Exam #2 Flashcards
Separation Anxiety Disorder
Single sentence
Recurrent anxiety or fear concerning separation from an individual to whom they are attached.
What is the difference between anxiety and fear?
Anxiety is a higher level emotion and future oriented.
Fear is a primitive emotion and present oriented.
in DSM 5 the terms are interchangeable
What are the three characteristic components of anxiety?
1) Physiological- Heart pounding, heavy breathing, sweating.
2) Cognitive- What are they thinking? often dictated by schemas. *Key cognitive distortion in anxiety disorders is *catastrophizing- imagining worst case scenarios
3) Behavioural- One of the key behaviours for anxiety disorders is avoidance. Treatment- Individual must face the thing they fear.
Treatment: Drug therapy if physiological is high. Cogntitive therapy is cognitive component is high
Two factor theory of conditioning
Classical conditioning during the acquisition and operant conditioning in the maintenence phase. Used to explain phobias.
Etiology of anxiety disorders
No single cause
Moderate level of concordance in families 30-40%. (higher in some conditions, like agoraphobia).
Biological basis: Fear circuit: Percieve it-> Thalamus, Amygdala, hypothalamus, Periaduaductal grey, brain Stem
Behavioural Factors:
-Classical conditioning may be at the basis of many anxiety disorders. Classical conditioning alone can result in anxiety, while classical and operant conditioning can also result in anxiety. Ie Phobias are explained by a combination of classical and operant conditioning, known as two factor conditioning
- Two Factor Conditioning: Classical Conditioning during the acquisition phase and operant conditioning during the maintenance phase
- Vicarious Learning- Modelling can result in anxiety. Ie Watching 911 and acquiring fear of buildings, planes. So not just limited to classical conditioning
Cognitive Factors: Biased perceptions. Ie Person has a tendency to filter and only and only see negatives of a situation, schemas are often danger related beliefs- the world is dangerous. *Common cognitive distortion is catastrophizing- imagining the worst outcome for a situation.
Interpersonal Factors: If you come from a home where parents are critial and catastrophic then children can internalize this dialogue- known as the internal working model- this pessimistic view of reality is internalized by the children and then as adults they live out their life in a particular way.
Selective Mutism
Consistent failure to speak in social situations
- Can speak in other situations
- Interferes with education or employment
- Duration – at least 1 month
- Lack of speaking not otherwise explained
- Can’t occur exclusively during autism, psychotic disorder
Selective Mutism
Consistent failure to speak in social situations
- Can speak in other situations
- Interferes with education or employment
- Duration – at least 1 month
- Lack of speaking not otherwise explained- ie no language difficulty or medical condition
- Can’t occur exclusively during autism, psychotic disorder
Selective Mutism: Associated Features
- Shyness, fear of embarrassment, social isolation
- Compulsive traits, tantrums, negativism
- normal language skills
Selective Mutism
Consistent failure to speak in social situations
-Can speak in other situations
-Interferes with education or employment
-Duration – at least 1 month
-Lack of speaking not otherwise explained- ie no language difficulty or medical condition
-Can’t occur exclusively during autism, psychotic disorder. With autism the child may be quiet across a wide variety of situations, with selective mutism it is only during social situations. With
psychotic disorders they may be silent as well, but there will be additional factors such as hallucinations and delusions.
Selective Mutism: Associated Features
- Shyness, fear of embarrassment, social isolation
- Compulsive traits, tantrums, negativism
- normal language skills
- Anxiety is usually oresent
- Disorder does not occur in isolation
Comorbid Disorders for selective mutism
- Social Anxiety Disorder
- Seperation Anxiety
- Specific Phobia
Etiology of selective mutism
- Usually in children, not adolescents/adults
- Usually occurs before age of 5
- parents may be shy and withdrawn
- risk factors are high neuroticism and behavioural inhibition
- may receive genetic loading of genetic risk factors combined with behavioural modelling.
Separation Anxiety Disorder
Recurrent anxiety OR fear regarding separation from an individual to whom they are attached.
Associated features for Separation Anxiety Disorder
-Social Withdrawal, Apathy, Sadness
-Concentration Difficulties
Misery when away from home
-Unusual perceptual experiences
-anger and aggression
-need for constant attention and demanding
Comorbidity for seperation anxiety disorder
GAD and specific phobia
Separation Anxiety Disorder
Recurrent anxiety OR fear regarding separation from an individual to whom they are attached.
Distress anticipating separation
Worry about losing attached figure
Refusal/Reluctance to go out or be alone
Refusal/reluctance to sleep without being close to attached figure
Must be chronic pattern for 4 weeks in children or 6 months in adults
Must be distress or impairment
Associated features for Separation Anxiety Disorder
-Social Withdrawal, Apathy, Sadness
-Concentration Difficulties
Misery when away from home
-Unusual perceptual experiences
-anger and aggression
-need for constant attention and demanding
-most prevalent in children under the age of 12 (good prognosis,most grow out of/resolve anxiety)
Associated features for Separation Anxiety Disorder
-Social Withdrawal, Apathy, Sadness
-Concentration Difficulties
Misery when away from home
-Unusual perceptual experiences
-anger and aggression
-need for constant attention and demanding
-most prevalent in children under the age of 12 (good prognosis,most grow out of/resolve anxiety)
In Children- Refusal to go to school
in Adults- problems moving out of the house or getting married
Panic Disorder
Must be series of panic attacks, discrete periods of fear
Panic Disorder
Must be series of panic attacks, discrete periods of fear
Peaks within 10 minutes, meets 4/13 of the criteria for Panic Disorder
**Uncued- occurs out of the blue
1 month or more of:
- Concern about the attacks
- Implications of the attacks
- Change in behaviour
Causes of panic disorder
1st attack begins during a stressful period
- caffeine and other stimulants
- vigorous exercise
- alcohol, weed, and nicotine
What is the cognitive model of panic?
some sort of trigger in the environment(may even be a thought), the person then perceives this trigger as a threat, then apprehension. Bodily sensations intensify which results in catastrophic misinterpretation (ie feeling like they are having a heart attack)
Cognitive model of panic: Trigger-> perceived threat-> Apprehension->Bodily Sensations->Catastrophic Misinterpretation-> Perceived threat
Treatment point of view : Model is useful to explain what is happening to the client.
What is the cognitive model of panic?
some sort of trigger in the environment(may even be a thought), the person then perceives this trigger as a threat, then apprehension. Bodily sensations intensify which results in catastrophic misinterpretation (ie feeling like they are having a heart attack)
Cognitive model of panic: Trigger-> perceived threat-> Apprehension->Bodily Sensations->Catastrophic Misinterpretation-> Perceived threat
Treatment point of view : Model is useful to explain what is happening to the client. Address each stage and how it impacts panic, then begin de-escalation. Get them to examine their own experience
Associated features of panic disorder
Constant feelings of anxiety
- Demoralization
- Absent from work/school
- Disrupted Relationships
Comorbid conditions for Panic Disorder
MDD
GAD
Social phobia
What is the general prognosis for most disorders?
1/3 greatly improve, 1/3 improve somewhat, and 1/3 remain ill.
Comorbid conditions for Panic Disorder
MDD(most common)
GAD
Social phobia
Panic Disorder Differential Diagnosis
Due to general medical condition
-Thyroid problems
Panic Disorder Differential Diagnosis
Due to general medical condition
-Thyroid problems
Substance-induced anxiety disorder
-Stimulants, cannabis, depressant withdrawal
Other anxiety disorders
Social phobia, specific phobia, PTSD
What drugs are used to treat panic disorder?
Tricyclics
Monoamine Oxidase Inhibitors
SSRIs
Benzodiazepines
Panic Disorder Differential Diagnosis
Due to general medical condition
-Thyroid problems
Substance-induced anxiety disorder
-Stimulants, cannabis, depressant withdrawal
Other anxiety disorders:
Social phobia, specific phobia, PTSD
*Determine if it is uncued or not. Uncued = panic disorder
5 steps of Panic Control Treatment
Developed by David Barlow
1) Education
2) Cognitive restructuring about misappraisals
3) Breathing Retraining
4) Interoceptive exposure
5) Behavioural exposure
David Barlow
Developed Panic Control Treatment
List and give a brief definition of all anxiety disorders
Separation Anxiety Disorder *Selective Mutism *Panic disorder *Agoraphobia Specific Phobia *Social Anxiety Disorder GAD Substance/Medication Induced Anxiety Disorder Anxiety due to Another Medical Condition Other Specified Unspecified
5 steps of Panic Control Treatment
Developed by David Barlow
1) Education- Educate the person about their condition.
2) Cognitive restructuring about misappraisals- getting them to restructure catastrophizing.
3) Breathing Retraining- Upper chest breathers are more susceptible to panic attacks. Therefore, teach belly breathing.
4) Interoceptive exposure- Stimulus is internal. Exposure to physiological sensations that precipitate a panic attack, Ie stimulation may be achieved through breathing through a straw, running up stairs etc. then you can intervene to develop coping skills in the moment and de-escalate.
5) Behavioural exposure- Real life situations doing/confronting things that they fear.
What is a Phobia
Marked fear or anxiety about a specific object or situation
Specific Phobia
Marked fear or anxiety about a specific object or situation
-Fear or anxiety is CUED by a specific object or situation
-Exposure provokes fear or anxiety
object/situation is avoided
-Fear is out of proportion to the situation
-Lasts for more than 6 months
Causes distress or impairment
-Not better explained by another mental disorder
What are the 5 sub types of phobias?
1) Animal
2) Natural environment-storms, heights, water
3) Blood-Injection-Injury
4) Situational-tunnels, bridges, flying, enclosed spaces
5) other- Choking, vomiting clowns
4 basic treatments for phobias
Slide 32
1) Systematic Desensitization
2) Graduated Exposure
3) Implosive therapy
4) Flooding
What is systematic desensitization? What are the three main steps associated with this?
1) Relaxation training (tense and relax muscle groups- progressive muscle relaxation)
2) Anxiety Hierarchy- list of 12-20 anxiety generating items, ranked by subjective units of distress SUD
3) Exposure to items when relaxed- they cannot engage in avoidance or it will reinforce the avoidant behaviour
Ie fear of snakes. Start off relaxing. Then on step 2 you choose an item that is the least anxiety provoking. In step 3 you expose them to that item. You expose them to all of the items while they are relaxed, and they cannot avoid it. Must not retreat when they are anxious
Joseph Wolpe
The father of modern behaviour therapy
developed systematic desensitization
Social Anxiety Disorder
- Marked fear or anxiety about one or more social situations
- Fears the display of anxiety
- Social situations almost always provoke anxiety/fear
- Feared situation is avoided or endured with intense anxiety
- Feared situation is out of proportion
- 6 months or more
- Distress/Impairment
- Not better explained by another disorder
What would be a cognitive behavioural model of social anxiety disorder?
Anticipatory Anxiety-> Poor performance-> Embarrassment-> Avoidance (Looped)
Social Anxiety Disorder (Single sentence)
Marked fear or anxiety about one or more social situations
Associated features of social anxiety disorder
Hypersensitive to criticism
- Hypersensitivity to evaluation or rejection
- Unassertive- can be treated with assertiveness training
- Low self-esteem
- Self-conscious- very concerned with how others evaluate them
- Feelings of inferiority
- Less likely to marry
- No friends
- Cling to unfulfilling relationships
- Refrain from dating
- Remain with Family of Origin
- Lack social syntax
What is Rappee’s work? What are the three steps associated with the therapy?
A form of cognitive behavioural therapy, premised in Aaron Beck’s work.
1) Self monitoring- Person keeps via journal for one week or two
- Keeps a record called *Social Situations Record- You get them to track (Situation/ My thoughts/Anxiety/Physical Reaction/Avoidance)
- Ie someone has a fear of people regarding going to the supermarket. Situation: Supermarket Automatic thought, rating Anxiety 0-10, evaluate the physical reactions that they have in those circumstances, track their avoidance patterns.
- Process is education for client
2) Realistic thinking
-Situation-> Thoughts-> feelings
Challenging illogical thought patterns – ‘What is the evidence, what is the probability, alternative interpretations?
Ie someone walks past a table and the people at the table laugh when he walks by. Therapist will suggest alternative interpretations – is it possible that you walked past the table and someone made an unrelated joke? It is likely that someone made a joke and that it doesn’t involve you. Cognitive distortion of personalization- everything is about you. Even if someone is laughing at you, who cares, so what?
3) Graded exposure- Put self in actual situations
-start with low anxiety situations
-have client test-out realistic thinking
Truth of situation may be different from perceived situation
Differential diagnosis of social anxiety disorder
- Fear of object or situation- specific phobia
- Fear of difficulty in escape- Agorophobia
- Fear or contamination/germs etc-OCD
- Fear of past stressor (memories) is associated with PTSD
- Fear of having disease- illness anxiety disorder
- Fear of becoming fat- anorexia
Drug treatments for social anxiety disorder
Beta Blockers
MOAIs
SSRIs
Benzodiazepines
What is Rappee’s work? What are the three steps associated with the therapy?
A form of cognitive behavioural therapy, premised in Aaron Beck’s work.
1) Self monitoring- Person keeps via journal for one week or two
- Keeps a record called *Social Situations Record- You get them to track (Situation/ My thoughts/Anxiety/Physical Reaction/Avoidance)
- Ie someone has a fear of people regarding going to the supermarket. Situation: Supermarket Automatic thought, rating Anxiety 0-10, evaluate the physical reactions that they have in those circumstances, track their avoidance patterns.
- Process is education for client
2) Realistic thinking
-Situation-> Thoughts-> feelings
Challenging illogical thought patterns – ‘What is the evidence, what is the probability, alternative interpretations?
Ie someone walks past a table and the people at the table laugh when he walks by. Therapist will suggest alternative interpretations – is it possible that you walked past the table and someone made an unrelated joke? It is likely that someone made a joke and that it doesn’t involve you. Cognitive distortion of personalization- everything is about you. Even if someone is laughing at you, who cares, so what?
3) Graded exposure- Put self in actual situations
-start with low anxiety situations
-have client test-out realistic thinking
Truth of situation may be different from perceived situation
*perceptions of reality do not make it reality
Why are beta blockers unique for social anxiety disorder?
Different than a lot of other drugs because they operate in the peripheral nervous system, not the CNS. Popping a beta blocker and then going in and giving a presentation
Different things are sources of feedback regarding our thinking. If someone goes in to give a presentation and they are shaking then this in turn affects their thinking. If you take a beta blocker than there is no nervousness, and then you are evaluating your behaviour and think “I must be doing a good job in this situation”
What is agorophobia?
A) Anxiety/fear about: 2 or more
- Using public transportation, being in open spaces
- Being in enclosed spaces, standing in line or being in a crowd
- Being outside the home alone
If you look at these features, if an individual had one of these things then it might point towards a specific phobia, but if they have two or more combined with other criteria then this could be agoraphobia
B) Tend to avoid these situations because of fear of escape or lack of help
C) Situations almost always provoke anxiety
D)Need a companion
E) Anxiety/Fear out of proportion to situation
f) Present for 6 months or more
G) Distress/Impairment
Associated features for agoraphobia
Severe- Completely home bound in 1/3 of cases Abuse of alcohol/sedatives 1.7% of adolescents F to M is about even Mean age of onset is 17 Course is persistent and chronic
Comorbid conditions for Agorophobia
- Anxiety, depressive and substance disorders are comorbid with it
- *Anxiety Disorders will preceed agoraphobia. The individual will have another anxiety condition and then develop agoraphobia
- Depressive and substance secondary to agoraphobia, they follow agoraphobia
Agoraphobia treatment
Confrontive in vivo approaches- Flooding
Generalized anxiety disorder
A) Excessive worry and anxiety, greater than 6 months
B) Can’t control worry
C) Restless, easily fatigued, irritability, difficulty concentrating, muscle tension, sleep disturbances
D) Worry not part of another disorder ie PTSD
E) Impairment
F) Not due to another condition
GAD is a free floating anxiety. The person is constantly anxious about various things
Generalized anxiety disorder
A) Excessive worry and anxiety, greater than 6 months
B) Can’t control worry
C) Restless, easily fatigued, irritability, difficulty concentrating, muscle tension, sleep disturbances
D) Worry not part of another disorder ie PTSD
E) Impairment
F) Not due to another condition
GAD is a free floating anxiety. The person is constantly anxious about various things
Comorbidity for Generalized Anxiety Disorder
Mood problems, other anxieties, substance abuse, headaches and irritable bowel syndrome
Treatment for GAD
Hard to treat- low success rates compared to other anxiety conditions.
Psychotherapy
CBT
Relaxation exercises
Drug treatments- Old and New Generation Anti-Anxiety
What are benzodiazepines? What are the advantages and disadvantages?
Benzodiazepines are Old Generation anti anxiety medication:
Drug of choice for anxiety
Ie. Xanax, Valium, Ativan
Advantage: Rapidly acting
25-30% fail to respond
Problems with benzos: Cross tolerance Tolerance and dependence can occur Impaired alertness Decreased capacity to learn
What is buspar?
New Generation anti anxiety medication
-is a serotonin agonist
Advantages: Not Addictive. No cross tolerance
Problem: 1-3 weeks to take in, effect is not immediate as it is with benzos
Side effects: Loss of balance, headaches, nervousness, agitation, light headedness, nausea
What are some of the medical causes for things like anxiety disorders?
Endocrine Related- Hypo, Hyperthyroidism
Cardiovascular- arrythmia
Respiratory-Pneumonia
Metabolic- Vitamin b12 deficiency
Neurological- encephalitis
Medication induced anxiety disorder
Substance or medication induced anxiety
A) Anxiety or panic attacks
B) B) Due to intoxication-withdrawal, must establish that the substance capable of producing symptoms
C) Not better accounted for by another disorder
D) Does not occur exclusively during delirium
E) Impairment as a result
Causes of substance or medication induced anxiety
*Intoxication
From Alcohol, stimulants, cannabis, hallucinogens, inhalants
Withdrawal
From Alcohol, cocaine, sedatives, hypnotics, anxiolytics
Can also result from Anesthetics, Insulin, Thyroid hormones, oral contraceptives, lithium, antipsychotic and antidepressant meds
What conditions are found in the OCD category? Define each
OCD
1) *Body Dysmorphic Disorder
* 2)Hoarding Disorder (new)
3) *Trichotillomania
4) *Exoriation Disorder (new)
5) Substance/Medication Induced
6) OC Due to Medical Condition
7) Specified and Unspecified OCD
What is OCD?
OCD
A)Obsessions AND/OR Compulsions – usually both, but may only be only one
B) Very time consuming -Individuals engage in these obsessions or compulsions for more than one hour a day OR marked distress OR impairment
C) Not due to Substance/Medication
D) Not due to general medical condition
Specifiers of OCD
tick related, delusional specifiers
Obsessions
Persistent ideas, thoughts, impulses or images that are intrusive and distressing to the individual
Ego-dystonic- they are foreign to an individual. The thoughts pop in and they cant believe they are thinking about themselves
Contamination, Repeated doubts ( both very common), need for order, aggressive or sexual impulses
Not everyday concerns ie bills etc must be intrusive and very disturbing
Attempts to ignore or suppress them, but the harder they try to suppress the obsessions, the stronger that they come back
Compulsions
Repetitive behaviours OR mental acts. This differentiation is important, If compulsions are overt and involve behaviour then you have a greater probability of treatment success than if they are mental acts, because a client may not admit to you that they are having these mental acts.
Behaviours- Washing, Checking are the two most common
Mental Acts: praying or counting. Ie praying all day compulsively to the point that nothing else gets done
Goal is to reduce anxiety- although objectively it is unreasonable and excessive
Excessive or unreasonable
Time consuming- 1 hour plus per day
OCD Symptoms and subtypes
93% of the time both Obsessions and Compulsions
5% just Obsessions
2% just Compulsions
Specifiers of OCD
tick related, delusional specifiers
With good or fair insight- the person recognizes that what they are doing is irrational or unreasonable, they cant help themselves from doing it, but they realize that its totally irrational, but they just cant help themselves
Some have poor insight- here they may think that they are reasonable in what they are doing. There may be no insight
With absent insight/delusional beliefs- has a psychotic element to it.
with tic-related- OCD and tics tend to be comorbid
What is an obsession? What is a compulsion?
Obsessions are persistent ideas, thoughts, impulses or images that are intrusive and distressing to the individual Compulsions are Repetitive behaviours OR mental acts
What disorders are comorbid with OCD?
MDD- Most common. Sometimes MDD precedes OCD and then other times MDD is secondary to OCD. The majority of the time it is OCD first and then MDD.
Phobias travel with OCD
Eating disorders like bulimia
Explain what ERP is, how succesful is it?
ERP is the gold standard for OCD treatment. Stands for Exposure with Response Prevention.
ERP= Exposure to fear stimulus+ prevention of response
Explain what ERP is, how succesful is it?
ERP is the gold standard for OCD treatment. Stands for Exposure with Response Prevention.
ERP= Exposure to fear stimulus+ prevention of response
Operant conditioning of OCD
Argument is the Antecedent is the obsession that they are exposed to. Behavioural part is the compulsion. Consequence is negative reinforcement for what they do
Exposure to the thing you fear, then prevented from engaging in the compulsion
Breaking the connection between the antecedent and the behaviour. Teaching them that bad things don’t happen when you don’t engage in the behaviour
ERP success- Very successful. 75% are still symptom free 5 years after ERP.
What is a cingulotomy?
A surgical treatment for OCD. utilized when all other treatments have failed.
Medical approaches to OCD
Gold standard for treatment with OCD from a medical point of view is an SSRI **
SSRI combinations with lithium, buspar, antipsychotic. Depending on secondary features
Ie anxiety- add in buspar, depression-lithium, tics/delusional-antipsychotic medication
If medications don’t work, ECT may be used. If ECT doesn’t work, you may do a cingulotomy
Cingulotomy- brain surgery- very last step, everything else has been tried. ERP, ECT, and Drugs.
Cinguolotomy isn’t always effective
The Cingulum is destroyed by a surgical probe
What disorders are comorbid with OCD?
MDD- Most common. Sometimes MDD precedes OCD and then other times MDD is secondary to OCD. The majority of the time it is OCD first and then MDD.
- Phobias travel with OCD
- Eating disorders like bulimia
5 Associated features OCD
Avoidance of situations Hypochondriacal concerns Pathological sense of responsibility Sleep disturbances Excessive use of alcohol or sedative
What is body dysmorphia?
Preoccupation with an imagined defect in appearance . Imagined is key
They must engage in repetitive behaviours at some point in the course of the condition. Ie People with BDD will constantly look in the mirror, excessive grooming, preoccupation with area, mental comparisons constantly to other people
- causes distress or impairment- difficult for them to hold jobs
- not better accounted for by another disorder
What are the specifiers for body dysmorphia disorder?
**Specificers- with muscle dysmorphia*-new to DSM 5- Ie an individual believes they are physically too small. Happens to some weightlifters who grow muscles but still think that they are too small
With good or fair insight- varying degrees
With poor insight
With absent insight/Delusional beliefs
Differential diagnosis of Body Dysmorphic Disorder
Normal concerns about appearance
Eating disorders- * here concern is about their weight. If it is height then BDD
OCD-related disorders
-Excoriation- Skin picking is the focus of behaviour
Trichotillomania-Hair pulling is the focus of behaviour
-Certain psychotic disorders such as somatic delusion
In early versions of the DSM it is sometimes difficult to tell the difference between BDD and somatic delusion- one way to tell the difference is that with BDD you are looking at a specific area (usually hair, skin or nose) tied to appearance. With somatic delusion the person is likely concerned about bodily sensations or function of body
Hoarding Disorder
Hoarding Disorder New to DSM 5 A)Individuals that have difficulty discarding or parting with items B) Distress at the idea of discarding items C) Congest and Clutter D) Distress or Impairment E) Not due to another medical disorder F) Not due to another mental disorder
Trichotillomania
A) Compulsive urge to pull out one’s hair B) Attempts to stop this activity C) Distress or impairment D) Not due to another medical disorder E) Not due to another mental disorder
Excoriation disorder
A) Recurrent skin picking B) Tries to stop C) Distress or impairment D) Not due to another medical condition E) Not due to another mental disorder
Key physical features associated with body dysmorphic disorder are
hair, skin, nose
Hoarding disorder specifiers
- With excessive acquisition*
- With good or fair insight
- With poor insight
- With absent insight/delusional beliefs
