Psychosocial Exam 1

Bipolar and Related Disorders 7

--Bipolar I Disorder --Bipolar II Disorder --Cyclothymic Disorder --Substance/Medication-induced Bipolar and Related Disorder --Bipolar and Related Disorder Due to Another Medical Condition --Other Specified Bipolar and Related Disorder --Unspecified Bipolar and Related Disorder

Effects of Phobia

--Can disrupt daily routines --Limit work efficiency --Reduce self-esteem --Place a strain on relationships --Because people will do whatever they can to avoid the uncomfortable and often-terrifying feelings of phobic anxiety

Types of Depressive Disorders

--Disruptive Mood Dysregulation Disorder --Major Depressive Disorder, Single and Recurrent Episodes --Persistent Depressive Disorder (Dysthymia) --Premenstrual Dysphoric Disorder --Substance/Medication-Induced Depressive Disorder --Depressive Disorder Due to Another Medical Condition --Other Specified Depressive Disorder --Unspecified Depressive Disorder They dropped reactive depression from the list --Depression in reaction to something happening to you --This is considered normal

Persistent Depressive Disorder (Dysthymia): Implications for OT

--Identifying meaningful occupations --Encouraging active participation --Identifying strategies for understanding, expressing, and reframing emotions --CBT focused on specific occupations --Psychoeducational interventions focused on learning to manage a chronic disorder

Generalized Anxiety Disorder: Implications for OT

--Management strategies that enable individuals to cope with on-going symptoms --Reframing life challenges --Exercise and other activities that refocus energy and attention --Energy conservation strategies --Mindfulness

Therapeutic Use of Pets for depressive disorders

--Petting a cat or dog or watching fish swim has been found to decrease anxiety --Facilitates social interaction --Brightens mood --Promotes expression of feelings --Increases self-esteem and self worth --Provides unconditional love and companionship -----Sense of duty/responsibility --Forces one to get out of bed and not remain socially withdrawn --Accompany those with disabilities to decrease their depression and promote positive affect

Anxiety Disorders (7)

--Separation anxiety disorder --Selective mutism --Specific phobia --Social anxiety disorder (social phobia) --Panic disorder --Agoraphobia --Generalized anxiety disorder

Premenstrual Dysphoric Disorder: Treatment

--Symptom management --Reduction of distress during the menstrual cycle --Diet, especially avoidance of high glycemic foods during menses --Exercise seem beneficial --Birth control medications

Major Depressive Episode: Treatment (10)

-Psychotropic medications (numerous types) -Psychotherapy -Cognitive-behavioral therapy -Exercise -Light therapy -CAM ---Hypnotherapy ---Acupuncture ---Mindfulness -For intractable cases: electroconvulsive therapy (ECT)

1) Avolition 2) Prodromal Periods 3) Redidual Periods 4) Loose Associations

1) Avolition - the absence of motivation and energy 2) Prodromal periods - those times that lead up to major psychosis 3) Residual periods - time when psychotic symptoms lessen after a major episode 4)Loose associations - a thought and conversational style marked by odd departures from the topic - might answer a question about the weather by launching into a discussion of weather patterns in outer space Peculiar psychomotor behavior may be present. Odd mannerisms, grimacing, hyperactivity or waxy rigidity may be observed.

1) DSM-III 2) DSM-III-R 3) DSM- IV

1) DSM-III represented a major change in the nature of the diagnostic process (Blacker & Tsuang, 1999). Coincided with revision of ICD. --Committee work to develop descriptions --Major research effort to validate diagnoses and determine reliability in a systematic fashion. --Expansion of diagnoses to a total of 150 --Hierarchical --Multiaxial 2) DSM-III-R (1987) --Minor changes --Removed hierarchies 3)DSM-IV (1994) --Addressed culture --Addressed function --Five axes (as in DSM-III) -----Axis I Clinical disorders -----Axis II Personality disorders; mental retardation -----Axis III General medical conditions ----Axis IV Psychosocial and environmental problems -----Axis V Global assessment of functioning

1) Denial 2) Regression 3) Acting Out

1) Denial: refusal to accept reality or fact; acting as if a painful event, thought or feeling did not exist. 2)Regression: reverting to an earlier stage of development in the face of unacceptable thoughts or impulses. --During finals you just want to crawl in bed and want your mom 3) Acting Out: performing an extreme behavior to express thoughts or feelings the person feels incapable of otherwise expressing. Can serve as a pressure release. --Jackass

1)Hallucinations 2) Delusions 3) Flat Affect 4) Anhedonia

1) Hallucinations - distorted sensory experiences, such as hearing voices that are not evident to others 2) Delusions - firmly held, fixed beliefs that are not held by others, such as a belief that one is being pursued by the FBI, when it is inconsistent with reality 3) Flat affect - lack of emotional expression and response 4) Anhedonia - lack of experience of pleasure

1) Intellectualization 2) Rationalization 3) Undoing

1) Intellectualization: the overemphasis on thinking when confronted with an unacceptable impulse, situation, or behavior without employing any emotions whatsoever, to help mediate and place the thought into an emotional, human context. --Engineers 2) Rationalization: putting something into a different light or offering a different explanation for one's perceptions or behaviors in the face of a changing reality. --"He was a loser all along." 3) Undoing: the attempt to take back an unconscious behavior or thought that is unacceptable or hurtful.

Psychosexual Stages 1) Birth --> 1 year 2) 1-3 years 3) 3-5 years 4) 5-12 years 5) 12- adulthood

1) Oral Stage: early - sucking; late - biting --Theme: Trust, dependency --Regression: Psychosis 2) Anal Stage: early - excreting; late-retaining --Theme: Control/autonomy --Regression: Neurosis, character disorders 3)Phallic Stage: genital interest; penis envy --Theme: Oedipal/Electra Complex 4) Latency stage: sublimation of sexual drive; superego develops --Theme: Skill development; social role development; emergence of guilt 5) Genital stage: Puberty; Capacity for intimacy --Theme: sexual identity; adult responsibility for love and work

1) Prodromal Phase of Schizo 2) Active Phase of Schizo 3) Residual Phase

1) Prodromal phase: function begins to deteriorate --Withdrawal from friends and family. --Work, self-care, and avocational activities suffer --They wont tell you about their symptoms 2) Active phase --Delusions and hallucinations --Thought disorder, and other psychotic symptoms --Global functional deficits --This phase may occur spontaneously or as a result of stress. 3) Residual phase --Function continues to be below the highest level ever achieved. --Continued flat affect, peculiar behavior, and functional difficulties in self-care, work, social spheres --In all phases, symptoms vary from individual to individual

1) Projection 2) Reaction Formation

1) Projection: 'projecting' a person's undesired thoughts, feelings or impulses onto another person who does not have those thoughts, feelings or impulses. Often the result of a lack of insight and acknowledgement of one's own motivations and feelings. 2) Reaction Formation: converting unwanted or dangerous thoughts, feelings or impulses into their opposites. --someone who hugs you and prays over you but really hates you

1) Repression 2) Displacement

1) Repression: the unconscious blocking of unacceptable thoughts, feelings and impulses. 2) Displacement: the redirecting of thoughts, feelings, and impulses directed at one person or object, but taken out upon another persons or object. People often use displacement when they cannot express their feelings in a safe manner to the person at which they are directed.

Alternative: International Classification of Functioning, Disability, and Health (WHO, 2001)

10 areas of functioning interpersonal interactions, social, civil life, etc. Addresses reasons for dysfunction, but function comes first

Origins of Psychoanalytic Theory

1890s: Sigmund Freud (a neurologist) sought an effective treatment for patients with psychological symptoms.  Foundational belief: The existence of mental processes that are not conscious * Since the time of Freud's first work, the theory has undergone many revisions. EX: don't know where that thought came from! I have no idea why I just said that! I just did that without thinking. That came from out of the blue! I never thought twice about that! Who knew I'd be capable of that? I just let my hands do what they wanted, and it came out that way!

Symptoms of Phobia

A feeling of imminent  danger or doom The need to escape Heart palpitations Sweating Trembling Shortness of breath or a smothering feeling A feeling of choking Chest pain or discomfort Nausea or abdominal discomfort Feeling faint, dizzy or lightheaded A sense of things being unreal, depersonalization A fear of losing control or "going crazy" A fear of dying Tingling sensation Chills or heat flush

Psychic Energy

A finite amount of psychic energy (energy for the psyche) is shared by all three parts  of the personality Some people cease to function in the world (psychosis) or function poorly (neurosis) when too much energy is being used by one personality component, causing clinical symptoms.

Compartmentalization

A lesser form of dissociation, wherein parts of oneself are separated from awareness of other parts and behaving as if one had separate sets of values. An example might be an honest person who cheats on his or her income tax return and keeps their two value systems distinct and unintegrated while remaining unconscious of the cognitive dissonance. Or a person who cheats on their spouse but acts like a good person at home but can act however they want away from home b/c they have a different set of rules

Social Anxiety Disorder (Social Phobia) Diagnostic criteria: 4

A period of at least 6 months with excessive and consistent fear and anxiety in some or all social situations Fear of being negatively evaluated Avoidance of social encounters Anxiety out of proportion to the threat

Symptoms of Manic Episode

Abnormal and persistent elevated, expansive or irritable mood with abnormal and persistent increased goal-directed activity or energy At least three other symptoms: --Inflated self-esteem or grandiosity --Decreased need for sleep --Excessive talkativeness or pressure to speak --Distractibility --Increase in goal-directed activity or psychomotor agitation. Potential for bad consequences (financial difficulties, legal difficulties, physical injury) Impaired function and/or need for hospitalization

Bipolar Course

About 65% of adults with BD have onset prior to age 19 Episodes may recur after years with no symptoms More frequent cycling of episodes associated with declining functional abilities

Prevalence of Depression in the U.S

About 9 percent of American adults from all walks of life suffer from some form of depression. Women are 70 percent more likely than men to experience depression during the course of their lifetimes, in part due to hormones. Depression risk goes up for women after pregnancy, during menstruation, and during menopause. Another reason for higher recorded numbers among women? They are more likely to seek help and be diagnosed. "Men are more likely to try to self-medicate with drugs or alcohol, whereas women are more likely to seek help from friends and family or psychiatrists," explains Carole Lieberman, MD, a psychiatrist, author, and member of the clinical faculty at the University of California at Los Angeles Semel Institute for Neuroscience and Human Behavior. Research published in The American Journal of Psychiatry found that major depression rates for American adults increased from 3.33 percent to 7.06 percent from 1991 through 2002. Depression is also considered a worldwide epidemic, with 5 percent of the global population suffering from the condition, according to the World Health Organization.

Psychosexual stages

According to Freud, one's personality is largely determined  by one's early childhood experiences Psychosexual stages of development, spanning a range of  18 years from birth to maturity, are differentiated by  changes in objects that potentially provide need  satisfaction. When needs are satisfied, the child thrives and is able to  develop and move on to the next stage When needs are continually frustrated, he or she develops  a fixation that can remain in the unconscious and cause  many problems seen in adulthood (i.e. symptoms of illness)

Mental Disorder

According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-5]; APA, 2013), a mental disorder is: a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual.

Top Ten Phobias 1) Acrophobia 2) Claustrophobia 3) Nyctophobia 4) Ophidiophobia 5) Arachnophobia 6) Trypanophobia 7) Astraphobia 8) Nosophobia 9) Myosphobia (germaphobia) 10) Triskaidekaphobia

Acrophobia - Fear of Heights Claustrophobia - Fear of Enclosed Spaces Nyctophobia - Fear of the Dark Ophidiophobia - Fear of Snakes Arachnophobia - Fear of Spiders Trypanophobia - Fear of Injection or Medical Needles Astraphobia - Fear of Thunder and Lightning Nosophobia - Fear of Having a Disease Myosphobia AKA Germaphobia - Fear of Germs Triskaidekaphobia - Fear of the Number 13

Delusional Disorder Treatment

Antipsychotic medications (limited benefit) Psychotherapy Cognitive-behavioral therapy

Antipsychotic Medications

Antipsychotic medications have been available since approximately 1955. The older types of antipsychotic medications are called conventional or "typical" antipsychotics. Some of the more commonly used include: --Chlorpromazine (Thorazine) --Haloperidol (Haldol) --Perphenazine (Etrafon, Trilafon) --Fluphenazine (Prolixin) In the 1990's, new antipsychotic meds were developed; these are called second generation, or "atypical" antipsychotics. One of these meds, clozapine (Clozaril) is an effective medication that treat psychotic symptoms, hallucinations, and breaks with reality. But clozapine can sometime case a serious problem called agranulocytosis, which is a loss of the white blood cells that help a person fight infections. Symptoms of schizophrenia, such as feeling agitated and having hallucinations, usually go away within days. Symptoms like delusions usually go away within a few weeks. After about six weeks, many people will see a lot of improvement.

The most common mental illnesses in adults are ___ and ___ ___ (bipolar and depressive disorders).

Anxiety Mood Disorders

Background of Anxiety Disorders

Anxiety and fear are natural responses to environmental threats A functional fear response aids in survival Situational anxiety is not pathological Anxiety stimulates ANS function --Hyperarousal --Increased heart rate and blood pressure Which division of the ANS do you think is responsible for these physiological responses? SNS Anxiety can become disordered if fear response is prolonged or inappropriate Statistics: --Most common psychiatric disorder --40 million adults (18%) in U.S. affected --11% family physician visits prompted by anxiety/nervousness

Anxiety Disorders (DSM change, what 2 were moved in and what 2 were moved out)

Anxiety disorders as a group are characterized by: --Excessive fear and worry --Possibly have associated behaviors that either reflect functional deficits related to the anxiety or behaviors designed to ameliorate the anxiety The 5th Edition of the DSM has moved some disorders into this cluster (e.g., separation anxiety disorder, selective mutism) from their prior classification of disorders of infancy, childhood, and adolescence. --This cluster reflects the recognition that although there are some conditions - particularly the neurodevelopmental disorders that by definition, emerge early in life - most including psychotic, bipolar, depressive, and anxiety disorders, may be seen in children as well as in adults. DSM V --It also reflects the recognition that adults may experience separation anxiety and other disorders that were previously categorized as disorders of childhood. --Some of the conditions previously included in this cluster have been moved out of the anxiety d/o's cluster. Specifically, obsessive-compulsive disorders and stress-related disorders now have separate chapters, even though anxiety is a key symptom in all of them. Those d/o's were deemed sufficiently different in presentation and etiology to be described separately, and they will be discussed in later chapters of our text.

Co-existing Illnesses with bipolar

Anxiety disorders such as PTSD and social phobia ADHD Higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity, and other physical illnesses Substance abuse is very common --They may try to treat symptoms with alcohol or drugs

Anxiety Disorders: Lifespan Considerations

Anxiety may be diagnosed early in life; characterizes greater risk of poor outcomes Early intervention essential In older adults, anxiety may be exacerbated by cognitive difficulties In older adults, high rates of comorbid conditions In older adults, anxiety is associated with poorer quality of life, and with lower rates of help-seeking

Agoraphobia: Diagnostic Criteria

Anxiety or fear about: --Using public transportation (including automobiles) --Being in open spaces --Being in enclosed places --Standing in line or being in a crowd --Being outside the home alone --Actually fear of losing control (they might be able to drive but not take the bus) The situations almost always cause fear or anxiety The situations are avoided, require a companion, or cause intense fear and anxiety Fear is out of proportion to the actual danger Distress or dysfunction

Rapid-Cycling of bipolar

Applies only to BP I and BP II At least 4 manic or depressive episodes within a year Usually begins with depressive episode rather than manic episode Direct transition from one mood to another --There is no normal limits period. They go directly from one state to the other Applies only to BPI and BPII; individual experiences at least four manic or depressive episodes within a year; severe variety of BP that does not respond well to standard treatments; about 20-40% experience rapid cycling and of these 60-90% are female; unlike BP patients in general, most people with rapid cycling begin with a depressive episode rather than a manic episode; fewer than 3% of patients continue with rapid cycling across a 5-year period with 80% returning to a nonrapid-cycling pattern within 2 years Rapid switching or rapid mood switching: direct transition from one mood state to another; this is a particularly treatment-resistant form of the disorder

Depression and school performance

Associations between levels of depression and school performance. --7th - 9th grade students (13 - 17 years old) From questionnaire, R-Beck Depression Inventory completed: --18.4% of girls & 11.1% of boys were classified as depressed. As GPA decreases the more likely the students would be depressed. --They are feeling like a failure Depression associated with difficulties in: --Concentration --Self - reliant performance --Reading/writing --Social relationships

Premenstrual Dysphoric Disorder: Diagnostic Criteria

At least five symptoms must be present in the majority of menstrual cycles in the week before onset of menses, with improvement a few days after the onset of menses One or more of the five symptoms must be --Emotional ability --Irritability, anger, or interpersonal conflict --Depressed mood --Anxiety, tension Symptoms may include --Decreased interest in activities --Difficulty concentrating --Lethargy or fatigue --Change in appetite (particularly overeating or food cravings) --Sleep changes --Feelings of being overwhelmed or out of control --Physical symptoms like breast tenderness, joint or muscle pain, bloating, or weight gain The symptoms occurred in most menstrual cycles in the past year and cause distress or dysfunction

Bipolar II Disorder:  Diagnostic Criteria

At least one hypomanic episode Abnormally elevated or irritable mood with increased activity or energy for at least four consecutive days Three or more of: --Grandiosity or inflated self-esteem --Decreased need for sleep --Talkativeness and/or pressured speech --Flight of ideas --Distractibility --Increase in goal-directed activity --Excessive involvement in activities with a high probability of bad outcome (excessive spending, sexual indiscretions, poor investment decisions) The episode is not severe enough to cause substantial functional impairment or a need for hospitalization (note that this is a distinguishing characteristic as opposed to the criteria for a manic episode) At least one major depressive episode and no manic episode

Bipolar I Disorder: Diagnostic Criteria

At least one manic episode Consistent elevated or irritable mood with abnormal increased goal-directed activity or energy most of the time for at least a week. At least three of: --Inflated self-esteem or grandiosity --Decreased need for sleep --Excessive talkativeness or pressure to speak --Distractibility --Increase in goal-directed activity or psychomotor agitation Excessive involvement in activities with possible bad consequences Impairment in work function or to require hospitalization to prevent harm May include one or more major depressive episodes: Depressed mood most of every day almost every day --Anhedonia—lack of pleasure or interest in daily activities, again, most every day for most of the day --Weight loss without dieting or decrease in appetite --Insomnia or hypersomnia almost every day --Fatigue or low energy --Feelings of worthlessness or guilt --Difficulty concentrating --Recurrent thoughts of death, suicidal ideation, or suicide attempt --Distress and functional impairment -----Might try and kill themselves

Bipolar I Symptoms, Summary

At least one manic episode May include hypomanic and/or depressive episodes, but not required

Cyclothymic Disorder: Symptoms

At least two years during which there have been multiple periods of hypomanic symptoms that do not meet the criteria for a hypomanic episode and depressive symptoms that do not meet the criteria for a major depressive episode These symptomatic periods are present at least half the time, and there has been no period of more than two months at a time completely symptom free The individual's symptoms have never met the criteria for a manic, hypomanic, or major depressive episode

Psychoanalytical theory (Id, Ego, and Superego)

Based on work of Sigmund Freud in late 19th and early 20th centuries Organizes personality into three parts: -- Id - is largely unconscious; comprised of primitive drives and instincts, needs and conflicts that the ego is unable to integrate --Ego - psychological component that has contact with the external world; it functions logically and works to achieve a balance between the internal drives and the external expectations --Superego - the social component of personality that serves as an individual's moral code, his or her sense of 'good' and 'bad,' right and wrong. It is often illogical and unrealistic in its quest for idealism and perfection

Agoraphobia: Treatment

Behavioral fear reduction and avoidance reduction procedures (Van Apeldoorn et al., 2010) Cognitive-behavioral treatments help (Butler, Chapman, Forman, & Beck, 2006; White et al., 2012) Psychotropic medications, including SSRIs Technology-based intervention (e.g. online therapy) Complementary and alternative strategies, including hypnotherapy

Facilitate and reinforce desirable behaviors. Extinguish negative behaviors

Behavioral frame

Substance/Medication Induced Psychosis

Between 7 and 25% of individuals presenting with psychosis have a substance-induced condition. Severity and persistence of substance-induced psychosis vary

Categories of bipolar

Bipolar I Bipolar II Cyclothymia Bipolar NOS (Not otherwise specified)

Analysis of the psyche

Breaking down a construct or entity or process into its parts or components Considering the elements of an entity in order to understand it better

Treatment of bipolar

Can't be cured but can be treated effectively Helps to control mood swings and related symptoms Long term, continuous treatment is needed to treat symptoms Mood Stabilizers Atypical antipsychotics (Anti-convulsants) Anti-depressants

Social Anxiety Disorder (Social Phobia) Etiology:

Caused by a combination of biological and psychosocial factors (Bandelow et al., 2004). Specifically, social anxiety d/o is associated with early traumatic life events (for example, bullying or victimization at school), parental rearing styles (overcontrolling or ineffectively attached), family history of mental disorders, and birth risk. Genetic factors are thought to account for between 30 and 60% of the risk for SAD. It appears that the previously mentioned factors affect neurotransmission, especially of norepinephrine, dopamine, and serotonin (Fink et al., 2009). Additional risk factors include discontentedness with, the absence of a partner, loneliness, self-rated low intelligence, not feeling part of a whole, unhappiness, low quality of life, and low meaningfulness (Flensborg-Madsen, Tolstrup, Sorensen, & Mortensen, 2012). The last factor (low meaningfulness) is particularly relevant to OT. It is important to distinguish social anxiety from ordinary shyness, which some speculate is an evolutionary tactic with performance benefits.

Teens & Youth with Depressive Disorder

Challenges may be seen in these areas of Occupation: Social Participation --Family stress can affect withdrawal --Low energy and feeling of inadequacy may lead to isolation ADL --Eating patterns could change -----Eating too much or too little --Loss of interest in self-care activities (bathing, dressing) Work --May not be interested in tasks given --May not arrive on time --May work at a slow pace or leave out crucial steps --Difficulty with cognitive tasks making decisions Leisure/Play --May not want to engage in leisure activities they previously enjoyed Sleep/Rest --May have trouble sleeping or staying asleep throughout the night --Could contribute to an increase in fatigue during the day

Implications for OT for Separation Anxiety Disorder (SAD)

Children with SAD experience significant difficulty in school and social occupations. These difficulties can be exacerbated by how the child's behavior is being interpreted by others. For example, Crawford and Manassis (2011) found that the social difficulties these children display can lead to peer victimization (e.g., bullying), which may further increase anxiety. OT interventions should focus on supporting school and social occupations. Practice managing anticipated events and the development of coping strategies (e.g., meditation, guided imagery, and role playing) may help to reduce anxiety and increase self-confidence. Support and education for families can be of great help in reducing symptoms of anxiety, (Beesdo, Pine, Lieb & Wittchen, 2010), particularly in families where overprotection is an issue. Parents benefit from learning how their own anxiety may contribute to the child's anxiety.

Schizoaffective Disorder: Prognosis

Chronic Prognosis is better than that of schizophrenia and worse than that of a mood disorder

Cyclothymia

Chronic state of cycling between hypomanic and depressive episodes that do not reach the diagnostic standard for bipolar disorder At least 2 years ⅓ - ½ of patients develop into full-blown BP Cyclothymic Disorder: a chronic (at least 2-year period) mood disturbance characterized by fluctuating hypomanic symptoms and depressive symptoms that are not of sufficient number or severity to reach criteria for either manic episodes or major depressive episodes For at least 2 years, numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode Since onset, the person has not been without the symptoms for more than 2 months at a time No major depressive episodes, manic episode, or mixed episode has been present during the first 2 years of the disturbance Mood symptoms are not better accounted for by schizoaffective disorder or superimposed on another disorder such as schizophrenia The symptoms are not caused by the physiological effects of a substance or a general medical condition Clinically significant distress or impairment of functioning

People who take ___ must get their white blood cell counts checked every week or two. This problem and the cost of blood tests make treatment with this med difficult for people.

Clozapine

Use awareness and rational/sound thinking to change behavior

Cognitive-behavioral frame

Panic Disorder: Treatment

Combination of psychotropic medication and CBT Relaxation therapy Psychodynamic psychotherapy --Comes from the Freudian Philosophy

Compensation Assertiveness

Compensation: a process of psychologically counter-balancing perceived weaknesses by emphasizing strength in other arenas. By focusing on one's strengths, a person is recognizing the cannot be strong at all things and in all areas in their lives. --"I may not know how to cook, but I can sure do the dishes!" Assertiveness: the emphasis of a person's needs or thoughts in a manner that is respectful, direct and firm. Becoming more assertive is one of the most desired communication skills and helpful defense mechanisms most people want to learn, and would benefit in doing so.

Ego

Conscious contact w/world Thinking: Secondary process Logical, works to achieve balance between internal drives and external expectations. Attempts to adapt to environment

Defense Mechanisms

Defense mechanisms are manners in which we behave or think in certain instances to better protect or 'defend' ourselves from unpleasant thoughts, feelings and behaviors.  Categorized by how 'primitive' they are. The more primitive a defense mechanism, the less effective it works over the long-term. However, they can be effective in the short-term.  Most defense mechanisms are unconscious; most of us don't realize we're using them in the moment

Schizophrenia Spectrum and Other Psychotic Disorder Clusters 12

Delusional Disorder Brief Psychotic Disorder Schizophreniform Disorder Schizophrenia Schizoaffective Disorder Substance/Medication-Induced Psychotic Disorder Psychotic Disorder Due to another Medical Condition Catatonia Catatonic Disorder Due to another Medical Condition Unspecified Catatonia Other Specified Schizophrenia Spectrum and Other Psychotic Disorder Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

Defense Mechanisms: Primitive (7)

Denial Regression Acting Out Dissociation Compartmentalization Projection Reaction Formation

Persistent Depressive Disorder (Dysthymia): Diagnostic Criteria

Depressed mood most of the day most of the time for at least two years At least two of the following: --Appetite changes (poor eating or overeating) --Sleep disruption --Fatigue or low energy --Low self-esteem --Poor concentration --Feelings of hopelessness During the two year period the individual has never been without symptoms for more than two months at a time No manic or hypomanic episode, no cyclothymic disorder

Relationships of Drives to Mental Illness

Depression --Anger turned inward --Aggressive drive turned on self Anxiety --Conflict over control of psychic energy within the personality. --Fear that the id will take over and cause chaos --Fear the superego will take over and cause guilt ------If you had someone that felt guilty you would give them a repetitive task such as sanding "Defense mechanisms" ward off (defend against) anxiety to protect the ego

Mental Health: Depression

Depression estimates generally are highest in the Southeastern states (e.g., 13.7% in Mississippi and West Virginia vs. 4.3% in North Dakota). Mental illness is associated with use of tobacco products and abuse of alcohol

Seasonal Pattern of bipolar

Depressive episode that begins in late fall and ends with beginning of spring May become depressed during winter and manic during summer Excessive sleep is common in winter depression Most usual pattern is a depressive episode that begins in the late fall and ends with the beginning of spring; individuals may become depressed during the winter and manic during the summer; affects as many as 2.7% of Americans but fully 15-25% of the population might have some vulnerability to seasonal cycling of mood that does not reach criteria for a disorder; may be related to daily and seasonal changes in the production of melatonin; people with winter depression tend toward excessive sleep rather than decreased sleep and increased appetite and weight gain rather than decreased appetite and weight loss When comparing the three courses, the longitudinal is more drawn out than rapid-cycling and seasonal pattern

Generalized Anxiety Disorder: Differential Diagnosis and Comorbidities

Differential Diagnosis --Agoraphobia --Depression --Cyclothymia Comorbidities --Depression --Substance use disorders --Personality disorders

Schizoaffective Disorder: Differential Diagnosis and Comorbidities

Differential Diagnosis --Other psychotic disorders --Mood disorders --Substance-related disorders Comorbidities --Substance-related disorders

Bipolar Disorders: Differential Diagnosis and Comorbidities

Differential Diagnosis --Other psychotic disorders --Mood disorders --Substance-related disorders Comorbidities --Substance-related disorders. ----Some people will drink alcohol to control the mania but they end up getting substance abuse

Premenstrual Dysphoric Disorder: Differential Diagnosis and Comorbidities

Differential Diagnosis --Rule out other depressive disorders Comorbidity --May be comorbid with any other mental disorder

Agoraphobia: Differential Diagnosis and Comorbidities

Differential Diagnosis --Specific phobias --Generalized anxiety disorder --Depression --Personality disorder Comorbidities --Depression --Personality disorder --Substance use disorders

Panic Disorder: Differential Diagnosis and Comorbidities

Differential Diagnosis --Substance use disorder Comorbidities --Substance use disorders --Depression --Agoraphobia --Specific phobia

Schizophrenia: Differential Diagnosis and Comorbidities

Differential Diagnosis (first must rule out these other disorders) --Bipolar disorder Comorbidities --Depression --Bipolar disorder --Personality disorder --Substance abuse

Brief Psychotic Disorder: Differential Diagnosis and Comorbidities

Differential Diagnosis (i.e., these must be ruled out first) --Other medical conditions --Substance-related disorders --Mood disorders --Other psychotic disorders --Personality disorders Comorbidities --Medical conditions --Substance-related disorders --Personality disorders

Persistent Depressive Disorder (Dysthymia): Differential Diagnosis and Comorbidities

Differential diagnosis --Cyclothymic disorder --Schizoaffective disorder --Delusional disorder --Schizophrenia --Medical and substance abuse problems Comorbidities --Anxiety disorders --Substance abuse --Personality disorders

Depressive Disorders: Cultural Considerations

Differential rates --Higher among African-Americans Cultural difference in identification/treatment --Hispanic backgrounds are likely to emphasize the social aspects --Native Americans focus on balance with the environment --Kuwaiti students showed greater religiosity and depression --Individuals from Turkey were more likely to present with somatic symptoms Differential explanatory models --Indians likely to attribute to karma

Schizophrenia: Implications for Function

Difficulty with work, social interaction, self-care, and leisure occupations. Skills deficits in visual processing (Perez, Shafer, & Cadenhead, 2012), emotional identification (Tremeau & Antonius, 2012), communication skills, emotional regulation, and visual-motor perception (Szöke et al., 2008). Processing speed and working memory are impaired (Su, C., Tsai, P., Su, W., Tang, & Tsai, A.Y., 2011). Body structure/body function issues, including, for example, changes in brain structure and function (Onitsuka et al., 2006).

Schizophrenia: Additional Characteristics

Disorder of thought and perception Loose association, incoherence, or excessively concrete or abstract thought Perception and affect are also disturbed Peculiar psychomotor behavior Onset in adolescence or early adulthood

Dissociation

Dissociation: when a person loses track of time and/or person, and instead finds another representation of him or herself to continue in the moment. People who have a hx of any kind of childhood abuse often suffer from some form of dissociation. (make up someone else to deal with it) Can lead to 'multiple personality' d/o. Have a disconnected view of themselves in their world. Time and their own self-image may not flow continuously. In this way, a person who dissociates can 'disconnect' from the real world for a time, and live in a world not cluttered with thoughts, feelings or memories that are unbearable.

Signs of overactive Id:

Drives are in charge; no concern over harming others or self; immorality of all kinds Example: Boston Marathon Bombers

Bipolar and Related Disorders: Lifespan Considerations

Early development predicts more severe and chronic course and greater probability that psychopharmacological intervention will be less effective Diagnosis in children is complicated by potential for overlap with ADHD and other conditions Anxiety, school refusal or school problems, and negative behavior, irritability, aggressiveness and anger all common in children. Low self-esteem, school problems common in children In older adults, high risk of accompanying dementia More severe functional deficits Changes in physiology make medication management more difficult in older adults

Premenstrual Dysphoric Disorder: Implications for OT

Education of the client, and to assist her in developing habits and patterns that will minimize exacerbations Develop exercise habits Develop strategies for managing work tasks through energy efficient activity

OT Interventions for bipolar

Education on Bipolar Support Groups Family education Talk Therapy Triggers Goals

The ___ developed through learned experiences in reaching compromises and applying logic and discipline in an attempt to adapt to the environment The ___ is where the OT Intervention is aimed!!!

Ego Ego

Types of Delusions (Erotomanic, Grandiose, Jealous, Somatic, Persecutory)

Erotomanic, in which the individual believes that he or she is loved by someone else, usually a prominent figure whom the individual does not actually know --A lady thought that she was dating Chris Brown and was in his house Grandiose, a belief that the individual has some special, great characteristic --People might think they are Jesus Jealous, in which the individual is convinced that a spouse or lover is unfaithful Somatic, a belief that the individual has some gross physical problem --Someone may believe that they are pregnant and you cant convince them Persecutory, a belief that the individual is being conspired against (these are the most common) --They might believe the CIA is after them

Agoraphobia: Etiology and prognosis

Etiology --Early experiences of loss, childhood separation or school anxiety, and recent experience of loss (Kessler et al., 2005) --Family history of anxiety disorders --Childhood respiratory disease --Temperamental emotional reactivity at young age Prognosis: --Chronic with exacerbations and remissions --Comorbidity with other mental disorders predicts worse outcome

Generalized Anxiety Disorder: Etiology and Prognosis

Etiology --Genetic component --Dysfunction in the amygdala and various prefrontal cortical regions --Environmental, family, and personality factors (Lightfoot, Seay, Goddard, 2010). --Learned response --Parenting style that is overcontrolling or lacking in warmth may be factors Prognosis --Chronic, especially if untreated --Exacerbations and remissions dependent on level of stress

Brief Psychotic Disorder: Etiology and Prognosis

Etiology --Genetics --Stress is a factor in exacerbations (Bentall & Fernyhough, 2008). --Poor parenting and family dysfunction --But multifactorial: -----Environmental factors (Prasad et al., 2010) psychosocial stressors, such as maladjusted family relationships -----Childhood trauma Prognosis --Variable --9% move into schizophrenia --Disorder typically remits completely within the 1 month time frame --If substance abuse related, resolving substance use resolves psychosis

Delusional Disorder: Etiology and Prognosis

Etiology --Neurocognitive disorder --More common among deaf or immigrant individuals Prognosis --Most commonly chronic, with exacerbations and remissions --Appears best when somatic delusions are most evident, and worse in cases in which erotomanic or paranoid content is prevalent --Function typically unimpaired except as related to the delusion

Premenstrual Dysphoric Disorder: Etiology and Prognosis

Etiology --Poor physical health, stress, medical conditions --Genetics --Hormonal and/or steroid influences Neurotransmitter alterations --Nutrition and micronutrients --Immunologic factors --Psychosocial factors such as stress Prognosis --Resolves with onset of menopause

Persistent Depressive Disorder (Dysthymia): Etiology and Prognosis

Etiology --Probably similar to major depressive disorder. --Less well understood Prognosis --Intractable. 70% had symptoms a year after diagnosis --Worse outcome with -----Early onset -----History of abuse -----Family difficulties -----Less education -----------Less job options -----------If you are depressed how are you going to do well in school

Schizophreniform Disorder: Etiology and Prognosis

Etiology (same as for Brief Psychotic D/O) --Genetics --Stress is a factor in exacerbations (Bentall & Fernyhough, 2008). --Poor parenting and family dysfunction --But multifactorial: -----Environmental factors (Prasad et al., 2010) psychosocial stressors, such as maladjusted family relationships -----Childhood trauma Prognosis --Often becomes schizophrenia (the diagnosis if symptoms last beyond six months)

Generalized Anxiety Disorder: Diagnostic Criteria

Excessive anxiety and worry more days than not Difficulty controlling the worry Three or more of the following: --Restlessness or feeling on edge --Difficulty concentrating or mind going blank --Irritability --Tension -Sleep disturbance Distress or dysfunction

Characteristics of Bipolar Disorders

Excessive elation or some combination of periods of elation interspersed with periods of depression and lethargy Affect functional ability in global fashion Most often fluctuate between mania and depression, although an individual who has a single manic episode may be diagnosed with bipolar I disorder. --People who have Bipolar usually have someone else manage their finances because they will empty their accounts during their mania

Major Depressive Disorder: Diagnostic Criteria

Five of the following during a two week period: --Depressed mood most of every day almost every day --Anhedonia—lack of pleasure or interest in daily activities, again, most every day for most of the day --Weight loss without dieting or decrease in appetite --Insomnia or hypersomnia almost every day --Fatigue or low energy --Feelings of worthlessness or guilt --Difficulty concentrating --Recurrent thoughts of death, suicidal ideation, or suicide attempt Distress and functional impairment --If you are fatigues and cant concentrate your quality of work will be affected Not a grief reaction following a loss

Symptoms of Major Depressive Episode

Five symptoms that may include: --Depressed mood or anhedonia (must be present) --Weight loss or loss of appetite --Insomnia or hypersomnia --Fatigue or low energy --Feelings of worthlessness or guilt --Problems concentrating --Suicidal ideation --Functional deficits

Exposure Therapy

Form of CBT Reduces anxiety and fear Especially effective for patients with phobias and OCD

Schizoaffective Disorder: Etiology

Genetic Other factors --Loss of a parent, especially as a result of suicide --Advanced parental age at birth --Urban residence --Preterm birth

Major Depressive Disorder: Etiology

Genetic factors (but less prominent than in schizophrenia or bipolar disorders) Neurotransmitters, especially monoamine deficiency Inflammation (but may be a co-existing factor, rather than etiological) Social/environmental Stress (esp. abuse, trauma history) Strong association with physical disorders (CVA, cardiovascular)

Schizophrenia: Etiology

Genetics Stress is a factor in exacerbations (Bentall & Fernyhough, 2008). Poor parenting and family dysfunction But multifactorial: --Environmental factors (Prasad et al., 2010) psychosocial stressors, such as maladjusted family relationships --Childhood trauma, TBI, many other factors considered --Found in lower SES, but may be because of functional limitations

DSM-5

Guided by four principles: --The DSM is above all a manual to be used by clinicians; must be implementable in routine specialty practices. --Recommendations should be guided by research evidence. --Continuity with previous editions should be maintained when possible. --No a priori constraints on the degree of change between DSM-IV and DSM-V. Changes in the DSM-5: Eliminates the multiaxial system --Issues of function, severity now reflected in specifiers for each diagnosis --Went to a more spectrum organization --Reorganization of chapters/separation of some clusters --Increased emphasis on the idea of spectrum disorders Criticisms of DSM-5: --The process was secretive --Important diagnoses (e.g. Asperger's Syndrome) were removed depriving some of treatment --Some diagnoses (e.g. intermittent explosive disorder; binge eating disorder) pathologize normal individuals --Inadequate attention to cultural differences -----Some cultures it is normal to not cry when someone dies --Biomedicalization of mental disorders ------Trying to find out the biological reason for Mental Disorders ------They are still in the medical model

OTs can help all populations with depressive disorders by...

Helping create a balance in life (work, school, leisure, rest, etc.) Modify the environment to reduce stress (physical, social, etc.) Teaching them to challenge their negative self-talk and use coping strategies Providing individuals with relaxation and mindfulness techniques Improving interpersonal communication and sharing of feelings Educating the individual, the family, peers, coworkers, etc Provide a daily schedule --Prioritize --Increase participation --Replace bad habits with good habits --Promote responsibility --Provide a sense of achievement Perform task analysis to breakdown into manageable steps and identify barriers Lifestyle changes/management --Diet dietitian --Sleep schedule --Exercise --Decrease unhealthy habits

__ is the source of libidinal and aggressive drives (drives for pleasure and dominance). _____ reflects external expectations and shapes moral sense, shame, and guilt ___ balances (or serves as moderator between) personal drives and external expectations.

Id Superego Ego

Myths About Anxiety

If you have an anxiety disorder, it is important to avoid stress and situations that make you feel "stressed." --Treating yourself as if you are fragile and avoiding risk leads to feeling demoralized. Avoiding anxiety tends to reinforce it. You can be anxious and still do whatever you have to do. The causes of anxiety disorders are usually rooted in your childhood, so effective therapy must focus on that time period. --Whatever the causes (usually a combination of heredity and personal experiences), research shows that effective treatment focuses on the here and now, including new skills to manage thoughts, emotions, discomforts, and behavior. Medication is the only treatment for anxiety disorders. --Medication can be effective. But scientific research shows that cognitive-behavioral therapy, or CBT, may be just as or more effective than medication (or a combination of CBT and medication) for most people, especially in the long run. If you eat right, exercise, avoid caffeine, and live a healthy lifestyle, your anxiety will go away. --While some of your anxiety might go away, your disorder won't be cured. Anxiety disorders are certainly sensitive to stress, but stress does not cause them. One way to get rid of bad or disturbing thoughts is to snap a rubber band on your wrist every time you have the thought. --Might actually reinforce it because you are paying attention to it

Panic Attacks

Important to note that a panic attack does not necessarily indicate panic disorder.

History of the DSM

In 1840, the United States had a one-category classification system for mental illness: "idiocy/insanity" (Williams, 1988). By 1880, the system had increased to eight categories. As understanding and awareness increased over time, the classification system was refined, eventually formalized both as a chapter in the International Classification of Diseases, 10th edition (ICD) (Moriyama et al., 2011), the diagnostic system for all diseases used around the world, and as the DSM. The Diagnostic and Statistical Manual, Mental Disorders, later to be known as DSM-I, was published in 1952 by the APA. It was a major breakthrough for the field of mental health, as it provided the first comprehensive volume describing a range of mental disorders. The descriptions were quite general, however, making diagnosis unreliable. As psychiatric knowledge grew, it became clear that a revision was needed. DSM-II appeared in 1968, following three years of work by the APA (APA, 1968). It coincided with the eighth revision of the ICD. The differences between DSM-I and DSM-II were minor. --Criticisms: Vague, poor reliability

Catatonia

In DSM-5, a symptom, rather than a distinct type of schizophrenia Three or more of the following: --Stupor (absence of psychomotor activity, failure to interact with the environment) --Catalepsy (passive induction of a posture against gravity, like an arm held in front of the face for long periods of time) --Waxy flexibility (resistance to being positioned by the therapist) --Mutism (absence of verbal response in the absence of aphasia) --Negativism (opposition to or failure to respond to instructions or stimuli) --Posturing (spontaneous, active maintenance of a posture against gravity) --Mannerism (odd caricature of normal actions) --Stereotypy (repetitive, frequent, non-goal-directed movement) --Agitation --Grimacing --Echolalia (mimicking others' speech) --Echopraxia (mimicking others' movements)

Psychotic Disorders: Cultural Considerations

In some cultures, hallucinations, delusions might be part of culturally sanctioned rituals Health disparities in the U.S. --Evidence of overdiagnosis of schizophrenia among African-Americans

Schizophreniform Disorder: Diagnostic Criteria

Includes the same symptoms as schizophrenia, but with a shorter duration - between 1 and 6 months - at which point the dx of schizophrenia would be appropriate Thus, the main distinction between schizophreniform D/O and schizophrenia is duration Two or more of the major signs of psychosis for a significant portion of at least one month --Delusions, hallucinations, or disorganized speech --Disorganized or catatonic behavior --Negative symptoms like diminished emotional expression or avolition

Depressive Disorders: Lifespan Considerations

Increasing rates of diagnosis of depression among children Symptoms in children reflect their developmental stage --Anxiety --School phobias, school refusal --Difficulty sleeping Play therapy is helpful In adolescence, behavior may be sullen, irritable In later life symptoms may mimic dementia --Poverty of response --Lethargy --Poor quality of life --Poor health Treatment with ECT may be indicated

Bipolar Disorders: Prognosis

Individual episodes resolve relatively quickly (days to a month or more) But disorder tends to be chronic with exacerbations and remissions Early onset suggests more severe course 13% encounter legal difficulties

Anxiety Disorders: Cultural Considerations

Japan and Korea, a condition known as taijin kyofusho, characterized by fear of harming others Hispanic cultures, a condition known as nervios Misdiagnosis because of differing cultural expectations of behavior (e.g., immigrant children to be diagnosed with selective mutism) Differences in help seeking behavior/acceptability of receiving help

Cyclothymic Disorder

Least severe of bipolar disorders Etiology similar to bipolar disorders Typically chronic Both manic and depressive episodes cause fewer functional deficits But mood tends to be consistently either excessively high or depressed At high risk of developing bipolar I or bipolar II disorder

Two types of psychic energy seen as drives

Libidinal drive: --"Life force" --Sexual/pleasurable energy --Urge to perpetuate life, to love, to generate and/or reproduce --Seen in the making of relationships Aggressive drive: --"Death force" --Hostility, hatred, urge to destroy or dominate --Expressed in tendency to be self-sufficient and keep others at a distance These drives can be in conflict with one another and be a cause of anxiety

Mood Stabilizers for bipolar

Lithium carbonate (Eskalith, Lithobid, Lithonate, Lithotabs) --"Gold standard" --Reduces manic symptoms and stabilizes mood Side effects: --Weight gain --Nausea --Slowing of cognitive functioning --Tremors --Metallic taste

Depression and work performance

Looking at if web based screening may be an effective tool in screening for depression. Telecommunication company in UK --Negative linear relationship between workgroup performance and depression --Found that those groups with higher levels of depression had decreased work performance

Bipolar I

Manic episodes are primary symptom presentation or rapid (daily) cycling episodes of mania and depression More common presentation Bipolar I Disorder: alternation of major depressive episodes with one or more full manic episodes or mixed episodes (i.e., frequent fluctuations between low and expansive mood)

Agoraphobia: Implications for Function

May be mild to severe If mild, limited impairment in activities outside familiar/comfortable settings If severe, global impairment Self-care less affected. Work and social performance more significantly affected Performance patterns tend to be avoidant (will not do anything that might provoke anxiety)

Schizoaffective Disorder: Implications for Function

May or may not be functional deficits At least some functional deficits are likely. --Cognitive skills, especially visual-spatial and visual-motor coordination are affected, although to a smaller extent than in schizophrenia

Major Depressive Disorder: Implications for OT

Meaningful activities Support for routines and habits Self-expression --Dancing --Painting Social skills training Sleep-related intervention Work-related interventions --Identifying meaningful work --Making appropriate modifications to work --Developing coping mechanisms

Why is Mental Health Important?

Mental disorders are among the most common causes of disability. The resulting disease burden of mental illness is among the highest of all diseases. According to the National Institute of Mental Health (NIMH), in any given year, an estimated 13 million American adults (approximately 1 in 17) have a seriously debilitating mental illness. Mental health disorders are the leading cause of disability in the United States and Canada, accounting for 25 percent of all years of life lost to disability and premature mortality.3 Moreover, suicide is the 11th leading cause of death in the United States, accounting for the deaths of approximately 30,000 Americans each year.

Brief Psychotic Disorder/Schizophreniform Disorder: Implications for OT

Monitor the effectiveness of medications --At this point, the OT becomes the eyes and ears of the Psychiatrist to determine if meds are working and client is experiencing less symptoms. Minimize damage to occupational status resulting from a period of severe disorder.

Bipolar Disorders: Implications for OT

Monitoring behavior changes as medication is implemented Providing a structured environment Assist the individual in coping with chronic illness Help the individual identify strengths, weaknesses, likes, and dislikes through exposure to a wide range of activities Psychoeducational approaches may assist Manage behavioral difficulties by altering lifestyle, monitoring symptoms Family education and support

OT Assessment of bipolar

Mood Disorder Questionnaire --Self-report --Screening purposes

Brain Involvement of Depression

Most commonly affects the Limbic System --Amygdala --Hippocampus --Hypothalamus --Mamillary Bodies --Cingulate Gyrus

Delusional Disorders

Most often occurs in middle or later life, and it is more common in first-generation immigrants and people with hearing impairments, although it is not clear why this might be the case Course of delusion disorder is variable, although it is most often chronic, with exacerbations and remissions. Impairment of vocational, avocational, and self-care occupations is rare. Social impairment is frequent and often severe.

Selective Mutism Etiology

Most theories focus on psychodynamic explanations, which are focused on the understanding of the underlying psychic phenomena that contribute to the disorder, (Bussey & Downey, 2011) , especially family dynamics and experience of trauma. There may be conflicts in family relationships or a learned pattern in which the child uses silence as a way to manage anxiety. It is frequently comorbid with social anxiety disorder, suggesting a common etiology. Tempermental factors, such as shyness and family issues may be involved. One study found that 37% of parents of children with selective mutism had social phobias, compared with 14.1% of a control group (Chavira, Shipon-Blum, Hitchcock, Cohan & Stein, 2007). Recognize that selective mutism has different etiology and presentations than typical communication disorders. Selective mutism is, by definition, selective or voluntary. --They will speak in other settings but they will not speak in the area in which they had the trauma --It is your clue as to where the trauma occurred With appropriate treatment, SM can be successfully remediated (Bussey & Downey, 2011). Although it is associated with other anxiety disorders that may be more chronic, good evidence exists that most children with SM resume normal speech, particularly if intervention is provided early in the course of the disorder.

Schizophrenia: Implications for OT

Need to find meaning/purpose in life Must be comprehensive, with particular emphasis on occupational engagement (Bejerholm & Eklund, 2007) --Motor and praxis --Sensory perceptual --Cognitive skills --Communication skills --Social skills --Performance areas: self-care, leisure, and work Activities/instrumental activities of daily living training (Hamera & Brown, 2000) Vocational assessment and work skills training --Work as an activity is clearly important as an intervention and as an outcome (Bond & Drake, 2008; Lysaker, Davis, Bryson, & Bell, 2009). --Match job demands to the skills of the individual (Kopelowicz, Liberman, Wallace, Aguirre, & Mintz, 2006). Remediating skill deficits through education, behavioral, or sensorimotor approaches "Life skills" training (Mairs & Bradshaw, 2004) Strengths as well as weaknesses should be incorporated into treatment. Educate families/employers Advocacy regarding public policy

Panic Disorder: Etiology

Neurological disorder (Zwanzger, Domschke, & Bradwejn 2012) --Either by flawed neuronal circuitry --Flawed neurotransmitter production Amygdale and the prefrontal cortex Elevated corticotrophin-releasing factor (Mathew, Price, & Charney, 2008) Genetic component (Cosci, 2012) Evolutionary consequence of a "fight or flight" response gone awry (Grillon, 2008) Environmental factors --Relationship with parents

Emerging Issues in Mental Health and Mental Disorders

New mental health issues have emerged among some special populations, such as: --Veterans who have experienced physical and mental trauma -----Mild Head Injuries: the skull doesn't open up but the brain has a coup and counter-coup injury -----Open Head Injury: the skull opens up and expands with the swelling People in communities with large-scale psychological trauma caused by natural disasters Older adults, as the understanding and treatment of dementia and mood disorders continues to improve As the Federal Government begins to implement the health reform legislation, it will give attention to providing services for individuals with mental illness and substance use disorders, including new opportunities for access to and coverage for treatment and prevention services.

Disruptive Mood Dysregulation Disorder

New to DSM-5 Controversial --This diagnosis may pathologize normal childhood behavior --But may also minimize overdiagnosis of bipolar in young children -----They wanted something less severe than bipolar in children -----The guy at the Denny's threw a temper tantrum when they didn't have mac and cheese

Bipolar Disorders: Changes in the DSM-5 (on the spectrum b/w __ & __ disorders)

No longer in the same chapter as depressive disorders Conceptualized on a spectrum, between psychotic disorders and depressive disorders Psychosis <--> Bipolar Disorder <--> Mood Disorders

Schizoaffective Disorder: Implications for OT

Not well studied Cognitive interventions may be effective (Waltermie, Walton, Steese, Riley, & Robertson, 2010) Reintegration into the community is an important emphasis for OT ****

Implications for OT for Phobias

OT can assist in direct behavioral interventions that are focused on the phobia. OT can also address and functional deficits that may have emerged as a result of the phobia. In situations where the phobia has been prolonged and has had significant functional impact, chances for engagement in meaningful occupations with opportunities for success can ameliorate the negative consequences of the phobia on the individual's self esteem. --OTs do not attempt to desensitize phobias but only do BCT

Prognosis of SAD

One of the 1st hurdles of improving outcomes of SAD is encouraging the individual to seek treatment. Only about 20% of individuals with diagnosable social anxiety seek treatment (Lampe, 2009). A number of reasons may be responsible for this, including fear of stigma, a preference for trying to address the problem independently, and a sense that there are no useful treatments. However good evidence exists that treatment can be highly effective.

definition of Bipolar Disorder

One of the mood disorders characterized by recurrent episodes of both ends of an extreme from low end (depression) to elevated end (mania)

Brief Psychotic Disorder: Diagnostic Criteria

One or more of the symptoms associated with psychosis: --Delusions --Hallucinations --Disorganized speech --Disorganized behavior --Lasting more than a day but less than a month* --Often emerges in adolescence or early adulthood --May be a precursor to a more chronic psychotic disorder**

Psychotic Disorders: Lifespan Considerations

Onset in adolescence or young adulthood means that individuals may miss developmental accomplishments in education, work, leisure, and social participation Older adults typically have endured an extended illness. --In later life, the neurological components of the disorder may be prominent --The individual may have significantly lowered energy and motivation --There may be significant and permanent deficits associated with long-term antipsychotic medication use

Panic Disorders

Panic disorder is a diagnosis made only in the presence of recurrent panic attacks - surges of significant fear and discomfort that may last several minutes or longer. Specific diagnostic criteria consist of repeated panic attacks that involve at least 4 symptoms of panic, including palpitations, sweating, shaking, a feeling of shortness of breath or choking, chest pain, nausea, dizziness, chills, paresthesia (numbness or tingling), derealization (feelings of unreality) or depersonalization (feeling of being detached from onself), or a fear of dying

Structure of DSM-5

Part I --DSM Basics: describes the manual, its development, structure, and use. Part II --22 chapters focused on specific diagnostic clusters, with diagnostic criteria, characteristics, etiology, prognosis, and other information Part III --Supplemental information: assessment, cultural factors, potential diagnoses needing more research, etc. Appendices --Glossary, codes, ICD/DSM comparisons, etc.

Schizophrenia: Additional Symptoms

Perception and affect are disturbed. Hallucinations are typical. Auditory hallucinations (i.e., hearing voices) are most common (Moritz& Laroi, 2008), although any sense may be involved. The individual may smell peculiar smells and interpret this as being poisonous gas in the room or he or she may see strange figures when looking at his or her own face in the mirror. Affect is either flat or inappropriate. Some are totally expressionless, whereas others may have bizarre smiles, laugh inappropriately, and so on.

Implications for Function and Treatment for Selective Mutism

Performance will be affected primarily in settings where the child refuses to speak. Frequently, this is school, which means that education is most likely to be impaired. If the child refuses to speak at home, or in other social settings, those occupations would also be affected. Early diagnosis and treatment can be helpful as a way to avoid having the choice to remain silent, thus becoming habitual and ingrained (Viana, Beidel & Rabian, 2009). Early treatment can reduce the negative impact on the child's social and academic occupations (Crundwell, 2006). If left untreated, the disorder can become an accepted part of the child's identity (Omdal, 2008). Interventions should focus on behavior strategies, including Cognitive Behavioral Therapy (CBT), as well as operant conditioning that sets up a reinforcement structure for speech, including reward for successive approximation (gradual improvement) of expected speech. Group therapy in which the child can practice speech in a safe, supportive environment may be helpful. --The closer they to speaking the more they are rewarded (you are grading the task) Intervention with parents and teachers should focus on their education about the onset and causes of selective mutism, as well as strategies for encouraging speech. For example, expecting children to respond verbally and requiring a verbal response, rather than using gestures, while sympathizing with the child's anxiety may increase his or her comfort with speaking Accompanying the treatment with appropriate reinforcement may be helpful. --Behavioral Modification

Signs of overactive Superego:

Person seems dominated by guilt, shame, and a press toward perfectionism Example: Can you think of anyone?

Schizophrenia: Prognosis

Poor** But indications this is changing as better medications are identified Stopping medications predicts relapse Higher levels of negative symptoms and greater cognitive dysfunction have worse functional outcomes (Versterager et al., 2013) Higher levels of education and briefer duration of untreated psychosis also predict better outcomes (Whitty et al., 2008) Better premorbid function predicts better outcomes High risk of suicide (10-13%)****

Positive Symptoms of Schizophrenia Negative Symptoms of Schizophrenia

Positive symptoms --Hallucinations -----seeing, hearing, smelling, tasting something that is not there (most common is auditory) --Delusions -------Belief about themselves that is not real (thinking process) --Disorganized speech --Disorganized behavior Negative symptoms --Flat affect --Anhedonia ------Cannot experience pleasure

Superego

Preconscious level Thinking: Judgmental Shapes a moral code, sense of right/wrong Can be illogical & unrealistic about quest for perfection Societal rules Internalized from the culture Ex: NUNS

Brain Structure of bipolar

Prefrontal cortex --Activity reduced during depressive phase --Activity increased during manic phase

Delusional Disorder: Diagnostic Criteria

Presence of one or more delusions for at least a month Absence of all the criteria required for a diagnosis of schizophrenia Absence of functional or behavioral peculiarities except those related to the delusions Delusions that last longer than any symptoms of depression or mania; (To rule out bipolar disorder) And, symptoms that cannot be attributed to substance abuse or a medical condition Must use caution to distinguish from accepted cultural beliefs/practices (e.g. spirit possession, visions, voodoo curses)

Encourage the growth and development of a person's ego strength

Psychodynamic frame

Schizophrenia: Treatment

Psychotropic medications (Hasan et al., 2012). --Older antipsychotic medications effective in reducing positive symptoms, minimizing exacerbations --Newer, "atypical" medications have fewer side effects and show promise in treating negative symptoms. But adherence a problem because of cognitive deficits and unpleasant side effects Cognitive-behavioral therapy*** --Most effective in concert with medication Social supports (inpatient or community) Psychotherapy Art and other creative therapies*** Behavior therapy*** (addresses cognition) Family therapy Close monitoring of physical health --Potential damage from medications --Inability to manage nutrition, physical activity, other health promotion strategies --High risk of cardiovascular and other health problems

Generalized Anxiety Disorder: Treatment

Psychotropic medications, especially SSRIs CBT Best in combination

Bipolar Disorders: Treatment

Psychotropic medications, particularly lithium --Must be maintained over time, leading to difficulty with adherence --Subset for whom not effective --Side effects can be dangerous. Monitoring is required Group psychotherapy Family therapy Educational approaches Behavioral interventions Interventions work best in combination Hospitalization may be required Rapid intervention to avoid problematic consequences of behaviors

Suicide Risk and Intervention of Depressive Disorder

Rates are particularly high among older adults and adolescents. 60% of attempts are associated with depression May also be associated with other mental disorders All professionals must be aware of and assess risk: --Ask whether suicidal --Determine whether the individual has a plan --Watch for sudden improvement in mood --Watch for giving possessions away --Showing early signs that medication is effective (the individual has increased energy to act) Careful monitoring, often in inpatient settings Removal of means to cause death until the individual is clearly no longer actively suicidal (Hamilton, 2000; Tummey, 2001) Contract with the patient Report any expressions of suicidal ideation to the primary therapist without delay and should never assume that these are idle threats OT interventions focus on engagement in occupation for adolescents and social support

Longitudinal Course of bipolar

Recurrent course that occurs over a long period of time Whether the individual suffering from an episode has had major episodes of depression or mania in the past is important, as is whether the individual fully recovered between past episodes

Separation Anxiety Disorders (SAD)

Reflects extreme anxiety of an individual, which is related to separation from others to whom the person is attached. The anxiety must be inappropriate for the individual's developmental stage For this diagnosis to be made, at least three signs of excessive anxiety must be demonstrated at times when the individual faces separation from an important figure. These include: --Excessive distress when thinking about or experiencing a separation from major people in one's life; --Worry about losing these people or about unlikely events (like being kidnapped) that would cause separation; --Refusal to participate in activities away from home. --Excessive fear of being alone --And/or frequent nightmares or physical complaints when separation occurs. The symptoms must be persistent over at least 4 weeks for children, or 6 months for adults, and the symptoms must cause distress or functional impairment.

Agoraphobia: Implications for OT

Refocus attention toward positive engagement in occupations Provide supportive environments in which to gradually develop or re-establish previous valued occupational patterns Gradual reintroduction of activities accompanied by trusted friend (or therapist)

Defense Mechanisms: Less Primitive, More Mature Mechanisms (5)

Repression Displacement Intellectualization Rationalization Undoing

Typical antipsychotic meds can cause side effects related to physical movement:

Rigidity Persistent muscle spasms Tremors Restlessness

Major Depressive Disorder: Differential Diagnosis and Comorbidity

Rule out: --Schizoaffective disorder Frequent comorbidity: --Anxiety disorders --Substance use disorders --Personality disorders.

Depressive Disorders

Sad, empty, or irritable mood are primary characteristics of these disorders Somatic and cognitive changes, typically affecting the individual's ability to function --Tend to focus on physical symptoms of their bodies Changes from DSM-5 --Grouped with the bipolar disorders in previous editions of the DSM --Removal of bereavement exclusion in diagnosis of depression generated controversy

Persistent Depressive Disorder (Dysthymia): Implications for Function

Same as major depressive disorder but less severe More persistent and chronic

OT for Adolescence with Depressive Disorder (Home, School, and Community Environment)

School-wide promotion --Healthy lifestyles --Support --Self-esteem --Bullying Target at-risk groups --After-school programs Home environment --Lower stress --Incorporate opportunities for success -----Chores, homework, interactions --Avoid pressure --Leisurely morning routine at their pace (side effects of medications) --Promote one-on-one social interaction School environment --Modify the environment and assignments to reduce stress --Modify school schedule --Education to educational providers Community --Make sure goals are realistic and appealing --Incorporate enjoyable activities --Avoid environments with high sensory input

Selective Mutism

Selective Mutism reflects an unwillingness to speak in certain settings. It assumes that there is no clear reason - such as hearing impairment - that results in an inability to produce speech. Rather, it is to some extent a choice by the individuals. Diagnostic criteria includes: --Repeated failure to speak in a setting where speech is expected, --The individual speaks in other settings; --Failure to speak interferes with function; --Failure to speak is not the result of language differences, --Disturbance lasts at least 1 month The unwillingness to speak that characterizes selective mutism emerges in situations that cause high anxiety for the individual. Where there is unwillingness to speak at school, it may be difficult to assess the individual - almost always a child - in terms of academic performance, which sometimes leads to inaccurate identification of requirements for special services. Social interaction with peers can also be a contributing factor if the individual feels worried about his or her ability to manage the situation. In some instances, other forms of communication - gestures, grunts, pointing, writing - may be substituted. The disorder is often accompanied by excessive shyness, social isolation, withdrawal, and other signs of excessive anxiety in interaction with others. Although the child perceives a need for silence, usually to manage his or her anxiety, there are no biological or structural impediments to speech; indeed, the child will have established spoken language and may speak freely in some settings.

Implications for OT for Selective Mutism

Selective mutism is a condition in which the OT's role in educating others can be of great value. The OT may be able to help guide the parents and teachers in understanding how to best minimize the child's anxiety and encourage appropriate speech. The OT also has the opportunity to encourage speech in a safe and welcoming setting. Activities that engage the child's interest, while also requiring speech can provide opportunities for practice in a low-stress environment. --For example, the child might play Go Fish or be encouraged to draw a picture and describe its contents, each of which is a potentially enjoyable activity that requires speech. The ability to provide activities in which speech is not the central focus of attention can diminish anxiety.

Prevalence of Anxiety Disorders

Separation Anxiety: .9-1.9% (1:1 more common in women in the community) Selective Mutism: .03-1% (1:) Specific Phobias: 8.7% (1:2) Social Anxiety: 7% (1:1.5- 1:1.22) Panic disorder: 2.7% (1:2) Agoraphobia: 3.1% (1:2) Generalized Anxiety Disorder: 3.1% (1:2)

Neurotransmitter Imbalances (Serotonin, Glutamate, GABA, Dopamine, Norepinephrine)

Serotonin: --responsible for serenity and hopefullness --SSRI antidepressants like Prozac increases these levels Glutamate: --Responsible for learning and memory --Too much= agitation, impulsivity and anger --Excitatory NTM. Depression can be a result from the inability of the CNS to effectively use glutamate. GABA: --increases tranquility --Anxiety medication boosts GABA --Inhibitory NTM. Low levels of GABA can result in anxiety and depression. --(GABA and Glutamate balance each other) Dopamine: --Respinsible for arousal and stimulation --associated with reward --too much= substance abuse Norepinephrine: --Inhibitory & Excitatory --"Fight or Flight" response --Decreased levels = tired & lethargic --Increase levels = nervousness & high blood pressure

Symptoms of Hypomanic Episode

Shorter duration than manic episode (four days rather than 1 week) Symptoms of manic episode but less severe Less problematic functional consequences --Probably not enough to go to the hospital

Social Anxiety Disorder (Social Phobia)

Social anxiety disorder is closely associated with separation anxiety and selective mutism. All 3 disorders are characterized by significant anxiety in specific situations, in this case, social encounters. Although separation anxiety and selective mutism are disorders that often begin in childhood, social anxiety disorders may also emerge in adulthood.

Major Depressive Episode: Implications for Function

Social, work, leisure Possibly ADL and IADL Habits, roles, routines deteriorate during major depressive episodes Motor, process, and communication slowing Significant executive function deficits Emotional regulation deficits Sexual interest/function impaired All improve between episodes

What are the side effects of anti-psychotics?

Some people have side effects when they start taking these medications. Most side effects go away after a few days and often can be managed successfully. People taking antipsychotics should not drive until they adjust to their new medication. Drowsiness Dizziness when changing positions Blurred vision Rapid heartbeat Sensitivity to the sun Skin rashes Menstrual problems for women Atypical antipsychotic medications can cause major weight gain and changes in a person's metabolism. This may increase a person's risk of getting diabetes and high cholesterol. A person's weight, glucose levels, and lipid levels should be monitored regularly by a doctor.

Psychodynamic frame of reference

Strands from early psychoanalytic views for ANALYSIS --Components of the personality --Drives and psychic energy --Defense mechanisms And constructs from later derivative views for --EGO WORK Ego psychology --Humanistic psychology --Human spirituality --Positive psychology 1. Psychoanalytical influences (early work) --sigmund Freud --carl jung 2. Influences of ego psychology (later work)

Triggers of Bipolar

Stress Substance Abuse- cocaine, ecstasy, amphetamines Medication- OTC medications can trigger mania Seasonal changes --She would see her patients in the summer Sleep deprivation can trigger episodes of mania Other drugs that can cause mania include over-the-counter cold medicine, appetite suppressants, caffeine, corticosteroids, and thyroid medication.

Changes in the DSM-5 for Schiz0

Stronger requirement for presence of positive symptoms, Dimensional diagnostic system rating eight symptoms on a scale of severity Deletion of sub-categories of schizophrenia, such as paranoid, disorganized, and undifferentiated. Catatonia is now described as a symptom and not a separate type of schizophrenia.

Mature Defense Mechanisms (3)

Sublimation Compensation Assertiveness

Panic Disorder: Implications for OT

Support cognitive-behavioral interventions (Lambert, Caan,& McVicar, 2008) Support establishment of positive performance patterns that substitute effective habits and routines for those that are dysfunctional Sensory perceptual intervention to address misperceptions of sensory input

Cyclothymic Disorder: Implications for OT

Support in coping with chronic illness Education and information Assistance in clarifying valued goals and activities Time management strategies Self-appraisal/self-esteem Combination of approaches, much like those suggested for bipolar disorder

Schizoaffective Disorder: Diagnostic Criteria

Symptoms of schizophrenia with at least one period of illness during which there is a major episode of depression or mania Delusions or hallucinations must be present for two or more weeks without a major mood episode at some point during the illness Mood episodes must be present for the majority of the duration of the illness.

Long-term use of typical antipsychotic meds may lead to a condition called ___ ___

Tardive Dyskinesia TD causes muscle movements a person cannot control. The movements commonly happen around the mouth. TD can range from mild to severe, and in some people the problem cannot be cured even when taken off of the med. Sometimes people with TD recover partially or fully after they stop taking the medication.

Disruptive Mood Dysregulation Disorder: Diagnostic Criteria

Temper outbursts, verbal and/or behavioral out of proportion to the situation, at least three times a week for at least a year Inappropriate for developmental level Mood is irritable or angry most of the day most days No period of three or more months without symptoms Behavior seen in at least two settings among home, school, and with peers Should be diagnosed for children between the ages of 6 and 18 Onset before age 10 New diagnosis, therefore little information about etiology, prognosis, treatment or implications for OT

Panic Disorder: Prognosis

Tends to be intractable (very difficult to deal with) Only 50% of individuals with panic disorder reported either partial or complete remission

Mental Illness

The term mental illness refers collectively to all diagnosable mental disorders. Effects of the illnesses include sustained abnormal alterations in thinking, mood, or behavior associated with distress and impaired functioning. The effects of mental illnesses include disruptions of daily function; incapacitating personal, social, and occupational impairment; and premature death. Mental illness is associated with increased occurrence of chronic diseases (comorbid conditions) such as cardiovascular disease, diabetes, obesity, asthma, epilepsy, and cancer. According to the World Health Organization, mental illnesses account for more disability in developed countries than any other group of illnesses, including cancer and heart disease. Published studies report that about 25% of all U.S. adults have a mental illness and that nearly 50% of U.S. adults will develop at least one mental illness during their lifetime

Psychodynamic theory:

This theory related to the dynamics of the psyche Dynamics (ever-changing actions and interactions) of the psyche (mind, soul, intellect, mental part of the self)

Bipolar and Related Disorders: Cultural Considerations

Timing of diagnosis following the onset of symptoms, especially delay before diagnosis The consequences in terms of access to and outcomes of care Extent to which manic behavior is tolerated varies --Homeless shelters Acceptability of use of medication Extent of associated stigma

Schizophrenia: Diagnostic Criteria

Two or more signs of psychosis for a significant portion of at least one month --Delusions, hallucinations, or disorganized speech --Disorganized or catatonic behavior --Negative symptoms like diminished emotional expression or avolition Functional limitations (differentiates from brief psychosis or schizophreniform disorder) Signs of disturbance last at least six months, including prodromal and residual periods

Anti-Convulsants for bipolar

Types: --Carbmazepine (Tegretol) --Divalproex sodium (Depakote,Depakote ER) --Gabapentin (Neurotonin) Effective as mood stabilizers Reduces psychotic symptoms in acute mania and severe depression

Anti Depressants for bipolar

Types: --Prozac (Have a tendency to make people suicidal) --Paxil --Zoloft --Wellbutrin Side effects: --Headache --Nausea --Agitation --Sexual problems

Bipolar Disorders: Etiology

Typical onset in adolescence or young adulthood Two major patterns of onset: --early and repeated depression --initial manic symptoms (Forty, 2009). Genetic component Environmental, social, personal factors Situational stressors Unclear Genetics Major life events causing emotional stress Insufficient transport of sodium and potassium ions --The drug of choice for manic depression is Lithium which is a salt Family tension associated with relapse

Brief Psychotic Disorder/Schizophreniform Disorder: Treatment

Typically pharmacological in nature, using some of the many antipsychotic medications, such as chlorpromazine, that are now available (Ehlis et al., 2005). Because of the potential side effects and fundamental symptoms of various psychotic disorders, maintaining effective medication strategies can be difficult.

Id

Unconscious drives & instincts Thinking: Primary process Illogical, undisciplined, pleasure seeking Dreams and unbidden thoughts

Older Adults with Depressive Disorder

Usually comes from physical symptoms --Headaches, stomachaches, bowel/bladder Depression decreases when individuals enter SNFs, hospitals, and nursing homes. Fearful of falls - if fallen before and/or have broken a bone Anxious to leave the house This will ultimately affect all aspects of occupational performance Older adults 65 years and older made up 12% of the population that was depressed in 2007 Older adults made up 16% of suicides in 2004

Symptoms of Manic/Hypomanic Episodes

Usually with abrupt onset Major changes in attitude, behavior, and cognition Decreased need for sleep Talkativeness Distractibility Increased activity Excessive involvement in pleasurable activities with disregard for the consequences

Major Depressive Disorder: Prognosis

Variable. 40% have symptoms a year after diagnosis Worse outcomes associated with: --Older age --Early onset --Accompanying physical symptoms Better outcome associated with: --Younger females --Fewer childhood traumas --Fewer somatic symptoms --More positive emotion expressed during episodes

Brief Psychotic Disorder/Schizophreniform Disorder: Implications for Function

When psychotic symptoms are present, function is severely impaired Cognition is particularly impaired, with resultant deterioration of social and vocational roles

Premenstrual Dysphoric Disorder: Implications for Function

Work performance in particular, possibly social and leisure Possibly cognitive and emotional regulation skills Remit during weeks between menstrual periods

Panic Disorder: Implications for Function

Work, leisure, and ADL during attacks Fear of attack may impact on any function Affects routines and habits as individual attempts to avoid panic attacks Poor quality of life due to worry about attacks

Generalized Anxiety Disorder: Implications for Function

Work, leisure, other performance areas essentially intact, but persistent anxiety and worry while engaged in occupation Cognition and emotional skills distorted by anxiety Patterns, habits, roles may be circumscribed in an attempt to avoid or manage anxiety

Bipolar Disorders: Implications for Function

Work, social, leisure habits, roles, and routines deteriorate during episodes Motor hyperactivity Process deficits Executive function particularly impaired Communication not severely affected Function tends to improve between episodes Less severe for hypomanic episodes

Bipolar II

alternation of one or more major depressive episodes with at least one hypomanic episodes (not full manic episodes)

Specific Phobia

anxiety reactions related to one or more particular stimuli. This is a common disorder, and most of us know someone who has a profound fear of flying, snakes or public speaking. An encounter with the feared stimulus can lead to crippling anxiety that makes functioning in that setting almost impossible. Diagnostic criteria, for a period of at least 6 months, include the following: noticeable fear of a particular object or situation with resulting anxiety; avoidance of the stimulus; reactions out of proportion to the actual danger or risk associated with the stimulus, and anxiety and avoidance that cause distress and dysfunction. Strong, irrational fear reactions Avoids places, situations, or objects Feels powerless to stop it Onset --Some arise in childhood --Some arise unexpectedly in adolescents and young adulthood --Sudden --Occur in situations that previously did not cause any discomfort or anxiety Women are twice as likely to be affected as men Typically begins in childhood; the median age of onset is 7

Anxiety: A Current Definition

emotional state in which people feel uneasy, apprehensive, or fearful. People usually experience anxiety about events they cannot control or predict or about events that seem threatening or dangerous. There is a feeling of vulnerability and severe anxiety can persist and become disabling

Sublimation

the channeling of unacceptable impulses, thoughts, and emotions into more acceptable ones. It can be done with humor or fantasy. Humor when used as a defense mechanism is the channeling of unacceptable impulses or thoughts into a light-hearted story or joke. Humor reduces the intensity of a situation, and places a cushion of laughter between the person and the impulses.