abnormal exam 2

cog model

"I feel dizzy → I think I am going to faint → I am losing control → I can't breathe → I am going to die"

AS CBT cogntive restructuring

"change your thoughts" panic attacks are dangerous; my heart is racing; something is wrong! im going to die --> what im feeling is a normal sensation)

Generalized Anxiety Disorder

(GAD) Generalized anxiety disorder worry= key characteristic 1)Worry is the key characteristic of GAD. Individuals with GAD spend a lot of their time preoccupied by thoughts of negative and catastrophic outcomes. The worry must be present almost every day for a period of 6 months and it must be difficult to control. 1)Many individuals with GAD believe that by worrying, they can keep negative events from occurring. Sometimes being able to anticipate negative events does prevent them from occurring (for example, the last time I went camping, I worried that I might get blisters, so I brought moleskin to apply to my feet..); however, in the case of GAD, that belief becomes excessive or impairing. (for example, if I worry that my brother will get into a car crash; so I worry about him getting into a car accident all day and he doesn't get into an accident; If I didn't worry, who knows what will happen?) 1)People who have GAD are caught in conflict between two beliefs: I'm miserable because I worry all the time about potential negative outcomes, but I need to worry otherwise those outcomes will actually happen and I'll be miserable. 4) Another way that this worry can lead to negative outcomes is that sometimes people with GAD attempt to prevent negative outcomes by avoiding any risky situations. For example, they may be worried that they will drown, and so despite being able to swim, they may avoid water at all costs. Their anxious anticipation of negative things can lead them to avoid less risky situations as well as risky ones. Anxious anticipation Anxious avoidant Physical tension 5) To meet criteria for a GAD diagnosis, a person must also experience at least three symptoms that are characteristic of tension in the body: restlessness, easily fatigued, muscle tension, sleep difficulties, etc..

anxiety vs phobia examples

- Is feeling queasy while climbing a tall ladder an anxiety or a phobia? It's anxiety, because you are still climbing the ladder so you're not distressed or impaired enough to avoid it. Refusing to attend your best friend's wedding because it's on the 25th floor of a hotel That's a phobia. Your fear of heights is impairing your ability to attend fun events. Worrying about taking off in an airplane during a lightning storm It's anxiety. It's reasonable to be a little nervous about traveling during a storm. Turning down a big promotion because it involves air travel Phobia, you're impaired at your job because of your fear of flying

impact of panic disorder

- chornic course and early onset leads to potentially devasting for continued development - agoraphobia "fear of the marketplace" fear places where they might hvae trouble eascaping or getting help if they become anxious or have a panic attack the most poeple avoid public spaces, the worse the fear of the public spaces gets --- People with panic disorder avoid situations and places that might make them nervous or that would be a terrible place to have a panic attack (driving a car). Associated with panic disorder Avoid situations in which escape is difficult or help not available Avoidance is the hallmark symptom of anxiety disorders Avoidance is the hallmark symptom of anxiety disorders (afraid of spiders-avoid them, afraid of public speaking-avoid it, in terms of panic attacks-afraid of panic attacks avoid places in which they may occur-escape is difficult or help is not available)

PD neuroimaging studies

- differences in limbic system neuro-imaging studies show differences between people with panic disorder and those wtihout it in several areas of the limbic system, includes the hypothalamus poeple with PD have overactive norepinephrine/adrenaline

specfic phobias key features

- fear that is excesssive or unreasoanble, cued by the presence of a specific object or situation - immediate anxiety response, may even panic attack - person recognizes fear is excessive or unreasobale (absent in kidds) - obejct or situation is avoided or endured with intense anxiety and distress

PD diagnostic criteria

- not a "clinical disorder" - recurrent unexpected panic attacks ---these are out of the blue attacks - A person with panic disorder will develop concern about future attacks, they will worry that these attacks mean something serious (losing control, having a heart attack, "going crazy") - and they may change behavior due to the attacks (could be avoiding driving on the interstate, not going out of the house alone, avoiding grocery stores or other places that an attack could occur, only going places with a specific person, making sure they are always near an exit, etc.) - These criteria are essentially determining that there is a significant impact in the individuals life --- Panic disorder is the body's alarm going off all the time. A person with panic disorder is constantly trying to figure out what's wrong with the body. Most folks go to the emergency room the first time...

PD cognitive model

- pay close attention to bodily sensations, herat beating fast, face getting hot - misinterpret bodily sensations, tihnk something is wrong with the body because of those physiological symptoms - engage in snowballing/catastropic interpretations because the think something is wrong it make the heart beat even faster, and more facial flushing, now their also sweating and unable to focus on anything but their body

AS biological treatments

- tricyclic antidepressants imipramine tricyclic antidepressants work for decreasing panic attacks but have strong side effects (blurred vision, constipation, weight gain, sexual dysfunction) patients relapse when meds are dicontinued - selective serotonin reuptake inhibitors (SSRIs) prozac, paxil, zoloft, celexa - serotonin norepinephrine reuptake inhibitors (SNRIs) effexor SSRIs and SNRIs are more effective than placebos for treating disorder but side effects include gastrointestinal irritability, insomnia, agitation and sexual dysfunction - benzodiazepines xanax, valium - benzos suppress the central nervous system are often used to treat anxiety. short term relief. prescribed to take when feeling anxious rather than take one every day at the same time may end up functioning as a form of avoidance that actually reinforces fears (e.g. maybe work more to "cover up" the anxiety but general fear may still be there)

4-cateogires of specific phobias

-- Animal type Specific animals or insects Snake phobias are the most common in the US (We are biological predisposed to anxiety about certain things...or fear is learned)...body knows when something is a threat...but in specific phobia these fears become excessive and disproportionate to threat and impairing -- Natural environment type Events or situations in the natural environment Stroms, heights or water -- Situational type Specific situations Another category is situational type: like elevators, flying in an airplane, or enclosed places, public transportation, tunnels, bridges, driving If you have more than one situational fear, you may be diagnosed with agoraphobia rather than a specific phobia, because that makes it seem more like your fear is about being in public and not being able to escape, rather than specific to one situation. -- Blood-injection-injury type (BII-type) Seeing blood or an injury or receiving an injection The last category is Blood injection injury type. People are scared of seeing blood or sustaining an injury, or receiving an injection. When a person with this phobia does see blood or get an injection it often results in them fainting. Different from other types Unlike typical physiological response, involves drop in blood pressure But, when people with BII experience their feared stimulus they have a decrease in blood pressure, so much so that they often faint. This is likely a maladaptive evolutionary response. Ideally, when we start to lose blood our blood pressure does decrease so that the rate at which we lose blood is slowed down. But, a scratch on the knee should not require such an extreme drop in blood pressure. Much more difficult to treat than other phobias BII phobias are much more difficult to treat than other phobias because if you expose someone to a needle and they pass out, they do not get to habituate to the fear because they are unconscious. Instead, applied tension (tensing muscles over and over to increase blood pressure) is used to help these folks get through medical procedures. Runs more strongly in families than other types

OCD Prevalence and course

1-3% lifetime prevalence Chronic course Onset : Age of onset ranges from early adolescence to young adulthood, with earlier onset in males (6-15 years) than in females (20-29 years). NO CLEAR GENDER DIFFERENCE in prevalence 70% report that their OCD caused problems in family relationships (Hollander et al., 1997)

Anxiety prevalence & course

10-11% lifetime prevalence 90% don't seek treatment But, 90% don't seek treatment. Either they don't THINK they are distressed enough by their symptoms to get treatment or they want to avoid treatment because exposure is scary. In general, women are twice as likely as men to have a specific phobia. But, some fears are more even across genders (fear of heights and blood-injection-injury) Onset varies Most during childhood Some during the mid-twenties

GAD prevalence & course

3-5% of general population Highly comorbid with other disorders 2) Highly comorbid with other disorders. Over 50% have an additional anxiety disorder and about 70% of individuals with GAD have a mood disorder. ~33% with comorbid substance use disorder (why might this have high comorbidity with anxiety disorders)?? High comorbidity is because GAD is trait anxiety! Individuals high in trait anxiety are at risk for other anxiety disorders in addition to GAD! 50% onset in childhood or adolescence Course is chronic, but fluctuates Often worse during times of stress Women are at greater risk More women than men have GAD; 5% of women and 3% of men What do people with GAD worry about? Sanderson and barlow People who were diagnosed with GAD were asked what they worry about Family's safety and happiness was #1 Followed by financial stability Work stability And acquiring their own illness

Social anxiety disorder vs just shy

48% of college students classified as "shy" Only 18% had symptoms qualifying them for SAD SAD is different than "being shy"...being shy is a very common personality trait...The person needs to be distressed and impaired by the shyness for it to be a disorder.

SAD OVERALL CBT EFFECTIVENESS:

50-70% respond No added benefit from combined meds and CBT People who complete CBT show improvement at follow-up, while those receiving meds more likely to relapse

Is the amount of fear in proportion to the threat?

A person should experience proportionally more fear to a loose black widow than a caged tarantula.

OCD Biological treatments

Antidepressants that affect serotonin (SSRIs) 50-80% experience decreases in OCD symptoms vs 5% on placebo meds After taking SSRIs, PET scans indicate reductions in the rate of activity in the caudate nucleus & thalamus (that pathway we just talked about) Psychological perspectives Think of the last unwanted thought you had Was yours something you'd prefer not to share with others? 90-100%.... They are actually pretty normal. It is super common for new mothers, under sleep deprivation and stress, to report intrusive thoughts about harming their child, even though they would never do it. People without OCD are able to turn these thoughts "off".

GAD cognitive theories cont.

Avoidance behaviors can also be maintained through negative reinforcement. Let's say you're worried that you will get into a car accident if you drive at night. Maybe, as you go toward your car keys, your worries start to increase. Eventually, the worries and negative feelings get so bad that you give up and decide not to drive. Then the negative feelings get better and the likelihood that you'll avoid driving at night next time increases. The avoidance is negatively reinforced. At the same time, worrying itself can be something that is increased through negative reinforcement. If you worry to prevent something bad from happening, then each time that feared event doesn't occur, your negative feelings of anxiety decrease, and if you think the worry was the reason the event didn't occur (or a reason the event didn't occur) then you'll be more likely to worry in the future.

GAD Biological treatments

Benzodiazepines (i.e., Xanax, Valium) Short term relief Very addictive, many side effects instant These medications do provide short-term relief from anxiety, but once people stop using them their anxiety returns, so they merely treat the symptoms of GAD, not the whole disorder It's also true the these medications are super addictive and have side effects of drowsiness and dizziness; people on benzos can seem really out of it; Overall, these medications are not used for long-term treatment of GAD Tricyclic antidepressants (Tofranil) and SSRIs (Paxil) Paxil reduces anxiety better than benzodiazepines Tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRI) reduce the symptoms of GAD better than a placebo. The SSRI Paxil also reduced anxiety better than benzodiazepines and is safer for long-term use SNRI (Effexor) Serotonin-norepinephrine reuptake inhibitors (like effexor) have also been effective in reducing anxiety and worry in GAD compared to a placebo.

OCD Biological theories

Biological theories of OCD have focused on a circuit in the brain involved in executing primitive patterns of behavior, such as aggression, sexuality, and bodily excretion. This circuit begins in the orbital region of the frontal cortex. Impulses (like the impulse to act violently) are then carried to a part of the basal ganglia called the caudate nucleus The caudate nucleus allows only the strongest impulses to flow through to the thalamus. If these impulses reach the thalamus, the person is motivated to think further about them and possibly act on them. The action might be a set of behaviors appropriate to the impulse. Once these behaviors are executed, the impulse diminishes. People with OCD may have a dysfunction in this circuit that may result in the system's inability to turn off the primitive impulses of the execution of the stereotyped behaviors. (When we feel dirty we have the impulse to wash our hands, then the impulse disappears. When people with OCD feel dirty they have the impulse to wash their hands over and over because the circuit does not shut off at the appropriate time). PET scans in pts with OCD have shown excessive activation in this primitive brain circuit ALSO, ROLE OF GENETICS: Twin studies support substantial genetic components of OCD.

GAD Psychological treatments

Cognitive behavioral therapy (CBT) Cognitive Behavioral Therapy (CBT). In CBT the therapist helps the patient confront the issues they worry about most, challenge their negative, catastrophizing thoughts, and develop coping strategies. Some techniques: Identify and alter negative automatic thoughts ("it's always best to expect the worst") Cognitive restructuring (ex: if I fail my exam that will be the end of the world because I will never get into grad school) Ex. The therapist would ask what is the likelihood 1) that you actually fail, and if you did fail, what is the likelihood that you won't get into grad school because of this one exam?) (what if you didn't get into grad school, what else could you do?) The therapist would Focus on these exaggerated threat appraisals and help the patient re-evaluate their beliefs about worry The therapist helps the patient Tolerate of uncertainty (a fact of life) by asking questions like: "And then what would happen? How would you cope with that?" (peel back the worry layers) "Looking back 10 years from now, will it matter?" "What's another way of looking at that?" The therapist may also ask the patient to Self-monitor worrying so the patient gets an idea of how much time they actually spend worrying each day Based on how long the patient worries and schedule "worry time" Why would worry time be beneficial?? (answer: frees up some time in the day) Self-monitor worrying "Worry time": make goal, set aside time, deep dive into worry Find solutions to worry Relaxation techniques The therapist may also use relaxation techniques to help with the symptoms of physical stress and tension I.e., progressive muscle relaxation, deep breathing PMR is when you tighten and release muscles one by one; deep breathing feels very meditative

PTSD Treatments

Cognitive-behavioral therapy Exposure (include imaginal): uses fear hierarchy of event elements Stress-management Therapists teach client skills for overcoming problems in their lives that may be increasing stress and result from PTSD such as marital or relationship problems and/or social isolation, alcohol use..... Imagery rescripting treatment of traumatic nightmares Write out nightmare with a positive twist Read and imagine for several minutes right because bedtime Deep breathing, relaxation exercises Drug treatments SSRIs Similar to GAD, other anxiety disorders Many relapse after discontinuation

OCD Behavioral theories

Compulsions develop through operant conditioning Compulsions are negatively reinforced Wash hands and anxiety is gone Compulsions decrease anxiety in the short-term Cognitive-behavioral treatment Exposure & response prevention (EXRP) Exposure to content of obsessions ...& forced to experience the anxiety that comes along with those obsessions Prevent of compulsive response 60 to 90% effective How does it work? Habituation to anxiety (without doing compulsion) Disprove feared result EXRP vs Medication (SSRIs) Foe et al. (2005) compared EXRP, clomipramine and combination treatment (EXRP+clomipramine) in double-blind trial 12 weeks: all treatment better than placebo No differences between EXRP and Combination Treatments EXRP and Combination Treatment were superior to clomipramine alone

What are the anxiety disorders?

DSM-IV-TR - Generalized anxiety disorder - Panic disorder - Specific phobias - Social anxiety disorder - Obsessive compulsive disorder Obsessive Compulsive Disorder has joined a new category of "Obsessive Compulsive and Related disorders" (which includes things like: BDD, Hoarding, skin picking and trichotillomania) - Post traumatic stress disorder Another change is that Post traumatic stress disorder and the related, acute stress disorder, have joined a new category of "Trauma and Stress Related Disorders" (which include others like adjustment disorder and reactive attachment disorder) - Acute stress disorder

Comorbidity with OCD

Depression Almost 80% of OCD patients display depression symptoms. Approximately 30% of OCD patients meet full criteria for major depression. Other anxiety disorders 30% - specific phobia; 20% social anxiety disorder, and 15% panic disorder. Sleep disturbance Roughly 40% of OCD patients report disturbances in sleep. Eating disorders 10% of women with OCD have a history of anorexia nervosa (Kasvikis et al, 1986), and over 33% of patients with bulimia have a history of OCD (Hudson et al, 1987). Tourette syndrome and motor tics 25-50% of those with tourette have OCD Among OCD patients, 20-30% report a current or past tic disorder (Pauls, 1989). The prevalence of OCD among patients meeting for Tourette's is quite high (36 to 52%; Leckman et al, 1990), the converse is not true. Namely, only a small percentage of OCD patients (5 to 7%) meet for Tourette's.

Acute Stress Disorder

Diagnostic criteria nearly identical to PTSD Symptoms last <4 weeks A person may come to a clinic and be diagnosed with ASD because it hasn't been a month since the trauma happened Sometimes ASD clears up on its own, other progress into full blown PTSD Dissociative symptoms Derealization: alternation in the perception or experience of the external world so that it seems strange or unreal Depersonalization: an alteration in the perception or experience of the self so that one feels detached from, and as if one is an outside observer of, one's mental processes or body (e.g., like one is in a dream)

OCD Examples: obsession

Dirt and contamination Aggressive impulses Impulse to hurt someone; constant thought of hurting something even though they don't want to Secual thoguths These are not pleasant sexual thoguhts; having sex with your mother or father Immoral behavior Shouting foul language in church or school Doubting Thoughts that you forgot to do something Locking the door, turning off the stove *people with obsessions are BOTHERED by having these thoughts.. Don't carry them out.

Does the concern persist in the absence of the threat?

Does the person think about spiders even when they are nowhere to be seen?

anxiety behavioral theories

Evolutionary Evolutionary theory suggest that Humans are prepared through evolutionary history to develop phobias to objects or situations that are ancestrally dangerous Prepared classical conditioning Thus, according to prepared classical conditioning, a person would be more prone to be afraid of snakes/spiders than small fish Classical conditioning Classical Conditioning can lead to fear of object when it is paired with a naturally frightening event. John B watson Demonstrated how phobias could be conditions "Little albert" experiment Watson demonstrated how phobias could be conditioned into a person. He used a toddler who he called "little Albert". Little Albert loved to play with a cute white rat but after a few times that exposure to the rate was paired with the ringing of a loud, startling bell, little Albert began to fear the rat. His fear of the rat was conditioned into him. His fear also generalized to other white furry objects, like a bunny rabbit. Avoidance ---> decreased theories Operant conditioning 1)In all anxiety disorders, avoiding the feared object or situations leads to decreased anxiety. This means that the act of avoidance is negatively reinforced. A punishing feeling (anxiety) is taken away (negative reinforcement) because of acting to avoid a situation or object. 1)This is very much in-line with operant conditioning. Remember, rewards and punishments shape behavior during operant conditioning. 3) Example: Say I have a fear of speaking in public...if I am faced with having to do that so I get VERY anxious. The best way to immediately decrease my anxiety is to avoid public speaking!! But, this doesn't get rid of my fear...in fact, it keeps it going...I'm still going to be afraid every time I am in this situation. biological/psychological vulnerabilities + experience (trauma, observation, information) ----> specific phobia 2) Phobias do run in families... there is a biological/genetic component. Some people have a temperament characterized by chronic low-level anxiety which makes them more susceptible to developing phobias given even mildly aversive experiences. 3&4) So it takes both a vulnerability to fear plus some experience with the situation or object to result in a specific phobia.

Cognitive theory of SAD

Exaggerated likelihood of negative evaluation Exaggerated costs of negative evaluation Safety behaviors Over-prepare for speech Robotic and memorized Avoid eye contact Alcohol use Attentional biases Self-focused attention 5) People with SAD have a self-focused attentional bias, meaning that they only focus on how they are feeling during a social interaction. This is weird considering they are so scared of what the other person thinks of them, but they are only focusing on how they are feeling. (oh now my cheeks are red, now I can't find the right word, I'm so stupid, this story I'm telling must be so boring)

Worry in GAD

Excessive 2) Worry must be excessive in terms of content of worry... (example: student who is worried about a test for the whole week before the test won't meet GAD criteria if that is the only thing they are worried about....if this student is also worried about getting in a plane crash, getting some rare disease, finances even though is financially stable...then may be more likely to meet criteria).... But also must be excessive in the amount of time spent worrying...several hours a day!! Not just in passing....

Behavioral exposure therapy

Exposure therapies are often used to treat phobias 1)Exposure therapies are often used to treat phobias. Just like in panic disorder the patient is exposed to their feared physiological sensations. In specific phobias, patients are exposed to their feared objects or situations. Systematic desensitization: Client is gradually exposed to the stimuli The client is gradually exposed to increasingly fear provoking situations. In this picture the girl first looks at a picture of a spider. This red area is how scared she is. Her fear declines over time, then she moves on to the next exposure. Then holds the picture closer, then plays with a toy spider, etc. Exposure therapy Exposure therapies are often used to treat phobias Systematic desentization: client is gradually exposed to the stimuli Modeling: therapist models behaviors most feared by clients before asking them to engage 1)Modeling is often used with systematic desensitization...Based on theories of observational learning/modeling. Flooding: saturated with fear-provoking stimuli until anxiety is extinguished 2) Flooding (start with the most intense situation) is as effective as systematic desensitization, but works more quickly, but it is used a lot less! Why? Clients drop out of treatment or never begin.

PTSD Key features

Exposure to an event involving actual or threatened death, serious injury or threat to physical integrity of self or others The person must have been exposed.... The person used to have to react in horror, now that's not the case. It could also be something that happened to someone you know. Or it could be a first responder who is repeatedly exposed to traumatic situations like collecting body parts. (Dexter) Presence of three types of symptoms Re-experiencing of the traumatic event Emotional numbing Hypervigilance Persistence of these symptoms for more than one month Symptoms must be present for more than one month to get the diagnosis, because naturally we all react with some negativity to traumatic events. PTSD represents a chronic negative reaction. Re Experiencing the trauma: Intrusive images, thoughts or perceptions Distressing dreams Feeling as if the traumatic event were recurring Dissociative reactions like feeling as if the trauma were happening again (e.g. flashbacks) Distress at exposure to cues that resemble event 1)Feeling uneasy if something cues a memory of the event (a war veteran may become very anxious if he hears a car engine kind of backfire, like a gun sound) Physiological reactivity Like the symptoms of panic disorder Avoidance and emotional numbing: Avoid trauma-related thoughts, feelings or conversations Avoid activities, people or places Inability to recall important aspects of trauma Diminished interest or participation in activities Detachment or estrangement from others Restricted range of affect Sense of shortened future Sense of something inevitably going to happen again and shorten the person's life Increased arousal: Difficulty falling or staying asleep Irritability or outburst of anger Difficulty concentrating Hypervigilance Exaggerated startle response Patient with PTSD, walked up to her at the clinic, jumped when heard noise of someone behind her

GAD Biological theories

GABA theory 1)One biological theory involves the neurotransmitter GABA. GABA is an inhibitory neurotransmitter. When GABA binds to a receptor it prevents the neuron from firing. Individuals with GAD have deficiency in GABA Limbic system Genetic theory Biological vulnerability to GAD is inherited General trait anxiety may play a role

Types of SAD

Generalized Generalized type is where people fear most social situations (going to class, going to a party, going on a date, eating in front of someone). Interestingly, men are more likely to present for treatment than women. WHY? (dating) Fears related to most social situations Men more likely to present for treatment Performance (public speaking) The other type of SAD is public speaking. It gets its own type because even people who are not generally afraid of social situations can be very impaired when asked to address an audience. Public speaking SAD is kind of like a specific phobia. Fears related to performance situations Most common onn-clinical fear

Avoidance in behavioral theory

Hallmark of anxiety avoidance= negative reinforcement 2) Avoiding situations is common because in the short term, this decreases anxiety (negative reinforcement)...but anxiety will still be there every time faced with an event. 3) Let's go back to the public speaking example. If a person is about to get on stage and give a speech, their anxiety rises over time. 4) Right at the point they are about to give that speech they bail and decide to not get on stage (i.e. avoidance/safety behavior) 5) Because they think their anxiety is going to continue to climb once they get on stage. But, in reality... 6) You can't be on high alert forever... Eventually your anxiety will start to decline if you sit with it long enough and refrain from using safe behavior. ...exposure works by having individual habituation to feared stimulus. When avoidance or safety behaviors are used, they reduce anxiety in the present. However, they reinforce the belief that there was something dangerous that needed to be avoided and actually make anxiety worse over time. They never got to experience the habituation because they used avoidance instead.

are concerns realistic given the circumstances?

If you have had to go to the hospital before because you were bitten by a black widow spider, then if you react with intense fear the next time a black widow is crawling toward you, that fear seems justifiable. It's a realistic fear because you know the spider is dangerous and it's on the loose near you. However, if your friend has a tarantula as a pet; it's in an aquarium, and you know that your friend has never been bitten by the tarantula, that spider is not a realistic threat to you.

SAD Examples of common exposures

Initiating conversations Asking for a data Public speaking Writing in front of others Eating or drinking in front of others Working or playing while being observed Assertion and interaction with authority figures Job interview Joining ongoing conversations Making mistakes in front of others Expressing opinions Revealing personal information

AS CBT outcome data

Interoceptive exposure techniques are better than pharmacological treatments meta-analytic techniques (combines results from lots of studies Interestingly, the combination of CBT and meds, which you think would be super extra effective, may actually decrease success of treatment. Why?? meds for treatment of panic disorder (e.g., xanax) may actually decrease the ability for someone to experience symptoms of anxiety and in turn limit the effectiveness of exposure exercises.

OCD Prevalence & course

Lifetime prevalence in U.S. -7% More common in women 2) PTSD is more common in women. Women and men experience different types of trauma (sexual and molestation vs. fights, combat), women still have more chances of dev. Ptsd and sxs persist more than men. Women get PTSD in less intense trauma. Women are over twice as likely as men to have suffered from PTSD (10.4% vs 5.0%). This is true even when exposed to similar trauma. Men are more likely to have comorbid substance use than women. Often persistent and chronic The trauma in this instance is that someone witnessed a trauma (e.g. like witnessed someone get shot on the street). Men are more likely than women to witness trauma (probably because of military duty). However, despite the fact that men are more likely to witness trauma happen to someone else, about the same percentage of women and men have PTSD due to witnessing harm come to someone else. You would expect men to have a higher percentage than women, but they don't. Point out threat/weapon; molestation; combat; rape!)

SAD key features

Marked and persistent fear of being humiliated or embarrassed in social or performance situations Exposure invariably provokes anxiety, sometimes situationally bound panic attack Recognition that fear is excessive or unreasonable (except in kids) Feared situations are avoided or endured with intense anxiety/distress

GAD Differ from "normal"

Most people worry about something at some point during the day People with GAD worry over 5 times longer each day

OCD key features

Obsessions and/or compulsions Recognized at some point as excessive or unreasonable (does not apply to children) Distress, time consuming (>1 hour/day)&/or impairment The obsessions or compulsions must be distressing to the individual and they must take up at least an hour of time each day. They are typically very impairing to a person's ability to work, go to school, keep friends, take care of household responsibilities, etc.

OCD Examples: compulsions

Often the link between obsessions & compulsions is magical thinking Example Magical Thinking: Believe that repeating a behavior a certain action a number of times will ward off danger to themselves.... Behavior becomes very ritualistic and they often develop obsessions about not performing these stereotypes or rituals correctly Sometimes there is no discernible link No Clear Link: Someone may have obsessions about their child dying and have compulsions to step over cracks in the sidewalk to make sure this doesn't happen (not clear link)...versus having obsessions/fear of contamination which leads to hand-washing compulsions Common compulsions: Cleaning Lokcing doors Washing hands Turning off lights Counting, things a certain time, counting to a certain number

Post-Traumatic Stress Disorder (PTSD) and Acute Stress Disorder

PTSD & Acute Stress Disorder Consequences of experiencing stressors Stressor can be wide range of traumatic experiences (e.g., terrorist attack to car accident) Result from experiencing an extreme stressor or multiple stressors The stressor can be a wide range of traumatic experiences Victim one time of sexual violence, repeated physical violent assaults from a significant other, car accident, war

GAD Cognitive theories

People with GAD think about threat constantly (Beck) Over-predict likelihood and cost of aversive outcomes 1)Over-predict the likelihood of something bad happening: Think there is a 90% chance that they will develop some rare disease, or that they may get in a car accident; and they exaggerate how terrible the outcome will be if it happens (if I lose my job I will be living on the street) Under-predict their ability to cope with outcomes 3) Under-predict ability to cope: Think that if they had disease they would be depressed or would not be able to handle it... Catastrophizing! In one study, GAD participants but not control participants significantly endorse the item... "Worrying about most things I worry about is a way to distract myself from worrying about even more emotional things" (Borkovec & Roemer, 1995) Worry actually prevents them from habituating (or getting used) to negative emotions and keeps them from considering ways they may cope with negative events. GAD maintained through cognitive and behavioral avoidance We've touched on this a bit but often people who have GAD think worry is adaptive because it prevents bad things from happening. Constat, low-level worry helps people to avoid sudden sharp increases in negative emotions One theory of GAD is that the constant low-level state of worry about avoidable catastrophes actually helps them cope with unavoidable catastrophes attended by sharp increases in negative emotions Serves as negative reinforcement for worry What's happening here is negative reinforcement. The person with GAD worries to avoid outcomes and negative feelings (takes away a punishment), and because it does that, the idea that worry is a good thing is reinforced (made more likely to happen).

Explanations of PTSD Vulnerability psychological factors

Personal assumptions (shattered) assumptions about the world and ourselves that help us feel good. Can be shattered by the experience of trauma. Personal invulnerability Personal invulnerability: bad things happen to other people but I am relatively invulnerable to trauma (e.g., car accidents, natural disasters, etc.). But when these things do happen people lose this illusion - chronically feeling vulnerable à may become hypervigilant for signs of new traumas and show signs of chronic anxiety. Just world belief (things happen for a good reason) 4) The world is meaningful and just and that things happen for a good reason: shattered by events that seem senseless, unjust, or perhaps evil (e.g., a terrorist bombing of a day-care or school shootings) "Bad things don't happen to good people" belief 5) People who are good and play by the rules do not experience bad things: trauma victims often say that they have lived good lives, have been good people, and thus cant understand how the trauma happened to them. Preexisting distress (anxiety, depression) Preexisting Distress: Already experiencing increased anxiety &/or depression symptoms before the trauma à more likely to develop PTSD than those who are not. (e.g., hurricane andrew study: kids already anxious before hurricane had greater levels of PTSD after hurricane, similar results for veterans) Coping styles People who use Coping styles such as avoidance or using substances, or social isolation are more likely to develop PTSD

PTSD biological factors

Physiological hyperreactivity Amygdala hyperactivity PET scans show that the amygdala appears to respond more actively to emotional stimuli in those with PTSD. Hippocampus shrinkage Some studies also show shrinkage of hippocampus brain matter among PTSD patients, possibly due to overexposure to neurotransmitters and hormones released in the stress response. The hippocampus functions in memory, so damage to it may result in some of the memory problems reported by PTSD patients. It also helps regulate the fear response. Thus, damage to the hippocampus may interfere with returning the fear response to a normal level after the threat has passed. They are constantly in fight or flight response rather than rest and digest. "Fight or flight" response Genetics Risk for PTSD also appears to be genetic to a certain extent. One study of about 4,000 twins who served in the Vietnam War found that if one developed PTSD, the other was much more likely to also develop PTSD if the twins were identical, rather than fraternal.

SAD Prevalence and course

Prevalence One of the most prevalent disorders Lifetime prevalence of generalized = 7-13.3% Women are at greater risk than men Course For >50% of patients, social anxiety disorder is chronic with onset prior to adolescence The implications of this are that those people may hate school (a social environment, obtain less education, be underemployed, and have fewer friends than they could have otherwise had)

OCD Obsessions

Recurrent & persistent thoughts, images or impulses that are experienced as intrusive, inappropriate or cause anxiety/distress Not simply excessive worries about real-life problems Attempts to ignore, suppress or neutralize with some other thought or action 3) With OCD, there must be some attempt to get rid of these intrusive thoughts; either by thinking a certain thing or doing a certain thing Recognized as a product of his or her own mind (not thought insertion) 4) Obsession must be...... Thought insertion is often a symptom of a psychotic disorder where the person literally believes that someone outside himself is putting thoughts into his mind...OCD is different in that the person understands that these are just thoughts that are coming up in their own head

Operant conditioning

Reinforcement: anything that increases the likelihood that a behavior will occur Punishment: anything that decreases the likelihood that a behavior will occur Positive: adding something Negative: removing something Negative reinforcement applies to a lot of anxiety disorders. It's the basis of avoidance.To help understand this, let's take a brief refresher on operant conditioning. In operant conditioning we have reinforcements and punishments. A reinforcement is anything that increases the likelihood that a behavior will occur. A punishment is anything that decreases the likelihood that a behavior will occur. Now, both reinforcement and punishment can be added or taken away. Positive reinforcement or punishment is when you ADD something Negative reinforcement or punishment is when you TAKE AWAY something. Negative reinforcement Something is taken away and it increases likelihood a behavior will occur A negatively reinforced behavior is one that is reinforced Putting a coat on is an example of a behavior that is often negatively reinforced If you feel cold and you put on a coat, then the aversive feeling of being cold goes away and the likelihood that you'll put a coat on the next time you feel cold is increased

OCD Compulsions

Repetitive behavior or mental acts performed in response to obsession, or according to rules that must be rigidly applied 1.Compulsions are repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person performs in response to obsession, or according to rules that must be rigidly applied. Aimed at preventing or reducing distress or preventing some dreaded event or situation 1.Aimed at preventing or reducing distress or preventing some dreaded event or situation; NEGATIVE REINFORCEMENT (avoidance) BUT not necessarily connected in a realistic way with what they are designed to neutralize/prevent OR clearly excessive.

Distress & impairment

Severe enough to lower quality of life the person's life would be better without the anxiety Chronic and frequent enough to interfere with functioning like holding a job; making and keeping friends Insight examples: Fear of flying "I'm not distressed by it because I don't fly anywhere." But what about that wedding in california you didn't go to because you couldn't fly there? That's impairment!

SAD CBT group therapy

Small groups (-6) treated together with CBT Can be more effective than individual treatment because Observational learning Exposure

SAD

Social anxiety disorder =/- specific phobia Not a fear of a specific thing SAD is not a specific phobia, although fear of public speaking is one situation that a person with SAD may fear. Severely disrupts daily life And it is more impairing than a specific phobia because social situations are much more difficult to avoid than things like snakes or elevators. Highly comorbid with substance use disorders, depression, etc Like most anxiety disorders, SAD is highly comorbid with Substance Use (alcohol at parties) and depression

SOCIAL ANXIETY DISORDER

Social anxiety disorder used to be called social phobia. Note: it is NOT one of the four types of specific phobias...it's its own category of anxiety disorders.

SAD treatments/therapies

Social skills training 1)Some people who have SAD have been avoiding social situations for so long that they don't have some basic social skills (shaking hands, eye contact, smiling, asking polite questions, small-talk topics) Behavioral therapies (exposure) Systematic desensitization Modeling Flooding Cognitive behavioral therapy CBT is the best treatment for SAD. cognitive= cognitive restructuring 1) Remember, cognitive restructuring is when a person's negative automatic thought is identified and challenged. Identifying automatic thoughts Goal to directly challenge thoughts Form of "manualized" therapy = has a manual for clinicians to follow...very systematic/structured Here are some negative automatic thoughts that a person with SAD might have. 1)The therapist would teach the patient to ask themselves questions like "do I know for certain everyone can tell that I'm nervous? What's the evidence that if I show signs of nervousness everyone will think I'm stupid? 1)We all know those people who get down from giving a great talk and say, wow, I was really nervous. But they didn't seem nervous at all! Part of treatment is proving that feeling nervous doesn't always come off as looking nervous.

Explanations of PTSD Vulnerability

Sociocultural factors Severity Duration Proximity Social support Many socio cultural factors contribute to the development of PTSD Severity of trauma: Minor vs. Major car accident Another is the duration of exposure to the trauma, or the frequency with which it happens. Duration: Physical or Sexual abuse one time versus occurring multiple times Proximity: Did the event happen directly to you...were you in the car accident or did you just see it happen? Also maybe your relationship with the person...happens to a close friend or a stranger? A lack of social support has been implicated in the development of PTSD. Those who have more social and emotional support after a trauma are more likely to recover in a healthy way.

PTSD Treatments: Prolonged Exposure

Treatment rationale Avoidance maintains PTSD symptoms Confronting fear cues helps process distressing memories, leads to cognitive change, reduces PTSD symptoms Prolonged exposure Two major treatment components: Imaginal exposure Relive memory repeatedly in session, audio record In-vivo "in life" Confront situations they have been avoiding since the trauma E.g., stay in dark room for 30-45 minutes, listen to repeated gunfire, go to wooded area, drive in parking lot 40-60% improvement rate

OCD Cognitive theories

Why can't individuals with OCD turn "off" thoughts? Depression or general anxiety makes even minor events to invoke thoughts 1)We know from research that depre..... Those who are prone to depression or anxiety may be more likely to have intrusive thoughts, and thus develop OCD. Rigid, moralistic thinking & feelings of responsibility People with OCD may have a tendency toward..... They judge their negative, intrusive thoughts as more unacceptable than most people and become more anxious and guilty about having them. Believe they should be able to control thoughts People with OCD are more likely to endorse the belief that they should be able to control their own thoughts and have trouble accepting that other people also have unwanted thoughts sometimes.

Risk factor research in PTSD

Why is risk factor research important? 60-70 exposed to a traumatic stressor → 8% develop PTSD Risk/vulnerability factors may lead to preventative interventions

adaptive vs maladaptive fears 3 questions

are concerns realistic given the circumstances? is the amount of fear in proportion to the threat? does the convern persist in the absence of the threat?

two systems acitivated in flight or flight

autonomic nervous system (ANS) - sympathetic NS - "fight or flight" primes us to fight or flee the situation; regulates stress response and increased heart rate, activates sweat glands, constricts blood vessels, dilate pupils, inhibits digestion - parasympathetic NS - "rest and digest" regulates activities that occur when the body is at rest; when the percieved danger passes, the parasympathetic NS helps the body return to body processes to normal endorcine system - it promotoes the release of endorphins (epinephrine and norepinephrine) = adrenalin; gets released during fight or flight response and is crucial component (increased hr, metabolic shifts) - promotes the release of cortisol: increases blood sugar (so we have more engergy to fihgt or run awar from daner), also suppresses immune system so energy of body can be used toward other functions

SAD CBT components

behavioral= exposure Systematic, graduated exposure to feared situations Both in-session and in-vivo How does exposure work? Stops reinforcing effects of avoidance Allows practice of skills Provides evidence against dysfunctional thoughts/beliefs Works in 4 ways: 1) Short-Circuits Avoidance 2) Allows practice of behavioral skills 3) Opportunity to test dysfunctional beliefs 4) Habituation of fear

panic attacks (under PD)

can occur in the context of any disorder - discrete period of intense fear - peaks within 10 minutes symptoms - heart papitations - pounding heartbeat - numbness or tingling sensations - chills or hot flashes - sweating - trembling or shaking - sensations of shortessness of breath or smothering - feeling of chking - chest pain and sicomfort - nausea and upset stomach - dizziness, unsteadiness, lightheadedness or faintness - feelings of unreality or being detached from oneself - fear of losing control or going crazy - fear of dying

Adjustment disorder

characterized by depressive symptoms, anxiety symptoms, or antisocial behavior symptoms that arise within 3 months of exposure to a stressor. Can be triggered by a stressor of any severity This stressor can be of any severity but is usually not one that we would consider traumatic (e.g. leaving home for college, starting a new job, getting fired from an old job, having a baby) Something you would have to adjust to The person can have other pre existing disorders if they do not account for symptoms of the adjustment disorder The person.... So the person could have major depressive disorder and then go to college and develop adjustment disorder on top of the MDD. Maybe adjustment disorder for this person would be characterized by symptoms they did not have before college (anxiety and aggression).

PD role of genetics

family members are 3 to 10 times more likely to develop PD is first degree family member has it early investigations support a genetic inheritance of vulnerability factors

normal fear

fear is a natural part of childhood - Many children have short periods of time during which they are extremely frightened of a particular object, animal, or situation...this does not qualify all children for a diagnosis of specific phobia... #1 childhood fear is clowns - Tends to decrease with age specific phobias may be adaptive fears expressed in a maladaptive manner - may be adaptive fears expressed in a maladaptive manner. In the caveman days it was good to be scared of snakes because they might actually kill you. These days, being outrageously scared of encountering a snake is not as reasonable.

anxiety sensitivity (AS)

fear of anxiety-related physical sensations due to the belief that these sensations have harmful somatic, psychological, or social consequcnes -- elevated in those anxiety problems -- AS predicts future occurence of anxiety symptoms and panic attacks in both adolescents and adults -- AS linked to the development of panic disorders

fight or flight

feels of arousal and fear happen because of activation of the brian strucuture called the hypothalamus

why do we get anxious?

fight or flgiht anxiexty is adaptive some anxiety is good and helps us prioritize and get things done

AS interoceptive exposure

if you want someone to feel dizzy, like theyre going to hyperventalilate, you have them breath into a bag if you want them to feel short of breath you do straw breathing, little coffee stirrers if you want their hear to race you make them climb stairs --- use these symptoms to prove that you can expereince these feelings without having a panic attack instead of allowing them to use safety behaviors they recite the mantra that these feelings are normal and they will pass for homework, patients do exposure exercises everyday, gradually working up to the most fear inducing symptoms the more you do them and the less you are to use safety behaviors while doing exposure, the better the treatment will work

Panic disorder prevalence and course

panic attacks have a lifetime prevalence rate of 28% panis disorder has a lifetime prevalence rate between 3-5% two to three times more common in women onset: between late adolescence and mid-30s

AS CBT other components of treatment

relaxation exercises - cant be both relaxed and scared at the same time - progressive muscle relaxation (PMR) after everyone recieved the treatment they were assigned, the relaxation group and the contorl group, neither of them got signifcantly better - the other two groups (CBT or CBT+ relaxation) did get better *relaxation component added nothing to the efectivenss of treatment for Panic relaxation by itself, is not effective treatment for panic

anxiety sensitivity cogntive perspectives

safety behaviors - actions to avoid or reduce anxiety-provoking situations -- slow down breathing, sit down, grab hold of something, distract, drink water during panic attack -- taking a Xanax -- avoidance of situations causing panic maintain fear by: - false attirution of safety it makes people feel like they are safe only because they use those safety behaviors, when in reality, theyd be safe without those safety behaviors - avoidance of discomforting evidence by using safety behaviors, poeple with panic disorder avoid evidence theat tehy woild not actually have a heart attack or go crazy without the use of those safety behaviors, never learn that panic attacks are not dangerous

key features of Generalized anxiety disorder

says she has trait anxiety, worries about parents health and school, sleep, irritable, tension, fatigue; problems at home and at work)

fight or flight response

stressor ---> the sympathetic nervous system stimulates key organs to prepare them for fight or flight. does things like dilated pupils and opens up the lungs, to preare us for detecting and running away from danger. also inhibits the use of organs that are necessary for the flight or flight process, like the stomach and pancreas - the hypothalamus activates the hypothalamic-pituitary-adrenal (HPA) pathway by releasing coritcoptin-release factor. this causes the release of adrenocorticotropic hormone (ACTH), the bodys major stress hormone

fight or flight important response

the hypothalamus activates the sympathetic nervous system, whcih primes the body's organs to react to threat by doing things like dilating pupils and opening up lungs --> hypothalalamus activates the HPA pathway, releases ACTH ---> ACTH causes the release of coritosl and adrenline, leads to changes in internal organs and muscles

maladaptive behavior

the symptoms make your funcitoning owrse in a certain situation

adaptive behavior

the symtpoms help you adapt, or be competent, in a certain situation

AS CBT exposure of some mind

therapists also use exposure= facing a feared situation --> shows that its not so bad, that anxiety will actually decrease the longer you stay in that situation - alters maladaptive fear/anxiety: provides evidence against irrational thoughts habituation to anxiety if someone sits with thier uncomfortable phyiscal sensations rather than allowing them to use their normal safety behaviors, they learn that these sensations are not actually going to harm them --- exposure allows for habituation to anxiety when we start to feel a rush of physical symptoms, those symptoms can only get so bad our bodies do not actually allow our hearts to explode from our chest because it is beating so fast problem is, people with panic disorder begin using safety behaviors before they get the cahnge to let their beating heart slow donw naturally habituation basically means you get used to something -- exposure allows people to habituate to their uncomfortable physical sensations