Psychopathology Ch.6 (end of 6-6.6, 6.7-end) 2/27

DSM-5-TR: Social Anxiety Disorder

A. Marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.

B. The individual fears that he or she will act in a way or will show anxiety that leads to negative evaluation by other

“public speaking anxiety” = performance anxiety only, social anxiety subtype

How many students identify as shy

• 48% college students

• only 18% of those individuals qualify for social anxiety diagnosis

Risk Factor of Social Anxiety: Behavioral Inhibition

behaviorally inhibited temperament = a risk factor

• Tendency to withdraw from unfamiliar situations

• Combo of neuroticism + introversion

• Reluctance to explore novel situations

• Behaviorally inhibited ages 2-6 -> 3x more likely to be

• diagnosed with SAD @ age 10

distorted cognitions in social anxiety

1. Excessive standards for social performance

   1. “I should be liked by everyone.”

2. Focus on negative aspects of social interactions

   1. “I know my feedback was really good, but my boss said I stuttered a bit. How terrible.”

3. Misinterpretation of social cues in self- defeating ways

   1. “The audience isn’t smiling. They must hate me.”

4. Over attunement to internal feelings

   1. “Wow my heart is beating really fast. That must be because this isn’t going well.”

5. Fortune telling/catastrophizing

   1. “If I ask my boss a question, he will think I’m stupid and I’ll get fired

Attention biases - Social anxiety

• Their “diet” of visual information is different!

• cognitive tendency to fixate on specific, often emotionally charged or threatening/negative, stimuli in the environment

• while ignoring other relevant, neutral information

Interpretation biases - Social anxiety

• a cognitive bias

• tendency o inappropriately analyze and interpret ambiguous stimuli, scenarios, or social events in a negative, threatening, or hostile manner

Is this face angry?

• Social Anxiety: Say “Yes” at lower threshold

• Social Anxiety: Stronger physiological reaction at lower threshold

Causes social anxiety

• Heritability estimate ~12-30%

• Early life experiences

  • High rates of difficult early social situations in school

  • Classical or vicarious conditioning

    • e.g.,Being bullied in childhood

    • >90% report humiliation experience

  • Remember diathesis-stress….

    • Those with underlying vulnerability = more likely to be affected by these events!

Social Anxiety Prevalence

• Lifetime prevalence 12%

  • Most common specific anxiety disorder after Specific Phobia.

• Female:Male is about 2:1

  • This is a theme of anxiety disorders

• Often develops in adolescence

  • Can begin as early as pre-school

• Often precedes depressive episodes

• Tends to be chronic if left untreated

Treatment social anxiety

CBT:

• Exposure

  • gradually approaching feared stimuli

  • e.g., attend a “mock” party and then a real party

    • habituation - anxiety at party decreases w time

    • extinction - realized that nothing bad happens and maybe good things happen

    • potentially disconfirm beliefs

• cognitive restructuring

  • process of working with a therapist to challenge unhelpful or unrealistic thoughts

  • therapist engages in Socratic Questioning

    • ask about belief

    • ask what the evidence is for the belief, against

  • initial estimate and estimate after cognitive restructuring

DSM: Generalized Anxiety Disorder

• Excessive anxiety and worry occurring more days than not

  • About a number of (more than 1) events or activities (“domains”)

  • Lasting at least 6 months

  • Out of proportion to circumstance

    • “If someone were in the same situation as you, do you think they’d worry as much?”

    • ”Do your friends and family think you worry too much?”

• It’s difficult to control the worry

• 3 of the following 6 when worrying:

  • Feeling on edge

  • Easily fatigued

  • Difficulty concentrating or mind going blank

  • Irritability

  • Muscle tension

  • Difficulty sleeping, or restless sleep

• Clinically significant distress and/or impairment

Common Domains of Worry (GAD)

• Job/academic concerns

• Finances

• Family

• Minor matters (e.g., getting places on time, getting things done)

• Health

• Global issues

need more than one for GAD

Prevalence GAD CHECK SLIDES

• Lifetime prevalence: ~6%

• Female:Male is 2:1

• Difficult to define onset because people often report having “always” been a worrier but onset typically based on interference

• Heritability estimate ~30%

A neurobiological factor GAD

• GABA = an inhibitory neurotransmitter

  • When it’s released, it inhibits (i.e., dampens) the stress response

• More GABA activity = better stress reduction

• People with GAD may have low GABA activity

GAD not dependent on

GAD is not dependent on objective stressors.

Patients with GAD engage in:

• Past-oriented rumination

• Future-oriented worries

Cognitive biases GAD

• GAD = extremely cognitive in nature!

• Beliefs about the future

  • Predict that bad things = more likely to happen

• Interpretation biases

  • Interpret ambiguous info in an anxious way

• “The doctor examined little Emma’s growth” → interpret this as bad news

Treatment GAD

CBT

• Behavioral

• Worry exposure

• Cognitive

• Worry logs

  • log and rate prediction, outcome, level anxiety

• Cognitive restructuring

• Mindfulness = Awareness that arises through paying attention, on purpose, in the present moment, non-judgmentally

  • Pulls mind away from past ruminations or future worries

  • Increases awareness of present feelings, goals, etc.

Anxiety Prevalence

• ~50% of children and adolescents will meet criteria for at least 1 diagnosis by age 18; anxiety most common

• Typical onset timing: anxiety (6 yrs), behavior disorders (e.g., conduct disorder; 11 yrs), mood (13 yrs), substance use disorders (15 yrs)

Anxiety Prevalence in Children

• Any anxiety disorder 32% (most common disorder in children)

• Anxiety: 32%

• Higher in girls than boys (1.5:1 ratio)

• Specific phobia most common (19%)

• SAD (9%)

• Selective mutism (1-2%)

• Separation anxiety disorder (8%)

DSM-5: Separation Anxiety Disorder

A. Developmentally inappropriate and excessive fear or anxiety concerning

separation from those to whom the individual is attached, 3+ of the

following:

1. Recurrent excessive distress upon separation.

2. Persistent and excessive worry about losing or harm to attachment

figure.

3. Persistent and excessive worry about event causing separation from

attachment figure.

4. Persistent reluctance or refusal to go places because of fear of

separation.

5. Persistent and excessive fear of or reluctance about being alone

6. Persistent reluctance or refusal to sleep away from attachment figure.

7. Repeated nightmares involving the theme of separation

8. Repeated complaints of physical symptoms when separation occurs or is

anticipated

B. Lasting at least 4 weeks in children/adolescents and 6 months in adults.

C. Clinically significant distress or impairment

Treatment Separation Anxiety

• CBT with child-friendly language

• Parent-Child Interaction Therapy

  • parent has earpiece w therapist in ear, tells them how to interact w kid

• Parent, Child, and Teacher Assessments

OCD DSM

• A. Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2):

  1. 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

  2. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

• Compulsions are defined by (1) and (2):

  1. 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

  2. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

• Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

• B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

• C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

• D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skinpicking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

OCD

• Obsessions

  • persistent thoughts, images or impulses

  • experienced as intrusive and inappropriate

  • generally about non-everyday things (sex, germs, murder)

• Compulsions

  • repetititve behvairos or mental rituals

  • provide short-term relief from the obsession

  • sometimes “logical” connection, other times not

• 90% of ppl w OCD experience both

• Disorder/Dysfunction

  • interference w regular functioning

  • occupation, relationships, daily routine

ego-dystonic

felt to be repugnant, distressing, unacceptable or inconsistent with one’s self-concept

• can occur with OCD

4 Subtypes of Obsession and Compulsion

1. Contamination → washing/cleaning

2. Responsibility → checking

3. Order/symmetry → arranging

4. taboo themes → neutralizing (feeling like some behavior has to be done to neutralize the obsession)

Thought-action fusion

• OCD

• concern that if thinking about something, worry that actually want to do something CHECK SLIDES

OCD Prevalence

• 2-3% liftetime prevalence

• genetic risk: 40% heritability estimate

• sex diff: 2:1 male:female ratio in children

• closer to even in adults (1-1.4:1 female:male)

• median age of onset

• CHECK SLIDES

Poor Insight

• OCD

• some don’t usually recognize that obsessions or compulsions as unreasonable CHECK SLIDES

Neurobiological factors OCD

• primitive circuit - including orbitofrontal corte CHECK SLIDES

Psychological Factors: Learned Behavior OCD

• classical conditioning

  • e.g., doorknob CS, fear germs US

• Intrusive thought (obsession) (“I’m going to contract a disease and die”) → distress → behavior reduces distress in short-term (compulsion) → temporary relief → learning that behavior made you feel better → (cycle starts over at intrusive thought)

Psychological Factors: Suppression OCD

• trying hard not to think about smth → often makes you think abt it more

  • typically not effective

Exposure and response prevention (ERP)

• OCD-specific exposure therapy

• Goal: face your fear

1. Trigger obsession

   1. e.g., touch a “dirty” object

2. resist urge to do the compulsion or engage in sbutle avoidance behaviors (safety behaviors)

   1. e.g., no washing hands (compulsion)

   2. may feel need to engage in incompatible behavior such as resting hands on table

• eventually patients learn that distress decreases over time

• feedback loop of relief - treatment

  • intrusive thought → distress → X no compulsion behavior → realize intrusive thought didn’t come true

Exposures can be in vivo or imaginal OCD

• in vivo - done in real life (e.g., touch dirty object)

• imaginal: done in your head (e.g., imagine touching a dirty object)

Does exposure therapy work for OCD

• yes, even more effective than SSRIs

Medications

• 1st choice: antidepressants

  • SSRIs (selective serotonin reuptake inhibitors), MAOIs (Monoamine Oxidase Inhibitors)

  • longer to take effect

  • no physiological dependence (can’t produce high)

  • better for certain diagnoses e.g., SAD (social anxiety disorder) and PD (personality disorder) > Specific phobia

• Benzodiazepines (“anti-anxiety medications”)

  • e.g., Xanax, ativan

  • may interfere w effects of CBT

    • can be just avoiding feelings

  • better if taken on regular schedule

  • fast acting

  • physiological dependence / risk for abuse (can produce high)

• Disadvantage of both: relapse of symptoms if go off