Anxiety disorders

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Anxiety disorders

  1. 1. Anxiety Disorders
  2. 2. Diagnostic Possibilities For Panic
  3. 3. Diagnostic Possibilities For Panic• Axis I: Panic Disorder With Agoraphobia
  4. 4. Diagnostic Possibilities For Panic• Axis I: Panic Disorder With Agoraphobia
  5. 5. Diagnostic Possibilities For Panic• Axis I: Panic Disorder With Agoraphobia• Axis I: Panic Disorder Without Agoraphobia
  6. 6. Diagnostic Possibilities For Panic• Axis I: Panic Disorder With Agoraphobia• Axis I: Panic Disorder Without Agoraphobia
  7. 7. Diagnostic Possibilities For Panic• Axis I: Panic Disorder With Agoraphobia• Axis I: Panic Disorder Without Agoraphobia• Axis I: Agoraphobia Without Panic Disorder
  8. 8. A “True” Panic Attack Involves 4 Out Of 13 Symptoms:
  9. 9. A “True” Panic Attack Involves 4 Out Of 13 Symptoms:1. Heart Palpitation
  10. 10. A “True” Panic Attack Involves 4 Out Of 13 Symptoms:1. Heart Palpitation2. Hyperventilation
  11. 11. A “True” Panic Attack Involves 4 Out Of 13 Symptoms:1. Heart Palpitation2. Hyperventilation3. Sweating (For no reason)
  12. 12. A “True” Panic Attack Involves 4 Out Of 13 Symptoms:1. Heart Palpitation2. Hyperventilation3. Sweating (For no reason)4. Choking
  13. 13. A “True” Panic Attack Involves 4 Out Of 13 Symptoms:1. Heart Palpitation2. Hyperventilation3. Sweating (For no reason)4. Choking5. Trembling
  14. 14. A “True” Panic Attack Involves 4 Out Of 13 Symptoms:1. Heart Palpitation2. Hyperventilation3. Sweating (For no reason)4. Choking5. Trembling6. Chest Pain
  15. 15. A “True” Panic Attack Involves 4 Out Of 13 Symptoms:1. Heart Palpitation2. Hyperventilation3. Sweating (For no reason)4. Choking5. Trembling6. Chest Pain7. Abdominal Distress
  16. 16. A “True” Panic Attack Involves 4 Out Of 13 Symptoms:1. Heart Palpitation 8. Dizziness2. Hyperventilation3. Sweating (For no reason)4. Choking5. Trembling6. Chest Pain7. Abdominal Distress
  17. 17. A “True” Panic Attack Involves 4 Out Of 13 Symptoms:1. Heart Palpitation 8. Dizziness2. Hyperventilation 9. Fear of Dying (These are now cognitive.3. Sweating (For no reason) Has to be in the moment of the panic attack. They feel like they are losing control of themselves/4. Choking5. Trembling6. Chest Pain7. Abdominal Distress
  18. 18. A “True” Panic Attack Involves 4 Out Of 13 Symptoms:1. Heart Palpitation 8. Dizziness2. Hyperventilation 9. Fear of Dying (These are now cognitive.3. Sweating (For no reason) Has to be in the moment of the panic attack. They feel like they are losing control of themselves/4. Choking 10. Fear Of Losing Control5. Trembling6. Chest Pain7. Abdominal Distress
  19. 19. A “True” Panic Attack Involves 4 Out Of 13 Symptoms:1. Heart Palpitation 8. Dizziness2. Hyperventilation 9. Fear of Dying (These are now cognitive.3. Sweating (For no reason) Has to be in the moment of the panic attack. They feel like they are losing control of themselves/4. Choking 10. Fear Of Losing Control5. Trembling 11. Derealization And/Or Depersonalization (Things don’t feel6. Chest Pain real, feels like a dream. Feeling that is real but doesn’t feel like it’s happening to me. Dissociative experiences.7. Abdominal Distress
  20. 20. A “True” Panic Attack Involves 4 Out Of 13 Symptoms:1. Heart Palpitation 8. Dizziness2. Hyperventilation 9. Fear of Dying (These are now cognitive.3. Sweating (For no reason) Has to be in the moment of the panic attack. They feel like they are losing control of themselves/4. Choking 10. Fear Of Losing Control5. Trembling 11. Derealization And/Or Depersonalization (Things don’t feel6. Chest Pain real, feels like a dream. Feeling that is real but doesn’t feel like it’s happening to me. Dissociative experiences.7. Abdominal Distress 12. Numbness/Tingling
  21. 21. A “True” Panic Attack Involves 4 Out Of 13 Symptoms:1. Heart Palpitation 8. Dizziness2. Hyperventilation 9. Fear of Dying (These are now cognitive.3. Sweating (For no reason) Has to be in the moment of the panic attack. They feel like they are losing control of themselves/4. Choking 10. Fear Of Losing Control5. Trembling 11. Derealization And/Or Depersonalization (Things don’t feel6. Chest Pain real, feels like a dream. Feeling that is real but doesn’t feel like it’s happening to me. Dissociative experiences.7. Abdominal Distress 12. Numbness/Tingling 13. Chills/Hot Flashes
  22. 22. Diagnostic Criteria For Panic Disorder
  23. 23. Diagnostic Criteria For Panic Disorder• Recurrent, Untriggered Panic Attacks – Not Due to Environmental Cues – Not Due To Distressing Thoughts
  24. 24. Diagnostic Criteria For Panic Disorder• Recurrent, Untriggered Panic Attacks – Not Due to Environmental Cues – Not Due To Distressing Thoughts• Panic Attacks Develop Quickly And Peak Within Ten Minutes (Symptoms are on the person quickly. The fact that it is untriggered by sudden sensation, the sudden onset makes them scarier. It only lasts for 10 minutes. Terrifying moment because you don’t know whats going to happen.)
  25. 25. Diagnostic Criteria For Panic Disorder• Recurrent, Untriggered Panic Attacks – Not Due to Environmental Cues – Not Due To Distressing Thoughts• Panic Attacks Develop Quickly And Peak Within Ten Minutes (Symptoms are on the person quickly. The fact that it is untriggered by sudden sensation, the sudden onset makes them scarier. It only lasts for 10 minutes. Terrifying moment because you don’t know whats going to happen.)• After Panic Attack At Least One Month Of – Persistent Concern About Future Panic Attacks (They are worrying that they don’t want to have another panic attack.)
  26. 26. Diagnostic Criteria For Panic Disorder• Recurrent, Untriggered Panic Attacks – Not Due to Environmental Cues – Not Due To Distressing Thoughts• Panic Attacks Develop Quickly And Peak Within Ten Minutes (Symptoms are on the person quickly. The fact that it is untriggered by sudden sensation, the sudden onset makes them scarier. It only lasts for 10 minutes. Terrifying moment because you don’t know whats going to happen.)• After Panic Attack At Least One Month Of – Persistent Concern About Future Panic Attacks (They are worrying that they don’t want to have another panic attack.) Or – Concern About Medical or Psychological Implications (They are concerned about the potential or psychological implications
  27. 27. Diagnostic Criteria For Panic Disorder• Recurrent, Untriggered Panic Attacks – Not Due to Environmental Cues – Not Due To Distressing Thoughts• Panic Attacks Develop Quickly And Peak Within Ten Minutes (Symptoms are on the person quickly. The fact that it is untriggered by sudden sensation, the sudden onset makes them scarier. It only lasts for 10 minutes. Terrifying moment because you don’t know whats going to happen.)• After Panic Attack At Least One Month Of – Persistent Concern About Future Panic Attacks (They are worrying that they don’t want to have another panic attack.) Or – Concern About Medical or Psychological Implications (They are concerned about the potential or psychological implications Or – Avoidance Behavior (Potential Connection to agoraphobia because the person can be They start to select out environments where they had those panic attacks as well as places where it’s easy to escape
  28. 28. Rule Out Medical Conditions
  29. 29. Rule Out Medical Conditions• Refer Patient For Medical Consultation
  30. 30. Rule Out Medical Conditions• Refer Patient For Medical Consultation• Medical Disorders May Mimic Panic D/O – Hypoglycemia (Low Blood Sugar) – Hyperthyroidism (Overactive Thyroid) (People who are super edgy.) – Cardiovascular Disease (Experiencing chest pain, – Respiratory Disease – 75% of people go to a emergency room when they have a panic attack because people think they are having a heart attack.
  31. 31. Rule Out Substance Intoxication/Withdrawal
  32. 32. Rule Out Substance Intoxication/Withdrawal• Illegal Stimulants
  33. 33. Rule Out Substance Intoxication/Withdrawal• Illegal Stimulants -Cocaine, Ecstasy, And Amphetamine Can Trigger Panic Attacks
  34. 34. Rule Out Substance Intoxication/Withdrawal• Illegal Stimulants -Cocaine, Ecstasy, And Amphetamine Can Trigger Panic Attacks• Legal Stimulants
  35. 35. Rule Out Substance Intoxication/Withdrawal• Illegal Stimulants -Cocaine, Ecstasy, And Amphetamine Can Trigger Panic Attacks• Legal Stimulants -Caffeine In Coffee Or Soda
  36. 36. Rule Out Substance Intoxication/Withdrawal• Illegal Stimulants -Cocaine, Ecstasy, And Amphetamine Can Trigger Panic Attacks• Legal Stimulants -Caffeine In Coffee Or SodaSubstance induced anxiety disorder- when see a pattern where they have panic attacks only when they are having the substances ^.
  37. 37. Rule Out Substance Intoxication/Withdrawal• Illegal Stimulants -Cocaine, Ecstasy, And Amphetamine Can Trigger Panic Attacks• Legal Stimulants -Caffeine In Coffee Or SodaSubstance induced anxiety disorder- when see a pattern where they have panic attacks only when they are having the substances ^.
  38. 38. Diagnostic Criteria For Agoraphobia
  39. 39. Diagnostic Criteria For Agoraphobia• Fear Of Situations In Which Escape Would Be Difficult Or Embarrassing, Or Situations Where Rescue Would Be Difficult
  40. 40. Diagnostic Criteria For Agoraphobia• Fear Of Situations In Which Escape Would Be Difficult Or Embarrassing, Or Situations Where Rescue Would Be Difficult• At Least One Of The Following: – Avoids Situation(s) Related To Panic Attack Experiences (They avoid the situation) – Endures Panic Attack-Related Situation(s) With Great Suffering (Person has anxiety or even panic attack in the lecture hall, but they stay because want to do good in class. You are in the situation causing anxiety but you are suffering through) – Requires The Presence Of A Special Person In Panic Attack-Related Situations (Person you know who feel calm with. If they are with you can sit in the lecture hall, go mall, etc. If they are not with you you can’t sit in the lecture hall or go mall, etc. (Person who has agoraphobia has panic attack incidents or high anxiety)
  41. 41. Facts About Panic Disorder and Agoraphobia
  42. 42. Facts About Panic Disorder and Agoraphobia• PANIC DISORDER – 1.5% to 3% Of Adults Meet Diagnostic Criteria – 15% of Adults Will Have At Least One Panic Attack During Their Life – Females Are Diagnosed With Panic Disorder Two times More Often Than Males.
  43. 43. Facts About Panic Disorder and Agoraphobia• PANIC DISORDER • AGORAPHOBIA – 1.5% to 3% Of Adults Meet – 5% Of Adults Meet Diagnostic Diagnostic Criteria Criteria – 15% of Adults Will Have At – “Places Of Confinement” Least One Panic Attack During • Bridges Their Life • Cars – Females Are Diagnosed With • Crowded Places Panic Disorder Two times More – “Safety Cues” Often Than Males. • Safe Person • Meds Or Pill Bottle
  44. 44. Biological Factors• Biological Causation With Secondary Psychological Influences• Lactate Theory (Biochemical) (People have higher level of lactate in their blood – Excessive Lactate (A Chemical Normally Present In the Blood) Causes Panic Attacks – Injection Studies• Norepinephrine (Neurotransmitter) (People who have panic attacks have higher amounts of norepinephrine.) – Excessive Amounts Of This Neurotransmitter Cause Panic Attacks – Injection Studies• GABA (Pertains to all anxiety disorders. The more GABA who never get stressed where most people would get stressed.) (People with panic disorders have low GABA activity.) – Reduced Amounts Of This Inhibitory Neurotransmitter Cause Panic Attacks
  45. 45. Psychological FactorsInitial Somatic Cues Of Anxiety Hypersensitivity Somatic Cues Of Anxiety Anxiety- Producing Cognitions
  46. 46. Treatment Of Panic Disorder And Agoraphobia• Medications – SSRI Antidepressants (Non-addictive. Take it everyday. Benzo- they take as needed, whenever they felt the need. Hopefully every 3-4 days to avoid addiction. • First Line Medication For Long-Term Anxiety Disorders • e.g., Paxil – Benzodiazapines (Very addictive, good for short-term anxieties)(If take 1-3 everyday for 8-9 months. They would need to take more later on to feel the same effect. Your body gets used to it. They would need to detox later though because you can have seizures. • Increase GABA Activity • Immediately Reduce Anxiety • Tolerance/ Addiction Potential • e.g., Valium, Librium, Xanax, Ativan
  47. 47. Treatment Of Panic Disorder And Agoraphobia• Cognitive - Behavioral Therapies – _____________________ • Progressive ___________________ Training – Sequential Tensing And Relaxing Of __________________ • Verbal Cue - Controlled Relaxation Training – “Relax” Paired With ________________________ • Differential Relaxation – Person Learns To ______________________ During Daily Activities • __________________ Breathing – ________________` Breathing Through The Diaphragm – ________________________ 1. Train Diaphragmatic Breathing & ______________ Thoughts(“I Can Do It,” “Calming Down”) 2. (a) Client Engages In _________________ To Bring On Somatic Signs Of __________________ (b) Client Uses Diaphragmatic Breathing & High Efficacy Thoughts To Reduce _______________________
  48. 48. Treatment Of Panic Disorder And Agoraphobia• Cognitive - Behavioral Therapies (Continued) – Exposure (Flooding) – In Vivo vs Imaginal • Intensive vs Graduated • Theory: Maximizing Exposure To Anxiety Cues Will Lead To Anxiety Reduction If Person Remains In The Anxiety-Producing Situation – Panic Control Therapy (David Barlow) Three Elements – Cognitive Restructuring » Reduce Catastrophic Thinking » Emphasize Benign Nature Of Attacks (it’s a scary 10 min. but not going to do damage in the long term) » Increase High Efficacy Statements (“I’m doing it, calm me down, its working”) – Develop Awareness Of Pre-Attack Body Cues (You want them to be aware of the body, increase their body of awareness in a positive way) – >>“Early Warning System” So May Begin Reversing Techniques – Diaphragmatic Breathing • Short-Term, As Effective As Anti-Anxiety Medications (comparing benzodiazapines to panic control therapy the procedures are about equally effective.) • Long-Term, More Effective Than Anti-Anxiety Medications (beyond 6 months show that panic control therapy is actually superior to Benzodiazapines. The more you practice the better you get, the more you take a pill the less affective the pill becomes )
  49. 49. Specific Phobia• Specific Phobia Vs Common Fear (Fear- it can be rational. Phobia must be irrational. The amount of fear is irrational) – Irrational Vs Rational – Dysfunction Vs Lack of Dysfunction (If the fear causes dysfunction in your current life then it’s dysfunction)• Specific Phobia – An Irrational and Persistent Fear Of An Object, Activity, Or Situation That Consistently And Immediately Causes Anxiety (Possibility Of Triggered Panic Attacks) – Current Dysfunction (Has to be dysfunction in their current life) – Avoidance Behavior Or Endures With Great Suffering (Either avoid the situation or suffer through) – Person Is Aware That The Fear Is Excessive (Adults Only) (This symptom is for adults only. They must be aware that their fear is excessive) – Duration Of At Least Six Months
  50. 50. Types of Specific Phobia• Axis I: Specific Phobia, Animal Type (for people who are scared of : – Large Dogs, Snakes, Spiders, Worms• Axis I: Specific Phobia, Natural Environment Type – Ocean, Earthquakes, Tornadoes, Hurricanes• Axis I: Specific Phobia, Blood/Injection/Injury Type – Injections, Amputations, Blood (Self or Others)
  51. 51. Facts About Specific Phobia• Gender Difference – Females 2x, Males x (2:1)• Co-Morbidity – Nearly Two-thirds Of People With Panic Disorder With Agoraphobia Also Have A Specific Phobia (Easily Conditioned, Low GABA Folks)
  52. 52. Biological Factors• Biological Preparedness Theory – Fear (Avoidance) Of Dangerous Situations Is An Evolutionary Advantage – Humans Are Neurologically Wired To Learn Fear Readily Because It Is Adaptive To Avoid Events/Objects That Threaten Our Existence (e.g., Large Animals, Fire) – As A Consequence, We Also Readily Acquire Fear Of Benign Events/Objects• Amygdala (Very involved in memory and emotion) – Structure In The Limbic System – Key Role In Fear Learning – Specific Phobia May Result From Events That Caused Substantial Stimulation of the Amygdala
  53. 53. Psychological Factors• Behavioral Factors – Classical Conditioning • Ivan Pavlov And Salivating (Appetitive Conditioning) – Unconditioned Stimulus (Bell + Meat Powder) -> Unconditioned Response(Dog Salivates) – Conditioned Stimulus (Bell Only) -> Conditioned Response (Dog Salivates) • John Watson And Little Albert (Aversive Conditioning) – Unconditioned Stimulus (Stuffed Animal + Sudden, Loud Noise) -> Unconditioned Response (Anxiety) – Conditioned Stimulus (Stuffed Animal Only) -> Conditioned Response (Anxiety)
  54. 54. Psychological Factors• Cognitive Factors – Cognitions Cause Anxiety – Persons With Specific Phobia • Misinterpret Benign Events • Magnify Mildly Threatening Events
  55. 55. Treatment Of Specific Phobia• Flooding (Exposure) – Classic (Intensive) Flooding • Immediate and Complete Exposure To The Feared Object Or Situation • Person Is Placed In The Feared Situation Or With The Feared Object – Graduated Flooding • Exposure In Graduated Steps • Progressing To Most Aversive Event
  56. 56. Treatment Of Specific Phobia• Cognitive Restructuring – Identify And Modify Anxiety- Producing Cognitions – Client Learns To Rationally Challenge Anxiety-Producing Cognitions As They Occur (“This Is An Exagerration, This Fear Is Not Necessary”) While In The Feared Situation Or Near The Feared Stimulus• Thought Stopping – Therapist Yells “Stop!” When Anxiety-Producing Thoughts Occur – Client Yells “Stop!” When Anxiety-Producing Thoughts Occur (Homework) – Client Learns To Yell “Stop!” in His/Her head
  57. 57. Treatment Of Specific Phobia• Stress Inoculation – Client Makes Positive, Brief Self-Statements While Confronting The Stimulus (e.g., “I Can Cope, I’m Calm,” “I Can do It”)• Systematic Desensitization – Objective: Minimize Anxiety In The Presence Of the Feared Object – Steps • Train Relaxation and Create Hierarchy • Relaxation At Each Level In The Hierarchy
  58. 58. Social Phobia• Marked Fear In Social Situations, Especially Situations Involving Unfamiliar People Or Evaluation• The Social Situation Invariably Provokes Anxiety• The Person Recognizes That The Fear Is Unreasonable (Adults Only)• Current Dysfunction• Duration: At Least 6 Months• Most common social phobia is public speaking. Invariable- It has to be every time. If they are an adult they have to realize that the fear is excessive, irrational, no harm is going to come to them. Has to cause current dysfunction in their life. Duration criteria at least 6 months.
  59. 59. Types Of Social Phobia• Axis I: Social Phobia, Public Speaking Type• Axis I: Social Phobia, Public Eating Type• Axis I: Social Phobia, Public Writing Type• Axis I: Social Phobia, Generalized Type – Anxiety Regarding Multiple Social Situations (e.g., Cocktail Parties, Public Speaking, Public Writing) (Stuttering, stammered, wet their pants. Can happen from people staring or laughing at them)
  60. 60. Social Phobia Facts• Lifetime Prevalence Of Social Phobia – With Severe Symptoms: 3% of Adults – With Nonsevere Symptoms: 8.5-13% of Adults• Social Phobia Is Slightly More Frequent In Females• Almost Everyone Hates Public Speaking• Best way to overcome is to do it again and again. You become a master of the material your speaking about.
  61. 61. Psychological Factors• Classical Conditioning – Aversive Experiences In Social Situations• Criticism-Related Cognitions – Magnify Mild Signs Of Criticism – Perceive Benign Social Cues As Signs Of Criticism.
  62. 62. Treatment of Social Phobia• Medications – SSRI Antidepressants• Cognitive-Behavioral Therapy – Cognitive Restructuring • Helping Person Identify And Modify Cognitions That Cause Social Anxiety – Social Skills Training• Flooding• Systematic Desensitization (Opposite of flooding in terms of anxiety. Looking to have 0 tolerance for anxiety. 15-20 steps. Have a large audience, 25 people.
  63. 63. Generalized Anxiety Disorder (GAD)• Diagnostic Criteria – Excessive Anxiety And Worry On The Majority Of Days For At least 6 months – The Anxiety Involves Varied Aspects Of One’s Life – The Anxiety Or Related Physical Symptoms Cause Distress Or Dysfunction – The Person Has Difficulty Controlling Their Worry – The Anxiety And Worry Are Manifest In At least of 3 of the following 6 sxs • Restlessness • easily fatigue • Difficulty Concentrating • irritability • Muscle Tension • sleep disturbance
  64. 64. GAD Facts• Lifetime Prevalence: 5% of adult Americans• More Common In women• Associated Factors – Hx Of Prior Marriage (e.g., Divorced Or Widowed) – Regional: More Common In The Northeast US – Homemaker – Series Of Negative Life Events
  65. 65. GAD and Children• Incidence – Far Less frequent in children , kids in “here and now”• Content Of Worries – Most Children With GAD Worry unrealistically About Their athletic and scholastic Performance – A Minority Of Children With GAD Worry About How natural disasters Or nuclear war May Affect Them Or Their parents
  66. 66. Comorbidity in GAD• GAD Patients Often Have Other psychiatric disorders• Dysthymic disorder Is The Most Common Comorbid Diagnosis Of GAD Patients
  67. 67. Factors• Biological Factors – Insufficient GABA Activity In GAD Patients • GABA is an inhibitory• Psychological Factors – Anxiety-Producing Thoughts Often Involve Magnification Or Catastrophizing – Cycle Of Dysfunction Interpersonal Event (Wife doesnt look at him) Poor Performance (he doesn’t talk to her) Cognitive Distortion (she hates me) Anxiety/Worry (anxiety of relationship (causes dysfunction not motivation
  68. 68. Treatment Of GAD• Medications – SSRI Antidepressants – Benzodiazapines• Cognitive-Behavioral Therapy – Cognitive Restructuring • Identify And Modify Cognitions That Cause Anxiety/Worry • Recognize Anxiety-Producing Cognitions (Magnifications, Catastrophizing), And Replaces Them With Cognitions That Reduce Anxiety And Improve Functioning – Relaxation Training (Can benefit from Diaphragmatic Breathing, Progressive Muscle Relaxation) • Increases Efficacy for Anxiety Control
  69. 69. Obsessive-Compulsive Disorder• Obsessions – Persistent Thoughts, Impulses, Or Images • Produce Significant Anxiety • Experienced By The Individual As Intrusive and Inappropriate – The Obsession Is Not Simply Excessive Worry About Real Problems – Person Attempts To Ignore or Replace The Obsessive Thoughts With Another Thought or Action – Person Realizes That The Obsessive Thinking Arises From His/Her Own Disturbed Thought Processes(tend to be realty based. not psychotic like aliens are taking over my brain.) – Examples • A Student Has Impulses To Shout Out Dirty Words During Class • A Young Man Experiences Mental Images Of Cars Running Him Down On The Sidewalk • A Mother Is Tormented By Thoughts That She Might Inadvertently Contaminate The Dinners She Cooks For Her Family
  70. 70. Obsessive-Compulsive Disorder• Compulsion (usually obsessive or just don’t make sense. They are obsessive and rigid. Why? because they anxiety based. If they are prevented from doing something compulsive their anxiety goes up) – A Repetitive Behavior Or Mental Act That The Person Is Driven To Perform In Response To An Obsession or According to a rigid set of rules – The Purpose Of The Behavioral Or Mental Act Is To Prevent or Reduce Anxiety Or The Probability Of A Dreaded Event – The Behavior Or Mental Act Is Clearly Excessive or not Realistically Connected To What It Is Intended To Neutralize – Examples Related To The Obsession Examples • The Student With The Urge To Shout Dirty Words In Class May Be Compelled To Twirl His Pen Exactly Three Times, Count To Three, Twirl Three Times, Count To Three, ..And So On • The Young Man Who Constantly Experiences Mental Images Of Cars Running Him Down On The Sidewalk May Need To Step On Every Third Crack He Sees On The Sidewalk • The Mother Who Is Tormented By Thoughts That She Might Inadvertently Contaminate The Dinners She Cooks For Her Family May Need To Wash Her Hands Thirty Or Forty Times In The Course Of Cooking A Meal – Classic Examples Of Compulsions • Hand Washing To Reduce Images Or Thoughts Of Contamination (motor act) • Checking All The Locks In The House Ten Times Before Going To Bed To Reduced Fears That Someone Will Have Access To You (motor act) • Counting the number of letters in each sentence (mental activity. When talking to someone she would start counting the number of words in each sentence. Would do this to reduce their anxiety.)
  71. 71. Diagnostic Criteria For OCD• Obsessions And/Or Compulsions• At Some Point, The Person With OCD Realizes That The Obsessions And/Or Compulsions Are Excessive (Adults Only)• The Obsessions Or Compulsions – Cause Marked Distress Or – Consume More Than One Hour Per Day Or – Cause Social or Occupational Dysfunction
  72. 72. OCD Facts• Lifetime Prevalence Of OCD – 2% of Adults• OCD Is More Common in Women• Onset: OCD Generally Begins By Early Adulthood• Onset X Gender Interaction – Early Onset (Onset In Childhood Or Adolescence) Is More Common in Males – Later (Adult) Onset Is More Common in Females (18-30)• Many Children Who Exhibit Compulsive Behaviors Do Not Retain Them Into Adolescence• Comorbidity: OCD Is Often Comorbid With Mood Disorders And Other Anxiety Disorders, Especially Panic Disorder and Specific Phobia(They are low GABA folks, have other anxiety disorders that have low GABA. They are born to be low GABA)
  73. 73. Biological Factors• Neurotransmitters (low GABA) – Reduced Levels Of Serotonin, Dopamine, or Acetylcholine • Little Empirical Support• Genetics – 10% Prevalence In First Degree Relatives Of OCD Pts – 1-2% Prevalence In The General Population• Brain Structures – Obsessions • Possibly From Increased Activation In The Frontal Lobes (Overacting thought, overacting frontal lobes) – Compulsions • Possibly From Increased Activation In The Basal Ganglia (associated with Parkinson’s disorder, well known to be associated with smooth motor movement)
  74. 74. Psychological Factors• Two Factor Theory 1. Classical Conditioning – Aversive Experience Causes Lasting Anxiety And Obsession – Physical, Sexual (person feels violated, feels dirty), Emotional Abuse 2. Operant Conditioning – Negative Reinforcement – The Compulsive Behavior Is Reinforced (Perpetuated) By Its Ability To Reduce Anxiety
  75. 75. Treatment Of OCD• Medications – SSRI Antidepressants (e.g., Prozac, Zoloft, Paxil) • Reduce Obsessions By Increasing Serotonin Activity • Therapeutic Dosage Is Typically Higher Than That Used to Treat Depression• Behavior Therapy – Thought Stopping – Exposure with Response Prevention • Exposure Therapy + Patient Not Allowed To Engage In Compulsive Behavior • e.g., Compulsive Hand Washer Must Hold A Dirty Diaper Without Being Able To Wash His Hands
  76. 76. Post-Traumatic Stress Disorder and Acute Stress Disorder• PTSD And ASD – trauma-related disorders That Differ In Duration And Severity – Traumatic Event • An Event During Which Your Physical Integrity Or Another’s Physical Integrity Is threatened or damaged • e.g., Witnessing A Murder, Being In An Automobile Accident, Suddenly Learning Of The Death Of A Loved One, Sexual Assault, War Experiences – In Both Disorders, The Traumatized Person Must experience intense fear, helplessness, or Horror During Or Immediately After The Event
  77. 77. • Duration Criteria: One Month or LongerPost-Traumatic Stress Disorder• Persistent Re-Experiencing Of Traumatic Event (1 Or More) – Distressing Recollections/Memories of the Trauma – Dreams Of The Trauma – Acting Or Feeling As If Event is Reoccurring (i.e, Flashbacks) – Distress At Internal Or External Cues Related To The Event – Physiological Activity Due To Cues Related To The Event (not stress or anxiety, but heart starts to pound)• Avoidance Of Associated Stimuli And Lack Of Responsiveness (3 Or More) – Avoidance Of Thoughts, Feelings, Or Conversations Regarding The Traumatic Event (person might be avoiding conversations. If had a car accident and people start talking about they just leave. If have thoughts, they push them down, I want to forget this but it keeps coming up. Avoidance behavior is toxic. – Avoidance of Activities, Places, or People Associated with the Trauma (person is in a car accident, they might avoid their was a accident and their friend had died. Other person who was alive as well avoids the other person alive to, too much anxiety. Avoids the place accident occurred, or avoids driving. – Inability To Recall Important Aspects Of The Trauma (Dissociative Amnesia) – Significantly Diminished Interest Or Involvement In Activities (Person comes back as a different person. He’s one way and events happen and he’s very different socially) – Feelings of Detachment from Others (Attached to people, goes to Afghanistan, does things he never thought he would do, see things he never thought he would do, Have this emotional cut off. He would see his buddy get shot and die.Saying I don’t want to get hurt again, he feels disconnected from people he used to be attached to when he comes back. Change in emotional attachment to people. – Restricted Range of Affect (prior to the trauma the person was typical. Expressive- happy situation they smile. Sad- frown. Since the trauma they’re flat- no expression) – Sense Of Foreshortened Future (Prior to accident believed she would live till 80. Since car accident she’s convinced she’s not going to live till 30)• Persistently Increased Arousal (2 Or More) (Their body is overly aroused) – Difficulty Falling or Staying Asleep (their memories of the trauma cause them difficulties) – Irritability Or Angry Outburst (Overreactive Hostility) (Although you can see them flat, all it takes is a push and they will get emotional very quickly. They would go off on the person. He used to be very easy going but the events that happened, ever since small stuff causes him to go off in a intense way) – Concentration Problems (you can’t concentrate, might affect balancing your checkbook or other things) – Hypervigilance (after the sexual assualt, now she’s thinking everywhere where the dangers would be. SInce coming back from combat every time John enters a room he’s always vigilence for danger. Wants to find the nearest exit everywhere he goes because thinks something dangerous is going to happen. – Exaggerated Startle Response (Has to be a change from base line too. Want to see a change from pre trauma to prior to.This person now if theirs a loud pop their going to jump. Have an anxious arousal since the trauma every time they hear a loud noise.
  78. 78. Acute Stress Disorder• Duration Criteria: 2-30 Days• Trauma• Response Of Intense Fear, Helplessness, Or Horror• Dissociative Sxs, During Or After The Trauma (3 or more) – Detachment, Numbing, Or Reduced Emotional Responsiveness – Reduced Awareness Of Surroundings – Feelings of Unreality – (Depersonalization) Feelings Of Being Detached from Oneself Or From One’s Experience (Feeling like your not involved. 6 days of your sexual assault she says i know there was one, but i feel like it didn’t happen to me, I wasn’t there) – Inability To Recall An Important Aspect Of The Trauma (Dissociative Amnesia) (Where a person with the strength of he trauma, they can’t remember part of all of the traumatic event)• Recurrent Reexperiencing (Dreams, Flashbacks, Memories) Or Intense Distress When Exposed To Event-Related Stimuli• Avoidance Of Stimuli That Elicit Memories Of The Trauma• Anxiety and Increased Arousal (e.g., Sleep Disturbance, Hypervigilance, Exaggerated Startle Response)
  79. 79. IncidenceIncidence Of Acute Stress Disorder• Over 90% of Rape Victims Meet Criteria For ASD• About 15% Of People In Injurious Motor Vehicle Accidents Meet Criteria For ASD• Although Some ASD Patients Never Meet the PTSD Criteria, Many People Who Meet Criteria For ASD Will Later Meet The Criteria For PTSD (Many people may convert to PTSD form ASD but not all)• Incidence Of PTSD• Vietnam Veterans – Low Combat Vets: 20 To 30% Incidence of PTSD – High Combat Vets: 25% to 70% Incidence of PTSD
  80. 80. Risk Factors For PTSDRisk Factors• More Severe Trauma, more probable PTSD• Perceived Threat To Life• Low Intelligence (Low Coping Skills?)• Female• Lack Of Social Support (Cue Exposure)• Early Separation From Parents• History Of Prior Trauma• Family History Of Psychiatric Disorders• Personal History Of Prior Mood or Anxiety Disorders
  81. 81. Biological FactorsPrimed Nervous System• Sympathetic Nervous System (Fight Or Flight) – Designed for Short-term Activation – Intense Or Recurrent Trauma Results In Permanent State Of Overarousal/ AnxietyNeurotransmitters• Diverse Symptoms in PTSD• “Dysregulation” of Neurotransmitter SystemsBrain (brain issue)• Reduced Size of the Hippocampus – Combat Vets – Women Abused As Children
  82. 82. Psychological FactorsTwo Factor Theory 1. Classical Conditioning – Traumatic Event Causes Lasting Anxiety That Is Associated With Stimuli Present During The Trauma (Single event or multiple events) 2. Operant Conditioning – Negative Reinforcement – Avoidance Behavior Is Reinforced (Perpetuated) By Its Ability To Reduce Anxiety – The Long-Term Effect Is That The Avoidance Behavior Prevents Cue Exposure… Causing The Anxiety To Continue
  83. 83. Psychological Factors• Cognitive Theory (Find huge amounts of avoidance behavior; not sharing their experience when they have a trauma) – Avoidance • Social Isolation • Alcohol And/Or Substance Abuse Negativistic Cognitions • Excessive Self-Blame For Events Beyond Control • Guilt Over Outcome Of Events • Blaming Others • Cynicism • Catastrophizing
  84. 84. Treatment Of PTSDMedications• Symptoms Relief Only• Symptom-Specific Prescribing – Anxiety-Related Symptoms (Hyperexcitability, Startle Reactions) -> SSRI Antidepressants or Benzodiazephines – Irritability, Aggression, Impulsiveness, Flashbacks (getting into fights) -> Mood Stabilizers/Anti-Manic Medications – Depressive Symptoms (Emotional Numbing, Intrusive Thoughts, Social Withdrawal) -> SSRI Antidepressants
  85. 85. Treatment Of PTSDPsychological Interventions• Covering Strategies (Help the person cope with daily living, not past event, trauma experiencing. Coping with their symptoms (anxiety) , stress of their kids. – Supportive Therapy – Stress Management (Developing Coping Skills)• Uncovering Strategies – Systematic Desensitization – Imaginal Flooding • Success With Rape Survivors (Edna Foa) • Lack Of Success With Vietnam Combat Veterans

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