From Last Class

1. Anxiety Disorders, Part I(Chapter 5)February 26, 2014PSYC 2340: Abnormal PsychologyBrett Deacon, Ph.D.

2. From Last Class • Panic disorder and agoraphobia • Symptoms • Treatment (video)

3. Example Interoceptive Exposure Exercises • Exposure to feared body sensations (“interoceptive exposure”) -Shaking head -Swallowing quickly -Head between legs -Hold push-up -Running in place -Straw breathing -Holding breath -Hyperventilation -Spinning in chair -Staring at spot on wall -Gag response -Caffeine ingestion

4. Interoceptive Exposure Exercises • What is the point of these exercises? • Class exercise: 60 seconds of hyperventilation • Panic-related sensations? • Feared outcomes? • How to use this exercise to help a client with panic disorder

5. Example In VivoExposure Exercises • Exposure to feared places and situations associated with panic -Riding a bus -Riding subway -Standing in lines -Vigorous exercise -Enclosed spaces -Sporting events -Movie theater -Crowded stores -Being home alone -Alone in remote areas -Airplanes -Traveling far from home

6. Case Example: A Client’s In Vivo Exposure Hierarchy Exposure SituationEstimated Anxiety 1. Back of hot car 90 2. Sauna 80 3. Riding crowded elevator 70 4. Walking outside on hot day 65 5. Shopping mall 60 6. Eating in restaurant 50

7. CBT + Medication: Better than CBT Alone? • Are two treatments better than one? • Arguments for combined treatment? • Arguments against combined treatment?

8. Multicenter Comparative Trial (N = 312) of Panic Disorder Treatments • Large clinical trial comparing CBT, imipramine (an older antidepressant), placebo, and their combination (Barlow, Gorman, Shear, & Woods, 2000) • Assessments at post-treatment (3 months), maintenance treatment (6 months later), follow-up (6 months later) • Data presented: % responders (> 40% reduction) on the Panic Disorder Severity Scale (PDSS)

9. Multicenter Comparative Trial Barlow, Gorman, Shear, & Woods (2000)

10. Multicenter Comparative Trial Barlow, Gorman, Shear, & Woods (2000)

11. Conclusions about Combined Treatment Across Anxiety Disorders • No consistent circumstances under which any psychotropic medication enhances exposure • Drug augmentation is more likely when exposure is delivered in a less effective manner • Medication rarely attenuates the effects of exposure • Adding medication to exposure increases cost, side effects, and attrition with no gain in efficacy • Medication does not “complement” exposure

12. Post-Traumatic Stress Disorder • A. Exposure to a traumatic event • B. Re-experiencing the trauma • C. Avoidance of related stimuli and emotions • D. Increased arousal • E. Duration of symptoms > 1 month • F. Clinically significant distress/impairment

13. A. Definition of a Trauma The person has been exposed to traumatic event in which: A.1) The person has experienced, witnessed, or been confronted with an event that involves actual or threatened death or injury, or a threat to the physical integrity of oneself or others. A.2) The person’s response involved intense fear, helplessness, or horror.

14. Traumas that can Lead to PTSD • What “counts” as an adequate criterion A.1 event? • Examples in the DSM: Violent military combat, torture, sexual assault, physical assault, kidnapping, accidents, natural disasters

15. B. Re-experiencing • Distressing recollections of the trauma • Distressing dreams of the event • Reliving the experience (flashbacks) • Psychological distress at exposure to trauma reminders (internal or external) • Physiological reactivity to trauma reminders

16. C. Persistent Avoidance • Efforts to avoid trauma-related thoughts or feelings • Efforts to avoid trauma-related activities or situations • Psychogenic amnesia • Diminished interest in activities • Detachment from others • Restricted range of affect • Foreshortened future

17. D. Increased Arousal • Sleep disturbances • Irritability or outburst of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response

18. Diagnostic Criteria for PTSD E. Duration of the disturbance is more than 1 month. F. The disturbance causes significant distress or impairment in important areas of functioning.

19. Prevalence of PTSD • Lifetime prevalence of PTSD is about 8% • 10% in women, 5% in men • About 50% of the US general population is exposed to a trauma during their lifetime • 10% to 20% of those exposed to a trauma develop PTSD

20. Most Common Traumas in PTSD • What types of trauma are most likely to cause PTSD?

21. Type of Event and Risk Percent w/ PTSD Breslau et al (1999)

22. Treatments for PTSD • National Institute for Clinical Excellence guidelines for treating PTSD: http://www.nice.org.uk/CG26 • Most effective treatment is trauma-focused cognitive-behavioral therapy (CBT) • Involves: • Imaginal exposure to traumatic memories • In vivo exposure to avoided situations • Modification of maladaptive beliefs about the trauma, oneself, and the world

23. Why Facing Traumatic Memories can be Helpful • Repeated exposure to traumatic memories helps to process (digest) the trauma, i.e., make sense of it, “file it in the right drawer” • Results in habituation, so that the trauma can be remembered without intense, disruptive anxiety • Fosters the realization that engaging the trauma memory does not result in loss of control or “going crazy” • Enhances sense of self control and competence

24. Sample in Vivo Exposure Hierarchy for a Sexual Assault Victim with PTSD Exposure Situation Estimated Anxiety Going to a bar by herself at night 100 Walking to her car alone at night after work 90 Walking across campus alone at night 80 Going to a house party with friends 70 Getting into car at night without checking back seat 65

25. CBT for PTSD • http://www.youtube.com/watch?v=9aTDIiTr99Y