Trauma, Anxiety, Obsessive-Compulsive Disorders PDF

TRAUMA, ANXIETY, OBSESSIVE-COMPULSIVE AND RELATED DISORDERS What happens when we are stressed or when we experience a crisis? FLIGHT-OR-FIGHT RESPONSE -a set of physical and psychological responses that help fight a threat and flee from it. When a stressful situation occurs the hypothalamus a...

TRAUMA, ANXIETY, OBSESSIVE-COMPULSIVE AND RELATED DISORDERS What happens when we are stressed or when we experience a crisis? FLIGHT-OR-FIGHT RESPONSE -a set of physical and psychological responses that help fight a threat and flee from it. When a stressful situation occurs the hypothalamus activates the following: Sympathetic Nervous System Adrenal-Cortical System Physiological changes that occur when the hypothalamus activates the SNS: ▪ The liver releases extra sugar (glucose) ▪ The body’s metabolism increases ▪ Heart rate, blood pressure, and breathing rate increases, and the muscles tense ▪ Less essential activities are curtailed ▪ Saliva and mucus dry up ▪ The body secretes endorphins and the surface blood vessels constrict ▪ The spleen releases more blood vessels When the hypothalamus activates the adrenal-cortical system: TURNS OFF after the threatening stimuli  EMOTIONAL COGNITIVE BEHAVIORAL Terror Anticipation of harm Escape Dread Exaggeration of danger Avoidance Irritability Problems in Aggression Restlessness concentrating Freezing Hypervigilance Worried, ruminative thinking Fear of losing control Fear of dying Sens of unreality WHAT IS A TRAUMA? TRAUMA AND RELATED DISORDERS TRAUMA are events in which individuals are exposed to actual or threatened death, serious injury, or sexual violation (American Psychiatric Association, 2013) POSTTRAUMATIC STRESS DISORDER AND EXTREME FORMS OF TRAUMA ACUTE STRESS DISORDER *The DSM-5 criteria for both disorder requires that the traumatic event happened to someone the sufferers are close to, they repeatedly experience, or they were extremely exposed to the details of the traumatic event.  FOUR TYPES OF SYMPTOMS OF PTSD AND ACUTE STRESS DISORDER ▪ Repeated reexperiencing of the traumatic event ▪ Persistent avoidance of situations, thoughts, or memories associated with the trauma ▪ Negative changes in thought and mood associated with the event ▪ Hypervigilance and chronic arousal  PTSD ACUTE STRESS DISORDER ▪ May experience some symptoms of ▪ Occurs in response to traumas similar to dissociation. For some, it may be prominent those involve in PTSD but is diagnosed when and persistent, and these people can be symptoms arise within one month of the diagnosed with a subtype PTSD with exposure to the stressor, and last no prominent dissociative longer than four weeks. (depersonalization/derealization symptoms) ▪ Dissociative symptoms are common, including numbing or detachment, reduced awareness of surroundings, derealization, depersonalization, and an inability to recall important aspects of the trauma. ▪ At high risk of continuing to experience posttraumatic stress symptoms.  -consists of emotional or behavioral symptoms that arise within three months of the experience of a stressor. ADJUSTMENT -it is a diagnosis for people experiencing emotional and DISORDER behavioral symptoms following a stressor who do not meet the criteria for a diagnosis of PTSD, acute stress disorder, or an anxiety or mood disorder resulting from stressful experience. TRAUMAS LEADING TO PTSD Natural Disasters Sexual Assault ▪ Floods ▪ Tsunamis ▪ Earthquakes ▪ Fires ▪ Hurricanes ▪ Tornadoes Human-made Disasters ▪ War ▪ Terrorists attack ▪ Torture THEORIES OF PTSD ENVIRONMENTAL AND SOCIAL FACTORS People who experience more severe and longer-lasting traumas and are directly affected by a traumatic event. People who have the emotional support of others after the trauma recover more quickly than people who do not. THEORIES OF PTSD Psychological Factors People who already are experiencing increased symptoms of anxiety or depression before a trauma occurs are more likely to develop PTSD following the trauma People with self-destructive, avoidant, and dissociative coping strategies are more likely to experience PTSD (Roberts et al., 2011) THEORIES OF PTSD Gender -Women are more likely than men to experience PTSD and -Women are more likely to develop PTSD because the types of traumas they experience are more stigmatizing than men. Thus, reducing their Cross- social support. cultural Difference -African Americans have higher rates of PTSD than whites, Hispanics, and Asian Americans (Roberts et al., 2011). -Asians had the most reports of being a refugee or a civilian in a warzone. -All racial/ ethnic minority groups were less likely than whites to seek treatment for trauma-related symptoms. THEORIES OF PTSD Gender -Culture appears to strongly influence the manifestation of anxiety: and ATAQUE DE NERVIOS (ATTACK OF NERVES)- found among Latinos Cross- cultural PHYSICAL SYMPTOMS: trembling, heart palpitations, a sense of heat in the chest rising into the head, difficulty moving limbs, loss of consciousness or the mind going blank, memory loss, a Difference sensation of needles in parts of the body (paresthesia), chest tightness, difficulty breathing (dyspnea), dizziness, faintness, and spells. BEHAVIORAL SYMPTOMS: the person begins to shout, swear, and strike out at others.The person then falls to the ground and either experiences convulsive body movements or lies as if dead. NERVIOS- more chronic-anxiety like symptoms among Latinos. It encompasses a broad array of physical ailments and emotional symptom. THEORIES OF PTSD Biological NEUROIMAGING FINDINGS Factors AMYGDALA- responds more actively to emotional stimuli in those with PTSD. MEDIAL PREFRONTAL CORTEX- less active in people with more severe symptoms. HIPPOCAMPUS- shrinkage among with those PTSD. THEORIES OF PTSD Biological BIOCHEMICAL FINDINGS Factors -Resting levels of cortisol among people with PTSD when not exposed to trauma reminders, tend to be lower than among people without PTSD (Yehuda, Pratchett, & Pelcovitz, 2012) -Lower cortisol levels may result in prolonged activity of the sympathetic nervous system following stress. -Extreme or chronic stress during childhood may permanently alter children’s biological stress response, making them more vulnerable to developing PTSD. THEORIES OF PTSD Biological GENETICS Factors -abnormally low cortisol levels and abnormalities in brain responses to emotional stimuli appears to have a genetic basis. TREATMENT OF PTSD COGNITIVE- BEHAVIORAL GOAL: THERAPY AND STRESS -Exposing clients to what they fear to extinguish it. MANAGEMENT -Challenge distorted cognitions that contribute to the symptoms -Help clients reduce stress in their lives. SYSTEMATIC DISENSITIZATION STRESS-INOCULATION THERAPY TREATMENT OF PTSD BIOLOGICAL THERAPY Selective-Serotonin Reuptake Inhibitor Benzodiazepines *The evidence for their effectiveness in treating PTSD is mixed (Institute of Medicine, 2008) SPECIFIC PHOBIA AND AGORAPHOBIA SPECIFIC PHOBIAS -are unreasonable or irrational fears of specific objects or situations (LeBeau et al., 2010) -when people encounter these feared objects, their anxiety is immediate and intense and may sometimes produce panic attacks. -mostly develop in childhood. -90% of those with specific phobia never seek treatment.  SPECIFIC PHOBIAS COMMON: Situational type Animal type -usually involve fear of public -focus is on specific animals transportation, tunnels, bridges, or insects, such as dogs, elevators, flying, or driving. cats, snakes, or spiders. ▪ Claustrophobia is a common Natural environment situational phobia. type -focus on events or situations in the natural environment, such as Blood-injection-or injury storms, heights, or water. type -diagnosed in people who fear seeing blood or an injury.  AGORAPHOBIA -“fear of the marketplace”. -often includes public transportation (being on a bus, train, plane, or boat), open spaces (such as a parking lot), being in shops or theaters, being in crowded places, or being alone anywhere outside their home. -50% of people with agoraphobia have a history of panic attacks (Wittchen et al., 2010). -typically have a history of another anxiety disorder, a somatic symptoms disorder, or depression (Wittchen et al.,2010). -are in their early 20s and is more common in women than in men.  THEORIES OF PHOBIAS PSYHOANALYTIC THEORY ACCORDING TO FREUD: “Phobias result when unconscious anxiety is displaced onto a neutral or symbolic object.”  THEORIES OF PHOBIAS BEHAVIORAL THEORIES -Mowrer's (1939) two-factor theory -Observational learning -Prepared Classical Conditioning  THEORIES OF PHOBIAS BIOLOGICAL THEORIES -The first-degree relatives of people with phobias are three to four times more likely to have a phobia than the first-degree relatives of people without phobias. -Some studies suggest that situational and animal phobias are associated with similar genes, while other studies suggest a general tendency toward phobias that is not isolated to one type of phobia (LeBeau et al., 2010).  TREATMENTS TO PHOBIAS BEHAVIORAL TREATMENTS -modeling, flooding, and systematic desensitization -applied tension technique– is used to treat blood- injection-injury type  TREATMENTS TO PHOBIAS BIOLOGICAL TREATMENTS BENZODIAZINEPINES- reduces anxiety when forced to confront phobic objects. SOCIAL ANXIETY DISORDER Extremely anxious in social situations Extremely afraid of being rejected, judged, or humiliated in public that they are preoccupied with worries about such events to the point that their lives may become focused on avoiding social encounters. More likely to create severe disruption in a person’s life (Bagels et al., 2010). SYMPTOMS: Tremble Perspire Feel confused and dizzy Have heart palpitations, and Have a full panic attack  > ▪ Social Anxiety Disorder is relatively common with a lifetime prevalence of about 12% in the US and 3 to 7% internationally ▪ Women are somewhat more likely than men to develop social anxiety (Lang & Stein, 2001). ▪ Social anxiety disorder tends to develop in either the early preschool years or adolescence. ▪ Co-occurs with mood disorders and other anxiety disorders. ▪ Once it develops, it tends to be chronic when left untreated.  Taijinkyofusho -is characterized by shame about and persistent fear of causing others offense, embarrassment, or even harm through one's personal inadequacies.  THEORIES OF SOCIAL ANXIETY DISORDER Social anxiety, or more generally shyness, runs in families, and twin studies suggest it has a genetic basis (Bogels et al., 2010). Genetic factors do not appear to lead specifically to anxiety about social situations, however, but rather to a more general tendency toward the anxiety disorders (Hettema, Prescott, Myers, & Neal, 2005). Cognitive perspective suggests people with social anxiety disorder have excessively high standards for their social performance. They also focus on negative aspects of social interactions and evaluate their own behavior harshly. They tend to notice potentially threatening social cues and to misinterpret them in self- defeating ways (Heinrichs & Hofman, 2001). They are exquisitely attuned to their self-presentation and their internal feelings (Clark & Wells, 1995). TREATMENTS OF SOCIAL ANXIETY DISORDER ▪ Selective serotonin reuptake inhibitors (SSRls) and serotonin-norepinephrine reuptake inhibitors (SNRls) ▪ Cognitive-Behavioral Therapy ▪ Mindfulness-based interventions  PANIC DISORDER PANIC ATTACKS - short but intense -heart palpitations -trembling -feeling of choking, dizziness, intense dread, and so on *A diagnosis of panic disorder is given when panic attacks become a common occurrence, when they are not usually provoked by any particular situation but are unexpected, and when a person begins to worry about having them and changes behaviors as a result of this worry.  PANIC DISORDER People with panic disorder often fear that they have a life-threatening illness, and they are more likely to have a personal or family history of serious chronic illness. Another common but erroneous belief is that they are "going crazy" or "losing control.” About 3 to 5 percent of people will develop panic disorder at some time (Craske & Waters, 2005; Kessler et al., 2005), usually between late adolescence and the mid- thirties. It is more common in women and tends to be chronic (Craske & Waters, 2005). Many of people who have a panic disorder also show chronic generalized anxiety, depression, and alcohol abuse (Wilson & Hayward, 2005).  THEORIES OF PANIC DISORDER BIOLOGICAL THEORIES -family history and twin studies suggest that the heritability of panic disorder is about 43 to 48 percent (Wittchen et al., 2010). -No specific genes have been consistently identified as causing panic disorder. -The fight-or-flight response appears to be poorly regulated in people who develop panic disorder, perhaps due to poor regulation of several neurotransmitters, including norepinephrine, serotonin, gamma- aminobutyric acid (GABA), and cholecystokinin (CCK; Charney et al., 2000).  THEORIES OF PANIC DISORDER BIOLOGICAL THEORIES ▪ Dysregulation of norepinephrine system in the locus ceruleus ▪ Fluctuations in progesterone levels can affect the activity of both serotonin and GABA neurotransmitter systems. ▪ Increase progesterone can induce mild chronic hyperventilation in women prone to panic attacks. THEORIES OF PANIC DISORDER COGNITIVE THEORIES ▪ People prone to panic attacks tend to: Pay close attention to bodily sensations Misinterpret theses sensations in a negative way Engage in catastrophic thinking ▪ ANXIETY SENSITIVITY- unfounded belief that bodily symptoms have harmful consequences. ▪ Increased interoceptive awareness ▪ Beliefs of controllability of symptoms appear to be important TREATMENTS OF PANIC DISORDER ▪Antidepressants ▪Benzodiazepines ▪Cognitive Behavior Therapy GENERALIZED ANXIETY DISORDER GENERALIZED ANXIETY DISORDER People worry about many things in their lives Focus on worries may shift frequently Spend ample time and energy fearing different situations, avoiding them, and are immobilized by procrastination and indecision, even to the point of needing other’s reassurance PHYSIOLOGICAL SYMPTOMS OF GAD: ▪Muscle Tension ▪Sleep disturbances ▪Chronic restlessness PREVALENCE RATES IN GAD GAD is relatively common, with longitudinal studies showing as many as 14 percent of individuals meeting the criteria for the disorder (Moffitt et al., 2010). More women than men develop GAD (VesgaLopez et al., 2008). It tends to be chronic (Kessler et al., 2002). Most commonly begins in childhood or adolescence Almost 90% of people with GAD have another anxiety disorder and it has a high rates of comorbidity with mood and substance abuse disorders (Grant et al., 2005; Newman et al., 2013). THEORIES OF GENERALIZED ANXIETY DISORDER EMOTIONAL AND COGNITIVE FACTORS ▪ People with GAD report experiencing more intense negative emotions, even compared to people with major depression (Aldao, Mennin, Linardatos, & Fresco, 2010), and are highly reactive to negative events (Tan et al., 2012). ▪ They report feeling that their emotions are not controllable or manageable (Newman et al., 2013). THEORIES OF GENERALIZED ANXIETY DISORDER PHYSIOLOGICAL SYMPTOMS COGNITIVE SYMPTOMS Chronically elevated activity of their SNS Makes a number of maladaptive assumptions Hyperactivity to threatening stimuli THEORIES OF GENERALIZED ANXIETY DISORDER COGNITIVE AVOIDANCE MODEL OF GAD (Borkovec, 2004)- worrying helps people with GAD avoid awareness of internal and external threats. It reduces their reactivity to unavoidable negative events. Michelle Newman and Sandra Llera (2011)- extended the cognitive avoidance model -suggested that people with GAD prefer a chronic but familiar state of distress than sudden shifts in emotion when dealing with negative events. THEORIES OF GENERALIZED ANXIETY DISORDER BIOLOGICAL FACTORS ▪ Heightened activity in the SNS. ▪ Greater reactivity to emotional stimuli in the amygdala. ▪ One theory suggests that people with GAD have a deficiency of GABA or of GABA receptors which results in excessive firing of neurons through many areas of the brain. ▪ Has a modest heritability. TREATMENTS FOR GENERALIZED ANXIETY DISORDER ▪ Cognitive Behavioral Therapy- more effective than benzodiazepine therapy, placebo, or nondirective support therapy ▪ Benzodiazepines- provide a short-term relief for anxiety symptoms. -their side effects and addictiveness preclude long-term use. ▪ Both the tricyclic antidepressant imipramine (trade name Tofranil) and the selective serotonin reuptake inhibitor paroxetine (trade name Paxil) have been shown to be better than a placebo in reducing anxiety symptoms in GAD, and paroxetine improves anxiety more than a benzodiazepine. Venlafaxine (trade name Effexor), a serotonin norepinephrine reuptake inhibitor, also reduces symptoms of anxiety in GAD better than a placebo (Davidson et al., 2008). SEPARATION ANXIETY DISORDER SEPARATION ANXIETY DISORDER ▪ Onset often occurs mostly in childhood. ▪ May refuse to go to school and may experience stomach aches, headaches, nausea, and vomiting due to fears of separation from caregivers. ▪ Have nightmares with themes of separation ▪ Unable to sleep at night unless they are with their caregivers. ▪ Separation anxiety disorder is not diagnosed unless symptoms persist for at least 4 weeks and significantly impair the child’s functioning. ▪ About 3 percent of children under age 11 years, more commonly girls, experience separation anxiety disorder (Angold et al., 2002; Rapee, Schniering, & Hudson, 2009). ▪ Can recur throughout childhood and adolescence when left untreated. ▪ Can significantly interfere with academic progress and peer relationships.  THEORIES OF SEPARATION ANXIETY DISORDER BIOLOGICAL FACTORS ▪ Children with separation anxiety disorder tend to have family histories of anxiety and depressive disorders (Biederman, Faraone, et al., 2001; Manicavasagar et al., 2001). ▪ Twin studies suggest that the tendency toward anxiety is heritable, more so in girls than in boys, although it is not clear that a specific tendency toward separation anxiety is heritable (Rapee et al., 2009). ▪ Behavioral inhibition appears to be a risk factor for developing anxiety disorders in childhood (Biederman et al., 1990, 1993; Caspi, Harrington, et al., 2003).  THEORIES OF SEPARATION ANXIETY DISORDERS PSYCHOLOGICAL AND SOCIOCULTURAL FACTORS ▪ Observational studies of interactions between anxious children and their parents show that the parents tend to be more controlling and intrusive both behaviorally and emotionally, and also more critical and negative in their communications with their children (Hughes, Hedtke, & Kendall, 2008). ▪ Children may learn to be anxious from their parents or as an understandable response to their environment (Rapee et al., 2009). TREATMENTS OF SEPARATION ANXIETY DISORDER ▪ Cognitive Behavioral Therapy- most often used ▪ Drugs used to treat anxiety disorders: Antidepressants- the SSRI Fluoxetine are used most frequently and have been shown to be most consistent in effectively reducing anxiety symptoms in children. Antianxiety drugs– benzodiazepines, stimulants, antihisthamines. OBSESSIVE- COMPULSIVE AND RELATED DISORDERS OBSESSIVE-COMPULSIVE AND RELATED DISORDERS OBSESSIONS COMPULSIONS -thoughts, images, ideas or urges that are -repetitive behaviors or mental acts that an persistent that uncontrollably intrude on individual feels he/she must perform. consciousness, and that usually cause anxiety and distress. OBSESSIVE-COMPULSIVE DISORDER ▪ They are aware that their thoughts and behaviors are irrational, but they cannot easily control them. ▪ The peak age of onset for males is between 6 and 15, and for females between 20 and 29 (Angst et al., 2004; Foa & Franklin, 2001). ▪ Tends to be chronic if left untreated (Leckman et al., 2010). ▪ Obsessional thoughts are distressing, while compulsive behaviors can be time consuming or harmful. ▪ As many as 66% of people with OCD are also significantly depressed (Foa & Franklin,2001). Panic attacks, phobias, and substance abuse are common among OCD sufferers. ▪ Between 1 and 3 percent of people will develop OCD. OBSESSIVE-COMPULSIVE DISORDER ▪ European Americans show higher rates of OCD than African Americans or Hispanic Americans (Hewlett, 2000). ▪ The prevalence of OCD does not seem to differ greatly across countries that have been studied, including the United States, Canada, Mexico, England, Norway, Hong Kong, India, Egypt, Japan, and Korea (Escobar, 1993; Insel, 1984; Kim, 1993). ▪ There is an ambivalent result towards prevalence of OCD among women.  OBSESSIVE-COMPULSIVE DISORDER The most common type of obsession across cultures are: ▪ Aggression, sexuality, religion ▪ Symmetry and ordering ▪ Contamination OBSESSIVE-COMPULSIVE DISORDER ▪ An individual’s compulsion may be logically tied to his/her obsession. ▪ People with OCD often engage in “magical thinking” (Rapoport, 1991).  HOARDING ▪ Epidemiological studies suggest that 2 to 5 percent of the population engage in hoarding -is a compulsive behavior that is closely (Iervolino et al., 2009). related to OCD, but is classified as a separate diagnosis in the DSM-5. ▪ Only a small subset of people who hoard also meet the criteria for OCD, but these people -they cannot throw away their possessions– also tend to have high rates of major even the things that are already considered as depression, social anxiety, and generalized trash. anxiety disorder (Frost et al., 2011; Samuels -they often show emotional attachments to et al., 2008). their possessions (Frost et al., 2012). ▪ People's hoarding behavior often increases as they age (Ayers et al., 2009). TRICHOTILLOMANIA (HAIR-PULLING DISORDER) -have a history of the recurrent pulling out of their hair, resulting in noticeable hair loss. SKIN-PICKING DISORDER -recurrently pick at scabs or places on their skin, creating significant lesions that often become infected and cause scars. *For diagnosis as a disorder, the behavior must cause significant distress or impairment and must not be due to another mental or medical condition (American Psychiatric Association, 2013).  PREVALENCE RATES ▪ The estimated prevalence of hair-pulling disorder is 1 to 3 percent (Christenson, Pyle, & Mitchell, 1991). ▪ It is seen most often in females, and the average age of onset is 13 (Christenson & Mansueto, 1999). ▪ The estimated prevalence of skin-picking disorder is 2 to 5 percent, and it most often begins in adolescence, often with a focus on acne lesions (Stein et al., 2010). BODY DYSMORPHIC DISORDER -excessively preoccupied with a part of their body that they believe is defective but that others see as normal or only slightly unusual. -preoccupations are often on the face or the head. -they spend an average of 3 to 8 hours on their preoccupations and their checking or grooming behavior. -they may seek surgery to correct their perceived flaws (Phillips et al., 2010).. -men and women tend to have different preoccupations in their body parts (Phillips et al., 2010).  PREVALENCE RATES ▪ Body dysmorphic disorder tends to begin in the teenage years and to become chronic if left untreated. ▪ The average age of onset of this disorder is 16, and the average number of bodily preoccupations is about four. ▪ Body dysmorphic disorder is highly comorbid with several disorders, including anxiety and depressive disorders, personality disorders, and substance use disorders (Cororve. & Gleaves, 2001). ▪ Obsessive-compulsive disorder is relatively common in people with body dysmorphic disorder (Stewart, Stack, & Wilhelm, 2008).  THEORIES OF OCD AND RELATED DISORDERS BIOLOGICAL THEORIES ▪ Alterations in the structure and activity of the striatum ▪ Taking drugs that regulate serotonin often gives relief to people with OCD and related disorders ▪ People with OCD who respond to behavior therapy also tend to show decreases in the rate of activity in the caudate nucleus and the thalamus (Schwartz et al., 1996). ▪ A sudden onset of OCD in children is associated with a strep infection (Swedo et al., 1998) ▪ Genes may help determine who is vulnerable to OCD.  THEORIES OF OCD AND RELATED DISORDERS COGNITIVE BEHAVIORAL THEORIES ▪ People with OCD and related disorders are unable to turn off their negative, intrusive thoughts (Clark, 1988; Rachman & Hodgson, 1980; Salkovskis, 1998). ▪ Compulsions develop through operant conditioning– negative reinforcement. ▪ People with hoarding disorder also often have an exaggerated sense of responsibility, feeling guilty about wasting things, having an excessive need to "be ready just in case," and feeling responsible for not "hurting" the item (Frost et al., 2012). TREATMENTS OF OCD BIOLOGICAL TREATMENTS ▪Antidepressant drugs COGNITIVE-BEHAVIORAL TREATMENTS ▪Cognitive-Behavioral therapies that use exposure and response prevention