Anxiety Disorders & Trauma-Related Disorders Fall 2023 PDF

ANXIETY DISORDERS & TRAUMA AND STRESSORRELATED DISORDERS Advanced Psychopathology Fall 2023 Dr. Fahey Review from last week: Suicide Risk Assessment u Prevalence of suicide u Suicide risk assessment u What to include u Common pitfalls u Treatment u **Everyone should have gotten Response...

ANXIETY DISORDERS & TRAUMA AND STRESSORRELATED DISORDERS Advanced Psychopathology Fall 2023 Dr. Fahey Review from last week: Suicide Risk Assessment u Prevalence of suicide u Suicide risk assessment u What to include u Common pitfalls u Treatment u **Everyone should have gotten Response Papers back u Thank you for patience u Email me or Danielle if you have questions about your paper Questions? Anxiety Disorders Fear and Anxiety u Normal responses to threats u Fear = emotional response to real or perceived imminent threat u Anxiety = anticipation of a future threat u Biologically-based “defense mechanisms” to support survival u Both are associated with physical symptoms (hard to tell them apart) u u Heart palpitations, hyperventilation, escape behaviors, muscle tension, butterflies in your stomach, hypervigilance, avoidance behaviors, etc. Overtime, anxiety becomes associated with maladaptive cognitions and behaviors u Worry thoughts & avoidance behaviors u When they become excessive, long-lasting, and/or developmentally inappropriate, they are considered “abnormal” and may become the focus of treatment u Significant cultural variations u Ex. separation anxiety DSM-5-TR Classifications: Anxiety Disorders Separation Anxiety Disorder Panic Disorder Selective Mutism Specific Phobia Social Anxiety Disorder (Social Phobia) Agoraphobia Generalized Anxiety Disorder Substance/Medicat ion-Induced Anxiety Disorder Anxiety Disorder Due to Another Medical Condition Other Specified and Unspecified Anxiety Disorders Persistent (usually 4 weeks or longer for children and 6 months or longer for adults – look at specific disorder) Common Criteria for Anxiety Disorders Triggers almost always provoke anxiety Causes clinically significant distress or impairment in functioning The situations/objects are either avoided, or they are endured with intense anxiety Anxiety is out of proportion to the actual threat posed by the trigger Anxiety is not better explained by another mental disorder, influence of a substance such as medications, or other condition u Prevalence: Anxiety Disorders Statistics (vary by reporting agency) u Most common class of mental disorders in general population u 15% lifetime prevalence – adults (CDC) u 25.1% of 13 – 18-year-olds (NIMH data) u u Women 60% more likely than men to be diagnosed with anxiety disorder u u Or is it just how symptoms are reported…? Generally higher in developed countries vs. developing countries u u 5.9% classified as severe Why do you think this might be? Anxiety disorders are highly treatable but only about 1/3 receive treatment u Why do you think this might be? u Developmentally inappropriate and excessive fear or anxiety about separation from home or attachment figures u Worry about… u Attachment Figure u u Separation Anxiety Disorder (F93.0) losing attachment figure or harm coming to them (illness, injury, disaster, or death) Self u Getting lost, kidnapped, an accident, becoming ill u Core issue: separation from attachment figure u Persistent (4 weeks in children and adolescents, and 6 months in adults) u Associated behaviors: u Clinging to attachment figure u School refusal u Social withdrawal u Refusing to be alone u May experience nightmares of separation and/or physical symptoms u Most prevalent anxiety disorder in children under 12 u Cultural variations in expectation/toleration u Consider role of parent's behavior on child’s behavior Diagnostic Criteria: DSM-5-TR pg. 217 Selective Mutism (F94.0) u Consistently not speaking in specific social situations where there is an expectation to speak (e.g., school) despite speaking in other situations u Interferes with educational/occupational achievement or social communication u Duration of at least one month (not limited to 1st month of school) u Not attributed to lack of knowledge/comfort with spoken language u u Cultural factors of comfort with English language DSM does not identify specific age requirements Diagnostic Criteria: DSM-5-TR pg. 222 How can we distinguish between ASD and selective mutism? u Selective mutism only diagnosed when child has capacity to speak in some social situations; ASD would not be differentiating between situations u ASD would have additional symptoms (flat affect, restricted interests, repetitive patterns of behavior, rigidity, etc.) Specific phobia u u u u u u u Marked fear or anxiety about a specific object or situation that is out of proportion to actual danger posed Provokes fear/anxiety Phobic object is avoided or endured with fear/anxiety Lasting 6 months or more Causes clinically significant distress or impairment in important areas of functioning Can be diagnosed with more than one specifier… Specify (determines coding): Animal u Natural environment u Blood-injection-injury u Situational u u Other Diagnostic Criteria: DSM-5-TR pg. 224 u Objects related to obsessions u u Social situations u u Important Rule Outs for Specific Phobias Posttraumatic stress disorder Separation from home or attachment figure(s) u u Agoraphobia Reminders of traumatic events u u Social anxiety disorder Situations associated with panic-like symptoms or other incapacitating symptoms u u Obsessive compulsive disorder Separation anxiety Concerns of germs related to COVID19 u Within normal limits of concern? Specific Phobia: Additional Considerations & Statistics u NIMH: 12.5% lifetime prevalence (adults) u DSM-5-TR: 8-12% 12-month prevalence (adults) u Lower rates in Asian, African, and Latin communities u Highest among adolescents (16%) u Lowest among older adults (3-6%) Women more likely to be affected (2:1) Average age of onset: 10 u u u u Individuals with specific phobias are up to 60% more likely to make a suicide attempt than individuals without the diagnosis Be sure to differentiate between a phobia vs. fear (meeting diagnostic criteria) Social Anxiety Disorder (Social Phobia) (F40.10) u Marked fear or anxiety about situations exposing the individual to possible scrutiny by others (ex. giving a speech, meeting unfamiliar people, eating/drinking in front of others) u Fear/anxiety about humiliation, embarrassment, negative evaluation, and/or rejection u In children: must occur with peers and not just adults u May be expressed by crying or tantrums, clinging, freezing, or failing to speak u How can you rule out selective mutism? u Situations are avoided or endured with intense fear/anxiety u Persistent and out of proportion to actual threat u Causes significant distress and impairment u Prevalence rates vary globally: u 7% US vs. 2.3% Europe u u Why do you think this is? Highest among non-Hispanic white u More common in women Diagnostic Criteria: DSM-5-TR pgs. 229 u Recurrent, unexpected panic attacks u Panic Disorder (F41.0) u Panic attack: “an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of the following symptoms occur:” u Palpitations, pounding heart, or accelerated heart rate (mimic cardiac event/precursor) u Sweating u Trembling/shaking u Sensations of shortness of breath or smothering u Feelings of choking u Chest pain/discomfort u Feeling dizzy, unsteady, light-headed, or faint u Chills or heat sensations u Numbing or tingling sensations u Feelings of unreality or depersonalization u Fear of losing control, “going crazy,” or dying One of the attacks is followed by 1 month (or more) with one or both of the following: u Persistent worry about having another attack u Significant maladaptive change in behavior (such as avoidance behaviors) Diagnostic Criteria: DSM-5-TR pg. 235 Anxiety vs. Panic Anxiety attack vs. panic attack •Anxiety attack = another common mistake in the language (antisocial, OCD, bipolar, etc.) •Typically used when someone is referring to a strong bout of anxious feelings •Panic attack = collection of specific symptoms (see DSM; pg. 242) •Not a mental disorder; cannot be coded •Can occur in the context of any mental health disorder/some medical conditions •Not used as a specifier in panic disorder Anxiety is triggered by specific event/trigger Panic is unexpected and random •Anxious thoughts within panic disorder focuses on worry about having another panic attack Agoraphobia (F40.00) u Marked fear or anxiety about two or more: u Using public transportation Being in open spaces u Being in enclosed spaces u Standing in line or being in a crowd u Being outside of the home alone u u Fear/avoidance is fueled by thoughts that they might not be able to escape, or help won’t be available, if they develop panic-like symptoms, or other incapacitating/embarrassing symptoms u If medical condition present, fear/anxiety/avoidance is “clearly excessive” 6 months u Distress or impairment present u Consider possible rule outs (social anxiety disorder; OCD; body dysmorphic disorder; PTSD) u Diagnostic Criteria: DSM-5-TR pg. 246 Panic Disorder & Agoraphobia u u Panic Disorder u 1.7% global lifetime prevalence u Highest among American Indian and non-Hispanic Whites u Average age of onset: 20-24 (US); 32 crossnationally u About 1 in 3 adults with panic disorder develop agoraphobia Agoraphobia u Every year, 1-1.7% of adolescents/adults receive diagnosis u Women twice as likely as men Excessive anxiety and worry, more days than not, for at least 6 months, about more than one event/situation/activity Generalized Anxiety Disorder (F41.1) Worry feelings difficult to control Symptoms may include restlessness, feeling on edge, difficulty sleeping and fatigue, muscle tension, irritability, difficulty concentrating Generalized Anxiety Disorder u NIMH/DSM Statistics u u u 12-month prevalence: u 0.9% for adolescents u 2.9% for adults 9% Lifetime prevalence for adults Risk increases with age (peaks in middle age and decreases over time) u Average age of onset: 35 12-month prevalence other countries: 0.2% to 4.3% u Women 2x as likely as men u More common in people from European descent u More common in developed countries u Only 42.3% receive treatment u Anxiety Treatment u Where to start: Understanding the Cycle of Anxiety u Exposure and Response Prevention u u u Build fear hierarchy u Begin at bottom and work way up with exposures u Measure anxiety during exposures u Provide rewards for completed exposures Biofeedback u Focus on the physiological symptoms of anxiety u Teaching clients to manage their physical symptoms when becoming anxious Psychopharmacotherapy u u SSRIs, SNRIs, tricyclic antidepressants, and benzodiazepines Skills training u Example: social skills, public speaking, etc. u Anxiety Treatment (continued…) u Cognitive-Behavioral Therapy u Psychoeducation on diagnosis u Behavioral activation u Thought journaling u Cognitive restructuring of maladaptive thoughts and beliefs u Positive self-statements Paradoxical Intervention for Panic Disorder u Have them do the opposite of what they are afraid of u Concept: If the person can have it voluntarily, this means he/she can also not have it voluntarily. u AKA Have a fake panic attack u Similar to Exposure & Response Prevention Questions about anxiety disorders? Trauma- and Stressor-Related Disorders DSM-5-TR Classifications: Trauma- and Stressor-Related Disorders Reactive Attachment Disorder Disinhibited Social Engagement Disorder Posttraumatic Stress Disorder Acute Stress Disorder Adjustment Disorder Other & Unspecified General Section Criteria Exposure to a traumatic or stressful event Psychological distress following exposure to this event Reactive Attachment Disorder (RAD) (F94.1) u Essential feature: absent or grossly underdeveloped attachment between the child and caregiving adults u Child can form attachments, but due to limited opportunities during early development, they fail to show the behavioral manifestations of selective attachments (aka when they are distressed, they don’t consistently seek comfort, support, nurturance, or protection from caregivers) u Child experienced pattern of severely insufficient care u u Not having basic emotional needs met by caregiving adults &lack of stable or limited attachments opportunities This pattern of insufficient care is presumed responsible for child’s behavior… u Consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers u u Rarely/minimally seeks/responds to comfort when distressed Consistent social and emotional disturbance u Minimal emotional responsiveness; limited positive affect; episodes of unexplained irritability, sadness, or fearfulness u Developmental age of at least 9 months; disturbance evident before age 5 u Often associated with developmental delays Diagnostic criteria: DSM-5-TR pages 295 u Shares etiology with RAD (e.g., social neglect or deprivation & limited opportunities for child to form selective attachments) u Pattern of behavior in which child actively approaches and interest with unfamiliar adults and… Disinhibited Social Engagement Disorder (F94.2) u Overly familiar verbally & physically u Not checking in with adult caregivers when venturing away even in unfamiliar settings u Willing to go off with unfamiliar adult with minimal or no hesitation u Culturally inappropriate u Differential diagnosis: ADHD (social impulsivity) Diagnostic Criteria: DSM-5-TR pg. 298 Posttraumatic Stress Disorder (PTSD) (F43.10) u Development of symptoms following exposure to a traumatic event: “actual or threatened death or serious injury, or sexual violence, or other threat to one’s physical integrity” u Experiencing or witnessing such an event happening to another person, or learning about such an event happening to a family member or close associate, or repeated exposure to aversive details about the event (such as with first responders or psychologists) Diagnostic Criteria: DSM-5-TR pg. 301 Emergence of PTSD u Identified by British soldiers in WWI (~1915) u Given the title “Shell shock” by Charles Myers (British medically-trained psychologist) u u Most original research on Shell Shock is from him and American psychiatrist Abram Kardiner u Shell Shock in France 1914-1918 (1940) u The Traumatic Neuroses of War (1941) Given so that combat Veterans could get treatment & compensation u Similar diagnosis: “neurasthenia” – no treatment or pension given u u The treating physician decided which diagnosis to give Symptoms included u Fatigue, tremor, confusion, nightmares and impaired sight and hearing u Diagnosed when a soldier was unable to function with no obvious cause being identified u Most symptoms were physical so looks different than modern day PTSD u 1917: “In no circumstances whatever will the expression ‘Shell Shock’ be used verbally or be recorded in any regimental or other casually report, or any hospital or other medical document.” u Soldiers were given the diagnosis of “NYDN” = “Not Yet Diagnosed, Nervous” Evolution of PTSD u Became increasingly worse over time, particularly in the British u 1922: the War Office appointed a Committee of Inquiry into Shell Shock u Produced Southborough Report u u u u Novel: All Quiet on the Western Front (1929) u Became a movie that won as Academy Award for Best Picture (1930) u Brought struggles to the mainstream DSM I (1952) = “Gross Stress Reaction” in a “Transient Situational Personality Disorders” section u “Transient response to severe physical demands or extreme emotional stress such as in combat or in civilian catastrophe (fire, earthquake, explosion, etc.)” u Temporary DSM II (1968) = “Adjustment Reaction of Adult Life” in a “Transient Situational Disturbances section.” u u View was well-trained and properly led troops wouldn’t develop it; anyone who developed disorder were undisciplined and unwilling Described as “an acute reaction to overwhelming environmental stress” PTSD not officially added to the DSM until 1980 PTSD Symptom Cluster Mnemonic Device: “TRAUMA” T: A Traumatic event occurred in which the person experienced, witnessed, learned about, or was repeated told details of an actual or threatened serious injury, death, or threat to the physical integrity of self or other and, as a response to such trauma, the person experienced intense helplessness, fear, and horror R: The person Reexperiences such traumatic events by intrusive thoughts, nightmares, flashbacks, or recollection of traumatic memories and images. A: Avoidance, negative Alterations, and emotional numbing emerge, expressed as detachment from others; flattening of affect; loss of interest; lack of motivation; and persistent avoidance of activity, places, persons, or events associated with the traumatic experience U: Symptoms are distressing and cause significant impairment in social, occupational, and interpersonal functioning (patients are Unable to function) M: These symptoms last more than 1 Month A: The person has increased Arousal, usually manifested by startle reaction, poor concentration, irritable mood, insomnia, and hypervigilance PTSD: Other Important Considerations u Specifiers: u u u With dissociative symptoms u Depersonalization (being detached from oneself or observing oneself) u Derealization (unreality of surroundings) With delayed expression (full criteria are met 6 months after the event) How does PTSD differ between children/adolescents vs. adults? u Symptoms are very similar; however, adults are better able to verbalize the traumatic event, how they are feeling, and what they are experiencing. u Children also have a more difficult time recognizing that the frightening thoughts and sensations they feel during flashbacks and memories of the trauma are not real; they often feel that the trauma is happening again. u A child with PTSD is more likely to physically react to these traumatic thoughts and feelings—for example, screaming, hiding or fighting—than an adult. Misconceptions about PTSD u u Only military members develop PTSD u Children u Survivors of sexual assault u Inmates u People who give birth u People who are in an accident Occurs immediately following traumatic event u u Everyone who experiences trauma develops PTSD u u u u Most people experience something traumatic, but only about 9% develop PTSD PTSD looks the same for everyone u u Remember specifier of delayed expression Look at DSM (very complex diagnostic criteria) People with PTSD are violent u Perpetuated by the media u Not universally true PTSD will just go away u May reduce overtime, but not always true u May worsen over time There is no treatment for PTSD u Look at last slide! Many options for people u Prevalence u Lifetime risk estimated at 6.8% in U.S. u Varies greatly based on DSM criteria, age, and ethnoracial background u u PTSD: Prevalence Rates and Treatment Cognitive Behavioral Therapy (CBT) u Education about disorder, cognitive restructuring, relaxation training, stress management, exposure (talking about the event, imaginal, recordings, etc.) u Cognitive Processing Therapy (evidence-based) u u u For children/adolescents Pharmacotherapy u SSRIs and SNRIs u Propranolol (beta blocker for blood pressure) u u Originally used with Veterans Trauma-Focused CBT (evidence-based) u u Highest among Latinx, African American, & American Indian Relieve exaggerated startle response, explosiveness, nightmares, and intrusive reexperiencing Eye Movement Desensitization and Reprocessing (EMDR) u Mixed results from research u a psychotherapy treatment that was originally designed to alleviate the distress associated with traumatic memories Single-session debriefing u Research: not effective and may worsen symptoms Acute Stress Disorder (F43.0) u Essentially same as PTSD but for a duration of 3 days to 1 month u Important not to mistake for a normal reaction to a traumatic event u Differential Diagnosis: u PTSD u Adjustment disorders u Dissociative disorders u Traumatic brain injury u Psychosis Diagnostic Criteria: DSM-5-TR pg. 313 d base r e d Co ecifie p s n upo Adjustment Disorders u Development of emotional or behavioral symptoms in response to an identifiable stressor u Onset within 3 months of the onset of the stressor u Marked distress that is disproportionate to the intensity of the stressor u Significant impairment in social, occupational, or other important areas of functioning u Specifiers: u u With depressed mood u u With anxiety With mixed anxiety and depressed mood u With disturbance of conduct u With mixed disturbance of emotions and conduct u Unspecified Pop quiz tim e differentiate ! How can we between ty pical stress reac tions and a n adjustmen t disorder? Consider context of culture u Migrants & refugees Diagnostic Criteria: DSM-5-TR pg. 319 istress nitude of d g a m e th n be “Whe uld normally o w t a h w s exceed adverse r when the o d te c e p x e ctional ipitates fun c re p t n e v e ” impairment. New: Prolonged Grief Disorder (F43.8) u Death had to have occurred at least 12 months ago u u 6 months for children/adolescents One or both of the following for nearly every day for the last month: u Intense yearning/longing for the deceased person u Preoccupation with thoughts/memories of deceased u person u u Children/adolescents: focused on circumstances of death At least three of the following for nearly every day for the last month: u Identity disruption u Disbelief about death u u Avoiding reminders u Intense emotional pain u Difficulty reintegrating into one’s relationships/activities u Emotional numbness u Feeling like life is meaningless u Intense loneliness Distress and/or impairment Exceed expected social, cultural, or religious norms Diagnostic Criteria: DSM-5-TR pg. 322 Cultural Considerations: Unique Grief practices Around the World u Tearing a Piece of Clothing: In Jewish traditions, immediate family members tear a piece of their clothing as a symbol of the loss and grief they are experiencing. u Sky Burials: An estimated 80% of Tibetan Buddhists choose sky burial instead of burial in the ground as a more organic way of returning the body to nature completely. This ancient death ritual ends with the body being left in an outdoor setting, typically on a hilltop, where birds of prey will consume it. u Scattering at Sea: 90% of families in Hong Kong choose cremation. Many people can’t or don’t want to pay for an expensive cremation niche, and it’s considered taboo to bring the ashes home. As a result, it’s popular to choose an ash scattering ceremony at sea. u Burial Beads: South Korea also has limited space for burial, so families are creative about ways to honor their loved ones. A common practice is to press the cremated remains into colorful beads. Then, they make a display with the decorative beads in a bottle or urn. u Pyre Cremation: On the holy site of the Ganges River banks, Hindu cremation grounds work around the clock to provide cremation services for Indian families. The family wraps the loved one in bright, colorful fabric and performs religious rituals. Then, the body is carried on a bamboo stretcher to the cremation site. u Dancing with the Dead: This death ritual in Madagascar happens five to seven years after the initial burial. The loved one's exhumation allows the family to strip the burial clothing and place them in fresh shrouds. Then a placement ceremony takes place to seal the crypt for another five to seven years. This practice is known as the “turning of the bones” or “dancing with the dead.” u Hanging Coffins: In the northern area of the Philippines, a common death ritual is to carve a beautiful coffin, then place this coffin on the side of a cliff for burial. Before the loved one is placed in the casket, family members participate in certain ceremonies, such as seating the person in a “death chair” and covering them with a blanket. Hope & Resilience (APA, 2022) u Resilience is the process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional, and behavioral flexibility and adjustment to external and internal demands. u A number of factors contribute to how well people adapt to adversities, predominant among them: • • the ways in which individuals view and engage with the world the availability and quality of social resources specific coping strategies Psychological research demonstrates that the resources and skills associated with more positive adaptation (i.e., greater resilience) can be cultivated and practiced. • u Thoughts/reactions on the concept of resilience? Small Groups: Vignette Practice Groups 1 & 2 u Jonathan is a 15-year-old Caucasian male. He was brought to therapy by his biological mother as he has been experiencing stomach pains, head aches, and vomiting whenever he has to go to school. His mother stated that he does not want to leave the house and that he is close to the point of having to repeat his sophomore year as he has missed so much school. His mother shared that he struggles to separate from her and that he does not have many friends. She reported that he has been experiencing these symptoms & challenges for the last year but was unable to identify what triggered them. When trying to talk to Jonathan, he makes no eye contact and only utilizes thumbs up/down to communicate with you. Groups 3 & 4 u Shawna is a 24-year-old Black female. She has sought treatment as she moved to California from New Jersey about 9 months ago and is wanting to make friends/date. She reported that she has tried to make connections with others, but on a recent date she went on, she was “attacked.” When asked for further details, she became tearful and said she didn’t remember. She shared she has been having nightmares about this attack 3-4x/week, she feels tense when in crowded areas, she has had difficulty concentrating at work, and has been feeling ”just really down every day.” She stated she has other previous experiences of being “assaulted” from when she was younger. u What symptoms do you notice (use DSM language)? u What symptoms do you notice (use DSM language)? u What diagnoses are you considering? u What diagnoses are you considering? u What information do you want to know and why is that information important? u What information do you want to know and why is that information important? u Any cultural, ethical, or safety concerns? u Any cultural, ethical, or safety concerns? u Extra, if there is time: u Extra, if there is time: u How do you build rapport with him? u How do you build rapport with her? u Where would you go with treatment? u Where would you go with treatment? Questions? Next week: OCD and Eating Disorders Reminder: Keep attending TA meetings with Danielle