Stress and Anxiety Disorders

Stress and Anxiety Disorders

• Characterized by elevated anxiety levels in the nervous system.
• Commonly co-diagnosed with mood disorders, but distinguished by the focus on anxiety rather than depressed functionality.
• Diagnosis considers biological symptoms within the context of environmental stressors.

Hans Selye's General Adaptation Syndrome

• Reflects excessive biological response or exhaustion in Generalized Anxiety Disorder (GAD).
• GAD describes how we respond to environmental stressors.
• Stages: alarm (fight/flight), resistance, and exhaustion (stress-related illness).
• Effects are influenced by the nature of the stressor (good/bad, short/long-term).

Post Traumatic Stress Disorder (PTSD)

• A long-term negative reaction to a traumatic event.
• Triggering event is usually life-threatening with a feeling of being trapped and powerless.
• DSM5 expanded to include people who did not directly experience the event (social workers).

PTSD: DSM Criteria

• Stressor: exposure to actual or threatened death, serious injury, or sexual violence (excluding non-professional media exposure).
• Intrusion Symptoms: persistent re-experiencing through memories, nightmares, dissociative reactions, distress after reminders, and physiologic reactivity.
• Avoidance: of trauma-related stimuli.
• Negative Alterations in Cognitions and Mood: dissociative amnesia, negative beliefs and expectations, self-blame, negative emotions, diminished interest, alienation, constricted affect.
• Alterations in Arousal and Reactivity: irritability, aggression, destructive behavior, recklessness, hypervigilance, exaggerated startle response, concentration problems, sleep disturbance.

Challenges Surrounding PTSD

• Military populations face fear of appearing weak.
• Expectations of military role (toughness) and potential undermining of career options deter treatment.
• Skepticism about treatment and lack of local support resources are also barriers.

PTSD and Pandemic

• Healthcare workers and survivors of near-death Covid-19 are at risk.

Anxiety Disorders

• Characterized by abnormal arousal, tension, fear, or a sense of foreboding trouble.
• Symptoms can be physical, emotional, cognitive, and behavioral.
• More often diagnosed in women than men due to factors like increased paid labor but remaining unpaid emotional labor and possible misdiagnosis where women more likely to get diagnosed with anxiety over ADHD due to underlying bio differences, cultural stigmas or circumstance specific to women (postpartum).
• Includes Generalized Anxiety Disorder (GAD), panic disorders, and phobic disorders.

Panic Disorder

• Recurring experiences of intense panic with no obvious trigger or cause.
• Manifested in bodily symptoms (heart rate, shortness of breath, sweating, dizziness).
• Panic attack features feelings of losing control or dying.
  • Uncued: no obvious trigger, out of the blue.
  • Situationally bound: specific, usually known trigger.
  • Can build over 10-15 minutes and last several minutes at worst.
• Driven by a combination of cognitive and biological factors.
• Suffocation False Alarm Theory: Minor cues of suffocation lead to disproportionate response from respiratory and alarm systems.
• Low levels of GABA can also cause it.
• DSM criteria: at least one of the attacks has been followed by 1+ month of:
  • Persistent concern about having additional attacks.
  • Worry about implications of attack or consequences (losing control, heart attack, "going crazy").
  • A significant change in behavior related to attacks.

Phobic Disorders

• An irrational fear, disproportionate to or without an objective basis.
• Powerful or overwhelming enough that it affects the way you live your life.
  • Specific phobias typically have earlier onset (often in childhood).
  • Social phobia and agoraphobia usually later onset (adulthood).

Phobic Disorders: Agoraphobia

• Fear of a situation that is "out of proportion to the actual danger in the situation".
• Fear of being in a place from which it will be difficult or embarrassing to escape if a panic attack begins.
• Typical onset around age 28, after several years of build-up.
• Often develops as vicious cycle: panic attacks make person scared to go out, worry about panic attack, triggers anxiety, panic attack when leave due to operant conditioning feedback loop.

Obsessive Compulsive Disorder (OCD)

• Includes related disorders: body dysmorphic disorder, hoarding disorder, trichotillomania (hair pulling), and excoriation (skin picking) disorder.

OCD: DSM Criteria

• Obsessions: recurrent or persistent thoughts or impulses, attempts to suppress or ignore through other thought or action.
• Compulsions: repetitive behaviors in response to obsession or according to rigid rules; behaviors to prevent or reduce stress or prevent some dreaded event that isn't connected.
• Obsessions or compulsions cause marked distress, are time-consuming (take 1+ hour/ day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usually social activities or relationships.
• Often compulsions used to ease anxiety of obsessions.
• Possible problem in feedback from amygdala (emotional experiences/ perceptions of threat).

Stress and Anxiety Disorders: Psychodynamic Perspective

• Anxiety is caused by unconscious fears.
• May impose fear of own impulses onto objects or situations.
• Object may be symbol for something else one fears.
• Treatment focuses on freeing the ego by making it aware of these unconscious urges.

Stress and Anxiety Disorders: Learning Perspective

• Initial association of neutral stimulus with aversive experience; then, avoidance is rewarded with no aversive experience.
• Panic attacks may be triggered by associational cues, and agoraphobic behavior is reinforced by absence of panic attacks.
• PTSD symptoms can be triggered by associational cues.
• Compulsive behaviors earn reward of relief from obsession.
• Classical and operant conditioning play a role.
• Systemic desensitization via gradual exposure to symbolic or actual stimuli.
• Flooding: overwhelming exposure to strong stimuli.

Stress and Anxiety Disorders: Cognitive Perspective

• Anxiety disorders are a product of maladaptive cognitions:
  • Overprediction and anticipation of fear.
  • Exaggeration of risks.
  • Oversensitivity to threat.
  • Oversensitivity to own physical cues.
  • Low level of self-efficacy (belief in our ability to do things).
• Cognitive restructuring seeks to fix thinking, self-defeating thoughts and coping thoughts.

Prolonged Exposure Therapy

• A form of CBT used in treatment of PTSD.
• Assumes emotions were not properly processed at the time of trauma.
• Involves both imaginal exposure to traumatic stimuli within therapy and in vivo exposure outside of therapy.
• Natural inclination of PTSD is avoidance.

Stress and Anxiety Disorders: CBT Treatments

• Virtual reality therapy: exposure to stimulated situations, to help learn to moderate response.
• Relaxation and breathing training.
• Biofeedback, monitoring of own physiological reactions may be used.
• Response prevention in OCD: to see that nothing bad happens when compulsion isn't exercised.
• Social skills training: teaches interpersonal skills and assertiveness to deal with social phobia.

Stress and Anxiety Disorders: Biological Therapy Treatments

• Anti-anxiety drugs are the most common treatment for anxiety-related symptoms.
• Beta-blocker drugs (Propanolol) can be somewhat successfully used for treating PTSD.
  • Does not excise the memory.
  • Reduces intensity of emotional response at time of recall, and occurrence of PTSD symptoms over the long-term.

Mood Disorders

• Unusually severe prolonged disturbances in mood.
• Two DSM categories:
  • Depressive Disorders: major depressive disorder, disruptive mood regulation disorder, premenstrual dysphoric disorder, persistent depressive disorder (dysthymia, more chronic maybe less severe).
  • Bipolar and Related Disorders: bipolar disorder, cyclothymic disorder.

History of Depression

• Hippocrates discussed problem of melancholy.
• Sufferers generally weren't subjected to asylums in the middle ages because they have less behavioral symptoms.
• Wealthy sufferers went to spa-like sanitariums for treatment.
• By the 1930s, psychoanalysis and ECT (40s/50s) had become commonplace treatments.
• Antidepressants (60s,70s,80s,90s).

Major Depressive Disorder: DSM

• Same 2-week period and represent a change from previous functioning.
• Can be comorbid w/ dysthenia.
• Depressed mood, diminished interest and pleasure, weight loss/ gain, appetite changes, slowing of thought, reduction physical movement, fatigue, worthlessness, guilt, attention issues, suicidal/ death ideation.

Major Depressive Disorder

• Estimates are that it affects 10-25% women, 5-12% men at some point in life.
• Both env (SES) and bio risk factors.
• Tied strongly to coping styles.
• When tied to or causing self-efficacy problems, can lead to a downward spiral that continues the disorder.

Coping Styles

• Problem focused coping: focus on solving problem.
• Emotion focused coping focus on emotional response.
• Success depends on type of problem.

Major Depressive Disorder: Biology

• Biological focus took over with 1965 catecholamine hypothesis (norepinephrine imbalance) and 1969 indolamine hypothesis (serotonin).
• Recent research suggests serotonin's role overstated.
• SSRI drugs might work by placebo effect/ a sense of certainty may contribute to improved self-efficacy (indirect improvement to mood).

Major Depressive Disorder: Other Theories of Depression

• Social: the stressful circumstances of people's lives.
• Cognitive: negative or maladaptive habits of thinking and ways of interpreting events.
• Diathesis Stress Model: person has an underlying biological vulnerability which is then triggered by stressors in the environment, diathesis is widely presumed to be genetic.

Major Depressive Disorder: Learned Helplessness (Seligman)

• Person learns that they are not effective in taking control over their own life, learns to rely on social support.
• This leads then to stop trying, which causes further problems, which in turn causes further depression.
• Tied into attributional style and locus of control (internal vs. external).
• Behavior to make positive changes oneself -> not reinforced, even punished.

Major Depressive Disorder: Interactional Theory

• At first people receive unconditional support.
• Over time supporters become angry at lack of progress (difficulty social skills of individual).
• This leads to rejection and further depression.
• Research supports broad model, but suggests that social rejection is based less on anger at actions than it is on poor social skills.

Major Depressive Disorder: Beck's Cognitive Triad Theory of Depression

• Dynamic interacting feedback loop.
• Negative view of oneself, environment, future.
• Distorted, maladaptive thinking is manifested via automatic thought.

Major Depressive Disorder: Treating Depression

• Most commonly treated with SSRIs and talk therapy (cognitive and behavioral).
• In case of seasonal affective disorder, may also be treated with phototherapy.
• People often seek of pharm. treatment with primary physicians vs cognitive therapy.
• As population becomes more skeptical of SSRIs, people take less seriously the depression of those who need the drugs.

Are SSRIs Overprescribed?

• Some ppl taking these die by suicide -> concern about effects.
• Usually tested on only a narrow cross-section of patients who meet struct diagnostic criteria.
• However, then prescribed to a broad cross-section of population without regard to diagnostic criteria.
• Zimmerman found that 86% of depression patients would have been excluded from clinical trials.
• However: 93% of them were prescribed medication.

Bipolar Disorder

• Mood disorder characterized by mood swings between depression and mania.
• Depressive episodes have diagnostic criteria similar to those in major depression.
• Manic episodes can take many forms.
  • Bipolar I: includes one full manic episode.
  • Bipolar II: includes mostly depression with at least one hypomanic episode, but no full manic episode, hypomanic episodes must persist at least 4 days, so shorter than full manic.

Manic Episode: DSM

• Elevated, expansive, irritable.
• Elevated self-esteem, decreased need for sleep, more talkative, flight of ideas, distractibility, increase in goal-directed activity, excessive involvement in activities that have high potential for painful consequences.
• Mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

Bipolar Disorder: Biology

• Mania and depression are reactions to each other.
• Chemistry of brain is self-correcting, but to the extreme.
• Problems in inhibition (don't act)/ disinhibition (act) of the pleasure centers of brain (impulses -> act/ don't act).
• Probably inherited --> relatives 5 times more likely to become afflicted than general public.

Bipolar Disorder: Lithium Carbonate

• Alleviates all or most symptoms for 80% individuals.
• Serious side effects if dosage not precise, side effects include damage to heart and kidneys.
• Problematic because patients are often not conscientious (or are reluctant) about taking their meds bc of pleasurable mania.

Mood Disorders: Broad Theoretical Perspectives

• Psychodynamic perspective: depression is based in mourning loss of someone or something to which you had ambivalent feelings, interpersonal therapy focuses on identifying problems in relationships and unresolved issues.
• Humanistic + Existentialist Perspective: mood disorders occur when people are unable to find meaning and self-fulfillment, loss of self-esteem drives continuing problems, human experience based on finding meaning, religion, confronting mortality.

What Is Normal Child Behavior?

• Perspectives vary by culture.
• Adults in dif cultures view behaviors differently.

ADHD and Culture

• A 2007 meta-analysis found no significant difference in prevalence rates when comparing North America vs. Europe and Asia while diagnosis rates vary greatly.
• While prevalence rates for various disorders might be stable, actual diagnosis rates vary substantially by nation.
• Culture and assumptions are a significant component of category of developmental disorders.

Autism Spectrum Disorder (ASD)

• Disorder characterized by deficits in communication, social behavior, fixated interests (abnormal focus) and repetitive behaviors.
• May be classified as mild, moderate, or severe.
• Milder range includes people formerly diagnosed with Asperger's syndrome (removed from DSM5, not quantitatively different from autism).

ASD: DSM Criteria

• Persistent deficits in social communication and social interaction, social, emotional reciprocity, nonverbal communication cues, relationships, repetitive motor movements, insistence on sameness, fixated interests hyper- or hyporeactivity to sensory input.
• Present in early developmental period, cause clinically significant impairment, not better explained by intellectual disability although often co-morbid.

ASD: Biology

• Recent research find amygdala (limbic system, screening incoming sensory info for threat -> occipital lobe and hippocampus) overreacts to faces, processing most gazes as threatening.
• Lack of eye contact means face perception is impaired in development (face perception vital, very detailed).
• Fusiform area, needed for face perception is fine, but doesn't get enough stimulation.
• Research suggests deficits in right hemisphere.
• Sperm mutations in older father seem to increase rate.
• Biomarkers for neural inflammation, possibly tied to immune response (increased rate false positives).

Autism: Cognitive Learning Perspective

• Brain abnormality allows processing of only one stimulus at a time.
• Right hemisphere more integrative (right hemispheric strokes).
• May have difficulty integrating input from various senses.

Autism: Sociobiology

• Research indicated that part of this is tied to environment, elevated practitioner knowledge, past underdiagnosis.
• Autism "clusters"" much higher diagnosis rate than general population, incidence increase -- typical rate is 4-5 per 10,000.

Autistic Savantism

• Some extremely high level ability (math, art), difficulty to articulate what you are doing.

Treating Autism

• Most rely on intensive behavioral therapy, known as Applied Behavior Analysis (varying), 40hrs/ week for multiple years improved social and intellectual skills, very costly and labor intensive.

Intellectual Disability

• Formerly referred to as mental retardation until DSM5.
• IQ score of 70 or below (2 SD below mean) --> IQ= your abilities/ what's expected for age *100.
• Impaired skills relative to others at same age.
• Development of the disorder before age 18.

Mild Intellectual Disability

• IQ 50-70 (3 SD).
• About 85% of cases.
• Can achieve basic life skills.

Moderate Intellectual Disability

• IQ 35-39.
• About 10% of cases.
• Can develop basic communication and maintenance skills, but limited in progress in academic skills.
• Can still function alone in limited situations.

Severe Intellectual Disability

• IQ 20-24 (estimated).
• Marked developmental delays in motor skills.
• Little or no communication skills.
• May achieve only simple life skills (ex: self feeding) and certain fixed routines.

Profound Intellectual Disability

• IQ need to renorm; when students are tested on a renormed test, they're more likely to be classified as having a disability, in one recent revision, test scores dropped 5.6 points from old version to renormed version.

ADHD: DSM Criteria

• Symptoms present for at least 6 months and inappropriate for developmental level.
• Attention: trouble giving/ holding attention, does not follow through on instructions/ finishing, trouble organizing, avoids dislikes/ reluctant towards long periods of effort, looses things, easily distracted, forgetful.
• Hyperactivity and impulsivity: fidgets, leaves seat unexpected moments, runs or climbs inappropriately, unable to play/ rest quietly, "on the go", talks excessively, blurts out answer, trouble waiting turn, interrupts.

ADHD: Issues with DSM Symptoms

• Large focus on academic/ chore tasks may be problematic in light of American educational structural choices.
• While children may outgrow hyperactivity, inattention may persist into adulthood, leading to under diagnosis in adult population.
• Potential oversight of issues of emotional dysregulation, especially young adults.

ADHD

• Most widely diagnosed childhood disorder (3-5%), usually boys.
• Most diagnosis is tied to hyperactivity symptoms -- diagnosis is tied to hyperactivity symptoms.
• Girls more likely to experience internalized, inattention symptoms without hyperactivity, leading to potential under diagnosis.
• Diagnostic criteria have some broadly interpretable language.

Treating ADHD

• Stimulants like Ritalin and Adderall can have an effect of activating the attention areas of the brain.