Test #2 (Chapters 5, 6, 7)

Face Physical Fears

1) avoidance (doing whatever to get rid of symptoms or avoid places where symptoms are expected to happen, staying away from bridges) 2). mistaken beliefs (the physical symptoms means death, loosing control, or going insane) 3). interoceptive conditioning (body has become highly sensitive to the physical feelings of the beginnings of panic attacks)

Goals of exposing one to physical symptoms - over breathing - run in place - drinking- straw breathing - lift head quickly

1) learn that the physical symptoms and anxiety itself are not harmful 2) learn that the symptoms can be handled

Treatment: Biological Approaches

Beta-blocks (propanolol) - prevent somatic symptoms of anxiety - effective only with performance anxiety Benzodiazepines (Xanax, Valium) - enhance GABA system - frequently prescribed for GAD, Social Phobia, and PD/A - risk of developing dependence, abuse - relapse rates high when medication is discontinued Selective Serotonin Reuptake Inhibitors (SSRIs) - Celexa, Lexapro, Prozac, Zoloft - increases serotonin

Persistent Depressive Disorder (Dysthymia/ Dysthymic): An Overview

- defined by a persistently depressed mood that continues for at least 2 years - milder and fewer symptoms of depression than major depression - symptoms can persist unchanged over long periods (20 years or more) Facts: -1.5%-5% 1 year prevalence - more common in women

Learned Helplessness

- depression develops when a person believes that they no longer have control over the reinforcements (rewards and punishments) in their lives and that they themselves are responsible for this helpless states

Distorted Thoughts view in Cognitive Models

- early experiences with uncontrollability and unpredictability (psychological vulnerability) - misinterpretation of anxiety symptoms exacerbates panic and contributes to development of anxiety (false alarms)

Generalized Anxiety Disorder: "Basic" Anxiety Disorder

- excessive uncontrollable anxious apprehension and worry about life events - difficult to control the worry - restlessness, difficulty concentrating, irritability - somatic symptoms muscle tension, fatigue, sleep disturbances - persists for 6 months or more Facts and Statistics - one-year prevalence 2.9% - females outnumber males - age of onset is 0-20 years

Specific Phobias

- extreme and irrational fear of a specific object or situation - markedly interferes with one's ability to function - recognize fears are unreasonable, but go to great lengths to avoid phobic objects Types - blood-injury-injection - situational - flying - animals

Social Phobia

- extreme and irrational fear/shyness in social and performance situations - speaking in front others, eating in front of others, starting conversations - markedly interferes with one's ability to function - often avoid social situations or endure them with great distress - generalized subtype- social phobia across numerous social situations Facts and Statistics - 7% 12 month prevalence - females are slightly more represented than males - onset 10-20 years

Anxiety

- future-oriented mood state characterized by marked negative affect - somatic symptoms of tension - apprehension about future danger or misfortune

Etiology - Biological

- genetics - biochemical (low levels of serotonin and norepinephrine) - brain anatomy

Etiology - Behavioral

- lack of rewards/reinforcements

Cognitive therapy - Depression

- list and challenge negative automatic thoughts with thought log (look at handout from class) Situation/trigger | Feelings | unhelpful thoughts/images | facts that support the unhelpful thought | facts that provide evidence against the unhelpful thought | alternative, more realistic and balanced perspective | outcome

Type of DSM-5 Depressive Disorder

- major depressive disorder - dysthymic disorder - double depression

SNRI (Negative Side Effects)

- nausea - dry mouth - dizziness

Etiology - Cognitive

- negative automatic thoughts - cognitive triad (experiences, themselves, and their futures) Example: "I'll never be loved" "I'm a bad boyfriend" "I'm worthless" "I messed up this relationship, I'm going to mess up all relationships"

Fear

- present-orientened mood state, marked negative affect - immediate fight or flight response to danger or threat - strong avoidance/escapist tendencies

Characteristics of Anxiety Disorders

- psychological disorders: pervasive and persistent symptoms of anxiety and fear - involve excessive avoidance and escapist tendencies - symptoms and avoidance causes clinically significant distress and impairment

Hypomanic Episodes

- same criteria as manic episodes, but duration only 4, and does not require clinical impairment of functioning

Why is it "good" to be anxious at times?

- shows you care - want to have goals for yourself

Social Contributions to Anxiety and Panic

- stressful life events as triggers of biological/psychological vulnerabilities - many stressors are familial and interpersonal

Causes Psychological Factors (DID)

- trauma is precipitating event; repeated trauma or extreme trauma for DID - escaping trauma and anxiety -suggestibility or ability to autohypnotize

Behavioral Activation - Depression

- useful for patients who may not have cognitive distortions, but have anhedonia (loss of the capacity to experience pleasure, inability to gain pleasure from normally pleasurable experiences)

Dissociative Amnesia

-generalized amnesia (loss all memory, including own identity) - localized, selective amnesia- lose of memory for specific events (usually trauma) during particular period of time

Facts and Statistics about OCD

- about 1.2% 12-month prevalence - most persons with OCD are female - OCD tends to be chronic - onset is typically in early adolescence or young adulthood

Agoraphobia DSM-5 Criteria

(A) Marked fear or anxiety about two (or more) of the following: 1. using public transportation 2. being in open spaces 3. being in enclosed spaces 4. standing in line or being in a crowd 5. being outside of the home alone

Panic Disorder DSM-5 Criteria

(A) recurrent unexpected panic attacks, peaking within minutes, and include 4 of the following: - palpitations or pounding heart - sweating - shortness of breath/feelings of smothering - feelings of chocking - chest pain or discomfort - nausea or abdominal distress - feeling dizzy - chills or heat sensations - numbness or tingling sensations - derealization or depersonalization - fear of losing control or "going ray" - fear of dying

Panic Disorders - DSM 5 Criteria

(B) At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1). persistent concern or worry about additional panic attacks or their consequences 2). A significant maladaptive change in behavior related to the attacks (avoidance)

Agoraphobia

(B) individual fears or avoids these situations because of the thoughts that escape might be difficult or help might not be available in the event of developing panic like symptoms or other incapacitating or embarrassing symptoms (C) situations almost always provoke fear or anxiety (D) situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety

PTSD

- 3.5% year prevalence - 7-9% lifetime prevalence must have symptoms for more than 1 month

Facts and Statistics on Specific Phobias

- 7-9% 12-month prevalence - females are again over-represented

Types of DSM-5 Bipolar Disorder

- Bipolar I disorder - Bipolar II disorder - Cyclothymic Disorder

Treatment DID

- No controlled studies of treatment, limited success - exposure treatment using PTSD model, extinguish cues triggering anxiety and dissociation - attempt to combine identities back into one

Distorted Thoughts view in Behavioral Models

- anxiety and fear result from direct classical and operant conditioning and modeling

Medication - Depression (Negative Side Effects)

- decreased sex drive - insomnia - gastrointestinal problems - takes weeks to see anti-depressive effects (if at all) - suicide risks

Double Depression: An Overview

- Person experiences major depressive episodes and dysthymic disorder - dysthymic disorder often develops first - further specified depending on whether a major depressive episode has been experienced or not facts: -associated with severe psychopathology - associated with a problematic future course

Dissociative Fugue

-unexpected travel associated with loss of memory - loss of memory of own past, may assume new identity

Symptoms of Depressive Episode

2 week period of: - depressed mood of the majority of each day and/or - decreased in enjoyment or interest across most activities for the majority of the day (anhedonia) - considerable weight or appetite change - insomnia or hypersomnia - psychomotor agitation or retardation - fatigue - feelings of worthlessness or excessive guilt - difficulty concentrating - thoughts of death or suicide

Stats on Depression

9% of americans have severe depression in any given year around 18% of american adults will experience an episode of severe depression at some point in their lives women are at least twice as likely to have episodes of severe unipolar depression typical onset is in young adulthood

Bipolar 1 Disorder: Overview

Alternations between depressive episodes and FULL MANIC episodes Facts: - average age on onset is 15-44 years, but can begin in childhood - people tend to have more depressive than manic episodes - tends to be chronic - suicide is a common consequence - 1.6% one year prevalence - women and men equal prevalence - individuals with bipolar disorder are 15 times more at risk of suicide than the general population

PTSD Criterion C (one required)

Avoidance of trauma - related stimuli after the trauma, in the following ways: - trauma-related thoughts or feelings - trauma-related reminders

Assessing Depression

Beck Depression Inventory (BDI) Patient Health Questionnaire (PHQ-9) MINI interview-depression module Center for Epidemiologic Studies Depression Scale (CES-D) Structured Clinical Interview for DSM-5 (SCID) PAI MMPI

Interpersonal Therapy (IPT)

Believes that 4 interpersonal problem areas lead to the development of depression - interpersonal loss - interpersonal role dispute - transition - interpersonal deficits Goal of treatment is to recognize deficits and learn skill and assertiveness in order to improve social effectiveness

Causes of PTSD

Biological - abnormal activity of cortisol (stress hormone) and norepinephrine (neurotransmitter) - dysfunctional hippocampus and amygdala Personality plays a part especially if the person is already anxious

Intereoceptive Exposure

Change the way the patient thinks: - catastrophizing - jumping to conclusions - evidence based thinking

Treatment: Psychological Approaches

Cognitive - Behavioral Treatment (CBT) ~ Assessment and Self-monitoring (thought log) ~ Relaxation Training (breathing, muscle relaxation, meditation) ~ Cognitive restructuring (thought log) ~ Exposure (imaginal and/or In Vivo) ~ Skills training (assertiveness, social skills)

Treatments PTSD

Cognitive Processing Therapy (CPT)/Trauma Focused CBT (TF-CBT) Prolonged Exposure Eye Movement Desensitization and Processing (EMDR)

Comparing Treatments

Cognitive, CBT, Interpersonal, and Medications are also highly effective in treating depression Medications can reduce depressive symptoms quicker than cognitive and interpersonal therapies, but both were matched in effectiveness by the final 4 weeks of treatment Recent studies suggest that cognitive and CBT may be more effective than medication at preventing recurrence of depression Long-term therapies (psychodynamic) are less effective than other treatments studies have found that a combination of psychotherapy (cognitive, CBT, or interpersonal) and medication is more helpful to treat depression that either treatment alone

Dissociative Disorders

Depersonalization Derealization

Mood Episodes

Extremes in normal mood- mood episodes - nature of depression (depressive episode) - nature of mania and hypomania (manic/hypomanic episode)

Manic Episode (Criterion A)

Distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary

Psychological Contributions to Anxiety and Panic

Distorted thoughts

Biological Aspect of Anxiety Disorders

Genetic tendency to be tense/anxious, or to panic - low levels of GABA and serotonin - genetic vulnerabilities of anxiety and panic - stress and life circumstances activate the underlying vulnerability

Question 5: What was the name of the patient in the casebook?

Gina

Other Anxiety Disorders

Illness Anxiety (Hypochondriasis) Hoarding Trichotillomania Excoriation (skin-picking) disorder body dysmorphic disorder

Treatment Panic Disorders (CBT)

Interoceptive Exposure (listening to tapes about panic situations)

Social Support

Lack of social support

Assessing PTSD

MINI Interview - PTSD module Post-traumatic checklist-5 (PCL5) Clinician Administered PTSD Scale for DSM-5 (CAPS)

Medication - Depression (3rd option)

Monoamine Oxidase Inhibitors (MAOIS) examples: - nardil - marplan - was discovered accidentally, as it made patients with tuberculosis happier - eating cheese, bananas, certain wines and other foods can be dangerous while taking MAOIs

Prevalence of Agoraphobia

More common in men average age of onset: 23-34 years More common in women, Why? - more acceptable for men to "tough it out" - more men may be more likely to self-medicate with substances than avoid situations Comorbidity - 83% of people with Panic disorder have at least one comorbid disorder - which ones? GAD, social phobia, depression, substance use disorders

Dissociative Identity disorder

Multiple personalities, identities or "alters" at least 2 distinct identities with own pattern take control of person's behavior unable to recall important information

PTSD Criterion D (two required)

Negative thoughts or feelings that began or worsened after the trauma: - inability to recall key feature of the trauma - overly negative thoughts and assumptions about oneself or the world - exaggerated blame of self or others for causing trauma - negative affect - decreased interest in activities - feeling isolated - difficulty experiencing positive affect

Obsessive-Compulsive Disorder (OCD)

Obsessions: recurrent and persistent thoughts, urges, or images that are unwanted and intrusive and cause anxiety or distress Compulsions: repetitive behaviors (handwashing, ordering, checking) or mental acts (praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession - aimed at preventing or reducing anxiety Obsessions and/or compulsions are time-consuming

Electroconvulsive Therapy (ECT)

Patient is sedated and electrodes are put on person's head, which send electrical currents through the brain causing a seizure - has been demonstrated to decrease depression - usually saved as a last resort for people who have severe depression - more than 1 treatment required - can cause memory issues

PTSD Criterion A (one required)

Person is exposed to death, actual or threatened serious injury or actual or threatened sexual violence, in the following way(s): - direct exposure - witnessing trauma - learning that a relative or close friend was exposed to a trauma - indirect exposure to aversive details of the trauma, usually in the course of professional duty (1st responders, medics)

People with ____________ are afraid of being in public places or situations where escape might be difficult or help unavailable, should they experience a panic attack

Post traumatic stress disorder

Mood Episodes and Mood Disorders

Presence of 1 or more Mood Episodes determine which Mood Disorders - depressed episode - manic episode - hypomanic episode

Acceptance and Commitment Therapy

Rather than trying to change the thoughts, just accept it as a thought diffuse from the thoughts

Major Depressive Disorder (MDD): An Overview

Requires presence of major depressive episode No history of manic, hypomanic, or mixed episodes single episode- highly unusual recurrent episode- more common

Medication - Depression (2nd medication option)

SNRIS (Selective Norepinephrine Reuptake Inhibitors) - increased norepinephrine activity examples: - strattera - cymbalta - effexor (also block serotonin)

Medication - Depression (what type and examples)

SSRIs (Selective Serotonin Reuptake Inhibitor) - 2nd generation antidepressant drugs that increase serotonin activity examples: - prozac - zoloft - lexapro

Autonomic Nervous System Sympathetic NS vs. Parasympathetic NS

Sympathetic - fight or flight Parasympathetic- rest and digest

Cognitive Triangle Conceptualization

Thoughts: "I'm going to look dumb in front of the class" / \ Feelings: "I feel -------- Behaviors: "I want/ will anxious" avoid class"

Ketamine

Tranquilizer been shown to have a very rapid decrease in depression (special K)

PTSD Criterion B (one required)

Trauma is persistently re-experienced, in the following ways: - intrusive thoughts - flashbacks - emotional distress after exposure to traumatic reminders - physical reactivity after exposure to traumatic reminder

PTSD Criterion E (2 required)

Trauma-related arousal and reactivity that began or worsened after the trauma - irritability or aggression - risky or destructive behavior - hypervigilance - heighted startle reaction - difficulty concentrating - difficulty sleeping

Medication- Depression (4th option)

Tricylics examples: - tofranil - also discovered on accident, was initially used on people who had schizophrenia Side Effects: - lightheadedness - blurred vision - constipation - dry mouth

Causes Biological (DID)

Twins studies do not support genetic vulnerability to DID

Panic Attack

abrupt, sudden intense fear/discomfort, physical symptoms

Xanax, Ativan, and Valium are types of what medication?

anti-anxiety medication, Benzodiazepine

__________ are periodic, short bouts of panic that occur suddenly reach a peak within minutes, and gradually pass

anxiety attack

Question 1: People with ____________ have a full manic episode and major depressive episode

bipolar one

____________ are repetitive and rigid behaviors or mental acts that people perform in order to prevent or reduce anxiety

compulsions/obsessions

Question 4: Some people have numerous periods of hypomanic and mild depressive symptoms, which is consistent with a diagnosis of __________________.

cyclothymic disorder

Rerouting thinking

event: Pain in chest + thought: sign of heart attack = panic attack event: pain in chest + thought: sign of indigestion = calm

Treatment OCD (CBT)

exposure (obsessions) and response prevention (compulsions)

Treatment GAD (CBT)

exposure to anxiety-provoking thoughts/ images, learn alternative coping, handle the unexpected

Treatment Social Phobia (CBT)

exposure to performance, social situations, evaluation; also social skills, assertiveness if needed

Treatment Specific Phobias (CBT)

exposure, coping strategies for the anxiety

Depersonalization

feeling detached from oneself or one's body

Derealization

feelings of unreality- outside change shape or size, people seem mechanical

Question 2: According to DSM-5, an "over-blown self esteem" is also called what?

grandioscity

Depersonalization- Derealization Disorder

having episodes of depersonalization and/or derealization

Behaviors that facilitate depression

learned helplessness Lack of social support

Question 3: ______________ was one of the first and most common medications for bipolar disorders

lithium

Mixed episodes

mixed features - individual experiences both elation and depression/anxiety at the same time - meet criteria for both depressive and manic episode (except duration) important to determine the course or temporal pattern of the disorder

People with ________ have severe, persistent, and irrational anxiety about social or performance situations

social anxiety