psychopathology exam 2

Anxiety disorders are the ____ common mental health condition in the US

most

Produces tension, worry, and ___ reactivity

physiological

Anxiety disorders

• unfound disorder

• produces clinically significant distress

• symptons interfere with an individual’s day-to-day functioning

Biological dimension of anxiety

• important to rule out any medical or physical cause for anxiety symptoms

• fear circuitry in the brain

• Genetics

  • decreased serotonin linked to depression

Fear circuitry in the brain

• amygdala plays a central role in triggering fear or anxiety

• sensory signals travel to hippocampus and prefrontal cortex

Psychological dimension of anxiety

• anxiety sensitivity

• Negative appraisal

What reduces likelihood of anxiety

• Skill of reappraisal

• self-control and mastery

Skill of reappraisal

looking at situations from various perspectives

Anxiety sensitivity

tendency to interpret physiological changes in the body as a sign of danger

Negative appraisal

• interpreting events as threatening

• what reduces the likelihood of anxiety

Social and sociocultural dimension of anxiety

• daily environmental stress

  • poverty, traumatic events, poor working conditions, limited social support

• Gender

  • women have higher anxiety rates than men

• Culture can influence expression of anxiety

  • exposure to discrimination, prejudice

  • internalized racism linked to increase in anxiety symptoms

Generalized anxiety disorder (GAD)

• Persistent, high levels of anxiety and excessive, difficult-to-control worry over life circumstances

• 3 or more of the following:

  • restless or ‘keyed up’

  • easily fatigued

  • irritability

  • difficulty concentrating

  • muscle tension

  • sleep disruption

• Symptoms must be present on the majority of days for 6 months and cause significant distress

Duration of symptoms to be considered GAD

6 months

How many symptoms to be considered GAD?

3 or more

Etiology of GAD

• Biological dimension

  • small but significant heritability factor (31%)

  • serotonin abnormalities

  • irregularities within the limbic system and prefrontal cortex

• Psychological dimension

  • cognitive theories: dysfunctional thinking and beliefs

    • interpretation bias, automatic attentional bias for negative info, impaired attentional control

    • worry about worrying

Treatment of GAD

• Medications

  • SSRI

  • Benzodiazepines (very short-acting and highly additive)

• Cognitive-behavioral treatment

  • 60% show significant symptom reduction that persisted 12 months after treatment

  • mindfulness practices (being aware in the moment)

Phobia

• Strong, persistent, unwarranted fear of a specific object or situation

• extreme anxiety or panic is expressed when persistent stimuli is encountered

• most adults recognize fear is excessive, but children may not

• Categories of phobias:

  • social anxiety disorder

  • specific phobias

  • agoraphobia

Social anxiety disorder (SAD)

• intense feeling of being scrutinized or doing something embarrassing or humiliating

• often comorbid w/ major depressive disorders, substance-use disorders, and suicidal thoughts/attempts

Specific phobia

• extreme fear of a specific object or situation

  • exposure to stimulus nearly always produces intense anxiety/panic attack

• Primary types

  • living creates (ex. spiders)

  • environmental conditions (ex. hurricanes)

  • situational factors (ex. flying)

  • blood, injection, injury (ex. needles)

Agoraphobia

• Intense fear of at least two of the following:

  • being outside of home alone

  • traveling via public transportation

  • being in open spaces, stores, theaters

  • standing in line or being in a crowd

• situations are feared because escape/help may not be readily available

Treatment of phobias

• Medications with efficacy for SAD

  • SSRI (antidepressants)

  • Benzodiazepines

• Cognitive behavioral treatments

  • systematic desensitization

  • cognitive restructuring

  • exposure therapy

Systematic desensitization

replaces fear and anxiety responses with relaxation through gradual, step-by-step exposure to a feared trigger

Cognitive restructuring

identify, challenge, and replace unhelpful or distorted thinking patterns with balanced, realistic alternatives

Exposure therapy

a cognitive behavioral technique that safely and gradually exposes people to feared objects, situations, or memories to break cycles of avoidance and reduce distress

Panic disorder

• recurrent and unexpected panic attacks

  • reactions present for 1 month or more

  • combined w/ apprehension about having another attack or behavior changes designed to avoid having another attack

• cultural variations in how symptoms are expressed

  • Caucasians generally report cardiac and respiratory symptoms

  • Cambodian refuges may have somatic symptoms

  • African Americans may experiences numbing sensations in their extremities and fears of dying

  • Native Americans may report a pounding heart, dizziness, and altered perceptions of time

How long should panic reactions occur before being called a panic disorder?

1 month

Etiology of panic disorders

• heritability 30%-40%

• decreased availability of neurotransmitters GABA and serotonin

• Hypersensitivity (SSRIs shown to be effective as they increase serotonin) in the neural network is associated w/ respiratory and carbon dioxide regulation

Treatment of panic disorders

• Medications

  • SSRIs, benzodiazepines

• Cognitive behavioral treatment

Obsessive compulsive disorder (OCD)

• Obsession

• compulsion

• more common among boys in childhood

• more common in women than men in adolescence/adulthood

Obsession

• consistent, anxiety-producing thoughts/images

• ex. contamination, errors of uncertainty, unwanted impulses, orderliness

Compulsion

• overwhelming need to engage in activities or mental acts to counteract anxiety or prevent occurrence of dreaded event

• ex. hand-washing, checking, ordering objects

Hoarding disorder

• inability to discard items regardless of their value

• perceived need for items and distress over the thought of giving or throwing them away

• results in distress or impairment in life activities or interferes with safety

Body dysmorphic disorder (BDD)

• preoccupation w/ perceived, physical defect, repetitive behaviors, and distress or impairment in life activities

• up to 60% undergo unnecessary cosmetic surgeries

• Muscle dysmorphia

Muscle dysmorphia

belief that one’s body is too small or insufficiently muscular

Trichitolllomania

• hair-pulling disorder

• recurrent and frequent hair-pulling despite attempts to stop

• women have increased likelihood

Excoriation disorder

• skin-picking disorder

• results in skin lesions

• more than 1hr per day thinking about, resisting or actually picking skin

• causes clinically significant distress

• majority are women/girls

Etiology of OCD and related disorders

• Genetics can increase risk of OCD w/ 1st degree relatives

• OCD impacts executive functioning

• pregnancy, c-section delivery and preterm birth can increase risk of OCD in mother

• Smoking mothers (10+ a day) can increase OCD risk in child

How does OCD impact executive functioning?

• impairment in decision making

• difficulty shifting attention away from intrusive thoughts/compulsive behaviors

Treatment of OCD

• Medications

  • SSRIs (60% effective)

  • improved when combined w/ behavioral interventions

• Behavioral therapy

  • exposure therapy

    • gradual exposure

Stressors

external events or situations that place physical or psychological demands on a person

Stress

internal psychological or physiological response to a stressor

• everyday stress can negatively influence our health and lead to the development of both psychological and physical conditions

  • negative impact on immune system and increase risk of illness

Trauma exposure trajectories

• resilience

• recovery

• delayed symptoms

• chronic symptoms

Resilience

relatively stable functioning, few symptoms

Recovery

initial distress w/ reduction in symptoms over time

Delayed symptoms

few initial symptoms followed by increasing symptoms

Chronic symptoms

consistently high trauma-related symptoms

Trauma and stressor related disorders

• adjustment disorder

• acute stress disorder (ASD)

• post-traumatic stress disorder (PTSD)

Adjustment disorder criteria

• emotional or behavioral symptoms in response to an identifiable stressor within 3 months

• Clinically significant by one or both of the following:

  • marked distress that is out of proportion to the severity of the stressor (consider cultural factors)

  • significant impairment in social, occupational, or other important areas of functioning

• Do NOT persist for more than 6 months once stressor has terminated

• Specifiers

  • with depressed mood, anxiety, mixed anxiety and depressed mood, mixed-disturbance of emotions and conduct

What is the time frame for which an event to happen to be considered part of an adjustment disorder?

within 3 months

Adjustment disorder is clinically significant by one or both of the following:

1. marked distress that is out of proportion to the severity of the stressor

2. significant impairment in social, occupational, or other important areas of functioning

How long should symptoms last for in adjustment disorder

6 months

Trauma

• exposure to actual or threatened death, serious injury, or sexual violation

What are the four ways in which trauma can be viewed?

1. directly experiencing the traumatic event

2. witnessing, in person, the event as it occurred to others

3. learning that the event occurred to a close family member or close friend

4. experience repeated or extreme exposure to aversive details of the traumatic event

Types of symptoms in trauma

• Intrusion

• Avoidance

• Negative alternations in mood or cognition

• Arousal

• Dissociation

intrusion

• intrusive thoughts

• nightmares

• flashbacks

avoidance

• thoughts

• feelings

• people

• places

• events

negative alternations in mood or cognition

• low mood

• trouble remembering details

• negative view of self/worth

• blame

Arousal

• irritability

• aggression

• reckless/self-destructive behaviors

• hyper vigilance

• poor sleep/concentration

Dissociation

protective reaction involving mental disconnection from trauma

Depersonalization

• feelings detached from one’s body or thoughts

• self-focused

Derealization

• a persistent sense of unreality

• environment- focused

Acute stress disorder criteria

• Exposure or witness to traumatic event

• Presence of 9+ symptoms from any category:

  • intrusion

  • negative mood

  • dissociation

  • avoidance

  • arousal

• Symptoms present at least 3 days BUT no longer than 1 month after event

• causes clinically significant distress and rule out medical & substance use

How many symptoms do you need to experience to be considered acute stress disorder?

9 symptoms from any of the following categories:

• intrusion

• negative mood

• dissociation

• avoidance

• arousal

Symptoms duration range

At least 3 days but no longer than 1 month

PTSD criteria

• exposure or witness to traumatic event

• Present of at least one or two symptoms from each category:

  • intrusion

  • negative mood

  • dissociation

  • avoidance

  • arousal

• Symptoms present for more than one month

  • may specify delayed expression if full symptoms are not present until 6 months

How many symptoms do you need to experience to be considered PTSD?

one or two symptoms from each category:

• intrusion

• negative mood

• dissociation

• avoidance

• arousal

Symptoms duration range

More than one month

Examples of PTSD risk factors

• 2x as prevalent in women

• ethnicity

• type of trauma

• rape or sexual assault

• personal factors

Ethnicity

• highest prevalence in African Americans

• intermediate risk for Latinx & European Americans

• Low prevalence in Asian Americans

• symptoms may vary across cultures

Types of trauma

• more severe physical injuries

• injury to the head or extremities

• major injuries

  • high rate of burnout

Rape or sexual assault

PTSD more likely when there is intentional trauma and when there is a close relationship with the perpetrator

Personal factors

• cognitive style

• childhood history

• genetics

• social supports

Biological dimension of PTSD

• some people are more prone to physiological reactivity

• fight, flight, or freeze response

  • raising blood pressure and heart rate w/ cortisol and epinephrine to respond to danger

• hyper-arousal, hyper vigilance, and increased startle response

• fair extinction

  • trauma-related fear responses do not decline over time

  • brain is vulnerable to cortisol and may cause changes (especially in childhood)

Psychological dimension of PTSD

• pre-existing conditions

  • anxiety, depression, anger

• cognitive patterns

  • interpreting stressors in a catastrophic manner

  • blaming self or others

  • negative worldview

• protective factors

  • active problem solving

  • reframing skills

  • optimism

  • shared experience

Social dimension of PTSD

Social support

Social support

• release endorphins to reduce stress prevent or challenge negative cognitions

• less than optimal social support during childhood can increase risk

• family conflict or overprotective family relationships

Sociocultural dimension of PTSD

• race-based discrimination can produce psychological trauma

• consider cultural differences in responding to stress

Medication treatments for PTSD

• SSRIs 60% effective, only 20-30% show full recovery

• Prazosin

• Propanolol

Prazosin

hypertension medication, may reduce nightmares and improve sleep

Propanolol

beta-blocker, improvement in sleep, and reduction of hyper-arousal (physical symptoms)

Psychotherapy treatments of PTSD

• CBT based therapies are MOST effective for trauma

• Prolonged exposure therapy (PE)

• Trauma forced cognitive behavioral therapy (TF-CBT)

• Eye movement desensitization and reprocessing (EMDR)

Prolonged exposure therapy (PE)

imaginary or real-life exposure in extinction of fear reactions

Trauma focused cognitive behavioral therapy (TF-CBT)

addressing underlying negative core beliefs or pervasive concerns about safety

Eye movement desensitization and reprocessing (EMDR)

• decrease physiological reactivity and weaken impact of negative emotions

• visualize trauma while engaging in activity involving both sides of the brain (think REM)

• trauma as a splinter

• successful with both single event trauma and complex trauma