Mood Disorders

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  • Anxiety is a response to a threat that is unknown, internal, vague, or conflictual.
    Fear is a response to a known, external, definite, or nonconflictual threat.
    Anxiety is normal
    What is good about anxiety?
    Warns of all sorts of danger so you can deal with it
    Prompts you into action to prevent damage
    E.g., makes you study, work harder
  • Why is the same event stressful for one person and not another?
    Perceived level of risk – may have to do with prior experiences
    Perceived coping skills – self confidence, new experiences, self esteem
    Biological status – sometimes biology interacts with environmental events to influence behavior
  • Symptoms of Anxiety
    Often the physical symptoms and the psychological status become a feedback loop, so that the physical sensations are interpreted in a way that heightens anxiety and makes the heart beat faster / the anxiety level rise even more. It can become a vicious cycle!
  • A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes
    Can happen without developing a disorder – just a temporary symptom of feeling overwhelmed. (Co-worker forgot his inhaler for asthma symptoms, panicked when he realized what he had done, he knew he was having a panic attack and was largely unconcerned, just embarrassed!)
    Often associated with other anxiety disorders in reaction to a specific stimulus.
  • Focus of anxiety is on place or situation where embarrassment might occur or escape might be difficult.
    Fear of flying? Might have panic attack and be embarrassed, cannot escape…
  • Social Phobia often results in a type of thinking that justifies avoiding provocative situations and can be accompanied with somatic symptoms that facilitate avoiding social situations (get sick before a party, presentation, etc.)
    Anxious anticipation of a social situation is common, and if the phobic person attends a social event, he or she may have the “deer in the headlight” syndrome.
    May cause / be caused by negative thoughts about self, convinced that others are judging and criticizing. May remember a long, long time comments made by others, internalizing early rejection experiences.
  • Posttraumatic stress disorder usually appears within three months of the trauma, but sometimes the disorder surfaces months or even years later.
    Symptoms are categorized into four categories: intrusive symptoms, avoidant symptoms, symptoms of hyperarousal, and associated features.
  • Intrusive Symptoms
    The traumatic event "intrudes" into their current life.
    Re-experiencing or flashbacks
    Sudden, vivid memories that are accompanied by painful emotions and take over the victim's attention.
    This "re-experience" of the trauma is a flashback-a recollection that is so strong that the individual thinks he or she is actually experiencing the trauma again or seeing it unfold before his or her eyes.
    When a person has a severe flashback, he or she is in a dissociative state, which sometimes can be mistaken for sleepwalking.
    When that happens, the person acts as if he or she were actually experiencing the traumatic event again. But he or she isn't fully conscious of what he or she is doing.
    For example, a war veteran may begin prowling around his neighborhood as if patrolling hostile territory.
    Nightmares
    Sudden, painful onslaught of emotions that seem to have no cause.
  • Symptoms of Avoidance
    Avoid anything to do with the trauma
    Frequently can't feel emotions, especially toward those who are closest.
    Even if they can feel emotions, they often can't express them.
    May seem bored, cold, or preoccupied.
    Family members often feel rebuffed by the person because he or she lacks affection and acts mechanically.
    May avoid accepting responsibility for others because they think they failed before
    May not expect to have a future
  • Symptoms of Hyperarousal
    May act as if constantly threatened by the trauma
    Suddenly irritable or explosive
    Trouble concentrating
    Insomnia
    Exaggerated startle reactions
    Panic attacks
  • Accompanied by despair and helplessness
    Can involve survivor guilt
    Feel responsible for the traumatic event
    Neglect of self, basic health and safety needs
    Increased risk of developing PTSD
    Impulsive risk taking behaviors may occur
  • Physical symptoms that seem as if they are part of a general medical condition, however no general medical condition, other mental disorder, or substance is present. In this case psychological conflicts may becoming translated into physical problems or complaints. With the number one complaint being of some type of physical symptom,  it is no wonder this disorder is often discovered in a general medical setting.
  • The symptoms just don’t make sense in light of physical evidence.
    The symptoms often logically connect to a psychological process or serve a functional role in the life of the person
    Numbness from the wrist down for someone who feels guilty about having done something (masturbation)
    Devastating pain that necessitates staying in bed and the focus of others’ attention and ministrations
    Wanting to avoid a big event may result in terrible concern about dying or being very sick, combined with an assortment of transient physical problems
    Repeated surgeries that do not help or are aimed at changing the person’s appearance (Michael Jackson)
  • Jenny (a pseudonym) was one of those "invisible" people we all know and overlook each day. A secretary for a manufacturing company, Jenny was as a diligent employee, but one who hadn't developed many friends at work. Nevertheless, she seemed to find all the companionship she needed in her relationship with her live-in boyfriend. Week in and week out, her world seemed never to change, and yet she seemed satisfied. Then one day everything, suddenly and quietly, fell apart.
    Jenny's boyfriend announced he was leaving her: he had fallen in love with another woman and was moving out. Horrified and adrift, with no one to call on for comfort, Jenny chose a remarkable way out of her loneliness. She mobilized an instant support network by showing up at work one day and announcing, "I've just been diagnosed with breast cancer. And it's too late. It's terminal."
    It was also a lie. Jenny had found a remarkable and desperate way to mobilize an instant support network of sympathetic co-workers. Eventually she enrolled in a breast cancer support group, shaved her head to mimic the effects of chemotherapy, and dieted to lose 50 pounds all to keep the illusion alive.
    Jenny was suffering not only from a broken heart, but from an emotional ailment called "factitious disorder." People with factitious disorder feign or actually induce illness in themselves, typically to garner the nurturance of others. In bizarre cases called "Munchausen syndrome by proxy," they even falsify illness in another person (such as their own children) in order to garner attention and sympathy for themselves as the heroic caregiver.
    Desperate? Of course. Yet more common than you might think. Experts estimate that one percent of hospitalized patients are faking their ailments. The medical bills in one case alone amounted to $6 million. Clearly factitious disorders are sapping an already-burdened health care system.
    They also defy the imagination. Patients have bled themselves into anemia and then showed up at a doctor's office stating they haven't a clue about how they became so ill. Others have secretly taken laxatives to induce diarrhea, or mimicked seizures so convincingly that neurologists hospitalized them on the spot.
  • Formerly considered rare and mysterious psychiatric curiosities, Dissociative Identity Disorder (DID) (previously known as Multiple Personality Disorder-MPD) and other Dissociative Disorders are now understood to be fairly common effects of severe trauma in early childhood, most typically extreme, repeated physical, sexual, and/or emotional abuse.
    In Diagnostic and Statistical Manual of Mental Disorders-IV (American Psychiatric Association, 1994), Multiple Personality Disorder (MPD) was changed to Dissociative Identity Disorder (DID), reflecting changes in professional understanding of the disorder resulting from significant empirical research.
    Posttraumatic Stress Disorder (PTSD), widely accepted as a major mental illness affecting 8% of the general population in the United States, is closely related to Dissociative Disorders. In fact, 80-100% of people diagnosed with a Dissociative Disorder also have a secondary diagnosis of PTSD. The personal and societal cost of trauma disorders is extremely high. Recent research suggests the risk of suicide attempts among people with trauma disorders may be even higher than among people who have major depression. In addition, there is evidence that people with trauma disorders have higher rates of alcoholism, chronic medical illnesses, and abusiveness in succeeding generations.
    Dissociation is a mental process, which produces a lack of connection in a person's thoughts, memories, feelings, actions, or sense of identity. During the period of time when a person is dissociating, certain information is not associated with other information as it normally would be. For example, during a traumatic experience, a person may dissociate the memory of the place and circumstances of the trauma from his ongoing memory, resulting in a temporary mental escape from the fear and pain of the trauma and, in some cases, a memory gap surrounding the experience. Because this process can produce changes in memory, people who frequently dissociate often find their senses of personal history and identity are affected.
    Cultural awareness is especially important in understanding dissociative experiences. Dissociation is common and accepted in some cultures as an expression of cultural or religious activities. Dissociation should not be considered necessarily pathological.
  • Mood Disorders

    1. 1. Anxiety and Dissociative Disorders Susan D. Odom, Ph.D.
    2. 2. Anxiety Disorders • Panic Attacks • Agoraphobia • Panic Disorder without Agoraphobia • Panic Disorder with Agoraphobia • Agoraphobia without History of Panic Disorder • Specific Phobia • Social Phobia • Obsessive-Compulsive Disorder • Posttraumatic Stress Disorder • Acute Stress Disorder • Generalized Anxiety Disorder • Anxiety Disorder due to a General Medical Condition • Substance-Induced Anxiety Disorder • Anxiety Disorder NOS
    3. 3. Anxiety is Normal • Anxiety can be a normal response to a situation that is perceived to be beyond our ability to cope • Is a great motivator – to study, work hard, move quickly So what makes Anxiety a Disorder? • The degree and duration of the symptoms! • Oh, and sometimes the trigger for the anxiety….
    4. 4. What makes an event stressful? • The nature of the event and how the person views it • The person’s resources • The person’s psychological defenses • The person’s coping mechanisms In other words, there is a mismatch between perceived demand and perceived ability. If this mismatch results in the person’s ego being challenged, anxiety disorders sometimes result. The demands can be external (social demands, for instance) or internal (aggressive, sexual, and/or dependent impulses)
    5. 5. Usual Anxiety Symptoms • Dizziness, light-headedness • Hypertension • Palpitations • Restlessness • Diarrhea • Tachycardia • Tingling in extremities • Tremors • Upset Stomach • Urinary frequency
    6. 6. Epidemiology • 1 in 4 have had an anxiety disorder (19 Million at one time) • Lifetime prevalence is 30.5% for women and 19.2% for men • Prevalence is lower for higher socioeconomic classes • Onset usually prior to age 35
    7. 7. Etiology • Psychological Causes  Defense against a psychic conflict – resolve the conflict and the anxiety is diminished • Behavioral Theory of Anxiety  Classical Conditioning – a cause and effect relationship is perceived (which may or may not be true) and then generalized to other situations  Social Learning – parents • Biology  Autonomic nervous system – don’t habituate well, overreact to stimuli.  Neurotransmitters – norepinephrine, serotonin, GABA • Genetics – genes that affect serotonin transportation • Neuroanatomical Considerations  Higher pressure in the spinal column due to increased levels of spinal fluid result in anxiety symptoms
    8. 8. Criteria for Panic Attack Four or more of the following symptoms that peak within 10 minutes: • Palpitations, pounding heart, or accelerated heart rate • Sweating • Trembling or shaking • Shortness of breath or smothering • Feeling of choking • Chest pain or discomfort • Nausea or abdominal distress • Dizzy, unsteady, lightheaded or faint • Derealization (feelings of unreality) or depersonalization (being detached from oneself) • Fear of losing control or going crazy • Fear of dying • Paresthesias (numbness of tingling sensations) • Chills or hot flashes
    9. 9. Agoraphobia • Agora – Greek for the market, a place that is crowded, filled with people and unexpected events! • Modern Day – An anxiety about or avoidance of places or situations from which escape might be difficult or embarrassing; help might not be available if a panic attack occurs • Usually includes a characteristic cluster of situations (being outside, away from home, standing in a line; being on a bridge or in an elevator; traveling by bus, train, automobile, jet • Situations are avoided or met with dread
    10. 10. Panic Disorder • Recurrent, unexpected panic attacks • Panic attack followed by 1 month or more of persistent concern about having another attack, worry about the implications of the attack, or significant change in behavior in relation to the attack • Can occur with or without agoraphobia
    11. 11. Specific Phobia • Most common mental disorder for women & 2nd for men – 5% - 10% of people have a specific phobia. • Types – Animal (dogs, bunnies, cats, bugs, reptiles) – Natural environment (storms, heights, water) – Blood, Injection, Injury (seeing blood, getting a shot, having blood drawn, illness or death) – Situational (public transportation, tunnels, bridges, etc.) – Other (clowns, loud sounds, toes, choking, vomiting, etc.) • Immediate response is unreasonable fear and the person knows the fear is unreasonable • Avoid or endure with intense anxiety
    12. 12. Social Phobia • Marked and persistent fear of social interactions or performance situations • Exposure causes intense anxiety or maybe panic attack • Hypersensitivity to criticism, evaluation by others • May be accompanied by poor social skills, noticeable anxiety symptoms, fear of authority figures • Social isolation, loneliness, lack of success in school, business, social relationships
    13. 13. Obsessive Compulsive Disorder • Recurrent, Persistent Obsessions (intrusive and/or inappropriate thoughts, images, impulses, ideas) and Compulsions (behaviors or thoughts to prevent or reduce anxiety or distress associated with obsession.) • Person recognizes the obsessions are outside of the realm of control but also the product of his or her own mind • Attempts to ignore or suppress usually fail • Mounting anxiety of obsession can be relieved by enacting the compulsion
    14. 14. Obsessive Compulsive Disorder Common types: • Fear of germs / compulsive hand washing • Repeated thoughts of having hurt someone or leaving some important task undone / checking behaviors • Need for order / placing things in symmetry or in a particular order, performing acts in a specific sequence, wearing the same clothes everyday • Desire to say or do inappropriate things / counting, tapping, distracting behaviors or rigid, idiosyncratic behaviors or rules to follow
    15. 15. Posttraumatic Stress Disorder • It's been called shell shock, battle fatigue, accident neurosis and post rape syndrome. • It is a set of symptoms that develop after a person sees, hears, or is involved in an extreme traumatic stressor. • It affects people who have survived earthquakes; accidental disasters such as airplane crashes; or manmade disasters such as a terrorist bombing, inner- city violence, domestic abuse, rape, war, and the Holocaust. • In some cases the symptoms of PTSD disappear with time, while in others they persist for many years. PTSD often occurs with-or leads to-other psychiatric illnesses, such as depression, social anxiety, GAD
    16. 16. Symptoms of PTSD • Usually appear within 3 months of the trauma, but can surface years later • Symptoms fall into 3 categories: – Reexperiencing the trauma – Avoidance of stimuli – Persistent increased arousal
    17. 17. Reexperiencing • Recurrent and intrusive recollections of the events (images, thoughts, perceptions) • Recurrent dreams or nightmares of the event • Feeling as if it is happening again (flashbacks, illusions, hallucinations, physical sensations) • Intense psychological distress upon exposure to internal or external triggers • Physiological reactivity upon exposure to internal or external triggers
    18. 18. Avoidance • Efforts to avoid thoughts and feelings or conversations about the trauma • Efforts to avoid the activities, places or people that activate memories • Inability to recall important aspects of the trauma • Markedly diminished interest or participation in significant activities • Feelings of detachment or estrangement from others • Restrict range of affect (unable to love) • Sense of foreshortened future (doesn’t expect to marry, have a career, children, normal life span)
    19. 19. Increased Arousal • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilence • Exaggerated startle response
    20. 20. Features Associated with PTSD • Substance abuse • Suicide
    21. 21. Acute Stress Disorder • Person is exposed to a traumatic event accompanied by 3 of the following: – Subjective sense of numbing, detachment, absence of emotions – A reduction in awareness – Derealization (doesn’t seem quite real / out of sync) – Depersonalization (as if it is happening to someone else) – Dissociate amnesia (cannot remember what happened) • Trauma is persistently reexperienced • Avoidance of triggers • Symptoms of anxiety • Lasts for a minimum of 2 days and a maximum of 4 week and occurs within 4 weeks of the trauma
    22. 22. Generalized Anxiety Disorder • Excessive worry and anxiety more days than not for at least 6 months across a number of situations (work, homelife, school performance) • Cannot control the worry • Feelings of: – Restlessness – Easily fatigued – Difficulty concentrating – Irritability – Muscle tension – Disturbed sleep
    23. 23. Anxiety Disorder Due to a General Medical Condition Anxiety is caused by a medical condition such as Hyper/hypothyroidism Cardiovascular conditions (congestive heart failure) •Respiratory conditions (COPD) •Metabolic conditions (vitamin B12 deficiency) •Neurological conditions (encephalitis) Anxiety can be expressed a number of ways •GAD symptoms •Panic Attacks •OCD symptoms
    24. 24. Anxiety Disorder Due toAnxiety Disorder Due to a General Medical Conditiona General Medical Condition Symptoms must occur after onset of physical condition and things like typical age of onset for the disorder, family psychological history, and remission when disease remits must be taken into consideration Can be caused by a wide variety of medical conditions and the anxiety looks just like a regular anxiety disorder The best treatment is to treat the underlying medical condition
    25. 25. Substance Induced AnxietySubstance Induced Anxiety DisorderDisorder Prominent anxiety, panic attacks, OCD symptoms, or phobia occurring during or within one month of substance intoxication or withdrawal or the medication use is etiologically related to the disturbance Symptoms are not better accounted for by symptoms of intoxication or withdrawal ((anxiety disorder sxs are more severe)  Amphetamine or amphetamine like substance  Caffeine, cannabis, cocaine  Hallucinogen, inhalant, phencyclidine  Sedative, hypnotic, anxiolytic  Other/unkown
    26. 26. Anxiety Disorders NOS Mixed Anxiety-Depressive Disorder but the criteria aren’t quite met for other disorders Clinically significant social phobic symptoms that are related to the social impact of a disease or mental disorder Situations where the clinician has concluded an anxiety order exists, but is unable to determine whether it is primary, due to a GMC, or substance induced
    27. 27. Somatoform Disorder Presence of physical symptoms that suggests a general medical condition – Not explained by a general medical condition – Not the effects of a substance – Aren’t explained by another mental disorder – Symptoms are not intentional or under voluntary control
    28. 28. Types of Somatoform Disorders • Somatization Disorder (< 30 y.o., polysymptomatic, extends over years, combination of pain, gastrointestinal, sexual and pseudoneurological) • Undifferentiated Somatization Disorder • Conversion Disorder (including seizures) • Pain Disorder • Hypochondriasis (preoccupation with having a disease) • Body Dysmorphic Disorder • Somatoform NOS (false pregnancy, subjective sensation of fetal movement, unexplained physical complaints of less than 6 months.)
    29. 29. Chronic Fatigue Syndrome • Chronic fatigue not improved by rest • Four of the following symptoms: – Substantial short-term memory impairment – Sore throat – Tender lymph nodes – Muscle pain – Multi-joint pain without swelling or redness – Headaches of a new type, pattern or severity – Unrefreshing sleep – Post-exertional malaise lasting more than 24 hours • Worsened by physical or mental activity • Levels of functioning are greatly reduced
    30. 30. Fibromyalgia • Chronic condition characterized by fatigue, widespread pain in the ligaments, muscles, and tendons, and multiple tender points where pressure causes pain. • Is not progressive, crippling, or life-threatening • Fatigue and sleep disturbances are common • Co-occurs with irritable bowel, headaches and facial pain, heightened sensitivity to odors, noises, bright lights, and touch • Diagnosis is very difficult – no tests • Treatment includes analgesics, antidepressants, muscle relaxants, CBT and psychological interventions such as biofeedback, chiropracty, massage therapy, osteopathy, and acupuncture.
    31. 31. Factitious Disorder • Deliberate production or feigning of physical or psychological symptoms – Fake symptoms or making up complaints – Self-inflicted wounds – Exaggeration or exacerbation of preexisting GMC • Motivation is to assume the sick role • No external motivation (see malingering) • Malingering  has an external motivation such as economic gain, avoiding legal responsibility, improving physical well-being
    32. 32. Dissociative Disorder The functions of consciousness, memory, identity, or perception of the environment become un-integrated or disrupted. • Dissociative Amnesia – cannot recall important, usually traumatic – memories or information. • Dissociative Fugue – sudden travel away from home/work with an inability to recall the past and confusion about identity or assumption of a new identity • Dissociate Identity Disorder – (MPD) presence of two or more distinct identities or personalities • Depersonalization Disorder – persistent or recurrent feeling of being detached from one’s mental processes or body accompanied by intact reality testing • Dissociative Disorder NOS

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