PSYC 336 - Clinical

Epidemiology

The prevalence and distribution of a disorder in a population.

Etiology

The cause(s) of a disorder.

Pathology

The underlying psychological/ neurobiological features of a disorder.

Transdiagnostic

factor that is part of serval diagnosis

The essentialist approach to mental disorders

Mental disorders are natural categories whose true nature can be discovered and described
Categories represent empirically verifiable similarities among and differences between people

The social constructionist approach of mental disorders

Concepts of mental disorders (of categories) are social constructions

Syndrome Heterogeneity

different causal mechanisms may relate to the same disorder, and multiple outcomes of interest can occur within one individual.

Comorbidity

the co-occurrence of two or more disorders in a single individual

RDoC

Psychopathology research moving toward transdiagnostic domains of functioning that have a clear neurobiological/cognitive basis (bottom up)

Panic Attack

Abrupt surge of intense fear or discomfort that is diagnosed by the presence of 4 or more of the 13 symptoms

Full blown panic attack

four or more symptoms

acrophobia

two of the following symptoms
Public transportation
Open spaces
Enclosed spaces
Standing in line
Being in a crowd
Being outside of the home alone

Noncognitive panic

no symptoms of loss of control, dying or going crazy despite reporting intense fear and arousal

Nocturnal panic attack

waking from sleep in a state of panic with symptoms that are similar to panic attacks
These are common for people with panic disorder

Agoraphobia without panic disorder occurs

1/3 of the rate of panic disorder

commorbity statistics for panic disorder

93.7% of individuals with this disorder have at least one or more chronic physical or mental disorder

People with panic disorder meet the criteria for 4.5 more mental disorders
Including

behavioural features of panic disorder

1. avoidance of particular situations
2. interoceptive avoidance
3. safety behaviours
4. experiential avoidance

interoceptive avoidance

Strong sensitivity to and avoidance of internal bodily symptoms associated with anxiety and panic
Exercise, sex, caffeine, alcohol, saunas, wearing neckties, anger, scary movies

safety behaviors

Behaviors intended to avoid disaster, dysfunctional emotion regulation strategies

Check pulse

Be near hospital

Carrying antianxiety medication

Having a safe person

Experiential avoidance

Person is unwilling to remain in contact with private experiences
Watching TV, Eating
Avoiding feelings

cognitive features of panic disorder

Greater anxiety responses to panic
They fear situations that elicit body sensations like cardiovascular, respiratory and audiovestibular exercises and inductions

Emotional features of panic disorder

neuroticism is a

Interaction With Environmental Factors inducing panic disorder

- early caregiving attachment
- parenting
- abuse
- stress

biological features of panic disorder

Heritability accounts for approximately 30%-40% of the variance

the gene polymorphism 5-HTTLPR - a promoter region of the serotonin transporter gene

Neurocircuitry for panic disorder

-reduced volume of the amygdala
-low baseline GABA levels
-blunted benzodiazepine sensitivity
- HPA axis is dysregulated

Etiological Models for panic disorder: Clark and others

Catastrophic misappraisals of bodily sensations are central to the development and the maintenance of panic disorder

Etiological Models for panic disorder: Interoceptive fear conditioning

Low-level somatic sensations of arousal or anxiety become conditioned stimuli due to their association with intense fear, pain, or distress

branches of CBT for panic disorder

PCT (panic control treatment)
Clark's cognitive therapy for panic disorder

Psychological treatments for panic disorder

- CBT (PCT + Clarkes)
- ACT (for resistant patients)
- MBSR
- CART (breathing only)

Biological Treatments for Panic Disorer

- SSRI
- Benzodiazepines (reduce number of attacks)

prevention of panic disorder

CBT prevention in people who have had 1-2 attacks
Group CBT for people who have experienced attacks but no panic disorder

Diagnostic criteria for panic disorder

Both 1 and 2

1. Recurrent unexpected panic attacks + at least 4 symptoms listed

2. 1 month of concern or changes of behavior to avoid

Prevalence of panic disorder

12 month: 2.4
Lifetime: 4.7
2x more common in women
age of onset: 20s

Cognitive-Behavioral Model of Panic Disorder

- People with this Disorder pay very close attention to their bodily sensations

- misinterpret bodily sensations as signs of imminent catastrophe

the fear of fear itself

classical conditioning of panic disorder

previously neutral situations (ex: driving) become associated with panic sensations

operant conditioning of panic disorder

avoidance is maintained by negative reinforcements (relief)

Social Anxiety Disorder - diagnostic delemas

a continuum of anxiety. Hard to know where to make that 'cut'

Diagnostic criteria for social anxiety disorder

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others.

B. The individual fears that they will act in a way or show anxiety symptoms that will be negatively evaluated

C. The social situations almost always provoke fear or anxiety

D. The social situations are avoided or endured with intense fear or anxiety

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context

F. The fear, anxiety, or avoidance is persistent (6+months)

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

lifetime prevalence of social anxiety, and one year prevalence

L: 8-13 %

Y: 6.7%

social anxiety disorder onset and sex ratio

- childhood and early adolescence
- 2x in women

people with psychological vulnerability's to developing social anxiety disorder display

Behavioral inhibition: An early childhood temperament factor that involves fear of novelty. Related to shyness and social reticence in preschool and elementary school years
STRONGEST RISK FACTOR

OCD defenition

the presence of obsessions or compulsions that produce significant distress and cause noticeable interference with various aspects of functioning

obsessions

intrusive thoughts, ideas, images, impulses, or doubts that a person experiences as senseless and that evoke anxiety

RESISTED, meaning they are accompanied by the sense that they need to be dealt with or neutralized or even avoided

categories of obsessions

Contamination
Guilt and responsibility of harm
Uncertainty
Taboo thoughts about sex
Violence and blasphemy
Need for order and symmetry

Compulsions

Urges to preform overt, or mental rituals in response to obsessions to reduce anxiety and distress

Categories of compulsions

Decontamination
Checking
Ordering and arranging
Mental rituals

the insight factor of OCD

the degree to which the person views their obsessional fears and compulsive behavior as reasonable

can be:
- good
- poor
- absent

tic OCD

OCD when patient has a history of Tourette's syndrome

Interpersonal Aspects of OCD

Negative impact on the sufferer's relationships

High relationship conflict

Worse if friends or partners or family engage in

Symptom accommodation

Body Dismorphic Disorder

Intrusive, distressing thoughts concerning one's appearance
Repeated checking

OCPD

Personality traits like perfectionism, inflexibility, need for control

Negatively impacts interpersonal relationships, occupational functioning, and other domains of a persons life

Ego-syntonic

Commodity with OCD and OCPD

23-32% OCD display OCPD symptoms
OCPD may be associated with poor OCD treatment

Prevalence and Epidemiology of OCD

Lifetime prevalence: 0.7-2.9%
Slightly more in females
Typical onset is 25
Men: 21
Females: 22-24

Learning Model of OCD

Mowrers 1960 two stage theory

- Fear acquisition

- Maintenance

Operant conditioning creating avoidance habits, maintaining the fear and OCD

Cognitive Deficit Models of OCD - Reality monitoring

The ability to discriminate between memories to actual versus imagined events

Cognitive Deficit Models of OCD - Inhibitory Deficits

Cognitive inhibition - the ability to dismiss extraneous mental stimuli
People with OCD have difficulty forgetting negative material

Limitations of cognitive deficit models

Don't account for heterogeneity of OCD
Some wash hands, some have metal compulsions

Cognitive Behavioural Models of OCD

The most promising
Emotional disturbance is brought not by situations and stimuli themselves, but how one make sense of the situations and stimuli

Limitations of the Cognitive Behavioural Models of OCD

implies that successful treatment for OCD must accomplish two things
1. Correction of maladaptive beliefs and appraisals that lead to obsessional fear
2. The termination of avoidance and compulsive rituals

seretonin hypothesis of OCD

Hypersensitivity of the postsynaptic serotonergic receptors

Neurobiological structural models of OCD

- Abnormalities in the orbitofrontal subcortical circuits
- Overactivity in the processing information in the initiation of behavioral process areas of the brain
- Increased glucose utilization in the orbitofrontal cortex

Psychological treatment of OCD

CBT is derived from the cognitive behavioral model
Considered the most effective approach to the psychological treatment of OCD

Two types of CBT

ERP
CT

exposure and response prevention

Entails confrontation with stimuli that provoke obsessional fear, but that objectively pose a low risk of harm

Habituation

Overtime the anxiety associated with physiological responding subsides

delivery of ERP

A few hours of assessment and treatment planning
Assessment of obsessions, compulsive rituals, avoidance strategies and anticipated consequences of confronting feared situations
15 hours of treatment sessions, about 90 minutes each

key requirements for ERP success

Physiological arousal and subjective fear must be evoked

Fear responses must gradually diminish during exposure

Initial fear response at the beginning of each exposure session
should decline across sessions

efficiency of ERP

Improvement rates 50-70%

Cognitive Therapy + Delivery

Targets faulty beliefs that lead to obsessive fear

Rationale for treatment

Socialized to the cognitive behavioral framework for understanding OCD

Biological Treatment for OCD

SSRI
20-40% reduction in obsessions and compulsions

Neurosurgical treatment (not favourable)

Panic Disorder and transdiognostic

Panic occurs in many situations ex: SAD

highly transdiognostic

Motivational Enhancement theory

a therapy designed to quickly produce internally motivated change, helps to develop internal motivation to change

Environmental Moderators of social anxiety

Parental anxiety: Can be a diathesis and/or stress

Insecure attachment: high parental rejection, low parental warmth

Stressful social experiences: Rejection, Victimization

in vivo exposure

Gradual exposure to feared situations in order to extinguish fear

Examples for panic disorder in vivo exposure:
Driving
Public Transporation
Bridges
Waiting in lines

Nomothetic

on average what happens in certain treatments and how they work

Idiographic

what is going to work for that particular person

dysfunctional beliefs of OCD

inflated responsibility, overestimation of threat, exaggeration of the importance of thoughts, need to control thoughts, perfectionism, uncertainty

Experiment to prove sub-threshold Psychopathology

2000 female twin pairs with symptoms of depression
Tested:
Risk of depression recurrence over 5 years
Risk of depression in co-twin over 5 years

Conclusion:
DSM diagnostic criteria are not reflective of natural discontinuity in depressive symptoms as experienced in the general population

Line separating no diagnosis from diagnosis is arbitrary - a convection not a fact

Traumatic stressors stats

quite common with a lifetime prevalence of trauma being 60.7% for men and 51.2% for women

strong predictors of unhealthy trauma recovery

- Severity of event
- Lack of social support
- Ongoing post-event stress

PTSD DSM-5 Criteria

A. exposure
- direct, eyewitness, learning, repeated
B. Intrusion
C. Avoidance
D. Negative cognition and mood
E. Hyperarousal

F. 1 month or more
G. distress impairment
H. Not another disorder

Acute Stress Disorder (ASD)

occurs within a month after exposure to traumatic stress

PTSD diagnostic specifier add ons

Presence of depersonalization

Presence of Derealization

Genetic factors of PTSD

1/3 of the variance in PTSD may be attributed to genetic factors

most studied candidate gene is 5-HTTLPR polymorphism

FK506-binding protein 5 is a marker of the HPA axis

Neaurobiological changes with PTSD

Decreased mPFC activation and increased amygdala activation

hippocampus changes

Classical conditioning model of PTSD

The experience of danger or perceived danger is the unconditioned stimuli (US) which then leads to the development of learned danger signals (the conditioned stimuli CS)

criticism of Classical conditioning model of PTSD

If a traumatic or stressful life event is conceptualized as a central etiologic event, then exposure should almost inevitably lead to disorder - which it does not

Impaired fear extinction hypothesis

People with PTSD have impairments in learning new inhibitory associations to trauma-related reminders

Dual representation of memory in PTSD

Provides an account of intrusive memories that makes explicit links to underlying neural processes

Contextual representations (C-reps)

Sensory representations (S-reps)

Contextual representations (C-reps)

Flexible representations that are consciously accessible, context-dependent, and connected to the inferior temporal cortex, hippocampus and Para-hippocampus brains structures

PTSD memory

Sensory representations (S-reps)

Inflexible, involuntary, sensation bound, disintegrated from the autobiographical memory base and are connected to the superior partial areas, amygdala, insula areas of the brain

Memories of the trauma are over represented in S-reps

Cognitive models of PTSD

-maladpative appraisals or interpretations of traumatic event, response and environment are pivotal in perpetuating sense of threat

Emotional models of PTSD

Emphasize the processing of the emotional experience of trauma exposure
A psychodynamic processing model in which PTSD symptoms are the result of an inability to intergrade the traumatic event into existing cognitive schemas

prolonged grief disorder

Prevent the individual from fully processing and accepting the loss of a loved one

Stress disorder

exposure based interventions for trauma

Help reduce trauma related distress by facilitating new learning about the meaning of the trauma and altering maladaptive beliefs about oneself, others, and the world
Prolonged exposure
In vivo exercise
Imagined exposure

ex:
EMDR
NET

Cognitive treatments for trauma

Changes in the person's understanding of the trauma and its meaning in their life

Update the trauma memory

Discussion of key themes:
Challenges to safety
Trust
Power
Self esteem

pre trauma

characteristics of the individual and environment that preceded trauma exposure

-Lower socio-economic status
-Lower intelligence
-Childhood trauma
-Prior adult or child trauma
-Prior worse adjustment

peri-trauma

Characteristics of the trauma and the environmental and individual response to the trauma

Things about the trauma that makes them likely to develop
- Trauma severity
- Perceived life threat
- Peri-traumatic emotions

post-trauma

Individual and environmental factors that occur after the trauma

Things that happened after event that makes them more likely to develop
- Ongoing life stress
- Lack of social support
- Negative cognitions

resilience factors to trauma development

Spirituality

Connections to family

Close bonds with others as a result of shared history, experiences, and culture