Activate the amygdala which alerts to the threat à Activates the hypothalamic-pituitary-adrenal axis (HPA) which releases hormones, including

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Katrina Richards
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2 Activate the amygdala which alerts to the threat à Activates the hypothalamic-pituitary-adrenal axis (HPA) which releases hormones, including cortisol Because most bodily cells have cortisol receptors, it affects many functions in the body: Blood sugar levels Regulates metabolism Helps reduce inflammation Assists with memory formulation Has a controlling effect on salt and water balance Helps control blood pressure 2

3 Hypothalamus triggers release of CRH (Corticotrophin Releasing Hormone) which activates the Pituitary Gland. Pituitary Gland releases ACTH (Adrenocorticotropic Hormone) which is carried in the blood to the Adrenal glands. Adrenal Glands release stress hormones: Cortisol, Adrenalin, Noradrenalin

4 : On body On mood On behavior Retain belly fat Headache Muscle tension or pain Chest pain Fatigue Stomach upset Sleep problems Increased HR Shortness of Breath Anxiety Restlessness Lack of motivation or focus Irritability or anger Sadness or depression Can t think straight Overeating or undereating Angry outbursts Drug or alcohol abuse Tobacco use Social withdrawal 4

5 While short-term cortisol release prepares to sustain fight or flight and fend off, long-term exposure causes neurons to shrink and interferes with their ability to send and receive information Prolonged stress or trauma is associated with decreased volume in areas of the brain responsible for regulating thoughts and feelings, enhancing self-control and creating new memories In addition to hippocampal shrinkage, major life stress may shrink brain neurons in the PFC

6 Fear is an emotional response to a perceived threat, which causes changes in brain and organ function, as well as in behavior. Fear can lead us to It is the basis for many unhealthy emotions and behavioral choices Deeply imprinted in brain due to need for survival Cannot un-break the fear connection neural network Differences in coping styles influence responses to fear. Proactive Style = reacting actively Reactive Style = reacting more passively 6

7 In the face of fear, one may feel: A desire to hide, run, or freeze Stuck Uncertainty Unsafe Desire to run away Shame/guilt Self-doubt Procrastination Lack of Confidence 7

8 Anxiety is a feeling of worry, nervousness or unease, typically about an uncertain outcome. Feeling anxious is a normal emotion under certain situations Anxiety disorders cause over-whelming distress that interferes with daily life (such as: panic disorder, social anxiety, phobias and Generalized Anxiety) 8

9 a prolonged, hypervigilant and pervasive state of imaginative dread and foreboding about impending fear à major cognitive distortion Genetic predisposition Research shows evidence that anxiety disorders are not a result of a personal weakness or character flaw, but are caused by a combination of factors including changes in the brain and environmental stress. 9

10 Possible Symptoms: Feelings of panic or fear Uneasiness Problems sleeping Cold or sweaty hands or feet Shortness of breath Heart palpatations Not being able to be still Self-doubt Approval seeking Unexplained fatigue (yawning) Unexplained pain Slower than expected performance response, or under-performing High pitch to voice Dry mouth Numbness or tingling in the hands or feet Nausea Muscle tension Dizziness 10

11 Fear Response to known or definite threat Objec7ve External Clear and present object of fear Anxiety Response to imprecise or unknown threat Subjec7ve Internal Mind s vision of possible dangers 11

12 Physiological Perceptual Imaginary Illness Injury Spinal Cord Environmental Threat Thoughts Thalamus Sensory Cortex Frontal Cortex Amygdala and Hypothalamus >>>> >>>> HPA Axis HPA Axis HPA Axis

13 1. Anxiety Disorders (separation anxiety disorder, selective mutism, specific phobia, social phobia, panic disorder, agoraphobia, and generalized anxiety disorder). 2. Obsessive-Compulsive Disorders (obsessive-compulsive disorder, body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder). 3. Trauma and Stressor-Related Disorders (reactive attachment disorder, disinhibited social engagement disorder, PTSD, acute stress disorder, and adjustment disorder)

14 DSM-5 added a new category of disorders called Obsessive-Compulsive and Related Disorders (OCRDs) (also called Obsessive-Compulsive Spectrum Disorders in the research literature). The OCRDs category includes: hoarding disorder and excoriation (skinpicking) disorder, body dysmorphic disorder (previously classified as a Somatoform Disorder) and trichotillomania (hair-pulling, previously classified as an Impulse Control Disorder Not Elsewhere Classified)

15 Based on whether there is evidence of an underlying relationship between two or more disorders (such as: symptom similarity; frequency of co-occurrence (comorbidity), the onset, presentation, and progression of the disorders, genetic risk factors, environmental risk factors, neural substrates, biological markers and treatment response. While anxiety remains a key feature in OCRDs, there are enough unique differences between Anxiety Disorders and OCRDs to justify a separate category.

16 Obsessive-Compulsive Disorder

17 Obsessive-compulsive disorder (OCD) is characterized by distressing, intrusive obsessive thoughts and/or repetitive compulsive physical or mental acts. Obsessions: recurrent and persistent thoughts, urges or images that are experienced, are intrusive and unwanted, especially during anxiety or distress. Attempts to ignore or suppress obsessions with some other thought or action (e.g. compulsion)

18 Compulsions: Repetitive behaviors that a person feels driven to perform in response to an obsession or to rigid rules Perform excessively carefully and slowly Two Types: Behaviors detailed cleaning, hand washing, ordering, arranging objects, checking, slowness, confessing/seeking reassurance Mental acts praying, counting, silently repeating words, list making

19 Compulsions are not connected to the feared situations Compulsions are excessive The behaviors or mental acts are aimed at: Preventing or reducing anxiety Preventing some dreaded event or situation

20 At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships. If another disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food, substances, body) The disturbance is not due to the direct physiological effects of a substance (a drug of abuse, a medication) or a general medical condition.

21 Common obsessions include the following: o Contamination o Safety o Doubting one's memory or perception o Scrupulosity (need to do the right thing, fear of committing a transgression, often religious) o Need for order or symmetry o Unwanted, intrusive sexual/aggressive thoughts Eczematous eruptions related to excessive washing Hair loss related to trichotillomania or compulsive hair pulling Excoriations related to neurodermatitis or compulsive skin picking Decreased cognitive flexibility (changes in prefrontal cortex)

22 Five Major Types: Type One Pure obsessions (aggressive, sexual, religious, somatic) or No obsessions Type Two Symmetry Obsessions (ordering, counting, repeating) Type Three Contamination Obsessions (cleaning compulsions) Type Four Hoarding Obsessions (collecting compulsions) Type Five Harm Obsessions (self or others) or Checking compulsions

23 Mood and anxiety disorders Somatoform disorders, especially hypochondriasis and body dysmorphic disorder Eating disorders Impulse control disorders, especially kleptomania and trichotillomania Attention deficit hyperactivity disorder (ADHD) Obsessive-compulsive personality disorder Tic disorder Suicidal thoughts and behaviors

24 Yale-Brown Obsessive Compulsive Scale (Y-BOCS) -- to define the range and severity of OCD symptoms Complete Mental Status Examination Look for comorbid symptoms and disorders

25 Serotonergic antidepressant medications Forms of behavior therapy (exposure and response prevention and some forms of cognitive-behavioral therapy [CBT]) Education and family interventions Neurosurgery (anterior capsulotomy, or deep brain stimulation), in extremely refractory cases

26 Anxiety Disorders

27 Unexpected and abrupt surge of intense fear or discomfort with 4 of the following symptoms: Heart pounding, palpitations Chest pain/discomfort Sweating Chills or heat sensations Parasthesia (burning or prickling, which happens without warning, is usually painless and described as tingling or numbness, skin crawling, or itching) Trembling or shaking Shortness of breath, feelings of choking or smothering Dizziness, unsteady, light-headed, faint Derealization (feelings of unreality) Depersonalization (feeling detached from one-self) Persistent concern about having another attack

28 Two underlying fears maintain panic disorder: Fear of dying Fear of losing control TREATMENT: Identify trigger symptoms and/or situations Predict panic attack occurance Desensitize the symptoms Relaxation techniques Stress management

29 Marked fear or anxiety about 2 or more of the following: Using public transportation Being in open or enclosed spaces Standing in line or being in a crowd Being outside of the home alone Fear that their thoughts might escape Provoke fear or anxiety

30 Marked fear or anxiety about a specific object or situation Aerophobia fear of flying Claustrophobia vs. Panic Disorder fear of dying Acrophobia fear of heights Zoophobia fear of animals Hodophobia fear of traveling Anachrophobia fear of spiders Odontophobia dental phobia (75% of US adults), needle, drill, odor (strong memory connection)

31 15 million Americans Begins in early adolescence Genetic predisposition Often with depression Important for survival: group cohesion, assistance, sharing tasks and emotional support ** Be mindful about social disapproval that leads to anxiety or incorrect cognitive appraisals

32 Marked fear or anxiety about one or more social situations in which the person is exposed to possible evaluation by others: Conversations Meeting unfamiliar people Being observed: eating, drinking, toileting Performance anxiety, including participating in a meeting or group Speech Treatment: create outline, practice! And allow for variations, practice in front of mirror, memorize first 30 seconds Group dynamics whoever speaks first (first 3 people), the rest expect that they will be the primary one to speak. Provide simple comments, questions within first 3 people, or will find it difficult to be heard in the group.

33 An unnatural fear of certain places and situations Two underlying fears maintain panic disorder: Fear of dying Fear of losing control TREATMENT: Identify trigger symptoms and/or situations Predict panic attack occurance Desensitize the symptoms Relaxation techniques Stress management

34 Education Relaxation techniques In vitro desensitization (image, imagine) In vivo desensitization (real life) Oxytocin (a hormone associated with a willingness to accept interpersonal social risks). Can sniff it for lower activity in the amygdala and reduced social fear. Distraction Deep breathing Pleasant imagery Systematic desensitization

35 50 to 75% come from lower socio-economic status 4 to 5% of children and adolescents Inappropriate and excessive fear or anxiety of being separated from parents and caretakers, as evidenced by 3 of the following: Excessive distress when anticipating or experiencing separation Excessive distress about losing major attachment figures School refusal (80% of school refusers) Nightmares about separation Repeated physical complaints in anticipation or actual separation from attachment figure (headaches, stomachaches, nausea, vomiting) Lasts 4 weeks in children and adolescents Lasts 6 months in adults

36 Treatment: Behavior therapy in children CBT in adolescents and adults Parental counseling Anti-anxiety medications If not treated, may lead to depression or other anxiety disorders in adulthood

37 Excessive anxiety and worry for at least 6 months, about work, school, performance, family, etc Difficulty in controlling worry Co-occurrence often with other anxiety disorders, depression and substance abuse Anxiety and worry associated with 3 or more of the following: Restlessness, feeling on edge, keyed up Irritability Difficulty concentrating or mind goes blank Muscle tension Being easily fatigued Shortness of breath Frequent urination Sleep disturbance (difficulty falling and staying asleep, restlessness, unsatisfying sleep)

38 TREATMENT: Psychotherapy for pathological worry Meditation Relaxation CBT (with medication) 12+ weeks, homework to help generalize learning to other situations. CBT is more effective long-term than meds. Requires action and persistence Medications alone seldom cure anxiety disorders

39 39

42 Deficits in Information Processing Problems in attention, organization, categorization, memory and decision making Everything is equally important Think if discard it they will loose the memory May need it or will forget Emotional Attachment and beliefs Four basic qualities of attachments: Emotion reminded of personal past events Memory Related if discard item, will not remember something (newspapers, bills, books, magazines) Responsibility for possessions make sure things are not wasted (take to recycling) Control over possessions possession is an extension of self. Removing or someone else touching the possession is a violation of self

43 Avoidance and Reinforcement Avoiding discarding allows postponing Not usually related to Treatment: Similar to OCD De-sensitize Friend or others monitor (fear of having a housekeeper in the home) Is a relapsing disorder that needs monitoring

44 I-turine works for OCD

45 Irrational attributions Poor skills

DSM-IV-TR Diagnostic Criteria For Posttraumatic Stress Disorder

DSM-IV-TR Diagnostic Criteria For Posttraumatic Stress Disorder PTSD When an individual who has been exposed to a traumatic event develops anxiety symptoms, re-experiencing of the event, and avoidance