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Abnormal psych test 2 (Autosaved)
Abnormal Psychology (PSYC 3303)
University of Colorado Boulder
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Test 2 Anxiety vs fear •Anxiety –mood-state -Negative affect / neuroticism –Future-oriented: concern about future negative events –executive function circuit is involved –Positive in small amounts –Too little or too much anxiety can be detrimental Fear –Alarm: the danger is here right now –Fight or flight (emotion/motivation circuit) –Amygdala –Can be critically adaptive if danger is real –Underactivation or overactivation can both be detrimental
DSM-5 Anxiety Disorders:Maladaptive and disproportionate fear and/or anxiety responses •Specific Phobias •Generalized Anxiety Disorder •Social Anxiety Disorder •Panic Disorder •Agoraphobia •Obsessive Compulsive Disorder( is now considered a separate disorder, but has some relationship with Anxiety Disorders )
Specific Phobia:DSM-5 Criteria •marked fear or anxiety about a specific object or situation –Animal (spiders, insects, dogs) –Natural environment (storms, heights, water) –Blood-injection-injury (needles, blood, medical procedures) –Situational (airplanes, enclosed places, elevators) •Pervasive and persistent (atypical) –Object/situation always provokes immediate and intense fear or anxiety –object/situation is avoided or endured with intense fear/anxiety –6 months or more •fear /anxiety is out of proportion to the actual danger –May or may not be insightful about this •Leads to significant distress or impairment Risk factors for specific phobias •Related to normative fears •Innate human tendency to fear certain things –Snakes, heights, dark, small places –Angry people •Individual differences in genetic risk
–Vulnerability to anxiety / negative emotions: neuroticism –Physiological reactivity •Exaggerated stress response •High arousal, increased blood flow, respiration –Key: Blood: injection injury seems to be a different process •Decreased blood flow, light headed, pass out •Classical conditioning after exposure to object of phobia –Modeling / indirect exposure: observe fear response by others –Direct exposure
Eitology -nonshared environment=50 percent heritability= shared= example:Classical conditioning leads to flying phobia
Treatment of Phobias •Among the most treatable psychopathologies –May not eliminate fear entirely –Make it more manageable so functioning is not impaired •All therapies: exposure to object of phobia becomes associated with feeling calm and relaxed •cognitive therapy: keep the fear alarm in context •Flooding: sustained exposure to feared stimulus without possibility of escape –Outlast the acute stress response •Systematic desensitization –exposure to feared stimulus in gradual way–paired with relaxation –Break pairing between stimulus and fear (extinction)
panic attack Discrete period of intense fear –rapid onset –short duration –no obvious trigger •Physiological symptoms –cardiac –respiratory
- “neurologic” –gastrointestinal •Psychological features –“derealization” / “depersonalization” –fear going crazy / dying Panic Disorder
–Breath into paper bag
DSM-5 Agoraphobia
- Marked, disproportionate fear in at least two situations –Public transportation –Open spaces–Shops, theaters, lines, crowds •Fear relates to concern that escape might be hard and help unavailable if experience panic •Often develops after a Panic Attack •Begin to avoid situations where an attack may occur •Distress and impairment . Generalized Anxiety Disorder A) Excessive anxiety and worry –Frequent (more days than not) –Pervasive (about a number of events/activities for 6+ months) –Long duration: hours rather than minutes –"free-floating anxiety": both major and minor things B) Difficulty controlling the worry C) three of six symptoms –Restless / keyed up –Easily fatigued –Difficulty concentrating / mind goes blank –Irritability –Muscle tension –Sleep disturbance D) Significant distress and/or impair
Clinical Description of GAD Prevalence
- Lifetime: 9% (4% one-year prevalence)
- 2 : 1 female : male Development and Course –Lifetime worriers, high harm avoidance, neuroticism
- Onset peaks: childhood, early adulthood, elderly –Chronic course without treatment (and sometimes with treatment) Dysfunction –Social withdrawal –Self esteem –Academic performance –Occupational performance –life satisfaction
Nonshared= Heritability=
Shared environment= Diathesis-Stress Mode l•Genetic risk (diathesis) is amplified when it co-occurs with environmental risk factors
- Genetic risk –tendency to experience anxiety –Physiological reactivity
- Environmental influences –Early experiences •Dangerousness of the world •Controllability of scary things –Acute stressful events –Family factors •Modelling of anxiety •Intrusive / controlling parenting Brain mechanisms of GAD
- Not well understood (compared to other disorders) •Smaller and less active frontal cortex •underactive executive function circuit •emotion-reward circuit also involved •Dysregulation of interaction between these circuits seems to be key (vs. specific problem in just one or the other) .•worrying may actually lower the physiological overarousal many people with GAD experience
Cognitive Contributions to Generalized Anxiety Disorder
- hypersensitivity to threat –Actively scan for threatening stimuli –Try to control the threat by intense cognitive processing –"worry about worrying" •Maladaptive "black and white" assumptions about one's ability to deal with anxiety –"If things are not as I wish them to be it will be awful and catastrophic" –"If this event occurs, I can't possibly deal with the outcome" •Intolerance of uncertainty / risk –Any risk is unacceptable and must be controlled –There must be a "correct" solution if I could only find it •Avoidance of physiological sensations –Intense cognitive processing may avoid sensations of anxiety
DSM-5 Social Anxiety Disorder A) Marked fear or anxiety about social situations that may expose the individual to scrutiny by others B) Fear that she or he will act in a way that will be negatively evaluated or offensive to others C) Social situations almost always provoke fear or anxiety D) Social situations are avoided or endured with intense fear or anxiety
•body dysmorphic disorder –preoccupied with perceived defects in physical appearance that are not apparent to others –repetitive behaviors to try to "fix" or mask the defect •hoarding disorder –persistent difficulty discarding or parting with possessions due to perceived value or need to save them –repetitively collect more and more items •trichotillomania and excoriation –repetitive hair pulling or picking at skin to the point that it leads to major hair loss or skin lesions DSM-5 Obsessive Compulsive Disorder:Obsessions •recurrent or persistent thoughts, urges, or images that are: –intrusive –unwanted –distressing (often catastrophic) –dysfunctional / time consuming –often unrealistic / nonsensical •lead to intense anxiety •the individual attempts to: –ignore or suppress the thoughts, urges, or images –neutralize them with another thought or action (this is the compulsion)
Examples of intrusive thoughts reported by individuals with OCD •Impulse to jump out a window •Impulse to push someone in front of a train •“If I say goodbye to someone, they will die” •I will catch a disease from a doorknob / public pool / toilet seat, etc. •my hands are too dirty •idea of swearing at my boss •thoughts of blurting out something in church •forgot to lock the house, turn off the iron, etc.
Common Obsessions reported by individuals with OCD(things we all tend to worry about) •Contamination / dirt / disease •Inappropriate behavior •Aggressive / violent urges •sexual impulses •Accidental harm to self or others •Need for symmetry
DSM-5 Obsessive Compulsive Disorder:Compulsions
- behaviors engaged in to try to prevent the obsession from coming true –something terrible will happen if the compulsion is not completed –clearly excessive
–may not be connected to the obsession in a realistic way
- repetitive behaviors or mental acts–hand washing, ordering, checking –praying, counting, repeating words silently •Cleaning rituals: hand washing, wiping shoes •Checking behaviors –Locks, burner on stove, important papers •Patterned movements and behaviors –Touching, smells, ordering of object
DSM-5 Obsessive Compulsive Disorder:Additional Descriptors
- dysfunctional cognitions –inflated sense of responsibility (protecting others) –tend to overestimate threat –perfectionism and intolerance of uncertainty –believe having a thought is as bad as acting on it, and must be controlled •variable insight about the realistic probability of the focus of the obsession –many individuals: reasonably good or fair insight –5%: very poor or nonexistent insight ; "if I don't engage in the compulsive behavior the event will definitely happen" •30%: comorbid tic disorder or Tourette Disorder–OCD = mental tics? Facts About OCDPrevalence: •2% lifetime•male = females (different from other anxiety-related disorders) Clinical course:
- Onset: 13-15 in males, 20-24 in females •chronic without treatment (often even with treatment)Comorbidity in clinical samples: •20-40% Tourette’s Disorder / Tic Disorder •major depression, Panic disorder
Etiology of OCDFamily and twin studies •4-5 times higher risk to first degree family members
- family risk appears to be primarily genetic •OCD and Tic disorder co-occur in the same families •shared family risk with other Obsessive Compulsive cluster disorders
Development of OCD
Post-Traumatic Stress Disorder •Exposure to an event that would be traumatic to anyone •In many ways a normal response to an abnormal event •Individual differences in risk among those exposed to the same trauma
]Treating PTSD •exposure to feared stimulus in safe / controlled manner –actively imagine the event (or engage with the memories in other ways like revisiting the scene or virtual reality) –"flooding" can be successful in many cases (although not very fun to do...) –always pair with relaxation / cognitive strategies
- target key environmental factors to promote healing –normalization of feelings –access to social support and other sources of comfort
-person attempts to avoid GAD-future anxiety and negative feelings-produce thoughts then challenge them Panic-physiological arousal-produce arousal+ relaxation: challenge attributions about implications Social Anxiety Disorder- social interaction-gradual exposure to social situations and relaxation Simple phobias-object of phobia- gradual exposure to object of phobia and relaxation PTSD- thoughts of trauma-safely “re-enact” trauma plus relaxation
Depressive and Bipolar Disorders Dramatic set of disorders that captures people's interest •Present across the lifespan •Present across cultures, economic strata •Huge individual and societal costs –Millions meet criteria –Economic costs = billions of dollars each year –Incredible human suffering
DSM-5 Major Depressive Episode A) 5 or more of the following in a 2 week period –Depressed mood (emotional) –Diminished pleasure in activities (anhedonia, emotional) –Significant weight loss or weight gain (physical) –Insomnia or hypersomnia nearly every day (physical) –Psychomotor agitation or retardation nearly every day (behavioral) –Fatigue or loss of energy nearly every day (physical) –Feel worthless or excessive /inappropriate guilt (cognitive) –Diminished ability to think or concentrate (cognitive) –Recurrent thoughts of death, suicidal thoughts or attempts (multiple) B) Symptoms cause clinically significant impairment C) Not due to substance use or medical condition
DSM-5:Manic Episode •A distinct period of abnormal mood (at least 1 week)
-elevated-expansive / excited-irritable / agitated •Other features -Inflated self-esteem / grandiosity
- Decreased need for sleep (for days)-Pressured speech-flight of ideas -Distractibility -Increased goal directed activity -Excessive involvement in pleasurable activities with potential for negative consequences •Significant impairment
Other Mood Episodes •Dysthymic Episode -Similar symptoms to depression
- Less severe
- Longer duration: at least 2 years •Hypomanic Episode -Persistent elevated mood -less impairment but similar to mania -Not severe enough to lead to hospitalization •Mixed Episode -Symptoms of mania and depression at the same time
DSM-5 Depressive and Bipolar Disorders •Major Depressive Disorder ("unipolar") –At least one major depressive episode –No current or previous manic or hypomanic episode •Persistent Depressive Disorder -Chronic low grade depressed mood (2+ years) •Bipolar I -At least one manic episode -Nearly all will eventually have a major depressive episode •Bipolar II -Hypomania -Current or past major depressive episode •Cyclothymic Disorder -Chronic, fluctuating mood disturbance -Separate periods of hypomanic and depressive symptoms -Up to half will eventually meet criteria for Bipolar I
Other Specifying Features of Depressive and Bipolar Disorders •Melancholic features –Profound depressed mood, despair, little or no pleasure –Major physical slowing, exhaustion •Psychotic features -Delusional thinking
–Severe stress often precedes onset (not required for diagnosis) •Clinical Course –episodes often last 6 -9 months –episodic course with recovery between episodes –very rare to have a single episode –each subsequent episode is typically more severe Development and Course of Bipolar Disorder •Onset–15 -
- Average: early 20s (and getting younger) •Developmental precursors –childhood impulsivity and hyperactivity –mood dysregulation in childhood –Severe stress often precedes onset (not required for diagnosis) •Clinical Course–manic episode = approximately one week –depression often follows immediately after –recovery between episodes–rare to have a single episode –each subsequent episode is typically more severe •"Rapid-cycling" bipolar disorder-4+ episodes per year -90% female
Causes of Major Depressive and Bipolar Disorders •family studies –all disorders run in families –shared family risk for both depression and bipolar disorder–some family risk is specific to bipolar disorder •Twin studies of major depression –genes account for about 40% of risk –most of this risk also increases risk for bipolar disorder –nonshared environment: 50 -60% of risk •Twin studies of bipolar disorder –genes account for about 80% of risk –some of this genetic risk also increases risk for depression –some genetic risk is specific to bipolar disorder –nonshared environment: about 20% of risk
Brain Correlates of Major Depressive Disorder •Structural and functional neuroimaging –Executive control system underactive –Amygdala hyperactivity –Hippocampus size and activity reduced •Neurotransmitters and stress hormones–chronic stress response •Elevated cortisol (stress hormone) •Lowered immune response–low serotonin
•Neuromodulator; low levels may decrease regulation of other neurotransmitters, permit wider range –Low norepinephrine –bottom line: complex dysfunction across multiple systems, but stress response system is central
Brain Correlates of Bipolar Disorder I •Structural and functional neuroimaging –Increased activity in entire brain during mania–Especially pronounced in amygdala –Hypersensitive to reward –Relative prefrontal cortex underactivation (dramatic during depressive phase) •Neurotransmitters and stress hormones –Elevated cortisol (stress hormone) –depleted serotonin •Neuromodulator loses ability to regulate other neurotransmitter systems– Norepinephrine, dopamine elevated (esp. in manic state)
MDD: Environmental Risk and Protective Factors •Diathesis-stress: interaction with genetic risk •Loss events –Divorce or other end of relationship = a key risk factor –can be more broad -losing a job, friend moving away •Chronic stress –May play a role in comorbidity of MDD and anxiety –Key contributor to relapse •Social support –Protective factor that is often lost when depression hits •A complication: are these risk factors or consequences? –Stressors are a clear risk factor for relapse –Low social support is a risk factor for depression –But depression also leads to a decline in social support –likely both are true: vicious cycle Bipolar Disorder:Environmental Risk and Protective Factors •Similar to MDD–Diathesis-stress: interaction with genetic risk –Loss events –Chronic stress (and severe shorter-term stress) –Social support •"Expressed emotion" in the family (key for relapse) –High levels of anger / distress–intrusive •Substance use –may precipitate –important consequence–dramatically increases risk of subsequent episodes
-Address issues in the context of the couple dyad (Mark Whisman) •Other factors -Exercise -Sleep hygiene -Substance use pharmaceutical treatment Selective Serotonin Reuptake Inhibitors –Prozac, Zoloft, Paxil –Increase availability of serotonin throughout the brain –Hard to overdose –Side effects: weight , sexual dysfunction –controversy about slightly increased risk of suicidal thoughts, aggressive behavior: benefits outweigh the costs, but careful tracking is key
Psychosocial interventions –Behavioral, cognitive, interpersonal, and marital therapies all have documented efficacy –Psychotherapy may reduce risk of relapse (although may need to continue therapy) •medication –SSRIs are effective for at least some individuals –The combined of therapy and medication may be optimal (and this may be particularly true among adolescents and among those with severe depression)
Treatment of bipolar disorder Lithium, antiseizure medication (Depakote, Lamictal), atypical antipsychotics (Abilify) •Frontline treatment –unethical in most cases to treat bipolar disorder without medication –Active mania = damage to the brain if sustained –Significantly reduce risk of relapse and suicide –Depressive phase of bipolar disorder can be very difficult to manage –Still not clear exactly how mood stabilizers work (but dopamine and serotonin are clearly involved) •Adjunctive psychotherapy –Family-focused Therapy (David Miklowitz) –Psychoeducation–Reduce "Expressed Emotion" in the family–Helpful to minimize risk of relapse
Abnormal psych test 2 (Autosaved)
Course: Abnormal Psychology (PSYC 3303)
University: University of Colorado Boulder
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