly consistent light input to the brain. b) Do not nap during the day c) Avoid any behavior in the bed other than sleep or sexual activity. -We're relying on those principles from behaviorism that we've talked about that is, don't do anything in the bed other than sleep and sexual activity. Don't nap during the day (this may decrease our sleep drive, when we get into bed and we experience wakefulness - that will not strengthen that association between bed and sleep that is so important hence the name stimulus.) d) Lie down to go to sleep only when you are sleeping to further strengthen that bond between sleep and your bed. This is not a feeling of fatigue or being drained of the body, this is actual sleepiness (eyelids are heavy, actually cannot stay awake). e) Leave the bed when awake for approximately 20 minutes. -If you happen to get into bed at the beginning of the night and cannot fall asleep or wake up in the middle of the night and are unable to return to sleep - SC says you should not be awake in the bed for more than 20 minutes. What is recommended is to move another location within the bedroom or in an adjacent room, be seated in a comfortable spot and do something that is minimally engaging. People often do things like flip through magazines, but not engaging one so often catalogues are recommended or do something very mild like knitting or perhaps even some meditation. This is certainly not the time to deep-clean the bathroom or organize the cupboards in the kitchen, this is something that one should be doing that is quiet activity as those activities just mentioned previously. f) And return to bed ONLY when sleepy (once one feels sleep is imminent, you should return to the bed and try to reinitiate sleep).

-Cardiovascular Disease example of pathways to illness -Looking at the inside of an artery, timeline for hardening of arteries known as Atherosclerosis. -The innermost cell layer of the artery is called the Endothelial. What is depicted in the diagram is Endothelial Dysfunction and Atherosclerosis, an underlying disease that contributes to a lot of outcomes we have heard of such as heart attacks and strokes.

-What happens in the beginning of the first decade of life is we see someone have lipid accumulation in the inner-lining of the arteries (evidence of white layer beginning to form). -Over time and into the 30s, we see some kinds of lesions and fatty streaks beginning to become more prominent in the formation of something called an Atheroma, characterized by the bulging portion here that occludes blood flow in the artery through a series of inflammatory processes and oxidative stress processes. Essentially the lipids depicted in the yellowish portion here become oxidized and are easily ingested by particular type of immune cell called Macrophages anf that leads to the formation of a Fibrous Plaque. -Finally, in the fourth decade of life, if things do not proceed very well at all, we see some sort of complicated lesion on the inner lining of the artery that when ruptured can lead to things like heart attack or stroke.

Evidence-Based Assessment of Insomnia Disorder -What is not indicated? Differential Diagnoses to Insomnia Disorder 1) Obstructive Sleep Apnea: Difficulties in memory, concentration, attention 2) Delayed Sleep Phase Syndrome 3) Shiftwork

-What is not indicated or always used in evidence-based assessments for Insomnia Disorder. -Comes from clinical guidelines in Journal of Clinical Sleep Medicine. -An overnight sleep test is not required. (Polysomnography or an overnight sleep study) - Indicated for the diagnosis of Obstructive Sleep Apnea, Central Sleep Apneas, and other REM-related sleep disorders, but not necessary for the diagnosis of Insomnia. -These kinds of tests place burden on the sleep patients and are very costly (not often fully covered by insurance). -Attached is a photo of what a polysomnography graph looks like. _____________________________________________________________________________ 1) When there is a cessation in breathing that cuts off the oxygen to the brain. When that happens, there is a choking or gasping for air that often times wakes the person up, sometimes outside of conscious awareness (trying to get oxygen back to the brain). -Happens because the airway is occluded for a lot of different reasons including... a) Facial or cranial structure, but most commonly b) Overweight/obesity -SA also has some daytime sequelae as well (excessive sleepiness) more likely to deal with... a) Difficulties in memory, concentration, attention -Although they are present in insomnia, also have b) Excessive daytime sleepiness (dozing off, cannot keep head up), whereas in insomnia most of the time individuals do not nap and report fatigue like they are running a marathon. c) SA individuals might wake up with sort throat or dry mouth too. 2) Circadian rhythm complaint characterized by excessively late bedtimes and very very late wake times. -Onset age adolescence. A person's sleep is delayed by two hours or more beyond what is considered an acceptable or conventional bedtime. The delayed sleep then causes difficulty in being able to wake up at the desired time. 3) When someone is working when he or she is supposed to be sleeping. Sleep occurs outside a typical or preferred sleep window and work typically occurs during that time for sleep.

-Reminder: Assessing Insomnia Disorder -'Natural Remedies for Poor Sleep' (As Found on Pinterest)

-When assessing for the presence of ID we don't necessarily need to do an overnight polysomnography (what's commonly known as an overnight sleep study). Instead, a thorough clinical interview is sufficient for the assessment of ID. These clinical interviews are usually conducted by trained professionals either in nursing, psychiatry, neurology, respiratory medicine, or clinical psychology. Specifically with these interviews we want to know about -a) Any current sleep complaints, including severity and duration of those complaints -b) Any past episodes of insomnia that may be present -c) Additionally we want to know about psychological aspects of the disorder (tendency to worry/be anxious) -d) And any sort of current stressors that may be contributing to the sleep complaint. Once we're established there is the presence of Insomnia Disorder, we can move on to treating insomnia. -Lavender Sleep Balm -Magnesium -Organic Tart Cherry Juice (there maybe evidence actually that it can be helpful) -Melatonin (a lot of people think melatonin is indicated for the treatment of insomnia, but it's really indicated for circadian rhythm complaints and actually not at all effective for the treatment of insomnia and moreover many people buy melatonin with the hopes it will actually promote sleep and it indeed does not work especially when you take large doses like 1, 3, or 5 milligrams prior to bedtime. Melatonin is a naturally-occurring hormone within the brain and any melatonin used for medicinal purposes should be used to treat circadian rhythm disorders and should be administered in small doses at the appropriate times. -Insomnia Cookies (IS good and can be helpful for the treatment of insomnia, delicious).

-Treatment of Social Anxiety Disorder -1) Family treatments -2) Beta blockers -3) Selective Serotonin Reuptake Inhibitors (SSRIs) -4) Safety behavior removal -Comparison study, Clark et al., 2003

1) Also quite effective. Given age of onset in early teens, giving feedback to parents through family-based treatment appears to outperform individual treatment especially when the child's parents also have an anxiety disorder. Long-term followup studies indicated that youth who receive a parental component as part of anxiety treatment are significantly more likely to be diagnosed as free in the three years following treatment than those who did not. -Not only is family-based therapy actually preventive in the onset of anxiety disorders in children of anxious parents, once a child develops an AD, and Social Anxiety Disorder is no exception, early treatment with CBT (Cognitive Behavioral Therapy) in the family setting can be successful to treat symptoms of Social Anxiety Disorder. 2) Sympathetic inputs to the heart that control heart rate and respiration. If we can cut these symptoms off it might reduce those symptoms that flare up during social evaluations such as giving a speech, and thus dampen the SPV that social evaluation is dangerous. 3) Particularly effective like #2. 4) People with Social Anxiety Disorder might engage in safety behaviors (a type of avoidance) to reduce the risk of negative social evaluation and/or rejection. One way to combat that is to remove these behaviors (drinking, bringing a friend along to a social gathering or party, etc.). -Comparison study: Clark et al., 2003 -3 different conditions: 1) Placebo + Self-Exposure (SE) 2) Prozac (SSRI) + SE 3) Cognitive therapy alone (focusing on restricting anxious thoughts about negative evaluation in social situations). -Horizontal axis: Phase of treatment (prior to treatment, beginning, mid-treatment, after/post-treatment, after a booster session one year later). -Vertical axis: Composite measure of social phobia or Social Anxiety Disorder. -Individuals in the conditions that included SE were encouraged to engage in more social situations, all the info they were given with respect to treatment. -At every time point, the cognitive therapy by itself outperformed the placebo + SE and the Prozac + SE. This demonstrates that cognitive therapy was superior to medication + self-exposure. -For other ADs, we talk about how we see that medication paired with some form of intervention was most effective, here the psychological intervention was induced by patients through SE, whereas the structured therapy alone was proven to be most effective.

-Treatments for Eating Disorders 1. Biological 2. Psychological

1) Anorexia: Drugs not particularly effective. -Prozac not helpful for preventing relapse once weight gain occurred. -Bulimia: Prozac for reduction in binging and purging. 2) Traction with respect to treatment. -Based on contemporary theories at that time -> Prior to 1980s psychological treatment targeted self-esteem. -Cognitive Behavioral Therapy-Enhanced (CBT-E) -Involves a series of steps... 1. What are the physical consequences? 2. Adjusting negative thoughts in relation to the ED especially around body image. 3. Coping strategies (replace the behaviors like binging and purging and other compensatory strategies such as excessive exercise and the use of laxatives to control weight gain and body image.) -Family therapy is also effective. -Minuchin: Role family can play in EDs and anorexia in particular. 1. The role of enmeshment: Over-control on part of parents in almost every aspect of the teenager's lives - helping families break those negative patterns seems to be particularly effective in the treatment of EDs.

-Circadian Rhythm Sleep-Wake Disorder -Categories: There are different types of Circadian Rhythm Disorders. -Treatments DSPS, the melatonin will be given at dinnertime and again just before bedtime.

1) Delayed Sleep Phase Type/Delayed Sleep Phase Syndrome: Talked about in respect to differential diagnosis of insomnia. Involves staying up really really late and waking up really really early in the morning. This is biologically driven predominantly. We might colloquially call these individuals 'night owls'. -Onset is usually middle to late adolescence. -Accompanied by Depression and often how we first diagnose DSPS is that we'll have teenagers in high school who are falling asleep in classes, earning poor grades particularly in morning classes. Also some balance of Depression and very very long sleep classes. Also some balance of Depression and very very long sleep in terms of total sleep hours earned per night or sleep duration. -This number can be an average anywhere from 10-12 upwards of 13/14 hours. 2) Advanced Sleep Phase Type: Opposite of DSPS. The person goes to bed very very early and wakes up very very early. Both of these (DSPS and ASPT) are misalignments between what's going on in the external world and the endogenous circadian clock). 3) Jet Lag Type: When you travel across time zones particularly when you cross into Europe, Asia, or the Middle East. Can even happen when you cross time zones across the US, but it's not marked or severe. 4) Shiftwork Disorder: Work that overlaps the period usually from 11 p.m. to 7 a.m. it can take up things like IT support, overnight vets, factory workers (people who work at the Nucor factory along the river, they're shift workers typically many of them). Treatments of Circadian Rhythm Sleep-Wake Disorders: 1) Melatonin: Usually given in very very low doses, 1/2 of a 1/2 to 1/2 of a milligram, that's a timing dose often times for especially DSPS, the melatonin will be given at dinnertime and again just before bedtime. 2) Light Therapy: Often used to advance the sleep cycle of a person, if we move around circadian rhythms and depending on whether or not you have ASPT or DSPS depends on when you will receive light either in the morning or the evening. 3) Regularize Schedule: Eating meals around the same time of day, doing physical activity around the same time of day, certainly going to bed and waking up at the same time.

-Contributions to Social Anxiety Disorder -1) Jerome Kagan: The inhibited or shy trait. -2) Learning that social evaluation is particularly dangerous. (Barlow) -3) Parents of people with Social Anxiety Disorder are more socially fearful and concerned with the opinions of others. -> Genetic contribution.

1) Inhibited or shy trait. Individuals who went onto develop Social Anxiety Disorder would best be characterized as inhibited or shy as early as 4 months of age. Kagan suggested that perhaps some infants may be born with a temperamental profile or a trait of inhibition/shyness that is evident very early and it may look like: being agitated, crying more frequently when presented with toys or age-appropriate stimuli. -This sort of behavioral inhibition, put forth by Kagan, was associated with an increased risk in several studies for developing Social Anxiety Disorder. 2) Learning that social evaluation is dangerous. Social learning takes place such that someone learns throughout the course of many examples that social evaluation is particularly dangerous. This is best demonstrated by Barlow. -Some sort of Generalized Psychological Vulnerability (belief that events particularly stressful are potentially uncontrollable) perhaps including Kagan's work on some sort of heritable component or aspect of behavioral inhibition that when under stress someone might anxiously interpret a false alarm that is associated with some sort social evaluative situation as being overly focused on or increased self-focused attention on the self and that that leads to a Specific Psychological Vulnerability that social evaluation is particularly dangerous and this finally leads to the actual disorder. -GPV along with Kagan's input of behavioral inhibition that both of these two things contribute to Social Anxiety Disorder so that when stress is present there may be some sort of false alarm associated with social evaluative situations that leads to a focus on the self that leads to the SPV that social evaluation is dangerous and finally leads to Social Anxiety Disorder. 3) Not only is there some sort of genetic contribution, but we also have a primary example of social learning through your primary caregivers. -Billy Madison: Social learning can also not be particularly dangerous -> "You ain't cool unless you pee your pants!"

-Health psychology: Main takeaway: How psychological and social factors influence health. Pathways linking psychological and social factors to health, using cardiovascular disease as a prime example (how psychological and social factors link up to physical health). -HP is very broad too. Includes idea of understanding how social and psychological factors influence physical health. Traditional research in HP has branched into 2 broad directions... -Stress and Health Psychology -Emergence of Health Psychology -Annual U.S. Causes of Death Today

1) Understanding how psychological and social factors influence health through health behaviors (physical activity, diet, smoking, alcohol use, etc.) 2) Physiological changes or intermediated markers that link psychological and social factors to health and disease. -In a previous lecture we talked about stress and how probably our cavemen and cavewomen ancestors experienced very different kinds of stress than we do today, that is they were often running from predators, trying to find food as a means to stay alive, whereas much of the stress we experience today, although can have some of those central elements like trying to stay alive and find food, is often psychological in nature and manifests through things like worry, anxiety, and perhaps even depression. 1. During the middle of the last century around the 1930s-50s, one of the things that lead to the emergence of HP was the decline in death rates due to infectious diseases and a simultaneous increase in chronic diseases as the primary cause of death. -Due to advancements in the treatment, particularly antibiotics, we saw an increase in life span in the latter part of the last century, primarily due to the fact that people can live longer, though not necessarily of higher quality or happier lives, with chronic diseases and were not succumbing to an earlier death due to an infectious disease (things like Tuberculosis, small pox, etc.) -Data from the last century and continuous data today, show Heart Disease, Cancer, Stroke, Chronic Lung Disease, and Diabetes as the first 6 or 5 of 6 of leading causes of death in the U.S. These diseases are all chronic diseases. Acute diseases like Influenza and Pneumonia are much farther down the list than they once were in the earlier part of the 20th century. This suggests the role of Health Psychology. We now have a much longer period of time to understand how someone's health unfolds in relation to psychological and social factors that wax and wane during the life course.

-Type A Behavior (Hostility, Dominance in particular) -Data from 2 large prospective group cohort studies. 1. Western Collaborative Group Study (WCGS) 2. Framingham Heart Study

1. 3,154 healthy men aged 39-59 were interviewed about their behavior and followed for 8 years (in their midlife). -Type A individuals were twice as likely to develop CHD than mild-mannered counterparts. -Among younger men (more on the 39 age range), 6x risk of developing CHD. -Shocking results from large number of people, holds a lot of weight when talking about psychosocial factors linking up to both the development and progression of cardiovascular disease. 2. Ongoing, Boston-area. Specific portion of the study. -1,674 men and women studied with follow-up 8 years later (Not just men as in WCGS, and we actually see similar results in women as in men!) -Similar results as WCGS. -For women those with Type A AND low level of education had the highest risk.

-A Brief History of Stress -1. Walter Cannon, 1932 Sympathetic Adreno-Medullary Response (SAM) -2. H. Selye, 1956 -3. R. Lazarus and Folkmen, 1966 Stress follows appraisal. -Cognitive appraisals and stress (2 types)

1. Fight or Flight and the Sympathetic Adreno-Medullary Response (SAM). -"Fight or flight response." -Cannon interested in a stress pathway that included sympathetic nerve innervation into the adreno-medullary end-target organs that ultimately ended in the release of stress hormones like Cortisol. This general theory about stress was taken up by Selye with his General Adaptation Syndrome. 2. General Adaptation Syndrome (alarm, resistance, exhaustion), hypothalamic-pituitary-adrenocortical response (HPA). -Your body is programmed (extrapolated from a series of animal models) to set off an alarm when something is distressing or stressing, to mount some sort of physiological resistance to that alarm and if that is sort of held constant for a period of time it can lead to exhaustion on sort of the physical level and perhaps even psychological level as well. -Interested in the hypothalamic-pituitary-adrenocortical response (HPA) where that is generated by the HPA axis. 3. Cognitive Appraisal. -Cognitive or thinking aspects of stress. Really interested in this idea of cognitive appraisals. -He divided these thought processes/appraisals into 2 main categories. 1. Primary Appraisals: What is at stake? Is it positive, negative, or neutral? Presently harmful? Threatening for the future? Potentially challenging? -Is it a challenge (not a threat at all)? Athletic performance - sometimes very stressful, but if you flip the script and think about it as being something challenging that can actually produce or engender better results whereas being chased by wild animals is probably uniformly very threatening and certainly negative. -What is going on in my environment right now (Is it harmful, positive, negative, neutral, threaten me or my future in some way, is it not even a threat at all/is it a challenge?) 2. Secondary Appraisals: Can I deal with it? Are my abilities and resources efficient? -Lamen terms: Can I deal with it? Do I have enough resources at my disposal to handle this particular stressor that I am feeling? Stress Follows Appraisal (These processes (primary and secondary appraisal processes) happen lightening fast.)

-How psychological and social factors influence health - Cardiovascular disease example [the leading cause of death in America], though we could talk about diabetes/cancer/etc. -The central role of Stress in health and disease. Two pathways (There are multiple pathways that link up psychological and social factors to the development and progression of cardiovascular disease.) 1. Biological: Stress hormones and blood pressure 2. Health Behaviors -If we think about these (with cardiovascular disease as our example), we would probably have to certainly talk about the role of stress linking up to cardiovascular disease risk. -The Central Role of Stress in Health Psychology -1. Stress and disease: -Stress has a "Direct" psychobiological effects on disease development and progression -2. Health Behavior and Prevention (other pathways we described besides direct psychobiological effects where stress interferes with a health behavior) -Stress interferes with health behavior Example: When you are particularly stressed out you might not eat as well, may let physical activity slip a little bit, increase consumption of alcohol or number of cigarettes you smoke, amount of dip you put in on a daily basis. -When Cribbet gets stressed out he likes really greasy Mexican food. This would be a signal that something is up. What are your stress signals? How do you know that things in your life are starting to interfere with certain behaviors that you normally engage in? -Examples like stop exercising, having extra drinks through the week or weekend, increase cigarette use, etc. -What is stress anyway? Well, stress is very difficult to define. Stress is a - - - accompanied by -/- -, -, and - changes that are directed (serve one of 2 purposes) either through (a) - - - or (b) - to - - (to the stress itself).

1. Increases in things like stress hormones and blood pressure. 2. Poor eating habits, sedentary lifestyle, drug and alcohol misuse, tobacco misuse. -Stress is a negative emotional experience accompanied by reliable/predictable physiological, cognitive, and behavioral changes that are directed (serve one of 2 purposes) either through (a) altering stressful circumstances or (b) accommodating to its effects (to the stress itself).

-Psychosocial Treatments of Physical Disorders -SR/TM, R/M, E, D, SC -American Heart Association Recommendations for Dieting

1. Stress reduction and time management (Engaging in things like meditative practice, scheduling out your day, making and setting aside time for relaxing activities you might enjoy, which in this case can be physical activity. Guidelines for physical activity listed below.) 2. Relaxation and Meditation 3. Exercise (Recommendations for physical activity: getting your heart rate up) ... 30-60 minutes a day for at least 3-4 times a week for the U.S. (Making it regular!) 4. Smoking cessation: Stop it! 5. Diet: Broadly looking at the literatures of dieting, we notice if we were to distill it into some very simple set of phrases it would read something like this... Eat real foods. Not too much. Mostly plants. -Do not eat a bunch of processed stuff (No Twinkies!), do not eat too much when you do eat, and when you do choose to eat things eat mostly plants. -Building off of this... ___________________________________________________________________________ 1. Eat 2 servings of fish with omega-3 fatty acids every week (salmon). 2. Eat variety of fruits and vegetables, 5 or more servings per day. 3. Eat a variety of grain products, including whole grain (like Quinoa, Farro, not just the ho-hum grains we're used to). 4. Use natural oils low in saturated fats when cooking like olive oil. Not butter! 5. Less than 6 grams of salt per day (about 1 teaspoon). 6. No more than 1 alcoholic drink per day for women, and no more than 2 more men.

-Psychological Treatments for Major Depression 1: Cognitive-Behavioral Therapy (CBT, Beck) -Behavioral activation, alter thoughts residing in the triad 2: Interpersonal Psychotherapy (IPT, Klerment and Weissman) (Effective and common alternative to CBT) -Dealing with interpersonal role disputes, adjusting to loss of relationship, acquiring new ones, identifying incorrect deficits in social skills -3 stages: negotiation, impasse, resolution

1: Hoping to as a first line of defense get people up and moving and doing things: Behavioral Activation. Walking, interacting with others, getting off the couch, out of the bed. -Maybe not even necessarily engaging in physical activities (exercise), though that would be helpful, simply just getting up and moving is very good. -This Behavioral Activiation alters the negative thoughts people are having as a result (while in a depressive episode). -Another way to approach a cognitive-behavioral treatment with respect to Depression is change the way people are thinking about the world around them, themselves, and the future (If we think back to Beck's Cognitive Triad). -Adjusting these thoughts can actually make you feel better and that is the whole point behind CBT for Depression. 2: Like traditional types of CBT approaches is very structured, often can be completed in 15-20 45-60 minute long session and includes a discussion of one or more interpersonal issues including... a. Dealing with interpersonal role disputes (martial conflict) b. Adjusting to the loss of a relationship (death of a loved one) c. Acquiring a new relationship (getting married) d. And identifying incorrect deficits in social skills (a barrier often times for initiating and maintaining an important interpersonal relationship(s)) -IPT comes in three different stages. IPT does involve two people usually. a. Negotiation Stage: both people trying to work towards resolving a dispute (simply negotiating about it). b. Impasse Stage: often accompanied by low levels of resentment, but no attempts made to resolve what is going on. c. Resolution Stage: both people take some action such as recommitting to a marriage, divorce, or separation. -Common example of what can lead to Depression in both husbands and wives and playing out of that according to IPT.

-Circadian Rhythm Sleep-Wake Disorder -Endogenous circadian rhythm (inside, deep within your brain that suprachiasmatic nucleus of the hypothalamus helps sort of regulate your 24-hour body clock)

A) A persistent or recurrent pattern of sleep disruption that is primarily due to an alteration of the circadian (timing) system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by an individual's physical environment or social or professional schedule. -Involves some kind of misalignment between what's going on in your endogenous circadian rhythm (inside, deep within your brain that suprachiasmatic nucleus of the hypothalamus helps sort of regulate your 24-hour body clock and what's actually required by your physical environment in terms of your social, professional, occupational roles or schedule. B) The sleep disruption leads to excessive sleepiness or insomnia or both. C) The sleep disturbance causes clinically significant distress or impairment in social, occupational, and other important areas of functioning.

-Manic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy lasting at least one week and present most of the day nearly every day (A period separate from normal functioning) B. During the period of mood disturbance and increased energy or activity, 3 or more of the following symptoms must be present, 4 or more if mood is only irritable: -Inflated self-esteem and grandiosity ("I believe I am the greatest. I can get anything done. I am the best.") -Decreased need for sleep (feels rested after 2 or 3 hours) -More talkative than usual or pressure to keep talking -Flight of ideas or subjective experience that thoughts are racing -Distractibility (easily distracted) -Increase in goal-directed activity (going to get stuck on the topic and going to pursue it until the end) -Excessive involvement in activities that have high potential for painful consequences (risky sexual behavior, increased use of alcohol or drugs, reckless driving) A. This particular change in mood, the mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning, or to necessitate hospitalization to prevent harm to themselves or others, or there are psychotic symptoms. B. The episode is not attributed to the physiological effects of a substance or to another general medical condition. -University of Rochester patient - in-patient hospital unit, young woman with BPD (placed in hospital due to episode of self-harm): -BPD is commonly displayed in media that people often talk about it and suspect that they might have it, but if you truly witness BPD you will know you are in the presence of something markedly different (it will smack you in the face). It's not just increased mood or increased irritability. You'll know it when you see it. -She had rapid speech, irritability, grandiosity and inflated self-esteem, increase in goal-directed activity. "IWASTHINKINGABOUTSELLINGMYHOUSEVANPARKEDOUTSIDETRYTOSELLTHATVANBUTBEFOREIDOTHATTRYTOWORKONMYHOUSELOOKATTHISLOOKATTHISLOOKATWHATITAPEDTOMYBINDERLOOKATTHISILLOPENTHISBINDERANDSHOWYOUALLOFTHESEMAGAZINEADSIVEBEENCLIPPINGLOOKATTHESEILOVETHEMILLSAVEALLTHESEANDGUESSWHATIMNOTTAKINGMYMEDICATION" -She attached to the front of her binder a maxi pad removed from her person and decided it would be a good idea to tape it to her magazine clippings binder where she was going to complete all of the things she had saved, do all the things she planned on doing from these magazine clippings inside this binder which there were probably four to five dozen cutouts, certainly she wasn't going to do all of these things, she was hospitalized in-patient. She had a flight of ideas around selling her house, selling her call and then all of a sudden her words just became unintelligible, she switched topics rapidly, but she certainly thought she was going to sell something.

-Bipolar II Disorder -Mania linked to BP1, hypomania linked to BP2 -Hypomanic episode: -Shorter, less severe version of manic episodes -Last at least 4 days -Have fewer and milder symptoms -Associated with less impairment than a manic episode (e.g. less risky behavior) -May not be problematic in and of itself, but usually occurs in the context of a more problematic mood disorder

A. Criteria have been met for at least one hypomanic episode and at least one major depressive episode. Criteria for a hypomanic episode: 1) Minimum duration of 4 days 2) Although the episode represents a definite change in functioning (must be a definite change in functioning), it is not severe enough to cause marked social or occupational impairment or hospitalization; 3) There has never been a manic episode B. There has never been a manic episode C. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by other psychological disorders D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, academic, or other important areas of functioning DIAGNOSTIC CRITERIA FOR BP1 ARE THE SAME WITH THE EXCEPTION THAT FULL MANIC EPISODES ARE PRESENT

-GAD key symptoms

A. Excessive anxiety and worry (apprehensive expectation), occurring more days (many days) than not for at least 6 months. B. Individual finds it difficult to control worry. C. Anxiety and worry are associated with at least 3 or more of the following six symptoms: 1. Restlessness or feeling keyed up or on edge 2. Being easily fatigued 3. Difficulty concentrating 4. Irritability 5. Muscle tension 6. Sleep disturbance What is important and what distinguishes GAD from everyday occurrences of worry: A. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in occupational, social, or other important areas of functioning (Problems in school, problems with your social life, problems with work, etc.). , B. The disturbance is not due to the direct physiological effects of a substance (drugs) or general medical condition (general medical complaint). , AND C. The disturbance is not better explained by another mental disorder. The most common likely culprit there is Major Depression.

-Diagnostic Criteria of Social Anxiety Disorder

A. Marked fear or anxiety about one or more social situations in which the person is exposed to possible scrutiny by others... B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated. Key: We can think of social anxiety as the fear of being negatively evaluated by other people. C. The social situations almost always provoke fear or anxiety. -Fear or fear of negative evaluation is confined to social situations, that is, when you are speaking, eating, writing in front of others, that type of social situation almost alwaays provokes fear or anxiety within the individual. D. The social situations are avoided (Avoidance: hallmark that cuts across all ADs.) or endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual threat posed by the social situation. EX: Many people get nervous when giving a speech in front of a class, but we are talking about something much more extreme than that. A. The fear, anxiety or avoidance is persistent, typically lasting 6 months or more. (Present for at least 6 months or more.) B. The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The fear, anxiety or avoidance is not attributable to the effects of a substance. D. The fear, anxiety or avoidance is not better explained by another mental disorder. Another telltale sign that Social Anxiety Disorder is present is when people often misuse substances such as alcohol or other elicit drugs to endure social situations, with alcohol being a very common substance of choice, or bringing along a friend to help them get through a party. This is not 'I'm going to go with my friends to hang out.' or 'I'm going to have some alcoholic beverages with my friends over the weekend if I'm 21.' This is used to prop someone up so they can endure the anxiety that goes along with social evaluation.

-Bulimia clinical description -Medical consequences of bulimia -Electrolyte imbalance could lead to cardia arrhythmia, seizures, and kidney failure

A. Recurrent episode of binge-eating: A. Eating in a discrete period of time (within any two hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. A. A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating: Not what we see sometimes on the Internet or TV where people participate in food challenges, this is a true lack of control over on'e seating, such as uncontrollably eating a giant package of Oreo's in a very short period of time not on purpose). B. Recurrent inappropriate compensatory behavior in order to prevent weight gain such as self-induced vomiting, misuse of laxatives, diuretics (medications often prescribed for high blood pressure to get you to urinate) or other medications, fasting, excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. D. Self-evaluation is unduly (excessively) influenced by body shape and weight (how someone views themselves is excessively set by their body shape and body weight) E. This disturbance does not include/does not occur exclusively during episodes of anorexia nervosa. ______________________________________________________________________ 1) Erode dental enamel (due to compensatory behaviors such as self-induced vomiting) 2) Tear esophagus 3) Electrolyte imbalance (could lead to cardia arrhythmia, seizures, and kidney failure) 4) Develop more body fat. 5) High rates of depression and anxiety.

-Diagnostic criteria for Panic Disorder

A. Recurrent or unexpected panic attacks are present. B. At least one of the attacks has been followed by 1 month or more of the following. -Persistent concern or worry about additional panic attacks and/or their consequences (e.g. losing control, having a heart attack, going crazy.) -A significant maladaptive change in behavior related to the attacks (usually avoidance). We'll talk more about agoraphobia - a specific kind of avoidance, but the hallmark for all anxiety disorders, the most central thing that cuts across all of them is the idea of AVOIDANCE and so people will go to great lengths to avoid having a panic attack for example, whereas with GAD they avoid getting to the end of that worry train. A. The disturbance is not due to the psychological effects of a substance or another medical disorder (e.g. cardiopulminary disorders -> most common differential diagnosis: has as their primary symptom as changes in heart rate and respiration or difficulty breathing or angina that can often be very similar to the symptoms of panic disorder.) B. The disturbance is not better explained by another mental disorder (e.g. the primary differential diagnosis being that panic attacks only occur in response to social situations as in social phobia: a fear of negative evaluation in social or performance situations). Panic attacks must come on spontaneously and unexpectedly!

-Anorexia clinical description -Anorexia types -Medical consequences of anorexia

A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of (not appropriate of an individual's:) age, sex, developmental trajectory and physical health. Low weight is defined as a weight that is less than minimally normal (15% below expected for individual's age, sex, developmental trajectory) B. Intense fear of becoming fat or gaining weight , or persistent behavior that interferes with weight gain , even though at a significantly low weight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body shape or weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. _________________________________________________________________________ A. Restricting type: During the past 3 months, the individual has not engaged in binge-eating or purging behavior. Weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. (What we probably think of the most.) B. Binge-Eating/Purging Type: During the past 3 months, the individual has engaged in recurrent episodes of binge-eating and purging behavior. (What people most commonly think of with Bulimia.) -Binge-eating: Eating large quantities of food in a very short amount of time that also includes with it a feeling of being out of control (lack of control of what one is eating). Once this binge-eating episode occurs, there needs to be some sort of compensatory behavior: Either through dieting or fasting (IN RESTRICTIVE TYPE), or through purging (IN B-E/P TYPE). __________________________________________________________________________ 1) Amenorrhea: Young women might see a cessation of menstruation 2) Dry skin 3) Brittle hair or nails 4) Sensitivity to cold temperatures 5) Downy hair on limbs or cheeks 6) Cardiovascular problems (low BP and heart rate)

-GAD treatments a. Biological b. Psychological

a. Benzodiazepines (relatively fast-acting, very good for short-term relief of anxiety especially with a temporary crisis or given a stressful event) -Effective in short-term, however on the long-term end... b. Cognitive-Behavioral Therapy (CBT) for GAD. -Worry is evoked during the therapy session. -Get them to worry actively in the therapy session and we help them tolerate that worry. -Cognitive interventions counteract worry -> help them tolerate that worry by learning that through changing the way we think about that worry, counteracting it, it can be manageable. -We are not trying to problem-solve what they are worrying about (such as 'Am I going to get a good grade on this exam?' or 'What's gonna happen on Saturday night?'), but we are just shifting the way they're thinking.

-Treatment of Major Depression -Biological -Antidepressant Medications a. SSRIs: Prozac, Zoloft, Paxil, Celexa, Lexapro, Lavox. b. Mixed Reuptake Inhibitors: Effexor, Celexa. c. MAOIs d. Tricyclic Antidepressants -Electroconvulsive Therapy (ECT), Shock therapy

a. Temporarily increases serotonin at the receptor site. Prozac, Zoloft, Paxil, Celexa, Lexapro, Lavox. b. Blocks reuptake of serotonin and norepinephrine. Makes sense when you think about the permissive hypothesis and rate of serotonin, with respect to its effect on norepinephrine. Wellbutrin, Effexor, Celexa. c. Older class of drugs. Block enzyme MAO: Breaks down norepinephrine and serotonin. d. Older class of drugs. Down-regulated norepinephrine. -In severe cases. Also known as shock therapy. Despite its depictions in movies and other popular media outlets, it is actually effective for Severe Depression and Treamtent-Resistant Depression in in-patient settings.