Final Flashcards
The DSM V criteria for panic attacks
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. The abrupt surge can occur from a calm state or an anxious state:
- Palpitations, pounding heart, or accelerated heart rate
- Sweating
- Trembling or shaking
- Sensations of shortness of breath or smothering
- Feeling of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, lightheaded, or faint
- Chills or heat sensations
- Paresthesias (numbness or tingling sensations)
- Derealization (feelings of unreality) or depersonalization (being detached from oneself)
- Fear of losing control or going crazy
- Fear of dying
DSM V criteria for panic disorder
A. Recurrent unexpected panic attacks
B. At least one of the attacks has been followed by 1 month (or more of one or both of the following:
- Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, going crazy).
- 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).
C. The Panic Attacks are not restricted to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).
D. The Panic Attacks are not restricted to the symptoms of another mental disorder, such as Social Phobia, Specific Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, or Separation Anxiety Disorder
DSM V criteria for agoraphobia
Criterion A: Extreme fear or anxiety concerning two or more following agoraphobic situations:
1) being outside the home alone,
2) public transportation, such as airplanes, buses, subways, etc.,
3) open spaces, including large parking lots or markets,
4) being in stores, theaters, or cinemas, or
5) standing in a line with other people or being in a crowd of people.
Criterion B: The person has become afraid of and may additionally be avoiding these situations because they feel it would be difficult to escape or help would not be available if they were to experience a panic attack or pass out.
DSM V criteria for PTSD
Diagnostic criteria for PTSD include a history of exposure to a traumatic event meeting two criteria and symptoms from each of three symptom clusters: intrusive recollections, avoidant/ numbing symptoms, and hyper-arousal symptoms. A fifth criterion concerns duration of symptoms and a sixth assesses functioning.
Criterion A: stressor
- The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following ways):
- Direct exposure
- Witnessing the trauma
- Learning that a relative or close friend was exposed to a trauma
- Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)
Criterion B: intrusive recollection (1)
- Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
- Recurrent distressing dreams of the event.
- Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: in children, trauma-specific reenactment may occur.
- Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
- Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
Criterion C: avoidance (1)
- Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following.
- Efforts to avoid thoughts, feelings, or conversations associated with the trauma
- Efforts to avoid activities, places, or people that arouse recollections of the trauma
- Inability to recall an important aspect of the trauma
- Markedly diminished interest or participation in significant activities
- Feeling of detachment or estrangement from others
- Restricted range of affect (e.g., unable to have loving feelings)
- Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
Criterion D: negative alterations in cognitions and mood (2)
- Inability to remember an important aspect of the events)
- Persistent and exaggerated negative beliefs about oneself, others, or the world
- Persistent, distorted cognitions about the cause or consequences of the events)
- Persistent negative emotional state
- Markedly diminished interest or participation in significant activities
- Feelings of detachment or estrangement from others
- Persistent inability to experience positive emotions
Criterion E: Altered reactivity (2)
- Irritable behavior and angry outbursts
- Reckless or self-destructive behavior
- Hypervigilance
- Exaggerated startle response
- Concentration problems Sleep disturbance
The remaining 3 criteria are as follows:
- The duration of symptoms is more than 1 month
- The disturbance causes clinically significant distress or impairment in functioning
- The disturbance is not attributable to the physiological effects of a substance or other medical condition
What are the steps in treating panic disorder?
- Psychoeducation
- Cognitive restructuring and breathing retraining
- Exposure
What consists of psychoeducation in treating panic disorder?
Provide accurate information about sympathetic arousal.
a) Adaptive value of anxiety (future danger) & panic (current danger) - activation of “fight or flight response” flee, fight, or free - body gets ready with increased heart rate, less blood in extremities etc. - good for survival
b) First panic attack = “false alarm” due to stress
c) Causes “fear of fear” and of further attacks
d) Leads to interoceptive conditioning & catastrophic misinterpretations of somatic sensations (interpreted of signs of loss of control, death)
e) Three-response system: Physical sensations (heart, sweat, trembling, breath), Cognitions (fear, dying), Behaviors (overbreathing, avoidance, escape) [use Socratic dialog to elicit examples]
f) Cognitive model: interceptive stimuli -> catastrophic misinterpretation -> Three system response (panic) -> further interceptive hypervigilance and misinterpretation.
g) In panic attacks, there is a misappraisal of the demands of the situation and sympathetic nervous system gets activation unnecessarily
h) What you are feeling is frightening but ultimately harmless
i) Anxiety response is very reinforcing - avoid situations to avoid anxious response however it is ultimately dysfunctional
What consists of cognitive restructuring during the treatment of panic disorder?
Teach a set of skills for developing evidence-based appraisals regarding bodily sensations and agoraphobic situations
- Catastrophic misappraisals of interceptive stimuli
- Overestimation of frequency, duration, intensity, consequences
- Disputation through empirical questioning and Socratic dialogue
- Treat thoughts as hypotheses not facts
What consists of breathing retraining during the treatment of panic disorder?
Provide information concerning the effects of hyperventilation and its role in panic attacks and extensive breathing retraining and applied relaxation
What consists of exposure during the treatment of panic disorder?
Repeated exposure to feared internal cues and agoraphobic situations
1. Develop hierarchy (for in vivo exposure)
2. Graduated in vivo exposure (in session, homework)
3. Interceptive exposure (e.g., hyperventilating, spinning, staring, in session and hw)
What is an treatment outline for panic disorder?
Initial Session(s):
Psycho-education and introduce method for self-monitoring (Panic Attack Record).
Intermediate Sessions:
1. Develop a hierarchy of agoraphobic situations (basis for in vivo exposure), introduce coping skills of breathing retraining and cognitive restructuring
2. Breathing retraining and continue cognitive restructuring.
3. Decatastrophize panic attacks.
4. In vivo exposure
- Explore increasingly anxiety-provoking situations.
- Use breathing as coping tool during in vivo exposure
- Exposure therapy not about reducing fear or anxiety, but about the patient facing situation despite anxiety and helping them realize anxiety is not actually harmful.
- Interceptive exposure (induce symptoms similar to panic through a variety of exercises - spinning in chair, holding a push up)
Later sessions:
1. Review past week in vivo exposure, design new experiments, review past week interoceptive exposure , and conduct interceptive exposure in session
2. Add in “naturalistic” interceptive exposure - exposure to daily tasks or activities that have been avoided because of associated sensations (e.g. vigorous physical activity, running up stairs)
3. identify and gradually remove safety signals and protective behaviors (e.g. walking slowly, lucky charms, mobile phones
What are the steps in treating PTSD?
- Psychoeducation
- Development of skills
- Exposure
- Cognitive restructuring
What consists of psychoeducation in the treatment of PTSD?
Psychoeducation:
Re-experiencing stimuli related to the event (internal or external) leads to sympathetic hyperarousal, numbness and avoidance, which prevents “unlearning ,” which in turn leads to more re-experiencing.
Explain the Cognitive model (event - cognition - emotion) -> Worldview changes.
What consists of skill development in the treatment of PTSD?
a) Physical skills: progressive muscle relaxation (PMR), breathing retraining
b) Behavioral skills: exposure
C) Cognitive skills: label distortions, dispute, positive self-verbalizations
What consists of exposure in the treatment of PTSD?
a) Establishment of hierarchy
b) Exposure to feared stimuli
c) Imaginary exposure to trauma
d) Increasing detail and realism
e) Homework: write about event, allowing feeling to dissipate
What consists of cognitive restructuring in the treatment of PTSD?
a) Present symptom diaries identifying distortions (self-blame, dangerous world)
b) Dispute distortions, probabilities, evidence
c) Explore cognitive meaning of event
d) Homework: Write about meaning & identify and dispute” stuck points” (e.g. core beliefs) such as “I don’t deserve to have a family”
