Anxiety, Obsessive- Compulsive, and Trauma Stressor-Related Disorders

1. Anxiety, Obsessive-Compulsive, and Trauma Stressor-RelatedDisorders Chapter 8

2. Anxiety, Obsessive-Compulsive, and Trauma- and Stressor-Related Disorders Disorders Anxiety Disorders Separation Anxiety Disorder Selective Mutism Specific Phobias Social Anxiety Order Panic Disorder and Agoraphobia Generalized Anxiety Disorder Anxiety, Obsessive-Compulsive, and Trauma- and Stressor-Related Disorders: The Biopsychosocial Perspective Trauma- and Stressor-Related Disorders Reactive Attachment Disorder and Disinhibited Social Engagement Disorder Acute Stress Disorder and Post-Traumatic Stress Disorder Obsessive-Compulsive and Related Disorders Body Dysmorphic Disorder Hoarding Disorder Trichotillomania (Hair-Pulling Disorder) Excoriation (Skin-Picking) Disorder

3. Anxiety vs. Anxiety Disorders • Anxiety is an inevitable part of life. • In anxiety disorders, anxiety: • is more intense(I.e., panic attacks). • lasts longer(I.e., anxiety that may persist for months instead of going away after a stressful situation has passes.) • (may) lead to phobias(I.e., irrational fears/avoidance of heights, elevators, people, etc.)

4. The Nature of Anxiety Disorders(Brief overview) • Anxiety disorders are characterized by the experience of: • physiological arousal, apprehension or feelings of dread, hyper vigilance, avoidance, and sometimes a specific fear or phobia • FEAR is an innate alarm response to a dangerous or life-threatening situation. • ANXIETY is the state in which an individual is inordinately apprehensive, tense, and uneasy about the prospect of something terrible happening. • People with anxiety disorders are incapacitated with chronic and intense feelings of anxiety.

5. Anxiety (Definitions) • Anxiety (Def.) (Latin anxius: a condition of agitation and distress). • The term has been is use since the 1500s • The difference between fear and anxiety can be distinguished in the following ways: • Fear • is usually directed toward some concrete, external object or situation. • Anxiety • it is not so specific; you may not be able to identify clearly what you are anxious about. • The focus of anxiety is more internal than external • It seems to be a response to a vague, distant, or even unrecognized danger.

6. Anxiety affects your whole being: • It is a physiological, behavioral, and psychological reaction all at once. • Physiologically : • Anxiety includes bodily reactions such as: a rapid heartbeat, muscle tension, queasiness, dry mouth and/or sweating. • Psychologically : • Anxiety is a subjective state of apprehension and uneasiness. • In its most extreme form, it can cause you to feel detached from yourself and even fearful of dying or going crazy. • It can range in severity from a mere twinge of uneasiness to a full-blown panic attack marked by: heart palpitations, disorientation, and terror.

7. The Nature of Anxiety Disorders • The essential feature of anxiety disorders is the experience of a chronic and intense feeling of anxiety. • A future-oriented response which involves a sense of dread about what might happen to you in the future. • Involving both cognitive and emotional components, in which an individual is inordinately apprehensive, tense, and uneasy about the prospect of something terrible happening • Fear: People with anxiety disorders also experience fear, which is the emotional response to real or perceived imminent threat • Innate alarm response to a dangerous or life-threatening situation. • Anxiety disorders are the most highly prevalent of all psychological disorders with the exception of substance use disorders.

8. Panic Disorder • Panic attacks on a recurrent basis • Has constant apprehension and worry about the possibility of recurring attacks • Panic attack: A period of intense fear and physical discomfort accompanied by the feeling that one is being overwhelmed and is about to lose control • During a panic attack, the individual feels overwhelmed by a range of highly unpleasant physical sensations: • Respiratory distress • Autonomic disturbances • Sensory abnormalities

9. 0 The relationship among: Anxiety, Fear and Panic Attack

10. Agoraphobia • Intense anxiety about being trapped or stranded in a situation without help if a panic attack occurs. • People with agoraphobia are fearful not of the situations themselves, but of the possibility that they can’t get help or escape if they have panic-like symptoms or other embarrassing or incapacitating symptoms. • Fear or anxiety about two of the following five: • Using public transportation • Being in an enclosed space (such as a theater) • Being in an open space (such as a parking lot) • Being outside of the home alone • Standing in line or being in a crowd • Their fear or anxiety is out of proportion to the actual danger involved in the situation

11. Theories and Treatment of Panic Disorder and Agoraphobia • Biological perspectives • Neurotransmitters • Anxiety Sensitivity • Psychological perspectives • Conditioned Fear Reactions • Relaxation training • Panic control therapy (PCT)

12. Separation anxiety disorderand selective mutism

13. Separation Anxiety Disorder • A childhood disorder characterized by • intense and inappropriate anxiety, lasting at least 4 weeks, concerning separation from home or caregivers. • The symptoms of separation anxiety disorder all revolve around a core of emotional distress involving situations in which they are parted from their caregivers. • Even the prospect of separation causes extreme anxiety. • Children with this disorder avoid situations in which they will be parted from their attachment figures. • People with separation anxiety disorder are also at greater risk of subsequently developing other anxiety and mood disorders, such as panic disorder. • Epidemiologists estimate that 4.1 percent of children have diagnosable separation anxiety disorder and about one-third of these persist into adulthood.

14. Theories and Treatment of Separation Anxiety Disorder • A bio-psychosocial model seems particularly appropriate for understanding separation anxiety disorder. • Results of twin studies suggest strong genetic support. • Important environmental contributions to the development of this disorder.

15. Selective Mutism • A disorder originating in childhood in which the individual consciously refuses to talk. • Children with this disorder are capable of using normal language, but they become almost completely silent under certain circumstances. • Anxiety may be at the root of selective mutismgiven that children most typically show this behavior in school rather than at home. • begin between the ages of 3 and 6, • equal frequencies among boys and girls • Behaviorist methods using shaping and exposure seem particularly well suited to treating children with selective mutism.

16. PHOBIASGeneralized anxiety disorder

17. Specific Phobias • Phobia: An irrational fear associated with a particular object or situation • Specific Phobia: An irrational and unabating fear of a particular object, activity, or situation • People with specific phobia go to great lengths to avoid the object or situation that is the target of their fear.

18. Specific Phobias • Categories • Animals • Natural environment • Blood-injection-injury • Engaging in activities in particular situations • Variety of miscellaneous stimuli

19. Specific Phobias: common

20. Specific Phobias: Less Common

21. Specific Phobias: Theories and Treatment • Biological perspectives focus on symptom management. • Systematic desensitization: learn to substitute adaptive (relaxation) for maladaptive (fear or anxiety) responses. • Flooding: Client is totally immersed in the sensation of anxiety by being exposed to the feared situation in its entirety. • Imaginal flooding: Client is immersed through imagination in the feared situation. • Graduated exposure: Clients initially confront situations that cause only minor anxiety and gradually progress toward those that cause greater anxiety. • Thought stopping: Individual learns to stop anxiety-provoking thoughts.

22. Social Phobia • A social phobia is a fear of being observed by others acting in a way that will be humiliating or embarrassing. • The primary characteristic of social phobia is an irrational an intense fear that one’s behavior in a public situation will be mocked or criticized by others. • They show the following characteristics: • recognizing their own fears as unreasonable • low self-esteem • underestimating their own abilities

23. Social Phobia: Treatments • In Vivo Exposure • Cognitive Restructuring • Social Skills Training • Sometimes Medication

24. Generalized Anxiety Disorder • Anxiety that is not associated with a particular object, situation, or event • A constant feature of a person's day-to-day existence • Symptoms – • General restlessness, • sleep disturbances, • feelings of being easily fatigued, • irritability, • muscle tension, and • trouble concentrating to the point where their mind goes blank.

25. Obsessive-Compulsive Disorder Obsessions as defined by 1, 2, 3, and 4 • Recurrent, persistent thoughts, impulses, or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress • The thoughts, impulses, or images are not simply excessive worries about real-life problems • The person attempts to ignore or suppress such thoughts, impulses, or images or tries to neutralize them with some other thought or action • The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind

26. Obsessive-Compulsive Disorder Compulsionsas defined by 1 and 2 • Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly • The compulsions are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

27. Obsessive-Compulsive Disorder • 4 major dimensions • Obsessions associated with checking compulsions • Need for symmetry and order • Obsessions about cleanliness associated with washing compulsions • Hoarding-related behaviors • Some individuals with OCD experience tics. • Tic: A rapid, recurring, involuntary movement or vocalization.

28. Typical Compulsions • Checking • Cleaning/washing • Doing things a certain number of times in a row • Doing and then undoing things • Doing things in a certain order, with symmetry • Mental acts such as praying, counting, etc.

30. Obsessive-Compulsive Disorder • So far, treatment with clomipramine or other serotonin reuptake inhibiting medications, such a fluoxetine (Prozac) is the most effective biological treatment available for OCD. • OCD is increasingly • being understood • as a genetic disorder.

31. Hoarding Disorder • A compulsion in which people have persistent difficulties discarding things, even if they have little value. • They believe these items to have utility, to have aesthetic or sentimental value, but in reality the items often consist of old newspapers, bags, or left over food

32. Trichotillomania (Hair-Pulling Disorder) • The compulsive, persistent urge to pull out one’s own hair. • They feel unable to stop this behavior, even when the pulling results in bald patches and lost eyebrows, eyelashes, armpit hair, and pubic hair. • Relief, pleasure, or gratification is typically experienced after pulling out their hair.

33. Excoriation (Skin-Picking) Disorder • Recurrent picking at one’s own skin which can be healthy skin, or skin with mild irregularities. • People with this disorder pick at these bodily areas either with their own fingernails or with instruments such as tweezers. These individuals spend a considerable amount of time engaging in skin-picking, perhaps as much as several hours per day • When they are not picking their skin, they think about picking it and try to resist their urges to do so. • These individuals may attempt to cover the evidence of their skin-picking with clothing or bandages, and they feel ashamed and embarrassed about their behavior.

34. Traumatic Experience • A traumatic experience is a disastrous or extremely painful event that has severe psychological and physiological effects. • Aftereffects of the traumatic event can include: • flashbacks, nightmares, and intrusive thoughts • Alternate with the individual's attempts to deny that the event ever took place.

35. Following a traumatic life event, people go through a series of characteristic responses, identified as occurring in two phases • Outcry Phase • Denial/Intrusion Phase Outcry Phase: The initial reaction is the outcry phase, during which the person reacts with alarm and a strong emotion, such as fear or sadness. • Denial/intrusion phase: The person alternates between denial, the experience of forgetting the event or pretending it did not occur, and intrusion, the experience of disruptive thoughts and feelings about the event.

36. Trauma-Induced Disorders Acute Stress Disorder: An anxiety disorder that develops during the month after a traumatic event. Lasts 2-4 weeks. • Some people develop an acute stress disorder soon after a traumatic event. In this condition, the individual develops intense fear, helplessness or horror during the month after trauma. • Despite the extreme nature of acute stress disorder, most people are able to return to relatively normal functioning within days or weeks. • People with this disorder may reexperience the event and desperately avoid reminders of the trauma. These symptoms arise within the month following the trauma and last from days to weeks. • Symptoms may include: • depersonalization, numbing, dissociative amnesia, intense anxiety, hypervigilance, and impairment of everyday functioning.

37. Diagnostic Criteria for PTSD • Exposed to traumatic event • The person experienced, witnessed, or was confronted with an event involving actual or threatened death, serious injury or a threat to physical integrity of self or others • The person’s response involved intense fear, helplessness or horror

38. Trauma-Induced Disorders Post-Traumatic Stress Disorder: More than a month after a traumatic event, stress interferes with the individual’s ability to function. • Symptoms fall into two related clusters: • Intrusions and Avoidance: includes intrusive thoughts, recurrent dreams, flashbacks, hyperactivity to cues of the trauma, and the avoidance of thoughts or reminders. • Hyperarousal and Numbing: includes symptoms that involve detachment, a loss of interest in everyday activities, sleep disturbance, irritability, and a sense of foreshortened future.

39. Diagnostic Criteria for PTSD • B. The traumatic event is reexperienced in one or more of the following ways • Recurrent images, thoughts or perceptions • Recurrent distressing dreams of the event • Acting or feeling as if the event was recurring • Intense psychological distress OR physiologic reactivity at exposure to cues that symbolize or resemble an aspect of the event

40. Diagnostic Criteria for PTSD • C. Persistent avoidance of stimuli associated with trauma and numbing as indicated by 3 or more: • Avoiding thoughts, feelings, or discussion, activities, places or people that bring back recollections; sense of foreshortened future • Inability to recall; restricted affect • Diminished interest or participation • Feeling detached or estranged

41. Diagnostic Criteria for PTSD • D. Persistent symptoms of increased arousal by 2 or more: • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response • E. Duration for more than 1 month

42. Diagnostic Criteria for PTSD F. Clinically significant impairment in functioning • Acute: Less than 3 months • Chronic: Greater than or equal to 3 months • With delayed onset: Onset at least 6 months after the stressor

43. Potential Risk Factors • Lack of social support • Family psychiatric history, esp. anxiety • Previous psychiatric history • Certain personality traits • Early separation of parents • Parental poverty • Abuse in childhood • Childhood behavioral problems • Limited education • Adverse life-events prior to trauma

44. Associated Symptoms Important for Treatment • Survival and behavioral guilt • Somatic distress • Paranoia • Interpersonal alienation • Vegetative changes of depression • Hopelessness • Impulsivity

45. Treatment • Talking about the trauma allowing: • confrontation • acceptance • process • integration • Individual or group therapy. • Followed by support.

46. Treatment: PTSD • Requires multiple modalities • Initial education, support and referrals important to establish trust • Pharmacotherapy • Psychotherapy • Relaxation Training

47. Treatment: PTSD- Individual Psychotherapy • Crisis Intervention • establish rapport, promote acceptance • educate, attend to general health • Trauma-focused psychotherapy • Implosive therapy • Systematic desensitization • Hospitalization may be necessary at times

48. Trauma- and Stressor-RelatedDisorders

49. trauma- and stressor-related disorders • These disorders are placed among the trauma- and stressor-related disorders because they are found in children who have experienced an abuse pattern of social neglect, repeated changes of primary caregivers, or rearing in institutions with high child-to-caregiver ratios. • Consequently, such children are significantly impaired in their ability to interact with other children and adults.

50. Reactive Attachment Disorder • A disorder involving a severe disturbance in the ability to relate to others. • The individual is unresponsive to people, is apathetic, and prefers to be alone rather than to interact with friends or family. • These children are emotionally withdrawn and inhibited and show little positive affect and an ability to control their emotions. • When distressed, they do not seek comfort