AbPsy L6 - Anxiety, Trauma and Stressor and Obsessive Compulsive Disorders (1).pdf

ABNORMAL PSYCHOLOGY Prepared by: Ms. Kezia Rapha F. De Guzman, RPsy, RPm  ❏ The complexity of Anxiety Disorder ❏ Anxiety Disorders ❏ Generalized Anxiety Disorder ❏ Panic Disorder and Agoraphobia ❏ Specific Phobia ❏ Social Anxiet...

ABNORMAL PSYCHOLOGY Prepared by: Ms. Kezia Rapha F. De Guzman, RPsy, RPm  ❏ The complexity of Anxiety Disorder ❏ Anxiety Disorders ❏ Generalized Anxiety Disorder ❏ Panic Disorder and Agoraphobia ❏ Specific Phobia ❏ Social Anxiety Disorder CONTENT ❏ Trauma- and Stressor-Related Disorders ❏ Posttraumatic Stress Disorder ❏ Obsessive-Compulsive and Related Disorders ❏ Obsessive-Compulsive Disorder ❏ Body Dysmorphic Disorder ❏ Other Obsessive-Compulsive and  The Complexity of Anxiety Disorder What is the difference between anxiety, fear, and panic?  Anxiety a negative mood state characterized by bodily symptoms of physical tension and by apprehension about the future - it can be a subjective sense of unease, a set of behaviors (looking worried and anxious or fidgeting), or a physiological response originating in the brain and reflected in elevated heart rate and muscle tension - Howard Liddell (1949) first proposed this idea when he called anxiety the “shadow of intelligence.” - Anxiety is good for us - Too much of it is unhelpful and distracting - Severe anxiety can cause dysfunction and distress  Fear - an immediate emotional reaction to current danger characterized by strong escapist action tendencies and, often, a surge in the sympathetic branch of the autonomic nervous system  Panic - Panic: sudden overwhelming reaction; after the Greek god Pan who terrified travelers with blood curdling screams - Panic attack: an abrupt experience of intense fear or acute discomfort, accompanied by physical symptoms that usually include heart palpitations, chest pain, shortness of breath, and, possibly, dizziness. a. Expected (Cued) panic attack b. Unexpected (uncued) panic attack  Diagnostic Criteria for 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: 1. Palpitations, pounding heart, or accelerated heart rate 2. Sweating 3. Trembling or shaking 4. Sensations of shortness of breath or smothering 5. Feeling of choking 6. Chest pain or discomfort 7. Nausea or abdominal distress 8. Feeling dizzy, unsteady, lightheaded, or faint 9. Chills or heat sensations 10. Paresthesias (numbness or tingling sensations) 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself) 12. Fear of losing control or going crazy 13. Fear of dying Causes of Anxiety and Related Disorders  Biological Contributions Genes - No single gene seems to cause anxiety or panic or any other psychiatric disorder; collection of genes make us vulnerable - a genetic vulnerability does not cause anxiety and/or panic directly. That is, stress or other factors in the environment can “turn on” these genes Brain Circuit and Neurotransmitters - depleted levels of gamma-aminobutyric acid (GABA) increases anxiety - Noradrenergic system and serotonergic neurotransmitter system is also involved - corticotropin-releasing factor (CRF) system as central to the expression of anxiety (and depression) and the groups of genes that increase the likelihood that this system will be turned on  Biological Contributions Brain Circuit and Neurotransmitters - CRF activates the hypothalamic–pituitary–adrenocortical (HPA) axis; effects on areas of the brain implicated in anxiety - emotional brain (the limbic system), particularly the hippocampus and the amygdala; the locus coeruleus in the brain stem; the prefrontal cortex; and the dopaminergic neurotransmitter system - The area of the brain most often associated with anxiety is the limbic system; The more primitive brain stem monitors and senses changes in bodily functions and relays these potential danger signals to higher cortical processes through the limbic system  Biological Contributions Brain Circuit and Neurotransmitters - Jeffrey Gray: a prominent British neuropsychologist, identified a brain circuit in the limbic system of animals that seems heavily involved in anxiety and may be relevant to humans - behavioral inhibition system (BIS): is activated by signals from the brain stem of unexpected events; major changes in body functioning that might signal danger; The BIS also receives a big boost from the amygdala. - When the BIS is activated: our tendency is to freeze, experience anxiety, and apprehensively evaluate the situation - fight/flight system (FFS): BIS circuit that is distinct from the circuit involved in panic; activated partly by deficiencies in serotonin - When stimulated in animals, this circuit produces an immediate alarm- and-escape response that looks very much like panic in humans  Psychological Contributions General sense of uncontrollability - awareness that events are not always in our control - may develop early as a function of upbringing and other disruptive or traumatic environmental factors Upbringing/Disruptive or Traumatic Experiences - parents who interact in a positive and predictable way with their children by responding to their needs - parents who provide a “secure home base” but allow their children to explore their world and develop the necessary skills to cope with unexpected occurrences enable their children to develop a healthy sense of control - parents who are overprotective and over intrusive and who “clear the way” for their children, never letting them experience any adversity  Social Contributions - Stressful events - Can trigger our biological and psychological vulnerabilities to anxiety - Common stressor are social and interpersonal in nature - Marriage, family, school, death, pressure, etc - The same stressor that can trigger physical reactions - Members of the family - The particular way we react to stress seems to run in families since we model or copy what we see from our parents and relatives.  An Integrated Model - Triple Vulnerability Theory - Generalized Biological Vulnerability - first vulnerability (or diathesis)’ heritable tendency - Generalized Psychological Vulnerability - sense that events are uncontrollable/unpredictable; believing the world is dangerous and out of control and you might not be able to cope when things go wrong - Specific Psychological Vulnerability - physical sensations are potentially dangerous; you learn from early experience  - Physical Disorders - Suicide Comorbidity Anxiety Disorders Anxiety Disorders GENERALIZED ANXIETY DISORDERS  Generalized Anxiety Disorder Clinical Description: worrywart / perfectionist; at least 6 months of excessive anxiety and worry; ongoing more days than not; difficult to turn off or control; worry about minor, everyday life events Physical Symptoms: muscle tension, mental agitation, susceptibility to fatigue, some irritability, difficulty sleeping  Generalized Anxiety Disorder Causes: Kendler and colleagues: tendency to become anxious rather than GAD itself. Anxiety sensitivity: tendency to become distressed in response to arousal related sensation  Generalized Anxiety Disorder Causes: a. Physiological responsivity - do not respond as strongly to stressors as individuals with anxiety disorders; less responsiveness on most physiological measures; low cardiac vagal tone leading to autonomic inflexibility; Therefore, people with GAD have been called autonomic restrictors b. Psychological (unconscious mental processes) - Generalized psychological vulnerability - highly sensitive to threat in general; This high sensitivity may have arisen in early stressful experiences where they learned that the world is dangerous and out of control, and they might not be able to cope - Tom Borkovec and his colleagues: although the peripheral autonomic arousal of individuals with GAD is restricted, they showed intense cognitive processing in the frontal lobes as indicated by EEG activity, particularly in the left hemisphere  Generalized Anxiety Disorder Treatment: a. Drug: i. Benzodiazepine ii. Antidepressant: Paroxetine (Paxil) and Venlafaxine (Effexor) b. Psychological: i. Cognitive-behavioral treatment (CBT) ii. Meditational and Mindfulness-based Approaches iii. Meta-cognitions  Anxiety Disorders PANIC DISORDER AND AGORAPHOBIA  Panic Disorder Severe, unexpected panic attacks; in many cases, PD is accompanied by a closely related disorder called agoraphobia Clinical description: - anxiety and panic are combined; must experience an unexpected panic attack and develop substantial anxiety over the possibility of having another attack or about the implications of the attack or its consequences; n must think that each attack is a sign of impending death or incapacitation.  Agoraphobia Coined in 1871 by Karl Westphal, German physician, refers to fear of the marketplace (busy, bustling area) Clinical description: - fear and avoidance of situations in which a person feels unsafe or unable to escape to get home or to a hospital in the event of a developing panic, panic-like symptoms, or other physical symptoms  Agoraphobia Clinical description: - If you had unexpected panic attacks and are afraid you may have another one, you want to be in a safe place or person - Anxiety is diminished if they think a location or person is “safe” - When going out, they plan for rapid escape - Hence, “agoraphobic avoidance is one way of coping - Other coping methods: drugs/alcohol or enduring the anxiety with “intense dread”  Diagnostic Criteria for Agoraphobia A. Recurrent unexpected panic attacks. A panic attack is 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: Note: The abrupt surge can occur from a calm state or an anxious state. 1. Palpitations, pounding heart, or accelerated heart rate. 2. Sweating. 3. Trembling or shaking. 4. Sensations of shortness of breath or smothering. 5. Feelings of choking. 6. Chest pain or discomfort. 7. Nausea or abdominal distress. 8. Feeling dizzy, unsteady, light-headed, or faint. 9. Chills or heat sensations. 10. Paresthesias (numbness or tingling sensations).  Diagnostic Criteria for Agoraphobia 11. Derealization (feelings of unreality) or depersonalization (being detached from one- self). 12. Fear of losing control or “going crazy.” 13. Fear of dying. Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms. B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”). 2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).  Diagnostic Criteria for Agoraphobia The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders). D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety dis- order; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).  Diagnostic Criteria for Agoraphobia A. Marked fear or anxiety about two (or more) of the following five situations: Using public transportation (e.g., automobiles, buses, trains, ships, planes). 2. Being in open spaces (e.g., parking lots, marketplaces, bridges). 3. Being in enclosed places (e.g., shops, theaters, cinemas). 4. Standing in line or being in a crowd. 5. Being outside of the home alone. B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence). C. The agoraphobic situations almost always provoke fear or anxiety. D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.  Diagnostic Criteria for Agoraphobia F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly excessive. I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder); and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder). Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.  Agoraphobia Typical situations avoided: - Shopping malls - Wide streets - Being far from home - Crowds - Cars (as driver or passenger) - Tunnels - Staying at home alone; Buses - Planes Waiting in line - Restaurants - Trains - Elevators - Supermarkets - Theaters - Subways - Escalators - Stores  Agoraphobia Distressing unpredictable experiences ➔ dizzy spells ➔ possible loss of bladder or bowel control such that they can never be far from a bathroom ➔ fear of falling (particularly in the elderly) ➔ any of which might be embarrassing or dangerous if away from a safe place or without the presence of a safe person.  Agoraphobia Interoceptive - Hot, stuffy cars; Hot, stuffy stores or shopping malls Having a sauna Avoidance - - Hiking Walking outside in very cold weather - avoidance of internal - Sports Aerobics - Drinking coffee or any caffeinated physical sensations beverages Examples: - Lifting heavy objects - Sexual relation - Running up flights of stairs - Dancing - Getting involved in “heated” - Watching horror movies - Eating chocolate debates - Eating heavy meals - Walking outside in intense - Standing quickly from a sitting position heat - Getting angry - Having showers with the - Watching exciting movies or sports events doors and windows closed  Agoraphobia Nocturnal Panic Isolated sleep paralysis - panic attacks occur more often between - the individual is unable to 1:30 a.m. and 3:30 a.m. than any other time move and experiences a - occur during delta wave or slow wave sleep, which typically occurs several hours surge of terror; vivid after we fall asleep and is the deepest stage hallucinations of sleep - occurs during the - Causes: the change in stages of sleep to transitional state between slow wave sleep produces physical sleep and waking sensations of “letting go” Sleep terrors - Causes: possible - Often children awaken imagining that explanation is that REM something is chasing them around the room sleep is spilling over into the - they do not wake up and have no memory waking cycle. of the event in the morning  Agoraphobia Causes of PD and Agoraphobia A. Generalized Biological Vulnerability a. Unexpected panic attack b. Conditioning c. Learned Alarms B. Psychological Vulnerability  Agoraphobia Treatment: A. Medication: high-potency benzodiazepines, the newer selective- serotonin reuptake inhibitors (SSRIs) such as Prozac and Paxil, and the closely related serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine B. Psychological Intervention a. Exposure-based treatments b. Panic Control Treatment (PCT) i. Cognitive Therapy ii. Relaxation or breathing retraining c. Calm Tools for Living - computer guide to assist novice clinicians in implementing a cognitive behavioral program C. Combined PSychological and Drug Treatment Anxiety Disorders SPECIFIC PHOBIA  Diagnostic Criteria for Specific Phobia Clinical description: - an irrational fear of a specific object or situation that markedly interferes with an individual’s ability to function - Four major subtypes: - Blood-injection-injury type - Situational Type - Natural Environmental - Animal Type - Others  Diagnostic Criteria for Specific Phobia A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. B. The phobic object or situation almost always provokes immediate fear or anxiety. C. The phobic object or situation is actively avoided or endured with intense fear or anxiety. D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.  Diagnostic Criteria for Specific Phobia E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive- compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).  Diagnostic Criteria for Specific Phobia Specify if: Code based on the phobic stimulus: 300.29 (F40.218) Animal (e.g., spiders, insects, dogs). 300.29 (F40.228) Natural environment (e.g., heights, storms, water). 300.29 (F40.23x) Blood-injection-injury (e.g., needles, invasive medical procedures). Coding note: Select specific ICD-10-CM code as follows: F40.230 fear of blood; F40.231 fear of injections and transfusions; F40.232 fear of other medical care; or F40.233 fear of injury. 300.29 (F40.248) Situational (e.g., airplanes, elevators, enclosed places). 300.29 (F40.298) Other (e.g., situations that may lead to choking or vomiting; in children, e.g., loud sounds or costumed characters). Coding note: When more than one phobic stimulus is present, code all ICD-10-CM codes that apply (e.g., for fear of snakes and flying, F40.218 specific phobia, animal, and F40.248 specific phobia, situational).  Specific Phobia Causes: 1. Direct experience 2. Experiencing false alarm 3. Observing someone else experience severe fear 4. Being told about danger Information Transmission - fear can be acquired through vicarious learning even after watching a brief film clip  Specific Phobia Causes: 1. Direct experience 2. Experiencing false alarm 3. Observing someone else experience severe fear 4. Being told about danger Information Transmission - fear can be acquired through vicarious learning even after watching a brief film clip  Specific Phobia Treatment - specific phobias require structured and consistent exposure- based exercise - the therapist spends most of the session with the individual, working through exposure exercises with the phobia object or situation - patient then practices approaching the phobic situation at home - After treatment, responsiveness is diminished in this fear- sensitive network but increased in prefrontal cortical areas Anxiety Disorders SEPARATION ANXIETY DISORDER  Separation Anxiety Disorder - characterized by children’s unrealistic and persistent worry that something will happen to their parents or other important people in their life or that something will happen to the children themselves that will separate them from their parents - refuse to go to school or even to leave home because they are afraid of separating from loved ones - refusing to sleep alone and may be characterized by nightmares Treatment: - parents are often included to help structure the exercises and also to address parental reaction to childhood anxiety - use of real-time coaching of parents Diagnostic Criteria for Separation Anxiety Disorder A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following: 1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures. 2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death. 3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure. Diagnostic Criteria for Separation Anxiety Disorder 4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation. 5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. 6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. 7. Repeated nightmares involving the theme of separation. 8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated. Diagnostic Criteria for Separation Anxiety Disorder B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults. C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder. Anxiety Disorders SOCIAL ANXIETY DISORDER  Social Anxiety Disorder - Also called Social Phobia Clinical Description - more than exaggerated shyness; people have no difficulty eating, writing, or urinating in private. Only when others are watching does the behavior deteriorate because of fear of being scrutinized - Performance Anxiety - have no difficulty with social interaction, but when they must do something specific in front of people, anxiety takes over and they focus on the possibility that they will embarrass themselves - Anxiety-provoking physical reactions include blushing, sweating, trembling, or, for males, urinating in a public restroom (“bashful bladder” or paruresis) - In Japan: “Shinkeishitsue”; subcategory: “Taijin kyofusho” - In North America: “Olfactory reference syndrome”  Diagnostic Criteria for Social Phobia Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). Note: In children, the anxiety must occur in peer settings and not just during interactions with adults. B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others). C. The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. D. The social situations are avoided or endured with intense fear or anxiety.  Diagnostic Criteria for Social Phobia 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, typically lasting for 6 months or more. G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder. J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive. Specify if: Performance only: If the fear is restricted to speaking or performing in public.  Social Phobia Causes 1. Generalized biological vulnerability to develop anxiety and generalized psychological vulnerability would increase an individual’s vulnerability 2. When under stress, a person might have an unexpected panic attack that would become associated (conditioned) to social cues 3. Someone might experience a real social trauma resulting in a true alarm. Anxiety would then develop (be conditioned)  Social Phobia Treatments 1. Cognitive Therapy Program 2. Interpersonal Psychotherapy (IPT) 3. Social mishap exposures - 4. Family-based treatment approaches 5. Medication: the SSRIs Paxil, Zoloft, and Effexor 6. Combined: Davidson, Foa, and Huppert (2004) found that a cognitive- behavioral treatment and an SSRI were comparable in efficacy but that the combination was no better than the two individual treatments; and Several exciting studies suggest that adding the drug D-cycloserine (DCS) to cognitive-behavioral treatments can enhance exposure therapy Anxiety Disorders Selective Mutism  Selective Mutism Selective Mutism - A rare childhood disorder characterized by a lack of speech in one or more settings in which speaking is socially expected. - clearly driven by social anxiety, since the failure to speak is not because of a lack of knowledge of speech or any physical difficulties, nor is it due to another disorder in which speaking is rare or can be impaired such as autism spectrum disorder. Treatment: - CBT - Socialization - Modeling, - Shaping - behavioral reward system  Diagnostic Criteria for Selective Mutism A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations. B. The disturbance interferes with educational or occupational achievement or with social communication. C. The duration of the disturbance is at least 1 month (not limited to the first month of school). D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation. E. The disturbance is not better explained by a communication disorder (e.g., childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.  RECITATION/ACTIVITY Differential Diagnosis 1. Generalized Anxiety Disorder 2. Panic Disorder and Agoraphobia 3. Specific Phobia 4. Social Anxiety Disorder Trauma- and Stressor- Related Disorders Trauma- and Stressor- Related Disorders POST TRAUMATIC STRESS DISORDER  Post Traumatic Stress Disorder Setting events: - Exposure to a traumatic event - Traumatic event occurred to a close family or friend - Repeated exposure to details of a traumatic event Results / Clinical Descriptions: - Flashbacks: Reexperiencing the event - most often avoid anything that reminds them of the trauma: restriction or numbing of emotional responsiveness - Unable to remember certain aspects of the event  Post Traumatic Stress Disorder Results / Clinical Descriptions: - Chronically over aroused, easily startled, and quick to anger - Reckless or self-destructive behavior - “Dissociative” subtype: have less arousal than normal along with (dissociative) feelings of unreality - Difficulty sleeping / recurring intrusive dreams - Feelings of guilt - the diagnosis of PTSD cannot be made until at least one month after the occurrence of the traumatic event. - Delayed onset: individuals show few or no symptoms immediately or for months after a trauma, but at least 6 months later, and perhaps years afterward, develop full-blown PTSD  Post Traumatic Stress Disorder Results / Clinical Descriptions: - Acute Stress Disorder: - similar to PTSD, occurring within the first month after the trauma, but the different name emphasizes the severe reaction that some people have immediately - 3 days to 1 month after the trauma event; Diagnostic Criteria for Post Traumatic Stress Disorder Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see corresponding criteria below. A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. Diagnostic Criteria for Post Traumatic Stress Disorder B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content. 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play. Diagnostic Criteria for Post Traumatic Stress Disorder 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Diagnostic Criteria for Post Traumatic Stress Disorder D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”). 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). Diagnostic Criteria for Post Traumatic Stress Disorder E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically ex- pressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Diagnostic Criteria for Post Traumatic Stress Disorder Specify whether: With dissociative symptoms: The individual’s symptoms meet the criteria for post- traumatic stress disorder, and in addition, in response to the stressor, the individual ex- periences persistent or recurrent symptoms of either of the following: 1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). 2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures). Specify if: With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate). Diagnostic Criteria for Post Traumatic Stress Disorder Diagnostic Criteria for Post Traumatic Stress Disorder Diagnostic Criteria for Post Traumatic Stress Disorder Diagnostic Criteria for Post Traumatic Stress Disorder  Post Traumatic Stress Disorder Causes - Precipitating event: personal experiences, intensity of exposure - The greater the vulnerability, the more likely we are to develop PTSD A. Generalized Biological Vulnerability - Monozygotic (identical) twin is more likely to develop PTSD than a dizygotic (fraternal) twin - Stress-diathesis model: genetic factors predispose individuals to be easily stressed and anxious - Serotonin transporter gene involving two short alleles (SS) - Characteristics: anxiousness & minimal education - Higher intelligence predicted decreased exposure to trauma event - Reciprocal gene-environment interactions  Post Traumatic Stress Disorder Causes B. Generalized Psychological Vulnerability - early experiences with unpredictable or uncontrollable events; Family instability (uncontrollable, potentially dangerous place) C. Social Factors - Support system - Reaction to trauma is similar across culture D. Neurobiological Systems: - elevated or restricted corticotropin-releasing factor (CRF), which indicates heightened activity in the HPA axis - evidence of damage to the hippocampus has appeared in groups of patients with war related PTSD; adult survivors of childhood sexual abuse  Post Traumatic Stress Disorder Treatment A. Psychological Treatment a. Psychoanalytic Therapy: catharsis; imaginal exposure b. Prolonged exposure therapy c. Cognitive Therapy B. Drugs a. SSRI (Prozac and Paxil) b. D-cycloserine (DCS)  Post Traumatic Stress Disorder Other Related Disorders: A. Adjustment Disorder - Anxious or depressive reactions to life stress that are generally milder than one would see in acute stress disorder or PTSD but are nevertheless impairing in terms of interfering with work or school performance, interpersonal relationships, or other areas of living A. Attachment Disorder - Refers to disturbed and developmentally inappropriate behaviors in children, emerging before five years of age, in which the child is unable or unwilling to form normal attachment relationships with caregiving adults Adjustment Disorder Adjustment Disorder  Post Traumatic Stress Disorder Other Related Disorders: B. Attachment Disorder - Reactive Attachment Disorder - Very seldom seek out a caregiver for protection, support, and nurturance; lack of responsiveness, limited positive affect; fearfulness and intense sadness - Disinhibited Social Engagement Disorder - Shows no inhibitions to approaching adults; engage in inappropriately intimate behavior; willingness to immediately accompany an unfamiliar adult figure Reactive Attachment Disorder Reactive Attachment Disorder Disinhibited Social Engagement Disorder Disinhibited Social Engagement Disorder Acute Stress Disorder Acute Stress Disorder Acute Stress Disorder Acute Stress Disorder Obsessive-Compulsive and Related Disorder Obsessive-Compulsive and Related Disorder Obsessive-Compulsive Disorder  Obsessive-Compulsive Disorder Clinical Description Obsessions are intrusive and mostly nonsensical thoughts, images, or urges that the individual tries to resist or eliminate. Compulsions are the thoughts or actions used to suppress the obsessions and provide relief. Types of Obsessions and Associated Compulsions 1. Symmetry/ exactness/ “just right”: 2. Forbidden thoughts or actions (aggressive/ sexual/religious) 3. Cleaning/contamination 4. Hoarding Obsessive-Compulsive Disorder Obsessive-Compulsive Disorder Obsessive-Compulsive Disorder  Obsessive-Compulsive Disorder Causes early experiences taught them that some thoughts are dangerous and unacceptable because the terrible things they are thinking might happen and they would be responsible - Thought-action fusion - the strength of religious belief - resist the thought by attempting to suppress it or “neutralize” it generalized biological and psychological vulnerabilities must be present for this disorder to develop.  Obsessive-Compulsive Disorder Treatment - Drugs: Clomipramine or the SSRI - Psychological: - Exposure and ritual prevention (ERP) - Cognitive Treatment - Psychosurgery - Deep Brain Stimulation Obsessive-Compulsive and Related Disorder Body Dysmorphic Disorder  Body Dysmorphic Disorder Clinical Description - complain of persistent, intrusive, and horrible thoughts about their appearance, and they engage in such compulsive behaviors as repeatedly looking in mirrors to check their physical features - in attempts to alleviate their concerns; to see whether any change has taken place. - “ideas of reference,”; fear of showing themselves to other people. - suicidal ideation, suicide attempts, and suicide itself are typical consequences of this disorder; - Men tend to focus on body build, genitals, and thinning hair ; Women focus on more varied body areas and are more likely to also have an eating disorder - Age of onset is 20; BDD is also stubbornly chronic; few people with this disorder get married Body Dysmorphic Disorder Body Dysmorphic Disorder  Body Dysmorphic Disorder Causes - Social and Cultural factors - Social and cultural determinants of beauty and body image largely define what is “deformed.” - BDD may not be so strange - we can’t investigate a specific genetic contribution. Similarly, there is no meaningful information on biological or psychological predisposing factors or vulnerabilities  Body Dysmorphic Disorder Treatments - Drugs: clomipramine (Anafranil) and fluvoxamine (Luvox); fluoxetine (Prozac - Exposure and Response Prevention - Plastic Surgery and other Medical Treatments - Dermatology (skin) treatment - plastic surgery - The most common procedures are rhinoplasties (nose jobs), facelifts, eyebrow elevations, liposuction, breast augmentation, and surgery to alter the jawline. Obsessive-Compulsive and Related Disorder Other Obsessive-Compulsive and Related Disorder  Hoarding Disorder - excessive acquisition of things - difficulty discarding anything - living with excessive clutter under conditions - usually begin acquiring things during their teenage years and often experience great pleasure, even euphoria, from shopping or otherwise collecting various items - Retail Therapy - then experience strong anxiety and distress about throwing anything away, - homes or apartments may become almost impossible to live in - don’t consider that they have a problem until family members or authorities insist that they seek help  Hoarding Disorder Hoarding Disorder - extraordinarily strong emotional attachment to possessions, an exaggerated desire for control over possessions, and marked deficits in deciding when a possession is worth keeping or not - Animal Hoarders - Treatment: CBT Diagnostic Criteria for Hoarding Disorder Diagnostic Criteria for Hoarding Disorder  Other OC Trichotillomania - hair pulling disorder - urge to pull out one’s own hair from anywhere on the body - results in noticeable hair loss, distress, and significant social impairments. Excoriation - skin picking disorder - repetitive and compulsive picking of the skin - noticeable damage to skin occurs, sometimes requiring medical attention - embarrassment, distress, and impairment in terms of social and work functioning Diagnostic Criteria for Trichotillomania Diagnostic Criteria for Excoriation  Other OC Treatments: - Psychological - Habit Reversal Training - Drugs - Serotonin-specific reuptake inhibitors RECITATION/ACTIVITY Differential Diagnosis 1. PTSD 2. RAD / DSED 3. OCD 4. BDD Next Topic: Somatic Symptom and Related Disorders and Dissociative Disorders